Rebecca Moore Physiotherapist Orange Health Service October 2012 Developing an Evidence Based Guideline and protocol for using Wii for Rehabilitation.

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)

Motor Assessment Scale

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

The Beginning!