Exergaming for balance training of elderly: state of the art and future developments

Can exergames contribute to improving walking capacity in older adults? A systematic review and meta-analysis

BACKGROUND

The accessibility, low cost and motivation generated by exergames has fostered its rapid expansion as a rehabilitation technique.

OBJECTIVE

To estimate the effectiveness of rehabilitation programs using IVGT in improving walking capacity of people aged 60 years and over.

MATERIALS AND METHODS

The electronic data research following the PRISMA Statement (Scopus, Cochrane, Web of Science, OT Seeker, National Guideline Clearinghouse, Trip Database, CSIC Spanish National Research Council) was completed in September 2018. The results of randomized clinical trials using exergames for rehabilitation of walking capacity were combined. The calculations have followed the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. The Grading of Recommendations Assessment, Development and Evaluation system was used to evaluate the quality of the evidence.

RESULTS

We obtained data from 14 trials, including 11 meta-analysis studies. The size of exergames effects on walking capacity is moderate, but significant (SMD -0.56; 95 % CI: -0.90, -0.21; p = 0.002). Effectiveness was greater to recover the ability to transfer from one position or place to another (SMD -1.02; CI 95 %: -1.70, -0.35; P = 0.003). The intervention protocols, their duration and intensity varied considerably. The lack of masking, the allocation concealment, the absence of assessor blinding were the main causes of bias so the final grade of evidence has been low for walking and very low for transfers.

CONCLUSIONS

Positive clinical effects of exergames have been found to improve walking capacity, but the quality of evidence to refute its effectiveness is weak with risk of bias. Further research is needed in order to know the actual magnitude of its effect.

A Pilot Study of an In-Home Multicomponent Exergame Training for Older Adults: Feasibility, Usability and Pre-Post Evaluation

Aging is associated with sensory, motor and cognitive impairments that may lead to reduced daily life functioning including gait disturbances, falls, injuries and mobility restrictions. A strong need exists for implementing effective evidence-based interventions for healthy aging. Therefore, the aim of this study was to (i) evaluate the feasibility and usability of an in-home multicomponent exergame training and (ii) explore its effects on physical functions, cognition and cortical activity. Twenty-one healthy and independently living older adults were included (11 female, 74.4 ± 7.0 years, range: 65-92 years) and performed 24 trainings sessions (each 40 min) over eight weeks. The first part was conducted in a living lab (home-like laboratory environment), the second part at participants' home. The multicomponent exergame included Tai Chi-inspired exercises, dance movements and step-based cognitive games to train strength, balance and cognition. Attendance and attrition rates were calculated and safety during training was evaluated to determine feasibility. Participants rated the usability of the exergame (System Usability Scale) and reported on their game experience (Game Experience Questionnaire). Physical and cognitive functions and cortical activity (resting state electroencephalopathy) were assessed pre and post intervention. Results showed a high training attendance rate for the living lab and the home-based setting (91.7 and 91.0%, respectively) with a rather high attrition rate (28.6%, six drop-outs). Half of the drop-out reasons were related to personal or health issues. System usability was rated acceptable with a mean score of 70.6/100. Affective game experience was rated favorable. Significant improvements were found for minimal toe clearance, short-term attentional span, and information processing speed (p < 0.05). No significant pre-post differences were found for cortical activity. To summarize, the exergame is generally feasible and usable for healthy older adults applied in an in-home setting and provides an overall positive emotional game experience. Nevertheless, flawless technical functionality should be a mandatory consideration. Additionally, the training might have potential positive influence on specific functions in older adults. However, the efficacy has to be evaluated in a future randomized controlled trial assessing the behavioral and neuroplastic changes in a larger population after a longer training period.

Validation of a Motor-Cognitive Assessment for a Stepping Exergame in Older Adults: Use of Game-Specific, Internal Data Stream

Objective: To comprehensively validate an assessment tailored to an exergaming training program with motor-cognitive challenges. Materials and Methods: Fifty-eight cognitively intact, multimorbid, independently living older adults (mean age [standard deviation]: 78.3 [6.5] years) with moderate functional limitations participated in the study. For construct validity, Spearman's rank correlations (r_s) between game parameters and established cognitive (Number-Connection-Test [Zahlen-Verbindungs-Test], Simple Response Time Task, Simon Task) and motor (Short Physical Performance Battery, Physiomat^® balance tests) measures were calculated. Test-retest reliability was documented by intraclass correlation coefficients (ICCs), sensitivity to change by effect sizes using partial eta squared (η_p²), and feasibility by mean completion time and completion rates. Results: Good construct validity of the assessment was observed, with on average moderate-to-high correlations between game parameters and cognitive tests, measures of lower extremity function and dynamic balance (range of r_s including extreme outliers = 0.00-0.70, P < 0.001-0.998). Test-retest reliability was good, with ICCs mostly ranging from moderate to high (ICCs = 0.37-0.93, P < 0.001-0.130), and sensitivity to change was excellent (η_p² = 0.16-0.81, P < 0.001-0.044). Completion rates for the initial challenge levels were 100%, mean completion time 36.3 minutes, and no clinical events or safety problems were observed. Conclusion: Study results documented on average good validity, test-retest reliability and feasibility, with an extraordinary high responsiveness of the presented game-based assessment in older adults with moderate functional limitations. The innovative, data-based assessment validated in this study may serve as a blueprint for future, tailored assessments for exergaming.

Is virtual reality beneficial for dual-task gait training in patients with Parkinson's disease? A systematic review

This systematic review examined the evidence about the effects of virtual reality (VR) on dual-task gait training in Parkinson's disease (PD).

Lessons Learned from Gamifying Functional Fitness Training Through Human-Centered Design Methods in Older Adults

Background: The design of meaningful and enjoyable Exergames for fitness training in older adults possesses critical challenges in matching user's needs and motivators with game elements. These challenges are often due to the lack of knowledge of seniors' game preferences and technology literacy as well as a poor involvement of the target population in the design process. Objective: This research aims at describing a detailed and scrutinized use case of applying human-centered design methodologies in the gamification of fitness training routines and illustrates how to incorporate seniors' feedback in the game design pipeline. Materials and Methods: We focus on how to use the insights from human-centered inquiries to improve in-game elements, such as mechanics or esthetics, and how to iterate the game design process based on playtesting sessions in the field. Results: We present a set of four Exergames created to train the critical functional fitness areas of older adults. We show how through rapid prototyping methods and multidisciplinary research, Exergames can be rigorously designed and developed to match individual physical capabilities. Moreover, we propose a set of guidelines for the design of context-aware Exergames based on the lessons learned. Conclusion: We highlight the process followed; it depicts 19 weeks of various activities delivering particular and actionable items that can be used as a checklist for future games for health design projects.

Estimating Center of Mass Trajectory in Quiet Standing: a Review

As falls prevalence increases with the aging of the population, early detection of balance degradation is of great importance for efficient prevention and treatment. This work compares a wide range of state-of-the-art methods to estimate the trajectory of the center of mass - a key aspect of postural control quantification. This comparison is done through multiple complementary metrics over a large dataset, highlighting the pros and cons of each method as well as the key influence of the data preprocessing. Additionally, we introduce several improvements and parameter tunings for these methods that increase their accuracy or reduce contextual information requirement.

