1138
ORIGINAL ARTICLE
Pilot Study Comparing Changes in Postural Control After
Training Using a Video Game Balance Board Program and 2
Standard Activity-Based Balance Intervention Programs
Alessandra Pluchino, MD, Sae Yong Lee, PhD, Shihab Asfour, PhD, Bernard A. Roos, MD,
Joseph F. Signorile, PhD
ABSTRACT. Pluchino A, Lee SY, Asfour S, Roos BA,
Signorile JF. Pilot study comparing changes in postural control
after training using a video game balance board program and 2
standard activity-based balance intervention programs. Arch
Phys Med Rehabil 2012;93:1138-46.
Objective: To compare the impacts of Tai Chi, a standard
balance exercise program, and a video game balance board
program on postural control and perceived falls risk.
Design: Randomized controlled trial.
Setting: Research laboratory.
Participants: Independent seniors (N40; 72.58.40) began
the training, 27 completed.
Interventions: Tai Chi, a standard balance exercise program,
and a video game balance board program.
Main Outcome Measures: The following were used as measures:
Timed Up & Go, One-Leg Stance, functional reach, Tinetti Perfor-
mance Oriented Mobility Assessment, force plate center of pressure
(COP) and time to boundary, dynamic posturography (DP), Falls
Risk for Older PeopleCommunity Setting, and Falls Efficacy Scale.
Results: No significant differences were seen between groups
for any outcome measures at baseline, nor were significant time
or group time differences for any field test or questionnaire.
No group time differences were seen for any COP measures;
however, significant time differences were seen for total COP,
3 of 4 anterior/posterior displacement and both velocity, and 1
displacement and 1 velocity medial/lateral measure across time
for the entire sample. For DP, significant improvements in the
overall score (dynamic movement analysis score), and in 2 of
the 3 linear and angular measures were seen for the sample.
Conclusions: The video game balance board program, which
can be performed at home, was as effective as Tai Chi and the
standard balance exercise program in improving postural con-
trol and balance dictated by the force plate postural sway and
DP measures. This finding may have implications for exercise
adherence because the at-home nature of the intervention elim-
inates many obstacles to exercise training.
From the Departments of Kinesiology and Sport Sciences (Pluchino, Lee, Roos,
Signorile) and Industrial Engineering (Asfour), University of Miami, Coral Gables, FL;
Geriatric Research, Education, and Clinical Center, Bruce W. Carter Department of Veterans
Affairs Medical Center, Miami, FL (Roos, Signorile); Departments of Medicine and Neurol-
ogy, University of Miami Miller School of Medicine, Miami, FL (Roos); and Stein Geron-
tological Institute, Miami Jewish Health Systems, Miami, FL (Roos).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Reprint requests to Joseph F. Signorile, PhD, Dept of Kinesiology and Sport
Sciences, MO 114, University of Miami, Coral Gables, FL 33146, e-mail:
jsignorile@miami.edu.
In-press corrected proof published online on Apr 26, 2012, at www.archives-pmr.org.
0003-9993/12/9307-01343$36.00/0
doi:10.1016/j.apmr.2012.01.023
Arch Phys Med Rehabil Vol 93, July 2012
Key Words: Exercise; Rehabilitation; Tai Ji.
2012 by the American Congress of Rehabilitation
Medicine
T HE DEMOGRAPHIC shift toward an older mean age in the
world population is associated with an increase in the number
of falls and falls-related injuries. In the United States, the rate of
fatal falls for persons 65 years and older increased 35% from 1990
to 2002.1 Impairments in balance and postural control are believed
to be the major neuromuscular factors that contribute to an in-
creased risk of falling with age.2,3 Both are complex motor skills
that depend on sensory input (propioceptive, vestibular, and visual
systems), central processing (motor control), and muscle strength
and power.4 The 2 main functional goals of postural control are
postural stability and postural orientation. Biomechanical con-
straints, movement strategies, sensory strategies, orientation in
space, control of dynamics, and cognitive processing are all re-
quired for postural stability and orientation. One of the most
important biomechanical constraints on postural control involves
controlling the bodys center of mass (COM) with respect to its
base of support. During stance, the limits of stability (the area over
which an individual can move his or her COM and maintain
balance without changing the base of support) inscribe a cone-
shaped pattern with the support base serving as the apex and the
COM moving freely within the limits of the individuals maxi-
mum sway angle in a given plane of motion (fig 1). The area of
each individuals limits of stability is determined by the size of the
support base, joint range of motion, muscle strength, and the
sensory information available to detect the limits.5 In older adults
who experience falls, this cone area tends to decrease with reduced
limits of stability,6 and the support base can be increased by
strategies such as stepping.7
Many studies have reported the positive effect of physical
activity-based interventions on balance. These include Tai
Chi,8-12 sitting, standing, and walking practice,13 direction-
specific weight-shifting tasks,14 traditional Greek and Turkish
List of Abbreviations
ADLs activities of daily living
COM center of mass
COP center of pressure
DMA Proprio 5000 dynamic motion analysis
DP dynamic posturography
FES Falls Efficacy Scale
FR functional reach
FROP-Com Falls Risk for Older PeopleCommunity Setting
OLS One-Leg Stance
POMA Performance Oriented Mobility Assessment
TB Tinetti balance
TUG Timed Up & Go
 CHANGES IN POSTURAL CONTROL, Pluchino
dance programs,15,16 balance and coordination drills,17 and
functional balance training using activities like single stance,
tandem gait, walking on toes and heels, walking backwards,
sideways, and turning around.3,4 However, these interventions
are underused by older persons, because they require atten-
dance at a formal class, which necessitates travel, adherence to
a specific class schedule, and lack of information concerning
progress across the training period.4
Activity-promoting video games are a new generation of
active computer and video-console games, also known as exer-
gaming (a portmanteau of exercise and gaming), which pro-
mote increased physical activity in the home.18
Wii Fit,a a console exer-game released in 2007, is an activity-
promoting video game that uses a new peripheral, the Wii balance
board. The Wii balance board contains multiple pressure sensors that
are used to measure the users center of balance (the location of the
intersection between an imaginary line drawn vertically through the
COM and the surface of the balance board) and weight.
To our knowledge, there are no controlled studies that have exam-
ined the effectiveness of the Wii Fit video game as a training tool to
improve balance in older persons. Such a home-based intervention
may increase exercise adherence, because it is entertaining, requires
no travel or adherence to a specific class schedule, allows participa-
tion in the family environment, and fits seamlessly into todays
technology-driven society.
The aim of this study was to compare changes in balance and
postural control resulting from the Wii Fit balance program
(Wii), a standardized balance exercise program, and a Tai Chi
program (Tai Chi). We hypothesized that the Wii Fit balance
program would produce significant improvements in balance
and would reduce perceived falls risk across 8 training weeks,
and these improvements would be similar to those produced by
either Tai Chi or the standard balance exercise program.
METHODS
Participants
A total of 40 healthy older participants (15 men and 25
women; mean age SD, 72.58.40y) agreed to participate in
the study. Individuals with any neurologic impairment that
would affect balance, severe cognitive impairment, severe
musculoskeletal impairment, unstable chronic disease state,
major depression, severe vestibular problems, severe ortho-
static hypotension, or simultaneous use of cardiovascular, psy-
chotropic, and antidepressant drugs were excluded from par-
Fig 1. Cone-shaped pattern denoting the limits of stability.
1139
ticipating in this study. Participants were recruited via flyers
and personal solicitations at meetings of local social clubs and
organizations frequented by older individuals. Participants had
no prior experience with any balance training program, Tai
Chi, or the Wii. All lived independently in the surrounding
communities and required no assistance in performing their
activities of daily living (ADLs). They were instructed not to
take part in any formal exercise program for the duration of the
study. A power analysis for repeated measures examining
within- and between-subject interactions, using 3 groups and 2
times, a moderate effect size of .25, an alpha error probability
of .05, and a power of .95 yielded a total sample size of 42.
Random assignment to 1 of the 3 training groups (standard
balance exercise program, Tai Chi, and Wii) was completed
after an initial assessment and baseline testing using a blocked
approach where 6 folded papers were placed in an opaque bowl
and subjects drew from the bowl to receive their group assign-
ment. After each group of 8 subjects, the papers were placed
back into the bowl to be used with the next 8 subjects. Char-
acteristics for participants in each of the training groups and for
the complete sample are presented in table 1. Figure 2 presents
a flow diagram for the study.
Preliminary Testing Schedule
Prior to the beginning of training and following the 8-week training
program, participants came to the lab for 3 visits, each lasting ap-
proximately 1 hour. Visits were separated by at least 24 hours and no
more than 3 days. Three visits were considered necessary because of
the number of tests being used and the potential for fatigue to affect
the results. During these visits the participants completed question-
naires designed to assess health status, falls efficacy, and falls risk, and
performed field and laboratory tests to assess static and dynamic
balance. The order of the tests was randomized among participants;
however, the testing order was held constant for each participant
across testing sessions.
During their first visit, each participant signed an informed
consent approved by the universitys subcommittee for the use
and protection of human subjects. They also completed a health
status questionnaire to confirm study eligibility. Each participants
height, weight, and blood pressure were also recorded. Finally, the
participants were familiarized with, and allowed to practice, all 4
field tests and 2 laboratory tests performed during the study.
Day 2 began with the participant completing the Falls Effi-
cacy Scale (FES).19 After completion of the questionnaire, the
participant performed the Timed Up & Go (TUG) test,20 One-
Leg Stance (OLS) test,21 the functional reach (FR) test,6 and
the Tinetti Performance Oriented Mobility Assessment
(POMA).22 Rest periods of 5, 7, and 10 minutes, respectively,
were allowed between these tests to reduce the potential of
fatigue affecting performances during any test.
Day 3 began with the completion of the Falls Risk for Older
PeopleCommunity Setting (FROP-Com) assessment tool.23
After this, the participant performed the postural sway and the
dynamic posturography (DP) tests. A 30-minute rest period
was allowed between the tests to reduce the potential impact of
fatigue on performance during the second test.
Training began the week after the last testing day for the last
subject. Because testing was accomplished within a 2-week
period, no more than 1 week lapsed between initial testing and
the beginning of the study. Posttests began the week after
training and were completed within a 1-week period.
Field Tests
The methods used to administer each field test have been
previously described in the literature. Lin et al24 examined the
Arch Phys Med Rehabil Vol 93, July 2012
1140 CHANGES IN POSTURAL CONTROL, Pluchino

