Up to 75% of people with Parkinson’s disease (PD) have impaired postural control, which can often lead to postural instability and an increased risk of falls as a consequence [
An innovative approach to fitness training and rehabilitation is exergaming with active video games that combine body movement with gaming skill, in which players use body movements to control and play games in engaging virtual reality (VR) scenarios. An additional advantage of exergaming is that it can be performed independently at home with minimal equipment and at accessible cost. For example, the highly popular Nintendo Wii Fit and balance board is a VR fitness application that holds potential for use as an adjunct to sensory integration balance training (SIBT), one of the most effective ways to improve postural stability in PD [
VR-based telerehabilitation balance programs have been proven feasible and effective in several neurological conditions [
Four neurorehabilitation units [Neuromotor and Cognitive Rehabilitation Research Center (CRRNC) AOUI Verona, Azienda ULSS N. 1 Belluno, Azienda ULSS N. 9 Treviso, and Azienda ULSS N. 15 Alta Padovana, Cittadella] participated in this multisite, single-blind randomized controlled trial (RCT). The participating centers, all located in Veneto, deliver rehabilitation services in predominantly rural areas.
From December 2013 to December 2015, consecutive outpatients with medical diagnosis of PD confirmed according to the United Kingdom Parkinson’s Disease Society Brain Bank criteria [
The trial steering committee designed two treatment protocols. To ensure uniform delivery of treatment, one physiotherapist from each center received instruction in the TeleWii protocol, and one physiotherapist received instruction in the SIBT protocol [
A TeleWii-Lab comprising the Nintendo Wii console for motion controlled inputs, the Wii Fit gaming system, and balance board (Nintendo Co., Ltd., Kyoto, Japan) was set up at each rehabilitation unit [
Patients were instructed to exercise with TeleWii only when in the ON state. The physiotherapist gave a full explanation of the training protocol and conducted a trial TeleWii session at the hospital lab. A logbook was provided for reporting any issues with the Skype connection or difficulties with the training program. In-home TeleWii training consisted of 21 sessions of balance exercises of 50 minutes each. During each session, the physiotherapist supervised two patients simultaneously. A brief warm-up consisted of stretching exercises of the upper and lower extremities with self-applied gentle joint mobilization while lying supine on a mat. TeleWii training included the following 10 exergames selected by the physiotherapist according to the patient’s clinical condition and progressive improvement over time [
TeleWii balance training program.
Name of exercise | Exercise description | Expected impact on mobility |
---|---|---|
Table tilt | Shift the body weight in all directions with feet placed in a fixed position. Make a plan of movements to tilt the virtual platform, bring the balls in the holes and go to the next level of difficulty | Improve the correct use of ankle and hip strategy during static condition. Improve the quick change of strategy from ankle to hip and vice versa |
Penguin slide | Shift the body weight toward the right and left direction to bend the virtual ice platform, with feet placed in a fixed position. Make a plan of movements to catch as much fishes as possible | Improve the correct use of ankle and especially hip strategy during static condition |
Balance bubble | Shift the body weight forward to move the avatar forward; lean left and right to steer | Improve the correct use of ankle and hip strategy during static condition. Improve the quick change of strategy from ankle to hip and vice versa |
Ski slalom | Lean the body left and right to ski down a slalom course and pass between flags with your avatar | Improve the correct use of ankle and hip strategy during static condition. Improve the quick change of strategy from ankle to hip and vice versa. Improve the ability to orientate the trunk in the space |
Skateboarding | Push off the ground with right/left foot to skate forward with your avatar, and lean left or right to turn; if the speed slows down, lean toward one side to pick up speed; jump off the virtual ramps by raising heels to perform a trick in midair | Improve the correct use of ankle, hip, and stepping strategy during quasi-static condition. Improve the quick change of strategy from ankle to hip or stepping and vice versa. Improve the ability to orientate the trunk in the space |
Perfect 10 | Shake hips back, front left, or right to add up to the given number with your avatar. The aim is to make a sum of 10 | Improve the correct use of ankle and hip strategy during static condition. Improve the quick change of strategy from ankle to hip and vice versa. Improve the dual task performance (motor & cognitive task) |
Tilt city | Tilt the Wii remote to move the virtual board at the top of the screen. Shift your body weight left and right to tilt the virtual boards at the bottom. Make a plan of movements to drop the balls into the matching colored pipe | Improve the correct use of hip strategy during static condition. Improve the coordination between upper and lower limbs (dual motor task) |