The KIMORE Dataset: KInematic Assessment of MOvement and Clinical Scores for Remote Monitoring of Physical REhabilitation

This paper proposes a free dataset, available at the following link,¹named KIMORE, regarding different rehabilitation exercises collected by a RGB-D sensor. Three data inputs including RGB, depth videos, and skeleton joint positions were recorded during five physical exercises, specific for low back pain and accurately selected by physicians. For each exercise, the dataset also provides a set of features, specifically defined by the physicians, and relevant to describe its scope. These features, validated with respect to a stereophotogrammetric system, can be analyzed to compute a score for the subject's performance. The dataset also contains an evaluation of the same performance provided by the clinicians, through a clinical questionnaire. The impact of KIMORE has been analyzed by comparing the output obtained by an example of rule and template-based approaches and the clinical score. The dataset presented is intended to be used as a benchmark for human movement assessment in a rehabilitation scenario in order to test the effectiveness and the reliability of different computational approaches. Unlike other existing datasets, the KIMORE merges a large heterogeneous population of 78 subjects, divided into 2 groups with 44 healthy subjects and 34 with motor dysfunctions. It provides the most clinically-relevant features and the clinical score for each exercise.¹https://univpm-my.sharepoint.com/:f:/g/personal/p008099_staff_univpm_it/EiwbKIzk6N9NoJQx4J8aubIBx0o7tIa1XwclWp1NmRkA-w?e=F3jtBk.

Age-related changes in leg proprioception: implications for postural control

In addition to being a prerequisite for many activities of daily living, the ability to maintain steady upright standing is a relevant model to study sensorimotor integrative function. Upright standing requires managing multimodal sensory inputs to produce finely tuned motor output that can be adjusted to accommodate changes in standing conditions and environment. The sensory information used for postural control mainly arises from the vestibular system of the inner ear, vision, and proprioception. Proprioception (sense of body position and movement) encompasses signals from mechanoreceptors (proprioceptors) located in muscles, tendons, and joint capsules. There is general agreement that proprioception signals from leg muscles provide the primary source of information for postural control. This is because of their exquisite sensitivity to detect body sway during unperturbed upright standing that mainly results from variations in leg muscle length induced by rotations around the ankle joint. However, aging is associated with alterations of muscle spindles and their neural pathways, which induce a decrease in the sensitivity, acuity, and integration of the proprioceptive signal. These alterations promote changes in postural control that reduce its efficiency and thereby may have deleterious consequences for the functional independence of an individual. This narrative review provides an overview of how aging alters the proprioceptive signal from the legs and presents compelling evidence that these changes modify the neural control of upright standing.

The Effectiveness of a Virtual Reality-Based Tai Chi Exercise on Cognitive and Physical Function in Older Adults with Cognitive Impairment

BACKGROUND

Tai Chi (TC) is a Chinese mind-body exercise with proven physical and psychological benefits. A modified TC via virtual reality (VR) may be suitable for the elderly owing to the immediate guidance and feedback regarding movement accuracy. This study explored the cognitive and physical effects of a VR-based TC (VRTC) exercise program on older adults with cognitive impairment (CI).

METHODS

Sixty older adults with CI were cluster-assigned to either the VRTC or the control group; the intervention was conducted twice weekly for 6 months. Outcomes included cognitive and physical functions. The movement accuracy score and attendance were recorded. Generalized estimating equation (GEE) and multiple regression analyses were performed.

RESULTS

Adjusted GEE analysis showed significant interaction effects in the 6-min walk test, 30-s sit-to-stand test, functional reach, 5-m gait speed, and abstract thinking and judgment. Overall, medium to large effect sizes (d = 0.50-0.82) were found in favor of the VRTC group. The average movement accuracy score in the first 3 months significantly predicted improvement in cognitive performance (p = 0.011).

CONCLUSIONS

The VRTC exercise posed a protective effect for some cognitive and physical functions in older adults with CI. The more engaging the program, the greater the improvement in the cognitive performance.

Falls Sensei: a serious 3D exploration game to enable the detection of extrinsic home fall hazards for older adults

Background

Falls are the main cause of death and injury for older adults in the UK. Many of these falls occur within the home as a result of extrinsic falls risk factors such as poor lighting, loose/uneven flooring, and clutter. Falls education plays an important role in self-management education about extrinsic hazards and is typically delivered via information leaflets, falls apps, and educational booklets. Serious games have the potential of delivering an engaging and informative alternative to traditional methods but almost exclusively, these are currently delivered as exergaming applications that focus solely on intrinsic falls risk factors. This study presents ‘Falls Sensei’ a first-person 3D exploration game that aims to educate older adults about extrinsic falls risk factors within the home environment. After presenting Falls Sensei, game usability and older adults’ perceptions and attitudes towards using the game in practice are explored.

Methods

This study involved 15 community dwelling older adults. After playing the Falls Sensei game, participants completed a Systems Usability Scale (SUS) questionnaire and post task interview, and follow-up interviews three weeks later. Inductive and deductive thematic template analysis, informed by the Unified Theory of Acceptance and Use of Technology model, was used to analyse the think-aloud, post-task and follow-up interview transcripts. Descriptive statistical analysis and one-sampled t-tests were used to analyse log-file data and SUS responses.

Results

Three high-level themes emerged from the analysis of transcriptions: Performance Expectancy; Effort Expectancy; Social Influence. The SUS score was 77.5/100 which indicates ‘Good’ levels of usability. Interestingly, reported usability of the game increased with participant age. Participants were positive about the usability of the game (p < = 0.05 for 9/10 items). The most memorable fall hazards were those most commonly encountered in the game or those most challenging to participants.

Conclusions

The results support the use of serious games as an engaging tool for educating older adults about extrinsic falls risk factors. Awareness of home hazard detection was raised by the game, and some older adults became more aware for the need to adapt their own homes after gameplay. Further research would be needed to draw comparisons with established interventions.

Effects of virtual dance exercise on skeletal muscle architecture and function of community dwelling older women

OBJECTIVES

The aim of this study was to analyze the effects of virtual dance exercise on skeletal muscle architecture and function in community-dwelling older women.

METHODS

Forty-two moderately active older women participated in this study and chose to join either the control group (CG; n=20; 70.3 ± 5.6 years) or exercise group (EG; n=22; 69.3 ± 3.7 years). Participants in the CG maintained their lifestyle and those in the EG performed group dance exercise using Dance Central game for Xbox 360® and Kinect for 40 min, 3 times/week, for 12 weeks. The primary outcomes were: ankle plantar flexion and dorsiflexion peak torque (PT), medial gastrocnemius muscle thickness (MT), fascicle length (FL), and pennation angle (PA). The secondary outcomes were: lower limbs range of motion (ROM), calf circumference (CC), 6 m customary gait speed, and handgrip strength. Data were analyzed using an ANOVA mixed model test (p<0.05).

RESULTS

EG participants improved plantar flexion PT at 60°/s (16.3%; p<0.01), MT (8.7%; p<0.01) and ankle dorsiflexion ROM (5.1%; p=0.04) when compared to baseline, and exhibited enhanced CC values compared to CG (1.7%; p=0.03).

CONCLUSIONS

Virtual dance exercise can be recommended to increase muscle mass. Moreover, ankle plantar flexion strength and dorsiflexion ROM gains may contribute to improve functionality and fall avoidance in moderately active older women.

