GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 2, Number 5, 2013 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2013.0042
Comparing the Effects of a Novel and a Traditional Proprioceptive Balance Training Program on Activity Adherence and Balance Control in a Healthy University Population: A Preliminary Study Chauntelle Melong, BSc(Hon),1 and Melanie R. Keats, PhD1–3
Abstract
Objective: This study explored balance performance and participant adherence to either the Wii Fit (Nintendo of America, Redmond, WA) or a proprioceptive BOSU (Ashland, OH) ball balance program. Materials and Methods: Twenty university-aged participants were randomly allocated to either a Wii Fit or BOSU ball balance training program. Participants engaged in one of the two training regimens for 20 minutes, three times a week, for 4 weeks. Adherence was measured by recording attendance and time spent at each session. Motivational factors associated with adherence were assessed using the Physical Activity Enjoyment Scale. Balance was measured using a stabilometer. Results: No significant difference in participant adherence was found between the groups. Significantly higher levels of activity enjoyment were reported from participants assigned to the Wii Fit intervention, and a positive correlation was found between physical activity enjoyment and adherence. A significant main effect for time demonstrating improved balance scores for both groups was found. No significant interaction between program type and time was found. Discussion: Although both interventions led to balance improvements, Wii Fit participants reported significantly higher levels of activity enjoyment. Although these higher levels of enjoyment did not lead to a statistically significant difference between the groups with regard to the number of sessions attended, participants assigned to the Wii Fit group spent more time engaged in the balance training activities than those allocated to the BOSU group. Although this study is preliminary and has the limitations of being statistically underpowered and dissimilar from the unsupervised home-based programs often prescribed by health professionals, results suggest that exergaming-based balance training may be an important adjunct to traditional training programs.
Introduction
A
lthough the positive relationship between physical activity (PA) and health is well established,1 one important and often overlooked component of physical fitness is balance.2,3 Balance is defined as the ‘‘ability to maintain the body’s center of gravity within the limits of stability as determined by the base of support’’ and is influenced by several interacting factors, including the nervous system, muscles, joints, reflexes, skeletal system, gravity and inertia, sensory input, central processing time, and learned strategies.4 Balance is considered to be an 1 2 3
important measure of skill-related fitness related to mobility, functional independence, and reducing injury risk across an individual’s lifespan.4–6 Balance training: The need In recent years, there has been a growing interest in exploring the use of balance training programs to help prevent injuries before they occur, particularly in elderly populations.7 Although such training is often overlooked in younger, active, and otherwise healthy populations, young adults may also benefit from balance training interventions.8–10 For
Schools of Health and Human Performance, Dalhousie University, Halifax, Nova Scotia, Canada. School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada. Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.
308
NOVEL AND TRADITIONAL BALANCE PROGRAMS example, ankle sprains are the most common sports-related musculoskeletal injury, particularly sports that require sudden stops and cutting movements, such as soccer and basketball.8 This is an important issue to address, as sizeable proportions of the population play these sports, with an average of 15 percent of these athletes being affected by ankle sprains.8 It is believed that ankle sprain prevention measures, such as proprioceptive balance training, can help reduce the number of injuries. Studies by Emery et al.10 support this idea, showing that implementing a balance training program has the ability to improve balance and decrease the risk of injury in healthy adolescents by as much as 80 percent. Although several balance training strategies exist (e.g., agility training, plyometric and sport-specific exercises), proprioceptive balance programs frequently incorporate the use of training aids such as wobble boards and BOSU (Ashland, OH) balls to create unstable surfaces.11,12 By changing the base of support (e.g., single leg versus double leg stance), altering sensory input (e.g., open or closed eyes), or varying the task complexity (e.g., single task versus multitask training), the exercises associated with traditional programs can be altered to increase or decrease difficulty.7 Although the typical duration of the traditional training program varies, studies have shown that balance can be improved in healthy individuals in as little as 10 minutes a day, 3 days a week, over a period of 4 weeks.9 However, despite the potential benefits associated with balance training, relatively few individuals regularly partake in such training. The problem of adherence and novel approaches to balance training Adherence is defined as the ability to follow through or carry out a plan without deviation and is the key component to the success of any intervention or training program. That is, participants must be able to adhere to a program if they are to gain the associated benefits.13 Low rates of adherence for home-based exercise programs can occur for several reasons and can depend on a combination of factors.14 Unfortunately, these factors may override the knowledge that a program may be of benefit, leaving participants with a lack of motivation to adhere to a program over time.13 With advances in technology, the introduction of exergaming has raised the question of how these tools might be used to increase PA and improve measures of fitness, including balance. The Wii (Nintendo of America, Redmond, WA) gaming system, in particular, has received a considerable amount of interest due to the fact that it can provide balance exercises and record balance measurements similarly to what would be measured via a force plate.15 The Wii Fit (Nintendo of America) is also considered to be easy to use and is widely available. Perhaps most important is that the Wii Fit was developed for the purpose of entertainment with the intention of being engaging, enjoyable, and fun,16 qualities that lend themselves well to the promotion of adherence.17 Although traditional balance training programs have been shown to be effective in improving balance,6 many individuals find the repetitious movements to be tedious and aimless, resulting in boredom and a lack of motivation to adhere.13 Alternatively, the attractive and engaging qualities associated with exergaming may foster improved adherence to balance training programs.16
