pPa

29 H

a r t i c l e i n f o

Accepted 15 July 2013

Keywords:Parkinsons diseaseFunctional movement

a b s t r a c t

impairments in PD, complementary therapies are also important in helping patients achieve maximum

signicant improvement in motor function, ameliorate the impactof non-motor symptoms and improve quality of life [4]. Exercise,physical therapy, occupational therapy and speech therapy arequite helpful for many PD patients, however, compliance withhome exercises after discharge from therapy can be a signicantproblem. Other therapeutic modalities need to be identied to

eurological disor-s [6]. Video gameslving, visuospatialmplete the game

ent of a joystickequire incorpora-ii (Wii) system,

s the element ofhaving the participant use functional movement (as would occurin playing the game in real life) in order to achieve results in thegame, 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 thedirection of ball release and roll the ball down the alley with orwithout spin in order to knock down the pins. This task usesvarious cognitive skills as well as functional movement to achievethe goal.

* Corresponding author. Tel.: 1 706 721 2798.

Contents lists availab

R

lse

Parkinsonism and Related Disorders xxx (2013) 1e4E-mail address: jmorgan@gru.edu (J.C. Morgan).Parkinsons disease (PD) leads to signicant impairment in ac-tivities of daily living (ADLs) and motor function as the diseaseprogresses. PD is also commonly associated with depression oranxiety and reduced quality of life [1,2]. Dopaminergic therapiesprovide tremendous benets for the motor aspects of the disease,but most non-motor symptoms of PD are not responsive to thesetherapies [3].

While pharmacotherapy provides tremendous benets for PDpatients, complementary therapies can also frequently provide

mentary therapy that has been used in other nders, such as acquired brain injury, is video gamerequire the participants to use logic, problem sofunction, motor sequencing and memory to coobjectives [7].

Handheld vide ogames that require movemand pushing buttons with the ngers do not rtion of functional movement. The Nintendo Wunlike most handheld video games, also add1. Introduction assist PD patients in functional task improvements by using newstrategies which might be more exciting [5]. One such comple-WiiADLsDepression1353-8020/$ e see front matter 2013 Published byhttp://dx.doi.org/10.1016/j.parkreldis.2013.07.014

Please cite this article in press as: Herz NB, etand Related Disorders (2013), http://dx.doi.benets and quality of life. We hypothesized that the Nintendo Wii (Wii) is a useful tool in improvingmotor and non-motor aspects in patients with PD, given its ability to drive functional movements andinteractive 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 playingthe Wii three times per week for four weeks. Subjects were then re-evaluated one month later after notplaying 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) afterfour weeks of Wii therapy. Follow-up assessments one month later showed continued improvement forquality 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.Received in revised form25 June 2013Article history:Received 26 February 2013

Parkinsons disease (PD) impairs both activities of daily living (ADLs) and motor function and has adverseeffects on mood in many patients. While dopaminergic medications are quite helpful for motor and ADLsNintendo Wii rehabilitation (Wii-hab)in Parkinsons disease

Nathan B. Herz, Shyamal H. Mehta, Kapil D. Sethi,John C. Morgan*

Movement Disorders Program, Department of Neurology, Georgia Regents University, 14

Parkinsonism and

journal homepage: www.eElsevier Ltd.

al., NintendoWii rehabilitatiorg/10.1016/j.parkreldis.2013.rovides benets

ula Jackson, Patricia Hall,

arper Street, HF-1154, Augusta, GA 30912, USA

le at ScienceDirect

elated Disorders

vier .com/locate/parkreldison (Wii-hab) provides benets in Parkinsons disease, Parkinsonism07.014

2. Methods

3. Results

appear to interfere with performance on the Wii m games, mostlikely due to improvement in parkinsonian tremor with movement.

As far as other secondary outcomes are concerned, there was asignicant improvement in the right-sided Timed Tap score and

Table 1Demographics of Study Subjects.

n Mean SD Range %Age 20 66.7 7.2 yrs (48e74) yrsMale 13 65White race 19 95Age of onset 20 61.3 8.7 yrs (42e73) yrs

Table 2Total NEADL scores at each time point.

