Shih CH: A standing location detector enabling people with developmental disabilities to control environmental stimulation through simple physical activities with Nintendo Wii Balance Boards. Res Dev Disabil 2011, 32: 699-704. 10.1016/j.ridd.2010.11.011 When it comes to talking to people about weight, the words we use matter,” Dr. Puhl said. During research, she found that in both adolescence and adults, words like obese or fat can lead to feelings of shame. Rather than labeling a patient as obese, her team of researchers recommend that doctors default to using neutral words that don’t suggest a moral judgement or failing. Miller CA, Hayes DM, Dye K, Johnson C, Meyers J: Using the Nintendo Wii Fit and body weight support to improve aerobic capacity, balance, gait ability, and fear of falling: two case reports. J Geriatr Phys Ther 2012, 35: 95-104. 10.1519/JPT.0b013e318224aa38 Padala KP, Padala PR, Malloy TR, Geske JA, Dubbert PM, Dennis RA, Garner KK, Bopp MM, Burke WJ, Sullivan DH: Wii-Fit for Improving Gait and Balance in an Assisted Living Facility: A Pilot Study. J Aging Res 2012, 2012: 597573.

To what extent two Wii Fit body test metrics correlate with standardized tests of older adult fitness, balance and mobility was recently determined by Reed-Jones and colleagues[ 13]. These researchers compared a battery of clinical examinations with the “Basic Balance Test” and the “Prediction test” of the Wii Fit software. Overall, there was little correlation between the clinical tests and the data provided from the Wii Fit software-based tests of balance. This finding mirrored that which was described by Gras et al.[ 6], who also found that the center of balance test was not a valid measure compared to its counterpart determined via a force platform. Further, Wikstrom[ 40] found poor validity and reliability for 12 of the exer-games associated with the Wii Fit software compared to a standard balance test. This result may reflect the different requirements of balance for gaming and the balance test utilized by Wikstrom[ 40]. Taken together, however, these results suggest that Wii Fit software-based measures of balance ability are not effective. Using the Wii Fit for balance intervention We know from research that weight is one of the most prevalent reasons that kids are teased or bullied.”When friends would come round to play, I would tell them that the Wii Fit board was broken because I didn’t want them to see what it said.” Wii Fit took none of these nuances into account. It might be easy to just write Wii Fit off as a well-intentioned game that used a common index for its time, but even then, the game was inconsistent with what it considered to be a good and bad BMI. Polygon reviewed one play through where the player had a “healthy” BMI of 22.97 by the game’s and medical standards, but the game still suggested that the person try to lower it. Shih C-H, Shih C-T, Chu C-L: Assisting people with multiple disabilities actively correct abnormal standing posture with a Nintendo Wii Balance Board through controlling environmental stimulation. Res Dev Disabil 2010, 31: 936-942. 10.1016/j.ridd.2010.03.004

Use and acceptance of the Wii Fit as a balance assessment and neurorehabilitation tool is growing rapidly. With respect to assessment, initial attempts to use the WBB as a low cost proxy for a scientific force platform via customized software applications appear to be an extremely promising area of exploration. Research relying on measurement of balance ability using Wii Fit software-based metrics, however, has been far less convincing to date. With respect to balance neurorehabilitation, there is reason for optimism regarding the use of Wii Fit-based interventions to foster meaningful balance improvements across a variety of clinical populations. Multiple studies now show improvement in balance control following reasonable periods of training with the Wii Fit games and custom designed applications. Koslucher F, Wade MG, Nelson B, Lim K, Chen FC, Stoffregen TA: Nintendo Wii Balance Board is sensitive to effects of visual tasks on standing sway in healthy elderly adults. Gait Posture 2012, 36: 605-608. 10.1016/j.gaitpost.2012.05.027 The only randomized control clinical study at the time of the fifth anniversary was carried out by Nilsagard[ 29] in individuals with multiple sclerosis (MS). MS Patients who played Wii Fit games twice a week for six weeks showed a moderate improvement in the timed up and go test (Cohen’s d = 0.4) and small improvements in the four square step test (Cohen’s d = 0.1) and activities based balance confidence assessment (Cohen’s d = 0.2) compared to a group of individuals with MS that did not play Wii Fit games. These results, while positive, were less impressive than those seen for healthy older adults. Bateni H: Changes in balance in older adults based on use of physical therapy vs the Wii Fit gaming system: a preliminary study. Physiotherapy 2012, 98: 211-216. 10.1016/j.physio.2011.02.004 Saposnik G, Mamdani M, Bayley M, Thorpe KE, Hall J, Cohen LG, Teasell R: Effectiveness of Virtual Reality Exercises in STroke Rehabilitation (EVREST): rationale, design, and protocol of a pilot randomized clinical trial assessing the Wii gaming system. Int J Stroke 2010, 5: 47-51.Franco JR, Jacobs K, Inzerillo C, Kluzik J: The effect of the Nintendo Wii Fit and exercise in improving balance and quality of life in community dwelling elders. Technol Health Care 2012, 20: 95-115. The ubiquitous importance of balance research for neurorehabilitation is unquestioned based on epidemiological reports indicating that older adults and various individuals with neuromuscular disability conditions have an increased likelihood for catastrophic fall-related injuries[ 43– 47]. The cost of such injures is not just to the individual but to the greater health care system at large. To this extent, the goal of the present review was to summarize the first half decade of Wii Fit balance research and provide insight regarding the important results that will shape the next five years. Literature for this review was obtained through a targeted search of PubMED and MEDline databases using keywords such as “Wii” and “Balance”. Papers were included that used the Wii Fit system or WBB for the assessment or training of balance ability. In the first half of this review, approaches are overviewed that utilized the Wii Fit as a neuroengineering tool for balance assessment. Alternatively, the second half of this review discusses detailed evidence supporting use of the Wii Fit as a balance intervention tool for both healthy and diseased populations. Balance assessment using the Wii Fit system Comparing the WBB and a scientific grade force platform Deutsch JE, Brettler A, Smith C, Welsh J, John R, Guarrera-Bowlby P, Kafri M: Nintendo wii sports and wii fit game analysis, validation, and application to stroke rehabilitation. Top Stroke Rehabil 2011, 18: 701-719. 10.1310/tsr1806-701 Goble, D.J., Cone, B.L. & Fling, B.W. Using the Wii Fit as a tool for balance assessment and neurorehabilitation: the first half decade of “Wii-search”.

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