The Feasibility and Appropriateness of Utilising the Nintendo Wii during Stroke Rehabilitation to Promote Physical Activity.
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The Feasibility and Appropriateness
of Utilising the Nintendo Wii during
Stroke Rehabilitation to Promote
Physical Activity.
Project Report
December 2011
A report produced by Liverpool John Moores University
Dr Toni Hilland
Dr Rebecca Murphy
Prof. Gareth Stratton
1Contents Page
List of Tables and Figures, Acronyms 4
Chapter 1. Introduction 5
1.1 Incidence and Prevalence 5
1.2 Importance of Physical Activity 5
1.3 Levels of Physical Activity 5
1.4 Wii – Rehabilitation 6
Chapter 2. Aims and Objective 7
2.1 Aim 7
2.2 Objectives 7
Chapter 3. Methods 8
3.1 Participants and Recruitment 8
3.2 Design and Methods 8
3.2.1 Stroke Care Practitioners 8
3.2.2 Stroke Patients 9
3.3 Data Preparation and Analysis 10
Chapter 4. Research Findings: Stroke Care Practitioners 12
4.1 Importance of Physical Activity 13
4.1.1 Physical 13
4.1.2 Psychological 14
4.2 Barriers to Physical Activity 14
4.2.1 Physical 15
4.2.2 Psychological 15
4.2.3 Environmental 15
4.3 Benefits and Best Practise of Employing the Wii with Stroke Patients during 16
Rehabilitation
4.3.1 Physical 17
4.3.2 Cognitive 17
4.3.3 Psychological 17
4.3.4 Social 18
4.3.5 PA 18
4.3.6 Therapy 19
4.3.7 Patient 19
4.3.8 Wii games 19
4.4 Challenges of Employing the Wii with Stroke Patients during Rehabilitation 20
4.4.1 Physical 21
4.4.2 Psychological 21
4.4.3 Patient 21
4.4.4 Wii games 22
Chapter 5. Research Findings: Stroke Patients 23
5.1 Physical Activity 24
5.2 Stroke Patients’ perceived benefits of employing the Wii during rehabilitation 25
5.3 Challenges faced by Stroke Patients when using the of employing the Wii during 26
rehabilitation
5.3.1 Physical 27
5.3.2 Social 27
5.3.3 Psychological 28
5.3.4 Environment 29
5.3.5 PA & Sport 29
5.4 Wii games 30
5.4.1 Wii Games 31
5.4.2 Game Design 31
2Chapter 6. Emergent themes 33
6.1 Practitioners 33
6.2 Patients 33
Chapter 7. Summary 34
7.1 Study limitations 34
7.2 Recommendations for future practise 35
7.3 Recommendations for future research 35
Chapter 7. References 36
Appendices 38
3List of Tables and Figures
Tables Page
Table 1. Descriptive characteristics of the sample 23
Figures Page
Figure 1. Stroke care practitioners’ views upon the importance of PA for stroke patients 12
Figure 2. Stroke care practitioners’ views upon the barriers to PA for stroke patients 14
Figure 3. Stroke care practitioners’ view upon the benefits of employing the Wii with stroke 16
patients during rehabilitation
Figure 4. Stroke care practitioner’s views upon the barriers of employing the Wii with stroke 20
patients during rehabilitation
Figure 5. Stroke patients’ average PA counts pre and post test 23
Figure 6. Stroke patients’ average steps pre and post test 24
Figure 7. Stroke patients’ average minutes with device off, standing, lying and sitting, pre 24
and post test
Figure 8. Stroke patients’ views upon the benefits of employing the Wii during rehabilitation 25
Figure 9. Stroke patients’ views upon the challenges of employing the Wii during 26
rehabilitation
Figure 10. Stroke patients’ views upon the Nintendo Wii’s games 30
Acronyms
OT: Occupational therapist
PA: Physical Activity
Physio: Physiotherapist
4Chapter 1 – Introduction
1.1 Incidence and Prevalence
Stroke is a preventable and treatable disease, and is the third most common cause
of death in the UK after myocardial infarction and cancer (Department of Health,
1999). It is a major health problem, accounting for over 56,000 deaths in England
and Wales in 1999, which represents 11% of all deaths (Mant et al., 2004). Most
people survive a first stroke, but often live with significant physical disabilities
manifested by reduced ability to perform activities of daily living (Mercier et al., 2001).
This in turn adversely affects quality of life (Nichols-Larsen et al., 2005). More than
900,000 people in England are living with the effects of stroke, with half of these
being dependent on other people for help with everyday activities (National Audit
Office, 2005).
1.2 Importance of Physical Activity
Physical activity in stroke survivors can result in improved recovery and increased
independence (Gordon et al., 2004; Kinne et al., 1999). Studies to date have
documented physiological, psychological, sensorimotor, strength, endurance, and
functional benefits from physical activity engagement (Macko et al., 2001; Potempa
et al., 1995; Weiss et al., 2000).
1.3 Levels of Physical Activity
Physical activity levels are reportedly low during inpatient stroke rehabilitation (Ada
et al., 1999; Bernhardt et al., 2007). In addition, Rand et al. (2009) reported that
outpatients did not meet the recommended levels of physical activity. Following
completion of conventional rehabilitation stroke patients adopt or return to a
sedentary lifestyle (Paolucci et al., 2001). Physical activity levels following a stroke
may be influence by several factors. These include stroke severity, depression,
fatigue, physical endurance, cognition and learning ability (Gordon et al., 2004).
Strategies for increasing physical activity levels in stroke patients should therefore be
wide-ranging. Those that do not rely on one-to-one supervision by a therapist that
are potentially transferable to other settings may be the most successful (Ada et al.,
1999; Rand et al., 2009).
