Conference PaperPDF Available

Improving patient motivation in game development for motor deficit rehabilitation


Abstract and Figures

It has been stated repeatedly that active participation in rehabilitation programs increases the benefit and effectiveness of therapy. In developing robotic devices for stroke rehabilitation, the existing use of boring task interfaces produces a significant reduction in elderly patient motivation. To combine robot-aided therapy with appealing games, then, is not only a matter of creating entertainment, but a real necessity for motor recovery. Besides emphasizing a lack of attention to elderly patients in conceiving games for post-stroke rehabilitation, this paper launches a challenge to two fields with tremendous collaborative potential. As a precursor to this collaboration, the following research consolidates the gaming scenario criteria for both rehabilitation and elderly entertainment. Conclusions are then formed from the adaptability of existing games to identify the direction of future game development.
Content may be subject to copyright.
Improving Patient Motivation in Game Development
for Motor Deficit Rehabilitation
Eletha Flores1, Gabriel Tobon1, Ettore Cavallaro2, Francesca I. Cavallaro2, Joel C. Perry2, Thierry Keller2
1Massachusetts Institute of Technology – EECS Dept.
Box 38-401, 77 Massachusetts Avenue
Cambridge, MA 02139- 4307 USA
+1 617 253 4600
2Fatronik Foundation – Biorobotics Department
Paseo Mikeletegi, 7
20009 Donostia-San Sebastian - Spain
+34 934 00 55 00
<ejflores, yehagt>, <ecavallaro, fcavallaro, jperry, tkeller>
It has been stated repeatedly that actively participating in
rehabilitation programs increases the benefits and the
effectiveness of the therapy. In developing robotic devices for
stroke rehabilitation, the existing use of boring task interfaces
produces a significant reduction in elderly patient motivation. To
combine robot-aided therapy with appealing games, then, is not
only a matter of creating entertainment, but a real necessity for
motor recovery. Besides emphasizing a lack of attention to elderly
patients in conceiving games for post-stroke rehabilitation, this
paper suggests a tool that consolidates the gaming scenario
criteria for both rehabilitation and elderly entertainment.
Conclusions are then formed from the adaptability of existing
games to identify the direction of future game development.
Categories and Subject Descriptors
K.4.2 [Computers and Society]: Social Issues
General Terms
Measurement, Performance, Design, Human Factors, Theory
Rehabilitation Gaming, Computer Games, Serious Games,
Assistive Technologies, Motivation, Biofeedback, Skill
Assessment, Motor Rehabilitation, Elderly, Stroke.
Over the past 3 decades, the field of computer entertainment
technology has seen substantial improvements in both the
complexity and realism of games produced. The increased
prevalence and availability of games and gaming platforms has
made accessible these advances for their application to new
audiences and new fields. A relatively new audience of particular
interest is the population of aging adults who suffer from
variations of muscular, neuromuscular, and orthopedic
impairments. While a few prototype systems for this population
exist, games remain simplistic and often unanalyzed in terms of
effectiveness and appropriateness for the rehabilitation process.
At present, serious games exist for a variety of educational
and training purposes. For the field of rehabilitation, research has
shown that games and related virtual technology can provide
significant motivation to post-stroke patients [5, 14, 6, 20].
Understandably, the greater the motivation to participate in
rehabilitation tasks, the more likely patients will be to continue
active participation. Additionally, it is known that longer
therapeutic sessions lead to greater functional outcomes over the
course of treatment. Acknowledging that participation is a
prerequisite to increased treatment, it follows that increases in
sustained participation will lead to greater motor recovery during
the rehabilitation process [5].
Despite the existence of a growing number of robotic
systems for rehabilitation, a thorough understanding of the
association between the design of the task-oriented interface, or
gaming scenario, and the overall effectiveness of the rehabilitation
system is yet to be achieved. This gap in the literature represents a
significant weakness in the current state of rehabilitation-oriented
gaming. In the awareness of this gap, the research effort reported
in this paper will present the following: 1) a summary of the
pertinent literature to date on rehabilitation-oriented gaming, 2) a
guide map of the critical factors in designing gaming scenarios for
motor impairment rehabilitation and elderly-specific adherence,
and 3) some example of how to use this map in developing new
games and/or adapting existing games for the purpose of
rehabilitation, particularly for aging adults.
To date, there have been many systems created and tested,
from exoskeleton robotic arms that aid with arm movement to
highly immersive virtual reality interfaces that provide task-
oriented environments. Among the work, different task-oriented
scenarios have been implemented to incorporate more motivating
and interactive patient-device interfaces using VR or related
technology. The interfaces commonly use high or low immersion
methods and are implemented both with and without robot aided
therapy. A number of existing robotic systems were reviewed,
including MIT-Manus (8), Gentle/s system (2, 14), ARMIn (17),
CADEN-7 (19), MIME (16), and the T-WREX (20), all of which
are devices that support the arm and many of which provide
movement assistance during arm exercises.
