1. health and fitness
2. therapy

The Feasibility and Appropriateness
of Utilising the Nintendo Wii during
Stroke Rehabilitation to Promote
Physical Activity.
Project Report
December 2011
A report produced by Liverpool John Moores University
Dr Toni Hilland
Dr Rebecca Murphy
Prof. Gareth Stratton
1
Contents
Page
List of Tables and Figures, Acronyms
4
Chapter 1. Introduction
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5
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5
6
1.1
1.2
1.3
1.4
Incidence and Prevalence
Importance of Physical Activity
Levels of Physical Activity
Wii – Rehabilitation
Chapter 2. Aims and Objective
2.1 Aim
2.2 Objectives
Chapter 3. Methods
3.1 Participants and Recruitment
3.2 Design and Methods
3.2.1 Stroke Care Practitioners
3.2.2 Stroke Patients
3.3 Data Preparation and Analysis
Chapter 4. Research Findings: Stroke Care Practitioners
4.1 Importance of Physical Activity
4.1.1 Physical
4.1.2 Psychological
4.2 Barriers to Physical Activity
4.2.1 Physical
4.2.2 Psychological
4.2.3 Environmental
4.3 Benefits and Best Practise of Employing the Wii with Stroke Patients during
Rehabilitation
4.3.1 Physical
4.3.2 Cognitive
4.3.3 Psychological
4.3.4 Social
4.3.5 PA
4.3.6 Therapy
4.3.7 Patient
4.3.8 Wii games
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4.4 Challenges of Employing the Wii with Stroke Patients during Rehabilitation
4.4.1 Physical
4.4.2 Psychological
4.4.3 Patient
4.4.4 Wii games
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Chapter 5. Research Findings: Stroke Patients
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5.1 Physical Activity
5.2 Stroke Patients’ perceived benefits of employing the Wii during rehabilitation
5.3 Challenges faced by Stroke Patients when using the of employing the Wii during
rehabilitation
5.3.1 Physical
5.3.2 Social
5.3.3 Psychological
5.3.4 Environment
5.3.5 PA & Sport
5.4 Wii games
5.4.1 Wii Games
5.4.2 Game Design
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2
Chapter 6. Emergent themes
6.1 Practitioners
6.2 Patients
Chapter 7. Summary
7.1 Study limitations
7.2 Recommendations for future practise
7.3 Recommendations for future research
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Chapter 7. References
36
Appendices
38
3
List of Tables and Figures
Tables
Page
Table 1. Descriptive characteristics of the sample
23
Figures
Page
Figure 1. Stroke care practitioners’ views upon the importance of PA for stroke patients
12
Figure 2. Stroke care practitioners’ views upon the barriers to PA for stroke patients
14
Figure 3. Stroke care practitioners’ view upon the benefits of employing the Wii with stroke
patients during rehabilitation
16
Figure 4. Stroke care practitioner’s views upon the barriers of employing the Wii with stroke
patients during rehabilitation
20
Figure 5. Stroke patients’ average PA counts pre and post test
23
Figure 6. Stroke patients’ average steps pre and post test
24
Figure 7. Stroke patients’ average minutes with device off, standing, lying and sitting, pre
and post test
24
Figure 8. Stroke patients’ views upon the benefits of employing the Wii during rehabilitation
25
Figure 9. Stroke patients’ views upon the challenges of employing the Wii during
rehabilitation
26
Figure 10. Stroke patients’ views upon the Nintendo Wii’s games
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Acronyms
OT: Occupational therapist
PA: Physical Activity
Physio: Physiotherapist
4
Chapter 1 – Introduction
1.1 Incidence and Prevalence
Stroke is a preventable and treatable disease, and is the third most common cause
of death in the UK after myocardial infarction and cancer (Department of Health,
1999). It is a major health problem, accounting for over 56,000 deaths in England
and Wales in 1999, which represents 11% of all deaths (Mant et al., 2004). Most
people survive a first stroke, but often live with significant physical disabilities
manifested by reduced ability to perform activities of daily living (Mercier et al., 2001).
This in turn adversely affects quality of life (Nichols-Larsen et al., 2005). More than
900,000 people in England are living with the effects of stroke, with half of these
being dependent on other people for help with everyday activities (National Audit
Office, 2005).
1.2 Importance of Physical Activity
Physical activity in stroke survivors can result in improved recovery and increased
independence (Gordon et al., 2004; Kinne et al., 1999). Studies to date have
documented physiological, psychological, sensorimotor, strength, endurance, and
functional benefits from physical activity engagement (Macko et al., 2001; Potempa
et al., 1995; Weiss et al., 2000).
1.3 Levels of Physical Activity
Physical activity levels are reportedly low during inpatient stroke rehabilitation (Ada
et al., 1999; Bernhardt et al., 2007). In addition, Rand et al. (2009) reported that
outpatients did not meet the recommended levels of physical activity. Following
completion of conventional rehabilitation stroke patients adopt or return to a
sedentary lifestyle (Paolucci et al., 2001). Physical activity levels following a stroke
may be influence by several factors. These include stroke severity, depression,
fatigue, physical endurance, cognition and learning ability (Gordon et al., 2004).
Strategies for increasing physical activity levels in stroke patients should therefore be
wide-ranging. Those that do not rely on one-to-one supervision by a therapist that
are potentially transferable to other settings may be the most successful (Ada et al.,
1999; Rand et al., 2009).
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1.4 Wii – Rehabilitation
Physical rehabilitation after stroke is a costly, resource intensive and time consuming
process (Jutail et al., 2003; Leder et al., 2008; Teasell et al., 2009). Intensive and
prolonged therapy must be provided to a large number of people with often limited
resources (Crosbie et al., 2007). There has been an exponential growth in the
availability of new technologies in clinical settings. Exergaming technology
represents a range of products that have been used in clinical and care settings for
the purposes of rehabilitation and to promote engagement in physical activity. The
Nintendo Wii has been used with diverse clinical populations, including hospitalised
patients (Crotty et al., 2011; Gargin & Pizzi, 2010), children and adolescents with
cerebral palsy (Deutsch et al., 2008; Snider et al., 2010), burn and nonburn patients
(Fung et al., 2010), patients with depression (Rosenberg et al., 2010) and stroke
patients (Leder et al., 2008; Saponsnik et al., 2010a, 2010b). Exergaming technology
(e.g., Nintendo Wii) has also been used to increase opportunity for and enjoyment of
physical activity in non-clinical populations (Graves et al., 2008a; Graves et al.,
2008b). The Wii is accessible at a relatively low cost, without requiring special
resources, assistance, or transportation to a specific facility (Crotty et al., 2011;
Saposnik et al., 2010).
