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Wii For Me

Applications for the use of Wii

Mary Saylor, MPT: mary.saylor@aegistherapies.com

Rebecca Setaro, OTR/L: rebecca.setaro@aegistherapies.com

Lynn Freeman, PT/MS/WCC: lynn.freeman@aegistherapies.com

Barb Christensen, OTR: barb.christensen@aegistherapies.com

Nintendo Wii™ Gaming System

Wii Sports Starter package

Accessories

Games

Memory card(s)

Wii remote

Wii Fit

Precautions/Safety Concerns

Fall prevention

Use of wrist strap

Monitoring vital signs

Physician clearance

Pacemakers

Seizure disorders

Wii Fit weight limitations

Benefits of Wii Gaming

Wii game participation improve

Balance & posture

Strength, range of motion (ROM), &

coordination

Problem solving & decision making

Cognition & attention span

Balance & Posture

Wii Sports

Wii FitBalance tests

Weight shifting activitiesTable tilt

Bubble course

Soccer ball heading

Penguin slide

Snowboarding/skiing

Yoga

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Strength, ROM, & Coordination

Wii Fit

Strength training

Yoga

Hula hoop

Tightrope

Step aerobics

Rhythm boxing

Problem Solving & Decision Making

Wii Fit

Wii Sports

Wii Resort

Photo Channel

Puzzles

Drawing

Cognition and Attention span

Mii Development

Wii Fit

Wii Sports

Wii Resort

Photo Channel

Puzzles

Drawing

Modifications

Activity planning

Intensity

Upper extremity activities, lower extremity activities, upper & lower extremity activities

Number of players

Wii remote accessories

Use of assistive devices

Modifications of floor surface

Sitting vs standing

Allen Cognitive Disability Model

Regardless of the activity in question,

we want to provide residents with successful experiences.

We need a model and tools which help determine not what a resident

can’t do, but what they can do.

Allen Cognitive Disability Model

The Allen Cognitive Disability Model helps identify the severity of the cognitive deficit of a person.

It measures cognitive ability and then classifies it in to 6 different levels.

The cognitive level is a measure of what the person can do.

Knowing the cognitive level of function, helps us with realistic goal setting for our residents.

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Allen Model cont.

A hierarchical scale of 0 to 6 where level 0 indicates profound cognitive deficit and 6 indicates normal cognitive functioning.

Allen levels 4,3 and 2 map to the early, middle and late stages of dementia, respectively.

The 6 levels are further classified in to 26 performance modes.

Early, Middle and Late

It’s helpful to start with the

classifications of early, middle and late stages of Dementia.

Once determined, this will help caregivers to establish programs

based upon the resident’s abilities.

Early Stage Dementia

Relies on procedural memory to make associations for new learning.

Capable of new learning related to things that are important to them.

Responds well to structure and routine.

Understands left/right and back/front.

Often very social

Needs cues for thoroughness

Activity is goal directed

Early Stage Dementia

In this stage of dementia, electronic gaming could be a viable activity.

The repetitive nature of the movements and the familiarity of some of the activities would ensure success for many.

The movements of many of the games could also assist with balance issues and falls prevention.

Middle Stage Dementia

At the stage repetitive actions and the

handling of objects are seen.

Manual actions are prevalent but

often random

Visual field of 12-14 inches

Follows one step directions

Frequent or constant cues are

needed.

Middle Stage Dementia

The desire to hold and manipulate

objects could make some aspects of electronic gaming successful.

The limited visual field and limited attention span would require

adaptations to most gaming

programs.

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Late Stage Dementia

Postural insecurity with a fear of

falling.

Cognitive processing is 2-3 times

slower.

Generally enjoys reciprocal

movement.

Responds better to visual cues

Becomes agitated if hurried.

Late Stage Dementia

The intense visual cues of some

electronic games may appeal to this resident.

Postural concerns and severely limited attention span may interfere

with this being a successful endeavor.

However, observing the game may be enjoyable.

References For Allen Tools

Allen, C.K. (1999). Structures of the cognitive performance modes. Ormond Beach, FL: Allen Conferences, Inc.

Allen, C.K., & Blue, T. (1995). Understanding the modes of performance. Ormond Beach, FL: Allen Conferences, Inc.

Earhart, C. (2006). Allen diagnostic module manual (2nd edition). Colchester, Connecticut: S&S Worldwide.

