Secondary Logo

Journal Logo

Counting Repetitions: An Observational Study of Video Game Play in People With Chronic Poststroke Hemiparesis

Peters, Denise M. DPT; McPherson, Aaron K. DPT; Fletcher, Blake DPT; McClenaghan, Bruce A. PT, PED; Fritz, Stacy L. PT, PhD

Journal of Neurologic Physical Therapy: September 2013 - Volume 37 - Issue 3 - p 105–111
doi: 10.1097/NPT.0b013e31829ee9bc
Research Articles
Free
SDC
Watch Video Abstract

Background and Purpose: The use of video gaming as a therapeutic intervention has increased in popularity; however, the number of repetitions in comparison with traditional therapy methods has yet to be investigated. The primary purpose of this study was to document and compare the number of repetitions performed while playing 1 of 2 video gaming systems for a time frame similar to that of a traditional therapy session in individuals with chronic stroke.

Methods: Twelve participants with chronic stroke (mean age, 66.8 ± 8.2 years; time poststroke, 19.2 ± 15.4 months) completed video game play sessions, using either the Nintendo Wii or the Playstation 2 EyeToy. A total of 203 sessions were captured on video record; of these, 50 sessions for each gaming system were randomly selected for analysis. For each selected record, active upper and lower extremity repetitions were counted for a 36-minute segment of the recorded session.

Results: The Playstation 2 EyeToy group produced an average of 302.5 (228.1) upper extremity active movements and 189.3 (98.3) weight shifts, significantly higher than the Nintendo Wii group, which produced an average of 61.9 (65.7) upper extremity active movements and 109.7 (78.5) weight shifts. No significant differences were found in steps and other lower extremity active movements between the 2 systems.

Discussion and Conclusions: The Playstation 2 EyeToy group produced more upper extremity active movements and weight shifting movements than the Nintendo Wii group; the number and type of repetitions varied across games. Active gaming (specifically Playstation 2 EyeToy) provided more upper extremity repetitions than those reported in the literature by using traditional therapy, suggesting that it may be a modality to promote increased active movements in individuals poststroke.

Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A50) for more insights from the authors.

Supplemental Digital Content is Available in the Text.

Physical Therapy Program, Department of Exercise Science, University of South Carolina, Columbia.

Correspondence: Denise M. Peters, DPT, Physical Therapy Program, Department of Exercise Science, University of South Carolina, 921 Assembly St, 3rd floor PHRC, Columbia, SC 29208 (petersd20@gmail.com).

Parts of this article were presented in poster format at the American Physical Therapy Association's Combined Sections Meeting in (1) New Orleans, Los Angeles, California, February 2011, and (2) San Diego, California, February 2010. Corresponding abstracts were published.

Financial support for this study was provided by a grant (64450) from Health Games Research, a national program of the Robert Wood Johnson Foundation.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jnpt.org).

Back to Top | Article Outline

INTRODUCTION

Each year, in the United States, approximately 795 000 individuals have a stroke,1 and it is a leading cause of disability. Weakness or paralysis associated with stroke often leaves individuals functionally impaired, and it is estimated that one-third of all stroke survivors are functionally dependent at 1 year poststroke.2 With approximately 6.4 million persons in the United States who are stroke survivors3 and many with deficits in motor function, it remains imperative to find or develop ways to assist with motor rehabilitation poststroke.

Regular practice of skilled motor tasks has been shown to be directly related to enlargement of the cortical representation in corresponding regions of the brain.4–6 Recovery after a neurological insult to the brain can occur through spontaneous reorganization or activity-dependent plasticity. Neuroplasticity may arise from numerous mechanisms,7 and neuroplastic changes are evident in studies using massed practice of task-specific functional activities that have shown increases in motor function scores.8–10

