Individuals with Down syndrome may struggle with anticipatory postural adjustments, and adapt slower to motor tasks and environmental changes, due to decreased motor proficiency.
To determine the effectiveness of virtual reality therapy (VRT), specifically Nintendo Wii, combined with physiotherapy or occupational therapy (OT) for improving motor proficiency in individuals with Down syndrome, compared to standard physiotherapy, OT or no intervention.
Nine computerised databases were searched from inception to July 2020. Methodological quality of randomised controlled trials and quasi-experimental studies was appraised using the physiotherapy evidence database (PEDro) scale and the Joanna Briggs Institute Critical Appraisal Checklist for Case Reports.
Two randomised controlled trials and four quasi-experimental studies were included, with an average PEDro score of 7.3. One included case study scored 5. This review included 345 participants. Motor proficiency includes balance, coordination, strength and agility. Agility showed a significant improvement after 5 (
Level II, III-1 and IV evidence suggested that VRT may be valuable to improve agility and strength in individuals with Down syndrome, and balance and coordination in children with Down syndrome.
It may be beneficial to use VRT in addition to standard physiotherapy or OT interventions for improving motor proficiency in individuals with Down syndrome.
Down syndrome, also known as trisomy-21, is a genetic condition that is caused by an error in cell division occurring at conception, resulting in an additional copy of chromosome 21 (Batshaw, Roizen & Pellegrino
Individuals with Down syndrome may present with numerous health complications (Charleton, Dennis & Marder
Quality of life (QOL) decreases in individuals with Down syndrome as a result of poor motor proficiency (Zwicker, Harris & Klassen
Physiotherapy interventions in children with Down syndrome do not aim to accelerate gross motor development, but rather to correct or minimise compensatory strategies by improving overall motor proficiency and QOL in this population (De Morais et al.
Alternative interventions to improve motor proficiency and overall QOL in individuals with Down syndrome include hydrotherapy, Pilates and global postural re-education (De Morais et al.
Virtual reality video games, such as Nintendo Wii Fit and Wii Sports, demand varying degrees of physical activity. Participation in VR games allows individuals to interact with displayed images, moving and manipulating virtual objects, and performing actions that immerse them in a simulated environment (Douris et al.
The purpose of this systematic review was to determine whether a VR therapeutic programme, specifically a Nintendo Wii-based exercise programme, alone or combined with standard physiotherapy is effective in improving motor proficiency in individuals with Down syndrome, compared with standard physiotherapy alone.
This systematic review was registered on PROSPERO (CRD42020190829) on 07 June 2020. This study followed reporting standards of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as outlined by Moher et al. (
The research question based on the Population, Intervention, Comparison, Outcome (PICO) format was as follows: What is the effect of VRT, alone or combined with physiotherapy or occupational therapy, compared with a standard physiotherapy or occupational therapy programme alone for improving motor proficiency in individuals with Down syndrome?
The objectives of this systematic review were to:
determine the effect of VRT, alone or combined with physiotherapy or occupational therapy, compared with standard physiotherapy or occupational therapy alone, on motor proficiency focussing on balance, strength, coordination and agility in individuals with Down syndrome
critically appraise and score the identified, available randomised controlled trials (RCTs) according to the PEDro principles (
describe the intervention programme for both the experimental and control groups of each included study
analyse and compare the results of the included studies
describe the outcome measures used to measure motor proficiency in individuals with Down syndrome.
Nine computerised bibliographic databases, accessed through the Stellenbosch University library services, were searched, namely, MEDLINE, OTSeeker, Cochrane library, EBSCOhost, PEDro, PubMed, Science Direct, Scopus and Google Scholar. The date limit was initially set from inception up to April 2018. An update of the search was performed in June 2018 and again in June 2020. Preliminary searches within each database allowed for the elimination of unnecessary search terms, where the addition of keywords did not yield varying results. Two reviewers were assigned to each database to ensure cross-checking of results found within the different databases. All the databases were searched using the same process, and were recorded and documented. Key search terms included Down syndrome, trisomy-21, VR, motor learning, Nintendo Wii, motor proficiency, motor performance, physiotherapy, physical therapy, exercises, physical fitness and functional mobility. The detailed search strategies, specifically developed for each database according to its functions, are provided in
Each of the reviewers independently searched two randomly selected databases and screened titles according to the eligibility criteria of the review. Thereafter reviewers compared results and eliminated duplicate titles. Abstracts for all selected titles were retrieved, and each reviewer independently screened the abstracts against the eligibility criteria. In the case where consensus could not be reached, the abstracts of those titles that could not be agreed upon were retrieved and assessed using the eligibility criteria. In the case of persisting disagreement, the rest of the reviewers or J.S. or M.B. were consulted to reach consensus. Full-text articles, from the selected abstracts, were subsequently retrieved and were independently screened for eligibility by each reviewer. The reviewers compared the eligible full texts identified for inclusion, and if consensus regarding the final inclusion of articles was not reached, J.S. or M.B. was contacted to resolve the matter. The search method is illustrated in
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.
