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Wii Move! The use of modern technology to enhance physical activity engagement on an Wii Move! The use of modern technology to enhance physical activity engagement on an inpatient mental health unit L. Breen & L. Mc. Taggart Interprofessional Management of Chronic Diseases, Fall 2009

Outline Enhancing engagement… Importance of physical activity for mental health Inpatient mental health program Outline Enhancing engagement… Importance of physical activity for mental health Inpatient mental health program at Sunnybrook Introduction of video game technology (Wii), Minding Our Bodies pilot project, Evaluation Next Steps…

Stats and Fast Facts • Individuals with emotional distress or mental illness report poorer Stats and Fast Facts • Individuals with emotional distress or mental illness report poorer physical health and have greater rates of chronic conditions • Canadians who report symptoms of depression report experiencing three times as many chronic physical conditions as the general population (Canadian Institute for Health Information, 2008) • Canadians with chronic physical conditions have twice the likelihood of also experiencing a mood or anxiety disorder compared to those without a chronic physical condition. (Government of Canada, 2006)

More Stats and Facts • 1 in 3 people who have a heart attack More Stats and Facts • 1 in 3 people who have a heart attack also have co-morbid depression that effects cardiac survival outcomes, rehabilitation compliance and recovery • The rate of obesity in persons with schizophrenia is 2 times that of the general population • Cardiovascular disease is the primary contributor to excess mortality in people with schizophrenia • 15% – 30 % of patients with diabetes also meet the criteria for depression (twice the rate of the general population)

Common Co-existing Mental Illnesses and Chronic Physical Conditions • Diabetes – Obesity rates are Common Co-existing Mental Illnesses and Chronic Physical Conditions • Diabetes – Obesity rates are up to 3. 5 times higher in people with serious mental illnesses vs. general population – 40% of people with diabetes also exhibit symptoms of anxiety • Heart Disease and Stroke – Women with depression are 80% more likely to experience heart disease than women without depression – Co-existing heart disease and mental illness contribute to worse health status and higher health care utilization rates • Arthritis – People with arthritis are at an elevated risk of developing mood anxiety disorders linked with more frequent or chronic pain

Common Co-existing Mental Illnesses and Chronic Physical Conditions • Respiratory Conditions – People with Common Co-existing Mental Illnesses and Chronic Physical Conditions • Respiratory Conditions – People with mental illness have high smoking rates • Increased risk of COPD, chronic bronchitis and asthma – 3 out of 4 with COPD experience anxiety and/or depression • Cancers – Cancer is associated with increased risk of depression that can interfere with treatment and remission

Factors Contributing to the Mind/Body Connection • Physiological and emotional processes involved in mental Factors Contributing to the Mind/Body Connection • Physiological and emotional processes involved in mental disorders can increase susceptibility of developing poor physical health – – Changes in hormone balances Sleep disturbances Medication side effects Decreased energy, impaired social and cognitive functioning impact ability to engage in healthy behaviors – Unhealthy habits as a response to symptoms • Social determinants of health – Income and nutrition – Housing and accessibility to physical activity and mental health resources

The Evidence: Exercise and Depression Level 1: Meta-analysis: Mead, Morley, Campbell, & Mc. Murdo, The Evidence: Exercise and Depression Level 1: Meta-analysis: Mead, Morley, Campbell, & Mc. Murdo, 2009 • Exercise for depression • Rigorous inclusion criterion • Moderate clinical effects, non-statistically significant • Standardized Mean Difference – 0. 42

The Evidence: Exercise and Depression • Exercise is recommended for adjunct treatment of depression The Evidence: Exercise and Depression • Exercise is recommended for adjunct treatment of depression • Effects of exercise not statistically different than cognitive therapy • More robust trials needed to determine effect sizes, risks and benefits, specific types of exercise most effective • Recommended systematic reviews re: exercise and dysthymia • Recognition that enjoyment important in reducing drop-out rates

Exercise and Mental Illness • Dementia – Prospective studies indicate a protective effect • Exercise and Mental Illness • Dementia – Prospective studies indicate a protective effect • Stress and Anxiety – Moderate reducing effect on state and trait anxiety – Reduced sensitivity to stress • Schizophrenia – Limited research, mostly pre-experimental – Possible association between exercise and reduction of negative symptoms – Goal of preventing co-morbid physical illness due to obesity and physical inactivity • Addictions – Positive effect on aerobic fitness and strength in alcohol rehab – Benefits less substantial with drug rehabilitation

