Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
International Journal of Therapies and Rehabilitation Research [E-ISSN: 2278-0343] http://www.scopemed.org/?jid=12
IJTRR 2016, 5: 4 I doi: 10.5455/ijtrr.000000157
Investigation of the effects of the Nintendo®Wii-Fit training on balance and advanced motor performance in children with spastic
hemiplegic cerebral palsy: A Randomized Controlled Trial Miraç Sezer Urgen1, Türkan Akbayrak2, Mintaze Kerem Günel2*, Özge Çankaya3,
Zehra Güçhan4, Emine Seda Türkyılmaz5
1 PT, MSc Hacettepe University, Health Sciences Institute, Ankara. Email: [email protected] 2 PT, PhD, Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Ankara. Email: [email protected] * PT, PhD, Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Ankara. *Corresponding author PT, PhD, Prof, Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Ankara, Turkey. Email: [email protected] 3 PT, MSc, Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Ankara, Turkey. Email: [email protected] 5PT, MSc, Eastern Mediterraean University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, North Cyprus, Turkey.Email: [email protected] 6PT, PhD Turgut Ozal University, School of Physical Therapy and Rehabilitation, Ankara, Turkey. Email: [email protected]
Abstract
BACKGROUND: The Nintendo®Wii-Fit offers an inexpensive, enjoyable, suitable alternative to more complex systems for children with cerebral palsy. OBJECTIVE: The aim of this study was to investigate the effects of Nintendo®Wii-Fit training on balance and advanced motor performance of children with spastic hemiplegic Cerebral Palsy (CP). METHODS: Thirty children with spastic hemiplegic CP who were 7-14 years of age, had Gross Motor Function Classification System (GMFCS) levels I and II, regularly participated in routine physiotherapy program twice a week. Children were randomly assigned to either the Nintendo®Wii-Fit training or the control groups. Nintendo®Wii-Fit training group were continued twice a week in addition to physiotherapy program. The Gross Motor Function Measure (GMFM), Gross Motor Performance Measure (GMPM), the Timed up and go (TUG) test, Pediatric Balance Scale (PBS), Pediatric Evaluation of Disability Inventory (PEDI) mean scores were recorded. RESULTS: Both groups had significant differences in the GMFM and GMPM scores, durations of single leg and tandem standing, and PBS (p<0.05). Nintendo®Wii-Fit training group also had more significant improvements in the mean duration of the TUG test and number of jumping than the control group (p<0.05). When the groups were compared, the GMFM, the GMPM and PEDI scores were similar following the program (p>0.05). CONCLUSIONS: Nintendo®Wii-Fit training may effect on advanced motor skills and improve balance of children with spastic hemiplegic CP with physiotherapy. Keywords: Cerebral Palsy, spastic hemiplegia, Nintendo®Wii-Fit, Balance, Advanced Motor Abilities
Original Article Open Access
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
Introduction Cerebral Palsy (CP) describes a group of disorders of the
development of movement and posture, causing activity
limitation, that are attributed to non-progressive
disturbances that occurred in the developing fetal or infant
brain. The motor disorders of CP are often accompanied by
disturbances of sensation, cognition, communication,
perception, and/or behavior, and/or by a seizure disorder
(1). Spastic CP is the most common type, accounting for up
to 75% of all CP cases and hemiplegic CP is the most
commonly seen subtype of spastic CP which occurs in
approximately 30-35% of all CP population (2).
The most obvious result is a varying degree of weakness,
stiffness (spasticity) and lack of control in the affected side
of the body, rather like the effects of a stroke. Hemiplegic
children with CP may be very obvious that have little use of
one hand, limp or have poor balance and the other hand
soem children will be so slight that it only shows when
attempting specific physical activities (3). Falling tendency
to their involved sides is a frequent problem due to the
inadequate righting, protective and equilibrium reactions
(4). Spastic hemiplegic childern with CP exhibit
heterogeneous gait impairments in both the affected and
unaffected lower extremities, resulting in abnormal
kinematic characteristics and temporospatial asymmetry
during their gait (5). Common pathological gait patterns
exhibited by hemiplegic patients are abnormal proximal
joint movement, such as excessive anterior tilt of the pelvis,
as well as abnormal distal joint movement, including foot
drop during gait (6). In addition, these abnormal kinematic
patterns lead to decreased cadence and walking velocity
and an unbalanced stance and swing phase, eventually
reducing energy efficiency (7). Due to these gait
deficiencies, patients with hemiplegia experience serious
barriers to functional recovery, as locomotive ability is
essential for many daily activities. Despite this, almost all
hemiplegic children walk independently (8). Motor control
problems, maintenance of primitive reflexes, inadequate
development of equilibrium and balance reactions, muscle
contracture and abnormal posture are the main reasons of
balance disorders seen in these children. Moreover, spastic
hemiplegic children have problems regarding muscular
coordination and sensory-motor integration and these also
negatively affect postural control and balance (9). Balance
functions of children with CP have been found to be related
to walking skill in the literature. Normal developed children
make oscillations and have coordination between proximal
and distal sections of their body while walking, but in
children with CP, these are inadequate or not available.
