Video game rehabilitation

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Video game rehabilitation
Other namesgaming rehabilitation

Video game rehabilitation is a process of using common video game consoles and methodology to target and improve physical and mental weaknesses through therapeutic processes. Video games are becoming an integral part of occupational therapy practice in acute, rehabilitation, and community settings. [1] The design for video games in rehabilitation is focused on a number of fundamental principles, such as reward, goals, challenge, and meaningful play. 'Meaningful play' emerges from the relationship between player action and system outcome, apparent to the player through, visual, physical and aural feedback. [2] Platforms that feature motion control, notably the Nintendo Wii, Microsoft's Xbox Kinect, Sony's Eye Toy, and virtual reality have all been effective in this field of research. Methodologies have been applied to all age groups, from toddlers to the elderly. It has been used in a variety of cases ranging from stroke rehabilitation, cerebral palsy and other neurological impairments, to tendinitis and multiple sclerosis. Researchers have promoted such technology based on the personalization of gaming systems to patients, allowing for further engagement and interaction. Additionally, gaming consoles have the ability to capture real-time data and provide instant feedback to the patients using the systems. Currently, several researchers have performed case studies to demonstrate the benefits of this technology. Repeat trials and experiments have shown that outcomes are easily replicated among various groups worldwide. Additionally, the outcomes have increased interest in the field, growing experiments beyond simple case studies to experiments with a larger participant base.

Contents

History

Since the early 1980s, there has been evidence in the literature of commercially available video games used for therapeutic purpose for different patients. The use of virtual feedback has been seen scattered throughout history for quite some time. However, though the feedback was virtual, the performances were not widely virtual until the 1990s. [3] With the early-stage experimentation, not many positive results were found causing some doubt of the systems. Some even found that too much virtual feedback increased poor performance outside of the controlled environment. [4] As virtual reality systems and virtual environments became more accessible and affordable, though, so too did the implementations of and research on them. The use of these systems in positive motor skill development began somewhere in the late 1990s as more researchers realized the benefit of internal, corrective feedback in such environments. [5] Additionally, at the same time, researchers across the world began experimenting with the effect of virtual reality in therapeutic measures for anxiety disorder and phobias. [6] With positive results, such as better motor control and lower anxiety in relation to phobias, coming from these experiments, researchers began looking into virtual reality systems as a form of rehabilitation in the early 2000s, and the research has expanded since. Now, common gaming consoles such as the Wii and Kinect allow researchers to use cheaper, more readily available systems in their labs, as well, opening up new possibilities for games and rehabilitation options. Case studies and use of systems in actual therapy offices have suggested that this field has the potential to impact therapy outside the lab setting, as well, making it a rapidly growing field of interest. Currently, several reviews of the findings have also suggested positive effects of this form of rehabilitation, garnering support for this field as well. [7]

Several studies have been conducted regarding the potential of applying virtual reality to different therapies. A systematic literature review published in 2012 analyzed 963 publications regarding virtual reality and rehabilitation from 1996 and 2010. Investigators found an increasing number of research done in the field yearly, from less than 10 articles per year in 1997 to more than 40 in 2010. More than the number of articles analyzed, this literature review found important issues to be addressed in future studies: i) the need to consider a greater number of participants in each study to best represent the target populations; ii) to improve the use of control groups; iii) to enhance the uniformity of the tests applied and iv) to execute more follow-up studies in the field. These aspects would allow the comparison among different studies and the conceptualization of the results from different studies. Lastly, this investigation cites the importance of research in the field of virtual reality and rehabilitation, once the potential of this technology is recognized to support the neural and cognitive rehabilitation of different patients. [8]

Rehabilitation through gaming vs. regular methods

Throughout its development, gaming in rehabilitation has gained a large amount of support for its differences in comparison to regular therapeutic methods. The biggest of these differences is the user engagement and enjoyment. It has been extensively shown that people feel more engaged in a gaming environment and less contained in a doctors office when interacting in a virtual reality, gaming environment. [9] Additionally, those who are able to participate in gaming rehabilitation have also been shown to use less energy than those participating in normal therapeutic methods. While this may not be positive for all patients, this is beneficial for those patients who may be elderly or have minimal energy to expend in therapy-type settings. [9] Saving energy while still participating in therapy has proven effective for these groups of people, since they are still able to progress in their goals towards rehabilitation, but not over-work themselves in the process. On the other hand, normal physical rehabilitation routine requires commitment to lengthy periods of difficult exercise which causes the patient to drop out of the therapy routines. Rehabilitation through gaming provides the opportunity to address two important areas: accessibility of rehabilitation and patient motivation. [10]

