JCLB-03927; No of Pages 4

Clinical Biomechanics xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Clinical Biomechanics

journal homepage: www.elsevier.com/locate/clinbiomech

Novel use of the Wii Balance Board to prospectively predict falls in

community-dwelling older adults
Boon-Chong Kwok a, Ross A. Clark b, Yong-Hao Pua c,⁎
a
Clinical Services (Collaborative Care), National Healthcare Group Polyclinics, 3 Fusionpolis Link, Nexus@one-north, Singapore
b
School of Exercise Science, Australian Catholic University, Melbourne, Australia
c
Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore

a r t i c l e i n f o a b s t r a c t

Article history: Background: The Wii Balance Board has received increasing attention as a balance measurement tool; however its
Received 31 July 2014 ability to prospectively predict falls is unknown. This exploratory study investigated the use of the Wii Balance
Accepted 4 March 2015 Board and other clinical-based measures for prospectively predicting falls among community-dwelling older
adults.
Keywords:
Methods: Seventy-three community-dwelling men and women, aged 60–85 years were followed-up over a year
Balance
for falls. Standing balance was indexed by sway velocities measured using the Wii Balance Board interfaced with
Older adult
Primary care
a laptop. Clinical-based measures included Short Physical Performance Battery, gait speed and Timed-Up-and-Go
Physiotherapy test. Multivariable regression analyses were used to assess the ability of the Wii Balance Board measure to
complement the TUG test in fall screening.
Findings: Individually, the study found Wii Balance Board anteroposterior (odds ratio 1.98, 95% CI 1.16 to 3.40,
P = 0.01) and mediolateral (odds ratio 2.80, 95% CI 1.10 to 7.13, p = 0.03) sway velocity measures predictive
of prospective falls. However, when each velocity measure was adjusted with body mass index and Timed-Up-
and-Go, only anteroposterior sway velocity was predictive of prospective falls (odds ratio 2.21, 95% CI 1.18 to
4.14). A faster anteroposterior velocity was associated with increased odds of falling. Area-under-the-curves
for Wii Balance Board sway velocities were 0.67 and 0.71 for anteroposterior and mediolateral respectively.
Interpretation: The Wii Balance Board-derived anteroposterior sway velocity measure could complement existing
clinical-based measures in predicting future falls among community-dwelling older adults.
Trial registration: Australian New Zealand Clinical Trials Registry number: ACTRN12610001099011.
© 2015 Elsevier Ltd. All rights reserved.

1. Background clinical-based measures, the Timed-Up-and-Go (TUG) test involves

Accidental falls and fall-related injuries among older people are im-
portant health issues (Herala et al., 2000). A fall can occur due to balance
impairment, which can be averted with early detection (Bigelow and
Berme, 2011; Whitney et al., 2005). There are currently two methods
of balance assessments to predict falls, clinical-based and laboratory-
based balance tests (Botolfsen et al., 2008; Close and Lord, 2011;
Mancini and Horak, 2010; Pajala et al., 2008).
In contrast to laboratory-based balance tests, most clinical-based
measures do not test balance as a single construct (Botolfsen et al.,
2008; Close and Lord, 2011; Guralnik et al., 1994). Indeed, among the
Abbreviations: WBB, Wii Balance Board; CoP, center of pressure; AP, anterior–posterior;
ML, medial-lateral; USD,UnitedStates dollars; MDC, minimaldetectablechange; SPPB, short
physical performance battery; TUG, Timed-Up-and-Go; OR, odds ratio; CI, confidence
interval.
⁎ Corresponding author at: Department of Physiotherapy, Singapore General Hospital,
Outram Road, 169608 Singapore.
E-mail addresses: kwokboonchong@gmail.com (B.-C. Kwok), ross.clark@acu.edu.au
(R.A. Clark), puayonghao@gmail.com (Y.-H. Pua).
myriad components of reaction time, lower limb strength, gait speed
and agility to evaluate function and predict falls (Botolfsen et al.,
2008; Close and Lord, 2011; Mancini and Horak, 2010). Another form
of clinical-based measure, the short physical performance battery
(SPPB), provides an evaluation of functioning status with components
of balance, gait speed and lower limb endurance tests (Close and Lord,
2011; Freire et al., 2012; Guralnik et al., 1994). Despite the multi-
construct nature of the clinical-based tests, the TUG and other clinical-
based measures have only low to moderate predictive validity for falls
among older adults (Lee et al., 2013; Power et al., 2014).
To complement existing clinical-based measures in predicting falls,
balance is best evaluated with the laboratory-based force-plate-
derived center of pressure (CoP) measure (Bigelow and Berme, 2011;
Pajala et al., 2008). However, the force-plate is neither small nor practi-
cal enough to be applied in large community cohorts (Pajala et al., 2008;
Schneider et al., 2011). The portable gaming Nintendo Wii Balance
Board (WBB) could potentially serve as a bridge between clinical-
based and force-plate balance tests. Previously, the WBB was used to
evaluate standing CoP (Clark et al., 2010), while a recent study found

