world stroke incidence studies have shown that there has been a 42% decrease in stroke 
 incidence in high - income countries and more than a 100% increase in low - to middle - income 
 countries .
early stroke case fatality has decreased in both high - income and low - to 
 middle - income countries1 . despite the 
 increase in stroke incidence , the decrease in mortality rate leads to an increase in people 
 living with disabilities .
therefore , stroke constitutes the leading cause of serious , 
 complex , and long - term adult disability2 , 3 .
although 1530% of the stroke survivors become permanently disabled , 5070% of stroke 
 patients regains functional independence and mostly regains walking ability4 , 5 . 
 due to residual functional disabilities such as impaired balance and motor weakness
a study by jorgensen et al . showed 
 that 73% stroke patients fell in the six months after a stroke , that 21% fell after 6 
 months , and that over half of all reported falls occurred during walking activities due to 
 problems such as loss of balance , misjudgement , and foot dragging6,7,8 .
balance deficits like reduced postural stability during quiet standing , delayed and less 
 coordinated responses to internal and external balance perturbations , and increased weight 
 bearing on the unaffected limb are one of the main risk factors for falls after stroke9,10,11 . together with the increased risk of 
 falling , fear of falling increases , self - confidence decreases , and individual autonomy and 
 participation in social activities reduces .
therefore , patients become more dependent on 
 caregivers , and as a result , quality of life decreases .
the rehabilitation approaches aiming 
 to increase the balance functions of patients promotes reintegration into the community , 
 recreational and daily life activities , positive behavioral changes , and social acceptance 
 of the patients12 , 13 .
balance rehabilitation programs after stroke were found to be effective in enhancing 
 functional recovery ; on the other hand , the limited resources of health - care systems hamper 
 the implementation of intensive practice14 , 15 .
therefore , innovative rehabilitation 
 technologies including virtual reality systems are currently being used in stroke 
 rehabilitation mainly because they provide an enriched environment , task - specific goals , and 
 repetitive practice16 , 17 .
these systems may decrease the amount of time spent for 
 one - to - one sessions with physiotherapists and may provide patients with the opportunity to 
 use the systems at home .
currently , nintendo wii fit , video game technology using virtual reality , has become a very 
 popular rehabilitation approach in balance treatment . in the wii fit games ,
patients are 
 directed to shift their weight anteriorly , posteriorly , and laterally within a center of 
 pressure ( cop ) range in order to reach a target and to enhance their limits of stability . 

the wii fit games have been used in the literature due to their effects in improving motor 
 skills and postural control by using visual - perceptual systems , providing information about 
 the performance , showing the direction , speed and acceleration changes , and being 
 interactive , motivating , useful and cheap18,19,20 .
few studies have used the wii fit method for balance treatment in chronic stroke patients . 

two case report studies have demonstrated that static and dynamic balance can be improved 
 with the wii fit system in patients with stroke21 , 
 22 . in a previous randomized controlled 
 study in which standard rehabilitation plus virtual reality balance training with wii fit 
 was compared with standard rehabilitation only greater improvement was observed in dynamic 
 balance23 .
this may be because of the 
 disparity in the duration ( length of session ) and intensity ( massed practice ) of the 
 treatment in the two groups .
therefore , it was expecting that more improvement would be 
 obtained in the experimental group due to more intensive treatment .
the aim of this study 
 was to compare the effectiveness of game technology based wii fit balance training ( wbt ) and 
 progressive balance training ( pbt ) in addition to a neurodevelopmental treatment program on 
 static and dynamic balance functions , activity specific balance confidence , and activities 
 of daily living in patients with chronic stroke .
individuals with stroke admitted to a physiotherapy and rehabilitation department over a 
 period of 12 months were considered for inclusion in this study .
the study was approved by 
 the local ethics committee for medical , surgery and drug research ( lut 11/01 ) , and written 
 informed consent was obtained from all patients prior to data collection .
the 
 criterion for inclusion was first ever stroke with hemiparesis (  6 months ) .
patients were 
 excluded if they had any other physical problem or epilepsy , moderate to severe cognitive 
 deficits as evaluated by the mini mental state examination test ( mmse ) ( 20 points ) , severe 
 depression as measured by the beck depression inventory ( bdi ) ( 30 points ) , and were unable 
 to walk independently according to the modified rankin scale ( mrs ) ( > 3 points ) . 

