Nintendo Wii rehabilitation (Wii-hab) provides benets

in Parkinsons disease
Nathan B. Herz, Shyamal H. Mehta, Kapil D. Sethi, Paula Jackson, Patricia Hall,
John C. Morgan
*
Movement Disorders Program, Department of Neurology, Georgia Regents University, 1429 Harper Street, HF-1154, Augusta, GA 30912, USA
a r t i c l e i n f o
Article history:
Received 26 February 2013
Received in revised form
25 June 2013
Accepted 15 July 2013
Keywords:
Parkinsons disease
Functional movement
Wii
ADLs
Depression
a b s t r a c t
Parkinsons disease (PD) impairs both activities of daily living (ADLs) and motor function and has adverse
effects on mood in many patients. While dopaminergic medications are quite helpful for motor and ADLs
impairments in PD, complementary therapies are also important in helping patients achieve maximum
benets and quality of life. We hypothesized that the Nintendo Wii (Wii) is a useful tool in improving
motor and non-motor aspects in patients with PD, given its ability to drive functional movements and
interactive nature. We enrolled twenty subjects with early to mid-stage PD in an open-label within-
subjects study design where each subject was evaluated at baseline and then re-evaluated after playing
the Wii three times per week for four weeks. Subjects were then re-evaluated one month later after not
playing the Wii for a month to see if effects carried over. Subjects demonstrated signicant improve-
ments in the primary outcome measure (Nottingham Extended Activities of Daily Living Test (NEADL)),
quality of life (PDQ-39) and motor function (UPDRS), and a trend toward improved mood (HAM-D) after
four weeks of Wii therapy. Follow-up assessments one month later showed continued improvement for
quality of life and UPDRS scores. The results demonstrate that Wii therapy provides short-term motor,
non-motor, and quality of life benets in PD. Further studies are needed to determine if there are long-
term benets of Wii therapy in PD.
2013 Published by Elsevier Ltd.
1. Introduction
Parkinsons disease (PD) leads to signicant impairment in ac-
tivities of daily living (ADLs) and motor function as the disease
progresses. PD is also commonly associated with depression or
anxiety and reduced quality of life [1,2]. Dopaminergic therapies
provide tremendous benets for the motor aspects of the disease,
but most non-motor symptoms of PD are not responsive to these
therapies [3].
While pharmacotherapy provides tremendous benets for PD
patients, complementary therapies can also frequently provide
signicant improvement in motor function, ameliorate the impact
of non-motor symptoms and improve quality of life [4]. Exercise,
physical therapy, occupational therapy and speech therapy are
quite helpful for many PD patients, however, compliance with
home exercises after discharge from therapy can be a signicant
problem. Other therapeutic modalities need to be identied to
assist PD patients in functional task improvements by using new
strategies which might be more exciting [5]. One such comple-
mentary therapy that has been used in other neurological disor-
ders, such as acquired brain injury, is video games [6]. Video games
require the participants to use logic, problem solving, visuospatial
function, motor sequencing and memory to complete the game
objectives [7].
Handheld vide ogames that require movement of a joystick
and pushing buttons with the ngers do not require incorpora-
tion of functional movement. The Nintendo Wii (Wii) system,
unlike most handheld video games, also adds the element of
having the participant use functional movement (as would occur
in playing the game in real life) in order to achieve results in the
game, which is particularly relevant to PD patients. For example,
if a patient was bowling they would have to use logic, visuo-
spatial function, sequencing and motor planning to line-up the
direction of ball release and roll the ball down the alley with or
without spin in order to knock down the pins. This task uses
various cognitive skills as well as functional movement to achieve
the goal.
* Corresponding author. Tel.: 1 706 721 2798.
E-mail address: jmorgan@gru.edu (J.C. Morgan).
