Wii Fit balance training or progressive balance training in patients with chronic stroke: a randomised controlled trial

Wii Fit-Based Biofeedback Rehabilitation Among Post-Stroke Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

BACKGROUND

Stroke is one of the most widespread reasons for acquired adult disability. Recent experimental studies have reported the beneficial influence of Wii Fit-based feedback on improving overall balance and gait for stroke survivors.

METHODS

We conducted a systematic review of the literature using the following keywords to retrieve the data: feedback, biofeedback, stroke, visual, auditory, tactile, virtual reality, videogame rehabilitation, Nintendo Wii stroke, videogame stroke, exergame stroke, Nintendo Wii rehabilitation, balance, and gait. A review and meta-analysis of RCTs regarding Wii Fit-based rehabilitation accompanied by conventional therapy effects on Berg Balance Scale (BBS), Timed Up and Go (TUG), functional reach test, and gait (speed) in stroke survivors was conducted.

OBJECTIVE

To determine the impacts of Wii Fit-based feedback combined with traditional therapy on balance and gait in stroke survivors.

RESULTS

22 studies were included. The meta-analysis results revealed statistically significant improvements in functional ambulation measured using TUG (p < 0.0001), balance measured using BBS (p = 0.0001), and functional reach test (p = 0.01), but not in gait speed (p = 0.32) following Wii Fit-based feedback. Regarding the types of feedback, significant differences were found in BBS scores when mixed visual and auditory feedback was used.

CONCLUSION

Wii Fit-based feedback has desired effects on improving balance in stroke patients, making it a suitable adjunct to physical therapy.

Effects of Virtual Reality Training Using Xbox Kinect on Balance, Postural Control, and Functional Independence in Subjects with Stroke

Purpose: To determine the effects of virtual reality training using Xbox Kinect on balance, postural control, and functional independence in subjects with stroke. Methods: The parallel double-blind randomized control trial was conducted on 41 individuals based on selection criteria. Participants were divided into two groups by concealed envelope method. Intervention group received exergaming by Xbox Kinect, and control group was given exercises comprising balance training, upper limb strengthening, and core strengthening. Berg balance scale (BBS), functional independence measure (FIM), trunk impairment scale (TIS), and timed up and go (TUG) were the outcome measures. Data were analyzed using SPSS v21. Results: Mean age of the participants of Xbox and exercise group were 58.6 ± 3.3 and 58.1 ± 4.3 years, respectively. Within group improvement was observed in both groups from baseline to 8 weeks postintervention; BBS: 34 ± 4.7 to 40.9 ± 4.9 in intervention group and 34.1 ± 4.4 to 38.1 ± 7.6 in control group, TUG: 25.6 ± 3.9 to 21.4 ± 3.8 and 28.6 ± 5.0 to 25.9 ± 4.7, TIS: 15.2 ± 1.8 to 19.2 ± 1.3 and 13.2 ± 1.7 to 15.3 ± 1.6 and FIM: 58.7 ± 7.7 to 52.5 ± 7.8 and 66.2 ± 7.6 to 62.6 ± 7.2 in intervention and control group, respectively. Between group improvement was observed in TUG, TIS, and FIM in experimental group with P-values 0.003, <0.001, and <0.001, respectively. Conclusions: Wii Fit improved functional mobility, independence, and trunk coordination extension in the stroke patients, whereas balance could be equally improved from Wii Fit and exercises. Trial Registration Number: ACTRN12619001688178.

Effects of Virtual Reality-Based Exercise on Balance in Patients With Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to quantify the effects of virtual reality-based exercise on balance after stroke.

DESIGN

The PubMed, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, and Web of Science databases were searched until December 31, 2021. Independent investigators abstracted data, assessed the quality of the evidence, and rated the certainty of the evidence. The intergroup differences were determined by calculating mean difference and 95% confidence interval by RevMan 5.3 software.

RESULTS

Fourteen randomized controlled trials involving 423 stroke patients were included. Patients who received virtual reality-based exercise illustrated marked improvements in the Berg Balance Scale (mean difference, 1.35; 95% confidence interval, 0.58 to 1.86; P < 0.00001; I2 = 44%), Timed Up and Go test (mean difference, -0.81; 95% confidence interval, -1.18 to -0.44; P < 0.0001; I2 = 0%), Functional Reach Test (mean difference, 3.06; 95% confidence interval, 1.31-4.80; P = 0.0006; I2 = 0%), 10-Meters Walking Test (mean difference, -1.53; 95% confidence interval, -2.92 to -0.13; P = 0.03; I2 = 33%), and Modified Barthel Index (mean difference, 5.26; 95% confidence interval, 1.70 to 8.82; P = 0.004; I2 = 0%) compared with the control group.

