Bonney et al. BMC Pediatrics  (2018) 18:78 
https://doi.org/10.1186/s12887-018-1029-7
RESEARCH ARTICLE Open Access
“Not just another Wii training”: a graded
Wii protocol to increase physical fitness in
adolescent girls with probable
developmental coordination disorder-a
pilot study
Emmanuel Bonney1,2*, Eugene Rameckers3,4, Gillian Ferguson1 and Bouwien Smits-Engelsman1
Abstract
Background: Adolescents with low motor competence participate less in physical activity and tend to exhibit
decreased physical fitness compared to their peers with high motor competence. It is therefore essential to identify
new methods of enhancing physical fitness in this population. Active video games (AVG) have been shown to
improve motor performance, yet investigations of its impact on physical fitness are limited. The objective of this
study was to examine the impact of the graded Wii protocol in adolescent girls with probable Developmental
Coordination Disorder (p-DCD).
Methods: A single-group pre-post design was conducted to assess the impact of a newly developed Wii
protocol in adolescent girls attending school in a low income community of Cape Town, South Africa.
Sixteen participants (aged 13-16 years) with p-DCD (≤16th percentile on the MABC-2 test) were recruited.
Participants received 45 min Wii training for 14 weeks. Outcome measures included the six-minute walk
distance and repeated sprint ability. Information on heart rate, enjoyment and perceived exertion ratings
were also collected.
Results: Significant improvements in aerobic and anaerobic fitness were observed. The participants reported
high enjoyment scores and low perceived exertion ratings. The graded Wii protocol was easily adaptable
and required little resources (space, equipment and expertise) to administer.
Conclusions: The findings provide preliminary evidence to support the use of the graded Wii protocol for
promoting physical fitness in adolescent girls with p-DCD. Further studies are needed to confirm these
results and to validate the clinical efficacy of the protocol in a larger sample with a more robust design.
Keywords: Active video games, Graded Wii protocol, Physical fitness, Probable DCD, Adolescents
* Correspondence: ebonney10@gmail.com
1Department of Health & Rehabilitation Sciences, Faculty of Health Sciences,
University of Cape Town, Cape Town, South Africa
2Department of Physiotherapy, School of Biomedical & Allied Health
Sciences, University of Ghana, Accra, Ghana
Full list of author information is available at the end of the article
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reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 2 of 13
Background on physical fitness in adolescents with DCD has not been
Developmental Coordination Disorder (DCD) is a neurode- determined.
velopmental condition that impairs the development of Providing opportunities for physical activity in adoles-
motor skills and coordination [1]. Children with DCD ex- cent girls with insufficient opportunity (low income
perience difficulty with motor tasks and participate less in community dwellers) [13] is increasingly becoming diffi-
physical activity. The symptoms of DCD track from child- cult. Two main reasons have been provided for this chal-
hood into adolescence [2, 3]. Compared to their typically lenge. First, traditional physical activities are viewed as
developing peers, children and adolescents with DCD ex- physically demanding and are therefore undesirable for
hibit low motor competence and decreased physical fitness, this population. Additionally, engaging in outdoor activ-
and tend to have greater risk for overweight and obesity [4]. ities and sports do not seem appealing due to safety con-
Given that children with DCD experience increased risk of cerns and lack of resources in most low income settings.
developing cardiovascular diseases [4], fitness promotion Secondly, girls with motor problems tend to exhibit
may be a vital preventative strategy for mitigating adverse motor impairments that hinder their participation in
health complications. Although the linkage between phys- everyday tasks. In South Africa, girls are reported to
ical fitness and motor competence is reported to be stron- have high prevalence of overweight and obesity com-
ger in adolescence [5], physical fitness declines from pared to boys. This problem has been partly attributed
childhood to adolescence [6, 7]. Therefore, it is critical to to low motor competence [19]. Also, it is well estab-
identify new ways of boosting physical fitness among ado- lished that during adolescence, several unhealthy habits
lescent populations with motor coordination problems. become entrenched [20], with negative implications for
Lately, the use of active video games in neuromotor re- adult life. Given the significant influence of physical fit-
habilitation is increasingly becoming pervasive. Active ness on health outcomes, developing new interventions
video games (AVGs) are motion-controlled computer that can be implemented to increase physical fitness in
games used to promote physical activity [8]. The Nintendo adolescent populations with DCD is reasonable. Compo-
Wii, used in the present study, consists of a video-based nents of physical fitness such as cardiovascular endur-
console, handheld remote and balance board that allow ance, muscular strength, and anaerobic performance are
the player to interact with the virtual environment via compromised in individuals with motor problems [21,
wireless controller. Players use whole body movements 22] leading to reduced perceived motor competence and
(mostly weight shifting in different directions) and arm withdrawal from physical activity [23]. As motor prob-
gestures to control the game. To enhance the players’ per- lems trail from childhood into adolescence, adolescents
formance, the Wii provides several augmented feedback with low motor competence may struggle with daily ac-
(visual and auditory forms) before, during and at the end tivities, academic work and social roles. Consequently,
of each episode of play [9, 10]. Earlier studies have shown their overall health status may deteriorate if tailor-made
that the Wii elicits improvements in motor coordination interventions are not provided.
