and rehabilitation technologies in use
How MossRehab and Moss Rehabilitation Research Institute (MRRI) are using Therapeutic Gaming and technology to Improve Recovery after neurological injuries
Laurel J. Buxbaum, Dylan J. Edwards and Amanda Rabinowitz
Rehabilitation is critical after a stroke or brain injury to improve an individual’s chances of regaining functional and cognitive abilities. Studies show that intensive therapy with highly repetitive and task-oriented practices offers the most benefits after neurological injuries. “After a stroke or brain injury, the neural pathways involved with the brain are interrupted,” explains Amanda Rabinowitz, PhD, institute scientist and director of the Brain Injury Neuropsychology Laboratory at the Moss Rehabilitation Research Institute (MRRI).
„Repetitive therapy exercises help to strengthen that pathway in the brain or develop a new one to restore function."
Maintaining patient interest and enthusiasm in traditional therapies over time is difficult. While therapists help engage patients in exercises, individuals often lose their drive in completing the same routines repeatedly. Therapeutic gaming provides the stimuli to keep patients engaged in rehab exercises with therapy equipment that features computer-based and/or virtual reality images. In addition, gaming therapy helps individuals to understand and visualize exercise goals.
“If somebody is working on their arms with a reaching exercise, therapy equipment with gamification can project an image, such as a fruit, to frame how to retrieve it,” Dr. Rabinowitz states. “Using this type of visualization helps patients to master the right movement for more natural motions. It would be hard to duplicate that motion by following a worksheet that outlines the exercise.” Therapeutic gaming also provides immediate, robust feedback. Flashing lights and sounds triggered when a patient makes the correct movement encourages them to keep going. At the same time, therapists get information on patient progress to determine if they should level up or move to another activity
Therapeutic gaming at MossRehab
MossRehab has more than 25 robotic devices that clinicians can use for rehabilitation inpatient and outpatient rehabilitation. Many feature gamification. The diversity of MossRehab’s equipment enables therapists to concentrate on various body functions and patients with different capacity levels.
For example, Armeo Therapy robots support different levels of arm rehabilitation. Other robots that focus on the upper limb include the Amadeo for hand-finger rehabilitation and the Diego for training arm-shoulder. These devices have interactive games.
“I used the therapy devices with a youngster diagnosed with acute flaccid myelitis that caused difficulties with finger extension. Through therapeutic games the patient seemed to view therapy as less of a chore and more of a video game,” says Casey McKee, OTR/L, who treats patients at MossRehab Elkins Park. Most of her patients have neurological deficits caused by stroke, traumatic brain injuries, multiple sclerosis, and Parkinson’s Disease that require occupational therapy to overcome impairments that limit their ability to complete everyday tasks. “This patient benefitted from the engagement prompted by the high-repetition movement patterns experienced in the various games. I am not certain he would have tolerated such repetitions if not motivated through therapeutic gaming.”
The Myro is another therapeutic technology with gamification features for upper extremity rehabilitation available at MossRehab. The Myro offers a sensor-based surface much like a large touch screen computer, with force control and tactile applications.
“I use this extensively in occupational therapy to improve arm range of motion and cognitive skills,” remarks Stephanie Farm, MS, OTR/L, who works with adult and pediatric persons with brain injuries and serves as the occupational therapy team leader at the MossRehab Drucker Brain Injury Center. “The Myro has various fine motor attachments so patients can use a joystick to work on gross grasp skills, a pencil for writing activities, or a piece to promote grasp. Cognitive games also prompt patients to scan the screen and identify items that don’t belong or find missing components or use colors to complete a sequence.”
Gaming therapy for gait rehabilitation
MossRehab is the only rehab facility with two Lokomat devices, a THERA-Trainer lyra and a G-EO at one site that offers robot-assisted gait therapy for patients who experienced neurological injuries. For the Lokomat, the patient is supported by a harness above the treadmill, while an exoskeleton assists the legs to improve walking. Various game-like exercises help patients to meet their goals. MossRehab also recently added the C-Mill, a high-tech treadmill that features a large LCD screen and an overhead projector for gait rehabilitation. The C-Mill device offers augmented and virtual reality games that replicate real-life activities to prepare patients for the outside world.
“One application requires a patient standing at an intersection of two crossing roads to lift their leg if a car approaches from the right or left to avoid it,” says Matthew Vnenchak, PT, MS, NCS. “The hightech treadmill gives visual and auditory feedback if a patient successfully or unsuccessfully completes the task for immediate feedback and reinforcement.”