CONCLUSIONS

Existing low-evidence analyses showed that virtual reality-based exercise could effectively and safely improve balance in chronic stroke. Longer-term virtual reality-based exercise was more effective on functional ability of stroke.

POSTURAL BALANCE ON BASKETBALL INJURIES

ABSTRACT Introduction: Contemporary basketball has become more competitive and aggressive in the competition process, increasing the corresponding sport's risks. Objective: Analyze the injury risks arising from basketball and study the effects that postural balance training has on them. Methods: A controlled experiment was conducted, in which the experimental group used balance training and the control group used general physical training. Each training lasted one hour, twice a week, and the experimental period was nine weeks. Results: The total FMS scores of the two groups were improved before and after sports training, and the FMS scores of the control group were raised from 14.71 to 15.15, showing no significant difference (P>0.05). The total FMS score in the experimental group increased from 14.38 to 17.69, much higher than the experimental group. It was found that there was a very significant difference. Conclusion: The method proposed in this paper can effectively increase the postural balance ability of athletes, thus reducing the risk of sports injuries in the development of sports. Level of evidence II; Therapeutic studies - investigation of treatment results.

Effects of Balance Training Using a Virtual Reality Program in Hemiplegic Patients

Therapeutic goals for hemiplegic patients with neurological impairments are mainly focused on improving their independent lives. Based on the previously reported effectiveness of Wii Fit balance training, this study investigated the most influential outcomes after long-term intensive training (including balance and functional factors) on quality of life in hemiplegic patients. The intervention group (n = 21) received Nintendo Wii Fit balance training under supervision, and control group (n = 20) received conventional balance training by an occupational therapist. Two groups were matched based on age and onset duration. Both groups received a total of 15 treatments for 30 min per session, twice a week for 8 weeks. There were significant improvements not only in balance confidence and activities of daily living, but also in body composition, such as fat proportion and metabolic rate, in the intervention group compared to the control group (p < 0.05). In particular, balance confidence significantly affected EuroQoL Visual Analogue Scale according to stepwise multiple regression analyses in this study. These results demonstrated that Wii Fit balance training using virtual reality improved the quality of life of hemiplegic patients while overcoming the asymmetrical weight distribution of the affected side via the self-modulating biofeedback exercises.

Effects of exergaming on functional outcomes in people with chronic stroke: A systematic review and meta-analysis

AIMS

The aim of this review is to synthesize and evaluate effectiveness of exergaming on balance, lower limb functional mobility and functional independence in individuals with chronic stroke.

DESIGN

The present review is a systematic review and meta-analysis. The review is written in accordance with the guidelines from the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) DATA SOURCE: Searches were conducted across seven databases (PubMed, EMBASE, Web of Science, CINAHL, CENTRAL, Scopus and PEDro) and in grey literature from inception until January 2021.

REVIEW METHODS

Only randomized controlled trials (RCTs) written in English were included. All eligible studies were assessed for risk of bias by two reviewers independently. Meta-analyses were performed using RevMan 5.4.1 software. Narrative syntheses were adopted whenever meta-analysis was inappropriate. The overall quality of evidence from included studies was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework.

RESULTS

4511 records were retrieved, with 32 RCTs eligible for inclusion and 27 RCTs included in meta-analysis. Meta-analyses reported statistically significant small effect sizes favouring exergaming on balance (pooled standardized mean difference [SMD] = 0.25, 95% confidence interval [CI, 0.08-0.41], p = .004), lower limb functional mobility (pooled SMD = 0.29, 95% CI [0.08-0.50], p = .007) and functional independence (pooled SMD = 0.41, 95% CI [0.09-0.73], p = .01). Most of the included studies failed to provide adequate description of the measures taken to prevent bias.

CONCLUSION

Exergaming has favourable effects on improving balance, lower limb functional mobility and functional independence among individuals with chronic stroke, making it a suitable adjunct to conventional physiotherapy.

IMPACT

People with chronic stroke have difficulty achieving the required rehab intensity. Exergaming can help individuals with chronic stroke to undertake further rehabilitation exercises at home. It can be a suitable adjunct to conventional physiotherapy.

