Commercially Available Video Games in Prosthetic Rehabilitation

Introduction Virtual reality, custom video games, and commercially available video games (CAVGs) are gaining popularity as rehabilitation tools. Gaming systems, including the Nintendo Wii, Sony EyeToy, and Xbox Kinect, and games like Dance Dance Revolution have been shown to encourage physical activity while improving rehabilitation outcomes in people with musculoskeletal or movement disorders. 1,2 Diverse patient populations have shown improvements in rehabilitation outcomes after using CAVGs as an aid or alternative to traditional rehabilitation therapy. 5-8 In a 2013 study by Jorgensen et al., older adults saw improvements in muscle strength (hip and knee extensors) after completing ten weeks of training using the Wii Balance Board twice per week. 1 Improvements in static balance were seen in patients with acquired brain injuries after 20 one-hour therapy sessions that incorporated a Wii Balance Board. The authors reported that this type of treatment is safe and as effective as traditional therapy for patients with acquired brain injuries. 4 A study of patients with Parkinson's disease also incorporated the Wii Balance Board and found improvements in dynamic and static balance and in temporal-spatial parameters of gait. 5 A recent study of children with cerebral palsy showed improvement in balance when therapy incorporating the Wii Balance Board was combined with traditional therapy. 6 Video game therapy has been studied most among people post-stroke. Two comprehensive systematic reviews conducted in 2014 and 2016 demonstrated that, while further research is needed for the post-stroke population, video game–based therapy could provide a benefit in their rehabilitation. 7-8 Other populations that have experienced benefits from incorporating video game systems into rehabilitation therapy include people with Down syndrome, spinal cord injury, multiple sclerosis, cancer, and lupus. 1 Overall, improvements in static balance, dynamic balance, gait, and muscle strength have been demonstrated as a result of using CAVGs in therapy interventions. 1-6 Patients of all ages reported enjoying using a video game system as part of the rehabilitations process. 1,12-14 Importantly, a recent literature review regarding CAVG therapy in rehabilitation by Taylor et al. reported no safety concerns related to falls or injuries during video game play. 2 In general, injuries related to video game play reported in the literature are due to excessive gameplay (over ten hours of gaming), supporting a conclusion that CAVGs can provide an enjoyable and safe environment for patients to work toward their rehabilitation goals. 2 As in the populations mentioned, rehabilitation for individuals after an amputation focuses on muscle strength, balance, and gait training. Following a lower-limb amputation, individuals are faced with functional limitations that include poor balance and decreased leg strength. 15 To support the goal of ambulation, prosthetic rehabilitation focuses largely on balance, strength, and aerobic training. 16 Walking capacity is considered one of the strongest determinants of quality of life for people with amputations. 17 Methods A semistructured literature review was performed in October 2016 to assess what research existed on the use of CAVGs during prosthetic rehabilitation, and to determine what advantages this type of therapy may have after lower-limb amputation. PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched, and data was extracted from the results of each study. The extracted data included study design and aim, participant demographics, CAVGs studied, key findings based on defined outcome measures, and author conclusions. Safety measures taken and adherence were commonly included in research performed with other populations, therefore they were also incorporated in this review. 1,12-14 Table 1 summarizes the articles included in this review. Results Five articles aligned with the inclusion and exclusion criteria and were used for the literature review. Of the five articles, three were written by the same group of researchers, Imam et. al. 18-20 Additionally, it is notable that only four of the five articles involved subject research, since one of the articles, Iman et. al. (2014), was a written protocol for the subsequent study. 18-19 The four studies that involved subject research included people with various types of amputations and whose ages ranged from children to older adults. Amputation levels included transtibial, Van Nes rotationplasty, knee disarticulation, and transfemoral. Time since amputation ranged from 32 months to nine years. Subjects' functional levels and the type of componentry used were not identified by the researchers. Gaming Technology Provides Upper- limb Prosthetic Training While commercially available video games are increasingly being used as rehabilitation tools for people after an amputation, a new game specifically designed to help people use their upper-limb prostheses may further blur the line between playing and learning. Months of intensive training can be required to master the operation of a myoelectric prosthesis, which is operated by using the muscles in the residual limb, and many users abandon the prosthesis before mastery is achieved. The difficult training process has been identified as a primary reason for low user acceptance. Design Interactive, Orlando, Florida, has developed ADAPT-MP, a mobile, adaptive game that teaches people with amputations to control their myoelectric prostheses. The company believes that their game will solve many of the problems shared by other training tools, which can be expensive, limited in their activation sites and transferability, and lacking personalized training capabilities. The goal for the game is to provide effective, engaging training and thereby reduce the likelihood of prosthesis abandonment. Each game within ADAPT-MP trains users to activate muscles in specific sequences and to control the duration and magnitude of activation to prepare for activities of daily living. Muscle activity from the user's residual limb is captured using a Myo Gesture Control Armband, Thalmic Labs, Waterloo, Ontario, Canada. The patient—now gamer—activates and deactivates his or her muscles to complete tasks within each of the four games. Volcanic Crush trains the prosthesis user on basic control and activation of musculature. Dino Sprint focuses on sequencing and temporal patterns of activation. Those