Evaluating the Nintendo Wii for assessing return to activity readiness in youth with mild traumatic brain injury.

Physical & Occupational Therapy in Pediatrics, 34(3):229–244, 2014 C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/potp DOI: 10.3109/01942638.2014.885103

ORIGINAL RESEARCH

Phys Occup Ther Pediatr Downloaded from informahealthcare.com by York University Libraries on 03/03/15 For personal use only.

Evaluating the Nintendo Wii for Assessing Return to Activity Readiness in Youth with Mild Traumatic Brain Injury Carol DeMatteo1,2,3 , Dayna Greenspoon4 , Danielle Levac3 , Jessica A. Harper3 , & Mandy Rubinoff2 1

McMaster Children’s Hospital, Hamilton, Ontario, Canada, 2 School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada, 3 CanChild Centre for Childhood DISABILITY Research, McMaster University, Hamilton, Ontario, Canada, 4 Holland-Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada

ABSTRACT. Adolescents with mild traumatic brain injuries (MTBI) are at substantial risk for repeat injury if they return to activity too soon. Post-concussion symptoms and impaired balance are two factors that limit return to activity. Post-injury assessments that challenge activity tolerance and balance skills are needed to ensure readiness to return to activity. This cross-sectional study evaluated the Nintendo Wii as a measure of exertion (heart rate [HR], respiration rate [RR], and caloric expenditure) and balance testing for youth with MTBI in a clinical setting. Twenty-four youth with MTBI, ages 9–18, played six Wii games. The Bruininks-Oseretsky Test of Motor Proficiency 2nd edition (BOT-2) and the Community Balance and Mobility Scale (CBM) were used as balance indicators. The Wii Fit Running game demonstrated the highest caloric expenditure and HR (p = .010). Frequency counts of balance loss during Wii game play did not correlate with performance on the BOT-2 or the CBM. Type, number, and time since injury were predictive of balance performance on the CBM (p = .008). Findings provide preliminary evidence for the use of the Wii as an exertion challenge to evaluate tolerance for exercise post-concussion. Frequency count of balance loss during Wii game play, however, was not a valid measure of balance impairment post-MTBI. KEYWORDS. balance, concussion, exertion, mild traumatic brain injury, pediatrics, virtual reality

Mild traumatic brain injury (MTBI), which includes concussion, is a common and debilitating event for adolescents that may impact their ability to function in school and perform daily activities (Kirkwood et al., 2008; Yeates et al., 2009; Yeates, 2010). MTBI has been defined by a World Health Organization task force as an acute brain injury resulting from mechanical energy to the head from Address correspondence to: Carol DeMatteo, MSc, Rehabilitation Sciences, McMaster University, 1400 Main Street W, McMaster University, Hamilton, Ontario, Canada LHS1C7 (E-mail: [email protected]). (Received 25 January 2013; accepted 14 January 2014)

229


230

DeMatteo et al.

external physical forces, including one or more of the following signs: confusion or disorientation, vomiting, loss of consciousness for 30 min or less, post-traumatic amnesia for less than 24 hr and/or other transient neurological symptoms and a Glasgow Coma Scale score of 13–15 (Carrol et al., 2004). Youth who develop post-concussion syndrome (PCS) after MTBI are at increased risk compared to adults for prolonged symptoms following injury (Moser et al., 2005). In addition to headache, symptoms of PCS in children may include dizziness, nausea, vomiting, reduced attention and concentration, fatigue, increased sensitivity to light and noise, memory dysfunction, and sleep and emotional disturbances that can be exacerbated by exertion (Barlow et al., 2010). Youth with MTBI may also experience deficits in balance and gross motor skills (Gagnon et al., 2004). Children and youth with MTBI are twice as likely to have a subsequent head injury of similar type within 12 months of the initial injury (Swaine et al., 2007) and repeated injuries may result in more significant post-concussive symptoms than the first event (Collins et al., 2002). The reasons for this vulnerability are not clearly understood. Children’s brains require longer healing periods compared to adults, and symptom profiles may not indicate brain recovery (Mayer et al., 2012). Given that symptoms are increased with cognitive and physical challenges, exertion challenges are increasingly performed (Leddy et al., 2012) to evaluate whether the youth is ready to return to activity; because symptom exacerbation during exertion testing suggests otherwise (Gagnon et al., 2009). Given that balance skills are inherent components of the gross motor activities involved in youth sports, the evaluation of balance performance is an important element of return to activity assessment. As such, a comprehensive assessment following MTBI should include evaluation of cognitive skills, motor ability, and symptom response to exertion in order to determine an individual’s readiness to return to activity (Gagnon et al., 2010). Safe return to play depends on symptoms being absent at one level of the sequential return to play testing before moving to the next level (McCrory, 2013). However, teams of physicians and rehabilitation professionals often make subjective decisions about return to activity on the basis of clinical evaluation and reports from parents and youth. It is important for clinicians to determine an objective and time efficient assessment tool that mimics multitasking game play in which to examine balance and exertion. The information gained from this assessment will better inform decisions about readiness for safe return to activity. This study evaluated whether the commercially available virtual reality (VR) Nintendo Wii gaming system (Nintendo of America Inc., 2007) could provide an exertion challenge and test of balance in adolescents with concussion as part of the return to activity assessment. The use of this commercially available VR gaming system may provide an objective and time efficient assessment tool to examine balance and exertion during multitasking game play and support decisions about readiness for return to activity. VR is defined as “the use of interactive simulations created with computer hardware and software to present users with opportunities to engage in environments that appear to be, and feel similar to, real world objects and events” (Weiss et al., 2004, p. 12). The Nintendo Wii is under evaluation to determine its effectiveness and feasibility in rehabilitation (Deutsch et al., 2008; Halton, 2010). It is an accessible, enjoyable, and motivating VR system that uses a variety of motion sensing interfaces (i.e. Wiimote, Wii balance board, and Wii dance mat). The Wiimote senses


