Thursday, May 24, 2012

The Wii, Game Design and Stroke

I recently took part in a research trial that aimed to determine if use of the Wii correlated with an improvement in dominant hand function, for patients who had dominant side damage from stroke. It was specific to stroke, rather than general traumatic brain damage, and if you're involved in the study and want to stay blind to whether I had a Wii, or not, stop reading now, because I'm about to get all dirty on your research protocol.

Over six weeks we either had some basic stretching to do, or we followed up the basic stretching with some (project-provided) Wii Sports action. I had the Wii. Our playing was supposed to be daily, no longer than 45 minutes a day, and seated. After two weeks, I felt I had to quit because it was so frustrating to play that it raised my blood pressure substantially. Since raised blood pressure correlates with death, the Wii study was a dud for me.

So, what was so annoying? Those of you who know my interest in game design, game systems, and now neurology will probably be unsurprised that I was looking at the experience analytically, and came away with some understanding of why I found it so frustrating, especially given the constraints of having had a stroke.

There are five games in Wii Sports, as well as training modes to help you play each game: Tennis, Baseball, Golf, Bowling and Boxing. Boxing was the first game I abandoned, after the first session I played it, because moving my left or right hand correlated so poorly with corresponding motion in my avatar, Sometimes, a punch with the right would end up coming from my Mii's left hand and vice versa. Since the goal was to improve right hand function, my left hand is just fine, and the correlation was so poor, I had no time to waste on the Boxing game, despite the satisfaction of punching the living daylights out of hapless automata.

Next to go, despite a real effort, was the Baseball: it was too hard. In other words the game itself was too coarse-grained, or required too much coordination for any improvement in my motor control to even register. Even if I was getting better at the hard stuff, and that wouldn't show up, the relatively easy stuff got such inconsistent results that the feedback loop necessary for getting my brain to rewire my right side more effectively was simply broken. A batter who missed two 90mph fastballs would then knock a 150mph fastball out of the park. (Please, I do not want to hear how this is, or is not, a reasonable approximation of how you play your rounders.)

Of them all, Bowling was easiest, and had a pretty consistent and tight relationship between the motion of my hand, the virtual motion of the game, and the score represented. But it was too easy: it was soon apparent that equivalent results could be obtained with far less right hand movement, and the brain wants to be efficient, so beyond a certain point, the game was useless therapeutically, it seemed to me. I still played it, though, because strikes are good.

Driving in the Golf game had a nice correspondence between the action of the arms and hands, and the action of the avatar. With wind and hazards to contend with, it was quite compelling, but the sport's scoring was, again, far too coarse. Since putting was horrible, and had a really bad (it seemed to me) correspondence between the controller and the avatar, it was possible to perform well in terms of motor control in the driving but get a terrible (real world) golf score, so as someone working on recovering motor control, the game was sending the wrong message.

Of them all, Tennis had perhaps the best relationship between hand, controller, virtual representation, and end result, but where I most often came to grief was in one of the study's constraints: I had to remain sitting down. So I fell foul of the chair I was sitting on rather than the game itself. Being of a generally placid mien, this was annoying as all hell. Although the result of the tennis match qua tennis match corresponded to my (perceived) performance less well, the ranking seemed to rise and fall according to how well I had done actually.

The study left me pissed off at Wii sports as a therapeutic tool, more than anything else. It seems like, in service to 'real world' considerations, both the Wii as a device and the Wii as a game engine have lost out. I admit to ignorance about the detailed capabilities of the Wii controller's accelerometer(s?), but the Wii has a USB port, and a Kinect will fit, so on that basis, here's what I can't believe doesn't exist already because it should:

- A game engine that exposes motion from tiny to full range of motion for the body parts of the player as easy-to-use quanta.
- Libraries that recognize good and bad use of hands and limbs that again offers very small quantized results. 
- Games that sit on top of the libraries that reward good motion and improved function only.

Our brains function when challenged appropriately, and we're wired to like it,but instead of using technology that already exists to make all people better, we're putting up with crap that makes Zuckerberg richer. There is no reason that, for example, the spell-casting system of a CRPG could not be built to reward good movement, and the game structured to require improvement for advancement. It would be mathematically trivial to scale advancement to handle the difference between a neuro-typical teen and a 60-year old stroke sufferer. If you get the level of abstraction right, your actual game designers barely need to think about what the player is actually doing: it doesn't matter. If the game is compelling and the mapping between improved function and granted reward is tight enough, the rest takes care of itself.

Of course, making the technology work well enough to genuinely determine whether someone's range of motion has improved in the right way with a Wii controller and a Kinect is not a trivial task. But, damn, it's not that hard and there is a huge market when it works.
Shit, make some of this recovery a bit more fun, please!

Friday, May 18, 2012

41st Birthday

I'm 41 today, and it's 7 months and 7 days since I had a big old stroke, so time for an update.

