GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 1, Number 4, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2012.0006

Improvements in Dynamic Balance Using an Adaptive Snowboard with the Nintendo Wii Brendan Sullivan, PT, CSCS,1 Alexandra G. Harding, PT, DPT,2 John Dingley, MD,3 and Laura Z. Gras, PT, DPT, DSc, GCS 2

Abstract

Objective: The purpose of this case report is to see if a novel balance board could improve balance and gait of a subject with dynamic balance impairments and enjoyment of virtual rehabilitation training. Materials and Methods: A novel Adaptive Snowboard (developed by two of the authors, B.S. and J.D.) was used in conjunction with the Nintendo (Redmond, WA) Wii snowboarding and wakeboarding games with a participant in a physical therapy outpatient clinic. Baseline measurements were taken for gait velocity and stride length, Four Square Step Test, Star Balance Excursion Test, Sensory Organization Test, and the Intrinsic Motivation Inventory. Two 60–90-minute sessions per week for 5 weeks included seven to nine trials of Wii snowboarding or wakeboarding games. Results: Improvements were seen in every outcome measure. Conclusions: This study had comparable results to studies performed using a wobble board in that improvements in balance were made. Use of virtual snowboard simulation improved the subject’s balance, gait speed, and stride length, as well as being an enjoyable activity.

Introduction

S

nowboarding is a sport that challenges balance, lower extremity and trunk strength, coordination, and proprioception. It requires the participant to hold positions that are often outside of his or her center of balance and forces the snowboarder to utilize the positive effects of momentum and gravity to prevent tipping over. Although there is no research that has been done examining the direct effect of snowboarding on improving a subject’s balance, a closely related intervention tool is the wobble board.1,2 Wobble board training, through the use of a multi-axial surface, has been shown to improve dynamic balance under visual control as well as under eyes-closed conditions.3 The Nintendo (Redmond, WA) Wii gaming system has provided the field of physical therapy with a tool for improving balance and strength, while keeping these activities fun for the participant.4 Most notable is that the Wii has been used in the geriatric community to improve a subject’s risk of falls and to allow participants to become more active, as well as examining the effects on subjects with neurological impairments.5–7 When used with older adults it has improve Berg Balance Scale scores, which is the gold standard for

balance testing.5,8–10 There is a lack of research done to examine the effects on middle-aged individuals with orthopedic issues using the Wii. The Adaptive Snowboard is a novel piece of equipment, developed by two of the authors (B.S. and J.D.), that uses existing videogame technology.11 The Adaptive Snowboard integrates dynamic movements required by snowboarding and translates that movement into game play with a virtual reality interface. This is accomplished by modifying and calibrating existing remote controllers used for videogame systems. The Adaptive Snowboard, seen in Figure 1, is a wooden balance board that is 30 inches long. The board has a contoured underside that allows for a degree of movement that a rider’s lower extremities would need to transverse to skillfully participate in board sports, similar to a wobble board. The amount of physical motion a rider’s ankles go through in the sagittal plane has been optimized for approximately 20 of ankle plantar/dorsiflexion in either direction from neutral. The board has two foot bindings to enable a rider full control over the board, thereby allowing for weight shifting and rotating the board 90 from the starting position. This inclusion of bindings allows a rider to more closely simulate the

1

Empire Health and Wellness Center, Latham, New York. Doctor of Physical Therapy Program, The Sage Colleges, Troy, New York. Swansea University Medical School, Swansea, United Kingdom.

2 3

269

270

FIG. 1. The Adaptive Snowboard has two foot bindings to enable a rider full x-, y-, and z-axis control. Color images available online at www.liebertonline.com/g4h

physical demand of being strapped into a wakeboard or snowboard with both lower extremities. Modifications were made to the Wiimote controller by affixing it to the balance board. This configuration enables the nunchuck’s controllers to effectively activate the buttons and controls now fixed onto the Wiimote controller. The purpose of the study was to determine if the Adaptive Snowboard used with the Nintendo Wii would improve a subject’s dynamic balance. This research project was approved by the Institutional Review Board at The Sage Colleges in Troy, NY.