Table 1: Demographics Characteristics of the Participants by Group

Characteristic Total SBEP Tai Chi Wii

No. of participants 40 14 14 12
Sex (F/M) 25/15 9/5 14/8 8/4
Age (y) 72.107.80 76.007.74 69.286.03 70.728.46
Height (cm) 165.239.99 166.1811.93 166.908.37 161.909.25
Weight (kg) 73.8115.65 73.5020.57 75.8112.99 71.2013.01

NOTE. Values expressed as mean SD.

Abbreviations: F, female; M, male; SBEP, standard balance exercise program.

validity, reliability, and discriminate ability of the field tests
used in this study. They noted that poor performances on the
TUG test and Tinetti balance (TB) assessment tool significantly
predicted fall occurrence, ADLs decline, and ADLs improve-
ments over a 1-year period. Poor scores on the OLS and FR
tests significantly predicted a decline in ADLs, but they did not
significantly predict falls or ADLs improvement. The effect
sizes of the responsiveness to falls and ADLs decline and
improvement were .12, .42, and .05 for the TUG test; .10, .19,
and .00 for the OLS test; .04, .11, and .38 for the FR test; and
.19, .94, and .39 for the TB assessment tool, respectively. They
also noted that the intraclass r and interrater reliability across a
2-week period for all of these measures ranged from .93 to .99
regardless of subjects cognitive status. The discriminate abil-
ity of the TUG, OLS, FR, and TB tests for subjects who had
suffered a fall in the previous year, used a walking aid, and had
substantial ADLs limitations was excellent with the TB having
the greatest discriminatory power.
Laboratory Tests
The Postural Sway test.25,26 Postural sway was assessed
using a portable force platform.b The force platform detected
the medial-lateral and the anterior-posterior displacement of
the center of pressure (COP),27 as well as time-to-boundary
measurements.28,29 The participant was asked to stand on the
force platform without shoes, quietly, gazing straight ahead,

Fig 2. Study flowchart.

