USE OF VIDEO GAMING AS AN ADJUNCT DURING OUTPATIENT STROKE REHABILITATION TO OBTAIN UPPER EXTREMITY TASK SPECIFIC PRACTICE AND

IMPROVE SITTING BALANCE

Combined Section Meeting 2010 San Diego, CA February 17-20, 2010
Ann Reinthal, PT, PhD, NCS Cleveland State University Susan Linder, PT, MHS, NCS Lakewood Hospital Kathy Szirony, PT Cleveland Clinic Mary Milidonis, PT, PhD Cleveland State University

Course description
Current research supports that multiple repetitions of task specific practice are essential to improvement in function post stroke. However, recent work has shown that individuals post stroke are not getting the necessary repetitive practice in the outpatient setting, especially related to upper extremity activities. This presentation describes the use of video gaming in individuals post stroke, with the goal of providing additional repetitive, task-specific upper extremity practice. It also reviews the results of a pilot study assessing the effectiveness using gaming in a group of individuals with chronic stroke.

Full handout available at:

www.csuohio.edu/Sciences/Dept/HealthSciences/Graduate/PT/Index .html Reinthal, Linder, Szirony, & Milidonis; not to
be copied without permission

Objectives
Understand the importance of repetitive task specific practice in recovery of function post stroke, discuss the difference and controversy regarding repetitive task practice versus impairment-based interventions, and review evidence on the occurrence of repetitive task specific practice in the current outpatient setting. Analyze how video games, specifically Wii, PlayStation2 with the EyeToy, and Rock Band can be used and modified for individuals at various levels of function post stroke to: Achieve repetitive task specific upper extremity practice Address impairments Improve sitting balance

Objectives
Discuss feasibility issues related to using video gaming in an outpatient environment Interpret changes in motor function in a group of individuals with chronic stroke (n=6) as a result of video gaming Identify additional questions raised by this pilot clinical study and directions for additional investigation.

Introduction
Literature Review and Study Aims

Repetitive Task Practice

1. Repetitive task practice for person with stroke 2. Obstacles for adequate practice 3. Approaches that apply repetitive task practice

Repetitive task specific practice

Task specific practice results in more functional improvement than traditional neuromuscular rehabilitation approaches.
(Brosseau et al. 2006; Duncan et al. 2005; Gresham et al. 1995)

Multiple repetitions of task practice, such as eating with a spoon or combing hair, are essential to improvement in that specific function post stroke. (Kleim & Jones 2008; Boyd &
Winstein 2003; Boyd & Winstein 2006; Wolf et al. 2006; Boyd et al. 2009)

Practice repetitions
While the magnitude of practice repetitions is not yet fully delineated for various motor skills and after differing degrees of brain injury, it is thought that individuals post stroke must practice a task for a minimum of several thousand repetitions in order to relearn a task. (Kleim & Jones 2008; Boyd et al.
2009)

Experience-dependent neuroplasticity (Kleim &

Jones 2008)

Repetitive practice in rehabilitation

Recent research has begun to measure the amount of practice that occurs in a typical rehabilitation program Individuals post stroke are not getting the necessary repetitive practice in the outpatient setting, especially related to upper extremity activities.

On average in a 36 minute session addressing the UE :

39 active assisted UE movements 12 purposeful UE movements (Boyd et al. 2009; Lang et al. 2007)

Obstacles to obtaining adequate practice

There are a large number of UE tasks to be practiced While there is some transfer of learning between similar tasks, such as picking up a coffee mug and a can of soda, practicing these tasks would not necessarily be helpful for learning to write with a pencil. (Kleim & Jones 2008; Lang
et al. 2007)

Obstacles to obtaining adequate practice

Repetitive practice of a single task is often boring for adults. (Betker et al. 2007;
Flynn et al. 2007; Rand et al. 2008; Yavuzer et al. 2008)

Both patient and therapist

Obstacles to obtaining adequate practice

Learner must actively engage in task practice
It is not adequate to be passively moved through the activity. (Lang et al. 2007; Lotze et al. 2003)

In order for the task to be completed correctly, a skilled professional must often supervise.
Expensive to provide the hours of training that are frequently part of the typical research trials that have resulted in changes in upper extremity function post stroke. (Flynn et al. 2007; Rand et al. 2008; Yavuzer et al. 2008)

Approaches that provide repetitive task practice

Constraint-induced or forced-use therapy
Hemiparetic arm is forced to practice various tasks repetitively, usually by constraining the non-hemiplegic arm. Individuals who improve in response to this type of therapy typically have higher functioning hands, with some active control of wrist and finger extension. (Wolf & Winstein
2006; Wolf 2007; Sunderland & Tuke 2005)

Approaches that provide repetitive task practice

Robotics
Devices that constrain movement to occur in the correct movement pattern during repetitive practice Some type of instrumentation that actively guides movement Have been utilized successfully with high and low level functioning hemiparetic arms post stroke These devices usually provide partial passive assistance with the movement, and also constrain the movement to occur in a specific correct movement pattern. (Banz et al. 2008; Barker et al. 2008; Hesse et al. 2005; Mirelman et al. 2009; Frick & Alberts 2006)

Approaches that provide repetitive task practice

Virtual reality (VR) environments
Have been successfully used to provide upper extremity repetitive task practice. (Crosbie et al. 2006;
Sveistrup 2004)

Typically provides a three-dimensional computer generated immersion experience The player completes the task similarly to in the real world The experience is typically engaging, realistic and transfers to a comparable real world activity.
(Sveistrup 2004)

Virtual Reality
The virtual reality literature discusses the concepts of immersion and presence
(Riva et al. 2004)

Immersion: the drawing in experience of VR Presence: a form of positive, active engagement that occurs during the VR experience

Video gaming systems

Video gaming systems are commercially available, inexpensive virtual reality-type systems
They provide engaging interaction Examples: Wii, PlayStation II with EyeToy, and Rock Band

Video gaming systems

Can be easily tailored to individuals with varying degrees of paresis post stroke
similar to some of the robotic and VR systems unlike constraint-induced interventions that are only appropriate for higher functioning arms.