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders
j ournal homepage: www. el sevi er. com/ l ocat e/ parkrel di s
1353-8020/$ e see front matter 2013 Published by Elsevier Ltd.
http://dx.doi.org/10.1016/j.parkreldis.2013.07.014
Parkinsonism and Related Disorders xxx (2013) 1e4
Please cite this article in press as: Herz NB, et al., Nintendo Wii rehabilitation (Wii-hab) provides benets in Parkinsons disease, Parkinsonism
and Related Disorders (2013), http://dx.doi.org/10.1016/j.parkreldis.2013.07.014
The Wii may be particularly suited for therapy in PD given the
problems that PDpatients have with programming, sequencing and
controlling movements [8,9]. While sequencing is not enough, the
sequencing itself should be within the context of correct timing and
activity for normal movement and activities. The Wii provides both
the context and timing. We hypothesized that the Wii might serve
as a useful complementary therapy for both motor and non-motor
symptoms in PD patients.
2. Methods
Early- to mid-stage PD patients (Hoehn & Yahr Stage 2 in the on state) were
enrolled from the Movement Disorders Clinic at Georgia Health Sciences University
and area Parkinsons support groups in this open label within-subjects study
design. Each subject gave written informed consent to participate in the study and
the study was granted approval to be conducted by the Human Assurance Com-
mittee of our university (our IRB). Each subject participated in the study for 8
weeks. Baseline demographics were collected for all patients enrolled which
included age, handedness, gender, and marital/caregiver status, however, baseline
physical activity was not assessed. Subjects were rated in the on state using the
Unied Parkinsons Disease Rating Scale (UPDRS) [10] and staged using the Hoehn
and Yahr scale [11]. Baseline assessments for all subjects included timed tests such
as the 9-hole peg test [12], the Tinnetti gait and balance test [13], the Purdue
Pegboard Test [14], a timed tapping test, timed up and go (TUG) [15], Hamilton
Depression Scale (HAMD) [16], and the Nottingham Extended Activities of Daily
Living Test (NEADL) [17]. Subjects were also evaluated on a PD quality of life scale
(PDQ-39) [18]. The primary outcome measure for the study was change in the
NEADL. Secondary outcome measures included changes in the UPDRS, the 9-hole
peg test, the Purdue Pegboard Test, a timed tapping task, TUG, HAMD, and the
PDQ-39.
All subjects received four weeks of Wii-hab with 3 sessions per week (each
session included 2 games of tennis, 2 games of bowling, and 1 game of boxing)
for approximately 1 h. These games were chosen for the study because subjects
were largely familiar with the movement programs required in these sports and
these games came with the system out of the box, maintaining a low cost for
subjects if they wanted to purchase a Wii device after the study. Boxing required
bilateral UE movements and theoretically promoted a greater increase in heart
rate and aerobic exercise compared to bowling and tennis. All three sports
required full body motion and balance. For further description of the movements
required to play these games please see the Supplemental Methods section
online.
The subjects played the Wii computer, not each other. If the study participant
nished the protocol prior to the hour they could play any of those aforementioned
games for the remainder of the time. Each study participant was re-evaluated on the
primary and secondary outcome measures after four weeks. As a nal step, subjects
were again evaluated four weeks after completion of Wii therapy to see if the
intervention had a lasting effect.
Inclusion criteria included the following: (1) Patients with idiopathic PD, (2)
Hoehn and Yahr Stage 2 in the on state, (3) expected stability of PDmedications for
the duration of the study (2e3 months), (4) little (<8 h total experience) or no
experience with the Wii gaming system. Exclusion criteria included: (1) dementia
(MMSE <25, adjusted for education level), (2) known non-compliance with medical
or other therapies, (3) any other co-morbid condition that could lend itself to uni-
lateral or bilateral sustained dysfunction (stroke, traumatic brain injury, frozen
shoulder, peripheral nerve palsies, myasthenia gravis, etc.) (4) uncontrolled
depression, (5) presence of psychosis/delusions, (6) severe levodopa-induced dys-
kinesias, (7) deep brain stimulation therapy.
