Computer games and spinal injuries

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Computer games and spinal injuries

  1. 1. Case ReportGame-based Exercises for DynamicShort-Sitting Balance Rehabilitation ofPeople With Chronic Spinal Cord andTraumatic Brain InjuriesAimee L Betker, Ankur Desai, Cristabel Nett, Naaz Kapadia, Tony Szturm AL Betker, MSc, is a PhD candi- date, Department of Electrical andBackground and Purpose Computer Engineering, UniversityGoal-oriented, task-specific training has been shown to improve function; however, of Manitoba, Winnipeg, Mani-it can be difficult to maintain patient interest. This report describes a rehabilitation toba, Canada.protocol for the maintenance of balance in a short-sitting position following spinal A Desai, BPhysio, is a student incord and head injuries by use of a center-of-pressure– controlled video game– based the School of Medical Rehabilita-tool. The scientific justification for the selected treatment is discussed. tion, University of Manitoba. C Nett, BMR (PT), is a physicalCase Descriptions therapist in public practice and aThree adults were treated: 1 young adult with spina bifida (T10 and L1–L2), 1 clinical lecturer with the School of Medical Rehabilitation, Universitymiddle-aged adult with complete paraplegia (complete lesion at T11–L1), and of Manitoba.1 middle-aged adult with traumatic brain injury. All patients used wheelchairsfull-time. N Kapadia, BPhysio, is a student in the School of Medical Rehabilita- tion, University of Manitoba.Outcomes T Szturm, PhD, is Associate Profes-The patients showed increased motivation to perform the game-based exercises and sor, Division of Physical Therapy,increased dynamic short-sitting balance. School of Medical Rehabilitation, University of Manitoba, R106-771Discussion McDermot Ave, Winnipeg, Mani- toba, Canada R3E 0T6. Address allThe patients exhibited increases in practice volume and attention span during correspondence to Dr Szturm at:training with the game-based tool. In addition, they demonstrated substantial im- ptsturm@cc.umanitoba.ca.provements in dynamic balance control. These observations indicate that a video [Betker AL, Desai A, Nett C, et al.game–based exercise approach can have a substantial positive effect by improving Game-based exercises for dy-dynamic short-sitting balance. namic short-sitting balance re- habilitation of people with chronic spinal cord and traumatic brain in- juries. Phys Ther. 2007;87:1389 – 1398.] © 2007 American Physical Therapy Association Post a Rapid Response or find The Bottom Line: www.ptjournal.orgOctober 2007 Volume 87 Number 10 Physical Therapy f 1389
  2. 2. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain InjuriesB alance of the human body re- proaches, however, is maintaining biofeedback were created. This in- quires timely control of the po- people’s interest in performing re- teractive exercise tool has been ap- sition and motion of the center petitive tasks and ensuring that they plied to standing balance.25,26 Betkerof body mass relative to the base of complete the treatment program. A et al25 administered a questionnairesupport. Maintaining balance in a lack of interest or a short attention to 15 subjects (7 with balance disor-short-sitting position at rest; during span also can impair the potential ders and 8 without balance disor-voluntary head, arm, and body move- effectiveness of therapeutic exer- ders) after they played a 10-minutements; and during transfers and cises. Conversely, the use of reward- session of each game. The resultswheelchair use (both indoors and ing activities has been shown to were encouraging. The subjects indi-outdoors) involves many essential improve people’s motivation to prac- cated that the games were challeng-sensory and motor processes. Feed- tice.7–11 Various approaches have ing and fun and would be a welcomeforward predictive controls, which been put forth to couple motivating addition to current treatment pro-initiate preparatory postural adjust- experiences with rehabilitation exer- grams. Subsequently, Betker et al26ments (goal-directed voluntary cises. Biofeedback, in which a bio- reported on the feasibility and bene-movements), are required to main- logical signal is recorded and pre- fits of interactive standing balancetain balance during these move- sented to people, has long been used exercises carried out with the COP-ments and to anticipate potential fu- clinically to create and strengthen controlled video game system for 3ture disturbances.1 Sensory feedback the awareness of a given task or people who had chronic neurologi-processes are essential for respond- performance.12–16 cal deficits. The postexercise obser-ing in a timely fashion to unexpected vations demonstrated that the peo-disturbances or to correct for move- Novel and promising methods of ap- ple exhibited few falls, decreasedment errors. plying biofeedback to rehabilitation COP excursion limits for some tasks, are virtual reality and video and increased attention span duringRestoration and maintenance of in- games.17–22 In a study by Webster et training.dependent dynamic short-sitting bal- al,23 a virtual environment was cre-ance* are priorities for many people ated