Frailty Level Monitoring and Analysis after a Pilot Six-Week Randomized Controlled Clinical Trial Using the FRED Exergame Including Biofeedback Supervision in an Elderly Day Care Centre

Background: Frailty is a status of extreme vulnerability to endogenous and exogenous stressors exposing the individual to a higher risk of negative health-related outcomes. Exercise using interactive videos, known as exergames, is being increasingly used to increase physical activity by improving health and the physical function in elderly adults. The purpose of this study is to ascertain the reduction in the degree of frailty, the degree of independence in activities of daily living, the perception of one's state of health, safety and cardiac healthiness by the exercise done using FRED over a 6-week period in elderly day care centre. Material and Methods: Frail volunteers >65 years of age, with a score of <10 points (SPPB), took part in the study. A study group and a control group of 20 participants respectively were obtained. Following randomisation, the study group (20) took part in 18 sessions in total over 6 months, and biofeedback was recorded in each session. Results: After 6 weeks, 100% of patients from the control group continued evidencing frailty risk, whereas only 5% of patients from the study group did so, with p < 0.001 statistical significance. In the case of the EQ-VAS, the control group worsened (-12.63 points) whereas the study group improved (12.05 points). The Barthel Index showed an improvement in the study group after 6 weeks, with statistically significant evidence and a value of p < 0.003906. Safety compliance with the physical activity exceeded 87% and even improved as the days went by. Discussion: Our results stand out from those obtained by other authors in that FRED is an ad hoc-designed exergame, significantly reduced the presence and severity of frailty in a sample of sedentary elders, thus potentially modifying their risk profile. It in turn improves the degree of independence in activities of daily living and the perception of one's state of health, proving to be a safe and cardiac healthy exercise. Conclusions: The study undertaken confirms the fact that the FRED game proves to be a valid technological solution for reducing frailty risk. Based on the study conducted, the exergame may be considered an effective, safe and entertaining alternative.

The effectiveness and cost-effectiveness of strength and balance Exergames to reduce falls risk for people aged 55 years and older in UK assisted living facilities: a multi-centre, cluster randomised controlled trial

BACKGROUND

Falls are the leading cause of fatal and non-fatal unintentional injuries in older people. The use of Exergames (active, gamified video-based exercises) is a possible innovative, community-based approach. This study aimed to determine the effectiveness of a tailored OTAGO/FaME-based strength and balance Exergame programme for improving balance, maintaining function and reducing falls risk in older people.

METHODS

A two-arm cluster randomised controlled trial recruiting adults aged 55 years and older living in 18 assisted living (sheltered housing) facilities (clusters) in the UK. Standard care (physiotherapy advice and leaflet) was compared to a tailored 12-week strength and balance Exergame programme, supported by physiotherapists or trained assistants. Complete case analysis (intention-to-treat) was used to compare the Berg Balance Scale (BBS) at baseline and at 12 weeks. Secondary outcomes included fear of falling, mobility, fall risk, pain, mood, fatigue, cognition, healthcare utilisation and health-related quality of life, and self-reported physical activity and falls.

RESULTS

Eighteen clusters were randomised (9 to each arm) with 56 participants allocated to the intervention and 50 to the control (78% female, mean age 78 years). Fourteen participants withdrew over the 12 weeks (both arms), mainly for ill health. There was an adjusted mean improvement in balance (BBS) of 6.2 (95% CI 2.4 to 10.0) and reduced fear of falling (p = 0.007) and pain (p = 0.02) in the Exergame group. Mean attendance at sessions was 69% (mean exercising time of 33 min/week). Twenty-four percent of the control group and 20% of the Exergame group fell over the trial period. The change in fall rates significantly favoured the intervention (incident rate ratio 0.31 (95% CI 0.16 to 0.62, p = 0.001)). The point estimate of the incremental cost-effectiveness ratio (ICER) was £15,209.80 per quality-adjusted life year (QALY). Using 10,000 bootstrap replications, at the lower bound of the NICE threshold of £20,000 per QALY, there was a 61% probability of Exergames being cost-effective, rising to 73% at the upper bound of £30,000 per QALY.

CONCLUSIONS

Exergames, as delivered in this trial, improve balance, pain and fear of falling and are a cost-effective fall prevention strategy in assisted living facilities for people aged 55 years or older.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov on 18 Dec 2015 with reference number NCT02634736 .

Contrasting performance between physically active and sedentary older people playing exergames

The increase in life expectancy associated with the increase in chronological age and less active people helps in the appearance of chronic and degenerative diseases. The encouragement of physical exercises contributes to older people abandoning sedentarism and preventing such diseases. Exergame is a promising alternative, for making exercise a pleasurable activity.In this study, we compared the performance of physically active older people with sedentary older people in exergames.Participants were 83 older adults over 65 years of age, of both sexes, divided into 2 physically active older people (AG) and sedentary older people (CG) groups. The participants performed a task through an exergame called "MoviLetrando" that uses the score, number of hits, number of omissions, and an average time of hits as an evaluation. A characterization questionnaire was applied, with information about sex, age, marital status, economic class, self-rated health, time of use of electronic games, a questionnaire on the practice of physical activity, and the Brunel Mood Scale.There was a higher exergame score in AG than in CG (P = .003), in the number of correct answers (P = .012). The number of omissions was lower in AG than in CG (P = .023). The mean time of correct answers was lower in AG than in CG (P = .013). The regression analysis revealed a significant finding F (3, 82) = 11.06, P < .001 and showed a prediction ability of 26.9% (r = .269). Three variables remained significantly associated with the score: physical activity was marginally significant (β = .19, P = .06), age (β = -.403, P < .001), depression (β = -.212, P = .028).Physically active older people perform better when compared with the sedentary older people. Age, depression, and physical activity influence the performance in exergame.

A Social Virtual Reality-Based Application for the Physical and Cognitive Training of the Elderly at Home

Frailty is a clinical condition affecting the elderly population which results in an increased risk of falls. Previous studies demonstrated that falls prevention programs are effective, but they suffer from low adherence, especially when subjects have to train unsupervised in their homes. To try to improve treatment adherence, virtual reality and social media have been proposed as promising strategies for the increase of users' motivation and thus their willingness to practice. In the context of smart homes, this work presents SocialBike, a virtual reality-based application aimed at improving the clinical outcomes of older frail adults in their houses. Indeed, SocialBike is integrated in the "house of the future" framework and proposes a Dual Task training program in which the users are required to cycle on a stationary bike while recognizing target animals or objects appearing along the way. It also implements the possibility of training with other users, thus reducing the risk of social isolation. Within SocialBike, users can choose the multiplayer mode they prefer (i.e., collaborative or competitive), and are allowed to train following their own attitude. SocialBike's validation, refinement, and business model are currently under development, and are briefly discussed as future works.

An Interactive Home-Based Cognitive-Motor Step Training Program to Reduce Fall Risk in Older Adults: Qualitative Descriptive Study of Older Adults' Experiences and Requirements

Background

Falls are a major contributor to the burden of disease in older adults. Home-based exercise programs are effective in reducing the rate and risk of falls in older adults. However, adherence to home-based exercise programs is low, limiting the efficacy of interventions. The implementation of technology-based exercise programs for older adults to use at home may increase exercise adherence and, thus, the effectiveness of fall prevention interventions. More information about older adults’ experiences when using technologies at home is needed to enable the design of programs that are tailored to older adults’ needs.

Objective

This study aimed to (1) explore older adults’ experiences using SureStep, an interactive cognitive-motor step training program to reduce fall risk unsupervised at home; (2) explore program features that older adults found encouraged program uptake and adherence; (3) identify usability issues encountered by older adults when using the program; and (4) provide guidance for the design of a future technology-based exercise program tailored to older adults to use at home as a fall prevention strategy.

Methods

This study was part of a larger randomized controlled trial. The qualitative portion of the study and the focus of this paper used a qualitative descriptive design. Data collectors conducted structured, open-ended in-person interviews with study participants who were randomly allocated to use SureStep at home for 4 months. All interviews were audiotaped and ranged from 45 to 60 min. Thematic analysis was used to analyze collected data. This study was guided by Pender’s Health Promotion Model.