SULLIVAN ET AL. his complaints of low back pain. The pretest was conducted 10 days prior to the start of the virtual snowboard intervention because of scheduling conflicts. The participant only participated in the virtual snowboard intervention and did not receive physical therapy during the time of the experiment. The pretests and posttests were performed by an examiner who did not participate in the intervention (L.Z.G.). At pretest, the participant’s gait velocity and stride length were measured at two speeds, normal pace and fast pace, using the GAITRite Mat System (CIR Systems, Inc., Havertown, PA).12 The participant began walking 2 meters before and ended 2 meters after the 12-foot mat to capture true gait velocity and stride length without acceleration or deceleration. On average, three trials were performed. The participant also performed the Four Square Step Test13 and Star Balance Excursion Test,14–17 both of which have been used in the literature to measure dynamic balance and coordination. The Four Square Step Test was used to examine the patient’s quick response to a change in direction. The Star Balance Excursion Test was scored based on the participant’s leg length versus the distance he was able to extend his leg in three different directions (anterior, posteromedial, and posterolateral) without allowing his extended leg to touch the floor, as seen in Figure 2.18 The NeuroCom (Clackamas, OR) EquiTest measured the participant’s balance, equilibrium, weight symmetry, and coordination. Literature has shown that computerized dynamic platform posturography is an appropriate indication for participants undergoing balance rehabilitation and evaluation of postural control under varying conditions and to monitor progress. The outcome measure used for this study using the NeuroCom EquiTest was the Sensory Organization Test.19 The intervention entailed two 60–90-minute sessions per week, which ramped up in minutes based on the participant’s tolerance for 5 weeks in an outpatient clinic that included a 5-minute warm-up on a recumbent bicycle followed by 5 minutes of lower extremity stretches held for 15 seconds each of the gastrocnemius, quadriceps, hamstrings, and lower trunk musculature. The participant’s feet were then strapped into the novel balance board, and a gait belt was donned. The participant viewed the Nintendo Wii games on a 73-inch

Subject and Methods The participant in this case was a 34-year-old man who is 6 feet tall and 184 pounds and who is married and has children. He was in the military stationed in Iraq when he was injured by a roadside bomb in 2005. He had undergone two back surgeries in 2005 and 2007 for a right and left laminectomy and discectomy at L5–S1 and was placed on light duty. He was recruited for the study because one of the researchers had treated him in the past in physical therapy for low back pain (B.S.). The participant continued to have chronic low back pain, making it difficult to do any activities of daily living that required lifting, bending, and pushing. The participant had been active prior to his back injury and enjoyed strenuous activities such as hiking, snowboarding, and judo but was concerned about his ability to perform the activity due to his poor dynamic balance from his previous diagnoses and

FIG. 2. The subject performing the Star Balance Excursion Test. Color images available online at www.liebertonline .com/g4h

ADAPTIVE SNOWBOARD AND THE NINTENDO WII

271 Table 1. Intrinsic Motivational Inventory Intrinsic Motivation Inventory

Week 1

Week 2

Week 3

Week 4

7 5 7 1.75 7

7 6.5 7 1.25 7

7 6.25 7 1 7

7 7 7 1 7

Interest/Enjoyment Perceived Competence Effort/Importance Pressure/Tension Value/Usefulness

The inventory assessment was graded on a scale from 1 (not at all) to 7 (very true).

FIG. 3. A subject being guarded while on the Adaptive Snowboard, participating in a Nintendo Wii wakeboarding game. Color images available online at www .liebertonline.com/g4h television and was approximately 4 feet from the television during the intervention sessions. The participant (Figure 3) was guarded using close supervision or contact guard assistance and also had the ability to right his balance using a parallel bar.20 The session included three games of the Wii ‘‘Sports Resort’’ wakeboard game, two to three games of the ‘‘Shaun White Snowboarding: Road Trip’’ game or the ‘‘Shaun White Snowboarding: World Stage’’ game, and two or three games of the Wii ‘‘Ski and Snowboard’’ game.21 Throughout the course of the intervention, more advanced snowboarding maneuvers were added as the participant became increasingly comfortable with the games based on his ability to balance on the adaptive snowboard without grabbing hold of the parallel bar, maintained proper alignment, and improved endurance. Advanced maneuvers including jumping and lifting the nose of the Adaptive Snowboard off of the ground while keeping the tail planted. He was encouraged to use these maneuvers as he became more adept with the games to improve his performance and increase his scores. Several times throughout the treatment, the participant completed an Intrinsic Motivation Inventory (IMI) to gauge

