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Table of Contents
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 196-201

Effect of balance exercises for person with multiple sclerosis using Wii® game: A systematic review of randomized and non-randomized control trials

International Master Physical Activity and Health, Institute of Sport Science and Sport, Friedrich-Alexander University Erlangen-Nürnberg, Germany

Date of Web Publication5-Jul-2017

Correspondence Address:
Hasan Tariq
International Master Physical Activity and Health, Institute of Sport Science and Sport, Friedrich-Alexander University Erlangen-Nürnberg
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Source of Support: None, Conflict of Interest: None

DOI: 10.5530/ami.2016.1.39

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Background: The recent engagement of Game base console is emerging in rehabilitation practice and its overall effectiveness has not been yetsubstantially manifested.
Objective: To evaluate the effectiveness of Wii based balance interventions among Multiple Sclerosis people.
Data Sources: A systemic search was conducted in the PubMed and Scopus data bases electronically up to February 2014.
Study Selection: Randomized and non-randomized control trials with Wii intervention on balance as an outcome measure among people with Multiple Sclerosis were included in this review.
Data Synthesis: After screening 57 studies, 7 were selected for full-text screening and 5 were included in this review. Three out of five were RCTs and rest were quasi experimental and 2-point crossover pilot studies. Total of 205 medically diagnosed mild to moderate MS people were in the selected studies with less than 6 expanded disability status scale (EDSS). Total of 13 different outcome measures were used on assessment of balance in Multiple sclerosis individuals and the most common outcomes were Berg balance scale (BBS), Center of Pressured (COP), Four Square step test (FSST), Time up and Go test (TUG). Three out of five studies report statistical significant improvement in the Four Square step test (FSST), Berg Balance Scale (BBS) and center of Pressure (COP) between intervention and control groups of MS.
Conclusion: Review of the selected studies indicates that the inclusion of Wii game in balance exercise on Multiple sclerosis people improve static balance more effectivelyas compare to dynamic balance in mild to moderate level of disability. However evidence on the mode selection in Wii, treatment setting and frequency lacking. Further studies with large sample size and more homogenize outcome measure and control setting is recommended for future.

Keywords: Wii games, Multiple sclerosis, Rehabilitation, Balance exercises, Visual feedback

How to cite this article:
Tariq H. Effect of balance exercises for person with multiple sclerosis using Wii® game: A systematic review of randomized and non-randomized control trials. Acta Med Int 2016;3:196-201

How to cite this URL:
Tariq H. Effect of balance exercises for person with multiple sclerosis using Wii® game: A systematic review of randomized and non-randomized control trials. Acta Med Int [serial online] 2016 [cited 2022 May 19];3:196-201. Available from: https://www.actamedicainternational.com/text.asp?2016/3/1/196/209708

  Introduction Top

Balance related disorder in Multiple Sclerosis (MS) is one of the cardinal predicament among the other disabilities and impairments as in Coordination, Muscle tone, Muscle strength, sensation and cognition.[1] About one quarter of the MS patients experiencedbalance related disorder[2] and according to research conducted by Cattaneo et al, reported 54% MS patients experience at least 1 fall over the last 2 months and 32% of them are recurrent faller and reported more than 2 falls.[3] Fear to fall and the fall related injuries are the limiting factor in functional capabilities of patients with Multiple sclerosis.

To overcome this disablement conventional Physiotherapy and Rehabilitations, balance and lower limb muscle strengthenexercises were implicated to MS patients to reduce functional limitation which was considered one of the major and worth considerable draw back accompanied with this disease. Although the relationship between physical activity and incident of relapses in multiple sclerosis was ambiguous paradox even in past medical community which was recently discarded by the latest studywhich report negative correlation between relapses and sport index.[4] Contemporary evidence illustrates considerable benefits if interventions were based on feedback and sensory strategies to improve or maintain motor functions.[5] Despite efficacious biomedical interventions research flow is directed towards the patient exercise adherence and behavior strategies so that efficient and long lasting results could be achieved. Research could declare the prediction on fall, as early as 6 months before with the probability of 82% that patient will fall again, if the patient has a history of fall in previous year.[1] Keeping this point of view to make the exercises more flexible, ecstatic, efficient and reliable gaming interactive technology revolutionize the rehabilitation science in 21st century. Recently growing trend of Interactive active gaming in rehabilitation science is gaining accent which claim supreme efficient intervention and long lasting exercise adherence behavior when compare with conventional physical therapy session. As this novel collaboration of interactive gaming technology and medical science recently emerge therefore there is a great deal to empirically quantify the overall competence, efficacy and reliability in the presence of available evidence. We specify the effectiveness of Wii games in the corporation of balance exercise in the MS patients. Wii games came in to surface in December 2006 in Japan which is a home based video game console developed by Nintendo.[6] Only few researches were conducted to evaluate the efficacy of the Wii game based balance exercised for Multiple sclerosis patients by using different parameters for assessment and interventions. To quantify the overall efficacy of Wii based balanced exercise program for MS patients of all age groups we conducted a systemic review on all these randomized and non-randomized controlled trials and summarize the reliable and valid outcome measures such as Berg Balance Scale (BBS), Postural assessment test, stabilometric Test, and Secondary outcome measures which include time-up and go Test (TUG), Four square step Test, 25 Feet walk test (25TW) and Dynamic gait Index (DGI).which measure the subjective and objective efficacy of Wii game based balanced exercise Plan.

