Unsupervised Virtual Reality-Based Exercise Program Improves Hip Muscle Strength and Balance Control in Older Adults: A Pilot Study

Navigating Through Innovation in Elderly's Health: A Scoping Review of Digital Health Interventions

Objectives

Comprehensively map and summarize digital health initiatives for the elderly and caregivers.

Methods

Scoping review between April and May 2022 based on Joanna Briggs methodology. Databases used included PubMed, Cochrane Library, CINAHL Plus, and Web of Science, along with grey literature and hand searches. Two reviewers independently conducted screening and eligibility phases, with a third resolving disagreements. Data were thematically analyzed.

Results

The review included 421 documents. Most documents were published between 2013 and 2022, with a recent increase. Most studies, originating from high-income countries, focused on home applications and were mainly in the testing and validation stages. Telephones and computers were the predominant devices. Health objectives included monitoring, prevention, and treatment, with interventions utilizing directed communication and personal health monitoring for individuals, and telemedicine and decision support for healthcare providers.

Conclusion

Increasing integration of technology in older adults' lives, along with their increasing proficiency, is driving a significant rise in digital health interventions. Despite this growth, further research in middle- and low-income countries, for caregivers and evaluating effectiveness and feasibility of these technological interventions is needed.

Transforming Sedentary Lifestyles: The impact of remote VR and flat-screen interventions on affective attitudes towards physical exertion, guided by avatar or human trainers

This study advances understanding of the impact of flat-screen and virtual reality (VR) remote exercise environments in a home setting on affective attitudes towards physical exertion, with either a human or an avatar trainer. Employing a two-by-two factorial design, we manipulated both the medium (flat screen vs. VR) and the type of trainer (human vs. avatar). A total of 108 participants engaged in the study using a custom VR application for the Oculus Quest 2 headset or training videos, both prepared specifically for this study. The participants underwent a 15-min high-intensity interval training (HIIT) regimen, completing six workouts in their homes within fourteen days. Data on their exercise experiences and their affective attitudes towards exercise were collected using the CAWI technique. These were next analysed using a model that presumes that exercise experiences can increase motivation to exercise. We also studied the roles of spatial presence and trainer relatedness. Our results show that VR physical training shifted affective attitudes towards exercise positively, in contrast to the flat-screen groups. Moreover, using a digital avatar as a trainer had no negative effect on this favourable change in attitude. The change in affective attitude was influenced primarily by baseline levels and the wellbeing experienced during training. The factors we added to the original model-relatedness to the trainer and spatial presence-also contributed significantly to wellbeing. Perception of competence was a critical determinant of wellbeing, while perceived exertion was largely irrelevant. The HIIT protocol in the study was suitable for VR exercise.

The Application of Virtual Reality in Shoulder Surgery Rehabilitation

To achieve a positive functional prognosis in orthopedic surgery, particularly in shoulder surgeries, effective rehabilitation is essential. Recently, there has been growing interest in the use of virtual reality (VR) in the field of orthopedics, particularly for preoperative education and training, as well as clinical and home-based rehabilitation. This report describes the process of developing an application utilizing Meta Quest 2 VR technology (Meta, CA, USA) for rehabilitation after shoulder surgery. This application assists patients in performing postoperative exercises at home by wearing VR equipment tailored to their postoperative weeks. The advantages of VR rehabilitation lie in overcoming the limitations of traditional rehabilitation methods and providing patients with a better rehabilitation experience. Moreover, automating the rehabilitation process and reducing patients' visits to clinics can lead to cost savings. This report raises expectations for the potential and scalability of VR utilization, extending beyond orthopedics to other fields. In addition, it anticipates that with better feedback and motivation, the rehabilitation effects for patients can be further enhanced.

Effects of kinect-based virtual reality training on bone mineral density and fracture risk in postmenopausal women with osteopenia: a randomized controlled trial

Osteopenia is a condition characterized by low bone mineral density (BMD) that increases fracture risk, particularly among postmenopausal women (PMW). This study aimed to determine the effects of Kinect-based VRT on BMD and fracture risk in PMW with osteopenia. The study was a prospective, two-arm, parallel-design, randomized controlled trial. The study enrolled 52 participants, 26 randomly assigned to each group. In the experimental group, Kinect-based VRT was provided thrice weekly for 24 weeks for 45 min/session. Both groups were instructed to engage in a daily 30-min walk outdoors. The fracture risk assessment tool (FRAX) was used to calculate fracture risk, and dual-energy X-ray absorptiometry was used to measure lumbar spine and femur neck BMD. Both variables were assessed at baseline and 24 weeks afterwards. After 24 weeks of Kinect-based VRT, the experimental group showed significant BMD increases in the right and left femoral necks and lumbar spine (p value < 0.001). In the control group, the BMD at the right and left femoral necks showed fewer significant changes (p value < 0.022 and 0.004, respectively). In the control group, lumbar spine BMD did not change (p = 0.57). The experimental group showed significantly lower FRAX scores for hip fracture prediction (HFP) and hip prediction of major osteoporotic (HPMO) at both femoral necks (p value < 0.001) than the control group (p = 0.05 and p = 0.01, respectively), but no significant change at the left femoral neck for HFP (p = 0.66) or HPMO (p = 0.26). These findings indicate that a Kinect-based VRT intervention resulted in significantly increased BMD and a reduced fracture risk, as predicted by HFP and HPMO measurements. These improvements were more pronounced in the experimental group than in the control group. Thus, Kinect-based VRT may be utilized as an effective intervention to improve BMD and reduce fracture risk in postmenopausal women with osteopenia.

The application of virtual reality meditation and mind-body exercises among older adults

Virtual reality (VR)-based mindfulness is a promising method to improve the health of older adults. Therefore, many attempts have been made to explore the application of VR-based mindfulness, such as VR meditation and mind-body exercises, in older adults. Generally, current studies indicate the heavy reliance on apparatus for implementing VR-based mindfulness interventions. In VR meditation, the crucial apparatus is VR headsets. In VR mind-body exercises, three essential components are required: motion capture sensors, main consoles, and display screens. In the aspect of health promotion, VR meditation is an effective method for improving mental health, pain, and quality of life in older adults. VR mind-body exercises contribute to increasing the mental health and physical function of older adults. Furthermore, VR mind-body exercises may be combined with other forms of exercise as a mixed method to promote the health of older adults. VR-based mindfulness interventions enhance the meditation and mind-body exercises experience for older adults while improving accessibility. However, their implementation still encounters a series of challenges, such as cost, technical anxiety, and apparatus-related issues. Additionally, we recommend future research to examine the optimal exercise dose for VR mind-body exercises to maximize their health benefits.

