Gitrenda Uswatte, PhD, Professor of Psychology and Physical Therapy at University of Alabama at Birmingham, talks about Recovery Rapids, a video game therapy based on a form of physical rehabilitation movement therapy, and its benefits for patients who have had a stroke.
Interview conducted by Ivanhoe Broadcast News in February 2018.
Tell me about recovery rapids and how did this idea come about?
Dr. Uswatte: Recovery Rapids is a video game that’s based on a form of physical rehabilitation called Constraint-Induced Movement therapy. It’s known for short as CI therapy. It is the physical rehabilitation for stroke patients with impairment in using one of their arms that has the most evidence of efficacy. But even though there’s strong evidence for CI therapy being effective it’s not offered on a very wide spread clinical basis. Part of the reason for that is that it’s expensive. It takes three and a half hours per day for ten consecutive week days. That’s a fair amount of therapist time and also not that many therapists are trained in this method. There’s some at a few medical centers but there are not many therapists who have received special training in this therapy. Putting the therapy in the form of the video game potentially allows us to get this effective treatment out to many, many patients. CI therapy is a form of upper extremity rehabilitation. It’s given three and a half hours per day for ten consecutive week days on an outpatient basis. And there are four principles that underlie the therapy. One is providing intensive training on functional tasks. The second is organizing that training according to shaping principles which means starting the task at a level of difficulty within the capability of the patient. Then gradually increasing the difficulty of the task as the patient gains mastery. The third element is placing a mitt on the less affected hand to discourage use of that side of the body. The last is a set of behavioral methods that we use to promote transfer of the improvements that take place in the treatment setting to promote the transfer of those improvements to patient’s everyday life.
What are the benefits of using this type of therapy for the patients?
Dr. Uswatte: We know from the CI therapy studies that patients show large improvements in use of their arm in everyday life. Patients go from using their arm five to ten percent of the time before treatment compared to fifty percent of the time after they finish CI therapy. Those are large changes. The benefits of the video game in particular are that the video game approach allows you to put the treatment in patient’s homes so they can do the therapy on their own time in their own home. They don’t have to be near a medical center. The costs are reduced because a therapist doesn’t have to be involved for the whole treatment period. The therapist can set up the patient with the game and then check in on them periodically.
They check in online right?
Dr. Uswatte: Yes. They can get a live video feed with the patient and check in on them that way.
What are some activities that you noticed people couldn’t do before, but after going through this they’re able to do, do you have any examples?
Dr. Uswatte: Yes. There are things we take for granted, things like being able to feed yourself, put your clothes in your drawer, put your clothes on. Those things that we take for granted are often very difficult to do for a stroke patient who has one of their arms affected. Patients who go through therapy are able to start doing those things on an independent basis whereas before they may have needed help from somebody.
You said the therapy right now is just focusing on the arm?
Dr. Uswatte: This trial focuses on the arm yes.
Are there any plans in the future to expand to other ones?
Dr. Uswatte: Yes, our laboratory has developed a form of CI therapy for helping people to walk and move around more effectively. There’s also a form called CI aphasia therapy which helps people who have had strokes who have trouble speaking to speak more effectively and to speak more in their everyday life.
So these are clinical trials ongoing as well?
Dr. Uswatte: For some those studies are complete. We don’t have current studies ongoing but we had studies in the past to address those issues.
Both the aphasia and the walking?
Dr. Uswatte: Yes.
What do you think about going through this for somebody that just is recovering from a stroke?
Dr. Uswatte: One of the things that is different from the CI therapy approach and the current trial, the recovery rapids approach, from other stroke treatments is that stroke patients who are many months after their stroke can take part and benefit. We treat patients who are more than a year after their stroke, or who are more than twenty years after their stroke. We see patients who are eighty nine years old and they’re twenty years after their stroke. Across that whole range, those patients all benefit. It doesn’t seem to be a limit to how long after your stoke is to benefit. One of the advances in knowledge with the research on CI therapy is that even if you’re a year, two years, three years after your stroke you don’t have to give up hope of having additional recovery. You can make additional recovery; you can improve further if you get the right therapy.