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Chapter 2 – Aim and objectives
2.1 Aim
This study aimed to explore the feasibility and appropriateness of utilising the
Nintendo Wii to encourage PA in stroke patients. Patient and practitioner
perspectives were sought.
2.2 Objectives
1. To explore the views and opinions of stroke care practitioners on
utilising the Nintendo Wii in stroke rehabilitation.
2. To explore the views and opinions of stroke patients on utilising the
Nintendo Wii in stroke rehabilitation.
3. To explore the influence of the Nintendo Wii on stroke patients’ PA
levels.
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Chapter 3 – Methods
3.1 Participants and Recruitment
A total of 15 stroke care practitioners (physiotherapists, n=9; occupational therapists,
n=5), and a PA co-ordinator) from Broadgreen University Hospital and Clatterbridge
Hospital participated in the study. Practitioners volunteered to take part in the
interviews. Furthermore, 26 stroke patients (23 males) from the stroke units within
Broadgreen University Hospital (n=10) and Clatterbridge Hospital (n=16) participated
in the study. Patients were selected by their stroke care practitioners, if they felt that
their patients would benefit from using the Nintendo Wii during supported discharge
in the home setting. Patients were asked to participate if it was their first stroke; if
they required rehabilitation in relation to balance, upper limb, ataxia, perceptual
deficits and deconditioned patients. Exclusion criteria involved patients who were not
suitable for using the Wii (as judged by the healthcare team), for example patients
who had significant communication and/or significant cognitive deficits. Ethical
approval was sought from NREC and LJMU.
3.2 Design and Methods
3.2.1 Stroke Care Practitioners
Focus groups (n=4) and interviews (n=7) were used to explore stroke care
practitioners perspectives of using the Nintendo Wii during stroke rehabilitation. Data
was collected between April and June 2011 in a non-clinical location within the
stroke units. To ensure the same basic line of enquiry was taken with each
practitioners a semi-structured interview schedule (Appendix A) was developed.
Questions related to practitioners perspective concerning the importance of PA,
barriers to PA, views on using the Wii in stroke rehabilitation to increase PA, the
potential for integrating the Wii during usual care effectively, the potential benefits
and challenges of using the Wii and the types of patients the Wii may be most
effective/feasible with. Each focus group or interview lasted between 15 and 46
minutes and were recorded using a Dictaphone. All were conducted and analysed by
the same researcher. After three months of sampling, categories emerging from the
analysis of the interviews began to repeat and no new categories were emerging.
8
This was taken to indicate that the most significant issues had been identified and
sampling was discontinued.
3.2.2 Stroke Patients
The stroke patients’ (n=26) PA was objectively assessed for three consecutive days
using ActiGraph accelerometers (Model GT1M, ActiGraph LLC, Pensacola, FL), at
the beginning of their home based rehabilitation (before the Wii was set-up), and
upon completion of the 6 week home based trial with the Wii. The ActiGraph is small
and lightweight and is the most commonly objective tool with which to assess
physical activity (Corder et al., 2008). The ActiGraph is a uni-axial accelerometer that
measures vertical acceleration and deceleration between the magnitudes of 0.05-2g.
The accelerometer enables the monitoring of human motion (frequency and
intensity), to be filtered and converted to a numerical value (counts) and these
counts are subsequently summed over a specified time interval (epoch). The
recorded counts for each epoch represent the intensity of the activity undertaken
during that time period. At the end of each epoch, the summed value is stored in the
memory and the ActiGraph is automatically reset to zero. In this study, a 5 second
epoch was used to collect the raw data to provide a more detailed picture of the
patients’ physical activity patterns.
Accelerometers are motion sensors that capture information regarding the intensity,
frequency and duration of physical activity (Rowlands et al., 2006). Acceleration is
defined as the change in velocity over time; therefore accelerometers assess
physical activity through the body’s acceleration (Corder et al., 2008; Freedson et al.,
2005). The stroke patients wore the ActiGraph accelerometer over their right hip
(anterior to the iliac crest) which was secured with an elastic belt. To maximise the
quality of the data, strategies were employed to encourage compliance. The stroke
patients were given simple written and verbal instructions to wear the monitor over
their right hip, making sure the belt was tight enough to stop the monitor from
flapping about but not so tight that it is uncomfortable, to wear it all day from waking
up to bedtime only removing the monitor for sleeping, bathing, showering and
swimming. Patients were also instructed to go about their normal activities whilst
wearing the monitor.
9
With regards to the PA data, at the end of the data collection period data were
downloaded using Actilife software (ActiGraph LLC, Pensacola, FL). This produced
individual files, linked according to participant, containing movement counts and step
counts recorded at each 5 second interval. Furthermore, the inclinometer feature
indicated the orientation of the device during each 2 second epoch (0–device off/not
being worn, 1–participant standing, 2–participant lying horizontal, 3–participant
sitting). Wilcoxon Signed Rank tests were applied to test for differences between pre
(PA levels at home without the Wii) and post scores (PA levels at the end of 6 weeks
with the Wii at home). Statistical significance was set at p< 0.05, and all analyses
were conducted using SPSS 17.0 for Windows.
The stroke patients were also interviewed at the end of their 6-week home based
trial with the Wii, to explore their views and experiences. These took place between
June – December 2011within the patients’ home. A semi-structured interview
schedule (Appendix B) was implemented, comprising of the same general topics;
views and experiences of utilising the Wii during home and hospital based
rehabilitation, Wii’s influence upon physical, social, emotional and mental well-being
and potential advice to other stroke patients and stroke care practitioners.
Opportunities were given at the end of each session for the patients to make
comments about issues that had not been covered. Each interview lasted between 7
and 28 minutes and were recorded using a Dictaphone. All were conducted and
analysed by the same researcher.
