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Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review
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JINJ-5868; No. of Pages 6 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Review
Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review Jessica Ruff, Tiffany L. Wang, Catherine C. Quatman-Yates, Laura S. Phieffer, Carmen E. Quatman * Department of Orthopaedics The Ohio State University Wexner Medical Center 725 Prior Hall, Columbus, OH 43201, United States of America
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 April 2014 Received in revised form 22 August 2014 Accepted 30 August 2014
Introduction: Commercially available gaming systems (CAGS) such as the Wii Balance Board (WBB) and Microsoft Xbox with Kinect (Xbox Kinect) are increasingly used as balance training and rehabilitation tools. The purpose of this review was to answer the question, ‘‘Are commercially available gaming systems valid and reliable instruments for use as clinical diagnostic and functional assessment tools in orthopaedic settings?’’ and provide a summary of relevant studies, identify their strengths and weaknesses, and generate conclusions regarding general validity/reliability of WBB and Xbox Kinect in orthopaedics. Materials and methods: A systematic search was performed using MEDLINE (1996–2013) and Scopus (1996–2013). Inclusion criteria were minimum of 5 subjects, full manuscript provided in English or translated, and studies incorporating investigation of CAG measurement properties. Exclusion criteria included reviews, systematic reviews, summary/clinical commentaries, or case studies; conference proceedings/presentations; cadaveric studies; studies of non-reversible, non-orthopaedic-related musculoskeletal disease; non-human trials; and therapeutic studies not reporting comparative evaluation to already established functional assessment criteria. All studies meeting inclusion and exclusion criteria were appraised for quality by two independent reviewers. Evidence levels (I–V) were assigned to each study based on established methodological criteria. Results: 3 Level II, 7 level III, and 1 Level IV studies met inclusion criteria and provided information related to the use of the WBB and Xbox Kinect as clinical assessment tools in the field of orthopaedics. Studies have used the WBB in a variety of clinical applications, including the measurement of center of pressure (COP), measurement of medial-to-lateral (M/L) or anterior-to-posterior (A/P) symmetry, assessment anatomic landmark positioning, and assessment of fall risk. However, no uniform protocols or outcomes were used to evaluate the quality of the WBB as a clinical assessment tool; therefore a wide range of sensitivities, specificities, accuracies, and validities were reported. Conclusion: Currently it is not possible to make a universal generalization about the clinical utility of CAGS in the field of orthopaedics. However, there is evidence to support using the WBB and the Xbox Kinect as tools to obtain reliable and valid COP measurements. The Wii Fit Game may specifically provide reliable and valid measurements for predicting fall risk. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Clinical assessment Gaming tools Orthopaedics Wii Kinect Balance Falls
Contents Introduction . . . . . . . . . Materials and methods Results . . . . . . . . . . . . . Discussion . . . . . . . . . . Conflicts of Interest . . . References . . . . . . . . . .
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* Corresponding author. Tel.: +1 614 293 2165; fax: +1 614 293 4755. E-mail address: [email protected] (C.E. Quatman). http://dx.doi.org/10.1016/j.injury.2014.08.047 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ruff J, et al. Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.08.047
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Introduction The Affordable Health Care Act emphasizes improvement in the quality and efficiency of health care, the development of innovative medical therapies, and the prevention of chronic disease [1]. As a result, the field of orthopaedics faces new socioeconomic pressures to develop and utilize evidence-based clinical tools that predict, monitor, and assess patient outcomes after musculoskeletal injuries. It is paramount that these clinical tools demonstrate clinical utility, cost-effectiveness, as well as high accuracy and reliability. As a result, the orthopaedic trauma community is now faced with the challenge to identify inexpensive, non-invasive, portable, clinician-friendly assessment tools that can be used to assess and predict clinical outcomes for orthopaedic patients. In order to meet these quality and efficiency standards, identification of technology that is commercially available offers high potential for adopting tools that can objectively assess functional capabilities in orthopaedic patients. Commercially available gaming systems (CAGS) may serve as relatively inexpensive, clinician friendly tools to assess objective functional measures in patients and their functional outcomes. Many of these devices for example, the Nintendo Wii with Balance Board (WBB; Fig. 1) and the Microsoft Xbox with Kinect (Xbox Kinect; Fig. 2), incorporate several technological options such as integrated accelerometer technologies, infrared detection, and movement tracking into their consoles. The appeal of the WBB and Xbox Kinect, in particular, is that they are portable, user-friendly, and significantly cheaper than the research-grade technologies that incorporate similar features. They also include a number of options for balance and motion training programs that can be used to assess postural control and the general quality of motion while performing various movement tasks. These tools even offer the capability of providing affordable therapeutic training protocols that could be used by both patients and clinicians to track the progress of objective functional measures during rehabilitation stages. A number of studies in the literature utilize CAGS in various orthopaedic applications. However, there remains a lack of synthesis of the findings of these studies. Consequently, there is not a clear understanding of the measurement properties and clinical utility of these devices. The purpose of this systematic review was to answer the following question: ‘‘Are commercially available gaming systems valid and reliable instruments for use as clinical diagnostic and functional assessment tools in orthopaedic settings?’’ Specific objectives for this review were to provide a descriptive summary of relevant studies and to generate conclusions regarding the general validity and reliability of CAGS in the field of orthopaedics. Materials and methods The methodological approach for this systematic review was modelled after the methods outlined by Harris et al. [2] Systematic searches using PubMed MEDLINE (from 1966) and SCOPUS (from 1996) were performed July 2013. Systematic searches of the electronic databases were designed using keywords to capture all literature relevant to the use of CAGS in orthopaedics, rehabilitation, and various other clinical settings. The electronic database searches were performed with keyword terms including ‘‘‘‘Wii,’’ ‘‘kinect,’’ ‘‘ebavir,’’ ‘‘game console,’’ ‘‘exergames,’’ ‘‘Wiihabilitation,’’ ‘‘computer assisted therapy,’’ ‘‘postural sway,’’ ‘‘therapy,’’ ‘‘stability,’’ ‘‘strength,’’ ‘‘rehabilitation,’’ ‘‘orthopaedic,’’ ‘‘orthopaedic,’’ ‘‘elderly 1,’’ ‘‘computer assisted rehabilitation.’’ The relatively 1
Elderly was used as an OR search term so as not to screen out articles.
