http://informahealthcare.com/idt ISSN 1748-3107 print/ISSN 1748-3115 online Disabil Rehabil Assist Technol, Early Online: 1–8 ! 2015 Informa UK Ltd. DOI: 10.3109/17483107.2015.1005031
RESEARCH PAPER
Commercial gaming devices for stroke upper limb rehabilitation: a survey of current practice Disabil Rehabil Assist Technol Downloaded from informahealthcare.com by University of Maryland on 02/03/15 For personal use only.
Katie Thomson1, Alex Pollock1, Carol Bugge2, and Marian C. Brady1 1
Department of Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK and School of Nursing, Midwifery and Health, University of Stirling, Stirling, UK
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Abstract
Keywords
Purpose: Stroke upper limb impairment is associated with disability in activities of daily living. Gaming (Nintendo Wii) is being introduced to rehabilitation despite limited evidence regarding effectiveness. Little data exists on how gaming is implemented resulting in a lack of clinical information. We aimed to gather therapists’ opinions on gaming. Methods: A survey was posted to therapists, identified from stroke services across Scotland. A second survey was posted to non-responders. Survey data were analysed using descriptive statistics and thematic coding. Results: Surveys were sent to 127 therapists (70 stroke services) and returned by 88% (112/127). Gaming was used by 18% of therapists, 61% (68/112) stated they would use this intervention should equipment be available. The most commonly used device was Nintendo Wii (83% of therapists using gaming) for 30 min or less once or twice per week. Half of therapists (51%) reported observing at least one adverse event, such as fatigue, stiffness or pain. Gaming was reported to be enjoyable but therapists described barriers, which relate to time, space and cost. Conclusions: Gaming is used by almost a fifth of therapists. Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage.
Gaming, rehabilitation, stroke, survey, upper limb History Received 17 October 2014 Revised 23 December 2014 Accepted 5 January 2015 Published online 30 January 2015
ä Implications for Rehabilitation
Commercial gaming devices are reported to be used by 1/5th of therapists for stroke upper limb rehabilitation, 3/5ths would use gaming if available. Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage. Current use of gaming in practice may not be achieving intense and repetitive upper limb task-specific practice.
Introduction Approximately 15 million people across the world will suffer a stroke per annum, 40% of which occur in people younger than 70 years [1]. Stroke is a major cause of serious, long-term disability in Europe [2] and the US [3], causing enormous economic burden. A widely recognised stroke symptom is a lack of motor skills [4] including upper limb impairment [5]. Of those stroke survivors who display upper limb impairment 30–66% will still have difficulties six months later [6]. Long-term upper limb impairment can be persistent and disabling [7] having a severe impact on activities of daily living (ADL). This can result in participation restriction for social, occupational and leisure activities [8]. Stroke upper limb impairment can have a detrimental impact on perceived quality of life [9], subjective wellbeing [10] and has been associated with anxiety [11].
Address for correspondence: Katie Thomson, Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Cowcaddens Road, Glasgow G40BA, UK. Tel: 0141 331 8456. E-mail: [email protected]
Evidence currently indicates that task specific, repetitive and intensive practice may be beneficial to upper limb recovery [12]. There are wide ranges of specific treatment techniques that aim to address upper limb impairment [4]; evidence relating to many of these is synthesized within systematic reviews [13]. Interventions frequently include technological advances labeled as assistive technology [14], such as virtual reality systems. Commercial gaming devices are being introduced to rehabilitation services to address upper limb impairment [15,16]. McHugh et al. [17] surveyed a sample of 53 English stroke units and reported that 18% of stroke survivors with mild levels of impairment will receive rehabilitation using devices, such as Nintendo Wii. Commercial gaming devices such as Nintendo Wii or Sony PlayStation are readily available but a recent systematic review [18] found that there was insufficient evidence to reach generalisable conclusions about benefits on ADL, upper limb function or movement. In order to be able to inform future research and aid health professionals in making clinical judgements, it is important to know how commercial gaming is currently being used. We therefore aimed to capture information on therapists’ opinions and
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use of commercial gaming devices for stroke upper limb rehabilitation.
Ethical & NHS R&D department approval
Methods
Identification of stroke services/therapy leads
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Survey We developed and piloted a short postal survey, which aimed to capture information on therapists’ opinions and use of commercial gaming devices for stroke upper limb rehabilitation. No published, validated surveys on this topic were available to the research team, therefore a bespoke survey was created (using open/closed questions) and piloted with 10 occupational therapists/physiotherapists linked to the university (both practice based & academic). Therapists were asked to complete the survey and give feedback on presentation and clarity of questions. Minor revisions were made to the wording of questions following piloting and prior to distribution. No data from the pilot were included in the survey results.
Phone call to service manager/therapy lead to identify potential participants Phone call to potential participants to inform of survey and ask consent to send questionnaire
Initial contact letter sent to participants within 7 working days of phone call
Participants Survey participants comprised of occupational therapists and physiotherapists working within acute stroke units, rehabilitation units and community teams within all Scottish Health Boards (responsible body for the provision of health care within a regional area). We defined ‘‘teams’’ as multi-disciplinary services that provided stroke rehabilitation and identified one lead occupational therapist and physiotherapist from each team to participate in our survey. Stroke services were identified via professional contacts, managed clinical networks, lead allied health professionals, discussions with therapists during recruitment and where necessary internet searching. All Scottish stroke services were contacted by telephone to identify participants, who were invited to provide a response from their own profession (occupational therapy/physiotherapy) on behalf of their team. Ethical permission was sought and granted from the university ethics panel followed by permission from all 14 Scottish NHS Boards’ research and development departments. Procedure Procedures were adopted which have been demonstrated to maximise response rates [19]. These included: short survey length, use of closed, factual questions at survey start with open questions placed at end and the use of hand written stamped addressed envelopes. A second reminder survey was posted to any non-responders (refer to Appendix 1 – survey). Figure 1. Data analysis Data were entered into a Microsoft Excel Database and NVivo 10. Quantitative data were analysed using descriptive statistics. The survey aimed to capture information on current practice, data captured provided an indication of how gaming was being implemented, it was not considered to be sufficiently robust for further statistical analysis. Qualitative data were thematically coded and analysed by identifying and describing themes.
Results Participants A total of 127 surveys were posted to Occupational Therapists (n ¼ 66) and Physiotherapists (n ¼ 61) over a 1-year period (2012–2013) from 70 stroke services throughout all 14 NHS Health Boards in Scotland. The response rate was 88% with 112 surveys returned (112/127) of which 13 (10%, 13/127) were in response to the reminder letter to complete and return the survey.
Questionnaire distribution within 7 working days of initial contact letter Reminder letter and second questionnaire distribution (14 working days following initial questionnaire distribution) where required
Figure 1. Survey flow chart.