Video gaming systems

Motor learning is best when an activity is meaningful
Practice of the task must be both functional and engaging to the individual. (Kleim & Jones 2008)

Gaming has become popular with older adults, with Wii systems appearing in many senior citizen facilities.

Video gaming systems

Gaming has been shown to utilize significantly more energy than sedentary activities. (Graves et al. 2007)

Enhanced cardiovascular fitness in turn has been shown to improve cognition as well as cortical plasticity. (Colcombe et al. 2004;
Kramer & Erickson 2007)

Physical activity is very low after stroke (Rand et al.

2009)

Physical activity and exercise may protect and enhance cognitive brain function across the adult lifespan (Kramer & Erickson 2007)

Neurologic gaming research

Gaming has recently begun to be utilized as an effective adjunct to physical and occupational therapy for individuals with neurologic deficits. (Flynn
et al. 2007; Rand et al. 2008; Yavuzer et al. 2008; Deutsch et al. 2008, Betker et al 2007)

Gaming research post stroke

Flynn et al 2007
PS EyeToy Case study, chronic stroke 20 1-hr sessions Feasible Dyn Gt Index Trend FMA, Berg, UE Func Ind, MAL, Beck Depression Inv.

Rand et al 2008
PS EyeToy 12 adults, subacute & chronic stroke Single session High sense of presence Difficulty grading games for lower functioning

Yavuzer et al 2008
PS EyeToy -- UE 20 inpt. <12 mo post stroke 30 min; 5 days/ wk; 4 wks FIM scores no in Brunnstrom stages

Gaming as an adjunct to the treatment of individuals with neurologic deficit

Offers:
Unilateral practice opportunities, such as playing tennis on the Wii Bilateral upper extremity activities such as swinging a golf club or baseball bat
Bilateral upper extremity practice has been utilized effectively in several studies (Hesse et al. 2005; Luft et al. 2004; Cauraugh & Kim 2002; Staines et al. 2001) probably by inducing reorganization in contralesional motor networks. (Luft et al. 2004; Calcautti & Baron 2003)

Gaming as an adjunct to the treatment

In previous research in our lab, participants found the gaming:
Engaging Enjoyable Physically tiring

We have rarely observed the same degree of task engagement as found during gaming
The only comparable activity was working on the golf swing with a group of golfers post stroke. (Reinthal et al.
2002)

Activity must be meaningful

Evidence-based practice triangle

Research evidence

Patientcentered care

Clinical expertise

Support from research literature (evolving) Clinical experience of therapist Meaningful to patient

Study Aims
Begin gaming trial in a natural clinical practice environment to assess:
Feasibility of adding gaming as an adjunct
without added therapy personnel costs using commercially available gaming equipment

In individuals post stroke, examine whether the practice completed through gaming leads to improvement in:
upper extremity function sitting balance

Study team
Multi-Centered Within and between Cleveland State University and Cleveland Clinic Health System (Lakewood Hospital and Cleveland Clinic Main Campus)

Multidisciplinary effort
Neurologic physical therapists Neurologic occupational therapists Epidemiologist/health services researcher Engineers Psychologist STUDENTS

Pilot Study Participants

Currently in exercise class at Lakewood Hospital Hemiplegic UE with some degree of dysfunction post stroke: Brunnstrom Stage 2-6, but not Brunnstrom Stage 1 Able to sit safely with back unsupported while playing games Adequate communication & cognition skills to learn and play game in three sessions or less Able to play game independently or with support personnel/family after set up

Beyond the Pilot Study Phase

Now enrolling outpatients at 2 sites

Study Design
Pre-test post-test within subject design
Clinical practice improvement research
No control group (not a randomized clinical trial) Evaluates practice in a natural clinical practice environment
Translational Can often be incorporated into daily clinical practice more readily than a RCT

Community Based Participatory Research

http://www.ahrq.gov/downloads/pub/evidence/pdf/cbpr/cbpr.pdf

CBPR has been proposed as an approach that combines research methods and the clinical community Capacity-building strategies to bridge the gap between knowledge produced through research

Translation of this research into interventions and policies.

Best Practice CBPR

www.ahrq.gov/downloads/pub/evidence/pdf/cbpr/cbpr.pdf

Encounter between researchers and their community collaborators during each stage of research.
utilize their respective, legitimate knowledge and expertise for examining and addressing a particular issue.

EFFECTIVENESS NOT EFFICACY

Blue Highways on NIH Road MAP

JAMA, Jan 2007, vol 297, No 4

http://www.sbm.org/outlook/0608/articles.asp?article=1

Clinical Decision Making:

Matching Individuals to Games

Clinical Decision Making: Two Step Model

STEP I: Establish goals using Patient Client Management Model (PCMM) and Nagi/ICF Model

STEP II: Based on goals, be able to select and modify the appropriate games

Clinical Decision Making: Step I

Establish goals using Patient Client Management Model (PCMM) and Nagi/ICF Model

Clinical Decision Making for Gaming Intervention based on ICF/Nagi Model and PCMM (PT Guide to Practice)
Examination: Meaningful, functional patient goal

Examination: Impairment, functional task analysis (activities), disability analysis (participation)

Evaluation: Hypothesize which impairments are limiting function

Prognosis: Collaborative goal setting and game selection based on impairments and functional limitations to meet functional patient-centered goal

Clinical Decision Making: Complete Examination

Examination 1. Impairment 2. Functional task analysis (activities) 3. Disability analysis (participation) Specific to diagnosis Normal physical therapy examination Additional specific outcome measures

