Gaming for Health: Systematic Review and Meta-analysis of the Physical and Cognitive Effects of Active Computer Gaming in Older Adults

Exercise and Sports Science Australia updated position statement on exercise for preventing falls in older people living in the community

BACKGROUNDS

Falls affect a significant number of older Australians and present a major challenge to health care providers and health systems with over 380 older Australians hospitalised for a fall each day.

OBJECTIVES

This statement seeks to inform and guide exercise practitioners and health professionals in safe and effective prescription of exercise to prevent falls amongst community-dwelling older people.

EXERCISE PRESCRIPTION TO PREVENT FALLS

Exercise is crucial for preventing falls in older age. Research evidence has identified that programmes which include functional balance and muscle strength training are the most effective in preventing falls. It is also important for exercise to be progressively challenging, ongoing and of sufficient dose to maximise its benefits in reducing falls. Additional (non-exercise) interventions are necessary for people with complex medical conditions, recent hospitalisation and/or particular risk factors not improved by exercise. People at a higher risk of falls may need greater support to undertake safe and effective fall prevention exercise.

SUMMARY

Global guidelines for fall prevention and management recommend that all older adults should receive advice about exercise to prevent falls. Qualified exercise professionals are well placed to prescribe and supervise functional balance and muscle strength training to older people with varied functional abilities, including those with co-morbidities.

The effects of a new immersive multidomain training on cognitive, dual-task and physical functions in older adults

The aim of this study was to assess the potential of multidomain training using Immersive and Interactive Wall Exergames (I2WE) to improve the cognitive and physical functions of older adults. This new generation of exergames offers specific advantageous characteristics (e.g., immersion, virtual cognitive solicitation, high physical stimulation, complex motor skills, multiple social interactions) that could make I2WE an enjoyable multidomain training medium for older adults. A pilot study was set up with 34 participants (M = 69.91 years old). It used the pre-tests - training (3 months, 2 one-hour sessions per week for the 2 groups) - post-tests method to compare: a) the cognitive and the Dual-Task (DT) effects (primary outcomes), b) the physical effects and perceived pleasure (secondary outcomes) between an experimental group following an I2WE program (n = 19) to an active control group performing a Walking and Muscle-Strengthening (WMS) program (n = 15). While visuospatial short-term memory was improved for both groups, only I2WE training enhanced visuospatial working memory, inhibition, and DT. All physical functions, except upper body strength, were enhanced for the 2 groups. The perceived pleasure was higher for the I2WE group than the WMS group. The results of this first study have important clinical implications, showing that I2WE can optimize strategies to improve older adults' physical and cognitive health. Virtual and immersive cognitive stimulation combined with varied physical activity (i.e., aerobic, muscle-strengthening, complex motor skills) appear to be major assets of these new exergames. Moreover, the high level of perceived pleasure to I2WE makes it a promising tool for engaging older adults in sustained multidomain practice.

Virtual Reality in Clinical Nursing Practice Over the Past 10 Years: Umbrella Review of Meta-Analyses

Background

Virtual reality (VR) has shown promising levels of effectiveness in nursing education, pain management, and rehabilitation. However, meta-analyses have discussed the effects of VR usage in nursing unilaterally and inconsistently, and the evidence base is diffuse and varied.

Objective

We aimed to synthesize the combined evidence from meta-analyses that assessed the effects of nurses using VR technology on nursing education or patient health outcomes.

Methods

We conducted an umbrella review by searching for meta-analyses about VR intervention in clinical nursing practice on Web of Science, Embase, Cochrane, and PubMed, and in reference lists. Eligible studies were published in English between December 1, 2012, and September 20, 2023. Meta-analyses of ≤2 intervention studies and meta-analyses without 95% CI or heterogeneity data were excluded. Characteristic indicators, population information, VR intervention information, and 95% CIs were extracted. A descriptive analysis of research results was conducted to discern relationships between VR interventions and outcomes. I2 and P values were used to evaluate publication bias. AMSTAR (A Measurement Tool to Assess Systematic Reviews) 2 and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) checklist were used to appraise literature quality.