The ability for gaming consoles to exist anywhere and be purchased by anyone also allows this sort of therapy to be quite personalized to the patient. Patients who use gaming rehabilitation have been shown to be more engaged in the therapy efforts and more likely to continue their therapy outside of the doctor's office than those engaging in regular therapeutic efforts. [11] Being able to bring their therapy into the comfort of their own home and at a relatively low cost contributes to these outcomes. Additionally, as a result of their increased adherence to therapy and motivation to engage in therapy, patients who engage in gaming rehabilitation have also shown improved outcomes of their efforts. [12]

Another benefit to using games for rehabilitation purposes is that they have the ability to be customized to real-life scenarios more so than typical therapy methods do. When asked about their therapy, patients have reported that they don't see the relation to their every-day life when performing the activities. Instead, they see it as an activity they do simply in their doctor's office, away from their regular life. [13] Virtual reality-based rehabilitation has the ability to be designed to introduce real-life challenges and every-day hurdles that can be seen in the real world. They're tailored to the needs of the individuals and to the environment that they are expected to encounter on a regular basis. This consideration contributes to the "ecological validity" of the rehabilitation method. [13] With gaming through rehabilitation, medical doctors have witnessed cancer patients who utilize video games during procedures have a lower pain tolerance when using an active distraction vs, a passive distraction. [14]

Typical rehabilitation methods have also been seen to present difficulties to those participating in them. At times these difficulties keep anywhere from 30%–66% of people from reaching their goals for their therapy. [15] When the goals are not achieved people are generally made to participate in longer therapy sessions, more therapy sessions, or more in-depth and difficult sessions than before, such as constraint-induced movement therapy. In each of these cases, patients are generally forced to pay more than before and are also put through more work than they initially planned. It has been found through research, however, that virtual reality situations can likely increase a person's desire to participate in therapy and therefore increase their chances of reaching their therapy goals, unlike those left underachieved with regular methods.

Physical rehabilitation

The University of Essex conducted a study to evaluate the efficacy of including the Wii in an established falls prevention training program to improve balance, mobility, and educate recovery from the instance of a fall. After a 7-week falls prevention training, the results indicated that Wii can positively support a standard rehabilitation, although the use of the game alone would not be encouraged. On the other hand, participants found the experience of Wii game as enjoyable, which can support patients engagement to training. A follow-up longitudinal study would be needed to conclude if the incidence of falls can be reduced along time. [16] Extending this study, another research conducted by the same University of Essex found that training with Wii can imply on mood and self-esteem. This behavior was observed in women who participated in this last mentioned research for fall prevention. As said by investigators, it would not be appropriate to generalize, however one participant who had the biggest improvement on the functional measures had the largest positive changes in well-being, which may indicate that the use of the Wii as an adjunct to standard falls prevention training can improve not only functional but also psychological outcomes. [17] There are many advances in the physical rehabilitation community, advances such as technology has created a more effective and easier way for patients to approach their rehabilitation journey. [18]

Neurological rehabilitation

Several games have been created to support stroke rehabilitation and to alleviate boredom and frustration patients can face with frequent visits to the therapeutic centers. The gaming therapy can be prescribed by physicians, physical or speech therapists to support the recovery of the damaged muscles and the brain to re-learn to control the damaged movements. As an example, 'Circus Challenge', created by Newcastle University scientists, is a Wii based game developed specifically to support hands and arms' muscles recovery. [19] Also,Wii Sports in Video Game Rehabilitation benefit the patient's recovery and provide motivation for alternative leisure actives. [20] The difficulty of the game is increased as the patient recovers, and their progress can be tracked by therapists.

