2013

http://informahealthcare.com/bijISSN: 0269-9052 (print), 1362-301X (electronic)

Brain Inj, 2013; 27(12): 1402–1408! 2013 Informa UK Ltd. DOI: 10.3109/02699052.2013.823654

ORIGINAL ARTICLE

Feasibility of gaming console exercise and its effect on endurance, gaitand balance in people with an acquired brain injury

Nelson J. McClanachan1,2, Janelle Gesch3, Nampech Wuthapanich4, Jennifer Fleming1,3,5, & Suzanne S. Kuys6,7

1School of Health and Rehabilitation Sciences, University of Queensland, Australia, 2Redcliffe Hospital, Brisbane, Australia, 3Princess Alexandra

Hospital, Brisbane, Australia, 4Centre for Research in Geriatric Medicine, University of Queensland, Australia, 5Centre of Functioning and Health

Research, Metro South Hospital and Health Service, Queensland Health, Queensland, Australia, 6Metro North Hospital and Health Service,

Queensland Health, Queensland, Australia, and 7Griffith Health Institute, Griffith University, Australia

Abstract

Objective: To determine feasibility of gaming console exercise and its effect on endurance, gaitand balance in people following acquired brain injury (ABI).Method: Twenty-one people following ABI were recruited to an 8-week randomized cross-overtrial where 4 weeks of gaming console exercise in addition to usual therapy and 4 weeks ofusual therapy alone were received. Feasibility measures included compliance, session durationand adverse events. Measures included endurance measured using a 6-minute walk test,spatiotemporal gait parameters (GAITRite) and balance using Balance Outcome Measure forElder Rehabilitation (BOOMER). Motivation was measured using the Change AssessmentQuestionnaire.Results: Compliance with gaming console exercise was high (99%), the majority of sessionsreached duration target (82%) and there were no adverse events. There were small, thoughnon-significant increases in 6-minute walk distance (18 metres, 95% CI¼�33 to 69), gait speed(0.11 m s�1, 95% CI¼�0.18 to 0.29) and balance compared to after usual therapy after gamingconsole exercise.Conclusions: Gaming console exercise appears feasible in people with ABI. Four weeks ofgaming console exercise in addition to usual therapy appears to result in similar improvementsin endurance, gait and balance compared to usual therapy alone and may enhance activeengagement in therapy.

Keywords

Brain injury, rehabilitation, virtual reality,Wii-Fit

History

Received 3 October 2012Revised 15 May 2013Accepted 7 July 2013Published online 3 October 2013

Introduction

Following an acquired brain injury many people live with

severe or profound activity limitations [1]. While the

heterogeneity of this population makes it difficult to establish

a deficit archetype [2], gait and balance deficits are common

following an acquired brain injury [2–4]. In comparison,

endurance deficits in this population have received limited

investigation [5]. This is surprising considering the import-

ance of endurance for community ambulation [6]; the level of

mobility that permits participation in social and leisure

activities [7]. In people with a traumatic brain injury, peak

aerobic capacity, a strong indicator of endurance [8], has been

reported as 65–74% of normative values [9], suggesting that

deficits in endurance, along with balance and gait, are present

in people with an acquired brain injury and necessitate

effective rehabilitation.

Cognitive, behavioural and personality impairments are

also common in people with an acquired brain injury. These

difficulties with attention, motivation and initiation [10] often

impact participation and engagement in therapy [11, 12] and

can be detrimental to physical recovery and progress in

rehabilitation [13]. With a large proportion of this population

being adolescents or young males [1] who may have difficulty

attending to a task for prolonged periods, virtual reality

represents a potentially appropriate intervention to facilitate

engagement in therapy.

Virtual reality refers to computer-generated, interactive

simulations that allow users to engage in ‘real life’ environ-

ments [14]. It has shown potential in neurological rehabili-

tation, most notably in people following stroke [14, 15].

Although upper limb retraining has generally been the focus

of investigations [14], the effects of virtual reality on

endurance, gait and balance have also been examined.

Despite a systematic review [16] finding insufficient evidence

to draw conclusions on the effect of virtual reality on gait

speed post-stroke, recent studies have reported benefits [17,

18]. Virtual reality retraining has received some investigation

in people after traumatic brain injury. Improvements in

balance [19, 20] and endurance [21, 22] have been

demonstrated, although the majority of these studies have

been single case studies. The effect of virtual reality on gait,

Correspondence: Dr Suzanne Kuys, Allied Health Research Collabora-tive, Metro North Hospital and Health Service, The Prince CharlesHospital, Rode Road, Chermside, Queensland, Australia, 4032. Tel: 61 731396319. Fax: 61 7 31396228. Email: suzanne_kuys@health.qld.gov.au

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balance and endurance deficits in people with an acquired

brain injury warrants further investigation.

