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International Journal of Neuroscience, 2016; 126(12): 1061–1070 Copyright © 2015 Informa UK Limited, trading as Taylor & Francis Group ISSN: 0020-7454 print / 1543-5245 online DOI: 10.3109/00207454.2015.1115993

ORIGINAL ARTICLE

The effects of Nintendo WiiTM-based balance and upper extremity training on activities of daily living and quality of life in patients with sub-acute stroke: a randomized controlled study

Tülay Tarsuslu Şimşek1 and Kübra Çekok2

1School of Physical Therapy and Rehabilitation, Dokuz Eylül University, İzmir, Turkey; 2Department of Physical Therapy and Rehabilitation, Medicalpark Izmir Hospital, İzmir, Turkey

Objective: The aim of this study was to investigate the effects of Nintendo WiiTM-based balance and upper ex- tremity training on activities of daily living and quality of life in patients with subacute stroke.Methods: 42 adults with stroke (mean age (SD) = 58.04 (16.56) years and mean time since stroke (SD) = (55.2 ± 22.02 days (∼8 weeks)) were included in the study. Participants were enrolled from the rehabilitation department of a medical center (a single inpatient rehabilitation facility). Participants were randomly assigned to Nintendo Wii group (n = 20) or Bobath neurodevelopmental treatment (NDT) (n = 22). The treatments were applied for 10 weeks (45–60 minutes/day, 3 days/week) for both of two groups. Nintendo Wii group used five games selected from the Wii sports and Wii Fit packages for upper limb and balance training, respectively. The patients in Bobath NDT group were applied a therapy program included upper extremity activites, strength, balance gait and functional training. The functional independence in daily life activities and health-related quality of life was assessed with Functional Independence Measure (FIM) and Nottingham Health Profile (NHP), respectively. Participant’s treatment satis- faction was recorded by using Visual Analogue Scale. A second evaluation (FIM and NHP) occurred after 10 weeks at the end of rehabilitative treatment (post-training). Treatment satisfaction was measured after 10 ses- sions. Results: There were significant difference between FIM and NHP values in NDT and Nintendo Wii group (p < 0.05). However, a significant difference was not found between the groups with regard to FIM and NHP (p > 0.05). The patients in Nintendo Wii group were detected to be better satisfied from the therapy (p < 0.05). A significant difference was found between subparameters and total FIM score, all subparameters and total NHP score in both groups (p < 0.05). Conclusion: These findings suggested that the Nintendo Wii training was as effective as Bobath NDT on daily living functions and quality of life in subacute stroke patients.

KEYWORDS: Nintendo Wii, stroke, quality of life, daily life activities

Introduction

Stroke is a leading cause of disability and is often associ- ated with impaired motor function. In addition to motor impairment people who have had a stroke often experi- ence sensory, cognitive and visual impairment impacting on their ability to perform activities of daily living such as self-care tasks and participation in work and leisure roles [1]. Stroke has some effects resulting in reduced postu-

Received 28 July 2015; revised 27 October 2015; accepted 31 October 2015

Correspondence: Tülay Tarsuslu Şimşek, School of Physical Therapy and Rehabilitation, Dokuz Eylül University, İzmir, Turkey. Tel: 02324124900. Fax: +02324124946. E-mail: tulay [email protected]; [email protected]

ral stability and gait imbalance [1,2]. The influences in the upper extremities lead to dependence in self-care ac- tivities, depending on the disease severity [3,4].

Stroke rehabilitation is considered to be a relearn- ing process in which motor learning mechanisms are operative and interact with spontaneous recovery [5]. Motor learning and neuroplasticity-based physiotherapy and rehabilitation approaches, balance and strengthen- ing exercises, virtual reality applications are reported to be effective in recovery process of stroke patients [6–9]. Previous studies have demonstrated video games as a beneficial, cost-effective, consistent, standardized and safe intervention for those with subacute and chronic stroke patients [6,10].