Snowball fight | Shift your body weight right or left to move out your avatar from behind a protective barrier; use the Wii remote at the screen to throw snowballs; when throwing, watch out for incoming snowballs and avoid them by shifting your body weight | Improve the correct use of ankle and hip strategy during static condition. Improve the quick change of strategy from ankle to hip and vice versa. Improve the coordination between upper and lower limbs (dual motor task). Improve the attentional strategies to multiple stimuli |
Rhythm parade | Stepping in place to move your avatar and wave the controller when scrolling icons coming from the top of the screen hit the circles place at the bottom | Improve the correct use of all strategies during static condition. Improve the quick change of strategy from hip to stepping and vice versa. Improve the coordination between upper and lower limbs (dual motor task) |
Bird’s-eye bulls-eye | Stand on the board with feet placed in a fixed position. Flap the arms to land your avatar on the targets; lean in and flap to fly your avatar forward; stay centered on the board and flap to go higher with your avatar; shift the body weight right or left to turn; stop flapping to land your avatar on a target and to get a bonus; rack up bonus time and head for the finish; small flaps help hover; big flaps help to soar | Improve the correct use of ankle and hip strategy during static condition. Improve the quick change of strategy from ankle to hip and vice versa. Improve the coordination between upper and lower limbs, and between upper limbs (dual motor task) |
CoM, center of mass; CoP, center of pressure. The exercises are listed in order of task difficulty starting from single-task through dual-task performance.
In-clinic SIBT consisted of 21 sessions of balance and gait exercises lasting 50 minutes each. A brief warm-up session of stretching exercises was followed by static and dynamic balance exercises under different sensory conditions (free vision, blindfolded, wearing a visual-conflict dome, firm/compliant surfaces, and neck extensions) (Table
Sensory integration balance training program.
Type of exercise | Task explanation | Expected impact |
---|---|---|
Self-destabilization exercises (mainly feedforward) | ||
Static weight bearing | In stance with feet placed shoulder-width apart, transfer the body weight back and forth on the tips of the toes and the heels |
Improve correct use of ankle strategy during static condition. |
In stance with feet placed shoulder-width apart, transfer the body weight mediolaterally from the right to the left foot |
Improve correct use of ankle and hip strategy during static condition; improve quick change of strategy from ankle to hip and vice versa. | |
In stance with feet placed shoulder-width apart, transfer the body weight in all directions (i.e., drawing a cone with head) |
Improve correct use of ankle and hip strategy during static condition; improve quick change of strategy from ankle to hip and vice versa. | |
Trunk twist | Sitting in a chair without armrests, with feet placed shoulder-width apart on the floor, twist the torso as much as possible toward the right and the left |
Improve trunk mobility in sitting conditions. |
In stance with feet placed shoulder-width apart, twist the torso as much as possible toward the right and the left |
Improve trunk mobility in standing conditions. | |
Postural transfers | Sitting in a chair without armrests, with feet placed shoulder-width apart on the floor, sit-to-stand |
Improve correct use of ankle and hip strategy during postural transfers. |
Sitting in a chair without armrests, with feet placed shoulder-width apart on the floor, sit-to-stand while grasping a glass of water |
Improve correct use of ankle and hip strategy during postural transfers; improve coordination between upper and lower limbs (dual motor tasking). | |
Dynamic weight bearing | In stance with feet placed shoulder-width apart, step up and down in place, varying the height with each step while catching and throwing a ball |
Improve correct use of ankle, hip, and stepping strategy during static condition; improve quick change of strategy from ankle to hip (or stepping) and vice versa; improve coordination between upper and lower limbs (dual motor tasking). |
Front and side lunges |
Improve correct use of all strategies during dynamic condition; improve quick change of strategy from hip to stepping and vice versa. | |
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||
External destabilization exercises (mainly feedback) | ||
External perturbed | In stance with feet placed shoulder-width apart on the floor, recover balance after external perturbations by the PT to the patients’ chest/upper back/shoulders in anteroposterior and mediolateral directions |
Improve correct use of all strategies during quasi-static condition; improve quick change of strategy; improve proper reaction to unexpected postural destabilization in all directions. |
Unstable surfaces | In stance work on progressively thicker compliant surfaces (1.5, 3.5, and 8 cm) according to patient’s abilities |
