- Email: [email protected]
Can the Wii Fit Balance Board be Used as a Fall Risk Assessment Tool among Poststroke Patients?
ARTICLE IN PRESS
Can the Wii Fit Balance Board be Used as a Fall Risk Assessment Tool among Poststroke Patients? Morris Casano Beato, PT, DPT, GCS, NCS,* Erin Morton, PT, DPT,† Christopher Iadarola, PT, DPT,‡ Lisa Winterberger, PT, DPT,§ and Nicole Dawson, PT, PhD, GCS*
Background: The prevalence of falls can be as high as 73% in the stroke population. Falls occur as a result of multiple factors. Factors such as balance impairments can be improved through physical therapy intervention. However, insurance payers limit the number of visits per patient. It is crucial to find other ways to assess balance after discharge from rehabilitation. Purpose: The purpose of this study is to determine if the Nintendo Wii Fit can be used as a fall risk assessment tool among the poststroke population. Methodology: A sample of 11 stroke survivors were recruited (mean age 63.36 years). Each participant completed a balance and fall risk assessment using the Berg Balance Scale, Timed Up & Go, Four Square Step Test, Five Times Sit-to-Stand and 8-Foot Walk Test. Bivariate correlation will examine the validity of the Nintendo Wii Fit as a fall risk assessment tool in this population. Results: The Nintendo Wii Fit Balance Test was found to be correlated with gait speed measured by the 8-Foot Walk Test. There is no correlation between the Wii Fit Balance Tests and most common standardized fall risk measures. Standardized fall risk outcome measures also significantly correlate with each other. Conclusions: The study suggests that while there is a potential utility of the game system to be used at home by patient and caregivers, the Wii Fit Balance Test may not be an appropriate substitute to the standardized fall risk assessment tool for stroke patients in the clinical setting. Key Words: Stroke—falls—balance—game system—outcome measure— balance—Wii Fit—rehabilitation © 2019 Elsevier Inc. All rights reserved.
Introduction Stroke or Cerebrovascular Accident affects various body systems and can lead to numerous functional deficits. The prevalence of falls can be as high as 73% in stroke From the *School of Kinesiology and Physical Therapy, University of Central Florida, Orlando, Florida; †Department of Rehabilitation Medicine, NYU Langone Health, New York, New York; ‡Department of Physical Therapy, Ability Rehabilitation, Orlando, Florida; and §Department of Sports Medicine and Rehabilitation, Advent Health, Orlando, Florida. Received June 27, 2019; revision received October 11, 2019; accepted October 23, 2019. Address correspondence to Morris Casano Beato, PT, DPT, GCS, NCS, School of Kinesiology and Physical Therapy, 12805 Pegasus Drive, HPA I, Room 255A, Orlando FL 32816. E-mails: [email protected], [email protected]. 1052-3057/$ - see front matter © 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104500
populations.1 Falls occur during routine activities as a result of multiple factors. These factors include physiological deficits such as muscle weakness and impaired balance, environmental hazards such as rugs, poor lighting and pets, and medication side effects.2 Various outcome measures have been utilized in physical therapy to assess the risk of falls including the Berg Balance Scale (BBS), Timed Up and Go (TUG), and Four Square Step Test (FSST). These tests have shown to be valid and reliable in assessing fall risk in different patient populations.3,4 However, most of these outcome measures require the skill of a trained healthcare professional to be administered. This study aims to find a tool that can be used by patients or their caregivers to track their progress after discharge without the skilled assistance of a healthcare professional. In order to facilitate neuroplasticity for recovery, thousands of repetitions are needed, which is unattainable in therapy sessions alone.5 With the Medicare therapy cap in
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place, stroke rehabilitation is limited to a certain amount of spending annually. The cap potentially minimize the number of out-patient physical therapy sessions being received by each patient.6 Many patients are not able to measure their current level of function and risk of falls on their own after discharge from physical therapy. The Nintendo Wii is increasingly utilized equipment in neurological physical therapy because of the gaming system’s ability to provide concurrent visual feedback, detect center of gravity, assess standing balance, and its relative low cost as compared to more expensive balance assessment equipment such as Biodex. The Nintendo Wii Fit balance board, an accessory to the Nintendo Wii System, is a 12 inches x 20 inches flat board similar to steps used in aerobic classes. The board receives information through 4 sensors embedded into the board and provides visual feedback on the patient’s center of mass on the board through a television monitor. In addition to the balance assessment feature, other Wii games require movement such weight shifting and stepping that challenges the patient’s dynamic standing balance. This gaming system has been utilized by physical therapists as a means to challenge balance and improve motor functions in poststroke patients. Nintendo Wii has shown to improve patient compliance with physical therapy interventions due to the