The effectiveness of gaming technology in neurological rehabilitation - Physiopedia, universal access to physiotherapy knowledge.
This wiki will examine the use of the Nintendo Wii, the Microsoft Kinect and tablets in the rehabilitation process of neurological patients. AudienceThis resource is for the use of practicing physiotherapists and may be of benefit to other health care professionals seeking further knowledge in the use of consoles and tablets in neurological rehabilitation. The therapist will be provided with information that explores the rationale behind game-based rehabilitation. The therapist will be introduced to the integration of technology into neurological rehabilitation with the aim of enhancing self-management and the independence to continue home-based therapy.
The therapist will be provided an analysis and critical evaluation of the evidence currently available for the use of technology in rehabilitation. The therapist will be provided with an overview of the robustness of prevailing research of technology within gaming therapy. The therapist will have available to them real world availability and application of current technology. The therapist will be able to make an informed decision on the appropriate console and games to use in the rehabilitation of patients with neurological conditions. There is a lack of infrastructure in place to allow for subsidisation when purchasing consoles or tablets for rehabilitation purposes. Another key element to consider when considering incorporating console based gaming into practice is patient engagement. It is important that patients not only enjoy partaking in aspects of the rehabilitation process but to also feel they are safe in doing so. Console-based therapy is the area of research pertaining to the use of technology within the realm of physiotherapy.
Integrating console based gaming into rehabilitation protocols has the potential to change the current structure of rehabilitation. Console based rehabilitation does not seek to replace therapists with computers; rather it is a useful tool that therapists can use to engage with their patients, make rehabilitation fun and exciting, and has the potential to improve compliance rates and thereby improve the functional outcome of these patients. The section serves as a refresher of some of the conditions seen in neurological rehabilitation and mentioned in this wiki.
Symptoms associated with stroke vary based on where the hemorrhage or block has occurred in the brain. The majority of the recovery occurs in the first three months and tends to decrease significantly after six months post-stroke. Rehabilitation of a stroke patient requires a “more is better” mentality therefore it is up to the patient to do their exercises post physiotherapy, as sessions may be limited. The injury can cause damage to the central and potentially to the peripheral nervous system, resulting in variable symptoms. Most recovery occurs during the first six months and like most neurological conditions, the prognosis improves with earlier obtained milestones. More importantly, the aim of rehabilitation is to get the patient as functional as possible in a timely manner.
The focus is on “hierarchy of quality-of-life improvements”, which recognises the importance of target focused rehabilitation that enables independence in basic skills and leads progresses to ambulation.
Cerebral palsy (CP) occurs when there is damage to the brain before, during, or shortly after birth that generally affects the muscle control. Characterised by high or low muscle tone, muscle weakness, uncontrolled body movement, balance, and coordination problems.
The main aims of rehabilitation are to prevent further muscle weakness in atrophied muscles, prevent contractures, and improve coordination. Patient centered care should be employed therefore be meaningful to the patient and should have engaging sensory input to facilitate motivation to move. Defined as an insult to the brain caused by an external force that can cause an altered state of consciousness which can be followed by physical, behavioural and cognitive changes.
With secondary damage there may be an increased intracranial pressure due to swelling or hematoma (can cause herniation), cerebral hypoxia or ischemia, intracranial haemorrhage, electrolyte imbalance and acid-base imbalance, infection from open wound, and seizures from pressure. Altogether, there may also be changes to the autonomic nervous system with the severity dependent on the extent of damage to the brain. Rehabilitation will likely involve interventions for cognition and memory, strength, flexibility, reaction time, speed of movement, endurance and fatigue, somatosensory, the visual system and vestibular system.
Parkinson’s Disease(PD) is a progressive disorder described as a depletion of dopamine stores in the substantia nigra causing a depigmentation of the substantia nigra along with the presence of Lewy bodies. Characterised by rigidity, bradykinesia and akinesia, micrography, masked face, postural abnormalities, and a resting tremor. The role of the Nintendo Wii gaming system has grown in patient rehabilitation since its introduction in November 2006 Henry and Barrett 2010.
Nintendo introduced a new style of VR by providing a wireless controller that interacts with the player through a motion detection system.
Initial interest in the Wii as a therapy tool for upper extremity rehabilitation was due to the console's’ unique wireless controller that allows games to respond to the physical movements of the player, rather than ‘joystick’ movements of traditional gaming systems Halton et al.[20]. Acceleration sensors are responsive to changes in direction, speed, and acceleration that enable participants to interact with games while performing wrist, arm, and hand movements. A two-point infrared light sensor, mounted on top of a television, captures and reproduces movements from the controller and depicts them as the avatar onto the screen Taylor et al.[18]. Patients with increased seizure activity may be susceptible to seizure-inducing stimuli[20]. Patients with pace-makers should keep the Wii remote at least 9 inches away from their chest[20]. When conceptualising commercial gaming as a therapeutic tool, the benefits of using this technology to enhance existing therapy practice need to be clear.