The advent of commercially available gaming consoles

means that widespread implementation of virtual reality

devices is now possible. As an affordable, accessible and

simple device, the Nintendo Wii-Fit represents a practical

therapy option. It uses a pressure sensitive balance board that

tracks centre of gravity and weight shift [23]. The Nintendo

Wii-Fit includes a range of aerobic, balance, yoga and

strengthening tasks. It incorporates games that are goal-

oriented and motivating, providing visual and verbal feed-

back. The games are competitive; users try harder to ‘win’

and this could lead to increased engagement and intensity of

rehabilitation.

Although the Wii-Fit is marketed as a tool to improve

balance and fitness there is limited evidence supporting its

role in neurological rehabilitation. A recent study reported

high levels of acceptability, learnability and confidence using

the Nintendo Wii-Fit in a group of people with neurological

conditions with balance deficits [24]; however, participants

undertook only one session using the Wii-Fit. Improvements

in balance and muscle strength have been demonstrated in

healthy middle-aged women after 10 weeks of Wii-Fit [25]

and improvements in walking speed and balance were also

found in a small sample of healthy elderly adults after the

implementation of a 3-month Wii-Fit home program [26].

These results are promising and suggest that the Nintendo

Wii-Fit may be beneficial for improving endurance, gait and

balance in a neurological population.

Therefore, the aim of this study is to determine whether the

Nintendo Wii-Fit is feasible to use as an intervention during

rehabilitation in people with an acquired brain injury. The

specific research questions are: (1) Is training using the

Nintendo Wii-Fit feasible in people following an acquired

brain injury? (2) Does a 4-week Nintendo Wii-Fit interven-

tion, in addition to usual therapy, lead to improvements in

endurance, gait and balance? (3) Does the addition of

Nintendo Wii-Fit to usual therapy alter the readiness to

engage in therapy? It is hypothesized that a Nintendo Wii-Fit

intervention will be feasible, will lead to improvements in

endurance, gait and balance in people with an acquired brain

injury and may improve readiness to engage in therapy.

Methods

Design

An 8-week randomized cross-over trial using blinded assessors

and intention-to-treat analysis was conducted at a brain injury

specific rehabilitation unit. Participants underwent two 4-week

blocks of therapy; a 4-week block of Wii-Fit in addition to their

usual therapy and 4 weeks of usual therapy alone, in a

randomized order. Ethical approval was obtained from both

Hospital and University Human Research ethics committees

and all participants provided written informed consent.

Participants and setting

Participants were recruited through the Brain Injury

Rehabilitation Unit at the Princess Alexandra Hospital in

Brisbane, Australia; a 26-bed ward providing tertiary

rehabilitation services for those with an acquired brain

injury. It is the largest brain-injury specific facility in

Queensland with an annual throughput of �200 patients.

To be eligible, patients needed to have a diagnosis of an

acquired brain injury, be able to walk with supervision (with

or without an aid), have the ability to understand and follow

simple instructions and be receiving inpatient rehabilitation.

Exclusion criteria included behavioural problems affecting

participation, uncontrolled health conditions or severe visual,

vestibular or orthopaedic problems.

Intervention

Participants completed two 4-week therapy blocks in a

randomized order. One block consisted of Wii-Fit in addition

to usual therapy, while the other was usual therapy alone.

Measures were taken by a blinded assessor prior to interven-

tion (baseline), at completion of the first 4-week block and at

completion of the second 4-week block. Demographic

information such as age, gender, occupation, history of

presenting brain injury, length of post-traumatic amnesia

(PTA) and admission Clinical Outcomes Variables Scale [27]

score was collected.

During the Wii-Fit block, participants received three

sessions of Wii-Fit each week for 4 weeks. Sessions lasted

for up to 30 minutes, incorporating aerobic and balance

activities selected according to the abilities, deficits and

interests of the participant. Verbal and manual facilitation was

provided to maintain safety, guide movement and improve

technique. The duration of play was recorded for each game.

Wii-Fit was administered in addition to each participant’s

usual physiotherapy programme.

Usual physiotherapy continued throughout the duration of

the study and was conducted by qualified physiotherapists

using a combination of motor relearning and Bobath

approaches. Sessions lasted from between 30–60 minutes

and were targeted at each participant’s functional problems

and deficits.

Outcome measures

Feasibility was determined by measuring compliance with the

intervention (number and duration of sessions completed) and

by recording any adverse events. Frequency, type and duration

of games played during the Wii-Fit block were also docu-

mented. Average and maximum heart rate during each Wii-Fit

session was measured using a Polar heart rate monitor.

Once a week, during the Wii-Fit block, participant

perception of the Wii-Fit was measured. Participants were

asked to rate their level of enjoyment, workload and fatigue

during the sessions using a 10 cm horizontal visual analogue

scale (VAS) with anchors at both ends. The left anchor

reflected a low score (i.e. not enjoyable, not fatigued, light

workload), while the right anchor denoted a high score (i.e.

extremely enjoyable, extremely fatigued, heavy workload).

