wii repetition reinthal et al csm final handout1
TRANSCRIPT
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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
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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
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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
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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.
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Introduction
Literature Review and Study Aims
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Repetitive Task Practice
1. Repetitive task practice for person with
stroke
2. Obstacles for adequate practice
3. Approaches that apply repetitive task
practice
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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)
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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)
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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)
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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)
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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
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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)
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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)
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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)
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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)
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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
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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
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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.
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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.
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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)
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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)
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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
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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)
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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
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Evidence-based practice triangle
• Support from research literature (evolving)
• Clinical experience of therapist
• Meaningful to patient
Research evidence
Patient-
centered
care
Clinical
expertise
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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
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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
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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
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Beyond the Pilot Study Phase
• Now enrolling outpatients at 2 sites
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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
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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.
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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
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Blue Highways on NIH Road MAPJAMA, Jan 2007, vol 297, No 4
http://www.sbm.org/outlook/0608/articles.asp?article=1
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Clinical Decision Making:Matching Individuals to Games
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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
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Clinical Decision Making:
Step I
• Establish goals using Patient Client
Management Model (PCMM) and
Nagi/ICF Model
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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
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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
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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
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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
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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)
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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
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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
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Stroke specific outcome measures
• Disability (Participation)
– Stroke Impact Scale (participation)
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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.)
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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
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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”
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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
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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
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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
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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
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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
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Clinical Decision Making
Model
STEP IISelection and Modification of
Games
INTERVENTION PLAN
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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
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Game selection: What you
need to know about the game
Motor control demands
Other considerations
Motivation
Game modifications and progression
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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
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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
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Clinical Decision Making for Game
Selection
• Brunnstrom stage IV with ability to complete fine and gross motor tasks of WMFT, but inefficiently and inconsistently
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Clinical Decision Making for Game
Selection
• Brunnstrom stage V-VI with difficulty performing fine motor tasks of WMFT consistently and efficiently
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Game Selection
• Bimanual yoked arm – Activities that incorporate large degrees of trunk
rotation• Golf, baseball swing, drumming
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Game Selection
• Bimanual hand (variable trunk demands)– Bilateral symmetrical
• Bubblepop, Wishi Washi
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Game Selection
• Bimanual hand (variable trunk demands)– Bilateral reciprocal
• Active assisted: Driving, Wakeboarding• Active: Boxing, Drumming
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Game Selection
• Bimanual hand (variable trunk demands)– Each hand doing something different
• Guitar, target shooting, archery
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Game Selection
• Unilateral arm, hand and wrist (variable trunk demands)– Frisbee, Table Tennis, Wii Resort Airsports
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Game Selection
• Trunk task demands
– Mobility / Stability
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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
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Clinical Decision Making:
Incorporating task-specificity
into gaming intervention
• Task specific practice is possible for
many games
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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.
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Adapting
to sensory
impairment
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Environmental
adaptation for
left neglect
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Game selection for spatial
relationship impairments
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Other Considerations
• Cardiopulmonary demands
• Communication
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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
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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
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Motivation Factor
• Taking Advantage of Patients’ Prior
Experiences
– Water Skiing
– Musicians
– Boxer
– Bowler
– Golfer
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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
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Game modifications• Be creative!
Aquaplast (splinting material) covers for controller buttons
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Grading task difficulty and
progressions
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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
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Feasibility of utilizing gaming
in an outpatient setting
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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
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Feasibility: Patient Considerations
1. Safety
2. Optimum therapeutic practice
3. Motivation to practice
4. Equipment cost/home support (HEP)
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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
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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
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Patient motivation to practice
• Must have gaming options that appeal
to patient
• Self-efficacy
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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
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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
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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
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Knowledge of Outcome
Measurement
• Appropriate matching of outcome
measures
• Administering outcome measures
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Knowledge for game selection
and use of gaming systems
–The correct games must be
selected
–The therapist must know how to
play the games
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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
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Recognition of time
commitment
• Therapist organizational skills
• Time investment outside of clinic,
especially learning to play the games
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Feasibility Considerations:
Facility
• Therapist productivity
• Support personnel
• Costs
• Reimbursement
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Productivity and Support
Personnel
• Facility expectations for productivity
• Support Personnel
– Cost
– Availability
– Creative options
• Family
• Students
• Friends
• Community
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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
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Reimbursement
• Gaming interventions
• Skilled reimbursable time
• Non-reimbursable independent
/supervised practice
• Documentation
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Practice repetitions and
practice time
11,500 29 11.1
# of
repetitions
# of sessions
attended
Total hours
played
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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
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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)
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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
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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)
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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
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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
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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
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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
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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
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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
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Subject #3: Practice
repetitions and practice time
# of
repetitions
# of sessions
attended
Total hours
played
7008 30 14.8
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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
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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
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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
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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
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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
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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
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Subject #4: Practice
repetitions and practice time
Reps Sessions Hours played
27,965 29 18.7
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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
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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
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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
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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
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Subject #6: High Function
• 59 yo F, 2 yr post, R hemiparesis
• Isolated arm and hand motion
antigravity, but with mild tremor and
dysmetria
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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
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Subject #6: Practice
repetitions and practice time
# of
repetitions
# of sessions
attended
Total hours
played
14,576 21 14.3
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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
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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
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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
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Future directions
• Utilize protocol with additional
individuals in outpatient therapy
• 8 outpatients currently enrolled in
outpatient phase
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Future directions• Harnesses with sensors
– Use of harness for safety
• Learning new limits of stability
• Permitting errors
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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
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Future directions
• Additional measures to be added
– Cognition
– Presence
– Engagement
– Higher level arm/hand function
• Dexterity
• Force control
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Future directions: Increase
Depth of Understanding
• Motion analysis
• Functional imaging
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Future directions
• Next generation of games
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Acknowledgments: Funding
• Cleveland State University’s Faculty
Research Development Grant 2009-
2010
• Cleveland State University’s Summer
Undergraduate Engaged Learning
Research/Creative Achievement Award
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Acknowledgments: Personnel
• Clinical-academic collaboration
• Area clinicians, academic faculty and
students
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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
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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)
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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
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Acknowledgments: Students –
Engaged Learning
Reinthal, Linder, Szirony, & Milidonis; not to
be copied without permission
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Appendix A
Project Games
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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
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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...
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Wii Sports
• Bowling
• Baseball
• Boxing
• Golf nintendic.com
• Tennis
• Full games plus training options
– Putting
– Batting practice
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Wii Resort
• Swordplay
• Wakeboarding
• Frisbee dog
• Frisbee golf
• Archery www.edge-online.com/news/wii-sports-sequel-le...
• Basketball
• Table Tennis
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Wii Resort
• Golf
• Bowling
• Power Cruising
• Canoeing
• Cycling
• Air sports wii.ign.com/dor/objects/14266992/wii-sports
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Other Wii Games
• Wii Play
– Find Mii - Pose Mii
– Shooting Range - Tanks
– Table Tennis - Charge
– Laser Hockey - Billiards
– Fishing
• Mario Kart
• Wii Music
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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