Stroke specific outcome measures

Impairments
Motor control: Fugl-Meyer UE Motor Sensation: Fugl-Meyer UE sensation Strength, communication, memory & thinking: Stroke Impact Scale Balance: Multi-directional functional reach in sitting, Five times sit to stand test, ActivitiesSpecific Balance Confidence Scale

Basis of Fugl-Meyer
Crow and Harmeling-van der Wel,PhysTher v88, 2008

Brunstrom Stages
Stage1: Flaccid paralysis

Fugl-Meyer Upper Extremity

None

Stage 2: Minimal Movement Synergy

Stage 3: Voluntary Movement Synergy Stage 4: Some out of Movement Synergy

Tendon Reflexes 4/40

Flexor and Extensor Synergy (4+18)/40 Hand to Lumbar Spine; Shld Flex > 90; Pron/Supination (4+18+6)/40 Shld Abd 0-90; Shld Flex 90-180 (4+18+6+6)/40 Tendon Reflex Symmetry and Normal Coordination (4+18+6+6+6)/40

Stage 5: Almost independent of Movement Synergy

Stage 6: Near normal movement & speed

Stroke specific outcome measures

Functional limitations (activities)
Wolf Motor Function Test
Task-specific analysis (timed based only)

Stroke Impact Scale (hand, ADL, and mobility sections)

Tasks of the WMFT

1. 2. 3. 4. 5. 6. 7. Forearm to table (side) Forearm to box (side) Extend Elbow (side) Extend elbow (weight) Hand to table (front) Hand to box (front) Reach and retrieve

Tasks of the WMFT

9. 10. 11. 12. 13. 14. 15. Lift pencil Lift paper clip Stack checkers Flip cards Turn key in lock Fold towel Lift basket

Stroke specific outcome measures

Disability (Participation)
Stroke Impact Scale (participation)

Clinical Decision Making: Evaluation What impairments are limiting function?

Analyze for specific motor control and strength impairments that may be limiting function on given tasks identified in exam - for example on Wolf Motor Function Test (WMFT)

Analyze for other impairments that must be considered (cognition, sensation, etc.)

Clinical Decision Making: Evaluation What impairments are limiting function?

Unable to complete item #6 on Wolf Motor Function Test (Hand to box in front)
Hypothesize impairments limiting function:
Inadequate antigravity shoulder flexion strength Inability to obtain isolated shoulder flexion with elbow extension

Clinical Decision Making: Prognosis Collaborative Goal Setting

Patients goal(s) from exam Develop realistic collaborative goal(s) with patient based on examination and evaluation EXAMPLE: Patient goal:
Use arm again

Collaborative goal after discussion with patient:

Use arm to stabilize paper/objects on table top

Clinical Decision Making: Prognosis TASK DEMANDS

Based on collaborative goal, analyze task to determine components that need to be addressed Analyze task demands Break into functional components that must be addressed based on exam (impairments, functional limitations, disability) EXAMPLE OF FUNCTIONAL COMPONENTS: Use arm to stabilize paper/objects on table top Must be able to place arm on table top Must be able to position arm over object to be stabilized Must be able to grade force to stabilize object while using other arm

Clinical Decision Making: Prognosis Determine impairments limiting function

For a given functional component, determine what impairments you hypothesize must be addressed in order to be able to accomplish the functional component Comparable to short term goals

EXAMPLE Collaborative goal: Use arm to stabilize objects on table top Functional component from task analysis: Must be able to reach arm over table top (WMFT #6 Hand to box) Impairments to be addressed (short term goals): 1. Inadequate antigravity shoulder flexion strength 2. Inability to obtain isolated shoulder flexion with elbow extension

Improved anti-gravity shoulder flexion with elbow extension after 5 sessions

80 elbow extension 45 elbow extension

40 shoulder flexion

55 shoulder flexion

Pre

Post

Improved anti-gravity shoulder flexion with elbow extension after 5 sessions

Achieved practice repetitions comparable to motor learning trials post stroke (>500) (Boyd & Winstein 2006) On 7 point Intrinsic Motivation Index (7 pt high), rated gaming a 6.6/7; completing his home exercise program 4.4/7

Practice time Reps of practice* Wakeboarding Baseball Total 74 min. 75 min. 2 hr; 29 min. 1628 600 2228

* Reps calculated from vidoetaped analysis

Clinical Decision Making: Prognosis Motor Learning Principles

Movement is COMPLEX and VARIABLE Gaming offers EXPANSIVE possibilities for retraining motor skills at multiple levels of complexity and variability Incorporate motor learning principles into development and implementation of therapeutic interventions

Only limited by our analysis skills, knowledge of gaming, and creativity

Clinical Decision Making Model STEP II

Selection and Modification of Games INTERVENTION PLAN

Game Selection
After establishing collaborative goal(s):
The therapist must know the motor control and other requirements for the game The correct games must be selected The therapist must know how to play the games
Will not address this specifically in this presentation, except under feasibility section See Appendix for games used in this project

Game selection: What you need to know about the game

Motor control demands

Other considerations Motivation Game modifications and progression

Game Selection
Motor Control Demands
Underlying available movement repertoire Unilateral versus bilateral arm use Trunk demands Task specificity Cognitive demands Sensory and spatial relations impact

Clinical Decision Making for Game Selection

Brunnstrom stages II - III with inability to complete fine motor tasks and variable ability to complete gross motor tasks of WMFT efficiently

Clinical Decision Making for Game Selection

Brunnstrom stage IV with ability to complete fine and gross motor tasks of WMFT, but inefficiently and inconsistently

Clinical Decision Making for Game Selection

Brunnstrom stage V-VI with difficulty performing fine motor tasks of WMFT consistently and efficiently

Game Selection
Bimanual yoked arm
Activities that incorporate large degrees of trunk rotation Golf, baseball swing, drumming

Game Selection
Bimanual hand (variable trunk demands)
Bilateral symmetrical Bubblepop, Wishi Washi

Game Selection
Bimanual hand (variable trunk demands)
Bilateral reciprocal Active assisted: Driving, Wakeboarding Active: Boxing, Drumming

Game Selection
Bimanual hand (variable trunk demands)
Each hand doing something different Guitar, target shooting, archery

Game Selection
Unilateral arm, hand and wrist (variable trunk demands)
Frisbee, Table Tennis, Wii Resort Airsports

Game Selection
Trunk task demands
Mobility / Stability

Is this task specific practice?