Improve correct use of ankle, hip, and stepping strategy during static condition; improve quick change of strategy; improve ability to orientate the trunk in space. |
In an upright position, recover balance on a rigid, square-shaped wooden platform with a roller surface |
Improve correct use of ankle, hip, and stepping strategy during dynamic conditions; improve quick change of strategy, improve weight bearing ability and capacity to properly orientate the trunk in space. | |
Walking over progressively thicker compliant surfaces (1.5, 3.5, and 8 cm) according to patient’s |
Improve correct use of ankle, hip, and stepping strategy during dynamic conditions; improve quick change of strategy; improve weight bearing ability and capacity to properly orientate the trunk in space. | |
Swiss ball | Maintain balance while sitting on a Swiss ball, with feet placed shoulder-width apart; in the second part of the exercise, the patient alternatively raises the right and the left leg from the floor |
Improve trunk control, orientation, and stability. |
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||
Self-destabilization and external destabilization exercises (feedback and feedforward) | ||
Dual-task | Keep walking while catching and throwing a ball with the PT |
Improve correct use of all strategies during dynamic condition; improve quick change of strategy; improve proper reaction to unexpected postural destabilization in all directions. |
Keep walking while quickly changing direction (forward, backward, sideways) |
Improve correct use of all strategies during dynamic condition; improve quick change of strategy. | |
Keep walking while bouncing a ball and switching from right to left hand |
Improve correct use of all strategies during dynamic condition; improve quick change of strategy; improve proper reaction to unexpected postural destabilization in all directions. | |
Keep walking while increasing the amplitude of leg movements (increasing stride length) and swing movement of the arms |
Improve correct use of ankle, hip, and stepping strategy during dynamic conditions; improve quick change of strategy; improve coordination between upper and lower limbs (dual motor tasking). | |
Keep walking while paddling with a stick |
Improve correct use of ankle, hip, and stepping strategy during dynamic conditions; improve quick change of strategy; improve coordination between upper and lower limbs (dual motor tasking). |
CoM, center of mass; CoP, center of pressure; PT, physiotherapist; manipulation of sensory conditions:
During each session, the patients performed 10 exercises, at random: 4 self-destabilization, 4 external destabilization, and 2 combined self-destabilization and external destabilization exercises. Each exercise was repeated from 5 to 10 times for 5 minutes depending on the patient’s capabilities. Exercises were progressed by increasing the number of repetitions, the task difficulty (greater forward/sideward stepping distance, thicker compliant surface), and the duration of holding a given position. The PT gave verbal and manual instructions and, when necessary, provided support at the patient’s pelvis or chest [
At each study center, outcomes were assessed by a single examiner blinded to treatment assignment. Gait and balance measures were evaluated before treatment (T0), after treatment (T1), and at 1-month follow-up (T2). The test order was the same across all evaluation sessions as reported below. Measurements and interventions were conducted with the patients in the ON state.
The Berg Balance Scale (BBS) is a 14-item validated scale that evaluates static and dynamic balance dysfunctions (score range 0–56, with higher scores indicating better performance). The minimal detectable change (MDC) is 5 points for PD patients [
The Activities-Specific Balance Confidence (ABC) scale evaluates a patient’s perceived level of balance confidence in activities of daily living (score range 0–100, with higher scores indicating better performance) [
Satisfaction questionnaire items.
(1) My privacy was respected during my rehabilitation care. |
(2) The instructions my physiotherapist gave me were helpful. |
(3) All staff members were courteous. |
(4) The rehabilitation sessions were carried out on time without delays. |
(5) I was satisfied with the number and duration of treatment sessions. |
(6) The location of the facility was easily accessible. |
(7) My physiotherapist seemed to have a genuine interest in me as a person. |
(8) All staff members understood my problem or condition. |
(9) I was satisfied with the treatment provided by my physiotherapist. |
(10) I was satisfied with the outcomes of rehabilitative treatment. |
(11) I was satisfied with the modalities of rehabilitative treatment. |
(12) I believe that this type of treatment is adequate to improve my balance disturbances. |
(13) I was satisfied with the overall quality of my rehabilitation care. |
(14) I would repeat this treatment if I need rehabilitation care in the future. |
Responses were scored on a 5-point Likert-type scale from 1 “strongly agree” to 5 “strongly disagree.”
Patients were provided with logbook to record their feelings and any difficulties or adverse events they had experienced at each training session.