Arch Phys Med Rehabil Vol 93, July 2012

 CHANGES IN POSTURAL CONTROL, Pluchino
with feet comfortably spaced, and arms by his or her sides. The
participant performed three 10-second repetitions of the double-
leg stance test with eyes open.
The COP parameters analysis included: COP area, the
mean, SD, maximum and minimum excursions of the COP
in the medial-lateral and anterior-posterior directions (COP
medial-lateral excursion average, COP medial-lateral excur-
sion SD, COP medial-lateral excursion maximum, COP
medial-lateral excursion minimum, COP anterior-posterior
excursion average, COP anterior-posterior excursion SD,
COP anterior-posterior excursion maximum, and COP ante-
rior-posterior excursion minimum, respectively), mean
velocity, and maximum and minimum velocities in the me-
dial-lateral and anterior-posterior directions (COP medial-
lateral velocity maximum, COP medial-lateral velocity min-
imum, COP anterior-posterior velocity maximum, COP
anterior-posterior velocity minimum, respectively).
Dynamic posturography. The participant completed a sin-
gle dynamic balance test on a DP platformc according to the
procedures described by Charnock et al.30 Briefly, the devices
ultrasonic sensor belt was placed on the participants waist with
the transmitter positioned between the spinous processes of L5
and S1. The participant was placed in a harness to ensure
safety, stood on the moveable platform with feet shoulder
width apart, and was told to maintain balance as the platform
moved in a progressively more difficult randomized pattern.
The device produced incremental increases in the platform
angle in random (lateral, up and down, anterior to posterior,
clockwise, and counterclockwise) directions. The program
gradually increased the platforms movement speed from
12.65/s-1 to 126.4/s-1. The test lasted for a maximum of 120
seconds. As a safety precaution, the test automatically stopped
before the 120 second limit if the platform sensors detected
transmitter movement of 7.6cm (in any direction) in .25 sec-
onds or 12.7cm of movement in 1 direction at any time. The
sensor recorded every .25 seconds (480 total readings during
the 2-minute test), and the total inches of movement (anterior/
posterior, superior/inferior, and lateral) were computed. The
data provided by the Proprio 5000c included the dynamic
motion analysis (DMA) score, up and down, side to side, and
anterior/posterior translational movements and rotational
movements including flexion/extension, lateral flexion, and
core rotation. The DMA score was calculated using the sum of
the successive translational difference scores for sensor posi-
tion throughout the entire trial. If the test stopped before the
2-minute time limit, the machines software added a score of
7.08cm (3in) for each remaining .25 second period not com-
pleted. Motion capture data have confirmed a strong correlation
between the medial-lateral and superior-inferior movements of
the COM of the body and the sacral marker of the Proprio
5000.30
Assessment Questionnaires
The FROP-Com23 and FES19 were used to assess fall risk and
fear of falling, respectively. The FROP-Com is a falls-assessment
questionnaire originally developed for use with hospitalized older
adults, but has been expanded so that it may be used in community
settings. It has high retest and interrater reliability, and a moder-
ately high capacity to predict falls in older adults.23 The FES used
in this study consisted of 14 questions providing self-assessments
of indoor and outdoor activities. The questions are used to deter-
mine the levels of confidence with which older persons approach
each activity. It is a reliable and valid measure of falls self-
efficacy.19 Completion of the FROP-Com and FES required ap-
proximately 15 and 5 minutes, respectively.
1141
Training
Each participant came to the training facility twice a week
for 8 consecutive weeks, for a total of 16 visits. Each visit was
approximately 60 minutes long and consisted of 5 minutes
warm-up, 50 minutes of the training, and 5 minutes of cool-
down. Although subjects who were part of the Wii Fit program
followed the same 2 day per week pattern at our laboratory,
they were able to make arrangements to use the machines at
their own convenience, not having to adhere to the specific
scheduling inherent to the formalized classes.
Standardized Balance Exercise Program
Of the 14 participants randomly assigned to the standard
balance exercise program, 8 participants finished the training
program. Three participants never began the program, 1 par-
ticipant started but could not continue because of other time
commitments, 1 participant had a muscle injury not associated
with the training program, and 1 participant fell during her
daily activities.
This program consisted of 14 functional activities with a
pronounced demand for balance.3 Included in the functional
activities were: (1) stepping on a compliant surface; (2) walk-
ing forward 10 steps and pivoting 180; (3) alternately moving
a weight between a high and low shelf situated just beyond 1
arms length; (4) turning around full circle; (5) a 2-leg stand;
(6) lifting an object from the floor, standing up, and placing it
back on the floor at a distance beyond arms length; (7) stand-
ing up from a chair with arms crossed over the chest; (8)
alternating single leg stands; (9) walking on a compliant sur-
face; (10) walking over obstacles of different height and depth;
(11) walking while holding a glass full of water; (12) tandem
walking forward along a line; (13) walking up and down a
flight of stairs; and (14) standing on a compliant surface.
During the 8 weeks of training, participants performed drills
1 through 7 on training day 1, and drills 8 through 14 on
training day 2. Increases in difficulty such as reductions in base
of support, closing of the eyes, increased speed of movement,
increasingly unstable surfaces, and combinations of skills were
used to increase the intensity of the program as necessary
throughout the training period.
Tai Chi Program
Fourteen participants were randomly assigned to the Tai Chi
training program. Eleven participants finished the training pro-
gram, 3 never started.
The Tai Chi program was based on Sun-style, originally
created by Sun Lu Tang. The Sun-style is 1 of the 4 main Tai
Chi styles, namely Chen, Wu, Yang and Sun. All 4 styles
contain the same basic principles of slow, continuous move-
ments combined with deep diaphragmatic breathing, and main-
tenance of an upright posture.31 The specific form used for the
participants training was one that is currently practiced and
promoted by arthritis foundations worldwide. A certified Tai
Chi exercise leader taught the class throughout the study. The
form taught consisted of 12 movements using small forward
and backward steps, as well as weight transfers from 1 leg to
the other. The form also focused on posture alignment, slight
bending of the knees and moving slowly with a gentle resis-
tance. One of the characteristics of the Sun-style is that it uses
high stances, limited stepping distances, and multiple fol-
