Game for health

The Straits Times (3 November 2011) - More hospitals are making use of virtual reality games to complement conventional therapy for patients

Many helping hands are needed to get stroke patients on the road to recovery.

And some of them are coming from tertiary students or engineers working with hospitals to design computer games that patients can practise on to regain their movement.

A handful of projects are on the boil to cook up solutions for rehabilitation that are inexpensive, useful and fun.

For instance, stroke patients often have upper arm weakness that can be strengthened by exercise that moves the arms sideways.

So some Temasek Polytechnic information technology students wrote a program for the Kinect, that requires patients to move a spaceship from side to side on a screen to avoid being hit by asteroids. The Kinect is a motion-sensing device for the Microsoft Xbox 360 video game console.

The students approached five rehabilitation centres earlier this year to see if they could design software to help patients with similar needs. They even tweaked the game so the spaceship would not respond if patients moved their bodies or legs instead of their arms to manoeuvre it.

The project took top prize in a competition and the students plan to hold clinical trials with hospitals this year to test the program out.

It is just the beginning but rehab doctors and therapists see potential in harnessing the technology of user-controlled consoles for therapeutic purposes.

Singapore Polytechnic students have also worked with hospitals such as the National University Hospital (NUH) and KK Women's and Children's Hospital (KKH) to develop therapeutic game software.

With NUH, the poly students customised a Nintendo Wii game to incorporate useful arm movements for stroke patients - such as flipping burger patties on a barbecue grill - to improve their hand and wrist movements. The Wii is a motion-sensing device which comes with a controller.

The Singapore General Hospital (SGH) is also working with an engineering company to develop a software which will train stroke patients to use their affected arm to pick up fruit in a virtual supermarket. They do this while they are standing, to also train their balance and endurance.

To a layman, using computer games for rehab might sound frivolous, but therapists say there are many advantages in using them for therapy.

Unlike traditional computer games played with a mouse, these motion-sensing consoles require players to move their bodies to mimic real-life movements.

There are few side effects to playing the games and they bring an element of entertainment, which has an impact on compliance and recovery rates.

Indeed, the fun and appeal of such games in rehabilitation cannot be ignored, said the authors of a study by Tan Tock Seng Hospital (TTSH) published in the Journal Of Rehabilitation Medicine last year. 

The study found that patients who used a combination of the Wii and conventional therapy appeared to recover faster, but the finding was limited in that the authors were not able to compare these patients with those on conventional therapy alone.

What was significant was how stroke patients had an 'overwhelming positive' experience from the use of the Wii, with about 75 per cent, or 12 out of 16, finding the Wii to be subjectively as useful as, if not better, than conventional rehabilitation.

Almost 88 per cent wanted to continue using the Wii as part of their rehabilitation.

These findings were all the more impressive as most of the patients had never played a computer game before, said the authors.

The main side effect of the virtual games? Temporary muscle soreness - no worse than that from conventional therapy, said Mr Donald Xu Tong, one of the study authors and a senior occupational therapist from TTSH. 

Even before the software could be customised, hospitals had been using commercial games to help patients with stroke or other neurological movement disorders.


SGH uses a webcam-based program called Ovogame, while Changi General Hospital and TTSH use the Wii or Kinect.

As the games are fun and interactive, patients find it easy to concentrate on them, said Dr Karen Chua, a senior consultant from TTSH rehabilitation centre. They can also receive immediate feedback on their progress. 

The consoles are also relatively cheap, with the Wii costing about $200 and the Kinect about $229. The Ovogame is just $20.

The hospitals stressed that such games complement, and do not replace, conventional therapy.

There are certain movements that cannot be translated completely from the virtual world to the real one, said Ms Natalie Chew, a senior principal occupational therapist from SGH.

For example, a patient who has used virtual games to practise finger movements may not necessarily know how to do up buttons. To learn that, he needs to practise on real buttons, she said.

Studies on the use of virtual games for physiotherapy so far have been small and lack long-term follow-up, according to a review of 19 trials involving 565 stroke patients published by the non-profit Cochrane Collaboration.

But therapists believe it is only a matter of time before it is accepted.

Ms Ong Ghim Hui, a senior physiotherapist from KKH, feels the limited evidence on the efficacy of virtual games in rehabilitation so far could be due to their recent introduction.