Results

In total, 768 records were identified; 74 meta-analyses were included for review. The most reported VR study conditions were neuronursing (25/74, 34%), pediatric nursing (13/74, 18%), surgical and wound care (11/74, 15%), oncological nursing (11/74, 15%), and older adult nursing (10/74, 14%). Further, 30% (22/74) of meta-analyses reported publication bias, and 15% (11/74) and 8% (6/74) were rated as "high" based on AMSTAR 2 and the GRADE checklist, respectively. The main outcome indicators among all included meta-analyses were pain (37/214, 17.3%), anxiety (36/214, 16.8%), cognitive function (17/214, 7.9%), balance (16/214, 7.5%), depression (16/214, 7.5%), motor function (12/214, 5.6%), and participation in life (12/214, 5.6%). VR treatment for cognition, pain, anxiety, and depression was effective (all P values were <.05), while the utility of VR for improving motor function, balance, memory, and attention was controversial. Adverse effects included nausea, vomiting, and dizziness (incidence: range 4.76%-50%). The most common VR platforms were Pico VR glasses, head-mounted displays, the Nintendo Wii, and the Xbox Kinect. VR intervention duration ranged from 2 weeks to 12 months (typically ≥4 wk). VR session length and frequency ranged from 5 to 100 minutes and from 1 to 10 times per week, respectively.

Conclusions

VR in nursing has positive effects-relieving patients' pain, anxiety, and depression and improving cognitive function-despite the included studies' limited quality. However, applying VR in nursing to improve patients' motor function, balance, memory, and attention remains controversial. Nursing researchers need to further explore the effects and standard operation protocols of VR in clinical practice, and more high-quality research on VR in nursing is needed.

Ageism in the Discourse and Practice of Designing Digital Technology for Older Persons: A Scoping Review

BACKGROUND AND OBJECTIVES

Involving older persons in the design process of digital technology (DT) promotes the development of technologies that are appealing, beneficial, and used. However, negative discourse on aging and ageism are potential underlying factors that could influence which and how DTs are designed and how older persons are involved in the design process. This scoping review investigates the explicit and implicit manifestations of ageism in the design process of DT.

RESEARCH DESIGN AND METHODS

Seven databases were screened for studies reporting on the design of DT with older persons between January 2015 and January 2020. Data regarding study and DT characteristics, discourse about older persons, and their involvement in the design process were extracted, coded, and analyzed using critical discourse analysis.

RESULTS

Sixty articles met the inclusion criteria and were included in the analysis. Various forms of exclusion of older persons from the design process were identified, such as no or low involvement, upper-age limits, and sample biases toward relatively "active," healthy and "tech-savvy" older persons. Critical discourse analysis revealed the use of outdated language, stereotypical categorizations, and/or design decisions based on ageism in 71.7% of the studies.

DISCUSSION AND IMPLICATIONS

A discrepancy was found between an "ideal" discourse regarding the involvement of older persons throughout the design process and actual practice. Manifestations of ageism, errors, and biases of designing DT with older persons are discussed. This article calls for more authentic inclusion of older persons and higher awareness toward the implications of ageism in the design process of DT.

Meta-analysis of the efficacy of digital therapies in children with attention-deficit hyperactivity disorder

Background

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that commonly occurs in childhood. The aim of this meta-analysis was to summarize the available evidence for the efficacy of digital therapeutics in children and adolescents with ADHD.

Methods

We searched the MEDLINE, EMBASE, Cochrane Library (Cochrane Database of Systematic Reviews), and Web of Science (science and social science citation index) databases for relevant studies and used Stata 15.0 software to carry out the meta-analysis.

Results

A total of 31 studies involving 2169 participants (1665 boys and 504 girls) aged 4-17 years old were included in the final analysis. The meta-analysis results showed that digital interventions improved the symptoms of inattention with an effect value of -0.20 (95% confidence interval [CI] -0.36, -0.04) and decreased the continuous performance task (CPT) reaction time (effect, -0.40, 95% CI -0.73, -0.07) in ADHD patients. The score for impulsive hyperactivity was slightly decreased (effect, -0.07, 95% CI -0.23, 0.09). Moreover, executive function was improved (effect, 0.71, 95% CI 0.37, 1.04). The capability of working memory appeared to be increased (effect, 0.48, 95% CI 0.21, 0.76) between the two groups. Visual appraisal of the sensitivity analysis suggested the absence of heterogeneity, and no obvious publication bias was detected.

Discussion

Based on the existing literature evidence, we conclude that digital therapy can be a promising therapeutic strategy for ADHD patients.