low-up steps, which makes it easy for the participants to learn
and reduces stress on the knee and ankle joints.32
Wii Fit Balance Program
Twelve participants were randomly assigned to the Wii
program. Eight participants finished the training program, 2
Arch Phys Med Rehabil Vol 93, July 2012
1142 CHANGES IN POSTURAL CONTROL, Pluchino
never started, 1 participant started but couldnt continue be-
cause of time commitments, and 1 participant didnt wish to
continue because her husband, who was participating in the
standard balance exercise program, had a muscle injury not
associated with the training program and could not continue in
the study.
This program was based on the Wii Fit game. The Wii Fit is
divided into 4 categories: yoga, strength training, aerobics, and
balance games. Only the balance game portion of the program was
used for the study. The personal profile of the participant was
entered into the system so his or her progress could be tracked and
difficulty levels could be adjusted to each persons training pro-
gram according to his or her progress. The system allowed the
user to map daily progress, set goals, and chart activities. The
system also provided an on-screen trainer to lead the user through
each exercise and demonstrate proper form. The participants were
instructed to step on the Wii Fit balance board, and follow the
instructions for the different games available. The list of games
used for the balance program were: soccer heading, where the
participants had to head soccer balls by moving their heads from
side to side; ski slalom, where the participant had to ski downhill
negotiating gates by shifting their body weights from side to side;
ski jump, where the participants had to go down a take-off ramp
by bending their knees, jump by extending their knees, and at-
tempt to land as far down on the hill as possible; table tilt, where
the participants had to shift body weight in multiple directions to
get balls into a series of holes; tightrope walk, where the partici-
pants had to cross a tightrope by marching in place and do
verticals jumps by bending and extending their knees to avoid
dynamic obstacles; river bubble, where the participants attempted
to navigate down a twisting river in a bubble by shifting their
weight without bursting the bubble on the river banks; penguin
slide, where the participants had to catch fish while balanced on a
piece of ice by shifting their weight from side to side; snowboard
slalom, where the participants had to snowboard downhill passing
through gates while shifting their body weights back and forward;
and, lotus focus, where the participant had to remain motionless
while sitting and looking at a flame. The lotus focus game was
used as cool down after the training was complete. The games
were based on the control of an on-screen avatar using body
movements that are detected by the balance board. The system
was simple to use, and allowed the participants to perform the
activities without a trainer/instructor, as well as to track their
progress and goals.
Each of the games described had 3 levels: beginner, profes-
sional, and expert. Scores ranged from 1 to 4 on each level,
with 4 being the highest score. On the first day of training, the
participants were instructed to play each game for 7 minutes.
The score obtained on each game was recorded. During the
second day of training the participants played 5 out of the 8
games, for 10 minutes each. The 5 games played were chosen
Table 2: Field Test Pretest and Posttest Measures
SBEP Tai Chi
Field Test Pretest Posttest Pretest Posttest
TUG (s) 9.381.86 9.441.49 8.251.8 8.861.76
OLS (s) 7.619.67 16.1118.83 28.2219.1 31.8523.24
FR (cm) 36.178.08 38.417.26 40.397.00 40.799.45
POMAbal 15.001.60 15.630.74 15.900.30 16.000.00
POMAgait 11.380.92 12.000.00 12.000.00 12.000.00
NOTE. Values expressed as mean SD.
Abbreviations: POMAbal, balance portion of the Tinetti Performance Oriented Mobility Assessment; POMAgait, mobility portion of the Tinetti
Performance Oriented Mobility Assessment; SBEP, standard balance exercise program.
Arch Phys Med Rehabil Vol 93, July 2012
as follows: the 3 games in which they scored the lowest on the
first day of training, and 2 games of their choice. For the
duration of the study, the participants played 5 out of the 8
games per session, for 10 minutes each. They first played the 3
games that were not played during the previous session. These
were then followed by the 2 games in which they produced
their lowest cumulative scores. Whenever a participant reached
the maximum score on a certain difficulty level, he or she was
directed to play at the next level.
Statistical Procedures
Data were analyzed using separate 3 (group) 2 (time)
repeated-measures analyses of variance. When statistically sig-
nificant group effects or group time interactions were de-
tected, Bonferroni post hoc tests were used to determine the
specific group differences.
RESULTS
No significant differences were seen among groups in any
response variables at baseline.
Field Tests
Table 2 presents the results for each of the field tests used to
evaluate the effectiveness of the training programs. No signif-
icant time or group time interactions were detected. Effect
sizes for time ranged from 2.022 to .108 and for group
time interactions ranged from 2.027 to .093.
Laboratory Tests
A significant increase in COP area across the training period
was seen for the entire sample (fig 3 and table 3). As can be seen
in the table 3, significant differences between pretest and posttest
values were detected for the sample in COP anterior-posterior
excursion maximum, COP anterior-posterior excursion minimum,
COP anterior-posterior excursion SD, and COP medial-lateral
excursion minimum. Additionally, COP anterior-posterior veloc-
ity maximum, COP anterior-posterior velocity minimum, and
COP medial-lateral velocity maximum showed significant
changes across the training period. No significant group time
interactions were detected for any COP measurements, and effect
sizes were small ranging from 2.005 to .183.
As was the case for the COP measurements, no significant
group time interactions were seen for any DP variables, and
effect sizes ranged from 2.003 to .041. A significant im-
provement in the DMA score was seen for the entire sample
(fig 4), and significant decreases were seen in Proprio 5000
anterior/posterior linear displacement score and Proprio 5000
up and down linear displacement score; while significant in-
creases were seen in Proprio 5000 lateral flexion rotational
score and Proprio 5000 core rotational score (table 4).
Wii Fit Effect Size
Effect Size (time
Pretest Posttest (time) group)
7.712.34 8.182.44 .105 .044
31.1827.94 28.7626.41 .050 .084
35.188.64 39.7115.80 .108 .060
15.131.46 15.132.10 .022 .027
11.751.16 11.950.35 .081 .093
 CHANGES IN POSTURAL CONTROL, Pluchino 1143

ance and postural control as a result of the Wii, standard

balance exercise program, and Tai Chi training were eval-
uated using 3 different types of postural control and balance
assessments: field tests, laboratory tests, and questionnaires.