Wii Assessment in Pediatric MTBI

231

acceleration, orientation, and movement along three axes and within six degrees of freedom by way of built-in accelerometers and infra-red technology (Deutsch et al., 2008; Halton, 2008; Halton, 2010). The Wii provides immediate multi-sensorial, tactile, and auditory feedback to the user to engage and motivate the user, potentially enhancing movement (Butler & Willett, 2010; Deutsch et al., 2008; LaViola, 2008). There is a growing body of literature demonstrating that exergaming, the term coined for playing physically active video games (AVG) such as the Wii, increases exertion in children and adults, as demonstrated by physiological measures of heart rate (HR) and caloric expenditure (Barnett et al., 2011; Graf et al., 2009; Lyons et al., 2011; Peng et al., 2011). These reviews illustrate that different games present various levels of exertion challenge with the ability to reach moderate intensity exercise challenge when measured in a laboratory environment. This body of knowledge also emphasizes the enjoyment, psychological and motivational aspects of performance on the AVGs, illustrating the potential of using AVGs to challenge exertion post-MTBI. To date, the majority of relevant literature focuses on the use of the Wii as an intervention tool. Few studies explore its use as a measure of balance as a potential assessment tool in rehabilitation. Clark et al. (2010) explored whether the Wii Fit balance board could be used to assess balance in a population of adolescents and adults without physical disabilities. Results showed that the Wii Fit balance board has similar properties to force plates, which are used to assess force distribution and movements. Overall, the Wii Fit balance board demonstrated excellent test–retest reliability and concurrent validity (Clark, 2010). Similarly, Levac et al. (2010) described the quantity of movement characteristics demonstrated by typically developing youth during Wii and Wii Fit game play, finding that Wii Fit games led to larger movement excursions. The findings of these two studies illustrate how the Wii and Wii Fit have potential to assess balance. Clinic time restrictions necessitate an objective and valid assessment tool that will allow clinicians to assess exertion and balance in youth with MTBI in a timely and age appropriate manner. The primary purpose of this study was therefore to determine if the Wii could be used to assess balance and exertion in children and youth with MTBI in order to evaluate their readiness to return to activity. The specific study objectives were to: (a) determine which Wii games result in the highest levels of exertion; (b) determine if frequency counts for loss of balance during Wii game play correlate with performance on two standardized balance measures: the Bruininks-Oseretsky Test of Motor Proficiency 2nd edition (BOT-2) (Bruininks & Bruninks, 2005) and the Community Balance and Mobility Scale (CBM) (Howe et al., 2006); (c) obtain the youths’ perceptions of the difficulty of the Wii challenge as compared to the standardized assessment measures; and (d) determine if injury variables are associated with frequency counts for loss of balance during Wii game play, exertion during Wii game play, CBM scores, and BOT-2 scores.

METHODS Participants A convenience sample of 24 youth (10 females and 14 males) 9–18 years of age (mean = 14.9) years were recruited from the Acquired Brain Injury follow-up clinic

232

DeMatteo et al.

TABLE 1. Descriptive Characteristics of Study Sample


Variable Gender n(%) Female Male Age (years) Mean; range Cause of Most Recent Injury n(%) Motor vehicle accident Falls Hockey Soccer Other sports Loss of Consciousness at Most Recent Injury n(%) Number of Previous Head Injuries Mean SD; range Number of Months Since Most Recent Injury Mean SD; range

Study sample (n = 24)

10 (41.67) 14 (58.33) 14.88; 9–18 5 (20.83) 3 (12.50) 5 (20.83) 3 (12.50) 8 (33.33) 12 (50.00) 2.14 SD 1.75; 1–9 5.50 SD 3.68; 1–12

