562111

research-article2014
NNRXXX10.1177/1545968314562111Neurorehabilitation and Neural RepairLiao et al

Clinical Research Article

Neurorehabilitation and

Virtual Reality–Based Training to

Neural Repair
2015, Vol. 29(7) 658­–667
© The Author(s) 2014
Improve Obstacle-Crossing Performance Reprints and permissions:
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and Dynamic Balance in Patients With DOI: 10.1177/1545968314562111

nnr.sagepub.com

Parkinson’s Disease

Ying-Yi Liao, PhD1,2, Yea-Ru Yang, PhD2, Shih-Jung Cheng, MD3,

Yih-Ru Wu, MD4,5, Jong-Ling Fuh, MD2,6, and Ray-Yau Wang, PhD2

Abstract
Background. Obstacle crossing is a balance-challenging task and can cause falls in people with Parkinson’s disease (PD).
However, programs for people with PD that effectively target obstacle crossing and dynamic balance have not been
established. Objective. To examine the effects of virtual reality–based exercise on obstacle crossing performance and
dynamic balance in participants with PD. Methods. Thirty-six participants with a diagnosis of PD (Hoehn and Yahr score
ranging 1 to 3) were randomly assigned to one of three groups. In the exercise groups, participants received virtual
reality–based Wii Fit exercise (VRWii group) or traditional exercise (TE group) for 45 minutes, followed by 15 minutes
of treadmill training in each session for a total of 12 sessions over 6 weeks. Participants in the control group received no
structured exercise program. Primary outcomes included obstacle crossing performance (crossing velocity, stride length,
and vertical toe obstacle clearance) and dynamic balance (maximal excursion, movement velocity, and directional control
measured by the limits-of-stability test). Secondary outcomes included sensory organization test (SOT), Parkinson’s
Disease Questionnaire (PDQ39), fall efficacy scale (FES-I), and timed up and go test (TUG). All outcomes were assessed
at baseline, after training, and at 1-month follow-up. Results. The VRWii group showed greater improvement in obstacle
crossing velocity, crossing stride length, dynamic balance, SOT, TUG, FES-I, and PDQ39 than the control group. VRWii
training also resulted in greater improvement in movement velocity of limits-of-stability test than TE training. Conclusions.
VRWii training significantly improved obstacle crossing performance and dynamic balance, supporting implementation of
VRWii training in participants with PD.

Keywords
obstacle crossing, balance, virtual reality, exercise training, Parkinson’s disease

