doi: 10.2522/ptj.20080062Originally published online August 8, 2008

2008; 88:1196-1207.PHYS THER. Huhn and Phyllis Guarrera-BowlbyJudith E Deutsch, Megan Borbely, Jenny Filler, KarenWith Cerebral PalsyConsole (Wii) for Rehabilitation of an Adolescent Use of a Low-Cost, Commercially Available Gaming

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Use of a Low-Cost, CommerciallyAvailable Gaming Console (Wii) forRehabilitation of an AdolescentWith Cerebral PalsyJudith E Deutsch, Megan Borbely, Jenny Filler, Karen Huhn,Phyllis Guarrera-Bowlby

Background and Purpose. The purpose of this retrospective and prospectivecase report is to describe the feasibility and outcomes of using a low-cost, commer-cially available gaming system (Wii) to augment the rehabilitation of an adolescentwith cerebral palsy.

Patient and Setting. The patient was an adolescent with spastic diplegiccerebral palsy classified as GMFCS level III who was treated during a summer sessionin a school-based setting.

Intervention. The patient participated in 11 training sessions, 2 of which in-cluded other players. Sessions were between 60 and 90 minutes in duration. Trainingwas performed using the Wii sports games software, including boxing, tennis,bowling, and golf. He trained in both standing and sitting positions.

Outcomes. Three main outcome measures were used: (1) visual-perceptual pro-cessing, using a motor-free perceptual test (Test of Visual Perceptual Skills, thirdedition); (2) postural control, using weight distribution and sway measures; and(3) functional mobility, using gait distance. Improvements in visual-perceptual pro-cessing, postural control, and functional mobility were measured after training.

Discussion and Conclusions. The feasibility of using the system in theschool-based setting during the summer session was supported. For this patientwhose rehabilitation was augmented with the Wii, there were positive outcomes atthe impairment and functional levels. Multiple hypotheses were proposed for thefindings that may be the springboard for additional research. To the authors’ knowl-edge, this is the first published report on using this particular low-cost, commerciallyavailable gaming technology for rehabilitation of a person with cerebral palsy.

JE Deutsch, PT, PhD, is Professorand Director of the Rivers Lab,Doctoral Programs in PhysicalTherapy, Department of Rehabili-tation and Movement Science,School of Health-Related Profes-sions, University of Medicine andDentistry of New Jersey, Stanley S.Bergen Building, 65 Bergen St,SSB 723, Newark, NJ 07101-3001(USA). Address all correspondenceto Dr Deutsch at: deutsch@umdnj.edu.

M Borbely was a DPT student,Doctoral Programs in PhysicalTherapy, Department of Rehabili-tation and Movement Science,School of Health-Related Profes-sions, University of Medicine andDentistry of New Jersey, at thetime this case report was written.

J Filler was a DPT student, DoctoralPrograms in Physical Therapy, De-partment of Rehabilitation andMovement Science, School ofHealth-Related Professions, Uni-versity of Medicine and Dentistryof New Jersey, at the time this casereport was written.

K Huhn, PT, MHS, is Instructor,Doctoral Programs in PhysicalTherapy, Department of Rehabili-tation and Movement Science,School of Health-Related Profes-sions, University of Medicine andDentistry of New Jersey.

P Guarrera-Bowlby, PT, MEd, PCS,is Associate Professor, DoctoralPrograms in Physical Therapy, De-partment of Rehabilitation andMovement Science, School ofHealth-Related Professions, Uni-versity of Medicine and Dentistryof New Jersey.

[Deutsch JE, Borbely M, Filler J,et al. Use of a low-cost, commer-cially available gaming console(Wii) for rehabilitation of an ado-lescent with cerebral palsy. PhysTher. 2008;88:1196–1207.]

© 2008 American Physical TherapyAssociation

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Virtual reality (VR) is definedas an immersive, interactive,3-dimensional computer expe-

rience occurring in real time.1 It pre-sents users with opportunities toengage in multidimensional, multi-sensory virtual environments (VEs)that appear to be and feel compara-ble to real events.2,3 Virtual realitysystems typically involve hardwareand software components. Userscontrol an interface to enter a VE orsetting for the simulation. Virtual re-ality systems offer clinicians the con-trol over exercise duration, intensity,and environments that real-worldtasks do not. Users in VR can per-form tasks that they may not be ableto execute safely or at all in real-world situations.4 Virtual reality sys-tems have been developed specifi-cally for rehabilitation of upper-extremity use,5–7 lower-extremitytraining,8 and gait retraining.8–11

Most of these systems are not com-mercially available and, when avail-able, are very expensive. For thisreason, low-cost, commercially avail-able technologies, such as gamingsystems, are being trial tested for re-habilitation applications.12

The feasibility and efficacy of usingVR systems for individuals with cere-bral palsy (CP), aged 8 to 15 years,have been explored by several inves-tigators. Reid13 found that childrenplaying in a VE felt safe and wereable to practice. In a comparison of12 VEs, Reid1 also found that playful-ness was increased if the child hadsome control and was allowed cre-ativity and persistence with the VE’stask. When compared with standardphysical and occupational care, stu-dents who practiced in VR had sim-ilar outcomes.14 In contrast, VR wasfound to be superior to standard an-kle exercises practiced at home foradherence, exercise repetition, andendurance, as well as to foot excur-sion measures.15 Training in upper-extremity movements in VR wasfound to improve reaching behaviors

and to produce cortical reorganiza-tion.16 Improved visual-perceptualprocessing using VEs in isolation andcombined with tabletop activitiesalso was reported for children withCP.17

