EFFICACY OF GAMING CONSOLE WII-BASED THERAPY FOR PEDIATRIC CEREBRAL PALSY IN

IMPROVING THEIR BALANCE

A Thesis Presented to the Faculty of the

College of Rehabilitative Sciences
Southwestern University PHINMA

In Partial Fulfillment of the

Requirements for the
Bachelor of Science in
Physical Therapy

Theresa Mae F. Galan

October 2017
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Abstract

Background/Rationale: Children with cerebral palsy is known to have a problem in their balance,
this study is conducted to assess the effects of a gaming console in improving their balance.
Objective: This research investigated the impact on children with cerebral palsy using Nintendo
Wii Fit games in improving balance.
Methods: This Study aims for collaboration between computer based and physical therapy
management. The study was conducted on the respective homes of the subjects. Performed
three times a week for a span of six-weeks.
Research Design: The research study used quasi-experimental method.
Research Locale: Participants where children from Lapu-lapu City diagnosed with cerebral palsy.
Research Respondents: Research respondents were aged 7-15 years old, both male and female
diagnosed with cerebral palsy who can stand, visually and orally comprehend instructions.
Research Instrument: The researcher used Timed-up-Go test before the span of intervention and
after the research study.
Methodology:
Results: This study includes eight ambulatory subjects with cerebral palsy ( 4 females, 4 males;
mean for age ± 8.25). The balance ability did not improve. No statistical significance was noted in
the outcomes measure in six weeks.
Conclusion: This computer based intervention that incorporated therapeutic movements for
balance improvement showed no significance (p = 0.17). A follow up study is recommended.
Keywords: Nintendo Wii and Cerebral Palsy
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Acknowledgment

For making this endeavor successful, my deep sense of gratitude to God Almighty. The peace of
mind, the wisdom and the strength you bestowed upon me.

To my family, expressing my gratitude for the encouragement in completing my papers, for

supporting me all through out, you are my inspiration to pursue.
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Approval Sheet

This thesis entitled “Efficacy of Gaming Console Wii-based Therapy for Pediatric Cerebral Palsy
in Improving their Balance” was prepared and submitted by Theresa Mae F. Galan to the Oral
Examination Committee as endorsed by:

Christopher Aladdin Capariño, PTRP

Research Mentor

ORAL EXAMINATION COMMITTEE

[Full name and title of Panel Chair]

Panel Chair

[Full name and title of Technical] [Full name and title of Ethical]
Panelist, Technical Review Panelist, Internal Ethical Review

Acceptance

This thesis entitled “Efficacy of Gaming Console Wii-based Therapy for Pediatric Cerebral Palsy
in Improving their Balance” upon approval of the Oral Examination Committee with a grade of
PASSED is hereby accepted in partial fulfillment of the requirements for the Bachelor of Science
in Occupational Therapy (change to Physical Therapy if PT).

Sergio T. Sarza Jr., PTRP

Research Coordinator

Lohindren V. Adorable, MD, DPBRM, FPARM

Dean

August 5, 2017
Date of Oral Examination
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Certificate of Antiplagiarism

With the knowledge that the College of Rehabilitative Sciences has set a maximum plagiarism
index of 10%, by signing below, I certify that the thesis entitled “Efficacy of Gaming Console Wii-
based Therapy for Pediatric Cerebral Palsy in Improving their Balance” submitted by Theresa
Mae F. Galan has been evaluated using PlagScan Pro, a plagiarism check software. The plagiarism
index is reported to be ____%.

Sergio T. Sarza Jr., PTRP

PlagScan Pro Administrator

Certificate of Originality

I hereby declare that this submission is my own work and that, to the best of my knowledge and
belief, it contains no material previously published or written by another person nor material to
which to a substantial extent has been accepted for award of any other degree or diploma of a
university or other institute of higher learning, except where due acknowledgement is made in
the text.

I also declare that the intellectual content of this thesis/dissertation is the product of my work,
even though I may have received assistance from others on style, presentation and language
expression.

