By Claire Coyne

• A private practice clinic notes an increase in patient compliance. Patients eagerly anticipate their next treatment sessions, and actively formulate their transition to a home-based program. The factor boosting patient participation? Introduction of the Wii to their physical therapy regimens.
• Participation in rehabilitation is soaring among residents of an extended care facility. With an adjustable skill level and a variety of programs, the Wii is allowing physical therapists (PTs) to find programs that are right for their patients and their rehabilitation.
• Upon the introduction of a virtual computer component to treatment sessions, PTs in a large city hospital record an outcome they hadn’t foreseen: a dramatic boost in their pediatric patients’ socialization and self-esteem.

Physical therapists across the nation are introducing the Wii to patients—and seeing dramatic increases in treatment program compliance, some encouraging outcomes, and a generally more upbeat mood in the clinic.

The Nintendo Wii is a computer gaming console that offers simulated sports games (baseball, bowling, tennis), specialty games like Cooking Mama: Cook Off, or WarioWare: Smooth Moves, and a fitness program, among other activities. A distinguishing feature of the Wii console is its wireless controller, the Wii Remote, which can be used as a handheld pointing device, and can detect acceleration and orientation in three dimensions. (See “More About the Wii.”)

While the efficacy of physical therapy treatments incorporating the Wii has yet to be proved—due to its recent introduction—results on a number of fronts are encouraging.

Private Practice

Lane Blondheim, PT, CWT, MT, first encountered the Wii when visiting his sister in Atlanta. As he watched family members swinging virtual rackets, shifting balance, and stepping and moving while absorbed in a virtual game of tennis, he thought, “I may be able to use this for my patients.” Like a growing number of physical therapists nationwide, Blondheim took on the Wii himself: “I proceeded to play for hours,” he recalls, “noting the use of my trunk muscles, shoulders, heels, one leg and then another, even toe movement.”

After hours of assessment, he chose to buy the Wii sports package for his private practice, Active Health & Rehab, in Montgomery, Alabama. Blondheim and his staff worked with the software program to determine how best it could be applied to physical therapy, taking into consideration a number of pathologies and factors such as safety, function, and treatment goals—as well as the fun factor.

“We introduced the Wii first to our patients with diminished shoulder range of motion (ROM), such as postoperative, poststroke, and Erb’s Palsy patients, as well as those with rotator cuff injury—those who could not reach 115 to 120 degrees of flexion/abduction,” he reports. Blondheim chose the Wii tennis game for this population because of its wide variety of upper-extremity (UE) movements.

As patients played the Wii, a PT stood next to them, to guide and limit ROM. “We focused on keeping them in the mid-range, using tactile cues, and hand blocks to limit abduction or rotation,” Blondheim notes. While the patient watched the Wii screen, the PT faced the patient.

The therapy team saw the most immediate results in patient compliance. “The fun factor had a dynamic impact,” Blondheim reports. “Instead of being focused on getting through a given intervention, patients were laughing and simply having a good time. They worked through pain with greater ease, and completed their sessions without noticing the time. They looked forward to their next treatment session, not just as a necessary visit to the clinic.”

Today, the staff are seeing positive treatment outcomes as well. “Patients are improving their shoulder ROM and increasing their functional activities of daily living (ADL),” Blondheim reports. “We also are seeing an increase in confidence, with patients taking charge of their rehabilitation, and focusing on improving their Wii scores—as well as their overall condition.”

The clinic also uses the Wii bowling and baseball programs to match patient preferences when the PTs deem the movement appropriate. They use the Wii fitness package for improving weight bearing and balance in patients following total knee replacement or back surgery.

For this patient population, and for others for whom balance is an issue, the PT “may use a gait belt to stabilize the patient and ensure there is no perturbation of the trunk,” Blondheim notes. The staff have developed a number of protection strategies for patients with different pathologies, he says.

For example, he reports the benefits to a post-polio patient. “She was able to use the tennis and boxing modules while sitting in her wheelchair,” he says. And she improved her UE strength as well as trunk stability.

