TITLE: Wii Fit balance training or progressive balance training in patients with
chronic stroke: a randomised controlled trial

  ABSTRACT:
[Purpose] The aim of this study was to compare the effects of Wii Fit balance training
(WBT) and progressive balance training (PBT) approaches on balance functions, balance
confidence, and activities of daily living in chronic stroke patients. [Subjects] A total
of 30 patients were randomized into the WBT (n=15) and PBT (n=15) groups. [Methods] All of
the subjects received exercise training based on a neurodevelopemental approach in
addition to either Wii Fit or progressive balance training for total of 1 hour a day, 3
days per week for 4 weeks. Primary measurements were static balance function measured with
a Wii Balance Board and dynamic balance function assessed with the Berg Balance Scale,
Timed Up and Go test, Dynamic Gait Index, and Functional Reach Test. Secondary measures
were balance confidence assessed with the Activities-specific Balance Confidence scale and
activities of daily living evaluated with the Frenchay Activity Index. [Results] There was
not remarkable difference between the two treatments in dynamic balance functions, balance
confidence, and activities of daily living. [Conclusion] Although both of the approaches
were found to be effective in improving the balance functions, balance confidence, and
activities of daily living, neither of them were more preferable than the other for the
treatment of balance in patients with chronic stroke.

BODY.INTRODUCTION:
World stroke incidence studies have shown that there has been a 42% decrease in stroke
incidence in high-income countries and more than a 100% increase in low-to middle-income
countries. Early stroke case fatality has decreased in both high-income and low-to
middle-income countries1). Despite the
increase in stroke incidence, the decrease in mortality rate leads to an increase in people
living with disabilities. Therefore, stroke constitutes the leading cause of serious,
complex, and long-term adult disability2, 3).  Although 15–30% of the stroke survivors become permanently disabled, 50–70% of stroke
patients regains functional independence and mostly regains walking ability4, 5).
Due to residual functional disabilities such as impaired balance and motor weakness,
patients with stroke may walk with an abnormal pattern. A study by Jorgensen et al. showed
that 73% stroke patients fell in the six months after a stroke, that 21% fell after 6
months, and that over half of all reported falls occurred during walking activities due to
problems such as loss of balance, misjudgement, and foot dragging6,7,8).  Balance deficits like reduced postural stability during quiet standing, delayed and less
coordinated responses to internal and external balance perturbations, and increased weight
bearing on the unaffected limb are one of the main risk factors for falls after stroke9,10,11). Together with the increased risk of
falling, fear of falling increases, self-confidence decreases, and individual autonomy and
participation in social activities reduces. Therefore, patients become more dependent on
caregivers, and as a result, quality of life decreases. The rehabilitation approaches aiming
to increase the balance functions of patients promotes reintegration into the community,
recreational and daily life activities, positive behavioral changes, and social acceptance
of the patients12, 13).  Balance rehabilitation programs after stroke were found to be effective in enhancing
functional recovery; on the other hand, the limited resources of health-care systems hamper
the implementation of intensive practice14, 15). Therefore, innovative rehabilitation
technologies including virtual reality systems are currently being used in stroke
rehabilitation mainly because they provide an enriched environment, task-specific goals, and
repetitive practice16, 17). These systems may decrease the amount of time spent for
one-to-one sessions with physiotherapists and may provide patients with the opportunity to
use the systems at home.  Currently, Nintendo Wii Fit, video game technology using virtual reality, has become a very
popular rehabilitation approach in balance treatment. In the Wii Fit games, patients are
directed to shift their weight anteriorly, posteriorly, and laterally within a center of
pressure (COP) range in order to reach a target and to enhance their limits of stability.
The Wii Fit games have been used in the literature due to their effects in improving motor
skills and postural control by using visual-perceptual systems, providing information about
the performance, showing the direction, speed and acceleration changes, and being
interactive, motivating, useful and cheap18,19,20).  Few studies have used the Wii Fit method for balance treatment in chronic stroke patients.
