Wii Balance Boards: One is as good as another

Measurement study

Interchangeability of the Wii Balance Board for Bipedal Balance Assessment

Bonnechere, B., Jansen, B., Omelina, L., Rooze, M & Van Sint Jan, S.

JMIR Rehabilitation and Assistive Technologies 2015; 2(2):e8
DOI:10.2196/rehab3832

Link to full text: rehab.jmir.org/2015/2/e8

Objective: How well do different Wii Balance Boards compare with each other, and with laboratory force plate measurements?

Process: Six subjects used four (out of the box, uncalibrated) Wii Balance Boards three times each in order to compare the Wii Balance Boards with each other and a laboratory force plate.

Findings: Balance and posture measurements from Wii Balance Boards did not differ significantly from one to another. The Balance Boards each compare very well to the laboratory force plate. Multi-site studies and use of larger populations can be accessed for research.

Wii Fit improves GMFCS 3 motor skills

RCT

Effects of interactive games on motor performance in children with cerebral palsy

AlSaif, A. A.& Alsenany, S.

Journal of Physical Therapy Science 27: 2001-2003, 2015

Link to full text: www.ncbi.nlm.nih.gov/pmc/articles/PMC4500030/

Objective: For children with cerebral palsy, what is the effect of training with Nintendo Wii on motor performance compared with no training?

Method: 40 6-to-10 year old children GMFCS 3 were randomly divided into a ‘no training’ group and a group that received game time at home for 20 minutes a day for 12 weeks. Subjects had a lower limb muscle power of no less than grade 4 and no fixed lower limb contractures.

Findings: Outcome measures used were the Movement Assessment Battery for Children-2 (mABC-2) manual dexterity, ball skills of aiming and catching and balance; Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) upper limb co-ordination (subtest 5:6), and the one-minute walk test. Significant results were found before and after the intervention between groups and within the treatment group, but not within the control group.

Video Games Through Therapist’s Eyes

Qualitative Research Report

Integrating Virtual Reality Video Games into Practice: Clinician’s Experiences
Levac, D. E. & Miller, P. A.
Physiotherapy Theory and Practice, 29(7) 504-512, 2013
DOI: 10.3109/09593985.2012.762078

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/23362843

Objective: Physical therapists report on using Wii video games with children with brain injuries.

Process: Six physical therapists were interviewed. Two themes arose "technology meets clinical practice", and "onus is on the therapist".

Outcome: There are benefits and challenges where technology meets clinical practice that call on the therapist to be committed to the technology to implement it successfully. "There is a substantial need for knowledge translation initiatives for clinicians in this area".

Patterns of Home Gameplay

Observational Study

Do people with intellectual disability use Nntendo Wii when placed in their home as part of a physitherapy program? An observational study.
Chung, A. M. J., Harvey, L. A, & Hassett, L. M.
Disability and Rehabilitation Assistive Techology Early online 1 – 6
DOI: 10.3109/17483107.2014.938705

Link to abstract www.ncbi.nlm.nih.gov/pubmed/25052846

Objective: In people with intellectual disability, how much Nintendo is played when prescribed as home physiotherapy?

Method: 20 participants with intellectual disability, average age 19, were receiving home-based physiotherapy. They were assigned Wii play for 12 weeks as an effective part of their therapy intervention. Participants or their carers recorded data biweekly. It is unknown whether or not the participants were encouraged to play by their carers or physiotherapists.

Findings: Weeks one and two recorded a median value of 100minuntes a week of play over a median of three days per week; in weeks 11 and 12, a median value of 35 muinutes of play once per week. Note: Averages were not available in the published data.

Kids Report on Active Videogames at Home

Qualitative Report

Real life active gaming practices of 7 – 11 year old children
Allsop, S., Rumbold, P.L.S., Debuse, D. & Dodd-Reynolds, C.
Games for Health Journal, 2(6), 2013 pp. 347 - 353
DOI: 10.1089/g4h.2013.0050

Link to abstract

Objective: to determine real life behaviors during children’s active videogame play.

Method: 40 questionnaires were returned from 7-11 year old children and their parents.

Findings: of this sample, most children play Wii Sports for around 80 minutes once or twice a week. More than half the children ate or drank during game play and this extended game play. Most perceive active videogaming as “an alternative form of exercise, and the main reasons for active videogame play included for entertainment, health benefits and the environment.”

Wii for UE for CP hemiplegia

Upper limb training using Wii Sports Resort for Children with Hemiplegic Cerebral Palsy: a Randomized, Single-blind Trial
Chiu, HC., Ada, L. & Lee, HM. Clinical Rehabilitation, 2014, May 21
DOI: 10.1177/0269215514533709

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/24849793

Objective: For children with cerebral palsy, are there sustainable gains from a six-week home trial of Wii vs. traditional therapy?

