Scandinavian Journal of Occupational Therapy.

2012; 19: 457463

ORIGINAL ARTICLE

Stroke patients experiences with Wii Sports during inpatient rehabilitation

DORA CELINDER1 & HANNE PEOPLES2

1 2

Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Glostrup, Denmark, and Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark

Abstract Introduction: Commercial virtual reality games have been used as adjunct therapy for stroke rehabilitation, mainly after patients have been discharged. The aim of this study was to explore stroke patients experiences with Wii Sports as a supplement to conventional occupational therapy in a controlled hospital setting. Materials and methods: The study had a qualitative triangulation design that included semi-structured interviews and eld notes. Nine Danish stroke patients participated, receiving between one and nine interventions with Wii Sports during a three-week period. Responses were coded by qualitative content analysis. Results: Analysis revealed one overarching category, Connecting to past, present, and future occupations, and three categories that encompassed patients experiences with Wii: (i) variety, (ii) engagement, and (iii) obstacles and challenges. Interview ndings were conrmed by eld notes that included observations of engagement and challenges. Discussion: Stroke patients in hospital settings may experience Wii Sports as a benecial and challenging occupation for both rehabilitation and leisure. Incorporation of Wii Sports into conventional occupational therapy services may benet patient rehabilitation directly or provide motivation for alternative leisure activities.

Key words: stroke, rehabilitation, qualitative content analysis, Nintendo Wii, leisure

Introduction In Denmark, 30 00040 000 people are currently living with some level of disability as a consequence of stroke (1). According to the Danish National Board of Health, approximately 12 500 people were hospitalized due to stroke in 2009 (2). Early rehabilitation is critical as maximum improvements in activities of daily living (ADL) are achieved within the rst ve months after stroke (3). Occupational therapy is integral to improving ADL (46). According to the Canadian Model of Occupational Performance and Engagement (CMOP-E), the overall aims of occupational therapy are to promote engagement in everyday living and to maximize independence through meaningful or necessary occupations (7,8). Common occupations during inpatient stroke

rehabilitation include self care, domestic, and to a lesser degree leisure activities (9). A Danish report underscores the need for diverse stroke rehabilitation methods, including information technology (IT) (10). One possible application of IT is virtual reality (VR), which has been used frequently over the past decade for motor and cognitive rehabilitation of children, adolescents, and adults (1116). Virtual reality also holds great potential as a benecial leisure intervention for stroke patients (17). A review of the effectiveness of VR in upper extremity stroke rehabilitation concluded that current evidence is limited yet encouraging (18). Stroke patients perceive VR as an opportunity for participation, although it may not fully replace authentic experiences (19). Rehabilitation using VR may also induce reorganization in the sensorimotor cortex (20). One popular VR videogame

Correspondence: D. Celinder, Occupational Therapist, Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Glostrup, Nordre Ringvej 57, DK-2600 Glostrup, Denmark. Tel: +45 38633106. Fax: +45 38633913. E-mail: domace01@regionh.dk (Received 19 June 2011; revised 1 January 2012; accepted 3 January 2012) ISSN 1103-8128 print/ISSN 1651-2014 online 2012 Informa Healthcare DOI: 10.3109/11038128.2012.655307

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D. Celinder & H. Peoples at hospitals in the capital region of Denmark during September 2009 and from March to May 2010. Duration of hospital stay at the beginning of this study was 946 days (mean 31.11 days, SD 13.17). Patient characteristics are presented in Table I. All patients gave informed consent, and anonymity was assured by the use of pseudonyms. Participants were chosen to reect diversity in gender, age, physical and cognitive impairments, and prior knowledge of Wii. A meta-analysis of VR in stroke rehabilitation revealed that most studies included only patients with mild to moderate stroke-related disabilities (26). In order to achieve a broader representation of stroke severity in this study, the stroke patients recruited had symptoms ranging from mild, allowing patients to remain self-sufcient in self care, to severe symptoms that required support in all aspects of life. Inclusion criteria were (i) patients currently undergoing occupational therapy and considered to have a continued need for occupational therapy following discharge from hospital due to inability to perform ADL independently, (ii) age 18 years or older, (iii) medically conrmed clinical stroke, and (iv) patients considered suitable for participation by an interprofessional team (occupational therapist, physiotherapist, speech therapist, nurse, and medical doctor). Exclusion criteria were transient ischemic attacks, epilepsy, dizziness, or implanted medical devices, the latter because Nintendo, the manufacturer of Wii, recommends against use by patients with implanted devices (27). Interventions Interventions with Wii were performed individually in a rehabilitation room at the hospital with support from one of seven occupational therapists. An occupational therapist who knew the patient assisted by making adjustments and by providing physical and verbal support. The duration of each session was approximately 30 min. The overall intervention period lasted a maximum of three weeks with no more than three Wii sessions each week. The number of sessions completed by each patient is shown in Table I. Data collection and procedure Data collection consisted of eld notes during intervention and semi-structured qualitative interviews following the study trial. Field notes included observations of the patients immediate physical and emotional reactions, both verbal and non-verbal. The rst author conducted a one-on-one interview with each participant, lasting approximately 30 min, in an undisturbed room at the hospital. The patients were asked questions based on a semi-structured interview guide containing general topics. The