Permission to make digital or hard copies of all or part of this work for
personal or classroom use is granted without fee provided that copies
are not made or distributed for profit or commercial advantage and that
copies bear this notice and the full citation on the first page. To copy
otherwise, or republish, to post on servers or to redistribute to lists,
requires prior specific permission and/or a fee.
Conference’04, Month 1–2, 2004, City, State, Country.
Copyright 2004 ACM 1-58113-000-0/00/0004…$5.00.
Studies that focused more on the virtual reality or related
technologies of their systems, such as the RGS (4), Broeren et al
(3), Two DoF (5), and Ma et al (15) were also reviewed. Many of
the interfaces used in these systems are not designed to be
entertaining or motivational for the users but present tasks in a
repetitive manner which leads one to question their ability to
sustain the interest of patients during extended exercise. Although
patient motivation for using the system was commonly evaluated
through questionnaires or mentioned as observations, none of the
papers reviewed provided follow-up studies that focused on the
impact their game design in particular had on patient outcome.
To our knowledge, there is a current lack of research
evaluating the effectiveness of rehabilitation regimes under a
standardized therapy (both technique and device) using different
virtual interfaces (i.e., gaming scenarios). The major question yet
to be addressed is to what degree patient outcome is influenced by
the design of the task environment. The only study reviewed that
focused on the central theme of game design for motor
rehabilitation presented a model for game design in general based
on the association between gaming patterns and the taxonomy of
stroke rehabilitation [10]. In this model, only a subset of stroke
symptoms and treatments were discussed which suggest the need
to expand analysis of the taxonomy and verify the associations
between game patterns and treatments. On the other end of the
spectrum, one study reviewed focused almost purely on the
motivation of the users of the robot-aided rehabilitation system
Two-Dof using the Intrinsic Motivational Inventory questionnaire.
This study developed an evaluation metric to measure user
performance with their particular system, but does not present
designs for games based on factors that influence motivation [5].
On the other hand, some commercial video games, such as
Pong, have been utilized as task interfaces for rehabilitation,
which brings into consideration the features of these games for
therapy purposes. As the next step in this process, we suggest that
professional game developers should be involved in the design of
the interfaces. Whether creating new games for rehabilitation or
modifying existing games, additional studies are needed that
address the following questions:
What are the design criteria that satisfy both the nature of
a motor rehabilitation program and the preferences of
most elderly users in order to create a motivational
program that promote patient adherence?
Given the criteria for game design, are commercial video
games suitable for implementation with rehabilitation
systems, or do gaming scenarios need to be specifically
designed/tailored for use in elderly motor rehabilitation?
If existing games can be suitable or modifiable for these
purposes, this is a field that invites the contributions of today's
game developers to further advance the state of motor
rehabilitation technology.
A comprehensive search of the pertinent journals and
databases was performed in order to compile a set of criteria for
designing the important game characteristics for stroke
rehabilitation. The literature was reviewed for both criteria used to
design effective therapy for stroke patients as well as for criteria
used to design entertainment for the elderly population. For the
former, much of the literature focused on the analysis of new
types of therapy, not tailored to the design of a proper therapeutic
game, but many shared the same criteria needed for effective
motor skills’ training of stroke patients. The majority of the
elderly entertainment criteria were derived from the ElderGAMES
project [7,9], which works closely with older populations to find
the most motivating and enjoyable games for elderly. The
combined set of design criteria as collected from the literature is
shown in Table 1. Represented in the table are two sets of criteria
and the relationship of each criterion to the corresponding gaming
classification. The ideal game to be used for stroke rehabilitation
would satisfy all of the listed criteria.
Table 1. Gaming design criteria for stroke rehabilitation
programs serving elderly users
Criteria for Stroke
Rehabilitation Criteria for Elderly
Adaptability to motor
skill level
Meaningful tasks
Appropriate feedback
Focus diverted from
Appropriate cognitive
Simple objective/interface
Element of social activity
Appropriateness of genre
Creation of new learning
Promotion of cognitive
capacities chosen by
experts of ElderGames
Sensitivity to decreased
sensory acuity and slower
Games for Stroke RehabilitationBecause of the extent to which
motor impairment varies from one patient to the next, successful
stroke rehabilitation requires that the game used with a robotic
device be able to adapt to a patient's motor level. Adaptability is
equally important for individuals so that the level of difficulty can
be raised as the patient's motor skills improve over time.
Meaningful tasks should be incorporated so that the patient can
have a direct correlation between use of their disabled limb during
therapy and use in activities of daily living (ADLs) [13]. The
game must also provide appropriate feedback for both patient and
therapist. This feedback is used to determine how well the patient
is doing, how much he or she is improving, and provides some
encouragement to the patient to continue with the therapy.
Charting the history of recorded feedback can also help to steer
the direction of future therapy sessions. Therapy-appropriate
range-of-motion (ROM) refers to the extent the game demands the
therapeutic motions needed for the particular motor rehabilitation
program of each patient. Skills need to be practiced extensively,
requiring intensive repetition, according to neurobiological and
VR technology for stroke rehabilitation research [18, 22]. Other
studies on motor rehabilitation therapy suggest that patients with
hemiplegia need an environment where they can practice skills as
the demands of that environment change in a variety of ways, in
order to develop versatile motor schemata that will allow them to
perform ADLs [21]. It follows that the game should divert the
focus away from the conscious effort to move the impaired arm,
and towards the objectives of game play, which can simulate the
varied demands of ADLs.
