Occupational Therapy in Health Care, 25(2–3):131–139, 2011C© 2011 by Informa Healthcare USA, Inc.Available online at http://informahealthcare.com/othcDOI: 10.3109/07380577.2011.560627

The Effect of Nintendo Wii on Balance: A PilotStudy Supporting the Use of the Wii in

Occupational Therapy for the Well Elderly

Barbara Williams, Nicole L. Doherty, Andrew Bender, Holly Mattox, &Jesse R. Tibbs

College of Nursing and Health Professions, University of Southern IndianaOccupational Therapy Program, Evansville, Indiana, USA

ABSTRACT. This study explored the benefits that Nintendo’s Wii Fit activities mayhave on the balance of 22 community living older adults. Over 4 weeks, participantscompleted twelve 20-min sessions using various programs in the Wii Fit. Pretest andposttest measurements were obtained using the Berg Balance Scale with participantsscoring an average of 9.14 points higher on the postintervention. Posttest balance scoreswere significantly greater [t (21) = −9.861, p < .01] than pretest scores. Reports fromthe participants supported the positive use and possible improvements in quality of life.The results of this study suggest the potential effectiveness of utilizing the Nintendo Wiias a therapeutic agent in occupational therapy practice.

KEYWORDS. balance, gaming system, well elderly

Balance is a major issue for older adults, as more than a third of adults aged 65and older fall each year, and falls are the major cause of injury resulting in deathin older adults [CDC (Centers for Disease Control and Prevention), 2009]. Every18 s, an older adult is treated in an emergency room secondary to a fall, and every35 min, an older adult dies as a result of injury from a fall (CDC, 2009), resulting insignificant medical costs. Additionally, injuries, such as bruises, fractures, and headinjuries, as well as the fear of falling lead to restrictions in activities of daily livingand often require occupational therapy intervention. Subsequently, these issues re-sult in higher health care costs.

Hay et al. (2002) demonstrated the potential cost effectiveness for preventativeoccupational therapy services in a geriatric population (N = 163) by revealing adecrease in medical expenditures for the study population. Although this decreasewas not significant, healthcare costs at follow-up were considerably lower for thegroup receiving occupational therapy group services as compared with the control

Received 26 July 2010; revised 25 January 2011; accepted 2 February 2011.Address correspondence to: Barbara Williams, DrOT, OTR, Program Director of Occupational Therapy andAssistant Professor, College of Nursing and Health Professions, University of Southern Indiana OccupationalTherapy Program, Evansville, Indiana 47712, USA (E-mail: bjwilliams4@usi.edu).

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groups. This study indicated that activities aimed at improving balance, cardiovas-cular endurance, and quality of life have the potential to offer health benefits to thegeriatric population.

Although there is limited research on using virtual environments or virtual real-ity with well-elderly populations, there are multiple studies that have investigatedthe use of virtual reality for intervention in rehabilitation with individuals aftercerebral vascular accidents. These studies demonstrated a positive relation for uti-lizing virtual reality in rehabilitation to improve participation in instrumental activ-ities of daily living (IADL), balance and gait, and hand dexterity (Betker, Szturm,Moussavi, & Nett, 2006; Kim, Jang, Kim, Jung, & You, 2009; Merians et al., 2002;Rand, Weiss, & Katz, 2009). Rand et al. (2009) examined the effects of VMall, avirtual reality system, on multitasking skills in four patients poststroke. Results in-dicated substantial improvement in scores of the Multiple Errands Test—HospitalVersion, which measures effects of executive impairment in everyday tasks (Knight,Alderman, & Burgess, 2002). In a randomized controlled study performed (Kimet al., 2009), the researchers examined the effects of virtual reality on gait and bal-ance in patients with hemiparetic stroke. In the study, the experimental and controlgroups undergo the same therapy with the experimental group having an additional30 min of virtual reality in each session. Results indicated that those in the experi-mental group had improved balance scores as measured by the Berg Balance Scale(BBS) (Berg, Maki, Williams, Holliday, & Wood-Dauphinee, 1992) and BalancePerformance Monitor (Haas & Burden, 1999). Gait performance also significantlyimproved as measured by the GAITRite (Bilney, Morris, & Webster, 2003). Theuse of virtual reality was also examined in case studies with three individuals inthe chronic stage of stroke (Merians et al., 2002). Intervention to address dexter-ity included real object exercises as well as virtual reality exercises. Although notstatistically significant, participants demonstrated improved range of motion, frac-tionation, movement speed, and force production in their hands, and two of thethree individuals improved test scores on the Jebsen Test of Hand Function.