Fig. 1. Wii Balance Board in Use.
broad search criteria identified any published relevant studies to maximize the generalizability of this review. The search was supplemented with a review of the bibliographies of the retrieved articles, personal correspondence with authors of retrieved articles, and hand search of pertinent journals to identify any additional studies addressing this topic of interest. The retrieved articles were screened and reviewed by two independent reviewers to identify articles that aligned with the following inclusion criteria: (1) a minimum of 5 subjects, (2) a full manuscript was provided in English or translated to English, and (3) the study incorporated an investigation of the measurement properties of CAGS that could be used for orthopaedic-related diagnostic and functional assessments. Exclusion criteria for articles included: (1) articles classified as review, systematic reviews, summary/clinical commentary, or case studies, (2) conference proceedings/presentations, (3) studies with cadaveric specimens, (4) studies focusing on non-reversible, non-orthopaedic-related musculoskeletal disease (i.e., stroke, Parkinson’s disease, etc.), and (5)therapeutic studies that did not report comparative evaluation to already established functional assessment criteria. All studies meeting inclusion and exclusion criteria were appraised for quality by two independent reviewers. Evidence levels (I–V) were assigned to each study based on the methodological criteria listed in the American Academy of Orthopedic Surgeons primer on evidence-based medicine. When there was a disagreement between the two independent reviewers, a third reviewer was utilized to reconcile these differences. Level I studies included high-quality randomized control trials (RCTs) for
Please cite this article in press as: Ruff J, et al. Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.08.047
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Fig. 2. Xbox Kinect in Use.
therapeutic studies, high-quality prospective studies, or comparisons of current diagnostic criteria against a gold standard. Level II studies included non-blinded RCTs for therapeutic studies, retrospective prognostic studies, or featured developing diagnostic criteria against a gold standard. Level III studies included casecontrol studies for therapeutic studies or prognostic studies, or diagnostic studies in which the diagnostic criteria under investigation were not compared to a gold standard. Level IV studies included case series for therapeutic and prognostic studies, and case-control studies for diagnostic studies. Level V studies included expert opinions expressed rather than studies conducted. Results The initial search yielded 1155 articles related to the use of CAGS in medicine (Fig. 3). Following removal of duplicate articles, 1050 articles remained. Review of the full text of the articles
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resulted in 11 articles that met the inclusion and exclusion criteria. Although the search was broad, the Wii Balance Board and the Xbox Kinect were the only CAGS identified by the search process that met the inclusion and exclusion criteria. Quality appraisals of these studies identified 3 Level II, 7 level III, and 1 Level IV studies. Eight studies [3–10] utilized the Nintendo Wii as a clinical tool and three studies utilized the Xbox Kinect [11–13]. These studies can be categorized into studies that compared (1) CAGS versus well-established measures of kinematics [11–13], (2) CAGS versus well-established measures of kinetics [4–6,8,12], (3) CAGS versus observer-rated or patient reported functional measures [9,10] or (4) studies that compared the ability of CAGS to capture subtle differences in kinetics or kinematics between different functional tasks [7]. In general, only the WBB was used for functional measures of kinetics (i.e. postural sway, center of pressure), comparison between observer-rated clinical functional measures (i.e. Timed Up-and-Go test, Senior Fitness Test, Balance Confidence Scale), and comparison between functional tasks (i.e. eyes open versus closed, or different reach tasks). In contrast, only the Xbox Kinect was used to evaluate kinematic measures (i.e. gait, trunk movement exercises). Three studies [11–13] compared a CAGD, the Xbox Kinect, to a research-grade motion analysis system, the Vicon MX motion capture system, to determine whether the Xbox Kinect was an inexpensive reliable motion detector. Vicon MZ is a suite of networked Vicon MX motion capture cameras and devices that provide real-time and offline digital-optical motion capture data. The Clark studies used a twelve-camera system, while the Dutta study used a seven-camera system. All studies reported excellent correlation and reliability with the Xbox Kinect compared to the Vicon MZ motion analysis system, posting correlation values between 0.84 and 0.99 (R2) and variation of 0.0057 m to 0.0109 m RMS [14]. Of the five studies that compared CAGS to well-established measures of kinetics, a variety of comparison systems were used
Fig. 3. Keyword search strategy and results from systematic review.
Please cite this article in press as: Ruff J, et al. Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.08.047
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including the CAPS Lite Force Platform, AMTI force plate, Kistler force plate, and Neurocom EquiTest1. All but the CAPS Lite Force Platform are research grade force plate systems that have also been utilized in peer-reviewed published postural sway studies in the past. The AMTI force plate uses strain gauges attached to proprietary load cells to measure three force components and three moment components along the XYZ axis [15]. ‘‘The Kistler force plate uses four strain gauges to measure only a vertical force component.’’ [6] The Neurocom EquiTest1 System utilizes a dual force plate with rotation and translation capabilities to measure the vertical forces exerted by the patient’s feet. Two studies [9,10] compared CAGS to observer-rated or patient reported functional measures. Reed-Jones et al. [9] did not find a correlation between traditional tests of balance and fitness (i.e. the Timed Up-and-Go) and the Wii balance test measurements (level and time to complete a balance game). However, the authors did find a correlation between the Wii Fit balance measures and other supplemental information, namely that quick completion of a higher level successfully correlated (p = 0.071) with visual processing speed. Yamada et al., 201 [10] found that a score of 111 or greater on the Wii Fit Basic Step game was able to discriminate between fallers and non-fallers in 88.6% of cases (p = 0.001). Furthermore, this score was also found to correlate with Dual Task Lag of Timed Up-and-Go (p = 0.003). These studies demonstrate that the Wii Fit game has activities available that correlate with real-life outcomes that may offer further support in the use of commercially available gaming devices to measure functional outcomes in orthopaedic patients. Six identified studies [3,4,6–9] specifically looked at using the WBB to measure different aspects of COP trajectories. COP is a measure of postural control and represents the sum of all vector forces acting upon an individual at a given point in time. Of note, COP is slightly different from both center of gravity (COG) and center of pressure path length, which are similar measures of postural control. The majority of these studies found data extracted from the WBB to be both reliable and valid when compared to research-grade force plates. Gras and Hine. [5] and Pagnacco et al. [8] were the only studies that did not find the WBB to be reliable or valid when compared to gold standard measures of research grade force plates. Overall, R-values between 0.81 and 0.99 were commonly reported when comparing WBB to other force plates.