Games for Elderly Entertainment Entertaining and motivating
elderly users means that the game must be challenging enough to
keep the interest and attention of the player. Elderly video game
players prefer simple games in thought-based genres such as
history and word trivia. Moreover, they enjoy the social aspects of
video games, both in side by side multiplayer games on the same
console and in large multiplayer games played over a network
[11]. Games designed for the elderly should also take into
consideration a decreased sensory acuity and longer response time
(i.e. using large font size, allow delayed responses, etc.) [7].
Based on the collection of criteria described above, the
information in Table 1 has been used to analyze a set of existing
games. The set contains games designed specifically for use with
stroke rehabilitation devices (Driver's SEAT and Whack-a-
Mouse), a game that has been used, although not designed, for
rehabilitation (Pong), as well as a few popular games that could be
adapted for this purpose (Tetris, Computer Chess, and Trivial
Pursuit). The existing stroke rehabilitation games were chosen
subjectively as the most entertaining for the elderly according to
our criteria. The popular games were chosen as examples of
games that have distinct advantages over existing games for
stroke rehabilitation against our complete set of criteria but have
not been adapted for stroke rehabilitation.
Table 2 provides a summary of a subjective analysis of six
games, where three of the games have been used for stroke
rehabilitation and three are popular games not currently used in
rehabilitation. The table illustrates the deficiencies present in both
sets of existing games. Additionally, an approximate rating is
given to the overall appropriateness of each game for elderly
rehabilition based on weighting values assigned to each of the
criteria. As seen in the Table, all of the games designed for stroke
rehabilitation fail to be cognitively challenging, to create new
learning, and to promote cognitive capacity for elderly users.
They also lack a social aspect that could allow the patients to
enjoy the interaction and encouragement from others playing the
same game. The games designed for entertainment, on the other
hand, are untested for efficacy in rehabilitation, lack meaningful
tasks, and do not provide thorough feedback about the user’s
motor abilities.
It is no surprise that by design, the games that are currently
used for stroke rehabilitation have qualities that make them
effective for therapy when used with a corresponding robotic
device. Compared to popular games that are designed to be
engaging and fun, current therapeutic games lack the qualities
required to be entertaining and are thus less motivating for
patients. On the other hand, the popular games have not been
thoroughly analyzed with the criteria of stroke rehabilitation in
mind and thus lack essential components for therapeutic
At present, one major criticism worth noting is that existing
gaming scenarios for rehabilitation have been designed solely by
engineers, scientists, and health professionals whose purpose is to
build and test the overall functionality of the developed hardware.
Careful attention must be given to the way in which we design the
patient-system interface to incorporate motivation for active
participation. Reviewing existing scenarios, it seems possible to
use certain games for elderly users in post-stroke motor
rehabilitation therapy. While some games can be modified to
better suit exercise programs, others can serve as models for the
creation of a specific motor rehabilitation game.
Table 2. Comparison assessment of existing gaming scenarios using the criteria of Table 1.
Adaptability to motor skill level (3)
Meaningful tasks (2)
Appropriate feedback (2)
Therapy-appropriate ROM (3)
? ? ?
Focus diverted from exercise (2)
Appropriate cognitive challenge (3)
Simple objective/interface (2)
Element of social activity (1)
Appropriateness of genre (1)
Creation of new learning (1)
Multiple levels of difficulty (3)
Sensitivity to decreased sensory acuity (2)
Sensitivity to slower responses (2)
Stroke Rehabilitation Criteria Score 10/12 12/12 10/12 2/12 2/12 2/12
Elderly Entertainment Criteria Score 10/16 10/16 9/16 14/16 16/16 16/16
Total Score 20/28 22/28 19/28 16/28 18/28 18/28
ü ü ü
ü ü ü
ü ü ü
ü ü ü ü ü ü
ü ü ü
ü ü ü ü ü ü
ü ü
ü ü ü ü ü
ü ü
ü ü ü ü ü ü
Promotion of the cognitive capacities
chosen by the experts (1) ü ü ü
ü ü ü ü ü ü
ü ü ü ü ü ü
In the results of this study, it is clear that the weighting
assigned to the design criteria is necessarily subjective rather than
indicative of a definitive study. However, the reported game
scores may serve as general indicators for the appropriateness or
adaptability of each game for use in elderly rehabilitation. It is
anticipated that these and other games can be modified in order to
satisfy a larger number of criteria from the above tables and
become more functional tools for therapy.
Further research is needed to fully assess the effectiveness of
games designed to combine elderly game preferences and
requirements of motor rehabilitation programs. The need for
serious games aimed at rehabilitation programs and elderly
audiences invites current game developers to contribute their
skills and imagination to this growing population of potential
[1] Aison, C, Davis, G, et al. 2002. Appeal and Interest of Video
Game Use Among the Elderly. Harvard Graduate School of
Education, (May 2002), i-28. DOI=
[2] Amirabdollahian, F., et al., 2007. Multivariate analysis of
the Fugl-Meyer outcome measures assessing the
effectiveness of GENTLE/S robot-mediated stroke therapy.