Unless noted otherwise, SAS version 9.1 was used for all statistical analyses.
Signicance was assessed at the a 0.05 level. The Wilcoxon signed rank test was
used to assess the change in scores for the various scales from baseline to post-
intervention and from post-intervention to follow-up.
3. Results
3.1. Demographics
Twenty subjects were enrolled in the study and their de-
mographic features are illustrated in Table 1. Most subjects were
male (65%) and the average disease duration was 5.5 years. Most
subjects were taking levodopa (16/18 subjects where mediations
were fully known) at an average levodopa dose equivalent of
552 mg/day [19]. One subject had to drop out of the study due to
medical reasons unrelated to the study.
3.2. Activities of daily living
The changes in the subjects activities of daily living were
assessed using primary outcome measure, the NEADL scale
(Table 2). The Wilcoxon signed rank test was used to assess the
changes in NEADL scores from baseline to post-intervention and
from post-intervention to follow-up. There was a signicant in-
crease in the NEADL score from pre- to post-intervention and a
subsequent signicant decrease in the NEADL score at follow-up,
suggesting that the benet was short-lived and was not sustained
after the intervention was stopped.
3.3. Quality of life
The PDQ-39 analysis showed there was a signicant decrease in
the mean ADL, Emotion, Communication, Bodily Discomfort, and
Total scores from pre- to post-intervention (Table 3). The Mobility
subscore did not improve from pre- to post-intervention but was
signicantly improved from post-intervention to follow-up 4
weeks later. The ADL and Emotion subscores of the PDQ-39
remained improved 4 weeks after stopping Wii therapy as did
the total PDQ-39 score. All other subscores of the PDQ-39 reverted
to non-signicant after 4 weeks of not playing the Wii.
3.4. Depression scores
Study subjects had a trend toward improvement of their
depression symptoms based on their HAM-D scores from baseline
to post-intervention (p 0.063) (Table 4) and this correlates with
improvement on the Emotion component of the PDQ-39 at the
same time point.
3.5. Motor function
Analysis of the change in UPDRS sub-scores and total score from
baseline to post-intervention and frompost-intervention to follow-
up (Supplementary Table 5) showed that there was a signicant
decrease in the Motor score (UPDRS Pt III) between pre- and post-
intervention which was maintained at follow-up. This change
correlated with a sustained improvement in the total UPDRS score
between the same time points. Tremor, when present, did not
appear to interfere with performance on the Wii m games, most
likely due to improvement in parkinsonian tremor with movement.
As far as other secondary outcomes are concerned, there was a
signicant improvement in the right-sided Timed Tap score and
Table 1
Demographics of Study Subjects.
n Mean SD Range %
Age 20 66.7 7.2 yrs (48e74) yrs
Male 13 65
White race 19 95
Age of onset 20 61.3 8.7 yrs (42e73) yrs
Disease duration 20 5.5 4.3 yrs (1e19) yrs
LED 18 552 296 mg (100e1300) mg
LED Levodopa Equivalent Dose.
Table 2
Total NEADL scores at each time point.
Time n Mean SD p-value
Total 1 20 63.2 4.6
2 20 64.6 2.8 0.015
a
3 19 63.1 4.9 1.000
a
Signicant at the 5% level.
N.B. Herz et al. / Parkinsonism and Related Disorders xxx (2013) 1e4 2
Please cite this article in press as: Herz NB, et al., Nintendo Wii rehabilitation (Wii-hab) provides benets in Parkinsons disease, Parkinsonism
and Related Disorders (2013), http://dx.doi.org/10.1016/j.parkreldis.2013.07.014
left-sided Purdue score between pre- and post-intervention. There
was also a signicant improvement in the right-sided 9-hole peg
test score and TUG score between pre- and post-intervention. No
other signicant differences were found.