Interestingly, with the exception ofthe visual-spatial study, all of thesestudies were conducted using theIREX (Interactive Rehabilitation EX-ercise)* platform. This is a commer-cially available motion-capture VRsystem that was specifically designedfor rehabilitation. Users wore glovesthat were detected by a camera andembedded them in a 2-dimensionalflat-space environment where theyinteracted with graphical objects.The VE was projected onto a largescreen in front of the user. Only inone report18 was gaming technol-ogy, the PlayStation 2 platform incombination with the EyeToy,† trialtested with children with CP. Thelow-cost PlayStation 2 gaming systemhas been shown to provide presence,enjoyment, usability, and performancecomparable to the IREX for a varietyof—but not all—patients.2

In their review of VR in rehabilita-tion, Weiss and colleagues2 con-cluded that motion-capture systemsshow great promise for a variety oftherapeutic goals, including improv-ing functional activities and motorrehabilitation. They also identifiedsome of the drawbacks of motion-capture VR systems, specifically lackof haptic (touch) feedback, an inabil-ity to have multiple players, the de-gree of presence afforded, and thehigh cost of those designed specifi-cally for rehabilitation.

The limitations identified for thevideo motion-capture systems are ad-dressed, in great part, by a commer-

cially available VR gaming systemthat could potentially be used for re-habilitation, the Nintendo Wii.‡ Thissystem uses a remote controller asthe input into the VE. Unique fea-tures of the controller relative toother low-cost, commercially avail-able gaming VR systems (such as thePlayStation 2 EyeToy) are its motionsensors and shape. Users hold thecontroller (or remote) in a mannerthat is congruent with the way thehand would hold and manipulatereal-world objects (such as the han-dle of a racket). The controller has asensor that measures the person’smotions and maps them into the VE.It also provides the user with hapticfeedback. This is the physical sensa-tion connected with interacting withobjects in the VEs.19 Users feel a ballcontacting a virtual racquet, al-though this sensation may not beidentical to a real-world sensation.The sensation, however, is enhancedwith auditory feedback. The Wii usesdifferences in the applied forcesand accelerations of the remote tochange the amount of feedback itprovides to the user. Multiple playerscan simultaneously participate in agame scenario. Some of the gamesresemble real-world games such astennis, golf, and boxing, requiringtotal body movement often congru-ent with real-world motions. Thereare many reports in the popularpress about using the Wii in clinicalsettings; however, to date, there areno published reports on the use ofthe Wii for rehabilitation.

Although we have had a positive ex-perience with a haptic-robot VR sys-tem to rehabilitate walking for peo-ple after stroke, we were frustratedwith the cost and time delay fromdevelopment and testing to imple-mentation in the clinic. Therefore,we wanted to explore a portable,lower-cost, and commercially avail-* Gesturetek Health, 317 Adelaide St W, Suite

903, Toronto, ON, M5V 1P9 Canada.† Sony Computer Entertainment America, 919Et Hillsdale Blvd, 2nd Floor, Foster City, CA94404

‡ Nintendo Domestic Distributor, 15–15132nd St, College Point, NY 11356.

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able system that could immediatelybe trial tested in the clinic. We iden-tified a candidate user, an adolescentwith CP whose physical capabilitiesallowed him to use the Wii butwhose functional limitations pre-vented real-life practice of the sport-ing activities provided by the Wii.We speculated that the practice ofthese activities would address hisphysical therapy goals, which in-cluded improving visual-perceptualprocessing, postural control, andfunctional mobility. The purpose ofthis retrospective and prospectivecase report is to describe the feasi-bility and outcomes of using the Wiito augment the rehabilitation of thispatient using individual and groupgaming sessions.

Case DescriptionPatient History and ExaminationAt the time of the intervention, thepatient was a 13-year-old adolescentattending a summer program at aschool for children with develop-mental disabilities. Based on a chartreview, his past medical history in-cluded being born heroin dependentat 28 weeks of gestational age. Hewas diagnosed with spastic diplegicCP and delayed development. Addi-tional diagnoses included severeasthma, requiring oxygen and theuse of inhalers, and tonic seizureactivity.

It was noted that, on several occa-sions in the patient’s medical andeducational chart, he had difficultymaintaining task focus and problemsolving, displayed task-avoiding be-haviors, and was easily distractible. Aneurological evaluation was com-pleted, and the findings suggestedthat he had poor motor planning,poor ability to sustain attention, andpoor ability to complete tasks. None-theless, 14 months prior to the in-tervention, the findings of an assess-ment using an attention-deficit/hyperactivity disorder index were re-ported in the chart to be in the nor-

mal range. According to his thera-pists, during the school year beforethe intervention, there was a dra-matic improvement in his attention.There was no specific explanation inthe chart for this change. Findingsfrom the Wechsler Intelligence Scalefor Children (WISC-IV) showed sig-nificant difficulty with verbal com-prehension, perceptual reasoning,processing speed, and number andletter sequencing. The interpretationof the WISC-IV findings classifiedhim as predominantly in the border-line to extremely low range. His fullIQ was scored as 79.

