HANDOUTslides-Balance in Older AdultsPart 3...Sony EyeToy Sony EyeToy for PS3 Bondoc, Hewitt & Benard, 2010 S Bondoc/OccupationalTherapy.com 3/31/14 Do not copy or reproduce without

S Bondoc/OccupationalTherapy.com 3/31/14

Do not copy or reproduce without consent of author. 1

USING WII-HAB TO ADDRESS BALANCE AND POSTURAL CONTROL ISSUES IN THE ELDERLY

Salvador Bondoc, OTD, OTR/L, FAOTA

OBJECTIVES

• AT THE END OF THIS PRESENTATION, YOU SHOULD BE ABLE TO:

1. Describe the therapeutic elements associated with virtual reality-based gaming technology and how these apply to a Nintendo Wii system; AND

2. State various considerations when incorporating the Nintendo Wii system as an intervention modality in the elderly population.

Outline

• 1:30 – 1:45 • Review of Intervention goals• Therapeutic elements of VR gaming technology

• 1:40 – 2:20 • Wii-based interventions• Case illustrations of various ways to apply Wii

• 2:20 – 2:30 • Wrap up and Q&A



Intervention goals

• 1. Resolve, reduce, or prevent impairments in systems that are important to balance

• 2. Develop effective task-specific sensory, motor, and cognitive strategies

• 3. Retrain functional tasks with varying postural control demands under changing environmental contexts

Task Oriented Training = Integrative

• Motor Aspects• Steady-State Strategy Training• Reactive Balance Training• Anticipatory Balance Training

• Sensory Aspects• Training to increase vestibular response• Incorporate multi-sensory cues (

• Cognitive training: • single to dual task condition

Motor - Intervention Strategies

• Steady-State Strategies• Ankle-hip-trunk control strategies to maintain CoM over Bos

• Progressive stance to challenge LoS

• Anticipatory or Proactive Control Strategies• Transitional movements (change in body positions)

• Mobility-related tasks

• Reactive Control Strategies• Reaction time with stepping strategy

• Equilibrium response



Sensory and Cognitive Strategies

SENSORY-RELATED

• Vestibular integration

• Visual and visual motor integration

COGNITIVE-RELATED

• Dual task training

• Problem solving

Motor Learning Principles

• Practice • Increased intensity• Varying schedules: Random vs. Blocked

• Environment• Practice in various conditions: predictable unpredictable• Virtual and real life contexts

• Feedback • Intrinsic motivation and sense of self-efficacy• Therapeutic feedback: Knowledge of results (KR), knowledge of

performance (KP)

VIRTUAL REALITY-BASED GAMINGOVERVIEW OF TECHNOLOGY AND FEATURES



Virtual Reality defined

• Virtual reality (VR) is a form of computer-based technology that simulates human activities, environments, and the interactions between humans and their environment in the actual world.

(Bondoc, Powers, Herz & Hermann, 2010)

Conceptual Model

Virtual Activities

Virtual Environment

Virtual Persona

Low-Cost

Virtual Reality-Based

Gaming Options



VR Modes of Control

• Head mounted devices

• Video capture + gesture control

• Hand-held device

How does the WiiMote Work?

http://www.nytimes.com/packages/khtml/2006/12/21/business/20061221_HOWW_GRAPHIC.html

Wii-Mote



How Does Motion Capture Work?

WHY GAMING?

“The beauty of a game is that it gives you a goal.”

- Debra Lieberman of the Institute for Social, Behavioral, and Economic Research (ISBER) at the University of California, Santa Barbara.

To be challenged and overcome these challenges is part of

Therapeutic Features

• “Just-right” physical demands

• Movement or actions required produce a magnitude of effect at lesser effort (vs. real world)

• Type of control varies

• Safety in controlled environment

• Variety of activities/ occupational forms are mimicked




• Novelty in which familiar tasks are performed

• Cognitive demands are similar but context is different

• Intrinsic learning is promoted through practice

• Multi-sensory and interactive experience affords FLOW! (presence and immersion)


Immersion objective assessment of aspects of the virtual environment

responsiveness of the virtual environment during interaction

“entexturing” or regulation of sensory inputs

Presence subjective experience of being “inside” the VR environment.

