PT Critically Appraised Topics

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Critically Appraised Topic

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Clinical Scenario

The patient who led me to pursue this question is a 92-year-old female with a diagnosis of mild Alzheimer’s-related dementia and generalized weakness. She ambulates with a front-wheeled walker (FWW) independently under nursing supervision and is considered a high fall risk based on her Tinetti Balance Assessment score of 18/28. This patient has refused physical therapy intervention on numerous occasions, explaining that she still walks and does not want to exercise. Medical treatment to date includes pharmacological management of her dementia and medical management of comorbidities as they arise. Physical impairments contributing to her fall risk include decreased strength, decreased static balance, and decreased gait-related dynamic balance. Several studies have found that older adults consistently preferred, and were more motivated to participate in, game-based rehabilitation over conventional exercise-based rehabilitation.1,2,3,4,5 In one study, a patient even remarked that “I worked harder than I would have in normal therapy [done] in the bars.”6 We have an underutilized Nintendo Wii™ gaming system at Kula Hospital, and I feel that this patient would benefit from mutually agreeable balance retraining intervention.

Clinical Question

Is the Nintendo Wii Balance Board™ + Wii Fit™ software an appropriate tool to retrain balance deficits in geriatric patients classified as a moderate or high fall risk?

Clinical Bottom Line

Based on two studies by Pigford and Andrews and Williams et al., integrating the Nintendo Wii Balance Board™ + Wii Fit™ software into a conventional balance retraining program may improve balance, in the short-term, in older adults at a moderate or high risk for falls. In a single case study, Pigford and Andrews demonstrated that balance retraining with the Nintendo Wii™ in addition to conventional balance exercises resulted in clinically significant improvements on the Berg Balance Scale (BBS) and the Timed Up & Go (TUG), and some improvement in gait speed in an 87-year-old resident of a long-term care facility. This study had fair to good internal validity and the subject of this study was similar to patients in long-term care facilities who share his level of fall risk, but extrapolation of the results is questionable because this was a case study. In 15 community-dwelling adults over the age of 70 years, Williams et al. demonstrated a statistically significant improvement in mean BBS score at four weeks (p = 0.02), but this improvement was not sustained through the week 12 assessment; no score change on the Tinetti Balance Assessment Tool was demonstrated at either four or 12 weeks. This study had poor internal validity and compromised the generalization of these results to the greater long-term care population. Both studies mentioned the Wii™ as a low-cost alternative to other force-plate systems, but the outcomes of these articles do not justify purchasing the system if one is not already available. Future studies should include standardized protocols for the Wii™ balance interventions, including a set frequency and duration for each Wii Fit™ game, and a progression of the level of difficulty within and between games. Ideally, future studies should randomize intervention and control groups from a single subject pool, with between-group analyses to determine any baseline differences in their level of fall risk, number of medications, and any other criterion which may contribute to falls. A randomized controlled study design would provide a higher level of evidence for inclusion of the Wii™ into a balance retraining regimen, and, hopefully, would validate the Wii™ as a fun, potentially very useful tool without any unique adverse effects compared to traditional balance retraining interventions.