Technology and Health Care 20 (2012) 95–115
The effect of the Nintendo Wii Fit and
exercise in improving balance and quality of
life in community dwelling elders
Jessie R. Francoa, Karen Jacobsb,∗, Catrina Inzerillocand JoAnn Kluzikb
aBoston University, Haskell, NJ, USA
bBoston University, Boston, MA, USA
cCovenant House, Brighton, MA, USA
Received 26 September 2011
Revised 7 November 2011
Abstract. Introduction: This study compared the effect of Nintendo Wii Fit to the Matter of Balance program, a valid and
reliable program, on improving balance, and well-being to decrease the risk of falls.
Methods: Residents of an independent living senior housing facility were recruited and thirty-two residents ages 63 to 90
participated. Participants were separated into three groups: (1) Wii Fit group (n = 11) completed balance games on the Wii Fit
inindividual sessionstwiceaweekandsupplemental homeexercises; (2)MatterofBalanceGroup(n =11)completedexercises
from the Matter of Balance Program in a group setting twice a week; (3) Control group (n = 10) received no intervention.
Intervention lasted three weeks.
Results/findings: One-way ANOVA’s were completed. Scores from the assessments were not statistically significant at
post-test Berg Balance Scale (p = 0.837); Tinetti Gait and Balance Assessment (p = 0.913); SF-36 (p = 0.256). Results from
a self-report demonstrated that Wii Fit is an enjoyable form of exercise for an elderly population.
Conclusion: Although, the interventions failed to significantly increase balance, with an increase in intervention duration of
Wii Fit or Matter of Balance balance may be improved. Although results were not significant this study adds to the growing
body of evidence regarding the use of Wii Fit as a rehabilitation tool.
Keywords: Fall prevention, balance, exergaming, Wii Fit
Over 35.9 million Americans are 65 years or older . The elderly population is defined to include
thosewith a chronologicalage of 65 yearsand older. The elderly populationis rapidly increasing and
currently makes up 12% of the population . By 2030 the number is estimated to grow to 72 million
and represent about 20% of the population .
Important health problem for the elderly population include changes in balance and an increased fall
risk, that increases with each decade over the age of 60 [3–6]. A fall is defined as any unintentional
positional change that results in a person coming to rest on the ground, floor, or other lower surface .
∗Address for correspondence: Karen Jacobs, Boston University, 635 Commonwealth Ave., Boston, MA 02215, USA. Tel.:
+1 617 353 7516: Fax: +1 617 353 2926; E-mail: firstname.lastname@example.org.
0928-7329/12/$27.50 ? 2012 – IOS Press and the authors. All rights reserved
96 J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise
Approximately one third of community-dwelling elders over the age of 65 fall each year resulting in a
widerangeofconsequences,from bruisingto fractures; halfoftheseindividualswill experiencemultiple
falls [7–12]. Falls and fall related injuries are a leading cause of non-fatal injury . It is important to
keep in mind that 40–50% of fallers admitted to a hospital will next be admitted to a nursing home .
As a result of falling, a fear of falling is developed, which is an excessive apprehension about falling
that causes the person to change their activities even in the absence of physical disability or injury .
This fear usually presents in a cyclical fashion consisting of decreased confidence to complete common
tasks, muscle atrophy, impaired balance, and overall reduced quality of life [11,13,14]. As the elderly
population continues to grow, it is prudent to investigate this phenomenon and create a solution that will
help decrease the incidence of falls.
Major risk factors and predictors of falls for the elderly population include impaired or decreased
mental status, medication side effects, visual impairments, balance and gait impairments, and lower
extremity weakness [11,12]. The addition of exercise and balance training to a faller’s daily life could
help address the risk factors of balance and gait impairments and lower extremity weakness.
The aim of this research study was to compare a traditional exercise program, Matter of Balance
(MOB) used to improve balanceand coordinationin the elderly population with the exergamingprogram
The Wii Fit is an example of active gaming or ‘exergaming’, which has begun to gain increasing
popularity across all ages, including the elderly population. The Wii Fit features yoga, strength training,
aerobics, and balance games. The player stands on the Wii Balance Board, which monitors and tracks
the position of the player’s center of pressure on the board so that the video monitor can provide the
participant with information about their alignment and balance control during the activities. Currently,
there is insufficient evidence to determine whether Wii Fit training improves balance in the elderly
The MOB program is an education and exercise program that has been used with the community
dwelling elder population with success since 1998. The MOB program focuses on teaching participants
practical coping strategies to reduce their fear of falling and risk of falling . Early program sessions
focus on first changing attitudes and self-efficacy before introducing exercises to improve balance and
strength in latter sessions . The MOB program has been shown to improve “confidencein managing
andcontrolling falls aswell as engagingin everydayactivities without falling” . Severalstudieshave
shown that participating in the MOB program improves activity levels and increases falls efficacy [16–
19]. Beginning sessions of the MOB program use a cognitive restructuring approach to help instill
adapted beliefs in participants and educate about self-conception regarding falls . Following the
cognitive restructuring, strength training exercises using an elastic resistance band were introduced to
help improve strength and balance to reduce fall risk . The MOB program was chosen as a control
exercise group due to its past success in improving falls efficacy and decreasing the fear of falling and
current adoption as a large scale community-wide fall prevention program [16,18,19].