Health Factors Affected By Exercise • Emotion and mood • Diversion from negative thinking Health Factors Affected By Exercise • Emotion and mood • Diversion from negative thinking • • • Self-esteem Sense of mastery Social activity and connection Cognitive function Physiological effects • Endorphin, mono-amine, cortisol • Possible improved stimulation and improvement of health of nerve cells via protein release

Use of Exercise as an Adjunct Treatment • Provides options and empowerment in treatment Use of Exercise as an Adjunct Treatment • Provides options and empowerment in treatment and requires active engagement • Helps to reduce stigma by encouraging participation in socially valued activities • Potential for independent maintenance after initial assessment, training and supervision • Potential to decrease medication side effects and improve adherence • Can be done at minimal cost

Patient Feedback and Challenges • Quality of care surveys indicate an interest in and Patient Feedback and Challenges • Quality of care surveys indicate an interest in and appreciation of physical activity • Requests from patients for exercise equipment and resources • Privilege level on the inpatient unit impacts access to physical activity resources • Safety considerations re: what can be offered, diversity of our clients (ages, dx, physical and cognitive, language, etc. ), staff and external resources

Minding Our Bodies • Funding from the Ontario Ministry of Health Promotion to support Minding Our Bodies • Funding from the Ontario Ministry of Health Promotion to support physical activity for mental health • CMHA accepted 6 proposals for pilot sites to develop physical activity programs for mental health clients • Focus on sustainability and outcomes as well as community partnerships to promote physical activity along the continuum of care • Includes partnerships with YMCA Ontario and York University Faculty of Health

Wii Move! • Initial proposed program – Physical activity using the Wii, stationary bikes, Wii Move! • Initial proposed program – Physical activity using the Wii, stationary bikes, stretching and educational components in a structured group setting • Program changes to meet client needs – – – Primary use of Wii Sports More client choice Facilitators as resources, not always leaders Less use of stationary bikes during group times Less formal education process Accommodation of higher # of participants per session

Wii Sports Copyright © 2009 Google Images Wii Sports Copyright © 2009 Google Images

Wii Sports options Tennis, Bowling, Boxing, Golf, Baseball Fitness components Cardio, Strength, Flexibility, Endurance, Wii Sports options Tennis, Bowling, Boxing, Golf, Baseball Fitness components Cardio, Strength, Flexibility, Endurance, Balance, Motor Coordination Equipment Nintendo Wii console, remotes, sensor, Nerf attachments, TV

Wii Evaluate • Consultations in the process of developing evaluation tool – – – Wii Evaluate • Consultations in the process of developing evaluation tool – – – Patients on F 2 Whitby Metabolic Clinic Physical Activity Resource Centre Health Communications Research Unit CMHA/ Minding Our Bodies Project Team • Existing tools did not provide optimal ‘fit’ for proposed outcomes – SF-36, Beck Depression Scale, Walking program survey • Research and identified outcomes led to development of a self-evaluation tool specific to the Wii experience • Survey developed and feedback from HCRU received

Outcomes for Evaluation • • Perception about physical activity Attitude Mood Anxiety Stages of Outcomes for Evaluation • • Perception about physical activity Attitude Mood Anxiety Stages of Change/ Transtheoretical Model Stress Management Physical Activity Benefit Opportunity for Socialization

Outcomes for Evaluation Short-Term Medium-Term (Learning) (Action) - Awareness - Aspirations - Attitudes - Outcomes for Evaluation Short-Term Medium-Term (Learning) (Action) - Awareness - Aspirations - Attitudes - Skills - Opinion - Knowledge - Motivation - Behaviour - Practice - Decisions

Wii Evaluate - Results 1. How important is physical activity to you? Not at Wii Evaluate - Results 1. How important is physical activity to you? Not at all 0% Very little 5. 4% Somewhat important 32. 4% Very much 21. 6% Extremely important 40. 5% 2. Do you think that participating in physical activity during your hospital stay will assist you in your recovery? Strongly Disagree 0% Disagree Undecided Agree 0% 11. 1% 33. 3% Strongly Agree 55. 6% 3. I have learned something new about physical activity that is important to my health. Strongly Disagree 0% Disagree Undecided Agree 5. 4% 24. 3% 40. 5% Strongly Agree 29. 7%

