Sensory Processing Disorders (Part 3 of 3)

(More on sensory processing disorder…)

 

School-based therapists recognize the entwined nature of the sensorimotor performance components and program plan accordingly.  The Wii provides another tool for the therapists, allowing them to challenge and grade movement through space as well as encourage targeted actions.  Are any readers using the Wii in your setting? 

 

Therapists must also identify issues in other performance areas such as cognitive and psycho-social.   Manifestations of problems within the cognition and psycho-social arenas will be discussed in future posts.

 

Please post your experiences under the comment section because in sharing your experience, you help increase everyone’s knowledge base.

Sources:

·        The Sensory Processing Disorder Resource Center

 www.sensory-processing-disorder.com/sensory-processing-disorder-checklist.html

·        Kranowitz, CS., Miller, LJ. (2005). The Out-of-Sync Child.  New York, NY. Penguin Group.

·        Bhojne,U, Chitnis, A. (2002). VESTIBULAR DYSFUNCTION IN CHILDREN WITH PERVASIVE DEVELOPMENTAL DISORDER. The Indian Journal of Occupational Therapy. XXXIV(1).3-6. Retrieved from http://medind.nic.in/iba/t02/i1/ibat02i1p3.pdf

 

Sensory Processing Disorders (Part 2 of 3)

(Continued from last post…)

 

More on sensory processing disorder:

• Visual – Refers to the brain’s interpretation of what one sees
• Hypersensitivity – May be sensitive to bright lights and may have difficulty keeping eyes focused on work.
• Hyposensitivity – May have difficulty discriminating between similar shapes, like a square and rectangle or similarly shaped letters like “p”, “q”, “b” and “d”.  Visual processing deficits result in problems described in the previous post on perceptual processing manifestations.  
• Vestibular – Refers to the interpretation of information gathered from the inner ear about one’s position in space, movement and balance.
• Hypersensitivity – May be overly sensitive to motion, avoiding swings or slides.  May get car sick and may be fearful of escalators.   May also demonstrate poor postural control.
• Hyposensitivity – May crave motion.  May spin, jump, run into walls, or purposely fall without the expected negative reaction.  Again, look at the previous posts.  Deficits in this area are closely aligned to deficits classified as motor problems (see October 27,2008 post) as well as perceptual processing problems described in the October 31, 2008 post.
• Proprioceptive – Refers to the interpretation of information gathered from joints and muscles about one’s position in space, movement, pressure and weight.
• May use excessive force when interacting with objects, animals or other people.
• May seek out activities that provide sensory input, like jumping and banging objects. 

 

Please post your experiences under the comment section because in sharing your experience, you help increase everyone’s knowledge base.

Sensory Processing Disorders (Part 1 of 3)

Therapists working with the K-8 population, especially students with diagnoses across the Autism spectrum must be equipped to address sensory processing disorders.  Sensory processing problems impact all areas of function and must be considered on a case by case basis. Subtle differences between children’s abilities require the therapist to individualize treatment protocols.  Components included in the sensory processing performance area are:

 

• Tactile –  Refers to the interpretation of sensory input, including temperature, pressure, pain, and touch, collected from receptors located in the skin
• Hypersensitivity – Tactile defensiveness- may avoid touch
• Hyposensitivity -  Decreased responsiveness to touch- may seek repetitive tactile input
• Auditory – Refers to the interpretation of  sound
• Hypersensitivity – Auditory defensiveness- may be overly sensitive to background sounds
• Hyposensitivity - Decreased responsiveness to sound – may not respond appropriately when called by name, may not be able to locate the source of a sound, or may make repetitive noises for no reason.
• Olfactory – Refers to the brain’s interpretation of  smell
• Hypersensitivity- May be overly sensitive to smells which others may not notice
• Hyposensitivity – May not notice smells others complain about.

 

(Continued next time…)

 

Please post your experiences under the comment section because in sharing your experience, you help increase everyone’s knowledge base.

