Using gaming technology to enhance rehabilitation for children:
findings from the Wii fit study and working with families
W J Farr1, I Male1, D Green2, C Morris3, H Gage5, S Bailey3, S Speller1, V Colville4, M Jackson4, S Bremner6, A Memon6
1Sussex Community NHS Trust, Brighton, West Sussex, ENGLAND 2Department of Rehabilitation, Oxford Brookes University, Oxford, ENGLAND3Medical School. University of Exeter, Exeter, ENGLAND 4, Parent partnership advisors, Sussex Community NHS Trust, Brighton, ENGLAND 5, School
of Economics, University of Surrey, Surrey, ENGLAND 6 Brighton and Sussex Medical School, Brighton, ENGLAND
“As a parent I know that my child, along with others, is keen to engage with modern technology in most aspects of life, from assisting with school work, communicating with others and as a form of entertainment. If therapy was
delivered using a "computer games" format, I feel that my child would be much keener to engage in undertaking necessary tasks and exercises".
What’s the problem?
• Children with cerebral palsy often struggle with home-based therapy. No intervention =
poor outcomes
• Ideal dose currently unknown for therapy programmes
• Children with CP in UK NHS experience decrease in therapy time as they age,
• 12 hours per year for 0–6 year olds,
• 7hours by 12–18 years of age.
• What can be done about it?
Home-based exercise programmes
Use of more motivating tools
• Children = ‘Digital natives’?
• Consoles in the home (now gathering dust!) – but how many?
• Pilot work: DCD study 2012 (Hammond et al 2012)
• Xbox versus Wii fit trial
• Feasibility trial 2015-2016
What is VRT?
• Virtual reality therapy (VRT) uses motion capture
digital technology to assist with therapy using
commercial systems like the Nintendo Wii, Wii
Fit, Xbox Kinect
• But what are the “active ingredients”?
Lessons from Families
1. Engage early and often – no conversation or question
is wasted
2. If there is evidence (anecdotal and published) let
families/patients guide you - they know their own
lives, you don’t!
3. Ignore naysayers – everyone seems to have an
opinion! (c/f education) e.g. Luddites in our case
4. Be thankful – write letters (e.g. handwritten),
postcards, keep families informed
Lessons from Families
• Useful conflict e.g. difference in
parent/child views – who should
you choose?
• Wider network - families a hidden
and powerful resource
CP Wii
A Feasibility Study of Virtual Reality as a Therapeutic Intervention in Children with
Ambulatory Cerebral Palsy
Cerebral Palsy Nintendo Wii fit Feasibility study
Lessons from Families
Lessons from Families
What is a feasibility study?
• Is the study do-able?
• Are there going to be enough recruits?
• Will there be enough interest?
• What does the population look like?
• What are the best outcome measures?
• Will there be any effect size?
Phase 1: Survey
• Finding: 90% of homes have some sort of
commercially available console
• Few are using them or have been advised to
use them for any sort of therapy
Method
• 300 surveys – out by post & face to face contact by 6 CDCs teams (teams visited, posters distributed)
• Inclusion: Parents of child with CP, 5-16YO, GMFCS I-V.
• Return rate 20% (61/300)
• Low response -postal recruitment with unsigned/un-headed/uncoloured letters
• High response - at or after clinic- (40/61), & direct face to face (19/61)
• CDCs departments under pressure e.g. some areas with 50% vacancies
Results
Must be treated with caution as small and possibly self-selecting sample
Q1 Respondent profile: Mean age: 11 years 3 months (SD 3Y 4M) – males 67%, females 33%
0
2
4
6
8
10
12
14
16
18
20
1 2 3 4 5
Fre
qu
en
cy
GMFCS level
Frequency of respondents by Gender and GMFCS
Females Males
Q3 Which of the following games consoles does your family possess?
0
5
10
15
20
25
30
35
40
Fre
qu
en
cy
Type of Console
Consoles Owned by Respondents
Results
Results
Q4 How many hours does your child play on each device in an average week?
0
50
100
150
200
250
300
350
Wii Wii Fit X Box Kinect PS PS Move Nin DS Wii U PS Vita iPad
Av.
min
sp
er
we
ek
Type of Console
Average number of minutes played on console per week
Active play (minutes)
Console play (minutes)
Q5 Has your child ever used a gaming system as treatment/therapy to improve their motor
function..
