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.