With massed-practice principles showing promise as an effective treatment in individuals with chronic stroke, the intensity and frequency of therapy likely represent a key variable in the effectiveness of stroke rehabilitation.11 In traditional therapy models, however, frequency of practice is most often measured in the number of therapy sessions and the length of each session in minutes, rather than in the numbers of repetitions per session.12 Lang et al13 analyzed the number of repetitions completed during 312 outpatient/inpatient physical and occupational therapy sessions from 7 sites with individuals poststroke. Regardless of the patients' functional level, each session (mean, 36 ± 14 minutes) averaged only 54 ± 75 active upper extremity exercise movements and 75 ± 113 active lower extremity exercise movements. The average number of gait steps taken per session was measured at 357 ± 432. Furthermore, Kimberley et al14 counted the number of repetitions in outpatient therapy sessions in individuals with traumatic brain injury and stroke; participants with stroke completed an average of 17.50 ± 26.38 upper extremity active repetitions and 37.25 ± 47.52 lower extremity active repetitions per session. These repetition values are far less than the 400 to 600 repetitions of upper limb tasks mentioned in published animal studies wherein training resulted in increases in cortical representation5,6 and the approximately 1000 to 2000 steps performed during treadmill sessions in animal studies of spinal cord injury to improve hind limb stepping.15,16 While the number of repetitions may not fully represent the intensity of therapy, it may provide a good window to analyze the amount of physical activity in which a patient is participating.

In an effort to provide greater numbers of functional repetitions in a therapy setting, active gaming has become a topic of increased interest. Active gaming, which requires individuals to use physical activity to control game play, may prove to be an effective adjunct therapy in individuals poststroke. Gaming systems such as the Nintendo Wii and the Playstation 2 systems allow therapists to control the exercise setting to create an optimal motor learning environment.17–19 This controlled environment may provide ease in creating a situation of large quantities of practice in a relatively short time frame.

Both the Nintendo Wii and the Playstation 2 EyeToy require active upper and lower extremity movements such as reaching, punching, and swinging with the upper extremity and stepping, kicking, and weight shifting of the lower extremities to control game play. With the requirement of active movements to achieve goals within the game, repetitive game play may be sufficient to represent a massed-practice component of therapy. Coupled with low cost and greater accessibility, therapists now have a resource that was designed for enjoyment that may engage an individual in a massed-practice therapeutic session with a higher participation rate than traditional therapy methods.19–21

As previously mentioned, research has shown that large quantities of functional repetitions may drive neural repair and/or restoration.5,6,8–10,22 Traditional outpatient therapy methods have been shown not to provide large number of repetitions among individuals poststroke.13 With the possibility of active gaming systems eliciting large numbers of functional repetitions from this population, these systems may have a place in the rehabilitation setting. However, their relatively recent development has limited the breadth of research on their impact as therapeutic interventions. Therefore, there is a great value in determining whether specific game play interventions provide an efficient production of active repetitions in comparison with traditional therapy interventions.

The primary purpose of this study was to document and compare the number of repetitions performed by participants with stroke while playing 1 of 2 video gaming systems for a period of time similar to that of a traditional therapy session (ie, as demonstrated by Lang et al.13). In addition, comparisons were made between the numbers of repetitions performed by participants using the Nintendo Wii versus the Playstation 2 EyeToy, as well as examining the number of repetitions performed within each of the 4 games (Wii Fit, Wii Sports, Kinetic, Play 2). The value of each game to provide an environment that promotes high repetitions of the more affected extremities to drive improvements of function was evaluated.

Back to Top | Article Outline

METHODS

Research Design

An observational study of video-recorded gaming sessions was conducted in a laboratory setting.

