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8/4/2019 How Can We Make Game Audio for the Rehabilitation of Stroke Patients
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How Can We Make Game Audio for
the Rehabilitation of Stroke Patients?
***************************Author*
Eri Shiroyama – Audio Designer
Course*
Utrecht School of the Arts, The
Netherlands
Oude Amersfoortseweg 131,
HilversumGame Design and Development
2009/2010
Client*
FOCAL MEDITECH BV
Team Komodo*
Adriaan de Jongh
Sandra da Cruz Martins
Ronald Houtermans
Tim Remmers
Francis Laclé
Jens van de Water
Supervisor*
Lies van Roessel
Arno Kamphuis
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1* Abstract These days the number of stroke patients is increasing in the entire world. Therefore
there is a lot of money invested in research and possible treatments.
With the rise of digital media, companies, and hospitals are looking for new ways of
the rehabilitation. One of these ways is by using game technology as a more fun
way to rehabilitate because they can enjoy the training. This makes the training less
painful and more enjoyable. Since the patients are not familiar with video games,
it’s important the game audio guides them through the training, and makes them
immersion to play game.
In this paper, I will explain how we should make game audio for the rehabilitation
game, how we can help for stroke patient by game audio.
Key Words Game audio, Rehabilitation, Stroke patients, Focal, Arm movement, Immersion,
Relax, Sound, Music, ‘Vogels!’, Instrument, Adobe Audition, Unity,
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2* Index 1* Abstract
2* Index
3* Introduction
4* what is a Stroke?
4-1* Physical problems
4-2* Mental problems
5* is game audio important for rehabilitation games?
5-1* Why do especially stroke patients need the audio?
5-2* what kind of sounds is suitable for rehabilitations?
6* Project
6-1* ‘Vogel!’
6-2* what did I do?
6-2-1* Audio trailer
6-2-2* Music for ‘Vogel’
6-2-3* Sound for ‘Vogel’
6-2-4* Managing the audio by Unity
6-3* Audio play test
7* How can we apply game audio for their rehabilitation in the
future?
7-1* Sounds for helping physical rehabilitation
7-2* Music for helping mental rehabilitation
8* Conclusion
9* Reference
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3* Introduction We worked for ‘FOCAL MEDITECH BV’ which is a company that develops technical
aids for people with disabilities. These aids assist disabled people in living as
independently as possible and help them in participating in society.
They gave us the assignments of making a serious game for stroke patients by using
their instrument called DYNAMIC ARM SUPPORT TOP/HELP (Presentation from Focal,
Introduction to FOCAL Meditech BV, 2 .2010).
Our purpose was making a game to improve the range of their arm movement for
their rehabilitation. Although posture and gait may improve significantly during their
rehabilitation, recovery of arm - hand function lags behind recovery of other
function. Many patients are left with severe and lasting impairment and disabilities.
That’s whyit will be very helpful for a lot of stroke patients.
(Philips research 2007, Philips Stroke Rehabilitation Exerciser)
The motion of the arm is the one of the most important things in our life. We need it
for eating, lifting things, putting on [taking off] clothes and so on. Also the
rehabilitation game can take away a lot of physical work from therapists, who are
then able to work on multiple patients at the same time.
Our team was made up of 7 students including 2 programmers from Utrecht
University; Adriaan de Jongh as Game Design & Project Coördinator, Sandra da
Cruz Martins as 2D Artist, Tim Remmers as 3D Character Artist, Ronald Houtermans as
3D Environment Artist, Francis Laclé as Programmer, Jens van de Water as Game
Programmer, and Eri Shiroyama as Audio Designer.
I designed all of the sound effects and managed the music with the assistance of a
composer student. For this reason I did research on the stroke patients, the game
audio, the interaction between them, and play testing.
In this paper I will explain what kind of geme audio is suitable and helpful for the
stroke patients on the basis of my research.
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4* what is a Stroke? Stroke, Cerebral Vascular Accident
(CVA) is an injury which is damaged by
blocked blood vessel in the brain. It
disturbs cerebral function. If it lasts more
that 24 hours, it leads to death.
Depending on the location which was
affected, the limitation in activity of the
patients might be different.
