Williams et al.

BMC Research Notes 2010, 3:238

http://www.biomedcentral.com/1756-0500/3/238

SHORT REPORT Open Access

EXercising with Computers in Later Life (EXCELL) -

pilot and feasibility study of the acceptability
of the Nintendo® WiiFit in community-dwelling
fallers
Marie A Williams1*, Roy L Soiza1, Alison McE Jenkinson2, Alison Stewart3

Abstract
Background: Falls management programmes have been instituted to attempt to reduce falls. This pilot study was
undertaken to determine whether the Nintendo® WiiFit was a feasible and acceptable intervention in community-
dwelling older fallers.
Findings: Community-dwelling fallers over 70 years were recruited and attended for computer-based exercises
(n = 15) or standard care (n = 6). Balance and fear of falling were assessed at weeks 0, 4 and 12. Participants were
interviewed on completion of the study to determine whether the intervention was acceptable.
Eighty percent of participants attended 75% or more of the exercise sessions. An improvement in Berg Score was
seen at four weeks (p = 0.02) and in Wii Age at 12 weeks (p = 0.03) in the intervention group. There was no
improvement in balance scores in the standard care group.
Conclusion: WiiFit exercise is acceptable in self-referred older people with a history of falls. The WiiFit has the
potential to improve balance but further work is required.
Trial Registration: ClinicalTrials.gov - NCT01082042

Background The Nintendo® WiiFit ("WiiFit”) is a software/hard-

Community dwelling individuals, over the age of 65, fall ware game package for the Nintendo® Wii, designed to
at a rate of 35% per year [1], and this increases with improve balance and fitness, whilst providing entertain-
advancing age [2]. Falls have significant implications for ment (further information in appendix 1). There is a
both the faller and the population, including the devel- lack of evidence showing the acceptability of interactive
opment of “fear of falling”, which can have a significant computer games in the older faller.
impact on individuals with self-imposed decline in func- This purpose of this pilot study was to determine the
tion and activity avoidance [3]. feasibility and acceptability of the WiiFit in community-
UK/US falls guidelines support referral of fallers for dwelling older fallers and whether it has the potential to
multidisciplinary assessment [1,4,5]. Significant improve- improve balance. Given the lack of published evidence it
ments in balance have been noted in trials of exercise would be unethical to withhold standard care in a
interventions involving gait, balance, coordination, func- randomised controlled trial.
tional exercises and muscle strengthening [6]. However,
the optimal mode, duration and intensity of exercise to Methods
reduce falls remain uncertain. This longitudinal intervention study was undertaken in
community dwelling people over the age of 70 years
who had fallen in the previous year. We compared 2
* Correspondence: mariefraser@nhs.net groups: an intervention group who attended for WiiFit
1
Department of Medicine for the Elderly, NHS Grampian, DOME Office,
Woodend Hospital, Eday Road, Aberdeen, AB15 6XS, Scotland, UK
Full list of author information is available at the end of the article

© 2010 Williams et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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exercise sessions and a standard care group who Acceptability of the intervention was assessed by mon-
attended the local falls group. itoring attendance, completion of an Attitude to Falls-
Related Interventions Scale (AFRIS) and a qualitative
Inclusion and Exclusion Criteria interview. The AFRIS is a validated measure of the
Inclusion criteria acceptability of falls-related interventions (range 6-42,
Age 70 years or older, living locally in the community higher scores reflect a greater degree of positivity about
(in sheltered accommodation or own home), fallen at the intervention) [11]. All members of the intervention
least once in the preceding 12 months and have an group were interviewed on completion or withdrawal
abbreviated mental test (AMT) [7] of seven or over from the study to determine acceptability of the WiiFit
(maximum score 10). (appendix 2). The interview was undertaken, and tran-
Exclusion criteria scribed, by one of the researchers. Two independent
Wheelchair bound individuals, people living in a care raters undertook thematic analysis of these interviews.
homes or long-term hospital care and current enrolment Intervention group only
in an exercise or rehabilitation programme. The intervention group had their WiiFit Age calculated
by the WiiFit software (based on the user’s current
Patient Recruitment age, weight and athletic ability) undertaken at weeks 0
Intervention group and 12 [12].
A press release was issued to recruit members to the
intervention group. This resulted in widespread press The Exercise Programme
coverage. Fifty-three potential participants contacted the Intervention group
research team, of these 14 were excluded as they had The intervention group attended individual exercise visits
not fallen in the preceding 12 months. The first 15 eligi- supervised by a member of the research team twice
ble people were included in the study. weekly for 12 weeks. A walking frame was placed in front
Standard Care of the balance board, if the participant deemed this
People referred to the local falls group were approached necessary. The exercise programme included balance and
by the research team. Of 13 potential recruits, one was aerobic exercises on the WiiFit (appendix 1) and was
excluded as a result of low AMT, two refused to partici- modified at weeks 4 and 8. Participants were allowed to
pate in standard care and four declined to participate in stop and move onto the next exercise at any point
the study. Thus six participants were recruited. Due to (including if they could not manage a particular exercise)
poor uptake/high drop-out rates recruitment was aban- and were allowed to terminate the session at any point.
doned after three months. They were advised not to play the Wii out with the study.
The actual time exercised was measured for each session.
Ethical Approval and Trial Registration Standard Care group
The North of Scotland Research Ethics Committee The standard care group was recruited from the local
granted ethical approval (Ref No. 08/S0801/186). falls group, which is run by the local NHS Hospital.
The study was registered with ClinicalTrials.gov Patients attend a 12-week exercise/education pro-
(NCT01082042). gramme supervised by NHS physiotherapists.

