# Exercise as it relates to Disease/Nintendo Wii training as a method for improving postural balance and lower body strength in community-dwelling older adults

This wiki-book aims to critique the research study 'Efficacy of Nintendo Wii Training on Mechanical Leg Muscle Function and Postural Balance in Community-Dwelling Older Adults: A Randomized Controlled Trial' by Martin G. Jorgensen et al.
This article critique is conducted for assessment for the "Health, Disease and Exercise (8340)" unit at the University of Canberra.

## What is the background to this research?

Falls in older populations pose one of the greatest threats to overall health and the ability to perform activities of daily living. The performance of regular physical activity provides one of the greatest modes in prevention of falls due to the associated health benefits. As the physical activity guidelines in older adults are very similar to younger adults, many elderly struggle to achieve the recommended threshold. Biofeedback technology has shown to improve development of similar performance measures, and may enable this population to perform increased physical activity with greater improvements, reducing falls risks and subsequent injuries.
The aforementioned article aimed to address issues related to falls risk, i.e., lower body strength and postural balance, with the utilisation of biofeedback by means of a Nintendo Wii. This research provides an insight into a new mechanism for promoting physical activity in an older population, whilst providing an opportunity to build upon research aiming to address issues related to mortality and morbidity in older populations.

## Where is the research from?

The research team behind the study resides in Denmark, a country which provides largely free healthcare, and who’s population has more than 20% of individuals aged 65 and over. This information indicates an older population, providing insight into the prerequisite for this research. The researchers have no affiliation with the technology used in the project and should not in this way be subject to bias. Each member of the research team has an extensive investigative background, particularly Per Aagaard, with a focus on health as it relates to ageing.

## What kind of research was this?

The study was a randomised control trial, an experimental research method which allocates a population into either a control or intervention group at random. This research method provides the greatest ability to infer cause and effect relationships regarding the outcome of the experiment. This helps solidify the results of the study, which would not be possible when utilising a method such as a survey. The study was performed with the control group receiving a placebo via EVA insoles, and included observer-blinding, meaning the researchers did not know which group each individual was assigned to. This helps remove another possible ground for observer bias.

## What did the research involve?

* A total of 58 participants; 30 in the control group and 28 in the Wii group.
* An experimental period of 10 weeks.
* Participants recruited via newspapers, senior clubs and organisations.
* Participants required a poor to average self-reported balance and an age of 65 or above.
* The Wii group performed two sessions a week, each session totalling 70 minutes ±10 minutes, with two thirds of the session focusing on balance control, and one third of the session focused on lower body strength. Participants were able to pick the postural control exercise from five options, whereas the strength exercise was predetermined.
* The control group was told to wear EVA insoles for the entirety of the 10 weeks, with a phone check-up every three weeks to identify any concerns.

### Limitations

Although this study does measure appropriate performance measures in the Wii group, the efficacy of this training method in comparison to traditional strength and balance training for older adults cannot be concluded. Additionally, the short length of the study does not provide the opportunity to see the long-term effects of this training method, and if barriers to progression may surface. Finally, the sample size of 58 participants diminishes the study's generalisability, especially as the cohort chosen for this study were presumably quite healthy.

## What were the basic results?

The baseline for each group was much the same. The Wii group saw an 82% compliance rate, however, with some parts of the program missed. Despite this, the Wii group saw an improvement of leg press maximum voluntary contraction of 17%, as the control group saw a decrease of 1%. The measure for postural control, centre of pressure velocity moment, saw a decrease of 7% in the Wii group and 8% in the control group. Additionally, we also see a statistically significant between group improvement to the following testing parameters: rate of force development, the timed up and go test, the shortened Falls Efficacy Scale-International and the 30-s Chair Stand test.

### What did the researchers conclude?

The researcher's conclusions are fairly logical, promoting the use of this technology as a mode for increasing lower body strength in this population. Recognition of the lack of development for postural balance is also made. Despite no improvements to postural control, the post-experimental tests identified advancements in the Wii group, and some improvements in the control group. The researchers fail to acknowledge that the efficacy of this program in comparison to traditional training is not identified. The lack of improvement for postural balance in this cohort is hypothesised to be a result of ceiling effects, which seems plausible given the participants baseline.

## What conclusions can we take from this research?

This study provides evidence suggesting that biofeedback technology, such as the Wii, provides a great opportunity for promoting physical activity in this population. A common barrier to physical activity is motivation, and the use of the Wii allows for something that may seem monotonous to become more enjoyable. A literature review on the use of the Wii in older populations further expresses how biofeedback can be used to improve exercise motivation. This review does not provide information on lower body power and focuses on physical activity promotion and balance. A systematic review of the literature implies that this technology can improve postural balance, but its long term efficacy is still debatable. Regardless, these articles highlight the effectiveness of biofeedback, identifying that the Wii can be used for increasing the amount and quality of physical activity performed in this population.