Vision: I had an eye test, and my eyeballs are basically the same as they ever were, which is good: there's no visual field loss or anything. I think they're slowly improving, in that the double vision seems to be gradually correcting, but boy is it slow. It will be interesting to see how well I handle the prescription swimming goggles, since at the moment with regular goggles I just let my eyes do whatever they do, as myopic as ever. My reading speed has improved, too, although it will take binocular vision to get back to where it was.

Balance and Walking: clear improvement. When I last did one of these monthly(ish) updates, I was just recovering some motor control of part of my right leg. Now the formerly missing bits of calf, quad and glute are back for sure. My right leg still sometimes declines to hold me, apparently at random, and I keep my stick handy when I go out, but I walk around the house without the stick. I've also been going to Tai Chi class, and while it is scientifically impossible to correlate any improvement in my balance with my daily Tai Chi practice, my practice has improved in that time, and so has my balance, which is evidence enough for me to keep at it.

Left Facial Palsy: I finally got to see the local speech and language therapist, who had done a bunch of homework by the second time I saw her, and had a load more exercises to try out. As a result there are tiny signs of improvement, and I feel less crazy when I can sense muscles trying to engage with no visible result. Although I'm supposed to do them in a mirror, it's pretty depressing to see nothing happen for weeks on end, so I often just do them blind, paying close attention to the sensations I feel. I suspect I'll have a lop-sided grin for quite a while.

Right Side: although my right side is clearly getting stronger, and it's been very useful to do exercises that isolate each side in the gym (i.e. dumbbell exercises have been more useful than barbells or machines, and form reigns supreme) I've developed or exposed a problem. My right hand and arm now have a tremor that is at least superficially similar to what you'd see in someone with Parkinson's. This means that while I should use my right hand as much as possible, so that I don't allow the left to compensate instead of forcing recovery, I don't want to use it if that means reinforcing the 'bad wiring' that's caused the tremor.

On the positive, however, acupuncture today (yes, I spent time on my birthday being treated to steel needles) was positive, seems to have reduced the tremor, and has left me feeling less asymmetrical. My sample size of one is sufficient for me, when I am that one.

I said to the acupuncturist that recovering from a stroke will either teach you patience or drive you mad. Last night, at Tai Chi, I was able to squat as low as the bulk of my legs would let me -- ass to ground -- and without falling over. It's taken me three months of persistent stretching, exercise, and an occasionally bruised ass to get there. There are many things left for me to do in life, but I am patient.

Wednesday, May 2, 2012


Ironically since I just decried most post-stroke tiredness as a learned behaviour, I had to take a rest this afternoon; I was just physically beat. 

I've been taking it fairly easy, given that I've had this chest bug: early nights, slow starts, no swimming, but I've still been exercising and stretching in the morning, and going to the gym. I guess I found out where my limits are at the moment; they keep getting better, which is good. 

I read recently, in a volume about stretching scientifically, that "flexibility improves from day to day, strength from week to week, speed from month to month, endurance from year to year." Now the person quoted (Ozolin) was talking about training Olympic athletes, but the biology is basically the same: it's going to take me a while to get my endurance back.

It has been something of a surprise, nevertheless, just how much having a relatively minor bug can take out of you. Normally, we'd mostly just shrug it off with some paracetamol and brazen it out. I count myself lucky that at present that's not an option for me: I get to experience full well how much effort we have to put in to fighting off an infection. I'm reminded that it really wasn't that long ago that a good bout of influenza could devastate a population.

All of which goes to say that my former employer, Google, had it right: when you have a bug, stay at home and get better. Don't bring it to the office to share, and don't go nuts working from home.

Which has nothing to do with what I wanted to talk about: myself, obviously. I have a tremor, and it seems to be getting worse (or not changing). It's in my right arm and hand, and I think it can be traced to muscle fibres in the bicep, forearm and hand that just won't relax. It's a pain in the neck because it means I can't hold a cup of fluid steady in my right hand (and guess where my stick is), and my writing is a lot worse than it would be without the tremor. 

It's clearly neurological; my guess is that those muscles were either contracted at a crucial moment of brain damage, which bites, or that they were not affected by the stroke, took on a lot of responsibility for making my hand and arm functional, and are now stuck, while the other muscles around fill in, and are acting against them (causing the intermittent tremor).

The biggest pain about the whole thing is that I have yet to come up with a strategy to fix this neural malfunction. I don't even know if my handwriting practice is actually reinforcing the tremor, which would be bad. Ditto with touch-typing, which has greatly improved, but the tremor renders slow.

I have an appointment with an acupuncturist, I'm continuing to learn and practice Tai Chi, I have another massage on Friday a foam roller (for self-myofascial release) arriving soon, and I continue to strengthen the muscles around the ones that are stuck, but I wonder if I just need time?