Games for Health Conference 2011

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Grace J Kim
"Utilizing Games/Technology for Stroke Population"

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  • Naturally, clinicians have utilized the games to promote intense mass practice needed to facilitate changes in the system in an engaging and fun way.
  • Sh: flexion/extension, adduction and abduction
  • Pronation/supination Wrist: flex/ext, ulnar/radial deviation
  • Belinda Lange-
  • Games for Health Conference 2011

    1. 1. Utilizing Games/Technology for Stroke Population Grace J Kim MS, OTR/L NewYork-Presbyterian Hospital [email_address] May 19, 2011
    2. 2. Objectives <ul><li>Describe use of technology/games in rehab at NYPH </li></ul><ul><ul><li>Upper extremity robotics therapy </li></ul></ul><ul><ul><li>Wii Sports </li></ul></ul><ul><li>Unique clinical needs for stroke population </li></ul><ul><li>Directions for future use </li></ul>
    3. 3. Stroke Rehab Framework <ul><li>Motor Learning </li></ul><ul><li>Neuroplasticity </li></ul>
    4. 4. Motor Learning <ul><li>Practice/experience leading to changes in capacity for skilled action </li></ul><ul><li>Performance improvement  amt of practice </li></ul><ul><li>Task variation </li></ul><ul><li>Cognition is vital </li></ul><ul><li>Performance feedback </li></ul>
    5. 5. Neuroplasticity <ul><li>Cortical areas are not fixed, but adaptive in response to demand on system (learning, disuse, environment) </li></ul><ul><li>Increased sensory/motor input  increase neural connections </li></ul><ul><li>Increase skill  increase cortical representation </li></ul>
    6. 6. Games <ul><li>Interactive </li></ul><ul><li>Fun/emotionally engaging </li></ul><ul><li>Active experiential learning </li></ul><ul><li>Immersion/sensory rich </li></ul><ul><li>Rules/cognition </li></ul><ul><li>Goals </li></ul>
    7. 7. Unique Qualities of Games in Rehab <ul><li>Motivation </li></ul><ul><li>Engagement </li></ul><ul><li>Distraction (pain, stiffness, anxiety) </li></ul><ul><li>Intervention for cognition, visual perceptual skills </li></ul><ul><li>Mass practice </li></ul>
    8. 9. Clinical Considerations <ul><li>Stroke population: physical, cognitive, and psychological deficits </li></ul><ul><li>Physical </li></ul><ul><ul><li>Hemiparesis of arm/leg </li></ul></ul><ul><ul><li>Decreased sitting/standing balance </li></ul></ul><ul><ul><li>Decreased mobility </li></ul></ul><ul><li>Visual/Perceptual </li></ul><ul><ul><li>Visual field cut </li></ul></ul><ul><ul><li>Inattention to left side </li></ul></ul><ul><li>Sensation </li></ul><ul><ul><li>Light touch </li></ul></ul><ul><ul><li>Proprioception </li></ul></ul>
    9. 10. Clinical Considerations <ul><li>Psychological </li></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>anxiety </li></ul></ul><ul><li>Cognitive </li></ul><ul><ul><li>Memory </li></ul></ul><ul><ul><li>Sustained attention/focus </li></ul></ul><ul><ul><li>Overall cognitive load </li></ul></ul><ul><ul><li>Receptive aphasia </li></ul></ul><ul><li>Cannot assume that stroke pop learns in same way or rate </li></ul>
    10. 11. Robotics Therapy <ul><li>Interactive Motion Technologies (Watertown, MA) </li></ul><ul><li>InMotion Shoulder </li></ul><ul><ul><li>Shoulder and elbow AAROM </li></ul></ul><ul><ul><li>Horizontal plane </li></ul></ul><ul><ul><li>Safe (excursions, arm supported) </li></ul></ul><ul><ul><li>Play games by moving shoulder/elbow </li></ul></ul>
    11. 12. Robotics Therapy <ul><li>InMotion wrist </li></ul><ul><ul><li>AAROM forearm </li></ul></ul><ul><ul><li>AAROM wrist </li></ul></ul><ul><ul><li>Play game with movements of the forearm or wrist </li></ul></ul>
    12. 13. Robotics Therapy <ul><li>Integrates motor learning principles </li></ul><ul><ul><li>increased practice </li></ul></ul><ul><ul><li>Task variability </li></ul></ul><ul><ul><li>Extrinsic feedback (visual, auditory, haptic) </li></ul></ul><ul><ul><li>Feedback on performance </li></ul></ul><ul><li>Integrates neuroplasticity principles </li></ul><ul><ul><li>Use it or lose it </li></ul></ul><ul><ul><li>Enriched environment  increased demand on system </li></ul></ul><ul><ul><li>Brain adapts to increased demand </li></ul></ul>
    13. 14. Robotics Therapy <ul><li>Very basic visual screen </li></ul><ul><li>No extraneous sensory information </li></ul><ul><li>Provides physical asst if needed to complete task </li></ul><ul><li>Stroke inpatients engaged and able to tolerate 45-60 min. </li></ul><ul><li>Pts tired at end of session, but engaged </li></ul>