Cannot practice a task until there is adequate strength and motor control to practice the actual task

This clinical decision making model allows for preparatory work on impairments and task components before moving on to practice the actual task, but as part of an engaging task

Clinical Decision Making:

Incorporating task-specificity into gaming intervention

Task specific practice is possible for many games

Cognitive Demands
Attentional demands
Moving objects, such as tennis ball in tennis

Executive functions
Plan game strategy (Golf: direction of wind, type of club to use, etc.) Dual-task performance Ability to complete a task, such as talking while walking, or playing a Wii game while in unsupported sitting or standing.

Adapting to sensory impairment

Environmental adaptation for left neglect

Game selection for spatial relationship impairments

Other Considerations
Cardiopulmonary demands Communication

Cardiopulmonary Considerations
Monitored for safety
Heart Rate (HR monitor versus manual) RPE Pulse oximetry

By-product: Cardiovascular conditioning

Potentially an efficient method to meet multiple therapeutic needs Consider speed demands of game Consider sitting versus standing practice

Aphasia and Communication

Some games have many written instructions or verbal comments
This should be considered if it may interfere with the patients ability to play the game

Motivation Factor
Taking Advantage of Patients Prior Experiences
Water Skiing Musicians Boxer Bowler Golfer

Motivation Factor
Competition with others Competition with gaming system Socialization within the group (Co-action) Need multiple game choices for a given individual for optimal motivation

Game modifications
Be creative!
Aquaplast (splinting material) covers for controller buttons

Grading task difficulty and progressions

Practice Repetitions in 5 Sessions

Game Drumming Bubblepop Practice time Repetitions* 122 min 107 min 8296 2568

Total

3 hrs 59 min

10,864

*Repetitions counted from videotape

Intrinsic Motivation Index 7/7 for gaming, 4.3/7 for HEP

Video Games Utilized Appendix A

Feasibility of utilizing gaming in an outpatient setting

Feasibility Considerations
Patient
Safety

Therapist

Facility

Optimum therapeutic practice

Knowledge: Therapist outcome productivity measurement Knowledge: game Equipment cost selection & use

Motivation to practice

Facilitating adherence

Support personnel
Reimbursement

Equipment Recognition of cost/home support time commitment (HEP)

Feasibility: Patient Considerations

1. 2. 3. 4. Safety Optimum therapeutic practice Motivation to practice Equipment cost/home support (HEP)

Is Independent Practice Feasible?

Safety
Fall risk / Fall prevention Guarding Performing gaming activities in sitting versus standing Consider use of harness Using hi-low tables or height-adjustable stools to modify demand on trunk balance implications Cardiopulmonary monitoring

Is Independent Practice Feasible?

Optimal practice to achieve therapeutic goals (ie: cheating)
Competitive spirit quest to win Overuse of non-hemiplegic UE Triggering games without full use of desired (therapeutic) movement

Patient motivation to practice

Must have gaming options that appeal to patient Self-efficacy

Gaming as a Home Exercise Program

Set up of games in preparation for home exercise program phase
Patients have learned various appropriate games as part of therapeutic intervention Several appropriate games can be utilized on one disc/game for a single session of gaming Patients learn basic gaming trouble shooting

Gaming as a Home Exercise Program

Performing gaming activities as a part of patients home exercise program
Affordability Motivation / Interest Compliance with home program Quantity of repetitions Life-long skills for ongoing training/practice
Promotes independent activity/exercise

Feasibility Considerations: Therapist

1. Knowledge of outcome measurement 2. Knowledge for game selection and use of gaming systems 3. Facilitating adherence 4. Recognition of time commitment

Knowledge of Outcome Measurement

Appropriate matching of outcome measures Administering outcome measures

Knowledge for game selection and use of gaming systems

The correct games must be selected

The therapist must know how to play the games

Patient-Centered Care:
Facilitating Adherence
(Shephard & Jenson 2002)

Negotiate common ground: collaborative relationships Identify and remove barriers Provide feedback Consider prescribed self-care regiment from patients perspective Customize treatment Enlist family support & access resources Anticipate non-adherence

Recognition of time commitment

Therapist organizational skills

Time investment outside of clinic, especially learning to play the games

Feasibility Considerations: Facility

Therapist productivity Support personnel Costs Reimbursement

Productivity and Support Personnel

Facility expectations for productivity Support Personnel
Cost Availability Creative options
Family Students Friends Community

Facility costs: Equipment and space

Reasonable compared to VR and robotics equipment
Affordability of commercially available games compared to virtual reality or computerized robotics Eye Toy (< $100), Wii ($200-300) Availability of gaming systems and games Used games, older models

Within discretionary budgets Space

Reimbursement
Gaming interventions Skilled reimbursable time Non-reimbursable independent /supervised practice Documentation

Outcome Results of Gaming for Individuals Post Stroke

Practice Repetitions Obtained Changes in measures Wolf Motor Function Fugl-Myer Intrinsic Motivation Case Analysis Low, moderate, and high functioning individuals

Preliminary Results
Pilot with chronic stroke population (N=6) who regularly attend a community-based stroke exercise class at Lakewood Hospital Expect less change than with more acute outpatient population

Demographics
Age Sex Side of hemiplegia Brunnstrom arm/hand stage Years post stroke 3 4.5 7 7 5.5 2 Aphasia Yes Yes No No No No *All could ambulate, at a minimum, independently at home with a device #1 73 M Right 2 #2 69 F Right 2-3 #3 86 F Right 3-4 #4 62 M Right 4-5 #5 75 F Left 4-5 #6 59 F Right 6-7