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1062 T. T. Şimşek & K. Çekok

Recently, the Nintendo Wii FitTM has been proposed as a new tool for balance training for neurological pa- tients [11]. The Nintendo WiiTM (N-Wii) video game console was first commercialized in late 2006 and intro- duced a new style of virtual reality. Wii FitTM is a sys- tem specifically designed to promote physical capacity [12]. Motor (balance training) and cognitive-based N- Wii games were shown to improve the activities of daily living performances in Parkinson’s patients [13]. Simi- larly, N-Wii games were observed to increase the per- formance of daily living activities and functional inde- pendence through increasing upper extremity function in stroke patients [10,14]. The N-Wii was shown to be an effective and safe alternative to promote the recovery of the upper limbs [15] for balance training [16–18] and it appeared to be a good alternative tool for rehabilita- tion [19,20]. However, a recent Cochrane review study reported that there are limited data about that virtual reality may be useful for improving arm function and activity of daily living with compared to the same dose conventional therapy [21].

Limited number of studies is available comparing N- Wii and direct exercise applications. Previous studies usually investigated the effectiveness of Wii applied in addition to conventional rehabilitation in subacute and chronic stroke patients, and the different therapeutical approaches (conventional physiotherapy, occupational therapy, exercise, etc.) [22,23]. Cheok et al. reported in their systematic review and meta-analysis study that randomized controlled studies are required to compare the direct effect of N-Wii application and exercise that not applied in combination or placebo group in stroke patients [24]. On the other hand, it was detected that the effects expected from therapies are focused on the improvement of motor function rather than cognitive functions and activity performance [16,21]. Laver et al. reported that they could collect data about activities of daily living outcome however not about cognitive func- tion, participation restriction and quality of life [21]. The main purpose of this study is to investigate the su- periority or similarity of N-Wii play systems with com- pared to Bobath neurodevelopmental treatment (NTD) approaches in patients with subacute stroke. To the best of our knowledge, this is the first study in the literature.

The aim of this study is to investigate the subacute effect of N-Wii. Our study was designed to investigate the influences of N-Wii play systems targeting upper ex- tremity fucntion and balance and conventional therapy (Bobath NTD) on dependence in daily living activities and health-related quality of life. We hypothesize that the games targeting to improve upper extremity function and balance through N-Wii would result in improved functional independency in daily living and quality of life in patients with mild-to-moderate stroke severity.

Material and methods

Study design

This was a randomized controlled trial comparing re- sponse to treatment across two different treatment groups: Nintendo Wii and Bobath neurodevelopmen- tal treatment (NDT) groups. Subjects in all two groups received treatment for 10 weeks (45–60 hours/day, 3 days/week). Measures were acquired at pre- and post- treatment. The study was accepted by the Ethics Com- mittee of Clinical Research in Dokuz Eylül University. The patients signed informed consent forms after the authors explained the purpose of the study (decision number 2013/27-14).

Participants

The study was planned as a randomized controlled study. This study was carried out in the Medicalpark İzmir Hospital, Department of Physical Therapy and Rehabilitation. Stroke was defined based on clinical fea- tures and supported by CT or MRI findings by a spe- cial neurologist. The patients included in the present study had first-ever, unilateral, ischemic or hemorrhagic stroke.

Patients were considered eligible if they met the fol- lowing inclusion and exclusion criteria.

Inclusion criteria were the patients who were first di- agnosed with hemiplegia, no conventional physical ther- apy treatment received in the early period after stroke, medically stable to participate in active rehabilitation, above 18 years old, whose Mini-Mental State Examina- tion (MMSE) score above 23, funtional level below 4 according to modified Rankin Scale (mRS) and upper extremity spasticity was below 3 according to Modified Ashword Scale (MAS). Patients who could stand and walk independently were tried to be selected for par- ticipation as N-Wii games would be played and as they could lead to balance problems and falls.

Exclusion criteria were the patients who had comor- bidity which could hinder rehabilitation, who had shoul- der subluxation and fracture risk, agnosia or visual dis- turbance, range of motion limitation in upper extremity on the hemiplegic side, who were attending to another study or therapy to improve arm–hand function and bal- ance, who were performed botulinum toxin injection or underwent an operation within the recent six months. MAS was applied to shoulder abductor, flexor and in- ternal rotators of the upper extremity, flexors of the el- bow, wrist and fingers. Total MAS values were used for the upper extremity. Figure 1 shows an overview of the study protocol.