  Methods Top

Eligibility Criteria

Studies were selected according to the PICOs (Population, Intervention, Comparison and Outcome) as follows:

Population: Medically diagnosed Multiple Sclerosis.

Intervention: Balance interventions by Wii balanced board.

Comparison: Control group with/without conventional Physiotherapy session of balance interventions.

Outcome: Outcome measure of Balance parameters like, TUG, 25TW, DGI and related measures as mentioned somewhere else here.

Other Inclusion criteria include population with medically diagnosed Multiple sclerosis with subjectively and objectively perceived balance control impairment.

Exclusion Criteria

  • Studies were not included if they were conducted on the subjects who werefullydependence on external support or ambulatory devices during walking.
  • Subjects, who have some Cognitive, linguistic or visual sensory impairment, which may interrupt in the understanding of instructions or become secondary barrier in maintaining balance.
  • Only those studies are included which are published in English. Studies of qualitative, single case studies are excluded in review.

Sources and Search Strategy

Data bases, PubMed and Scopus, were searched from the beginning up to the 15 February 2014. During the search process following keywords and MeSH terms combinations were used for example:

Gaming OR interactive games/active gamesOR Wii, Nintendo Games OR TELE games (TELE rehabilitation Keywords are used) AND Multiple Sclerosis ({MS}, Disseminated Sclerosis, Encephalomyelitis Disseminata) AND Balance Exercises (Equilibrium Exercises).

Study Selection

Data bases of PubMed and Scopus were searched by using different combinations of keyword and MeSH term, which include Multiple sclerosis, WII, gaming, rehabilitation and balance exercises etc., which gave us total of 57 studies. After title and abstract review, 50 were excluded(TELE-Rehabilitation based on Xbox {n=3}, outcome measure was cognitive and physical active behavior on MS patients {n=4}, Gamingissue {n=8}, other are related to genetic and biological nature {n=35}).

Seven full text articles were screened for eligibility criteria which contains relevant informations and two (n=2) were excluded because one study by Nilsagård, Forsberg, & Koch, 2013[7] was the replied, second study was by Plow & Finlayson, 2011[8] provided inadequate measures to assess Wii interventions in balance exercise on MS people.

Data Extraction

Fivestudies out of seven were selected for this systemic review after the full text reading and applying the criteria. All of these studies used the Wii Balance board as a major intervention in assessment of primary outcome variable which wasbalance and stability accompanied by secondary outcome measure, Modified fatigue impact score, while some studies also measure behavior outcome such as overall quality of life and physical active behaviors.

Data was extracted by the Author individually by full text reading from each research. Data consists of subject selection allocation, place and location where research was conducted and intervention applied, blinding and grouping into the intervention and control group, Objective of the study, Data collection instruments and data analysis software, limitation and further suggestion from the each paper. Quality assessment was not performed for the selected studies because of the limited number of studies and participants.