participants were randomly allocated to one of two different treatment groups : pbt and wbt . 

a simple randomization method was used to allocate patients in each group according to 
 registration number ( even numbers , pbt group ; odd numbers , wbt group ) .
a neurodevelopmental treatment , a problem solving and analytical approach , was applied to 
 each group .
the treatment programs were planned considering the functional level , individual 
 needs , and demands of the patients based on selective movement as a basis of functional 
 activity and successful goal acquisition24 .
patients assigned 
 to the wbt group received a 1 hour treatment program consisting of a 30-minute 
 neurodevelopmental training program and 30-minute wii balance training program for a total 
 of 12 sessions , which were held 3 days a week for 4 weeks .
patients assigned to the pbt group received a 1 hour treatment program 
 consisting of a 30-minute neurodevelopmental training program and 30-minute progressive 
 balance training program for a total of 12 sessions , which were held 3 days a week for 4 
 weeks .
the descriptive variables of the patients including age , gender , body mass index , duration 
 of stroke , and affected side were recorded before the treatment .
all participants were 
 assessed at baseline ( week 0 ) , after the treatment ( week 4 ) , and one month post treatment 
 ( week 8) .
the static balance , 
 that is the mediolateral weight distribution on the paretic and nonparetic extremities , was 
 measured with a wii balance board ( wbb ) , which has characteristics similar to 
 laboratory - based force platform ( fp ) systems that contain four transducers used to assess 
 weight distribution and cop25 .
dynamic balance was measured with four balance tests reflecting different aspects of 
 balance : the berg balance scale , timed up and go test , dynamic gait index , and functional 
 reach test .
the berg balance scale ( bbs ) , which is a psychometrically sound measure of balance 
 impairment post stroke , was used to assess functional balance of the patients26 , 27 .
the test is a 14-item objective measure used to assess the balance 
 performance of patients during functional tasks ranging from sitting to standing on one 
 foot28 .
the timed up and go test ( tug ) was used to measure the functional mobility level of the 
 patients . the time taken to complete the task ( standing up from a chair , walking 3 meters , 
 turning around , walking back , and sitting down )
the dynamic gait index ( dgi ) , which assesses an individual s ability to modify balance 
 while walking in the presence of external demands , was used to assess balance and gait 
 ability of the patients31 , 32 .
the functional reach test ( frt ) , which consists of measurement of the maximal distance one 
 can reach forward beyond arm s length while maintaining a fixed base of support in the 
 standing position , was used to measure the stability limits of the patients33 .
the balance 
 confidence of the patients was measured with the activities - specific balance confidence 
 ( abc ) scale developed to measure the confidence of subjects when performing various 
 ambulatory activities without falling34 . 

the activities of daily living of the patients were evaluated with the frenchay activity 
 index ( fai ) , which contains 3 factors ( indoor domestic activities , outdoor domestic 
 activities and outdoor social activities ) related to the self care and mobility of 
 patients35 .
we calculated that the required sample size was 30 subjects for 90% power with a 5% 
 significance level .
the 
 variables are presented as the mean  standard deviation ( x  sd ) .
the differences within 
 groups were tested using the wilcoxon signed - rank test , and those between groups were tested 
 using the mann - whitney nonparametric test . the friedman test was used for repeated 
 measurements , and bonferroni correction was used to assess changes in balance functions from 
 week 0 to week 8 between the groups .
the 95% level of confidence (  = 0.05 , or the margin of 
 error ) was used for the assumptions to identify differences in the variance analysis .
forty patients were assessed during the study period . of these , 33 patients were recruited 
 and randomly allocated into the wbt ( n=17 ) and pbt ( n=16 ) groups .
reasons for exclusions and 
 drop - outs are shown in the study profile ( fig .
