USE OF VIDEO GAMING AS AN ADJUNCT

DURING OUTPATIENT STROKE

REHABILITATION TO OBTAIN UPPER

EXTREMITY TASK SPECIFIC PRACTICE

AND IMPROVE SITTING BALANCE

Combined Section Meeting 2010

San Diego, CA February 17-20, 2010

Ann Reinthal, PT, PhD, NCS Cleveland State University

Susan Linder, PT, MHS, NCS Lakewood Hospital

Kathy Szirony, PT Cleveland Clinic

Mary Milidonis, PT, PhD Cleveland State University

Course description

• Current research supports that multiple repetitions of task specific practice are essential to improvement in function post stroke. However, recent work has shown that individuals post stroke are not getting the necessary repetitive practice in the outpatient setting, especially related to upper extremity activities. This presentation describes the use of video gaming in individuals post stroke, with the goal of providing additional repetitive, task-specific upper extremity practice. It also reviews the results of a pilot study assessing the effectiveness using gaming in a group of individuals with chronic stroke.

• Full handout available at: www.csuohio.edu/Sciences/Dept/HealthSciences/Graduate/PT/Index.html Reinthal, Linder, Szirony, & Milidonis; not to

be copied without permission

Objectives

• Understand the importance of repetitive task specific practice in recovery of function post stroke, discuss the difference and controversy regarding repetitive task practice versus impairment-based interventions, and review evidence on the occurrence of repetitive task specific practice in the current outpatient setting.

• Analyze how video games, specifically Wii, PlayStation2 with the EyeToy, and Rock Band can be used and modified for individuals at various levels of function post stroke to:

– Achieve repetitive task specific upper extremity practice

– Address impairments

– Improve sitting balance

Objectives

• Discuss feasibility issues related to using video gaming in an outpatient environment

• Interpret changes in motor function in a group of individuals with chronic stroke (n=6) as a result of video gaming

• Identify additional questions raised by this pilot clinical study and directions for additional

investigation.

Introduction

Literature Review and Study Aims

Repetitive Task Practice

1. Repetitive task practice for person with

stroke

2. Obstacles for adequate practice

3. Approaches that apply repetitive task

practice

Repetitive task specific practice

• Task specific practice results in more

functional improvement than traditional

neuromuscular rehabilitation approaches. (Brosseau et al. 2006; Duncan et al. 2005; Gresham et al.

1995)

• Multiple repetitions of task practice, such

as eating with a spoon or combing hair, are

essential to improvement in that specific

function post stroke. (Kleim & Jones 2008; Boyd &

Winstein 2003; Boyd & Winstein 2006; Wolf et al. 2006;

Boyd et al. 2009)

Practice repetitions

• While the magnitude of practice repetitions is not yet fully delineated for various motor skills and after differing degrees of brain injury, it is thought that individuals post stroke must practice a task for a minimum of several thousand repetitions in order to relearn a task. (Kleim & Jones 2008; Boyd et al. 2009)

– Experience-dependent neuroplasticity (Kleim & Jones 2008)

Repetitive practice in rehabilitation

• Recent research has begun to measure the amount of practice that occurs in a typical rehabilitation program

• Individuals post stroke are not getting the necessary repetitive practice in the outpatient setting, especially related to upper extremity activities.

• On average in a 36 minute session addressing the UE :– 39 active assisted UE movements

– 12 purposeful UE movements

(Boyd et al. 2009; Lang et al. 2007)

Obstacles to obtaining adequate

practice • There are a large number of UE tasks

to be practiced

• While there is some transfer of learning between similar tasks, such as picking up a coffee mug and a can of soda, practicing these tasks would not necessarily be helpful for learning to write with a pencil. (Kleim & Jones 2008; Lang et al. 2007)

Obstacles to obtaining

adequate practice

• Repetitive practice of a single task is

often boring for adults. (Betker et al. 2007;

Flynn et al. 2007; Rand et al. 2008; Yavuzer et al.

2008)

– Both patient and therapist

Obstacles to obtaining adequate practice

• Learner must actively engage in task practice– It is not adequate to be passively moved through

the activity. (Lang et al. 2007; Lotze et al. 2003)

• In order for the task to be completed correctly, a skilled professional must often supervise. – Expensive to provide the hours of training that are

frequently part of the typical research trials that have resulted in changes in upper extremity function post stroke. (Flynn et al. 2007; Rand et al. 2008; Yavuzer et al. 2008)

Approaches that provide

repetitive task practice

• Constraint-induced or forced-use therapy

– Hemiparetic arm is forced to practice various tasks repetitively, usually by constraining the non-hemiplegic arm.