Introduction the obstacle crossing task compared with normal older

adults.8 Therefore, strategies to improve balance and
Parkinson’s disease (PD) is a progressive neurodegenera-
tive disease. With progression of the disease, patients may
demonstrate postural instability, gait dysfunction, difficulty 1
managing functional tasks, such as obstacle crossing, and Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli,
Taiwan
frequent falls.1-4 More than two thirds of community-dwell- 2
National Yang-Ming University, Taipei, Taiwan
ing individuals with PD experience falls once per year, and 3
Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan
tripping over obstacles is the major cause of these falls.5 4
Department of Neurology, Chang-Gung Memorial Hospital, Linkou,
During obstacle crossing, participants with PD usually step Taiwan
5
their leading foot closer to the obstacle than age-matched Chang-Gung University College of Medicine, Linkou, Taiwan
6
Department of Neurology, Neurological Institute, Taipei Veterans
controls because of their smaller steps, which may result in General Hospital, Taipei, Taiwan
hitting the obstacle and subsequent falls.6 These individuals
also adopt a conservative strategy during obstacle crossing Corresponding Author:
Ray-Yau Wang, Department of Physical Therapy and Assistive
and maintain their center of mass (COM) more medially to Technology, National Yang-Ming University, 155, Sec 2, Li-Nong Street,
their stance leg.7 This alteration reduces the distance Shih-Pai, Taipei, Taiwan.
between the center of pressure (COP) and COM throughout Email: rywang@ym.edu.tw
Liao et al 659
obstacle crossing ability may help improve functional abil-
ity and to reduce the incidence of falls.
Some patients with PD may lack satisfactory to drug
regimens or surgical options, and they still have consider-
able symptoms while on medications. The lack of satisfac-
tory treatment options provides motivation to investigate
the effects of exercise on functional improvement.
Stretching, strengthening, balance exercise, and gait train-
ing improve motor function, balance, and gait performance
in participants with PD.9-13 Treadmill training has also been
used widely in participants with PD to improve gait perfor-
mance and walking economy.14-16 However, the effects of
such training on obstacle-crossing performance has not yet
been investigated. Combining resistance, aerobic, balance,
stretching, and treadmill training are likely to be optimal for
improving gait speed in participants with PD.17 Whether the
combination of training can carry-over to obstacle crossing
performance need further investigation.
Virtual reality (VR) systems are novel and potentially
useful technologies that allow users to interact with a com-
puter-generated scenario.18 Augmented visual, sensory, and
auditory feedback are provided when subjects performing
tasks in virtual environment.19 VR training has been used in
older adults and stroke patients to improve postural control,
increase mobility, and reduce fall risk.20-24 In PD partici-
pants, VR training has been demonstrated to improve sen-
sory organization.25 VR combining treadmill training was
also reported to improve gait performance during usual and
complex challenging condition (dual task and obstacle
crossing) in PD participants.26 However, VR combining dif-
ferent types of exercise on obstacle-crossing and balance
performance has not yet been explored. Recently, the gam-
ing industry has developed a variety of affordable and
accessible VR systems, such as Wii Fit, that have been
reported to improve functional ability in PD participants,
such as timed up and go (TUG), sit to stand, unipedal stance,
balance, walking speed, and overall quality of life.27-30
These effects, however, have yet to be validated in a ran-
domized controlled trial. Furthermore, whether this
VR-based Wii Fit exercise is more effective than traditional
exercise, especially regarding its effects on advanced gait
function such as obstacle crossing, warrants investigation.
Therefore, the purpose of this study was to elucidate the
effects of VR-based Wii Fit exercise on obstacle crossing
and dynamic balance ability in participants with PD by
comparing the results of Wii Fit training, traditional exer-
cise, and a no-exercise control.
Methods
Participants
Participants were recruited from a medical center in Taiwan
and were diagnosed with idiopathic PD by a neurologist.
The diagnostic criteria were at least 2 of the 4 features (rest-
ing tremor, bradykinesia, rigidity, and asymmetric onset) in
which the resting tremor or bradykinesia must be present.31
All participants met the following inclusion criteria: (a)
Hoehn and Yahr stages I to III, (b) ability to walk indepen-
dently without any walking aids, (c) stable medication
usage, (d) with or without deep brain stimulation, and (e) a
score of ≥24 on the Mini-Mental State Examination
(MMSE). The exclusion criteria were as follows: (a) unsta-
ble medical condition; (b) history of other neurological, car-
diopulmonary, or orthopedic diseases known to interfere
with participation in the study; (c) past history of seizure;
(d) use of cardiac pacemaker; and (e) vision deficits. In
total, 43 individuals were identified as potential participants
for this study. Of these, 36 participants provided informed
consent, which was approved by the Institutional Human
Research Ethics Committee of Chang Gung Medical
Foundation (Figure 1).
Experimental Design
This study was a single-blinded, stratified, randomized con-
trolled trial. The stratification was achieved based on the
Hoehn and Yahr stage as follows: stage 1 to 1.5, stage 2 to
2.5, and stage 3. An individual who was not involved with
the study selected sealed envelopes to assign participants to
1 of the 3 groups. Participants received VR-based Wii Fit
exercise (VRWii group) or traditional exercise (TE group)
for 45 minutes with additional treadmill training for 15 min-
utes. The exercise was administered for a total of 12 sessions
(2 sessions per week) over a 6-week period by the same
physical therapist. Individuals in the control group received
only fall-prevention education, such as minding the environ-
mental factors (slippery surface, obstacles, stairs, uneven
ground) after the baseline assessment and were encouraged
to carry out their regular exercise. All outcomes were mea-
sured the day before intervention (pre), the day after com-
pleting the intervention (post), and the 30th day after
completing the intervention (follow-up) by the same rater
blinded to group assignment. The measurement and inter-
vention were conducted with patients in the “on” state.
Interventions
Traditional Exercise (TE).  This program included 10 minutes
of stretching exercises, 15 minutes of strengthening exer-
cises, and 20 minutes of balance exercises in each session as
described below.
1. Stretching exercises: The stretching exercises
focused on upper body and upper and lower extrem-
ities with gentle joint extension and flexion and
trunk rotation in a standing position. Deep breathing
was emphasized during the exercise.
660 Neurorehabilitation and Neural Repair 29(7)
Figure 1.  Flowchart of participants recruited in this study.
2. Strengthening exercise: The strengthening exercises
focused on the lower extremity muscles that are
important for posture, balance, and gait. Participants
performed the following exercises in standing posi-
tion: (a) one leg forward/sideward swing, (b) stepping
up and down, (c) multidirectional leg raising, (d) heel
and toe raising, and (e) squatting. Participants per-
formed 3 sets of 10 to 15 repetitions for each activity.
Participants used ankle weights that started at 1 kg and
were gradually increased to 2 kg for each leg. Natural
breathing was emphasized during the exercise.
3. Balance exercises: The balance exercises were com-
binations of dynamic balance training and sensory
integration training. The dynamic balance training
exercises were symmetric weight shifting with slow
and fast speed, catching and throwing balls, and
multidirectional stepping in a standing position. The
sensory integration training exercises included sin-
gle leg stance with eyes open and closed and stand-
ing on foam with eyes open and closed.
The progressions in both TE and VRWii group included
adding more weights during strengthening exercise,
increasing the number of repetitions, and increasing difficulty
of exercise, such as increasing the height of the blocks during
the stepping-up exercise, increasing the forward/sideward
stepping distance during the stepping exercise, holding the
squatting position for longer duration during the squatting
exercise. The criteria for progression were determined by the
ability of the participant to perform the activities without dif-
ficulty and by the perceived exertion (Borg rate of perceived
exertion <13, somewhat hard).
Virtual Reality–Based Wii Fit Exercise.  The Wii Fit Plus gam-
ing system and Wii Fit balance board (Nintendo Phuten Co,
Ltd, Taiwan) were used for VRWii exercise. The Wii Fit
balance board is a novel system that tracks changes in the
COP during exercise. A virtual environment was displayed
on a screen with a 230 cm width and height in front of the
participant. Through avatar technology, images were pro-
jected on the screen through a projector. The virtual charac-
ter provides instantaneous visual and auditory feedback.
Participants can imitate the virtual character and adjust their
own movements according to feedback (knowledge of the
performance) in real time (<20 ms lag between player and
avatar movement). At the end of the game, the Wii Fit system
Liao et al 661
also provides the total score on the screen (knowledge of
the results). In each Wii Fit exercise session, participants
underwent 10 minutes of yoga exercises, 15 minutes of
strengthening exercises, and 20 minutes of balance games
as described below.
1. Yoga exercises: The yoga exercises were empha-
sized more on muscle stretching. This program
included sun-salutation modified lunges, chair pose,
tree pose with arms straight above the head and
palms together, and table top in standing position.
2. Strengthening exercises: The exercise program,
intensity, and principle of adding ankle weights
were similar to the strengthening exercise program
emphasized in the TE group, but in this case, the
strengthening exercises were performed in a
VR-based environment.
3. Balance games: The balance games included the
soccer heading, marble balance, ski slalom, and bal-
ance bubble. When performing these games, partici-
pants needed to shift their COM as quickly and
accurately as possible to hit the soccer, put the roll-
ing marble in the hole, ski without hitting the obsta-
cles, and navigate the bubble through the maze
without popping it.
Treadmill Training. Participants in both exercise groups
received treadmill training (Biodex, Shirley, NY) after the
above exercise training sessions to enhance the effects of
exercise training. Each treadmill session lasted 15 minutes.
The treadmill speed was set at 80% of the individual’s over-
ground comfortable walking speed and was increased by an
increment of 0.2 km/h per 5 minutes as tolerated. A safety
harness without body weight support was provided during
treadmill training to prevent falls.
Primary Outcomes
Obstacle-Crossing Performance.  The Liberty system (Polhte-
mus, Inc, Colchester, VT) was used to measure spatial tem-
poral variables during obstacle crossing. This system is an
electromagnetic motion capture device for tracking
3-dimensional movement at a speed of 240 updates per sec-
ond. Two sensors were attached to the top of the second toe
of each foot. These sensors recorded the 3-dimensional
positioning of the foot. The validity and reliability of the
Liberty system have been previously established.32 Obsta-
cle crossing required participants to walk on a 10-meter
walkway with an obstacle positioned in the middle of the
walkway. The obstacle was a plastic crossbar (60 cm long
and 1.5 cm in diameter) supported by 2 vertical posts. The
height of the obstacle was 20% of the subject’s leg length
(14-20 cm) to emulate the height of a curb or stair. During
obstacle crossing trials, participants initiated walking,
stepped over the obstacle, and continued to walk to the end
of the walkway at a comfortable speed without any con-
strain. Three obstacle-crossing variables were analyzed as
follows:
1. Crossing stride length: The distance from the heel-
strike of the leg before the obstacle to the heel-strike
of the same leg after crossing the obstacle.
2. Crossing stride velocity: The velocity from the heel-
strike of the leg before the obstacle to the heel-strike
of the same leg after crossing the obstacle.
3. Vertical toe-obstacle clearance: The vertical dis-
tance between the toe sensor of the leg and the
obstacle when the toe of the leg was directly above
the obstacle.
Dynamic Balance Performance. Dynamic balance was
assessed by the Balance Master system (NeuroCom Inter-
national, Inc, Clackamas, OR). Limits of stability (LOS)
testing was used to document dynamic balance perfor-
mance. 33,34 To assess the LOS, the subject stood on the for-
ceplate and shifted his or her center of gravity (COG) to
reach a maximal distance in the target direction as quickly
and accurately as possible without moving the feet. The
directions assessed included forward, right, and left.
Because of insignificant difference between right and left
direction, data from the right and left directions were aver-
aged to indicate sideward control. Movement velocity
(MV), maximum excursion (ME), and directional control
(DC) were collected during the LOS test in this study. MV
is defined as the average speed in degrees/second in a spe-
cific direction. ME is defined as the farthest distance trav-
eled by the COG during the trial. DC is defined as the
amount of movement in the intended direction minus the
amount of extraneous movement. A DC score of 100% indi-
cates that the participant does not deviate from a straight
path during the test.
Secondary Outcomes
Sensory Integration Ability. The sensory organization test
(SOT) was assessed using the Balance Master system to
evaluate sensory integration ability. The equilibrium score
was obtained under each of 6 visual and support surface
conditions (SOT1-SOT6). Through sway of the visual sur-
round and support surfaces, inaccurate information was
delivered to the somatosensory, visual, and vestibular sys-
tems. The SOT scores used in this study are the weighted
averages from all equilibrium scores to indicate sensory
integration ability.35
The 39-Question Parkinson’s Disease Questionnaire. This
questionnaire was developed to assess the quality of life of
patients with PD.36 This questionnaire contains 8
662 Neurorehabilitation and Neural Repair 29(7)

