GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 1, Number 6, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2012.0043
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Wii Fit Balance Intervention in Community-Dwelling Older Adults Elizabeth Orsega-Smith, PhD, Julie Davis, BS, Kelley Slavish, BS, and Laura Gimbutas, BS
Abstract
Objective: The purpose of this exploratory study was to investigate the impact of the Nintendo Wii Fit (Nintendo of America, Redmond, WA) on functional and perceived balance measures in an older adult population over a 4- or 8-week program. Subjects and Methods: Twenty-five participants (71.60 – 7.79 years old) from a local senior center played Wii Fit (balance games, hula hooping, and yoga) for 30 minutes 2 days per week in either a 4-week (n = 16) or 8-week (n = 9) program. An additional nine participants served as a control group. These participants were independent, community-dwelling healthy overweight older adults (mean body mass index, 27.19 – 4.99 kg/m2). Functional balance measures included the 8-foot time up-and-go, 30-second chair stands, and the Berg Balance Scale and perceived balance were measured using the following scales: Activities-specific Balance Confidence (ABC) Scale, Falls Self-Efficacy Scale, and the Activities of Daily Living (ADL) Scale. Results: A paired t test showed significant changes pre-post program in the mean scores of chair stands, Berg Balance Scale, and ADL Scale for the 4-week participants. For the 8-week participants, significant differences were seen pre–post-program for the Berg Balance Scale, ABC Scale, and ADL Scale. There were no statistical change in the control group in the Berg Balance, ABC, and ADL Scales. Conclusions: The results of this study suggest that Wii Fit playing may be a vehicle for physical activity participation in the older adult population. It is necessary that research on the effects of exergaming on functional and perceived balance in the older adult population must continue.
Introduction
T
he number of Americans over the age of 65 years has increased from 3.1 million people in 1900 and 35 million in 2001 to the current 40.4 million, with an estimated 55 million people being 65 and older in 2020.1 Currently, those reaching the age of 65 years have an expected additional 18.8 years of life. This may lead towards the need for older adults to maintain their independence as approximately 89 percent of adults 50 and older want to remain in their current homes for as long as possible, with this statistic increasing as individuals age.2 Maintaining independence is linked with the ability to complete activities of daily living (ADLs).3 Balance is part of maintaining independence and completing ADLs in the older adult population.4 Factors associated with maintaining independence are the avoidance of falls as well and the fear of falling. It is estimated that 50 percent of community dwelling older adults have a fear of falling.5 Often those who have a fear of falling decrease their activity level, which may lead to
frailty and decreased independence.6,7 Therefore, it is important that older adults participate in physical activity as this may help decrease the downward spiral of independence and confidence and may result in maintaining one’s balance.8 Over the years, many balance-related studies have been conducted with the older adult population. Zilstra and colleagues (2007) completed a review of the literature on interventions for community-dwelling older adults to reduce their fear of falling. In their review of 12 methodologically sound published interventions, the programs that showed the most promise for reducing fear of falling were ones that were multifactorial, based on Tai Chi or those that attempted to reduce fear of falling. Many of the balance-specific interventions have been conducted in settings of institutionalized older adults or have focused on those considered frail and not on community-dwelling older adults, for whom the programs could be considered as prevention efforts.9 The use of game technology has recently been used with the older adult population to increase physical activity levels and as a form of rehabilitation. Several recent case studies
Behavioral Health and Nutrition, University of Delaware, Newark, Delaware.
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Table 1. Demographics
Age (years) Gender [% (n)] Male Female Ethnicity [% (n)] African American White Health statusa BMI (kg/m2)
Total
4 weeks
8 weeks
Program
Control
72.1 – 7.79
73.97 – 8.59
70.06 – 8.49
71.60 – 7.79
70.61 – 4.86
11.8% (4) 88.2% (30)
6.25% (1) 93.75% (15)
11.1% (1) 88.9% (8)
8% (2) 92% (23)
22.2% (2) 77.8% (7)
NA NA NA 28.05 – 5.22
12.5% (2) 87.5% (14) 2.65 – 0.61 28.58 – 4.69
33.33% (3) 66.67% (6) 2.44 – 0.88 24.73 – 4.46
20% (5) 80% (20) 2.58 – 0.71 27.19 – 4.99
NA NA NA 30.37 – 5.75
a 1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor. BMI, body mass index; NA, not available.
