The effect of Nintendo Wii console on rehabilitation
The prevalence of serious neurological cases is increasing year after another. A prospective community-based study done in United Kingdome (UK) showed that the incidence of underlined neurological cases like Cerebral Palsy (CP), Multiple Sclerosis (MS), and Cerebro-vascular Accident (CVA) is about 0.6% of UK population in six years while 0.6% of the affected cases had recovered from the neurological case (Macdonald et. al 2000). Not only the neurological incidence has its remarkable effect on the patients and societies, but also the phase after it that is more challenging and time and money consuming. It has been revealed that up to 85% of stroke patients experience a stage of motor and sensory control loss that affects the quality of their life. (Sponik et al 2010).It was reported that a chronic need for intensive rehabilitation session is highly required for children with any neurological defects. (Golomb et al 2010). People with other neurological problems require different kinds of rehabilitation and treatment protocol including balance training, motor learning and sensory integration. The ideal rehabilitation protocol is known to have low feasibility, high affects and can extend into home and working areas. (Clark et al. 2010). It is also preferred to be amusing and motivating the patients while training. Therefore, a new system called Nintendo Wii console is being introduced and studied for rehabilitation from neurological problems. Wii, which is a home video gaming system, is based on engaging the patient into a 3-dimensional world and encouraging him or her to interact with this world. By this procedure, the patient will be achieving high levels of rehabilitation in a simple, low cost, and amusing way. For example, the patient will regain his motor control of upper limbs and lower limbs by playing basket ball or tennis in the virtual reality world by interacting with the wii console. Patient may also regain his or her balance and physical activities by playing a skate board game at the Wii Balance Board (WBB). (Deutsch et al 2009). In this report, the rationale of Nintendo Wii console will be presented, followed by the multi-usages of Wii console in rehabilitation from neurological problems. The report will summarize literature related to the effect of Wii on many neurological defects including stroke, cerebral palsy, balance problems, multiple sclerosis and aphasia. In particular, the report review some of the physiological and psychological effect of this gaming system when being introduced into medical intervention.
Body of knowledge:
As the medical intervention proceed to develop better and more efficient treatment protocols for better health and rehabilitation, advances in the world of technology could be used to achieve the same goal. The world of virtual reality (VR) and 3-dimensional world are first on the list of modern technology and as well, medical interventions. Virtual reality is a new computer technology that stimulates learning by engaging in a 3-dimensional semi-real life cooperated with visual, sensory or auditory feedback. (Sponik et al 2010). It has been noticed that the rationale behind VR is being used in medical field and physical therapy goals. It has been found that better and efficient outcomes could be achieved through engaging a patient into the VR world to perform a task that enhances his/her impairment, encouragement and motivation. (Sugarman, et al 2009). Based on the idea behind VR, a gaming system called (Wii) was invented and released at the end of 2006. (Loureiro et al. 2010). The commercially gaming system, Nintendo wii console, is reported as one of the top-selling video game which is easy to use interactive game. (Plow et al 2011). Many researches are interested on knowing the optimal effect of engaging the Nintendo Wii in a rehabilitation and treatment intervention. One of the Wii gaming systems, the Wiimote (fig. 1), was selected for study to be used in a medical field. The wiimote is hand held controller connected by the wii game with an-infrared camera. This connection allows the player to achieve tracking of the game showed on the computer screen by the hand motion that is holding the controller,stimulate the upper limb control and hence, treat impairments as shown in this research. (Decker et al 2009).
Fig. 1: the Wiimote hand held controller
Another wii- gaming system that engages a higher physical activity is the Wii Fit (fig. 2) . Wii fit is a game that interacts about 40 games including dancing, running, and yoga using a platform called the Wii Balance Board (WBB) which is placed on the floor controlling an on-screen action. The benefits of this game is not limited to its usage as a treatment for increasing the level of balance, strengthening, and general physical activities suiting all ages, (Plow et al 2011)., but also it is considered as an assessment tool for rating the balance level of the patients. The reason for this usage is that WBB consists of the transducers used to assess the force distribution and the Center Of Pressure (COP) movements. (Clark et al. 2010).
