Gamification and Biofeedback in Rehabilitation

By nature as humans, we all want to succeed or to “win” at whatever it is we are doing. When we see a goal achieved OR even if we expect the goal to be achieved, the “reward system” in the brain is activated, releasing the neurotransmitter dopamine. Dopamine, aka the “feel-good hormone” or “pleasure chemical,” enhances reward-related memories and strengthens synapses/communication in the brain. When you begin to associate a certain activity with feeling good, even just thinking about it may be enough to raise dopamine levels. It is a continuous a cycle of motivation, reward, and reinforcement. In the rehabilitation world, the goal of this cycle is increasing motivation and participation in functional activities/therapeutic tasks. Two major components that can enhance practice and activate this dopaminergic “reward system” are Gamification and Biofeedback.

Definitions:

Gamification: The use of computer games in physical therapy to promote participation in a patient using attractiveness, distraction, motivation, and engagement. These characteristics are important variables in physical therapy interventions because they involve reward-related systems in the brain that are known to facilitate learning through long-term potentiation of neural connections. Games are designed in a way to trigger physical and cognitive/behavioral patterns required for treatment and neurological recovery.

Biofeedback: Biofeedback refers to the information about performing a certain skill that comes from an external source. The feedback the patient is receiving includes the outcomes of performing the skill/achieving the goal (knowledge of result) AND gives information about the movement characteristics/quality leading to the performance outcome (knowledge of performance). In using biofeedback, a patient is able to learn how to control/modify bodily functions by observing the information on the screen before them. By immediately viewing that feedback (on either what they are doing incorrectly or what they can improve on) the patient is able to begin making small adjustments to necessary to complete the activity properly.

It has been found that both biofeedback and gamification are crucial components and work hand-in-hand when it comes to motor learning and improving neuroplasticity (the brain’s ability to modify, change, and adapt in structure and function in response to experience) after a neurological event. As we have learned more in recent years, the neuroplastic response in rehab is strongly driven by repetition and intensity of the activity. These two major components combined can assist in promoting both increased participation due to more fun and purposeful activities, as well as increasing the overall number of movement repetitions and intensity of the therapy session.

A study by Rand et. al. (2014) included 29 individuals, 1-7 years post-stroke: 15 individuals participated in a video game intervention and 14 in traditional therapy as part of a randomized controlled trial. They discovered that participants in the video game group performed a median 271 purposeful movements compared to 48 purposeful movements in the traditional therapy group. This study ultimately showed that therapy specific/functional activity targeted video games elicited more purposeful repetitions and higher acceleration of movement compared with traditional therapy in individuals with chronic stroke.

One program available that includes both gamification and biofeedback is the MediTouch Augmented Biofeedback System. There are four MediTouch devices: the Hand Tutor, Arm Tutor, Leg Tutor, and the 3D Tutor, each with specific tasks and functions. When using the MediTouch devices, patients interact with an object on the screen to achieve gameplay goals, which provides that feedback, encouragement, and motivation to practice targeted exercises or tasks. The reason this is considered “augmented” is that small physical movement in the joint is reflected back to the user as showing full range of motion across the screen. All the activities are structured to be repeatable with consistent targets and you can increase these targets over time to get the patients to move a little farther. For further customization, these devices can be used with ADL objects, weights, FES, etc. as well as built-in game modifications to optimize task for each patient’s needs. Some of the treatment goals include (but are not limited to) balance, fine motor, vestibular, range of motion limitations, functional movement, and cognitive stimulation.

Click below to see a case study example of MediTouch in action: