A Nintendo Wii training regimen, in addition to standard multidisciplinary therapy, could be a feasible tool in post-stroke balance rehabilitation, according to recently published study results.
“Video game technologies, like the Nintendo Wii, have been adopted by clinicians … as a potentially valuable addition to physical therapy,” Kelly Bower, Melbourne Health physiotherapist and PhD candidate at the University of Melbourne, told O&P Business News. “We wanted to find out whether this was a feasible and safe approach to use in stroke rehabilitation, and whether it showed promise as a way of improving physical outcomes.”
The primary aim of the study was to assess the practicality of a Nintendo Wii-based treatment approach, and the secondary goal was to investigate the efficacy of improving balance, mobility and upper limb function.
Researchers collected data in a phase two, single-blind, randomized controlled trial of 30 individuals, aged 31 years to 90 years, undergoing inpatient rehabilitation. Each participant experienced a non-cerebellar stroke less than 3 months prior, but retained functional use of at least one upper limb and ability to stand unsupported. In addition to standard therapy, subjects participated in training sessions 3 days per week, for a minimum of 2 weeks, or maximum of 4 weeks.
Based on the Stroke Rehabilitation Assessment of Movement, a baseline evaluation of the effects of stroke, participants were assigned to either the balance or the upper limb group.
Using the Wii Fit Plus package, patients in the balance group undertook standing balance activities, individualized to their unique ability. Tasks included static poses such as yoga, as well as more dynamic activities, such as weight-shifting and jogging.
The therapeutic challenge was also heightened by varying task complexity, increasing speed requirements, implementing dual-tasking and decreasing external support, such as hands-on assistance and cueing from testing administrators.
The upper limb group used either the Wii Sports package, the Wii Sports Resorts package or a combination of each. Patients remained in a seated position, as tasks were chosen primarily for upper limb function. Activities such as boxing and cycling were used for gross upper limb movement, and bowling and archery were applied to enhance dexterity. Difficulty and duration also increased over the course of the sessions, and the participants were encouraged to use their affected limb.
Feasibility outcomes were based on recruitment, retention, adherence, acceptability and safety. Safety was measured by documenting adverse events, such as falls during the treatment period, pain and fatigue between sessions and perceived level of exertion.
Efficacy outcomes were assessed at baseline, 2 week and 4 weeks, and measured balance, mobility and upper limb function, using a variety of clinical and force platform-based tests.
At the end of each session, participants evaluated acceptability by rating enjoyment, ease of use and perceived effectiveness of recovery, according to a 5-point Likert scale. Overall impression of the study compared with standard physiotherapy, independence in navigating the Nintendo Wii menus and general interaction with game activities was also recorded.
“The exercise intervention was overwhelmingly popular, with all study participants reporting high enjoyment, and most feeling that it benefited their recovery,” Bower said. “Participants really took to the technology…and were able to safely engage with a range of activities.”
No major adverse events occurred, and all participants rated their experience to be as enjoyable, or more enjoyable than standard physiotherapy. Patients also found the Nintendo Wii system easy to use, and expressed interest in continuing it after discharge.
Results showed significant improvements over time for both groups in outcome measures such as reaching and dynamic stepping.
Step test and force platform-based balance data, although equal between the groups at baseline, showed greater improvement within the balance group at the conclusion of the study.
“Although our study only looked at a small group of people…we did find a trend for greater improvements in balance ability in the group undertaking exercises using the Wii Fit,” Bower said.
Each group showed improvement in secondary outcome measures, but the upper limb group had larger non-significant improvements in arm function.
Small increases in fatigue and pain were reported by a number of study participants. Patients in the balance group had a considerably greater increase in post-session fatigue, and tended to report lower back or leg pain, while the upper limb group primarily reported shoulder and neck pain. However, no pain increase lasted more than 24 hours.
Bower said the study showed promise in post-stroke rehabilitation, but certain aspects should be studied further. For instance, outcome measures showed floor and ceiling effects within the selected cohort, and the retention period may not have been sufficient to detect clinically significant changes. Also, the use of an upper limb active control group did not allow comparison of the intervention to standard balance treatment.
Bower also said that further research is needed to compare Wii training to more traditional balance exercises, as well as to alternative exercises that utilize gaming systems.
“There are a range of different video game systems available. Even within a single system such as the Wii, there are many different activities to choose from,” Bower said. “We need to find out which are the most effective, what intensity we should be training and who is likely to receive the most benefit.”
A larger randomized controlled trial to further investigate efficacy, and a longer intervention period may be more effective in obtaining clinically significant results, Bower said. Yet, despite minor limitations, the study provides key findings on clinical feasibility, suggests that Nintendo Wii training is safe, feasible and can serve as an accessory to current therapy, she said.
Bower said although the sample size was small, the study sheds light on post-stroke rehabilitation, and opens the door for further investigation into gaming in the medical field. — by Shawn M. Carter
Disclosure: Bower has no relevant financial disclosures.