Results cont’d 4. I have been reminded of the importance of physical activity in Results cont’d 4. I have been reminded of the importance of physical activity in improving my health. Strongly Disagree 0% Disagree Undecided Agree 0% 14. 7% 41. 2% Strongly Agree 44. 1% 5. During my participation in this group: (Circle any that apply to you) a. b. c. d. e. f. I experienced some positive change in my mood…. = 71. 4% I felt more confident in myself……………. = 62. 9% I was distracted from my worries…………………. … = 60% I felt energized……………. = 62. 9% I felt more relaxed……………= 65. 7% I enjoyed being with others……………. . = 65. 7%

Results cont’d 6. This group is helpful in managing frustration and stress during my Results cont’d 6. This group is helpful in managing frustration and stress during my hospital stay. Strongly Disagree 2. 9% Disagree Undecided Agree 0% 8. 8% 44. 1% Strongly Agree 44. 1% 7. Has this experience encouraged you to participate in physical activity in the future? Definitely Not 0% Probably Not 0% Possibly 29. 4% Probably 11. 8% Definitely 58. 8%

Wii Evaluation Qualitative Results “New learning about physical activity that is important to health” Wii Evaluation Qualitative Results “New learning about physical activity that is important to health” (3 a. ) • Social – “It’s a great way to socialize with others” – “It’s fun to play with others” • Stress Management – “It relaxes me” – “I learned that it is a good way to release tension and stress buildup” • Self-Awareness – “How my competitive edge comes into play in certain circumstances” – “I enjoyed it” – “Persistence”

Wii Evaluation Qualitative Results “New learning about physical activity that is important to health” Wii Evaluation Qualitative Results “New learning about physical activity that is important to health” (3 a. ) • Specific to Wii Sports – “How to play the Wii Game” – “The games” • Other benefits and risks – “If you exercise, blood flows to the brain…” – “It helps you to build your muscles up” – “Many people get very active very quickly, to the point at which it is unsafe to continue”

Wii Evaluation Qualitative Results “Plans for future activity participation” (7 a. ) • Physical Wii Evaluation Qualitative Results “Plans for future activity participation” (7 a. ) • Physical Activity-Specific – – “Golf, baseball, tennis” “I work out with weights” “Walk, swim, yoga” “Feed birds at home in the fresh air, go to the gym… and do my stretches for my legs…” • Wii- or Technology-Specific – “More trials of computer games” – “Buy a Wii, but only if it is on sale” – “Play more Wii sports” • Miscellaneous Unrelated Responses – “This is the best activity that I have done i. e. lots of games” – “Stay with my family forever, live as before” – “Play cards, art therapy”

Other Observations Anecdotal: • Patients verbally reporting reduced anxiety, improved mood, release of anger, Other Observations Anecdotal: • Patients verbally reporting reduced anxiety, improved mood, release of anger, decreased frustration, experiences of enjoyment/fun, interest and motivation to “play again”, interest in improving their skills… MOB Monthly Tracking Form: • Significant age range in participants • Diversity and complexity in mental and physical health issues currently experienced by participants • Various stages along continuum of illness/recovery • Different levels of past/current fitness, exercise knowledge

Discussion of Experience: Challenges • Safety considerations related to: – – – – Balance Discussion of Experience: Challenges • Safety considerations related to: – – – – Balance concerns Cardiac health issues Recent and/or chronic injuries Dizziness (multiple causes) Poor self-awareness/ self-regulation Nutritional/ hydration deficiencies Impulse control • Sensory Impairments: – Visual/perceptual – Auditory – Proprioception

Discussion of Experience: Challenges • Cognitive Impairments: – – – – New learning Memory Discussion of Experience: Challenges • Cognitive Impairments: – – – – New learning Memory Multiple steps involved in skill (use of remote) Specific game(s) popular yet more difficult Requirement of flow in movement Flexibility Perseveration, disinhibition Response time, sensitivity of Wii Challenges & risks addressed through: Assessment, observation, facilitator support, modifications where needed, education and consultation with interprofessional team.

