Clinical Rehabilitation http://cre.sagepub.com/ Upper limb training using Wii Sports Resort for children with hemiplegic cerebral palsy: A randomized, single-blind trial Hsiu-Ching Chiu, Louise Ada and Hsien-Min Lee Clin Rehabil published online 21 May 2014 DOI: 10.1177/0269215514533709 The online version of this article can be found at: http://cre.sagepub.com/content/early/2014/05/21/0269215514533709
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CRE0010.1177/0269215514533709Clinical RehabilitationChiu et al.
CLINICAL REHABILITATION
Article
Upper limb training using Wii Sports Resort™ for children with hemiplegic cerebral palsy: A randomized, single-blind trial
Clinical Rehabilitation 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269215514533709 cre.sagepub.com
Hsiu-Ching Chiu1, Louise Ada2 and Hsien-Min Lee1
Abstract Objective: To investigate whether Wii Sports Resort™ training is effective and if any benefits are maintained. Design: Randomized, single-blind trial. Participants: Sixty-two hemiplegic children with cerebral palsy (6–13 years). Intervention: Experimental group undertook six weeks of home-based Wii Sports Resort™ training plus usual therapy, while the control group received usual therapy. Main measures: Outcomes were coordination, strength, hand function, and carers’ perception of hand function, measured at baseline, six, and 12 weeks by a blinded assessor. Results: There was a trend of mean difference (MD) for the experimental group to have more grip strength by six (MD 4.0 N, 95% confidence interval (CI) –0.8 to 8.8, p = 0.10) and 12 (MD 4.1 N, 95% CI –2.1 to 10.3, p = 0.19) weeks, and to have a higher quantity of hand function according to carers’ perception by six (MD 4.5 N, 95% CI –0.7 to 9.7, p = 0.09) and strengthened by 12 (MD 6.4, 95% CI 0.6 to 12.3, p = 0.03) weeks than the control group. There was no difference between groups in coordination and hand function by six or 12 weeks. Conclusion: Wii™ training did not improve coordination, strength, or hand function. Beyond the intervention, carers perceived that the children used their hands more. Keywords Cerebral palsy, hemiplegia, randomized controlled trial, upper limb, Wii™ Received: 5 November 2013; accepted: 7 April 2014
Introduction
1Department
Despite the known health benefits of regular participation in physical activity, people with cerebral palsy tend to participate less than their typically developing peers in Australia,1 the US,2,3 the Netherlands,4 Canada,5–8 and Israel.9 Even though cerebral palsy is a condition for which physical activity, and especially exercise, has been strongly
of Physical Therapy, I-Shou University, Kaohsiung City, Taiwan 2Discipline of Physiotherapy, The University of Sydney, Sydney, Australia Corresponding author: Hsiu-Ching Chiu, Department of Physical Therapy, I-Shou University, No. 8, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan. Email: [email protected]
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promoted,10,11 several studies have found that physical activity decreased with increasing age in children with cerebral palsy,1,12 and those who were non-ambulatory participated the least. These findings imply that there is a need to find strategies that will encourage children and adolescents with cerebral palsy to continue participating in exercise. Strategies that encourage continued participation in exercise will need to be enjoyable and acceptable to children with cerebral palsy. Recently, virtual reality has been proposed as a potential way of increasing physical activity in typically developing children,13 as well as children with cerebral palsy.14–16 Reid and Campbell17 suggest that virtual reality provides opportunities for social engagement between children with and without cerebral palsy, because children with cerebral palsy perceived a greater acceptance and recognition by seeing themselves performing the same activities as their peers. Virtual reality as a training tool offers the ability to prescribe the dose of exercise, i.e. the duration, frequency, and intensity of exercise. Furthermore, virtual reality may enable the performance of activities that are not able to be performed safely or at all in the real world. There have been a number of systematic reviews that point out that virtual reality motivates users to increase the duration or intensity of motor skill practice,14–16,18 provides enhanced environmental stimulation and augmented information to the user,19 and enables clinicians to control and repeat skill presentation to a greater extent than is possible in real life.19 However, all the reviews concluded that further high quality research is required to investigate the benefits of virtual reality for training children with cerebral palsy. Furthermore, most virtual reality systems are not commercially available and/or are very expensive. For this reason, low-cost, commercially available gaming systems are being examined. There are several advantages of using commercially available gaming systems to train children with cerebral palsy. First, they are readily available and relatively cheap. Second, they are portable and can, therefore, be used at home rather than requiring travel to an institution. The children and their families take responsibility for the training and this
is in line with principles of client-centred practice, patient empowerment, goal-directed training, cognitive behaviour modification, and motivational theory. Moreover, the advantages of a home programme have been documented in two previous studies.20,21 Finally, commercially available gaming systems may allow frequent, intensive exercise for a sufficiently long duration. Therefore, the aim of this study was to explore the use of Wii Sports Resorttm training for children with cerebral palsy in a home-based setting. The specific research questions were: 1. Is six weeks of Wii Sports Resorttm training effective at improving coordination, strength, hand function, and carers’ perception of hand function? 2. Are any benefits maintained six weeks beyond the period of intervention? 3. Can children with cerebral palsy carry out six weeks of Wii Sports Resorttm training at home?