dimensions with 39 items and assesses mobility, activities Table 1.  Demographic Characteristics of Included Participants.
of daily living, emotions, stigmas, social issues, cognition,
Control TE VRWii
communication, and body pain. Subjects filled out the ques- (n = 12) (n = 12) (n = 12)
tionnaire according to the presence of problems during the
previous month. The validity of the 39-question Parkinson’s Age (years) 64.6 ± 8.6 65.1 ± 6.7 67.3 ± 7.1
Disease Questionnaire (PDQ39) was reported previously.37 Gender (male/ 5/7 6/6 6/6
A higher score represents a poor quality of life. The Chinese female)
Disease duration   6.4 ± 3.0   6.9 ± 2.8   7.9 ± 2.7
version of the PDQ39 was used in this study.38
(years)
Hoehr and Yahr   1.9 ± 0.8   2.0 ± 0.8   2.0 ± 0.7
Falls Efficacy Scale–International.  The Falls Efficacy Scale– stage
International (FES-I) is widely used in elderly persons to  1-1.5 5 6 5
indicate concerns about falling. There are 16 items assess-  2-2.5 4 5 4
ing functional tasks and social-related activities, and scor-  3 3 3 3
ing ranges from 1 to 4. Subjects rated the items according to MMSE 29.7±0.6 29.8±0.3 29.5±0.7
their concerns about falling. A higher score indicates a
greater concern about falling. The validity of the FES-I has Abbreviations: MMSE, Mini-Mental State Examination; TE, traditional
exercise; VRWii, virtual reality–based Wii Fit exercise.
been reported for older adults.39,40