The Effects of Interactive Virtual Reality in Patients with Chronic Musculoskeletal Disorders: A Systematic Review and Meta-Analysis

Objective: Interactive virtual reality (iVR) has been widely used for treatment purposes in patients with chronic musculoskeletal disorders. However, no consensus has been reached on the effects of iVR on pain, psychological distress, and functional disability. Therefore, this study aims to investigate the effects of iVR on pain, psychological distress, and functional disability in patients with chronic musculoskeletal disorders compared with no rehabilitation and conventional rehabilitation. Methods: Five electronic databases (PubMed, Cochrane CENTRAL, Scopus, EMBASE, and Web of Science) were searched from January 2016 to December 2021. All randomized controlled trials using iVR for treating pain, psychological distress, and functional disability in patients with chronic musculoskeletal disorders were included. A subgroup analysis was conducted to compare the effects of nonimmersive and immersive types of iVR on the outcomes of interest. Results: Our study provides good quality evidence that iVR reduced overall pain by 9.28 points as compared with no rehabilitation and by 8.09 points as compared with conventional rehabilitation. In the subgroup analysis, nonimmersive iVR showed a reduction in psychological distress (standardized mean differences = -0.35) as compared with no rehabilitation. However, no statistically significant difference in the outcomes existed between nonimmersive and immersive iVR. Furthermore, there were no statistically significant differences in the outcomes of functional disability. Conclusions: iVR is recommended for reducing pain intensity more than no rehabilitation or conventional rehabilitation. Meanwhile, nonimmersive iVR has been proposed for psychological distress improvement, with effects similar to those of conventional rehabilitation. However, iVR may not be an effective intervention in the case of functional disability.

A Systematic Review and Meta-analysis of the Effect of Active Video Games on Postural Balance

OBJECTIVE

To conduct a comprehensive systematic review and meta-analysis of the effects of active video game (AVG) interventions on postural balance across all ages in populations with and without neurologic impairments, using all types of platforms.

DATA SOURCE

Six databases (PubMed, PsycINFO, Sport Discus, MEDLINE, Web of Science, and Google Scholar) were reviewed by December 31, 2020.

STUDY SELECTION

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42020204191). For inclusion, a study must be original, published in English peer-reviewed venues and employed AVGs as the sole or primary intervention to enhance, maintain, or regain postural balance. At least 2 within- or between-subjects conditions must be included with ≥10 participants per condition.

DATA EXTRACTION

Three reviewers independently performed data extraction and assessed the risk of bias.

DATA SYNTHESIS

129 studies were identified, with 102 eligible for meta-analysis. The total number of tested participants was 6407 (60.0% women, M_age=55.1 years, range=3-99 years, SD=22.6). The average intervention duration was 35.6 min/session with 3.1 sessions/week for 7.6 weeks. The overall effect favored AVG interventions (Hedges' g=0.469; 95% confidence interval [CI]=0.407-0.531). Although the overall study quality was relatively low, the analysis expectedly indicated significantly larger effects (P<.001) for AVG-interventions over passive controls (Hedges' g=0.627; 95% CI=0.466-0.788), but importantly also favored AVG-interventions over conventional treatment (Hedges' g=0.389; 95% CI=0.311-0.468). All clinical populations responded positively, although with different effect sizes (P=.023). Children experienced larger treatment effects (Hedges' g=0.550; 95% CI=0.336-0.764), closely followed by seniors (Hedges' g=0.529; 95% CI=0.402-0.656). The largest intervention effect on balance improvements was seen in healthy people without a medical condition (Hedges' g=0.609; 95% CI=0.465-0.753).

CONCLUSIONS

AVGs can produce postural balance improvements and better postural maintenance. All populations could benefit from AVG interventions.

Impact of Motor-Cognitive Interventions on Selected Gait and Balance Outcomes in Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Efficient performance of most daily activities requires intact and simultaneous execution of motor and cognitive tasks. To mitigate age-related functional decline, various combinations of motor and cognitive training have shown promising results. The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the efficacy of different types of motor-cognitive training interventions (e.g., sequential and simultaneous) on selected functional outcomes in healthy older adults.

Methods

Six online academic databases were used to retrieve eligible RCTs up to April 2021, following PRISMA guidelines and PICO criteria. A random-effects model was used for all meta-analyses conducted on selected functional outcomes: single- and dual-task gait speed, the Timed Up and Go Test (TUG), and Berg Balance Scale (BBS) score. Effect size (ES) was calculated as Hedges' g and interpreted as: trivial: <0.20, small: 0.20–0.60, moderate: 0.61–1.20, large: 1.21–2.00, very large: 2.01–4.00 or extremely large >4.00.