Using the Wii Therapeutically in a School Setting: PART 2

Therapists working with the K-8 population, including students with diagnoses across the Autism spectrum, will also need to address perceptual processing problems including:

• right-left discrimination (ability to distinguish or identify left and right directionality)
• form constancy (recognition of objects or shapes as the same regardless of size, spatial orientation, or texture)
• position in space (recognition of the spatial orientation of objects in relationship to the surrounding environment)
• body scheme (perception of one’s own body arrangement in relationship to self and environment which facilitates the individual’s ability to orchestrate purposeful movement through space and focused manipulation of objects)
• figure ground (ability to discriminate or isolate a particular object or shape surrounded by or embedded in a varied background)
• depth perception (ability to recognize three dimensions in objects and self while  perceiving the relationships among and judging  the distances between these objects and/or self)
• spatial relations (ability to sense one’s position or place within the environment in relationship to other objects or people as well as the ability to perceive the relationship of one’s own body parts to each other)
• topographical orientation (ability to plan out a route and follow a route through recognition of landmarks, perception of landmark relationships and directional memory)

 Wiihab using activities and games found on the Wii Sports menu, used in conjunction with other more traditional approaches, targets problems children may have with perceptual processing, especially body scheme.     Do any of you have experience using Wii in a school program?  A group of students in NewJersey used Wii with a 13 year old with cerebral palsy.  Wiihab can also be a great tool for the school based therapist for addressing frequently encountered cognitive problems and psychosocial problems.  The next post will clarify those issues.

Using the Wii Therapeutically in a School Setting: PART 1

Jan from Maine writes on October 23, 2008:

Hi There,

I am an OT who would like to use Wii with my kids in the school setting. I am writing a grant for funding this and would like some feedback as to which program might be the best for my K-8 population and with my Autistic population.

Thank you!

Jan from Maine

Thank you, Jan, for your question. This question, of course, covers a very broad subject, so I will break it down into several important areas.  If more specific or timelier information is needed, Jan from Maine could leave a comment with her email address and I could address those specifics directly.

My response to this question will appear in multiple posts.  In the first few posts, I will outline and define several potential areas for occupational therapy intervention for the K-8 population, with a special focus on areas of OT intervention for those with autism.  The second group of posts will give examples of specific Wii activities to address these areas.  And finally, I will suggest some current research to use as supporting literature for a grant proposal. 

Some potential areas for intervention in the K-8 population include but are not limited to:

• Motor
  
• Perceptual
  
• Cognitive
  
• Psycho Social 

Occupational therapy intervention areas for children in this population with Autism include but are not limited to:

• Psycho social
  
• Sensory (processing) Integration
  
• Cognitive
  
• Perceptual
  
• Motor

Deficits in any of these areas can make classroom and daily activities challenging.  Identified students receive needed intervention from Occupational, Physical and/or Speech Therapists. The Nintendo Wii is emerging as a popular tool for therapists working with school aged children with special needs.  Wiihabilitation incorporating Wii Sports and Wii Fit can be used to address many of these frequently encountered problems and strategies for incorporating Wiihab in School based therapeutic programs will be discussed in detail in the latter parts of this segmented post.

Movement disorders in the K-8 (including those with Autism) may result from neuromusculoskeletal issues as well as from a complex mix of perceptual, muscular and motor issues.  Musculoskeletal involvement may result in:

• Alterations in muscle tone – (spastic- increased or flaccid- low/decreased)
  
• Decreased range of motion and/or strength
  
• Poor endurance
  
• Decreased postural control – alignment (standing or sitting)  

Additional motor or movement problems stem from a complex mix of deficits across several systems and may manifest as problems with:

• Coordination –both gross and fine (dexterity)
  
• Bilateral integration (using both sides of the body cooperatively, either simultaneously or alternately)
  
• Crossing the midline (passing one extremity across the midline of the body into the opposite side)
  
• Motor planning (praxis- the ability to perceive [visualize], organize and execute a motion or action accurately)
  
• Visual motor integration (the combined ability to visually perceive an object while accurately grasping and manipulating the object efficiently to complete the desired task)

Problems in any of these areas contribute to a student’s difficulty with classroom and self care activities.

How can a game be therapy?

Medicare reimburses for therapeutic procedures or treatments provided by a skilled and licensed therapist for the purpose of improving function and reducing disability or impairment in an individual who has been referred to therapy and has a diagnosis supporting the medical necessity for therapy.  A Therapeutic Activity (CPT 97530) is further defined on the Highmark Medicare Services website as:

Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involves movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of a clinician and are designed to address a specific functional need of the patient.

In order for therapeutic activities to be covered, all of the following requirements must be met:

• The patient has a condition for which therapeutic activities can reasonably be expected to restore or improve functioning; and
  
• The patient’s condition is such that he/she is unable to perform therapeutic activities except under the direct supervision of a clinician and
  
• There is a clear correlation between the type of exercise performed and the patient’s underlying functional deficit(s) for which the therapeutic activities were prescribed.

Therapeutic activities may be medically necessary when the professional skills of a clinician are required, and the activity is designed to address a specific need of the patient. These dynamic activities must be part of a documented treatment plan and intended to result in a specific outcome. 