3.3 Data Analysis and Preparation
All interviews and focus groups were transcribed verbatim for analysis. Transcripts
were imported into Nvivo 2.0 software programme, and subjected to thematic
analysis using a recommended process (Boyatzis, 1998; Marshall & Rossman, 2006)
as outlined below:
1. Transcripts were read and re-read to get an overall feel of the material,
allowing the researcher to get familiar with the data.
2. The data were categorised into broad themes, by identifying recurring, similar
and underling themes.
3. Initially a deductive approach was employed as interviews contained similar
material, where findings were interpreted based on the interview schedule.
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4. An inductive approach was then employed, creating and categorising new
themes from data that did not fit the pre-determined categories.
5. Data were then organised schematically to assist with interpretation of the
higher and lower order themes.
6. To aid the credibility and trustworthiness of the results, analyses and
interpretations of the data were discussed and checked with the research
team.
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Chapter 4 – Research Findings (Stroke care practitioners)
4.1 Importance of PA
PHYSICAL
PSYCHOLOGICAL
Prevention
Functionality
Health & Fitness
Motivation
Self-efficacy
Mood
“So it is all
geared towards
that, you know
because as well
it’s to try and
decrease the risk
factors isn’t it, to
prevent them
from having
another stroke”
(Physio)
“It improves function so
by improving aspects
like balance, strength,
co-ordination and range
of movement in certain
joints, you are going to
make a patient feel
more confident, and
more able to complete
functional activities like
something simple like
getting up from a chair,
getting in and out of bed
or standing by a sink
and being able to wash”
(Physio)
“It helps with recovery if
they have got a good level
of fitness, and lots to do
with like muscle tone and
things, you know it helps
with some of the finer
strength training” (OT)
"It just gives them a
sense of motivation
and selfempowerment really I
think, if they can
participate in some
form of activity it might
make them feel a little
more normal again”
(Physio)
“I think part of
exercise is promoting
self-efficacy” (Physio)
“If you can get
them involved
which increases
mood and
motivation from
that point of view”
(Physio)
Figure 1. Stroke care practitioners’ views upon the importance of PA for stroke patients
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The stroke care practitioners brought up two major themes with regards to the
importance of PA for stroke patients (Figure 1), including physical and psychological
benefits.
4.1.1 Physical
Physical advantages included general health and fitness, prevention from a further
event and increased functionality;
“I mean it’s really important in day to day life but we definitely advocate it and
we tend to work on individual joints and getting facilitation to get muscles that
are weak more active” (Physio).
4.1.2 Psychological
Psychological gains of participating in PA incorporated mood, self-efficacy and
motivation;
“Well I think one of things is if people aren’t doing much with their time then
they’ll just loose the motivation to do anything, so I think it’s really important to
keep them active, to keep them motivated to get better” (Physio).
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4.2 Barriers to PA
PHYSICAL
Unable
Dependent
Fatigue
Therapy-driven
“Stroke
patients are
quite
inactive, on
the ward it
might be
because
they aren’t
physically
capable to
fully
participate”
(Physio)
“They are not
mobile on the
ward so they are
a lot more
dependent in
terms of people
taking them to
places or getting
things in place for
them or assisting
them, they can’t
really do that
independently”
(Physio)
“I would say
about
99.9% of
the stroke
patients that
I have
treated in
my career
will
complain of
fatigue, I
think it is a
recognised
symptom”
(Physio)
“Some have said
that they don’t want
to put their energy
into activities and
they just want to
save it for physio”
(PA co-ordinator)
ENVIRONMENTAL
Practitioners
Stimulation
Institutionalised
“There isn’t time
for other people
to help them to
be active”
(Physio)
“Patients come
in and they are
on the ward for
a significant
length of time
and there isn’t
much stimulus
for them really”
(Physio)
“They become quite
reliant upon constant
instruction and
prompts, in hospital
they tend to get things
done for them, they
become
institutionalised a little
bit and then they are
back on their own two
feet they may feel lost,
as they’ve got no one
to tell them how to do
it, when, where”
(Physio)
PSYCHOLOGICAL
Depression
Motivation
Cognition
Self-efficacy
Fear
“They usually
quote about 60%
of S patients will
suffer from
depression in the
early stages of
their post-S, and
it’s kind of
understandable”
(Physio)
“Like if they’re
not interested
or lacking in
motivation”
(OT)
“If someone has
got cognitive
problems, that
kind of thing
following the
stroke, that it’s
often quite
difficult to engage
them”
(OT)
“Self-efficacy’s
usually quite low.
So I think a lot of
it is that mindset”
(Physio)
“I think fear as
well, because
patients are
frightened that if
they start engaging
in physical activity
that potentially
they may have
another stroke”
(Physio)
Figure 2. Stroke care practitioners’ views upon the barriers to PA for stroke patients
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The stroke professionals also highlighted numerous barriers to PA engagement for
stroke patients (Figure 2), comprising of physical, psychological and environmental
barriers.
4.2.1 Physical
They suggested that patients may be physically unable or too fatigued, “a lot of
people after having a stroke will feel tired and fatigued” (Phyio). Furthermore, it was
proposed that patients become de-conditioned and overly dependent upon
practitioners, whilst some are so focused upon physio that they don’t want to expend
energy on other activities;
“some people can be really focused as well on just therapy, and that’s another
thing what I’ve come across they don’t want to do anything else but therapy”
(PA co-ordinator).
4.2.2 Psychological
The main psychological barriers included depression and motivation which are
obviously related;
“Well the big thing is motivation, that’s one of the big things really because
there is a massive link with stroke and depression and it can be developed
quite quickly, so obviously your motivation goes alongside that and so
sometimes people aren’t very keen to do anything at all” (OT).
Other psychological barriers involved patients not having the cognitive ability to
engage in PA, a lack of self-efficacy, and fear, “there’s possibly always an underlying
fear that if they do too much it might cause another stroke” (Physio).
4.2.3 Environmental
Finally, environmental barriers of a lack of stimulation in hospital, practitioners not
having the time to assist patients who want to be more active and patients becoming
institutionalised;
“Some people get into a very patient role as soon as they come into hospital
and so almost expect to be waited on when they are in hospital and they go
into this I am ill role and don’t want to, or don’t expect to be doing much during
the day” (Physio).
