Monday, September 02, 2013

Nintendo and the Wii: Interactions with Health and Science

Media stories often focus on the negative effects that violent video games have on society, but it is important to also point out that video games have a positive impact in treating numerous health care conditions and in advancing science.

The most well known video game system that does this the Nintendo Wii, which utilizes numerous motion sensitive devices (e.g., balance board, handheld motion controller, skateboards, exercise bikes), to detect motion in three dimensions, allowing the player to interface with the game more realistically. Because of this role that the Wii has in motor feedback, it plays an important part in physical rehabilitation. For this reason, it is sometimes referred to as “Wii-hab”.

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The main settings and ways that the Wii has been helpful can be broken down into the following areas: a) neurological disorders in adults, b) developmental disorders and disabilities, c) non-neurological disorders, d) the elderly and fall prevention, e) exercise, measurement, and scientific testing, and f) surgical training. Information about each of these sections from the scientific literature is described below. The article ends with a discussion of medical problems (some of which may surprise you) that have resulted from using the Nintendo Wii and other Nintendo-based systems.


As an example of the Wii’s rehabilitation benefits, use of the system has been shown to improve short-term motor abilities, postural stability, quality of life, and non-motor skills in Parkinson’s disease (PD) (Herz et. al, 2013; Holmes et al., 2013) although beneficial effects of the Wii Fit have not been found in all Parkinson’s patients (Pompeu et al, 2012).  PD is a type of brain disorder that leads to serious difficulties with muscle movements.  The Wii has also been used a home assessment device to measure motor abnormalities in PD such as tremor and motor slowness (Synnott et al., 2012).

The Wii has been shown to build confidence in abilities, achieve goals in leisure activities, and remove barriers from exercising in patients with multiple sclerosis (MS) (Huurnin et al., 2013). Multiple sclerosis is a condition in which people develop multiple areas of abnormal patches (also known as plaques or sclerosis) in the brain and/or spinal cord (depending on the stage of the illness). Others have found that the Wii improves balance in patients with MS (Brichetto et al., 2013). Both the Wii and PlayStation 2 have been used in stroke rehabilitation to improve motor movements, with use of games with the PlayStation 2 video camera improving movement and movement intensity (Neil et al., 2013).

The Wii Balance Board provides visual and balance feedback which has been found to be helpful in reducing hospital stays, improving sensory organization, dizziness, balance and vertigo in patients with acute vestibular neuritis. Acute vestibular neuritis refers to attacks of dizziness and spinning sensations that decrease over three to six weeks (Sparrer et al, 2013). The Wii Fit (Plus) has also been shown to be a useful balance treatment in patients with other vestibular and neurological diseases (Meldrum et al., 2012).


In children, Wii Fit training has been shown to improve motor performance in those with developmental coordination disorder (Ferguson et al, 2013). It has been hypothesized that the Wii would be beneficial in improving the motor functions of children with cerebral palsy (Gordon et al., 2012). However, when this topic has been studied, children with spastic cerebral palsy preferred the Wii Fit over conventional physical therapy but it did not improve their motor functioning (Jelsma et al., 2013). Cerebral palsy is a type of brain damage that occurs during pregnancy, during birth, during infancy, or during early childhood that causes the child to have difficulties with movement and posture.

Researchers have shown that the Wii remote control can be turned into a high performance 3D object orientation detector and used with children with disabilities to improve their ability to perform a designated occupational task (i.e., rotating a 3D cube to make a requested pattern) (Shih et al, 2012a; Shih and Chang, 2012) and other occupational activities (Shih et al, 2012b) and physical activities (Shih, 2011; Shih et al., 2011a, Shih et al., 2012c), including limb action (Shih et al., 2010a) and standing posture (Shih et al., 2010b). Playing Wii games was found to improve highly practiced motor skills and postural control in a child with Down syndrome (Berg et al, 2012). Down syndrome is an abnormality that is present from birth that results in mental impairments and a characteristic physical appearance (small facial features, large tongue that sticks out, a flat back area of the head, and hands that are short and broad).

