Neuroscientist David Putrino hopes to make physical therapy more fun and efficient for stroke patients by having them play an airplane video game.
Marty Stricks has always loved tinkering. For 42 years, he was a high school shop teacher in New York City, a job that requires working with your hands for most of the day, and he loved every second of it. When he retired in 1996, he expected to spend his newfound free time building toys with his grandchildren, walking his two greyhounds, playing racquetball — hobbies that, like his job, involved using his hands.
He enjoyed the good life for 12 years, before it was suddenly taken away: a stroke left him without feeling in most of the right side of his body in 2008. Strokes are one of the leading causes of death in the U.S. More than 795,000 people across the country suffer a stroke each year, 610,000 of them for the first time, according to the Centers for Disease Control and Prevention. Nearly 480,000 of those first-time patients survive, like Stricks. Most face a long road to recovering function, if they ever regain it at all.
Stricks was sitting “on the john” when he suffered his stroke, he told me on a recent afternoon. He completely lost control of the right side of his body. Even after a month of inpatient rehabilitation and several months of outpatient treatment, he remained unable to move the fingers in his right hand. It seemed his days of building Legos and gluing small pieces of projects together were behind him. He had to give his greyhounds up for adoption, as he couldn’t handle walking them anymore.
But Stricks has always been tenacious. Seven years later, he has regained partial control of his right hand, enough to again build with his grandson. His life is slowly starting to return to normal.
“I’ve been doing every kind of therapy imaginable, things that I invent, things that people have around here,” Stricks said. “There’s nothing more terrible than doing therapy. It’s boring, it’s painful, it forces you to accept the reality that you’re living, so the desire to shirk it becomes greater and greater the more you do.”
Recently, though, he found a form of therapy that wasn’t all that bad: video games.
“If you can find something that’s motivational and distracting, to keep you in that rehab mode, but still do the things that you’re supposed to do, it’s terrific,” he said. “It was a lot of fun.”
The game he played is not just any standard video game.
Last fall Stricks was part of a pilot study at the Burke Rehabilitation Center in White Plains, New York. Affiliated with the Weill Cornell Medical College, Burke doctors have been treating patients since 1915. The campus also features the Burke Medical Research Institute, where renowned scientists are rethinking the traditional treatments for everything from speech loss to paralysis.
The study that Stricks participated in was run by researcher David Putrino, Ph.D., P.T. Putrino, who is affiliated with Not Impossible Now, is the director of telemedicine and virtual rehabilitation at Burke. It involved 14 other adults aged 65 to 85 years, each of whom has suffered a stroke within the past 10 years. They visited Burke three times a week for six weeks. The task? Play a simple computer game for 30 minutes.
The game comes from another Putrino venture, GesTherapy. It requires a tablet device and a motion sensor, such as the $80 Leap Motion sensor, which tracks natural motion. The final element is the gaming software.
In this case, the goal of the game is to guide an airplane through a series of hoops of various sizes and depths. There are no controllers or anything to hold in your hand — the airplane is controlled just by moving your wrist over the Leap Motion sensor. The movement is the same as what they would normally be asked to do in therapy: rotating the hand side to side or up and down, concentrating on hand-eye coordination and similar tasks.
The game’s graphics are more simple than what you would see on Xbox or PlayStation games, a throwback to the look of 1990s computer games. It’s just an airplane flying through rings in the sky for now.
The game collects data on their progress, which a therapist can then analyze to determine how to move forward or whether the therapy is working. It saves them from the monotony of watching a patient perform a therapeutic exercise dozens or hundreds of times, while also saving the patient from the monotony of having to perform those tasks. Further, it adds an element of accomplishment for the patients. The system is individually calibrated to the abilities of the patient, so that no patient will become frustrated with a lack of progress or progress too quickly.
Eventually they see the game as a way for patients to continue therapy at home, even when they are not under therapist supervision.