Method A prospective, single-blind, randomized trial was undertaken. Children with cerebral palsy were recruited from elementary schools via advertisement or referral (from school therapists, cerebral palsy liaison officer, and word of mouth), screened by an independent recruiter, and randomly allocated to an experimental or control group after baseline measurement. Randomization was stratified by age and level of coordination using random permuted blocks of 2–4 participants. Age was divided into two strata: above and below 9.5 years old. Coordination was divided into two strata also: above and below a score of 0.35 out of 1.00 on a tracking task.22 The allocation sequence was computer-generated before the beginning of the study and participants were entered sequentially into their strata. The experimental group received six weeks of home-based Wii Sports Resorttm training plus usual therapy, whereas the control group received usual therapy only. The participants and therapists delivering the intervention could not be blinded to the intervention. Outcomes were measured at baseline (before intervention), at six weeks
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Chiu et al. (after intervention), and at 12 weeks (six weeks beyond the intervention) by an assessor blinded to group allocation. Blinding was ensured using several strategies: assessments were located outside of participants’ homes and participants were asked not to reveal details of intervention to the assessors. The Institutional Review Board of I-Shou University approved this study and informed consent was obtained from all parents or guardians of participants. Children with cerebral palsy were included if they had been diagnosed with cerebral palsy before five years of age, were aged between six and 13 years, were spastic hemiplegic (i.e. one side of body was affected much more than the other), and had enough hand function to hold the Wiitm remote control. They were excluded if they had severe cognitive or visual problems that precluded them from participating in the training sessions (as judged by relatives or at screening). The experimental group undertook home-based Wii Sports Resorttm training plus usual therapy three times a week for six weeks. Children sat or stood, depending on their ability, and this was kept constant across sessions. Training consisted of practicing four Wii Sports Resorttm games, from easiest to hardest – Bowling, Air Sports, Frisbee, and Basketball. They were chosen because these games target the upper limbs, are fun, provide immediate feedback, are easy to pick up and play, and progression is built in to the game. Bowling required the child to hold the remote in the affected hand, flex the shoulder, extend elbow, and extend the index finger to release a button on the remote, which rolled the bowling ball. Air Sports required the child to hold the remote in the affected hand with the buttons facing the ceiling, flex and then keep the shoulder still, flex/extend the elbow and the wrist to pilot a plane, and then to supinate/pronate the forearm to turn the buttons to face the ground to take pictures. Frisbee required the child to hold the remote in the affected hand, flex and then keep the shoulder still, extend the elbow horizontally, and release the index finger in a tossing motion to adjust the angle of the throw. Basketball required the child to hold the remote in the affected hand with buttons facing inward to
pick up a ball and then flex the shoulder, extend the elbow, and release the index finger to throw. Videotaped examples of the individual games can be found on the official Nintendo website.23 Each game was practiced for 10 minutes resulting in each session taking 40 minutes. A trained therapist familiar with the four games supervised one session a week and the parents/carers supervised the other two sessions. At the beginning of the six weeks training, the therapist made sure that the children and their parents understood the four games, and that they were available for follow-up telephone calls if necessary. Scores of each game played were recorded to estimate compliance. The experimental group continued usual therapy, which may have included upper limb training. The control group received usual therapy only, which may have included upper limb training. They were offered Wii Sports Resorttm training after the trial had finished. Coordination was measured at two joints separately using a tracking task. First, the children flexed and extended the elbow +5° around a midpoint of 60° in order to follow a semi-randomly moving target on a computer screen. Then, they flexed and extended the index finger +5° around a midpoint of 30° to follow the target. The ratio between the target and the response was used as the measure of coordination where a perfect score is 1.00. This task has been used previously to measure coordination in children in cerebral palsy.22 Strength was measured as maximum voluntary isometric contraction with the hand in a power grip using the PowerTrack IITM commander (Australasian Medical & Therapeutic Instruments P/L, Australia, 125 pounds rated capacity, linearity 1%) and reported in N. The children were required to grip the dynamometer as hard as possible against the palm using all fingers. The best of two trials was used in the analysis. Hand function was measured using the Ninehole Peg Test and the Jebsen–Taylor Test of Hand Function. The Nine-hole Peg Test times how long it takes to place nine dowels in nine holes and take them out again and was reported in pegs/s. The Jebsen–Taylor Test of Hand Function is also a
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timed test. The test was modified by eliminating the writing task to reduce frustration levels associated with failure to accomplish the task. The six remaining items included simulated page turning, lifting small common objects, simulated feeding, stacking checkers, lifting large light objects, lifting large heavy objects,24 and performance was reported in items/s. Carers’ perception of hand function was measured using the Functional Use Survey, scored from 0 to 65, where 65 is the best hand function. The Functional Use Survey consists of 13 unimanual and bimanual tasks, each rated on a six-point (0–5) scale separately for quantity and quality of hand use.25 The sample size was calculated to reliably detect a between-group difference in the tracking task of 0.15 out of 1.00 with 80% power at two-tailed significance level of 0.05. An effect size of 0.88 was derived from the tracking task scores of a population of people with hemiplegic cerebral palsy (Chiu et al.22) where the mean score on the tracking task was 0.32 (SD 0.17) using the same procedure as the current study. The smallest number of participants to detect an effect size of 0.88 estimated from independent samples is 21 participants per group, i.e. 42 participants in total. On the assumption that the children and/or their parents may discontinue the training, we set a target of around 60 participants in total. All measures were analysed using an intentionto-treat analysis. Descriptive statistics were calculated for all variables at the three times (weeks zero, six, and 12). The between-group differences in the change in coordination, strength, hand function, and carers’ perception of hand function from baseline to six weeks and from baseline to 12 weeks were analysed using two-way analyses of variance (ANOVA) to ascertain statistical significance, which was set at 0.05. The mean betweengroup differences (95% CI) were calculated to ascertain the clinical significance. Analyses were performed using Statistica, version 10.
Results A total of 136 children with cerebral palsy were screened for eligibility over two years (Figure 1).
Of these, 63 were excluded and 73 invited to participate. Eleven declined and so 62 children were enrolled in the trial. Of these, 32 were randomized to the experimental group and 30 to the control group. Participants in both groups were similar in terms of age, gender, side of hemiplegia, education, and level of disability according to the Manual Ability Classification System or the Gross Motor Function Classification System (Table 1). About 18 participants (29%) were undergoing any upper limb training at the time of recruitment. During the intervention phase, two participants withdrew, both from the control group. During the follow-up phase, a further three participants withdrew, two from the experimental group and one from the control. In total, 60 participants (97%) of measures were obtained at six weeks and 57 participants (92%) at 12 weeks. In terms of compliance, each experimental participant should have completed 18 sessions of training (three days a week for six weeks) so the 32 participants should have completed 576 sessions. Since 554 sessions were completed, the overall compliance was 96%. A total of 25 participants carried out all the sessions, seven carried out about 15 sessions. Bowling performance improved 14 points (15%) from good (96) to very good (110); Air Sports performance improved 14 points (47%) from moderate (30) to good (44); Frisbee performance improved 123 points (77%) from poor (160) to moderate (283); and Basketball performance improved 5 points (100%) from poor (5) to moderate (10). Group data for the three measurement occasions, within-group differences, and betweengroup differences are presented in Table 2 for all outcome measures. In terms of coordination, there was no difference between the experimental and the control group by six or 12 weeks, whether measured at the elbow (p = 0.30 and 0.15) or at the finger (p = 0.54 and 0.92). In terms of strength, there was a trend of mean difference (MD) for the experimental group to have more grip strength than the control group (MD 4.0 N, 95% CI –0.8 to 8.8, p = 0.10) by six weeks and (MD 4.1 N, 95% CI –2.1 to 10.3, p = 0.19) by 12 weeks. In terms of hand function, there was no difference between the
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Children with cerebral palsy screened by telephone (n = 136)
Excluded (n = 63) • • • • •
Not cerebral palsy (n = 7) Not spastic type (n = 7) Severe intellectual disability (n = 33) Not hemiplegia (n = 9) Botox-A injection (n = 7)
Declined (n = 11)
Measured strength, coordination, activity, participation Randomised (n = 62)
Week 0
(n = 30)
(n = 32) Experimental Group • Wii Sports Resort
TM
Control Group
• Usual therapy
Lost to Week 6 measure
-Bowling -Frisbee -Basketball -Air sports
•
• Usual therapy
Week 6
Lost to Week 12 measure
Withdrew after allocation (n = 2)
Measured strength, coordination, activity, participation (n = 32)
(n = 28)
• Usual therapy
Lost to Week 12 measure
• Usual therapy
Medical reasons (n = 1) • Did not attend (n = 1) •
•
Medical reasons (n =1)
Measured strength, coordination, activity, participation Week 12
(n = 30)
(n = 27)
Figure 1. Design and flow of participants through the trial.