309 Overall, although traditional balance training interventions have been shown to be beneficial, they are not effective unless individuals are willing and able to adhere to the prescriptions given. Thus, in order to maximize the benefits, it is important to develop programs that are both clinically effective and to which individuals are likely to adhere. Accordingly, the primary objective of the current exploratory study was to examine if activity adherence was higher for those participants training with the Wii Fit compared with a traditional training program using the BOSU ball. Motivational factors underlying adherence (e.g., enjoyment) were also explored. The secondary objective of the study was to compare changes in balance performance for those training with the Wii Fit compared with those using the BOSU program. It was hypothesized that participants would have higher adherence rates when training with the Wii Fit compared with the BOSU ball, as a result of greater activity enjoyment. With the anticipated higher adherence rate to the balance training regimen, it was also hypothesized that participants using the Wii Fit training program would demonstrate greater improvements in balance. Materials and Methods Study design, procedures, and recruitment This was a 4-week, randomized controlled balance training intervention designed to compare adherence and balance improvements between a novel and traditional proprioceptive balance program. Participants were recruited through the use of poster advertisements, e-mail, and class announcements. Details of the nature of the balance training programs (i.e., Wii Fit versus BOSU) were not disclosed in the recruitment materials. The study was conducted at Dalhousie University’s School of Health and Human Performance (Halifax, NS, Canada). Ethical review and approval were provided from the Dalhousie Research Ethics Board. Upon providing consent, eligible participants completed a baseline balance assessment. Participants were then randomly assigned to one of the two balance training programs using a computer-generated allocation sequence and were familiarized with the appropriate equipment and activities. Although every effort was made to blind participants from their group allocation, it was not possible to blind the exercise trainer to group assignment. After the intervention was completed, balance was reassessed, and participants were asked to complete a short survey to measure overall program enjoyment. Participants A convenience sample of 20 university students (mean age, 19.68 years; standard deviation [SD], 1.16) were recruited to the study. Most participants were female (58 percent) and were in their first year of study (42 percent). Participants were excluded from the study if they had any known neurological impairments or if they self-reported any other medical/ health condition that could affect their balance or preclude their safe participation (e.g., recent or recurrent lower extremity injuries and/or instability). Participants were also excluded if they were involved in any other balance training program at the time of study or had been involved in any other balance training program during the past year.
310 Intervention During the intervention, all participants were asked to come to the lab to perform the assigned program for a minimum of 20 minutes, three times a week, for a period of 4 weeks. Participants randomized to the Wii Fit training program were provided with a selection of balance board games (e.g., ‘‘Ski Jump,’’ ‘‘Soccer Heading,’’ ‘‘Ski Slalom,’’ ‘‘Table Tilt,’’ etc.) and were permitted to select and play the game(s) of their choice. Participants randomized to the traditional training group using the BOSU ball were provided with a program consisting of nine, progressively more difficult, dynamic balance and stabilization exercises (e.g., double leg balance, double leg balance with head movement, single leg balance). Participants in the BOSU group were instructed at baseline to increase or decrease the level of difficulty of exercises independently based on their overall ability to safely engage in the activity. All sessions were supervised by the same trainer to ensure participant safety; however, prescriptive programmatic feedback was not provided beyond the baseline instructions. In an effort to minimize scheduling barriers that may have negatively influenced program attendance, participant schedules were reviewed individually, and training sessions were made accessible based on participant availability. If participants were not able to attend a training session, they were asked to notify the research coordinator in advance via e-mail or phone. Participants were asked to reschedule the missed session if possible, as long as it did not interfere with other participants involved in the study or their scheduling, because participants were not permitted to train together or to train on two consecutive days.
MELONG AND KEATS relationship between group assignment and adherence to training program (i.e., number of sessions attended and total training time) and between group assignment and program enjoyment. A simple bivariate correlation was used to explore the relationship between adherence and program enjoyment. The main effects of group and time and the interaction effect of group by time for balance outcomes were tested by mixed between-within analysis of variance. Significance was set at P < 0.05 across all tests. Moreover, given the exploratory nature of this study, effect sizes have been reported regardless of statistical significance. Effect sizes (partial g2 [gp2]) were defined as small (0.01), medium (0.06), and large (0.14).20 Results Participant baseline characteristics An independent-samples t test and v2 test were conducted to compare demographic measures between the two experimental groups, who were shown to have no significant differences in age (t17 = 1.275, P = 0.219) or gender (v1 = 0.038, P = 0.845). An independent t test was also calculated for baseline balance measures, which revealed that there was no significant difference between the two groups on preintervention balance scores (t17 = - 1.939, P = 0.076). Following baseline testing and randomization, one participant from the BOSU group withdrew from the study. Two additional BOSU participants subsequently withdrew from the program prematurely. All self-withdrawn participants noted a ‘‘lack of time’’ as the primary reason for discontinuing their participation. These three participants were subsequently removed from further detailed adherence and balance analyses.