Back to Top | Article Outline

Participants

Twelve participants who had been part of a larger study investigating the effects of an interactive video game intervention on balance and mobility in individuals with chronic stroke were included in this study. Inclusion criteria were (1) 18 years of age or older, (2) more than 6 months poststroke, (3) clinical presentation of unilateral hemiplegia due to stroke, (4) the ability to follow simple 2-step instructions, (5) the ability to stand for 5 minutes with an assistive device with supervision or without an assistive device with minimal assistance, and (6) the ability to walk 10 feet with or without an assistive device. Exclusion criteria included body weight more than 330 lbs (150 kg, because of video game system requirements), pain that limited daily activity and rated more than 5 on 10 on the visual analog pain scale, severe visual impairment, other neurological conditions such as Parkinson disease, and/or severe arthritis or orthopedic problems that limited mobility. All participants gave written informed consent to be part of the study, which had been approved by the institutional review board at the University of South Carolina.

Back to Top | Article Outline

Procedures

Upon enrollment in the study, participants were randomly assigned to the “Nintendo Wii” or “Sony PlayStation 2 EyeToy” group. Participants completed a total of 20 hours of game play, consisting of 1 hour of video game–based game play for 4 days per week, for 5 weeks. Each 1-hour session was video recorded in an effort to capture the number of active repetitions completed using the hemiparetic extremities. Both the Nintendo Wii and the Sony PlayStation 2 EyeToy gaming systems require participants to use active upper and lower extremity movements to interact with virtual objects presented through a television monitor. Participants in the Nintendo Wii group played “Wii Sports” and “Wii Fit” games, and the Wii balance board accessory was used when required. Participants in the Sony PlayStation 2 group played the EyeToy “Play 2” and “Kinetic” games.

Each session consisted of at least 50 minutes of active game play during a 60-minute session. This allowed for up to 10 minutes of rest time for each participant. If more breaks were needed, then the intervention length was extended to ensure that a total of 50 minutes of game play was completed. The first 30 minutes of game play was standardized to include fitness-type games (“Wii Fit” or “Kinetic,” depending on the game system group in which individuals were assigned) and the final 30 minutes dedicated to fun-based games (“Wii Sports” or “Play 2”). The participants were allowed to choose from “mini games” on the game menu. This allowed for the sessions to be tailored individually to the participant's interest and activity level.

All game play was completed in the research laboratory and in the standing position. Trainers were available for guarding and maintaining safety, as well as for assistance with navigating through menus and clarifying game controls, but trainers made no attempt to change participants' body mechanics during game play, except to encourage them to play as if they were actually completing the task (ie, swinging the Nintendo Wii remote as if it were a real golf club) or by making suggestions to improve performance. Game play for each session was logged to record mini-games chosen, scores, difficulty level, and time played. This also allowed for participants to self-monitor progress and drive competition to better previous scores.

Back to Top | Article Outline

Observational Data Collection

All sessions were video recorded in their entirety from a diagonal behind the participant to capture the hemiparetic side. This allowed the documentation of the number of active repetitions performed by the affected upper and lower extremities, steps taken by the affected lower extremity, and weight shifts. These measurements were selected in an effort to provide a comparison with the number of repetitions documented by Lang et al13 in outpatient/inpatient physical and occupational therapy of individuals with hemiparesis poststroke. Definitions of each movement type are purposefully tailored to match as accurately as possible with the aforementioned study.

To quantify the recorded movements, an upper extremity active movement was defined as any movement in which the extremity leaves a starting point and returns to the starting point, a movement in which the extremity starts and has a clear stop before changing direction, or a motion that includes 1 flexion and 1 extension (at elbow, wrist, or shoulder). Only the repetitions on the hemiparetic side were counted. While the study by Lang et al13 delineated active exercise movements and functional movements as separate subcategories of upper extremity movements, we did not differentiate between these 2 subcategories as it is difficult to define functional movements in virtual space with game play. Lower extremity movements were broken into 3 subcategories: weight shifts, steps, and other active movements. Steps and other lower extremity active movements were compared with the corresponding classification in the study by Lang et al13Weight shifting, defined as shifting weight from one extremity to the other without lifting the contralateral foot, was not recorded in any category in the study by Lang et al,13 but we recorded weight shifting as a separate movement for our purposes. A step was defined as actively lifting 1 foot off the ground, relocating the foot to the ground or another surface with a weight shift to said foot, and subsequent lifting of the contralateral foot completely off the ground. Other lower extremity active movements were counted by using the same convention as for the upper extremity repetitions.

