Does the use of Nintendo Wii Sports™ improve arm function and is it acceptable to patients after stroke? Publication of the Protocol of the Trial of Wii™ in Stroke - TWIST

Feasibility of training using full immersion virtual reality video game in young stroke survivor: A case report

BACKGROUND

With the recent developments in science, full-immersion virtual reality devices have been developed, which may have feasibility for stroke rehabilitation.

OBJECTIVE

This case report investigated the feasibility of training using a full-immersion virtual reality video game for improving motor function, balance, and gait in a young stroke survivor.

METHOD

The case was a 27-year-old woman with stroke. A training using full-immersion virtual reality video game (Sony PlayStation®VR) was performed for 30 minutes per session, 3 sessions per week, for 6 weeks, with a total of 18 sessions. Before training and at each training for 6 weeks, with a total of 19 times, the motor function, balance, and gait were assessed using the Motor Assessment Scale (MAS), Berg Balance Scale (BBS), Timed Up and Go (TUG) Test, and Tinetti Balance Assessment, 10 Meter Walk Test (10MWT), Tinetti Gait Assessment, and Dynamic Gait Index (DGI).

RESULTS

During the training, there were no adverse events reported. The case achieved 14 points higher than the pre-assessment with 34 points on the MAS, 16 points higher than the pre-assessment with 48 points on BBS, 6.85 sec lower than the pre-assessment, with 13.58 sec on TUG, 5 points higher than the pre-assessment with 13 points on the Tinetti Balance Assessment, 5.36 sec lower than the pre-assessment, with 8.15 sec on the 10MWT, 4 points higher than the pre-assessment with 10 points on the Tinetti Gait Assessment, and 10 points higher than the pre-assessment with 21 points on the DGI.

CONCLUSION

This case report suggests that training using a full-immersion virtual reality video game may be a safe and effective method to improve motor function, balance, and gait in a young stroke survivor.

Effect of Wii-habilitation on spatiotemporal parameters and upper limb function post-burn in children

BACKGROUND

Limb burns can cause different functional disorders that greatly impact one's quality of life.

AIM

The purpose of the current study was to compare the effect of Nintendo Wii sports intervention, and traditional treatment methods on spatiotemporal parameters and upper limb function post-burn in children.

METHODS

Thirty children their age ranging from 7-12 years, with dominant side upper limb burn participated in the study.Vicon3-D motion analysis system and Jebsen hand function test were used to evaluate spatiotemporal parameters (movement duration, peak velocity, and time to peak velocity percentage in three functional tasks) and upper limb function respectively. The children were randomly divided into study and control groups. The study group was rehabilitated with Wii training in addition to traditional therapy, while the control group rehabilitated only with the traditional therapy program. For the study group, the games selected were Wii Bowling, Baseball, and Tennis. Both groups were trained for 60 min daily, three times/week for six weeks. The outcomes were measured pre and post the treatment period.

RESULTS

The whole-time duration and peak velocity improved significantly in the study group across the hand to head task (p = 0.001, p < 0.001, respectively), hand to mouth (p = 0.001), and hand to shoulder (p < 0.001, p = 0.0018, respectively) compared with the control group. The time to peak velocity percentage was enhanced significantly in the study group (p < 0.001) than the control group in all three-measured tasks. Moreover, the Jebsen hand function test improved significantly (p < 0.001) in the study group than in the control group.

CONCLUSION

Wii-habilitation could be advised as an effective tool in the rehabilitation program of children with post-burn injuries.

Rehabilitation of the upper arm early after stroke: Video games versus conventional rehabilitation. A randomized controlled trial

BACKGROUND

Few rehabilitation methods have proven their efficacy in increasing sensori-motor recovery and/or function of the upper limb (UL) after stroke. Video games (VGs) are promising tools in this indication.

OBJECTIVE

To compare UL rehabilitation by using VGs and conventional rehabilitation (CR) in patients with sub-acute stroke.

DESIGN

Single-blind, multicentric trial, with central randomization and stratification by center.

SETTING

Physical and rehabilitation medicine departments of 2 university hospitals.

PARTICIPANTS

Adults within 3 months after a first vascular cerebral accident, with UL Fugl Meyer Score (UL-FMS)<30/66 and without major cognitive impairment.

INTERVENTION

A 45-min additional session of conventional occupational therapy (OT) or a VG-based OT session as add-on therapy to usual rehabilitation programs, 5 days/week for 6 weeks.

MAIN OUTCOME MEASURES

Primary outcome: UL-FMS. Secondary outcome: Box and Block Test (BBT), Wolf Motor Function test (WMFT), Motor Activity Log (MAL), Barthel Index and quality of life (SF-36).