Results

From 2,546 retrieved records, 91 RCTs were included for meta-analysis (n = 3,745 participants; 64.7–86.9 years). The motor-cognitive interventions included differed according to the type of training (e.g., sequential, simultaneous with additional cognitive task or exergame training. The results showed that motor-cognitive interventions can improve gait speed under single-task conditions (small ES = 0.34, P = 0.003). The effect of the intervention was moderated by the type of control group (Q = 6.203, P = 0.013): passive (moderate ES = 0.941, P = 0.001) vs. active controls (trivial ES = 0.153, P = 0.180). No significant effect was found for dual-task walking outcomes (P = 0.063). Motor-cognitive intervention had a positive effect on TUG (small ES = 0.42, P < 0.001), where the effect of intervention was moderated by control group [passive (moderate ES = 0.73, P = 0.001) vs. active (small ES = 0.20, P = 0.020)], but not by the type of training (P = 0.064). Finally, BBS scores were positively affected by motor-cognitive interventions (small ES = 0.59, P < 0.001) with however no significant differences between type of control group (P = 0.529) or intervention modality (P = 0.585).

Conclusions

This study provides evidence for the effectiveness of various types of motor-cognitive interventions on performance-based measures of functional mobility in healthy older adults. With respect to significant effects, gait speed under single-task condition was improved by motor-cognitive interventions, but the evidence shows that this type of intervention is not necessarily more beneficial than motor training alone. On the other hand, motor-cognitive interventions are better at improving multicomponent tasks of dynamic balance and mobility function, as measured by the TUG. Because of substantial heterogeneity and the current limited availability of different types of interventions, the conclusions should be interpreted with caution.

Effectiveness and characteristics of physical fitness training on aerobic fitness in vulnerable older adults: an umbrella review of systematic reviews

OBJECTIVES

To present an overview of effectiveness and training characteristics of physical training on aerobic fitness, compared with alternative or no training, in adults aged over 65 years with various health statuses, providing a basis for guidelines for aerobic training of vulnerable older adults that can be used in geriatric rehabilitation.

DESIGN

An umbrella review of systematic reviews that included both randomised controlled trials and other types of trials.

DATA SOURCES

MEDLINE, Embase, CINAHL and the Cochrane Library were searched on 9 September 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included systematic reviews reporting on physical training interventions that are expected to improve aerobic fitness, presenting results for adults aged 65 years and older, describing at least one of the FITT-characteristics: Frequency, Intensity, Time or Type of exercise, and measuring aerobic fitness at least before and after the intervention.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted the data and assessed the risk of bias. A narrative synthesis was performed.

RESULTS

We included 51 papers on 49 reviews. Positive effect of training on aerobic fitness was reported by 33 reviews, 11 reviews remained inconclusive and 5 reviews reported no effect. Training characteristics varied largely. Frequency: 1-35 sessions/week, Intensity: light-vigorous, Time: <10-120 min/session and Types of exercise: many. The methodological quality was most often low. Subgroup analyses revealed positive effects for all health conditions except for trauma patients. Exercise characteristics from current existing guidelines are widely applicable. For vulnerable older adults, lower intensities and lower frequencies were beneficial. Some health conditions require specific adjustments. Information on adverse events was often lacking, but their occurrence seemed rare.

CONCLUSION

Physical fitness training can be effective for vulnerable older adults. Exercise characteristics from current existing guidelines are widely applicable, although lower frequencies and intensities are also beneficial. For some conditions, adjustments are advised.

PROSPERO REGISTRATION NUMBER

CRD42020140575.

Effects of Exergames on Brain and Cognition in Older Adults: A Review Based on a New Categorization of Combined Training Intervention

The literature on exergames has reported inconsistent benefits on brain and cognitive functions. Moreover, it is still unknown whether they yield to equal or superior benefits as compared to other forms of physical exercise. However, until now, a review of exergaming literature was lacking, that would reverse the “product first” approach to replacing it with a “training first” approach that is, an analysis of the different studies based on a detailed description of the type of combined training interventions that was supported by the utilized exergames. In the present review, thanks to a structured framework build around seven interacting constructs (stimuli, settings, targets, markers, outcomes, moderators, and mechanisms), which collectively afford a global picture of the determining factors of exergames training, we aimed to determine whether and under which conditions exergames could be more effective than conventional training. Twenty three studies were finally selected for review and analyzed. We concluded that, in spite of their potential to improve brain and cognition, beneficial factors contributing to exergaming efficacy as well as its underlying mechanisms need to be investigated more systematically thanks to common experimental designs based on gold standards. We proposed some directions in this respect.

