Therapeutic Games Research Articles

THERAPEUTIC SERIOUS GAME DESIGN GUIDELINES FOR STIMULATING COGNITIVE ABILITIES OF CHILDREN WITH SPEECH AND LANGUAGE DELAY

The creation of an effective therapeutic serious game (TSG) is highly dependent upon its design and the fundamental knowledge of the users. Furthermore, the TSG is designed for a purpose to the users by incorporating the needs of the users in all design components. Although numerous studies have been conducted on guidelines for designing serious games, to date, studies on the specific TSG’s design guidelines for stimulating the cognitive ability of children with speech and language delay (CSLD) has yet to be comprehensively studied. Therefore, this study focuses on the set of design guidelines for the development of TSG for CSLD, specifically on cognitive stimulation. The TSG design guidelines in this paper are derived through the study of relevant literature, and best practices gained from interviews with experts in the area of speech pathology. These guidelines would be useful for researchers and game designers to design TSG for CSLD focusing on cognitive stimulation.

Goal-oriented feedback on motor behavior in virtual reality based stroke therapy: A case study using the rehabilitation gaming system

Aims: We address the role of short-term goals in virtual reality (VR) applications for motor relearning, which benefit stroke therapy. Methods: We let stroke patients as well as healthy participants perform reaching tasks in a VR environment for motor rehabilitation, the so-called rehabilitation gaming system (RGS). During the task, patients were provided with feedback about one´s own performance (mastery goal), healthy participants additionally received feedback of others performances (ego goal). Measurements include protocols for motor learning and different kinetic variables (both stroke patients and healthy participants) as well as subscales of the intrinsic motivation inventory (IMI) (only healthy participants). As healthy participants showed lower fatigue levels, we could apply additional measurements. Result: Both mastery goals and ego goals potentially enhance intrinsic motivation and adherence, as they show to foster task performance (e.g., response time in mastery goals decreased with p = 0.014 for healthy participants, for stroke patients with p = 0.011 in the first iteration) as well as perceived effort (p = 0.007 for mastery, p = 0.008 for ego goals). As a secondary outcome, by controlling task difficulty, motor learning does not change across conditions (p = 0.316 for stroke patients, p = 0.323 for healthy participants). This raises the question whether or not task difficulty alone fosters the effectivity of VR based therapy applications, i.e., motor learning, to which motivators such as short-term goals provide little trade-off. Conclusion: Firstly, we suggest the implementation of mastery and ego goals in VR based stroke therapy, as adherence benefits from the motivational context they provide. Secondly, we argue towards simplicity regarding heuristics in therapeutic game design, which apparently often does not differ from conventional game design apart from setting the right level of challenge.

A Comparative Analysis of 2D and 3D Tasks for Virtual Reality Therapies Based on Robotic-Assisted Neurorehabilitation for Post-stroke Patients.

Post-stroke neurorehabilitation based on virtual therapies are performed completing repetitive exercises shown in visual electronic devices, whose content represents imaginary or daily life tasks. Currently, there are two ways of visualization of these task. 3D virtual environments are used to get a three dimensional space that represents the real world with a high level of detail, whose realism is determinated by the resolucion and fidelity of the objects of the task. Furthermore, 2D virtual environments are used to represent the tasks with a low degree of realism using techniques of bidimensional graphics. However, the type of visualization can influence the quality of perception of the task, affecting the patient's sensorimotor performance. The purpose of this paper was to evaluate if there were differences in patterns of kinematic movements when post-stroke patients performed a reach task viewing a virtual therapeutic game with two different type of visualization of virtual environment: 2D and 3D. Nine post-stroke patients have participated in the study receiving a virtual therapy assisted by PUPArm rehabilitation robot. Horizontal movements of the upper limb were performed to complete the aim of the tasks, which consist in reaching peripheral or perspective targets depending on the virtual environment shown. Various parameter types such as the maximum speed, reaction time, path length, or initial movement are analyzed from the data acquired objectively by the robotic device to evaluate the influence of the task visualization. At the end of the study, a usability survey was provided to each patient to analysis his/her satisfaction level. For all patients, the movement trajectories were enhanced when they completed the therapy. This fact suggests that patient's motor recovery was increased. Despite of the similarity in majority of the kinematic parameters, differences in reaction time and path length were higher using the 3D task. Regarding the success rates were very similar. In conclusion, the using of 2D environments in virtual therapy may be a more appropriate and comfortable way to perform tasks for upper limb rehabilitation of post-stroke patients, in terms of accuracy in order to effectuate optimal kinematic trajectories.