and aspects of physical fitness in young children. Smits- Based on earlier findings which sought to suggest
Engelsman et al. [11] evaluated the effectiveness of the that the Wii might improve physical fitness in chil-
Wii in children with DCD and their typically developing dren with DCD [11, 13], this study was set up as an
peers (TD). After 5 weeks, both groups improved on func- initial step to inform a larger randomized controlled
tional strength and anaerobic fitness. This suggests that trial aimed at evaluating the effectiveness of a newly
the Wii might be a useful tool to enhance physical fitness developed Wii intervention (the graded Wii protocol).
in individuals with low motor competence. In another Therefore, the primary purpose of the study was to
study, the authors investigated the effects of the Wii on examine the impact of the graded Wii protocol in
motor and psychological outcomes in children [12]. The adolescent girls with probable DCD. Specifically, we
children demonstrated improvements in motor profi- investigated the effects of the graded Wii protocol on
ciency and emotional well-being. In contrast, a recent aerobic and anaerobic fitness. To accomplish this, the
study revealed that the Wii offers lesser benefits in motor following were assessed;
proficiency, cardiorespiratory fitness and functional
strength [13]. Also, it has been established that the Wii (1)changes in performance on field-based aerobic and
can be implemented as an adjunct for treating children anaerobic fitness tests
with developmental delay [14] and those with motor co- (2)experiences of adolescent girls during the training
ordination deficits [15]. There is growing evidence to sup- sessions
port the use of the Wii for balance control training in (3)exercise intensity during the training sessions
children and adults with motor problems [16, 17]. Though (4)the ease of implementation of the protocol as
active video games have been found to increase total body reported by the supervising therapists and
movement in adolescents [18], the impact of these games (5)injury occurrence during the training sessions.
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 3 of 13
Methods physiotherapists with experience in exergames rehabili-
Design tation. The protocol incorporated the Newell’s con-
The study was a single group pre-post design. In South straints theory [32, 33] and exercise progression
Africa, the prevalence of overweight and obesity is principles [34, 35]. Specifically, the Wii games that had
higher in females than males, especially among those liv- the tendency to stimulate the cardiovascular system for
ing in low income communities [24]. Compared to boys, positive benefits in strength and conditioning were se-
girls exhibit low motor competence more often [19]. For lected by two experienced independent assessors. A
this reason, 16 girls aged 13-16 years, attending a local third person also re-evaluated all the selected games and
school in a low income community of Cape Town, South developed the protocol (the graded Wii) to consist of
Africa, were recruited. The school serves underprivileged various combinations of games and their adaptations.
black communities and is primarily attended by children Two main criteria were adopted for game selection and
of black South Africans (100%) who share similar socio- evaluation; (1) games should require whole bodily move-
economic status. Parents and participants gave written ment to control the avatar (2) games should be amen-
informed consent before involvement. The informed able to progressive external modifications without
consent process varied according to age. Essentially, the limiting playability. Backpacks with sandbags (which
content of the consent forms used was somewhat similar weighed 1 kg & 3 kg) and wooden platforms (25 cm
for both the parents and children. But the written ex- high) were used to externally change the physical
pression and structure were aligned to the children’s demands of the games. These items were used to pro-
cognitive abilities to facilitate comprehension. Inclusion gressively increase the level of challenge and physio-
criteria included a score ≤ 16th percentile on the Move- logical load over the training period. Each participant
ment Assessment Battery for Children 2nd edition was required to play 8 games for 45 min per session,
(MABC-2) test [25] (Criterion A). Participants did not once weekly for 14 weeks. For each training session, the
report any medical condition (including cerebral palsy participants were required to play different variation of
and epilepsy) known to affect motor performance and games chosen from the 4 available game categories (aer-
were at a mainstream high school confirming the ab- obics, balance, muscle workout and yoga). A detailed
sence of intellectual or cognitive impairment (Criterion scheme of the protocol is provided in Table 4 in Appen-
D). Also, the participants had normal IQ and good or dix. During Weeks 1 to 5, the participants were
corrected vision. It has been suggested that the term instructed to familiarize themselves with the selected
DCD should be used to refer to individuals with motor games; hence no alterations were introduced throughout
coordination problems that satisfy all the diagnostic cri- this period. From Week 6 to 14, gameplay was gradually
teria stipulated in the Diagnostic and Statistical Manual adjusted to increase the physiological load. This was
of Mental Disorders, Fifth Edition (DSM-V) [26–28]. In done through the use of backpacks filled with weights
this study, our sampled participants exhibited motor co- (1 kg at the midpoint and 3 kg towards the end of the
ordination deficits, but we could not confirm all the training period) and a 25 cm high wooden platform. The
DSM-V diagnostic criteria and so we decided to refer to training was delivered to a maximum of six participants
them as having probable DCD (p-DCD) [29, 30]. simultaneously in an enclosed room. Six Wii consoles
Ethical approval for the study was granted by the and TVs were arranged and partitioned so that partici-
Human Research Ethics Committee of the University pants were not distracted by other players. Each session
of Cape Town (HREC REF: 232/2016) and permission was supervised by physical therapy and human move-
was obtained from the school’s principal. The esti- ment science students.