The Borg Rate of Perceived Exertion (RPE) [28] scale was

used to measure participant perception of the intensity during

Wii-Fit sessions.

The effect of the Wii-Fit on endurance, gait and bal-

ance was also investigated. Endurance was measured using

the 6 Minute Walk Test (6MWT) conducted in accordance

DOI: 10.3109/02699052.2013.823654 Gaming console exercise in acquired brain injury 1403

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with the American Thoracic Society Guidelines [29].

Spatiotemporal gait parameters, speed, cadence and step

length (paretic and non-paretic) were measured using a

GAITRite system [30]. Participants made two passes over the

walkway, one at a comfortable pace and the other at a fast

pace. Balance was assessed using the Balance Outcome

Measure for Elder Rehabilitation (BOOMER), a composite

measure of the standing balance construct [31] comprising a

step test, functional reach, timed up and go and static stance

with eyes closed. Performance in each of the four components

is scored on an ordinal scale out of 4, providing a total score

of 16. High-level mobility was measured using the High-level

mobility assessment tool (HiMat) [32], which comprises

13 items including high level walking tasks, stairs, running,

hopping and bounding.

Readiness to engage in therapy was measured using the

Change Assessment Questionnaire [33] specifically devel-

oped for use with individuals with a brain injury. The Change

Assessment Questionnaire, based on the Stages of Change

model [34], identifies three stages of change (pre-contempla-

tion, contemplation and action) related to self-awareness of

problems and readiness to change behaviours resulting from

the brain injury [35]. Eight items from each stage of change

are rated using a 5-point Likert scale, with 1 indicating strong

disagreement and 5 indicating strong agreement. A total

score for each stage of change (out of 40) is calculated, with

higher scores indicative of the participant’s stage of change

(e.g. higher scores on the action sub-scale indicate the

participant is in the action stage of change).

Data analysis

Descriptive statistics were calculated for all measures over the

three assessment periods; baseline, following Wii-Fit and

after usual therapy. The mean (SD) change in endurance, gait

and balance measures following each block was also

calculated as the within-intervention difference (pre-interven-

tion minus post-intervention). Between-intervention differ-

ences for endurance, gait and balance outcomes were analysed

using paired t-tests for parametric variables and Wilcoxon

Signed Ranks test for non-parametric variables. Results

were reported as means and standard deviations or means

and 95% Confidence Interval (CI). Responses on the

Change Assessment Questionnaire were totalled for each

stage (pre-contemplation, contemplation and action).

Within-intervention and between-intervention comparisons

were made using Wilcoxon Signed Ranks test. Analysis was

performed using SPSS version 19.0 and statistical signifi-

cance was set at 0.05.

Results

Participant characteristics

Twenty-one participants were recruited into the study;

10 (48%) following traumatic brain injury and 11 (52%)

following other types of brain injuries (i.e. stroke, arterio-

venous malformation resection). There were 12 males and

nine females included. Eleven (52%) participants received

Wii-Fit intervention in the first 4-weeks. Due to earlier-

than-expected discharges, not all participants completed both

intervention blocks. Three participants were discharged prior

to week 4 and only baseline data was collected for them.

Outcome measures for two assessment periods (baseline,

week 4) were collected for 18 participants. Full data was

collected for 14 participants. Figure 1 illustrates the flow of

participants through the study. Participant characteristics are

presented in Table I.

Feasibility of the intervention

Feasibility measures were recorded for the first eight

participants to complete the Wii-Fit intervention block. Due

to staffing issues, this could not be maintained over the entire

duration of the study. Compliance with Wii-Fit sessions

was 99%, with only one of the 96 prescribed sessions

(8 participants� 3 sessions� 4 weeks) missed. The target of

30 minutes activity was achieved in 82% of sessions,

increasing from week 1 (62.5%) to week 4 (92%). Sessions

that did not reach 30 minutes ranged from 16–28 minutes in

length. Over the course of the intervention, no adverse events

were recorded. Sessions comprised a combination of activities

chosen from the Wii-Fit Plus suite of games. Four games were

played in more than 50% of sessions (448 times); Penguin

slide (played 73 times), Table Tilt (61 times), Balance Bubble

(49 times) and Ski Jump (47 times). The least popular games

played (played less than 5 times) were Step basic, Golf,

Snowboarding, Juggling and Balance Bubble Plus. The mean

(range) duration of play for any game was 4 (1–21) minutes.

Average heart rate for an individual Wii-Fit session was

107 bpm (SD¼ 3). The average maximum heart rate recorded

was 131 bpm (SD¼ 6), ranging from 125 bpm (SD¼ 22) in

week 2 with the highest intensity reported in week 4

(139 bpm, SD¼ 29).

