The Use of a Game to
Promote Arm Reach in
Persons With Traumatic
Brain Injury
]anine M. Sietsema, David L. Nelson,
Rebecca M. Mulder, Deborah Mervau­
Scheidel, Bob E. White
Key Words: developmental tasks. motor
control. movement analysis.
neurodevelopmental therapy
This study tested a principle of occupational therapy
and motor learning theory in the context of neurode­
velopmental treatment techniques. Ten tn'als of occu­
pationally embedded intervention (playing Simon, ™ a
computer-controlled game) were compared with 10
trials of rote arm-reach exercise. A counterbalanced
design was structured so that each subject experienced
each condition one week apart, Subjects were 17 men
and 3 women with traumatic brain injury who exhib­
ited mild to moderate spasticity in the upper extrem­
ity. Maximum distance from hip to wrist during active
reach of the affected extremity was measured by digi­
tization of videotape with the Motion Analysis ™ £V-3D
system. Results indicated that the use of the game elic­
ited significantly more range of motion than the rote
exercise (t (19) = 5. 77, P <001). These results sup­
port the use of an occupationally embedded interven­
tion for persons with traumatic brain injury and add
to the theoretical base of occupational therapy.
fundamental concept in occupational therapy is
that the activity (occupation) must be interest­
ing and must intrinsically promote the correct
movement. For therapy to be occupational, practice must
focus on the interrelationships of mind, body, and envi­
ronment (Christiansen & SaUln, 1991; West, 1984).
A systematic study of occupation reqUires a function­
al definition of occupation. Nelson (1988) defined occu­
pation as the relationship between occupational form
(context) and occupational performance (actions). Par­
ticular meanings of occupations depend on one's devel­
opmental structure, and occupational performance de­
pends on one's purpose. This focus on occupational
performance as a mechanism for adaptation is consistent
with the historical view of occupational therapy.
A skillful synthesis of the occupational form requires
consideration of all of the following components: physical
stimuli, including materials, environmental surroundings,
human context, and temporal context; and sociocultural
reality depending on social or cultural norms (Nelson,
1988). Altering any of these components can influence
occupational performance.
A
janine M. Sietsema, BS, is a certified fitness instructor, Hope
Nerwork Brain Injury Program and Western Michigan Arthritis
Institute, Grand Rapids, Michigan, and a graduate student in
occupational therapy, Western Michigan University, Kalama­
zoo, Michigan. (Mailing address: 817 Ballard Southeast, Grand
Rapids, Michigan 49507)
David L. Nelson, PhD, OTR, FAOTA, is Professor, Occupational
Therapy Department, Western Michigan University, Kalama­
zoo, Michigan.
Rebecca M. Mulder, OTR, is an Occupational Therapist, Nova­
Care, Grand Rapids, Michigan.
Deborah Mervau-Scheidel, OTR, is an Occupational Therapist,
Mary Free Bed Hospital and Rehabilitation Center, Grand
Rapids, Michigan.
Bob E. White, PhD, is Associate Professor, Industrial Engineer­
ing Department, Western Michigan University, Kalamazoo,
Michigan.
This article was accepted for publica/ion June 3, 1992.
Literature Review
Seven recent research studies have examined occupa­
tional performance as a dependent variable and synthe­
sized occupational forms as the independent variable.
One condition of the independent variable involves exer­
cise in the context of occupation. The term occupation­
ally embedded exercise is used to describe exercise that
occurs as a by-product of purSUing task-specific goals
(Nelson & Peterson, 1989; Yoder, Nelson, & Smith, 1989).
The other condition involves simple exercise done for its
own sake. Nelson and Peterson (1989) used the term rate
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19
exercise to describe this alternative to occupationally em­
bedded exercise. According to Nelson and Peterson, rote
exercise refers to the calisthenic-like, simple, repetitive
movement patterns that typically involve mental focus on
the exercise as opposed to focus on occupational
processes.
A study by Kircher (1984) and an extended replica­
tion study by Bloch, Smith, & Nelson (1989) compared
heart rates and exercise duration of women college stu­
dents jumping rope and jumping in place without a rope.
Subjects who jumped with a rope had significantly higher
heart rates than subjects who jumped without a rope, and
both studies concluded that the subjects' perceived exer­
tion was less when jumping with a rope than when jump­
ing without a rope. The authors in both studies claimed
that these results indicated a higher level of motivation in
subjects who jumped with a rope than in those who
jumped without a rope.