http://dx.doi.org/10.1016/j.clinbiomech.2015.03.006
0268-0033/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article as: Kwok, B.-C., et al., Novel use of the Wii Balance Board to prospectively predict falls in community-dwelling older adults,
Clin. Biomech. (2015), http://dx.doi.org/10.1016/j.clinbiomech.2015.03.006
2 B.-C. Kwok et al. / Clinical Biomechanics xxx (2015) xxx–xxx
that the WBB CoP measure was associated with fear-induced activity
limitation (Pua et al., 2013), but the validity of the WBB for prospective-
ly predicting falls has not been established. This pilot study was primar-
ily undertaken to investigate the WBB predictive validity for prospective
falls. Second, this study investigated the WBB CoP measure to comple-
ment existing clinical-based measures to predict falls for the
community-dwelling older adults.
2. Methods
2.1. Participants
The study sample was derived from the randomized controlled trial
“Evaluation of the Frails' Fall Efficacy by Comparing Treatments”
(EFFECT) study and detailed recruitment inclusion and exclusion
criteria have been described elsewhere (Kwok et al., 2011). The study
included 73 community-dwelling older adults above 60 years old and
participants were primarily excluded for significant cognitive disorder
(Abbreviated Mental Test score below 7 for 60–74 years old, below 6
for 75 years old and above), and unstable medical or surgical conditions
(Kwok et al., 2011).
This study was undertaken from week 13 in the EFFECT study. The
participants were assessed with clinical-based measures (TUG and
SPPB) and WBB CoP velocity measures. Gait speed was calculated
from the 4-meter walk of SPPB. The study was approved by the
Centralised Institutional Review Board (Reference: 2010/177/D and
2010/639/D) and written informed consent was obtained from the par-
ticipants prior to the study enrolment. No adverse events were reported
in this study.
2.2. Clinical-based measures
TUG test: The test required participant to rise from a chair (seat
height 45 cm) without using the arms to assist, walk 3 m to a cone,
turn around the cone and return to the seat (Shumway-Cook et al.,
2000). Participants were instructed to walk safely with prior demon-
stration (Podsiadlo and Richardson, 1991). This test has good test–retest
reliability, intra-class correlation coefficient (ICC) 0.84 (Botolfsen et al.,
2008).
SPPB: This measure comprises three physical tests — tandem stance,
gait speed and 5 times chair stands (Guralnik et al., 1994). These validat-
ed tests provide useful information about physical frailty (functional
decline) of an older adult and have good test–retest reliability, ICC
0.83 to 0.89 (Freire et al., 2012).
2.3. WBB CoP measures
Standing balance was assessed using the WBB (Nintendo, Kyoto,
Japan) in a protocol previously validated against a laboratory force-
plate (Clark et al., 2010). To perform the test, participants stood bare-
footed on the WBB in their usual comfortable stance, and they were
instructed to keep their hands by their side, look straight ahead, and
stand quietly. A previous study showed that this safe assessment
method had similar fall prediction accuracy when compared with
more challenging tasks such as eyes closed tandem stance (Pajala
et al., 2008). Two 30-second trials were performed, and the mean of
two trials was used.
The WBB was interfaced with a laptop computer using custom-
written software (Labview 8.5 National Instruments, Austin, TX,
U.S.A.), and was calibrated by placing a variety of known loads at differ-
ent positions on the WBB. AP and ML CoP coordinates were recorded at
40 Hz and low-pass filtered at 6.25 Hz using an undecimated Symlet-8
wavelet with the detail levels removed. Given the multitude of CoP
measures, we have a priori focused on AP and ML sway velocity to min-
imize Type I error from multiplicity (Ottenbacher, 1998). CoP velocity
Please cite this article as: Kwok, B.-C., et al., Novel use of the Wii Balance Board to prospectively predict falls in community-dwelling older adults,
