Computers in Human Behavior 31 (2014) 384392

Contents lists available at ScienceDirect

Computers in Human Behavior

journal homepage: www.elsevier.com/locate/comphumbeh

Review

The Nintendo Wii as a tool for neurocognitive rehabilitation, training and

health promotion
Tamires Marinho Pessoa , Danielle Sousa Coutinho, Valeska Martinho Pereira,
Natalia Pinho de Oliveira Ribeiro, Antonio Egidio Nardi, Adriana Cardoso de Oliveira e Silva
Laboratory of Panic & Respiration, Institute of Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), INCT Translational Medicine (CNPq), Brazil

a r t i c l e

i n f o

Article history:
Available online 6 December 2013
Keywords:
Video game
Mental health
Therapeutics
Rehabilitation
Cognitive therapy

a b s t r a c t
Health professionals have used virtual reality as an aid for several types of treatment. Given that virtual
reality systems are expensive and not always available, a more accessible type of virtual reality technology is video games. The Nintendo Wii (NW) is a video game system that uses virtual reality technology,
as dened by Deutsch, Borbely, Filler, Huhn, and Guarrera-Bowlby (2008), which may be used for health
promotion. The Nintendo Wii also provides an opportunity for social interaction; thus, it is a promising
tool with great potential for the treatment of specic disorders.
The aim of this article is to evaluate the ways in which the Nintendo Wii has been used to treat specic
disorders or to promote cognitive or physical improvements through a review of the literature. The
results have shown that the NW is a potentially useful tool in some therapeutic treatments that can
be used with people of diverse social statuses and tastes. Despite the positive initial results, further studies are required to provide a better evaluation of video game usage in therapeutic programs.
2013 Elsevier Ltd. All rights reserved.

Contents
1.
2.
3.

4.
5.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
Self-image and avatars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.
Cerebro vascular accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.
Motor behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4.
Cognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.5.
Rehabilitation of children and adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.6.
Depression and sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.7.
Retirement homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Financial and competing interests disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction
Virtual reality (VR) is dened as a type of interaction with a
computer that offers the user an experience that can be compared
Corresponding author. Address: Universidade Federal do Rio de janeiro,
Laboratrio de Pnico e Respirao, Rua Visconde de Piraja, 407/702, Rio de Janeiro,
RJ, CEP: 22410-003, Brazil. Tel.: +55 21 2521 6147; fax: +55 21 2523 6839.
E-mail address: tamiresmarinho@aol.com (T.M. Pessoa).
0747-5632/$ - see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.chb.2013.10.025

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to real situations in three dimensions in a virtual environment

(Deutsch, Borbely, Filler, Huhn, & Guarrera-Bowlby, 2008). For this
interaction, software (in this case, games) and hardware (structural
physical components) are developed and produced to build the
technology in video game consoles and joysticks to offer the user
the control of a graphic environment in which to interact (Ackerman, Kanfer, & Calderwood, 2010).

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The range of movements that the software is able to reproduce

is almost limitless. Aside from that, software can also measure the
intensity and duration of performed exercises, offering the user not
only a strong connection with the software but also the safety of a
controlled activity that encourages further exploration of the virtual environment (Joo et al., 2010). Nevertheless, the majority of
these virtual reality systems are not commercially available; in
fact, when these systems become commercially available, they
are expensive (Deutsch et al., 2008). Video games are a cheaper
and more accessible way to use this type of technology (Ackerman
et al., 2010).
The Nintendo Wii (NW) video game console was rst commercialized in late 2006 and introduced a new style of VR. It has
a joystick (wiimote) containing an accelerometer that records
movements in three dimensions and broadcasts data to the console, which can communicate with the joystick and also obtain updates on the internet. According to Plow and Finlayson (2011), one
of todays most widely used video game consoles for home use is
the Nintendo Wii. The games are considered to be easy and are
aimed at different ages and educational levels (Ackerman et al.,
2010). An attractive feature of these games is that they are intended to be fun and interactive, encouraging people to play
through a wide variety of motivational tools, such as music, playback and bonuses. As a result, the users are motivated to improve
their performance (Anderson, Annett, & Bischof, 2010).
The games can have a variety of goals. Cognitive games prioritize activities that involve attention, memory and movement skills.
Some of these types of games are focused on movement-skills
tasks, and others offer the possibility of social interaction.
Additionally, there are also exergames, which are games that include a signicant amount of exercise using the capture device to
sense physical movements. All these games can be played at home,
offering customers a better experience through the console.
Through a literature review, the purpose of this article is to analyze how the NW games have been used in the neuropsychiatric
eld either for cognitive rehabilitation or for the improvement of
the quality of life of patients and to understand how the NW games
have been used in the treatment of psychiatric signs and symptoms. Health professionals are increasingly interested in the innovations and cost-benet ratios of new treatment approaches
(Fernndez-Aranda et al., 2012). The NW games are designed for
entertainment; however, they can be a useful in healthcare. The
authors believe that the use of video games in therapy can somehow help patients explore a satisfying world (Langlois, 2011) and
extend this pleasant experience to the real world. An example of
this is the use of video games for depression. Studies have shown
that recreational activities combined with physical activity can improve not only the framework of depression but also the quality of
life and cognitive function of patients (Rosenberg et al., 2010). It
can be a useful psychiatric tool; a study showed that video games
helped 18 patients relieve their frustrations, learn relaxation techniques and develop their own emotional regulation (FernndezAranda et al., 2012). Although the use of video games is typically
associated with young people, the majority of studies involve participants in early adulthood to old age; this includes studies involving depression, risk of falls and rehabilitation. There are also
descriptions of working with children and using video games to
improve adolescent health. The use of videogames to promote
health and physical activity has also shown good results; a small
increase in physical activity in children (Maloney, Bethea, Kelsey,
Marks, et al., 2008) and in the elderly was obtained (Studenski
et al., 2010). Although studies have proved that playing video
games help people to temporarily turn off the problems of everyday life and to return to those problems with a greater focus on
solving them, for people who play more than 3 or 4 h per day,
the benecial effects of the game are drastically reduced (KENT.,

