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Voloshyn T.B.
MD, neurologist, International Clinic of Rehabilitation, Truskavets, Ukraine
Волошин Тарас Богданович
Врач-невролог, Международная клиника восстановительного лечения, г. Трускавец, Украина
COMPUTER GAME THERAPY IN REHABILITATION OF CHILDREN WITH AUTISM
SPECTRUM DISORDERS. КОМПЬЮТЕРНАЯ ИГРОТЕРАПИЯ В РЕАБИЛИТАЦИИ ДЕТЕЙ С РАССТРОЙСТВАМИ
АУТИСТИЧЕСКОГО СПЕКТРА.
Summary: Motor discoordination and dyspraxia are often observed in children with autism spectrum disorders (ASD). The formation of the correct movements, improved concentration of an attention and social interaction are one of the most important goals of rehabilitation of children with ASD. The effectiveness of rehabilitation depends on the plasticity of the nervous system, which is stimulated by repetition of specific active movements, the intensity of training and positive motivation. The imperfection of mechanical equipment used for that aim is in the monotony and lack of motivation for regular and sustained training. In the International Clinic of Rehabilitation (ICR), Truskavets (Ukraine) and the Rehabilitation center "Elita", Lviv (Ukraine) useful but boring training was combined with exciting computer games. For patients with impairments in psychomotor sphere more than 25 specialized computer games has been developed both for home-based usage and usage during intensive course in the rehabilitation center.
Key words: ASD, Intensive neurophysiological rehabilitation system (INRS), computer games, home web-based rehabilitation.
Аннотация. При расстройствах аутистического спектра (РАС) моторная дискоординация и диспрак-сия наблюдаються очень часто. Издание правильного двигательного стереотипа, улучшение концента-ции внимания и соцальной интеракции являются одними из главных целей реабилитации детей с РАС. Эффективность реабилитации зависит от пластичности нервной системы, которую стимулирует многократное повторение необходимых движений, интенсивность тренировок и позитивная мотивация. Несовершенство механических тренажеров, которые испльзуются для этих целей, состоит в монотонности и отсутствии мотивации к регулярным и длительным занятиям. В Международной клинике восстановительного лечения (МКВЛ), г. Трускавец (Украина) и Реабилитационном центре «Элита», г. Львов (Украина) соединили полезные, но скучные тренировки с захватывающими компьютерными играми. Для пациентов с нарушениями психомоторной сферы уже создано 25 таких игр для использования как в домашних условиях, так и во время интенсивного курса в реабилитационном центре.
Ключевые слова: РАС, Система интенсивной нейрофизиологической реабилитации (СИНР), компьютерные игры, интернет-система домашних игровых тренировок.
Introduction.
The exceptional diversity of autism spectrum disorders (ASD) and its severity allows to consider training and education of these children as the most difficult section of correctional pedagogics. While mostly researches in the field of childhood autism are devoted to violations in socialization, problems in communication and interaction can also contribute to limiting motor skills.
The development of motor capabilities is critical because children with ASD often "hide" their inability to perform simple physical exercises. If the child refuses to play with other children, the cause is often not a problem in social interaction but in lack of confidence in child's physical ability to play games. In most cases these patients suffer violations in both fine
and gross motor functions. Number of children with motor discoordination and dyspraxia in ASD, according to various studies, is as high as 85% [1]. Formation of correct movements, improvements in concentration and social interaction are important tasks of rehabilitation of children with ASD.
Recovery of motor functions depends on the plasticity of nervous system that is stimulated by repetition of movements, the intensity of training and positive motivation. Traditionally, mechanical simulators that are used to improve motor performance do not always bring the desired effect. Imperfection is in their monotony and lack of motivation of a child to perform long and regular exercises.
In the International Clinic of Rehabilitation (ICR), Truskavets (Ukraine) and Rehabilitation center
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"Elita", Lviv (Ukraine) useful, but rather tedious process of training of the child was combined with interesting and exciting computer games [2]. Up to now, more than a dozen of games for patients with impairments in psychomotor area were created and are available free of charge to patients on web sites: www.game.reha.lviv.ua and www.rehagame.com.
Movement of the arms, legs or torso of the patient with ASD coincides with the movement of video game characters or patient's image is projected on the screen and therefore child becomes a part of the game. Game parameters can be changed during the game session, the instructor chooses the appropriate level of speed and complexity according to the needs of a certain patient.
The first commercially successful computer games were developed in the 1970s as entertainment [3]. Almost at the same time, doctors and psychologists have used computer and video games as a part of the therapy [4] and began to develop therapeutic computer games [5]. According to recent estimates of prevalence, computer and video games are played by 59% [6] to 63% [7] of all children. This provides a lof of new opportunities for usage of augmented reality within the rehabilitation process.
