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.