Gaming Technology in Neurological Rehabilitation

Introduction

This wiki will look at the use of consoles and other technological formats in physiotherapy for the rehabilitation in neurological patients.

Audience
The resource was produced for use by Band 6 physiotherapists may be of benefit to other health professionals seeking background knowledge.

Learning Outcomes

1. Provide the therapist with information that explains the rationale behind game based rehabilitation (Explain why gaming therapy is good)
2. Introduction and integration of technology into neurological rehabilitation to enhance self management and enable patients to independently continue home based therapy (Explain how games enhance rehab)
3. Provide analysis and critically evaluate the evidence available for current technology currently available
4. Provide an evaluation of the robustness of current research and technology within the realm of gaming therapy
5. The learner will have available to them the real world availability and application of current technology
6. Professionals making an informed decision on what console/games to use

Introduction to Neurological Rehabilitation

This section will give a brief outline of a number of neurological disorders that will be mentioned in this wiki.

Stroke

Definition/Description
“A clinical syndrome characterised by a rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that is vascular origin” (Hatano 1976, p. 541)
There are two types of stroke; ischemic and hemorrhagic stroke. The most common type of stroke is an ischemic stroke. It is caused by a blockage of a blood vessel in the brain. In hemorrhagic strokes, a burst blood vessel causes the stroke.

Signs and Symptoms
Symptoms associated with stroke differentiate based on where the hemorrhage or block has occurred in the brain. A stroke on the left side of the brain affects the right side of the body and vice versa for a right sided stroke.
Some of the most common symptoms are hemiparesis/hemiplegia (body part depends on where the stroke is in the brain), altered sensations, slurred speech, aphasia, dysphagia, ataxia, visual field defects, neglect, dyspraxia, memory and personality issues, altered tone, pain (neuro lecture reference).

Table 3.1: Perceptual deficits in CNS dysfunction

Left hemiparesis: right hemisphere—general spatial-global deficits Visual-perceptual deficits Hand-eye coordination Figure-ground discrimination Spatial relationships Position in space Form constancy Behavioural and intellectual deficits Poor judgement, unrealistic behaviour Denial of disability Inability to abstract Rigidity of thought Disturbances in body image and body scheme Impairment of ability to self-correct Difficulty retaining information Distortion of time concepts Tendency to see the whole and not individual steps Affect lability Feelings of persecution Irritability, confusion Distraction by verbalization Short attention span Appearance of lethargy Fluctuation in performance disturbances in relative size and distance of objects

Right hemiparesis: left hemisphere—general language and temporal ordering deficits Apraxia Motor Ideational Behavioural and intellectual deficits Difficulty initiating tasks Sequencing deficits Processing delays Directionality deficits Low frustration levels Verbal and manual perseveration Rapid performance of movement or activity Compulsive behaviour Extreme distractibility

(Umphred pp. 870)
Rehabilitation

The majority of the recovery occurs in the first 3 months and tends to decrease significantly after 6 months post-stroke. Repetition and specificity of exercises has been shown to be the most effective for recovery. The aim of physiotherapy is to restore function and re-educate the body to move in a functional manner. For the rehabilitation of a stroke patient; “more is better” therefore it’s up to the patient to do their exercises as time with a physiotherapist is limited. Most stroke rehabilitation interventions involve an impairment-based strategy to re-educate movement and allow appropriate compensatory actions. These interventions may include strengthening of the muscles that link movements between the trunk and the extremities as well as promotion of functional movements in relation to the link between the trunk and extremities.

Spinal Cord Injury

Description
Causes of spinal cord injury are more commonly traumatic in nature. The traction and compression forces due to a motor vehicle accident, violence, falls, and recreational activities can cause dynamic changes to the spinal cord and the structures surrounding it, resulting in an injury to the spinal cord. A spinal cord injury can less commonly stem from non-traumatic causes such as congenital or degenerative disorders.

