Post on 16-Dec-2015
Wiihabilitation
Rebecca Moore
Physiotherapist
Orange Health Service
October 2012
Developing an Evidence Based Guideline and protocol for using Wii for
Rehabilitation
OutlineOverview of the Wii System Background (Issue and Aims of the project) Evidence for intervention Limitations to the evidenceProtocol Development and Use Future Directions
What is Wii?The Nintendo Wii was developed and released by
Nintendo in 2006 as an of the shelf virtual reality gaming system.
It involves interacting with a virtual environment projected on the TV screen using hand held remotes or a weight sensing balance board.
Components TV screen
Used to display the virtual environmentProvides feedback on interaction with the environment
Wii ConsoleHolds the software disc
ComponentsWii Remote/s
Wireless, hand held, motion-sensitive controlsCan be used as a direct pointing deviceFeedback provided by a rumble device and a built-in
speaker in the remote.
Wii Fit Balance BoardMotion sensitive Interprets the movement of the feet and senses weight
distribution over base of support
What is Wiihabilitation? “Wiihabilitation” refers to the
use of the Nintendo Wii
virtual reality system as a
form of rehabilitative
therapy.
The IssueNintendo Wii was purchased for OHS Rehab Unit
but it was being under-utilised.
The Aim • To develop an evidence based guideline for using Wii
for Rehab.• To develop a protocol for using Wii in the rehab setting.
The Evidence for WiihabLimited research presentlyReview of evidence revealed 5 studies appropriate
to relate to our PICOT question “Can Nintendo Wii be used as a useful adjunct to physiotherapy service in a rehabilitation unit to facilitate improved patient outcomes regarding function and independence post stroke?”
1 x meta analysis – Looked at multiple Virtual Reality Technologies
3 x RCT’s one of which was included in the meta analysis
Saposnik et al - Effectiveness of Virtual Reality
Using Wii Gaming Technology in Stroke Rehabilitation A Pilot Randomised Control Trial and Proof of Principle
(Stroke. 41(7): 1477-84, 2010 Jul.) Purpose
To examine the feasibility, safety and efficacy of using Wii in patients post stroke to facilitate motor function of the upper extremity required for activities of daily living.
DesignRandomised, Single Blind, Parallel group trial
Sample22 participants, aged 18-85, sub acute phase (up to 6
months) Able to shrug shoulders and touch chin with affected arm.
Saposnik et al - Cont. (Stroke. 41(7): 1477-84, 2010 Jul.) Results
Wii group had a significant improvement in mean motor function (Wolf Motor Function Test) of 7 seconds compared to control
ConclusionWii gaming technology does represent a safe, feasible
and potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke.
Kim et al – Use of Virtual Reality to Enhance Balance and ambulation in Chronic Stroke. A double-blind Randomised Controlled Study (Am J of Phy Med and Rehab. 88: 693-701, 2009.)
PurposeTo examine the additive effect of virtual reality on balance
and gait function in patients with chronic hemiparetic strokeDesign
Double Blinded Randomised Control Study Sample
24 Adults, at least 1 year post stroke, With the ability to stand and walk indoors
Kim et al – Cont. (Am J of Phy Med and Rehab. 88: 693-701, 2009.)
ResultExperimental group had improved BBS and significant
improvements in velocity, modified MAS scores, cadence, step time, step length and stride length.
ConclusionVirtual reality has an augmented effect on balance and
associated locomotor recovery in adults with hemiparetic stroke when added to conventional therapy.
Hurkmans et al – Energy Expenditure in Chronic Stroke Patients playing
Wii Sports: a pilot study
Journal of Neuroengineering and Rehab. 8:38,2011 Purpose
To investigate if the intensity of physical activity and therefore energy expenditure among chronic stroke patients while playing Wii Sports is sufficient to meet current evidence based guidelines for maintenance and improvement of health among stroke survivors.
ConclusionMean energy expenditure reached appropriate levels
for moderate exercise, 3.7 METs for tennis and 4.1 METs for boxing
What the evidence doesn’t tell usWhat about the patients that don’t’ fit the inclusion
criteria of the studies?
Only looks at a very few select games
Doesn’t indicate how to pick which games to use with which patients
Requirements of a protocolA way to match the patients ability and skill level with
the difficulty and skill requirements of a game
A way to pick the right game to train what you want to improve
Simple decision mechanism for therapists not familiar with Wii games to use Wii
Developing a protocolStep 1 – Compile a database of games that
included: Skills required for each game (motor and cognitive) Equipment required for each game Various ways to play the game (ie. seated, standing)
Database SampleDisc Game SubGame UL/LL/WB/
BalanceUnilateral or Bilateral
Equipment Required
Seated or Standing
MET levels
Skills Required
Wii Fit Training Plus
Perfect 10 Balance NA Balance Board Standing 2.5 -Standing Balance -Weight shift 4 directions-Simple Calculation
Cycling Whole Body
Bilateral Balance Board + Controller
Standing 2.5 - Standing Balance - March on spot -BIlat arm steering
Rhythm Kung Fu
Whole Body
Bilateral Balance Board + Controller + nunchuck
Standing 3 - High Level balance skills - Timing
Driving Range
Whole body
Bilateral Balance board + controller
Standing 3 -Standing balance-UL bilat swing
Segway Circuit
Whole body
Bilateral Balance Board + controller
Seated or standing
2 -weight shift forward and back -steering with bilat upper limbs
Birds Eye Bulls Eye
Whole body
Bilateral Balance Board Seated or standing
2.5 -weight shift in four directions -bilat arm abd/flapping
Developing a protocolStep 2 – Choose a standardised tool to assess a
patients impairments and skill level. Motor Assessment Scale 8 items Scored from 1-6 (Rolling, Bed Mobility, Sitting
Balance, Sit to Stand, Walking, Upper Arm Function, Hand Movements, Advanced Hand Activities)
Developing a protocolStep 3 – Create a system by which therapists can
match the skills of the patient to the appropriate games available on Wii.
Decision Trees Static BalanceLower limb function and dynamic balance Arm functionCardiovascular Fitness
Where we are at nowTrialling the decision trees in our rehab unit
Set up as part of circuit training group at present Biggest limitation to use is cognition
Getting feedback from patients and therapists Continuing to monitor emerging evidence and adapt
practise to meet evidence recommendations
Future DirectionsResearch project in the clinical setting
Rotating staff through the area Blinding difficult in a small setting Ethics approval Needs to be an adjunct to routine
therapy .. Time constraintsApplicability across settings
Paediatrics Acute wardsIn the community