Voice access video game

Proof of Concept

King SN, Davis L, Lehman JJ, Ruddy BH. A Model for Treating Voice Disorders in School-Age Children within a Video Gaming Environment. J Voice. 2011 Dec 29. [Epub ahead of print]

Link to abstract:
www.ncbi.nlm.nih.gov/pubmed/22209055

Objective: The authors altered a voice-themed video game to make it voice activated, for use at home with school-age children with hyperfunctional voice disorders.

Video games can provide compelling ‘homework’ for children undergoing voice therapy, and may contribute to generalizing the learned behaviours to the home. The authors modified the video game Opera Slinger, an interactive game that requires players to score points by matching sound pitch and volume.

Process: The article is written about three cycles of trying and modifying the video game: firstly to adapt the game to voice activation, then to increase playability for children and adults. The third iteration was a case study of a 9 year old boy with the target condition. He received weekly one hour traditional speech therapy for two weeks before playing the video game at home for two weeks.

Findings: The voice-activated game was found to be functional, playable, and highly engaging. The players produced vocalizations that may be beneficial therapy outcomes, but video play and traditional therapy outcomes were not compared here. “Voice video games may contribute to the success of voice therapy by helping the generalization that needs to occur from the therapy session to home life”.

CP and Video games: Systematic Review

Sandlund M, McDonough S, Häger-Ross C.
Interactive computer play in rehabilitation of children with sensorimotor disorders: a systematic review.
Dev Med Child Neurol. 2009 Mar;51(3):173-9

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/19191834

This review is notable because of the focus on cerebral palsy. The researchers used the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) levels of evidence guidelines, and many of the articles used the Bruninks-Oseretsky Test for Motor Efficiency (BOTMP) as an outcome measure.

Objective:
A systematic review of evidence using interactive computer play for motor rehabilitation for children. Therapeutic active video gaming is defined here as “play with virtual objects in a computer-generated environment” (including mouse and keyboard interaction) for improved motor control and motor learning as a primary or secondary outcome.

Method:
Eleven databases were searched for literature from 1995 to May 2008.
Some studies used the Gross Motor Functioning Classification System and included children with level IV and V disabilities. AACPDM levels of evidence guidelines were used to assess and categorize each (quantitative) research design and methodology of the 16 included articles. Of them, three were randomized control trials (level II), four were level III (cohort studies), six were level IV (case series) and three were level V (case reports).

Findings:
Two of the three level II and one level III study found no significant improvements. Several of the level IV, cohort studies used the BOTMP (subtest 5:6), the Peabody Developmental Motor Scale, or the Quality of Upper Extremities Skills Test. One study used the Canadian Occupational Performance Model.

In summary, “nine studies investigated movement quality; two showed no significant improvements and seven, mostly low-level studies, reported positive findings”, and a call for “further and more convincing research”.

Selected References

AACPDM levels of evidence

Butler C. AACPDM methodology to develop systematic reviews
of treatment interventions 1999; (Revision 1.1, 2004). Available
from URL: http://www.aacpdm.org/resources/systematicReviews
Methodology.pdf.

Studies using BOTMP assessing motor quality

Eliasson AC, Rosblad B, Hager-Ross C. Control of reaching
movements in 6-year-old prematurely born children with motor
problems - an intervention study. Adv Physiother 2003; 5: 33–48.

Petrofsky JS, Petrofsky D. A simple device to assess and train
motor coordination. J Med Eng Technol 2004; 28: 67–73.

Bartscherer ML, Dole RL. InteractiveMetronome training for a
9-year-old boy with attention and motor coordination difficulties.
Physiother Theory Pract 2005; 21: 257–69.

Krichevets AN, Sirotkina EB, Yevsevicheva IV, Zeldin LM. Computer
games as a means of movement rehabilitation. Disabil Rehabil
1995; 17: 100–5.

Reid DT. The use of virtual reality to improve upper-extremity
efficiency skills in children with cerebral palsy: a pilot study.
Technol Disabil 2002; 14: 53–61.

