Unibaso-Markaida et al. Journal of NeuroEngineering and Rehabilitation (2019) 16:32 https://doi.org/10.1186/s12984-019-0500-5 RESEARCH Open Access Effect of the Wii Sports Resort on the improvement in attention, processing speed and working memory in moderate stroke Iratxe Unibaso-Markaida* , Ioseba Iraurgi, Nuria Ortiz-Marqués, Imanol Amayra and Silvia Martínez-Rodríguez Abstract Background: Stroke is the most common neurological disease in the world. After the stroke, some people suffer a cognitive disability. Commercial videogames have been used after stroke for physical rehabilitation; however, their use in cognitive rehabilitation has hardly been studied. The objectives of this study were to analyze attention, processing speed, and working memory in patients with moderate stroke after an intervention with Wii Sports Resort and compared these results with a control group. Methods: A pre-post design study was conducted with 30 moderate stroke patients aged 65 ± 15. The study lasted eight weeks. 15 participated in the intervention group and 15 belong to the control group. They were assessed in attention and processing speed (TMT-A and B) and working memory (Digit Span of WAIS-III). Parametric and effect size tests were used to analyze the improvement of those outcomes and compared both groups. Results: At the baseline, there was no difference between TMT-A and B. A difference was found in the scalar score of TMT-B, as well as in Digit Backward Span and Total Digit Task. In TMT-A and B, the intervention group had better scores than the control group. The intervention group in the Digit Forward Span and the Total Digit obtained a moderate effect size and the control group also obtained a moderate effect size in Total Digit. In the Digit scalar scores, the control group achieved better results than the intervention group. Conclusions: The results on attention, processing speed and working memory improved in both groups. However, according to the effect sizes, the intervention group achieved better results than the control group. In addition, the attention and processing speed improved more than the working memory after the intervention. Although more studies are needed in this area, the results are encouraging for cognitive rehabilitation after stroke. Keywords: Moderate stroke, Cognition, Attention, Processing speed, Working memory, Nintendo Wii sports resort Background suffering a stroke can appear on a physical level, such as Stroke is a really common neurological circulatory dis- motor disorders [3, 4], hemiparesis [5], dizziness, vertigo order, around 795,000 people suffer a new stroke every and various sight and speech problems [6]. There can year and 185,000 are recurrent cases [1]. It is the second also be cognitive side-effects [7, 8], such as cognitive most common cause of dementia, death and more than impairment [9, 10] and various attention disorders [11] 32% people after stroke suffer from cognitive impair- on a spatial cognition [12] and behavioral [13] level. ments [2], and the third most common cause of disabil- Various studies have been conducted to improve the ity which in five years after stroke the disabilities levels physical after-effects and to analyze functional capacity increase from 14 to 23% [1]. The after-effects of through physical activity and motor skills [3, 14, 15], and evidence has been found to suggest that physical activity * Correspondence: [email protected] leads to changes in brain structure [16, 17]. On a phys- Faculty of Psychology at University of Deusto (Office DARC 1 BIS), 24 Avda. ical level, rehabilitation exercises have also been Universidades, 48007 Bilbao, Basque Country, Spain © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Unibaso-Markaida et al. Journal of NeuroEngineering and Rehabilitation (2019) 16:32 Page 2 of 8 designed to recover the mobility of the affected hands and after a stroke who are in unstable clinical condition and upper limbs [4, 18], as well as botox (botulinum or are suffering from complications that require active toxin type A) treatments to improve the spasticity of the medical treatment, people with comprehension difficul- affected upper limbs [19]. ties that prevent them from following verbal instruc- There has also been research on a psychological level tions, people with dementia or cognitive impairment [20] to analyze post-stroke depression [21, 22] and qual- and people with uncontrolled psychiatric illnesses. ity of life [2, 23]. To improve the effects on a cognitive Table 1 shows the socio-demographic variables for the level, rehabilitation studies have been conducted to re- entire sample and by intervention groups, revealing that duce attention deficits [11], aphasia [24] and to work on most of them are comparatively similar. There are statis- cognition to improve functional activity [25, 26]. The tically significant differences in terms of age (p = .014; d cognitive after-effects have been studied in the fields of = .99), in that the control group is older than the inter- neuropsychology [27] and neurorehabilitation [28, 29]. vention group (71.55 vs 58.43, respectively); and in edu- In neuropsychology, two of the most widely used instru- cational level (p = .040), in that the control group has a ments to measure cognitive abilities such as attention, higher proportion of participants with a primary educa- processing speed and working memory, among others, tion (60%), while the intervention group has a greater have been the Trail Making Test [30, 31] and the WAIS proportion, with respect to the expected values, of sub- Digit Span task [32]. jects with higher education (26.7%). Meanwhile, to decrease the affect-effects of strokes, there have also been studies on the impact of physical Measures activity using commercial videogames, and their use in The demographic information was collected using a rehabilitation to control mainly physical consequences questionnaire created by the research team. [33, 34], such as balance and gait disorders [33, 35] and The Trail Making Test (Part A and Part B) created by effects on the upper limbs [36, 37]. However, there is Reitan [40], revised in 1992 [41], measures visuomotor hardly any scientific evidence regarding the use of com- speed, attention, motor function, visual scanning, work- mercial videogames to do physical activity in order to re- ing memory, processing speed and executive function- cover cognition [38, 39]. Hence, the main goal of this ing. The instrument was created for use with people study was to evaluate the effect on the cognitive areas of aged between 16 and 80. The test has two parts. In Part attention, processing speed and working memory in A, the subject has to connect numbers in order from people that have suffered a moderate stroke following an lowest to highest, from 1 to 25; this measures sustained intervention with the Nintendo Wii Sports Resort and attention and hand-to-eye coordination. Part B adds let- compared to a control group who did not receive the ters of the alphabet, whereby numbers from 1 to 13 and intervention with the Nintendo Wii Sport Resort. letters from A to L must be ordered alternately; this as- sesses the ability to alternate between stimuli and, there- Methods fore, mental flexibility. Performance on the test is Participants assessed according to the time taken and errors made. The doctors evaluated all patients in the rehabilitation Our study will consider the time taken. There will be no area, 40 of 182 were selected to this study. However, ten time limit for completing the test, and times will be re- patients didn’t take part in the study because different corded in seconds. circumstances (didn’t want to participate, recurrences, The Digit Span task is a subtest of the WAIS-III scale respiratory problems, etc.). Therefore, the participants created by David Wechsler [42]. It is used to assess at- were 30 patients in rehabilitation at a specific hospital tention, resistance to distraction, immediate auditory for such problems that forms part of the public network memory and working memory. It is applicable to people in Biscay (Basque Country, Spain) (see Fig. 1). aged between 16 and 89. The test consists of three parts. The average age of the participants was 65 (SD = 15) The first is direct digit-sequencing (DST Forward), in and they were mainly men (67%). The inclusion criteria which the participant is given a series of numbers and were: being of legal age (+ 18), having been diagnosed as must repeat them in the same order. The second part in- having suffered a moderate stroke using the Oxfordshire volves digits in reverse order, whereby the participant is Community Stroke Project (OCSP) instrument, a score given a series of numbers and must repeat them back- on the Barthel Scale of between 60 and 90, Mini-Mental wards (DST Backward). One point is awarded for each (MMSE) with a cut-off of 23 or higher, having suffered a correct item and zero points are awarded for each wrong stroke at least 1 month ago, but not more than 1 year answer. Each of these two tasks is scored between 0 and ago and those the preservation of the dominant hand in 16, in such a way that the maximum total score for the order to conduct the assessment tasks. The exclusion Digit Span test is 32 (Total DST).