– Individuals who improve in response to this type of therapy typically have higher functioning hands, with some active control of wrist and finger extension. (Wolf & Winstein 2006; Wolf 2007; Sunderland & Tuke 2005)

Approaches that provide

repetitive task practice

• Robotics

– Devices that constrain movement to occur in the correct

movement pattern during repetitive practice

– Some type of instrumentation that actively guides

movement

– Have been utilized successfully with high and low level

functioning hemiparetic arms post stroke

– These devices usually provide partial passive

assistance with the movement, and also constrain the

movement to occur in a specific “correct” movement

pattern. (Banz et al. 2008; Barker et al. 2008; Hesse et

al. 2005; Mirelman et al. 2009; Frick & Alberts 2006)

Approaches that provide

repetitive task practice • Virtual reality (VR) environments

– Have been successfully used to provide upper

extremity repetitive task practice. (Crosbie et al. 2006;

Sveistrup 2004)

– Typically provides a three-dimensional computer

generated immersion experience

– The “player” completes the task similarly to in the

real world

– The experience is typically engaging, realistic and

transfers to a comparable real world activity. (Sveistrup 2004)

Virtual Reality

• The virtual reality literature discusses the

concepts of “immersion” and “presence” (Riva et al. 2004)

• Immersion: the drawing in experience of VR

• Presence: a form of positive, active

engagement that occurs during the VR

experience

Video gaming systems

• Video gaming systems are

commercially available, inexpensive

virtual reality-type systems

– They provide engaging interaction

– Examples: Wii, PlayStation II with EyeToy,

and Rock Band

Video gaming systems

• Can be easily tailored to individuals with varying degrees of paresis post stroke

– similar to some of the robotic and VR systems

– unlike constraint-induced interventions that are only appropriate for higher functioning arms.

Video gaming systems

• Motor learning is best when an activity is

meaningful

– Practice of the task must be both functional and

engaging to the individual. (Kleim & Jones 2008)

• Gaming has become popular with older

adults, with Wii systems appearing in many

senior citizen facilities.

Video gaming systems

• Gaming has been shown to utilize significantly more energy than sedentary activities. (Graves et al. 2007)

• Enhanced cardiovascular fitness in turn has been shown to improve cognition as well as cortical plasticity. (Colcombe et al. 2004; Kramer & Erickson 2007)

– Physical activity is very low after stroke (Rand et al. 2009)

– Physical activity and exercise may protect and enhance cognitive brain function across the adult lifespan (Kramer & Erickson 2007)

Neurologic gaming research

• Gaming has recently begun to be

utilized as an effective adjunct to

physical and occupational therapy for

individuals with neurologic deficits. (Flynn

et al. 2007; Rand et al. 2008; Yavuzer et al. 2008;

Deutsch et al. 2008, Betker et al 2007)

Gaming research post stroke

Flynn et al 2007 Rand et al 2008 Yavuzer et al 2008

PS EyeToy PS EyeToy PS EyeToy -- UE

Case study, chronic

stroke

12 adults, subacute

& chronic stroke

20 inpt. <12 mo post

stroke

20 1-hr sessions Single session 30 min; 5 days/ wk;

4 wks

•Feasible

• Dyn Gt Index

•Trend FMA, Berg,

UE Func Ind, MAL,

Beck Depression Inv.

•High sense of

presence

•Difficulty grading

games for lower

functioning

• FIM scores

•no in Brunnstromstages

Gaming as an adjunct to the treatment

of individuals with neurologic deficit

• Offers:

– Unilateral practice opportunities, such as

playing tennis on the Wii

– Bilateral upper extremity activities such as

swinging a golf club or baseball bat

• Bilateral upper extremity practice has been utilized

effectively in several studies (Hesse et al. 2005;

Luft et al. 2004; Cauraugh & Kim 2002; Staines et

al. 2001) probably by inducing reorganization in

contralesional motor networks. (Luft et al. 2004;

Calcautti & Baron 2003)

Gaming as an adjunct to the treatment

• In previous research in our lab, participants found the gaming:– Engaging

– Enjoyable

– Physically tiring

• We have rarely observed the same degree of task engagement as found during gaming– The only comparable activity was working on the golf

swing with a group of golfers post stroke. (Reinthal et al. 2002)

– Activity must be meaningful

Evidence-based practice triangle

• Support from research literature (evolving)

• Clinical experience of therapist

• Meaningful to patient

Research evidence

Patient-

centered

care

Clinical

expertise

Study Aims• Begin gaming trial in a natural clinical practice

environment to assess:

– Feasibility of adding gaming as an adjunct

• without added therapy personnel costs

• using commercially available gaming equipment

• In individuals post stroke, examine whether the

practice completed through gaming leads to

improvement in:

– upper extremity function

– sitting balance

Study team• Multi-Centered

– Within and between Cleveland State University

and Cleveland Clinic Health System (Lakewood

Hospital and Cleveland Clinic Main Campus)

• Multidisciplinary effort

– Neurologic physical therapists

– Neurologic occupational therapists

– Epidemiologist/health services researcher

– Engineers

– Psychologist

– STUDENTS

Pilot Study Participants

• Currently in exercise class at Lakewood Hospital

• Hemiplegic UE with some degree of

dysfunction post stroke: Brunnstrom Stage 2-6,

but not Brunnstrom Stage 1

• Able to sit safely with back unsupported while

playing games

• Adequate communication & cognition skills to

learn and play game in three sessions or less

• Able to play game independently or with

support personnel/family after set up

Beyond the Pilot Study Phase

• Now enrolling outpatients at 2 sites

Study Design

• Pre-test post-test within subject design

• Clinical practice improvement research

– No control group (not a randomized clinical trial)

– Evaluates practice in a natural clinical practice

environment

• Translational Can often be incorporated into daily

clinical practice more readily than a RCT

Community Based Participatory

Research http://www.ahrq.gov/downloads/pub/evidence/pdf/cbpr/cbpr.pdf

• CBPR has been proposed as an approach that

combines research methods and the clinical

community

• Capacity-building strategies to bridge the gap

between knowledge produced through

research

• Translation of this research into

interventions and policies.

