WiiHab in the Forefront - Preview of Premier Issue of G4H - GAMES FOR HEALTH -Journal Now Available

One frequently heard criticism of video games in therapy has been the lack of evidence that using gaming actually impacts specific outcomes. Now a group of dedicated professionals has created a forum which will share the results of studies that use gaming as a variable in health care research. This peer review journal, Games for Health Journal: Research, Development, and Clinical Applications, will be published bimonthly by Mary Ann Liebert, Inc., publishers. Therapists interested in using Wii or other gaming systems in their therapeutic setting may want to check this source out. A preview is available as well as an opportunity to sign up for a biweekly eNewsletter.
Just yesterday I was reminded of the importance of fun in therapy as I spoke with a student struggling in her fieldwork experience. Seasoned OTs forget from time to time to encourage our proteges to seek therapeutic activities that allow our clients to succeed while they experience a sense of enjoyment. Gaming is the perfect tool for bringing laughter, enjoyment and success into therapy. Follow the articles published in Games for Health Journal: Research, Development, and Clinical Applications to boost your own confidence for using Wii and other gaming systems during therapy sessions.

WiiHab in the News Throughout The Summer (Part 1)

Frequently, during the summer months articles appeared in newspapers, on television, and in blogs explaining the benefits people gain when Wii activities are incorporated into their rehabilitation programs. In June, the El Paso Times printed an article about Del Sol rehabilitation center’s use of the Wii in their Physical and Occupational therapy programs. The accompanying picture tells the whole story! Also in June, Hulig News ( an independent public news organization) placed a great story on line about a patient at University of Wisconsin, Madison’s American Family Children’s Hospital. This story offers some insight into the versatility of Wii as a therapeutic activity. More positive reviews of Wiihab can be found when you read an article from June 15, 2009 in the Vail Daily. Therapists in Silverstone, Colorado include many different Wii programs into the plan of care for their patients. They report improved outcomes, particularly with knee replacement patients. A study which will contribute to the evidence-base for using Wii in therapy for knee replacement patients is taking place in Toronto. Researchers hope to complete this study by the end of the year.

Reports of Injuries from Wii Sports and Wii Fit

Whenever a certain colleague of mine mentions the Wii, talk of fear of injuries to players creeps into the conversation. An article appeared recently in the New York Times entitled, More Wii Warriors are Playing Hurt. Readers find references to strains and sprains as well as rotator cuff tears and knee injuries. This article suggests that Wii related injuries are increasing along with the popularity of the Wii gaming system, itself. In the therapeutic setting, I have not had any experience with patients adding to their injuries or pain using the Wii, because we are very careful to follow the"Play It Safe" (for Wii Sports) suggestions while working with patients. Earlier this summer though, I met someone who had broken his toe playing the Wii. Aaron Martin, a delightful and inspiring speaker, known best as the face of BASSEDGE, related the story of how he broke his toe playing a Wii game with friends. He hit his foot on a chair as he lunged to make the play. A reminder ofPoint # 4 from the "Play it Safe" sheet may have helped Aaron avoid that injury.

Although reports fill the internet of Wii related injuries to players and equipment, many more reports tout the benefits of using the Wii. Any activity can result in injury if the participant over-indulges or disregards safe practices. Using Wii Fit in therapy requires additional safety measures to insure against potential falls, especially when using this tool to improve balance and encourage weight-shifting in an elderly population. Safe use of therapeutic tools is common sense and usual practice for therapists. I always remind my colleague that stories of Wii injuries relate to public use of the gaming system, not to the supervised use of Wii as a therapeutic tool for Wii-hab.

Following Stroke, The Wii Encourages Bilateral Upper Extremity Use

Using  Wiihab encourages many responses.  Often occupational and physical therapists are challenged to  find therapeutic activities to elicit one desired response,  bilateral upper extremity use.   Those recovering from stroke may find using the involved extremity uncomfortable and challenging because of muscle weakness, increased or decreased muscle tone, poor sensation, or loss of position sense (proprioception).   Boxing in Wii Sports, especially, offers an opportunity to use both upper extremities reciprocally and spontaneously.   Boxing in virtual reality creates a need to make alternating movements with the arms to protect yourself from punches or to knock out your opponent.  If the participant's bilateral cordination is sluggish, their opponent will punch them.  Many will work hard to avoid that!  All of the Wii games promote therapeutic movement and many news reports explain the value patients find in using games as therapy.  

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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.

"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!