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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 142-144

Preliminary data of a game-based protocol for acute treatment of cervical spinal cord injury rehabilitation with Kinect

1 Imaginary Srl, Milan, Italy
2 Spinal Unit, Niguarda Hospital, Milan, Italy

Date of Web Publication18-Oct-2018

Correspondence Address:
Antonio Ascolese
Imaginary Srl, Piazza Caiazzo 3, Milan 20124
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/digm.digm_23_18

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Game-based rehabilitation proved its efficacy in recent years, and the areas of intervention are increasing. In this article, we report the definition of a protocol for the treatment of people suffering from acute cervical spinal cord injury and its preliminary application with five patients. A suite of serious games using Kinect as device for game sessions is adopted for upper-limb rehabilitation. The possibility to customize the training plans by selecting different games for each patient gives the chance to include game created for other training targets (e.g., balance) that train further body parts (e.g., the trunk) and that can thus adapt the training to specific patient's needs.

Keywords: Acute treatment, cervical spinal cord injury, game-based rehabilitation, trunk, upper limbs

How to cite this article:
Morganti L, Ascolese A, Vitelli D, Spinelli M. Preliminary data of a game-based protocol for acute treatment of cervical spinal cord injury rehabilitation with Kinect. Digit Med 2018;4:142-4

How to cite this URL:
Morganti L, Ascolese A, Vitelli D, Spinelli M. Preliminary data of a game-based protocol for acute treatment of cervical spinal cord injury rehabilitation with Kinect. Digit Med [serial online] 2018 [cited 2023 Mar 29];4:142-4. Available from: http://www.digitmedicine.com/text.asp?2018/4/3/142/243638

  Introduction Top

The spinal cord injury (SCI) is a condition, due to a traumatic or nontraumatic etiology, that causes death or a great disability to the patients affected. According to the completeness or incompleteness of the lesion and to its level different disability degrees come from involving the respiratory function, hand abilities, the possibility to walk and to physiologically control the voiding of the bladder and the function of the intestine. SCI patients present different levels of independence impairment; because of this, the patients are often in need to identify a caregiver who can support the patient in all the activities of the daily living. It has been demonstrated that the quality of life of patients affected by SCI is related to the level of independence gained.[1] The early identification of incomplete lesions as compared to those complete will influence in the main way the rehabilitation program. A wide number of publications support the fact that intensive and precocious treatment is related to a better global outcome instead of complete lesions.[2],[3],[4] In the past years, the trend has shown an increase in cases of incomplete paraplegia and a reduction of complete tetraplegia.[5],[6]

A specific issue when dealing with cervical SCI is the rehabilitation of the upper limbs that require specific attention due to the huge impact on patients' quality of life and independence. Arms become the main fulcrum of the movements for all the activities, and because of this reason, we need to prevent further traumas and to integrate their movements within a global rehabilitation program that involves the whole body, including the trunk. In the case of specific impairments related to the SCI, both motor control and sensitivity may be affected. Because of this reason, a rehabilitation program should focus on the range of motion (ROM) and the recover from weakness and pain. In the field of rehabilitation research and practice, there have been previous attempts to leverage on low-cost gaming platforms, such as Wii®[7] and PlayStation 2 EyeToy®[8] to support the therapy and rehabilitation of patients with neurological diseases. However, these solutions are difficult to deploy with SCI patients due to the specific clinical conditions previously defined. In this article, we define a specific protocol to test the possibility to apply Kinect® with a game-based rehabilitation system (REHABILITY®) as a complementary rehabilitative treatment in the acute phase of recovery from a cervical SCI.

  Case Report Top

Materials and methods

A cohort of five patients (mean age = 47.6 years, min = 27, max = 63) was selected to test the protocol. Inclusion and exclusion criteria are reported in [Table 1].
Table 1: Inclusion and exclusion criteria

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Lesion levels for the cohort ranged from C4 to C7. The American Spinal Injury Association Impairment Scale is applied to evaluate the motor functioning and the sensitivity after traumatic SCI. The injury level is set through the last caudal segment neurologically preserved in both sides of the body. The motor examination is summarized through Frankel's classification.[9] Further, a set of measures is taken as follows:

  • ROM, Medical Research Council Scale for strength and Ashworth scale at the beginning (t0) and at the end of the protocol (t1)
  • Borg scale for fatigue and Numeric Rating Scale for pain after each session
  • A satisfaction questionnaire at the end of the protocol (t1) adapting items from PTPSQ and System Usability Scales.