According to the patient’s chart, dur-ing his re-evaluation (3 months priorto the intervention), he was de-scribed as having active movementin all extremities, with better iso-lated movement of the upper ex-tremities relative to the lower ex-tremities. He used his left upperextremity as his dominant functionalarm. Posture in supported standingwas described as semicrouched,with hip medial (internal) rotationand adduction. Sitting posture in-cluded a posteriorly tilted pelvis, lat-erally flexed trunk with convexity tothe right and flexed posturing of theright upper extremity, and de-creased loading through both lowerextremities. He also had decreasedrange of motion in hip extension andlateral (external) rotation, knee flex-ion, and ankle plantar flexion; he hadpoor abdominal strength (force-generating capacity); and he lackedcore stability. At that time, he wasambulating independently with bi-lateral ankle-foot orthoses and a pos-terior rolling walker throughoutschool, in his home environment,and for short distances in the com-munity. This would classify him asGross Motor Function ClassificationSystem level III.20 For the previous 2school years, he had been workingon ambulation with bilateral forearmcrutches in physical therapy. He am-bulated with his bilateral forearm

crutches up to 75 ft (22.9 m) withclose supervision; however, he com-pleted this task at a slow speed andoccasionally lost his balance, requir-ing assistance to regain control. Theprojected physical therapy goals forthe upcoming school year included:independent standing for 5 minutesusing one forearm crutch while per-forming an activity; ambulating 200ft (61 m) using forearm crutcheswith contact guard assistance with-out loss of balance; and upright mid-line sitting on a bench or bolster forup to 10 minutes, requiring fewerthan 2 verbal cues.

This adolescent appeared to be agood candidate for trial testing theWii gaming system. He was selectedfor several reasons, including havingadequate functional hand skills tomanage the Wii remotes, gross mo-tor skills to work in either a sitting orstanding position, and sufficient cog-nitive skills to follow directions, stayon task, and understand the games.Based on the physical therapy goalsthat involved trunk control and mo-bility combined with the challengesobserved in the patient’s ability tomaintain attention, we felt that agaming activity that engaged himand provided opportunities to reme-diate his physical limitations mightbe a useful adjunct to his therapeuticregimen. After obtaining consentfrom the adolescent’s guardian, testsand measures and the interventionwere administered.

Tests and MeasuresSeveral standardized measures wereused exclusively to characterize themotor control profile of the patient.These measurements were not re-peated because they were not ex-pected to change during the shortinterval of the intervention. Obser-vations of posture confirmed thedescriptions in the chart. Tests ofvisual-perceptual discrimination,postural control, and functional mo-bility were administered as outcome

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measures. The timing of administra-tion of the pretesting and posttestingvaried according to the measure andwho was conducting the testing.Testing that we conducted was ad-ministered immediately before andfollowing the intervention. Testingperformed by the treating clinicianswas administered at the scheduledre-evaluations for the patient in theschool setting. It was our clinical hy-pothesis that he would exhibitchanges in visual-perceptual process-ing and postural control becausethey would be directly addressed bythe intervention. What we did notknow was whether the trainingwould transfer to his functionalmobility.

To characterize the patient’s motorcontrol, we used the Quality of Up-per Extremity Skills Test (QUEST)21

and the Gross Motor Function Mea-sure (GMFM).22 These tests were se-lected because they have been vali-dated for people with CP.21

The patient completed subtests D(standing) and E (walking, running,and jumping) of the GMFM priorto the third treatment session. Highintrarater and interrater reliability(intraclass correlation coefficient[ICC]�.92–.99) have been reportedfor both subtests.22 Subtest D in-cludes items such as coming to astanding position from a kneeling po-sition, standing independently, andreaching for objects on the floorfrom a standing position. On subtestD, the patient achieved a raw scoreof 12, with a total percentage of30.77%. Subtest E includes itemssuch as cruising, walking forward,stepping over objects, jumping, hop-ping, and stair climbing. On subtestE, the patient had a raw score of 21,with a total percentage of 29.17%. Ascore of 100% on each subtest indi-cates that the person can perform allof the activities. A child who is de-veloping typically would receive a

score of 100% on all subtests by theage of 5 years.22

Prior to the third treatment session,the dissociated movements andgrasp subtests of the QUEST wereadministered, which were deemedappropriate given the functionallevel of the patient. High test-retestreliability (ICC�.93–95) and interra-ter reliability (ICC�.91) have beenreported for these subtests.21 The pa-tient’s raw score for dissociatedmovements was 95.31, with a stan-dardized score of 90.62, and his rawscore for grasp was 81.48, with astandardized score of 62.96. Forboth subtests, the patient scoredhigher—64.06 (SD�22.20) for dis-sociated movements and 48.71(SD�30.73) for grasp—than the old-est group of children in the valida-tion study.21 A score of 100% indi-cates perfect performance. Theitems of the QUEST are essentialcomponents of movement devel-oped during the first 18 months oflife.21

Outcome MeasuresVisual-perceptual processing wastested because it is known to be im-

paired in children with CP.23–25 Vi-sual perception is a high-order sys-tem that allows people to perceive aworld beyond their bodies and plana vast range of different actions.26

We hypothesized that training in theVE may enhance these processesand, in turn, may improve mobility.The Test of Visual Perceptual Skills,third edition, (TVPS-3) was selectedbecause it is a nonmotor assessmentof visual perception for individuals 4to 18 years of age.27 The TVPS-3 com-prises 7 subtests arranged in order ofdifficulty from least difficult to mostdifficult. It includes categories ofperception such as spatial relation-ships and figure-ground that are par-ticularly pertinent to integrating per-ception and action. A description ofeach subtest is presented in Table 1.The test was administered by an oc-cupational therapist who wasmasked to the intervention. Test-retest reliability for the overall testwas reported as r�.97. Standard er-rors of measurement for the subtestsrange from 1.10 to 1.51.28

Scaled scores are calculated using aperson’s raw scores and chronologi-cal age. Scaled scores range from 1 to

Table 1.Definitions of the Subtests of the Test of Visual Perceptual Skills, Third Edition,(TVPS-3)27

TVPS-3 Subtest Definition

Visual discrimination The ability to match, or determine exactly, characteristics of twoforms when one of the forms is among similar forms.