51.4 Wii – Rehabilitation
Physical rehabilitation after stroke is a costly, resource intensive and time consuming
process (Jutail et al., 2003; Leder et al., 2008; Teasell et al., 2009). Intensive and
prolonged therapy must be provided to a large number of people with often limited
resources (Crosbie et al., 2007). There has been an exponential growth in the
availability of new technologies in clinical settings. Exergaming technology
represents a range of products that have been used in clinical and care settings for
the purposes of rehabilitation and to promote engagement in physical activity. The
Nintendo Wii has been used with diverse clinical populations, including hospitalised
patients (Crotty et al., 2011; Gargin & Pizzi, 2010), children and adolescents with
cerebral palsy (Deutsch et al., 2008; Snider et al., 2010), burn and nonburn patients
(Fung et al., 2010), patients with depression (Rosenberg et al., 2010) and stroke
patients (Leder et al., 2008; Saponsnik et al., 2010a, 2010b). Exergaming technology
(e.g., Nintendo Wii) has also been used to increase opportunity for and enjoyment of
physical activity in non-clinical populations (Graves et al., 2008a; Graves et al.,
2008b). The Wii is accessible at a relatively low cost, without requiring special
resources, assistance, or transportation to a specific facility (Crotty et al., 2011;
Saposnik et al., 2010).
6Chapter 2 – Aim and objectives
2.1 Aim
This study aimed to explore the feasibility and appropriateness of utilising the
Nintendo Wii to encourage PA in stroke patients. Patient and practitioner
perspectives were sought.
2.2 Objectives
1. To explore the views and opinions of stroke care practitioners on
utilising the Nintendo Wii in stroke rehabilitation.
2. To explore the views and opinions of stroke patients on utilising the
Nintendo Wii in stroke rehabilitation.
3. To explore the influence of the Nintendo Wii on stroke patients’ PA
levels.
7Chapter 3 – Methods
3.1 Participants and Recruitment
A total of 15 stroke care practitioners (physiotherapists, n=9; occupational therapists,
n=5), and a PA co-ordinator) from Broadgreen University Hospital and Clatterbridge
Hospital participated in the study. Practitioners volunteered to take part in the
interviews. Furthermore, 26 stroke patients (23 males) from the stroke units within
Broadgreen University Hospital (n=10) and Clatterbridge Hospital (n=16) participated
in the study. Patients were selected by their stroke care practitioners, if they felt that
their patients would benefit from using the Nintendo Wii during supported discharge
in the home setting. Patients were asked to participate if it was their first stroke; if
they required rehabilitation in relation to balance, upper limb, ataxia, perceptual
deficits and deconditioned patients. Exclusion criteria involved patients who were not
suitable for using the Wii (as judged by the healthcare team), for example patients
who had significant communication and/or significant cognitive deficits. Ethical
approval was sought from NREC and LJMU.
3.2 Design and Methods
3.2.1 Stroke Care Practitioners
Focus groups (n=4) and interviews (n=7) were used to explore stroke care
practitioners perspectives of using the Nintendo Wii during stroke rehabilitation. Data
was collected between April and June 2011 in a non-clinical location within the
stroke units. To ensure the same basic line of enquiry was taken with each
practitioners a semi-structured interview schedule (Appendix A) was developed.
Questions related to practitioners perspective concerning the importance of PA,
barriers to PA, views on using the Wii in stroke rehabilitation to increase PA, the
potential for integrating the Wii during usual care effectively, the potential benefits
and challenges of using the Wii and the types of patients the Wii may be most
effective/feasible with. Each focus group or interview lasted between 15 and 46
minutes and were recorded using a Dictaphone. All were conducted and analysed by
the same researcher. After three months of sampling, categories emerging from the
analysis of the interviews began to repeat and no new categories were emerging.
8This was taken to indicate that the most significant issues had been identified and
sampling was discontinued.
3.2.2 Stroke Patients
The stroke patients’ (n=26) PA was objectively assessed for three consecutive days
using ActiGraph accelerometers (Model GT1M, ActiGraph LLC, Pensacola, FL), at
the beginning of their home based rehabilitation (before the Wii was set-up), and
upon completion of the 6 week home based trial with the Wii. The ActiGraph is small
and lightweight and is the most commonly objective tool with which to assess
physical activity (Corder et al., 2008). The ActiGraph is a uni-axial accelerometer that
measures vertical acceleration and deceleration between the magnitudes of 0.05-2g.
The accelerometer enables the monitoring of human motion (frequency and
intensity), to be filtered and converted to a numerical value (counts) and these
counts are subsequently summed over a specified time interval (epoch). The
recorded counts for each epoch represent the intensity of the activity undertaken
during that time period. At the end of each epoch, the summed value is stored in the
memory and the ActiGraph is automatically reset to zero. In this study, a 5 second
epoch was used to collect the raw data to provide a more detailed picture of the
patients’ physical activity patterns.
Accelerometers are motion sensors that capture information regarding the intensity,
frequency and duration of physical activity (Rowlands et al., 2006). Acceleration is
defined as the change in velocity over time; therefore accelerometers assess
physical activity through the body’s acceleration (Corder et al., 2008; Freedson et al.,
2005). The stroke patients wore the ActiGraph accelerometer over their right hip
(anterior to the iliac crest) which was secured with an elastic belt. To maximise the
quality of the data, strategies were employed to encourage compliance. The stroke
patients were given simple written and verbal instructions to wear the monitor over
their right hip, making sure the belt was tight enough to stop the monitor from
flapping about but not so tight that it is uncomfortable, to wear it all day from waking
up to bedtime only removing the monitor for sleeping, bathing, showering and
swimming. Patients were also instructed to go about their normal activities whilst
wearing the monitor.