Commercial videogames in stroke rehabilitation: systematic review and meta-analysis

Objective: The aim of this article was to perform a systematic review of all studies (both observational and experimental) wherein commercial video games were used in comprehensive rehabilitation (both physical and cognitive areas) after stroke.Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed, and all observational and experimental studies that met at least six PEDro scale criteria were included. A total of 50 studies were included in the Meta-Analysis. Data analysis was performed using RevMan 5.3 and the bias with JAMOVI.Results: In observational studies, results favored intervention with video games in terms of functionality such as Fulg-Meyer Assessment scores [standard mean difference (SMD) = -0.45; 95% CI = -0.74 to -0.15; p = .94; I2 = 0%)] and when measured in the upper limbs using the Wolf Motor Function Test (SMD = 0.41; 95% CI = 0.07 to 0.74; p = .47; I2 = 0%). Other results showed heterogeneity. In the experimental group, most results tended to favor the experimental group and showed homogeneity, but they were not significant. Fail Safe N was calculated, and the results were not biased.Conclusions: Results tend to favor intervention with commercial video games, but the heterogeneity of the measuring instruments and small sample size do not allow for significant results to be obtained. Future research should provide the number of participants, mean, and standard deviation to facilitate future meta-analyses. Commercial video games appear to be a feasible tool in physical and cognitive stroke rehabilitation.

Effect of posture control training using virtual reality program on sitting balance and trunk stability in children with cerebral palsy

OBJECTIVE

We aimed to determine whether the posture control training in the sitting posture using virtual reality (VR) training program affects sitting balance and trunk stability in children with spastic cerebral palsy (CP).

METHODS

The experiment was conducted for 4 weeks by randomly allocating 20 children with CP. The experimental group (n = 10) performed balance training in the sitting position using a VR training program, and the control group (n = 10) performed arm reach training in the sitting position. To evaluate static and dynamic sitting balance and trunk stability, the Wii Balance Board and Balancia software, the modified functional reach test, and the Korean version of the Trunk Control Measurement Scale were used.

RESULTS

There were significant differences between the two groups in the changes in speed and postural swing distance before and after training (p < 0.05). The mFRT measurement showed significant differences in all directions before and after training between the two groups (p < 0.05). However, there was no significant difference between the two groups in the K-TCMS score.

CONCLUSIONS

Posture control training in the sitting position using a VR training program was found to be more effective in improving the sitting balance and trunk stability of children with CP.

Effectiveness of Nintendo Wii and Physical Therapy in Functionality, Balance, and Daily Activities in Chronic Stroke Patients

OBJECTIVES

The aim of this study was to assess whether a virtual rehabilitation program using Nintendo Wii added to conventional physical therapy improved functionality, balance, and daily activities in chronic stroke survivors, when compared with conventional physical therapy.

DESIGN

We undertook a randomized controlled clinical trial. The participants of this study were randomized to 2 groups: (1) conventional physical therapy (CPTG), which included exercises related to functionality, balance, and activities of daily living; and (2) virtual reality with Nintendo Wii (VRWiiG), which included balance training with the Wii Balance Board and upper limb exercises with the Wii Sports package, added to conventional physical therapy.

SETTING AND PARTICIPANTS

This study was conducted in a university rehabilitation clinic and 29 stroke survivors were admitted.

METHODS

Both interventions lasted 4 weeks, 2 sessions per week. Assessments were performed at baseline and at the end of the study, including functionality [Timed up and go (TUG)], balance [Tinetti Performance-Oriented Mobility Assessment (POMA)], Berg Balance Scale (BBS), and activities of daily living [Fugl-Meyer Upper Limb Motor Assessment, Barthel Index, Frenchay Activity Index (FAI)].

RESULTS

Regarding TUG, POMA, and BBS, the analysis of variance showed significant differences for time and group∗time interaction. Post hoc analysis showed between-group differences (P = .044, d = -0.78; P = .012, d = 1.00; P = .042, d = 0.79, respectively) and within-group differences only in the VRWiiG (P < .001, d = 0.75; P < .001, d = -0.76; P < .001, d = -0.57, respectively). Regarding activities of daily living, post hoc analysis showed within-group differences only in VRWiiG.

CONCLUSIONS AND IMPLICATIONS

Our study showed promising results in functionality, balance, and activities of daily living when adding virtual reality with Nintendo Wii to conventional physical therapy in chronic stroke survivors. All procedures were approved by the Human Research Ethics Committee of the University of Valencia (H1518177391901). ClinicalTrials.gov database (NLM identifier NCT04144556).

How Commercially Available Virtual Reality-Based Interventions Are Delivered and Reported in Gait, Posture, and Balance Rehabilitation: A Systematic Review

OBJECTIVE

Virtual reality (VR) technologies are increasingly used in physical rehabilitation; however, it is unclear how VR interventions are being delivered, and, in particular, the role of the therapist remains unknown. The purpose of this study was to systematically evaluate how commercially available VR technologies are being implemented in gait, posture, and balance rehabilitation, including justification, content, procedures, and dosage of the intervention and details of the therapist role.

METHODS

Five databases were searched between 2008 and 2018. Supervised interventional trials with >10 adult participants using commercially available VR technologies to address mobility limitations were independently selected by 2 authors. One author extracted reported intervention characteristics into a predesigned table and assessed methodological quality, which was independently verified by a second author. A total of 29 studies were included.