Therapists have traditionally used “games” such as balloon volleyball, bean bag toss, modified basketball, and obstacle courses to reach therapeutic goals. The Wii is not the first computer game or program to be used in a therapeutic setting.  Therapists have used dance programs such as Dance, Dance Revolution, and some virtual reality programs to help them meet rehab goals.  Using the Wii as a therapeutic activity is supported by the requirements set forth by Medicare. Games available on The Wii, especially those included in Wii Sports and Wii Fit, are a perfect addition to the therapeutic activity toolkit.  Through various games functional loss can be improved and restored.  Tennis for example, encourages a patient to use the shoulder through a more complete range of motion than traditional activities such as stacking cones or moving the plastic pieces along the tubular track on the shoulder arc contraption.  Patients seem to enjoy the Wii and this element of fun appears to reduce the anxiety and anticipation of the pain.  The therapist must monitor the patient, ensuring safety, pacing and appropriate rests.

Each time I use the Wii with a patient, I learn another way the Wii provides a therapeutic experience.  Recently, I used the Wii boxing training module , “Working the Bag” with an elderly patient who has difficulty dressing due to decreased range of motion in both shoulders and a decline in cognitive functioning.  The newness of a computer game required a gradual introduction and a careful explanation.  But once the patient tried out the activity, the personal exhilaration resulting from the rapid movement of both arms and the Wii’s animation and audible reinforcement was apparent.  This experience seemed to elevate this patient’s mood and create a stimulus for returning to therapy for another session later in the week.  As a result of the enthusiasm that the Wii stimulated, I was able to add to the treatment plan additional therapeutic exercises aimed at improving arm strength, range of motion and endurance to help this improve this patient’s ability to play the Wii. In this case, a game was therapeutic not only because it was a dynamic activity used to improve the functional use of both upper extremities, but also because it motivated the patient to participate in an enhanced treatment plan, hoping to improve their ability to play the Wii.

Answering your colleagues' questions about Wiihabilitation Therapy

Over the past year, conversations with colleagues have often included several questions about the therapeutic use of Wii in various clinical settings.  Below are a few of the questions I frequently encounter and the answers I provide.  What are some questions you have about incorporating Wii into your program?

Will patients take the Wii seriously?  

Initially, many patients view the Wii skeptically, not unlike the way they view any therapeutic activity.  I find that many patients in rehab often seem wary of the treatment plan and at first proceed doubtfully through 3 sets of 10 of this exercise and/or 15 minutes of bilateral upper extremity reaching activities. However, in contrast to traditional, often repetitive, exercises or activities, the patients quickly begin to enjoy the Wii activities and games.  By using activities available in the training module of Wii Sports, a therapist can design a highly effective program to meet many goals.  For example, following joint replacement surgery, the therapist may wish to encourage weight shifting and increased standing tolerance, two outcomes necessary for increased independence in self care and home management.  The Wii Sports Boxing Training Module offers 3 activity choices.  The first activity is labeled “Working the Bag”.  This activity requires the participant to hold the Wii remote in one hand and the Nunchuk in the other.  A boxing bag appears in front of the Mii and by extending the arms forward at chest height alternately, the participant punches the bag.  If enough forceful punches are thrown, the bag falls from the ceiling, a bell sounds and the next bag appears in front of the Mii. 

When using this activity therapeutically, the therapist must monitor the patient to guard against over exertion, against loss of balance, and against poor body mechanics.  During the first attempts at this activity, fatigue may prevent the patient from completing the round in a standing position. Since this activity can also be performed from a chair, the patient may continue in a seated position affording benefit by challenging the upper body, overall endurance and sitting balance.  Upon completion of this activity, skepticism will be replaced by belief that the Wii can provide a very beneficial therapeutic experience.

 

Wii in Health Promotion

A recent vacation opportunity brought to light other clinically relevant uses of the Wii.  The Wii can play a motivating role in Health Promotion and Lifestyle Modification across all ages.  For many who have a more sedentary lifestyle, the Wii proves to be useful tool in encouraging change.  The Wii stimulates those who may usually choose to only watch sports, to get up (or remain seated) and swing the remote at the tennis ball, the golf ball or the baseball.  Others swing the remote to bowl or box.

Photo by abbynormy on Flickr

In the school setting, students who might usually shy away from physical education (PE) classes rush to sign up for PE revolving around Wii Sports and other Wii programs. Teachers have found that the students who are reluctant to play team sports are more than willing to get out of their desks for some friendly Wii competition.  The students like the feedback Wii provides and are motivated by the improvement that the Wii makes readily visible.