An affordable and immersive virtual reality-based exercise therapy in forward head posture

Forward Head Posture (FHP) is one of the most commonly occurring musculoskeletal abnormalities. Despite exercise therapy being an effective approach for FHP treatment, it can be long, monotonous, and tedious. Virtual reality (VR) can be used as an innovative solution to address these challenges. We designed an affordable and immersive VR-based exercise therapy (VRET) system for FHP correction. The VRET contents (i.e., exercises and VR scenarios) were determined by physiotherapists and game designers at the focus group meetings. Hardware requirements include a VR box, smartphone, and sensors (i.e., a smartphone accelerometer and an affordable Inertial Measurement Unit (IMU)) to measure head motions and transfer them via Wi-Fi to the VRET system. The IMU was designed using the MPU6050, Arduino Nano, and ESP8266-01S. Gwet's AC1, Game Experience Questionnaires (GEQ), and System Usability Scale (SUS) were used to measure intra-rater reliability, user experience, and system usability, respectively. The determined exercises, including Capital Flexion-Extension and Chin Tuck, were designed in the form of a shooting game. A physiotherapist and twenty-one FHP individuals took part in evaluating the system. High precision was obtained for the designed IMU (i.e., pitch and roll < 0.1° and yaw < 1.3 °). Gwet's AC1 and SUS results showed very good intra-rater reliability (coefficient = 0.892) and excellent usability (score = 87.14), respectively. According to the mean scores of the GEQ, participants were confident about competence, immersion, flow, and positive affect components. The development of low-cost VRET systems for FHP correction is a step towards facilitating rehabilitation challenges by providing positive experiences for users as well as helping them perform therapeutic exercises correctly.

Effectiveness of Virtual Reality Therapy on Balance and Gait in the Elderly: A Systematic Review

Virtual reality (VR) therapies are presently utilized to treat physical and cognitive impairments among elderly people. This systematic review aims to collect the most recent evidence on the effectiveness of VR in improving balance and gait among healthy elderly individuals, in comparison with other therapies. A literature search was conducted using the PubMed, SCOPUS, PEDro, and WoS databases, by selecting randomized clinical trials that evaluated balance, both static and dynamic, as well as gait in a population of healthy older adults who underwent virtual reality therapy. The methodological quality of the studies was assessed using the PEDro scale. After eligibility criteria were applied and duplicates were removed, 20 studies were selected out of 1705 initially identified. The present systematic review concludes that virtual reality therapy is more effective than minimal intervention or usual care in enhancing static balance, dynamic balance, and gait in healthy elderly individuals. Moreover, virtual reality therapy yields better outcomes compared to traditional balance training and physical exercise in improving balance and gait in this demographic. However, both methods have shown effectiveness.

Virtual Reality-Based Exercise Therapy for Patients with Chronic Musculoskeletal Pain: A Scoping Review

This scoping review aimed to identify interventions utilizing virtual-reality-based exercise therapy in patients with chronic musculoskeletal pain. Searches were conducted in four databases using descriptors related to virtual reality, exercise, and chronic musculoskeletal pain. Two reviewers screened the titles and abstracts of the studies to assess eligibility, with a third author resolving any discrepancies. Data were extracted and summarized in a narrative format by three independent raters. Clinical trials were evaluated using the PEDro scale to assess the effectiveness of virtual-reality-based exercise therapy in chronic musculoskeletal pain patients. A total of 162 articles were identified from the databases. After applying the inclusion criteria, nine articles were considered suitable for analysis, including six randomized clinical trials. The selected articles were categorized based on study characteristics, virtual-reality-based exercise therapy interventions (including technologies and equipment used), exercise interventions, outcome measures, and effectiveness. The findings indicate that virtual-reality-based exercise therapy shows promising results in reducing pain, improving disability, enhancing range of motion, and increasing treatment satisfaction in patients with chronic musculoskeletal pain. However, it is not possible to conclude that virtual-reality-based exercise therapy is superior to other treatments due to the limited number of available studies, heterogeneity in application protocols, and varying methodological quality. Further research is needed to draw more definitive conclusions.

The effect of virtual reality technology on anti-fall ability and bone mineral density of the elderly with osteoporosis in an elderly care institution

OBJECTIVE

To explore the impact of virtual reality (VR) training on anti-fall ability and bone mineral density (BMD) among elderly patients admitted to a healthcare institution.

METHODS

People (aged 50) with osteoporosis in an elderly care institution in Anhui Province June 2020 to October 2021 were selected and randomly divided into VR group (n = 25) and control group (n = 25). In VR group, the virtual reality rehabilitation training system was used for training, while control group was treated with traditional fall prevention exercise intervention. The changes of Berg Balance Scale (BBS), timed up and go test (TUGT), functional gait assessment (FGA), bone mineral density (BMD) and falls during 12 months of training were compared between the two groups.

RESULTS

BBS and FGA were positively correlated with BMD of the lumbar vertebrae and femoral neck, and TUGT was negatively correlated with BMD of the lumbar vertebrae and femoral neck. After 12 months of training, the BBS score, TUGT evaluation and FGA evaluation of the two groups were significantly improved compared with those prior to training (P < 0.05). However, there was no significant difference in the lumbar spine and femoral neck BMD between the two groups 6 months after the intervention. The femoral neck and lumbar spine BMD of the VR group improved, and it was significantly higher than that of the control group 12 months after the intervention. Nevertheless, there was no significant difference in terms of the incidence of adverse events between the two groups.

CONCLUSION

VR training can improve anti-fall ability and increase femoral neck and lumbar spine BMD and can effectively prevent and reduce the risk of injury among elderly people with osteoporosis.

Virtual Reality Exergaming Capability to Change Muscle Strategy During the Limits of Stability Test and Reduce Fear of Falling in Primary Osteoporotic Women

Objective: Muscle strength and balance impairment change the control strategy and increase the probability of falling. This study aimed to investigate the effect of 6-week strength-balance training through virtual reality exergaming (VRE) on muscle strategy during the limits of stability (LOS) test, fear of falling, and quality of life (QOL) in osteoporotic women. Materials and Methods: Twenty volunteer postmenopausal women with osteoporosis were randomly allocated to the VRE (n = 10) and traditional training (TRT as control, n = 10) groups. The VRE and TRT strength-balance training was performed for 6 weeks and three sessions per week. Before and after exercise, the muscle activity (onset time, peak root means square [PRMS]) and hip/ankle activity ratio were assessed by the wireless electromyography system. The muscle activities of the dominant leg were recorded during LOS functional test. The fall efficacy scale and QOL were assessed. Paired t-test was used to compare results within groups, and an independent t-test was used to compare the percentage changes in parameters between the two groups. Results: The VRE improved the onset time and PRMS. The VRE significantly reduced the hip/ankle activity ratio in the LOS test's forward, backward, and right directions (P < 0.05). No significant change was seen in all directions of the LOS functional test in the TRT group (P > 0.05). VRE reduced the fall efficacy scale (P = 0.042). Both VRT and TRT improved the total QOL score (P = 0.010). Conclusion: VRE was more effective in decreasing the onset time and hip/ankle ratio of muscle activation. The VRE is recommended to induce a better ability to reduce the fear of falling and control balance during functional activity in osteoporotic women. Clinical Trial Registration number: IRCT20101017004952N9.