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4.3 Benefits and best practise of employing the Wii with stroke patients during rehabilitation
PA
PHYSICAL
Visual
COGNITIVE
PSYCHOLOGICAL
“It just keeps
them active and
it provides them
with a good
level of
exercise
intensity which
is really
important”
(Physio)
“I think it works
on balance, it’ll
work on coordination, and
it’ll work on
muscle
strength”
(Physio)
“I suppose at
the same time
you could be
asking well can
you see the
whole game,
and if not well
you’ve got to
move your
head and scan
and then you
could use it as
more of a
teaching tool”
(Physio) “About
visual problems
so you know
those sorts of
patients where
you have to
scan, so they
are looking
around the
whole screen”
(OT)
“On Brain
Training to
work on
cognitive
aspects like
focused
attention and
sustained
attention”
(Physio)
“The patients’ faces light
up because it is fun, it is
interesting and engaging”
THERAPY
“They
participated
and tolerated a
lot longer
session than
what we would
have probably
done
otherwise”
(Physio)
WII GAMES
“It’s more
interactive so
you maybe get
a lot more out
of people” (OT)
“The visual to it
is really good,
the TV, the
feedback”
(Physio)
PATIENT
Experience
Type
Age
“I think most
appropriate for
probably
people who
have some
experience of
using computer
games or who
are at least
open to using
computer
games”
(Physio)
“I could
probably
see it
might
have more
benefit for
the
community
patients,
because
of the level
they are
at”
(Physio)
“We are
now
getting a
lot
younger
generation
of patients
unfortunat
ely; it’s
something
they can
relate to”
(Physio)
SOCIAL
“I know one
family in
particular they
would all come
in and they
would have a
massive
bowling game
all together, so
the patient, his
mum and dad,
brother and
sister and they
were all like
playing it
together, it’s
that kind of
thing when you
know it’s good,
because that
guy in particular
he wouldn’t do
anything at all”
(OT)
Figure 3. Stroke care practitioners’ views upon the benefits and best practise of employing the Wii with stroke patients during rehabilitation
16
Overall the stroke care practitioners emphasised a whole host of benefits of
employing the Wii with stroke patients during rehabilitation (Figure 3), for example;
physical, cognitive, psychological, social and participatory benefits.
4.3.1 Physical
Hypothesised physical benefits comprised of core stability, co-ordination, muscle
strength, endurance, motor re-learning, exercise tolerance and weight transfer, “I’ve
done bits on here with people with physical problems, upper limb problems and coordination problems” (OT). The major physical benefit mentioned by all of the
practitioners that were interviewed, was balance;
“I’ll tend to use it for patients who have balance problems to improve their
balance using the balance board and all the different games for that, working
on people’s balance and core stabilities which are obviously inherent things
that we work towards as physio’s” (Physio),
“Those that have got good activity who need a bit of strengthening and mainly
have balance problems which are affecting things like their walking or ability
to climb up and down the stairs, so mainly using the Wii Fit board which I
love” (Physio).
4.3.2 Cognitive
Practitioner’s emphasised cognitive gains of employing the Big Brain Academy game
on the Wii with stroke patients as an OT stated, “in the community it’s great for
people with cognitive problem, absolutely the brain training is really, really good.”
They expressed that this game could lead to improved concentration, attention and
the ability to problem solve, “I think it’s something to get them engaged, to explore
and problem solve” (OT), and, “I liked the Brain Academy, the fact that they have got
to sit and concentrate on something for a period of time that was good” (OT).
4.3.3 Psychological
A range of psychological advantages were discussed in the practitioner interviews
and focus groups. For example a physio remarked that the Wii may improve patients’
mood and motivation;
17
“I think it will boost mood and motivation, I think it will give them a sense that
they are doing something worthwhile and that they are achieving something in
their day, it might give them something to look forward to.”
Furthermore, motivation may be enhanced as the Wii is viewed positively by the
patients, “it helps with motivation because its fun, it’s enjoyable” (Physio), and;
“Certainly from an enjoyment point of view it was always like an enjoyable
treatment session, you always like got a smile and a laugh, which you don’t
get quite a lot of the time really because these patients are often quite low and
it’s something that’s a bit fun but you are still working on the goals, which is
what’s important really” (OT).
Finally, practitioners also mentioned that the Wii may boost self-esteem and
confidence, “doing something like this may improve their confidence to be able to do
more things independently” (Physio).
4.3.4 Social
The stroke care professionals discussed an array of social advantages consisting of
interaction, stimulation, engagement and benefits in terms of incorporating family
and friends;
“It was also nice because with one person in particular they were able to bring
family in and he had grandchildren, and his grandchildren came in and could
play with him on it, and they knew how to set it up and it just really boosted his
mood, and from then on it just really gave him a bit of a spurt and made him
see what he wanted to achieve, so I think for a mood enhancer that was a
really positive experience with the family” (Physio).
4.3.5 PA
In addition, practitioners commented that the Wii could aid and engagement in PA
and exercise;
“A lot of the evidence is trying to get people more active and giving them more
independence to facilitate their own exercise and facilitate their own home
exercise plans, and the Wii is doing that so you need to encourage it in the
sense that it’s promoting that” (Physio).
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4.3.6 Therapy
It was also suggested that the Wii may facilitate therapy sessions, as it is something
different and patients have been more compliant and participate in longer sessions;
“like the balance work and working on weight transfer that kind of stuff, quite
often the patient didn’t really realise that that’s what you were working on if
they are just playing a game like they are not thinking too much about what
they are working on, which is always the best way as you are getting more
automatic movement then” (OT).
In addition, the majority of the practitioners commented that the Wii will be a, “really
handy adjunct,” “it would give us another tool to our belt,” and, “it definitely has a role
alongside other approaches to kind of just mix your treatments up a little bit.”