J. Neuroeng. and Rehabil. (Feb. 4 2007), 4:4.
[3] Broeren, J., et al., 2008. Virtual rehabilitation after stroke.
Studies in Health Tech. and Informatics, (2008) 136:77-82.
[4] Cameirao, M. S., et al., 2007. The Rehabilitation Gaming
System: a Virtual Reality Based System for the Evaluation
and Rehabilitation of Motor Deficits. Virtual Rehabilitation,
2007 (September 27-29) 29-33.
[5] Colombo, et al., 2007. Design strategies to improve patient
motivation during robot-aided rehabilitation. Journal of
NeuroEngineering and Rehabilitation (February, 2007),
4(3):33-39. DOI=
[6] Crosbie, J. H., Lennon, S., Basford, J. R., McDonough,
S. M., 2007. Virtual reality in stroke rehabilitation: Still
more virtual than real. Disabil. Rehabil. (2007),
DOI= /09638280600960909
[7] Fabregat, M., 2006. D1.2 - Game Typologies to be
developed and their relationship with the parameters to
measure. Development of High Therapeutic Value IST-based
Games for Monitoring and Improving the Quality of the Life
of Elderly People. Information Society Technologies project
CN 034552. ElderGames Project, final report version.
[8] Fasoli, S., Krebs, H., Stein, J.,Frontera, W., Hogan, N., 2003.
Effects of robotic therapy on motor impairment and recovery
in chronic stroke, Arch. Phys. Med. Rehabil., 84(4), 477-482,
2003. DOI=
[9] Gamberini L., et al., 2006. Cognition, technology and games
for the elderly: An introduction to ELDERGAMES Project.
PsychNology Journal, (December. 2006), 4(3):285 -308.
[10] Goude, D., Björk, S., Rydmark, M. 2007. Game Design in
Virtual Reality Systems for Stroke Rehabilitation. Stud
Health Technol. and Inform. 125:146-148.
[11] Griffiths M, Davies M, Chappell D. Online computer
gaming: a comparison of adolescent and adult gamers.
Journal of Adolescence. Video Games and Public Health,
(February 2004) 27(1):87-96.
[12] Ijsselsteijn W, Nap H, de Kort Y, Poels K, Digital game
design for elderly users. Future Play: Proc. of the 2007
Conf. on Future Play. ACM Press. New York, NY, 17-22.
[13] Johnson M, et al., 2006. Systems that Rehabilitate as well as
Motivate: Three Strategies for Motivating Impaired Arm
Use. The First IEEE/RAS-EMBS Intl. Conf. on Biomed.
Robotics and Biomechatronics, 2006. BioRobotics. (Feb.
20-22, 2006), 254-9.
[14] Loureiro, R.C.V., Collin, C.F., Harwin, W.S., 2004. Robot
aided therapy: challenges ahead for upper limb stroke
rehabilitation. In Proc. of 5th Intl. Conf. of Disability, VR
& Assoc. Tech. (Sep. 20-22 2004), 4(1):7-11.
[15] Ma, M., et al., 2007. Adaptive Virtual Reality Games for
Rehabilitation of Motor Disorders. Universal Access in
Human-Computer Interaction. Ambient Interaction, (August
2007) 4555:681-690.
[16] Masiero, S., Celia, A., Rosati, G., Armani, M., 2007.
Robotic-assisted rehabilitation of the upper limb after acute
stroke. Arch. Phys. Med. Rehabil., (Feb. 2007) 88(2):142-9.
[17] Nef, T., Mihelj, M., Colombo, G., Riener, R., 2006. ARMin -
robot for rehabilitation of the upper extremities. In
Proceedings of IEEE Intl. Conf. on Robotics and
Automation, (May 15-19 2006) 3152 – 3157.
[18] Nelles G., Jentzen W, et al. 2001. Arm Training Induced
plasticity in stroke studied with serial positron emission
tomography. Neurological Image 2001; 13; 1146-1154.
[19] Perry, J.C., Rosen, J., Burns, S., 2007. Upper-Limb Powered
Exoskeleton Design. IEEE-ASME Trans. on Mechatronics
(Aug 2007) 12(4):408-417. DOI=
[20] Reinkensmeyer, D.J., Housman S.J., 2007. “If I can´t do it
once, why do it a hundred times?”: Connecting volition to
movement success in a virtual environment motivates people
to exercise the arm after stroke. Virtual Rehabil.. (Sept.
27-29 2007) 44 – 48.
DOI= 10.1109/ICVR.2007.4362128
[21] Sabari J: Motor learning concepts applied to activity-based
intervention with adults with hemiplegia. Amer. J. of Occup.
Therapy (1991), 45:523-530.
[22] Small S, Solodkin A. 1998. The Neurobiology of stroke
rehabilitation. Neuroscientist (1998), 4:426-434.