Children with CP use special patterns to provide their
balance. They have narrow stride wide, inadequate body
coordination, and high gait velocity as they may not provide
balance (10).
Balance problems seen in school-aged children affect
independence and functional capacity so these cause both
physical and psychological issues in children. Thus, studies
in the literature focused on balance training to improve
motor skills (11).
Nintendo®Wii-Fit therapy is an interactive and individual
therapy method which can present desired environment
and immediate feedback (12) Some virtual reality practices
have increasingly started to be used in recent years. A wide
range of people including adults, children, neurological
patients, orthopedic patients were involved in these
studies. The users participate in virtual reality by observing
their own views in the mirror world of virtual reality
environments. Nintendo ®Wii-Fit is appropriate for this
definition and the movements of the user are represented
by a virtual person on television. Deutsch et al. firstly
published the use of game console (Nintendo ®Wii-Fit) in
children with CP which was cost efficient and accessible.
They included a child with diplegic CP who was 13 years of
age and the child played the games boxing, tennis, bowling,
and golf among Nintendo ®Wii-Fit Sports games so it was
considered that these practices could be beneficial to
improve the visual perception, functional mobility, and
postural control of the child Following this report, the use
of the Nintendo ®Wii-Fit console became widespread (13).
Gordon et al. conducted a pilot study and revealed the
convenience of using the Nintendo ®Wii-Fit practices in the
rehabilitation of children with CP (14). Similarly, in the
review by Snider et al., it was indicated that virtual reality
therapy could be an effective and motivating approach in
children with CP (15). Jelsma et al. revealed that the
Nintendo ®Wii-Fit game was found to be effective on the
balance training of children with spastic hemiplegic CP (16).
The use of the virtual reality methods is a recent practice in
rehabilitation. Particularly, in pediatric rehabilitation, the
virtual reality practices provide fun and motivation to
children and improve various skills of them such as motor
and cognitive skills in their daily life. The results of multiple
studies conducted on the children with CP were promising
in this area. Therefore, virtual reality has many therapy
options including functional and motivating aspects.
However, no adequate study is now available in our
country. Rehabilitation has taken for a long time and cause
a decrease in motivation and reluctance in the participation
of children. Therefore, over time, children do not follow the
tasks given by the therapist and this limits to obtain an
effective outcome from rehabilitation (17).
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
This study was considered to acquire the targets of
physiotherapist in a shorter and more motivating period in
addition to the routine physiotherapy and rehabilitation
program of children. Nintendo ®Wii-Fit games were chosen
since they presented an opportunity to be used in any
clinical environment. As a result, this study was planned to
contribute to the literature on the clinical practice of the
Nintendo ®Wii-Fit virtual reality practice and to examine
whether it affected the balance and advanced motor skills
of the children with CP.
In the light of the evidence to support in children with CP
and the need to investigate the impact on specific
hemiplegic group this study aimed to assess whether
intervention with the Nintendo ®Wii-Fit improves advance
gross motor performance in children with spastic
hemiplegic CP. The specific research question was: ‘Does a
Nintendo ®Wii-Fit intervention given regularly over 9 weeks
improve the balance and gross motor performance of
children with spastic hemiplegic CP performing at GMFCS
level I or II more than routine twice weekly physiotherapy?’
Additional research questions related to whether
improvement was related to increase gaming time,
whether children with CP could improve their performance
on the games and finally, whether children preferred
conventional physiotherapy or time on the Nintendo ®Wii-
Fit Console.
METHODS
The study was approved by the Ethics Committee of the
Hacettepe University (LUT 11/33).
Participants
Frothy seven children with hemiplegic spastic CP
attending a special education and rehabilitation center
were determined. The inclusion criteria of the study were
to be a child with spastic hemiplegic CP, to be from 7 to 14
years of age, to have GMFCS level II, to attend the routine
rehabilitation program during the specified period and not
to be injected by Botulinum Toxin A (BTX-A) for at least 6
months. Children who have any limitation of ranges of
motions preventing ankle reactions, have no any surgery
from knee and ankle-foot articulations, have no adequate
mental level to complete verbal tasks, and have severe
auditory and vision impairments to prevent communication
were excluded from the study.
According to these criteria, 37 spastic hemiplegic
CP children were included in the study. The purpose of the
study and its methods were explained to the parents of the
children and they were invited to the study.