4.3.7 Patient
All of the stroke care practitioners agreed that the Wii will play a role depending on
the type of patient. It was suggested that those patients that it will be most useful for
involve higher level, community patients and those with good activity, ““I suppose
that’s the higher level patients, and I guess it’s going to suit many of the other client
groups really” (Physio). Most of the stroke care professionals agreed that the Wii will
be more successful with younger patients, who will be able to relate and engage with
it;
“I’m probably thinking more about our younger patients that we are getting in
now and I think I can see the benefit, I think it’s possibly giving us another way
of engaging them and getting them motivated” (Physiotherapist).
Furthermore, several practitioners commented that the Wii may be more appropriate
for those who have had previous experience and an interest in gaming, “I think it’s
very dependent on the patient really, if they have an interest in like computers and
games and have done stuff like that before” (OT).
4.3.8 Wii games
Various positive themes surfaced with regards to the Wii and its games, for example
that it’s interactive, visual, goal-led and provides feedback.
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4.4 Challenges of employing the Wii with stroke patients during rehabilitation
PSYCHOLOGICAL
PHYSICAL
“People might get
offended from what the
Wii is saying, like you’re
not doing good enough,
you’re unbalanced, or
you’ve got a high Wii Fit
age” (OT)
“In terms of
their negative
behaviours, so
encouraging
poor patterning,
bad selectivity
of muscles, it
could
encourage
what we call
high tone”
(Physio)
WII GAMES
PATIENT
Experience
Type
Age
“I have tried to
use it once
before with
someone who
had never used
computer
games before
and they didn’t
really
understand and
to be honest it
wasn’t very
successful”
(Physio)
“Patients
that might
struggle are
people with
cognitive
problems,
people that
can’t follow
things, that
have visual
problems
obviously if
they can’t
see the
screen, or
language
problems,
people who
can’t
express or
receive
information,
so it’s not
for
everybody”
(Physio)
“If
someone
is maybe
more
elderly,
and you
know it’s
all a bit
new
technology
then I
don’t know
how much
they would
actually
use it”
(OT)
“People might
get offended
from what the
Wii is saying,
like you’re not
doing good
enough, your
unbalanced,
your rubbish or
you’ve got a
high Wii Fit
age” (Physio)
Figure 4. Stroke care practitioners’ views upon the challenges of employing the Wii with stroke patients during rehabilitation
20
The stroke professionals also highlighted a number of challenges of employing the
Wii with stroke patients during rehabilitation (Figure 4), for example; physical,
psychological, patient age and experience.
4.4.1 Physical
The practitioners stated that the Wii has the potential to have adverse effects on
rehabilitation, resulting in poor muscle patterning and selectivity, high tone,
inattention and neglect;
“What if they’re doing bad patterns of movement repetitively not under
supervision then it’s going to go against everything we’re trying to achieve”
(Physio),
“You don’t want to encourage bad muscle selectivity, so by getting a patient to
just hold it and play tennis for example, they might be using that tennis in any
which way they possibly can just to get the movement out of their arm, which
will be encouraging the wrong muscles to work at the wrong time, as opposed
to the right muscles kicking in at the right time, so it might encourage bad
selectivity or poor muscle patterning” (Physio).
4.4.2 Psychological
They also suggested that the Wii may reduce mood and cause frustration if patients
are unsuccessful or unable to play the game;
“If the person you are using it with doesn’t grasp it, can’t play it, doesn’t win,
they’re going to feel worse, like more low because they can’t compete in the
activity” (Physio).
4.4.3 Patient
It was commented upon that the Wii may not be appropriate for patients for different
groups of patients. For example, lower level patients with dense heavy weaknesses
and those with severe cognitive, communication and visual problems;
“I think maybe certain patients with either communication problems in terms of
their perception and understanding, like they can’t really follow commands, if
somebody has got significant problems in terms of their understanding, then
you are never going to be able to explain to them what they need to do” (OT).
21
It transpired from the practitioner focus groups and interviews that there may be
barriers with regards to employing the Wii with older patients, “The elderly they just
see computer games and think no no” (PA co-ordinator)
It also surfaced that it may not be very successful for those who have had little or no
experience, as an OT stated, “There are some patients who wouldn’t even use a
computer.”
4.4.4 Wii games
A number of therapists commented that the feedback from the Wii games maybe
quite damaging, “it could really hurt someone” (OT), and;
“Yeah with the feedback, with patients that are already depressed and low
mood, it’s not exactly a mood enhancer” (Physio).
22
Chapter 5 – Research Findings (Stroke patients)
5.1 Physical Activity
Participant characteristics are presented in Table 1. The females were generally
older, from less deprived areas and further on from their stroke than the males. With
regards to the two hospitals, those patients from Clatterbridge were on average
younger, from less deprived areas and further on from their stroke compared to the
patients from Broadgreen.
Overall sample
Males (n=23)
Female (n=3)
Clatterbridge
Broadgreen
(n=16)
(n=10)
Age (years)
57.84 ± 14.68
55.15 ± 13.08
78.47 ± 9.41
55.62 ± 13.72
61.39 ± 16.20
Deprivation score
11535.31 ±
10599.87
18708 ±
14899.88 ±
6152 ±
10645.11
±10346.07
12321.26
10738.95
8380.91
Deprivation rank
35.51 ± 32.77
32.63 ± 31.85
57.59 ± 37.93
45.87 ± 33.06
18.94 ± 25.80
Post stroke
.33 ± .43
.34 ± .45
.19 ± 0.14
.38 ± .53
.24 ± .19
(years/months)
Table 1. Descriptive characteristics of the sample (n = 26; mean ± SD)
Physical activity was assessed utilising accelerometers, at the beginning of their
home based rehabilitation before the Wii was set-up (pre), and on completion of the
6 week home based programme with the Wii (post). As shown below in Figure 5,
there was a statistically significant increase in the samples average PA counts, from
pre to post test, z = -2.33, p = .02, with a medium effect size (r = .35).
*
Figure 5. Stroke patients’ average PA counts pre and post test
23
The patients’ average steps pre and post the 6 week home trial with the Wii, is
shown below in Figure 6. A Wilcoxon Signed Rank test revealed a statistically
significant increase in the samples average steps, from pre to post test, z = -2.29, p
= .02, with a medium effect size (r = .35).