is Wii Sports, in which the direction and speed of hand movements are transferred to an avatar via a handheld wireless controller, allowing the player to engage in a variety of virtual sporting activities. Wii provides auditory and visual feedback from the screen and tactile feedback from the controller. A randomized pilot trial has shown that Wii promotes motor recovery and is a safe, feasible, and potentially effective tool in stroke rehabilitation (21). A case report also found that rehabilitation therapy including Wii Sports improved the visual-perceptual processing (visual discrimination), postural control, and functional mobility (ambulation) of an adolescent cerebral palsy patient (22), and therapists have reported that patients enjoy using Wii within rehabilitation programmes (23,24). Previous research in stroke rehabilitation using VR games like Wii has focused on improving motor functions rather than on patients experiences during rehabilitation in hospital settings. The aim of this study was to explore stroke inpatients experiences of Wii Sports when used as a supplement to conventional occupational therapy practice. This paper summarizes the qualitative results derived from a pilot study of nine stoke patients. Materials and methods Design This study used a qualitative triangulation design to investigate patients experiences (25). Prior to patient enrolment, the rst author formulated guidelines for the use of Wii Sports in occupational therapy based on selected literature (1524) and basic rehabilitation principles in order to dene patient inclusion criteria and enhance patient safety during sessions. The occupational therapists were trained in the use of these guidelines and Wii during a practical workshop. Data were obtained via transcripts of individual semi-structured patient interviews following the intervention programme. Occupational therapists also recorded patients reactions in eld notes during each intervention. This study was approved by the Danish Data Protection Agency, and the procedures were in accordance with the Helsinki Declaration of 1975 as revised in 1983. Approval was sought from the Danish National Committee for Research Ethics; the committee determined that approval was unnecessary for this type of study. Participants Nine stroke patients age 5195 years (mean 68.22 years, SD 13.57) were recruited from two stroke units

Stroke patients experiences with Wii

Notes: All names are pseudonyms. The Wii hand and number of Wii sessions are derived from eld notes. Abbreviations: M = male; F = female; I = ischaemic; H = haemorrhagic; ND = not described; L = left; R = right. First L, then R Ivan ND ND 71 43 M R L 6

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Left side inattention

interview guide ensured that all patients were asked questions relating to the same topics associated with their physical and emotional experiences during Wii sessions. The interview was semi-structured to allow the interviewer to respond to answers and facilitate participant storytelling about experiences during the intervention with Wii, thereby capturing patients spontaneous responses and reections. Whenever needed, the interviewer pursued and claried the meaning of answers. All interviews were audiorecorded and transcribed verbatim by the interviewer within 48 h. Data analysis Interview transcripts were initially analysed by the rst author using the method of qualitative content analysis (28,29). Each transcript was reviewed twice, and margin notes were used to clarify patient experiences. Phrases relevant to study aims were coded in the style of open coding throughout all transcripts. Codes were initially sorted into three categories and nine subcategories. Therapist observations from eld notes were used to aid categorization. The authors discussed and revised categories and nally formulated one overarching category. All categories are integrated in Table II. Patients statements that are included in the Results were translated into English by the authors after discussion and consultation with native English-speaking editors. Results Field notes Patient characteristics and selected eld note data are included in Table I. Two patients participated only once because they were discharged earlier than expected. During the sessions, patients were silent or spoke only of topics relevant to the game. Initially, patients with no prior knowledge of Wii were nervous or sceptical, but they became engaged within one or
Table II. Categories derived from qualitative content analysis of interview data. Connecting to past, present, or future meaningful occupations Obstacles and challenges Being disappointed Physical challenges Cognitive challenges

Left side neglect

Hans

62

24

Gabriella

68

27

R R R R Both First L, then R L R

Impaired problem solving

None

Flora

ND

81

17

Impaired problem solving

Elias

71

46

Uncritical

Dan

51

Christian

Impaired initiative

60

41

Left side inattention

Birgitte

95

44

Impaired initiative

Anton

29

55

Table I. Patient characteristics.