multiple fun challenges to a patient’s standing balance that the gaming system can provide.7 As mentioned earlier, a patient’s compliance to physical therapy intervention and physical activity regimen has been an issue for physical therapists, especially in treating patients with chronic conditions. Poststroke patients are at increased risk for depression, which can reduce motivation for therapy.8 One study suggests that using the Wii as a means of delivering a physical therapy intervention greatly improved compliance in stroke rehabilitation.9 Considering that the Nintendo Wii has been validated as a potential treatment tool for individuals with stroke, there is a good potential of using the Wii for post-discharge home exercise programs. However, more research is required to validate the use of Wii as a fall risk assessment tool in patients with stroke. Previous studies have examined the potential use of the Nintendo Wii Fit as effective intervention tool to improve motor function in individuals with stroke and the use of this game console in assessing fall risk in older adults.10 The Wii Fit has been utilized in the clinical setting in stroke patients and in fall risk assessment, it is important to determine if the system can be used to assess fall risk in stroke patients. There is no existing evidence in the use Nintendo Wii as a falls risk assessment tool in stroke patients. The purpose of this study is to examine if the Nintendo Wii Fit balance test can be utilized as an assessment tool to determine fall risk in the poststroke patient population. It is our hypothesis that due to the motor challenges and visual feedback that the Nintendo Wii can provide, it
can be utilized as an assessment tool to help predict the risk of fall in the poststroke population.
Materials and Methods Participants An observational study was conducted with a convenience sample of 11 stroke survivors (63% being male, 36% being female, mean age 63.4 years). The University of Central Florida (UCF) Institutional Review Board approved the study and written informed consent was obtained from the participants preceding data collection. The participants were recruited from 2 facilities located in the Orlando area, the UCF Aphasia House outpatient clinic and Central Florida Stroke Support Group using flyers and announcements. The participants were initially screened via telephone interview to determine eligibility on the basis of the following inclusion criteria: age 18 years or older, able to ambulate at least 10 feet with or without an assistive device, and able to stand independently with or without an assistive device on a stable surface for at least 5 minutes to complete the body test on the Wii Fit Plus. Individuals were excluded based on the following criteria: fracture of a lower limb within 6 months before the study onset; other neurologic diagnoses, including multiple sclerosis or vestibular disease, and any difficulty completing basic Activities of Daily Living secondary to a hearing or vision impairment. Individuals who were determined eligible to participate in the study via telephone were scheduled an appointment for a 30 minute session of physical screening to determine further eligibility using the inclusion criteria. Out of the 28 individuals that were screened, 11 stroke patients met the inclusion/exclusion criteria.
Game-Based Performance Measures The Nintendo Wii gaming console, the Nintendo Wii Fit Balance Board accessory and Wii Fit Plus 2007-2009 software system was used by the researchers for virtual balance testing (Fig 1). Verbal instructions were provided by the researchers as participants learned to shift their body weight over their left and right lower extremities while standing on the Wii Fit Balance Board. The Wii Fit Balance Board detected signals from the participant’s feet that were sent to the main console and projected into a television screen. The center of gravity, Wii Fit Balance Score, and Wii Fit Age, were the selected measures recorded on the gaming console. The Wii Fit Balance Board identified the participant’s center of balance when the patient first stepped on to the board (Fig 2). The Balance Score was obtained from basic balance test on the Wii Fit. This test required patients to shift and maintain their weight according to visual representations of target ranges on the television screen (Fig 3). The Wii Fit Age was
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Figure 3. Wii Fit balance board assessment has the participant perform the basic balance test following the Center of Balance mapping.
Figure 1. Balance testing using the Nintendo Wii Fit balance board.
calculated by the console and provided information based on their Center of Balance (COB) and balance scores. For safety, a standard walker was placed in front of the board with an investigator guarding from behind and towards the patient’s weaker side.
Physical Performance Measures The Activities-Specific Balance Confidence (ABC) Scale requires individuals to report their confidence in maintaining their balance when performing various daily activities. Sixteen different scenarios were given to a participant and the participant rates their confidence on a 0%-100% confidence scale (0 being no confidence, 100 being completely confident). For patients with fluent
Figure 2. Determination of the Center of Balance (COB) based on the participant’s weight distribution.
