Designing a Game-based Solution for In-home Rehabilitation

Silvia Gabrielli

, Rosa Maimone

, Giancarlo Bo

, Johanna Jonsdottir

, Wolfhard Klein

and Hadas Raz

CREATE-NET, Via Alla Cascata 56/D, Trento, Italy

Imaginary Srl, Milano, Italy

Fondazione Don Carlo Gnocchi Onlus, Milano, Italy

Neurological Therapeutic Centre Gmundnerberg, Altmünster, Austria

Edna Pasher Ph.D & Associates, Management Consultants, Tel Aviv, Israel

Keywords: Serious Games, Motor-cognitive Rehabilitation, Patient-centred Design, Formative Evaluation.

Abstract: This paper presents initial concepts and formative evaluation results from a research (REHAB@HOME)

investigating the patient-centred design of game environments aimed at raising patients’ motivation and

compliance with motor-cognitive rehabilitation programs. During the initial phase of the project five games

were deployed through main gaming platforms and interaction devices (Kinect, LeapMotion, Sifteo Cubes).

A pilot study involving six patients from two different rehabilitation centres (one in Italy and one in Austria)

was conducted to assess usability and motivational factors implied in the initial usage of the solutions

proposed. From the pilot study results we derive indications to inform the future design of game solutions

for raising patients’ compliance with upper body rehabilitation programs.

1 INTRODUCTION

Stroke is the second most common cause of death in

Europe (EU Cardiovascular Disease statistics 2012)

and it affects about 15 million people worldwide

each year. Stroke survivors experience a broad range

of problems that can impact their cognitive and

motor systems, leading to chronic disability (e.g.,

hemiparesis) more often affecting the upper body

(i.e., arms, Dobkin, 2005). The goal of rehabilitation

is to help survivors become as independent as

possible and to attain the best possible quality of

life. For over half of stroke patients, rehabilitation

will be a long‐term process requiring work

supervised by therapists, supported by specialized

equipment, lasting several months. However,

increasing cost pressure on the healthcare system is

leading to shorter periods of intensive rehabilitation

at specialized facilities. Therefore the adoption of

suitable technologies for in home rehabilitation,

together with a proper training about the execution

of a personalized program of exercises, can help

reduce the patient’s stay at the hospital, as well as

the need and cost of reaching the rehabilitation

facilities. In this work, we present early results from

the REHAB@HOME European project where game

solutions for rehabilitation of the upper body were

designed and tested in a pilot study conducted at two

different rehabilitation centers, one in Italy and one

in Austria.

2 RELATED WORK

In the area of rehabilitation research and practice,

there have been previous attempts to leverage on

low cost gaming platforms, such as Wii (Deutsch et

al., 2008) and Playstation 2 EyeToy (Flynn et al.,

2007), to support post-stroke therapy. However,

these solutions are difficult to deploy with patients

in earlier stages of recovery when they have only

limited range of motion. For this type of patients

other more specific game-based solutions have been

recently proposed. Huber et al. (2008) and Jack et al.

(2001) developed haptic glove based games in which

users scare away butterflies, play the piano, and

squeeze virtual pistons to improve the player’s

finger flexion and extension. Burke et al. (2009)

built two webcam color tracked games similar to

whack-a mole. In addition, they created a physics-

145

Gabrielli S., Maimone R., Bo G., Jonsdottir J., Klein W. and Raz H..

Designing a Game-based Solution for In-home Rehabilitation.

DOI: 10.5220/0005130401450149

In Proceedings of the 2nd International Congress on Neurotechnology, Electronics and Informatics (VirtRehab-2014), pages 145-149

ISBN: 978-989-758-056-7

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

based orange catching game and a whack-a-mouse

game, both controlled with magnetic sensors and a

vibraphone game, using a Wii remote as a pointing

device. Game concepts and solutions more related to

everyday tasks and activities of daily living have

been explored to increase patients’ motivation to

play, by providing more meaningful settings

(Sanchez et al., 2006; Burke et al., 2009). Flores et

al. (2008) identified game design criteria that stem

from stroke rehabilitation and elderly entertainment.

Vandermaesen et al. (2013) developed the Liftacube

prototype for training of the upper extremities and

tested it with four patients (affected by

cerebrovascular accident or paraplegia) finding

encouraging results and benefits regarding patients’

motivation.

In our work, instead of focusing on developing

games for specific ranges of disability we aim to

realize solutions that can be adapted for use by

patients at different levels of recovery (a similar

approach was proposed in Alankus, 2011). By

informing our design with requirements from

therapists and patients, we aim to realize a

rehabilitation platform enabling therapists to select

and tailor games for individual patients’ programs.

