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Comparison of efficacy between traditional and video game based balance programs.

Key Words: Dance Dance Revolution[R], injury prevention, training, Wii Fit[TM].


Previous balance research has validated the efficacy of various balance training programs on the prevention, treatment, rehabilitation, and reduction of re-injury rates of lower extremity injuries at and around the ankle (1, 2, 5-10). While there is some disagreement regarding the clinical usefulness of balance programs in chronically unstable ankles (3, 7) the data regarding the benefits of balance training for prevention, treatment, and reduction of re-injury in first or second time acute ankle injuries is such that balance training programs should be an important clinical intervention during pre-season, in-season, and post injury balance programs (1, 2, 6, 7, 9, 10). Traditional balance programs have historically involved many different exercises aimed at increasing balance by performing single and double leg stance activities on various stable and unstable surfaces while also performing other distracting tasks. While these activities have proven helpful in improving balance they can be considered boring and not very stimulating to the individual performing them. This lack of interest in the exercises can lead to less than desired engagement and performance. Emery, et. al. (2) recommended that future research into balance training programs involve ways to develop increased compliance within the program. It is understood that any good preventative or restorative program needs compliance of the involved parties. It is with this in mind that this research program was conducted.

The research team involved in this project evaluated the impact on balance performance of two common market video games. One of the video games was used as created by the manufacturer, whereas the other was modified slightly to facilitate balance improvements. The physical performance benefits of exercise programs involving these two games were compared against a traditional balance training program, as well as, a control group.

Dance Dance Revolution[R] (DDR) and Nintendo Wii Fit[TM] are two examples of the activity based video gaming craze that has become quite popular in recent years. Unlike many video games, DDR[R] and Wii Fit[TM] require weight bearing physical activity to play. Instead of the typical hand controller, the DDR[R] and Wii Fit[TM] use floor mats or platforms activated by the participant's feet. During play, the games provide auditory and visual commands on a television screen, to which a player must respond by moving their feet and/or body to complete the objective of each game. The tempo, combination of commands, and difficulty increases as level of play escalates ultimately leading to a video gaming experience that stimulates metabolism, creates general and specific body fatigue, and potentially facilitates performance improvement. The Wii Fit[TM] video game system has built in balance programs that utilize bilateral stance in balance training activities. It cannot be played using only one foot.

In contrast, DDR[R] was created for dual foot play, but with a simple "rule" change forcing participants into single foot stance during play, the game mimics other balance training exercises. The researchers have been prescribing preventative and rehabilitative exercises using DDR[R] based balance exercises for several years. With the recent consumer market release of the Wii Fit[TM] video game system, this research project was designed to determine if the use of either video game based balance programs were as effective as previous research has shown traditional balance programs to be.


Study Design: The study was completed over a 5-week period. Pre and post test measurements consisted of Star Excursion Balance Tests (SEBT) measurements and single leg force plate balancing data obtained from an AMTI [AccuSway.sup.PLUS] Balance Platform (AMTI: Watertown, Mass.) and associated Balance Clinic balance software. Participants were randomly assigned an identification number and again randomly assigned to one of four treatment groups (control, n=7; traditional balance program, n = 5; DDR[R] balance program, n = 7; Wii Fit[TM] balance program, n = 6). The participants were notified of their treatment assignments following pre-testing procedures. The traditional, DDR[R] and Wii Fit[TM] exercise groups participated in balance training exercises three days a week for four weeks. Each training session was conducted in such a manner to provide between 12 to 15 minutes of actual balance exercises per session, which is an approximate time allocated during balance improvement programs. The control group only participated in the pre and port testing sessions. All training sessions were conducted in the same room during pre-determined times. A member of the research team supervised each training session.

Participants: Upon approval by the institutional review board for the testing of human participants, twenty-eight individuals were recruited for the study. However due to extenuating circumstances only twenty-five successfully completed the balance training exercise requirements and post testing. Therefore, twenty-five participants, men (n = 12) and women (n = 13) between the ages of 18 and 24 (m = 19.56, sd = 1.69), were included in the final study and data analysis. Prior to testing all participants participated in a face-to-face interview to evaluate study inclusion criteria. Any participant with a previously diagnosed condition inhibiting balance or significant history of injury/surgery to their ankle was disqualified from participation in the study. Participants were not currently enrolled in a structured strength or cardiovascular training program and were not actively competitive athletes. Participants were encouraged to wear athletic apparel during testing and training sessions.