In the clinic setting, the Wii has an application in Health Promotion.  Researchers in the area of Fall Prevention (Lachman, M., Howland, J.,& Tennstedt, A.,1998) have identified a sedentary lifestyle as a primary risk factor for falls.  In older adults, a sedentary lifestyle and a fear of falling (Edelberg, 2001) often go hand in hand, creating a reciprocal nature among fall risk factors in the elderly population.  Using Wii as a therapeutic activity with elders allows the clinician to work towards goals such as increasing standing and activity tolerance, improving dynamic balance and reducing fear and anxiety.  The fun nature of Wii along with the built-in reinforcement of improved scores encourages and motivates elders to be more active and engaged in therapy.

Another great therapeutic use of Wii is in Lifestyle Modification Programs.  Lifestyle Modification Programs help clients struggling with obesity, type 2 Diabetes, or other chronic conditions to implement changes in daily routines, reducing disease burden. Initially, the Wii gently introduces increased physical activity into the daily schedule.  For those participants with a history of computer gaming, the Wii allows them the familiar pleasure of gaming while increasing physical activity.  Wii also encourages social interaction and creates opportunity for community building through the creation of bowling leagues and baseball teams. 

Exercising in the virtual environment created through the Wii should not be considered a replacement for exercise in the real world, but Wii Gaming can be used effectively to provide additional activity throughout the day.   The Wii may help those who are extremely sedentary to take initial steps toward increasing activity.   By increasing the level of daily activity, participants may gain strength, endurance and improved balance, leading to improved well-being.

References:

Edelburg, H. (2001). Falls and function: How to prevent falls and injuries in  patients with impaired mobility. Geriatrics. 56(3). 41-45.

Lachman, M., Howland, J.,& Tennstedt, A.(1998). Fear of falling and activity restriction: The survey of activities and fear of falling in the elderly (SAFE).Journals of Gerontology: Series B: Psychological Sciences and Social Sciences. 53B(1). 43-50.

The Wii and Autism

Occupational therapists provide care in diverse settings for a wide range of ages. One of the most rewarding settings for the occupational therapist involves working with children with developmental issues. OT intervention may be offered as soon as the child arrives in the NICU through a hospital based service, once the child goes home through a birth to 3 program, and once the child enters school within the school based setting.  Children with Autism Spectrum Disorder comprise a growing number of the case-load mix.  The occupational therapists’ contribution to these children’s plan of care or IEP includes activities aimed at improving physical, sensory and social issues.

One mother found an innovative way to help her son improve his ability to filter auditory sensory input as well as a way to increase all types of coordination and encourage appropriate social interactions.  This mother, MaryTara Wurmser purchased an Nintendo Wii for her son to use at home.  She tells about her experience and explains the benefits afforded her son from this activity.  She encourages others to “Consider the Nintendo Wii for Kids with Autism.”

Using Wii to Detect Changes in Center of Balance

Following hip or knee joint replacement, a slight leg-length discrepancy can often occur. This slight difference in leg length shifts an individual’s center of balance, challenging both the static and dynamic balance of the joint recipient. The leg-length discrepancy can be a contributing factor in a person’s decrease in functional ability.

Those recovering from joint replacement surgery often demonstrate decreased standing tolerance and balance, decreased flexibility, and pain. Faced with increased pain and decreased flexibility, individuals avoid weight bearing and weight shifting, which can contribute to the development of a compensatory gait pattern. Though the literature points out that the impact of a leg length discrepancy continues to be debated, for the clinician whose goal is to restore functional independence, this possible contributor to dysfunction should be considered.

The Wii Fit Balance Board offers the therapist an easy way to assess center of balance. The Body Test calculates the players center of balance as well as their BMI. This Body Test also measures an individual’s body control, or their ability to keep their weight centered. Games or activities included with Wii Fit help teach a person how to move their body to improve their ability to maintain the optimal center of balance. The games provide feed back for improvement in several ways. For example, in the ski jump activity, a small box in the upper right hand corner of the screen uses a small blue dot floating inside a larger yellow dot to indicate the player’s center of balance. If the individual maintains their body alignment in an optimal position prior to extending their knees for the “jump”, the distance of the jump is longer, resulting in a higher score. The visual feedback from the dot, along with the positive reinforcement from increasing scores, help motivate the participant to keep trying to improve their weight shifting and weight bearing.

If a client has continued difficulty maintaining their center of balance, the therapist may suspect a leg length discrepancy. Although length discrepancies are often not reported and may be rare, following surgery for a single knee replacement, some patients report discrepancies of up to a quarter of an inch. An orthotist can place an insert inside the shoe, correcting this issue. Often, clients sense the correction immediately because eliminating the difference in leg length, helps to align the pelvis. An orthotist can again use a lift to correct this imbalance. Hip replacements may also lead to one leg being shorter and one being longer.

