Chapter 3

You're Never Too Old to Have Fun

“Games offer us a socially acceptable form of play at any age, and an enjoyable stimulus to the imagination.”

(Miller, 2004, p. 219)

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This chapter discusses the findings from background research that was conducted before the development of the digital game (which later came to be known as 12-12). It covers the selection of digital games, design recommendations for older audiences, case studies of digital games for older adults and rehabilitation, design precedents for motion-based gaming and consultation with clinicians. The knowledge obtained in this chapter formed the foundation for decision-making and critique during the subsequent design phase.

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3.1 Literature Review

For physiotherapeutic rehabilitation to be effective, it must be practiced repeatedly and regularly (Chen et al., 2014, p. 2, Jack et al., 2009, p. 220, McLean, Burton, Bradley, Littlewood, 2010, p. 514). Despite this, poor levels of adherence to prescribed medical treatment are extremely common in patients both young and old (Myers & Midence, 1997, p. 161). This can be attributed to a number of individual factors such as pain, monotony, low self-esteem or poor social support. For physiotherapy to be effective, participants are required to attend appointments, follow clinical advice and performing prescribed exercises correctly and frequently (Jack, et al., 2009, p. 220).

Many papers discussing the effectiveness of physiotherapy practice use the term “adherence” when referring to the consistency of individuals performing their prescribed physiotherapy. While being integral to rehabilitation, “adherence” can have somewhat insensitive connotations that imply the patient to be a passive recipient of care rather than an active participant (McPherson et al., 2014, p. 108, N. Kayes, personal communication, 10 August 2015). In contrast, our use of the term engagement grants the user more agency in their relationship with their rehabilitation. They choose to use the rehabilitation system because they find it entertaining or compelling, not because they were told to do so.

3.1.1 Why digital games?

“By understanding what parts of the game contribute to its enjoyability we can design games that enhance player's desirability to continue play, therefore prolonging their exposure to elements of change.”

(Baranowski, 2014)

It is generally agreed upon that games are an intrinsically motivating platform for engagement. The more motivated a person is to perform a task, the more time and effort they will invest into its completion and the more satisfied they will feel as a result (Malone, 1981, p. 335).

Serious games, or “games that have a main purpose other than entertainment” (Moreira et al., 2010), are becoming more and more common as the industry develops. Typical applications of these games tend to be educational or medical. Due to their nature, the entertainment value of serious games is often seen as less effective than their primary industry counterparts. This is most likely the result of the medium still being in a state of development and having not fully explored the characteristics that make games so captivating (Alankus et al., 2010, p. 2115, Flores, et al., 2008, p. 381, Gerling et al., 2010, p. 66, Martin et al., 2014, p. 101, McLean et al., 2010, p. 520, Moreira et al., 2010, Orvis et al., 2008, p. 2416).

Serious games for an aging community are slowly being recognised for their ability to improve mental and physical well-being, social connectivity, as well as simply offering an enjoyable pastime (Chen et al., 2015, p. 7, Barzilay & Wolf, 2013, p. 183. Ijsselsteijn, Nap, de Kort, & Poels, 2007, p. 17). However, the 65+ demographic is largely underrepresented by commercial games (Gerling et al. 2011, Gregor et al., 2002, p. 151, Ijsselsteijn et al., 2007, p. 17, Jung et al., 2009). This will become more relevant as those who have grown up with digital games get older.

Some scholars suggest that serious games are simply tools to encourage a specific interaction (Bogost, 2007, p. 57, Moreira et al., 2010, Lee et al., 2012, p. 436). In some cases the use of the term “tool” may be chosen arbitrarily, but Malone illustrates the point that there is a significant, fundamental difference between tools and toys (1981, p.359), or in this case games. Tools should be invisible; simply a means to an end, yet a good game deliberately provides opposition against the user. This focus on the “gamification” of serious topics may be what is limiting the success of serious games. Gamification, or “the use of game design elements in non-game contexts” (Deterding, Dixon, Khaled, & Nacke, 2011, p. 10), is a versatile concept. One limitation of gamification is that it functions as an addition to the context that hosts it. The host needs to have some intrinsic motivation already present (Deterding, 2012, p. 17). Perhaps a greater focus is necessary on generating experiences that are engaging at their core, yet accessible to an audience with (and despite of) specific impairments.