9With regards to the PA data, at the end of the data collection period data were
downloaded using Actilife software (ActiGraph LLC, Pensacola, FL). This produced
individual files, linked according to participant, containing movement counts and step
counts recorded at each 5 second interval. Furthermore, the inclinometer feature
indicated the orientation of the device during each 2 second epoch (0–device off/not
being worn, 1–participant standing, 2–participant lying horizontal, 3–participant
sitting). Wilcoxon Signed Rank tests were applied to test for differences between pre
(PA levels at home without the Wii) and post scores (PA levels at the end of 6 weeks
with the Wii at home). Statistical significance was set at p< 0.05, and all analyses
were conducted using SPSS 17.0 for Windows.
The stroke patients were also interviewed at the end of their 6-week home based
trial with the Wii, to explore their views and experiences. These took place between
June – December 2011within the patients’ home. A semi-structured interview
schedule (Appendix B) was implemented, comprising of the same general topics;
views and experiences of utilising the Wii during home and hospital based
rehabilitation, Wii’s influence upon physical, social, emotional and mental well-being
and potential advice to other stroke patients and stroke care practitioners.
Opportunities were given at the end of each session for the patients to make
comments about issues that had not been covered. Each interview lasted between 7
and 28 minutes and were recorded using a Dictaphone. All were conducted and
analysed by the same researcher.
3.3 Data Analysis and Preparation
All interviews and focus groups were transcribed verbatim for analysis. Transcripts
were imported into Nvivo 2.0 software programme, and subjected to thematic
analysis using a recommended process (Boyatzis, 1998; Marshall & Rossman, 2006)
as outlined below:
1. Transcripts were read and re-read to get an overall feel of the material,
allowing the researcher to get familiar with the data.
2. The data were categorised into broad themes, by identifying recurring, similar
and underling themes.
3. Initially a deductive approach was employed as interviews contained similar
material, where findings were interpreted based on the interview schedule.
104. An inductive approach was then employed, creating and categorising new
themes from data that did not fit the pre-determined categories.
5. Data were then organised schematically to assist with interpretation of the
higher and lower order themes.
6. To aid the credibility and trustworthiness of the results, analyses and
interpretations of the data were discussed and checked with the research
team.
11Chapter 4 – Research Findings (Stroke care practitioners)
4.1 Importance of PA
PHYSICAL PSYCHOLOGICAL
Prevention Functionality Health & Fitness Motivation Self-efficacy Mood
“So it is all “It improves function so “It helps with recovery if "It just gives them a “I think part of “If you can get
geared towards by improving aspects they have got a good level sense of motivation exercise is promoting them involved
that, you know like balance, strength, of fitness, and lots to do and self- self-efficacy” (Physio) which increases
because as well co-ordination and range with like muscle tone and empowerment really I mood and
it’s to try and of movement in certain things, you know it helps think, if they can motivation from
decrease the risk joints, you are going to with some of the finer participate in some that point of view”
factors isn’t it, to make a patient feel strength training” (OT) form of activity it might (Physio)
prevent them more confident, and make them feel a little
from having more able to complete more normal again”
another stroke” functional activities like (Physio)
(Physio) something simple like
getting up from a chair,
getting in and out of bed
or standing by a sink
and being able to wash”
(Physio)
Figure 1. Stroke care practitioners’ views upon the importance of PA for stroke patients
12The stroke care practitioners brought up two major themes with regards to the
importance of PA for stroke patients (Figure 1), including physical and psychological
benefits.
4.1.1 Physical
Physical advantages included general health and fitness, prevention from a further
event and increased functionality;
“I mean it’s really important in day to day life but we definitely advocate it and
we tend to work on individual joints and getting facilitation to get muscles that
are weak more active” (Physio).
4.1.2 Psychological
Psychological gains of participating in PA incorporated mood, self-efficacy and
motivation;
“Well I think one of things is if people aren’t doing much with their time then
they’ll just loose the motivation to do anything, so I think it’s really important to
keep them active, to keep them motivated to get better” (Physio).
134.2 Barriers to PA
PHYSICAL
Unable Dependent Fatigue Therapy-driven
“Stroke “They are not “I would say “Some have said ENVIRONMENTAL
patients are mobile on the about that they don’t want
quite ward so they are 99.9% of to put their energy Practitioners Stimulation Institutionalised
inactive, on a lot more the stroke into activities and
the ward it dependent in patients that they just want to
might be terms of people I have save it for physio” “There isn’t time “Patients come “They become quite
because taking them to treated in (PA co-ordinator) for other people in and they are reliant upon constant
they aren’t places or getting my career to help them to on the ward for instruction and
physically things in place for will be active” a significant prompts, in hospital
capable to them or assisting complain of (Physio) length of time they tend to get things
fully them, they can’t fatigue, I and there isn’t done for them, they
participate” really do that think it is a much stimulus become
(Physio) independently” recognised for them really” institutionalised a little
(Physio) symptom” (Physio) bit and then they are
(Physio) back on their own two
feet they may feel lost,
as they’ve got no one
to tell them how to do
it, when, where”
PSYCHOLOGICAL (Physio)
Depression Motivation Cognition Self-efficacy Fear
“They usually “Like if they’re “If someone has “Self-efficacy’s “I think fear as
quote about 60% not interested got cognitive usually quite low. well, because
of S patients will or lacking in problems, that So I think a lot of patients are
suffer from motivation” kind of thing it is that mindset” frightened that if
depression in the (OT) following the (Physio) they start engaging
early stages of stroke, that it’s in physical activity
their post-S, and often quite that potentially
it’s kind of difficult to engage they may have
understandable” them” another stroke”
(Physio) (OT) (Physio)
Figure 2. Stroke care practitioners’ views upon the barriers to PA for stroke patients
14The stroke professionals also highlighted numerous barriers to PA engagement for
stroke patients (Figure 2), comprising of physical, psychological and environmental
barriers.