Discussion In the face of a new era in healthcare transformation and the urgent need to provide ‘‘comparative effectiveness research’’ to support clinical decision making and reimbursement practices, the orthopaedic community is required to generate new evidence to demonstrate the clinical effectiveness of treatments, procedures and health-care services provided by the orthopaedic community. Given the time constraints of a personalized, patient-oriented medical practice, the development and adoption of clinical assessment tools requires that the tools be easy to use, portable, non-invasive and relatively inexpensive. Currently, physical exam techniques used to assess musculoskeletal pathology in the clinical setting can detect gross strength and physical abnormalities but are limited for detection of subtle changes in balance, coordination and strength during functional activities that often accompany musculoskeletal pathology. Identification of neuromuscular changes can be difficult, if not impossible, to capture without more sophisticated, expensive tools such as force plates and motion analysis testing that are not readily available in outpatient orthopaedic clinics. However, the subtle neuromuscular deficits that are associated with musculoskeletal pathology may be the
most important predictors of disease progression, injury risk or treatment outcomes and help target rehabilitation strategies. This systematic review was conducted in order to provide a descriptive summary of studies evaluating the validity and reliability of CAGS that could be used in the field of orthopaedics and to determine the general validity and reliability of CAGS as orthopaedic clinical assessment tools of function. Only 11 of the 1050 uniquely identified articles identified studies that used CAGS met the inclusion and exclusion criteria for this review. The results of this review indicated that the WBB and Xbox Kinect have been the preferred gaming devices studied for assessing functional measures in clinical settings. This is likely because the WBB and Xbox Kinect are among the more popular gaming consoles available on the market today. However, the studies identified by this systematic review highlighted the use of only two CAGS – the WBB and the Xbox Kinect. These studies utilized a limited number of tasks and procedures in their assessment of the WBB and Xbox Kinect. This small sample of WBB and Xbox Kinect tasks performed by the participants in the studies may not capture the myriad of games, tasks, and procedures that can be done with those CAGS. Fortunately, the technologies utilized in CAGS (i.e., motionsensing in the Xbox Kinect, and balance and postural games in the WBB) allow for these devices to be easily incorporated into the field of orthopaedics for evaluation of functional deficits and injury risk prediction. CAGS were found to be useful to collect objective data for a variety of functional tasks that may have clinical applications, including the measurement of center of pressure (COP), measurement of medial-to-lateral (M/L) or anterior-to-posterior (A/P) symmetry, assessment of anatomic landmark positioning, and assessment of fall risk. However, no uniform protocols or outcomes were used to evaluate the quality of the WBB as a clinical assessment tool; therefore a wide range of sensitivities, specificities, accuracies, and validities were reported. Preliminarily, the evidence indicates a good potential for CAGS to be useful as orthopaedic clinical tools. Gras and Hine [5] and Pagnacco et al. [8] were the only studies that did not find the WBB to be reliable or valid when compared to a gold standard. However, it is important to note that both these studies had significant flaws in their methodology, thus compromising the quality of these individual studies. One relied on final Wii Fit Balance Test Scores and data points hand drawn by the examiners. The other compared the WBB to a self-designed gold standard that could measure COP to the 0.01 mm accuracy, which the authors report is fifty times more accurate than that of the WBB. It is important to note however, that the authors of this study had financial conflicts of interest as the force plate was designed by the author group. The precursors to CAGS (force plates, motion analysis systems) have been available for years, but often are used only in research labs due to its high cost. Only recently has this type of technology become available in a setting that is more readily available to the general population. Both the WBB and the Xbox Kinect bring these technological advances to the general population in an affordable and fun way. While there is more information available related to the WBB, there is increasing information about the Xbox Kinect’s capabilities to assess functional measures as well. Clark et al., 2010 [3], Clark et al., 2013 [11], and Huunink et al. [6] all showed that the Xbox Kinect had excellent correlation and reliability with the gold standard, posting correlation values between 0.84 and 0.99 (R2) and variation of 0.0057 m to 0.0109 m RMS. Given these results, there is potential for future use of the Xbox Kinect in medical settings. One common methodological weakness of the studies was the use of convenience samples. The studies often recruited study
Please cite this article in press as: Ruff J, et al. Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.08.047
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participants by fliers or volunteer lists. While this sampling method helps to obtain adequate numbers for a properly powered study, it may leads to data that does not accurately represent the population to which the data are being generalized. Of note, comparison across studies indicated that no uniform protocol was used with regard to the procedures and analysis techniques that were utilized. For example, different devices (i.e. AMTI force plate system, Neurocom EquiTest1 System, CAP LiteForce platform) were used to compare the reliability and outputs of the CAGS. Likewise, the Xbox Kinect was compared to different 3D motion analysis systems and the studies each called for different activities to be performed on the WBB or Xbox Kinect. Several studies had participants complete a game-like activity on the CAGS in order to assess postural control, whereas other studies asked that participants perform more standard balance such as one-leg stands or reaches. These studies highlight the lack of consistency in using CAGS as functional assessment tools in the current literature. It is difficult to make generalizations or recommendation about the clinical utility of CAGS, since the best available data are studies with levels of evidence of II, III or IV correlating with a moderate or weak recommendations for evidence-based clinical practice guidelines [16]. Even though this area of study lacks a double blind, randomized control trial demonstrating the reliability and validity of using the WBB or Xbox Kinect as orthopaedic functional assessment tools, it is still possible to envision the clinical utility of CAGS in orthopaedic clinic settings. It is known that a prior fragility fracture is one of the strongest predictors for future fracture risk [17,18]. With over 1.5 million fragility fractures occurring in the United States annually and the substantial financial costs of surgical treatment, hospitalization and rehabilitation, the socioeconomic impact of caring for these orthopaedic trauma patients is profound [19,20]. If CAGS could be used to identify patients who are fallers compared to non-fallers, then resources could be directed at fall prevention for these patients. The ability to predict and prevent of even a small percentage of fragility fractures could have substantial medical and economic benefits for society. Common biomechanical and neuromuscular deficits found to be associated with musculoskeletal injuries and fall risk include alterations or deficits in kinematics, postural sway/coordination, and core control (lumbo-pelvic trunk control). As demonstrated in this review CAGS have potential for identifying some of these clinical deficits. Furthermore, some of the WBB games have been found to reliably and validly predict the risk of falls in over 80% patients [10]. CAGS may offer the opportunity for orthopaedic surgeons to collect valuable research information (in isolation or as part of multi-center studies) to guide evidence based practices as well optimize the opportunity for clinicians to practice personalized health care and tailor rehabilitation and treatment strategies based on subtle deficits difficult to detect by conventional physical exam techniques. Although the amount of literature on the use of CAGS as orthopaedic clinical assessment tools is relatively scarce, devices such as the WBB and Xbox Kinect are gaining popularity with clinicians. There are several other types of CAGs available on the market today, and there will likely be further development and marketing of newer CAGS in the coming years. Our systematic review only identified 11 studies that met the inclusion and exclusion criteria, out of a possible 1050 unique articles identified in the initial search process. There is clearly abundant research regarding the use of CAGS in medicine; however, the strict inclusion and exclusion criteria of this study limited the results to a subset of studies related to the field of orthopaedics. Although other non-orthopaedic clinicians may be interested in integrating the use of CAGS in their own clinical settings, this systematic review does not allow for robust conclusions regarding the use of CAGS in other clinical
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applications. In addition, there are inherent limitations to using technology that is portable, including the possible need for calibration of equipment between testing centers and the need for simplification of much of the technology’s internal equipment. For example, the force plate utilized in the Wii Balance Board has fewer load cells then the typical high-grade force plate utilized for optimal biomechanics studies. However, current physical exam techniques used to assess musculoskeletal pathology in the clinical setting can detect gross strength and physical abnormalities, but are limited for detection of subtle changes in balance, coordination and strength during functional activities that often accompany musculoskeletal pathology. Identification of neuromuscular changes can be difficult, if not impossible, to capture without more sophisticated, expensive tools such as dynamometry, and motion analysis testing that are not readily available in outpatient orthopaedic clinics. As indicated by some of the emerging literature in this field, CAGS may offer a reasonable alternative to provide better objective data for functional measures, albeit at the expense of exact accuracy or computational power of the current devices. We anticipate as validity and reliability of CAGS continue to be confirmed and improved, there will be an increase in the volume and quality of the studies available. Given the increasing pressure to increase the quality and effectiveness of healthcare, it is imperative the clinicians develop novel treatment and assessment tools that can deliver healthcare at lower costs with better outcomes. The results of this systematic review suggest that CAGS have the potential to serve as a low-cost, yet accurate and reliable clinical assessment tool in the field of orthopaedics. As the use of these devices are relatively new, care must be taken in evaluating the reliability, accuracy, sensitivity, and specificity of these devices prior to their use in clinical applications. Currently, due to the variable methodological procedures used for CAGS in the orthopaedic setting, strong conclusions regarding the reliability and validity cannot be made based on the current state of the literature. As new gaming consoles develop, it will be increasingly important to evaluate the quality of their measurements before implementing these devices in orthopaedic settings. CAGS have the potential to change the paradigm in how current functional deficits and outcomes are evaluated in the orthopaedic clinic setting. Given the evolving and progressive nature of the research in this field, it is imperative to critically analyse the quality of future studies when exploring the use of CAGS in orthopaedic outcomes measurements in order to utilize these evolving technologies to their highest potential. Conflicts of Interest The authors have no conflicts of interest to disclose. References [1] Summary of the Affordable Care Act. Henry J. Kaiser Family Foundation, 2013. (Accessed Nov. 14, 2013, at http://kff.org/health-reform/fact-sheet/summaryof-new-health-reform-law/.). [2] Harris JD, Quatman CE, Manring MM, Siston RA, Flanigan DC. How to write a systematic review. Am J Sports Med 2013. [3] Clark RA, Bryant AL, Pua Y, McCrory P, Bennell K, Hunt M. Validity and reliability of the Nintendo Wii Balance Board for assessment of standing balance. Gait Posture 2010;31:307–10. [4] Hubbard B, Pothier D, Hughes C, Rutka J. A portable, low-cost system for posturography: a platform for longitudinal balance telemetry. J Otolaryngol Head Neck Surg 2012;41(Suppl 1):S31–5. [5] Gras LHA, Hine E. Reliability and validity of the Nintendo Wii Fit. J Cyber Ther Rehabil 2009;2:329–35. [6] Huurnink A, Fransz DP, Kingma I, van Dieen JH. Comparison of a laboratory grade force platform with a Nintendo Wii Balance Board on measurement of postural control in single-leg stance balance tasks. J Biomech 2013;46:1392–5.