to help people with the control In our treatment program, COP-who use wheelchairs because of a and mobility of their wheelchairs, controlled video game-based exer-spinal cord lesion or an acquired or and participants had to navigate cises were used to attempt to im-traumatic brain injury. As in standing through a virtual obstacle course. Af- prove dynamic short-sitting balanceposture, poor balance in a short- ter treatment, the participants exhib- in people with central nervous sys-sitting position will increase the fear ited a decrease in wheelchair acci- tem injuries. We thought that theof falling, fall risk, and mobility limi- dents and falls and showed better inclusion of motivational and func-tations, creating greater patient de- performance on an actual obstacle tional gaming in rehabilitation andpendency in basic and instrumental course compared with subjects who sports training might increase theactivities of daily living. Poor posture did not have training with the virtual people’s desire to perform their ex-also can have an effect on a person’s course. Video games were used by ercises and therefore result in im-self-confidence in dealing with other O’Connor et al24 in an attempt to proved dynamic balance control af-people.2 In turn, these issues can increase the physiologic responses ter the exercises.cause reduced levels of physical ac- of people using manual wheelchairstivity, participation in sports, and, and to examine their effects on the Case Descriptionsmore generally, quality of life. motivation of the people to perform Patient Histories their exercises. The GAMEWheels Three people consented to beEvidence from human studies shows system interfaced commercial video treated and provided the followingthat goal-oriented, task-specific train- games with rollers, allowing station- information.ing improves function and that in- ary propulsion of the wheelchairs.creased amounts of training produce The observations showed that 87% Patient 1 was a 26-year-old man withbetter outcomes3–5 (for a complete of the subjects found that the games spina bifida (myelomeningocele) ex-review, see Kwakkel6). One problem motivated them to perform their tending from T10 to L1–L2 and re-with task-specific treatment ap- exercises. sulting in complete paraplegia and poorly developed lower extremities. On the basis of these ideas and re- At the time of initial assessment, he* Defined as maintaining an upright position sults, 3 interactive video game-based demonstrated good static and dy-of the torso while sitting on the buttocks orthighs (or both), with the shank hanging over exercises that are controlled by use namic short-sitting balance and wasthe sitting surface. of center-of-pressure (COP) signal independent with all transfers, activ-1390 f Physical Therapy Volume 87 Number 10 October 2007
  3. 3. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuriesities of daily living, and work. As a hands for support because of im- their weight back and forth; and inperson who participated in Paralym- paired balance and trunk control. As both modes together, players mustpic sports, he actively raced for a result (and because of his size), he shift their weight in all directions.Team Canada and was actively train- had to be transferred with a Hoyer Thus, movement range and speed ining to improve dynamic balance con- lift. He used a powered wheelchair all or targeted directions are exer-trol, an important requirement for for mobility indoors and outdoors. cised. Difficulty levels can be config-high-speed wheelchair racing. He had no sensory loss, and his in- ured through the receptacle size, the tellectual and memory functions also object speed, the number of objects,Patient 2 was a 52-year-old man with were intact. However, he was easily and the option of multiple objectscomplete paraplegia (T11-L1) and a distracted during most activities and appearing at specified intervals.transfemoral amputation; these inju- therapy, requiring constant cuingries resulted from a motor vehicle and verbal commands to stay fo- In Memory Match (Fig. 1b), the goalaccident 10 months before recruit- cused on the task at hand. is to select 2 matching cards from ament into our treatment program. 3 3 or 4 4 array of squares.After the accident, he received in- COP-Controlled Video Game players select a card (square)patient rehabilitation for 6 months. Game– based Exercise Tool by shifting their weight to move theAt the time of initial assessment, be- The COP position signal has long on-screen COP indicator to 1 of the 9fore the current treatment program, been used as an indicator of balance or 16 possible cards (squares). Oncehe demonstrated complete motor performance.27–30 We developed the the COP is held still in a square for aand sensory loss below the T11 level, COP-controlled video game-based duration selected by the player, thedemonstrated dependent short- exercise tool for use with the Force- card is revealed. The second cardsitting balance (he sat with a ky- Sensitive Applications (FSA) soft- then is selected in a similar manner;photic posture with bilateral upper- ware† and pressure mat.