are followed by Dino Feast and Dino Claw that train application of proportionate strength and the ability to sustain and isolate muscle contractions while moving the limb in three-dimensional space, similar to activities of daily living training. The training system can be tailored to individual patient needs. ADAPT-MP includes a dashboard with training performance data, which can be accessed remotely by the patient's prosthetist, occupational therapist, or other members of the medical team. Clinicians can see whether the patient is adhering to or progressing in his or her training, and will have access to the raw and rectified EMG signals. Development of ADAPT-MP was funded through a U.S. Army Medical Research Acquisition Activity contract and received the Innovation Award at the annual Serious Games Showcase and Challenge at the 2016 Interservice/Industry Training, Simulation and Education Conference. It is currently undergoing clinical piloting across the United States. For more information, contact Matthew Johnston at matthew@designinteractive.net. All studies used the Nintendo Wii Fit Video Game System with Balance Board. One study also allowed outside physical therapy, one added body weight support training, and the remaining two studies restricted any outside therapy while completing the video game therapy. 20-21 Length of sessions ranged from 20 to 40 minutes, sessions per week ranged from two to five, and the number of weeks in the program ranged from two to six. The type of games played within the Nintendo Wii Fit System varied. One study allowed patients to choose the games, while the other studies assigned the games. 21 In two of the studies, the intervention included home-based therapy sessions. 7,8 One study included supervision by a physical therapist over Skype for the home sessions 19 and the other study allowed subjects to complete it independently at home. 22 Outcome measures included the two-minute walk test (2MWT), the activities-specific balance confidence (ABC) scale, center of pressure (COP) displacement, oxygen uptake efficiency slope (OUES), and temporal-spatial parameters of gait, dynamic balance, community balance and mobility (CB&M) scale, short feedback questionnaire- modified (SFQ-M), short physical performance battery (SPPB), the L-test of functional mobility, and the walking while talking test. However, the outcomes measured in the four studies varied so significantly that comparisons could not be made. Study Results Overall, all four research studies demonstrated positive results from undergoing therapy that incorporated CAVG systems. In the case studies in Miller et al., both subjects showed improved walking velocity and all other outcome measures with one exception: participant A did not improve in OUES. 21 Additionally, both participants moved above "moderate" balance confidence as measured by the ABC scale. All participants in Andrysek et al.'s study demonstrated improved CB&M scale scores and increased COP. 22 COP improvements were greatest for the subjects who had a transfemoral amputation. Imam et al. (2013) reported that subjects found therapy enjoyable and acceptable (SFQ-M median = 35). Five of six participants showed statistical improvement on the 2MWT. Four of six showed statistical improvement on the ABC Scale and the SPPB score. Lastly, Imam et al. (2015) reported that the in-home telehealth Wii Fit intervention they developed, Wii.n.Walk, appeared to be feasible with a medium effect size for improving walking capacity. 18 Study Conclusions Miller et al. reported that body weight support was incorporated to allow participants to ambulate at increased velocities with a decreased fear of falling. 21 They reported that "Nintendo Wii Fit training and body weight support were effective interventions to achieve functional goals for improving balance confidence, reducing use of assistive devices, and increasing energy efficiency when ambulating with a transfemoral prosthesis." 21 Andrysek et al. reported that "in-home video game– based therapies to improve balance and mobility can be engaging, enjoyable, and motivation adjunct to conventional prosthetic rehabilitation." 22 Some improvements were seen in the children and adolescents, but longterm retention is still unclear. Imam et al. (2013) reported that the "intervention was found to be feasible in individuals with unilateral [lower-limb amputations]. The results of this study suggest that the Wii Fit may contribute to improved walking capacity and functional outcomes." 20 Imam et al. (2015) determined that 72 participants were needed to obtain reliable results, but only 36 participants were used in the study. 18 However, the authors stated the Wii.n.Walk is a promising in-home telehealth option for lower-limb amputation rehabilitation. Conclusion Although there were only four research studies from which to draw conclusions, it is notable that the Nintendo Wii Fit Gaming System with Balance Board was used in all four of the studies. The Nintendo Wii Fit seems to be the popular choice because the balance board that comes with the system allows for shifting of weight between the affected side and the nonaffected side. Additionally, the patient receives real-time feedback so he or she can react and adjust his or her body position. The variability among the subjects is a testament to the applicability of this type of video game therapy for a diverse group of individuals with a limb absence. The use of a CAVG system in therapy, specifically the Nintendo Wii Fit with Balance Board, seems to improve motivation and balance among people with amputations during rehabilitation. Safety also seems to be ensured, even in a home setting. Further studies are needed to determine the optimal dosage, and more studies need to measure and evaluate similar outcomes for analysis. Preliminary results indicate that this type of CAVG therapy can have a positive effect on the rehabilitation journey. Amanda Coldren, MPO, is a resident at Walkabout Orthotics & Prosthetics in Wausau, Wisconsin. She received a bachelor's degree in biomedical engineering from the University of Arizona and a master's degree in O&P at Northwestern University Prosthetics-Orthotics Center (NUPOC). John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at NUPOC. He has more than 20 years of experience treating a wide variety of patients. References 1. Staiano A. E., R. Flynn. 2014. Therapeutic uses of active videogames: A systematic review. Games For Health Journal 3(6):351-65.