2. Review of the literature
2.1. Balance in everyday activities
Balanceis the ability to maintain an upright postureagainstthe changingeffects of gravity on the body
segments . Postural control mechanisms help a person maintain balance by ensuring that the center
of gravity is maintained within the base of support . There are three different ways a person’s center
J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise97
of gravity can be displaced during the completion of daily activities 1) by an external force applied to
the body (i.e., during contact sports), 2) by external movement of the support surface (i.e., when moving
from sit to stand), or 3) during activities that require movement of the head, limbs, or trunk .
Balance is a complex activity that requires input from many different sensory systems to regulate the
relationship between the center of mass and base of support. The four main sensory systems for balance
are the vestibular, visual, tactile, and proprioceptive systems [20,21]. Information from the different
sensory systems is integrated in the central nervous system, which coordinates movement commands to
the musculoskeletal system to perform balance maintenance and correction actions . Age-related
deterioration of the sensory systems occurs as a person grows older and is one reason why there are
changes in balance control and fall risk in the elderly population [3–6]. Impaired vision and vision
diseases can alter depth perception, visual acuity and peripheral vision, which limits one’s ability to
safely negotiate the environment . Some of these sensory changes can be repaired or compensated
for, however these compensatory abilities also decrease with age; thus balance is a function usually
impaired in the older adult .
In addition to changes in sensory systems, there are age-related changes in the musculoskeletal and
neuromuscular control systems that also effect balance control with advancing age . Major changes
that occur in the neuromuscular and musculoskeletal systems include a stiffening and loss of elasticity
in the tissues, decreased bone density, and a decrease in muscle mass and strength . The elderly
are also more susceptible to chronic diseases, such as diabetes, arthritis, osteoporosis, and Alzheimer’s
disease,that affect their sensory, motor and/or cognitive functions . Also decreased physicalactivity
tends to lead to decreased muscle strength and skeletal integrity, which leads to decreased balance, and
an increased fall risk .
There are several other factors that lead to an increased fall risk in aging individuals. Decreased bone
density due to osteoporosis contributes to fractures when falls occur . Lack of physical activity
leads to poor muscle tone, decreased strength, and loss of bone mass and flexibility . Medications
can reduce mental alertness and drop systolic blood pressure while standing and lead to a greater fall
risk . Environmental hazards such as poor lighting, loose rugs, and excess floor clutter increase the
chance of falling while in the home .
2.2. Maintaining older adults in their home
Independence in the home plays an important role in the quality of life in older adults . People
create part of their identity from living in one place for a long period of time and their home becomes a
place associated with family and friends .
A survey completed by AARP in July 2010 compiled the responses from 1,616 adults’ ages 45 and
older . Nearly three-quarters (73%) of respondents strongly agreed with the statement “what I’d
really like to do is stay in my current residence for as long as possible” . Two-thirds of participants
noted that being near friends or family and being near where one wants to go is extremely or very
important to them . Additionally aspects of one’s community continue to be a motivating factor
for aging in place, as two-thirds of respondents want to stay in their home because they like what their
community has to offer them . These responses show that a large majority of older adults want to
stay in their home as long as possible.
Balance difficulty and high fall risk is one important reason why elders cannot safely remain living
independentlyin their homes. One effective way to keep more seniors independentat home is to provide
balance and fall prevention training. Fall prevention training helps seniors learn how to respond to
98 J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise
different situations where falls could occur (i.e. icy sidewalks). In addition, education about home mod-
ifications can reduce fall risk. Home modification such as replacing outside stairs with a ramp, installing
handrails, and installing bathroom grab bars, can help seniors live more safely and independentlyin their
2.3. Improving balance and reducing fall risk through exercise
Impairments in muscle strength, reaction time, vision, cognition, gait, and balance increase the risk of
falls for the elderly population [27,28]. It has been shown that physical activity and exercise improve
balance and reduce the risk of falls [9,29]. Specifically, programs with a strong balance component
that includes a challenging component such as practice of reactive recovering from change-in-support
reactions, recovery during self-initiated movements and practice with narrowing or different bases
of support, are especially effective [10,30,31]. Also, multifactorial exercise programs, in a group
or individual format, incorporating at least two different types of exercise, either strength, balance, or
27,32]. Strengthening exercises are not effective in preventing falls on their own but are an important
component of a multifactorial program . Exercises can be diverse but usually target specific muscle
groups and vary the frequency,intensity and progression of the exerciseswith the thoughtthat increasing
muscle mass and strength of weak muscles will help to improve balance [9,28]. Walking, treadmill
walking, and stationary bicycles with levels monitored using target heart rates are typically used to
increase endurance and aerobic capacity .
