Wii Fit balance training in outpatient people with subacute stroke - Henri Hurkmans

1. GAMES FOR HEALTH EUROPE CONFERENCE 2018
WII FIT BALANCE TRAINING
IN OUTPATIENT PEOPLE WITH SUBACUTE STROKE
Henri Hurkmans
Department of Orthopedics - Physical Therapy
Erasmus MC, Rotterdam

2. WII FIT BALANCE TRAINING
IN OUTPATIENT PEOPLE WITH SUBACUTE STROKE
A Randomized Multicenter Clinical Trial
Henri Hurkmans
Department of Orthopedics - Physical Therapy
Erasmus MC, Rotterdam

3. Introduction
• Balance impairments
• Frequently seen following a stroke1
• Great impact on walking ability and activities of daily living2
• Increased risk of falling: 38% fall incidents in subacute phase3
88% develop fear of falling1
1. Weerdesteyn V, Niet Md, van Duijnhoven HJR, Geurts ACH. Falls in individuals with stroke. J Rehabil Res Dev 2008;45(8):1195.
2. Kamphuis JF, de Kam D, Geurts AC, Weerdesteyn V. Is weight-bearing asymmetry associated with postural instability after stroke? A systematic review. Stroke Res Treat 2013;2013:692137.
3. Kim EJ, Kim DY, Kim WH, Lee KL, Yoon YH, Park JM et al. Fear of falling in subacute hemiplegic stroke patients: associating factors and correlations with quality of life. Ann Rehabil Med 2012;36(6):797-803.
4. Forkan R, Pumper B, Smyth N, Wirkkala H, Ciol MA, Shumway-Cook A. Exercise adherence following physical therapy intervention in older adults with impaired balance. Phys Ther 2006;86(3):401-10.
5. Shumway-Cook A, Gruber W, Baldwin M, Liao S. The effect of multidimensional exercises on balance, mobility, and fall risk in community-dwelling older adults. Phys Ther 1997;77(1):46-57.
• Conventional balance therapy
• Effective in improving balance of patients with (subacute) stroke
Physical health : hip fractures, physical inactivity and less independent living2
• Repetition of specific movements and postures Monotonous, Dull and Not Challenging
Motivation4
Adherence4
Outcome5

4. Introduction
• Last decade video game based technology has become popular for use in rehabilitation
• Motivational character7
• More enjoyable than conventional therapy8
• Availability, usability and low costs9
7. Lohse K, Shirzad N, Verster A, Hodges N, Van der Loos HF. Video games and rehabilitation: using design principles to enhance engagement in physical therapy. J Neurol Phys Ther 2013;37(4):166-75
8. Hung JW, Chou CX, Hsieh YW, Wu WC, Yu MY, Chen PC et al. Randomized comparison trial of balance training by using exergaming and conventional weight-shift therapy in patients with chronic stroke. Arch Phys Med Rehabil 2014;95(9):1629-37.
9. Bateni H. Changes in balance in older adults based on use of physical therapy vs the Wii Fit gaming system: a preliminary study. Physiotherapy 2012;98(3):211-6.
10. Darekar A, McFadyen BJ, Lamontagne A, Fung J. Efficacy of virtual reality-based intervention on balance and mobility disorders post-stroke: a scoping review. J Neuroeng Rehabil 2015;12:46.
11. Goble DJ, Cone BL, Fling BW. Using the Wii Fit as a tool for balance assessment and neurorehabilitation: the first half decade of "Wii-search". J Neuroeng Rehabil 2014;11(1):12.
Adherence Therapy effect
• The Nintendo® Wii Fit
• One of the most used and investigated commercially gaming consoles10
• Balance-training device using real-time visual and auditory feedback
• Promising effects as a balance training device in rehabilitation11
• More enjoyable than conventional balance therapy8