Review of the literature indicates that computer games have already been successfully used to improve diet and physical activity in children for the treatment of chemotherapy-dependent nausea, preoperative anxiety, in fitness, exercise therapy and cognitive rehabilitation [8, 9].
Side effects of computer games are very rare, they include isolated cases of epilepsy and muscle tension [10]. Computer game therapy is used with proven efficacy in children and adults [11], including the elderly [12], in short and long-term rehabilitation [13,14], to improve overall physical activity [15], for reduction of level of pain [14], for improvement of cognitive functioning after traumatic brain injury [16], stroke, Huntington's disease [17], in cases of multiple sclerosis [18].
A series of pilot studies [10, 12, 15, 16] indicates improvement after using the computer play therapy in psychosocial functioning, reducing signs of distress
[19], positive dynamics of emotional state is observed
[20], level of confidence [21], socialization [21 22] and quality of life [21].
Recent studies and reviews identified four main components of the beneficial effects of computer games: cognitive, motivational, emotional and social [23, 24].
Computer game training increases speed in daily activity, improves concentration of an attention; such cognitive skills as learning, memory, executive functions, creativity; problem solving skills. Motivational benefits include improvement in perseverance. Emotional benefits are in improvement of mood and regu-
lation of adaptive management strategies of such negative emotions as anger, anxiety and depression. Hranik I. et al. [23] noted the positive social changes during computer game training, namely expansion of cooperation, support, mutual aid and improved behavior along with better social activity.
In a recent study, conducted during individual behavioral therapy, patients with childhood autism were taught to manipulate game controller for the PlayStation 2 in the game "Hero player» (Guitar Hero). Accuracy in tasks fulfilment after training increased significantly and improved up to 70% [25].
Behavior, socialization, ability to make compliments to peers much improved after the group sessions of Nintendo Wii computer games [26]. Classes were held for 10 weeks in a group of 10 children aged 7-11 years, nine of whom were diagnosed with childhood autism.
Research on the use of computer games shows that the amount of playing time and duration of gaming sessions is related to the likelihood of socio-emotional and educational problems, while playing together with children and social promotion are protective factors [27, 28]. Parents (instructors) should play with their children and monitor their game in duration and content, encourage them to play with other children, preferably personally, not online [29].
Mostly systems for virtual training and rehabilitation movements are rather complicated, expensive and may be used only in a rehabilitation center. On the other hand, there is a number of inexpensive, commercially available gaming systems that have a high potential to train movements. These games are designed for healthy children and are too complicated for patients with psychomotor impairments.
The aim of the study.
The aim of the study was to analyse current state of the usage of computer game therapies and its effectiveness in rehabilitation of children with movement disorders and disturbances of speech and mental development. Implementation of specialized computer games on the wrist manipulator, Dance mats, Nintendo Wii platforms and Xbox Kinect, that are adapted to the capabilities and needs of patients with childhood autism into the Intensive neurophysiological rehabilitation system (INRS).
Materials and methods.
A number of programs and games have been developed and tested [13] for usage in a computer game therapy, which gradually becomes important part of the INRS method or method of prof. V.I. Kozyavkin. Rehabilitation of patients with ASD using computer game devices can be provided both in the clinic and at home. Currently already 25 such games were created and used in clinical practice. Pic. 1.
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Pic. 1. Children with ASD playing computer games.
General algorithm of created games is constructed for constant motivation of the patient, to increase range of active motions, increase patient's speed and accuracy, improve concentration of attention. During the game task gradually becomes more complicated and requires more and more sophisticated motions. A fun story stimulates patient with ASD to proper activity, increasing the speed and range of motion, speed of reaction and oculomotor coordination. We also use logic games where physical activity is combined with selecting a proper subject from few pictures. To enhance the emotional impact elements of virtual reality and robotic therapy are used. The process is constantly monitored by computer training instructor.
Results and discussion
The first of this series of devices were created for the wrist, which is designed to improve hand movements. Depending on the position of the handles can be trained either flexion-extension of the wrist or forearm pronation-supination. During the sessions the patient's hand is fixed on the armrest that is adjustable to patient's height. Regulator set requires load re-
sistance, and the first training exercise moves with little resistance, which then gradually increases according to the changes in patient's capabilities.
For carpal manipulator two special games "Bee" and "Cossacks" were developed. The game "Bee" is intended to train turns left and right by hand flexion and extention, that pronation-supination. This game is about the adventures of bees that collect honey from flowers on the green meadow. The bees migration to the playing field children control by the movements of their hands. When the bee touches the periwinkle or daisies drop of honey falls down to a bucket. After earning a full jug, the child moves to the next level of the game. At different levels of the game games should evade flying agaric, avoid Bumblebee, escape from the rain.