Cognitive impairment

Duration of hospital stay before enrolment (days)

Variety Breaking up the day New topic of conversation Desiring meaningful occupations

Engagement Excitement and motivation Gaining control and benets Wishing to play Wii again

More affected side

Hand dominance

Wii hand

Wii sessions

Stroke type

Gender

Age

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D. Celinder & H. Peoples example, Flora experienced difculty with Wii, but said I probably looked forward to it . . . because something happened. Several patients said that Wii became a recurring topic of conversation on the ward with their visitors or among peers. For some patients it was important to share the experiences with others and encouraging support was given by staff, peers, and/or family. Hans pointed out the signicance of sharing the experience with his family. [While] my wife watched [me playing Wii], she said, Oh yes, it looks like a lot of fun. We should probably have one like that at home, also for our grandchildren. Many patients were pleased by the ability to engage in simulations of valued past or current occupations. Elias stated that the [Wii] bowling ball is not so heavy. I have gone bowling in the past, but as far as I can see, I will not go again for a long time. Now, I have heard that there is a shing game. This I want to try because I have been shing for more than fty years. Elias was very concentrated and engaged during the Wii sessions. Some patients who had used Wii prior to their stroke remembered positive experiences of socializing with friends, children, or grandchildren. Birgitte said that before the stroke she played Wii with her grandchildren, but had no desire to play after being discharged. Nonetheless, she felt a real need for occupation. Not much happens here, [it would be] nice with more activities (Birgitte). This desire for meaningful activities and the perception that not much happened on the ward was common. In the beginning [of my hospitalization], nothing happened. I thought it was odd (Christian). Engagement This category encompassed three subcategories: (i) excitement and motivation, (ii) gaining control and benets, and (iii) wishing to play Wii again. According to Ivan, the Wii experience was connected to the rehabilitation. The rehabilitation sessions can bring a bit of colour to daily life (Ivan). Patients viewed the opportunity to play Wii as an important factor leading to a feeling of engagement during rehabilitation. Wii provided motivation for rehabilitation. You get motivated to go down there [to play Wii], and there you have a faster result. You can see if you win or what you can do. It motivates you for the next session, for example in bowling, to beat your own record and get more and more points (Christian). Male patients especially expressed a feeling of vigour and control associated with playing Wii. For example, Ivan stated It [should] really be with force. You nd out in bowling, that its no use to make soft moves constantly; the pace of the ball wont be

two sessions, showing recurring smiles and signs of immersion while they concentrated on the game. Other frequent observations included sighs, irritation, or frustration whenever the patients movements or reaction speeds were insufcient. During the rst session, several patients reported physical or mental fatigue and required breaks, but by the last session, observations of contentment and smiles increased, and no breaks were required. In a few cases, therapists observed indications of boredom interpreted as impaired concentration, and these patients required additional therapeutic support. In other cases, therapists noted that patients were fully engaged but exhibited no facial or emotional reactions. Patients opinions were divided; some felt that the game was boring or difcult, while others found it entertaining and wanted to continue beyond the scheduled 30-min session. Despite these varied reactions (concentration, immersion, joy, disappointment, annoyance, or boredom), most indicated engagement with the activity. Interviews An overarching category emerged related to patients experiences, Connecting to past, present, or future occupations. The interviews prompted the patients to reect and connect to valued or desired meaningful occupations, regardless of whether the experiences with Wii were more or less positive. Narratives of past occupations (prior to the stroke) involved work or leisure. Those of present occupations involved fragility in daily endeavour or resilience with a desire to continue rehabilitation with Wii during hospitalization and to engage in other leisure occupations as well. Finally, narratives of future occupations involved a desire to continue using Wii during outpatient rehabilitation and with friends or family, as well as to engage in other leisure occupations. The overarching category encompassed three categories, each with multiple related subcategories (see Table II). In the following description of the categories, illustrative quotes from patients are included. Variety This category of patient statements was related to the need for variety in daily routines and encompassed three subcategories: (i) breaking up the day, (ii) new topic of conversation, and (iii) desiring meaningful occupations. Patients stated that their stroke and hospitalization made every day a monotonous routine, which highlighted the importance of breaking up the day by engaging in meaningful occupations. In general, Wii sessions were seen as a pleasant respite. For