5. Introduction
• Effectiveness of Wii Fit for balance training in stroke patients (RCT’s)
12. Lee HY, Kim YL, Lee SM. Effects of virtual reality-based training and task-oriented training on balance performance in stroke patients. J Phys Ther Sci 2015;27(6):1883-8.
13. Hung JW, Chou CX, Hsieh YW, Wu WC, Yu MY, Chen PC et al. Randomized comparison trial of balance training by using exergaming and conventional weight-shift therapy in patients with chronic stroke. Arch Phys Med Rehabil 2014;95(9):1629-37.
14. Morone G, Tramontano M, Iosa M, Shofany J, Iemma A, Musicco M et al. The efficacy of balance training with video game-based therapy in subacute stroke patients: a randomized controlled trial. Biomed Res Int 2014;2014:580861.
15. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on balance and mobility in individuals with chronic stroke: a randomized controlled trial. Top Stroke Rehabil 2013;20(3):218-25.
16. Barcala L, Grecco LA, Colella F, Lucareli PR, Salgado AS, Oliveira CS. Visual biofeedback balance training using wii fit after stroke: a randomized controlled trial. J Phys Ther Sci 2013;25(8):1027-32.
17. Cho KH, Lee KJ, Song CH. Virtual-Reality Balance Training with a Video-Game System Improves Dynamic Balance in Chronic Stroke Patients. Tohoku J Exp Med 2012;228(1):69-74.
Author/
Year
Age (yr)/ Time
since stroke (m)
Intervention - Wii Fit
(min/day - days/wk - wks)
Control
(min/day - days/wk - wks)
Setting Outcome/Results
Lee et al.
201512
Interv: 46 / >6
Control: 49 / >6
n=12
30 - 5 - 6
+ General exercise therapy
n=12
30 - 5 - 6 Task oriented training
+ General exercise therapy
Under supervision
(Hospital)
FRT: Sign more in Wii group
COP: Sign in both groups
Hung et al.
201413
Interv: 55 / 21
Control: 53 / 16
n=13
30 - 2 – 12
+ Standard rehab training
n=15
30 - 2 - 12 Conventional weight shift
training + Standard rehab training
Under supervision SI: Sign more in Wii group
TUG, FRT: Sign in both groups
Morone et al.
201414
Interv: 58 / 2
Control: 62 / 1,5
n=25
20 - 3 - 4
+ Standard phys therapy
n=22
20 - 3 – 4 Balance therapy
+ Standard phys therapy
Under supervision
(Rehab center)
BBS, BI: Sign more in Wii group
10MWT: Sign in both groups
Fritz et al.
201315
Interv: 68 / 30
Control: 65 / 43
n=15
50 - 4 - 5
n=13
Normal activity
Under supervision
(Clinical Lab
setting)
BBS, DGI, TUG, 6MWT
No sign results
Barcala et al.
201316
Interv: 65 / 12
Control: 64 / 15
n=10
30 - 2 - 5
+ Conventional phys therapy
n=10
Conventional phys therapy
Under supervision
(PT Clinic)
BBS, TUG, COP
Sign in both groups
Cho et al.
201217
Interv: 65 / 13
Control: 63 / 13
n=11
30 - 3 - 6
+ Standard rehab training
n=11
+ Standard rehab training
Under supervision BBS, TUG: Sign more in Wii group
Postural sway: No sign results
COP = Center of Pressure
FRT = Functional Reach Test
TUG = Timed up and Go
SI: Stability Index
TIBS = Tetrax Interactive Balance System
10 MWT = 10 meter walk test
BBS = Berg Balance Scale
BI = Barthel Index

6. Aim
• Primary Aim of our study
To compare the effectiveness of Wii Fit balance training with conventional balance
therapy in patients with subacute stroke, conducted in an outpatient setting.
• Secondary Goals of our study
Assess whether the Wii Fit balance training results in:
higher physical activity levels
higher quality of life
better therapy adherence
Adverse events

7. Hypothesis
Hypothesis:
Wii Fit balance training is more effective than conventional balance therapy in an outpatient setting

8. Methods
Participants
Inclusion Exclusion
- Subacute stroke (>6 weeks and <6 months) - Traumatic intracranial hemorrhage
- Discharged from the rehabilitation center - History of disorders that might have an influence on balance
- Aged >18 years - Serious deviations in muscles or anatomy of the lower limbs
- Continued outpatient physical therapy - Unable to perform the tasks as a consequence of serious visual,
- Functional Ambulation Category (FAC) ≥4 sensory, cognitive and linguistic impairments
- Berg Balance Scale (BBS) score <56 or - No Wii gaming for at least the last 4 weeks before the trial
a BBS score of 56 and a score of 0 or 1 at item 5
of the Dynamic Gait Index (DGI)
- Understanding of simple exercises
- Written informed consent
Randomization
Patients were randomly assigned, using random permuted blocks (using blocks of 2 patients for each of the 2
treatments)18 22 to either the Wii Balance group, or the control group
18. Pocock SJ. Clinical Trials A Practical Approach. 1 ed. New York: John Wiley & Sons; 1994.