Theresa Mae F. Galan

Researcher

Christopher Aladdin Capariño, PTRP

Research Mentor
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Table of Contents

Abstract ............................................................................................................................................ii
Acknowledgment ............................................................................................................................iii
Approval Sheet ................................................................................................................................ iv
Certificate of Antiplagiarism ............................................................................................................v
Certificate of Originality ...................................................................................................................v
Table of Contents ............................................................................................................................ vi
Introduction and Rationale ............................................................................................................. 1
Literature Review ........................................................................................................................ 2
Conceptual Framework ............................................................................................................... 3
Research Objectives .................................................................................................................... 3
Research Hypothesis ................................................................................................................... 4
Significance of the Study ............................................................................................................. 4
Scope and Limitations of the Study ............................................................................................ 4
Definition of Temrs ..................................................................................................................... 4
Materials and Methods................................................................................................................... 5
Research Duration ...................................................................................................................... 5
Research Design .......................................................................................................................... 5
Research Respondents ................................................................................................................ 5
Inclusion Criteria ..................................................................................................................... 5
Exclusion Criteria..................................................................................................................... 5
Power Analysis and Sample Size Determination .................................................................... 5
Sampling Frame ...................................................................................................................... 5
Sampling Design ...................................................................................................................... 5
Site of the Study and Available Facilities .................................................................................... 5
Materials and Equipment ........................................................................................................... 6
Study Plan and Data Collection ................................................................................................... 6
Data Processing and Analysis ...................................................................................................... 6
Work Plan Schedule .................................................................................................................... 6
Ethical Considerations................................................................................................................. 6
Research Utilization .................................................................................................................... 6
Estimated Budgetary Requirements ........................................................................................... 6
Results and Discussion .................................................................................................................... 7
Specific Objective 1 ..................................................................................................................... 7
Specific Objective 2 ..................................................................................................................... 7
Specific Objective 3 ..................................................................................................................... 7
Specific Objective 4 ..................................................................................................................... 7
Conclusion ....................................................................................................................................... 8
Recommendations .......................................................................................................................... 8
References ...................................................................................................................................... 8
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Appendix A: Tables and Figures ...................................................................................................... 9

Appendix B: Research Instruments ............................................................................................... 10
Appendix C: Certifications ............................................................................................................. 11
Appendix D: Transmittal Letters ................................................................................................... 12
Appendix E: Informed Consent Form ........................................................................................... 13
Appendix F: Research Budget ....................................................................................................... 14
Appendix G: Timetable of Research Activities .............................................................................. 15
Appendix H: Documents, Maps, Additional Information ............................................................. 16
Appendix I: Documentation .......................................................................................................... 17
Researcher Profile ......................................................................................................................... 18
Electronic Copy File ....................................................................................................................... 19
 1

Introduction and Rationale

A neurologic disorder called Cerebral Palsy (CP) is an insult or defect to the brain that occurred
before or during the baby’s birth. It affects normal functioning, movement, muscle tone, balance,
coordination, reflexes and motor skills. This motor disability is non-progressive, it does not
generally give life expectancy problems but affects the ability of the child’s movement in a
purposeful and coordinated way. Patients with CP will suffer from cognitive and motor
disabilities, it requires drastic and well-faceted treatment strategy over a long period of time
which involves different and numerous health professionals. This movement and postural
disorder are caused by damage to the Cerebrum’s motor cortex. Undesirable consequence comes
with imbalance of the muscle and the deformities can lead to increase of disability with age.
Consequences of chronic imbalance of the muscle wil result in deformities and will cause an
increasing disability as the patient ages. Patients with CP show motor control problems and gait
pattern abnormalities secondary to central nervous system injury during brain development.
Balance control problems is known for its important cause in gait problems resulting in injuries
and risk of falls. Poor control in balance is a well known causative problem in gait among these
children.
A newly developed software/hardware the Nintendo® Wii Fit a challenging and fun way to
engage and encourage children to do exercise at home. This computer based program provides
entertainment while enhancing fitness and balance. This system is said to improve and has effects
on enhancing and training our body’s strength, flexibility, coordination, and balance. Visual
feedback is another advantage that the patient can receive. This visual feedback can will help in
improving balance, while the games stimulate and creates perceptions that they can do higher
level of activities. The gaming console is inexpensive and simple way of experiencing virtual
reality that has increasingly been famous as part of the rehabilitation program in children with
cerebral palsy.
Videogaming with motion detection technology is increasingly used for rehabilitation. Studies in
patients with CP, traumatic brain injury, stroke, and Parkinson’s disease have shown successful
motor rehabilitation using these interactive technologies. Computer-based videogames are
hypothesized to be effective by creating engaging activities that motivate people to exercise.
This motivation theoretically improves compliance with home-based exercise programs. One of
the benefits of videogames is that they can provide a progression of increasingly difficult
challenges that help keep players engaged and motivated over extended periods of time.
Challenges that are in the sweet spot between ‘‘too easy and therefore boring’’ and ‘‘hard and
therefore frustrating’’ tend to maximize player engagement (Radtka S, 2013).