mated sample size was determined using previous Prior to each session, participants received brief
data [31]. Based on this information, it was estab- orientation of the Wii games. The supervisors used
lished that 16 participants were needed to detect a the orientation period to introduce the games for the
difference between pre and post training measures session and to encourage the participants to fully
with power of 0.8 and effect size of 0.7. Outcome engage with the protocol to gain positive benefits in
measures were assessed at baseline and at the end of physical fitness. Also, the orientation segment
the training period. None of the participants had afforded the participants unique opportunity to ask
prior Wii experience and no participant played any of questions regarding aspects of the protocol that were
the Wii games outside the training hours. unclear and to report any technical difficulties with
the set up.
Intervention
The graded Wii protocol was developed from commer- Measurements
cially available Wii games selected from the Nintendo Demographic data including age, grade and hand
Wii system. The protocol was created by qualified preference were collected from each participant.
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 4 of 13
Also, BMI and physical activity data (number of days Bland-Altman plot that there was no significant learn-
in which participants were physically active for ing effect between the first and second trials. In the
30 min or more) were collected. Assessments were same paper, the measurement error was found to be
done in the school’s playground by two groups of in- 16.8 W with an estimated SDD of 33 W.
dependent assessors at pre and post intervention.
The second group of assessors was blinded to the Heart rate
pretest scores. Participants’ perceived exertion, heart The American College of Sports Medicine recom-
rate and enjoyment ratings were monitored during mends that individuals with chronic diseases and dis-
the training and at the end of each session. Injuries abilities achieve moderate intensity physical activity
that occurred during the training were also recorded. (40-70% of maximal HR) for improved cardiorespira-
Each supervisor was interviewed to share his or her tory fitness [41]. To monitor exercise intensity during
experiences regarding the organization of the the training sessions, participants wore Polar heart
protocol. rate monitors (Polar S810) across their chest accom-
panied by wristwatches. The Polar S810 has good ac-
Physical fitness, heart rate, perceived exertion, enjoyment curacy compared to ambulatory [42] and supine ECG
and experiences of supervisors [43]. Participants’ resting heart rate (HR) and peak
Physical fitness heart rate were recorded. Resting heart rate was re-
The six-minute walk test (6MWT) was used to corded in sitting (3-5 min) whereas peak heart rate
evaluate the aerobic fitness of the participants. The was recorded in the course of play. Estimated max-
test was chosen because it uses everyday functional imum heart rate based on resting HR and partici-
activity (walking), and has been extensively used in pants’ age was also calculated using the formula
studies involving children and adolescents. Also, it is derived by Gulati [44]: Estimated maximum Heart
known to be safe, easy to perform and highly accept- rate (HRmax) = 206 − (0.88 × age).
able to children [36]. It provides a valid and inex- Lastly, we calculated the percentage of the esti-
pensive means to measure functional capacity in mated HR reached during the training to check if
children [37–39]. The 6MWT measures aerobic fit- individual peak HR was above the recommended
ness across all ages. The test was executed according level.
to recommended protocol [36] over a 20 m distance
walkway. During the test, each participant was Perceived exertion
instructed to cover much distance in 6 min. How- Table 1 shows the Borg’s Rating of Perceived Exertion
ever, they were allowed to rest if they wished and (RPE) scale that was used to measure the participants’
continued when they were ready to do so [37–39]. perceived exertion. The scale consists of numerical
Two trials were performed on the same day with a values (6-20, where 6 means “no exertion at all” and
30-min rest between trials and the mean score is re-
ported in this paper. Test-retest reliability of the Table 1 Borg’s Rate of Perceived Exertion (RPE) Scale
6MWT is high [ICC 0.94 (95% CI = 0.89–0.96)] in Rate of Perceived Exertion (RPE) Scale
healthy children indicating high reliability, and the 6
Smallest Detectable Difference (SDD) is estimated to
7 Very very light
be 50 m [36].