Number of youth reporting post-concussive symptoms prior to testing n(%) Headache 21 (87.50) Fatigue 19 (79.17) Dizziness 17 (70.83) Memory changes 18 (75.00) Reduced concentration 18 (75.00) Balance disturbances 10 (41.67) Sleep disturbances 13 (54.17) Vomiting 10 (41.67) Amnesia 13 (54.17) Disorientation 12 (50.00) Emotional disturbances 11 (45.83) Vision changes 5 (20.83) Hearing changes 7 (29.17) Speech changes 5 (20.83) Mean number of symptoms reported per person 7.61 SD 2.61; range 3–14

at McMaster Children’s Hospital (MCH) in Hamilton, Ontario. Inclusion criteria were as follows: youth who (a) experienced a diagnosed MTBI within the last year, with or without loss of consciousness, (b) were ambulatory at time of testing, and (c) received clearance from a physician on the ABI team to participate in the Wii games and testing. Youth with significant brain injury who required resuscitation, paediatric critical care unit admission, or surgical intervention were excluded from the study. Youth with a history of seizures were also excluded from the study due to Nintendo’s warning regarding risk of play among individuals with seizure disorders. Ethics approval was obtained from the Research Ethics Board at McMaster University. Written consent and assent were obtained from youth and their legal guardians prior to participation in the study. Table 1 provides the demographic characteristics of the study sample. Measures Exertion Exertion was measured by HR, respiration rate (RR), and caloric expenditure as recommended by Peng et al. (2011).


233

Wii Balance Measure Frequency counts of loss of balance were recorded throughout each Wii game by two senior occupational therapy students on a form designed for the study. Loss of balance included any off centre movement that required a protective response of feet or hands to regain balance and any actual falls.


Bruininks-Oseretsky Test of Motor Proficiency balance subtest (BOT-2) The BOT-2 (Bruininks & Bruninks, 2005) balance subtest is one of eight subtests of the BOT-2, which is a standardized norm referenced outcome measure of motor proficiency (Gagnon et al., 1998). The BOT-2 balance subtest was chosen because it measures stability of the trunk, stasis and movement, and the use of visual cues. Nine items comprised this subtest (e.g., standing with feet apart on a line eyes opened and closed and on a balance beam, walking forward on a line, standing on one leg eyes open and closed and standing on a balance beam on one leg). Standard scores were interpreted based on a descriptive scale including well above average, above average, average, below average, well below average (Bruininks et al., 2005). The test–retest reliability for this subtest has an adjusted intraclass correlation coefficient of 0.51–0.66 for the age group of 8–21 years (Bruininks et al., 2005). The first edition of BOT (Bruininks, 1987) has been used with the paediatric MTBI population by rehabilitation professionals to assess motor challenges (Collins et al., 2002; Gagnon et al., 1998; Gagnon et al., 2001; Gagnon et al., 2004) and in exploratory studies to identify deficits in balance and response speed to compare to the normative population (Gagnon et al., 1998). Community Balance and Mobility Scale The CBM (Howe et al., 2006) is an outcome measure of balance and mobility that was designed for use with the young adult population who have high ambulatory function after sustaining an MTBI (Knorr et al., 2010; Rocque et al., 2005). The CBM is well suited for use with the paediatric population because it includes items that require multi-tasking, sequencing and dynamic balance, which are often key requirements in the sports and activities in which children commonly participate (Wright et al., 2010). CBM items require rapid directional changes, coordinated limb movements, and quick performance (Rocque et al., 2005). The CBM consists of 19 items that are scored on a scale of 0–5. Items are scored based on time components, and quality of performance (Howe et al., 2006). The CBM has shown moderate to high convergent validity with other commonly used balance assessments (e.g., Berg Balance Scale and the Timed Up and Go Test) (Knorr et al., 2010). The CBM has demonstrated high inter-rater reliability and high test-retest reliability with intraclass correlation coefficients of 0.93 and 0.9, respectively among a sample of youth with high ambulatory function following MTBI (Wright, Ryan, and Brewer et al., 2010). Procedures This study employed a within subject cross-sectional design with youth participating in testing on one occasion. Testing occurred in the Occupational Therapy area at MCH during a regularly scheduled follow-up visit to the Acquired Brain Injury clinic. Each child completed the Post-Concussion Symptom Scale (Lovell et al.,


234

DeMatteo et al.

2006) before testing to assess current symptom level. Examiners monitored postconcussion symptoms and child health status during testing, and the presentation of any symptoms was recorded. Data on HR, RR, and caloric expenditure were collected once in start position, which was standing still on the Wii mat facing the screen, immediately prior to game play, and immediately upon completion of each Wii game. It was important that all measures could be conducted efficiently within the clinic, where sophisticated exercise testing equipment is not available. An examiner measured HR by taking the participant’s radial pulse in intervals of 10 s. RR was observed by chest or diaphragm expansion in intervals of 10 s. Caloric expenditure was measured following each game using the commercially available Mio Step 1 pedometer that was calibrated to each participant’s weight as per instrument instructions. Participants played five Wii mini games (Dinosaur, Arrows, Hamburger, Running, and Basketball) using the dance mat, that were included in the Wii Ultimate Party Challenge (UPC) and Wii Fit game (Basic Run). These six games were presented in a pre-determined order by investigators based on level of difficulty, quantity of movements, balance and exertion requirements, moving from simple task low exertion to multi-task high exertion. In addition to the physical challenges necessary for completion of the game, each game also provided memory, concentration and sequencing challenges. A number of games were trialled by the occupational therapists in the Acquired Brain Injury clinic and these Wii games were chosen based on key performance requirements outlined in Table 2. Each game took between 2 and 3 min to complete, and 3 min rest was allowed between games. Following Wii testing, the youth completed the BOT-2 balance subtest and the CBM. The participants did not report any post-concussion symptoms immediately before, during or after testing. Upon completion of the standardized assessments, participants completed a post-evaluation interview that explored their perceptions of both use of the Wii as an assessment tool for balance and exertion and Wii game versus standardized balance measure difficulty. Sample questions include: Did you enjoy the Wii? What did you find more challenging, balance tests or the Wii? Which game was the hardest? Data Analysis Quantitative data were analyzed using Statistical Package for Social Sciences (SPSS) 19.0. Descriptive statistics and frequency data were used to characterize the sample and identify trends in Wii games. Repeated measures one way analyses of variance (ANOVA) were used to evaluate differences between Wii games for measures of exertion within each youth, including HR, RR, and caloric expenditure. Bivariate correlation analyses were used to determine correlations between the BOT-2 balance subtest and CBM total scores and the frequency counts of loss of balance during all Wii games. In order to test the hypothesis that factors related to severity of injury and symptoms are associated with poorer performance on balance, linear regression analyses using the enter method were used to determine whether number of injuries, cause of injury coded as motor vehicle versus sport, time since injury, and number of post-concussion symptoms were predictive of BOT-2 balance subtest and CBM total scores. Significance was evaluated at the level of p < .05 for all analyses.


