Therapeutic Gaming Research Articles

Competitive Versus Cooperative Forms of Therapeutic Gaming With Subacute Stroke Patients

Competitive Versus Cooperative Forms of Therapeutic Gaming With Subacute Stroke Patients

Surface Electromyography-Driven Therapeutic Gaming for Rehabilitation of Upper Extremity Weakness: A Pilot Study.

In patients with severe upper extremity weakness that may result from peripheral nerve injuries, stroke, and spinal cord injuries, standard therapy in the earliest stages of recovery consists primarily of passive rather than active exercises. Adherence to prescribed therapy may be poor, which may contribute to suboptimal functional outcomes. The authors have developed and integrated a custom surface electromyography device with a video game to create an interactive, biofeedback-based therapeutic gaming platform. Sensitivity of the authors' custom surface electromyography device was evaluated with simultaneous needle electromyography recordings. Testing of this therapeutic gaming platform was conducted with a single 30-minute gameplay session in 19 patients with a history of peripheral nerve injury, stroke, spinal cord injury, and direct upper extremity trauma, including 11 patients who had undergone nerve and/or tendon transfers. The device was highly sensitive in detecting low levels of voluntary muscle activation and was used with 10 distinct muscles of the arm, forearm, and hand. Nerve and tendon transfer patients successfully activated the donor nerve/muscle and elicited the desired movement to engage in gameplay. On surveys of acceptability and usability, patients felt the system was enjoyable, motivating, fun, and easy to use, and their hand therapists expressed similar enthusiasm. Surface electromyography-based therapeutic gaming is a promising approach to rehabilitation that warrants further development and investigation to examine its potential efficacy, not only for building muscle strength and endurance but also for facilitating motor relearning after nerve and tendon transfer surgical procedures. Therapeutic, IV.

Role-Playing Games and Well-Being

Do role-playing games (RPGs) affect the player’s well-being? Several studies suggest that they might have an impact, but the topic of RPGs and well-being is usually only mentioned as a side note or curiosity. A clear, coherent picture on the topic of RPGs and well-being is missing. This review article aims to provide that picture by compiling the already existing knowledge in one place. I ask the questions: What can we learn from the already existing research? How should RPGs and well-being be studied? What questions need resolving? What can be gained from studying RPGs and well-being?
 RPG studies is a young academic interdisciplinary field of research, as is also the research of arts and well-being. They both are heterogeneous and related to a variety of academic traditions. They both are also dispersed, pragmatic, and until recently, scattered and lacking cohesive traditions or methodologies. Many basic ontological questions remain unsolved and the definitions of key concepts vary. They overlap in several discourses, such as the ones about (1) practices of sociodrama and replication therapy; (2) social, cultural, and digital capital; (3) leisure time research; (4) performance studies; (5) the topic of erotic role-play; (6) problematic vs. therapeutic gaming; and (7) health education. Previous research and practices focus mainly on live action role play (larp) and well-being, suggesting a positive impact. Online RPGs share their own traditions, but studies on tabletop RPGs and well-being are difficult to find. The studies are often case-studies or examine abstract topics such as human experiences.
 In these studies, it becomes evident that RPGs do indeed impact well-being. However, questions such as how, why, and what features in RPGs affect well-being remain unanswered. In addition, the research has mainly been executed from the perspective of either RPGs or arts and well-being. Interdisciplinary cooperation is the key to successfully diving into the world of RPGs and well-being. Doing so would offer both fields useful practices, interesting perspectives, new opportunities for publication and academic discussion. It would not only add knowledge about RPGs and well-being but offer perspective to the unresolved ontological questions of each field. Eventually, further study on RPGs and well-being could transfer into the usage of RPGs in the fields of well-being, health, and therapy in a similar manner that arts are currently being used.

Acceptability of a Mobile Phone-Based Augmented Reality Game for Rehabilitation of Patients With Upper Limb Deficits from Stroke: Case Study.