† The COP if the cards match, they remain faceextremity support and was unable to position signal input is acquired via a up. This process is repeated until allperform any functional activity with flexible pressure mat measuring of the card pairs are selected. Diffi-the upper extremities in an unsup- 53 53 0.036 cm and containing culty levels can be configuredported short-sitting position), and re- a 16 16 grid of piezoelectricity- through the number of seconds thequired moderate assistance from resistive sensors spaced 2.8575 cm players have to select their cards andone person for transfers. His primary apart (other mat sizes are available). the number of cards displayed (9 ortreatment goal was to regain inde- The flexibility of the pressure mat 16).pendent short-sitting balance for re- permits games to be performed onturn to office work. solid, fixed surfaces and allows pro- In Balloon Burst (Fig. 1c), a newly gression to compliant surfaces, with created game, the goal is to “pop”Patient 3 was a 41-year-old man who the FSA pressure mat being placed balloons. Stationary balloons appearhad had a severe traumatic brain in- between the patient and the surface. at random locations on the screen.jury more than 5 years before the The position of the COP is calculated Game players must shift their weightcurrent treatment program. He had from the pressures produced by the in all directions in order to move thereceived physical therapy interven- patient seated on the pressure mat. on-screen COP marker over the bal-tion several times during those 5 This COP position signal then is loon to pop it. The difficulty levelyears for trunk and lower-extremity mapped as an input to each of 3 can be configured through the sizemotor control and balance re- different games (Under Pressure, of the balloon.education. His upper-limb function Memory Match, and Balloon Burst),was good bilaterally, but he had poor which are described below. In order to allow a customized andtrunk and lower-limb motor control graded protocol for each player, theand high muscle tone (velocity- In Under Pressure (Fig. 1a), game interactive video game system of-dependent resistance to stretch), players shift their weight to move a fered the following features. The ad-which fluctuated from extensor tone receptacle in order to “catch” an ob- justable difficulty levels within theto flexor tone, depending on his po- ject. The game comprises 3 modes: game software helped to ensure thatsitioning. He had a progressive in the horizontal mode, players must each player was competitive andplantar-flexion contracture of the shift their weight side to side; in the could successfully play the videoright ankle secondary to spasticity vertical mode, players must shift games while exercising his full range(hypertonity of the plantar flexors). and speed of voluntary movement.He was unable to maintain short- †Vista Medical, 3–55 Henlow Bay, Winnipeg, This feature is important to prevent asitting balance without the use of his Manitoba, Canada R3Y 1G4. player from becoming frustrated andOctober 2007 Volume 87 Number 10 Physical Therapy f 1391
  4. 4. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain InjuriesFigure 1.Screenshots of games. (a) Under Pressure during horizontal mode. The game player must move the flower under the bee. The totalnumber of bees, the number of bees caught, and mediolateral (ML) and anteroposterior (AP) movement ranges (in centimeters) aredisplayed. (b) Memory Match. The game player must select cards in order to find the pairs. The number of pairs found and the MLand AP movement ranges (in centimeters) are displayed. (c) Balloon Burst. The game player must move the cursor over the balloonto pop it. The total number of balloons, the number of balloons popped, and the ML and AP movement ranges (in centimeters) aredisplayed.quickly losing interest. The game games increase your motivation to plane; the disturbance can be multi-software allows the player’s move- perform your exercises? Were the directional.32 For the purpose of ourment range to be determined dynam- video game-based exercises chal- treatment program, an air bladderically or manually and can be scaled, lenging? Did the difficulty levels of was used to distort and produce anallowing even people who are se- the video games enhance the exer- unstable support surface, in a man-verely disabled to play and be cises? and Do you prefer video ner similar to the compliant foamcompetitive. game-based balance exercises to tra- pad used during standing. The air ditional balance exercises? The re- bladder modified the surface reac-Evaluations and Outcome sponse options were: “strongly dis- tion forces under the seat; thus, theMeasures agree,” “disagree,” “agree,” and surface could not completely recip-Two different test protocols were “strongly agree.” rocate the normal forces beneath theused to obtain quantitative out- seat as the center of body masscome measurements: (1) a question- Dynamic balance assessment. In moved. The result was an increasenaire that was administered after the keeping with the Sensory Organiza- in the magnitude and frequencyexercises and (2) stability measure- tion Test concept, Shumway-Cook of involuntary (unpredictable) bodyments that were obtained during a and Horak31 devised a