Results

Overall, 24 older adults aged 70 to 97 years were interviewed. Findings suggest older adults are open to use technology-based exercise programs at home, and in the context of optimizing adherence to home-based exercise programs for the prevention of falls, findings suggest that program developers should develop exercise programs in ways that provide older adults with a fun and enjoyable experience (thus increasing intrinsic motivation to exercise), focus on improving outcomes that are significant to older adults (thus increasing self-determined extrinsic motivation), offer challenging yet attainable exercises (thus increasing perceived self-competence), provide positive feedback on performance (thus increasing self-efficacy), and are easy to use (thus reducing perceived barriers to technology use).

Conclusions

This study provides important considerations when designing technology-based programs so they are tailored to the needs of older adults, increasing both usability and acceptability of programs and potentially enhancing exercise participation and long-term adherence to fall prevention interventions. Program uptake and adherence seem to be influenced by (1) older adults’ perceived benefits of undertaking the program, (2) whether the program is stimulating, and (3) the perceived barriers to exercise and technology use. Older adults shared important recommendations for future development of technologies for older adults to use at home.

Dynamic Balance Measurement and Quantitative Assessment Using Wearable Plantar-Pressure Insoles in a Pose-Sensed Virtual Environment

The center of plantar pressure (COP) reflects the dynamic balance of subjects to a certain extent. In this study, wearable pressure insoles are designed, body pose measure is detected by the Kinect sensor, and a balance evaluation system is formulated. With the designed games for the interactive actions, the Kinect sensor reads the skeletal poses to judge whether the desired action is performed, and the pressure insoles simultaneously collect the plantar pressure data. The COP displacement and its speed are calculated to determine the body sway and the ability of balance control. Significant differences in the dispersion of the COP distribution of the 12 subjects have been obtained, indicating different balancing abilities of the examined subjects. A novel assessment process is also proposed in the paper, in which a correlation analysis is made between the de facto sit-to-stand (STS) test and the proposed method; the Pearson and Spearman correlations are also conducted, which reveal a significant positive correlation. Finally, four undergraduate volunteers with a right leg sports injury participate in the experiments. The experimental results show that the normal side and abnormal side have significantly different characters, suggesting that our method is effective and robust for balance measurements.

The effectiveness of virtual reality training in reducing the risk of falls among elderly people

Background

Virtual reality (VR) training using modern game consoles is an innovative rehabilitation method for fall-prone elderly people. The aim of this study was to assess the effectiveness of VR training using the "Xbox 360 Kinect" in people over 60 years of age.

Materials and methods

The study involved 23 people, including 19 women and 4 men (mean age 75.74±8.09 years). The following functional tests were employed as research instruments: the 6-minute walking test (6MWT), the Dynamic Gait Index (DGI), the tandem stance test (TST), the tandem walk test (TWT), and the Beck Depression Inventory (BDI). A "spring hand dynamometer" was also used. The participants underwent 30-day VR training using an Xbox 360 Kinect. They trained 3 times a week, with each exercise lasting 30 minutes.

Results

The 6MWT (P<0.001), the DGI (P=0.008), the TST (P<0.001), the TWT (P=0.002), and the BDI (P<0.001) outcomes were significantly improved. There were differences in the results for the strength of the "pressing muscles" in the right (P=0.106) and left (P=0.043) hands of the participants. Both participants under 80 years of age and those aged 80 years and over had visibly better results on the 6MWT (P<0.001 and P=0.008, respectively), the TST (P<0.001 and P=0.008, respectively), and the BDI (P=0.003 and P=0.012, respectively).

Conclusion

Training based on VR increases the possibilities of motor training and can help reduce the risk of falls by improving the static and dynamic balance.

Time course of changes in motor-cognitive exergame performances during task-specific training in patients with dementia: identification and predictors of early training response

Background

Some studies have already suggested that exergame interventions can be effective to improve physical, cognitive, motor-cognitive, and psychological outcomes in patients with dementia (PwD). However, little is known about the training volume required to induce such positive effects and the inter-individual differences in training response among PwD. The aim of the study was to analyze the time course of changes in motor-cognitive exergame performances during a task-specific training program and to identify predictors of early training response in PwD.

Methods

Secondary analyses of data from the intervention group (IG) of a randomized, placebo-controlled trial to improve motor-cognitive performances in PwD. Fifty-six geriatric patients with mild-to-moderate dementia randomized to the IG underwent a 10-week, task-specific training program (2×/week) on an exergame-based balance training system (Physiomat®), combining postural control tasks with cognitive tasks of an established neuropsychological test (Trail Making Test). Main outcome was the time required to complete different Physiomat®-Tasks (PTs) assessed at baseline (T1), training session 7 (TS7) and 14 (TS14), and post-intervention after 20 training sessions (T2). Reliable change indices were used to identify early responders from T1 to TS7. A multivariate logistic regression analysis was performed to determine independent predictors of early training response.

Results

Completion time significantly improved already from T1 to TS7 in all PTs (p ≤ .001–.006), with moderate to very large effect sizes (r = .38–.52; Cohen’s d = .85–1.45). For most PTs, significant progressive improvements from TS7 to TS14 and TS14 to T2 were not observed. Thirty-one (59.6%) participants were classified as early responders and 21 (40.4%) as non-early responders. Lower baseline exergame performance and lower visuospatial and divided attention abilities were independently associated with early training response.

Conclusions

Substantial task-specific improvements in complex motor-cognitive exergame performances can be obtained within a surprisingly short intervention period in PwD. Our results confirm that not only an excellent training response can be achieved in this patient population, but also that more vulnerable patients with greater deficits in domain-specific cognitive functions associated with fall risk may even reap the most and fastest benefit from motor-cognitive exergame interventions.

Trial registration

ISRCTN registry, ISRCTN37232817 (retrospectively registered on 04/02/2012).

Understanding Motivations and Player Experiences of Older Adults in Virtual Reality Training

OBJECTIVE

We studied which games and underlying game mechanics are considered motivating by older adults, so that designers and therapists make informed choices when designing or selecting virtual reality (VR)-training interventions.

MATERIALS AND METHODS

We conducted a repeated measures design with 30 older participants, who played eight different VR-training games and afterward filled out the intrinsic motivation inventory (IMI). Differences in intrinsic motivation between games were analyzed using Friedman's tests. In addition, in-depth interviews were conducted according to the laddering technique, to unveil the underlying game mechanics that lead to the players preferences.

RESULTS

IMI scores were relatively high for all games, indicating that these VR games seem effective for inducing a high intrinsic motivation. Wii yoga and Kinect Adventures were the highest scoring games on all but the negative subscale tension. Both games provided regular positive feedback. An important game mechanic was Variation, which showed a strong link to important values such as: to Stay Focused, Improve Fitness, and Health and Independency. Furthermore, the game mechanics Visual Feedback and Positive Feedback, which lead to an increased Drive to Perform, were perceived valuable. Seemingly contradicting, but both important attributes such as Speed versus Slow Movements emphasize the importance of designing VR training that adapts to the skill level of the player.

CONCLUSION

We have shown that games with different game mechanics can induce high intrinsic motivation. When designing or selecting VR balance training games for older adults, these game mechanics should be incorporated to optimize a positive user experience and increase intrinsic motivation.

Motor-cognitive effects of a computerized game-based training method in people with dementia: a randomized controlled trial

OBJECTIVES

To examine the effects of a computerized, game-based training on motor-cognitive performances, the transfer of training effects on untrained tasks, and the sustainability of training gains in people with dementia.

METHOD

Ninety-nine individuals with a mean age of 82.9 (5.8) and dementia participated in a 10-week randomized controlled trial with three-month follow-up. The intervention group (IG) received a motor-cognitive training on (Physiomat®) including concurrent dual-tasks of balance control with cognitive demands (Physiomat®-Trail Making Tasks (PTMTs)). The control group (CG) performed non-specific, low-intensity exercises. Duration and accuracy at different complexity levels of trained and untrained PTMTs and the number of successfully performed tasks (PTMT score) were assessed.

