New Developments in the Gesture Therapy Platform

Past, Present and Future of our Research

Felipe Orihuela-Espina

, Paloma

Alvarez-C

ardenas

, Lorena Palafox

, Israel S

anchez-Villavicencio

Alberto L. Mor

, Jorge H

ernandez-Franco

and Luis Enrique Sucar

National Institute for Astrophysics, Optics and Electronics (INAOE), Sta. Mar

ıa Tonantzintla, Puebla, Mexico

Universidad Veracruzana, Xalapa, Veracruz, Mexico

National Institute of Neurology and Neurosurgery, Mexico D.F., Mexico

Universidad Autonoma de Baja California (UABC), Ensenada, Baja California, Mexico

Keywords:

Virtual Rehabilitation, Stroke, Cerebral Palsy.

Abstract:

Gesture Therapy (GT) is a virtual rehabilitation tool for the upper arm that has been in the making since

2008, and by now has successfully demonstrated therapeutic validity in two small clinical trials for stroke

survivors. During this time, our group has published a number of contributions regarding different aspects of

this platform ranging from hardware controllers to artiﬁcial intelligence algorithms guiding different aspects

of the serious games behaviour, and clinical trial data from observable improvements in dexterity to changes

in functional neuroreorganization. As we continue our research efforts in virtual rehabilitation and realising

this knowledge in the GT platform, this paper presents an overview of the latest developments as well as a

roadmap for future research.

1 INTRODUCTION

Virtual rehabilitation (VR) (Levin, 2011) is becoming

an accepted alternative therapy, as evidence slowly

piles up suggesting beneﬁts comparable to traditional

alternatives (Parsons et al., 2009; Snider et al., 2010;

Sucar et al., 2013). Yet, the full potential has not

been unleashed and evidence is still insufﬁcient to

draw conclusions (Laver et al., 2011). Although by

now a few dozens of VR platforms exist most of them

are still conﬁned to research labs. In most if not all

cases, VR is administered by means of serious games,

which are used for proposing, delivering, monitoring

and evaluating the therapeutic exercises in an engag-

ing and safe virtual environment.

VR platforms capable of assisting rehabilitation

must support rehabilitation principles: promote rep-

etition, task oriented training, appropriate feedback

and a motivating environment (Holden, 2005). As

such, development of these platforms is an artcraft

requiring to harmonize complex elements and pro-

cesses. Work in this area is highly multidisciplinary

involving both technical input including hardware and

electronics, software engineering, human-computer

interaction and virtual reality, and of course, clini-

cal input; rehabilitatory, neurological and psycholog-

ical. Figure 1 illustrates this multidisciplinary envi-

ronment.

Since 2008, our group has been proposing contri-

butions in VR research across the many subdomains

Figure 1: Developing a VR platform requires a multidisci-

plinary work.

106

Orihuela-Espina F., Álvarez-Cardenas P., Palafox L., Sánchez-Villavicencio I., L. Morán A., Hérnandez-Franco J. and Sucar L..

New Developments in the Gesture Therapy Platform - Past, Present and Future of our Research.

DOI: 10.5220/0004663801060113

In Proceedings of the International Congress on Neurotechnology, Electronics and Informatics (VirtRehab-2013), pages 106-113

ISBN: 978-989-8565-80-8

 2013 SCITEPRESS (Science and Technology Publications, Lda.)

of the ﬁeld. From engineering to clinical applications,

and from traslational research to neuroergonomics;

we have contributed with controllers for arm and ﬁn-

ger exercising (Sucar et al., 2013), different artiﬁ-

cial intelligence based adaptation algorithms to make

the therapy adjusts to the changing needs of the pa-

tient as well as learning instructions from the ther-

apist (

Avila-Sansores et al., 2013), a compensation

detection algorithm that can ensure trunk compensa-

tion is avoided (Sucar et al., 2009), an initial set of

necessary design criteria for serious games develop-

ment in VR (Oropeza Salas, 2012), a set of serious

games formulated capitalizing on these design princi-

ples (Oropeza Salas, 2012; Sucar et al., 2013), clini-

cal evidence of the validity of the technique as com-

pared to occupational therapy (Sucar et al., 2010),

and an initial picture of how the brain responds to

VR in terms of functional reorganization strategies

(Orihuela-Espina et al., 2013). In parallel to this re-

search efforts, we have been developing the platform

Gesture Therapy (GT) (Sucar et al., 2010; Sucar et al.,

2013), the practical realization of all the knowledge

we have been gathering. Of course, the ﬁeld of neu-

rorehabilitation is still in its infancy with rehabilita-

tion treatments having a disappointingly modest ef-

fect on impairment (Krakauer et al., 2012) and thus

the journey has just begun.