Strokes are the leading cause of severe
long term disability and high social
costs. In the Netherlands, the amounts
of incidents are estimated at 34,500 per
year and prevalence at 190,000. Also
prevalence will increase with 27% in this
decade.
About 95% of the CVA patients are 45
year and older. And 66% is over 65
years old. In most cases the patients
rehabilitate in either a rehabilitation
center or an elderly home depending
on their age. Most of them need
wheelchairs to move around. Because
this limits them, 70% of them have
problems in Activities of Daily Life (ADL)
and social participation. Of the
consequences of strokes 44% are mild,
21% are moderate, 16% are severe, and
19% are very severe.
(Presentation from Focal, What is a
Stroke, 2.2010)
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4-1* Physical problems
Over 80% of all stroke patients suffer from unilateral deficits. (Kamper D 2002,pp702-707)
But there are a lot of differences in the level of impairment.
There is also a huge variety in what stroke patients can feel in their paralyzed limbs.
Their limbs can feel warm or cold, tingling (similar to a ‘sleeping limb’), extra sensitive,
no feeling at all or they can feel a continuous pain.
Mostly because of their age, but also because of their brain damage, the stroke
patients often have trouble dealing with dual tasks ( two separate actions that take
place at the same time). For example walking and swinging your arm at the same
time.
4-2* Mental problems In most cases, not only half of the motor functions of the stroke patients are disabled
but also anything else in their body might be partially disabled like their short
memory, their emotions, their ability to take initiative, their special aptitude, and so
on. If someone would lose half of their vision, for instance, they would only see half
of what we see, which does not simply means that only one eye does not work, but
they literally lose half of their vision.
That’s why they often get depressed and panic easily.
Also, Stroke patients often get cognitive deficits. For example, some patients have
trouble even remembering their training schedule while training.
(Research Document, 2. 2010)
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5* is game audio importantfor rehabilitation games? What can mere game audio alone do for the stroke patients?
It’s normal if you think it won’t help anything. But I think game audio can help a lot
for their rehabilitation.
I researched about sound therapy for patients to the Japanese hospital called
Nagao Hospital in Fukuoka/Japan. One doctor and one therapist replied that they
use practically some sound therapy for the patients who are damaged their brain
like a Parkinson as alternative medicine. Though I will introduce what kind of sound
therapy might be possible to apply to game audio in chapter 7, in this chapter I will
explain the importance of audio for game.
5-1* Why do especially stroke patients need the audio? Audio can move the feeling of people like excited, scared, relax, and calm and so
on. So the good game always has the fine sounds and music for making people
being absorbed. But actually sophisticated audio is much more necessary for the
stroke patients for playing the game.
First of the reason, some of them have the ear problem and are much sensitive of
the sounds compare with healthy people.
Second of the reason, in most case they have the problem of their concentration,
so we have to lead them to immersion for playing game by audio. Also
rehabilitation is quite painful and bitter for them. They need to forget the bitterness
as much as possible in the game.
Thirdly, some of them have the eye problem. Therefore we need to make them feel
the circumstances and the atmosphere of game by sound effect and environment
sound.
The last of the reason, according to a research they can understand much easier of
the way of playing game when we explain it by not only letters but also speech.
(Philips research 2007, Philips Stroke Rehabilitation Exerciser)
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5-2* what kind of sounds is suitable for rehabilitations?
For the stroke patient, how can we be attentive to when we make the audio?I heard about the experience of the family of a stroke patient when he played the
rehabilitation game. He had a game for the Wii, but he always didn’t want to play it
because of the endless noise of electronic music from the game, and it was hard to
understand the game because his brain got tired easily. Eventually he couldn’t
continue his rehabilitation by using the game.
Therefore when I edit the sounds I always keep the following 5 things in mind
- Not too stimulating,
- Not negative
- Realistic with a touch of fantasy
- Immersion
- Relaxing and calm.
I will explain why and how can I make them in Chapter 6-2-2.
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6* Team Komodo Project Our game named ‘Vogels!’ was made for the improvement of the arm movement
of disabled people. The game is a 3D game which is effective because the patients
mind is not focused on the actual training anymore. Instead, it is focused on the
challenge of the fantasy game, as assigned by FOCAL.