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Injury journal homepage: www.elsevier.com/locate/injury
Review
Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review Jessica Ruff, Tiffany L. Wang, Catherine C. Quatman-Yates, Laura S. Phieffer, Carmen E. Quatman * Department of Orthopaedics The Ohio State University Wexner Medical Center 725 Prior Hall, Columbus, OH 43201, United States of America
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 April 2014 Received in revised form 22 August 2014 Accepted 30 August 2014
Introduction: Commercially available gaming systems (CAGS) such as the Wii Balance Board (WBB) and Microsoft Xbox with Kinect (Xbox Kinect) are increasingly used as balance training and rehabilitation tools. The purpose of this review was to answer the question, ‘‘Are commercially available gaming systems valid and reliable instruments for use as clinical diagnostic and functional assessment tools in orthopaedic settings?’’ and provide a summary of relevant studies, identify their strengths and weaknesses, and generate conclusions regarding general validity/reliability of WBB and Xbox Kinect in orthopaedics. Materials and methods: A systematic search was performed using MEDLINE (1996–2013) and Scopus (1996–2013). Inclusion criteria were minimum of 5 subjects, full manuscript provided in English or translated, and studies incorporating investigation of CAG measurement properties. Exclusion criteria included reviews, systematic reviews, summary/clinical commentaries, or case studies; conference proceedings/presentations; cadaveric studies; studies of non-reversible, non-orthopaedic-related musculoskeletal disease; non-human trials; and therapeutic studies not reporting comparative evaluation to already established functional assessment criteria. All studies meeting inclusion and exclusion criteria were appraised for quality by two independent reviewers. Evidence levels (I–V) were assigned to each study based on established methodological criteria. Results: 3 Level II, 7 level III, and 1 Level IV studies met inclusion criteria and provided information related to the use of the WBB and Xbox Kinect as clinical assessment tools in the field of orthopaedics. Studies have used the WBB in a variety of clinical applications, including the measurement of center of pressure (COP), measurement of medial-to-lateral (M/L) or anterior-to-posterior (A/P) symmetry, assessment anatomic landmark positioning, and assessment of fall risk. However, no uniform protocols or outcomes were used to evaluate the quality of the WBB as a clinical assessment tool; therefore a wide range of sensitivities, specificities, accuracies, and validities were reported. Conclusion: Currently it is not possible to make a universal generalization about the clinical utility of CAGS in the field of orthopaedics. However, there is evidence to support using the WBB and the Xbox Kinect as tools to obtain reliable and valid COP measurements. The Wii Fit Game may specifically provide reliable and valid measurements for predicting fall risk. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Clinical assessment Gaming tools Orthopaedics Wii Kinect Balance Falls
Contents Introduction . . . . . . . . . Materials and methods Results . . . . . . . . . . . . . Discussion . . . . . . . . . . Conflicts of Interest . . . References . . . . . . . . . .
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* Corresponding author. Tel.: +1 614 293 2165; fax: +1 614 293 4755. E-mail address: [email protected] (C.E. Quatman). http://dx.doi.org/10.1016/j.injury.2014.08.047 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ruff J, et al. Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.08.047
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Introduction The Affordable Health Care Act emphasizes improvement in the quality and efficiency of health care, the development of innovative medical therapies, and the prevention of chronic disease [1]. As a result, the field of orthopaedics faces new socioeconomic pressures to develop and utilize evidence-based clinical tools that predict, monitor, and assess patient outcomes after musculoskeletal injuries. It is paramount that these clinical tools demonstrate clinical utility, cost-effectiveness, as well as high accuracy and reliability. As a result, the orthopaedic trauma community is now faced with the challenge to identify inexpensive, non-invasive, portable, clinician-friendly assessment tools that can be used to assess and predict clinical outcomes for orthopaedic patients. In order to meet these quality and efficiency standards, identification of technology that is commercially available offers high potential for adopting tools that can objectively assess functional capabilities in orthopaedic patients. Commercially available gaming systems (CAGS) may serve as relatively inexpensive, clinician friendly tools to assess objective functional measures in patients and their functional outcomes. Many of these devices for example, the Nintendo Wii with Balance Board (WBB; Fig. 1) and the Microsoft Xbox with Kinect (Xbox Kinect; Fig. 2), incorporate several technological options such as integrated accelerometer technologies, infrared detection, and movement tracking into their consoles. The appeal of the WBB and Xbox Kinect, in particular, is that they are portable, user-friendly, and significantly cheaper than the research-grade technologies that incorporate similar features. They also include a number of options for balance and motion training programs that can be used to assess postural control and the general quality of motion while performing various movement tasks. These tools even offer the capability of providing affordable therapeutic training protocols that could be used by both patients and clinicians to track the progress of objective functional measures during rehabilitation stages. A number of studies in the literature utilize CAGS in various orthopaedic applications. However, there remains a lack of synthesis of the findings of these studies. Consequently, there is not a clear understanding of the measurement properties and clinical utility of these devices. The purpose of this systematic review was to answer the following question: ‘‘Are commercially available gaming systems valid and reliable instruments for use as clinical diagnostic and functional assessment tools in orthopaedic settings?’’ Specific objectives for this review were to provide a descriptive summary of relevant studies and to generate conclusions regarding the general validity and reliability of CAGS in the field of orthopaedics. Materials and methods The methodological approach for this systematic review was modelled after the methods outlined by Harris et al. [2] Systematic searches using PubMed MEDLINE (from 1966) and SCOPUS (from 1996) were performed July 2013. Systematic searches of the electronic databases were designed using keywords to capture all literature relevant to the use of CAGS in orthopaedics, rehabilitation, and various other clinical settings. The electronic database searches were performed with keyword terms including ‘‘‘‘Wii,’’ ‘‘kinect,’’ ‘‘ebavir,’’ ‘‘game console,’’ ‘‘exergames,’’ ‘‘Wiihabilitation,’’ ‘‘computer assisted therapy,’’ ‘‘postural sway,’’ ‘‘therapy,’’ ‘‘stability,’’ ‘‘strength,’’ ‘‘rehabilitation,’’ ‘‘orthopaedic,’’ ‘‘orthopaedic,’’ ‘‘elderly 1,’’ ‘‘computer assisted rehabilitation.’’ The relatively 1
Elderly was used as an OR search term so as not to screen out articles.