Addressing balance, Betker et al. (2006) examined whether coupling foot cen-ter of pressure-controlled video games with standing balance exercises would im-prove dynamic balance control. The center of pressure game required participantsto complete anterior–posterior and lateral weight shifts similar to those made whenengaging in Wii Fit activities. While results of this study did not reveal a statisti-cally significant pattern, findings did indicate that the participants demonstratedimproved dynamic balance and a decrease in number of falls after participating invideo-game-based exercise regimen.

Virtual reality is exemplified by Nintendo, a leading company in the video gameindustry that developed the Wii gaming system that combines gaming with thehealth benefits of physical activity. Wii Fit, software designed for the Nintendo Wii,utilizes a balance board for a unique experience in interactive gaming. Since thisgaming system combines purposeful movement with a game (purposeful) activity,the Nintendo Wii may be suitable for occupational therapy intervention if the oc-cupational therapy practitioners’ understanding of client factors and activity de-mands as indicated in the Occupational Therapy Practice Framework (AmericanOccupational Therapy Association, 2008) enables the therapist to integrate

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The Effect of Nintendo Wii on Balance 133

gaming systems appropriately and safely into health and wellness routines. Al-though the use of physically interactive video games for rehabilitation purposes isan increasingly popular phenomenon, empirical evidence does not exist to supportthe numerous benefits that older adults may acquire from participating in inter-active video games (Trout & Christie, 2007). Thus, there is a need for research tosupport the health benefits of physically interactive video games integrated as oc-cupational therapy intervention. Therefore, the purpose of the present study wasto explore the health benefits of the Nintendo’s Wii with a well-elderly population.Specifically, this study examined the implications this form of exercise has on thebalance, and correspondingly daily occupations, for a well-elderly population.

METHOD

Research Design

The specific research question is whether using the Nintendo’s Wii Fit game im-pacts the balance of a group of well-elderly individuals as measured by the BBS.This quasi-experimental, pilot study utilized a single group, pretest–posttest design.The intervention phase consisted of each subject participating in Nintendo’s Wii Fitactivities for three 20-min sessions per week, over a 4-week period. In each session,participants engaged in 10 min of Wii Fit R© balance activities directly followed by10 min of Wii Fit R© aerobic activities. University of Southern Indiana’s InstitutionalReview Board approved the study.

Participants

Participants consisted of a sample of convenience of the well-elderly population re-siding in three facilities that were independent retirement communities or skillednursing facilities in three cities in Indiana. For purposes of the inclusion criteria,the term well elderly referred to individuals with no significant medical conditions.To recruit participants for this study, we obtained a convenience sample from thefacilities via verbal encouragement, demonstrations of intervention, and promo-tional flyers in the mail. Exclusion criteria for this study included unstable health,injuries, decreased mobility, or the inability to attend interventions sessions on aconsistent basis. During the recruitment phase, potential participants received andsigned informed consent, media release, and health consent forms. Two individuals,from a skilled nursing facility, met the criteria, and all other participants were fromretirement communities.

Twenty-two older adults who met the inclusion criteria chose to participate inthis research study with no dropouts. Four participants were male and 18 female,all were of Caucasian decent. Participants in this study ranged in age from 74 to 94.The mean age was 83.86 with standard deviation (SD) of 5.47. All participants wereindependent with no functional deficits and were given authorization to participateby their physicians. In order for participants’ data to be included in the study, an80% attendance policy was mandated, and at the conclusion, there was a 98.11%attendance rating with three participants missing no more than two sessions eachthroughout the entire duration of the study.