3.1.2 Games for older adults

“Research results suggest that the [Nintendo Wii] is widely accepted among senior citizens and that playing Wii games has a positive impact on the overall well-being of institutionalized elderly.”

(Gerling et al., 2010, p. 66)

Gregor et al. notes that developers of serious games have a tendency to separate their target audience into either “disabled people” or “normal people,” overlooking the diverse range of capabilities that exist within the user-base (2002, p. 152). An older audience is rich with diversity, yet their broad range of capabilities means there are numerous barriers for engagement that can present themselves. The following section addresses these barriers and potential means of accounting for them.

3.1.3 Level of Confidence

Older adults have repeatedly shown open-mindedness towards the use of new technology (Gerling et al., 2010, p. 69, Gerling et al., 2011, Ijsselsteijn et al., 2007, p.18, Jung et al., 2009). Scholars such as Ijsselsteijn et al. (2007, p.18) and Nap et al. (2009, p. 248) claim technology is more likely to be positively received if interaction with it is simple and the benefits of its use are clear. Despite this, the user’s level of confidence can limit their ability to engage with computer systems i.e. cell phones, laptops or tablets (Nap. et al., 2009, p. 260).

Confidence with computer technology can be drawn from personal experience. Some studies suggest that existing digital games deviate too much from the physical games older adults are familiar with such as card or board games (Mahmud, Mubin, Shahid, & Martens, 2008, p. 403, Nap et al., 2009, p. 247, Orvis et al., 2008, p. 2418). The lack of a conceptual model of computer functions can limit what older users are willing to attempt. This is not necessarily due to the complexity of computer systems, given the complexity of traditional games older adults may play. Ma et al. highlight the importance of users being familiar with a system before it requires them to perform complex actions (2007, p. 688). Therefore, if the game is built around concepts familiar to older adults, they can prioritise learning how to navigate the unfamiliar interface.

Ijsselsteijn et al. state that another way to combat ‘computer anxiety’ is to provide encouraging feedback (2007, p. 19). Self-efficacy relates directly to motivation: a user who feels capable of accomplishing tasks is more likely to engage with them (Sampayo-Vargas, Cope, He, & Byrne, 2013, p. 458). In-game feedback functions as a motivator to complete the task at hand. Post-session feedback enables players to track their progress and view information about their functional ability (Shirzad et al., 2015, p. 366). Granting players a clear sense of progression will help maintain motivation levels as the more perceived control one has over a system, the more positively they react towards it (Lee et al., 2012, p. 445, Mathwick & Rigdon, 2004, p. 325).

The subjective nature of self-efficacy and motivation renders them difficult to measure. In fact, there is little concrete evidence that one method for improving self-efficacy is more or less effective than another. This is not necessarily a problem, as an objective perspective may not be appropriate. Although inconclusive, these papers provide a variety of avenues with which further research can be pursued.

3.1.4 Ergonomics

The second main barrier for engagement is the ergonomics of interaction with a computer system. The system’s usability is one of the most important factors that contributes to a user’s sense of control (Shirzad et al., 2015, p. 364). The natural physical decline that occurs with age includes visual and auditory decline and reduced fine motor skills.

Visual decline greatly affects how users interpret digital interfaces. Gerling et al. (2011), Gregor et al. (2002, p. 151), Ijsselsteijn et al. (2007, p. 18) and Kopacz (2004, p. 212) break down the changes as follows:

• A loss in static and dynamic visual acuity (keenness).
• Reduction of visual accommodation range (ability to track an object as its distance to the eye changes).
• Loss of contrast sensitivity.
• Decrease in dark adaptation (ability of the eye to adjust to low-light conditions).
• Declines in colour sensitivity.
• Heightened susceptibility to problems with glare.
• Fine text becomes difficult to focus on and loses readability.

Digital interfaces allow for high flexibility in this area, where it is possible to include features such as resizable font or colour filters.

