Detailed and formatted blog posts prior to April 2014 can be found in the following locations:

Kinect: Gaming for health – MIRA rehab

Article about gaming in health, focusing on MIRA Rehab software

Found on page 42.


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DMD console and controller access

I was asked the other day by a fellow clinician about how to best advise a young man with Duchennes Muscular Dystrophy (DMD) whose hand function was beginning to interfere with his ability to grip and access his Xbox One game playing. Those of you who work with DMD patients will know that they often find great recreation in playing on their gaming consoles whether it be an Xbox, PlayStation or any other.  The variety of games, online challenges, friendships and general pastime enjoyment offers quality to their lives where physical movement is itself challenging and sometimes uncomfortable.  By using the consoles they compete without barriers or bias and are very often incredibly good at the finer controls required to be successful.  I mention the PlayStation and Xbox but the Wii also has its place with DMD, it just doesn’t have the graphics, online community or range of high spec games that attract and keep the interest of hardened gamers.

So I see these consoles as a window and opportunity for normal activity amongst these young men – irrespective of their general independence, ability or prognosis.  So what happens when that fine motor control and high level thumb/finger control starts to be compromised by the condition?  The reality is that of potentially losing access to a hobby, a pastime and potentially a lifeline to normality.  For these reasons I consider it important, as a therapist to facilitate access and use to such consoles and their controllers even through, unlike the Wii, the control requires very little movement and has limited therapeutic benefits.  The benefits are with the continued well-being and quality of life for the young patient.

So what are the options?  Initially positioning is key.  Whilst movement may be reducing it doesn’t mean that access is impossible.  By assessing and identifying the position in which their forearms and hands have the most movement and function it maybe as easy as advising on how to access the controller for longer.  It maybe that props are used- wedges, towels, sponge, memory foam, cradles or anything else that as therapists we have to hand.

Once supporting current controller use has been explored and exhausted then looking at an alternative controller might offer a solution.  Different brands (3rd party) will require slightly different hand positioning and may require more sensitive controls.   This process would be that of trial and error and could have cost implications.  A cheaper solution would be to purchase second hand in order to use for assessment and therefore best inform the patient of what they need.

Lastly when a replacement and more accessible controller cannot be found there are addons that can be purchased that fit on the two joystick controllers.  The joystick extensions have the main purpose of increasing the sensitivity and therefore should allow control with less movement required.  The additional height that the addon adds to the joystick may also compromise the access to play, but it’s an option that’s worth looking into.

So what happens when accessing a console via controller is no longer feasible? All may not be lost, but the solutions can’t necessarily be bought ‘off the shelf’.  The website may have alternative adapted controllers that may be suitable, although they may not look like a conventional and modern controller and may also have cost implications.  Equally the local REMAP team ( may have electrical engineers who can adapt the controllers to remove the casing making the joystick and buttons more accessible in a process referred to as ‘modding’.  This would be a bespoke solution.  Moving away from consoles there are other gaming options, but these are often PC based using either adapted keys or mouse and do not offer the complexity, variety and challenge that mainstream consoles do.

Thanks to Anthony Rhys from GestureSEN who pointed out that Special Effect work on this type of project to continue to enable access for those struggling with console controllers – Definitely worth getting in touch. Great work!

To conclude, as therapists I believe that we can help, at least in the early stages where support is needed to continue to access traditional controllers.  New technology is emerging all the time and so it is reasonable to think that in the not too distant future technologies such as the Kinect will pick up even the smallest movements (such as finger/thumb) and be able to use them to continue game play.  Such technologies already exists to help assess movement of ‘reachable workspaces’ as reported in the following research article:

There are other links online that touch on this topic, see below:






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NEWS: Motion-sensing video game may be the future of rehab – MIRA Rehab

A broken arm as a boy led Cosmin Mihaiu and some inventive colleagues to turn tedious physical rehabilitation exercises into a game that they hope can make it easier for people to recover from injuries.
The Romania-born software engineer demonstrated the game Thursday at the prestigious TED Conference in Vancouver, showing how it can be played on the motion-sensing video game platform Kinect for Micosoft’s Xbox.
“We need to come up with solutions to get patients motivated to get better,” Mihaiu told AFP.

Read More :  HERE

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RESEARCH: Perceptions of using videogames in rehabilitation: a dual perspective of people with multiple sclerosis and physiotherapists

Disability and Rehabilitation, 2015; 37(4): 338–344

Anette Forsberg, Ylva Nilsagard, and Katrin Bostrom

Purpose: Our aim was to describe experiences of using Nintendo Wii Fit for balance exercise,
from the perspectives of patients with multiple sclerosis (MS) and their physiotherapists (PT).

