Document Type : Original Research


Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran



Background: Many studies have investigated ankle sprain injury and it has been reported that in 80% of cases, ankle sprains lead to functional ankle instability (FAI). The conventional exercises for FAI rehabilitation neglect the associated neurocognitive dysfunction.
Objective: This study aims to evaluate the effect of Wii Fit Plus as a virtual reality training on neurocognitive function in athletes with FAI compared to athletes without FAI.
Material and Methods: In this matched randomized clinical trial study, 25 athletes with unilateral FAI and 25 athletes without FAI were assigned to two groups randomly: 1) the intervention group, subjects performed the Wii training including balance and strengthening games three times a week for 12 sessions and 2) subjects in the control group received no intervention. Before and after the training, the neurocognitive function was assessed through the computerized-reaction time test based on the detection or identification of ‘X’ mark on a computer monitor. Between-groups and within-group comparisons were done by the independent T-test and paired T-test, respectively.
Results: A significant difference was observed in mean differences of neurocognitive function between athletes with and without FAI. Comprising before and after training was significant in the intervention group. 
Conclusion: Based on the results, the information-processing speed of athletes with FAI increased after the training, utilized for rehabilitation protocols.


Mohammad-Reza Hadian (Google Scholar)


  1. Brinkman RE, Evans TA. History of ankle sprain as a risk factor of future lateral ankle sprain in athletes. J Sport Rehabil. 2011;20(3):384-8. doi: 10.1123/jsr.20.3.384.
  2. Akbari M, Karimi H, Farahini H, Faghihzadeh S. Balance problems after unilateral lateral ankle sprains. J Rehabil Res Dev. 2006;43(7):819-24. doi: 10.1682/JRRD.2006.01.0001.
  3. Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med. 1994;28(2):112-6. doi: 10.1136/bjsm.28.2.112.
  4. Buchanan AS, Docherty CL, Schrader J. Functional performance testing in participants with functional ankle instability and in a healthy control group. J Athl Train. 2008;43(4):342-6. doi: 10.4085/1062-6050-43.4.342. PubMed PMID: 18668180. PubMed PMCID: PMC2474827.
  5. Hutchison M, Comper P, Mainwaring L, Richards D. The influence of musculoskeletal injury on cognition: implications for concussion research. Am J Sports Med. 2011;39(11):2331-7. doi: 10.1177/0363546511413375.
  6. Luoto S, Taimela S, Hurri H, Aalto H, et al. Psychomotor speed and postural control in chronic low back pain patients: a controlled follow-up study. 1996;21(22):2621-7. doi: 10.1097/00007632-199611150-00012. PubMed PMID: 8961450.
  7. Luoto S, Taimela S, Hurri H, Alaranta H. Mechanisms explaining the association between low back trouble and deficits in information processing: a controlled study with follow-up. 1999;24(3):255-61. doi: 10.1097/00007632-199902010-00011. PubMed PMID: 10025020.
  8. Nguyen T, Hau R, Bartlett J. Driving reaction time before and after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthros 2000;8(4):226-30. doi: 10.1007/s001670000115. PubMed PMID: 10975263.
  9. Swanik CB, Covassin T, Stearne DJ, Schatz P. The relationship between neurocognitive function and noncontact anterior cruciate ligament injuries. Am J Sports Med. 2007;35(6):943-8. doi: 10.1177/0363546507299532. PubMed PMID: 17369562.
  10. Wilkerson GB. Neurocognitive reaction time predicts lower extremity sprains and strains. Int J Athl Ther Train. 2012;17(6):4-9. doi: 10.1123/ijatt.17.6.4.
  11. Mohammadi N, Hadian MR, Olyaei G. Information Processing Speed and Accuracy in Basketball Players With and Without Functional Ankle Instability. J Mod Rehabilit. 2019;13(3):179-84. doi: 10.32598/ JMR.13.3.179.
  12. Brox E, Luque LF, Evertsen GJ, Hernández JE. Exergames for elderly: Social exergames to persuade seniors to increase physical activity. International Conference on Pervasive Computing Technologies for Healthcare (PervasiveHealth) and Workshops; Dublin, Ireland: IEEE; 2011. p. 546-9.
