探索：虚拟引导式自动精准上肢运动评估系统的可靠性研究

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Abstract

Post-stroke cognitive impairment (PSCI) is frequently accompanied by upper limb motor dysfunction, while traditional assessment methods are limited by high cognitive demands and subjectivity. Mixed reality (MR) technology can balance immersion and comprehensibility, offering a novel approach for automated motor function evaluation.

In this study, we developed an MR-based upper limb assessment system that integrates a virtual demonstration hand with wearable sensors to capture kinematics during seven standardized tasks derived from the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT). Ten healthy participants completed video-, VR-, and MR-based assessments, followed by a one-week retest of MR and VR conditions. Subjective experience was evaluated using multidimensional questionnaires, while the reliability of objective kinematic features was examined using intraclass correlation coefficients (ICC), standard error of measurement (SEM), and coefficient of variation (CV%).

Compared with video and VR, MR achieved significantly higher ratings in usefulness, comprehensibility, satisfaction, and willingness to continue, while inducing lower fatigue and cybersickness. Presence improved after MR exposure, whereas disorientation-related cybersickness decreased. Test–retest analysis indicated good reliability for path length (ICC = 0.85), average velocity (ICC = 0.76), mean acceleration (ICC = 0.77), and forearm velocity peaks (ICC = 0.77).

The MR system demonstrated good feasibility, acceptance, and kinematic quantification performance. By reducing cognitive burden and enabling objective assessment, it shows potential as a tool for rehabilitation monitoring in PSCI populations.

Key words: Mixed Reality; Post-stroke Cognitive Impairment; Upper Limb Function; Kinematic Assessment

Comments from the Editors and Reviewers:编者和审稿人的评论：

Editorial Office: 编辑部：

Please correct the following irregular formats for completing the revision.请纠正以下不规范的格式以完成修订。

1. Highlights: 1. 突出显示：

3~5 bullet points to list the most important findings. Maximum 85 characters, including spaces, per bullet point.3~5 个要点列出最重要的发现。每个要点最多 85 个字符（含空格）。

2. Reference style： 2. 参考文献格式：

Please correct the reference style according to the following examples and you can visit the 'Guide for Authors' in the Journal homepage for more detailed contents. You need to check carefully each of the references according to examples below for completing the revision.请根据以下示例修正参考文献格式，您可以访问期刊主页上的《作者指南》获取更详细的内容。您需要根据以下示例仔细检查每一项参考文献，以完成修订。

Text: Indicate references by number(s) in square brackets in line with the text. The actual authors can be referred to, but the reference number(s) must always be given.通过方括号中的数字在正文中标明参考文献。可以引用实际作者，但必须始终给出参考文献编号。

List: Number the references (numbers in square brackets) in the list in the order in which they appear in the text.列表：按文本中出现的顺序对参考文献编号（方括号中的数字）。

Examples: 示例：

Reference to a journal publication:期刊出版物的引用：

[1] Van der Geer J, Hanraads JAJ, Lupton RA. The art of writing a scientific article. J Sci Commun 2010;163:51–9. https://doi.org/10.1016/j.Sc.2010.00372.[1] Van der Geer J, Hanraads JAJ, Lupton RA. 如何撰写科学论文. 科学交流期刊 2010;163:51–9. https://doi.org/10.1016/j.Sc.2010.00372.

Reference to a journal publication with an article number:引用期刊文章，并附带文章编号：

[2] Van der Geer J, Hanraads JAJ, Lupton RA. The art of writing a scientific article. Heliyon. 2018;19:e00205. https://doi.org/10.1016/j.heliyon.2018.e00205[2] Van der Geer J, Hanraads JAJ, Lupton RA. 如何撰写科学论文. Heliyon. 2018;19:e00205. https://doi.org/10.1016/j.heliyon.2018.e00205

Reference to a book: 引用书籍：

[3] Strunk Jr W, White EB. The elements of style. 4th ed. New York: Longman; 2000.[3] Strunk Jr W, White EB. 《风格要素》. 第 4 版. 纽约: 长青出版社; 2000.

Reference to a chapter in an edited book:参考文献中编辑书籍章节的引用：

[4] Mettam GR, Adams LB. How to prepare an electronic version of your article. In: Jones BS, Smith RZ, editors. Introduction to the electronic age, New York: E-Publishing Inc; 2009, p. 281–304.[4] Mettam GR, Adams LB. 如何准备您的文章的电子版本. In: Jones BS, Smith RZ, 编者. 电子时代的导论, 纽约: E-Publishing Inc; 2009, 第 281-304 页.

Reference to a website: 网站引用：

[5] Cancer Research UK. Cancer statistics reports for the UK, http://www.cancerresearchuk.org/aboutcancer/statistics/cancerstatsreport/; 2003 [accessed 13 March 2003].[5] Cancer Research UK. 英国癌症统计报告, http://www.cancerresearchuk.org/aboutcancer/statistics/cancerstatsreport/; 2003 [访问于 2003 年 3 月 13 日].