Visual memory The ability to remember for immediate recall (after 4 or 5seconds) all of the characteristics of a given form and to beable to find this form from an array of similar forms.

Visual-spatial relationships The ability to determine, from among 5 forms of identicalconfiguration, the single form or part of a single form that isgoing in a different direction from the other forms.

Visual form constancy The ability to see a form, and be able to find that form, eventhough the form may be smaller, larger, rotated, reversed, orhidden.

Visual sequential memory The ability to remember for immediate recall (after 4 or 5seconds) a series of forms from among 4 separate series offorms.

Visual figure-ground The ability to perceive a form visually and to find this formhidden in a conglomerated ground of matter.

Visual closure The ability to determine, from among 4 incomplete forms, theone that is the same as the completed form.

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19 and are based on a populationdistribution with a mean of 10 and astandard deviation of 3. Percentilerankings provide a reflection of theperformance of one patient com-pared with the population. Func-tional classifications such as theWISC-IV also can be used to furtherdefine a person’s performance onthe test. The patient’s preinterven-tion results are presented in Table 2.

The patient’s overall standard base-line score of 86 was within 1 stan-dard deviation of the mean from thenormal distribution.29 This score wasslightly higher than that found in chil-dren with CP whose TVPS scores (anearlier version of the TVPS-3 was used)were more than 1 standard deviationlower than those of children whowere developing typically.29,30 Hissuperior baseline score may be ex-plained by his age, which at 13 yearswas higher than that of subjectstested by previous investigators.28

Postural control was examined usingmeasures of weight distribution andsway collected during static stancewith eyes open and with eyes closedon a Posture Scale Analyzer.§ Thesystem consists of 4 scales that arejoined as a single plate on which aperson stands. A computer con-nected to the system calculatesweight distribution, center of pres-sure, and sway rates. Measurementsfor each condition were taken 3times for 10 seconds. The patientstood on the PSA with the walkerbehind him. He was instructed to“stand as tall as possible and not holdon to your walker.” This instructionwas designed to encourage loadingthrough the lower extremities tominimize support on the walker.

Validity of the weight measurementswas established, using a scale, on 25

subjects who were healthy. Therewas a 0.7-lb (0.3-kg) measurementerror (unpublished data). Test-retestreliability of the PSA also was mea-sured in subjects who were healthyusing a coefficient of variation andreported standard errors of measure-ment that ranged from 1% to 2% inthe medial-lateral plane and 4% to 6%in the anterior-posterior plane.31 As 3trials were measured for each condi-tion, we were able to calculate thecoefficients of variation, which were3% to 8% in the medial-lateral direc-tion (for eyes open and eyes closed)and 1% to 30% in the anterior-posterior direction (for eyes openand eyes closed). The preinterven-tion results are presented in Table 3.

Functional mobility measurementswere extracted using retrospectivedata from the chart review. Thismethod was selected to have re-peated measurements relative to thepatient’s therapy goals by the same

§ Midot Medical Technology, Irus 276, GanNer, 19351 Israel.

Table 2.Preintervention and Postintervention Test of Visual Perceptual Skills, Third Edition, (TVPS-3) Scores and Wechsler IntelligenceScale for Children (WISC-IV) Classifications

TVPS-3 Subtest

Preintervention

WISC-IVClassification

Postintervention

WISC-IVClassification

ScaledScore Percentile

ScaledScore Percentile

Visual discrimination 5 5 Borderline 12 75 Normal/average

Visual memory 8 25 Normal/average 10 50 Normal/average

Visual-spatial relationships 10 50 Normal/average 12 75 Normal/average

Visual form constancy 3 1 Extremely low 5 5 Borderline

Sequential memory 10 50 Normal/average 6 9 Borderline

Visual figure-ground 8 25 Normal/average 10 50 Normal/average

Visual closure 7 16 Low average 10 50 Normal/average

Table 3.Preintervention and Postintervention Measurements on the Posture Scale Analyzer (PSA)

PSA Measures

Preintervention Postintervention

Eyes Open Eyes Closed Eyes Open Eyes Closed

Percentage of body weight 96 89 97 98

Sway rate (mm/s) 103 143 40 64

Percentage of right/left weight distribution 39/61 31/69 37/63 51/49

Percentage of anterior/posterior weight distribution 74/25 71/29 55/45 73/27

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rater over time. Because it wasperformed retrospectively, reliabilitywas not established. His walking dis-tance with forearm crutches, as mea-sured by the treating physical thera-pist, was initially 30 ft (9.1 m) withmoderate assistance (approximately2 years prior to initiating the Wiiintervention). It ranged from as littleat 10 ft (3 m) with contact guardassistance to minimal assistance to asmuch as 150 ft (45.7 m) with contactguard assistance.

