Using Commercial Video Games for Upper Limb Stroke Rehabilitation: Is This the Way of the Future? Eva Pietrzak, PhD, Cristina Cotea, BSc (Hons), and Stephen Pullman, Lt Cdr, RAN Centre for Military and Veterans’ Health, Research Coordination Unit, The University of Queensland, Mayne Medical School, Herston, Queensland, Australia Background: The increasing number of people living with poststroke sequelae has stimulated the search for novel ways of providing poststroke rehabilitation without putting additional stress on overburdened health care systems. One of them is the use of commercially available technology and off-the-shelf video games for hemiparetic upper limb rehabilitation. Methods: The MEDLINE, EMBASE, and Cochrane Library databases were searched using key word synonyms for stroke, upper limb, and video games. Included studies investigated upper limb stroke rehabilitation using commercially available consoles and video games, reported outcomes that included measures of upper limb functionality, and were published in a peer-reviewed journal written in English. Results: Thirteen studies were identified – 6 published as full articles and 7 as abstracts. Studies were generally small and only 3 were randomized. The gaming systems investigated were the Nintendo Wii (n = 10), EyeToy PlayStation (n = 2), and CyWee Z (n = 1). The Nintendo Wii appears to provide the greatest benefits to patients, with improvements seen in upper extremity function measures such as joint range of motion, hand motor function, grip strength, and dexterity. Three studies indicate that video therapy appears to be safe and that long-term improvements continue at follow-up. Conclusions: At present, the evidence that the use of commercial video games in rehabilitation improves upper limb functionality after stroke is very limited. However, this approach has the potential to provide easily available and affordable stroke rehabilitation therapy in settings where access to therapy is limited by geographical or financial constraints. Key words: poststroke rehabilitation, review, upper limb, video games, virtual reality
pproximately 60,000 new or recurrent strokes occur in Australia per year, with around 14% of these resulting in death.1 Of the patients who recover, between 55% and 75% continue to experience motor deficits that result in daily activity limitations.2,3 The main deficits in areas such as walking, eating, toileting, communication, and socialization are associated with reduced quality of life. After hospitalization, many patients must undergo prolonged periods of intense rehabilitation and may require long-term home care.3 The total financial burden of stroke in Australia is estimated at $2.14 billion a year.1 The main focus of early rehabilitation is on recovery of deficits such as aphasia, dysphagia, and paralysis. Hemiparesis affects about 80% of stroke patients, and Australian statistics show that 37.5% of stroke patients have incomplete use of their arms or fingers after stroke rehabilitation.3
A
There is increasing evidence that a neurologically injured brain has the potential for remodeling if it undergoes proper rehabilitation training.4 For neuroplasticity to occur, this training has to be challenging, repetitive, task specific, motivating, salient, and intensive. 5 Clinical guidelines recommend that poststroke rehabilitation provides as much practice as possible within the first 6 months after a stroke. The intensity of poststroke rehabilitation that should be provided after discharge from the hospital is estimated to be a minimum of 1 hour of active practice a day, at least 5 days a week, and this rehabilitation practice should involve a multidisciplinary team.1 Current resources are generally unable to fulfill the intensity requirement. The shortage has limited the provision of adequate and appropriate rehabilitation services to stroke patients in various
Corresponding author: Stephen Pullman, Centre for Military and Veterans’ Health, Research Coordination Unit, The University of Queensland, Mayne Medical School, Herston Road, Herston, QLD Australia 4006; fax: +61 7 3346 4878; e-mail: [email protected]
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regions, especially in rural areas. In Australia, 107 hospitals provide stroke rehabilitation services; however, there are only 13 dedicated rehabilitation stroke units. Both the hospitals and dedicated stroke units are situated mainly in metropolitan areas (89% and 92%, respectively).6 As a result, up to 25% of patients are discharged from hospital without any follow-up plans for continued rehabilitation.6 The most important limitations to conventional rehabilitation may be summarized as follows7: • Limited availability depending on geography • Time-consuming • Labor- and resource-intensive • Dependent on patient compliance • Dependent on transportation to special facilities • Initial benefits often underappreciated by stroke survivors • Dependent on health insurance and/or outof-pocket expenses after the initial phase of treatment In view of these limitations, novel strategies targeting motor skill recovery have recently been developed, including activities using robotics, virtual reality (VR), and Internetenabled technologies.7 Two major systematic reviews published in 2011 investigated the use of VR in stroke rehabilitation.7,8 Laver et al8 investigated a wide range of outcomes, such as upper limb function, balance, gait, global motor function, cognitive function, activity limitation, participation restriction, and quality of life in randomized controlled trials (RCTs) only. The use of VR and interactive video gaming, when compared with the same dose of conventional therapy, significantly improved arm function (based on 7 studies with 205 participants) and activities of daily living (based on 3 studies with 101 participants). Overall, few adverse events were reported across studies, and those reported were relatively mild. There was insufficient evidence to reach conclusions about other outcomes.8 The review by Saposnik and Levin 7 includes studies of both randomized controlled and observational design and concentrated on the outcome of upper limb function. In the pooled analysis of 5 RCTs, the improvement in motor impairment was significantly greater after using VR than after conventional therapy. In
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observational studies, there was a significant 15% reduction in motor impairment and a 20% improvement in motor function after VR, compared with baseline.7 Based on the results of these reviews, it can be concluded that VR and video game applications are potentially useful new interventions that can be effective in poststroke rehabilitation of the upper extremity. However, it is unclear which characteristics of VR are most important for rehabilitation, and it is not known whether the effects are sustained in the longer term. The main advantages of using VR for stroke rehabilitation are summarized by Laver et al8: • Virtual tasks have been described as more interesting and enjoyable, compared with traditional rehabilitation, thus encouraging higher numbers of repetitions. • Grading of tasks and immediate feedback provided in real time optimize motor learning. • VR allows practice of tasks that are unsafe in the real world, such as crossing the street. • Many programs are designed to be used without supervision; therefore, an increased dosage of therapy can be provided without increased staffing levels. The most VR programs evaluated in the reviews were specifically designed for the studies and are therefore not available to other clinicians. In contrast, commercial gaming consoles and off-the-shelf video games are being increasingly used in clinical practice. A recent audit of urban stroke rehabilitation facilities in Australia showed that 61% of these facilities had purchased a Nintendo Wii system.6 Since the publication of the 2 systematic reviews, which cover articles published up to 2010, new studies evaluating the use of VR rehabilitation have been published. There are currently no publications summarizing this development. We were interested in home-based stroke rehabilitation that could supplement conventional therapy or be a substitute when conventional therapy is not available because of insufficient resources or patient noncompliance. The aim of this review is to examine the latest literature on the feasibility and effectiveness of commercial gaming consoles and off-the-shelf video games in upper limb stroke rehabilitation.