Task-Oriented and Imitation-Oriented Movements in Virtual Reality Exercise Performance and Design

OBJECTIVE

This study investigated the influence of game features and practice type on human kinematic and muscular performance in a virtual reality exercise (VRE). Participants demonstrated changes in shoulder flexion angle and muscle activation under different virtual scenarios.

BACKGROUND

Conventional VRE studies often compared the outcomes between an experimental group that underwent exercise in VR and a real-world exercise control group, whereas comparisons between VRE programs are lacking. Besides, the attributes of VREs received little attention.

METHOD

Thirteen able-bodied participants performed upper extremity exercise movements in immersive VR using a head-mounted display. Participants performed task-oriented and imitation-oriented movements with different game features. Shoulder muscle activity (the deltoid, supraspinatus, and infraspinatus) and shoulder motion were collected.

RESULTS

Practice type (task-oriented, imitation-oriented) significantly influenced the flexion angle of the shoulder complex (F(1,11) = 9.53, p = .01), and the muscle activity of the supraspinatus (F(1,9) = 12.61, p = .006) and the infraspinatus (F(1,9) = 12.71, p = .006). Game features did not have a statistically significant effect on shoulder flexion angle or shoulder muscles' activations.

CONCLUSIONS

Compared to imitation-oriented practice, task-oriented practice elicited more intensive shoulder movements and muscular efforts but also induced greater movement variations. Substantial differences across game features levels should be further investigated to have significant effects.

APPLICATIONS

This research may help guide the design of future VREs. For strength training or rehabilitation where intensive practice is required, task-oriented practice should be considered; for movement learning where movement consistency is required, imitation oriented practice should be adopted.

Feasibility, Safety, Enjoyment, and System Usability of Web-Based Aerobic Dance Exercise Program in Older Adults: Single-Arm Pilot Study

BACKGROUND

During the COVID-19 epidemic, opportunities for social interaction and physical activity among older people are decreasing, which may have a negative impact on their health. As a solution, a web-based group exercise program provided through a videoconferencing platform would be useful. As a web-based exercise program that older adults can easily, safely, and enjoyably perform at home, we developed a short-duration, light-intensity aerobic dance exercise program. Before studying the effectiveness of this exercise program, its characteristics, such as feasibility, safety, enjoyment, and system usability, should be examined among older adults.

OBJECTIVE

This pilot study aimed to examine the feasibility, safety, and enjoyment of a web-based aerobic dance exercise program and the usability of a web-based exercise delivery system using a videoconferencing platform for older adults.

METHODS

This study was designed as a prospective single-arm pilot study. A total of 16 older adults participated in an 8-week web-based aerobic dance program held every morning (8:30 AM to 8:50 AM) on weekdays at home. Retention and adherence rates were measured for the program's feasibility. Safety was assessed by the heart rate reserve, an index of exercise intensity calculated from heart rate, and the number of adverse events during exercise sessions. Enjoyment of this exercise program was assessed by an 11-point Likert scale ranging from 0 (not enjoyable at all) to 10 (extremely enjoyable) obtained through telephone interviews after the first-, third-, sixth-, and eighth-week intervention. For usability, the ease of the videoconferencing platform system was assessed through telephone interviews after the intervention.

RESULTS

A female participant with hypertension dropped out in the second week because of the continuously reported high blood pressure (≥180 mmHg) before attending the exercise session in the first week. Therefore, the retention rate was 93.8% (15/16). Among the remaining participants, the median (IQR) overall adherence rate was 97.4% (94.7-100). Regarding safety, the mean (SD) heart rate reserve during the aerobic dance exercise was 29.8% (6.8%), showing that the exercise was relatively safe with very light to light intensity. There were no adverse events during the exercise session. The enjoyment score (0-10 points) significantly increased from the first (6.7 [1.7]) to sixth (8.2 [1.3]) and eighth week (8.5 [1.3]). Regarding usability, 11 participants reported difficulties at the beginning, such as basic touch panel operations and the use of unfamiliar applications; however, all got accustomed to it and subsequently reported no difficulty.

CONCLUSIONS

This study showed high feasibility, enjoyment, and safety of the web-based aerobic dance exercise program in older adults, and the web-based exercise delivery system may have areas for improvement, albeit without serious problems. Our web-based aerobic dance exercise program may contribute to an increase in physical and social activities among older adults.

Effectiveness of Early Rehabilitation with Exergaming in Virtual Reality on Gait in Patients after Total Knee Replacement

Total knee replacement (TKR) is the treatment of choice for advanced stages of osteoarthritis but it requires good postoperative rehabilitation. This study aimed to assess the effectiveness of exercises using virtual reality to improve gait parameters in patients after TKR. Fifty-nine patients 7−14 days after TKR surgery were divided into a study group (VRG, n = 38) and a control group (CG, n = 21). Both groups underwent the same 4-week rehabilitation protocol. The VRG group had 12 additional nonimmersive virtual reality game sessions on the Virtual Balance Clinic prototype system at 30 min each, focusing on gait and balance improvement. Spatiotemporal, force and foot plantar pressure parameters were collected on an instrumented treadmill during a 30 s walk. The most significant improvement was in the symmetry indices of forefoot force, maximum forefoot force, loading response time, and preswing time (p < 0.05) in both groups. Gait speed increased by 31.25% and 44% in the VRG and CG groups, respectively (p < 0.005). However, the extra exergaming sessions did not significantly improve rehabilitation outcomes. Therefore, additional VR training does not improve gait better than standard rehabilitation alone, but the improvement of gait, especially its symmetry, is significant within the first six weeks after surgery.

The Effect of Exergame Training on Physical Functioning of Healthy Older Adults: A Meta-Analysis

Exergames have attracted increasing attention from both the public and researchers. Although previous systematic reviews provided evidence that exergame training is beneficial for improving balance or mobility in older adults, multidimensional physical function measurements, including balance, upper body strength, lower body strength, aerobic endurance, and gait, might help us achieve more robust and reliable results. This meta-analysis aims to quantify the effects of exergame training on overall and specific physical function in healthy older adults. We systematically searched exergame training studies published between January 1985 and June 2021. Forty-eight studies were included in the present meta-analysis, with a total of 1099 participants included in the training group and 1098 participants in the control group. Random-effects meta-analyses found that older adults obtained a small benefit in overall physical function performance (g = 0.43, 95% confidence interval [CI] = 0.33 to 0.53), moderate benefits in balance (g = 0.59, 95% CI = 0.46 to 0.71), upper body strength (g = 0.65, 95% CI = 0.20 to 1.10), lower body strength (g = 0.51, 95% CI = 0.37 to 0.65), and aerobic endurance (g = 0.65, 95% CI = 0.44 to 0.86), a small benefit in gait (g = 0.33, 95% CI = 0.08 to 0.59), and negligible effects on upper body flexibility (g = 0.13, 95% CI = -0.06 to 0.32) and lower body flexibility (g = 0.10, 95% CI = -0.45 to 0.67) from exergame training. The mini-mental state examination score was positively associated with the overall training efficacy (β = 0.08, P = 0.01), while body mass index and the sample size in the training group were negatively associated with the overall training efficacy (β = -0.01, P < 0.01; β = -0.004, P < 0.01). The current meta-analytic findings revealed that exergame training produced general benefits for overall physical function and different effects on specific physical function domains in older adults.