Randomised controlled- or clinical-trials, non-randomised controlled- or clinical-trials, pilot and case studies published in English from inception of the database until July 2020 were considered for inclusion in this systematic review. Including studies with control groups with no active intervention was a change to the original protocol and deemed to be appropriate if the control group had pre–post assessment of the same outcome measures.
Study participants with Down syndrome included were children and adults (6–60 years). Participants were excluded from the review if they had additional neuro-musculoskeletal disorders and/or severe sensory (visual and auditory) impairments.
Studies in which participants received VRT, alone or combined with physiotherapy or OT.
Control groups had to receive standard physiotherapy care, occupational therapy care or no intervention.
Any valid outcome measures of motor proficiency (i.e. balance, strength, coordination and agility) were included in the review:
balance, for example, Bruininks-Oseretsky Test of Motor Proficiency, Second edition (BOT-2); Flamingo balance test; Paediatric balance test; Timed up-and-go test; Five-times-sit-to-stand test; and Pressure sensing mat systems
agility, for example, shuttle run test; BOT-2; Test of Gross Motor Development, Second Edition (TGMD-2)
strength, for example, hand-grip test, 30-s sit-up; standing broad jump test
coordination, for example, Bruininks-Oseretsky Test of Motor Proficiency, Second edition; TGMD-2.
The National Health and Medical Research Council (NHMRC) Evidence Hierarchy was used to appraise each of the articles identified and considered for the study, and was, thus, needed to ensure validity and reliability of the included articles (Merlin, Weston & Tooher
Reviewers individually scored each article, where after discrepancies were discussed within the review group and resolved by contacting J.S. or M.B. The methodological quality of each of the included RCTs was determined by critical appraisal using the Physiotherapy Evidence Database (PEDro) scale, aimed at establishing the methodological quality of an RCT (De Morton
Data were extracted from each of the selected articles using the adapted JBI Data Extraction Form for Systematic Review of Experimental studies (Pearson, Field & Jordan
Following the data extraction process, the critical analysis of the data was performed by the reviewers. Each article was reviewed by at least two reviewers. The two reviewers responsible for an article independently analysed the data, thereafter, compared their findings. Contrasted findings were shared and discussed with the rest of the group. J.S. or M.B. were consulted for the final decision where consensus was not reached amongst group members. Statistical pooling was not possible because of the heterogeneous nature of the data and the intervention, and follow-up periods. The results are presented in a narrative form and illustrated in tables.
A total of 3840 initial hits were found. Of these, 42 titles and abstracts were considered, and 35 of these abstracts were duplicates, leaving seven eligible full-text articles for quality assessment, for use in this systematic review.
The final seven eligible articles that were used in this systematic review are two RCTs (Ghafar & Abdelraouf
The methodological quality of six experimental studies was assessed using the 11-item PEDro scale (Maher et al.
Methodological quality of included studies.
S. no. | PEDro criteria | Álvareza et al. ( |
Ghafar and Raouf ( |
Lin and Wuang ( |
Rahman ( |
Silva et al. ( |
Wuang et al. ( |
---|---|---|---|---|---|---|---|
1 | Eligibility criteria were specified. | Yes | Yes | Yes | Yes | Yes | Yes |
2 | Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received). | Yes | Yes | Yes | No | Yes | Yes |
3 | Allocation was concealed. | No | No | No | No | No | No |
4 | The groups were similar at baseline regarding the most important prognostic indicators. | Yes | Yes | Yes | Yes | Yes | Yes |
5 | There was blinding of all subjects. | No | No | No | No | No | No |
6 | There was blinding of all therapists who administered the therapy. | No | No | No | No | No | Yes |
7 | There was blinding of all the assessors who measured at least one key outcome. | No | Yes | Yes | No | Yes | Yes |
8 | Measures of at least one key outcome were obtained for more than 85% of the subjects initially added to the groups. | Yes | Yes | Yes | Yes | Yes | No |
9 | All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by ‘intention to treat’. | Yes | Yes | Yes | Yes | Yes | No |
10 | The results of between-groups statistical comparisons are reported for at least one key outcome. | Yes | Yes | Yes | Yes | Yes | Yes |
11 | The study provides both point measures and measures of variability for at least one key outcome. | Yes | Yes | Yes | Yes | Yes | Yes |
Sample descriptions for each study are summarised in
Study sample description.
Criteria | Groups | Álvareza et al. ( |
Ghafar and Abdelraouf ( |
Lin and Wuang ( |
Rahman ( |
Silva et al. ( |
Wuang et al. ( |
Berg et al. ( |
---|---|---|---|---|---|---|---|---|
Sample size ( |
Experimental | |||||||
Control | - | |||||||
Gender ( |
Experimental | Female = 3 |
Not specified | Female = 25 |
Female = 9 |
Not specified | Not specified | Male |
Control | - | Not specified | Female = 24 |
Female = 8 |
Not specified | Not specified | - | |
Age mean (SD) (years) | Experimental | 8.30 ± 2.06 | 7.18 ± 1.85 | 15.6 ± 3.6 | 10.92 ± 1.16 | 18–60 years | 7–12 years | 12-year-old |
Control | 8.43 ± 1.62 | 7.40 ± 1.27 | 14.9 ± 3.9 | 11.56 ± 0.44 | 18–60 years | 7–12 years | - | |
Baseline difference reported | Experimental | No baseline differences reported | No baseline differences reported | No baseline differences reported | No baseline differences reported | No baseline differences reported | No baseline differences reported | Not applicable |
Control | No baseline differences reported | No baseline differences reported | No baseline differences reported | No baseline differences reported | No baseline differences reported | No baseline differences reported | Not applicable | |
Country of study | - | Chile | Saudi Arabia | Taiwan | Saudi Arabia | Portugal | Taiwan | USA |
Type of study | - | Quasi-experimental | Randomised controlled trial | Randomised controlled trial | Quasi-experimental | - | Quasi-experimental | Case study |
SD, standard deviation; SOT, standard occupational therapy; USA, United States of America.