Best Practice CBPR www.ahrq.gov/downloads/pub/evidence/pdf/cbpr/cbpr.pdf

• Encounter between researchers and their community collaborators during each stage of research.– utilize their respective, legitimate knowledge and

expertise for examining and addressing a particular issue.

• EFFECTIVENESS NOT EFFICACY

Blue Highways on NIH Road MAPJAMA, Jan 2007, vol 297, No 4

http://www.sbm.org/outlook/0608/articles.asp?article=1

Clinical Decision Making:Matching Individuals to Games

Clinical Decision Making: Two

Step Model

• STEP I: Establish goals using Patient

Client Management Model (PCMM) and

Nagi/ICF Model

• STEP II: Based on goals, be able to

select and modify the appropriate

games

Clinical Decision Making:

Step I

• Establish goals using Patient Client

Management Model (PCMM) and

Nagi/ICF Model

Clinical Decision Making for Gaming Intervention

based on ICF/Nagi Model and PCMM (PT Guide to

Practice)

Examination: Meaningful, functional patient goal

Examination: Impairment, functional task analysis (activities), disability analysis (participation)

Evaluation: Hypothesize which impairments are limiting function

Prognosis: Collaborative goal setting and game selection based on impairments and functional

limitations to meet functional patient-centered goal

Clinical Decision Making: Complete

Examination

• Examination

1. Impairment

2. Functional task analysis (activities)

3. Disability analysis (participation)

• Specific to diagnosis

– Normal physical therapy examination

– Additional specific outcome measures

Stroke specific outcome measures

• Impairments

– Motor control: Fugl-Meyer UE Motor

– Sensation: Fugl-Meyer UE sensation

– Strength, communication, memory & thinking:

Stroke Impact Scale

– Balance: Multi-directional functional reach in

sitting, Five times sit to stand test, Activities-

Specific Balance Confidence Scale

Basis of Fugl-MeyerCrow and Harmeling-van der Wel,PhysTher v88, 2008

Brunstrom Stages Fugl-Meyer Upper Extremity

Stage1: Flaccid paralysis None

Stage 2: Minimal Movement Synergy

Tendon Reflexes

4/40

Stage 3: Voluntary Movement Synergy

Flexor and Extensor Synergy

(4+18)/40

Stage 4: Some out of Movement Synergy

Hand to Lumbar Spine; Shld Flex

> 90º; Pron/Supination

(4+18+6)/40

Stage 5: Almost independent of Movement Synergy

Shld Abd 0-90º; Shld Flex 90-180º

(4+18+6+6)/40

Stage 6: Near normal movement & speed

Tendon Reflex Symmetry and

Normal Coordination

(4+18+6+6+6)/40

Stroke specific outcome measures

• Functional limitations (activities)

– Wolf Motor Function Test

• Task-specific analysis (timed based only)

– Stroke Impact Scale (hand, ADL, and mobility

sections)

Tasks of the

WMFT

1. Forearm to table (side)

2. Forearm to box (side)

3. Extend Elbow (side)

4. Extend elbow (weight)

5. Hand to table (front)

6. Hand to box (front)

7. Reach and retrieve

Tasks of the

WMFT

9. Lift pencil

10. Lift paper clip

11. Stack checkers

12. Flip cards

13. Turn key in lock

14. Fold towel

15. Lift basket

Stroke specific outcome measures

• Disability (Participation)

– Stroke Impact Scale (participation)

Clinical Decision Making:

Evaluation

What impairments are limiting function?

– Analyze for specific motor control and strength impairments that may be limiting function on given tasks identified in exam - for example on Wolf Motor Function Test (WMFT)

– Analyze for other impairments that must be considered (cognition, sensation, etc.)

Clinical Decision Making:

Evaluation

What impairments are limiting function?

• Unable to complete item #6 on Wolf Motor Function Test (Hand to box in front)

• Hypothesize impairments limiting function:– Inadequate antigravity

shoulder flexion strength

– Inability to obtain isolated shoulder flexion with elbow extension

Clinical Decision Making:

Prognosis

Collaborative Goal Setting

• Patient’s goal(s) from exam

• Develop realistic collaborative goal(s) with patient based on examination and evaluation

EXAMPLE:

• Patient goal:– “Use arm again”

• Collaborative goal after discussion with patient:– “Use arm to stabilize paper/objects on table top”

Clinical Decision Making: Prognosis

TASK DEMANDS

• Based on collaborative goal, analyze task to determine components that need to be addressed

– Analyze task demands

– Break into functional components that must be addressed based on exam (impairments, functional limitations, disability)

EXAMPLE OF FUNCTIONAL COMPONENTS:

“Use arm to stabilize paper/objects on table top”

• Must be able to place arm on table top

• Must be able to position arm over object to be stabilized

• Must be able to grade force to stabilize object while using other arm

Clinical Decision Making: Prognosis

Determine impairments limiting function

• For a given functional component, determine what impairments you hypothesize must be addressed in order to be able to accomplish the functional component

