cerebral palsy ( cp ) is a neurologic disorder that results from a defect or insult to the 
 immature brain , and it is one of the most common causes of motor disability in childhood .
cp 
 describes a group of disorders of movement and posture , causing activity limitation and is 
 attributed to non - progressive disturbances occurring in the developing fetal or infant 
 brain1 .
children with cp suffer from 
 motor and cognitive disabilities , which usually require a multi - faceted treatment strategy 
 over many years involving a number of different health professionals2 .
cp includes the following components : aberrant control of 
 movement and/or posture , early onset , and no recognizable underlying progressive pathology . 

the consequences 
 of chronic muscle imbalance and the resultant deformities can cause increasing disability 
 with age3 , 5 .
one of the most significant problems for children with cp is 
 defective postural control .
maintaining postural control , required for the performance of 
 activities of daily living , is often a major challenge for children with cp6 .
children with cp show affected motor 
 control with an associated pathological gait pattern due to injury to the central nervous 
 system in the developing brain .
poor balance control is known to be an important causative 
 element of the gait problems in these children7 , 8 .
the nintendo wii fit (  wii fit  ) is a 
 software / hardware game package for the nintendo wii , designed to improve balance 
 and fitness , while providing entertainment9 .
the nintendo wii system has been postulated to be effective at 
 improving functional performance by enhancing flexibility , balance , strength and 
 coordination training .
the additional advantage of the nintendo wii system is the visual 
 feedback that the participant receives during the training session .
this visual feedback 
 aids the participants improv balance , while the game simulation creates a perception that 
 they can perform high level activities10 . 

the nintendo wii offers a simple and affordable mode of virtual reality therapy that is 
 being increasingly used to treat children with cerebral palsy , but to date few studies of 
 its efficacy have been published .
therefore the aim of the current study was to investigate 
 the effects of wii - based balance therapy on balance and walking function of patients with 
 cp .
  progress of study participants fourteen patients with cp ( 3 girls , 11 boys ) with an age range of 517 participated in this 
 study ( fig .
the patients were recruited from the pediatric neurology 
 outpatient clinic of the department of pediatric neurology , faculty of medicine , istanbul 
 university , and were diagnosed with cp .
exclusion criteria were the presence of 
 epilepsy , gross motor function classication system expanded and revised 
 ( gmfmcs - er ) level 4 or 5 , spasticity of 3 or more according to modified 
 ashworth scale in the lower extremities , and inability to cooperate with exercise or 
 measurement .
all patients and their parents were informed about the study , and written 
 informed consent was obtained from the parents of the patients .
the study was approved by 
 the ethics committee of istanbul university and was conducted in accordance with the 
 decleration of helsinki .
patients ' weight and height were measured and body mass index ( bmi ) was calculated as the 
 weight divided by the square of the height .
clinical features such as disease duration , and 
 the subtype of cp were assessed by a pediatric neurologist .
the gross motor function classication for cp ( gmfcs ) is a ve - level classication . in 
 short
, class 1 means that the child is freely ambulatory , class 2 means inability to run or 
 jump , class 3 means dependency on devices for walking , and classes 4 and 5 mean 
 non - ambulatory cp11 .
the gmfmcs - er was 
 developed using the 12-to18  year age band , on the basis of the concept that performance of 
 gross motor function is influenced by physical , social , and attitudinal environment and 
 personal factors such as preferences , interests , and motivation in 200712 .
the gross motor level of children with cp was assessed 
 using the gmfmcs - er in our present study .
the one leg standing test is a commonly used balance assessment of postural stability among 
 physiotherapist and occupational therapists .
patients are given specific instructions to 
 stand on one leg for as long as possible in one of two conditions , with the eyes open or 
 eyes closed .
the one leg standing test is considered to be potentially useful for 
 predicting functional decline , and has been shown to be sensitive to clinical 
 interventions15 .
the timed up and go test ( tug ) was designed to 
 measure speed during functional tasks that potentially threaten balance16 .
the participants sat on a standard armchair and were instructed to get up and walk at a 
 comfortable and safe pace to a line on the floor 3 metres away , turn around , return to the 
 chair and sit down again .
the functional reach test ( frt ) was developed as a measure of the margin of stability .
the 
 frt has been used to describe and monitor an individual 's balance and to screen for or 
 predict an individual who is at risk of falling .
the test consists of measuring the distance that an individual 
 can reach forward without moving his or her feet .
variations of the test , having individuals reach in different directions , have 
 been suggested17 . the 6-minute walking test has been used as a measure of the functional status of patients . 