2001). For occupational therapy, video games have been used for
the elderly in nursing homes, and studies have obtained excellent
results for increasing the quality of life and increasing the incentive
to drive (Hsu et al., 2011). As we can see, video games are used in
several areas of healthcare. The literature includes studies involving physical and mental health, and the results have been encouraging but are not yet conclusive. In recent years, the islands have
been updated and are accompanied by a wide range of games that
may be a good tool for both health professionals and the patients
themselves. With this in mind, we designed a study focused on
the Nintendo Wii, the rst console to have a technology similar
to virtual reality technology and to make the island more interactive. Because this technology has existed for several years, it offers
a wider range of games that can be used in healthcare, which is
why this review is focused on the Nintendo Wii.
2. Methods
This paper aims to assess, through a literature review, how the
NW has been used in different health contexts and with different
populations as an adjuvant the rapyor in innovative ways to contribute to the engagement of patients in practices that benet their
health status. To access anytype of NW use for health purposes, we
searched using the terms Nintendo Wii and Wii. Thus, any articles that existed in the databases regarding the NW were included.
There was no linguistic or temporal restriction on the literature
search. There was no population or design restriction for inclusion
of articles in this study. The inclusion criteria for the articles were
the discussion of any aspect related to mental health and the
involvement of the NW or its components. Research was conducted by two independent researchers in March 2013 using the
following databases: Web of Knowledge (ISI), PubMed and
Psycinfo.
These arch found 551 articles initially, and all were in English.
Cross-referencing was carried out to eliminate repetitions of articles found in multiple databases. Articles focusing on the following
subjects were excluded: accidental injuries generated by NW (16),
studies on aspects related to technology equipment (engineering
or development of parts) or marketing strategies, no relation with
the eld of health (8), software/hardware development (159) and

Fig. 1. Flowchart.

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T.M. Pessoa et al. / Computers in Human Behavior 31 (2014) 384392

NW use for weight loss and increased energy expenditure (44). In

addition, articles that used the term Wii to design ate issues
other than the video game NW (119)and articles published in Congressional proceedings were excluded (32). All papers with outlines of clinical trial studies (although none were found), cohort
studies, cross-sectional studies and case studies were selected for
inclusion in this literature review. In all, 378 studies were excluded, and 48 articles were selected for review. They were divided
into the following subjects: self-image and avatars, cerebro vascular accident (CVA), rehabilitation with children and adolescents,
depression and sclerosis, and risk of falling. The work ow is described in Fig. 1. Some studies have characteristics that allow their
classication into more than one category; when this was the case,
the study was classied according to its predominant theme.
3. Results
3.1. Self-image and avatars
Avatars are visual resources a player uses to interact within the
virtual environment and can be customized according the players
physical features, such as skin color, hair color, eye color and
height; clothes and accessories can also be customized, depending
on the game. Before starting the game, the players are encouraged
to create a customized avatar, which will represent them in the virtual environment. The included studies on avatars are listed in
Table 1.
Jins studies explored avatars and the role of self-image, noting
the difference between participants who created an avatar related
to their own characteristics and the participants who created an
avatar based on an ideal that represents something that the participant would like to be (Chen & Hung, 2010; Cherney & Poss, 2008).
These studies showed that participants who created an avatar projecting an ideal self-image reported higher degrees of interaction
(Jin, 2009) and satisfaction (Jin, 2010a, 2010b) with the game.
In another study, Jin and Park (2009)examined the parasocial
interaction of 60 NW players with their avatars. They found that
those players with a positive self-image showed the closest parasocial interaction and higher self-presence level than the players
with low self-esteem, pointing to a personal inuence on the perceived proximity of the player with their avatar. Finally, Jin (2010a,
2010b) tested the interaction effects of self-image on losing the
game; he concluded that participants who were not prepared for
self-interpretation showed negative results and low pleasure,
while those who were prepared showed no signicant differences
in mood after the game.
3.2. Cerebro vascular accidents
Cerebro vascular accidents (CVAs) are one of the main causes of
long-term incapacity and can lead to the reduction or cessation of