Blondheim is finding that the Wii improves patients’ compliance with home programs as well. “We only encourage acquisition of the Wii for home use once the patient has attained discharge status,” Blondheim stresses, and he notes that patients are discouraged from considering home use until the staff deem them ready.

Extended Care Facility

Improvement in balance is one of the most positive outcomes seen in geriatric patients using the Wii, reports Jodi White, PT. She cites an example: A patient following a cardiovascular accident was operating the Wii baseball program with her PT carefully safeguarding her stance. “When she swung her bat, she immediately changed her feet to optimize her balance. The activity automatically triggered the response that might have taken the PT longer to demonstrate and prompt.”

Results such as this have made the Wii a popular acquisition for the Hoyt Nursing & Rehab Centre in Saginaw, Michigan. When the facility was building an addition to its therapy gym, a member of the activities staff, who had seen the Wii in use at her mother’s assisted living facility, suggested they include a Wii in the equipment upgrades.

After some research, and a determination of safety factors, the facility installed a Wii in the new gym. The therapists studied the possibilities that the virtual software offered for rehabilitation. “We spent many lunch hours assessing the Wii,” White recalls. Working together, they evaluated each program, while noting ROM, stability, balance, and movement factors, and considering patient conditions and treatment goals.

“We now use the baseball, tennis, boxing, and bowling programs with our patients,” White reports, “as well as the Cooking Mama: Cook-Off, which is particularly interesting for female patients with hand and upper-extremity challenges.” The cook-off includes timed cutting, dicing, and other kitchen activities.

White describes one factor affecting the use of the Wii with geriatric populations: “Coordination and timing factors can be defeating for these patients,” she cautions. “We always begin each program at zero – the lowest skill level. This keeps the timing and the actions required at their most basic, so as not to discourage participation.”

And participation is soaring. White finds that most patients can find a program that is right for them. “Boxing is the easiest,” she says. “If you can accomplish a forward motion, at any level, you can participate.” With baseball, “All you have to do is swing your arm—even just a little—to simulate swinging the bat,” she reports. White notes that the facility requires each patient to use the wrist strap provided by Nintendo to anchor the remote to the wrist—to ensure that it doesn’t fly out of their hands with vigorous motion.

Cognitively impaired patients also can participate. The key, White says, is for the PT to choose the program, and “tailor it to the condition or the resident.”

As reported at other facilities, patients are enthusiastically keeping their physical therapy appointments. The social benefits of the game are particularly apparent with the geriatric population. White reports. “The Wii [appears] to be a remarkable tool for socialization.” Nurses also stop by to watch their patients in action, she notes.

She says the sound component of the games is a stimulus: “The sound of the bat striking the ball, the roar of the crowd, the music, the sounds when the player scores, all add to the game-like atmosphere,” she says. “For the residents, it can simulate the fun of attending an actual sporting event. This has made quite a difference in the daily lives of some of these residents.”

Hospital-Based Physical Therapy Unit

Massachusetts General Hospital (MGH) Children’s Service in Boston acquired a Wii system just a few months ago. The acquisition did not require a hard sell, because the physical therapy service already had seen dramatic results for their pediatric patients from the use of the Dance Dance Revolution (DDR) system. (See “More About the Wii.”)

“We have incorporated DDR into therapy sessions for some time now,” reports Jessica Jacavage, PT, “specifically to address the aerobic conditioning and airway clearance components of the plan of care for our patients with cystic fibrosis.”

“By getting our pediatric patients focused on dancing with the DDR program, we have been able to make the exercise fun, engaging, and competitive—and we have achieved impressive treatment outcomes,” Jacavage reports.

As with the other facilities and populations utilizing the Wii, the MGH physical therapists also have seen a boost in patient compliance. “Specifically, our adolescent patients look forward to their physical therapy; many arrive early and wait to play, and socialize in the process,” says Maria Fitzpatrick, PT.

