A

OteaSPpwIaMowRti{1AiCotar©

K

T

0h

Physiotherapy 98 (2012) 189–195

Effectiveness of a low-cost virtual reality system for children withdevelopmental delay: a preliminary randomised single-blind

controlled trial�

Yasser Salem a,d,∗, Stacy Jaffee Gropack a, Dale Coffin b, Ellen M. Godwin c

a Division of Physical Therapy, Long Island University, Brooklyn, NY, USAb ACE PreSchool/ACE Head Start, Hospital Clinic Home Center Instructional Corp., Brooklyn, NY, USA

c Human Performance Laboratory, SUNY Downstate Medical Center, Brooklyn, NY, USAd Faculty of Physiotherapy, Cairo, Egypt

bstract

bjectives Physical and occupational therapists have started to use the Nintendo WiiTM gaming system with adults and children as part ofheir regular treatment. Despite the growing use of the Wii and trend towards evidence-based practice, limited evidence is available on theffectiveness of virtual reality using the Wii for children with developmental delay. The purpose of this study was to determine the feasibilitynd preliminary effectiveness of a low-cost gaming system for young children with developmental delay.tudy design Single-blind, randomised controlled trial.articipants and setting Forty children with developmental delay (age 39 to 58 months) who attended a segregated or integrated preschoolarticipated in this study. All children’s parents read and signed an informed consent form approved by the institutional review board. Childrenere assigned at random to an experimental (Wii) group (n = 20) or a control group (n = 20).

ntervention Two weekly sessions for 10 weeks using Nintendo Wii SportsTM and Nintendo Wii FitTM, including balance, strength trainingnd aerobics games.

ain outcome measures Participants were evaluated 1 week before and 1 week after the programme by a blinded investigator. Primaryutcomes were gait speed, timed up and go test, single leg stance test, five-times-sit-to-stand test, timed up and down stairs test, 2-minutealk test and grip strength. The Gross Motor Function Measure (GMFM) was used to assess gross motor skills.esults The two groups were homogenous regarding all parameters at baseline. The Wii training was feasible and enjoyable for those in

he experimental group. There were no adverse effects or injuries reported over 267 training sessions. Comparison of groups following thentervention indicated that the experimental group showed significant improvements compared with the control group in single leg stance testmean difference 1.03 [standard deviation (SD) 1.7], 95% confidence interval (CI) 0.2 to 1.9; P = 0.017}, right grip strength [mean difference.11 (SD 1.84), 95% CI 0.15 to 2.06; P = 0.024] and left grip strength [mean difference 0.90 (SD 1.67), 95% CI 0.03 to 1.77; P = 0.043].lthough changes in other outcome measures were not significant between the study groups, there were trends towards greater improvements

n the experimental group compared with the control group.onclusion This study supports use of the Wii as a feasible, safe and potentially effective therapeutic tool to augment the rehabilitationf young children with developmental delay. The potential application of the Wii to increase the intensity of therapy or as a rehabilitation

ool in children’s homes and rural settings is an area worthy of investigation. The promising results of this study suggest that further studiesre warranted to validate the potential benefits of a low-cost commercially available gaming system as a treatment strategy to supplementehabilitation of children with disabilities.

Ltd. A

2012 Chartered Society of Physiotherapy. Published by Elsevier

eywords: Wii gaming system; Virtual reality; Children with developmental delay

� This paper is based on a paper presented at WCPT in Amsterdam 2011.∗ Correspondence. Present address: Department of Physical Therapy, Universityel.: +1 817 735 2982; fax: +1 817 735 2518.

E-mail address: yasser.salem@unthsc.edu (Y. Salem).

031-9406/$ – see front matter © 2012 Chartered Society of Physiotherapy. Publisttp://dx.doi.org/10.1016/j.physio.2012.06.003

ll rights reserved.

of North Texas Health Science Center, Fort Worth, Texas, USA.

hed by Elsevier Ltd. All rights reserved.

1 otherap

I

nVhtvinboit

rnoaTtmptaag

Ngaiioto

foliVwdsgAeiw

idbom

dideirstsd

M

D

P

affUt(d(tcwswga6spto

edrdnaod

p

90 Y. Salem et al. / Physi

ntroduction

In recent years, the integration of video gaming tech-ologies in the field of rehabilitation has been increasing.ideo gaming technology using virtual reality (VR) systemsas enabled users to become active participants in the vir-ual environment. The incorporation of physical activity intoideo gaming facilitates the integration of this technologynto rehabilitation therapies. Previously, the use of VR tech-ology developed specifically for rehabilitation was limitedy substantial cost and decreased access. The availabilityf low-cost commercial gaming systems has significantlyncreased the use of VR video gaming for rehabilitation inhe clinic, school and home settings [1,2].