Before it can become an at-home technique, they needed to determine if patients would even be interested. The study was designed to test the system usability and enjoyment, rather than efficacy, Putrino explained. It was an opportunity for the physical therapists at Burke to get to know the system, to work with the backend logistics, login information and other elements.
Stricks and fellow participants confirmed that it was fun and that it encouraged them to stick with their therapy more than any method they had previously tried.
“I enjoyed it, I really did,” Terry Woodland said. Terry suffered a debilitating stroke in 2006 when she was 70 years old. Doctors didn’t think she would make it, according to her husband, Art. “She didn’t know who I was, she didn’t know who she was.” After six weeks of inpatient rehab, Art started caring for her at home.
She had no experience with video games before the stroke.
“It makes your hands go, it...” Art jumps in to help her find her words, as Terry is battling aphasia. People with aphasia fully understand what people are saying to them, but aphasia hinders their ability to express their response.
“It was very easy for me,” Terry added. “I thought it was very good, wonderful.”
She says she never felt competitive, but she felt motivated. Fellow study participant Fred Watson, 62, added that it helped him with his hand-eye coordination.
“We cheered each other on,” Stricks said. “We had fun.”
Every participant scored the study as “enjoyable,” Putrino said. But “what really blew us away was there was no correlation between ability level and physical activity enjoyment.”
Normally, patients with lower ability levels don’t enjoy therapy as much, and are more negative when talking about it. It was encouraging to see them react differently to the video game.
“Because the video game calibrates down to your ability level and then builds you up, you’re as challenged as the next person,” he said. “We were really thrilled with that result, that was great for us.”
An Unexpected Result
Because they weren’t really worried about efficacy, Putrino’s team was surprised to find that every patient showed modest to significant gains in upper limb function during the trial.
All of the participants are in what is known as the chronic phase of recovery, the point at which insurance companies will no longer cover therapy sessions because previous studies have shown that they will no longer benefit from therapy. The chronic phase is said to start six months post-stroke. Most of the participants in this study were years post-stroke, yet they saw improvements, calling in to question the accepted literature on stroke recovery.
Imagine the potential that this implies: playing a special video game for 30 minutes, three times a week, shows significant gains in patients whom insurance companies have already deemed incapable of improving.
The next step is to have 20 patients test the game at home. The team will look at how often they use it and if it shows similar improvements when they are solely playing at home. They are also starting to redesign the graphics to make the game more appealing to younger patients who are battling different disabilities.
The Future of Therapy
Despite what insurance companies will cover, the current literature shows that in stroke patients, “therapy helps recover function, and more therapy is better than no therapy, but no specific therapy is better than any other therapy,” Putrino said. Doctors and scientists have not identified a best possible method. But it’s clear that enjoyability is one of the most important factors in getting patients to stick with therapy.
“If you have a patient who has had a stroke and they’ve lost the ability to move their body, the way to get that movement back is to put them in an environment where they’re stimulated and continually thinking about how do I move my hand,” Putrino said.
The key is to engage them and excite them, he added, in order to break the mold of what appropriate therapy is; to move away from the notion that a patient does therapy “because the doctor told me so” towards “something happened to my brain and I can’t move properly, but if I practice and practice I will move better and I want to move better, and once I’ve gotten to a point where I’m moving better, I’m going to keep practicing, and I’ll become stronger.”
He also sees the potential to tap into the gaming world’s existing infrastructure, both in graphics and the structure of online gaming communities.
“One of the biggest problems stroke patients have is feelings of isolation. Why not create communities?” he asked. If they could connect with each other and talk about their therapy, while playing the games at home, they would likely feel less alone.
As much as they want people to talk to, though, they don’t want someone trying to do the exercises for them, Stricks said. “With the game, no one can come in and help.”
It’s helping him regain the autonomy he enjoyed over all those years as a high school shop teacher.
Before the game goes public, though, Stricks has a few ideas for how it can get even better. “I kept telling [Putrino], you have to put a gun on that plane!” he said. “I’m a gamer. I’m a tech person. I want more sound effects!”
Top photo credit: Danielle Elliot