Reid D, Campbell K. The use of virtual reality with children with
cerebral palsy: a pilot randomized trial. Ther Recreation J 2006;
40: 255–68.

Chen YP, Kang LJ, Chuang TY, et al. Use of virtual reality to
improve upper-extremity control in children with cerebral palsy:
a single-subject design. Phys Ther 2007; 87: 1441–57.

Shaffer RJ, Jacokes LE, Cassily JF, Greenspan SI, Tuchman RF,
Stemmer PJ Jr. Effect of interactive metronome training on
children with ADHD. Am J Occup Ther 2001; 55: 155–62.

You SH, Jang SH, Kim YH, Kwon YH, Barrow I, Hallett M.
Cortical reorganization induced by virtual reality therapy in a
child with hemiparetic cerebral palsy. Dev Med Child Neurol 2005;
47: 628–35.

Study using Peabody Developmental Motor Scale

Chen YP, Kang LJ, Chuang TY, et al. Use of virtual reality to
improve upper-extremity control in children with cerebral palsy:
a single-subject design. Phys Ther 2007; 87: 1441–57.

Study using Quality of Upper Extremities Skills Test

Reid DT. The use of virtual reality to improve upper-extremity
efficiency skills in children with cerebral palsy: a pilot study.
Technol Disabil 2002; 14: 53–61.

Realistic and adapted movements in play

Research article
Berry T, Howcroft J, Klejman S, Fehlings D, Wright V, Biddiss, E. (2011)
Variations in Movement Patterns during Active Video Game Play in Children with Cerebral Palsy. J Bioengineer & Biomedical Sci S1:001. doi:10.4172/2155-9538. S1-001

Link to article: www.omicsonline.org/2155-9538/2155-9538-S1-001.php

Objective:
Low-cost active video games (AVG) such as Ninteno Wii® are popular physical therapy tools for children with cerebral palsy. While not specifically designed to match rehabilitation goals, various studies have found clinically-relevant improvements in functional motor ability. The games reward realistic movements involving more proximal joints and bilateral upper extremity use but play can also proceed with adapted, more conservative movements of distal joints.

This study investigates play styles of three Nintendo Wii® games; boxing, bowling and tennis for realistic movement patterns related to the real-world activity and variations of adapted movement patterns.

Method:
A purposive sample of 16 children with GMFCS level I hemi- or diplegic cerebral palsy played each of three Wii® games. One minute of play was captured and analyzed as realistic or adapted movement.

Findings:
Game play was either realistic or adapted depending on the game and the child. Wii® bowling was performed more realistically, tennis and boxing less so. Children adapted their play style to succeed at the games, favouring their dominant arm in bilateral activities. Therapists need to encourage children to play realistically to derive the most therapeutic benefits from video game playing.

Virtual Reality: Cochrane Review

Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database of
Systematic Reviews 2011, Issue 9. Art. No.: CD008349. DOI: 10.1002/14651858.CD008349.pub2.

Link to abstract: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008349.pub2/abstract

Objective:
To evaluate the effects of virtual reality (VR) and interactive video gaming on upper limb, lower limb and global motor function after stroke.

Method: The authors searched for randomized trials (RT) and quasi-randomized trials for a population of adults that had had strokes, and that met their definition: “an advanced form of human-computer interface that allows the user to "interact’ with and become ’immersed’ in a computer-generated environment in a naturalistic fashion". 19 trials that involved 565 participants met the criteria. These studies largely do not evaluate commercial gaming consoles such as Wii.

Findings:
Significant results imply limited evidence for the benefits of virtual reality over conventional therapies specifically for arm function (7 studies) and for activities of daily living (3 studies). The properties of VR which are effective and how long the results last are not yet conclusively known.

Accessibility wish list

The AbleGamers Foundation reviews mainstream videogames with a focus on accessibility. Here is their annual shopping list of controllers, mounts and games; as recommended by the Foundation, providing “game accessibility for the gamer with disability”.

www.ablegamers.com/general-game-news/ablegamers-2011-holiday-shopping-list.html

What makes therapy work?