RESULTS

Physiomat® training significantly improved the duration and accuracy at almost all complexity levels of trained (P ≤ 0.001-0.047, η_p² = 0.065-0.589) and untrained PTMTs (P < 0.001-0.005, η_p² = 0.073-0.459). Significant effects were also found for the PTMT score of trained (P < 0.001, η_p² = 0.211) and untrained PTMTs (P < 0.001, η_p² = 0.184). Training gains were partly sustained at follow-up.

CONCLUSION

Physiomat® is feasible and has the potential to sustainably improve motor-cognitive performances in people with dementia.

Is Kinect Training Superior to Conventional Balance Training for Healthy Older Adults to Improve Postural Control?

OBJECTIVE

To investigate the effects of balance training to improve postural control in adults older than 60. Our aim was to find out if Kinect training is superior to the conventional balance training in aspects of functional balance tests and posturography measurements testing postural stability through visual feedback.

MATERIALS AND METHODS

Thirty subjects participated in the Kinect training group (29 women and 1 man), practiced Kinect Adventures and Sports, 23 volunteers (22 women and 1 man) attended the conventional balance training, and 22 participants (18 women and 4 men) were allocated to the no-intervention control group. Both interventions lasted for 6 weeks, three times a week, and 30 minutes per session. The Four-Square Step Test, Functional Reach Test, Timed Up and Go test, Timed Up and Go cognitive dual-task test were measured, and for the assessment of the limit of stability (LOS), we used computerized posturography. Measurements were taken before the training at baseline and 6 weeks after (follow-up) the interventions. Statistical analysis was done through two-factor mixed analysis of variance and Newman-Keuls post hoc test.

RESULTS

Both training groups showed progress in the follow-up measurements; however, more statistically significant improvements were found in favor of the Kinect balance training group (Timed Up and Go test [P < 0.05], Timed Up and Go cognitive dual-task test [P < 0.05], Four-Square Step Test [P < 0.05], Functional Reach Test [P < 0.05], LOS movement velocity [P < 0.05]).

CONCLUSION

Our results suggest that Kinect balance training may be a preferable and safe method for the healthy older adults to improve postural control and reduce the possibility of falling.

Feasibility of Kinect-Based Games for Balance Rehabilitation: A Case Study

We aimed at determining the effects of prototype games on older adults attending a rehabilitation program in an elderly house in this work. We conducted an initial case study where two participants underwent a 5-week intervention. Feasibility was assessed by examining recruitment, adherence, and safety. The Tinetti balance test was used as pretest and posttest assessments. Results show that adherence was very high and no adverse effects were registered during the sessions. The included participants also reported enjoyment during the playtime and exhibited improvements in Tinetti scores. The findings suggest that game-based rehabilitation can be useful for improving balance in elderly people and can be incorporated in a fall prevention program.

Acceptance of different design exergames in elders

For promoting the successful aging of elderly residents of Chang Gung Silver Village in Taiwan, five interactive exergames were developed to promote the well-being of the elderly. The exergames included both physical games and cognitive games, and were implemented using various computer-based technologies in the Chang Gung Silver Village. The exergames were trialed by 39 elderly residents (15 male, 24 female; mean age 79.5 ± 17.5 years) of Chang Gung Silver Village. Following the trials, the participants were requested to complete a Technology Acceptance Model 2 (TAM2) questionnaire. The results showed that the perceived playfulness and perceived usefulness of the exergames were significantly related to the users’ usage behavior and intention to use for both the physical games and the cognitive games. However, a relationship between the output quality of the game and the usage behavior was apparent only in the case of the cognitive exergames. Finally, the impact of social influence on the intention to use and the usage behavior was more pronounced for the physical exergames. Overall, the results revealed that the acceptance of exergames by the elderly depends not so much on the awareness of fun in using the game, but the perceived usefulness of the related physical and cognitive abilities.

Feasibility of a smartphone-based balance assessment system for subjects with chronic stroke

BACKGROUND

Stroke is a cerebral artery disease that may lead to long-term disabilities or death. Patients that survive a stroke usually suffer balance impairments, which affect their performance in activities of daily living (ADLs) and quality of life (QoL). In recent years, smartphones have become very popular and have many capabilities. Smartphone built-in sensors have shown their ability and potential in balance performance assessment. However, the feasibility of smartphones on subjects with chronic strokes remains to be proved. Therefore, the purpose of this study is to evaluate the feasibility of a smartphone-based balance assessment system for subjects with chronic stroke.

METHODS

Ten subjects with chronic stroke and thirteen healthy adults were recruited in the study. The smartphone HTC 10 (HTC Corporation, Taiwan) was used to perform the balance assessment, and its built-in accelerometer and gyroscope were used to record data from the subjects. Six postures were tested for thirty seconds each: shoulder-width stance (SWS) with eyes opened (E/O) and eyes closed (E/C), feet-together stance (FTS) with E/O and E/C, and semi-tandem stance (STS) with E/O and E/C. The smartphone was fixed to the back of subjects at the second sacral spine (S2) level. The changes registered in the accelerometer and gyroscope data were used to represent the balance performance, in which higher values indicate more instability. Data was analyzed using the independent t-test with the software SPSS 20, and the statistical significance level was set to α < 0.05.

RESULTS AND DISCUSSION

Significant difference in the acceleration data was found among subjects with chronic stroke and healthy adults under four assessment postures: SWS with E/C (p = 0.048), FTS with E/O (p = 0.027), FTS with E/C (p = 0.000), and STS with E/C (p = 0.048). Furthermore, according to the gyroscope data, there were significant differences in how the two groups performed the postures. The results demonstrate that a smartphone with a built-in accelerometer and gyroscope can be used to classify balance performances between healthy adults and subjects with chronic stroke.

CONCLUSION

This study shows that smartphones are feasible to assess balance for subjects with chronic stroke.

Sensor-based balance training with motion feedback in people with mild cognitive impairment

Some individuals with mild cognitive impairment (MCI) experience not only cognitive deficits but also a decline in motor function, including postural balance. This pilot study sought to estimate the feasibility, user experience, and effects of a novel sensor-based balance training program. Patients with amnestic MCI (mean age 78.2 yr) were randomized to an intervention group (IG, n = 12) or control group (CG, n = 10). The IG underwent balance training (4 wk, twice a week) that included weight shifting and virtual obstacle crossing. Real-time visual/audio lower-limb motion feedback was provided from wearable sensors. The CG received no training. User experience was measured by a questionnaire. Postintervention effects on balance (center of mass sway during standing with eyes open [EO] and eyes closed), gait (speed, variability), cognition, and fear of falling were measured. Eleven participants (92%) completed the training and expressed fun, safety, and helpfulness of sensor feedback. Sway (EO, p = 0.04) and fear of falling (p = 0.02) were reduced in the IG compared to the CG. Changes in other measures were nonsignificant. Results suggest that the sensor-based training paradigm is well accepted in the target population and beneficial for improving postural control. Future studies should evaluate the added value of the sensor-based training compared to traditional training.

The feasibility of using exergames as a rehabilitation tool: the attitudes, awareness, opinions and experiences of physiotherapists, and older people towards exergames

[Purpose] The aim of this study was to investigate the feasibility of using exergames as a rehabilitation tool by determining the attitudes, awareness, opinions and experiences of physiotherapists, and older people towards exergames. [Subjects and Methods] A cross-sectional study was conducted and two short self-developed questionnaires (for physiotherapists and older people) were distributed in three hospitals in Cork (Ireland) to assess the attitudes towards and familiarity with exergames among physiotherapists and older people. The data were analysed using Microsoft Excel version 2013. [Results] The results show that a lot of older people have seen exergames devices but have not attempted to play them. This may indicate a lack of interest in or information about these devices and how to use them. With regard to the second group, physiotherapists underestimate older people's knowledge about exergames. [Conclusion] Older people were not very familiar with exergames but they were willing to try them. In addition, despite physiotherapists being familiar with exergames, they see them as an additional tool that will not replace or change any traditional exercise methods.