Since 4 parents did not accept to participate in the
study, informed consent was obtained from 33 parents.
Following the initial assessments, the children were
randomly assigned to either Nintendo ®Wii-Fit program or
control group. Therefore 16 children were in the Nintendo
®Wii-Fit therapy group and 17 children were in the control
group.
Outcome Measures
Age, gender, height, weight, hemiplegic side,
birth history, medical history, undergoing of any previous
surgery or uptake of BTX-A, orthotic use, physiotherapy
duration, any device for ambulation, the type of this device
if available, fall history (frequency, type, reason, location
and any injury), of the children were recorded by same
author.
The Gross Motor Function Measure (GMFM) (only
the sections D and E were including the skills standing;
walking-running- jumping skills) was used to measure gross
motor function quantitatively (18)
The Gross Motor Performance Measure (GMPM)
was administered to measure the quality of movement (19).
Examining the balance of the children, standing
duration on flat and soft surfaces with eyes open and eyes
closed, single leg standing duration, and tandem standing
duration were recorded. In addition, the number of jumping
on single leg by both sides in 30 seconds was also recorded
(20).
The Timed-up and go (TUG) test was both simple
and valid so it was used to assess the dynamic balance.
Following a test which was allowed to the children, three
real test was done and the average result was obtained.
Walking velocity was calculated as seconds (21).
The children were also assessed with the Pediatric
Balance Scale (PBS) (22), failing status and Pediatric
Evaluation of Disability Inventory (PEDI) (23).
Routine Physiotherapy and Rehabilitation Program
All of the children attended to this program. The
limitations in standing, walking and advanced motor skills
were identified and physiotherapy was given to solve these
problems. Moreover, the program was planned according
to the limited activities in daily life of the children. Exercise
balls, balance board, and soft surfaces were used to
improve standing up, squatting, trunk control, equilibrium
reactions, and weight transfer. The children were
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
motivated in one leg standing and tandem standing. The
program was carried out for 9 weeks twice a week.
Nintendo ®Wii-Fit
This program was only given to the intervention
group, two times per weeks. Every session was applied 45
minutes. Eight games were chosen to improve balance,
weight transfer, coordination, and reaction time. These
were Jogging plus, penguin slide, heading, ski jump,
snowball fight, tilt city, perfect 10, and segway circuit play.
Each section of weight shifting was played at least
ten times. . Each game should be played for at least ten
minutes and in each session the child may choose two
different games, each from a different category. . At the end
of 9 weeks, each section should have had at least eight ticks
and each game should have been played at least twice.
Following 18 interventions sessions, all children
were re- evaluated
Statistical Analysis
The statistical analysis was conducted using the
statistical package SPSS software, version 15.0 (SPSS Inc.,
Chicago IL, USA). Mean±standart deviation or median were
used for numerical variables. Categorical variables were
shown as numbers and percentages (%). The Chi square test
was used to compare the differences between groups in
terms of qualitative variables. Because the assumptions of
a parametric test were not met, the Mann-Whitney U test
was used to reveal the quantitative differences between
the groups. Wilcoxon test was performed to compare the
outcome before and after 9-week therapy. A difference at
the p<0.05 level was considered to be statistically
significant. When significant differences were found, effect
sizes were also examined. Therefore; <0,2 no effect, 0,2-0,5
small effect, 0,5-0,8 medium effect and >0,8 large effect.
RESULTS
Seventeen children and 16 children were
initially included in the control and intervention groups,
respectively. Two children left from the control group at the
first and fifth sessions due to health problems and a child
left from the intervention group at forth session due to due
to the BTX-A indication. These children whose ages were 9,
10 and 12 years were not involved in analysis.
The mean ages of the control group and the
intervention group were 11,33 ± 2,19 ages and 11,07± 2,37
ages, respectively. 30 children (14 girls, 16 boys) with
spastic hemiplegic CP were included in the study. 70% of
them were right, 30% of them were left hemiplegic CP. All
of the children were at GMFCS level II (Table 1).
Falling frequencies of the children, the reasons,
the locations, and the injuries were assessed. 73,3% of the
children fell 1-3 times a week. Falling was seen in 76,66%
outside, 60% uneven surfaces, and 23,33% stairs. Attention
deficiency (%83,33) was the most commonly seen reason of
falling and balance loss (%73,33) followed it. The children
stated that they mostly fell forward (66,66%), over their
involved side (56,66%), on their knees (50%), and on their
hands (43,33%). They also informed that their knees
(83,33%), hands (76,66%), and elbows (63,33%) were
commonly injured (Table 2).
