Developmental Neurorehabilitation, 2012, 1–15, Early Online Wii-habilitation as balance therapy for children with acquired brain injury SANDY K. TATLA1, ANNA RADOMSKI2, JESSICA CHEUNG2, MELISSA MARON2, & TAL JARUS2 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 1 Acute Rehabilitation Team, Sunny Hill Health Centre for Children, 3644 Slocan Avenue, Vancouver, BC V5M 3E8, Canada and 2Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada (Received 12 October 2012; accepted 12 October 2012) Abstract Purpose: To evaluate the effectiveness of the Nintendo Wii compared to traditional balance therapy in improving balance, motivation, and functional ability in children undergoing acute rehabilitation after brain injury. Methods: A non-concurrent, randomized multiple baseline single-subject research design was used with three participants. Data were analyzed by visual inspection of trend lines. Results: Daily Wii balance training was equally motivating to traditional balance therapy for two participants and more motivating for one participant. While improvements in dynamic balance were observed, the results for static balance remain inconclusive. All participants demonstrated improvements in functional ability. Conclusion: Wii balance therapy is a safe, feasible, and motivating intervention for children undergoing acute rehabilitation after an acquired brain injury. Further research to examine the effectiveness of Wii balance therapy in this population is warranted. Keywords: Nintendo Wii, balance, brain injury, virtual reality, rehabilitation Introduction Acquired brain injury (ABI) is a leading cause of death and disability in children [1, 2]. With an estimated incidence of 1–300 per 100 000 children [2], this group remains the largest seen in pediatric inpatient settings [3]. After a severe brain injury, children can experience persistent and debilitating deficits impacting their physical, cognitive, and psycho-emotional functioning [4]. Children with ABI present with decreased balance performance when compared to age-matched controls, which can significantly impact their daily activities and participation [5]. Consequently, activities of daily living (ADLs), leisure pursuits, and physical activities such as walking, dancing, and playing team sports are affected in individuals with mild, moderate or severe brain injuries [4–9]. Therefore, balance is an area commonly targeted by rehabilitation professionals in ABI rehabilitation [5]. Motivation and attention are considered critical modulators of neuroplasticity, which is often experience dependent [10]. To harness plasticity and promote recovery, clinicians are left with the challenge of designing innovative and effective interventions [11]. Facilitating intensive practice in a client-centered manner requires a consideration of children’s preferences when designing rehabilitation interventions [12, 13]. Ultimately, clinicians must incorporate interventions that are motivating and salient for the child because lack of motivation can limit children from realizing their full functional potential [14]. Virtual reality (VR) has recently emerged as a promising intervention for rehabilitation in both children and adults with a diverse range of physical and cognitive impairments [15, 16]. VR presents artificially generated sensory information and is interactive, in that the user senses a virtually created environment, primarily through visual experiences and can kinesthetically control events on a monitor through manipulation of a device (e.g., the Nintendo Wii-mote) or motion detection through video Correspondence: S.K. Tatla, Acute Rehabilitation Team, Sunny Hill Health Centre for Children, 3644 Slocan Avenue, Vancouver, BC V5M 3E8, Canada. Tel: 604-453-8300. Fax: 604-453-8309. E-mail: statla2@cw.bc.ca ISSN 1751–8423 print/ISSN 1751–8431 online/12/000001–15 ! 2012 Informa UK Ltd. DOI: 10.3109/17518423.2012.740508 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 2 S. K. Tatla et al. capture (e.g., as in the GestureTek Interactive Rehabilitation Exercise System (IREX) or X-Box Kinect systems) [16]. VR has been described as an engaging rehabilitation intervention for children and youth, motivating them to repeatedly practice goal-directed tasks thereby potentially improving motor skill performance [17]. Over the past decade, the use of VR in populations such as traumatic brain injury (TBI), stroke, cerebral palsy (CP), Down Syndrome, and others with sensorimotor impairments has been investigated, demonstrating promising results [15, 17–20]. In the pediatric TBI population, enriched virtual environments have been shown to promote neural plasticity and improve functional outcomes [11]. In their systematic review, Snider and colleagues [21] reported positive outcomes from VR use in children with CP, including brain reorganization, motor capacity, visual–perceptual skills, social participation, and personal factors; however, these findings are limited by the poor methodological quality of studies. Overall, there was conflicting evidence for the effectiveness of VR interventions in improving outcomes at the International Classification of Functioning, Disability and Health (ICF) levels of body structures and functions in children with CP [21]. While research examining VR use for balance rehabilitation in children is also limited [16, 17, 21], two quasi-experimental studies in children with Down Syndrome have shown that Wii-Fit games were more effective in improving balance than traditional physiotherapy exercises [22] and occupational therapy [18]. In addition, outcomes of VR interventions were found to be equally successful when employed with adults within six months of a stroke compared to six months post-stroke [15]. These findings suggest that VR interventions incorporated in the acute rehabilitation phase for children with ABI may also offer positive results. In particular, the WiiFit and balance games can potentially be utilized as an innovative intervention with this population. Although VR-related research has been growing over the past decade, the literature has primarily focused on the investigation of highly specialized systems, such as the GestureTek IREX, designed specifically for rehabilitation [15]. Specialized systems offer benefits such as enhanced accessibility options promoting use among individuals with a range of abilities, the ability to track, and manipulate game variables, and isolate or target specific movements [17]. However, such systems can be costly and are less readily available to clinicians. With the availability and popularity of commercially available VR systems, such as the Nintendo Wii and X-Box Kinect, there is a need for research to further examine the role of these systems in neurological rehabilitation [15]. To date, no studies have evaluated the effectiveness of the Wii in children during acute rehabilitation following an ABI. The ICF provides a useful framework to categorize outcomes [23]. Accordingly, the aim of this study was to determine whether playing Wii balance games on a daily basis would improve outcomes measured at the ICF levels of body function (static balance), activity and participation (dynamic balance and functional abilities in self-care and mobility), and personal factors (motivation to participate in rehabilitation). We hypothesized that a daily 30-minute Wii balance intervention would result in improvements in: (1) balance as measured by the Timed Up and Go (TUG) test, the Modified Functional Reach Test (MFRT) and the Wii-Fit Balance Board; (2) motivation to participate in rehabilitation as measured by the Pediatric Motivation Scale (PMS); and (3) functional abilities as measured by the Pediatric Evaluation of Disability Index (PEDI). Methods Study design A non-concurrent, randomized multiple baseline across subjects’ single-subject research design (SSRD) was used for this study [24]. SSRDs are particularly appropriate designs for research applied to clinical settings because the low prevalence of the targeted population can be difficult to study with traditional group designs in which large samples are required to achieve statistical power [25]. In addition, SSRDs can be used to monitor, guide, and evaluate clinical practice at the individual level to produce preliminary evidence at the exploratory phase of intervention research [26]. Replication across at least three subjects and randomization are recommended to strengthen the findings of an SSRD. For a phase to qualify as an attempt to demonstrate an effect, the phase must have a minimum of three data points [24]. To control for the effects of history and maturation, a multiple baseline design was used with three different baseline lengths [24]. Each participant underwent (A) a baseline and (B) an intervention phase. Blinded assessment for primary outcomes was used, with a minimum of five data points collected for each phase of this study. Participants Ethical approval for this study was obtained through the local university and children’s hospital clinical research ethics boards. To meet the inclusion criteria, participants had to: (1) be current inpatients of 3 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Balance therapy for children with acquired brain injury the Acute Rehabilitation Program at the regional center; (2) be aged 5–18 years old; (3) be at a level I–II or VII–VIII on the Pediatric Rancho Los Amigos level of consciousness scale if less than 13 years old or older than 13 years old, respectively; (4) be able to safely stand for a duration of three minutes with support of a chair, walker, or rail if needed; and (5) display decreased balance as a result of an ABI, based on the primary clinician’s verbal report. Individuals were excluded if they had a seizure disorder that was not being medically managed, a visual impairment, or a known pre-existing balance condition. Researchers aimed to recruit four subjects to strengthen the study design. During the period of the study, seven subjects meeting the inclusion criteria were admitted to the inpatient unit; two subjects refused participation, and two subjects were to be discharged from hospital before study completion, therefore were excluded, resulting in three participants included in this study (Table I). All participants presented with impaired balance and required a gait aid for long distances. Participant one (P1) required a forearm-supported walker when walking short periods (i.e. 510 minutes) and a wheelchair when mobilizing beyond 10 minutes. Participant 2 (P2) and participant three (P3) ambulated with the assistance of a cane. Outcome measures Two primary outcomes were examined: (1) changes in dynamic and static balance; and (2) motivation levels during traditional and Wii sessions. The secondary outcome examined was functional ability. Balance (i) TUG test – The TUG test was used to assess dynamic functional balance and is suitable for populations aged three years or older [27]. During the TUG test, an individual is timed while they stand up from a chair, walk three meters, and return to sitting, after which an average time is calculated. A shorter time to complete the task indicates better functional mobility. The TUG test has been shown to have excellent inter-rater reliability with an intraclass correlation coefficient (ICC) of 0.99 and good test–retest reliability with an ICC of 0.83, indicating that it is responsive to change when used with children who have a disability [4]. The TUG test has excellent criterion validity (r ¼ 0.86–0.92) and adequate construct validity (r ¼ 0.55–0.66) [28]. (ii) MFRT – The MFRT was used to assess dynamic standing balance. Functional reach is determined by the maximum distance one can reach forward beyond arm’s length while maintaining a fixed base of support in the standing position [29]. Individuals complete three reaching tasks, in which the participants’ reach distance is measured to obtain a score while standing perpendicular, and while standing with their back to a wall, reaching to each side. Each reaching task is completed Table I. Participant characteristics. Participant’s age (years) and sex Protocol (days) Nature of injury Impairment Post-injury days 240 1. 