In one important way, the addition of a virtual component to treatment has had an unanticipated result: “We have seen an increase in our patients’ self-esteem,” reports Denise Montalto, PT, NCS. The DDR system, for example, has the ability to track patient’s scores, providing them with a record of their own personal improvement over time. It also can compare one person’s scores with others. “The children celebrate each step up, and are eager for their next exercise session. They also share this activity with their friends and family,” Montalto says.

Meaghan Costello, PT, notes the importance of the Wii for wheelchair-bound patients at MGH. “A number of the sports programs such as bowling, tennis, baseball, and boxing can be played in a sitting position, which opens up a lot of possibilities for this population,” she says. MGH has added Wii and DDR to the children’s play room. “This has helped to make the hospital visit more fun for patients’ siblings and visitors as well,” Costello reports.

MGH physical therapists use a variety of video/virtual games to engage patients in exercise. Not all patients enjoy treadmill walking or stationary bike riding, according to Dayan-Cimadoro. “Therefore, we have made Pilates exercise, yoga, Tai-Bo, hip-hop, Antigrav, and Kinetic exercise videos available on the MGH television system, which help patients find an exercise that they enjoy while achieving therapeutic outcomes of improving strength, flexibility, and balance.”

The PTs monitor their patients as they interact with the equipment. “We choose the level, speed, and other characteristics of specific programs based on an individual patient’s needs. We monitor vital signs, oxygenation, rate of perceived exertion (RPE), and dyspnea on exertion (DOE), and set the level of activity for each patient,” Jacavage explains.

Contraindications

A complete examination including systems review that includes cardiovascular-pulmonary tests should be completed prior to incorporating the Wii into a plan of care, according to PTs.

White stresses again that care must be taken with geriatric populations to ensure that the use of the Wii does not cause frustration. “The speed of required activities is definitely a factor” in matching patients to the software programs, she says. For those with cognitive, movement, or balance limitations, the physical therapist needs to first instruct the patient regarding required movements, and stand next to them throughout the game to assist them and to ensure stability and safety.

White also notes that some of the exercise can be fatiguing for an older patient. “Also, some older patients may not be able to get the timing down to match the movements required,” she says. Still, she notes, no one has refused to use the Wii, and the PTs always find some level or activity that the patient can accomplish.

“The biggest safety challenge for this population is balance,” she notes. Those with significant balance or endurance issues operate the Wii from their wheelchairs. The tennis, baseball, and golf programs, which all focus on UE movements, can be operated by older patients from a sitting position. Some geriatric patients even bowl sitting down, she reports.

The key to keeping the use of the Wii safe and effective is the physical therapist’s active involvement, the same as in any rehabilitation program: “Choose the game, tailor it to the patient, provide patient education, and guide the patient through completion of the motions,” White advises.

Blondheim notes that patients with seizure disorders are strongly contraindicated for use of the Wii. “Our clinic has a large, open floor plan, with the large TV screen in the center, facing an 8 x 12 floor area. Since the TV screen is visible from all areas of the clinic, we ensure that the TV is turned off when patients who have experienced seizures are receiving therapy,” he reports. As with all treatment regimens, “we use protection/safety strategies for different pathologies” when employing the Wii, he says—such as the use of gait belts with patients for whom balance is an issue.

As with the Wii, DDR is contraindicated for patients with seizure disorders, Dayan-Cimadoro notes. “Individualized assessment for the use of DDR and the Wii needs to be considered as with any other equipment that a PT may choose to use in a treatment program,” she advises.

Judith Deutsch, PT, PhD, and Alma Merians, PT, PhD, agree that some patient conditions are contraindicated for use of the Wii. “It is clear that the Wii may not be appropriate for treatment of some patients with movement dysfunctions,” Merians states. “For example, the UE movements required in some of the games can be quite challenging, and a certain amount of hand control of the remote is necessary for optimum play. The speed of the programs, and the subtlety of some of the movements required, may not lend the Wii to use by patients with hemiparesis, for example, or those with hand problems.”