1 ) . 
 fifteen patients in the pbt group and fifteen patients in the wbt group completed the 4-week 
 treatment program and the follow - up assessment at 8 weeks . before treatment
, there were no 
 significant differences between the wbt and pbt groups with respect to demographic 
 characteristics , mental state , and level of depression .
however , disease severity measured 
 by the modified rankin scale was found to be higher in the pbt group ( table 1table 1.demographical and physical characteristics of patientswbt(n=15)(xsd)pbt(n=15)(xsd)gendermale67female98affected sideright87left 78age ( years)mean62.8056.60sd10.8716.42body mass index ( kg / m)mean29.1428.30sd4.524.56duration ( years)mean3.704.23sd4.424.86modified rankin scale ( 06)mean1.802.40*sd0.770.82mini mental test ( 030)mean22.8622.26sd2.382.05beck depression inventory ( 063)mean14.0014.00sd6.147.58*p0.05 ) .
the functional balance performance scores of the patients in the wbt group were higher for 
 the bbs and tug tests performed before treatment ( week 0 ) .
the results of the four different 
 functional balance tests ( bbs , tug , dgi , and frt ) showed that both groups improved 
 significantly after treatment ( week 4 ) . however , there was no significant difference between 
 the groups after treatment ( week 4 ) .
the patients in the pbt group showed a significantly 
 lower results of the bbs and tug tests in their follow - up measurements ( week 8) ( table 2table 2.within-and between - group comparisons of all outcome measuresweek 0xsdweek 4xsdweek 8xsdweek 0 vs. 4(wilcoxon test)week 4 vs. 8(wilcoxon test)weight distribution ( % ) wbtparetic44.047.4748.002.8046.644.40*nonparetic55.887.4552.002.8053.364.41*pbtparetic 47.5410.1648.598.3848.148.94nonparetic52.4610.1651.278.3651.868.94wbt vs pbt(mann - whitney u test ) ( friedman test ) bbs ( 056)wbt45.605.2650.334.0950.334.16*pbt39.609.3144.807.4844.207.77**wbt vs. pbt(mann - whitney u test)***(friedman test)*tug ( sec)wbt 17.967.7716.178.2315.957.93*pbt26.3611.6022.1111.8822.7311.95**wbt vs pbt(mann - whitney u test)*(friedman test ) * dgi ( 024)wbt14.864.1216.863.3516.863.33*pbt12.603.9614.463.4814.864.06*wbt vs. pbt(mann - whitney u test)(friedman test ) * frt ( cm)wbt 25.265.9229.405.1630.065.16*pbt24.206.6627.136.1926.806.58*wbt vs. pbt(mann - whitney u test ) ( friedman test ) * asbct ( 0100)wbt 59.6217.2668.3617.2270.1016.92*pbt53.1017.4759.3718.0859.0418.27*wbt vs. pbt(mann - whitney u test ) ( friedman test ) * fai ( 1560)wbt 14.466.5416.267.1816.206.79*pbt10.406.5212.536.5813.267.37**wbt vs. pbt(mann - whitney u test)*(friedman test ) * * statistically significant values ( p0.05 ) are indicated with an asterisk .
bbs : berg 
 balance scale ; tug : timed up and go test ; dgi : dynamic gait index ; frt : functional 
 reach test ; asbct : activity specific balance confidence test ; fai : frenchay activity 
 index ) .
bbs : berg 
 balance scale ; tug : timed up and go test ; dgi : dynamic gait index ; frt : functional 
 reach test ; asbct : activity specific balance confidence test ; fai : frenchay activity 
 index both groups showed significant improvement in terms of the balance confidence ( abc ) scale 
 from baseline to after the treatment period ( week 4 ) .
no significant difference was recorded 
 between the two groups after treatment ( weeks 4 and 8) ( table 2 ) .
the activities of daily living measured with the fai were found to be increased in both 
 groups after treatment ( week 4 ) .
when comparing the groups , no significant differences were 
 found between them after treatment ( weeks 4 and 8) .
the results at follow - up showed that adl 
 continued to improve in the pbt group despite cessation of treatment ( week 8) ( table 2 ) .