Measures
Adherence
Baseline demographics included age, gender, and degree of study. Program adherence was measured by recording attendance and length of time spent at each training session. Program enjoyment was measured using the original 18-item PA Enjoyment Scale (PACES).18 Specifically, participants were asked to rate their current level of activity enjoyment on a 7-point Likert scale. Higher PACES scores reflect greater activity enjoyment. The scale has been reported to have excellent validity and external consistency (0.93).18 The reliability of the scale measured in this study was shown to be 0.928. For balance assessments, participants were asked to stand on a wooden platform (107 cm long · 65 cm wide) that recorded postural sways by tracking deviation to the right or left side. Participants were instructed to keep the platform as close to horizontal as possible for the duration of the 30second trial. A timer with resolution to two decimal points was used to measure time in balance (i.e., amount of time that the participant was able to keep the platform within – 10 of horizontal). The use of the stabilometer to measure balance has been shown to have good validity and reliability.19
No significant difference in participant adherence with regard to the number of sessions attended between the Wii Fit (mean, 10.60; SD, 1.90) and BOSU (mean, 10.43; SD, 1.27; t15 = 0.838, P = 0.838, gp2 = 0.003) groups or the amount of total time (in minutes) spent in either the Wii Fit (mean, 222.45; SD, 40.0) or BOSU (mean, 206.84; SD, 30.31; t15 = 0.869, P = 0.399, gp2 = 0.05) intervention was found. Activity enjoyment A significant difference was found in PA enjoyment scores for individuals assigned to the Wii Fit group (mean, 100.70; SD, 8.50) and the BOSU group (mean, 84.14; SD, 17.18; t15 = 2.645, P = 0.018, gp2 = 0.32). Enjoyment and adherence Pearson product moment correlations revealed that there was a strong, positive correlation between PA enjoyment scores and the number of sessions attended (r = 0.47, P = 0.028) and between activity enjoyment scores and time spent at each intervention (r = 0.58, P = 0.007).
Analyses Data were analyzed using SPSS version 20 for Windows (SPSS, Inc., Chicago, IL). Descriptive statistics were used to examine demographic variables. The Wii Fit and BOSU training groups were compared on demographics and balance at baseline using independent t tests or v2 tests. Two separate independent t tests were used to examine the
Balance A significant main effect for time (F1,15 = 12.98, P = 0.003, gp2 = 0.464) was found. No significant interaction effect was found (F1,15 = 0.170, P = 0.686, gp2 = 0.011). The main effect comparing the two intervention groups was not significant (F1,15 = 3.46, P = 0.083, gp2 = 0.187).
NOVEL AND TRADITIONAL BALANCE PROGRAMS Discussion The primary objective of this study was to compare participant adherence to a proprioceptive balance training program using either the Wii Fit or a BOSU ball. The secondary objective of the study was to compare changes in balance for participants assigned to either of the two groups. Although both training programs demonstrated meaningful improvements in balance, as hypothesized, a significant difference was found between the groups for activity enjoyment, with the Wii Fit participants rating the program as being more enjoyable. This study seems to support a growing body of evidence suggesting that activities such as the Wii Fit are more enjoyable than traditional exercise and balance training programs such as the BOSU ball.16,21,22 Although no significant differences were noted in participant adherence with regard to the number of sessions attended (P = 0.838) or total time spent engaged in the training program (P = 0.399), a small to moderate effect (gp2 = 0.05) was noted. We have found that most university student volunteers, despite being informed that attendance was voluntary, do feel a sense of obligation to finish what they started. Consequently, as participants were informed at baseline that this was a 4-week program consisting of 12 training sessions, we were not surprised to see that those who completed the study did attend the bulk of the sessions. What is perhaps more interesting is the total time spent engaged in the balance activities. Although all participants who completed the study were adherent to the thrice weekly training program, attending an average of 86.7% (BOSU) or 88.3% (Wii Fit) of the sessions, the Wii Fit participants were more likely to engage in the balance training activities for longer periods of time compared with those participants training with the BOSU ball. As predicted, given the general monotonous nature of traditional programs and resultant decrease in program enjoyment, those allocated to the BOSU group devoted less time to the assigned balance training tasks compared with those assigned to the Wii Fit group, who found the activities more enjoyable. Moreover, although the BOSU participants who withdrew prematurely from the study cited a lack of time to continue, studies have shown that being too busy to participate is a commonly reported barrier that is often the result of a lack of priority.23 Thus, although this is speculative, we would suggest that perhaps withdrawal from the current study may be more accurately attributed to a lack of motivation to continue as result of a lack of enjoyment. Future study is warranted to better explore participant motives for program adherence and withdrawal. These results may have important implications for balance training interventions, particularly when we acknowledge the growing concern of poor treatment adherence across various health professions, including physiotherapy,24 and that individuals must be willing and able to adhere to the program if they are to gain the associated benefits.13 Low adherence can occur for several reasons and can affect patient health outcomes.24 Although several techniques have been developed to improve short-term and long-term adherence to training programs (e.g., providing written information, individualized feedback), each technique has only been shown to have a moderate effect for improving adherence.24 As a result, McLean et al.24 suggested that programs use a wide array of strategies to improve adherence.