14, Female BL: 5 Wii: 15 Motor vehicle accident resulting in traumatic brain injury (diffuse axonal injury) Right hemiparesis Left upper limb intention tremor Decreased memory Decreased balance Decreased mobility (requiring a walker for short distances and wheelchair for long distances) 2. 13, Male BL: 8 Wii: 12 Non-traumatic brain injury: intracranial subarachnoid hemorrhage and atrial ventricular malformation Left hemiparesis Left hemianopia Decreased cognition Decreased balance and Decreased mobility (requiring a gait aid when ambulating long distances) 97 3. 12, Male BL: 12 Wii: 8 Non-traumatic brain injury: hematoma and atrial ventricular malformation Left hemiparesis Decreased cognition Decreased balance Decreased mobility (requiring a gait aid when ambulating long distances) 94 Note: BL: baseline. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 4 S. K. Tatla et al. three times, resulting in a total of nine trials, and the average of these three trials is calculated. The MFRT has excellent test–retest reliability with an ICC of 0.95 and excellent inter-rater reliability with an ICC of 0.98 [29]. The MFRT is strongly correlated with the TUG test and its test items reflect skills of forward weight shifting and anticipatory control of balance [30]. Criterion validity for the MFRT is adequate (r ¼ 0.48–0.56) [31]. (iii) Nintendo Wii balance board – Static balance was determined by measuring center of pressure (COP) using the Wii balance board, a pressure sensitive board that measures the percentage of pressure contributed by the left and right sides of the user’s body. Visual feedback is provided on a monitor, which reflects changes in COP over the three seconds during which time the measurement is computed. To determine the participants’ score, the percentages were converted to a ratio between the two sides. Ideally, each side of the body will contribute 50% of the pressure exerted onto the board; thus, the perfect COP ratio is 50/50 or 1.00. The Wii balance board has been shown to be a valid and reliable assessment tool for both test–retest reliability and concurrent validity with a good to excellent ICC of 0.66–0.94 [32]. Motivation PMS – The PMS was created for this study to assess children’s motivation to participate in their rehabilitation. The scale consists of four questions that examine both the level of enjoyment and the child’s feelings of confidence in their rehabilitation using a visual analog scale consisting of five smiley faces, ranging from ‘‘did not enjoy at all’’ to ‘‘extremely enjoyed.’’ The reliability and validity of this instrument has not yet been tested. There is currently no valid outcome measure for evaluating motivation for rehabilitation therapy from the perspective of a child. Functional ability PEDI – Two subscales of the PEDI were used to evaluate each participant’s functional abilities [2]. The self-care and mobility domains of the Caregiver Assistance and Modification Scale described the participant’s functional capacity in ADLs and transfers as well as locomotion. This assessment provides an indication of the level of assistance the participant required in performing their ADLs and mobility, on a scale ranging from zero (dependent) to five (completely independent). The PEDI was standardized for typically developing children aged six months to seven and a halfyears and has also been validated for use in older children whose physical function is that of a seven and a half-year old or younger child. This measure is commonly used with children 1–19 years of age who have an ABI and are in an inpatient rehabilitation center [33]. Reliability studies of the PEDI have determined good inter-observer reliability [34]. Concurrent validity of the PEDI has been established with other pediatric functional measures such as the WeeFim and Gross Motor Function Measure [2, 33, 35]. Data collection Participants were randomly assigned to one of three protocols, each with varying baseline and intervention periods (Table I) over the four-week study. Thirty minutes of daily balance rehabilitation was provided over five consecutive days per week. The Wii balance training was introduced at different times, depending on the protocol randomly assigned to each participant. As each participant was undergoing acute rehabilitation, concurrent therapies were continued during the study; these included three one-hour sessions of speech and language therapy and recreation therapy and two one-hour sessions of aquatic therapy per week. Baseline: Traditional balance training During the baseline phase, the participants did not have access to the Wii balance board in their rehabilitation or leisure time. Participants completed their daily traditional balance rehabilitation program for 30 minutes per day with their physiotherapist and/or occupational therapist. Traditional balance activities were individualized based on each participant’s unique needs. Examples of activities included: throwing and catching balls/beanbags outside of their base of support, reaching for objects while standing or sitting on stable or unstable surfaces, side stepping, walking up and down stairs, single-leg stance, and kicking activities. During the baseline phase therapists recorded the types and duration of traditional balance rehabilitation activities in a daily logbook. Intervention: Wii-Fit balance training Participants engaged in Wii-Fit balance training 30 minutes per day with either a physiotherapist or occupational therapist; a list of approved Wii-Fit balance games, along with a description were provided (Table A.I). Therapists decided what level of game was most suitable for each client and Balance therapy for children with acquired brain injury gave each client a choice of which games they would prefer to play that day. In addition, the selection and duration of Wii-Fit games were recorded in a daily logbook by therapists. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Assessment Primary outcomes were assessed daily by blinded assessors during both the baseline and intervention phases of the study, while the secondary outcome was measured weekly; the assessors were unaware of each participant’s protocol and whether each participant was in the baseline or intervention phase. Balance was assessed daily, using the TUG, MFRT, and Wii balance board. Motivation to participate in balance rehabilitation was measured daily with the PMS, given to the participant to complete immediately following their therapy session for that day by the therapist providing the therapy. The PEDI was completed once per week by both the treating occupational therapist and physiotherapist to assess the participants’ function in the areas of mobility and self-care. Data analysis Data were analyzed using visual inspection of trend lines to determine if a basic effect occurred as a result of the Wii intervention. While traditional models of SSRD analysis apply linear methods for data analysis (e.g., two standard deviation band method), a non-linear mixed effects (NLME) modeling technique, which predicts the recovery trajectory of children with closed head injury, was used for analysis of balance outcomes [36, 37]. The NLME model represents the pattern of recovery in rehabilitation with a trajectory characterized by a slow phase representing early recovery, followed by rapid change, and then finally plateaus [38]. Participants in this study were functioning beyond the slow phase of the non-linear model, as they had emerged from a minimally conscious state. Therefore, the latter two phases of the non-linear model, represented by a logarithmic curve, were used as the line of best fit to reflect the recovery and change over time. The rapid recovery phase represents the initial time when neuroplasticity has its greatest potential. The plateau phase is appropriate, as a ceiling would be reached for the assessments used to measure the independent variables. Using this NLME method allows researchers to create individual trajectories and account for the differences in recovery stage in which data collection begins [36]. A logarithmic curve is produced based on the data points during the baseline interval, called the null model [36]. It is then forecasted forward until the end 5 of the intervention period. An alternative model is produced based on the data points of the intervention period [36]. A basic effect would occur if the final point of the alternative model exceeds that of the null model in the desired direction [36]. Trend lines were visually analyzed to determine if a basic effect occurred as a result of the Wii intervention. Motivation, measured by the PMS, was visually analyzed using the two standard deviation band method because motivation levels were expected to follow a linear trajectory. Statistical significance occurs if two or more consecutive points fall outside the bands [25]. Data for the PEDI was plotted on a graph for visual analysis of any progression in function over time as participants were assessed weekly on this measure, resulting in four data points. Findings