1KOLLECT: Virtual Reality Rehabilitation for Youth with Cerebral PalsyIntroduction & BackgroundPatients and caregivers are critical members of the healthcare team and active partners inclinical decision making.1Children and youth (patients) with cerebral palsy (CP) and theirparents (caregivers) are encouraged to participate in management of the child’s health andrehabilitation needs in family-centered service delivery models.2However, youth with CP andtheir families have involvement in research processes to integrate technology for clinicaldecision making and health outcomes. It is important for youth with CP and their parentsparticipate in this research to be sure their goals and preferences are addressed.CP is the most common physical disability of childhood with a prevalence of 2.0-3.0 per1000 live births.3,4Although CP is a non-progressive neuromuscular disorder, it is a lifelongcondition in which children often experience decreased physical activity, motor skills, functionalmobility and health problems.5,6Despite these limitations, most children with CP are ambulatory,however, children with moderate CP often need assistive devices (walkers, crutches) and mayrely on wheelchair use for community mobility.7Parents of children with CP share concerns about their children’s walking and functionalmobility skills.8They seek information for decisions on rehabilitation and health services topromote their children’s function, quality of life, health and independence.9-10Virtual reality (VR) is a popular rehabilitation strategy to promote health and fitness;motor and cognitive skills; and increased confidence and self esteem in children and youth withdisabilities.11-14VR provides a safe environment for children with CP to access activerecreation, games and sports.14VR interventions are important because they motivate youth toincrease activity levels and adhere to rehabilitation programs with fun experiences.15-18VRmay be especially important to children and youth with CP because there are few communityrecreation facilities and opportunities for active recreation for health, function and socialization.19Despite the growing popularity of VR in rehabilitation for youth with CP, supportiveresearch evidence is limited. 20Most research evidence is focused on upper extremity functionwith little research focused on health promotion, fitness, functional mobility, and physicalactivity.12-13, 21-26A small body of research examines VR for children with CP to improvecognitive and executive function using neurotechnology designs.27There is no research bycollaborative teams of youth with CP, their parents, their health providers and researchers fromrehabilitation and digital media fields to design and test VR in clinical and community setting.Usability, scalability, and design of applicationKOLLECT is the prototype VR gaming system that has been developed by the DrexelExCITe team with input from clinicians, youth with CP and their parents. The KOLLECT VRgame was developed using the Kinect SDK (Software Development Kit). The avatar interfaceincreases accessibility for youth with CP who often have limitations in hand function making itdifficult to use haptic devices. The Kinect SDK was used to create KOLLECT becausecommercial games for the X-Box 360 Kinect system are not compatible to ability levels of youthwith CP (i.e., games are often too fast with too many distractions). Also, commercial gamesdon’t have enough flexibility to modify parameters to promote participation for youth with CP.KOLLECT was designed as a proof-of-concept system to test various aspects of the finalgoal system. This system was designed with flexible settings so parents or clinicians can adjustparameters to challenge youth with CP and still promote play. The settings allow the clinician orparent to adjust components of exercise prescription (FITTE principles) 28to increase challengewhile improving overall health, function and mobility. FITTE principles are: Frequency, Intensity,Time, Type and Enjoyment).
2KOLLECT’s architecture has broad scalability capacity in that it has built-in settingsflexibility and it has broad application via website access for game play remotely among multipleplayers. While KOLLECT was prototyped with only a handful of accessible settings and controlgame parameters such as game theming, gameplay characteristics (i.e., difficulty and duration),and player characteristics (i.e., mobility), the architecture supports expanding the settings is infull production to provide optimal controls for the clinician and widest application for youth withCP of varying ages, gender, physical and cognitive levels, and recreational interests. Thisfeature is key for youth with CP to encourage ‘social networks’ of friends because youth with CPmay become isolated due to mobility restrictions and lack of resources and opportunities foractive recreation and play.19KOLLECT was designed using simple gaming features so that the game has: 1) fewdistracting elements; 2) objects that can move at different speeds (to challenge reaction time,accuracy and precision) and across different trajectories to promote variable range of motionand mobility; and 3) “hand prints” that cue the youth on hand placement to focus and anchor thereaching activities. The user tests to date have been very successful in demonstratingfeasibility but further testing is needed for more and varied populations of persons with CP.Innovation and creativityKOLLECT is innovative and creative because it has distinct design features that wereincluded in the game in response to youth, parent and clinician input. All features have flexibilityto increase difficulty to match and challenge the players’ physical and cognitive abilities.Current features that promote game play are: 1) less complex game objectives and tasks; 2)slower moving and larger objects; 3) fewer distractions (ie, lights, noises) and 4) longer playtime (determined remotely by the clinician/therapist based on the recorded individual playerhistory and metrics) to promote fitness and functional mobility. The goal of this first KOLLECTprototype was to be determine accessibility and enjoyment for youth with moderate CP whomay play video games in sitting or standing but who engage in the game with upper-extremitiesmore than lower extremities. The rationale for choosing these children and youth is that theymay have limited opportunity for active recreation.Scientific rigorScientific rigor has been used in the design and testing of KOLLECT. A pilot study toexamine physical activity in youth with CP (n=52, average age = 12 years (SD: 3.35 years; 52%girls) was recently completed. In this study youth completed a nine task physical activityprotocol in which each activity was 5-6 minutes in length to ensure that the children and youthreached “exercise steady state” in each task (at approximately 3 minutes). However, twoactivities included active X-box 360 Kinect commercial games which could not be adjusted formore than 3 minutes of continuous play and for which no children were successful in gettingbeyond 2-3 minutes of play. Therefore, no Kinect activity trials in the pilot study allowed forextended play time for increased mobility, health-related fitness or fun! 29The current KOLLECT video game has been tested by two youth with moderate CPwhile their parents observed the sessions. The youth and parents completed questionnairesabout the experience (See Table 1 for select responses). Note that the youth many (n=5)KOLLECT features as “Good to Excellent” with other features (n=6) as OK. Parents indicatedthey would change nothing in the KOLLECT game features. One parent suggested that settingsand the ability to document her son’s reaching and range of motion provided good informationso she could track how he improves his reaching during play. She thought it would be good toshare this tracking data with her son’s doctor when they discuss his progress and medicalmanagement.