  Results Top

The initial search yield 57 studies with keywords Wii or multiple sclerosis and balance in the PubMed and Scopus data bases. After applying selection criteria and abstract reading, 50 studies out of 57 were excluded because of absence of Wii intervention orunmatched protocol. In the end we studied 7 full text articles and 2 were excluded in second phase because one study by Nilsagård et al., 20137was the reply to other author and second study by Plow & Finlayson, 20118 was behavior study of Wii intervention on physical activity among multiple sclerosis people. In the second study although author used balance assessment to check overall physical activity but the tool used to quantify balance outcome was not reliable and valid, because balance assessment was nor the primary outcome of the study neither the main objective.Complete study selection is shown below in the flow diagram of [Figure 1].
Figure 1: Flow diagram of the studies selection (n=number of studies)

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Collectively, selected studies include 205 MS diagnose people by neurologists using the McDonald criteria and the expanded disability status scale (EDSS) range from minimum 1 to maximum 6 with mild to moderate multiple sclerosis. Only one study use the MS Impact Score 29(MSIS-29) for measuring the disability.[7] (Summary of all information is listed in the [Table 1]. One study reported Chronic MS course[9] and three reported relapsing and secondary progressive course.[2],[7],[10] In all studies, persons with MS were reported ambulatory. In our review, three were RCTs and one was two period crossover pilot study[10]and other one was pilot quasi experimental study design.[9] (Second Colum in [Table 1] present this information). All the five studies applied Wii intervention in balance exercise among people with MS. Only one study applied Wii intervention in Home based setting[10] while rest were outpatient and in clinical setting. Out of five, One study did not used control group intervention[9] and one used cross over design[10] in which one intervention group (IGa) used Wii console for first session of 12 months and after 12 month no intervention. And in second intervention group (IGb),they did not used any intervention at all in first session of 12 weeks and then used Wii intervention for next 12 week until the end of study period(Fourth Colum in [Table 1] present this information). All studies record measures at the baseline (T0) and after the completion of program (T1), only one study recorded measures just after the exercise program, which was lasted 30 min per session.[9]
Table 1: Summary of extracted variables from all the included researches related to Wii intervention on Balance exercise on MS patients

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A total of 13 different outcome measures were identified from the five selected studies (Sixth Colum in [Table 1] present the details). Two studies[7],[10] used more than two different outcome measures to assess balance among MS people. Most common outcome measures were Berg balance scale (BBS), Center of Pressured (COP),Four Square step test (FSST), Time up and Go test (TUG). Other outcome measures are mentioned in the sixth Colum of [Table 1] and also in [Table 2]. BBS is a five point scale 0-4 where 0 indicates lower level of functioning and 4 is the highest level of functioning, maximum score 56. COP is distance from the center of pressure and it is used from the Wii platform which give reliable and valid measurement of displacement in balance and reported here in millimeter.[11],[12] FSST and TUG is also excellent and former have high validity and reliability in measuring balance problem in multiple sclerosis patients and it is measured in seconds and minutes respectively.[13],[14] Two studies out of five report no statistical significant improvement in BBS and TUG in intervention and control groups[2],[7] however Nilsagard et al., 2013[7] reported a significant improvement of p < 0.01 in Four square step test. Studies by Kalron & Frid, 2012; Prosperini et al., 2013[9],[10] reported significant improvement in FSST and in static and dynamic stability in intervention group. Considerable statistical improvement was reported in Intervention group (IG) vs control group (CG) by Guidi, Giovannelli, & Paci, 2013[15] in BBS mean change 1.89±1.05 (IG) vs 0.13±0.64 (CG) With p =.002 while in COP mean change was 5.32±4.71 (IG) vs -0.83±8.97 (CG) with p =.027.
Table 2: Summary of the selected studies

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  Discussion Top

The primary goal of this review was to evaluate the effectiveness of the balance exercises with multiple sclerosis people using the Wii balance board. Studies included in this review has heterogeneous result and range of outcome measure with vary mode of Wii console but the major objective in all the studies was to evaluate Wii intervention among MS people regarding balance. Out of five selected studies three was randomize control trials and reset was quasi experimental and two point cross over studies design. The quality of overall selected studies was difficult to measure because of impropriate blinding procedure which is not possible in the exercise intervention. The sample size ranges from minimum to 17 MS people to 84 maximum and diagnoses was made in most of the studies by neurologist. Diagnosis was basically based on the radiological & symptomatic findings and also using multiple sclerosis impact score (MSIS-29) or Expanded disability status scale (EDSS) while two studies also utilize Romberg test. We also find out that the course of disease, consent procedure and randomization technique and procedure was poorly reported which also contribute in decline the level of overall quality of study. Most of the studies used different mode for Wii exercise console for intervention, inappropriate information regarding methodology selection and intervention settings make the review difficult to conclude evidence. As Wii balance board intervention was designed for the MS patients who can stand on board therefor all the MS patients have EDSS less than 6 disability level and were in stable phase while only one study reported MS with chronic phase so the results can be generalize to Mild to moderate course of MS. However it is suggested for future researcher to study separately in relapsing and progressive phase. Still there are insufficient evidence about the effectiveness of mode and intensity of Wii exercises. As most of studies included MS people with expanded disability status scale (EDSS) less than 6 where 1 is for no disability and 6 for constant bilateral disability support and all of them receive same intervention so outcome were considered uncertain regarding this point of view.