Making the Best Out of IT: Design and Development of Exergames for Older Adults With Mild Neurocognitive Disorder - A Methodological Paper

Background: Utilizing information technology (IT) systems, for example in form of computerized cognitive screening or exergame-based (also called active videogames) training, has gained growing interest for supporting healthy aging and to detect, prevent and treat neurocognitive disorders (NCD). To ameliorate the effectiveness of exergaming, the neurobiological mechanisms as well as the most effective components for exergame-based training remain to be established. At the same time, it is important to account for the end-users' capabilities, preferences, and therapeutic needs during the design and development process to foster the usability and acceptance of the resulting program in clinical practice. This will positively influence adherence to the resulting exergame-based training program, which, in turn, favors more distinct training-related neurobiological effects. Objectives and Methods: This methodological paper describes the design and development process of novel exergame-based training concepts guided by a recently proposed methodological framework: The 'Multidisciplinary Iterative Design of Exergames (MIDE): A Framework for Supporting the Design, Development, and Evaluation of Exergames for Health' (Li et al., 2020). Case Study: A step-by-step application of the MIDE-framework as a specific guidance in an ongoing project aiming to design, develop, and evaluate an exergame-based training concept with the aim to halt and/or reduce cognitive decline and improve quality of life in older adults with mild neurocognitive disorder (mNCD) is illustrated. Discussion and Conclusion: The development of novel exergame-based training concepts is greatly facilitated when it is based on a theoretical framework (e.g., the MIDE-framework). Applying this framework resulted in a structured, iterative, and evidence-based approach that led to the identification of multiple key requirements for the exergame design as well as the training components that otherwise may have been overlooked or neglected. This is expected to foster the usability and acceptance of the resulting exergame intervention in "real life" settings. Therefore, it is strongly recommended to implement a theoretical framework (e.g., the MIDE-framework) for future research projects in line with well-known checklists to improve completeness of reporting and replicability when serious games for motor-cognitive rehabilitation purposes are to be developed.

Effectiveness of Exergame Intervention on Walking in Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The objective of this review was to systematically evaluate the effectiveness of exergaming on walking in older adults. In addition, the aim was to investigate the relationship between the exergaming effect and age, baseline walking performance, exercise traits, technology used, and the risk of bias.

METHODS

A literature search was carried out in the databases MEDLINE, CINAHL, CENTRAL, EMBASE, WoS, PsycInfo, and PEDro up to January 10, 2020. Studies with a randomized controlled trial design, people ≥60 years of age without neurological disorders, comparison group with other exercise or no exercise, and walking-related outcomes were included. Cochrane RoB2, meta-analysis, meta-regression, and Grading of Recommendations, Assessment, Development and Evaluation were used to estimate quality, treatment effect, covariates' effect, and the certainty of evidence, respectively.

RESULTS

In the studies included (n = 66), the overall risk of bias was low (n = 2), unclear (n = 48), or high (n = 16). Compared with comparison groups, exergaming interventions were more effective for walking improvements (standardized mean difference = -0.21; 95% CI = -0.36 to -0.06; 3102 participants, 58 studies; moderate-quality evidence) and more or equally effective (standardized mean difference = -0.32; 95% CI = -0.64 to 0.00; 1028 participants, 13 studies; low-quality evidence) after nonexergaming follow-up. The strongest effect for covariates was observed with the type of comparison group, explaining 18.6% of the variance.

CONCLUSION

For older adults without neurological disorders, exergame-based training improved walking, and improvements were maintained at follow-up. Greater benefits were observed when exergaming groups were compared with inactive comparison groups. To strengthen the evidence, further randomized controlled trials on the effectiveness of gamified exercise intervention are needed.

IMPACT

Exergaming has an effect equivalent to other types of exercising on improving walking in older adults. Physical therapists and other rehabilitation professionals may consider exergaming as a promising form of exercise in this age group.

