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The Safety of using the Wii FitTM Balance Board for Individuals with

Mild to Moderate Parkinsons Disease


by
Devon Chan

A Proposal Submitted in Partial Fulfillment


of the Requirements for the Degree of
BACHELORS OF KINESIOLOGY
in the School of Exercise Science, Physical and Health Education

Devon Chan, 2014


University of Victoria

All rights reserved. This thesis may not be produced in whole or in part, by photocopy or other
means, without the permissions of the author.

Devon Chan

Abstract
Individuals with Parkinsons disease (PD) face a high risk of falling due to motor
impairments associated with the disease. As a result, some research suggests the Nintendo Wii
FitTM and Balance board accessory (WBB) as a method of exercise and balance therapy for PD.
However, the safety of implementing the WBB with regards to falling and tripping remains
unclear. This study will recruit individuals with stage 2.5 and stage 3 PD (Modified Hoehn and
Yahrs scale) from 2 PD support groups and 2 PD exercise groups organized by the Victoria
Epilepsy and Parkinsons Center in Victoria, BC. Participants will be purposively sampled on
inclusion and exclusion criteria. This study will follow an observational descriptive design
examining frequency of falls and trips during Wii-fit Ski Slalom, Bubble Balance, and Penguin
Slide. Data will be collected during 3 sessions through video capture of each participants
gameplay. Falls and trips will be recorded using a subjective counting scale devised for this
study. Frequency of trips and falls for each game will be calculated using the means of trips and
falls from all participants.

Table of Contents
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Chapter 1: Introduction

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Page 4

Definitions of Terms

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Page 5

Assumptions

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Page 5

Chapter 2: Literature Review ..

Page 6

Chapter 3: Methods

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Page 10

Sampling Procedure

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Page 10

Participants

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Page 10

Measurements

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Page 11

Procedure

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Page 12

Data Analysis

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Page 14

References

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Page 15

Appendix

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Devon Chan

Chapter 1: Introduction
One of the most concerning and dangerous consequences of Parkinsons disease (PD) is
an increased risk of falling due to the motor impairments associated with the disease. In British
Columbia, approximately 11,000 individuals are diagnosed with PD and face the burdens related
to falling on a daily basis (Parkinsons Society British Columbia, 2014). Commonly,
experiencing a fall leads to higher risks of hip fractures and an increased fear of falling;
consequently, this fear leads to a decreased quality of life (Lindholm et al., 2014; Idjadi et al.,
2005).
In order to address this problem, some research suggests exercise gaming or
exergaming as exercise and therapy to improve balance of PD individuals; thus, it may reduce
the risk of falls. The Nintendo Wii Fit TM with Wii balance board accessory (WBB) is a popular
exergame observed to improve balance and other motor impairments in PD individuals (Esculier,
Vaudrin, Beriault, Gagnon, & Tremblay, 2012; Barros Gonalves, Leite, Orsini, & Santos
Pereira, 2014; Zettergren, Franca, Antunes, & Lavallee, 2011;Holmes, Gu, Johnson, & Jenkins,
2013). While the WBB has the potential of being a beneficial method of exercise and therapy, the
structure of the system poses as a possible risk for PD individuals. More specifically, the Wii
FitTM games with WBB require an individual to dual task and manipulate their body position on a
raised platform; therefore, the WBB may elicit falling and tripping during gameplay. Despite the
growing research examining balance adaptations using the WBB, little is known about the safety
of implementing the WBB for PD individuals. Especially since PD individuals face high risks of
falling, determining the safety is important before recommending the use of the WBB for
exercise or therapy.
For that reason, the purpose of this study is to investigate the safety of using the Wii FitTM
balance board as home-based exercise and balance therapy for individuals with mild to moderate
Parkinsons disease. Specifically, the focus of the study will address the following research
question: what is the frequency of trips and falls during the gameplay of 3 games using the Wii
FitTM balance board? Additionally, participants perceived safety using the WBB will be
addressed.

Devon Chan

Definition of Terms
In this study, falling and tripping were operationally defined based on the individuals
orientation around the WBB. The three games chosen for this study require the individual to
keep both feet on the WBB; therefore, a fall is defined as both feet on the ground or both feet
neither on the ground or WBB. Commonly, a trip is defined as imbalance that would result in a
fall if proper recovery mechanisms are not activated (Iluz et al., 2014); thus, a trip is
operationally defined as one foot on the ground and one foot on the WBB as this would require
an individual to utilize their recovery mechanisms to prevent both feet from leaving the board.
Based on the Modified Hoehn and Yahr staging scale, mild to moderate Parkinsons
disease is operationally defined as stage 2.5 to stage 3 PD. Stage 2.5 is classified by mild
bilateral disease with recovery on a pull test and Stage 3 is associated with mild to moderate
bilateral disease; some postural instability; physically independent(Hoehn & Yahr, 1967;
Kompoliti & Metman, 2009).

