Effectiveness of the Wii in Improving High Level Functions in Children with Down Syndrome: An Evidence-Based Review - PT 209-910 Amanda Giles, DPTc
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Effectiveness of the Wii in
Improving High Level Functions in
Children with Down Syndrome:
An Evidence-Based Review
Amanda Giles, DPTc
PT 209-910
Down Syndrome (DS)
Genetic:
error in
cell
division
Motor,
Mild to Down cognitive,
severe and
disability Syndrome language
delays
physical
activity;
obesity
Berg 2012, Campbell 2012, Umphred 2007, www.ndss.org
Significance
Most common chromosomal disorder
1 in 691-800 live births
Incidence: 6,000 new cases per year
Prevalence: 400,000 people in the U.S.
Berg 2012, Umphred 2007, www.nads.org, www.ndss.org
Gross Motor Difficulties
Hypotonia
Slow reaction
times Ligament laxity
Decreased Joint
strength hypermobility
Impaired
postural control
and balance
Campbell 2012
PT Treatment Techniques
Sensory-motor integration or perceptual motor
techniques
Vestibular stimulation
Neurodevelopmental techniques (NDT)
Delavarian 2012, Wuang 2011
PT Treatment Techniques
Uyanik et al.
• Sensory integration (SI) ≠ improved gross motor skills
• Sensory integration + vestibular stimulation =
improvements in balance and reflex development
• NDT = improvements in gross and fine motor
Harris
• No significant difference in motor performance after
NDT
Uyanik 2003, Harris 1981
Clinical Problem
Children with DS have delays in motor
development often requiring PT care
Current PT techniques have varying
results reported
PTs need interventions that are
effective, engaging, and motivating for
pediatric patients with Down syndrome
Clinical Problem
Do not qualify for California
Children’s Services (CCS)
PT costs = private insurance or
out-of-pocket
Cost effective, at-home
interventions would be beneficial
Virtual Reality (VR)
“computer-user interface
consisting of real-time
environmental stimulation”
Interactive
3D computer
environment
Wuang 2011, Delavarian 2012
“Wii-habilitation”
http://0.tqn.com/d/nintendo/1/0/Z/0/-/-/wiiconsole.jpg
http://www.nintendo.com/wii/what-is-wii/
Rahman 2010, Delavarian 2012“Wii-habilitation”
http://www.youtube.com/watch?v=hHwxP9VlpjwVR and Cerebral Palsy (CP)
Brien and Sveistrup
• Improvements on Community Balance and
Mobility Scale
• Improvements on Six-minute Walk Test
• No difference on Gross Motor Function
Measure-66
Mitchell et al.
• Varied results in functional outcomes
Brien and Sveistrup 2011, Mitchell 2012Theoretical Construct
Varied
Engaging Increased Increased
scenarios Enjoyment
attention Improved
environment adherence
and and task practice
activities motivation
Berg 2012, Delavarian 2012, Wuang 2011Theoretical Construct
Carry-over to
functional
Cognitive activities
Sensorimotor feedback
feedback
Improve
Perceptual postural
feedback control and
balance
Feed forward Experiment
mechanism with
Direct knowledge of performance techniques
and real-time feedback
Wuang 2011, Berg 2012Theoretical Construct
Task driven
Goal
Repetitive
directed
Neuroplasticity
Wuang 2011Gap in the Literature Majority of literature about VR in healthy elderly population Limited evidence for use of VR with pediatric population No meta-analysis performed on current literature
Purposes/Questions
Primary Purpose
• Is the Wii effective at improving balance, LE
strength, and speed and agility in children with DS?
