wii announced to help with stroke and motor function

8/9/2019 Wii announced to Help with Stroke and Motor Function

http://slidepdf.com/reader/full/wii-announced-to-help-with-stroke-and-motor-function 1/41

Games For Upper-limb

StrokeRehabilitation

James Burke Michael McNeillPhilip Morrow Darryl CharlesSchool of Computing and Information Engineering

Suzanne McDonough Jacqui CrosbieSchool of Life and Health Sciences

School of Computing & Information Engineering,University of Ulster, Northern Ireland



Contents

1. Research Overview

2. Background on Stroke & Traditional Therapy

3. Technology for Stroke Rehabilitation

4. Previous Studies5. Game Design for Rehabilitation

6. Outcome Measures

7. Previous University of Ulster Work

8. Webcam Games (with evaluation)

9. Augmented Reality Games

10. Final Remarks



Research Overview

The Problem Area:

Stroke is a leading cause of severe physicaldisability.

1,100,000 people living in the UK with impairmentsas the result of a stroke.

111,000 first time strokes occurring each year.1

Often difficult to provide appropriate level of therapy to meet a patient’s rehabilitationneeds.

Difficult to maintain patient motivation.2

1. British Heart Foundation & Stroke Association (2009) Stroke Statistics.http://tinyurl.com/stroke09

2. Burdea (2002) "Key note address: Virtual rehabilitation – benefits and challenges."

http://tinyurl.com/stroke09

http://tinyurl.com/stroke09



Research Overview

The Proposed Solution:

Video games may be effective in optimisingengagement & motivation.

Create a framework for the design of games forupper-limb stroke rehabilitation.

Evaluation of appropriate technology for home-based therapy.

Design, development and evaluation of rehabilitation games using novel technology.



Research Overview

Mapping to rehabilitation

TechnologyGameDesign

Rehabilitation Therapy

Tasks for rehabilitativesystems



Stroke

Effects of stroke: Attention and concentration deficiencies

Balance loss

Pain

Weakness and paralysis

Depression

Fatigue

Can make day-to-day activities difficult. Upper limb remains weak in up to 66% cases.1

1. Van der Lee et al. (1999) “Forced use of the upper extremity in chronic stroke patients” .



Stroke Rehabilitation

Rehabilitation programmes usually devised withrealistic goals for that particular patient.

Phases of rehabilitation: In hospital

Travel to specialised units

Home-based rehabilitation

May involve a visiting professional

Patients often do not receive optimal level of therapy.1




Stroke Rehabilitation

Early and intensive practice of functional tasks show morepositive outcomes for upper-limb rehabilitation.1

Typical movements practised:2

Reach towards object.

Grasp object.

Manipulate object.

Release object.

Single handed and bimanual tasks.

Tasks often perceived to be mundane and boring.

Therapy can be insufficient.

1. Kwakkel et al. (1999) "Intensity of leg and arm training after primary middle-cerebral-artery stroke”.

2. Carr & Shepherd (2002) “Stroke Rehabilitation: Guidelines for Exercise and Training to



Technology for StrokeRehab. Benefits:

Rehabilitation systems can be novel, interesting, safe andcustomisable to a particular user’s abilities and interests.

Motivate, involve and immerse the user.

Potential for home use.1

No need for therapist to be present?

Session data can be recorded at home & uploaded to remote site.2

Limitations: Clinically valid?1,2

Cost of equipment? Logistics?

Expertise required to setup/operate?

1. Rizzo & Kim (2005) “A SWOT analysis of the field of virtual reality rehabilitation and therapy”.




Technology Interfaces

Input mechanisms

Electromagnetic sensors

Data-gloves

Mixed reality systems

Vision-based tracking (cameras)

Force feedback devices Nintendo Wii remote

Output devices

Head mounted displays (HMDs)

Projectors

Monitors



Existing Studies

Bespoke:

Sensor-based systems (Crosbie 2004, Yeh 2005)

Xbox console with P5 glove (Morrow 2006)

Haptics & Robotics (Boian 2002, Guo 2007, Podobnik 2008)

Adapted:

Sony EyeToy (Rand 2004, Yavuzer 2008)

Some patients experienced difficulty playing games.

Lack of level grading and suitable challenge for games.

Clearly, rehab games need to be flexible to impairments.

Nintendo Wii (ongoing studies)



Game Design for StrokeRehab Existing systems use few or no game design principles.