Howell, T. (1998) An interdisciplinary approach to using the model of cognitive disability. Workshop. West Palm Beach Florida

Clinical Benefits of Wii

Increased motivation

Promotes healthy competition and camaraderie

Increased confidence/sense of

accomplishment

Family involvement

Improved strength, endurance, function, motor planning, cognition, hand-eye

coordination, balance, reaction time

Early Stage Dementia & Wii Use

Develop Mii

Single or multiple players

New or familiar activities

Improved ability for button and arm

movement coordination

Middle Stage Dementia & Wii Use

May need assistance to develop Mii

Multiple player activities may be more

difficult

New activities may be more difficult

Decreased ability for button and arm movement coordination

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Late Stage Dementia & Wii Use

Increased difficulty with timed/scored

activities

Single player activity

Rely on familiarity of task or image

Limited ability for button and arm movement coordination

Bowling examples for early, middle,

and late stage dementia

EarlyManual Mode

Optional features (100 pin, barriers in path, etc)

MiddleAutomatic mode

Traditional 10 pin

LatePhoto channel bowling options

Documentation in the clinical setting

Recommended documentation componentsActivity performedAssistance level (physical assistance and cueing)Score achieved or duration toleratedVital signs (if applicable)Frequency of useIndividual’s response to treatmentClinical rationale for activity/treatment

GoalsCombine desired Wii performance with anticipated functional outcome

Case Studies

Gladys

Jim

Ruth

Research Review

Allen D. You're never too old for a Wii. Nurs Older People. 2007 Oct;19(8):8.

The “proof” is in

the evidence…

“You’re Never too old for a Wii”

Evidence

Epidemiology/Impact68% of American households have gaming consoles in their home1

More than 25% of gamers are age 50 and over1

Nursing home chains and senior centers now offer health gaming as part of their programming2

Over 85% of games on market are labeled “E” = Everyone3

Gaming industry has evolved to include a new area of research called “Health Games”4

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EvidenceEpidemiology/Impact

Cognitive rehabilitation improves functional performance5

“Adding a treatment regiment that stimulates cognitive function might further enhance functional level or prevent decline of functional status compared with an exercise intervention alone”5

Commercially available health games can provide cognitive stimulation and potentially increase an older adults physical activity levels5

EvidenceCurrent and Future Research

Most published studies are in pediatric or adolescent care6-9

Funding for gaming projects in senior care10

– Interactive Games for Individuals with Chronic Mobility and Balance Deficits Post-Stroke USC

– Seniors Cyber-Cycling with a Virtual Team:

Effects on Exercise Behavior,

Neuropsychological Function, and Physiological Outcomes at Union College

– Action Games to Improve Cognitive Function in

Older Adults University of Florida

– Game to Enhance Cognitive Health in Older

Adults at University of California, San Francisco

EvidenceCurrent and Future Research

Brains of Expert Video Gamers

Improve hand-eye coordination24

Increased processing in the periphery25

Greater divided attention abilities

Faster reaction times26

Enhanced contrast sensitivity27

Improved visual processing (attentional blink) (multiple object tracking Paradigm)28

EvidenceCurrent and Future Research

Training with Action Video Games can enhance

Visuo-spatial attention25

Dynamics of visual attention25

Number of objects of attention29

Video game players have faster reaction time26

Integrate sensory information more efficiently

EvidenceCurrent and Future Research

Wii

Individuals in their 90s and 100s are using the system11

The most popular senior game is bowling6

Early publications focused on overuse injuries in youths12-15

Three recent publications (2 case reports and pilot study) demonstrated improvements with strength, balance, and fall risk in older adults16-18

Erickson Living/Nintendo “Bowling Championships”

EvidenceCurrent and Future Research

Wii

Funded studies (NIH and Medical College of Georgia)

– Wii Mote reliability and validity19

– Wii gaming vs recreational activity stroke rehab20

– Effect of Wii on movement and depression in

Parkinson’s21

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Efficacy

Ten (10) women ages 30-58 with balance and QOL

limitations received pre-programmed Wii Fit regimes

determined for age and physical ability or a sham treatment for 30 minutes, 2 times weekly, for 10 weeks.

Balance and lower limb muscle strength showed

significant improvement. CV endurance, mobility,

weight change, activity level and well-being were not

clinically, but not statistically significant. Authors report

the need to confirm findings through statistically powered studies. 17

Efficacy

89 year old female with unspecified balance disorder

resulting in multiple falls. Hx included controlled bipolar

disease and schizophrenia. Intervention consisted of 6 one hour Wii bowling simulation sessions over a 2

weeks. Game aligned meaningful recreation with

rehab of impaired physiological systems (visual,

somatosensory, vestibular). Subject played 2 games

per session competing against the investigator. Berg

Balance Scale improved from 48 to 53, Dynamic Gait Index improved from 14.9 to 10.5 seconds, and

Activities-specific Balance Confidence score improve

from 88 to 90%. Subjects overall fall risk was reduced

by 30-40% and likelihood of falling decreased by 12-

16%.16

Other Systems for Older Adults

DanceTown

Slower dance steps and grab bars

Incorporates valid, senior-specific

assessments

Senior Fitness Test

Timed Up and Go

Tinetti

Six Minute Walk Test

Generates performance reports

Its precursor, Dance, Dance, Revolution, is

equivalent to moderate intensity walking in children 6-9, 22

Other Systems for Older Adults

DanceTown

References1. Gaudiosi J. Health Games Become Serious Business.