Timed Up and Go Test.  For the Timed Up and Go (TUG) test,
participants were asked to stand up from a chair, walk 3 m,
turn around, return to the chair, and sit down. The time
taken to complete this task was measured with a stopwatch.
This test has been demonstrated to have high reliability in
people with PD.41
Statistical Analysis
Descriptive statistics were generated for all variables, and
distributions of variables were expressed as mean ± stan-
dard deviation. Intergroup differences among baseline char-
acteristics were evaluated using the 1-way analysis of
variance (ANOVA) or χ2 analysis with significant level at
P < .05. Change values were calculated by subtracting the
baseline data from the post-training data or by subtracting
the baseline data from the follow-up data. To analyze inter-
group improvement, the changes values were analyzed
using a 1-way ANOVA with group as a factor, followed by
Tukey post hoc test. As change values (between post and
pre, and between follow-up and pre) in 1-way ANOVA
were examined twice, the significance level was corrected
with a Bonferroni correction (P = .025) to reduce the pos-
sibility of statistical error.
Results
Thirty-six participants were randomly assigned to the con-
trol, TE, or VRWii groups (n = 12 for each group). None of
the participants reported any adverse events. One partici-
pant in the control group withdrew at the time of follow-up
because of low motivation (Figure 1). No significant group
differences in baseline demographic characteristics were
found (Table 1). Similarly, no significant group differences
were noted in the outcome measures at preintervention
assessment (Tables 2-4).
Obstacle-Crossing Performance
The results of the obstacle crossing performance evaluation
are shown in Table 2 and Figure 2. The VRWii group
showed significant improvements in crossing stride length
and velocity compared with the control group after training
and at the 1-month follow-up (stride length, VRWii vs con-
trol, P = .003 at posttraining, P = .001 at follow-up; stride
velocity, VRWii vs control, P = .011 at posttraining, P =
.001 at follow-up); however, no significant difference
between the VRWii and the TE groups was found. The par-
ticipants contacted the obstacle in 2% of the trials (15 fail-
ure trials out of total 642 trials with 6 leading foot toe
contact and 9 trailing foot toe contact).
Dynamic Balance and Sensory Organization
Test
The results of dynamic balance assessment are shown in
Table 3. Both the VRWii and the TE groups exhibited sig-
nificant improvements in MV and SOT compared with the
control group after training and at the 1-month follow-up
(forward MV, VRWii vs control, P < .001 at posttraining,
P < .001 at follow-up, TE vs control, P = .015 at posttrain-
ing, P = .012 at follow-up; sideward MV, VRWii vs control,
P < .001 at posttraining, P < .001 at follow-up, TE vs con-
trol, P = .004 at posttraining; SOT, VRWii vs control, P <
.001 at posttraining, P < .001 at follow-up, TE vs control,
P = .015 at posttraining, P = .001 at follow-up). Moreover,
the VRWii group exhibited greater improvement than the
TE group on MV (forward MV, VRWii vs TE, P < .001 at
posttraining, P < .001 at follow-up; sideward MV, VRWii
vs TE, P < .001 at posttraining, P < .001 at follow-up). The
VRWii group also showed significant improvements in ME
and DC compared with the control group after training and
at follow-up (forward ME, VRWii vs control, P = .023 at
Liao et al 663