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Methods The MEDLINE, EMBASE, and the Cochrane Library databases were searched using a combination of MESH terms and key words. The search included the following terms: virtual reality OR video gaming OR videogames OR Nintendo Wii OR PlayStation OR dance AND stroke AND upper limb OR upper extremity. Databases were searched separately, and the results were combined. The search was performed in March 2012. Additionally, reference lists of identified publications and the Evidence-Based Review of Stroke Rehabilitation module 10 were screened for relevant articles. The review was restricted to peerreviewed journal articles published in English. To be included, the studies had to meet the following criteria: investigate stroke rehabilitation, include use of commercially available consoles and video games, provide reports on outcomes that included measures of upper limb functionality, and follow any study design with the exception of single-person case studies. The search identified 139 references. Forty-nine articles, which appeared potentially relevant, were downloaded as full text. Twenty-two articles were excluded as reviews. Reasons for the exclusion of the remaining articles were as follows: Video games that were not available commercially were used (n = 8); the feasibility of the system, rather than patient outcomes, was investigated (n = 2); outcomes outside the scope of this study were investigated (n = 2); or they were abstracts of studies for which full-text articles were available (n = 2). Results Thirteen articles were included. Of these, only 6 were full articles9-14; the remaining 7 were abstracts.15-21 The study characteristics and outcomes are presented in greater detail in Tables 1 and 2. Five studies were performed in Australia,14,15,19-21 and the remaining 8 studies were performed in Turkey,9 Israel,10 Canada,11 Singapore,12 New Zealand, 13 Scotland, 16 the Philippines, 17 and Ireland.18 The gaming system investigated most often was the Nintendo Wii, which was used in 10 studies.
Two studies used the EyeToy PlayStation.9,10 One study used the CyWee Z, a Wii-like gaming system, that was slightly modified by the attachment of handlebars to allow for bilateral exercises.13 Only 3 of the studies were RCTs9,11,17: one was a crossover design,13 and the remaining were observational, with before-after comparison. Two of the observational studies introduced an additional group of healthy subjects who underwent the same therapy as stroke patients.14,19 This was to demonstrate that the improved scores in the game resulted from gains in functionality of the upper limb, not from increased proficiency in playing the game. All studies involved small sample sizes, with the number of stroke patients per study ranging from 215 to 22.11 Five studies were performed on patients in the subacute recovery stage, generally within 3 months of stroke diagnosis9,11,12,15,18; patients in 7 studies were in the chronic stage of recovery,13,14,16,17,19-21 and in 1 study the population included a mix of patients in the chronic and subacute stages.10 Generally, patients in the chronic stage were characterized by moderate function, with the exception of 1 study in which function was defined as very low.21 Patients in the subacute stage were generally treated in inpatient rehabilitation units of their respective hospitals. Patients in the chronic stage were treated as outpatients in various rehabilitation units with the exception of one study in which the entire rehabilitation therapy for some of the patients in the chronic stage was carried out at home.10 In 4 Australian studies, part of the rehabilitation included at-home exercises.14,19-21 Outcomes included a wide range of measures of upper limb and hand functionality, dexterity, and strength. The most common outcome measures included the Wolf Motor Function Test (WFMT) and Fugl-Meyer Assessment (FMA). The details of other outcome measures used are provided in Tables 1 and 2. Outcomes were measured at baseline and directly after the intervention; 3 studies included a follow-up measurement at 1,11 2,20 and 39 months. In the studies that investigated patients in the subacute stage, the VR gaming interventions were added to conventional rehabilitation therapy. In patients in the chronic stage who completed
System: EyeToy PlayStation. All patients received conventional therapy, 2-5 hr/day, 5 days a week, for 4 wk. Additionally: • Intervention: 30 min per day of PlayStation • Control: watching games for same duration without physical involvement Outcome measures: • FIM • Tests were performed at baseline, at 4 wk (post treatment), and 3 mo (follow-up) after treatment. System: PlayStation 2 EyeToy: 2 games—Wishy-Washy and Kung-Fu Intervention: Each game was practiced for 1 min and played for 3 min. After each game, patients filled in the SFQ and rated their perceived exertion. Outcome measures: • Gaming experience: SFQ • Borg’s Scale of Perceived Exertion
N = 20 Design: RCT Participants: Generally, stroke patients in subacute stage; mean time post stroke: 3 mo in intervention group, 5 mo in control group; average age, 61 yr Setting: Inpatient rehabilitation center, Turkey
N = 12 Design: Observational Participants: 7 patients in chronic stage: 1-5 yr post stroke and 5 patients in subacute stage. Patients in chronic stage lived at home, mostly independently. Patients in subacute stage were dependent on others for basic activities and used wheelchairs. Setting: Home or rehabilitation center for patients in chronic stage and hospital for patients in subacute state, Israel.