InterventionThe goal of the intervention was todetermine the feasibility of introduc-ing this novel gaming technology toaddress a specific patient’s goals. Weselected the gaming system based onseveral factors. First, the handheldinterface to the virtual world readsacceleration changes to map themovements of the person into thegaming environment. This type ofsystem encourages movements thatcan be performed in both sitting andstanding positions. The patient wasable to learn the movements in asitting position and then practicethem in a standing position. Second,there are stock games available in thesystem that can be analyzed for theirbiomechanics and motor control re-quirements. The games then wereselected based on patient interestand task requirements. Third, it pro-vides users with knowledge of per-formance (KP) and knowledge ofresults (KR). Knowledge of perfor-mance is information about the ki-nematics of the movement, andknowledge of results is informationabout the outcome of the move-ment,32 which have been shown toimprove performance and skill inchildren with CP.33,34 Finally, it al-lowed for multiple users, and wewere interested in probing how in-teraction with other users (in thiscase, the therapists and a child whowas developing typically) would bereceived by the patient.

Using a client-centered approach,the Wii Sports games were selectedbased on the patient’s interest aswell as the therapeutic goals address-ing motor control and visual-perceptual processing. The gameswere played in a training or gamemode in both sitting and standingpositions. For games played in a sit-ting position, a therapist guardedfrom behind, occasionally stabilizingthe chair. For games played in astanding position, the therapistguarded from behind or on the sideto stabilize the posterior walker. Adetailed description of each of thegames selected, along with its thera-peutic aim, is provided in theAppendix.

Each game had different motor con-trol and visual-spatial demands. Forexample, golfing required judgmentsof force, distance, and figure-grounddiscrimination, with high accuracyconstraints. Upper-extremity controlwas promoted by all games. The re-mote was held with the left (domi-nant) hand for the bowling game;with both hands for the baseball, ten-nis, and golf games; and with onehand holding a Wii remote and theother hand holding a nunchuk forthe boxing game. Trunk control waspromoted by all games. For example,the boxing game required midlinetrunk orientation and endurance oftrunk muscles. The bowling game re-quired trunk stabilization while mov-ing a single upper extremity withvarying degrees of force. The gamesplayed in a standing position empha-sized balance with weight transferbetween the lower extremities.

Treatment was administered duringthe summer session in addition to hisregular therapies. The patient partic-ipated in 11 sessions over 4 weeks.Sessions ranged from 60 to 90 min-utes. Individual games ranged from 5seconds to 5 minutes. This dosingwas selected based on the patient’savailability, and it resembled a short,

intensive trial of a new therapy. It islikely that frequency could be main-tained but possibly not duration. Thefirst 7 sessions focused on the pa-tient using the system by himself. Inthe 8th session, a child who was de-veloping typically worked with thepatient. In the 11th session, he ex-perienced 2- and 3-person games.During the treatment, he continuedto receive his physical therapy (3times a week) and his occupationaltherapy (2 times a week). He alsoparticipated in a 1.5-hour occupa-tional therapy group.

Position and tasks were varied basedon observation of performance.Doses of treatment were adjusted toincrease duration, repetition, andcomplexity of tasks based on patientperformance using observations ofposture and movement as well as theperformance in the VE. For example,the boxing activity required bilateralupper-extremity reciprocal move-ments that promoted midline trunkalignment. The boxing activity wasselected early to establish good pos-tural control before playing morechallenging unilateral upper-extremity activities such as bowlingor tennis.

Activities were stopped or modifiedwhen the therapists observed deteri-oration in the patient’s physical per-formance, technique, or posturalcontrol resulting from overexertion.For the most part, the patient con-trolled the flow of activity. Rest pe-riods lasted for the duration that ittook the patient to reposition the Wiiremote and adjust the settings for thenext game. Training time was di-vided between sitting and standingpositions and varied based on thepatient’s performance (Fig. 1). Thedistribution of time spent on eachgame is illustrated in Figure 2.

OutcomesOutcomes were assessed at differenttimes after training. A repeat TVPS-3

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was administered by the occupa-tional therapist approximately 1month after the training. We retestedthe postural control measures 1 dayafter training, and walking was eval-uated by the treating therapist dur-ing the training and approximately 3months after the training ended.

Visual-perceptual processing im-proved in all domains except visualmemory. Improvements ranged froma 4th percentile change in form con-stancy to a 70th percentile changein visual discrimination (see Tab. 2for all visual-perceptual processingresults).

Postural control improved in a vari-ety of measures. There was greaterloading on the lower extremities andless reliance on the walker duringthe eyes-closed condition. Center-of-pressure sway decreased by approx-imately 60% in both eyes-open and

eyes-closed conditions. Medial-lateral weight distribution becamemore symmetrical during the eyes-closed condition and more symmet-rical in the anterior-posterior direc-tion with eyes open (see Tab. 3 forall postural control results).

Functional mobility (ambulationwith the forearm crutches) was mea-sured by the physical therapist dur-ing treatment sessions independentof the researchers. It increased dur-ing the training (from 15 ft [4.6 m] to150 ft [45.7 m]) and continued toincrease to 250 ft (76.2 m) after train-ing (Fig. 3). This distance had neverbeen achieved or maintained by thepatient prior to training.

DiscussionThe purpose of this case report is todescribe the feasibility and outcomesof incorporating the Wii as an inter-vention for an adolescent with CP.

