An investigation into utilising a Therapeutic Exergame to improve the Rehabilitation Process

1. An investigation into utilising a Therapeutic Exergame to improve the Rehabilitation Process Sarah O'Neill M.Sc. – sloneill@wit.ie Dr. Patrick Felicia – pfelicia@wit.ie

2. Outline • Limitations • Games Applicability to Physiotherapy • Game Development Technologies • Game Design Approach • The Game Developed • Preliminary Study & Results

3. Background • Serious need to improve rehabilitation process for physiotherapy • Challenges impacting negatively on success rates and recovery times • Low Adherence • Detected – Modify Programme • Success – Dependent upon adherence • Adherence falters – Recovery could take longer or be unsuccessful

4. Background • Monitoring • Exercise Sheets • Common practice • Essential Intervention • Difficult to understand • Exercise Technique • Crucial exercise is accurate • Further Injury = Prolonged recovery time

5. Games Applicability to Physiotherapy • Gesture-based games • Natural Interaction • New realm – players are not sedentary • Feedback is more appropriate • Gaming is ubiquitous! • Gesture based consoles • Generational Acceptance • Opportunities for Serious Games

6. Games Applicability to Physiotherapy • Learning is more engaging • Innovative and playful  Increase motivation • Multi-sensory environments  Learning styles • Multimedia Elements • Exercise demonstrations • Correct technique

7. Games Applicability to Physiotherapy • Distraction • Pain management • Remove the idea of exercise or treatment • Drill and Practice • Skill and competence through repetition • Achieved easily through game elements

8. Game Development - Technologies Unity3D OpenNi • 3D & fast code execution • C++, C# & JavaScript • Open Source • Graphical User Interface • ZigFu • Open- Source Software Development Kit (SDK) • Integration with Unity3D • Platform Independence • Tracking System

9. Game Design Approach User Centered Design • Analysis Phase • Exercises to be incorporated • Exercise Repetitions • Design, Evaluation and Implementation Phases • Game Content • Storyboarding • Prototyping • Deployment

10. The Game Developed

11. Preliminary Study • Single Session Study • Physiotherapy clinic in Waterford • Ten Participants • 20 – 55yrs old • Self-Determination Theory (SDT) • Study of human motivation and personality • Different types of motivation inspire human behaviour & exist on a continuum

12. Preliminary Study • Self-Determination Theory (SDT) • Intrinsic Motivation • Performing an activity for its own sake • Extrinsic Motivation • External Regulation • Positive incentives/Avoid negative consequences • Identified Regulation • Valuable / Chosen by oneself

13. Preliminary Study • Self-Determination Theory (SDT) • Amotivation • Lack of intention to act • Situational Motivation • Motivation at a given point in time • SItuational Motivation Scale (SIMS) • 16 Item adaptable self report questionnaire

14. Overall Motivation - SDI ScoresSDI formula: (2 * IM + 1 * IR) – (1 * ER + 2 * A)

15. Different Types of Motivation

16. Exercise Technique • 8 Participants – Accurate • 2 Participants – Inaccurate • 2 Participants had used the Microsoft Kinect before • Game Scores - Successfully completed games with high scores