The Wii remote controller has helped people with disabilities keep their head in an upright position to obtain desired environmental stimulation during a head position correction program (Shih, Shih, and Shih, 2011). Use of the Wii remote has also helped reduce hyperactive limb behavior in children with attention deficit hyperactivity disorder (Shih et al, 2011b).


In non-neurological disorders, the Wii balance board has been used in research on improving postural control impairments in people who undergo reconstruction of the ACL (anterior cruciate ligament) which is in the knee(Howells et al, 2013). However, one study did not find that the Wii Fit provided additional benefit compared to conventional physical therapy in patients who have undergone ACL reconstruction (Baltaci et al., 2013). The Wii balance board has been found to be a potentially acceptable rehabilitation adjunct to physical therapy in patients who have undergone total knee replacement (Fung et al., 2012). There have been indications that use of the Wii may help with improving pain, anxiety, active range of motion, function, and enjoyment in patients undergoing acute burn rehabilitation although this has not been scientifically proven (Yohannan et al., 2012). Residents of long-term care facilities using the Wii bowling game in addition to standard physical therapy for arm dysfunction enjoyed the therapy more and tended to report more improvements than a physical therapy program without the Wii bowling game, but not significantly so (Hsu et al., 2011).


Elderly people playing the popular Wii Sports game in residential care centers have had fun using it, feel a sense of empowerment and achievement, and feel that it allows for greater socialization (Keough et al, 2013; Williams et al., 2010). Use of the Wii has been shown to increase exercise capacity, energy expenditure, motivation to exercise, and decreased barriers to exercising in the elderly , such as an elderly man who suffered heart failure (Griffin et al., 2012; Klompstra et al, 2013). Staff at health care centers where the Wii was used for at least three months believes that Wii activities promote physical (mobility, range of motion, dexterity, coordination, distraction from pain) and psychological benefits (social engagement, self-esteem, mastery, ability to pacify challenging behaviors) with aged (and disabled) clients (Higgins et al., 2010).

Use of the Wii has been found to improve leg strength in the elderly, which can help decrease falls in a safe, adaptable, and low cost manner (Clark and Kraemer, 2009; Jorgensen et al., 2013; Young et al., 2011). It is thus used to prevent falls in numerous rehabilitation programs (Taylor et al,. 2012) and to improve balance in other settings with the elderly (Williams et al., 2011) . Although the elderly enjoy the Wii Fit, not all studies have shown that it improves their balance (Franco et al, 2012). However, in older patients who have needed to wear a prosthesis for leg amputation, the Wii Fit it has been shown to improve balance confidence, to decrease reliance on assistive devices, and to increase energy efficiency when walking with the prosthesis (Miller at al, 2012). Importantly, the elderly, including those in long-term care facilities, enjoy playing the Wii for exercising, socializing, nostalgia, and competition, which enhances adherence to continuing its use (Brandt and Paniaqua, 2011) although some elderly prefer traditional therapy techniques (Laver et al., 2011). Although an initial attempt was made to use cognitive games on the Wii as a form of neuropsychological testing for the elderly, this idea never materialized into clinical practice, perhaps due to difficulties encountered by requiring physical interactions (Gamberini, et al., 2010).


In times where it has become increasingly costly to cut medical costs, the Wii has been shown to provide a low cost, objective, valid, and reproducible way to measure standing and postural balance in adults (Clark et al., 2009 Jorgensen et al, 2013). The Nintendo Wii hand controllers have also been shown to be a portable and valid measure of running velocity (Clark et al, 2011a). The Wii remote controllers have also been used for the measurement of the angle of head posture (Kim et. al, 2012). Use of multiple Wii balance boards has been shown to be a reliable measure of weight bearing (Clark et al., 2011) and to improve weight bearing in athletes (McGough et al, 2012). The Wii remote has been used in functional magnetic resonance imaging (MRI) studies to track one or more moving points that can correspond to limbs, fingers or any other object whose position needs to be known (Modrono et al., 2011b).

