Nintendo Wii training on postural balance and mobility rehabilitation of adults with Parkinson's disease: a systematic review

Ferraz, Daniel Dominguez; Trippo, Karen; Dominguez, Adriana; Santos, Adriana; Oliveira, Jamary

doi:10.1590/1980-5918.030.S01.AR07

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Review articles • Fisioter. mov. 30 (suppl 1) • 2017 • https://doi.org/10.1590/1980-5918.030.S01.AR07 copy

Nintendo Wii training on postural balance and mobility rehabilitation of adults with Parkinson's disease: a systematic review

Treinamento com Nintendo Wii na reabilitação do equilíbrio postural e mobilidade de indivíduos com Doença de Parkinson: uma revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Postural instability affects balance control in Parkinson disease (PD) patients and increases the particular risk of falling compared with healthy older adults. Video games with not immersive virtual reality have been used in neurological disorders rehabilitation process.

Objective:

To evaluate the effectiveness of the video game console Nintendo Wii (NW) on postural balance and mobility treatment of adults with PD in Hoehn and Yahr stages I to III.

Methods:

The following databases were searched electronically on MEDLINE, Cochrane Library, PEDro, CAPES Periodic, BIREME, and LILACS databases. The search period for this review was January 2010 to June 2016. The assessment of methodological quality was performed using the PEDro Scale as reference.

Results:

12 original studies were selected, but only 3 were randomized controlled trials (RCTs).

Conclusion:

Some of the studies analysed suggest that NW can provide improvement in balance and mobility of adults with PD. These benefits should be interpreted with caution because of the low methodological quality of the included trials, and the lack of common assessment of treatment effects. There is little evidence to ensure the effectiveness and support the inclusion of the treatment with NW of patients with PD.

Keywords:
Parkinson Disease; Virtual Reality Exposure Therapy; Video Games; Rehabilitation

Electronic databases	Key words (DECS/MeSH)
MEDLINE/PubMed	((("Virtual Reality Exposure Therapy"[Mesh)) OR "Video Games"[Mesh]) AND "Postural Balance"[Mesh]) AND "Parkinson Disease"[Mesh]
Cochrane Library	Parkinson Disease AND Video Games; Parkinson Disease AND Wii; Parkinson Disease AND Virtual Reality; Parkinson Disease AND virtual reality exposure therapy.
PEDro	Parkinson Disease AND Video Games; Parkinson Disease AND Wii; Parkinson Disease AND Virtual Reality; Parkinson Disease AND virtual reality exposure therapy.
CAPES Periodic	Parkinson Disease AND Video Games AND Postural Balance; Parkinson Disease AND Wii AND Postural Balance; Parkinson Disease AND Virtual Reality AND Postural Balance; Parkinson Disease AND virtual reality exposure therapy.
BIREME	Parkinson Disease AND Video Games; Parkinson Disease AND Wii; Parkinson Disease AND Virtual Reality; Parkinson Disease AND virtual reality exposure therapy.
LILACS	Parkinson Disease AND Video Games; Parkinson Disease AND Wii; Parkinson Disease AND Virtual Reality; Parkinson Disease AND virtual reality exposure therapy.

Authors	1^*	2	3	4	7	8	10	11	Score
Pompeu et al, 2012²⁰20 Pompeu JE, Mendes FA, Silva KG, Lobo AM, Oliveira Tde P, Zomignani AP, et al. Effect of Nintendo Wii(tm)-based motor and cognitive training on activities of daily living in patients with Parkinson's disease: a randomised clinical trial. Physiotherapy. 2012;98(3):196-204.		x		x	x		x	x	5
Liao et al, 2015²¹21 Liao YY, Yang YR, Cheng SJ, Wu YR, Fuh JL, Wang RY. Virtual Reality-Based Training to Improve Obstacle-Crossing Performance and Dynamic Balance in Patients With Parkinson's Disease. Neurorehabil Neural Repair. 2015;29(7):658-67.	x	x	x	x	x	x	x	x	7
Lee, Lee and Song, 2015²²22 Lee NY, Lee DK, Song HS. Effect of virtual reality dance exercise on the balance, activities of daily living, and depressive disorder status of Parkinson's disease patients. J Phys Ther Sci. 2015;27(1):145-7.		x		x			x	x	4