... 11 Games can be effective for motor recovery as the high dosage repetitive task practice necessary to facilitate motor learning can be embedded within an interactive entertainment platform, keeping the user engaged for prolonged periods of time and relaying crucial performance related feedback to the user and health professionals. 12 When used as an adjunct to conventional therapy, games have shown to be beneficial in motor recovery. 13 However, the design of the system is crucial, 14 with games which deliver established neurorehabilitation principles providing greater positive impact on motor function. ...
... Additionally, the method does not offer real-time operation which is crucial for integration within game-based systems to provide motivational and performance feedback to the user. 12 However, it is acknowledged that all systems operate with a delay. Classification algorithms which aim to detect and categorise human motion have been explored. ...
Full-text available
Introduction: Interactive game systems can motivate stroke survivors to engage with their rehabilitation exercises. However, it is crucial that systems are in place to detect if exercises are performed correctly as stroke survivors often perform compensatory movements which can be detrimental to recovery. Very few game systems integrate motion tracking algorithms to monitor performance and detect such movements. This paper describes the development of algorithms which monitor for compensatory movements during upper limb reaching movements in real-time and provides quantitative metrics for health professionals to monitor performance and progress over time. Methods: A real-time algorithm was developed to analyse reaching motions in real-time through a low-cost depth camera. The algorithm segments cyclical reaching motions into component parts, including compensatory movement, and provides a graphical representation of task performance. Healthy participants ( n = 10) performed reaching motions facing the camera. The real-time accuracy of the algorithm was assessed by comparing offline analysis to real-time collection of data. Results: The algorithm’s ability to segment cyclical reaching motions and detect the component parts in real-time was assessed. Results show that movement types can be detected in real time with accuracy, showing a maximum error of 1.71%. Conclusions: Using the methods outlined, the real-time detection and quantification of compensatory movements is feasible for integration within home-based, repetitive task practice game systems for people with stroke.
... In addition, visual biofeedback (for example, tools like Kinect) promotes higher levels of active participation [38]. Patients who use virtual environment video games are more motivated, rely more on rehabilitative exercises [50,51], enjoy treatment more, work harder to heal themselves, and ultimately have better upper limb function [19,52]. Some studies [48,53] have also shown that VR-based games can provide effective sensory feedback and place subjects in a virtual environment to watch their body's movements. ...
Full-text available
Abstract Background: Upper limb (UL) disabilities have attracted worldwide attention due to the high economic costs of health care and the negative effects on the quality of life of patients with these disabilities. Telerehabilitation technologies are one of the most important ways to reduce rehabilitation costs and increase the quality of life of patients. Therefore, the aim of this study was to investigate the role of telerehabilitation in improving the health status of patients with upper limb disabilities. Methods: This scoping review was conducted by searching the Web of Science, PubMed, and Scopus until July 30, 2021. We used a data extraction form with 18 fields to extract data from primary studies. The selection of articles and data extraction was made by four researchers using a data collection form based on inclusion and exclusion criteria. Disagreements were resolved through consultation with the fifth and sixth researchers.Inclusion criteria were studies published in English, studies on upper limb disability, and telerehabilitation based on any technology (synchronous telerehabilitation, asynchronous, or both). Exclusion criteria were articles that did not focus on telerehabilitation and upper limb disabilities. Also, books, book chapters, letters to the editor, and conference abstracts were also removed. Results: A total of 458 articles were retrieved, and after removing irrelevant and duplicate articles, 29 articles were finally included in this review. Most telerehabilitation was performed for patients with stroke (65%). Among the 15 different services provided with telerehabilitation technologies, "Evaluation of exercises and also a musculoskeletal function of patients by the therapist","Recording of patients' rehabilitation exercises and sending them to the therapist” and "Prescribing new rehabilitation exercises by the therapist" were the most widely used services, respectively. Virtual reality technologies, smart wearables, and robots were used to provide telerehabilitation services. Among the 13 types of evaluation used for telerehabilitation systems, “Evaluation and measurement of upper limb function” was the most used evaluation in the studies. "Improvement in musculoskeletal functions”, "Increasing patients' interest and motivation to perform rehabilitation exercises", and "Increasing adherence to rehabilitation exercises and greater participation in treatment processes" were the most important outcomes, respectively. Conclusion: Our findings indicate that telerehabilitation provides individuals with equitable access to rehabilitation services, improves musculoskeletal function, and empowers individuals by providing a variety of rehabilitation capabilities.
... There is increasing interest in the use of robots to assist the rehabilitation of stroke patients, partly due to the repetitive nature of post-stroke rehabilitation and the integration of stimulating video games [1] to increase patient motivation and partly due to a projected increase in strokes due to an ageing population, causing a strain on rehabilitation services [2]. Stroke can have severe consequences for the patient's quality of life, with reports estimating that up to 20% of patients require intensive rehabilitation programs [3]. ...