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Effects of Nintendo Wii training 1063

Assessing for eligibility

n=55

44 randomly elocated

11 excluded

-do not meet inclusion criteria (n=9)

-refused the study (n=2)

22 allocated to experimental group (N-Wii)

22 allocated control group (NDT)

Pre-treatment outcome measures (n=22)

Interven�on (10 weeks) Interven�on (10 weeks)

Post-treatment outcome measures (n=20)

Post-treatment outcome measures (n=22)

Losses (n=2)

Figure 1. Flow diagram of the study.

The sample size was calculated with the Epi InfoTM

7 (7.1.1.14) software. The calculations were based on confidence intervals 95%, an α level of 0.05 and a de- sired power (β) of 80%. The estimated desired sample size was calculated to be at least 20 subjects per group.

Forty-four adults with stroke participated in the study. Forty-four patients included in the study were di- vided into two groups with simple randomization tech- nique using sequentially numbered, opaque sealed en- velopes: one group was treated at N-Wii system (n = 22), the other one was treated with conventional physio- therapy (Bobath NDT) (n = 22). One patient in N-Wii group dropped from the study as he had to go abroad and one patient dropped as she experienced cardiac problems at 3 week of the study. The study was com- pleted with 20 patients in N-Wii group and 22 patients in NDT group.

Assessment

Baseline demographics were collected for all the patients enrolled which included age, body mass index (BMI), gender, duration of disease, the affected hemisphere and comorbid conditions.

Baseline assessments for all subjects included Func- tional Independence Measure (FIM) and health- related qulaity of life (NottinghamHealth Profile-NHP) [25,26].

Turkish translation of the FIM was used to evalu- ate functional independence status in daily life activities [25]. It is divided into two domains with 13 motors and 5 cognitive items. It consists of a 7-level ordinal scale based on how much help the subject requires when per- forming a given activity, with ratings from total depen- dence [1], to complete independence [7]. Higher scores represent better functioning and greater independence.

1064 T. T. Şimşek & K. Çekok

In order to collect information about health-related quality of life, the Turkish version of a generic instru- ment, NHP was used [26]. NHP consists of six domains with a total of 38 items (physical mobility (eight items), pain (eight items), sleep (five items), emotional reac- tions (nine items), social isolation (five items) and en- ergy level (three items)). All items have a yes/no answer format. Scores for each section can range from 0 (indi- cating the best possible score) to 100 (the worst possible score).

Satisfaction of treatment was measured on a 10-cm scale (Visual Analogue Scale (VAS)). All subjects were asked to rate their overall satisfaction between 0 (indi- cating no satisfaction) and 10 (most satisfied). Although VAS is most frequently used to evaluate the degree of pain, it has also been used to assess the burden and satis- faction of treatment in various studies [27–29]. The fol- lowing questions were asked to the participants to eval- uate satisfaction after 10 weeks of therapy: “Could you please mark your satisfaction on the chart?”. The num- ber marked on the line by the patient was measured us- ing a ruler.

All baseline and post-treatment (after 10 weeks) as- sessments were performed by a trained outcome as- sessor, blinded to patient randomization, who was not involved in administration of study interventions. Treat- ment of both groups was applied by the same physio- therapist.

The N-Wii group performed training using video games for 10 weeks (45–60 hours/day, 3 days/week) and NDT group received conventional treatment (Bobath NDT) for 10 weeks (45–60 hours/day, 3 days/week). Before and after the intervention, the participants were measured for performance of activities of daily living and health-related quality of life.

N-Wii group used five games selected from the Wii sports and Wii Fit packages for upper limbs (tennis and punch out) and balance training (tightrope tension, tilt table and heading), respectively. Each game was per- formed as three sets with five-minute intervals between each.