To train movement of flexion-extension there was designed game "Cossacks." Bending and straightening steering wheel of the ship (and thus controlling your ship), the player, passing rocky islands, deals with the enemy fleet. At the next level of the game the player has to jump on the field, where he has to combat his opponents. Pic. 2.
Pic. 2. Carpal manipulator.
Each child has its own motor capabilities and limitations, so before the first training it is necessary to adjust the game: to show the range in which the player can carry out the necessary movements. Further information on the initial parameters of the game, along with data on the impact of each game session is stored in a database and can later be used to analyze the impact of training.
The use of wrist manipulator in complex rehabilitation of patients with childhood autism improves the grasping function, increases the volume of active movements and strength of the hand.
Dance mat, Xbox Kinect, Nintendo Wii are inexpensive, commercially available devices. They provide a greater variety of operations and games compared to usual game controllers [30].
Computer Nintendo game therapy is a part of a complex treatment system of Intensive neurophysio-logical rehabilitation (INPR) and it delights children of all ages. Nintendo Wii platform and Wi Remote are used. The game gives great emotional impact, becoming the gaming platform, the child no longer feels sick. Athletes, team members have a real chance to win the grand prize 0 overcome their disease and the
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difficulties of life not only now, within the game time, but in the future adult life. Pic. 3.
Pic. 3.
The main objective of this area of work is to assist in the formation and improvement of functional abilities of patients to improve balance and body control. Rehabilitation of computer game lets you increase the motivation to perform necessary movements and exercise. For each patient game tasks are individually selected, as well as assumptions and tempo in the performance of motor actions. Personalization process is given accorirding to the initial state of each child.
Dance Pad (Dance Mat) - a game controller pad that is divided into 9 sectors with touch sensor in each one, and consists of nine platforms with multidirectional arrows. To control the game you must put foot on the relevant sector. Due to the established program "Step test" [31, 32] on the Dance Mat we can measure the reaction speed and the level of concentration: the game is based on stepping as soon as possible on the mat sector that is highlighted on the screen. Pic. 4.
Pic. 4. Gognitive games on a Dance mat.
Classes at Dance Mat are aimed not only at improving motor performance, but also at improvement of cognitive abilities. Thanks to the created logical games children can choose a shape or object and press the appropriate arrow. Dance mat can be freely purchased in online shops.
To train accuracy and speed of hand movements were developed games that are managed through the Kinect sensor [33]. This is a new gaming controller that tracks the movements of the body and limbs by
analyzing the video of the patient. The controller is developed by Microsoft and is used in game consoles Xbox 360. Developed by us are the games named "The Lord of the balls," "World of Animals", "Transport-1", "Transport-2", "Apple Orchard" that are guided by movements of the hand. It is assumed that before conducting individual workouts calibration range of motion should be set according to the amount of hand movements and difficulty settings of the game. Pic. 5.
Pic. 5.
However, the software has also a diagnostic value. While playing we constantly measure and monitor some important parameters: speed of execution, performance of the game. With established in ICR program "Stabilometriya" on the Wii-platform we can quantify the displacement of the center of body mass
and standard deviation during standing for 15 seconds (measured equilibrium). This data is stored, then it can be used to analyze the achievements of the patient during treatment. According to statistics, in 89±9% of patients with childhood autism already after the first
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course of rehabilitation in ICR the positive dynamics of these indicators is observed. Pic. 6.
LeFt Leg RESULTS Right Leg
Pic. 6. Step-test on a Dance mat.
An important step in the feedback control and the possibility of continuous employment is acreation of a home online training game [34-35].
The therapist prepares the patient for home training program, which identifies certain games, training location, frequency and duration of sessions. The optimal duration of lessons is about 30 minutes per day. At home the patient himself or with parents' aid adjusts home computer training in accordance with the detailed instructions given on the website. The patient enters his password online for systematic training (http://game.reha.lviv.ua), chooses games and the recommended starting level. Information about the course gaming sessions, their duration and the results is stored in the system and displayed on the website in the form of graphs. Instructor provides remote monitoring of the process of training, the program adjusts your home training and make recommendations to the patient. The home-based game rehabilitation system for treatment of movement disorders is the new tool in rehabilitation process provided at home.
Conclusions.
For the interest of the patient with childhood autism in fulfilment of the right exercises, to increase speed, frequency and amplitude of movements, in ICR has been developed a series of rehabilitation games and devices that combine mechanical simulator with exciting computer game. Games that are developed using scenic beauty, interesting animation and plot, provide effective training during gaming sessions and encourage psychomotor development of the child with ASD. The developed system of domestic online gaming training allows continuous remote monitoring and analysis of gaming sessions acocording to duration and results. This combination makes it possible to integrate all the necessary factors for successful learning: allows you to choose the right moves, submit feedback on the successful implementation and significantly reinforces incentives for employment, which is one of the keys to successful rehabilitation.