9. Methods
Intervention: Wii Fit balance training
• 2 days/week 30 minutes under supervision
• 5 days/week 30 minutes (or more) at home
• 8 weeks
• Wii balance board
• 11 games (e.g Table tilt, ski slalom)
selection: feasibility and enjoyment
• Safety: walker was allowed
Control: Conventional balance training
• 2 days/week 30 minutes under supervision
• 5 days/week 30 minutes (or more) at home
• 8 weeks
• Dynamic and static exercises (reducing base of support)
• Change surface (solid, foam, wobble)

10. Methods
Primary Outcome measure Assessed function Score Reliability/validity
Berg Balance Scale
(BBS)
Balance and risk for falls.
14 items are tested on a 5-
points ordinal scale (0-4),
giving a maximal score of 56.
The higher the score, the
better the balance.
Reliability and validity varies
from good to excellent, for
stroke patients. Minimal
detectable change of 5.8
points.
Dynamic Gait Index
(DGI)
Functional stability during
gait activities and risk of
falling.
Eight items are tested on a 4-
points ordinal scale (0-3),
giving a maximal score of 24.
The higher the score, the
better the balance.
Reliability is excellent and
validity varies from moderate
to good, for stroke patients

11. Methods
Secondary Outcome measure Assessed function Score Reliability/validity
5 Meter Walk Test (5MWT)
Time in seconds on 5 meters of comfortable
walking. Patient had to walk 3 times 5 meter. If
the patient used a walking aid, the test was
performed with and without walking aid.
The average time of the 3 attempts is taken.
The lower the time, the better.
Reliability and validity is very good.
Fatigue Severity Scale (FSS) Impact of fatigue on daily life.
Nine statements on fatigue are scored ranging
from 1-7. Total score is the mean of 9 item
scores. The higher the score, the higher the
fatigue.
Reliability and validity is good.
Visual Analogue Scale- fatigue
(VAS-f)
Subjective experience of fatigue.
Item 1of the VAS-f scale.100mm horizontal
line. The higher the score, the higher the
fatigue.
Reliability and validity of the VAS-f is moderate.
Barthel Index (BI)
Measures independence of Activities of Daily
Living (ADL).
Ten ADL’s are tested. Total maximum score is
100 points. The higher the score, the more
independent.
A valid and reliable measure of independence of
ADL.
Actigraph (GT1M-1 and GT1M-2)
Uniaxial accelerometer that measures patient’s
physical activity for 7 days, in total counts per
day.
The higher the amount of counts, the more
active the person has been.
Good reliability for measuring counts
Physical Activity Scale for
Individuals with Physical
Disabilities (PASIPD)
Questionnaire to evaluate physical activity in
METS in past 7 days in persons with a physical
disability.
The higher the amount of METS, the more
active the person has been.
Good validity and test-retest reliability
Life Habits
Individuals perceived functioning in daily
activities and social participation.
It assesses 69 items in 13 categories. The
higher the score, the better the health.
Good validity and acceptable test-retest
reliability.
Short-Form 36 (SF-36)
Individual perceived general health (quality of
life).
Thirty-six items on 8 health aspects are scored
on a 0-100 scale. The higher the score, the
better the health.
Reliability and validity of this questionnaire is
good.

12. Methods
Adherence
• Diary
• Patients noted when (day, time) and for how long (minutes) they performed walking exercises,
and standing or Wii Fit exercises
Adverse events
• e.g. (near) falls, dizziness, nausea, musculoskeletal pain
• Monitored by patient query during the supervised training sessions

13. Methods
Statistical analysis
• Dependent T-test for within-group (Wilcoxon signed rank test)
• Independent T-test for between-group differences (Mann-Whitney U test)
• Cohen’s d was calculated to evaluate and compare the strength of the effects on each outcome measure.
• Significant if P < 0.05.
• SPSS version 24.0

14. Results
Patients

15. Results
Patients Baseline characteristics of included patients.
Variables WFBT (n=13) CBT (n=15) P
Sex (male) 6 (46.2) 7 (46.7) .98
Age (years) 62.9 ± 11.63 66.8 ± 10.2 .35
Duration Stroke (days) 91.9 ± 58.4 85.7 ± 54.5 .77
Location of lesion .82
Right hemisphere 6 (46.2) 6 (40.0)
Left hemisphere 4 (30.8) 6 (40.0)
Brainstem 2 (7.7) 1 (13.3)
Cerebellum 2 (15.4) 1 (6.7)
Functional Status
BI 18.75 ± 1.29 18.87 ± 1.30 1.00
BBS 46.9 ± 8.3 44.8 ± 5.0 .42
DGI 14.9 ± 5.8 16.4 ± 4.5 .49
Walking speed
(m/s)
0.74 ± 0.24 0.72 ± 0.24 .81
Values are mean ± SD or n(%). WFBT, Wii Fit balance training; CBT, Conventional balance therapy.