In tennis play, the patient was asked to hit the ball using the remote control of Wii by moving the body forward and backward while keeping the support sur- face. In tilt table play, the patient was asked to hole the balls while weight shifting in forward and back- ward, to right and left. In tightrope tension game, the patient was asked to stay stable on balance board through transferring balance to right and left. In punch out game, the patient was asked to kick the com- petitor forward–backward or upward–downward using his/her upper extremity and Wii remote control and nunchuck equipment. The arm movements involved in the use of the Wii included shoulder flexion and ex- tension (tennis), shoulder rotation (tennis), shoulder

flexion–extension, elbow extension and flexion (punch out), wrist supination and pronation (tennis) and dif- ferent degress of wrist flexion and extension as well as thumb flexion involved in all activities. Trunk stabiliza- tion of lower extemities, weight transfer and weight shift- ing (forward–backward and right–left) activities were supported by the other games (heading, tightrope ten- sion and tilt table). All five sports required full body mo- tion and balance. N-Wii training was carried out by one experienced physiotherapist. The therapist monitored participants’ vital signs, established target distance, used verbal promptings to minimize compensatory strategies and ensured safety.

The therapist stood near the affected side of the pa- tient in order to prevent falls and to conrol the patient, motivated the patient during N-Wii applications. The patient was allowed to be supported by the therapist only when he/she felt that he/she would fall. The exercise was terminated for that session when the patient felt fatigue, shoulder, arm or hand pain or when he/she did not feel good. Wii exercises were done in a poorly lit room in the ground floor where physical therapy department is in or- der to minimize light sensitivity and related seizure risk. Frequent video records were done in order to improve the patient motivation and to enable them to see their faults. Themaximum score of each patient was recorded and used in order to improve their motivation in the next session.

A therapy program was applied to the patients depending of the functional level in NDT group. Bobath NDT procedures were applied as upper ex- tremity activities, trunk exercises, sitting, standing and walking exercises, balance exercises and lower extrem- ity exercises depending on the functional needs of the patient.

NDT exercises were done in the bed, in sitting and standing positions. Scapular mobilization, exercises, M. latissumus dorsi stretching, weight shifting to the af- fected upper extremity, selective strengthening of shoul- der stabilizators were done for upper extremity and also strengthening exercises of the abdominal muscles (rec- tus abdominus and oblique abdominal muscles), bilat- eral arm activities, grip activities when the elbow is in flexion and extension, pronation, supination exercises, grip and unhand activities were done focusing on the facilitation of movements on the paretic side.

Balance, weight shifting to lower extremities and walking exercises were also done. First, pelvic elevation in the bed, balance training in sitting and standing po- sition, standing without sitting, weight shifting to lower extremities, squatting down activities, walking exercises (right–left, stepping forward–backward and walking), going up and down stairs activities were also done. The exercises were gradually made more difficult consider- ing the functional status of the patient.

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The participants were provided not to be included in another treatment program during the study period. The patients were stated that they would be included in a routine physiotherapy and rehabilitation program; how- ever they were asked not to participate in another exer- cise program during the study period in order to moni- tor the effectiveness of the procedure. Informed consent was obtained from the patients.

Statistical analysis

Statistical analyses were performed using the SPSS soft- ware version 20. The variables were investigated us- ing visual (histograms and probability plots) and ana- lytical methods (Kolmogorov–Simirnov/Shapiro–Wilk’s test) to determine whether or not they are normally distributed. Demographic and clinical characteristics of the patients in the N-Wii group and the NDT group were compared using the chi-squared and un- paired t-test. Kolmogorov–Smirnov and Levene tests were used to assess the normality and homogeneity of variance, respectively, for all measures. Since the FIM, NHP and satisfaction of treatment values were not nor- mally distributed, the Mann–Whitney U-test was used to compare these parameters between the groups. The Wilcoxon test was used to compare the change in val- ues of FIM, NHP and satisfaction of treatment between baseline and after the treatment within the groups. A p value of less than 0.05 was considered to show a statis- tically significant result.