experimental and the control group by six or 12 weeks, whether measured using the Nine-hole Peg Test (p = 0.91 and 0.34) or using the total score of
the Jebsen-Taylor Test of Hand Function (p = 0.89 and 0.46). In terms of the carers’ perception of hand function, there was a trend for the
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Table 1. Baseline characteristics of participants. Characteristic of participants
Age (years), mean (SD) Gender, n males (%) Gestation, n premature (%) Side of hemiplegia, n right (%) Education, n main stream (%) MACS, n (%) Level I–III Level IV–V GMFCS, n (%) Level I–III Level IV–V Usual therapy included upper limb training, n (%)
Randomized (n = 62)
Lost to follow-up (n = 5)
Exp. (n = 32)
Con. (n = 30)
Exp. (n = 2)
Con. (n = 3)
9.4 (1.9) 15 (47) 13 (41) 16 (50) 27 (84)
9.5 (1.9) 13 (43) 21 (70) 15 (50) 24 (80)
11.3 (1.1) 1 (50) 2 (100) 1 (50) 2 (100)
8.6 (1.4) 2 (67) 2 (67) 3 (100) 2 (67)
21 (66) 11 (34)
21 (70) 9 (30)
1 (50) 1 (50)
2 (67) 1 (33)
26 (81) 6 (19) 9 (28)
26 (87) 4 (13) 9 (30)
1 (50) 1 (50) 1 (50)
3 (100) 0 (0) 0 (0)
Exp.: experimental group; Con.: control group; SD: standard deviation; MACS: Manual Ability Classification System; GMFCS: Gross Motor Function Classification System.
experimental group to score higher in quantity of hand function than the control group (MD 3.2, 95% CI -1.3 to 7.7, p = 0.16) by six weeks and this perception had strengthened (MD 3.5, 95% CI -2.3 to 9.3, p = 0.23) by 12 weeks. However, this perception was not as strong in terms of quality of hand function (p = 0.16 and 0.23).
Discussion This randomized trial found that children with cerebral palsy could carry out six weeks of homebased Wii Sports Resorttm training. There was no between-group difference in coordination, hand function, or carers’ perception of the quality of hand function at any time. However, there was a trend for more grip strength in the experimental group than the control group by six and 12 weeks. There was also a trend for the carers to perceive a higher quantity of hand function in the experimental group than the control group by six weeks and this perception had strengthened by 12 weeks.
An important issue in relation to this type of home-based training is to what an extent the training was accepted by the children and their families and made a part of daily life. Six weeks is generally considered to be the minimum time needed to elicit a measurable effect.26 A rule of thumb is that athletes need to train around 10,000 hours (which corresponds to around 5 hours per day for 5–6 years) to become as good as possible. The fact that most of the children undertook all sessions and even desired to do more is encouraging and is in line with Dodd et al., 20 who found that a six-week home-based strength training programme was feasible and lead to lasting changes of muscle strength without any serious adverse events. In contrast, in a study of interactive computer games, children with cerebral palsy undertaking training 30 minutes every day for 20 weeks found that it was ‘hard work’ and all families experienced problems persuading the children to do the training.27 The children’s interest in gaming faded somewhat over time, and the authors27 suggest that these types of games are especially suitable for
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0.30 (0.22) 0.15 (0.17) 26.0 (17.8) 0.12 (0.10) 0.22 (0.15) 34.0 (16.9) 34.7 (14.9)
0.26 (0.18) 0.17 (0.18)
23.5 (21.5)
0.10 (0.09) 0.21 (0.14)
28.1 (17.9) 30.1 (17.6)
32.7 (15.9) 34.0 (16.7)
0.10 (0.09) 0.26 (0.18)
28.3 (22.3)
0.28 (0.20) 0.17 (0.17)
32.6 (13.4) 34.5 (14.9)
0.13 (0.11) 0.27 (0.20)
26.9 (21.3)
0.28 (0.21) 0.16 (0.18)
35.6 (15.8) 34.8 (13.4)
0.11 (0.11) 0.31 (0.19)
29.7 (23.3)
0.26 (0.21) 0.18 (0.16)
33.8 (15.5) 35.3 (14.5)
0.13 (0.11) 0.34 (0.21)
29.4 (21.4)
0.25 (0.20) 0.16 (0.18)
4.6 (9.9) 3.9 (9.4)
0.00 (0.02) 0.05 (0.06)
4.9 (10.7)
0.03 (0.13) 0.01 (0.07)
Exp. Con. Exp. Con. Exp. Con. Exp. (n = 32) (n = 30) (n = 32) (n = 28) (n = 30) (n = 27)
0.1 (10.2) 0.7 (7.8)
0.01 (0.03) 0.05 (0.06)
0.9 (7.5)
–0.01 (0.13) 0.02 (0.14)
Con.
8.1 (9.7) 5.2 (10.3)
0.01 (0.11) 0.09 (0.07)
7.1 (13.1)
0.01 (0.14) 0.02 (0.11)
Exp.
1.7 (12.3) 1.7 (11.7)
0.01 (0.03) 0.10 (0.07)
3.0 (9.5)
–0.04 (0.12) 0.02 (0.11)
Con.
