Mr. Steven P Miller Jr.

Augmenting therapy utilizing the Nintendo Wii™

http://www.bayraider.tv/2007/02/nintendo_rehabi.html

http://www.google.com/

The RehabCare Group

Agenda

• Purpose• Video Games• Therapeutic Activities• Goals• Beginnings of a Wii™

program

• Physiological Changes• Gender Differences• Psychological &

Behavior Outcomes• Available Resources

http://www.wiiwii.tv/2008/02/25/calling-dr-nintendo-wii-used-in-burn-therapy/

http://dvice.com/archives/2009/04/nintendo-wii-pa.php

Purpose

• Awareness of Wii in therapy• Provide evidence – Received 70+ surveys in 2009

• Get Input for future work

http://www.8bitreview.com/blog/8bitrants.php?cat=7http://www.hospitalnews.com/modules/magazines/mag.asp?ID=3&IID=128&AID=1647

Video games currently used in rehabilitation clinics

• Wii Sports™[1, 8, 9, 10, 12, 13, 14, 15, 16, 19, 21, 24, 25, 27, 28, 29, 31, 62]

– Tennis– Bowling– Boxing– Golf (rare)

• Wii Fit™[1, 3, 8, 10, 12, 13, 14, 23, 27, 28, 30, 61, 62] – Table tilt– Bubble balance– Tightrope tension– Torso & waist twist– Hula hoop game– Ski slalom– Ski jump– Jogging

• We Ski & Snowboard™ [28]

• Wii Music™[28, 62]

• Link’s Crossbow Training™ [28]

• Blazing Angels™ [28]

• Shaun White: Snowboarding Road Trip™[28]

• Smarty Pants™[12]

• Big Beach Sports™[12]

• Wii Fit Plus™[28]

• Kororinpa: Marble Mania™[28]

• BOOM BLOX™[27]

• Mario & Sonic at the Olympic Games™[8, 13, 28]

• Wii Play™[8, 15, 19, 52, 62]

• Wii Sports Resort™[28]

• DECA Sports™ (a.k.a. Sports Island)[12, 28]

• EA SPORTS Active™[28]

• Samba De Amigo™[28]

• Carnival Games™[12, 28]

• Cooking Mama: Cook Off™[19, 28]

• WarioWare: Smooth Moves™[28]

• Big Brain Academy: Wii Degree™[19, 24, 28]

• SSX Blur™[28]

• We Ski™ (a.k.a. Family Ski)[28]

• Rayman Raving Rabbids 2™ [28]

• Trauma Center: Second Opinion™ [28]

• Trauma Center: New Blood™[19]

• Super Monkey Ball Banana Blitz[12]

• Are You Smarter Than A 5th Grader? Make the Grade™ [12]

• Cranium Kabookii™[12]

• Game Party 2™[8]

• Mario Kart Wii™[62]

All images from Nintendo.com

Additional Gamesmention in my research

• Tiger Woods PGA Tour 08• Mario Party 8• Mario Kart Wii• Nerf-N-Strike• Karaoke Revolution Presents American Idol Encore

All images from Nintendo.com

Therapeutic Activities ( 1 of 3 )• Balance training[5, 8, 10, 12, 13, 14, 19, 24]

– Sitting & standing [2, 5, 9, 12, 14, 24, 27, 28, 29]

– Shifting weight between lower extremities [1, 23]

http://gaygamer.net/2008/06/wii_fit_eyed_for_rehab_patient.html

http://www.google.com/

Nintendo.com

Therapeutic Activities (2 of 3)

• Physical Movement [18, 21]

– Motor planning/ body awareness [2, 9, 13]

– Stretching [12, 13]

– Endurance training [2, 5, 10, 12, 19, 24]

– Strengthening training [8, 10, 13, 14, 24, 28, 29]

– Functional movement & exercise[8, 14, 19]

http://www.heraldtimesonline.com/

http://blog.cleveland.com/lifestyles/2008/06/wii_fit_nintendo_game_makes_ph.html

“Using Nintendo Wii in Therapy” by Liza Jochem

Therapeutic Activities (3 of 3)

• Cognitive Training: [5, 19, 24]

– Timing [14, 23]

– Following directions [19]

– Visual-perceptual skills [9, 19]

– Listening [19]

“A Wii spot of fun” by Tim Dixon

“Virtual rehabilitation with video games: A new frontier for occupational therapy” by Jonathan Halton