4. Discussion
The results demonstrate that the Nintendo Wii is effective in
improving motor and non-motor symptoms and quality of life of
individuals with PD. Wii-hab therapy provided signicant bene-
ts in ADLs (NEADL), quality of life (PDQ 39), gait/mobility as evi-
denced by the TUG and the motor and total scores of the UPDRS.
There was also a trend toward improvement in mood in PD patients
undergoing Wii therapy (HAM-D and Emotion section of the PDQ-
39), although the results did not achieve full signicance.
Previous studies have demonstrated video games as a benecial,
cost-effective, consistent, standardized and safe intervention for
those with PD [20,21]. Although there have been previous studies
on virtual reality systems, there are currently no published studies
elucidating the benecial effects of the Wii therapy as a treatment
method in PD outside of a recently published study looking at the
Wii Fit for balance in PD [22].
When patients are diagnosed with PD, dopamine levels are
decreased by perhaps 70% in the nigrostriatal pathway. It is also
known that depression is common in PD occurring in perhaps half
of patients. Previous studies have conrmed that dopamine in-
creases in the brain during participation in video games [20].
Perhaps this is one mechanism by which our subjects benetted in
addition to the exercise and increased mobility provided by Wii
therapy.
Praamstra et al. [23] found that visual cues created externally
have a stronger and quicker activation in patients with PD than
those without the disease. Jiang and Norman [24] studied the ef-
fects of visual and auditory cues on gait initiation in people with PD
in order to determine whether or not external cues are benecial.
The results indicated that visual cues had a greater effect than
auditory cues on gait initiation in PD. The Nintendo Wii gaming
system could be considered both an external and visual cue as it
relates to functional movement affecting activity, with the im-
mersion of the participant functionally in the games themselves.
Unfortunately, many of the positive effects of Wii therapy are
short-lived, as evidenced by return to baseline levels after 4 weeks
without Wii therapy on many measures in our study. This nding
parallels clinical practice in that many PD patients return to their
prior baseline following signicant gains in various therapies if
they are not engaged by a therapist and continuing to practice what
they learned. In fact, a recent meta-analysis demonstrated that
physical therapy benets are typically short-lived unless the
intervention is continued and in most cases supervised by a ther-
apist [25]. Anecdotally, the majority of our patients continued to
play the Wii regularly after completion of this study, and in those
that did, they perceived continued benets. Adherence to a home
therapy regimen may be an advantage of a video game-based
system given the enjoyment patients receive in accomplishing a
task (a perfect game of bowling, beating their high score, etc.).
Important limitations of this study include the relatively small
sample size and the inclusion of only Hoehn and Yahr Stage 2
subjects. As typical of most practices, our practice has more Hoehn
and Yahr Stage 2 patients than any other group, and it would be
difcult for individuals in Hoehn and Yahr stage 3 or 4 to participate
safely in a study of this nature. In future work, it would also be
important to measure baseline level of activity in our subjects and
to measure the physical exertion of subjects using appropriate
scales and/or measures of heart rate. The open label design of the
intervention is also a signicant limitation.
This pilot study demonstrates that the Nintendo Wii gaming
systemcan be an effective treatment modality for patients with PD.
The Nintendo Wii shows great promise as a treatment modality for
motor rehabilitation, functional activities, leisure activities, and
perhaps depression as shown in the results for the NEADL, PDQ-39,
TUG, UPDRS, and HAM-D. The Nintendo Wii presents as an easily
gradable, cost-effective, and standardized treatment modality that
is safe and provides clients with access to activities that may not be
available otherwise. Our results are consistent with previous liter-
ature describing virtual reality as a benecial intervention for other
patient populations [26]. We believe further research is needed to
conrm the Nintendo Wiis potential as a rehab tool in the treat-
ment of patients with PD.
Acknowledgments
We would like to thank the National Parkinson Foundation for
funding this study and supporting this research project. We would
also like to acknowledge the contributions of the students, Chasity
Carter, OTR, Megan Knight, OTR, Natalie Muchnick, OTR, Brandon
Robinson, OTR, and Jason Shew, OTR, for their assistance with this
project.