Joint-Specific Play Controller for Upper Extremity Therapy: Feasibility Study in Children With Wrist Impairment.

Challenges with any therapeutic program for children include the level of the child's engagement or adherence. Capitalizing on one of the primary learning avenues of children, play, the approach described in this article is to develop therapeutic toy and game controllers that require specific and repetitive joint movements to trigger toy/game activation. The goal of this study was to evaluate a specially designed wrist flexion and extension play controller in a cohort of children with upper extremity motor impairments (UEMIs). The aim was to understand the relationship among controller play activity, measures of wrist and forearm range of motion (ROM) and spasticity, and ratings of fun and difficulty. This was a cross-sectional study of 21 children (12 male, 9 female; 4-12 years of age) with UEMIs. All children participated in a structured in-clinic play session during which measurements of spasticity and ROM were collected. The children were fitted with the controller and played with 2 toys and 2 computer games for 5 minutes each. Wrist flexion and extension motion during play was recorded and analyzed. In addition, children rated the fun and difficulty of play. Flexion and extension goal movements were repeatedly achieved by children during the play session at an average frequency of 0.27 Hz. At this frequency, 15 minutes of play per day would result in approximately 1,700 targeted joint motions per week. Play activity was associated with ROM measures, specifically supination, but toy perception ratings of enjoyment and difficulty were not correlated with clinical measures. The reported results may not be representative of children with more severe UEMIs. These outcomes indicate that the therapeutic controllers elicited repetitive goal movements and were adaptable, enjoyable, and challenging for children of varying ages and UEMIs.

New Developments in Video Games for Psychotherapy

A literature survey on new developments in the area of video games and psychotherapy of children and adolescents was conducted. Despite the omnipresence of computers and the internet, development of therapeutic games seems rather slow. The video game Treasure Hunt was introduced in 2008 to support treatment of children with internalizing and externalizing disorders. Camp Cope-A-Lot was developed for treatment of anxious children, whereas the self-help game SPARX is directed at depressed adolescents. Rage-Control is a biofeedback game for children with anger problems. The game Zoo U aims to assess and train social skills of primary school children. Ricky and the Spider for young children with obsessive compulsive disorder is meant to support the cognitive-behavioural treatment of these patients. Clash- Back is a French game for adolescents with externalizing problems. Possible reasons for the relatively slow development of therapeutic games are the high methodological demands concerning an evaluation as well as the high costs of game development. Nonetheless, computers and the internet are bound to influence psychotherapy with children and adolescents in the long run.

An inclusive design approach for developing video games for children with Autism Spectrum Disorder

The efficacy of therapeutic treatments for Autism Spectrum Disorder is mainly associated with the treatment's intensity in terms of weekly hours. This has led mental health professionals to explore the use of video games to complement traditional treatments. However, major weaknesses have been found due to poor game design, which has failed to fulfill therapeutic objectives or to properly engage children. These weaknesses are typically characterized by the poor integration of knowledge from mental health experts, children's interests and designers' expertise. Starting from this necessity, we propose an inclusive design approach to develop therapeutic games. The method presents strategies to integrate the expertise of clinicians, contributions of children and experience of designers through a set of elicitation and merging techniques. The goal of this method is to design games that are effective in terms of therapeutic objectives and that are enjoyable for children. To describe this method, we present its application in the design and development of a Kinect-based game for high-functioning children with ASD called “Pico's Adventures”. This game aims at promoting social initiation in young children with autism. Findings from a first exploratory study with 10 children with ASD showed the effectiveness of the game in eliciting social initiation behaviors. This provides a first validation of the method. An essential aspect of the game's success was the use of elements and mechanics that were appealing for the children. As a result, we have identified effective design concepts and paths for further research on games for children with ASD.

Using health games for rehabilitation of patients with infantile cerebral palsy.