Reference to a dataset: 数据集引用：

[dataset] [6] Oguro M, Imahiro S, Saito S, Nakashizuka T. Mortality data for Japanese oak wilt disease and surrounding forest compositions, Mendeley Data, v1; 2015. https://doi.org/10.17632/xwj98nb39r.1.[数据集] [6] Oguro M, Imahiro S, Saito S, Nakashizuka T. 日本栎枯萎病死亡数据及周围森林组成，Mendeley 数据，版本 1；2015。https://doi.org/10.17632/xwj98nb39r.1。

Note shortened form for last page number. e.g., 51–9, and that for more than 6 authors the first 6 should be listed followed by 'et al.' 注意末页编号的缩写形式。例如，51–9，以及超过 6 位作者时，应列出前 6 位，后接 'et al.'。

Reviewers: 审稿人：

Reviewer #1: This manuscript reports a mixed-reality (MR) system for upper-limb assessment modeled on standardized tasks, compares user experience across Video/VR/MR, and examines test-retest reliability of nine kinematic features in healthy adults. The topic is timely and clinically relevant; the system design is coherent and the results suggest MR offers favorable usability with several features showing good reliability.审稿人 #1：该稿件报告了一个基于标准化任务的混合现实（MR）上肢评估系统，比较了视频/VR/MR 的用户体验，并检验了健康成年人中九个运动学特征的测试-重测信度。该主题具有时效性和临床相关性；系统设计合理，结果表明 MR 具有良好的可用性，且部分特征显示出良好的信度。However, several issues require revision before the paper is acceptable:然而，在论文被接受之前，有几个问题需要修改：

1. The title and several statements imply validation in post-stroke cognitive impairment (PSCI) patients, while the present data are from healthy adults. Suggest to revise the title to something not mentioning "patients" . For example:"Mixed Reality-Based Upper Limb Motor Function Assessment System: Feasibility and Reliability Study for PSCI Rehabilitation". Align title/ abstract/conclusions also. Try to state this is a feasibility and reliability study with implications for PSCI, not validation in PSCI.1. 标题和若干陈述暗示了对卒中后认知障碍（PSCI）患者的验证，而目前的数据来自健康成年人。建议修改标题，使其不提及"患者"。例如："基于混合现实的上肢运动功能评估系统：针对 PSCI 康复的可行性和信度研究"。请统一标题/摘要/结论，并说明这是一项可行性和信度研究，对 PSCI 具有启示意义，而非 PSCI 的验证。

2. Reference style is inconsistent and a lot of information is missing in a lot of references. Please replace incorrect citations, specify reference style (read author instruction).2. 参考文献格式不一致，许多参考文献中信息缺失较多。请替换错误的引用，并明确参考文献格式（请阅读作者指南）。

3. The result state of significant differences without reported models and p-values. Please add a statistics analysis if you want to claim significantly higher (add significance mark*). Figure 4 and 5 has similar issue. Provide sample size, exact p-values to the data if you want to claim the significance. 3. 未报告模型和 p 值的情况下存在显著差异的结果状态。若要声称显著更高（需添加显著性标记*），请提供统计分析。图 4 和图 5 存在类似问题。若要声称显著性，请提供样本量和精确的 p 值。

4. Text in Figure 7/8 is too small to be recognized. May revise the figure font so the data on the figure can be accessible by readers.4. 图 7/8 中的文字太小，难以辨认。建议修改图中的字体，以便读者能够识别图中的数据。

5. Mismatched figure number. Caption says Fig. 8, text says "plots were generated (Figure 5)" in the same section.5. 图表编号不匹配。图注说明为图 8，而同一部分的文本中提到"生成的图表（图 5）"。

6. When comparing the Presence Questionnaire factor scores, the text states "all dimensions showed increases", but several PQ factors droped (NATRL, RESOL, IFQUAL). Please clarify the claims.6. 在比较存在问卷因子得分时，文本声称"所有维度均有所增加"，但有几个 PQ 因子得分下降（NATRL、RESOL、IFQUAL）。请澄清相关声明。

Reviewer #2: This manuscript presents a well-designed mixed reality-based assessment system for upper limb motor function in post-stroke patients with cognitive impairment. The integration of virtual demonstration hands with wearable sensors represents a significant advancement in rehabilitation technology. The authors' approach of using first-person perspective to activate mirror neuron systems while reducing cognitive load is particularly innovative and addresses a critical gap in existing assessment tools for PSCI populations. The comprehensive evaluation comparing video, VR, and MR modalities provides strong evidence for the superiority of MR in terms of user acceptance, reduced cybersickness, and improved comprehension. The test-retest reliability analysis with ICCs ranging from 0.76-0.85 for key kinematic parameters (path length, average velocity, mean acceleration) demonstrates robust measurement properties suitable for clinical application. The inclusion of both subjective (questionnaires) and objective (kinematic) measures strengthens the validity of the findings. The authors' consideration of individual differences through ITQ correlation analysis adds depth to understanding user experience variations. This work makes a valuable contribution to the field of technology-assisted rehabilitation assessment and is suitable for publication pending the resolution of the following comments.

