Wii Fit U games utilize a Wii Balance Board™ (WBB) in a manner that can provide precise feedback contingencies similarly to some forms of balance rehabilitation, thereby potentially increasing the dose of quality therapy with or without the presence of a therapist during post-brain injury rehabilitation. Additionally, an engaging video-game could improve treatment adherence, a critical aspect of making positive functional gains, by potentially increasing the rate and quality of reinforcement embedded in therapy. The present study had three aims: (1) develop a rigorous behavioral therapy for improving balance in individuals living with chronic brain injury using a Wii Fit U game and the WBB; (2) evaluate the program's effects on balance measures using a within-subject experimental design; and (3) assess social validity of behavioral gains by evaluating the program's effects on participant's "subjective balance confidence" (i.e., their Activities-Specific Balance Confidence (ABC) scores). A reversal design is proposed for use with primary study participants, wherein the experimental gameplay condition and no intervention condition are alternated for 6 to 10 weeks. A similar design was used in a truncated fashion with pilot participants, and a multiple baseline design was used with follow-up pilot participants. It was expected that participants would exhibit greater performance in the game as well as better balance score improvement when the Wii Fit U game was administered at a high therapeutic dose, and that increased ABC scores would correlate with directly measured balance scores.

Neurorehabilitation, a relatively new domain of clinical intervention has, from its outset, been a rapidly evolving practice, with ongoing advancements in neuroimaging and neuroscience leading to new insights into how the brain grows and recovers from insult. The field of neurorehabilitation is tasked with translating this research into maximally effective treatments. This document addresses how digitally augmented neurorehabilitation, has, and can help meet, these translational needs and clinical imperatives. The first chapter is a review of the literature on the use of avatars in neurorehabilitation and their potential to promote neurological repair and plasticity. The second explores the use of a wearable remote control device for the promotion of enjoyability and intensity in the pediatric neurorehabilitation context. The third chapter pilot tests a video-based assessment methodology and explores the telehealth potential of such an assessment methodology and the final chapter demonstrates how such an assessment methodology can be implemented in pediatric neurorehabilitation in a case study on the treatment of Kernicterus. Collectively these works provide an overview of a selection of digitally augmented neurorehabilitation techniques and tools and preliminary data on how these approaches might be implemented in the field of pediatric neurorehabilitation. / Doctor of Philosophy / Neurorehabilitation, is the clinical effort to repair brain injuries. Telehealth, or telemedicine, is the use of digital technologies to assist in the delivery of healthcare. Telehealth can take many forms- you can do a teleconference with your doctor, you can access your medical records online, you can use a fitbit to promote preventative healthcare. One form is telerehabilitation, examples include video conferencing with your physical therapist, using video game based rehabilitation systems, or the use of digital cameras and programs to capture and analyze your movements. This document explores some of the ways neurorehabilitation can use these digital technologies to help promote neurological repair and recovery. The first chapter is a review of the literature on the use of avatars, or digital placeholders such as animated characters or virtual representations of the patient, in neurorehabilitation and how their use has the potential to promote neurological repair. The second chapter explores the use of a wearable remote control device for the promotion of enjoyability and intensity (high repetitions of desired movements) in the pediatric neurorehabilitation context. The third chapter pilot tests a video-based assessment methodology and explores the telehealth potential of such an assessment methodology and the final chapter demonstrates how this assessment methodology can be used in pediatric neurorehabilitation in a case study on the treatment of Kernicterus, a pediatric disorder that results from bilirubin toxicity. Collectively these works provide a review of the potential for digitally augmented neurorehabilitation and preliminary data on how these approaches might be implemented in the field of pediatric neurorehabilitation.

