Serious games for upper limb rehabilitation following stroke

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Presented at First International IEEE Conference in Serious Games and Virtual Worlds.

Presented at First International IEEE Conference in Serious Games and Virtual Worlds.

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  • 1. Serious games for upper limb rehabilitation following stroke J. W. Burke, M. D. J. McNeill, D. K. Charles, P. J. Morrow School of Computing and Information Engineering J. H. Crosbie, S. M. McDonough School of Health Sciences University of Ulster
  • 2. Contents
    • Overview
    • Background on Stroke
    • Technology for Stroke Rehabilitation
    • Previous Studies
    • Game Design & Rehabilitation
    • University of Ulster Work
        • Virtual Reality Games
        • Webcam Games
        • Nintendo Wiimote
    • Design Principles in Our Games
    • Usability Study
    • Final Remarks
  • 3. Overview
    • THE PROBLEM AREA:
    • Stroke is a leading cause of severe physical disability.
    • Effective rehabilitation must be early , intensive and repetitive .
    • Difficult to maintain patient motivation.
    • THE PROPOSED SOLUTION:
    • Games may be effective in optimising engagement.
    • We have developed a serious game system for upper limb post-stroke rehabilitation .
  • 4. Stroke
    • Impairments : attention and concentration deficiencies, balance loss, pain, weakness and paralysis.
    • Can cause depression and fatigue .
    • Early and intensive practice of functional tasks in an enriched environment show more positive outcomes for upper limb rehabilitation.
    • Tasks often mundane and boring .
    • Rehabilitation can require patients to travel to specialised units.
    • High healthcare costs.
  • 5. Traditional Therapy Video
  • 6. Technology for Stroke Rehabilitation
    • BENEFITS:
    • Rehabilitation systems which are novel , interesting , safe and customisable to a particular user’s abilities and interests.
    • Motivate , involve and immerse the user.
    • Potential for home use .
      • Performance data recorded at home, uploaded to remote site.
    • LIMITATIONS:
    • Clinically valid? [Burdea, 2002; Crosbie, 2008; Rizzo, 2005]
    • Cost and size of equipment?
    • Expertise required?
  • 7. Previous Studies
    • BESPOKE:
    • S ensor-based systems [Crosbie, 2004; Yeh, 2005]
    • Xbox console with P5 glove [Morrow, 2006]
    • Haptics & Robotics [Boian, 2002; Guo, 2007; Podobnik, 2008]
    • ADAPTED:
    • Gesture Xtreme / IREX [Rand, 2004]
    • Sony EyeToy [Rand, 2004; Yavuzer, 2008]
    • Open source games [Herbelin, 2008]
    • Nintendo Wii [ongoing studies]
    • REVIEWS: [Burdea, 2003; Crosbie, 2004; Weiss, 2004; Rizzo, 2005; Rizzo, 2008; Flores, 2008]
  • 8.
    • Designers of rehabilitation tasks can benefit from examining the formulas that commercial game developers use… [Rizzo & Kim, 2005]
    • MEANINGFUL PLAY:
    • Conservative response to failure – reward all engagement .
    • Goals spanning multiple sessions to reward atypical player behaviour .
      • E.g. Rewards for time spent playing game.
    Game Design & Rehabilitation ” “ Inputs choices Discernable and integrated outcome Player Game Meaningful play Feedback
  • 9. Game Design & Rehabilitation
    • CHALLENGE:
    • Challenge needs to match patient’s abilities .
    • Maintains engagement .
    • How to maintain challenge?
      • Manual difficulty adjustment?
      • Adaptivity ?
      • Levels of increasing difficulty?
    • Speed , position and size of game elements can set level of challenge.
    • In-game calibration can determine suitable level of challenge for player’s abilities.
    [Rabin, 2005]
  • 10. Uni. of Ulster Work
    • VIRTUAL REALITY GAMES:
    • Bilateral catch task:
      • Uses an electromagnetic sensor attached to a real physical basket.
      • User moves basket with both hands to catch falling oranges.
      • Various adjustable parameters.
    • Adaptive ‘Whack-a-Mouse’ game:
      • Sensor attached to player’s hand.