Discussion of Experience: Benefits • Trend in participation throughout the PA groups (Wii and Discussion of Experience: Benefits • Trend in participation throughout the PA groups (Wii and other PA focused groups offered) • For clients with longer lengths of stay: improvement in physical endurance, self awareness and regulation, motor and visual coordination, building on skill level within the games, concentration and attention • Clients repeating attendance in Wii Move! group, reporting enjoyment, providing mutual social support within group, exhibiting changes in attitude and opinion regarding the Wii and other forms of physical activity • Staff interest, participation and engagement with patients

Discussion of Experience: Benefits Anecdotes 1. Nick: “It’s so important…it makes me more happier…” Discussion of Experience: Benefits Anecdotes 1. Nick: “It’s so important…it makes me more happier…” 2. Kevin: “This is the only thing that’s useful, that I look forward to in my day…” 3. Rachel: “I was really mad before we starting playing…I had a bad phone call with my mom right before I came to group…now I feel more calm…” 4. Len: “I’ll help you set up but I’m not going to play, I’m into real sports. ” 5. Antonio: “It’s like anything in life…you get better through experience…”

Wii Conclude • A high percentage of patients on F 2 are interested in Wii Conclude • A high percentage of patients on F 2 are interested in physical activity and recognize its value in recovery • Patients recognize small changes in health factors during group participation • The Wii Move group provides patients with a unique opportunity for new learning and physical activity engagement • The Wii move group assists a high number of participants in managing stress during admission • A high percentage of participants are motivated to continue participating in physical activity in the future but many do not identify specific goals

Wii Conclude • The Wii Move group provides access to physical activity engagement within Wii Conclude • The Wii Move group provides access to physical activity engagement within the inpatient environment on F 2, increasing the support for physical activity to individuals with a diverse range of needs • Ongoing development of evaluation tool is needed to capture experiences of clients with decreased cognitive abilities • Ongoing development of the structure of the group is required to develop and incorporate community partnerships – Increase formal education sessions regarding physical activity and resources outside the hospital • Further education and incorporation of other interested members of the inter-professional team on F 2 in the use of Wii technology to promote physical activity is recommended

References • • • • Canadian Mental Health Association. (2006). Network: Minding the body, References • • • • Canadian Mental Health Association. (2006). Network: Minding the body, the relationship between physical and mental health. 22 (1). www. ontario. cmha. on. Canadian Mental Health Association. (2008). Backgrounder: The relationship between mental health, mental illness and chronic physical conditions. www. ontario. cmha. ca Bingham, P. H. (2009). Minding our Bodies: Physical activity for mental health, Literature Review. www. mindingourbodies. ca Gilmour, H. (2008). Depression and Risk of Heart Disease. Health Reports 19(3), Statistics Canada, Catalogue no 82 -003 -XPE, http: //www. statcan. ca/english/freepub/82 -003 -XIE/2008003/article/10649 -en. htm Lawlor, D. , & Hopker, S. (2001). The effectiveness of exercise as an interventino in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ, 322, 1 -8. Mark, R. , & Rhodes, R. (2009). Wellspring: Active video games: A good way to exercise? Alberta Centre for Active Living, 20 (4). www. centre 4 activeliving. ca Mead, G. E. , Morley, W. , Campbell, P. , Greig, C. A. , Mc. Murdo, M. , & Lawlor, D. A. (2009). Exercise for depression (Review). The Cochrane Library, 3. Patten, S. B. (1999). Long-Term Medical Conditions and Major Depression in the Canadian Population. Canadian Journal of Psychiatry 44(2): 151 -157. Schmitz, N. , Kruse, J. , & Kugler, J. (2004). The Association between Physical Exercises and Health. Related Quality of Life in Subjects with Mental Disorders: Results from a Cross-Sectional Survey. Preventive Medicine 39(6): 1200 -1207. Public Health Agency of Canada. Physical Activity Unit. Physical Activity Guide to Healthy Active Living. www. phac-aspc. gc. ca/pau-uap/fitness/about/html. Richardson, C. (2005). A Lifestyle Physical Activity Program for Persons with Serious Psychiatric Disabilities. Psychiatric Services 56(3): 354. Richardson, C. , Faulkner, G. , Mc. Devitt, J. , et al. (2005). Integrating Physical Activity into Mental Health Services for Persons with Serious Mental Illness. Psychiatric Services 56(3): 324 -331. Schmitz, N, Kruse, J. , & Kugler, J. (2004) The association between physical exercises and health-related quality of life in subjects with mental disorders: results from a cross-sectional survey. Prev Med, 39 (6), 1200 -7. Copyright © 2009 Breen & Mc. Taggart

Questions and Discussion… Copyright © 2009 Breen & Mc. Taggart Questions and Discussion… Copyright © 2009 Breen & Mc. Taggart