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Clinical Kinesiology62(4); Winter, 2008 27

facilitates performance improvement. The Wii Fit

video game system has built in balance programs that

utilize bilateral stance in balance training activities. Itcannot be played using only one foot.

In contrast, DDR was created for dual foot

play, but with a simple rule change forcing

participants into single foot stance during play, thegame mimics other balance training exercises. The

researchers have been prescribing preventative and

rehabilitative exercises using DDR based balanceexercises for several years. With the recent consumer

market release of the Wii Fitvideo game system,this research project was designed to determine if the

use of either video game based balance programs

were as effective as previous research has shown

traditional balance programs to be.

METHODSStudy Design:The study was completed over a

5-week period. Pre and post test measurements

consisted of Star Excursion Balance Tests (SEBT)measurements and single leg force plate balancingdata obtained from an AMTI AccuSwayPLUSBalance

Platform (AMTI: Watertown, Mass.) and associated

Balance Clinic balance software. Participants were

randomly assigned an identification number andagain randomly assigned to one of four treatment

groups (control, n=7; traditional balance program, n =

5; DDR balance program, n = 7; Wii Fitbalanceprogram, n = 6). The participants were notified of

their treatment assignments following pre-testing

procedures. The traditional, DDR and Wii Fit

exercise groups participated in balance training

exercises three days a week for four weeks. Eachtraining session was conducted in such a manner to

provide between 12 to 15 minutes of actual balance

exercises per session, which is an approximate time

allocated during balance improvement programs. Thecontrol group only participated in the pre and port

testing sessions. All training sessions were conductedin the same room during pre-determined times. A

member of the research team supervised each training

session.

Participants: Upon approval by the institutional

review board for the testing of human participants,

twenty-eight individuals were recruited for the study.However due to extenuating circumstances only

twenty-five successfully completed the balance

training exercise requirements and post testing.Therefore, twenty-five participants, men (n = 12) and

women (n = 13) between the ages of 18 and 24 (m =

19.56, sd = 1.69), were included in the final studyand data analysis. Prior to testing all participants

participated in a face-to-face interview to evaluate

study inclusion criteria. Any participant with a

previously diagnosed condition inhibiting balance or

significant history of injury/surgery to their ankle was

disqualified from participation in the study.

Participants were not currently enrolled in a

structured strength or cardiovascular training

program and were not actively competitive athletes.Participants were encouraged to wear athletic apparel

during testing and training sessions.

Pre and Post Test Measurements: Pre-test andpost-test procedures preceded and followed 4 weeks

of balance training exercise. Measurements and

procedures used in testing were performed in the

same manner and sequence during both testingperiods.

Performance of the SEBT testing was completed

in the anteromedial, medial, and posteromedial

directions to reduce redundancy (4). The participantshad leg length measurements taken from the distal tip

of their medial malleolus to their anterior superior

iliac spine (ASIS). This measurement allowed fornormalization of the SEBT reach data between all

participants regardless of gender and height (3).

SEBT reach measurements were taken while

participants were balancing on their

preferred/dominant weight-bearing limb. Threerepetitions for each tested direction were obtained.

Fifteen seconds of rest time were allowed between

repetitions. The three values were averaged and

normalized for data analysis procedures. To ensureeach participant used their dominant weight bearing

leg throughout testing, researchers asked participants

which leg they would use if they had to jump formaximum height off of one foot. The preferred leg

was used throughout the study for pre and post

testing, as well as the training protocol. Allparticipants completed the SEBT testing proceduresprior to testing on the force plate.

Force plate testing consisted of two ten second

trials; one with eyes open and one with eyes closed.

Participants were instructed to stand on theirdominant weight bearing leg, place hands on their

hips, slightly flex opposite hip and knee. For the eyes

open trial the participants were asked to focus on adot, which was drawn on a dry erase board and

placed 65 cm away at eye level.

Exercise Protoco ls

Traditional Balance Program: The traditional

exercise protocol consisted of: 1) SEBT in eightdirections; 2) DynaDisc balance with eyes open; 3)DynaDisc balance with eyes closed; 4) DynaDisc

ball toss; 5) DynaDisc ORBITS. These activities

were selected because it was felt that they matchedthe various styles of exercise commonly used during

non-video based balance training programs. All

exercises were timed using a hand-help stopwatch so

that time actually spent performing the balance

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Figure 1. DynaDisc Single Leg ORBITS

exercises matched up with study design protocols.