Time n Mean SD p-valueTotal 1 20 63.2 4.6

2 20 64.6 2.8 0.015a3 19 63.1 4.9 1.000

d Related Disorders xxx (2013) 1e43.1. Demographics

Twenty subjects were enrolled in the study and their de-mographic features are illustrated in Table 1. Most subjects weremale (65%) and the average disease duration was 5.5 years. Mostsubjects were taking levodopa (16/18 subjects where mediationswere fully known) at an average levodopa dose equivalent of552 mg/day [19]. One subject had to drop out of the study due toEarly- to mid-stage PD patients (Hoehn & Yahr Stage 2 in the on state) wereenrolled from the Movement Disorders Clinic at Georgia Health Sciences Universityand area Parkinsons support groups in this open label within-subjects studydesign. Each subject gave written informed consent to participate in the study andthe 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 8weeks. Baseline demographics were collected for all patients enrolled whichincluded age, handedness, gender, and marital/caregiver status, however, baselinephysical activity was not assessed. Subjects were rated in the on state using theUnied Parkinsons Disease Rating Scale (UPDRS) [10] and staged using the Hoehnand Yahr scale [11]. Baseline assessments for all subjects included timed tests suchas the 9-hole peg test [12], the Tinnetti gait and balance test [13], the PurduePegboard Test [14], a timed tapping test, timed up and go (TUG) [15], HamiltonDepression Scale (HAMD) [16], and the Nottingham Extended Activities of DailyLiving 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 theNEADL. Secondary outcome measures included changes in the UPDRS, the 9-holepeg test, the Purdue Pegboard Test, a timed tapping task, TUG, HAMD, and thePDQ-39.

All subjects received four weeks of Wii-hab with 3 sessions per week (eachsession 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 subjectswere largely familiar with the movement programs required in these sports andthese games came with the system out of the box, maintaining a low cost forsubjects if they wanted to purchase a Wii device after the study. Boxing requiredbilateral UE movements and theoretically promoted a greater increase in heartrate and aerobic exercise compared to bowling and tennis. All three sportsrequired full body motion and balance. For further description of the movementsrequired to play these games please see the Supplemental Methods sectiononline.

The subjects played the Wii computer, not each other. If the study participantnished the protocol prior to the hour they could play any of those aforementionedgames for the remainder of the time. Each study participant was re-evaluated on theprimary and secondary outcome measures after four weeks. As a nal step, subjectswere again evaluated four weeks after completion of Wii therapy to see if theintervention 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 forthe duration of the study (2e3 months), (4) little (

ts in ADLs (NEADL), quality of life (PDQ 39), gait/mobility as evi-

The results indicated that visual cues had a greater effect than

intervention is continued and in most cases supervised by a ther-

Table 3PDQ-39 scores at each time point.

Time n Mean SD Median (range) p-valueMobility 1 20 19.9 8.8 20.5 (10, 39)

2 20 18 7.2 18 (10, 29) 0.2023 19 16.4 6.5 15 (10, 30) 0.003a

ADL 1 20 11.2 3.9 10.5 (6, 19)a

N.B. Herz et al. / Parkinsonism and Rdenced by the TUG and the motor and total scores of the UPDRS.Therewas also a trend toward improvement in mood in PD patientsundergoing 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,left-sided Purdue score between pre- and post-intervention. Therewas also a signicant improvement in the right-sided 9-hole pegtest score and TUG score between pre- and post-intervention. Noother signicant differences were found.

4. Discussion

The results demonstrate that the Nintendo Wii is effective inimproving motor and non-motor symptoms and quality of life ofindividuals with PD. Wii-hab therapy provided signicant bene-

2 20 9.8 3.5 8 (6, 16) 0.0373 19 9.8 3.3 9 (6, 16) 0.029a

Emotion 1 20 13.5 6.9 11.5 (7, 33)2 20 11.1 4.2 10.5 (7, 21) 0.003a3 19 10.4 3.9 9 (7, 20) 0.005a

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) 0.254Communication 1 20 4.6 2.9 3 (3, 13)

2 20 3.8 1.5 3 (3, 8) 0.023a3 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) 0.002a

3 19 20.6 7.5 20 (10, 38) 0.165Total 1 20 77 27.6 67 (40, 127)

2 20 67.3 21.8 58.5 (39, 107) 0.001a3 19 66.1 20.8 62 (39, 108) 0.002a

a Signicant at the 5% level.cost-effective, consistent, standardized and safe intervention forthose with PD [20,21]. Although there have been previous studieson virtual reality systems, there are currently no published studieselucidating the benecial effects of the Wii therapy as a treatmentmethod in PD outside of a recently published study looking at theWii Fit for balance in PD [22].