RESULTS

Generally, minimal clinical reasoning was provided to justify technology or activity selection, with recreational systems and games used most commonly (n = 25). All but 1 study used a single interventional technology. When explicitly described, the intervention was delivered by a physical therapist (n = 14), a therapist assistant (n = 2), both (n = 1), or an occupational therapist (n = 1). Most studies reported supervision (n = 12) and safeguarding (n = 8) as key therapist roles, with detail of therapist feedback less frequently reported (n = 4). Therapist involvement in program selection, tailoring, and progression was poorly described.

CONCLUSION

Intervention protocols of VR rehabilitation studies are incompletely described and generally lack detail on clinical rationale for technology and activity selection and on the therapist role in intervention design and delivery, hindering replication and translation of research into clinical practice. Future studies utilizing commercially available VR technologies should report all aspects of intervention design and delivery and consider protocols that allow therapists to exercise clinical autonomy in intervention delivery.

IMPACT STATEMENT

The findings of this systematic review have highlighted that VR rehabilitation interventions targeting gait, posture, and balance are primarily delivered by physical therapists, whose most reported role was supervision and safeguarding. There was an absence of detail regarding complex clinical skills, such as tailoring of the intervention and reasoning for the choice of technology and activity. This uncertainty around the role of the therapist as an active ingredient in VR-based rehabilitation hinders the development of implementation guidelines. To inform the optimal involvement of therapists in VR rehabilitation, it is essential that future studies report on all aspects of VR intervention design and delivery.

Video Game-Based Therapy on Balance and Gait of Patients with Stroke: A Systematic Review

Background: Stroke patients with motor, sensory and cognitive diseases can take profits from information and communication technologies—in particular, from the latest commercial video consoles, which are based on motion capture. These technologies are positioning themselves as complementary therapeutic tools for treating gait and balance disorders. In this paper, a systematic review of the effect of video game-based therapy on balance and gait in stroke patients is shown and compared with other types of treatments. Methods: A systematic review of prospective controlled clinical trials published in the main biomedical databases in English and Spanish between 2005 and 2020 was performed. The systematic review presented in this paper has been done following the Cochrane Manual recommendations and the PRISMA Declaration by two independent reviewers. Data about participants, intervention, outcome measurements and outcome measurement results were extracted. The quality of evidence of each study was assessed using Cochrane’s standard quality assessment format, which includes a description of the risk of bias. Additionally, the Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of each paper. Results: A total of 18 papers, including 479 patients, were included in this systematic review, in which the use of video consoles (in combination with conventional rehabilitation or exclusively) was compared with conventional rehabilitation to treat balance or gait in post-stroke patients. In all studies, a tendency to improve balance was found in both intervention groups, finding, in 10 of 17 studies that analysed it, a better capacity in the experimental group that included video consoles compared to the conventional rehabilitation control group. Regarding gait, in six of seven studies that analysed it, improvements were found in both intervention groups, and these improvements were greater in the experimental group than compared to the control group in three of them. Conclusions: Commercial video game systems, in combination with conventional rehabilitation, have shown positive results on balance and gait in post-stroke patients. There were variations between the trials in terms of the video consoles used and the duration, frequency and number of sessions with commercial video games. Future studies should compare the effects of commercial video game treatments on balance and gait in stroke patients with a nonintervention group to know their real efficacy.

Exergames for balance dysfunction in neurological disability: a meta-analysis with meta-regression

OBJECTIVE

To evaluate systematically the efficacy of exergames for balance dysfunction in neurological conditions and to identify factors of exergaming protocols that may influence their effects.

METHODS

We searched electronic databases for randomized clinical trials investigating the effect of commercial exergames versus alternative interventions on balance dysfunction as assessed by standard clinical scales in adults with acquired neurological disabilities. Standardized mean differences (Hedge's g) were calculated with random-effects models. Subgroup analyses and meta-regression were run to explore potential modifiers of effect size.

RESULTS

Out of 106 screened articles, 41 fulfilled criteria for meta-analysis, with a total of 1223 patients included. Diseases under investigation were stroke, Parkinson's disease, multiple sclerosis, mild cognitive impairment or early Alzheimer's disease, traumatic brain injury, and myelopathy. The pooled effect size of exergames on balance was moderate (g = 0.43, p < 0.001), with higher frequency (number of sessions per week) associated with larger effect (β = 0.24, p = 0.01). There was no effect mediated by the overall duration of the intervention and intensity of a single session. The beneficial effect of exergames could be maintained for at least 4 weeks after discontinuation, but their retention effect was specifically explored in only 11 studies, thus requiring future investigation. Mild to moderate adverse events were reported in a minority of studies. We estimated a low risk of bias, mainly attributable to the lack of double-blindness and not reporting intention-to-treat analysis.