  13. Müller H, Schumacher B, Blischke K, Daugs R. Optimierung sportmotorischen Technik-Trainings durch computergestützte Videosysteme. Sport Inform. 1990:37-47.
  14. Satyen L, Ohtsuka K. Strategies to develop divided attention skills through video game training. Engineering Psychology and Cognitive Ergonomics Volume Six. 2001:191-8.
  15. Rosenberg BH, Landsittel D, Averch TD. Can video games be used to predict or improve laparoscopic skills? J Endourol. 2005;19(3):372-6. doi: 10.1089/end.2005.19.372. PubMed PMID: 15865530.
  16. Kim KJ. Effects of Virtual Reality Programs on Proprioception and Instability of Functional Ankle Instability. 2015;6(2):891-5. doi: 10.5854/JIAPTR.2015.10.30.891.
  17. González-Fernández M, Gil-Gómez JA, Alcañiz M, et al. eBaViR, easy balance virtual rehabilitation system: a study with patients. Stud Health Technol Inform. 2010;154:61-6. PubMed PMID: 20543271.
  18. Middlemas DA, Basilicato J, Prybicien M, Savoia J, Biodoglio J. Incorporating gaming technology into athletic injury rehabilitation: a review of the literature. Athl Train Sports Health Care. 2009;1(2):79-84. doi: 10.3928/19425864-20090301-06.
  19. Saposnik G, Teasell R, Mamdani M, Hall J, et al. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle. 2010;41(7):1477-84. doi: 10.1161/STROKEAHA.110.584979. PubMed PMID: 20508185. PubMed PMCID: PMC4879973.
  20. Anderson-Hanley C, Arciero PJ, Brickman AM, et al. Exergaming and older adult cognition: a cluster randomized clinical trial. Am J Prev Med. 2012;42(2):109-19. doi: 10.1016/j.amepre.2011.10.016.
  21. Maillot P, Perrot A, Hartley A. Effects of interactive physical-activity video-game training on physical and cognitive function in older adults. Psychol Aging. 2012;27(3):589-600. doi: 10.1037/a0026268. PubMed PMID: 22122605.
  22. Read JL, Shortell SM. Interactive games to promote behavior change in prevention and treatment. 2011;305(16):1704-5. doi:  10.1037/a0026268. PubMed PMID: 21447802.
  23. Barcelos N, Shah N, Cohen K, et al. Aerobic and Cognitive Exercise (ACE) pilot study for older adults: executive function improves with cognitive challenge while exergaming. J Int Neuropsychol Soc. 2015;21(10):768-79. doi: 10.1017/S1355617715001083. PubMed PMID: 26581789.
  24. Akre A, Kumaresan K. Comparison of a strengthening programme to a proprioceptive training in improving dynamic balance in athletes with chronic ankle instability (CAI). IOSR J Sports Phys Educ. 2014;1:18-20. doi: 10.9790/6737-0151820.
  25. Hall EA, Docherty CL, Simon J, et al. Strength-training protocols to improve deficits in participants with chronic ankle instability: a randomized controlled trial. J Athl Train. 2015;50(1):36-44. doi: 10.4085/1062-6050-49.3.71. PubMed PMID: 25365134. PubMed PMCID: PMC4299733.
  26. McKeon PO, Ingersoll CD, Kerrigan DC, et al. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc. 2008;40(10):1810-9. doi: 10.1249/MSS.0b013e31817e0f92. PubMed PMID: 18799992.
  27. Powers ME, Buckley BD, Kaminski TW, et al. Six weeks of strength and proprioception training does not affect muscle fatigue and static balance in functional ankle instability. J Sport Rehabil. 2004;13(3):201-27. doi: 10.1123/jsr.13.3.201.
  28. Sefton JM, Yarar C, Hicks-Little CA, Berry JW, Cordova ML. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2011;41(2):81-9. doi: 10.2519/jospt.2011.3365. PubMed PMID: 21169716.