Star excursion balance testing was done with the

participant balancing on the dominant weight bearingleg in the center of the eight-direction SEBT asterisk.

The participants held their hands on their hips and

reached out as far as they could with their non-dominant leg in each direction, gently touching their

toe on the ground. They would return to starting

position and immediately proceed to the nextsequential direction. This exercise was continued in

all eight directions in a clockwise manner for 90

seconds and repeated it for another 90 seconds in a

counterclockwise direction. Following the SEB

training, the participants were asked to balance on theDynaDisc for three minutes with their eyes open,

trying to avoid losing their balance. Ball tossing andcatching was added to open eyed DynaDisc

balancing for three minutes, followed by balance onthe DynaDisc for three minutes with eyes closed.

The final activity was three minutes of DynaDisc

Single Leg ORBITS (see Figure 1). This exercise wascreated by one of the investigators (TB) and

consisted of single-leg balance on the DynaDisc,

while simultaneously using the toes of the opposite

foot to move a tennis ball around their DynaDisc

platform in a fashion similar to the moon orbiting theearth. The participants were to use their non-

supportive leg to roll the tennis ball on the ground

around the DynaDisc as far as they could and thenreversing the pattern. Light toe touch of the non-

stance foot was allowed on the tennis ball in order to

maintain balance, but verbal motivation was given toencourage as light a touch as possible without loss of

balance. Exercises during the traditional program

were timed for a total of 12 minutes of actual

exercise. Participants had the option to rest in

between exercises, but this time was not counted intheir total exercise time.

Figure 2.Dance Dance Revolution

Dance Dance Revolution (DDR) Program:

Inclusion in the DDR exercise protocol, allowed

participants the opportunity to play DDR games

using one foot. The typical DDR pad consists of

four directional (anterior, posterior, medial, and

lateral) response arrows on the edges of a game mat.The game mat measures approximately 3 meters by 3

meters, with the center of the pad serving as a non-

responsive free zone. During play, the player mustrespond to a series of arrows pointing left, right, up,

or down continually scroll on the television screen,

by moving their non weight bearing foot andtouching the corresponding arrow on the game mat

with the arrow on the television screen. Typically the

game is performed using both feet, but the

researchers have begun using single leg stance play

as a way to focus on balance training (see Figure 2).During the balance training sessions the participants

were required to perform a single leg stance with one

foot in the middle of the pad and the hip and kneeslightly flexed while touching the direction arrows

with the heel or toes of the opposite foot for theduration of each song (approximately 90 seconds). If

the game presented the participants with a doublearrow they were advised to choose one direction and

continue play. The DDR training sessions consist of

game participation of three repetitions for each of

three pre determined songs. This format created nineperformance opportunities of approximately 90

seconds each, so that total balance training exercise

time was between 12 and 15 minutes. The difficulty

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Figure 3. Wii Fit

setting was pre-determined by the researchers and

was consistent for each participant throughout the

testing period regardless of ability.Wii Program: The Wii Fit exercise protocol

consisted of game play of selected balance training

exercises created by the Nintendo Corporation. TheWii Fit Balance Board was placed about 2 meters

from the television screen with ample space around

the board to prevent injury (see Figure 3). Each

session, the subjects were instructed to perform thesame three games on the balance board, each for a

minimum of 4 minutes and a maximum of 5 minutes

in an attempt to remain within the parameters of 12 to

15 minutes of actual balance training exercise.Members of the research time used hand held stop

watches to record actual activity time for each

participant to ensure accuracy and compliance.Three games were pre selected by the research

team and were used throughout the training period.

They consisted of Ski Slalom, Table Tilt, andBalanceBubble. In Ski Slalom, the subjects stood on the WiiFit Balance Board and weight shifted in medial and

lateral directions to facilitate navigation of a downhillskiing slalom course. Anterior and posterior postural

sway affected speed of the virtual skier. Table Tiltis

a virtual re-creation of the old childhood game wherea tabletop is tilted to assist in getting a ball to drop

through a hole in the table. By modifying their baseof support and center of pressure, the participants

were able to virtually tilt the table to complete the

game. The tilt of the table corresponded to the

movement of participants center of gravity in all

directions.Balance Bubblewas also a game based on

postural movement in both the frontal and sagittal

planes. The participants character was located in a

large bubble that floated on water. By using anterior

lean to propel the bubble and posterior sway to slowit, along with medial and lateral movement to steer

away from obstacles the object of the game was to

complete travel down a virtual river avoiding theriver edge during switchbacks and bends. In all game

play, participants were instructed to keep both feet on

the board at all times and to only use postural sway as

methods for game play control.