235

TABLE 2. Key Performance Requirements for Nintendo Wii Games Gamea 1. UPC Dinosaur


2. UPC arrows

3. UPC hamburger

4. UPC running

5. UPC basketball

6. Wii fit basic run

a

Game description Sort two colors of dinosaurs to either the left or right by stepping on the dance mat arrows within a time limit. Step on the dance mat arrows that corresponded to the multidirectional arrows on the television screen with correct sequence and within an allotted time. Use your feet to select the appropriate arrows corresponding to the hamburger toppings on the screen to create a hamburger. The speed at which the toppings were presented increased throughout the game. Run and repeatedly, jump, and shift from the left and right sides of the dance mat in order to clear obstacles on the television screen. Simultaneously jump on the dance mat and make a throwing motion with the Wiki controller to get basketballs into the nets on the screen. Run on the spot as fast as you can while following the trail on screen for 2 min and 30 s.

Performance requirements Balance, crossing midline, cognition, reaction time Balance, crossing midline, cognition, jumping, reaction time, sequencing

Balance, memorization, crossing midline, reaction time, sequencing

Balance, reaction time, jumping, exertion

Hand eye coordination, jumping, balance, cognition anticipatory posture, exertion Balance, prolonged exertion

Games were ordered by increasing levels of balance and exertion challenge.

RESULTS Wii Fit Basic Run had the highest mean post-game HR (109.9 beats/min SD 18.2) and highest mean calorie expenditure on the Mio Step 1 (9.6 kcal SD 4.1). Wii UPC Running had the highest mean post-RR (30.8 respirations/min SD 11.8). Results of one way repeated measures ANOVAs showed a significant effect for game for both HR, Wilk’s Lambda = .09, F(5, 8) = 15.99, p = .001; and calorie expenditure, Wilke’s Lambda = .08, F(5, 5) = 11.022, p = .01. Wii Fit Basic Run resulted in a significantly higher caloric count compared to all the UPC mini games (p = .01) and a significantly higher HR than all UPC mini games (p = .001) with the exception of UPC Running. Figures 1–3 provide boxplots illustrating the distribution of values and the differences between games for HR, RR, and caloric expenditure, respectively.

Wii Balance Measures Fifteen participants (62.5%) never lost balance, as measured by frequency counts of loss of balance. Of the nine participants (37.5%) that did lose their balance during Wii game play, eight participants (33.3%) lost balance 1–3 times, and one participant (4.2%) lost balance 9 times. However, there were no falls.


236

DeMatteo et al.

FIGURE 1. HR comparison by Wii game. Note: Symbol o outlier more than 1.5 box lengths from the box edge. The whiskers represent the maximum and minimum values excluding outliers; the top and bottom borders of the box represents the upper and lower 25% between which is the interquartile range containing half of the data.; the dark line across the box is the median.

Standardized Measures of Balance With respect to the BOT-2 balance subtest, the mean performance standard score was 12.1 (range, 3–22); whereas the normative “Average” expected score is 12–18. In addition, 10 participants (41.7%) demonstrated below and well below average performance on the BOT-2 balance subtest compared to age norms. The mean percentage score of the participants on the CBM was 83.9% (range, 49–95%). Of the 24 participants, 87.5% (n = 21) had deficits in balance on one or both measures. Scores on the BOT-2 balance subtest were significantly correlated with scores on the CBM (r = 0.61, p = .002). There were no significant correlations between Wii loss of balance scores and CBM (r = −0.02, p = .92) or BOT-2 (r = −0.15, p = .51) scores. Variables Predicting Balance Performance Number of injuries (standardized coefficient Beta = .25, p = .19), cause of injury (standardized coefficient Beta = .36, p = .07), and time since injury (standardized coefficient Beta = −.52, p = .008), explained 38% of the variance in CBM scores (n = 22, adjusted R2 = 0.382, F [3,18] = 5.32, p = .008).