the main objective of this study was to compare the effects of balance training with an 
 increasingly popular virtual reality based game technology , nintendo wii fit ( wbt ) , and 
 progressive balance training ( pbt ) on balance functions , activity specific balance 
 confidence , and activities of daily living in patients with chronic stroke .
although the two 
 approaches tend to be more effective on different parameters of functional balance measures , 
 there were no remarkable superiorities of either treatment approach over the other .
on the basis of the idea that visual feedback , which was used more intensely in the wii fit 
 group , would have additional effects on symmetrical weight bearing on the paretic and 
 nonparetic extremities36 , the effects of 
 the two treatment approaches on symmetrical weight distribution were compared in our study . 

although the weight bearing on the paretic extremity was found to be improved and was more 
 symmetrical in the wbt group , no significant superiority of either treatment method over the 
 other was observed for the weight distribution of the patients .
we speculate that the 
 results might be due to the baseline weight distribution of the patients in our study .
the 
 average weight distribution of the patients on the nonparetic extremity at the beginning of 
 this study was relatively symmetrical ( 5255% ) compared with the values specified for stroke 
 patients in the literature ( 6180%)11 . 

moreover , the weight distribution was more symmetrical in the pbt group ( 52% ) than in the 
 wbt group ( 55% ) ; thus the effects of the treatment methods might not have emerged 
 exactly .
the balance exercises used in both treatment methods included weight shifting activities 
 closely related to static balance , i.e. , the ability to maintain a chosen posture with 
 minimal postural sway10 .
these exercises 
 aims to improve postural control by increasing anteroposterior and mediolateral weight 
 transfer and reducing postural sway , but do not especially focus on improving dynamic 
 balance . as postural control is a prerequisite for most functional activities , weight 
 shifting exercises aimed at improving postural control , may have significant effects on 
 balance during functional activities .
all of the functional balance measurements ( bbs , tug , 
 dgi , and frt ) applied to the patients for that purpose showed that functional performance 
 was improved in both groups .
we supposed that training approaches emphasizing weight 
 shifting abilities , whether using visual feedback ( wbt ) or not ( pbt ) , provides benefits to 
 both static and dynamic aspects of balance .
the measurements after 8 weeks showed that there was a decline in the bbs and tug test 
 results in the pbt group . in a case - control report of deutsch et al .
, two individuals in the 
 chronic phase post stroke received balance training with either a nintendo wii and wii fit 
 program or standard of care balance and mobility program for 12 training ( 60-minute ) sessions , and it was found that the patient who received the standard 
 therapy maintained his improvements after treatment .
it was propounded that the activities 
 used for the treatment ( balance and coordination exercises and outdoor activities e.g. 
 crossing the road , walking in the busy areas , and market shopping ) were transferred to real 
 life activities due to the similarity between them , and thus the patient had used these 
 activities after treatment22 .
considering 
 the activities of the study mentioned above , we did not include outdoor activities in 
 addition to the balance exercises in our study ; this may constitute a reason why the 
 improvements were not maintained after treatment in our study .
 balance confidence , defined as the perceived ability or confidence to perform an activity 
 or action without falling37 , was found in 
 our study to be improved in both groups after treatment .
bandura s theory identifies four 
 factors affecting self - efficacy , that is , one s belief in one s ability to succeed in 
 specific situations : performance accomplishments ( physical practice ) , vicarious experience 
 ( mental practice ) , verbal persuasion ( encouragement ) , and emotional sources 
 ( motivation)38 . associating these 
 factors with falls - related self - efficacy
, it can be said that both the pbt and wbt 
 approaches may involve adequate physical practice , mental practice , encouragement , and 
 motivation , which lead to improved balance confidence in patients .
the results for activities of daily living results indicate that the patients in both 
 groups improved after treatment .
in addition to this result , improvements in the pbt group 
 proceeded after the cessation of treatment ( week 8) .
it is known that the wii fit balance 
 training method includes task - specific activities , though wii fit exercises are not very 
 similar to daily life activities in many ways .