2. Taylor M. J.D., D. McCormick, T. Shawis, R. Impson, M. Griffin. 2011. Activity-promoting gaming systems in exercise and rehabilitation. Journal of Rehabilitation Research & Development 48(10):1171-86.

3. Jorgensen M. G., U. Laessoe, C. Hendriksen, O. B. F. Nielsen, P. Aagaard P. 2013. Efficacy of Nintendo Wii training on mechanical leg muscle function and postural balance in community-dwelling older adults: A randomized controlled trial. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences . 68(7):845-52.

4. Gil-Gomez J. A., R. Llorens, M. Alcaniz, C. Colomer. 2011. 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 8:30.

5. P. V. Mhatre, I. Vilares, S. M. Stibb, M. V. Albert, L. Pickering, C. M. Marciniak, et al. Wii Fit Balance Board playing improves balance and gait in Parkinson Disease. Physical Medicine and Rehabilitation 5(9):769-77.

6. Tarakci D., B. Ersoz Huseyinsinoglu, E. Tarakci, A. Razak Ozdincler. 2016. The effects of Nintendo Wii-Fit video games on balance in children with mild cerebral palsy. Pediatrics International 58(10):1042-50.

7. Lohse, K. R., C. G. Hilderman, K. L. Cheung, S. Tatla, H. F. Van der Loos. 2014. Virtual reality therapy for adults post-stroke: a systematic review and meta-analysis exploring virtual environments and commercial games in therapy. PLOS ONE 9(3):e93318.