Description of intervention and control procedures.
Groups | Variables | Álvareza et al. ( |
Ghafar and Abdelraouf ( |
Lin and Wuang ( |
Rahman ( |
Silva et al. ( |
Wuang et al. ( |
Berg et al. ( |
---|---|---|---|---|---|---|---|---|
Experimental group: Nintendo Wii Games | Type of Nintendo Wii Games | Wii fit software, along with the Wii balance board. The following games were practised: Snowboarding, the Penguin Slide, Super Hoola Hoop, heading Soccer and Skii Jumping. | Wii Sports, Wii Fit, Wii balance board. The following three Wii games were practised: Football heading game, Ski Slalom game and, finally, the Table Tilt game. | Wii Sports games. The five most popular games being Boxing, bowling, table tennis, Frisbee and golfing. | Wii Fit with Wii balance board, Wii console, Wii remote and Wii nun chuck. Balance games: Soccer heading game, Tightrope walk game, Penguin slide game As well as the following: Approximation and strengthening exercises, walking on an even surface in the treatment room and climbing stairs. | Wii fit balance board. Games targeting balance or isometric strength: Freerun, Heading, Snowboard Slalom, Table tilt, Tight rope tension, Hoolahoop, Balance bubble, Penguin slide Wii Sports, Wii Sports Resort, Wii Fit and Just Dance 2 targeted aerobic endurance. Games performed: Sword play, Boxing, Cycling, Table tennis, Just Dance 2. | A Nintendo Wii gaming console, that is, Wii Sports. |
Wii Sports bowling, baseball, rhythm boxing and snowboarding game. |
Frequency and dosage of intervention | The intervention was 5 weeks with two weekly sessions of 20-min duration. | Treatment sessions consisted of 30 min, three times per week for 8 weeks. Each game was played for 10 min. | Treatment sessions consisted of three 35-min sessions per week for 6 weeks. | Approximation and strengthening exercises (15 min, 5-min rest) |
Participants completed 1 h session, three times per week, to 22 sessions over a period of 2 months. | Treatment sessions consisted of 1 h, 2 days per week for 24 weeks. | Participant asked to use Wii 20 min, four times per week for 8 weeks. | |
Control group: SPT; SOT; No intervention | Method of SPT or SOT | Continued normal daily activities along with psycho-educational therapies included in school. | Throwing or catching balls or beanbags outside of their base of support, reaching for objects whilst standing or sitting on stable or unstable surfaces, walking up and down stairs, balance beam walk, single-leg stance and kicking activities. Individualised treatments based on functional limitations and abilities of child. | No intervention. | Approximation or strengthening exercises. Walking on an even surface in the treatment room and climbing stairs. | The control group completed their usual daily activities, such as vocational rehabilitation, life-skill training and art-related activities. | Various activity combinations incorporating the principle of sensory integrative therapy, neuro developmental treatment, and perceptual motor approaches. | Not applicable. |
Frequency and dosage of intervention | None reported. | Treatment sessions consisted of 30 min, three times per week for 8 weeks. | None reported. | Approximation or strengthening exercises (15 min, 5 min rest). Walking on even surfaces and climbing stairs for 35 min (15 min each and 5 min rest in between). Programme performed twice a week for 6/52. | None was mentioned or specified. | Treatment sessions consisted of 30 min, three times per week for 8 weeks. | Not applicable. |
SPT, standard physiotherapy; SOT, standard occupational therapy.
The outcome measures used within the included studies assessed balance, agility, strength and coordination. The formal explanation for each outcome measure is described in
Balance was the only outcome that was measured across most of the included studies. Rahman (
Silva et al. (
The effect of VRT, alone or combined with physiotherapy, on motor proficiency (including balance, agility, coordination and strength) in children and adults with Down syndrome compared with standard physiotherapy is discussed under the following subheadings:
Results reported for balance measures of included studies.