Pre and Post Test Measurements: Pre-test and post-test procedures preceded and followed 4 weeks of balance training exercise. Measurements and procedures used in testing were performed in the same manner and sequence during both testing periods.

Performance of the SEBT testing was completed in the anteromedial, medial, and posteromedial directions to reduce redundancy (4). The participants had leg length measurements taken from the distal tip of their medial malleolus to their anterior superior iliac spine (ASIS). This measurement allowed for normalization of the SEBT reach data between all participants regardless of gender and height (3). SEBT reach measurements were taken while participants were balancing on their preferred/dominant weight-bearing limb. Three repetitions for each tested direction were obtained. Fifteen seconds of rest time were allowed between repetitions. The three values were averaged and normalized for data analysis procedures. To ensure each participant used their dominant weight bearing leg throughout testing, researchers asked participants which leg they would use if they had to jump for maximum height off of one foot. The preferred leg was used throughout the study for pre and post testing, as well as the training protocol. All participants completed the SEBT testing procedures prior to testing on the force plate.

Force plate testing consisted of two ten second trials; one with eyes open and one with eyes closed. Participants were instructed to stand on their dominant weight bearing leg, place hands on their hips, slightly flex opposite hip and knee. For the eyes open trial the participants were asked to focus on a dot, which was drawn on a dry erase board and placed 65 cm away at eye level.

Exercise Protocols

Traditional Balance Program: The traditional exercise protocol consisted of: 1) SEBT in eight directions; 2) DynaDisc[R] balance with eyes open; 3) DynaDisc[R] balance with eyes closed; 4) DynaDisc[R] ball toss; 5) DynaDisc[R] ORBITS. These activities were selected because it was felt that they matched the various styles of exercise commonly used during non-video based balance training programs. All exercises were timed using a hand-help stopwatch so that time actually spent performing the balance exercises matched up with study design protocols. Star excursion balance testing was done with the participant balancing on the dominant weight bearing leg in the center of the eight-direction SEBT asterisk. The participants held their hands on their hips and reached out as far as they could with their non-dominant leg in each direction, gently touching their toe on the ground. They would return to starting position and immediately proceed to the next sequential direction. This exercise was continued in all eight directions in a clockwise manner for 90 seconds and repeated it for another 90 seconds in a counterclockwise direction. Following the SEB training, the participants were asked to balance on the DynaDisc[R] for three minutes with their eyes open, trying to avoid losing their balance. Ball tossing and catching was added to open eyed DynaDisc[R] balancing for three minutes, followed by balance on the DynaDisc[R] for three minutes with eyes closed. The final activity was three minutes of DynaDisc[R] Single Leg ORBITS (see Figure 1). This exercise was created by one of the investigators (TB) and consisted of single-leg balance on the DynaDisc[R], while simultaneously using the toes of the opposite foot to move a tennis ball around their DynaDisc[R] platform in a fashion similar to the moon orbiting the earth. The participants were to use their non-supportive leg to roll the tennis ball on the ground around the DynaDisc[R] as far as they could and then reversing the pattern. Light toe touch of the non-stance foot was allowed on the tennis ball in order to maintain balance, but verbal motivation was given to encourage as light a touch as possible without loss of balance. Exercises during the traditional program were timed for a total of 12 minutes of actual exercise. Participants had the option to rest in between exercises, but this time was not counted in their total exercise time.



Dance Dance Revolution (DDR) Program: Inclusion in the DDR[R] exercise protocol, allowed participants the opportunity to play DDR[R] games using one foot. The typical DDR[R] pad consists of four directional (anterior, posterior, medial, and lateral) response arrows on the edges of a game mat. The game mat measures approximately 3 meters by 3 meters, with the center of the pad serving as a non-responsive "free zone". During play, the player must respond to a series of arrows pointing left, right, up, or down continually scroll on the television screen, by moving their non weight bearing foot and touching the corresponding arrow on the game mat with the arrow on the television screen. Typically the game is performed using both feet, but the researchers have begun using single leg stance play as a way to focus on balance training (see Figure 2). During the balance training sessions the participants were required to perform a single leg stance with one foot in the middle of the pad and the hip and knee slightly flexed while touching the direction arrows with the heel or toes of the opposite foot for the duration of each song (approximately 90 seconds). If the game presented the participants with a "double arrow" they were advised to choose one direction and continue play. The DDR[R] training sessions consist of game participation of three repetitions for each of three pre determined songs. This format created nine performance opportunities of approximately 90 seconds each, so that total balance training exercise time was between 12 and 15 minutes. The difficulty setting was pre-determined by the researchers and was consistent for each participant throughout the testing period regardless of ability.


