Scandinavian Journal of Occupational Therapy.

2012; 19: 457463

ORIGINAL ARTICLE

Stroke patients experiences with Wii Sports
during inpatient

rehabilitation

DORA CELINDER1 & HANNE PEOPLES2

1

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

458

D. Celinder & H. Peoples

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

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

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.

6
6
8
7
Wii sessions

First L,
then R
R
R
Both
Wii hand

First L,
then R

43
24
46
41
Duration of hospital stay
before enrolment (days)

29

44

17

27

ND

R
R
R

Impaired
problem solving

R
L

Impaired
initiative

R
R

Impaired
initiative
Cognitive impairment

Hand dominance

Left side
inattention

Uncritical

Impaired
problem solving

L
L

Left side
neglect

ND
H
I

ND

None

I
I

R
L
R

I
Stroke type

More affected side

71

62

68

81

71

M
M

60

Age

55

95

51

Left side
inattention

Ivan
Flora

Gender

Table I. Patient characteristics.

Anton

Birgitte

Christian

Dan

Elias

Gabriella

Hans

Stroke patients experiences with Wii

459

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

Variety

Engagement

Breaking up the day

Excitement and
motivation

Being disappointed

New topic of
conversation

Gaining control
and benets

Physical challenges

Desiring meaningful
occupations

Wishing to play
Wii again

Cognitive challenges

460

D. Celinder & H. Peoples

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

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

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

461

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.

462

D. Celinder & H. Peoples

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

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.

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.
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