This thesis aimed to critique the research on person centred care (PCC) in neurorehabilitation, and consider how PCC in this setting can be further developed. Paper One reviews the extant literature on PCC in neurorehabilitation. The literature search returned 27 papers, which were critiqued for quality, how they conceptualised PCC, how they practiced PCC and the feasibility of PCC. Conceptualisations of PCC used varied from narrow conceptualisations of PCC as participation in goal setting, to broader ones which also incorporated issues such as shared decision making, outcomes, respect and emotional support. Similarly, methods of practicing PCC primarily used goal setting, with a minority of papers addressing outcomes and communication aspects of PCC. The review found that PCC is feasible for neurorehabilitation, with important benefits for clients and professionals. Providing PCC in neurological rehabilitation can be challenging and the literature review discusses ways to overcome barriers to PCC. The literature review highlights the need for methods to assess and develop PCC which are suitable for people with and without cognitive impairments. Paper Two addresses this need, by presenting research investigating the feasibility of using Dementia Care Mapping (DCM) on a neurorehabilitation ward. DCM is an observational method aims to document the quality of care from the perspective of the patient. DCM was found to be feasible for use on a neurorehabilitation ward, as shown by the suitability of the coding system. Q-methodology was used to assess staff perceptions of DCM. This further supported DCM feasibility, with staff reporting that DCM provided useful information for staff that they could use to improve the care they provided. DCM required some minor amendments in order to be used in a hospital rehabilitation environment and further amendments could improve its suitability for use in neurorehabilitation settings. Paper Three is a critical appraisal of both the literature review and research paper. The strengths and weaknesses of the use of both DCM and Q-methodology are critiqued, and consideration given to the limitations of the research.

no / Person-centred care can improve the well-being of patients and is therefore a key driver in healthcare developments in the UK. The current study aims to investigate the complex relationship between cognitive impairment, dependency and well-being in people with a wide range of acquired brain and spinal injuries. Sixty-five participants, with varied acquired brain and spinal injuries, were selected by convenience sampling from six inpatient clinical neuroscience settings. Participants were observed using Dementia Care Mapping – Neurorehabilitation (DCM-NR) and categorised based on severity of cognitive impairment. A significant difference in the behaviours participants engaged in, their well-being and dependency was found between the severe cognitive impairment group and the mild, moderate or no cognitive impairment groups. Dependency and cognitive impairment accounted for 23.9% of the variance in well–ill-being scores and 17.2% of the variance in potential for positive engagement. The current study highlights the impact of severe cognitive impairment and dependency on the behaviours patients engaged in and their well-being. It also affirms the utility of DCM-NR in providing insights into patient experience. Consideration is given to developing DCM-NR as a process that may improve person-centred care in neuroscience settings.

An extensive body of literature supports the clinical utility and feasibility of client-centric goal-setting techniques in neurorehabilitation. However, such techniques are seldom used and difficult to adopt in mainstream clinical practice. Two primary barriers that limit uptake and adoption of individualized goal-setting techniques into routine practice include: (1) lack of an operationalized framework susceptible to variations in the characteristics of the user and constraints of a medical setting and (2) limited knowledge on the part of clinicians and clients to confidently engage in goal-setting conversations. The eGAS app was designed to address the need for a semi-structured client-centric goal-setting framework for clinicians engaged in neurorehabilitation. This study used a single-subject design to investigate the effects of using eGAS in an outpatient hospital setting on clinician behavior and client responsiveness. A nonconcurrent, multiple-baseline design was used across three clinicians to determine if use of eGAS would result in functional changes in collaborative interviewing behaviors, validity of generated goal scales, and reliability of the process. Results revealed that using eGAS had strong functional effects on collaborative interviewing behaviors and validity of goal scales, and a weak effect on reliability. Another noteworthy finding was that eGAS could be implemented with relatively high fidelity within the constraints of a clinical context despite variations in the characteristics of the end-user, i.e. clients and clinicians. I discuss support for ecological validity of eGAS in terms of implementation barriers and facilitators that affected outcomes, methodological limitations, and future steps to improve design validity and implementation integrity.