Two case report studies have demonstrated that static and dynamic balance can be improved
with the Wii Fit system in patients with stroke21,
22). In a previous randomized controlled
study in which standard rehabilitation plus virtual reality balance training with Wii Fit
was compared with standard rehabilitation only greater improvement was observed in dynamic
balance23). This may be because of the
disparity in the duration (length of session) and intensity (massed practice) of the
treatment in the two groups. Therefore, it was expecting that more improvement would be
obtained in the experimental group due to more intensive treatment. The aim of this study
was to compare the effectiveness of game technology based Wii Fit balance training (WBT) and
progressive balance training (PBT) in addition to a neurodevelopmental treatment program on
static and dynamic balance functions, activity specific balance confidence, and activities
of daily living in patients with chronic stroke.

BODY.SUBJECTS AND METHODS:
Individuals with stroke admitted to a physiotherapy and rehabilitation department over a
period of 12 months were considered for inclusion in this study. The study was approved by
the local Ethics Committee for Medical, Surgery and Drug Research (LUT 11/01), and written
informed consent was obtained from all patients prior to data collection.  Thirty-three patients with chronic stroke enrolled in the rehabilitation program. The
criterion for inclusion was first ever stroke with hemiparesis (≥ 6 months). Patients were
excluded if they had any other physical problem or epilepsy, moderate to severe cognitive
deficits as evaluated by the Mini Mental State Examination test (MMSE) (≤20 points), severe
depression as measured by the Beck Depression Inventory (BDI) (≥30 points), and were unable
to walk independently according to the Modified Rankin Scale (MRS) (> 3 points).
Participants were randomly allocated to one of two different treatment groups: PBT and WBT.
A simple randomization method was used to allocate patients in each group according to
registration number (even numbers, PBT group; odd numbers, WBT group). Figure 1Fig. 1.Study profile shows the patient profile for the study.  A neurodevelopmental treatment, a problem solving and analytical approach, was applied to
each group. The treatment programs were planned considering the functional level, individual
needs, and demands of the patients based on selective movement as a basis of functional
activity and successful goal acquisition24). The details of the NDT are given in Appendix 1. Patients assigned
to the WBT group received a 1 hour treatment program consisting of a 30-minute
neurodevelopmental training program and 30-minute Wii balance training program for a total
of 12 sessions, which were held 3 days a week for 4 weeks. The details of the WBT are given
in Appendix 2. Patients assigned to the PBT group received a 1 hour treatment program
consisting of a 30-minute neurodevelopmental training program and 30-minute progressive
balance training program for a total of 12 sessions, which were held 3 days a week for 4
weeks. The details of the PBT are given in Appendix 3.  The descriptive variables of the patients including age, gender, body mass index, duration
of stroke, and affected side were recorded before the treatment. All participants were
assessed at baseline (week 0), after the treatment (week 4), and one month post treatment
(week 8).  Primary measurements were static and dynamic balance function tests. The static balance,
that is the mediolateral weight distribution on the paretic and nonparetic extremities, was
measured with a Wii Balance Board (WBB), which has characteristics similar to
laboratory-based force platform (FP) systems that contain four transducers used to assess
weight distribution and COP25).  Dynamic balance was measured with four balance tests reflecting different aspects of
balance: the Berg Balance Scale, Timed Up and Go Test, Dynamic Gait Index, and Functional
Reach Test.  The Berg Balance Scale (BBS), which is a psychometrically sound measure of balance
impairment post stroke, was used to assess functional balance of the patients26, 27). The test is a 14-item objective measure used to assess the balance
performance of patients during functional tasks ranging from sitting to standing on one
foot28).  The Timed Up and Go Test (TUG) was used to measure the functional mobility level of the
patients. The time taken to complete the task (standing up from a chair, walking 3 meters,
turning around, walking back, and sitting down) was recorded in this test29, 30).  The Dynamic Gait Index (DGI), which assesses an individual's ability to modify balance
while walking in the presence of external demands, was used to assess balance and gait
ability of the patients31, 32).  The Functional Reach Test (FRT), which consists of measurement of the maximal distance one
can reach forward beyond arm's length while maintaining a fixed base of support in the
standing position, was used to measure the stability limits of the patients33).  The secondary measures were balance confidence and activities of daily living. The balance
confidence of the patients was measured with the Activities-specific Balance Confidence
(ABC) scale developed to measure the confidence of subjects when performing various
ambulatory activities without falling34).