Assumptions
Since baseline measurements will be collected through a confidence survey and balance
survey, it will be assumed that the participants are answering honestly and correctly. This
assumption will also be expected as the participants self-report their perceived safety after each
session. Lastly, it will be assumed that individuals recording trips and falls during gameplays
understand the definitions of terms and the criteria of the scale.

Devon Chan

Chapter 2: Literature Review


Within Canada, nearly 5,500 individuals are diagnosed with PD each year (Parkinsons
Society British Columbia, 2014). Additionally, individuals with PD have a 51% greater risk of
injury mortality with falls being a major cause of injuries (Jones, Martin, Wielder, King-Jesso, &
Voaklander, 2012). With such consequences related to falls, exercise gaming is suggested as a
non-pharmacological treatment for balance impairments. For the purpose of this study, the
literature related to Parkinsons disease and exercise gaming will be described in this chapter.
More specifically, this literature review will overview Parkinsons disease motor-symptoms
related to falls, effect of exercise for PD individuals, influence of the Nintendo Wii Fit TM in PD
population, and the risks and safety of using the Wii FitTM balance board for individuals with PD.
PD is a neurodegenerative disease associated with dysfunction of the basal ganglia and
disruption of dopamine release. As a consequence, PD individuals suffer from many motor
symptoms such as postural instability, postural sway, imbalance, bradykinesia, rest tremor,
rigidity, and freezing gait (Hoehn & Yahr, 1967). In particular, many studies have focused on
imbalance as it increases the risks of falling during everyday activity and living (Lindholm et al.,
2014; Gazibara et al., 2014). Subsequently, falling tends to burden many PD individuals by
increasing their susceptibility to hip fractures and early mortality (Idjadi et al., 2005; Chen,
Cheung, Wu, & Lai, 2012). In order to improve balance, exercise has been suggested as a nonpharmacological method of therapy to increase balance and reduce falls in PD individuals (Kara,
Genc, Colakoglu, & Cakmur, 2012; Lauhoff, Murphy, Doherty, & Horgan, 2013; Gao et al.
2014). According to Kelly et al. (2013), high-intensity exercise leads to improvements in
mobility and balance as it induces adaptations to myofiber hypertrophy, shifts to a less fatigue
muscle type, and increases in mitochondrial activity. As well, many studies have documented
improvements in balance through participation in various exercise such as dance and tai chi
(Hackney & Earhart, 2010; Gao et al., 2014).
Along with the recent advances in technology, some research in exercise and therapy for
PD individuals has shifted towards examining the influences of exercise gaming or exergaming
on balance. Commonly, exergaming refers to video game systems that integrate exercise with
virtual reality by tracking body movements and reactions in real time with the gameplay. One of
the most popular system used throughout exergaming researcher is the Nintendo Wii Fit TM
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Devon Chan
balance board system. The Wii Fit TM balance board (WBB) is similar to a force platform as it
produces information about the position of an individuals center of gravity by using a four load
cell (Park & Lee, 2014). Information from the WBB can be connected to a monitor to track the
position of an individuals center of gravity or it can be connected to the Wii console as an
accessory to the Wii FitTM games (Park & Lee).
Regardless of its growing popularity, it was not until recently that studies began to
examine the effect of the Nintendo Wii Fit TM system for PD population. In many studies,
increases in static balance, dynamic balance, and gait of PD individuals occurred after
experimental interventions using the WBB with balance-related Wii Fit TM games and balance
games not requiring the WBB (Esculier, Vaudrin, Beriault, Gagnon, & Tremblay, 2012; Barros
Gonalves, Leite, Orsini, & Santos Pereira, 2014; Zettergren, Franca, Antunes, & Lavallee,
2011; Herz, Mehta, Sethi, Jackson, & Hall, 2013). In contrast, some studies did not see
significant improvements in static balance or in balance games that included fast decision
making and quick gait changes (Mendes et al., 2012; Mhatre et al., 2013). One study did not
observe a statistically significant improvement in balance after PD individuals completed a 12
week intervention only including Wii FitTM games performed on the WBB (Holmes, Gu,
Johnson, & Jenkins, 2013). Additionally, studies have noted that improvements in balance were
retained after the intervention finished (Mendes et al.; Esculier et al.). However, some retention
scores showed that balance improvements were short term and regressed back to baseline
without the continuation of Wii-therapy (Herz et al.; Barros Gonalves et al.; Holmes et al).
The presented evidence on the influence of Wii FitTM therapy on PD individuals has
