Dr. Nathan “Ben” HerzMedical College of Georgia

Occupational Therapy

WiiThe console was conceived in 2001, as the

Nintendo Game Cube was first seeing release. Its major concept involved focusing on a new form of player interaction

So how does it work with different

Diagnoses?

Why is it good for rehabilitation Allows the therapist to have a virtual reality/environment in which to work .

Motivation/FunMeaningful and purposeful to both the therapist and the client

Goal directed activitiesCan be modified for use across the lifespan

Social Interaction

Other reasons for use in rehabilitationAdaptable: In Bed, Sitting, Standing,

and in motionVariety: of activity/games that could

stimulate anyone’s interestAddresses and collaborates with goal accomplishment.

Can do various activities such as aerobic, strengthening, endurance etc…

The WiiAddresses the movement issues but also

the cognitive perceptual, visual perceptual, endurance, and balance issues.

The fact that there is eye-hand coordination, form constancy, figure ground, sequenced movement (motor planning), timing, and depth perception adds to the aspects associated with the Wii system.

And all of the activities are completed in a safe and supervised environment.

Other aspects to considerEye hand

coordinationFigure groundDepth perceptionBilateral motionsBalanceTimingProprioception

EnduranceFine motor

coordinationMotor PlanningDepressionStrengtheningSequencingReaction time

Creating a Mii CharacterGo to Mii Site on the Wii menu Create based on child or clientAllows for personalization and

tracking of progressAlso child and client can relate to

game better

How does it work?Uses interaction to complete the games

successfully in a virtual environmentSports

BowlingTennisGolfBoxingBaseball

Functional Motion and everything

IntegrationOne standout aspect is the functional

Movement involved in the integration of the games

Functional aspects (Cooking Mama Cook- offCooking is not only functional but safe…

Buttering a pan

Filling a pot

Cracking an egg

ImplicationsThe Wii requires functional movementCan be meaningful and purposefulThe areas that need rehab are addressed in

many of the “Sports” games and others in speciality games

These games provide “Occupation” for the clients and something that they do not necessarily realize as improving their functional status

Duncan: Columbia Area PD Support Group Mascot

EVIDIENCEIt is widely recognized that upon diagnosis of PD that

dopamine levels are decreased by 70-80%.One study (Koepp et al., 1998) shows that physical

and mental activity, particularly that of playing a video game, can increase the amount of dopamine released as compared to baseline levels.

An earlier, unpublished 2007 MCG study on the “Efficacy of Occupational Therapy in Clients with PD” demonstrated increases in activities of daily living (ADL) and cognition from baseline performance using the Nintendo Wii gaming system.

EVIDIENCEPrevalence estimates vary, but depressed mood is

common in patients with PD (up to 45%) (Rickards, 2005)

According to Zhang et al. virtual reality is a useful tool for grading leisure activities so that clients with PD may pursue activities in a safe environment.

Based on the Koepp et al. study indicating that dopamine increases with participation in video games and the 2007 MCG study, it was necessary to isolate the Wii system as a treatment method to determine it’s effectiveness in improving performance in ADL, leisure, productivity, IADL, and psychosocial aspects.

EVIDIENCEVirtual reality environments demonstrate skill

acquisition comparable to real world environments(Rose, Attree, & Brooks, 1997)

Virtual reality environments are cost-effective, consistent, standardized, safe, and controlled (Zhang et al., 2003)

Why is it good for PD Dopamine Depletion is approximately 70% at

time of diagnosisExercise increases the production of

Dopamine

“USE IT OR LOSE IT”

QuestionsThose that do exercise have better

performance with activities and may slow the PD process, so with that in mind what about…

Functional Activity vs Exercise?

In PD the WiiIt addresses the movement issues but also

the cognitive perceptual, visual perceptual, endurance, and balance issues.

The fact that there is eye-hand coordination, form constancy, figure ground, sequenced movement (motor planning), timing, and depth perception adds to the aspects associated with the Wii system.

All of the activities are completed in a safe and supervised environment.

The implementation of the Wii system has demonstrated increases in participants as it relates to movement, amplitude of movement, endurance, agility, balance, social participation, and fine/gross coordination as well a in the visual/cognitive perceptual areas mentioned above.

Study OverviewOur proposed research study attempted to

determine the effect of the Nintendo® Wii system as a treatment modality in clients with Parkinson’s disease (PD) as it relates to functional activities.

We hypothesized that the Wii will improve the ability of clients with PD to perform ADL tasks, as well as functional movement, and decrease depression in the short-term (after 4 weeks of intervention) and over one month following treatment.  

We hope the Wii can be validated as an inexpensive intervention strategy that effectively increases the functional independence and quality of life of clients with PD.