Tai Chi has been found to positively affect participants’ “balance, mental outlook, and stress” .
Movements emphasize weight shifting, coordination, trunk rotation, and the gradual narrowing of the
lower extremity stance . Following a weekly tai chi group (n = 30) over a six-month period, with
a 3-week learning period, fear of falling during daily activities was significantly decreased in the older
female with osteoarthritis population . Sattin et al. , investigated the effects of an intense tai chi
exercise program versus a wellness education program on decreasing fear of falling. Intense tai chi was
defined as two sessions per week with initial sessions lasting 60 minutes increasing to 90 minutes over
a period of 48 weeks . Results showed a significant reduction (P < 0.001) in fear of falling for the
tai chi group after 12 months of intervention. Tai Chi has also been shown to improve performance on
functional balance measures .
2.4. Matter of Balance
The aim of the MOB program is to reduce fear of falling in older individuals, stop the fear of falling
cycle, increase activity levels, and address attitudes and beliefs about falls [15,36]. The program is a
standardized set of educational instruction and exercise that is run with two 2-hour group sessions per
week for 9 weeks, although there is some flexibility to vary the program delivery. Numerous studies
have demonstrated positive effects of the MOB intervention on participants’ self-reported activity levels,
balance confidence, and self-efficacy for fall prevention [16–19]. MOB sessions are typically lead by
a trained facilitator who is a health care professional, volunteer lay leader, or community member/non-
health care professional. A discussion portion of the program uses cognitive restructuring techniques to
change negative beliefs into more adaptive ones . For example changing the thought of “I am too
old. If I engage in exercise I will injury myself” into “With guidance and some adaptations I can safely
participate in exerciseregardlessof my age”. Throughoutthe program, participants’ concernsabout
falls are acknowledged and recognized as a rational response to the threat falls pose to older adults .
J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise99
A randomized trial completed by Tennstedt et al.  and then repeated by Zijlstra et al. , showed
that the MOB program increased fall self-efficacy, which is the confidence a person has in performing
common tasks without falling, and activity levels in community-dwelling adults who have restricted
activity due to fear of falling .
Beling and Roller  measured the effectiveness of the MOB program on muscle strength, gait,
balance and fall risk among community-dwelling elders. Those in the experimental group (n = 12)
attended MOB class 3 times a week for 1 hour over a period of 12 weeks, with participants required to
attend a minimum of 30 sessions. The intervention consisted of exercises from the exercise portion of
the MOB program and additional activities that challenged and trained balance. The additional activities
worked on balance with a decreasing base of support, weight shifting, forward reaching, and challenges
to dynamic visual acuity. The MOB exercises and additional balance exercises were conducted in a
large group format. These large-group activities were followed by smaller group station activities and
concluded with a large group repeated sit-to-stand exercises while holding onto a therapy ball, of which
size and weight increased as performance improved. The smaller group station activities were done in
addition to the standard MOB exercises. Results on the Berg Balance Scale showed improvements over
time for the experimental group (from 48.1 to 52.9 out of 56) and decreases for the control group (from
49.1 to 47.8 outof 56) . Although this study hada small sample size,those participating experienced
a decreased fall risk and improved functional balance (p ? 0.05), which could be generalized to other
community dwelling elders.
2.5. Wii Fit
The Nintendo Wii Fit is an interactive video exercise game that has shown promise for improving
balance in the elderly [38–40]. Wii Fit is structured as a series of games, intended to be fun and
motivating. The Wii Fit software provides a number of ’fun’ games that feature balance training, yoga
(body alignment and controlled movements), strength training, and aerobic games. In addition to being
fun,theWii Fitalsoprovidesthe participantwith immediatefeedbackaboutthe movementsofthebody’s
center of gravity, a key measure of balance control. All exercises are performed on the Wii Balance
Board, which has pressure sensors that can measure a user’s center of gravity and weight. A video
monitor displays visual feedback about the approximate location of the body’s center of pressure with
respect to their base of support, i.e. foot location. The participant receives online feedback about how
much and in what direction they are swaying or leaning while they perform balance exercises. Studies
using instrumented force plates, which are costly, suggest visual feedback on postural control can be
used to predict fall risk in both those with and without balance problems [41,42]. The Wii Fit board is
a low-cost alternative to an instrumented force plate and Clark et al.  showed that the Wii balance
board is an adequate tool to measure standing balance through center of pressure location.
Severalrecent studies, all with small sample sizes, suggestexercisewith the Wii Fit improves balance.
Nitz et al.  conducted a study with 10 healthy women, 30–58 years using Wii Fit. Intervention con-
sistedof30minutesessionstwiceweeklyfor10weeks. ParticipantsfollowedaWii Fitregimeconsisting
of balance games,yoga, aerobic, and strength activities. Results showed a significant improvement(p <
0.05) in balance and lower limb strength. However, reaction times and flexibility did not improve. The
samplesize ofthe study wasrelatively small, with only three participants completingall Wii Fit sessions.