resulted from small sample sizes, lack of control groups, and short intervention periods. The
small samples sizes have been a prevalent limitation throughout the literature with the largest
sample size being 20 PD individuals (Herz, Mehta, Sethi, Jackson, & Hall, 2013). As well,
evidence was derived from relatively short intervention periods as the longest intervention lasted
12 weeks with the PD individuals attending Wii FitTM therapy 3 times each week (Holmes, Gu,
Johnson, & Jenkins, 2013). Lastly, only two studies have matched the PD individuals with
healthy elderly individuals to act as a comparison group; however, no studies have included a
control group (Esculier, Vaudrin, Beriault, Gagnon, & Tremblay, 2012; Mendes et al., 2012).
According to Mhatre et al. (2013), the lack of a control group limits the ability of researchers to
correct for any effects from the natural progression of PD.
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Devon Chan
Despite the emerging literature and potential benefits of WBB on balance, the safety of
implementing the Wii FitTM games using the WBB for PD individuals remains unclear. Since the
WBB is a raised platform, it may pose as a potential risk for tripping and falling during
gameplay. According to Gazibara et al. (2014), the most common extrinsic cause of falls in PD
individuals in outdoor and indoor settings is tripping. More specifically, stepping up or over an
obstacle was a frequent cause of tripping due to motor impairments associated with PD
(Gazibara et al.). In addition, the Wii FitTM games require the individual to dual task by moving
their body according to the visual and auditory cues in the games. Dual tasking has been seen to
significantly increase falls in PD individuals compared to healthy elderly individuals (Jacobs,
Mutt, Carlson-Kuhta, Allen, & Horak, 2014).
Presently, only three studies address safety of PD participants during gameplay using the
WBB. In a study by Mhatre et al. (2013), safety of the individuals during therapy was ensured
through supervision of a therapist and implementation of a balance bar for additional support.
During this study, PD individuals engaged in group therapy playing marble tracking, bubble
rafting, and skiing on the WBB three times a week. It was noted there were no adverse effects
and that WBB was safe and feasible (Mhatre et al.). However, the study fails to explain how
safety was determined as they did not include measurements of trips or falls during the training.
In contrast, research staff in another study ensured safety of gameplay by closely monitoring the
first training sessions; however, safety was not addressed further in this study (Esculier, Vaudrin,
Beriault, Gagnon, & Tremblay, 2012). Lastly, one study addressed fall risks related with the Wii
FitTM Ski Jump game as the required body positions during this game may promote falling
(Holmes, Gu, Johnson, & Jenkins, 2013). Nevertheless, safety regarding frequency of trips or
falls were not monitored during training sessions aside from once a week phone calls from
therapists addressing technical or ill health concerns (Holmes et al.).
Consequently, there is an absent of evidence examining safety associated with WBB
therapy with regards to the frequency of falls or trips during gameplay. Primarily most studies
occurred within clinic settings with the focus being on balance adaptations; therefore, safety may
not have been a concern for the researchers (Barros Gonalves, Leite, Orsini, & Santos Pereira,
2014; Zettergren, Franca, Antunes, & Lavallee, 2011; Herz, Mehta, Sethi, Jackson, & Hall, 2013;
Mendes et al., 2012; Mhatre et al., 2013). Only two studies examined WBB therapy within a
home-based setting where gameplay was self-supervised; however, measurement of trips and
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Devon Chan
falls were not included in the analysis (Esculier, Vaudrin, Beriault, Gagnon, & Tremblay, 2012;
Holmes, Gu, & Jenkins, 2013).
Considering the high risks of falling associated with PD and the potential risks of the
WBB, identifying the safety of using the WBB is important before recommending it as a method
of exercise or therapy for PD individuals. More specifically, it is important to identify the safety
of WBB within a home setting where PD individuals would be more likely to engage in WBB
therapy. In general, exergaming has a potential for improving balance of PD individuals; thus, it
could reduce of high risk of falls associated with the motor-symptoms of the disease.
Particularly, the Wii FitTM system and WBB has the potential of being a beneficial method of
exercise and therapy for PD individuals; however, many risks may occur due to the structure of
the WBB and dual tasking requirements of the Wii Fit TM games. Currently, there is a large gap in
the literature examining the safety of PD individuals using this system with regards to tripping or
falling. Therefore, the aim of this study is to measure the safety of implementing the WBB as
home-based balance therapy for individuals with mild to moderate PD based on frequency of
tripping and falling during gameplay.

