Maggie Reynolds, 72, is playing a video game. On the screen before her, a barrel moves up and down, its motion controlled by her fist thanks to a Microsoft Kinect camera aimed her way, taking in the position of her head, neck, shoulders, elbows, wrists and hands.
Brightly colored stars dart across the screen, just begging to be caught in the barrel’s depths. Maggie inhales, determined to capture one. Her eyes dart between the screen and her upright fist. She struggles, trying to raise her fist a few inches higher. But the desires of her brain can’t connect with her muscles. She fails, and a percussive clunking sound issues from the laptop's speakers, a telltale sign that she's come up short. She lowers and massages her numb left arm, fist still clenched.
Reynolds looks over at Luke Buschmann, the lanky UC Santa Cruz graduate student whose motion-sensing, therapeutic video game she's playing. Focused on a mathematics textbook balanced on his knees, Buschmann hadn’t noticed her struggle, or that Reynolds has good news to share. “That was my highest score,” she boasts.
Four years ago, a massive stroke on Christmas Day robbed Reynolds of control over half her body, though not her zeal. As she spoke about her love of the sun, the violin and Arizona, she sat alert in a ruby-red wheelchair in her Aptos, California living room. Under her faded auburn hair, her lively face was creased with decades of laughter but below her neck, her movements were one-sided. In a stroke, a blood clot or a hemorrhage cuts off the flow of oxygen to part of the brain; within minutes, that region shuts down. “I had a bleed on my right hemisphere, so I lost my left side,” she says. “The bleed just destroyed an immense area of my brain.”
Nearly 800,000 people suffer strokes each year in the United States, with about 75 percent of survivors reporting lasting numbness or paralysis. A century ago, stroke survivors were encouraged to lead quiet, still lives. Today, fueled by overwhelming evidence of the brain’s natural “plasticity”—allowing it to resurrect old pathways and bypass damage—modern therapies try to get stroke survivors moving again. For stroke survivors with damage restricted to one side of their bodies, an often-used therapy involves restricting movement on their good side, forcing them to use their weak sides.
Reynolds is determined to take back every inch of territory she lost, but that constraint-induced movement therapy will not help her. Her left side is too weak. So she’s trying Buschmann’s experimental video game therapy instead.
Buschmann and his advisor, UC Santa Cruz computer engineer Sri Kurniawan, are testing to see whether motion-sensing games can motivate stroke survivors to help themselves heal. They think that video games can help the brain and the body reconnect.
Buschmann created his first game by modifying a basic keyboard-and-mouse game from an open-source website. He simplified the background, added music and sound effects, and adapted it for the Kinect system. From this first game, Buschmann made three more. A month later, he set it up in five different homes within a few miles of UCSC. He visited Reynolds and four other stroke survivors to have them each play his game five times over a two-week period. They could choose from among four games to play for 20 minutes.
All of the volunteers who played Buschmann’s games improved use of their weak sides. After two weeks, the ranges of motion in their shoulders improved. But Buschmann wants more stroke survivors to try the games; five players isn’t enough to make any sweeping claims of victory.
“I wanted to do something in the field of virtual rehab, and it’s a very crowded field,” Buschmann said, explaining his motivation for the study. Researchers, doctors and physical therapists have been studying virtual therapies for two decades, developing games for neurological conditions ranging from dementia to multiple sclerosis.
By its broadest definition, virtual rehabilitation includes any computer- or game-based therapy that can aid in recovery from illness or trauma. Before settling on stroke survivors, Buschmann had considered approaches to help the blind, hearing-impaired and even people with dyslexia.
“I think there’s enough people in this world designing weapons,” he said. “I would like to devote my time to something decent.”
Buschmann isn’t just coming to this solely from a programmer's perspective. His approach to the game design was shaped by months working with stroke survivors as a computer class volunteer at the Stroke and Disability Learning Center, a full-service learning center for people with neurological conditions, located on the Cabrillo College campus in Aptos, about five miles from Reynolds’s home.