All participants completed the study, adhered to the study protocols, and reported no adverse events. To meet the complex physical needs of P1, modifications to the testing protocol were made on the MFRT and TUG. Specifically, this participant used a four-wheeled forearm walker as an ambulation aid during the TUG assessment. For the MFRT right arm-reaching task, the distance reached was measured from the elbow rather than the fifth finger as this participant’s right extremity had significant contractures in the elbow and wrist joints. The raw and transformed data for all outcomes are graphically presented for each participant in Figures 1–5. Dynamic balance TUG: As illustrated in Figure 1, a basic effect during the Wii intervention was observed on the TUG for all participants, with the greatest decelerating slope seen in P2 and P3. Although a basic effect was achieved, the close overlap in trend lines suggests that the rate of improvement during the Wii intervention was not vastly different from the baseline phase, particularly in P1. MFRT: On the MFRT, P1 clearly demonstrated a basic effect on all three measurements during the intervention phase, with the alternative model exceeding the value of the null model (Figure 2a–c). P2 and P3 demonstrated a basic effect on MFRT measure taken while the subjects were positioned with their backs against the wall and reaching with their non-affected arm. However, the data for P2 and P3 demonstrated a high degree of variability and a decelerating slope during the intervention phase for the measurements taken with back to wall and the affected arm indicating a decline in function during S. K. Tatla et al. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 6 Figure 1. Visual representation of the TUG test for baseline and intervention phases for participants 1–3. Notes: The vertical line divides the graph into the baseline and intervention phases. The logarithmic curves represent the rate of change during each phase. A basic effect can be seen if the final point during the intervention phase exceeds that of the baseline phase in a downward direction. 7 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Balance therapy for children with acquired brain injury Figure 2. (a–c) Visual representation of the MFRT for baseline and intervention phases for participants 1–3. (a) Forward reach with unaffected arm, (b) side reach with unaffected arm, (c) side reach with affected arm. Notes: The vertical line divides the graphs into the baseline and intervention phases. The logarithmic curves represent the rate of change during each phase. A basic effect can be seen if the final point during the intervention phase exceeds that of the baseline phase in an upward direction, demonstrating greater reaching distance. S. K. Tatla et al. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 8 Figure 2. Continued. the Wii intervention. The largest effect on dynamic balance was seen in P1, who received the longest duration of intervention. Static balance COP: COP data was collected for P2 and P3 only (Figure 3), as the Wii balance board could not produce a COP reading for P1. Impairments, such as intention tremor and decreased coordination interfered with P1’s ability to step onto the balance board and remain still for the required three seconds to produce a response. Despite repeated attempts, a reliable reading could not be obtained for this participant. P2 and P3 approached COP ratios of 1.0 during the intervention phase, which Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Figure 2. Continued. Balance therapy for children with acquired brain injury 9 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 10 S. K. Tatla et al. Figure 3. Visual representation of COP measured by the Wii-Fit balance board for baseline and intervention phases for participants 2 and 3. Notes: The vertical line divides the graph into the baseline and intervention phases. The logarithmic curves represent the rate of change during each phase. A basic effect can be seen if the final point during the intervention phase exceeds that of the baseline phase in the desired direction, in this case reaching a COP ratio of 1.0 to demonstrate equal weight shifting. demonstrates a trend toward improved static balance. However, high variability affected the reliability of the trend line produced; therefore, the results for static balance are inconclusive. Functional ability PEDI: Results indicate that all participants improved in the self-care and mobility domains of the PEDI (Figure 5). However, the magnitude of change does not appear to correlate with the length of intervention. Motivation PMS: Motivation for therapy treatment remained high for all participants. There was a clear increase in motivation upon starting the Wii treatment for P1. Although motivation did not change significantly in P2 and P3, scores remained high and all participants verbally expressed enthusiasm toward Wii-habilitation. P1, with the longest intervention period experienced a change in motivation upon initiating Wii-habilitation (Figure 4). Discussion This pilot study is the first to examine the effect of an intensive Wii balance intervention in children during the acute phase of rehabilitation after an ABI. A rigorous SSRD methodology was employed with three participants, using a randomized, singleblinded, multiple baseline design in order to account for history and maturation effects. An innovative non-linear data analysis was used to measure changes in balance in order to account for the 11 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Balance therapy for children with acquired brain injury Figure 4. Visual representation of the PMS for baseline and intervention phases for participants 1–3. Notes: The vertical line divides the graph into the baseline and intervention phases. The solid horizontal lines indicate "2 standard deviations from the mean of the baseline data (dashed horizontal line). Statistically significant differences in motivation are present if at least two consecutive points fall outside of the 2 standard deviation bands. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 12 S. K. Tatla et al. Figure 5. Visual representation of the PEDI for baseline and intervention phases for participants 1–3. Notes: The vertical line divides the graph into the baseline and intervention phases. Visual analysis demonstrates a progression in self-care and mobility function over time. recovery patterns of this population. Results from our study support four major findings. First, our results demonstrate that participants complied with treatment protocols and that the Wii is a safe and feasible balance intervention that can be carried out daily with this population. Second, results support principles of motor learning, such as task specificity and repetitive task practice [39]. The principle of task specificity identifies the importance of improving motor skills through practicing tasks that are similar to those needing to be acquired [39]. Therefore, tasks practiced during rehabilitation should be specific to the desired outcome. Dynamic balance results showed a greater trend toward improvement and were less variable than static balance. As the Wii intervention primarily focused on and challenged the participants’ dynamic balance, this finding suggests that the improvement in dynamic balance is task specific and may not generalize to static balance. In addition, the participant who received the longest duration of intervention demonstrated the greatest improvement in dynamic balance. Thus suggesting that longer phases of Wii intervention provided an opportunity for additional task practice resulting in the greatest improvement. It is of note that P1, presenting with the most severe injury and complex sequellae, displayed the clearest improvement in dynamic balance in comparison to the other participants. It is possible that the effect of the Wii balance games on dynamic balance is dependent on the severity of impairment or the point in time during recovery that it is introduced. Further studies should explore this possible correlation and specifically examine the significance the impact of playing Wii balance games has on balance, depending on the severity of injury or phase of recovery. In addition, P1 had a TBI. Previous literature has concluded that children with non-TBIs often do not display as much improvement in their self-care abilities as children with TBIs, as measured by the Caregiver Assistance and Modification Scale [33]; thus, the improvement with P1 is consistent with those findings. Third, although the Wii balance board was a feasible tool for intervention, its appropriateness for assessment of static balance is questionable for this population given that it failed to produce a reading for one participant, and produced unreliable readings for the other two participants. Other measures of COP, such as force plates may be more sensitive for this population. Lastly, all participants reported high motivation levels throughout the Wii intervention confirming that the Wii is a motivating therapy; however, in two of the three participants, it did not appear to be significantly more motivating than traditional balance rehabilitation. This result is consistent with other literature exploring the Wii as a means of motivating therapy for people with neurological deficits [40, 41]. Nonetheless, there is currently no self-report pediatric assessment that assesses motivation to participate in therapy and it is possible that the scale created for this study is not a sensitive Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Balance therapy for children with acquired brain injury measurement of motivation, thus not able to differentiate level of motivation between the traditional and Wii balance rehabilitation periods. It is important for clinicians to use motivating interventions to engage children in therapy; a recent review of pediatric literature enforced that meaningful intervention that promotes participation in everyday pursuits of children is critical not only for physical and cognitive rehabilitation but also for building a sense of self-efficacy and personal confidence in one’s abilities [42]. A direction for future research would be to develop a tool that would be a valid measure of a child’s motivation to participate in their rehabilitation and one that would guide clinicians in creating motivational therapy for that child. Such a tool will allow future researchers to further explore the relationship of motivation levels with Wii interventions compared to traditional balance interventions in this population. Functional abilities in activities requiring balance were a secondary outcome measured in this study. As function most probably does not change on a dayto-day basis, it was impossible to measure it daily and therefore function was a secondary outcome in this study while recognizing that it is a primary goal of occupational therapy. All participants showed an upward trend in their functional abilities in both the domains of self-care and mobility. This indicates that the participants were becoming increasingly independent in their ability to care for their basic needs such as feeding, bathing, and toileting, as well as becoming more mobile and more able to transfer independently and safely between surfaces. 