N = 22 Design: RCT, single-blinded Participants: Stroke patients in subacute stage, < 3 mo from diagnosis; mean age, 61 (41 to 83) yr Completers: 9 in the Wii arm and 8 in the control arm Setting: Inpatient, Toronto Rehabilitation Institute, Canada
Yavuzer et al9 (2008 )
Rand et al10 (2008)
Saposnik et al11 (2010)
System: Nintendo Wii All patients received standard rehabilitation: 1 hr of physiotherapy and another hour of occupational therapy per day, as tolerated. All received 8 intervention sessions of 60 min each over a 14-day period. • VR group played Wii (Sports and Cooking Mama packages, 30 min each). • Recreational Therapy group played cards, bingo, or Jenga. Outcome measures: • Feasibility: total time receiving the intervention • Safety: % of patients with adverse events • Efficacy with WMFT, Box and Block Test, and Stroke Impact Scale • Tests were performed at baseline, after intervention, and at 4 weeks’ follow-up.
Intervention, outcome measures
Study characteristics
Commercial video games in poststroke rehabilitation of upper limbs: Full-text articles
Study
Table 1.
(Continued)
There was no difference in the mean total session time between groups (388 and 364 min in the RT and Wii groups). • There were no serious adverse events in any group. • Compared with Recreational Therapy control subjects, Wii group participants had a significant improvement in mean motor function (WMFT) of 7 sec and grip strength. • At follow-up, the improvements were even larger than those observed directly after therapy.
Stroke patients in the chronic stage: • Enjoyed Kung-Fu more than Wishy-Washy • Had high mean SFQ scores for both games (>26/30) • Perceived exertion as slightly higher for Kung-Fu • All reported fatigue of their weak upper extremity Stroke patients in the subacute stage: • Enjoyed the experience and would like to repeat it • Became frustrated (2 participants) because they could not use their more affected limb to interact with the virtual objects • All had trouble isolating the movements and thus controlling the game properly • Only 1 participant appeared to benefit from these games
Compared with the control group, the EyeToy group showed: • Significant improvement in FIM self-care score (5.5 vs 1.8) • No differences in Brunnstrom stages of motor recovery • No adverse events
Results
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System: Nintendo Wii Sports; games used: boxing, bowling, tennis, golf, and baseball Intervention: All patients received: • conventional rehabilitation (at least 1 hr of occupational therapy and 1 hr of physical therapy daily) • 6 sessions of upper limb Wii exercises, 30 min each, over 2 wk Different games or parts of the game were played in sitting or standing positions, depending on patient’s preferences, upper limb functional capacity, and balance capability. Outcome measures: • FMA of Upper Limb Motor Function • Motoricity Index • visual analogue scale of upper limb pain • a questionnaire on patients’ experience of gaming
N = 20 Design: Observational Participants: Stroke patients in subacute stage, 30 min of additional practice every day and most continued to play Wii after therapy concluded.
• At baseline, stroke patients displayed approximately 50% sensory deficits compared with control subjects. • After therapy, on the more affected side, significant improvements were seen in: • finger-tapping speed (by 18%) • von Frey thresholds (by 92%) • Improvements that did not reach significance were seen in: strength, by 21%; dexterity, by 15%; texture discrimination, by 14%, and forearm position-matching error. • No change was seen on the less affected side.
Results
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their conventional rehabilitation previously, VR interventions were “stand alone” therapies. VR interventions were generally of a 2-week duration and consisted of 30 to 60 minutes of 8 to 12 game-playing sessions. A shorter single session of 4 minutes per game was used in the feasibility study by Rand, Kizony, and Weiss.10 Three studies had a longer duration: 1 had a duration of 4 weeks,9 and 2 had a duration of 6 weeks.16, 17 The most intensive treatment was developed by the Sydney group of McNulty et al.22 The program consisted of formal 1-hour therapist-guided sessions on 10 consecutive weekdays (5 days per week for 2 weeks). These were augmented by home practice that gradually increased in duration from 30 minutes to 3 hours per day over 14 days. A selection of Wii Sports games of golf, tennis, bowling, baseball, and boxing was used. Patients had to alternate games at least every 10 to 20 minutes within each session to avoid overuse discomfort. This protocol has been used in 4 Australian studies performed by the group.14,19-21 In the comparative studies, the control therapy involved receiving the same duration of conventional therapy,15 passively watching VR games,9 or playing non-VR social games.11 Two RCTs, although small, appeared to be of adequate quality, with the allocation concealment being adequate in 1 trial.9 The outcome assessment was blinded in both studies.9,11 Furthermore, 1 of the RCTs included intention-to-treat analyses,11 whereas the other had no missing data.9 It is not possible to assess the quality of the third RCT because of the scarcity of data provided by the abstract.17 The observational trials are subject to the usual biases. Benefits to the patients PlayStation 2 EyeToy
A small observational study showed that the use of the PlayStation 2 EyeToy is feasible in the rehabilitation of patients in both the chronic and subacute stages.10 However, a randomized trial in which the system was used revealed no evidence that it improves poststroke recovery.9 Nevertheless, the trial found a potential to improve a patient’s functional independence with no adverse effects.