• Comparable to short term goals

EXAMPLE

Collaborative goal: Use arm to stabilize objects on table top

Functional component from task analysis: Must be able to reach arm over table top (WMFT #6 Hand to box)

Impairments to be addressed (short term goals):

1. Inadequate antigravity shoulder flexion strength

2. Inability to obtain isolated shoulder flexion with elbow extension

Improved anti-gravity shoulder flexion

with elbow extension after 5 sessions

Pre Post

40 shoulder flexion 55 shoulder flexion

80 elbow extension 45 elbow extension

Improved anti-gravity shoulder flexion

with elbow extension after 5 sessions

Practice time Reps of practice*

Wakeboarding 74 min. 1628

Baseball 75 min. 600

Total 2 hr; 29 min. 2228

* Reps calculated from vidoetaped analysis

•Achieved practice repetitions comparable to motor learning

trials post stroke (>500) (Boyd & Winstein 2006)

•On 7 point Intrinsic Motivation Index (7 pt high), rated

gaming a 6.6/7; completing his home exercise program 4.4/7

Clinical Decision Making: Prognosis

Motor Learning Principles

• Movement is COMPLEX and VARIABLE

• Gaming offers EXPANSIVE possibilities for retraining

motor skills at multiple levels of complexity and

variability

• Incorporate motor learning principles into

development and implementation of therapeutic

interventions

• Only limited by our analysis skills, knowledge of

gaming, and creativity

Clinical Decision Making

Model

STEP IISelection and Modification of

Games

INTERVENTION PLAN

Game Selection

• After establishing collaborative goal(s):

– The therapist must know the motor control and

other requirements for the game

– The correct games must be selected

– The therapist must know how to play the games• Will not address this specifically in this presentation,

except under feasibility section

• See Appendix for games used in this project

Game selection: What you

need to know about the game

Motor control demands

Other considerations

Motivation

Game modifications and progression

Game Selection

• Motor Control Demands

– Underlying available movement repertoire

– Unilateral versus bilateral arm use

– Trunk demands

– Task specificity

– Cognitive demands

– Sensory and spatial relations impact

Clinical Decision Making for Game

Selection

• Brunnstrom stages II - III with inability to complete fine motor tasks and variable ability to complete gross motor tasks of WMFT efficiently

Clinical Decision Making for Game

Selection

• Brunnstrom stage IV with ability to complete fine and gross motor tasks of WMFT, but inefficiently and inconsistently

Clinical Decision Making for Game

Selection

• Brunnstrom stage V-VI with difficulty performing fine motor tasks of WMFT consistently and efficiently

Game Selection

• Bimanual yoked arm – Activities that incorporate large degrees of trunk

rotation• Golf, baseball swing, drumming

Game Selection

• Bimanual hand (variable trunk demands)– Bilateral symmetrical

• Bubblepop, Wishi Washi

Game Selection

• Bimanual hand (variable trunk demands)– Bilateral reciprocal

• Active assisted: Driving, Wakeboarding• Active: Boxing, Drumming

Game Selection

• Bimanual hand (variable trunk demands)– Each hand doing something different

• Guitar, target shooting, archery

Game Selection

• Unilateral arm, hand and wrist (variable trunk demands)– Frisbee, Table Tennis, Wii Resort Airsports

Game Selection

• Trunk task demands

– Mobility / Stability

Is this task specific practice?

• Cannot practice a task until there is adequate strength and motor control to practice the actual task

• This clinical decision making model allows for preparatory work on impairments and task components before moving on to practice the actual task, but as part of an engaging task

Clinical Decision Making:

Incorporating task-specificity

into gaming intervention

• Task specific practice is possible for

many games

Cognitive Demands

– Attentional demands

• Moving objects, such as tennis ball in tennis

– Executive functions

• Plan game strategy (Golf: direction of wind, type of

club to use, etc.)

– Dual-task performance

• Ability to complete a task, such as talking while

walking, or playing a Wii game while in unsupported

sitting or standing.

Adapting

to sensory

impairment

Environmental

adaptation for

left neglect

Game selection for spatial

relationship impairments

Other Considerations

• Cardiopulmonary demands

• Communication

Cardiopulmonary

Considerations

• Monitored for safety

– Heart Rate (HR monitor versus manual)

– RPE

– Pulse oximetry

• By-product: Cardiovascular conditioning

– Potentially an efficient method to meet

multiple therapeutic needs

– Consider speed demands of game

– Consider sitting versus standing practice

Aphasia and Communication

• Some games have many written

instructions or verbal comments

– This should be considered if it may

interfere with the patient’s ability to play the

game

Motivation Factor

• Taking Advantage of Patients’ Prior

Experiences

– Water Skiing

– Musicians

– Boxer

– Bowler

– Golfer

Motivation Factor

• Competition with others

• Competition with gaming system

• Socialization within the group

(Co-action)

• Need multiple game choices for a given

individual for optimal motivation

Game modifications• Be creative!