physical activities (Hurkmans, Ribbers, Streur-Kranenburg, Stam, &

van den Berg-Emons, 2011)that are essential for the rehabilitation
and maintenance of health. Five studies were found (Table 2) on
post-CVA patients using the NW for the rehabilitation of upper
limb weakness (Joo et al., 2010; Mouawad, Doust, Max, & McNulty,
2011; Saposnik et al., 2010), to increase energy expenditure
through activity (Hurkmans et al., 2011) and for balance training
(Brown, Sugarman, & Burstin, 2009).
The studies for rehabilitation of the upper limb (Joo et al., 2010;
Mouawad et al., 2011; Saposnik et al., 2010) involved a total of 43
adult patients 4183 years of age. One of the studies used the game
Wii Sports(Joo et al., 2010); in another study, the use of the NW
was compared with card games using traditional decks (Saposnik
et al., 2010). The NW was shown to be an effective and safe alternative to promote the recovery of the upper limb (Saposnik et al.,
2010), and it appeared to be a good alternative tool for rehabilitation (Farrell, 2009; Joo et al., 2010).
The boxing and tennis modalities of Wii Sports were used in a
study of energy expenditure in a sample of 8 chronic CVA patients.
One patient could not play tennis;all other participants were able
to play with moderate intensity, which was considered an adequate level of energy expenditure to maintain health in this population (Hurkmans et al., 2011). The balance training using the NW
included the game Wii Fit (with the aid of the Balance Board
accessory) and a set of balance scales. An 86-year-old patient
who was unable to walk without supervision even with the support of a walker trained for 5 weeks. After the intervention with
the NW and Wii Fit, she was able to walk using a walker with
minimal supervision (Brown et al., 2009). The use of the Wii by
post-CVA patients of various ages proved to be clinically relevant
(Mouawad et al., 2011) and effective in improving the daily lives
of the participants.
3.3. Motor behavior
With greater acceptance of the Nintendo Wii by health professionals, the growth of its use as an alternative therapy has been
observed. These studies on motor behavior are presented in
Table 3.
In a study by Higgins, Horton, Hodgkinson, and Muggleton
(2010), although the effects of NW use on motor behavior was
not the main objective of the study, professionals reported that
NW activities produced physical benets, such as physical mobility, coordination, and distraction from pain as well as psychosocial
benets, such as social engagement, self-esteem and improved
behavior. For research investigating the perceptions of occupational therapists and physical therapists on the use of the Wii for
rehabilitation, a signicant percentage had a good opinion of its
use for rehabilitation (Fung et al., 2010). Other studies dealt with
the creation of software to monitor (Martin-Moreno, Ruiz-Fernandez, Soriano-Paya, & Jesus Berenguer-Miralles, 2008) and record
(Anderson et al., 2010) patient activities with the aim of making

Table 1
Avatar.
Authors
(year)

Journal

N
(sample)

Main objective

Design

Participants

Jin (2009)

Cyberpsychology & Behavior

126

Randomized controlled trial

Jin (2010a,
2010b)
Jin (2010a,
2010b)
Jin and
Park
(2009)

Cyberpsychology Behavior
and Social Networking
Cyberpsychology Behavior
and Social Networking
Cyberpsychology & Behavior

76

Research on the effects of the interaction with

the avatar game
Effects of an avatar that replicates the ideal or
real in connection with the game
Measuring the mood of the players in response
to negative feedback
Effect of video game interaction and
involvement with their avatars

Students, 84 females
and 42 males
Students, 50 females
and 26 males
Students, 39 females
and 19 males
Students, 36 females
and 24 males

58
60

Randomized controlled trial with

two-group comparison
Randomized controlled trial
Randomized controlled trial with
two-group comparison

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T.M. Pessoa et al. / Computers in Human Behavior 31 (2014) 384392

Table 2
Cerebrovascular accident CVA.
Authors
(year)

Journal

Brown et al.
(2009)
Hurkmans
et al.
(2011)
Joo et al.
(2010)
Saposnik
et al.
(2010)
Mouawad
et al.
(2011)

International Journal of
Rehabilitation Research
Journal of
Neuroengineering and
Rehabilitation
Journal of Rehabilitation
Medicine
Stroke

N
(sample)
1

Main objective

Design

Participants

Use of the NW in a patient after CVA for

balance training

Case report

Woman, 86 years old, ve

weeks after stroke
Chronic stroke patients

10

16
9

J Rehabil Med

Non-randomized clinical Trial

Evaluation of the feasibility of NW in

combination with traditional rehabilitation
Use NW for training for upper body versus
recreational therapy
To investigate the efcacy of therapy with
the NW for rehabilitation after CVA

Randomized clinical trial

Randomized single-blinded
clinical trial, with 2 parallel groups
Non-randomized clinical trial

Patients after stroke with

upper limb weakness
Stroke patients

138 months post-stroke

Table 3
Motors Rahabilitation.
Authors (year)

Journal

N (sample)

Main objective

Design

Participants

Anderson et al.
(2010)
Clark and
Kraemer
(2009)
Clark et al.
(2010)
Dougherty
et al. (2011)
Fung et al.
(2010)

Stud. Health Technol.