3Two pediatric physical therapists (PTs) participated in a KOLLECT demonstration tolearn game features and settings and they completed a questionnaire to rate the game.(See Table 2) Both PTs rated the majority of KOLLECT features and all settings as good toexcellent. Also, they provided comments on other features to increase flexibility of featuresand settings for clinical applicationsThe PLAN for the next phase of KOLLECT development is to expand testing andobtain feedback from 25 youth and parents and 15-20 clinicians. These data will informnext steps in revision of the KOLLECT prototype and dissemination of the game for widertest distribution.Patient-centerednessThe KOLLECT video game is patient-centered in that this first version was designed inresponse to patient and clinician input. Parents, youth with moderate CP and PTs havebegun to test and provide feedback on this prototype. Thus, the game is designed with andfor youth, families and clinicians. Further development of the KOLLECT system in the nextphase will follow an Agile development approach guided by playtest sessions involving youthwith CP as well as adults with neurologic disabilities. The Agile process is an iterative methodfrequently used in software design and game development, and has been taught at Drexel’snationally-ranked Game Design program for almost 10 years. This development andassociated scrum methodology leverages external stakeholders central to a project’s success toguide development and revision of the project’s goals through the entire product timeline. Thegoal of the KOLLECT game is to provide youth and families with a viable option for activerecreation that is fun and that contributes to improved health, functional mobility, fitness andcognitive training. Future versions will have options for more complex gaming to promotecognitive skills and executive function which is important for many youth with CP ascognitive delay is a common co-morbidity for this condition.Degree of development of model or prototypeThe KOLLECT prototype was a functional prototype demonstrating every major component ofthe system, and was architected in such a way that further development involves expanding thelevel of support for each component.The game play component addressed a range of physical capabilities of the childrenwith CP, and performed simple analysis to dynamically alter gameplay to address varying reachspace or speed of the child. The parameterized configuration interface permitted gross-levelcontrol of numerous game characteristics such as duration, game object size and type, andsupport for a single or both arms playing the game. The networked configuration interfacepermitted adjustment of those same parameters via a clinician, doctor, or therapist at a remotelocation. The database component supported archiving of a subset of game-generated datasuch as collection points or joint angles, and display and simple plotting of this data over timefor any selected player or play session.Utility of this prototype was demonstrated through use of the system by actual childrenwith CP, and subsequent playtest sessions with a diverse test population will help further definethemes, pacing, complexity, and other gameplay characteristics to best serve the CPcommunity. While KOLLECT in its current form has utility and benefits over many currentgames for a subset of children with CP, the extensions to this as proposed in this documentwould both address a larger target population of children with CP at various degrees of affect,as well as provide a more powerful configuration and performance monitoring tool for the child’stherapists, doctors, and other health professionals.