At the initial assessments, the groups were similar
in demographic information, clinical features, GMFM and
GMPM mean scores, single leg and tandem standing
durations on soft surfaces, jumping number, the TUG test
duration, and PEDI mean scores.
There was no significant difference between the
GMFM-88 results of the groups before the treatments
(p>0,05). The pre-treatment and post-treatment GMFM
results (sections D and E) were found significantly different
in both groups (p<0,05). Significant differences were also
found between groups following the treatments (p<0,05).
For section D, the effect sizes of intervention and control
groups were also investigated as significant differences
between groups were specified when the pre-treatment
and post-treatment results were compared (p<0,05).
Therefore, virtual reality group had significantly better
improvement in the section D, whereas no significant
difference was determined between the groups for the
section E of the GMFM (p>0,05) (Table 3).
In the assessment of the Gross Motor
Performance Measure (GMPM), the control group had
significant change in the sitting and standing sections
following the physiotherapy (p<0,05), whereas no
difference was acquired in the walking section. (p>0,05). In
the virtual therapy group, there was significant differences
in the sections; sitting, standing, and walking following the
intervention period (p<0,05). When the groups were
compared before the applied program, they were
statistically similar in the all sub scores of GMPM (p>0,05).
Following the program, the groups were significantly
different in the standing section (p<0,05). The GMPM total
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
Table 1. Mean age, gender and effected side of the groups
Table 2. Distribution and percentages about falling
Control group (n=15) Nintendo®Wii-Fit (n=15)
Total
n % n % n %
Frequency of falling (week) 0 2 13,33 2 13,33 4 13,33 1-3 11 73,33 11 73,33 22 73,33 4-7 2 13,33 2 13,33 4 13,33 8 and more 0 0 0 0 0 0 Where does he/she fall? In home 2 13,33 0 0 2 13,33 Out home 11 73,33 12 80 23 76,66 Stairs 1 6,66 6 40 7 23,33 Irregular surface 6 40 12 80 18 60 Crowded areas 1 6,66 3 20 4 13,33 Lonely 1 6,66 2 13,33 3 10 Falling direction Anterior 7 46,66 13 86,66 20 66,66 Posterior 0 0 1 6,66 1 3,33 Effected side 5 33,33 12 80 17 56,66 Non-hemiplegic side 2 13,33 3 20 5 16,66 On hands 7 46,66 6 40 13 43,33 On knees 9 60 6 40 15 50 On hips 0 0 1 6,66 1 3,33 Supine 0 0 0 0 0 0 On head 0 0 0 0 0 0 Cause of falling Loss of balance 12 80 10 66,66 22 73,33 Physically inability 5 33,33 8 53,33 13 43,33 Balance deficiency 12 80 13 86,66 25 83,33 Not protect himself/herself 1 6,66 2 13,33 3 10 Visual impairment 0 0 4 26,66 4 13,33 Injured area Hands 11 73,33 12 80 23 76,66 Elbows 8 53,33 11 73,33 19 63,33 Shoulders 0 0 0 0 0 0 Knees 13 86,66 12 80 25 83,33 Hips 1 6,66 0 0 1 3,33 Back 0 0 0 0 0 0 Head 0 0 1 6,66 1 3,33 Forehead 0 0 0 0 0 0 Nose 0 0 0 0 0 0
Control Group
n=15 Nintendo®Wii-Fit Group
n=15 % % Age 11,33±2,19 years 11,07±2,37 years Sex
Boy 7 46,6 7 46,6
Girls 8 53,3 8 53,3 Effected Side
Right 10 66,6 11 73,3
Left 5 33,3 4 26,6
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
Table 3. Results of Gross Motor Function Measurement (GMFM)
Control Group (n=15) Nintendo®Wii-Fit Group (n=15) Between groups
GMFM Before After Before After Before After
X±SD X±SD z p Cohen's d X±SD X±SD z P Cohen's d z p z p
Part D 85,81±7,74 90,26±5,33 -2,952 0,003* 1,097 91,28±4,63 96,92±3,24 -3,331 0,001* 1,403 -2,109 0,037 -3,392 0,001*
Part E 90,09±7,33 91,58±6,63 -2,699 0,007* 0,917 92,50±4,45 95,19±3,71 -3,314 0,001* 1,394 -0,625 0,539 -1,648 0,106
Total score 87,95±6,04 90,92±5,04 -3,297 0,001* 1,526 91,89±3,80 96,05±2,43 -3,411 0,001* 1,735 -1,971 0,074 -3,134 0,003*
*p<0,05 Table 4. Results of Gross Motor Performance Measurement Evaluation (GMPM)