Fig 3. Pretest and posttest values (mean SD) of the COP area for
the entire sample. *Significantly different than pretest values
(P.000).
Questionnaires
No significant time or group time interactions were seen
for the FROP-Com or FES. Effect size for time for the FROP-
Com was 2.072 and for group time interaction was
2.086. The time and group time effect sizes for the FES
were 2.072 and 2.104, respectively. Results for each
group are presented in table 5.
DISCUSSION
The principle finding of this study was that the Wii system
produced similar improvements in postural control and balance
when compared with the other interventions, which normally
require attending a formal class with the associated member-
ship cost, need to travel, time restraints, dress requirements,
and lack of immediate quantifiable feedback. Changes in bal-
Field Tests
No significant changes were found in the field tests in
response to any intervention. While the results of our study are
not consistent with others, which have reported significant
improvements on functional tests as the result of exercise
programs designed to improve balance,3,9,16,33,34 the difference
may be explained, in part, by the inability of these tests to
detect differences in fall status and lack of sensitivity to change
reported in healthy, independent-living older persons. In fact, a
number of researchers have reported values ranging from 16 to
22.9 seconds for fallers among healthy, community-dwelling
older individuals20,35,36; and average times were 82 and 82
seconds, 93 and 92 seconds, and 101 and 113 seconds
for active, independently living men and women aged 60 to 69
years, 70 to 79 years, and 80 to 89 years, respectively.37
Finally, in a meta-analysis examining normative values for
healthy, independently living older persons, Bohannon38 re-
ported means (95% confidence intervals) of 8.1 seconds (range
7.19.0s), 9.2 seconds (range 8.210.2s), and 11.3 seconds
(range 10.0 12.7s) for individuals aged 60 to 69 years, 70 to 79
years, and 80 to 99 years, respectively. The TUG mean score
for our healthy, independent sample was 8.52.0, which when
compared with the scores reported in these earlier studies,
allowed little opportunity for changes to occur. Additionally,
the ability of the TUG test to evaluate the effectiveness of
interventions designed for rehabilitation has yet to be deter-
mined.35-37,39
Although the OLS test has been reported to be a good
indicator of falls risk in community-dwelling older individu-
als,21,24,40,41 there are conflicting data concerning its capacity
to detect changes resulting from exercise programs targeting
balance. While improvements in the OLS with training have

Table 3: Center of Pressure Measurements in the Study Sample

Effect
SBEP Tai Chi Wii Fit Effect Size
COP Size (time
Variable Pretest Posttest Pretest Posttest Pretest Posttest P (time) group)

COParea 1.271.39 1.861.54 0.610.34 2.390.85 0.390.23 1.651.47 .000* .471 .128
APDavg 0.532.00 0.860.75 0.601.00 0.920.92 0.171.10 0.871.40 .453 .025 .124
APDmax 0.360.19 0.620.37 0.250.07 0.720.25 0.200.08 0.590.39 .000* .608 .080
APDmin 0.430.30 0.690.36 0.240.11 0.730.23 0.200.08 0.580.38 .000* .599 .087
APDSD 0.170.14 0.280.15 0.110.04 0.350.11 0.080.03 0.270.17 .000* .616 .142
MLDavg 1.762.07 1.611.66 2.261.99 1.891.69 2.261.99 1.921.57 .891 .001 .092
MLDmax 0.770.27 0.830.27 0.700.16 0.750.12 0.560.15 0.660.25 .129 .098 .013
MLDmin 0.860.31 0.850.27 0.700.12 0.840.19 0.600.18 0.740.27 .022* .208 .146
MLDSD 0.350.11 0.330.09 0.320.06 0.370.62 0.260.08 0.310.10 .080 .128 .183
APVmax 4.122.19 4.492.63 2.430.70 3.671.00 2.570.51 4.192.19 .009* .259 .077
APVmin 5.872.31 7.325.20 4.191.19 4.671.28 4.440.89 4.941.74 .045* .164 .056
MLVmax 3.641.36 4.402.85 2.270.46 3.630.78 2.700.50 4.042.30 .005* .297 .024
MLVmin 7.104.33 7.404.04 4.151.00 4.901.30 4.450.90 5.091.73 .123 .100 .013
Vavg 2.040.80 2.421.41 1.430.37 1.730.36 1.670.57 1.900.71 .013* .240 .005

NOTE. Values expressed as mean SD.

Abbreviations: APDavg, anterior/posterior average displacement; APDmax, anterior/posterior maximum displacement; APDmin, anterior/
posterior minimum displacement; APDSD, anterior/posterior SD of displacement values; APVmax, anterior/posterior maximum velocity;
APVmin, anterior/posterior minimum velocity; COParea, total displacement area for center of pressure; MLDavg, medial/lateral average displace-
ment; MLDmax, medial/lateral maximum displacement; MLDmin, medial/lateral minimum displacement; MLDSD, medial/lateral SD of displace-
ment values; MLVmax, medial/lateral maximum velocity; MLVmin, medial/lateral minimum velocity; SBEP, standard balance exercise program;
Vavg, average velocity.
*Significant effect by time.