SensitivityA limitation of the Wii technology at present is the fact that it is not sensitive enough to measure some levels of functional ability.


Perceptions that there is a lack of ability to observe and track client progress Tatla et al. Despite its emerging popularity, current research suggests that the Wii is not a suitable replacement for conventional therapy. Although the evidence suggests some benefits of using the Wii console in UL rehabilitation, movements by patients playing the Wii are more complex than those in a conventional physiotherapy programme[32]. Further research into the effects and experience of Wii gaming for UL rehabilitation is required, in order to evaluate the efficacy of Wii therapy compared with conventional rehabilitation of the UL. How can we improve the sensitivity of Wii consoles and tailor games to different patient populations? Wii Sports - UL RehabNintendo Wii exergames, such as Wii Sports and Wii Fit, are becoming popular in rehabilitation settings. The therapist will pre-select games, taking into consideration an individual’s preferences, and UL functional capacity. Games have been designed for patients with burns, diabetes, asthma, and bladder and bowel dysfunction. Kinect enables users to control and interact with the game console by using gestures rather than game controllers [36][37][34], as the Kinect PrimeSense body sensors are not needed as they would in a lab setting [38]. The PrimeSense utilises a RGB camera and a depth sensor, the combination of these components provide full-body 3D motion capture [36].
Kinect is appropriate for individuals with a wide array of injuries and disorders [37][41][38][42][35][36]. Patients can complete game-based tasks while standing or seated[42], allowing for greater accessibility to those with disability including wheelchair users[35][41]. Kinect measures three degrees of freedom of the upper limb, one at the elbow and two at the shoulder[37][44][35].
Our aim is to draw attention to the potential use of easily accessible and affordable technologies that are available to everyone. This is vital for any individual with a neurological condition that must live with long term disability. Whatever the cause of impairment, the main aim of most neurological rehabilitation is to facilitate learning or relearning of motor skills.
Repetition and specificity of exercises has been shown to be the most effective for recovery.
The majority of stroke rehabilitation interventions involve an impairment-based strategy to re-educate movement and allow appropriate compensatory actions. The traction and compression forces due to a motor vehicle accident, violence, falls, and recreational activities can cause dynamic changes to the spinal cord and the structures surrounding it, resulting in injury to the spinal cord. One of the main goals of rehabilitation is to prevent secondary impairments including but not limited to respiratory complications, oedema, bowel issues, and pressure sores. Functional retraining, such as transfer training, wheelchair mobility training and gait training, is combined with strengthening and cardiovascular training to enable the best results for each individual. These can be manifest either locally or globally and may lead to complications such as respiratory and bowel issues[15].
Treatment is always individualised because of the plethora of symptoms associated with different classifications of CP. Stabilisation of one part of the body (typically the trunk, shoulders, and hip) may be necessary to enable the extremities to move functionally.
There may also be acquired trauma to the spinal cord (see spinal cord injury) depending on the mechanism of injury.
Primary damage, may exhibit injury to the cranial nerves with subsequent symptoms due to cranial nerve damaged. The rehabilitation requires synergistic organisation, anticipatory and adaptive responses, dynamic pattern theory and new patterns to engage in the motor control theory.
Interventions should involve functional tasks that are both mentally and physically challenging. Overall, the treatment must focus on preventing secondary impairment and keeping the patient as independent as possible. Movement is monitored by the components including the Wii remote, “nunchuk”, or balance board. The games offer immediate visual and audio feedback, as patients can observe their movements in real time as projected on screen. One therapist noted: “whether it’s a game for lower functioning individuals…we’re working on just a basic exercise, there need to be maybe 6 different options within that…”[23]. A more sensitive system could perhaps overcome these compensatory movements using sensors or vibration to feed back to the patient when they are compensating. Some studies found that Wii practice can lead to benefits on UL function, movement and ADL, but there is insufficient evidence to reach general conclusions. This can interfere with tailoring a standard treatment plan for a patient because the patient will use different movements with various levels of force. The Wii console’s handheld wireless pointing device has embedded sensors that detect changes in direction and speed in three-dimensions.
Although they can be used to assist with rehabilitation goals, Wii games are not designed to do so. Future research should focus on designing more specific games that are suited to the needs of the patient in rehabilitation. No longer does the player need to hold a remote, instead cameras and motion capture sensors recognise the player and tracks their movement and displays it on the screen.