The use of video games as a form of rehabilitation incorpo-ates fundamental elements of motor learning [3]. It providesot only real-time practice of tasks and activities, but alsopportunities to engage in intensive, meaningful, enjoy-ble and purposeful tasks related to real-life interests [3,4].he physical activities in these games include motor tasks

hat involve a wide range of sensory feedback; adjustableovement amplitudes, speed and precision levels; and incor-

oration of a variety of visual–spatial, cognitive and attentionasks. The practice of these activities may be promisings it may increase the child’s motivation during therapy,nd can be used as part of the child’s home therapy pro-ramme.

Various low-cost commercial VR systems, including theintendo WiiTM, have been used in many studies that useaming technology in rehabilitation [1,2,5–10]. The efficacynd feasibility of use of the Wii have been demonstratedn various populations, including healthy individuals, age-ng populations and individuals with disabilities. The resultsf those studies have suggested that the Wii can be used effec-ively to improve motor skill rehabilitation of a wide rangef functional deficits [1,2,5–10].

Use of the Wii has become a popular form of therapyor children with disabilities, supported by a growing bodyf evidence substantiating its effectiveness with this popu-ation. A recent literature review by Wang and Reid [11]dentified 21 studies that investigated the effectiveness ofR systems in paediatric rehabilitation including childrenith cerebral palsy, autism and attention deficit hyperactivityisorder (ADHD). The present authors identified additionaltudies that examined the effectiveness of VR using Wiiames for children with cerebral palsy, traumatic brain injury,DHD and Down’s syndrome [5,7–10,12–14]. The available

vidence suggests that use of the Wii has great potential formproving gross motor skills, posture and balance in childrenith developmental disabilities.Children with developmental delay demonstrate deficits

n motor control and gross motor abilities. They present with

elay of acquisition of motor skills, and poor postural control,alance and coordination. They often receive physical andccupational therapy to help improve their gross and fineotor skills [15].

gfTF

y 98 (2012) 189–195

Although the Wii is often recommended for children withisabilities, and therapists are using the Wii on an increas-ng basis, the use of video gaming and VR in children withevelopmental disabilities has not been identified in the lit-rature. Before recommending these gaming systems for usen clinical practice, it is important to determine the evidenceegarding feasibility and effectiveness. The purpose of thistudy was to demonstrate the feasibility, safety and effec-iveness of using a low-cost commercially available gamingystem in the rehabilitation of children with developmentalelay.

ethods

esign

Single-blind, randomised controlled trial.

articipants

In total, 40 children with developmental delay whottended a segregated or integrated preschool were recruitedrom two centres to participate in this study. The Committeeor the Protection of Human Subjects at Long Islandniversity, USA, approved this study. Children were eligible

o participate if they met the following inclusion criteria:1) age 3 to 5 years; (2) clinical diagnosis of developmentalelay; (3) documented physical impairments or motor delay;4) no musculoskeletal defects that might prevent abilityo use the Wii and grasp the Wii RemoteTM; (5) normal ororrected hearing and vision; (6) no previous experienceith the Wii; and (7) ability to understand and follow

imple directions and perform requested tasks. Childrenere excluded from this study if they had: (1) knownenetic/medical conditions; (2) a diagnosis of autism; (3)ttention deficit disorders; (4) orthopaedic surgery in the pastmonths prior to participation in the study; (5) uncontrolled

eizures; and (6) inability to follow instructions. Twoaediatric physical and occupational therapists working inhe two clinical sites (schools) preselected the children basedn the inclusion and exclusion criteria.

All children attended one of two clinical sites, werenrolled in a special education programme, and were stu-ents in segregated or integrated classrooms. Children areeferred to this programme because they have an establishedevelopmental delay. None of the children had a complexeurological condition. All children were able to ambulatend were receiving related services including physical andccupational therapy at each clinical site to address theirevelopmental delay.