4.2.1 Physical
They suggested that patients may be physically unable or too fatigued, “a lot of
people after having a stroke will feel tired and fatigued” (Phyio). Furthermore, it was
proposed that patients become de-conditioned and overly dependent upon
practitioners, whilst some are so focused upon physio that they don’t want to expend
energy on other activities;
“some people can be really focused as well on just therapy, and that’s another
thing what I’ve come across they don’t want to do anything else but therapy”
(PA co-ordinator).
4.2.2 Psychological
The main psychological barriers included depression and motivation which are
obviously related;
“Well the big thing is motivation, that’s one of the big things really because
there is a massive link with stroke and depression and it can be developed
quite quickly, so obviously your motivation goes alongside that and so
sometimes people aren’t very keen to do anything at all” (OT).
Other psychological barriers involved patients not having the cognitive ability to
engage in PA, a lack of self-efficacy, and fear, “there’s possibly always an underlying
fear that if they do too much it might cause another stroke” (Physio).
4.2.3 Environmental
Finally, environmental barriers of a lack of stimulation in hospital, practitioners not
having the time to assist patients who want to be more active and patients becoming
institutionalised;
“Some people get into a very patient role as soon as they come into hospital
and so almost expect to be waited on when they are in hospital and they go
into this I am ill role and don’t want to, or don’t expect to be doing much during
the day” (Physio).
154.3 Benefits and best practise of employing the Wii with stroke patients during rehabilitation
PA PHYSICAL Visual COGNITIVE PSYCHOLOGICAL
“It just keeps “I think it works “I suppose at “On Brain “The patients’ faces light
them active and on balance, it’ll the same time Training to up because it is fun, it is
it provides them work on co- you could be work on interesting and engaging”
with a good ordination, and asking well can cognitive
level of it’ll work on you see the aspects like
exercise muscle whole game, focused
intensity which strength” and if not well attention and
is really (Physio) you’ve got to sustained
important” move your attention”
(Physio) head and scan (Physio)
and then you
could use it as
THERAPY PATIENT more of a SOCIAL
teaching tool”
“They Experience Type Age (Physio) “About “I know one
participated visual problems family in
and tolerated a so you know particular they
“I think most “I could “We are would all come
lot longer those sorts of
appropriate for probably now in and they
session than patients where
probably see it getting a would have a
what we would you have to
people who might lot massive
have probably scan, so they
have some have more younger bowling game
done are looking
experience of benefit for generation all together, so
otherwise” around the
using computer the of patients the patient, his
(Physio) whole screen”
games or who community unfortunat mum and dad,
are at least patients, ely; it’s (OT)
brother and
WII GAMES open to using because something sister and they
computer of the level they can were all like
“It’s more games” they are relate to” playing it
interactive so (Physio) at” (Physio) together, it’s
you maybe get (Physio) that kind of
a lot more out thing when you
of people” (OT) know it’s good,
“The visual to it because that
is really good, guy in particular
the TV, the he wouldn’t do
feedback” anything at all”
(Physio) (OT)
Figure 3. Stroke care practitioners’ views upon the benefits and best practise of employing the Wii with stroke patients during rehabilitation
16Overall the stroke care practitioners emphasised a whole host of benefits of
employing the Wii with stroke patients during rehabilitation (Figure 3), for example;
physical, cognitive, psychological, social and participatory benefits.
4.3.1 Physical
Hypothesised physical benefits comprised of core stability, co-ordination, muscle
strength, endurance, motor re-learning, exercise tolerance and weight transfer, “I’ve
done bits on here with people with physical problems, upper limb problems and co-
ordination problems” (OT). The major physical benefit mentioned by all of the
practitioners that were interviewed, was balance;
“I’ll tend to use it for patients who have balance problems to improve their
balance using the balance board and all the different games for that, working
on people’s balance and core stabilities which are obviously inherent things
that we work towards as physio’s” (Physio),
“Those that have got good activity who need a bit of strengthening and mainly
have balance problems which are affecting things like their walking or ability
to climb up and down the stairs, so mainly using the Wii Fit board which I
love” (Physio).
4.3.2 Cognitive
Practitioner’s emphasised cognitive gains of employing the Big Brain Academy game
on the Wii with stroke patients as an OT stated, “in the community it’s great for
people with cognitive problem, absolutely the brain training is really, really good.”
They expressed that this game could lead to improved concentration, attention and
the ability to problem solve, “I think it’s something to get them engaged, to explore
and problem solve” (OT), and, “I liked the Brain Academy, the fact that they have got
to sit and concentrate on something for a period of time that was good” (OT).
4.3.3 Psychological
A range of psychological advantages were discussed in the practitioner interviews
and focus groups. For example a physio remarked that the Wii may improve patients’
mood and motivation;
17“I think it will boost mood and motivation, I think it will give them a sense that
they are doing something worthwhile and that they are achieving something in
their day, it might give them something to look forward to.”
Furthermore, motivation may be enhanced as the Wii is viewed positively by the
patients, “it helps with motivation because its fun, it’s enjoyable” (Physio), and;
“Certainly from an enjoyment point of view it was always like an enjoyable
treatment session, you always like got a smile and a laugh, which you don’t
get quite a lot of the time really because these patients are often quite low and
it’s something that’s a bit fun but you are still working on the goals, which is
what’s important really” (OT).
Finally, practitioners also mentioned that the Wii may boost self-esteem and
confidence, “doing something like this may improve their confidence to be able to do
more things independently” (Physio).
4.3.4 Social
The stroke care professionals discussed an array of social advantages consisting of
interaction, stimulation, engagement and benefits in terms of incorporating family
and friends;
“It was also nice because with one person in particular they were able to bring
family in and he had grandchildren, and his grandchildren came in and could
play with him on it, and they knew how to set it up and it just really boosted his
mood, and from then on it just really gave him a bit of a spurt and made him
see what he wanted to achieve, so I think for a mood enhancer that was a
really positive experience with the family” (Physio).