Applicability of an immersive virtual reality system for assessing route learning in older adults

Spatial orientation is defined as the ability to find one’s way around an environment, follow familiar routes, recognize places, and learn new routes. Spatial disorientation is one of the early symptoms of Alzheimer’s disease (AD), and traditional cognitive evaluation lacks ecological validity. Therefore, new assessment methods are needed for the early identification of this cognitive impairment.

Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study as a Multistakeholder Team During the COVID-19 Pandemic

BACKGROUND

Advancements in supporting personalized health care and well-being using virtual reality (VR) have created opportunities to use immersive games to support a healthy lifestyle for persons living with dementia and mild cognitive impairment (MCI). Collaboratively designing exercise video games (exergames) as a multistakeholder team is fundamental to creating games that are attractive, effective, and accessible.

OBJECTIVE

This research extensively explores the use of human-centered design methods that involve persons living with dementia in long-term care facilitates, exercise professionals, content developers, game designers, and researchers in the creation of VR exergames targeting physical activity promotion for persons living with dementia/MCI.

METHODS

Conceptualization, collaborative design, and playtesting activities were carried out to design VR exergames to engage persons living with dementia in exercises to promote upper limb flexibility, strength, and aerobic endurance. We involved a total of 7 persons living with dementia/MCI, 5 exercise professionals, 5 community-dwelling older adults, a VR company for content creation, and a multidisciplinary research team with game designers, engineers, and kinesiology experts.

RESULTS

An immersive VR exergame called Seas the Day was jointly designed and developed and it is freely available to be played in state-of-the-art VR headsets (Oculus Quest 1, 2). A model for the triadic interaction (health care institution, industry partner, academia) is also presented to illustrate how different stakeholders contribute to the design of VR exergames that consider/complement complex needs, preferences, and motivators of an underrepresented group of end users.

CONCLUSIONS

This study provides evidence that a collaborative multistakeholder design results in more tailored and context-aware VR games for persons living with dementia. The insights and lessons learned from this research can be used by others to co-design games, including remote engagement techniques that were used during the COVID-19 pandemic.

Feasibility of Cognitive-Motor Exergames in Geriatric Inpatient Rehabilitation: A Pilot Randomized Controlled Study

Objective: The aim of this pilot randomized clinical trial was to test the feasibility and efficacy of an exergame-based cognitive-motor training program in geriatric inpatients. Methods: The study participants were randomly allocated to either the exergame intervention group or the control group. The control group received the standard rehabilitation treatment offered in the clinic. In addition to the standard rehabilitation program, the intervention group conducted supervised exergame training on 5 days per week using the Dividat Senso, an exergame system specifically designed for older adults. The primary outcome was feasibility, as measured by e.g., adherence rate, attrition rate, occurrence of adverse events, System Usability Scale (SUS) and NASA-TLX score. Secondary outcomes included measures of physical and cognitive functioning such as comfortable walking speed, maximal walking speed, dual task walking speed, Short Physical Performance Battery (SPPB), Timed Up and Go test (TUG), Color-Word Interference test (D-KEFS), Trail Making test A and B (TMT), Go/No-Go test and Step Reaction Time test (SRTT). All secondary outcome measures were assessed pre- and post-intervention. Results: Thirty-nine persons were included in the study. Average adherence rate was 99%, there were no intervention-related dropouts and no adverse events. The mean System Usability Scale (SUS) score was 83.6 and the mean NASA-TLX score 45.5. Significant time-group interaction effects were found for the dual task walking speed, the Go/No-Go test and Step Reaction Time test (SRTT). Conclusion: Exergaming is a feasible, safe and effective cognitive-motor training approach in inpatient rehabilitation of geriatric patients. Incorporating exergaming in the rehabilitation program of geriatric patients offers potential to reduce fall risk factors and to increase patients' exercise motivation and rehabilitation success.

Effect of the Nintendo Ring Fit Adventure Exergame on Running Completion Time and Psychological Factors among University Students Engaging in Distance Learning during the COVID-19 Pandemic: A Randomized Prospective Study (Preprint)

Background

The COVID-19 outbreak has not only changed the lifestyles of people globally but has also resulted in other challenges, such as the requirement of self-isolation and distance learning. Moreover, people are unable to venture out to exercise, leading to reduced movement, and therefore, the demand for exercise at home has increased.

Objective

We intended to investigate the relationships between a Nintendo Ring Fit Adventure (RFA) intervention and improvements in running time, cardiac force index (CFI), sleep quality (Chinese version of the Pittsburgh Sleep Quality Index score), and mood disorders (5-item Brief Symptom Rating Scale score).

Methods

This was a randomized prospective study and included 80 students who were required to complete a 1600-meter outdoor run before and after the intervention, the completion times of which were recorded in seconds. They were also required to fill out a lifestyle questionnaire. During the study, 40 participants (16 males and 24 females, with an average age of 23.75 years) were assigned to the RFA group and were required to exercise for 30 minutes 3 times per week (in the adventure mode) over 4 weeks. The exercise intensity was set according to the instructions given by the virtual coach during the first game. The remaining 40 participants (30 males and 10 females, with an average age of 22.65 years) were assigned to the control group and maintained their regular habits during the study period.

Results

The study was completed by 80 participants aged 20 to 36 years (mean 23.20, SD 2.96 years). The results showed that the running time in the RFA group was significantly reduced. After 4 weeks of physical training, it took females in the RFA group 19.79 seconds (P=.03) and males 22.56 seconds (P=.03) less than the baseline to complete the 1600-meter run. In contrast, there were no significant differences in the performance of the control group in the run before and after the fourth week of intervention. In terms of mood disorders, the average score of the RFA group increased from 1.81 to 3.31 for males (difference=1.50, P=.04) and from 3.17 to 4.54 for females (difference=1.38, P=.06). In addition, no significant differences between the RFA and control groups were observed for the CFI peak acceleration (CFIPA)_walk, CFIPA_run, or sleep quality.

Conclusions

RFA could either maintain or improve an individual’s physical fitness, thereby providing a good solution for people involved in distance learning or those who have not exercised for an extended period.

Trial Registration

ClinicalTrials.gov NCT05227040; https://clinicaltrials.gov/ct2/show/NCT05227040

Effects of Xbox Kinect exercise training on sleep quality, anxiety and functional capacity in older adults

The aim of this study was to examine the effects of an Xbox Kinect exercise program on sleep quality, anxiety and functional capacity in older adults. Twenty-nine older adults were randomized into two treatment groups: XBOX (n = 15) or CONTROL (n = 14). The XBOX group performed exercise with an Xbox Kinect for 60 min, three times per week for 6 weeks. The CONTROL group did not exercise. Improvements in sleep quality (p = 0.04), anxiety (p = 0.007), aerobic endurance (p = 0.003), agility/balance (p = 0.02), and lower limb strength (p = 0.05) were observed in the XBOX group compared with the CONTROL. Xbox Kinect exercise program improved sleep quality, reduced anxiety, and increased the functional capacity of older adults. These results support the value of exercise in the Xbox Kinect for sleep quality and anxiety in older adults. (Clinical Trials Registration NCT04692272).