CyWee Zii
In one cross-over study, the motor performance as measured by the FMA after therapy was significantly improved compared with baseline, but no changes were found in the mean motor function (WMFT) and other secondary outcomes.13 Wii
In patients in the subacute stage, compared with control subjects, Wii participants showed significant improvements in mean motor function (WMFT) and grip strength (RCT)11 and hand function and fine motor function (9-Hole Peg Test, 2 subjects: 1 VR and 1 control).15 In observational trials, there were improvements in the FMA and Motoricity scores12 and dexterity (timed 9-Hole Peg Test).18 In patients in the chronic stage with moderate function, there were significant improvements in motor function, joint range of motion for upper limb joints (WMFT and FMA scores), and activities of daily living14, 20; median grip strength and 2 of 7 domains of the hand functionality test16; strength, dexterity, and texture discrimination19; and FMA scores.17 In patients in the chronic stage with very low function, the functional movement ability significantly improved in both tests (WMFT and FMA), activities of daily living, and joint range of motion, but not in dexterity.21 Safety
Only 3 studies reported on the safety of the interventions. There were no adverse events in 2 studies.7,18 In one study, investigators reported that patients experienced mild pain, which occurred after 3 of 96 sessions, but the pain did not affect the patients’ participation in the therapy the following day.12 Patient satisfaction
Participants generally found VR gaming enjoyable, 16,12 useful, and comparable to conventional therapy.12 Furthermore, participants had high satisfaction ratings20 and wanted to continue gaming as therapy.12, 20 Some participants continued to play Wii after the formal therapy ended. 20
Commercial Video Games in Stroke Rehabilitation
Discussion The novelty of research on the use of commercial gaming consoles and off-the-shelf video games in upper limb stroke rehabilitation explains the limited number of studies published in the area and the general lack of high-quality evidence. However, published studies do indicate that this therapy may be beneficial, especially therapy with the Nintendo Wii, which appears to show benefits to the patients, including improvements in upper extremity function measures such as joint range of movement, hand motor function, grip strength, and dexterity. Although only a small number (2 to 3) of studies investigated these outcomes, the therapy appears to be safe, with high user satisfaction and improvements lasting up to 3 months. However, the duration of the rehabilitation effects after VR training has been discontinued is crucial and should be determined in controlled follow-up studies in a more systematic way. Careful selection of games and alternating games to avoid overuse discomfort is essential for successful rehabilitation. For example, in the protocol developed by McNulty,22 a selection of Wii Sports games of golf, tennis, bowling, baseball, and boxing was used; games were alternated every 10 to 20 minutes within each session. In a study by Saposnik et al,11 games were selected to promote specific movements, such as shoulder flexion and extension (bowling and tennis), shoulder rotation (tennis), elbow extension and flexion (Cooking Mama), wrist supination and pronation (tennis and Cooking Mama), and wrist flexion and extension and thumb flexion, which were involved in all activities. However, a theory-based selection of games is still lacking. Although one study indicated that practice with the whole arm promoted greater recovery than training of the arm and hand separately,23 a recent systematic review on the use of VR for stroke rehabilitation provided insufficient evidence to draw conclusions regarding the most effective type of VR programs, the most effective dose of therapy, or the time point at which VR programs are best delivered.8 The most appealing aspect of game therapy is the lack of a time limit on the initiation of the therapy. No Australian national data indicate when
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rehabilitation begins for stroke patients.1 There is some evidence coming from one study that some rehabilitation occurs early after a stroke. A group of 64 patients treated in 5 stroke units in the Melbourne metropolitan area were observed within 2 weeks of stroke onset. Between 8:00 a.m. and 5:00 p.m., stroke patients spent more than 50% of their time resting in bed, 28% of their time sitting out of bed, and 13% engaged in activities with the potential to prevent complications and improve recovery of mobility. Patients were alone for more than 60% of the time.24 Because the majority of these patients in the semi-acute stage of recovery were not confined to bed, it appears that they would be good candidates for game rehabilitation to intensify the traditional therapy they were receiving. The hospital stay for stroke patients usually includes the rehabilitation provided in the semiacute stage. Stroke patients are discharged home from the hospital after a median length of stay of 24 days. Approximately 70% of discharged patients continue with further rehabilitation, mainly using outpatient or community rehabilitation services.1 However, access to rehabilitation may be restricted by geography, cost, limited means of transportation, and reliance on formal and informal carers.3 Traditional rehabilitation will continue only for so long, after which stroke patients are forced to live and cope with their functional deficits. At this stage, game therapy may be used to provide rehabilitation that is no longer provided by traditional poststroke care.
Conclusions Although evidence that the use of commercial video games in rehabilitation improves upper limb functionality after stroke is limited, this approach is promising as an add-on therapy or when access to other forms of therapy is restricted. Compared with conventional rehabilitation methods, it is widely accessible and relatively affordable and does not require special resources, assistance, or transportation to a specialized facility. Overall, it has the potential to improve access to poststroke rehabilitation in areas limited by geographical or financial
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constraints. However, well-designed randomized studies investigating the use of commercial video games in upper limb rehabilitation after stroke are needed to obtain conclusive evidence of the therapy benefits.
Acknowledgements This review was undertaken on behalf of and funded by the e-Health Research Unit, UQ Node, CMVH. The authors declare no potential conflicts of interest.
REFERENCES 1. National Stroke Foundation. Clinical Guidelines for Stroke Management 2010. Melbourne, Australia; Author; 2010. 2. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: A systematic review. Lancet Neurol. 2009;8(8):741-754. 3. Australian Institute of Health and Welfare; Senes S. How We Manage Stroke in Australia (AIHW cat. no. CVD 31). Canberra: Author; 2006. 4. Kleim JA, Jones TA. Principles of experiencedependent neural plasticity: Implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008;51(1):S225-S239. 5. Kwakkel G. Impact of intensity of practice after stroke: Issues for consideration. Disabil Rehabil. 2006;28(13-14):823-830. 6. National Stroke Foundation. National Stroke Audit Rehabilitation Services 2010. Melbourne, Australia: Author; 2010. 7. Saposnik G, Levin M, for the Stroke Outcome Research Canada Working Group. Virtual reality in stroke rehabilitation: A meta-analysis for clinicians. Stroke. 2011;42(5):1380-1386. 8. Laver KE, George S, Thomas S, et al. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2011;(9):CD008349. 9. Yavuzer G, Senel A, Atay MB, et al. ’’Playstation eyetoy games’’ improve upper extremityrelated motor functioning in subacute stroke: A randomized controlled clinical trial. Eur J Phys Rehabil Med. 2008;44(3):237-244. 10. Rand D, Kizony R, Weiss PTL. The Sony PlayStation II EyeToy: Low-cost virtual reality for use in rehabilitation. J Neurol Phys Ther. 2008;32(4):155163. 11. 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;41(7):1477-1484. 12. Yong JL, Soon YT, Xu D, et al. A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. J Rehabil Med. 2010;42(5):437-441. 13. Hijmans JM, Hale LA, Satherley JA, et al. Bilateral upper-limb rehabilitation after stroke using a movement-based game controller. J Rehabil Res Dev. 2011;48(8):1005-1013.