The Wii Sports boxing game has been found to provide moderate to vigorous aerobic activity for exercise (Bosch et al., 2012). The Wii boxing game has been shown to involve more non-dominant upper extremity movement, energy expenditure, and heart rate than the Wii tennis or bowling games (Graves et al., 2008).

The Wii Fit has been shown to be an acceptable alternative to traditional moderately intense aerobic exercise in sedentary young adults (Douris et al., 2012). One problem with the Wii Fit is that the balance board scores it produces have been found to have poor reliability (consistency) within and between sessions and not to match up well with similar measures from other more established balance measurement systems (Wikstrom, 2012). However, others have found the Wii balance board to be reliable in measuring bodily sway in the elderly (Koslucher et al., 2012).

The handheld Nintendo DS system has been shown to be capable of integrating healthcare monitoring functions (e.g., heart monitoring signals, fall detection)  and transmit the information wirelessly to a separate location, allowing it to be used in an ambulance, nursing home, or general hospital (Lee et al., 2009; Lee et al., 2011). The Wii has also been used to show that men perform best at hunting games (navigation and shooting) but that men and women perform the same on gathering games (fine motor and visual search) (Cherney and Poss, 2008).


Use of the Wii has also shown promise in predicting and improving basic laproscopic surgical skills in students and surgical trainees, particularly with the non-dominant hand (Badurdeen et al. 2010; Bokhari et al., 2010; Boyle et al., 2011; Middleton, et al, 2013). These benefits in enhancing laproscopic surgery skills have been replicated by others (Giannotti et al, 2013) and have also been shown for the PlayStation 2 when playing a gun arcade game (Time Crisis II) (Ju et al, 2012).


While the Nintendo Wii has had many positive benefits as it relates to healthcare, some negative impacts have been reported in the scientific literature. This includes a hand tendon rupture suffered by a community doctor after playing tennis on the Wii and striking a wall with her wrist and thumb while attempting a backhand motion (Bhangu et al, 2009). Even more dangerous was the case of a 55-year-old woman who sustained a large hemothorax (chest bleed) when playing tennis on the Nintendo Wii because she swung around too fast (Peek et al., 2008). A chest drain was inserted to drain out the blood and she was discharged home 5 days later.

Injuries while playing Nintendo are not unique to the Wii. In 2001, Dr. Johanna Wood documented the case of an 8-year-old child and his two friends who developed a blister in the middle of one of their hands due to overplaying the game, Mario Party, when rotating the central joystick with the palm of the hand.  Back in 1992, Bright and Bringhurst coined the term, “Nintendo elbow” in a 12-year-old boy with several days of right elbow pain, presumably from playing Nintendo alot. The problem resolved 9 days after stopping Nintendo play and use of ibuprofen. It was recommended that children support the elbow on a firm surface during Nintendo play. Nintendo elbow was preceded by “Nintendo neck” which was described in the scientific literature one year prior by Dr. David Miller. The term was coined after the author observed his son develop neck pain after 30 minutes of playing the hand-held Game Boy system. This was presumably caused by the position held while playing the game (hunched over, chin on the  chest, elbows bent, screen close to the face, while staring intently).

In 1990, the term “Nintendinitis” was used by Brasington  to describe thumb pain in a 35-year-old who pushed the Nintendo button repeatedly while playing. The term, “Nintendo epilepsy” was used the same year by Hart due to seizures that occurred in a 13-year-old girl after playing Super Mario Brothers for three hours with only a 10 minute break. The presumed cause was the shifting pattern of the video game image. Nintendo has also been associated with urinary accidents (Schink, 1991) and fecal accidents (Corkery et a., 1992) in children because they try to hold in bodily waste longer than they can due to not pausing the game.


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