Fig. 1. Wii Balance Board in Use.
broad search criteria identified any published relevant studies to maximize the generalizability of this review. The search was supplemented with a review of the bibliographies of the retrieved articles, personal correspondence with authors of retrieved articles, and hand search of pertinent journals to identify any additional studies addressing this topic of interest. The retrieved articles were screened and reviewed by two independent reviewers to identify articles that aligned with the following inclusion criteria: (1) a minimum of 5 subjects, (2) a full manuscript was provided in English or translated to English, and (3) the study incorporated an investigation of the measurement properties of CAGS that could be used for orthopaedic-related diagnostic and functional assessments. Exclusion criteria for articles included: (1) articles classified as review, systematic reviews, summary/clinical commentary, or case studies, (2) conference proceedings/presentations, (3) studies with cadaveric specimens, (4) studies focusing on non-reversible, non-orthopaedic-related musculoskeletal disease (i.e., stroke, Parkinson’s disease, etc.), and (5)therapeutic studies that did not report comparative evaluation to already established functional assessment criteria. All studies meeting inclusion and exclusion criteria were appraised for quality by two independent reviewers. Evidence levels (I–V) were assigned to each study based on the methodological criteria listed in the American Academy of Orthopedic Surgeons primer on evidence-based medicine. When there was a disagreement between the two independent reviewers, a third reviewer was utilized to reconcile these differences. Level I studies included high-quality randomized control trials (RCTs) for
Please cite this article in press as: Ruff J, et al. Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.08.047
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Fig. 2. Xbox Kinect in Use.
therapeutic studies, high-quality prospective studies, or comparisons of current diagnostic criteria against a gold standard. Level II studies included non-blinded RCTs for therapeutic studies, retrospective prognostic studies, or featured developing diagnostic criteria against a gold standard. Level III studies included casecontrol studies for therapeutic studies or prognostic studies, or diagnostic studies in which the diagnostic criteria under investigation were not compared to a gold standard. Level IV studies included case series for therapeutic and prognostic studies, and case-control studies for diagnostic studies. Level V studies included expert opinions expressed rather than studies conducted. Results The initial search yielded 1155 articles related to the use of CAGS in medicine (Fig. 3). Following removal of duplicate articles, 1050 articles remained. Review of the full text of the articles
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resulted in 11 articles that met the inclusion and exclusion criteria. Although the search was broad, the Wii Balance Board and the Xbox Kinect were the only CAGS identified by the search process that met the inclusion and exclusion criteria. Quality appraisals of these studies identified 3 Level II, 7 level III, and 1 Level IV studies. Eight studies [3–10] utilized the Nintendo Wii as a clinical tool and three studies utilized the Xbox Kinect [11–13]. These studies can be categorized into studies that compared (1) CAGS versus well-established measures of kinematics [11–13], (2) CAGS versus well-established measures of kinetics [4–6,8,12], (3) CAGS versus observer-rated or patient reported functional measures [9,10] or (4) studies that compared the ability of CAGS to capture subtle differences in kinetics or kinematics between different functional tasks [7]. In general, only the WBB was used for functional measures of kinetics (i.e. postural sway, center of pressure), comparison between observer-rated clinical functional measures (i.e. Timed Up-and-Go test, Senior Fitness Test, Balance Confidence Scale), and comparison between functional tasks (i.e. eyes open versus closed, or different reach tasks). In contrast, only the Xbox Kinect was used to evaluate kinematic measures (i.e. gait, trunk movement exercises). Three studies [11–13] compared a CAGD, the Xbox Kinect, to a research-grade motion analysis system, the Vicon MX motion capture system, to determine whether the Xbox Kinect was an inexpensive reliable motion detector. Vicon MZ is a suite of networked Vicon MX motion capture cameras and devices that provide real-time and offline digital-optical motion capture data. The Clark studies used a twelve-camera system, while the Dutta study used a seven-camera system. All studies reported excellent correlation and reliability with the Xbox Kinect compared to the Vicon MZ motion analysis system, posting correlation values between 0.84 and 0.99 (R2) and variation of 0.0057 m to 0.0109 m RMS [14]. Of the five studies that compared CAGS to well-established measures of kinetics, a variety of comparison systems were used
Fig. 3. Keyword search strategy and results from systematic review.
Please cite this article in press as: Ruff J, et al. Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.08.047
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including the CAPS Lite Force Platform, AMTI force plate, Kistler force plate, and Neurocom EquiTest1. All but the CAPS Lite Force Platform are research grade force plate systems that have also been utilized in peer-reviewed published postural sway studies in the past. The AMTI force plate uses strain gauges attached to proprietary load cells to measure three force components and three moment components along the XYZ axis [15]. ‘‘The Kistler force plate uses four strain gauges to measure only a vertical force component.’’ [6] The Neurocom EquiTest1 System utilizes a dual force plate with rotation and translation capabilities to measure the vertical forces exerted by the patient’s feet. Two studies [9,10] compared CAGS to observer-rated or patient reported functional measures. Reed-Jones et al. [9] did not find a correlation between traditional tests of balance and fitness (i.e. the Timed Up-and-Go) and the Wii balance test measurements (level and time to complete a balance game). However, the authors did find a correlation between the Wii Fit balance measures and other supplemental information, namely that quick completion of a higher level successfully correlated (p = 0.071) with visual processing speed. Yamada et al., 201 [10] found that a score of 111 or greater on the Wii Fit Basic Step game was able to discriminate between fallers and non-fallers in 88.6% of cases (p = 0.001). Furthermore, this score was also found to correlate with Dual Task Lag of Timed Up-and-Go (p = 0.003). These studies demonstrate that the Wii Fit game has activities available that correlate with real-life outcomes that may offer further support in the use of commercially available gaming devices to measure functional outcomes in orthopaedic patients. Six identified studies [3,4,6–9] specifically looked at using the WBB to measure different aspects of COP trajectories. COP is a measure of postural control and represents the sum of all vector forces acting upon an individual at a given point in time. Of note, COP is slightly different from both center of gravity (COG) and center of pressure path length, which are similar measures of postural control. The majority of these studies found data extracted from the WBB to be both reliable and valid when compared to research-grade force plates. Gras and Hine. [5] and Pagnacco et al. [8] were the only studies that did not find the WBB to be reliable or valid when compared to gold standard measures of research grade force plates. Overall, R-values between 0.81 and 0.99 were commonly reported when comparing WBB to other force plates.