Following the pre-intervention outcome assessment, thearticipants were randomly assigned to the experimentalroup (n = 20) or the control group (n = 20) by a staff member

rom each clinical site who did not participate in the study.he flow of participants through the study is illustrated inig. A (see supplementary online material).

otherap

A

sawcttisfitFsasra

T

teoltwtctw

T

odaaFt

S

bthtoea

F

tr‘tc

T

mt[tstt

T

oi[imTdj

G

tsohea

T

fcuaEii

Y. Salem et al. / Physi

ssessment

Data were collected at each of the participating clinicalites. Participants were evaluated 1 week before and 1 weekfter the training programme by the principal investigator,ho is a licensed physical therapist and paediatric certified

linical specialist with 17 years of experience working withhis population and using the outcome measures. The inves-igator was blinded to group allocation and was not involvedn the intervention. The primary outcome measures were gaitpeed, the timed up and go test, the single leg stance test, theve-times-sit-to-stand test, the timed up and down stairs test,

he 2-minute walk test and grip strength. The Gross Motorunction Measure (GMFM) was used to assess gross motorkills. These outcome measures were chosen because theyre common assessment tools used in clinical and researchettings, provide reliable performance data, and sample aange of the dimensions relevant to physical functioning andctivity limitations common to children.

en-metre walking test

The 10-m walking test is a simple test used to measurehe speed of walking. The test has good psychometric prop-rties [16], and has shown to be a valid and reliable measuref walking ability in children with and without neuromuscu-ar disability [17]. A 10-m level walkway was marked withape. One metre before the start and 1 m after the finish lineere allocated to allow for acceleration and deceleration of

he walk. Participants were instructed to walk two trials at aomfortable, normal pace. A stopwatch was used to recordhe time it took to walk the middle 10 m, and the two trialsere averaged.

he timed up and go test

The timed up and go test is a valid and reliable measuref balance in typically developing children and children withisabilities [18–21]. The participant was seated in a chair withrmrests and was instructed to get up from the chair, walk topoint 3 m away, turn around, walk back to the chair, and sit.ollowing one practice trial, each participant performed two

rials and the results of the two trials were averaged.

ingle leg stance test

The single leg stance test is a useful test for determiningalance impairments in higher functioning children [22]. Par-icipants were asked to stand on one leg with hands on theirips, and the total time that the participant was able to main-ain standing on one leg was recorded. Participants performed

ne practice trial, then the test was repeated three times forach leg and the average score of the three trials was used fornalysis.

ifIl

y 98 (2012) 189–195 191

ive-times-sit-to-stand test

The five-times-sit-to-stand test was used to measure abilityo perform transitional movements. The test is a valid andeliable measure of balance [23]. Participants were asked tostand up and sit down five times as quickly as you can’ withheir arms folded across their chests. The total time taken toomplete the test was recorded using a stopwatch.

imed up and down stairs test

The timed up and down stairs test is a test for functionalobility that has been demonstrated to be a reliable test for

ypically developing children and children with disabilities24]. The participant was asked to stand 20 cm from the bot-om of an 18-step staircase, and “quickly but safely go up thetairs, turn around on the top step and come all the way downo the bottom step”. The total time taken to walk up and downhe staircase was recorded using a stopwatch.

wo-minute walk test

The 2-minute walk test is a performance-based test devel-ped to measure the distance walked in 2 minutes as anndication of aerobic fitness and cardiopulmonary endurance25]. The 2-minute walk test is a valid test with excellentnter-rater and test–retest reliability [26]. At each site, the 2-

inute walk tests were performed in an enclosed corridor.he corridors were 20-m long, on level ground and free fromistractions. The starting point was clearly marked. The sub-ects were instructed to walk as far as they could in 2 minutes.

rip strength

Grip strength was measured using a hand-held dynamome-er. Handheld dynamometry has been used to measure griptrength of normal children and those with neurological dis-rders. The reliability of handheld dynamometer in childrenas been reported [27]. Participants performed three trials forach hand and the average of the three trials was used for datanalysis.

he Gross Motor Function Measure

The GMFM is a criterion-referenced measure designedor use by paediatric therapists to assess motor skills inhildren. It is a standardised assessment tool commonlysed to measure gross motor function skills and changes asresult of intervention in clinical and research settings [28].vidence of the validity and reliability of the GMFM for use

n children with motor disorders and children with disabil-ties has been established [28,29]. The GMFM-88 was used

n this study to provide information regarding gross motorunction and to assess changes as a result of the intervention.t consists of 88 items grouped in five dimensions: (A)ying and rolling; (B) sitting; (C) crawling and kneeling;

1 otherapy 98 (2012) 189–195

(sosmtpaa

I

wttdsbflmWgwswteas((cttt

Table 1Subjects’ demographic data (n = 40).