Results

Mean age of the participants was 58.04 ± 16.56 years (54.15 ± 20.29 years for N-Wii group; 61.5 ± 0.99 years for NDT group). Of the patients in N-Wii group, 51.7% were male, 55% had ischemia, the left hemi- sphere was affected in 54.5% and duration of disease was 50.6 ± 15.04 days (∼7 weeks). Of the patients in NTD group, 61.5% were female, 45% had ischemia, the right hemisphere was affected in 60% and dura- tion of disease was 59.9 ± 30.99 days (∼8 weeks). No difference was found between groups with regard to age, duration of disease, gender, clinical characteristics of stroke, the affected hemisphere, comorbidities, mRS and MMSE ( p > 0.05). There was a difference with re- gard to BMI values ( p < 0.05). The patients in NTD group were overweight ( p > 0.05, Table 1). No dif- ference was found between groups with regard to total MAS value ( p> 0.05). All patients included in the study could stand independently.

A statistically significant difference was not found be- tween groups with regard to FIM subparameters and to-

tal FIM score and NHP subparameters and total NHP score before and after the treatment ( p> 0.05, Table 2).

A statistically significant difference was detected be- tween pre- and post-treatment FIM motor, cognitive and total FIM score mean difference values, NHP sub- parameters and total NHP mean difference values in N- Wii group ( p < 0.05, Table 3).

A statistically significant difference was found be- tween before and after treatment FIM motor, cognitive and total FIM mean difference values in NDT group ( p< 0.05). Similarly, a statistically significant difference was found between before and after treatment all subpa- rameters of NHP and total NHPmean difference values ( p < 0.05, Table 3).

Satisfaction from therapy was different between groups and the patients in N-Wii group were detected to be better satisfied by the therapy ( p< 0.05).While satis- faction from therapy was found as 7.85 ± 1.46 in N-Wii group, it was found as 6.18± 0.90 inNTD group (Table 2).Video records were done during N-Wii games. The patients stated that watching themselves enabled them to see and correct their faults during playing the games. They also stated that they looked forward to play the next session and came to the therapy more willingly in order to improve their scores.

No safety problems were experienced during the exercises. However, some patients used compensatory mechanisms and movements in order to do optimal movements, so continuous therapist guidance was re- quired.

Discussion

The main findings of the study include that Nintendo Wii and Bobath NDT approaches which are applied in similar durations have no difference in effects on gain- ing independence in daily living activities and improving quality of life.

Functional skills and independence in daily activi- ties are achieved with a good postural control [30]. Be- side, self-care activities and transfer activities require a good upper extremity function [31]. Computer game- based techniques, which are applied for improving up- per extremity function, are reported to increase upper extremity use and function, provide positive contribu- tions in daliy living of the subjects [32,33]. Paquin and da Silva Ribeiro reported that N-Wii games applied in addition to standard physiotherapy improved upper ex- tremity motor functions in stroke patients [15,34]. Sim- ilarly, Pietrzak et al. reported in their review study that although there are limited evidence about the influence of video games (Nintendo Wii, Eye Toy Play Station and CyWee Z) on upper extremity function improve- ment, they could be used for upper extremity stroke

1066 T. T. Şimşek & K. Çekok

Table 1. Socio-demographic and clinical data of the subjects.

N-Wii group (n = 20) NDT group (n = 22) X ± SD X ± SD t,χ2 p

Age (year), (X ± SD) 54.15 ± 20.29 61.5 ± 11.63 −680 0.496 Duration of disease (days), (X ± SD) 50.6 ± 15.04 59.9 ± 30.99 −1.605 0.109 BMI (kg/m2), (X ± SD) 24.37 ± 3.71 28.22 ± 5.22 −2.721 ∗0.007 mRS (0–5), (X ± SD) 2.0 ± 0.85 1.8 ± 0.88 −0.524 0.600 MMSE (0–30), (X ± SD) 26.10 ± 1.83 26.86 ± 2.47 −1.087 0.277 Total MAS Before treatment 0.60 ± 0.82 1.13 ± 1.32 −1.562 0.126 After treatment 0.50 ± 0.68 0.95 ± 1.09 −1.597 0.118 Sex, n (%) 0.633 0.426 Female 5 (38.5) 8 (61.5) Male 15 (51.7) 14 (48.3) Clinical characteristic, n (%) 0.834 0.361 Ischemic 11 (55) 9 (45) Hemorrhagic 9 (40.9) 13 (51.9) The affected hemisphere, n (%) 0.889 0.346 Right 8 (40) 12 (60) Left 12 (54.5) 10 (45.5) Comorbidities 2.854 0.240 No 9 (64.5) 5 (35.7) Diabetes mellitus 4 (50) 4 (50) Hypertension 7 (35) 13 (65)

∗p < 0.05. Note: Mann–Whitney U-test; χ2 = Chi-square test; BMI: Body mass index; mRS: modified Rankin Score; MMSE: Mini-Mental State Examination.