311 Although preliminary, the findings from this study provide evidence that exergaming may be an additional viable strategy to improve the level of enjoyment that patients feel toward balance training programs. Increased program enjoyment may translate to improved patient adherence over longer training periods. Limitations An obvious limitation of the current study was the relatively short duration of the intervention, which limited our ability to examine the role of exergaming on long-term activity adherence. Moreover, the small study sample precluded more rigorous statistical analyses. Furthermore, it can be noted that the training program used in this study is not identical to unsupervised home-based training programs, which is a method of intervention primarily prescribed and used by health professionals. Despite these limitations, with its randomized design, this study sets the stage for future, larger-scale trials. Conclusions Although both programs appear efficacious for improving balance, nonadherence to the treatment is often more problematic than treatment efficacy. Consequently, health professionals should consider using novel techniques to improve adherence to a balance training program. Although the findings are preliminary, the current study provides additional support for the role of exergaming, as it appears that individuals are more likely to enjoy a program using the Wii Fit compared with a traditional balance program. This is important, as improved activity enjoyment may lead to increased motivation for patients to devote their time to following a prescribed training or rehabilitation program. As a result, it may be more beneficial for health professionals to prescribe training programs that incorporate the use of active gaming technology, such as the Wii Fit, to achieve the best health outcomes in the future. Author Disclosure Statement No competing financial interests exist. References 1. Lee IM, Skerrett, PJ. Physical activity and all-cause mortality: What is the dose-response relation? Med Sci Sports Exerc 2001; 33:459–471. 2. Clemson L, Fiatarone SM, Bundy A, et al. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): Randomized parallel trial. BMJ 2012; 345:4547. 3. Micheo W, Baerga L, Miranda G. Basic principles regarding strength, flexibility, and stability exercises. PM&R 2012; 4:805–811. 4. Yim-Chiplis PK, Talbot LA. Defining and measuring balance in adults. Biol Res Nurs 2000; 1:221–231. 5. Bateni H. Changes in balance in older adults based on use of physical therapy vs the Wii Fit gaming system: A preliminary study. Physiotherapy 2012; 98:2011–2016. 6. Emery CA, Rose SM, McAllister JR, Meeuwisse WH. A prevention strategy to reduce the incidence of injury in high school basketball: A cluster randomized controlled trial. Clin J Sport Med 2007; 17:17–24.
312 7. Granacher U, Muehlbauer T, Zahner L, et al. Comparison of traditional and recent approaches in the promotion of balance and strength in older adults. Sports Med 2011; 41:377– 400. 8. McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med 2006; 34:1103–1111. 9. DiStefano LJ, Clarke MA, Padua DA. Evidence supporting balance training in healthy individuals: A systemic review. J Strength Cond Res 2009; 23:2718–2731. 10. Emery CA, Cassidy JD, Klassen TP, et al. Effectiveness of a home-based balance-training program in reducing sportsrelated injuries among healthy adolescents: A cluster randomized controlled trial. CMAJ 2005; 172:749–754. 11. Launder KG, Koschnitzky MM. Ankle muscle activation when using the Both Sides Utilized (BOSU) balance trainer. J Strength Cond Res 2010; 24:218–222. 12. Ogaya S, Ikezoe T, Soda N, Ichihashi N. Effects of balance training using wobble boards in the elderly. J Strength Cond Res 2011; 25:218–222. 13. Rhodes RE, Fiala B. Building motivation and sustainability into the prescription and recommendations or physical activity and exercise therapy: The evidence. Physiother Theory Pract 2009; 25:424–441. 14. Medina-Mirapeix F, Escolar-Reina P, Gasco´n-Ca´novas JJ, et al. Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: An observational study. BMC Musculoskelet Disord 2009; 10:155. 15. Clarke RA, Bryant AL, Pua Y, et al. Validity and reliability of the Nintendo Wii Balance Board for assessment of standing balance. Gait Posture 2010; 31:307–310. 16. Graves LE, Ridgers ND, Williams K, et al. The physiological cost and enjoyment of Wii Fit in adolescents, young adults, and older adults. J Phys Act Health 2010; 7:393–401.