Week 12 minus Week 0
Week 6 minus Week 0
Week 12
Week 0
Week 6
Difference within groups
Groups
Exp: experimental group; Con: control group SD: standard deviation; CI: confidence interval.
Coordination Elbow (0–1) Finger (0–1) Strength Grip (N) Hand function Nine-hole Peg Test (pegs/s) Jebsen total (Item/s) Carers’ perception Quantity (0–65) Quality (0–65)
Outcome
Table 2. Mean (SD) of groups, mean (SD) difference within groups, and mean (95% CI) difference between groups.
Exp. minus Con.
Week 12 minus Week 0
4.1 (–2.1 to 10.3)
4.5 (–0.7 to 9.7) 3.2 (–1.3 to 7.7)
6.4 (0.5 to 12.3) 3.5 (–2.3 to 9.3)
–0.01 0.00 (–0.02 to 0.00) (–0.04 to 0.04) 0.00 –0.01 (–0.03 to 0.03) (–0.05 to 0.03)
4.0 (–0.8 to 8.8)
0.04 0.05 (–0.03 to 0.11) (–0.02 to 0.12) –0.01 0.00 (–0.07 to 0.05) (–0.06 to 0.06)
Exp. minus Con.
Week 6 minus Week 0
Difference between groups
Chiu et al. 7
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short periods of intensive training because this amount of training is high compared with most exercise programmes for children with cerebral palsy.11 The impact of motivation and engagement is highlighted as a key element of therapy, with children who are motivated being more likely to practice, leading to the potential for improved motor outcomes.28 The home-based training is used in a number of previous studies20,21,26,27 and a recent systematic review found that home programmes are as effective as expert-provided therapy.29 It was somewhat surprising that no improvement was found in coordination and hand function, since most of the games required movements to be precise, quick, and deft. This finding is consistent with Wille et al., 30 who also used the Nine-hole Peg Test as an outcome measure after virtual reality training and found no significant improvement. It is also in line with the finding that the carers perceived no improvement in quality of hand function. However, they did perceive an increase in quantity of hand function and provided anecdotal comments in support of this perception. For example, some parents reported that their children started using affected hand and thumb for the first time and one parent reported that their child produced new movements, such as being able to rotate the forearm from pronation to supination. Other parents were excited that the gaming enabled their children to do more things with and alike their peers. These anecdotes are supported by You et al.,31 who reported manifestation in the development of motor skills in the child’s affected limb after virtual reality therapy by functional magnetic resonance imaging, which indicated the development of neural motor pathways that have never been utilized. They also showed that the child was able to perform spontaneous reaching, self-feeding, and dressing, which were not possible before the intervention.31 The trend towards improvement in grip strength may be the result of forced use. Wii Sports Resorttm training, as it was used in this trial, required that the children use their affected arm and hand. Children with hemiplegic cerebral palsy generally favour
the use of their less affected upper limb in everyday activities and might not have had an opportunity to learn and develop motor skills because of learned non-use.32 The high number of repetitions while holding the remote in a power grip may have contributed to a potential benefit in grip strength. This is similar to a previous study that showed improvement in muscle strength after intervention of interactive computer games.27 A crucial question of the importance of a training programme is not only its immediate benefit, but whether any significant changes have a longlasting effect. In this study, it is encouraging that the trend towards an increase in grip strength and carers’ perception of more hand function found after six weeks of intervention was maintained or strengthened for at least a period of six weeks beyond the intervention. The mechanism for this longer term effect is not known, but it is possible that the improvement of muscle strength might lead to more permanent changes in everyday physical activities, which in turn might lead to maintenance of the strength benefits. This randomized trial has both strengths and limitations. The main limitation is that randomization was not fully concealed. Although the allocation sequence was generated by computer before the beginning of data collection, it was not hidden during recruitment. The main strength of the study is that it was fully powered to detect a reasonable between-group difference of 15% in coordination. The finding that the 95% CI of neither elbow or finger coordination at any time crossed this point, suggests that the negative finding is not owing to a Type II error, i.e. it is not owing to lack of power, but rather is owing to a lack of effect. Although the participants’ Wiitm scores improved over the six weeks of training, this did not carry over to coordination or hand function. Maybe participants used cognition to increase the Wiitm score instead of coordination.27 Therefore, more specific training, such as computer tracking at one joint, is necessary to see whether it is possible to increase coordination and whether this in turn improves hand function. Wii Sports Resorttm training did not improve coordination, strength, or hand function. However, beyond the period of intervention, carers perceived
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Chiu et al. that their children used their hands more. Commercially available gaming provides a way of exercising at home that provides motivation, intensity of training, and allows children with cerebral palsy to play with their typically developing peers.
Clinical messages • W ii Sports Resorttm training did not improve coordination, strength, or hand function. • Carers perceived that their children used their hands more after training. • Commercially available gaming is a way of exercising at home. Acknowledgements The authors would also like to acknowledge the participation of the children and their parents to make this study possible.
Conflict of interest The author declares that there is no conflict of interest.
Funding This research was, in part, supported by the National Science Council, R.O.C., under grant number NSC 99-2320-B-214 -004 and NSC 100-2320-B214-004, and by I-Shou University, under grant number ISU 99-S-04, ISU 101-S-03, and ISU 102-07-01.
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Clinical Rehabilitation cerebral palsy. Develop Med Child Neurol 2003; 45(10): 652–657. Katz-Leurer M, Rotem H, Keren O and Meyer S. The effects of a ‘home-based’ task-oriented exercise programme on motor and balance performance in children with spastic cerebral palsy and severe traumatic brain injury. Clin Rehabil 2009; 23(8): 714–724. Chiu HC, Ada L, Butler J and Coulson S. Relative contribution of motor impairments to activity and participation in people with hemiplegic cerebral palsy. Clin Rehabil 2010; 24(5): 454–462. Nintendo. Wii Sports 2010 [23 Sep]. Available at: http:// wiisportsresort.com (accessed 15 March 2014). Jebsen RH, Taylor N, Trieschmann RB, Trotter MJ and Howard LA. An objective and standardized test of hand function. Arch Phys Med Rehabil 1969; 50(6): 311–319. Charles JR, Wolf SL, Schneider JA and Gordon AM. Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: a randomized control trial. Develop Med Child Neurol 2006; 48(8): 635–642. Sandlund M, Waterworth EL and Hager C. Using motion interactive games to promote physical activity and enhance motor performance in children with cerebral palsy. Development Neurorehabil 2011; 14(1): 15–21.