Also to support the recovery of upper extremity muscles, ARMStrokes was recently introduced as a mobile app to help stroke survivors to complete their rehabilitation exercises. The game is a real-time application that provides a communication platform to facilitate interaction of patients with their therapists or physicians. Research to evaluate if this technology can positively impact the stroke recovery process is currently underway. [21]

Cerebral palsy has also been target of using games to support both children and adults affected by this disorder. Research has indicated that children with cerebral palsy can benefit from Wii games such as jogging, bicycling, snowboarding, and skiing to increase their physical activity levels. This physical activity can be challenging and limited to these children due to accessibility problems that financial and societal barriers impose, such as a lack of equipment or availability of exercise instructors, and even transportation issues. [22] While there is great interest in using video game rehabilitation with children with cerebral palsy, it is difficult to compare outcomes between studies, and therefore to reach evidence-based conclusions on its effectiveness. [23] Because video gaming is popular, it may help children's motivation to continue with the therapy.[ citation needed ] There is moderate evidence for improvements with balance and motor skills in children and teens, but it is not recommended as an effective therapy. [24] One invention aimed towards Cerebral Palsy patients is THE ORBIT Gaming System which improves Cerebral Palsy patients with hand impairments. The orbit Gaming System contains the results of utilizing both hands to physically trains the patients strength in their hands while creating a fun environment for recovery. [25]

Mobile phone applications

Expanding outside of virtual reality and gaming systems, a newer segment of video game rehabilitation focuses on games that can be played on mobile phones or tablet computers - mobile apps. While these are not necessarily the standard video gaming console, these are being seen more frequently as alternatives with the introduction of more and more smart phones in the market. As such, researchers have recently begun to experiment with how mobile phone applications can also contribute to rehabilitation measures. While still relatively new, this concept has shown to be effective in wrist and hand rehabilitation on multiple different occasions. Wrist rehabilitation through a droid-based game, for example, revealed that patients can have more flexibility in their therapy sessions by keeping track of their progress on their phone and taking exercises home with them. [26] It was also found that they could create a more customized therapy session through use of a patient's mobile device. Increasing finger use after a stroke is another area this methodology has proven effective for. In this case, the common mobile app, Fruit Ninja, was used to track patient use of their fingers and control of their hand when making fine movements such as cutting a fruit in the game. [27] Positive results suggested that a patient's interaction with the game could determine and complement other therapy methods being used. Evidence in studies show that these types of game systems (apps and haptic devices are effective in the rehabilitation process. [28]

Results

The Wii Balance Board, which is bundled with Wii Fit, measures both a person's weight and center of balance. Wii Balance Board.JPG
The Wii Balance Board, which is bundled with Wii Fit, measures both a person's weight and center of balance.

Timed Up and Go test (TUG) scores have been seen to improve after having engaged in gaming rehabilitation. Several studies have produced output that suggests that Wii games are able to effectively increase patients' scores after a certain period of rehabilitation through them. [29] [30] Stroke recovery patients and patients with an Acquired brain injury are two such examples of this output. Both patient classes have been shown to display slightly better improvements when using the Wii game or Wii balance board than when engaging in regular therapeutic methodologies. Continuing past these classes, studies are continually proving that these scores can be increased in a variety of patients with a variety of physical disabilities and from a variety of backgrounds.

In recent studies, professionals have proven that the therapist and patient create a positive relationship during physical rehabilitation with video games. [31]

Balance and energy expenditure are other great improvements seen amongst patients of gaming rehabilitation methods. Methods such as using the Wii Fit board and Wii Sports games have proven effective at increasing these numbers amongst a variety of patients. Elderly and cerebral palsy patients have been the focus of these outputs, as both have the ability to improve these categories of their lives. Specifically, elderly have been shown to display poor balance and mobility due to aging conditions, resulting in a need for rehabilitation intervention [32] [33] and cerebral palsy patients display a combination of poor posture and poor balance which result in a need for therapy, as well. [34] [35] Both, after a period of engaging in a variety of Wii-based games, have shown improvement comparable to, or better than, what they display during regular methodologies, gaining support for these systems. Specifically, for the elderly community, interactive video-game based system exercise on the balance can improve balance after 6 weeks of implementation [36] Elderly patients with Parkinson's disease showed improved performance in activities of daily living after 14 sessions of balance training, with no additional advantages associated with the Wii-based motor and cognitive training. [37]

