The EPIK Island

Serious Game for Stroke Recovery

Inés Pinilla Giménez

, Francisco J. Díaz-Pernas

, Sonia Garrote Fernández

Juan Azael Herrero Alonso

, David González Ortega

and Mario Martínez-Zarzuela

Department of Signal Theory and Communications and Telematics Engineering, University of Valladolid, Spain

Miguel de Cervantes European University, Spain

Keywords: Stroke, Rehabilitation, Serious Game, Virtual Reality, Microsoft Kinect.

Abstract: In this paper we describe the features of a serious game with virtual reality for use as a complement in

rehabilitation therapies for patients who have suffered a stroke with subsequent motor and/or cognitive

sequelae. We will expose the importance of rehabilitation in this kind of patients, and how virtual reality

video games can be a good complement to the classical rehabilitation method. The game is divided in two

applications: one for the therapists where they can change the parameters of the game for adapting it to the

patient’s limitations, and the user’s application where the patient can play the different scenes and can

perform the prescribed rehabilitation exercises. Each one of the scenes allows the patient to perform some

movements aimed at the rehabilitation of some of its limitations, both motor and cognitive.

1 INTRODUCTION

Nowadays, strokes are responsible for up to 10% of

the total deaths in the world. Among the survivors, a

large number of cases have a bad prognosis: 29% die

in the first year, 30% cannot live independently, and

16% need to live in long-term institutions (Ruiz-

Ares et al., 2015).

Specifically, in Occidental countries, stroke is the

third most frequent cause of death, the second cause

of neurological disability after Alzheimer's disease,

and the leading cause of institutionalization for loss

of independence in adults (Martín-Zurro et al.,

2003). This means that it is one of the main reasons

for the economic resources of health systems.

A stroke is undoubtedly a personal tragedy, as

well as a social, health and economic burden.

Therefore, it requires an important demand of care

so that the patient adequately surmounts his sequelae

and prevent future accidents.

In general, the identification and control of vascular

risk factors are the basic preventive pillars of stroke.

These can be developed at two levels: primary,

controlling vascular risk factors, and in the

symptomatic phase, treating the patients who have

suffered previous accidents.

It is estimated that 50% of strokes occur in 10% of

the population, who should benefit from the

adequate treatment of its risk factors (Martín-Zurro

et al., 2003).

The 90-95% of strokes are due to modifiable risk

factors, so it is crucial to develop strategies to

prevent them. (Feigin et al., 2016).

In Spain there are 186 cases per 100,000

inhabitants per year. Among people over 65 years,

7,500 cases per 100,000, being the second cause of

general mortality and the first in women (Ruiz-Ares

et al., 2015).

In recent years, the number of accidents has been

gradually reduced, and their mortality has been

decreased to 50% (Ruiz-Ares et al., 2015). The

reduction in mortality and the better functional

evolution observed in the stroke units is due to a

greater adherence to care protocols, and a growing

awareness of the specific rehabilitation needs of

each patient (Cayuela et al., 2014).

The aim of rehabilitation is to help them to be as

independent as possible and thus improve their

quality of life. Helping them to relearn skills that are

lost when part of the brain is damaged (coordination

of movements, communicating ...), or teaching them

to perform tasks in a new way to avoid or

compensate for any residual disabilities.

192

Giménez, I., Díaz-Pernas, F., Fernández, S., Alonso, J., Ortega, D. and Martínez-Zarzuela, M.

The EPIK Island - Serious Game for Stroke Recovery.

DOI: 10.5220/0006366501920197

In Proceedings of the 3rd International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2017), pages 192-197

ISBN: 978-989-758-251-6

A clear basis in any rehabilitation program is that it

must be voluntary, repetitive and specific to the

affected area.

Studies in multiple hospitals have shown that

survivors spend about half the day alone and

inactive, being most of the time in bed without

exercising any muscle. In addition, at weekends,

patients reach even lower activity levels (Stewart et

al., 2016).

This creates the need to give opportunities for

survivors to perform activities that allow them to be

rehabilitated, both in hospitals without the

continuous supervision of a specialist, and at home

during vacation periods. Among those opportunities

we find serious games of virtual reality.