Clin. Biomech. (2015), http://dx.doi.org/10.1016/j.clinbiomech.2015.03.006
represents the sway distance covered by the CoP in the respective
planes (path length) divided by the sampling duration (30 s).
2.4. Prospective falls
The primary outcome was prospective falls over a year using
Kellogg's definition of a fall: “a fall is an event which results in a person
coming to rest inadvertently on the ground or other lower level and
other than as a consequence of the following: sustaining a violent
blow, loss of consciousness, sudden onset of paralysis as in a stroke, or
an epileptic seizure.”Zecevic et al., 2006 In order to minimize recall
bias, we employed three methods in collecting fall data. Firstly, partici-
pants were instructed to record events of falling during the one-year
follow-up by indicating their occurrence on a fall calendar. Second,
they were contacted monthly via telephone to check for any event of
fall (Fleming et al., 2008). Last, the study Principal Investigator initiated
a 24-hour point of contact for participants to report falls.
2.5. Statistical analysis
We used descriptive statistics to characterize the study sample:
means with SDs for continuous variables and frequencies with percent-
ages for categorical variables. We analyzed the characteristics of age,
body mass index (BMI), gender, ethnicity, abbreviated mental test
score, medical co-morbidities, non-psychotropic medication usage per
day, visual contrast and 1-year fall history, between non-fallers and
fallers with Student's t-tests or Pearson's chi-squared tests. Fallers and
non-fallers were similarly compared on SPPB, TUG, and gait speed mea-
sures, and WBB velocity measures using Student's t-test. In addition,
Spearman's correlation was used to establish the association between
SPPB, TUG, gait speed, and WBB velocity measures.
The association between fall outcome and each measure was first
analyzed using univariable logistic regression. Next, the multivariable
logistic regression model, adjusted for BMI (a standard covariate associ-
ated with falls) (Sheehan et al., 2013), was used to investigate if WBB AP
or ML velocity measure could complement the TUG measure — a com-
mon clinical-based measure (Close and Lord, 2011). Because we used
data from a treatment study, treatment variable and its interaction
with the screening measures were also included in the multivariable
models. As the joint test for treatment and its interaction terms gave
non-significant results, we removed these terms from the final model.
Given that the various measures were quantified on different scales,
the ORs were scaled to the difference between the 75th and the 25th
percentiles (the interquartile range) of each measure (Harrell, 2001).
Besides allowing valid between-measure comparisons, interquartile
range ORs represented a more clinically meaningful distinction than
the conventional one-unit change in predictor values (Harrell, 2001).
The area under the receiver-operating characteristic curve (AUC)
was used to assess the predictive validity of falls for each measure. An
AUC value of 1 represents perfect discrimination and 0.5 represents
chance discrimination. All statistical analyses were performed with
SPSS version 19.0 (Chicago: SPSS Inc.). Statistical significance was set
at P(2-tailed) b 0.05.
3. Results
In this study, 18 (~25%) participants reported a fall in the 12-month
monitoring period. The demographics of the non-fallers and fallers are
presented in Table 1, which showed no statistical difference between
the two groups except for WBB velocity measures (P b 0.05). All the
clinical-based measures were weakly correlated to the WBB velocity
measures (Table 2).
The study found that at the univariable level, older adults had in-
creased odds of falling with higher WBB velocity measures
(ORs ≥ 1.98, P's b 0.05), but the clinical-based measures did not reach
statistical significance (Table 3). Both the AUC values for the WBB AP
 B.-C. Kwok et al. / Clinical Biomechanics xxx (2015) xxx–xxx 3