In addition, the Muscle Power Sprint Test (MPST) 8
was used to assess anaerobic fitness. The MPST in- 9 Very light
volved the completion of six 15 m sprints at max- 10
imum speed with 10 s rest interval. The test took 11 Fairly light
place on a 15 m level ground at the school’s soccer 12
field. Each participant’s sprint time was recorded
13 Somewhat hard
using stopwatches in milliseconds [11]. Based on the
time and weight of the participant, the mean power 14
(Watts) over 6 repetitions was calculated. Greater 15 Hard
mean power indicates the ability to maintain power 16
output over time and translates into better mainten- 17 Very hard
ance of anaerobic performance. The mean power of 18
the MPST demonstrated an ICC of 0.90 (95% CI =
19 Very very hard
0.85-0.99) for test-retest reliability in this age group
[40]. Steenman and colleagues [40] showed with a 20 Maximum exertion
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 5 of 13
20 means “maximal exertion”), and expresses one’s Next we calculated single-group, pretest–posttest raw
subjective feeling regarding the intensity of an exer- score effect size [47]; A standardized mean difference
cise programme. The tool is reported to be valid and was calculated by subtracting the mean of the scores at
reliable [45]. posttest from the mean at pretest and dividing this raw
mean difference by the standard deviation of the scores
Enjoyment rating scale at the first time point. The magnitude of the effect size
Since enjoyment is an important motivator, the Enjoy- was interpreted using the conventions of Cohen: small =
ment rating scale, was used to measure the participants’ 0.2, medium = 0.5 and large = 0.8 [48]. To compensate
enjoyment experienced during the training sessions. The for test-retest bias, we looked at the individual change
scale uses 5 smiley faces with numeric scores (0-4, 0 and reported the number of children that improved
means boring; 4 is awesome) to assess how much the more than the SDD on the 6MWT and MPST. All statis-
participants enjoy playing the Wii games at any given tical analyses were performed with SPSS (SPSS Inc.,
time. The Enjoyment rating scale used in this study has version 23).
been adequately described elsewhere [16]. It was hypoth-
esized that the harder the level of challenge, the less Results
enjoyable participants would find the games. Baseline characteristics of participants
The mean age of the participants was (14.5 ± 1.0 years,
range 13-16 years). The mean weight and BMI was
The supervisors’ experiences (68.1 ± 18.5 kg) and (27.5 ± 7.3 kg/m2) respectively.
At the end of the training period, each supervisor was Eleven were classified as “at risk of DCD” and five had
requested to share their experiences regarding the “definite motor impairments” on the MABC-2 test
organization and delivery of the protocol. Also, they (Mean TSS ± SD: 62.8 ± 5.6; Range: 48-69) [25]. The me-
were asked to report on technical difficulties associated dian reported days that the participants were physically
with the administration of the protocol. Additionally, active for 30 min or more was 3. Only 3 out of the 16
injuries that occurred during the training sessions were reported to be active for 30 min every day. All the par-
monitored and recorded. ticipants scored below the 5th percentile on the 6MWT
(mean walking speed 1.13 m/s ± 0.19) [49]. Nine per-
Data analysis ceived themselves as being low motor skilled and all
Data were checked for normality using the reported their willingness to be more active.
Kolmogorov-Smirnov test and appropriate analyses
are reported. Mean and standard deviation (SD) are Participants’ characteristics during training sessions
reported for age, height, weight, and BMI, and pretest As shown in Fig. 1, the average peak HR was (148.1 ±
values on the MABC-2 test. To estimate the intensity 23.4) beats per minute (bpm) and the mean increase in
of the training, averages of the RPE, and peak HR HR per training computed from the difference in resting
over 14 sessions are reported. Also, enjoyment over HR and peak HR values was 48.3 ± 24.6 bpm. The esti-
the 14 sessions was assessed. The individual Peak HR mated max HR was 193.3 ± 0.78 bpm. The measured
was compared to the percentage of the estimated mean peak HR over all sessions reached 74.9% (SD:
maximum HR. Next, correlation between Peak HR 13.1) of the estimated max HR (Fig. 2). Of all the HR
and RPE and between Peak HR and enjoyment scores
was determined to ascertain if greater exertion made
playing the games less fun. Also, we tested if the aer-
obic fitness (six-minute walk distance) changed be-
tween pre and posttest using a paired t-test. To test
if anaerobic fitness and susceptibility to fatigue chan-
ged, the 6 runs of the 15 m sprint test were analyzed
using a repeated measure ANOVA with runs (6 repe-
titions) and time of measurement (pre post) as within
subject factors at p < 0.05. Since fatigue index or the
percentage decrement score is believed to be a valid
indicator of anaerobic capacity, we also calculated the
percentage decrement score using the recommended
formula [46]. The percentage decrement score quanti-
fies fatigue by comparing actual performance to an Fig. 1 Participants’ resting HR, Peak HR and perceived exertion (RPE ×
10) during the 14 sessions. Note: Error bars indicate Standard Error
imagined ‘ideal performance’.
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 6 of 13
1.11; 6MWD2; pre 401 ± 65.0, post 509 ± 34.0, t = − 5.18,
p < 0.001, d = 2.08). Respiratory rate (RR) in the posttest
increased (t = − 5.88, p < 0.001) compared to the pretest
during the first trial of the 6MWT. No differences in HR
(p = 0.167 and p = 0.736) or RPE (p = 0.089 and p = 0.743)
between pre and posttest was found for both test occa-
sions (For means see Table 3). The test was not terminated
prematurely for any participant.