Wii Program: The Wii Fit [R] exercise protocol consisted of game play of selected balance training exercises created by the Nintendo Corporation. The Wii[R] Fit Balance Board was placed about 2 meters from the television screen with ample space around the board to prevent injury (see Figure 3). Each session, the subjects were instructed to perform the same three games on the balance board, each for a minimum of 4 minutes and a maximum of 5 minutes in an attempt to remain within the parameters of 12 to 15 minutes of actual balance training exercise. Members of the research time used hand held stop watches to record actual activity time for each participant to ensure accuracy and compliance.

Three games were pre selected by the research team and were used throughout the training period. They consisted of Ski Slalom, Table Tilt, and Balance Bubble. In Ski Slalom, the subjects stood on the Wii Fit[R] Balance Board and weight shifted in medial and lateral directions to facilitate navigation of a downhill skiing slalom course. Anterior and posterior postural sway affected speed of the virtual skier. Table Tilt is a virtual re-creation of the old childhood game where a tabletop is tilted to assist in getting a ball to drop through a hole in the table. By modifying their base of support and center of pressure, the participants were able to virtually tilt the table to complete the game. The tilt of the table corresponded to the movement of participant's center of gravity in all directions. Balance Bubble was also a game based on postural movement in both the frontal and sagittal planes. The participant's character was located in a large bubble that floated on water. By using anterior lean to propel the bubble and posterior sway to slow it, along with medial and lateral movement to steer away from obstacles the object of the game was to complete travel down a virtual river avoiding the river edge during switchbacks and bends. In all game play, participants were instructed to keep both feet on the board at all times and to only use postural sway as methods for game play control.

Qualitative Questionnaire

Following the post testing procedures a brief email survey was sent to each participant requesting their feedback on the balance training exercise programs that they participated in. Each participant was sent the following message:

Please reflect on the exercise activity you were asked to perform during the 4-week training session and answer the following questions. Please use the following numbers to explain your response: 1= Not Very, 2= Mildly, 3=Somewhat, 4=Moderately, 5=Very

1) How difficult was your program?

2) How engaged were you during your program?

3) How enjoyable was your program?


Data was analyzed using Statistical Package for Social Sciences (SPSS), Version 14. Paired sample t-tests were performed to examine pre and post test differences among individual measurements for all groups. Statistical significance was found between pre and post testing of Star Excursion Balance testing of the traditional group in the anteromedial (p = 0.004) and medial (p = 0.027) directions. The DDR[R] trained group showed significant improvement in the average displacement from the force plate platform center on the y-axis, as well as, the average deviation of the center of pressure (COP) from the y centroid of the base of support (BOS) at (p = 0.028, p = 0.031) respectively. Significant improvement was elicited from the Wii Fit[TM] trained group at (p = 0.043) for reducing the average deviation from the COP from the y centroid of the BOS. The improvements for all three groups were noticed only within the pre and post testing trials performed with eyes open.

Analysis of Variance (ANOVA) tests were run examining between group performance for each pre and post testing measurement. Significant improvement was noted between the groups during the post test eyes open force plate trials for average displacement from the force plate platform center on the y-axis (p = 0.022) and the average deviation of the COP from the y centroid of the BOS (p = 0.013) Tukey post hoc evaluation determined the significant difference was found between the traditional and DDR[R] trained groups for average displacement from the center of the force plate platform with the DDR[R] group showing significant improvement over the traditional group (p = 0.029). With regard to the average deviation of the COP from the y centroid of the BOS, it was noted that both the DDR[R] and Wii Fit[TM] balance trained groups showed significant improvement over the traditional group (p = 0.014 and p = 0.028) respectively.

Descriptive statistics for the qualitative portion of the study can be found in Table 1. Analysis of the responses to the qualitative survey questions educed that the participants reported statistically significant differences between the difficulty (p = 0.016) and enjoyment (p= 0.003) of their programs. Post hoc analysis regarding difficulty detailed that the traditional group felt that their exercise program was between somewhat and moderately difficult, whereas the Wii Fit[TM] group felt that their program was between not very and mildly difficult. There was a significant difference between perceived difficulty with the traditional program being considered to be more difficult than the Wii Fit[TM], program (p = 0.014). Significance was approached when comparing the perceived difficulty of the DDR[R] program to that of Wii Fit[TM] (p= 0.073) with Wii Fit[TM] being the easier of the two games to play. Upon evaluation of perceived enjoyment of the program, both video game based programs showed a significant increase in amount of enjoyment over the traditional program (DDR[R], p = 0.007, Wii Fit[TM], p = 0.006). Although the mean scores for both video game based programs were higher than that of the traditional program regarding engagement in the program, no statistical significance was noted between the groups.