Serious virtual reality games offer therapy based

on multisensory devices and involves interacting

with a simulated real-time environment. The basis of

this rehabilitation is that a more interesting

environment for a patient can improve motivation

for practice. In addition, they offer the opportunity

to practice activities that cannot be performed within

the clinical setting.

The use of virtual reality programs designed for

rehabilitation is still not very common in clinical

contexts, but little by little a gap is being formed

between therapies (Laver et al., 2017) (Alfageme et

al., 2002). Rehabilitation studies with virtual reality

try to determine if it really is a substitute for

traditional rehabilitation, but one undoubted

conclusion is that they are a good complement as

long as the virtual world provides the patient a

complete sensory reflection of the real world

(Todorov et al., 1997) (Guzmán et al., 2016). In

addition, there is no doubt that the patients'

motivation to the therapies increases regardless of

the age range studied (Broeren et al., 2008)

(Sveistrup et al., 2003).

In a previous work (Garrote et al., 2015), we

presented the serious game EPIK, designed by the

ASPAYM Foundation Castilla y León (Spain),

institution which works for getting a better life for

people with disabilities (strokes, spinal cord injury,

etc.), and developed by Telematics and Imaging

Group, University of Valladolid, Spain. EPIK

Platform was focused on allowing the therapist to

evaluate the exercises of the patients so that they

could carry out their rehabilitation at home and

without a specialist controlling him. It was

concluded that it was a good way to evaluate and

treat patients in a simple and cheap way.

In this article, we will show the continuation of

that idea, the serious game The EPIK Island. Unlike

EPIK, it is designed to offer a greater gameplay, so

the patient finds it more entertaining and helping

with their attitude towards therapies. It is designed

as a graphic adventure in which the player moves,

thanks to the camera of capture of movements

Microsoft Kinect 2.0, by different scenarios getting

points and resources.

2 METHODS

2.1 Purpose of the Game

The main objective of this system is to complement

the rehabilitation of patients with some type of

motor and/or cognitive limitation due to stroke,

facilitating the work of the therapist in controlling

the correct execution of the different movements,

and increasing the motivation of the patient.

In addition, it offers a great flexibility in face of

the different limitations of patients, because it allows

to calibrate motor ranges, to determine a series of

difficulty parameters, to differentiate in real time

between sitting and standing, and offers a guided

game mode for patients with very severe limitations.

All these differentiations have been determined

through different tests with ASPAYM patients, as

well as evaluating the opinions of physiotherapists.

2.2 Technologies

The EPIK Island game, uses the Microsoft Kinect

2.0 motion capture camera

(http://www.microsoft.com/en-us/kinectforwindows)

as it allows us to evaluate the patient's entire body

without the need for added elements.

It has been developed through the Unity game

engine (http://unity3d.com), which allows us to

create 3D or 2D games and implement them on

numerous platforms.

The integration between both is done through the

plugin Kinect for Windows SDK 2.0, and thanks to

it we can take full advantage of the technology that

both offer for the evaluation of the different

movements of patients.

2.3 Main Features

The EPIK Island needs the implementation of two

applications:

Web application: in this application (developed

by the Javacoya team, belonging to ASPAYM) the

therapist will be able to define the scenarios that

each patient should perform and their difficulty

parameters (Figure 1). With these parameters,

The EPIK Island - Serious Game for Stroke Recovery

193

therapies can be customized for the patient

limitations, as well as the therapist can control if

he’s making progress in solving increasing

difficulties.

Figure 1: Web application developed by Javacoya.

User application: in this application, the patient

will interact with the different scenarios that have

been developed. Currently two game modes are

implemented: in the first one, the patient will

download through the net the work plan determined

by the therapist and must complete all the scenarios

with their parameters, and in the second one, if any

node of the network fails, the patient can work on a

local plan with the basic parameters.

As we have explained previously, this game

pretends to be flexible for all the patients with motor

limitations that have suffered a stroke. Specifically,

it differentiates between patients with lower limb

limitations (if the limitation is severe, it will be

detected that the patient remains seated whereas, if it

is mild, the therapist can select a guided mode to

facilitate the therapy), and also allows, if the patient

has low mobility in one arm, to select a lateral

restriction in each scenario.

2.4 Game Modules

The user application is divided into three general

scenes:

data (Figure 2). If they are correct and there is a

correct connection to the server, the sessions

predefined by the therapist will automatically be

downloaded. If the connection fails, a file will be

loaded with the basic parameters.