237

FIGURE 2. Respiration rate comparison by Wii game. Note: Symbol o outlier more than 1.5 box lengths from the box edge, and ∗ extreme outlier more than 3 box lengths from the box edge. The whiskers represent the maximum and minimum values excluding outliers; the top and bottom borders of the box represents the upper and lower 25% between which is the interquartile range containing half of the data.; the dark line across the box is the median.

Time since injury provided a significant unique contribution to the model. More recent time since injury was associated with lower CBM scores. Number of injuries (standardized coefficient Beta = .09, p = .59), cause of injury (standardized coefficient Beta = .71, p < .001), and time since injury (standardized coefficient Beta = −.17, p = .29) explained 51% of the variance in BOT-2 balance subscale scores (n = 22, adjusted R2 = 0.511, F [3, 18] = 8.32, p = .001). Cause of injury was the most significant predictor of BOT-2 subscale scores, with motor vehicle accidents predicting the lowest balance performance. The greater the number of injuries, and closer time to injury were associated with poorer balance performance on the BOT-2. Number of concussion symptoms reported on first presentation to clinic, did not contribute to either model. Youth Perceptions The participants’ answers to the interview questions were collected and examined informally for trends in responses. These trends showed that all participants preferred the Nintendo Wii to the standardized balance measures for testing balance.


238

DeMatteo et al.

FIGURE 3. Caloric expenditure comparison by Wii game, Note: Symbol o outlier more than 1.5 box lengths from the box edge, and ∗ extreme outlier more than 3 box lengths from the box edge. The whiskers represent the maximum and minimum values excluding outliers; the top and bottom borders of the box represents the upper and lower 25% between which is the interquartile range containing half of the data.; the dark line across the box is the median.

However, the participants also indicated that the standardized balance measures were more challenging than the Wii.

DISCUSSION This study demonstrated three major findings. First, this research provides evidence that the Nintendo Wii can be used to assess exertion in youth with MTBI. As previously reported by Peng et al. (2011) there were significant differences in exertion by game. Wii Fit Basic Run proved to be the most challenging based on calorie expenditure. Second, the results did not support the use of the Nintendo Wii for assessment of balance in youth with MTBI using the evaluation technique of frequency counts of loss of balance. Third, the study highlights the importance of using standardized measures to identify balance impairments in youth with MTBI. The performance of 87.50% of the participants in our study was below age expectations on either the BOT-2 or CBM or both. Given that youth with MTBI may experience deficits in balance and gross motor skills (Collins et al., 2002), a comprehensive assessment following MTBI should



239

include evaluation of motor ability, including balance, and symptom response to exertion in order to determine an individual’s readiness to return to activity (Gagnon et al., 2010). It is now well established by a number of high-quality systematic reviews that physically AVG, including the Wii, can increase energy expenditure and provide a moderate intensity exercise challenge with intensity varying by games (Barnett et al., 2011; Graf et al., 2009; Lyons et al., 2011; Peng et al., 2011). Although this study was carried out in a small sample of youth with MTBI, in a clinic environment and without laboratory technology, our findings replicated previous studies. This suggests that the Wii may be helpful in providing an exertion challenge when evaluating symptom exacerbation before making decisions about return to activity in youth after MTBI/concussion in a routine clinic environment. The results showed that the UPC Running game and the Wii Fit Basic Run created the greatest exertion challenge in comparison to the other games. This is understandable as current research illustrates that games that require a greater number of movements and/or full body involvement result in greater energy expenditure (Graves et al., 2008; Hurkmans et al., 2010; White et al., 2011). Further, it has been found that the need for continued use of larger muscle groups and whole body displacement also creates greater metabolic demands (White et al., 2011). The finding that the youth did not have exacerbation of their symptoms during testing was anticipated as the protocol did not involve physical activity to the point of symptom exacerbation. The goal was to see if significantly increased HR and caloric expenditure could be easily achieved in the clinic without laboratory instruments and to determine which Wii game could provide the biggest challenge in a short time. The participants had 15 min of physical activity in total, 3 min per game, and a return to resting HR between games. We did not measure symptoms at time points after the study testing—such as that evening or the next day—therefore it is not known if symptoms appeared later. The next stage would be to incorporate a more challenging protocol for exertion training and rigorous symptom monitoring, now that it has been determined that this modality can successfully be used to measure exertion. Clinical balance testing is an important component of the determination of post-concussion symptoms (Davis et al., 2009). As good balance is crucial for safe play in active sports, decisions regarding return to play should include an evaluation of balance (David et al., 2009). Clark et al. (2010) and Levac et al. (2010) have begun to provide normative data for balance performance using the Wii balance board in a similar method to force plate analyses. As force plate balance analysis is not available within most clinic settings, we endeavored to determine whether frequency count of loss of balance during Wii game play might serve as a simple way to evaluate balance performance following MTBI. This frequency count of lost balance and falls method of measurement was not sensitive enough to quantify the existence of balance problems, as evidenced by the fact that minimal loss of balance during Wii game play was seen, yet participants demonstrated poor performance on the standardized balance measures. Not only were there very few loss of balance events, there was no correlation between loss of balance frequency counts and BOT-2 balance subtest and CBM scores. In contrast to the limited instances of loss of balance during Wii game play, 87.50% of youth had below average balance on BOT-2 and below 90% on CBM,