Now the client, wearing his adjusted shoes, may have an easier time maintaining his center of balance. The therapist will need to always take precautions for fall prevention when using the Wii Sports or the Wii Fit for therapy in a population with joint replacements. Some of the balance games may not be appropriate for early stages of rehab for those with joint replacement because of pain or weight bearing restrictions or precautions, but maybe quite helpful in the latter stages of therapy as the client progress toward full recovery.

Wii Sports - Learning the Basics

When a therapist chooses to use a new technique for rehabilitation, the first step is to become familiar with the basics. Using the Wii as a therapeutic activity or exercise requires the same approach. Dan Birlew authored You & Wii – Everything You Need to Know and Prima Games, a Division of Random House, published it. This book not only explains the basics, but also includes a full explanation of Wii Sports. By reading this book, the therapist can learn what Wii Sports offers.

Wii Sports offers both an opportunity to play a game and an opportunity to improve skills. In the Bowling Training section, power throws can be utilized to increase standing tolerance and standing balance, build strength in the upper extremity, encourage shoulder flexion and improve flexibility throughout the upper extremity. Once the player has signed into this activity, they are allowed 10 throws to knock down as many pins as possible. This training module builds in difficulty as the bowling lane as additional pins are added. On the first throw, the player attempts to bowl down 10 pins. By the tenth throw, the player bowls the ball into a field of 91 pins.

The therapist can increase the workout gained from Wii Sports activities in so many ways. By simply placing wrist weights on the targeted upper extremity or by increasing the length of time that the participant must stand while playing are just a sample of the ideas. Have you tried using any of the Wii Sports training sections? If you have, you know that by spending time in an existing activity, the participant can open new training games. Once earned, these new challenges appear on the menu.

"Technical Difficulties" - What if the Wii isn't Working?

If the technology that supports the Wii Gaming System is not working, is the OT out of luck? No, but she better be able to quickly figure out another therapeutic activity to substitute in its place.

Last week, a technical difficulty at a facility where I was working brought down the entire cable/TV system, and even after trying to follow the cable company's detailed directions for use, no picture appeared on the screen. Just as we were getting ready for a Wiihab session, we realized we were out of luck.

The patient was in occupational therapy to improve upper body strength along with overall endurance and activity tolerance following a recent hospitalization for an infection. Prior to the recent hospitalization, this particular patient ambulated short distances with a rolling walker while wearing bilateral static ankle supports. Functional transfers from bed to wheelchair and from wheelchair to power rover were independent.

Following hospitalization, this patient required contact guard for all transfers. Dressing and bathing, which were performed with modified independence before hospitalization, required minimal assist to contact guard following the hospitalization. The plan of care was designed to restore the patient to the prior level of independence.

Therapeutic exercises for upper body strengthening, therapeutic activities to increase endurance, balance and standing tolerance, and retraining in energy conservation techniques for self care filled the treatment time. Following a unit of traditional graded upper body exercises, the patient usually participated in several games of Wii Tennis. Prior to the initial injury, tennis was an enjoyable activity for this individual and introducing Wii Tennis into the treatment plan brought new enthusiasm for therapy. Keenness for therapy was assessed by the patient’s insistence on being seen promptly. This eagerness for treatment replaced the past behavior of cancelling appointments or disregarding appointment time.

When the Wii didn’t work, both the therapist and the patient were understandably disappointed. As a substitute for swinging arms through complete range of motion while serving and returning the virtual tennis ball, the patient had to transfer black and orange cones from tabletop to upper shelf and back again. Instead of guarding the patient myself to protect against possible falls as the swing of the remote sent the ball across the net, another person in the clinic had to become involved in the treatment session to either stand along side the patient or to toss the beach ball toward the patient. Though the physical aspects of the activities used as an alternative to the Wii game may have been equivalent, the cognitive and psycho-social aspects seemed far lacking. Even if I could mope or gloat in response to the work, my patient seemed to miss the reaction of the personal avatar painstakingly created during the first Wii session. And though the movements were all completed, I sensed little, if any, push or determination with stacking the cones or batting the beach ball.

“I hope they fix that Wii before my next session”, was all that was said when therapy ended.

I was in complete agreement!

