Effect of Nintendo Wii Fit TM Balance Games
on Postural Control and Balance Among Adults with Down Syndrome

Michelle Miller, M.S.

Oklahoma State University

Melissa Powers, PhD

University of Central Oklahoma

Jacilyn Olson, PhD

University of Central Oklahoma

Donna Kearns, PhD

University of Central Oklahoma

ABSTRACT

A Nintendo Wii Fit gaming device may eliminate several barriers to exercise and promote participation in balance training among adults with Down syndrome (DS). This study seeks to determine if a Nintendo Wii balance exercise regimen will improve postural control and balance among adults with DS over the age of 18. Nine participants were randomly divided into a treatment (TR) and control (CR) group. A TekScan HR mat was used to measure the following variables: anterior/posterior sway (AP), medial/lateral sway (ML), area (A), distance (D), and variability (V) in two feet eyes open (EO) and two feet eyes closed (EC) stances. A 2X2 RM ANOVA was utilized to analyze results as well as Cohen's d for effect size calculations. There were no significant differences found within group-by-time interaction, time, and group effects for any dependent variable (p>.05). Effect sizes were calculated for EOTR: AP (d = -.44), ML (d = -.03), A (d = -.47), D (d = -.48), and V (d = -.29. Values for the EOCR saw a larger effect among all variables: AP (d = -.84), ML (d = -.17), area (d = -.73), D (d = -.78), and V (d = -.67). ECTR values were as follows: AP (d = -.91), ML (d = -.53), A (d = -.76), D (d = -.69), and V (d = -.71). Values for ECCR are as follows: AP (d = -.41), ML (d = +2.81), A (d = -.48), D (d = -.42), and V (d = -.21). Although there were not statistically significant improvements in postural control between groups or over time, based on effect size calculations either of these training methods may still be an effective mode of improving postural control.

INTRODUCTION

The prevalence of Down syndrome (DS) births every year in the United States has significantly increased (p<.05) from year 1979 to 2003 from 9.0 to 11.8 per 10,000 live births (Shin et al., 2009). Significant lack of postural control among adults with DS appears to be associated with impaired balance, which may negatively affect their ability to carry out every day functional activities such as putting on clothes, carrying in groceries, and walking up stairs (Galli et al., 2008). Traditional balance training has been shown to be an effective way of improving strength and balance among children with DS (Berg, Becker, Martian, Primrose, & Wingen, 2012; Gupta, Bhagway, Rao, & Kumaran, 2011; Mahy, Shields, Taylor, & Dodd, 2010). However, the possibility that using virtual reality gaming can produce equivalent balance improvements may promote better long term exercise adherence (Berg et al., 2012; Gupta et al., 2011; Mahy et al., 2010). It has been suggested that feasible exercise programs which can be easily maintained, are entertaining and affordable, and provide a social aspect may produce the greatest improvements among those with DS (Mahy et al., 2010). Implementing a Nintendo Wii Fit balance regimen may be one way to improve balance; however, there is a lack of literature on the effects of using the Wii to improve postural control and balance among adults with DS. Thus, the primary purpose of this study was to determine if implementing a Nintendo Wii balance exercise regimen would improve postural control and balance among adults with DS.

METHODOLOGY

Participants

Adults with DS over the age of 18 who participated in activities at a local special needs facility were recruited to participate in this study (n=9). There were five participants in the experimental group and four in the control group. Participants were required to communicate effectively and efficiently, be able to understand general rules and guidelines, and function independently (i.e., go to the bathroom by themselves, eat by themselves, walk and move around by themselves). A letter was sent home to the parent/guardian of the potential participants describing the project as well as an informed consent form, assent form, and request to contact the primary care physician. Prescreening required a medical release from each participant's primary care physician. All procedures were approved by the university's Institutional Review Board.

Instrumentation

Subjects

TekScan HR-MatTM. The TekScan HR-Mat is commonly used to measure foot function, gait, pressure differences between feet, and asymmetries during regular stance and balance (Nomura et al., 2009; Rule et al., 2012). In this study, the TekScan HR Mat was used to measure sway path length looking at the participant's center of mass (COM) and how it moves from medio/lateral (left to right), anterior/posterior (front to back), area (complete area of the COM), distance (total distance COM traveled), and variability (distance of COM per frame), to analyze postural control and balance.

Nintendo Wii Fit balance board and games. The Nintendo Wii Fit is a virtual reality gaming system used with the treatment group in this study. The games utilized were Penguin Slide, Candle Light and Ski Slalom.

Nintendo Wii Sports Games. The Nintendo Wii Sports is a virtual reality gaming system used in the comparison group in this study. The games used were bowling and tennis. The participant used the remote in simulation for the "equipment" used in each game, such as a tennis racket.