Participants rated the intensity of Wii-Fit sessions with a

mean Borg RPE score of 4.3 (SD¼ 0.3), which corresponds

to a ‘somewhat hard to hard’ level of exertion. Mean VAS

scores for workload and fatigue were 5 (SD¼ 0.2) and 4.6

(SD¼ 0.4), respectively. The Wii-Fit sessions were rated as

moderately enjoyable, with a mean VAS score of 6.7

(SD¼ 0.3).

Effect of Nintendo Wii-Fit

Table II presents the mean (SD) endurance, gait (spatiotem-

poral parameters) and balance measures taken at baseline,

following the Wii-Fit intervention (Post-Wii) and after usual

therapy (Post-Usual). The mean (SD) distance walked in

6 minutes was 374 metrres (184) post-Wii-Fit intervention

and 381 metres (197) post-usual therapy. After 4 weeks of

Wii-Fit, mean (SD) comfortable and fast gait speed were

0.98 m s�1 (0.49) and 1.31 m s�1 (0.71), respectively.

Participants achieved a mean (IQR) BOOMER score of

13 (10–16) after the Wii-Fit block.

The mean (SD) within-intervention differences for endur-

ance, gait and balance measures after Wii-Fit and usual

therapy are presented in Table II. Distance walked in 6

minutes improved 70 metres (SD¼ 49) following Wii-Fit

compared by 54 metres (SD¼ 73) after usual therapy. At a

comfortable pace, participants walked 0.18 m s�1 (SD¼ 0.17)

faster after Wii-Fit and 0.09 m s�1 (SD¼ 0.20) faster follow-

ing usual therapy. At a fast pace, participants walked

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0.22 m s�1 (SD¼ 0.23) faster following Wii-Fit and

0.24 m s�1 (SD¼ 0.25) faster after usual therapy.

Table II presents the mean (95% CI) between-intervention

differences for endurance, gait and balance measures. There

were no significant between-intervention differences for any

measure.

Engagement in therapy

At baseline, the average (SD) pre-contemplation score out of a

maximum 40 points was 16 (4), the contemplation score was

30 (6) and action score was 31 (5). These remained largely

unchanged following the Wii intervention and usual care. The

only significant difference was for the contemplation score

following usual care which increased to 33 (SD¼ 3)

(p¼ 0.05). At baseline there were 15 participants who

scored highest on the action scale, three with highest scores

on the contemplation scale, one with equal action and

contemplation scores and one with equal pre-contemplation

and action scores. After the usual care phase, there were eight

participants who scored highest on the action scale, five who

scored highest on the contemplation scale and four who

scored equally on the action and contemplation scales. After

the Wii Fit phase, 14 of the remaining 15 participants scored

highest on the action scale and the other had equal scores on

the contemplation and action scales. Therefore, the proportion

of participants endorsing statements related to the action stage

of change was greatest following the Wii-Fit phase.

Discussion

This study demonstrates that the Wii-Fit is feasible to use in

the rehabilitation of people with an acquired brain injury.

Compliance with the intervention was high, the majority of

sessions reached the target duration and participants rated the

sessions as enjoyable. Four weeks of Wii-Fit, in addition to

usual therapy, led to improvements in endurance, gait and

balance in people with an acquired brain injury. These

improvements, however, were not statistically significantly

compared to those found after usual therapy alone.

There are several features of the Wii-Fit that make it

a feasible rehabilitation tool. One is its capacity to engage

users via goal-orientated and fun virtual games. This has

been reported following other types of virtual rehabilitation

[20, 36] as well as Wii-Fit [24] and is important in people

with an acquired brain injury. The long recovery period

following acquired brain injury further emphasizes the need

for engaging, motivating and varied therapy [37]. Throughout

the entire intervention, only one Wii-Fit session was missed

Figure 1. Participant flow.

WEEK 4 - Assessment – Endurance, gait, balance measures(n = 18)

Block 2: Usual therapyalone (n = 9)

Block 2: Wii-Fit +Usual therapy (n = 9)

WEEK 8 Assessment – Endurance, gait and balance measures(n = 14)

DischargeEarly (n = 3)

Randomised to Wii-Fit + Usualtherapy (n = 11)

Randomized to Usual therapy alone(n= 10)

WEEK 0 - Baseline Assessment(Endurance, Gait, balance

measures)

Discharge Early(n =1)

DischargeEarly (n = 2)

Discharge Early(n = 1)

Assessed for eligibility andrecruited to study (n = 21)

Table I. Participant characteristics.

Characteristic M (SD) n (%)

Age (years) 33 (13)Gender

Male 12 (57)Female 9 (43)

HemiplegiaRight 5 (24)Left 10 (48)Both 6 (28)

Admission COVs score 59 (19)Admission FIM 79 (18)Time post-injury to recruitment (days) 86 (60)Length of PTA (days) (n¼ 10) 58 (27)Length of rehabilitation stay (days) 88 (44)

COVs, Clinical outcomes variables score; FIM, Functional independencemeasure; PTA, Post-traumatic amnesia.