aphasia who have difficulty of verbally expressing their answer, the participants were instructed to point on the scale for their response. The Timed Up and Go (TUG) is an assessment tool that examines mobility, balance, walking ability, and falls risk in stroke survivors. In the TUG, the participants were asked to stand up from a standard chair with a seat height of 17.5 inches, walk a distance of 3 m at their normal walking speed, turn around, and walk back to the chair to sit down. Time measured in seconds was counted from the moment the word “go” was said and stopped when the participant’s made contact with the seat. Participants were given one practice trial before their time was recorded for the assessment. The Berg Balance Scale (BBS) is a 14-item clinical balance assessment tool. Patients are scored out of a maximum 56 points on their ability to perform a variety of static and dynamic balance tasks. There are 14 components of the overall test and each component of the test is graded on a scale of 0-4 based on the participant's ability to maintain balance during various activities. Activities assessed include sitting balance, standing balance, standing with eyes closed, standing with narrow base of support/feet together, sit-stand transfers, transferring to a chair, standing and reaching, standing and looking over shoulders, picking up an object off of the floor, turning in a full circle, tandem standing, tapping on a step, and standing on one leg. Cutoff scores for falls risk for individuals with stroke has been suggested to be less than or equal to 45 of 56.11 The Five-Times-Sit-To-Stand Test (FTSST) is used to measure functional lower limb strength. Each participant is required to sit in a chair with their arms folded across their chests and stand only using lower extremity force. The amount of time in seconds it takes to perform 5 repetitions of the activity is recorded. Normative values for various age groups have been established. The 8-Foot Walk Test (8FWT) is often used to measure gait speed in patients. In this test, individuals are instructed to walk at their normal speed across 8 feet, with 2 feet measured prior to the starting point for gaining
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start-up speed. The time in seconds it takes to complete the activity is recorded, and the gait speed is converted to a meters/second format. The Four Square Step Test (FSST) is a falls assessment tool that looks at a patient’s dynamic balance as the individual steps over canes forward, backwards, and to the side. The amount of time in seconds to complete 2 revolutions in different directions around the canes in the shape of a square is recorded. This outcome measure has been utilized as a fall risk assessment tool in different populations such as older adults.12 The Trail Making Test is a test utilized for detecting cognitive impairment and executive function. The test is comprised of 2 sections. Each section had a practice test prior to administration of the actual test. The first section, Trail Making Test A required participants to connect circles are numbered 1-25 in ascending order. The second section, Trail Making Test B has numbers 1-13 and letters A-L. Participants were required to draws lines to connect the circles in a sequential pattern, but with the added task of alternating between the numbers and letters (i.e., 1-A2-B-3-C, etc.).
Statistical Analysis Data analysis was performed using Statistical Package for the Social Sciences software (Version 22.0, IBM Statistics) to calculate the frequency, mean, range. Bivariate correlation using Pearson’s product coefficient (Pearson r) was the primary statistical analysis used in this study. A correlation matrix was created to display correlations between each of the outcome measures. Each correlation was assessed for statistical significance using a P value of less than .05.
Patient Communication Many participants included in this study presented with aphasia. The investigator’s adjusted their form of communication to allow for increased processing time to answer questions, pointing to available answers on paper, and asking caregivers to give clarification. Additionally, the investigators provided visual demonstration and modeling of the physical performance outcome measures.
Results Baseline Patient Characteristics General demographics of the study population is presented in Table 1. Total mean age of the participants was 63.36 years old, 63.36% (n = 7) were Caucasians and 63.36% (n = 7) were female. Approximately 27.27% (n = 3) used an assistive device for ambulation.
Table 1. Demographics and characteristics of participants Variable
Gender Male Female Race Caucasian American African American Hispanic American Assistive Device Quad Cane Rolling Walker No Assistive Device
Number of participants n = 11 n (%) 7 (63.63%) 4 (36.36%) 8 (72.72%) 1 (9.09%) 2 (18.18%) 2 (18.18%) 1 (9.09%) 8 (72.72%)
Game-Based and Performance-Based Measure Correlation Bivariate correlation analysis among the Nintendo Wii Fit Basic Balance Test, as represented through the WiiFit Age and Wii Fit Age/Actual Age, and the physical performance outcome measures such as the TUG, FSST, FTSST, ABC, and BBS indicate no significant correlation at an alpha level of .05 or .10 (Table 2). However, when using an alpha level of .10, the percentage of Wii Fit Age/Actual Age was moderately correlated to the 8FWT (r = .552). Several standardized fall risk outcome measures were found to have strong significant correlations with the TUG, one of the most common fall risk screening tool, including the FSST (r = .948), ABC (r = .814), BBS (r = .924), and 8FWT (r = .715) at an alpha level of .05 (Table 2).