Inform.
J Geriatr Phys Ther

Clinical trial

Creating software more adapted to people

with cognitive or motor impairment
Intervention using NW to decrease fall risk

Case report

89-year-old resident with balance

disorder and multiple falls

Gait Posture

30

NW as a tool to evaluate equilibrium

Mo Med

J Burn Care Res

6380

Participants without lower limb

pathology
Participants from a local
community center for seniors
Occupational therapists and
physiotherapists

Journal of
Neuroengineering
and Rehabilitation
Stud Health Technol
Inform.

17

To evaluate improvement of balance in a

community center
To evaluate the perception of professional
occupational therapists and
physiotherapists on the use of the NW
To describe and evaluate a system based
on NW for the rehabilitation of balance

Randomized clinical
trial
Randomized clinical
trial
Observational study

Acquired brain injury hemiparetic

patients

20

To test the virtual rehabilitation system in

balance rehabilitation in brain injury

Randomized controlled
single blinded clinical
trial
Randomized controlled
trial with control group

J Cyb. Ther Rehabil.

Randomized clinical
trial
Observational study

Health Promot J
Austr.

To investigate whether the Wii Fit is a

reliable tool to evaluate balance
To evaluate perceptions of employees
regarding the use of the NW as an
alternative physical activity
Comparison of the conventional
rehabilitation together with the NW
A game is designed to balance body
weight using peripheral NW.

Randomized activecontrol trial

Non-randomized
clinical trial

Older adults, aged above 60, fallers

and non-fallers
Two kind of samples, clinicians
and with persons with
neurological injury
Patients during rehabilitation

Gil-Gomez
et al. (2011)
GonzalezFernandez
et al. (2010)
Gras et al.
(2009)
Higgins et al.
(2010)

Patients suffered from acquired

brain injury

Care staff

Kwok et al.
(2011)
Lange et al.
(2010)

Trials

53 centers for
the elderly
home
80

Top Stroke Rehabil.

MartinMoreno
et al. (2008)
Roettger et al.
(2011)

Conf Proc IEEE Eng

Med Biol Soc

NW-based solution for control of

movements

Observational study

Dtsch. Z. Sportmed

29

Randomized clinical
trial

Healthy adults

Williams et al.
(2010)

BMC Res Notes

21

Randomized clinical
trial

Community-dwelling older fallers

Yamada et al.
(2011)

Geriatr Nurs

45

Training of postural stability and whether

the Wii-t could be used as a
sensorimotor tool
Using the NW for the management of falls
and determining whether NW is an
alternative for this type of intervention
Evaluation of fall risk in women living in a
senior community

Randomized controlled
trial with control

Community-dwelling older fallers

the activities as safe as possible. Therefore, the NW has become an

additional tool for the practical care of the elderly and for those
with the range of physical problems described above.
The largest number of articles found were related to postural
stability (Roettger, Mornieux, & Gollhofer, 2011), restoration of
balance (Gil-Gomez, Llorens, Alcaniz, & Colomer, 2011; GonzalezFernandez, Gil-Gomez, Alcaniz, Noe, & Colomer, 2010; Lange,
Flynn, Proftt, Chang, & Rizzo, 2010), evaluation of balance (Clark
et al., 2010; Gras, Hummer, & Hine, 2009; Yamada et al., 2011)
and assessment of falling risks (Clark & Kraemer, 2009; Dougherty,
Kancel, Ramar, Meacham, & Derrington, 2011; Kwok, Mamun,

Chandran, & Wong, 2011; Williams, Soiza, Jenkinson, & Stewart,

2010). There were eleven such studies, and while the Wii usage
varied according to the study, in most cases, the Wii was used in
individual or group applications on a weekly basis. Studies have
indicated reports of fear of falling by post-CVA patients; virtual
environments have been shown to facilitate adherence to the therapeutic protocol.
Falls are common among older adults and often result in injuries (Clark et al., 2010). People with brain damage have increased
falling risks. Specic software for the NW called eBaVir was developed as a virtual rehabilitation system to improve balance in

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T.M. Pessoa et al. / Computers in Human Behavior 31 (2014) 384392