4.3.5 PA
In addition, practitioners commented that the Wii could aid and engagement in PA
and exercise;
“A lot of the evidence is trying to get people more active and giving them more
independence to facilitate their own exercise and facilitate their own home
exercise plans, and the Wii is doing that so you need to encourage it in the
sense that it’s promoting that” (Physio).
184.3.6 Therapy
It was also suggested that the Wii may facilitate therapy sessions, as it is something
different and patients have been more compliant and participate in longer sessions;
“like the balance work and working on weight transfer that kind of stuff, quite
often the patient didn’t really realise that that’s what you were working on if
they are just playing a game like they are not thinking too much about what
they are working on, which is always the best way as you are getting more
automatic movement then” (OT).
In addition, the majority of the practitioners commented that the Wii will be a, “really
handy adjunct,” “it would give us another tool to our belt,” and, “it definitely has a role
alongside other approaches to kind of just mix your treatments up a little bit.”
4.3.7 Patient
All of the stroke care practitioners agreed that the Wii will play a role depending on
the type of patient. It was suggested that those patients that it will be most useful for
involve higher level, community patients and those with good activity, ““I suppose
that’s the higher level patients, and I guess it’s going to suit many of the other client
groups really” (Physio). Most of the stroke care professionals agreed that the Wii will
be more successful with younger patients, who will be able to relate and engage with
it;
“I’m probably thinking more about our younger patients that we are getting in
now and I think I can see the benefit, I think it’s possibly giving us another way
of engaging them and getting them motivated” (Physiotherapist).
Furthermore, several practitioners commented that the Wii may be more appropriate
for those who have had previous experience and an interest in gaming, “I think it’s
very dependent on the patient really, if they have an interest in like computers and
games and have done stuff like that before” (OT).
4.3.8 Wii games
Various positive themes surfaced with regards to the Wii and its games, for example
that it’s interactive, visual, goal-led and provides feedback.
194.4 Challenges of employing the Wii with stroke patients during rehabilitation
PSYCHOLOGICAL PHYSICAL PATIENT WII GAMES
“People might get “In terms of Experience Type Age “People might
offended from what the their negative get offended
Wii is saying, like you’re behaviours, so from what the
“I have tried to “Patients “If
not doing good enough, encouraging Wii is saying,
use it once that might someone
you’re unbalanced, or poor patterning, like you’re not
before with struggle are is maybe
you’ve got a high Wii Fit bad selectivity doing good
someone who people with more
age” (OT) of muscles, it enough, your
had never used cognitive elderly,
could unbalanced,
computer problems, and you
encourage your rubbish or
games before people that know it’s
what we call you’ve got a
and they didn’t can’t follow all a bit
high tone” high Wii Fit
really things, that new
(Physio) age” (Physio)
understand and have visual technology
to be honest it problems then I
wasn’t very obviously if don’t know
successful” they can’t how much
(Physio) see the they would
screen, or actually
language use it”
problems, (OT)
people who
can’t
express or
receive
information,
so it’s not
for
everybody”
(Physio)
Figure 4. Stroke care practitioners’ views upon the challenges of employing the Wii with stroke patients during rehabilitation
20The stroke professionals also highlighted a number of challenges of employing the
Wii with stroke patients during rehabilitation (Figure 4), for example; physical,
psychological, patient age and experience.
4.4.1 Physical
The practitioners stated that the Wii has the potential to have adverse effects on
rehabilitation, resulting in poor muscle patterning and selectivity, high tone,
inattention and neglect;
“What if they’re doing bad patterns of movement repetitively not under
supervision then it’s going to go against everything we’re trying to achieve”
(Physio),
“You don’t want to encourage bad muscle selectivity, so by getting a patient to
just hold it and play tennis for example, they might be using that tennis in any
which way they possibly can just to get the movement out of their arm, which
will be encouraging the wrong muscles to work at the wrong time, as opposed
to the right muscles kicking in at the right time, so it might encourage bad
selectivity or poor muscle patterning” (Physio).
4.4.2 Psychological
They also suggested that the Wii may reduce mood and cause frustration if patients
are unsuccessful or unable to play the game;
“If the person you are using it with doesn’t grasp it, can’t play it, doesn’t win,
they’re going to feel worse, like more low because they can’t compete in the
activity” (Physio).
4.4.3 Patient
It was commented upon that the Wii may not be appropriate for patients for different
groups of patients. For example, lower level patients with dense heavy weaknesses
and those with severe cognitive, communication and visual problems;
“I think maybe certain patients with either communication problems in terms of
their perception and understanding, like they can’t really follow commands, if
somebody has got significant problems in terms of their understanding, then
you are never going to be able to explain to them what they need to do” (OT).
21It transpired from the practitioner focus groups and interviews that there may be
barriers with regards to employing the Wii with older patients, “The elderly they just
see computer games and think no no” (PA co-ordinator)
It also surfaced that it may not be very successful for those who have had little or no
experience, as an OT stated, “There are some patients who wouldn’t even use a
computer.”
4.4.4 Wii games
A number of therapists commented that the feedback from the Wii games maybe
quite damaging, “it could really hurt someone” (OT), and;
“Yeah with the feedback, with patients that are already depressed and low
mood, it’s not exactly a mood enhancer” (Physio).
22Chapter 5 – Research Findings (Stroke patients)
5.1 Physical Activity
Participant characteristics are presented in Table 1. The females were generally
older, from less deprived areas and further on from their stroke than the males. With
regards to the two hospitals, those patients from Clatterbridge were on average
younger, from less deprived areas and further on from their stroke compared to the
patients from Broadgreen.