Responses were received from all Health Boards and participants were asked to respond on behalf of their profession. Data provided by respondents indicated that this included a total of 311 therapists (173 occupational therapists/138 physiotherapists) and 224 assistants (142 assistants linked to occupational therapy/82 linked to physiotherapy) (Table 1). Place of work Most therapists represented within survey responses worked within inpatient services (78); 14 worked within outpatient services and 19 within community teams (1 not stated). Team sizes were calculated by the number of occupational therapists or physiotherapists plus therapy assistants as reported by respondents. A large variation existed in relation to the size of professional teams; the smallest being 0.5 and the largest containing 52 whole time equivalents. Use of commercial gaming devices Commercial gaming devices were used as a rehabilitation intervention by 18% of therapists (57/311) and 19% of therapy assistants (42/224) within Scotland. A similar proportion of occupational therapists (19%, 33/173) and physiotherapists (17%, 24/138) used commercial gaming. The most popular gaming device was Nintendo Wii, which was identified by 83% of therapists who used gaming (47/57). Microsoft Xbox Kinect was used by 14% of therapists (8/57), whilst only 4% (2/57) used Sony Playstation. iPad with applications was used by 1 therapist.
Survey of gaming use for stroke upper limb rehabilitation
Total number of therapists using gaming ¼ 57 Total number of assistants included in teams ¼ 224
Physiotherapists ¼ 138
Total number of therapists included in teams ¼ 311
89%
88%
Occupational therapy assistants ¼ 24 Physiotherapy assistants ¼ 18 Total number of therapy assistants using gaming ¼ 42 Occupational therapists ¼ 33 Physiotherapists ¼ 24 Occupational therapy assistants ¼ 142 Physiotherapy assistants ¼ 82 Occupational therapists ¼ 173 88%
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The most commonly used game with Nintendo Wii was Wii Sports (74%, 42/57); 14% used Wii Play (8/57) and 9% used Wii Fit (5/57). Cognitive games were used by 4% of therapists (2/57), including Big Brain Academy and Brain Training, whilst 4% (2/57) used a balance board and 1 therapist used an ADL game (Cooking Mama). Although two therapists highlighted that they were using Sony Playstation only one detailed the game used (Zumba). Games used on the Microsoft X Box Kinect included Kinect Sports (9%, 5/57) and Xbox golf (2%, 1/57) with two not stated. Therapists were asked if they would use gaming devices should equipment be available; 61% of therapists said yes (68/112) with 43% (48/112) identifying Nintendo Wii, 13% (14/112) Xbox and 3% (3/112) Sony Playstation. Overall therapists reported that the use of commercial gaming offered a fun and meaningful activity, which offered opportunities for social interaction and self-practice. Table 2 provides a summary of reasons therapists reported for using gaming. In addition, therapists identified disadvantages of using commercial gaming (Table 3); these included a weak evidence base with therapists’ lack of knowledge concerning gaming and a need for additional training. Therapists also highlighted that they felt practice of real rather than simulated activities was of more benefit. A lack of space, time and funding were also reported. Patient population (who used gaming with therapists) Table 4 provides details of the types of stroke patients with whom therapists reported to use gaming. Patients were most likely to be in the acute stages of recovery (less than 6 months post–stroke 72%) with near normal (53%) or weak upper limb movement (37%). In addition, patients were not excluded if they had other impairments, such as sensory/proprioceptive impairments or communication difficulties. Treatment sessions Table 5 provides information on how therapists delivered the intervention. Gaming was most likely to take place in therapy units (60%) once or twice per week (53%) for 30 min or less (51%). Patients were most likely to play on their own (46%) but pairs (21%) and groups also played (16%), and two-thirds (77%) required some form of adaptation such as positioning of the gaming console.
Number
66
61
127
Sent to occupational therapists Sent to physiotherapists
Sent in total
Returned from occupa- 58 tional therapists Returned from 54 physiotherapists Returned in total 112
Adverse events
Surveys
Table 1. Survey responses.
Surveys
Response Number rate
Total number of therapists in professional teams
Total number of assistants included in professional teams
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Number using commercial Number using commercial gaming for stroke upper gaming for stroke upper limb rehabilitation limb rehabilitation
DOI: 10.3109/17483107.2015.1005031
Half of therapists using gaming (51%, 29/57) reported that some of their stroke patients experienced adverse events. Fatigue was the most common effect reported by therapists (45%, 13/29) followed by stiffness (10%, 3/29) and pain (7%, 2/29). In addition, three therapists (10%, 3/29) highlighted other adverse events, which included feelings of having exercised, frustration, increased muscle tone and feeling childish.
Discussion Principal findings A high survey response rate was achieved (88%) and results indicated that nearly one-fifth of therapists (18%) used commercial gaming devices for stroke upper limb rehabilitation. Our findings also suggest that 61% of therapists would use commercial gaming devices should equipment be available. The most commonly used gaming device for stroke upper limb rehabilitation was Nintendo Wii (reported to be used by 83% of therapists using gaming), which is also consistent with other surveys [17,20]. The popularity of Nintendo Wii can also be seen
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Table 2. Why therapists used commercial gaming. Theme
Description
Fun and meaningful activity
Gaming is a fun and meaningful activity which patients enjoy. It motivates patients to participate in their rehabilitation and offers variety. Of particular use for younger stroke patients. ‘‘to be able to give a fun alternative to more traditional treatment methods’’ (Participant No. 105) Gaming can be played with others encouraging social interaction and competition. ‘‘as part of group therapy within day hospital, makes exercise less serious, good feedback for patient’’ (Participant No. 44) Encourages upper limb movement and co-ordination as well as developing other skills, such as balance, stamina, strengthening and function. ‘‘it can be a good way of encouraging movement using a fun activity’’ (Participant No. 80) Families often have access to gaming and patients could continue rehabilitation at home ‘‘easy to set up and use, allows patients to see improvement, patients can use with family if they have console at home, well tolerated by patients, cost effective’’ (Participant No. 48)
Socialisation Practising movements
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Self-practice
Table 3. Perceived disadvantages of using commercial gaming within stroke upper limb rehabilitation. Theme
Description
Lack of evidence base
Lack of a clear evidence base that supports use ‘‘research is limited’’ (Participant No. 118) Older stroke patients do not like working with computers/may struggle to use technology such as gaming. ‘‘elderly population do not like working with computers/unfamiliar with technology’’ (Participant No. 5) Availability of equipment/cost, space and time. Focus on functional tasks/discharge planning. Additional training required. ‘‘time taken to set up, space for equipment and secure storage’’ (Participant No. 12) ‘‘we make only limited use because we don’t all know how to use them ourselves’’ (Participant No. 110) Concerns regarding quality of movement achieved, risk of compensatory movements/increased tone. Could exclude stroke patients with cognitive/visual problems, games were too fast/complex therefore frustration would be experienced. Difficulties measuring outcomes, stroke patients did not always follow instructions on use. ‘‘maintaining balance/safety awareness during games such as Wii sports, not over reaching etc.’’ (Participant No. 2) A simulated activity not always related to function. Tasks completed not real life and less relevant to practice. ‘‘unless they are familiar with gaming it is not very functional and therefore not very relevant’’ (Participant No. 63)
Unfamiliarity for older stroke patients Organisational barriers
Games too difficult for rehabilitation Games not functional
Table 4. Patient population (who were reported to use gaming with therapists). Age Length of time post stroke Level of upper limb impairment Additional impairments
49 yrs or under: 25% (14/57) 56 mths: 72% (41/57) Near normal mvmt: 53% (30/57) Cognitive: 26% (15/57)