*
Figure 6. Stroke patients’ average steps pre and post test
Table 7 below depicts the patients’ average minutes with the accelerometer off,
standing, lying and sitting, pre and post test. Both standing and lying time increased
with post test, by 6.56 and 13.63 minutes respectively. In addition, sitting time
decreased on average by 63.38 minutes, however no significant differences were
found.
Pre
Post
Figure 7. Stroke patients’ average minutes with device off, standing, lying and sitting, pre and post
test
24
5.2 Stroke patients’ perceived benefits of employing the Wii during rehabilitation
COGNITIVE
SPORT & PA
ENVIRONMENT
PHYSICAL
SOCIAL
PSYCHOLOGICAL
“The brain trainer was
very helpful with my
memory and things”
“When I was using the
Wii I found my heart
was beating faster, I
found it made my
body work harder, so
yes it was exercise I
wouldn’t have
otherwise had”
“If it starts raining you
know you’ve always
got the Wii and you
could go on that, and
you’re in relatively
safe environment and
you can exercise”
“I’m able now to walk
around without my
walking cane and I’m
moving limbs I thought
I’d never ever use
again”
“Yeah I played with
my wife, my
grandchildren, son
and daughter-in-law
and they had a go on
it with me, and we all
really enjoyed it as
family entertainment, it
was really good, it’s
nice to see when the
family get involved
with you as well”
“Oh and it certainly
relieves boredom, it
certainly does stop the
boredom instead of
looking at the TV all day,
you can actually do
something”
“It’s good because it
concentrates the mind
as far as I’m
concerned”
“It gave me an edge, a
competitive edge so I
really felt like I
belonged to this world
instead of shut out
from it”
“You don’t need to go
out of the house to do
it and you’re not
reliant upon
somebody else to do
it”
“My leg was like a
stump, you know like
a tree stump and I got
the movement in my
knee back”
“When the kids are
there they would
encourage me, so I’d
enjoy the social
element of it with the
family”
“You’ll find even small
successes make you feel
very good, and feeling
good about yourself is
great yeah, it is a good
thing”
Figure 8. Stroke patients’ views upon the benefits of employing the Wii during rehabilitation
25
5.3 Challenges faced by Stroke patients when using the of employing the Wii during rehabilitation
TECHNOLOGY
SOCIAL
PSYCHOLOGICAL
ENVIRONMENT
PHYSICAL
“If you’re older like me
and you’re learning to
play on this kind of
machine for the first
time, then it is a
challenge”
“And playing with
others doesn’t always
help your confidence,
they are nearly always
better than you”
It was frustrating at
times and I was ready to
throw the thing across
the room”
“A de-motivator would
be if it was sunny in
the garden, I’d want to
be out there not stuck
inside”
“It is hard there’s been
sometimes where I’ve
gone a bit overboard”
“I suddenly felt that I
needed a bit of
exercise, I’d just go for
a walk, the Wii
wouldn’t come first on
my list of things,
whether that’s a
generation thing or
what I don’t know”
“I must say he was a
very reluctant
participant in games
where I would have
liked to have a go with
him, you know I
always had to drag
him to do it, so he
hasn’t been great in
that way”
“Sometimes I was
abysmal and failed
horribly and that really
undermines you a little
bit and makes you feel
like a failure”
“I would rather get out
and about on a nice
day and do what
limited physical activity
I can do outside rather
than being in the
house playing on the
Wii”
“Yes, I pushed myself
too far, and I was
really aching from
head to foot the next
day”
Figure 9. Stroke patients’ views upon the challenges of employing the Wii during rehabilitation
26
After 6 weeks of having the Wii in place at their homes, the stroke patients
highlighted several key benefits of employing the Wii during rehabilitation (Figure 8),
for example; physical, PA, cognitive, psychological and social benefits. In contrast,
the stroke patients also drew attention to numerous challenges and barriers of
employing the Wii during rehabilitation (Figure 9), for example; frustration,
technology, and social issues.
5.3.1 Physical
The patients believed that the Wii assisted them with their physical progress and
recovery;
“I knew it would help me to progress and basically that’s why I really got into
using the Wii,”
“It aids me to get better and back to my normal self again, if it wasn’t for the
Wii I wouldn’t have come this far.”
They emphasised in particular that the Wii had improved their balance, strength and
movement;
“The good thing about it is that it makes you feel or be aware of balance, your
muscles, I think mainly balance and getting your centre of gravity,”
“The exercises have helped me with my balance, my stance and my core
muscles,”
“Boxing was my favourite because I could feel it moving more and using more
muscles, I could feel more power going through the shoulders,”
“You can do the boxing on the Wii, and that’s good because it’s getting more
movement out of your arm and you use both arms.”
However, a couple of patients revealed that they got carried away on the Wii, and
pushed themselves too hard which resulted in pain and injury;
“Because playing games is such a pleasurable activity, I found that I got
carried away and tried things that were unsuitable and as a result of that I
pulled a muscle in my back which was very painful,”
“I was absolutely exhausted.”
5.3.2 Social
From a social point of view the patients took pleasure from playing on the Wii with
their family and friends;
27
“I did enjoy playing with others, I played with my daughters when they came
round or my wife’s sisters, I enjoyed it more playing with others than just being
on it by myself, because I just enjoy being with people and interacting, it’s just
more social.”
Overall the patients enjoyed the support, competition and interaction that comes
from playing with others;
“Support from the family was perhaps the biggest thing, my son and daughter
took turns being with me and supporting me on the Wii, and so on many
occasions it’s been sort of like my daughter saying to me ‘I’ve got to go out his
afternoon so we’ll do your Wii exercises now,’ and that has been another
significant driving force. I’m sure I would have ended up doing them but it’s
just a bit of a push,”
“I played sometimes with my wife and my brother in law; we had a bit of a
competition. I liked playing with others.”
In contrast others preferred to play by themselves;
“Yes, my son and he was very tender and considerate and said ‘oh, I’m
hopeless’ but I knew quite well he was just pretending, and the family did that
they pretended that they found it terribly difficult and then amazingly
progressed in about 2 minutes to being on difficult, so I was like ‘go out, I
don’t want to know you’ it didn’t help with my confidence at all.”