Overall sample Males (n=23) Female (n=3) Clatterbridge Broadgreen
(n=16) (n=10)
Age (years) 57.84 ± 14.68 55.15 ± 13.08 78.47 ± 9.41 55.62 ± 13.72 61.39 ± 16.20
Deprivation score 11535.31 ± 10599.87 18708 ± 14899.88 ± 6152 ±
10645.11 ±10346.07 12321.26 10738.95 8380.91
Deprivation rank 35.51 ± 32.77 32.63 ± 31.85 57.59 ± 37.93 45.87 ± 33.06 18.94 ± 25.80
Post stroke .33 ± .43 .34 ± .45 .19 ± 0.14 .38 ± .53 .24 ± .19
(years/months)
Table 1. Descriptive characteristics of the sample (n = 26; mean ± SD)
Physical activity was assessed utilising accelerometers, at the beginning of their
home based rehabilitation before the Wii was set-up (pre), and on completion of the
6 week home based programme with the Wii (post). As shown below in Figure 5,
there was a statistically significant increase in the samples average PA counts, from
pre to post test, z = -2.33, p = .02, with a medium effect size (r = .35).
*
Figure 5. Stroke patients’ average PA counts pre and post test
23The patients’ average steps pre and post the 6 week home trial with the Wii, is
shown below in Figure 6. A Wilcoxon Signed Rank test revealed a statistically
significant increase in the samples average steps, from pre to post test, z = -2.29, p
= .02, with a medium effect size (r = .35).
*
Figure 6. Stroke patients’ average steps pre and post test
Table 7 below depicts the patients’ average minutes with the accelerometer off,
standing, lying and sitting, pre and post test. Both standing and lying time increased
with post test, by 6.56 and 13.63 minutes respectively. In addition, sitting time
decreased on average by 63.38 minutes, however no significant differences were
found.
Pre
Post
Figure 7. Stroke patients’ average minutes with device off, standing, lying and sitting, pre and post
test
245.2 Stroke patients’ perceived benefits of employing the Wii during rehabilitation
COGNITIVE SPORT & PA ENVIRONMENT PHYSICAL SOCIAL PSYCHOLOGICAL
“The brain trainer was “When I was using the “If it starts raining you “I’m able now to walk “Yeah I played with “Oh and it certainly
very helpful with my Wii I found my heart know you’ve always around without my my wife, my relieves boredom, it
memory and things” was beating faster, I got the Wii and you walking cane and I’m grandchildren, son certainly does stop the
found it made my could go on that, and moving limbs I thought and daughter-in-law boredom instead of
“It’s good because it body work harder, so you’re in relatively I’d never ever use and they had a go on looking at the TV all day,
concentrates the mind yes it was exercise I safe environment and again” it with me, and we all you can actually do
as far as I’m wouldn’t have you can exercise” really enjoyed it as something”
concerned” otherwise had” “My leg was like a family entertainment, it
“You don’t need to go stump, you know like was really good, it’s “You’ll find even small
“It gave me an edge, a out of the house to do a tree stump and I got nice to see when the successes make you feel
competitive edge so I it and you’re not the movement in my family get involved very good, and feeling
really felt like I reliant upon knee back” with you as well” good about yourself is
belonged to this world somebody else to do great yeah, it is a good
instead of shut out it” “When the kids are thing”
from it” there they would
encourage me, so I’d
enjoy the social
element of it with the
family”
Figure 8. Stroke patients’ views upon the benefits of employing the Wii during rehabilitation
255.3 Challenges faced by Stroke patients when using the of employing the Wii during rehabilitation
TECHNOLOGY SOCIAL PSYCHOLOGICAL ENVIRONMENT PHYSICAL
“If you’re older like me “And playing with It was frustrating at “A de-motivator would “It is hard there’s been
and you’re learning to others doesn’t always times and I was ready to be if it was sunny in sometimes where I’ve
play on this kind of help your confidence, throw the thing across the garden, I’d want to gone a bit overboard”
machine for the first they are nearly always the room” be out there not stuck
time, then it is a better than you” inside” “Yes, I pushed myself
challenge” “Sometimes I was too far, and I was
“I must say he was a abysmal and failed “I would rather get out really aching from
“I suddenly felt that I very reluctant horribly and that really and about on a nice head to foot the next
needed a bit of participant in games undermines you a little day and do what day”
exercise, I’d just go for where I would have bit and makes you feel limited physical activity
a walk, the Wii liked to have a go with like a failure” I can do outside rather
wouldn’t come first on him, you know I than being in the
my list of things, always had to drag house playing on the
whether that’s a him to do it, so he Wii”
generation thing or hasn’t been great in
what I don’t know” that way”
Figure 9. Stroke patients’ views upon the challenges of employing the Wii during rehabilitation
26After 6 weeks of having the Wii in place at their homes, the stroke patients
highlighted several key benefits of employing the Wii during rehabilitation (Figure 8),
for example; physical, PA, cognitive, psychological and social benefits. In contrast,
the stroke patients also drew attention to numerous challenges and barriers of
employing the Wii during rehabilitation (Figure 9), for example; frustration,
technology, and social issues.
5.3.1 Physical
The patients believed that the Wii assisted them with their physical progress and
recovery;
“I knew it would help me to progress and basically that’s why I really got into
using the Wii,”
“It aids me to get better and back to my normal self again, if it wasn’t for the
Wii I wouldn’t have come this far.”
They emphasised in particular that the Wii had improved their balance, strength and
movement;
“The good thing about it is that it makes you feel or be aware of balance, your
muscles, I think mainly balance and getting your centre of gravity,”
“The exercises have helped me with my balance, my stance and my core
muscles,”
“Boxing was my favourite because I could feel it moving more and using more
muscles, I could feel more power going through the shoulders,”
“You can do the boxing on the Wii, and that’s good because it’s getting more
movement out of your arm and you use both arms.”
