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In a small open-label trial, patients who had had a mild stroke showed some improvements in grip strength and motion speed after playing with the Wii technology.
SAN ANTONIO, TX—Patients with arm weakness due to stroke appear to regain speed of motion and may improve grip strength by a two-week course of playing Nintendo Wii tennis and a cooking skills game.
“Our outcomes are something that is meaningful for patients, for physical therapists, for people who help in rehabilitation, and to neurologists,” said Gustavo Saposnik, MD, director of the Stroke Outcomes Research Unit at the Li Ka Shing Institute, St. Michael's Hospital and lead investigator of the study carried out at the Toronto Rehabilitation Institute at the University of Toronto.
Dr. Saposnik, reporting his work here at the International Stroke Conference, said that the improvements seen after two weeks were maintained. “The main result is that we found benefit at four weeks after the intervention ended. The whole point is whether the benefit is sustainable,” he said.
However Dr. Saposnik noted that his work was an open-label pilot study and therefore, he said, it is premature to recommend that stroke patients go out and buy a Wii console. “We advise these patients to wait until we have clear evidence from a larger randomized clinical trial and that is underway,” he said.
Dr. Saposnik said the pilot study “represents the first steps in understanding how virtual reality technology may improve motor function and it provides a hope that this system may actually augment or enhance motor improvement after a stroke. It is a proof-of-principle concept.”
He said the study was difficult to perform, because the researchers were diligent in excluding anyone who might be at risk of experiencing a seizure — a significant adverse event that could skew the results of the study
Eventually, doctors were able to recruit 20 patients. These stroke survivors were recruited about two months after suffering their stroke. They were assigned to playing recreational games — card games or Jenga, a block stacking and balancing game—or they played Wii tennis and Wii Cooking Mama. The cooking game involves movements that simulate cutting a potato, peeling an onion, slicing meat, and shredding cheese.
“In order to be eligible for the study, patients basically had to have some degree of weakness but also some degree of strength,” Dr. Saposnik explained. “They have to be able, basically, to touch their chin or the contralateral knee. They may have a significant weakness but at least they are able to move their arm. If somebody had a very severe distal weakness but proximally mild to moderate weakness, we allowed patients to use a strap to hold the controller. Most of the patients had a mild to moderate deficit. Patients who had a severe deficit and couldn't move their arm were not eligible for the study.”
Figure. DR. GUSTAVO SAPOSNIK:“Our outcomes are something that is meaningful for patients, for physical therapists, for people who help in rehabilitation, and to neurologists.”
“At the end of the intervention and after a four week post-intervention, we used tests to measure whether there was a difference in terms of several motor skills and grip strength,” Dr. Saposnik said. Since this was not a randomized study, the researchers used multivariate analyses to sort through confounding patient characteristics, and concluded that the patients in the group that used the Wii were able to do these tasks faster than those who did not have the same intervention.
On one motor function test, for example, patients assigned to recreational activity were able to complete tasks in 28 seconds; those playing Wii were able to complete the test in19.8 seconds, a statistically significant difference.
“We are not expecting that this will replace rehabilitation,” Dr. Saposnik said. “This could be used as an adjunct therapy in combination with other rehabilitation. If this is proven to be true in a larger randomized study, it may facilitate stroke rehabilitation.”
Figure. DR. PAMELA DUNCAN:“One of the things about the technology in this particular study is that it works very well in individuals who have a mild stroke who can move but don't move well and don't move often.”
He noted a number of barriers make it difficult for patients to undergo stroke rehabilitation: among them are the energy expended in the actual intervention as well as transportation costs to a facility and the time and inconvenience to caregivers.
“Some patients may actually benefit from doing rehab, initially under supervision, then by themselves at home,” Dr. Saposnik said. “Virtual reality is relatively attractive compared to standard physical therapy which is boring.”
He also speculated as to why the patients showed an improvement using the Wii technology. The activity is highly-repetitive, task-specific, and intense, he said, and these three paradigms seem to affect motor improvement in stroke. “There is some evidence that if you are moving your hand, some part of your brain is activated,” Dr. Saposnik said. These activities may enhance brain plasticity.
“We believe that by patients watching themselves play Wii and adjusting their movements they may activate brain plasticity,” Dr. Saposnik said. “We don't really have this evidence from our study. We would require functional MRI to prove this,” he suggested.
Commenting on the study, Pamela Duncan, PhD, professor of physical therapy at Duke University School of Medicine, Durham, NC, who is also a spokesperson for the American Stroke Association, said: In order to get optimized recovery you need lots of repetition. General exercise can be very boring if someone tells you to just exercise and exercise.
“What is so intriguing about the gaming technology is that it engages the patient both cognitively and motivationally and it allows you to do numerous repetitions. So if you combine Wii and a lot of the gaming with specific, goal-directed activities, you can get the patients to practice on their own a lot and they enjoy it.”
“This technology is being put in nursing homes, in rehab facilities, and outpatient facilities,” she continued. “We haven't systematically evaluated it as these investigators are trying to do but it is already being implemented in practice.”
“One of the things about the technology in this particular study is that it works very well in individuals who have a mild stroke who can move but don't move well and don't move often,” Dr. Duncan continued. “It allows individuals who have some motor control to practice, practice, practice, and be engaged. They can play it with their grandchildren or their spouses.”
Dr. Saposnik said that the limited number of patients in the study did not rule out whether there are downsides to using the Wii. “The study showed that there were no major concerns.” On the other hand, he added, there were not a large enough number of patients to rule out less common side effects or risks.
A study is being designed to include 120 patients in seven to eight centers in Canada, Dr. Saposnik said. He noted that the study was performed without input or assistance from Nintendo. He said the company did not appear to be interested in using its devices in the health care arena. •Back to top