have utilized the Nintendo Wii (Nintendo of America, Redmond, WA) in rehabilitation of older adults 10,11as well as to test the feasibility of using the Wii Fit in healthy females.12 Nitz et al. studied the use of the Nintendo Wii Fit in women 30–58 years old as they engaged in 30-minute sessions twice per week for 10 weeks in an unsupervised setting. The women participated in all of the categories in Wii Fit (yoga, aerobic, balance, strength) but independently chose their own activities within each category. After 10 weeks, these healthy women demonstrated improvements in balance and strength measures. Pigford and Andrews implemented Wii Fit as part of a 2-week balance training intervention with an elderly man (87 years old) with a hip fracture who had a history of falls and was living in a long-term care facility. In this case, Wii Fit balance activities were included as part of the 60-minute intervention sessions held 5 days per week for 2 weeks. The segment using Wii Fit was 15–25 minutes of the overall 60minute therapy session. This participant was able to increase his scores on the Berg Balance Scale, Activities-specific Balance Confidence (ABC) Scale, and Timed Up-and-Go (TUG). Similarly, Clark and Kraemer (2010) used the Nintendo Wii as part of their therapy for an 89-year-old woman residing in a skilled nursing facility. This participant played Wii bowling for 60 minutes 3 days per week for 2 weeks. This individual also showed improvements in the TUG, Berg Balance Scale score, and the Dynamic Gait index. These studies have demonstrated evidence of improvements in balance with individual case studies of people residing in some type of care facility in which they used the Nintendo Wii. There have been few studies of communitydwelling older adults participating in balance interventions using the Wii Fit. Bainbridge et al. (2011) implemented a 6week intervention in six participants using the Wii Fit Balance Board for 30-minute sessions two times per week. Each session began and ended with yoga poses, and the aerobic and balance games varied as the weeks went on. These researchers did not find statistically significance results; this may be due the small sample size (n = 6).13 Similarly, Williams et al. (2010conducted a pilot study to determine the feasibility of use of the Wii Fit in community-dwelling older adults with a history of falling. For this study, participants (n = 15) were all over the age of 70 years and had fallen in the previous year. These participants attended individual visits twice weekly for 12 weeks; this program included balance and aerobic exercises, but the specific activities were modified at weeks 4 and 8. This study concluded that the Wii Fit is an acceptable falls
intervention in this population, although further research must be completed.14 Because of the need for more extensive studies of use of the Wii in community-dwelling older adult population, our research questions are as follows: 1. Could participation in a balance related program using the Wii Fit lead to changes in perceived and functional balance? 2. Will there be differences in changes of perceived and functional balance measures between 4- and 8-week programs using the Wii Fit?? Subjects and Methods Thirty participants were recruited during an interest meeting and through word of mouth at a Mid-Atlantic region senior center to participate in the Wii Fit program. Participants were between 55 and 86 years of age (mean age, 71.60 – 7.79 years), were mostly female (92 percent), and considered to be overweight (mean body mass index, 27.19 – 4.99 kg/m2). The majority of the sample reported their health as ‘‘very good’’ (44.0 percent) or ‘‘good’’ (44.0 percent), and no one reported their health to be ‘‘poor’’ (Table 1). Five individuals dropped out of the study because of trouble remembering their session time, medical issues, or family obligations. Therefore, the final sample consisted of 25 individuals. Sixteen of these individuals participated in the program for 4 weeks, and nine participated for the entire 8week program. Participants were assigned to groups based on their availability and commitment to a 4- or 8-week program during the intervention period. Nine participants were recruited from the same senior center as a control group and did not participate in the Wii Fit program. They had similar demographics as the participants in the study. Procedures Prior to the start of the program, participants completed a set of pre-test questionnaires (ABC Scale, ADL Scale, and Falls Efficacy Scale [FES]) addressing their perceived balance and functional balance tests (chair stands, Berg Balance Scale, and TUG). Following the pre-testing, each participant received an orientation session to the Wii Fit Plus where he or she was introduced to the games and activities. Participants played the Wii Fit Plus protocol of games for 30 minutes 2 days per week over either a 4- or 8-week period of time. The program activities included balance games (‘‘Penguin Slide,’’
Games for Health Journal 2012.1:431-435. Downloaded from online.liebertpub.com by GEORGE MASON UNIVERSITY on 01/06/15. For personal use only.
