The ‘Toap run’ videogame

The videogame (‘Toap Run’) was built specifically for this study. The videogame was controlled by a laptop (Asus®, Model G551 J, Intel® Core™ i7, NVIDIA® GEFORCE® GTX TM8, 8 GB of RAM) and displayed on a high definition television screen (Phillips, 50-in. plasma, resolution 1920 by 1080 pixels) placed 2 m in front of the patient. The patient played by moving in front of a RGB-D (Red Green Blue + Depth) Kinect™ motion sensor (Version 2, Microsoft, USA) placed below the screen.

The scenario consists of a small animal (the avatar) that moves around three different environments: a garden, a mine cart and a surfboard on a lake (Fig. 1). To play, the patient, standing upright in front of the screen, has to move to induce displacements of the avatar in real time within these different environments, to collect coins and avoid obstacles to gain points, in relationship to visual and auditory cues. The movements consist of large amplitude rapid movements of all four limbs, pelvis and trunk, with lateral, vertical and forward displacements of the legs, to reinforce foot lifting and postural control (Fig. 1):

In ‘The Garden’, the patients had to extend their arms to collect coins and perform lateral displacements to avoid laterally placed obstacles,

In ‘The Mine’, the patients had to collect coins and avoid obstacles with the same movements as in ‘The Garden’, plus knee flexion/extension to avoid high level obstacles and lateral trunk displacements with one leg flexion to move the wagon and collect coins,

In ‘The River’, the patients had to perform trunk rotation and arm movements to collect coins, and anteroposterior trunk movements to avoid obstacles.

The ‘Toap Run’ videogame training. The images show screen shots of one patient during videogame training with ‘Toap Run’ in the three different scenarios. From Top to Bottom: ‘The Garden’, ‘The Mine’, and ‘The River’. The movements are schematically represented to the side of the images, from top to bottom: arm extension, lateral shift, trunk lateral displacement with knee flexion, knee flexion/extension, trunk rotation with arm movements, and anteroposterior trunk movement

Visual cueing consisted of a schematic representation of the movements required to perform along the trajectory of the avatar. Auditory cueing consisted of rhythmic music that beats in relationship to the velocity of the avatar displacement. Three different rhythms were presented: 20, 30 and 40 beats/min. The first session was stereotyped and consisted of a 15 min session with a 20 beat velocity first in the garden and then in the mine, corresponding to a total of 100–150 movements. Game difficulty, i.e. velocity and number of movements to capture the coins and avoid obstacles, was then adjusted manually and individually by the physiotherapist for subsequent rehabilitation sessions, in relation to the patient’s ability. For this purpose, the physiotherapist was instructed to increase the rhythm, number and complexity of movements, i.e. the environment, depending on the performance in the previous session with a view to obtain a session of at least 40 min duration after the 9th session [26].