Eling D. de Bruin
REWIRE: Exergames based platform for autonomous rehabilitation
„Whoever wants to understand much must play much“
Gottfried Benn.
Juni 2007 Vorname / Nachname / Institut
Themes
� [1] Theoretical background
� [2] General Overview
� Technologies
� Study Populations
� [3] Example REWIRE
� [4] Practical Application
Juni 2007 Vorname / Nachname / Institut
Requirements for walking?
� Processes include
� mechanoreceptor stimulation,
� neural transmission,
� integration of the signals by the
central nervous system (CNS),
� transmission of an efferent
signal,
� muscle activation,
� and force production .
Juni 2007 Vorname / Nachname / Institut
Adapted from Hausdorff et al. J Appl Physiol. 90: 2117-2129, 2001
Juni 2007 Vorname / Nachname / Institut
The age-related loss of muscle strength is weakly associated with the loss of muscle mass.
Brian C. Clark , Todd M. Manini. What is dynapenia? Nutrition Volume 28, Issue 5 2012 495 – 503.
Juni 2007 Vorname / Nachname / Institut
Proposed biologic mechanisms contributing to dynapenia (the age-associated loss of strength). It shows the influence of multiple factors that may lead to muscle weakness in the elderly. Adapted from J Gerontol A Biol Sci Med Sci 2008. 63: 829-34
Juni 2007 Vorname / Nachname / Institut
Conceptual model of how nervous and muscle system impairments lead to dynapenia
Brian C. Clark , Todd M. Manini. What is dynapenia? Nutrition Volume 28, Issue 5 2012 495 – 503.
Juni 2007 Vorname / Nachname / Institut
Scott. Nature Reviews Neuroscience 5, 532-546; 2004
Neurophysiologicmechanisms (dynapenia):
• Cortex• Aging ►▼motor cortex
excitability/cortical plasticity ► muscleperformance▼
• Spinal Cord• Aging ►▼ General excitability spinal
reflexes ►∆motor unit discharge ►▼
muscle functional properties
• Muscle• ▼ Maximal motor unit firing rates
Clark & Manini. Nutrition 28(5), 2012: 495 – 503
Juni 2007 Vorname / Nachname / Institut
Microstructural Changes: Different For Different Motor Training Regimes
Nonskilled training : Overlearned,
automatic, or endurance based
tasks
� ↑ number of capillaries in
cerebellum and motor cx
� No change in motor cx
topography, synapse number or
glial cells
Black et al. ’90, Kleim et al. ’02
Juni 2007 Vorname / Nachname / Institut
Microstructural Changes: Different For Different Motor Training Regimes
Skilled training : Tasks that require
a high amount of attentional
guidance
� ↑ synapses/neuron in cerebellum
& motor Cx
� ↑ glial cells/neuron in cerebellar
Cx
� Expansion of cortical motor maps
Black et al. ’90, Kleim et al. ’02
Anderson et al. ’94
Kleim et al. ’02
Juni 2007 Vorname / Nachname / Institut
Motor Learning: Video Game Play
� There is evidence to suggest that certain types of video games positively affect physical functioning� postural control� walking abilities and� general functions of the upper
and lower extremities(Pichierri et al. BMC Geriatrics 2011, 11:29)
Juni 2007 Vorname / Nachname / Institut
Adapted from Hausdorff et al. J Appl Physiol. 90: 2117-2129, 2001
PHYSICAL ACTIVITY
American Geriatrics Society (2001) JAGS 49:664-672.
«……two possible mechanisms that could operate to improve motor function in this [Neurorehabilitation] setting:
volition and motor imagery» Lotze & Cohen, Cog Behav Neurol 2006;19:135–140
Juni 2007 Vorname / Nachname / Institut
Technologies
Five categories according to the physical exercise component
of the intervention:
[1] Step training
[2] Balance board training
[3] Balance board plus aerobic training
[4] Programs using inertial sensors and/or motion capture devices
[5] Aerobic programs - locomotive training using VR displays
Juni 2007 Vorname / Nachname / Institut
Pre-to-post intervention changes in maximal leg extension strength (maximal voluntary contraction [MVC]; left panel) and postural balance (center of pressure velocity moment [CoP-VM], right panel)
adjusted for gender, age, and baseline level in the Nintendo Wii group (dark grey bars) and the control group (light grey bars).