Steinbeck (1986) studied frequency of repetitions
elicited from college students in two different exercise
contexts. One context compared a bulb-squeezing exer­
cise that suspended a table-tennis ball with a rote bulb­
squeezing exercise. The other context compared a pedal­
ing exercise that operated a drill press with a rote
pedaling exercise. The frequency of repetitions in both
occupationally embedded exercises was significantly
greater. Steinbeck concluded that the occupationally em­
bedded exercises were more motivating than the rote
exercises.
Heck (1988) compared the duration of tolerance of
pain from electrical stimuli in college students who were
duplicating patterns with a blunt srylus with duration of
pain tolerance of those performing a rote tracing exercise
with a blunt srylus. Subjects performing the occupational­
ly embedded exercise tolerated pain significantly longer
than those performing the rote exercise. Mullins, Nelson,
and Smith (1987) studied elderly nursing home residents'
choice of subsequent exercise after performing a stencil­
ing activity and after performing the same type of exercise
without stenciling materials. Results were not statistically
significant, and the authors suggested that the men in the
study might have been less motivated by the stenciling
than were the women.
Miller and Nelson (1987) and Yoder et al. (1989)
compared exercise repetitions elicited by stirring cookie
dough with those elicted by rote stirring. The first study
involved college students; the second involved women
who lived in nursing homes. Miller and Nelson obtained
results on the evaluation factors of the Osgood semantic
differential that approached statistical significance (p =
.052) in favor of stirring cookie dough. Yoder et al. found
that stirring cookie dough elicited significantly more exer­
cise repetitions (p = .012) than performing the rote
exercise.
The seven articles reviewed above focus on the core
concept of occupational therapy: the inherent value of
20
occupation. None of the studies applied this concept to
rehabilitation of persons with traumatic brain injUry. Can
occupations enhance the motor performance of clients
with profuse cognitive and physical impairments? The
steady increase in brain injuries and the increased surviv­
al rate of persons with severe injuries present major chal­
lenges to occupational therapists (Dow, 1989). The ex­
tensive rehabilitation after brain injury involves physical,
sensory integrative, cognitive, psychosocial, and behav­
ioral aspects.
Motor control is one performance component that
affects all occupational performance areas. Motor control
can be assessed after the client begins functioning at level
IV to V of the Rancho Los Amigos scale of cognitive func­
tioning (Malkmus, Booth, & Kodimer, 1980). A client at
this level is confused and unable to focus attention on an
activity without frequent redirection. When spasticity de­
velops, abnormal posture and movement patterns im­
pede occupations. A rypical pattern of spasticiry includes
the following:
Retraction and depression of scapula
Adduction and internal rotation of shoulder
Flexion of elbow, wrist, and fingers
Pronation of forearm
Ulnar deviation of wrist
Adduction of fingers
Lateral flexion of neck and trunk toward involved
side
• Posterior pelVic tilt
• Extension of hip, knee, and ankle
• Internal rotation of thigh. (Bobath, 1979)
•
•
•
•
•
•
•
Research in motor learning supports the idea that
occupationally embedded intervention improves motor
control. Bernstein (1967) promoted the concept that pur­
poseful movement is organized to solve motor problems.
Motor problems are challenges to the neuromuscular sys­
tem that arise from interaction with the external environ­
ment (Sabari, 1991). Bernstein (1967) also introduced the
concept of degrees offreedom, the number of individual
components of movement that are free to vary and need
to be controlled. Motor control is the ability to control
these degrees of freedom. Persons with traumatic brain
injury often do not disassociate the various degrees of
freedom. For example, they tend to reach forward by
using the whole shoulder instead of protracting the
scapula.
Feedback from the occupation is necessary for reac­
quisition of motor skills. "It is through such action with
feedback from both the human and nonhuman objects
that an individual comes to know the potential and limita­
tions of self and the environment and achieves a sense of
competence and intrinsic worth" (Fidler & Fidler, 1978,
p. 306). Kielhofner and Burke (1980) emphasized the
importance of feedback in completing the open sys-
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tem's cycle of input, throughput, and output. Feedback
includes knowledge of results and knowledge of per­
formance. Knowledge of results is feedback about the
outcome of movement and knowledge of performance
is feedback about the nature of movement (Schmidt,
1988).