This research aims to investigate and study the efficacy of Wii-based therapy in improving
balance and function to children diagnosed with cerebral palsy.
 2

Literature Review

Several researches were conducted regarding gaming console in improving balance and function
of cerebral palsy patients. A gaming console is a computer, electronic and digital device that
displays visual image for a video game. On November 2006, released by Nintendo the Wii, a
home video game console that brings all ages of people to play, this will give virtual reality
experience and promotion of physical activities that’s interactive and fitness games. Its
advantage is that it has variety of games to choose for all ages, from children to adults and comes
with different fitness level.

There are potential benefits of Nintendo® Wii Fit among people having neurologic and
musculoskeletal deficits. One example of a pilot study and a published article on 2013 by (Tarakci
D, 2013) featuring a Wii Fit standardized training program showed a significant improvement in
walking and balance functions. Balance Function is a key element of postural control that allows
a child to do his activities of daily living (ADL), activities at the community, school and at home.

Therefore, the focus of the study was to improve functional walking, the study showed significant
improvements in balance of children with CP after the Wii-based therapy. The study used
Functional Reach Test (FRT), 6-Minute Walk Test (6MWT). Several Interventions were chosen for
gait improvement such as soccer heading, walking a tight rope, ski slalom and tilt table games.
The game showed significant improvements on movements through a large spectrum
perturbations involving trunk and extremities that varies in location and amplitude. Not just it,
but it also improved trunk control and dynamic balance through transferring the body’s weight
in left and right. Professional health care providers are now starting to incorporate technology of
the gaming systems to help in the rehabilitation program for patients with neurologic and
musculoskeletal deficits.

Another published article on 2008 by (Tarakci D, 2013) . Using a low-cost gaming console for
spastic CP demonstrated that improvements with visual perception, functional mobility and
posture (Ramstrand N, 2012). On 2013 another research was conducted using Nintendo® Wii Fit
in gross motor function and control in balance for children diagnosed with Cerebral Palsy which
includes 14 subjects with physical therapy in lieu of the Wii Fit Program. Outcome measures
include agility scale based on a test called Bruiniks Oserestky test of Motor Performance,
modified scoring for balance and running speed, and a timed assessment for ascending and
descending stairs. The study showed significant difference in balance scores but they stated
further research must still be conducted with the adjunct of physical therapy rehabilitation
(Michalski A, 2012).
 3

Commercially available videogames, such as the Nintendo Wii_ (Nintendo of America,

Redmond, WA) are being used by children with CP as part of PT and have been shown to
improve standing balance and gait. These videogames are feasible for use in-home-based
exercise PT programs given their portability, accessibility, and low cost. However, ‘‘off the-
shelf’’ games are designed for the general public and do not address the specific needs of
children with functional limitations. The movements are not based on therapeutic principles,
and thus their therapeutic efficacy is limited. In addition, neurorehabilitation usability studies
have found that off-the-shelf games may actually provide negative auditory
and visual feedback because patients are not fast enough or efficient enough to perform the
movements required to play the game successfully. Because of these user limitations,
researchers are developing games specifically targeted for rehabilitation in particular
populations (Radtka S, 2013).