Discussion In the face of a new era in healthcare transformation and the urgent need to provide ‘‘comparative effectiveness research’’ to support clinical decision making and reimbursement practices, the orthopaedic community is required to generate new evidence to demonstrate the clinical effectiveness of treatments, procedures and health-care services provided by the orthopaedic community. Given the time constraints of a personalized, patient-oriented medical practice, the development and adoption of clinical assessment tools requires that the tools be easy to use, portable, non-invasive and relatively inexpensive. Currently, physical exam techniques used to assess musculoskeletal pathology in the clinical setting can detect gross strength and physical abnormalities but are limited for detection of subtle changes in balance, coordination and strength during functional activities that often accompany musculoskeletal pathology. Identification of neuromuscular changes can be difficult, if not impossible, to capture without more sophisticated, expensive tools such as force plates and motion analysis testing that are not readily available in outpatient orthopaedic clinics. However, the subtle neuromuscular deficits that are associated with musculoskeletal pathology may be the
most important predictors of disease progression, injury risk or treatment outcomes and help target rehabilitation strategies. This systematic review was conducted in order to provide a descriptive summary of studies evaluating the validity and reliability of CAGS that could be used in the field of orthopaedics and to determine the general validity and reliability of CAGS as orthopaedic clinical assessment tools of function. Only 11 of the 1050 uniquely identified articles identified studies that used CAGS met the inclusion and exclusion criteria for this review. The results of this review indicated that the WBB and Xbox Kinect have been the preferred gaming devices studied for assessing functional measures in clinical settings. This is likely because the WBB and Xbox Kinect are among the more popular gaming consoles available on the market today. However, the studies identified by this systematic review highlighted the use of only two CAGS – the WBB and the Xbox Kinect. These studies utilized a limited number of tasks and procedures in their assessment of the WBB and Xbox Kinect. This small sample of WBB and Xbox Kinect tasks performed by the participants in the studies may not capture the myriad of games, tasks, and procedures that can be done with those CAGS. Fortunately, the technologies utilized in CAGS (i.e., motionsensing in the Xbox Kinect, and balance and postural games in the WBB) allow for these devices to be easily incorporated into the field of orthopaedics for evaluation of functional deficits and injury risk prediction. CAGS were found to be useful to collect objective data for a variety of functional tasks that may have clinical applications, including the measurement of center of pressure (COP), measurement of medial-to-lateral (M/L) or anterior-to-posterior (A/P) symmetry, assessment of anatomic landmark positioning, and assessment of fall risk. However, no uniform protocols or outcomes were used to evaluate the quality of the WBB as a clinical assessment tool; therefore a wide range of sensitivities, specificities, accuracies, and validities were reported. Preliminarily, the evidence indicates a good potential for CAGS to be useful as orthopaedic clinical tools. Gras and Hine [5] and Pagnacco et al. [8] were the only studies that did not find the WBB to be reliable or valid when compared to a gold standard. However, it is important to note that both these studies had significant flaws in their methodology, thus compromising the quality of these individual studies. One relied on final Wii Fit Balance Test Scores and data points hand drawn by the examiners. The other compared the WBB to a self-designed gold standard that could measure COP to the 0.01 mm accuracy, which the authors report is fifty times more accurate than that of the WBB. It is important to note however, that the authors of this study had financial conflicts of interest as the force plate was designed by the author group. The precursors to CAGS (force plates, motion analysis systems) have been available for years, but often are used only in research labs due to its high cost. Only recently has this type of technology become available in a setting that is more readily available to the general population. Both the WBB and the Xbox Kinect bring these technological advances to the general population in an affordable and fun way. While there is more information available related to the WBB, there is increasing information about the Xbox Kinect’s capabilities to assess functional measures as well. Clark et al., 2010 [3], Clark et al., 2013 [11], and Huunink et al. [6] all showed that the Xbox Kinect had excellent correlation and reliability with the gold standard, posting correlation values between 0.84 and 0.99 (R2) and variation of 0.0057 m to 0.0109 m RMS. Given these results, there is potential for future use of the Xbox Kinect in medical settings. One common methodological weakness of the studies was the use of convenience samples. The studies often recruited study
Please cite this article in press as: Ruff J, et al. Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.08.047
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participants by fliers or volunteer lists. While this sampling method helps to obtain adequate numbers for a properly powered study, it may leads to data that does not accurately represent the population to which the data are being generalized. Of note, comparison across studies indicated that no uniform protocol was used with regard to the procedures and analysis techniques that were utilized. For example, different devices (i.e. AMTI force plate system, Neurocom EquiTest1 System, CAP LiteForce platform) were used to compare the reliability and outputs of the CAGS. Likewise, the Xbox Kinect was compared to different 3D motion analysis systems and the studies each called for different activities to be performed on the WBB or Xbox Kinect. Several studies had participants complete a game-like activity on the CAGS in order to assess postural control, whereas other studies asked that participants perform more standard balance such as one-leg stands or reaches. These studies highlight the lack of consistency in using CAGS as functional assessment tools in the current literature. It is difficult to make generalizations or recommendation about the clinical utility of CAGS, since the best available data are studies with levels of evidence of II, III or IV correlating with a moderate or weak recommendations for evidence-based clinical practice guidelines [16]. Even though this