Method: 62 children 6 – 13 years old (GMFCS levels I – V) played Wii bowling, air sports, frisbee and basketball at home 3 times weekly for 6 weeks. In addition all children received traditional therapy 3 times weekly. Participation, coordination, strength and hand function were measured at baseline, 6 and 12 weeks.

Results: Overall, the children completed 96% of all home-based Wii sessions and increased their Wii scores on all games through the test period. There were no differences in coordination or hand function noted. An increase in grip strength between the experimental and control groups was shown at 12 weeks. This may be related to the forced use of the children’s affected hand and arm. Anecdotes from caregivers report new hand movements and increased functional movements.

VR on UE in Children with CP: Meta-analysis

Effect of Virtual Reality on Upper Extremity Function in Children with Cerebral Palsy: A Meta-analysis
Chen, Y-P., Lee, S-Y. & Howard A.M. Pediatric Physical Therapy 2014:00 1 - 12
DOI: 10.1097/PEP.0000000000000046

Link to abstract:
www.ncbi.nlm.nih.gov/pubmed/24819682

Purpose: To systematically examine studies that consider the effect of active video games, virtual reality and robot therapy (VR) on improving upper extremity motor function in children with CP.

Method: A considered search strategy was used to include 14 research articles. A scoring system was used for the 3 RCTs, for 10 case series and one cohort study; a level of evidence was assigned to each based on the Oxford Centre for Evidence Based Medicine rating system.

Results: The RCT studies compared VR to traditional therapy, and the case series compared children before and after VR interventions. 5 studies were based on commercially available systems: Wii (1), Sony EyeToy Play (1), Gesturetek (3); the rest were experimental, custom engineered systems (7) or robot assisted interventions (2). The meta-analysis reports the 3 RCTs showed effectiveness for VR vs. traditional therapy, and ‘at least one positive change in one outcome measure in all the case series’. No relationship was seen between effectiveness and intervention length, duration, or frequency. Engineer-built experimental systems are found to be more effective than commercial systems. Commercially available active video games do not meet children’s needs as they cannot be adjusted individually to the child. Overall, the evidence was poor to fair. This meta-analysis makes no conclusive recommendations.

Wii balance board for rehabilitation

Review

Using the Wii Fit as a tool for balance assessment and neurorehabilitation: the first half decade of “Wii-search”

Goble, D. J., Cone, B. L. & Fling, B. W., Journal of Neuroeng Rehabil. 2014; 11:12

DOI: 10.1186/1743-0003-11-12

Link to full text article: www.jneuroengrehab.com/content/11/1/12

Objective: to review the Wii balance board controller (WBB) as a balance force platform measurement tool and as a neurorehabilitation intervention.

Process: WBB was compared with a scientific grade balance platform.

A literature search for “Wii Fit system or WBB for the assessment or training of balance ability” resulted in 11 papers that “trained balance in healthy adults” and 8 papers “that rehabilitated balance in clinical populations”; these were reviewed.

Outcomes: Custom applications have potential to provide low-cost ways to assess balance. Wii research using custom software is “an extremely promising area of exploration”. Research using Wii metrics for measuring balance is “far less convincing to date”. There is little correlation between Wii outcomes and clinical balance tests.

Wii is a motivating tool that typically generates improvements in balance. More robust research is required for the Wii Fit system as a balance intervention.

Balance measurement: Wii vs. BOT-2

Instrument Assessment

Evaluating the Nintendo Wii for Assessing Return to Activity Readiness in Youth with Mild Traumatic Brain Injury

DeMatteo, C., Greenspoon, D., Levac, D., Harper, J. A. & Rubinoff, M., Physical and Occupational Therapy in Pediatrics, Early online 1-16 2014-02-26

doi: 10-3109/01942638.2014.855103>/p>

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/24547689

Intent: “Post-injury assessments that challenge activity tolerance and balance are needed to determine readiness return to activity.” The maximal exertion and a count of loss-of-balance instances while playing Wii is compared to balance measures within Bruininks – Oseretsky Test of Motor Proficiency 2 ed. and the Community Balance and Mobility Scale.

Process: 24- 9 to 18 year olds who had experienced mild traumatic brain injury within the past year played a suite of Wii games one time. Losses of balance requiring a protective response were counted during game play and exertion as measured by heart rate, respiration rate and calorie expenditure.

Results: The technique of counting losses of balance during game play did not prove to be a useful assessment of balance and did not correlate with balance measures in BOT-2 and CBM. Of 6 games played, maximal exertion was generated by “Wii Fit Basic Run”.