About 150 men and women take courses at the center each semester—as students not “patients”— usually at the urging of a primary care doctor. Center staff review each student’s case and recommend courses, including mobility, speech, memory and calisthenics, but they can also take ceramics, painting, singing, dancing, yoga and oral history. When Buschmann decided to design a game for stroke survivors, he turned to Lenny Norton, a physical therapist who teaches movement classes at the center. Norton showed Buschmann the basic movements that paralyzed stroke survivors often struggle with, taught Buschmann how physical therapists measure the range of motion and strength and helped him recruit the five survivors who tested his games.
With Norton’s recommendations, Buschmann designed his games so players could switch arms in the middle, a novel addition, and one that appealed to Maggie Pasquetti. A stroke nearly three years ago left her with paralysis on her left side. But the 62-year-old’s medical insurance didn’t cover comprehensive therapy for her upper limbs. She used self-taught exercises to improve coordination in her weakened left arm, but she yearned for more. “I’d really like to get this arm so I can do more than just hold a can or open a loaf of bread,” she says. Her motivation is evident. In one game, Pasquetti used her weak side 80 percent of the time.
Many researchers see promise in virtual therapy. But the field hasn’t matured—even after 20 years.
“There’s a lot of evidence to show it’s effective, but how much more effective is still in question,” says Mindy Levin, a virtual rehabilitation expert at McGill University in Montreal. The variables for designers and researchers—from consoles to patients—make it almost impossible to compare different games and neurological conditions. But these options also make virtual therapies adaptable to each patient’s needs. “In virtual reality we can modify the practice to fit the person,” Levin says.
Virtual therapy has its critics, often from within the field. Opinions differ on the proper place of virtual approaches, but many agree they should not replace sessions where patients receive face-to-face treatment, guidance and encouragement. A world in which seniors spend all their time with robots isn't one embraced by these researchers.
“They’re a tool. It just depends on how you use it,” says neuroscientist Joaquin Anguera of UC San Francisco, who uses video games to study cognition and multitasking among the elderly. “You can use it right or wrong.”
“You’d have to prove that [virtual therapy] is better than a very good therapist giving you years of traditional therapy,” stresses neurologist John Krakauer of Johns Hopkins University in Baltimore. No large-scale study has measured whether virtual therapy really helps treat neurological conditions. “You need large trials with lots of controls,” adds Mindy Levin. “And a lot of money.”
The same is true for so-called “brain games,” video games marketed to the elderly as products that could boost cognition and improve memory. Last year, 75 scientists acknowledged that the human brain retains a lifelong plasticity and capacity to recover and form new neuronal connections, but cautioned that the promises of “brain games” remain largely untested and unproven.
Some believe the lack of a large comprehensive study is holding fields like virtual rehabilitation back. Others favor the current piecemeal approach. “It may be a bit early,” cautions Chen. “A well-controlled large-scale study will not be easy, even if certain technology shows [promise].” Patients with the same neurological condition are affected in different ways, making a large-scale study difficult, says Chen. But Chen and Levin laud the flexibility of virtual therapy and its potential as a tool to enhance existing therapies.
Krakauer supports virtual therapy under limited circumstances. He argues that patients need intense, aggressive and repetitive therapy right after a stroke, when the brain’s ability to repair itself is primed and ready for action. Most stroke therapies today, including virtual approaches, miss this repair window.
Buschmann’s games might have potential in living rooms beyond California's central coast; they could offer a cheaper and more appealing therapy option to stroke survivors. But video games alone probably can’t heal people. Aggressive, in-person therapy within days of their trauma is crucial, making the most of the brain’s natural window to repair itself. Virtual therapy could come into play though for long-term therapy.
“Find out how they like to play the game, what their favorite settings are,” Buschmann says. “That’s a way you can motivate people.” One volunteer loved Buschmann’s baseball video game because he was a former athlete. Properly applied, these small motivations could be seeds of effective virtual therapy—the difference between doing an exercise a dozen times and quitting, and completing it 200 times each day until the brain bypasses dead zones and builds new neural connections.
James Urton is a science writer at his alma mater, the University of Washington. Go Huskies!