  29. Clarkson-Smith L, Hartley AA. Relationships between physical exercise and cognitive abilities in older adults. Psychol Aging. 1989;4(2):183-9. doi: 10.1037//0882-7974.4.2.183. PubMed PMID: 2789745.
  30. Hillman CH, Motl RW, Pontifex MB, et al. Physical activity and cognitive function in a cross-section of younger and older community-dwelling individuals. Health Psychol. 2006;25(6):678-87. doi: 10.1037/0278-6133.25.6.678. PubMed PMID: 17100496.
  31. Perrot A, Gagnon C, Bertsch J. Physical activity as a moderator of the relationship between aging and inductive reasoning. Res Q Exerc Sport. 2009;80(2):393-7. doi: 10.1080/02701367.2009.10599576. PubMed PMID: 19650407.
  32. Shay KA, Roth DL. Association between aerobic fitness and visuospatial performance in healthy older adults. Psychol Aging. 1992;7(1):15-24. doi: 10.1037//0882-7974.7.1.15.
  33. Dustman RE, Ruhling RO, Russell EM, et al. Aerobic exercise training and improved neuropsychological function of older individuals. Neurobiol Aging. 1984;5(1):35-42. doi: 10.1016/0197-4580(84)90083-6. PubMed PMID: 6738784.
  34. Hawkins HL, Kramer AF, Capaldi D. Aging, exercise, and attention. Psychol Aging. 1992;7(4):643-53. doi: 10.1037/0882-7974.7.4.643. PubMed PMID: 1466833.
  35. Kramer AF, Hahn S, Cohen NJ, et al. Ageing, fitness and neurocognitive function. 1999;400(6743):418-9. doi: 10.1038/22682. PubMed PMID: 10440369.
  36. Rahnama L, Salavati M, Akhbari B, Mazaheri M. Attentional demands and postural control in athletes with and without functional ankle instability. J Orthop Sports Phys Ther. 2010;40(3):180-7. doi: 10.2519/jospt.2010.3188. PubMed PMID: 20195021.
  37. Kim K-J, Heo M. Effects of virtual reality programs on balance in functional ankle instability. J Phys Ther Sci. 2015;27(10):3097-101. doi: 10.1589/jpts.27.3097. PubMed PMID: 26644652. PubMed PMCID: PMC4668143.
  38. Haji-Maghsoudi M, Naseri N, Nouri-Zadeh S, Jalayi S. Evidence of reliability for persian version of the “Cumberland Ankle Instability Tool (CAIT)” in Iranian athletes with lateral ankle sprain. Arch Rehabil. 2016;16(4):304-11.
  39. Mohammadi N, Hadian MR, Olyaei G. The Effects of Wii Fit Plus Training on Functional Ability in Athletes with Functional Ankle Instability. Sports Orthop Traumatol. 2020;36(1):52-9. doi: 10.1016/j.orthtr.2020.01.003.
  40. Deary IJ, Liewald D, Nissan J. A free, easy-to-use, computer-based simple and four-choice reaction time programme: the Deary-Liewald reaction time task. Behav Res Methods. 2011;43(1):258-68. doi: 10.3758/s13428-010-0024-1. PubMed PMID: 21287123.
  41. Mohammadi N, Kahlaei AH, Salavati M, et al. Reliability of functional performance and neurocognitive tests in athletes with and without functional ankle instability. Phys Treat J. 2015;5(2):63-71. doi: 10.15412/J.PTJ.07050201.
  42. Cohen J. A power primer. Psychol Bull. 1992;112(1):155-9. doi: 10.1037/0033-2909.112.1.155. PubMed PMID: 19565683.
  43. Hughes TF, Flatt JD, Fu B, Butters MA, et al. Interactive video gaming compared with health education in older adults with mild cognitive impairment: a feasibility study. Int J Geriatr Psychiatry. 2014;29(9):890-8. doi: 10.1002/gps.4075. PubMed PMID: 24452845. PubMed PMCID: PMC4326259.
  44. Zimmermann R, Gschwandtner U, Benz N, et al. Cognitive training in Parkinson disease: cognition-specific vs nonspecific computer training. 2014;82(14):1219-26. doi: 10.1212/WNL.0000000000000287. PubMed PMID: 24623840.