abstract: As the application of interactive media systems expands to address broader problems in health, education and creative practice, they fall within a higher dimensional space for which it is inherently more complex to design. In response to this need an emerging area of interactive system design, referred to as experiential media systems, applies hybrid knowledge synthesized across multiple disciplines to address challenges relevant to daily experience. Interactive neurorehabilitation (INR) aims to enhance functional movement therapy by integrating detailed motion capture with interactive feedback in a manner that facilitates engagement and sensorimotor learning for those who have suffered neurologic injury. While INR shows great promise to advance the current state of therapies, a cohesive media design methodology for INR is missing due to the present lack of substantial evidence within the field. Using an experiential media based approach to draw knowledge from external disciplines, this dissertation proposes a compositional framework for authoring visual media for INR systems across contexts and applications within upper extremity stroke rehabilitation. The compositional framework is applied across systems for supervised training, unsupervised training, and assisted reflection, which reflect the collective work of the Adaptive Mixed Reality Rehabilitation (AMRR) Team at Arizona State University, of which the author is a member. Formal structures and a methodology for applying them are described in detail for the visual media environments designed by the author. Data collected from studies conducted by the AMRR team to evaluate these systems in both supervised and unsupervised training contexts is also discussed in terms of the extent to which the application of the compositional framework is supported and which aspects require further investigation. The potential broader implications of the proposed compositional framework and methodology are the dissemination of interdisciplinary information to accelerate the informed development of INR applications and to demonstrate the potential benefit of generalizing integrative approaches, merging arts and science based knowledge, for other complex problems related to embodied learning. / Dissertation/Thesis / This video shows a demonstration of the home-based AMRR system in use with a stroke survivor. Participant is shown receiving instructions, followed by performance of one interactive Level 1 set of reaching to grasp and lift a portable cylinder. / This video shows a demonstration of the home-based AMRR system in use with a stroke survivor. Participant is shown performing an interactive Level 1 set of reaching to touch a flat object. / This video shows a demonstration of the home-based AMRR system in use with a stroke survivor. Participant is shown performing an interactive Level 2 set of reaching to grasp a cone. / This video shows a demonstration of the home-based AMRR system in use with a stroke survivor. Participant is shown performing an interactive Level 3 set of reaching to grasp and transport the cylinder between two locations. / This video shows a demonstration of the home-based AMRR system in use with a stroke survivor. Participant is shown setting up the targets used for training. / This video shows the clinical AMRR feedback for trajectory performance and speed. Video depicts the image formation and plays the musical phrase generated by a reach that is (1) efficient, (2) with horizontal trajectory deviation, (3) and slow. / This video shows the clinical AMRR feedback for joint function and compensation. Video depicts (1) image rotation for wrist rotation, (2) the orchestral sound for elbow extension, (3) the shoulder compensation sound and (4) the torso compensation sound. / This video shows the clinical AMRR feedback demonstrating different aspects of joint correlation. Video depicts (1) an efficient reach with elbow extension and (2) inefficient reach with shoulder compensation sound. / This video shows the home-based AMRR Level 1 visual feedback for negative vertical trajectory error. Rocks are depicted to have sunken underwater. / This video shows the home-based AMRR Level 1 visual feedback for a successful lift with an efficient reaching path. The clearance of the fog indicates the portable object was lifted beyond a height threshold. / This video shows the home-based AMRR Level 2 visual feedback for overall path and grasp performance. Video depicts feedback for the following types of overall performance: efficient path, curvature, segmentation, and grasp completion. / This video shows the home-based AMRR Level 3 audiovisual feedback for overall efficiency of a sequence task. Video depicts (1) efficient performance, (2) slightly inefficient performance, and (3) severely inefficient performance. / This video shows the home-based AMRR Level 3 audiovisual feedback for overall efficiency of a transport task. Video depicts (1) efficient performance, (2) slightly inefficient performance, and (3) severely inefficient performance. / This video shows a demonstration of the clinical AMRR system in use with a stroke survivor and supervising therapist. Participant is shown performing interactive reaches to a cone. / Doctoral Dissertation Media Arts and Sciences 2014