CONCLUSIONS

The pooled evidence suggests that exergames improve balance dysfunction and are safe in several neurological conditions. The findings of high-frequency interventions associated with larger effect size, together with a possible sustained effect of exergaming, may guide treatment decisions and inform future research.

Combining physical therapy and cognitive behavioral therapy techniques to improve balance confidence and community participation in people with unilateral transtibial amputation who use lower limb prostheses: a study protocol for a randomized sham-control clinical trial

BACKGROUND

Low balance confidence is a prevalent yet overlooked issue among people who use lower limb prostheses (LLP) that can diminish community integration and quality of life. There is a critical need to develop rehabilitation programs that specifically target balance confidence in people who use LLP. Previous research has shown that multicomponent interventions including cognitive-behavioral therapy (CBT) techniques and exercise are feasible and effective for improving balance confidence in older adults. Therefore, a cognitive behavioral-physical therapy (CBPT) intervention was developed to target balance confidence and increase community integration in people who use LLP.

METHODS/DESIGN

This randomized control trial will recruit 60 people who use LLP with low balance confidence. Participants will be randomized to the CBPT intervention condition or control condition.

DISCUSSION

The trial is designed to test the effects of the CBPT intervention on balance confidence and functional mobility in lower limb prosthesis users by examining self-reported and objective measures of community integration and quality of life. The trial will also examine the relationship between changes in balance confidence and changes in community integration following participation in CBPT intervention. Additionally, through participant feedback, researchers will identify opportunities to improve intervention efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03411148. Registration date: January 26, 2018.

Effects of Virtual Reality Compared to Conventional Therapy on Balance Poststroke: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to systematically review the effect of virtual reality on balance as compared to conventional therapy alone poststroke.

METHODS

The databases of PubMed, Cochrane, and Ovid were searched using select keywords. The randomized controlled trials published between January 2000 and August 2017 in English language were included if they assessed the effect of virtual reality on balance ability compared to conventional therapy alone in adults' poststroke. The Physiotherapy Evidence Database scale was used to assess the methodological quality.

RESULTS

Fourteen papers were included in this review. The experimental groups largely (n = 13) used virtual reality in combination with conventional therapy. Among the high quality studies, significant between-group improvement favoring virtual reality in combination with conventional therapy was found on Berg Balance Scale (n = 7) and Timed Up and Go Scale (n = 7) when compared to conventional therapy alone. The studies were limited by low powered, small sample sizes ranging from 14 to 40, and lack of blinding, concealed allocation, and reporting of missing data. Thirteen homogenous (n = 348, I² = 37.6%, P = .083) studies were included in the meta-analysis using Berg Balance Scale. Significant improvement was observed in the experimental group compared to control group with a medium effect size of .64, confidence interval of .36-.92.

CONCLUSIONS

The findings of this review indicate that virtual reality when combined with conventional therapy is moderately more effective in improving balance than conventional therapy alone in individuals' poststroke.

Balance Training in Virtual Reality Promotes Performance Improvement but Not Transfer to Postural Control in People with Chronic Stroke

Objective: In people with chronic stroke, we investigated the transfer of gains obtained after balance training with virtual reality (VR) to an untrained task with similar balance demands. Materials and Methods: This study included 29 people with chronic stroke randomized into two groups: experimental (EG, n = 16) and control (CG, n = 13). The EG performed three sessions of balance training with VR using a platform-based videogame (Nintendo Wii Fit system™) for 1 week. The CG received no intervention. Transfer was evaluated through balance tests on the force platform Balance Master™, performed before and after the intervention period, for both groups. Results: The analysis of variance for repeated measures for game performance in the EG showed statistically significant improvement in scores in all five games after training (AT). In contrast, similar analysis for balance tests for the EG and CG showed no significant differences in performance index scores derived from the Balance Master tests after the intervention period for both groups. Conclusion: People with chronic stroke showed performance improvement AT with VR, but there was no transfer of the gains obtained to an untrained task with similar balance demands.

Home-based balance training using Wii Fit™: a pilot randomised controlled trial with mobile older stroke survivors

Background

Several studies have reported that using the Wii™ Balance Board can provide added value regarding balance (re-)training in neurological diseases. However, for the large group of mobile older stroke survivors, there is no evidence regarding the feasibility of an unsupervised Wii™ Balance Board training in the home setting. The aim of this study was to investigate the feasibility of a home-based Wii™ balance training for these patients and to identify methodological challenges for randomised controlled trials in the future.