Of a total of 203 video-recorded sessions, 50 Nintendo Wii sessions (average of 7.1 ± 3.5 sessions per subject) and 50 Playstation 2 sessions (average of 10 ± 5.1 sessions per subject) were randomly selected to be included in the study by a random number generator. Any missing data preventing the recording of observations led to the selection of the next randomly generated assigned session number. From each 60-minute session, the first 18 minutes from each 30-minute fitness- and fun-based gaming block were selected for a total of 36 minutes. This selection of time was chosen to mimic the mean session time of participants in the study by Lang et al.13 Data were collected by 2 raters who were student physical therapists. Inter- and intrarater reliabilities were assessed after viewing 10 video sessions each. Among the upper extremity active movements, lower extremity weight shifts, and steps categories, there was a difference of 7% or less in intrarater counts and a difference of less than 9% in interrater counts. The “other” active lower extremity category had very limited repetitions, making any percentage difference inflated. However, in this category, there was found to be an average of less than 1 repetition difference in both intra- and interrater counts across all 10 video sessions observed by each rater.

Back to Top | Article Outline

Statistical Analyses

Demographic information was collected for all participants. Data were analyzed using SPSS version 19 (SPSS Inc, Chicago, Illinois). Descriptive statistics were generated for each category and subcategory of movement-repetition types. Among the different repetition types, 95% confidence intervals for means were produced to determine whether there were differences between the repetition counts for each subcategory. In addition, a Mann-Whitney U test was performed to determine whether there were differences in upper and lower extremity movement variables between the Nintendo Wii and Playstation 2 EyeToy groups. Kruskal-Wallis tests with Mann-Whitney U test post hoc analyses were performed to examine differences in the total number and each subcategory of repetitions between the 4 games (Wii Fit, Wii Sports, Kinetic, Play 2). The level of significance was set at P ≤ 0.05, with a Bonferroni correction used for multiple comparisons.

Back to Top | Article Outline

RESULTS

The sample consisted of 12 individuals with chronic stroke (10 men and 2 women). The mean age of the participants was 66.8 ± 8.2 years, with a mean time poststroke of 19.2 ± 15.4 months. The Nintendo Wii group consisted of 7 participants (mean age, 65.0 ± 7.5 years; time poststroke, 16.9 ± 9.4 months; preintervention Berg Balance Scale score, 49.1 ± 4.3; preintervention Fugl-Meyer upper extremity motor score, 41.7 ± 24.0) and the Playstation 2 EyeToy group consisted of 5 participants (mean age, 69.4 ± 9.2 years; time poststroke, 22.4 ± 22.4 months; preintervention Berg Balance Scale score, 48.8 ± 3.6; preintervention Fugl-Meyer upper extremity motor score, 41.0 ± 18.3), with no significant baseline differences between the groups for age, time since stroke, or Berg Balance Scale and Fugl-Meyer scores (all P > 0.05).

Descriptive statistics for each category and subcategory for the Nintendo Wii and Playstation 2 EyeToy are shown in Table 1. Repetition counts for each subcategory are exclusive to that classification, with no repetition counted twice for inclusion into different subcategories. In both types of game play, weight shifts were the most common lower extremity repetition observed, followed by steps and other active movements, respectively. In addition, more lower extremity repetitions were observed when compared with upper extremity repetitions with Wii game play; however, the opposite was true with Playstation 2 EyeToy game play.

Table 1

Table 1

When comparing the number of repetitions from Nintendo Wii game play with those of Playstation 2 EyeToy, there were significant differences found in upper extremity active movements (P < 0.001) and weight shifts (P < 0.001) subcategories, with the Playstation 2 EyeToy group having significantly more repetitions. No significant differences were found in steps and other lower extremity active movements between the 2 gaming systems.