A study conducted by Hermes et al.  compared the use of Wii Fit (n = 4) versus traditional
exercise (n = 4) versus no exercise (n = 4). Intervention occurred over a period of eight weeks,
with four participants in each group. Wii Fit sessions were offered at a senior center twice a week for
100 J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise
40 minutes. Sessions included flexibility, balance, strength training, and cardio exercises all using the
Wii Fit program and balance board. Participants in the traditional exercise group attended traditional
group exercise classes (traditional exercise was not defined). The Wii Fit group showed large changesin
exercise group showed greater changes in functional fitness (chair stand, arm curl, and 12 minute walk).
Results show that Wii Fit instead of traditional exercise could be used as an effective tool for improving
balance although it needs to be studied further with a larger sample size.
Bomberger et al.  compared the effects of Wii Fit on normal elderly (NE) and elderly with mild to
moderate balance concerns (MC). Eight participants in the NE group completed four weeks of Wii Fit
training for 20-minute sessions three times per week on non-consecutive days for a total of 240 minutes
measured using a stopwatch. Six participants in the MC group completed six weeks of Wii Fit training
for a total of 360 minutes measured using a stopwatch. All sessions began with three poses from the
yoga section and concluded with balance games. Results from the Berg Balance Scale showed a 3.84%
increase for the NE group and a 0.41% increase for the MC group. The Tinetti Gait and Balance
Assessment showed a total score increase of 1.80% and gait increase of 5.35% for the NE group and a
0.76% total score increase for the MC group. These results showthat Wii Fit training can be an effective
tool to improve balance in the typical elder population who do not present with balance concerns.
Part of why the Wii Fit may be effective in improving balance is that it may be more enjoyable
and motivating than traditional exercise. Older adults enjoyed participating in Wii Fit over traditional
treadmill walking and jogging . Greater improvements will be seen in those who continue to
participatein exerciseorbalancetraining andenjoymentis adeterminant,whichwill influencecontinued
engagement. Although promising, there is no evidenceto date aboutwhether older people exercisemore
consistently when using the Wii Fit versus other exercise approaches.
Although all the previously described research studies showed some improvement in participants’
balance when using the Wii Fit, changes were small and no evidence was provided about whether
ceased. Small sample sizes decreased the studies’ power and decreased their ability to generalize to
the community dwelling elder population at large. However, results are promising and justify further
research with larger sample sizes.
2.6. Improving overall quality of life through exercise
Quality of life is a very broad concept that looks at areas such as physical, psychological, and social
well-being [45,46]. Quality of life measures can provide a comprehensive profile of an individual.
Fall prevention programs effect fall risk as well as other aspects of health in a person’s life. It could be
A research study conducted by Lin et al.  compared the effects of three different interventions,
including exercise training, on improving quality of life, functional balance and gait, activities of daily
exercise portion of this intervention focused on stretching, muscle strengthening, and balance training.
Each session lasted 40 to 60 minutes over a period of 4 months. Resulted showed improved quality of
life for the exercise-training group. In comparison to the falls prevention education group, the exercise-
training group scored 2.1 points higher in the physical domain, 3.8 points higher in the psychological
domain, 3.4 points higher on the social domain, and 3.2 points higher in the environmental domain on
the World Health Organization Quality of Life instrument .
J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise101
power training (PT) on improving measures of quality of life in older adults. Over a period of 12 weeks,
participants in the ST and PT groups completed three training sessions per week, with the intervention
focus on lowerbody exercisesusing both Nautilus machinesanddumbbells . Participants completed
the Self-Efficacy for Strength (SE), the Satisfaction with Physical Function (SPF), and The Satisfaction
With Life Scale (SWL). Results showedsignificantchangein SE, SPF,and SWL for the PT group versus
control group and greater change in SE for the ST group versus control group . These results show
that PT may affect more levels of quality of life for the older adult, although more evidence is needed.
2.7. Purpose of study
Preventing falls as people age is an important public health issue and an important part of maintaining
activity levels and quality of life. Several systematic reviews identified balance exercises as one of the
critical components of effective fall prevention intervention programs [10,30,31].
fall risk in older individuals. The Wii Fit is widely available commercially, is relatively user friendly,
and can independently be used by an elderly population, thus would be a low-cost option for improving
balance. Wii Fit is also structured as a game and designed to be fun and motivating, which means that
people might exercise more frequently and consistently than they would with more traditional exercise
programs. However, there is very little evidence on whether exercises with the Wii Fit are feasible and
improve balance in older individuals. This study was conducted with community dwelling elders to
determine whether: 1) balance improves after a 3-week period of exercising with the Wii Fit, 2) balance
improves more using Wii Fit as compared to MOB exercises, which are not structured as games and do
not provide video feedback about body movements to the participant, and 3) the Wii Fit activities are
enjoyable. In addition to effects on balance, we investigated whether participation in the Wii exercise
intervention program improved perception of health and well-being.