“Designers of rehabilitation tasks can benefit fromexamining the formulas that commercial gamedevelopers use…” 1

Video games are often highly engaging.

Since rehabilitation should be intensive, games may thereforeoffer high quality rehabilitation environment.

Commercial off-the-shelf games may already offer somebenefits to people with stroke, but this could be improved!

1. Rizzo & Kim (2005) “A SWOT analysis of the field of virtual reality rehabilitation and therapy”.



Game Design for StrokeRehab Play

Voluntary activity, rule-bound and meaningful.1

Manipulation that satisfies curiosity.3

Game A system defined by rules, with a quantifiable outcome.2

A problem-solving activity, approached with a playful attitude.3

A series of meaningful choices.4

Game design Determinant of game-play.

Aim to achieve meaningful play .2

1. Huizinga (1955) “Homo Ludens: A Study of the Play-Element in Culture”.

2. Salen & Zimmerman (2003) “Rules of Play: Game Design Fundamentals” .3. Schell (2008) “The art of game design: a book of lenses”.4. Sid Meier, game designer. Cited in 2.



Game Design for StrokeRehab Why play?

Challenge and competition

Dynamic interactive experience

Social interaction

Locally or remotely (online)

Escapism

Emotional experience

Fun

T-shirt from

http://www.zazzle.co.uk/id_rather_be_playing_video_games_tshirt-235013304923558036





Game Design Principles

Three importantprinciples selected forrehabilitation:

Meaningful Play

Handling Failure

Appropriate level of

challenge

Image from www.ubercool.com

http://www.ubercool.com/

http://www.ubercool.com/




Meaningful Play

Feedback allows the player to measure their progress.

Progress towards goals.

Upgrading equipment or gaining a level.

Goals can be short-term and long-term.

Motivate and increase longevity.

Inputs choices

Discernable and integrated outcome

Player GameMeaningful playMeaningful play

Feedback




Handling Failure

Failure is a prominent and expected element of video games.

Should only occur due to player’s incorrect choice.

Rehabilitation games should handle failureconservatively.

Reward all engagement.

Positive and encouraging feedback, even if performance is“poor”.

Scoring principles redesigned.




Maintaining ChallengeAppropriately

Match patient abilities.

How to maintain challenge?

Speed, position and size of game elements can set

level of challenge. In-game calibration can determine suitable level of

challenge for player’s abilities.

1. Csikszentmihalyi (1988) “Optimal Experience: Psychological Studies of Flow inConsciousness” .

2. Rabin (2005) “Introduction to Game Development” .

1, 2



Outcome Measures

Usability

Playability

Motivation Engagement / Immersion

Enjoyment

Functional outcomeAssessed by health professional.



Game Usability

In software engineering, usability refersto the ease of use of an application’suser interface.1

Measured in terms of efficiency , effectivenessand satisfaction.

Differs in relation to video games:

A good tool should be both easy to learn and easy to master.

A good game should be easy to learn but difficult to master.2

Game satisfaction emerges from both UI and playability .

Both games & software require effective feedback mechanisms.

1. ISO 9241 Part 11 : Guidance on usability - http://tinyurl.com/ISO9241-11 2. Malone (1982) “Heuristics for designing enjoyable user interfaces: Lessons from

computer games”

http://tinyurl.com/ISO9241-11

http://tinyurl.com/ISO9241-11



Motivation

Goal-orientated behaviour

Intrinsic: Rewards inherent to the task itself.

The enjoyment of play, the resulting score,beating a previous high score, improving motorfunction.

Extrinsic: Rewards outside of the task.

Peer/therapist encouragement, competition,improving motor function.



Engagement / Immersion

Engagement

Entry level to immersion: Time, effort and attention need to be invested.

Player adequately in control of the game and gaining appropriate feedback.

Engrossment

The emotional investment the player puts into the game.

Player is less self-conscious and less aware of their surroundings.

Total immersion Player no longer thinks about the fact that they are playing the game.

Brown & Cairns (2004) “A Grounded Investigation of Game Immersion”.

A F k f S k



A Framework for StrokeGames Design a framework as a guideline for designing

stroke rehabilitation games.

Map game design principles to stroke rehabilitation: Suitable level of difficulty.

Smooth learning curve.

Exercise appropriate range of motions.

Locus of movement.

Competition.