The 15 m sprint time decreased by 10%; from
(4.32 ± 0.68 s) to (3.89 ± 0.47 s) (F (1, 15) 4.56, p =
0.05, η2 = 0.23) (Fig. 4). No main effect of repetition
Fig. 2 Percentage of the estimated maximum heart rate (EMHR) was found, indicating that repeated sprints did not
reached across 14 sessions. Note: Error bars indicate Standard Error lead to poorer (or better) performance. The inter-
and Red line represents target EMHR of 60% action effect with number of sprints and time of
testing was also not significant. Moreover, no signifi-
readings, 88.1% were above the 60% level and 61.9% cant difference was found in the percentage decre-
above the 70% level. This confirms that in most cases an ment score between pre and post test (Mean 15.67 ±
adequate maximum level of intensity was reached. 9.58 and 18.67 ± 17.2 for pre and post, respectively; t
Overall, the participants liked the training (Fig. 3). (1, 15)-0.60; p = 0.56). Generally, the participants did
The mean enjoyment score was 3.5 ± 0.75 (Median: not slow down much upon repeated trials and this
4). 58.6% rated the training as awesome, 30.5% as was similar in pre and posttest (Fig. 4).
fun, 8.6% as a bit of fun and 2.4% as boring. Interest-
ingly, there was no correlation between the peak HR
Individual change
and enjoyment scores.
Of the 16 children, 11 improved more than the SDD of
The mean RPE was 9.93 ± 2.85 (Median: 9). 46.2%
the 6MWT whereas 12 improved more than SDD of the
of all the ratings were at least 11 or more whereas
Mean Power produced from the MPST data.
8.6% reported 13 or more. Because of the skewed dis-
tribution of the enjoyment scores, we tabulated the
percentage of choices of the enjoyment scale against Experiences of supervisors
the RPE ratings. It can be noticed that low and high Regarding the training supervisors’ experience, all re-
intensity ratings could either be felt as awesome or ported that when equipment is available, it is simple
boring (Table 2). to administer the graded Wii protocol. They also re-
No correlation was found between Peak HR and the vealed that it required little space and minimal tech-
RPE. Low non-parametric correlations (rs = 0.12, p = nical expertise. The supervisors suggested that for
0.008) were seen between the increase in HR during the the training to be effective, it is important to explain
training and RPE. the aim of a gaming session, and to establish good
rapport with the participants. Provision of positive
Comparison of physical fitness outcomes (pre and post) verbal feedback (Knowledge of Performance) was
After the training, the recorded six-minute walk distance also highlighted as critical for successful perform-
(6MWD) was longer (≥20%) in both trials (6MWD1; pre ance. Lastly, no injury was recorded during the
409 ± 66.9 m, post 481 ± 63.0 m, t = − 3.26, p = 0.005, d = training.
Fig. 3 Enjoyment of games played by participants over 14 sessions
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 7 of 13
Table 2 Values for ratings of perceived exertion (RPE) and enjoyment scale
RPE 6 7 8 9 10 11 12 13 15 16 17
Enjoyment- boring 0 0 0 0 0 1 0 3 0 0 1 5
Enjoyment- a bit of fun 0 1 1 3 0 3 0 6 2 0 2 18
Enjoyment- Fun 11 9 2 9 3 15 2 8 4 0 1 64
Enjoyment- Awesome 14 24 3 31 2 29 0 12 5 1 2 123
Total 25 34 6 43 5 48 2 29 11 1 6 210
Abbreviation: RPE ratings of perceived exertion
Discussion out, one being test-retest effects. However, the tests
This pilot study was designed to examine the impact used have high test-retest reliability; the reported
of the graded Wii protocol on aspects of physical effect sizes are moderate to large. To our knowledge,
fitness in adolescent girls with p-DCD. While the there is only one intervention study that has used
usefulness of AVGs has been demonstrated in chil- the 6MWT and has reported effect sizes of a non-
dren with DCD, its impact on physical fitness re- treatment control group [29]. The reported effect
mains unknown. The study involved a sample of size of 0.12 in that study is much smaller than the
physically unfit girls with low motor competence. 1.11 and 2.08 in the present study. Moreover, most
Besides, the girls had limited opportunities to par- children improved beyond the Smallest Detectable
ticipate in physical activity. This could be due to Change. Nevertheless, we cannot exclude other
cultural and environmental challenges such as lack explanations for the observed changes. Therefore,
of facilities, poor weather conditions and unsafe further investigations with control groups are
neighborhoods. required to confirm the outcomes of the present
Generally, we have demonstrated that the collective study. Indeed, if a protocol of this nature could elicit
experience of the girls during the training sessions individual changes in aerobic and anaerobic fitness,
was positive (fun to awesome) and that they reached then it could be considered as a viable alternative
the required 60-70% estimated peak HR. More im- for physical education programmes in schools where
portantly, there were significant improvements in physical educators are in short supply. The protocol
walking distance and sprint time, an indication of in- can also be implemented in less-endowed communi-
creased physical fitness. Additionally, the graded Wii ties to promote physical activity and fitness, as
protocol was easy to administer even with little re- fitness programmes are often not available in such
sources. This suggests that the Wii protocol might settings.