Table 2.  Comparisons of Obstacle Crossing Performance.

Control (n = 12) TE (n = 12) VRWii (n = 12)
a
  Pre Post Follow-up Pre Post Follow-up Pre Post Follow-up

Velocity (cm/s) 80.4 ± 16.1 78.5 ± 17.0 78.2 ± 17.3 77.5 ± 21.8 85.8 ± 18.0 84.7 ± 21.4 75.2 ± 11.4 87.0 ± 16.5 91.1 ± 20.0
  Change valuesb –1.9 ± 3.9 –0.9 ± 3.9 8.3 ± 9.0 7.4 ± 7.0 11.9 ± 16.2* 16.0 ± 15.5**
Stride length (cm) 109.8 ± 17.5 108.3 ± 19.0 107.0 ± 19.3 110.3 ± 19.12 118.6 ± 18.7 115.7 ± 18.6 108.9 ± 8.4 123.0 ± 14.2 125.2 ± 13.7
  Change valuesb –1.5 ± 11.9 –1.9 ± 9.2 7.3 ± 7.3 5.4 ± 9.4 14.4 ± 12.3** 16.9 ± 12.3**
Toe-obstacle 14.1 ± 4.0 14.0 ± 3.7 14.9 ± 3.6 14.9 ± 4.2 14.7 ± 3.5 15.7 ± 1.6 12.9 ± 4.0 12.5 ± 3.4 13.2 ± 3.7
clearance (cm)
  Change valuesb 0.3 ± 2.7 0.8 ± 2.6 0.1 ± 2.7 –0.9 ± 1.1 –0.5 ± 2.9 –0.5 ± 2.5

Abbreviations: TE, traditional exercise; VRWii, virtual reality–based Wii Fit exercise.
a
n = 11.
b
Change values were calculated by subtracting the baseline data from the posttraining data (post) or by subtracting the baseline data from the follow-up data (follow-up).
*Significance level <.025 for intergroup comparisons (TE vs Control; VRWii vs Control).
**Significance level <.01 for intergroup comparisons (TE vs Control; VRWii vs Control).

Table 3.  Comparisons of Dynamic Balance and SOT Score.

Control (n = 12) TE (n = 12) VRWii (n = 12)
a
  Pre Post Follow-up Pre Post Follow-up Pre Post Follow-up