Stroke patients experiences with Wii sufcient. It must have a proper push down [the bowling alley]. Some patients reported benets and improved skills. For example, Hans reported reduced neglect after participating. I know that I went in there [to play Wii] to see if it could help or reveal anything about my left-sided neglect. I must say I do not understand how it could possibly do that, but I must admit that I feel it has helped tremendously. I still have some left-sided trouble, but it has become signicantly better after I have done it [Wii] (Hans). Elias also mentioned experiencing improved cognitive skills. Despite nding Wii to be a great challenge, he said I also think it helps my thinking, and I am very pleased. I suspect that the gaps are about to heal, and they are being lled up with something positive, which is a good thing (Elias). Several patients expressed a desire to play Wii again, as the excitement of playing was motivating. Elias and Ivan had no experience with Wii prior to participation in this study, but both used the word interesting to describe it, suggesting a sense of fascination or discovery. Christian, who lived in a seniors home before the stroke, reported that his fellow residents bought a Wii and started to play during his hospitalization. He was looking forward to playing with them after his discharge. Wii seemed desirable as a future leisure occupation for some patients. Anton stated that he wished that his local rehabilitation facility had one. Gabriella was not initially eager to continue Wii after discharge, but later expressed a desire to play again, I think I will try it [Wii] at my daughters place, just for the sake of trying again. Ivan experienced pain in his affected arm during the study, allegedly because he had been sleeping on the arm. However, this obstacle did not prevent him from wanting to try Wii again, as he said, I do not know whether the municipality has such a game. If they do [have one], I will try again. Obstacles and challenges This category encompassed three subcategories: (i) being disappointed, (ii) physical challenges, and (iii) cognitive challenges. In general, patients experienced reduced skills while playing Wii. Disappointments with Wii were closely connected to present challenges during rehabilitation. The need for quick reactions was seen as a challenge that caused disappointment and frustration because it stopped the game and required intervention by the occupational therapist. As Anton said, When I accidentally double-tapped the B button, I got mad at myself. Patients reported varying levels of physical activity prior to stroke. For the majority, the type of physical activity simulated by Wii happened in their youth, and

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rehabilitation using Wii was perceived as a series of challenges. Both Anton and Gabriella talked about their difculties with Wii while sighing or shaking their heads. Patients had trouble with the complex motor tasks of simultaneously handling the controller while pressing the buttons and moving the arm using sufcient power and range. Patients were also challenged cognitively, reporting how demanding and exhausting sessions were. Elias said, It felt very stressful in my brain. I could feel when I had been playing Wii, how tired I was. And I used so many resources on it . . . sometimes I was about to collapse. I did not want to have lunch or anything. I was so, so tired . . . as if I had been out walking 20 kilometres. Discussion We recorded stroke patients experiences using Wii Sports during hospital rehabilitation through interviews and direct eld observations. Stroke patients reported both benecial and challenging experiences when Wii was included in their rehabilitation. This study supports previous ndings of positive engagement and motivation during VR-based leisure activities (11) and provides a guide for further renements of this rehabilitation strategy by revealing experiences of difculty and disappointment. Patient statements in the category of obstacles and challenges related to frustration and fatigue, illustrating that physical and cognitive challenges were closely related. Playing Wii required physical stability, repetitive movements, concentration, and for some patients the learning of new skills. Fatigue could be due to physical impairments related to selective motor control, trunk stability, arm movements, or balance, as well as cognitive impairments related to concentration, attention, understanding the game, or mental fatigue. In addition, the reasons for negative experiences with Wii could be caused by disinterest, scepticism, or fear of unfamiliar technology. Common technologies are often perceived as difcult by older people with cognitive impairments (30,31), so technologies such as Wii could pose particular problems for stroke patients. Indeed, some patients had no interest in playing Wii. For example, although Birgitte played Wii with her grandchildren before the stroke, her motivation was to spend time with them, not to play Wii per se. For most patients, challenges did not prevent participation, as the patients were engaged and were supported by an occupational therapist while playing Wii. Patients who experienced disappointment because of reduced skills while playing Wii were most likely experiencing similar difculties in other occupations, including basic ADL. However, the engagement and excitement during Wii sessions appeared to compensate for some patients discontent.