However, a couple of patients revealed that they got carried away on the Wii, and
pushed themselves too hard which resulted in pain and injury;
“Because playing games is such a pleasurable activity, I found that I got
carried away and tried things that were unsuitable and as a result of that I
pulled a muscle in my back which was very painful,”
“I was absolutely exhausted.”
5.3.2 Social
From a social point of view the patients took pleasure from playing on the Wii with
their family and friends;
27“I did enjoy playing with others, I played with my daughters when they came
round or my wife’s sisters, I enjoyed it more playing with others than just being
on it by myself, because I just enjoy being with people and interacting, it’s just
more social.”
Overall the patients enjoyed the support, competition and interaction that comes
from playing with others;
“Support from the family was perhaps the biggest thing, my son and daughter
took turns being with me and supporting me on the Wii, and so on many
occasions it’s been sort of like my daughter saying to me ‘I’ve got to go out his
afternoon so we’ll do your Wii exercises now,’ and that has been another
significant driving force. I’m sure I would have ended up doing them but it’s
just a bit of a push,”
“I played sometimes with my wife and my brother in law; we had a bit of a
competition. I liked playing with others.”
In contrast others preferred to play by themselves;
“Yes, my son and he was very tender and considerate and said ‘oh, I’m
hopeless’ but I knew quite well he was just pretending, and the family did that
they pretended that they found it terribly difficult and then amazingly
progressed in about 2 minutes to being on difficult, so I was like ‘go out, I
don’t want to know you’ it didn’t help with my confidence at all.”
5.3.3 Psychological
Psychological benefits of the Wii from the stroke patients’ perspective involved
enhanced mood, motivation, self-confidence, and enjoyment. It was mentioned that
the Wii, “was quite a mood changer, having something positive to do, it helped with
mood changes and got rid of low feelings.” The patients also thoroughly enjoyed
being successful and improving, for example, “it makes you want to get on a chair
and cheer and tell the whole world,” and, ““I thoroughly enjoyed it.”
Conversely, frustration was a common theme to emerge from the interviews with the
stroke patients. They mentioned being frustrated when they were unsuccessful,
didn’t progress, or were unable to play a particular game;
“Some of the games were frustrating when I couldn’t do it or I couldn’t get the
right answer, that’s when it gets frustrating,”
28“Mostly frustrated, because I wasn’t getting any scores over 650 on the brain
game thing, and I couldn’t get past that point so that frustrated me quite a lot.”
5.3.4 Environment
It was emphasised that the Wii provides a convenient opportunity to engage in
physical activity and exercise even when the weather is bad outside, as they can
participate in the Wii in their safe home environment;
“When the weathers bad and it’s raining and pouring, you’ve got the likes of
the Wii to go on.”
However, it was also revealed that if the weather was good, patients would select to
participate in other activities outside, rather than going on the Wii;
“I now play on it much less because I’m getting out and about more, and I
would prefer to do that than play on the Wii to be honest,”
“If I get up and the sun’s out I’d go out and have a walk.”
5.3.5 PA and Sport
The stroke patients suggested that the Wii made them exercise and be physically
active, which they may not have achieved if the Wii wasn’t in place. In addition, they
suggested that it made their body and heart work harder than normal;
“From a physical point of view I’m pretty much convinced that if it wasn’t for
the Wii I wouldn’t be doing anything which helps me break a sweat, where as
with the Wii even if you are just playing the games its giving me some
physical activity, which I wouldn’t have got otherwise.”
Furthermore, numerous patients revealed that the Wii had revived their sporting
memories and that it had encouraged them to get back into sport;
“I’ve used it mainly for the golf, I found it very very helpful, in fact so helpful
that I’ve had seven games of golf in the last four weeks and I actually won a
competition, so it was very helpful getting my swing back into operation and
that. When I went out the first time I didn’t hit any bad shots so obviously it’s
helped me properly, because it explains what you are doing and puts you right
with the swing and all of that, the degree of angle that you get with shots and
speeds, so yeah it’s been very good,”
“I think I always liked sport and this gave me a chance to get back into some
of it.”
295.4 Wii games
Wii Sports & Wii Fit Big Brain GAME DESIGN
Sports Resort Academy
“I’ve used mainly the Feedback Problems
“Yeah I liked the balance board, so I’ve “I preferred to do the
sword fencing one, I gone for the slalom ones that would “Some of the
liked the boxing one, skiing, the marble tilt challenge me the “I get to see my games were too
and I liked the bowls” board thing and the most, the balls going end result fast and
one where they aim into the net were very straight away happened to
“Golf was one of the the footballs at you, challenging, also the with the quickly, like the
games I played, one they’ve been the main ones where you had feedback, Ski Slalom and
of my favourites and 3 that I’ve had a go at” to distinguish what which boosts your reaction
table tennis” kind of animal or plant my confidence” time needs to be
“I just done the keep was coming up, that so quick in order
fit because I thought it was particularly “It was insulting to get through the
was more important to challenging” sometimes like posts, so
me, doing the with your sometimes you
exercises and the “I tended to want to weight and all find yourself
yoga, and the muscle test myself on the of that, like you throwing yourself
building” brain trainer, because need to lose around in a
I hoped as well as this and you hazardous
helping my eyes, that need to lose manner, just
it also might help my that” trying to get
memory and train my through the posts
brain in the things that rather than trying
I have seemed to to just do
have lost. So I used purposefully”
the brain trainer the
vast majority of the
time”
Figure 10. Stroke patients’ views upon the Nintendo Wii’s games
30The stroke patients provided a great deal of feedback with regards to the Wii games
they were provided with, including the Wii Fit, Wii Sports and Sports Resort and the
Big Brain Academy.