Table 2. Comparison of the groups at baseline and after 10 weeks (between the groups).

N-Wii group NDT group Before

treatment N-Wii group NDT group After treatment

FIM X ± SD X ± SD z p X ± SD X ± SD z p Motor 64.60± 20.89 70.68± 18.24 −1.008 0.31 77.95± 12.99 75.04± 17.08 −0.368 0.71 Cognitive 32.30± 2.36 30.04± 4.99 −1.683 0.09 33.30± 2.79 31.59± 4.14 −1.515 0.13 Total score 96.80± 22.33 101.09± 21.69 −0.630 0.52 111.7± 15.06 107.09± 19.24 −0.785 0.43 NHP Energy level 1.90± 1.02 2± 0.61 −0.083 0.93 0.90± 0.55 0.90± 0.52 −0.063 0.94 Pain 2.85± 2.15 2.90± 1.01 −0.077 0.93 1.30± 1.21 1.45± 0.73 −0.711 0.47 Emotional reaction 2.70± 2.27 2.72± 1.20 −0.422 0.67 1.20± 1.36 1.36± 0.90 −0.880 0.37 Social isolation 2.20± 1.39 2.50± 1.18 −0.637 0.52 1± 0.72 1.22± 0.68 −1.031 0.30 Sleep 2.45± 1.39 2.90± 1.15 −1.163 0.24 1.10± 0.96 1.45± 0.80 −1.195 0.23 Physical activity 3.55± 1.60 3.45± 1.05 −0.700 0.48 1.55± 0.68 1.68± 0.83 −0.494 0.62 Total NHP 15.65± 8.27 16.63± 4.08 −0.353 0.72 6.95± 3.73 8.5± 3.05 −1.455 0.14 Satisfaction of treatment − − − − 7.85± 1.46 6.18± 0.90 −3.611 ≤0.001∗ ∗p < 0.05. Note: Mann–Whitney U-test; FIM: Functional Independet Measure; NHP: Nottingham Health profile.

rehabilitation due to being easily available and used [34]. Similarly, improvement was observed in FIM mo- tor (self-care including upper limb function, locomotion and tranfer activities) in both groups in our study. Al- though NDT and Wii applications are not superior to each other, treatment programs were detected to im- prove motor function in both groups so as to influence daily living independence.

Lee investigated that the influences of video games (played on the Xbox Kinect) on muscle tone, power

and daily living activities detected that significant im- provements could be achieved in post-stroke patients who were applied traditional occupational therapy, com- bination of video games and traditional occupational therapy. However, a significant difference was not de- tected in inter-group comparisons [35]. In their system- atic review study, Laver et al. found limited evidence that the use of virtual reality and interactive video gam- ing (such as Wii (Nintendo), Move (Sony) and Kinect (Microsoft)) may be beneficial in improving arm

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Table 3. The comparison of baseline and 10 weeks data of the groups (within the groups).