Fig 2. The Wii Fit game
The effect of Wii on stroke rehabilitation
Many studies have been conducted to the study the effectiveness of virtual reality (VR) as treatment and rehabilitation system for stroke and all kinds of cerebro-vascular accidents. The first randomized single blinded study with two parallel groups to compare the influence of virtual reality using Nintendo Wii & gaming technology (VRWii), versus recreational therapy (RT) on motor function of the upper extremity was conducted in Canada in 2010. Two groups of 18-85 years old participants and six-month from first-time stroke were included in the study. The first group had 8 intensive Wii 60-min sessions of over a 14 day period whereas the other group had a recreational therapy including playing pingo, playing cards and playing "jenga". Measuring the Primary Safety and the efficacy outcomes using the Wolf Motor Function Test (WMFT) showed significant improvement of the post stroke patient's upper limb function. (Sponik et al 2010). Another research studied the Wii- rehabilitation or (Wii-habilitation) among regaining the function of wrist extension and flexion prior to stroke and wrist fractures. Wiimote which was released by Nintendo as the hand held game controller for its sixth game console named the Wii. The Wiimote is held in the hand like a remote control that tracks motion and hand movement by an infrared (IR) camera. Based on the fact that the main reason of the lost flexion and extension of the wrist is due to the range of motion of each, the participants' ROM was measured after and before the Wii training. It was concluded that the range of motion rehabilitation through the use of a Wiimote technology based system is very much feasible, effective, and inexpensive option. (Decker et al 2009). The usability of Nintendo Wii has been studied also in a pilot study at the Royal Berkshire NHS Foundation Trust Hospital. The study focused on the gaming and social interaction in the rehabilitation session upon all kinds of brain injuries including stroke, traumatic brain injuries (TBI), Berri Berri and korsakoff's syndrome when using Nintendo Wii console. A sample of nine acute cases undergoing rehabilitation was selected to play with the Nintendo Wiimote games including bowling, golf, boxing and baseball. After a demonstration lecture provided by an occupational therapist to show them how to use the gaming system, each patient picked a suitable game and play for one session. Questionnaires were then provided to the participant to rate their opinion and self evaluation of the Wii-habilitation session. Analysis of the collected data found that there are significant positive feedbacks and comments and that Wii in general has a positive effect upon the brain injury rehabilitation. (Loureiro et al. 2010).
The effect of Wii on cerebral palsy
Talking about the importance of the visual reality and Wii-rehabilitation among the Cerebral Palsy (CP), a study was conducted in 2010 to study the outcomes and effectiveness of Wii. In this study, a 15-years old boy with hemiplegic CP and epilepsy, due to perfumed perinatal stroke, was kept under observation while spending 14 months virtual reality using videogame hand tele-rehabiltation intervention. The tele-rehabilitation system incorporated an Ultra Glove, a high-definition TV, a keyboard, and a PlayStation3 game console programmed with custom rehabilitation game. Measurements and outcomes of the hand function were measured using grip strength and the Jasben test for hand function. The Jasben test measures the different hand functions including writing, stimulated page turning, pick up small objects, simulated feeding, staking checkers, lifting large, light objects and lifting large and heavy objects. The study showed a significant increase and improvement in the child’s hand function after conducting a training course. (Golomb et al 2010). Another study was conducted to examine the use of a low-cost and commercially available gaming console (Wii) for rehabilitation of an Adolescent with CP. In this study, an adolescent with spastic diplegic CP classified as GMFCS level III, participated in 11 training session using the Wii sports games software, including boxing, tennis, bowling, and golf. In the study, the child was trained in both sitting and standing positions and three outcome measures to study the effect were studied. The selected outcome measures were visual perceptual process using a motor free perceptual test, postural control by the weight distribution and the sway measures, and the functional mobility using gait distance. Outcomes were re-measured after one month and showed that: visual-perceptual process was improved in all dominance except the visual memory. Postural control improved and showed that there is a greater loading on the lower extremities and center of pressure sway was increased by 60%, and finally functional mobility with the forearm crutches was measured and it was revealed that the distance achieved by the patient now was never achieved before the training session. (Deutsch et al. 2008).
The effect of Wii on balance problems:
Not only Wii has been used for CP and stroke rehabilitation, but also it was tested to be a candidate for balance training. Many researches have been studying the validity and reliability of virtual reality (VR) and Natindo Wii for treating and overcoming balance problems. A study conducted in 2010 was based on a comparison between the Wii Balance Board (WBB) and a laboratory-grade force platform (FP). In this comparison, a sample of thirty young injury free individuals was tested in two occasions. In each occasion, participants performed four balance tasks that were chosen based on difficulty. The four balance tasks were: single limb standing with eye closed, single limb standing with eye open, double limb standing with eye closed and feet together and double limb standing with eye open and feet a comfortable distance apart. All of these tasks were performed on a laboratory-grade force platform (FP) and then by the WBB which was placed beside the FP. Data were collected for 10 seconds during single limb trials and for 30 seconds during double limb trials for both devices. The study showed that the WBB provides comparable data to a FP when assessing center of pressure COP path length during standing balance trials. Consequently, the WBB has the potential to ‘bridge the gap’ between laboratory testing and clinical assessment of standing balance. (Clark et al. 2010). Another study was designed to compare between a Wii-based balance training and a standard balance training program. the two selected participant had cerebro-vascular accident in a chronic post-stroke phase with balance problems were randomly assigned to either Wii- balance training or standard balance care. Both participants were tested before and after training by many outcome measures including: Gait speed, walking endurance (six minute walk test), balance (Dynamic Gait Index) balance confidence (Activity Balance Confidence Questionnaire) and dual tasks mobility tests (Timed-Up and Go). The participant trained by Wii and Nintendo Wii had activities that stimulate balance, coordination and strengthening. He played games included boxing, bowling and baseball. From the Wii Fit, he used balance (ski jump, ski slalom, tightrope), strength (lunges) and aerobic activities (park strolls), whereas, the other participant has balance and coordination exercises while sitting and standing. After 12 hour training for four weeks, participants were re-tested after the training and results were compared. Result showed no significant improvement in the outcome measurements, however, subjective improvements as the sustained intensity and accurate treatment time of the Wii- balance training program were seen. (Deutsch et al 2009). As elders have high risk of falling, a study was conducted to test the feasibility of using the Wii-fit system for the treatment of balance problem in this age group. An 86 year-old woman who was recovering five weeks after stroke and who had major difficulty in walking without close supervision was tested before training on a Wii fit gaming system using outcome measures including Berg Balance Scale (BBS), Functional and Lateral Reach test, Time Up and Go test, and Short Feedback Questionnaire (SFQ). The Wii fit gaming system includes several balance games like: the Table Tilt, Bubble Balance, Torso and Waist Twist and Tightrope tension all of which are used for balance and coordination treatment. After the training sessions the subject was retested and the results revealed a great success of the Wii games as the results of the subject improved significantly. For example, there were a 10 second decrease in the Time Up and Go test which indicate a 90% confidence that there is a significant change in the balance and coordination. Finally, the Wii fit helped the participant to improve both her balance and confidence to walk safely and without supervision. (Sugarman, et al 2009).