50–70 yrs: 30% (17/57) 6 mths–1 yr: 5% (3/57) Weak/unco-ordinated: 37% (21/57) Communication: 35% (20/57)
71 yrs+: 4% (2/57) 1 yr+: 33% (19/57) Weak/isolated mvmt: 2% (1/57) Sensory: 37% (21/57)
Any age: 40% (23/57) Any length: 11% (6/57) Any types: 11% (6/57) Perceptual: 19% (11/57)
Visual: 19% (11/57)
Table 5. Format of treatment sessions. Location Aim of session
Ward: 19% (11/57) Assessment: 4% (2/57)
Number of players Frequency
Individual: 46% (26/57) Every day: 2% (1/57)
Duration (per session) Adaptations made:
30 mins: 51% (29/57) Handset (velcro/tubigrip): 33% (19/57)
Therapy area: 60% (34/57) Upper limb function: 39% (22/57) Pairs: 21% (12/57) Once/twice per week: 53% (30/57) 31–60 mins: 21% (12/57) Gameplay (positioning): 44% (25/57)
within our recent systematic review [18] where 9 of the 19 studies included in the review employed this device (other studies looked at a range of consoles/devices). In addition, our survey identified use of alternative gaming devices, such as Xbox Kinect (reported to be used by 14% of therapists), Sony Playstation (4% therapists) and iPad (1 therapist). No other surveys appear to have reported
Home: 9% (5/57) Upper limb mvmt: 46% (26/57) Groups: 16% (9/57) Three/four per week: 4% (2/57) 60 mins: 0% No adaptations: 33% (19/57)
Any location: 0% All aims: 9% (5/57) Any number of players: 14% (8/57) All frequency: 0% All duration: 0% Both handset and gameplay: 2% (1/57)
use of alternative gaming devices within stroke upper limb rehabilitation. Despite the popularity of Nintendo Wii as a rehabilitation intervention it would appear that use within the UK might be inconsistent. McHugh et al. [17] in their survey of 53 English stroke units reported that only two stroke units used Nintendo Wii
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DOI: 10.3109/17483107.2015.1005031
for stroke upper limb rehabilitation. This seems to indicate a large variation in practice between different geographical areas in the UK and differences to Australian stroke units [20], where 76% of stroke units had access to Nintendo Wii. Therapists reported that they were most likely to use Nintendo Wii gaming console once or twice per week with sessions lasting 30 min or less (never more than 60 min). This is in sharp contrast to research studies where an average of 180 min of gaming per week is reported [18]. In a recent randomized control trial, Rand et al. [21] identified that one-hour of gaming within stroke rehabilitation achieved on average 271 active purposeful movements (in comparison to 48 within traditional therapy). In addition, Abdullahi et al.’s [22] systematic review highlighted that the number of upper limb movements required for neuroplasticity is in the region of 300–800 repetitions. Given that the aim of using commercial gaming devices for stroke upper limb rehabilitation is to achieve intense and repetitive practice, it would suggest that this aim is not being met within many practice settings. The lack of time available for rehabilitation is highlighted by McHugh et al. [17], who found that staffing levels and face-to-face contact times for therapy in some stroke services are suboptimal. Given time available for stroke upper limb rehabilitation and the low priority that can be placed on this aspect of recovery [23], it could be questioned if therapists are able to offer the same level of high-intensity/repetitive task-specific practice delivered within research literature. Limitations This study has achieved a high response rate (88%) and could therefore be considered as representative of current practice within Scotland. However, Scotland is only one geographical area of the UK and given the results of other surveys [17] may not reflect practice across the wider stroke rehabilitation community. A large number of acute services were represented (70%), every attempt was made to locate community stroke services but it may be that some services with a small number of therapists were missed. Respondents were often identified by senior managers; therefore, this may have introduced selection bias with managers identifying staff known to be specifically interested in gaming devices. Respondents were, however, asked to complete the survey on behalf of their professional group in their clinical area in order to gather data from a service perspective. However, responses may not have accurately reflected how their colleagues were using commercial gaming. Therapists were also asked to provide information on patient feedback (collecting this information directly from patients would have been more desirable), however, this survey aimed to capture therapists’ opinions of feedback. Finally, commercial gaming is a rapidly developing area with new products regularly entering the marketplace making it difficult for surveys to react and capture rapid changes in practice. Implications for practice To increase the intensity of upper limb rehabilitation within current time constraints, therapists may wish to focus on models of delivery, which include opportunities for self-practice, as highlighted in the National Clinical Guidelines for Stroke [24]. The use of virtual reality systems has been proposed as offering self-practice opportunities [25]. Encouraging self-practice may offer a potential solution, increasing the likelihood of patients achieving the desired amount of intensive and repetitive movements. Minor adverse events were reported by 51% (29/57) of therapists indicating that some patients may experience adverse
Survey of gaming use for stroke upper limb rehabilitation
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events following gaming. The most commonly reported adverse event was fatigue identified by 23% (13/57) of therapists. Other adverse events reported included stiffness (5%, 3/57) and pain (4%, 2/57). Implications for research In designing and planning future studies particular focus should be placed on pragmatic issues identified within our survey including training for therapists, adaptations required for play, sufficient space within rehabilitation units and the lack of emphasis placed on this aspect of recovery by some services. In addition, trial design should examine a dose-response relationship to explore whether current clinical practice is effective. Within our survey, gaming sessions were most likely to take place in therapy areas (60%) with only 9% taking place in patients’ homes. A number of research studies [26–28] have delivered home-based gaming, however, location of therapy is an important consideration for future research if in practice this is difficult to implement. Finally, further research of adverse events is merited to investigate the frequency and impact on rehabilitation.
Conclusion Commercial gaming for stroke upper limb rehabilitation is reported to be used by almost a fifth of therapists in stroke rehabilitation settings across Scotland with three-fifths reporting they would use gaming if available. There appears to be a sharp contrast between the number and length of sessions reported by those using commercial gaming and the dose delivered within clinical trials exploring effectiveness of this intervention. Our evidence suggests that current clinical practice may not be achieving the intense and repetitive task-specific practice, which is the purported aim of gaming devices for stroke upper limb rehabilitation. We recommend further research to explore the effectiveness of current clinical practice using gaming. Adverse events were observed by 51% of therapists and should be carefully recorded and monitored when prescribing use and dosage. Furthermore, in order to increase the intensity of upper limb rehabilitation, we believe there is a need for therapists to explore models of delivery which provide opportunities for self-practice.
Declaration of interest The Nursing Midwifery and Allied Health Professions (NMAHP) Research Unit is supported by the Scottish Government Health Directorate’s Chief Scientist Office. The work presented here represents the view of the authors and not necessarily those of the funding bodies. The authors report no declarations of interest.
References 1. Truelsen T, Heuschmann PU, Bonita R, et al. Standard method for developing stroke registers in low-income and middle income countries: experiences from a feasibility study of a stepwise approach to stroke surveillance (STEPS Stroke). Lancet Neurol 2007;6:134–9. 2. European Stroke Organisation. Stroke Facts 2014. Available from: http://www.eso-stroke.org/eso-stroke/stroke-information/ stroke-facts.html [last accessed 29 Jan 2014]. 3. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics - 2013 update: a report from the American Heart Association. Circulation 2012;127:e2–241. 4. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol 2009;8:741–54.