14. Mouawad MR, Doust CG, Max MD, et al. Wiibased movement therapy to promote improved upper extremity function post-stroke: A pilot study. J Rehabil Med. 2011;43(6): 527-533. 15. Hawkes A. Wii-rehabilitation for stroke-gimmick or goal achieving? A pilot study evaluating the use of a commercially available games console in improving upper limb function as part of stroke rehabilitation [abstract]. Int J Stroke. 2010;5(Suppl 1):36. 16. Christie LK, Kennedy S, Brennan K, et al. Does stroke Wii HAB work? Use of the Nintendo Wii for upper limb rehabilitation following stroke [abstract]. Cerebrovasc Dis. 2010;29(Suppl 2):254255. 17. Manlapaz DG, Silverio LA, Navarro JA, et al. Effectiveness of using Nintendo Wii in rehabilitation of chronic stroke patients with upper limb hemiparesis [abstract]. Hong Kong Physiother J. 2010;28(1):25. 18. Young AM, NiDhuibh C, Harbison JA, et al. Stroke “Wiihabilitation”: Is the use of the Wii and Wii FIT associated with better rehabilitation outcomes in stroke patients? [abstract]. Cerebrovasc Dis. 2010;29(Suppl 2):252. 19. Bowden J, Lin G, Thompson-Butel A, et al. Changes in post-stroke upper limb sensorimotor function after Wii-based movement therapy. Int J Stroke. 2011;6(Suppl 1):33. 20. McNulty P, Mouawad M, Scheuer S, et al. Wiibased movement therapy, upper limb functional recovery and more [abstract]. Int J Stroke. 2011;6(Suppl 1):26. 21. McNulty PA, Shiner CT, Thompson-Butel AG. Wiibased movement therapy benefits patients with very low function poststroke. Neurorehabil Neural Repair. 2012;26(6):679-680. 22. McNulty PA. Games for rehabilitation: Wiibased movement therapy improves poststroke movement ability. Games Health J. 2012;1(5):384387. 23. Merians AS, Tunik E, Fluet GG, et al. Innovative approaches to the rehabilitation of upper extremity hemiparesis using virtual environments. Eur J Phys Rehabil Med. 2009;45(1):123-133. 24. Bernhardt J, Dewey H, Thrift A, et al. Inactive and alone: Physical activity within the first 14 days of acute stroke unit care. Stroke. 2004;35(4):10051009.
pproximately 60,000 new or recurrent strokes occur in Australia per year, with around 14% of these resulting in death.1 Of the patients who recover, between 55% and 75% continue to experience motor deficits that result in daily activity limitations.2,3 The main deficits in areas such as walking, eating, toileting, communication, and socialization are associated with reduced quality of life. After hospitalization, many patients must undergo prolonged periods of intense rehabilitation and may require long-term home care.3 The total financial burden of stroke in Australia is estimated at $2.14 billion a year.1 The main focus of early rehabilitation is on recovery of deficits such as aphasia, dysphagia, and paralysis. Hemiparesis affects about 80% of stroke patients, and Australian statistics show that 37.5% of stroke patients have incomplete use of their arms or fingers after stroke rehabilitation.3
A
There is increasing evidence that a neurologically injured brain has the potential for remodeling if it undergoes proper rehabilitation training.4 For neuroplasticity to occur, this training has to be challenging, repetitive, task specific, motivating, salient, and intensive. 5 Clinical guidelines recommend that poststroke rehabilitation provides as much practice as possible within the first 6 months after a stroke. The intensity of poststroke rehabilitation that should be provided after discharge from the hospital is estimated to be a minimum of 1 hour of active practice a day, at least 5 days a week, and this rehabilitation practice should involve a multidisciplinary team.1 Current resources are generally unable to fulfill the intensity requirement. The shortage has limited the provision of adequate and appropriate rehabilitation services to stroke patients in various
Corresponding author: Stephen Pullman, Centre for Military and Veterans’ Health, Research Coordination Unit, The University of Queensland, Mayne Medical School, Herston Road, Herston, QLD Australia 4006; fax: +61 7 3346 4878; e-mail: [email protected]
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regions, especially in rural areas. In Australia, 107 hospitals provide stroke rehabilitation services; however, there are only 13 dedicated rehabilitation stroke units. Both the hospitals and dedicated stroke units are situated mainly in metropolitan areas (89% and 92%, respectively).6 As a result, up to 25% of patients are discharged from hospital without any follow-up plans for continued rehabilitation.6 The most important limitations to conventional rehabilitation may be summarized as follows7: • Limited availability depending on geography • Time-consuming • Labor- and resource-intensive • Dependent on patient compliance • Dependent on transportation to special facilities • Initial benefits often underappreciated by stroke survivors • Dependent on health insurance and/or outof-pocket expenses after the initial phase of treatment In view of these limitations, novel strategies targeting motor skill recovery have recently been developed, including activities using robotics, virtual reality (VR), and Internetenabled technologies.7 Two major systematic reviews published in 2011 investigated the use of VR in stroke rehabilitation.7,8 Laver et al8 investigated a wide range of outcomes, such as upper limb function, balance, gait, global motor function, cognitive function, activity limitation, participation restriction, and quality of life in randomized controlled trials (RCTs) only. The use of VR and interactive video gaming, when compared with the same dose of conventional therapy, significantly improved arm function (based on 7 studies with 205 participants) and activities of daily living (based on 3 studies with 101 participants). Overall, few adverse events were reported across studies, and those reported were relatively mild. There was insufficient evidence to reach conclusions about other outcomes.8 The review by Saposnik and Levin 7 includes studies of both randomized controlled and observational design and concentrated on the outcome of upper limb function. In the pooled analysis of 5 RCTs, the improvement in motor impairment was significantly greater after using VR than after conventional therapy. In
153