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and this was due to a lack of available staff. The high

compliance, level of enjoyment and engagement found in the

current study could be related to several factors including

positive participant perception [24]; feeling a sense of control

by being involved in game selection and through the

competitive element participants were motivated to beat

both their own and each other’s scores. Although this latter

issue assisted with maintaining attention, it made it difficult to

correct technique and facilitate good movement as partici-

pants were pre-occupied with winning. The effectiveness of

the Wii-Fit at engaging people with an acquired brain injury

may be further illustrated by the fact that 82% of sessions

reached the prescribed duration of 30 minutes. However,

participants did change games frequently (every 4 minutes),

highlighting the need for a large selection of games and the

importance of Wii-Fit extensions such as the Wii-Fit Plus.

Another positive feature of the Wii-Fit is that it can be a

form of social activity. Following a brain injury, participation

in leisure activities is reduced [38]. Outside a hospital

environment, the Wii-Fit is a mainstream and popular leisure

activity that is viewed positively by young people and is not

associated with rehabilitation. Incorporating Wii-Fit into

therapy may assist people with an acquired brain injury to

develop the skills and confidence to use it as a form of social

activity. One participant set a goal of playing Wii-Fit with his

son at home.

Each participant’s functional ability and interests influ-

enced the selection of games played during Wii-Fit sessions.

The most frequently played games came under the ‘Balance’

category of the Wii-Fit suite. These games involved

controlled weight shifting to a target and were appropriate

for low-level patients. High-level participants, experiencing

difficulties with timing and amplitude of weight shift, also

found these games challenging. Interestingly, low-level par-

ticipants were often better at the balance games, perhaps

because of their poverty of movement. The severity of

hemiparesis also influenced game selection and some

participants were unable to play games that required two

arms (i.e. boxing) due to their hemiplegic upper limb.

Throughout the intervention period, games were often

modified to facilitate improved performance and maintain

safety. Many participants found it difficult to step repeatedly

on and off the balance board during boxing so only the

‘punching’ component was included. Several participants

with poor balance and gait required the environment to be

altered to provide increased support. This included having a

bolster set up on the unaffected side, providing manual

facilitation to the hemiplegic leg and giving rests as required.

It appears that the Wii-Fit may be feasible as a form of

endurance training. The American College of Sports

Medicine [39] proposes that, to improve cardiovascular

fitness, a training intensity of at least 55–65% of maximum

heart rate is required. Mean heart rate during Wii-Fit sessions

was between 52–64% of maximum heart rate. While this is at

the lower end of the recommended range, two participants

(out of the first eight for whom feasibility measures were

recorded) were unable to complete any aerobic games,

resulting in their heart rate showing little increase during a

session. Without these two participants, the average heart rate

within a session corresponded to between 60–72% of

maximum heart rate. Participant’s perception of the Wii-Fit

sessions also indicates that improving endurance is feasible.

Intensity of the Wii-Fit sessions was rated as ‘somewhat hard

to hard’, with moderate VAS scores also recorded for

workload and fatigue. This is positive in terms of feasibility,

demonstrating that the sessions were demanding enough to

have an effect, but did not fatigue participants to such an

extent that other therapy was affected.

It appears that 4 weeks of inpatient rehabilitation may have

some impact on endurance in people with an acquired brain

injury. This is the first study to investigate this. Participants

walked 70 metres (SD¼ 73) further in 6 minutes following

Wii-Fit and 54 metres (SD¼ 73) further after usual therapy.

This is at least the proposed minimum clinically important

difference of 54 metres [40]. Gait speed is an important

clinical measure that is associated with mortality [41],

community ambulation [6] and discharge destination [42].

The improvements recorded in comfortable (0.18 m s�1,

SD¼ 0.17) and fast gait speed (0.22 m s�1, SD¼ 0.23)

following the Wii-Fit intervention block are both more than

Table II. Mean (SD) endurance, gait and balance measures at baseline, post-Wii and post-usual. Mean (SD) within-intervention (post-Wii and post-usual) and mean (95% CI) between-intervention differences.

