“Defining ‘patient engagement’ is not an easy or clear exercise”
(Gallivan, Kovacs Burns, Bellows, & Eigenseher, 2012)
1.1 Setting the Scene
“Quality of life is defined as psychological well-being, which is dependent on the realization of both social and physical needs.”
(Jung, Li, Janissa, Gladys, & Lee, 2009)
Stroke, or a cerebrovascular accident, is one of the most common causes for long term disability among older adults in industrialised nations (Alankus, Lazar, May, & Kelleher, 2010, p. 2113). It is the equivalent of a heart attack for the brain. A clot forms and blocks blood flow to a portion of the brain, causing the cells deprived of oxygen to start dying. Depending on the part of the brain that is deprived, the victim may suffer cognitive, visual and motor losses (ibid., p. 2113). The effects can be devastating and achieving a full recovery is not always possible.
Hemiparesis (the weakening or loss of control of one side of the body) is the main post-stroke impairment (Shirzad et al., 2015, p. 361). This can result in the non-use of the affected limb(s), which reduces chances of recovery. Such impairment greatly restricts a person’s ability to lead an independent life. It not only affects their motor capabilities, but their sense of individualism and self-esteem.
Older adults’ sense of identity is very important, thus ‘elderly’ is a problematic term for researchers to use. Many people find the label stigmatizing and it may not reflect their physical or mental capabilities correctly (Blythe, Monk, & Doughty, 2005, p. 673). Any product or service developed to suit this older demographic should account for their desire for independence and identity. Additionally, it should enable friends, family and caregivers to support them in a meaningful way (ibid., p. 687).
Rehabilitation is the process of adaptive response to an unexpected change in lifestyle imposed by disease or trauma (Moreira, Rego, & Reis, 2010). It can only be effective if repeated regularly. More often than not, this can be incredibly tedious for patients and a lack of interest or motivation can result in incomplete treatment and lower recovery rate (Barzilay & Wolf, 2013, p. 182, Gerling Schild, & Masuch, 2010, p. 67, Lee, Tien, Chen, & Chen, 2012, p. 435, Moreira et al., 2010, Schonauer et al., 2011). Consequently, the exploration of patient engagement with physiotherapy has been acknowledged as a priority for researchers (Jack, McLean, Moffett, & Gardiner, 2010, p. 227, Lee et al., 2012, p. 435).
The physiotherapeutic focus of this thesis is on lower-limb rehabilitation. The loss of lower-limb functionality in particular can produce a feeling of social isolation through a loss of independence, affecting one’s sense of identity (Binstock and George, 2001, p. 232). Lower-limb functionality impacts a person’s basic needs (e.g. walking, going to the lavatory, getting out of bed), yet we found lower-limb rehabilitation research to be less prominent than upper-limb.
1.2 The Task Ahead
“Success in rehabilitation requires three key concepts: feedback, repetition, and motivation.”
(Barzilay & Wolf, 2013, p. 182)
Games are an excellent means of generating engaging experiences. They generally involve the repetition of specific behaviours, yet elements of their design keep these behaviours from becoming monotonous. These elements can be utilized to motivate patients undergoing physiotherapeutic rehabilitation. Motivation-based cognitions have a large impact on patients’ choices during training, as well as subsequent performance (Orvis, Horn, & Belanich, 2008, p. 2428). A player who enjoys the content of rehabilitation expressed through gameplay will likely play more often and for longer, exposing them frequently to beneficial content (Flores et al., 2008, p. 381, Liu, Ip, Shum, & Wagner, 2014, p.4).
The development of computer technology over recent decades has improved accessibility to digital gaming. Research into the benefits of digital games is relatively new, but results include increased attention span, hand-eye coordination, mental functions, motor skills, problem solving, reaction time, short-term memory, and vision (Jung et al., 2009, Lee et al., 2012, p. 436). In this thesis, we explored the incorporation of digital games into the rehabilitation process, asking the question:
How can digital games facilitate engagement for lower-limb physiotherapeutic rehabilitation for older adults recovering from stroke?
The concept of engagement has been broadly discussed with “little critical exploration of the underpinning concepts the term may represent” (Bright, Kayes, Worrall, & McPherson, 2015, p. 643). In this paper the word ‘engagement’ will be defined as ‘the active participation and investment in one’s own health care, involving energy, enthusiasm, and commitment.’ This definition is derived from the works of Bright et al. (2015), Gallivan, Kovacs Burns, Bellows, & Eigenseher (2012), and Menichetti, Libreri, Lozza, & Graffigna (2014).
1.3 Research Aims
In order to investigate the research question, the main aims were as follows:
1: Define criteria for designing a digital lower-limb rehabilitation game that engages older adults recovering from stroke.
a. Systematically analyse existing digital game theory and systems to situate the research in a body of knowledge.
b. Acquire professional insight on how digital games can facilitate lower-limb rehabilitation for stroke.
2: Create and test a prototype digital game that facilitates lower-limb recovery from stroke.
a. Explore game mechanics and genres that incorporate rehabilitation into gameplay and evaluate with clinician reviews.
b. Iterate chosen concept to develop a final design.
c. Critically evaluate the game through clinician reviews and user testing, iterating the design process based on the findings.