Gul Baltaci Gulcan Harput Bunyamin Haksever Burak Ulusoy Hamza Ozer

Transcription

1 Knee Surg Sports Traumatol Arthrosc (2013) 21: DOI /s KNEE Comparison between Nintendo Wii Fit and conventional rehabilitation on functional performance outcomes after hamstring anterior cruciate ligament reconstruction: prospective, randomized, controlled, double-blind clinical trial Gul Baltaci Gulcan Harput Bunyamin Haksever Burak Ulusoy Hamza Ozer Received: 29 January 2012 / Accepted: 19 April 2012 / Published online: 29 April 2012 Ó Springer-Verlag 2012 Abstract Purpose The aim of this prospective, randomized, controlled, double-blind clinical trial was to compare the outcomes, including knee strength, balance, coordination, proprioception and response time, of Nintendo Wii Fit with those of conventional rehabilitation on the subjects with anterior cruciate ligament reconstruction. Methods Thirty volunteer subjects were enrolled in either Wii Fit (n = 15; mean age, 29 ± 7 years) or conventional rehabilitation (n = 15; mean age, 29 ± 6 years) programmes from the first week up to 12th weeks of the operation. Endoscopic reconstruction of a completely ruptured ACL was performed by using graft harvested from hamstrings. Each subject underwent an individual therapeutic programme. Functional examinations included the measurements of the balance using modified star excursion balance test, coordination, proprioception and response time using functional squat system and strength of flexor and extensor muscles of the involved and uninvolved leg using an isokinetic machine. Results There was no significant difference between Wii Fit and conventional group in terms of isokinetic knee strength at 12th week, and dynamic balance, and functional squat tests including coordination, proprioception and response time at first, 8th and 12th weeks of the rehabilitation. G. Baltaci (&) G. Harput B. Haksever B. Ulusoy Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey ybaltaci@hacettepe.edu.tr H. Ozer Department of Orthopedics and Traumatology, Faculty of Medicine, Gazi University, Ankara, Turkey Conclusion Two different 12-week-physiotherapy programmes following ACL reconstruction have the same affect on muscle strength, dynamic balance and functional performance values in both groups. We considered that the practice of Wii Fit activities like conventional rehabilitation could also address physical therapy goals, which included improving visual perceptual processing, coordination, proprioception and functional mobility. Level of evidence Randomized, controlled trials with adequate statistical power, Level I. Keywords Strength Balance Proprioception Coordination ACL Rehabilitation Introduction Rehabilitation after anterior cruciate ligament (ACL) reconstruction is essential for knee functional outcomes [14, 28]. Since clinical practices in the management of ACL injury are varied, there is no standard agreement on the ideal treatment algorithm for individuals with ACL reconstruction [1, 26]. The relationship between the biomechanical dose of rehabilitation exercises administered after anterior cruciate ligament (ACL) reconstruction and the healing response of the graft and knee is not well understood [26, 29, 30]. Enhancement of the neuromuscular control of the knee following ACL injury or reconstruction may lead to better outcomes in terms of returning back to functional activities and a reduced rate of reinjury [3, 6, 18]. Two major goals of ACL rehabilitation are the enhancement of functional ability and the realization of greater participation in work or sport activities. These goals are only achieved by intensive intervention to improve strength, proprioception and reaction time and by practice in daily activities to increase participation [3, 6, 14].