      • Encourages arm movement and visual discrimination.
      • Initial configuration based on assessment prior to play.
    • Further information - [Ma, 2007]
    Slide of
  • 11. Uni. of Ulster Work
    • WEBCAM GAMES:
    • Simple 2D games which use a webcam image as input.
    • Game library where all games share patient profile .
      • Profile stores reaching ability, play-time, scores, long-term progress, regions of difficulty and skill level.
    • Played with coloured gloves or any single coloured object.
    • No attaching of wires required , untethered movement.
    • Games can be played standing up or seated .
    • Potential for home rehabilitation .
    • No expertise required .
  • 12. Uni. of Ulster Work
    • Single Arm Exercise:
    • “ Rabbit Chase”
      • Player must catch a rabbit as it peers out of holes on the screen.
    • “ Bubble Trouble”
      • Player must burst bubbles as they float around the screen.
    • Bimanual Arm Exercise:
    • “ Arrow Attack”
      • Player must touch corresponding arrows with both hands simultaneously as they enter boxes.
  • 13. Uni. of Ulster Work
    • Initial reach calibration:
    • Player must roll each ball as far as they possibly can.
    • Allows system to determine range of movement and position game elements accordingly.
    • Camera calibration tool:
    • Allows refining of colour detection settings.
    • Hope to improve automation of colour detection in future.
  • 14. Webcam Games Video
  • 15. Uni. of Ulster Work
    • NINTENDO WIIMOTE VIBRAPHONE:
    • Instrument simulator using multiple Nintendo Wii remotes.
    • Works with PC, interfacing through a bluetooth dongle .
    • User can create a tune, or play back a tune in a timed game mode.
    • Potential for wrist and arm rehabilitation.
  • 16. Design Principles in Our Games
    • Auditory feedback: Sound indicators (hit, miss, play note).
    • Visual feedback: Hit or miss messages, target changing colour, particle effects, score indicator, time indicator, progress graph.
    • Level of challenge can be manually adjusted.
    • Optional adaptivity to adjust speed and position of game elements according to player’s successive hits or misses.
  • 17. Usability Study
    • Usability study of 10 able bodied users playing the two webcam games and vibraphone application.
    • Majority of participants enjoyed all games .
    • Players felt games were enjoyable , replayable and easy to play due to intuitive controls.
    • Apativity approved by those who noticed it (>80%), indicating the game would be less enjoyable without it.
      • One user expressed that the adaptivity was too aggressive.
    • > 80% agreed that the feedback was effective .
      • Some players reported it was difficult to see their score during gameplay.
    • With the Vibraphone game, some users found the controls to be too sensitive.
  • 18. Final Remarks
    • FURTHER WORK:
    • Single patient case studies for playability evaluation are underway with people with stroke – initial feedback is very positive.
    • Larger study planned to assess impact of games on motor function.
    • How to provide a consistent level of challenge for a patient during rehabilitation?
    • CONCLUSION:
    • Games have potential to engage and motivate during rehabilitation.
    • No need for computer or video game experience.
    • Low-cost off-the-shelf hardware may offer an opportunity for home rehabilitation in addition to traditional therapy.
  • 19. Questions?
    • This work was supported by the Department for Employment and Learning (DEL) , Northern Ireland.
    • E-mail: [email_address]
    • Website: http://php.infc.ulst.ac.uk/vr-therapy
  • 20. References
    • BOIAN, R., SHARMA, A., HAN, C., MERIANS, A., BURDEA, G., ADAMOVICH, S., RECCE, M., TREMAINE, M. and POIZNER, H., 2002. Virtual Reality-Based Post-Stroke Hand Rehabilitation, 2002 Proceedings of Medicine Meets Virtual Reality Conference, 2002, IOS Press pp. 64-70.
    • BURDEA, G., 2002. Key Note Address: Virtual Rehabilitation - Benefits and Challenges, 1st International Workshop on Virtual Reality Rehabilitation (Mental Health, Neurological, Physical, Vocational), VRMHR’2002, November 7-8 2002, pp. 1-11.
