April 2013

Ready Patient One: Exer-gaming for rehabilitation

IntroArt_Vert_APR13Video gaming technology is finding its way into clinical practice, and research supports its effectiveness for improving balance, strength, and function. But studies also suggest some patient populations may be more responsive to exer-gaming than others.

By Samantha Rosenblum

Video games and health improvements typically do not go hand in hand. Most games require just mental focus and a pair of opposable thumbs, and results are usually limited to entertainment and satisfaction.

Recently, however, lower extremity researchers have been finding ways to use active video gaming, or “exer-gaming,” as a method of treatment and therapy for a variety of patients. Accessible and inexpensive, exer-games, including Nintendo Wii Fit, Wii Sports, and others, have been found to improve balance and gait mechanics in an array of patient populations.

Selective seniors

Many exer-gaming studies have focused on the effectiveness of such treatments in older adults. Researchers have looked not only at the physical benefits but also at older adults’ acceptance of exer-gaming treatments, as they generally have limited exposure to video game technology.

Despite the “fun” nature of exer-gaming, Australian researchers found that adults aged 65 years and older preferred traditional therapy programs to programs using the Wii Fit.1 In this discreet choice study, 21 hospitalized older adults participants used the Wii Fit under a physical therapist’s supervision for 25 minutes per day, five days per week for the duration of their hospitalization. Prior to beginning the therapy, the patients expressed no preference related to the Wii Fit, but after completing the therapy most said if given the choice they would opt against exer-gaming—a statistically significant finding in the discreet-choice statistical model.

Kate Laver, PhD, an author of the study and research fellow in the Department of Rehabilitation and Aged Care at Flinders University in Adelaide, speculated that participants might have been resistant to the Wii because it was introduced as a replacement to their familiar therapy.

“It may have been more appealing if it was offered in addition to their usual therapy,” Laver said. “It may have been that people viewed the Wii Fit as ‘gimmicky,’ as a ‘game’ rather than a legitimate exercise tool, or too childlike. There is also some research to suggest that people prefer what they know so are more resistant to any new treatment approaches.”

On balance

Despite this evidence that Wii Fit may not always be the preferable choice, researchers at Loma Linda University in California found that virtual reality gaming proved to be a useful tool for improving dynamic balance and balance confidence in 40 community-dwelling older adults (aged 60 to 95 years) who could participate in physical activity for 45 to 60 minutes, had self-reported normal vision, and did not have known orthopedic, neurological, or circulatory conditions.2

The study evaluated a 20-person intervention group, which received three different supervised Wii Fit balance interventions three times per week for six weeks, and compared them to a control group that received no intervention. Compared with the 20 individuals in the control group, participants who received the intervention demonstrated significant improvements. The intervention group’s 8-foot Up and Go test median score decreased by 1 s, while the control group’s median score decreased by only .2 s. Additionally, the intervention group showed a 6.9% increase on the Activities-specific Balance Confidence Scale, whereas the control group’s increase was 1.3%.

“Balance in itself is so complicated and can influence so many different systems in our body,” said Abel Rendon, DSc, DPT, PT, an instructor in the Department of Physical Therapy at Loma Linda University. “It is up to the therapist to assess and evaluate which system needs more attention. I feel, for general conditioning with no underlying neurological influence, using the Wii for balance training is a good option in the geriatric population.”

Further evidence demonstrated a positive correlation between Wii Fit treatment and improved balance.3 A study conducted at Northern Illinois University in DeKalb analyzed 17 participants who were split into three groups: one group received physical therapy, one received supervised Wii Fit training, and a third group received both physical therapy and Wii Fit training. The participants were all healthy individuals with no signs of impairment or disability that could potentially affect their balance or postural control. Participants receiving physical therapy alone and those receiving combined treatment demonstrated the greatest improvements in balance, but those using just the Wii Fit showed improvements, as well.

The researchers used the Berg Balance Scale to measure all participants’ balance; those in the Wii Fit group also completed the Bubble Test, a Wii Fit game that requires weight shifting. The investigators found the gaming system was associated with significant improvements in postural control as measured by the Berg Balance Scale, according to Hamid Bateni, PhD, assistant professor in the Physical Therapy Program in the School of Allied Health and Communicative Disorders, at Northern Illinois University.