2 Knee Surg Sports Traumatol Arthrosc (2013) 21: The Wii Balance Board (WBB) (Nintendo, Kyoto, Japan), the part of the popular video game Wii Fit, designed as a video game controller, is predominantly used in combination with a video game console and its associated software. Given the capacity for providing instant feedback and the potential for enhanced motivation levels [11], this system has already been integrated into the neurological rehabilitation programmes of subjects with balance defects [9, 19, 20]. Most of these systems are not commercially available and, if available, are very expensive [10]. For this reason, low-cost, commercially available systems, such as gaming systems, are being trial tested for rehabilitation applications [2]. In the review of the use of gaming systems in rehabilitation, Weiss and colleagues [27] concluded that motion-capture systems showed great promise for a variety of therapeutic goals, including improving functional activities and motor rehabilitation. Therefore, Wii Fit activities are designed to improve balance, aerobic capacity, strength and are displayed on a television screen as the user interacts with the programme using a wireless remote control and balance board [4, 5, 31]. The number of studies that include Nintendo Ò Wii or WBB in the rehabilitation process is increasing, but still limited. The aim of this study was to determine the acceptability of the Nintendo Wii Fit compared to the conventional rehabilitation as a therapy tool for patients with ACL reconstruction. It was hypothesized that compared to the conventional rehabilitation, more positive outcomes including proprioception and balance, coordination, response time and knee muscle strength for Wii Fit group would be attained. Materials and methods Thirty men who underwent unilateral arthroscopic ACL reconstruction with hamstring tendon graft by the same surgeon participated in this study (Fig. 1). The subjects were divided into two groups by using randomized sampling that was computer generated with a basic random number generator. One of the groups was trained with Nintendo Wii Fit system and the other group enrolled into conventional ACL rehabilitation programme during 3 months after reconstruction. Two physical therapists were responsible for Wii Fit (BH) and conventional rehabilitation (BU) programmes. The researchers were not involved in the day-to-day treatment of the participants so as to prevent the response bias. The subjects with multiple injuries around knee or a history of previous knee surgery or neuromuscular disorder affecting motor coordination and perception were excluded. All subjects provided written consent to participation by using an informed consent document approved by the University Research Institutional Review Board. Fig. 1 Flow chart of participants Surgery The patients were operated on an outsubject surgical basis. Autogenous quadrupled semitendinosus and gracilis grafts were used in the ACL reconstruction. An oblique incision two fingerbreadth below the medial joint line over the pes anserinus tendons was used for harvesting the tendons. A hockey stick incision above the pes anserinus was used to elevate the insertion site of the tendons. The tendons were harvested with a tendon stripper, and all the muscle remnants were removed bluntly with scissors. Both ends of the tendons were sutured separately and grafts were tensioned with 6.8 kg at least 5 min on the table with a graft tensioning system. Tibial and femoral tunnels were created respectively, and suspension-type fixation on the femoral side, intratunnel fixation with interference screws plus supplemental staples on tibial side, was used. Group 1: Nintendo Wii Fit Each participant was asked to read over the summarized setup instructions for the Nintendo Wii and safety recommendations related to its use. All participants completed four Nintendo Wii games identified by the investigators as

3 882 Knee Surg Sports Traumatol Arthrosc (2013) 21: having potential to influence various subject outcomes. The bowling and skiing games in Wii Sports, Boxing, Football and Balance Board within Sports Pro Series were chosen for their potential to influence physical and functional movement, cognitive functioning, and driving. Each game was tried for 15 min. Each subject participated in 1-h rehabilitation sessions and accomplished 3 sessions per week. Group 2: conventional rehabilitation During the first 3 weeks after the operation, ACL rehabilitation aiming early motion was applied. The subjects were allowed weight bearing activities as much as they could tolerate. Closed kinetic chain flexion exercises were performed to gain flexion as much as possible. Prone hanging exercise was used to accomplish and keep full knee extension. Straight leg rise and isometric quadriceps sets were applied to increase quadriceps control. Aggressive exercises were avoided during this period. Then, 3 4 weeks postoperatively, cycling and balance exercises on balance board were applied to increase quadriceps hamstring co-contraction and coordination. Resistive knee extension and flexion exercises were started at 6th 8th weeks; jogging was allowed when it was 12 weeks after the operation. Clinical follow-up appointments were at 12th week after the operation to follow the subjects outcome and motivation for the rehabilitation. 