Like many therapists, Jim Poore, PTA, was eager to try the Nintendo Wii game with patients as a mode of therapy. He soon learned it was helpful with younger patients, who are accustomed to the fast-moving action of video games, but the level of difficulty and lack of flexibility was not suitable for older patients.
That changed when he beta tested a new virtual reality system with a 3D camera designed specifically to capture the slower, more hesitant movements of older patients. The system, called OmniVR, offers six different skilled exercises, including seated exercise, wheelchair propulsion and control, upper extremity, balance, walking, and cognitive skills, as well as several objective measurement tests.
At Life Care Center, a skilled nursing home and rehabilitation center in Hendersonville, N.C., Poore uses the technology with older patients with knee and hip joint troubles to improve balance, posture, gait, range of motion and strength. "Patients don’t realize they are doing therapy and act like they are playing a game, but it provides a real therapeutic benefit," Poore said.
Unlike Wii systems, this technology does not require hand controllers, special mats or platforms — which can create difficulty for older patients. What Poore finds particularly impressive is how the technology allows him to better monitor his patients’ performance and progress. For instance, one exercise program called The Mole (after the Whac-a-Mole arcade game) challenges patients to step forward, backward and sideways. The system measures the number of steps, accuracy and the total exercise time. "That’s not something I could ever do, even with a stop watch," Poore said.
The system also allows therapists to choose the level of difficulty, and can be set for individual use or group therapy, said Ed Dunlay, PT, vice president of market development at Accelerated Care Plus of Reno, Nev., which makes the OmniVR. "Therapists are able to monitor the patients’ level of activity and progress them up as their performance improves."
Dunlay added, "We also purposely chose simple graphics and interactive scenarios that an older generation would be comfortable with, such as gardening and bingo games."
The system — which includes hardware and software components — is being used in about 215 sites across the country at a cost of about $20,000 to $23,000, depending on accessories. The system also can be leased by rehab facilities.
New gaming tools
The introduction of the Wii, Wii Fit and Microsoft Kinect for the Xbox system brought virtual reality technology into many physical therapy practices for the first time. It has been used to enhance conventional therapy in patients with conditions ranging from musculoskeletal problems and stroke-induced paralysis to cognitive deficits. While the technology encouraged patients to perform physical movements and fitness exercises, the systems did not necessarily involve the right types of movements, said Belinda Lange, PhD, senior research scientist at the University of Southern California’s Institute for Creative Technologies in Playa Vista.
"Games can make therapy fun and help improve adherence to exercise — which is very difficult in a clinical setting," Lange said. "But most existing games are designed for entertainment and not specifically for rehabilitation because the tasks are usually much too difficult for most patients."
For geriatric patients, the games are particularly difficult to follow visually because of all the colors and movement. Additionally, the games can cause patients to make compensatory movements that may cause harm, she said.
At her game-based rehabilitation lab, Lange and her colleagues have devoted countless hours to adapting off-the-shelf programs like Kinect that track the body in 3D through gesture recognition or motion-capture technology. The lab has developed software that is designed to be used with any PC rather than with the Xbox, making the technology portable for clinic or home use.
The 3D technology, which is undergoing testing in several clinics, allows therapists to adjust the level of difficulty to match a patient’s ability. One game requires patients to reach out and grab gems in a virtual mining environment to improve posture, endurance and increase mobility and range of motion. Another game challenges users to touch objects as they light up on the screen.
With a grant from the National Institute on Disability and Rehabilitation Research, the software is being tested in older patients to help further refine the technology to suit the needs of the senior population, she said.
Future of 3D
In Philadelphia, researchers at Temple University have developed "immersive" virtual reality technology that monitors patients’ posture in a room that simulates a normal environment. The goal is to record the biochemical and physiological responses to combined visual, vestibular and proprioceptive inputs, said Emily Keshner, PT, EdD, professor and chair of physical therapy.
"With this technology, patients see nothing else but the environment projected on the screen so we can accurately evaluate posture in the elderly and patients with stroke," Keshner said. "With this technology, we are trying to play with all the pathways that can impact postural control and see if by augmenting some or reducing others we can actually modify the way people respond to disturbances."
Current studies are focused on whether immersive technology is needed in a clinical setting or just for purposes of research. "Ultimately, we would like to translate our research into an easily purchased product that every clinic could have," Keshner said. "We’re working on applications for iPads so patients could take it home and work on their exercises there."
Lange also sees a bright future for virtual reality in physical therapy. "As the video game industry is driving this technology forward, it really is just the beginning of the use of this technology for fields like rehabilitation."