A new video game assessment tool?

Instrument Development

Development and Use of an Observation Tool for Active Video Gaming and Movement (OTAGM) to Measure Children’s Movement Skill Components During Active Video Game Play

Rosa, R.L., Ridgers, N.D. & Barnett, L.M. in Perceptual and Motor Skills 117:3 (2013) 935-949

doi: 10.2466/03.25.PMS.117x28z4

Link to abstract amsciepub.com/doi/abs/10.2466/03.25.PMS.117x28z4

Objective: There is a growing interest in usefulness of active video games (AVG) for improving movement skills for children with CP. The Observation Tool of Active Gaming and Movement (OTAGM) is an observational tool for movement skills during AVG play. It aims to “capture and quantify specific skill components of children’s movement skills” during free play of AVG. The OTAGM was developed from the Test of Gross Motor Development-2ed (TGMD-2) with a subset of items that mesh with Nintendo Wii game offerings: strike, throw and roll. Specific components of movement skills are coded as well as task engagement, coded as ON/OFF; and body movement, further categorized as stationary-no movement, stationary-some movement, arm movement, leg movement, whole body movement.

This article reports on development, pilot testing and within-rater reliability of the measurement tool.

Process: 18 typically developing children 5 – 8 y/o played Nintendo one hour a week for six weeks. During play, 55-10 minute observations were coded. One child was videotaped for rating after a ten day interval.

Results: The tool needs to have further clarification between categories. Within-rater reliability was at least 83% across all categories. The usefulness of this tool will grow as it is tested in differently-abled populations and as it is able to report typical changes in the motor skills of children with CP.

What make up good video game interventions?

Scoping review

Defining the active ingredients of interactive computer play interventions for children with neuromotor impairments: A scoping review.

Levac, D., Rivard, L. & Missiuna C. in Research in Developmental Disabilities 33 (2012) 214 – 223

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/22093667

Scoping reviews summarize research activity in an area of health evidence to clarify concepts, disseminate information or identify gaps; typically without evaluating the strength of the studies, and often in emerging areas where there is little RCT-based evidence.

Objective: “New rehabilitation interventions are often evaluated in research and incorporated into practice without a clear understanding of their active ingredients.” The authors focus on the components of video game interventions that may affect motor performance in children with neuromotor impairments.

Process: A literature search based on the kernels ‘interactive computer play’ and ‘intervention’ resulted in 23 articles, and led to a thematic analysis explicitly and implicitly linking intervention components with outcomes.

Results: Themes that emerged…

• Video game properties: opportunities for practice, similarity of tasks to real-world movements , adaptability for individuals, feedback, social play.
• Outcomes for the user: neuroplastic changes, problem-solving & motivation due to competition and game characteristics.
• Therapist role as support person.

Video games are an emerging technology applied to rehabilitation. Identifying the components of video games that may contribute to outcomes is a step on the way.

Wii for balance. Does it transfer?

Design: Randomized controlled trial
Effect of Wii-intervention on balance of children with poor motor performance
Mombarg, R., Jelsma, D. & Hartman, E. Research in Developmental Disabilities, 34 (2013) 2996-3003

Link to abstract

Objective: What is the effect of Wii training on balance in children with motor delay? Does a training effect transfer to other activities?

Method: 30 children aged 7 – 12 with balance problems (as determined by falling below the 16th percentile on the total and balance scores on the Movement Assessment Battery for children - 2) were recruited and randomized into Wii and control groups. All performed pre- and post-tests of the MABC2 and Bruininks-Oseretsky test of motor proficiency -2 (balance, running speed and agility items). The Wii group exercised with the Wii for 30 minutes three times weekly for 6 weeks. The control group had no intervention.

Results: Pre- and post-test scores of Wii group and control group were compared. A “small to medium” intervention effect was found for balance across the Wii and control groups. No intervention effect was apparent in the transfer of skills from Wii balance games to running speed and agility tasks.

Exercise works for all

Design: Cross-sectional study
Evaluating exercise intensity levels in children with cerebral palsy playing the Wii Robert, M., Ballaz, L., Hart, R & Lemay, M, Physical Therapy, Early online, April 11, 2013 DOI: 10.2.2522/ptj.20120204

Link to abstract: http://www.ncbi.nlm.nih.gov/pubmed/23580626

Objective: Measuring the difference in exercise intensity of children with cerebral palsy compared with typically developing children playing the Wii Fit.

Method: Ten 7-to-12 year old children with spastic diplegic cerebral palsy (GMFCS I or II) were matched with 10 typically developing children. All children played one session of four Wii Fit (lower-extremity focused) games of 10 minutes duration. Heart rate was measured and exercise intensity was measured as percent of heart rate reserve.