Author/year/study	Sample / Age mean / Level of PD	Instruments of evaluation	Results / Conclusions
Zettergren et al, 2011³²32 Zettergren K, Franca J, Antunes M, Lavallee C. The effects of Nintendo Wii Fit training on gait speed, balance, functional mobility and depression in one person with Parkinson's disease. ATI. 2011;5(2):38-44. (Case Study)	n = 1	TUG	After 8 weeks, the subject’s BBS score and the gait speed have increased, the TUG decreased and and GDS scores remained unchanged. The Nintendo Wii Fit may be a viable alternative to independent exercise programs for people diagnosed with idiopathic PD.
	69 years	BERG
		Self selected gait speed
		Fall history
		GDS
Esculier et al, 2012²⁵25 Esculier JF, Vaudrin J, Bériault P, Gagnon K, Tremblay LE. Home-based balance training programme using Wii Fit with balance board for Parkinsons's disease: a pilot study. J Rehabil Med. 2012;44(2):144-50. (Clinical Trial)	n = 20	STST	The PD group significantly improved their results in TUG (p < 0.04), STST (p < 0,01), unipodal stance (p < 0.05), 10-m walk test (p < 0.001), CBM (p < 0.001), POMA (p < 0.05) and force platform after the training programme. The healthy subjects group significantly improved in TUG (p < 0.001), STST (p < 0.01), unipodal stance and CBM (p < 0.02). This study suggests that a home-based balance programme using Wii Fit could improve static and dynamic balance, mobility and functional abilities of people with PD.
		TUG
	n = 9 Health people	POMA
	64 years	10-m walk test
		CBM
	n = 11 People with PD	ABC
	62 years	Unipodal stance duration Force platform
	18.4 - UPDRS
Pompeu et al, 2012²⁰20 Pompeu JE, Mendes FA, Silva KG, Lobo AM, Oliveira Tde P, Zomignani AP, et al. Effect of Nintendo Wii(tm)-based motor and cognitive training on activities of daily living in patients with Parkinson's disease: a randomised clinical trial. Physiotherapy. 2012;98(3):196-204. (Randomised clinical trial)	n = 32	UPDRS-II	Both groups showed a significant improvement (p < 0.05) on the UPDRS-II, BBS, Unipedal Stance Test and Montreal Cognitive Assessment after training that was maintained at follow-up. Wii Fit could be used as a new tool in association with physical therapy in order to improve motivation, and consequently adherence.
	67 years	BERG
	Hoehn and Yahr stages 1 and 2	Unipedal Stance Test
		Montreal Cognitive Assessment
Loureiro et al, 2012³³33 Loureiro APC, Ribas CG, Zotz TGG, Chen R, Ribas F. Feasibility of virtual therapy in rehabilitation of Parkinson's disease patients: pilot study. Fisioter. Mov. 2012;25(3):659-66. (Quasi-experimental design)	n = 6	Borg’s Scale	Statistically significant differences were found in the following tests: Borg’s Scale and BERG. The TUG and Notthingham’s Scale was not statistically significant when comparing the initial and final values. It is believed that exercises with virtual reality therapy can be a useful tool to improve the balance in PD patients.
	65 years	BERG
	Hoehn and Yahr stages 2 and 3	Notthingham’s Scale
		TUG
		Functional Reach
Mhatre et al, 2013³⁴34 Mhatre PV, Vilares I, Stibb SM, Albert MV, Pickering L, Marciniak CM, et al. Wii Fit balance board playing improves balance and gait in Parkinson disease. PM R. 2013;5(9):769-77. (Quasi-experimental design)	n = 10	BERG	The BBS (p < 0.016) and DGI (p < 0.004) improved significantly, as did postural sway measured with the balance board. The Sharpened Romberg improvements significance only for eyes open (p < 0.049). There were no significant changes on patient ratings for the Activities-specific Balance Confidence. An exercise training class by using the Wii Fit balance board improved selective measures of balance and gait (p < 0.035) in adults with PD. However, no significant changes were seen in mood or confidence regarding balance.
	67 years	DGI
	Hoehn and Yahr stages 2,5 and 3	Sharpened Romberg with eyes open and closed
		Postural sway using the Wii balance board
		ABC
		GDS
Herz et al, 2013²³23 Herz NB, Mehta SH, Sethi KD, Jackson P, Hall P, Morgan JC. Nintendo Wii rehabilitation ( »,» ®,® §,§ , ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ Wii-hab »,» ®,® §,§ , ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ ) provides benefits in Parkinson's disease. Parkinsonism Relat Disord. 2013;19(11):1039-42. (Quasi-experimental design)	n = 20	9-hole peg test	There was a significant improvement in the right-sided 9-hole peg test score and TUG score between pre- and post-intervention. This study demonstrates that the Nintendo Wii gaming system can be an effective treatment modality for patients with PD. However further studies are needed to determine if there are long-term benefits of this therapy in PD.