Discussion The Nintendo WiiFit has been widely used around the world as an interactive fitness game system for the last decade. While the game system has been utilized as an examination tool and balance intervention in rehabilitation, there is limited evidence in the literature supporting the use of the game system in assessing balance of patients with stroke. Based on the results of the study, the individual components of the Nintendo Wii Fit Basic Balance Test such as the WiiFit Age, Wii Fit Age/Actual Age and Center of Balance measures indicates no correlation with the standard fall risk assessments in stroke survivors such as the TUG, FSST, FTSST, ABC and BBS. However, a potentially significant correlation exists between the Wii Fit Age/Actual Age and 8FWT, a physical measure of gait speed. It is interesting to note that the correlation only occurred in one physical measure of fall risk, the gait speed and not the other balance measures. The authors posit that this relationship exists because gait speed, as measured by the 8FWT, is a unidimensional assessment of balance while the other physical measures such TUG, FSST, and BBS are more dynamic and complex
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Table 2. Pearson product correlation coefficient among Nintendo Wii balance measures and standardized fall risk assessment measures
TUG FSST ABC BBS 8FWT TA TB FTSTS % Wii Age/Act
TUG
FSST
ABC
1 .948 .814 .924 .715 -
.948 1 .735 .917 .613 1.0 -
.814 .735 1 .861 .691 -
BBS .924 .917 .861 1 .739 -
8FWT
TA
TB
.715 .613 .691 .739 1 * .615 *.552
1 .635 -
1.0 1 -
FTSST * .615 .365 1 -
% Wii Age/Act .187 .489 .252 .133 *.552 .509 .851 .188 1
Abbreviations: ABC, Activities Specific Balance Confidence Scale; BBS, Berg Balance Scale, FSST, four square step test, FTSST, five time sit to stand test; TA, trail making test part A; TB, trail making test part B; TUG, timed up and go; 8 FWT, 8 Foot Walk Test; % Wii Age/Act, %Wii age/actual age. *Indicates alpha level of .10.
assessment of balance requiring performance of difference tasks such as transfers, turns, and change of directions. However, this correlation is important as gait speed has been found to be one of the most significant predictors of health and functional status.13 The Nintendo Wii Fit Basic Balance Test is widely used and a cost-effective tool that may potentially be used as a fall risk assessment tool at home by stroke patients and their caregivers, the system does not require the skill of a healthcare professional to administer. However, the Nintendo Wii Fit Basic Balance Test should not be used in the clinical setting a substitute of well validated physical performance measures used in examination of balance and fall risk of patients with stroke.
Study Limitation Future research should include a larger sample size and more variable patient population to replicate and validate the results of this study. Although the study contributes information to the existing literature, the study has existing limitations that must be recognized. Majority of the sample population was not able to complete the trail making part B indicating possible cognitive impairment which would impact the validity of TUG and FSST as fall risk assessments. Only 11 participants met the inclusion/ exclusion criteria, which decreases the statistical power of the study. Due to the small sample size of this study and the complexity of the impairments of stroke, further research is warranted to validate the use of the Nintendo Wii Fit as a fall risk assessment in fall risk survivors.
Conclusion A significant correlation exist between the Wii Fit Age/ Actual Age and 8FWT suggesting that the Wii Fit Balance Board may be used at home as a cost-effective tool in assessment of balance in patients with stroke in the
absence of skilled healthcare professional that can perform validated physical performance measures. The study also suggest that there is no correlation between the Wii Fit Balance Tests and most of the standard fall risk assessments in stroke survivors such as the TUG, FSST, FTSST, ABC, and BBS. This may indicate that while there is a potential utility of the game system to be used at home by patient and caregivers, the Wii Fit Balance Test may not be an appropriate substitute to the standardized fall risk assessment tool for stroke patients in the clinical setting. Acknowledgment: The authors would also like to thank the UCF Aphasia House, the Central Florida Stroke Support Group, Dr. Janet Whiteside and Dr. Amy Engelhoven of the UCF School of Communication Science Disorders, Ms. Karen Kalich of Advent Health Department of Rehabilitation and the individuals who participated in the study.
Conflicts of interest The authors do not have any conflicts of interest to declare.
References 1. Czernuszenko A. Risk factors for falls in poststroke patients treated in a neurorehabilitation ward. Neurol Neurochir Pol 2007;41:28-35. 2. Important Facts about Falls. Centers for disease control and prevention. https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Published February 10, 2017. Accessed April 4, 2017. 3. Nocera J, Stegem€ oller E, Malaty I, et al. Using the timed up & go test in a clinical setting to predict falling in Parkinson's disease. Arch Phys Med Rehabil 2013;94:13001305. 4. Brauer S, Shumway-Cook A, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther 2000;80:896-903.
