Gaming for the Brain: Video Gaming to Rehabilitate the Upper Extremity After Stroke

Rehabilitation Gaming Can Address Major Care Disparities

Upper extremity motor disability following damage to the brain makes everyday tasks such as dressing and preparing meals extremely challenging and time-consuming to accomplish. These difficulties exert notable effects on a person’s quality of life ( ). Upper extremity disability is also hugely costly to society. There are an estimated 2.4 million chronic stroke survivors in the United States ( ), of whom approximately 50% have difficulty moving an upper extremity and 26% require assistance for activities of daily living ( ). Care for stroke survivors and lost productivity cost an estimated $34 billion annually in the United States ( ). In the United Kingdom, poststroke care comprises 5% of total healthcare costs ( Fig. 33.1 ).

Poststroke disability is made worse by inadequate access to long-term rehabilitation care ( ). Clinical practice guidelines recommend outpatient rehabilitation for anyone who remains disabled after discharge from inpatient rehabilitation ( ). Although these guidelines would recommend that the majority of stroke survivors receive at least some outpatient rehabilitation ( ), substantially fewer stroke survivors actually receive this care ( ). Inadequate rehabilitation results in higher disability as well as increased mortality ( ).

Among those individuals who do undergo outpatient rehabilitation, most do not receive evidence-based treatments. found in an observational study of 312 rehabilitation sessions involving 83 occupational and physical therapists (OT/PTs) at seven rehabilitation sites across the United States that functional rehabilitation (i.e., movement that accomplishes a functional task, such as eating, as opposed to strength training or passive movement) was provided in only 51% of the sessions of upper extremity rehabilitation, with only 45 repetitions per session on average. Functional upper extremity movements are most likely to generalize to everyday tasks ( ), an aspect of recovery that is critically important to patients and their families ( ). Yet, passive movement and non-goal-directed exercise are more frequently administered ( ). Meta-analytic data suggests that the intensity of motor intervention, as measured by hours of treatment, is associated with the magnitude of the treatment effect ( ), yet the Centers for Medicare & Medicaid Services (CMS) therapy cap limits the number of sessions of occupational and physical therapy combined to about 20 per year.

The standard of care for upper extremity rehabilitation is thus characterized by inadequate provision of rehabilitation services, particularly for rural and underserved populations ( ), as well as poor utilization of interventions that are sufficiently intense. Moreover, traditional home practice programs are not sufficiently engaging to result in adequate adherence ( ), making traditional home practice programs an infeasible alternative for most people. The end result is that motor function often remains generally unchanged after discharge from inpatient rehabilitation and actually declines in underserved populations ( ). Innovative and cost-cutting rehabilitation approaches are thus sorely needed to reform the rehabilitation care delivery system.

Enter rehabilitation gaming. The use of “smart” gaming rehabilitation systems has the potential to increase access to rehabilitation, particularly for those residing far from rehabilitation centers or with limited access to transportation. By reducing task setup and intensely engaging the client, a greater portion of session time can be spent in active motor practice, potentially increasing the efficiency of rehabilitation sessions. Finally, widespread adoption of rehabilitation gaming could markedly reduce the costs associated with rehabilitation by enabling the majority of rehabilitation to be self-led between consultations with a therapist. Rehabilitation gaming thus has the potential to address a huge social need in the field of rehabilitation.

The Pros and Cons of Available Gaming Technologies

Three main s of technologies have been used in rehabilitation gaming systems: controller-based systems, camera-based motion-tracking systems, and wearable sensor systems. The oldest consumer-grade systems and those most commonly studied to date are accelerometer-based controller systems, such as the Nintendo Wii. This type of system has the advantage of being the lowest-cost system but has substantial drawbacks, including inability to track movements made by the player, requiring a user to be able to grasp a hand-held controller, and lack of sensitivity to movement patterns.

Camera-based motion-tracking systems, such as the Microsoft Kinect, are becoming the preferred platform for rehabilitation gaming. These systems integrate information from a traditional video camera and an infrared depth sensor to infer the approximate location in space of up to 25 parts of the body ( Fig. 33.2 ). As such, these systems offer several advantages over accelerometer-based systems, yet they remain relatively inexpensive. Gaming software can be written to require specific movement patterns to drive game play, thereby discouraging players from using atypical or compensatory movement patterns, such as disallowing the player to compensate for decreased shoulder abduction by leaning to the side. Because these systems track actual body movement, the rehabilitation principle of action–observation can be harnessed when a figure on the screen mirrors the player’s movements ( ). Personalization of rehabilitation can also be realized when the software automatically adjusts the difficulty of the movements required to drive game play based on a user’s current ability. This capacity allows the gaming system to respond to a player in the same way that a live therapist would, progressing the difficulty of a task as a client improves. Finally, fine motor skills and active grasp are not required because there are no buttons to push and no controller to hold, making these systems more widely accessible to individuals with a wide range of motor ability.

Very recently, advances in wearable motion capture technology have reduced the cost of such sensors, making them more accessible to the rehabilitation gaming market. These wearables can very precisely track the position and orientation of the sensors in space. Several sensors applied to the body allow for reconstruction of body movements, similar to that provided by the Microsoft Kinect. These sensor systems have the added advantages over the Kinect of portability and increased temporal precision but are more cumbersome to set up. They are also not yet available as consumer-grade systems and have not incorporated user-centric design, making them more challenging to implement for clinical and home-based gaming applications.

There is strong rationale for the use of rehabilitation gaming. However, it is unclear to what extent existing systems will live up to their potential to improve motor outcomes following neurologic injury. Rehabilitation gaming systems offer the following potential advances but also have potential drawbacks compared with conventional rehabilitation.