Devon Chan

Chapter 3: Methods
This design of this study will be an observational descriptive design used to examine the
frequency of trips and falls in individuals with mild to moderate Parkinsons disease during three
Wii FitTM games using the Nintendo Wii FitTM balance board.

Sampling Procedure and Participant Characteristics


The sampling method of this study will follow a purposive sampling method based on
inclusion and exclusion criteria described in the following section. The aim of this study is to
focus on PD individuals from 2 Parkinsons disease support groups and 2 Parkinsons exercise
groups organized by the Victoria Epilepsy and Parkinsons Center in Victoria, BC. From this
sampling frame, individuals with PD classified as stage 2.5 or stage 3 based on the Modified
Hoehn and Yahr staging scale will be recruited (Hoehn & Yahr, 1967; Kompoliti & Metman,
2009). Stage 1 and stage 2 PD individuals were not included in the study as these stages are
classified by individuals lacking impairment of balance (Hohen & Yahr). Also, PD individuals
with Hohen and Yahr scores higher than stage 3 present a significantly higher risk of falling;
therefore, this study excluded PD individuals higher than stage 3 due to the rarity of these
individuals being recommended to use the WBB (Hiorth, Lode, & Larsen, 2013). Other
exclusion criteria for this study is the present of other neurodegenerative diseases, lower limb
injury, inability to stand unassisted, and change in medication 2 weeks before screening or during
the study. Inclusion criteria for this study is diagnosed stage 2.5 or 3 PD, normal or corrected
vision, good or corrected auditory perception, and no previous experience using WBB.
Individuals will be contacted through phone calls or email to request their participation in the
study. Interested participants will then get medical clearance and be screened for inclusion and
exclusion criteria by a physician. Ethics approval will be sought because this study involves
human participants and data collected through video capture. As well, informed consent will be
collected from participants prior to the start of the study.

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Devon Chan

Measurements
Baseline Measurements
After participants undergo screening by a physician, baseline data will be collected:
balance confidence, dynamic balance, and static balance. Balance confidence will be assessed
using the Activity-specific Balance Confidence Scale (ABC scale). The ABC scale includes 16
items targeting daily functional tasks that are ranked on a scale from no confidence (0%) to
completely confident (100%) in order to determine an individuals self-efficacy (Powell &
Myers, 1995). The ABC scale is reliable and valid method of measuring balance confidence as
determined through testing on a general sample of older community-dwelling adults (Cleary &
Skornyakov, 2014). For dynamic and static balance, the Berg Balance Scale (BBS) will be used.
The BBS is a qualitative scale that ranks functional balance between 0 (low) to 4 (high) during
14 different tasks such as sitting, standing, and turning. The interpretation of the BBS scores are
reflective of an individuals fall risk: low fall risk (41-56), medium fall risk (21-40), and high fall
risk (0-20). The BBS significantly correlated with the Hoehn & Yahr Scale, Unified Parkinsons
Disease Rating Scale, and Modified Schwab and England Capacity for Daily Living Scale in a
study testing 38 men with PD; therefore, the BBS has concurrent validity (Qutubuddin, Pegg,
Cifu, Brown, McNamee, & Carne, 2005). The BBS is determined to also be a valid and reliable
measure of balance for a PD adult population (Qutubuddin et al; Steffen & Seney, 2008).

Primary Measurement
The primary measurement of this study is frequency of trips and falls during game play.
Gameplays will be recorded through video capture. From the recorded video, frequency of trips
and falls during each gameplay will be tracked through a subjective counting system (see
Appendix). The counting system was designed to include dual tasking considerations of the
game. The system will include columns for the parameters, parameter description, and frequency.
In the present study, the parameters will be trips and falls. Classification of a trip and fall was
defined in a previous section (page 5). These parameters were then subdivided into two
categories centred on the dual tasking requirements of the game. If the participant is looking at
the screen during a trip or a fall, it will be classified as a fall or trip while dual tasking; therefore,
it will be considered as a higher risk parameter (Jacobs, Mutt, Carlson-Kuhta, Allen, & Horak,
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Devon Chan
2014). If the participant is not looking at the screen, it will be classified as less of a risk because
the participant is focusing more on their body positioning than the game. Preliminary testing of
the scale will be done prior to the start of the study to determine the validity and reliability of the
counting scale.

