Gaming in Physiotherapy

Original Editor - The Open Physio project.

Top Contributors - Sam A. Ayeni, Rachael Lowe 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.[1]

Video gaming is a popular recreational activity for children andadults across the world. Gaming technology using virtual reality systems has enabled users to become active participants in the virtual environment. The incorporation of physical activity into video gaming facilitates the integration of this technology into rehabilitation therapies[2].

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[3]

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.[4]

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.[4]

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.

[5]



Evidence

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[6][7][8].

In recent years the integration of gaming system technologies in the field of rehabilitation has been expanding. The use of gaming systems as a treatment strategy incorporates essential elements of motor learning. When used as a rehabilitation tool, gaming systems provide, not only real time practice of tasks and activities, but opportunities to engage in intensive, meaningful, enjoyable and purposeful tasks related to real-life environment. Physical activity in these games includes a great deal of movements and tasks that involves a wide range of sensory feedback; adjustable movement amplitudes, speed, and precision levels; and incorporation of a variety of visual-spatial, cognitive, and attention tasks. The practice of these activities may be promising as it may increase participation and motivation during therapy and can be used as part of the home therapy program[2].

Various low-cost commercial gaming systems and game packages are available for use as rehabilitation tools. The role of clinicians is essential in prescribing and promoting the use of gaming systems as they relate to patients’ physical function and wellness. A major responsibility of clinicians is to select and educate patients on use of gaming systems that are safe and appropriate for the patients’ goals and needs. Clinicians should consider dosing intensity of training and the balance between practicing tasks using gaming systems and practicing functional tasks outside the simulated environment.Selection and progression of training should allow transfer of training from the simulated environment to the real-life environment.

One potential issue of repetitive use of a gaming system is a possible increased incidence of musculoskeletal injuries. It is important to determine the evidence regarding safety, suitability, and risk factors. Current evidence does not provide enough information regarding the safety and risk factors of unsupervised use of gaming systems for people with disabilities. Safety should be a consideration, particularly in home settings for people with disabilities especially children[2].

Current evidence focused on the validity of gaming systems as a novel approach. The consensus from the literature is that gaming systems are valid tools to augment rehabilitation. While studies provide useful information regarding its validity as a novel treatment, there is lack of evidence that has examined if the use of gaming systems is superior to traditional approaches or it can be an adequate substitute of traditional rehabilitation. Because of lack of evidence at this point, clinicians and patients should not consider using a gaming system as a replacement for a physical therapy program; it should instead be used to increase the intensity of exercises and to complement traditional exercise programs.[2]

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[7] However, another study found no additional benefit of adding Wii Fit training to conventional balance training for persons with Parkinson’s disease[8]. 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[9] 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[10] Due to these balance disorders, accidental falls are common[11][12] 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[13][14][15][16]

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)[13]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 week[14]and after 12 weeks of daily training[15] Plow et al. [16] 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[4].

Resources

References

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  1. Computerhope. Available from: https//:www. computerhope.com > Dictionary < G- Definitions
  2. 2.0 2.1 2.2 2.3 Yasser S.Gaming Systems in Rehabilitation. Novel Physiotherapies 2102, 2;1
  3. SkillBuilder LMS: Available from: https://www.skillbuilderlms.com/top-features-game-based-learning/ (accessed 2 June 2019)
  4. 4.0 4.1 4.2 Forsberg A, Nilsagård Y, Boström K. Perceptions of using videogames in rehabilitation: a dual perspective of people with multiple sclerosis and physiotherapists. Disability and rehabilitation. 2015 Feb 13;37(4):338-44.
  5. Gamed-based Rehabilitation. Available from:https://www.youtube.com/watch?v=UQqisA89pAw [last accessed 11/6/2019]
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  9. Gil-Gómez JA, Lloréns R, Alcañiz M, Colomer C. Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: a pilot randomized clinical trial in patients with acquired brain injury. Journal of neuroengineering and rehabilitation. 2011 Dec;8(1):30.
  10. Martin CL, Phillips BA, Kilpatrick TJ, Butzkueven H, Tubridy N, Mcdonald E, Galea MP. Gait and balance impairment in early multiple sclerosis in the absence of clinical disability. Multiple Sclerosis Journal. 2006 Sep;12(5):620-8.
  11. Matsuda PN, Shumway-Cook A, Ciol MA, Bombardier CH, Kartin DA. Understanding falls in multiple sclerosis: association of mobility status, concerns about falling, and accumulated impairments. Physical Therapy. 2012 Mar 1;92(3):407-15.
  12. Nilsagård Y, Lundholm C, Denison E, Gunnarsson LG. Predicting accidental falls in people with multiple sclerosis—a longitudinal study. Clinical rehabilitation. 2009 Mar;23(3):259-69.
  13. 13.0 13.1 Nilsagård YE, Forsberg AS, von Koch L. Balance exercise for persons with multiple sclerosis using Wii games: a randomised, controlled multi-centre study. Multiple sclerosis journal. 2013 Feb;19(2):209-16.
  14. 14.0 14.1 Brichetto G, Spallarossa P, de Carvalho ML, Battaglia MA. The effect of Nintendo® Wii® on balance in people with multiple sclerosis: a pilot randomized control study. Multiple Sclerosis Journal. 2013 Aug;19(9):1219-21.
  15. 15.0 15.1 Prosperini L, Fortuna D, Giannì C, Leonardi L, Marchetti MR, Pozzilli C. Home-based balance training using the Wii balance board: a randomized, crossover pilot study in multiple sclerosis. Neurorehabilitation and neural repair. 2013 Jul;27(6):516-25.
  16. 16.0 16.1 Plow M, Finlayson M. Potential benefits of Nintendo Wii Fit among people with multiple sclerosis: a longitudinal pilot study. International journal of MS care. 2011 Mar;13(1):21-30.