Study | Assessment interval | Test description | Control |
Experimental group |
Mean difference between groups (95% CI) | |||
---|---|---|---|---|---|---|---|---|
mean | (SD) | mean | (SD) | |||||
Álvareza et al. ( |
Baseline | Pressure centre eyes open (m2) | 0.06 | 0.05 | 0.06 | 0.04 | 0.00 (−0.05 to 0.05) | 0.83 |
5 weeks | 0.04 | 0.03 | 0.07 | 0.005 | 0.03 (0.01 to 0.05) | 0.31 | ||
0.36 | - | 0.52 | - | - | - | |||
Sample size ( |
7 | - | 9 | - | - | - | ||
Baseline | Pressure centre eyes closed (m2) | 0.05 | 0.02 | 0.05 | 0.03 | 0.00 (−0.03 to 0.03) | 0.86 | |
5 weeks | 0.04 | 0.02 | 0.02 | 0.019 | −0.02 (−0.04 to 0.00) | 0.13 | ||
0.31 | - | 0.039* | - | - | - | |||
Sample size ( |
7 | - | 9 | - | - | - | ||
Ghafar and Abdelraouf ( |
Baseline | Pediatric balance test | 47.35 | 3.8 | 48.2 | 4.6 | 0.85 (−2.57 to 4.27) | 0.046 |
8 weeks | 52.15 | 4.7 | 57.75 | 2.6 | 5.60 (2.53 to 8.67) | - | ||
Not reported | - | Not reported | - | - | - | |||
Sample size ( |
13 | - | 13 | - | - | - | ||
Baseline | Timed up and go test | 10.65 | 1.7 | 10.21 | 2.0 | −0.44 (−1.94 to 1.06) | 0.043 | |
8 weeks | 8.95 | 1.4 | 7.01 | 1.8 | 1.94 (0.63 to 3.25) | - | ||
Not reported | - | Not reported | - | - | - | |||
Sample size ( |
13 | - | 13 | - | - | - | ||
Baseline | Five times sit to stand test | 16.56 | 2.3 | 15.6 | 2.6 | −0.96 (−2.95 to 1.03) | 0.027 | |
8 weeks | 14.62 | 3.2 | 11.2 | 2.9 | −3.42 (−5.89 to −0.95) | - | ||
Not reported | - | Not reported | - | - | - | |||
Sample size ( |
13 | - | 13 | - | - | - | ||
Rahman ( |
Baseline | BOT-2 balance subsection | 8.87 | 5.53 | 10.27 | 4.83 | 1.4 (−2.48 to 5.28) | 0.466 |
6 weeks | 10.40 | 4.93 | 17.47 | 3.50 | 7.01 (3.87 to 10.27) | 0.000 | ||
0.017 | - | 0.000 | - | - | - | |||
Sample size ( |
15 | - | 15 | - | - | - | ||
Silva et al. ( |
Baseline | Flamingo balance test | 3.31 | 8.20 | 6.08 | 11.09 | 2.77 (−5.25 to 10.79) | 0.477 |
24 weeks | 1.69 | 6.10 | 9.92 | 12.53 | 8.23 (0.18 to 16.28) | - | ||
Effect size – within group ( |
0.228 | - | 0.372 | - | - | - | ||
Sample size ( |
13 | - | 12 | - | - | - | ||
Wuang et al. ( |
Baseline | BOT-2 balance subsection | 11.40 | 8.91 | 11.08 | 7.02 | −0.32 (−3.43 to 2.79) | < 0.003 |
24 weeks | 12.66 | 7.99 | 13.27 | 8.91 | 0.61 (−2.66 to 3.88) | - | ||
Effect size – within group ( |
0.72 | - | 1.60 | - | - | - | ||
Sample size ( |
53 | - | 52 | - | - | - |
SD, standard deviation; CI, confidence interval; BOT-2, Bruininks–Oseretsky Test of Motor Proficiency, Second edition.
Results reported for agility measures of included studies.
Study | Assessment interval | Test description | Control |
Experimental group |
Mean difference between groups (95% CI) | |||
---|---|---|---|---|---|---|---|---|
mean | (SD) | Mean | (SD) | |||||
Álvareza et al. ( |
Baseline | TGMD-2 locomotion subsection | 33.71 | 3.69 | 34.56 | 5.94 | 0.85 (−5.85 to 7.55) | 0.75 |
5 weeks | 33.71 | 4.82 | 36.67 | 3.39 | 2.96 (−1.43 to 7.35) | 0.17 | ||
1.00 | - | 0.3 | - | - | - | |||
Sample size ( |
7 | - | 9 | - | - | - | ||
Lin and Wuang ( |
Baseline | BOT-2 agility subsection | 11.0 | 5.9 | 11.0 | 6.3 | 0.00 (−2.53 to 2.53) | 0.466 |
6 weeks | 10.0 | 6.8 | 16.0 | 6.6 | 6.0 (3.22 to 8.78) | 0.01 | ||
Not reported | - | Not reported | - | - | - | |||
Sample size ( |
46 | - | 46 | - | - | - | ||
Silva et al. ( |
Baseline | Shuttle run test | 33.01 | 5.69 | 35.42 | 12.55 | 2.41 (−5.54 to 10.36) | 0.014 |
24 weeks | 35.31 | 9.06 | 31.62 | 6.32 | −3.69 (−10.21 to 2.83) | - | ||
Effect size – within group ( |
0.508 | - | 0.478 | - | - | - | ||
Sample size ( |
13 | - | 12 | - | - | - | ||
Wuang et al. ( |
Baseline | BOT-2 agility subsection | 7.47 | 5.58 | 7.38 | 5.48 | −0.09 (−2.23 to 2.05) | < 0.003 |
24 weeks | 9.36 | 6.81 | 10.12 | 5.64 | 0.76 (−1.66 to 3.18) | - | ||
Effect size – within group ( |
1.89 | - | 2.56 | - | - | - | ||
Sample size ( |
53 | - | 52 | - | - | - |
SD, standard deviation; CI, confidence interval; BOT–2, Bruininks–Oseretsky Test of Motor Proficiency, Second edition; Test of Gross Motor Development, Second Edition.