Assessment Measures Statistics

At an initial interview baseline information was SPSSv16.0 (Chicago, IL) was used to analyse the data.
obtained. Balance was assessed by a physiotherapist at Normally distributed data were compared using Inde-
weeks 0, 4 and 12. Functional balance was assessed by pendent samples T-Test between groups and equal var-
the Berg Balance Scale (BBS), a performance based mea- iances were assumed. AMT scores were compared using
sure using 14 activities of daily living (range 0-56) [8]. A Mann-Whitney U-Test. Fisher’s exact test was used to
Tinetti Balance Assessment Tool (part of the Perfor- compare living situation and use of walking aid, and
mance Orientated Mobility Assessment) was also under- Pearson-Chi Squared test was used to compare number
taken (range 0-16) [9]. Higher scores on both scales of falls. Paired samples T-Test was used to assess
indicate better balance and both appear to have good change in the formal balance scores following the exer-
inter- and intra- rater reliability [8,9]. cise programmes.
The Falls Efficacy Scale - International (FES-I), which
is reliable and valid [10], was undertaken at weeks 0, 4 Results
and 12 to assess the degree of concern about falling in Baseline Characteristics
certain situations. Higher scores indicate more concern Figure 1 provides the baseline characteristics of both
about an individual falls risk (range 16-64). intervention and standard care groups. The standard
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Interventions Standard Care

(n=15) (n=6) P

Age, mean (SD) 76.8 (5.2) 76.5 (4.8) 0 . 90

Weight, mean (SD) 74.3 (13.7) 57.7 (15.9) 0.03

Height, mean (SD) 163.6 (8.4) 159.7 (10.9) 0.39

Number of Medications, mean (SD) 6.9 (4.6) 9.0 (3.3) 0.33

Number of Co-morbidities, mean (SD) 2.6 (1.3) 4.3 (1.2) 0.01

AMT, median (IQR) 10 (10-10) 8.5 (7.8-10) 0.04

Living at Home 1 3/ 15 3/6 0. 1 2

Use of walking aid 7/15 3/6 1.00

Number of falls

4 or more 4 2 0.24

3 1 1

2 6 0

1 4 2

Missing data 0 1

Berg Week 0, mean (SD) 45.4 (9.2) 37.0 (9.6) 0.08

Tinetti Week 0, mean (SD) 13.6 (2.7) 12.2 (2.9) 0.30

FES-I Week 0, mean (SD) 30.1 (12.6) 37.7 (10.1) 0.21

Figure 1 Baseline Characteristics

care group were found to have statistically significant Attendance was good with 80% of participants attending
lower weight, higher number of co-morbidities and 75% or more of the sessions. No significant difference in
lower AMT score. AFRIS score (p = 0.45) between the intervention group
One member of the intervention group had previous (Mean (SD) = 34.3 (7.2)) and the standard care group
experience of the Wii but had not played the WiiFit. (Mean (SD) = 37.3 (3.3)) were found.
Two of the intervention group had previously attended At interview we found that 100% of the intervention
a falls group (equivalent to standard care). group (inclusive of the two dropouts) found the inter-
vention to be enjoyable and acceptable. Over half of par-
Acceptability ticipants felt that the exercise sessions were the right
On study completion there were 13 (86.7%) in the inter- length and the right frequency (69%), with 23% expres-
vention group and 4 (66.7%) in standard care. Follow up sing that the sessions were too short. The intervention
is shown in figure 2. group felt that “people like me” would participate in a
The mean number of sessions completed by the inter- similar exercise programme if it was more widely avail-
vention group was 19 (range=3 - 24, maximum 24). able (77%). Participants expressed a strong desire to
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Intervention Group
n = 15