Control Group (n=15) Nintendo®Wii-Fit Group (n=15) Between Groups
Before After Before After Before After
X±SD X±SD z p Cohen's d X±SD X±SD Z p Cohen's d z p z p
Sitting 103,07±10,57 104,73±9,83 -2,825 0,005* 1,049 107,27±1026 109,47±9,81 -3,351 0,001* 1,183 -1,351 0,187 -1,685 0,098
Standing 41,40±10,05 44,27±9,49 -3,089 0,002* 0,828 47,87±4,38 51,73±4,13 -3,426 0,001* 1,973 -1,895 0,061 -2,413 0,015*
Walking 40,67±8,73 41,40±8,41 -1,807 0,071 0,439 42,07±3,99 44,80±4,12 -3,202 0,001* 1,525 -0,188 0,870 -1,25 0,217
Total score 185,13±24,89 190,40±22,65 -3,191 0,001* 1,061 197,20±15,42 206,00±15,51 -3,416 0,001* 2,633 -1,597 0,116 -2,202 0,026*
*p<0,05 Table 5.Results of soft floor eyes open and closed balance reactions
Control Group (n=15) Nintendo®Wii-Fit Group (n=15) Between Groups
Before After Before After Before After
X±SD X±SD z p Cohen's d X±SD X±SD Z p Cohen's d z p z p
SFEO 281,29±135,19 283,51±131,38 -1,826 0,068 0,433 277,99±141,48 292,99±116,26 -1,826 0,068 0,524 -0,16 -0,16 0,902 0,838
SFEC 90,39±116,55 105,12±114,58 -3,059 0,002* 0,632 151,99±155,75 186,09±131,64 -2,599 0,009* 0,794 -0,605 0,567 -2,238 0,026*
*p<0,05 SFEO: Soft floor eyes opened, SFEC: Soft floor eyes closed Table 6. Results of Single Leg Standing and Tandem Standing
Control Group (n=15) Treatment Group (n=15) Between Groups
Before After BT AT BT AT
X±SD X±SD z p Cohen's d X±SD X±SD z p Cohen's d z p z p
Effected 5,54±8,94 9,85±14,91 -2,726 0,006 0,49 8,67±9,61 14,26±18,80 -2,726 0,006 0,463 -1,97 0,05 -1,887 0,061
Uneffected 77,50±117,74 84,00±118,14 -1,992 0,046 0,404 116,84±129,84 137,91±123,34 -2,589 0,01 0,788 -1,434 0,161 -1,873 0,061
Tandem effected 61,20±91,08 76,55±94,12 -3,296 0,001 0,619 73,47±120,39 100,47±114,92 -3,18 0,001 1,081 -0,519 0,624 -0,645 0,539
Tandem unaffected 41,57±42,65 48,28±46,24 -2,48 0,013 0,514 98,77±137,99 126,73±130,08 -3,059 0,002 0,657 -0,436 0,683 -1,972 0,05
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
Table 7. Results of Jumping
Control Group (n=15) Treatment Group (n=15) Between Groups
Before After Before After Before After
X±SD X±SD z p Cohen's d X±SD X±SD z p Cohen's d z p z p
Flat floor 53,07±21,95 54,07±21,29 -1,633 0,103 0,385 63,20±5,07 68,67±8,11 -2,044 0,041* 0,572 -0,749 0,461 -1,974 0,050*
Soft floor 48,27±16,48 49,87±15,68 -1,648 0,099 0,27 55,87±8,29 62,20±6,36 -2,836 0,005* 0,929 -0,955 0,345 -2,493 0,011*
Effected side 6,26±14,38 7,93±17,14 -1,604 0,109 0,294 15,4±26,90 18,80±31,76 -2,201 0,028* 0,633 -1,151 0,367 -1,151 0,367
Uneffected side 54,53±17,19 55,26±17,67 -1,114 0,265 0,357 58,20±20,84 66,20±23,60 -3,303 0,001* 1,192 -0,893 0,372 -2,242 0,025*
*p<0,05
Table 8. Results of Timed Up and Go test
Control Group (n=15)
Nintendo®Wii-Fit Group (n=15) Between Groups
Before After Before After Before After
X±SD X±SD z p Cohen's d X±SD X±SD z p Cohen's d z p z p
TUG 6,60±0,82 6,55±0,71 -1,365 0,172 0,324 6,48±0,85 6,26±0,67 -2,159 0,031* 0,535 -0,332 0,744 -1,265 0,217
*p<0,05, TUG: Timed up and go test Table 9. Intra- and Inter- group Results of Paediatric Balance Scale (PBS)
Control Group (n=15)
Nintendo®Wii-Fit Group (n=15) Between Groups
Before After Before After Before After
X±SD X±SD z p Cohen's d X±SD X±SD z p Cohen's d z p z p
PBM 48,47±3,50 49,27±3,12 -2,401 0,016* 0,788 50,07±2,86 53,80±1,61 -3,44 0,001* 1,616 -2,273 0,023* -3,545 0,001*
*p<0,05, PBM: Pediatric balance measurement Table 10. Functional Evaluation Results (PEDI)
Control Group (n=15)
Nintendo®Wii-Fit Group (n=15) Between Groups
Before After
X±SD X±SD z p z p
PEDI 181,73±8,18 180,07±12,36 -0,457 0,653 -0,457 0,653
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
score of each group had changed significantly
when the scores were compared as before and after the
interventions (p<0,05). When the total scores of the groups
collected following the interventions were compared, they
were significantly different (p<0,05), (Table 4).