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6 5. Sathian K, Buxbaum LJ, Cohen LG, et al. Neurological principles and rehabilitation of action disorders: common clinical deficits. Neurorehabil Neural Repair 2011;S25:21S-32S. 6. Center for Medicare & Medicaid Services. Therapy cap. center for medicare & medicaid website.d https://www. cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/ Medical-Review/TherapyCap.html. Updated February 9, 2016. Accessed April 4, 2017. 7. Saposnik G, Teasell R, Mamdani M, et al. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle. Stroke 2010;41:1477-1484. 8. Kotila M, Numminen H, Waltimo O, et al. Depression after stroke: results of the FINNSTROKE study. Stroke 1998;29:368-372.
9. Bower K, Louie J, Landesrocha Y, et al. Clinical feasibility of interactive motion-controlled games for stroke rehabilitation. J Neuroeng Rehabil 2015;12:63. 10. Yamada M, Aoyama T, Ichihashi N, et al. The reliability and preliminary validity of game-based fall risk assessment in community-dwelling older adults. Geriatr Nurs 2011;32:188-194. M, et al. Evaluation of the 11. Dog gan A, Meng€ ull€ uoGGlu effect of ankle-foot orthosis use on balance and mobility in hemiparetic stroke patients. Disabil Rehabil 2011;33: 1433-1439. 12. Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil 2002;83:1566-1571. 13. Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital sign. J Aging Phys Act 2015;23:314-322.
Can the Wii Fit Balance Board be Used as a Fall Risk Assessment Tool among Poststroke Patients? Morris Casano Beato, PT, DPT, GCS, NCS,* Erin Morton, PT, DPT,† Christopher Iadarola, PT, DPT,‡ Lisa Winterberger, PT, DPT,§ and Nicole Dawson, PT, PhD, GCS*
Background: The prevalence of falls can be as high as 73% in the stroke population. Falls occur as a result of multiple factors. Factors such as balance impairments can be improved through physical therapy intervention. However, insurance payers limit the number of visits per patient. It is crucial to find other ways to assess balance after discharge from rehabilitation. Purpose: The purpose of this study is to determine if the Nintendo Wii Fit can be used as a fall risk assessment tool among the poststroke population. Methodology: A sample of 11 stroke survivors were recruited (mean age 63.36 years). Each participant completed a balance and fall risk assessment using the Berg Balance Scale, Timed Up & Go, Four Square Step Test, Five Times Sit-to-Stand and 8-Foot Walk Test. Bivariate correlation will examine the validity of the Nintendo Wii Fit as a fall risk assessment tool in this population. Results: The Nintendo Wii Fit Balance Test was found to be correlated with gait speed measured by the 8-Foot Walk Test. There is no correlation between the Wii Fit Balance Tests and most common standardized fall risk measures. Standardized fall risk outcome measures also significantly correlate with each other. Conclusions: The study suggests that while there is a potential utility of the game system to be used at home by patient and caregivers, the Wii Fit Balance Test may not be an appropriate substitute to the standardized fall risk assessment tool for stroke patients in the clinical setting. Key Words: Stroke—falls—balance—game system—outcome measure— balance—Wii Fit—rehabilitation © 2019 Elsevier Inc. All rights reserved.
Introduction Stroke or Cerebrovascular Accident affects various body systems and can lead to numerous functional deficits. The prevalence of falls can be as high as 73% in stroke From the *School of Kinesiology and Physical Therapy, University of Central Florida, Orlando, Florida; †Department of Rehabilitation Medicine, NYU Langone Health, New York, New York; ‡Department of Physical Therapy, Ability Rehabilitation, Orlando, Florida; and §Department of Sports Medicine and Rehabilitation, Advent Health, Orlando, Florida. Received June 27, 2019; revision received October 11, 2019; accepted October 23, 2019. Address correspondence to Morris Casano Beato, PT, DPT, GCS, NCS, School of Kinesiology and Physical Therapy, 12805 Pegasus Drive, HPA I, Room 255A, Orlando FL 32816. E-mails: [email protected], [email protected]. 1052-3057/$ - see front matter © 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104500
populations.1 Falls occur during routine activities as a result of multiple factors. These factors include physiological deficits such as muscle weakness and impaired balance, environmental hazards such as rugs, poor lighting and pets, and medication side effects.2 Various outcome measures have been utilized in physical therapy to assess the risk of falls including the Berg Balance Scale (BBS), Timed Up and Go (TUG), and Four Square Step Test (FSST). These tests have shown to be valid and reliable in assessing fall risk in different patient populations.3,4 However, most of these outcome measures require the skill of a trained healthcare professional to be administered. This study aims to find a tool that can be used by patients or their caregivers to track their progress after discharge without the skilled assistance of a healthcare professional. In order to facilitate neuroplasticity for recovery, thousands of repetitions are needed, which is unattainable in therapy sessions alone.5 With the Medicare therapy cap in