17. Thank you for listening I will be happy to answer any questions you may have

18. References Baranowski, T., Baranowski, J., Cullen, K.W. (2003) ‘ Squire’s Quest! dietary outcome evaluation of a multimedia game’. Am J Prev Med. 24(1), pp. 52-61. Baranowski, T., Buday, R., Thompson, D.I., Baranowski, J. (2008) ‘Playing for Real Video Games and Stories for Health-Related Behavior Change’. Am J Prev Med. 34(1) pp. 74–82. Baranowski T, Lin LS, Wetter DW, Resnicow K, Hearn MD. Theory as mediating variables: Why aren’t community interventions working as desired? Annals of Epidemiology 1997;S7:S89–S95. Bee, H. and Boyd, D. (2006) The Developing Child. Pearson, Boston. Birch, A., Malim, T. (1998) Introductory Psychology. Palgrave, Hampshie. Burdea, G. C., Tamar Weiss, P. L., Thalmann, D. (2007) ‘Guest Editorial Special Theme on Virtual Rehabilitation’, Neural Systems and Rehabilitation Engineering, IEEE Transactions on , 15(1), pp. 1. Institute of Electrical and Electronics Engineers [Online] Available at: http://ieeexplore.ieee.org.ezproxy.wit.ie:2048/stamp/stamp.jsp?tp=&arnumber=4126534&isnumber=4126524 (Accessed 21 December 2011). Codori A-M, Nannis E D and Pack A D (1992): The development of a clinical measure of compliance with hand rehabilitation. Journal of Hand Therapy 5: 29-33. Csikszentmihalyi M. (1990) Flow: The Psychology of Optimal Experience. New York: Harper & Row. de Freitas, S., Levene, M. (2004) ‘An investigation of the use of simulations and video gaming for supporting exploratory learning and developing higher-order cognitive skills’ IADIS International Conference in Cognition and Exploratory Learning in the Digital Age. Lisbon: Portugal. de Freitas, S., Jarvis, S. (2007) 'Serious games - engaging training solutions: A research and development project for supporting training needs’. British Journal of Educational Technology. 38(3), pp. 523-525. Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior.New York: Plenum. Deci, E. L., & Ryan, R. M. (1991). A motivational approach to self: Integration in personality. In R. Dienstbier (Ed.), Nebraska Symposium on motivation: vol. 38. Perspectives on motivation. (p. 237–288). Lincoln: University of Nebraska press. Doyle, J., Kelly, D., Caulfield, B. (2011) ‘Design considerations in therapeutic exergaming’. Pervasive Computing Technologies for Healthcare (PervasiveHealth), 2011 5th International Conference on. pp. 389-393 Institute of Electrical and Electronics Engineers [Online] Available at: http://ieeexplore.ieee.org.ezproxy.wit.ie:2048/stamp/stamp.jsp?tp=&arnumber=6038836&isnumber=6038756 (Accessed: 14 December 2011). Doyle, J., Kelly, D., Patterson, M., Caulfield, B. (2011) ‘The effects of visual feedback in therapeutic exergaming on motor task accuracy’ Virtual Rehabilitation (ICVR), 2011 International Conference on. pp. 1-5. Institute of Electrical and Electronics Engineers [Online] Available at: http://ieeexplore.ieee.org.ezproxy.wit.ie:2048/stamp/stamp.jsp?tp=&arnumber=5971821&isnumber=5971805 (Accessed: 14 December 2011).

19. References Encarnação, M 2010, 'Beauty and the Beast -- Serious Games in Healthcare', International Journal Of Computer Science In Sport, 9, 2, pp. 27-39, SPORTDiscus with Full Text, EBSCOhost, viewed 21 December 2011. Gee, J. (2003). What video games have to teach us about learning and literacy. New York: Palgrave-Macmillan. Guay, F., Vallerand, R. J., Blanchard, C.. (2000). ‘On the Assessment of Situational Intrinsic and Extrinsic Motivation: The Situational Motivation Scale’, Motivation and Emotion. 24 (3), p. 175 - 210. Hofstetter, F. (1995) Multimedia literacy. New York: McGraw- Hill Johnson, L., Smith, R.., Willis, H., Levine, A., and Haywood, K., (2011). The 2011 Horizon Report Austin, Texas: The New Media Consortium. Jones, D.C. (2006) ‘Scavenger Hunt Enhances Students' Utilization of Blackboard’ MERLOT Journal of Online Learning and Teaching. 2(2), pp. 86-99. Keen, P. (1997) Business Multimedia Explained: A managers guide to key terms and concepts. America: Harvard Business School Press. Koster, R. (2004) A Theory of Fun for Game Design. United States:Paraglyph Press Laikari, A. (2009) ‘Exergaming - Gaming for health: A bridge between real world and virtual communities’, Consumer Electronics, IEEE 13th International Symposium. pp. 665-668. Institute of Electrical and Electronics Engineers [Online] Available at: http://ieeexplore.ieee.org.ezproxy.wit.ie:2048/stamp/stamp.jsp?tp=&arnumber=5157004&isnumber=5156791 (Accessed: 14 December 2011). Ley P, Bradshaw PW, Eaves DE, Walker, CM 1973 A method for increasing patients’ recall of information presented by doctors. Psychological Medicine 3: 217-220. Lieberman, D. (1997). Interactive Video Games for Health Promotion: Effects on Knowledge, Self-Efficacy, Social Support and Health. In R. L. Street, W. R. Gold, & T. R. Manning (Eds.), Health promotion and interactive technology (pp. 103-119). Mahwah, NJ: Lawrence Erlbaum Associates. Mitchell, A., Savill-Smith, C. (2001) ‘The Use of Computer and Video Games for Learning’. A Review of the Literature, Learning and Skills Development Agency. O'Huiginn, B., Smyth, B., Coughlan, G., Fitzgerald, D., Caulfield, B. (2009) ‘Therapeutic Exergaming’ Wearable and Implantable Body Sensor Networks, 2009. BSN 2009. Sixth International Workshop on. pp.273-277. Institute of Electrical and Electronics Engineers [Online] Available at: http://ieeexplore.ieee.org.ezproxy.wit.ie:2048/stamp/stamp.jsp?tp=&arnumber=5226878&isnumber=5226857 (Accessed: 14 December 2011). Park, D.C., Willis, S.L., Morrow, D., Diehl, M., Gaines, CL. (1994) ‘Cognitive function and medication usage in older adults’. Journal of Applied Gerontology. 13, pp. 39-57. Prensky, M. (2001). Digital-game-based learning. New York and London: McGraw Hill.