RESULTS

We included 51 patients (20 women) at a mean (SD) of 27.2 (19.4) days post-stroke (mean age 58 years [range 24-83]), 26 in the CR group and 25 in the VG group (23 in each group at 6-month follow-up). The mean duration of the additional rehabilitation session was similar in both groups: 29.3 (4.3) vs 28.0 (4.4) min in CR and VG groups. Shoulder pain occurred in 4 patients in the VG group versus 7 in the CR group. At day 45, gain in UL-FMS did not significantly differ between the groups (CR mean 17.8 [14.6] vs VG 24.1 [14.8]; P=0.10), whereas gain in BBT was doubled in the VG group (CR 7.4 [12.2] vs VG 15.7 [16.3]; P=0.02). At 6-month follow-up, the study was inconclusive about between-group differences in UL-FMS, BBT and other criteria. Post-hoc analysis showed that gains in UL-FMS or BBT were significantly higher in the VG than CR group for patients included within 30 days post-stroke.

CONCLUSION

In general, we cannot conclude that video gaming and conventional OT led to different long-term sensorimotor recovery of the UL after sub-acute stroke. However, when applied within the first month after stroke, video gaming was more efficient than conventional rehabilitation on both sensorimotor recovery and gross grasping function.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01554449).

Caregiver-mediated exercises for improving outcomes after stroke

BACKGROUND

Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

OBJECTIVES

To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, Issue 10), MEDLINE (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

MAIN RESULTS

We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention.We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; P = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; P = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; P = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; P = 0.45; low-quality evidence).Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; P = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; P = 0.37; very low-quality evidence).At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; P = 0.002; low-quality evidence) and quality of life (1 study; physical functioning: MD 12.40, 95% CI 1.67 to 23.13; P = 0.02; mobility: MD 18.20, 95% CI 7.54 to 28.86; P = 0.0008; general recovery: MD 15.10, 95% CI 8.44 to 21.76; P < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; P = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; P < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (i.e.

PATIENT

motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life).In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; P = 0.01; moderate-quality evidence).The methodological quality of the included trials and variability in interventions (e.g. content, timing, and duration), affected the validity and generalisability of these observed results.

AUTHORS' CONCLUSIONS

There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.

A low cost virtual reality system for home based rehabilitation of the arm following stroke: a randomised controlled feasibility trial

Objective:

To assess the feasibility of conducting a randomised controlled trial of a home-based virtual reality system for rehabilitation of the arm following stroke.

Design:

Two group feasibility randomised controlled trial of intervention versus usual care.

Setting:

Patients’ homes.

Participants:

Patients aged 18 or over, with residual arm dysfunction following stroke and no longer receiving any other intensive rehabilitation.

Interventions:

Eight weeks’ use of a low cost home-based virtual reality system employing infra-red capture to translate the position of the hand into game play or usual care.

Main measures:

The primary objective was to collect information on the feasibility of a trial, including recruitment, collection of outcome measures and staff support required. Patients were assessed at three time points using the Wolf Motor Function Test, Nine-Hole Peg Test, Motor Activity Log and Nottingham Extended Activities of Daily Living.

Results:

Over 15 months only 47 people were referred to the team. Twenty seven were randomised and 18 (67%) of those completed final outcome measures. Sample size calculation based on data from the Wolf Motor Function Test indicated a requirement for 38 per group. There was a significantly greater change from baseline in the intervention group on midpoint Wolf Grip strength and two subscales of the final Motor Activity Log. Training in the use of the equipment took a median of 230 minutes per patient.

Conclusions:

To achieve the required sample size, a definitive home-based trial would require additional strategies to boost recruitment rates and adequate resources for patient support.

Does the use of Nintendo Wii SportsTM improve arm function? Trial of WiiTM in Stroke: a randomized controlled trial and economics analysis

OBJECTIVE

The Trial of Wii™ in Stroke investigated the efficacy of using the Nintendo Wii Sports™ (Wii^TM) to improve affected arm function after stroke.

DESIGN

Multicentre, pragmatic, parallel group, randomized controlled trial.

SETTING

Home-based rehabilitation.

SUBJECTS

A total of 240 participants aged 24-90 years with arm weakness following a stroke within the previous six months.

INTERVENTION

Participants were randomly assigned to exercise daily for six weeks using the Wii^TM or arm exercises at home.

MAIN MEASURES

Primary outcome was change in the affected arm function at six weeks follow-up using the Action Research Arm Test. Secondary outcomes included occupational performance, quality of life, arm function at six months and a cost effectiveness analysis.

RESULTS

The study was completed by 209 participants (87.1%). There was no significant difference in the primary outcome of affected arm function at six weeks follow-up (mean difference -1.7, 95% CI -3.9 to 0.5, p = 0.12) and no significant difference in secondary outcomes, including occupational performance, quality of life or arm function at six months, between the two groups. No serious adverse events related to the study treatment were reported. The cost effectiveness analysis showed that the Wii^TM was more expensive than arm exercises £1106 (SD 1656) vs. £730 (SD 829) (probability 0.866).

CONCLUSION

The trial showed that the Wii^TM was not superior to arm exercises in home-based rehabilitation for stroke survivors with arm weakness. The Wii^TM was well tolerated but more expensive than arm exercises.