Qualitative Questionnaire

Following the post testing procedures a brief e-

mail survey was sent to each participant requesting

their feedback on the balance training exerciseprograms that they participated in. Each participant

was sent the following message:

Please reflect on the exercise activity you were

asked to perform during the 4-week training sessionand answer the following questions. Please use the

following numbers to explain your response: 1= Not

Very, 2= Mildly, 3=Somewhat, 4=Moderately,

5=Very

1) How difficult was your program?2) How engaged were you during yourprogram?

3) How enjoyable was your program?

RESULTS

Data was analyzed using Statistical Package for

Social Sciences (SPSS), Version 14. Paired sample t-

tests were performed to examine pre and post test

differences among individual measurements for allgroups. Statistical significance was found between

pre and post testing of Star Excursion Balance testing

of the traditional group in the anteromedial (p =0.004) and medial (p = 0.027) directions. The DDR

trained group showed significant improvement in the

average displacement from the force plate platform

center on the y-axis, as well as, the average deviationof the center of pressure (COP) from the y centroid of

the base of support (BOS) at (p = 0.028, p = 0.031)

respectively. Significant improvement was elicited

from the Wii Fit trained group at (p = 0.043) for

reducing the average deviation from the COP from

the y centroid of the BOS. The improvements for allthree groups were noticed only within the pre and

post testing trials performed with eyes open.

Analysis of Variance (ANOVA) tests were run

examining between group performance for each preand post testing measurement. Significant

improvement was noted between the groups during

the post test eyes open force plate trials for average

displacement from the force plate platform center on

the y-axis (p = 0.022) and the average deviation of

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Table 1. Descriptive Statistics for Qualitative Questionnaire

Group Question N Minimum Maximum Mean SD

Traditional Difficult 6 2 4 3.17 .753

Engaged 6 2 5 3.33 1.211

Enjoy 6 1 5 2.17 1.472

DDR Difficult 7 1 4 2.71 .951

Engaged 7 2 5 4.14 1.069

Enjoy 7 3 5 4.14 .690

Wii Fit Difficult 5 1 2 1.60 .548

Engaged 5 4 5 4.40 .548

Enjoy 5 4 5 4.40 .548

the COP from the y centroid of the BOS (p = 0.013)

Tukey post hoc evaluation determined the significantdifference was found between the traditional and

DDR trained groups for average displacement from

the center of the force plate platform with the DDRgroup showing significant improvement over the

traditional group (p = 0.029). With regard to theaverage deviation of the COP from the y centroid of

the BOS, it was noted that both the DDR and Wii

Fit balance trained groups showed significantimprovement over the traditional group (p = 0.014and p = 0.028) respectively.

Descriptive statistics for the qualitative portion

of the study can be found in Table 1. Analysis of the

responses to the qualitative survey questions educed

that the participants reported statistically significant

differences between the difficulty (p = 0.016) and

enjoyment (p= 0.003) of their programs. Post hocanalysis regarding difficulty detailed that the

traditional group felt that their exercise program wasbetween somewhatand moderately difficult, whereas

the Wii Fit group felt that their program wasbetween not very and mildly difficult. There was a

significant difference between perceived difficulty

with the traditional program being considered to be

more difficult than the Wii Fit, program (p =

0.014). Significance was approached when

comparing the perceived difficulty of the DDR

program to that of Wii Fit (p= 0.073) with Wii

Fitbeing the easier of the two games to play. Upon

evaluation of perceived enjoyment of the program,both video game based programs showed asignificant increase in amount of enjoyment over the

traditional program (DDR, p = 0.007, Wii Fit, p =0.006). Although the mean scores for both video

game based programs were higher than that of the

traditional program regarding engagement in the

program, no statistical significance was notedbetween the groups.

DISCUSSION

This research is the first to critically evaluate theefficacy of video game based balance training

programs. Previous research studies have shown that

balance programs have proven effective in improvingbalance measurements in a variety of settings (1, 2, 6,

7, 9, 10). This study does not disprove the results ofthose previous studies, but instead provides positive

evidence of efficacy for the clinician who chooses to

use video game based activities in their balancetraining programs.

