Choosing Between Games for Rehab

Subject Review:
Facilitating clinical decision-making about the use of virtual reality within paediatric motor rehabilitation: Application of a classification framework

Levac, D. C. & Galvin, J., Developmental Rehabilitation, June 2011; 14(3): 177-184. Link to the abstract: www.ncbi.nlm.nih.gov/pubmed/21410403

The authors create a clinical tool to enable therapists to choose when they would use different virtual reality game systems. Game systems covered include: Nintendo Wii, Sony EyeToy, Dance Dance Revolution (DDR), GestureTek IREX, Pediatric Intensive Therapy System (PITS) glove and Sony PlayStation 3 (PS3) glove. The decision tool is applied to three case studies of children with motor impairments.

Levac and Galvin identify (but don’t define) their therapist-friendly criteria for sorting out the video games. The criteria include the following. Is it possible to manipulate game levels to grade activity difficulty, or track the variables to evaluate activity performance? Can the therapist choose games that focus separately on upper extremity or lower extremity activities? Are the cognitive requirements to follow the game separate from increasing motor demands as the game progresses? What is the type of motor input and user capabilities, such as fine motor control, required to operate the game? And what seated or standing position is required to play the various games? These criteria are assembled into a table that sorts the game systems.

Then, by way of example, the criteria are applied to three case studies to choose game systems. The authors also provide a comparison of game systems, based on the criteria. This has value in clinical settings where only one system can be purchased. Generally, commercial systems (Wii, EyeToy, DDR) are seen to have fewer motor rehabilitation qualities than the game systems specifically developed for rehabilitation (IREX, PITS, PS3 glove).

The classification system is continuing to be studied to establish validity and clinical utility.

Alternate Access: Speech used as a form of input to mediate video games

Prototype development paper

Audition, the Game: Assessing the possibilities of speech as a non-trivial gameplay element in video games, Lavender, T. J., (2011)

Contact Terry Lavender: tjl.sfu@gmail.com

Link to the article: www.terrylavender.ca/wordpress/wp-content/uploads/2010/06/lavender_finalprojectIAT881.pdf

Speech as a motor-free way of driving video games is not common yet, but Terry Lavender at Simon Fraser University’s School of Interactive Arts and Technology has developed a prototype game that uses speech to change the outcome of a game. The game requires the player to say a certain speech in a given amount of time in order to advance the game.

Players in this prototype game are also hooked up to sensors which make a physiological measure of galvanic skin response (GSR) or hand sweatiness. This is a common way to detect stress or emotion, and may also be a way to indirectly measure speech difficulty. Currently, there is little evidence of the link between speech difficulty and stress. As a possible connection is explored, there could be opportunity to develop therapeutic applications. Physiological measures like GSR, heart rate or temperature are expected to be available in commercial hand held game controllers in the future as effective ways to mediate game play.

Further in the future, speech-mediated qualities like verbal memory and vocal clarity could be more direct game controllers and make motor-free game play a realistic avenue for participation of children with motor difficulties or a way to engage children in speech rehabilitation.

CONSORT Statement for Ehealth randomized controlled trials

www.consort-statement.org/ CONSORT stands for Consolidated Standards of Reporting Trials. The group exists to encourage good reporting of randomized controlled trials (RCTs) by offering recommendations on a standard way to report findings.

CONSORT has recently created a checklist for reporting Ehealth trials as a draft version. www.jmir.org/ojs/public/journals/1/CONSORT-EHEALTH-v1-5.pdf

The opportunity exists to comment on the CONSORT items as this document evolves.
tinyurl.com/consort-ehealth-v1-5

CONSORT seeks “to improve the reporting of different types of health research, and indeed, to improve the quality of research used in decision-making in healthcare”.

Does Virtual Reality improve Upper Extremity Function: Systematic Review

Galvin, J., McDonald, R., Catroppa, C. & Anderson, V. (2011). Brain Injury, 1-8, Early Online

Objective: One randomized control trial (RCT) and four case studies were found that fit the criteria of the literature search; research articles that “specifically refer to upper limb interventions and outcomes of the use of virtual reality (VR) with children who had neurological impairment.”

Process: Studies were rated for level of evidence using the Australian National Health and Medical Research Council scale (1) and for study quality using the Downs and Black Checklist (2). The Downs and Black scale assesses internal validity, generalizability, bias, confounders and power. The instruments used within the studies were the Quality of Upper Extremity Skills Test, the Melbourne Assessment, the Pediatric Motor Activity Log and the Canadian Occupational Performance Measure. Three of the studies used one item of one sub-test of the Bruininks-Oseretsky Test of Motor Proficiency.

Results: The RCT showed an evidence level of II (n = 34) and the remaining articles are all case studies (n =1-5) with an evidence level of IV. The studies scored from 9 to 22 of a possible 32 points on the Downs and Black scale, with only the RCT scoring more than 50% on each of the sub-scales. The case studies are weak in the areas of reporting and analysis which limits their external validity. Power is limited due to sample size.

Conclusion: “Small sample sizes and inconsistencies in outcome measures limit the ability to generalize findings.” There is a continuing need to establish evidence for the clinical utility of VR as a treatment medium.

Link to abstract: http://informahealthcare.com/doi/abs/10.3109/02699052.2011.558047

References: (1) NHMRC. (1999) A guide to the development, implementation and evaluation of clinical practice guidelines. In: Council NNHaMR, editor. Canberra: Australian Government. (2) Downs, S.H. & Black, N. (1998). The feasibility of creating a checklist for the assessment of the methodological quality both of randomized and non-randomized studies of health care interventions. Journal of Epidemiology and Community Health, 52: 377- 384.

