Does Stroke Wiihab work? Use of the Nintendo Wii for upper limb rehabilitation following stroke Dr LK Christie 1, Mrs S Kennedy 2, Mrs K Brennan 2, Dr G Ellis 2, Dr M Barber2 1 Geriatric Medicine, Gartnavel General Hospital, 2 Stroke Services, NHS Lanarkshire Action Research Arm Test Abstract In this pilot study we aimed to assess tolerability, safety and effectiveness of the Nintendo Wii (Wii) games console as a form of therapy for patients with upper limb weakness following stroke. We report that the Wii can be a safe and acceptable therapy tool for this patient group. Further larger scale studies with randomisation are required to further investigate the efficacy of this therapy tool. Four subtests of grasp, grip, pinch and gross movement. High levels of reproducibility and specificity. Dynamometer Computer-linked Dynamometer enables an objective measurement to be recorded of grip strength and pinch strength between thumb and each finger. Table 3: Patient Characteristics Introduction and Purpose Neural plasticity research suggests that multiple repetitions of movement are essential to regain function. However, upper limb rehabilitation can be resource intensive. We aimed to ascertain if the repetitive movements of arm, wrist and fingers employed when using the Nintendo Wii games console could be used safely and would be tolerated by patients for upper limb rehabilitation following stroke. Patients n=9 Sex Age Dominant arm affected Barthel index scores Days from stroke to recruitment Male =7 Female =2 Median 55yrs (range 45-66 years) 5/9 Mean = 95 (range 77-100) Mean 187 (range 5-983) The Nintendo Wii console employs infra-red technology to allow a hand-held controller to direct on-screen action within games. Of 11 patients recruited, 9 completed the project. One failed to attend following recruitment and the second found the console too technically challenging and requested to withdraw. Methods We recruited stroke patients following completion of standard upper limb rehabilitation, in accordance with local ethics and research board approval. Patients were selected for recruitment by our Occupational Therapist following referral from stroke rehabilitation services. Our study population were required to retain some movement of upper limb in order to hold and use the controller appropriately. Patients with stroke affecting either hemisphere and dominancy, and both haemorrhagic and ischaemic strokes were considered. Baseline characteristics in the form of age, Barthel index, and time from stroke were recorded. Assessments of hand strength and function were performed twice at baseline, one week apart, and following 6 weeks of therapy with Wii. We used week 2 data as baseline in an attempt to exclude the influence of practise and learning on our results. Patients were given a Wii console with Wii Sports package; comprising of golf, tennis, boxing, baseball and bowling; and instructed to use the controller in the upper limb affected by the stroke, on a daily basis for six weeks. Table 1: Study Design Study procedure Week 0 Week 1 Week 2 Review of suitability by Occupational Therapist Baseline characteristics recorded 8 Informed Consent Baseline assessments 8 Repeat assessment Instruction and supply of Wii 8 Therapy 6 week period Telephone call review within 3 weeks of therapy commencing Final assessments Results Week 2-8 w Patient questionnaires revealed high levels of patient enjoyment and the majority (>75%) reported improved function of upper limb with everyday tasks. Transient pain and upper limb stiffness were reported by all patients but did not prohibit ongoing participation w Diaries of usage were completed and returned by 6 of the patients, reporting use on a near daily basis for between 10mins-3hours at a time. w Results of Action Arm Research test were high for all patients at baseline and did not show any significant change following therapy. w Affected arm grip strength increased from median 21 to 42 pounds (lbs) (p=0.03) during the 6 weeks. There were trends for improvement in all domains of the Jebsen-Taylor but these were significant for picking up and placing small objects (p=0.008) and moving light large cans (p=0.05). w A general trend for improvement was shown throughout all domains in both affected and unaffected arm. However grip strength was found to improve to a statistically significant degree in the treated affected arm only. (p=0.028) w Data of finger pinch strength was only recorded in 7 of the 9 patients due to operator error. This showed a trend to improvement in both affected and unaffected fingers; no clear treatment effect demonstrated. Table 4: 8 8 8 Assessments The primary objective in this study was to investigate safety and tolerability of the Wii in this patient group. To assess this, telephone consultations mid-way through therapy were employed and patient questionnaires were completed at the end of therapy. A diary of usage was also completed by the patients to demonstrate frequency and intensity of usage. As secondary endpoints we investigated the efficacy of the Wii to improve strength and hand function using assessments previously validated in stroke therapy. Jebsen-Taylor Hand Function Test Timed completion of six domains of hand function,testing both upper limbs; validated in therapy literature as being reproducible, with previous use in stroke therapy trials. Dynamometer Grip strength Jebsen Taylor Test of Hand Function w Writing w Turning cards over w Picking up small objects w Simulated feeding w Stacking objects w Lifting large light objects w Lifting large heavy objects Stroke arm (P value) 0.028 Non-stroke arm (P value) 0.260 0.441 0.110 0.008 0.110 0.260 0.051 0.139 0.594 0.173 0.051 0.008 0.139 0.767 0.214 Table 5: Stroke arm P value Non-stroke arm P value Index-thumb 0.128 0.398 Dynamometer pincer strength Mid-thumb Ring finger-thumb Small finger-thumb 0.75 0.249 0.310 0.63 0.028 0.236 Conclusion We have ascertained that the Nintendo Wii console is a safe and acceptable therapy tool for use in patients with upper limb weakness following stroke. Further larger scale studies with randomisation are required to further investigate the efficacy of this therapy tool. Table 2: Jebsen-Taylor Hand Function Test Test one Test two Test three Date administered Date administered Date administered Subtest Non-Dominant Dominant Non-Dominant Dominant Non-Dominant Dominant Hand Hand Hand Hand Hand Hand Writing 46.s 16.5s 57.6s 16.8s 59.7s 15.4s Simulated page turning 20.s 8.6s 14.1s 8.5s 10.0s 5.7s Lifting small common objects 26.5s 8.6s 21.7s 8.8s 20.9s 8.8s Simulated feeding 16.7s 8.4s 59.1s 9.7s 19.7s 6.5s Stacking checkers 18.3s 3.4s 16.9s 3.2s 18.2s 2.4s Lifting large, light objects 8.1s 5.0s 11.4s 4.1s 6.1s 4.7s Lifting large, heavy objects 8.0s 5.4s 7.1s 5.8s 6.4s 5.5s Data entered in seconds (s). Data for illustrative purposes only References 1. Use of a Low-Cost, Commercially Available Gaming Console (Wii) for Rehabilitation of an Adolescent With Cerebral Palsy PHYSICAL THERAPY Vol. 88, No. 10, October 2008, pp. 1196-1207 Judith E Deutsch, Megan Borbely, Jenny Filler, Karen Huhn and Phyllis Guarrera-Bowlby 2. Effectiveness of Virtual Reality Exercises in STroke Rehabilitation (EVREST): Rationale, Design, and Protocol of a Pilot Randomized Clinical Trial Assessing the Wii Gaming System Journal of Stroke Clinical trial protocols G. Saposnik , M. Mamdani , M. Bayley , K.E. Thorpe , J. Hall, L.G. Cohen and R. Teasell 3. Functional Evaluation of Upper Extremity Use following Stroke: A Literature Review Topics in Stroke Rehabilitation vol 4:4 1998 K. Okkema, KH Culler Kathleen A. Okkema MBA, OTR/L1, Kathleen H. Culler MS, OTR/L2 CTP.WIIWR2.63368.M