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Instruments

The BBS (Berg et al., 1992) was used to determine balance at both testing times. Itconsists of 14 items, each scored on a 5-point scale ranging from 0 (lowest function)to 4 (highest function) based on the quality of the subjects’ task performance (Whit-ney, Poole, & Cass, 1998). To calculate total score, all 14 items are added togetherfor a global score calculated out of a possible 56 points. The BBS ranks individuals’risk of falling by percentage and whether the score is indicative of the need for anassistive device (i.e., score lower than 45) or in need of balance training (i.e., scoreslower than 40). Mackintosh, Datson, and Fryer (2006) consider the BBS the goldstandard in their study examining the psychometric properties of various balancescales. In addition, several studies indicate high validity and reliability ratings ofthe BBS (Bennie et al., 2003; Mackintosh et al., 2006; Whitney, Wrisley, & Furman,2003). To ensure inter-rater reliability in this study, two researchers scored the BBSfor each participant with an inter-rater reliability of 94.8% being established.

Procedures

At the first session at each setting, participants completed their consent formsand participated in the BBS. Prior to administering the BBS, the researchers weretrained by a physical therapist regarding proper administration of the assessment.The two researchers then had additional experience observing and administeringthe BBS with trained physical therapists present. For each of the three facilitiesinvolved in this study, data were collected one time, 3 days prior to implementingintervention and then a final time, within 3 days of completion of the intervention.

The two researchers also provided intervention for this study. During the inter-vention phase, participants were encouraged to continue their daily routines (e.g.,golf, resident council, shuffleboard, and aerobics class). Intervention sessions weremonitored by 5 researchers who gained experience by participating in numeroustraining practice sessions with the Wii Fit. Throughout the intervention sessions,participants were encouraged to select their own games from the balance and aer-obic categories. The activities that consisted of balance activities challenged par-ticipants to lean forward and backward and right to left on the balance board inorder to “win” at the virtual game. Aerobic activities challenged participants to jogin place, perform step aerobics, sway their hips, and move upper extremities as ifboxing. Many of theaerobic activities also challenged balance. Upon completion ofthe intervention phase, the BBS was readministered within 3 days to assess whetherchange occurred.

RESULTS

A paired t-test was utilized to confirm the hypothesis that participation in Nin-tendo’s Wii Fit activities will enhance participants’ balance as demonstrated byimprovements in BBS scores from preintervention and postintervention measure-ments. No participant exhibited a decline in balance. The paired samples t-test indi-cated that the intervention may have had a significant impact on improving balancefor participants. Posttest BBS scores (mean = 48.55, SD = 4.58) were significantlygreater [t (21) = −9.861, p < .01] than pretest BBS scores (39.41, 6.28). In addition,

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The Effect of Nintendo Wii on Balance 135

means and SD were used to compare individual participant BBS scores with theoverall older adult population’s BBS scores. Furthermore, we utilized percent ofimprovement to analyze the degree of change between each participant’s baselineand final BBS measurements.

DISCUSSION

The results of this study suggest that the Nintendo Wii, as provided throughoccupational therapy intervention, is effective in increasing the balance of 22well-elderly participants. Although there are no studies directing the use of theNintendo Wii as a therapeutic medium for increasing balance of well elderly, theseresults are similar to other studies that show using virtual games in a therapeuticmanner can have a positive outcome on individuals’ performance factors dexterity(Betker et al., 2006; Kim et al., 2009; Merians et al., 2002; Rand et al., 2009).Specifically, Table 1 summarizes the cumulative change in each participant’sBBS scores following his or her participation in Nintendo’s Wii Fit activities. Inaddition, baseline BBS scores indicate that 10 of the 22 participants were in needof specific balance training. Following the study, only one participant met thiscriterion (BBS scores lower than 40). Furthermore, prior to intervention, onlyfour participants’ BBS scores exceeded the criteria for the recommendation of anassistive device. Subsequently, following intervention, 17 of the 22 participants’BBS scores revealed no need for an assistive device. The top three components of