probably be useful for promoting fitness in situations Although the graded Wii protocol was adjudged en-
where it is impossible or unsafe for people to engage tertaining and enjoyable, it created sufficient challenge
in outdoor activities or sports. Given the fact that for improved outcomes among the participants. This
no control group was used in our design, other ex- suggests that the Wii games could be manipulated to
planations for the observed changes cannot be ruled provide adequate intensity for health benefits, without
Table 3 Pre and post mean scores of outcomes
Variables Pre Post t, or P-value
(Mean ± SD) (Mean ± SD) F value (df = 15)
Six minute walk distance trial 1(m) 409 ± 66.9 481 ± 63.0 −3.26 0.005
Respiratory rate (breaths per minute) 92 ± 12.9 126.1 ± 21.2 −5.88 0.001
Heart rate (bpm) 123.7 ± 17.6 133.5 ± 22.1 −1.45 0.167
Rate of Perceived Exertion (#) 9 ± 2.6 10.2 ± 2.2 −1.82 0.089
Six minute walk distance trial 2 (m) 401 ± 65.0 509 ± 34.0 −5.18 0.001
Respiratory rate (breaths per minute) 94.8 ± 13.4 99.8 ± 31.9 −0.58 0.569
Heart rate (bpm) 126.8 ± 21.6 129.3 ± 18.7 −0.34 0.736
Rate of Perceived Exertion (#) 8.4 ± 2.3 8.7 ± 2.2 −0.33 0.743
Mean 15-m sprint time (s) 4.32 ± 0.68 3.89 ± 0.47 4.56 0.005
Mean power (Watts) 221.2 ± 101.9 341.3 ± 166.7 −2.69 0.017
Abbreviations: m metre, # number, s seconds, bpm beats per minute
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 8 of 13
physiological load of the games. These loads (back-
packs) provided some kind of resistance and
increased the strength of the muscles of the legs.
The wooden blocks elevated the balance board and
eventually raised the participants’ base of support.
Thus, increasing the task constraints regarding their
step-up pattern and balance control.
Though this study provides preliminary evidence to
support the adaptation of the Wii games to increase
measures of physical fitness, there are several limita-
tions that should be recognized. The major limita-
Fig. 4 Running time before (pre) and after (post) training for the 6 tion of this study is the lack of a control group. The
repetitions of the 15 m sprint. Note: Error bars indicate lack of a control group makes the present study
Standard Error vulnerable to threats of internal validity. It was prac-
tically impossible to include a control group due to
the insufficient number of participants and other
reducing the players’ motivation and enjoyment. The ethical concerns. We recommend that future studies
introduction of add-ons (such as backpacks with should consider the inclusion of controls when
weights) produced competitive stimulus and increased assessing the effects of the graded Wii protocol in a
the participants desire to succeed and might explain much larger sample. Another limitation is the use of
the observed changes in HR. While the RPE was low peak HR as indicative of training intensity. Mean HR
for the participants, their peak HR was higher than and time above 60-70% max HR would be more
the required estimated peak HR. Importantly, exercise appropriate indicators of training intensity. In the
intensity was considered adequate enough to improve present study we could not record HR continuously
the physical fitness indicators assessed in the present over an entire training session. It would be useful to
study. employ a more appropriate measure to estimate the
The perception of exertion was low for a greater training intensity in future research. Given that it
proportion of the girls. Robert et al. [41] reported has been shown that intervention works in children
much higher perceived exertion ratings among with DCD [50] it could be unethical to have a non-
children with cerebral palsy. This disparity could be treatment control group, and therefore a cross-over
attributed to the differences in the nature of games, design might be valuable. Research on the effects of
level of motor impairments and level of maturity the graded Wii protocol on age and gender should
(differences in age). In that study, younger children be considered in future works. Also, investigations of
(7-12 years) played only jogging and bicycling games. the impact of the graded Wii protocol in individuals
These two games exert the cardiorespiratory systems with and without co-occurring disorders and in pop-
and given that children with cerebral palsy have ulations with neurodevelopmental disorders such as
reduced cardiorespiratory fitness, we expect their Cerebral palsy, intellectual disabilities and Autism
perception of exertion to be much higher than our Spectrum Disorder is recommended. Studies that
sample that played a mix of aerobics, balance, would increase the training frequency to 2 or 3
strength and yoga games. times per week may yield greater outcomes. Lastly,
The exercise intensity was relatively high and elic- the impact of the graded Wii protocol on activity
ited significant improvements in both aerobic and levels, motor skills and perceived competence might
anaerobic fitness. This finding does not conform to be worth considering.
previous reports by Nitz et al. [9]. In their study,
cardiovascular endurance did not yield any improve- Conclusions
ments in women (aged 30-58 years) who had two Based on the findings of this study, it can be concluded
30 min training per week for 10 weeks. Several that the graded Wii protocol could be implemented to
reasons could explain this discrepancy. Firstly, our increase important components of physical fitness in
participants are much younger and had lower levels adolescent girls with probable DCD. Since the partici-
of motor coordination, physical activity and fitness. pants found the games enjoyable even in the midst of all
Also, the intensity of the protocol (a product of the adaptations, the protocol could be easily used to
time, frequency and game difficulty) was higher than stimulate physical activity and to promote fitness in
what was reported. In the present study, extra loads sedentary individuals who have little or reduced motiv-
were progressively added to increase the ation to exercise.