We worked at it for 40 hours every week from February to May.
Our team is composed of 7 students. The Game Design & Project Coördinator is
Adriaan de Jongh who led our project, made sure that we proceeded on time, led
each part, contacted all of the other people like a client, helped with other parts,
and programmed the game using Unity. He taught me how to use Unity and how to
advance my work. Our 2D Artist is Sandra da Cruz Martins who created the general
image of the game by designing the 2D graphics and she also designed the
concept-art of characters. Our 3D Character Artist is Tim Remmers who created the
3D characters and the elements of environment, and also created the motion of all
of the elements. Our 3D Environment Artist is Ronald Houtermans who created the
general environment of the game. Our programmers are Francis Laclé and Jens
van de Water who are from Utrecht University.
They made the code for connecting the instrument of arm movement with the
game and programmed the game in Unity.
My role is doing the Audio Design for the game. I designed the character’s voice
sound , the character’s motion sound , the effect sound, and environment sound. I
also took care of the music by asking a composer to make game music that was
suitable for our game and stroke patients. Then I put the audio in the game by using
Unity and adjusted their effects and their volume.
I will explain ‘Vogels’ on the following contexts (7-1*) and my study and the play test
(6-2*, 6-3*).
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6-1* ‘Vogels!’
Playing ‘Vogels!’ is very simple. You make the main
character move up, down, right, and left by using the
instrument for arm movement instrument. By doing that,
you help the main character to make contact with the
other birds. When you touch the other bird with your
hand, you get a point. The objective is to get as many
points as possible.
The level of the game can be changed
dynamically according to the level of
impairments of the patients. This is
because depending on the person the
limitation of the moment of the arm is
totally different. Also the game needs
to keep pace with their speed of
recovery.
Therefore in this game you can
calibrate the range of arm movement.
First you need to measure the neutral
position of their arm while keeping in
mind that you should be able to move
right and left after this. Next you set their
limitation of range by moving left, right
and up as much as you can. In this case
it should be much more effective if their
therapist helps them with their aim of
arm range when you calibrate.
Also, in this game the speed of the main
character can be changed. For
instance, the patients are given more
time for moving their arm and flying to
the other birds when you set the speed
to slow.
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Also our explanation of the game is written in Dutch, not in English. It’s more
comfortable and useful for the patients because a lot of them are over 65.
‘Vogels!’ has three environments which are Sky, Land, and Water. In each
environment you can see the different characters and different scenery and
different music. By these changes, you can get a new feeling in every world so you
will not (won’t) get bored.
6-2* what did I do? I worked on the audio of ‘Vogels’ in this project. I was an absolute beginner at
game audio when we started the project. So I could learn many things about
audio and game software in the project thanks to the help of a lot of people. I
especially learned a lot from Mr. Richard van Tol who is a game audio designer and
teacher in HKU.
6-2-1* Audio mood board and Audio trailerBefore creating the sounds I designed an audio mood board and an audio trailer in
order to convey the mood of the audio to our client, the composer student, the
other project members and so on. At first I collected a lot of sounds through the
Internet. After that I made the sound fit with the character image table which was
made by our 3d designer. I think it is very important for the game audio that we
always keep contact with our graphic designer; for example we should always ask
about the process of their design. Then you can make a mood board by putting
your image sounds even if you only have a rough sketch from your designer.
(Audio Mood board)
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Also I created the audio trailer which was composed with some sounds, some music
and some rough drawings which were made by our 2D designer. I think they workedvery well for designing the music and the sounds in context. It helped me to explain
my game image easily to other project members, so we could synchronize the
difference between the designers and me, which was necessary because they also
had their own idea about the character’s voice. It also made it really easy for me to
communicate my idea about the music to the composer student.
You can see my audio trailer at the following link. http://vimeo.com/10725316
6-2-2* How did I make sound for ‘Vogel!’? I designed the sounds using Adobe Audition, which can record, edit, and creat a lot
of effects.
When I edit the sounds I always keep the following 5 things in mind. (5-2 )
- Not too stimulating,
- Not negative
- Realistic with a touch of fantasy
- Immersion
- Relaxing and calm.