WII BALANCE INTERVENTION FOR OLDER ADULTS
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‘‘Table Tilt,’’ ‘‘Ski Slalom,’’ and ‘‘Balance Bubble’’), light aerobics ("Hula Hoop"), and yoga exercises (deep breathing, half-moon, palm tree). As some participants advanced, more challenging games were added (‘‘Snowboard Slalom,’’ ‘‘Ski Jumping’’). Those who continued on to participate for 8 weeks were given the questionnaire containing perceived measures at the midpoint, and all participants completed the perceived and functional balance testing at the end of their program. The control group participants completed functional tests 4 weeks apart. Perceived measures Balance. The ABC scale15 was used to assess participants’ confidence in performing specific activities without losing one’s balance. Participants were asked to rate their level of confidence (0–100 percent) in being able to perform 15 different tasks such as getting into or out of a car, walking in a crowded mall where people walk past them, and sweeping the floor without losing their balance or becoming unsteady on their feet. ADL. Rating of ADL16 was administered to all participants. In this 20-item scale, participants rated the extent to which they could complete each activity on a 7-point Likert scale from 1 = cannot do easily to 7 = can do easily. Examples of activities included ‘‘reaching up over head,’’ ‘‘getting items down from shelves,’’ ‘‘stooping, crouching, kneeling,’’ and ‘‘getting in and out of a tub.’’ FES. The FES17 (was used to assess the participant’s confidence in performing daily activities without falling. For each of the 10 items, participants rated their perceived ability on a 10-point Likert scale from 1 = no confidence at all to 10 = completely confident. Examples of activities included ‘‘reaching into cabinets or closets,’’ ‘‘answer the door or telephone,’’ and ‘‘do light housekeeping.’’ Functional measures Berg Balance Scale. This scale was used to measure the balance in participants through a series of 14 functional balance test measures, such as sitting to standing, standing on one foot, or standing with their eyes closed. Participants performed each of the tasks and were rated on a scale of 0–4 specific to each task. A score of 0 was indicative of being completely unable to perform the task, and a score of 4 was the ability to complete the task with no impairment.
Therefore, higher scores result in one being assessed as more independent.18 TUG. This is considered to be a good measure of several fitness indices including balance, speed, agility, and power combined into one test.19,20 Participants sat in a sturdy chair with their hands on their laps. Upon receiving a start command, they stood up, walked around a cone that was placed on the ground 8 feet away, returned to the chair, and sat down. Participants were not permitted to use their hands for support or run around the cone. Two trials were given, and the shortest time required to complete the task was recorded. Chair stands. This is a measure of lower body strength and has been deemed reliable (0.77) compared with a one repetition maximum leg press.21 Participants sat in a sturdy chair with their arms across their chests. They were instructed to stand up and sit down as many times as possible in 30 seconds. Subjects were notified when 20 seconds and when 10 seconds remained. The number of full repetitions completed during the 30 seconds was recorded. Analysis Paired t tests were used to determine the difference pre– post program. SPSS version 18 (SPSS, Inc., Chicago, IL) was used to run the statistical analysis. Analysis of variance was conducted on change scores between baseline and 4 weeks using program group (control or 4-week program) as the independent factor. Results Paired t tests showed that there was no significant change in the control group scores between baseline and the 4-week time period. For the 4-week group, there was a statistically significant improvement pre–post program in chair stands (t = 4.73; P < 0.05) and Berg Balance Scale (t = 2.46, P < 0.05). Specifically, participants’ chair stands increased from a mean of 11.81 – 3.62 chair stands in 30 seconds to 13.69 – 3.89. Scores on the Berg Balance Scale increased from 51.69 – 10.05 to 53.13 – 8.48 points. Paired t tests also showed statistical improvements for the perceived measures; there were significant changes in scores of the ADL Scale (t = 4.21; P < 0.05). However, the mean scores in the TUG, ABC, and the FES improved, indicating some individual improvements over the course of the 4-week period.