Practice repetitions per minute of playing time

Extremely variable Depends on:
Type of game played
Continuous task vs. discrete task (Golf vs. BubblePop) Time demands of game (Golf vs. KnockOut)

Number of players
Fewer repetitions when more than one player

Motor function of player

Some players move more slowly than others

Average Practice Repetitions per Minute

Repetition counting equipment still under development Counting presented here (unless otherwise stated) is an estimate based on a normal individual playing the game for ten minutes, at the beginning level
Counted repetitions Averaged to find repetitions/minute

Average Practice Repetitions per Minute

Discrete tasks/game
Wii Bowling

Continuous tasks/games
PS BubblePop PS WishiWashi Wii Island Flyover

10 30 14 14 11 38 65

Wii Golf
Wii Frisbee

4
4

Wii Powercruising
Wii Wakeboarding

PS Kung2*
PS KnockOut*

* Boxing games can be considered continuous when played in a continuous manner, as measured here; otherwise discrete

Practice repetitions and time

# of repetitions 8183 11500 7008 27965 15987 14576 # of sessions attended 29 29 30 29 26 21 Total hours played 9.9 11.1 14.8 18.7 10.4 14.3

1 2 3 4 5 6

Wolf Motor Function Test

Minimal Clinically Important Difference (MCID) 19 seconds in acute stroke (Lang et al.,2008) 1.5 to 2 seconds in subacute stroke (Lin et al, 2009) Minimal detectable change 4.36 seconds in subacute stroke (Lin et al 2009) Mean improvement of 10 seconds in this chronic population

*P = 0.043 Wilcoxon Signed Ranks Test

Mean SD Median

Pre 52 51 36

Post 42 54 11

Functional Change: Wolf Motor Function Test

120 100 S e c o n d s 80 60 40 20 0
Subject
Pre Post

Mean Time WMFT*

#1

#2

#3

#4

#5

#6

Fugl-Meyer
66 point Likert scale Scale from 0 cannot perform, 1 performs partially, 3 performs fully Minimal Clinically Important Difference (MCID): 10% of score (6.6 points) (Gladstone et al 2002)
Only one participant with >6 point improvement, although two others with 5 point improvement

P = 0.102 Wilcoxon Signed Ranks Test

Mean SD Median

Pre 35 24 39

Post 39 26 49

Changes in Motor Control: Fugl-Meyer UE Motor

60 F 50 M 40 S c 30 o r 20 e 10 0 Subject

Pre Post

#1

#2

#3

#4

#5

#6

Trunk control and balance?

Multi-directional Functional Reach in Sitting
140
120

Combined Functional Reach

Pre Post

100
C m

80

60
40

20
0
Subject #1

#2

#3

#4

#5

#6

Intrinsic Motivation Index (IMI)

Survey instrument 7 point scale (maximum score showing high motivation is 7.0) Motivation to complete home exercise program (HEP) significantly less than to game or attend exercise class Gaming Ex HEP Friedman test Class
*P=0.028
Mean SD Median 6.6 0.49 6.7 6.5 0.74 6.8 5.2 0.87 5.2

Intrinsic Motivation Index*

7
I M6 I 5 S c 3 o 2 r 1 e

Video gaming Exercise class Home program

0 #1
Subject

#2

#3

#4

#5

#6

Five-times Sit to Stand Test Activities-specific Balance Confidence Scale Stroke Impact Scale Functional Reach Test

No significant changes in pilot group p>0.05

Three Levels of Function: Case Analysis

Clinical Implications and Discussion
Low functioning upper extremity
Brunnstrom UE/hand Stage 2 to 3

Moderate functioning upper extremity

Brunnstrom UE/hand Stage 3 to 6

High functioning upper extremity

Brunnstrom UE/hand Stage 6 to 7

Subject #2: Low Function

69 y.o. F 4.5 years post; R hemiparesis Dense expressive aphasia Probable apraxia History of cardiovascular disease, post CABG

Subject #2: Low Function

Brunnstrom stage 2, beginning 3 arm/hand
Beginning motion in R shoulder and elbow in flexion and extension synergy patterns
Shoulder abd/add, elevation, retraction, int rot Elbow flexion/extension

Hand fisted with possible slight voluntary finger flexion FM UE motor score of 7

Subject #2: Low Function

Ambulates at home with hemi cane and R AFO Only able to complete reach and retrieve gravity eliminated elbow flexion item on WMFT

Goals
Collaborative goal(s):
Exercise in aerobic conditioning range Improved socialization and communication Improve trunk control/balance in sitting Improved arm/hand function?????
Few evidence-based therapeutic options for low level UE Apraxia and functional gaming

Practice repetitions and practice time

# of repetitions # of sessions attended Total hours played

11,500

29

11.1

Clinical decision making: games chosen

Began with EyeToy games due to:
Difficulty of managing buttons on Wii games Decreased complexity of gaming options

Used yoked UE protocol

Tested with sEMG unit to assess whether more activity of shoulder and elbow muscles while gaming as compared to using upper body ergometer during same session

Clinical decision making: games chosen

Early EyeToy games
BubblePop Kung2 WishiWashi Knock-out

Progressed to some Wii games

Bowling (played others) Wakeboarding Golf WiiFit soccer (heading with yoked paddle)

Achievement of goals: Aerobic exercise

Cardiovascular conditioning range of 60-80% MHR = HR of 91 to 121 Post exercise HR in CV conditioning range 50% of time
Depending on games played
Less likely when playing golf, bowling More likely with BubblePop, Kung2, etc.