MELONG AND KEATS 17. O’Loughlin EK, Dugas EN, Sabiston CM, O’Loughlin JL. Prevalence and correlates of exergaming in youth. Pediatrics 2012; 130:1–10. 18. Kendzierski D, DeCarlo KJ. Physical Activity Enjoyment Scale: Two validation studies. J Appl Sport Psychol 1991; 13:50–64. 19. Murray JF. Construction of a stabilometer capable of indicating the variability of non-level performance. Percept Mot Skills 1982; 55:1211–1215. 20. Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd ed. Mahwah, NJ: Lawrence Erlbaum; 1988. 21. Brumels KA, Blasius T, Cortright T, et al. Comparison of efficacy between traditional and video game based balance programs. Clin Kinesiol 2008; 62:26–31. 22. Fitzgerald D, Trakarnratanakul N, Smyth B, Caulfield B. Effects of a wobble board-based therapeutic exergaming system for balance training on dynamic postural stability and intrinsic motivation levels. J Orthop Sports Phys Ther 2010; 40:11–19. 23. Lox CL, Martin Gilis KA, Petruzzello SJ. The Psychology of Exercise: Integrating Theory and Practice, 3rd ed. Scottsdale, AZ; Holcomb Hathaway; 2010. 24. McLean SM, Burton M, Bradley L, Littlewood C. Interventions for enhancing adherence with physiotherapy: A systematic review. Man Ther 2010; 15:514–521.
Address correspondence to: Melanie Keats, PhD School of Health and Human Performance (Kinesiology) Dalhousie University P.O. Box 15000 6230 South Street Halifax, NS, Canada B3H 1T8 E-mail: [email protected]
Comparing the Effects of a Novel and a Traditional Proprioceptive Balance Training Program on Activity Adherence and Balance Control in a Healthy University Population: A Preliminary Study Chauntelle Melong, BSc(Hon),1 and Melanie R. Keats, PhD1–3
Abstract
Objective: This study explored balance performance and participant adherence to either the Wii Fit (Nintendo of America, Redmond, WA) or a proprioceptive BOSU (Ashland, OH) ball balance program. Materials and Methods: Twenty university-aged participants were randomly allocated to either a Wii Fit or BOSU ball balance training program. Participants engaged in one of the two training regimens for 20 minutes, three times a week, for 4 weeks. Adherence was measured by recording attendance and time spent at each session. Motivational factors associated with adherence were assessed using the Physical Activity Enjoyment Scale. Balance was measured using a stabilometer. Results: No significant difference in participant adherence was found between the groups. Significantly higher levels of activity enjoyment were reported from participants assigned to the Wii Fit intervention, and a positive correlation was found between physical activity enjoyment and adherence. A significant main effect for time demonstrating improved balance scores for both groups was found. No significant interaction between program type and time was found. Discussion: Although both interventions led to balance improvements, Wii Fit participants reported significantly higher levels of activity enjoyment. Although these higher levels of enjoyment did not lead to a statistically significant difference between the groups with regard to the number of sessions attended, participants assigned to the Wii Fit group spent more time engaged in the balance training activities than those allocated to the BOSU group. Although this study is preliminary and has the limitations of being statistically underpowered and dissimilar from the unsupervised home-based programs often prescribed by health professionals, results suggest that exergaming-based balance training may be an important adjunct to traditional training programs.
Introduction
A
lthough the positive relationship between physical activity (PA) and health is well established,1 one important and often overlooked component of physical fitness is balance.2,3 Balance is defined as the ‘‘ability to maintain the body’s center of gravity within the limits of stability as determined by the base of support’’ and is influenced by several interacting factors, including the nervous system, muscles, joints, reflexes, skeletal system, gravity and inertia, sensory input, central processing time, and learned strategies.4 Balance is considered to be an 1 2 3
important measure of skill-related fitness related to mobility, functional independence, and reducing injury risk across an individual’s lifespan.4–6 Balance training: The need In recent years, there has been a growing interest in exploring the use of balance training programs to help prevent injuries before they occur, particularly in elderly populations.7 Although such training is often overlooked in younger, active, and otherwise healthy populations, young adults may also benefit from balance training interventions.8–10 For
Schools of Health and Human Performance, Dalhousie University, Halifax, Nova Scotia, Canada. School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada. Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.