Older adults also experience auditory decline meaning pure tones and notes of higher frequencies become difficult to hear. According to Ijsselsteijn et al., 500-1000 Hz is the preferable range for audio elements (2007, p. 18). It is also recommended to use multiple modes of output to generate layered information, such as haptic vibration and synchronized visual and aural cues. This enables users who are less receptive to still receive information through their strongest sensory channel (Gerling et al., 2010, p. 67, Gregor et al., 2002, p. 154, McLean et al., 2010, p. 516). Sampayo-Vargas et al. warn against confusing this with oversaturation, as redundancy should be avoided (2013, p. 453).

The decline of motor skills also impedes the user experience for older adults. This affects balance, posture and the person’s ability to interact fully with their environment (Gerling et al., 2010, p.67, Gerling et al., 2011). Consequently, default input methods for computer systems, such as a computer mouse and keyboard, may not be appropriate for an older user. Instead, a specialised device that caters to their personal capabilities would be beneficial, especially if the device enables intensive repetitive training for gameplay (Alankus et al., 2010, p. 2113, Dickerson & Brown, 2007, p. 564, Shirzad, 2015, p. 361). Such a device needs to be easy to set up in a home environment as not all survivors of stroke will have access to adequate facilities for training.

Additionally, one must consider how cognitive processes decline with age. This includes “attention processes, working memory, discourse comprehension, problem solving and reasoning and memory encoding and retrieval” (Ijsselsteijn et al., 2007, p. 18). Studies have found that older adults tend to favour tabletop games, i.e. games that utilize a deck of cards or a game board (Gerling et al., 2010, p. 66, Mahmud et al., 2008, p. 404). Gerling et al. refer to these games as “simple” (2010, p. 66), however the strategic complexity of games such as poker or bridge can be very deep. The interfaces of these games are simple; cards in hand or pieces on a board, yet the potential for rich, intelligent play is abundant (see chess). A similar approach can be applied to digital games. The user interface (UI) needs to be simple for accessibility, yet the gameplay can have deep mechanics that give players room to learn and develop strategy. The game needs to respect the cognitive capabilities of its audience.

Separate to user confidence and ergonomics, another means of engaging users is setting goals. Goals are an essential component of a person’s experience of life as meaningful and worthwhile (Emmons, 2003, p. 107) and are therefore integral for evoking the long-term commitment to exercise needed for effective rehabilitation (Dickerson & Brown, 2007, p. 569). Accordingly, goal setting is common practice for clinicians in stroke therapy (McPherson et al., 2014, p. 105). The close connection between goal attainment, motivation, affect and sense of self (ibid., p. 109) indicates that goal setting should be a core component of any digital game designed with a rehabilitative function.

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3.2 Case Studies

Several studies of of serious games for older adults have been conducted with varying degrees of success. This section discusses the work of Alankus et al. (2010), Gregor et al. (2002) with BrookesTalk, Gerling et al. (2010) with SilverBalance, Gerling et al. (2011) with SilverPromenade and Holden and Dyar (2002) with Virtual Teacher.

3.2.1 Towards Customizable Games for Stroke Rehabilitation

The goal of the work by Alankus et al. (2010) was to acquire knowledge on how to generate digital games that were effective at promoting home-based rehabilitation from stroke. The “lessons” they learned came from rapidly prototyping a range of games and testing them on people affected by stroke. The lessons were compiled in a detailed report (ibid., p. 2119).

One of the challenges faced by Alankus et al. was the hardware (2010, p. 2115). For accessibility and affordability they chose to use Nintendo Wii remotes to detect the player’s motion. Singular remotes found it difficult to accurately map the larger motions common to physiotherapy. To combat this, researchers added more remotes to different parts of the body. Even with the inclusion of a webcam for improved accuracy, the system’s affordability was compromised by the additional remotes and a more robust design would be necessary.

Alankus et al. claim the main ways games can contribute to stroke rehabilitation are social context, motion types and cognitive challenge (2010, p. 2117). They developed a large quantity of games to explore these spaces and tested them on four participants with varying degrees of affect from stroke. Although the researchers were able to extract a detailed and comprehensive list of qualities from their user testing sessions, the small sample size limits the usability of their results. The lessons learned through their research can be summarized as such (ibid., p.2119):

• Assume no use of hands.
• Simple games should support multiple methods of user input.
• Calibrate through example motions.
• Direct and natural mappings are necessary.
• Ensure that users’ motions cover their full range.
• Detect compensatory motion.
• Allow coordinated motions.
• Let therapists determine difficulty.
• Audio and visuals are important.
• Automatic difficulty adjustments provide adequate challenge.
• Non-Player Characters (NPCs) and Storylines are intriguing.