Table 2. Functional and Perceived Pre–Post-Intervention Scores by Group 4 weeks Scale
Pre score
Post score
Berg Balance 51.69 – 10.05 53.13 – 8.48 CS 11.81 – 3.62 13.69 – 3.89 TUG 7.61 – 2.17 7.44 – 2.76 ADL 126.14 – 19.53 130.36 – 12.70 ABC 86.38 – 20.70 130.36 – 12.70 FES 8.77 – 2.39 9.62 – 0.60
8 weeks t (significance) 2.46 4.73 0.76 2.01 0.92 1.31
Pre score
Post score
(P < 0.05) 54.22 – 1.79 55.44 – 0.89 (P < 0.01) 11.78 – 1.79 12.78 – 1.56 (P = 0.46) 7.14 – 1.08 6.74 – 0.76 (P < 0.05) 130.22 – 8.00 135.00 – 3.50 (P = 0.37) 87.85 – 11.19 93.93 – 5.52 (P = 0.22) 9.79 – 0.33 9.94 – 0.10
Control t (significance) 3.36 1.38 2.14 2.61 2.59 1.33
Pre score
Post score
(P < 0.05) 55.56 – 0.88 54.67 – 1.23 (P = 0.21) 12.89 – 1.61 12.22 – 1.79 (P = 0.06) 6.84 – 1.1 6.92 – 1.03 (P < 0.05) NA NA (P < 0.05) NA NA (P = 0.22) NA NA
ABC, Activities-specific Balance Confidence Scale; ADL, Activities of Daily Living; CS, chair stands; FES, Falls Efficacy Scale; NA, not available; TUG, Timed Up-and-Go.
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ORSEGA-SMITH ET AL. Table 3. Functional and Perceived Balance Change Scores by Group
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Change in scores
Berg Balance CS TUG ADL ABC FES
4 weeks
8 weeks
Control
1.44 – 2.34 1.88 – 1.59 –0.17 – 0.88 4.21 – 7.84 3.20 – 13.88 0.85 – 2.06
1.22 – 1.09 1.00 – 2.18 –0.40 – 0.57 4.78 – 5.50 6.07 – 7.04 0.16 – 0.35
–0.89 – 1.27 –0.67 – 1.00 0.08 – 0.65 NA NA NA
F statistic (significance) 5.01 6.89 0.94 0.04 0.33 0.99
(P < 0.05) (P < 0.01) (P = 0.40) (P = 0.85) (P = 0.57) (P = 0.33)
ABC, Activities-specific Balance Confidence Scale; ADL, Activities of Daily Living; CS, chair stands; FES, Falls Efficacy Scale; NA, not available; TUG, Timed Up-and-Go.