240

DeMatteo et al.

indicating that these measures were able to identify deficits in balance in this sample. Our finding that most of the youth with MTBI had deficits in static and dynamic balance and postural stability support the previous findings of Gagnon et al. (2010) and Wright et al. (2010). Considering that scores on the BOT-2 and CBM were significantly correlated, the busy clinician may ask, do we need to administer both measures? BOT-2 and CBM may be measuring different aspects of balance (Howe et al., 2006; Wright et al., 2010). The CBM has been proposed as a useful tool for assessment of balance among youth with MTBI because it assesses higher order balance, and includes items that require multitasking and sequencing, which are typical requirements of many sport and leisure activities (Howe et al., 2006; Wright et al., 2010). The benefits of using the BOT-2 balance subtest to assess youth with MTBI are that it challenges higher level anticipatory control, static optical and vestibular based balance, provides norm references in order to compare clients’ performance to youth of the same age and it is easier to administer compared to other standardized balance measures (Collins et al., 2002; Gagnon et al., 2010). Administering both measures may ensure that more aspects of balance are assessed, an important safety consideration in return to play. It is clear through observations of the youth playing the Wii games that balance skills, in addition to other motor and cognitive abilities, are required to play the games. It is reasonable to assume that these games may contribute to training balance. More research is recommended to determine how the Wii can be used to accurately measure balance in an everyday clinical environment. Predictors of Balance Performance Children and youth are known to have post-concussion symptoms, including balance deficits, (Barlow et al., 2010; Kirkwood et al., 2008; Yeates et al., 2009; Yeates, 2010). There is growing evidence that specific symptoms and cumulative effects of repeated injury are significant predictors of outcome (Sabini & Reddy, 2010). Therefore, it is reasonable to hypothesize that factors related to severity of injury and symptoms may be associated with poorer performance on balance. The regression analyses showed that the number of injuries, cause of injury, and time since injury explained a significant percentage of the variance in scores on the BOT-2 balance subtest and the CBM. The model illustrates that as the time since injury increased, the expected performance on the CBM also increased suggesting recovery is occurring. Cause of injury, with MVA having the lowest balance scores, was found to significantly predict performance on the CBM and the BOT-2. Youth Perceptions The enjoyment factor and motivation are discussed and occasionally measured in the exergaming literature (Barnett et al., 2011; Graf et al., 2009; Lyons et al., 2011; Peng et al., 2011). All studies suggest that it is indeed a factor in performance. In this study, all participants identified that they enjoyed the Wii and preferred it to the standardized balance assessments. This finding supports previous research, which demonstrated that the use of the Wii as an intervention tool in rehabilitation resulted in higher scores on a paediatric volitional questionnaire (Harris & Reid, 2005). Participants also found the standardized assessments to be more challenging


241

than the Wii. Similarly, Law et al. (2011) reported that youth with MTBI demonstrated limited participation in skill based activities and preferred recreation based activities support. The Nintendo Wii is a popular leisure activity among youth and several participants had previous Wii experience. Experience playing Wii games may decrease the cognitive challenge they present and facilitate understanding of body movements required to play the games, thus minimizing exertion and balance challenge.


Study Limitations The small convenience sample used to test the developed Wii protocol was a study limitation. The small sample makes it difficult to generalize the findings to the wider MTBI paediatric population and to have sufficient power to detect further differences between games and predictors of outcome. Cognitive issues, somatic symptoms, and fatigue in this population could have influenced performance on the games, particularly with the increasing order of complexity and effort required. We did monitor symptoms during game play in order to account for this and did not find that the games elicited symptoms. The inter-rater reliability of the exertion measures and balance frequency counts were not calculated, but the two evaluators compared scores for consistency before proceeding with further evaluations. Lastly, frequency counts of loss of balance during the Wii game play were not sensitive enough to detect balance impairments in this population; other ways of evaluating balance performance during Wii game play, which needed to be more precise and standardized but still achievable in a busy clinic setting could have been considered. As such, whether or not observing Wii game play could be a way to determine the extent of balance impairments in this population remains unclear. CONCLUSION Our results indicate that Wii interactive video games can be used to assess exertion in youth with MTBI. Frequency counts of loss of balance during Wii game play was not an accurate measure of balance performance in this population, even though youth may be more motivated to participate in Wii testing. The BOT-2 and CBM are measures that can be used to identify balance impairments among youth with MTBI. Each measure provides information on different aspects of balance, suggesting that both may be required for a comprehensive assessment of static and dynamic balance. ACKNOWLEDGMENTS The authors would like to thank the children and families from the Acquired Brain Injury Clinic at McMaster Children’s Hospital who eagerly participated in research projects in order to expand the knowledge in the field of brain injury in children. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. ´ This study was funded by the Ontario Neurotrauma Foundation and Reseau ´ provincial de recherche en adaptation–readaptation Partnership (ONF-REPAR).