Introducing the Wii for this studentwas feasible. His class schedule wasadjusted to allow for 2 or 3 weeklytraining sessions, for a total of 11sessions. The intervention was ren-dered over the summer when sched-uling is more flexible in the school.The student was able to indepen-dently walk to the session. He ar-rived promptly and was engaged forthe entire time. The sessions weresupervised by 2 people (ie,professional-level [entry-level] DPTstudents, faculty, or a clinician whoworked at the facility). Two peoplewere required partly because all ofthe sessions were observed and doc-umented. We speculate that a singleperson would be able to conduct thesessions, thereby increasing the fea-sibility of implementing this type oftherapy in the clinic.

The clinic already had a television setin its therapy space, so only the pur-chase of the Wii would be requiredto continue the therapy initiated inthe case report. An in-service train-ing session that we provided to theclinic staff after the trial interventionelicited enough interest for them tomake such a purchase. Other stu-dents were identified by the staff asbeing likely candidates to trial test asimilar intervention.

Cognition and motivation were im-portant considerations in selectingthis particular patient. His IQ ratingwas low, and he had some reportedattention deficits, both of whichwere previously identified as a limi-tation for VR training.18 However, hehad recently increased his attentionand was motivated to try the system,partly based on his previous experi-ence with commercially availablegaming systems. Therefore, we be-lieved that he would have the mini-mum attention requirements and,importantly, the motivation to ad-dress a variety of therapeutic goals.Consistent with previous work,1 weenhanced his inherent motivation by

Figure 1.Training distribution by position.

Figure 2.Distribution of games for each week.

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giving him control over task selec-tion and creativity in the sessionplanning.

The multiple-player capability of thesystem was feasible and facilitatedsocial interaction and unexpectedtherapeutic benefits. In the 10th ses-sion, we introduced a child who wasdeveloping typically as a secondplayer. During that session, we ob-served turn taking, strategy sharing,and encouragement. In the subse-quent session, the patient com-pletely changed his bowling strategyand reported that he used the strat-egy of the child who was developingtypically. The change in strategybased on modeling may explain hisimproved bowling game score from119 to 157 points, which was main-tained in the subsequent sessionwhen he bowled 160 points.

The feasibility of long-term use maybe enhanced by the system’smultiple-player capability. Duringthe ninth session, we observed a de-cline in the patient’s enthusiasm andinterest in the gaming system. Hereported, “I had more fun in the be-ginning, but I still like it,” and “I amOK with the games but new gameswould make it more fun.” We intro-duced new players and observedthat he maintained his interest in thetask for 8 minutes without interrup-tion and did not require verbal cues.A gaming system that accommodatesmultiple players could involve sev-eral patients working at once and

may offer efficient options for ther-apy delivery.

It is important to highlight that es-sential clinical decisions were madeby the therapist throughout the train-ing, and—at least for this patient—itwould not have been advisable orsafe to have him train on his own.The feasibility of implementing someof the exercises at home, as has beendone by other researchers,12 how-ever, would warrant furtherinvestigation.

The gaming intervention was de-signed to address 3 therapeuticgoals: postural control, functionalmobility, and visual-perceptual pro-cessing. Functional mobility was ad-dressed indirectly by combiningvisual-perceptual processing, pos-tural control, and endurance trainingin a standing position. We had spec-ulated that improvements could beobtained for the outcomes that weretrained directly. We were less certainwhether there would be a positivetransfer to walking.

We speculate that visual-perceptualprocessing improved because it waspracticed in all of the games. Thepatient’s greatest improvement wasin visual discrimination, where his75th percentile postinterventionscore placed him in the normalrange. Improved performance onsome of subtests, such as the 100%improvement in figure-ground, areeasy to interpret based on the figure-

ground relationships embedded ineach of the games. These games arerepresentative of real-world environ-ments and require extracting rele-vant features from background infor-mation. For example, the golf gamerequires a player to locate the redflag and hole in a sea of green andtrees. Other improvements, such asvisual closure, are more difficult toexplain. We do not know why thevisual memory score decreased,which is the only score that did notimprove. There is evidence in theliterature that visual-perceptual defi-cits can be remediated for both chil-dren who are healthy and childrenwith CP.35 It is important, however,that visual-perceptual training occurin the context of action.

In this case report, the emphasis ofthe training was on performance ofthe task in the VE. This training ap-proach stimulated motor behaviorsthat had visual-perceptual require-ments rather than training visual-spatial perception in isolation. Thistraining approach is consistent withthe notion that it is necessary to en-gage the individual in the motor be-havior to acquire the spatial process-ing ability.35,36

Postural control, measured byweight distribution and amount ofsway in a standing position, im-proved after training. During theeyes-closed condition, the patient’sweight distribution between thelower extremities became more sym-

Figure 3.Ambulation distance with forearm crutches measured during physical therapy sessions. The single peak of walking 150 ft (45.7 m)achieved 21 weeks prior to training was not replicated or sustained until after intervention with the Wii. I�intervention, CS�closesupervision, CG�contact guard assistance, min A�minimal assistance, Pre�prior to training, Post�after training.

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metrical. The decrease in sway thatwas observed after training can beinterpreted as a sign of increasedstance stability. This finding is con-sistent with work by Shumway-Cooket al,37 where massed balance train-ing produced a decrease in center-of-pressure sway in children with CP.The training provided in this casecombined massed practice of bal-ance with vision and attention di-rected at the game rather than main-taining balance, which we believestimulated the proprioceptive-vestibular system.