Figure 2: Login scene.

Scenario selection scene: in this scene the patient

will select one by one the scenarios to perform

(Figure 3). If there has been a correct web

communication, he must do the scenarios in the

order that the therapist has determined. If not, he

will have full access freedom.

Figure 3: Scenario Selection Scene.

Developed Scenarios: In these scenes, the patient

will rehabilitate their motor functions, moving

through the camera Kinect an avatar that will

represent their movements, and picking up different

objects that he will find on the stage for a time

determined by the therapist. The number of objects

collected will be saved as points, and will motivate

the patient to get new records in future sessions. If

there are exercises for arm rehabilitation, a

calibration option is added previously to the game in

which it will be determined to how much distance it

is able to pick up the different objects, in order to

adapt it even more to the patient.

2.5 Developed Scenarios

2.5.1 First Scenario

This scenario, called “La Playa del Alivio”, focuses

on the rehabilitation of the upper limbs, causing the

patient to collect some coconuts that will fall to their

sides, along with a part of cognitive rehabilitation,

because he will must to avoid collecting bananas.

The dynamics of the game is that the avatar must

move along a beach reaching different palms, which

ICT4AWE 2017 - 3rd International Conference on Information and Communication Technologies for Ageing Well and e-Health

194

must hit by stretching the arms or lifting them a

predetermined number of times, and later pick up the

coconuts that fall to their sides (Figure 4).

Figure 4: Scenery of collecting objects from “La Playa del

Alivio”.

The game parameters that the therapist can vary

are: the playing time, the number of palms that the

patient is, the number of times that each palm has to

be repeated, the blows for the coconuts to fall, the

difficulty of the distance of collect depending on the

calibrated range, the number of objects falling, the

percentage of coconuts relative to the total number

of objects, the difficulty in the speed of falling of the

objects, and whether the patient can move freely,

guided by a path, or the avatar automatically

advances.

2.5.2 Second Scenario

This scenario, called “La Selva Contaminada”,

focuses on the rehabilitation of the upper and lower

extremities, causing that the patient must collect two

types of objects: trunks that appear on the ground

and for which he will need to do a squat, and leaves

in the trees for which he will need to stretch his arms

upwards.

The dynamics of the game is that the avatar must

cross a jungle collecting the objects that appear for

getting points (Figure 5).

Figure 5: Scenario of “La Selva Contaminada”.

The game parameters that the therapist can vary

are: the playing time, the number of logs and leaves

that will appear, the difficulty of collecting the

trunks and leaves, and the freedom of movement that

the patient will have around the stage.

2.5.3 Third Scenario

This scenario, called “La Cueva del Volcán”,

focuses on the rehabilitation of balance, causing that

the patient must collect objects by lateral

inclinations of the trunk. Specifically, he must

collect diamonds while avoiding to collect some red

gems, which will allow a cognitive rehabilitation.

The dynamics of the game is that the avatar

automatically moves in a wagon on rails along a

cave, and the user only has to lean to pick up the

diamonds (Figure 6). In addition, in some cases, the

wagon will stop at a bifurcation and the patient must

have to choose the side that wishes to choose to

continue, with a lateral inclination.

Figure 6: Scenario of “La Cueva del Volcán”.

The game parameters that the therapist can vary

are: the playing time, the number of objects that

appear, the percentage of diamonds that will appear

in relation to the total objects, the speed of the car,

and the minimum angles of inclination that the

patient must perform to collect objects.

2.6 The EPIK Island in the

Rehabilitation Center

Three testing sessions with patients were conducted

at the rehabilitation center during the developing

process. The feedback collected allowed to fix bugs,

incorporate different parameters for the scenarios,

and adjust the difficulty levels. Thanks to these

modifications, therapists can customize the sessions

depending on the needs of every patient.

In these sessions we have instructed the therapists in

the use of the game: how to control the parameters,

where to place the patient correctly and, finally, how

to read the quantitative measurements of the sessions

(Figure 7).

The EPIK Island - Serious Game for Stroke Recovery

195

Figure 7: Testing the game with the therapists.

After installing the final version in the

rehabilitation center, the opinions of the therapist

are:

1. The game is beneficial for getting a better

static balance of the patients.