clinical tool sway. To prevent a loss of balance,set of 6 tasks performed under 2 for testing the sensory component a fall, or both, an individual must beconditions (before and after exer- of balance: the Clinical Test of Sen- able to sense and respond to thiscise). The 2 protocols are described sory Interaction and Balance. In the condition. This condition consti-below. Clinical Test of Sensory Interaction tutes a demand on whole-body and Balance, a compliant foam pad balance reactions, and continuousQuestionnaire. After exercise, a is used as an unstable support base automatic postural adjustments arequestionnaire that included the fol- to simulate the Sensory Organization required to maintain upright short-lowing questions was administered: Test in terms of somatosensory dis- sitting balance and postural stability.Were the video game-based exer- tortion, with an added advantage The degree of difficulty of the bal-cises fun to play? Did the video that it is not limited to the pitch ance tasks could be adjusted by se-1392 f Physical Therapy Volume 87 Number 10 October 2007
  5. 5. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain InjuriesTable 1.Task Descriptions Task Description 1 Maintain erect short-sitting balance with eyes open and looking straight ahead, as part of the CTSIB.a 2 Maintain erect short-sitting balance with eyes closed, as part of the CTSIB. 3 Perform rhythmic left and right horizontal head rotations to visual targets placed 120° apart. 4 Perform a rhythmic arm lifting and lowering task while holding a 50-cm lightweight wooden pole, 1.91 cm in diameter, with the hands kept shoulder width apart. Raise the pole to eye level and then back down to the legs, keeping elbows extended. 5 Perform rhythmic left and right horizontal trunk rotations to approximately 30° in each direction. 6 Perform rhythmic forward trunk bending and extension to return to the upright (erect) short-sitting position. The amplitude of trunk flexion should be approximately 30°.a CTSIB Clinical Test of Sensory Interaction and Balance.lecting different shapes and sizes The 4 movements (tasks 3– 6) were based exercises; the patients did notfor the air bladder, just as different paced by the beat of a metronome, receive any other balance training orthicknesses and densities could be set to a frequency of 0.4 Hz. These physical therapy intervention duringselected for the foam pad used dur- movements were selected because the treatment period. The patientsing standing. they represent important functional were transferred from their wheel- activities of daily living and work. chairs to a low treatment plinth forA SwisDisk‡ was used for patients 2 The metronome frequency was se- all treatments.and 3, and a deflated (80%–90% of lected to represent relatively slowthe air removed) yellow Physio Gym- self-paced movement speeds. For all Patient 1 played Under Pressure in allnic§ ball (a more difficult and unsta- 6 tasks and both surfaces (cushion modes only. Patient 2 played Underble surface) was used to challenge and air bladder), a fall was recorded Pressure 80% of the time, playedpatient 1. Patients were transferred if the patients could not maintain in- Memory Match 19% of the time, andfrom their wheelchairs to a low treat- dependent balance for 20 seconds or tried the new game, Balloon Burst,ment plinth for all testing. To mini- if they could not perform the move- for the remaining 1% of the time.mize any skin irritation during test- ments without holding on with their Patient 3 played Under Pressure 70%ing (and treatment), the patients hands. A physical therapist was po- of the time and Memory Match forwere seated on their regular seat sitioned directly behind the patients the remainder of the time. Thecushions (foam-type cushions de- to provide assistance, if needed. games were played with the patientssigned to help distribute forces sitting on the treatment plinth andevenly, away from bony promi- Intervention progressed (as appropriate) to sittingnences, thus reducing the risk of ul- All treatments were performed at an on a deflated Physio Gynmic ball orceration). Each patient was in- outpatient physical therapy clinic SwisDisk; the FSA pressure mat wasstructed to perform 6 tasks (Tab. 1), operated by the Division of Physical placed between the patient and theeach 20 seconds in duration, under 2 Therapy, School of Medical Rehabil- surface (Fig. 2). The ball or diskdifferent conditions: first while sit- itation, University of Manitoba; the added uncertainty to the system, as itting on their regular seat cushions program was designed partially for would randomly modify the surfaceand then while sitting on the air blad- the clinical training of undergraduate reaction forces; for people with sen-ders. Hand support was not permit- physical therapist students under su- sation, it would distort or delay theted for this test. pervision. Each patient attended pressure information from seat-to- twelve 30- to 45-minute exercise ses- surface contact.‡ PI Professional Therapy Products Inc, PO sions 2 or 3 times per week. TheBox 1067, Athens, TN 37371.§ Ledraplastic Spa, Via Brigata Re 1, Osoppo, exercise regimen consisted solely of As improvements in game playUdine, Italy 33010. our COP-controlled video game- scores were noted and as improve-October 2007 Volume 87 Number 10 Physical Therapy f 1393