The proportion of time spent train-ing in a standing position varied byweek and ranged from a low of 35%to a high of 50%. The longest singletraining time in a standing positionwas 34 minutes. Interestingly, thistime far exceeded the therapeuticgoal of standing for 5 minutes whileengaged in an activity set for thecoming school year. Importantly, thetherapist’s suggestions for improvingposture were secondary to cues forimproving gaming performance. Aswith the visual-perceptual process-ing, attention was focused on thegame and performance in the gam-ing environment rather than attend-ing to posture. The duration and in-tensity of training facilitated by theengagement with the Wii games dis-tinguish this balance interventionfrom those currently available tophysical therapists as the standard ofcare.

Transfer of training from gaming towalking is a finding with importanttherapeutic implications, althoughthese data should be interpretedwith caution because they were col-lected from the patient’s chart. Fu-ture studies should include a6-minute walk test to measure walk-ing endurance.38 We speculate thatboth visual-perceptual processingand postural control training cou-pled with endurance may explainour patient’s improvements in func-

tional mobility. Other authors37 haveshown that training relevant ele-ments of a balance task may transferto the entire task. There also is workwhere training a visual-spatial task inthe virtual world transferred to im-proved way-finding in the realworld.39 In people poststroke, train-ing relevant lower-extremity featuresof gait in VEs has been shown totransfer to improved walking in thereal world.8 However, we are notaware of similar work with childrenwith CP.

There are a variety of explanationsfor why our patient improved aftertraining with the gaming system.One explanation may be the inten-sity of treatment. He certainly ex-ceeded duration on task relative tohis therapy sessions, as well as repe-titions. The training also was taskdriven and required problem solv-ing. These features of training havebeen shown to promote behavioralchanges40–42 as well as neural plas-ticity16 in children with CP. Finallythe multisensory feedback providedby the system may explain improve-ments in performance as well aslearning.33 The rich feedback in-cluded auditory, visual, and hapticinformation along with provision ofKP and KR. All of these hypothesizedmechanisms would be amenable totesting. In addition, it would be ofinterest to compare outcomes oftraining between this low-cost, com-mercially available system and otherssuch as the Sony PlayStation 2.

SummaryA low-cost, commercial gaming sys-tem was trial tested in an adolescentwith CP. He participated in 11 train-ing sessions to augment his existingrehabilitation program, 2 of whichincluded other players. The feasibil-ity of using the system in a school-based setting during the summer ses-sion was supported. Improvementsin postural control, visual-perceptualprocessing, and functional mobility

were measured after training. To ourknowledge, this is first published re-port on using the Wii to augmenttherapy for a person with CP.

All authors provided concept/idea/projectdesign and data collection. Dr Deutsch, MsBorbely, Ms Filler, and Ms Guarrera-Bowlbyprovided writing. Dr Deutsch, Ms Borbely,and Ms Filler provided data analysis. DrDeutsch provided project management andfund procurement. Ms Huhn provided thepatient. Dr Deutsch and Ms Huhn providedfacilities/equipment and institutional liai-sons. Dr Deutsch and Ms Guarrera-Bowlbyprovided consultation (including review ofmanuscript before submission). The authorsacknowledge John DeMaio, OTR, for admin-istering the TVPS-3, and Daniel Stern for hisparticipation in the session and consultationregarding the Wii.

This project was funded by the Rivers Laband the University of Medicine and Dentistryof New Jersey Foundation Summer Intern-ship Program (JF).

This article was received May 12, 2008, andwas accepted June 10, 2008.

DOI: 10.2522/ptj.20080062

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Appendix.Wii Sports Games Descriptions and Therapeutic Aimsa

Activity Mode General DescriptionTherapeutic Goal/Rationale and

Feedback

Tennis game, sitting and standing,duration�1–2 min

Tennis matches are doubles games in which thegame player controls both of the players on hisor her team by holding the remote like a racketwith one or both hands and swinging. A gameplayer can play against the computer or anopponent. A single game, best of 3, or best of 5games can be played. The computer positions theplayer in the correct spot to hit the ball. Thegame player is responsible for the type of swing(eg, forehand, backhand) and the timing, angle,and speed with which his or her player contactsthe ball on the screen. The player serves the ball,receives serves, and volleys until the ball is missedor hit out of bounds.

Increase trunk control and endurance whilereaching across the midline of the body

Incorporate trunk rotation into the UE movement

Increase hand-eye coordination and attention

FBKR: haptic and auditory FB is provided as the

player hits the ball

KR: visual and auditory FB is provided in aninstant replay of the volley after a point isawarded

Tennis training, sitting and standing,duration�5–20 s

The training activities consist of returningcontinuous serves from the computer’s ballmachine, hitting a ball to a targeted area at theend of the court, and hitting a target on a wall.These training games are relatively short,depending on the skill level of the game playerand are terminated once the player misses aserve, hits a ball out of bounds, does not hit theball to the targeted area, or fails to hit the ballafter the first bounce. The training activities areplayed similar to the actual game by holding theremote and swinging it like a tennis racket.

Improve trunk control during short bursts ofUE motions

Promote segmental trunk rotation duringunilateral UE movements while crossingmidline

Increase attention and hand-eye coordination

FBKR: haptic and auditory FB is provided as the

player hits the ball

KR: visual and auditory FB is provided in aninstant replay of the volley after a point isawarded

Boxing game, sitting, duration�3 min Boxing matches are played against a computer or anopponent. The matches are terminated at the endof the 3 rounds or after a knockout. The Wii remoteis connected to a nunchuk controller, with one heldin each hand. The player punches and blocks theopponent’s punches while holding the remotes inhis or her hands to fight against the opponent onthe screen. Once a player loses all his or her pieces,the player is knocked down and has 10 counts toget up. After a certain number of knockdowns, theplayer is considered to be knocked out and thematch is over.