Alankus et al. acknowledge their findings are “suggestive rather than conclusive” (2010, p. 2121), as is to be expected when the field of research is so fresh. What separates Alankus et al.’s work from the other studies in this section is the breadth of their approach. Despite the lack of precise findings, the sheer variety of options they explored helped inform basic concept development, as they gave samples of how certain features might succeed or fail.

Figure 3.1 - SilverBalance (GErLING et al., 2010, p.68)

3.2.2 SilverBalance & SilverPromenade

The studies conducted by Gerling et al. (2010) and Gerling et al. (2011) specifically targeted the usability of digital game systems for older adults. Both studies generated a prototype game that was designed around the age-related changes older adults typically experience with cognition and motor capabilities. SilverBalance (Gerling et al., 2010) was developed following a set of criteria that served to maximize the usability of the product. The criteria were as follows (ibid., p. 67):

• Interaction mechanisms should allow for navigation while sitting or standing.
• Extensive or sudden movements should be avoided.
• Older players should be able to adjust the difficulty, game speed and sensitivity of the input device.
• The game should focus on simple interactions and provide constructive criticism.

SilverBalance’s gameplay and aesthetic was incredibly minimalistic. This simplicity was positively received by a focus group of nine participants (ibid., p. 68). Gerling et al’s second game, SilverPromenade (2011), was clearly built on the findings from SilverBalance.

Figure 3.2 - SilverPromenade (Gerling et al., 2011)

SilverPromenade expanded where SilverBalance was lacking by explored research questions regarding Interface Design, Player Experience and Game Design. Twice as many participants were involved in the testing sessions and the focus group was replaced with a questionnaire to account for the increase in numbers. The use of likert scales in the questionnaire were translated into graphs, however the limited sample size renders these results inconclusive in a quantitative sense. Likert scales are efficient at producing quick results but the effectiveness is lessened when the data is small. For this reason, questionnaires were expanded into full interviews during the user testing phase of this research.

Additionally, both studies by Gerling et al. (2010) and Gerling et al. (2011) only involved their participants once during their research process. This leaves the sustainability of the systems’ novelty untested. If a digital game is to function as a means of home-based rehabilitation, playing needs to be desirable for patients on a regular basis.

Figure 3.3 - BrooksTalk (Gregor et al., 2002)

3.2.3 BrooksTalk & Virtual Teacher

Both the studies conducted by Gregor et al. (2002) and Holden and Dyar (2002) explore the significance of adaptability with digital systems. Gregor et al. claim adaptability within the system is a necessity due to the immense level of diversity within an older demographic (2002, p. 152). Their sheer range of physical and cognitive capabilities makes developing systems for older adults very complex. It is understandable then that many of the studies in this field reach inconclusive results. Even Holden and Dyar, whose detailed process involved subjects to perform thirty test sessions over several weeks and mapped their clinical progress using the Fugl-Meyer Test and Wolf Motor Test, used only nine participants and warned readers to interpret their results with caution (2002, p. 70).

Gregor et al.’s “user sensitive inclusive design (USID)” (2002, p. 153) methodology provides a largely applicable alternative to the traditional user centred design (UCD) approach. USID has enough differences to address a complex audience but not be so bold as to claim universal application. Ultimately USID is a formal way of acknowledging that any user groups involved in tests will not be truly representative of the whole demographic, nor would it be possible to achieve such a thing. Instead, Gregor et al. discuss the many of the ways diversity can manifest; vision, confidence, memory and how one might account for these (2002, p. 153). In most cases it comes down to having a flexible interface, which Holden and Dyar agree improves learning and performance (2002, p. 66). It is clear that any design ‘solution’ developed alongside an older user base will only ever be representative of that particular group of users. This does not lower the value of any solutions of this type, as all contribute to a rapidly growing field of research.