This paper presents some of the latest features

added to the GT platform; two more new games, a

brand new interface inspired in the home paradigm

that serious games should reﬂect functional tasks of

daily living, and the new user proﬁling capabilities.

The goal pursued by the incorporation of these fea-

tures is facilitating translational research e.g. mak-

ing possible point-of-care patient application, as well

as enabling more ecological testing environments e.g.

the patient’s home. This paper also presents prelimi-

nary steps taken to demonstrate (i) that the same plat-

form can be shared across different medical condi-

tions responsible of upper limb impairment, in partic-

ular from stroke to cerebral palsy, and (ii) that serious

games originally developed for VR can also be useful

beyond their original intended domain and can further

help to ease cognitive decline. Finally, we also want

to use this paper to sketch some of the work ahead.

2 GESTURE THERAPY (GT)

GT is a VR platform for the motor rehabilitation of

the impaired upper limb. GT was conceived for home

usage and consequently exhibits low cost. The plat-

form has two major hardware elements pictured in

Figure 2; a computer with a webcam and a controller

Figure 2: The Gesture Therapy platform. The user interacts

with the games by means of the gripper.

or gripper. This speciﬁcally designed controller facil-

itates arm and hand tracking and incorporates a pres-

sure sensor for ﬂexion of ﬁngers. The solution mixes

hardware and software elements in an integrated plat-

form with ﬁve major modules schematically depicted

in Figure 3.

• The physical system encompasses the hardware

platform incorporating a computer, a webcam for

tracking and speciﬁcally designed controllers e.g.

a handgrip.

• The monocular tracking system is the software

responsible for tracking the arm surrogated by the

controller’s ball. Tracking is based on a particle

ﬁlter using colour and texture and is capable of

estimating depth.

• The simulated environment presents the games

and interacts with the user. It is also responsible

for providing visual and auditory feedback.

• The trunk compensation detector controls the

platform response to detected compensatory

movements with the trunk by the patients. It cap-

italizes on Haar features and a cascade of classi-

ﬁers.

• Finally, the adaptation module adjusts the 3D

space in which the exercise occurs intra-game in

real time tailoring the challenge to the progress of

the patient. The underlying algorithm exploits so-

phisticated artiﬁcial intelligence decision models.

Further details of the platform status before this pub-

lication can be found in (Sucar et al., 2013). This pa-

per presents the new modiﬁcations and enhancements

made to the platform since then.

2.1 Clinical Trials

So far, we have carried out two clinical trials, both

in Mexico at the National Institute of Neurology and

Neurosurgery and focused on stroke patients.

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Figure 3: Conceptual modules of the GT platform.

• Clinical Trial I. 42 patients were randomised to

two groups; a control group of 22 patients re-

ceived 21 sessions of 60 minutes of occupational

therapy, and the intervention group received an

equal amount of virtual reality based rehabilita-

tion therapy with Gesture Therapy. Both groups

presented a signiﬁcant improvement in terms of

motor recovery assessed using Fugl-Meyer (Fugl-

Meyer et al., 1975) and Motricity Index (De-

meurisse et al., 1980) scales (Wilcoxon; p <

0.05). Differences in improvement between the

therapies were not signiﬁcant. Motivation as

evaluated with the Intrinsic Motivation Inventory

(IMI) (McAuley et al., 1989) was stronger among

patients treated with Gesture Therapy. Patients

treated with GT demonstrated greater interest and

claimed higher importance and utility. Full details

can be found in (Sucar et al., 2010).