  6. 6. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain InjuriesFigure 2.System setup. The patient sits on the pressure mat (1), which is connected to the laptop by the interface box (2). The laptop currentlydisplays the game Balloon Burst. The pressure mat is currently placed on top of the SwisDisk (3); the Physio Gymnic (4) ball also isdepicted.ments in balance and head-arm-trunk computer display. Initially, the movement. Alternately, very slowcontrol were observed, the treat- program was set so that a rela- speeds required the patients toment program progressed. In gen- tively small COP excursion pro- hold the COP position at the de-eral, the minimum game play score duced a moderate to large game sired locations for longer periodswas set at 50% success—for exam- cursor movement. As game play of time. For example, when a lat-ple, catching the object 50% of the scores improved and as balance eral or anterior trunk tilt was re-time in Under Pressure. or trunk control improved, scal- quired to catch the object at a ing was increased so that larger very slow target speed, the pa-There were a number of game pa- and larger COP excursions were tient would have to hold the tiltedrameters and task conditions that required to move the game position for a few seconds. Gamecould be adjusted and modified cursor. speed was adjusted, scaling waswhen appropriate in order to permit adjusted, or both as game playthe treatment program to progress 2. The speed of the game targets scores improved and as balanceand to challenge the patients. These (objects) was adjusted. Initially, improved.included the following 5 items: the speed was set to slow; this setting permitted more time for 3. The exercise interval was in-1. A scaling factor was used to map the patients to move and posi- creased by increasing the number the magnitude of COP excursion tion the game cursor (COP) to of game targets, that is, the num- (movement range) to the excur- catch the object. Increasing the ber of objects. Initially, the in- sion of the game cursor on the game speed required faster COP terval duration was set to be-1394 f Physical Therapy Volume 87 Number 10 October 2007
  7. 7. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries tween 15 and 30 seconds of Dynamic Balance Assessment recorded before exercise for patient game play. As tolerated, this dura- The results of the dynamic balance 3. In addition, hand support was re- tion was increased to 60 to 90 assessment are shown in Table 2. quired during all 6 tasks on both sur- seconds in order to increase the faces (cushion and disk). After exer- number of repetitions and to Before exercise, patient 1 main- cise, patient 3 was able to maintain build endurance. tained independent short-sitting bal- independent short-sitting balance for ance for the full 20 seconds during 20 seconds during all tasks on both4. Reliance on hand support for bal- all 6 tasks when he sat on his regular surfaces. ance progressed to less reliance, wheelchair cushion; in addition, from using both hands to using short-sitting balance was maintained Discussion one hand and then using no hand for the eyes-open, head rotation, and Here we report on the feasibility and support. arm lifting tasks when he sat on the benefits of interactive COP-controlled deflated Physio Gymnic ball. How- video game-based exercises for short-5. Air bladders were used to intro- ever, for 3 other conditions, when sitting balance rehabilitation. Our ob- duce a destabilizing compliant patient 1 sat on the deflated Physio servations demonstrate that improved support surface. Once the pa- Gymnic ball, he clearly lost short- rehabilitative interventions, which in- tients were able to play the games sitting balance, and therapist inter- corporate a functional approach to without hand support, a compli- vention was required to prevent a training and graded balance condi- ant support surface was intro- fall. After exercise, patient 1 main- tions or disturbances (ie, sensory feed- duced. By changing the amount tained independent short-sitting bal- back and increased muscle activity), of air in the Physio Gymnic ball or ance for the full 20 seconds during can produce substantial improve- SwisDisk, an appropriate training all 6 tasks on both surfaces. ments in dynamic short-sitting bal- level was achieved and progress ance. Complete spinal cord lesions was made. For patients 2 and 3, For patient 2, 9 falls were recorded below T10, T11, or T12 will abolish within 3 treatment sessions, air before exercise. Patient 2 was able to proprioceptive and cutaneous or bladders were being used for the maintain independent short-sitting pressure sensation in the hip joints entire treatment session. For pa- balance (without the use of his and in the pelvis structures and tient 1, an air bladder was used hands for support) only while sitting thereby will reduce the available spa- immediately, as this type of sup- on the wheelchair cushion in the tial information, which is needed to port surface was required to chal- eyes-open, head rotation, and arm maintain