Prospects for further research are to develop new rehabilitation games for training of cognitive functions, language, logical thinking, socialization, and to conduct testing and evaluation of the effectiveness of this method of treatment both individually and in complex rehabilitation of children with ASD.
Home web-based computer game rehabilitation is a necessary tool for constant rehabilitation process
provided not just within treatment course in a rehabilitation center but constantly during intercourse periods.
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Гордиевич Михаил Степанович
врач ООО «Международная клиника восстановительного лечения», г. Трускавец, Украина
Gordievich Mykhail Stepanovich doctor of LLC "International Clinic of Rehabilitation", Truskavets, Ukraine.
МЕДИКО-ПСИХОЛОГИЧЕСКАЯ РЕАБИЛИТАЦИЯ ДЕТЕЙ С СИНДРОМОМ ДЕФИЦИТА ВНИМАНИЯ И ГИПЕРАКТИВНОСТИ ПО СИСТЕМЕ ИНТЕНСИВНОЙ НЕЙРОФИЗИОЛОГИЧЕСКОЙ РЕАБИЛИТАЦИИ В. И. КОЗЯВКИНА
MEDICAL AND PSYCHOLOGICAL REHABILITATION OF CHILDREN WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER OF THE INTENSIVE NEUROPHYSIOLOGICAL REHABILITATION SYSTEM OF V. I. KOZYAVKIN
Аннотация. В статье представлены результаты применения системы интенсивной нейрофизиологической реабилитации В.И. Козявкина (СИНР) для медико-психологической реабилитации детей с синдромом дефицита внимания и гиперактивности (СДВГ). Показано, что применение СИНР позволило значительно снизить выраженность основных симптомов СДВГ у этих детей, а также способствовало повышению уровня их интеллектуального развития, улучшению мнестических функций, эмоционального состояния и социально-психологической адаптации в целом.
Ключевые слова: дети, синдром дефицита внимания и гиперактивности, дизонтогенез, интеллектуальное развитие, психические функции, реабилитация, система интенсивной нейрофизиологической реабилитации В. И. Козявкина.
Summary: The article presents the results of the application of the Intensive Neurophysiological Rehabilitation System of V. I. Kozyavkin (INRS) for medical and psychological rehabilitation of children with attention deficit hyperactivity disorder (ADHD). It is shown that the use of INRS has significantly reduced the severity of the main symptoms of ADHD in these children, as well as contribute to improving the level of their intellectual development, improve mnemonic function, emotional status and psychosocial adaptation in general.
Key words: children, attention deficit hyperactivity disorder, dizontogeneza, intellectual development, mental functions, Rehabilitation, the Intensive Neurophysiological Rehabilitation System of V. I. Kozyavkin.
Постановка проблемы. Создание эффективных методов лечения и реабилитации детей с различными психическими и неврологическими заболеваниями является одой из наиболее актуальных проблем в настоящее время. Безусловно, что такие методы и технологии должны носить комплексный характер и способствовать не только улучшению здоровья ребенка, но и повышению качества его жизни в целом.
В конце 80-х гг. ХХ столетия проф. В. И. Козявкиным была разработана принципиально новая система интенсивной нейрофизиологической реабилитации (СИНР) для больных ДЦП [3, 4]. Она предполагает применение разносторонних методов воздействия на пациента, действие которых дополняет друг друга. Основой системы является оригинальная методика полисегментарной биомеханической коррекции позвоночника, направленная на устранение функциональных блокад позвоночно-двигательных сегментов и восстановление нормальной подвижности суставов
позвоночника. Это позволяет уменьшить проявления дизрегуляции нервной системы на разных уровнях чувствительных и двигательных систем [3]. В целом, комплекс лечебных мероприятий СИНР включает биомеханическую коррекцию позвоночника, мобилизацию суставов конечностей, рефлексотерапию, мобилизующую гимнастику, специальную систему массажа, ритмическую гимнастику и механотерапию [3].
Система интенсивной нейрофизиологической реабилитации состоит из двух подсистем: подсистемы интенсивной коррекции и подсистемы стабилизации и потенцирования эффекта. Интенсивная коррекция проводится в условиях реабилитационного центра в течение двух недель. Период стабилизации и потенцирования эффекта лечения длится от одного-трех до шести-двенадцати месяцев в домашних условиях, в соответствии с полученными рекомендациями, после чего проводится повторный курс интенсивной коррекции. Перерыв