Too many high tones and keys are big problem for the stroke patients because they
might stimulate them too much and surprise them easily. Also I try to erase the
background noises as much as possible. Even if you almost can’t hear these noises,
they might make the patients sensitive, because some stroke patients have ear
problems.
.
The quality of the sounds is also really important for their emersion and the game’s
realism. Therefore we had to be careful of negative change by compressing sound
files. But we didn’t want to end up having big files for only sound because many 3D
graphics and the motion already made it huge.
Keeping these both in consideration, I decided the quality of the sounds should be
standardized to 22050Hz and 16 bit.
I will explain the basics of how I edited the sounds for the patients.
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(1), Graphic Equalizer
I used the graphic equalizer for cutting the high frequency and the low frequency.
For example, if you record some bird’s voices, in most case it’s including too
high-pitched voice. We don’t need these sounds for them. That’s way I cut these
high frequencies.
Also according to research, a too low frequency might pose a hazard to health l ike
headaches, even to healthy people. ( Infrasound: http://en.wikipedia.org/wiki/Infrasound )
(2), Delete Noise
(Noise Reduction)
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(Spectral Frequency Display)
Noise always bothers us. Almost all sound files contain several place with noise. I
often used the Noise Reduction and Spectral Frequency Display for that. Noise
Reduction can delete the constant noise which expands all over in the sound files.
For the partial noises, you can erase it using Spectral Frequency Display.
(3)Time Stretch and Pitch shift
The real bird’s voices which were recorded were sometimes too stimulating and too
high key and tone. Therefore I changed the pitch and tempo to a more calm voice
by using Stretch.
(4)Echo and Delay
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In odder to create feeling of realism and immersion, I gave an echo to the sky birds,
because their twitter should sound faraway sound. Also all of sounds in the cave
need more echo as well because they rebound each other.
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6-2-3* Music for ‘Vogel!’ Music is also one of the most important things in our game. I asked the music
composer student that basically we need relaxing music for the patients becausethey need to feel at ease and get comfortable on their rehabilitation without the
beat for of the music over-stimulating them. The beat is normally necessity for
making people excited, but for the patients sometimes it makes too much.
In order to convey our image correctly to the composer I made a music design
document which contains my design image, the format (mp3, wav...), the rate (Hz)
the bit depth (bit) and so on.
This is part of the music design document.
■■■■ Design image for music
Land music (3minutes):
calm, comfortable, slow, peaceful
Sample: land1.mp3, land2.mp3
Water music (3minutes):
relax, clear, refresh
Sample: water1.mp3, water2.mp3
Sky music (3minutes):
freedom, shine, bright
Sample: sky1.mp3, sky2.mp3
■■■■ Technology
Platform - Windows
Sound engine - Unity
Editing tool - Adobe Audition
Format – ○wav △mp3
Rate – 22050Hz
Bit depth - 16bit
Cannels – stereo
But it was still difficult to explain the music image in words. Therefore I include a
music sample for each environment with the music design document.
After that it is also very important we often contacted each other. The composer
student gave me each music demo before he designed it, then we (including our
team members) discussed whether this music was correct or not.
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6-2-4* Managing the audio by UnityWe used game Unity to integrate all of the elements for ‘Vogels!’. The following
figure is a picture of the global world of ‘Vogels’. You can see a lot of audio in there.It is essential to put many environment sounds to express a realistic world. Also, lots of
environment sounds will help the patients to feel immersion and fascination.
To put the sounds in Unity, we have to take care of not only their volume but also the
range of the effects (from how far we can hear each sound). For example, the sky
birds make flapping sounds. When they get closer to you, you can hear this flapping
sound gradually. Then it is important to adjust from when till when you can hear it. If
it’s too long, these sounds will become annoying. But if it too short, it lacks realism.
Especially for patients who have weak sight, these sounds let them know that birds
are approaching you.
Also I designed multiple sound effects for the characters, even if they are totally the
same characters and same motions. You can hear the sounds variation when you
approach the birds. In this way multiple sound effects ads realism and avoids
making the patients lose interest.
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6-3* Audio play test
we had a play test for audio at 20th
May in an elderly home in Hilversum.