area of study lacks a double blind, randomized control trial demonstrating the reliability and validity of using the WBB or Xbox Kinect as orthopaedic functional assessment tools, it is still possible to envision the clinical utility of CAGS in orthopaedic clinic settings. It is known that a prior fragility fracture is one of the strongest predictors for future fracture risk [17,18]. With over 1.5 million fragility fractures occurring in the United States annually and the substantial financial costs of surgical treatment, hospitalization and rehabilitation, the socioeconomic impact of caring for these orthopaedic trauma patients is profound [19,20]. If CAGS could be used to identify patients who are fallers compared to non-fallers, then resources could be directed at fall prevention for these patients. The ability to predict and prevent of even a small percentage of fragility fractures could have substantial medical and economic benefits for society. Common biomechanical and neuromuscular deficits found to be associated with musculoskeletal injuries and fall risk include alterations or deficits in kinematics, postural sway/coordination, and core control (lumbo-pelvic trunk control). As demonstrated in this review CAGS have potential for identifying some of these clinical deficits. Furthermore, some of the WBB games have been found to reliably and validly predict the risk of falls in over 80% patients [10]. CAGS may offer the opportunity for orthopaedic surgeons to collect valuable research information (in isolation or as part of multi-center studies) to guide evidence based practices as well optimize the opportunity for clinicians to practice personalized health care and tailor rehabilitation and treatment strategies based on subtle deficits difficult to detect by conventional physical exam techniques. Although the amount of literature on the use of CAGS as orthopaedic clinical assessment tools is relatively scarce, devices such as the WBB and Xbox Kinect are gaining popularity with clinicians. There are several other types of CAGs available on the market today, and there will likely be further development and marketing of newer CAGS in the coming years. Our systematic review only identified 11 studies that met the inclusion and exclusion criteria, out of a possible 1050 unique articles identified in the initial search process. There is clearly abundant research regarding the use of CAGS in medicine; however, the strict inclusion and exclusion criteria of this study limited the results to a subset of studies related to the field of orthopaedics. Although other non-orthopaedic clinicians may be interested in integrating the use of CAGS in their own clinical settings, this systematic review does not allow for robust conclusions regarding the use of CAGS in other clinical
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applications. In addition, there are inherent limitations to using technology that is portable, including the possible need for calibration of equipment between testing centers and the need for simplification of much of the technology’s internal equipment. For example, the force plate utilized in the Wii Balance Board has fewer load cells then the typical high-grade force plate utilized for optimal biomechanics studies. However, current physical exam techniques used to assess musculoskeletal pathology in the clinical setting can detect gross strength and physical abnormalities, but are limited for detection of subtle changes in balance, coordination and strength during functional activities that often accompany musculoskeletal pathology. Identification of neuromuscular changes can be difficult, if not impossible, to capture without more sophisticated, expensive tools such as dynamometry, and motion analysis testing that are not readily available in outpatient orthopaedic clinics. As indicated by some of the emerging literature in this field, CAGS may offer a reasonable alternative to provide better objective data for functional measures, albeit at the expense of exact accuracy or computational power of the current devices. We anticipate as validity and reliability of CAGS continue to be confirmed and improved, there will be an increase in the volume and quality of the studies available. Given the increasing pressure to increase the quality and effectiveness of healthcare, it is imperative the clinicians develop novel treatment and assessment tools that can deliver healthcare at lower costs with better outcomes. The results of this systematic review suggest that CAGS have the potential to serve as a low-cost, yet accurate and reliable clinical assessment tool in the field of orthopaedics. As the use of these devices are relatively new, care must be taken in evaluating the reliability, accuracy, sensitivity, and specificity of these devices prior to their use in clinical applications. Currently, due to the variable methodological procedures used for CAGS in the orthopaedic setting, strong conclusions regarding the reliability and validity cannot be made based on the current state of the literature. As new gaming consoles develop, it will be increasingly important to evaluate the quality of their measurements before implementing these devices in orthopaedic settings. CAGS have the potential to change the paradigm in how current functional deficits and outcomes are evaluated in the orthopaedic clinic setting. Given the evolving and progressive nature of the research in this field, it is imperative to critically analyse the quality of future studies when exploring the use of CAGS in orthopaedic outcomes measurements in order to utilize these evolving technologies to their highest potential. Conflicts of Interest The authors have no conflicts of interest to disclose. References [1] Summary of the Affordable Care Act. Henry J. Kaiser Family Foundation, 2013. (Accessed Nov. 14, 2013, at http://kff.org/health-reform/fact-sheet/summaryof-new-health-reform-law/.). [2] Harris JD, Quatman CE, Manring MM, Siston RA, Flanigan DC. How to write a systematic review. Am J Sports Med 2013. [3] Clark RA, Bryant AL, Pua Y, McCrory P, Bennell K, Hunt M. Validity and reliability of the Nintendo Wii Balance Board for assessment of standing balance. Gait Posture 2010;31:307–10. [4] Hubbard B, Pothier D, Hughes C, Rutka J. A portable, low-cost system for posturography: a platform for longitudinal balance telemetry. J Otolaryngol Head Neck Surg 2012;41(Suppl 1):S31–5. [5] Gras LHA, Hine E. Reliability and validity of the Nintendo Wii Fit. J Cyber Ther Rehabil 2009;2:329–35. [6] Huurnink A, Fransz DP, Kingma I, van Dieen JH. Comparison of a laboratory grade force platform with a Nintendo Wii Balance Board on measurement of postural control in single-leg stance balance tasks. J Biomech 2013;46:1392–5.
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