审稿人#2：该稿件展示了一个针对认知障碍的卒中后患者上肢运动功能的混合现实评估系统，设计合理。虚拟演示手与可穿戴传感器的集成代表了康复技术的重大进步。作者采用第一人称视角激活镜像神经元系统，同时降低认知负荷的方法尤为创新，解决了现有针对 PSCI 人群评估工具中的关键空白。对比视频、VR 和 MR 模式的综合评估为 MR 在用户接受度、减少网络病和提升理解能力方面的优越性提供了有力证据。关键运动参数（路径长度、平均速度、平均加速度）的测试-重测信度分析显示 ICC 值在 0.76-0.85 之间，表明其具有适合临床应用的稳健测量特性。主观（问卷）和客观（运动学）测量方法的结合增强了研究结果的效度。作者通过 ITQ 相关性分析考虑个体差异，为理解用户体验差异增添了深度。这项工作对技术辅助康复评估领域做出了宝贵贡献，并适合在解决以下评论后发表。

1. Please specify in the table (Table 3, 4 and 5) whether the reported values represent ‌standard error (SE)‌ or ‌standard deviation (SD)‌.1. 请在表格（表 3、4 和 5）中明确说明所报告的值代表标准误差（SE）还是标准差（SD）。

2. The manuscript mentions individual differences affecting results (such as ITQ, SSQ, MRT, etc.) multiple times; it is suggested to briefly analyze possible causes (such as gender, gaming experience, cognitive style, etc.) in the discussion and explain how to incorporate personalized adaptation strategies in the system in the future.2. 手稿多次提到个体差异影响结果（如 ITQ、SSQ、MRT 等）；建议在讨论中简要分析可能的原因（如性别、游戏经验、认知风格等），并解释如何在未来将个性化适应策略纳入系统中。

3. It is recommended to cite recent systematic reviews or clinical trials on MR applications in neurorehabilitation, for example: Figeys, M., Koubasi, F., Hwang, D., Hunder, A., Cruz, A., & Rincón, A. (2023). Challenges and promises of mixed-reality interventions in acquired brain injury rehabilitation: A scoping review.International journal of medical informatics, 179, 105235. 3. 建议引用关于MR在神经康复中应用的最新系统评价或临床试验，例如：Figeys, M., Koubasi, F., Hwang, D., Hunder, A., Cruz, A., & Rincón, A. (2023). Challenges and promises of mixed-reality interventions in acquired brain injury rehabilitation: A scoping review.International journal of medical informatics, 179, 105235.

Reviewer #3: 1. The manuscript mentions a 5-minute pre-adaptation session but does not describe its specific content (such as whether it includes basic operation training, simple task experience, etc.). It is suggested to briefly describe the pre-adaptation process to enhance the completeness of the experimental method. 2. The criteria for determining movement start and end need to be described in detail: The manuscript does not clearly state how the start and end points of each action are defined. It is suggested to add whether a velocity threshold method (such as velocity exceeding a threshold as action start, below a threshold as end) or manual annotation was used, and specify the exact threshold or annotation criteria. This will enhance the transparency of the method and comparability of results.

审稿人 #3：

1. 手稿中提到有一个 5 分钟的预适应环节，但未描述其具体内容（例如是否包括基本操作训练、简单任务体验等）。建议简要描述预适应过程，以增强实验方法的完整性。

2. 需要详细描述确定运动开始和结束的标准：手稿未明确说明如何定义每个动作的开始和结束点。建议补充说明是使用了速度阈值方法（例如速度超过阈值作为动作开始，低于阈值作为结束）还是手动标注，并明确指出具体的阈值或标注标准。这将增强方法的透明度和结果的可比性。

为我下面的几个图添加关于p值的说明

Fig. 3 Mental Rotation Task performance in pre-test and post-test. Bar charts with overlaid individual data points and lines depict participants' accuracy rates and reaction times in the pre-test and post-test, illustrating the changes in spatial ability performance after the intervention. Fig. 4 Presence Questionnaire factor scores in pre-test and post-test. Bar charts compare the pre-test and post-test scores across the eight factors of the Presence Questionnaire. Fig. 5 Simulator Sickness Questionnaire (SSQ) subscale scores in pre-test and post-test. Bar charts present the scores for the Nausea, Oculomotor, and Disorientation subscales of the SSQ, highlighting the differences in simulator sickness symptoms before and after the intervention.