16. Results

17. Results
Values Change values
Wii Fit Control Wii Fit Control
T0 T1 P ES T0 T1 P ES T1-T0 T1-T0 P ES
Primary outcomes
BBS
46.92
±8.34
50.25
±5.12
0.03* 0.74
44.80
±4.96
48.27
±5.16
0.03* 0.64
3.33
±4.50
3.47
±5.40
0.95 0.03
DGI
14.85
±5.80
18.62
±4.66
0.00** 1.35
16.40
±4.53
18,40
±4.34
0.01* 0.74
3.77
±2.80
2.00
±2.70
0.09 0.64
Secondary outcomes
5MWT
7.62
±3.12
6.04
±1.51
0.01** 0.75
7.73
±2.76
6.80
±2.22
0.08 0.45
-1.58
±2.01
-0.94
±2.38
0.46 0.15
FSS
37.00
±13.16
36.62
±11.46
0.92 0.03
36.53
±12.01
33.33
±11.17
0.21 0.33
-0.38
±14.20
- 3.20
±9.43
0.54 0.12
VAS
Right
now
24.31
±26.19
25.31
±28.25
0.72 -0.10
31.80
±26.92
27.60
±20.72
0.24 0.30
1.00
±13.37
-4.20
±11.42
0.28 0.21
Last
week
33.38
±26.82
37.62
±26.31
0.50 -0.18
36.87
±22.39
33.80
±19.24
0.55 0.15
4.23
±24.51
-3.07
±12.44
0.32 0.20
BI
18.75
±1.29
18.58
±1.51
0.67 -0.12
18.87
±1.30
19.33
±1.23
0.28 0.28
-0.17
±1.90
0.47
±1.60
0.30 0.20
Actigraph
44211
±9834
71759
±27732
0.08 0.75
138955
±90119
123440
±63940
0.48 -0.07
27548
±26775
-15516
±59346
0.16 0.41
PASIPD
5.05
±3.36
7.32
±4.58
0.07 0.51
5.84
±4.17
6.62
±4.24
0.48 0.19
2.26
±3.95
0.78
±4.14
0.36 0.19
Life Habits
260.77
±21.11
252.54
±20.61
0.09 0.48
262.73
±23.30
249.13
±24.59
0.00** 0.70
-8.23
±15.83
-13.60
±14.28
0.35 0.18
Significant
within-group differences
• BBS: Berg Balance Scale
• DGI: Dynamic Gait Index
• 5MWT: 5 Minute Walk Test
• PASIPD: Physical Activity
Scale for Individuals with
Physical Disabilities
ES = Effect size; Small: 0.20; Medium: 0.50 ; Large: 0.80
Cohen J. Statistical power analysis for the behavioral sciences. New York; London: Psychology Press Taylor&Francis Group; 2009.
No significant
between-group differences

18. Conclusion
Wii Fit balance training is not more effective in improving balance of patients with subacute
stroke in an outpatient setting than conventional balance therapy.

19. Discussion
Compared to literature
• First study outpatient setting and subacute stroke patients
• Morone (2014) - acute stroke patients, but supervised: BBS: Wii Fit ≥ Control
Theory/assumption: Wii Fit more enjoyable adherence therapy effect
• No significant difference on adherence
• Poor health status stroke patients in subacute phase
Poor health is negatively related to therapy adherence
Practical implications
• Wii Fit balance training is in itself an effective way of improving balance in the patient’s home environment
• Improvement dynamic balance  improvement gait / falls during gait
• No adverse events
• Potential cost saving: No supervision all the time  Time saving for physical therapist

20. Contributors to this study
Researchers
Pim de Meulemeester, dept. of Physical Therapy, Erasmus Mc Rotterdam
Prof. dr. Gerard Ribbers, Rijndam Rehabilitation Center, Rotterdam
Prof dr. Henk Stam, dept. of Rehabilitation Medicine, Erasmus Mc Rotterdam
Dr. Hans Bussmann, dept. of Rehabilitation Medicine, Erasmus Mc Rotterdam
Dr. Henri Hurkmans, dept. of Physical Therapy, Erasmus Mc Rotterdam
Inclusion of patients
Marian van Engen, Laurens Antonius IJsselmonde, Rotterdam
Petra de Graaf , Rijndam Rehabilitation Center, Vlietland
Chantal Hoefsloot en Eduard Storm, Maastad ziekenhuis, Rotterdam