Full-text available
Tracking patient progress through a course of robotic tele-rehabilitation requires constant position data logging and comparison, alongside periodic testing with no powered assistance. The test data must be compared with previous test attempts and an ideal baseline, for which a good understanding of the dynamics of the robot is required. The traditional dynamic modelling techniques for serial chain robotics, which involve forming and solving equations of motion, do not adequately describe the multi-domain phenomena that affect the movement of the rehabilitation robot. In this study, a multi-domain dynamic model for an upper limb rehabilitation robot is described. The model, built using a combination of MATLAB, SimScape, and SimScape Multibody, comprises the mechanical electro-mechanical and control domains. The performance of the model was validated against the performance of the robot when unloaded and when loaded with a human arm proxy. It is shown that this combination of software is appropriate for building a dynamic model of the robot and provides advantages over the traditional modelling approach. It is demonstrated that the responses of the model match the responses of the robot with acceptable accuracy, though the inability to model backlash was a limitation.
... This meaningful game design was intended to emphasize the importance of benefits for elderly people. Flores et al. [17] researched games created for stroke rehabilitation and suggested visual adaptability, including appropriate therapeutic exercise and cognitive challenges. Aarhus et al. [18] highlighted the importance of allowing elderly users to adjust game speed and difficulty to adapt to individual differences. ...
Full-text available
Existing motion capture technology can efficiently track whole-body motion and be applied to many areas of the body. This whole-body interaction design has gained the attention of many researchers. However, few scholars have studied its suitability for elderly users. We were interested in exercise-based whole-body interactive games, which can provide mental and physical exercise for elderly users. We used heuristic evaluation to measure participants’ actions during exergame tasks and analyzed preference differences between elderly and younger users through the distribution of actions in four dimensions. We found that age affected the actions performed by users in exergame tasks. We discuss the mental model of elderly users during the process of performing these tasks and put forward some suggestions for interactive actions. This model and these suggestions theoretically have guiding significance for the research and application of exergame design for elderly users and may help designers develop more effective exergames or other whole-body interaction interfaces suitable for elderly users.
... A game interface has also been created to make the rehabilitation sessions more fun for the user than a series of repetitive tasks, as shown in Figure 14. The goal of this game is not only to entertain the patients, but also showed benefits in motor recovery, since the users are more engaged during therapy [33]. Figure 14. ...
Full-text available
With the growing popularity of Human-Robot Interactions, a series of robotic assistive devices have been created over the last decades. However, due to the lack of easily integrable resources, the development of these custom made devices turns out to be long and expensive. Therefore, the SMARCOS, a novel off-the-shelf Smart Variable Stiffness Actuator for human-centered robotic applications is proposed in this paper. This modular actuator combines compliant elements and sensors as well as low-level controller and high-bandwidth communication. The characterisation of the actuator is presented in this manuscript, followed by two use-cases wherein the benefits of such technology can be truly exploited. The actuator provides a lightweight design that can serve as the building blocks to facilitate the development of robotic applications.
... These are not as customisable for individuals with motor dysfunction as games specifically designed to that end [46]. The literature recommends adapting the motor skill level and providing meaningful tasks to increase users' motivation [47,48]. For the specific case of Harry, he showed the need to have some targets, which generally were to do better than the last score. ...
Purpose To understand the impact of an intensive rehabilitation program based on exergames in balance and lower limb function in a teenager with cerebral palsy. Methods The rehabilitation program comprised different customised exergames and was delivered in 5 weekly sessions of 30 min for 4 weeks. Pre-, post-, and 1-month Follow-up assessments included the following metrics: Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Gross Motor Function Measure (GMFM), Posturography, and Gait analysis. Results We observed increased scores after the intervention of 9/72 points in GMF – Module E (Walk, Run and Jump) and of 9/56 points in BBS, sustained at Follow-up. Changes in function, specifically in the quality and independence of the performance of specific movements such as turning 360°, increased distance reaching forward, walk behind, step over obstacles, and step stairs up and down were also observed. Gait kinematics and Spatio-temporal parameters tended to get closer to the 50th percentile. Conclusions We observed positive changes in motor function of a teenager with cerebral palsy, with sustained increased scores at a 1-month Follow-up. Findings are suggestive that intensive rehabilitation programs using exergames with high customisation features are a potentially valuable rehabilitation tool for training balance in teenagers with Cerebral Palsy. • Implications for rehabilitation • Exergames may be a useful for providing balance training for teenagers who have a mixed form of cerebral palsy. • Exergames that require body displacement may be suitable for modulating gait kinematics and spatio-temporal parameters. • The customisation of virtual rehabilitation tools seems to impact the motivation and effort of the user positively.
Conference Paper
This paper presents our approach to predicting future error-related events in a robot-mediated gamified physical training activity for stroke patients. The ability to predict future error under such conditions suggests the existence of distinguishable features and separated class characteristics between the casual gameplay state and error prune state in the data. Identifying such features provides valuable insight to creating individually tailored, adaptive games as well as possible ways to increase rehabilitation success by patients. Considering the time-series nature of sensory data created by motor actions of patients we employed a predictive analysis strategy on carefully engineered features of sequenced data. We split the data into fixed time windows and explored logistic regression models, decision trees, and recurrent neural networks to predict the likelihood of a patient making an error based on the features from the time window before the error. We achieved an 84.4% F1-score with a 0.76 ROC value in our best model for predicting motion accuracy related errors. Moreover, we computed the permutation importance of the features to explain which ones are more indicative of future errors.