N-Wii group NDT group

X ± SD z p X ± SD Z p FIM motor 13.35± 10.77 −3.865 ≤0.001∗ 4.36 ± 8.36 −2.560 ≤0.001∗ FIM cognitive 1± 2.27 −1.715 0.008∗ 1.54 ± 2.13 −2.848 0.004∗ FIM total score 14.90± 11.89 −3.921 ≤0.001∗ 6 ± 9.26 −2.259 0.008∗ NHP Energy level 1± 0.72 −3.601 ≤0.001∗ 1.09 ± 0.29 −4.523 ≤0.001∗ Pain 1.55± 1.27 −3.448 ≤0.001∗ 1.45 ± 0.67 −4.122 ≤0.001∗ Emotional reaction 1.50± 1.27 −3.448 ≤0.001∗ 1.36 ± 0.58 −4.144 ≤0.001∗ Social isolation 1.2± 0.95 −3.471 ≤0.001∗ 1.27 ± 0.98 −3.834 ≤0.001∗ Sleep 1.35± 0.74 −3.739 ≤0.001∗ 1.45 ± 0.85 −4.141 ≤0.001∗ Physical activity 2± 1.16 −3.692 ≤0.001∗ 1.77 ± 0.86 −4.234 ≤0.001∗ Total NHP 8.7± 5.03 −3.731 ≤0.001∗ 8.13 ± 3.01 −4.115 ≤0.001∗ ∗p < 0.05. Note: Wilcoxon signed ranks test; FIM: Functional Independet Measure; NHP: Nottingham Health Profile; X ± SD: The value of the difference before and after treatment.

function and activities of daily living function when compared with the same dose of conventional therapy in an adults post-stroke population [36]. On the other hand, virtual reality applications (it is included com- puter workstation connected to a 3D motion-tracking system (Polhemus 3Space Fastrak, Colchester, VT) and a high-resolution LCD projector displaying the virtual scenarios on a large wall screen) in post-stroke patients were detected to increase functional activity and inde- pendency in daily life compared to conventional exer- cise applications used in control group in the study of Piron et al. [37]. In meta-analyis trial of Saposnik et al., virtual reality (VR) systems were reported to increase motor impairment, activities and social participation in stroke patients; however, it was stated that more mul- ticenter randomized controlled studies are required be- fore making a conclusion [38]. In our study, treatment programs applied in both groups were observed to lead to improvement in daily living activities, similar to the above-mentioned studies. Both NDT and Wii games provided significant improvements in FIM total score which indicates daily living functions. Despite the ab- sence of a difference between groups, FIM values of Wii group improved better following therapy. A difference was also not found between MAS values which signifi- cantly influence upper limb function, as in the study of Lee et al. Upper limb function was mild in both groups (pre-treatment value is 1.13 ± 1.32 for NTD group and 0.60± 0.82 forWii group). We consider that upper limb function improvement and daily living independence improvement are positively affected from tonus severity.

In some studies, it has been shown that N-Wii games applied to in addition to conventional therapy improves the functional balance and mobility in stroke patients significantly improvement [16,18,19,39]. Virtual reality applications were detected to increase independency

in daily living through increasing balance and mobility [40]. Previous studies on VR rehabilitation have sug- gested that learning can be sustained up to three or six months [41] and that functional recovery can be trans- ferred to daily activity [42]. In our study, FIM motor subparameter which evaluates transfer and locomotion which significantly influence balance and mobility level significantly; physical activity and energy level subunit of NHP were detected to improve significantly. Therapies were not detected to be superior to each other. In the literature, studies evaluating the influence of N-Wii games alone are quite insufficient [23]. Our study is the first which compares Wii games and NDT applications. In our study, significant differences were not found with regard to daily living independency and quality of life when N-Wii and conventional therapy were compared. Considering the gradually increasing popularity of video games like N-Wii, we suggest that more studies are required to investigate the superiority of N-Wii to specific exercise programs applied alone or conventional therapies.

An interesting finding of our study was that the pa- tients in NDT group were more overweight than the pa- tients in N-Wii group. Despite this, a difference was not detected between groups with regard to functional im- provement and change in quality of life after treatment programs. However, FIM motor improvement was bet- ter in N-Wii group, although statistically insignificant. Overweight/obesity may impair quality of life by affect- ing the success of rehabilitation and mobility level of the patient, thereby independency in daily life in patients who have a neurologic disease like stroke [43]. Address- ing this detail in planned treatment programs would be important for rehabilitation outcomes and success.