Signs and Symptoms
The injury can cause damage to the central and/or peripheral nervous system, resulting in variable symptoms. Symptoms depend heavily on the location and severity of the injury.

Rehabilitation
Most recovery occurs in the first 6 months and, like most neurological conditions, the prognosis improves with earlier achievements of milestones.
One of the main goals of rehabilitation is to prevent secondary impairments such as respiratory complications, oedema, bowel issues, pressure sores etc.
More importantly, the aim of rehabilitation is to get the patient as functional as possible in a timely manner. Functional retraining, such as transfer training, wheelchair mobility training and gait training, is combined with strengthening and cardiovascular training to enable the best results for each individual.
The focus is on “hierarchy of quality-of-life improvements”, which recognizes the importance of targeting rehab that enables independence in basic skills and the progression to ambulation. Individualized and specialized programs that are persistent and in cooperation with orthopaedics are essential for best outcomes.

Cerebral Palsy

Description
Cerebral palsy (CP) occurs when there is damage to the brain before, during, or shortly after birth that generally affects the control of muscles. Classification of CP can be made in multiple ways. Depending on the setting, it is most commonly categorized using the Gross Motor Function Classification System (GMFCS level I-V)(link to GMFCS) or based on the motor function in combination with the number of limbs that are affected:

• Hemiplegic CP: when one arm and one leg are affected on the same side
• Diplegic CP: when both legs are affected
• Quadriplegic CP: when all four limbs are affected
• Monoplegic CP: when one arm or one leg is affected
• Triplegic CP: when a combination of three limbs are affected

Note: not all types of classifications are mentioned here

Signs and Symptoms
Characterized by high or low muscle tone, muscle weakness, uncontrolled body movement, balance, and/or coordination problems. These can be manifest either globally or locally and may lead to associated problems such as respiratory and bowel issues.

Rehabilitation
The main aims of rehabilitation are to prevent further muscle weakness in underused muscles, prevent contractures (shortening of muscles), and improve coordination. Treatment is always individualized because of the variable symptoms associated with different classifications of CP. Physiotherapist look for opportunities for motor learning and are able to facilitate it.
The treatment must be meaningful to the patient and should have engaging sensory input to facilitate motivation to move. Stabilization of one part of the body (typically the trunk, shoulders, and hip) may be necessary to enable the extremities to move in a meaningful manner.
The exercises are always taught to parents so that the rehab can continue at home.

Traumatic Brain Injury

Description
Defined as an insult to the brain caused by an external physical force that can cause altered state of consciousness which can be followed by impairments in cognitive and physical abilities. There may also be implications on behavioural and emotional functioning. Due to the mechanism of this type of injury, there are also implications on the spinal cord (see spinal cord injury)
The damage can be classified into primary or secondary. Primary damage indicates bruising or bleeding on the brain while secondary damage is due to reduction of oxygen to the brain.

Signs and Symptoms
The signs and symptoms differ slightly between primary and secondary damages. With primary damage, there may be injury to cranial nerves with subsequent symptoms based on the cranial nerve damaged. Further symptoms depend on where the damage is on the brain. Some deficits that may occur with primary damage are memory loss, concentration difficulties, decreased attention span, headaches, sleep disturbances and seizures.
With secondary damage there may be increased intracranial pressure due to swelling or hematoma (can cause herniation), cerebral hypoxia or ischemia, intracranial hemorrhage, electrolyte imbalance and acid-base imbalance, infection from open wound, seizures from pressure.
Altogether, there may also be changes to the autonomic nervous system with the severity depends on the extent of damage to the brain. Motor changes often manifest as well (see table).