Conceptual Framework

INPUT
PROCESS OUTPUT

Children with Standardized Significant

CP engaged in game, level of changes in
a difficulty functional
standardized increased. mobility and
game using Performed three improvement of
Nintendo Wii times a week for the TUG
Fit six weeks with 25- assessment
minute duration after
completion of
the study

Research Objectives

This research investigated the impact on children with cerebral palsy using Nintendo Wii Fit
games in improving balance.

Specifically, the thesis aimed to:

1. Determine the demographics of the respondents.
2. Compare the pre-test and post-test intervention of balance using timed-up-go test of
children with cerebral palsy
 4

Research Hypothesis

There is a significant effect in improving balance using Nintendo Wii Fit games among children
with Cerebral palsy living in Lapu-Lapu City

Significance of the Study

This study demonstrated the safety of using computer-based program, technical feasibility,
appeal and ease of use in Wii Fit using Balance Board for children with Cerebral Palsy. This gaming
system can provide quantifiable outcome that will engage them in an artificial conflict and are
defined by rules. Through this, it will keep the children engage and maintain in the rehabilitation
program (Radtka S, 2013).

Scope and Limitations of the Study

There is only one limitation to this study, only small sample size is obtained. The importance of
this study is to spread use of Wii Fit in rehabilitation of children with cerebral palsy in the
Philippines

Definition of Terms
1. Cerebral Palsy (CP) – is a neurologic disorder that results from a defect or insult to the
immature brain, and it is one of the most common causes of motor disability in childhood
(Tarakci D, 2013)
 5

Materials and Methods

Research Duration
This research project was conducted on summer, 17th of April 2017 and ended on the month June
2017

Research Design
The research study used quasi-experimental method

Research Respondents
Research respondents were aged 7-15 years old, both male and female diagnosed with cerebral
palsy who can stand, visually and orally comprehend instructions

Inclusion Criteria
Subjects were children and adolescents under the age of 18 both male and female diagnosed
with cerebral palsy who can stand, visually and orally comprehend instructions Primary
intervention for addressing motor issues will be Wii training system. This research will focus on
balance and motor disabilities with outcome measures.

Exclusion Criteria
Mixed Samples that had children not diagnosed with CP and CP children who cannot stand,
visually and orally comprehend instructions.

Power Analysis and Sample Size Determination

We are planning a study of a continuous response variable from independent control and
experimental subjects with 1 control(s) per experimental subject. In a previous study the
response within each subject group was normally distributed with standard deviation 4.22. If the
true difference in the experimental and control means is 3.69, we will need to study 12
experimental subjects and 12 control subjects to be able to reject the null hypothesis that the
population means of the experimental and control groups are equal with probability (power) 0.8.
The Type I error probability associated with this test of this null hypothesis is 0.05.

Sampling Frame
The sampling frame consisted of pediatric patients that ages from seven to ten years old who
are listed and diagnosed with cerebral palsy at Lapu-Lapu City

Sampling Design
Convenience Sampling was used by the researcher.

Site of the Study and Available Facilities

Research was conducted in Lapu-Lapu City Research intervention may take place on the home of
the respondents or centers near the patient depending on the convenience, availability and
safety.
 6

Materials and Equipment

During the study, the researcher used Nintendo Wii Fit that consisted downloaded and purchased
games, a Nintendo Wii Balance Board and an Athletic Kit and a television, if projector is not
available for usage, a laptop will be used. For the assessment, Timed Up and Go test (TUG) will
be used to identify if improvement of balance and walking ability and risks of fall may also be
identified. It is convenient to use because the time to administer it will be less than five minutes.
A permission will be provided in using the tool from the licensers. TUG has an adequate test-
retest reliability for community dwelling elderly (ICC=0.56), and sensitivity of 87%. Further
research will be made to identify its reliability for children with CP.