Clinical implication: some individuals can use gaming to achieve cardiovascular exercise, however appropriate game selection is critical for this goal

Achievement of goals: Socialization and communication

Increase from 14% to 32% in Communication subsection of Stroke Impact Scale
Other densely aphasic participant also increased substantially in Communication subsection

Increased vocalization, but probably no actual change in language (not measured) Much interaction and engagement during gaming Change in perception of communication May impact on participation level (ICF model)

Achievement of goals: Socialization and communication

Learned gaming in sitting during this study
Initially somewhat frustrated and bored with EyeToy games; really began to enjoy gaming once she started playing with others Had been unable to game while standing before study; able to do so after study
Very gratified with this new skill

Clinical implication: consider gaming to increase socialization; interaction/ communication; self-efficacy

Achievement of goals: Trunk control and sitting balance

Slight increase in combined FR scores (29 cm pre increased to 33 cm post) Perceived improvement in balance on Activities-specific Balance Confidence Scale (0% confidence pre to 23% confidence post) By observation, participant moved more in sitting than during other activities Unclear if measures adequate Clinical implication: consider gaming activities that involve large trunk motion components for this patient-specific goal

Achievement of goals: UE motor control and function

No change in FM score; improved speed on one item able to complete on WMFT (reach and retrieve) Probably no change in UE motor control and function, although few other treatment options available for this level of arm/hand Clinical implications: probably cannot change motor control in many individuals with low level arm/hand function

Subjects #3 & 4: Moderate Function

Subject #3
Brunnstrom stage 34 arm, 4-5 hand Focus on shoulder

Subject #4
Brunnstrom stage 5 arm, 4 hand Focus on fine motor control of hand

Subject #3
86 yo F, 7 yr post, R hemiparesis Scoliosis, arthritis Independent ambulator with wheeled walker, household distances Unable to do many items initially on WMFT Unable to flex or abd shoulder against gravity without elbow flexion

Subject #3: Goals

Collaborative goal:
Complete activities involving lifting hand up in space: turn a light switch on and off, open refrigerator door, etc.

Task analysis
Adequate hand function for tasks Improve shoulder function: Antigravity shoulder flexion with elbow extension (isolation of shoulder from elbow) Increase antigravity shoulder flexor strength

Subject #3: Practice repetitions and practice time

# of repetitions 7008 # of sessions attended 30 Total hours played 14.8

Subject #3: Clinical decision making: games chosen

Wii Golf with left handed swing out of flexion synergy pattern Wii Bowling shoulder flexion with elbow extension PS BubblePop, gradually increasing height of camera to demand increased antigravity shoulder flexion

Subject #3: Achievement of goals: UE motor control and function

Pre Post 4/4 16/30 9/10 16/16

Fugl-Meyer UE Motor Score changes

Reflexes 4/4 UE Wrist Hand 11/30 3/10 11/16

Coord
Total

3/6
32/66

2/6
47/66

Subject #3: Achievement of goals: UE motor control and function

120.00 100.00 80.00 Sec. 60.00 40.00 20.00 0.00 1 3 5 7 9 WMFT Item 11 13 15
Mean
Pre Post

Subject #3: Clinical Implications

Clinically significant level of change in FM and WMFT tests Achieved collaborative goal (at least for lower light switches, etc.) Enjoyed gaming and using a Wii at home

Subject #4
62 yo M, 7 yr post, R hemiparesis Independent ambulator with standard cane Brunnstrom stage 5 arm, 4 hand Able to do first items on WMFT easily; slower with fine motor tasks Good antigravity shoulder movement but lacking fine motor control of hand/wrist/forearm

Subject #4: Goals

Collaborative goal:
Improve golf swing Gaming with grandchildren

Therapist goals:
Increased fine motor control of hand
Picking up and manipulating small objects Isolated finger control (thumb IP flexion) on Wii controller

Improve ability to position hand in space for function

Wrist/forearm control

Subject #4: Practice repetitions and practice time

Reps Sessions Hours played

27,965

29

18.7

Subject #4: Clinical decision making: games chosen

Various PS games (DIY, Secret Agent, Mr. Chef, etc.)
Beginning holding screw driver and moving gradually to smaller diameter objects pen/pencil Lots of variable arm/forearm/hand movement

Subject #4: Achievement of goals: UE motor control and function

Pre Fugl-Meyer UE Motor Score changes Reflexes 4/4 UE Wrist Hand 24/30 7/10 8/16 Post 4/4 26/30 10/10 8/16

Coord
Total

2/6
45/66

2/6
50/66

Subject #4: Achievement of goals: UE motor control and function

90.00 80.00 70.00

60.00
50.00 40.00 30.00 20.00 10.00
Pre Post

0.00
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Mean

WMFT Item

Subject #4: Clinical Implications

Clinically significant level of change in WMFT test and close to the 10% level of significance on FM
LOTS of practice repetitions

Collaborative goal achieved gaming goal; involved with golfers with disability program Enjoys gaming and using a Wii at home with grandchildren

Subject #6: High Function

59 yo F, 2 yr post, R hemiparesis Isolated arm and hand motion antigravity, but with mild tremor and dysmetria

Subject #6: Goals

Collaborative goals:
Improve aerobic fitness Improve grooming skills to fix her hair Improve fine motor control of hand in space
Position of hand/wrist/forearm Grading of force and movement in function

Subject #6: Practice repetitions and practice time

# of repetitions

# of sessions attended

Total hours played

14,576

21

14.3

Subject #6: Clinical decision making: games chosen

Games requiring bimanual hand function
Wii Archery & Duckhunt Rock Band Guitar

Games requiring control of hand position in space and grading of force for function
Wii Frisbee Wii Island Flyover and Skydiving

Subject #6: Achievement of goals

Already a 64/66 on Fugl-Meyer (deficits in coordination section)
no change in FM

No change in mean WMFT time of 2.1 seconds

Ceiling effect FM & WMFT(Lin et al 2009, Hsuch et al 2008)
Do not know if her function changed Need better measures for higher functioning individuals

Subject #6: Achievement of goals

Clinical implications:
Could she have practiced an actual task and gotten same benefit, such as typing, actually throwing a frisbee, etc? Would she have practiced as much?