Method8 people played the game while using headphones to listen to the music and
sounds. The first 4 people were shown the game for about 5 minutes because they
weren't allowed to play it. Just watch and listen. The other 4 people were allowed to
play the game while listening to the music.
All of them were given these questions: ’what do you like in the audio? And, what
don’t you like in the audio?’
Result1: Female (58)
What do you like in the audio: The water part was the most clear to her, she liked the waterfalls
What don't you like in the audio: She couldn't recognize the land part
Comments: The world and it's audio gave her a realistic feeling of the world, and it was calming.
2: Female (72)
What do you like in the audio: The music was very clear and suited the environment
What don't you like in the audio: The sound effects were too noisy and chaotic in her opinion
Comments: She couldn't really pay attention to the game, because of the noise of the
environment sounds. She did have some hearing problems.
3: Female (64)
What do you like in the audio: Beautiful music! It suited the environment very well,
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What don't you like in the audio: She really liked all the audio in it, even the strange bird sounds.
Comments: She was able to name almost all of the sounds she heard during the playtime.
4: Female (55)
What do you like in the audio: The music and the bird sounds were good together
What don't you like in the audio: She thought some of the birds sounds were a little bit strange
and not very realistic
Comments: The game gave her calming experience.
5: Female (70)
What do you like in the audio: She really liked the animation of the bird together with the music,
the rhythm was good!
What don't you like in the audio: Some of the bird sounds sounded a bit ine panic. That's why she
was avoiding the birds.
Comments: The music, together with the game, really gave her a soothing feeling. She mentioned
that she often listen to this kind of music to relax.
6: Female (67)
What do you like in the audio: She liked the fact that the music/sounds adapted to the
environment, she was able to hear in what part she was flying.
What don't you like in the audio: The sounds of the birds she had to catch sounded like you were
hurting them. She also thought the main character was making that sound instead of the other
birds.
Comments: She thought she was flying in the Grand Canyon. The audio really blended in with the
game.
7: Male (80)
What do you like in the audio: The music, which was like the music on the Discovery Channel
documentaries .
What don't you like in the audio: The flapping sound was a bit annoying, sometimes.
Comments: The environment sound felt very natural and realistic. He could recognize the
landscapes in the music a bit.
8: Female (50)
What do you like in the audio: The realistic feel of the waterfall, she could really feel it coming.
What don't you like in the audio: Although the waterfall felt good, it was a bit too loud in her
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opinion. The music is fading away there.
Comments: She was getting very relaxed by the music.
The people who didn't play the game and only watched/listened were able to mention more
environment sounds than the people who were playing the game, they only recognized the
waterfall.
Conclusion and SolutionA lot of people like the music, and some of them said felt relaxed.
But some people think a sky bird sounds panicking and like you were attacking and
wounding the other birds. That‘s why they avoid the birds instead of coming in
contact with them. This was big problem for me. Actually their sounds were
sounding a little bit negative and using too high tones. In order to solve this
problem, first I tried to pull down the pitch, but still the sound was too negative.
Therefore I changed the way in which the pitch was changed.
You can see the shape of the changed the pitch in the figure above. The last part of
the sound file is in a higher pitch than opening parts of it. As a result the tone of
sounds became higher, and sound more positive.
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7*
How can we develop game audio for
their rehabilitation in the future? I already explain you that in some hospital and rehabilitation center, they do use
sound therapy in practical for the patients who have the damage in their brain like
a Parkinson and cerebral palsy. They classified the sound therapy as the stimulation
from rhythm and stimulation from music. The rhythm stimulation might be effective
for their physical motion. The music stimulation should affect their mental problem.
Regrettably I couldn’t incorporate the system of these researches to ‘Vogels!’, but
these will be very useful for developing rehabilitation game in future.
I will introduce you what kind of sound could apply to game audio for the
rehabilitation of stroke patients.
7-1* Sounds for helping physical rehabilitationThe surprising thing is that some sounds stimulate and help the physical motion of the
patients on their rehabilitation. It has been proven in a medical dissertation.