2. The scenarios of the beach and the jungle

improve the lateral reaches, and the cave

improves the lateral translations.

3. The anterior-posterior stability is trained

with the anterior translation, needed for

moving the avatar.

4. We can incorporate unstable fitness training

devices such as bosus or balls (Figure 8),

for users with a higher level of balance.

5. Is really useful the constant requirement of

cognitive processes, such as attention,

reasoning and spatial perception to achieve

improvements in postural control and

mobility ranges.

6. Finally, the variability of the parameters

will allow them to adapt the game

individually to the needs of the patients.

Figure 8: Testing the game with fitness training devices.

3 CONCLUSIONS

The main objective of this serious game is to

complement the therapies of rehabilitation of

patients of stroke using virtual reality, in such way

that it increases significantly the motivation of these

before the therapies. Due to the great playability of

the scenarios patients perform the exercises in a

repetitive and completely voluntary way. Therapists

find this system flexible enough to be easily adapted

for the training of patients with different sequelae.

REFERENCES

Alfageme, B., Sánchez-Murcia, P., 2002. Aprendiendo

habilidades con videojuego.

Broeren, J., Bjorkdahl, A., Claesson, L., Goude, D., 2008.

Virtual Rehabilitation alfer Stroke, Studies in Health

Technology and Informatics, vol. 139, pp. 77-82.

Cayuela, A., Cayuela, L., Escudero-Martínez, I.,

Rodríguez-Domínguez, S., González, A., Moniche, F.,

Jiménez, M.D., Montaner, J., 2014. Análisis de las

tendencias en la mortalidad por enfermedades

cerebrovasculares en España 1980-2011, Neurología.

Sociedad española de neurología.

Garrote, S., Herrero, A.J., Pedraza-Hueso, M., González-

Gutiérrez, C., Fernández-San Román, M.V., Díaz-

Pernas, F.J., Menéndez, H., Ferrero, C.M., Martínez-

Zarzuela, M., 2015. EPIK: Virtual Rehabilitation

Platform Devised to Increase Self-reliance of People

with Limited Mobility, SCITEPRESS.

Guzmán, D.E., Londoño, J., 2016. Rehabilitación de

miembro superior con ambientes virtuales: revisión,

Revista mexicana de Ingeniería Biomédica.

Laver, L., George, S., Deutsch, J.E., 2017. Virtual Reality

for Stroke Rehabilitation.

Martín-Zurro, A., Cano-Pérez, J.F, 2003. Atención

primaria: conceptos, organización y práctica clínica,

Mosby / Doyma Libros.

Ruiz-Ares, G., Martínez-Sánchez, P., Fuentes, B., 2015.

Enfermedades Cerebrovasculares, Servicio de

Neurología y Centro de Ictus. Hospital Universitario

La Paz, Madrid, España.

Stewart, C., McCluskey, A., Ada, L., Kuys, S., 2016.

Structure and feasibility of extra practice during

stroke rehabilitation: A systematic scoping review,

Australian Occupational Therapy Journal.

Sveistrup, H., McComas, J., Thornton, M., Marshall, S.,

Finestone, H., McCormick, A., Babulic, K., 2003.

Experimental studies of virtual reality delivered

compared to conventional exercise programs for

rehabilitation, Cyberpsycholy Behav, vol. 6, no. 3, pp.

245–249.

Todorov, E., Shadmehr, R., Bizzi, E., 1997. Augmented

feedback presented in a virtual environment

accelerates learning of a difficult motor task, Journal

of Motor Behavior, vol. 29, no. 2, pp. 147–158.

ICT4AWE 2017 - 3rd International Conference on Information and Communication Technologies for Ageing Well and e-Health

196

Feigin, V.L., Roth, G.A., Naghavi, M., Parmar, P.,

Krishnamurthi, R., Chugh, S., Mensah, G.A.,

Norrving, B., Shiue, I., Ng, M., Estep, K., Cercy, K.,

Murray, C.J., Forouzanfar, M.H., 2016. Global burden

of stroke and risk factors in 188 countries, during

1990-2013: a systematic analysis for the Global

Burden of Disease Study 2013, Lancet Neurol. Vol 15.

The EPIK Island - Serious Game for Stroke Recovery

197