Aquaplast (splinting material) covers for controller buttons

Grading task difficulty and

progressions

Practice Repetitions in 5

Sessions

Game Practice time Repetitions*

Drumming 122 min 8296

Bubblepop 107 min 2568

Total 3 hrs 59 min 10,864

*Repetitions counted from videotape

Intrinsic Motivation Index 7/7 for gaming,

4.3/7 for HEP

Video Games Utilized

Appendix A

Feasibility of utilizing gaming

in an outpatient setting

Feasibility Considerations

Patient Therapist Facility

Safety Knowledge:

outcome

measurement

Therapist

productivity

Optimum

therapeutic

practice

Knowledge: game

selection & use

Equipment cost

Motivation to

practice

Facilitating

adherence

Support personnel

Equipment

cost/home support

(HEP)

Recognition of

time commitment

Reimbursement

Feasibility: Patient Considerations

1. Safety

2. Optimum therapeutic practice

3. Motivation to practice

4. Equipment cost/home support (HEP)

Is Independent Practice

Feasible?

• Safety– Fall risk / Fall prevention

– Guarding

– Performing gaming activities in sitting versus standing

– Consider use of harness

– Using hi-low tables or height-adjustable stools to modify demand on trunk balance implications

– Cardiopulmonary monitoring

Is Independent Practice

Feasible?

• Optimal practice to achieve therapeutic

goals (ie: cheating)

– Competitive spirit quest to win

– Overuse of non-hemiplegic UE

– Triggering games without full use of

desired (therapeutic) movement

Patient motivation to practice

• Must have gaming options that appeal

to patient

• Self-efficacy

Gaming as a Home Exercise

Program

• Set up of games in preparation for

home exercise program phase

– Patients have learned various appropriate

games as part of therapeutic intervention

– Several appropriate games can be utilized

on one disc/game for a single session of

gaming

– Patients learn basic gaming trouble

shooting

Gaming as a Home Exercise

Program

• Performing gaming activities as a part of

patient’s home exercise program

– Affordability

– Motivation / Interest

– Compliance with home program

– Quantity of repetitions

– Life-long skills for ongoing training/practice

• Promotes independent activity/exercise

Feasibility Considerations:

Therapist

1. Knowledge of outcome

measurement

2. Knowledge for game selection and

use of gaming systems

3. Facilitating adherence

4. Recognition of time commitment

Knowledge of Outcome

Measurement

• Appropriate matching of outcome

measures

• Administering outcome measures

Knowledge for game selection

and use of gaming systems

–The correct games must be

selected

–The therapist must know how to

play the games

Patient-Centered Care: Facilitating Adherence

(Shephard & Jenson 2002)

• Negotiate common ground: collaborative

relationships

• Identify and remove barriers

• Provide feedback

• Consider prescribed self-care regiment from

patient’s perspective

• Customize treatment

• Enlist family support & access resources

• Anticipate non-adherence

Recognition of time

commitment

• Therapist organizational skills

• Time investment outside of clinic,

especially learning to play the games

Feasibility Considerations:

Facility

• Therapist productivity

• Support personnel

• Costs

• Reimbursement

Productivity and Support

Personnel

• Facility expectations for productivity

• Support Personnel

– Cost

– Availability

– Creative options

• Family

• Students

• Friends

• Community

Facility costs:

Equipment and space

• Reasonable compared to VR and

robotics equipment– Affordability of commercially available games

compared to virtual reality or computerized robotics

– Eye Toy (< $100), Wii ($200-300)– Availability of gaming systems and games

• Used games, older models

• Within discretionary budgets

• Space

Reimbursement

• Gaming interventions

• Skilled reimbursable time

• Non-reimbursable independent

/supervised practice

• Documentation

Outcome Results of Gaming for

Individuals Post Stroke

• Practice Repetitions Obtained

• Changes in measures

• Wolf Motor Function

• Fugl-Myer

• Intrinsic Motivation

• Case Analysis

• Low, moderate, and high functioning

individuals

Preliminary Results

• Pilot with chronic stroke population

(N=6) who regularly attend a

community-based stroke exercise class

at Lakewood Hospital

• Expect less change than with more

acute outpatient population

Demographics

#1 #2 #3 #4 #5 #6

Age 73 69 86 62 75 59

Sex M F F M F F

Side of hemiplegia Right Right Right Right Left Right Brunnstrom arm/hand stage

2 2-3 3-4 4-5 4-5 6-7

Years post stroke 3 4.5 7 7 5.5 2

Aphasia Yes Yes No No No No *All could ambulate, at a minimum, independently at

home with a device

Practice repetitions per minute

of playing time• Extremely variable

• Depends on:

– Type of game played

• Continuous task vs. discrete task (Golf vs. BubblePop)

• Time demands of game (Golf vs. KnockOut)

– Number of players

• Fewer repetitions when more than one player

– Motor function of player

• Some players move more slowly than others

Average Practice Repetitions per Minute

• Repetition counting equipment still

under development

• Counting presented here (unless

otherwise stated) is an estimate based

on a normal individual playing the

game for ten minutes, at the beginning

level

– Counted repetitions

– Averaged to find repetitions/minute

Average Practice Repetitions per Minute

Discrete tasks/game Continuous tasks/games

Wii Bowling 5

Wii Golf 4

Wii Frisbee 4

PS BubblePop 10

PS WishiWashi 30

Wii Island Flyover 14

Wii Powercruising 14

Wii Wakeboarding 11

PS Kung2* 38

PS KnockOut* 65

* Boxing games can be considered continuous when played

in a continuous manner, as measured here; otherwise

discrete

Practice repetitions and time

# of

repetitions

# of sessions

attended

Total hours

played

1 8183 29 9.9

2 11500 29 11.1

3 7008 30 14.8

4 27965 29 18.7

5 15987 26 10.4

6 14576 21 14.3

Wolf Motor Function Test• Minimal Clinically Important Difference (MCID)