The activities of daily living of the patients were evaluated with the Frenchay Activity
Index (FAI), which contains 3 factors (indoor domestic activities, outdoor domestic
activities and outdoor social activities) related to the self care and mobility of
patients35).  We calculated that the required sample size was 30 subjects for 90% power with a 5%
significance level. The results were analyzed with the SPSS 15.00 software program. The
variables are presented as the mean ± standard deviation (X ± SD). The differences within
groups were tested using the Wilcoxon signed-rank test, and those between groups were tested
using the Mann-Whitney nonparametric test. The Friedman test was used for repeated
measurements, and Bonferroni correction was used to assess changes in balance functions from
week 0 to week 8 between the groups. The 95% level of confidence (α = 0.05, or the margin of
error) was used for the assumptions to identify differences in the variance analysis.

BODY.RESULTS:
Forty patients were assessed during the study period. Of these, 33 patients were recruited
and randomly allocated into the WBT (n=17) and PBT (n=16) groups. Reasons for exclusions and
drop-outs are shown in the study profile (Fig. 1).
Fifteen patients in the PBT group and fifteen patients in the WBT group completed the 4-week
treatment program and the follow-up assessment at 8 weeks. Before treatment, there were no
significant differences between the WBT and PBT groups with respect to demographic
characteristics, mental state, and level of depression. However, disease severity measured
by the Modified Rankin Scale was found to be higher in the PBT group (Table 1Table 1.Demographical and physical characteristics of patientsWBT(n=15)(X±SD)PBT(n=15)(X±SD)GenderMale67Female98Affected sideRight87Left 78Age (years)Mean62.8056.60SD10.8716.42Body mass index (kg/m2)Mean29.1428.30SD4.524.56Duration (years)Mean3.704.23SD4.424.86Modified Rankin Scale (0–6)Mean1.802.40*SD0.770.82Mini Mental Test (0–30)Mean22.8622.26SD2.382.05Beck Depression Inventory (0–63)Mean14.0014.00SD6.147.58*p≤0.05).  The functional balance performance scores of the patients in the WBT group were higher for
the BBS and TUG tests performed before treatment (week 0). The results of the four different
functional balance tests (BBS, TUG, DGI, and FRT) showed that both groups improved
significantly after treatment (week 4). However, there was no significant difference between
the groups after treatment (week 4). The patients in the PBT group showed a significantly
lower results of the BBS and TUG tests in their follow-up measurements (week 8) (Table 2Table 2.Within-and between-group comparisons of all outcome measuresWeek 0X±SDWeek 4X±SDWeek 8X±SDWeek 0 vs. 4(Wilcoxon test)Week 4 vs. 8(Wilcoxon test)Weight distribution (%)WBTParetic44.04±7.4748.00±2.8046.64±4.40*Nonparetic55.88±7.4552.00±2.8053.36±4.41*PBTParetic 47.54±10.1648.59±8.3848.14±8.94Nonparetic52.46±10.1651.27±8.3651.86±8.94WBT vs PBT(Mann-Whitney U test) (Friedman test) BBS (0–56)WBT45.60±5.2650.33±4.0950.33±4.16*PBT39.60±9.3144.80±7.4844.20±7.77**WBT vs. PBT(Mann-Whitney U test)***(Friedman test)*TUG (sec)WBT 17.96±7.7716.17±8.2315.95±7.93*PBT26.36±11.6022.11±11.8822.73±11.95**WBT vs PBT(Mann-Whitney U test)*(Friedman test) *DGI (0–24)WBT14.86±4.1216.86±3.3516.86±3.33*PBT12.60±3.9614.46±3.4814.86±4.06*WBT vs. PBT(Mann-Whitney U test)(Friedman test) *FRT (cm)WBT 25.26±5.9229.40±5.1630.06±5.16*PBT24.20±6.6627.13±6.1926.80±6.58*WBT vs. PBT(Mann-Whitney U test) (Friedman test) *ASBCT (0–100)WBT 59.62±17.2668.36±17.2270.10±16.92*PBT53.10±17.4759.37±18.0859.04±18.27*WBT vs. PBT(Mann-Whitney U test) (Friedman test) *FAI (15–60)WBT 14.46±6.5416.26±7.1816.20±6.79*PBT10.40±6.5212.53±6.5813.26±7.37**WBT vs. PBT(Mann-Whitney U test)*(Friedman test) **Statistically significant values (p≤0.05) are indicated with an asterisk. BBS: Berg
Balance Scale; TUG: Timed Up and Go Test; DGI: Dynamic Gait Index; FRT: Functional