Withdrew before 4 week Attended 4 week assessment

assessment n = 12b
n = 1a

Withdrew before 12 week Attended 12 week assessment

assessment n = 13
n = 1c

Standard Therapy Group

n=6

Withdrew before 4 week Attended 4 week assessment

assessment n = 3e
n = 1d

Withdrew before 12 week Attended 12 week assessment

assessment n=4
n = 1f

a = due to knee pain

b = 2 participants did not attend for 4 week assessment but attended subsequent
visits
c = due to death of spouse (NB this participant did not attend for 4 week assessment)
d = admitted to hospital
e = 2 participants did not attend for 4 week assessment but attended subsequent
visits
f = admitted to hospital

Figure 2 Follow up of trial participants a = due to knee pain b = 2 participants did not attend for 4 week assessment but attended
subsequent visits c = due to death of spouse (NB this participant did not attend for 4 week assessment) d = admitted to hospital e = 2
participants did not attend for 4 week assessment but attended subsequent visits f = admitted to hospital

exercise with the WiiFit in the future (92%), showing no confidence following the intervention, a sense of positiv-
preference towards exercising on their own/with com- ity about the researchers and the company the sessions
pany or towards supervised/unsupervised sessions. provided and that the participants would like a Wii of
When asked for a preference to falls group or exercise their own. Negative themes identified were pain or dis-
with the WiiFit in the future, 61% chose the WiiFit, 8% comfort, feeling tired and difficulties getting to the
chose falls group, 8% chose both and 23% did not know. sessions.
A number of recurring themes were identified during There was no difference between FES-I at the start
the interviews. Positive themes were an improvement in and end of the study in the intervention group.
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However, there was a trend towards increasing FES-1 There are low levels of willingness of older adults to
scores in the standard care group on completion of the participate in group strength and balance training [13].
study. In our study, there was no difference in AFRIS score
suggesting that the WiiFit is as acceptable as standard
Study Feasibility care. For future trials to be feasible the target population
For a future trial to be feasible the target population must be able to comply with the intervention. This pilot
must be able to comply with the intervention. A low study has shown that older community-dwelling fallers
number of adverse events were recorded. One partici- are willing to attend exercise sessions with the WiiFit as
pant fell backwards (no injuries sustained) when step- shown by the high attendance, low drop-out rate and
ping from the balance board, and another felt positive responses obtained in the qualitative interviews.
temporarily lightheaded on completion of one of the In addition, a low number of adverse events occurred
exercise sessions. during the exercise sessions.
We sought to determine whether the WiiFit has the A randomised controlled trial would probably be feasi-
potential to improve balance and whether this is compar- ble given our findings, and is essential to establish
able to standard care. The results are shown in figure 3. whether exercise with the WiiFit is, at least, as beneficial
A statistically significant improvement in BBS was seen as standard care. As the standard care group repre-
at four weeks (p = 0.02) and in Wii Age at 12 weeks sented a frailer population, we were unable to effectively
(p = 0.03) in the intervention group. Six intervention compare standard care and the WiiFit intervention.
(40%) and 5 standard care (83.3%) participants had a BBS However, the potential to improve balance in this speci-
of less than 45. Thirty-three percent of participants who fied population was seen, as there was a significant
completed a 4 week assessment had a change in BBS of 8 improvement in BBS at 4 weeks in the intervention
or more. group. Conradsson et al have suggested that a change of
7.7 BBS score points is required to reveal a genuine
Discussion modification of function between 2 assessments [14]. In
This pilot study is one of the first to look at acceptabil- both standard therapy and the intervention group 33%
ity of the WiiFit as a falls intervention in older adults. of participants who completed a 4 week assessment had