patients after brain injuries (Gil-Gomez et al., 2011; Gonzalez-Fernandez et al., 2010).
The authors describe eBaVir as safe and effective, and the results of this type of intervention were positive (Gil-Gomez et al.,
2011; Gonzalez-Fernandez et al., 2010) and corroborated the results of another study on balance improvement after a neurological
injury. Using the previously available software for the NW, the results were considered inconclusive, and they highlighted the
necessity of a game that would meet the specic needs of this population (Lange et al., 2010). The results with respect to balance
evaluation were inconsistent. Two studies (Clark et al., 2010; Yamada et al., 2011) indicated that NW usage in the clinic was useful
and appropriate; however, a third study (Martin-Moreno et al.,
2008) did not consider NW usage valid or reliable for balance
evaluation.
Studies off all risk evaluated 105 people over 60 years of age.
The results indicated a reduction in risk, but some authors suggested the necessity of further studies (Clark & Kraemer, 2009;
Dougherty et al., 2011; Kwok et al., 2011; Williams et al., 2010).
Postural stability and endurance were improved through the use
of the game Wii Sports for 15 min, three times per week for
6 weeks (Roettger et al., 2011).
Although we know that virtual environments simulate the real
world, we do not know how our brain reacts to the virtual environment. A study by Baumeister, Reinecke, Cordes, Lerch, and Weiss
(2010) measured cortical activity by comparing real-world and
simulated activities in the NW using electroencephalography
(EEG).
The study included 10 male golfers with an average experience
of 2.9 years and an average age of 26 years. All subjects were
healthy and did not use drugs. The study was conducted as follows:
when the participants arrived at the study site, the EEG electrodes
were placed on them, and they were asked to rest for 3 min. The
real-world activities were conducted outside the laboratory, with
a distance of 3 m between the participants and the target. On the
Wii, the distance was padronized without tracks, similar to the
real-world situation.
The results of this study (Baumeister et al., 2010) showed no
difference in cortical activity related to working memory during
the real and virtual activities. The virtual environment seemed to
require more neuronal resources, as is characteristic of a new

activity, even though the participants had experience in real-world

golf. The scores were different in the real and virtual tasks. The
authors also concluded that real training could not be replaced
by training using the Wii Virtual Golf game.

3.4. Cognition
Studies of cognition using the Nintendo Wii have focused on a
number of topics (Table 4).
Studies by Ackerman et al., 2010 presented attempts to delay
cognitive decline using the NW and considered the hypothesis that
adults who performed well in the video game would also perform
well in reading. For this research, the game Big Brain Academy
was used for a total of 20 h a month, with an equal amount of reading. The subjects included 78 adults with a mean age of 60.7 years
who were recruited through a newspaper advertisement.
It was observed that the use of the NW produced initial performance gains, followed by gains that became smaller with each session. Therefore, neither the Wii program nor the reading proved to
be effective in improving cognitive performance. Despite this result, Weybright, Dattilo, & Rusch, 2010 proposed the NW as a tool
for activity aimed at the elderly with mild cognitive impairment
using the bowling software and noted higher levels of affection
among the participants.
Quiroga et al. (2009) examined the relationship between intelligence and the use of video games. This study also used Big Brain
Academy in a format of two blocks of 50 challenges, every
15 days. All 27 subjects were psychology students and performed
the same sequence of challenges. The authors concluded that features of game-specic tasks inuenced the results, but good performance was not correlated with general intelligence in most of the
tasks.
Cherney and Poss (2008) performed a study comparing the difference in cognitive performance between men and women using
the NW in a population of 28 psychology students evenly divided
by gender between 19 and 24 years in age.
Four games were used: Racing Bird (a mini-game of the
Super Monkey Ball game), Banana Blitz, Red Steel and Number Ball. The study concluded that men have better visual and perceptual skills, while women have better motor learning skills.

Table 4
Cognitive.
Authors
(year)

Journal

N
(sample)

Main objective

Design

Participants

Ackerman
et al.
(2010)
Baumeister
et al.
(2010)
Chen et al.
(2010)
Cherney and
Poss
(2008)
Edwards
et al.
(2011)
Gamberini
et al.
(2010)
Quiroga
et al.
(2009)
Weybright
et al.
(2010)

Psychol Aging

78

Research on the use of the NW, associated with other

approaches, could slow cognitive decline

Randomized clinical trial

Adults amid the ages of 50

and 71

Neurosci Lett.

10

Cortical activity study comparing real movements and

virtual performance

Male golfers

Expert Syst.
Appl.
Psychological
Reports

Use of NW components to teach motions

Non- randomized controlled

trial with two-group
comparison
Randomized clinical trial

28

Comparative study of cognitive performance between

men and women

Randomized controlled trial

with two-group comparison

Psychology students

Perceptual and
Motor Skills

19

The study questions concerned whether exposure to a

hot or cold environment affects executive function

Randomized clinical trial

Adults

Stud Health
Technol Inform.