Reach Test; ASBCT: Activity Specific Balance Confidence Test; FAI: Frenchay Activity
Index).  Both groups showed significant improvement in terms of the balance confidence (ABC) scale
from baseline to after the treatment period (week 4). No significant difference was recorded
between the two groups after treatment (weeks 4 and 8) (Table 2).  The activities of daily living measured with the FAI were found to be increased in both
groups after treatment (week 4). When comparing the groups, no significant differences were
found between them after treatment (weeks 4 and 8). The results at follow-up showed that ADL
continued to improve in the PBT group despite cessation of treatment (week 8) (Table 2).

BODY.DISCUSSION:
The main objective of this study was to compare the effects of balance training with an
increasingly popular virtual reality based game technology, Nintendo Wii Fit (WBT), and
progressive balance training (PBT) on balance functions, activity specific balance
confidence, and activities of daily living in patients with chronic stroke. Although the two
approaches tend to be more effective on different parameters of functional balance measures,
there were no remarkable superiorities of either treatment approach over the other.  On the basis of the idea that visual feedback, which was used more intensely in the Wii Fit
group, would have additional effects on symmetrical weight bearing on the paretic and
nonparetic extremities36), the effects of
the two treatment approaches on symmetrical weight distribution were compared in our study.
Although the weight bearing on the paretic extremity was found to be improved and was more
symmetrical in the WBT group, no significant superiority of either treatment method over the
other was observed for the weight distribution of the patients. We speculate that the
results might be due to the baseline weight distribution of the patients in our study. The
average weight distribution of the patients on the nonparetic extremity at the beginning of
this study was relatively symmetrical (52–55%) compared with the values specified for stroke
patients in the literature (61–80%)11).
Moreover, the weight distribution was more symmetrical in the PBT group (52%) than in the
WBT group (55%); thus the effects of the treatment methods might not have emerged
exactly.  The balance exercises used in both treatment methods included weight shifting activities
closely related to static balance, i.e., the ability to maintain a chosen posture with
minimal postural sway10). These exercises
aims to improve postural control by increasing anteroposterior and mediolateral weight
transfer and reducing postural sway, but do not especially focus on improving dynamic
balance. As postural control is a prerequisite for most functional activities, weight
shifting exercises aimed at improving postural control, may have significant effects on
balance during functional activities. All of the functional balance measurements (BBS, TUG,
DGI, and FRT) applied to the patients for that purpose showed that functional performance
was improved in both groups. We supposed that training approaches emphasizing weight
shifting abilities, whether using visual feedback (WBT) or not (PBT), provides benefits to
both static and dynamic aspects of balance.  The measurements after 8 weeks showed that there was a decline in the BBS and TUG test
results in the PBT group. In a case-control report of Deutsch et al., two individuals in the
chronic phase post stroke received balance training with either a Nintendo Wii and Wii Fit
program or standard of care balance and mobility program for 12 training (60-minute) sessions, and it was found that the patient who received the standard
therapy maintained his improvements after treatment. It was propounded that the activities
used for the treatment (balance and coordination exercises and outdoor activities e.g.