The direct cost categories included the cost of personnel for screening, assessments (before, after, and follow-up), treatments (one-session training and treatments), and resource utilization. Personnel costs (in euro) were calculated based on the amount of work an average worker performs in 1 hour (staff-hour approach) according to national standard rates. Costs for resource utilization (per type) were calculated taking into account a depreciation rate of 20% per year of the average market value. Indirect costs (utilities, facilities, etc.) were calculated as 25% of the direct costs according to the Italian manual for costing healthcare in public hospitals.
For sample size calculation, we estimated that 70 patients (35 per group) would provide 90% power (5% probability of type 1 error) to detect a difference pre- and posttreatment of 4.5 points (variance 33.64) on the BBS score (primary outcome) [
The principal investigator (NS) was responsible for randomization procedures. After screening, a list was generated using computer-generated random number tables (allocation ratio 1 : 1). Eligible patients were consecutively entered into the list and allocated to the TeleWii or the SIBT group.
The single imputation (simple mean) method was used to handle missing data. Descriptive statistics included means and standard deviation. The
One hundred and thirty-five patients were consecutively assessed to the neurorehabilitation centers. Twenty-six patients were excluded because they did not meet the inclusion criteria, 13 declined to participate in this study, and 20 had technological issue including the lack of Internet connection and motivation of using technology.
A total of 76 patients with idiopathic PD were randomized to the TeleWii (
Flow diagram.
There were no significant between-group differences in demographic and clinical data (Table
Baseline demographic and clinical characteristics.
Characteristic | TeleWii Group ( |
SIBT group ( |
Baseline comparison |
---|---|---|---|
Age (years) (mean ± SD) | 67.45 (7.18) | 69.84 (9.41) | 0.14 |
Gender (number of males/females) | 23/15 | 28/10 | 0.22 |
Disease duration (years) (mean ± SD) | 6.16 (3.81) | 7.47 (3.90) | 0.14 |
Dominant PD phenotype (NT/T/YO) | 21/12/5 | 14/15/9 | 0.24 |
More affected side (B/R/L) | 7/21/10 | 8/20/10 | 0.95 |
Modified H&Y stage median (Q1–Q3) | 2.50 (2.5–2.5) | 2.50 (2.5–3.0) | 0.76 |
UPDRS score (mean ± SD) | 44.13 (24.05) | 50.76 (24.12) | 0.15 |
Falls (number) (mean ± SD) | 0.58 (1.44) | 1.84 (5.29) | 0.24 |
MMSE score | 26.77 (1.48) | 28.64 (6.96) | 0.16 |
GDS score | 8.26 (5.17) | 9.79 (5.34) | 0.21 |
SD, standard deviation; PD, Parkinson’s disease; NT, nontremor dominant; T, tremor dominant; YO, younger onset; B, bilateral; R, right; L, left; Q1: lower quartiles in degrees; Q3: upper quartiles in degrees; H&Y, Hoehn and Yahr; UPDRS, Unified Parkinson’s Disease Rating Scale; Falls, number of falls in previous month; MMSE, Mini-Mental State Examination; GDS, Geriatric Depression Scale;
Significant between-group differences were found for BBS scores (
Descriptive and inferential statistics for clinical outcome measures.
Outcomes | Before T0 | After T1 | Follow-up T2 | Intervention phase | Repeated-measures ANOVA | Post hoc analysis | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Mean |
Mean |
Mean |
Between-group difference (95% CI) |
Group | Time | Time × group | Between-group differences | Within-group differences | |||||||||
TeleWii | SIBT | ||||||||||||||||
TeleWii | SIBT | TeleWii | SIBT | TeleWii | SIBT | After | FU |
|
|
|
After |
FU |
After |
FU |
After |
FU |
|
|
|||||||||||||||||
BBS |
48.63 |
45.61 |
52.37 |
49.82 |
51.84 |
49.66 |
2.54 |
2.18 |
0.0 |
<0.00 |
n.s. | 0.0 |
n.s | <0.00 |
0.00 |
<0.00 |
<0.00 |
|
|||||||||||||||||
ABC |
70.31 |
64.12 |
79.62 |
72.52 |
76.34 |
71.73 |
7.10 |
4.61 |
n.s. | <0.00 |
n.s. | n.s. | n.s. | <0.00 |
<0.00 |
<0.00 |
<0.00 |
10-MW |
1.59 |
1.46 |
1.62 |
1.60 |
1.57 |
1.52 |
0.35 |
0.04 |
n.s. | 0.0 |
n.s. | n.s. | n.s. | n.s | n.s. | 0.035 | n.s |
DGI | 20.39 |
19.34 |
21.24 |
21.18 |
21.32 |
21.05 |
0.53 |
0.26 |
n.s. | <0.00 |
0.0 |
n.s. | n.s. | 0.00 |
0.00 |
<0.00 |
<0.00 |
Falls |
0.58 |
1.84 |
0.38 |
0.61 |
0.29 |
0.81 |
−0.23 |
−0.52 |
n.s. | n.s | n.s | n.s. | n.s. | n.s. | 0.03 |
n.s. | n.s. |
PDQ-8 | 30.72 |
30.53 |
24.16 |
24.21 |
25,82 |
23.91 |
−0.05 |
1.90 |
n.s. | <0.00 |
n.s. | n.s. | n.s. | <0.00 |
0.0 |
0.01 |
0.00 |