308
NOVEL AND TRADITIONAL BALANCE PROGRAMS example, ankle sprains are the most common sports-related musculoskeletal injury, particularly sports that require sudden stops and cutting movements, such as soccer and basketball.8 This is an important issue to address, as sizeable proportions of the population play these sports, with an average of 15 percent of these athletes being affected by ankle sprains.8 It is believed that ankle sprain prevention measures, such as proprioceptive balance training, can help reduce the number of injuries. Studies by Emery et al.10 support this idea, showing that implementing a balance training program has the ability to improve balance and decrease the risk of injury in healthy adolescents by as much as 80 percent. Although several balance training strategies exist (e.g., agility training, plyometric and sport-specific exercises), proprioceptive balance programs frequently incorporate the use of training aids such as wobble boards and BOSU (Ashland, OH) balls to create unstable surfaces.11,12 By changing the base of support (e.g., single leg versus double leg stance), altering sensory input (e.g., open or closed eyes), or varying the task complexity (e.g., single task versus multitask training), the exercises associated with traditional programs can be altered to increase or decrease difficulty.7 Although the typical duration of the traditional training program varies, studies have shown that balance can be improved in healthy individuals in as little as 10 minutes a day, 3 days a week, over a period of 4 weeks.9 However, despite the potential benefits associated with balance training, relatively few individuals regularly partake in such training. The problem of adherence and novel approaches to balance training Adherence is defined as the ability to follow through or carry out a plan without deviation and is the key component to the success of any intervention or training program. That is, participants must be able to adhere to a program if they are to gain the associated benefits.13 Low rates of adherence for home-based exercise programs can occur for several reasons and can depend on a combination of factors.14 Unfortunately, these factors may override the knowledge that a program may be of benefit, leaving participants with a lack of motivation to adhere to a program over time.13 With advances in technology, the introduction of exergaming has raised the question of how these tools might be used to increase PA and improve measures of fitness, including balance. The Wii (Nintendo of America, Redmond, WA) gaming system, in particular, has received a considerable amount of interest due to the fact that it can provide balance exercises and record balance measurements similarly to what would be measured via a force plate.15 The Wii Fit (Nintendo of America) is also considered to be easy to use and is widely available. Perhaps most important is that the Wii Fit was developed for the purpose of entertainment with the intention of being engaging, enjoyable, and fun,16 qualities that lend themselves well to the promotion of adherence.17 Although traditional balance training programs have been shown to be effective in improving balance,6 many individuals find the repetitious movements to be tedious and aimless, resulting in boredom and a lack of motivation to adhere.13 Alternatively, the attractive and engaging qualities associated with exergaming may foster improved adherence to balance training programs.16
309 Overall, although traditional balance training interventions have been shown to be beneficial, they are not effective unless individuals are willing and able to adhere to the prescriptions given. Thus, in order to maximize the benefits, it is important to develop programs that are both clinically effective and to which individuals are likely to adhere. Accordingly, the primary objective of the current exploratory study was to examine if activity adherence was higher for those participants training with the Wii Fit compared with a traditional training program using the BOSU ball. Motivational factors underlying adherence (e.g., enjoyment) were also explored. The secondary objective of the study was to compare changes in balance performance for those training with the Wii Fit compared with those using the BOSU program. It was hypothesized that participants would have higher adherence rates when training with the Wii Fit compared with the BOSU ball, as a result of greater activity enjoyment. With the anticipated higher adherence rate to the balance training regimen, it was also hypothesized that participants using the Wii Fit training program would demonstrate greater improvements in balance. Materials and Methods Study design, procedures, and recruitment This was a 4-week, randomized controlled balance training intervention designed to compare adherence and balance improvements between a novel and traditional proprioceptive balance program. Participants were recruited through the use of poster advertisements, e-mail, and class announcements. Details of the nature of the balance training programs (i.e., Wii Fit versus BOSU) were not disclosed in the recruitment materials. The study was conducted at Dalhousie University’s School of Health and Human Performance (Halifax, NS, Canada). Ethical review and approval were provided from the Dalhousie Research Ethics Board. Upon providing consent, eligible participants completed a baseline balance assessment. Participants were then randomly assigned to one of the two balance training programs using a computer-generated allocation sequence and were familiarized with the appropriate equipment and activities. Although every effort was made to blind participants from their group allocation, it was not possible to blind the exercise trainer to group assignment. After the intervention was completed, balance was reassessed, and participants were asked to complete a short survey to measure overall program enjoyment. Participants A convenience sample of 20 university students (mean age, 19.68 years; standard deviation [SD], 1.16) were recruited to the study. Most participants were female (58 percent) and were in their first year of study (42 percent). Participants were excluded from the study if they had any known neurological impairments or if they self-reported any other medical/ health condition that could affect their balance or preclude their safe participation (e.g., recent or recurrent lower extremity injuries and/or instability). Participants were also excluded if they were involved in any other balance training program at the time of study or had been involved in any other balance training program during the past year.