13 rate of falls and greater potential for participation in physical activities [5, 44], both of which are often primary goals of therapy. These findings have important clinical implications for use in rehabilitation settings as they show promise for Wii use with patients presenting with a range of physical and cognitive abilities and demonstrate that clinicians can use the Wii system as a tool in their treatment. Limitations This study had a number of limitations that cannot go without mention. The variability of the data suggests that the length of baseline and intervention phases may have been too short to demonstrate a basic effect. Although this study protocol adhered to, and exceeded, the guidelines of SSRD (i.e., minimum of three data points for each phase), extending this study beyond one month may result in greater stability. In addition, concurrent therapies, such as modification in ankle-foot orthoses may have affected the results. Furthermore, the heterogeneity of this sample, which is typical to this population, and the small sample size limit the generalizability of these results. According to the single-case design technical guide [24] experimental control is demonstrated when the design documents three demonstrations of the experimental effect across three cases, which did not occur in this study. Rather, amongst the three participants in this study, only one of the three participants demonstrated such an effect. Furthermore, motivation findings using the PMS are limited by the lack of psychometric testing of this measure. Clinical implications Findings from a recent scoping review reveal a need for researchers to evaluate the active ingredients of technology-based interventions, specifically in the areas of system or game properties, intervention effects on the user, and the role of the therapist [43]. This study demonstrated that children were motivated and able to achieve the desired intensity of daily practice. Therapists were able to mediate the motor learning process by offering verbal feedback and manual assistance and guidance with positioning while participants were involved in the virtual rehabilitation. Thus, participants engaged in motor learning while using this complex interactive technology. The system parameters of the Wii and of the games used in this study enabled therapists to provide guidance to clients during balance therapy and for clients to use a walker or other mobility aid while standing on the balance board. In addition, all participants demonstrated improvements in dynamic balance. Previous research has found that an increase in dynamic balance means a decreased Conclusion While balance deficits are a common sequellae of ABI [4], therapists treating individuals with ABI do not have sufficient evidence to guide clinical decision-making and inform evidence-based balance interventions [45, 46]. This study contributes to the evidence by demonstrating that the Wii is a safe and motivating therapy that can be carried out daily in children with ABI during acute rehabilitation. Despite multiple impairments, the participants were able to engage in the Wii intervention and demonstrated improvement of dynamic balance. Although these preliminary results offer some promise, future research across a larger sample is needed to determine if Wii balance intervention results in significant improvement when compared to traditional therapy. In addition, further research is required to evaluate optimal duration and frequency of Wii intervention and the impact of type and severity of injury on balance outcomes. 14 S. K. Tatla et al. Key points Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. . Daily Wii balance intervention with children is safe and feasible within the acute rehabilitation phase after ABI. . While there was a greater trend toward improvement in dynamic balance during Wii intervention, a basic effect was only demonstrated in one of three participants. . The Wii intervention was motivating for all participants. . Further research exploring the effectiveness of Wii balance training in this population is warranted. Acknowledgements The authors wish to sincerely thank the participants and their families for their support and commitment in this study. The authors would also like to acknowledge Sunny Hill Health Centre for Children for providing the equipment and facilities for this study and thank the clinicians who participated in the delivery of the intervention with all participants. The authors also wish to thank Dr Bruno Zumbo for his assistance with statistical analysis. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. Sandy Tatla is supported by funding from the Child and Family Research Institute. References 1. Canadian Institute for Health Information. The burden of neurological diseases, disorders and injuries in Canada. Ottawa: CIHI; 2007. Available from http://www.cihi.ca. Accessed 8 July 2012. 2. Hawley CA, Ward AB, Long J, Owen DW, Magnay AR. Prevalence of traumatic brain injury amongst children admitted to hospital in one health district: A population based study. Injury 2003;34:256–260, Epub 2003/04/02. 3. 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Patterns of participation in recreational, leisure activities among children with complex physical disabilities. Developmental Medicine & Child Neurology 2006;48:337–342. 13. Harris K, Reid D. The influence of virtual reality play on children’s motivation. Canadian Journal of Occupational Therapy 2005;72:9–21. 14. Jennings KD, Connors RE, Stegman CE. Does a physical handicap alter the development of mastery motivation during the preschool years? Journal of the American Academy of Child & Adolescent Psychiatry 1988;27:312–317. 15. Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews 2011;(9): Art. no. CD008349. DOI: 10.1002/14651858.CD008349.pub2. 16. Laufer Y, Weiss PL. Virtual reality in the assessment and treatment of children with motor impairment: A systematic review. Journal of Physical Therapy Education 2011;25: 59–71. 17. Levac DE, Galvin J. Facilitating clinical decision-making about the use of virtual reality within paediatric motor rehabilitation: Application of a classification framework. Developmental Neurorehabilitation 2011;14:177–184, Epub 2011/05/10. 18. Wuang YP, Chiang CS, Su CY, Wang CC. Effectiveness of virtual reality using Wii gaming technology in children with down syndrome. Research in Developmental Disabilities 2011;32:312–321. 19. Saposnik G, Teasell R, Mamdani M, Hall J, McIlroy W, Cheung D, Thorpe KE, Cohen LG, Bayley M. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: A pilot randomized clinical trial and proof of principle. Stroke 2010;41:1477–1484, Epub 2010/05/29. 20. Sandlund M, McDonough S, Hager-Ross C. Interactive computer play in rehabilitation of children with sensorimotor disorders: A systematic review. Developmental Medicine & Child Neurology 2009;51:173–179. 21. Snider L, Majnemer A, Darsaklis V. Virtual reality as a therapeutic modality for children with cerebral palsy. Developmental Neurorehabilitation 2010;13:120–128, Epub 2010/03/13. 22. Abdel R. Efficacy of virtual reality-based therapy on balance in children with down syndrome. World Applied Sciences Journal 2010;10:254–261. 23. WHO. 2001. International Classification of Function, Disability and Health. World Health Organization. Balance therapy for children with acquired brain injury 24. 25. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. Available from http://www.who.int/classifications/icf/en/. Accessed 12 August 2012. Kratochwill TR, Hitchcock J, Horner RH, Levin JR, Odom SL, Rindskopf DM, Shadish WR. Single-case design technical documentation, Version 1 (Pilot). What Works Clearinghouse; 2010. Available from http://ies.ed.gov/ncee/ wwc/documentsum.aspx?sid=229 Logan L, Hickman R, Harris S, Heriza C. Single-subject research design: Recommendation for levels of evidence: Quality rating. Developmental Medicine & Child Neurology 2008;50:99–103. Seel RT, Dijkers MP, Johnston MV. Developing and using evidence to improve rehabilitation practice. Archives of Physical Medicine and Rehabilitation 2012;93:S97-S100. Available from http://dx.doi.org/10.1016/j.apmr. 2012.04.008. Accessed 05 October 2012. Williams E, Carroll S, Reddihough D, Phillips B, Galea M. Investigation of the ‘‘timed up & go’’ test in children. Developmental Medicine & Child Neurology 2005; 47:518–524. Flansbjer U, Holmback A, Downham D, Patten C, Lexell J. Reliability of gait performance tests in men and women with hemiparesis after stroke. Journal of Rehabilitation Medicine 2005;37:75–82. Gan S, Tung L, Tang Y, Wang C. Psychometric properties of functional balance assessment in children with cerebral palsy. Neurorehabilitation and Neural Repair 2008;22:745–753. Betker A, Sztrum T, Moussavi Z, Nett C. Video game-based exercises for balance rehabilitation: A single-subject design. Archives of Physical Medicine and Rehabilitation 2006;87:1141–1149. Katz-Leurer M, Fisher I, Neeb M, Schwartz I, Carmeli E. Reliability, validity of the modified functional reach test at the sub-acute stage post-stroke. Disability & Rehabilitation 2009;31:243–248. Clark RA, Bryant AL, Pua Y, McCrory P, Bennell K, Hunt M. Validity and reliability of the Nintendo Wii Balance Board for assessment of standing balance. Gait and Posture 2010;31:307–310. Tokan GHS, Gill-Body K, Dumas H. Item-specific functional recovery in children and youth with acquired brain injury. Pediatric Physical Therapy 2003;15:16–22. Nichols DCS. Reliability and validity of the pediatric evaluation of disability inventory. Journal of Pediatric Physical Therapy 1996;8:15–24. Ziviani J, Ottenbacher K, Shephard K, Foreman S, Astbury W, Ireland P. Concurrent validity of the Functional Independence Measure for Children (WeeFIM) and the Pediatric Evaluation of Disabilities Inventory in children 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 15 