A recurrent theme throughout the studies presented is the lack of conclusive findings. Many targeted a specific aspect of the user experience such as game mechanics, visual design, hardware, etc. The complexity of an older user-base means focusing too heavily on one element will lead to inevitable errors. In this paper we attempted to develop a digital game for rehabilitation from a holistic viewpoint, where aspects of human-computer interactions, game design, visual and sound design and rehabilitation were considered in equal portions.

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3.3 Design Precedents

Many commercial games require rapid or complex responses from players as part of their interaction. This makes them unsuitable for older adults with motor impairments. However, there are digital game systems that enable engagement from an older audience.

Figure 3.4 - Nintendo Wii Console and Wii Fit Board

3.3.1 Nintendo Wii & Wii Fit

A reoccurring system in studies is the Nintendo Wii. The Wii’s games, particularly Wii Fit, are very popular in older communities and are heavily referenced in relevant literature (Bainbridge, Bevans, Keeley, & Oriel, 2011, Chen et al., 2014, Gerling et al., 2010, Ijsselsteijn et al. 2007, Jung et al., 2009). Wii Fit’s popularity can be derived from its beneficial nature; providing a means to stay both fit and socially connected with peers (Gerling et al., 2010, p. 66, Jung et al., 2009). Wii Fit strikes a balance between functioning as a serious game for personal health and a commercial game for entertainment. The serious aspects of the game are packaged in yoga classes, training regimes and personal statistics, but players are given the freedom to meet their exercise targets within playful contexts such as ski-jumping or tightrope walking. The use of vibrant colour and humour enhances the joyful nature of the interaction.

Engaging with Wii Fit provides the extrinsic motivation of improving one’s physical health. Physical development is a slow process with very little gratification during the early phases. Wii Fit counters this by rewarding regular interaction and gradual development through badges, high scores and personal goals. It even includes a “fitness age” which can serve another means of extrinsically motivating players to either maintain an age similar to their own, or achieve a lower age to feel fitter than average.

The Nintendo Wii also expands the opportunities for player engagement through “real-time visual representation of the player (i.e., avatars)” (Jung et al., 2009). These customizable avatars enable players to invest in their gameplay experience. They also foster social interaction between players through online leaderboards and social hubs (ibid., 2009).

Many commercial games that use motion-based input are unsuitable as rehabilitation aids due to the expectation that their audience has a full range of motion (Alankus et al., 2010, p. 2114). The Wii is no different. However, the Wii has clear personal benefits in its use, such as focusing on hand-eye coordination and balance to help reduce the risk of falls. The Wii encourages goal setting, which is integral in a physiotherapeutic context (McPherson et al., 2014, p. 105). The popularity of the Wii debunks the notion that digital games are explicitly for younger audiences (Jung et al., 2009) and greatly contributes to the acceptance of modern technology by the older community.

Figure 3.5 - Lokomat in use 1 (Hocoma, 2016)

3.3.2 Garbarello

A less versatile but highly applicable game developed for lower-limb rehabilitation is Garbarello. Although primarily designed for children, there are many elements of Garbarello that are relevant to this study. Garbarello was designed with the purpose of making physiotherapy motivational, optimized and purposeful (Martin et al., 2014, p. 101). To play, patients strap into a Lokomat: a driven gait orthosis that guides patients walking on a treadmill, which can be connected to an interactive virtual environment. The combination of the Lokomat’s physical support and Garbarello’s virtual guidance provides patients with a sense of individualism and frees the practitioner from the need to intervene. In addition to the Lokomat, “Pediatric Interactive Therapy System” (PITS) gloves are used to perform tasks with the patient’s upper limbs. By diverting the focus of the patient to upper limb functions, Garbarello trains the user to automate the gait process (Martin et al., 2014, p. 102).

Figure 3.6 - Lokomat in use 2 (Hocoma, n.d.)

The main restriction of this system is the size of the Lokomat. Interacting with the device is strictly limited to time spent in the clinic as its price and size restrict accessibility. Despite this limitation, there are several things to be learned from Garbarello’s development. The game is aimed at helping people physically recover from a traumatic incident, balancing the physical and cognitive demands on the player and offering positive incentives only, even at minimal exertion (Martin et al., 2014, p. 103). The creators of Garbarello used analysis of gait-orthosis therapy training and consultation with target audience experts to generate criteria for the development of the game. These criteria were as follows:

• It must be self-explanatory for the benefit of both the target audience (children) as well as for therapists in order to avoid introducing additional stress to the therapy setting.