the test was performed on an 8-meter track in a straight corridor as described in the 
 literature .
patients were instructed to cover the largest possible distance in 6 minutes at 
 a self - chosen walking speed .
each time the patient returned to the starting line , 
 the lap counter was clicked once .
every minute the patients were encouraged in a 
 standardized way , and time , recorded with a stopwatch , was called every minute18 .
the patients ' demographic 
 information were recorded in the system , and the right and left foot as a percent of the 
 total weight on the balance board was registered by the system .
if the wii 
 age of the person is greater than their actual age , it shows inability in exercise and 
 balance . a physiotherapist prescribed the wii fit activities , and supervised and supported the 
 patients during the therapy sessions .
wii training was performed in a standardized program , 
 2 times a week for 12 weeks , with sessions lasting approximately 40 minutes .
a brief explanation of the purpose of each one of these games can 
 be found in table 1 .
all the participants were 
 assessed before and after the training program by a physiotherapist .
the data were evaluated using the statistical package for social science ( spss ) v.17.0 
 software for windows and by analysing descriptive statistics ( frequency , mean , and standard 
 deviation ( sd ) .
the mann - whitney u test was used to determine the effects of the exercise 
 program .
sd : standard deviation , bmi : body mass index , f : female , m : male , cp : cerebral palsy , 
 gmfmcs - er : gross motor function classication system expanded and revised gmfmcs - er : gross motor function classication system expanded and revised . , mas : 
 modified ashworth scale , flex : flexion , r : right , l : left , hms : hamstring , gcs : 
 gastrocnemius sd : standard deviation , sec : second , cm : centimeter . * significantly different from 
 pre - treatment p<0.05 sd : standard deviation , * significantly different from pre - treatment to post - treatment 
 p<0.05 a total of 26 eligible patients with cp were included in this study .
the patient population comprised 7 diplegic 
 type cp , 5 patients with hemiplegic type cp , and 2 patients with dyskinetic type cp .
their mean age was 12.07  years ( sd 3.36 , range 
 1116  years ) .
table 3 shows the levels of the gmfmcs - er and modified ashworth 
 scale scores of all the participants .
the changes in outcome measures at the end of training 
 program for one leg standing time , the timed up and go test , the functional reach test , the 
 6- minute walking test and wii fit parameters are shown in table 4 . at the end of training program the wii game score changes 
 are shown in table 5 . statistically significant 
 improvements ( p<0.05 ) were found in all the outcome measures , wii fit parameters and wii 
 game scores of the participants after 12 weeks .
the results of our study show that cp patients participating in a 12-week wii fit training 
 program showed improved balance function and walking . functional balance , which is an 
 element of postural control ,
allows a child to perform activities of daily living ( adl ) , 
 social activities , and recreational activities at home , school , and in the community .
children with 
 cp may have impaired postural balance that contributes to their gait abnormalities19 . therefore , the main focus of this study 
 was to improved balance parameters and functional walking .
our study showed significant 
 improvements in balance parameters of cp patients after the wii - based balance therapy . 