Characteristics Experimentalgroup (n = 20)

Control group(n = 20)

Age (months), mean(standard deviation)

49.3 (5.6) 48.0 (5.8)

Age (months), range 39 to 58 39 to 57Sex (male/female) 12/8 10/10Use of assistive devices 1 0Known complex neurological

problems0 0

PO

D

dlwaccfiSU

R

to(

TO

V

GTSFTTGGGG

G

92 Y. Salem et al. / Physi

D) standing; and (E) walking, running and jumping. Thecore for each dimension is presented as a percentagef the maximum score for that dimension, and the totalcore is obtained by averaging the percentage scores of theeasured dimensions. As all of the children participating in

he study were ambulatory and were high-functioning partici-ants, only Dimensions D (standing) and E (walking, runningnd jumping) were administered. The GMFM was used inccordance with the manual’s detailed guidelines [30–32].

ntervention

The training programme consisted of two 30-minuteeekly individual sessions over a period of 10 weeks. All

raining sessions were conducted in a physical/occupationalherapy room at each of the participating clinical sites. Chil-ren in the control group received traditional rehabilitationessions that focused on facilitation of movement transitions,alance, walking, and gross and fine motor control. Treatmentor control groups was individualised based on functionalimitations and abilities of the child. Children in the experi-

ental group participated in the Wii training using Nintendoii SportsTM and Nintendo Wii FitTM. The Wii training pro-

ramme focused on the children’s balance, walking, strength,eight bearing and aerobics. The training activities were

elected to challenge the participant’s balance, strength andalking. A personal profile was created for each child, and

he selection of games and activities were individualised forach child based on their interests, functional limitations andbilities. In each training session, the child played gamesuch as strength (Lunges and Single Leg Stance), balanceSoccer Heading, Penguin Slide and Tightrope) and aerobicsBasic Run, Hula Hoop and Basic Step). Each session was

oncluded by playing one of the following games based onhe interest of the child: Baseball, Boxing or Bowling. Eachraining session was supervised by a therapist from one ofhe clinical sites.

lte

able 2utcome measures at pre-intervention and post-intervention for the experimental g

ariables Pre-intervention (n = 40) Post-in

ExperimentalMean (SD)

Control Mean(SD)

ExperimMean (

ait speed (m/second) 0.83 (0.08) 0.83 (0.09) 0.91imed up and go test (seconds) 10.3 (1.7) 10.8 (1.9) 9.8 (ingle leg stance test (seconds) 2.7 (0.9) 2.7 (0.7) 4.1 (ive-times-sit-to-stand test (seconds) 16.2 (2.3) 16.6 (2.4) 15.1 (wo-minute walk test (m) 122.45 (15.92) 123.05 (18.77) 143.55imed up and down stairs test 28.8 (2.0) 27.7 (1.6) 26.8 (rip strength – right hand (kg) 3.34 (1.17) 3.33 (1.07) 5.18rip strength – left hand (kg) 3.27 (1.20) 3.20 (1.13) 4.75MFM Dimension D 80.15 (4.05) 77.95 (3.05) 87.31MFM Dimension E 77.08 (7.12) 75.63 (5.85) 82.08

MFM, Gross Motor Function Measure; CI, confidence interval; SD, standard deva Significantly different from control group.

hysical therapy services 20 20ccupational therapy services 20 20

ata analysis

Frequency distributions as well as means and standardeviations (SD) were used for descriptive purposes. At base-ine, differences in age and gender between the two groupsere analysed. Two-way repeated-measures analysis of vari-

nce for repeated measures on the time factor was used toompare the difference between groups (experimental andontrol) and timing (pre-intervention and post-intervention)or each studied outcome. The alpha level of statistical signif-cance was set at P < 0.05. Statistical Package for the Socialciences Version 19.0 (IBM Corporation, New York, NY,SA) was used for the analysis.

esults

In total, 40 subjects participated in this study. The age ofhe participants ranged from 39 to 58 months, with a mean agef 48.6 months (SD 5.7). There were 22 (55%) boys and 1845%) girls. Subject demographics are presented in Table 1.

No significant group differences were found at base-

ine in subject demographics (age and gender) or any ofhe variables measured. The Wii training was feasible andnjoyable for those in the experimental group. No adverse

roup and the control group.

tervention (n = 40) Mean difference(post-intervention)

95% CI P-value

entalSD)

Control Mean(SD)

(0.09) 0.87 (0.09) 0.04 0.02 to 0.10 0.1451.7) 10.24 (1.95) 0.5 1.66 to 0.68 0.3991.5) 3.1 (1.0) 1.03 0.2 to 1.9 0.017a

3.0) 14.8 (2.4) 0.3 1.5 to 2.1 0.723(18.40) 139.85 (20.71) 3.70 8.84 to 16.24 0.5542.0) 26.8 (2.7) 0.01 1.5 to 1.5 0.99(1.60) 4.07 (1.38) 1.11 0.15 to 2.06 0.024a