Goal Achievement: Able to fix her hair into a pony tail independently

Future directions
Utilize protocol with additional individuals in outpatient therapy
8 outpatients currently enrolled in outpatient phase

Future directions
Harnesses with sensors
Use of harness for safety Learning new limits of stability Permitting errors

Future directions
Begin customization of commercially available gaming equipment to the stroke population Develop/refine methods of counting repetitions for discrete tasks
Complete development of accelerometer to count repetitions

Future directions
Additional measures to be added
Cognition Presence Engagement Higher level arm/hand function
Dexterity Force control

Future directions: Increase Depth of Understanding

Motion analysis

Functional imaging

Future directions
Next generation of games

Acknowledgments: Funding
Cleveland State Universitys Faculty Research Development Grant 20092010 Cleveland State Universitys Summer Undergraduate Engaged Learning Research/Creative Achievement Award

Acknowledgments: Personnel
Clinical-academic collaboration Area clinicians, academic faculty and students

Acknowledgments: Clinicians
Kathy Szirony, PT; Michelle Wilson, OT (Cleveland Clinic Main) Susan Linder, PT, NCS; Cindy Clark, OT (Lakewood) Marcy Stalvey, PT, NCS (Edwin Shaw) Expanding to other facilities soon

Acknowledgments: Academic faculty from Cleveland State University

Ann Reinthal, PT, PhD, NCS (neurologic PT) Mary Milidonis, PT, PhD (health services researcher) Ann Begovic-Juhant, PhD (psychologist) Nigamanth Sridhar, PhD (engineering sensor technology) Wenbing Zhao, PhD (engineering gaming systems technology)

Acknowledgments: Students!!!!!
Pre PT, OT, and engineering undergrads Julie Petrash, Logan Huba, Colleen Conway, Julie Chaya DPT students Janet Fonovic, Lauren Heath, Cara Doerschuk, Scott Goia, Michelle Kellicker, Matt Shultz Other graduate students Milind Mehta

Acknowledgments: Students

Engaged Learning

Reinthal, Linder, Szirony, & Milidonis; not to be copied without permission

References
Agency for Healthcare Research and Quality. Community Based Participatory Research: Assessing the Evidence. http://www.ahrq.gov/downloads/pub/evidence/pdf/cbpr/c bpr.pdf. Accessed February 14, 2010 Banz R, Bollinger M, Colombo G, Dietz V, Lunenburger L. Computerized visual feedback: an adjunct to roboticassisted gait training. Physical Therapy. 2008;88(10):1135-1145.

Barker R, Brauer S, Carson R. Training reaching in stroke survivors with severe and chronic upper limb paresis using a novel nonrobotic device: a randomized clinical trial. Stroke. 2008;39:1800-1807. Betker A, Desai A, Nett C, Kapadia N, Szturm T. Gamebased exercises for dynamic short-sitting balance rehabilitation of people with chronic spinal cord and traumatic brain injuries. Physical Therapy. 2007;87(10):1389-1398. Boyd L, Lang C, Scheets P. Categorizing practice and counting repetitions: what are we doing for people after stroke? Combined Sections Meeting 2009. Las Vegas, NV: American Physical Therapy Association; 2009. Boyd L, Winstein C. Impact of explicit information on implicit motor-sequence learning following middle cerebral artery stroke. Physical Therapy. 2003;83(11):976-989.

 Boyd L, Winstein C. Explicit information interferes with implicit motor learning of both continuous and discrete movement tasks after stroke. Journal of Neurologic Physical Therapy. 2006;30(2):46-59. Brosseau L, Wells G, Finestone H, al e. Ottawa panel evidence-based clinical practice guidelines for post-stroke rehabilitation. Topics in Stroke Rehabilitation. 2006;13:1279. Calcautti C, Baron J. Functional neuroimaging studies of motor recovery after stroke in adults. Stroke. 2003;34:1553-1566. Cauraugh J, Kim S. Two coupled motor recovery protocols are better than one: electromyogram-triggered neuromuscular stimulation and bilateral movements. Stroke. 2002;33:1589-1594.

 Colcombe C, Kramer A, Erickson K, et al. Cardiovascular fitness, cortical plasticity, and aging. Proceedings of the National Academy of Sciences of the USA. 2004;101(9):3316-3321. Crosbie J, Lennon S, McNeil M, McDonough S. Virtual reality in rehabilitation of the upper limb after stroke: the user's perspective. Cyberpsychol Behav. 2006;9:137-141. Crow et al. Hierarchical properties of the motor function section of the FMA scale for people after stroke: A retrospective study. PTJ. 2008;88:1554-1567. Crutchfield C, Barnes ML. Motor Control and Motor Learning in Rehabilitation (2nd ed.). Stokesville Publishing, 1993. Deutsch J, Borberly M, Filler J, Huhn K, Guarrera-Bowlby P. Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Physical Therapy. 2008;88(10):1196-1207.

 Duncan P, Zorowitz R, Bates B, al e. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36:e100-e143. Frick E, Alberts J. Combined use of repetitive practice and an assistive robot device in a patient with sub acute stroke. Physical Therapy. 2006;86(10):1378-1386. Flynn S, Palma P, Bender A. Feasibility of Using the Sony PlayStation 2 Gaming Platform for an Individual Post stroke: A Case Report. Journal of Neurologic Physical Therapy. 2007;31(4):180-189. Gladstone et al. The FMA of motor recovery after stroke: a critical review of its measurement properties. Neurorehab and Neural Repair. 2002;16(3):232-240

 Graves L, Stratton G, Ridgers N, Cable N. Comparison of energy expenditure in adolescents when playing new generation and sedentary computer games: cross-sectional study. British Medical Journal. 2007;335(7633):1282-1284. Gresham G, Duncan P, Stason W, al e. Clinical Practice Guideline 16. In: US Department of Health and Human Services PHS, ed: Agency for Health Care Policy and Research; 1995. Hesse S, Werner C, Pohl M, Ruechriem S, Mehrholz J, Lingnau M. Computerized arm training improves motor control of severely affected arm after stroke. Stroke. 2005;36(9):1960-1966. Hsueh et al. Psychometric comparison of 2 versions of the FM motor scale and 2 versions of the stroke rehab assessment of movement. Neurorehab and Neural Repair. 2008;22(6).

