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Neuro rehab technology

Player power in neuro-rehab



The lightning speed of games technology development in recent decades has unearthed a multitude of opportunities in healthcare

Yet for all the headway made since 
the dawn of the home computing era, a gaping lack of knowledge about the true impact of games on the body and brain remains.

Behind the mind-blowing graphics, Hollywood soundtracks – and vast global games industry– a mystery exists; why do we, as humans, play games?

Answering this could quicken the drive to better harness game play in neuro-rehab, believes neural gaming expert and prominent global neuro-rehab figure Professor Volker Hömberg.

“There is a fascination with game play,” he says. “It’s the reason people go to football and like to gamble when they sit in the casino. I am not entirely certain that we fully understand this fascination.

“One aspect is that it is related to freedom. The basic difference between work and play
is that when you play, you are free. You are not embedded into some restraint system as you are in work. This is not sufficient to explain the real fascination which is attached to games, however.

“Children like to play and we provide them with toys; the question is why? One theory is that playing is an effortless type of activity that helps children to train their brains. It helps multisystem connections to be made, and so on.

“This early-infancy type of game playing is important for
brain maturation.”

Hömberg is director of neurology at Gesundheitszentrum Bad Wimpfen rehabilitation centre and senior neurology group leader for the SRH-Group, one of Germany’s biggest hospital operators.

He founded the German Society for Neurorehabilitation and is secretary general of the World Federation of Neurorehabilitation, among other international roles.

He has seen the power of gaming in neuro-rehab at close- hand, but also sees its flaws.

He says: “Fundamentally, games help to keep motivation up. They can also help to remodel patients’ motor or cognitive abilities. Due to enormous progress in technology, they are also relatively cheap and available.”

Clearly, motivating patients perhaps still coming to terms with a life-changing injury, often with the added burden of neural fatigue, is crucial in neuro-rehab.

“We have learned over the years that the more intensively we treat patients, the better the outcomes will be. To do so you must keep motivation up.

“But if you do too much, motivation may eventually
drop and you must avoid what, in neurobiology, is called habituation. This occurs when the response of the nervous system to particular stimuli melts away if you repeat them too often. Effectively, things become boring and the system shuts down.”

Professionals using gaming in rehab must be careful to avoid this situation by ensuring games are challenging, fun, competitive or all three, says Hömberg.

A bigger challenge facing the neuro-rehab field in general is establishing exactly which types of gaming can have the biggest positive impact on individual patients.

Over the centuries various philosophers and theorists have sought to identify the essence of games and why they so stimulate us.

Hömberg identifies six main types of play that each have potential benefits to the human mind.

They cover pure playful fun (in the sense of a leisure activity or child’s play), combat or competitive play, gambling, performing in-front of an audience through mimicry or imitation, play that incites a state of ecstasy and spectacle – watching sport or a show, for example.

The power of competitive play in helping people in rehab is of particular interest to Hömberg.

He is currently involved in a study measuring the effect of competition on
stroke patients.
“We are aiming to find out whether competition is an
 extra element that can speed up improvement in rehab.

“Patients with moderate or mild motor problems in the upper extremities, often play games against robots who
are connected to computers or so ware.

“We took this one step forward and asked what would happen if the patients played against each other in a competitive way. Within a year we’ll be able to analyse the data but it is looking like this approach could be really helpful in keeping motivation up and improving patients.”

Evidence linking video games with speedier rehabilitation has grown rapidly in recent years.

‘Active’ video games sold in the commercial mainstream, have shown mixed results 
in terms of boosting general fitness.

They may have more tangible benefits in rehab, however. A 2013 study by US university Central Michigan found that playing such games improved coordination in people with traumatic brain injury (TBI).

Patients who participated in a Microsoft Xbox Kinect-supported virtual therapy session had significantly improved balance, gait, and functional reach scores from baseline.

Video games may be particularly beneficial to children with brain injuries, meanwhile.

A clinical trial earlier this year found that cognitive training game Project: EVO was able
to eradicate sensory processing disorder in children with brain injuries, albeit in a minority of cases.

A third of the 
57 brain injured children no longer met the criteria for the disorder, which affects how the brain receives and responds to sensorial data.