Results reported for strength measures of included studies.
Study | Assessment interval | Test description | Control |
Experimental group |
Mean difference between groups (95% CI) | |||
---|---|---|---|---|---|---|---|---|
mean | (SD) | mean | (SD) | |||||
Lin and Wuang ( |
Baseline | BOT-2 strength subsection | 10.94 | 1.59 | 10.69 | 1.25 | −0.25 (−0.84 to 0.34) | 0.466 |
6 weeks | 14.36 | 1.87 | 15.37 | 1.80 | 1.01 (0.25 to 1.77) | 0.000 | ||
Not reported | - | Not reported | - | - | - | |||
Sample size ( |
46 | - | 46 | - | - | - | ||
Silva et al. ( |
Baseline | Handgrip test | 22.38 | 5.91 | 23.67 | 6.89 | 1.29 (−4.01 to 6.59) | 0.837 |
24 weeks | 23.92 | 6.45 | 25.42 | 5.53 | 1.5 (−3.49 to 6.49) | - | ||
Effect size – within group ( |
0.693 | - | 0.618 | - | - | - | ||
Sample size ( |
13 | - | 12 | - | - | - | ||
Baseline | 30-s sit-up | 9.96 | 5.44 | 7.17 | 5.51 | −2.79 (−7.32 to 1.74) | 0.040 | |
24 weeks | 7.69 | 5.22 | 8.00 | 5.36 | 0.21 (−4.17 to 4.59) | - | ||
Effect size – within group ( |
0.585 | - | 0.271 | - | - | - | ||
Sample size ( |
13 | 12 | - | - | - | |||
Baseline | Standing broad jump | 88.04 | 44.02 | 82.67 | 31.52 | −5.37 (−37.29 to 26.55) | 0.003 | |
24 weeks | 90.69 | 35.20 | 99.33 | 29.49 | 8.64 (−18.35 to 35.63) | - | ||
Effect size – within group ( |
0.235 | - | 1.691 | - | - | - | ||
Sample size ( |
13 | - | 12 | - | - | - | ||
Wuang et al. ( |
Baseline | BOT-2 strength subsection | 10.94 | 8.14 | 10.69 | 6.40 | −0.25 (3.09 to 2.59) | < 0.003 |
24 weeks | 14.36 | 9.58 | 15.37 | 9.22 | 1.01 (−2.63 to 4.65) | - | ||
Effect size – within group ( |
2.15 | - | 3.74 | - | - | - | ||
Sample size ( |
53 | - | 52 | - | - | - |
SD, standard deviation; CI, confidence interval; BOT-2, Bruininks–Oseretsky Test of Motor Proficiency, Second edition.
Results reported for coordination measures of included studies.
Study | Assessment interval | Test description | Control |
Experimental group |
Mean difference between groups (95% CI) | |||
---|---|---|---|---|---|---|---|---|
mean | (SD) | mean | (SD) | |||||
Álvareza et al. ( |
Baseline | TGMD-2 manipulation subsection | 30.14 | 6.67 | 28.44 | 5.46 | −1.7 (−8.19 to 4.79) | 0.58 |
5 weeks | 29.43 | 5.86 | 35.00 | 5.50 | 5.57 (−0.54 to 11.68) | 0.07 | ||
0.09 | - | 0.01* | - | - | - | |||
Sample size ( |
7 | - | 9 | - | - | - | ||
Silva et al. ( |
Baseline | Bean bag overhead throw test: Right hand | 6.69 | 3.38 | 5.17 | 3.76 | −1.52 (−4.47 to 1.43) | 0.150 |
24 weeks | 5.23 | 2.89 | 6.67 | 3.11 | 1.44 (−1.042 to 3.92) | - | ||
Effect size – within group ( |
0.478 | - | 0.591 | - | - | - | ||
Sample size ( |
13 | - | 12 | - | - | - | ||
Baseline | Beanbag overhead throw test: Left hand | 8.15 | 3.76 | 6.92 | 3.53 | −1.23 (−4.25 to 1.79) | 0.083 | |
24 weeks | 5.38 | 3.15 | 6.67 | 3.37 | 1.29 (−1.4 to 3.99) | - | ||
Effect size – within group ( |
0.635 | - | 0.010 | - | - | - | ||
Sample size ( |
13 | - | 12 | - | - | - | ||
Wuang et al. ( |
Baseline | Upper limb coordination | 8.11 | 1.12 | 7.96 | 1.14 | −0.15 (−0.59 to 0.29) | <0.003 |
24 weeks | 9.32 | 2.44 | 10.62 | 2.64 | 1.3 (0.32 to 2.28) | - | ||
Effect size – within group ( |
1.08 | - | 2.33 | - | - | - | ||
Sample size ( |
53 | - | 52 | - | - | - | ||
Baseline | Bilateral coordination | 10.94 | 8.14 | 10.69 | 6.40 | −0.25 (−3.09 to 2.59) | < 0.003 | |
24 weeks | 14.36 | 9.58 | 15.37 | 9.22 | 1.01 (−2.63 to 4.65) | - | ||
Effect size – within group ( |
0.96 | - | 1.90 | - | - | - | ||
Sample size ( |
53 | - | 52 | - | - | - |
SD, standard deviation; CI, confidence interval; BOT-2, Bruininks–Oseretsky test of Motor Proficiency, Second edition.