Procedures

Baseline assessments included measuring postural control utilizing the TekScan HR-Mat. Participants were asked to balance on the TekScan HR Mat for 30 seconds on both feet with eyes open and eyes closed. The following dependent variables were measured for postural sway, medio/lateral, anterior/posterior, area, distance, and variability. Measurements were taken one week prior and one week post intervention. The control group (n = 4) was allowed to use up to four Nintendo Wii Sport games and the experimental group (n=5) was allowed to use up to six balance games, both groups participated in 30 minute sessions two times per week. There was not a true control group because the facility where the intervention took place ran a full inclusion criterion, meaning if one group participated in fun Nintendo games then the other group should also be allowed to participate. During the 30 minute sessions participants in both groups would take turns playing the games in order to implement appropriate rest periods. There was one television hooked up to one Nintendo Wii. The participants took turns playing games in both groups.

For the second testing session, subjects were given 10 warm-up punches from their dominant side staggered stance. The subjects were then positioned to where their outstretched clinched fist was just in reach of the punching bag while in their staggered punching stance. Wearing a Neoprene bag glove (Century Martial Art Supply LLC, Oklahoma City, OK), each subject was instructed to punch the bag (Original Wavemaster, Century Martial Art Supply LLC, Oklahoma City, OK) "as hard as they could". The punches had to hit an F-Scan force sensory shoe sole that was used to measure force of impact in peak newtons (Tekscan, Inc. Boston, MA). The F-Scan was equipped with a 750 hertz sampling rate via the Data Logger system (Tekscan, Inc. Boston, MA). The shoe sole was anchored to the punching bag with adhesive backed Velcro and a Velcro strap (see figure 1). The punching bag was equipped with vertical adjustments capabilities to accommodate each subject's height. The researcher's attempts were to set the height of the force sensor to the approximate shoulder height of each subject. This was to try and replicate the same height as the 1RM testing from session one. Subjects were given a 2 second interval with which they needed to perform the strike. All subjects where given 3 attempts and the highest value was used for analysis.

Statistical Analysis

A 2 x 2 Repeated Measures ANOVA was utilized to test the null hypotheses for each dependent variable. Univariate effect sizes and percent change were calculated to examine non-significant, but potentially meaningful changes within each group. Independent samples t tests were conducted to examine baseline differences between groups. Descriptive statistics including examination of outliers and normality were conducted for each variable.

Results
There were no significant differences between groups at baseline measures (p>.05). No significant interaction or main effects were found for any dependent variables (p > .05). Due to these statistically non-significant results, the primary researcher's hypotheses were not supported. A Nintendo Wii Fit balance regimen was not able to significantly improve balance and postural control among these adults with DS over the age of 18 years old; however this study may still provide meaningful results due to effect size calculations (See Figures 1 & 2; Table 1 & 2).

In regard to the two feet eyes open stance in the treatment group, Cohen's effect size value's for over-time results are as follows, anterior/posterior sway (d = -.44), medial/lateral sway (d = -.03), area (d = -.47), distance (d = -.48), and variability (d = -.29). Interestingly, Cohen's effect size values for the control group were higher during the two feet eyes open stance among all variables, anterior/posterior sway (d = -.84), medial/lateral sway (d = -.17), area (d = -.73), distance (d = -.78), and variability (d = -.67).


Table 1. Descriptive Statistics, Effect Size, and Percent Change of Postural Control for Eyes Open Measures.

Pre-Testing

Post-Testing

 

 

N

Mean+/-SD

Mean+/-SD

Mean Diff

ES

EO_A/P (cm)

Treatment

5

7.26 +/- 4.23

5.39+/-1.82

1.87

-0.44

-25.76%

Control

4

8.09 +/- 4.15

4.6+/-1.08

3.49

-0.84

-43.14%

Total

9

7.63 +/- 3.95

5.04+/-1.51

2.59

-0.66

-33.94%

EO_M/L (cm)

Treatment

5

8.34 +/- 6.11

8.14+/-9.21

0.2

-0.03

-2.40%

Control

4

7.91 +/- 2.76

7.45+/-9.69

0.46

-0.17

-44.06%

Total

9

8.17 +/- 4.64

7.83+/-8.82

0.34

-0.07

-5.82%

EO_Area (cm2)

Treatment

5

38.99 +/- 44.2

18.26+/-26.39

20.73

-0.47

-53.17%

Control

4

25.68 +/- 12.62

16.45+/-21.71

9.23

-0.73

-35.94%

Total

9

33.08 +/- 32.95

17.46+/-22.93

15.62

-0.47

-47.22%

EO_Dist (cm)

Treatment

5

138.53 +/- 93.83

93.84+/-43.9

44.69

-0.48

-32.26%

Control

4

172.48 +/- 114.23

85.97 +/- 29.36

86.51

-0.78

-50.16%

Total

9

153.62 +/- 98.06

90.34+/-36.11

63.28

-0.65

-41.19%

EO_Var (cm)

Treatment

5

0.12 +/- 0.07

0.1+/-0.08

0.02

-0.29

-16.67%

Control

4

0.16 +/- 0.09

0.1+/-0.09

0.06

-0.67

-37.50%




Figure 1. Effect Size Calculation for Dependent Variables in Eyes Open Stance Among Treatment and Control Groups.

