Gaming in Physiotherapy

Original Editor - The Open Physio project.

Top Contributors - Sam A. Ayeni, Rachael Lowe, Admin, WikiSysop, Rucha Gadgil and Kim Jackson  

Introduction

This article will look at the use of gaming in physiotherapy from two perspectives, namely; education and treatment.

Game: a competitive activity involving skill, chance, or endurance on the part of two or more persons who play according to a set of rules, usually for their own amusement or for that of spectators. Also, alternatively referred to as a video game, a game is software code designed to entertain or educate an individual. Today, computer gaming is a big business, and there are millions of different computer games that are enjoyed by people of all ages.

The problem

• Education is not seen as exciting by students
• Textbooks are not sufficiently engaging for this generation of students
• Clinical placements are seen as very intimidating places where one cannot afford to make any mistakes
• Traditional education methods are not reinforced and do not go further than the classroom
• Education out of books can seem overwhelming to students

Features of games in general

Games generally involve:

• Engagement with the content or story
• Entertainment
• Education (e.g. Civilisation teaches players general concepts, for example the relevance of trade, religion, war and resources on the development of society)
• Reasoning (e.g. games that include puzzle solving and logic)
• Good learning objectives
• Interactivity
• Experimentation
• Consequences- customer feedback
• Challenge the learner

Gaming in physiotherapy education

The following section looks at a possible design strategy for the development of an educational game for physiotherapy students at different stages of their studies. The concepts highlighted in this scenario are equally applicable in other gaming environments.

Game design should focus on usability / playability to engage users, rather than relying purely on visual stimulation. The game should be designed to encourage interaction with content. This could be content presented within the game, as well as content the player must interact with outside the game. Players should also be encouraged to interact with other players, again, both within the game and in reality.

The game should follow a narrative (a story that takes place over time), both in the game and in reality and that provides context. Important elements of the gameplay include the actual story (depth, breadth, detail), the setting or environment in which the story (game) takes place, logical flow (realism) and level design.

Players could structure a career, based on either their interests or on areas in which they feel they would like more experience. Levels in the game could correspond to different stages of their careers i.e. undergraduate studies, community service, etc. At various stages of the game they could be presented with level appropriate “challenges” in the form of the interactions they engage in.

Key concepts in game design include:

• The environment (e.g. an outpatient department)
• Objects within the environment that change state (e.g. patients)
• Rules that govern the object's change of state (e.g. correct decisions lead to patient progress, whereas incorrect decisions may lead to regression)
• Rewards and punishment are given according the objects' change of state (e.g. promotion to the next year of study, completion of community service, disciplinary action)
• Gameplay, or the experiences of the player during interactions can be thought of as “what the player does” and excludes visuals, sound, etc. It can be used to describe the quality of the story, the ease of play and overall desirability. Some consider it the most important indicator of the quality of a game.

Content design Designers need to be able to juggle many interrelated concepts, resolve creative / ethical / educational conflicts and understand the target audience (i.e. students). Content should be designed by:

• Educators – to ensure sound educational principles are adhered to
• Physiotherapists – to ensure clinical accuracy
• Students – to ensure the game has entertainment value

Rules of the game (“game mechanics”) should closely mirror the "rules" of professional physiotherapy practice and the curriculum.

Usability

• Provide help (when questioned / stuck)
• Provide feedback (players respond to positive feedback after elegant solutions)
• Prevent waiting (prompt responses to solutions given by players)
• Avoid errors (inaccuracy in games are very frustrating)
• Adapt the game to the player (e.g. change scenarios dynamically based on player feedback)

Potential roles within the game

• Physiotherapist
• Educator
• Researcher
• Patient

Environments

• Hospital wards (e.g. orthopaedic ward)
• Outpatient department
• Private practice (owner or employee)
• Sports team
• Community work / Primary health care

Interactions

• Clinical cases (followed through their “lifetime” e.g. admission, initial assessment, treatment phase, discharge)
• Ethical dilemmas
• Practice management / Administration

Levels

• Level 1 – Beginner (e.g. first and second year students)
• Level 2 – Intermediate (e.g. third and fourth year students)
• Level 3 – Advanced (e.g. community service)
• Level 4 – Expert (e.g. independent practitioner / clinical specialist)

Players can focus their careers as they progress through stages of the game, with facilitators offering guidance to allow players to explore the processes they will go through in the real world.