[Purpose] The purposes of this study were to evaluate whether the therapeutic games developed by the study team are significantly effective for upper limb rehabilitation of patients with cerebral palsy and to assess the development of the games and the evolution of patients throughout the therapy sessions. [Subjects and Methods] This study demonstrates the results of using therapeutic games in patients with infantile cerebral palsy. The therapies were performed in 30-minute sessions for about 1 to 4 months. This study shows the progress of five children with cerebral palsy during the sessions. The time it took the children on each road and the times required to complete a task were measured. In addition, the level of difficulty of the games was gradually increased at each session. [Results] Results have shown good progress on the accuracy of the movements and an increase in concentration level during the execution of the games, showing an improvement in the patients’ performance by 40–55% faster. [Conclusions] Health games encourage children to comply with therapy. The advantage of the game is that the patient can perform the therapy at home, which could help achieve further progress in patients.

Novel Virtual Environment for Alternative Treatment of Children with Cerebral Palsy.

Cerebral palsy is a severe condition usually caused by decreased brain oxygenation during pregnancy, at birth or soon after birth. Conventional treatments for cerebral palsy are often tiresome and expensive, leading patients to quit treatment. In this paper, we describe a virtual environment for patients to engage in a playful therapeutic game for neuropsychomotor rehabilitation, based on the experience of the occupational therapy program of the Nucleus for Integrated Medical Assistance (NAMI) at the University of Fortaleza, Brazil. Integration between patient and virtual environment occurs through the hand motion sensor “Leap Motion,” plus the electroencephalographic sensor “MindWave,” responsible for measuring attention levels during task execution. To evaluate the virtual environment, eight clinical experts on cerebral palsy were subjected to a questionnaire regarding the potential of the experimental virtual environment to promote cognitive and motor rehabilitation, as well as the potential of the treatment to enhance risks and/or negatively influence the patient's development. Based on the very positive appraisal of the experts, we propose that the experimental virtual environment is a promising alternative tool for the rehabilitation of children with cerebral palsy.

Personas-Driven Design for Mental Health Therapeutic Applications

Digital applications for mental therapy can support the rehabilitation treatments and help patients to motivate themselves, understand and persist in therapeutic practices. Although the importance and use of these software systems continue to increase, the literature does not specify a consolidated methodology to design such applications. This paper describes a participatory process to enrich Personas, aiming to characterize the intended audience of therapeutic applications in the context of mental health. Moreover, the paper presents how the information obtained in the process can aid on therapeutic games design aiming to support the rehabilitation of chemical dependent and depressive patients.

Software framework for sensor-based therapy games

We expect that the proposed framework and game development cycle will simplify interdisciplinary therapy game development by providing a unified platform for team members to contribute to and routinely bring state-of-the-art game technology to therapeutic games.

WS05.4 Video games for positive expiratory pressure (PEP) therapy in children with cystic fibrosis: A pilot study

Background Adherence to respiratory physiotherapy is a major challenge in children with cystic fibrosis (CF). Video games have shown promising results in improving adherence to treatment in chronic diseases. However, the feasibility of adapting video games to positive expiratory pressure (PEP) therapy in CF has not been explored. Hypothesis Therapeutic games can be adapted to PEP therapy. Methods In collaboration with students in the game design program of University of Montreal, we developed and adapted 3 video games to the parameters of PEP therapy (6 series of 15 respirations). The PARI's PEP S™ device was connected to a computer by a pressure sensor. Ten children (5 girls, 5 boys) between the age of 8 and 10 tested the video games on one occasion during PEP therapy under the supervision of the physical therapist of the CHU Sainte-Justine CF clinic. Questionnaires were completed before and after the trial by all participants which consisted of their overall evaluation of the games, their interest in pursuing the video games at home and whether they believe the games may improve adherence to PEP therapy. Results The PARI's PEP S™ device was successfully connected to a computer and all PEP parameters were monitored adequately. Nine children (9/10) were very interested in pursuing the video games while doing their PEP therapy at home. All of them thought that the games were well adapted to the PEP therapy and that it may improve their adherence to the treatment. Conclusion Video games can be adapted to PEP therapy. A second study is currently being planned to investigate whether video games may improve adherence to respiratory physiotherapy in children with CF.