Exercising With Embodied Young Avatars: How Young vs. Older Avatars in Virtual Reality Affect Perceived Exertion and Physical Activity Among Male and Female Elderly Individuals

This study demonstrated that implementation of the Proteus effect via manipulation of avatar age in VR is effective among elderly individuals in the context of exercise. One hundred and four elderly adults aged 60 years and older who did not engage in vigorous physical activities participated in this experiment with a 2 (avatar age: young vs. older) × 2 (sex: male vs. female) design. The results showed that the embodiment of younger avatars (age approximately 20 years) in VR leads to greater perceived exercise exertion regardless of sex after controlling for age and emotion. Older adults with young avatars perceived a greater contribution of efforts to exercise. This study also found that among those who did not engage in vigorous exercise, female older adults who embodied young avatars reported greater self-efficacy for future exercise and greater physical activity during the exercise phase than those who embodied older avatars. This study suggests that females are more likely to be motivated to continue exercising through young avatar embodiment. In contrast, female elderly who embodied old avatars reported significant fewer physical activity than male elderly who embodied old avatars. This indicated that the Proteus effect had stronger effects among females than among older males. Although we found the Proteus effect through VR avatar manipulation, the effect was temporary and limited to the experimental phase. This study is the first to examine the Proteus effect among elderly individuals in the context of exercise. It also contributes to the literature by indicating that avatar age manipulation is an effective means of promoting exercise among elderly individuals and helping them achieve exercise outcomes. This study further demonstrates that female elderly individuals respond to young avatars differently than male elderly individuals, with female elderly individuals showing more positive effects of young avatar embodiment than males. Implications and theoretical contributions are discussed.

Exploring the Acceptability and Feasibility of Providing a Balance Tele-Rehabilitation Programme to Older Adults at Risk for Falls: An Initial Assessment

Falls are a major health concern. The HOLOBALANCE tele-rehabilitation system was developed to deliver an evidence based, multi-sensory balance rehabilitation programme, to the elderly at risk of falls. The system delivers a series of balance physiotherapy exercises and cognitive and auditory training tasks prescribed by an expert balance physiotherapist following an initial balance assessment. The HOLOBALANCE system uses augmented reality (AR) to deliver exercises and games, and records task performance via a combination of body worn sensors and a depth camera. The HOLOBALANCE tele-rehabilitation system provides feedback to the supervising clinical team regarding task performance, participant usage and user feedback. Herewith we present the findings from the first 25 study participants regarding the feasibility and acceptability of the proposed system. The results of the clinical study indicate that the system is acceptable by the end users and also feasible for using in hospital and home environments.

Multisensory Exercise Improves Balance in People with Balance Disorders: A Systematic Review

OBJECTIVE

To examine the effect of multisensory exercise on balance disorders.

METHODS

PubMed, Scopus and Web of Science were searched to identify eligible studies published before January 1, 2020. Eligible studies included randomized control trials (RCTs), non-randomized studies, case-control studies, and cohort studies. The methodological quality of the included studies was evaluated using JBI Critical Appraisal Checklists for RCTs and for Quasi-Experimental Studies by two researchers independently. A narrative synthesis of intervention characteristics and health-related outcomes was performed.

RESULTS

A total of 11 non-randomized studies and 9 RCTs were eligible, including 667 participants. The results supported our assumption that multisensory exercise improved balance in people with balance disorders. All of the 20 studies were believed to be of high or moderate quality.

CONCLUSION

Our study confirmed that multisensory exercise was effective in improving balance in people with balance disorders. Multisensory exercises could lower the risk of fall and enhance confidence level to improve the quality of life. Further research is needed to investigate the optimal strategy of multisensory exercises and explore the underlying neural and molecular mechanisms of balance improvement brought by multisensory exercises.

Does Physical Dance Training with Virtual Games Change Muscle Quality of Community-Dwelling Older Women?

Objective: The aim of the study is to analyze the effects of physical dance training with a virtual game on muscle quality (MQ) of community-dwelling older women. Materials and Methods: In total, 46 older women participated in the study and were assigned to either a control group (CG, n = 25, 71 ± 5 years) or training group (TG, n = 21, 69 ± 4 years). The following assessments were performed at baseline and after 12 weeks: quadriceps, ankle plantar flexor, and dorsiflexor isokinetic peak torque (PT) (Biodex System 4 Dynamometer); quadriceps cross-sectional area (CSA) measured using magnetic resonance imaging; intramuscular noncontractile tissue (IMNCT) (Image-Pro Plus 4.5.0.29 for Windows); and MQ (ratio of quadriceps PT to CSA). Each week for 12 weeks, the TG undertook three 40-minute sessions of physical training with the "Dance Central" game for Xbox 360^® with Kinect, while the CG was instructed to maintain usual activities of daily living. Results: The TG increased quadriceps eccentric PT at 60°/s (P = 0.04) and ankle plantar flexor concentric PT at 60°/s (P = 0.02) when compared with the CG. No significant difference in quadriceps CSA, IMNCT, and MQ was observed. Conclusion: Physical dance training with virtual games can increase quadriceps and ankle plantar flexor strength without changing IMNCT and MQ of community-dwelling older women. Trial number: RBR-8xkwyp (ensaiosclinicos.gov.br-Brazilian Clinical Trials Registry).

Effects of virtual reality versus conventional balance training on balance of the elderly

OBJECTIVE

The aging population is growing in the world, and the reduction in physical function caused by this is an important issue that, particularly, causes a disorder of balance and an increased risk of falling. This study aimed at the comparison between the effects of virtual reality training (VRT) and Conventional balance training (CBT) on the balance of the elderly.

METHODS

The present study was conducted on 36 elderly (men and women) who are living in nursing homes. Participants were randomly divided into three groups: virtual reality training (6 males, 6 females; age = 66.5 ± 3.8 years), Conventional balance training (6 males, 6 females; age = 67.5 ± 3.1 years), and control (5 males, 7 females; age = 66.7 ± 3.2 years). Each group participated in a 60-min session, 3 times per week, for 9 weeks. To assess the participants' balance, the balance tests were used on single-leg stance (SLS) with open and closed eyes, Functional reach test (FRT), Timed up and Go Test (TUG), and Fullerton Advance Balance Scale (FABS). Data analysis was done using paired t-test and analysis of covariance by SPSS software version 24 at the significant level (P = 0.05).

RESULTS

In both groups (VRT, CBT), SLS with open and closed eyes, FRT, TUG, and FABS were significantly improved (P˂0.05). After the intervention, changes in both groups were similar (P > 0.05), which indicates that neither VRT and CBT training methods were superior to the other.