This research study compares two different exercise programs for improving balance: Matter of
Balance and Wii Fit exercises. The study’s hypotheses are:
1. Participants in the Wii Fit group and MOB group will significantly improve in balance as measured
by the Berg Balance Scale and the Tinetti Gait and Balance Assessment.
2. Participants in the Wii Fit group and MOB group will significantly improve in health and wellness
as measured by the SF-36.
3. Participants in the Wii Fit group will make greater improvements in balance than the Matter of
3.1. Design of the study
This randomized group intervention study was structured using a mixed design with one repeated
factor (time: pre- and post-intervention) and one between-subject factor (intervention group: Wii Fit,
102J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise
(n = 11)
79.8 ± 4.7
Matter of Balance
(n = 11)
77.9 ± 6.9
(n = 10)
76.9 ± 6.3
Note: Age is given as Mean ± SD.
MA. All residents of the CovenantHousewere invited to participate in the study (n = 250). Thirty-eight
residents were interested in participating and of these, 32 residents (mean age 78.27 ± 6 yrs) completed
the study. Boston University Institutional Review Board approval was obtained prior to the initiation of
recruitment. Each participant gave informed consent before beginning testing and intervention.
Interested participants were screened for the following inclusion criteria: 1) being over the age of
sixty; 2) living independently within the community; 3) having the ability to see the television clearly
from 8 to 10 feet away; and 4) having the ability to ambulate independently with or without an assistive
device. Participants were excluded if they: 1) had decreasedendurance and could not stand long enough
to participate in the games (e.g., > 2 minutes); 2) had limited weight bearing capacity on both lower
extremities due to pain, injury or weakness; 3) had decreased cognitive ability to follow instructions and
grasp game objectives; or 4) unable to engage in 10–15 minutes of physical activity without a break.
There was no distinction or particular recruitment of participants based on gender, socioeconomicstatus,
religion, or ethnicity.
The participants were randomly divided into three subject groups. The groups were similar in age,
gender, and ethnicity (Table 1).
The three study groups were:
Experimental Group 2 – MOB Group: completed exercises from the MOB Program, administered
by the staff exercise physiologist.
Control group: received no intervention.
The age range for participants in the Wii Fit group was 73.9–90.9 years. In the Wii Fit group, one
participant ambulated with the assistance of a cane and one participant ambulated with the use of a
The age range for participants in the MOB Group was 63.2–84.9 years. In the MOB group, one
participant ambulated with the assistance of a cane.
The age range for participants in the Control group was 63.8–83.2 years. All participants were able to
ambulate independently without the use of assistive devices.
J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise103
3.3. Description of instrumentation
Three outcome measures were administered, with each participant completing all measures pre- and
post- intervention. The Berg Balance Scale and the Tinetti Gait and Balance Assessment were used to
quantify balance performance. The SF-36 was used to quantify health and well-being.
3.3.1. The Berg Balance Scale
The Berg Balance Scale  is a valid instrument for measuring balance in elderly individuals. The
scale consists of 14 items that test postural stability, including static and dynamic balance. Items are
graded on a scale of 0–4, with a total score ranging from 0 to 56 points. Higher scores reflect better
balance. The Berg was selected for use in this study because 1) it is a commonly used tool to screen for
fall risk and 2) it is a widely used tool to quantify balance in intervention studies aimed at improving
balance or reducing fall risk.
3.3.2. The Tinetti Gait and Balance Assessment
The Tinetti Gait and Balance Assessment  is used to assess mobility, balance, gait, and to predict
risk for falls . The assessment consists of 10 balance items for a total balance score of 16 and 8 gait
items for a total gait score of 12 with an overcall total possible Tinetti test score of 28. Like the Berg
Balance Scale, the Tinetti Assessment was selected as a balance measure because it is widely used to
assessfall risk and as an outcome measure to look at the effectivenessof interventions to reduce fall risk.
3.3.3. SF-36 health survey
The SF-36 health survey  consists of 36 questions yielding an 8-scale profile of functional health
and well-being scores. Scores range from 0 to 100 and higher scores mean that quality of life is high or
not hindered by health issues.
3.3.4. Wii Fit Enjoyment Questionnaire
Participants in the Wii Fit group completed the Wii Fit Enjoyment Questionnaire, a questionnaire
developed specifically for this study. Questions were related to enjoyment of the Wii Fit balance games,
motivation, interest, and perceived improvement in balance.
3.3.5. Wii Fit program and balance board
The Nintendo Wii Fit program and accessory balance board were used with the Wii Fit group. The
balance board contains several pressure sensors that enable real-time measurement of the location of the
participant’s center of pressure .