Sabari (1991) emphasized feedback in her frame­
work for the integration of a motor relearning program
with a neurodevelopmental treatment perspective. She
combined motor learning research and the works of
Carr and Shepherd (1987) with Bobath treatment tech­
niques. Eggers (1983) creatively applied neurodevel­
opmental treatment techniques within occupationally
embedded intervention. The combination of these
techniques provides both intrinsic and extrinsic feed­
back to facilitate occupational performance. Neurode­
velopmental positioning and handling techniques pro­
vide intrinsic feedback by reminding clients with brain
injuries how nondysfunctional postural alignment and
functional movement patterns feel (Bobath, 1971). Pos­
tural alignment, which is essential for functional move­
ment, can be learned only in the context of task per­
formance (Carr & Shepherd, 1987).
Neurodevelopmental treatment begins with estab­
lishing an appropriate base of support for the client, shift­
ing his or her center of graVity, and aligning the posture to
allow for both stability and mobility (Bobath, 1979). The
combination of neurodevelopmental treatment with oc­
cupationally embedded intervention occurs naturally be­
cause everyday occupations require the client to establish
a proper base of support. After establishing this base
of support, the client uses feedback from the occupa­
tional form to establish memory traces of relearned
movements.
Figure 1. Occupationally embedded exercise.
The Simon ™ game was easily understood, prOVided im­
mediate visual and auditory feedback, and required no
contrivance. The rote exercise condition consisted of
leaning forward and reaching out the affected arm on
command (see Figure 2). Neurodevelopmenral handling
and positioning techniques were performed by the fourth
author, who is certified in neurodevelopmental treatment
to promote postural alignment and functional movement.
Would occupationally embedded intervention promote
greater range of motion (i.e., trunk inclination, shoulder
flexion, and elbow extension) than pure exercise? The
hypothesis was that range of motion would be greater in
the occupationally embedded exercise than in the rote
exercise condition.
Method
Subjects
Purpose
This study applied motor learning theory and a principle
of occupational therapy in the context of neurodevelop­
mental treatment techniques for persons with traumatic
brain injury. The purpose of this study was to compare
the movements elicited by occupationally embedded in­
tervention with those elicited by rote exercise. The
occupationally embedded condition was leaning forward
and reaching out the affected arm to play Simon, ™ 1 a
computer-controlled game that challenges the player to
repeat its sequences of flashing lights and sounds by
pressing colored lenses (see Figure 1). This game was
chosen because it facilitated nondysfunctional movement
patterns while allOWing subjects to succeed and be chal­
lenged. All subjects were able to press the lenses with
their affected hands. Other games, such as checkers and
cards, could not have been used as easily because some
subjects could not open and close their affected hands.
IMaoufauured by Milton Bradley Cornp~ny, Springfield, MA 01101
The sample of thiS study was composed of 20 adults (17
men and 3 women) who had sustained traumatic brain
Figure 2. Rote exercise.
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21
injury. Subjects' ages ranged from 22 to 54 years (M =
31.6 years, SD = 7.6) and the number of years since the
injury ranged from 1 to 15 (M = 6,SD = 4.1). All subjects
were medically stable and functioning at level IV or V to
VII on the Rancho Los Amigos scale of cognitive function­
ing (Malkmus et aI., 1980). All subjects had mild to moder­
ate spasticity; 11 had an involved right arm, 7 had an
involved left arm, and 2 had equal bilateral upper extrem­
ity involvement. Seventeen subjects used wheelchairs; 3
subjects used canes. All subjects were receiving services
at one of three rehabilitation facilities in Grand Rapids,
Michigan. Subjects were evaluated and referred by thera­
pists at the rehabilitation facilities.
Apparatus
The research was conducted at the subjects' rehabilita­
tion facility. Materials used during the experiment includ­
ed a chair 18 in. wide, 20 in. deep, and 17 in. high with an
additional IS-in. backrest, a work table 22 in. by 15 in.
with adjustable height, and a Simon ™ game. Subjects had
2 1/2 in. adhesive reflectors attached to their skin at the
shoulder, elbow, and wrist, and to their pants at the hip.
The adhesive reflectors were attached at the folloWing
anatomical landmarks to define segment centers of mass
positions from videotaped data: the acromion process of
scapula, the greater tuberosity of the humerus, the ole­
cranon process of the ulna, the styloid process of the
ulna, and the iliac crest. The hip reflector was placed after
the iliac crest was palpated through the pants. To control
for any shifting of clothing, the hip measurement was
taken when the subject was positioned in proper
alignment.