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place, stroke rehabilitation is limited to a certain amount of spending annually. The cap potentially minimize the number of out-patient physical therapy sessions being received by each patient.6 Many patients are not able to measure their current level of function and risk of falls on their own after discharge from physical therapy. The Nintendo Wii is increasingly utilized equipment in neurological physical therapy because of the gaming system’s ability to provide concurrent visual feedback, detect center of gravity, assess standing balance, and its relative low cost as compared to more expensive balance assessment equipment such as Biodex. The Nintendo Wii Fit balance board, an accessory to the Nintendo Wii System, is a 12 inches x 20 inches flat board similar to steps used in aerobic classes. The board receives information through 4 sensors embedded into the board and provides visual feedback on the patient’s center of mass on the board through a television monitor. In addition to the balance assessment feature, other Wii games require movement such weight shifting and stepping that challenges the patient’s dynamic standing balance. This gaming system has been utilized by physical therapists as a means to challenge balance and improve motor functions in poststroke patients. Nintendo Wii has shown to improve patient compliance with physical therapy interventions due to the multiple fun challenges to a patient’s standing balance that the gaming system can provide.7 As mentioned earlier, a patient’s compliance to physical therapy intervention and physical activity regimen has been an issue for physical therapists, especially in treating patients with chronic conditions. Poststroke patients are at increased risk for depression, which can reduce motivation for therapy.8 One study suggests that using the Wii as a means of delivering a physical therapy intervention greatly improved compliance in stroke rehabilitation.9 Considering that the Nintendo Wii has been validated as a potential treatment tool for individuals with stroke, there is a good potential of using the Wii for post-discharge home exercise programs. However, more research is required to validate the use of Wii as a fall risk assessment tool in patients with stroke. Previous studies have examined the potential use of the Nintendo Wii Fit as effective intervention tool to improve motor function in individuals with stroke and the use of this game console in assessing fall risk in older adults.10 The Wii Fit has been utilized in the clinical setting in stroke patients and in fall risk assessment, it is important to determine if the system can be used to assess fall risk in stroke patients. There is no existing evidence in the use Nintendo Wii as a falls risk assessment tool in stroke patients. The purpose of this study is to examine if the Nintendo Wii Fit balance test can be utilized as an assessment tool to determine fall risk in the poststroke patient population. It is our hypothesis that due to the motor challenges and visual feedback that the Nintendo Wii can provide, it
can be utilized as an assessment tool to help predict the risk of fall in the poststroke population.
Materials and Methods Participants An observational study was conducted with a convenience sample of 11 stroke survivors (63% being male, 36% being female, mean age 63.4 years). The University of Central Florida (UCF) Institutional Review Board approved the study and written informed consent was obtained from the participants preceding data collection. The participants were recruited from 2 facilities located in the Orlando area, the UCF Aphasia House outpatient clinic and Central Florida Stroke Support Group using flyers and announcements. The participants were initially screened via telephone interview to determine eligibility on the basis of the following inclusion criteria: age 18 years or older, able to ambulate at least 10 feet with or without an assistive device, and able to stand independently with or without an assistive device on a stable surface for at least 5 minutes to complete the body test on the Wii Fit Plus. Individuals were excluded based on the following criteria: fracture of a lower limb within 6 months before the study onset; other neurologic diagnoses, including multiple sclerosis or vestibular disease, and any difficulty completing basic Activities of Daily Living secondary to a hearing or vision impairment. Individuals who were determined eligible to participate in the study via telephone were scheduled an appointment for a 30 minute session of physical screening to determine further eligibility using the inclusion criteria. Out of the 28 individuals that were screened, 11 stroke patients met the inclusion/exclusion criteria.
Game-Based Performance Measures The Nintendo Wii gaming console, the Nintendo Wii Fit Balance Board accessory and Wii Fit Plus 2007-2009 software system was used by the researchers for virtual balance testing (Fig 1). Verbal instructions were provided by the researchers as participants learned to shift their body weight over their left and right lower extremities while standing on the Wii Fit Balance Board. The Wii Fit Balance Board detected signals from the participant’s feet that were sent to the main console and projected into a television screen. The center of gravity, Wii Fit Balance Score, and Wii Fit Age, were the selected measures recorded on the gaming console. The Wii Fit Balance Board identified the participant’s center of balance when the patient first stepped on to the board (Fig 2). The Balance Score was obtained from basic balance test on the Wii Fit. This test required patients to shift and maintain their weight according to visual representations of target ranges on the television screen (Fig 3). The Wii Fit Age was
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Figure 3. Wii Fit balance board assessment has the participant perform the basic balance test following the Center of Balance mapping.
Figure 1. Balance testing using the Nintendo Wii Fit balance board.
calculated by the console and provided information based on their Center of Balance (COB) and balance scores. For safety, a standard walker was placed in front of the board with an investigator guarding from behind and towards the patient’s weaker side.