When patients are diagnosed with PD, dopamine levels aredecreased by perhaps 70% in the nigrostriatal pathway. It is alsoknown that depression is common in PD occurring in perhaps halfof 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 inaddition to the exercise and increased mobility provided by Wiitherapy.

Praamstra et al. [23] found that visual cues created externallyhave a stronger and quicker activation in patients with PD than

Table 4Total HAM-D scores at each time point.

n Mean SD Median (range) p-valueTime 1 20 9.7 8.1 8.5 (0. 28)Time 2 20 3.2 4.8 0.5 (0, 17) 0.063Time 3 19 3.0 3.8 2 (0, 15) 0.125

Signicant at the 5% level.

Please cite this article in press as: Herz NB, et al., NintendoWii rehabilitatiand Related Disorders (2013), http://dx.doi.org/10.1016/j.parkreldis.2013.apist [25]. Anecdotally, the majority of our patients continued toplay the Wii regularly after completion of this study, and in thosethat did, they perceived continued benets. Adherence to a hometherapy regimen may be an advantage of a video game-basedsystem given the enjoyment patients receive in accomplishing atask (a perfect game of bowling, beating their high score, etc.).

Important limitations of this study include the relatively smallsample size and the inclusion of only Hoehn and Yahr Stage 2subjects. As typical of most practices, our practice has more Hoehnand Yahr Stage 2 patients than any other group, and it would bedifcult for individuals in Hoehn and Yahr stage 3 or 4 to participatesafely in a study of this nature. In future work, it would also beimportant to measure baseline level of activity in our subjects andto measure the physical exertion of subjects using appropriatescales and/or measures of heart rate. The open label design of theintervention is also a signicant limitation.

This pilot study demonstrates that the Nintendo Wii gamingsystem can be an effective treatment modality for patients with PD.The Nintendo Wii shows great promise as a treatment modality formotor rehabilitation, functional activities, leisure activities, andperhaps depression as shown in the results for the NEADL, PDQ-39,TUG, UPDRS, and HAM-D. The Nintendo Wii presents as an easilygradable, cost-effective, and standardized treatment modality thatis safe and provides clients with access to activities that may not beavailable otherwise. Our results are consistent with previous liter-ature describing virtual reality as a benecial intervention for otherpatient populations [26]. We believe further research is needed toconrm 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 forfunding this study and supporting this research project. We wouldalso like to acknowledge the contributions of the students, ChasityCarter, OTR, Megan Knight, OTR, Natalie Muchnick, OTR, BrandonRobinson, OTR, and Jason Shew, OTR, for their assistance with thisproject.

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 NationalParkinson Foundation as a Center of Excellence.

Appendix A. Supplementary data

Supplementary data related to this article can be found at http://auditory cues on gait initiation in PD. The Nintendo Wii gamingsystem could be considered both an external and visual cue as itrelates 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 areshort-lived, as evidenced by return to baseline levels after 4 weekswithout Wii therapy on many measures in our study. This ndingparallels clinical practice in that many PD patients return to theirprior baseline following signicant gains in various therapies ifthey are not engaged by a therapist and continuing to practicewhatthey learned. In fact, a recent meta-analysis demonstrated thatphysical therapy benets are typically short-lived unless thethose without the disease. Jiang and Norman [24] studied the ef-fects of visual and auditory cues on gait initiation in people with PDin order to determine whether or not external cues are benecial.

elated Disorders xxx (2013) 1e4 3dx.doi.org/10.1016/j.parkreldis.2013.07.014.

on (Wii-hab) provides benets in Parkinsons disease, Parkinsonism07.014

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N.B. Herz et al. / Parkinsonism and Related Disorders xxx (2013) 1e44Please cite this article in press as: Herz NB, et al., NintendoWii rehabilitatiand Related Disorders (2013), http://dx.doi.org/10.1016/j.parkreldis.2013.on (Wii-hab) provides benets in Parkinsons disease, Parkinsonism07.014

Nintendo Wii rehabilitation (Wii-hab) provides benefits in Parkinson's disease1 Introduction2 Methods3 Results3.1 Demographics3.2 Activities of daily living3.3 Quality of life3.4 Depression scores3.5 Motor function

4 DiscussionAcknowledgmentsAppendix A Supplementary dataReferences