Methods

We conducted a pilot randomised controlled trial with two intervention arms in participants' homes. Mobile stroke survivors (aged 60 years or above; 12 weeks after discharge from hospital) received a 6-week (once per week) supervised balance training at the study centre, followed by a 6-week (three times per week) unsupervised balance training at home. We used the Nintendo Wii™ Balance Board for one intervention arm and conventional balance exercises for the other intervention arm. Feasibility was assessed by recruiting rates, appropriateness of assessments regarding sensitivity to changes and acceptance of the intervention by the participants.

Results

In two German hospital stroke units, 349 stroke survivors were screened over a period of 6 months, 91 were eligible and 52 were interested. Twelve weeks after discharge, 14 participants agreed and 11 completed the intervention (7 men and 4 women, mean age 74 years). The Berg Balance Scale and Dynamic Gait Index showed ceiling effects already at baseline measure. The participants in both intervention arms evaluated the unsupervised training positively and feasible for self-application. No falls or injuries occurred over the intervention period, while the required scope of the exercises could largely be achieved.

Conclusions

In this pilot study, the recruitment of participants and the chosen assessments were not satisfactory due to selection bias and corresponding ceiling effects. However, the two home-based balance interventions proved feasible for mobile older stroke survivors with low functional limitations.

Trial registration

ClinicalTrials.gov, NCT02251470. Registered 29 September 2014.

Effects of a 12-month task-specific balance training on the balance status of stroke survivors with and without cognitive impairments in Selected Hospitals in Nnewi, Anambra State, Nigeria

BACKGROUND

Stroke results in varying levels of physical disabilities that may adversely impact balance with increased tendency to falls. This may intensify with cognitive impairments (CI), and impede functional recovery. Therefore, task-specific balance training (TSBT), which presents versatile task-specific training options that matches varied individual needs, was explored as a beneficial rehabilitation regime for stroke survivors with and without CI. It was hypothesized that there will be no significant difference in the balance control measures in stroke survivors with and without CI after a 12-month TSBT.

OBJECTIVE

To determine if TSBT will have comparable beneficial effects on the balance control status of sub-acute ischemic stroke survivors with CI and without CI.

METHODS

One hundred of 143 available sub-acute first ever ischemic stroke survivors were recruited using convenience sampling technique in a quasi-experimental study. They were later assigned into the cognitive impaired group (CIG) and non-cognitive impaired group (NCIG), respectively, based on the baseline presence or absence of CI, after screening with the mini-mental examination (MMSE) tool. With the help of four trained research assistants, TSBT was applied to each group, thrice times a week, 60 mins per session, for 12 months. Their balance was measured as Bergs Balance scores (BBS) at baseline, 4th, 8th, and 12th month intervals. Data were analyzed statistically using Kruskal Wallis test, and repeated measure ANOVA, at p < 0.05.

RESULTS

There was significant improvement across time points in the balance control of CIG with large effect size of 0.69 after 12 months of TSBT. There was also significant improvement across time points in the balance control of NCIG with large effect size of 0.544 after 12 months of TSBT. There was no significant difference between the improvement in CIG and NCIG after 8th and 12th months of TSBT.

CONCLUSIONS

Within the groups, a 12-month TSBT intervention significantly improved balance control, respectively, but with broader effects in the CIG than NCIG. Importantly, though between-group comparison at baseline revealed significantly impaired balance control in the CIG than NCIG, these differences were not significant at the 8th month and non-existent at the 12th month of TSBT intervention. These results underscore the robustness of TSBT to evenly address specific balance deficits of stroke survivors with and without CI within a long-term rehabilitation plan as was hypothesized.

Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review

BACKGROUND

Virtual reality (VR) has emerged as a therapeutic tool facilitating motor learning for balance and gait rehabilitation. The evidence, however, has not yet resulted in standardized guidelines. The aim of this study was to systematically review the application of VR-based rehabilitation of balance and gait in 6 neurologic cohorts, describing methodologic quality, intervention programs, and reported efficacy.

METHODS

This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. VR-based treatments of Parkinson disease, multiple sclerosis, acute and chronic poststroke, traumatic brain injury, and cerebral palsy were researched in PubMed and Scopus, including earliest available records. Therapeutic validity (CONTENT scale) and risk of bias in randomized controlled trials (RCT) (Cochrane Collaboration tool) and non-RCT (Newcastle-Ottawa scale) were assessed.

RESULTS

Ninety-seven articles were included, 68 published in 2013 or later. VR improved balance and gait in all cohorts, especially when combined with conventional rehabilitation. Most studies presented poor methodologic quality, lacked a clear rationale for intervention programs, and did not utilize motor learning principles meticulously. RCTs with more robust methodologic designs were widely recommended.