The authors have no relative conicts of interest for this study
(no funding from Nintendo or manufacturers of games for Nin-
tendo), but our center has received funding from the National
Parkinson Foundation as a Center of Excellence.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.parkreldis.2013.07.014.
Table 4
Total HAM-D scores at each time point.
n Mean SD Median (range) p-value
Time 1 20 9.7 8.1 8.5 (0. 28)
Time 2 20 3.2 4.8 0.5 (0, 17) 0.063
Time 3 19 3.0 3.8 2 (0, 15) 0.125
Signicant at the 5% level.
Table 3
PDQ-39 scores at each time point.
Time n Mean SD Median (range) p-value
Mobility 1 20 19.9 8.8 20.5 (10, 39)
2 20 18 7.2 18 (10, 29) 0.202
3 19 16.4 6.5 15 (10, 30) 0.003
a
ADL 1 20 11.2 3.9 10.5 (6, 19)
2 20 9.8 3.5 8 (6, 16) 0.037
a
3 19 9.8 3.3 9 (6, 16) 0.029
a
Emotion 1 20 13.5 6.9 11.5 (7, 33)
2 20 11.1 4.2 10.5 (7, 21) 0.003
a
3 19 10.4 3.9 9 (7, 20) 0.005
a
Social 1 20 5.5 3.2 4.5 (3, 15)
Support 2 20 4.8 2.2 4 (3, 10) 0.125
3 19 4.7 2.6 4 (3, 12) 0.254
Communication 1 20 4.6 2.9 3 (3, 13)
2 20 3.8 1.5 3 (3, 8) 0.023
a
3 19 4.2 2.3 3 (3, 10) 0.406
Bodily 1 20 22.4 7.6 20.5 (10, 38)
Discomfort 2 20 20 7.6 16 (10, 36) 0.002
a
3 19 20.6 7.5 20 (10, 38) 0.165
Total 1 20 77 27.6 67 (40, 127)
2 20 67.3 21.8 58.5 (39, 107) 0.001
a
3 19 66.1 20.8 62 (39, 108) 0.002
a
a
Signicant at the 5% level.
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References
[1] Aarsland D, Phlhagen S, Ballard CG, Ehrt U, Svenningsson P. Depression in
Parkinsons diseasedepidemiology, mechanisms, and management. Nat Rev
Neurol 2011;8:35e47.
[2] Den Oudsten BL, Van Heck GL, De Vries J. Quality of life and related concepts in
Parkinsons disease: a systematic review. Mov Disord 2007;22:1528e37.
[3] Zesiewicz TA, Sullivan KL, Arnulf I, Chaudhuri KR, Morgan JC, Gronseth GS,
et al. Quality standards subcommittee of the American academy of neurology.
Practice parameter: treatment of nonmotor symptoms of Parkinson disease:
report of the quality standards subcommittee of the American academy of
neurology. Neurology 2010;74:924e31.
[4] Zesiewicz TA, Evatt ML. Potential inuences of complementary therapy on
motor and non-motor complications in Parkinsons disease. CNS Drugs
2009;23:817e35.
[5] Giladi N, McMahon D, Przedborski S, Flaster E, Guillory S, Kostic V, et al. Motor
blocks in Parkinsons disease. Neurology 1992;42:333e9.
[6] Gil-Gmez JA, Llorns R, Alcaiz M, Colomer C. Effectiveness of a Wii balance
board-based system (eBaViR) for balance rehabilitation: a pilot randomized
clinical trial in patients withacquired braininjury. J Neuroeng Rehabil 2011;8:30.
[7] Amory A, Naicker K, Vincent J, Adams C. The use of computer games as an
educational tool: identication of appropriate game types and game elements.
Brit J Ed Tech 1999;30:311e21.