Results: No difference was observed between groups for time spent at an intensity of > 40% of heart rate reserve across all games.

Is Wii better than standard balance therapy?

Single-subject research

Wii-habilitation as balance therapy for children with acquired brain injury

Tatla, S. K., Radomski, A., Cheung, J., Maron, M. & Jarus, T. Developmental Neurorehabilitation, 2012, 1 – 15, Early Online

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/23231377

Objective: Comparing Nintendo Wii balance therapy to standard therapeutic balance activities for change in balance, motivation and functional ability in children during brain injury rehabilitation.

Method: Single subject testing occurred over four weeks. Three subjects were randomly assigned to one of several protocols that provided standard therapeutic balance activities (baseline) either following or preceding Wii balance activities. Each condition was delivered as a 30-minute therapy, five times a week. Balance was measured with the Timed Up and Go (TUG) test, the Modified Functional Reach Test (MFRT) and the Wii-Fit balance board; motivation by the use of the Pediatric Motivation Scale, and functional abilities with the Pediatric Evaluation of Disability Index (PEDI).

Findings: Dynamic balance improved for all participants regardless of whether baseline followed or preceded Wii balance therapy and static balance results were inconclusive. Balance activities were equally motivating for 2 of 3 subjects and Wii balance activities were more motivating for one. Functional ability improved for all participants regardless of whether baseline followed or preceded Wii balance therapy.

Towards a core set of gaming outcomes

Gaming supports youth with acquired brain injury? A pilot study

de Kloet, A. J., Berger, M. A., Verhoeven, I. M., van Stein Callenfels, K., & Vliet Vleiland, T. P. Brain Injury, 2012, May 25, 1 – 9, Early Online

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/22632604

Objective: Do children and young adults with brain injury benefit from Nintendo Wii sessions?

Method: Fifty 6 – 29 year olds with acquired brain injury were required to independently play at least two hours of Wii games weekly for 12 weeks. Participants were interviewed to help self-identify three limitations to activities of daily living; three Nintendo games were matched to individual’s interests and limitations via a protocol called “TherapyWii”, available at www.TherapyWii.nl

Participants were assessed before and after the intervention. The Children’s Assessment of Participation and Enjoyment (CAPE), the Amsterdam Neurological Tasks (ANT), Goal Attainment Scaling (GAS), Pediatric Quality-of-Life Inventory (PedsQL) were used.

Findings: Two thirds of the participants reported improvement towards their self-identified goals, mostly in gross motor performance and information processing. Significant changes were seen in the level of physical activity (CAPE), speed of processing information, attention, response inhibition, and visual-motor coordination (ANT). No difference was seen for PedsQL.

The authors make a call for a core set of outcomes for studies of virtual reality and interactive video gaming in patients with brain injury. This study “substantiates the potential benefits of gaming in patients with ABI”.

Measured family-supported Wii use

Case report
Berg, P., Becker, T., Martian, A., Primrose, K. D. & Wingen, J.
Motor control outcomes following Nintendo wii use by a child with down syndrome. Pediatric Physical Therapy 2012 Spring;42(1):78-84

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/22207475

The benefit of this study is that it is well documented and easily reproduced.

Objective: A child with Down Syndrome plays family-supported Wii for eight weeks, tested before and after to compare motor and self-efficacy outcomes.

Process: An 11-year-old boy, eldest of three siblings had minimal prior exposure to the Wii. Family members were encouraged to participate in the suite of four games the boy chose. He was encouraged to play for at least 20 minutes at a time, four times a week for eight weeks. Outcome measures assessed change in activity and body structure and function, and included measures of strength, agility, coordination, balance, visual perceptual skills and body composition. The tests administered were the Test of Visual Perceptual Skills (TVPS), Self-Perception Profile for Children (SPPC), Perceived Physical Ability Scale (PPSA), Bruininks-Oseretsky Test of Motor Proficiency (BOT-2), Biodex BioSway Balance System, and the BodyStat Quadscan 4000.

Findings: The results show positive significant changes in BOT-2 scores for balance, manual dexterity, and running speed and dexterity across the 4 games. Postural stability and limits of stability were improved (undeclared significance) according to balance system data.