For the 8-week group, there was a statistically significant positive difference pre–post program in the Berg Balance Scale scores (t = 3.36, P < 0.05), specifically increasing from 52.22 – 1.79 to 55.44 – 0.89 points. Paired t tests also showed statistical improvements for the ABC Scale (t = 6.07; P < 0.05) and the ADL Scale (t = 4.78; P < 0.05) over the 8-week period. Similarly to the 4-week program, however, the mean scores for the chair stands, TUG, and FES improved but not significantly (Table 2). One-way analysis of variance showed a statistical significance between groups in the change scores of chair stands (F = 6.89; P < 0.01) and the Berg Balance Scale (F = 5.90; P < 0.05) (Table 3). Tukey’s post hoc test demonstrated the significant differences were between the 4-week group and the control group. This is true for both the chair stands with a mean difference of 2.54 – 0.69 (P = 0.002) and the Berg Balance Scale with a mean difference of 2.33 – 0.77 (P = 0.004). The change score between the 8-week and the control change scores for chair stands (P = 0.10) and Berg Balance Scale (P = 0.05) approached significance. Discussion Our results show that after completion of the Wii Fit program, the participants did see significant changes in measures of functional and perceived balance. Because the control group showed no significant changes between their pre- and postintervention scores, it can be assumed that the changes may be due to the actual program rather than an underlying factor. Overall, the most significant changes were seen in the change scores of the chair stands and the Berg Balance Scale, whereas there was no significant change noted for the TUG in any of the groups. This may be for a variety of reasons. The Wii Fit activities and games used in the protocol focused on static movements, which emphasized increasing one’s awareness of center of balance, overall core body strength, and lower body strength. Of the three functional balance tests that were administered, chair stands and the Berg Balance Scale utilized one’s lower body strength and incorporated static movements. In contrast, the movements for TUG began with a static movement and progressed from a static into a dynamic movement; such dynamic motions were not incorporated into the Wii Fit protocol. It is possible that this theory would explain why there were no significant improvements with the TUG. Results of one-way analysis of variance post hoc tests showed that the significance in the data was due to differences in the change scores between control group and 4-week
participants. Although the pre-intervention scores were not statistically different for the 4- and 8-week groups, for five out of the six tests, the 8-week participants did score slightly higher on pre-test scores. It may be that these higher baseline scores impacted the differences between the groups. Compared with previous studies, this research has various strengths. It was truly a community design conducted in a local community center and was not part of a specific rehabilitation therapy as in the literature where case studies used the Wii for.10,11All of the Wii Fit balance activities and sessions were supervised by trained researchers resulting in continuity in the games played, the time spent in the various Wii Fit activities, and the encouragement provided to each participant. The sample size for this study (n = 25) was larger than those previously conducted as either case studies 10,11 (or a small group of six with no control group.13,14 Limitations of this study include that the playing of the Wii games outside of the sessions was not controlled, although the majority of the participants did not use the Wii outside of the sessions. Some of the participants may have also been partaking in other forms of physical activity while participating in the program as these members of the senior center had a variety of exercise classes available to them. Furthermore, there was a ceiling effect in place for several of the functional and perceived balance tests including the Berg Balance Scale test, ABC Scale, ADL Scale, and FES. Many of the participants scored high on the pre-intervention test, leaving little or no room for improvement over the course of the program. The study population was heavily female, with two males. However, this is consistent with the gender distribution of the older adult members of the community centers from where the sample was selected. Accidental falls are the leading cause of death and injury among older adults. With the world’s population aging, this can lead to a substantial increase in health-related expense due to injuries from accidental falls among older adults.22 To combat potential expenses associated with accidental falls, researchers suggest that participation in physical activity with an emphasis in balance could help aging adults decrease their risk for fall-related injuries.7,23 Preliminary data from this study suggest that playing balance-oriented games incorporating the Wii Fit Plus may improve the balance of older adults who may be at risk for accidental falls. Furthermore, this type of program can easily be implemented in community centers, assisted living facilities, and nursing homes and in residences where the Nintendo Wii is already popular with the older adult population.