    14. 15. InMotion Shoulder <ul><li>Set up/ research protocol </li></ul>
    15. 16. InMotion Shoulder <ul><li>Shoulder abduction/adduction </li></ul>
    16. 17. InMotion Shoulder <ul><li>Shoulder flex/extension </li></ul>
    17. 18. InMotion Shoulder <ul><li>Pong Game </li></ul>
    18. 19. InMotion Shoulder <ul><li>Squeegie Game </li></ul>
    19. 20. Whose Appropriate for robotics? <ul><li>Mod A transfers </li></ul><ul><li>At least trace AROM </li></ul><ul><li>Able to attend to task for 15 minutes blocks </li></ul><ul><li>Adequate visual acuity </li></ul><ul><li>Supervision for sitting balance </li></ul>
    20. 21. Robotics <ul><li>Pros </li></ul><ul><ul><li>Severely impaired patient can participate in intense mass practice </li></ul></ul><ul><ul><li>Provides physical asst </li></ul></ul><ul><ul><li>Low visual/cognitive load </li></ul></ul><ul><ul><li>Tolerates 45-60 min </li></ul></ul><ul><li>Cons </li></ul><ul><ul><li>Expensive </li></ul></ul><ul><ul><li>Space </li></ul></ul><ul><ul><li>Does not lead to functional improvements </li></ul></ul>
    21. 22. Wii Sports <ul><li>Bowling </li></ul><ul><li>Tennis </li></ul>
    22. 23. Wii Sports <ul><li>Various games such as bowling, tennis, golf, etc with differing demands on sensory and motor system </li></ul><ul><li>Very engaging sensory enriched environment </li></ul><ul><li>Interact with game with hand control device </li></ul><ul><li>Stroke pt tolerates ~ 10 min, non-neuro pt 60 min </li></ul>
    23. 24. Whose Appropriate for Wii Sports? <ul><li>Able to tolerate enriched sensory stimuli </li></ul><ul><li>Able to tolerate sitting upright </li></ul><ul><li>No shoulder or elbow AROM ok </li></ul><ul><li>Adequate wrist/hand function to use control device (grasp, dexterity) </li></ul>
    24. 25. Limitations to using Wii <ul><li>Extraneous sensory stimuli  high cognitive load </li></ul><ul><li>Grasp/dexterity </li></ul><ul><li>Minority of pts are appropriate </li></ul><ul><li>Tolerate ~10 min </li></ul>
    25. 26. Benefits of Wii <ul><li>Fun! </li></ul><ul><li>Motivating/engaging </li></ul><ul><li>Higher level pts (balance, endurance) </li></ul><ul><li>Increasing cognitive load (visual stim, divided attention) </li></ul><ul><li>Inexpensive/accessible </li></ul>
    26. 27. Gaming and Rehab Technology <ul><li>Build in ways to modify the sensory stimuli </li></ul><ul><li>Consider physical deficits of clients when designing control device </li></ul><ul><li>Ability to adjust game to fit the cognitive and physical needs of patient </li></ul><ul><li>Collaboration of game designers and clinicians critical </li></ul><ul><li>Combine other technology with games (assist with AROM while playing game) </li></ul>
    27. 28. Expanding Scope of Rehab Games <ul><li>Games for Stroke Population </li></ul><ul><ul><li>motor learning </li></ul></ul><ul><ul><li>Compliance with home exercises </li></ul></ul><ul><ul><li>Speech </li></ul></ul><ul><ul><li>Cognition </li></ul></ul><ul><ul><li>Stroke prevention education </li></ul></ul>
    28. 29. References <ul><li>Burridge, J (2009). Principles of motor learning in rehabilitation. International Neurorehabilitation Symposium . University of Zurich </li></ul><ul><li>Cole, M. (2008). Applied theories in occupational therapy: a practical approach. Thorofare, NJ: Slack Inc </li></ul><ul><li>Cramer, S.C., Sur, M., Dobkin, B.H., O’Brien, C., Sangar, T. D., Trojanowski, J.Q. et al (2011). Harnessing neuroplasticity for clinical applications . Brain , 1-19. </li></ul><ul><li>Krakauer, J. (2006). Motor learning: its relevance to stroke recovery and neurorehabilitation. Current Opinion ni Neurology , 19: 84-90. </li></ul><ul><li>Metcalf B.L., & Yankou, D. (2003). Using gaming to help nursing students understand ethics. Journal of Nursing Education , 42(5): 212-215. </li></ul><ul><li>Ross, D. (2010). Game Theory,  The Stanford Encyclopedia of Philosophy (Fall 2010 Edition) , Edward N. Zalta (ed.), URL = <http://plato.stanford.edu/archives/fall2010/entries/game-theory/>. </li></ul><ul><li>Schmidt, R. A. and Wrisberg, C. A. (2004). Motor Learning and Performance , Third Edition . Champaign, IL: Human Kinetics. </li></ul><ul><li>Sprengel, A.D. (1994). Learning can be fun with Gaming. Journal of Nursing Education , 33(4): 151-152. </li></ul>

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