(1.46) 3.85 (1.26) 0.90 0.03 to 1.77 0.043a

(4.03) 85.13 (4.04) 2.18 0.40 to 4.76 0.096(7.15) 79.38 (6.76) 2.71 1.75 to 7.16 0.226

iation; CI, confidence interval.

otherap

eAfgfg(lAgsotg

D

sdaiiaWtstt

itsdovd

sastgppmt

nWbmpWt

pg

stciit

amlmaaafoabcTcistspvdptb

iiaTttsrshtie

itr

Y. Salem et al. / Physi

ffects or injuries were reported over 267 training sessions.ll variables were significantly improved in both groups

rom baseline to post-intervention. The raw data for theroups are shown in Table 2. Comparison of the groupsollowing the intervention indicated that the experimentalroup showed significant improvements in single leg stanceP = 0.017) and grip strength (right grip strength, P = 0.024;eft grip strength, P = 0.043) compared with the control group.lthough changes in the 10-m walking test, the timed up ando test, the five-times-sit-to-stand test, the timed up and downtairs test, the 2-minute walk test, and Dimensions D and Ef the GMFM were not significant between the study groups,here were trends towards greater gains in the experimentalroup compared with the control group.

iscussion

The results indicate that training with the Wii is feasible,afe and beneficial for young children with developmentalelay. The feasibility of the programme was supported bydequate recruitment and ease of implementation of the train-ng programme. Moreover, there were no adverse effects ornjuries reported over 267 training sessions. The feasibilitynd safety data are important given concerns that extensiveii training may result in musculoskeletal injuries [33], and

he young age of the participants. The guidance and supervi-ion by the therapists during training may have contributedo prevention of abnormal biomechanical alignments duringraining, and prevention of repetitive strain injuries.

The results indicate that Wii training yielded significantmprovements in some of the measured outcomes, and trendsowards improvements in all of the measures. These resultsuggest that this training strategy could benefit children withevelopmental delay. The results concur with the findingsf other studies which determined that VR training usingideo games is a useful rehabilitation tool for children withisabilities [2,5,7–10,12–14,34,35].

On comparing the pre-intervention and post-interventioncores, children in both groups improved their motor skillsnd motor performance over time. This finding should not beurprising given that the control group continued to receiveheir rehabilitation programme, and the participants in bothroups were young, high-functioning children who typicallyresent with mild disabilities. Changes from baseline toost-intervention seen in the control group may be due toaturation or participation in the physical therapy interven-

ion.The study findings indicated that training with the Wii sig-

ificantly improved single leg stance and grip strength. Theii training programme included activities that focused on

alance, and involved repetitive practice of activities that pro-

ote ability to stand on one foot. Moreover, the Wii training

rogramme involved constant grasp and manipulation of theii Remote in different directions and speeds when prac-

ising the training activities. These features of the training

cihv

y 98 (2012) 189–195 193

rogramme may explain the improvements in balance andrip strength observed in the experimental group.

Although changes in other outcome measures were notignificant between the study groups, there were trendsowards greater improvements in the experimental groupompared with the control group. It is possible that the train-ng programme did not provide participants with sufficientntensity. The modest sample size probably contributed tohe decrease in the significance of these measures.

The Wii training programme in this study provided massnd random real-time practice of balance tasks, a feature thatay explain improvements in the experimental group fol-

owing the intervention programme. The Wii games includeotor tasks that involve a wide range of sensory feedback;

djustable movement amplitudes, speed and precision levels;nd incorporation of a variety of visual–spatial, cognitive andttention tasks. The use of the Wii games involves augmentedorms of sensory feedback that allow participant detectionf posture and balance disturbances and corrections, thusllowing the participant to practice balance activities usingoth timely feedback control and feed-forward preparatoryontrol required to deal with different balance conditions.he interaction with the Wii games required rapid and pre-ise whole body movements in a standing position. Thisnteraction stimulates adjustment of movement amplitudes,peed and precision. These aspects are important to promoterunk stability and preparatory postural adjustments neces-ary for balance during functional activities [36]. The tasksractised during video games incorporate a wide range ofisual–perceptual processing, and cognitive and attentionemands [2,37]. Visual–perceptual, attention and cognitiverocesses promote balance by influencing anticipatory pos-ural control during voluntary movements and adjustment toalance perturbations [37,38].