Outcome Group Baseline Week 4 Week 12 P Value P Value

Measure Mean (SD) Mean (SD) Mean (SD) Baseline Baseline

vs week vs week 12

Berg Intervention 43.7 (9.5) 48.1 (7.2) 44.8 (11.8) 0.02 0.77

Standard 36.3 (9.9) 40.0 (3.0) 39.0 (10.2) 0.49 0.94

Care

Tinetti Intervention 13.2 (2.9) 13.4 (2.9) 13.9 (2.9) 0.67 0.40

Standard 11.7 (4.2) 11.0 (3.6) 11.2 (5.5) 0.64 0.77

Care

FES-I Intervention 32.5 (13.0) 33.8 (11.3) 33.3 (15.0) 0.58 0.60

Standard 35.3 (5.1) 38.0 (7.0) 40.0 (9.3) 0.58 0.09

Care

WiiFit Age Intervention 72.2 (8.0) n/a 57.3 (18.7) n/a 0.03

Standard n/a n/a n/a n/a n/a

Care

Figure 3 Berg, Tinetti and FES-I scores at baseline, 4 weeks and 12 weeks
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a change in BBS of 8 or more. Thus it is plausible that in the standard care group led to problems with com-
both intervention and standard therapy have the poten- parison of the groups.
tial to improve BBS. Improvement in intervention group A further limitation is that our intervention group had
BBS was not sustained at 12 weeks. It is possible that a mean BBS at baseline of 45 and Berg et al have pre-
this phenomenon is a reflection of the lack of the viously determined that a BBS of 45 or more indicates
study’s statistical power. A further possibility is that that an individual is likely to be safe in independent
there was an inadequate increase in exercise intensity ambulation [8]. Thus any target population for falls
over the study period. The games used in this study interventions should have a Berg score at baseline of 45
were selected on the basis that they were ‘open’ to all or less.
users from the initial session and the researchers felt In addition WiiFit sessions were undertaken in a
they would be acceptable to the study participants. supervised hospital environment and are unlikely to be
However, a number of participants expressed that a reflective of people exercising with the WiiFit in their
wider range of games might have prevented boredom. own homes. However participants indicated they were
The reason for the lack of sustained improvement in willing to exercise with the Wii in their own homes.
BBS remains unclear. In the intervention group a statis- This is important as research has found that older peo-
tically significant decrease in WiiFit age was found - ple are more open to exercise programmes undertaken
also suggesting an improvement in balance. However in their own home [13].
WiiFit age is not a validated measure and further work
would be required to valid this finding. Conclusions
There was no change in FES-I in the intervention The WiiFit appears to be an acceptable falls intervention
group at 4 weeks despite improvement in BBS. Further- in the community dwelling older individuals who have
more a significant deterioration in FES-I score was seen fallen and has the potential to improve balance and self-
in the standard care group at 12 weeks. The lack of perceived confidence. Future work must be undertaken
improvement in balance confidence despite improve- to determine an acceptable exercise programme with
ment in balance ability has been previously shown [15]. the greatest potential to improve balance. A randomised
It is plausible that as a result of attending a falls inter- controlled trial is required to determine whether the
vention programme, perception of falls risk is heigh- WiiFit is comparable to standard care.
tened and this is reflected in a higher FES-I score. Falls
and confidence measures are subjective and thus the Appendix 1
participants score will be dependent on how individuals The Nintendo® Wii and Nintendo® WiiFit
feel at time of completion of the score only. Interest- The Wii is a video game console which detects move-
ingly our qualitative data for the intervention group sug- ment allowing the individual to play interactive games.
gested that the participants’ confidence had improved. It WiiFit is an exercise game which combines a balance
is not clear why this discrepancy between qualitative board on which the individual stands (a flat board that
data and FES-I score has occurred. looks like bathroom weight scales) with the Wii games
Further work must be undertaken to determine system. The balance board incorporates pressure sensors
whether exercise with the WiiFit should be included in to monitor centre of balance and shifts in weight/
falls prevention programmes. If improvements in bal- balance.
ance can be shown then the WiiFit could be used as See the following for further information: http://www.
part of supervised physiotherapy based exercise sessions nintendo.com/wii
or within the patients’ own homes. With advances in http://wiifit.com
telemedicine it is plausible that participants may be able http://en.wikipedia.org/wiki/Wii
to undertake exercise sessions within their own homes http://en.wikipedia.org/wiki/Wii_Fit
with the therapists monitoring progress from their base
hospital. This may prove more cost-effective than stan- Exercise Programme Week 0 - 4
dard care due to reductions in transport and staffing 1. Aerobic games - Jogging - 1 attempt to half way on
costs. the circuit