0
2
4
6
8
10
12
Fre
qu
en
cy
Type of Console
Respondents who Indicated "yes" they have used a Gaming System as
therapy
Results
Advice
Levels of engagement &
accessibility
What is being
targeted?
Skills?
Functioning?
Muscle group?
Posture?
Balance?
How much help is required?
Will my child like it?
Will my child get frustrated or bored?
Can it be used unaided?
If not how can it be
adapted?
How much help is
needed?
Will my child
understand?
AccessibilityType of
therapy/Game
Main themes
Population
Q5d How do you think your child felt about having to do these games as
‘therapy’?:
Q5e How easy was it encourage your child to participate in the
games/programmes?:
Liked very much Liked Did not mind Did not like Strongly dislike
15 (58%) 4 (15%) 6 (23%) 1 (4%) 0
Self-initiated Minimal prompting
needed
Needed much prompting
14 (52%) 8 (30%) 5 (18%)
Phase 2: Method
• N = 30
• Randomization through minimisation to two groups:
• Therapist-directed games group (‘SG’ or supported
group)
• Group with freedom over game choice (‘USG’ or
unsupported group
• Participants asked to do:
• 30 minutes, 3 x wk x 12 wks of listed games (SG) or
free choice from a pack of games (USG)
Recruitment
• 44 children assessed for eligibility.
• 14 excluded: 3 outside age, 1 GMFCS III, 5
declined to participate, 4 no further response,
1 recruited/consented but not randomised
due to upcoming operation.
• 30(68% of approached) met inclusion criteria
and consented;
Phase 2 Results
Average age of participants overall 9.41 Y (s.d. 3.1)
SG mean age 10.1 Y (s.d. 3.0)
USG mean age 8.8 Y (s.d. 3.3)
Overall 70% of children completed trial (10 SG, 11 USG)
60% of recommended play completed, few problems
(no adverse events)
Adherence
SG
N
SG
Mean
SG
S.D.
USG
N
USG
Mean
USG
S.D.
No.
Sessions
(/36)
11 19/36 14.6 11 24/36 13.3
Av rating
(/5)
10 2.4 2 8 2.5 1.3
Total mins 10 819 634 11 1230 1003
Adherence
SG
N
SG
Mean
SG
S.D.
USG
N
USG
Mean
USG
S.D.
No.
Sessions
(/36)
11 19/36 14.6 11 24/36 13.3
Av rating
(/5)
10 2.4 2 8 2.5 1.3
Total mins 10 819 634 11 1230 1003
Results
Outcome measure Supported group
Unsupported
group Difference
n mean s.d. median n mean s.d. median in means
Gross Motor Function
Measurement-66 baseline 15 75.2 11.1 72.6 15 81.4 13.1 84 -6.2
6 weeks 12 79.2 8.5 79.1 11 82.8 10.4 88 -3.6
12 weeks 10 81.7 8.4 82.5 11 84.8 10.1 83 -3
Timed Up and Go test (in
seconds) baseline 15 6.2 1.6 5.7 14 6.6 1.8 6.4 -0.4
6 weeks 12 5.7 1.5 5.5 11 6.3 1.8 6.2 -0.6
12 weeks 10 5.5 1.5 5.3 11 5.7 1.8 5.3 -0.2
Goal attainment scale baseline 14 35.2 3.6 36.4 15 37.6 11.7 33.3 -2.4
12 weeks 10 54.9 15.5 55 11 58.8 7.1 56.7 -3.9
Strengths and Difficulties
Questionnaire baseline 15 12.5 6.8 11 15 12.6 6.7 10 -0.1
6 weeks 13 9.5 7.4 9 11 9.8 3.5 10 -1.3
12 weeks 10 10.9 6.8 13 11 9.4 3.4 10 0.1
C.I.* bias-corrected and accelerated
confidence interval
6.5 point change vs. 3.4 (15 percentile points)
Results
Outcome measure Supported group
Unsupported
group Difference
n mean s.d. median n mean s.d. median in means
Gross Motor Function
Measurement-66 baseline 15 75.2 11.1 72.6 15 81.4 13.1 84 -6.2
6 weeks 12 79.2 8.5 79.1 11 82.8 10.4 88 -3.6
12 weeks 10 81.7 8.4 82.5 11 84.8 10.1 83 -3
Timed Up and Go test (in
seconds) baseline 15 6.2 1.6 5.7 14 6.6 1.8 6.4 -0.4
6 weeks 12 5.7 1.5 5.5 11 6.3 1.8 6.2 -0.6
12 weeks 10 5.5 1.5 5.3 11 5.7 1.8 5.3 -0.2
Goal attainment scale baseline 14 35.2 3.6 36.4 15 37.6 11.7 33.3 -2.4
12 weeks 10 54.9 15.5 55 11 58.8 7.1 56.7 -3.9
Strengths and Difficulties
Questionnaire baseline 15 12.5 6.8 11 15 12.6 6.7 10 -0.1
6 weeks 13 9.5 7.4 9 11 9.8 3.5 10 -1.3
12 weeks 10 10.9 6.8 13 11 9.4 3.4 10 0.1
C.I.* bias-corrected and accelerated
confidence interval
6.5 point change vs. 3.4 (15 percentile points)
Dropout
• Tiredness (3), after-school activities (1),
homework (1), surgery (1), or difficulties with
using the technology, no time (2), comorbidity
with autism could not adhere to
measurements (1). Participants willing to be
randomised.