Evidence suggests that high-intensity repetitive train-ng that focuses on goal-directed and task-specific practicemproves function and results in better outcomes [37]. Thispproach was incorporated with the Wii training programme.he use of Wii games in this study did provide real-time prac-

ice of dynamic, goal-directed task-specific activities similaro those the participants use during daily functional activitiesuch as standing, walking, standing on one leg, bending trunk,unning and jumping. Although the two groups received theame duration of treatment, the use of the Wii games allowedigh treatment intensity in terms of repetitions of selectedasks for the experimental group [2]. The intensity of train-ng and practice of goal-directed, task-oriented training mayxplain the improvements in the experimental group.

Lack of motivation and interest in treatment activities aredentified barriers to rehabilitation. Facilitating and main-aining a child’s motivation during treatment is an importantehabilitation strategy, and is most likely to improve the out-

ome of rehabilitation [39]. Several studies have reported thatnteracting with VR systems during rehabilitation involves aigh level of enjoyment and motivation [40–42]. The use ofideo games for children is part of the ‘natural play pattern’.

1 otherap

Tttsmi

L

tatctibctirtilstoiwwictvma

C

omdbsiuaageadtat

otppdeWabdtipsr

A

SlwaBt

EU0

FG

C

A

fj

R

94 Y. Salem et al. / Physi

he Wii training allowed the participants to actively engage inasks and movement activities that can be fun, enjoyable andherapeutic, with environmental conditions that encourageelf-initiated activity with natural restrains. These featuresay have contributed to the improvements seen in the exper-

mental group.

imitations and future research

The first limitation is related to the lack of blinding ofhe therapists supervising the training programme. Second,clear limitation of the study is that no attempt was made

o control for physical activity of the children outside thelinical site. Another limitation to this study was the facthat a true control group was not included. The participantsn the control group continued to receive their regular reha-ilitation programme during the duration of the study. Ashildren in the control group received traditional rehabilita-ion sessions, it is possible that the children in this groupmproved as a result of the intervention and this may haveesulted in lack of significance in many outcomes betweenhe control and experimental groups. Future studies shouldnclude a true control group to allow the evaluation of “abso-ute” effect of intervention. The modest sample size in thistudy may have reduced the statistical power and increasedhe risk of type II error. Finally, children with a mild degreef physical disability were included in this study, making itmpossible to generalise these training effects for childrenith more severe disabilities. This study focused on childrenith developmental delay, who typically present with mild

mpairments and physical limitations compared with otherhildren with different disabilities; further studies are neededo determine the effect of Wii intervention in children witharying degrees of disabilities. Further studies should deter-ine whether unsupervised use of the Wii at home is feasible

nd safe for children with disabilities.

linical relevance and conclusion

This study demonstrated the feasibility and effectivenessf a low-cost commercially available gaming system to aug-ent the rehabilitation of young children with developmental

elay. The results of this study lend support to the growingody of literature regarding the beneficial effects of gamingystems to augment the rehabilitation of children with disabil-ties. However, there is insufficient evidence to support these of gaming systems as a replacement for traditional ther-py. Clinicians should not consider using a gaming systems a replacement for a physical therapy programme; instead,aming systems should be used to increase the intensity ofxercises and to complement traditional exercises. The avail-bility of different games and the ability to modify the level of

ifficulty in those games suggest that clinicians would be ableo use games to target participants with diverse impairmentsnd functional abilities and to address various clinical objec-ives. This study provides baseline data on the effectiveness

y 98 (2012) 189–195

f a low-cost VR system and useful clinical information forherapists using VR as a treatment modality for the paediatricopulation. Integration of VR systems such as the Wii intoaediatric rehabilitation is appealing and motivating for chil-ren. In addition, children with motor disabilities typicallyxperience limited opportunity to engage in play. Use of theii provides children with the opportunity to participate in

n exercise programme that is fun, enjoyable, playful andeneficial to address their disabilities. Many children withevelopmental delay or disabilities do not have easy accesso rehabilitation centres, particularly in rural areas, makingt difficult to participate in rehabilitative programmes. Oneotential application of this low-cost commercially availableystem may include increasing intensity of therapy or as aehabilitation tool in children’s homes and rural settings.

cknowledgements

The authors wish to thank Barry Eckert, PhD, Dean,chool of Health Professions, Long Island University, Brook-

yn Campus for providing funding for this study. The authorsould also like to thank the participating therapists and

dministrators at ACE Integration Preschool and Headstart,rooklyn, NY for their cooperation and allowing participa-

ion at their sites.

thical approval: Institutional Review Board, Long Islandniversity, Brooklyn, NY, USA (Reference number: 09/06-80).

unding: Long Island University Worksite Wellness Instituterant.

onflict of interest: None declared.

ppendix A. Supplementary data

Supplementary data associated with this article can beound, in the online version, at http://dx.doi.org/10.1016/.physio.2012.06.003.

eferences

[1] Anderson F, Annett M, Bischof WF. Lean on Wii: physical rehabil-itation with virtual reality and Wii peripherals. Stud Health TechnolInform 2010;154:229–34.