2. Balance games - Tilt Table - 3 attempts
Study Limitations 3. Aerobic games - Step Basics - 2 attempts up to the
The standard therapy group are likely to represent a point where the feet turn blue
frailer population in that there are statistically significant 4. Balance games - Ski Slalom - 5 attempts
differences in weight, number of co-morbidities and 5. Game of own choice from list above - 1 attempt
AMT score, and a trend towards difference in baseline 6. Yoga game - Breathing Exercise - 1 attempt
BBS. Difficulties in recruitment and a high drop out rate All games played at beginner level.
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Exercise Programme Week 4 - 8 9. If given the option of falls group or Wii in the
1. Aerobic games - Jogging - 1 attempt to half way on future what would you chose?
the circuit 10. Any falls or problems during the study
2. Balance games - Tilt Table - 2 attempts - option of
advanced level Interview Schedule for Interventions who Withdrew from
3. Aerobic games - Step Basics - 2 attempts up to the Study
point where the feet turn blue 1. Why did you withdraw from the study?
4. Balance games - Heading - 2 attempts - beginner 2. Do you feel your balance has improved following
level the balance training with the Wii?
5. Balance games - Ski Slalom - 5 attempts - option of 3. How did you feel about the exercise sessions?
advanced level 4. Was the Wii an acceptable form of exercise to you?
6. Balance games - Ski Jump - 2 attempts - beginner 5. What did you think about the length of the exercise
level sessions?
7. Yoga game - Breathing Exercise - 1 attempt 6. What did you think about the frequency of the
exercise sessions?
Exercise Programme Week 8 - 12 7. Do you think people like you would participate in
1. Aerobic games - Jogging - 1 attempt to half way on an exercise programme like this if it was more widely
the circuit available?
2. Balance games - Tilt Table - 2 attempts - option of 8. Would you undertake exercise with the Wii again?
advanced level
3. Aerobic games - Step Basics - 2 attempts up to the a. Yes or No?
point where the feet turn blue b. On your own or with others?
4. Balance games - Heading - 2 attempts - option of c. Supervised or unsupervised?
advanced level
5. Aerobic games - Hula Hoop - 1 attempt - beginner 9. Anything else you would like to say about the exer-
level cise sessions?
6. Balance games - Ski Slalom - 3 attempts - option of 10. If given the option of falls group or Wii in the
advanced level future what would you chose?
7. Balance games - Ski Jump - 2 attempts - option of
advanced level
Acknowledgements
8. Yoga game - Breathing Exercise - 1 attempt A British Geriatric Society Specialist Registrar Start Up Grant provided the
funding to allow this study to take place. We would like to thank Mark
Appendix 2 Lawson, Estelle Lowry, Catriona Malecki, Anne Hayman, Kim Sim, Ruth Berry,
Morven Ritchie and Nicola Preston who supervised the exercise sessions and
Interview Schedule for Interventions who Completed undertook the balance assessments.
Study
1. Do you feel your balance has improved following the Author details
1
Department of Medicine for the Elderly, NHS Grampian, DOME Office,
balance training with the Wii? Woodend Hospital, Eday Road, Aberdeen, AB15 6XS, Scotland, UK. 2School of
2. How did you feel about the exercise sessions? Medical Sciences, University of Aberdeen, IMS Building, Foresterhill,
3. Was the Wii an acceptable form of exercise to you? Aberdeen, AB25 2ZD, Scotland, UK. 3Bone and Musculoskeletal Research
Programme, School of Medicine, University of Aberdeen, Foresterhill,
4. What did you think about the length of the exercise Aberdeen, AB25 2ZD, Scotland, UK.
sessions?
5. What did you think about the frequency of the Authors’ contributions
MAW contributed to the data collection, coordinated the study, contributed
exercise sessions? to the statistical analysis and led the writing of the manuscript. RLS
6. Do you think people like you would participate in participated in the design of the study, and contributed to the statistical
an exercise programme like this if it was more widely analysis and manuscript writing. AMcEJ contributed to the design of the
study and manuscript writing. AS conceived the study, participated in its
available design and contributed to the statistical analysis and manuscript writing. All
7. Would you undertake exercise with the Wii again? authors read and approved the final manuscript.

Competing interests
a. Yes or No? The authors declare that they have no competing interests.
b. On your own or with others?
c. Supervised or unsupervised? Received: 30 March 2010 Accepted: 13 September 2010
Published: 13 September 2010

8. Anything else you would like to say about the exer-

cise sessions?
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doi:10.1186/1756-0500-3-238
Cite this article as: Williams et al.: EXercising with Computers in Later
Life (EXCELL) - pilot and feasibility study of the acceptability of the
Nintendo® WiiFit in community-dwelling fallers. BMC Research Notes 2010
3:238.

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