Cognitive effects of weight-shifting controlled exergames in patients with chronic stroke: a pilot randomized comparison trial.

BACKGROUND: The exergaming training involves motor as well as cognitive stimulation. Although exergame studies have been reported to have benefits in motor function, the effects of exergames on improving cognitive function remain inconclusive. Moreover, no study has been reported in stroke patients. AIM: The objective of this study was to compare the cognitive effects of 2 weight-shifting controlled exergaming systems and conventional weight- shifting training in patients with chronic stroke. DESIGN: This was a single-blind randomized controlled trial. SETTING: All participants were recruited from a rehabilitation department of a tertiary hospital. POPULATION: Patients (N.=37) with chronic hemiplegic stroke. METHODS: Patients were randomly allocated to one of the Wii Fit, Tetrax biofeedback, or conventional weight-shifting training groups. All interventions were administered 30 minutes per session, twice a week for 12 weeks. We used total score and the 9 domain scores of Cognitive Abilities Screening Instrument Chinese version (CASI C-2.0), and Berg Balance Scale (BBS) as the outcome measures. The outcome measures were assessed before and after training, and at 3 months follow-up. RESULTS: There were no significant differences among the 3 groups in the percentage of change in CASI total score and BBS, either post intervention or at the 3-month follow-up. At assessing the percentage of change in each domain of CASI, we found significant differences among the 3 groups in the abstraction/judgment domain after intervention (Wii Fit 16.25 [9.77, 37.50]% vs. Tetrax 0.00 [-10.00, 0.00]% vs. weight-shift 11.00 [0.00, 14.38]%, P=0.01], and at the 3-month follow-up (Wii Fit 20.00 [10.83, 31.25]% vs. Tetrax -10.00 [-11.11, 10.00]% vs. weight-shifting 0.00 [-2.27, 11.46]%, P=0.01). The differences came from the differences between Wii Fit and Tetrax mainly. There were significant differences among the 3 groups in language domain after intervention (Wii Fit 0.00 [0.00, 5.54]% vs. Tetrax 0.00 [-3.00, 0.00]% vs. weight-shift 0.00 [0.00, 0.00]%, P=0.045), but not at the 3-month follow-up (P=0.13). There was no correlation between the percentage of change in BBS and CASI total score postintervention ( r=-0.15 P=0.38). CONCLUSIONS: Wii Fit games training might be beneficial in some cognitive functions, such as abstraction/judgment, language in patients with chronic stroke. Wii Fit games, the commercial entertainment exergames, had superior effect in abstract/judgment and language domains as compared to the rehabilitation exergame (Tetrax balance system). Hence, Wii Fit games might be considered as a tool in post-stroke cognitive rehabilitation programs.

Feasibility of Using Tetrax Biofeedback Video Games for Balance Training in Patients With Chronic Hemiplegic Stroke.

BACKGROUND: Decreased weight bearing on the affected lower limb and poor weight shifting are common after a stroke occurs. The Tetrax biofeedback system is a center-of-pressure controlled video game system designed for patients with balance deficits. Although it is a commercial product, information about its clinical use for patients affected by stroke is limited. OBJECTIVE: To investigate the feasibility and potential efficacy of the Tetrax biofeedback system for balance training in patients with chronic stroke. DESIGN: Feasibility study. SETTING: Rehabilitation department of a medical center. PARTICIPANTS: Participants who had sustained a hemiplegic stroke at least 6 months prior to enrollment but were still able to stand independently for more than 5 minutes. METHODS: Participants were randomly assigned to an intervention group (IG) or control group (CG). All participants received conventional rehabilitation training. The IG also received 20 minutes of exposure to Tetrax biofeedback games controlled by change in center of pressure 3 times a week for 6 weeks. MAIN OUTCOME MEASUREMENTS: The primary outcome was feasibility, addressed by adherence, safety, and satisfaction. The secondary outcome was efficacy, which was evaluated by the subtests of physiological profile assessment, posturography, Timed Up and Go, and Forward Reach tests. We used percentage change (post-training score - pretraining score/pretraining score) to quantify the intervention effects. Mann-Whitney U tests were used to analyze differences in percentage of change between groups. RESULTS: A total of 14 participants were assigned to the IG, and 13 were assigned to the CG; 12 participants in the IG and 11 in the CG completed the study. In the IG group, those who completed the 6-week intervention attended 89.5% of planned sessions. No major adverse events or falls occurred within the intervention sessions. With use of 5-point Likert scales, participants rated their enjoyment of Tetrax games as 4.33 ± 0.78, their motivation as 4.17 ± 1.03, and perceived helpfulness as 4.25 ± 0.97. The IG demonstrated a significantly greater improvement in reaction time (P = .002), proprioception (P < .001), symmetric weight bearing (P = .027), Timed Up and Go (P < .001), and Forward Reach (P < .001) compared with the CG. CONCLUSIONS: Using Tetrax biofeedback video games for balance training is a feasible adjunctive program that may augment conventional therapy in persons affected by chronic hemiplegic stroke. LEVEL OF EVIDENCE: II.