CONCLUSION

Our results suggest that VR-based rehabilitation is developing rapidly, has the potential to improve balance and gait in neurologic patients, and brings additional benefits when combined with conventional rehabilitation. This systematic review provides detailed information for developing theory-driven protocols that may assist overcoming the observed lack of argued choices for intervention programs and motor learning implementation and serves as a reference for the design and planning of personalized VR-based treatments.

REGISTRATION

PROSPERO CRD42016042051.

Virtual Reality-Based Center of Mass-Assisted Personalized Balance Training System

Poststroke hemiplegic patients often show altered weight distribution with balance disorders, increasing their risk of fall. Conventional balance training, though powerful, suffers from scarcity of trained therapists, frequent visits to clinics to get therapy, one-on-one therapy sessions, and monotony of repetitive exercise tasks. Thus, technology-assisted balance rehabilitation can be an alternative solution. Here, we chose virtual reality as a technology-based platform to develop motivating balance tasks. This platform was augmented with off-the-shelf available sensors such as Nintendo Wii balance board and Kinect to estimate one’s center of mass (CoM). The virtual reality-based CoM-assisted balance tasks (Virtual CoMBaT) was designed to be adaptive to one’s individualized weight-shifting capability quantified through CoM displacement. Participants were asked to interact with Virtual CoMBaT that offered tasks of varying challenge levels while adhering to ankle strategy for weight shifting. To facilitate the patients to use ankle strategy during weight-shifting, we designed a heel lift detection module. A usability study was carried out with 12 hemiplegic patients. Results indicate the potential of our system to contribute to improving one’s overall performance in balance-related tasks belonging to different difficulty levels.

Fall risk during opposing stance perturbations among healthy adults and chronic stroke survivors

Studies examining recovery from SLIPS and TRIPS indicate higher incidence of falls during SLIPS than TRIPS however, differences in the recovery mechanisms during these opposing perturbations have not been examined. We therefore aimed to compare the reactive balance responses contributing to fall risk during SLIPS and TRIPS at comparable perturbation intensity among community-dwelling healthy adults and chronic stroke survivors. Younger adults (N = 11), age-matched adults (N = 11) and chronic stroke survivors (N = 12) were exposed to a single SLIP and TRIP through a motorized treadmill (16 m/s²_, 0.20 m). Center of mass (COM) state stability was measured by recording COM position and velocity relative to base of support, i.e., Ḋ _COM/BOS and Ẋ _COM/BOS, respectively. Trunk and compensatory step kinematics were also recorded. During SLIPS, the incidence of falls among stroke survivors was greater than healthy adults (53.83% vs. 0%), however not for TRIPS. All groups showed higher change in postural stability from liftoff to touchdown during TRIPS than SLIPS. Among healthy adults higher change in Ḋ _COM/BOS during TRIPS was accompanied by the ability to control trunk flexion at step touchdown and lower peak trunk velocity as compared with SLIPS, with no significant differences in compensatory step length between the perturbations (p > 0.05). Chronic stroke survivors increased compensatory step length during TRIPS versus SLIPS (p < 0.05) contributing to greater stability change. They were unable to control trunk excursion and peak trunk velocity as compared with the healthy adults leading to lower stability than healthy younger and age-matched adults during SLIPS and lower stability than younger adults during TRIPS. Difficulty in trunk control during SLIPS among all individuals and compensatory step length  among stroke survivors emphasizes higher fall risk for SLIPS than TRIPS among these populations.

The contribution of Nintendo Wii Fit series in the field of health: a systematic review and meta-analysis

Background

Wii Fit was originally designed as a health and fitness interactive training experience for the general public. There are, however, many examples of Wii Fit being utilized in clinical settings. This article aims to identify the contribution of Wii Fit in the field of health promotion and rehabilitation by: (1) identifying the health-related domains for which the Wii Fit series has been tested, (2) clarifying the effect of Wii Fit in those identified health-related domains and (3) quantifying this effect.

Method

A systematic literature review was undertaken. The MEDLINE database and Games for Health Journal published content were explored using the search term “Wii-Fit.” Occurrences resulting from manual searches on Google and material suggested by experts in the field were also considered. Included articles were required to have measurements from Wii Fit activities for at least one relevant health indicator. The effect of Wii Fit interventions was assessed using meta-analyses for the following outcomes: activity-specific balance confidence score, Berg balance score (BBC) and time-up-and-go test (TUG).

Findings

A total of 115 articles highlighted that the Wii Fit has been tested in numerous healthy and pathological populations. Out of these, only a few intervention studies have focused on the prevention of chronic diseases. A large proportion of the studies focus on balance training (N = 55). This systematic review highlights several potential benefits of Wii Fit interventions and these positive observations are supported by meta-analyses data (N = 25). For example, the BBC and the TUG respond to a similar extend to Wii Fit interventions compared with traditional training.