CONCLUSION

According to the results of this study, it seems that a virtual reality training program can be used as a new training method to improve the elderly's balance in daily programs of nursing homes.

The effects of exergames on muscle strength: A systematic review and meta-analysis

This systematic review and meta-analysis examined studies on the chronic effects of exergames on muscle strength in humans. PubMed, Scopus, CENTRAL, Web of Science, SciELO, Biblioteca Virtual em Saúde, and Google Scholar were searched, and manual searches of the reference lists of included studies and hand-searches on Physiotherapy Evidence Database and ResearchGate were conducted from inception to August 10, 2020. Randomized and non-randomized exergame intervention studies with or without a non-exercise group and/or a "usual care intervention group" (any other intervention that did not incorporate exergames), which evaluated muscle strength through direct measurements, were included. Forty-seven and 25 studies were included in the qualitative review and meta-analysis, respectively. The between-groups meta-analyses showed no significant differences between exergames and non-exercise control groups for handgrip strength in heathy/unhealthy middle-aged/older adults or knee extension maximum voluntary isometric contraction (MVIC) in healthy older adults. However, exergames provided a greater increase in handgrip strength, knee flexion MVIC, and elbow extension MVIC, but not knee extension MVIC or elbow flexion MVIC, in individuals with different health statuses when compared to usual care interventions. Also, there was a greater increase in handgrip strength in children with hemiplegic cerebral palsy favouring usual care plus exergames compared to usual care interventions. These results suggest that exergames may improve upper and lower limb muscle strength in individuals with different heath statuses compared to usual care interventions, but not muscle strength in middle age/older adults after accounting for random error. Also, exergames appear to be a useful tool for improving handgrip strength in children with hemiplegic cerebral palsy when added to usual care. However, as the exergame interventions were applied in different populations and there currently are many different approaches to perform exergames, future randomized controlled trials with high methodological quality and large sample sizes are needed to provide more compelling evidence in favour of a specific exergame protocol, or to elucidate exergame protocol design principles that appear to strongly influence outcomes.

Effect of sensorimotor rehabilitation based on an immersive virtual reality model on mental health

The aim of this study was to determine the immersive virtual reality-based sensorimotor rehabilitation (IVR-SRB) effect on mental health (global mental health, depression, anxiety and well-being) in older adults.

METHODS

This study was experimental, with a sample of 111 older adults (control-experimental), considering an application of IVR-SRB in four different virtual settings with exteroceptive synchronization, proprioceptive and vestibular stimuli, for 6 weeks.

OUTCOME VARIABLES

symptoms associated with depression and anxiety; positive mental health (psychological well-being). A descriptive and inferential approach was used to analyze the data, and the ANCOVA test was used to compare the post-intervention groups, controlled by the baseline; In case of baseline moderation, a linear regression model was applied to identify the level of moderation and a region of significance analysis.

RESULTS

An IVR-SRB positive net effect was found in the reduction of symptoms of global mental health (p < 0.0001) and depression (p < 0.0001), without baseline moderation. The anxiety scores showed moderation at the beginning (p < 0.0001; b = -0.53), identifying that the greater the presence of anxiety symptoms, the greater the effect of IVR-SRB in reducing these symptoms; its effect is present from scores of 2.9 (Goldberg-12). There were no changes in well-being.

CONCLUSION

IVR-SRB is recognized as a great intervention tool among elderly population, showing its multidimensional approach capacity, properly responding to the reduction of symptoms associated with mental disorders.

The Efficacy of Fall Hazards Identification on Fall Outcomes: A Systematic Review With Meta-analysis

Objective

To investigate the efficacy of fall hazards identification programs when compared to no intervention or other fall prevention programs on number of falls, falls incidence, and identifying fall hazards in community-dwelling adults.

Data Sources

CINAHL, PubMed, EMBASE, Scopus, and PsychINFO were used to identify articles.

Study Selection

Studies were selected to compare fall hazards identification programs to a control group. Studies were eligible if they were randomized controlled trials and enrolled adults older than 50 years with the incidence rate of falls as an outcome.

Data Extraction

Study or authors, year, sample characteristics, intervention or comparison groups, number of falls, and number of hazards identified in the intervention and control groups, and follow-up were extracted. The risk of bias assessment was performed using the Cochrane Risk of Bias tool. Quality was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach per outcome.

Data Synthesis

A total of 8 studies (N=8) and 5177 participants were included. There was a high risk of bias across the studies mostly due to improper blinding of personnel of the outcome assessor. Pooled estimate effects from 5 studies assessing the incidence rate of falls from 3019 individuals indicated no difference between fall hazards identification programs and control (incidence rate ratio=0.98; 95% confidence interval, 0.87-1.10).

Conclusions

The current study suggests that there may be a benefit for fall hazards programs in reducing incident falls. However, because of a moderate GRADE rating, more large-scale studies with a higher number of falls events and more consistent control groups are required to determine the true effect.

Assessment of the Effectiveness of Rehabilitation after Total Knee Replacement Surgery Using Sample Entropy and Classical Measures of Body Balance

Exercises in virtual reality (VR) have recently become a popular form of rehabilitation and are reported to be more effective than a standard rehabilitation protocol alone. The aim of this study was to assess the efficacy of adjunct VR training in improving postural control in patients after total knee replacement surgery (TKR). Forty-two patients within 7-14 days of TKR were enrolled and divided into a VR group and a control group (C). The C group underwent standard postoperative rehabilitation. The VR group additionally attended twelve 30-min exercise sessions using the Virtual Balance Clinic prototype system. Balance was assessed on the AMTI plate in bipedal standing with and without visual feedback before and after the four-week rehabilitation. Linear measures and sample entropy of CoP data were analyzed. After four weeks of rehabilitation, a significant reduction in parameters in the sagittal plane and ellipse area was noted while the eyes remained open. Regression analysis showed that sample entropy depended on sex, body weight, visual feedback and age. Based on the sample entropy results, it was concluded that the complexity of the body reaction had not improved. The standing-with-eyes-closed test activates automatic balance mechanisms and offers better possibilities as a diagnostic tool.

Virtual Reality Balance Games Provide Little Muscular Challenge to Prevent Muscle Weakness in Healthy Older Adults

Objective: Muscle weakness is an important risk factor for falls in older adults. Intensity and duration of muscle activity are important determinants of exercise effectiveness in combating muscle weakness. The aim of this article was to assess the intensity and duration of muscle activity in virtual reality (VR) balance games. Materials and Methods: Thirty young and 30 healthy older adults played seven different VR balance games. Muscle activity of the vastus lateralis, vastus medialis, soleus, and gluteus medius was obtained using surface electromyography (EMG). The processed EMG signals were divided into 200-ms blocks, after which each block was categorized by its average normalized EMG activity, that is, >80%, 60%-80%, 40%-60%, or <40% of maximum voluntary contraction (MVC). We calculated the total number of blocks in each category to score intensity, as well as the maximal number of consecutive 200-ms blocks (MCBs) >40% MVC, to identify prolonged muscle activity. Results: Muscle activity during game play was mostly <40% MVC and prolonged activation was lacking. Only the games that included more dynamic movements showed activation blocks of higher intensity and resulted in more MCBs. Conclusion: Our method allowed us to analyze the overall muscle activity and the distribution of activity over a trial. Although the activation levels during these VR games were low in general, we identified game elements that could potentially provide a strength training stimulus. Future research should aim to implement these elements, such that the intensity, prolonged activity, and rest are optimized to sufficiently challenge lower limb muscles in VR training.