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5. Goulding R, Thompson D, Beech C. Caring for patients with hemiplegia in an arm following a stroke. Br J Nurs 2004;13: 534–9. 6. Kwakkel G, Boudewijn J, Kollen BJ, Krebs HI. Effects of robotassisted therapy on upper limb recovery after stroke: a systematic review. Neurorehabil Neural Repair 2008;22:111. 7. Lai S, Studenski S, Duncan P, Perera S. Persisting consequences of stroke measured by the Stroke Impact Scale. Stroke 2002;33: 1840–4. 8. Broeks JG, Lankhorst GJ, Rumping K, Prevo AJ. The long-term outcome of arm function after stroke: results of a follow-up study. Disabil Rehabil 1999;21:357–64. 9. Franceschini M, La Porta F, Agosti M, Massucci M. Is health-related quality of life of stroke patients influenced by neurological impairments at one year after stroke? Eur J Phys Rehabil Med 2010;44:389–99. 10. Wyller TB, Sveen U, Sodring KM, et al. Subjective well-being one year after stroke. Clin Rehabil 1997;11:139–45. 11. Morris JH, van Wijck F, Joice S, Donaghy M. Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction. Disabil Rehabil 2013;35:291–9. 12. Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet 2011;377:1693–702. 13. Pollock A, Farmer SE, Brady MC, et al. Interventions for improving upper limb function after stroke (Protocol). Cochrane Database Syst Rev 2013. Art. No.: CD010820. DOI: 10.1002/14651858. CD010820. 14. Farmer S, Durairaj V, Swain I, Pandyan A. Assistive technologies: can they contribute to rehabilitation of the upper limb after stroke? Arch Phys Med Rehabil 2014;95:965–85. 15. Burke J. Video games in stroke rehabilitation. Stroke Matt 2011;6: 4–5. 16. Halton J. Virtual rehabilitation with video games: a new frontier for occupational therapy. Occup Ther Now 2008;9:12–14. 17. McHugh G, Swain I, Jenkinson D. Treatment components for upper limb rehabilitation after stroke. Disabil Rehabil 2014;36: 925–31.
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18. Thomson K, Pollock A, Bugge C, Brady M. Commercial gaming devices for stroke upper limb rehabilitation: a systematic review. Int J Stroke 2014;9:479–88. 19. Edwards PJ, Robers I, Clarke MJ, et al. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev 2009. Art. No.: MR000008. DOI: 10.1002/14651858. MR000008.pub4. 20. National Stroke Foundation. National stroke audit rehabilitation services report. 2012. Available from: http://strokefoundation.com. au/site/media/NSF_Audit-Report_2012_web2.pdf [last accessed 13 Sept 2013]. 21. Rand D, Kizony R, Weiss P. The Sony PlayStation II Eye Toy: lowcost virtual reality for use in rehabilitation. J Neuro Phys Ther 2008; 32:155. 22. Abdullahi A. Is time spent using constraint induced movement therapy an appropriate measure of dose? A critical literature review. Int J Ther Rehabil 2014;21:140–6. 23. Saposnik G, Teasell R, Mamdani M, et al. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle. Stroke 2010;47: 1477–84. 24. Royal College of Physicians. National clinical guidelines for stroke. 2012. Available from: http://www.rcplondon.ac.uk/sites/default/ files/national-clinical-guidelines-for-stroke-fourth-edition.pdf [last accessed 14 Jun 2014]. 25. Laver K, George S, Thomas S, et al. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev 2011. Art. No.: CD008349. DOI: 10.1002/14651858.CD008349.pub2. 26. Flynn S, Palma P, Bender A. Feasibility of using the Sony PlayStation 2 gaming platform for an individual post stroke: a case report. J Neurol Phys Ther 2007;31:180. 27. Christie LK, Kennedy S, Brennan K, et al. Does stroke Wiihab work? Use of the Nintendo Wii for upper limb rehabilitation following stroke. Cerebrovasc Dis 2010;29:2. 28. Mouawad M, Doust C, Max M. Wii-based movement therapy to promote improved upper extremity function post stroke: a pilot study. J Rehabil Med 2011;43:527–33.
Survey of gaming use for stroke upper limb rehabilitation
DOI: 10.3109/17483107.2015.1005031
Appendix 1 - Survey
Commercial Gaming for Stroke Upper Limb Rehabilitaon Your service
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1. What profession do you belong to?
2. What is your main area of work? (Please tick one)
Occupational Therapy
Stroke Inpaent Care
Community Stroke Team
Physiotherapy
Stroke Outpaent Care
Other (Please state):
3. How many therapists and assistants are employed within your main area of work? (Only include staff from your own profession):
Please enter number
5. How many therapists and assistants use commercial gaming for stroke upper limb rehabilitaon within your main area of work? (Only include staff from your own profession):
Therapists:
Assistants:
Please enter number
4a. Which, if any commercial gaming devices are available to use as part of stroke rehabilitaon within your workplace?
Therapists:
(Please ck all that apply)
Nintendo Wii
X-box Kinect
Sony Playstaon
None (please proceed to Q.13)
Assistants:
Other (Please state): b. Which games do you use? Wii Sports
(Please ck all that apply)
Cooking Mama
Eye Toy
Wii Play
Kinect Sports
Other (please state) Your stroke paents 6. Within our workplace we use commercial gaming with stroke paents who are............ (Please ck all that apply) a......
b......
c......
Male
49yrs or under
1 year post stroke
7. Within our workplace we use commercial gaming with stroke paents whose upper limb movement can be described as…. (Please ck all that apply)
8. Within our workplace we use commercial gaming with stroke paents who are also affected by.... (Please ck all that apply)
Near normal movement and coordinaon of the impaired upper limb
Cognive impairments
A range of weak and/or uncoordinated movements of the impaired upper limb
Sensory or propriocepve impairments
Small, weak isolated movements of the impaired upper limb
Visual problems
Communicaon difficules
Perceptual problems
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Within your workplace how do you use commercial gaming? . 9. Commercial gaming is used ……………..(Please ck all that apply) a….
b….
With individual paents
On the ward
With pairs
Treatment of UL Funcon
In therapy area
With groups
Treatment of UL Movement
In paent’s home
d…. Disabil Rehabil Assist Technol Downloaded from informahealthcare.com by University of Maryland on 02/03/15 For personal use only.
c…. For assessment
e….
f….
Every day
For ≤ 30 mins per session
Once or twice per week
For 31-60 mins per session
Three/four mes per week
For ≥ 60 mins per session
With adaptaons to handset (use of velcro/tubigrip)
With adaptaons to gameplay (paent posion)
Without any adaptaons
10. Have stroke paents ever reported any adverse effects from using commercial gaming? (Please ck all that apply) Pain
Sffness
Fague
No adverse effects reported
Other (Please state):_________________________________________________________________ 11. What feedback do paents give on the use of commercial gaming as part of their upper limb rehabilitaon? (Please give as much detail as you can):
12. Why does your service use commercial gaming as part of upper limb rehabilitaon?
Connue on another page if necessary
Please proceed to Queson 14
(Please give as much detail as you can):
Your opinions on the use of commercial gaming for stroke upper limb rehabilitaon. 13. If commercial gaming devices were available would you use them for stroke upper limb rehabilitaon?
14. In your opinion what are the advantages and disadvantages of using commercial gaming for stroke upper limb rehabilitaon?
If, Yes Which device would you use? Advantages:
If No
Why not?