Assessment period Within-intervention difference Between-interventiondifference, Wii

OutcomeBaseline(n¼ 21)

Post-Wii(n¼ 15)

Post-usual(n¼ 16)

Wii(n¼ 15)

Usual(n¼ 16)

minus usual(n ¼ 14)

Endurance6MWTa (m) 288 (181) 374 (184) 381 (197) 70 (49) 54 (73) 18 (�33 to 69)

Gait parametersGait speed – comfortable (m s�1) 0.77 (0.47) 0.98 (0.49) 0.91 (0.48) 0.18 (0.17) 0.09 (0.20) 0.11 (�0.18 to 0.29)Cadence – comfortable (step min�1) 79 (32) 95 (32) 89 (32) 12 (10) 7 (14) 9 (�9 to 27)Step length – paretic (m) 0.52 (0.19) 0.58 (0.19) 0.56 (0.19) 0.04 (0.05) 0.02 (0.1) 0.05 (�0.04 to 0.12)Step length – non-paretic (m) 0.52 (0.17) 0.58 (0.20) 0.57 (0.18) 0.04 (0.07) 0.03 (0.1) 0.09 (�0.03 to 0.21)Gait speed – fast (m s�1) 1.10 (0.62) 1.31 (0.71) 1.38 (0.74) 0.22 (0.23) 0.24 (0.25) �0.03 (�0.26 to 0.20)

BalanceBOOMERb/16 12 (4) 13 (4) 13 (3) 1 (2) 0 (1) 1*HiMat/54 13 (13) 19 (15) 21 (16) 6 (6) 6 (8) �1*

a6-minute walk test; bbalance outcome measure for elder rehabilitation.*No 95% CI as Wilcoxin Signed Ranks test for non-parametric variables performed.

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the minimum clinically important difference of 0.16 m s�1

[43]. These findings support other studies that have shown

increases in gait speed following virtual rehabilitation

compared to a control intervention [15, 19, 36]. Similarly,

balance also demonstrated improvement following the Wii-Fit

intervention. These findings indicate that the addition of Wii-

Fit to usual therapy is not detrimental and may lead to

improvements in endurance, gait and balance.

Generally speaking this group of patients with an acquired

brain injury had some awareness of the problems resulting

from their brain injury; were coming to terms with their

problems and were actively seeking to change their behaviour.

The average score on the pre-contemplation sub-scale of the

Change Assessment Questionnaire was 16 points, ranging

from 10–23. Scores for the contemplation and action sub-

scales were high; in excess of 30 points. This suggests that

these participants recognized the need to change and were

already actively engaged in the rehabilitation process [33].

Participation in the Wii-Fit program was associated with

an even greater proportion of participants who scored

highest on the active scale of the Change Assessment

Questionnaire. These results, while preliminary and descrip-

tive in nature, suggest that use of a mainstream virtual reality

device in adjunct to usual therapy may enhance the level of

engagement in rehabilitation and at the very least it does not

detract from the patient’s perceived value of the therapy

experience.

There are several limitations of this study that should be

acknowledged. One of these was the relatively small sample

size. As the study was only examining feasibility and the

potential of the Wii-Fit to be used an adjunct to therapy, it was

not designed to recruit a large enough sample size to show the

benefit of Wii-Fit compared to usual therapy. The heterogen-

eity of participants recruited into the study suggests that these

results can be generalized to a large cross-section of the brain-

injured population. Stroke patients and people with a

traumatic brain injury were included, with participants

ranging from 17–52 years of age who were in varying

phases of their rehabilitation; however, this may also have

limited findings. Future studies could consider recruiting

participants that are more homogenous. This would help

clarify the benefits of a Wii-Fit intervention for brain-injured

patients of differing physical abilities and time post-injury.

A sub-set of the brain-injured population not included in this

study was those with higher-level endurance, gait and balance

deficits who did not require intensive inpatient therapy.

As they were not receiving therapy at the Brain Injury Unit for

an extended period of time, these patients were not recruited.

As a result, the findings may not be applicable to this

component of the brain-injured population.

A further limitation of the study is the cross-over design.

Typically, a cross-over study includes a washout period [44].

It was decided that this was not feasible for this study due to

the short length of stay of participants once they were eligible

for inclusion. Although it is possible that the natural rate of

recovery was faster during the first 4-week period, the large

number of participants unable to complete the third assess-

ment due to being discharged highlights the difficulty of using

a cross-over study in this setting. In future, randomized

control trials need to be conducted to more accurately

investigate the effect of Wii-Fit on endurance, gait and

balance deficits in people with an acquired brain injury.

Summary

Wii-Fit, when implemented in addition to usual therapy, is

feasible to use in the rehabilitation of people with an acquired

brain injury. Compliance was high, participants rated the

sessions as enjoyable and no adverse events were recorded.

The study suggests that the incorporation of Wii-Fit in a

rehabilitation programme is not detrimental to the therapy

programme and may result in at least similar endurance, gait

and balance improvements in people with an acquired brain

injury as usual therapy.

Acknowledgements

The authors would like to acknowledge the support of the

staff at the Brain Injury Rehabilitation Unit at the Princess

Alexandra Hospital without which this study would not have

been possible. Metro South Health Service District and The

University of Queensland Human Research and Ethics

Committees approved this study. All participants gave written

informed consent before data collection began. Trial

Registration: ACTRN12610000875000.

Declaration of interest

This project was supported by a Queensland Health HP

Research Grant. The authors report no conflicts of interest.