[Exergames to promote physical activity and mobility in inpatient long-term nursing-An overview]

Maintaining and promoting mobility is a key objective and central goal of nursing care. Active video games or so-called exergames can also be used for this purpose. In the group of older people some studies showed indications of positive effects with respect to mobility. In this article the focus is on studies that examined the use of exergames for the purpose of maintaining or promoting physical activity and mobility in the setting of long-term inpatient nursing. In summary, a literature search in databases indicated that individual studies on this topic found indications of positive effects: however, the informative value of the results is limited due to their heterogeneity and small samples.

Can Reactivity of Heart Rate Variability Be a Potential Biomarker and Monitoring Tool to Promote Healthy Aging? A Systematic Review With Meta-Analyses

Background: Monitoring phasic responses of heart rate variability (HRV) in terms of HRV reactivity [i. e., the absolute change from resting state to on-task (i.e., absolute values of HRV measured during exercise)] might provide useful insights into the individual psychophysiological responses of healthy middle-aged to older adults (HOA) to cognitive and physical exercises. Objectives: To summarize the evidence of phasic HRV responses to cognitive and physical exercises, and to evaluate key moderating factors influencing these responses. Methods: A systematic review with meta-analyses was performed. Publications up to May 2020 of the databases Medline (EBSCO), Embase, Cochrane Library, CINAHL, Psycinfo, Web of Science, Scopus, and Pedro were considered. Controlled clinical trials and observational studies measuring phasic HRV responses to cognitive and/or physical exercises in HOA (≥50 years) were included. Results: The initial search identified 6,828 articles, of which 43 were included into the systematic review. Compared to resting state, vagally-mediated HRV indices were significantly reduced during all types of exercises [Hedge's g = -0.608, 95 % CI (-0.999 to -0.218), p = 0.002] indicating a significant parasympathetic withdrawal compared to rest. The key moderating variables of these responses identified included exercise intensity for physical exercises, and participant characteristics (i.e., level of cognitive functioning, physical fitness), task demands (i.e., task complexity and modality) and the individual responses to these cognitive challenges for cognitive exercises. In particular, higher task demands (task complexity and physical exercise intensity) were related to larger HRV reactivities. Better physical fitness and cognition were associated with lower HRV reactivities. Additionally, HRV reactivity appeared to be sensitive to training-induced cognitive and neural changes. Conclusion: HRV reactivity seems to be a promising biomarker for monitoring internal training load and evaluating neurobiological effects of training interventions. Further research is warranted to evaluate the potential of HRV reactivity as a monitoring parameter to guide cognitive-motor training interventions and/or as a biomarker for cognitive impairment. This may facilitate the early detection of cognitive impairment as well as allow individualized training adaptations that, in turn, support the healthy aging process by optimizing individual exercise dose and progression of cognitive-motor training.

Potential of Commercially Available Active Video Game for Application to Cardiac Rehabilitation: A Scoping Review (Preprint)

Background

Commercially available active video games (AVGs) have recently been used for rehabilitation in some specific patient populations but rarely in those with cardiovascular disease (CVD). Commercially available AVGs are designed to increase motivation for continuous play, which could be applicable to the long-term cardiac rehabilitation process.

Objective

The objective of this scoping review was to assess the effectiveness of AVG-induced physical exercise, safety management, and patient adherence by applying commercially available AVGs to cardiac rehabilitation.

Methods

Four databases (CINAHL, MEDLINE, PubMed, and SPORTDiscus) were searched for all years up to August 12, 2020. Articles were retained if they were written in English, included patients with CVD who were aged 18 years or older, and used AVGs as part of a physical exercise program. The included studies were then evaluated from the viewpoints of effectiveness as physical exercise, safety, and adherence management.

Results

Among 120 nonduplicate articles reviewed, 5 (4.2%) were eligible for inclusion, of which 3 (2.5%) were reported by the same research group. The AVG consoles used were Xbox Kinect and Nintendo Wii, and sports-related programs were adopted for the intervention. No adverse cardiac events occurred in the identified studies, and dropout rates tended to be low.

Conclusions

AVGs appear to be safe and feasible for promoting an active lifestyle in patients with CVD. However, the effectiveness of AVGs alone as a therapeutic exercise to improve physical function may be limited.