Another finding of the study was that there was no difference between quality of life of the patients who

1068 T. T. Şimşek & K. Çekok

were treated with N-Wii game systems and NDT ap- proach. Although there was an improvement in quality of life of the patients in both groups, there was no differ- ence between effectiveness of both programs. However, satisfaction from treatment was better in N-Wii group. Studies have reported that quality of life improved, sat- isfaction from treatment improved as patient motivation increased after upper extremity training in stroke pa- tients treated with video games [44,45]. However, an improvement was also detected in patients treated with NDT approach [46]. On the other hand, it is empha- sized that combination of video games and conventional treatment programsmay bemore effective for functional healing, participation in activity and improving quality of life in rehabilitation of stroke patients [47]. Piron et al. observed that there was not a difference between the stroke patients who were applied virtual reality and tele- virtual reality with regard to satisfaction and both groups were detected to be satisfied from therapy [48]. Paquin et al. reported that virtual reality applications like Wii improve motivation of stroke patients for the participa- tion in rehabilitation programs [15]. Hart et al. showed similar levels of usability and high satisfaction with the gaming systems in their study conducted with physical therapy students and stroke patients [49]. In parallel with the studies, we consider that video-based game re- habilitation would be beneficial for providing the conti- nuity of patient motivation used together with conven- tional therapy beginning from the early period in stroke patients (and thereby preserving and increasing satisfac- tion from treatment), preserving activity level, benefiting from early plasticity and improving quality of life [38].

In some studies, Wii Fit game was reported to be able to be used safely in home environment [23,42,50]. How- ever, compensatory movements (body hyperextension, complex reactions, hyperextension of the body, shoulder abduction, etc.), imbalance and muscle tone increase were observed in some patients in our study as in the study of Hung et al. [19]. Therefore all patients did their exercises under supervision of a physiotherapist. This in- dicates that the patients who were not supported with another treatment and who experienced balance prob- lems should certainly be monitored during the exercises.

The optimal duration and frequency of Wii Fit bal- ance training required to achieve therapeutics is unclear [19]. Kwakkel emphasized that minimum 16 hours of training is required in order to achieve a functional ef- fect [51]. Barcala et al. offered one hour of Wii game play per week, whereas Cho et al. offered 1.5 hours of Wii activity per week [11,39]. Duration was little longer in our study as the patients did not participate in another treatment program. Training was about 45–60 minutes for three days a week and a total of 25–30 hours for each patient. We believe that this schedule is a strength of our study.

This study had a number of limitations. A limitation of this study was the absence of a control group that received no intervention, which could suggest the in- fluence of a placebo effect on the results. When we de- signed this study, it was difficult to blind the treatment to the non-treated control group because all the subjects were recruited from the same hospital and we could not find a sham treatment program for the control group at that time. Influences of treatment may be analyzed by forming a third group as a combination treatment group. Second limitation of our study is not evaluating the long-term effects of treatment programs. Random- ized controlled studies investigating the contribution of treatment methods on the long-term quality of life and functional independency are required. Third limitation was use of only a select number of Wii-based activities. The chosen games were the ones usually used in stud- ies in the literature and they were chosen as they were reported to be safe. Wii games may be increased in vari- ety and their ifluences on patients may be investigated. Another limitation of our study was inadequacy of out- come measurements. The influences on patients could be evaluated with regard to cognitive function, participa- tion restriction and life satisfaction and the study could be discussed with its various results. Randomized con- trolled studies are required on this issue. In our study, therapy programs were applied by the same therapist in both groups. The influences on patients may be inves- tigated through double-blind controlled. The final lim- itation of the study is the absence of a BMI limit for inclusion criteria. Effectiveness of two different treat- ment methods may be analyzed in studies conducted with only normal weight or only overweight/obese patients.

Conclusion

The results of the study showed that both N-Wii and NDT groups improved over time. However, no statis- tical differences in improvement were found between groups in terms of daily life functions and health-related quality of life. Although N-Wii training was not superior to NDT alone, this study demonstrates the feasibility of N-Wii training in subacute stroke patients. More ran- domized controlled studies investigating the influences of video games alone and/or in combination with differ- ent treatment methods on healing capacity, participa- tion in activity and quality of life are required.

Acknowledgements

We thank all of the participants.

International Journal of Neuroscience

Effects of Nintendo Wii training 1069

Declaration of interest

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publica- tion of this article.

Funding

The authors received no financial support for the re- search and/or authorship of this article.

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