Disadvantages:
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE PLEASE RETURN IN SAE TO: Kae Thomson, NMAHP Research Unit, Buchanan House, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA
Tel: 0141 331 8456
RESEARCH PAPER
Commercial gaming devices for stroke upper limb rehabilitation: a survey of current practice Disabil Rehabil Assist Technol Downloaded from informahealthcare.com by University of Maryland on 02/03/15 For personal use only.
Katie Thomson1, Alex Pollock1, Carol Bugge2, and Marian C. Brady1 1
Department of Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK and School of Nursing, Midwifery and Health, University of Stirling, Stirling, UK
2
Abstract
Keywords
Purpose: Stroke upper limb impairment is associated with disability in activities of daily living. Gaming (Nintendo Wii) is being introduced to rehabilitation despite limited evidence regarding effectiveness. Little data exists on how gaming is implemented resulting in a lack of clinical information. We aimed to gather therapists’ opinions on gaming. Methods: A survey was posted to therapists, identified from stroke services across Scotland. A second survey was posted to non-responders. Survey data were analysed using descriptive statistics and thematic coding. Results: Surveys were sent to 127 therapists (70 stroke services) and returned by 88% (112/127). Gaming was used by 18% of therapists, 61% (68/112) stated they would use this intervention should equipment be available. The most commonly used device was Nintendo Wii (83% of therapists using gaming) for 30 min or less once or twice per week. Half of therapists (51%) reported observing at least one adverse event, such as fatigue, stiffness or pain. Gaming was reported to be enjoyable but therapists described barriers, which relate to time, space and cost. Conclusions: Gaming is used by almost a fifth of therapists. Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage.
Gaming, rehabilitation, stroke, survey, upper limb History Received 17 October 2014 Revised 23 December 2014 Accepted 5 January 2015 Published online 30 January 2015
ä Implications for Rehabilitation
Commercial gaming devices are reported to be used by 1/5th of therapists for stroke upper limb rehabilitation, 3/5ths would use gaming if available. Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage. Current use of gaming in practice may not be achieving intense and repetitive upper limb task-specific practice.
Introduction Approximately 15 million people across the world will suffer a stroke per annum, 40% of which occur in people younger than 70 years [1]. Stroke is a major cause of serious, long-term disability in Europe [2] and the US [3], causing enormous economic burden. A widely recognised stroke symptom is a lack of motor skills [4] including upper limb impairment [5]. Of those stroke survivors who display upper limb impairment 30–66% will still have difficulties six months later [6]. Long-term upper limb impairment can be persistent and disabling [7] having a severe impact on activities of daily living (ADL). This can result in participation restriction for social, occupational and leisure activities [8]. Stroke upper limb impairment can have a detrimental impact on perceived quality of life [9], subjective wellbeing [10] and has been associated with anxiety [11].
Address for correspondence: Katie Thomson, Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Cowcaddens Road, Glasgow G40BA, UK. Tel: 0141 331 8456. E-mail: [email protected]
Evidence currently indicates that task specific, repetitive and intensive practice may be beneficial to upper limb recovery [12]. There are wide ranges of specific treatment techniques that aim to address upper limb impairment [4]; evidence relating to many of these is synthesized within systematic reviews [13]. Interventions frequently include technological advances labeled as assistive technology [14], such as virtual reality systems. Commercial gaming devices are being introduced to rehabilitation services to address upper limb impairment [15,16]. McHugh et al. [17] surveyed a sample of 53 English stroke units and reported that 18% of stroke survivors with mild levels of impairment will receive rehabilitation using devices, such as Nintendo Wii. Commercial gaming devices such as Nintendo Wii or Sony PlayStation are readily available but a recent systematic review [18] found that there was insufficient evidence to reach generalisable conclusions about benefits on ADL, upper limb function or movement. In order to be able to inform future research and aid health professionals in making clinical judgements, it is important to know how commercial gaming is currently being used. We therefore aimed to capture information on therapists’ opinions and
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use of commercial gaming devices for stroke upper limb rehabilitation.
Ethical & NHS R&D department approval
Methods
Identification of stroke services/therapy leads
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Survey We developed and piloted a short postal survey, which aimed to capture information on therapists’ opinions and use of commercial gaming devices for stroke upper limb rehabilitation. No published, validated surveys on this topic were available to the research team, therefore a bespoke survey was created (using open/closed questions) and piloted with 10 occupational therapists/physiotherapists linked to the university (both practice based & academic). Therapists were asked to complete the survey and give feedback on presentation and clarity of questions. Minor revisions were made to the wording of questions following piloting and prior to distribution. No data from the pilot were included in the survey results.
Phone call to service manager/therapy lead to identify potential participants Phone call to potential participants to inform of survey and ask consent to send questionnaire
Initial contact letter sent to participants within 7 working days of phone call
Participants Survey participants comprised of occupational therapists and physiotherapists working within acute stroke units, rehabilitation units and community teams within all Scottish Health Boards (responsible body for the provision of health care within a regional area). We defined ‘‘teams’’ as multi-disciplinary services that provided stroke rehabilitation and identified one lead occupational therapist and physiotherapist from each team to participate in our survey. Stroke services were identified via professional contacts, managed clinical networks, lead allied health professionals, discussions with therapists during recruitment and where necessary internet searching. All Scottish stroke services were contacted by telephone to identify participants, who were invited to provide a response from their own profession (occupational therapy/physiotherapy) on behalf of their team. Ethical permission was sought and granted from the university ethics panel followed by permission from all 14 Scottish NHS Boards’ research and development departments. Procedure Procedures were adopted which have been demonstrated to maximise response rates [19]. These included: short survey length, use of closed, factual questions at survey start with open questions placed at end and the use of hand written stamped addressed envelopes. A second reminder survey was posted to any non-responders (refer to Appendix 1 – survey). Figure 1. Data analysis Data were entered into a Microsoft Excel Database and NVivo 10. Quantitative data were analysed using descriptive statistics. The survey aimed to capture information on current practice, data captured provided an indication of how gaming was being implemented, it was not considered to be sufficiently robust for further statistical analysis. Qualitative data were thematically coded and analysed by identifying and describing themes.
Results Participants A total of 127 surveys were posted to Occupational Therapists (n ¼ 66) and Physiotherapists (n ¼ 61) over a 1-year period (2012–2013) from 70 stroke services throughout all 14 NHS Health Boards in Scotland. The response rate was 88% with 112 surveys returned (112/127) of which 13 (10%, 13/127) were in response to the reminder letter to complete and return the survey.
Questionnaire distribution within 7 working days of initial contact letter Reminder letter and second questionnaire distribution (14 working days following initial questionnaire distribution) where required
Figure 1. Survey flow chart.