• This is a foreground question
Secondary Purpose
• Is the Wii more effective than traditional PT/OT or
no therapy at improving balance, LE strength, and
speed and agility in children with DS?PICO
P • Children under 18 with medical
diagnosis of DS
I • Wii Sport and Wii Fit
C • control (usual PT/OT therapy
or no therapy)
O • balance, LE strength, speed and
agility (measured by the BOT)Results: Outcome Measures
BOT
• Common
evaluation tool
• Criterion
validity, good
reliability
BOT-2
Wuang 2009Hypotheses
Primary
H0 • The Wii is not effective at improving
• a) balance b) LE strength or c) speed and agility
HA • The Wii is effective at improving
• a) balance b) LE strength and c) speed and agility
Secondary
H0 • The Wii has no effect vs traditional therapy or no therapy on
• a) balance b) LE strength c) or speed and agility
HA • The Wii has a significant effect vs traditional or no therapy on
• A) balance b) LE strength c) or speed and agilityExpected Findings 5-10 articles on use of VR for children with DS Statistically significant improvements in balance, LE strength, and speed and agility Statistically significant improvements when compared to traditional therapy
Methods
Inclusion Criteria Exclusion Criteria
Written in Comorbidities not
English related to DS
Intervention
using VR
Medical
diagnosis of
DS
Children
ages 4-18Methods Databases Searched Search Terms • Down syndrome, Wii, virtual reality, and trisomy 21
Methods: Statistics
Hypothesis I
Extract means and standard deviations. Calculate
effect size (ES) and 95% CI for pre-post changes in
strength, agility, and balance for each study
Weight ES by inverse variance
Calculate Q statistic to determine if random effects model
or fixed effect model will be used to pool effect sizes
Calculate grand effect size and 95% CI
Convert to clinical unitsMethods: Statistics
Hypothesis II
Extract means and SDs. Calculate ES and 95%
CI for post intervention difference in strength,
agility, and balance between treatment groups
Weight effect sizes by inverse variance
Calculate Q statistic to determine if random effects model
or fixed effect model will be used to pool effect size
Calculate grand effect size and 95% CI
Convert to clinical unitsResults: PRISMA
Articles identified through
database search (n=17)
Duplicates identified
(n=8)
Articles screened for eligibility
(n=9)
Articles not relevant or not
meeting specified criteria
(n=5)
Articles included in this review
(n=4)
As of December 1st, 2012Results: Primary Articles
Level of
Author, Year Type of Study
Evidence
Rahman
Clinical Trial 3b
(2010)
Wuang
RCT 2b
(2011)
Lin
RCT 2b
(2012)
Berg
Case Report 4
(2012)Results: Primary Articles
Treatment Dose
# Significant
Duration Days/ Week VR Outcome Outcomes
Study N Age (minutes) wk s used Measures p < .05
Experimental:
Rahma BOT –
50 + 15 Wii
n 30 10-13 2 6 Wii-Fit balance Balance
(2010) subset
Control: 50
Experimental:
Wuang 60 Wii
155 7-12 2 24 BOT-2 Speed/Agility
(2011) Sports
Control: 60
Lin Experimental: Wii Strength,
92 13-18 3 6 BOT-2
(2012) 25 Sports Speed/Agility
Berg Balance
1 11-12 20 4 8 Wii BOT-2
(2012) Speed/AgilityResults: Balance, Within Group
Q statistic: 7.7
p-value: 0.005
Random-effects
model
0.8 (-0.44, 2.04)Results: Balance, Between Group
Q statistic: 11.8
p-value: 0.0006
Random-effects
model
0.81 (-0.76, 2.38)Results: Strength, Within Group
Q statistic: 0.87
p-value: 0.35
Fixed-effect
model
0.65 (0.36, 0.93)Results: Strength, Between Group
Q statistic: 3.12
p-value: 0.08
Fixed-effect
model
0.61 (0.32, 0.9)Results: Speed/Agility, Within Group
Q statistic: 2.24
p-value: 0.13
Fixed-effect
model
0.55 (0.27, 0.84)Results: Speed/Agility, Between Group
Q statistic: 2.96
p-value: 0.09
Fixed-effect
model
0.62 (0.33, 0.91)Cost
None of the studies directly addressed cost
• Lin stated VR’s “affordability”
Cost of a Nintendo Wii and Wii-Fit
• $130.00
• $100.00
Less expensive option for clinics and families
Wuang 2009, www.nintendo.com/wii/buynowHarm/Adverse Events
No studies reported adverse events
Wuang acknowledged possible events
• Photosensitive seizures
• Repetitive motion injuries
Falls
• Due to balance interventions
Wuang 2011Discussion
Primary
H0 ✗
• The Wii is not effective at improving
✗
• a) balance b) LE strength or c) speed and agility
HA ✗ ✓
• The Wii is effective at improving
✓
• a) balance b) LE strength and c) speed and agility
Secondary
H0 ✗ ✗
• The Wii has no effect vs traditional therapy or no therapy on
• a) balance b) LE strength c) or speed and agility
HA ✗ ✓ ✓