20

A group of elderly people was asked to perform a

cognitive task using the NW

Randomized clinical trial

Computers &
Education

27

To test if playing a video game requires intelligence

Clinical trial

Old people without any

physical or cognitive
impairment
Studants of Psychology

Therapeutic
Recreation
Journal

To examine the effects of an interactive video game in

women with mild cognitive impairment

Non- randomized trial

Students

Older women with mild

cognitive impairment

389

T.M. Pessoa et al. / Computers in Human Behavior 31 (2014) 384392

Due to population growth, the widespread use of video game

devices and the need for neuropsychological tests, Gamberini, Cardullo, Seraglia, & Bordin, 2010 saw an opportunity to use the NW to
develop a game that can assess and also exercise the cognitive ability of elderly people. The study included 20 participants who
played the NW in the rst session, and in the following week, they
took a series of standard neuropsychological tests. The results
showed a signicant positive correlation between the electronic
assessments and the tests, except in the case of the short-term
memory test.
Edwards and Crowther (2011) examined whether exposure to
hot or cold environments impairs executive function and coordination activities. The subjects included 19 volunteers, who played
Guitar Hero and Archeryin cold (2 C), neutral (20 C) and
hot (38 C) conditions. At 2 C, the performance in the games
decreased signicantly compared with the neutral condition, and
the participants reported that the cold condition required more
concentration and effort, presenting a greater challenge to the
participants (Edwards et al., 2011).
Chen and Hung (2010) proposed the use of components of the
NW to teach physical exercises with greater accuracy, thereby
reducing the burden on coaches. They concluded that the NW system improves teaching, learning and student performance and
thus reduces the workload of a teacher while leading to a better
learning outcome.
The results of cognitive studies with the NW are still contradictory. Further research in this area is needed. The use of games for
rehabilitation and testing is attractive to the adult public, and for
this reason, video games should be considered as a tool in current
rehabilitation programs and as a motivational factor that facilitates
program adherence.
3.5. Rehabilitation of children and adolescents
We also found exploratory studies that used the NW in the process of rehabilitation of children and adolescents for movement
(Levac et al., 2010) and cognition (Deutsch et al., 2008). It was also

used as a tool in occupational therapy for children with Down syndrome (Wuang, Chiang, Su, & Wang, 2011) and for children (Shih,
Shih, & Chiang, 2010) and adolescents (Shih, 2011 & Standen,
Camm, Battersby, Brown & Harrison) with multiple disabilities
(Table 5).
The rst (Levac et al., 2010) study reported the difference between movements of children with and without experience using
the NW. This study showed that the quantity of movement in children with more experience using the video game is greater; however, the quality of the movements did not differ between the
groups.
Cognitive rehabilitation using the NW was studied by Deutsch
et al. (2008). A 13-year-old with spastic diplegic cerebral palsy participated in 11 sessions of 6090 min each, using the game Wii
Sports over four weeks in addition to her routine therapies. The
outcome was evaluated using three parameters: postural control,
walk distance and visual processing and perception. The patient
showed a signicant improvement over a range of postural measures but had no signicant changes related to memory and visual
perception.
The NW was studied for the rehabilitation of sensory-motor
functions with 110 children with Down syndrome (Wuang et al.,
2011). In patients with multiple deciencies, a number of responses were observed: increased response to the virtual environment by body shaking (Shih, Chang, & Shih, 2010) and members
action (Shih et al., 2010); execution of simple tasks through
instructions transmitted through the video game (Shih, Chung,
Shih & Chen, 2011); accomplishment of simple physical activities
(Shih, 2011); lowering of hyperactive behavior (Shih, Yeh, Shih, &
Chang, 2011); and increased maintenance of head posture (Shih,
Shih & Shih, 2011). In all studies, a signicant increase in the target
response could be observed, but it should be noted that in all these
experiments, there was a software or hardware adaptation to better match this population.
With the same intention (Standen, Camm, Battersby, Brown, &
Harrison, 2011), a part of NWs hardware, the Nunchuck, was
used for the adaptation of standard control devices, such as com-

Table 5
Rehabilitation of children and adolescents.
Authors
(year)

Journal

Deutsch
et al.
(2008)
Levac
et al.
(2010)
Shih
(2011)

Physical
Therapy

Shih et al.
(2011)
Shih et al.
(2010)

Res Dev
Disabil.
Res Dev
Disabil.

Shih et al.
(2011)
Shih et al.
(2011)
Shih et al.
(2010)
Standen
et al.
(2011)
Wuang
et al.
(2011)

Res Dev
Disabil.
Res Dev
Disabil.
Res Dev
Disabil.
Computers
& Education

Human
Movement
Science
Res Dev
Disabil.

Res Dev
Disabil

N
(sample)

Main objective

Design

Participants

Case study of a patient with cerebral palsy, with the idea

of using low-cost systems for recovery

Case report

Adolescent with spastic diplegic

cerebral palsy

38

Quantity and quality of the movements performed while

the children play NW

Children (aged 712)

Non- randomized trial

Two patients with disabilities

Non- randomized trial

Two patients with disabilities

To evaluate whether two people with disabilities can

control the virtual environment through simple physical
activity
To evaluate whether two people could execute simple
commands through the NW
This study evaluated whether two people with
disabilities would be able to control a virtual
environment
NW for correction of hyperactivity subjects

Non- randomized trial

with two-group
comparison
Non- randomized trial

Non- randomized trial

Objective of maintaining the posture of the head

Non- randomized trial

NW as an evaluator of standing posture

Non- randomized trial

Evaluated the use of the Nunchuk among volunteers

with mental or physical disabilities

Non- randomized trial

Compares traditional occupational therapy to the virtual

environment offered by the NW

Randomized controlled
trial with two-group
comparison

Two persons with multiple

disabilities
Two persons with multiple
disabilities
Two persons with multiple
disabilities
Participants aged between 17 and 21
with intellectual and physical
disabilities
Children with Down syndrome

