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Gaming in Stroke Rehabilitation

Gaming in Stroke Rehabilitation
Deborah Espy, PT, PhD
July 7, 2016

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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...

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deborah espy

Deborah Espy, PT, PhD

Debbie Espy, PT, PhD received her MSPT from Virginia Commonwealth University in 1992 and her PhD in Human Movement Science from the University of Illinois at Chicago in 2010.  She has practiced in the areas of acute care, neuro rehab and outpatient, and assistive technology before taking a faculty position at Cleveland State University, where she is currently an Assistant Professor in the Physical Therapy Program.  She teaches courses in Professional Issues, Functional Anatomy, Adult Neurological Dysfunction, and Neuro-motor Interventions.  Her research interests are in the areas of motor learning, and postural control and falls.  Her current lines of research are in the use of video gaming as a therapeutic exercise modality; in novel uses of sensor technology in therapeutic exercise; in balance training for fall prevention; and in educational models to enhance DPT education.  
 



Related Courses

Gaming in Stroke Rehabilitation
Presented by Deborah Espy, PT, PhD
Recorded Webinar
Course: #2431Level: Intermediate2 Hours
This course presents evidence for the issues and advantages of gaming in therapy for stroke rehab, and presents a framework to guide clinical decision making in game selection, modification, and progression for games used to address mobility, movement, balance and motor re-learning goals for individuals who have had a stroke. Current research related to gaming in stroke rehabilitation will be reviewed as will cases illustrating the use of the framework to design and advance interventions in various phases of stroke rehab. This course is directly related to the practice of physical therapy and athletic training and therefore appropriate for Physical Therapists, Physical Therapist Assistants and Athletic Trainers.

Put Down the Drugs: Evidence-Based Interventions to Reduce Unwanted Behaviors with Dementia
Presented by Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP
Recorded Webinar
Course: #3072Level: Intermediate1 Hour
PTs can apply evidence-based interventions to improve dementia care. This session reviews the etiology of common behaviors. Cognitive-emotion, multi-sensory, animal-assisted, and exercise interventions to reduce agitation are discussed as well as specific strategies for improving task-related engagement. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

Strategies for Treating Patients With Neurobehavioral Disorders
Presented by Kelli Broussard, MS, CCC-SLP, Kelly Ramsey, MS, CCC-SLP
Recorded Webinar
Course: #3074Level: Introductory2 Hours
This course will provide an overview of neurobehavioral disorders and their impact on function and community re-entry. The course will provide functional strategies to improve the effectiveness of treatment sessions when working with individuals who have behavioral deficits. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

Physical Rehabilitation Following Traumatic Brain Injury
Presented by Jill Seale, PT, PhD, NCS
Recorded Webinar
Course: #3080Level: Intermediate2 Hours
This course will provide an overview of physical rehabilitation for persons with traumatic brain injury (TBI) across the continuum of care. Evidence based interventions for both Occupational Therapy and Physical Therapy will be reviewed, along with information for referral to the most appropriate level of care. This course is directly related to the practice of physical therapy and athletic training and is therefore appropriate for the PT/PTA and AT.

The Science of Fall Prevention
Presented by Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST, FAPTA
Recorded Webinar
Course: #2825Level: Intermediate2 Hours
What is the difference between screening and testing? What is the science of imbalance? What are the differences between unsteadiness, imbalance, dizziness, lightheadedness, and vertigo? How do I document to prove my worth, my role, or this patient’s potential? What is the evidence for helping someone improve balance? What is the best method to select the most sensitive and responsive balance test for each patient? What psychological influences could be involved with this person? The answers to these questions and more are in this seminar intended for advanced dizziness management- differential diagnostics and treatment. Expect practical techniques, readily applied to the clinic, incorporating current evidence and revealing future advances in balance and dizziness rehabilitation. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

Editor's Note: Regarding Pennsylvania credits, this course is approved by the PA State Board of Physical Therapy for 1 hour of general and 1 hour of Direct Access CE credit.