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: miracsezer@yahoo.com 2 PT, PhD, Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Ankara. Email: takabayrak@yahoo.com * 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: mintaze@hacettepe.edu.tr 3 PT, MSc, Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Ankara, Turkey. Email: ozgemuezzinoglu@gmail.com 5PT, MSc, Eastern Mediterraean University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, North Cyprus, Turkey.Email: fztzehra@ymail.com 6PT, PhD Turgut Ozal University, School of Physical Therapy and Rehabilitation, Ankara, Turkey. Email: seda6585@gmail.com

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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