6 8 months after surgery, the subject was gradually allowed to return back to sportive activity [6, 29, 30]. Testing procedures Coordination, proprioception, response time and SEBT were evaluated at first week, 8th and 12th weeks of rehabilitation programme. The isokinetic test was executed only at 12th week of the programme [14]. Dynamic balance testing Modified star excursion balance test (SEBT) was used to assess dynamic balance of both reconstructed and healthy knees. The subjects received verbal instruction and visual demonstration of SEBT from the same physiotherapist. This test requires the subject to stand on one leg in the middle of three directions and other leg reaching along a previously marked line. The subjects were asked to reach anterior, posteromedial and posterolateral directions as far as possible while maintaining their balance on the standing leg. Each direction was performed three times and the average of three scores was calculated, and the difference between healthy and reconstructed knee was recorded. The order of limb was randomized by the tester, so the effects of fatigue on balance could be prevented [13, 16, 21]. Functional squat tests Coordination, proprioception and response time were assessed by using functional squat system (Monitored Rehab System, Haarlem, and the Netherlands) [23]. This system is like a leg press machine, but it is also a computer game. A multi-joint lower-limb tracking-trajectory test was performed as outlined by Maffiuletti et al. [21]. The subjects were placed supine on the machine and hip and knee were placed at 90 flexion and the ankle was at neutral. Before testing, the subjects were asked to perform full knee extension and return to start position to calculate minimum and maximum range of the knee [23]. Coordination testing Tracking ability of each leg was assessed to determine the coordination deficit of the subjects. The subject was placed one-leg half-squat position in supine on horizontal leg press machine with the hip and knee flexed at 90, and the ankle joint was neutral. 20 % of individual body weight was calculated for each subject and applied as resistance load during entire test [8]. 1. Concentric component of coordination measurement Concentric component of the test includes hip, knee and ankle extension from half squat to the fully extended knee by means of concentric contraction of lower-limb extensor muscles. 2. Eccentric component of coordination measurement Eccentric component of the test includes returning to the half squat position from fully extended knee by means of eccentric contraction of lower-limb extensors while the agonist flexor muscles are coactivated. After standardized warm-up including 10 concentric eccentric repetitions was completed, the subjects were allowed a 30-s trial with both the injured and non-injured leg before the main coordinative test. The squat machine was connected to a computer, and the relevant software provided real-time data analysis during both eccentric and concentric phases of the coordinative test. During the test, the subjects had real-time visual feedback of their position via cursor displayed on a video monitor. The subjects were instructed to match cursor with so-called route that is shown on the screen of the video monitor (Fig. 2). 60 s of the target tracking was completed during eccentric concentric contractions of the lower-limb muscles. Then, 1-min rest period was given to the subjects. Tracking deficits of the injured knee were calculated by software and then compared with the uninjured knee and described as a percentage of the coordination deficit [28].

4 Knee Surg Sports Traumatol Arthrosc (2013) 21: centre of the box, the box will turn green. Then, the box will randomly move to either the left or right of its initial position. The subjects were instructed to relocate the stick figure into the box as quick as possible (Fig. 2). The time that it takes for the test subject to react and that initiates the movement of the stick figure is the Response Time. When the stick figure is properly located in the box, the box turns red. It is essential to control and hold that new position so that the box remains red. The time for this to occur is appointed as the Time to Finish. Muscle strength Isomed 2000 isokinetic dynamometer was used to assess the concentric strength of knee flexors and extensors. The subjects were seated in such a position that knee and