3.4.1. Initial meeting and pre-testing
Informed consent was obtained from participants during the recruitment phase. Russian participants
were given Russian versions of the consent form to read, although they signed an English copy. The
author and an exercise physiologist from The Covenant House held meetings to inform the residents
about the project and to explain procedures and requirements for participation. Participants who signed
consentforms were scheduledfor pre-testing sessions in either an individual or group session depending
on the need for translator assistance. At the start of each pre-testing session, participants were again
informed of all procedures, their group placement, and the participation requirements based on their
group. Next, the authoradministered the Berg BalanceScaleandTinetti Gait andBalanceAssessmentto
the participant. The SF-36 and a demographic questionnaire were also completed. Intervention sessions
and post-testing schedules were arranged at this time.
104J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise
Interventions varied by group. Participants were randomly assigned to one of three groups using
a random number table. Participants in the Wii Fit group received the following interventions over a
three-weekperiod: 1) individualWii Fit training twice aweek; and2) supplementalhomeexercises. The
home exercises included exercises recommended by the National Institute on Aging to improve balance
and flexibility . The supplemental exercises were included to add a strengthening component to
the Wii Fit group’s intervention because systematic reviews have shown that multifactorial exercise
programs which include balanceexercisesand strengtheningare the most effective types of programs for
decreasing fall risk . The MOB group received the following interventions over a three-week period:
1) group strength/balance training using exercises from the MOB Program twice a week.
3.4.3. Wii Fit intervention
Participants in the Wii Fit group met for individual sessions led by the author twice a week for three
weeks. Each exercise session lasted for 10–15 minutes of total playing time, with an average time of
13 minutes per participant (as tracked by the Wii Fit Bank) excluding rest breaks and instructional trials
before each game.
A total of five Wii Fit games were introduced to participants across the three-week intervention
period with the five games being the same for all participants. Participants were encouraged to try
each introduced game at least once and then used their own discretion to select games to play for the
remainder of the session. Participants engaged in as many as three to five different games within a
session, depending on their self-reported level of fatigue and motivation. The author maintained control
overthe remote throughoutthe sessionto decreasethe chanceof incorrectbutton inputfrom participants.
During the first week, participants were introduced to soccerheading, which simulates heading soccer
balls in the goalie position; ski jumping, which simulated skiing down a take-off ramp and jumping to
attemptto landas far aspossibledownthe hill; andskislalom, in which participants skiedbetweengates.
During the second week, participants were presented with the Wii tightrope game in which they had to
maintain balance while walking across a tightrope. During the third week, participants were introduced
to table tilt, in which they had to shift their balance to get the marble into the holes and advance to the
next level; and the balance bubble, in which participants attempted to navigate down a river in a bubble
without bursting it on the sides.
During each of the Wii Fit Sessions, the researcher documented the duration and games chosen. In
addition, during the first intervention session, participants completed the Wii Fit Evaluation, which
assessed their Body Mass Index (BMI) and Wii Fit Age. All information was kept confidential in a
secure coding system.
3.4.4. Supplemental exercises
Each participant in the Wii Fit group was instructed in a set of supplemental home exercises. First,
the researcher gave brief demonstrations of the exercises to ensure that participants understood how
to perform the exercise. Next, participants were given a packet of the home exercises, with English
instructions and photographs of each exercise. Participants were requested to complete each exercise
daily during the intervention period. The instruction packet provided a checklist for participants to track
which days they completed each exercise. During the initial exercise instruction session and in each
Wii Fit session, participants were given the opportunity to ask additional questions about the exercises.
The staff exercise physiologist was also available to complete the exercises with participants. With each
progressing week, participants were given a new checklist of exercises and asked to turn in their old
checklist. These packets were coded as they were submitted to maintain confidentiality.
J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise 105
3.4.5. Matter of Balance interventions
Participants in Experimental Group 2 completed the exercise component of the MOB Program, which
30–45 minutes, twice a week for three weeks. The exercise physiologist followed the MOB exercises
exactly as indicated in the manual . Each MOB session began with warm-up exercises, followed by
strength and balance exercises and concluded with cool-down exercises. Participants completed eight
repetitions of each exerciseduring the first week, increasing to twelve repetitions per exercise during the
second week, and culminating in fifteen repetitions per exercise during the third week. Participants in
the MOB were not required to complete the MOB class exercises outside of class.
3.4.6. Post evaluation
After three weeks of Wii Fit and MOB intervention were completed, each participant was re-evaluated
by the author using the Berg Balance Scale, the Tinetti Gait and Balance Assessment, and SF-36.
In addition, the participants in the Wii Fit group completed the Wii Fit Evaluation and Enjoyment
Questionnaire. Each of the forms associated with the assessments were coded to ensure participant
confidentiality and all data obtained was saved in a password-protected document on a password-
3.5. Data analysis
Repeated measures ANOVAs were used to determine whether there was an effect of the interventions
on both balance and health and well-being and whether there were any differences between intervention
groups. The within-subjects factor was time (pre-post intervention) and the between-subjects factor was
exercise(Wii Fit, MOB,Control). StatisticalProgramsfortheSocialSciences19(SPSS)wasusedforall
statistical analyses. One-way ANOVA’s were also performed on pre-test scoresto determine whether the
groups were similar in balance and health and well being at baseline, prior to beginning the intervention
programs. Results were considered significant when p < 0.05. Descriptive, homogeneity of variance
test, and Welch statistics were also analyzed.