– 19 seconds in acute stroke (Lang et al.,2008)

– 1.5 to 2 seconds in subacute stroke (Lin et al, 2009)

– Minimal detectable change

– 4.36 seconds in subacute stroke (Lin et al 2009)

– Mean improvement of 10 seconds in this chronic population

*P = 0.043 Wilcoxon

Signed Ranks Test

Pre Post

Mean 52 42

SD 51 54

Median 36 11

Functional Change: Wolf

Motor Function Test

0

20

40

60

80

100

120

#1 #2 #3 #4 #5 #6

S

e

c

o

n

d

s

Subject

Mean Time WMFT*

Pre

Post

Fugl-Meyer

• 66 point Likert scale

• Scale from 0 cannot perform, 1 performs partially, 3 performs fully

• Minimal Clinically Important Difference (MCID): 10% of score (6.6 points) (Gladstone et al 2002)

• Only one participant with >6 point improvement, although two others with 5 point improvement

Pre Post

Mean 35 39

SD 24 26

Median 39 49

P = 0.102 Wilcoxon

Signed Ranks Test

Changes in Motor Control:

Fugl-Meyer UE Motor

0

10

20

30

40

50

60

#1 #2 #3 #4 #5 #6

F

M

S

c

o

r

e

Subject

Pre

Post

Trunk control and balance? Multi-directional Functional Reach in Sitting

0

20

40

60

80

100

120

140

#1 #2 #3 #4 #5 #6

C

m

Subject

Combined Functional ReachPre

Post

Intrinsic Motivation Index (IMI)• Survey instrument

• 7 point scale (maximum score showing high

motivation is 7.0)

• Motivation to complete home exercise program

(HEP) significantly less than to game or attend

exercise class

• Friedman test

*P=0.028

Gaming Ex

Class

HEP

Mean 6.6 6.5 5.2

SD 0.49 0.74 0.87

Median 6.7 6.8 5.2

Intrinsic Motivation Index*

0

1

2

3

4

5

6

7

#1 #2 #3 #4 #5 #6Subject

I

M

I

S

c

o

r

e

Video gaming

Exercise class

Home program

Five-times Sit to Stand Test

Activities-specific Balance Confidence Scale

Stroke Impact Scale

Functional Reach Test

No significant changes in pilot group

p>0.05

Three Levels of Function:

Case AnalysisClinical Implications and Discussion

• Low functioning upper extremity

– Brunnstrom UE/hand Stage 2 to 3

• Moderate functioning upper extremity

– Brunnstrom UE/hand Stage 3 to 6

• High functioning upper extremity

– Brunnstrom UE/hand Stage 6 to 7

Subject #2: Low Function

• 69 y.o. F

• 4.5 years post; R hemiparesis

• Dense expressive aphasia

• Probable apraxia

• History of cardiovascular disease, post

CABG

Subject #2: Low Function

• Brunnstrom stage 2, beginning 3 arm/hand

– Beginning motion in R shoulder and elbow in flexion and extension synergy patterns

• Shoulder abd/add, elevation, retraction, int rot

• Elbow flexion/extension

– Hand fisted with possible slight voluntary finger flexion

– FM UE motor score of 7

Subject #2: Low Function

• Ambulates at home with hemi cane and R

AFO

• Only able to complete “reach and

retrieve” gravity eliminated elbow flexion

item on WMFT

Goals

• Collaborative goal(s):

– Exercise in aerobic conditioning range

– Improved socialization and communication

– Improve trunk control/balance in sitting

– Improved arm/hand function?????

• Few evidence-based therapeutic options for

low level UE

• Apraxia and functional gaming

Practice repetitions and

practice time

11,500 29 11.1

# of

repetitions

# of sessions

attended

Total hours

played

Clinical decision making: games chosen

• Began with EyeToy games

due to:

– Difficulty of managing buttons

on Wii games

– Decreased complexity of

gaming options

• Used yoked UE protocol

– Tested with sEMG unit to

assess whether more activity of

shoulder and elbow muscles

while gaming as compared to

using upper body ergometer

during same session

Clinical decision making: games chosen

• Early EyeToy games

– BubblePop

– Kung2

– WishiWashi

– Knock-out

• Progressed to some Wii games

– Bowling (played others)

– Wakeboarding

– Golf

– WiiFit soccer (heading with yoked paddle)

Achievement of goals: Aerobic

exercise

• Cardiovascular conditioning range of 60-80% MHR = HR of 91 to 121

• Post exercise HR in CV conditioning range 50% of time– Depending on games played

• Less likely when playing golf, bowling

• More likely with BubblePop, Kung2, etc.