Standing durations on flat and soft surfaces with eyes open
and closed:
Since 93,3% of the children could stand on flat
surface with eyes open and closed, no statistical analysis
was conducted. No significant improvement was
determined in the standing durations of the groups on soft
surfaces with eyes open when the results before and after
were compared (p>0,05). The groups had also no significant
different durations when they were compared both before
and after the programs (p>0,05). The standing durations on
soft surfaces with eyes closed different improved following
the programs in both groups (p<0,05). When the groups
were compared following the programs, Nintendo ®Wii-Fit
group had significantly better result than the control group
(p<0,05), ( Table 5).
Single Leg and Tandem Standing Duration
Standing duration on the involved leg was
significantly higher following the programs in both groups
(p<0,05). When the groups were compared following the
programs there was no significant difference between them
(p>0,05). Standing duration on the uninvolved leg was
significantly higher following the programs in both groups
(p<0,05). When the groups were compared following the
programs, there was no significant difference between
them (p>0,05). There was a significant change in the
Tandem standing durations of both groups following the
programs (p<0,05). No significant difference was recorded
when the groups were compared following the programs
(p>0,05), (Table 6).
Independent Jumping
The number of jumping with involved and
uninvolved leg on soft and flat surfaces had no significant
change following the program in the control group (p>0,05)
whereas all differences were significant in the intervention
group (p<0,05). When the groups were compared,
significant differences were determined in the number of
jumping with uninvolved leg on soft surface (p<0,05), (Table
7).
The mean duration of the TUG test was no
significantly different in the control group following the
programs (p>0,05), while it was significantly different in the
virtual reality group (p<0,05). When the groups were
compared following the programs, there was no significant
difference between them (p>0,05), (Table 8).
Significant increases in balance were recorded in both
groups following the programs (p<0,05). When the groups
were compared, the results acquired from the PBS were
significantly different in both groups before and after the
programs (p<0,05). Therefore, when the effect sizes were
analyzed, the effect on the virtual reality group was large
and the effect on the control group was medium-leveled,
(Table 9).
Examining the PEDI mean scores, no significant differences
were found between the groups both before and after
therapy (p>0,05), ( Table 10).
DISCUSSION The purpose of this study was to investigate
whether the Nintendo ®Wii-Fit game console which is an
accessible device was effective on balance and advanced
motor skills. This paper is the first randomized controlled
study which included 15 children in the control group and
15 children in the intervention group. The groups were
homogeny in terms of age, gender, involved side, GMFCS
level, and functional level. The effects of Nintendo ®Wii-Fit
practice on the balance of children with CP were assessed
and compared with a control group considered. It is
remarkable that the studies investigating the virtual reality
in children with CP were pilot studies and they had no
control group.
The results of the study indicate that a 9-week
period of daily practice on the Nintendo ®Wii-Fit improved
gross motor performance of children with spastic
hemiplegia.
The children with GMFCS I and II were planned to
be involved in this study. Independent standing and
functional mobilization are required to achieve balance and
advanced motor skills. Independent mobility is also
required to achieve them and defined as the GMFCS I and
II. Examining the literature, children with these levels of the
GMFCS were included in the studies aiming to increase in
balance and the functions of legs (24,25,26).
A relatively long time is required to achieve
maximum independence in children with hemiplegic CP.
During this period, children often have problems regarding
participation in therapy and realizing the therapeutic tasks
so it can take longer times to reach at the targets of
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
physiotherapy. While planning the Nintendo ®Wii-Fit
intervention, the aim was to maintain a high motivation of
children and to reach at the targeted motor level in a
shorter period.
As a result of our study, the intervention group
participated in therapy more actively than the control
group. Similarly, in the pilot study by Reid, 3 children with
CP were included and virtual reality play-based methods
increased motivation, interest, satisfaction, and
participation rate of children during therapy. Therefore,
Reid DT offered this intervention as a therapeutic way (27).
Nintendo ®Wii-Fit was found to be effective on
the improvement of balance and advanced motor skills.