observational studies, there was a significant 15% reduction in motor impairment and a 20% improvement in motor function after VR, compared with baseline.7 Based on the results of these reviews, it can be concluded that VR and video game applications are potentially useful new interventions that can be effective in poststroke rehabilitation of the upper extremity. However, it is unclear which characteristics of VR are most important for rehabilitation, and it is not known whether the effects are sustained in the longer term. The main advantages of using VR for stroke rehabilitation are summarized by Laver et al8: • Virtual tasks have been described as more interesting and enjoyable, compared with traditional rehabilitation, thus encouraging higher numbers of repetitions. • Grading of tasks and immediate feedback provided in real time optimize motor learning. • VR allows practice of tasks that are unsafe in the real world, such as crossing the street. • Many programs are designed to be used without supervision; therefore, an increased dosage of therapy can be provided without increased staffing levels. The most VR programs evaluated in the reviews were specifically designed for the studies and are therefore not available to other clinicians. In contrast, commercial gaming consoles and off-the-shelf video games are being increasingly used in clinical practice. A recent audit of urban stroke rehabilitation facilities in Australia showed that 61% of these facilities had purchased a Nintendo Wii system.6 Since the publication of the 2 systematic reviews, which cover articles published up to 2010, new studies evaluating the use of VR rehabilitation have been published. There are currently no publications summarizing this development. We were interested in home-based stroke rehabilitation that could supplement conventional therapy or be a substitute when conventional therapy is not available because of insufficient resources or patient noncompliance. The aim of this review is to examine the latest literature on the feasibility and effectiveness of commercial gaming consoles and off-the-shelf video games in upper limb stroke rehabilitation.
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Methods The MEDLINE, EMBASE, and the Cochrane Library databases were searched using a combination of MESH terms and key words. The search included the following terms: virtual reality OR video gaming OR videogames OR Nintendo Wii OR PlayStation OR dance AND stroke AND upper limb OR upper extremity. Databases were searched separately, and the results were combined. The search was performed in March 2012. Additionally, reference lists of identified publications and the Evidence-Based Review of Stroke Rehabilitation module 10 were screened for relevant articles. The review was restricted to peerreviewed journal articles published in English. To be included, the studies had to meet the following criteria: investigate stroke rehabilitation, include use of commercially available consoles and video games, provide reports on outcomes that included measures of upper limb functionality, and follow any study design with the exception of single-person case studies. The search identified 139 references. Forty-nine articles, which appeared potentially relevant, were downloaded as full text. Twenty-two articles were excluded as reviews. Reasons for the exclusion of the remaining articles were as follows: Video games that were not available commercially were used (n = 8); the feasibility of the system, rather than patient outcomes, was investigated (n = 2); outcomes outside the scope of this study were investigated (n = 2); or they were abstracts of studies for which full-text articles were available (n = 2). Results Thirteen articles were included. Of these, only 6 were full articles9-14; the remaining 7 were abstracts.15-21 The study characteristics and outcomes are presented in greater detail in Tables 1 and 2. Five studies were performed in Australia,14,15,19-21 and the remaining 8 studies were performed in Turkey,9 Israel,10 Canada,11 Singapore,12 New Zealand, 13 Scotland, 16 the Philippines, 17 and Ireland.18 The gaming system investigated most often was the Nintendo Wii, which was used in 10 studies.
Two studies used the EyeToy PlayStation.9,10 One study used the CyWee Z, a Wii-like gaming system, that was slightly modified by the attachment of handlebars to allow for bilateral exercises.13 Only 3 of the studies were RCTs9,11,17: one was a crossover design,13 and the remaining were observational, with before-after comparison. Two of the observational studies introduced an additional group of healthy subjects who underwent the same therapy as stroke patients.14,19 This was to demonstrate that the improved scores in the game resulted from gains in functionality of the upper limb, not from increased proficiency in playing the game. All studies involved small sample sizes, with the number of stroke patients per study ranging from 215 to 22.11 Five studies were performed on patients in the subacute recovery stage, generally within 3 months of stroke diagnosis9,11,12,15,18; patients in 7 studies were in the chronic stage of recovery,13,14,16,17,19-21 and in 1 study the population included a mix of patients in the chronic and subacute stages.10 Generally, patients in the chronic stage were characterized by moderate function, with the exception of 1 study in which function was defined as very low.21 Patients in the subacute stage were generally treated in inpatient rehabilitation units of their respective hospitals. Patients in the chronic stage were treated as outpatients in various rehabilitation units with the exception of one study in which the entire rehabilitation therapy for some of the patients in the chronic stage was carried out at home.10 In 4 Australian studies, part of the rehabilitation included at-home exercises.14,19-21 Outcomes included a wide range of measures of upper limb and hand functionality, dexterity, and strength. The most common outcome measures included the Wolf Motor Function Test (WFMT) and Fugl-Meyer Assessment (FMA). The details of other outcome measures used are provided in Tables 1 and 2. Outcomes were measured at baseline and directly after the intervention; 3 studies included a follow-up measurement at 1,11 2,20 and 39 months. In the studies that investigated patients in the subacute stage, the VR gaming interventions were added to conventional rehabilitation therapy. In patients in the chronic stage who completed
System: EyeToy PlayStation. All patients received conventional therapy, 2-5 hr/day, 5 days a week, for 4 wk. Additionally: • Intervention: 30 min per day of PlayStation • Control: watching games for same duration without physical involvement Outcome measures: • FIM • Tests were performed at baseline, at 4 wk (post treatment), and 3 mo (follow-up) after treatment. System: PlayStation 2 EyeToy: 2 games—Wishy-Washy and Kung-Fu Intervention: Each game was practiced for 1 min and played for 3 min. After each game, patients filled in the SFQ and rated their perceived exertion. Outcome measures: • Gaming experience: SFQ • Borg’s Scale of Perceived Exertion
N = 20 Design: RCT Participants: Generally, stroke patients in subacute stage; mean time post stroke: 3 mo in intervention group, 5 mo in control group; average age, 61 yr Setting: Inpatient rehabilitation center, Turkey
N = 12 Design: Observational Participants: 7 patients in chronic stage: 1-5 yr post stroke and 5 patients in subacute stage. Patients in chronic stage lived at home, mostly independently. Patients in subacute stage were dependent on others for basic activities and used wheelchairs. Setting: Home or rehabilitation center for patients in chronic stage and hospital for patients in subacute state, Israel.