Conference Paper
Proprioceptive deficits are common after a stroke and are thought to negatively impact motor learning. Despite this, there is a lack of practical robotic devices for assessing proprioception, as well as few robotic rehabilitation techniques that intensely and engagingly target proprioception. This work first presents the design of a simple robotic device, PINKIE, developed to assess and train finger proprioception. PINKIE uses low-cost actuators and sensors and is fabricated completely from 3D printed, laser cut, and off-the-shelf components. We then describe the design and testing of a gamified proprioceptive training technique, Proprioceptive-Pong (P-Pong), implemented with PINKIE. In P-Pong, players must continuously make game decisions based on sensed index and middle finger positions, as the game robotically moves their fingers instead of screen pixels to express the motion of the ball and paddle. We also report the results of a pilot study in which we investigated the effect of a short bout of P-Pong play on proprioceptive acuity, and quantified user engagement and intrinsic motivation of game play. We randomly assigned 15 unimpaired human participants to play 15 minutes of P-Pong (proprioceptive training group) or a similar but video-only version of Pong (control group). We assessed finger proprioception acuity before and after game play using the Crisscross assessment previously developed by our laboratory, engagement using the User Engagement Scale, and motivation using the Intrinsic Motivation Inventory survey. Following game play, there was a significant improvement in proprioceptive acuity (2.2 ± 2.6 SD mm, p = 0.023) in the proprioceptive training group but not the control group (0.5 ± 0.9 SD mm, p = 0.101). Participants rated P-Pong highly on all survey subscales, and as highly as visual Pong, except in the Perceived Usability and Competence subscales, a finding we discuss. To our knowledge, this work presents the first computer gaming approach for providing intense and engaging finger proprioception training, by splitting the feedback of game elements between the visual and proprioceptive senses. The pilot experiment indicates that the human sensory motor system has the ability to at least temporarily improve proprioception acuity with such game-based training.
Background Physiological changes resulting from aging can impair postural balance. Exergames have been used to treat balance disorders, enabling sensory-motor training due to their content, and with targeted goals and purposes beyond entertainment. Aim The aim of this investigation was to describe the development of a serious game, VirtualTer, and to test content validity. Methods A Brazilian group from the Federal University of Rio Grande do Norte developed a serious game called VirtualTer for postural balance rehabilitation in older adults. In game navigation, the avatar needed to save the environment from catching harmful energy that destroys nature. The avatar performs stationary walking, lateral reaching, and climbing up and down steps to capture the energies. Content validity was determined using content matter experts by the Delphi method. Eleven content matter experts played the game and expressed their opinions using the assessment instruments: VirtualTer Dimensions (VD) and System Usability Scale (SUS). Results VirtualTer was designed with regard to variability in practice, since the game was constructed under three levels and offers continuous and terminal feedback. The participants needed to achieve at least 70% of the total score to advance to the next phase. The limits of stability for lateral reach test were right 23.2 ± 4.77 cm and left 22.9 ± 4.86 cm, which was applied in the game. The content validity index of the VD was 0.8, and Cronbach’s alpha coefficient was 0.924. The content matter experts reported the game as having a 67.73 satisfaction with the SUS. Conclusion This game has good usability, low-cost investment, and supports access to innovative and valid technology for rehabilitation in countries with little investment in technology for health.
Background: Sustained engagement is essential for the success of telerehabilitation programs. However, patients' lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science-based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR). Objective: This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert. Methods: In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users' range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software's response to their movements. During calibration, the time series of the users' movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements. Results: The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%). Conclusions: Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation.
Conference Paper
Full-text available
The current paper reviews and discusses digital game design for elderly users. The aim of the paper is to look beyond the traditional perspective of usability requirements imposed by age-related functional limitations, towards the design opportunities that exist to create digital games that will offer engaging content combined with an interface that seniors can easily and pleasurably use. Keywords Digital game design, elderly users, social and cognitive benefits of games, review.
Full-text available
People who have been discharged from hospital following a stroke still have a potential to continue their recovery by doing therapy at home. Unfortunately it is difficult to exercise a stroke affected arm correctly and many people simply resort to using their good arm for most activities. This strategy makes many tasks difficult and any tasks requiring two hands become nearly impossible. The use of haptic interface technologies will allow the reach and grasp movements to be retrained by either assisting movement, or directing movement towards a specified target. This paper demonstrates how initial work on machine mediated therapies can be made available to a person recovering at home.
Full-text available
Eldergames is a EU funded project to develop games using advanced visualisation and interaction interfaces to improve the cognitive, functional and social skills of older users. The project merges two major areas to which technology for the elderly people is applied, health and social engagement. Its platform will allow to improve the users' cognitive skill and individual well-being by playing on a mixed reality platform; on the other hand, it will offer the unusual experience of communicating with people located on other countries without the need to share the same language. After introducing the field of gerontology and the project, the paper describes the main cognitive abilities that change with aging (perception, attention, memory, and other more specific processes such as decision making), and that have to be taken into account while designing a technology for the elderly people. Some guidelines that are specifically meant to ensure usability of these products are listed in the conclusions.