“Having participants focus on their score would elevate their level of motivation,” Bateni said. “Knowing that Wii gaming, and, in a more general sense, computer-assisted gaming, can improve older adults’ performance and postural control, motivating older adults to play this game would benefit them significantly.”

Wii Fit has been shown to improve balance and gait when used in an assisted living facility.4 Researchers are not sure, however, that the same effects can be achieved when older adults complete unsupervised training at home.5

Show of strength

Wii training has also been associated with improvements in maximal leg muscle strength, rapid force capacity, and functional performance in community-dwelling older adults.6 However, this study, conducted at the Aalborg University Hospital in Denmark, found no effect on static bilateral postural balance.

Researchers compared 28 participants using Wii training to 30 controls, who were instructed to wear ethylene vinyl acetate (EVA) copolymer insoles but did no administered exercise. After 10 weeks of treatment, those in the Wii training group experienced about a 20% increase in maximal muscle strength and capacity for rapid force generation.

Increasing strength capacity helps prevent fall-related accidents in older adults, according to Martin Jorgensen, MSc, a doctoral student in the department of geriatrics at Aalborg University Hospital. Jorgensen also emphasized the benefits of biofeedback. When using the device, participants were able to view their progress over time and subsequently reported that the Wii training was fun and motivating, which Jorgensen said was an important result of the biofeedback component.

“With the Wii games, a virtual world is created which is more interesting than doing regular exercise where biofeedback is absent,” Jorgensen said. “One might ask why a bodybuilder uses a mirror. I believe a mirror is the simplest form of biofeedback. It is a basic human need: comparing ourselves to others and evaluating our own performance against earlier achievements.”

Jorgensen speculated that the rowing squats, completed at the end of each Wii training session after participants chose their own games, contributed heavily to the lower extremity improvements accomplished in this trial. He suggested adding an elastic exercise band to the rowing squats to make the exercises more progressive. Based on the evidence collected, Jorgenson said he would recommend Wii exercise to individuals who do not exercise on a regular basis or are at risk of fall-related accidents.

To expand the use of Wii treatment, researchers at St. John’s Rehab Hospital in Toronto, Canada assessed the effect of exer-gaming on balance and lower extremity function and strength in out­patients following total knee replacement.7 The investigators com­pared two groups receiving physiotherapy. While the 23 participants in the control group followed each physiotherapy session with 15 minutes of lower extremity strengthening and balance exercises, the 27 members of the study group received 15 minutes of Wii Fit gaming exercises.

Each participant was assessed on their first study visit and every two weeks thereafter until they were discharged from physiotherapy by their clinician. The evidence showed no significant differences between the two groups, demonstrating the potential for Wii Fit as an adjunct to physiotherapy intervention for outpatients following total knee replacement.

A complementary approach

Despite Wii Fit’s success as an adjunct treatment, Vera Fung, MScPT, physiotherapist and clinical researcher at St. John’s Rehab Hospital’s Sunnybrook Health Sciences Center, emphasized the continued importance of traditional physiotherapy programs.

“It is important for a physiotherapist to determine the exercises and exercise level appropriate for patients at various stages at recovery,” Fung said. “As well, total knee replacement physiotherapy treatment often involves manual therapies that aim to restore knee range of motion, [something] that video games such as the Wii cannot provide.”

Fung emphasized the need to tailor active video games for physical rehabilitation, explaining that the current selection is intended for the healthy population.

“Games that would be more rehab-appropriate would need to take into account the physical deficits that are experienced by various patient populations and would need to offer gaming and progression of difficulty at levels that can be tolerated by those populations,” she said.

Future games will hopefully contain more of these capabilities as they pertain to certain patient populations, Fung said, but currently practitioners must advise patients about adapting game play to accommodate any clinical limitations. Fung also noted exer-gaming’s potential to complement physiotherapy in a fun and innovative way, especially in the late stages of postsurgical recovery.