his interest and motivation for completing the intervention, as shown in Table 1.22 The IMI is a multidimensional measurement tool for use as a subjective assessment of the participant’s enjoyment of the experimental activity. The posttest, which included repeating the same initial test measures, was conducted 2 days after the last intervention session. Results The participant demonstrated significant increases in gait velocity and left stride length for both his self-selected pace and his faster pace, which were above the minimal detectable change found in the literature.23–25 He had made improvements in Condition 3 of the Sensory Organization Test, which was within normal limits, as well as improvements in the Four Square Step Test. The largest gains were seen in the Star Balance Excursion Test, which was above the minimal detectable change for left anterior reach and bilateral posteriolateral and posteriomedial reach.17 Table 2 gives the results of these tests. The participant also noted that throughout the course of the intervention, his perceived competence improved, and he felt less pressure/tension as measured by the IMI (Table 1). Discussion The participant’s score on the IMI consistently improved throughout his sessions, indicating that he felt less pressure and tension while playing, and he felt increased comfort with the training sessions. The participant reported that

Table 2. Participant’s Dynamic Balance and Gait Outcomes Outcome measure Gait velocity (cm/second) Self-selected Fast Left/right stride length (cm) Self-selected Fast SOT Condition 3 Four Square Step Test (seconds) SBET, left/right Anterior Posteriolateral Posteriomedial

Pretest

Posttest

Change score

MDC from the literature

124.7 199.4

134.6 215.6

9.9 16.2

8.2 10

128.26/138.00 182.22/182.76 80.33% 4.95

138.77/139.85 186.98/186.82 89% 4.06

10.51/1.85 4.76/4.06 9% 0.89

7 NA NA NA

86.59%/92.69% 87.71%/89.39% 89.39%/85.39%

96.54%/95.62% 124.92%/119.89% 113.52%/115.62%

9.95%/2.93% 37.21%/30.50% 24.13%/30.23%

7.29% 7.96% 10.42%

MDC, minimal detectable change; NA, not applicable; SBET, Star Balance Excursion Test; SOT, Sensory Organization Test.

272 subsequent to the testing sessions, he was able to return to nearly all of his favorite activities except for judo. He also stated that he ‘‘felt the best [he’d] ever been.’’ Unfortunately, on the day of final testing, the participant noted that his back had been sorer than usual and rated a 4 out of 10 on the Numeric Pain Scale,26 which he attributed to the weather, whereas his typical rating during treatment was a 1 out of 10. The participant returned to full duty 1 month after the study ended. This research had comparable results to studies performed using a wobble board in that improvement in balance was made, although the duration of the studies differed from ours. In an article by Fitzgerald et al.,1 their subjects were tested on a wobble board over a 4–5-week period, with three sessions each week (for a total of 12 sessions), for 15 minutes per session. Onigbinde et al.2 used a 6-week protocol for their subjects. This case report was a two session per week program for 5 weeks with an average session lasting approximately 60 minutes. This length of intervention closely represents what a typical patient would experience in a physical therapy setting. The results of this study support the need for continued research in this field with more test subjects and to be able to have them participate in snow sports to contrast their IMI scores both in clinic and on the mountain. In this study, the application to snowboarding on a mountain was not accomplished because of seasonal restrictions, although the participant felt that he was confident enough to attempt it, and the researchers concurred. A limitation to this research is that it is a case report, which limits its generalizability. Future research would benefit from follow-up testing to determine if the clinical treatment carried over to a return to sport for a larger number of subjects. Further technological advancements to the interface with the Wii and forthcoming motion control gaming systems will allow for a more diverse experience for the rider to participate in and for researchers to test the subjects based on their individual sport of choice. Ideally, these types of gaming systems would be more easily adaptable to accommodate those individuals who have physical or mental disabilities. The motivation for this project was to create sport-specific devices and interfaces for adaptive sports participants who seek the modes beyond what traditional rehabilitation offers. The incorporation of videogames into therapeutic settings is becoming increasingly popular. Efforts to further legitimize their use as therapy through peer-reviewed research has not yet determined their efficacy in the world of advanced adaptive board sports. Physical therapists are in a unique position both to analyze the physical requirements of a sport and to evaluate the participant’s potential physical capabilities. The therapists’ responsibility is to then pair this knowledge with tools that will enable participants to return to sports with a more realistic picture of both their limitations and extent of their injury. Conclusions This case report is the first of its kind to address the successful use of a novel snowboard and the Nintendo Wii to improve dynamic balance in a participant with dynamic balance deficits. More research is warranted to determine the most effective and beneficial length and duration of treatment, as well as determining any carryover into sport-specific situations.

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Address correspondence to: Brendan Sullivan, PT, CSCS Empire Health and Wellness Center 8 Century Hill Drive, Suite 201 Latham, NY 12110 E-mail: [email protected]