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 9 of 13
Appendix
Table 4 Details of the graded Wii protocol administered over 14 sessions
Week # Names of Number of Game adaptations
the selected repetitions
games per session
1 Jogging (short 2 Familiarization phase.
distance) No add-on
Single leg extension 10
Lunge 1
Hula hoop 1
Soccer heading 1
Ski slalom 1
Warrior 1
Half moon 1
2 Jogging (short 2 Familiarization phase.
distance) No add-on
Hula hoop 2
Rowing squat 1
Torso twist 1
Penguin slide 1
Perfect 10 1
Obstacle course 1
Sun salutation 1
3 Jogging (short 2 Familiarization phase.
distance) No add on
Rhythm cycling 2
Single leg twists 10
Jack knife 1
Boxing 1
Penguin slide 1
Table tilt 1
Warrior 1
4 Jogging (short 2 Familiarization phase.
distance) No add on
Basic steps 2
Lunge 1
Rowing squat 10
Boxing 1
Soccer heading 1
Penguin slide 1
Half moon 1
5 Jogging (short 2 Familiarization phase.
distance) No add on
Island cycling Short 2
Basic steps 10
Single leg extension 1
Torso twists 1
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 10 of 13
Table 4 Details of the graded Wii protocol administered over 14 sessions (Continued)
Week # Names of Number of Game adaptations
the selected repetitions
games per session
Ski slalom 1
Perfect 10 1
Sun salutation 1
6 Jogging (Long 2 The games were graded
distance) by making participants
carry a backpack with
Hula hoop 2 1 kg load while gaming.
Rowing squat 2 The height of the balance
board remained unchanged.
Single leg twist 10
Obstacle course 2
Penguin slide 2
Half moon 2
Tree 2
7 Jogging (Long 2 The games were graded
distance) by making participants
carry a backpack with 1 kg
Basic steps 2 load while gaming. The
Kung Fu 2 height of the balance board
remained unchanged.
Single leg extension 10
Table tilt 2
Soccer heading 2
Warrior 2
Half moon 2
8 Jogging (Long distance) 2 The games were graded by
making participants carry a
Basic steps 2 backpack with 1 kg load
Rowing squat 2 while gaming. The height
of the balance board
Single leg twist 10 remained unchanged.
Penguin slide 2
Obstacle course 2
Tree 2
Palm tree 2
9 Jogging (Long 2 The games were graded
distance) by making participants
carry a backpack with
Hula hoop 2 1 kg load while gaming.
Rhythm boxing 2 The height of the balance
board remained
Single leg extensions 10 unchanged.
Lunge 2
Sun salutation 2
Palm tree 2
Just Dance 1 song
10 Jogging (Long 2 The games were graded
distance) by making participants
carry a backpack with
Hula hoop 2 1 kg load while gaming.
Torso twists 2 The height of the
balance board remained
Table tilt 2 unchanged.
Ski slalom 2
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 11 of 13
Table 4 Details of the graded Wii protocol administered over 14 sessions (Continued)
Week # Names of Number of Game adaptations
the selected repetitions
games per session
Sun salutation 2
Half moon 2
Just Dance 3 songs
11 Jogging Long 2 The load was increased
from 1 kg to 3 kg. Each
Step Basics 2 participant carried the
Kung Fu 2 new load (3 kg) during
gameplay. Also, the height
Rowing squat 2 of the balance board
Single leg extension 20 was raised with a 25 cm
high elevation (wooden
Obstacle course 2 platform).
Half moon 2
Just Dance 5 songs
12 Jogging (Long 2 The load was increased
distance) from 1 kg to 3 kg. Each
participant carried the
Step Basics 2 new load (3 kg) during
Rhythm boxing 2 gameplay. Also, the height
of the balance board was
Rowing squat 20 raised with a 25 cm high
Soccer heading 2 elevation (wooden
platform).
Ski slalom 2
Half moon 2
Just Dance 5 songs
13 Jogging (Long 2 The load was increased
distance) from 1 kg to 3 kg. Each
participant carried the
Basic steps 2 new load (3 kg) during
Single leg extension 20 gameplay. Also, the
height of the balance
Lunge 2 board was raised with
Penguin slide 2 a 25 cm high elevation
(wooden platform).
Tree 2
Palm tree 2
Just Dance 5 songs
14 Jogging Long 2 The load was increased
from 1 kg to 3 kg. Each
Step basics 2 participant carried the
Single leg twist 20 new load (3 kg) during
gameplay. Also, the
Table tilt 2 height of the balance
Kung Fu 2 board was raised with
a 25 cm high elevation
Sun salutation 2 (wooden platform).
Half moon 2
Just Dance 5 songs
Bonney et al. BMC Pediatrics  (2018) 18:78 Page 12 of 13
Abbreviations 2. Cantell M, Crawford SG, Doyle-Baker PK. Physical fitness and health indices
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CI: Confidence interval; DCD: Developmental coordination disorder; DSM- 3. Kirby A, Sugden D, Beveridge S, Edwards L. Developmental co-ordination
V: Diagnostic and statistical manual of mental disorders, Fifth Edition; disorder (DCD) in adolescents and adults in further and higher education.