IoT Based Virtual Reality Game for Physio-therapeutic Patients

Biofeedback therapy trains the patient to control voluntarily the involuntary process of their body. This non-invasive and non-drug treatment is also used as a means to rehabilitate the physical impairments that may follow a stroke, a traumatic brain injury or even in neurological aspects within occupational therapy. The idea behind this study is based on using immersive gaming as a tool for physical rehabilitation that combines the idea of biofeedback and physical computing to get a patient emotionally involved in a game that requires them to do the exercises in order to interact with the game. This game is aimed towards addressing the basic treatment for ‘Frozen Shoulder’. In this work, the physical motions are captured by the wearable ultrasonic sensor attached temporarily to the various limbs of the patient. The data received from the sensors are then sent to the game via serial wireless communication. There are two main aspects to this study: motion capturing and game design. The current status of the application is a single ultrasonic detector. The experimental result shows that physio-therapeutic patients are benefited through the IoT based virtual reality game.

Virtual reality in pain therapy: a requirements analysis for older adults with chronic back pain

BACKGROUND

Today immersive environments such as Virtual Reality (VR) offer new opportunities for serious gaming in exercise therapy and psychoeducation. Chronic back pain (CBP) patients could benefit from exergames in VR. The requirements in older CBP patients for a VR pain therapy have not yet been determined in studies. The aim of the study was to perform a requirements analysis for the user group of geriatric patients with CBP for a VR exergame. The objective was to find out the expectations, desires, preferences and barriers in order to collect them as requirements for this vulnerable group and to determine frameworks of therapy by physiotherapists and psychotherapists.

METHODS

We conducted a requirements analysis through semi-structured interviews with 10 elderly participants with CBP. Furthermore, two focus groups were conducted with three physiotherapists and two psychotherapists to determine frameworks of therapy programs for the target group. The qualitative data were transcribed and examined through a structuring content analysis. Subsequently, the results of the analysis were prioritized by all participants of the study.

RESULTS

The results of the requirements analysis indicate mandatory requirements for the overall system, hardware, software and gamification elements. The key requirements were target-group-specific applications of the VR exergame through e.g. individual briefing, user-friendly handling, inclusion of movement limitations, presentation of everyday scenarios in combination with biofeedback, age-appropriate feedback through praise and awards and a maximum exercise duration of 30 min and 15 min of relaxation.

CONCLUSION

It should be possible to use the determined requirements productively to create user-friendly VR exergames that motivate elderly chronic back pain patients to perform exercises regularly.

TRIAL REGISTRATION

The study is registered in the German Clinical Trials Register (DRKS-ID: DRKS00015294 12.10.2018).

The Potential of Immersive Virtual Reality for Cognitive Training in Elderly

The number of elderly is growing rapidly, including those that struggle with cognitive decline and, consequently, activities of daily living. Developing interventions that slow down cognitive decline would greatly benefit the autonomy of these elderly, as well as their caretakers. Virtual reality (VR) is an immersive and interactive human-computer interface with real-time simulation that is suggested to be a promising tool to improve cognitive functioning. This literature review discusses the features of immersive VR, including its opportunities and limitations, that are of special relevance for improving cognition in elderly. First, the high flexibility of VR allows for personalized and safe training of potentially harmful situations and isolated aspects of tasks. Second, VR's dynamic and real-time feedback on performance provides a labor-extensive tool for caretakers in elderly care. Third, the acquisition of high resolution data enables the exposure of subtle changes over time, relevant for detecting the nature and extent of cognitive changes in elderly, including those with dementia. Fourth, immersive VR has been related to cybersickness. Finally, VR is immersive and enables the perception and expression of emotions, motor behaviors, and multiple senses. Aged subjects are found to have sparing of emotional learning and show increased reliance on multisensory integration for learning. Moreover, they experience high levels of flow, motivation, and presence in VR setups. Despite the clear potential of immersive VR, the studies available are small scale and have not been replicated. The digital illiteracy of elderly and healthcare personnel form an additional barrier for implementation. Hence, while replication of outcomes and standardization of VR interventions is required before it can be used in standard care, VR may provide a particularly effective tool for training cognition in elderly.

Effects of Kinect exergames on balance training among community older adults: A randomized controlled trial

BACKGROUND

Recent years have witnessed wide applications of exergames to balance training among the older adults. However, research concerning balance training with the use of Kinect for Xbox has remained scarce. While previous studies have shown the positive effects of exergames on improving balance and preventing falling among the older adults, there has been a paucity of empirical evidence supporting the superiority of Kinect exercise to conventional exercise over balance training among the older adults. Therefore, this study aimed to compare the feasibility, safety, and effectiveness of Kinect exercise against conventional exercise over balance training among the community older adults.

METHOD

A total of 20 participants were randomly assigned to the Kinect Exercise Group (N = 10) or the Conventional Exercise Group (N = 10) for a 5-week balance training (45 minutes a time, 2 times a week). Assessor blinding was employed to assess the participants' performance before and after the treatment, including 30-Second Chair Stand Test (30-sec CST), Timed Up and Go (TUG), Functional Reach Test (FRT), and One-Leg Stance Test (OLST) respectively with eyes open and closed. Subjective feeling of the intensity of pain and side effects were recorded throughout the investigation period. Nonparametric statistics was used for data analysis.

RESULTS

Within-group comparison between the pre-test and post-test indicated that significant differences existed in all of the 5 tests (30-sec CST, TUG, FRT, OLST with eyes open, and OLST with eyes closed) in the Kinect exercise group. To the Conventional exercise group, however, significant differences were only observed in 30-sec CST, FRT and OLST with eyes open. With regard to between-group comparison, significant differences were only found in FRT.

CONCLUSION

Such results indicated that both treatments were helpful in improving the participants' balance performance, that Kinect exercise was more effective in terms of overall balance ability, and that Kinect exercise was particularly beneficial to functional reach enhancement in comparison with traditional exercise. Kinect exercise could be a feasible, safe, and effective alternative for dynamic balance training among older adults.