(Mutsumi Abiru, 2007, Neurologic Music therapy for Rehabilitation for Stroke patients)
Rhythmic Auditory Stimulation (RES)
In this paper, there are two ways for improving physical motion. One of them is
called Rhythmic auditory stimulation (RAS), which facilitates the rehabilitation of
movements using external and rhythmical stimulation. The sounds are used to
decide the tempo and speed in which is being moved.
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RAS was known to be effective against a handicap of the central nervous system.
According to other research, it helps with Parkinson’s disease, stroke, Spinal Cord
Injury and so on.
Patterned sensory enhancement (PSE)
The other way is Patterned sensory enhancement (PSE), which improves motor
dysfunction of stroke patients, using rhythmic, melodic, harmonic and dynamic
elements of music to provide temporal, spatial and kinematic cues.
It affects upward and downward motion, and enables stroke patients to perform a
wide range of motions like for instance a squat. In the case of a squat, if we need
the patients to reach lower positions, we can make the sound go lower and lower
gradually and we can also make it go slower.
I think we can apply these researches to a rehabilitation game quite easily. For
example we can program these sound effects to coincide with the motion of hte
arm.
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7-2* Music for helping mental rehabilitation Music has the power to stimulate people easily, like to excite and heal and make
people feel relaxed.I found it interesting that their favorite music works very well for stroke patients not
only for use with physical motion but also especially for the recovery of their
memory.
This was investigated at Helsinki University in Finland. The group of 60 stroke patients
was the target for this research, and all of them had problem with their memory and
trouble with keeping focused.
Everyone was divided between group1 (listening to their favorite music at least 2
hours per day), and group2 (listening to someone reading a book for them), and
group3 (nothing). This figure is the result 3 months of research.
Improvement probability of their memory after 3 months
Group1 60%
Group2 29%
Group3 18%
Also group1 became less depressed than any other group, and the music helped
them to stay forcused.
The treatment is more effective if they include lyrics which they can understand the
meaning and language of.
(http://www.afpbb.com/article/life-culture/health/2353313/2659976)
It should be possible to include their favorite music in game, like for example games
of based on music like Guitar Hero, Dance Dance Revolution and so on.
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8* Conclusion
In the introduction I talked about ‘what is a stroke?’, ‘why do we need audio in
games for stroke patients?’, ‘what is ‘Vogels!’?’, ‘how did I make the audio?’ and,
‘how can we develop the game audio of rehabilitation in the future?’
In conclusion, I think game audio is a very effective tool for the rehabilitation game
of the stroke patients, and that’s why we have to be attentive of making good
audio for the stroke patients. This time I took care of the following five things when I
designed the audio; not too stimulating, not negative, realistic with a touch of
fantasy, Immersive, relaxing and calm.
We got a really good response to the game ‘Vogels!’ from the patients.
Also now I know we can help their rehabilitation by implementing good game
audio. Probably we can apply game audio not only to the stroke patients but also
to the patients of other several diseases.
It was the absolute first time for me to make game audio for stroke patients, but I’m
satisfied with our game and the audio. I hope I can continue the research and I will
be able to make the more game for rehabilitation. I appreciate that a lot of people
helped me in making the audio and this paper. Also I’m glad I had a good team
and a nice client.
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9* Reference * Paper*Kamper D | Alterations in Reaching after Stroke and Their Relation to Movement
Direction and Impairment Severity. Arch Phys Med Rehabil, o1(83), 2002, pp 702-707
Philips research 2007| Philips Stroke Rehabilitation Exerciser
Mutsumi Abiru, Yutaka Kikuchi, Kouji Tokita, Yoshiko Mihara, Mikio Fujimoto, Ban
Mihara, 2007| Neurologic Music therapy for Rehabilitation for Stroke patients –
Prospects of Music therapy for Gait Disturbance -
Adriaan de Jongh |Komodo Research Document, 2. 2010
*Web site*Infrasound| http://en.wikipedia.org/wiki/Infrasound
脳梗塞患者の回復には好きな音楽が効果的、フィンランドの研究結果|
BB News. 20. Febulary. 2008.
http://www.afpbb.com/article/life-culture/health/2353313/2659976
* Other*Presentation from Focal Meditech BV(2.2010) | Focal gave us the presentation for
introduction.