health care professionals have begun to use interactive gaming systems and technology to 
 help rehabilitate patients with musculoskeletal and neurologic conditions .
the growing 
 popularity of interactive gaming is partially due to the belief that playing interactive 
 video games during a rehabilitation session can direct a patient 's focus away from the 
 repetitive and mundane nature of rehabilitation exercises and toward the fun and competitive 
 aspects of the video game20 .
the 
 literature include some d studies of interactive games , especially wii fit games , in 
 different neurological diseases and geriatrics21 , 
 22 .
however in the literature , we found 
 only a few trials demonstrating the benefits of wii - based training for cp patients .
deutsch 
 et al.23 demonstrated that wii games 
 improved visual perception , posture and functional mobility with wii games in a case study 
 with spastic diplegic cp .
unlike our study , ramstrand et al.24 recruited eighteen children with hemiplegic or diplegic cp .
their results suggest that use 
 of a nintendo wii balance board and wii fit software for a minimum of thirty minutes per day 
 in the patient 's own home , over a five week period , is not effective as a balance training 
 tool for children with cp .
jelsma et al.25 included 14 children with spastic hemiplegic cerebral palsy in 
 their study .
nintendo wii fit training in lieu of regular physiotherapy was given for 3 
 weeks .
outcome measures included modified balance score running speed , and agility scales of 
 the bruininks - oserestky test of motor performance , and the timed ascent and descent of 
 stairs .
their study showed balance scores improved significantly but nintendo wii fit 
 training should not be used in place of conventional therapy , and further research is needed 
 into its use as an adjunct to therapy .
for this reason , we used the ski 
 slalom , soccer heading , tilt table and walking a tightrope games to attempt to improve their 
 balance .
michalski et al.26 evaluated 
 postural control strategies healthy individuals use to play wii fit videogames .
centre of 
 pressure ( cop ) excursion and three - dimensional movement data were acquired to determine 
 variability in medial 
lateral cop sway and shoulder  pelvic movement . while there was no 
 difference in medial 
lateral cop variability between games during trial 1 , there was a 
 significant difference after 10 trials .
our study found improvements in the frt , tug , and the 6- minute walking test .
the 
 interventions chosen to improve gait were ski slalom , soccer heading , tilt table and walking 
 a tightrope games .
the games improved movements of the trunk and extremities through a large 
 spectrum of balance perturbations that vary in both amplitude and location of the 
 destabilizing force . at the same time
these games improve dynamic balance and trunk control 
 through right and left transfer of body weight .
this study is 
 important for the spread of wii fit use in the rehabilitation of cerebral palsy in our 
 country .
therapists working in this area will provide a different perspective . in conclusion , this study demonstrated that wii based balance training has the potential to 
 improve the balance and functional walking of patients with cp .
this wii - based training is 
 more fun and provides motivation , and may be a preferable method of treatment for children 
 with cp .
further research is needed to develop evidence - based guidelines for wii - based 
 balance therapy in cp .
   [ purpose ] cerebral palsy is a sensorimotor disorder that affects the control of posture 
 and movement . 
 the nintendo wii fit offers an inexpensive , enjoyable , suitable 
 alternative to more complex systems for children with cerebral palsy . 
 the aim of this 
 study was to investigate the efficacacy of wii - based balance therapy for children with 
 ambulatory cerebral palsy . 
 [ subjects ] this pilot study design included fourteen ambulatory 
 patients with cerebral palsy ( 11 males , 3 females ; mean age 12.07  3.36  years ) . [ methods ] 
 balance functions before and after treatment were evaluated using one leg standing , the 
 functional reach test , the timed up and go test , and the 6-minute walking test . 
 the 
 physiotherapist prescribed the wii fit activities , and supervised and supported the 
 patients during the therapy sessions . 
 exercises were performed in a standardized program 2 
 times a week for 12 weeks . 
 [ results ] balance ability of every patient improved . 
 
 statistically significant improvements were found in all outcome measures after 12 weeks . 
 
 [ conclusion ] the results suggest that the nintendo wii fit provides a safe , 
 enjoyable , suitable and effective method that can be added to conventional treatments to 
 improve the static balance of patients with cerebral palsy ; however , further work is 
 required . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION