Using Computer Gaming for Stroke Rehabilitation

Using Computer Gaming in the Rehabilitation of Post-Stroke Patients

Khiem Bui, SPT

 

Background

Prior to going to PT school, I had worked as an engineer for about 16 years, in two different stints. I spent the first one doing mechanical design and in the second, I analyzed and benchmarked software for competitive purposes. I have always been intrigued by how technology can be integrated into PT, especially since several members of my extended family had suffered strokes.  I was closely involved with their rehab and saw first-hand how they struggled with motor deficits (this is before starting PT school). When the Microsoft Kinect and similar avatar-based computer games became popular, I immediately thought of how they could be used to improve the movements of post-stroke patients, or to encourage older adults to exercise. I decided to do my capstone on computer gaming for stroke rehabilitation, after discussions with Karen McCulloch and Prue Plummer.

 

Overview

Between half and three-quarter of post-stroke patients have lingering motor deficits that impact their ADLs¹. After their discharge from the hospital, such patients have to undergo intense rehabilitation to mitigate impairments in gait, toileting, eating, and communication that may directly impact their quality of life.

Starting in 2010, avatar-based computer games such as those available for the Microsoft Kinect, Wii and Sony PlayStation became popular as increased processing power allowed the game action to be more fluid and natural. Unlike conventional exercises, computer games inject a degree of randomness into the players’ movements since it is not possible to precisely predict how a virtual ball would rebound, or how a virtual adversary boxer would throw a punch (if the player is playing a boxing game). Not only do players have to learn to react to a dynamic system, they also frequently need to perform multi-planar movements (e.g., reaching an arm out at an angle, and across the body) which realistically simulate many activities in everyday life.

Articles on using computer games in movement therapy began to appear in research journals from 2008 on. However, compared to conventional therapy, computer gaming for movement therapy is still in its infancy. Studies on computer gaming are often feasibility or proof-of-concept studies. Randomized controlled trials (RCTs) typically have a small patient sample size (n= 10 or fewer), possibly due to the difficulty in recruiting a relatively “homogeneous” patient base for the intervention groups as well as the control groups. Frequency, duration and intensity of the gaming sessions were also highly variable between studies, ranging from 10 minutes to 2 hours, done on alternate days or on consecutive days. The patient population varied widely, both in age (ranging from 30 y.o. to 80 y.o.) and in time elapsed since the initial stroke (from 3 months to 7 years). As computer gaming for movement therapy becomes more accepted, it is expected that large-scale RCTs will be conducted, leading to the emergence of better guidelines for clinicians.

Thomson et al. summarized the current evidence best in a 2014 article in The International Journal of Stroke². After performing a systematic review of 19 studies covering 215 participants, the authors concluded that there is currently limited evidence that commercial computer gaming results in positive impact on ADLs, upper-limb function, and movement. However, computer gaming can be beneficial as an adjunct modality to conventional therapy for post-stroke patients. Lastly, the vast majority of participants find enjoyment in the games and this may ultimately result in higher compliance with the intervention program. This “enjoyment” dimension is consistently reflected across several other studies.

An effective application of computer gaming in movement therapy can be seen in the following short video (total length: 4 mins) from Neuroscience Research Australia (NRA). Clinicians at NRA are actively using Wii games to help post-stroke patients improve the range of motion of their upper extremities; of particular interest is the segment from 1:30 to 2:30, which shows 2 stroke patients before, and after, two weeks of computer-gaming therapy: Using Wii Gaming for Stroke Rehabilitation (the video will open up in a new window).

 

The Project

The UNC Physical Therapy Clinic in Hillsborough has a working Kinect system installed. I analyzed all 5 games included in the “Kinect Adventures” DVD (this DVD is included free of charge with every Kinect purchase). After I analyzed the games, I developed an algorithm for game selection, depending on the type of improvement desired. Some games require the player to perform numerous UE movements, others require more weightshifting or side-stepping, and others still focus on LE movements. I developed a flowchart to guide game selection; for example, if the patient needs rehabilitation of his UEs but does not possess good balance, then game A is recommended; if the patient does have good balance, then game B should be played. The game analysis and recommendations, along with instructions on how to properly set up the Kinect, can be found in a binder in the “Kinect room” at the clinic. I have also included some game tips that could be useful for post-stroke patients as they play the games. Setting up the Kinect is a relatively short process (approximately 3 minutes), and the system can be paused between patients.

 

Self-Assessment

This project has helped me learn how to introduce software that is commercially available into a clinical environment. While avatar-based computer games were certainly not designed for movement therapy with post-stroke patients, they can be adapted to serve that goal. “Workarounds” exist for patients who have limitations: all the Kinect games are available at different levels of difficulty, with the lower levels offering a slower pace and easier-scoring moves. Additionally, many games can be played with the player sitting down in a chair, such as “RallyBall”.

 

Acknowledgements

I would like to thank Karen for helping me refine the original topic, Prue for pointing me in the right direction, Mary Beth for providing feedback on the material that I produced, and my classmate Jonathan Samuelson for his tips and tricks when using the Kinect.

 

References

1. Pietrzak E., Cotea C., Pullman S. Using commercial video games for upper limb stroke rehabilitation: is this the way of the future? Top Stroke Rehabil. 2014;21(2):152-162
2. Thomson, K., Pollock, A., Bugge, C. et al. Commercial gaming devices for stroke upper limb rehabilitation: A systematic review. International Journal of Stroke. Vol 9, June 2014, 479–488

I have also extensively drawn on the articles listed below when researching and completing the project. My evidence table can be found at this link.

Bower K. J., Clark R., McGinley J., et al. Clinical feasibility of the Nintendo Wii for balance training post-stroke: a phase II randomized controlled trial in an inpatient setting. Clin Rehabil. 2014

Chen M-H., Huang L-L., Lee C-F., et al. A controlled pilot trial of two commercial video games for rehabilitation of arm function after stroke. Clin Rehabil. 2014

Fritz S., Peters D., Merlo A., Donley, J. Active video-gaming effects on balance and mobility in individuals with chronic stroke: a randomized controlled trial. Top Stroke Rehabil. 2013;20(3):218-225

Joo L., Yin T., Xu D., et al. A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. J Rehabil Med. 2010;42(5):437-441

Lee, G. Effects of training using video games on the muscle strength, muscle tone, and activities of daily living of chronic stroke patients. J Phys Ther Sci. 2013;25(5):595-597

Morone G., Tramontano M., Iosa M., et al. The efficacy of balance training with video game-based therapy in subacute stroke patients: A randomized controlled trial. Biomed Res Int. 2014;2014:1-6

Mouawad M., Doust C, Max M., McNulty P. Wii-based movement therapy to promote improved upper extremity function post-stroke: A pilot study. J Rehabil Med. 2011;43(6):527-533

Rand D., Givon N., Weingarden H., et al. Eliciting Upper Extremity Purposeful Movements Using Video Games: A Comparison With Traditional Therapy for Stroke Rehabilitation. Neurorehabil Neural Repair. (2014)

Saposnik G., Teasell R., Mamdani M., et al. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: A pilot randomized clinical trial and proof of principle. Stroke. 2010;41(7):1477-1484

Saposnik G, Levin M. Virtual reality in stroke rehabilitation: A meta-analysis and implications for clinicians. Stroke. 2011;42(5):1380-1386

Sin H., Lee G. Additional Virtual Reality Training Using Xbox Kinect in Stroke Survivors with Hemiplegia. Am J Phys Med Rehabil. 2013;92:871-880