310 Intervention During the intervention, all participants were asked to come to the lab to perform the assigned program for a minimum of 20 minutes, three times a week, for a period of 4 weeks. Participants randomized to the Wii Fit training program were provided with a selection of balance board games (e.g., ‘‘Ski Jump,’’ ‘‘Soccer Heading,’’ ‘‘Ski Slalom,’’ ‘‘Table Tilt,’’ etc.) and were permitted to select and play the game(s) of their choice. Participants randomized to the traditional training group using the BOSU ball were provided with a program consisting of nine, progressively more difficult, dynamic balance and stabilization exercises (e.g., double leg balance, double leg balance with head movement, single leg balance). Participants in the BOSU group were instructed at baseline to increase or decrease the level of difficulty of exercises independently based on their overall ability to safely engage in the activity. All sessions were supervised by the same trainer to ensure participant safety; however, prescriptive programmatic feedback was not provided beyond the baseline instructions. In an effort to minimize scheduling barriers that may have negatively influenced program attendance, participant schedules were reviewed individually, and training sessions were made accessible based on participant availability. If participants were not able to attend a training session, they were asked to notify the research coordinator in advance via e-mail or phone. Participants were asked to reschedule the missed session if possible, as long as it did not interfere with other participants involved in the study or their scheduling, because participants were not permitted to train together or to train on two consecutive days.
MELONG AND KEATS relationship between group assignment and adherence to training program (i.e., number of sessions attended and total training time) and between group assignment and program enjoyment. A simple bivariate correlation was used to explore the relationship between adherence and program enjoyment. The main effects of group and time and the interaction effect of group by time for balance outcomes were tested by mixed between-within analysis of variance. Significance was set at P < 0.05 across all tests. Moreover, given the exploratory nature of this study, effect sizes have been reported regardless of statistical significance. Effect sizes (partial g2 [gp2]) were defined as small (0.01), medium (0.06), and large (0.14).20 Results Participant baseline characteristics An independent-samples t test and v2 test were conducted to compare demographic measures between the two experimental groups, who were shown to have no significant differences in age (t17 = 1.275, P = 0.219) or gender (v1 = 0.038, P = 0.845). An independent t test was also calculated for baseline balance measures, which revealed that there was no significant difference between the two groups on preintervention balance scores (t17 = - 1.939, P = 0.076). Following baseline testing and randomization, one participant from the BOSU group withdrew from the study. Two additional BOSU participants subsequently withdrew from the program prematurely. All self-withdrawn participants noted a ‘‘lack of time’’ as the primary reason for discontinuing their participation. These three participants were subsequently removed from further detailed adherence and balance analyses.
Measures
Adherence
Baseline demographics included age, gender, and degree of study. Program adherence was measured by recording attendance and length of time spent at each training session. Program enjoyment was measured using the original 18-item PA Enjoyment Scale (PACES).18 Specifically, participants were asked to rate their current level of activity enjoyment on a 7-point Likert scale. Higher PACES scores reflect greater activity enjoyment. The scale has been reported to have excellent validity and external consistency (0.93).18 The reliability of the scale measured in this study was shown to be 0.928. For balance assessments, participants were asked to stand on a wooden platform (107 cm long · 65 cm wide) that recorded postural sways by tracking deviation to the right or left side. Participants were instructed to keep the platform as close to horizontal as possible for the duration of the 30second trial. A timer with resolution to two decimal points was used to measure time in balance (i.e., amount of time that the participant was able to keep the platform within – 10 of horizontal). The use of the stabilometer to measure balance has been shown to have good validity and reliability.19
No significant difference in participant adherence with regard to the number of sessions attended between the Wii Fit (mean, 10.60; SD, 1.90) and BOSU (mean, 10.43; SD, 1.27; t15 = 0.838, P = 0.838, gp2 = 0.003) groups or the amount of total time (in minutes) spent in either the Wii Fit (mean, 222.45; SD, 40.0) or BOSU (mean, 206.84; SD, 30.31; t15 = 0.869, P = 0.399, gp2 = 0.05) intervention was found. Activity enjoyment A significant difference was found in PA enjoyment scores for individuals assigned to the Wii Fit group (mean, 100.70; SD, 8.50) and the BOSU group (mean, 84.14; SD, 17.18; t15 = 2.645, P = 0.018, gp2 = 0.32). Enjoyment and adherence Pearson product moment correlations revealed that there was a strong, positive correlation between PA enjoyment scores and the number of sessions attended (r = 0.47, P = 0.028) and between activity enjoyment scores and time spent at each intervention (r = 0.58, P = 0.007).
Analyses Data were analyzed using SPSS version 20 for Windows (SPSS, Inc., Chicago, IL). Descriptive statistics were used to examine demographic variables. The Wii Fit and BOSU training groups were compared on demographics and balance at baseline using independent t tests or v2 tests. Two separate independent t tests were used to examine the
Balance A significant main effect for time (F1,15 = 12.98, P = 0.003, gp2 = 0.464) was found. No significant interaction effect was found (F1,15 = 0.170, P = 0.686, gp2 = 0.011). The main effect comparing the two intervention groups was not significant (F1,15 = 3.46, P = 0.083, gp2 = 0.187).