Methods: Individual interviews with 15 patients with MS were conducted, recruited from a
multi-centre study investigating the effects of balance exercising using Wii Fit. We also
conducted a single focus group interview with nine PT involved in the study. The interviews
were audio-recorded, transcribed, and analysed using content analysis.

Results: Both patients and PT said that exercising with Wii Fit games was fun, and that it challenged the patients’
physical and cognitive capacities. The competitive content in the games provided motivation to
continue playing. Patients and PT reported improved body control and, more importantly,
positive effects on balance and walking in daily life. The PT regarded Wii training as an effective
alternative to other balance training, but some felt unsure in how to manage the video game.
The patients regarded Wii training as a possible home training solution.

Conclusions: Patients with MS and their PT considered Wii Fit exercises to be fun, challenging, and self-motivating. Exercising with Wii games can address balance impairments in MS, and can be performed at
home as well as in rehabilitation settings.

Multiple sclerosis, physiotherapists, postural balance, qualitative research, videogames


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RESEARCH: Development and preliminary evaluation of a novel low cost VR-based upper limb stroke rehabilitation platform using Wii technology

Disability Rehabilitation: Assistive Technology. 2014 Nov 13:1-10. [Epub ahead of print]

Authors: Emmanuel Tsekleves, Ioannis Theoklitos Paraskevopoulos, Alyson Warland, and Cherry Kilbride


Purpose: This paper proposes a novel system (using the Nintendo Wii remote) that offers customised, non-immersive, virtual reality-based, upper-limb stroke rehabilitation and reports on promising preliminary findings with stroke survivors.
Method: The system novelty lies in the high accuracy of the full kinematic tracking of the upper limb movement in real-time, offering strong personal connection between the stroke survivor and a virtual character when executing therapist prescribed adjustable exercises/games. It allows the therapist to monitor patient performance and to individually calibrate the system in terms of range of movement, speed and duration.
Results: The system was tested for acceptability with three stroke survivors with differing levels of disability. Participants reported an overwhelming connection with the system and avatar. A two-week, single case study with a long-term stroke survivor showed positive changes in all four outcome measures employed, with the participant reporting better wrist control and greater functional use. Activities, which were deemed too challenging or too easy were associated with lower scores of enjoyment/motivation, highlighting the need for activities to be individually calibrated.
Conclusions: Given the preliminary findings, it would be beneficial to extend the case study in terms of duration and participants and to conduct an acceptability and feasibility study with community dwelling survivors.

Implications for Rehabilitation

– Low-cost, off-the-shelf game sensors, such as the Nintendo Wii remote, are acceptable by stroke survivors as an add-on to upper limb stroke rehabilitation but have to be bespoked to provide high-fidelity and real-time kinematic tracking of the arm movement.

– Providing therapists with real-time and remote monitoring of the quality of the movement and not just the amount of practice, is imperative and most critical for getting a better understanding of each patient and administering the right amount and type of exercise.

– The ability to translate therapeutic arm movement into individually calibrated exercises and games, allows accommodation of the wide range of movement difficulties seen after stroke and the ability to adjust these activities (in terms of speed, range of movement and duration) will aid motivation and adherence – key issues in rehabilitation.

– With increasing pressures on resources and the move to more community-based rehabilitation, the proposed system has the potential for promoting the intensity of practice necessary for recovery in both community and acute settings.

Feedback, games, motion capture, Nintendo Wii, stroke rehabilitation, virtual reality

Read More:

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RESEARCH: Pilot Study to Assess the Benefit of a Virtual Reality Game System, Nintendo Wii, on Balance and Gait in Persons With Parkinson’s Disease

Poster of research – available at

Publication/Presentation Date
Published In/Presented At
Barbour, P., Kerstetter, A., Tremblay, S., Danni, A., Hammer, J., & Weiss, M. (2014, June 8-12). Pilot study to assess benefit of virtual reality game system, wii, on balance and gait in persons with parkinson’s disease. Poster presented at: The 2014 International Congress of Parkinson’s Disease and Movement Disorders, Stockholm, Sweden.
Document Type

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RESEARCH: Home-Based Balance Training Using the Wii Balance Board A Randomized, Crossover Pilot Study in Multiple Sclerosis.

Neurorehabilitation & Neural Repair 2013; 27: 516-525

Luca Prosperini, MD
Deborah Fortuna, MS
Costanza Giannì, MD
Laura Leonardi, MD
Maria Rita Marchetti, MS
Carlo Pozzilli, MD, PhD


Objective. To evaluate the effectiveness of a home-based rehabilitation of balance using the Nintendo Wii Balance Board System (WBBS) in patients affected by multiple sclerosis (MS).