Descriptive statistics for the 4 games used (Wii Fit, Wii Sports, Kinetic, and Play 2) for each category and subcategory of movement are shown in Tables 2 and 3. Across all the 4 games, weight shifts were the most common lower extremity repetition observed, followed by steps and other active movements. In the Nintendo Wii games, weight shifts were the most common repetition observed with game play, while upper extremity active repetitions were the most common repetition observed with Playstation 2 EyeToy game play.

Table 2

Table 2

Table 3

Table 3

Among the 4 games, significant differences in the number of total repetitions, upper extremity active movements, weight shifts, steps, and other lower extremity active movements (all P < 0.001) were found, with the Playstation 2 EyeToy Kinetic game exhibiting the most repetitions among each subcategory. Post hoc analyses for between-game differences in the total number and each subcategory of repetitions are shown in Table 4. A comparison between the mean number of repetitions elicited by each type of video game play and that of traditional therapy sessions as reported by Lang et al13 is shown in Table 5.

Table 4

Table 4

Table 5

Table 5

Back to Top | Article Outline

DISCUSSION

Our results show that video game play, specifically Playstation 2 EyeToy game play, may be an intervention that provides an increase in the overall number of active movements compared with traditional outpatient/inpatient therapy sessions in hemiparetic poststroke populations. However, when compared with the number of repetitions required for cortical changes in animal studies,5,6,15,16 these numbers are still relatively small. There is also a high variability in the number and categorical type of repetitions observed among the 4 games used across the Nintendo Wii and Playstation 2 EyeToy gaming systems. When considering the use of 1 of these gaming systems as an adjunct to traditional therapy, it is important to select a game that will address the patient's individual deficits. Each game had its own strengths and weaknesses to produce the various subcategories of repetitions, which must be considered when directing a patient toward the most appropriate gaming system and game.

Back to Top | Article Outline

Repetitions Observed in Video Game Play Versus Traditional Therapy Sessions

Our study was structured to closely mimic the study by Lang et al13 in an effort to compare the number of repetitions completed in video game play with those observed in traditional outpatient/inpatient therapy sessions. Using the same average session length (36 minutes), we found that video game play provided, on average, more active upper extremity repetitions than traditional therapy. However, video game play resulted in fewer lower extremity stepping repetitions than traditional therapy sessions. This may have been expected, as participants were required to maintain a position in front of the video monitor during game play, which may have limited stepping. Also, while we found that video game play encouraged active lower extremity weight shifts in our participants, comparisons cannot be made with traditional outpatient/inpatient therapy sessions as weight shifts were not recorded in any category in the comparison study.

The focus of this study was only on active movements, so comparisons concerning passive exercise repetitions or sensory interventions cannot be made. Furthermore, as we did not differentiate between active upper extremity movements and functional movements, our data may have overestimated the amount of active upper and lower extremity movements performed during game play in comparison with the active exercise movements as defined by Lang et al.13 In addition, the aforementioned study provided a category for observed balance interventions. Because of the nature of video game play, all video games were played in the standing position without any external balance support. This would classify almost the entirety of all gaming sessions as a “balance activity” by the standards of Lang et al,13 and it was impossible to differentiate the beginning or conclusion of “balance activities” in our study.

While video game play may provide an opportunity to elicit a greater number of active upper extremity movements than traditional therapy, research has shown the most effective interventions for improving motor recovery employ intense, repetitive, task-specific training.23–26 So, while video game play may elicit more upper extremity movement repetitions, it is unknown whether this intervention will translate into improved functioning of the affected extremity. Further investigation is needed to determine how well these gaming systems and games are able to improve functional motor deficits in the poststroke population.

