de intensivist

Abstract

Purpose: ICU patients are increasingly awake. Interactive video gaming, as a form of early mobilization, is a new and challenging way of engaging patients in their own rehabilitation program.

Materials and Methods: We developed a trolley with a Wii device that can be used when the patient is mobilized in a chair. We asked 20 participants to play the games for 5 minutes and fill out the situational motivational scale after finishing the game.

Results: The use of the Wii-device was feasible in the ICU environment. Patients enjoyed playing the games and did not feel pressure to participate.

Conclusions: Interactive gaming could play a part in improving patient’s motivation to participate in ICU rehabilitation programs.

Introduction

In recent years, light sedation is increasingly used as part of standard daily care in intensive care units (ICUs) and probably increases patient’s quality of care.^[1] As a consequence, patients are actively engaged in rehabilitation activities in an early stage of their ICU stay. This decreases the time on the ventilator, ICU length of stay and mortality.^[2] Interactive video gaming, as a form of early mobilization, is a new and challenging way of engaging patients in their own rehabilitation program.^[3] Indeed, participation in videogames may increase the motivation of patients to participate in rehabilitation.^[4,5] In non-ICU stroke patients, there is some evidence that use of video games in addition to physical therapy may improve upper limb motor function and may benefit performance of daily activities.^[5] Moreover, the use of virtual reality goggles may be useful in the rehabilitation of stroke patients.^[6] Nevertheless, the same effects seem to be achievable when adding other recreational activities such as playing cards or bingo.^[7] In coronary artery bypass graft surgery patients, physiotherapy combined with virtual reality games and the Nintendo Wii seemed to improve autonomic function.^[8] In this study we assessed the (intrinsic and extrinsic) motivation of longstay ICU patients while using video games as a rehabilitation activity.

Materials and methods

This was a prospective observational study in the ICU of Gelre Hospitals, Apeldoorn, the Netherlands. The hospital is an university affiliated teaching hospital with a mixed medical-surgical ICU of 14 beds. Patients were eligible for inclusion in the study if they were adults, were awake (Richmond Agitation and Sedation Scale (RASS -1 to +1), non-delirious as defined by a negative score on the confusement assessment method for the ICU (CAM-ICU), had a minimal medical research council (MRC) score of 3 in their arm and hand muscles, were able to communicate with the researcher, and had been in the ICU for at least 7 days in order to focus on rehabilitation aspects during ICU stay (longstay patients). The local IRB waived the necessity for obtaining formal informed consent. Nevertheless, all eligible patients we invited to participate were informed about the study set up and goals of playing a game using the Wii Nintendo device and filling out the motivational survey.

Nintendo Wii setup in the ICU

We developed a trolley with a Nintendo Wii device that can be easily used when the patient is mobilized in a chair (figure 1). Patients could choose one game to play from a selection of games including bowling, playing tennis, playing golf or boxing. After explanation of the game by the observer, the game was also demonstrated to the patient by the observer before the patient started the actual playtime. Duration of the game was standardized at 5 minutes playtime. For this study, only the first experience with a chosen Wii game was evaluated.

Figure 1

Motivational aspects while engaging in a Nintendo Wii game

After finishing the game, participants were asked to fill out the 16-item situational motivational scale (SIMS)^[9] with a 7-point (1 = strongly agree to 7 = strongly disagree) Likert scale for every question used (table 1). The final scale scores were (reverse-)coded to ensure that higher scores conformed to higher levels on the SIMS scale. The SIMS distinguishes between four motivation constructs; intrinsic motivation, identified regulation, external regulation, and amotivation, each consisting of four items. Intrinsic motivation is high when a person derives pleasure and satisfaction from performing the task. Identified regulation is high when the task is seen as a means to an end. External regulation is high when the task is regulated by external reinforcement (i.e., rewards and/or punishment). Finally, amotivation is high when there is no sense of purpose to the task and there are neither rewards nor desired goals to be reached.

Statistics

Statistics were performed with SPSS 21. Data are shown as frequencies, medians, and interquartile ranges [P25-P75]. Reliabilities of the SIMS were calculated using Cronbach alpha. Correlations were tested using Pearson’s correlation coefficient.

