Developing an Evidence Based
Guideline and protocol for using Wii
for Rehabilitation
Rebecca Moore
Physiotherapist
Orange Health Service
October 2012
Outline
 Overview of the Wii System
 Background (Issue and Aims of the project)
 Evidence for intervention
 Limitations to the evidence
 Protocol Development and Use
 Future Directions
What 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.
Components
 TV screen
 Used to display the virtual environment
 Provides feedback on interaction with the environment
 Wii Console
 Holds the software disc
Components
 Wii Remote/s
 Wireless, hand held, motion-sensitive controls
 Can be used as a direct pointing device
 Feedback provided by a rumble device and a built-in
speaker in the remote.
 Wii Fit Balance Board
 Motion sensitive
 Interprets the movement of the feet and senses weight
distribution over base of support
What is Wiihabilitation?
 “Wiihabilitation” refers to the
use of the Nintendo Wii
virtual reality system as a
form of rehabilitative
therapy.
The Issue
 Nintendo Wii was purchased for OHS Rehab Unit
but it was being under-utilised.
The Aim
• To develop an evidence based guideline for using
Wii for Rehab.
• To develop a protocol for using Wii in the rehab
setting.
The Evidence for Wiihab
 Limited research presently
 Review 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
Technologies
 3 x RCT’s

one of which was included in the meta analysis
Saposnik 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): 1477-84, 2010 Jul.)
 Purpose
 To 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.
 Design
 Randomised, Single Blind, Parallel group trial
 Sample
 22 participants, aged 18-85, sub acute phase (up to 6
months)
 Able to shrug shoulders and touch chin with affected arm.
Saposnik et al - Cont. (Stroke.
41(7): 1477-84, 2010 Jul.)
 Results
 Wii group had a significant improvement in mean
motor function (Wolf Motor Function Test) of 7 seconds
compared to control
 Conclusion
 Wii gaming technology does represent a safe, feasible
and potentially effective alternative to facilitate
rehabilitation therapy and promote motor recovery
after stroke.
Kim 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: 693-701, 2009.)
 Purpose
 To examine the additive effect of virtual reality on balance
and gait function in patients with chronic hemiparetic stroke
 Design
 Double Blinded Randomised Control Study
 Sample
 24 Adults, at least 1 year post stroke, With the ability to
stand and walk indoors
Kim et al – Cont.
(Am J of Phy Med and Rehab. 88: 693-701, 2009.)
 Result
 Experimental group had improved BBS and significant
improvements in velocity, modified MAS scores, cadence,
step time, step length and stride length.
 Conclusion
 Virtual reality has an augmented effect on balance and
associated locomotor recovery in adults with hemiparetic
stroke when added to conventional therapy.
Hurkmans et al – Energy Expenditure in Chronic
Stroke Patients playing Wii Sports: a pilot study
Journal of Neuroengineering and Rehab. 8:38,2011
 Purpose
 To 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.
 Conclusion
 Mean energy expenditure reached appropriate levels
for moderate exercise, 3.7 METs for tennis and 4.1
METs for boxing
What 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 games
 Doesn’t indicate how to pick which games to use
with which patients
Requirements of a protocol
 A way to match the patients ability and skill level with
the difficulty and skill requirements of a game
 A way to pick the right game to train what you want
to improve
 Simple decision mechanism for therapists not
familiar with Wii games to use Wii
Developing a protocol
 Step 1 – Compile a database of games that
included:
 Skills required for each game (motor and cognitive)
 Equipment required for each game
 Various ways to play the game (ie. seated, standing)
Database Sample
Disc
Game
SubGame UL/LL/WB/ Unilateral or
Balance
Bilateral
Wii Fit
Training Plus Perfect 10 Balance
Equipment
Required
Seated or
Standing
MET
levels
Skills Required
NA
Balance Board
Standing
2.5
-Standing Balance
-Weight shift 4 directions
-Simple Calculation
Cycling
Whole
Body
Bilateral
Balance Board
+ Controller
Standing
2.5
- Standing Balance
- March on spot
-BIlat arm steering
Rhythm
Kung Fu
Whole
Body
Bilateral
Balance Board
+ Controller +
nunchuck
Standing
3
- High Level balance skills
- Timing
Driving
Range
Whole
body
Bilateral
Balance board
+ controller
Standing
3
-Standing balance
-UL bilat swing
Segway
Circuit
Whole
body
Bilateral
Balance Board
+ controller
Seated or
standing
2
Birds Eye
Bulls Eye
Whole
body
Bilateral
Balance Board
Seated or
standing
2.5
-weight shift forward and back
-steering with bilat upper
limbs
-weight shift in four directions
-bilat arm abd/flapping
Developing a protocol
 Step 2 – Choose a standardised tool to assess a
patients impairments and skill level.
 Motor Assessment Scale
 8 items Scored from 1-6 (Rolling, Bed Mobility, Sitting
Balance, Sit to Stand, Walking, Upper Arm Function,
Hand Movements, Advanced Hand Activities)
Motor Assessment Scale
Developing a protocol
 Step 3 – Create a system by which therapists can
match the skills of the patient to the appropriate
games available on Wii.
 Decision Trees
 Static Balance
 Lower limb function and dynamic balance
 Arm function
 Cardiovascular Fitness
Where we are at now
 Trialling the decision trees in our rehab unit
 Set up as part of circuit training group at present
 Biggest limitation to use is cognition
 Getting feedback from patients and therapists
 Continuing to monitor emerging evidence and adapt
practise to meet evidence recommendations
Future Directions
 Research project in the clinical setting
 Rotating staff through the area
 Blinding difficult in a small setting
 Ethics approval  Needs to be an adjunct to routine
therapy .. Time constraints
 Applicability across settings
 Paediatrics
 Acute wards
 In the community
The Beginning!