Physical Performance Measures The Activities-Specific Balance Confidence (ABC) Scale requires individuals to report their confidence in maintaining their balance when performing various daily activities. Sixteen different scenarios were given to a participant and the participant rates their confidence on a 0%-100% confidence scale (0 being no confidence, 100 being completely confident). For patients with fluent
Figure 2. Determination of the Center of Balance (COB) based on the participant’s weight distribution.
aphasia who have difficulty of verbally expressing their answer, the participants were instructed to point on the scale for their response. The Timed Up and Go (TUG) is an assessment tool that examines mobility, balance, walking ability, and falls risk in stroke survivors. In the TUG, the participants were asked to stand up from a standard chair with a seat height of 17.5 inches, walk a distance of 3 m at their normal walking speed, turn around, and walk back to the chair to sit down. Time measured in seconds was counted from the moment the word “go” was said and stopped when the participant’s made contact with the seat. Participants were given one practice trial before their time was recorded for the assessment. The Berg Balance Scale (BBS) is a 14-item clinical balance assessment tool. Patients are scored out of a maximum 56 points on their ability to perform a variety of static and dynamic balance tasks. There are 14 components of the overall test and each component of the test is graded on a scale of 0-4 based on the participant's ability to maintain balance during various activities. Activities assessed include sitting balance, standing balance, standing with eyes closed, standing with narrow base of support/feet together, sit-stand transfers, transferring to a chair, standing and reaching, standing and looking over shoulders, picking up an object off of the floor, turning in a full circle, tandem standing, tapping on a step, and standing on one leg. Cutoff scores for falls risk for individuals with stroke has been suggested to be less than or equal to 45 of 56.11 The Five-Times-Sit-To-Stand Test (FTSST) is used to measure functional lower limb strength. Each participant is required to sit in a chair with their arms folded across their chests and stand only using lower extremity force. The amount of time in seconds it takes to perform 5 repetitions of the activity is recorded. Normative values for various age groups have been established. The 8-Foot Walk Test (8FWT) is often used to measure gait speed in patients. In this test, individuals are instructed to walk at their normal speed across 8 feet, with 2 feet measured prior to the starting point for gaining
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start-up speed. The time in seconds it takes to complete the activity is recorded, and the gait speed is converted to a meters/second format. The Four Square Step Test (FSST) is a falls assessment tool that looks at a patient’s dynamic balance as the individual steps over canes forward, backwards, and to the side. The amount of time in seconds to complete 2 revolutions in different directions around the canes in the shape of a square is recorded. This outcome measure has been utilized as a fall risk assessment tool in different populations such as older adults.12 The Trail Making Test is a test utilized for detecting cognitive impairment and executive function. The test is comprised of 2 sections. Each section had a practice test prior to administration of the actual test. The first section, Trail Making Test A required participants to connect circles are numbered 1-25 in ascending order. The second section, Trail Making Test B has numbers 1-13 and letters A-L. Participants were required to draws lines to connect the circles in a sequential pattern, but with the added task of alternating between the numbers and letters (i.e., 1-A2-B-3-C, etc.).
Statistical Analysis Data analysis was performed using Statistical Package for the Social Sciences software (Version 22.0, IBM Statistics) to calculate the frequency, mean, range. Bivariate correlation using Pearson’s product coefficient (Pearson r) was the primary statistical analysis used in this study. A correlation matrix was created to display correlations between each of the outcome measures. Each correlation was assessed for statistical significance using a P value of less than .05.
Patient Communication Many participants included in this study presented with aphasia. The investigator’s adjusted their form of communication to allow for increased processing time to answer questions, pointing to available answers on paper, and asking caregivers to give clarification. Additionally, the investigators provided visual demonstration and modeling of the physical performance outcome measures.
Results Baseline Patient Characteristics General demographics of the study population is presented in Table 1. Total mean age of the participants was 63.36 years old, 63.36% (n = 7) were Caucasians and 63.36% (n = 7) were female. Approximately 27.27% (n = 3) used an assistive device for ambulation.
Table 1. Demographics and characteristics of participants Variable
Gender Male Female Race Caucasian American African American Hispanic American Assistive Device Quad Cane Rolling Walker No Assistive Device
Number of participants n = 11 n (%) 7 (63.63%) 4 (36.36%) 8 (72.72%) 1 (9.09%) 2 (18.18%) 2 (18.18%) 1 (9.09%) 8 (72.72%)
Game-Based and Performance-Based Measure Correlation Bivariate correlation analysis among the Nintendo Wii Fit Basic Balance Test, as represented through the WiiFit Age and Wii Fit Age/Actual Age, and the physical performance outcome measures such as the TUG, FSST, FTSST, ABC, and BBS indicate no significant correlation at an alpha level of .05 or .10 (Table 2). However, when using an alpha level of .10, the percentage of Wii Fit Age/Actual Age was moderately correlated to the 8FWT (r = .552). Several standardized fall risk outcome measures were found to have strong significant correlations with the TUG, one of the most common fall risk screening tool, including the FSST (r = .948), ABC (r = .814), BBS (r = .924), and 8FWT (r = .715) at an alpha level of .05 (Table 2).