BackgroundUpper limb functional deficits are common after stroke and result from motor weakness, ataxia, spasticity, spatial neglect, and poor stamina. Past studies employing a range of commercial gaming systems to deliver rehabilitation to stroke patients provided short-term efficacy but have not yet demonstrated whether or not those games are acceptable, that is, motivational, comfortable, and engaging, which are all necessary for potential adoption and use by patients.ObjectiveThe goal of the study was to assess the acceptability of a smartphone-based augmented reality game as a means of delivering stroke rehabilitation for patients with upper limb motor function loss.MethodsPatients aged 50 to 70 years, all of whom experienced motor deficits after acute ischemic stroke, participated in 3 optional therapy sessions using augmented reality therapeutic gaming over the course of 1 week, targeting deficits in upper extremity strength and range of motion. After completion of the game, we administered a 16-item questionnaire to the patients to assess the game’s acceptability; 8 questions were answered by rating on a scale from 1 (very negative experience) to 5 (very positive experience); 8 questions were qualitative.ResultsPatients (n=5) completed a total of 23 out of 45 scheduled augmented reality game sessions, with patient fatigue as the primary factor for uncompleted sessions. Each patient consented to 9 potential game sessions and completed a mean of 4.6 (SE 1.3) games. Of the 5 patients, 4 (80%) completed the questionnaire at the end of their final gaming session. Of note, patients were motivated to continue to the end of a given gaming session (mean 4.25, 95% CI 3.31-5.19), to try other game-based therapies (mean 3.75, 95% CI 2.81-4.69), to do another session (mean 3.50, 95% CI 2.93-4.07), and to perform other daily rehabilitation exercises (mean 3.25, 95% CI 2.76-3.74). In addition, participants gave mean scores of 4.00 (95% CI 2.87-5.13) for overall experience; 4.25 (95% CI 3.31-5.19) for comfort; 3.25 (95% CI 2.31-4.19) for finding the study fun, enjoyable, and engaging; and 3.50 (95% CI 2.52-4.48) for believing the technology could help them reach their rehabilitation goals. For each of the 4 patients, their reported scores were statistically significantly higher than those generated by a random sampling of values (patient 1: P=.04; patient 2: P=.04; patient 4: P=.004; patient 5: P=.04).ConclusionsBased on the questionnaire scores, the patients with upper limb motor deficits following stroke who participated in our case study found our augmented reality game motivating, comfortable, engaging, and tolerable. Improvements in augmented reality technology motivated by this case study may one day allow patients to work with improved versions of this therapy independently in their own home. We therefore anticipate that smartphone-based augmented reality gaming systems may eventually provide useful postdischarge self-treatment as a supplement to professional therapy for patients with upper limb deficiencies from stroke.

Developing an automated VR cognitive treatment for psychosis: gameChange VR therapy

The automated delivery of psychological treatment using virtual reality (VR) has the potential to revolutionise patient access to evidence-based care. VR creates immersive, interactive computer simulations, which elicit responses similar to the real world. VR simulations provide an ideal opportunity for the experimentation and experiential learning that are key to successful cognitive therapy. If automated, and using the latest consumer kit, VR treatment can substantially scale-up the delivery of psychological therapy. However, the successful application of automated VR to mental health difficulties requires precise treatment targets linked to the right psychological theory and techniques. This paper describes the process of development of an automated VR cognitive therapy targeting anxious avoidance of everyday social situations by patients with psychosis. In the gameChange project, a person-centered design process was used involving people with lived experience of psychosis, clinical psychologists, designers, and software developers. The six-session gameChange VR therapy consists of six everyday scenarios: a street, a bus, a café, a pub, a doctor's waiting room, and a shop. Each scenario has five levels of difficulty. Every level provides an opportunity to test out fearful cognitions while limiting the use of safety-seeking behaviours, allowing patients to build confidence in their ability to cope. Learning is facilitated by a virtual coach and therapeutic gaming elements are included. Data from user testing indicates that the gameChange VR therapy is easy to use and engaging. The clinical effectiveness of gameChange VR therapy is now being tested in a randomised controlled trial with several hundred patients with psychosis.