• The Wii has a significant effect vs traditional or no therapy on
• A) balance b) LE strength c) or speed and agilityDiscussion: Clinical Relevance
Minimal Important Difference Balance
(MID) for the BOT
• Within Group: 7.2 points
• Between Group: 3.5 points
• Balance: 0.57
Strength
• Strength: 1.73 points • Within Group: 5.9 points
• Between Group: 6.7 points
• Speed/agility: 0.59 points
Speed/agility
• Within Group: 4.2 points
• Between Group: 4.7 points
Wuang 2009Discussion: Balance
Absence of
specificity of training
• Rahman: large effect size
Contradicting results • Wuang: small effect size
• Wii-Fit
Differing type of Wii • Wii SportDiscussion: Limitations
• Small data pool
Search • May not have found all relevant articles
• Lack of random assignment
Articles • Common author
Meta- • Heterogeneous studies
• Form of Wii
analysis • Variations in type of controlDiscussion: Directions for
Future Research
RCTs with large sample sizes
Balance-oriented studies
Clarify games and
parametersClinical Significance
Cost effective Benefit those in rural
alternative areas
confidence,
motivation, and
participation
Variable, enjoyable,
Maintain progress
meaningful
made in PT
interventionConclusions Increased use of the Wii would benefit therapists and patients Wii produces significantly improved outcomes for children with DS in terms speed/agility and strength Additional data needed to support use for improving balance Cost-effective, at-home alternative or adjunct to treatment for children with DS
References • Berg P, Becker T, Martian A, Primrose K, Wingen J. Motor Control Outcomes Following Nintendo Wii Use by a Child With Down Syndrome. Pediatr Phys Ther. 2012;24:78–84. • Brien M, Sveistrup H. An Intensive Virtual Reality Program Improves Functional Balance and Mobility of Adolescents With Cerebral Palsy. Pediatr Phys Ther. 2011;23:258–266. • Campbell S, Palisano R, Orlin M. Physical Therapy for Children. 4th ed. St. Louis: Elsevier Saunders; 2012. • Delavarian M, Afrooz G, Gharibzadeh S. Virtual Reality and Down Syndrome Rehabilitation. J Neuropsychiatry and Clin Neurosci. 2012;24:E7–E7. • Facts About Down Sydrome. National Association for Down Syndrome. Available at: http://www.nads.org/pages_new/facts.html. Accessed December 5, 2012. • Harris S. Effects of Neurodevelopmental Therapy on Motor Performance in Infants with Down’s Syndrome. Develop Med Child Neurol. 1981;23:477–483. • Jewell D. Guide to Evidence-Based Physical Therapy Practice. Sudbury, MA: Jones and Bartlett; 2008. • Keysers C. Mirror neurons. Current Biology. 2009;19(21):R971–R973. • Lin H, Wuang Y. Strength and agility training in adolescents with Down Syndrome: A randomized controlled trial. Res Dev Disabil. 2012;33:2236–2244. • Mitchell L, Ziviani J, Oftedal S, Boyd R. The effect of virtual reality interventions on physical activity in children and adolescents with early brain injuries including cerebral palsy. Develop Med Child Neurol. 2012;54(7):667–671.
References • Overview of CCS Medical Eligibility. California Department of Health Care Services. Available at: http://www.dhcs.ca.gov/services/ccs/Pages/medicaleligibility.aspx. Accessed January 2, 2013. • Rahman S. Efficacy of Virtual Reality-Based Therapy on Balance in Children with Down Syndrome. World Appl. Sci. J. 2010;10(3):254–261. • Shumway-Cook A, Woollacott M. Dynamics of postural control in the child with Down syndrome. Phys Ther. 1985;65:1315–1322. • Umphred D. Neurological Rehabilitation. 5th ed. St. Louis: Mosby Elsevier; 2007. • Uyanik M, Bumin G, Kayihan H. Comparison of different therapy approaches in children with Down syndrome. Pediatrics Internaional. 2003;45:68–73. • What is Down Syndrome? National Down Syndrome Society. Available at: http://www.ndss.org/Down- Syndrome/What-Is-Down-Syndrome/. Accessed December 5, 2012. • Wii - Buy Now. Wii Official Site at Nintendo. Available at: http://www.nintendo.com/wii/buynow. Accessed April 11, 2013. • Wuang Y, Chiang C, Su C, Wang C. Effectiveness of virtual reality using Wii gaming technology in children with Down Syndrome. Res Dev Disabil. 2011;32:312–321. • Wuang Y, Su C. Reliability and responsiveness of the Bruininks-Oseretsky Test of Motor Proficiency-Second Edition in children with intellectual disability. Res Dev Disabil. 2009;30:847–855.
Acknowledgements
• Marsha Melnick, PT, PhD
• Monica Rivera, PT, MS, DPTSc
• Diane D. Allen, PT, PhD
• Mahz Shaikh, DPTc
• Alyssa Haines, DPTc
• Friends and Family
http://www.etsy.com/market/wiiQuestions?
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