A tool for home-based rehabilitation allowing for clinical evaluation in a visual markerless scenario

This work deals with the design of an interactive monitoring tool for home-based physical rehabilitation. The software platform includes a video processing stage and the exercise performance evaluation. Image features are extracted by a Kinect v2 sensor and elaborated to return the exercises score. Furthermore the tool provides to physiotherapists a quantitative exercise evaluation of subject's performances. The proposed tool for home rehabilitation has been tested on 5 subjects and 5 different exercises and results are presented. In particular both exercises and relative evaluation indexes were selected by specialists in neurorehabilitation.

Movements of older adults during exergaming interventions that are associated with the Systems Framework for Postural Control: A systematic review

One in three older adults fall annually, in part due to impairments in the physiological systems that make up the postural control (PC) system. Exercise, particularly balance training, helps to prevent deterioration and even to improve outcomes in the PC system. Exergaming (exercise-gaming) is interactive computer gaming whereby an individual moves the body in response to onscreen cues in a playful format. Exergaming is an alternative method to standard practice for improving PC outcomes, which has been shown to reduce the risk of falling. Exergaming has received research attention, yet the intervention is still in its infancy. There could be benefit in exploring the movements trained with respect to a framework known for identifying underlying deficits in the PC system, the Systems Framework for Postural Control (SFPC). This may help target areas for improvement in balance training using exergames and shed light on the impact for fall prevention. A literature search was therefore conducted across six databases (CINAHL, EMBASE, PubMed, ISI, SPORTdiscus and Science Direct) using a range of search terms and combinations relating to exergaming, balance, exercise, falls and elderly. Quality assessment was conducted using the PEDro Scale and a custom-made quality assessment tool. Movements were rated by two reviewers based on the 9 operational definitions of the SFPC. Eighteen publications were included in the analysis, with a mean PEDro score of 5.6 (1.5). Overall, 4.99 (1.27) of the 9 operational definitions of the SFPC are trained in exergaming interventions. Exergaming does encourage individuals to stand up (3), lean while standing (4), move upper limbs and turn heads (6) and dual-task while standing (9), to some extent move the body forwards, backwards and sideways (1), and coordinate movements (2) but hardly at all to kick, hop, jump or walk (7), or to force a postural reaction from a physical force to the individual (5) and it does not mimic actual changes in sensory context (8). This is the first review, to our knowledge, that synthesises the literature on movements trained in exergaming interventions with respect to an established theoretical framework for PC. This review could provide useful information for designing exergames with PC outcomes in mind, which could help target specific exergames for multi-factorial training to overcome balance deficits. Some elements of PC are too unsafe to be trained using exergames, such as restricting sensory inputs or applying physical perturbations to an individual to elicit postural responses.

Flexible, Stretchable Sensors for Wearable Health Monitoring: Sensing Mechanisms, Materials, Fabrication Strategies and Features

Wearable health monitoring systems have gained considerable interest in recent years owing to their tremendous promise for personal portable health watching and remote medical practices. The sensors with excellent flexibility and stretchability are crucial components that can provide health monitoring systems with the capability of continuously tracking physiological signals of human body without conspicuous uncomfortableness and invasiveness. The signals acquired by these sensors, such as body motion, heart rate, breath, skin temperature and metabolism parameter, are closely associated with personal health conditions. This review attempts to summarize the recent progress in flexible and stretchable sensors, concerning the detected health indicators, sensing mechanisms, functional materials, fabrication strategies, basic and desired features. The potential challenges and future perspectives of wearable health monitoring system are also briefly discussed.

Assessing Dynamic Balance Performance During Exergaming Based on Speed and Curvature of Body Movements

Improving balance performance among the elderly is of utmost importance because of the increasing number of injuries and fatalities caused by fall incidences. Digital games controlled by body movements (exergames) have been proposed as a way to improve balance among older people. However, the assessment of balance performance in real-time during exergaming remains a challenging task. This assessment could be used to provide instantaneous feedback and automatically adjust the exergame difficulty. Such features could potentially increase the motivation of the player, thus augmenting the effectiveness of exergames. As clear differences in balance performance have been identified between older and younger people, distinguishing between older and younger adults can help identifying measures of balance performance. We used generalized linear models to investigate whether the assessment of balance performance based on movement speed can be improved by incorporating curvature of the movement trajectory into the analysis. Indeed, our results indicated that curvature improves the performance of the models. Five-fold cross validation indicated that our method is promising for the assessment of balance performance in real-time by showing more than 90% classification accuracy. Finally, this method could be valuable not only for exergaming, but also for real-time assessment of body movements in sports, rehabilitation, and medicine.

Virtual reality balance training for elderly: Similar skiing games elicit different challenges in balance training

BACKGROUND

Virtual Reality (VR) balance training may have advantages over regular exercise training in older adults. However, results so far are conflicting potentially due to the lack of challenge imposed by the movements in those games. Therefore, the aim of this study was to assess to which extent two similar skiing games challenge balance, as reflected in center of mass (COM) movements relative to their Functional Limits of Stability (FLOS).

METHODS

Thirty young and elderly participants performed two skiing games, one on the Wii Balance board (Wiiski), which uses a force plate, and one with the Kinect sensor (Kinski), which performs motion tracking. During gameplay, kinematics were captured using seven opto-electronical cameras. FLOS were obtained for eight directions. The influence of games and trials on COM displacement in each of the eight directions, and maximal COM speed, were tested with Generalized Estimated Equations.

RESULTS

In all directions with anterior and medio-lateral, but not with a posterior component, subjects showed significantly larger maximal %FLOS displacements during the Kinski game than during the Wiiski game. Furthermore, maximal COM displacement, and COM speed in Kinski remained similar or increased over trials, whereas for Wiiski it decreased.

CONCLUSIONS

Our results show the importance of assessing the movement challenge in games used for balance training. Similar games impose different challenges, with the control sensors and their gain settings playing an important role. Furthermore, adaptations led to a decrease in challenge in Wiiski, which might limit the effectiveness of the game as a balance-training tool.

Feasibility, Acceptability and Effects of a Home-Based Exercise Program Using a Gerontechnology on Physical Capacities after a Minor Injury in Community-Living Older Adults: A Pilot Study

CONTEXT

Several studies have demonstrated that physical activity can help limit decline in functional capacities of older adults. Nevertheless, many adults aged 65 and over are inactive.

OBJECTIVE

To explore the feasibility, the acceptability and the effects of a home-based exercise program (HEP) using a motion capture gerontechnology in independent community-living older adults at risk of function decline.

DESIGN

Interventionnal clinical trial.

PARTICIPANTS

Sixteen previously independent individuals aged 65 and older recruited at the Emergency Department after being treated for a minor injury and discharged home were assigned to a home-based exercise program group (HEP=8) or to a control group (CONTR=8). Twelve participants completed the study, 6 in each group Setting: Canadian Community-dwelling in Montreal area.

INTERVENTION

The HEP group engaged in a twelve-week physical activity intervention using a gerontechnology while the CONTR group continued with discharge plan from ED.

MEASUREMENTS

Participants were evaluated for functional status using validated questionnaires and objective physical measures at baseline, three and six months later. Feasibility and acceptability of the HEP was assessed using data reports from the gerontechnology and from self-reported assessments.