N = 22 Design: RCT, single-blinded Participants: Stroke patients in subacute stage, < 3 mo from diagnosis; mean age, 61 (41 to 83) yr Completers: 9 in the Wii arm and 8 in the control arm Setting: Inpatient, Toronto Rehabilitation Institute, Canada
Yavuzer et al9 (2008 )
Rand et al10 (2008)
Saposnik et al11 (2010)
System: Nintendo Wii All patients received standard rehabilitation: 1 hr of physiotherapy and another hour of occupational therapy per day, as tolerated. All received 8 intervention sessions of 60 min each over a 14-day period. • VR group played Wii (Sports and Cooking Mama packages, 30 min each). • Recreational Therapy group played cards, bingo, or Jenga. Outcome measures: • Feasibility: total time receiving the intervention • Safety: % of patients with adverse events • Efficacy with WMFT, Box and Block Test, and Stroke Impact Scale • Tests were performed at baseline, after intervention, and at 4 weeks’ follow-up.
Intervention, outcome measures
Study characteristics
Commercial video games in poststroke rehabilitation of upper limbs: Full-text articles
Study
Table 1.
(Continued)
There was no difference in the mean total session time between groups (388 and 364 min in the RT and Wii groups). • There were no serious adverse events in any group. • Compared with Recreational Therapy control subjects, Wii group participants had a significant improvement in mean motor function (WMFT) of 7 sec and grip strength. • At follow-up, the improvements were even larger than those observed directly after therapy.
Stroke patients in the chronic stage: • Enjoyed Kung-Fu more than Wishy-Washy • Had high mean SFQ scores for both games (>26/30) • Perceived exertion as slightly higher for Kung-Fu • All reported fatigue of their weak upper extremity Stroke patients in the subacute stage: • Enjoyed the experience and would like to repeat it • Became frustrated (2 participants) because they could not use their more affected limb to interact with the virtual objects • All had trouble isolating the movements and thus controlling the game properly • Only 1 participant appeared to benefit from these games
Compared with the control group, the EyeToy group showed: • Significant improvement in FIM self-care score (5.5 vs 1.8) • No differences in Brunnstrom stages of motor recovery • No adverse events
Results
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System: Nintendo Wii Sports; games used: boxing, bowling, tennis, golf, and baseball Intervention: All patients received: • conventional rehabilitation (at least 1 hr of occupational therapy and 1 hr of physical therapy daily) • 6 sessions of upper limb Wii exercises, 30 min each, over 2 wk Different games or parts of the game were played in sitting or standing positions, depending on patient’s preferences, upper limb functional capacity, and balance capability. Outcome measures: • FMA of Upper Limb Motor Function • Motoricity Index • visual analogue scale of upper limb pain • a questionnaire on patients’ experience of gaming
N = 20 Design: Observational Participants: Stroke patients in subacute stage, 30 min of additional practice every day and most continued to play Wii after therapy concluded.
• At baseline, stroke patients displayed approximately 50% sensory deficits compared with control subjects. • After therapy, on the more affected side, significant improvements were seen in: • finger-tapping speed (by 18%) • von Frey thresholds (by 92%) • Improvements that did not reach significance were seen in: strength, by 21%; dexterity, by 15%; texture discrimination, by 14%, and forearm position-matching error. • No change was seen on the less affected side.
Results
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their conventional rehabilitation previously, VR interventions were “stand alone” therapies. VR interventions were generally of a 2-week duration and consisted of 30 to 60 minutes of 8 to 12 game-playing sessions. A shorter single session of 4 minutes per game was used in the feasibility study by Rand, Kizony, and Weiss.10 Three studies had a longer duration: 1 had a duration of 4 weeks,9 and 2 had a duration of 6 weeks.16, 17 The most intensive treatment was developed by the Sydney group of McNulty et al.22 The program consisted of formal 1-hour therapist-guided sessions on 10 consecutive weekdays (5 days per week for 2 weeks). These were augmented by home practice that gradually increased in duration from 30 minutes to 3 hours per day over 14 days. A selection of Wii Sports games of golf, tennis, bowling, baseball, and boxing was used. Patients had to alternate games at least every 10 to 20 minutes within each session to avoid overuse discomfort. This protocol has been used in 4 Australian studies performed by the group.14,19-21 In the comparative studies, the control therapy involved receiving the same duration of conventional therapy,15 passively watching VR games,9 or playing non-VR social games.11 Two RCTs, although small, appeared to be of adequate quality, with the allocation concealment being adequate in 1 trial.9 The outcome assessment was blinded in both studies.9,11 Furthermore, 1 of the RCTs included intention-to-treat analyses,11 whereas the other had no missing data.9 It is not possible to assess the quality of the third RCT because of the scarcity of data provided by the abstract.17 The observational trials are subject to the usual biases. Benefits to the patients PlayStation 2 EyeToy
A small observational study showed that the use of the PlayStation 2 EyeToy is feasible in the rehabilitation of patients in both the chronic and subacute stages.10 However, a randomized trial in which the system was used revealed no evidence that it improves poststroke recovery.9 Nevertheless, the trial found a potential to improve a patient’s functional independence with no adverse effects.