Goals

• Increase • Maintain • Improve• Reduce

http://www.rdehospital.nhs.uk/trust/pr/2009/wii_exercise.htmlhttp://www.oefoif.va.gov/HowDoIGetHelp.asp

http://www.spanish-meadows.com/Services.html

Strive for an Increase

– Upper-Extremity • ROM [24, 29]

• Muscle Strength [24, 29]

• Coordination [29]

• Function [18, 19]

– Duration of participation in therapy [18, 27]

– Attention span [2, 19]

– Body awareness

– Dynamic balance [29]

• Sitting and standing [5, 9, 14]

– Patient compliance [23]

– Trunk control [24] & endurance [2, 5, 13, 19, 24]

– Hand-eye coordination [2, 24]

– Participation in group [16]

http://www.mississippimedicalnews.com/news.php?viewStory=1186http://www.usatoday.com/tech/gaming/2008-02-08-wiihabilitations-hospitals_N.htm

Targeting Improvement

– Balance [5, 11, 14]

– Attention [2]

– Timing [14]

– Upper-extremity coordination [5]

– Trunk control [24]

– Core stability– Self confidence– Hand-eye coordination [2,

5, 11, 16]

– Social participation [11, 16]

• Socialization skills [23]

– Self –esteem [23]

http://www.tbirecovery.org/ashblog/2008/03/wii-brain-injury-rehab-therapy.htmlhttp://www.zimbio.com/pictures/ujDTGDY4YZS/Medical+Center+Uses+Wii+Gaming+System+Physical/2w1-_rUL4xu

Others

• Maintain – Midline, erect

sitting/standing posture for a period of time

• Reduce– Feelings of helplessness

[16]

– Isolation– Stress

http://www.zimbio.com/pictures/ujDTGDY4YZS/Medical+Center+Uses+Wii+Gaming+System+Physical/2w1-_rUL4xu

Precautions

• “…Wii was not designed to be used for persons with physical or mental disabilities, so practitioners need to be alert for negative feedback and its effect on their clients.” [19]

• “Patients not recommended for Wii therapy are those who are not medically stable, have violent tendencies, or throw things.” [15]

Images were from http://www.google.com/

Setting Up a Wii program

http://www.8bitreview.com/blog/8bitrants.php?cat=7

Wii™ should augment/enhanced a patient’s therapeutic treatment not replaced it [24]

Starting a Wii™ Program

• Select individuals as Wii™ techs [15]

• Create a multidisciplinary team to determine which patients would benefit from Wii™ [15]

http://www.newenglandsinai.org/press_releases/nr_wii_fit.html

http://www.google.com

http://www.google.com

Wii™ Work Environment

• Utilize CRDAMC’s occupational health clinic• OSHA 3092: Working Safely with Video Display

Terminals (VDT) http://www.osha.gov/

• “To be safe, the environment needs to be arranged to accommodate the type of games being played.” [19]

Images were from http://www.osha.gov/

Setting up & Configuring the Wii™

• Connects to more that just TV– Projectors & computers

• Surf the Internet– Can be used as an adaptive device– Can add a wireless keyboard

• You can adjust its sensitivity– Sensor bar through Wii Settings

http://www.jabulela.com/miscellaneous/twenty-most-visited-web-sites-2008Other images were from Nintendo.com

Reference: http://www.nintendo.com/

Suggestion Layout

http://www.wiihabilitation.co.uk/adaptations.shtml

“Use of the Wii Fit system for the treatment of balance problems in the elderly: A feasibility study.” by H. Sugarman, A. Weisel-Eichler, A. Burstin, R. Brown

Optional Equipment

• Exercise ball – http://www.wiifitforum.org/video-wii-hab-pelvic-c

lock-for-low-back-pain-t521.html

• Thera-tubing/thera-band– http://www.hope.edu/academic/kinesiology/athtr

ain/dlssm/docs/Wiihab.ppt

Images were from Google

Wii™ Safety

• Safety First!– Gait belts [23, 29]

– “Therapist monitoring is essential for client safety.” [18]

• Patients should be assessed for adequate physical and mental abilities prior– Aggression scale [15]

• “Those who become more aggressive after a game may need to change games or removed from the [Wii] program.” [15]