Methods. In this 24-week, randomized, 2-period crossover pilot study, 36 patients having an objective balance disorder were randomly assigned in a 1:1 ratio to 2 counterbalanced arms. Group A started a 12-week period of home-based WBBS training followed by a 12-week period without any intervention; group B received the treatment in reverse order. As endpoints, we considered the mean difference (compared with baseline) in force platform measures (ie, the displacement of body center of pressure in 30 seconds), 4-step square test (FSST), 25-foot timed walking test (25-FWT), and 29-item MS Impact Scale (MSIS-29), as evaluated after 12 weeks and at the end of the 24-week study period.

Results. The 2 groups did not differ in baseline characteristics. Repeated-measures analyses of variance showed significant time × treatment effects, indicating that WBBS was effective in ameliorating force platform measures (F = 4.608, P = .016), FSST (F = 3.745, P = .034), 25-FWT (F = 3.339, P = .048), and MSIS-29 (F = 4.282, P = .023). Five adverse events attributable to the WBSS training (knee or low back pain) were recorded, but only 1 patient had to retire from the study.

Conclusion. A home-based WBBS training might potentially provide an effective, engaging, balance rehabilitation solution for people with MS. However, the risk of WBBS training-related injuries should be carefully balanced with benefits. Further studies, including cost-effectiveness analyses, are warranted to establish whether WBBS may be useful in the home setting.

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RESEARCH: Exergaming With Additional Postural Demands Improves Balance and Gait in Patients With Multiple Sclerosis as Much as Conventional Balance Training and Leads to High Adherence to Home-Based Balance Training.

Archives of Physical Medicine and Rehabilitation
October 2014 Volume 95, Issue 10, Pages 1803–1809
Authors: Andreas Kramer, PhD, Christian Dettmers, MD, Markus Gruber, PhD

To assess the effectiveness of and adherence to an exergame balance training program with additional postural demands in patients with multiple sclerosis (MS).

Matched controlled trial, assessment of balance before and after different balance training programs, and adherence to home-based balance exercise in the 6 months after the training.

A neurorehabilitation facility and center for MS.

Patients with balance problems (N=70) matched into 1 of the training groups according to age as well as balance and gait performance in 4 tests. Nine patients dropped out of the study because of scheduling problems. The mean age of the 61 remaining participants was 47±9 years, and their Expanded Disability Status Scale score was 3±1.

Three weeks of (1) conventional balance training (control), (2) exergame training (playing exergames on an unstable platform), or (3) single-task (ST) exercises on the unstable platform.

Main Outcome Measures
Test scores in balance tests and gait analyses under ST and dual-task (DT) situations. Furthermore, in the 6 months after the rehabilitation training, the frequency and type of balance training were assessed by using questionnaires.

All 3 groups showed significantly improved balance and gait scores. Only the exergame training group showed significantly higher improvements in the DT condition of the gait test than in the ST condition. Adherence to home-based balance training differed significantly between groups (highest adherence in the exergame training group).

Playing exergames on an unstable surface seems to be an effective way to improve balance and gait in patients with MS, especially in DT situations. The integration of exergames seems to have a positive effect on adherence and is thus potentially beneficial for the long-term effectiveness of rehabilitation programs.

Accidental falls, Postural balance, Rehabilitation, Video games

List of abbreviations:
DT (dual task), MS (multiple sclerosis), ST (single task)

Link to article

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RESEARCH: Usability evaluation of a kinematics focused Kinect therapy program for individuals with stroke.

Technology and Health Care. 2014 Nov 25. [Epub ahead of print]

Brokaw EB, Eckel E, Brewer BR.

Continued and frequent use of the affected arm can result in increased function after stroke. However, long-term access to therapy is often limited, and home exercise compliance is low. While rehabilitation gaming is becoming increasingly prevalent, concerns about therapeutic method, safety, and usability for independent home use remain largely unaddressed.
The following paper presents usability evaluation of a game based home therapy program called Home Arm Movement Stroke Training Environment (HAMSTER), which is focused on retraining normal arm kinematics and preventing compensation strategies that limit recovery.
Kinect games were created with special consideration for the stroke population and retraining normal movement kinematics. Ten individuals with stroke evaluated the games in focused interviews and one individual with chronic stroke completed one month of independent HAMSTER use in the home.
The focused interviews showed the need for motivational upper extremity home interventions. Usability evaluation showed the ability for individuals with stroke to interact with the kinematics focused Kinect games after a short exposure time. The single participant evaluation of home use showed good compliance and improvement on all of the clinical outcome measures after the one month of HAMSTER use.
These positive results merit further evaluation of kinematic-focused home gaming interventions like HAMSTER to reduce the use of compensation strategies during home exercise and provide a supplement to conventional care to improve exercise compliance and upper extremity function after stroke.
Stroke; kinematics; neurorehabilitation; upper extremity

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Making physiotherapy fun

Great link to article about MIRA kinect software used for rehab.
Making physiotherapy fun

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