short-sitting balance in the lenge his balance control. lifting tasks. After exercise, patient 2 unsupported upright position. This ef- was able to maintain independent fect is amplified without vision—thatOutcomes short-sitting balance for the full 20 is, in dark or low-light conditions—Questionnaire seconds during all tasks on both sur- and during sitting on different compli-The questionnaire results were very faces (cushion and disk). ant surfaces. Learning a new balancepositive, with all patients answering sense is an important objective during“strongly agree” to all 5 questions. Before training with the COP- rehabilitation for people with com-All of the patients indicated that they controlled video game-based system, plete thoracic spinal cord lesions andenjoyed the video game-based tool, patient 3 typically would attend only traumatic brain injuries. Functionally,preferring it over exercise programs to balance exercises for 20 to 30 sec- during game play, interactive move-that they had performed in the past, onds at a time, with the training ses- ments are random, varying in direc-and indicated that they would like to sions typically lasting for only 10 to tion, amplitude, and precision; thus,continue the treatment. The adjust- 15 minutes. After practice with the during game play, people need toable parameters and different modes COP-controlled video game-based make slow, maintained goal-directedof the tool offered sufficient diffi- system, patient 3 was able to main- movements or quick shifts in the COPculty levels; even patient 1, who par- tain concentration during the games trajectory. At moderate to high targetticipated in Paralympic sports, found (balance exercises) for up to 2 to 3 (object) speed settings, these bodythe games to be challenging. In ad- minutes at a time and would repeat movements require active mediolat-dition, patient 2 particularly enjoyed this activity 10 to 15 times. The du- eral and anteroposterior weightthe new game, Balloon Burst, prefer- ration of the exercises increased shifts—for example, acceleration ofring it over the other games. from short-interval training (approx- the center of mass toward the in- imately 20 seconds for 10 –15 min- tended target, followed quickly by utes) to 2-minute interval training for body deceleration to stop the 20 to 30 minutes. Twelve falls were movement.October 2007 Volume 87 Number 10 Physical Therapy f 1395
  8. 8. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain InjuriesTable 2.Dynamic Balance Assessment Resultsa Surface Task Result for: Patient 1 Patient 2 Patient 3 Before After Before After Before After Exercise Exercise Exercise Exercise Exercise Exercise Cushion 1 — — — — Fall — 2 — — Fall — Fall — 3 — — — — Fall — 4 — — — — Fall — 5 — — Fall — Fall — 6 — — Fall — Fall — Air bladder 1 — — Fall — Fall — 2 Fall — Fall — Fall — 3 — — Fall — Fall — 4 — — Fall — Fall — 5 Fall — Fall — Fall — 6 Fall — Fall — Fall —a Dashes indicate that no fall occurred.The interactive gaming activities (ex- fects produced in the COP trajectory In future treatment programs, theercises) were designed around a flex- by different materials.33 questions used to quantify the levelible pressure mat for COP recording. of motivation or fun during a partic-This method allows training to be A main observation in this case re- ular therapy program will be neutralconducted on compliant or uneven port was that the interactive gaming in order to not lead or bias an indi-surfaces; that is, the mat may be intervention can motivate people vidual’s responses.placed on top of a compliant or ir- with chronic spinal cord and trau-regular surface rather than on a force matic brain injuries to practice dy- Another observation was that afterplatform. The ability to apply a namic movement tasks. This ap- exercise, all patients exhibited de-graded compliant support surface, proach was applied effectively to creased fall rates. In particular, afteralong with the adjustable parameters people with severe balance and mo- exercise, patients 2 and 3 were ableof the tool, offers a variety of diffi- bility limitations and to an individual to maintain independent short-culty levels. For example, a deflated who actively participated in sports. sitting balance while performingPhysio Gymnic ball was required to All 3 people indicated that they en- many demanding functional tasks.challenge the balance of patient 1, joyed the video game-based tool, pre- This observation is consistent withwho is active in wheelchair racing ferring it to normal treatment regi- the observation that intense practiceand team sports. Similarly, a Swis- mens, and that they would like to of a motor task following a completeDisk was used to increase the bal- continue the treatment. These obser- spinal cord lesion can result in sub-ance requirements of the exercises vations showed that our COP- stantial functional improvements.for patients 2 and 3. Thus, each game controlled video game system pro-and session could be enhanced to vided a motivational and challenging During game play, voluntary move-meet the needs and performance lev- environment. It has been shown that ments were generated in multipleels of each patient. Such flexibility with the proper experiences and vol- directions and were varied in ampli-can better prepare people to interact ume of practice, the spinal cord can tude and speed. The patients pro-and deal with more dynamic envi- establish new neuronal associations duced accurate targeted movements,ronmental conditions. Flexible pres- and demonstrate functional improve- were competitive at least 50% of thesure mats permit accurate COP ments.34,35 One limitation of our time, and did not fall. It was evidentrecording while eliminating the non- treatment program is the potentially that there was a temporary loss oflinear distortions and damping ef- biased language in the questionnaire. balance and unwanted movements1396 f Physical Therapy Volume 87 Number 10 October 2007
