Gaming for the Brain
Games can enhance outcomes from inpatient rehabilitation if they are played frequently for short periods of time
The AVERT clinical trial showed that receiving rehabilitation more times per day improved outcomes, but that the total amount of time spent in rehabilitation did not. 1 In fact, longer rehab sessions may even be harmful. 1,2 However, implementing short rehab sessions distributed throughout the day is nearly impossible within the U.S. model of inpatient care that emphasizes 3+ hours of daily practice, often delivered in back-to-back sessions. Rehab games that are simple to set-up and operate may be a way to get patients moving between sessions with a therapist and during “down” times, such as evenings and weekends. They may also be a way to harness early brain plasticity by providing a fun way to engage in rehabilitation that is otherwise nearly impossible. For example, they can provide a vehicle for rehabilitating arm function when a person is incapable of manipulating actual objects, and therefore cannot engage in task practice. Many clients that I’ve worked with in an outpatient setting have expressed regret that they did not receive much upper extremity rehabilitation while inpatient due to limited function and other pressing needs. Games can serve as virtual therapists to fill in these gaps in a person’s rehabilitation program.
Games produce better upper extremity outcomes than standard care in an outpatient setting
Similarly to robotic therapy, a Cochrane Review by Laver and colleagues found that rehabilitation gaming produced equivalent improvements in motor function and can enhance outcomes if it provides additional practice opportunities between sessions with a therapist.3 A limitation of this Cochrane review, however, was that it did not examine who will most benefit from rehab gaming. Our research group thus followed up with an additional review of the literature and found that gaming/virtual reality rehabilitation produced the best outcomes compared to standard care (approximately twice the treatment effect) in people with chronic (>6 months) hemiparesis.4 People with moderately severe hemiparesis that affected proximal movement tended to fare best. 5 Gaming may convey an advantage because it simulates action-observation (seeing one’s movements as one is performing them).6-10
Different sensor types used in rehabilitation gaming: how to tell if a product will meet your needs
Rehab games typically use one of 3 different sensor types. The most primitive sensors are accelerometers, like what is used in the Wii gaming system. These sensors register motion, but cannot quantify whether the movement pattern is good or poor. Accelerometer systems are good for promoting movement or physical activity, but cannot provide useful data back to the clinician.
If capturing patterns of movement is important to you (e.g., you want to discourage improper movement mechanics or record the data to assess patient progress), then you would want a system with either camera-based (e.g., Kinect) or wearable sensors. Camera-based systems hit the sweet spot for most applications. They are lower cost and track more body parts than wearable sensors (e.g. Kinect provides the x,y,z coordinates of 26 points on the body, including parts of the hand). A Limitations of these systems is that they require the person to remain in view of the camera. They also sample movement too slowly to capture slight variations in performance of high-performance athletes.
Wearable sensor systems involve strapping on several devices the size of a wrist-watch that each contain an accelerometer, gyroscope, and magnetometer. They have a longer set-up time, are more costly, and typically still have many kinks associated with first-generation products (e.g., loss of data, more difficult set-up). They are ideal for measuring performance in situations where other sensors cannot be used, such as underwater or during athletic competitions. The number of sensors needed depends on how many body segments the user wants to capture. For example, a 7-sensor system would be needed to capture wrist, elbow, shoulder and trunk motion bilaterally.
In sum, if you want to just make movement fun, an accelerometer sensor may be sufficient. If you want to capture movement in a clinic setting with a fast and easy set-up, a camera-based system is probably best. Wearable sensors may work best for high-performance applications.
Below is the link to my CSM 2018 presentation slides on how motion capture through rehabilitation gaming will rapidly accelerate the pace of discovery and move the rehabilitation field forward.
(1) Bernhardt J, Churilov L, Ellery F, Collier J, Chamberlain J, Langhorne P, et al. Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT). Neurology. 2016;86:2138-2145.
(2) Dromerick AW, Lang CE, Birkenmeier RL, Wagner JM, Miller JP, Videen TO, et al. Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS): A single-center RCT. Neurology. 2009;73:195-201.
(3) Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. The Cochrane Library. 2017.
(4) Gauthier LV, Richter TA, George LC, Schubauer KM. Gaming for the Brain: Video Gaming to Rehabilitate the Upper Extremity after Stroke. In: Rezai A, editor. Textbook of Neuromodulation. 2nd ed.: Elsevier; 2018. p. In Press.
(5) George SH, Rafiei MH, Borstad A, Adeli H, Gauthier LV. Gross motor ability predicts response to upper extremity rehabilitation in chronic stroke. Behav Brain Res. 2017;333:314-322.
(6) Friesen CL, Bardouille T, Neyedli HF, Boe SG. Combined action observation and motor imagery neurofeedback for modulation of brain activity. Frontiers in human neuroscience. 2017;10:692.
(7) McGregor HR, Gribble PL. Changes in visual and sensory-motor resting-state functional connectivity support motor learning by observing. J Neurophysiol. 2015;114:677-688.
(8) Stefan K, Classen J, Celnik P, Cohen LG. Concurrent action observation modulates practice-induced motor memory formation. Eur J Neurosci. 2008;27:730-738.
(9) Ertelt D, Small S, Solodkin A, Dettmers C, McNamara A, Binkofski F, et al. Action observation has a positive impact on rehabilitation of motor deficits after stroke. Neuroimage. 2007;36 Suppl 2:T164-73.
(10) Celnik P, Webster B, Glasser DM, Cohen LG. Effects of action observation on physical training after stroke. Stroke. 2008;39:1814-1820.