Other patient populations have benefited from Wii training rehabilitation methods. For example, researchers in Turkey demonstrated the gaming system’s ability to support the physical therapy goals of individuals rehabilitating from anterior cruciate ligament (ACL) reconstruction.8 After 12 weeks of treatment 15 patients who used the Wii Fit and 15 who underwent conventional rehabilitation had similar levels of isokinetic knee strength. Dynamic balance and functional squat tests, including coordination, proprioception, and response time, were similar at weeks one, eight, and 12.

Although the researchers concluded the Wii Fit produces the same effect as conventional rehabilitation, it’s not clear how well the findings will fit the broader ACL patient population. The participants in this study were young and active, demonstrating a high motivation toward rehabilitation, and, for them, the game provided a fun method of treatment that may have encouraged a longer participation in rehabilitation.

Seeking symmetry

Additionally, the Nintendo Wii Balance Board with visual feedback can be used to improve weightbearing asymmetry.9 Researchers from Australian Catholic University in Melbourne, Australia, utilized Wii Balance Boards in 15 Australian Rules football players and 32 untrained adults. Each participant was tested for measures of weightbearing asymmetry while squatting on the Balance Board. The Balance Board and customized software provided participants with real-time feedback on their weightbearing asymmetry for half of the trials.

The researchers found that, when the visual feedback was added, weightbearing asymmetry (mean mass difference and interlimb symmetry index) was reduced significantly for the untrained adults, but not for the professional athletes. The two groups had similar percentages of improvement, but the improvements were significant only in the untrained adults—a finding that is likely due to their low initial levels of symmetry, according to Kade Paterson, MAPodA, PhD, a podiatrist at Lakeside Sports Medicine Centre in Melbourne.

“Basically, if you’re more asymmetrical, you are more likely to benefit from the visual biofeedback,” Paterson said.

Paterson explained that increasing the complexity of the task would increase its benefit for trained athletes. He also said visual feedback could be helpful in other types of lower extremity training.

Swedish researchers have also demonstrated the benefits of Wii Fit treatment for individuals with multiple sclerosis (MS).10 The study, conducted through the Örebro County Council’s Center for Health Care Sciences, compared 42 MS patients using Wii games as an exercise method with 42 MS patients in a control group who did no exercise. Wii treatment involved 30-minute sessions twice a week for six to seven weeks. There were no statistically significant between-group differences in outcome measures following the
intervention, but the intervention group had better scores with moderate effect sizes for the Timed Up and Go (TUG) test, TUG-cognitive, and Dynamic Gait Index.

Again, the Wii was fundamental in providing individuals with performance feedback. Trying to beat one’s own score helped motivate participants, according to Ylva Nilsagård, PhD, clinical researcher and research supervisor at the Center for Health Care Sciences.

“Self-triggering exercise increases the motivation, making the person more likely to do more repetitions, continue the exercise session for a longer time, test their limits, and also gain health effects other than balance performance, such as muscular endurance, cardiovascular effects, and strength,” Nilsagård said.

Nilsagård emphasized the importance of allowing individuals to choose their own activities while maintaining a level of motivation with which the individual feels secure.

“Interventions that can be tailored to each and everyone’s specific needs secure a patient-centered approach in physiotherapy and rehabilitation,” she said. “We believe that using Wii games fulfilled this.”

Challenges in CP

Despite the studies supporting exer-gaming for treating and rehabilitating a variety of conditions, attempts to use Wii therapy to improve lower extremity function in children with cerebral palsy have not yielded such success. Researchers at Jönköping University in Sweden found that five weeks of at-home use of Wii Fit and the Wii Balance Board was not effective as a balance-training tool for 12 children with cerebral palsy (six additional children did not complete the study).11 Researchers found no significant changes in performance on the modified sensory organization test, reactive balance test, and rhythmic weight shift test.

Nerrolyn Ramstrand, PhD, associate professor in prosthetics and orthotics at the School of Health Sciences at Jönköping, attributed the lack of progress to unsupervised nature of the treatment.