This article followed all ethical standards for research without direct contact with human or animal subjects.
To the authors’ knowledge, our study is the first systematic review conducted in English on the effectiveness of VRT, specifically using Nintendo Wii, alone or combined with physiotherapy or occupational therapy, compared with standard physiotherapy or occupational therapy alone or no intervention, on motor proficiency in individuals with Down syndrome. The only literature review that was found was conducted by De Menezes et al. (
The main outcome assessed was motor proficiency, which consists of the following components: balance, strength, coordination and agility. Of the included studies, only Rahman (
Silva et al. (
Other studies carried out by Lin and Wuang (
Strength was assessed by Silva et al. (
Assessment of coordination was carried out by both Silva et al. (
One of the main limitations of the included studies was the inability of the researchers to blind the assessors and participants. The included studies had insufficient descriptions on the exact method of implementation of the interventions. All included studies had a wide variety of games that were available to the participants to choose from. However, none of the studies specified whether the participants were required to play all of the included games or whether they were given the option to choose one. Wuang et al. (
The inclusion criteria of this review led to two major limitations: Firstly, only seven of the studies complied with the inclusion criteria of this review, which may have an effect on the overall validity of the results because of the lack of available evidence. Secondly, articles that were not published in English were automatically excluded, potentially introducing a language bias. Furthermore, this review included only published studies, resulting in a publication bias.
Of the included studies, two were conducted over 24 weeks (Silva et al.
As a result of large difference in intervention periods, it was not possible to pool the data in a meta-analysis. Wuang et al. (
A comprehensive, systematic search strategy was implemented, using nine computerised scientific databases. Also, each step of the review was completed independently by a reviewer and cross checked by another. The six included experimental studies were of high methodological quality ranging from 6/11 to 9/11 on the PEDro scale. The case study scored 6/8 on the JBI Critical Appraisal Checklist for case reports. Another strength of our review is the broad age range of the participants (6–60 years), making the data obtained in our review applicable to a broader population. However, this may have an impact on the validity of the results for our review, as the results are not applicable to a specific age group.
Clinicians are advised that it may be beneficial to use VRT, when available, in addition to standard physiotherapy or occupational therapy interventions for improving agility in individuals with Down syndrome, as it could be a valuable addition to standard physiotherapy or occupational therapy practice. Virtual reality therapy can also be used for balance training in a younger population, specifically children. The advised duration of intervention is 5–24 weeks. However, this relatively expensive electronic device may not be feasible in low- and middle-income countries or low-resource settings. The findings for both strength and coordination are inconclusive.
The evidence of Level II, III-1 and IV does not favour the use of VRT, specifically Nintendo Wii, combined with physiotherapy or occupational therapy, over the use of standard physiotherapy or occupational therapy alone for motor proficiency. However, the results revealed that VRT was effective in improving agility within a five- or 24-week intervention. Furthermore, VRT may be effective in improving the strength within a 6 or 24-week period. Balance showed inconclusive results as a significant improvement was only seen in the child population and not in the adult population. Finally, results were inconclusive for coordination as not all studies showed significant improvements. However, upper limb and bilateral coordination improved significantly within a 24-week period. Further research should focus on frequent intervention sessions with regular follow-up assessments, as well as long-term follow-up, to investigate the carry-over effect of VRT. Although VRT is a valuable tool to include in a physiotherapy programme to increase agility in individuals with Down syndrome, as well as balance in children with Down syndrome, it cannot be used to replace standard physiotherapy. Clinicians are, therefore, advised to use VRT, when available, in addition to standard physiotherapeutic intervention.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them
in writing this article.
J.S., J.C.d.P., C.K., N.M.O., S.S., N.v.W., J.Z. and M.B. contributed equally to this article.
During the completion of this manuscript, Marlette Burger was funded by the South African Medical Research Council through its Division of Research Capacity Development under the National Health Scholarship Programme from funding received from the Public Health Enhancement Fund/South African National Department of Health.
The study’s data are available from the corresponding author, J.S., upon reasonable request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for systematic reviews and meta-analyses.