Responses were received from all Health Boards and participants were asked to respond on behalf of their profession. Data provided by respondents indicated that this included a total of 311 therapists (173 occupational therapists/138 physiotherapists) and 224 assistants (142 assistants linked to occupational therapy/82 linked to physiotherapy) (Table 1). Place of work Most therapists represented within survey responses worked within inpatient services (78); 14 worked within outpatient services and 19 within community teams (1 not stated). Team sizes were calculated by the number of occupational therapists or physiotherapists plus therapy assistants as reported by respondents. A large variation existed in relation to the size of professional teams; the smallest being 0.5 and the largest containing 52 whole time equivalents. Use of commercial gaming devices Commercial gaming devices were used as a rehabilitation intervention by 18% of therapists (57/311) and 19% of therapy assistants (42/224) within Scotland. A similar proportion of occupational therapists (19%, 33/173) and physiotherapists (17%, 24/138) used commercial gaming. The most popular gaming device was Nintendo Wii, which was identified by 83% of therapists who used gaming (47/57). Microsoft Xbox Kinect was used by 14% of therapists (8/57), whilst only 4% (2/57) used Sony Playstation. iPad with applications was used by 1 therapist.
Survey of gaming use for stroke upper limb rehabilitation
Total number of therapists using gaming ¼ 57 Total number of assistants included in teams ¼ 224
Physiotherapists ¼ 138
Total number of therapists included in teams ¼ 311
89%
88%
Occupational therapy assistants ¼ 24 Physiotherapy assistants ¼ 18 Total number of therapy assistants using gaming ¼ 42 Occupational therapists ¼ 33 Physiotherapists ¼ 24 Occupational therapy assistants ¼ 142 Physiotherapy assistants ¼ 82 Occupational therapists ¼ 173 88%
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The most commonly used game with Nintendo Wii was Wii Sports (74%, 42/57); 14% used Wii Play (8/57) and 9% used Wii Fit (5/57). Cognitive games were used by 4% of therapists (2/57), including Big Brain Academy and Brain Training, whilst 4% (2/57) used a balance board and 1 therapist used an ADL game (Cooking Mama). Although two therapists highlighted that they were using Sony Playstation only one detailed the game used (Zumba). Games used on the Microsoft X Box Kinect included Kinect Sports (9%, 5/57) and Xbox golf (2%, 1/57) with two not stated. Therapists were asked if they would use gaming devices should equipment be available; 61% of therapists said yes (68/112) with 43% (48/112) identifying Nintendo Wii, 13% (14/112) Xbox and 3% (3/112) Sony Playstation. Overall therapists reported that the use of commercial gaming offered a fun and meaningful activity, which offered opportunities for social interaction and self-practice. Table 2 provides a summary of reasons therapists reported for using gaming. In addition, therapists identified disadvantages of using commercial gaming (Table 3); these included a weak evidence base with therapists’ lack of knowledge concerning gaming and a need for additional training. Therapists also highlighted that they felt practice of real rather than simulated activities was of more benefit. A lack of space, time and funding were also reported. Patient population (who used gaming with therapists) Table 4 provides details of the types of stroke patients with whom therapists reported to use gaming. Patients were most likely to be in the acute stages of recovery (less than 6 months post–stroke 72%) with near normal (53%) or weak upper limb movement (37%). In addition, patients were not excluded if they had other impairments, such as sensory/proprioceptive impairments or communication difficulties. Treatment sessions Table 5 provides information on how therapists delivered the intervention. Gaming was most likely to take place in therapy units (60%) once or twice per week (53%) for 30 min or less (51%). Patients were most likely to play on their own (46%) but pairs (21%) and groups also played (16%), and two-thirds (77%) required some form of adaptation such as positioning of the gaming console.
Number
66
61
127
Sent to occupational therapists Sent to physiotherapists
Sent in total
Returned from occupa- 58 tional therapists Returned from 54 physiotherapists Returned in total 112
Adverse events
Surveys
Table 1. Survey responses.
Surveys
Response Number rate
Total number of therapists in professional teams
Total number of assistants included in professional teams
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Number using commercial Number using commercial gaming for stroke upper gaming for stroke upper limb rehabilitation limb rehabilitation
DOI: 10.3109/17483107.2015.1005031
Half of therapists using gaming (51%, 29/57) reported that some of their stroke patients experienced adverse events. Fatigue was the most common effect reported by therapists (45%, 13/29) followed by stiffness (10%, 3/29) and pain (7%, 2/29). In addition, three therapists (10%, 3/29) highlighted other adverse events, which included feelings of having exercised, frustration, increased muscle tone and feeling childish.
Discussion Principal findings A high survey response rate was achieved (88%) and results indicated that nearly one-fifth of therapists (18%) used commercial gaming devices for stroke upper limb rehabilitation. Our findings also suggest that 61% of therapists would use commercial gaming devices should equipment be available. The most commonly used gaming device for stroke upper limb rehabilitation was Nintendo Wii (reported to be used by 83% of therapists using gaming), which is also consistent with other surveys [17,20]. The popularity of Nintendo Wii can also be seen
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Table 2. Why therapists used commercial gaming. Theme
Description
Fun and meaningful activity
Gaming is a fun and meaningful activity which patients enjoy. It motivates patients to participate in their rehabilitation and offers variety. Of particular use for younger stroke patients. ‘‘to be able to give a fun alternative to more traditional treatment methods’’ (Participant No. 105) Gaming can be played with others encouraging social interaction and competition. ‘‘as part of group therapy within day hospital, makes exercise less serious, good feedback for patient’’ (Participant No. 44) Encourages upper limb movement and co-ordination as well as developing other skills, such as balance, stamina, strengthening and function. ‘‘it can be a good way of encouraging movement using a fun activity’’ (Participant No. 80) Families often have access to gaming and patients could continue rehabilitation at home ‘‘easy to set up and use, allows patients to see improvement, patients can use with family if they have console at home, well tolerated by patients, cost effective’’ (Participant No. 48)
Socialisation Practising movements
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Self-practice
Table 3. Perceived disadvantages of using commercial gaming within stroke upper limb rehabilitation. Theme
Description
Lack of evidence base
Lack of a clear evidence base that supports use ‘‘research is limited’’ (Participant No. 118) Older stroke patients do not like working with computers/may struggle to use technology such as gaming. ‘‘elderly population do not like working with computers/unfamiliar with technology’’ (Participant No. 5) Availability of equipment/cost, space and time. Focus on functional tasks/discharge planning. Additional training required. ‘‘time taken to set up, space for equipment and secure storage’’ (Participant No. 12) ‘‘we make only limited use because we don’t all know how to use them ourselves’’ (Participant No. 110) Concerns regarding quality of movement achieved, risk of compensatory movements/increased tone. Could exclude stroke patients with cognitive/visual problems, games were too fast/complex therefore frustration would be experienced. Difficulties measuring outcomes, stroke patients did not always follow instructions on use. ‘‘maintaining balance/safety awareness during games such as Wii sports, not over reaching etc.’’ (Participant No. 2) A simulated activity not always related to function. Tasks completed not real life and less relevant to practice. ‘‘unless they are familiar with gaming it is not very functional and therefore not very relevant’’ (Participant No. 63)
Unfamiliarity for older stroke patients Organisational barriers
Games too difficult for rehabilitation Games not functional
Table 4. Patient population (who were reported to use gaming with therapists). Age Length of time post stroke Level of upper limb impairment Additional impairments
49 yrs or under: 25% (14/57) 56 mths: 72% (41/57) Near normal mvmt: 53% (30/57) Cognitive: 26% (15/57)