3 GAME DESIGN FOR MOTOR

REHABILITATION

During the first year of the REHAB@HOME project

we conducted a patient centered design process to

realize a set of rehabilitation games targeting post-

stroke and multiple sclerosis patients in need of

upper body motor rehabilitation. The design process

also involved requirements collected by interviewing

a number of therapists at Fondazione Don Gnocchi

(Italy) and Neurological Therapeutic Centre

Gmundnerberg (Austria). We ended up developing

four games, three of which could be played with the

Kinect gaming platform, one with the SifteoCubes

platform. We also decided to include in the

experimentation an available game for the novel

LeapMotion device (a sensor controller that supports

hand and finger motions as input, analogous to a

mouse, but requiring no hand contact or touching).

The criteria for inclusion and development of

these 5 games, was to assess their benefits for

deployment in the context of arm/hand motor

rehabilitation sessions. The specific movements

required by the games were the following: shoulder

abduction, adduction, flexion, extension, wrist

flexion, extension, supination, opening/closing of

Figure 1: Screenshot of the menu to select the Kinect

games.

hand, reaching movements and finger movements of

precision.

In the following we briefly describe the games

considered for our initial pilot testing (Fig.1 shows

the menu screen for selecting the Kinect games

developed): 1) Bombs&Flowers minigame [Kinect]:

the patient interacts in a living room environment

where s/he has to touch flowers items and avoid

bombs, s/he is required to use both hands and is

provided instructions, visual feedback, and total

score achieved during the session. 2) Can minigame

[Kinect]: the patient needs to move cans from a

central table to the correct shelf, by matching

corresponding colors which change position during

the game; s/he can use just one hand per session and

get instructions, visual feedback and overall score

achieved. 3) Blackboard minigame [Kinect]: the

patient needs to move different shapes from the left

side to colored spots on the right side, by following a

random path. Random pairings are proposed (e.g.

star-blue, square-red) on the top of the screen, red

dots appear along the path, which should be

collected; instructions, visual feedback and overall

score are also provided. 4) Caterpillar game

[LeapMotion]: the patient needs to guide a

caterpillar around the screen with one finger to

collect numbers in a sequential order, achieve levels

and eventually become a butterfly; instructions,

visual and auditory feedback are provided. 5) Simon

game [Sifteo Cubes, Fig.2]: 3 (1.7 inch) cubes are

provided in fixed positions on a table which display

colours randomly assigned by the system; the patient

is asked to tilt a fourth cube to select a colour on its

display and put the cube in contact with the

corresponding cube (same colour) in the fixed

positions; visual, auditory feedback, number of

sessions played and score are provided through the

cubes displays; typically the patient plays by using

one hand for 3 consecutive sessions.

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Figure 2: Simon game played with Sifteo Cubes.

3.1 The Pilot Study

To preliminary assess the level of usability and

engagement of the games and devices described

above, we conducted a pilot study involving 6 post-

stroke and multiple sclerosis patients (age range 54-

74, Mean: 66) with motor impairments of the upper

body, enrolled in rehabilitation programs (since at

least a month before) at the two rehabilitation

centers in Italy and Austria (Table 1). The test

sessions were run in dedicated rooms at each center

(where the devices and games had been previously

set up) and demonstrated to patients by a member of

the research team. Each patient was asked to try at

least one session with each device/game available

and then to provide feedback and ratings on their

user experience, perceived usefulness, motivation to

use of the device/games experienced in a final semi-

structured interview. Example of the questions used

in the interviews: "How useful would you rate the

devices\games used to support the rehabilitation

program at home?" on a Likert scale from 1 to 7.

The overall session lasted about 1 hour. The sessions

were video recorded for subsequent analysis, the

input devices and games were presented randomly to

avoid order effects. The contents of the video

recordings were analysed independently by 3 human

factors specialists to extract relevant usability and

user experience indicators regarding ease-of-use,

learnability, level of engagement, effectiveness,

satisfaction, error frequency and prevention. The

individual reports of the 3 specialists were then

discussed in a meeting and results summarized in a

final document shared with the developers’ team.

The post session interview data were analysed to

identify the main points of strength and weakness of

the solutions tested and inspire our next

development phases.

Table 1: Patients demographics and clinical

characteristics.

Patient

(Gender)

Age Clinical characteristics

P1 (M)

Post-stroke, motor

impairment of the right

upper limb

P2 (M) 71 Post-stroke, motor

impairment of the left

limb

P3 (F) 54 Multiple Sclerosis, motor

impairment of left

hand/arm, on a wheelchair

P4 (M) 71 Post-stroke, right

hemiplegia

P5 (M) 74 Post-stroke, motor

impairments affecting

walking, right hand,

voice, ataxia

P6 (M) 68 Post-stroke, motor

impairment of right upper

limb

3.1.1 Main Results

Table 2 below reports patients’ ratings on a Likert

scale (1-7) about the usefulness of the devices and

games experienced during the pilot testing, based on

the post-session interview asking each patient how

useful each device and game experienced they

thought would be for their rehabilitation needs.