	67 years	POMA
	Hoehn & Yahr Stage 2	Purdue Pegboard Test
		Timed tapping test
		TUG
		Hamilton Depression Scale Nottingham
		Extended Activities of Daily Living Test
		PDQ-39
		NEADL
		UPDRS
Zalecki et al, 2013²⁶26 Zalecki T, Gorecka-Mazur A, Pietraszko W, Surowka AD, Novak P, Moskala M, et al. Visual feedback training using WII Fit improves balance in Parkinson's disease. Folia Med Cracov. 2013;53(1):65-78. (Quasi-experimental design)	n = 24	BERG	There was a significantly improvement in BERG (p < 0.0001), POMA (p < 0.001), TUG (p < 0.05), Sit-to-stand test (p < 0,05), 10-Meter Walk test (p < 0.05) and Activities-specific Balance Confidence scale (p < 0.003) at the end of the programme.
	69 years	POMA
		TUG
		Sit-to-stand test
		10-Meter Walk test
		ABC
da Silva et al, 2013³⁰30 Silva FD, Polese JC, Alvarenga LFC, Schuster RC. Efeitos da Wiireabilitação Na Mobilidade de Tronco de Indivíduos com Doença de Parkinson: Um Estudo Piloto. Rev Neurocienc. 2013;21(3):364-8. (Quasi-experimental design)	n = 6	Goniometry	It was observed that treatment using Wii Sports (Nintendo Wii®) games was able to increase, range of movement (p < 0.03), trunk mobility (p < 0,003), balance (p < 0.02) and quality of life of individuals with PD (p < 0.03).
		Trunk Mobility Scale
		BERG
		PDQ-39
Liao et al, 2015³⁶36 Liao YY, Yang YR, Cheng SJ, Wu YR, Fuh JL, Wang RY. Virtual Reality-Based Training to Improve Obstacle-Crossing Performance and Dynamic Balance in Patients With Parkinson's Disease. Neurorehabil Neural Repair. 2015;29(7):658-67. (Randomized controlled trial)	n = 36	Obstacle crossing performance Dynamic balance	The Wii Fit group showed greater improvement in obstacle crossing velocity, crossing stride length, dynamic balance, SOT, TUG, FES-I, and PDQ39 than the control group. Wii Fit training also resulted in greater improvement in movement velocity of limits-of-stability test than Traditional Exercise training.
	Hoehn and Yahr score ranging 1 to 3	SOT
	Wii Fit exercise (n = 12)	PDQ-39
	Traditional exercise (n = 12)	FES-I
	No structured exercise program (n = 12)	TUG
Pompeu et al, 2014³⁵35 Pompeu JE, Andrade G, Mendonça MS, Pompeu SMAA, Lange B. Safety, Feasibility and Effectiveness of Balance and Gait Training Using Nintendo Wii Fit PlusTM on Unstable Surface in Patients with Parkinson's Disease: A Pilot Study. J Alzheimers Dis Parkinsonism. 2014;4(1):1-4. (Case series)	n = 4	BESTest	There was an improvement of 9.19% in the BESTest score. This improvement may be related to the motor and cognitive demands of the games.
	67 years
	Hoehn and Yahr stages 2 and 3
Lee, Lee and Song, 2015²⁹29 Lee NY, Lee DK, Song HS. Effect of virtual reality dance exercise on the balance, activities of daily living, and depressive disorder status of Parkinson's disease patients. J Phys Ther Sci. 2015;27(1):145-7. (Randomized controlled trial)	n = 20	BBS	There was significantly difference between before and after treatment in the experimental group (46.0 ± 1.3 to 48.1 ± 3.0; p < 0.05) and significantly differed between the experimental and control group in the balance (p < 0.05), activities of daily living, and depressive disorder status. Virtual reality dance exercise has a positive effect on balance, activities of daily living, and depressive disorder status of PD patients.
	68 years	Modified Barthel Index
	Experimental group (n = 10)	Beck Depression Inventory
	Control group (n = 10)
Negrini et al, 2016³¹31 Negrini S, Bissolotti L, Ferraris TA, Noro F, Bishop MD, Villafañe JH. Nintendo Wii Fit for Balance Rehabilitation in Patients with Parkinson's Disease: a compartive study. J Bodyw Mov Ther. 2017;21(1):117-23.	n = 27	BBS	The results revealed significant differences for the low dose group and for the high dose group (all, p < 0.02) for BBS and FRT, but not significant difference was identified in POMA (all, p < 0.2) for the high dose group. There was no significant difference between the groups (p > 0.05).
	66 years	POMA
		FRT

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[1] *DDF: Doctoral student, e-mail: danieldf@ufba.br