Secondary Measurement
Participants perceived safety will be collected as a secondary measurement. The sessions will
conclude with participants self-reporting their perceived safety through paper and pen by
addressing the following: did they feel safe during game play?, did they feel they needed
additional support or supervision?, and would they continue to use this system at home?

Procedure
Prior to the start of the study, preliminary testing will be done to determine the reliability
and validity of the subjective counting scale for trips and falls. A video will be recorded of a PD
individual displaying a few falls and trips during 60 second gameplay of Wii-fit Ski Slalom. This
video will be scored using the trips and falls scale devised for this study. In order to determine
reliability, this video will be rescored 1 and 3 days later. The video will also be scored and
reviewed by a physiotherapist to determine validity and ensure the scale reflects tripping and
falling risk. Furthermore, individuals recording trips and falls will undergo training to reduce
inter-observer error. Training will ensure individuals understand the definitions of falls and trips,
as well as the criteria for determining if they participant is dual tasking. They will practice
scoring a pre-scored video using the trips and falls counting scale.
The participants will be screened by a physician for inclusion and exclusion criteria and
complete baseline tests within the same day. Once results from the tests are reviewed, 1 session
each week will be arranged based on the participants availability for the next 3 weeks. Sessions
will be held in laboratory settings with only 1 participant present at a time. At the start of each
session, participants will receive an explanation of the game and they will observe 3 trials of the
game performed by the test administrator. The test administer will be the same individual for all
sessions and all participants. The participant can also practice the motions of the game; however,
this must be done on the ground. This observation period will last 10 minutes and the participant
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Devon Chan
may ask any questions within this period. Subsequently, the participant will be attached to a
safety harness connected to the roof to prevent any real falls from occurring. In order to create a
home setting, the participant will not be given any additional supports and the test administer
will not be present during game play. The participant will then engage in three Wii Fit TM balance
games on the WBB. Three consecutive trials of each game will be played with 30 sec rest
between each trial and a 5 minute rest between each game. The three Wii Fit TM games were
chosen based on their prevalent use in previous studies examining the Wii FitTM system and
balance: Slalom Skiing, Penguin slide, and Balance bubble.
The purpose of Slalom Skiing is to ski down a mountain while maneuvering between
flags in the shortest amount of time. The game requires the individual to stand with both feet on
the board while shifting their weight side to side in smooth and controlled motions. The game
also includes a visual image to represent where the individuals weight is on the board during
game play. Participants will be told to try to complete the game in the shortest time. In penguin
slide, the purpose is to score as many points by collecting fish without falling off the iceberg in
90 seconds. This game requires the individual to stand with both feet on the board and shift their
weight side to side in quick sharp movements. Participants will be told to try to score the highest
points. Lastly, the purpose of bubble balance is to manipulate around a course in the shortest time
without touching the walls. The individual must stand with both feet on the board while slowly
shifting their weight in all directions in order to change the movement of the bubble. Participants
will be told to try to complete the course in the shortest time.
During gameplay, data will be collected through 4 GoPro Hero4 Black edition video
cameras simultaneously recording 4 different views of the performer. One camera will be set up
perpendicular to each side of the board to result in one camera on each side. These cameras will
be positioned to capture from the ground to 5 inches above the participants head. The camera
model was chosen based on equipment considerations for motion analysis using video (Payton &
Barlett, 2008). After each sessions is complete, participants will answer the 3 guided questions.
Lastly, trips and falls will be counted for each gameplay using the subjective counting
system by 2 trained individuals. The individuals will view and score the videos independently.

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Data Analysis
Once the frequency of each sub-classification of the parameters is summed for each
gameplay, means and standard deviations for each game will calculated to be used for
comparison in the discussion. Each participants mean and standard deviation of the total
frequency for all parameters will then be calculated for each game. The average frequency of
trips or falls during game play will then be calculated using mean scores from all participants per
game. The overall frequency of trips and falls for each game will be used to reflect the safety of
using the WBB for PD individuals with stage 2.5 to stage 3 PD. Participants perceived safety
will not analysed, but it may be referred to during the discussion.

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18

Devon Chan

Appendix
Risk of Trips and Falls Subjective Counting Scale

Parameter

Parameter Description

Trips

Focusing on body position:


Participant is not looking at the
screen with one foot on board
and one foot on the ground
Focusing on screen:
Participant is concentrating on
screen with one foot on board

Falls

and one foot on the ground


Focusing on body position:
Participant is not looking at the
screen with two feet off the
board
Focusing on screen:
Participant is looking at the
screen with 2 feet off the board
Participant has no feet on the
ground or floor and is fully
dependant on safety harness to
prevent full fall

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Frequency/ gameplay

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