with developmental disabilities and acquired brain injuries. Occupational Therapy in Pediatrics 2002;21:91–101. Forsyth R, Thuy V, Salorio C, Christensen J, Holford N. Review: Efficient rehabilitation trial designs using disease progress modeling: A pediatric traumatic brain injury example. Neurorehabilitation and Neural Repair 2010;24: 225–234, Epub 2009/12/05. Chu B, Millis S, Arango-Lasprilla J, Novack T, Hart T. Measuring recovery in new learning and memory following traumatic brain injury: A mixed-effects modeling approach. Journal of Clinical and Experimental Neuropsychology 2007;29:617–625. Forsyth R, Salorio C, Christensen J. Modelling early recovery patterns after paediatric traumatic brain injury. Archives of Disease in Childhood 2009;95:266–270. Lee T, Schmidt R. Motor control and learning: A behavioural emphasis, 4th ed. Champaign, IL: Human Kinetics; 2005. pp 301–432. Halton J. Rehabilitation with the Nintendo Wii: Experiences at a rehabilitation hospital. Occupational Therapy Now 2010;23:11–14. Gil-Gomez J, Llorens R, Alcaniz M, Colomer C. Effectiveness of a Wii balance board-based system for balance rehabilitation: A pilot randomized clinical trial in patients with acquired brain injury. Journal of NeuroEngineering and Rehabilitation 2011;8:1–9. Available from http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3120756/10.1186/ 1743-0003-8-30. Accessed 03 April 2012. Bendixon R, Krieder C. Review of occupational therapy research in the practice area of children and youth. American Journal of Occupational Therapy 2011;65:351–359. Levac D, Rivard L, Missiuna C. Defining the active ingredients of interactive computer play interventions for children with neuromotor impairments: A scoping review. Research in Developmental Disabilities 2012;33:214–223, Epub 2011/11/19. Katz-Leurer M, Rotem H, Lewitus H, Keren O, Meyer S. Relationship between balance abilities and gait characteristics in children with post-traumatic brain injury. Brain Injury 2008;22:153–159. Levac D, DeMatteo C. Bridging the gap between theory and practice: Dynamic systems theory as a framework for understanding and promoting recovery of function in children and youth with acquired brain injuries. Physiotherapy Theory and Practice 2009;25(8):544–554, Epub 2009/11/21. Bland DC, Zampieri C, Damiano DL. Effectiveness of physical therapy for improving gait and balance in individuals with traumatic brain injury: A systematic review. Brain Injury 2011;25(7–8):664–679, Epub 2011/05/13. Appendix Table A.I. Wii-Fit games. Games Soccer heading Ski jump Ski slalom Snowboard slalom Table tilt Tightrope walk Balance bubble Penguin slide Lotus focus Description and movements required Lateral weight shifting over wide base of support on balance board to head the balls on the screen Squat with knees bent on balance board until approaching the jump, then extend, and maintain position Anterior, posterior, and lateral weight shifting to pass between the flags with feet parallel on the balance board Anterior and posterior weight shifting to pass between the flags with one foot in front of the other on the balance board Weight shifting left, right, forward, and back to tilt the balls into the holes Walk on the spot on the balance board to move the character across the tightrope on the screen Guide the character down the river by shifting body weight left, right, front, and back Lateral weight shifting to both left and right to tilt the iceberg, combined with squat and rising up to feed the penguin Sit on the balance board with legs folded. If that is difficult, sit with legs unfolded 

Developmental Neurorehabilitation, 2012, 1–15, Early Online Wii-habilitation as balance therapy for children with acquired brain injury SANDY K. TATLA1, ANNA RADOMSKI2, JESSICA CHEUNG2, MELISSA MARON2, & TAL JARUS2 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 1 Acute Rehabilitation Team, Sunny Hill Health Centre for Children, 3644 Slocan Avenue, Vancouver, BC V5M 3E8, Canada and 2Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada (Received 12 October 2012; accepted 12 October 2012) Abstract Purpose: To evaluate the effectiveness of the Nintendo Wii compared to traditional balance therapy in improving balance, motivation, and functional ability in children undergoing acute rehabilitation after brain injury. Methods: A non-concurrent, randomized multiple baseline single-subject research design was used with three participants. Data were analyzed by visual inspection of trend lines. Results: Daily Wii balance training was equally motivating to traditional balance therapy for two participants and more motivating for one participant. While improvements in dynamic balance were observed, the results for static balance remain inconclusive. All participants demonstrated improvements in functional ability. Conclusion: Wii balance therapy is a safe, feasible, and motivating intervention for children undergoing acute rehabilitation after an acquired brain injury. Further research to examine the effectiveness of Wii balance therapy in this population is warranted. Keywords: Nintendo Wii, balance, brain injury, virtual reality, rehabilitation Introduction Acquired brain injury (ABI) is a leading cause of death and disability in children [1, 2]. With an estimated incidence of 1–300 per 100 000 children [2], this group remains the largest seen in pediatric inpatient settings [3]. After a severe brain injury, children can experience persistent and debilitating deficits impacting their physical, cognitive, and psycho-emotional functioning [4]. Children with ABI present with decreased balance performance when compared to age-matched controls, which can significantly impact their daily activities and participation [5]. Consequently, activities of daily living (ADLs), leisure pursuits, and physical activities such as walking, dancing, and playing team sports are affected in individuals with mild, moderate or severe brain injuries [4–9]. Therefore, balance is an area commonly targeted by rehabilitation professionals in ABI rehabilitation [5]. Motivation and attention are considered critical modulators of neuroplasticity, which is often experience dependent [10]. To harness plasticity and promote recovery, clinicians are left with the challenge of designing innovative and effective interventions [11]. Facilitating intensive practice in a client-centered manner requires a consideration of children’s preferences when designing rehabilitation interventions [12, 13]. Ultimately, clinicians must incorporate interventions that are motivating and salient for the child because lack of motivation can limit children from realizing their full functional potential [14]. Virtual reality (VR) has recently emerged as a promising intervention for rehabilitation in both children and adults with a diverse range of physical and cognitive impairments [15, 16]. VR presents artificially generated sensory information and is interactive, in that the user senses a virtually created environment, primarily through visual experiences and can kinesthetically control events on a monitor through manipulation of a device (e.g., the Nintendo Wii-mote) or motion detection through video Correspondence: S.K. Tatla, Acute Rehabilitation Team, Sunny Hill Health Centre for Children, 3644 Slocan Avenue, Vancouver, BC V5M 3E8, Canada. Tel: 604-453-8300. Fax: 604-453-8309. E-mail: statla2@cw.bc.ca ISSN 1751–8423 print/ISSN 1751–8431 online/12/000001–15 ! 2012 Informa UK Ltd. DOI: 10.3109/17518423.2012.740508 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 2 S. K. Tatla et al. capture (e.g., as in the GestureTek Interactive Rehabilitation Exercise System (IREX) or X-Box Kinect systems) [16]. VR has been described as an engaging rehabilitation intervention for children and youth, motivating them to repeatedly practice goal-directed tasks thereby potentially improving motor skill performance [17]. Over the past decade, the use of VR in populations such as traumatic brain injury (TBI), stroke, cerebral palsy (CP), Down Syndrome, and others with sensorimotor impairments has been investigated, demonstrating promising results [15, 17–20]. In the pediatric TBI population, enriched virtual environments have been shown to promote neural plasticity and improve functional outcomes [11]. In their systematic review, Snider and colleagues [21] reported positive outcomes from VR use in children with CP, including brain reorganization, motor capacity, visual–perceptual skills, social participation, and personal factors; however, these findings are limited by the poor methodological quality of studies. Overall, there was conflicting evidence for the effectiveness of VR interventions in improving outcomes at the International Classification of Functioning, Disability and Health (ICF) levels of body structures and functions in children with CP [21]. While research examining VR use for balance rehabilitation in children is also limited [16, 17, 21], two quasi-experimental studies in children with Down Syndrome have shown that Wii-Fit games were more effective in improving balance than traditional physiotherapy exercises [22] and occupational therapy [18]. In addition, outcomes of VR interventions were found to be equally successful when employed with adults within six months of a stroke compared to six months post-stroke [15]. These findings suggest that VR interventions incorporated in the acute rehabilitation phase for children with ABI may also offer positive results. In particular, the WiiFit and balance games can potentially be utilized as an innovative intervention with this population. Although VR-related research has been growing over the past decade, the literature has primarily focused on the investigation of highly specialized systems, such as the GestureTek IREX, designed specifically for rehabilitation [15]. Specialized systems offer benefits such as enhanced accessibility options promoting use among individuals with a range of abilities, the ability to track, and manipulate game variables, and isolate or target specific movements [17]. However, such systems can be costly and are less readily available to clinicians. With the availability and popularity of commercially available VR systems, such as the Nintendo Wii and X-Box Kinect, there is a need for research to further examine the role of these systems in neurological rehabilitation [15]. To date, no studies have evaluated the effectiveness of the Wii in children during acute rehabilitation following an ABI. The ICF provides a useful framework to categorize outcomes [23]. Accordingly, the aim of this study was to determine whether playing Wii