Overall, the feedback from patients was quite

positive. The device scoring less was LeapMotion

(Mean=3.6), which was rated lower for some

difficulties patients experienced in controlling it.

The Kinect device was considered useful, but some

improvements to the calibration of the sensor were

required to improve interaction. While all the games

tested were judged as useful, the Caterpillar and

Simon ones were scored higher due to their

intuitiveness and facility of play for the patients.

Table 2: Patients perceived usefulness of the devices and

games experienced (Likert scale 1=Not useful at all,

7=Extremely useful).

Type of Device / Game Mean SD

Kinect device

4.8

2.04

LeapMotion device 3.6 1.14

Sifteo Cubes device 6.3 0.57

Bomb&Flowers minigame 4.8 1.30

Can minigame 4.8 0.75

Blackboard minigame 3.8 1.67

Caterpillar game 5 2.16

Simon game 6.6 0.57

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From the analysis of the videos and patients’

comments we derived the following needs for

improvements of the gaming environments for

rehabilitation goals:

a) Enable games to be easily adapted to patients’

different needs and range of movement: the solutions

proposed during the pilot were still too rigid to fit

the needs and range of arm/hand movements of most

patients. Customization of the solutions should be

supported in the future by providing a better

calibration module for the Kinect device. In

particular, it is very important to clearly define the

minimal requirement of the movement abilities of

the patients in addition to the limitations of the

devices.

b) Ensure correct execution of the movements, detect

compensation: many patients showed compensatory

motion, like rotating/moving their trunk to achieve

the game goal as a way of overcoming limitations in

their range of motion in the affected limb. In the

Simon game (Sifteo Cubes) some patients pushed

the cube to be put in contact with the target cube

instead of performing precise grasp and release

actions. For future sessions we have developed a

paper frame and setup where target cubes will be

located, thus requiring a patient to raise a cube and

move it more precisely to reach the target.

c) Engage patients by providing more variability

and difficulty levels in the games: we observed that

even games that required some effort to be played

were able to engage patients with several repetitions

performed during a session. However, even within

the small group of patients involved, individual

differences in needs, preferences and motivation

were found that could be better fulfilled by a more

comprehensive set of games and within game

alternatives provided.

d) Audio and visual elements should be improved for

accessibility and usability: size and contrast of

colors, sounds, animations and other motivational

effects available in the game environments were

found to require improvements for accessibility and

usability. Some of the patients involved had visual

impairments (e.g., wore glasses) or had difficulties

in reading text, perceiving colors. Accessibility

requirements are particularly important to address

when considering the target user groups of

rehabilitation, to facilitate their adoption.

e) Motivational elements and incentives should be

added: in the pilot we deployed a limited set of

motivational elements, rewards, feedback and

incentives, but they played an important role in

motivating patients to further engage with the

playing setting. Feedback and incentives are

fundamental for a patient to keep track of progress

made, goals/improvements achieved (Flores et al.,

2008), and to avoid over performing or getting tired

too soon (with the risk of getting bored) thus

jeopardizing the aims of any rehabilitation program

in the home setting.

f) Collaborative forms of play should be added

(Alankus et al., 2010): as many patients reported in

the final interviews the possibility of playing some

of the games proposed in a collaborative way (e.g.,

with caregivers, family members) would be

important to further raise their motivation and

interest in the therapy sessions. We are currently

planning to design collaborative forms of play (e.g.,

with the Sifteo Cubes) to meet this request of the

patients.

4 CONCLUSION

This work has presented some initial game concepts

for upper body rehabilitation of post-stroke and

multiple sclerosis patients, which have been

developed for usage through low-cost gaming

platforms suitable for home environments.

Preliminary results from a pilot study conducted

have shown that patients would be willing to use

these gaming environments for rehabilitation

purposes, provided that professional therapists

supervision is also combined with these solutions.

We are currently working at implementing a more

integrated and improved version of our rehabilitation

gaming environment that will include more

advanced and complete versions of the games

presented. Furthermore the rehabilitation gaming

environment will be combined with a professional

web client to remotely supervise the training

sessions of patients from the rehabilitation centre. A

second pilot testing of the integrated solution is

planned for Fall 2014 involving a larger number of

patients from the two clinics in Italy and Austria.

ACKNOWLEDGEMENTS

This work has been supported by the FP7 STREP

Project REHAB@HOME N. 306113.

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