Structured Therapeutic Games for Nonoffending Caregivers of Children Who Have Experienced Sexual Abuse

Game-based cognitive-behavioral therapy group model for nonoffending caregivers utilizes structured therapeutic games to assist parents following child sexual abuse. Game-based cognitive-behavioral therapy group model is a manualized group treatment approach that integrates evidence-based cognitive-behavioral therapy components with structured play therapy to teach parenting and coping skills, provide psychoeducation, and process trauma. Structured therapeutic games were designed to allow nonoffending caregivers to process their children’s abuse experiences and learn skills necessary to overcome trauma in a nonthreatening, fun, and engaging manner. The implementation of these techniques allow clinicians to address a variety of psychosocial difficulties that are commonly found among nonoffending caregivers of children who have experienced sexual abuse. In addition, structured therapeutic games help caregivers develop strengths and abilities that they can use to help their children cope with abuse and trauma and facilitates the development of positive posttraumatic growth. Techniques and procedures for treatment delivery along with a description of core components and therapeutic modules are discussed. An illustrative case study is provided.

A Therapeutic Exercise Game System with a “Tailor-made Video-game Image” That Accommodates Anyone Irrespective of Athletic Ability

A Therapeutic Exercise Game System with a “Tailor-made Video-game Image” That Accommodates Anyone Irrespective of Athletic Ability

Novel integrative virtual rehabilitation reduces symptomatology of primary progressive aphasia - a case report

Purpose: BrightBrainer™ integrative cognitive rehabilitation system evaluation in an Adult Day Program by a subject with Primary Progressive Aphasia (PPA) assumed to be of the mixed nonfluent/logopenic variant, and for determination of potential benefits. Methods: The subject was a 51-year-old Caucasian male diagnosed with PPA who had attended an Adult Day Program for 18 months prior to BrightBrainer training. The subject interacted with therapeutic games using a controller that measured 3D hand movements and flexion of both index fingers. The computer simulations adapted difficulty level based on task performance; results were stored on a remote server. The clinical trial consisted of 16 sessions, twice/week for 8 weeks. The subject was evaluated through neuropsychological measures, therapy notes and caregiver feedback forms. Results: Neuropsychological testing indicated no depression (BDI 0) and severe dementia (BIMS 1 and MMSE 3). The 6.5 h of therapy consisted of games targeting Language comprehension; Executive functions; Focusing; Short-term memory; and Immediate/working memory. The subject attained the highest difficulty level in all-but-one game, while averaging 1300-arm task-oriented active movement repetitions and 320 index finger flexion movements per session. While neuropsychological testing showed no benefits, the caregiver reported strong improvements in verbal responses, vocabulary use, speaking in complete sentences, following one-step directions and participating in daily activities. This corroborated well with therapy notes. Conclusions: Preliminary findings demonstrate a meaningful reduction of PPA symptoms for the subject, suggesting follow-up imaging studies to detail neuronal changes induced by BrightBrainer system and controlled studies with a sufficiently large number of PPA subjects.

Reducing Compensatory Motions in Motion-Based Video Games for Stroke Rehabilitation

Stroke survivors’ unsupervised therapeutic exercise motions are often accompanied by harmful compensatory motions that prevent proper motor recovery and introduce additional health issues. These compensatory motions are often performed unconsciously and are difficult to prevent. Motion-based games show promise for motivating patients to perform stroke rehabilitation exercises at home by themselves. Currently, exercises with these games are likely to contain undesired compensatory motions. In this article, we provide the design and empirical evaluation of a motion-based game system that addresses the issue of compensation in therapeutic games. We introduce a technique to identify and measure compensation, develop a game that meaningfully uses exercise and compensation as inputs, and use incentives and disincentives to reduce compensation. We show that this technique outperforms existing approaches by significantly reducing compensatory motions during therapeutic exercise. This has important implications for therapeutic games, which can use our findings to improve the quality of motions to be closer to therapist-supervised motions. Our techniques can increase the effectiveness of therapeutic games and reduce the possibility that they may cause harm in long-term use.