This is highly applicable beyond Garbarello. Not only does it cater to a broad user-base, it is essential for the game to be set up and played in a home environment by patients.

• It had to be naturally, subtly and constantly motivating, even after several training sessions.

The game cannot rely solely on novelty to keep its audience engaged.

• It had to have no gender or age bias.

Keeping the game gender-neutral and age-neutral is a secure way of keeping it accessible to a wide audience. This is important as there is no guarantee of survivors of stroke sharing any personal traits.

• It had to be easily integrated into therapy and could not distract the therapist from monitoring the patient.

If the game requires too much effort to set up, is difficult to interpret, or detracts from the therapy process in any way, then it limits its application in a physiotherapeutic setting. The game’s primary purpose is rehabilitation, therefore any elements that may hinder the process should be removed.

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3.4 A Clinical Point of View

To expand and challenge our understanding of developing a system for stroke rehabilitation, we consulted with three doctors from Auckland’s University of Technology. These specialists were Prof. Denise Taylor, Dr. Nada Signal and Dr. Nicola Kayes. Throughout the development process several subsequent meetings were conducted to ensure the medical integrity of the system was maintained. This section explores the ideas the doctors presented and applies them to the criteria established in Chapter 2.

Figure 3.7 - Aspirations to Tasks

3.4.1 A Research Session with Dr. Nicola Kayes

Dr. Kayes, a specialist in the field of neuro-rehabilitation, has conducted studies into understanding the perspective of people suffering from stroke.

Kayes stressed the importance of differentiating between “adherence” and “engagement.” Adherence, like compliance, implies the patient is the recipient of care; that they are following recommendations and doing what they are told. Engagement implies active commitment to the recovery process; that they are a driving factor in their own recovery. This active participation and dedication is what allows the patient to receive the optimal benefits of their rehabilitation.

Kayes’ research into rehabilitation from the perspective of the patient highlighted the significance of connectivity. This can be separated into two components. The first connection is between the patient and the practitioner. The patient must be able to trust the practitioner in their judgement and advice and trust them with their physical safety. The second connection is between the patient and their personal aspirations, hopes and goals. Each person has their own desires of what they want to accomplish outside of their rehabilitation. This might be playing with their grandkids, go fishing with their friends, or simply be able to move independently without supervision. Rehabilitation is the path they must travel that connects them to these goals.

Figure 3.8 - Progression of Tasks

Kayes emphasised that rehabilitation is an extensive journey, therefore it is important that those taking it have a clear sense of progression. Without it, patients run the risk of losing faith in their ability to recover. Therefore, it is important to bridge the gap between the patient’s broader aspirations and smaller, manageable goals.

Each patient’s therapy tasks should be linked to their broader aspirations, allowing for a more personal and relevant experience. Examples of such are depicted in figures 3.7 and 3.8.

The system must also be noticeably connected to the clinic to function as an extension of it. To support this, Dr. Kayes illustrated the ideal qualities of a practitioner. These qualities should be apparent in any system that is substituting the role of the practitioner.

(For additional notes on this session, see Appendix A)

Figure 3.9 - The Ideal Practitioner

3.4.2 Application of Kayes’ Ideas

In light of Kayes’ comments, each quality could be represented in a different way; be it in the UI, the use of language, the nature of interactions with the system, or the information that is shared between the clinician and patient. Some are more easily accomplished than others. For example; a digital system can be highly adaptive and reciprocating but lacks the human qualities that allow it to be “entrusting.”

There are plenty of successful games that utilize endowed progression to provide addictive and satisfying gameplay. Endowed progression entails granting artificial momentum towards a task by giving the person free points (e.g. stamps, badges, or stars) while extending the goal to account for the free points. Although both versions of the goal require the same amount of work to accomplish, the one with free points elicits stronger motivation for its completion (Nunes & Dreze, 2006, p. 504).