Finally, motor-skill rehabilitation has been proposed as another possible way in which games can be used for rehabilitation purposes. Stroke patients with upper extremity motor difficulties have been the primary focus of this subject and, in this case, a variety of gaming environments have been experimented with. Output has shown that their Fugl-Meyer UE scores and their Functional Independence Measure scale score increase after a period of engaging in virtual rehabilitation, suggesting that their mobility dysfunction decreased and their degree of independence increased due to the intervention. [38] Additionally, output has suggested improved motor skills on a higher level, having several researchers suggesting positive improvements in their stroke patients as a result of virtual rehabilitation methods. [39] At this higher level, researchers have suggested improved ability to walk, or ambulation, and improved use of larger motor skills after intervention. One other class of patients that has been studied less frequently in this category of rehabilitation is cerebral palsy patients. Ability to walk certain distances without the use of an assistive device was the method of measurement for this category. After a period of working with a Wii-based system, it was shown that a patient who struggled with walking large distances before, was able to walk a noticeably longer distance. [34] This suggests an improvement in larger motor skills, whereas the stroke patients demonstrated an improvement in finer motor skills, focused strictly on their use of upper extremities during the gaming rehabilitation.

Negative results

If by one hand rehabilitation through gaming may be beneficial since it can improve motivation to the rehabilitation and reduce distraction from the routine of a tedious medical treatment, injuries arisen from excessive gameplay have been occasionally reported, such as tendonitis, dislocation of patella or hand laceration. A recent study proves that when incorporating video games into a patient's therapy routine can increase their chance of developing musculoskeletal. [40] Although these injuries might be occasional or rare, a large scale study would be needed to investigate the occurrence of these damages facing the millions of users of games worldwide. [41]

It's also been suggested that the use of gaming systems for home-based rehabilitation may promote a lack of communication between the therapist and the patient. [42] [43] In these cases, it is difficult to track the progress of the patient appropriately, and the effects of the therapy are unknown. It's also possible in these scenarios that a lack of tracking also increases time spent on task, since the therapist does not properly see what level the patient is performing at. Another challenge in video game rehabilitation, can result to lack of computer skills on the part of therapists, lack of support infrastructure, expensive equipment, inadequate communication infrastructure, and patient safety concerns. [44]

Additionally, common effects of virtual reality environments, such as dizziness, nausea, and disorientation, have also been found to result in the case of rehabilitation through these methodologies. As these scenarios work the same as other virtual reality scenarios, they are not exempt from the negative results that can be seen across the board from these sorts of systems, and patients have shown this to be evident. Virtual reality systems have also proven difficult to maintain and sanitize after use, which has caused some to stray away from their use and stick to regular methodologies instead. [45]

Finally, gaming technology is believed to promote physical activity on clinical populations with multiple sclerosis, although there is no consensus about training duration, intensity or outcomes used to assess the clinical effectiveness, which suggests that randomized controlled trial should be carried out comparing gaming technology to traditional exercise for this population. [46] Similarly, the same can be said with results in the field of video game rehabilitation with elderly patients. While there are consensus's being built, there are still some results that seem insignificant in their findings and remain inconclusive either way. [33] There is not much data available about adverse results such as falls when using video games as part of rehabilitation. [47]

Theories

In the next 100 years, researchers believe technology will be at the heart of occupational therapy as a fundamental part of human occupation and the human experience. Moving in the future, technology will grow stronger and stronger and will emerge deeply into the occupational career. Video game rehabilitation will take over the occupation career and what it used to be. [48]

See also

Related Research Articles

Hemiparesis, or unilateral paresis, is weakness of one entire side of the body. Hemiplegia is, in its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused by different medical conditions, including congenital causes, trauma, tumors, or stroke.

<span class="mw-page-title-main">Cerebral palsy</span> Group of movement disorders that appear in early childhood

Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensation, vision, hearing, and speaking. Often, babies with cerebral palsy do not roll over, sit, crawl or walk as early as other children of their age. Other symptoms include seizures and problems with thinking or reasoning, each of which occur in about one-third of people with CP. While symptoms may get more noticeable over the first few years of life, underlying problems do not worsen over time.

Spasticity is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles.