Each session was videotaped with a camera placed 6
ft from the subject and perpendicular to the sagittal
plane. Movements were measured by a Videotaped bio­
mechanical analysis with Motion Analysis n,2 equipment.
This computerized analysis digitizes movements by as­
signing x and y coordinates at a rate of 60 frames per sec.
Range of motion measurements included trunk inclina­
tion, shoulder flexion, and elbow extension. The total
movement (leaning forward and reaching) was measured
by the maximum distance between the hip and the wrist,
and the related maximum distance between the scapula
and the wrist was also measured.
Procedure
Acounterbalanced research design was structured so that
each subject was seen on two days one week apart. Ten
subjects were asked to reach out their hands in a rote'
manner during the first session and to play Simon ™ dur­
ing the second session; session activities for the other 10
2Manufacrured by Motion Analysis Corp., 3650 North Laughlin Rd., Santa
Rosa, CA 95403, 707-579---{)500, 800-733-6746.
subjects were reversed. Acounterbalanced design is pow­
erful because it compares subjects with themselves under
both conditions. Subjects had diverse characteristics
(e.g., arm length, contractures, etc.), and this design
eliminated error due to individual differences. Each ses­
sion took approximately 20 min and involved a warm-up
with neurodevelopmental positioning and handling tech­
niques. The session followed Bobath's (1979) gUide­
lines and incorporated the sequence presented in the
Adult Hemiplegia Bobath Certification Course by Neuro­
Developmental Treatment Association, Inc. (Davis,
1985).
The therapists (the third and fourth authors)
achieved an appropriate base of support by rotating the
subject's hips into anterior pelVic tilt. This anterior tilt
prepared the subject for arm reach by allowing the neces­
sary mobility in the hips, trunk, and scapula. After achiev­
ing trunk mobility and control, the therapists promoted
shoulder girdle separation by opening their hands over
the scapula and applying pressure laterally, medially, then
upward. The subject was then positioned in proper align­
ment to help normalize tone. The head was in midline,
the hips were in anterior pelvic tilt, the shoulders were
over the hips, and the knees were over the feet. All func­
tional movements began from this position.
The therapists then facilitated the movement pattern
required for the arm reach exercise by moving the shoul­
der joint into forward flexion. The subject was moved
through the motion required for the exercise to elicit
maximum range of trunk flexion, shoulder flexion, and
elbow extension. While the subject was held in thiS pOSi­
tion, the table was positioned in front of him or her with
the center of the palm at the center of the table and with
the subject's hand 3 in. above the table to match the
height of the Simon '" game. For the occupationally em­
bedded condition, the center of the Simon ™ game was
placed at the center of the table. After repositioning the
subject in proper alignment, one therapist instructed the
subject to perform the arm reach exercise.
For the rote exercise condition, she said, "I would
like you to lean forward and reach out your affected hand
10 times like this." She then demonstrated one repeti­
tion. For the occupationally embedded condition, she
said, "I would like you to lean forward and reach out your
affected hand 10 times to play Simon like this." She then
demonstrated one repetition. No more than three
prompts were proVided whenever the subject hesitated
over 3 sec. If a subject assisted the reach of the involved
extremity with the non involved extremity, the subject was
reminded not to do so, and the trial did not count. When
subjects in the rote exercise condition heSitated, the
therapist said, "Can you reach out your hand some more
without feeling too uncomfortable?" When subjects in the
occupationally embedded condition heSitated, the thera­
pist said, "Can you play Simon some more without feeling
too uncomfortable?"
22
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Results
Each repetition was analyzed separately. Due to technical
difficulties with the video camera, one subject's last rep­
etition was cut off, and the next subject's first two repeti­
tions were missing. To analyze the data, the cells for the
missing repetitions were supplied with the means of the
remaining repetitions for that subject. A t test was con­
ducted to check for a significant difference between the
means of those who did the rote exercise first and the
means of those who did the rote exercise second. An­
other t test was done to investigate order effects in the
game condition. Neither t test was statistically significant
at the .05 level, so there were no significant order effects.
Range of motion across both conditions is shown in
Table 1. Results indicated a significant difference in favor
of the occupationally embedded condition (t (19) = 5.77,
P < .001 according to the t test for paired samples).