Arch Phys Med Rehabil Vol 93, July 2012

1144 CHANGES IN POSTURAL CONTROL, Pluchino

capacity to discriminate levels of disability and the lowest

Fig 4. Pretest and posttest values (mean SD) of the overall linear
displacement (DMA) for the entire sample. *Significantly different
than pretest values (P.036).
been reported by some authors,9-11,33,42 others have reported no
response.12,43,44 In his review of the impact of Tai Chi on
balance and falls prevention, Wu45 reports that discrepancies in
the ability of the OLS to detect changes because of training are
related to the frequency and duration of training. This may
explain, in part, the lack of response seen in the OLS in the
current study, because limited response has been reported in
other studies where the duration of the intervention was less
than 10 weeks.10,11,42,43
The high functional level of our subjects may also have
reduced the potential for significant increases in FR. Duncan
et al6 reported mean SD values for men and women in the
20 to 40 year and 41 to 69 year age groups of 42.494.93cm
and 37.195.54cm, and 38.055.61cm and 35.085.89cm,
respectively, and a cutoff of 6.9in for fall risk. The average
pretest and posttest values across all training programs in the
current study were 14.803.10in and 15.674.26in, respec-
tively, which constitute considerably high performance val-
ues for our sample whose average age was 72.107.80
years. There are also questions concerning the sensitivity of
the FR test to training interventions. For example, of the 3
functional tests used by McMurdo and Johnstone46 to eval-
uate the impact of a home-based exercise intervention in
mobility limited older adults, the FR test had the lowest
sensitivity to change.
The Tinetti POMA, more than any other measure used in this
study, demonstrates the high performance levels of our sample
and the related ceiling effect, which allowed little or no margin
for measuring improvement. In this study, we used the 28-point
version of the test first described by Tinetti et al,19 where the
original total cutoff score for predicting high risk of falling was
18 or less. In both portions, Balance Component of the Perfor-
mance Oriented Mobility Assessment and Gait Component of
the Performance Oriented Mobility Assessment of the Tinetti
POMA, our participants scored near or at the ceiling values (16
and 12, respectively). When adding these scores, the total
values were far above the cutoff value of 18, making it very
difficult to see any improvement as a result of training in our
sample. Once again, the sensitivity of this test to change has yet
to be systematically assessed47; however, there are indicators
of a lower sensitivity to change compared with other functional
measures.48
Even in the face of the potential lack of sensitivity to change
expected in these tests because of the high functional level of
our participants, the effects sizes for this testing battery, rang-
ing from 2.027 to .093, argues against any differences being
seen among groups even with substantial increases in sample
size or training duration.
Laboratory Tests
For DP we observed a significant decrease for the entire
sample in the DMA score and 2 of the 3 linear measurements,
Proprio 5000 anterior/posterior linear displacement score and
Proprio 5000 up and down linear displacement score. However,
there was a significant increase in 2 of the 3 angular parame-
ters, Proprio 5000 lateral flexion rotational score and Proprio
5000 core rotational score. The reductions in linear displace-
ment when reacting to the moving platform (base of support) of
the Proprio 5000 reflect a better stabilization of the body as the
participant counteracts the platform movements and maintains
the COM within the limits necessary for the test to continue.
The decrease in DMA score is consistent with findings in our
laboratory that nonfallers produced significantly lower scores
than fallers drawn from a similar healthy, independent-living
population (A.M. Bedient et al, unpublished data, 2011), and
may reflect changes in movement strategies as the test becomes
progressively more difficult throughout its duration.49 They are
also in agreement with other DP results showing the positive
impact of Tai Chi and balance training on linear displacement

Table 4: Comparison of Dynamic Posturography Measurements in the Total Sample Before and After Training
Effect
Dynamic SBEP Tai Chi Wii Fit Effect Size
Posturography Size (time
Variables Pretest Posttest Pretest Posttest Pretest Posttest P (time) group)

DMA 919.63152.07 875.1382.03 870.90105.22 834.45129.76 808.7598.17 761.13131.75 .036* .170 .003
LINLat 659.95144.10 654.98128.72 639.80108.87 649.36142.54 588.99168.06 571.75161.46 .839 .002 .013
LINAP 569.30138.29 505.3871.35 509.3286.20 433.7583.32 446.1449.18 404.1553.77 .001* .357 .029
LINUD 209.1939.59 198.2348.95 233.1847.59 211.5765.80 243.7152.82 221.9542.26 .021* .202 .019
ANGFlex/Ext 229.99123.37 282.6087.14 219.2181.88 244.87100.57 293.96107.49 294.7586.59 .198 .068 .041
ANGLatFlex 134.6855.69 188.1880.91 147.5855.77 202.4693.82 155.1020.68 188.8482.30 .004* .296 .017
ANGRot 179.3677.80 270.30116.45 208.77120.07 255.64123.28 212.4548.20 265.98130.21 .004* .304 .038

NOTE. Values expressed as mean SD.

Abbreviations: ANGFlex/Ext, flexion/extension rotational movements; ANGLatFlex, lateral flexion rotational movements; ANGRot, core rotational
movement; LINAP, anterior/posterior translational movements; LINLat, side to side translational movements; LINUD, up and down translational
movements; SBEP, standard balance exercise program.
*Significance pretest to posttest difference.