Technology developer Akili Interactive Labs tested children playing the game over a four-week period and is now investigating its potential application in ADHD cases.

Furthermore, Australia’s Macquarie University recently found evidence that first-person shooter games such as the popular Medal of Honour franchise, can help in TBI rehab.

In a pilot study, brain injured participants were trained in how to play the game, learning skills and strategies to help overcome specific challenges within it.

As well as getting better at blasting baddies and completing levels, the trialists were able to complete some everyday tasks faster and more successfully than a control group.

The fact that the study was based on a relatively cheap and commercially available console and game gives the findings obvious appeal.

The overall consensus is that video games can indeed have a direct impact on the brain – even if scientists don’t quite know why.

A report published this year in the neuroscience journal Frontiers collated 116 studies into how video games affect brain structure and activity.

Lead author Marc Palaus summarised that video games can improve several types of attention, including sustained and selective.

The brain regions involved in attention are also more efficient in gamers and require less activation to sustain attention on demanding tasks.

It also cited evidence that video games can increase the size and efficiency of brain regions related to visuospatial skills.

It noted that the right hippocampus was enlarged in both long-term gamers and volunteers following a video game training program.

Researchers referenced in the report also found functional and structural changes in the neural reward system in gaming addicts – similar to those seen in other addictive disorders.

Yet despite the hefty pile of research papers evidencing the power of video games on people with brain injuries and neurological conditions, Hömberg believes much more insight is needed.

“The theoretical question remains, what aspect of gaming is the most important, in terms of rehabilitation? We don’t have a definitive answer yet.

“Nevertheless, I believe we are just scratching the surface of a very interesting, powerful

and useful introduction to rehabilitation.”

As technologists and neuroscientists dig ever deeper into this fertile ground of research, new advances for neuro- rehab will surely emerge.

An aggravating factor continues to hold progress back, however, says Hömberg.

“It has taken many years to close the discourse differences between clinicians and technology engineers. The engineers have great ideas about amazing technology. On the other side is the clinician, saying ‘it’d be nice if we had this and that’.”

The challenge has been ensuring that a technology’s suitability for a particular clinical role takes priority over how advanced the technology can be, he says.

He draws on the teachings of the 19th Century philosopher Ludwig Wittgenstein who conceded that communication
is a world of language games.

It’s as though the techies are immersed in a frighteningly realistic 3D shoot ‘em up game while the people in white coats play Pong or Space Invaders.

“The language games the engineers and clinicians are playing are different and they think in different worlds. They are restricted to their own languages,” says Hömberg.

“We must cross this communication divide. It is vitally important that the developers understand the problem their technology is addressing.”

Hömberg believes tackling this challenge will help to unleash the potential of games in rehab – perhaps even more so than developments in the great looming AI age.

“Developing artificial intelligence will probably open up completely new possibilities – we are not in a position to say exactly what they might be. But more importantly, we need to tighten up the discourse between clinicians and technology developers.”

Like AI, virtual reality (VR) has also been vaunted as a potentially revolutionary force in rehab.

There is non- conclusive, although compelling, evidence that VR can improve cognitive and motor functionality after
brain injury and in other neurological conditions.

VR advancements are being made at a rapid pace and momentum is building. The technology is partly being sold to the world as an alternative and cost-effective type of rehab therapy.

Researchers are also investigating other ways it can aid rehab and recovery. At UCLA in the US, for example, VR is being used to monitor and analyse how memories are formed.

Patients are transported into a virtual world and brain activity is recorded as they respond to their pixelated surroundings.

UCLA says the work could lead to the development of therapeutic tools that help

to restore memories in people with Alzheimer’s, TBI and other disorders.

Hömberg believes VR has an important role in rehab; but argues that the continual push to make VR environments ever-more realistic perhaps misses the point of the value of gaming.

“I’m sceptical about the application of virtual reality because there is nothing more real than reality,” he says.

“Patients have to learn to adapt to reality after a stroke or injury, for example. You can train patients in the real world in rehabilitation, except for in certain circumstances such as driving, where a simulator is likely to be used.

“The emotional and motivational elements of game play are much more important than how real the game’s setting feels,” he says.

“The important point is that there is a playful reality present.”

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