Subjects playing the game leaned forward and reached an
average of 12.22 cm. farther, and their related scapula-to­
wrist measurement was an average of 3.52 cm. greater
than it was during the rote exercise. No statistical test was
done on the scapula-to-wrist measurement because it was
highly correlated to the main dependent variable, the hip­
to-wrist measurement. Subjects' reaching patterns were
fairly consistent during both conditions. The stable range
of motion across the 10 trials in both conditions indicated
no significant trend.
Discussion
When spasticity develops, early occupational therapy in­
tervention is essential to maintain function and promote
motor relearning. A well-known characteristic of the early
phase of motor skill learning is that concentration is nec­
essary to process the information needed to perform
(Fitts & Posner, 1967; Marteniuk, 1979). Therefore, a ma­
jor challenge is to structure occupations that require the
use of the client's involved spastiC arm while invoking his
or her optimum motivation. Mosey (1986) emphasized
this need for structuring occupationally embedded exer­
cise because "performance components are not acqUired
through random activity or mindless exercise; rather they
are acquired through active, goal-directed interaction
with the environment" (p. 234).
This study supported the hypothesis that the occu­
oationally embedded intervention promoted more range
Table 1
Comparisons of Occupational Performance
R~nge
of Motion
(cm)
Hip to wrist
Sc~pula to wrist'
Game
_
Rote Exercise
M
SD
M
SD
71.60
54.16
19.46
10.45
59.38
50.64
20.82
1.3 71
p
S.77
< .001
aNot analyzed by inferential statistics becaw,e it is a component of the
other variable and therefore related in a nonindcpendent fashion.
The American Journal
of motion than did rOte exercise. The flashing lenses and
sounds of the Simon ™ game provided motivating feed­
back to enhance performance, and the game promoted
more enthusiasm and increased attention span. Subjects
required less cuing during the occupationally embedded
condition and many subjects continued playing Simon ™
after they had completed 10 repetitions.
This research enhances the knowledge base of occu­
pational therapy. Whereas the studies previously re­
viewed involved healthy elderly persons or healthy col­
lege students, this study focused on intervention for
persons with traumatic brain injury, a growing population
on which few studies are aVailable. This study was also
different because it quantified the quality of movement
elicited by occupation.
A limitation of this study was that the therapists
(third and fourth authors) administering. the inde­
pendent variable were aware of the theoretical back­
ground and the hypothesis. The mitigating factors were
training and the use of a script. Because qualitative re­
search is reductionistic, this study could not consider all
individual differences in volitional and habitual subsys­
tems. Although one game was used for control purposes,
we cannot assume that one intervention is appropriate
for all clients with brain injuries. A holistic treatment ap­
proach considers clients' personal interests and choices.
Future research could examine whether occupation­
ally embedded intervention promotes more repetitions
or more nondysfunctional movement patterns than does
rote exercise in persons with spastiCity. Replication of this
study will strengthen the hypothesis and similar studies
could test other neurologically involved populations. The
effects of neurodevelopmental treatment on functional
movement could also be studied. Motion Analysis™ and
other computerized systems open doors for eXCiting new
research by allowing us to quantify occupational perform­
ance. Such systems can also address velocity, accelera­
tion, and smoothness of movement.
Many fruitful opportunities for occupational therapy
research involve biomechanical analysis of movement
patterns. Mathiowetz (1992) analyzed the motor perform­
ance of persons with and without multiple sclerosis while
they performed activities of daily living in impoverished,
partial, natural, and simulated conditions. McPherson et
al. (1991) compared the arm movements in four sitting
pOSitions eliCited by persons with and without cerebral
palsy. KJuzik, Fetters, and Coryell (1990) studied the ef­
fects of neurodevelopmental treatment on the smooth­
ness of arm reach in children with spastic quadriplegia.
Similar research providing quantitative data about the
quality of movement can strengthen the scientific base of
occupational therapy. A
Acknowledgments
We lhank lhe subjecls and lhe slaff al lhe rehabililalion facililies
who helped make lhis sLUdy possible, including lhe followmg
0/ Occupational Therapy
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23
persons who assisted with suhject recruitment: Sue Kremkow,
CTRS, K. C. Hammerle, erRS, Kevin Arnold, MA, and Linda Pie­
chocki, MS, OTR We also thank the industrial engineering depart­
ment at Western Michigan University for the use of the Motion
Analysis
TM
equipment.
This manuscript was completed as a partial requirement
for the first author'S master of science degree in occupational
therapy at Western Michigan University, Kalamazoo, Michigan.
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