“The biggest problem with at-home treatments is getting people to do them,” she said. “We chose to do the study in the home setting as it would be great to find something that had an effect, was enjoyable, and did not require supervision of a therapist. In this case, it did not work as we had hoped.”

Ramstrand noted, however, that some children had large improvements in balance.

“These were children with parents who were very interested and engaged and took it upon themselves to play Wii with their child every evening throughout the study,” she said.

Similarly, researchers at the University of Groningen in the Netherlands and the University of Cape Town in South Africa found that the Wii Fit did not improve motor function in 14 children with spastic hemiplegic cerebral palsy.12 For three weeks, the patients performed interactive video gaming in lieu of their regular physical therapy. Although participants preferred the Wii treatment to conventional therapy, the timed up and down stairs test and the running, speed, and agility test did not improve significantly during the intervention period. Pediatric physical therapist Dorothee Jelsma, MPPT, a doctoral student in developmental and clinical neuropsychology at the University of Groningen and the Faculty of Kinesiology and Rehabilitation Sciences at KU Leuven in Heverlee, Belgium, noted the Wii Fit is a starting point for a future game tool that may be more effective than current systems.

For many patient populations, exer-gaming is becoming a suitable method of therapy. Although improvements and adjustments are needed, lower extremity practitioners worldwide are finding ways to use exer-gaming as a fun and affordable method of treatment.

Samantha Rosenblum is a journalism student at Northwestern University in Evanston, IL.

REFERENCES

1. Laver K, Ratcliffe J, George S, et al. Is the Nintendo Wii Fit really acceptable to older people? A discrete choice experiment. BMC Geriatrics 2011;11:64.

2. Rendon A, Lohman EB, Thorpe D, et al. The effect of virtual reality gaming on dynamic balance in older adults. Age Ageing 2012;41(4):549-552.

3. Bateni H. Changes in balance in older adults based on use of physical therapy vs the Wii Fit gaming system: a preliminary study. Physiother 2012;98(3):211-216.

4. Padala KP, Padala PR, Malloy TR, et al. Wii-Fit for improving gait and balance in an assisted living facility: A pilot study. J Aging Res 2012; 2012:597573.

5. Agmon M, Perry CK, Phelan E, et al. A pilot study of Wii Fit exergames to improve balance in older adults. J Geriatr Phys Ther 2011;34(4):161-167.

6. Jorgensen MG, Laessoe U, Hendriksen C, et al. Efficacy of Nintendo Wii Training on mechanical leg muscle function and postural balance in community-dwelling older adults: A randomized controlled trial. J Gerontol A Biol Sci Med Sci 2012 Oct 31. [Epub ahead of print]

7. Fung V, Ho A, Shaffer J, Chung E, Gomez M. Use of Nintendo Wii Fit in the rehabilitation of outpatients following total knee replacement: a preliminary randomized controlled trial. Physiother 2012;98(3):183-188.

8. Baltaci G, Harput G, Haksever B, et al. Comparison between Nintendo Wii Fit and conventional rehabilitation on functional performance outcomes after hamstring anterior cruciate ligament reconstruction: prospective, randomized, controlled, double-blind clinical trial. Knee Surg Sports Traumatol Arthrosc 2013;21(4):880-887.

9. McGough R, Paterson K, Bradshaw EJ, et al. Improving lower limb weight distribution asymmetry during the squat using Nintendo Wii balance boards and real-time feedback. J Strength Cond Res 2012:;26(1):47-52.

10. Nilsagard YE, Forsberg AS, von Koch L. Balance exerise for persons with multiple sclerosis using Wii games: a randomized, controlled multi-centre study. Mult Scler 2013;19(2):1-8

11. Ramstrand N, Lygnegard F. Can balance in children with cerebral palsy improve through use of an activity promoting video game? Technol Health Care 2012;20(6):501-510.

12. Jelsma J, Pronk M, Ferguson G, Jelsma-Smit D. The effect of Nintendo Wii Fit on balance control and gross motor function of children with spastic hemiplegic cerebral palsy. Dev Neurorehabil 2012;16(1):27-37.

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