News Updates on Wii Therapy

For Wednesday -- a News roundup on Wiihab and using the Wii in therapy:

'Wiihabilitation' helps patients recover quicker
Dayton Daily News (July 29, 2008)

Senior center adds Wii system
Marshfield Mariner (July 29, 2008)

Nintendo Wii Used For Rehab
KSAT.com, TX (July 28, 2008)

Golden gamers
New Orleans CityBusiness, LA (July 28, 2008)

Foundation Grant Funds "Wii-habilitation" Therapy
Southern Pines Pilot (July 26, 2008)

Bayfront uses Wii for rehab
Tampa Bay's 10, FL (July 25, 2008)

Wii Therapy for Patients with Alzheimer’s Disease

In February 2007, an article appearing in the Journal of the American Geriatrics Society reported that nursing home residents with a diagnosis of Alzheimer’s disease can change the rate of deterioration through exercise. Residents who participate in moderate exercise can experience a significantly slower decline in function than those residents who receive routine care. In this study, individuals in the study group participated in hour long therapy sessions twice a week for 12 months. The therapy program included walking, along with strength, balance and flexibility training. The control group received normal care. This study, which took place in Toulouse, France was lead by Dr. Yves Rolland and measured the effects of the exercise program on individual’s activities of daily living, physical performance nutritional status, behavioral disturbance and depression. This study, which had 134 participants whose average age was 83, showed that individuals in the exercise group improved their activities of daily living scores significantly. Average walking speeds improved significantly in the exercise group also.

The Wii gaming system could be utilized in therapy for Alzheimer's patients with reduced ability to perform activities of daily living. Wii Bowling, Wii Baseball, Wii Tennis and Wii Golf provide a therapeutic opportunity to improve both flexibility and balance. The therapist may also place weights on the patients’ wrists as a means of incorporating strength training into the activity.

Furthermore, Wii encourages reminiscing. Individuals with Alzheimer’s disease experience short term memory loss and often retreat to the past. These past memories often become their reality. Even though hand over hand cueing may be required for successful use of the game with this population, therapeutically playing Wii Bowling, Wii Baseball, Wii Tennis or Wii Golf, may stir memories of pleasant past experiences for these individuals. The therapeutic use of Wii may help reduce anxiety in this population.

Printout: Wii - Play it Safe

Playing the Wii is a great activity for older adults living in retirement communities. These independent elders are excited to find a computer related activity that both contains subject matter familiar to them (Bowling, Baseball, Tennis) and presents new technology in an easy to learn format. The enthusiasm that Wii generates may result in over-indulgence in the activity.

For maximum enjoyment, suggestions for the safe use of the Wii Gaming System should be posted in an obvious spot near where the game is set up for casual use. Below is a Safety Tip Sheet from The Wii OT, Mershon W. Hinkel, MSPH, OTR/L, that may be copied and placed either in a free-standing frame on the table top, or on the wall where the Wii is being used.

Wii PLAY IT SAFE

Wii is a great activity for all ages. By using a wireless remote, Wii has taken "playing" video games off the couch. Wii games are a physical activity, a social activity, and a wonderful way to interact with younger generations.

For an enjoyable, safe, and healthy time playing the Wii, follow the guidelines below:

1. Always use the included Wii wrist strap and the Wii remote safety jacket. The wrist strap prevents accidentally dropping or throwing the remote, and the jacket gives the remote a softer and less slippery surface.

2. Don't overdo it, especially when you're first starting out. Like with playing any new game or sport, you may find yourself using muscles you don't usually use, and these muscles may become strained or sore. Stretching before playing and using ice to relieve any soreness after playing can protect muscles and tendons from injury.

3. If you are concerned about your ability to balance, many of the Wii games can be played sitting down. You may also wish to use a form of support for extra safety to avoid falling.

4. Be sure the playing area is clear of potential obstacles that may get in the way of your arms or legs when playing. Be sure you are not too close to other players or observers.

5. If you have a condition such as epilepsy, are prone to motion sickness, or have a pacemaker, you may want to discuss using Wii and other video games with your health care provider prior to playing.

6. To avoid the spread of germs, wipe the remote's surface with a sanitizing wipe. Players may also want to use hand sanitizing gels between turns.

Safety Tips for Wiihab Therapy

Maintaining a safe environment for patients during therapy is always important. A good therapist should pay attention to and avoid potential risks. For example, therapists should think about fall prevention, infection control, and injury prevention in conjunction with any modality they choose to use, including Wii. Avoiding injury to other people (or damage to furniture, belongings, or equipment) is also important.

Fall Prevention and Wii

Many Wii games can be played from a seated position. However, sometimes the goals of therapy include getting a patient to stand and balance. For a patient whose balance may be in question, the therapist may wish to use a gait belt. Another option would be to use parallel bars for support or for safety, or using a walker with therapist at the side. For example, while the Wii balance board is very sensitive to shifts in weight, it can still be effectively used to train balance while the user relies partly on upper-body strength to support the lower body.