Virtual Reality Exercise as a Coping Strategy for Health and Wellness Promotion in Older Adults during the COVID-19 Pandemic

The December 2019 COVID-19 outbreak in China has led to worldwide quarantine, as recommended by local governments and the World Health Organization. Particularly affected are older adults (i.e., those aged ≥ 65 years) who are at elevated risk for various adverse health outcomes, including declines in motor ability and physical activity (PA) participation, increased obesity, impaired cognition, and various psychological disorders. Thus, given the secular increases in the older adult population, novel and effective intervention strategies are necessary to improve physical activity behaviors and health in this population. Virtual reality (VR)-integrated exercise is a promising intervention strategy, which has been utilized in healthcare fields like stroke rehabilitation and psychotherapy. Therefore, the purpose of this editorial is to synthesize recent research examining the efficacy and effectiveness of VR exercise in the promotion of favorable health outcomes among the older adults. Results indicate the application of VR exercise to facilitate improved physical outcomes (e.g., enhanced motor ability, reduced obesity), cognition and psychological outcomes. VR exercise has also been observed to be an effective intervention strategy for fall prevention in this population. Future research should employ more rigorous research designs to allow for a more robust quantitative synthesis of the effect of VR exercise on the preceding outcomes to elucidate which type(s) of VR-based PA interventions are most effective in promoting improved health outcomes among older adults. Findings from this study will better inform the development of technology-savvy PA programs for wellness promotion in older adults who practice social distancing and exercise from home under the unprecedented global health crisis.

An Exploratory Study on the use of Virtual Reality in Balance Rehabilitation

Studies have shown the potential of Virtual Reality and motion tracking devices in physical rehabilitation. This paper addresses the topic of using non-immersive Virtual Reality therapeutic games with motion tracking in physical rehabilitation and describes an exploratory study performed in collaboration with a national public Rehabilitation Center about their use to motivate patients to perform exercises relevant for balance rehabilitation. The work involved developing and adapting mini-games to track patients posture; tests with patients recovering from Spinal Cord Injury suggest that this type of games can be helpful in the recovery process namely in patients' motivation for performing the therapeutic gestures.

Digital Medicine in Rheumatology: Challenges and Opportunities

The exponential growth in technology has had a significant effect on the practice of medicine and will likely transform the practice of medicine. In this article, the authors review select technologies that are already influencing the practice of rheumatology. Social media Websites such as Twitter are now important sources of information and discussion for health care professionals interested in rheumatology. Virtual reality is an innovative technology with great potential for acute and chronic pain management. The authors also review several low-cost technology alternatives to commonly used tools used in rheumatology.

HOLOBALANCE: An Augmented Reality virtual trainer solution forbalance training and fall prevention

Balance disorders affect a large number of older people, leading to falls. To promote independence, self-care and the quality of living of the long-lived population, an innovative solution is devoped to act as a virtual trainer for people that suffer from vestibular dysfunction related balance disorders. Our solution offers a virtual balance therapy, supported by Information and Communication Technology devices, to monitor user's activity during the day and provide real time feedback for the correct execution of physiotherapy exercises. Wearable sensors are utilized to monitor user activity, while during the execution of exercises, cameras are used to track the body of the user. An Augmented Reality headset is used to project the virtual trainer's 3D avatar in front of the user, providing real time guidance for the correct execution of the exercises.

Using Virtual Environments to Improve Real-World Motor Skills in Sports: A Systematic Review

In many settings, sports training can be difficult to organize, logistically complicated and very costly. Virtual environments (VE) have garnered interest as a tool to train real-world sports skills due to the realism and flexibility that they can deliver. A key assumption of VE-based training is that the learned skills and experiences transfer to the real world, but do they? Using PRISMA guidelines, this systematic review evaluated the available evidence regarding the transfer of motor skills from VE training to real-world sporting contexts. The initial search identified 448 articles, but only 4 of these articles met basic criteria necessary to assess real-world transfer. Key factors regarding the study design, learner characteristics and training environment of these studies are considered. In a relatively new area of research, the findings from these 4 articles are encouraging and provide initial support for the notion that skills training in a VE can improve real-world performance in sports. However, for a wider uptake of VEs in sports training, it is important that more research demonstrates real-world transfer. Study design recommendations are suggested for researchers, developers or trainers who are considering demonstrating real-world transfers from virtual to real-world environments.

Effects of physical, virtual reality-based, and brain exercise on physical, cognition, and preference in older persons: a randomized controlled trial

Background

Physical exercise (PE), virtual reality-based exercise (VRE), and brain exercise (BE) can influence physical and cognitive conditions in older persons. However, it is not known which of the three types of exercises provide the best effects on physical and cognitive status, and which exercise is preferred by older persons. This study compared the effects of PE, VRE, and BE on balance, muscle strength, cognition, and fall concern. In addition, exercise effort perception and contentment in older persons was evaluated.

Methods

Eighty-four older persons (n = 84) were randomly selected for PE, VRE, BE, and control groups. The exercise groups received 8-week training, whereas the control group did not. Balance was assessed by Berg Balance Scale (BBS) and Timed Up and Go test (TUG), muscle strength by 5 Times Sit to Stand (5TSTS) and left and right hand grip strength (HGS), cognition by Montreal Cognitive Assessment (MoCA) and Timed Up and Go test Cognition (TUG-cog), fall concern by Fall Efficacy Scale International (FES-I), exercise effort perception by Borg category ratio scale (Borg CR-10), and exercise contentment by a questionnaire.

Results

After exercise, PE significantly enhanced TUG and 5TSTS to a greater extent than VRE (TUG; p = 0.004, 5TSTS; p = 0.027) and BE (TUG; p = 0,012, 5TSTS; p < 0.001). VRE significantly improved MoCA (p < 0.001) and FES-I (p = 0.036) compared to PE, and 5TSTS (p < 0.001) and FES-I (p = 0.011) were improved relative to BE. MoCA was significantly enhanced by BE compared to PE (p < 0.001) and both MoCA and TUG-cog were improved compared to VRE (p = 0.04). PE and VRE significantly (p < 0.001) increased Borg CR-10 in all exercise sessions, whereas BE showed a significant improvement (p < 0.001) in the first 4 sessions. Participants had a significantly greater satisfaction with BE than controls (p = 0.006), and enjoyed VRE and BE more than PE (p < 0.001). Subjects in all exercise groups exhibited benefits compared to the control group (p < 0.001).

Conclusions

PE provided the best results in physical tests, VRE produced measurable improvements in physical and cognition scores, while BE enhanced cognition ability in older persons. Older persons preferred VRE and BE compared to PE. Both exercises are suggested to older persons to improve physical and cognitive conditions.

Exercise Intensity-Driven Level Design

Games and experiences designed for virtual or augmented reality usually require the player to move physically to play. This poses substantial challenge for level designers because the player's physical experience in a level will need to be considered, otherwise the level may turn out to be too exhausting or not challenging enough. This paper presents a novel approach to optimize level designs by considering the physical challenge imposed upon the player in completing a level of motion-based games. A game level is represented as an assembly of chunks characterized by the exercise intensity levels they impose on players. We formulate game level synthesis as an optimization problem, where the chunks are assembled in a way to achieve an optimized level of intensity. To allow the synthesis of game levels of varying lengths, we solve the trans-dimensional optimization problem with a Reversible-jump Markov chain Monte Carlo technique. We demonstrate that our approach can be applied to generate game levels for s of motion-based virtual reality games. A user evaluation validates the effectiveness of our approach in generating levels with the desired amount of physical challenge.