Is there anyone that would not be a good candidate for this kind of therapy?
Dr. Uswatte: For the video game form of CI therapy we need the patient to have what we term as a mild to moderate impairment. That means that they can voluntarily extend their fingers more than ten degrees. They have some movement at their finger joints and at the wrist. If a patient has no or minimal movement at the fingers and the wrist then they’re not a candidate for the video game form of CI therapy.
What three tips would you give to somebody recovering from a stroke?
Dr. Uswatte: Not to give up hope, that with the right therapy and with work that there is, they can regain some of their function. Another thing is to value what you can do. It’s easy when we face a challenge to focus on what we’ve lost and what we don’t have. But one of the things that’s very helpful for recovering from a stroke or any other kind of disabling injury is to focus on what you have.
Are there any like mistakes that people make going through recovery that they probably shouldn’t do?
Dr. Uswatte: I wouldn’t describe it as a mistake but this is something about the way current physical rehabilitation is orientated and there are reasons for it. After a stroke typically one side of the body is affected and the other side moves pretty close to as well as before the stroke. Sometimes the focus in rehabilitation is helping the patient to use the intact side of their body to do things. The reason for that is they can get back to their everyday activities more quickly that way. So there’s a good reason for doing that but the downside is if you get in to the habit of using your intact side of the body to do all your activities then that is going to hurt the recovery of your impaired side of the body over the long term.
You mentioned the other arm, the one that they do use; can you talk a little bit about that and the process for that?
Dr. Uswatte: Yes. In CI therapy for the arms we put a padded safety mitt on what we call the less affected arm, the arm that’s not or least affected by the stroke. The patient is asked not only to wear the mitt while they’re in the treatment but also when they go home at the end of the treatment day. The reason for that is to discourage the patient from using the intact side of their body to do things. To break that habit of using the less affected side of the body to accomplish activities.
Can you explain the science behind how restricting one arm can help them use the other one more?
Dr. Uswatte: Yeah. It’s a basic idea called learned nonuse. This concept was developed by my close colleague Edward Taub who is also here at the University of Alabama at Birmingham. The idea of learned nonuse is that after a stroke or really any kind of disabling nervous system injury that part of the deficit is learned. It’s not due to the physical injury to the nervous system that takes place but it is behavior that is learned soon after the injury. So for example, say somebody has a stroke that affects the right side of their body. They’re not able to move their right leg effectively and they’re not able to move their right arm effectively. Typically what happens is soon after the stroke the impairment is severe and then with time, in many but not all patients, there’s gradual recovery. But in that period soon after the stroke when the impairment is severe if the patient attempts to pick up a cup with their more affected hand they will spill the contents of the cup. Or they try to button their shirt and they won’t be able to button their shirt. So those failures in use punish the patient for using that arm. It’s also much more effortful to use that arm and that’s punishing too. We know from thousands of experiments from behavioral psychology that if you punish a behavior it becomes less frequent. So what happens to them after stroke is when they attempt to do things with their more affected arm they’re not successful. Those failures punish those attempts to use the arm, and make them less frequent. At the same time they can use their other arm to successfully do things. Those successes are rewarding. That pattern of behavior using the un-affected side of the body but ignoring the affected side of the body becomes stronger and stronger. Now three to six months down the line the patient may recover their ability to use the more affected arm but they don’t use the capacity that they now have because of that habit that they learned soon after the stroke to avoid using that arm. Putting the mitt on the less affected arm breaks that habit in effect.
What are the next steps for this research?
Dr. Uswatte: I think the next step is that we really need to try and disseminate it on a broader basis. If we’re able to demonstrate that patients using Recovery Rapids, the video game for CI therapy, can benefit as much as patients who receive CI therapy the traditional way face-to-face one-on-one in the clinic. If we can demonstrate that it gives equivalent or better outcomes, then to get the word out and to encourage therapists to connect patients with this opportunity.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Gitendra Uswatte, PhD
205-975-5089
Alicia Rohan
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