27. Bilde PE, Kliim-Due M, Rasmussen B, Petersen LZ, Petersen TH and Nielsen JB. Individualized, home-based interactive training of cerebral palsy children delivered through the Internet. BMC Neurology 2011; 11: 32. 28. Winkels DG, Kottink AI, Temmink RA, Nijlant JM and Buurke JH. WiiTM-habilitation of upper extremity function in children with cerebral palsy. An explorative study. Development Neurorehabil 2013; 16(1): 44–51. 29. Novak I. Effective home programme intervention for adults: a systematic review. Clin Rehabil 2011; 25(12): 1066–1085. 30. Wille D, Eng K, Holper L, et al. Virtual reality-based paediatric interactive therapy system (PITS) for improvement of arm and hand function in children with motor impairment—a pilot study. Development Neurorehabil 2009; 12(1): 44–52. 31. You SH, Jang SH, Kim YH, Kwon YH, Barrow I and Hallett M. Cortical reorganization induced by virtual reality therapy in a child with hemiparetic cerebral palsy. Develop Med Child Neurol 2005; 47(9): 628–635. 32. Gordon AM, Charles J and Wolf SL. Methods of constraint-induced movement therapy for children with hemiplegic cerebral palsy: development of a child-friendly intervention for improving upper-extremity function. Arch Phys Med Rehabil 2005; 86(4): 837–844.
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research-article2014
CRE0010.1177/0269215514533709Clinical RehabilitationChiu et al.
CLINICAL REHABILITATION
Article
Upper limb training using Wii Sports Resort™ for children with hemiplegic cerebral palsy: A randomized, single-blind trial
Clinical Rehabilitation 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269215514533709 cre.sagepub.com
Hsiu-Ching Chiu1, Louise Ada2 and Hsien-Min Lee1
Abstract Objective: To investigate whether Wii Sports Resort™ training is effective and if any benefits are maintained. Design: Randomized, single-blind trial. Participants: Sixty-two hemiplegic children with cerebral palsy (6–13 years). Intervention: Experimental group undertook six weeks of home-based Wii Sports Resort™ training plus usual therapy, while the control group received usual therapy. Main measures: Outcomes were coordination, strength, hand function, and carers’ perception of hand function, measured at baseline, six, and 12 weeks by a blinded assessor. Results: There was a trend of mean difference (MD) for the experimental group to have more grip strength by six (MD 4.0 N, 95% confidence interval (CI) –0.8 to 8.8, p = 0.10) and 12 (MD 4.1 N, 95% CI –2.1 to 10.3, p = 0.19) weeks, and to have a higher quantity of hand function according to carers’ perception by six (MD 4.5 N, 95% CI –0.7 to 9.7, p = 0.09) and strengthened by 12 (MD 6.4, 95% CI 0.6 to 12.3, p = 0.03) weeks than the control group. There was no difference between groups in coordination and hand function by six or 12 weeks. Conclusion: Wii™ training did not improve coordination, strength, or hand function. Beyond the intervention, carers perceived that the children used their hands more. Keywords Cerebral palsy, hemiplegia, randomized controlled trial, upper limb, Wii™ Received: 5 November 2013; accepted: 7 April 2014
Introduction
1Department
Despite the known health benefits of regular participation in physical activity, people with cerebral palsy tend to participate less than their typically developing peers in Australia,1 the US,2,3 the Netherlands,4 Canada,5–8 and Israel.9 Even though cerebral palsy is a condition for which physical activity, and especially exercise, has been strongly
of Physical Therapy, I-Shou University, Kaohsiung City, Taiwan 2Discipline of Physiotherapy, The University of Sydney, Sydney, Australia Corresponding author: Hsiu-Ching Chiu, Department of Physical Therapy, I-Shou University, No. 8, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan. Email: [email protected]
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promoted,10,11 several studies have found that physical activity decreased with increasing age in children with cerebral palsy,1,12 and those who were non-ambulatory participated the least. These findings imply that there is a need to find strategies that will encourage children and adolescents with cerebral palsy to continue participating in exercise. Strategies that encourage continued participation in exercise will need to be enjoyable and acceptable to children with cerebral palsy. Recently, virtual reality has been proposed as a potential way of increasing physical activity in typically developing children,13 as well as children with cerebral palsy.14–16 Reid and Campbell17 suggest that virtual reality provides opportunities for social engagement between children with and without cerebral palsy, because children with cerebral palsy perceived a greater acceptance and recognition by seeing themselves performing the same activities as their peers. Virtual reality as a training tool offers the ability to prescribe the dose of exercise, i.e. the duration, frequency, and intensity of exercise. Furthermore, virtual reality may enable the performance of activities that are not able to be performed safely or at all in the real world. There have been a number of systematic reviews that point out that virtual reality motivates users to increase the duration or intensity of motor skill practice,14–16,18 provides enhanced environmental stimulation and augmented information to the user,19 and enables clinicians to control and repeat skill presentation to a greater extent than is possible in real life.19 However, all the reviews concluded that further high quality research is required to investigate the benefits of virtual reality for training children with cerebral palsy. Furthermore, most virtual reality systems are not commercially available and/or are very expensive. For this reason, low-cost, commercially available gaming systems are being examined. There are several advantages of using commercially available gaming systems to train children with cerebral palsy. First, they are readily available and relatively cheap. Second, they are portable and can, therefore, be used at home rather than requiring travel to an institution. The children and their families take responsibility for the training and this
is in line with principles of client-centred practice, patient empowerment, goal-directed training, cognitive behaviour modification, and motivational theory. Moreover, the advantages of a home programme have been documented in two previous studies.20,21 Finally, commercially available gaming systems may allow frequent, intensive exercise for a sufficiently long duration. Therefore, the aim of this study was to explore the use of Wii Sports Resorttm training for children with cerebral palsy in a home-based setting. The specific research questions were: 1. Is six weeks of Wii Sports Resorttm training effective at improving coordination, strength, hand function, and carers’ perception of hand function? 2. Are any benefits maintained six weeks beyond the period of intervention? 3. Can children with cerebral palsy carry out six weeks of Wii Sports Resorttm training at home?