5.4.1 Wii games
On the Wii Fit the patients used the yoga exercises, muscle workouts, balance
games, aerobics exercises and the body test. The balance games were highlighted
as the most popular and helpful;
“Oh yeah the balance games I found that very good, it helped me get my
balance back and I mainly played the bubble in the water game where you’ve
got to go down the river and sway from side to side and forwards to direct it,
and I got to quite a good level,”
“I thought the table tilt was the best for me, and really it was quite a good help
for my balance.”
Furthermore, it was mentioned that the daily body test, which creates a Wii Fit Age,
was made use of;
“When you first do it each day it goes through tests to get your Wii Fit Age,
that’s a bit of an eye opener and has helped me, just doing those test things.”
A number of the games on the Wii Sports and Sports Resort package were utilised
by the patients, “I thought they were very very good games,” the most popular
included golf, bowling and boxing;
“Golf that was one of the games I played, one of my favourites.”
Also, the patients seemed to thoroughly enjoy the Big Brain Academy game, as they
thought it assisted their cognition and memory;
“Very positive, especially on the brain trainer thing I really enjoyed that. I like
the different activities on the brain trainer, like memory and the birds in the
cage.”
5.4.2 Game Design
Stroke patients outlined some challenges relating to game design. These included
issues relating to feedback provided during the games and the speed with which the
games progressed. Most of the patients throughout their interviews discussed the
31feedback that is provided from the Wii. Some suggested it is very positive in that it
allows you to visually track your score and observe improvements;
“It gives me a lot of information and feedback which made me feel better
because it actually tells you how well you are doing and then it tells you how
you can improve,”
“I found out with the Wii it was visual so I could see what I was doing and
followed that little red dot on the balance tests, which meant a great deal to
me.”
In contrast, some patients felt the feedback was upsetting, frustrating and insulting;
“The Wii Fit put my age at 71 and that was a bit of a kick in the teeth, I was a
bit miffed at that, and it also tells you if you are overweight or not and that can
be a bit of a blow,”
“It’d tell me I’m rubbish.”
Problems with the Wii and games, involved it being too difficult, fast or unsuitable for
the stroke patients
“Sometimes it was a little bit frustrating in that it’ll ask you to step onto the
board, and because I’m slow moving my left foot and finding my left foot
position, it would mean that the board would have to be reset again and I’d
have to step off and start again, so that would happen a few times,”
Some of the balance games I didn't enjoy, the one with the bubble on the lake,
it’s very unforgiving and so I gave up on that one.”
32Chapter 6 – Emergent themes
6.1 Practitioners
• Two major themes arose with regards to the importance of PA for stroke
patients, including physical (e.g., prevention, health & fitness), and
psychological benefits (e.g., motivation, mood).
• They also highlighted numerous barriers to PA engagement for stroke
patients, comprising of physical (e.g., fatigue), psychological (e.g.,
depression), and environmental barriers (e.g., institutionalised).
• The stroke care practitioners cited a large number of benefits of employing the
Wii during rehabilitation;
o Physical (balance, co-ordination, endurance and motor re-learning),
o Cognitive (concentration, attention, and ability to problem solve),
o Psychological (mood, motivation, enjoyment, confidence),
o Social (interaction, engagement),
o Therapy (adjunct, different, tool to belt),
o Participation (stimulation, independent exercise, self-management).
• Furthermore, they suggested the Wii may be more appropriate for higher
level/community patients who have good activity, younger patients, and those
who have had prior experience of the Wii or gaming.
• Major challenges of employing the Wii with stroke patients were highlighted by
the practitioners;
o Physical (neglect, high tone, inattention, poor muscle patterning),
o Psychological (mood, frustration).
6.2 Patients
• PA levels (counts/steps) increased from pre to post test, when the Wii was in
the patients’ homes.
• They highlighted numerous benefits of employing the Wii;
o Physical (balance, strength, recovery, movement),
o Cognitive (concentration, memory, focus, perception)
33Chapter 7 – Summary
7.1 Study limitations
• Findings of the research cannot be generalised but provide points for
consideration when using the Nintendo Wii during stroke rehabilitation.
• The lack of a control group means that the increases in PA and patient
improvements cannot be causally attributed to the Wii.
• Physio’s and OT’s recruited stroke patients that were interested and keen on
utilising the Wii at home, which may have biased the results.
7.2 Recommendations for future practice
The findings of this research can contribute to recommendations for successful use
of the Nintendo Wii during stroke rehabilitation, these may include;
1. The Wii can provide another tool to practitioners’ belts.
2. The Wii should be utilised with certain patients (e.g., higher level, community
patients, good activity) and not others (e.g., lower level, dense heavy
weakness, severe cognitive/communication/visual problems).
3. It can aid patients both physically and cognitively (e.g., balance,
concentration), and can boost patients psychologically and socially.
4. A bespoke Wii package for stroke patients from a therapeutic perspective
could be developed, for example re-design of games with slower speeds and
lower levels.
5. Self-paced games should be used in the first instance to familiarise
participants with the technology.
6. There needs to be a support structure in place to help patients set-up and
become comfortable with the Wii (there may be unintended consequences in
terms of staff time/resources/training.
7. It may be more effective utilising the Wii with patients who have prior
experience of computers and technology.
347.3 Recommendations for future research
1. A Randomised Controlled Trial to compare the effectiveness of the Nintendo
Wii to other methods of rehabilitation.
2. A Randomised Controlled Trial to determine the effect of the Nintendo Wii on
physical activity in stroke survivors.
3. Develop a bespoke package for stroke patients and then conduct and
determine its effectiveness in practice
4. To conduct a further study that is similar in nature to the current study but
utilising the Wii therapeutically in a range of populations (i.e. falls patients,
diabetics, cancer patients).
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