Figure 3.10 - Level Progression (Fruit Ninja) (HALFBACK Studios, 2010)

Jetpack Joyride and Fruit Ninja utilize multiple layers of progress tracking to encourage repeated attempts. The layering of simple ‘missions,’ gaining experience for levels and earning points for buying upgrades combines to give players a staggered series of goals that are never too far away. Nunes and Dreze’s experiment suggest “people are increasingly motivated to complete a task as the get closer to completion” (2006, p. 507), meaning these staggered goals can generate consistent, high levels of motivation.

Figure 3.11 - Rewards (Jetpack Joyride) (Halfbrick Studios, 2011)

Many of the elements Kayes discussed relate to extrinsic motivation and are evident in game systems like Wii Fit. The popularity of the Wii (Bainbridge et al., 2011, p. 127, Jung et al., 2009) improves the credibility of these elements. The effectiveness of personalized goals and progress tracking shows a lot of promise for embedding extrinsic motivation into the game. Players can see their goals reflected in the game’s design and are rewarded for reaching them. This combines with the intrinsic motivation of playing the game for entertainment to make a compelling and engaging experience.

Figure 3.12 - Contextual Factors

3.4.3 A Research Session with Dr. Nada Signal

Dr. Signal is a physiotherapy expert and researcher. She has conducted research into developing physiotherapy practice and has explored the benefits of “Strength for Task Training” (STT) (2014).

Signal explained how the clinical reasoning that determines each patient’s type of rehabilitation comes from a mixture of circumstances. These contextual factors are both subjective (what is important to the patient, what is their social context, who looks after them, or what their goals are) and objective (patient difficulties and limitations determined through tests). These do not determine why the patient has their problems or restrictions but do indicate the level to which they are affected.

Personal factors include the individual's view on their rehabilitation scheme, their relationships with others and their perspective on personal health. Signal spoke of how a patient’s mindset can have a heavy influence on their ability to recover, therefore it is important for them to feel empowered by their recovery process.

These factors interact with each other; a person’s ability to perform an activity is dependent on both their contextual factors and the symptoms of their health condition. The combination of these factors illustrates the sheer complexity of each individual’s journey towards recovery. While patients’ symptoms may be similar, the nature of their impairment(s) can vary greatly, thereby requiring different treatment. The types of impairments commonly experienced by survivors of stroke include the following:

Motor impairments:

• Passive range (amount of motion at a given joint when the joint is moved by an external force)
• Muscle length (the distance the muscle tissue stretches)
• Muscle tone (the tension in the muscle; its resistance to passive stretch)
• Muscle strength (how much force the muscle is capable of exerting)
• Neuromuscular control (the amount of influence the individual has over the nerves that control their voluntary muscles)

Sensory impairments:

• Pain
• Somatosensory (touch, pain, temperature, proprioception - static and dynamic)
• Visual
• Vestibular (balance, eye movement)

Perceptual and cognitive impairments:

• Memory
• Attention

Figure 3.13 - Strength for Task Training

3.4.4 Application of Signal’s Ideas

Signal made it clear that developing a solution that could be deemed ‘universal’ would be impossible. Achieving such complexity and detail is not within the scope of this research. Rather, focusing on a more refined set of qualities will allow our solution to be more usable. As it is not within our capabilities to embed clinical reasoning into our system, we will not implement any functionality that performs diagnosis. Instead, the system would be prescribed to patients by clinicians who think it beneficial. Signal stated that some exercise is better than none, so despite the system not catering to all people within the survivor of stroke community, it can still be an asset for it.

Our interview ended with Signal explaining the clinical reality that patients spend a lot of time during clinical sessions inactive, recovering from exercises, etc. Patient contact time with their clinic is limited. A mode of rehabilitation that can be addressed several times throughout the day will allow for more exercise overall.

Ex. An individual performs their exercises in the morning, breaks for breakfast/lunch, performs more in the afternoon between stationary activities and performs another set before going to sleep.

To enable this type of interaction the system needs to be portable as not to restrict users to a specific location in their homes. Ideally the device that hosts the media would be something like a tablet (e.g. Samsung Galaxy or Apple iPad), allowing for high mobility with ample screen-space for in-game graphics.