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IQ: Intelligence quotient; MABC-2: Movement Assessment Battery for 4. Philips NE, Chirico D, Cairney J, Hay J, Faught BE, O’Leary DD. Arterial
Children second edition; MPST: Muscle power sprint test; p-DCD: probable stiffness in children with and without probable developmental coordination
Developmental Coordination Disorder; RPE: Rating of perceived exertion; disorder. Res Dev Disabil. 2016;59:138–46.
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Authors’ contributions functional strength, anaerobic fitness, balance and agility in children with
EB, GF and BS conceived the design of the study. EB and BS participated in and without motor coordination difficulties living in low-income
data collection and analysis. EB wrote the first draft of the manuscript. ER communities. Hum Mov Sci. 2016;55:327–33.
and GF were involved in the training of research assistants and contributed 12. Hammond J, Jones V, Hill EL, Green D, Male I. An investigation of the
to preparation of the manuscript. BS and EB analysed and interpreted all the impact of regular use of the Wii fit to improve motor and psychosocial
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Authors’ information 13. Ferguson GD, Jelsma D, Jelsma J, Smits-Engelsman BC. The efficacy of two
EB is a doctoral candidate at the Department of Health & Rehabilitation task-orientated interventions for children with developmental coordination
Sciences, University of Cape Town. ER is a lecturer and a rehabilitation expert disorder: Neuromotor task training and Nintendo Wii fit training. Res Dev
from the Netherlands. GF is a senior lecturer at the Department of Health & Disabil. 2013;34(9):2449–61.
Rehabilitation Sciences, University of Cape Town and is a co-supervisor to 14. Salem Y, Gropack SJ, Coffin D, Godwin EM. Effectiveness of a low-cost
the first author. BS is a professor at the Department of Health & Rehabilita- virtual reality system for children with developmental delay: a preliminary
tion Sciences, University of Cape Town and is the primary supervisor of the randomised single-blind controlled trial. Physiotherapy. 2012;98(3):189–95.
first author. 15. Ashkenazi T, Weiss PL, Orian D, Laufer Y. Low-cost virtual reality intervention
program for children with developmental coordination disorder: a pilot
Ethics approval and consent to participate feasibility study. Pediatr Phys Ther. 2013;25(4):467–73.
The study was approved by the Human Research Ethics Committee of the 16. Jelsma D, Geuze RH, Mombarg R, Smits-Engelsman BC. The impact of Wii fit
University of Cape Town. Both parents and participants provided written intervention on dynamic balance control in children with probable developmental
informed consent before participation. The consent process varied according coordination disorder and balance problems. Hum Mov Sci. 2014;33:404–18.
to age. 17. Pompeu JE, dos Santos Mendes FA, da Silva KG, Lobo AM, de Paula OT,
Zomignani AP, Piemonte ME. Effect of Nintendo Wii™-based motor and
Consent for publication cognitive training on activities of daily living in patients with Parkinson's
Not applicable. disease: a randomised clinical trial. Physiotherapy. 2012;98(3):196–204.
18. Maddison R, Mhurchu CN, Jull A, Jiang Y, Prapavessis H, Rodgers A. Energy
Competing interests
expended playing video console games: an opportunity to increase
The authors declare that they have no competing interests.
children’s physical activity? Pediatr Exerc Sci. 2007;19(3):334–43.
19. Truter L, Pienaar AE, Du Toit D. The relationship of overweight and obesity
Publisher’s Note to the motor performance of children living in South Africa. S Afr Fam Pract.
Springer Nature remains neutral with regard to jurisdictional claims in 2012;54(5):429–35.
published maps and institutional affiliations. 20. Ortega FB, Ruiz JR, Castillo MJ, Sjostrom M. Physical fitness in childhood and
adolescence: a powerful marker of health. Int J Obes (London). 2008;32(1):1–11.
Author details 21. Hands B. Changes in motor skill and fitness measures among children with
1Department of Health & Rehabilitation Sciences, Faculty of Health Sciences, high and low motor competence: a five-year longitudinal study. J Sci Med
University of Cape Town, Cape Town, South Africa. 2Department of Sport. 2008;11(2):155–62.
Physiotherapy, School of Biomedical & Allied Health Sciences, University of 22. Hands B, Larkin D, Parker H, Straker L, Perry M. The relationship among
Ghana, Accra, Ghana. 3Adelante Centre of Expertise in Rehabilitation and physical activity, motor competence and health-related fitness in 14-year-
Audiology, Hoensbroek, the Netherlands. 4Department of Functioning and old adolescents. Scand J Med Sci Sports. 2009;19(5):655–63.
Rehabilitation, Maastricht University, Maastricht, the Netherlands. 23. Bouffard M, Watkinson EJ, Thompson LP, Dunn JL, Romanow SK. A test of
the activity deficit hypothesis with children with movement difficulties.
Received: 30 January 2017 Accepted: 29 January 2018 Adapt Phys Act Q. 1996;13(1):61–73.
24. Monyeki MA, Neetens R, Moss SJ, Twisk J. The relationship between body
composition and physical fitness in 14 year old adolescents residing within
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