4.1. Time spent in intervention
There was a 100% attendance rate for all participants in both the Wii Fit group and MOB group. On
average, participants in the Wii group played for 13.34 minutes each session according to data from
the Wii Fit’s log. This is a shorter duration than the 30–45 minutes sessions of the MOB participants.
However, the Wii Fit group was also instructed in a supplemental set of daily exercises (15 minutes per
session) that made the duration of exercise per week more similar between the Wii Fit and MOB groups.
According to self-reported exerciselogs, only 8 out of the 11 participants in the Wii Fit group completed
the exercises. Of these 8 only 6 participants reported daily completion of the exercisesand 2 participants
reported completion 5–6 days per week.
4.2. Balance performance
The Wii Fit, MOB, and control groups were similar in their balance performance at the start of
intervention programs began (ANOVA of pre-test Berg Balance Scale: F(2,29)= 0.257, p = 0.775;
106J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise
Fig. 1. Effects of intervention on the berg balance scale.
ANOVA of the Tinetti Gait and Balance Assessment: F(2,29)= 0.149, p = 0.863). There was no
statistical difference in the amount that the exercise groups improved as compared to the control group,
although the actual amounts were greater for the exercise groups.
Balance improved in all three groups after the intervention period (Figs 1 and 2; Table 3). In the
repeated measures ANOVA, there was a significant main effect of time (pre- to post-intervention) on
balance (F(1,29)= 17.034, p < 0.001 for the Berg; F(1,29)= 9.715, p < 0.004 for the Tinetti). There
were no interactions between time (pre-, post-) and group (Wii Fit, MOB, Control) (F(2,29)= 1.45, p =
0.251 for the Berg; F(2,29)= 0.162, p = 0.852 for the Tinetti). The exercise groups improved more in
their Berg balance scores than the Control group, however differences were not statistically different.
The changes in scores for the Berg Scale were 3.55 ± 5.03, 3.45 ± 2.50, and 1.1 ± 2.99 for the Wii Fit,
MOB, and Control groups, respectively. Furthermore, at pre-testing, 25% of participants in the Wii Fit
group scored 54 or higher out of 56 on the Berg Balance Scale. This improved to 37.5% of participants
scoring greater than 54 at post-test. Improvements from pre- to post-intervention for the Tinetti scores
weresmallandsimilaracrossgroups: Wii Fitimprovedby0.91±2.39points,MOBimprovedby1.36±
1.69 points and the Control improved by 1.00 ± 1.76 points.
Only one participant in the study used a walker and this subject was in the Wii Fit group. This subject
had among the lowest baselineBerg and Tinetti scores. To make sure that this single subjectdid not have
an outlier effect on the overall results, data was re-analyzed with this subject excluded. Excluding the
subject from the analysis did not alter the results.
J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise107
Fig. 2. Effects of intervention on the Tinetti gait and balance assessment.
4.3. Health and well-being
The groups were different at pre-test in their perception of health and well-being, with differences
between SF-36 scores approaching significance (F(2.29)= 3.154, p = 0.058) (Fig. 3, Table 3). The Wii
Fit grouphadhigherbaselinescoresthan the MOBandControlgroups. Atpre-testthe meanSF-36 score
was 75.4 ± 6.6 for the Wii Fit group, 65.5 ± 17.2 for the MOB group and 58.6 ± 15.9 for the Control
group, all out of a possible 100 point total score. There was no significant change in SF-36 scores from
pre- to post-intervention (ANOVA main effect on time: F(1,29)= 2.095, p = 0.159; non-significant
group-time interaction F(2,29)= 0.624, p = 0.543).
4.4. Enjoyment of Wii Fit
Results of the Wii Fit Enjoyment Questionnaire showed that 81% of the participants reported high
levels of enjoyment while playing the Wii games. The majority of participants also reported perceived
improvements in balance: 18% reported high improvements in their balanceand 64% reported moderate
improvements in their balance. Participants also identified that they preferred the Wii Fit games to
traditional balance exercises: 27% reported they were much better and 55% reported they were better
in using the Wii and a desire to continue using the games. One participant said “I’m going to ask my
children to buy me this [Wii Fit] for my birthday”. The interactive component and competitive nature
of scoring added elements typically lacking in traditional exercise. At completion of the study all
participants were able to use the Wii Fit and it has become a sustainable program at the facility.
in the Control group entered and completed the pre-test evaluation.
108 J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise
Fig. 3. Effects of intervention on the SF-36.