20. References Rastall, M., Brooks, B., Klarneta, M., Moylan, N., McCloud, W., Tracey, S. (1999) ‘An investigation into younger and older adults’ memory for physiotherapy exercises’. Physiotherapy. 85, pp. 122-128. Ryan R, Rigby C, Przybylski A. (2006) ‘The motivational pull of videogames: a self-determination theory approach’. Motivation and Emotion. pp. 347–63. Shaffer, D.W., Squire, K.D., Halverson, R. and Gee, J.P. (2005) ‘Video Games and the Future of Learning’. Phi Delta Kappan. 87(2), pp. 104-111. Smith, E. Nolen-Hoeksema, S. Fredrickson, B and Loftus, G. (2003) Atkinson & Hilgard’s Introduction to Psychology. 14th Edition. Wadsworth, Belmont. Smith, J, Lewis, J, & Prichard, D 2005, 'Physiotherapy exercise programmes: Are instructional exercise sheets effective?', Physiotherapy Theory & Practice, 21, 2, pp. 93-102, Academic Search Complete, EBSCOhost, viewed 18 December 2011. Tang, S., Hanneghan, M. (2010) ‘A Model-Driven Framework to Support Development of Serious Games for Game-based Learning’. Developments in E-systems Engineering (DESE). pp.95-100. Institute of Electrical and Electronics Engineers [Online] Available at: http://ieeexplore.ieee.org.ezproxy.wit.ie:2048/stamp/stamp.jsp?tp=&arnumber=5633373&isnumber=5629955 (Accessed: 20 November 2011). Taylor, N.F., Dodd, K.J., Shields, N., Bruder, A. (2007) ‘Therapeutic exercise in physiotherapy is beneficial: a summary of systematic reviews 2002- 2005’ Australian Journal of Physiotherapy. 53, pp. 7-16. Thompson, D. Baranowski, T., Buday, R., Baranowski, J., Thompson, V., Jago, R., Griffith, M.J. (2010) ‘Serious Video Games for Health: How Behavioral Science Guided the Development of a Serious Video Game’ Simulation & Gaming. 41(4), pp. 587–606. Vallerand, R. J. (1997). Toward a hierarchical model of intrinsic and extrinsic motivation. In M. P. Zanna (Ed.), Advances in experimental social psychology (pp. 271–360). New York: Academic Press. Vredenburg, K., Isensee, S. and Righi, C. (2002) User-Centered Design – An Integrated Approach. New Jersey: Prentice Hall. Web Accessibility Initiative. (1994-2006) Notes on User Centered Design Process (UCD). [Online] Available at: http://www.w3.org/WAI/redesign/ucd (Accessed 14 January 2012). Yusoff, A., Crowder, R., Gilbert, L., Wills, G. (2009) ‘A Conceptual Framework for Serious Games’ Advanced Learning Technologies, 2009. ICALT 2009. Ninth IEEE International Conference on. pp. 21-23. Institute of Electrical and Electronics Engineers [Online] Available at: http://ieeexplore.ieee.org.ezproxy.wit.ie:2048/stamp/stamp.jsp?tp=&arnumber=5194153&isnumber=5194138 (Acessed: 14 December 2011).