Presentation on theme: "Rebecca Moore Physiotherapist Orange Health Service October 2012"— Presentation transcript:
1Rebecca Moore Physiotherapist Orange Health Service October 2012 WiihabilitationDeveloping an Evidence Based Guideline and protocol for using Wii for RehabilitationRebecca MoorePhysiotherapistOrange Health ServiceOctober 2012
2Outline Overview of the Wii System Background (Issue and Aims of the project)Evidence for interventionLimitations to the evidenceProtocol Development and UseFuture Directions
3What 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.
4Components TV screen Wii Console Used to display the virtual environmentProvides feedback on interaction with the environmentWii ConsoleHolds the software disc
5Components Wii Remote/s Wii Fit Balance Board 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 sensitiveInterprets the movement of the feet and senses weight distribution over base of support
6What is Wiihabilitation? “Wiihabilitation” refers to theuse of the Nintendo Wiivirtual reality system as aform of rehabilitativetherapy.
7The IssueNintendo Wii was purchased for OHS Rehab Unit but it was being under-utilised.The AimTo develop an evidence based guideline for using Wii for Rehab.To develop a protocol for using Wii in the rehab setting.
8The Evidence for Wiihab Limited 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 Technologies3 x RCT’sone of which was included in the meta analysis
9Saposnik 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): , 2010 Jul.)PurposeTo 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 trialSample22 participants, aged 18-85, sub acute phase (up to 6 months)Able to shrug shoulders and touch chin with affected arm.Method:8 x 60 minute sessions over 14 daysAll received 1 hour of PT and OT standard per dayBowling and tennis and cooking mamaControl: Jenga, cards and bingo9
10Saposnik et al - Cont. (Stroke. 41(7): 1477-84, 2010 Jul.) ResultsWii group had a significant improvement in mean motor function (Wolf Motor Function Test) of 7 seconds compared to controlConclusionWii gaming technology does represent a safe, feasible and potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke.
11Kim 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: , 2009.)PurposeTo examine the additive effect of virtual reality on balance and gait function in patients with chronic hemiparetic strokeDesignDouble Blinded Randomised Control StudySample24 Adults, at least 1 year post stroke, With the ability to stand and walk indoorsMethodControl: 40 minutes on 4 days per week for 4 weeks routine therapy for gait and balanceIntervention: Additive 30 minutes of virtual reality therapyGames: Stepping up and down, snow boarding and sharkbait11
12Kim 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.
13Hurkmans et al – Energy Expenditure in Chronic Stroke Patients playing Wii Sports: a pilot study Journal of Neuroengineering and Rehab. 8:38,2011PurposeTo 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 boxingSample: 10 chronic stroke patients (greater than 6 months post stroke) who were able to mobilise independently on level groundMethod: Gas analysis for 2 x 15 sessionsGas analysis13
14What the evidence doesn’t tell us What about the patients that don’t’ fit the inclusion criteria of the studies?Only looks at a very few select gamesDoesn’t indicate how to pick which games to use with which patients
15Requirements of a protocol A way to match the patients ability and skill level with the difficulty and skill requirements of a gameA way to pick the right game to train what you want to improveSimple decision mechanism for therapists not familiar with Wii games to use Wii
16Developing a protocolStep 1 – Compile a database of games that included:Skills required for each game (motor and cognitive)Equipment required for each gameVarious ways to play the game (ie. seated, standing)
17Database Sample Disc Game SubGame UL/LL/WB/ Balance Unilateral or BilateralEquipment RequiredSeated or StandingMET levelsSkills RequiredWii FitTraining PlusPerfect 10NABalance BoardStanding2.5-Standing Balance-Weight shift 4 directions-Simple CalculationCyclingWhole BodyBilateralBalance Board + Controller- Standing Balance- March on spot-BIlat arm steeringRhythm Kung FuBalance Board + Controller + nunchuck3- High Level balance skills- TimingDriving RangeWhole bodyBalance board + controller-Standing balance-UL bilat swingSegway CircuitBalance Board + controllerSeated or standing2-weight shift forward and back-steering with bilat upper limbsBirds Eye Bulls Eye-weight shift in four directions-bilat arm abd/flapping
18Developing a protocolStep 2 – Choose a standardised tool to assess a patients impairments and skill level.Motor Assessment Scale8 items Scored from 1-6 (Rolling, Bed Mobility, Sitting Balance, Sit to Stand, Walking, Upper Arm Function, Hand Movements, Advanced Hand Activities)
20Developing a protocolStep 3 – Create a system by which therapists can match the skills of the patient to the appropriate games available on Wii.Decision TreesStatic BalanceLower limb function and dynamic balanceArm functionCardiovascular Fitness
24Where we are at now Trialling the decision trees in our rehab unit Set up as part of circuit training group at presentBiggest limitation to use is cognitionGetting feedback from patients and therapistsContinuing to monitor emerging evidence and adapt practise to meet evidence recommendations
25Future Directions Research project in the clinical setting Rotating staff through the areaBlinding difficult in a small settingEthics approval Needs to be an adjunct to routine therapy .. Time constraintsApplicability across settingsPaediatricsAcute wardsIn the community