The Pros and Cons of Online Competitive Gaming: An Evidence-Based Approach to Assessing Young Players' Well-Being

This research addresses a lack of evidence on the positive and negative health outcomes of competitive online gaming and esports, particularly among young people and adolescents. Well-being outcomes, along with mitigation strategies were measured through a cross sectional survey of Australian gamers and non-gamers aged between 12 and 24 years, and parents of the 12–17-year-olds surveyed. Adverse health consequences were associated with heavy gaming, more so than light/casual gaming, suggesting that interventions that target moderated engagement could be effective. It provides timely insights in an online gaming landscape that has rapidly evolved over the past decade, and particularly during the COVID-19 pandemic, to include the hyper-connected, highly commercialized and rapidly growing online gaming and esports sector.

Effects of exergames and cognitive-motor dual-task training on cognitive, physical and dual-task functions in cognitively healthy older adults: An overview

This overview aims to summarize the effectiveness of cognitive-motor dual-task and exergame interventions on cognitive, physical and dual-task functions in healthy older adults, as well as the feasibility, safety, adherence, transfer and retention of benefits of these interventions. We searched for systematic reviews or meta-analyses assessing the effects of cognitive-motor dual-task and exergame interventions on cognitive, physical and dual-task functions in cognitively healthy older adults through eight databases (CDSR (Cochrane), MEDLINE (PubMed), Scopus, EMBASE, CINAHL, PsycINFO, ProQuest and SportDiscus). Two reviewers performed the selection, data extraction and risk of bias evaluation independently (PROSPERO ID: CRD42019143185). Eighteen reviews were included in this overview. Overall, positive effects of cognitive-motor dual-task interventions on cognitive, physical and dual-task functions, as well as exergames on cognitive functions only, were observed in cognitively healthy older adults. In contrast, the effects of exergames on physical functions are more controversial, and their effects on dual-task functions have not been studied. The feasibility, safety, adherence, transfer and retention of benefits for both intervention types are still unclear. Future studies should follow more rigorous methodological standards in order to improve the quality of evidence and provide guidelines for the use of cognitive-motor dual-task and exergame interventions in older adults.

Augmented reality glasses as a new tele-rehabilitation tool for home use: patients' perception and expectations

MATERIALS AND METHODS

A qualitative approach was employed to track perspectives from a range of patients with chronic lung and/or heart diseases. COPD, IPF and MI outpatients from Denmark and Finland were invited to participate. Data were collected through focus group and semi-structured in-depth interviews. Qualitative analysis was performed using standard thematic analytical approaches. A topic guide was used to explore experiences and perceptions of the ARG telerehabilitation device among participants.

RESULTS

Thirteen patients (4 MI, 2 IPF and 7 COPD), 3 women and 10 men aged 56 to 75 years (mean age 63.3 years) were allocated into one focus group (9 patients) and 4 interviews (4 patients). Twelve patients reported the added value of ARG and suggested constructive changes such as the adjustable screen/brightness, robust head fixation for exercise performance, easy to navigate interface and supported feedback based on exercise performance.

CONCLUSION

Patients with chronic heart or lung diseases described the added value in an ARG telerehabilitation programme. Improvements for a future version of the ARG were suggested.IMPLICATIONS FOR REHABILITATIONPatients with chronic pulmonary and heart diseases have difficulties to change behaviour to a more active and healthy lifestyle, offers from the health sector to participate in rehabilitation programmes at the hospital are feasible and improves quality of life and exercise capacity. Not all the patients are capable of participating in such rehabilitation programmes due to frailty and long distance to the hospital. Telerehabilitation seems to be a potential treatment to cope with the needs expressed above.Patient involvement in the development of a telerehabilitation solution to empower chronic pulmonary and heart patients to train, ensures a positive contribution to the design of the expected augmented reality software and hardware envisioned solution for telerehabilitation.The development of a user-centered telerehabilitation platform responding to the preferences of patients with chronic disease will remove barriers that limit use and compliance and improve empowerment in future research projects.