The effect of Wii on Aphasia:
Some researches highlighted other conditions that show a remarkable effect of Wii in treating other cases. For example, a study conducted to observe the communicative acts in cases of aphasia during Wii training. Four aphasia groups, all of which represent a different types and severities of aphasia, were trained for two weekly one hour sessions during consecutive trimesters. They all were engaged in a Nintendo’s® Wii™ Sports (2007) that includes bowling games. After that, eight communicative acts were collected and tested. Communicative acts include: humor, anticipation, reaction, response, celebration, assistance, competition and support. is the study revealed that the use of Nintendo’s® Wii™ Sports (2007) with aphasia cases provides psychosocial benefits including experiencing group camaraderie, virtually engaging in a past activity, and sharing the experience with others. (Szabo et al 2010).
The effect of Wii on Multiple sclerosis (MS):
A longitudinal pilot study examined the potential of Nintendo Wii Fit to increase physical activity (PA) behavior among people with multiple sclerosis (MS). Thirty people with MS who had the ability to walk were included in the study. The outcome measures were the Physical Activity and Disability Survey, Modified Fatigue Impact Scale, and 36-item Short Form Health Status Survey. Results from the questionnaires indicated that PA had significantly improved. Physical assessments indicated that people with MS may be able to improve their fitness levels by using Wii Fit. (Plow et al 2011).
Physical and psychological effects when playing with Wii
A pilot study was conducted to observe the physical and psychosocial effect while using Nintendo Wii in community dwelling older adult women. All participants were tested and retested by outcome measures including full body movements using accelerometers, and assessed psychosocial effects through end-of-study focus group meetings. Consisting of a baseline period and an intervention period, participants played Nintendo Wii Sports twice weekly. The researchers conclude large self-reported psychological effects related to positive changes in self perception. The study found that the Wii-game did not have substantial physical effects, nevertheless; qualitative data showed that the participants perceived an improved sense of physical, social and psychological wellbeing. ( Wollersheim et al 2010). As a confirmation to the previous study, another research studied the physiological cost and enjoyment of exergaming on Wii Fit compared to a sedentary video gaming among three populations: adolescent, young adults and older adults. The cardio-respiratory and enjoyment were measured for fourteen adolescents, fifteen young adults and thirteen older adults after playing inactive video gaming, Wii Fit including yoga, balance games, brisk treadmill walking and jogging. Results showed that the Wii Fit exegaming increases the energy expenditure and physiological activity compared to any other regular inactive game. (Graves et al 2010).
In conclusion, the known to be amusing and entertaining Nintendo Wii console has been introduced widely into the rehabilitation and medical treatment. As shown in the previous studies, Wii can be used to increase both upper limb and lower limb motor control though increasing the rehabilitation and recovery speed among stroke patients. It is also known to improve sensory and proprioception input on all patients with neurological defects. Balance and quality of activities of daily living are also improving using Wii. Not to forget the psychological effects when playing with Wii gaming system, Wii has proved to have positive changes in self-perception and improve social, psychological and physiological wellbeing. Although Wii console is amusing and highly effective, it may be associated with some problems and dangers while using this gaming system as a treatment intervention. Similar to sporting, stretching is highly recommended before playing with Wii. If the patient didn't stretch, he/she might suffer from muscle fatigue or a spasm as well as a repetitive stress injury. In addition, clearing the area and preparing it before playing should be taking care of. Finally, introducing such new technology based on high involvement of the patient into a 3-D world has proved itself as an effective intervention if safety precautions were considered. Wii makes it possible for patients to have fun and enjoyable time while recovering from their injuries.
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