Patients in Focus 2011 Runner up:

'‘Wii-hab’ for RA patients with

moderate to severe foot deformity'

By Helen Nutland (far left in photograph), Allison Dean (far right in photograph), Subha Arthanari, Mohamed Nisar, Rheumatology Dept, Burton Hospitals NHS Trust, Burton on Trent

Background

The management of rheumatoid arthritis (RA) in the United Kingdom is guided by publications from the British Society for Rheumatology (BSR) and the National Institute for Clinical Excellence (NICE) detailing evidence-based best practice. The emphasis is on early diagnosis of disease mainly through prompt referral for specialist assessment. Drug treatment is instituted as early as possible and intensified in a timely fashion. In parallel with this, the expertise of a multidisciplinary team, including physio and occupational therapy, is engaged from the outset.

Rheumatoid is a chronic and progressive arthritis and this is recognised in the requirement to maintain specialist high quality care beyond the initial diagnosis as highlighted in a further publication from the BSR (RA beyond 2 yrs), the NICE guidance and also the national audit of provision of care for patients with RA published by the King’s Fund (2009).

The objectives of high quality, multidisciplinary clinical care for patients with RA both early in the disease process and subsequently include limitation of the physical, personal and social impact of disease on the patient. In practical terms this equates to minimizing physical disability and its impact on functional capacity both at home and where appropriate, the work environment.

Foot pathology in Rheumatoid Arthritis is common, diverse and complex. Foot disease often has far reaching effects including pain, deformity, poor balance and abnormal gait as well as secondary lower limb joint and spinal pain, and problematic skin symptoms. In time over 90% of RA patients have foot disease and in 75% of these cases this causes walking difficulty and limitation of weight bearing. The adverse impact on quality of life and employment prospects should not be underestimated.

The attention given to the RA foot in out-patient clinics can be limited as patients are often embarrassed by and reluctant to expose their feet and avoid this by minimising their symptoms. Foot health in general is therefore frequently overlooked. It is not even included in the DAS28 assessment tool.  Foot care in RA is therefore often left to the patients’ own self management techniques, which at best are limited and usually poor. Compliance may be further eroded if patients struggle to access and tend to their feet because of difficulties at other joints.

Patients with established foot deformity admit to being reluctant to exercise appropriately, often because exercises are not considered effective and make little difference to symptoms and functional capacity.  They are inclined to assume that ‘nothing can be done’ resulting in poor engagement and compliance with physical therapy instructions.

The “Wii Hab” Project

With this in mind, the Rheumatology Dept at Burton Hospitals NHS Trust has re-focused attention on foot care, disability, functional loss and education through meaningful and effective exercises for our RA patients with moderate to severe foot disease.  To achieve this, an innovative approach has been devised using interactive home entertainment technology.

The Nintendo Wii Fit Interactive games console is now endorsed by the NHS in the United Kingdom and used in some physiotherapy departments particularly in rehabilitation programmes, for example in patients with persistent neurological deficit. A wide range of appropriate exercises can be completed through simulation of sports and other activities by digitalized display of movements on a TV screen.

Burton Rheumatology Dept has examined the feasibility and value of the Wii-Fit console in the assessment and rehabilitation of RA foot disease. The Wii Fit stand-on balance board converts foot pressure into an on-screen activity. In patients with RA damage to the feet, the balance board provides a safe and effective platform for an activity, sport or task driven exercise program.

Before the study began, a cohort of RA patients was formed into a focus group and informed of the study and invited to interrogate the study proposal and contribute suggestions to enhance study design. They were invited back at intervals for feedback and to receive updates on progress. The aim of the initiative was to increase confidence, movement, strength and balance, and reduce pain safely and enjoyably. Above all, it was hoped the activity with its convergence towards real life needs would motivate patients to acquire the Wii Fit game and continue at home for enjoyment with their families. Many patients attending the feedback forum had been inspired to acquire the WII-fit and reported increased inclusion in family leisure activities.

In the activity/game initially selected for this group of patients, balls drop on to a tilt table on screen. The patient controls the tilting and tipping of the board in every direction by weight transference through the feet. The aim is to get the balls to drop into the holes on the table on screen to beat the clock. As the patient improves, the shape of the board becomes more complex and more balls drop at the same time.