5.3.3 Psychological
Psychological benefits of the Wii from the stroke patients’ perspective involved
enhanced mood, motivation, self-confidence, and enjoyment. It was mentioned that
the Wii, “was quite a mood changer, having something positive to do, it helped with
mood changes and got rid of low feelings.” The patients also thoroughly enjoyed
being successful and improving, for example, “it makes you want to get on a chair
and cheer and tell the whole world,” and, ““I thoroughly enjoyed it.”
Conversely, frustration was a common theme to emerge from the interviews with the
stroke patients. They mentioned being frustrated when they were unsuccessful,
didn’t progress, or were unable to play a particular game;
“Some of the games were frustrating when I couldn’t do it or I couldn’t get the
right answer, that’s when it gets frustrating,”
28
“Mostly frustrated, because I wasn’t getting any scores over 650 on the brain
game thing, and I couldn’t get past that point so that frustrated me quite a lot.”
5.3.4 Environment
It was emphasised that the Wii provides a convenient opportunity to engage in
physical activity and exercise even when the weather is bad outside, as they can
participate in the Wii in their safe home environment;
“When the weathers bad and it’s raining and pouring, you’ve got the likes of
the Wii to go on.”
However, it was also revealed that if the weather was good, patients would select to
participate in other activities outside, rather than going on the Wii;
“I now play on it much less because I’m getting out and about more, and I
would prefer to do that than play on the Wii to be honest,”
“If I get up and the sun’s out I’d go out and have a walk.”
5.3.5 PA and Sport
The stroke patients suggested that the Wii made them exercise and be physically
active, which they may not have achieved if the Wii wasn’t in place. In addition, they
suggested that it made their body and heart work harder than normal;
“From a physical point of view I’m pretty much convinced that if it wasn’t for
the Wii I wouldn’t be doing anything which helps me break a sweat, where as
with the Wii even if you are just playing the games its giving me some
physical activity, which I wouldn’t have got otherwise.”
Furthermore, numerous patients revealed that the Wii had revived their sporting
memories and that it had encouraged them to get back into sport;
“I’ve used it mainly for the golf, I found it very very helpful, in fact so helpful
that I’ve had seven games of golf in the last four weeks and I actually won a
competition, so it was very helpful getting my swing back into operation and
that. When I went out the first time I didn’t hit any bad shots so obviously it’s
helped me properly, because it explains what you are doing and puts you right
with the swing and all of that, the degree of angle that you get with shots and
speeds, so yeah it’s been very good,”
“I think I always liked sport and this gave me a chance to get back into some
of it.”
29
5.4 Wii games
Wii Sports &
Sports Resort
“Yeah I liked the
sword fencing one, I
liked the boxing one,
and I liked the bowls”
“Golf was one of the
games I played, one
of my favourites and
table tennis”
Wii Fit
“I’ve used mainly the
balance board, so I’ve
gone for the slalom
skiing, the marble tilt
board thing and the
one where they aim
the footballs at you,
they’ve been the main
3 that I’ve had a go at”
“I just done the keep
fit because I thought it
was more important to
me, doing the
exercises and the
yoga, and the muscle
building”
Big Brain
Academy
“I preferred to do the
ones that would
challenge me the
most, the balls going
into the net were very
challenging, also the
ones where you had
to distinguish what
kind of animal or plant
was coming up, that
was particularly
challenging”
“I tended to want to
test myself on the
brain trainer, because
I hoped as well as
helping my eyes, that
it also might help my
memory and train my
brain in the things that
I have seemed to
have lost. So I used
the brain trainer the
vast majority of the
time”
GAME DESIGN
Feedback
“I get to see my
end result
straight away
with the
feedback,
which boosts
my confidence”
“It was insulting
sometimes like
with your
weight and all
of that, like you
need to lose
this and you
need to lose
that”
Problems
“Some of the
games were too
fast and
happened to
quickly, like the
Ski Slalom and
your reaction
time needs to be
so quick in order
to get through the
posts, so
sometimes you
find yourself
throwing yourself
around in a
hazardous
manner, just
trying to get
through the posts
rather than trying
to just do
purposefully”
Figure 10. Stroke patients’ views upon the Nintendo Wii’s games
30
The stroke patients provided a great deal of feedback with regards to the Wii games
they were provided with, including the Wii Fit, Wii Sports and Sports Resort and the
Big Brain Academy.
5.4.1 Wii games
On the Wii Fit the patients used the yoga exercises, muscle workouts, balance
games, aerobics exercises and the body test. The balance games were highlighted
as the most popular and helpful;
“Oh yeah the balance games I found that very good, it helped me get my
balance back and I mainly played the bubble in the water game where you’ve
got to go down the river and sway from side to side and forwards to direct it,
and I got to quite a good level,”
“I thought the table tilt was the best for me, and really it was quite a good help
for my balance.”
Furthermore, it was mentioned that the daily body test, which creates a Wii Fit Age,
was made use of;
“When you first do it each day it goes through tests to get your Wii Fit Age,
that’s a bit of an eye opener and has helped me, just doing those test things.”
A number of the games on the Wii Sports and Sports Resort package were utilised
by the patients, “I thought they were very very good games,” the most popular
included golf, bowling and boxing;
“Golf that was one of the games I played, one of my favourites.”
Also, the patients seemed to thoroughly enjoy the Big Brain Academy game, as they
thought it assisted their cognition and memory;
“Very positive, especially on the brain trainer thing I really enjoyed that. I like
the different activities on the brain trainer, like memory and the birds in the
cage.”
5.4.2 Game Design
Stroke patients outlined some challenges relating to game design. These included
issues relating to feedback provided during the games and the speed with which the
games progressed. Most of the patients throughout their interviews discussed the
31
feedback that is provided from the Wii. Some suggested it is very positive in that it
allows you to visually track your score and observe improvements;
“It gives me a lot of information and feedback which made me feel better
because it actually tells you how well you are doing and then it tells you how
you can improve,”
“I found out with the Wii it was visual so I could see what I was doing and
followed that little red dot on the balance tests, which meant a great deal to
me.”
In contrast, some patients felt the feedback was upsetting, frustrating and insulting;
“The Wii Fit put my age at 71 and that was a bit of a kick in the teeth, I was a
bit miffed at that, and it also tells you if you are overweight or not and that can
be a bit of a blow,”
“It’d tell me I’m rubbish.”