Images were from Google

Wii™ Safety

http://compulsivec.wordpress.com/2006/12/

http://www.wisdump.com/design-critiques/fun-with-design-in-case-you-missed-these/http://www.gamespot.com/pages/unions/forums/show_msgs.php?topic_id=25212711&union_id=11403

http://www.flickr.com/photos/iconfactory/sets/72157594406897342/

http://gizmodo.com/219119/the-japanese-wii-safety-manual-is-crazy

Recommended Practices

• Warm-up before use [4]

• Length of sessions– Start at 10 mins [3]

– 30 - 45 mins [3, 4]

• most people

– 20 - 30 mins [3, 4]

• Not regularly exercise

http://www.mlive.com/entertainment/index.ssf/2008/08/03-week/

http://www.gearfuse.com/anatowii-the-anatomy-of-a-console/

Documentation Tips

• “The response of the patient should be reflected in functional terms and not related to fun or recreational activities.”

• “The documentation should not indicate the use of the Wii™ as a treatment device but the outcome of coordination, balance, etc.”

• CPT Codes: – 97110 (Therapeutic Procedures)– 97112 (Neuromuscular Re-education)– 97150 (Group Therapy)– 97530 (Therapeutic Activities)

http://www.wiinoob.com/anatowii-nintendo-wii-design/

Reference: “Wii habilitation, using Wii Sports in rehabilitation.” by RehabCare Group, Inc.

04/09/2023

Reported Physiological Responses (1 of 2)

• Increased oxygen consumption (VO2 max) [37]

• Increased energy expenditure (Jkg-1 min-1 or METS)[31, 32, 33, 34, 36]

• Increased heart rate (beats min-1)[31, 34]

• Greater caloric expenditure [38]

• Greater total body activity [34]

– Especially, the upper limb• The game effects amount of activity in non-

dominant limb [34] Images from http://www.google.com/

04/09/2023

Reported Physiological Responses (2 of 2)

• Level of exertion does not differ between playing against a human or computer opponent [35, 37]

• Impacted by player’s motivation [53]

– “Relaxing” vs. “Achieving”

• Impacted by player’s strategy [53]

– “Game” vs. “Simulation”• Impacted by player’s level of enthusiasm– From flicking of wrist to fully body movement [28]

Images were from http://www.google.com/

Reported Gender differences

• Gender plays a role in video game performance– Heart rates were significantly higher in females [37]

– Energy expenditure were significantly higher in males for WiiSports™: Tennis. [32, 33]

– Males have better navigation 3D environment skills and spatial abilities than females. [48]

Images from http://www.google.com/

04/09/2023

Psychological & Behavioral Responses• It is speculated that gamers’ behavior changes

as they gain expertise in a game– Changing moods & motivations [53]

• Decreased snacking behavior– Compared to Xbox [46, 47]

• “Some [patients] report that as their focus turned to the game, there was a less negative focus on the affected limb. [18]

– Intervention for pain management and behavior problems?

http://www.google.com/

Sources on the Web

• LinkedIn Group “Wii-hab”– http://www.linkedin.com/

• Twitter– http://www.twitter.com/wii_hab

• Blog– http://wiihabtherapy.blogspot.com/

• Websites– http://virtualsimrehab.com/ – http://www.wiihabilitation.co.uk/

Resources linking Wii activities to therapeutic goals

• Deutsch, J. E., Borbely, M., Filler, J., Huhn, K., & Guarrera-Bowlby, P. (2008, October). Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Physical Therapy, 88(10), 1196-1207. Alexandria, VA: The American Physical Therapy Association.– Look at its appendix

• Redmond, R. (2009). Wii Games used in WiiHabilitation Therapy. WiiHab within Therapy [Website]. http://www.wiihabilitation.co.uk/ – Click on the games summary page

• Briggs, K. & Kappenman, W. (2009). Serious gaming instructions and therapeutic applications for the Nintendo Wii. Innovations in VirtualSim Rehab [Website]. http://www.virtualsimrehab.com/publications_wii.html – Click on “Wii Therapeutic Applications” link

• RehabCare Group, Inc. (2008, March 11). Wiihabilitation: using WiiSports in rehabilitation [Brochure]. St. Louis, MO: RehabCare Group, Inc.

• Enam, N., & Turner, D. (2009, June 22). Nintendo Wii as a modality in TBI rehabilitation. Carlisle, PA: Brain Injury Association of Pennsylvania, Inc. http://www.biapa.org/atf/cf/%7BE07F6363-A589-41AA-B9C1-990FEE288F44%7D/Nintendo.pdf