Getting into a “Flow” state: a systematic review of flow experience in neurological diseases

Abstract

Background Flow is a subjective psychological state that people report when they are fully involved in an activity to the point of forgetting time and their surrounding except the activity itself. Being in flow during physical/cognitive rehabilitation may have a considerable impact on functional outcome, especially when patients with neurological diseases engage in exercises using robotics, virtual/augmented reality, or serious games on tablets/computer. When developing new therapy games, measuring flow experience can indicate whether the game motivates one to train. The purpose of this study was to identify and systematically review current literature on flow experience assessed in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson’s disease. Additionally, we critically appraised, compared and summarized the measurement properties of self-reported flow questionnaires used in neurorehabilitation setting. Design A systematic review using PRISMA and COSMIN guidelines. Methods MEDLINE Ovid, EMBASE Ovid, CINAHL EBSCO, SCOPUS were searched. Inclusion criteria were (1) peer-reviewed studies that (2) focused on the investigation of flow experience in (3) patients with neurological diseases (i.e., stroke, traumatic brain injury, multiple sclerosis and/or Parkinson’s disease). A qualitative data synthesis was performed to present the measurement properties of the used flow questionnaires. Results Ten studies out of 911 records met the inclusion criteria. Seven studies measured flow in the context of serious games in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson’s disease. Three studies assessed flow in other activities than gaming (song-writing intervention and activities of daily living). Six different flow questionnaires were used, all of which were originally validated in healthy people. None of the studies presented psychometric data in their respective research population. Conclusion The present review indicates that flow experience is increasingly measured in the physical/cognitive rehabilitation setting in patients with neurological diseases. However, psychometric properties of used flow questionnaires are lacking. For exergame developers working in the field of physical/cognitive rehabilitation in patients with neurological diseases, a valid flow questionnaire can help to further optimize the content of the games so that optimal engagement can occur during the gameplay. Whether flow experiences can ultimately have positive effects on physical/cognitive parameters needs further study.

Using Large-Scale Sensor Data to Test Factors Predictive of Perseverance in Home Movement Rehabilitation: Optimal Challenge and Steady Engagement

“…Flow theory posits that an activity becomes intrinsically rewarding (hence, more likely to be initiated and sustained) when the individual's skillset is appropriate for the task but continues to develop, and the level of challenge is gradually increased. Our findings support what others have proposed—incorporating elements that optimize flow into design games for rehabilitative therapy could be helpful for promoting adherence and optimizing outcomes ( 34 , 35 ).…”

Desenvolvimento de jogos sérios para reabilitação neurológica de pacientes

“…O conceito denominado de "flow" será considerado no desenvolvimento dos jogos, ou seja, eles irão estimular a concentração, envolvimento e absorção durante a atividade pelos participantes de forma que os erros nem sempre os levem ao fracasso ou que a atividade seja muito difícil a ponto de desmotiva-los quebrando o fluxo de engajamento in-game (Ng, et al, 2018;Ottiger et al, 2021). É importante manter os pacientes engajados ao experimentarem os jogos, sem frustrá-los a ponto de desistirem e imprimindo uma dificuldade acessível para que alcance o sucesso.…”

The brain in flow: A systematic review on the neural basis of the flow state

“…If so, then you have experienced what Csikszentmihalyi (1975) called "flow state", a subjective experience in which the person is absorbed in the task and action seems to occur smoothly and automatically. The interest in this phenomenon has resulted in a wealth of literature investigating its subjective and behavioural manifestation (e.g., Csikszentmihalhi, 2020;Ottiger et al, 2021;Swann et al, 2012), albeit much less research has been conducted to pinpoint its neural signatures. Here, we systematically review the extant evidence on the neural correlates of flow state from a critical perspective, highlighting both the advances in the field and what we consider major limitations.…”