Accessibility

• Physical disabilities
• Visual disabilities
• Auditory disabilities
• Attention deficit disorders
• Confidence booster

Possible outcomes of gaming in education

For students:

• Engage with the content on a deeper, more exciting level
• Encourage interaction with other students / educators beyond the classroom
• Introduce key clinical concepts in a simulated but practical and safe environment

For educators:

• Go through the development process to gain a better understanding of the coursework
• Gain a deeper understanding of the students approach to learning

Gaming in physiotherapy treatment

Gaming has already proven useful in physiotherapy practice. Specifically, the Wii gaming console has proven to be a low cost platform that aids in the rehabilitation of patients with Stroke and Parkinsons_D. The components are essential in physical therapy for older persons and for persons with neurological disorders.

The Wii gaming console78

One home video game console on themarket is the Nintendo (Kyoto, Japan) Wii Fit�, a systemspecifically designed to promote physical activity. The Wii Fit� incorporates a console connected to a television, and a force platform (Wii balance board) placed on the floor. The balance board automatically provides personalized feedback on the gamer’s movements when playing the games. Wii Fit� has been used for rehabilitation in various populations and disorders in order to improve physical capacity. The focus has mainly been on improving balance and thus reducing the risk of falls.

Features of this console that could affect its use by a physiotherapist include

• Remote controls that are position aware in all 3 dimensions (think, Proprioception)
• Wireless
• Additional hardware components that enhance the basic package (e.g. Wii balance board)
• Internet connectivity,

Advantages of the Wii in physiotherapy

• Low cost
• Visual and auditory feedback built in
• Mobile, as opposed to, for example, a treadmill
• Objective outcome measure (e.g. scores, progressing through levels)
• Connection to the Internet allows remote reviewing of scores

Disadvantages of the Wii in physiotherapy

• No research to provide valid, reliable measurements of it's use in treatment
• No readily available software specific to the needs of physiotherapists

Special feature

The Wii balance board is a hardware enhancement to the basic Wii console that is extremely sensitive to weight shift on the platform due to the inclusion of four very accurate pressure sensors. This enables the game to monitor the players shifting centre of gravity which is used to provide input (in the same way a joystick might) that allows the player to interact with objects in the game (e.g. a snowboard).

With this in mind, imagine the potential for developing dynamic hip and knee control of a patient in a standing (or supported standing) position while they engage in a downhill skiing contest. Or developing static Balance while the game provides visual and auditory feedback of their progress.

In older people with balance deficits, small but clinically and statistically significant improvements in dynamic balance have been seen after 4–6 weeks of training with the Wii Fit.

In a study investigating home based training on the Wii balance board for people with Parkinson’s disease, improvements in static and dynamic balance were recorded However, another study found no additional benefit of adding Wii Fit training to conventional balance training for persons with Parkinson’s disease. In persons with acquired head injury, significant improvements in static balance were seen after a period of Wii Fit training, but no significant changes were seen compared with a control group receiving standard rehabilitation The most common neurological disorder in young adults is multiple sclerosis (MS). The wide range of symptoms associated with MS may cause gait and balance disorders even in the early stages of the disease Due to these balance disorders, accidental falls are common and hence physiotherapy has focused on interventions for improving balance. Studies using Wii Fit balance exercises have shown promising results in improving static and dynamic balance

In a multi-centre randomized controlled trial including 84 persons with MS, we found significant improvements in dynamic balance in the intervention group (Wii Fit Plus balance exercises twice a week for 6 weeks)However, there were no significant differences compared to the untreated control group,though the effect sizes were larger in the intervention group. Improvements in static and dynamic balance have also been reported after 4 weeks of training on the Wii balance board 3 times a weekand after 12 weeks of daily training Plow et al. examined the potential of Wii Fit to increase physical activity and health. Increased levels of physical activity were seen at the midway assessment at 7 weeks, but had declined by the final assessment at 14 weeks.

A study conducted by Forsberg et al,(2015) found out that Wii Fit training is a fun and challenging way of exercising that can address common balance impairments in MS. The competitive aspect of the games provides feedback on achieved scores which was appreciated by many, but the negative visual feedback was considered unnecessary. Improvements in daily life as well as during the training sessions were expressed by both the persons with MS and the PT. These findings suggest that training with Wii Fit may be a feasible option for balance training that can be performed at home or in a rehabilitation clinic.

Resources

• Help you play
• Gameplay
• Design document
• Game bo
• Game design
• Wii homesite
• Wikipedia article on the Wii platform

References

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