242

DeMatteo et al.


ABOUT THE AUTHORS Carol DeMatteo, MSc, McMaster Children’s Hospital, Hamilton, Ontario, Canada; School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada; CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada. Dayna Greenspoon, MSc, OT, HollandBloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada. Danielle Levac, PhD, CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada. Jessica A. Harper, BSc, CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada. Mandy Rubinoff, MSc, OT, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.

REFERENCES Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F. (2010). Epidemiology of post concussion syndrome in pediatric mild traumatic brain injury. Pediatrics 126:374–381. Barnett A, Cerin E, Baranowski T. (2011). Active video games for youth: A systematic review. Journal of Physical Activity and Health 8:724–737. Bruininks RH. (1987). Bruininks-Oseretsky Test of Motor Proficiency. Circle Pines, MN: American Guidance Service. Bruininks RH, Bruininks BD. (2005). Bruininks–Oseretsky Test of Motor Proficiency (2nd Edition). Circle Pines, MN: Pearson. Butler DP, Willett K. (2010). Wii-habilitation: Is there a role in trauma? International Journal of the Care of the Injured 41:671–673. Carrol LJ, Cassidy JD, Holm L, Kraus J, Coronado VG. (2004). Methodological issues and research recommendations for mild traumatic brain injury: The WHO collaborating centre task force on mild traumatic brain injury. Journal of Rehabilitation Medicine 36(Suppl 43), 113–125. Chen YP, Kang LJ, Chuang TY, Doong JL, Lee SJ, Tsai MW (2007). Use of virtual reality to improve upper-extremity control in children with cerebral palsy: A single-subject design. Journal of the American Physical Therapy Association 87:1441–1457. Clark RA, Bryant AL, Pua Y, McCrory P, Bennell K, Hunt M. (2010). Validity and reliability of the Nintendo Wii balance board for assessment of standing balance. Gait & Posture 31:307–310. Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. (2002). Cumulative effects of concussion in high school athletes. Neurosurgery 51:1175–1181. Davis GA, Iverson GL, Guskiewicz KM, Ptito A, Johnston KM. (2009). Contributions of neuroimaging, balance testing, electrophysiology and blood markers to the assessment of sportrelated concussion. British Journal of Sports Medicine 43(Suppl I):i36–i54. Deutsch JE, Borbely M, Filler J, Huhn K, Guarrera-Bowlby P. (2008). Use of low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Physical Therapy 88:1196–1207. Gagnon I, Forget R, Sullivan J, Friedman D. (1998). Motor performance following a mild traumatic brain injury in children: An exploratory study. Brain Injury 12:843–853. Gagnon I, Friedman D, Swaine B, Forget R. (2001). Balance findings in a child before and after a mild head injury. Journal of Head Trauma Rehabilitation 16:595–602. Gagnon I, Galli C, Friedman D, Grilli L, Iverson GL. (2009). Active rehabilitation for children who are slow to recover following sport-related concussion. Brain Injury 23:956–964. Gagnon I, Swaine B, Friedman D, Forget R. (2004). Children show decreased dynamic balance after mild traumatic brain injury. Archives of Physical Medicine and Rehabilitation 85:444–452.