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Deficits in working memory (WM) functions represent one of the main causes of limited participation in daily life and impaired recovery after brain injury. Based on promising research in clinically healthy individuals, which suggest that repetitive training may improve WM performance and other related cognitive functions, this thesis aimed at exploring the potential and limits of WM training in clinical populations. Existing research on WM training and relevant neuropsychological outcomes were examined with a special focus on individuals with acquired brain injury by means of a meta-analysis (study I). The findings indicated relevant impact of WM training on both behavioral performance and disease-related symptom reduction. To determine the primary outcome variable for the evaluation studies, the Corsi Block-Tapping Task was reviewed (study II). Due to the lack of an appropriate theory-based intervention tailored for the needs of individuals with low WM capacity, the program 'WOME' was developed (study III). Three randomized, double-blind, placebo-controlled trials were carried out to evaluate the efficacy of the new intervention and to provide valuable recommendations for its application in clinical practice (study IV, V and VI). Significant improvements in the trained tasks, moderate to large transfer effects in overall WM performance, and related benefits in daily life were demonstrated. The effects were short-termed with very limited evidence supporting transfer to other cognitive functions. In accordance with the results of the meta-analysis (study I), the number of sessions was identified as an important modulator of efficacy by comparing different training intensities and training tasks. The specific content, in contrast, seemed to be less relevant. Mediation analyses revealed that inter-individual differences influence the successful application of the intervention, in particular initial WM capacity. Implications for clinical application and WM training research are discussed.:1. Introduction 1.1. Definition of the working memory system 1.2. Functional neuroanatomy of working memory 1.3. Functional relevance of working memory 1.4. Training of working memory functions 1.5. Objectives of the current thesis 2. Experimental work 2.1. Study I: Can impaired working memory functioning be improved by training? A meta-analysis with a special focus on brain injured patients 2.2. Study II: „Was misst eigentlich die Blockspanne?“ — Der Gold-Standard im Fokus. 2.3. Study III: WOME working memory training — A new intervention for individuals with low WM capacity 2.4. Study IV: WOME: Theory-based working memory training — A placebo-controlled, double-blind evaluation in older adults 2.5. Study V: Effects of working memory training in patients with acquired brain injury: a double-blind randomized controlled trial. 2.6. Study VI: The effect of high vs. low intensity neuropsychological treatment on working memory in patients with acquired brain injury. 3. General discussion 3.1. Summary of the empirical findings 3.2. Implications for clinical practice 3.2.1. Benefits and limits of working memory training 3.2.2. The importance of training dose and its practical implementation 3.2.3. The influence of inter-individual differences on training efficacy 3.3. Implications for working memory training research 3.4. Critical comments and directions for future research 3.5. Conclusion 4. References 5. Summary 6. Zusammenfassung Appendices List of abbreviations List of Tables List of Figures Supplemental material Curriculum vitae List of publications Selbstständigkeitserklärung

Die vorliegende Arbeit untersucht die aktuelle wissenschaftliche Evidenz zur Diagnostik und Therapie neuropsychologischer Störungen nach Hirnschädigung, wie sie bis 2020 in Leitlinien publiziert wurde. Deren Umsetzung ist nur möglich, wenn die institutionellen Rahmenbedingungen dies erlauben. Unter Einbezug der klinischen Erfahrung wurden daher auf Basis der Leitlinien Standards für eine wissenschaftlich fundierte neuropsychologische Diagnostik und Therapie erarbeitet. Es entstanden Best-Practice-Empfehlungen zu Strukturund Prozessqualität, insbesondere zu Intensität und Häufigkeit der Interventionen. Diese werden für die wichtigsten neuropsychologischen Funktionsbereiche vorgestellt. Sowohl die Deutsche Gesellschaft für Neuropsychologie e. V. (GNP) als auch die Deutsche Gesellschaft für Neurologie e. V. (DGN) unterstützen diese Empfehlungen. Sie richten sich an Neuropsycholog_innen sowie an Einrichtungsleitende und Sozialversicherungsträger und definieren die Rahmenbedingungen für eine auf den individuellen Fall angepasste leitliniengerechte neuropsychologische Behandlung. / Recent years have seen the establishment of evidence-based guidelines for neuropsychological diagnostics and therapy; however, implementing these guidelines depends on structures and processes necessary to enable essential aspects like therapy frequency and intensity. The present work examines the current scientific evidence for the neuropsychological treatment of traumatic and nontraumatic brain injury, as published in guidelines up to 2020. Standards for evidence-based neuropsychological diagnostics and therapy were developed on this basis, including clinical experience and additional literature research. Best-practice recommendations on both general and specific structural and process quality emerged, especially on the intensity and frequency of interventions. These are presented for the most important neuropsychological functional areas. The German Neuropsychological Society (GNP) and the German Society for Neurology (DGN) support these recommendations. They are aimed at neuropsychologists as well as facility managers and social insurance providers, and they define the framework for guideline-based neuropsychological treatment adapted to individual cases.