Integration of Biofeedback into Pediatric Multidisciplinary Programs at Children's Mercy Hospital Kansas City

Research supports multidisciplinary care as an efficacious, and cost-effective approach for treating pain.An interdisciplinary approach to treatment for chronic pain in children and adolescents has been successfully implemented at Children's Mercy Hospital Kansas City. The hospital has supported the establishment and growth of an Integrative Pain Management Team (IPMT), an Abdominal Pain Program (APP), and recently has added multidisciplinary teams that deal with a variety of difficult, chronic gastrointestinal issues. Biofeedback-assisted relaxation training (BART) has been integrated into the Abdominal Pain and Integrative Pain Management programs and is a valued component of their comprehensive treatment care plans. A description of current biofeedback training protocols, training modalities, therapeutic games, and home practice tools is provided.

Book Review: Therapeutic games and guided imagery Volume II: Tools for professionals working with children and adolescents with specific needs and in multicultural settings

Book Review: <i>Therapeutic games and guided imagery Volume II: Tools for professionals working with children and adolescents with specific needs and in multicultural settings</i>

PocketPT – A Personalized Therapeutic Game Platform

AbstractConsumer gaming platforms such as the Nintendo Wii and Xbox Kinect have been used for therapeutic purposes with varying levels of success. One limitation is the fact that most commercially available video games are designed for the general population and are often overwhelming and difficult for patients to use that present with motor and cognitive impairments as a result of brain injury. Specialized therapeutic medical devices are not only expensive and non-portable, they also make limited use of video games features to better engage and motivate the patient. This study aims to overcome these shortcomings and provide game developers and stakeholders with a more nuanced understanding of how video game technology can be effectively used for physical therapy. A collaborative initiative involving a group of software developers, hardware designers and physical therapists, set out to identify and address the issues that have made the adoption of existing game platforms for therapeutic purposes problematic in a clinical setting. The outcome of this initiative is PocketPT – a personalized therapeutic game platform that provides a therapist designed and configured therapeutic game experience that is customized for a particular patient’s unique presentation. Results from an initial clinical study with participants with brain injuries are reported and discussed.

Psychotherapy Through Video Game to Target Illness Related Problematic Behaviors of Children with Brain Tumor

With the rapid development in serious games, health games have been demonstrated as a useful tool to enhance treatment effects with respect to some problematic behaviors. Every health game has its own game design which can affect the health in a positive manner. In this paper we fixed Imagery Psychotherapy into game design and then developed the 3D Graphical Imagery Psychotherapy video game with cognitive behavioral effects on the children suffering from brain tumor. This therapeutic game attempts to provide a new way to target the psychological illness related to this disease. Experimental user tests were conducted in three hospitals of Pakistan analyzing the different problematic behaviors of a cancer patient before and after the therapy application. The outcome of the study proved that 3D Graphical Imagery Therapy game has been effective in recovering from psychological illness related to brain tumor. The results showed a significant improvement regarding the behaviors, hence this game design found to be effective. Keywords: 3D graphical imagery psychotherapy, brain tumour, health games, psychological illness, therapeutic game design.

Design Parameters in Multimodal Games for Rehabilitation

Objectives: The repetitive and sometimes mundane nature of conventional rehabilitation therapy provides an ideal opportunity for development of interactive and challenging therapeutic games that have the potential to engage and motivate the players. Certain game design parameters that may encourage patients to actively participate by making the games more enjoyable have been identified. In this article, we describe a formative study in which we designed and evaluated some of these parameters with healthy subjects. Materials and Methods: The "operant conditioning" and "scoring" design parameters were incorporated in a remake of a classic labyrinth game, "Marble Maze." A group of participants (n=37) played the game twice: Once in the control condition without both modalities and then with either one of the parameters or with both. Measures of game duration and number of fails in the game were recorded along with survey questionnaires to measure player perceptions of intrinsic motivation on the game. Results: Longer playtimes, higher levels of interest/enjoyment, and effort to play the game were recorded with the introduction of these parameters. Conclusions: This study provides an understanding on how game design parameters can be used to motivate and encourage people to play longer. With these positive results, future aims are to test the parameters with stroke patients, providing much clearer insight as to what influences these parameters have on patients undergoing therapy. The ultimate goal is to utilize game design in order to maintain longer therapeutic interaction between a patient and his or her therapy medium.