[2] Deutsch JE, Borbely M, Filler J, Huhn K, Guarrera-Bowlby P. Useof a low-cost, commercially available gaming console (Wii) for reha-bilitation of an adolescent with cerebral palsy. Phys Ther 2008;88:1196–207.

[3] Yen C, Lin K, Hu M, Wu R, Lu T, Lin C. Effects of virtualreality-augmented balance training on sensory organization and atten-tional demand for postural control in people with Parkinson disease: a

randomized controlled trial. Phys Ther 2011;91:862–74.

[4] Teasell R, Meyer MJ, McClure A, Pan C, Murie-Fernandez M, FoleyN, et al. Stroke rehabilitation: an international perspective. Top StrokeRehabil 2009;16:44–56.

otherap

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[[

[

[

[

[

[

[

[

Y. Salem et al. / Physi

[5] Abdel-Rahman S. Efficacy of virtual reality-based therapy on balancein children with Down syndrome. WASJ 2010;10:254–61.

[6] Saposnik G, Mamdani M, Baley M, Thorpe KE, Hall J, Cohen LG,et al. Effectiveness of virtual reality exercises in stroke rehabilitation(EVREST): rationale, design, and protocol of a pilot randomized clin-ical trial assessing the Wii gaming system. Int J Stroke 2010;5:47–51.

[7] Shih CH, Shih CJ, Shih CT. Assisting people with multiple disabilitiesby actively keeping the head in an upright position with a Nintendo WiiRemote Controller through the control of an environmental stimulation.Res Dev Disabil 2011;32:2005–10.

[8] Shih CH, Shis CT, Chiung-Ling C. Assisting people with multiple dis-abilities actively correct abnormal standing posture with a NintendoWii Balance Board through controlling environmental stimulation. ResDev Disabil 2010;3:936–42.

[9] Shih CH, Yeh JC, Shih CT, Chang ML. Assisting children with atten-tion deficit hyperactivity disorder actively reduces limb hyperactivebehavior with a Nintendo Wii Remote Controller through controllingenvironmental stimulation. Res Dev Disabil 2011;32:1631–7.

10] Wuang Y, Chiang C, Su C, Wang C. Effectiveness of virtual realityusing Wii gaming technology in children with Down syndrome. ResDev Disabil 2011;32:312–21.

11] Wang M, Reid D. Virtual reality in pediatric neurorehabilitation:attention deficit hyperactivity disorder, autism and cerebral palsy. Neu-roepidemiology 2011;36:2–18.

12] Chen YP, Kang LJ, Chuang TY, Doong JL, Lee SJ, Tsai MW, et al. Useof virtual reality to improve upper-extremity control in children withcerebral palsy: single-subject design. Phys Ther 2007;87:1441–57.

13] Eisenzopt LL, Salem Y, Godwin EM. Use of gaming system for reha-bilitation of an adolescent with post-traumatic brain injury. Brain Inj2010;24:53.

14] Hurkmans HL, van den Berg-Emons RJ, Stam HJ. Energy expenditurein adults with cerebral palsy playing Wii Sports. Arch Phys Med Rehabil2010;91:1577–81.

15] Kirk MA, Rhodes RE. Motor skill interventions to improve fundamen-tal movement skills of preschoolers with developmental delay. AdaptPhys Activ Q 2011;28:210–32.

16] Boyd R, Fantone S, Rodda J, Olesch C, Starr R, Cullis E, et al. High-or low-technology measurements of energy expenditure in clinical gaitanalysis? Dev Med Child Neurol 1999;41:676–82.

17] Pirpiris M, Wilkinson AJ, Rodda J, Nguyen TC, Baker RJ, Nattrass GR,et al. Walking speed in children and young adults with neuromusculardisease: comparison between two assessment methods. J Pediatr Orthop2003;23:302–7.

18] Posiadlo D, Richardson S. The timed ‘up & go’: a test of basic functionalmobility for frail elderly persons. J Am Geriatr Soc 1991;39:142–8.

19] Habib Z, Westcott S. Assessment of anthropometric factors on balancetests in children. Pediatr Phys Ther 1998;10:101–9.

20] Habib Z, Westcott S, Valvano J. Assessment of balance abilitiesin Pakistani children: a cultural perspective. Pediatr Phys Ther1999;11:73–82.