The hospital has been using Wii for its paediatric patients with balance and body awareness problems only since 2009.

Said Ms Ong: 'Wii adds variety to the children's therapy sessions. It encourages them to pay attention and comply with therapy.'

The only thing that one needs to be aware of is the fact that frequent and intensive gaming can lead to repetitive strain-induced injuries such as 'Wii-shoulder or Wii-elbow'.

However, for one 44-year-old patient who is recovering from a brain haemorrhage, these concerns are far from her mind.

She said: 'I have never liked to exercise. Without these games, I wouldn't have found my therapy sessions so positive.' 

Games arcade at hospital for therapy

Even stroke patients who have lost the use of their arms and legs can benefit from exercise, and robots are helping them with it.

While patients are working their physical bodies, they also get mental stimulation from the virtual reality games that come with the robots.

The newly opened 3,000 sq ft Centre for Advanced Rehabilitation Therapeutics (Cart) at Tan Tock Seng Hospital is the first centre in the region to combine robotics and virtual reality with rehabilitation given by trained doctors and therapists, said the centre's senior consultant, Dr Karen Chua. 

The main aim is to use innovative technology to maximise patients' performance and help them recover faster, she said.

To train patients with walking difficulties, the centre uses a pair of robotic leg braces called Lokomat, developed by Hocoma, a Swiss medical technology company.

The patient is suspended in a safety harness while robotic leg braces help him to move his legs in a pre-programmed normal walking pattern on a treadmill. As the patient gets stronger, the robot can be programmed to deliver less guidance force, so that the patient has to work harder to move his own legs.

The advantage of the Lokomat is that it can offer patients intensive individualised training so they get better faster, said principal physiotherapist Wee Seng Kwee. 

Patients can practise at least 1,000 steps in half an hour on the Lokomat, the minimum number of steps needed to stimulate the brain to make new connections so that the limbs can move again. In contrast, patients may practise just 100 steps in the same amount of time with the help of a physiotherapist, before both therapist and patient are exhausted.

Normally, patients who undergo daily rehabilitation may take their first steps with a walking aid only after four to five weeks. The Lokomat can reduce the time to just three weeks.

It is especially useful for severely disabled or heavy patients, who would otherwise not be able to walk at all, said Mr Wee.

Research shows that such patients tend to recover faster on the Lokomat compared to those who are not so severely disabled.

Without the Lokomat, at least three therapists may be needed to work with such patients. With the robot, only one therapist is needed to operate the machine and customise the training parameters.

The patient can see his own movements through an avatar of himself on a computer screen. He can play games or practise changing direction and speed.

Said Mr Wee: 'Many patients find the games fun and motivating. This makes them more engaged in the walking practice and improves their attention and concentration.'

But because the patient is supported by the safety harness on the Lokomat, he is unable to re-learn his sense of balance or experience walking on different terrains. Hence, robotic and virtual reality therapy have to be combined with conventional therapy, such as balance training and walking on different terrains, for a better outcome, said Mr Wee.

Besides the Lokomat, the centre also uses two robotic arm braces from Hokoma. The Armeo Spring trains patients with moderate arm power and the Armeo Boom helps patients who are stronger.

In both, a robotic arm brace is strapped around the patient's weak arm while his fingers hold a controller. With the arm brace bearing part of his arm's weight, he can move his upper limb to shoot virtual flying chickens or pick apples off supermarket shelves on the computer screen in front of him.

Each robot is estimated to cost a six-figure sum.

The only side effects so far reported in using the robots are superficial skin abrasions. In Lokomat, this can be caused by friction between the leg braces and the body, but it happens in fewer than four out of every 100 patients, said Mr Wee.

Dr Chua added that the robots are not recommended for patients with severe osteoporosis or 'brittle bones', as they could cause fractures from the repetitive movements.

The new centre is used for patients with stroke, head injury or other movement dysfunctions.

Aside from therapies combining robotics and virtual reality, the centre also uses other types of virtual reality programs played through the Wii, Kinect and PlayStation game consoles.

To challenge patients further during therapy, TTSH therapists enhanced the Wii sword and archery games by making their own sword and bow and strapped each weapon onto the controller. This is to motivate patients to swing their weapons harder during the sessions.

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Source: The Straits Times © Singapore Press Holdings Limited. Reproduced with permission.