Back to Top | Article Outline

Repetitions Observed in Video Game Play Versus Neuroplasticity Studies in Animals

When compared with animal studies, our study did not produce the 400 to 600 daily repetitions that were found in these studies to produce cortical reorganization.5,6 However, our study only accounted for 36-minute sessions of game play from 1-hour recorded sessions. When the data from our study are extrapolated to the full session length (50 minutes of game play), estimates of upper extremity repetitions approach 420 in the Playstation 2 EyeToy group and 86 in the Nintendo Wii group; lower extremity repetitions (a total of all 3 classifications) are estimated to be 360 for the Playstation 2 EyeToy group and 235 for the Nintendo Wii group. These figures are much closer to the aforementioned threshold for increased cortical representation shown in animals.

Back to Top | Article Outline

Nintendo Wii Versus Playstation 2 EyeToy

There are distinct differences between the Nintendo Wii and Playstation 2 EyeToy gaming systems, which likely contributed to the large differences in the numbers of repetitions observed during this study. Our results show that the Playstation 2 group produced significantly more active upper extremity and lower extremity weight shift repetitions than the Nintendo Wii group. The Playstation 2 group, on average, produced approximately 240 more upper extremity active movements and approximately 80 more weight shifts per session than the Wii group. This may be because of several different factors: (1) The Playstation 2 EyeToy games require repetitive hand waving to navigate the menu, while Nintendo Wii menus are controlled by aiming the controller at the screen and pressing a button. (2) Playstation 2 EyeToy games often require the player to move to the edges of the screen for game play, while Nintendo Wii games often have a character centrally located on the screen and participants are often required to stand on a small “Wii balance board” during many fitness-based games. (3) Nintendo Wii games have more static activities with downtime in between repetitions, while most Playstation 2 EyeToy games promote longer bouts of dynamic movement. In addition to these inherent differences between the gaming systems, large differences in repetition counts between games may be attributed to the participants' preferences during game play. This study does not include any subjective data, but anecdotal comments from study participants may suggest that lower intensity and ease of Nintendo Wii games may be more enjoyable than the Playstation 2 with EyeToy. There were, however, subjective reports that the Playstation 2 EyeToy games were difficult to navigate by participants with fine motor deficits, revealing a topic for further investigation.

Back to Top | Article Outline

Comparison of the Playstation 2 EyeToy Kinetic and Play 2 Games and the Nintendo Wii Fit and Wii Sports Games

The Playstation 2 EyeToy Kinetic game produced the highest average of upper extremity active movements, lower extremity weight shifts, steps, and other active movements when compared with the other 3 games. The subcategories of movement types in which there were no significant differences between the Kinetic game and the other games were as follows: upper extremity active movements when compared with the Play 2 game, steps when compared with the Play 2 game, and other lower extremity active movements when compared with the Wii Fit game. The Playstation 2 EyeToy Kinetic game has a selection of mini-games designed to produce dynamic movements of the upper extremity and lower extremity to perform in-game tasks, including stepping toward and touching multiple orbs falling down the screen and punching/kicking orbs as they float around on screen. Most fast-paced mini-games within the Kinetic game may prove beneficial as an additional form of therapy for higher-functioning individuals poststroke. In contrast, lower-functioning individuals poststroke could become frustrated by the high intensity and have difficulty keeping up and succeeding with the in-game tasks.

The Playstation 2 EyeToy Play 2 game had a higher average number of upper extremity repetitions than both the Wii Fit and Wii Sports games. In addition, the Play 2 game compared favorably with the Wii Fit game in the number of weight shifts. Although the average number of upper extremity repetitions achieved with the Play 2 game was not as high as that with the Kinetic game, the post hoc analyses revealed no significant difference between the 2 games. Play 2 mini-games are more “fun” oriented, providing a moderate intensity of activity for the participant. While there are some games that require simultaneous upper extremity and lower extremity dynamic movements similar to the Kinetic games, most of the games only require 1 or 2 subcategories of repetitions to perform the in-game tasks.

The Nintendo Wii Fit game promoted more weights shifts than any other subcategory of repetition, yet it did not have significantly more weight shifts than the Wii Sports game. This finding is a little surprising, as the Wii Fit game has participants balancing on the Wii balance board and coordinating fine weight shifts to achieve in-game tasks, while the Wii Sports game does not use such a balance board. This game could benefit patients poststroke when individualizing treatments to address balance deficits.