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D. Celinder & H. Peoples Wii as a meaningful occupation when it had this dual focus. When patients preferences are considered, Wii Sports can be an appropriate supplement to conventional occupational therapy services. Methodological considerations Several limitations of this study deserve mention. First, the ndings represent experiences of only nine patients, two of whom had only one Wii session due to early discharge. Disagreements exists on how many subjects are sufcient for qualitative research; Kvale recommended 15 to 20 subjects (36), while Creswell recommended up to 10 (37). It is also possible that some information from these patients was missed despite extensive interviews and conrmation by eld observations. Second, the patients were included after interprofessional team agreement, which could introduce selection bias. Third, the presence of cognitive disabilities, including aphasia, minimized the richness of narratives, although again eld observations partially compensated for verbal limitations or memory lapses. Strengths of this study included triangulation of data, which limited interviewer bias, and the completion of all interviews by the same investigator. Clinical implications and need for further research Our results suggest that Wii could be an effective therapeutic tool in occupational therapy for promoting stroke inpatients engagement in leisure occupations and potentially improving physical and cognitive impairments. Leisure occupations, especially activities that can be adapted to each patients skill level, may improve long-term clinical outcome by promoting engagement in therapy and providing patients with recreational and social opportunities following discharge. Future research could investigate how Wii affects socialization during group occupational therapy for stroke patients and whether Wii affects ADL performance in individual stroke patients. Acknowledgements: The authors wish to thank the stroke patients for sharing their experiences, the occupational therapists for valuable assistance, and the interprofessional teams for support. This study was supported by the Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Glostrup and by the Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre. Research grants were provided rst author by Copenhagen University Hospital in Hvidovre, the Tryg Foundation, and the Danish Association of Occupational Therapists.

Benets of Wii included engagement and added variety to daily routines. Wii gives instant feedback and an opportunity to observe ones own movements displayed on a screen, generating positive reinforcement (21). Some patients experienced engagement and concentration and even lost track of time. These are some of the prerequisites for the feeling of ow, which involves concentration, losing track of time, clear goals, immediate feedback, sense of control, balancing skills and challenges, and positive reinforcement so that the activity becomes worth doing for its own sake. When people experience ow, they stop worrying and experience interest and arousal (32,33). Wii was quite challenging for the majority of patients. However, when the activity was perceived as meaningful, enthusiasm and signs of ow were observed in some patients. A lack of emotional reactions was observed in several of the right hemisphere stroke patients, such as Elias, but it is important not to misinterpret at affect as a lack of interest. A signicant nding in this study of stroke patients experiences with Wii was that it provided a means for the patients to reect and connect to past, present, or future meaningful occupations. This suggests that the experience with Wii was meaningful whether or not it was positive, consistent with a previous study (19) that observed stroke patients perceive opportunities for participation while interacting in VR games. A stroke changes a patients daily life signicantly, as illness and disability limit daily occupations (34). It is therefore not surprising that stroke patients emphasized the importance of variety in their daily routines during inpatient rehabilitation. By including new game technologies in rehabilitation, occupational therapists can present different physical and cognitive challenges while promoting leisure and providing variety. According to the basic assumptions of CMOP-E (7), people need occupations and occupations have therapeutic potential. The CMOP-E denes the dynamic interactions between the person, occupation, and environment. Each patients perceptions of Wii reected their own personal impairments. When engagement was present, Wii was perceived as a meaningful occupation, meeting a need for variety in the environment. As occupational therapy for stroke patients in hospital environments has a tendency to focus on impairments or basic ADL over leisure occupations (9,35), occupational therapists could take advantage of VR technologies like Wii to incorporate leisure occupations that may directly or indirectly aid in rehabilitation. The potential for Wii in rehabilitation is to improve impairments and provide leisure occupation. However, occupational therapy interventions with Wii require graduated support to enable these experiences of meaningful occupation. The present study indicated that some hospitalized stroke patients experienced

Stroke patients experiences with Wii Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper. References
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