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