• Clinical Trial II. 28 subjects were allocated to 3

groups; group one received 20 sessions of 45 min-

utes of occupational therapy, whilst groups 2 and

3 received equal amount of Gesture Therapy, with

the third group further undergoing neuroscans for

exploration of the neural underpinnings respon-

sible for behavioural improvements. Both thera-

pies exhibited signiﬁcant motor improvements as

evaluated with Fugl-Meyer and Motricity Index

(Mann-Whitney U; p < 0.05), and differences in

improvements between them were not signiﬁcant.

GT matched the control improvements for hand,

wrist and elbow. Prefrontal cortex and cerebel-

lar activity were found to be the driving forces of

the recovery associated with Gesture Therapy. We

found that those with stronger disabilities appear

to beneﬁt the most from this paradigm (Orihuela-

Espina et al., 2013).

3 NEW TECHNICAL FEATURES

FOR GT

3.1 New Games

Two new games have been added to the game set of

GT that until now had 3 games. The new games at-

tend the obvious necessity for a larger variety of tasks

to reduce boredom caused by excessive repetition of

games in a game set. Also by diversifying the tasks

the enlarged game set might appeal to other patients.

Screenshots of the games are pictured in Figure 4.

• Spiders on the Wall. In this game the pa-

tient armed with a hammer as an unlikely tool

for killing spiders has to combat these annoy-

ing creatures creeping up the wall. The distance

at which the next spider appears is dictated by

the challenge level at play which in turn is gov-

erned by the adaptation policy, optimally designed

to ensure matching user progress. The game

favours bidirectional movements including eleva-

tion/depression and abduction/adduction.

• Fungi in the Sink. Cleaning time. The sink is

dirty and the patient has to clean the mold stains.

Similarly, the distance at which the next mold

stain appears is dictated by the challenge level

again ruled by the adaptation module. The game

also favours bidirectional movements including

elevation/depression and abduction/adduction.

Similarly to previous games in GT, these have

been developed using the Torque game engine and

communicate with the rest of the platform by means

of a shared memory address. They both incorporate

visual and audio feedback and this is given in the

two classical ﬂavours; knowledge of performance and

knowledge of results (Deutsch et al., 2008). These

games still have to face clinical trialling.

3.2 New Interface

The home paradigm is our conceptualization that ex-

ercises promoted by the serious games should mimic

natural movements inspired in functional tasks of

daily living mostly occurring in the home environ-

ment, thus stressing the rehabilitation goal of mak-

ing the patient self-sufﬁcient (at home). Although the

paradigm has been integral to GT for a while now

(Oropeza Salas, 2012), it has not been until recently

that we have developed a brand new interface that re-

ally exploits this paradigm. The new interface inte-

grates the menus to be navigated by the patient within

different views of a house from outside and from the

inside as illustrated in Figure 5. A lighting effect

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Figure 4: Screenshots of the two new games added to GT’s

game set.

highlights buttons as the user crosses above them with

the cursor. Currently, navigation through the interface

is made by means of the mouse, but we expect the GT

gripper to be also an optional input device for the in-

terface very soon, thus further facilitating the use by

the impaired person without help from thirds.

3.3 User Proﬁling Capabilities

User proﬁling refers to all the managerial capabili-

ties to track patients and physicians use of the system,

as well as the therapy compliance of the former and

the clinical annotations of the latter. We have now en-

riched GT with user proﬁling capabilities, a necessary

addition for regular use whether at home or in health

institutions. The user proﬁling capabilities of GT con-

form a new module (to add to those in Figure 3) that

tracks all activity occurring in an instance of GT.

The database is implemented in postgreSQL and

permits tracking of user activity. From the patient

point of view it tracks times spent on the therapy,

and in each particular game individually. It further

keeps track of the traces of the user avatar at all times

Figure 5: The new interface inspired in the home paradigm.

Top: Different elements of the facade of the house (i.e. win-

dows) disguise the main menu. Bottom: The house inte-

rior permits access to the different games in different rooms

highlighting the relation between the exercise and the func-

tional task associated.

and records timestamps and performances associated.

Therapies can be delivered following game selection

by the therapist or a pre-dictated plan. The therapist

can add clinical annotations to every session played

by the patient. The Entity-Relation diagram of the

database is shown in Figure 6.