NOVEL AND TRADITIONAL BALANCE PROGRAMS Discussion The primary objective of this study was to compare participant adherence to a proprioceptive balance training program using either the Wii Fit or a BOSU ball. The secondary objective of the study was to compare changes in balance for participants assigned to either of the two groups. Although both training programs demonstrated meaningful improvements in balance, as hypothesized, a significant difference was found between the groups for activity enjoyment, with the Wii Fit participants rating the program as being more enjoyable. This study seems to support a growing body of evidence suggesting that activities such as the Wii Fit are more enjoyable than traditional exercise and balance training programs such as the BOSU ball.16,21,22 Although no significant differences were noted in participant adherence with regard to the number of sessions attended (P = 0.838) or total time spent engaged in the training program (P = 0.399), a small to moderate effect (gp2 = 0.05) was noted. We have found that most university student volunteers, despite being informed that attendance was voluntary, do feel a sense of obligation to finish what they started. Consequently, as participants were informed at baseline that this was a 4-week program consisting of 12 training sessions, we were not surprised to see that those who completed the study did attend the bulk of the sessions. What is perhaps more interesting is the total time spent engaged in the balance activities. Although all participants who completed the study were adherent to the thrice weekly training program, attending an average of 86.7% (BOSU) or 88.3% (Wii Fit) of the sessions, the Wii Fit participants were more likely to engage in the balance training activities for longer periods of time compared with those participants training with the BOSU ball. As predicted, given the general monotonous nature of traditional programs and resultant decrease in program enjoyment, those allocated to the BOSU group devoted less time to the assigned balance training tasks compared with those assigned to the Wii Fit group, who found the activities more enjoyable. Moreover, although the BOSU participants who withdrew prematurely from the study cited a lack of time to continue, studies have shown that being too busy to participate is a commonly reported barrier that is often the result of a lack of priority.23 Thus, although this is speculative, we would suggest that perhaps withdrawal from the current study may be more accurately attributed to a lack of motivation to continue as result of a lack of enjoyment. Future study is warranted to better explore participant motives for program adherence and withdrawal. These results may have important implications for balance training interventions, particularly when we acknowledge the growing concern of poor treatment adherence across various health professions, including physiotherapy,24 and that individuals must be willing and able to adhere to the program if they are to gain the associated benefits.13 Low adherence can occur for several reasons and can affect patient health outcomes.24 Although several techniques have been developed to improve short-term and long-term adherence to training programs (e.g., providing written information, individualized feedback), each technique has only been shown to have a moderate effect for improving adherence.24 As a result, McLean et al.24 suggested that programs use a wide array of strategies to improve adherence.
311 Although preliminary, the findings from this study provide evidence that exergaming may be an additional viable strategy to improve the level of enjoyment that patients feel toward balance training programs. Increased program enjoyment may translate to improved patient adherence over longer training periods. Limitations An obvious limitation of the current study was the relatively short duration of the intervention, which limited our ability to examine the role of exergaming on long-term activity adherence. Moreover, the small study sample precluded more rigorous statistical analyses. Furthermore, it can be noted that the training program used in this study is not identical to unsupervised home-based training programs, which is a method of intervention primarily prescribed and used by health professionals. Despite these limitations, with its randomized design, this study sets the stage for future, larger-scale trials. Conclusions Although both programs appear efficacious for improving balance, nonadherence to the treatment is often more problematic than treatment efficacy. Consequently, health professionals should consider using novel techniques to improve adherence to a balance training program. Although the findings are preliminary, the current study provides additional support for the role of exergaming, as it appears that individuals are more likely to enjoy a program using the Wii Fit compared with a traditional balance program. This is important, as improved activity enjoyment may lead to increased motivation for patients to devote their time to following a prescribed training or rehabilitation program. As a result, it may be more beneficial for health professionals to prescribe training programs that incorporate the use of active gaming technology, such as the Wii Fit, to achieve the best health outcomes in the future. Author Disclosure Statement No competing financial interests exist. References 1. Lee IM, Skerrett, PJ. Physical activity and all-cause mortality: What is the dose-response relation? Med Sci Sports Exerc 2001; 33:459–471. 2. Clemson L, Fiatarone SM, Bundy A, et al. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): Randomized parallel trial. BMJ 2012; 345:4547. 3. Micheo W, Baerga L, Miranda G. Basic principles regarding strength, flexibility, and stability exercises. PM&R 2012; 4:805–811. 4. Yim-Chiplis PK, Talbot LA. Defining and measuring balance in adults. Biol Res Nurs 2000; 1:221–231. 5. Bateni H. Changes in balance in older adults based on use of physical therapy vs the Wii Fit gaming system: A preliminary study. Physiotherapy 2012; 98:2011–2016. 6. Emery CA, Rose SM, McAllister JR, Meeuwisse WH. A prevention strategy to reduce the incidence of injury in high school basketball: A cluster randomized controlled trial. Clin J Sport Med 2007; 17:17–24.
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Address correspondence to: Melanie Keats, PhD School of Health and Human Performance (Kinesiology) Dalhousie University P.O. Box 15000 6230 South Street Halifax, NS, Canada B3H 1T8 E-mail: [email protected]
