# Exercise as it relates to Disease/Does playing the Wii Fit video game assist the balance of children with Cerebral Palsy?

Article being critiqued: Effects of Nintendo Wii-Fit® video games on balance in children with mild cerebral palsy
https://doi.org/10.1111/ped.12942

## Contents

* 1What is the background to this research?
* 2Where is the research from?
* 3What kind of research was this?
* 4What did the research involve?
* 5What were the basic results?
* 6What conclusions can we take from this research?
* 7Practical advice
* 8Further information/resources
* 9References

## What is the background to this research?[edit | edit source]

A common motor disorder that impairs one's ability to move and maintain balance is cerebral palsy (CP). CP can develop before, during, or up to a year after birth when there is abnormal brain development or injury to the developing brain. It is regarded as a chronic illness and the most common cause of physical disability in children.
People with CP struggle with postural control, which makes activities like walking, reaching, gripping, and balance particularly challenging. Therefore, CP rehabilitation focuses on improving these from a young age. Clinicians have come up with many methods to do this, including neural development treatment (NDT), reactive balance training and interactive computer play (ICP).
ICP can be modified to provide balance training while simulating real-world situations using Virtual Reality (VR). It is used in rehabilitation to create a play environment where people can feel at ease and allows users and clinicians to monitor performance via a spacial representation on a screen. A small-scale study was conducted earlier using CP-diagnosed participants and VR play-based interventions and it pointed favourably towards the success of such rehabilitation methods.
The study conducted in "Effects of Nintendo Wii-Fit® video games on balance in children with mild cerebral palsy" takes this a step further, with a larger scale investigation undertaken comparing the effects of Nintendo Wii-Fit$^®$ balance-based video games and conventional balance training in children with mild CP. There is very little research into this, so the study assists the broadening of options for CP treatment.
It is critical that research into therapy methods continues because CP is currently incurable. The more that is understood about this illness, the simpler it will be to treat. The goal of rehabilitation is to increase the functionality and health of people with CP in order to improve their quality of life.

## Where is the research from?[edit | edit source]

The study was conducted by a team of researchers from the Faculty of Health Science at the Istanbul University, Turkey. It was published in the peer -reviewed International Journal of Pediatrics, which has an above average impact factor of 1.617. .
Three of the four authors have multiple publications in the journal. All authors declared no conflicts of interest in relation to the article.
The Clinical Research Ethics Committee at the Istanbul Faculty of Medicine approved the study. It complied with the standards set in the Declaration of Helsinki for medical research involving human beings.

## What kind of research was this?[edit | edit source]

This study involved a randomised controlled trial (RCT) with 30 CP-diagnosed ambulatory (able to walk) participants. Randomised studies conducted in controlled setting are regarded as a very effective technique to gauge an intervention's effectiveness.. Randomisation ensures participant characteristics are balanced and bias is reduced, while the controlled aspect allows outcomes to be directly attributed to the various interventions the groups were exposed to.

## What did the research involve?[edit | edit source]

30 children, aged 5 to 18, were divided into two groups for the study. One group, the "control" group, performed conventional balance. The other group used the Wii-Fit video game's balance board to improve their balance.
The CP patients were recruited from the pediatric neurology clinic of the Department of Pediatric Neurology, Faculty of Medicine of Istanbul University (where the researchers were based).
To be included as part of this trial there was specific selection criteria:
* Had to be diagnosed with CP
* Fitted in either level 1, 2 or 3 of the Gross Gross Motor Function Classification System (GMFCS)
* A score of less than 2 on the Modified Ashworth Scale
* A confirmed mental ability to be able to adapt to exercise
This could be considered a limiting factor, as the selection criteria narrows down the number of people this trial (and the subsequent results) applies to. The very small sample size (30 people only) also brings into question the validity of the study.
Each group performed a 12 week exercise program of either conventional balance training or Wii-Fit balance training on the board. Outcome measures of certain tests (balance, posture and muscle strength) were taken before and after the 12 weeks to assess the success of the programs. There were two sessions conducted per week for balance training. Each session was supervised by a physiotherapist who supported and motivated the patients throughout their time in the program.
The methodology used makes sense to assess the different outcomes that may occur based on training type. The main goal of research into rehabilitation methods for patients with CP is to figure out how to best improve balance and posture, which can be judged using appropriately chosen outcome measures. In this study, the assessments done before and after the exercise program would have given researchers a very solid idea of the success of each training type.