Examining the GMFM results, both groups had increases in
each section and total score. When two groups were
compared, the effect size of the standing section was higher
in the virtual reality group. In addition, the GMFM total
score of the intervention group was found to be
significantly higher.
Almost all hemiplegic children are able to walk
since 3 years old and they are independent in daily life
activities. Therefore, only the sections; standing and
walking-running-jumping (D and E) were used. Multiple
studies which used GMFM as an outcome measure in
assessing the Nintendo ®Wii-Fit practice also supported the
use of these two sections.
In the study by Salem Y et al., forty children with
developmental disorders were allocated into therapy
(n=20) and control (n=20) groups. Traditional therapy
including fine and gross motor activities, walking and
balance training was applied to the control group. The
Nintendo ®Wii-Fit Sports and the Nintendo ®Wii-Fit games
including balance, walking, strengthening, weight transfer,
and aerobic training were applied to the therapy group. In
contrast to our finding, there was no change in the scores
of the GMFM in both groups (29).
Gross Motor Performance Measure (GMPM) uses
same movements with the GMFM, but it differently
specifies the quality of the movements rather than
assessing how much child could achieve the movement.
Our study also used it and revealed that the improvements
in the general scores and in the sections sitting and
crawling; standing and walking were found to be significant
following the Nintendo ®Wii-Fit therapy. In the control
group, the improvements in all sections, except walking,
were found significant. When the groups were compared,
the scores of the standing section were similar before the
program, whereas there were differences between the
groups following the program. In several sections, there
were similar improvements when the groups were
compared so effect sizes were compared and the effect in
the virtual reality group was found to be larger. As a result,
Nintendo ®Wii-Fit therapy was considered to increase the
quality of movement. No study used the GMPM in the
practices of virtual reality.
Jumping on right and left leg as a parameter of the
GMFM and the GMPM was also used to assess advanced
motor skill in this paper. When the literature regarding
virtual reality was investigated, no study was found to
assess jumping skill by using jumping number and jumping
quality. Following the interventions, there was no change in
number of jumping on involved and uninvolved legs over
flat and soft surfaces in the control group, whereas
significant changes were observed in the virtual reality
group. When two groups were compared, Nintendo ®Wii-
Fit group had significantly higher changes in the number of
jumping on uninvolved leg over soft surfaces following the
programs. Number of jumping on involved leg over flat
surfaces were similar in both groups so examining the effect
sizes, the effect on the virtual reality group was found to be
larger. It is considered that the games of the Nintendo ®Wii-
Fit may cause these improvements as the chosen games,
particularly ski jump and segway circuit games, provide the
transfer of body weight to the fingers and increase the
activity of the gastro-soleus muscles.
Balance problems negatively affects child as both
physical and psychological as they decrease functional
independence of children with different ages and different
involvement. Therefore, various studies in the literature
have focused on balance education in order to improve
motor skills.
Children achieve the maximum level of balance
skill at 12 years of age and this age is not affected by gender.
Therefore, the children who approached the completion of
balance skill were included in our study. The mean age of
control group was 11,33 ± 2,19 years, whereas it was 11,07±
2,37 years in the intervention group.
Standing duration with eyes open over a soft
surface had no significant differences in both groups after
the programs. On the other hand, both groups had
significant changes in the standing duration with eyes
closed over a soft surface following the programs.
Comparing the groups, larger effect was determined on the
standing duration with eyes closed on a soft surface in the
virtual reality group than the control group. Therefore,
Nintendo ®Wii-Fit was found to be effective on standing
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
with eyes closed and this may be explained that Nintendo
®Wii-Fit practice supports sensory motor development.
We also used single leg standing test in order to
assess balance. In both groups, there were significant
differences in the standing duration on both involved and
uninvolved sides following the programs. When the groups
were compared, the differences were found to be similar in
the groups so the effect sizes of the standing duration on
involved leg were also similar, whereas the virtual therapy
group had a larger effect size on the standing duration with
uninvolved leg than the control had.
Looking at the Tandem standing duration, both
programs were found to be effective to increase the
duration significantly, but there was no significant
difference between the groups so no effect of the Nintendo
®Wii-Fit was observed.
Falling tendency is one of the most commonly
seen problems in children with hemiplegic CP due to
inadequate equilibrium and righting reactions. Therefore,
these reactions of uninvolved side are hyperactive which
aim to compensate involved side. This is the first study
which included children with CP and assessed their fall
histories.