(Schuemie, Van der Straaten, Krijn &Van der Mast, 2001)

FLOW

Pragmatic Considerations

• Encumberance• ease of use vs.

“clunkiness”

• Type of control• Required body

movements

• Required postures

• Use of control devices

• Cost

• Availability

• Portability

• Space requirements



Common VR Platforms

• Nintendo Wii

• GestureTek – IREX

• Silverfit/ ACP Omni VR

• Sony Play Station 2 EyeToy

• Sony Play Station 3 Move

• Xbox 360 Kinect

Bondoc, Hewitt & Benard, 2010

Sony EyeToy

Sony EyeToy for PS3




GestureTek IREX


Silverfit/ OmniVR


Adaptationshttp://www.broadenedhorizons.com/ultimatearcade.htmhttp://www.enablemart.com/Catalog/Video-Gaming/GimpGear-Accessible-Nintendo-Wii-Controls



USING THE WII SYSTEMS

SELECT APPLICATIONS

ANALYSIS OF THERAPEUTIC DEMANDS

Getting Started: Mii Set-Up



Choosing Games

• Motor demands• Pace of activity: slow vs. intermediate vs. fast

• Postural demands: steady-state vs. dynamic

• Type of control: reactive vs. proactive

• Sensory demands• Visual demands

• Vestibulo-ocular integration

• Cognitive demands• Single vs. dual vs. multi-task

• Sequencing

Wii Bowling

1. Player holds the back (B) button

2. Swings the Wii-mote backwards

3. Then swings the Wii-mote forward while timing the release of the B button.

Wii Bowling



Activity Analysis: Bowling• UE Motor control

• Hand grip and release of trigger• Forward arm motions• Gross motor coordination (i.e., speed and direction)

• Postural Control• Anticipatory/proactive control• Forward step sequence• Standing tolerance

• Sensory and Cognitive Demands• Visual fixation, VOR integration• Dual-task attention and sequencing

Wii Tennis• Player maintains grip on Wii-Mote

• Serves ball by pressing the A button and immediately swings a forehand motion

• Volleys ball by swinging the Wii-mote against the direction of the ball

Wii Tennis



Activity Analysis: Tennis

• UE Motor control• Hand grip with variable arm motions• Gross motor coordination (i.e., multi-directional)

• Postural Control• Anticipatory/proactive control• Ongoing side-steps, shifts in BoS• Trunk rotation (as compensatory strategy)

• Sensory and Cognitive Demands• Visual tracking• Depth perception• VOR and OKR integration• Dual-task attention

Wii Fit Set-Up

Requires initial calibration based on

1. BMI analysis

2. Fitness analysis• Measurement of

Center of Gravity

• Balance screening (variable)

Wii Menu



Tilt Table

Activity Analysis: Tilt Table

• Required balance and postural control• Steady-state balance with hip strategies • Multi-directional weightshifts• Pace of movement: slow to intermediate

• Required cognitive and perceptual skills• Low level VOR integration• Significant somatosensory input• Dual cognitive tasks

• Required standing tolerance• Initial 30 seconds will extend up to 5 minutes

Ski Slalom



Activity Analysis: Ski Slalom

• Required balance and postural control• Steady-state balance with hip strategies • Repetitive medio-lateral weightshifts• Pace of movement: intermediate to fast

• Required cognitive and perceptual skills• OKR and VOR integration – busy visual stimuli• Significant somatosensory input• Dual cognitive tasks

• Required standing tolerance• Usually 60 seconds at a time

Wii Soccer

Activity Analysis: Soccer

• Required balance and postural control• Steady-state balance with ankle and hip strategies • Repetitive antero-posterior weightshifts• Pace of movement: intermediate to fast