Researching the future
MossRehab continues to evaluate new technologies and conduct research to develop new therapeutic gaming technology. One study led by Dylan Edwards, PhD, Director of MRRI and the Human Motor Recovery Laboratory, is testing a new therapeutic gaming system for motor recovery after a stroke that uses immersive digital gaming to create an environment in which patients control a dolphin swimming through the water. The engaging exercises will help people with impaired arm function to improve their recovery.
Another study using virtual reality gamification focuses on reducing phantom limb pain. Laurel Buxbaum, PsyD, Associate Director of MRRI and Director of the Cognition and Action Laboratory, is working on a virtual reality treatment based on the theory of providing alternative feedback to the brain in the form of a visual image of a missing limb to eliminate a sensory mismatch to reduce pain.
Wearing a VR headset, patients with limb amputations will perform a series of activities such as scooting around a maze on a virtual chair while kicking down barricades and typing on a virtual keyboard with the legs to surf the Internet. The VR system fills in an image of the missing limb so that amputees see themselves complete. “Visualizing and moving limbs simultaneously provides a corrective signal to the brain that reduces phantom limb pain,” explains Dr. Buxbaum.
Creating VR patient assessments
Dr. Bauxbaum also developed a Virtual Reality Lateralized Attention Test (VR-LAT) that assesses the severity of a stroke on attention, visual search, and multi-tasking. Typically, pencil and paper tests diagnose this problem where patients bisect lines or cross out specific items in a listing. However, these tests are not sensitive enough to detect subtle deficits and are not strong predictors of performance in the real world.
„There is a great deal of technology available to assist with patient mobilization in a way that is safer for both the patient and clinician. One of the challenges with technology is how to keep the patient engaged for the entire time the equipment is being utilized to allow for increased intensity and frequency of use. The THERA-soft software used in conjunction with the Balo makes it fun and interesting for patients when we are working on dynamic standing balance tasks. THERA-soft can be tailored to the patient‘s specific needs so they can easily appreciate gains being made“
Naomi Greenberg, DPT, ATP, FSOAE, PT Team Leader, Spinal Cord Injury and Acute Care Units, MossRehab
The VR-LAT creates a virtual environment where individuals travel a path while naming trees and statues of animals and ignoring auditory distractions. Using test results, clinicians can assess spatial neglect and the disposition to visual and auditory distraction to determine patient safety in navigating environments. The assessment also provides a baseline measurement for therapy.
The Virtual Reality Non-Use Test (VR-NU) is another assessment tool developed by Dr. Bauxbaum team that uses gaming theory to evaluate arm function after a stroke. Wearing a VR headmounted display equipped with headphones and motion tracking sensors affixed to the wrists, patients reach for objects on different virtual shelves. The VR-NU test tracks accuracy, trajectory, response time in the completion of tasks under different conditions. The ten-minute assessment tool will help clinicians determine the severity of arm limitations after stroke.
Home-based therapy devices help those having transportation or resource challenges or needing to supplement outpatient rehabilitation. That’s the premise behind a portable gaming console for homes use that assists patients in recovering upper extremity functions after a stroke. Dr. Edwards was a principal investigator for a pivotal trial of the home-based therapy equipment that features arcade like computer-based and cognitive games.
Dr. Rabinowitz is working with a Rehabilitation Engineering Resource Center (RERC) on developing mobile rehabilitation interventions and therapies for home-based use in persons with TBI. Currently, she is leading the development of a chatbot for personalized interactions with patients to track activities, plans, and goals between therapy sessions, all via text message. Designed to support outpatient brain injury treatment, the chatbot provides encouraging messages, activity updates, and other feedback to help patients meet therapy goals.
Another research program is evaluating feedback received from sensor-based neurorehabilitation devices offered by FlintRehab to determine how people use different gamification features during therapy. Findings will enable developers to design more effective and engaging applications. In addition, Dr. Rabinowitz is working to integrate homebased rehab devices (one is a sensorized glove worn while performing hand and finger exercises to music) with an application called PT Pal to create a platform that collects data and identifies trends to monitor and track patient progress between clinical visits.
With the help of MRRI researchers, MossRehab remains on the pulse of therapeutic gaming in research and developing new innovative technologies for both clinical and home-based use. Our goal is to provide patients and therapists with the best tools and clinical programs to boost the effectiveness of rehabilitation in achieving long-term recovery goals.