balance games on a daily basis would improve outcomes measured at the ICF levels of body function (static balance), activity and participation (dynamic balance and functional abilities in self-care and mobility), and personal factors (motivation to participate in rehabilitation). We hypothesized that a daily 30-minute Wii balance intervention would result in improvements in: (1) balance as measured by the Timed Up and Go (TUG) test, the Modified Functional Reach Test (MFRT) and the Wii-Fit Balance Board; (2) motivation to participate in rehabilitation as measured by the Pediatric Motivation Scale (PMS); and (3) functional abilities as measured by the Pediatric Evaluation of Disability Index (PEDI). Methods Study design A non-concurrent, randomized multiple baseline across subjects’ single-subject research design (SSRD) was used for this study [24]. SSRDs are particularly appropriate designs for research applied to clinical settings because the low prevalence of the targeted population can be difficult to study with traditional group designs in which large samples are required to achieve statistical power [25]. In addition, SSRDs can be used to monitor, guide, and evaluate clinical practice at the individual level to produce preliminary evidence at the exploratory phase of intervention research [26]. Replication across at least three subjects and randomization are recommended to strengthen the findings of an SSRD. For a phase to qualify as an attempt to demonstrate an effect, the phase must have a minimum of three data points [24]. To control for the effects of history and maturation, a multiple baseline design was used with three different baseline lengths [24]. Each participant underwent (A) a baseline and (B) an intervention phase. Blinded assessment for primary outcomes was used, with a minimum of five data points collected for each phase of this study. Participants Ethical approval for this study was obtained through the local university and children’s hospital clinical research ethics boards. To meet the inclusion criteria, participants had to: (1) be current inpatients of 3 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Balance therapy for children with acquired brain injury the Acute Rehabilitation Program at the regional center; (2) be aged 5–18 years old; (3) be at a level I–II or VII–VIII on the Pediatric Rancho Los Amigos level of consciousness scale if less than 13 years old or older than 13 years old, respectively; (4) be able to safely stand for a duration of three minutes with support of a chair, walker, or rail if needed; and (5) display decreased balance as a result of an ABI, based on the primary clinician’s verbal report. Individuals were excluded if they had a seizure disorder that was not being medically managed, a visual impairment, or a known pre-existing balance condition. Researchers aimed to recruit four subjects to strengthen the study design. During the period of the study, seven subjects meeting the inclusion criteria were admitted to the inpatient unit; two subjects refused participation, and two subjects were to be discharged from hospital before study completion, therefore were excluded, resulting in three participants included in this study (Table I). All participants presented with impaired balance and required a gait aid for long distances. Participant one (P1) required a forearm-supported walker when walking short periods (i.e. 510 minutes) and a wheelchair when mobilizing beyond 10 minutes. Participant 2 (P2) and participant three (P3) ambulated with the assistance of a cane. Outcome measures Two primary outcomes were examined: (1) changes in dynamic and static balance; and (2) motivation levels during traditional and Wii sessions. The secondary outcome examined was functional ability. Balance (i) TUG test – The TUG test was used to assess dynamic functional balance and is suitable for populations aged three years or older [27]. During the TUG test, an individual is timed while they stand up from a chair, walk three meters, and return to sitting, after which an average time is calculated. A shorter time to complete the task indicates better functional mobility. The TUG test has been shown to have excellent inter-rater reliability with an intraclass correlation coefficient (ICC) of 0.99 and good test–retest reliability with an ICC of 0.83, indicating that it is responsive to change when used with children who have a disability [4]. The TUG test has excellent criterion validity (r ¼ 0.86–0.92) and adequate construct validity (r ¼ 0.55–0.66) [28]. (ii) MFRT – The MFRT was used to assess dynamic standing balance. Functional reach is determined by the maximum distance one can reach forward beyond arm’s length while maintaining a fixed base of support in the standing position [29]. Individuals complete three reaching tasks, in which the participants’ reach distance is measured to obtain a score while standing perpendicular, and while standing with their back to a wall, reaching to each side. Each reaching task is completed Table I. Participant characteristics. Participant’s age (years) and sex Protocol (days) Nature of injury Impairment Post-injury days 240 1. 14, Female BL: 5 Wii: 15 Motor vehicle accident resulting in traumatic brain injury (diffuse axonal injury) Right hemiparesis Left upper limb intention tremor Decreased memory Decreased balance Decreased mobility (requiring a walker for short distances and wheelchair for long distances) 2. 13, Male BL: 8 Wii: 12 Non-traumatic brain injury: intracranial subarachnoid hemorrhage and atrial ventricular malformation Left hemiparesis Left hemianopia Decreased cognition Decreased balance and Decreased mobility (requiring a gait aid when ambulating long distances) 97 3. 12, Male BL: 12 Wii: 8 Non-traumatic brain injury: hematoma and atrial ventricular malformation Left hemiparesis Decreased cognition Decreased balance Decreased mobility (requiring a gait aid when ambulating long distances) 94 Note: BL: baseline. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 4 S. K. Tatla et al. three times, resulting in a total of nine trials, and the average of these three trials is calculated. The MFRT has excellent test–retest reliability with an ICC of 0.95 and excellent inter-rater reliability with an ICC of 0.98 [29]. The MFRT is strongly correlated with the TUG test and its test items reflect skills of forward weight shifting and anticipatory control of balance [30]. Criterion validity for the MFRT is adequate (r ¼ 0.48–0.56) [31]. (iii) Nintendo Wii balance board – Static balance was determined by measuring center of pressure (COP) using the Wii balance board, a pressure sensitive board that measures the percentage of pressure contributed by the left and right sides of the user’s body. Visual feedback is provided on a monitor, which reflects changes in COP over the three seconds during which time the measurement is computed. To determine the participants’ score, the percentages were converted to a ratio between the two sides. Ideally, each side of the body will contribute 50% of the pressure exerted onto the board; thus, the perfect COP ratio is 50/50 or 1.00. The Wii balance board has been shown to be a valid and reliable assessment tool for both test–retest reliability and concurrent validity with a good to excellent ICC of 0.66–0.94 [32]. Motivation PMS – The PMS was created for this study to assess children’s motivation to participate in their rehabilitation. The scale consists of four questions that examine both the level of enjoyment and the child’s feelings of confidence in their rehabilitation using a visual analog scale consisting of five smiley faces, ranging from ‘‘did not enjoy at all’’ to ‘‘extremely enjoyed.’’ The reliability and validity of this instrument has not yet been tested. There is currently no valid outcome measure for evaluating motivation for rehabilitation therapy from the perspective of a child. Functional ability PEDI – Two subscales of the PEDI were used to evaluate each participant’s functional abilities [2]. The self-care and mobility domains of the Caregiver Assistance and Modification Scale described the participant’s functional capacity in ADLs and transfers as well as locomotion. This assessment provides an indication of the level of assistance the participant required in performing their ADLs and mobility, on a scale ranging from zero (dependent) to five (completely independent). The PEDI was standardized for typically developing children aged six months to seven and a halfyears and has also been validated for use in older children whose physical function is that of a seven and a half-year old or younger child. This measure is commonly used with children 1–19 years of age who have an ABI and are in an inpatient rehabilitation center [33]. Reliability studies of the PEDI have determined good inter-observer reliability [34]. Concurrent validity of the PEDI has been established with other pediatric functional measures such as the WeeFim and Gross Motor Function Measure [2, 33, 35]. Data collection Participants were randomly assigned to one of three protocols, each with varying baseline and intervention periods (Table I) over the four-week study. Thirty minutes of daily balance rehabilitation was provided over five consecutive days per week. The Wii balance training was introduced at different times, depending on the protocol randomly assigned to each participant. As each participant was undergoing acute rehabilitation, concurrent therapies were continued during the study; these included three one-hour sessions of speech and language therapy and recreation therapy and two one-hour sessions of aquatic therapy per week. Baseline: Traditional balance training During the baseline phase, the participants did not have access to the Wii balance board in their rehabilitation or leisure time. Participants completed their daily traditional balance rehabilitation program for 30 minutes per day with their physiotherapist and/or occupational therapist. Traditional balance activities were individualized based on each participant’s unique needs. Examples of activities included: throwing and catching balls/beanbags outside of their base of support, reaching for objects while standing or sitting on stable or unstable surfaces, side stepping, walking up and down stairs, single-leg stance, and kicking activities. During the baseline phase therapists recorded the types and duration of traditional balance rehabilitation activities in a daily logbook. Intervention: Wii-Fit balance training Participants engaged in Wii-Fit balance training 30 minutes per day with either a physiotherapist or occupational therapist; a list of approved Wii-Fit balance games, along with a description were provided (Table A.I). Therapists decided what level of game was most suitable for each client and Balance therapy for children with acquired brain injury gave each client a choice of which games they would prefer to play that day. In addition, the selection and duration of Wii-Fit games were recorded in a daily logbook by therapists. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Assessment Primary outcomes were assessed daily by blinded assessors during both the baseline and intervention phases of the study, while the secondary outcome was measured weekly; the assessors were unaware of each participant’s protocol and whether each participant was in the baseline or intervention phase. Balance was assessed daily, using the TUG, MFRT, and Wii balance board. Motivation to participate in balance rehabilitation was measured daily with the PMS, given to the participant to complete immediately following their therapy session for that day by the therapist providing the therapy. The PEDI was completed once per week by both the treating occupational therapist and physiotherapist to assess the participants’ function in the areas of mobility and self-care. Data analysis Data were analyzed using visual inspection of trend lines to determine if a basic effect occurred as a result of the Wii intervention. While traditional models of SSRD analysis apply linear methods for data analysis (e.g., two standard deviation band method), a non-linear mixed effects (NLME) modeling technique, which predicts the recovery trajectory of children with closed head injury, was used for analysis of balance outcomes [36, 37]. The NLME model represents the pattern of recovery in rehabilitation with a trajectory characterized by a slow phase representing early recovery, followed by rapid change, and then finally plateaus [38]. Participants in this study were functioning beyond the slow phase of the non-linear model, as they had emerged from a minimally conscious state. Therefore, the latter two phases of the non-linear model, represented by a logarithmic curve, were used as the line of best fit to reflect the recovery and change over time. The rapid recovery phase represents the initial time when neuroplasticity has its greatest potential. The plateau phase is appropriate, as a ceiling would be reached for the assessments used to measure the independent variables. Using this NLME method allows researchers to create individual trajectories and account for the differences in recovery stage in which data collection begins [36]. A logarithmic curve is produced based on the data points during the baseline interval, called the null model [36]. It is then forecasted forward until the end 5 of the intervention period. An alternative model is produced based on the data points of the intervention period [36]. A basic effect would occur if the final point of the alternative model exceeds that of the null model in the desired direction [36]. Trend lines were visually analyzed to determine if a basic effect occurred as a result of the Wii intervention. Motivation, measured by the PMS, was visually analyzed using the two standard deviation band method because motivation levels were expected to follow a linear trajectory. Statistical significance occurs if two or more consecutive points fall outside the bands [25]. Data for the PEDI was plotted on a graph for visual analysis of any progression in function over time as participants were assessed weekly on this measure, resulting in four data points. Findings All participants completed the study, adhered to the study protocols, and reported no adverse events. To meet the complex physical needs of P1, modifications to the testing protocol were made on the MFRT and TUG. Specifically, this participant used a four-wheeled forearm walker as an ambulation aid during the TUG assessment. For the MFRT right arm-reaching task, the distance reached was measured from the elbow rather than the fifth finger as this participant’s right extremity had significant contractures in the elbow and wrist joints. The raw and transformed data for all outcomes are graphically presented for each participant in Figures 1–5. Dynamic balance TUG: As illustrated in Figure 1, a basic effect during the Wii intervention was observed on the TUG for all participants, with the greatest decelerating slope seen in P2 and P3. Although a basic effect was achieved, the close overlap in trend lines suggests that the rate of improvement during the Wii intervention was not vastly different from the baseline phase, particularly in P1. MFRT: On the MFRT, P1 clearly demonstrated a basic effect on all three measurements during the intervention phase, with the alternative model exceeding the value of the null model (Figure 2a–c). P2 and P3 demonstrated a basic effect on MFRT measure taken while the subjects were positioned with their backs against the wall and reaching with their non-affected arm. However, the data for P2 and P3 demonstrated a high degree of variability and a decelerating slope during the intervention phase for the measurements taken with back to wall and the affected arm indicating a decline in function during S. K. Tatla et al. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 6 Figure 1. Visual representation of the TUG test for baseline and intervention phases for participants 1–3. Notes: The vertical line divides the graph into the baseline and intervention phases. The logarithmic curves represent the rate of change during each phase. A basic effect can be seen if the final point during the intervention phase exceeds that of the baseline phase in a downward direction. 7 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Balance therapy for children with acquired brain injury Figure 2. (a–c) Visual representation of the MFRT for baseline and intervention phases for participants 1–3. (a) Forward reach with unaffected arm, (b) side reach with unaffected arm, (c) side reach with affected arm. Notes: The vertical line divides the graphs into the baseline and intervention phases. The logarithmic curves represent the rate of change during each phase. A basic effect can be seen if the final point during the intervention phase exceeds that of the baseline phase in an upward direction, demonstrating greater reaching distance. S. K. Tatla et al. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 8 Figure 2. Continued. the Wii intervention. The largest effect on dynamic balance was seen in P1, who received the longest duration of intervention. Static balance COP: COP data was collected for P2 and P3 only (Figure 3), as the Wii balance board could not produce a COP reading for P1. Impairments, such as intention tremor and decreased coordination interfered with P1’s ability to step onto the balance board and remain still for the required three seconds to produce a response. Despite repeated attempts, a reliable reading could not be obtained for this participant. P2 and P3 approached COP ratios of 1.0 during the intervention phase, which Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Figure 2. Continued. Balance therapy for children with acquired brain injury 9 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 10 S. K. Tatla et al. Figure 3. Visual representation of COP measured by the Wii-Fit balance board for baseline and intervention phases for participants 2 and 3. Notes: The vertical line divides the graph into the baseline and intervention phases. The logarithmic curves represent the rate of change during each phase. A basic effect can be seen if the final point during the intervention phase exceeds that of the baseline phase in the desired direction, in this case reaching a COP ratio of 1.0 to demonstrate equal weight shifting. demonstrates a trend toward improved static balance. However, high variability affected the reliability of the trend line produced; therefore, the results for static balance are inconclusive. Functional ability PEDI: Results indicate that all participants improved in the self-care and mobility domains of the PEDI (Figure 5). However, the magnitude of change does not appear to correlate with the length of intervention. Motivation PMS: Motivation for therapy treatment remained high for all participants. There was a clear increase in motivation upon starting the Wii treatment for P1. Although motivation did not change significantly in P2 and P3, scores remained high and all participants verbally expressed enthusiasm toward Wii-habilitation. P1, with the longest intervention period experienced a change in motivation upon initiating Wii-habilitation (Figure 4). Discussion This pilot study is the first to examine the effect of an intensive Wii balance intervention in children during the acute phase of rehabilitation after an ABI. A rigorous SSRD methodology was employed with three participants, using a randomized, singleblinded, multiple baseline design in order to account for history and maturation effects. An innovative non-linear data analysis was used to measure changes in balance in order to account for the 11 Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Balance therapy for children with acquired brain injury Figure 4. Visual representation of the PMS for baseline and intervention phases for participants 1–3. Notes: The vertical line divides the graph into the baseline and intervention phases. The solid horizontal lines indicate "2 standard deviations from the mean of the baseline data (dashed horizontal line). Statistically significant differences in motivation are present if at least two consecutive points fall outside of the 2 standard deviation bands. Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. 