• Non-compliance with intervention
Conclusions and future work
• Therapeutic use of Nintendo Wii Fit in-home
inexpensive
• Acceptable in short periods of around six
weeks.
• Need to compare effectiveness with standard
physiotherapy
• Console maker willing to donate 70+ wii fits
for definitive national trial
• Patients will vote with feet – so listen
Selected References
Dempsey, W., Liao, P., Klasnja, P., Nahum-Shani, I., & Murphy, S. A. (2015). Randomised trials for the Fitbit generation.Significance, December 2015, 20-23.
Farr, W., & Male, I. (2013). A Meta-Analysis of “Wii Therapy” in Children with Cerebral Palsy. Archives of Disease in Childhood,98(1), A97.
Farr, W., Male, I., Green, D., Morris, C., Gage, H., Bailey, S., et al. (in submission). Methodological Issues of using Placebos inInterventions Based on Digital Technology. Journal of Mobile Technology in Medicine
Farr, W., Male, I., Speller, S., Morris, C., Green, D., Bailey, S., et al. (2015). A Survey of Home Ownership and Therapeutic Use ofCommercially Available Consoles in Children with Cerebral Palsy. Paper presented at the Annual Scientific Meeting BritishAssociation for Community Child Health 2015, Leeds Beckett University
Huckvale, K., Tomas Prieto, J., Tilney, M., Benghozi, P., & Car, J. (2015). Unaddressed privacy risks in accredited health andwellness apps: a cross-sectional systematic assessment. BMC Medicine, 13(214).
Klasjna, P., Consolvo, S., & Pratt, W. (2011). How to evaluate technologies for health behaviour change in HCI. Paper presented atthe CHI'11 Proceedings of the 29th International Conference on Human factors in Computing Systems.
Labrique, A., Vasudevan, L., Chang, L. W., & Mehl, G. (2013). H_pe for mHealth: More “y” or “o” on the horizon? InternationalJournal of Medical Informatics, 82, 467-469.
Morris, C., Simkis, D., Busk, M., Morris, M., Allard, A., Jacob Denness, et al. (2015). Setting research priorities to improve thehealth of children and young people with neurodisability: a British Academy of Childhood Disability-James Lind Alliance ResearchPriority Setting Partnership. BMJ Open, 5(1). doi: doi:10.1136/bmjopen-2014-006233
Pagoto, S., & Bennett, G. G. (2013). How behavioral science can advance digital health. Translational Behavioral Medicine, 3,271-276.
World_Health_Organisation. (2007). International Classification of Functioning, Disability and Health: Version for Children andYouth. from Geneva, World Health Organisation
Zaczynski, M. (2013). Efficacy Before Novelty: Establishing Design Guidelines in Interactive Gaming for Rehabilitation andTraining. Master of Applied Science, Carleton University, Ottawa, Canada•
Disclaimer: This presentation summarises independent research funded by the NIHR under its Research for Patient Benefit Programme (Grant Number PB-PG-0613-31046). The views expressed are those of the authors and not
necessarily those of the NHS, the NIHR or the Department of Health