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WII BALANCE INTERVENTION FOR OLDER ADULTS Moving ahead, it is necessary to continue research on the varying effects of use of the Wii Fit on functional and perceived balance of older adults. It will be important to examine potential long-term balance effects that utilization of exergaming has on older adults after a particular program ends. Will the benefits remain, or will the participant’s balance begin to subside with time and return to his or her original level? Furthermore, research must begin to look at strategies to get more older adults to utilize Wii Fit and how to get participants to continue with a similar program in community centers or at home once research programs end. This may involve investigating some specific determinants of exercise adherence (social support, ease of activity, competition) and determining how they can be incorporated into exergaming systems. With development of more exergames aimed specifically at the older adult population, perhaps more senior centers and older living communities will continue to permanently implement exergames into their programming. Participation in such innovative balance-related activities may help combat potential aging expenses associated with accidental falls due to decreased balance. Acknowledgments This study was funded by the University of Delaware’s Summer Service Learning 2011 Program. Author Disclosure Statement No competing financial interests exist. References 1. U.S. Department of Health and Human Services, Administration on Aging. A Profile of Older Americans: 2011. US Department of Health & Human Service, Washington DC. 2. AARP. Aging in Place Initiative. A Blue Print for Action. National Association of Area Agencies on Aging and Partners for Livable Communities. 2007.Washington, DC. 3. Katz S, Down TD, Cash HR, Grotz RC. Progress in the development of the index of ADL. Gerontologist 1970; 10: 20–30. 4. Maki BE, Holliday PJ, Topper AK. Fear of falling and postural performance in the elderly. J Gerontol 1991; 46:M123– M131. 5. Fletcher P, Hirdes J. Restriction in activity associated with fear of falling among community-based seniors using home care services. Age Ageing 2004; 33:273–279. 6. Cummings S, DeWeaver K, Kropf N. Knowledge of and attitudes toward aging among non-elders: Gender and race differences. J Women Aging 2000; 12:1–2. 7. Howland J, Peterson EW, Levin W, et al. Fear of falling among the community-dwelling elderly. J Aging Health 1993; 5:229–243. 8. Shepard J. Sociology, 10th edition. Belmont, CA; Wadsworth Cengage Learning; 2009.
435 9. Zijlstra G, van Haastregt J, van Eijk J, et al. Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. Age Ageing 2007; 36:304–309. 10. Clark R, Kraemer T. Clinical use of Nintendo Wii bowling simulation to decrease fall risk in an elderly resident of a nursing home: A case report. J Geriatr Phys Ther 2010; 32:174–180. 11. Pigford T, Andrews AW. Feasibility and benefits of using Nintendo Wii Fit for balance rehabilitation in an elderly patient experiencing recurrent falls. J Student Phys Ther Res 2010; 2:12–20 12. Nitz JC, Kuys S, Isles R, Fu S. Is the Wii Fit a new generation tool for improving balance, health and well-being? A pilot study. Climacteric 2010; 13:487–491. 13. Bainbridge E, Bevans S, Keeley B, Oriel K. The effects of the Nintendo Wii Fit on community-dwelling older adults with perceived balance deficits: A pilot study. Phys Occup Ther Geriatr 2011; 29:126–135. 14. Williams M, Soiza R, Jenkinson A, Stewart A. Exercising with Computers in Later Life (EXCELL)—Pilot and feasibility study of the acceptability of the Nintendo Wii Fit in community-dwelling fallers. BMC Res Notes 2010; 3:238. 15. Powell LE, Myers AM. The activities-specific balance confidence (ABC) scale. J Gerontol A Biol Sci Med Sci. 1995 Jan;50A(1):M28–34. 16. Mihalko S, McAuley E. Strength training effects on subjective well-being and physical function in the elderly. J Aging Phys Act 1996; 4:56–68. 17. Tinetti, M., Richman, D., Powell, L. Falls efficacy as a measure of fear of falling. J Gerontol 1990; 45:239–243. 18. Berg K, Wood-Dauphine SL, Williams SJ, Maki B. Measuring balance in the elderly: Validation of an instrument. J Public Health 1992; 2(Suppl):7–11. 19. Podsiadlo D, Richardson S. The timed ‘‘up and go’’: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39:142–148. 20. Tinetti M, Williams, TF, Mayeweski R. Fall risk index for elderly patients based on a number of chronic conditions. Am J Med 1986; 80:429–434. 21. Jones C, Rikli RE, Beam WC. A 30 s chair stand test as a measure of lower body strength in community dwelling older adults. Res Q Exerc Sport 1999; 69:338–343. 22. Federal Interagency Forum on Aging-Related Statistics. 2011. www.agingstats.gov (accessed May 23, 2012). 23. Logghe IH, Verhagen AP, Rademaker AC, et al. The effects of tai chi on fall prevention, fear of falling and balance in older people: A meta-analysis. Prev Med 2010; 51:222–227.
Address correspondence to: Elizabeth Orsega-Smith, PhD Behavioral Health and Nutrition University of Delaware 9 Carpenter Sports Building 26 North College Ave Newark, DE 19716 E-mail:
[email protected]