games , therefore , even though there are improvements in functional balance , these 
 activities do not contribute to the transfer of improvements to daily life activities .
in a 
 further aspect , progressive balance training is more similar to daily life activities , and 
 patients may perceive pbt activities as 
games , therefore , pbt may 
 result in more improvement in patients daily lives .
the limitations of this study include the fact that , the feedback given with wii fit may 
 not be sufficient for patients to use normal movement strategies ; therefore , 
 physiotherapists should prevent abnormal patterns during activities . in another way , during 
 the wii fit training
, the need for a physiotherapist to help with symmetrical weight 
 shifting poses a problem with respect to use of this technology at home .
the main aim of 
 this study was to use wii fit technology in order to reduce the need for one - to - one 
 interaction between physiotherapist and patients ; however , if there is a necessity for 
 physiotherapists to correct the abnormal patters used by patients , it should be questioned 
 whether this technology can be used at home or not .
this study found that 
 physiotherapist - assisted wii fit balance training is an effective method , but there is a 
 need to compare the effects of wii fit balance training with and without any help from 
 physiotherapists in future studies .
another limitation of this study was the disease 
 severity , which was found to be higher in the pbt group .
this limitation was due to the 
 randomization procedure ; therefore it could not be eliminated .
some studies have asserted that although there are beneficial effects of using wii fit in 
 rehabilitation , this technology may have some safety problems . like the other commercial 
 game systems
, the wii fit system is a  black box ; thus various parameters of the system 
 can not be controlled . in this sense , not being a rehabilitation - specific tool , being 
 difficult for people with physical problems , allowing the use of abnormal movement patterns , 
 having an incomprehensible scoring system , giving feedback that is not rehabilitation 
 specific , and making degrading comments sometimes are some problems preventing the wii fit 
 system from becoming widely used in rehabilitation22 , 
 39 .
there are also reports of injuries 
 arising from the use of nintendo wii game systems ( metacarpal and metatarsal fractures , 
 wrist and ankle traumas , clavicular fracture , patellar dislocation , muscle and tendon 
 injuries , c7 fracture , stroke , and hemothorax ) in the literature40,41,42,43,44,45,46 . in this sense
, there were no negative effects and/or any 
 injuries attributable to use of wii fit in our study .
to our knowledge , this is the first study comparing the effectiveness of wii fit balance 
 training ( wbt ) and progressive balance training ( pbt ) in addition to neurodevelopmental 
 treatment approaches in patients with chronic stroke .
the two treatment programs used in the 
 current study were both found to be effective on balance functions , activity - specific 
 balance confidence , and activities of daily living .
when comparing the two treatment 
 approaches , they seem to be effective on different parameters of balance performance , with 
 no superiorities of either treatment approach over the other .
wii fit balance treatment can 
 be used as an effective method for patients with difficulty accessing treatment or for 
 physiotherapists who require alternative methods of treatment .
 [ purpose ] the aim of this study was to compare the effects of wii fit balance training 
 ( wbt ) and progressive balance training ( pbt ) approaches on balance functions , balance 
 confidence , and activities of daily living in chronic stroke patients . [ subjects ] a total 
 of 30 patients were randomized into the wbt ( n=15 ) and pbt ( n=15 ) groups . 
 [ methods ] all of 
 the subjects received exercise training based on a neurodevelopemental approach in 
 addition to either wii fit or progressive balance training for total of 1 hour a day , 3 
 days per week for 4 weeks . 
 primary measurements were static balance function measured with 
 a wii balance board and dynamic balance function assessed with the berg balance scale , 
 timed up and go test , dynamic gait index , and functional reach test . 
 secondary measures 
 were balance confidence assessed with the activities - specific balance confidence scale and 
 activities of daily living evaluated with the frenchay activity index . 
 [ results ] there was 
 not remarkable difference between the two treatments in dynamic balance functions , balance 
 confidence , and activities of daily living . 
 [ conclusion ] although both of the approaches 
 were found to be effective in improving the balance functions , balance confidence , and 
 activities of daily living , neither of them were more preferable than the other for the 
 treatment of balance in patients with chronic stroke . 