<span class="mw-page-title-main">Kinesiology</span> Study of human body movement

Kinesiology is the scientific study of human body movement. Kinesiology addresses physiological, anatomical, biomechanical, pathological, neuropsychological principles and mechanisms of movement. Applications of kinesiology to human health include biomechanics and orthopedics; strength and conditioning; sport psychology; motor control; skill acquisition and motor learning; methods of rehabilitation, such as physical and occupational therapy; and sport and exercise physiology. Studies of human and animal motion include measures from motion tracking systems, electrophysiology of muscle and brain activity, various methods for monitoring physiological function, and other behavioral and cognitive research techniques.

The primary goals of stroke management are to reduce brain injury and promote maximum patient recovery. Rapid detection and appropriate emergency medical care are essential for optimizing health outcomes. When available, patients are admitted to an acute stroke unit for treatment. These units specialize in providing medical and surgical care aimed at stabilizing the patient's medical status. Standardized assessments are also performed to aid in the development of an appropriate care plan. Current research suggests that stroke units may be effective in reducing in-hospital fatality rates and the length of hospital stays.

The Bobath concept is an approach to neurological rehabilitation that is applied in patient assessment and treatment. The goal of applying the Bobath concept is to promote motor learning for efficient motor control in various environments, thereby improving participation and function. This is done through specific patient handling skills to guide patients through the initiation and completing of intended tasks. This approach to neurological rehabilitation is multidisciplinary, primarily involving physiotherapists, occupational therapists, and speech and language therapists. In the United States, the Bobath concept is also known as 'neuro-developmental treatment' (NDT).

<span class="mw-page-title-main">Mirror therapy</span> Treatment for some kinds of pain

Mirror therapy (MT) or mirror visual feedback (MVF) is a therapy for pain or disability that affects one side of the patient more than the other side. It was invented by Vilayanur S. Ramachandran to treat post-amputation patients who had phantom limb pain (PLP). Ramachandran created a visual illusion of two intact limbs by putting the patient's affected limb into a "mirror box," with a mirror down the center.

<span class="mw-page-title-main">Fitness game</span> Video games that are also a form of exercise

Fitness game, exergame, and gamercise are terms used for video games that are also a form of exercise. Fitness games rely on technology that tracks body movement or reaction. The genre has been used to challenge the stereotype of gaming as a sedentary activity, and promoting an active lifestyle. Fitness games are seen as evolving from technology aimed at making exercise more fun.

Monoplegia is paralysis of a single limb, usually an arm. Common symptoms associated with monoplegic patients are weakness, numbness, and pain in the affected limb. Monoplegia is a type of paralysis that falls under hemiplegia. While hemiplegia is paralysis of half of the body, monoplegia is localized to a single limb or to a specific region of the body. Monoplegia of the upper limb is sometimes referred to as brachial monoplegia, and that of the lower limb is called crural monoplegia. Monoplegia in the lower extremities is not as common of an occurrence as in the upper extremities. Monoparesis is a similar, but less severe, condition because one limb is very weak, not paralyzed. For more information, see paresis.

Cerebellar ataxia is a form of ataxia originating in the cerebellum. Non-progressive congenital ataxia (NPCA) is a classical presentation of cerebral ataxias.

<span class="mw-page-title-main">Telerehabilitation</span> Delivery of rehabilitation services over the internet

Telerehabilitation (or e-rehabilitation is the delivery of rehabilitation services over telecommunication networks and the internet. Telerehabilitation allows patients to interact with providers remotely and can be used both to assess patients and to deliver therapy. Fields of medicine that utilize telerehabilitation include: physical therapy, occupational therapy, speech-language pathology, audiology, and psychology. Therapy sessions can be individual or community-based. Types of therapy available include motor training exercises, speech therapy, virtual reality, robotic therapy, goal setting, and group exercise.