4 CLINICAL EXPLORATION

BEYOND STROKE

4.1 Extension to other Motor Impairing

Conditions: Cerebral Palsy

Because of the large prevalence and incidence of

stroke (Roger et al., 2012), GT was originally de-

veloped focused on these patients. However, as the

main principles of motor rehabilitation are shared

with other motor impairing medical conditions, it is

likely that a platform developed for stroke would also

be suitable for treating the rehabilitation process of

these other conditions. In this sense, we have already

started a clinical trial to test the feasibility of using

GT in children with cerebral palsy. However, as the

game set of GT was thought for adults, we have tem-

porally borrowed games from the Armeo system (Ho-

coma, 2013); an strategy that we already used in the

past before GT had its initial game set.

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Figure 6: The diagram representing the database supporting the user proﬁling capabilities.

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So far data from 14 patients of palsy have been

collected from two groups following a between

groups pre-post design; a control group following an

occupational therapy and an intervention group that

has been administered Gesture Therapy. Motor dex-

terity improvements have been measured by means of

Fugl-Meyer scale (Fugl-Meyer et al., 1975) measured

prior to therapy onset and after therapy ends. Inter-

mediate results so far are illustrated in Figure 7. A

patient of palsy using GT during the most recent trial

is shown in Figure 8.

Figure 7: Normalised improvement achieved by the patients

in the ongoing clinical trial. Pairing of bars is only for il-

lustrative purposes, but it is not meant to represent the ex-

perimental design (between groups). Large beneﬁts can be

appreciated in those patients allocated to the intervention

group.

Figure 8: A patient of palsy using GT during the most recent

trial.

4.2 Extension to other Medical

Domains: Cognitive Decline

A current trend in VR is exploiting commercially

available platforms such as the Wii, the Xbox, the

PlayStation or the Kinect to reduce costs and afford

faster developing times. Off-the-shelf game sets for

these platforms hardly ever are suited for rehabilita-

tion and may lack essential components for ensuring

therapeutic effectiveness. An unconventional alterna-

tive might be to bridge domains, and reutilize seri-

ous games out of their original intended context. The

hypothesis is that serious games speciﬁcally designed

for a certain purpose can escape their realm to be used

in other more or less related purposes.

In this sense, we are evaluating the appealing of

virtual games originally developed for motor rehabil-

itation in GT, to be used for enhancing cognitive stim-

ulation of older adults (Mor

an et al., 2013).

We have chosen cognitive stimulation as a target

application for exporting virtual rehabilitation games

because the population affected by cognitive decline,

i.e. elders, is also the population most affected by

stroke; the original target population of GT. The se-

lection of this sufﬁciently close domain can boost the

chances of the exported games to be successful in

their new domain; yet, the new functional require-

ments in the new domain (cognitive stimulation) are

different enough from the original domain (virtual re-

habilitation) to represent a considerable challenge in

the migration.

Towards this end we conducted a usability evalu-

ation of GT as a cognitive stimulation tool with 32 el-

ders from a local municipal third-age support group.

Participants were exposed to a subset of the games

currently available from the GT platform (steak cook-

ing, window cleaning and ﬂy killer). The elderly were

asked to evaluate the platform in terms of perceived

usefulness, ease of use and user experience. The main

goal was to assess GT’s usability aspects as a bor-

rowed platform from the rehabilitation domain.

Elders were introduced to the use of the tool (2-

minute demo), later they were allowed to freely ex-

plore its use to familiarize with it and solve any doubts

regarding its use (3-minute training session), and then

they were allowed to play a complete session with

each of the three games (15-minute play session in

total). Finally, the elders answered an on-exit ques-

tionnaire regarding their perception on the use of the

tool using a set of TAM-based items (Venkatesh and

Davis, 2000) and open questions.

Results from the analysis of the TAM-based items

support that elders perceived the GT platform as a

useful (93.75/100), easy to use (93.75/100) and plea-

surable to use (91.66/100) cognitive stimulation tool.

However, results from the open questions data pro-

vide evidence about elders considering the proposed

activities (games) as being entry level cognitive stim-

ulation activities, and recommended to include ad-

ditional more challenging activities such as puzzles,

memory games or simple math problems.

These results suggest that the transfer of games

across realms could be, in some cases, a feasible

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enterprise but their effectiveness and usability may

be compromised, thus demanding small adaptations.

This is encouraging as small adaptations might be less

costly and faster to perform than starting new games

from scratch.