Realistic and adapted movements in play

Research article
Berry T, Howcroft J, Klejman S, Fehlings D, Wright V, Biddiss, E. (2011)
Variations in Movement Patterns during Active Video Game Play in Children with Cerebral Palsy. J Bioengineer & Biomedical Sci S1:001. doi:10.4172/2155-9538. S1-001

Link to article: www.omicsonline.org/2155-9538/2155-9538-S1-001.php

Objective:
Low-cost active video games (AVG) such as Ninteno Wii® are popular physical therapy tools for children with cerebral palsy. While not specifically designed to match rehabilitation goals, various studies have found clinically-relevant improvements in functional motor ability. The games reward realistic movements involving more proximal joints and bilateral upper extremity use but play can also proceed with adapted, more conservative movements of distal joints.

This study investigates play styles of three Nintendo Wii® games; boxing, bowling and tennis for realistic movement patterns related to the real-world activity and variations of adapted movement patterns.

Method:
A purposive sample of 16 children with GMFCS level I hemi- or diplegic cerebral palsy played each of three Wii® games. One minute of play was captured and analyzed as realistic or adapted movement.

Findings:
Game play was either realistic or adapted depending on the game and the child. Wii® bowling was performed more realistically, tennis and boxing less so. Children adapted their play style to succeed at the games, favouring their dominant arm in bilateral activities. Therapists need to encourage children to play realistically to derive the most therapeutic benefits from video game playing.

Wii Balance Board vs. Force Plate

Research paper: Validity and Reliability of the Nintendo Wii Balance Board for assessment of standing posture

Clark, R. A., Bryant, A. L., Pua, Y., McCrory, P., Bennell, K. & Hunt, M. (2010). Published in:
Gait & Posture 31 pp.307-310

Link to abstract: ncbi.nlm.nih.gov/pubmed/20005112

Objective: The Nintendo Wii Balance Board has the ability to inexpensively measure standing balance. In clinical settings where the Wii is used as a rehabilitation tool, measuring improvement in standing balance becomes an asset to the therapist for tracking rehabilitation gains.

This paper demonstrates the Balance Board’s equivalence to the ‘gold standard’ of a force plate to assess standing balance. Thirty able-bodied subjects with an average age of 23.7 years, stood on both devices with one or two legs and eyes open or closed. Subjects were tested on these four conditions twice; at least one day and not more than 14 days apart. Testing device and order of balance tasks was randomly assigned. The outcome measure used in this study is the length of the center of pressure (COP) path, known to be a valid and reliable measure of standing balance.

Findings: Comparison of COP path lengths across the Balance Board and the force plate for the four test conditions show good to excellent reliability within and across the two devices, and the Balance Board “possesses concurrent validity with a laboratory-grade force plate.”

Less expensive than force plates, the Wii is now often found in clinical settings. In addition to being popular with therapists and children, providing a way to measure change and give therapists quantitative data gives the Wii extra value.

Wii are not alone: games with motion control interfaces

Although Wii has captured the early market for low cost interactive games, other game systems are coming. Microsoft’s Xbox Kinect allows full body controller-free gaming, due to launch in November. Sony PS3 Move is played with a handheld motion controller and is due to launch on September 17.

Pc world: Playstation Move vs. Kinect
www.pcworld.com/article/199305/kinect_for_xbox_360_vs_playstation_move.html

Msnbc: Xbox (Kinect) vs. Wii vs. PS3 (Move)
www.msnbc.msn.com/id/37911691/ns/technology_and_science-games/

Pc mag: Kinect vs. Move vs. Wii
www.pcworld.idg.com.au/article/356395/kinect_vs_move_vs_wii_/

XBox Kinect official site
www.xbox.com/en-CA/kinect

Wikipedia: Kinect
en.wikipedia.org/wiki/Kinect

CBC article: Kinect
www.cbc.ca/technology/story/2010/06/14/microsoft-xbox-kinect-video-games.html

Engadget: Kinect game descriptions
www.engadget.com/2010/06/13/microsoft-kinect-gets-official/

Cnet: Kinect review
reviews.cnet.com/8301-21539_7-20007681-10391702.html

Sony PS3 Move official site
us.playstation.com/ps3/playstation-move/

Wikipedia: Move
en.wikipedia.org/wiki/PlayStation_Move

Cnet: Move
news.cnet.com/8301-13772_3-10467340-52.html

Medgadget: Dr. Richard Marks, inventor of Sony Eyetoy, talks about Move
medgadget.com/archives/2010/06/games_for_health_2010_interview_with_ps3_move_creator_dr_richard_marks.html

Pc world: Move
www.pcworld.com/article/203652/sonys_ps3_move_bundle_costs_more_and_less_than_you_think.html

Search Youtube for videos
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Sony PS3 Move
www.youtube.com/results?search_query=sony+move&aq=f

Xbox Kinect
www.youtube.com/results?search_query=kinect&aq=f

Wii
www.youtube.com/results?search_query=wii&aq=f