When using the balance board, be sure it is not on a slippery surface and that other people will not trip over it. The balance board is white and may be difficult to see on a white or light colored floor, especially for patients with low vision. This potential risk can be mitigated by placing the balance board on top of a non-stick mat, such as a yoga mat, in a darker color. For patients at risk for falls, Wii use that involves standing should always be supervised.

Infection control and Wii

If the Wii equipment is shared in a clinic setting, it must be appropriately cleaned between uses to prevent potential transfer of any pathogens (germs).

To fully clean the remote, the protective safety jacket should be removed from the remote. The jacket can be immersed for cleaning, but the remote can NOT be immersed. The remote itself should be wiped with disinfectant solution readily available in the clinic (use the same wiping method as for similar plastic items). The Wii remote strap can be removed and washed as well. (See the photo below of a Wii remote with safety jacket and with jacket removed.)


Photo by frostova on Flickr

Also, users can wear latex gloves while handling the remote for extra precaution.

Injury Prevention and Wii

Therapists incorporating Wii into a therapeutic plan should use the same strategies that they would use if a person had started a new sport. For example, if the patient has been bothered by a wrist or elbow in the past, the therapist may consider using ice and monitoring a patient to prevent overuse. Because of the "fun" element involved in Wii, overuse may be of particular concern. Also, therapists should make sure all movements are being done correctly and that patients do not compensate for a weak muscle with a stronger muscle group.

Avoiding injury to others or damage to equipment with the Wii

In the early days of the Wii, anecdotes of Wii bowlers accidentally throwing the Wii remote through a television screen abounded. The Wii remote's safety strap and safety instructions given at the start of each Wii session and game, as well as the new safety jacket, should help prevent this type of damage (or injury that could result if the remote hit another person).

Always clear the area of potential hazards or obstructions before using the Wii, make sure he safety strap is secured to the player's wrist, and use the padded secure-grip safety jacket on the remote (see the photo above of the remote with and without the safety jacket). Also, follow all safety precautions given by the Wii software.

Robert Wood Johnson funds video game health research

Robert Wood Johnson foundation has devoted more than $8 million to fund Health Games Research, a research group dedicated to discovering more about how video games can be used to improve health. The goals of the program are to support research that either increases physical activity or improves self-care (the activities involved in taking care of oneself).

This research funding is a wonderful step towards developing an evidence-base that supports use of video games as therapeutic activities. Many of the movements involved in playing the Wii or other interactive video games are already based on evidence and research that certain tasks improve balance, strength, coordination, and self-care abilities. Continuing to conduct research in this area will yield even more information about how providers can implement the use of video games in their practices and bring this technology to a wide variety of patients.

ABC News in Chicago reports on using the Wii in therapy

Check out this news report from Chicago on using the Wii in therapy. The article mentions the utility of Wii as a therapeutic modality for both adults and children. A therapist in the article discusses added benefits of using the Wii, such as the multigenerational interaction that takes place when children play the Wii with a therapist or parent.

Guitar Hero for Wii and fine motor control

William Randolph Hearst Burn Center at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York City is using the Wii as part of therapy for burn victims. Many patients recovering from burns have skin grafts, and flexing, stretching, and moving the skin is an important part of therapy.

Guitar Hero uses a wireless guitar-shaped controller. The player "strums" a bar-shaped button on the body of the "guitar" and presses buttons on the neck of the "guitar" to select notes while following along with songs on the monitor. The game requires finger dexterity, and it has different modes and levels so that people can progress to more difficult movements. Playing games such as Guitar Hero that require movement of the fingers can help patients regain fine motor skills in the hands and also improve coordination. For patients with skin grafts on the hands or arms, the game can help them practice moving and stretching the skin as it heals.

Video: Wiihab for surgical patients

Today on CNET -- a video that includes using Wiihab for surgical patients. Physicians at St. Mary's Medical Center started a Wiihab program in the beginning of 2008, and they are prescribing time on the Wii using Wii Fit. Therapists there have found that patients benefit the most from the Wii Fit games using the balance board. (The part about Wiihab comes towards the end of the segment.)

• Taking virtual bullets and Wiihab
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Using Mario Kart in Wiihab (Part 1 of 6)

Have you thought about using Mario Kart in therapy but are wondering what goals it can help your patients reach? This post is the first in a series of six on areas that Mario Kart can target for improvement as part of a rehab plan. Many of the areas that will be described in this series are important in conditions including pervasive developmental disorders and sensory integration dysfunction.