Virtual rehabilitation: What are the practical barriers for home-based research?

Virtual reality technologies are becoming increasingly accessible and affordable to deliver, and consequently the interest in applying virtual reality within rehabilitation is growing. This has resulted in the emergence of research exploring the utility of virtual reality and interactive video gaming interventions for home use by patients. The aim of this paper is to highlight the practical factors and difficulties that may be encountered in research in this area, and to make recommendations for addressing these. Whilst this paper focuses on examples drawn mainly from stroke rehabilitation research, many of the issues raised are relevant to other conditions where virtual reality approaches have the potential to be applied to home-based rehabilitation.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training after stroke reduces death, dependence, and disability and to assess the effects of training with regard to adverse events, risk factors, physical fitness, mobility, physical function, quality of life, mood, and cognitive function. Interventions to improve cognitive function have attracted increased attention after being identified as the highest rated research priority for life after stroke. Therefore we have added this class of outcomes to this updated review.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1: searched February 2015), MEDLINE (1966 to February 2015), EMBASE (1980 to February 2015), CINAHL (1982 to February 2015), SPORTDiscus (1949 to February 2015), and five additional databases (February 2015). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 58 trials, involving 2797 participants, which comprised cardiorespiratory interventions (28 trials, 1408 participants), resistance interventions (13 trials, 432 participants), and mixed training interventions (17 trials, 957 participants). Thirteen deaths occurred before the end of the intervention and a further nine before the end of follow-up. No dependence data were reported. Diverse outcome measures restricted pooling of data. Global indices of disability show moderate improvement after cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) 0.19 to 0.84; P value = 0.002) and by a small amount after mixed training (SMD 0.26, 95% CI 0.04 to 0.49; P value = 0.02); benefits at follow-up (i.e. after training had stopped) were unclear. There were too few data to assess the effects of resistance training.Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 6.71 metres per minute, 95% CI 2.73 to 10.69), preferred gait speed (MD 4.28 metres per minute, 95% CI 1.71 to 6.84), and walking capacity (MD 30.29 metres in six minutes, 95% CI 16.19 to 44.39) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), and walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95). Balance scores improved slightly after mixed training (SMD 0.27, 95% CI 0.07 to 0.47). Some mobility benefits also persisted at the end of follow-up. The variability, quality of the included trials, and lack of data prevents conclusions about other outcomes and limits generalisability of the observed results.

AUTHORS' CONCLUSIONS

Cardiorespiratory training and, to a lesser extent, mixed training reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve the speed and tolerance of walking; some improvement in balance could also occur. There is insufficient evidence to support the use of resistance training. The effects of training on death and dependence after stroke are still unclear but these outcomes are rarely observed in physical fitness training trials. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription and identify long-term benefits.

Is Nintendo Wii an Effective Intervention for Individuals With Stroke? A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the effectiveness of Nintendo Wii compared with no intervention or other exercise interventions in the rehabilitation of adults with stroke.

DATA SOURCES

Seven electronic databases were systematically searched to source for full-text studies published in peer-reviewed journals up to July 2014. Hand searches of reference lists were performed.

STUDY SELECTION

Randomized controlled trials (RCTs) comparing Wii with no intervention or other exercise interventions, in patients with stroke, were selected.

DATA EXTRACTION

Methodological quality was assessed by 2 independent reviewers. Data pertaining to participants, interventions, outcomes, and clinical effectiveness were independently extracted by 2 reviewers using a standardized form and compared for accuracy. We calculated mean or standardized mean differences for analysis of continuous variables. Risk ratios were derived and 95% confidence intervals (CIs) calculated.

DATA SYNTHESIS

Six studies were included. Three trials (64 participants) compared Wii and conventional rehabilitation versus conventional rehabilitation alone. Three trials (102 participants) compared Wii with other exercise interventions. The addition of Wii to conventional rehabilitation resulted in significant mean differences in favor of additional Wii compared with standard care for Timed Up and Go test (TUG) (0.81 points, CI 0.29-1.33, P = .002), but not for other mobility and functional outcomes: Functional Independence Measure (FIM) score (0.45, CI -0.21-1.11, P = .18), Berg Balance Score (-0.64, CI -3.66-2.39, P = .68), anteroposterior postural sway (0.23, CI -0.38-0.84, P = .46). No serious adverse events were reported, and when Wii was compared with exercise alone, we demonstrated a decreased risk of participants dropping out of follow-up (RR 0.40, CI 0.20-0.78, P = .007).

CONCLUSIONS

The addition of Wii gaming to conventional rehabilitation in patients with chronic stroke significantly improved performance in TUG and not in the other physical measures. The pooled effect was small and not beyond the minimal detectable change. However, Wii can be used safely in patients with stroke and participants were less likely to drop out in the Wii group. This review highlights the need for further high-quality studies to demonstrate the efficacy of Wii in stroke rehabilitation.