In regard to effect sizes for the two feet eyes closed treatment group, Cohen's effect size values were as follows, anterior/posterior sway (d = -.91), medial/lateral sway (d = -.53), area (d = -.76), distance (d = -.69), and variability (d = -.71). As suspected, Cohen's effect size values for the control group during two feet eyes closed stance had smaller effect sizes when compared to the treatment group, respectively, anterior/posterior sway (d = -.41), medial/lateral sway (d = +2.81), area (d = -.48), distance (d = -.42), and variability (d = -.21).

Table 2. Descriptive Statistics, Effect Size, and Percent Change of Postural Control for Eyes Closed Measure.

Pre-Testing

Post-Testing

 

 

N

Mean+/-SD

Mean+/-SD

Mean Diff

ES

EC_A/P (cm)

Treatment

5

9.19+/-5.58

4.09+/-2.43

5.1

-0.91

-55.50%

Control

4

7.74+/-6.94

4.92+/-1.99

2.82

-0.41

-43.14%

Total

9

8.55+/-5.85

4.46+/-2.15

4.09

-0.7

-47.84%

EC_M/L (cm)

0

Treatment

5

9.6+/-7.96

5.37+/-5.94

4.23

-0.53

-44.06%

Control

4

4.83+/-1.94

10.28+/-10.32

5.45

+2.81

+112.84%

Total

9

7.48+/-6.28

7.56+/-8.01

0.08

+0.01

+1.07%

EC_Area (cm2)

Treatment

5

47.9+/-46.53

12.66+/-15.63

35.24

-0.76

-73.57%

Control

4

15.31+/-14.8

8.14+/-6.52

7.17

-0.48

-54.97%

Total

9

33.42+/-38.21

10.65+/-11.99

22.77

-0.6

-68.13%

EC_Dist (cm)

Treatment

5

164.02+/-120.69

79.77+/-38.23

84.25

-0.69

-51.37%

Control

4

210.433+/-274.1

94.76+/-69.64

114.67

-0.42

-54.97%

Total

9

184.65+/-189.88

86.43+/-51.12

98.22

-0.52

-53.19%

EC_Var (cm)

Treatment

5

0.17+/-0.14

0.07+/-0.05

0.1

-0.71

-58.82%

Control

4

0.17+/-0.24

0.12+/-0.05

0.05

-0.21

-29.41%

Total

9

0.17+/-0.18

0.09+/-0.08

0.08

-0.44

-47.06%



Figure 2. Bar Graph of Effect Size Calculations for Dependent Variables in Eyes Closed Stance Among Treatment and Control Groups.

DISCUSSION

This research study is significant and beneficial to the field because to the primary researcher's knowledge it is the first of its kind. This is the first study designed focusing on adults with DS over the age of 18 years old and use of a Nintendo Wii Fit balance regimen implemented in a community setting for improvement of balance and postural control. Wuang, Chiang, Su, and Wang (2011) conducted a similar study to determine if virtual reality using Wii gaming technology could improve sensorimotor functions when compared to standard occupational therapy among children with DS. Fine motor integration, upper-limb coordination, and running speed and agility improved among the intervention group when compared to the control (p<.05). Wuang et al. (2011) had a larger sample size (n=105) and a longer intervention period (24 weeks) when compared to this research study (n=11, 5 weeks).

Similarly, Berg et al. (2012) conducted an eight week case study to determine if motor outcomes would improve following a Nintendo Wii intervention for a child with DS. Berg et al. (2012) had a longer time frame to implement their Nintendo Wii intervention (4 sessions per week for eight weeks). Berg et al. (2012) used the Biodex BioSway Balance system to measure postural sway. Similar results were found when the study by Berg et al. (2012) was compared to the current research study, concluding that anterior/posterior sway improved as medial/lateral sway declined. Berg et al. (2012) calculated minimum important difference (MID) for balance (which is similar to effect size calculations for this research study) to find meaningful results and found that mean change score did exceed the MID (1.61 to .57), with lower numbers meaning an improvement. Similarly, for this research study effect size was calculated to determine potentially meaningful results and even though the treatment effects were not better than the control effects in the eyes open stance, the eyes closed provided larger effects in the treatment group for the variable anterior/posterior sway (d = .91) which showed 55.50% decrease in sway.