23

105

Two patients with disabilities

390

T.M. Pessoa et al. / Computers in Human Behavior 31 (2014) 384392

Table 6
Sclerosis and Depression.
Authors

Journal

N
(sample)

Fenney and Lee

(2010)
Plow and
Finlayson
(2011)
Rosenberg et al.
(2010)

Activities, Adaptation &

Aging
Int J MS Care

The American Journal of

Geriatric Psychiatry

3
30

19

Main objective

Design

Participants

Study to investigate whether people with

dementia must learn new tasks
NW to increase physical activity and behavior

Case report

Participants with dementia

Non- randomized
trial

Patients with multiple sclerosis

relapsing-remitting

NW to motivate physical activity to improve

depression

Randomized
controlled trial

Community-dwelling older
adults

Table 7
Nursing home.
Authors

Journal

N
(sample)

Main objective

Design

Participants

Hsu et al.
(2011)
Yuen
et al.
(2011)

Physiother
Theory Pract
Lupus

34

To investigate the action of a video game as the

standard regimen of exercise of residents
The implementation NW in a patient with lupus
erythematosus

Randomized singleblind crossover trial

Non-randomized trial

Persons with upper extremity dysfunction and

to identify individual characteristics
Sedentary women with systemic lupus
erythematosus

15

puters for people with disabilities; however, studies with 23 people ranging from 17 to 21 years of age were unsuccessful due to
non-compliance with the use of the Nunchuck.
3.6. Depression and sclerosis
Three studies were found on depression and sclerosis, which are
shown in Table 6.
Depression is highly associated with negative health outcomes,
according to Rosenberg et al. (2010). Physical activities can improve depression, but adherence to the exercises can be difcult.
A 12-week intervention with the NW, with a 2024-week followup with 19 adults ranging from 63 to 94 years in age, showed a
reduction of the symptoms of depression and an improvement in
the quality of life and cognitive performance of the participants.
There was, however, no physical improvement related to quality
of life (Rosenberg et al., 2010).
Plow and Finlaysons (2011) studies analyzed the potential of
the game Wii Fit to increase physical activity in people with multiple sclerosis with an average age of 43 years, and Fenney and Lee
(2010) studied the ability of people with dementia to learn new
motor tasks in a 9-week intervention. The two studies detailed in
Table 7 showed improvements, and the evaluations indicated
greater physical balance and strength (Plow & Finlaysons, 2011).
The scores of procedural memory components also increased (Fenney & Lee, 2010).
3.7. Retirement homes
The NW has also been used with retirement home residents
(Hsu et al., 2011) and hospitalized patients (Yuen, Holthaus, Kamen, Sword, & Breland, 2011) (Table 7).
The results of the studies conducted in retirement homes suggest that activities with the NW were pleasant for the patients
and represented a signicant factor in the rehabilitation of the elderly; some studies also suggested that there are negative effects
on loneliness and the residents mood. The NW was also used over
three weeks for 15 patients admitted with a diagnosis of systemic
lupus erythematosus. All of the subjects were sedentary. Outcomes
included reduction in fatigue, lower levels of anxiety as well as
weight and waist circumference reduction (Yuen et al., 2011).

4. Discussion
In this review, it was found that the Nintendo Wii has been a
versatile tool for different healthcare treatments, and thus has
been distinguished from the earlier approaches commonly used
in health care. The professionals qualied the Nintendo Wii as
interactive, fun and useful for different ages; however, they also
indicated several challenges, particularly in the methodology of
the studies.
Some methodological aspects must be considered: there was no
uniformity in terms of the population ages and treatments for
which the NW was used, many studies did not use objective measures, and the studies were mostly on small populations. For this
reason, it was necessary to establish groups of studies that were
similar in the application of the NW, which, in this case, meant
establishing groups based on the type of population and the main
objective of the studies.
Furthermore, each study dened a different service protocol;
most used the NW as an adjunctive tool to conventional treatment,
with application of the NW one or two times a week. These studies
sought participants who had little or no experience with virtual
games so that previous experience was not a motivating factor.
With respect to the instruments of measurement, those used in
the majority of cases were questionnaires. Despite the advantages
of the low cost and rapid implementation of questionnaires, it was
difcult to compare the data from the questionnaires with that obtained using psychological tests, such as the Wisconsin-IV Test
(Deutsch et al., 2008), 5-DAT Numerical Reasoning Test, COGLAB-UAM Battery Test, Rotation of Solid Figures Test (Quiroga
et al., 2009), Test of Visual Perceptual Skills, and Preintervention
and Postintervention Measurements on the Posture Scale Analyzer
(PSA) (Deutsch et al., 2008). The psychological tests showed no
conclusive results with regards to the use of the NW, which may
be a result of the time required to obtain the variables during the
study.
In studies with patients after stroke, the energy expenditure
during NW activities was sufcient to maintain the health of patients. Although these activities can only be classied as mild or
moderate, the studies used anthropometric and physiological measures to measure increased activity and the promotion of a healthy
lifestyle among the patients after stroke (Hurkmans et al., 2011).