RESULTS

There was no differences between groups at baseline except for the fallrelated self-efficacy: HEP=8.33/28±1.51 vs CONTR=7/28±0 p=0.022. The HEP was found to be feasible and acceptable (adherence rate at 86% and average quality of movements at 87.5%). Significant improvement in walking speed on 4m was observed three months after baseline for HEP vs CONTR group (+0.25 vs +0.05 m/sec, p=0.025). Effects remained at follow-up. Only CONTR group resulted in a significant increase in SF-36 global score.

CONCLUSION

This twelve-week HEP intervention using the Jintronix® gerontechnology is feasible, acceptable and safe for community-living older adults who sustained a minor injury. This intervention could increase walking speed, the most important predictor of adverse events in the elderly population, and that the improvement could be maintained over time.

FRED: Exergame to Prevent Dependence and Functional Deterioration Associated with Ageing. A Pilot Three-Week Randomized Controlled Clinical Trial

Introduction: Frailty syndrome and advanced age may decrease the acceptance of illness and quality of life, and worsen patients' existing health conditions, as well as leading to an increase in health care expenses. Purpose: The purpose of this study is to reduce frailty risk via the use of a FRED game which has been expressly designed and put together for the study. Materials and methods: A total of 40 frail volunteers with a score of <10 points in the short physical performance battery (SPPB) took part in a feasibility study in order to validate the FRED game. Following randomisation, the study group (20 subjects) took part in nine sessions of 20 min each over a three-week period. The control group (19 subjects) continued to lead their daily lives in the course of which they had no physical activity scheduled; Results: After three weeks and having taken part in nine physical activity sessions with the FRED game, 60% of subjects from the study group (12/20) obtained a score of ≥10 points at the end of the study, i.e., less risk of evidencing frailty. This result proved to be statistically significant (p < 0.001). The degree of compliance with and adherence to the game was confirmed by 100% attendance of the sessions. Discussion: Our findings support the hypothesis that FRED, an ad hoc designed exergame, significantly reduced the presence and severity of frailty in a sample of sedentary elders, thus potentially modifying their risk profile. Conclusions: The FRED game is a tool that shows a 99% certain improvement in the degree of frailty in frail elderly subjects. The effectiveness of the design of ad hoc games in a certain pathology or population group is therefore evidenced.

Exergame technology and interactive interventions for elderly fall prevention: A systematic literature review

Training balance and promoting physical activities in the elderly can contribute to fall-prevention. Due to the low adherence of conventional physical therapy, fall interventions through exergame technologies are emerging. The purpose of this review study is to synthesize the available research reported on exergame technology and interactive interventions for fall prevention in the older population. Twenty-five relevant papers retrieved from five major databases were critically reviewed and analyzed. Results showed that the most common exergaming device for fall intervention was Nintendo Wii, followed by Xbox Kinect. Even though the exergame intervention protocols and outcome measures for assessing intervention effectiveness varied, the accumulated evidences revealed that exergame interventions improved physical or cognitive functions in the elderly. However, it remains inconclusive whether or not the exergame-based intervention for the elderly fall prevention is superior to conventional physical therapy and the effect mechanism of the exergaming on elderly's balance ability is still unclear.

Performance of a visuomotor walking task in an augmented reality training setting

Visual cues can be used to train walking patterns. Here, we studied the performance and learning capacities of healthy subjects executing a high-precision visuomotor walking task, in an augmented reality training set-up. A beamer was used to project visual stepping targets on the walking surface of an instrumented treadmill. Two speeds were used to manipulate task difficulty. All participants (n = 20) had to change their step length to hit visual stepping targets with a specific part of their foot, while walking on a treadmill over seven consecutive training blocks, each block composed of 100 stepping targets. Distance between stepping targets was varied between short, medium and long steps. Training blocks could either be composed of random stepping targets (no fixed sequence was present in the distance between the stepping targets) or sequenced stepping targets (repeating fixed sequence was present). Random training blocks were used to measure non-specific learning and sequenced training blocks were used to measure sequence-specific learning. Primary outcome measures were performance (% of correct hits), and learning effects (increase in performance over the training blocks: both sequence-specific and non-specific). Secondary outcome measures were the performance and stepping-error in relation to the step length (distance between stepping target). Subjects were able to score 76% and 54% at first try for lower speed (2.3 km/h) and higher speed (3.3 km/h) trials, respectively. Performance scores did not increase over the course of the trials, nor did the subjects show the ability to learn a sequenced walking task. Subjects were better able to hit targets while increasing their step length, compared to shortening it. In conclusion, augmented reality training by use of the current set-up was intuitive for the user. Suboptimal feedback presentation might have limited the learning effects of the subjects.

Motivational Determinants of Exergame Participation for Older People in Assisted Living Facilities: Mixed-Methods Study

Background

Exergames (exercise-based videogames) for delivering strength and balance exercise for older people are growing in popularity with the emergence of new Kinect-based technologies; however, little is known about the factors affecting their uptake and usage by older people.

Objective

The aim of this study was to determine the factors that may influence the motivation of older people to use exergames to improve their physical function and reduce fall risk.

Methods

Mixed methods were employed in which 14 semistructured interviews were conducted with older people (n=12, aged 59-91 years) from 2 assisted living facilities in the North West of the United Kingdom. The older people participated in a 6-week trial of exergames along with one manager and one physiotherapist; 81 h of observation and Technology Acceptance Model questionnaires were conducted.

Results

The findings suggest that the participants were intrinsically motivated to participate in the exergames because of the enjoyment experienced when playing the exergames and perceived improvements in their physical and mental health and social confidence. The social interaction provided in this study was an important extrinsic motivator that increased the intrinsic motivation to adhere to the exergame program.

Conclusions

The findings of this study suggest that exergames may be a promising tool for delivering falls prevention exercises and increasing adherence to exercise in older people. Understanding the motivation of older people to use exergames may assist in the process of implementation.

A Study Protocol for Applying User Participation and Co-Learning-Lessons Learned from the eBalance Project

The eBalance project is based on the idea that serious exergames-i.e., computer gaming systems with an interface that requires physical exertion to play-that are well adapted to users, can become a substantial part of a solution to recognized problems of insufficient engagement in fall-prevention exercise and the high levels of fall-related injuries among older people. This project is carried out as a collaboration between eight older people who have an interest in balance training and met the inclusion criteria of independence in personal activities of daily living, access to and basic knowledge of a computer, four staff working with the rehabilitation of older adults, and an interdisciplinary group of six research coordinators covering the areas of geriatric care and rehabilitation, as well as information technology and computer science. This paper describes the study protocol of the project's initial phase which aims to develop a working partnership with potential users of fall-prevention exergames, including its conceptual underpinnings. The qualitative methodology was inspired by an ethnographical approach implying combining methods that allowed the design to evolve through the study based on the participants' reflections. A participatory and appreciative action and reflection (PAAR) approach, accompanied by inquiries inspired by the Normalization Process Theory (NPT) was used in interactive workshops, including exergame testing, and between workshop activities. Data were collected through audio recordings, photos, and different types of written documentation. The findings provide a description of the methodology thus developed and applied. They display a methodology that can be useful for the design and development of care service and innovations for older persons where user participation is in focus.