Due to lack of literature on the effects of a Nintendo Wii Fit balance program on postural control and balance among adults with DS research utilizing the Wii Fit, balance games on other populations were analyzed. Byrne, Roberts, Squires, and Rohr (2012) conducted a study to determine if a three week intervention (total of eight sessions) using Wii Fit balance games was capable of improving dynamic balance among healthy young adults (n=19). All variables improved with the exclusion of posterolateral and anteromedial (p<.05). These variables are similar to the medial/lateral sway measured within this research study as well as research by Berg et al. (2012) who found that medial/lateral sway declined after the intervention. It should be noted that Byrne et al. (2012) conducted their intervention in a laboratory setting. It may be suspected that if participants in the present study were taken into a laboratory setting along with an increased sample size there may have been statistically significant differences at post testing measures.

Future Directions/Limitations

Based on the findings of this research study and literature by Heller, Hsieh, and Rimmer (2002), it may be beneficial to add a qualitative dependent variable that measures enjoyment as well as adding a dependent variable that measures the participant's parent/guardian perception on the Nintendo Wii Fit games. Importantly, future studies should also focus on gathering a larger sample size and to increase the length of the intervention. It would also be beneficial to include a true control group that only continues the activities the participants were previously participating in, a comparison group utilizing games such as the Nintendo Wii Sport, and an experimental group that utilizes the Nintendo Wii Balance. Future studies may also consider implementing a smaller participant to researcher ratio, due to those with DS having a shorter attention span than the general population (National Down Syndrome Society, 2014b). It may also be speculated that adding a familiarization period will help eliminate any test learning effects that could have occurred between the pre and post testing of this research study. Additional functional balance testing for pre and post assessments may provide insight into the practical improvements of balance after a Nintendo Wii Balance intervention.

Conclusion

The Nintendo Wii Fit balance games can be easily implemented as well as an enjoyable mode of exercise for adults with DS. Based on previous literature and meaningful effect size calculations of this study, it may be determined this is one possible method for improving balance among adults with DS. Specifically implementing this game into special needs communities similar to Wings would be an easy and efficient way to incorporate training for improvement of quality of life by working on improving balance. It should also be addressed that within this research study there were greater improvements in the comparison group, who used the Nintendo Wii Sports games, only in the eyes open stances. This may also be an indicator that if the Nintendo Wii Sports and/or the Nintendo Wii Fit Balance games are implemented in a special needs community setting, they would elicit better balance, more fun, and greater quality of life. In conclusion, although there were not statistically significant improvements in balance among adults with DS after completion of a Nintendo Wii Fit Balance intervention, this mode of balance training still may be effective in improving balance due to meaningful effect sizes. The adults with DS who played both the balance and sports games appeared to enjoy the games and looked forward to playing the games every session; this information in itself is important for exercise adherence. The Nintendo Wii Fit may be an innovative and exciting mode of improving balance among adults with DS.

References

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About the Authors

Michelle Miller, M.S.
Michelle is a Doctoral student at Oklahoma State University, majoring in Health and Human Performance.
She earned her B.S. in Sports Wellness and Recreation management from Oklahoma Christian University
and her M.S. in Wellness Management - Exercise Science at the University of Central Oklahoma.
Her current research interests include improving balance and postural control and gait analysis among older adults and adults with special needs.

Melissa Powers, Ph.D.
Melissa is an associate professor in the Department of Kinesiology and Health Studies at the University of Central Oklahoma.
She earned her B.S.E in Kinesiology, M.S. in Exercise Science, and her Ph.D in Exercise Science from the University of Arkansas.
Her current research interests include physical activity promotion and fall prevention among older adults.

Jacilyn Olson, Ph.D.
Jacilyn is an assistant professor in the Department of Kinesiology and Health Studies at the University of Central Oklahoma.
She earned her B.S. and M.S. from Fort Hays State University and her Ph.D in exercise science from the University of Arkansas.
Her research interests include the interaction of biological markers of stress and fitness as well as exercise programming forspecial populations, especially Parkinson 's disease.

Donna Kearns, Ph.D.
Donna is a professor in the Department of Psychology at the University of Central Oklahoma and has 45 years of experience working with people with disabilities. She earned her B.Ed. in
Mental Retardation and her M.Ed. in Educational Psychology both from the University of Hawaii, and she earned her Ed.D. in Special Education Administration and Learning Disabilities from the University of Missouri. Currently she specializes in working with individuals with autism, behavioral issues, and transition from school to life.

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