hip were at 90 flexion, and shoulders, ankle and pelvis were fixed to the machine. The centre of the knee joint was aligned with the centre of the dynamometer by using a laser-pointing device. Before testing, 5-min warming programme was performed by using treadmill. Isokinetic test were performed with 5 repetitions at 60 /s and with 10 repetitions at 180 /s angular velocities. During the tests, the subjects were instructed to push the lever arm and to return to start position as strong as possible. The deficits in peak torque and total work of the operated and healthy knees were calculated [30]. Statistical analysis Fig. 2 Coordination, proprioception and response tests in functional squat system, respectively Proprioception testing The subjects were instructed to follow red cursor in response to a computer-generated blue route representing joint position four times. After the first and the second repetitions took place with feedback, the red cursor disappeared during the third and forth repetitions, and the subject was instructed to attempt to reposition the joint at the same angle without visual feedback (Fig. 2). The deficit between visual and non-visual results was calculated by the system for each leg [23]. Response time The subjects were instructed to move the stick figure into the empty box. When the stick figure is relocated to the SPSS 15.0 (SPSS Inc., Chicago, IL, USA) was used for all statistical analyses. Prior to this study, a power analysis based on modified star excursion balance test was calculated, and this study including 15 patients has 80 % power to detect a significant difference of 1.1 cm with an overall 5 % type-i error level. As a consequence of normality test, Kolmogorov Smirnov, the statistical analyses were performed with non-parametric tests. The data were analysed by using Friedman Test with time as the repeated-measures factor for outcome measures, and Mann Whitney U Test was used to determine the group differences at the first, 8th and 12th weeks of the rehab. Wilcoxon test was used for time of test differences in each group. The level of significance was set at p \ Results Flow chart of the subjects was shown in Fig. 1, and the physical characteristics of the subjects were shown in Table 1. We found no significant difference between Wii Fit and conventional groups with respect to isokinetic knee strength (Fig. 4), dynamic balance (Table 2), and

5 884 Knee Surg Sports Traumatol Arthrosc (2013) 21: functional squat tests including coordination, proprioception and response time (Table 3) at the first, 8th and 12th weeks of the rehabilitation (n.s.). As a consequence of the repeated measures for each group, SEBT, coordination and proprioception test results significantly differed depending on time. For both groups, anterior division of SEBT showed significant differences between first and 8th weeks (Wii: p = 0.004, Con: p = 0.039) and between first and 12th weeks (Wii: p = 0.019, Con: p = 0.016) of the rehabilitation, as well. Similarly, posteromedial division of SEBT also showed significant difference for both groups between first and 8th weeks (Wii: p = 0.004, Con: p = 0.005) and between first and 12th weeks (Wii: p = 0.006, Con: p = 0.02) of the rehabilitation, too (Table 2). It was found that there was a significant difference in coordination test between first and 8th weeks of the rehab in Wii group (p = 0.017) (Fig. 3). The proprioception test including deviation first movement deficit was recognized as significantly different in both groups between the first and 12th weeks of the rehab (Wii: p = 0.032, Con: p = 0.012) (Table 3). There was no difference in either group at first, 8 and 12th weeks of the rehab in terms of response time and the time to finish that are the parts of the response time test, and flexion and extension strength as regards peak torque and total work at 60 /s and 180 /s angular velocities in isokinetic test (n.s.). When the involved side was compared to the noninvolved side, the isokinetic test results were as follows (Fig. 4): Table 1 Demographic characteristics of the subjects N = 30 Wii (n = 15) Conventional (n = 15) p Age (years) 28.6 ± ± 5.7 n.s. Weight (kg) 77.3 ± ± 8.1 Height (cm) ± ± 0.6 BMI (kg/m 2 ) 24.8 ± ± 2.1 n.s. non-significant In Wii group, while the flexion strength in peak torque at 180 /s reached 73.6 %, that of at 60 /s reached 76.6 %, and the extension strength in peak torque at 180 /s reached 69.6 %, whereas 64.4 % was reached at 60 /s. In conventional group, while the flexion strength in peak torque at 180 /s reached 88 %, that of at 60 /s reached 70.7 %, and the extension strength in peak torque at 180 /s reached 61.5 %, whereas 64.9 % was reached at 60 /s. Discussion The most important finding of the present study was that Nintendo Wii Fit program versus conventional rehabilitation after ACL reconstruction would have same results on knee