5 ROADMAP FOR RESEARCH

ASSOCIATED WITH GT

During this journey GT has become a solid piece of

research in virtual rehabilitation with contributions in

many aspects of the domain. Yet, research continues

at our laboratory. These are a few of the efforts we

plan to make in the near future:

• Games Design Criteria. The design criteria tax-

onomy in (Oropeza Salas, 2012) is a naive effort.

Encompassing the rehabilitation goals is arduous,

but a few game design criteria are already spring-

ing for facilitating the development of rehabilita-

tory serious games e.g. (Flores et al., 2008), an

effort which is so far uncoordinated. It is desir-

able to establish a framework of serious game de-

sign criteria and guidelines for virtual reality re-

habilitation, and identifying critical elements that

make a game an effective tool for rehabilitation.

We aim to demonstrate that by better understand-

ing the necessities of rehabilitation games, spe-

ciﬁc aspects of the development process of seri-

ous games for rehabilitation can be streamlined,

thus speeding up the development of platforms for

supporting virtual reality based therapies.

• Transfer of Knowledge. The question of how

virtual practice translates to the real world is not

new (Holden, 2005), yet remains largely unex-

plored. The overlap between the real and the vir-

tual task must be understood to optimize or facil-

itate transfer. It is not sufﬁcient simply to demon-

strate that training does transfer in a given situa-

tion; rather, it is crucial to identify whether a spe-

ciﬁc skill is being transferred (Sveistrup, 2004).

We believe it is critical to investigate indispens-

able elements that make a serious game an effec-

tive tool for rehabilitation, with special emphasis

on transfer of knowledge from the virtual to the

real world and identifying game elements that in-

crease adherence to the games and by extension

to the therapy. Additionally, this may reduce the

excessive reliance on premature clinical trials.

• Functional Reorganization of the Brain.

Krakauker got it right (Krakauer et al., 2012);

training of compensatory strategies have minimal

impact on impairment. Current understanding

of motor learning and brain plasticity has to be

a primary research direction. Our only study

so far in this direction (Orihuela-Espina et al.,

2013) was just an initial step, and was limited by

the enforced imagery-based task imposed by the

fMRI neuroimaging modality. We believe that

employing other neuroimaging techniques such

as diffuse optical neuroimaging (Villringer and

Chance, 1997) will permit us to interrogate the

brain with higher ecological validity, even if that

means sacriﬁcing some spatial resolution.

6 CONCLUSIONS

This paper has summarised our current research ef-

forts in the different areas of VR, and in particular

how these efforts are being coordinated around the

GT platform. By enlarging our gameset, the new

games will give patients more variability and we ex-

pect this to result in higher motivation and adherence

to therapy. The new interface makes the platform

more user friendly, dropping the need for a researcher

or therapist trained in the platform to be present at

all times. In this sense, installation and application

launch are now trivial, software is all integrated in a

single executable (previously the tracking and games

have to be launched separately), and menu naviga-

tion is expected to be more natural. Also, the new

user proﬁling capabilities was a necessary step be-

fore more ecologically aggressive trials could be at-

tempted opening the door for releasing the platform

to more rehabilitation wards and ultimately, the pa-

tient’s home without direct or on-site clinical super-

vision. Efforts are being also made to extrapolate the

virtual paradigm of GT beyond stroke. First steps in-

volve extension to other motor impairing conditions

(e.g. palsy) and other less similar medical domains

(e.g. cognitive decline). Preliminary results in both

directions are promising. Finally, we have also re-

ﬂected about near future research that we think might

make an impact on VR. We look forward to keep ad-

vancing knowledge that can consolidate VR as a cut-

ting edge alternative for motor rehabilitation and re-

covery from impairment.

ACKNOWLEDGEMENTS

The authors would like to thank R. Leder, R. L.

Vel

azquez, H. Avil

es-Arriaga, S.

Avila-Sansores, J.

Oropeza-Salas and D. Carrillo who have actively col-

laborated in the building of the Gesture Therapy plat-

form. This work has been funded by the following

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112

projects: SALUD-2007-C01-70074 from the CONA-

CYT, Project 95185 from the FONCICYT (European

Union-Mexico), and the MARSRERC program of the

Rehabilitation Institute of Chicago.

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