Method A prospective, single-blind, randomized trial was undertaken. Children with cerebral palsy were recruited from elementary schools via advertisement or referral (from school therapists, cerebral palsy liaison officer, and word of mouth), screened by an independent recruiter, and randomly allocated to an experimental or control group after baseline measurement. Randomization was stratified by age and level of coordination using random permuted blocks of 2–4 participants. Age was divided into two strata: above and below 9.5 years old. Coordination was divided into two strata also: above and below a score of 0.35 out of 1.00 on a tracking task.22 The allocation sequence was computer-generated before the beginning of the study and participants were entered sequentially into their strata. The experimental group received six weeks of home-based Wii Sports Resorttm training plus usual therapy, whereas the control group received usual therapy only. The participants and therapists delivering the intervention could not be blinded to the intervention. Outcomes were measured at baseline (before intervention), at six weeks
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Chiu et al. (after intervention), and at 12 weeks (six weeks beyond the intervention) by an assessor blinded to group allocation. Blinding was ensured using several strategies: assessments were located outside of participants’ homes and participants were asked not to reveal details of intervention to the assessors. The Institutional Review Board of I-Shou University approved this study and informed consent was obtained from all parents or guardians of participants. Children with cerebral palsy were included if they had been diagnosed with cerebral palsy before five years of age, were aged between six and 13 years, were spastic hemiplegic (i.e. one side of body was affected much more than the other), and had enough hand function to hold the Wiitm remote control. They were excluded if they had severe cognitive or visual problems that precluded them from participating in the training sessions (as judged by relatives or at screening). The experimental group undertook home-based Wii Sports Resorttm training plus usual therapy three times a week for six weeks. Children sat or stood, depending on their ability, and this was kept constant across sessions. Training consisted of practicing four Wii Sports Resorttm games, from easiest to hardest – Bowling, Air Sports, Frisbee, and Basketball. They were chosen because these games target the upper limbs, are fun, provide immediate feedback, are easy to pick up and play, and progression is built in to the game. Bowling required the child to hold the remote in the affected hand, flex the shoulder, extend elbow, and extend the index finger to release a button on the remote, which rolled the bowling ball. Air Sports required the child to hold the remote in the affected hand with the buttons facing the ceiling, flex and then keep the shoulder still, flex/extend the elbow and the wrist to pilot a plane, and then to supinate/pronate the forearm to turn the buttons to face the ground to take pictures. Frisbee required the child to hold the remote in the affected hand, flex and then keep the shoulder still, extend the elbow horizontally, and release the index finger in a tossing motion to adjust the angle of the throw. Basketball required the child to hold the remote in the affected hand with buttons facing inward to
pick up a ball and then flex the shoulder, extend the elbow, and release the index finger to throw. Videotaped examples of the individual games can be found on the official Nintendo website.23 Each game was practiced for 10 minutes resulting in each session taking 40 minutes. A trained therapist familiar with the four games supervised one session a week and the parents/carers supervised the other two sessions. At the beginning of the six weeks training, the therapist made sure that the children and their parents understood the four games, and that they were available for follow-up telephone calls if necessary. Scores of each game played were recorded to estimate compliance. The experimental group continued usual therapy, which may have included upper limb training. The control group received usual therapy only, which may have included upper limb training. They were offered Wii Sports Resorttm training after the trial had finished. Coordination was measured at two joints separately using a tracking task. First, the children flexed and extended the elbow +5° around a midpoint of 60° in order to follow a semi-randomly moving target on a computer screen. Then, they flexed and extended the index finger +5° around a midpoint of 30° to follow the target. The ratio between the target and the response was used as the measure of coordination where a perfect score is 1.00. This task has been used previously to measure coordination in children in cerebral palsy.22 Strength was measured as maximum voluntary isometric contraction with the hand in a power grip using the PowerTrack IITM commander (Australasian Medical & Therapeutic Instruments P/L, Australia, 125 pounds rated capacity, linearity 1%) and reported in N. The children were required to grip the dynamometer as hard as possible against the palm using all fingers. The best of two trials was used in the analysis. Hand function was measured using the Ninehole Peg Test and the Jebsen–Taylor Test of Hand Function. The Nine-hole Peg Test times how long it takes to place nine dowels in nine holes and take them out again and was reported in pegs/s. The Jebsen–Taylor Test of Hand Function is also a
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timed test. The test was modified by eliminating the writing task to reduce frustration levels associated with failure to accomplish the task. The six remaining items included simulated page turning, lifting small common objects, simulated feeding, stacking checkers, lifting large light objects, lifting large heavy objects,24 and performance was reported in items/s. Carers’ perception of hand function was measured using the Functional Use Survey, scored from 0 to 65, where 65 is the best hand function. The Functional Use Survey consists of 13 unimanual and bimanual tasks, each rated on a six-point (0–5) scale separately for quantity and quality of hand use.25 The sample size was calculated to reliably detect a between-group difference in the tracking task of 0.15 out of 1.00 with 80% power at two-tailed significance level of 0.05. An effect size of 0.88 was derived from the tracking task scores of a population of people with hemiplegic cerebral palsy (Chiu et al.22) where the mean score on the tracking task was 0.32 (SD 0.17) using the same procedure as the current study. The smallest number of participants to detect an effect size of 0.88 estimated from independent samples is 21 participants per group, i.e. 42 participants in total. On the assumption that the children and/or their parents may discontinue the training, we set a target of around 60 participants in total. All measures were analysed using an intentionto-treat analysis. Descriptive statistics were calculated for all variables at the three times (weeks zero, six, and 12). The between-group differences in the change in coordination, strength, hand function, and carers’ perception of hand function from baseline to six weeks and from baseline to 12 weeks were analysed using two-way analyses of variance (ANOVA) to ascertain statistical significance, which was set at 0.05. The mean betweengroup differences (95% CI) were calculated to ascertain the clinical significance. Analyses were performed using Statistica, version 10.
Results A total of 136 children with cerebral palsy were screened for eligibility over two years (Figure 1).