In a study investigating the quality of movement
and the change in the center of gravity, it was found that
some games (boxing, heading, soccer) need more change in
the center of gravity. In addition, more experienced people
changed their center of gravity more in order to win games
(29). Postural control strategies were observed in healthy
people and they were asked to play the games soccer
heading and ski slalom. Kinetic and kinematic analyses were
conducted and while the participants practiced the games,
their shoulder rotation, shoulder tilt, pelvic rotation and
pelvic tilt decreased and the change in the center of gravity
increased. They explained the reason of these changes as
the participants observed their virtual profiles from the
screen and moved more independently (140). In the
studies which focused on balance and motor development,
the games Nintendo®Wii-Fit Sport and Nintendo® Wii-Fit
were found to be effective. Despite this, more studies are
required to make the video games applicable as a
physiotherapy program (30).
The PBS is other clinical method assessing
balance. The previous studies related to Nintendo®Wii-Fit
practice did not use this scale. In our study, total scores of
this scale following the programs had significant changes in
both groups. Examining the effect sizes, the effect in the
virtual reality group was found large, while the effect in the
control group was medium-leveled. Desire to be more
successful in the games which aim to transfer weight in all
directions fast could be the reason of the increase in
balance.
The TUG test was also used in this study. No
difference was found in the control group, whereas a
significant change was observed in the virtual therapy
group. This difference could be caused by the motivation
factor.
The Timed-up and Go (TUG) test and the Timed-
up and down stairs (TUDS) test were some of the methods
to measure dynamic balance. The TUDS was mostly used in
the studies which conducted Nintendo®Wii-Fit practice in
children. In the papers by Marie Brien et al. and Salem Y et
al., no significant differences in the TUDS were found
following their intervention. Moreover, only one study by
Salem et al. used the TUG test to investigate the effects of
Nintendo®Wii-Fit practice in children with developmental
problems, but no significant change was recorded following
the intervention (28, 31).
The aim of the therapies applied to children with
CP is to increase functionality. The the PEDI mean score was
the most commonly used tests in order to measure the
function so these were preferred in this study to do this.
Since the children had the GMFCS level I, they had high
scores in terms of their mobility. The activities such as
having bath, zipping up, and tying shoelace were difficult
activities for them. No difference was determined in PEDI
mean scores as the both control and interventions mostly
aimed to increase balance and gross motor skills.
Fifth patients underwent a total knee
replacement surgery were involved in the study by Fung et
al. Routine balance and strengthening exercises were given
to the control group, whereas Nintendo®Wii-Fit was
applied to the intervention group. There was no difference
in pain, knee flexion-extension range, gait velocity, standing
durations, and patient satisfaction between the groups so
they stated that Nintendo®Wii-Fit was appropriate to be
used as an additional method in the therapy of this group
of people (32).
In the study by You et al., IREX virtual reality
system was used in children with hemiplegic CP for 60
minutes a day, 5 days per week. The results were firstly
assessed by the Functional Magnetic Resonance (fMRI) and
following 4 weeks, abnormal activations disappeared and
clinical data was supported (33).
Urgen M et al., International Journal of Therapies and Rehabilitation Research 2016; 5 (4):146- 157
Similar to this paper, Marie Brien et al. assessed 4
adolescents with the GMFCS level I and investigated the
effects of virtual reality program on their balance and
functional mobility. 6 minute walking test, section E of the
GMFM, the Timed-Up and Down Stairs (TUDS), and
Community Balance and Mobility Scale (CB&M) were used
as the assessment methods. As a result, Marie Brien et al
stated that 5 day consecutively applied virtual therapy was
found to be effective on the improvement of functional
mobility and balance and its effects lasted one month (31).
As a limitation of this study, the standing duration
was recorded according to the falling factor, but different
results could have been acquired if the postural stability
factor was chosen since the equilibrium reactions of the
participants were at high level. Therefore, further studies
could stop the standing duration when any problem in the
postural stability was observed.
The findings obtained from this study were
adequate to support the hypotheses. Nintendo®Wii-Fit
practice as one of the virtual reality methods was found to
be effective on the improvement of balance and advanced
leveled motor skills. More randomized controlled studies
including larger sample sizes and using laboratory
assessment methods are required. Moreover, children with
different types of CP should be compared to reveal the
differences among them.
Therefore, further study of a randomized
controlled trial is necessary to compare the diffrent virtual
reality treatment effects with those of a conventional
physiotherapy group. This study also needs future
investigation to better suggest a functional and quality of
life to motivation and family reactions also need long term
results. In conclusion, as the study to investigate the effect
of Nintendo®Wii-Fit training with rotuine physiotherapy on
advance gross motor performance changes in children with
spastic hemiplegia, this study provided that may try to not
only routine pysiotherapy and exdrcises for advance gross
motor performance also add some reality program to in
physiotherapy program for locomotor rehabilitation and
ambulatory function.
Acknowledgements
The authors would like to thank the children who
participated in this study and their parents.
Conflict of Interest: None.
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