  9. 9. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries(because of poor sensory control, be coupled effectively with video 2 Douglas J. Wheelchair exercises for fitness and confidence. Diabetes Self Manag.motor control, or both and the effect game play and that this treatment 2005;22:47– 48, 51–53, 55.of the compliant support surface); offers the following values for reha- 3 Remple MS, Bruneau RM, VandenBerg PM,however, corrective balance reac- bilitation: goal-directed and intended et al. Sensitivity of cortical movement rep- resentations to motor experience: evi-tions were generated successfully. behavior with random target pre- dence that skill learning but not strengthThus, both goal-directed voluntary sentation and motion; the ability to training induces cortical reorganization. Behav Brain Res. 2001;123:133–141.movements (feedforward control) map small to large active COP excur- 4 Garr JH, Shepherd RB. Neurological Reha-and corrective balance reactions sions to game cursor excursion on bilitation: Optimizing Motor Performance.(feedback control) were evident dur- the computer display; the choice of a Oxford, United Kingdom: Butterworth- Heinemann Ltd; 1998.ing game play. wide range of game speeds and 5 Richards CL, Malouin F, Bravo G, et al. The thus movement speeds; the ability role of technology in task-oriented trainingLike current biofeedback and virtual to select accuracy from small to large in persons with subacute stroke: a ran- domized controlled trial. Neurorehabilreality systems, the interactive video target (object) sizes; multitasking (in- Neural Repair. 2004;18:199 –211.game system provided the patients corporation of gaze control [head 6 Kwakkel G. Impact of intensity of prac-and the therapist with instantaneous and smooth pursuit], attention to tice after stroke: issues for consideration. Disabil Rehabil. 2006;28:823– 830.feedback about performance and game play strategy [target motion 7 Cogan A, Madey J, Kaufman W, et al. Ponggoal attainment on a moment-to- and prediction of final location], game as a rehabilitation device. In: Warrenmoment basis. The patients and the body movements, and balance con- CG, ed. Fourth Annual Conference on Systems and Devices for the Disabled. Se-therapist were able to measure their trol); and rewards, with moment-to- attle, Wash: University of Washingtonsuccessful progression to more com- moment feedback about goal attain- School of Medicine; 1977:187–188.plex tasks and support surfaces in ment and positive reinforcement, 8 Nelson DL, Konosky K, Fleharty K, et al. The effects of an occupationally embed-real time. Performance also could be both visual and audio. In addition to ded exercise on bilaterally assisted supina-logged on a trial-by-trial basis by use the training program being enjoy- tion in persons with hemiplegia. Am J Oc- cup Ther. 1996;50:639 – 646.of the report feature. In future treat- able, all 3 patients showed decreased 9 Malone TW. Heuristics for designing en-ment programs, the functionality of fall rates after the video game-based joyable user interfaces: lessons fromthe report feature of the video game exercise therapy. The portability of computer games. In: Proceedings of the 1982 Conference on Human Factors insystem will be expanded to include the system affords its use in moni- Computing Systems. New York, NY: ACMadditional outcome measures detail- tored at-home programs, a feature Press; 1982:63– 68.ing a patient’s performance. that makes this therapy approach 10 Cunningham D, Krishack M. Virtual real- ity: a holistic approach to rehabilitation. cost-effective. Stud Health Technol Inform. 1999;Further motivation might be 62:90 –93.achieved through the development Ms Betker, Mr Desai, and Dr Szturm pro- 11 Tsang WW, Hui-Chan CW. Effects of exer- cise on joint sense and balance in elderlyof a universal input device to allow vided concept/idea/project design and writ- men: Tai Chi versus golf. Med Sci Sportsthe pressure mat to be used with ing. Mr Desai, Ms Nett, and Ms Kapadia Exerc. 2004;36:658 – 667.commercial video games. This mod- provided data collection. Ms Betker, Mr De- 12 Glanz M, Klawansky S, Chalmers T. sai, and Ms Kapadia provided data analysis. Biofeedback therapy in stroke rehabilita-ification will increase the selection tion: a review. J R Soc Med. 1997; Ms Betker and Dr Szturm provided projectof games (an important factor in management and facilities/equipment. Ms 90:33–39.keeping players motivated and inter- Nett and Dr Szturm provided patients. Dr 13 Dozza M, Chiari L, Chan B, et al. Influence of a portable audio-biofeedback device onested) and eliminate the cost of hav- Szturm provided institutional liaisons. All au- structural properties of postural sway.ing to program new games. Masked, thors provided consultation (including re- J Neuroengineering Rehabil. 