The Nintendo Wii Sports game had the lowest average of total repetitions of all the 4 games played, although it was not significantly different from the Wii Fit game in post hoc analyses. The Wii Sports game is a more “fun” based game similar to Playstation 2 EyeToy Play 2 game, with game pacing controlled more by the player. Mini-games such as bowling and golf have breaks during game play that allow the player to progress through the mini-game at their own speed between frames or holes, which can affect the amount of time or the number of opportunities to perform upper and lower extremity movements during game play.

Analyses were also performed at the mini-game level (see Tables, Supplemental Digital Content 2, http://links.lww.com/JNPT/A48, and Supplemental Digital Content 3, http://links.lww.com/JNPT/A49, which show the repetitions per minute for Playstation 2 EyeToy and Nintendo Wii mini-games). Results revealed large variability in the number and categorical type of repetitions observed across mini-games, as each mini-game has different demands for movements (eg, the running mini-game for the Nintendo Wii Fit encourages stepping, while the “Backlash” mini-game for the Playstation 2 Kinetic encourages upper extremity active movements—“punching”—as this mini-game features punching bags that alternately appear from each corner of the screen). Total game play time also varied largely across mini-games, as participants were allowed to choose which mini-games they wanted to play during each 30-minute fitness- and fun-based gaming sessions.

Back to Top | Article Outline

LIMITATIONS

There are several limitations to our study. The observational method of counting repetitions means repetitions are classified on the basis of the rater's judgment. However, strict definitions were established to define particular movement types in an effort to maximize objectivity, and reliability analyses performed after counting 10 sessions also showed limited variability between raters' observations. Another limitation is that only active movements were counted, excluding from analysis a large number of movement types that are components of traditional therapy sessions. Furthermore, our study only assessed the quantity of movement produced, not the quality. This is contradictory to the focus of most rehabilitation sessions in this population, wherein movement quality is an important focus.

The inclusion of only game play of 2 games from each gaming system is another limitation. There are many games available for each system, and the number of repetitions observed in our study cannot be generalized across all games available for these systems. Furthermore, our study design allowed for the participants to choose from the “mini-games” offered in each game; while this made each session more individualized, it added a source of variability to the study. In addition, participants were allowed to interact with the games by using any method they chose. These choices allowed the participant to dictate how many active repetitions were performed by the affected extremities, and as our results showed, there was high variability in the number and categorical type of repetitions observed among the 4 games used across the 2 gaming systems. This is contradictory to the methods of traditional therapy sessions, in which therapists target functional deficits. By allowing participants this freedom, our study may not capture the full potential of video game play as a therapeutic intervention.

Back to Top | Article Outline

CONCLUSIONS

The results of our study indicate that active gaming, specifically Playstation 2 EyeToy game play, produced more upper extremity repetitions than those reported in the literature by using traditional therapy across similar session times; however, traditional therapy sessions produce larger average numbers of gait steps per session. In addition, of the 2 gaming systems we observed, the Playstation 2 EyeToy group produced more upper extremity active movements and weight shifting movements than the Nintendo Wii group. The numbers of repetitions produced by active gaming in 36-minute sessions were found to be less than the number shown to produce cortical changes in animal studies, but video gaming does show promise. It has potential as a cost-effective intervention that may promote the initiation of more active movements in individuals poststroke, and the motivation provided through the games may increase adherence to activity.