© The Author 2012. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].
Martin G. Jorgensen et al. J Gerontol A Biol Sci Me d Sci 2013;68:845-852
Juni 2007 Vorname / Nachname / Institut
Molecular Psychiatry (2014) 19, 265-271;
doi:10.1038/mp.2013.120
Juni 2007 Vorname / Nachname / Institut
Seline Wüest
Nunzio Alberto Borghese
Michele Pirovano
Renato Mainetti
Eling D. de Bruin
Juni 2007 Vorname / Nachname / Institut
Pre Pilot Project: Elderly Users
� Do elderly people accept and use the new exergame-based technology developed within the
REWIRE project?
� Do the study participants adhere well to the virtual reality-based REWIRE games
intervention?
� Do the study participants accept the virtual reality-based REWIRE games training method?
� Is the virtual reality-based balance training intervention with the REWIRE games able to
improve the balance of elderly?
� Is the REWIRE games-based training able to improve aspects of gait of elderly?
Juni 2007 Vorname / Nachname / Institut
Background Methods Results & Discussion Conclusion
�Intervention
• Exergame-based balance training
• 3 times / week
• 1 training session: 20 minutes
• In total: 36 training sessions
Juni 2007 Vorname / Nachname / Institut
Background Methods Results & Discussion Conclusion
�Secondary outcomes – BBS, TUG, SPPB
Baseline
(mean ± SD)
Post-
intervention
(mean ± SD)
Pwithin
r
BBS (points) 51.7 ± 3.3 54.8 ± 1.4 0.007 0.51
7-Meter TUG
(seconds)19.8 ± 2.8 17.5 ± 2.4 0.002 0.56
SPPB (points) 9.9 ± 1.0 11.2 ± 0.8 0.013 0.48
Juni 2007 Vorname / Nachname / Institut
Points of discussion
� To what degree and how end-users have been engaged
� What are the unpublished and possibly unpublishable lessons from your work
� What are the challenges and opportunities for the future
Juni 2007 Vorname / Nachname / Institut
“Man does not cease to play because he grows old. Man grows old because he ceases to play”
George Bernard Shaw
Juni 2007 Vorname / Nachname / Institut
Thank youfor your attention!
The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement N. 287713, project REWIRE, of the European Union (EU).
Juni 2007 Vorname / Nachname / Institut
� Good balance skills: an important determinant of walking performance
� Impaired balance ability assumed to be related to decreased locomotor function [Clin Rehabil 20 (11):960-969; Expert review of neurotherapeutics 7 (10):1417-1436]
� Task-related activities lead to greater improvements in post-stroke walking competency vs. non-task-related practices [Annu Rev Med 60:55-68; Clin Rehabil 18 (5):509-519; Arch Phys Med Rehab 81 (4):409-417]
� Variable practice leads to better transfer and retention of motor skills [e.g., Curr Opin Neurol 19 (1):84-90]
� Progression : rehabilitation programs benefit from a continuous adaptation of task difficulty to increasing skill level [Journal of Neurological Physical Therapy 28 (1):35]
Juni 2007 Vorname / Nachname / Institut
Gentile’s Taxonomy of Motor Skills
� Two dimensions:
− Environmental Context
− subdivided into: (1a) regulatory conditions and (1b) intertrial variability
− Action Function
− Involves: (2a) body orientation and (2b) object manipulation
Magill RA. Motor learning and control: Concepts and applications.
McGraw-Hill Boston, MA; 2007
Juni 2007 Vorname / Nachname / Institut
• 16 skill categories
• 3 different levels of difficulty per box
− Level 1: No restrictions
− Level 2: Time limit
− Level 3: Time limit + adequate accuracy
• Balance & Strength: each 16 skill categories & 3 levels of
difficulty (for each category) � 96 training exercises