Using Exergaming as a Therapeutic Intervention Dr Murray Griffin Activity promoting computer systems Balance board games Anecdotal evidence The Wii is used in a number of settings within the NHS elderly and patients with pathologies (stroke, amputation, and Parkinson disease). The Wii has also been employed to facilitate rehabilitation at Department of Veterans Affairs (VA) centres in the US. http://www.wiihabilitation.co.uk/ Why we “need” Exergaming • Like most groups PwMS need to do more exercise eg. Motl (2014) • Energy Expenditure – Typically Exergaming uses 30% less energy than traditional exercise (Taylor el 2014) • There is some evidence that it is beneficial - pubmed search 375 articles relevant to Exergaming (11 in MS) • Not all confirm the efficacy of an Exergaming intervention Using the Wii for persons with MS Nilsgard et al 2012 – Wii vs. No intervention PT supervised sessions (1:1). 30 min, 2 x week for 6-7 weeks Balance exercises playing Wii-Fit Plus Nilsgard et al 2012 – Outcomes No significant difference between Wii and control in all outcomes: TUG TUG cognitive 4 square step Timed chair stands 25 ft walk DGI - Dynamic Gait Index ABC (Activities Balance Confidence scale) MSWS-12 – (MS walking Scale) However…… Guidi et al (2012) A pilot study – Wii vs. control Wii – Physiofun balance training (WiiWare) Control group - no improvement Wii group – improved balance measures Brichetto et al (2013) – Wii vs. traditional rehabilitation 12 session – 3 x 60 min per week Wii – supervised Wii balance board/Wii Fit game play Traditional – static/dynamic exercises in both SLS/DLS and half kneeling exercises. Brichetto et al (2013) – Wii vs. traditional rehabilitation Both modes improved outcomes. Eyes open/closed balance and MFIS (Modified Fatigue Impact Scale) However – the interaction suggests that there was a greater effect over time for the Wii-group. So – disagrees with Nilsgard et al (2012) …..why?? Different methodological approach (dynamic vs. static measures; duration of training sessions) Activity promoting computer games Current research with the Wii Future directions in rehabilitation Wii in Rehabilitation Reasons for employing video games in rehabilitation • Increased motivation • Distraction from mundane and boring and/or painful treatments Falls •Currently costs the NHS £1.7 billion per year (£4.6 million pounds per day) •Around 14,000 die annually after a fall (Age UK, 2010). • Falls negatively effect well being and quality of life (QoL). • 80% of women surveyed would rather be dead than experience the loss of independence and QoL that results from a bad hip fracture (after a fall) and subsequent admission to a nursing home (Salkeld et al., 2000) • It is widely recognised that PwMS have impaired balance that may lead to frequent falls • PwMS who have reported falling in the last 3 months have a high prevalence of falls (approximately 2 falls per month) Introducing the Wii into training: What games to play ? Balance board games Bubble river and tilt table seemed to be easiest – most popular Also play • Ski slalom • Tightrope • Ski jump Balance board games The effectiveness of Wii training in a hospital falls programme Griffin et al., (2012). Journal of the American Geriatrics Society. 60: 2. 385-387 The aim was to evaluate the efficacy of including the Wii in an established falls prevention training program. Methods Falls prevention training at CHUFT lasts for 7 weeks. The Wii was introduced into the training. Non-Wii group (n =24) and Wii group (n =41 ). The Wii group performed the same 7 week prevention training as the Non-Wii except the patients played a number of balance games on the Wii. Measures: TUG, functional reach, Turn180, flexibility Results Functional measures Control 1:1 Wii Timed Up and Go time (s) %∆ 7.50% 53% 27% 10 m walk speed (m.s-1) %∆ 12% 29% 40% Confidence in Balance score %∆ 5% 0% 32% Psychological measures Control 1:1 Wii Overall (TMD) %∆ 0.75% 25% 30% Rosenberg Self-Esteem Scale %∆ 4% 16% 18% Outcomes None of the women fell during the training session or 18 weeks post- intervention. Functional outcomes The woman who trained on the Wii reduced her TUG time by 27%, to below the cut-off time of 13.5 s for predicting fallers. The increase in walking speed moved all three from slow (≤0.6 m/s) to intermediate (0.6–1.0 m/s) walkers. The walking velocity of the woman who trained on the Wii after training approached the clinically meaningful cut point for normal gait speed (1.0 m/s). Psychological outcomes Improvements in well-being and self-esteem after intervention for all three women The most change was seen in the woman who trained on the Wii and the least in the control. Comparing the energy expenditure of Nintendo Wii based therapy vs. traditional physiotherapy Griffin et al (2013) Games for Health Journal: Research, Development, and Clinical Applications Compare the physiological cost and enjoyment of Wii-Fit based therapy to traditional based physiotherapy training. Cardiorespiratory and enjoyment measurements in 35 participants (young adults) carrying out both Wii-Fit based training and traditional physiotherapy based training. Results EE (J/kg/min) Wii Traditional Task performance - Young 146.5 ± 35.2* 186.0 ± 24.8 Task performance - Elderly 135.2 ± 47.6* 189.1 ± 42.1 *P≤0.001 significantly different from traditional The lower physiological cost for the Wii-Fit suggests that it is less demanding than the traditional therapy even though this modality of training has been shown to elicit improvements in rehabilitative outcomes. This suggests that frailer individuals or those who fatigue easily, or whose energy levels are impaired (i.e. PwMS), may benefit from using the Wii-Fit as rehabilitative tool because of the lower demand on energy. Planned future work in PwMS. Does customised Exer•gaming improve balance and reduce falls in adults affected by MS? • Move towards a more therapeutically orientated tool = change in gaming platform (XBox Kinect). • The Xbox Kinect is a programmable tool. Virtualware has produced video games that can be tailored to the individual and are specifically designed for PwMS. •Randomised controlled trial •usual care; •usual care plus exercise; •usual care plus Wii (generic) Exergaming •usual care plus Kinect (bespoke) Exergames •This research will target PwMS who are fallers and have a Expanded Disability Status Scale (EDSS) between 4-6 .