The authors alone are responsible for the content and writing

of the paper.

References

1. Australian Institute of Health and Welfare. Disability in Australia:acquired brain injury. Bulletin no 55. Cat no. AUS 96. Canberra:AIHW; 2007.

2. Williams G, Morris ME, Schache A, McCrory PR. Incidence of gaitabnormalities after traumatic brain injury. Archives of PhysicalMedicine & Rehabilitation 2009;90:587–593.

3. Basford JR, Chou L, Kaufman KR, Brey RH, Walker A, Malec JF,Moessner AM, Brown AW. An assessment of gait and balancedeficits after traumatic brain injury. Archives of Physical Medicine& Rehabilitation 2003;84:343–349.

4. Williams G, Galna B, Morris ME, Olver J. Spatiotemporal deficitsand kinematic classification of gait following a traumatic braininjury: a systematic review. Journal of Head Trauma Rehabilitation2010;25:366–374.

5. Mossberg KA, Ayala D, Baker T, Heard J, Masel B. Aerobiccapacity after traumatic brain injury: comparison with a nondis-abled cohort. Archives of Physical Medicine & Rehabilitation2007;88:315–320.

6. van de Port IG, Kwakkel G, Lindeman E. Community ambulationin patients with chronic stroke: how is it related to gait speed?Journal of Rehabilitation Medicine 2008;40:23–27.

7. Lord SE, McPherson K, McNaughton HK, Rochester L,Weatherall M. Community ambulation after stroke: how importantand obtainable is it and what measures appear predictive? Archivesof Physical Medicine & Rehabilitation 2004;85:234–239.

8. Tang AT, Sibley KM, Thomas SG, Bayley MT, Richardson D,McIlroy WE, Brooks D. Effects of an aerobic exercise program onaerobic capacity, spatiotemporal gait parameters, and functionalcapacity in subacute stroke. Neurorehabilitation & Neural Repair2009;23:398–406.

9. Mossberg KA, Amonette WE, Masel BE. Endurance training andcardiorespiratory conditioning after traumatic brain injury. Journalof Head Trauma Rehabilitation 2010;25:173–183.

DOI: 10.3109/02699052.2013.823654 Gaming console exercise in acquired brain injury 1407

Bra

in I

nj D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

10. Lippert-Gruner M, Kuchta J, Hellmich M, Klug N.Neurobehavioural deficits after severe traumatic brain injury(TBI). Brain Injury 2006;20:569–574.

11. Mackay LE, Bernstein BA, Chapman PE, Morgan AS, Milazzo LS.Early intervention in severe head injury: long-term benefits of aformalized program. Archives of Physical Medicine &Rehabilitation 1992;73:635–641.

12. Rappaport M, Herrero-Backe C, Rappaport ML, Winterfield KM.Head injury outcome up to ten years later. Archives of PhysicalMedicine & Rehabilitation 1989;70:885–892.

13. Lequerica AH, Rapport LJ, Loeher K, Axelrod BN, Vangel SJ,Hanks RA. Agitation in acquired brain injury: impact on acuterehabilitation therapies. Journal of Head Trauma Rehabilitation2007;22:177–183.

14. Henderson A, Korner-Bitensky N, Levin M. Virtual reality in strokerehabilitation: a systematic review of its effectiveness for upperlimb motor recovery. Topics in Stroke Rehabilitation 2007;14:52–61.

15. Holden MK. Virtual environments for motor rehabilitation: review.Cyberpsychological Behaviour 2005;8:187–219.

16. Laver K, George S, Thomas S, Deutsch JE, Crotty M. Virtualreality for stroke rehabilitation. Cochrane Database System Review2011;9:CD008349.

17. Kim JH, Jang SH, Kim CS, Jung JH, You JH. Use of virtual realityto enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled study. American Journal of PhysicalMedicine & Rehabilitation 2009;88:693–701.

18. Yang YR, Tsai MP, Chuang TY, Sung WH, Wang RY. Virtualreality-based training improves community ambulation in individ-uals with stroke: a randomized controlled trial. Gait and Posture2008;28:201–206.

19. Thornton M, Marshall S, McComas J, Finestone H, McCormick A,Sviestrup H. Benefits of activity and virtual reality based balanceexercise programmes for adults with traumatic brain injury:perceptions of participants and their caregivers. Brain Injury2005;19:989–1000.

20. Betker AL, Moussavi Z, Szturm T. Visual-based sensory motorlearning during dynamic balance tasks viewed in a virtualenvironment. Conference Proceedings IEEE Engineering inMedicine and Biology Society 2007;26:6110–6113.

21. Fulk GD. Locomotor training and virtual reality-based balancetraining for an individual with multiple sclerosis: a case report.Journal of Neurologic Physical Therapy 2005;29:34–42.