Systematic review: VR for children with motor impairment

Virtual reality in the assessment and treatment of children with motor impairment: a Systematic review
Laufer, Y. & Weiss, P.L. (2011) Journal of Physical Therapy Education, 25 (1), Winter 2011, 59-71.

The objective of this article is to present a systematic review of publications where virtual reality (VR) has been used to provide rehabilitation to children with sensorimotor deficits. Articles were chosen from research reported in English, peer-reviewed journals.

Process: 26 studies were first classified by study design to reveal strength of evidence. Of them, 20 had sufficient strength of evidence to be evaluated using the American Academy for Cerebral Palsy and Developmental Medicine conduct questions. Based on positive responses to 10 study characteristics (such as adequate description of randomization, exclusion criteria and power calculations); the studies ranged from 3-10 positive responses with an average score of 5.25.

Results: Most studies reported positive outcomes with fair to poor evidence quality. Research of a higher quality is necessary for stronger assessment of the claims of VR. As noted, evaluation is limited by poor research design and methodology, but also by the “diversity of research objectives, outcome measures and treatment intensity presented in the different studies.”

Link to abstract: www.library.nhs.uk/booksandjournals/details.aspx?t=*systematic+review&stfo=True&sc=bnj.ovi.amed,bnj.ovi.bnia,bnj.ebs.cinahl,bnj.ovi.emez,bnj.ebs.heh,bnj.ovi.hmic,bnj.pub.MED,bnj.ovi.psyh&p=1&sf=srt.publicationdate&sfld=fld.title&sr=bnj.ebs&did=2010897080&pc=2295&id=6

Videogames in Therapy: A Therapist's Perspective

Annema, J-H., Verstraete, M., Vanden Abeele, V., Desmet, S., & Geerts, D. (2010). Videogames in therapy: a therapist's perspective Proceedings of the 3rd International Conference on Fun and Games doi>10.1145/1823818.1823828

Motion sensing video games have a certain appeal to physical and occupational therapists, but could be configured to serve the therapist and client better. This paper explores the use of video games for theraputic purposes from the perspective of the therapist. Therapeutic video games should be quick to start, should pause to allow the therapist to accommodate the client and should support store performance data.

The methodology consisted of both contextual inquiry (observing therapists and clients during therapy to organise observations into focus points) and workshops (to elicit feedback from therapists) to identify game characteristics that could be improved. The therapists were 11 physical and seven occupational therapists; clients were from two clinics for children with cerebral palsy; a clinic for adults with multiple sclerosis, and a centre that organized leisure activities for people with mental and physical impairments.

Findings

• Starting and calibrating the game should be quick and as straightforward as possible.
• On-screen instructions should be able to be skipped.
• Player-specific settings should be stored in profiles and automatically retrieved.
• Pausing play without exiting the game should be available to change settings; to position, encourage or instruct the client.
• Games should store performance data.

Link to article abstract
portal.acm.org/citation.cfm?id=1823828

Autism and video game engagement

Engagement with electronic screen media among students with autism spectrum disorders
Mineo, B. A., Zeigler, W., Gill, S. & Salkin, D. Journal of Autism and Developmental Disorders (2009) 39:172-187

doi>10.1007/s10803-008-0616-0

 “Studies comparing the relative appeal and impact of technology-enabled interventions are few.” This study is concerned with the relative strength of engagement of four types of video-based content presented to a heterogeneous population of 42 children with autism.

The engaging quality of video-based media, combined with the preference for children with autism spectrum disorder (ASD) for screen media, suggest its suitability for delivering instructional material. Movies, video games and virtual reality (VR) games all exist in popular culture and can thus non-stigmatizing. Benefits of video presentation in comparison to live instruction include consistently presented, infinitely repeatable content. Screen media make good use of limited resources and can communicate visually, with or without language. Virtual reality puts the person into the game as an avatar, or some closer rendition of themselves. VR scenarios can represent unreal situations – ones that simulate impractical or dangerous real life situations. Like other video games,  tasks presented in the virtual environment can be graded to accommodate the learners’ ability and feedback sculpted to be effective for that learner.

Design

To reflect the heterogeneous nature of ASD, baseline data were collected using a basket of five communication characteristics, reported in a binary fashion. Expressive language may be understood to be a predictor of functioning in the ASD population. The primary metric in selecting candidates was having an expressive lexicon of greater than 50 words and 38 of 42 participants “passed” this criteria.. Other scales included receptive lexicon, frequency of conventional yes/no use, frequency of conversation, and frequency of echolalia. Additionally, informants reported on the participants attention to and previous experience of screen media.

Individuals were sequentially assigned to one of three groups: seeing themselves doing a familiar activity ( self video), seeing a familiar other in a video game (other VR), or seeing themselves as they played a virtual reality game (self VR). Measures of engagement included gaze duration and vocalizations during a two-minute presentation of  the various media. All participants watched a video movie clip to establish a baseline response level. Reliability across two raters was established. (94% for vocalizations, 86% for gaze). Scores were adjusted for baseline score, expressive language score, and age.

Findings: Gaze was significantly higher in the “self VR” condition (p = .014) than the “other VR” condition, possibly related to the novelty of the VR game, seeing themselves or being able to interact with the game. Vocalizations were significantly higher in the “other VR” condition (p = .03) than “self VR” condition due either to seeing a familiar person on the screen, seeing the game or a combination of the two. There were no other significant differences between groups. Possibly participants high attention to movie clips during the baseline exposure to a movie clip created a ceiling effect that limited the ability to demonstrate a difference compared to other conditions.

“While the study did not yield definitive data about the relative engagement potential of media alternatives it does provide a foundation for future research including  guidance related to participant profiles stimulus characteristics and data coding challenges.”

Link to article: www.udel.edu/cds/downloads/Mineo_J.AutismDev.Disord_2009.pdf