Abstract 11: Surface Electromyography-Based Gamification Therapy For Rehabilitation Of Upper Extremity Weakness: An Acceptability Study

Purpose: Upper extremity weakness may be debilitating and results from a variety of causes, including peripheral nerve and cervical spinal cord injury, stroke, and disuse atrophy. Therapy is critical for regaining function but patients are unable to engage with traditional methods of therapy until evidence of motor recovery is seen on clinical exam. In this study, we have developed an innovative system of gamified therapy that uses signals detected by surface electromyography (EMG), a well-established, noninvasive technique that measures electrical activity generated by muscle contractions from electrodes placed on the overlying skin. Methods: We constructed a highly sensitive custom surface EMG device and integrated it with multiple gaming platforms. In our system, adhesive electrodes are placed over a muscle of interest, and muscle activation greater than a set threshold triggers a single action in the virtual gaming environment. Patients with upper extremity weakness from any cause were recruited to use the surface EMG device to play games. Acceptability surveys were administered after each gaming session, and additional metrics to assess feasibility were examined, including task learning speed, length of gameplay session, high scores achieved, and technical problems encountered. Results: The sensitivity of our custom surface EMG device was assessed through simultaneous needle EMG recordings. Our device is capable of detecting muscle activation even during recruitment of a single motor unit, and signals recorded represent activity from the specific muscle of interest and not of opposing muscle groups nearby. Patients quickly learned how to activate their muscles to interact with the virtual gaming environment. Interestingly, patients lacking antigravity muscle strength, scoring as low as 2/5 on manual muscle testing, were still able to engage in reliable gameplay. Responses from acceptability surveys showed that the majority of patients found the surface EMG-based gaming platform to be motivating, enjoyable, easy to understand, and safe. Conclusion: Gamified therapy represents a novel approach to rehabilitation that promotes patient engagement, motivation, and compliance. The use of surface EMG signals as input for therapeutic gaming has tremendous potential for severe muscle weakness in the earliest stages of recovery, as nascent signals from underlying affected muscles are detectable on EMG before significant movement is observed on clinical exam. This creates the opportunity for earlier initiation of therapy in many patients with upper extremity weakness. In patients with brachial plexus injuries who have undergone nerve transfer surgeries, surface EMG-based therapy may have the added benefit of facilitating cortical retraining by helping patients learn the association between donor nerve activation and recipient muscle movement. Future studies are needed to assess the clinical efficacy of surface EMG-based gamification therapy in these distinct patient populations.

The validity and usability of an eight marker model for avatar-based biofeedback gait training

BackgroundVirtual reality presents a platform for therapeutic gaming, and incorporation of immersive biofeedback on gait may enhance outcomes in rehabilitation. Time is limited in therapeutic practice, therefore any potential gait training tool requires a short set up time, while maintaining clinical relevance and accuracy. The aim of this study was to develop, validate, and establish the usability of an avatar-based application for biofeedback-enhanced gait training with minimal set up time. MethodsA simplified, eight marker model was developed using eight passive markers placed on anatomical landmarks. This allowed for visualisation of avatar-based biofeedback on pelvis kinematics, hip and knee sagittal angles in real-time. Retrospective gait analysis data from typically developing children (n = 41) and children with cerebral palsy (n = 25), were used to validate eight marker model. Gait outcomes were compared to the Human Body Model using statistical parametric mapping. Usability for use in clinical practice was tested in five clinical rehabilitation centers with the system usability score. FindingsGait outcomes of Human Body Model and eight marker model were comparable, with small differences in gait parameters. The discrepancies between models were <5°, except for knee extension where eight marker model showed significantly less knee extension, especially towards full extension. The application was considered of ‘high marginal acceptability’ (system usability score, mean 68 (SD 13)). InterpretationGait biofeedback can be achieved, to acceptable accuracy for within-session gait training, using an eight marker model. The application may be considered usable and implemented for use in patient populations undergoing gait training.