Table 1 Table 3
Characteristics of non-fallers (n = 55) and fallers (n = 18). Predictive validity of each screening measure for future falls.

Characteristics Non-fallers Fallers P value Screening measures OR (95% CI)a P value AUC (95% CI)

Age (years) 69.7 (7.8) 70.7 (5.2) 0.64 Clinical balance test
Body mass index (kg m−2) 22.8 (3.7) 21.6 (3.7) 0.26 Short Physical Performance 0.62 (0.36 to 1.10) 0.10 0.61 (0.46 to 0.77)
Gender — Female, n (%) 45 (81.8) 17 (94.4) 0.20 Battery score (/12)
Ethnic — Chinese, n (%) 54 (98.2) 17 (94.4) 0.40 Timed-Up-and-Go (s) 1.31 (0.90 to 1.96) 0.16 0.64 (0.50 to 0.79)
Abbreviated Mental Test score (/10) 8.9 (1.1) 8.7 (1.3) 0.33 Gait speed (m s−1) 0.51 (0.22 to 1.25) 0.14 0.61 (0.46 to 0.77)
Medical history — co-morbidities, n (%)
0 6 (10.9) 0 (0) 0.83 Wii Balance Board test (unadjusted)
1 10 (18.2) 4 (22.2) Anteroposterior velocity 1.98 (1.16 to 3.40) 0.01 0.67 (0.52 to 0.82)
2 15 (27.2) 6 (33.3) (cm s−1)
−1
≥3 24 (43.6) 8 (44.4) Mediolateral velocity (cm s ) 2.80 (1.10 to 7.13) 0.03 0.71 (0.56 to 0.85)
a
ORs estimate the odds of future falls at the 75th vs the 25th percentile for all contin-
Medications per day, n (%)
uous predictors. For example, increasing the mediolateral velocity variable from its lower
0 14 (25.5) 3 (16.7) 0.61
quartile (0.65 cm s−1) to its higher quartile (0.84 cm s−1) was associated with a 2.8-fold
1 7 (12.7) 4 (22.2)
(95%CI, 1.10- to 7.13-fold) increase in the odds of future falls.
2 7 (12.7) 2 (11.1)
≥3 27 (49.1) 9 (50.0)
Vision — Melbourne-edge test (dB) 19.7 (1.6) 18.9 (2.5) 0.19
Had a fall in the past 1 year, n (%) 28 (51.0) 13 (72.2) 0.12 by visual inspection (Mancini and Horak, 2010). Thus, in community
fall screening, the WBB balance measure could provide valuable
Screening measures
Short Physical Performance Battery 10.6 (1.6) 9.8 (2.0) 0.14 information to complement existing clinical-based measures to identify
score (/12) individuals with fall risk.
Timed-Up-and-Go (s) 9.10 (4.07) 10.91 (5.47) 0.14
Gait speed (ms−1) 1.27 (0.44) 1.10 (0.42) 0.14
4.2. Clinical-based measures
WBB anteroposterior velocity (cm s−1) 1.02 (0.26) 1.27 (0.45) 0.049
WBB mediolateral velocity (cm s−1) 0.73 (0.13) 0.82 (0.14) 0.02
The clinical-based measures did not predict falls among community-
Continuous variables were analyzed with t-test and presented as mean (SD). Categorical
variables were analyzed with chi-squared test. WBB: Wii Balance Board.
dwelling older adults. Despite a combination of balance, gait speed and
lower limb strength measures, the SPPB was not predictive of falls. The
TUG measure was also not predictive of falls in our study, similar to pre-
and ML velocity measures were statistically significant: 0.67 and 0.71 vious literature (Boulgarides et al., 2003; Haines et al., 2008), of which
respectively (P b 0.05). At the multivariable level (Table 4), only WBB one study attributed the null findings to a possible ceiling effect in
AP velocity retained its predictive ability of falls (OR 2.21, 95% CI 1.18 higher-functioning older adults (Boulgarides et al., 2003). Higher-
to 4.14, P = 0.01), whereas WBB ML velocity did not (OR 2.43, 95% CI functioning older adults are at risk of fall but would not be identified
0.86 to 6.90, P = 0.09). based on cut-off values of 14 s in one study and 15 s in another
(Shumway-Cook et al., 2000; Whitney et al., 2005). Finally, as suggested
4. Discussion by the Reviewer, another potential explanation for the null results is
that because clinical-based measures are multi-construct in nature,
This prospective pilot study identified and established the predictive their “non-predictive” components may attenuate the overall predictive
validity of WBB-derived CoP velocity measures for falls. We found that value of the test. Future studies should examine this possibility.
the WBB balance measure – in particular, the velocity AP measure –
could potentially complement the TUG to predict future falls in 4.3. WBB balance measure
community-dwelling older adults.
WBB CoP sway velocity quantifies the speed of the movement re-
4.1. Relationship between clinical-based and WBB measures quired to maintain postural stability, and reflects the postural response
of the neuromuscular system to somatosensory, visual and vestibular
Each of the clinical-based measures was moderately correlated to information. Older adults with poorer balance may produce greater
each other but not with the WBB measures (Table 2). The weak relation- muscle co-contraction or stiffening to maintain balance (Carpenter
ship between the clinical-based measure and the WBB balance measure et al., 2001; Ho and Bendrups, 2002), which would result in rapid move-
showed that the two methods were non-redundant with one another. ments, and hence conceivably higher CoP velocities. Irrespective of AP
Our study finding was similar to that of recent literature investigating or ML directions in this study, the WBB velocity measures had better
the relationship between clinical-based and laboratory balance mea- odds in predicting future falls (Table 3) and these findings concur
sures (Nguyen et al., 2012). The main difference between these two with existing evidence using laboratory force-plate to identify fallers
methods of measures was that the WBB could quantify gross to subtle (Bigelow and Berme, 2011; Schneider et al., 2011). However, when ad-
sway displacements, while clinical-based measures could not identify justed for BMI and in complementing the TUG measure (Table 4), only
the AP velocity measure remained predictive of falls. In other words,
Table 2 the predictive effects of AP velocity for future falls were not confounded
Non-parametric correlation of screening measures. by those of TUG and BMI; hence, AP velocity could complement the TUG
in fall screening. Earlier literature had shown that the AP velocity was
higher among older adults with impaired balance (Baloh et al., 1995;
Pajala et al., 2008).