According to a study by Nilsagard, Forsberg, & Koch, 2013[7] there were no statistical improvement found in the TUG and 25TW test which were the primary outcome measures however moderate improvement were reported in the self-reported MSWS-12 test between the experimental and no exercise group. Physiotherapists who were supervising the exercise session observer excellent compliance and motivation when WII game incorporated in the exercise regime. Another study[2] supported this evidence that there were no statistical improvement were reported in BBG, MFIS and EDSS however significant improvement in stabilometry and BBG was noted when time factor incorporate in groups. While the time factor was negated by the Prosperini et al., 2013[10] instead they found significant improvement in time x treatment factor after WII intervention in the FSST and COP outcome measures. One of the most important finding was the overall improvement in the quality of life and the increase in the gate speedin the MS people which was due to improve static and dynamic balance strategies.Improvement in speed in FSST test was also evident in the study by Kalron & Frid, 2012[9] where improvement was reported in the experimental group after the WII intervention on balance in MS. It was well known evident that visual and sensory motor feedback with improve vestibular system correlates with the postural stability.[16]

Implication for Future Studies

Recommendation for future studies are to repot briefly about the course of disease and the previous fall history. Author found recall bias in reporting fall in previous 12 month as impairment in cognitive domain was also found in MS people.[17],[18],[19] The results would be more useful if studies utilize large sample size and used most evident mood of WII console with comparative group of conventional rehabilitation session because most of the studies employ unsupervised or no exercise control group in their studies. The present review also reveals that there is utmost need for application of WII intervention on the MS people with stratify disability level to conclude reliable results about efficacy in specific group.

  Conclusion Top

Under the light of current studied evidence we can conclude that the Wii implication with balance interventions on Multiple sclerosis people could improve static and dynamic balance. Progressive improvement in gate speed and overall quality of life was reported in studies which might be due to audio-visual or sensorimotor feedback that improve the postural strategies. Most of the studies report excellent compliance and paramount motivation with the Wii regime which could beconsidered a favorableapproach in rehabilitation sciences. There is need for more vigorous and homogenous scientific sound research based on the accurate, validate and standardize methodology which finally improve the MS research.