From the Wii Fit group, two participants withdrew from the study following pre-testing citing they no
in pre-and post-testing conditions, as the pre-test was completed using a walker and post-testing was
completed without a walker. Leaving a total of eleven participants.
From the MOB group, one participant was moved to the control group, as only pre- and post-test
data was obtained and one participant was excluded due to age. The MOB group had a total of eleven
All Wii Fit group participants successfully completed the entire three weeks of training (two sessions
per week for three weeks) as well as the pre- and post-testing sessions. Eight participants completed the
supplemental home exercises. All MOB participants successfully completed the entire three weeks of
training (two sessions per week for three weeks) as well as the pre- and post-testing sessions.
The main result of this study is that the Wii Fit exercise program proved to be feasible and enjoyable
by a group of community-dwelling elders. The results also suggest that exercises with the Wii Fit may
improve balance, however, the improvements in balance were small and not significantly greater than
that observed for the control groups. The reason for the small size and non-significance of intervention
effects is likely that the intervention period was too brief, only 3-weeks duration, although a number of
other limitations may also have influenced the results. There was no intervention effect on health and
well-being as measured by the SF-36, which may be due to language barriers as English was a second
language for most participants.
Following a three-week period, all participants made small, but significant improvements in their
balance. Improvements were larger for the exercise than non-exercise groups, an encouraging finding.
J.R. Franco et al. / The effect of the Nintendo Wii Fit and exercise109 Download full-text
However, the difference in improvement was non-significant. There are several reasons why there were
not greater improvements in balance with exercise, including that 1) the intervention may have been
for too brief a period (3 weeks); 2) the balance measures used may have not have been able to capture
and small sample size made it difficult to show statistical differences between groups; 4) the Wii Fit
video game and all exercise instruction were in English which is not the native language of any of our
participants; 5) age related changes, such as slower reaction times and altered vision, may have affected
success with performing the balance activities in the Wii Fit games; and 6) lack of compliance with
supplementalhomeexercisesfor someparticipants in the Wii Fit group, thus reducingtheir total exercise
time per week.
The small increasein balanceafter exercisingwith the Wii Fit in this study is in contrastto thefindings
in other studies that included much longer periods of intervention than the 3 weeks of the present study
(10weeks; 8weeks; 4or6 weeksdependingongroup). The3-weekdurationofthepresent
study is also much shorterthan the MOB intervention programs that havedemonstrated improvementsin
fall self-efficacy after intervention [17–19]. Multifactorial exercise programs that have been successful
in improving balance were conducted over a 12-week period . Thus, too brief of an intervention
period is the most likely reason why this study did not show greater improvements in balance for the
Wii Fit and MOB groups. Interventions that last only three weeks may not be long enough to produce
a large change in balance. Since the participants in the exercise groups in this study showed a trend of
increased scores in only 3 weeks, it is possible that an additional 3 weeks of intervention would results
in changes similar to those reported other studies [38–40].
Of the three Wii Fit studies discussed in this article, we can only directly compare amounts of
improvement with intervention to a study by Bomberger et al.  as this is the only other study that
used the same balance measures, the Berg Balance Scale and Tinetti Gait and Balance Assessments.
The amount of improvement in balance that we observed,after the exercise interventions is comparable,
and slightly greater than, Bomberger et al.  (Current study Berg: Wii Fit: 5.03 ± 3.55; MOB:
3.45 ± 2.50; Control: 1.1 ± 2.99; Tinetti: Wii Fit: 2.39 ± 0.91; MOB: 1.36 ± 1.69; Control: 1 ±
1.76; Bomberger et al. Berg: NE: 3.84%; or 2 points MC: 0.41% or 0.84 points; Tinetti: NE: 1.80% or
0.5 points; MC: 0.76% or 0.83 points).
Animportantquestionis howmuchchangeontheBergandTinettiis clinicallymeaningful,translating
to a real increase in balance function. For the Berg Scale, a study by Conradsson et al.  suggests
that a change of at least 8 points is required to show genuine change. Another study by Donoghue and
Stokes found that the amountof changenecessarywas dependenton baselinescores(4 point change
for baseline scores within 45–56, 5 points for baseline scores within 35–44, 7 points for baseline scores
within 25–34, and 5 points for baseline scores within 0–24). The improvements for the exercise groups
in the present study approaches the 4 point-change mark identified by Donahue and Stokes for subjects
with high baseline Berg scores.
Another factor besides short intervention dose that may explain why this study did not shower greater
study were all community dwelling elders who had sufficiently good balance able to live independently
in their homes. At pre-testing, 25% of participants scored 54 or higher out of 56 on the Berg and 81%
scored 24 or higher out of 28 on the Tinetti at pre-testing. Since many of our subjects were already
scoring high on both assessments prior to intervention, they had very little room to show change.
It is unlikely that the choice of activities included in the Wii Fit and MOB interventions explain why
larger improvements in balance were not observed in this study. The Wii Fit and MOB intervention