Full-text available
This paper presents a framework for the integration of motor learning research findings with a neurodevelopmental treatment perspective. The importance of activity-based intervention is emphasized, and a strategy for activity synthesis is presented. Clinical problems seen in persons with hemiplegia are used to clarify concepts and illustrate therapeutic interventions.
This paper offers an overview of recent game-based applications for therapy and rehabilitation of elderly people. Information and Communication Technologies represent a viable solution to meet the various physical and psychological needs of a population growing at an incredibly fast rate. In particular, videogames have proven to improve elderly people's cognitive abilities and take care of psychological problems accompanying illnesses and social isolation. We will present several examples of videogames adopted within training programs for elderly people, and tested through scientific procedures. We will include both old-fashioned games and recent ones. Characterized by a higher naturalness in the input system, the latter rely on already established usage practices with non-digital tools (a pen, a bowling ball, etc) that make the interface more accessible. Finally, we will describe a current European project that aligns with these efforts towards natural interfaces and aims at developing a mixed reality game for cognitive training and sociability of elderly users.
Cerebrovascular disease plays a paramount role in mortality and morbidity, and the clinical and basic sci entific study of acute stroke has blossomed, leading both to increased survival and to increasing numbers of people with disabilities from stroke. Neurobiological study of the chronic form of this prevalent neurological disease has lagged behind investigation of the acute illness. This article reviews how and why this situation will change. Four major points are addressed: 1) The anatomical organizations of functional brain systems are less topographically precise than commonly believed. 2) Cortical plasticity exists in adults and takes a number of forms, including unmasking of existing circuits, growth of new synapses via axonal sprouting or dendritic proliferation, and development of compensatory processes. 3) It is possible to manipulate this plasticity with behavioral and pharmacological interventions, and such manipulations can have a beneficial effect on recovery. 4) Functional neuroimaging, particularly the noninvasive method of fMRI, can be used to study in vivo both cerebral plasticity after stroke and the interventions that might influence recovery by affecting this plasticity. Although there is much to be accomplished, the prognosis is extremely good for a neuroscience of stroke rehabilitation. NEUROSCIENTIST 4:426-434, 1998
Abstract Based on previous ,research finding positive effects of video ,game ,use on the ,cognitive and neuro-motor skills of the elderly, researchers investigated the appeal and interest of video games among,this population. Four focus groups were conducted with a total of eleven participants between,the ages of 66 and 79 years of age. Participants were asked to play ,an assortment ,of video games while their reactions and responses were noted. The majority ofparticipants showed ahigh,degree of interest in technology. While appeal of the selected video games varied greatly
Conference Paper
This paper describes the development of a Virtual Reality (VR) based therapeutic training system aimed at encourage stroke patients with upper limb motor disorders to practice physical exercises. The system contains a series of physically-based VR games. Physically-based simulation provides realistic motion of virtual objects by modelling the behaviour of virtual objects and their responses to external force and torque based on physics laws. We present opportunities for applying physics simulation techniques in VR therapy and discuss their potential therapeutic benefits to motor rehabilitation. A framework for physically-based VR rehabilitation systems is described which consists of functional tasks and game scenarios designed to encourage patients’ physical activity in highly motivating, physics-enriched virtual environments where factors such as gravity can be scaled to adapt to individual patient’s abilities and in-game performance.
Conference Paper
Task-oriented repetitive movements can improve motor recovery in patients with neurological or orthopaedic lesions. The application of robotics can serve to assist, enhance, evaluate, and document neurological and orthopaedic rehabilitation. ARMin is a new robot for arm therapy applicable to the training of activities of daily living in clinics. ARMin has a semiexoskeletal structure with six degrees of freedom, and is equipped with position and force sensors. The mechanical structure, the actuators and the sensors of the robot are optimized for patient-cooperative control strategies based on impedance and admittance architectures. This paper describes the mechanical structure, the control system, the sensors and actuators, safety aspects and results of a first pilot study with hemiplegic and spinal cord injured subjects
We used serial positron emission tomography (PET) to study training-induced brain plasticity after severe hemiparetic stroke. Ten patients were randomized to either task-oriented arm training or to a control group and scanned before and after 22.6 +/- 1.6 days of treatment using passive movements as an activation paradigm. Increases of regional cerebral blood flow (rCBF) were assessed using statistical parametric mapping (SPM99). Before treatment, all stroke patients revealed bilateral activation of the inferior parietal cortex (IPC). After task-oriented arm training, activation was found bilaterally in IPC and premotor cortex, but also in the contralateral sensorimotor cortex (SMC). The control group only showed weak activation of the ipsilateral IPC. After treatment, the training group revealed relatively more activation bilaterally in IPC, premotor areas, and in the contralateral SMC. Five normal subjects showed no statistical significant differences between two separate PET studies. In this group of patients, task-oriented arm training induced functional brain reorganization in bilateral sensory and motor systems.