  References Top

Cameron, M. H., Thielman, E., Mazumder, R., & Bourdette, D. Predicting Falls in People with Multiple Sclerosis: Fall History Is as Accurate as More Complex Measures. Multiple Sclerosis International. 2013(11), 1–7. doi:10.1155/2013/496325.  Back to cited text no. 1
Brichetto, G., Spallarossa, P., de Carvalho, M. L. L., & Battaglia, M. A. The effect of Nintendo(R) Wii(R) on balance in people with multiple sclerosis: a pilot randomized control study. Multiple Sclerosis Journal. 2013;19(9):1219–1221. doi:10.1177/1352458512472747.  Back to cited text no. 2
Cattaneo, D., Nuzzo, C. de, Fascia, T., Macalli, M., Pisoni, I., & Cardini, R. Risks of falls in subjects with multiple sclerosis. Archives of physical medicine and rehabilitation. 2002;83 (6):864–867.  Back to cited text no. 3
Tallner, A., Waschbisch, A., Wenny, I., et al. Multiple sclerosis relapses are not associated with exercise. Multiple Sclerosis Journal. 2012;18(2): 232–235. doi:10.1177/1352458511415143.  Back to cited text no. 4
Cattaneo, D., Jonsdottir, J., Zocchi, M., & Regola, A. Effects of balance exercises on people with multiple sclerosis: a pilot study. Clinical rehabilitation. 2007;21(9):771–781. doi:10.1177/0269215507077602.  Back to cited text no. 5
Wikipedia.(2014).Wii-Wikipedia, the free encyclopedia. Retrieved from http://en.wikipedia.org/w/index.php?oldid=593313923.  Back to cited text no. 6
Nilsagard, Y. E., Forsberg, A. S., & Koch, L. von. Balance exercise for persons with multiple sclerosis using Wii games: a randomised, controlled multi-centre study. Multiple Sclerosis Journal. 2013b;19 (2): 209–216. doi:10.1177/1352458512450088.  Back to cited text no. 7
Plow, M., & Finlayson, M. Potential Benefits of Nintendo Wii Fit Among People with Multiple Sclerosis. International Journal of MS Care. 2011; 13 (1): 21–30. doi:10.7224/1537-2073-13.1.21.  Back to cited text no. 8
Kalron, A., & Frid, L. Nintendo wii virtual reality game improves short term balance capabilities in multiple sclerosis patients: A pilot quasi-experimental study. Journal of Physical Therapy.2012a; 5 (2): 54-62. Retrieved from http://www.scopus.com/inward/record. url?eid=2-s2.0-84872779800&partnerID=40&md5=f57f5cc2254da d78e7bf1a7c0b83d69b.  Back to cited text no. 9
Prosperini, L., Fortuna, D., Gianni, C., Leonardi, L., Marchetti, M. R., & Pozzilli, C. Home-Based Balance Training Using the Wii Balance Board: A Randomized, Crossover Pilot Study in Multiple Sclerosis. Neurorehabilitation and Neural Repair. 2013a; 27 (6): 516–525. doi:10.1177/1545968313478484.  Back to cited text no. 10
Huang, C.W., Sue, P.D., Abbod, M., Jiang, B., & Shieh, J.S. Measuring Center of Pressure Signals to Quantify Human Balance Using Multivariate Multiscale Entropy by Designing a Force Platform. Sensors. 2013;13 (8): 10151–10166. doi:10.3390/ s130810151.  Back to cited text no. 11
Scaglioni-Solano, P., & Aragón-Vargas, L. F. Validity and reliability of the Nintendo Wii Balance Board to assess standing balance and sensory integration in highly functional older adults. International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation. 2014.doi:10.1097/MRR.0000000000000046.  Back to cited text no. 12
Wagner, J. M., Norris, R. A., Van Dillen, Linda R., Thomas, F. P., & Naismith, R. T. Four Square Step Test in ambulant persons with multiple sclerosis. International Journal of Rehabilitation Research. 2013; 36(3):253–259. doi:10.1097/MRR.0b013e32835fd97f.  Back to cited text no. 13
Whitney, S. L., Marchetti, G. F., Morris, L. O., & Sparto, P. J. The reliability and validity of the Four Square Step Test for people with balance deficits secondary to a vestibular disorder. Archives of physical medicine and rehabilitation. 2007;88(1): 99–104. doi:10.1016/j.apmr.2006.10.027.  Back to cited text no. 14
Guidi, I., Giovannelli, T., & Paci, M. Effects of Wii exercises on balance in people with multiple sclerosis. Multiple Sclerosis Journal. 2013;19 (7): 965 doi:10.1177/1352458512461971.  Back to cited text no. 15
Shumway-Cook, A., Woollacott, M., Kerns, K. A., & Baldwin, M. The effects of two types of cognitive tasks on postural stability in older adults with and without a history of falls. The journals of gerontology. Series A, Biological sciences and medical sciences.1997; 52(4): M232–40.  Back to cited text no. 16
Koenig, K. A., Sakaie, K. E., Lowe, M. J.,et al, Hippocampal volume is related to cognitive decline and fornicial diffusion measures in multiple sclerosis. Magnetic resonance imaging. 2013; doi:10.1016/j.mri.2013.12.012.  Back to cited text no. 17
Messina, S., & Patti, F. Gray Matters in Multiple Sclerosis: Cognitive Impairment and Structural MRI. Multiple sclerosis international. 2014; 609694. doi:10.1155/2014/609694.  Back to cited text no. 18
Nilsagård, Y. E., Forsberg, A. S., & Koch, L. von. Reply to Guidi et al. ‘Effects of balance-specific Wii exercises on balance in persons with multiple sclerosis’. Multiple Sclerosis. 2013; 19 (7): 964. Retrieved from http://www.scopus.com/inward/record.url?eid=2- s2.0-84878344741&partnerID=40&md5=b749b001d44014420af147 c0fe008744.  Back to cited text no. 19


  [Figure 1]

  [Table 1], [Table 2]

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