2005;2:13.randomized clinical trials also are re- view of manuscript before submission). 14 Geiger RA, Allen JB, O’Keefe J, Hicks RR. Balance and mobility following stroke: ef-quired to confirm these preliminary This work was funded by a Manitoba Health fects of physical therapy interventionsobservations and to provide a com- Research Council Studentship and a Natural with and without biofeedback/forceplate Sciences and Engineering Research Council training. Phys Ther. 2001;81:995–1005.parison of the effects of this treat- Fellowship. 15 Bourbonnais D, Bilodeau S, Lepage Y,ment with the effects of other, con- et al. Effect of force-feedback treatmentsventional therapies in parallel groups This article was submitted August 10, 2006, in patients with chronic motor deficits af- and was accepted May 23, 2007. ter a stroke. Am J Phys Med Rehabil.of patients. 2002;81:890 – 897. DOI: 10.2522/ptj.20060229 16 Yoo E-Y, Chung B-I. The effect of visualConclusions feedback plus mental practice on symmet- rical weight-bearing training in peopleHere we report on the benefits of with hemiparesis. Clin Rehabil. 2006;our video game-based exercise regi- 20:388 –397. Referencesmen. Our observations demon- 1 Huxham FE, Goldie PA, Patla AE. Theoret- 17 Jack D, Boian R, Merians AS, et al. Virtual reality-enhanced stroke rehabilitation.strated that graded, dynamic balance ical considerations in balance assessment. IEEE Trans Neural Syst Rehabil Eng.exercises on different surfaces can Aust J Physiother. 2001;47:89 –100. 2001;9:308 –318.October 2007 Volume 87 Number 10 Physical Therapy f 1397
  10. 10. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries18 Todorov E, Shadmehr R, Bizzi E. Aug- 24 O’Connor TJ, Cooper RA, Fitzgerald SG, 30 Collins JJ, De Luca CJ, Burrows A, et al. mented feedback presented in a virtual et al. Evaluation of a manual wheelchair Age-related changes in open-loop and environment accelerates learning of a dif- interface to computer games. Neuroreha- closed-loop postural control mechanisms. ficult motor task. J Mot Behav. 1997; bil Neural Repair. 2000;14:21–31. Exp Brain Res. 1995;104:480 – 492. 29:147–158. 25 Betker AL, Szturm T, Moussavi Z. Develop- 31 Shumway-Cook A, Horak FB. Assessing the19 Schultheis MT, Rizzo AA. The application ment of an interactive motivating tool for influence of sensory interaction of bal- of virtual reality technology for rehabilita- rehabilitation movements. Conf Proc IEEE ance: suggestion from the field. Phys Ther. tion. Rehabil Psychol. 2001;46:296 –311. Eng Med Biol Soc. 2005;3:2341–2344. 1986;66:1548 –1550.20 You SH, Jang SH, Kim YH, et al. Virtual 26 Betker AL, Szturm T, Moussavi ZK, Nett C. 32 Allum JH, Zamani F, Adkin AL, Ernst A. reality-induced cortical reorganization and Video game-based exercises for balance re- Differences between trunk sway charac- associated locomotor recovery in chronic habilitation: a single-subject design. Arch teristics on a foam support surface and on stroke: an experimenter-blind randomized Phys Med Rehabil. 2006;87:1141–1149. the Equitest ankle-sway-referenced sup- study. Stroke. 2005;36:1166 –1171. port surface. Gait Posture. 2002; 27 Baratto L, Morasso PG, Re C, et al. A new 16:264 –270.21 Fung J, Richards CL, Malouin F, et al. look at posturographic analysis in the clin- Treadmill and motion coupled virtual real- ical context: sway-density versus other pa- 33 Betker AL, Moussavi Z, Szturm T. On mod- ity system for gait training post-stroke. Cy- rameterization techniques. Motor Control. eling center of foot pressure distortion berpsychol Behav. 2006;9:157–162. 2002;6:248 –273. through a medium. IEEE Trans Biomed Eng. 2005;52:345–352.22 Bryanton C, Bosse J, Brien M, et al. Feasi- ´ 28 Szturm T, Fallang B. Effects of varying ac- bility, motivation, and selective motor celeration of platform translation and 34 Edgerton VR, Kim SJ, Ichiyama RM, et al. control: virtual reality compared to con- toes-up rotations on the pattern and mag- Rehabilitative therapies after spinal cord ventional home exercise in children with nitude of balance reactions in humans. injury. J Neurotrauma. 2006;23:560 –570. cerebral palsy. Cyberpsychol Behav. J Vestib Res. 1998;8:381–397. 35 Harkema SJ. Neural plasticity after human 2006;9:123–128. 29 Norris JA, Marsh AP, Smith IJ, et al. Ability spinal cord injury: application of locomo-23 Webster JS, McFarland PT, Rapport LJ, of static and statistical mechanics posturo- tor training to the rehabilitation of walk- et al. Computer-assisted training for im- graphic measures to distinguish between ing. Neuroscientist. 2001;7:455– 468. proving wheelchair mobility in unilateral age and fall risk. J Biomech. 2005; neglect patients. Arch Phys Med Rehabil. 38:1263–1272. 2001;82:769 –775.1398 f Physical Therapy Volume 87 Number 10 October 2007
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