## What were the basic results?[edit | edit source]

According to the study's results, the WiiFit group improved more in the outcome measure tests after training than the control group did. Tests done using the WiiFit games also found that the group that trained on them scored higher then the group doing conventional training, but this could be attributed to the fact that they had practise on the games.
The researchers were very positive regarding the results of this study. They believed that while both groups showed improvements in balance and body control, the actual transfer of these skills ,from the WiiFit VR environment to real life was the key differentiator and possibly something that could be important to consider when conducting CP rehabilitation.
The small sample size is a limiting factor, but the researchers noted this. They were of the opinion that their trial results were of a significant enough difference between the groups to be used as the basis for a more longterm, larger-scale clinical trial to gain a better understanding of the effects of WiiFit training.

## What conclusions can we take from this research?[edit | edit source]

The main objective of CP rehabilitation is to improve walking and balance, and good postural control is essential to this. The findings of this study suggest that including WiiFit into rehabilitation programmes may lead to improvements in these areas. The WiiFit method benefits from the nature of ICP treatment, which makes it a more enjoyable form of rehabilitation for kids than conventional approaches.
A systematic review of the WiiFit balance training approach for CP therapy was conducted in 2021. Eleven RCTs were included (270 children) and the paper concluded that this approach to rehabilitation was viable, especially when incorporated with more traditional methods.

## Practical advice[edit | edit source]

Rehabilitation ought to begin as early as feasible in order to improve quality of life as CP patients become older. Although research is being conducted to learn ways to prevent CP, for now, the only option is treatment. This study, along with others, provides clinicians with another method for treating the CP patients they are responsible for. Given that WiiFit training looks to be quite beneficial, take into account including it into the care of these individuals.

## Further information/resources[edit | edit source]

For more CP information see below;
* https://worldcpday.org/
* https://www.cdc.gov/ncbddd/cp/features/cerebral-palsy-11-things.html
* https://cerebralpalsy.org.au/our-research/about-cerebral-palsy/what-is-cerebral-palsy/interventions/

## References[edit | edit source]

* 1 2 3 4 5 6 7 Tarakci, D. et al. (2016). 'Effects of Nintendo Wii-Fit® video games on balance in children with mild cerebral palsy'. Pediatrics international. 58(10): 1042–1050.
* ↑ Agarwal, A. and Verma, I. (2016).'Cerebral palsy in children: An overview'. Journal of Clinical Orthopaedics and Trauma. 3(2): 77-81.
* 1 2 Kerem Gunel, M. et al. (2016). 'Cerebral Palsy - Current Steps'. Intech.
* ↑ Dewar, R. Love, S. Johnston, LM. (2015). 'Exercise interventions improve postural control in children with cerebral palsy: A systematic review.' Dev. Med. Child Neurol. 57: 504–20.
* 1 2 Snider, L. Majnemer, A. Darsaklis, V. (2010). 'Virtual reality as a therapeutic modality for children with cerebral palsy.' Developmental Neurorehabilitation. 13(2): 120-128
* ↑ Reid, DT. (2002). 'Benefits of a virtual play rehabilitation environment for children with cerebral palsy on perceptions of self-efficacy: a pilot study'. Pediatric Rehabilitation. 5:3: 141-148.
* ↑ Richards, C. Malouin F. (2013). 'Cerebral palsy: definition, assessment and rehabilitation'. Handbook of Clinical Neurology. 183-195.
* ↑ WMA Declaration of Helsinki - Ethical Principles for Medical Research involving Human Subjects. Last amended 2013. World Medical Association.
* ↑ Hariton, E. and Locascio, J.J. (2018). 'Randomised controlled trials – the gold standard for effectiveness research.' BJOG: Int J Obstet Gy. 125: 1716-1716.
* ↑ Palisano et al. (1997). Dev Med Child Neurol. 39: 214-23.
* ↑ Harb, A. Kishner, S. (2022). Modified Ashworth Scale. Statpearls Publishing.
* 1 2 Faber, J. Fonseca, LM. (2014). 'How sample size influences research outcomes.' Dental Press J Orthod. 19(4): 27-9.
* ↑ Coster, WJ. (2013). Making the best match: selecting outcome measures for clinical trials and outcome studies. Am J Occup Ther. 67(2): 162-70.
* ↑ Montoro-Cárdenas, D. et. al. (2021). 'Nintendo Wii Balance Board therapy for postural control in children with cerebral palsy: a systematic review and meta-analysis'. Dev Med Child Neurol. 63: 1262-1275.
* ↑ Cerebral Palsy: Hope Through Research. Last updated 2022. National Institute Of Neurological Disorders And Stroke.