Defining the active ingredients of interactive computer play interventions for children with neuromotor impairments: A scoping review


Levac, D., Rivard, L. & Missiuna, C.
Research in Developmental Disabilities, 33 (2012) 214-223

Link to abstract: www.sciencedirect.com/science/article/pii/S089142221100343X

Objective:
Active ingredients are why a treatment is expected to be effective. Rehabilitation therapists might identify the dosage, intensity of treatments, or the therapist-client interaction, as active ingredients in usual or traditional treatments. The goal of this article is defining the active ingredients of interactive computer play.

New pediatric rehabilitation interventions like interactive computer play are often incorporated into clinical practice without a clear understanding of their active ingredients. Reviews of the literature, while positive, lack strong conclusions and urge more stringent designs.

Method: Scoping reviews can be applied to identify a field of research and interpret the findings of the studies that are reviewed. The purpose of this scoping review is to identify the potential active ingredients of video game and virtual reality interventions used to improve motor outcomes in children and youth with neuromotor impairments.

Findings:A number of studies were gathered and analyzed for themes revealing potential active ingredients either explicitly or implicitly referred to in the study.
Authors explicitly linked the following as possible active ingredients. They were characterized as belonging to a property of the game, an effect of the intervention on the user, or a role of the therapist.

Properties of the game include: duration, frequency or intensity of practice; task relevance to real-world activities, within-game parameters, feedback, and equal-opportunity play. Effects on the user included: neuroplastic changes, problem-solving and motivation. Support roles included one-to-one support, verbal feedback, and parental involvement and enthusiasm.

While little is currently known about the active ingredients in successful therapeutic interventions using virtual reality or video gaming, there is the opportunity to develop theoretical models that predict these ingredients.

Success & Motivation

Research paper

Hocine, Nadia and Gouaich, Abdelkader
"Therapeutic Games’ Difficulty Adaption: An Approach Based on Player’s Ability and Motivation", Published in the Proceedings of the 16th International Conference on Computer Games, pp. 257-261

Link to the abstract: ieeexplore.ieee.org/xpl/freeabs_all.jsp?arnumber=6000349

Objective: the authors set out to describe general principles for therapeutic video games, and to test how the success-to-failure ratio in game play affects motivation.
In traditional therapy, therapists improve the client’s functional skills such as movement using feedback to create a balance between the challenging activity and an reachable goal. Benefits of video games include their motivating and engaging nature: requirements of therapeutic games is that they have measureable outcomes and offer recovery-focused activities to meet rehabilitation goals. This study considers embedding difficulty adjustment into video games, including assessing the client’s ability, and providing variability to minimize boredom.

• Initial evaluation: Video games can provide an initial assessment by requiring the player to go through a series of movements that help create a profile and provide a game starting point and difficulty strategy.



• Variability: The game should be able to operate in a way that separates the therapeutic goals from game play so the therapeutic difficulties and accomplishments can be embedded in different levels of play and in different games.



• Motivation-based difficulty adjustment: This involves disrupting a player’s satisfaction from success at some level of game play. Called “constructive dissatisfaction”, the idea is that this disruption motivates the player to re-seek the satisfaction of successful accomplishment. The authors have created an algorithm that feeds back from motivation and success-to-failure rate to dynamically adjust the game parameters, to both meet the therapy goal of motor skills improvement, and to support the player’s motivation by manipulating the balance between success and failure.

Method: This pilot experiment compares random difficulty adjustment with motivation-based difficulty adjustment for two groups of four able-bodied adults. Hypotheses were i) there will be a difference across conditions for the balance of sucesses to failures and for perceived difficulty. Data included for analysis was the success-to-failure rate in the game session across conditions and the player’s perceived difficulty.

Findings: There is no evidence that motivation-based difficulty adjustment (operating by these authors’ algorithm) is different from randomly generated difficulty adjustment, by the measure of perceived difficulty. Both conditions may contribute to motivation.