Forward ME (%) 58.9 ± 14.0 59.5 ± 15.0 58.8 ± 15.4 57.8 ± 12.2 65.3 ± 12.8 64.9 ± 16.4 55.8 ± 16.7 68.9 ± 16.8 68.5 ± 17.8
  Change valuesb 0.6 ± 13.6 –0.0 ± 10.1 7.5 ± 8.3 7.1 ± 10.7 13.1 ± 11.5* 12.6 ± 10.4*
Sideward ME 77.2 ± 14.5 74.0 ± 15.0 75.3 ± 14.3 75.8 ± 12.9 79.9 ± 10.8 79.0 ± 9.6 74.5 ± 11.7 81.0 ± 11.0 82.5 ± 13.8
  Change valuesb –3.0 ± 10.1 –1.9 ± 10.6 4.1 ± 8.9 3.2 ± 5.7 6.6 ± 8.3 8.0 ± 6.2*
Forward MV (%) 2.4 ± 0.7 2.4 ± 0.8 2.3 ± 1.1 2.2 ± 0.9 3.0 ± 1.1 3.0 ± 1.3 2.0 ± 0.6 3.6 ± 0.8 3.6 ± 1.3
  Change valuesb 0.1 ± 0.1 –0.1 ± 0.7 0.8 ± 0.9* 0.8 ± 0.7* 1.6 ± 0.4**† 1.6 ± 0.9**†
Sideward MV 2.9 ± 0.9 2.7 ± 1.0 2.9 ± 1.2 2.9 ± 1.2 3.8 ± 1.6 3.7 ± 1.3 2.7 ± 0.6 4.3 ± 0.9 4.3 ± 1.1
  Change valuesb –0.2 ± 0.5 –0.0 ± 0.5 0.8 ± 0.8* 0.8 ± 0.7 1.7 ± 0.9**† 1.7 ± 1.1**†
Forward DC (%) 76.6 ± 10.4 76.1 ± 11.0 76.5 ± 11.0 74.5 ± 9.7 81.3 ± 6.4 80.5 ± 3.8 73.5 ± 14.8 84.0 ± 10.0 83.2 ± 10.7
  Change valuesb –0.5 ± 2.6 –0.1 ± 1.9 6.1 ± 7.6 5.6 ± 6.8 10.4 ± 6.6** 9.7 ± 7.0**
Sideward DC (%) 76.7 ± 6.6 74.2 ± 9.2 73.6 ± 11.0 77.3 ± 5.8 80.1 ± 5.8 78.2 ± 6.9 74.9 ± 9.3 79.7 ± 6.3 81.6 ± 4.2
  Change valuesb –2.5 ± 5.7 –3.1 ± 7.1 2.8 ± 4.7 0.8 ± 9.2 4.8 ± 5.6** 6.7 ± 6.9*
SOT score (%) 68.2 ± 8.1 67.2 ± 11.0 65.7 ± 9.3 67.9 ± 10.5 74.3 ± 8.2 74.7 ± 6.7 65.4 ± 8.5 75.9 ± 5.0 75.8 ± 6.2
  Change valuesb –1.0 ± 5.2 –2.5 ± 4.0 5.0 ± 4.6* 5.3 ± 5.4** 10.5 ± 5.9** 10.4 ± 4.9**

Abbreviations: DC, directional control; ME, maximal excursion; MV, movement velocity (scores range from 0% to 100%, and higher percentages indicate better balance
control); SOT, sensory organization test (scores range from 0% to 100%, and higher percentages indicate better sensory integration ability); TE, traditional exercise; VRWii,
virtual reality–based Wii Fit exercise.
a
n = 11.
b
Change values were calculated by subtracting the baseline data from the posttraining data (post) or by subtracting the baseline data from the follow-up data (follow-up).
*Significance level <.025 for intergroup comparisons (TE vs Control; VRWii vs Control).
**Significance level <.01 for intergroup comparisons (TE vs Control; VRWii vs Control).
†
Significance level <.025 for intergroup comparisons (VRWii vs TE).

posttraining, P = .014 at follow-up; sideward ME, VRWii
vs control, P = .011 at follow-up; forward DC, P = .001 at
posttraining, P = .002 at follow-up; sideward DC, P = .006
at posttraining, P = .012 at follow-up).
Timed Up and Go
The results of TUG analysis are shown in Table 4. Both the
VRWii and the TE groups showed significant improvement
in TUG results compared with the control group after train-
ing and at follow-up (VRWii vs control, P < .001 at
posttraining, P < .001 at follow-up; TE vs control, P = .025
at posttraining, P = .008 at follow-up).
PDQ39 and FES-I
Both the VRWii and TE groups showed significant improve-
ments in PDQ39 and FES-I scores compared with the con-
trol group at follow-up (PDQ39, VRWii vs control, P = .004
at posttraining, P = .001at follow-up, TE vs control, P = .022
at follow-up; FES-I, VRWii vs control, P < .001 at posttrain-
ing, P = .001 at follow-up, TE vs control, P = .019 at
664 Neurorehabilitation and Neural Repair 29(7)

Table 4.  Comparisons of TUG, PDQ39, and FES-I.