[8] Harrington D, Haaland KY. Sequencing in Parkinsons disease. Abnormalities
in programming and controlling movement. Brain 1991;114:99e115.
[9] Roy EA, Saint-Cyr J, Taylor A, Lang A. Movement sequencing disorders in
Parkinsons disease. Int J Neurosci 1993;73:183e94.
[10] Fahn S, Elton RL., UPDRS program members. Unied Parkinsons disease rating
scale. In: Fahn S, Marsden CD, Goldstein M, Calne DB, editors. Recent de-
velopments in Parkinsons disease, vol. 2. Florham Park, NJ: Macmillan
Healthcare Information; 1987. p. 153e63.
[11] Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality.
Neurology 1967;17:427e42.
[12] Earhart GM, Cavanaugh JT, Ellis T, Ford MP, Foreman KB, Dibble L. The 9-hole
PEG test of upper extremity function: average values, test-retest reliability,
and factors contributing to performance in people with Parkinson disease.
J Neurol Phys Ther 2011;35:157e63.
[13] Tinetti ME. Performance-oriented assessment of mobility. Problems in elderly
patients. J Am Geriatr Soc 1986;34:119e26.
[14] Tifn J, Asher EJ. The Purdue pegboard; norms and studies of reliability and
validity. J Appl Psychol 1948;32:234e47.
[15] Podsiadlo D, Richardson S. The timed up & go: a test of basic functional
mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142e8.
[16] Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry
1960;23:56e62.
[17] Clarke CE, Furmston A, Morgan E, Patel S, Sackley C, Walker M, et al. Pilot
randomised controlled trial of occupational therapy to optimise indepen-
dence in Parkinsons disease: the PD OT trial. J Neurol Neurosurg Psychiatry
2009;80:976e8.
[18] Peto V, Jenkinson C, Fitzpatrick R, Greenhall R. The development and valida-
tion of a short measure of functioning and well being for individuals with
Parkinsons disease. Qual Life Res 1995;4:241e8.
[19] Razmy A, Lang AE, Shapiro CM. Predictors of impaired daytime sleep and
wakefulness in patients with Parkinson disease treated with older (ergot) vs.
newer (nonergot) dopamine agonists. Arch Neurol 2004;61:97e102.
[20] Koepp MJ, Gunn RN, Lawrence AD, Cunningham VJ, Dagher A, Jones T, et al.
Evidence for striatal dopamine release during a video game. Nature 1998;393:
266e8.
[21] Zhang L, Abreu BC, Seale GS, Masel B, Christiansen CH, Ottenbacher KJ.
A virtual reality environment for evaluation of a daily living skill in brain
injury rehabilitation: reliability and validity. Arch Phys Med Rehabil 2003;84:
1118e24.
[22] Esculier JF, Vaudrin J, Briault P, Gagnon K, Tremblay LE. Home-based balance
training programme using Wii Fit with balance board for Parkinsonss disease:
a pilot study. J Rehabil Med 2012;44:144e50.
[23] Praamstra P, Stegeman DF, Cools AR, Horstink MW. Reliance on external cues
for movement initiation in Parkinsons disease. Brain 1998;121:167e77.
[24] Jiang Y, Norman KE. Effects of visual and auditory cues on gait initiation in
people with Parkinsons disease. Clin Rehabil 2006;20:36e45.
[25] Tomlinson CL, Patel S, Meek C, Herd CP, Clarke CE, Stowe R, et al. Physio-
therapy intervention in Parkinsons disease: a systematic review and meta-
analysis. BMJ 2012;345:e5004.
[26] Yip BC, Man DW. Virtual reality (VR)-based community living skills training for
people with acquired brain injury: a pilot study. Brain Inj 2009;23:1017e26.
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Please cite this article in press as: Herz NB, et al., Nintendo Wii rehabilitation (Wii-hab) provides benets in Parkinsons disease, Parkinsonism
and Related Disorders (2013), http://dx.doi.org/10.1016/j.parkreldis.2013.07.014