No Overt Effects of a 6-Week Exergame Training on Sensorimotor and Cognitive Function in Older Adults. A Preliminary Investigation

Several studies investigating the relationship between physical activity and cognition showed that exercise interventions might have beneficial effects on working memory, executive functions as well as motor fitness in old adults. Recently, movement based video games (exergames) have been introduced to have the capability to improve cognitive function in older adults. Healthy aging is associated with a loss of cognitive, as well as sensorimotor functions. During exergaming, participants are required to perform physical activities while being simultaneously surrounded by a cognitively challenging environment. However, only little is known about the impact of exergame training interventions on a broad range of motor, sensory, and cognitive skills. Therefore, the present study aims at investigating the effects of an exergame training over 6 weeks on cognitive, motor, and sensory functions in healthy old participants. For this purpose, 30 neurologically healthy older adults were randomly assigned to either an experimental (ETG, n = 15, 1 h training, twice a week) or a control group (NTG, n = 15, no training). Several cognitive tests were performed before and after exergaming in order to capture potential training-induced effects on processing speed as well as on executive functions. To measure the impact of exergaming on sensorimotor performance, a test battery consisting of pinch and grip force of the hand, tactile acuity, eye-hand coordination, flexibility, reaction time, coordination, and static balance were additionally performed. While we observed significant improvements in the trained exergame (mainly in tasks that required a high load of coordinative abilities), these gains did not result in differential performance improvements when comparing ETG and NTG. The only exergaming-induced difference was a superior behavioral gain in fine motor skills of the left hand in ETG compared to NTG. In an exploratory analysis, within-group comparison revealed improvements in sensorimotor and cognitive tasks (ETG) while NTG only showed an improvement in a static balance test. Taken together, the present study indicates that even though exergames might improve gaming performance, our behavioral assessment was probably not sensitive enough to capture exergaming-induced improvements. Hence, we suggest to use more tailored outcome measures in future studies to assess potential exergaming-induced changes.

Effects of Virtual Reality Training (Exergaming) Compared to Alternative Exercise Training and Passive Control on Standing Balance and Functional Mobility in Healthy Community-Dwelling Seniors: A Meta-Analytical Review

BACKGROUND

Balance training is considered an important means to decrease fall rates in seniors. Whether virtual reality training (VRT) might serve as an appropriate treatment strategy to improve neuromuscular fall risk parameters in comparison to alternative balance training programs (AT) is as yet unclear.

OBJECTIVE

To examine and classify the effects of VRT on fall-risk relevant balance performance and functional mobility compared to AT and an inactive control condition (CON) in healthy seniors.

DATA SOURCES

The literature search was conducted in five databases (CINAHL, EMBASE, ISI Web of Knowledge, PubMed, SPORTDiscus). The following search terms were used with Boolean conjunction: (exergam* OR exer-gam* OR videogam* OR video-gam* OR video-based OR computer-based OR Wii OR Nintendo OR X-box OR Kinect OR play-station OR playstation OR virtua* realit* OR dance dance revolution) AND (sport* OR train* OR exercis* OR intervent* OR balanc* OR strength OR coordina* OR motor control OR postur* OR power OR physical* OR activit* OR health* OR fall* risk OR prevent*) AND (old* OR elder* OR senior*).

STUDY SELECTION

Randomized and non-randomized controlled trials applying VRT as interventions focusing on improving standing balance performance (single and double leg stance with closed and open eyes, functional reach test) and functional mobility (Berg balance scale, Timed-up and go test, Tinetti test) in healthy community-dwelling seniors of at least 60 years of age were screened for eligibility.

DATA EXTRACTION

Eligibility and study quality (PEDro scale) were independently assessed by two researchers. Standardized mean differences (SMDs) served as main outcomes for the comparisons of VRT versus CON and VRT versus AT on balance performance and functional mobility indices. Statistical analyses were conducted using a random effects inverse-variance model.

RESULTS

Eighteen trials (mean PEDro score: 6 ± 2) with 619 healthy community dwellers were included. The mean age of participants was 76 ± 5 years. Meaningful effects in favor of VRT compared to CON were found for balance performance [p < 0.001, SMD: 0.77 (95 % CI 0.45-1.09)] and functional mobility [p = 0.004, SMD: 0.56 (95 % CI 0.25-0.78)]. Small overall effects in favor of AT compared to VRT were found for standing balance performance [p = 0.31, SMD: -0.35 (95 % CI -1.03 to 0.32)] and functional mobility [p = 0.05, SMD: -0.44 (95 % CI: -0.87 to 0.00)]. Sensitivity analyses between "weaker" (n = 9, PEDro ≤5) and "stronger" (n = 9, PEDro ≥6) studies indicated that weaker studies showed larger effects in favor of VRT compared to CON regarding balance performance (p < 0.001).

CONCLUSIONS

Although slightly less effective than AT, VRT-based balance training is an acceptable method for improving balance performance as well as functional mobility outcomes in healthy community dwellers. VRT might serve as an attractive complementary training approach for the elderly. However, more high-quality research is needed in order to derive valid VRT recommendations compared to both AT and CON.

A systematic review and meta-analysis of outcome measures to assess postural control in older adults who undertake exergaming

Exergaming has been shown to be an effective tool to improve postural control (PC) in older community-dwelling individuals. The outcome measures (OMs) used to assess PC are varied and this could limit the estimation of the effectiveness of the intervention. This systematic review and meta-analysis aims to explore the OMs currently used to assess PC in exergaming interventions, for healthy elderly individuals aged over 60 years. The literature search was conducted across five databases (CINAHL, EMBASE, PubMed, ISI, SPORTdiscus and Science Direct) using a range of search terms and combinations relating to exergaming, balance, exercise, falls and elderly. Quality assessment was conducted using the PEDro Scale and a custom-made quality assessment tool. Eleven trials were included in the meta-analysis, with a mean (SD) PEDro score of 5.36 (1.57). Primary and secondary OMs showed small effects in favour of alternative training modes, although these effects were statistically insignificant for all primary OMs. Tertiary OMs could not be included in the meta-analysis due to varying output parameters from different instruments. Heterogeneity remained high across trials and no studies performed long-term follow-up. Exergaming is a potential alternative to PC training, although still in its infancy. Strong and well-designed RCTs are needed, targeting specific populations aged over 60 years. Variability in instrumented OMs prevents generalisation of results. Technological improvements may provide data not currently available from clinical and laboratory-based methods, and may allow PC to be assessed more realistically and specifically in relation to a population's activities of daily living, though this remains a new area of research.

Do virtual reality games improve mobility skills and balance measurements in community-dwelling older adults? Systematic review and meta-analysis

OBJECTIVE

To summarize evidence on the effectiveness of virtual reality games and conventional therapy or no-intervention for fall prevention in the elderly.

DATA SOURCES

An electronic data search (last searched December 2016) was performed on 10 databases (Web of Science, EMBASE, PUBMED, CINAHL, LILACS, SPORTDiscus, Cochrane Library, Scopus, SciELO, PEDro) and retained only randomized controlled trials.

REVIEW METHOD

Sample characteristics and intervention parameters were compared, focusing on clinical homogeneity of demographic characteristics, type/duration of interventions, outcomes (balance, reaction time, mobility, lower limb strength and fear of falling) and low risk of bias. Based on homogeneity, a meta-analysis was considered. Two independent reviewers assessed the risk of bias.

RESULTS

A total of 28 studies met the inclusion criteria and were appraised ( n: 1121 elderly participants). We found that virtual reality games presented positive effects on balance and fear of falling compared with no-intervention. Virtual reality games were also superior to conventional interventions for balance improvements and fear of falling. The six studies included in the meta-analysis demonstrated that virtual reality games significantly improved mobility and balance after 3-6 and 8-12 weeks of intervention when compared with no-intervention. The risk of bias revealed that less than one-third of the studies correctly described the random sequence generation and allocation concealment procedures.

CONCLUSION

Our review suggests positive clinical effects of virtual reality games for balance and mobility improvements compared with no-treatment and conventional interventions. However, owing to the high risk of bias and large variability of intervention protocols, the evidence remains inconclusive and further research is warranted.