Of these, 63 were excluded and 73 invited to participate. Eleven declined and so 62 children were enrolled in the trial. Of these, 32 were randomized to the experimental group and 30 to the control group. Participants in both groups were similar in terms of age, gender, side of hemiplegia, education, and level of disability according to the Manual Ability Classification System or the Gross Motor Function Classification System (Table 1). About 18 participants (29%) were undergoing any upper limb training at the time of recruitment. During the intervention phase, two participants withdrew, both from the control group. During the follow-up phase, a further three participants withdrew, two from the experimental group and one from the control. In total, 60 participants (97%) of measures were obtained at six weeks and 57 participants (92%) at 12 weeks. In terms of compliance, each experimental participant should have completed 18 sessions of training (three days a week for six weeks) so the 32 participants should have completed 576 sessions. Since 554 sessions were completed, the overall compliance was 96%. A total of 25 participants carried out all the sessions, seven carried out about 15 sessions. Bowling performance improved 14 points (15%) from good (96) to very good (110); Air Sports performance improved 14 points (47%) from moderate (30) to good (44); Frisbee performance improved 123 points (77%) from poor (160) to moderate (283); and Basketball performance improved 5 points (100%) from poor (5) to moderate (10). Group data for the three measurement occasions, within-group differences, and betweengroup differences are presented in Table 2 for all outcome measures. In terms of coordination, there was no difference between the experimental and the control group by six or 12 weeks, whether measured at the elbow (p = 0.30 and 0.15) or at the finger (p = 0.54 and 0.92). In terms of strength, there was a trend of mean difference (MD) for the experimental group to have more grip strength than the control group (MD 4.0 N, 95% CI –0.8 to 8.8, p = 0.10) by six weeks and (MD 4.1 N, 95% CI –2.1 to 10.3, p = 0.19) by 12 weeks. In terms of hand function, there was no difference between the
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Children with cerebral palsy screened by telephone (n = 136)
Excluded (n = 63) • • • • •
Not cerebral palsy (n = 7) Not spastic type (n = 7) Severe intellectual disability (n = 33) Not hemiplegia (n = 9) Botox-A injection (n = 7)
Declined (n = 11)
Measured strength, coordination, activity, participation Randomised (n = 62)
Week 0
(n = 30)
(n = 32) Experimental Group • Wii Sports Resort
TM
Control Group
• Usual therapy
Lost to Week 6 measure
-Bowling -Frisbee -Basketball -Air sports
•
• Usual therapy
Week 6
Lost to Week 12 measure
Withdrew after allocation (n = 2)
Measured strength, coordination, activity, participation (n = 32)
(n = 28)
• Usual therapy
Lost to Week 12 measure
• Usual therapy
Medical reasons (n = 1) • Did not attend (n = 1) •
•
Medical reasons (n =1)
Measured strength, coordination, activity, participation Week 12
(n = 30)
(n = 27)
Figure 1. Design and flow of participants through the trial.
experimental and the control group by six or 12 weeks, whether measured using the Nine-hole Peg Test (p = 0.91 and 0.34) or using the total score of
the Jebsen-Taylor Test of Hand Function (p = 0.89 and 0.46). In terms of the carers’ perception of hand function, there was a trend for the
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Table 1. Baseline characteristics of participants. Characteristic of participants
Age (years), mean (SD) Gender, n males (%) Gestation, n premature (%) Side of hemiplegia, n right (%) Education, n main stream (%) MACS, n (%) Level I–III Level IV–V GMFCS, n (%) Level I–III Level IV–V Usual therapy included upper limb training, n (%)
Randomized (n = 62)
Lost to follow-up (n = 5)
Exp. (n = 32)
Con. (n = 30)
Exp. (n = 2)
Con. (n = 3)
9.4 (1.9) 15 (47) 13 (41) 16 (50) 27 (84)
9.5 (1.9) 13 (43) 21 (70) 15 (50) 24 (80)
11.3 (1.1) 1 (50) 2 (100) 1 (50) 2 (100)
8.6 (1.4) 2 (67) 2 (67) 3 (100) 2 (67)
21 (66) 11 (34)
21 (70) 9 (30)
1 (50) 1 (50)
2 (67) 1 (33)
26 (81) 6 (19) 9 (28)
26 (87) 4 (13) 9 (30)
1 (50) 1 (50) 1 (50)
3 (100) 0 (0) 0 (0)
Exp.: experimental group; Con.: control group; SD: standard deviation; MACS: Manual Ability Classification System; GMFCS: Gross Motor Function Classification System.
experimental group to score higher in quantity of hand function than the control group (MD 3.2, 95% CI -1.3 to 7.7, p = 0.16) by six weeks and this perception had strengthened (MD 3.5, 95% CI -2.3 to 9.3, p = 0.23) by 12 weeks. However, this perception was not as strong in terms of quality of hand function (p = 0.16 and 0.23).
Discussion This randomized trial found that children with cerebral palsy could carry out six weeks of homebased Wii Sports Resorttm training. There was no between-group difference in coordination, hand function, or carers’ perception of the quality of hand function at any time. However, there was a trend for more grip strength in the experimental group than the control group by six and 12 weeks. There was also a trend for the carers to perceive a higher quantity of hand function in the experimental group than the control group by six weeks and this perception had strengthened by 12 weeks.
An important issue in relation to this type of home-based training is to what an extent the training was accepted by the children and their families and made a part of daily life. Six weeks is generally considered to be the minimum time needed to elicit a measurable effect.26 A rule of thumb is that athletes need to train around 10,000 hours (which corresponds to around 5 hours per day for 5–6 years) to become as good as possible. The fact that most of the children undertook all sessions and even desired to do more is encouraging and is in line with Dodd et al., 20 who found that a six-week home-based strength training programme was feasible and lead to lasting changes of muscle strength without any serious adverse events. In contrast, in a study of interactive computer games, children with cerebral palsy undertaking training 30 minutes every day for 20 weeks found that it was ‘hard work’ and all families experienced problems persuading the children to do the training.27 The children’s interest in gaming faded somewhat over time, and the authors27 suggest that these types of games are especially suitable for
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0.30 (0.22) 0.15 (0.17) 26.0 (17.8) 0.12 (0.10) 0.22 (0.15) 34.0 (16.9) 34.7 (14.9)
0.26 (0.18) 0.17 (0.18)
23.5 (21.5)
0.10 (0.09) 0.21 (0.14)
28.1 (17.9) 30.1 (17.6)
32.7 (15.9) 34.0 (16.7)
0.10 (0.09) 0.26 (0.18)
28.3 (22.3)
0.28 (0.20) 0.17 (0.17)
32.6 (13.4) 34.5 (14.9)
0.13 (0.11) 0.27 (0.20)
26.9 (21.3)
0.28 (0.21) 0.16 (0.18)
35.6 (15.8) 34.8 (13.4)
0.11 (0.11) 0.31 (0.19)
29.7 (23.3)
0.26 (0.21) 0.18 (0.16)
33.8 (15.5) 35.3 (14.5)
0.13 (0.11) 0.34 (0.21)
29.4 (21.4)
0.25 (0.20) 0.16 (0.18)
4.6 (9.9) 3.9 (9.4)
0.00 (0.02) 0.05 (0.06)
4.9 (10.7)
0.03 (0.13) 0.01 (0.07)
Exp. Con. Exp. Con. Exp. Con. Exp. (n = 32) (n = 30) (n = 32) (n = 28) (n = 30) (n = 27)
0.1 (10.2) 0.7 (7.8)
0.01 (0.03) 0.05 (0.06)
0.9 (7.5)
–0.01 (0.13) 0.02 (0.14)
Con.
