➣ By Kanav Kahol et al.
Integrative Therapy: Combining Different Modalities to Offer Comprehensive Rehabilitation
Traditionally, rehabilitation therapy has been based on a deconstructionist approach wherein complex activities in daily life have been divided into simpler units of activities. This division process allows therapists to focus on individual movements and activities, measure the progress of patients, and train the patients to perform these individual activities. This approach has been very successful in the past few decades and has been supported by third party payers. However, there is a lack of therapy that trains patients to combine these individual modular activities into complex activities. Patients are expected to naturally achieve this combination through self-practice. Yet lack of actual feedback on completed skills and the ability to link some of the complex activities, severely impedes patients’ motivation and may be an important reason for a decline in compliance.
Studies have consistently shown that most patients do not complete their therapy due to a lack of engagement and feedback [Task Force Traumatic Brain Injury 2007]. Research has shown that technology – such as Virtual Reality (VR) and imaging systems – has potential benefits to therapy and is an interesting and effective way of providing rehabilitation to people with aneurism. A significant amount of research has been devoted to employing off-the-shelf games and game units such as the Nintendo Wii® and the Sony EyeToy® in rehabilitation. Some researchers have even recognized the problems and frustrations that people with impaired motor skills face when trying to play a commercial game targeted for a nonimpaired audience; hence these scientists are developing customized games with a more suitable entry level. Examples of these games are the Rabbit Chase and the Arrow Attack games [Burke, 2008]. In most of these approaches, games have been employed to offer a motivational and persuasive environment for patients to practice skills that they traditionally practice in rehabilitation therapy.
We propose that gaming can actually offer a means of training patients on a combination of individual skills. Games such as Halo, God of War, etc., combine a variety of skills including both psychomotor and cognitive skills. Games that combine physical and cognitive exercises can actually be very effective in providing integrative therapy. This paradigm is shown in Figure 1. Our approach suggests viewing a given rehab exercise not only as a mechanical task-based skill, but an applied skill with both cognitive and psychomotor dimensions. There are several advantages to this approach of employing gaming and cybertherapy:
1. It fills a void in the therapy by offering an engaging means of providing integrative therapy.
2. It provides a means for patients to get a comprehensive score for a combination of activities. Unlike conventional approaches of gaming, wherein patients only receive a score per game or per activity, this paradigm can track the score of patients across different activities and generate a comprehensive score. This addresses a major concern of patients who may feel disillusioned at the end of a session in visualizing how the individual exercises they perform may help them in activities in daily living.
3. Gaming is ideal for offering integrative environments. Often in gaming, imperfect graphics, and sounds and vibrations can be combined to offer a realistic, immersive gaming experience. Games often contain stages that allow for testing different capabilities of a user. In a similar manner, gaming can be employed to allow users to combine different rehabilitation movements and progressively improve not only on individual rehabilitation activities but on combining them. A story-driven game can make the combination meaningful and seamless because it provides a context for the activities.
The patient wears movement sensors on legs, hands and head and is moved to cross-country skiing exercise unit. The patient is welcomed to an exercise driven towards increasing awareness of sustainability. In the first stage of the game, the patient skies to power an airplane that is carrying cans to the recycling plant nearby. The skiing offers physical therapy. To add the dimension of occupational therapy, the patient has to control the direction of the plane by moving his/her torso left or right to guide the plane. As the plane moves through the terrain, the patient gains virtual currency. When the patient reaches the factory (s)he opens the gates by repeating numbers that show randomly on the screen. This is integration of the digit span test. Inside the factory, the patient wears exercise bands and takes cans from the bag they brought on the plane and places them in receptacles that appear at different locations and heights. This exercise trains the patient’s upper and lower limbs as some receptacles appear near the legs. At the end of this stage the patient has to open the door to the next stage by performing a mental rotation task wherein shapes appear on the screen and have to be matched to their rotated counterpart. Once the new stage of the game is opened, the patient’s goal is to crush the collected aluminum cans to make a recycling bin or a metallic toy from the material. The patient physically stepping on a machine that virtually crushes the cans – while similarly using his/her hands to press the levers – actualizes this process. In this manner the patient goes through four stages that combine physical therapy, cognitive therapy, speech therapy, and occupational therapy.
Creation of an Integrative Therapy Unit
In order to create an integrative therapy unit, we employed a scientific design methodology shown in Figure 2. In order to identify the issues of integrative therapy and its adoption, we performed an ethnographic study composed of observations and shadowing in a rehabilitation institute. We interviewed several stake holders and identified several factors. Using these interviews as well as an understanding of the workflow and environment as a basis, we designed personas and scenarios that guide the design process. Personas are design tools that help product designers and engineers visualize the characteristics of their final users (in this case therapists and patients), and helps design user-centered products. Scenarios are tools that help the designer visualize different conditions under which the product will be employed. Together scenarios and personas help in the creation of the design space, which outlines the specifications that a product may have and helps make critical design decisions. Once the design choices are made, we validate the design by ensuring that our choices will be in agreement with interviewed users and designed personas and scenarios.
At the end of the iterative process of design validation and choices, a prototype design is created. Figure 3 shows the overall prototype design for our integrative therapy unit. In this design, a hexagonal central unit links a variety of exercise equipment together into a single unit. The choice of six units was arbitrary and could be as low as two units, to as high as required. A patient can start with any exercise equipment and then move in a counter clockwise or clockwise manner through the different exercises. LCD screens (46 inches full HD) give users visual feedback on their performance by providing a persuasive game scenario. In this prototype, every exercise can be visualized as a stage of a game where the story of the game links all the activities in a single cohesive unit. Sensors on the patient or exercise equipment help record movement and drive the games. An important design choice was that the transitions between exercises would actually provide an opportunity for cognitive therapy. As an example (see game scenario inset), a digit span test could be performed when shifting from one exercise station to another. This allows for seamless integration of the different types of therapy (see Figure 1) in a single unit. This system is analogous to circuit training, but with persuasive elements to encourage exercises and measure cross-platform and cross-therapy proficiency of the patient.
A user-centered, integrative gaming therapy system design is proposed. The system addresses a void in modern-day therapy by using games and Virtual Reality as a basis to provide a means to offer comprehensive rehabilitation training environments. Initial results of the prototype have been very encouraging. While the system will require extensive testing, the provided design and concept has significant merit and may provide a novel research direction for gaming and rehabilitation.
Kanav Kahol, Ph.D.
Camilla Nørgaard Jensen
Arizona State University
Marshall L. Smith
Suzanne Dilli, M.S., P.T.
Kelly Johnson, P.T.
Banner Good Samaritan
President of Virtual Reality Medical Institute (VRMI) in Brussels, Belgium. Executive VP Virtual Reality Medical Center (VRMC), based in San Diego and Los Angeles, California. CEO of Interactive Media Institute a 501c3 non-profit Clinical Instructor in Department of Psychiatry at UCSD Founder of CyberPsychology, CyberTherapy, & Social Networking Conference Visiting Professor at Catholic University Milan.