50–70 yrs: 30% (17/57) 6 mths–1 yr: 5% (3/57) Weak/unco-ordinated: 37% (21/57) Communication: 35% (20/57)
71 yrs+: 4% (2/57) 1 yr+: 33% (19/57) Weak/isolated mvmt: 2% (1/57) Sensory: 37% (21/57)
Any age: 40% (23/57) Any length: 11% (6/57) Any types: 11% (6/57) Perceptual: 19% (11/57)
Visual: 19% (11/57)
Table 5. Format of treatment sessions. Location Aim of session
Ward: 19% (11/57) Assessment: 4% (2/57)
Number of players Frequency
Individual: 46% (26/57) Every day: 2% (1/57)
Duration (per session) Adaptations made:
30 mins: 51% (29/57) Handset (velcro/tubigrip): 33% (19/57)
Therapy area: 60% (34/57) Upper limb function: 39% (22/57) Pairs: 21% (12/57) Once/twice per week: 53% (30/57) 31–60 mins: 21% (12/57) Gameplay (positioning): 44% (25/57)
within our recent systematic review [18] where 9 of the 19 studies included in the review employed this device (other studies looked at a range of consoles/devices). In addition, our survey identified use of alternative gaming devices, such as Xbox Kinect (reported to be used by 14% of therapists), Sony Playstation (4% therapists) and iPad (1 therapist). No other surveys appear to have reported
Home: 9% (5/57) Upper limb mvmt: 46% (26/57) Groups: 16% (9/57) Three/four per week: 4% (2/57) 60 mins: 0% No adaptations: 33% (19/57)
Any location: 0% All aims: 9% (5/57) Any number of players: 14% (8/57) All frequency: 0% All duration: 0% Both handset and gameplay: 2% (1/57)
use of alternative gaming devices within stroke upper limb rehabilitation. Despite the popularity of Nintendo Wii as a rehabilitation intervention it would appear that use within the UK might be inconsistent. McHugh et al. [17] in their survey of 53 English stroke units reported that only two stroke units used Nintendo Wii
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DOI: 10.3109/17483107.2015.1005031
for stroke upper limb rehabilitation. This seems to indicate a large variation in practice between different geographical areas in the UK and differences to Australian stroke units [20], where 76% of stroke units had access to Nintendo Wii. Therapists reported that they were most likely to use Nintendo Wii gaming console once or twice per week with sessions lasting 30 min or less (never more than 60 min). This is in sharp contrast to research studies where an average of 180 min of gaming per week is reported [18]. In a recent randomized control trial, Rand et al. [21] identified that one-hour of gaming within stroke rehabilitation achieved on average 271 active purposeful movements (in comparison to 48 within traditional therapy). In addition, Abdullahi et al.’s [22] systematic review highlighted that the number of upper limb movements required for neuroplasticity is in the region of 300–800 repetitions. Given that the aim of using commercial gaming devices for stroke upper limb rehabilitation is to achieve intense and repetitive practice, it would suggest that this aim is not being met within many practice settings. The lack of time available for rehabilitation is highlighted by McHugh et al. [17], who found that staffing levels and face-to-face contact times for therapy in some stroke services are suboptimal. Given time available for stroke upper limb rehabilitation and the low priority that can be placed on this aspect of recovery [23], it could be questioned if therapists are able to offer the same level of high-intensity/repetitive task-specific practice delivered within research literature. Limitations This study has achieved a high response rate (88%) and could therefore be considered as representative of current practice within Scotland. However, Scotland is only one geographical area of the UK and given the results of other surveys [17] may not reflect practice across the wider stroke rehabilitation community. A large number of acute services were represented (70%), every attempt was made to locate community stroke services but it may be that some services with a small number of therapists were missed. Respondents were often identified by senior managers; therefore, this may have introduced selection bias with managers identifying staff known to be specifically interested in gaming devices. Respondents were, however, asked to complete the survey on behalf of their professional group in their clinical area in order to gather data from a service perspective. However, responses may not have accurately reflected how their colleagues were using commercial gaming. Therapists were also asked to provide information on patient feedback (collecting this information directly from patients would have been more desirable), however, this survey aimed to capture therapists’ opinions of feedback. Finally, commercial gaming is a rapidly developing area with new products regularly entering the marketplace making it difficult for surveys to react and capture rapid changes in practice. Implications for practice To increase the intensity of upper limb rehabilitation within current time constraints, therapists may wish to focus on models of delivery, which include opportunities for self-practice, as highlighted in the National Clinical Guidelines for Stroke [24]. The use of virtual reality systems has been proposed as offering self-practice opportunities [25]. Encouraging self-practice may offer a potential solution, increasing the likelihood of patients achieving the desired amount of intensive and repetitive movements. Minor adverse events were reported by 51% (29/57) of therapists indicating that some patients may experience adverse
Survey of gaming use for stroke upper limb rehabilitation
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events following gaming. The most commonly reported adverse event was fatigue identified by 23% (13/57) of therapists. Other adverse events reported included stiffness (5%, 3/57) and pain (4%, 2/57). Implications for research In designing and planning future studies particular focus should be placed on pragmatic issues identified within our survey including training for therapists, adaptations required for play, sufficient space within rehabilitation units and the lack of emphasis placed on this aspect of recovery by some services. In addition, trial design should examine a dose-response relationship to explore whether current clinical practice is effective. Within our survey, gaming sessions were most likely to take place in therapy areas (60%) with only 9% taking place in patients’ homes. A number of research studies [26–28] have delivered home-based gaming, however, location of therapy is an important consideration for future research if in practice this is difficult to implement. Finally, further research of adverse events is merited to investigate the frequency and impact on rehabilitation.
Conclusion Commercial gaming for stroke upper limb rehabilitation is reported to be used by almost a fifth of therapists in stroke rehabilitation settings across Scotland with three-fifths reporting they would use gaming if available. There appears to be a sharp contrast between the number and length of sessions reported by those using commercial gaming and the dose delivered within clinical trials exploring effectiveness of this intervention. Our evidence suggests that current clinical practice may not be achieving the intense and repetitive task-specific practice, which is the purported aim of gaming devices for stroke upper limb rehabilitation. We recommend further research to explore the effectiveness of current clinical practice using gaming. Adverse events were observed by 51% of therapists and should be carefully recorded and monitored when prescribing use and dosage. Furthermore, in order to increase the intensity of upper limb rehabilitation, we believe there is a need for therapists to explore models of delivery which provide opportunities for self-practice.
Declaration of interest The Nursing Midwifery and Allied Health Professions (NMAHP) Research Unit is supported by the Scottish Government Health Directorate’s Chief Scientist Office. The work presented here represents the view of the authors and not necessarily those of the funding bodies. The authors report no declarations of interest.
References 1. Truelsen T, Heuschmann PU, Bonita R, et al. Standard method for developing stroke registers in low-income and middle income countries: experiences from a feasibility study of a stepwise approach to stroke surveillance (STEPS Stroke). Lancet Neurol 2007;6:134–9. 2. European Stroke Organisation. Stroke Facts 2014. Available from: http://www.eso-stroke.org/eso-stroke/stroke-information/ stroke-facts.html [last accessed 29 Jan 2014]. 3. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics - 2013 update: a report from the American Heart Association. Circulation 2012;127:e2–241. 4. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol 2009;8:741–54.