Maintain an erect, midline posture whileperforming a bilateral UE task that requiresthe player to reach away from his or hercenter of mass

Improve core stability

Improve attention and UE coordination

FBKR: visual FB for the player’s and the

opponent’s power level is displayed in apie chart that decreases in pieces whenthe player or opponent is hit

KP about arm movement trajectory

KR: haptic FB is provided when opponent is hit

Boxing training, sitting, duration�1 min Training sessions consist of punching a bag,dodging balls, or hitting the trainer’s gloves.

Maintain an erect midline posture for 1 minwhile performing a bilateral UE activity thatrequires the player to reach away from his orher center of mass

Improve core stability

Encourage dissociated movement of the headand trunk during dodges

FBPunching bag

KR: visual FB with pie chart as above

Haptic FB indicates a successful hit

Boxing and dodgeballBandwidth and KP FB: haptic sensation

when player hits opponent rather thanwhen glove or ball hits the player

(Continued)

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Appendix.Continued

Activity Mode General Description Therapeutic Goal/Rational and Feedback

Bowling game, sitting and standing,duration�5–17 min

Bowling games can be played by a single player oragainst multiple players. Bowling games consist of10 frames. The game is played by holding theremote in the dominant hand, swinging the remotewhile holding down the B button in the frontalplane as if one were bowling, and releasing the Bbutton at the top of the swing to release the ball.The player changes the trajectory and startingposition of the ball by using the buttons on theremote before swinging.

Endurance and balance in a standing position usingthe posterior rolling walker while performing aunilateral UE task

Incorporate trunk rotation into the swing

Eye-hand coordination, attention, and motor planning

FBKP visual display of speed and trajectory of ball

KR auditory and haptic FB provided when playermakes a strike

KR visual instant replay

Bowling training, sitting, duration�2–3 min Bowling training games consist of hitting variouscombinations of pins (eg, splits that are set up oneach lane, avoiding randomly placed obstacles onthe lane, and knocking down as many pins aspossible when an increasing number of pins arepresented).

Endurance and balance in a standing position usingthe posterior rolling walker while performing aunilateral UE task

Incorporate trunk rotation into the swing

Eye-hand coordination, attention, and motor planning

FBKP visual display of speed and trajectory of ball

KR auditory and haptic FB provided when playermakes a strike

KR visual instant replay

Baseball game, sitting and standing,duration�8–10 min

The baseball game consists of 3 innings in which theplayer alternates between batting and pitching.When up at bat, the player bats for every player onhis or her team by holding the remote with one orboth hands and swinging it like a bat. The player isresponsible for the timing, the force, and thedirection of the swing. In the outfield, the player isonly a pitcher, as the computer automaticallycontrols the other player. Pitching is done byholding the remote in an upward direction andmoving the arm in a pitching motion.

Maintain proper sitting or standing posture withoutloss of balance while performing a task with theleft UE

Improve timing

Increase attention and hand-eye coordination

FB (batting)KR haptic and auditory FB provided when

contacting the ball, visual trajectory of the ball

Baseball training, sitting and standing,duration�2 min

Training activities consist of practicing the timing ofthe swing and hitting the ball toward a specificsection of the field.

Maintain proper sitting or standing posture withoutloss of balance while performing a task with theleft UE

Improve timing

Increase attention and hand-eye coordination

FB (batting)KR haptic and auditory FB provided when

contacting the ball, visual trajectory of the ball

Golf game, sitting and standing, duration�3–21 min

Golf games are 3, 6, or 9 holes The game is played byholding the remote pointed downward with one orboth hands, holding down the A button, andswinging the remote as if it were a golf club. Onthe screen, there is a map of the hole and a swinggauge for visual FB. The player can take as manypractice swings as necessary before taking theactual shot. Before swinging, the player can changethe type of club and the trajectory of the ball. Theobjective of the game is to get the ball in the holein as few strokes as possible.

Maintain a midline, erect sitting posture whileperforming a task with the left UE that requirescognitive planning

Increase attention and eye-hand coordination

FBBandwidth FB: haptic FB is provided when the

player’s swing is not fluid or when the force ofthe player’s swing exceeds the target on thegauge for that shot

KR visual FB of ball trajectory and endpointlocation on the green

Golf training, sitting and standing,duration�2–3 min

Training games consist of driving the ball onto thegreen, putting the ball on the green, and trying toearn points by hitting a targeted area. Each traininggame has 10 swings. These drills resemble theactual game. The map and gauge are displayed onthe screen.

Same as the golf game; in addition, the player canpractice the individual parts of golf (driving andputting)

FBSame as the golf game; in addition, KR isprovided as haptic FB when ball misses the edgeof the hole

a FB�feedback, KP�knowledge of performance, KR�knowledge of results, UE�upper extremity.

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doi: 10.2522/ptj.20080062Originally published online August 8, 2008

2008; 88:1196-1207.PHYS THER. Huhn and Phyllis Guarrera-BowlbyJudith E Deutsch, Megan Borbely, Jenny Filler, KarenWith Cerebral PalsyConsole (Wii) for Rehabilitation of an Adolescent Use of a Low-Cost, Commercially Available Gaming

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