During this study, traditional balance program

participation significantly improved two of the three

tested Star Excursion Balance activities from pre topost testing. It should be pointed out that these areas

of improvement were noted in activities that were

also used as a training exercise during the 4-week

training period. It is a distinct possibility that atraining effect occurred from these activities.

However, despite their effectiveness, traditional

balance programs often elicit patient compliancedifficulties. It is also important to note that in this

study the traditional balance program had the lowest

observed scores for patient engagement and

enjoyment. This confirms the suspicions andconcerns of previous researchers regarding the

compliance in traditional balance programs (2).

In addition to the improvements from the

traditional program exercises, statistical examination

of pre and post test performance measurements also

determined that both DDR and Wii Fit

balancetraining programs significantly reduced anterior and

posterior postural sway. DDR training reduced the

average deviation from the centroid of the data in the

y-axis, whereas both DDR and Wii Fit reduced

the average deviation of the COP from the y centroid

of the BOS. The improvement in reducing posturalsway in the sagittal plane was improved only through

the use of video game based balance exercises.

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Examination of qualitative perceptions regarding

the individual balance programs allowed the

researchers to discover that video game based

balance programs were apparently less difficult and

more engaging and enjoyable than the traditionalprogram exercises. It is unclear whether these

programs are actually easier, but it stands to reason

that this lower level of perceived difficulty leads toincreased enjoyment and therefore compliance.

Regardless of whether the video game based

programs are actually easier or whether the

performance improvements in the video game basedparticipants occurred due to the increased enjoyment

and attention; the fact remains that there was balance

performance improvement in the video game based

exercise groups. Consequently, based on both theobjective and subjective data of this study there is

scientific reason to include and use video game based

balance programs in clinical practice.

REFERENCES1. Chaiwanichsiri, D., Lorprayoon, E., &

Noomanoch, L. Star excursion balance training

Effects on ankle functional stability after ankle

sprain.J Med Assoc Thail Suppl 4:S90- 4, 1988.

2. Emery, C.A., Rose, m.S., McAllister, J.R., &Meeuwisse, W.H. A prevention strategy to

reduce the incidence of injury in high school

basketball: a cluster randomized controlled trial.Clin J Sport Med17(1):17-24, 2007.

3. Gribble, P.A., & Hertel, J. Considerations for

normalizing measures of the Star Excursion

Balance test. Measurement in Physical

Education and Exercise Science7(2):2003

4. Hertel, J., Braham, R.A., Hale, S.A., & Olmsted-

Kramer, L.C. Simplifying the Star Excursion

Balance Test: Analyses of subjects with andwithout chronic ankle instability. J Ortho Sports

Phys Ther36(3):2006.

5. Kidgell, D.J., Horvath, D.M., Jackson, B.M., &Seymour, P.J. Effect of six weeks of dura disc

and mini-trampoline balance training on postural

sway in athletes with functional ankle instability.J Strength Cond Res21(2):466-9, 2007.

6. McGuine, T.A., & Keen, J.S. The effects of abalance training program on the risk of ankle

sprains in high school athletes. Am J Sports Med

34(7):1103-11, 2006.7. McHugh, M.P., Tyler, T.F., Mirabella, M.R.,

Mullaney, M.J., & Nicholas, S.J. The

effectiveness of a balance training intervention in

reducing the incidence of noncontact anklesprains in high school football players. Am J

Sports Med35(8):1289-9, 2007.

8. McKeon, P.O. & Hertel, J. Systematic review of

postural control and lateral ankle instability, Part

2: is balance training clinically effective? J Athl

Train 43(3):3-5-315, 2008.

9. Verhagen, E, van der Beek, A., Twisk, J., Bahr,

R., & van Mechelen. W. The effect of a

proprioceptive balance board training programfor the prevention of ankle sprains: a prospective

controlled trial.Am J Sports Med32(6);1385-93,

2004.10. Yaggie, J.A. & Campbell, B.M. Effects of

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AUTHOR CORRESPONDENCE:

Kirk Brumels, PhD, ATCHope College - DeVos Fieldhouse

222 Fairbanks Ave

Holland, Michigan 49423616-395-7356 phone

616-395-7175 fax

[email protected]

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