Results

Twenty-one patients participated in the study with a median age of 70 [61-76] years, APACHE-II scores 22 [17-29], and an ICU-length of stay preceding the Wii-games of 14 [5-29] days. The median MRC score was 5.0 [3.5-5.0].

Patients enjoyed using the Nintendo Wii device, particularly because the ability to choose a game made it more interesting to use. Tennis, bowling and boxing were most frequently chosen. The use of the Nintendo Wii device was incorporated in the daily mobilization schedule together with a physiotherapist or with an attending ICU nurse.

The psychometric properties of the SIMS were adequate to very good, with Cronbach alpha values of .93 (intrinsic motivation), .82 (identified regulation), .72 (external regulation), and .91 (amotivation). Patients experienced high intrinsic motivation (M = 6.01, SD = 1.35) and identified regulation (M = 5.62, SD = 1.17). Both differed significantly from the (neutral = 4) midpoint, with respectively t(df = 20) = 6.83, p < .001, d = 1.49 (intrinsic motivation) and t(df = 20) = 6.33, p < .001, d = 1.38 (identified regulation). Patients were not sure about the purpose of the game, having a relatively neutral amotivation score (M = 3.95, SD = 1.81, t(df = 20) = -0.12, p = .905, d = -0.02), but they also did not feel pressured to play the game, resulting in a low external regulation score (M = 2.95, SD = 1.47, t(df = 20) = -3.27, p = .004, d = -0.71). Patients with high identified regulation also showed high levels of intrinsic motivation (r = .57, p = .007). Furthermore, patients with high levels of external regulation were also more likely to show high levels of amotivation (r = .49, p = .024). Patients with high intrinsic motivation and identified regulation showed low levels of amotivation (resp. (r = -.61, p = .003 and r = -.52, p = .015), but there were no significant relations between external regulation and either intrinsic motivation (r = -.03, p = .882) or identified regulation (r = .19, p = .408). That is, intrinsic reinforcers (intrinsic motivation and identified regulation) were found to be independent from extrinsic reinforcers (external regulation). The results are summarized in table 2.

Discussion

The use of interactive video games such as the Nintendo Wii as part of routine rehabilitation programs in the ICU environment is feasible and safe in this short observation period. This is in line with previous observations.^[3] We demonstrated that interactive gaming using the Wii-device in the ICU setting may also improve the motivation of patients to participate in these interactive rehabilitation programs. Similar motivational effects have been described due to in-bed cycling during ICU stay.^[10] Keeping in mind that our study was a feasibility study in a small group of patients, the high intrinsic motivation scores may be interpreted as a sign of a patient’s desire for (mental) distraction during ICU stay. The high identified regulation scores are likely to imply an expected benefit from using the Wii. Patients did not seem pressured to play, indicated by low scores on external motivation. In accordance with the above, this belief may have a positive impact on patients mental / emotional wellbeing because of feelings of “being in control” of their revalidation, especially because they can use it themselves without the need for assistance of e.g. a physical therapist. The neutral amotivation and low external regulation scores are in line with these findings.

Several study limitations should be mentioned. First, the Nintendo Wii device is rather old and newer devices have been developed since then. However, we think that the principle of interaction between patient and exergame has not changed. As such, the results may very well reflect the situation with usage of more modern games too. Second, the SIMS has not formally been validated for use in an ICU setting. However, all patients were clear minded and cooperative. In that respect, the population in our study is not different from previous experience with the SIMS.^[11] Third, this was a small feasibility study, although N=20 is considered acceptable of one aims to assess potential; problems and barriers while evaluating a certain intervention.^[12]

In conclusion, we suggest that interactive video game therapy using the Wii-device and other new devices may be promising tools that could complement existing rehabilitation techniques and increase motivation for ICU patients to be engaged in their own rehabilitation program.

Author contribution

PES and REdV conceived  of the study. MF, and AR assisted in data acquisition. PES and REdV performed data  analysis. PES, IvI and REdV drafted the final version of the paper.

Acknowledgements

Christiaan Stiphout, Marc Grevelink, and Iris Vaneker helped to develop a program to use the Wii in the ICU setting

Disclosures

All authors declare no conflict of interest. No funding or financial support was received.