The rehabilitation system applied is REHABILITY®, a game-based platform integrating games for the upper limbs, legs, and balance, so that the rehabilitation of the global movement can be targeted. Recent studies already proved the efficacy of this gaming solution for multiple sclerosis rehabilitation.[10] The serious games are carried out in a virtual home and garden environment requiring activities such as putting away cans in a cupboard or capturing flowers while avoiding being stung by bees [Figure 1].
Figure 1: Exercise for upper limbs (left, touching flowers on the screen) and for the balance (right, moving oranges along the squeezer)

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Each patient follows a games-based upper extremity rehabilitation plan consisting of 15 session (3 sessions of 30 min each, per week). All the patients still continue undergoing the rehabilitation activities planned by the SCI rehabilitation unit. A personalized calibration is conducted at the beginning of each session to get the normal range of anthropometric and physical parameters of each patient; thanks to this calibration the virtual environment can be adapted to the participant's personal abilities irrespective of disability level. The patient is sitting on the wheelchair in front of a large screen and a Microsoft Kinect®, a motion sensing input device, two meters away from the screen. The adaptation of the treatment to individual needs is driven by a therapist interface (doctor station) that can customize the plan in a simple way by modifying the difficulty level or other game elements, such as the number of elements on the screen and their location in it. The adjustable difficulty of levels guides the patient through different activities of the arms and hands because the exercises require to move in a virtual space to interact with the virtual objects in it. Three movements for each patient are identified, and games got selected accordingly.

  Discussion Top

This pilot study investigated the feasibility of a game-based rehabilitation protocol for patients with cervical SCI. The solution deployed allowed the execution of all the training sessions and the adaptation of the rehabilitation plans according to patient-specific needs and improvements from one game session to the following one. A game-based rehabilitation allows to tailor the training plan focusing on the different skills targeted through each game: in the case of an SCI, adding balance games can support the rehabilitation of those patients who need to train also trunk mobility and balance when working with upper limbs. Although the preliminary results are promising and provide initial evidence on the positive effect and feasibility of the serious games approach in rehabilitation for persons affected by SCI, efficacy, and validity of the approach will be further explored.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sakakibara BM, Hitzig SL, Miller WC, Eng JJ, SCIRE Research Team. An evidence-based review on the influence of aging with a spinal cord injury on subjective quality of life. Spinal Cord 2012;50:570-8.  Back to cited text no. 1
Ferguson AR, Huie JR, Crown ED, Baumbauer KM, Hook MA, Garraway SM, et al. Maladaptive spinal plasticity opposes spinal learning and recovery in spinal cord injury. Front Physiol 2012;3:399.  Back to cited text no. 2
Krishna V, Andrews H, Varma A, Mintzer J, Kindy MS, Guest J, et al. Spinal cord injury: How can we improve the classification and quantification of its severity and prognosis? J Neurotrauma 2014;31:215-27.  Back to cited text no. 3
Grabher P, Callaghan MF, Ashburner J, Weiskopf N, Thompson AJ, Curt A, et al. Tracking sensory system atrophy and outcome prediction in spinal cord injury. Ann Neurol 2015;78:751-61.  Back to cited text no. 4
Lee BB, Cripps RA, Fitzharris M, Wing PC. The global map for traumatic spinal cord injury epidemiology: Update 2011, global incidence rate. Spinal Cord 2014;52:110-6.  Back to cited text no. 5
Deutsch JE, Borbely M, Filler J, Huhn K, Guarrera-Bowlby P. Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Phys Ther 2008;88:1196-207.  Back to cited text no. 6
Flynn S, Palma P, Bender A. Feasibility of using the sony playStation 2 gaming platform for an individual poststroke: A case report. J Neurol Phys Ther 2007;31:180-9.  Back to cited text no. 7
Furlan JC, Sakakibara BM, Miller WC, Krassioukov AV. Global incidence and prevalence of traumatic spinal cord injury. Can J Neurol Sci 2013;40:456-64.  Back to cited text no. 8
Capaul M, Zollinger H, Satz N, Dietz V, Lehmann D, Schurch B, et al. Analyses of 94 consecutive spinal cord injury patients using ASIA definition and modified Frankel score classification. Paraplegia 1994;32:583-7.  Back to cited text no. 9
Jonsdottir J, Bertoni R, Lawo M, Montesano A, Bowman T, Gabrielli S, et al. Serious games for arm rehabilitation of persons with multiple sclerosis. A randomized controlled pilot study. Mult Scler Relat Disord 2018;19:25-9.  Back to cited text no. 10


  [Figure 1]

  [Table 1]


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