Background and NeedIt is widely recognized that upon diagnosis of PD that

dopamine levels are decreased by 70-80%.One study (Koepp et al., 1998) shows that physical

and mental activity, particularly that of playing a video game, can increase the amount of dopamine released as compared to baseline levels.

An earlier, unpublished 2007 MCG study on the “Efficacy of Occupational Therapy in Clients with PD” demonstrated increases in activities of daily living (ADL) and cognition from baseline performance using the Nintendo Wii gaming system.

Methods/ Subjects Clients were recruited for participation from the

CSRA and Columbia Parkinson’s Support Group, as well as Dr. Sethi, Dr. Morgan, and Dr. Mehta’s Clinics

50 clients were invited to participate 27 clients declined invitation for participation 2 participants did not meet inclusion criteria A total of 21 clients with PD were selected

Methods/ Subjects Cont’d 7 had Wii experience (use of Wii

greater than eight times), 14 having no Wii experience (individuals having played the Wii System less than eight times previously and not owning a Wii system)

2 withdrew secondary to medical reasons (1 withdrew prior to beginning the study; 1 withdrew during the study)

2 groups; one group consisting of 14 participants and the second group consisting of 7 participants

Methods/ Design Open Label Study (Level III, Intervention)

A type of study in which both the health providers and the patients are aware of the treatment being given.

Inclusion Criteria Idiopathic PD Men and women of any age Hoehn and Yahr Stage 2 in the “on” state Anticipated stability of PD medications for 8 weeks Meeting one of the following criteria:

Previous experience with the Wii System – defined as previous use of the system greater than eight times

No previous experience with the Wii System – defined as previous use of the system less than eight times.

Exclusion Criteria Dementia (MMSE < 24, adjusted for education level) Known non-Compliance with medical or other therapies Any other co-morbid condition that could lend itself to

unilateral or bilateral sustained dysfunction (stroke, traumatic brain injury, frozen shoulder, peripheral nerve palsies, myasthenia gravis, etc)

Uncontrolled depression as determined by the Investigator Presence of psychosis/delusions Severe levodopa-induced dyskinesias as determined by the

Investigator Deep Brain Stimulation Therapy Subjects without prior experience with the Nintendo Wii will

be excluded if they purchase and use the system throughout the duration of study participation 

Project/Research Questions To determine if treatment with the Nintendo Wii

system provides improvement in ADLs, timed tasks, and functional movement in clients with PD. 

To determine if the Wii system improves outcomes on the Unified Parkinson's Disease Rating Scale (UPDRS), a measure of quality of life in PD (PDQ-39), and the Hamilton Rating Scale for Depression (HAMD).

Methods/Instruments Used Primary Outcomes9-Hole Peg TestThe Tinetti Gait and

Balance TestPurdue Pegboard TestTimed Tapping TestNottingham Extended

ADL ScaleTimed Up, and GoHamilton Depression

Rating Scale (HAMD)

Secondary OutcomesUPDRSPDQ-39

Interview to determine Wii experience

Measured VariablesDescriptive Variables (Time, Performance, Rating,

Self-Report)Independent Variable: WiiDependent Variable:

Psychosocial, gait, balance, fine motor, ADL, and IADL outcomes on instruments used

Pre, Post, and 1 Month Post TestingConfounding Variables:

2 groups of test administrators Various amount of supervision

Operational Definitions Nintendo Wii: Interactive gaming system which

utilizes virtual reality and incorporates functional activity to be successful

Hoehn and Yahr stage 2: bilateral involvement without deficits in gait and balance

Virtual reality: computer simulation of a real or imaginary system that enables a user to perform operations on the simulated system

“On” state: when symptoms are controlled by medication

Methods/Procedure Pre and post testing / 1 month follow up Sessions: 3 x /week for 4 weeks, 45 – 60 minutes per

session using the Wii Protocol: 2 games of tennis, 2 games of bowling, and

1 game of boxing Game sequence was alternated each visit to decrease practice

effect Clients were allowed to play sport games of their

choice after sequence was completed

Statistical AnalysisAll statistical analyses were performed by MCG

Biostatisticians using the following:

Wilcoxon signed rank test

Exact binomial proportion test

Results/FindingsHAMD (Depression)

Pre / Post Test: Post Test / 1 month follow up:

NEADL Total Pre/Post Test Total Post Test/ 1 month follow up:

PDQ-39 (Quality of life) Total Pre/Post Test

UPDRS Motor Post/1 month follow up: Stability Pre/Post Test Total Pre/Post Test

Results/Findings: MotorTimed Tap R

Pre/Post Test:

Left Purdue Pre/Post Test:

9 Hole Peg R: Pre/Post Test:

TUG: Pre/Post Test:

SummaryThe Nintendo Wii has many different

applications for Rehabilitation The System requires integrated functional

movements for success in the activitiesThere is a physical, cognitive, psychological,

and social aspect to these influencing the heath and wellness of participants