TABLE 1. Participant Demographics and Berg Balance Scale Scores

Participant # Sex Age % of Improvement

1 M 80 23.262 F 89 24.323 F 87 33.334 F 88 54.555 M 76 26.836 F 74 26.837 F 83 21.628 M 84 6.389 F 87 17.07

10 F 91 28.5711 F 79 37.5012 M 80 6.6713 F 90 60.0014 F 81 16.2815 F 87 22.2216 F 86 37.5017 F 75 0.0018 F 79 38.7119 F 94 25.0020 F 81 13.0421 F 89 16.2822 F 85 14.71

Group Mean 25.03SD

Note. BBS, Berg Balance Scale.

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the BBS in which the participants exhibited the most improvements were standingon one leg, standing tandem unsupported, and turning 360◦. More specifically,six participants went from not being able to stand in the tandem position, tomaintaining balance in the tandem position for a minimum of 1 min.

Figure 1 illustrates each participant’s final BBS scores in relevance to the base-line mean. Only three participants’ baseline BBS scores exceeded the mean es-tablished prior to the intervention phase of the study. Final BBS measurementsindicate that 15 of the 22 participants demonstrated improvements in balance thatexceeded the norms of the group BBS baseline measurements. This suggests that 15of 22 participants’ balance at the conclusion of the study were significantly abovefrom the group average BBS scores established at baseline. In addition, three of theseven participants (i.e., participants 13, 16, and 18), who did not achieve final BBSscores above the group norms established at baseline, exhibited a difference scoreabove the group average (i.e., M = 9.14). These data suggest that although thesethree participants did not achieve final BBS scores above the group norms estab-lished at baseline, they still demonstrated above average balance improvementsindividually.

In addition to providing a therapeutic intervention for occupational therapypractitioners, the Nintendo’s Wii Fit may have some advantages over other treat-ment modalities. All participants reported enjoying the use of the game platform.Specifically, several participants mentioned benefiting from the increased social-ization they experienced since the activities were performed competitively andin a group setting. Consequently, two of the participants purchased the NintendoWii gaming system in order to continue incorporating this form of exercise in theirdaily routines. One participant experienced a decrease in back pain, and anotherparticipant indicated less overall pain. Prior to participating in this study, oneparticular participant was unable to ambulate in the community without the useof a wheelchair. At the conclusion of the intervention phase, the daughter of this

FIGURE 1. The heavy-dashed line represents the baseline mean (M = 39.41) and the light-dashed lines represent the baseline standard deviation (SD = ±6.43) bands. (Participant17 had the same score pretest and posttest.)

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The Effect of Nintendo Wii on Balance 137

participant reported that her mother is now able to go into the community withoutthe assistance of a wheelchair.

The quantitative results, along with the anecdotal information received after thisstudy, suggest that utilizing the Nintendo Wii in occupational therapy practice couldbe an effective, appealing form of client-centered intervention, as well as a meansfor improving balance and an overall increase in stamina. For the occupational ther-apy clinic, the Wii can be easily used in an area of 20 square feet that includes avideo screen of 32 inches, a 2 × 4 foot balance board, and a small computer boxwith electrical connections. It can be easily stored and set up with the system, ableto keep track of each client’s performance in a friendly competitive format. Thevirtual environment on screen gives the client the suggestion of participating in theactual activity. Although it is not actual skiing, the participant sees his or her move-ments on the virtual mountain. These “game” activities can be specifically selectedto address client deficits that are directly related to his or her inability to functionin daily life, such as standing tolerance, motor planning, attention, problem solving,socialization, and visual-motor integration.