Kleim J, Jones T. Principles of exercise-dependent neural plasticity: implications for rehabilitation after brain injury. J Speech Lang Hear Res. 2008;51(1):S225-239. Kramer A, Erickson K. Capitalizing on cortical plasticity: influence of physical activity on cognition and brain function. Trends in Cognitive Science. 2007;11(8):342-348. Lang C, MacDonald J, Gnip C. Counting repetitions: an observational study of outpatient therapy for people with hemiparesis post-stroke and invited commentary. Journal of Neurologic Physical Therapy. 2007;31(1):3-11. Lin et al. Minimal detectable change and clinically important difference of the SIS in stroke patients. Neurorehab and Neural Repair. 2008;23(5):429-434. Lin et al. Psychometric comparisons of 4 measures for assessing UE function in people with stroke. PTJ. 2009;89(8):840-850.

 Lotze M, Braun C, Birbaumer N, Anders s, Cohen L. Motor learning elicited by voluntary drive. Brain. 2003;126:866-872. Luft A, McCombe-Waller C, Whitall J, al e. Repetitive bilateral arm training and motor cortex activation in chronic stroke: a randomized controlled trial. JAMA. 2004;292(15):1853-1861. Mirelman A, Bonato P, Deutsch J. Effects of Training With a Robot-Virtual Reality System Compared With a Robot Alone on the Gait of Individuals After Stroke. Stroke. 2009;40:169-174. McCulloch K. Attention and dual-task conditions: physical therapy implications for individuals with acquired brain injury. Journal of Neurologic Physical Therapy. 2007;31:104-118.

 Rand D, Eng J, Tang P, Jeng J, Hung C. How Active Are People With Stroke?: Use of Accelerometers to Assess Physical Activity Stroke. 2009;40:163-168. Rand D, Kizony R, Weiss PL. The Sony PlayStation II EyeToy: Low-Cost Virtual Reality for Use in Rehabilitation. Journal of Neurologic Physical Therapy. 2008;32(4):155-163. Reinthal M, Anderson B, Bukovec T, Runion B. Use of the golf swing as a physical therapy adjunct in individuals with chronic stroke. Neurology Report. 2002;26(4). Riva G, Mantovani F, Gaggioli A. Presence and rehabilitation: toward second-generation virtual reality applications in neuropyschology. J Neuroeng Rehabil. 2004;1(9).

 Staines W, McIlroy W, Graham S, Black S. Bilateral movement enhances ipsilesional cortical activity in acute stroke: a pilot functional MRI study. Neurology. 2001;56(3):401-404. Sunderland A, Tuke A. Neuroplasticity, learning, and recovery after stroke: a critical evaluation of constraintinduced therapy. Neuropsychological Rehabilitation. 2005;15(2):81-96. Shepard KF, Jensen GM. Handbook of Teaching for Physical Therapists. 2nd ed. Boston, MA: Butterworth Heinemainn Publishers; 2002. Sveistrup H. Motor rehabilitation using virtual reality: a review. J Neuroeng Rehabil. 2004;1:10-18.

 Wolf S. Revisiting constraint-induced movement therapy: are we too smitten with the mitten? is all nonuse "learned"? and other quandaries. Physical Therapy. 2007;89(9):1212-1223. Wolf S, Winstein C, Miller J, Taub E, Uswatte G, Morris D. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;296(17):2095-2104. Yavuzer G, Senel A, Atay M, Stam H. PlayStation EyeToy games improve upper extremity-related motor functioning in subacute stroke: a randomized controlled clinical trial European Journal of Physical and Rehabilitation Medicine. 2008;44(3):237-244. Westfall JM, Mold J, Fagan L. Practice Based Research Blue Highways on NIH Roadmap. JAMA. 2007;297(4): 403-406.

Appendix A
Project Games

Playstation 2 with Eye Toy Play 1

Wishi Washi Beat Freak Kung Foo Soccer craze Boxing Chump UFO Juggler Slapstream Plate spinner Disco Stars Ghost Eliminator Mirror Time Rocket Rumble

wiki.groept.be/confluence/display/GL/Eye+Toy

news.bbc.co.uk/2/hi/3123993.stm

Playstation 2 with Eye Toy Play 2

Bubblepop Kung 2 Knockout Mr. Chef Home Run Drummin Monkey Bars DIY Goal Attack Table Tennis Secret Agent Air Guitar

www.videogamesblogger.com/2006/01/14/ps2-revi...

Wii Sports
Bowling Baseball Boxing Golf nintendic.com Tennis Full games plus training options
Putting Batting practice

Wii Resort
Swordplay Wakeboarding Frisbee dog Frisbee golf Archery Basketball Table Tennis

www.edge-online.com/news/wii-sports-sequel-le...

Wii Resort
Golf Bowling Power Cruising Canoeing Cycling Air sports

wii.ign.com/dor/objects/14266992/wii-sports

Other Wii Games

Wii Play
Find Mii Shooting Range Table Tennis Laser Hockey Fishing - Pose Mii - Tanks - Charge - Billiards

Mario Kart Wii Music

Rock Band
Guitar Drums Microphone Implications for individuals with aphasia Utilization of song versus practice mode
Reinthal, Linder, Szirony, & Milidonis; not to be copied without permission

www.wired.com/.../magazine/1 5-10/mf_harmonix