Back to Top | Article Outline

REFERENCES

1. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e46–e215.
2. Murray CJL, Lopez AD (Eds). Global Burden of Disease: a Comprehensive Assessment of Mortality and Disability From Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard School of Public Health; 1996.
3. American Heart Association. Heart disease and stroke statistics: update; 2010. http://circ.ahajournals.org/content/early/2009/12/17/CIRCULATIONAHA.109.192667.full.pdf#page=1&view=FitH. Published online before print December 17, 2009, doi: 10.1161/CIRCULATIONAHA.109.192667
4. Elbert T, Pantev C, Wienbruch C, Rockstroh B, Taub E. Increased cortical representation of the fingers of the left hand in string players. Science. 1995;270:305–307.
5. Kleim JA, Barbay S, Nudo RJ. Functional reorganization of the rat motor cortex following motor skill learning. J Neurophysiol. 1998;80:3321–3325.
6. Nudo RJ, Milliken GW, Jenkins WM, Merzenich MM. Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys. J Neurosci. 1996;16:785–807.
7. Chen H, Epstein J, Stern E. Neural plasticity after acquired brain injury: evidence from functional neuroimaging. PM R. 2010;2:S306–S312.
8. Kunkel A, Kopp B, Muller G, et al. Constraint-induced movement therapy for motor recovery in chronic stroke patients. Arch Phys Med Rehabil. 1999;80:624–628.
9. Sterr A, Freivogel S. Motor-improvement following intensive training in low-functioning chronic hemiparesis. Neurology. 2003;61:842–844.
10. Miltner W, Bauder H, Sommer M, Dettmers C, Taub E. Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke: a replication. Stroke. 1999;30:586–592.
11. Kwakkel G, van Peppen R, Wagenaar RC, et al. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke. 2004;35:2529–2539.
12. Kwakkel G. Impact of intensity of practice after stroke: issues for consideration. Disabil Rehabil. 2006;28:823–830.
13. Lang CE, Macdonald JR, Reisman DS, et al. Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil. 2009;90:1692–1698.
14. Kimberley TJ, Samargia S, Moore LG, Shakya JK, Lang CE. Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke. J Rehabil Res Dev. 2010;47:851–862.
15. Chau C, Barbeau H, Rossignol S. Early locomotor training with clonidine in spinal cats. J Neurophysiol. 1998;79:392–409.
16. de Leon RD, Hodgson JA, Roy RR, Edgerton VR. Locomotor capacity attributable to step training versus spontaneous recovery after spinalization in adult cats. J Neurophysiol. 1998;79:1329–1340.
17. Weiss PL, Rand D, Katz N, Kizony R. Video capture virtual reality as a flexible and effective rehabilitation tool. J Neuroeng Rehabil. 2004;1:12.
18. Betker AL, Szturm T, Moussavi ZK, Nett C. Video game–based exercises for balance rehabilitation: a single-subject design. Arch Phys Med Rehabil. 2006;87:1141–1149.
19. Flynn S, Palma P, Bender A. Feasibility of using the Sony PlayStation 2 gaming platform for an individual poststroke: a case report. JNPT. 2007;31:180–189.
20. Rand D, Kizony R, Weiss PT. The Sony PlayStation II EyeToy: low-cost virtual reality for use in rehabilitation. J Neurol Phys Ther. 2008;32:155–163.
21. Yavuzer G, Senel A, Atay MB, Stam HJ. “Playstation EyeToy games” improve upper extremity-related motor functioning in subacute stroke: a randomized controlled clinical trial. Eur J Phys Rehabil Med. 2008;44:237–244.
22. Nudo RJ, Wise BM, Sifuentes F, Milliken GW. Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science. 1996;272:1791–1794.
23. Carr J, Shepherd R. Neurological Rehabilitation. Oxford, UK: Butterworth & Heinemann; 1998.
24. Werner RA, Kessler S. Effectiveness of an intensive outpatient rehabilitation program for postacute stroke patients. Am J Phys Med Rehabil. 1996;75:114–120.
25. French B, Thomas LH, Leathley MJ, et al. Repetitive task training for improving functional ability after stroke. Stroke. 2009.
26. Liepert J, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke. 2000;31:1210–1216
Keywords:

rehabilitation; repetitions; stroke; video games

Supplemental Digital Content

Back to Top | Article Outline
© 2013 Neurology Section, APTA