CyWee Zii
In one cross-over study, the motor performance as measured by the FMA after therapy was significantly improved compared with baseline, but no changes were found in the mean motor function (WMFT) and other secondary outcomes.13 Wii
In patients in the subacute stage, compared with control subjects, Wii participants showed significant improvements in mean motor function (WMFT) and grip strength (RCT)11 and hand function and fine motor function (9-Hole Peg Test, 2 subjects: 1 VR and 1 control).15 In observational trials, there were improvements in the FMA and Motoricity scores12 and dexterity (timed 9-Hole Peg Test).18 In patients in the chronic stage with moderate function, there were significant improvements in motor function, joint range of motion for upper limb joints (WMFT and FMA scores), and activities of daily living14, 20; median grip strength and 2 of 7 domains of the hand functionality test16; strength, dexterity, and texture discrimination19; and FMA scores.17 In patients in the chronic stage with very low function, the functional movement ability significantly improved in both tests (WMFT and FMA), activities of daily living, and joint range of motion, but not in dexterity.21 Safety
Only 3 studies reported on the safety of the interventions. There were no adverse events in 2 studies.7,18 In one study, investigators reported that patients experienced mild pain, which occurred after 3 of 96 sessions, but the pain did not affect the patients’ participation in the therapy the following day.12 Patient satisfaction
Participants generally found VR gaming enjoyable, 16,12 useful, and comparable to conventional therapy.12 Furthermore, participants had high satisfaction ratings20 and wanted to continue gaming as therapy.12, 20 Some participants continued to play Wii after the formal therapy ended. 20
Commercial Video Games in Stroke Rehabilitation
Discussion The novelty of research on the use of commercial gaming consoles and off-the-shelf video games in upper limb stroke rehabilitation explains the limited number of studies published in the area and the general lack of high-quality evidence. However, published studies do indicate that this therapy may be beneficial, especially therapy with the Nintendo Wii, which appears to show benefits to the patients, including improvements in upper extremity function measures such as joint range of movement, hand motor function, grip strength, and dexterity. Although only a small number (2 to 3) of studies investigated these outcomes, the therapy appears to be safe, with high user satisfaction and improvements lasting up to 3 months. However, the duration of the rehabilitation effects after VR training has been discontinued is crucial and should be determined in controlled follow-up studies in a more systematic way. Careful selection of games and alternating games to avoid overuse discomfort is essential for successful rehabilitation. For example, in the protocol developed by McNulty,22 a selection of Wii Sports games of golf, tennis, bowling, baseball, and boxing was used; games were alternated every 10 to 20 minutes within each session. In a study by Saposnik et al,11 games were selected to promote specific movements, such as shoulder flexion and extension (bowling and tennis), shoulder rotation (tennis), elbow extension and flexion (Cooking Mama), wrist supination and pronation (tennis and Cooking Mama), and wrist flexion and extension and thumb flexion, which were involved in all activities. However, a theory-based selection of games is still lacking. Although one study indicated that practice with the whole arm promoted greater recovery than training of the arm and hand separately,23 a recent systematic review on the use of VR for stroke rehabilitation provided insufficient evidence to draw conclusions regarding the most effective type of VR programs, the most effective dose of therapy, or the time point at which VR programs are best delivered.8 The most appealing aspect of game therapy is the lack of a time limit on the initiation of the therapy. No Australian national data indicate when
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rehabilitation begins for stroke patients.1 There is some evidence coming from one study that some rehabilitation occurs early after a stroke. A group of 64 patients treated in 5 stroke units in the Melbourne metropolitan area were observed within 2 weeks of stroke onset. Between 8:00 a.m. and 5:00 p.m., stroke patients spent more than 50% of their time resting in bed, 28% of their time sitting out of bed, and 13% engaged in activities with the potential to prevent complications and improve recovery of mobility. Patients were alone for more than 60% of the time.24 Because the majority of these patients in the semi-acute stage of recovery were not confined to bed, it appears that they would be good candidates for game rehabilitation to intensify the traditional therapy they were receiving. The hospital stay for stroke patients usually includes the rehabilitation provided in the semiacute stage. Stroke patients are discharged home from the hospital after a median length of stay of 24 days. Approximately 70% of discharged patients continue with further rehabilitation, mainly using outpatient or community rehabilitation services.1 However, access to rehabilitation may be restricted by geography, cost, limited means of transportation, and reliance on formal and informal carers.3 Traditional rehabilitation will continue only for so long, after which stroke patients are forced to live and cope with their functional deficits. At this stage, game therapy may be used to provide rehabilitation that is no longer provided by traditional poststroke care.
Conclusions Although evidence that the use of commercial video games in rehabilitation improves upper limb functionality after stroke is limited, this approach is promising as an add-on therapy or when access to other forms of therapy is restricted. Compared with conventional rehabilitation methods, it is widely accessible and relatively affordable and does not require special resources, assistance, or transportation to a specialized facility. Overall, it has the potential to improve access to poststroke rehabilitation in areas limited by geographical or financial
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constraints. However, well-designed randomized studies investigating the use of commercial video games in upper limb rehabilitation after stroke are needed to obtain conclusive evidence of the therapy benefits.
Acknowledgements This review was undertaken on behalf of and funded by the e-Health Research Unit, UQ Node, CMVH. The authors declare no potential conflicts of interest.
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