Conclusion

Wii Fit has the potential to be used as a rehabilitation tool in different clinical situations. However, the current literature includes relatively few randomized controlled trials in each population. Further research is therefore required.

The use of commercial video games in rehabilitation: a systematic review

The aim of this paper was to investigate the effect of commercial video games (VGs) in physical rehabilitation of motor functions. Several databases were screened (Medline, SAGE Journals Online, and ScienceDirect) using combinations of the following free-text terms: commercial games, video games, exergames, serious gaming, rehabilitation games, PlayStation, Nintendo, Wii, Wii Fit, Xbox, and Kinect. The search was limited to peer-reviewed English journals. The beginning of the search time frame was not restricted and the end of the search time frame was 31 December 2015. Only randomized controlled trial, cohort, and observational studies evaluating the effect of VGs on physical rehabilitation were included in the review. A total of 4728 abstracts were screened, 275 were fully reviewed, and 126 papers were eventually included. The following information was extracted from the selected studies: device type, number and type of patients, intervention, and main outcomes. The integration of VGs into physical rehabilitation has been tested for various pathological conditions, including stroke, cerebral palsy, Parkinson's disease, balance training, weight loss, and aging. There was large variability in the protocols used (e.g. number of sessions, intervention duration, outcome measures, and sample size). The results of this review show that in most cases, the introduction of VG training in physical rehabilitation offered similar results as conventional therapy. Therefore, VGs could be added as an adjunct treatment in rehabilitation for various pathologies to stimulate patient motivation. VGs could also be used at home to maintain rehabilitation benefits.

The effects of bilateral movement training on upper limb function in chronic stroke patients

[Purpose] This study compared the functional and kinematic changes associated with two rehabilitation protocols: bilateral and unilateral movement training. [Subjects and Methods] Twenty-five patients with chronic stroke were randomly assigned to two training protocols for four weeks of training. Each training session consisted of three tasks. The tasks were performed with either the impaired and unimpaired arms moving synchronously (bilateral training) or with the impaired arm alone (unilateral training). To compare the changes associated with each rehabilitation protocol, functional and kinematic assessments were performed before and after the interventions. The functional state of each patient was measured by the Box and Block Test, and the kinematic variables were assessed by three-dimensional motion analysis. The Box and Block Test was used to assess the functional abilities of the affected upper limb. Kinematic measurements of upper limb movement were measured with a 3-dimensional motion analysis system. [Results] Results showed that the bilateral movement group had significantly improved motion of the shoulder compared to the unilateral movement group. [Conclusion] Bilateral movement training should be used to improve upper limb function in patients with chronic stroke.

Effects of Wii Fit(®) balance game training on the balance ability of students with intellectual disabilities

[Purpose] The aim of this study was to assess the effects of 8 weeks of Wii Fit balance game training on the balance abilities of students with intellectual disabilities. [Subjects and Methods] Twenty-four students with intellectual disabilities were selected and randomly divided into Wii Fit balance game training, physical education, and sedentary activity groups. The Wii Fit balance game training group received two 40-minute Wii Fit balance game training sessions per week for a total of 8 weeks. Kruskal-Wallis one-way analysis of variance and the Wilcoxon signed rank test were used to compare differences. [Results] After eight weeks of training, the Wii Fit balance game training group showed significant differences between the pre- and post-training parameters, including the duration of standing on one leg with the eyes closed, average anteroposterior movement speed, swing area per unit time, and speed strength index. The physical education group showed significant differences between the pre- and post-training speed strength index values. The sedentary activity group did not show any significant differences between the pre- and post-training parameters. [Conclusion] Wii Fit balance game training can improve static balance and lower extremity muscle strength in students with intellectual disabilities.

Immediate effects of kinesio taping on fixed postural alignment and foot balance in stroke patients

[Purpose] The main aim of this study was to identify the short-term effects of Kinesio taping (KT) on the static body alignment and overall balance function presented by the coordinate and foot balance in stroke patients. [Subjects and Methods] Thirty-eight stroke subjects were randomly allocated into the study groups. The kinematic analysis measured deviation or changes from standard body alignment and foot pressure by the human anatomy-based coordinates were examined using the Shisei Innovation System PA200 ver.9.0. [Results] The glabellas on the front view, larynx on the front view, rt. greater tubercle of the humerus (vertical changes), lt. greater tubercle of the humerus (vertical changes), posterior superior iliac spine, and greater trochanter (horizontal changes) showed statistically significant decreases, indicating dislocation from the axis center, after taping. [Conclusion] The clinical use of KT for stroke patients who have asymmetrical and imbalanced body posture could be an optimal therapeutic approach. Since more evidence based practices are needed, future studies should include large numbers of subjects and examine diverse KT application patterns.