Evidence of Effectiveness?

The team at the University of Medicine and Dentistry of New Jersey is exploring possible adaptations of the Wii for clinical use. PT first reported in an interview with Deutsch and Merians in 2003 on the university’s research into the use of virtual reality as a component of treatment.¹

Merians, along with her colleague, Sergei Adamovich, PhD, is studying the Wii remote and experimenting with how to obtain kinematic data to quantify patient activity and progress. “The software in the remote currently holds data such as the angle of movement, the reaction time, and the strength and speed of response, in order to adapt the game to the player’s actions,” Merians explains. “We are working with computer engineers and biomechanical engineers to see if these data can be used to measure patient progress and quantify treatment outcomes.”

Deutsch’s work with patients is demonstrating results similar to those reported by the other interviewees—increased compliance, adherence to the program, and motivation to improve—as well as other unexpected tangential benefits.

Deutsch recounts an experience with an adolescent client with cerebral palsy (CP) who played the Wii bowling program with “Daniel,” a visiting healthy child. “At his next therapy session, the PT noticed that the patient had changed the way he was releasing the simulated ball—a more efficient movement. When asked how he had made the change, he said, ‘I learned it from Daniel.’ This indicates modeling by a healthy child to improve movement in a child with CP.”

“Our ongoing question regarding the use of the Wii is, ‘Can we address our therapeutic goals by augmenting treatment with this software?’ So far, we have seen improvement in an adolescent with CP’s functional ability, postural control, and visual/spatial processing,” Deutsch reports.

For example, “we measured his performance before and after 11 training sessions with the Wii, and found that he was able to stand longer (up to 34 minutes while playing a game), stand more symmetrically (measured by weight distribution on a posture scale analyzer), and walk farther,” she explains. “He also improved his scores on tests of visual spatial processing.”

However, Deutsch and Merians both stress that PTs over time will be the best test of the Wii’s effectiveness. “PTs are extremely time-conscious, and focused on finding the most efficacious treatment for specific conditions within the timeframe of treatment,” Deutsch says. “If they find they are getting better outcomes with another intervention, they will choose that over the Wii.”

Will the ultimate benefit of the Wii to treatment be a largely social and psychological one—an increase in patient enthusiasm and compliance? Will this alone deem it a valuable rehabilitation tool? Time, and research, will tell.

“The Wii may go the way of other video games we have seen employed in clinics, where the initial response is strong, but over time the game sits idle as other treatment regimens prove more effective,” Deutsch concludes. “Or, it may fold neatly into the way PTs provide treatment. The answer, as with any new modality, will be in measured outcomes.”

Advice for Those Considering a Wii Acquisition

With the immediate boosts in patient enthusiasm and compliance being reported in clinics nationwide, more PTs are considering purchasing the system for their facilities. “It is exciting to see a program like the Wii that can be purchased off-the-shelf and adapted to treatment by vigilant PTs; this is a cost-effective tool that deserves more research,” Deutsch says.

For PTs considering a purchase, Dayan-Cimadoro offers some advice: “First, learn about the different systems, and try them yourself. As you use them, ask yourself: ‘What could I use this as an exercise modality for? For what purpose could I add this to a treatment regimen?’ This is really the same assessment process that PTs work through when considering any new piece of exercise equipment. How might this tool help our specific patient population?”

Blondheim agrees that the interaction with the Wii must begin with the PT. “Find someone you know who has the Wii, and go and play with it,” he advises. “Remember that you are performing all of these actions as a PT first—as you keep in mind a geriatric patient using the game, a pediatric patient, or a sports rehab patient. PTs excel at identifying with their patients; you can use that talent here, as you assess how the movements encouraged by the software can help improve specific patient conditions.”
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Claire Coyne is a freelance writer.

References
Waldrop S. The future is now: technology and its impact on physical therapy. PT—Magazine of Physical Therapy. 2003;(11(6):34-39.

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