    • BURDEA, G., 2003. Virtual Rehabilitation - Benefits and Challenges. International Medical Informatics Association Yearbook of Medical Informatics, , pp. 170-176.
    • CROSBIE, J.H., LENNON, S., MCGOLDRICK, M.C., MCNEILL, M.D.J., BURKE, J.W. and MCDONOUGH, S.M., 2008. Virtual reality in the rehabilitation of the upper limb after hemiplegic stroke: a randomised pilot study, Proc. 7th ICDVRAT with ArtAbilitation, 2008, pp. 229-235.
    • CROSBIE, J.H., MCDONOUGH, S.M., LENNON, S., POKLUDA, L. and MCNEILL, M.D.J., 2004. Virtual Reality in the Rehabilitation of the Upper Limb After Stroke: The User’s Perspective, 5th International Conference for Disability, Virtual Reality and Associated Technology, 2004, ICDVRAT / University of Reading pp. 215-224.
    • FLORES, E., TOBON, G., CAVALLARO, E., CAVALLARO, F.I., PERRY, J.C. and KELLER, T., 2008. Improving Patient Motivation in Game Development for Motor Deficit Rehabilitation, Advances in Computer Entertainment Technology, 2008, pp. 381-384.
    • GUO, S., SONG, G. and SONG, Z., 2007. Development of a Self-assisted Rehabilitation System for Upper Limbs Based on Virtual Reality, International Conference on Mechatronics and Automation 2007. 2007, IEEE pp. 1452-1457.
    • HERBELIN, B., CIGER, J. and BROOKS, A.L., 2008. Customization of gaming technology and prototyping of rehabilitation applications, Proc. 7th ICDVRAT with ArtAbilitation, 2008, pp. 211-218.
    • MA, M., MCNEILL, M., CHARLES, D., MCDONOUGH, S., CROSBIE, J., OLIVER, L. and MCGOLDRICK, C., 2007. Adaptive Virtual Reality Games for Rehabilitation of Motor Disorders. Lecture Notes in Computer Science. Springer Berlin / Heidelberg, pp. 681-690.
    • MORROW, K., DOCAN, C., BURDEA, G. and MERIANS, A., 2006. Low-Cost Virtual Rehabilitation of the Hand for Patients Post-Stroke, 2006 International Workshop on Virtual Rehabilitation, 2006, IEEE pp. 6-10.
    • PODOBNIK, J., MUNIH, M. and CINKELJ, J., 2008. HARMiS: hand and arm rehabilitation system, Proc. 7th ICDVRAT with ArtAbilitation, 2008, pp. 237-244.
    • RAND, D., KIZONY, R. and WEISS, P.L., 2004. Virtual reality rehabilitation for all: Vivid GX versus Sony PlayStation II EyeToy, Proceedings of the 5th International Conference on Disability, Virtual Reality & Associated Technology, 2004, ICDVRAT pp. 87-94.
    • RIZZO, A.A., 2008. Virtual reality in psychology and rehabilitation: the last ten years and the next! Proc. 7th ICDVRAT with ArtAbilitation, 2008, pp. 3-6.
    • RIZZO, A. and KIM, G.J., 2005. A SWOT Analysis of the Field of Virtual Reality Rehabilitation and Therapy. Presence: Teleoperators and Virtual Environments, 14(2), pp. 119-146.
    • WEISS, P.L., RAND, D., KATZ, N. and KIZONY, R., 2004. Video Capture Virtual Reality as a Flexible and Effective Rehabilitation Tool. Journal of NeuroEngineering and Rehabilitation, 1(12).
    • YAVUZER, G., SENEL, A., ATAY, M.B. and STAM, H.J., 2008. Playstation eyetoy games improve upper extremity-related motor functioning in subacute stroke: a randomized controlled clinical trial. European Journal of Physical and Rehabilitation Medicine, 44.
    • YEH, S., RIZZO, A., ZHU, W., STEWART, J., MCLAUGHLIN, M., COHEN, I., JUNG, Y. and PENG, W., 2005. An Integrated System: Virtual Reality, Haptics and Modern Sensing Technique (VHS), Proceedings of the ACM symposium on Virtual reality software and technology, 2005, ACM pp59-62.