• Clinical implication: some individuals can use gaming to achieve cardiovascular exercise, however appropriate game selection is critical for this goal

Achievement of goals:

Socialization and communication

• Increase from 14% to 32% in Communication

subsection of Stroke Impact Scale

– Other densely aphasic participant also increased

substantially in Communication subsection

• Increased vocalization, but probably no actual

change in language (not measured)

• Much interaction and engagement during

gaming

• Change in perception of communication

• May impact on participation level (ICF model)

Achievement of goals:

Socialization and communication

• Learned gaming in sitting during this study

– Initially somewhat frustrated and bored with

EyeToy games; really began to enjoy gaming

once she started playing with others

– Had been unable to game while standing

before study; able to do so after study

• Very gratified with this new skill

• Clinical implication: consider gaming to

increase socialization; interaction/

communication; self-efficacy

Achievement of goals: Trunk

control and sitting balance• Slight increase in combined FR scores (29

cm pre increased to 33 cm post)

• Perceived improvement in balance on Activities-specific Balance Confidence Scale (0% confidence pre to 23% confidence post)

• By observation, participant moved more in sitting than during other activities

• Unclear if measures adequate

• Clinical implication: consider gaming activities that involve large trunk motion components for this patient-specific goal

Achievement of goals: UE

motor control and function

• No change in FM score; improved speed on

one item able to complete on WMFT (reach

and retrieve)

• Probably no change in UE motor control and

function, although few other treatment options

available for this level of arm/hand

• Clinical implications: probably cannot change

motor control in many individuals with low

level arm/hand function

Subjects #3 & 4: Moderate

Function• Subject #3

– Brunnstrom stage 3-

4 arm, 4-5 hand

– Focus on shoulder

• Subject #4

– Brunnstrom stage 5

arm, 4 hand

– Focus on fine motor

control of hand

Subject #3

• 86 yo F, 7 yr post, R hemiparesis

• Scoliosis, arthritis

• Independent ambulator with wheeled walker, household distances

• Unable to do many items initially on WMFT

• Unable to flex or abd shoulder against gravity without elbow flexion

Subject #3: Goals

• Collaborative goal:– Complete activities involving lifting hand up in

space: turn a light switch on and off, open refrigerator door, etc.

• Task analysis– Adequate hand function for tasks

– Improve shoulder function:

• Antigravity shoulder flexion with elbow extension (isolation of shoulder from elbow)

• Increase antigravity shoulder flexor strength

Subject #3: Practice

repetitions and practice time

# of

repetitions

# of sessions

attended

Total hours

played

7008 30 14.8

Subject #3: Clinical decision making:

games chosen

• Wii Golf with left handed swing out of flexion synergy pattern

• Wii Bowling shoulder flexion with elbow extension

• PS BubblePop, gradually increasing height of camera to demand increased antigravity shoulder flexion

Subject #3: Achievement of

goals: UE motor control and

function

Pre Post

Reflexes 4/4 4/4

UE 11/30 16/30

Wrist 3/10 9/10

Hand 11/16 16/16

Coord 3/6 2/6

Total 32/66 47/66

•Fugl-Meyer UE

Motor Score

changes

Subject #3: Achievement of goals:

UE motor control and function

0.00

20.00

40.00

60.00

80.00

100.00

120.00

1 3 5 7 9 11 13 15

Sec.

WMFT Item

Pre

Post

Mean

Subject #3: Clinical

Implications• Clinically significant level of change in

FM and WMFT tests

• Achieved collaborative goal (at least for lower light switches, etc.)

• Enjoyed gaming and using a Wii at home

Subject #4

• 62 yo M, 7 yr post, R hemiparesis

• Independent ambulator with standard cane

• Brunnstrom stage 5 arm, 4 hand

• Able to do first items on WMFT easily; slower

with fine motor tasks

• Good antigravity shoulder movement but

lacking fine motor control of

hand/wrist/forearm

Subject #4: Goals

• Collaborative goal:

– Improve golf swing

– Gaming with grandchildren

• Therapist goals:

– Increased fine motor control of hand

• Picking up and manipulating small objects

• Isolated finger control (thumb IP flexion) on Wii

controller

– Improve ability to position hand in space for

function

• Wrist/forearm control

Subject #4: Practice

repetitions and practice time

Reps Sessions Hours played

27,965 29 18.7

Subject #4: Clinical decision making:

games chosen

• Various PS games (DIY, Secret Agent,

Mr. Chef, etc.)

– Beginning holding screw driver and moving

gradually to smaller diameter objects

pen/pencil

– Lots of variable arm/forearm/hand

movement

Subject #4: Achievement of

goals: UE motor control and

function

Pre Post

Reflexes 4/4 4/4

UE 24/30 26/30

Wrist 7/10 10/10

Hand 8/16 8/16

Coord 2/6 2/6

Total 45/66 50/66

• Fugl-Meyer UE

Motor Score

changes

Subject #4: Achievement of

goals: UE motor control and

function

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Mean

Pre

Post

WMFT Item

Subject #4: Clinical Implications

• Clinically significant level of change in WMFT test and close to the 10% level of significance on FM

• LOTS of practice repetitions

• Collaborative goal – achieved gaming goal; involved with golfers with disability program

• Enjoys gaming and using a Wii at home with grandchildren

Subject #6: High Function

• 59 yo F, 2 yr post, R hemiparesis

• Isolated arm and hand motion

antigravity, but with mild tremor and

dysmetria

Subject #6: Goals

• Collaborative goals:

