Gaming in Stroke Rehabilitation

The following text is an edited transcript of a live webinar titled “Gaming in Stroke Rehabilitation”.  Please follow along with course handouts to ensure understanding of material.   Gaming in Stroke Rehabilitation Objectives: The participant will be able to define video gaming and identify at least three issues and advantages and the evidence for the use of gaming as a therapeutic modality or adjunct in neuro-rehab.The participant will be able to identify at least two unique therapeutic and motor learning features of video gaming as compared to traditional rehabilitation interventions for individuals who have had a stroke.The participant will be able to apply the evidence and the framework presented to design, modify, and progress at least three video game based interventions for patients/clients who have had a stroke.   Introduction and Overview In clinical practice, I did a lot of work with stroke rehab, along with balance retraining across many different pathologies and diseases. Over time, I came to the realization that successful balance rehab depends on the patient getting a lot of practice. Furthermore, the patient receives greater benefit from rehab if that practice is intense. As I became more involved with research in balance retraining and fall prevention, I looked to gaming as a way to achieve this frequent, intense practice for people doing a lot of different balance activities. Although I began using gaming in the stroke rehab realm, the information in this presentation is relevant across other rehab applications. Virtual Reality DefinedVirtual reality (VR) is also known as “immersive multimedia” or “computer simulated reality.” It replicates an environment, either real or imagined. It simulates the user's presence in that environment and allows the user to interact with the environment. In many cases, it can create sensory experiences. Sight and sound are the easiest to achieve, but in some instances, touch and smell are experienced. In the case of some rehab virtual realities, vestibular and other movement experiences are replicated. Most virtual realities are displayed on a screen of some sort (e.g., a computer screen or a surround screen). Sometimes, it is a headset that mimics a 3-D experience, also called a head-mounted display. Some virtual reality simulations can also include sensory information. Some advanced haptic systems now include tactile information, generally known as force feedback. These applications are used in industries, such as the medical field and the military. The immersive environment can be similar to the real world, in order to create a lifelike experience, such as for pilot or combat training. Or, it can differ significantly from reality, such as in VR games. VR Technology in Physical TherapyGaming systems created specifically for physical therapy are full-immersion virtual reality environments. They may have haptic systems or simulators. One particular system uses a 180-degree surround visual. These systems are generally very expensive. They tend to be created for a narrow market, which limits the number of systems a clinic can purchase, if they are even able to afford one. There are some slightly less expensive systems, but they are still geared toward a much smaller market than commercial gaming systems, so they are still fairly expensive. They tend to be not as well made as Xbox or Nintendo, which are intended for a large commercial market. These PT-specific gaming/VR systems are usually tailored to very specific therapeutic goals, and as such, they are not as flexible. They cannot be modified as off-the-shelf games can. The 180-degree surround visuals can be adjusted to flow or to change (Figure 1). The support surface is a split-belt treadmill. A harness if needed can support the person. There is motion-capture, so that the result of what the person does can be recorded. Also, that support surface can be translated forward, back, and side-to-side. It can be tilted. It can be turned, raised and lowered. There are many possible perturbations to the person’s balance, which can be matched or mismatched to the visual flow. Figure 1. An example of virtual reality technology used in rehab. Insert Slide 5  Video Game DefinedA video game is an electronic game that involves human interaction with a user interface to generate visual feedback, usually on a TV screen or computer monitor. The electronic systems used to play video games are known as platforms. There are a couple of different platforms that are most commonly used for rehab. Examples of platforms are personal computers and video game consoles. The input device used for games (e.g., the game controller) varies across platforms. Controllers include gamepads, computer mice, keyboards, joysticks, the touchscreens of mobile devices and buttons. It can also be the accelerometers, like in a Wii game, where your whole body is the controller (as an avatar). Newer systems also have sort of a haptic vibration, and there are some peripherals that we will talk about later which use force feedback. The Wii and Xbox Kinect both have games that are often used in rehab. Also, Eye Toy by PlayStation 2 is used, however it is mostly available secondhand or in used versions at this point. Gaming Technology in Physical TherapyAccelerometers are handheld devices that measure the user’s movements, and those movements are then communicated to the game through the handheld device. The PlayStation Eye Toy and the Xbox Kinect utilize a depth camera to sense the user’s movements, without having to hold controllers to interact with the game – your body is the controller. Mechanical plug-ins are also common (e.g., in Rock Band you can plug in instruments, like a guitar). The Dance Revolution has a plug-in mat that detects the foot placement and movements of the user as they dance. You can use traditional controllers, joysticks, buttons – or a combination of technologies. For instance, some of the Wii fit games can be played with the balance board and the accelerometer controls. Many of these video games are being used increasingly for the therapeutic potential across settings and practice areas. Pros and Cons of Commercially Available GamesAs previously stated, the large systems built specifically for rehab are very expensive and are not as easily tailored. The off-the-shelf video games...