Utilizing Games/Technology for Stroke Population

Grace J Kim MS, OTR/LNewYork-Presbyterian Hospital

grk9006@nyp.orgMay 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

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