4.4. Study implications and limitation

The study provided the first evidence for the WBB-derived CoP
TUG: Timed-Up-and-Go, SPPB: Short Physical Performance Battery, WBB: Wii Balance
Board, AP: anteroposterior, ML: mediolateral. velocity measures to predict future falls in a sample of community-
⁎ P b 0.001. dwelling older adults. All participants completed two 30-second stand-
⁎⁎ P b 0.05. ing trials on the WBB without adverse events, supporting the time-

Please cite this article as: Kwok, B.-C., et al., Novel use of the Wii Balance Board to prospectively predict falls in community-dwelling older adults,
Clin. Biomech. (2015), http://dx.doi.org/10.1016/j.clinbiomech.2015.03.006
4 B.-C. Kwok et al. / Clinical Biomechanics xxx (2015) xxx–xxx

Table 4 and effort, and the co-authors of previously published literature that
Logistic regression adjusted for BMI and TUG to predict future falls. led to this study.
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percentile percentile References
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ML velocity (cm s−1) 0.65 0.84 2.43 (0.86 to 6.90) 0.09
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guage and editorial input, the participants who volunteered their time

Please cite this article as: Kwok, B.-C., et al., Novel use of the Wii Balance Board to prospectively predict falls in community-dwelling older adults,
Clin. Biomech. (2015), http://dx.doi.org/10.1016/j.clinbiomech.2015.03.006