Discussion The Nintendo WiiFit has been widely used around the world as an interactive fitness game system for the last decade. While the game system has been utilized as an examination tool and balance intervention in rehabilitation, there is limited evidence in the literature supporting the use of the game system in assessing balance of patients with stroke. Based on the results of the study, the individual components of the Nintendo Wii Fit Basic Balance Test such as the WiiFit Age, Wii Fit Age/Actual Age and Center of Balance measures indicates no correlation with the standard fall risk assessments in stroke survivors such as the TUG, FSST, FTSST, ABC and BBS. However, a potentially significant correlation exists between the Wii Fit Age/Actual Age and 8FWT, a physical measure of gait speed. It is interesting to note that the correlation only occurred in one physical measure of fall risk, the gait speed and not the other balance measures. The authors posit that this relationship exists because gait speed, as measured by the 8FWT, is a unidimensional assessment of balance while the other physical measures such TUG, FSST, and BBS are more dynamic and complex
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Table 2. Pearson product correlation coefficient among Nintendo Wii balance measures and standardized fall risk assessment measures
TUG FSST ABC BBS 8FWT TA TB FTSTS % Wii Age/Act
TUG
FSST
ABC
1 .948 .814 .924 .715 -
.948 1 .735 .917 .613 1.0 -
.814 .735 1 .861 .691 -
BBS .924 .917 .861 1 .739 -
8FWT
TA
TB
.715 .613 .691 .739 1 * .615 *.552
1 .635 -
1.0 1 -
FTSST * .615 .365 1 -
% Wii Age/Act .187 .489 .252 .133 *.552 .509 .851 .188 1
Abbreviations: ABC, Activities Specific Balance Confidence Scale; BBS, Berg Balance Scale, FSST, four square step test, FTSST, five time sit to stand test; TA, trail making test part A; TB, trail making test part B; TUG, timed up and go; 8 FWT, 8 Foot Walk Test; % Wii Age/Act, %Wii age/actual age. *Indicates alpha level of .10.
assessment of balance requiring performance of difference tasks such as transfers, turns, and change of directions. However, this correlation is important as gait speed has been found to be one of the most significant predictors of health and functional status.13 The Nintendo Wii Fit Basic Balance Test is widely used and a cost-effective tool that may potentially be used as a fall risk assessment tool at home by stroke patients and their caregivers, the system does not require the skill of a healthcare professional to administer. However, the Nintendo Wii Fit Basic Balance Test should not be used in the clinical setting a substitute of well validated physical performance measures used in examination of balance and fall risk of patients with stroke.
Study Limitation Future research should include a larger sample size and more variable patient population to replicate and validate the results of this study. Although the study contributes information to the existing literature, the study has existing limitations that must be recognized. Majority of the sample population was not able to complete the trail making part B indicating possible cognitive impairment which would impact the validity of TUG and FSST as fall risk assessments. Only 11 participants met the inclusion/ exclusion criteria, which decreases the statistical power of the study. Due to the small sample size of this study and the complexity of the impairments of stroke, further research is warranted to validate the use of the Nintendo Wii Fit as a fall risk assessment in fall risk survivors.
Conclusion A significant correlation exist between the Wii Fit Age/ Actual Age and 8FWT suggesting that the Wii Fit Balance Board may be used at home as a cost-effective tool in assessment of balance in patients with stroke in the
absence of skilled healthcare professional that can perform validated physical performance measures. The study also suggest that there is no correlation between the Wii Fit Balance Tests and most of the standard fall risk assessments in stroke survivors such as the TUG, FSST, FTSST, ABC, and BBS. This may indicate that while there is a potential utility of the game system to be used at home by patient and caregivers, the Wii Fit Balance Test may not be an appropriate substitute to the standardized fall risk assessment tool for stroke patients in the clinical setting. Acknowledgment: The authors would also like to thank the UCF Aphasia House, the Central Florida Stroke Support Group, Dr. Janet Whiteside and Dr. Amy Engelhoven of the UCF School of Communication Science Disorders, Ms. Karen Kalich of Advent Health Department of Rehabilitation and the individuals who participated in the study.
Conflicts of interest The authors do not have any conflicts of interest to declare.
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