For more information using robotics-assisted rehabilitation solutions to assess and treat neurological deficits, visit www.mossrehab.com/technology.
Photo credits: Tübingen University Hospital/Tobias Wuntke
Laurel J. Buxbaum, PsyD, is Associate Director of the Moss Rehabilitation Research Institute (MRRI) in Elkins Park, PA, Director of MRRI’s Cognition and Action Laboratory, and Professor of Rehabilitation Medicine at Thomas Jefferson University in Philadelphia. She has authored more than 100 peer-reviewed articles and book chapters, and has served as Associate Editor of the scientific journals Cognition, Cortex, and Journal of Neuropsychology. She has received grant funding from the National Institute of Health, National Institute of Disability and Rehabilitation Research, and the James S. McDonnell Foundation. Dr. Buxbaum is the recipient of numerous professional awards, including the International Neuropsychological Society’s Arthur Benton Mid-Career Award, the Widener University Graduate Award for Excellence in Professional Psychology, the American Society of Neurorehabilitation’s Viste Award, and the British Neuropsychological Society’s Freda Newcombe Prize. Her laboratory focuses on understanding how complex skilled action is represented in the brain, how action representations influence manipulable object knowledge, relationships between action and language processing, spatial neglect, and phantom limb phenomena in persons with amputation. Her work spans a translational “pipeline” from basic cognitive neuroscience to neurorehabilitation.
Dylan J. Edwards, PhD, is Director of the Moss Rehabilitation Research Institute (MRRI) and Director of MRRI’s Human Motor Recovery Laboratory which aims to understand the basis of motor symptoms and motor recovery in order to inform and develop rehabilitation treatment strategies. He is also Professor of Neuroscience and Director of the NeuroRehabilitation and Robotics Laboratory at Edith Cowan University which has several lines of research addressing recovery of functional movement in humans following neurological damage caused by stroke, spinal cord injury, or other neurological conditions. He was awarded his PhD in clinical neurophysiology from the Centre for Neuromuscular and Neurological Disorders at the University of Western Australia (now the Perron Institute for Neurological and Translational Sciences). Before coming to MRRI in 2018, Dr. Edwards served as Director of the Non-Invasive Brain Stimulation Laboratory at Burke Neurological Institute, and he was Associate Professor of Clinical Neurophysiology at Weill Cornell Medicine in New York. While in New York, he led a long-standing collaboration between Harvard Medical School and Massachusetts Institute of Technology in Boston, as well as Burke-Cornell Neurological Institute in New York, to bridge engineering, neurology, and rehabilitation medicine. This cross disciplinary collaboration led to over a decade of extramural funding in studies of human motor recovery. Dr. Edwards is recognized internationally as a leader in the field of Neurorehabilitation, and his work has resulted in scientific advancements in rehabilitation outcome predictors, non-invasive brain stimulation techniques, and rehabilitation robotics, in method as well as application.
Amanda Rabinowitz, , PhD, is an Institute Scientist and Director of the Brain Injury Neuropsychology Laboratory at the Moss Rehabilitation Research Institute (MRRI), as well as a Research Assistant Professor of Rehabilitation Medicine at Thomas Jefferson University. In addition, Dr. Rabinowitz leads the Moss Traumatic Brain Injury (TBI) Model System, a world class center of excellence providing state-of-the-art research, innovative treatment, and valuable programs for people with Traumatic Brain Injury which has been continuously funded since 1997. Dr. Rabinowitz is a clinical neuropsychologist, and her research examines chronic brain injury outcomes across the spectrum of TBI severity. In particular, Dr. Rabinowitz’s work focuses on the psychosocial factors that confer resilience after brain injury, with an interest in self-regulation as a key mechanism. A number of Dr. Rabinowitz’s projects leverage mobile technology to augment brain injury assessment and intervention. She works with local and national collaborators on studies of long term brain injury outcomes. Dr. Rabinowitz has authored or co-authored more than 100 publications in academic journals, and she is internationally regarded as an expert in TBI neuropsychology. Dr. Rabinowitz received her BA in Cognitive Neuroscience and Psychology from the University of Pennsylvania and her MS and PhD in Clinical Psychology from The Pennsylvania State University. During graduate school, she completed her Residency in Neuropsychology at the Warren Alpert Medical School of Brown University. Prior to establishing her research laboratory at MRRI, Dr. Rabinowitz completed a postdoctoral fellowship at the University of Pennsylvania.