Kinecting the moves: the kinematic potential of rehabilitation-specific gaming to inform treatment for hemiplegia

IntroductionThe use of commercial gaming systems is gaining momentum in the field of rehabilitation (1). Virtual reality and active video games can increase user engagement and enjoyment in rehabilitation, increasing the potential for enhancing patient outcomes (2, 3). Therapeutic gaming may be one treatment tool selected by therapists for individuals with hemiparesis as a means of providing motivating opportunities for repetitive motor practice that encourages specific movement patterns and use of the impaired limb (4, 5). Bimanual therapy is an effective approach to reduce impairment and to improve functional ability of the paretic arm (6). However, commercial video games are not designed to consistently optimize the use of both arms simultaneously. Challenges exist, therefore, in the application of these systems to meet the therapeutic needs and physical capacities of different patient populations (7). Accordingly, the development of novel game applications and user interfaces for commercial gaming systems is expanding the potential for the technology to be adapted and integrated for these purposes, both in clinics and in the home.Motion tracking technology is being used increasingly both as a movement interface in these gaming systems, and as a means of capturing data about participants' kinematic movements during rehabilitation (8,9). The Vicon system (Oxford, UK) (10), the FASTRAK system (League City, TX) (11), and the Microsoft Kinect(TM) (Redmond, WA) (12) are three examples of this technology. The marker-based Vicon and FASTRAK systems provide higher accuracy compared to the Kinect, however at a higher cost and required expertise, making them unsuitable for most rehabilitation applications. Conversely, the Kinect has demonstrated centimetre-level accuracy, yet high correlations of tracked data with those obtained by marker-based systems (13). These findings, along with its commercial availability, make the Kinect a potential candidate for use in a clinical or home setting for rehabilitation. Furthermore, at this time, no documented guidance exists to translate the Kinect's kinematic data into clinically relevant information that is useful to therapists prescribing gaming interventions.The (Functional Engagement in Assisted Therapy through Exercise Robotics) project focuses on the development, testing and implementation of rehabilitation-specific interfaces for bimanual therapy, and the extraction of kinematic data to inform therapists monitoring patients' performance and progress. By applying custom algorithms to data collected from the Sony PlayStation Move (Tokyo, Japan) and the Kinect systems, it is possible to determine the total distance moved by the participant, their range of motion (ROM), and the vertical hand offsets for different directional movements. Moreover, the Kinect system is capable of providing data about excessive trunk movements.The purposes of this paper are therefore: (i) to describe the adaptation of two commercial interfaces (PlayStation Move and Microsoft Kinect) to promote bilateral arm use during social media-based game play; and (ii) to share preliminary kinematic data from two participants with hemiparesis using the systems. The analysis of the kinematic data offered by the systems allows for the extraction of clinically relevant information that can be shared with therapists to inform their treatment decisions.MethodsIn order to use the two motion capture interfaces for the upper limb rehabilitation of individuals with hemiparesis, a computer application called FEATHERS was developed. The Motion application relies on the use of bimanual motions in the frontal plane to control the mouse cursor on a Windows® 7 personal computer. Two motion modes (Visual Symmetry and Point Mirror Symmetry) are available for mapping the hand with the least movement into cursor motion. In Visual Symmetry mode, users are required to move both hands at the same time in the same direction, while in Point Mirror Symmetry Mode, users must move both hands around the circumference of a circle, similar to turning a steering wheel. …

English

Introduction Mobility limitations and cognitive impairments which are common with ageing, cause a reduction in the levels of physical and mental activity and are prognostic of future adverse health events, including falls. Consequently, multi-task training paradigms that simultaneously address both mobility and cognition benefit healthy ageing and are important to consider in rehabilitation. In this regard, the application of computer technology provides a number of promising approaches, in particular, virtual reality and therapeutic gaming. These approaches have the potential to improve clinical outcomes by making therapy more motivating, more ecological, and effective, blending of balance, mobility, gaze and cognitive exercises/tasks. Using a computer-based platform, one can also objectively quantify duration and intensity of both exercise and cognitive activity. Performance can also be quantified, trend analysis can be conducted and dose–response relationships established. The aim of this critical review is to discuss the technology-assisted and motivational programme approach to prevent and manage balance, gaze, mobility and cognitive decline with age. Conclusion There is a need to develop and validate low-cost, engaging exercise and cognitive platforms with automated monitoring tools that can extend quality health care and support to the community and ultimately the home.