Arch Phys Med Rehabil Vol 93, July 2012

 CHANGES IN POSTURAL CONTROL, Pluchino
Table 5: Comparison of FES and FROP-Com Across Training Groups
SBEP Tai Chi
Questionnaire Pretest Posttest Pretest Posttest
FES 12.02.6 11.01.4 10.92.1 11.22.1
FROP-Com 5.53.1 5.32.1 5.63.5 5.93.5
NOTE. Values expressed as mean SD.
Abbreviation: SBEP, standard balance exercise program.
values.50 The increases in Proprio 5000 lateral flexion rota-
tional score and Proprio 5000 core rotational score also reflect
our earlier findings that nonfallers produced greater angular
values than fallers (A.M. Bedient et al, unpublished data,
2011). The increases in Proprio 5000 lateral flexion rotational
score and Proprio 5000 core rotational score were likely the
result of improved movement strategies50 developed during
training. Different strategies for the maintenance of balance
can involve the use of different musculoskeletal segments, such
as raising an arm or stepping, or they may involve the use of
overlapping or nested segments, such as ankle-hip coordination
for postural control.29 Taken together, the decreases in the
linear scores (DMA, Proprio 5000 anterior/posterior linear
displacement score, and Proprio 5000 up and down linear
displacement score) reflected a higher capacity to maintain
balance on a moving platform as a result of the interventions,
while the increases in Proprio 5000 lateral flexion rotational
score and Proprio 5000 core rotational score reflect an en-
hanced ability to incorporate multiple body parts and increase
the degrees of freedom used to achieve body stabilization and
postural control.
In general, older individuals show larger COP values than
younger adults.29 There is inconsistency in the literature in
interpreting COP results when studying postural control during
quiet stance. For example, Horak et al51 associated postural
stability with decreases in COP amplitude, while other au-
thors52,53 have suggested that higher sway amplitudes are re-
lated to increased postural stability. Our results reveal an
increase because of training in the COP area, as well as an
increase of the COP variability for COP anterior-posterior
excursion SD for all training conditions. These results are
consistent with those suggested by Newel,52 van Emmerik,53
and colleagues, who related postural stability to an increase in
variability. This increased variability could be because of our
training interventions producing more complex compensatory
strategies (using a greater number of degrees of freedom) when
maintaining postural control.54
These results indicate that the Wii balance program is as
effective as formalized training programs at improving balance
in healthy, independent-living persons; however, because of
the small sample size, it may be argued that the lack of
differences among training interventions across the training
period is a result of the low statistical power. The small effect
sizes seen for our laboratory variables challenge this line of
reasoning because a tenfold increase in sample size would be
necessary to achieve significance using the highest effect size
computed for any laboratory variable (2.183).
Study Limitations
A limitation of this study was the small sample size and short
duration of the study. It is suggested that future studies should
increase both sample size and the length of the training period
and employ an intent-to-treat design. A longer duration study
might also allow participants to be tracked for falls and asso-
ciated levels of injury.
1145
Wii Fit
Effect Size Effect Size
Pretest Posttest (time) (time group)
14.110.2 11.32.8 .072 .086
5.63.2 7.34.6 .072 .104
CONCLUSIONS
In this study, with a small sample size, it seems that the Wii
balance program is as effective as formalized training programs
at improving balance in healthy community-dwelling older
persons. Given the fact that the Wii program can be used at
home, many of the barriers to training, such as membership
cost, need to travel, time restraints, dress requirements, and
lack of immediate quantifiable feedback, are addressed, thereby
increasing the likelihood of exercise compliance.
References
1. Healy TC, Peng C, Haynes P, McMahon E, Botler J, Gross L. The
feasibility and effectiveness of translating a matter of balance into
a volunteer lay leader model. J Appl Geron 2008;27:34-51.
2. Horak FB, Mirka A, Shupert CL. The role of peripheral vestibular
disorders in postural discontrol in the elderly. In: Wollacott MH, Shum-
way-Cook A, editors. The development of posture and gait across the life
span. Columbia: Univ of South Carolina; 1989. p 253-9.
3. Rugelj D. The effect of functional balance training in frail nursing
home residents. Arch Gerontol Geriatr 2010;50:192-7.
4. Judge JO. Balance training to maintain mobility and prevent
disability. Am J Prev Med 2003;25:150-6.
5. Horak FB. Postural orientation and equilibrium: what do we need
to know about neural control of balance to prevent falls? Age
Ageing 2006;(35 Suppl 2):ii7-ii11.
6. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a
new clinical measure of balance. J Gerontol 1990;45:M192-7.
7. Maki BE, Edmonstone MA, McIlroy WE. Age-related differences
in laterally directed compensatory stepping behavior. J Gerontol A
Biol Sci Med Sci 2000;55:M270-7.
8. Judge JO, Underwood M, Gennosa T. Exercise to improve gait
velocity in older persons. Arch Phys Med Rehabil 1993;74:400-6.
9. Li F, Harmenr P, Fisher KJ, et al. Tai Chi and fall reductions in
older adults: a randomized controlled trial. J Gerontol 2005;60:
187-94.
10. Schaller KJ. Tai Chi Chin: an exercise option for older adults. J
Gerontol Nurs 1996;22:12-7.
11. Tse AK, Bailey DM. Tai Chi and postural control in the well
elderly. Am J Occup Ther 1992;46:295-300.
12. Wolfson L, Whipple R, Derby C, et al. Balance and strength
training in older adults: intervention gains and Tai Chi mainte-
nance. J Am Geriatr Soc 1996;44:498-506.
13. Wolf B, Feys H, Weerdt W, Van der Meer J, Noom M, Aufdem-
kampe G. Effect of a physical therapeutic intervention for balance
problems in the elderly: a single-blind, randomized, controlled
multicentre trial. Clin Rehabil 2001;15:624-36.
14. Hatsitaki V, Amiridis IG, Nikodelis T, Spiliopoulou S. Direction-
induced effects of visually guided weight-shifting training on
standing balance in the elderly. Gerontol 2009;55:145-52.
15. Sofianidis G, Hatzitaki V, Douka S, Grouios G. Effect of a
10-week traditional dance program on static and dynamic balance
control in elderly adults. J Aging Phys Act 2009;17:167-80.
16. Eyigor S, Karapolat H, Durmaz B. Effects of a group-base exercise
program on the physical performance, muscle strength and quality of life
in older woman. Arch Gerontol Geriatr 2007;45:259-71.
Arch Phys Med Rehabil Vol 93, July 2012