This research is the first to critically evaluate the efficacy of video game based balance training programs. Previous research studies have shown that balance programs have proven effective in improving balance measurements in a variety of settings (1, 2, 6, 7, 9, 10). This study does not disprove the results of those previous studies, but instead provides positive evidence of efficacy for the clinician who chooses to use video game based activities in their balance training programs.

During this study, traditional balance program participation significantly improved two of the three tested Star Excursion Balance activities from pre to post testing. It should be pointed out that these areas of improvement were noted in activities that were also used as a training exercise during the 4-week training period. It is a distinct possibility that a training effect occurred from these activities. However, despite their effectiveness, traditional balance programs often elicit patient compliance difficulties. It is also important to note that in this study the traditional balance program had the lowest observed scores for patient engagement and enjoyment. This confirms the suspicions and concerns of previous researchers regarding the compliance in traditional balance programs (2).

In addition to the improvements from the traditional program exercises, statistical examination of pre and post test performance measurements also determined that both DDR[R] and Wii Fit[TM] balance training programs significantly reduced anterior and posterior postural sway. DDR[R] training reduced the average deviation from the centroid of the data in the y-axis, whereas both DDR[R] and Wii Fit[TM] reduced the average deviation of the COP from the y centroid of the BOS. The improvement in reducing postural sway in the sagittal plane was improved only through the use of video game based balance exercises.

Examination of qualitative perceptions regarding the individual balance programs allowed the researchers to discover that video game based balance programs were apparently less difficult and more engaging and enjoyable than the traditional program exercises. It is unclear whether these programs are actually easier, but it stands to reason that this lower level of perceived difficulty leads to increased enjoyment and therefore compliance. Regardless of whether the video game based programs are actually easier or whether the performance improvements in the video game based participants occurred due to the increased enjoyment and attention; the fact remains that there was balance performance improvement in the video game based exercise groups. Consequently, based on both the objective and subjective data of this study there is scientific reason to include and use video game based balance programs in clinical practice.


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(5.) Kidgell, D.J., Horvath, D.M., Jackson, B.M., & Seymour, P.J. Effect of six weeks of dura disc and mini-trampoline balance training on postural sway in athletes with functional ankle instability. J Strength Cond Res 21(2):466-9, 2007.

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(7.) McHugh, M.P., Tyler, T.F., Mirabella, M.R., Mullaney, M.J., & Nicholas, S.J. The effectiveness of a balance training intervention in reducing the incidence of noncontact ankle sprains in high school football players. Am J Sports Med 35(8):1289-9, 2007.

(8.) McKeon, P.O. & Hertel, J. Systematic review of postural control and lateral ankle instability, Part 2: is balance training clinically effective? J Athl Train 43(3):3-5-315, 2008.

(9.) Verhagen, E, van der Beek, A., Twisk, J., Bahr, R., & van Mechelen. W. The effect of a proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial. Am J Sports Med 32(6);1385-93, 2004.

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Kirk A. Brumels, PhD, ATC, Troy Blasius, Tyler Cortright, Daniel Oumedian, and Brent Solberg Hope College, Holland, MI


Kirk Brumels, PhD, ATC

Hope College--DeVos Fieldhouse

222 Fairbanks Ave

Holland, Michigan 49423


Table 1. Descriptive Statistics for Qualitative Questionnaire

Group Question N Minimum Maximum Mean SD

Traditional Difficult 6 2 4 3.17 .753
 Engaged 6 2 5 3.33 1.211
 Enjoy 6 1 5 2.17 1.472
DDR Difficult 7 1 4 2.71 .951
 Engaged 7 2 5 4.14 1.069
 Enjoy 7 3 5 4.14 .690
Wii Fit Difficult 5 1 2 1.60 .548
 Engaged 5 4 5 4.40 .548
 Enjoy 5 4 5 4.40 .548
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Article Details
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Author:Brumels, Kirk A.; Blasius, Troy; Cortright, Tyler; Oumedian, Daniel; Solberg, Brent
Publication:Clinical Kinesiology: Journal of the American Kinesiotherapy Association
Article Type:Report
Geographic Code:1USA
Date:Dec 22, 2008
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