Control (n = 12) TE (n = 12) VRWii (n = 12)
a
  Pre Post Follow-up Pre Post Follow-up Pre Post Follow-up

TUG (seconds) 11.9 ± 2.7 12.6 ± 3.6 12.9 ± 3.8 12.1 ± 2.1 11.0 ± 1.8 10.7 ± 1.5 12.6 ± 4.1 9.7 ± 2.1 9.7 ± 2.3
  Change valuesb 0.7 ± 1.7 1.0 ± 1.9 –1.1 ± 0.1* –1.3 ± 0.9** –2.9 ± 2.2** –2.9 ± 2.2**
PDQ39 78.2 ± 23.3 79.0 ± 24.3 80.2 ± 24.5 82.2 ± 27.3 70.8 ± 27.1 70.0 ± 26.5 84.5 ± 26.0 68.8 ± 20.0 65.8 ± 18.3
  Change valuesb 0.7 ± 3.5 2.0 ± 3.6 –11.4 ± 8.2 –12.2 ± 8.5* –15.7 ± 18.2** –18.7 ± 19.4**
FES-I 34.4 ± 11.0 34.9 ± 12.0 35.2 ± 13.0 38.7 ± 12.4 31.5 ± 9.0 31.5 ± 10.8 39.0 ± 14.0 27.8 ± 9.4 28.0 ± 11.4
  Change valuesb 0.5 ± 3.6 0.8 ± 6.6 –7.1 ± 8.0* –7.2 ± 7.5* –11.2 ± 7.0** –11.0 ± 6.7**

Abbreviations: FES-I, Falls Efficacy Scale–International; PDQ39, 39-question Parkinson’s Disease Questionnaire; TUG, timed up and go; TE, traditional exercise; VRWii,
virtual reality–based Wii Fit exercise.
a
n = 11.
b
Change values were calculated by subtracting the baseline data from the posttraining data (post) or by subtracting the baseline data from the follow-up data (follow-up).
*Significance level <.025 for intergroup comparisons (TE vs Control; VRWii vs Control).
**Significance level <.01 for intergroup comparisons (TE vs Control; VRWii vs Control).
†
Significance level <.025 for intergroup comparisons (VRWii vs TE).

Figure 2.  Change values of crossing velocity (A) and change values of crossing stride length (B) at post and follow-up. VRWii group
showed significant improvements in crossing velocity (P = .011) and stride length (P = .003) compared with the control group after
training. The improvements at posttraining were retained at follow-up (crossing velocity, P = .001; crossing stride length, P = .001).
* Indicates significant difference between groups.