Reuters.com, 2009.

2. Gaudiosi J. Health games become serious business. Reuterscom. 2009

3. Allen D. You're never too old for a wii. Nurs Older People.

2007;19 (8)

4. Essential facts about the computer and software gaming

industry. Entertainment Software Association; 2008.

5. Shubert TE. The use of commercial health video games to promote physical activity in older adults. Annals of Long-

Term Care Clinical Care and Aging. 2009;In Press:1-15

6. Morala DT, Shiomi T, Maruyama H. Factors associated

with the functional status of community-dwelling elderly. J Geriatr Phys Ther. 2006;29:101-106

References7. Graf DL, Pratt LV, Hester CN, Short KR. Playing active

video games increases energy expenditure in children. Pediatrics. 2009

8. Lanningham-Foster L, Jensen TB, Foster RC, Redmond

AB, Walker BA, Heinz D, Levine JA. Energy expenditure

of sedentary screen time compared with active screen time for children. Pediatrics. 2006;118:e1831-1835

9. Sell K, Lillie T, Taylor J. Energy expenditure during

physically interactive video game playing in male college

students with different playing experience. J Am Coll Health. 2008;56:505-511

10. Maloney AE, Bethea TC, Kelsey KS, Marks JT, Paez S,

Rosenberg AM, Catellier DJ, Hamer RM, Sikich L. A pilot

of a video game (ddr) to promote physical activity and decrease sedentary screen time. Obesity (Silver Spring).

2008;16:2074-2080

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References11. Health games research: Advancing the effectiveness of

interactive games for health. http://www.healthgamesresearch.org/. Accessed January

30, 2010.

12. Parker A. Oaps say nurse, i need a wii. The Sun. 2007

13. Sparks D, Chase D, Coughlin L. Wii have a problem: A

review of self-reported wii related injuries. Inform Prim Care. 2009;17:55-57

14. Robinson RJ, Barron DA, Grainger AJ, Venkatesh R. Wii

knee. Emerg Radiol. 2008;15:255-257

15. Bhangu A, Lwin M, Dias R. Wimbledon or bust: Nintendo

wii related rupture of the extensor pollicis longus tendon. J Hand Surg Eur Vol. 2009;34:399-400

16. Peek AC, Ibrahim T, Abunasra H, Waller D, Natarajan R.

White-out from a wii: Traumatic haemothorax sustained

playing nintendo wii. Ann R Coll Surg Engl. 2008;90:W9-10

References17. Clark R, Kraemer T. Clinical use of nintendo wii bowling

stimulation to decrease fall risk in an elderly resident of a nursing home: A case report. J Geriatr Phys Ther.

2009;32:174-179

18. Nitz JC, Kuys S, Isles R, Fu S. Is the wii fit a new-

generation tool for improving balance, health and well-being? A pilot study. Climacteric. 2009

19. Nichols B. Case review: Use of the nintendo wii fit and

outdoor challenge for rehabilitation of an elderly female

patient with age-related balance impairments. J Geriatr Phys Ther. 2009;33 (3):123

20. Wiimote game controller as a device to study movement

disorders. 2009

21. Effectiveness of virtual reality exercises in stroke

rehabilitation (evrest). 2009

References22. Hinley P. Wii-hab may enhance parkinson's treatment.

Medical College of Georgia News. 2009

23. Murphy EC, Carson L, Neal W, Baylis C, Donley D, Yeater R. Effects of an exercise intervention using dance dance

revolution on endothelial function and other risk factors in

overweight children. Int J Pediatr Obes. 2009:1-10

24. Griffith JL, Voloschin P, Gibb GD, Bailey JR. Differences in eye-hand motor coordination of video-game users and

non-users. Percept Mot Skills. 1983;57:155-158

25. Green CS, Bavelier D. Enumeration versus multiple object

tracking: The case of action video game players. Cognition. 2006;101:217-245

26. Castel AD, Pratt J, Drummond E. The effects of action

video game experience on the time course of inhibition of

return and the efficiency of visual search. Acta Psychol (Amst). 2005;119:217-230

References27. Li R, Polat U, Makous W, Bavelier D. Enhancing the

contrast sensitivity function through action video game training. Nat Neurosci. 2009;12:549-551

28. Pylyshyn ZW, Storm RW. Tracking multiple independent

targets: Evidence for a parallel tracking mechanism. Spat

Vis. 1988;3:179-197

29. Green CS, Bavelier D. Action video game modifies visual selective attention. Nature. 2003;423:534-537