Virtual reality therapy (VRT), also known as virtual reality immersion therapy (VRIT), simulation for therapy (SFT), virtual reality exposure therapy (VRET), and computerized CBT (CCBT), is the use of virtual reality technology for psychological or occupational therapy and in affecting virtual rehabilitation. Patients receiving virtual reality therapy navigate through digitally created environments and complete specially designed tasks often tailored to treat a specific ailment; and is designed to isolate the user from their surrounding sensory inputs and give the illusion of immersion inside a computer-generated, interactive virtual environment. This technology has a demonstrated clinical benefit as an adjunctive analgesic during burn wound dressing and other painful medical procedures. Technology can range from a simple PC and keyboard setup, to a modern virtual reality headset. It is widely used as an alternative form of exposure therapy, in which patients interact with harmless virtual representations of traumatic stimuli in order to reduce fear responses. It has proven to be especially effective at treating PTSD, and shows considerable promise in treating a variety of neurological and physical conditions. Virtual reality therapy has also been used to help stroke patients regain muscle control, to treat other disorders such as body dysmorphia, and to improve social skills in those diagnosed with autism.

Virtual reality in telerehabilitation is a method used first in the training of musculoskeletal patients using asynchronous patient data uploading, and an internet video link. Subsequently, therapists using virtual reality-based telerehabilitation prescribe exercise routines via the web which are then accessed and executed by patients through a web browser. Therapists then monitor the patient's progress via the web and modify the therapy asynchronously without real-time interaction or training.

Neurorehabilitation is a complex medical process which aims to aid recovery from a nervous system injury, and to minimize and/or compensate for any functional alterations resulting from it.

Constraint-induced movement therapy is a form of rehabilitation therapy that improves upper extremity function in stroke and other central nervous system damage patients by increasing the use of their affected upper limb. Due to its high duration of treatment, the therapy has been found to frequently be infeasible when attempts have been made to apply it to clinical situations, and both patients and treating clinicians have reported poor compliance and concerns with patient safety. In the United States, the high duration of the therapy has also made the therapy not able to get reimbursed in most clinical environments.

<span class="mw-page-title-main">Management of cerebral palsy</span>

Over time, the approach to cerebral palsy management has shifted away from narrow attempts to fix individual physical problems – such as spasticity in a particular limb – to making such treatments part of a larger goal of maximizing the person's independence and community engagement. Much of childhood therapy is aimed at improving gait and walking. Approximately 60% of people with CP are able to walk independently or with aids at adulthood. However, the evidence base for the effectiveness of intervention programs reflecting the philosophy of independence has not yet caught up: effective interventions for body structures and functions have a strong evidence base, but evidence is lacking for effective interventions targeted toward participation, environment, or personal factors. There is also no good evidence to show that an intervention that is effective at the body-specific level will result in an improvement at the activity level, or vice versa. Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it.

Rehabilitation robotics is a field of research dedicated to understanding and augmenting rehabilitation through the application of robotic devices. Rehabilitation robotics includes development of robotic devices tailored for assisting different sensorimotor functions(e.g. arm, hand, leg, ankle), development of different schemes of assisting therapeutic training, and assessment of sensorimotor performance of patient; here, robots are used mainly as therapy aids instead of assistive devices. Rehabilitation using robotics is generally well tolerated by patients, and has been found to be an effective adjunct to therapy in individuals with motor impairments, especially due to stroke.

A gait trainer is a wheeled device that assists a person who is unable to walk independently to learn or relearn to walk safely and efficiently as part of gait training. Gait trainers are intended for children or adults with physical disabilities, to provide the opportunity to improve walking ability. A gait trainer offers both unweighting support and postural alignment to enable gait practice. It functions as a support walker and provides more assistance for balance and weight-bearing, than does a traditional rollator walker, or a walker with platform attachments. It also provides opportunities to stand and to bear weight in a safe, supported position.

<span class="mw-page-title-main">Adeli suit</span>

The ADELI Suit is derived from a suit originally designed for the Soviet space program in the late 1960s that was first tested in 1971. The purpose then was to give the cosmonauts in space a way to counter the effects of long-term weightlessness on the body. The ADELI Suit is currently used to treat children with physical disabilities resulting from cerebral palsy, other neurological conditions originating from brain damage or spinal cord injury.

Horseback riding simulators are intended to allow people to gain the benefits of therapeutic horseback riding or to gain skill and conditioning for equestrian activity while diminishing the issues of surrounding cost, availability, and individual comfort level around horses. Horseback therapy has been used by many types of therapists to advance their physical, mental, emotional, and social skills.

References

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