8.1 (9.7) 5.2 (10.3)
0.01 (0.11) 0.09 (0.07)
7.1 (13.1)
0.01 (0.14) 0.02 (0.11)
Exp.
1.7 (12.3) 1.7 (11.7)
0.01 (0.03) 0.10 (0.07)
3.0 (9.5)
–0.04 (0.12) 0.02 (0.11)
Con.
Week 12 minus Week 0
Week 6 minus Week 0
Week 12
Week 0
Week 6
Difference within groups
Groups
Exp: experimental group; Con: control group SD: standard deviation; CI: confidence interval.
Coordination Elbow (0–1) Finger (0–1) Strength Grip (N) Hand function Nine-hole Peg Test (pegs/s) Jebsen total (Item/s) Carers’ perception Quantity (0–65) Quality (0–65)
Outcome
Table 2. Mean (SD) of groups, mean (SD) difference within groups, and mean (95% CI) difference between groups.
Exp. minus Con.
Week 12 minus Week 0
4.1 (–2.1 to 10.3)
4.5 (–0.7 to 9.7) 3.2 (–1.3 to 7.7)
6.4 (0.5 to 12.3) 3.5 (–2.3 to 9.3)
–0.01 0.00 (–0.02 to 0.00) (–0.04 to 0.04) 0.00 –0.01 (–0.03 to 0.03) (–0.05 to 0.03)
4.0 (–0.8 to 8.8)
0.04 0.05 (–0.03 to 0.11) (–0.02 to 0.12) –0.01 0.00 (–0.07 to 0.05) (–0.06 to 0.06)
Exp. minus Con.
Week 6 minus Week 0
Difference between groups
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short periods of intensive training because this amount of training is high compared with most exercise programmes for children with cerebral palsy.11 The impact of motivation and engagement is highlighted as a key element of therapy, with children who are motivated being more likely to practice, leading to the potential for improved motor outcomes.28 The home-based training is used in a number of previous studies20,21,26,27 and a recent systematic review found that home programmes are as effective as expert-provided therapy.29 It was somewhat surprising that no improvement was found in coordination and hand function, since most of the games required movements to be precise, quick, and deft. This finding is consistent with Wille et al., 30 who also used the Nine-hole Peg Test as an outcome measure after virtual reality training and found no significant improvement. It is also in line with the finding that the carers perceived no improvement in quality of hand function. However, they did perceive an increase in quantity of hand function and provided anecdotal comments in support of this perception. For example, some parents reported that their children started using affected hand and thumb for the first time and one parent reported that their child produced new movements, such as being able to rotate the forearm from pronation to supination. Other parents were excited that the gaming enabled their children to do more things with and alike their peers. These anecdotes are supported by You et al.,31 who reported manifestation in the development of motor skills in the child’s affected limb after virtual reality therapy by functional magnetic resonance imaging, which indicated the development of neural motor pathways that have never been utilized. They also showed that the child was able to perform spontaneous reaching, self-feeding, and dressing, which were not possible before the intervention.31 The trend towards improvement in grip strength may be the result of forced use. Wii Sports Resorttm training, as it was used in this trial, required that the children use their affected arm and hand. Children with hemiplegic cerebral palsy generally favour
the use of their less affected upper limb in everyday activities and might not have had an opportunity to learn and develop motor skills because of learned non-use.32 The high number of repetitions while holding the remote in a power grip may have contributed to a potential benefit in grip strength. This is similar to a previous study that showed improvement in muscle strength after intervention of interactive computer games.27 A crucial question of the importance of a training programme is not only its immediate benefit, but whether any significant changes have a longlasting effect. In this study, it is encouraging that the trend towards an increase in grip strength and carers’ perception of more hand function found after six weeks of intervention was maintained or strengthened for at least a period of six weeks beyond the intervention. The mechanism for this longer term effect is not known, but it is possible that the improvement of muscle strength might lead to more permanent changes in everyday physical activities, which in turn might lead to maintenance of the strength benefits. This randomized trial has both strengths and limitations. The main limitation is that randomization was not fully concealed. Although the allocation sequence was generated by computer before the beginning of data collection, it was not hidden during recruitment. The main strength of the study is that it was fully powered to detect a reasonable between-group difference of 15% in coordination. The finding that the 95% CI of neither elbow or finger coordination at any time crossed this point, suggests that the negative finding is not owing to a Type II error, i.e. it is not owing to lack of power, but rather is owing to a lack of effect. Although the participants’ Wiitm scores improved over the six weeks of training, this did not carry over to coordination or hand function. Maybe participants used cognition to increase the Wiitm score instead of coordination.27 Therefore, more specific training, such as computer tracking at one joint, is necessary to see whether it is possible to increase coordination and whether this in turn improves hand function. Wii Sports Resorttm training did not improve coordination, strength, or hand function. However, beyond the period of intervention, carers perceived
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Chiu et al. that their children used their hands more. Commercially available gaming provides a way of exercising at home that provides motivation, intensity of training, and allows children with cerebral palsy to play with their typically developing peers.
Clinical messages • W ii Sports Resorttm training did not improve coordination, strength, or hand function. • Carers perceived that their children used their hands more after training. • Commercially available gaming is a way of exercising at home. Acknowledgements The authors would also like to acknowledge the participation of the children and their parents to make this study possible.
Conflict of interest The author declares that there is no conflict of interest.
Funding This research was, in part, supported by the National Science Council, R.O.C., under grant number NSC 99-2320-B-214 -004 and NSC 100-2320-B214-004, and by I-Shou University, under grant number ISU 99-S-04, ISU 101-S-03, and ISU 102-07-01.
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