Short-term & long-term goals.

Simple game premise.

Appropriate time limits.

Focus on affected side.

Meaningful tasks (for ADLs).

Good usability & playability.

Effective feedback.

A F k f St k



A Framework for StrokeGames

Rehabilitation

System

Mapping GameDesign to

Rehabilitation Tailored Experience

MeaningfulFeedback

Engagement

Enjoyment Motivation ChallengeLongevity

Improved Outcome?

Meaningful Play

P i UU VR St k



Previous UU VR StrokeProjects

Bilateral catch task:

Uses an electromagnetic sensorattached to a real physical basket.

User moves basket with both hands

to catch falling oranges.

Adaptive ‘Whack-a-Mouse’ game:

Sensor attached to player’s hand.

Encourages arm movement andvisual discrimination.

Not suitable for home use.



Webcam Games

PlayerMovement

WearingGloves

ImageCaptured

by USBWebcam

ImageProcessed

– Pixelsidentifiedfor each

glove

Output toMonitor /Projector

R

L



Webcam Games

Profile setup

Stores individual playerprofile, per player.

Stores playerinformation:

Player identifier.

Affected side.

Game speed settings.

Game session duration.



Webcam Games

Initial ability determinationtest:

Player must roll each ball as faras they possibly can.

Test done for each arm. Allows system to determine

range of movement and positiongame elements accordingly.

Stored in player profile.

Can be used as baseline test.



Webcam Games

Effective feedback

Large, bold, easily identifiable graphics.

“Hit” and “Miss” colour coded messages.

Particle effects to show a hit. Identifiable sound effects for hits and

misses.

Encouraging messages, regardless of performance.

Score performance chart showsprogress over previous sessions.



Webcam Games - Tools

Camera Calibration tool Allows refining of colour

detection settings.

Improve automation of colour detection in future.

Log Analyser

Shows graphical representationof movements.

Allows replay of game sessions.

View scores.

Potential for remote viewing.



Evaluation of Games

Initial phase – Evaluation with able-bodied users:

10 able bodied users playing webcam games.

Majority of participants enjoyed all games.

Players felt games were enjoyable, replayable and easyto play due to intuitive controls.

Adaptivity approved by those who noticed it (>80%),indicating the game would be less enjoyable without it.

One user expressed that the adaptivity was tooaggressive.

> 80% agreed that the feedback was effective.



Evaluation of Games



Evaluation of Games

All participants displayed enthusiasm and excitement duringgameplay.

Some expressed interest in obtaining the games for home use.

All were able to play the games well despite varying levels of impairment.

Lowest score obtained in any game was a respectable 61%.

All rated games to be enjoyable and replayable.

Lowest score given for enjoyment of game was 7/10.

Feedback effective: all agree that they were able to identify

when they had made a mistake and know how they made it. All approved of adaptivity feature; however, felt that the games

speeded up too quickly when performing well.



Evaluation of Games

Phase 3 – Three weeksingle user case studies:

Results not yet published.

Feedback from study verypositive.

Included motivationquestionnaire.

Performance results andmotor function outcomeare encouraging.

Augmented Reality



Augmented RealityGames Marker-Based AR.

Markers tracked via image from standardwebcam.

Real-world image augmented with virtualelements.

Allows use of physical objects of varyingsize, shape and weight.

Rehabilitate high quality motor skillswhich are more transferable to activities

of daily living? Various libraries: ARToolKit ,

ARToolKitPlus, ARTag.

Augmented Reality



Augmented RealityGames “Brick ‘a’ Break”

Clone of Atari’s Breakout game.

Aim to encourage reach and grasp movement.

Player holds a small cube, representing apaddle.

No time limit for the player to clear a level –player’s score determined by time taken.

Player does not lose a life for missing a ball –short pause while the ball is re-spawned.

Future versions will contain multiple levels.

Different level layouts.

Different ball speeds.

Different playfield size.

Augmented Reality



Augmented RealityGames “Shelf Stack”

Designed to encourage reach, grasp, liftand release motor function.

Player has several different real world

objects. Prompted to pick up a particular object,

move it to a specific location on theshelf, then return it to its position.

Points awarded for completion of

selection-placement tasks and speed. Score as highly as possible within time

limit.

Requires cognitive skills to discriminatethe correct object and placement of the

object.

wii announced to help with stroke and motor function

Documents