## Practical advice

* The device used in this study did not result in any injuries or illnesses, deeming it safe for use in this population. Consequently, practitioners and caretakers should look to use the Wii and similar technologies such as virtual reality headsets to decrease sedentary behaviour in this population .
* The population in this study was healthy, as those with recent injury or illnesses were excluded. In populations with morbidities, the technology needs to be used with caution. However, literature indicates that this technology can provide effective methods of rehabilitation in other populations.
* Putting aside the contradictive findings, health practitioners should use the Wii and similar technologies as they show high compliance and motivation results, whilst remaining mindful of the potential ceiling effects of the technology.

## Further information/resources

* Top 10 Wii Games for Seniors:
* Games for a better life: effects of playing Wii games on the well-being of seniors in a long-term care facility.
* Physical activity and exercise guidelines for all Australians.

## References

* ↑ Jorgensen MG, Laessoe U, Hendriksen C, Nielsen OB, Aagaard P. Efficacy of Nintendo Wii training on mechanical leg muscle function and postural balance in community-dwelling older adults: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013 Jul;68(7):845-52. doi: 10.1093/gerona/gls222. Epub 2012 Oct 31. PMID: 23114461.
* ↑ Evan-Amos. The Wii console by Nintendo. Featured with the Wiimote. In: Wii-console.jpg, editor. WIkipedia WIkipedia Evan-Amos; 2010.
* ↑ Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: A review of the literature. Maturitas. 2013;75(1):51-61.
* ↑ Vogel T, Brechat P-H, Leprêtre P-M, Kaltenbach G, Berthel M, Lonsdorfer J. Health benefits of physical activity in older patients: a review. International Journal of Clinical Practice. 2009;63(2):303-20.
* ↑ Sparling PB, Howard BJ, Dunstan DW, Owen N. Recommendations for physical activity in older adults. BMJ : British Medical Journal. 2015;350(jan20 6):h100-h.
* ↑ Yip SL, Ng GY. Biofeedback supplementation to physiotherapy exercise programme for rehabilitation of patellofemoral pain syndrome: a randomized controlled pilot study. Clinical Rehabilitation. 2006;20(12):1050-7.
* ↑ Vrangbæk K. International Health Care System Profiles, Denmark The Commonwealth Fund: The Commonwealth Fund; 2020 [Available from: https://www.commonwealthfund.org/international-health-policy-center/countries/denmark.
* ↑ Department SR. Total population in Denmark from 2011 to 2021, by age group Statista: Statista; 2021 [Available from: https://www.statista.com/statistics/570654/total-population-in-denmark-by-age/.
* ↑ Aagaard P. Per Aagaard Personal Profile Southern Denmark University Website: Southern Denmark University; 2021 [Available from: https://portal.findresearcher.sdu.dk/en/persons/PAAgaard.
* ↑ Kendall JM. Designing a research project: randomised controlled trials and their principles. Emergency Medicine Journal. 2003;20(2):164-8.
* ↑ Hróbjartsson A, Thomsen ASS, Emanuelsson F, Tendal B, Hilden J, Boutron I, et al. Observer bias in randomised clinical trials with binary outcomes: systematic review of trials with both blinded and non-blinded outcome assessors. BMJ. 2012;344:e1119.
* ↑ Hoare E, Stavreski B, Jennings GL, Kingwell BA. Exploring Motivation and Barriers to Physical Activity among Active and Inactive Australian Adults. Sports. 2017;5(3):47.
* 1 2 Chao Y-Y, Scherer YK, Montgomery CA. Effects of Using Nintendo WiiTM Exergames in Older Adults: A Review of the Literature. Journal of Aging and Health. 2015;27(3):379-402. doi:10.1177/0898264314551171
* ↑ Alhasan H, Hood V, Mainwaring F. The effect of visual biofeedback on balance in elderly population: a systematic review. Clin Interv Aging. 2017;12:487-97.
* ↑ Bisson E, Contant B, Sveistrup H, Lajoie Y. Functional Balance and Dual-Task Reaction Times in Older Adults Are Improved by Virtual Reality and Biofeedback Training. CyberPsychology & Behavior. 2007;10(1):16-23.
* ↑ Gil-Gómez J-A, Lloréns R, Alcañiz M, Colomer C. Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: a pilot randomized clinical trial in patients with acquired brain injury. Journal of NeuroEngineering and Rehabilitation. 2011;8(1):30.
* ↑ P P. Old man tries VR googles. In: googles.jpg OmtV, editor. Szaradanet. Wikipedia: Przemek P; 2015.