• Required cognitive and perceptual skills• OKR and VOR integration – busy visual stimuli• Significant depth perception• Dual cognitive tasks

• Required standing tolerance• Usually 75-90 seconds at a time



Yoga

Yoga

CASE ILLUSTRATIONS: USES OF VIRTUAL REALITY IN

GERIATRIC PRACTICE

Productive Aging Short Term Long Term CareWell Elderly Rehabilitation Frail Elderly



Wellness and Productive Aging

Settings:

• Senior centers

• Assisted living

• Retirement Communities

Health Goals:

• Maintain physical fitness including balance and endurance/ activity tolerance

• Promote socialization

Wellness/Productive Aging

• Allows partners to engage in activities together

• Encourages participation in leisure time interests and sports


Pilot Program @ Elim Park

• Each participant is evaluated for Wii “readiness” and to identify specific needs

• The program was held weekly over 7 weeks

• Each session ran 45-60 minutes long



Evaluation1. Occupational Profile2. Medical history 3. Performance Skills and Client Factors:

• Vision, visual perceptual skills and visual motor skills• Balance, postural control and gross motor coordination• Ambulation/mobility status incl. AD needs• UE Range of motion • Fine motor coordination• Cardiovascular and activity tolerance

4. Occupational Patterns• Typical routine and use of time• Leisure activities – past (given up), present

5. Participant Goals

Wellness Program Protocol• Week 1-2: Activities and Objectives:

1. Become familiar to the set-up and controls of the Wii 2. Create a Mii avatar3. Decide the best positioning for the participant during gaming (sitting,

standing) in relation to the monitor4. Trial one or two simple games5. For carry over, continue playing trial games with Recreation Director

• Week 3-4: Activities and Objectives:1. Review independent training program2. Review recommended cues from Week 1 training session to increase

independence with navigation of the game 3. Trial more games; participate games with or other residents, friend or

spouse 4. Evaluate participants’ independence in doing the games themselves5. Evaluate need for adaptations or review of how to operate the device

Wellness Program Protocol

• Week 5-6: Activities and Objectives:1. Facilitate group interactions – where they can be more

independent; encourage those who are independent to teach others/ entice others to join.

2. Final competency check: Have resident do a return demo / repeat instructions and strategies

3. Encourage participating in competitive leagues within the institution and extramurals

• Week 7: Activities and Objectives:1. Review of progress towards goals2. Re-evaluation of performance skills and occupational

performance3. Discuss with Recreation Director ways to promote carry-

over



Geriatric Rehabilitation

Goals of Therapeutic Interventions

1. Endurance/Activity Tolerance Building

2. Cognitive Training

3. Balance Training

4. Flexibility and AROM Promotion

** Stimulated continued interest in participation in therapy programs**


Therapeutic Rationale for Endurance Building

1. Participate along mobility continuum:• Seated only

• Sit to stand transitions

• Standing for the entire game

2. Timed participation• Measured by number of rests needed

• Number of games played

• Length of time of participation in a game.


Therapeutic Rationale for Cognitive Integration

1. Incorporates sensory perceptual skills and motor planning (anticipatory control)

2. Executive Function: Problem Solving and Sequencing

3. Attention and Online Awareness

4. Procedural Memory



SideNote: Cognitive Considerations

• What type of cues work best for the patient?• Verbal – must be short and concrete• Physical/ Manual – i.e., hand over hand, guidance

• Document type and amount of prompting

• Short term memory loss may affect the ability to understand how the game works from one session to the next or one game to the next

• Consider the environment, be aware of a “sun downing” effect, make sure there is enough light in the room to not induce sleepiness.