Before: pretreatment; after: posttreatment; FU: one-month follow-up; SD: standard deviation; TeleWii: telerehabilitation using virtual reality-based training; SIBT sensory integration balance training;
There were no significant between-group differences in secondary outcomes. A significant “Time
There was no statistical significant difference in satisfaction rates between the TeleWii (mean score
The total cost of rehabilitation was €23.299,00 for the TeleWii group and €28.899,80 for the SIBT group. In both groups, the breakdown in total cost per patient was €24 for physiatrist screening and €28.20 for physiotherapy evaluation (posttreatment and follow-up). The initial physiotherapy evaluation cost is €56.40 because an additional session was required (the first part of the two-step procedure). The total treatment cost was €246.75 for the TeleWii group and €493.50 for the SIBT group. The equipment cost was €106.90 for the TeleWii group and €6.30 for the SIBT group. The indirect costs were €122.63 for the TeleWii group and €152.11 for the SIBT group. The total cost for rehabilitation for patient was € 383.55 for the TeleWii group and € 602. 1 for the SIBT group.
Two main findings emerged from this study. First, static and dynamic postural control was improved in the PD patients who had received in-home VR-based balance training (TeleWii), while improvements in mobility and dynamic balance were greater, on average, in those who had received in-clinic SIBT. However, the practical relevance of these differences was minimal. Second, comparable effects on perceived confidence in performing ambulatory activities, gait speed, fall frequency, and quality of life were achieved with both treatment modalities. In addition, the total cost of rehabilitation using TeleWii was lower than that of SIBT.
The Nintendo Wii Fit system has been proposed as a feasible and useful tool for balance training in people with PD [
Exergaming with Nintendo Wii has been shown to improve static and dynamic postural control in people with PD as evaluated on the BBS [
In both groups, the training effects may be ascribed to the improved use of different resources for postural stability and orientation [
Second, it is conceivable that Wii training led to improvements in sensory strategies (i.e., sensorimotor integration and reweighting). With progressive training, patients were able to rapidly reweight and select the more reliable sensory information to maintain their postural stability. Although postural instability may have multifactorial causes, it primarily results from impaired central integration [
Finally, VR-based exercise programs have been shown to elicit the integration of motor and cognitive abilities (i.e., attention, executive functions) and stimulate the brain’s reward circuitry [
SIBT was found to be more effective than TeleWii on the DGI, reaching a higher MCID score than TeleWii after training. This is particularly relevant, given that postural instability and falls [
TeleWii opens new opportunities for treating postural instability, giving individuals access of care from their home [
The strengths of the present study are the large patient sample and the comprehensive evaluation of balance disorders about different functions and domains. Its limitations are the lack of instrumental evaluation to assess balance performance, postural reactions, and changing muscle strength and lean body mass. Moreover, these findings cannot be generalized to PD patients with significant cognitive decline, because the use of TeleWii may be unsafe.
To conclude, as a part of the multifaceted management of motor symptoms in PD, TeleWii is a feasible and valid alternative to SIBT for reducing postural instability in PD patients at modified Hoehn and Yahr stages 2.5–3 and having caregiver assistance. TeleWii holds promise and potential to enrich rehabilitation care at home in people with PD but policy issues, especially reimbursement, need still to be addressed.
No commercial party has a direct financial interest in the results of the research supporting this manuscript. No organization has or will confer a benefit on the authors with which the authors are associated.
The authors declare no potential conflicts of interest regarding the research, authorship, and publication of this article.
The authors thank the patients, their family members, and caregivers for participating in this study. This work was supported by the grant of Ricerca Sanitaria Finalizzata Regionale 2010 [Grant no. 319/10].