8. J. Iruthayarajah, A. McIntyre, A. Cotoi, S. Macaluso, R. Teasell. 2016. The use of virtual reality for balance among individuals with chronic stroke: a systematic review and meta-analysis. Topics in Stroke Rehabilitation 1-12.

9. Esculier, J. F., J. Vaudrin, P. Beriault, K. Gagnon, L. E. Tremblay. 2012. Home-based balance training programme using Wii Fit with balance board for Parkinson's disease: a pilot study. Journal of Rehabilitation Medicine 44(2):144-50.

10. Jelsma, J, M. Pronk, G. Ferguson, D. Jelsma-Smit. 2013. The effect of the Nintendo Wii Fit on balance control and gross motor function of children with spastic hemiplegic cerebral palsy. Developmental Neurorehabilitation 16(1):27-37.

11. Jorgensen M. G. 2014. Assessment of postural balance in community-dwelling older adults - methodological aspects and effects of biofeedback-based Nintendo Wii training. Danish Medical Journal 61(1):B4775.

12. Deutsch, J. E., A. Brettler, C. Smith, J. Welsh, R. John, P. Guarrera-Bowlby, et al. 2011. Nintendo Wii sports and Wii fit game analysis, validation, and application to stroke rehabilitation. Topics in Stroke Rehabilitation 18(6):701-19.

13. Rand D., R. Kizony R, P. T. Weiss. 2008. The Sony PlayStation II EyeToy: low-cost virtual reality for use in rehabilitation. Journal of Neurologic Physical Therapy 32(4):155-63.

14. Yong Joo L, T. Soon Yin, D. Xu, E. Thia, C. Pei Fen, C. W. Kuah, et al. A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. Journal of Rehabilitation Medicine 42(5):437-41.

15. Van Velzen, J. M., C. A. Van Bennekom, W. Polomski, J. R. Slootman, L. H. Van der Woude, H. Houdijk. 2006. Physical capacity and walking ability after lower limb amputation: a systematic review. Clinical Rehabilitation 20(11):999-1016.

16. Esquenazi A., R. DiGiacomo. 2001. Rehabilitation after amputation. Journal of the American Podiatric Medical Association 91(1):13-22.

17. Fortington L. V., P. U. Dijkstra, J. C. Bosmans, W. J. Post, J. H. Geertzen. 2013. Change in health-related quality of life in the first 18 months after lower limb amputation: a prospective, longitudinal study. Journal of Rehabilitation Medicine 45(6):587-94.

18. Imam B., W. C. Miller, H. Finlayson, J. J. Eng, T. Jarus. 2015. A randomized controlled trial to evaluate the feasibility of the Wii Fit for improving walking in older adults with lower limb amputation. Clinical Rehabilitation 31(1) 92-92.

19. Imam B., W. C. Miller, H. C. Finlayson, J. J. Eng, M. W. Payne, T. Jarus, et al. 2014. A telehealth intervention using Nintendo Wii Fit Balance Boards and iPads to improve walking in older adults with lower limb amputation (Wii.n.Walk): Study protocol for a randomized controlled trial. JMIR Research Protocols . 3(4):e80.

20. Imam B., W. C. Miller, L. McLaren, P. Chapman, H. Finlayson. 2013. Feasibility of the Nintendo WiiFit for improving walking in individuals with a lower limb amputation. SAGE Open Medicine 1:2050312113497942.

21. Miller C. A., D. M. Hayes, K. Dye, C. Johnson, J. Meyers. 2012. Using the Nintendo Wii Fit and body weight support to improve aerobic capacity, balance, gait ability, and fear of falling: Two case reports. Journal of Geriatric Physical Therapy 35(2):95-104.

22. Andrysek J., S. Klejman, B. Steinnagel, R. Torres-Moreno, K. F. Zabjek, N. M. Salbach, et al. 2012. Preliminary evaluation of a commercially available videogame system as an adjunct therapeutic intervention for improving balance among children and adolescents with lower limb amputations. Archives of Physical Medicine and Rehabilitation . 93(2):358-66.

Commercially Available Video Games in Prosthetic Rehabilitation

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