Therapeutic Rationale for Balance Facilitation

• Dynamic standing• With or without device

• Can be graded: walker quad cane 1-pt cane

• Low impact simulation of games/sports• Steps approaching bowling lane

• Sidesteps toward tennis ball with trunk rotation

• Reaching in various ranges to pop bubbles with finger


Therapeutic Rationale for Flexibility and AROM

• Functional upper extremity movement patterns

• Nintendo Wii Sports: • Tennis, bowling and golf games are self-calibrating

• Progressively gets more challenging (Levels)




Murray

• 88 yo married man. Primary caregiver for wife of 42 years, now with Alzheimer’s Disease. Lives in a Retirement Community

• PLOF: Independent with all ADLs and IADLs; drives during the day to senior center, food shopping, occasional golf game.

PMH: Spinal Stenosis, Osteoarthritis of the hips, knees and hands

Underwent spinal fusion > developed bilateral lobe emboli.

Remained in acute care for 2 weeks > decline in strength, endurance, functional mobility, participation in ADLs


Murray

Short Term Rehabilitation:Occupational Therapy

program included goals to regain independence in ADLs, functional transfers and mobility and meal preparation.

Occupational Therapy Interventions included, strengthening, endurance training, dynamic balance activities and occupation-based activities.

Most difficulty with regaining endurance to tolerate standing for ADLs.Becamediscouraged with his progress

Occupational Therapist added the Nintendo Wii Golf gaming activity to his interventions program.

Murray

Established Goals to:

• Increase endurance based on seated verses standing time while participating and

Length of playing time number of holes played.

• Increase functional transfers and mobility based on standing with walker SBQC straight cane independent standing during occupation based activity.




Wii Golf Program


1. Standing tolerance2. Gentle weight shifts3. Anticipatory balance4. Sit-to-stand ability

MurrayResults:

1. Stimulated interest to participate in established OT program

2. Improved standing tolerance and dynamic balance

3. Improved general endurance

4. Able to carry over these improvements into bathing, dressing, sink side grooming, functional transfers and meal prep


Billing and Goal Setting

• Therapeutic Exercises (97110) and Activities (97530)• Improve strength

• Increase activity tolerance

• Improve gross motor coordination

• Neuromuscular Re-education (97112)• Improve UE control

• Improve balance and postural control



Wii Fit Intervention:Experimental Group

• Frequency/Duration: • 2x/week x 8 weeks• 1 – hour session, • Each participant took turns

and accumulated a total of 9-13 minutes of playtime.

• Sessions included:• Session 1: Building a Mii

character, Wii Fit Testing (BMI, Wii Fit Age)

• Intervention Sessions 2-15: • Old Style Tilt Table Game• Tight Rope• Slalom Skiing • Hula Hooping• Soccer

Control Group(Bingo)

• Orientation to the use of Wii controls and console

• Creation of a Mii character

• Note: Center has a dedicated Wii time where seniors form groups informally for “pick up” Wii game


Wii Fit Games InvolvedGame Task requirements

Tilt Table Weight shifting and Rotation at the Ankles and Hips

Tight Rope Steadying balance with light squats

Soccer Weight shifting at the Hip M-L and A-P

Slalom Skiing Dynamic Squat with M-L weightshifting

Hula Hoping Circular hip motion over a sustained duration/ weightshifting

In the first 3 weeks, the games were gradually introduced one at a time. Each week thereafter, participants picked and chose which game to play.



Study Results

• Participants in the Wii Group improved their BBS Scores vs. Bingo Group (t=2.77, p = 0.05)

• No statistically significant differences in the DGI (p = .189)

• Participants find Wii Fit gaming to be motivating and more appealing than typical exercise regimes to improve fitness and balance.

Other Lessons Learned

• Cognitive level is important

• Spend plenty of time with controls

• Modify for visual impairments

• Group dynamics and group cohesion is important

• Apply “marketing” approaches with older adults

QUESTIONS?

Documents

HANDOUTslides-Balance in Older AdultsPart 3...Sony EyeToy Sony EyeToy for PS3 Bondoc, Hewitt & Benard, 2010 S Bondoc/OccupationalTherapy.com 3/31/14 Do not copy or reproduce without