Motor, Functional, Sensory, and perceptual changes resulting from brain injury

Motor changes may include any or all of the following: Paralysis or paresis such as monoplegia or hemiplegia Cranial nerve injury resulting in paralysis of eye muscles, facial paralysis, vestibular and vestibule-ocular reflex abnormalities, slurred speech (dysarthria), swallowing abnormalities (dysphagia), and paralysis of the tongue muscles Poor coordination of movement Abnormal reflexes, including appearance of early reflexes such as tonic neck reflexes Abnormal muscle tone: flaccidity, spasticity, or rigidity. (The terms “decorticate rigidity” and “decerebrate rigidity” are often used to denote abnormal posturing. Decerebate rigidity denotes extension in al four limbs. Decorticate posturing includes flexion of the upper extremities and extension of the legs.) Combination of asymmetrical cerebellar and pyramidal signs and of bilateral pyramidal and extrapyramidal signs have all been reported Loss of selective motor control Poor balance Loss of bowel and bladder control Sensory and perceptive involvement may include any or all of the following: Hypersensitivity to light or noise Loss of hearing or sight Visual field changes Numbness and tingling (peripheral nerves are often injured) Loss of somatosensory functions Dizziness or vertigo Visuospatial abnormalities# Agnosia Agraphia

(Umphred pp. 534)

Rehabilitation
Rehabilitation tends to be based on motor control and learning theories. The rehabilitation needs to include synergistic organization, anticipatory and adaptive responses, dynamic pattern theory and new patterns to engage in the motor control theory. With motor learning, it is important to recognize the need for knowledge of results and practice type (slow, simple, and relatively functional). There has been evidence in promoting “forced use” therapy in combination with complex movements for better outcomes.
Rehabilitation will likely involve interventions for cognition and memory, strength, flexibility, reaction time, speed of movement, endurance and fatigue, somatosensory, the visual system and vestibular system. Interventions should involve functional tasks that are both mentally and physically challenging.

Problems with Current Rehabilitation Practices

time
feasibility
age

• The demands are increasing with the increase in population with an increase in age
• Neurological patients require prolonged rehabilitation to have the best results
• Rehabilitation can be viewed as monotonous as variation may be required
• Physiotherapists may not be aware of or may feel intimidated by the different forms of technology available
• Reliability and validity of the different technologies may be unknown to therapists

Features of Consoles

Camera vs tactile vs remotes
Consoles generally involve

• A box or equipment which is attached to a TV or other medium to transmit information
• May be used with various games
• May be deemed a luxurious item or simply one for entertainment only
• Tablets and robotics may have different interface that do not require inputs into televisions or other mediums
  

What is a console based therapy?

-Introduction to the area of research regarding the use of technology within the realm of physiotherapy
Whatever the cause of the impairment, the main aim of most neurological rehabilitation is to facilitate
[Neurological rehabilitation is focused on helping patients to build up their motor skills, either after an incident such as a stroke, brain injury or cerebral palsy, or else to help improve functional status in patients with degenerative diseases such as MS or Parkinson’s Disease. Whatever the cause of the impairment, the rehabilitation aims to facilitate] learning or relearning of motor skills. The process of gaining motor skills involves repeating the same movement hundreds or even thousands of times. Traditional rehabilitation is time consuming and requires lengthy sessions with therapists that place a large demand on personnel and healthcare budgets. Patients often tire of rehabilitation or find it frustrating or dull. [Citation and statistic needed]

Integrating console based gaming into rehabilitation protocols has the potential to change all of this. Used appropriately game based rehabilitation can be challenging, engaging and fun. No longer is a patient repeatedly flexing and extending their elbow, using a computer game they could be taming a lion, stirring cake batter or shooting multi-coloured balloons. Instead of asking a patient to balance while they reach out and touch a physiotherapy assistant’s hand, patients can work on their balance while playing virtual golf, throwing a strike in the virtual bowling alley or driving a go-kart around a race course on a desert island.

Console based rehabilitation does not seek to replace therapists with computers; rather it is a useful tool that therapists can use to engage with their patients, make rehabilitation fun and exciting, and has the potential to improve compliance rates and thereby improve the functional outcome of these patients.