243

Gagnon J, Galli C, Grilli L, Simard J. (2010). Assessing balance in children after a mild traumatic brain injury: Choosing the right tools. Brain Injury 243:32. Graf DL, Pratt LV, Hester CN, Short KR. (2009). Playing active video games increases energy expenditure in children. Pediatrics 124:534–540. Graves LEF, Ridgers ND, Stratton G. (2008). The contribution of upper limb and total body movement to adolescents’ energy expenditure whilst playing Nintendo Wii. European Journal of Applied Physiology 104:617–623. Halton J. (2010). Rehabilitation with the Nintendo Wii: Experiences at a rehabilitation hospital. Occupational Therapy Now 12:11–14. Halton J (2008). Virtual rehabilitation with video games: A new frontier for occupational therapy. Occupational Therapy Now 9.6:12–14. Harris K, Reid D. (2005). The influence of virtual reality play on children’s motivation. Canadian Journal of Occupational Therapy 72:21–29. Howe JA, Inness EL, Venturini A, Williams JI, Verrier MC. (2006). The community balance and mobility scale-a balance measure for individuals with traumatic brain injury. Clinical Rehabilitation 20:885–895. Hurkmans HL, Van Den Berg-Emons RJ, Stam HJ. (2010). Energy expenditure in adults with cerebral palsy playing Wii Sports. Archives of Physical Medicine and Rehabilitation 91:1577–1581. Kirkwood MW, Yeates KO, Taylor HG, Randolph C, McCrea M, Anderson VA. (2008). Management of pediatric mild traumatic brain injury: a neuropsychological review from injury through recovery. The Clinical Neuropsychologist 22:769–800. Knorr S, Brouwer B, Garland SJ. (2010). Validity of the community balance and mobility scale in community-dwelling persons after stroke. Archives of Physical Medicine and Rehabilitation 91:890–896. LaViola J. (2008). Bringing VR and spatial 3D interaction to the masses through video games. IEEE Computer Graphics and Applications 10–15. Law M, Anaby D, DeMatteo C, Hanna S. (2011). Participation patterns of children with acquired brain injury. Brain Injury 25:587–595. Leddy JJ, Sandhu H, Sodhi V, Baker JG, Willer B. (2012). Rehabilitation of concussion and post-concussion syndrome. Sports Health 4:147–154. Levac D, Pierrynowski MR, Canestraro M, Gurr L, Leonard L, Neeley C. (2010). Exploring children’s movement characteristics during virtual reality video game play. Human Movement Science 29:1023–1038. Lovell MR, Iverson GL, Collins MW. (2006). Measurement of symptoms following sports-related concussion: reliability and normative data for the Post-Concussion Scale. Applied Neuropsychology 13:166–173. Lyons EJ, Tate DF, Ward DS, Bowling JM, Ribisl KM, Kalyararaman S. (2011). Energy expenditure and enjoyment during video game play: differences by game type. Medicine and Science in Sports and Exercise 43:1987–1993. Mayer AR, Ling JM, Yang Z, Pena A, Yeo RA, Klimaj S. (2012). Diffusion abnormalities in pediatric mild traumatic brain injury. Journal of Neuroscience 32:17961–17969. Moser RS, Schatz P, Jordan BD. (2005). Prolonged effects of concussion in high school athletes. Neurosurgery 57:300–306. Nintendo of America Inc. (2007). The Nintendo America [Video game console]. Redmond, WA: Nintendo America. Peng W, Lin JH, Crouse J. (2011). Is playing exergames really exercising? A meta-analysis of energy expenditure in active video games. Cyberpsychology, Behaviour, and Social Networking 14:681–688. Ryan J, Brewer K. (2010). Reliability of the Community Balance and Mobility Scale (CB&M) in high-functioning school-aged children and adolescents who have an acquired brain injury. Brain Injury 24(13–14):1585–1594. Rocque R, Bartlett D, Brown J, Garland SJ. (2005). Influence of age and gender of healthy adults on scoring patterns on the Community Balance & Mobility Scale. Physiotherapy Canada 57:285–292.


244

DeMatteo et al.

Sabini RC, Reddy CC. (2010). Concussion management and treatment considerations in the adolescent population. Physician and Sports Medicine 38:139–146. Swaine BR, Tremblay C, Platt RW, Grimard G, Zhang X, Pless IB. (2007). Previous head injury is a risk factor for subsequent head injury in children: a longitudinal cohort study. Pediatrics 119:749–758. Weiss PL, Rand D, Katz N, Kizony R. (2004). Video capture virtual reality as a flexible and effective rehabilitation tool. Journal of NeuroEngineering and Rehabilitation 1:1–12. White K, Schofield G, Kilding AE. (2011). Energy expended by boys playing active video games. Journal of Science and Medicine in Sport 14:130–134. Wright VF, Ryan J, Brewer K. (2010). Reliability of the Community Balance and Mobility Scale (CB&M) in high-functioning school-aged children and adolescents who have an acquired brain injury. Brain Injury 24:1585–1594. Yeates KO, Taylor HG, Rusin J. (2009). Longitudinal trajectories of postconcussive symptoms in children with mild traumatic brain injuries and their relationship to acute clinical status. Pediatrics 123:735–743. Yeates KO. (2010). Mild traumatic brain injury and postconcussive symptoms in children and adolescents. Journal of International Neuropsychological Society 16:953–960.

Medical-School Partnership in Guiding Return to School Following Mild Traumatic Brain Injury in Youth.

Imaging "brain strain" in youth athletes with mild traumatic brain injury during dual-task performance.

Understanding Why Patients Return to the Emergency Department after Mild Traumatic Brain Injury within 72 Hours.

Systematic review of return to work after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

Mild traumatic brain injury.

Mild traumatic brain injury.

Considerations for return to work following traumatic brain injury.

The potential for DHA to mitigate mild traumatic brain injury.

White matter alterations in youth with acute mild traumatic brain injury.

Neurocognition in the emergency department after a mild traumatic brain injury in youth.

Return to work after traumatic brain injury: Systematic review.

Assessing the consequences of traumatic brain injury.

Mild traumatic brain injury: neurosensory effects.

Autonomic Dysfunction after Mild Traumatic Brain Injury.

Advanced neuroimaging of mild traumatic brain injury.

Identification of hematomas in mild traumatic brain injury using an index of quantitative brain electrical activity.

Low-frequency connectivity is associated with mild traumatic brain injury.

Resilience Is Associated with Outcome from Mild Traumatic Brain Injury.

Pain Catastrophizing Correlates with Early Mild Traumatic Brain Injury Outcome.

Proposed objective visual system biomarkers for mild traumatic brain injury.

The Role of Thalamic Damage in Mild Traumatic Brain Injury.

Resilience is associated with fatigue after mild traumatic brain injury.

A novel traumatic brain injury model for induction of mild brain injury in rats.

Damage to the Optic Radiation in Patients With Mild Traumatic Brain Injury.