Photo by SMercury98 on Flickr

Post 1: Bilateral Coordination

Bilateral coordination is the coordinated use of both sides of the body at the same time, either in similar movements or in alternating movements. An example of a similar movement is using both hands to pick up an object or using both hands to throw a beach ball; an example of alternating movement is walking up the stairs or pedaling with the feet or the hands.

In Mario Kart Wii, players insert the regular Wii remote, which is rectangular in shape, into a wheel-shaped adapter. Because the wheel Wii controller is held and controlled with both hands, bilateral coordination is involved in playing the game.

Also, effective playing of the game can involve alternating movements, such as holding down the "2" button to speed up the kart while using the "b" button on the reverse of the controller to "drift" while in manual mode. (Manual mode is optional, and less advanced patients can play in automatic mode.)

Nurses in NY using Wii to complement rehabilitation therapy

A hospital in New York has been using the Wii as part of therapy for more than nine months. As the article reports. Candy Perotti, a COTA from St. Francis hospital in Poughkeepsie had this to say:

"The Wii system has been an asset to our rehab unit...The system encourages patients to perform the actual movements of the sport. Driving games help patients with visual tracking and scanning. Bowling, tennis, and baseball improve hand/eye coordination."

(As a note, the driving game mentioned is likely Mario Kart -- if you're not familiar with the game, it is a driving game that allows the player to attach the regular Wii remote to a driving wheel-shaped remote.)


Photo by Michael T. Gilbert on Flickr

The article also mentions that using the Wii can help improve memory skills, as the patient has to remember the motions and steps involved in using each particular game. The social aspects of playing Wii with others can also help aid in patients' feelings of loneliness or isolation.

News reports of Wii use in pediatric therapy

Using the Wii as part of therapy can work for all age groups. Children especially enjoy video games and have grown up as "digital natives" who are fluent in the use of computers and technology, and so using the Wii as a component of OT/PT in pediatrics makes sense.

This story from Texas reports on how therapists are using Wii games to help children not only gain strength and flexibility, but also improve coordination. As in many cases, the games chosen are tailored to patients' needs, such as Bowling and Boxing for arm strength and coordination.

Wiihab might be particularly useful for children because it removes the boredom factor from therapy. Using the Wii is also a distraction technique, reduces anxiety, and incorporates play into therapy.

For OTs, using the Wii with pediatric patients can be an especially important component of a well-rounded therapy program because playing is part of a child's "occupation." Additionally, because the Wii is a popular toy for younger age groups, learning how to use the Wii may help a child with social interaction and playing with peers. Playing Wii also is an opportunity for children to interact with parents and adults in a way that has therapeutic value.

Pediatric centers in UK using Wii for children with hemiplegic cerebral palsy

In Newcastle, England, a professor at Newcastle University's Institute of Neuroscience has opened a research study in using video games, including the Wii, as a rehab tool for children with hemiplegic cerebral palsy. Hemiplegia affects one side of the body, and children diagnosed with this disability often neglect the disabled arm and leg. The study is using Wii controllers and laptops with specially designed games to encourage children to use their disabled arm. These adapted games have a lower level of complexity and a lower speed than those commercially available; the study has tested two games and a third will be added.

The principal researcher, Professor Janet Eyre, has noted improvements in the children's use of the less frequently used limb as well as improvements in coordination and social interaction:

"What has been striking to us, and the parents and children, is that by playing the games the children are using their [disabled] arm more in everyday life. We're trying to give them an incentive so that they will use it a lot."

She also notes the social value of using games, which are an integral part of childhood, to de-stigmatize therapy for children and families:

"Children sometimes feel stigmatised by therapy but everyone plays games, and they can play them with their parents or their brothers and sisters."

Therapy may hold a stigma even for adults; using the Wii and other video game / interactive tools may be of use even with older patients who resist therapy or who are unlikely to adhere to recommended courses of therapeutic treatment.

I Haz Wiihab?

Just a funny Friday post based on a photo found on Flickr. Apparently, even cats like the Wii Fit Balance Board.


Photo by Tscherno at Flickr

Wii use in nursing homes

A news report in Cincinatti discusses use of the Wii in nursing homes. In the video, elderly patients play Bowling and discuss what they think of using the Wii.

Wiihab for burn victims

The BBC has reported that the Wii has therapeutic value for improving flexibility and range of motion for burn victims. Wii is being used as a complementary therapy technique in the East Grinstead Hospital, which is a regional center for treating patients with burns in the southeast regions of England. Burns specialists at the hospital noted several advantages to using the Wii, such as patients' enjoyment of the activity and the ability of patients to continue using the Wii at home once they are discharged.