strength, balance, proprioception, coordination and response time at 8th and 12th weeks. The main focus of our study was to examine the effect of Wii Fit rehabilitation after ACL reconstruction. To our knowledge, the efficacy study of Wii Fit use with an average of 12 weeks after surgical intervention is limited. Other Wii Fit studies focused on balance in subjects with acquired brain injury and older people [10, 19, 20]. Compensatory neuromuscular patterns including muscle activation and joint stabilization may be developed and enhanced by utilizing treatments that incorporate destabilizing activities and exercises. For these reasons, balance and proprioceptive exercises on Wii Fit program, defined as exercises that challenge stability and neuromuscular control, have been advocated in the clinical setting [4, 17, 31]. Games and software for commercially available systems also come at a lower cost and with a greater variety, making it possible to adapt their use to different rehabilitation needs. Various game applications offer potential benefits in achieving treatment goals such as increasing joint movement, stimulating cognitive functions such as concentration, and stimulating functional activities such Table 2 Star excursion balance test results including the differences between non-involved and involved side reaching distances for all subjects N = 30 Group First week X ± SD (min-max) 8 week X ± SD (min max) 12 week X ± SD (min max) p ANT (cm) ± 7.2 ( ) 9.4 ± 9.2 ( ) 4.7 ± 7.03 ( ) \0.001* ± 6.4 ( ) 8.8 ± 5.8 ( ) 6.5 ± 5.2 ( ) 0.005* PM (cm) ± 3.2 ( ) 1.7 ± 4.5 ( ) 3.1 ± 6.9 ( ) 0.002* ± 4.3 ( ) 4.1 ± 4.2 (-0.7) 5.5 ± 5.3 ( ) 0.038* PL (cm) ± 5.6 ( ) 0.9 ± 4.7 ( ) -0.3 ± 4.3 (-8 7.4) n.s ± 5.6 (-7 14) 3.4 ± 4.2 (-2 9.6) 2.9 ± 4.3 ( ) n.s. *p \ 0.05 (ANT anterior division, PM posteromedial division, PL posterolateral division, n.s. non-significant)

6 Knee Surg Sports Traumatol Arthrosc (2013) 21: Table 3 Functional squat system test results for all subjects *p \ 0.05 (n.s. non-significant) (CCDD coordination concentric deviation deficit, CEDD coordination eccentric deviation deficit, RLTTF response label time to finish, RRT response time, PFMDD proprioception first movement deviation deficit, PMDD proprioception second movement deviation deficit) (Group 1: Wii, Group 2: conventional) N = 30 Group First week X ± SD 8 week X ± SD 12 week X ± SD CCDD ± ± ± * ± ± ± 12.2 n.s. CEDD ± ± ± 42.9 n.s ± ± ± n.s. RLTTF ± ± ± 17.1 n.s ± ± ± 28.2 n.s. RRT ± ± ± 13.1 n.s ± ± ± 17.2 n.s. PFMDD ± ± ± * ± ± ± * PSMDD ± ± ± n.s ± ± ± * p PTF 180 /s PTE 180 /s PTF 60 /s PTE 60 /s Nm/kg Wii Conventional Fig. 4 Involved/non-involved (I/NI) strength ratio in peak torque flexion and extension at 180 and 60 /s angular velocities. (PTF peak torque flexion, PTE peak torque extension) Fig. 3 The coordination test results of at first, 8 and 12th weeks of rehabilitation (CorConDevDef: coordination concentric deviation deficit, CorEccDevDef: Coordination eccentric deviation deficit) as driving and cooking. Gaming systems can introduce additional motivators to generate interest in therapeutic activities [13, 22, 27] and can be intended for an enjoyable method of encouraging physical movement [2, 5]. SEBT was used as a dynamic postural control measurement. This test was chosen as it is a reliable test that assesses dynamic stability in multiple planes, and detects performance deficits related to pathology [16, 25]. Herrington et al. [12] found that the statistical analyses revealed significant differences between the control group and the ACL limb about the limb movement directions of anterior (p = ), lateral (p = 0.005), posterior-medial (p = ) and medial (p = 0.001). The findings of the recent studies are in an alignment with Herrington et al. in that there are significant differences on the SEBT among the subjects with ACL deficit. In our study, the ACL subjects appear to have deficiencies in their dynamic postural control when compared to the first, 8 and 12th weeks after the rehabilitation, but there was not any significant difference between the groups. This may be an indicative of a postural control deficit in these subjects, which may have as a result of ACL injury and would need further studies. It was found that both rehabilitation programmes influenced peak torque of isokinetic knee strength. This influence might be due to an interaction between the time of