1146 CHANGES IN POSTURAL CONTROL, Pluchino
17. Seidler RD, Martin PE. The effects of short term balance
training on the postural control of older adults. Gait Posture
1997;6:224-36.
18. Lanningham-Foster L, Foster RC, McCrady SK, Jensen TB, Mitre
N, Levine JA. Activity-promoting video games and increased
energy expenditure. J Pediatr 2009;154:819-23.
19. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of
fear of falling. J Gerontol 1990;45:239-43.
20. Podsiadlo D, Richardson S. The timed up & go: a test of basic
functional mobility for frail elderly persons. J Am Geriatr Soc
1991;39:142-8.
21. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein
LZ, Garry PJ. One-leg balance is an important predictor of inju-
rious falls in older persons. J Am Geriatr Soc 1997;45:735-8.
22. Tinetti ME. Performance-oriented assessment of mobility prob-
lems in elderly patients. J Am Geriatr Soc 1986;34:119-26.
23. Russell MA, Hill KD, Blackberry I, Day LM, Dharmage SC. The
reliability and predictive accuracy of the falls risk for older people
in the community assessment (FROP-com) tool. Age Ageing
2008;37:634-9.
24. Lin MR, Hwang HF, Hu MH, Wu HD, Wang YW, Huang F.
Psychometric comparisons of the timed up and go, one-leg stand,
functional reach, and Tinetti balance measures in community-
dwelling older people. J Am Geriatr Soc 2004;52:1343-8.
25. Stel VS, Smit JH, Pluijm SM, Lips P. Balance and mobility
performance as treatable risk factors for recurrent falling in older
persons. J Clin Epidemiol 2003;56:659-68.
26. Yim-Chiplis PK, Talbot LA. Defining and measuring balance in
adults. Biol Res Nurs 2000;1:321-31.
27. Maki BE, Holliday PJ, Topper AK. A prospective study of pos-
tural balance and risk of falling in an ambulatory and independent
elderly population. J Gerontol 1994;49:M72-84.
28. Hertel J, Olmsted-Kramer LC, Challis JH. Time-to-boundary
measures of postural control during single leg quiet standing.
J Appl Biomech 2006;22:67-73.
29. Van Wegen EE, van Emmerik RE, Riccio GE. Postural orienta-
tion: age-related changes in variability and time-to-boundary.
Hum Mov Sci 2002;21:61-84.
30. Charnock BL, Williams MW, Sims EL, Garret WE, Queen RM.
Proprio 5000: a new method for assessing dynamic balance. Med
Sci Sports Exerc 2007;39:s154-5.
31. Fuzhong L, Harmer P, Fisher KJ, et al. Tai Chi and fall reduction
in older adults: a randomized controlled trial. J Gerontol 2005;
60A:187-94.
32. Song R, Lee EO, Lam P, Bae SC. Effects of tai chi exercise on
pain, balance, muscle strength, and perceived difficulties in phys-
ical functioning in older women with osteoarthritis: a randomized
clinical trial. J Rheumatol 2003;30:2039-44.
33. Hauer K, Rost B, Rutschle K, et al. Exercise training for rehabil-
itation and secondary prevention of falls in geriatric patients with
a history of injurious falls. J Am Geriatr Soc 2001;49:10-20.
34. Faber MJ, Bosscher RJ, van Wieringen PC. Clinimetric properties
of the performance-oriented mobility assessment. Phys Ther 2006;
86:944-54.
35. Okumiya K, Matsubayashi K, Nakamura T, et al. The timed up
& go test is a useful predictor of falls in community dwelling
older people. J Am Geriatr Soc 1998;46:928-30.
36. Shumway-Gook A, Brauer S, Woollacott M. Predicting the prob-
ability for falls in community-dwelling older adults using the
Timed Up & Go Test. Phys Ther 2000;80:896-903.
37. Steffen TM, Hacker TA, Mollinger L. Age- and gender-related
test performance in community-dwelling elderly people: Six-
Arch Phys Med Rehabil Vol 93, July 2012
Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and
gait speeds. Phys Ther 2002;82:128-37.
38. Bohannon RW. Reference values for the timed up and go test: a
descriptive meta-analysis. J Geriatr Phys Ther 2006;29:64-8.
39. Nikolaus T, Bach M, Oster P, Schlierf G. Prospective value of
self-report and performance-based tests of functional status for
18-month outcomes in elderly patients. Aging 1996;8:271-6.
40. Thomas J, Lane JV. A pilot study to explore the predictive validity
of 4 measures of falls risk in frail elderly patients. Arch Phys Med
Rehabil 2005;86:1636-40.
41. Gehlsen G, Whaley M. Falls in the elderly: part II, balance,
strength, and flexibility. Arch Phys Med Rehabil 1990;71:739-41.
42. Hong Y, Li JX, Robinson PD. Balance control, flexibility, and
cardio-respiratory fitness among older Tai Chi practitioners. Br J
Sports Med 2000;34:29-34.
43. Ross MC, Bohannon AS, Davis DC, Gurchiek L. The effects of a
short-term exercise program on movement, pain, and mood in the
elderly. Results of a pilot study. J Holist Nurs 1999;17:139-47.
44. Hartman CA, Manos TM, Winter C, Hartman DM, Li B, Smith
JC. Effects of Tai Chi training on function and quality of life
indicators in older adults with osteoarthritis. J Am Geriatr Soc
2000;48:1553-9.
45. Wu G. Evaluation of the effectiveness of Tai Chi for improving
balance and preventing falls in older populationsa review. J Am
Geriatr Soc 2002;50:746-54.
46. McMurdo ME, Johnstone R. A randomized controlled trial of a
home exercise programme for elderly people with poor mobility.
Age Ageing 1995;24:425-88.
47. Hayes KW, Johnson ME. Measures of adult general performance tests:
the Berg Balance scale, Dynamic Gait Index (DGI), gait velocity, Phys-
ical Performance Test (PPT), Timed Chair Stand Test, Timed Up and
Go, and Tinetti Performance-Oriented Mobility Assessment (POMA).
Arthritis Care Res 2003;49(Suppl 5):S28-S42.
48. Harada N, Chiu V, Damron-Rodriquez J, Fowler E, Siu A, Reuben
DB. Screening for balance and mobility impairment in elderly
individuals living in residential care facilities. Phys Ther 1995;
75:462-9.
49. Broglio SP, Sosnoff JJ, Rosengren KS, McShane K. A comparison of
balance performance: computerized dynamic posturography and a
random motion platform. Arch Phys Med Rehabil 2009;90:145-50.
50. Li H, Waite GN, Moga MM, Lam P, Geib RW. Balance improvements
after a week-long tai chi workshop as determined by dynamic posturog-
raphy - biomed 2010. Biomed Sci Instrum 2010;46:172-7.
51. Horak FB, Shupert CL, Mirka A. Components of postural dys-
control in the elderly: a review. Neurobiol Aging 1989;10:727-38.
52. Newell KM, van Emmerik RE, Lee D, Sprague RL. On postural
stability and variability. Gait Posture 1993;4:225-30.
53. van Emmerik RE, van Wegen EE. On the functional aspects of
variability in postural control. Exerc Sport Sci Rev 2002;30:
177-83.
54. Davids K, Glazier P, Araujo D, Bartlett R. Movement systems as
dynamical systems: the functional role of variability and its im-
plications for sports medicine. Sports Med 2003;33:245-60.
Suppliers
a. Nintendo of America Inc, 4600 150th Ave NE, Redmond, WA
98052.
b. AccuSway System; Advanced Mechanical Technology Inc, 176
Waltham St, Watertown, MA 02472.
c. Proprio 5000; Perry Dynamics Inc, 2810 N Jasper St, Decatur, IL
62526.