Study Plan and Data Collection

Eight Qualified subjects were chosen from Lapu-Lapu City that ranges from seven to ten years
old.
1. Subjects were tested using timed-up-go test as assessment tool for identifying the risk of
falls.
2. Subjects received same intervention for three times a week that approximately runs for
30-45 minutes for six weeks duration.
3. After the six week duration, All results gathered from the pre-intervention and post-
intervention was analyzed and compared using t-test method.

Data Processing and Analysis

This research study used t-test in assessing the significant difference in between pre-intervention
and post-intervention timed-up-go test.

Work Plan Schedule

Ethical Considerations

Research Utilization

Estimated Budgetary Requirements

 7

Results and Discussion

Specific Objective 1

Specific Objective 2

Specific Objective 3

Specific Objective 4
 8

Conclusion

Based upon the gathered data by the researcher, it showed that there is no significance in the six
weeks intervention for improving balance using Nintendo Wii for pediatric cerebral palsy. Pre-
intervention and post-intervention results showed no significant difference.

Recommendations
Thus, further research is advised with incr

References

Deutsch JE, B. M.-B. (2008). Phys Ther 88(10): 1196-207. Use of a low-cost
commercially available gaming console (Wii) for rehabilitation of an adolescent
with cerebral palsy.
Michalski A, G. C.-M. (2012). Gait Posture 36(3):449-53. Assessment of the postural
control strategies to play Wii Fit videogames.
Radtka S, R. H. (2013). Games Health 2(4): 222-228. Feasibility of Computer-Based
Videogame Therapy for Children with Cerebral Palsy.
Ramstrand N, L. F. (2012). Technol Health Care 20(6)501-10. Can balance in children
with cerebral palsy improve through use of an activity promoting computer
game?
Tarakci D, O. A. (2013). J Phys Ther Sci. 25(9): 1123-1127. Wii-based Balance Therapy
to Improve Balance Function of Children with Cerebral Palsy: A Pilot Study.
 9

Appendix A: Tables and Figures

 10

Appendix B: Research Instruments

 11

Appendix C: Certifications
 12

Appendix D: Transmittal Letters

 13

Appendix E: Informed Consent Form

 14

Appendix F: Research Budget

This research is entirely self-financed by the researchers, with no sources of external funding
from any private or public agency or institution. The researcher also does not have any official
affiliation with any private or public agency or institutions that may conflict interest in the
conduct of this research.

Quantity Budget Unit Price Amount

1
8

TOTAL (in PHP)

 15

Appendix G: Timetable of Research Activities

 16

Appendix H: Documents, Maps, Additional Information

ONLY INCLUDE THIS APPENDIX IF IT IS APPLICABLE TO YOUR THESIS.

 17

Appendix I: Documentation

THERE MUST A CAPTION FOR EVERY PICTURE THAT YOU INSERT HERE.
 18

Researcher Profile

Name: Theresa Mae F. Galan

City Address: Don Gervacio Quijada St., Villa San Lorenzo,
Guadalupe, Cebu City
Provincial Address: Poblacion North, Pinan, Zamboanga del Norte INSERT GRAD PIC
Email Address: thfa.galan@gmail.com HERE
Mobile Number: 09470625676
Birthday: July 31,1996

Educational Background
Tertiary Bachelor of Science in Physical Therapy)
Southwestern University PHINMA
Urgello, Cebu City
October 2014 – March 2017
Secondary Saint Vincent’s College
Dipolog City, Zamboanga del Norte
June 2011 – March 2013
Elementary Cabancalan I Elementary School
Casuntingan, Mandaue City, Cebu
June 2003 – March 2009
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Electronic Copy File

ATTACH THE SOFT PAPER CASING OF YOUR CD-R or DVD-R, which contains a soft copy of the
thesis and all of its attachments.