7 886 Knee Surg Sports Traumatol Arthrosc (2013) 21: training and the duration of physiotherapy. Figure 4 shows the comparison between involved/non-involved (I/NI) strength ratio in peak torque flexion and extension at 180 and 60 /s angular velocities in both groups. We propose that the short recovery period such as 12 weeks for a peak torque flexion at 60 and 180 /s in both groups was thanks to the improvement of the coordination and neural activation of the operated limb. The training protocol was designed to be increasingly more difficult over the 12 weeks period by integrating speed and complex balance and agility tasks. However, an emphasis on the sufficient practice of basic motor tasks at slow speeds may be more important for regaining normal neuromuscular control after the injury [7, 24, 26]. The strength results of our study showed that quadriceps and hamstring strengths were significantly high in both groups at the 12th week of post operation, which means a clear improvement compared to the previous papers [7, 15, 18]. De Jong et al. [7] reported that quadriceps strength deficit considerably increased after ACL reconstruction, and strength was regained during 6th 12th months, but it was seen that there was a persistent deficit compared to pre-operation. Dynamic assessment of motor control and muscle coordination is essential for understanding normal joint function [15]. This study showed the deficit of injured knee under dynamic circumstances and the role of both joint position sense and motor control pattern in ACL injury. In our study, the coordination results were evaluated in a separate category unlike other studies handling proprioception with these features together. Wii group, compared to the conventional group, showed a greater change in deficit results of coordination test (Fig. 4). Functional squat testing relies totally on the coordination of the tested limb [21, 28, 30]. Thus, the greater gains in concentric coordination demonstrated by the both groups may be due to better performance of the desired motor pattern compared to the eccentric coordination. We also argued that both programmes contributed significantly to neural activation involved in the early stages of the strength gains (at 12th week). To our knowledge, the effects of response time with functional squat system after the ACL surgery had not previously been examined. We used the percentage difference to compare response time between the two groups. The smaller the Response Time, the faster the subject s ability was in reacting to unexpected demands during the rehabilitation stages as out study mainly consisted of young subjects (mean age 28 years). Our subjects in both groups completed Time to Finish in a short time. This may be related to quick fine motor control abilities necessary for holding the moved weight. There were two limitations with our study. First, it was not possible to account for differences in the rehabilitation programmes among the subjects. It was a small sample size from one clinic. This makes it difficult to generalize findings to a larger ACL patient population. Second, the subjects included in this study were young and active individuals who might have had higher motivation for exercise and rehabilitation than other subjects with ACL injury. Our results are thus dependent on high compliance with the exercise therapy programme. The participants were willing to play the game during their normal physical therapy treatment and were willing to provide feedback. Despite these limitations, this study is the first randomized clinical trial showing that Wii Fit is a feasible, safe, and potentially effective intervention to enhance motor function and performance outcomes recovery in subjects with ACL reconstruction. It would be interesting to further investigate balance, strength, coordination, proprioception and response time before the reconstruction process and with more subjects and their rehabilitation after surgery. Further knowledge of this process could aid clinicians in their decision on when to return subjects to full activity after ACL reconstruction. It was recommended that proprioceptive coordination exercises should be included in long-term rehabilitation programmes because of the fact that the subject with ACL reconstruction kept to having significant motor coordination and strength deficits at 12th week. Comparing the Wii Fit to conventional therapy techniques illustrated the efficacy of this study and a Wii Fit off-the-shelf game within a randomized, controlled, double-blind trial for the subjects with ACL reconstruction. In fact, Wii Fit is a fun-to-play-game that provides an appropriate level of challenge and appropriate feedback for a wide range of abilities. It also provides clinicians with control over the game-based exercise tools according to the phases of the rehabilitation in ACL reconstruction. Conclusion It is obvious that Wii Fit and conventional training programmes, which were conducted within a mean time frame of 12 weeks, are important in ACL rehabilitation. However, it is not clear whether one is significantly more effective in restoring neuromuscular control and increasing the functional performance. Instead of conventional rehabilitation, Wii Fit Balance program might be recommended since it is safe, feasible and cheap. References 1. 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