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5. Goulding R, Thompson D, Beech C. Caring for patients with hemiplegia in an arm following a stroke. Br J Nurs 2004;13: 534–9. 6. Kwakkel G, Boudewijn J, Kollen BJ, Krebs HI. Effects of robotassisted therapy on upper limb recovery after stroke: a systematic review. Neurorehabil Neural Repair 2008;22:111. 7. Lai S, Studenski S, Duncan P, Perera S. Persisting consequences of stroke measured by the Stroke Impact Scale. Stroke 2002;33: 1840–4. 8. Broeks JG, Lankhorst GJ, Rumping K, Prevo AJ. The long-term outcome of arm function after stroke: results of a follow-up study. Disabil Rehabil 1999;21:357–64. 9. Franceschini M, La Porta F, Agosti M, Massucci M. Is health-related quality of life of stroke patients influenced by neurological impairments at one year after stroke? Eur J Phys Rehabil Med 2010;44:389–99. 10. Wyller TB, Sveen U, Sodring KM, et al. Subjective well-being one year after stroke. Clin Rehabil 1997;11:139–45. 11. Morris JH, van Wijck F, Joice S, Donaghy M. Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction. Disabil Rehabil 2013;35:291–9. 12. Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet 2011;377:1693–702. 13. Pollock A, Farmer SE, Brady MC, et al. Interventions for improving upper limb function after stroke (Protocol). Cochrane Database Syst Rev 2013. Art. No.: CD010820. DOI: 10.1002/14651858. CD010820. 14. Farmer S, Durairaj V, Swain I, Pandyan A. Assistive technologies: can they contribute to rehabilitation of the upper limb after stroke? Arch Phys Med Rehabil 2014;95:965–85. 15. Burke J. Video games in stroke rehabilitation. Stroke Matt 2011;6: 4–5. 16. Halton J. Virtual rehabilitation with video games: a new frontier for occupational therapy. Occup Ther Now 2008;9:12–14. 17. McHugh G, Swain I, Jenkinson D. Treatment components for upper limb rehabilitation after stroke. Disabil Rehabil 2014;36: 925–31.
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18. Thomson K, Pollock A, Bugge C, Brady M. Commercial gaming devices for stroke upper limb rehabilitation: a systematic review. Int J Stroke 2014;9:479–88. 19. Edwards PJ, Robers I, Clarke MJ, et al. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev 2009. Art. No.: MR000008. DOI: 10.1002/14651858. MR000008.pub4. 20. National Stroke Foundation. National stroke audit rehabilitation services report. 2012. Available from: http://strokefoundation.com. au/site/media/NSF_Audit-Report_2012_web2.pdf [last accessed 13 Sept 2013]. 21. Rand D, Kizony R, Weiss P. The Sony PlayStation II Eye Toy: lowcost virtual reality for use in rehabilitation. J Neuro Phys Ther 2008; 32:155. 22. Abdullahi A. Is time spent using constraint induced movement therapy an appropriate measure of dose? A critical literature review. Int J Ther Rehabil 2014;21:140–6. 23. Saposnik G, Teasell R, Mamdani M, et al. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle. Stroke 2010;47: 1477–84. 24. Royal College of Physicians. National clinical guidelines for stroke. 2012. Available from: http://www.rcplondon.ac.uk/sites/default/ files/national-clinical-guidelines-for-stroke-fourth-edition.pdf [last accessed 14 Jun 2014]. 25. Laver K, George S, Thomas S, et al. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev 2011. Art. No.: CD008349. DOI: 10.1002/14651858.CD008349.pub2. 26. Flynn S, Palma P, Bender A. Feasibility of using the Sony PlayStation 2 gaming platform for an individual post stroke: a case report. J Neurol Phys Ther 2007;31:180. 27. Christie LK, Kennedy S, Brennan K, et al. Does stroke Wiihab work? Use of the Nintendo Wii for upper limb rehabilitation following stroke. Cerebrovasc Dis 2010;29:2. 28. Mouawad M, Doust C, Max M. Wii-based movement therapy to promote improved upper extremity function post stroke: a pilot study. J Rehabil Med 2011;43:527–33.
Survey of gaming use for stroke upper limb rehabilitation
DOI: 10.3109/17483107.2015.1005031
Appendix 1 - Survey
Commercial Gaming for Stroke Upper Limb Rehabilitaon Your service
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1. What profession do you belong to?
2. What is your main area of work? (Please tick one)
Occupational Therapy
Stroke Inpaent Care
Community Stroke Team
Physiotherapy
Stroke Outpaent Care
Other (Please state):
3. How many therapists and assistants are employed within your main area of work? (Only include staff from your own profession):
Please enter number
5. How many therapists and assistants use commercial gaming for stroke upper limb rehabilitaon within your main area of work? (Only include staff from your own profession):
Therapists:
Assistants:
Please enter number
4a. Which, if any commercial gaming devices are available to use as part of stroke rehabilitaon within your workplace?
Therapists:
(Please ck all that apply)
Nintendo Wii
X-box Kinect
Sony Playstaon
None (please proceed to Q.13)
Assistants:
Other (Please state): b. Which games do you use? Wii Sports
(Please ck all that apply)
Cooking Mama
Eye Toy
Wii Play
Kinect Sports
Other (please state) Your stroke paents 6. Within our workplace we use commercial gaming with stroke paents who are............ (Please ck all that apply) a......
b......
c......
Male
49yrs or under
1 year post stroke
7. Within our workplace we use commercial gaming with stroke paents whose upper limb movement can be described as…. (Please ck all that apply)
8. Within our workplace we use commercial gaming with stroke paents who are also affected by.... (Please ck all that apply)
Near normal movement and coordinaon of the impaired upper limb
Cognive impairments
A range of weak and/or uncoordinated movements of the impaired upper limb
Sensory or propriocepve impairments
Small, weak isolated movements of the impaired upper limb
Visual problems
Communicaon difficules
Perceptual problems
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Within your workplace how do you use commercial gaming? . 9. Commercial gaming is used ……………..(Please ck all that apply) a….
b….
With individual paents
On the ward
With pairs
Treatment of UL Funcon
In therapy area
With groups
Treatment of UL Movement
In paent’s home
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c…. For assessment
e….
f….
Every day
For ≤ 30 mins per session
Once or twice per week
For 31-60 mins per session
Three/four mes per week
For ≥ 60 mins per session
With adaptaons to handset (use of velcro/tubigrip)
With adaptaons to gameplay (paent posion)
Without any adaptaons
10. Have stroke paents ever reported any adverse effects from using commercial gaming? (Please ck all that apply) Pain
Sffness
Fague
No adverse effects reported
Other (Please state):_________________________________________________________________ 11. What feedback do paents give on the use of commercial gaming as part of their upper limb rehabilitaon? (Please give as much detail as you can):
12. Why does your service use commercial gaming as part of upper limb rehabilitaon?
Connue on another page if necessary
Please proceed to Queson 14
(Please give as much detail as you can):
Your opinions on the use of commercial gaming for stroke upper limb rehabilitaon. 13. If commercial gaming devices were available would you use them for stroke upper limb rehabilitaon?
14. In your opinion what are the advantages and disadvantages of using commercial gaming for stroke upper limb rehabilitaon?
If, Yes Which device would you use? Advantages:
If No
Why not?
Disadvantages:
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE PLEASE RETURN IN SAE TO: Kae Thomson, NMAHP Research Unit, Buchanan House, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA
Tel: 0141 331 8456