21] William EN, Caroll SG, Reddihough DS, Phillips BA, Galea MP. Inves-tigation of the timed ‘up & go’ test in children. Dev Med Child Neurol2005;47:518–24.

22] Zumbrunn T, MacWilliams BA, Johnson BA. Evaluation of a single legstance balance test in children. Gait Posture 2011;34:174–7.

23] Whitney SL, Wrisley DM, Marchetti GF, Gee MA, Redfern MS, Fur-man JM. Clinical measurement of sit-to-stand performance in people

[

Available online at www.s

y 98 (2012) 189–195 195

with balance disorders: validity of data for the five-times-sit-to-standtest. Phys Ther 2005;85:1034–45.

24] Zaino CA, Marchese VG, Westcott SL. Timed up and down stairs: pre-liminary reliability and validity of a new measure of functional mobility.Pediat Phys Ther 2004;16:90–8.

25] Solway S, Brooks D, Lacasse Y, Thomas S. A qualitative systematicoverview of the measurement properties of functional walk tests usedin the cardiorespiratory domain. Chest 2001;119:256–70.

26] Finch E, Brooks D, Stratford PW, Mayo NE. Physical rehabilitationoutcome measures: a guide to enhanced clinical decision making. 2ndedn. Philadelphia, PA: Lippincott Williams and Wilkins; 2002.

27] Macfarlane TS, Larson CA, Stiller C. Lower extremity muscle strengthin 6- to 8- year-old children using hand-held dynamometry. PediatrPhys Ther 2008;20:128–36.

28] Russell DJ, Rosenbaum PL, Avery LM, Lane M. Gross motor functionmeasure (GMFM-66 & GMFM-88) user’s manual. 2nd edn. London:Mac Keith Press; 2002.

29] Russell DJ, Rosenbaum PL, Lane M, Gowland C, Goldsmith CH,Boyce WF, et al. Training users in the Gross Motor Function Measure:methodological and practical issues. Phys Ther 1994;74:630–6.

30] Bjornson KF, Graubert CS, McLaughlin JF, Kerfeld CI, Clark EM.Test–retest reliability of the gross motor function measure in childrenwith cerebral palsy. Phys Occup Ther Pediatr 1998;18:51–61.

31] Russell DJ, Avery LM, Rosendaum PL, Raina PS, Walter SD, PalisanoRJ. Improved scaling of the Gross Motor Function Measure for chil-dren with cerebral palsy: evidence of reliability and validity. Phys Ther2000;80:873–85.

32] Russell DJ, Rosendaum PL, Cadman D, Gowland C, Hardy S, JarvisS. The Gross Motor Function Measure: a means to evaluate the effectsof physical therapy. Dev Med Child Neurol 1989;21:341–52.

33] Eley KA. A Wii fracture. N Engl J Med 2010;362:473–4.34] You SH, Jang SH, Kim YH, Kwon YH, Barrow I, Hallett M. Cor-

tical reorganization induced by virtual reality therapy in a childwith hemiparetic cerebral palsy. Dev Med Child Neurol 2005;47:628–35.

35] Miller S, Reid D. Doing play: competency, control, and expression.Cyber Psychol Behav 2003;6:623–32.

36] Bouisset S, Do MC. Posture, dynamic stability, and voluntary move-ment. Neurophysiol Clin 2008;38:345–62.

37] Sztum T, Betker AL, Moussavi Z, Desai A, Goodman V. Effects of aninteractive computer game exercise regimen on balance impairment infrail community-dwelling older adults: a randomized controlled trial.Phys Ther 2011;91:1449–62.

38] Müller ML, Redfern MS, Jennings JR. Postural prioritization definesthe interaction between a reaction time task and postural perturbations.Exp Brain Res 2007;183:447–56.

39] Bartlett DJ, Palisano R. Physical therapists’ perceptions of factors influ-encing the acquisition of motor abilities of children with cerebral palsy:implications for clinical reasoning. Phys Ther 2002;82:237–48.

40] Graves LE, Ridgers ND, Williams K, Stratton G, Atkinson G, CableNT. The physiological costs and enjoyment of Wii fit in adolescents,young adults, and older adult. J Phys Act Health 2010;7:393–401.

41] Penko AL, Barkley JE. Motivation and physiologic responses of playing

a physically interactive video game relative to a sedentary alternativein children. Ann Behav Med 2010;39:162–9.

42] Rizzo AA, Kim GJ. A SWOT analysis of the field of VR rehabilitationand therapy. Presence-TeleopVirt 2005;14:119–46.

ciencedirect.com