This balance game was specifically chosen because everyone, whatever age, physical ability, level of deformity or disease activity could manage the game safely and make progress while enjoying the personal challenge.

The patients were supervised and instructed by physiotherapists (HN & AD) to ensure safe and sequential recruitment of muscles and joints. As the patient improved, the game level was advanced with additional instruction in technique, pertaining to lower limb joints and impacting on range of movement, stability, proprioception and therefore function.

Inevitably patients used multiple muscle groups and joints to assist in achieving the objectives and this was addressed throughout the process from initiation through to the advanced game settings as a positive feature of our innovative approach and entirely reflective of real life. We have been alert to the possibility that other problems may be aggravated but in fact patients adapted quickly to the dynamic challenge through body weight transference improving not only foot function but also core stability and balance. The Wii-fit itself gives a saved game score which is the patient’s own reference point, providing real time feedback, motivation and an objective outcome measure.

The original pilot study included 13 patients (3 Male/10 Female, mean age 57 range 38-70 yrs) with inflammatory arthritis and moderate to severe plano-valgus deformity. All had lost confidence, and reported pain, altered gait and poor balance affecting their daily living.  Each patient attended for 6 sessions to play the balance game. Five objective scores were recorded.

OLB - The patient’s ability to stand on one leg and balance (OLB) was measured in seconds, as a mean of 5 attempts for each leg.

VAS - Foot pain was documented using visual analogue scale (VAS).

OLB and VAS were measured before and after each game session along with the game score.

TUG - Timed up and go (TUG) was also measured; this is a composite measure, which involves standing from a chair, walking 3 metres turning round, walking back and sitting down. It is a measure of dynamic balance, and as such is a good indicator of foot function.

ABC - The Activity-specific balance confidence (ABC) scale, a validated measure of confidence to balance during functional activities, was recorded as a measure of the patients’ anxiety regarding their balance, and an indicator of likely future compliance.  

The ABC and TUG were measured at the first and last sessions only
Wii Fit Score - The Wii Fit game score (time needed to succeed) provided a further objective measure.

The results were remarkable. In the single leg balancing test (OLB) the scores were seen to almost double. In the “timed up and go” (TUG) there were improvements for every patient. However, the patients own perception of their ability to balance during specific activities, such as walking up and down stairs and getting in and out of a car showed only a small improvement. This reflects the multitude of factors which contribute to the patients’ perception of confidence to balance over time. The patients’ individual game scores showed that their technique and performance changed over the sessions. The software generated performance score is stored and serves as a further objective marker as well as on screen motivation to do better.

Summary

The foot is a complex biomechanical area and over time, many factors will determine the progression of foot disease and how the patient copes irrespective of the underlying diagnosis. The management of foot disease has been poorly studied. To address this we have used the Wii games console to a) generate enthusiasm and engagement with a new and different approach to exercise; b) objectively measure progress over time; c) achieve meaningful functional rehabilitation.  As a bonus significantly improved confidence both in ability to complete routine physical tasks and in social interaction within the family unit and beyond was reported but proved difficult to capture objectively.

The Wii-fit is one of the most popular indoor recreational games consoles and we would encourage physiotherapy colleagues to embrace this technology and adopt it to maximum effect.  

Medical drug management of RA has improved greatly since the advent of engineered biologic therapies.  To compliment and maximize the benefits of these pharmacologic advances we need continuous review and refinement of established physical therapy techniques as well as adoption and adaptation of readily available, affordable interactive technological advances such as the Nintendo Wii Fit (IMAGE 3). We hope this innovative pilot project will serve as a platform on which to build other exercise programmes for other areas of the body especially for the RA patient.  Through this collective, team approach we believe the outcome for RA patients can be improved dramatically.

This study was accepted as an oral presentation at EULAR 2010 conference in Rome. Feedback from that event has been universally positive and supportive of the project but also of our innovative approach to patient care.

The Wii-fit is now routinely used in the Rheumatology physiotherapy department at Burton Hospital for RA and other patients.

Acknowledgements

We would like to extend our grateful thanks to the Burton Branch of the Reynaud’s and Scleroderma Association for donation of the Wii-fit console and the TV to the Burton Rheumatology Physiotherapy Department.

We also acknowledge the support, good will, courage and forbearance of our patients who inspire us daily.