Section or topic | # | Checklist item | Page # |
---|---|---|---|
Title | 1 | Identify the report as a systematic review, meta-analysis, or both. | 1 |
Structured summary | 2 | Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number. | 2–3 |
Rationale | 3 | Describe the rationale for the review in the context of what is already known. | 6 |
Objectives | 4 | Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS). | 7 |
Protocol and registration | 5 | Indicate if a review protocol exists, if and where it can be accessed (e.g. Web address), and, if available, provide registration information, including registration number. | 6 |
Eligibility criteria | 6 | Specify study characteristics (e.g. PICOS, length of follow-up) and report characteristics (e.g. years considered, language, publication status) used as criteria for eligibility, giving rationale. | 8–9 |
Information sources | 7 | Describe all information sources (e.g. databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched. | 7–8 |
Search | 8 | Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated. | App. B |
Study selection | 9 | State the process for selecting studies (i.e. screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis). | 9–10 |
Data collection process | 10 | Describe method of data extraction from reports (e.g. piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators. | 10 |
Data items | 11 | List and define all variables for which data were sought (e.g. PICOS, funding sources) and any assumptions and simplifications made. | 9 |
Risk of bias in individual studies | 12 | Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis. | 10 |
Summary measures | 13 | State the principal summary measures (e.g. risk ratio, difference in means). | 12 |
Synthesis of results | 14 | Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g. I2) for each meta-analysis. | N/A |
Risk of bias across studies | 15 | Specify any assessment of risk of bias that may affect the cumulative evidence (e.g. publication bias, selective reporting within studies). | N/A |
Additional analyses | 16 | Describe methods of additional analyses (e.g. sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified. | N/A |
Study selection | 17 | Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram. | 10–11 |
Study characteristics | 18 | For each study, present characteristics for which data were extracted (e.g. study size, PICOS, follow-up period) and provide the citations. | 14 |
Risk of bias within studies | 19 | Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). | N/A |
Results of individual studies | 20 | For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot. | 14–17 |
Synthesis of results | 21 | Present results of each meta-analysis done, including confidence intervals and measures of consistency. | N/A |
Risk of bias across studies | 22 | Present results of any assessment of risk of bias across studies (see Item 15). | N/A |
Additional analysis | 23 | Give results of additional analyses, if done (e.g. sensitivity or subgroup analyses, meta-regression [see Item 16]). | N/A |
Summary of evidence | 24 | Summarise the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g. healthcare providers, users, and policymakers). | 18–19 |
Limitations | 25 | Discuss limitations at study and outcome level (e.g. risk of bias), and at review-level (e.g. incomplete retrieval of identified research, reporting bias). | 20–21 |
Conclusions | 26 | Provide a general interpretation of the results in the context of other evidence, and implications for future research. | 18–19 |
Funding | 27 | Describe sources of funding for the systematic review and other support (e.g. supply of data); role of funders for systematic review. | 24 |
The following nine computerised bibliographic databases were accessed and searched through the Stellenbosch Library services: MEDLine, Pubmed, Cochrane Library, PEDro, CINAHL, Science Direct, Scopus, Otseeker and Google Scholar. Stepwise documentation of the search process was done. Each database was independently searched by six researchers, thereby automatically cross-checking them. Each researcher independently identified relevant review titles from the databases and discussed the options with the other researchers. Preliminary searches within each database allowed for the elimination of unnecessary search terms, where the addition of key words did not yield varying results. Keywords included: Down syndrome, trisonomy-21, virtual reality, motor learning, Nintendo Wii, motor proficiency, motor performance, physiotherapy, physical therapy, exercises, physical fitness, functional mobility. The following search strategies for the various databases were developed according to the function of each database:
‘Down Syndrome’ AND ‘Motor Proficiency’
#1 AND ‘Nintendo Wii’
#1 AND ‘Virtual Reality’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Virtual Reality’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Physiotherapy’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Physical Therapy’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Virtual Reality’ AND ‘Physiotherapy’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Virtual Reality’ AND ‘Physical Therapy’
Limits applied to database
Type of search: Advanced search
Publication dates: Inception to April 2018, searches updated June 2018 and June 2020
Publication types: Randomised or non-randomised Controlled/ Clinical Trials or pilot studies
Population: Humans
Language: English
‘Down Syndrome’ AND ‘Motor proficiency’
#1 AND ‘Nintendo Wii’
#1 AND ‘Virtual Reality’
‘Down Syndrome’ AND ‘Virtual Reality’
#1 AND ‘Virtual Reality’ AND ‘Physical therapy’
Limits applied to the database:
Type of search: Simple and advanced search
Publication dates: Inception to April 2018, searches updated June 2018 and June 2020
Publication types: Randomised or non-randomised Controlled/ Clinical Trials or pilot studies
‘Down Syndrome’ AND ‘Motor Proficiency’