crossing the road, walking in the busy areas, and market shopping) were transferred to real
life activities due to the similarity between them, and thus the patient had used these
activities after treatment22). Considering
the activities of the study mentioned above, we did not include outdoor activities in
addition to the balance exercises in our study; this may constitute a reason why the
improvements were not maintained after treatment in our study.  'Balance confidence', defined as the perceived ability or confidence to perform an activity
or action without falling37), was found in
our study to be improved in both groups after treatment. Bandura's theory identifies four
factors affecting self-efficacy, that is, one's belief in one's ability to succeed in
specific situations: performance accomplishments (physical practice), vicarious experience
(mental practice), verbal persuasion (encouragement), and emotional sources
(motivation)38). Associating these
factors with falls-related self-efficacy, it can be said that both the PBT and WBT
approaches may involve adequate physical practice, mental practice, encouragement, and
motivation, which lead to improved balance confidence in patients.  The results for activities of daily living results indicate that the patients in both
groups improved after treatment. In addition to this result, improvements in the PBT group
proceeded after the cessation of treatment (week 8). It is known that the Wii Fit balance
training method includes task-specific activities, though Wii Fit exercises are not very
similar to daily life activities in many ways. Patients may perceive the Wii Fit activities
as 'games', therefore, even though there are improvements in functional balance, these
activities do not contribute to the transfer of improvements to daily life activities. In a
further aspect, progressive balance training is more similar to daily life activities, and
patients may perceive PBT activities as 'training' rather than a 'games', therefore, PBT may
result in more improvement in patients' daily lives.  The limitations of this study include the fact that, the feedback given with Wii Fit may
not be sufficient for patients to use normal movement strategies; therefore,
physiotherapists should prevent abnormal patterns during activities. In another way, during
the Wii Fit training, the need for a physiotherapist to help with symmetrical weight
shifting poses a problem with respect to use of this technology at home. The main aim of
this study was to use Wii Fit technology in order to reduce the need for one-to-one
interaction between physiotherapist and patients; however, if there is a necessity for
physiotherapists to correct the abnormal patters used by patients, it should be questioned
whether this technology can be used at home or not. This study found that
physiotherapist-assisted Wii Fit balance training is an effective method, but there is a
need to compare the effects of Wii Fit balance training with and without any help from
physiotherapists in future studies. Another limitation of this study was the disease
severity, which was found to be higher in the PBT group. This limitation was due to the
randomization procedure; therefore it could not be eliminated.  Some studies have asserted that although there are beneficial effects of using Wii Fit in
rehabilitation, this technology may have some safety problems. Like the other commercial
game systems, the Wii Fit system is a 'black box'; thus various parameters of the system
cannot be controlled. In this sense, not being a rehabilitation-specific tool, being
difficult for people with physical problems, allowing the use of abnormal movement patterns,
having an incomprehensible scoring system, giving feedback that is not rehabilitation
specific, and making degrading comments sometimes are some problems preventing the Wii Fit
system from becoming widely used in rehabilitation22,
39). There are also reports of injuries
arising from the use of Nintendo Wii game systems (metacarpal and metatarsal fractures,
wrist and ankle traumas, clavicular fracture, patellar dislocation, muscle and tendon
injuries, C7 fracture, stroke, and hemothorax) in the literature40,41,42,43,44,45,46). In this sense, there were no negative effects and/or any
injuries attributable to use of Wii Fit in our study.  To our knowledge, this is the first study comparing the effectiveness of Wii Fit balance
training (WBT) and progressive balance training (PBT) in addition to neurodevelopmental
treatment approaches in patients with chronic stroke. The two treatment programs used in the
current study were both found to be effective on balance functions, activity-specific
balance confidence, and activities of daily living. When comparing the two treatment
approaches, they seem to be effective on different parameters of balance performance, with
no superiorities of either treatment approach over the other. Wii Fit balance treatment can
be used as an effective method for patients with difficulty accessing treatment or for
physiotherapists who require alternative methods of treatment.

Question: Compared to progressive balance training (PBT) what was the result of Wii Fit balance training (WBT) on activities of daily living measured with the FAI, week 4?
Evidence: Both groups showed significant improvement in terms of the balance confidence (ABC) scale
from baseline to after the treatment period (week 4). No significant difference was recorded
between the two groups after treatment (weeks 4 and 8) 
Answer: no significant difference