– Improve aerobic fitness

– Improve grooming skills to fix her hair

– Improve fine motor control of hand in

space

• Position of hand/wrist/forearm

• Grading of force and movement in function

Subject #6: Practice

repetitions and practice time

# of

repetitions

# of sessions

attended

Total hours

played

14,576 21 14.3

Subject #6: Clinical decision making:

games chosen

• Games requiring bimanual hand function

– Wii Archery & Duckhunt

– Rock Band Guitar

• Games requiring control of hand position in

space and grading of force for function

– Wii Frisbee

– Wii Island Flyover and Skydiving

Subject #6: Achievement of goals

• Already a 64/66 on Fugl-Meyer (deficits in

coordination section)

– no change in FM

• No change in mean WMFT time of 2.1 seconds

• Ceiling effect FM & WMFT(Lin et al 2009, Hsuch

et al 2008)

– Do not know if her function changed

– Need better measures for higher functioning

individuals

Subject #6: Achievement of goals

• Clinical implications:

– Could she have practiced an actual task and

gotten same benefit, such as typing, actually

throwing a frisbee, etc?

– Would she have practiced as much?

• Goal Achievement: Able to fix her hair into

a pony tail independently

Future directions

• Utilize protocol with additional

individuals in outpatient therapy

• 8 outpatients currently enrolled in

outpatient phase

Future directions• Harnesses with sensors

– Use of harness for safety

• Learning new limits of stability

• Permitting errors

Future directions

• Begin customization of commercially available gaming equipment to the stroke population

• Develop/refine methods of counting repetitions for discrete tasks

– Complete development of accelerometer to count repetitions

Future directions

• Additional measures to be added

– Cognition

– Presence

– Engagement

– Higher level arm/hand function

• Dexterity

• Force control

Future directions: Increase

Depth of Understanding

• Motion analysis

• Functional imaging

Future directions

• Next generation of games

Acknowledgments: Funding

• Cleveland State University’s Faculty

Research Development Grant 2009-

2010

• Cleveland State University’s Summer

Undergraduate Engaged Learning

Research/Creative Achievement Award

Acknowledgments: Personnel

• Clinical-academic collaboration

• Area clinicians, academic faculty and

students

Acknowledgments: Clinicians

• Kathy Szirony, PT; Michelle Wilson, OT

(Cleveland Clinic Main)

• Susan Linder, PT, NCS; Cindy Clark,

OT (Lakewood)

• Marcy Stalvey, PT, NCS (Edwin Shaw)

• Expanding to other facilities soon

Acknowledgments: Academic faculty

from Cleveland State University

• Ann Reinthal, PT, PhD, NCS (neurologic PT)

• Mary Milidonis, PT, PhD (health services

researcher)

• Ann Begovic-Juhant, PhD (psychologist)

• Nigamanth Sridhar, PhD (engineering – sensor

technology)

• Wenbing Zhao, PhD (engineering – gaming

systems technology)

Acknowledgments: Students!!!!!• Pre PT, OT, and engineering undergrads

– Julie Petrash, Logan Huba, Colleen Conway,

Julie Chaya

• DPT students

– Janet Fonovic, Lauren Heath, Cara Doerschuk,

Scott Goia,

Michelle Kellicker,

Matt Shultz

• Other graduate students

– Milind Mehta

Acknowledgments: Students –

Engaged Learning

Reinthal, Linder, Szirony, & Milidonis; not to

be copied without permission

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Appendix A

Project Games

Playstation 2 with Eye Toy

Play 1– Wishi Washi

– Beat Freak

– Kung Foo

– Soccer craze

– Boxing Chump

– UFO Juggler

wiki.groept.be/confluence/display/GL/Eye+Toy

– Slapstream

– Plate spinner

– Disco Stars

– Ghost Eliminator

– Mirror Time

– Rocket Rumble

news.bbc.co.uk/2/hi/3123993.stm

Playstation 2 with Eye Toy

Play 2– Bubblepop

– Kung 2

– Knockout

– Mr. Chef

– Home Run

– Drummin

– Monkey Bars

– DIY

– Goal Attack

– Table Tennis

– Secret Agent

– Air Guitar

www.videogamesblogger.com/2006/01/14/ps2-revi...

Wii Sports

• Bowling

• Baseball

• Boxing

• Golf nintendic.com

• Tennis

• Full games plus training options

– Putting

– Batting practice

Wii Resort

• Swordplay

• Wakeboarding

• Frisbee dog

• Frisbee golf

• Archery www.edge-online.com/news/wii-sports-sequel-le...

• Basketball

• Table Tennis

Wii Resort

• Golf

• Bowling

• Power Cruising

• Canoeing

• Cycling

• Air sports wii.ign.com/dor/objects/14266992/wii-sports

Other Wii Games

• Wii Play

– Find Mii - Pose Mii

– Shooting Range - Tanks

– Table Tennis - Charge

– Laser Hockey - Billiards

– Fishing

• Mario Kart

• Wii Music

Rock Band

• Guitar

• Drums

• Microphone

• Implications for

individuals with

aphasia

• Utilization of song

versus practice modewww.wired.com/.../magazine/1

5-10/mf_harmonix

Reinthal, Linder, Szirony, & Milidonis; not to be copied

without permission