#1 AND ‘Nintendo Wii’
#1 AND ‘Virtual Reality’
‘Down Syndrome’ AND ‘Virtual Reality’ AND ‘Physical therapy’
‘Down Syndrome’ AND ‘Nintendo Wii’ AND ‘Physical therapy’
#1 AND ‘Virtual Reality’ AND ‘Physical Therapy’
Limits applied to the database:
Type of search: Simple search
Publication dates: Inception to April 2018, searches updated June 2018 and June 2020
Publication types: Randomised or non-randomised Controlled/ Clinical Trials or pilot studies
‘Down Syndrome’ AND ‘Motor Proficiency’
#1 AND ‘Virtual Reality’
#1 AND ‘Nintendo wii’
#1 AND ‘Virtual Reality’ AND ‘Physiotherapy’
Limits applied to the database:
Type of search: Advanced search
Publication dates: Inception to April 2018, searches updated June 2018 and June 2020
‘Down Syndrome’ AND ‘Motor Proficiency’
#1 AND ‘Nintendo Wii’
#1 AND ‘Virtual Reality’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Nintendo Wii’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Virtual Reality’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Nintendo Wii’ AND ‘Physiotherapy’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Virtual reality’ AND ‘Physiotherapy’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Nintendo Wii’ AND ‘Physical Therapy’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Virtual reality’ AND ‘Physical Therapy’
Limits applied to the database:
Type of search: Advanced search
Publication dates: Inception to April 2018, searches updated June 2018 and June 2020
Publication type: Randomised or non-randomised Controlled/ Clinical Trials or pilot studies
Language: English
Subject Areas: Health Sciences
‘Down Syndrome’ AND ‘Motor proficiency’
#1 AND ‘Nintendo Wii’
#1 ’Virtual Reality’
#1 AND ‘Nintendo Wii’ AND ‘Virtual Reality’
#1 AND ‘Virtual Reality’ AND ‘Physiotherapy’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Nintendo Wii’
‘Down Syndrome’ AND ‘Motor Proficiency’ AND ‘Virtual Reality’
#1 AND ‘Physiotherapy’
#2 AND ‘Physiotherapy’
‘Down Syndrome’
#1 AND ‘Motor Proficiency’
#1 AND ‘Virtual Reality’
#1 AND ‘Nintendo Wii’
#2 AND ‘Virtual Reality’
#5 AND ‘Physiotherapy’
‘Down syndrome’ AND ‘Motor Proficiency’
‘Down syndrome’ AND ‘Virtual Reality’
‘Down syndrome’ AND ‘Nintendo Wii’
#1 AND ‘Virtual Reality’
#1 AND ‘Nintendo wii’
#1 AND ‘Physiotherapy’
Author: Berg et al. Year: 2012 Record Number: 01
Yes | No | Unclear | Not applicable | |
---|---|---|---|---|
Were patient’s demographic characteristics clearly described? | - | □ | X | □ |
Was the patient’s history clearly described and presented as a timeline? | □ | X | □ | □ |
Was the current clinical condition of the patient on presentation clearly described? | X | □ | □ | □ |
Were diagnostic tests or assessment methods and the results clearly described? | X | □ | □ | - |
Was the intervention(s) or treatment procedure(s) clearly described? | X | □ | □ | □ |
Was the post-intervention clinical condition clearly described? | X | □ | □ | □ |
Were adverse events (harms) or unanticipated events identified and described? | X | □ | □ | □ |
Does the case report provide takeaway lessons? | X | □ | □ | □ |
Overall appraisal: Include:
Comments (Including reason for exclusion)
Good takeaway lesson and reinforces the overall message of our systematic review
Description of outcome measures.
Variable | Description |
---|---|
BOT-2 | Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) is similar to the Bruininks–Oseretsky Test of Motor Proficiency-Second Edition (BOT-2). The BOT-2 is a shorter version but still measures the same components as the BOTMP with the same activities. Rahman ( |
Eurofit Test Battery | This is a physical fitness test consisting of numerous domains (Oja & Tuxworth |
Handgrip test | The handgrip strength test is designed to replicate the grip strength required to hold objects such as the wii-remote. The test is completed using a dynamometer that measures grip strength in kilograms (Bechtol |
Standing Broad Jump | Standing broad jump is used to measure explosive leg power. The test is executed with the participant standing behind a line drawn on the floor. The participant then jumps forward from a still standing position and the distance jumped is measured from the starting line to the back of the heels (Glencross |
Beanbag Overhead Throw | The beanbag overhead throw involves throwing a beanbag over the ipsi-lateral shoulder in the direction of a hoop located at the centre of a gymnastic mat. It is performed standing 2 m away from the mat facing away from the mat. This tests spatial orientation and mental rotation (Carmeli et al. 2008). |
Pediatric Balance Scale (PBS) | The Berg Balance Scale has been modified to create the PBS. The PBS is specifically used to assess balance in young children that present with mild to moderate disabilities, and it has already been established that the PBS is a reliable and valid tool for the measurement of balance (Franjoine et al. |
Timed-up-and-go test | This test measures the time it takes for an individual to stand up from an armchair, walk 3 m, turn around, and sit back in the chair again. It was originally developed to measure the functional ability of elderly people who were at risk of falling. The timed-up-and-go test has been proven to be a reliable test when assessing the functional mobility of individuals with Down syndrome. This is a good test to use as it is easily re-producible (Nicolini-Panisson & Donadio |
Five-times-sit-to-stand test | The Five-times-sit-to-stand-test can be used to assess the ability to perform transitional movements and it is a reliable test to use for the measurement of balance (Posiadlo & Richardson |
TGMD-2 | The TGMD-2 is a tool used to identify deficits in gross motor development in children between the age of 3 and 10 years, evaluating 12 skills, grouped into two categories, namely locomotor skills and object control skills (Álvareza et al. |
Pressure Centre | Berg ( |
TGMD-2, Test of Gross Motor Development, Second Edition.