The game 20,000 leaks has the participant use their hands, feet, and head to side step or lunge to plug various leaks that are generated by fish or sharks crashing into a virtual glass bubble [39]. The Kinect One is reported to have a 1080p, HD camera that captures video at 30 frames per second [40]. People are living will illness and disability longer than ever and this places an increasing strain on the healthcare system.


The rehabilitation process may take months to years before the patient is able to function to their full capacity. It was also noted that the patients themselves stated that they felt safe and able to practice within the home setting.
The process of gaining motor skills involves repeating the same movement hundreds or even thousands of times. No longer is a patient repeatedly flexing and extending their elbow, using a computer game they could be taming a lion, stirring cake batter or shooting multi-coloured balloons.
Altered sensations, slurred speech, aphasia, dysphagia, ataxia, visual field defects, neglect, dyspraxia, memory and personality issues, altered tone, and pain.
The current NICE guidelines[16] recommend a minimum of 45 minutes, five days a week of focused rehabilitation. It is important exercises are taught to parents in order to facilitate rehabilitation at home[15].
It is important to recognise the need for knowledge of results and practice type (slow, simple, and relatively functional) with motor control. It may be influenced by infection, environmental factors grouped with aging, genetics, and a history of depression.
A sensor that sits above or below the screen monitors where the player’s hand is (by reading signals sent from the remote in the player’s hand) and translates these signals into movement. Over 75 million units have been sold worldwide, and it is becoming a popular rehabilitation tool around the world Taylor et al.
However, a limited number of studies have adapted the Wii hardware to turn the Wii into a more useful rehabilitation tool. However, commercial gaming can provide high intensity UL practice that is safely tolerated for 180 minutes per week[26].
As discussed earlier, the Wii can potentially motivate patients to spend more time participating in active UL movement because of its fun and interactive approach.
It is the therapist’s role to monitor for appropriate responses to the game, ensure correct muscles usage, and to be aware of fatigue or pain. The potential of the Wii may improve if games and accessories are designed with rehabilitation in mind. The PrimeSense detects the players’ movements and provides feedback regarding the quality of movement thus determines if the player has succeeded in completing each task.
New active-infrared capabilities increase precision, allowing Kinect One to work in various lighting condition with an expanded field of view. The projections predicted for Scotland, state the total population will reach 5.78 million by 2033 with those aged 65 and over with an increase of 62 per cent and those over 85 years of age. Traditional rehabilitation is time consuming and requires lengthy sessions with therapists that place high demand on personnel and healthcare budgets. Instead of asking a patient to balance while they reach out and touch a physiotherapy assistant’s hand, patients can work on their balance while playing virtual golf, throwing a strike in the virtual bowling alley or driving a go-kart around a race course on a desert island.
The aim of physiotherapy is to restore function and re-educate the body to move in a functional way.
Some deficits that may occur with primary damage include memory loss, difficulty concentration, decrease in attention span, sleep disturbances, headaches and seizures. There has been evidence in promoting “forced use” therapy in combination with complex movements for improved outcomes. Evidence for the use of relaxation techniques have been described to decrease rigidity and tremor. Stroke rehabilitation is a complex area with gaps in the evidence base on how to promote motor recovery. Therapists clearly play a key role in selecting and adapting games and activities to meet the needs of patients in the rehabilitation process. The therapist can provide verbal encouragement, support the client’s hand with a cuff to hold the Wii remote if the patient’s grip is inadequate, or even provide hand-over-hand assistance or play with the patient. Microsoft proprietary ‘Time-of-Flight’ technology measures the time it takes individual photons to rebound off of the player to create unprecedented accuracy and precision. Once relaxation is used, movement must be initiated to promote activity in the most effective manner. Increased use of the Wii for rehabilitation can be attributed to: versatility toward treatment goals, affordability, and increased engagement in therapy.
Some interventions show promise; particularly studies that focus on high-intensity, repetitive task-specific practice[26]. Microsoft Kinect sensor can be connected to PC through USB allowing data to be uploaded or downloaded from the server [35]. The new noise-isolating multi-microphone array filters ambient sound to recognise natural speaking voices. This combination will give rise to the number of pharmaceuticals, time, facilities, doctors and therapists required to assist in rehabilitating or managing the plethora of conditions. It has been reported that patient adherence to long-term rehabilitation programs involving exercise protocols may be as low as 23% [14]. The therapist may be required to provide encouragement and instructions to compensate for the Wii’s usability limitations. More research is needed in order to design Wii games with a more sensitive rehabilitation focus.
The camera has greater sensitivity than its predecessors and is able to detect additional data points of articulation including the heartbeat of the player. It is through the 2020 Vision and e-health initiatives that the Scottish government aims to continue to provide quality care to the masses.



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