Limitations

A limitation of this study is the sample of convenience as only 22 participants wererecruited from facilities near the researchers. Additionally, demographic character-istics of the male to female ratio of the participants limit the generalizations of theseresults, as a significantly higher number of females participated in this study. Thisstudy also had no control group since it was not a true experimental study there-fore decreasing the generalizability of the study. Additionally, we encouraged theparticipants to select the specific Wii Fit balance games they wanted to perform.Although the researchers allowed this freedom of choice to ensure client-centeredservices, this variable may have influenced the results. Finally, the nonblind designof this study makes it vulnerable to participant and rater bias due to the degree towhich the researchers knew the participants’ pretest BBS score. Also, participantsmay have performed differently because they knew they were being studied.

Implications of Use

As with any therapeutic intervention, therapists intending to utilize the NintendoWii in occupational therapy practice must examine the therapeutic benefits of Nin-tendo’s Wii activities. Researchers must incorporate the use of rigorous design (i.e.,control, random assignment to groups, larger sample size, and blinded study) to ad-dress the therapeutic benefits. There are a variety of directions that are warrantedfor future research. First, in addition to examining balance, addressing the associa-tion of fear of falling is important. Because of the possible fact that the activity isfun, it would be interesting to examine the motivational effects of participation inNintendo’s Wii Fit activities. This may reveal pertinent information about the par-ticipants’ self-perception of balance. Researchers may also consider studying thedifferent Nintendo Wii Fit balance activities separately to identify if one specificgame is more effective than others. Lastly, researchers should study the therapeuticbenefits of using the Nintendo Wii with a diversity of clients to identify the potential

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benefits of incorporating this interactive game into occupational therapy practiceto specific therapeutic issues.

CONCLUSION

The results of this study suggest the potential effectiveness of utilizing the NintendoWii as a therapeutic agent in occupational therapy practice. Occupational therapistsworking with older adults frequently address issues of balance and falls. Discov-ering the best methods for improving these factors is imperative for occupationaltherapy practitioners. The present study indicates that therapists working with geri-atric clientele might consider utilizing the Nintendo Wii Fit as an evidence-basedintervention to improve balance with the well-elderly population. This could resultin less falls and a decreased need for an assistive device for mobility. Additionally,intervention including the Nintendo Wii Fit offers participants increased opportu-nities for socialization with others, as this is a gaming system that has potential foruse with clients across the lifespan. This, combined with the physical benefits, couldlead to increased participation, independence, and fulfillment in important dailyoccupations.

ACKNOWLEDGEMENTS

We would like to thank the residents and staff at the Communities of Solarbron,Mitchell Manor, and River Terrace for their involvement and participation in thisstudy. We also thank the Graduate Student Grant Research Program at the Uni-versity of Southern Indiana for their financial contributions. This research was sup-ported by a Graduate Student Grant Research Program at the University of South-ern Indiana.

Declaration of interest: The authors report no conflict of interest. The authorsalone are responsible for the content and writing of this paper.

ABOUT THE AUTHORS

Barbara Williams, DrOT, OTR, is Program Director of Occupational Therapy Pro-gram and Associate Professor, College of Nursing and Health Professions, Uni-versity of Southern Indiana Occupational Therapy Program, Evansville, Indiana,USA. Nicole L. Doherty, MSOT, is student, College of Nursing and Health Profes-sions, University of Southern Indiana Occupational Therapy Program, Evansville,Indiana, USA. Andrew J. Bender, MSOT, NASM-PES, is student, College of Nurs-ing and Health Professions, University of Southern Indiana Occupational TherapyProgram, Evansville, Indiana, USA. Holly N. Mattox, MSOT, is student, Collegeof Nursing and Health Professions, University of Southern Indiana OccupationalTherapy Program, Evansville, Indiana, USA. Jesse R. Tibbs, MSOT, is student, Col-lege of Nursing and Health Professions, University of Southern Indiana Occupa-tional Therapy Program, Evansville, Indiana, USA.

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The Effect of Nintendo Wii on Balance 139

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