posttraining, P = .021 at follow-up); however, there was no
significant difference between the VRWii and TE groups in
the PDQ39 and FES-I results (Table 4).
Discussion
In this study, we demonstrated that 12 sessions of VRWii as
part of a multifaceted training intervention is effective in
improving obstacle-crossing performance in participants
with PD compared with control group. Such improvement
is accompanied by concurrent increases in dynamic balance
control and sensory integration ability, and these improve-
ments persisted for at least one month. We further demon-
strated that the VR-based Wii Fit exercise is more effective
than traditional exercise in improving MV in LOS test. The
LOS test can indicate balance control in participants with
PD.42 In addition, the LOS is useful in the prospective
assessment of falls risk in PD patients.43,44 Therefore, the
VRWii as part of a multifaceted training intervention can
exert better results than traditional intervention with both
statistical and clinical meaningfulness.
The relationship between obstacle-crossing perfor-
mance and dynamic balance has been demonstrated in our
previous study, in which crossing stride length and velocity
correlated with ME, MV, DC in the LOS test, and SOT.45 In
the present study, we designed the treatment program
according to these influencing factors and noted that
improved dynamic balance and SOT after 12 sessions of
VRWii training coincides with improved crossing perfor-
mance. Obstacle crossing is a balance demanding task that
requires control of single leg support and COM forward
shifting46 which are core programs of our balance exercise.
With improved balance, the individuals may move their
COM further, faster and more correctly.47 Meanwhile, with
Liao et al 665
improved SOT, the individuals may process sensory infor-
mation (vision, vestibular, and somatosensory) more accu-
rately in order to control their trunk and limbs in response to
sensory challenges.48 Therefore, participants in the VRWii
group demonstrated increased stride length and velocity
strategies during obstacle crossing. Previous studies
reported that individuals with PD place their leading foot
closer to the obstacle and more often hit the obstacle.6
Therefore, a longer stride length may reduce the risk of the
leading foot hitting the obstacle.49 Also, a faster crossing
velocity may represent an effective motor coordination
strategy. However, this safe and efficient crossing strategy
was not achieved with the traditional exercise training.
Previous studies indicated that participants with PD can
adjust the vertical toe-obstacle clearance in response to dif-
ferent obstacle heights, although the short stride length
remains. Therefore, PD participants have greater difficulty
in lengthening their step over the obstacle than increasing
the foot height during the obstacle crossing.6,50 Our results
suggest that VRWii training is especially effective in
increasing the horizontal crossing length and velocity as
opposed to improving vertical toe clearance in participants
with PD.
Previous studies on exercise intervention found that PD
participants improved their dynamic balance after 20 ses-
sions over 10 weeks of training.13 In the present study, par-
ticipants in both exercise groups showed significant
improvements in MV of LOS test as compared with the
control. However, VRWii exercise resulted in additional
improvements in ME and DC, which are key factors of
crossing performance.45 Furthermore, the MV was improved
more in the VRWii group than the TE group, suggesting that
incorporating VRWii training into the exercise program is
effective for patients with PD for improving balance and
obstacle crossing ability.
Virtual reality–based Wii Fit exercise was more effective
than traditional exercise on improving dynamic balance
which may be due to the following factors. First, VR is a
form of external feedback. In this study, knowledge of per-
formance and knowledge of results were provided during
training in the form of auditory and visual feedback.
Participants were then able to make corrections according to
the feedback to enhance their motor performance. Previous
studies reported that PD participants rely more on external
cues or feedback to execute movement as a result of an inter-
nal trigger deficit.36 Second, some of our VRWii gaming
programs require either attention or problem-solving ability.
Active participation in cognition-demanding programs may
activate cognitive pathway networks and consolidate the
learning effect.18 Third, observation of the virtual perfor-
mance on the screen may also facilitate the participation of
mirror neurons. Activation of mirror neurons located in
cerebral cortices may help to make connections in the neu-
ral network that enhance learning and motor performance.51
Taken together, these possibilities may help participants
with PD improve their mobility and balance control, as
demonstrated in the LOS test. It should also be noted that
treadmill training was part of our training program. The
effect of treadmill training is known to improve gait perfor-
mance and balance, thus we included the treadmill training
after VR-based Wii Fit exercise (VRWii group) and tradi-
tional exercise (TE group) for 15 minutes to enhance the
effects of exercise training. Therefore, the improvements in
both exercise groups could also partly be attributed to the
treadmill training.
A previous study indicated that an increase in the weigh-
ing of sensory inputs is required to prepare for an ensuing
change in direction.52 During TE and VRWii training, the
participants were required to adjust their joint angles to
shift their body weight and to move the head and trunk.
These changes in joint angles and head positions stimu-
lated somatosensory and vestibular receptors to enhance
the central integration ability, as demonstrated by the
results of SOT.
Improvement in dynamic balance (ME, MV, and DC)
and SOT may also increase functional ability in daily life,
including transitioning between sitting and standing posi-
tion, turning, and walking. These functional tasks are key
components of TUG. In addition, the training effect also
extended to patients’ concerns about falling as indicated by
the improvement in FES-I. The questions identified in
FES-I are not just limited to basic daily activities at home
but also contain social activities outside the home. After
training, patients may become more confident in balance-
demanding tasks, such as walking on a slippery or uneven
surface, walking up or down a slope, and walking in a place
with crowds. The significant improvement in PDQ39 scores
for both the TE and VRWii groups further supported the
notion that exercise not only increases physical function but
also increases emotional well-being, social support, cogni-
tion, and communication, and decreases bodily discomfort.
The significant improvements observed in TUG, fall effi-
cacy, and quality of life in patients with PD in the present
study support the benefits of both traditional and VRWii
training.
The small sample size of our study is one of the limita-
tions. A larger randomized controlled clinical trial is needed
to validate the reported benefits of the VR intervention.
Despite the small sample size, the statistical power is rela-
tively strong for our outcomes (crossing velocity, 0.96;
crossing stride length, 0.94). In addition, the therapist was
not blinded to the exercise group and, although unavoidable,
this limitation may introduce bias. Also, the FES-I does not
represent the real incidence of falls, and therefore the reduc-
tion of fall incidence after training warrants further follow-
up, especially for PD patients with a history of falls.
Furthermore, it should be noted that both interventions
included treadmill training to enhance the effects of exercise
666 Neurorehabilitation and Neural Repair 29(7)
training. However, this may dilute the distinction between
the VR Wii and TE groups. In summary, VRWii as part of a
multifaceted training intervention is effective in improving
obstacle-crossing performance, dynamic balance, functional
ability, and quality of life in PD patients. These improve-
ments can persist for at least 1 month. These findings sup-
port the inclusion of VRWii training in the exercise program
for participants with PD.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Support was provided by the National Science Council (NSC
100-2314-B-010-022-MY2) and Aim for the Top University Plan
(101AC-P508) of the Ministry of Education of the Republic of
China.
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