1. The Role of Exergaming in Parkinson’s Disease Andrea Strickland PTA 2700

2. Purpose The aim of this systematic review was to explore whether exergaming can potentially be a rehabilitation tool for people with PD, the studies focused on: Safety- referred to subjective or objective measures Feasibility- referred to if the participant is able to play the games, whether they improve in their gameplay, and whether they enjoy and were motivated by the gameplay Effectiveness- referred to whether participants improved on clinical tests of motor performance, including balance, or disease severity and whether these improvements were retained after the exergaming intervention

3. Review Sample Characteristics Six studies used commercial Wii games and one game designed for Parkinson’s Disease using the Sony Playstation Eye camera 121 healthy and Parkinson’s Disease (89) participants ranging from ages 44-91 years, both male and female, were the sample subjects for this review The studies trained people with PD over 12-18 sessions (4-8 weeks) and measured performance on clinical tests directly before and after the Wii interventions

4. What Is Exergaming Exergaming are computer games that are driven by gross physical movements of the player which work by combining real-time motion detection with engaging video games that can help motivate people to exercise Exergaming as a therapeutic tool incorporates functional, purposeful and engaging exercise in a quantifiable and reliable way Exergaming has shown benefits in Parkinson’s Disease as well as stroke, cerebral palsy, and Traumatic Brain Injury recovery programs

5. The Wii Balance Board The Nintendo Wii Balance Board contains four pressure sensors that are used to measure the user's center of balance and weight The balance board has shown to be a valid assessment tool that can improve sensorimotor performance with the use of visual feedback in Parkinson’s Disease Games like Penguin Slide, Tilt City, Balance Bubble and yoga have been used as interventions in these studies

6. How the Wii challenges Balance Ankle and Hip strategies are challenged as well as the 3 balance systems when exergaming on the Wii Balance Board: Eyes: The visual stimuli from the games helps the player see where their head and body are in relationship to their environment. They can sense the motion of their body while mimicking the virtual player on the TV screen Ears: The inner ear tells the players brain about the movements of their head during gameplay which helps them keep upright to avoid falling off the balance board Proprioception: when the player moves their body on the balance board, their pressure and stretch receptors from joints and muscles help them feel where their feet and legs are positioned to keep balance and posture during gameplay

7. Safety of the Wii More evidence is needed regarding the safety of people with PD playing exergames before it can be recommended for wide spread clinical use, especially in the home with out supervision Since the Wii fit is a raised platform, it can present as a trip risk for people with PD, particularly when they are focused on the TV screen Other exergaming systems are now available like the XBOX Kinect that do not have the raised platform which may improve safety of exergaming activities It is suggested that PD patients have appropriate supervision during any exergaming interventions

8. Feasibility of the Wii These preliminary studies indicate that exergaming is feasible for PD however games may need to be tailored towards specific clinical populations In three of the studies people with PD improved their performance on the Wii games Some participants did retain their improvements in gameplay 60 days after the cessation of the exergaming intervention There is concern that some games are too difficult for people with PD which reflects the need for appropriate game selection for rehabilitation purposes Overall most participants did enjoy the games and appreciated the immediate biofeedback of their performance with the visual cues from the game which can attribute to improved motor learning

9. Effectiveness of the Wii The findings of the review suggests that 14 sessions, 2-3 times a week for 30-60 minutes each of playing the Wii can improve clinical measures of balance to the same extent as traditional balance training in people with PD The participants of the studies also received stretching, strengthening, and axial mobility exercises before each exergaming session. The Wii Balance Board may be an effective tool for balance training, BUT should not replace other therapy interventions including strength, cardio and flexibility exercises The Wii has also improved clinical test scores such as the Berg Balance Scale, Timed Get Up and Go, Functional Reach Test, and 10 Meter Walk Test

10. Conclusion Initial studies have shown that exergaming is a feasible intervention to improve motor symptoms in people with PD, however evidence is still lacking regarding safety and clinical effectiveness Exergaming may augment exercise therapy for people with PD although the use of commercial exergames may prove too complex for people with PD Exergames specifically tailored towards PD symptoms may help improve both player and enjoyment, motivation and effectiveness

11. References “The role of Exergaming in Parkinson’s Disease rehabilitation: a systematic review of the evidence.” Gillian Berry, Brook Galna and Lynn Rochester. Journal of NeuroEngineering and Rehabilitation 2014, 11:33. “Effects of Using the Nintendo Wii Fit Plus Platform in the Sensorimotor Training of Gait Disorders in Parkinson’s Disease.” Giovanna Barros Goncalves, Marco Antonio A. Leite, Marco Orsini, and Joao Santos Pereira. Neurol Int. Jan 2014; 6(1): 5048. “Validity of the Nintendo Wii Balance Board for the assessment of standing balance in Parkinson’s Disease.” Jeffrey D Holmes, Mary E Jenkins, Andrew M Johnson, Michael A Hunt and Ross A Clark. Clinical Rehabilitation 2012, 27(4) 361-366. http://www.parkinsons.org.uk/content/parkinsons-and-wii http://vestibular.org/understanding-vestibular-disorder/human-balance- system