4Ability to serve “hard-to-reach” audiences and stakeholdersVR gaming system used to promote a child’s functional mobility should be easy to: 1) use by thechild, parent and clinician; 2) use at home or in the clinic; 3) modify on site or remotely; and 4)low cost and portable for home, school and community purchase; and 5) interactive and able tobe link into social networks so that children can “play” with other children remotely when theycannot access recreation centers or active-recreation games and events in their communities.Low cost and remote features will make the KOLLECT VR gaming system more readilyavailable for families with children with CP who have limited means and for those from ruralpopulations where community mobility is limited. The system can be run on low-cost hardwareacross several operating systems, and only requires a low-cost Kinect interface which is thefastest selling consumer electronics device ever launched with over 8 million sales in its first 2months.25Any web connectivity with minimal bandwidth permits remote access and monitoringby the child’s heath care professionals. This gaming system will be useful in inner city urbanareas where there is limited access community recreation centers due to limited transportationservices, unsafe neighborhoods, or community centers that lack services for individuals withdisabilities. The KOLLECT game has features that will improve access to fun, healthy activerecreation in hard to reach underserved and under-resourced neighborhoods and communitiesand will provide active recreation to a vulnerable population (youth with disabilities) that isclassified as experiencing “health disparities” because of limited access to health resources.Table 1: Parent & Child KOLLECT Questionnaires: Specific Item ResponsesItems & Responses (n=2)KOLLECT video game features you rate as Good to Excellent (Child) (n=11 features)Child: #1 FIVE (Look & feel; Hand prints; Play in sit or stand; Overall goal; Overall sound)Child #2: FIVE (Adjust object speed; Play in sit or stand; Overall goal; Overall fun; Overall look of game)KOLLECT – what needs to be improved (Parent)Parent #1: NOTHING Parent #2: NOTHINGTable 2: Physical Therapist (PT) KOLLECT Questionnaire: Specific Item ResponsesItem & Responses (n=2)Rating KOLLECT video features (n=11)PT #1: THREE@EXCELLENT(adjust object speed and trajectory; play in sitting or standing);FIVE@GOOD (look and feel of objects; “hand prints”; overall goal; overall difficult/ complexity; overall“sound”); THREE@OK (look of the “Red Bombs”; overall fun, overall “look” of the game)PT#2: FOUR@EXCELLENT (look and feel of objects; ability to adjust objects trajectory);SEVEN@GOOD (look and feel of the “Red Bombs”; adjust object speed; “hand prints”; overall difficulty/complexity; overall fun; overall “look”; overall “sound”)PT COMMENTS: Would be nice if…. the “Red Bombs” were optional since might be too difficult for some there was an option of foot print too for balance or leg exercise for w/c users there were more options for different kinds of games with more variety in sounds/musicRating KOLLECT video game settings (n=5)PT#1: THREE@EXCELLENT (change play time; change settings remotely; multiple players (real spaceor remotely); TWO@GOOD (scatter plots; line graphs)PT#2: TWO@EXCELLENT (change settings remotely; multiple players (real space or remotely);THREE@GOOD (scatter plots; line graphs; ability to change play time)PT COMMENTS: For changing settings remotely - love the idea but not sure the children will like that feature! For scatter plots - Can you tell which arm (or leg) was used? For line graphs - Can this include head and trunk movements (esp. for youth with severe CP) For time setting – have options for more time in game play
5The goals of this grant application are to continue development of the KOLLECTprototype for an innovative game system that will:Be valid and accessible in the “field” (home or community environment) 30 The prototype system was developed to support the commercial Kinect stand-alonecontroller. The Kinect for the Xbox console is widely found in the home and porting tosupport this platform lessens the need to purchase any additional hardware. Current network connectivity involves a combination web-email interface for the remotesetting of the configuration file. In the final version, the remote monitoring and control ofthe player system would be transparent.Adapt game play to individual player capabilities to support longer duration Player population varies tremendously in age, physical abilities, and cognitive function,so the game has to be individually adapted. The prototype has rudimentary analysis ofreach space which drove the spawn points of the collected items. In the final version,the heuristics to intelligently adapt and support players with varying ability will include: Spawning and motion dynamically adaptable to monitored player capabilities.While remote parameter setting will permit complete control over the playenvironment by the clinician, the game will support adaptation to the individualplay session. Complexity of spawned objects to support varying cognitive function and playerskill. Sequences, patterns, and variety will be supported to enable minimalcomplexity for children with lower-function while permitting extension andengagement for the most patients with high physical and cognitive function.Address goals of KOLLECT as a remote or in person rehabilitation tool by examining/validatingmetrics such as range of motion and joint tracking systems and by using other instruments(heart rate monitors, accelerometers) during play to examine physical activity and fitness.30 The Kinect’s use of skeletal tracking permits measuring of joint limits, joint speed, reachspace, and other metrics which requires both monitoring and filtering as well as archivingand analysis over time. The system will be expanded for increased access and time-based trending of the data. In addition to the purely physical capabilities of the player as defined by the reachmetrics, the game will be made more adaptable for cognitive function with cognitivemetrics such as identification of colors and shapes or the ability to identify and performsequences of actions/goals ranging in complexity.31Provide custom character and theme selection for promoting engagement and motivation forplayers in activities they normally are not physically able to participate in; Engagement is the key to a successful experience, and the prototype systemdemonstrated theming with a sports theme and shape theme. This will be greatlyexpanded to support a variety of childhood interests such as animals, music, sports, etc.for child and teen audience. One expansion may be the ability to customize thecollection objects with images meaningful to the playerSupport networked access of player metrics and game configuration by parents, youth,clinicians (doctors, therapists, etc) involved in designing and modifying therapeutic interventions A minimal network interface was prototyped for viewing player session data, but thecontrols for the selection and archiving of this data was minimal.The Drexel ExCiTe Team: Dr. Maggie O’Neil, Associate Professor, College of Nursing andHealth Professions, Dr. Paul Diefenbach and Prof. Dave Mauriello, College of Media Arts andDesign; Tim Day, School of Biomedical Engineering. Our Advisory Stakeholder Group includestwo youth with CP, their parents and two PTs. We will expand this group in the next phase.
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