Signal’s STT model (2014) is a developmental rehabilitation technique whose novelty resonates with using a digital game for stroke rehabilitation. STT utilizes strength training to “systematically prime the central nervous system prior to task specific training” to maximize gains in locomotor ability (ibid., p. 46). STT is broken into two distinct phases; priming and task-training. Because of this, any game that incorporates STT into play needs to have phases that are proportionally similar to their therapy counterpart.

(For additional notes on this interview, see Appendix A)

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3.5 Clinical Observation

Early in the process we visited a physiotherapy clinic with Prof. Denise Taylor and Dr. Nada Signal. This provided the opportunity to observe a physiotherapy session conducted by professional clinicians. We were able to experience the type of exercises we would promote within our system.

(For more detail on this observations of this session, see Appendix A)

The patient performed simple mobility tasks to test strength and balance. During these tasks, the clinician engaged the patient in conversation.

The purpose of distracting the patient with conversation was explained to promote an unconscious response. For the patient to regain their original mobility, their movements need to be functioning on an unconscious level. Distracting the patient can also help them manage or even forget pain (Lee et al., 2012, p. 436, Moreira et al., 2010). And, of course, an action that is perceived to be less painful is more likely to be repeated than one that is.

This is where the digital game could excel. While interaction with the game facilitates the mobility task, the in-game goal combined with the visual and aural feedback draws the patient’s focus.

The clinician used a technique described as “cueing” where they explained the actions the patient was to perform. This was different to feedback as it occurred prior to the action’s execution. The purpose of cueing is to aid the patient in visualising their goal, giving the action meaning. This can double as instruction for patients have difficulty remembering their therapy motions.

Imagine the movement > Apply the movement

Cueing was not limited to verbal instruction. Sometimes it was as simple as rhythmic clapping to encourage momentum. Something as subtle and a vibration could cue a patient’s movements and would provide them with haptic feedback. Such a function on the device could be tied to key moments of gameplay, for example: a player is about to perform a significant task and receives an auditory prompt combined with a gentle vibration that increases to a brief purr on the task’s completion.

Sometimes an individual with a brain injury cannot filter out additional information, both visual and aural, so any form of feedback should be able to be toned up or down as appropriate. It is also possible for such individuals to experience “central neuro-muscular fatigue,” which affects the drive from the cortex to the muscle. We were told, however, that rarely do patients experience genuine muscle fatigue. If the rehabilitation system is engaging enough and can successfully distract a patient from this type of fatigue, they will be able to maximise the time they spend exercising their limb before becoming too tired to continue.

This observation session prompted consideration of how supportive messages could be included in the software. A basic tutorial is necessary, but it would also be worthwhile to include feedback specific to rehabilitation. Prof. Taylor and Dr. Signal discussed how if a person is not familiar with physical exercise and then suffers a stroke, they may confuse the two sensations and categorise both as negative. It is part of the physiotherapist's job to normalise these sensations with their patients. The software could support this with reminders such as “not all pain is bad. Sometimes it just means you’re working hard. If the pain persists, however, please contact your doctor.” Ijsselsteijn et al. emphasize the importance of encouraging feedback during the early phases of the game where the player’s confidence would be at its lowest (2007, p. 19). The game should encourage players to keep trying in spite of failed attempts, rather than risking them concluding that the system is too difficult to use.

The last observation we discussed was how task-specific training is constructed differently for different patients. Task-specific training (a core component of Dr. Signal’s Strength for Task Training, 2014) is an effective means of generating salience for those partaking in it. Giving context to the patient’s actions can make the task’s relevance (and benefit) more apparent. Patients and clinicians alike tend to prioritise tasks that the patient deems important to complete. This varies greatly depending on the individual. Luckily independent mobility is a universal priority, increasing the importance of focussing on lower-limb rehabilitation.

The information gathered from this observation session combined with an interview with rehabilitation researcher Samantha Ogilvie helped establish a set of user profiles. These profiles helped maintain the UCD methodology by emulating potential users until formal user tests were conducted.

(For additional notes on this interview, see Appendix A)

Figure 3.14 - Bruce

Figure 3.15 - Janet

Figure 3.16 - Paxton