T.M. Pessoa et al. / Computers in Human Behavior 31 (2014) 384392

Thus, the results for this population were conrmed (Biddiss &
Irwin, 2010).
Physical activity can reduce depressive symptoms and improve
the quality of life of patients with various health conditions. The
use the NW encourages exercise at different levels of intensity,
depending on what software (game) is chosen for the activity,
making it accessible to various population demands and allowing
it to contribute to the reduction of depressive symptoms. Thus,
the NW can be used not only as an adjunct in the treatment of
depression but also as a prophylactic tool because the symptoms
of depression are associated with negative health (Rosenberg
et al., 2010). In studies involving depressive patients using the
NW, the patients were encouraged to enjoy some exercise and observe the reduction of their depressive symptoms; however, there
were no signicant improvements in the quality of life measures
for these patients.
Some games allow NW custom avatars that can be customized
according to the self-image of the player, inuencing the way in
which the avatar interacts with the game (Jin, 2010a, 2010b).
Although until now there are no studies using avatars in the NW
specically for the treatment of health, the studies on other interfaces using avatars have shown the potential use of the information provided to complement diagnosis and help to determine
treatments. The virtual social facilitation can also increase the
exercise effort of patients, which is very important in rehabilitation
programs.
The studies on using games for cognition were split among several objectives, which made it difcult to compare the results of
those studies. Some studies were not able to correlate any cognitive improvement, whereas other studies reported improvement
of visual learning and perceptual and motor skills, indicating that
the NW can be a good tool for teaching exercises. The studies also
indicated that the cognitive test showed good results using the NW
compared to non-digital evaluations. One of the advantages offered
by the NW is the access to a complementary tool for a low cost that
allows patients to perform cognitive tasks more often in their own
home, favoring the development or improvement of specic cognitive functions in pleasurable activities.
Studies of motor rehabilitation and balance were all successful
in the populations studied, showing that the Wii is a good alternative for the promotion of recovery. Practitioners also adopted the
NW for occupational therapy with good results, although the
way in which the NW was used differed in various studies. It can
be observed that the Nintendo Wii is used in various ways and,
despite the limitations mentioned, is a useful and easy tool for
therapeutic applications.
The results for the use of the NW were not homogeneous; however, they indicate the power of the NW as a motivational tool. The
NW possesses the characteristics necessary for use in healthcare,
both in rehabilitation and in the promotion of. As the NW is a relatively new tool, its potential uses are still beginning to be examined. Future studies with larger samples of specic populations,
better measurement tools with good psychometric properties
and even biological measurements as well as control groups are
important for providing evidence of the effectiveness of the NW
in different health contexts.
5. Conclusions
Used by many health professionals, virtual reality is an innovative and promising technology (Jin, 2009). Virtual reality through
video games is accessible, safe (Jin, 2010a, 2010b), realistic and
clinically practical (Jin, 2009). The NW can be employed by many
professionals and suitable to different clinical demands. Moreover,
because of its entertaining features, the NW sometimes makes
tasks pleasant that are normally regarded by patients as tiresome

391

or boring; this facilitates the adherence of patients to the recommended procedures. Thus, its ability to promote greater motivation
among patients can be considered a great advantage in using this
technology as a complement to conventional therapeutic
procedures.
The possibility of using this therapy in a home setting may lead
to more rapid therapeutic results. The patient could add the recommended practices to their life routine and, thus, have better compliance than if they were required to attend a health care facility
or other institution. The possibility of domestic practice also favors
those who, for whatever reason, have difculty leaving the home
environment.
Therapeutic exercises with the NW can be performed either
through the constant monitoring of health professionals or without
it, as homework, to complement the treatment implemented in the
conventional therapeutic environment. Use in the home setting
will require development and validation of additional therapeutic
protocols; these should take advantage of the positive motivational
aspects of the games to make the required tasks enjoyable, facilitating adherence to the protocols.
As a recent technology, developed less than 10 years ago, existing studies on the use of the NW are mostly case reports. However,
the results are promising and have shown great potential in the
clinical treatment of mood disorders and anxiety, improving the
quality of life and in maintaining the focus on rehabilitation of cognitive functions. With the increase of studies on the application of
the NW, and especially with the development of clinical trials to
evaluate the effectiveness of therapeutic video game programs,
the use of the NW may be expanded.
It is also worth mentioning that technological developments,
particularly relating to software, are continuous, and some programs are currently being developed specically for therapeutic
purposes. The investment in such software will facilitate the planning of protocols more suited to specic problems, increasing the
usability of the NW in both therapeutic and prophylactic
applications.
Thus, for all the features mentioned above, the NW shows a
high potential to become a tool of great utility for health
professionals.
Financial and competing interests disclosure
This study was supported by the National Institute for Translational Medicine (INCT-TM) and the Brazilian Council for Scientic
and Technological Development (CNPq). The authors have no other
relevant afliations or nancial involvement with any organization
or entity with a nancial interest in or nancial conict with the
subject matter or materials discussed in the manuscript apart from
those disclosed.
Writing assistance, provided by American Journal Experts, was
utilized in the production of this manuscript.
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