12 S. K. Tatla et al. Figure 5. Visual representation of the PEDI for baseline and intervention phases for participants 1–3. Notes: The vertical line divides the graph into the baseline and intervention phases. Visual analysis demonstrates a progression in self-care and mobility function over time. recovery patterns of this population. Results from our study support four major findings. First, our results demonstrate that participants complied with treatment protocols and that the Wii is a safe and feasible balance intervention that can be carried out daily with this population. Second, results support principles of motor learning, such as task specificity and repetitive task practice [39]. The principle of task specificity identifies the importance of improving motor skills through practicing tasks that are similar to those needing to be acquired [39]. Therefore, tasks practiced during rehabilitation should be specific to the desired outcome. Dynamic balance results showed a greater trend toward improvement and were less variable than static balance. As the Wii intervention primarily focused on and challenged the participants’ dynamic balance, this finding suggests that the improvement in dynamic balance is task specific and may not generalize to static balance. In addition, the participant who received the longest duration of intervention demonstrated the greatest improvement in dynamic balance. Thus suggesting that longer phases of Wii intervention provided an opportunity for additional task practice resulting in the greatest improvement. It is of note that P1, presenting with the most severe injury and complex sequellae, displayed the clearest improvement in dynamic balance in comparison to the other participants. It is possible that the effect of the Wii balance games on dynamic balance is dependent on the severity of impairment or the point in time during recovery that it is introduced. Further studies should explore this possible correlation and specifically examine the significance the impact of playing Wii balance games has on balance, depending on the severity of injury or phase of recovery. In addition, P1 had a TBI. Previous literature has concluded that children with non-TBIs often do not display as much improvement in their self-care abilities as children with TBIs, as measured by the Caregiver Assistance and Modification Scale [33]; thus, the improvement with P1 is consistent with those findings. Third, although the Wii balance board was a feasible tool for intervention, its appropriateness for assessment of static balance is questionable for this population given that it failed to produce a reading for one participant, and produced unreliable readings for the other two participants. Other measures of COP, such as force plates may be more sensitive for this population. Lastly, all participants reported high motivation levels throughout the Wii intervention confirming that the Wii is a motivating therapy; however, in two of the three participants, it did not appear to be significantly more motivating than traditional balance rehabilitation. This result is consistent with other literature exploring the Wii as a means of motivating therapy for people with neurological deficits [40, 41]. Nonetheless, there is currently no self-report pediatric assessment that assesses motivation to participate in therapy and it is possible that the scale created for this study is not a sensitive Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. Balance therapy for children with acquired brain injury measurement of motivation, thus not able to differentiate level of motivation between the traditional and Wii balance rehabilitation periods. It is important for clinicians to use motivating interventions to engage children in therapy; a recent review of pediatric literature enforced that meaningful intervention that promotes participation in everyday pursuits of children is critical not only for physical and cognitive rehabilitation but also for building a sense of self-efficacy and personal confidence in one’s abilities [42]. A direction for future research would be to develop a tool that would be a valid measure of a child’s motivation to participate in their rehabilitation and one that would guide clinicians in creating motivational therapy for that child. Such a tool will allow future researchers to further explore the relationship of motivation levels with Wii interventions compared to traditional balance interventions in this population. Functional abilities in activities requiring balance were a secondary outcome measured in this study. As function most probably does not change on a dayto-day basis, it was impossible to measure it daily and therefore function was a secondary outcome in this study while recognizing that it is a primary goal of occupational therapy. All participants showed an upward trend in their functional abilities in both the domains of self-care and mobility. This indicates that the participants were becoming increasingly independent in their ability to care for their basic needs such as feeding, bathing, and toileting, as well as becoming more mobile and more able to transfer independently and safely between surfaces. 13 rate of falls and greater potential for participation in physical activities [5, 44], both of which are often primary goals of therapy. These findings have important clinical implications for use in rehabilitation settings as they show promise for Wii use with patients presenting with a range of physical and cognitive abilities and demonstrate that clinicians can use the Wii system as a tool in their treatment. Limitations This study had a number of limitations that cannot go without mention. The variability of the data suggests that the length of baseline and intervention phases may have been too short to demonstrate a basic effect. Although this study protocol adhered to, and exceeded, the guidelines of SSRD (i.e., minimum of three data points for each phase), extending this study beyond one month may result in greater stability. In addition, concurrent therapies, such as modification in ankle-foot orthoses may have affected the results. Furthermore, the heterogeneity of this sample, which is typical to this population, and the small sample size limit the generalizability of these results. According to the single-case design technical guide [24] experimental control is demonstrated when the design documents three demonstrations of the experimental effect across three cases, which did not occur in this study. Rather, amongst the three participants in this study, only one of the three participants demonstrated such an effect. Furthermore, motivation findings using the PMS are limited by the lack of psychometric testing of this measure. Clinical implications Findings from a recent scoping review reveal a need for researchers to evaluate the active ingredients of technology-based interventions, specifically in the areas of system or game properties, intervention effects on the user, and the role of the therapist [43]. This study demonstrated that children were motivated and able to achieve the desired intensity of daily practice. Therapists were able to mediate the motor learning process by offering verbal feedback and manual assistance and guidance with positioning while participants were involved in the virtual rehabilitation. Thus, participants engaged in motor learning while using this complex interactive technology. The system parameters of the Wii and of the games used in this study enabled therapists to provide guidance to clients during balance therapy and for clients to use a walker or other mobility aid while standing on the balance board. In addition, all participants demonstrated improvements in dynamic balance. Previous research has found that an increase in dynamic balance means a decreased Conclusion While balance deficits are a common sequellae of ABI [4], therapists treating individuals with ABI do not have sufficient evidence to guide clinical decision-making and inform evidence-based balance interventions [45, 46]. This study contributes to the evidence by demonstrating that the Wii is a safe and motivating therapy that can be carried out daily in children with ABI during acute rehabilitation. Despite multiple impairments, the participants were able to engage in the Wii intervention and demonstrated improvement of dynamic balance. Although these preliminary results offer some promise, future research across a larger sample is needed to determine if Wii balance intervention results in significant improvement when compared to traditional therapy. In addition, further research is required to evaluate optimal duration and frequency of Wii intervention and the impact of type and severity of injury on balance outcomes. 14 S. K. Tatla et al. Key points Dev Neurorehabil Downloaded from informahealthcare.com by University of British Columbia on 12/13/12 For personal use only. . Daily Wii balance intervention with children is safe and feasible within the acute rehabilitation phase after ABI. . While there was a greater trend toward improvement in dynamic balance during Wii intervention, a basic effect was only demonstrated in one of three participants. . The Wii intervention was motivating for all participants. . Further research exploring the effectiveness of Wii balance training in this population is warranted. Acknowledgements The authors wish to sincerely thank the participants and their families for their support and commitment in this study. The authors would also like to acknowledge Sunny Hill Health Centre for Children for providing the equipment and facilities for this study and thank the clinicians who participated in the delivery of the intervention with all participants. The authors also wish to thank Dr Bruno Zumbo for his assistance with statistical analysis. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. Sandy Tatla is supported by funding from the Child and Family Research Institute. References 1. Canadian Institute for Health Information. The burden of neurological diseases, disorders and injuries in Canada. Ottawa: CIHI; 2007. Available from http://www.cihi.ca. Accessed 8 July 2012. 2. Hawley CA, Ward AB, Long J, Owen DW, Magnay AR. Prevalence of traumatic brain injury amongst children admitted to hospital in one health district: A population based study. Injury 2003;34:256–260, Epub 2003/04/02. 3. 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Games Soccer heading Ski jump Ski slalom Snowboard slalom Table tilt Tightrope walk Balance bubble Penguin slide Lotus focus Description and movements required Lateral weight shifting over wide base of support on balance board to head the balls on the screen Squat with knees bent on balance board until approaching the jump, then extend, and maintain position Anterior, posterior, and lateral weight shifting to pass between the flags with feet parallel on the balance board Anterior and posterior weight shifting to pass between the flags with one foot in front of the other on the balance board Weight shifting left, right, forward, and back to tilt the balls into the holes Walk on the spot on the balance board to move the character across the tightrope on the screen Guide the character down the river by shifting body weight left, right, front, and back Lateral weight shifting to both left and right to tilt the iceberg, combined with squat and rising up to feed the penguin Sit on the balance board with legs folded. If that is difficult, sit with legs unfolded