22. Flynn S, Palma P, Bender A. Feasibility of using the SonyPlayStation 2 gaming platform for an individual poststroke: a casereport. Journal of Neurologic Physical Therapy 2007;31:180–189.

23. Clark RA. Validity and reliability of the Nintendo Wii BalanceBoard for assessment of standing balance. Gait and Posture 2010;31:307–310.

24. Meldrum D, Glennon A, Herdman S, Murray D, McConn-Walsh R.Virtual reality rehabilitation of balance: assessment of the usabilityof the Nintendo Wii� Fit Plus. Disability & Rehabilitation:Assistive Technology 2012;7:205–210.

25. Nitz JC, Kuys S, Isles R, Fu S. Is the Wii Fit a new-generation toolfor improving balance, health and well-being? A pilot study.Climacteric 2010;13:487–491.

26. Agmon M, Perry CK, Phelan E, Demiris G, Nguyen H. A pilotstudy of Wii Fit exergames to improve balance in older adults.Journal of Geriatric Physical Therapy 2011;34:161–167.

27. Low Choy N, Kuys S, Richards M, Ilses R. Measurement offunctional ability following traumatic brain injury using the

Clinical Outcomes Variable Scale: a reliability study. AustralianJournal of Physiotherapy 2002;48:35–39.

28. Borg GA. Psychophysical bases of perceived exertion. Medicine &Science in Sports & Exercise 1982;14:377–381.

29. Enright PL. The six-minute walk test. Respiratory Care 2003;48:783–785.

30. Kressig RW, Beauchet O. Guidelines for clinical applications ofspatio-temporal gait analysis in older adults. Aging Clinical &Experimental Research 2006;18:174–176.

31. Haines T, Kuys S, Morrison G, Clarke J, Bew P, McPhail S.Development and validation of the balance outcome measure forelder rehabilitation. Archives of Physical Medicine &Rehabilitation 2007;88:1614–1621.

32. Williams GP, Greenwood KM, Roberston VJ, Goldie PA,Morris ME. High-Level Mobility Assessment Tool (HiMAT):interrater reliability, retest reliability, and internal consistency.Physical Therapy 2006;86:395–400.

33. Lam CS, McMahon BT, Priddy DA, Gehred-Schultz A. Deficitawareness and treatment performance among traumatic head injuryadults. Brain Injury 1988;2:235–242.

34. Prochaska JO, Velicer WF. The transtheoretical model of healthbehavior change. American Journal of Health Promotion 1997;12:38–48.

35. Fleming JM, Strong J, Ashton R. Cluster analysis of self-awareness levels in adults with traumatic brain injury andrelationshipto outcome. Journal of Head Trauma Rehabilitation1998;13:39–51.

36. Rand D, Kizony R, Weiss PT. The Sony PlayStation II EyeToy:low-cost virtual reality for use in rehabilitation. Journal ofNeurological Physical Therapy 2008;32:155–163.

37. Fleming J, Sampson J, Cornwell P, Turner B, Griffin J. Brain injuryrehabilitation: the lived experience of inpatients and their familycaregivers. Scandinavian Journal of Occupational Therapy 2012;19:184–193.

38. Fleming J, Braithwaite H, Gustafsson L, Griffin J, Collier AM,Fletcher S. Participation in leisure activities during brain injuryrehabilitation. Brain Injury 2011;25:806–818.

39. American College of Sports Medicine, Whaley MH, Brubaker PH,Otto RM, Armstrong LE. ACSM’s guidelines for exercise testingand prescription. 7th ed. Baltimore, MD: Lippincott Williams &Wilkins; 2006. p 366.

40. Fulk GD, Echternach JL, Nof L, O’Sullivan S. Clinometricproperties of the six-minute walk test in individuals undergoingrehabilitation poststroke. Physiotherapy Theory & Practice 2008;24:195–204.

41. Hardy SE, Perera S, Roumani YF, Chandler JM, Studenski SA.Improvement in usual gait speed predicts better survival in olderadults. Journal of the American Geriatric Society 2007;55:1727–1734.

42. Brauer SG, Bew PG, Kuys S, Lynch MR, Morrison G. Prediction ofdischarge destination after stroke using the motor assessment scaleon admission: a prospective, multisite study. Archives of PhysicalMedicine & Rehabilitation 2008;89:1061–1065.

43. Tilson JK, Sullivan KJ, Cen SY, Rose DK, Koradia CH, Azen SP,Duncan PW. Meaningful gait speed improvement during the first 60days poststroke: minimal clinically important difference. PhysicalTherapy 2010;90:196–208.

44. Portney LG, Watkins MP. Foundations of clinical research:applications to practice. 3rd ed. 2008. Upper Saddle River, NJ:Prentice Hall.

1408 N. J. McClanachan et al. Brain Inj, 2013; 27(12): 1402–1408

Bra

in I

nj D

ownl

oade

d fr

om in

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re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.