Problems with the Wii and games, involved it being too difficult, fast or unsuitable for
the stroke patients
“Sometimes it was a little bit frustrating in that it’ll ask you to step onto the
board, and because I’m slow moving my left foot and finding my left foot
position, it would mean that the board would have to be reset again and I’d
have to step off and start again, so that would happen a few times,”
Some of the balance games I didn't enjoy, the one with the bubble on the lake,
it’s very unforgiving and so I gave up on that one.”
32
Chapter 6 – Emergent themes
6.1 Practitioners
•
Two major themes arose with regards to the importance of PA for stroke
patients, including physical (e.g., prevention, health & fitness), and
psychological benefits (e.g., motivation, mood).
•
They also highlighted numerous barriers to PA engagement for stroke
patients, comprising of physical (e.g., fatigue), psychological (e.g.,
depression), and environmental barriers (e.g., institutionalised).
•
The stroke care practitioners cited a large number of benefits of employing the
Wii during rehabilitation;
o Physical (balance, co-ordination, endurance and motor re-learning),
o Cognitive (concentration, attention, and ability to problem solve),
o Psychological (mood, motivation, enjoyment, confidence),
o Social (interaction, engagement),
o Therapy (adjunct, different, tool to belt),
o Participation (stimulation, independent exercise, self-management).
•
Furthermore, they suggested the Wii may be more appropriate for higher
level/community patients who have good activity, younger patients, and those
who have had prior experience of the Wii or gaming.
•
Major challenges of employing the Wii with stroke patients were highlighted by
the practitioners;
o Physical (neglect, high tone, inattention, poor muscle patterning),
o Psychological (mood, frustration).
6.2 Patients
•
PA levels (counts/steps) increased from pre to post test, when the Wii was in
the patients’ homes.
•
They highlighted numerous benefits of employing the Wii;
o Physical (balance, strength, recovery, movement),
o Cognitive (concentration, memory, focus, perception)
33
Chapter 7 – Summary
7.1 Study limitations
•
Findings of the research cannot be generalised but provide points for
consideration when using the Nintendo Wii during stroke rehabilitation.
•
The lack of a control group means that the increases in PA and patient
improvements cannot be causally attributed to the Wii.
•
Physio’s and OT’s recruited stroke patients that were interested and keen on
utilising the Wii at home, which may have biased the results.
7.2 Recommendations for future practice
The findings of this research can contribute to recommendations for successful use
of the Nintendo Wii during stroke rehabilitation, these may include;
1. The Wii can provide another tool to practitioners’ belts.
2. The Wii should be utilised with certain patients (e.g., higher level, community
patients, good activity) and not others (e.g., lower level, dense heavy
weakness, severe cognitive/communication/visual problems).
3. It can aid patients both physically and cognitively (e.g., balance,
concentration), and can boost patients psychologically and socially.
4. A bespoke Wii package for stroke patients from a therapeutic perspective
could be developed, for example re-design of games with slower speeds and
lower levels.
5. Self-paced games should be used in the first instance to familiarise
participants with the technology.
6. There needs to be a support structure in place to help patients set-up and
become comfortable with the Wii (there may be unintended consequences in
terms of staff time/resources/training.
7. It may be more effective utilising the Wii with patients who have prior
experience of computers and technology.
34
7.3 Recommendations for future research
1. A Randomised Controlled Trial to compare the effectiveness of the Nintendo
Wii to other methods of rehabilitation.
2. A Randomised Controlled Trial to determine the effect of the Nintendo Wii on
physical activity in stroke survivors.
3. Develop a bespoke package for stroke patients and then conduct and
determine its effectiveness in practice
4. To conduct a further study that is similar in nature to the current study but
utilising the Wii therapeutically in a range of populations (i.e. falls patients,
diabetics, cancer patients).
35
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Appendix A: Stroke care practitioners focus group interview schedule
Physical activity
Can you explain to me the importance of PA and exercise during rehabilitation for stroke patients.
Can you tell me what the barriers are to engagement in PA for stroke patients?
Can you tell me how these barriers may be overcome?
What are your views on utilising the Nintendo Wii to increase patients’ PA levels?
How does the Nintendo Wii compare to other modes of physical activity?
Nintendo Wii & Rehabilitation
Do you think the Nintendo Wii has the potential to be integrated effectively into stroke rehabilitation?
Do you think it will it be feasible?
Do you think it will be effective (clinically and cost effective)?
Can you describe exactly how you will be using the Nintendo Wii during rehabilitation programmes?
What are your views and expectations of employing the Nintendo Wii in stroke rehabilitation?
Stroke Care Practitioners & Patients
Do you envisage any benefits to practitioners and patients from using the Nintendo Wii?
Do you envisage any barriers of using the Nintendo Wii as part of the rehabilitation process?
For what types of patients do you expect the Nintendo Wii to be most appropriate and successful?
For what types of patients do you expect the Nintendo Wii to be inappropriate and unsuccessful?
What are the practical implications of using the Nintendo Wii during stroke rehabilitation?
What advice would you give to other practitioners considering using the Nintendo Wii for stroke
rehabilitation?
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Appendix B: Stroke care patients interview schedule
Wii Home and Hospital Rehabilitation
How did you feel about using the Nintendo Wii during your home based rehabilitation?
If/how have you used the Nintendo Wii during your rehabilitation programme at home?
Did you experience using the Nintendo Wii used during your hospital based rehabilitation?
Did your experience of using the Nintendo Wii in hospital and at home differ?
Wii Rehabilitation Experiences
What was your experience of using the Nintendo Wii during your rehabilitation at home like?
What factors affected your participation playing on the Nintendo Wii?
Can you describe if/how the Nintendo Wii influenced your physical, social, emotional or mental wellbeing?
How do you feel the Nintendo Wii has influenced the progress you have made during rehabilitation?
Would you like to continue using the Nintendo Wii for further rehabilitation?
Stroke Care Practitioners & Patients
What advice would you give to other individuals thinking about using the Nintendo Wii during
rehabilitation?
What advice would you give to stroke care professionals when using the Nintendo Wii?
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