Perceptive-Cognitive and Physical Function in Prefrail Older Adults: Exergaming Versus Traditional Multicomponent Training

Research highlights the benefits of regular traditional multicomponent training in older adults. The potential effect of exergames on perceptive-cognitive and physical function in prefrail older adults is still little explored. The study aimed to compare the effects of two physical exercise training programs (exergaming vs. traditional multicomponent) on perceptive-cognitive and physical functions of prefrail older adults. This study was a randomized controlled trial having 66 prefrail older adults assigned to two groups (exergame group [EG]: n = 32, 70.84 ± 4.53 years; multicomponent group [MG]: n = 34, 70.76 ± 5.60 years). Frailty phenotype, fall history, basic and advanced cognition, perceptual, physical (mobility, gait speed, and balance), and muscle (strength and power) functions were evaluated. Intervention was conducted during 12 weeks. The EG and MG performed similar exercise routines involving the main lower limb muscle groups required in daily activities. A mixed model analysis of variance (ANOVA) and effect size (d) revealed that both programs were effective in postponing frailty status, reducing the fear of falling (EG: d = 1.65; MG: d = 1.40), increasing fall risk awareness (EG: d = 2.14; MG: d = 1.60), improving cognitive status (EG: d = 0.83-2.61; MG: d = 0.86-1.43), muscle (EG: d = 0.54; MG: d = 0.51-0.73), and physical function (EG: d = 0.97-1.55; MG: d = 1.01-2.23). The exergame training might be a better alternative to improve cognition, whereas the multicomponent program may be a better option to provide physical function gains.

Older adults' preferences for, adherence to and experiences of two self-management falls prevention home exercise programmes: a comparison between a digital programme and a paper booklet

BACKGROUND

Fall prevention exercise programmes are known to be effective, but access to these programmes is not always possible. The use of eHealth solutions might be a way forward to increase access and reach a wider population. In this feasibility study the aim was to explore the choice of programme, adherence, and self-reported experiences comparing two exercise programmes - a digital programme and a paper booklet.

METHODS

A participant preference trial of two self-managed fall prevention exercise interventions. Community-dwelling adults aged 70 years and older exercised independently for four months after one introduction meeting. Baseline information was collected at study start, including a short introduction of the exercise programme, a short physical assessment, and completion of questionnaires. During the four months intervention period, participants self-reported their performed exercises in an exercise diary. At a final meeting, questionnaires about their experiences, and post-assessments, were completed. For adherence analyses data from diaries were used and four subgroups for different levels of participation were compared. Exercise maintenance was followed up with a survey 12 months after study start.

RESULTS

Sixty-seven participants, with mean age 77 ± 4 years were included, 72% were women. Forty-three percent chose the digital programme. Attrition rate was 17% in the digital programme group and 37% in the paper booklet group (p = .078). In both groups 50-59% reported exercise at least 75% of the intervention period. The only significant difference for adherence was in the subgroup that completed ≥75% of exercise duration, the digital programme users exercised more minutes per week (p = .001). Participants in both groups were content with their programme but digital programme users reported a significantly higher (p = .026) degree of being content, and feeling supported by the programme (p = .044). At 12 months follow-up 67% of participants using the digital programme continued to exercise regularly compared with 35% for the paper booklet (p = .036).

CONCLUSIONS

Exercise interventions based on either a digital programme or a paper booklet can be used as a self-managed, independent fall prevention programme. There is a similar adherence in both programmes during a 4-month intervention, but the digital programme seems to facilitate long-term maintenance in regular exercise.

TRIAL REGISTRATION

ClinTrial: NCT02916849.

Effects of an In-home Multicomponent Exergame Training on Physical Functions, Cognition, and Brain Volume of Older Adults: A Randomized Controlled Trial

Aging is associated with a decline in physical functions, cognition and brain structure. Considering that human life is based on an inseparable physical-cognitive interplay, combined physical-cognitive training through exergames is a promising approach to counteract age-related impairments. The aim of this study was to assess the effects of an in-home multicomponent exergame training on [i] physical and cognitive functions and [ii] brain volume of older adults compared to a usual care control group. Thirty-seven healthy and independently living older adults aged 65 years and older were randomly assigned to an intervention (exergame training) or a control (usual care) group. Over 16 weeks, the participants of the intervention group absolved three home-based exergame sessions per week (à 30–40 min) including Tai Chi-inspired exercises, dancing and step-based cognitive games. The control participants continued with their normal daily living. Pre- and post-measurements included assessments of physical (gait parameters, functional muscle strength, balance, aerobic endurance) and cognitive (processing speed, short-term attention span, working memory, inhibition, mental flexibility) functions. T1-weighted magnetic resonance imaging was conducted to assess brain volume. Thirty-one participants (mean age = 73.9 ± 6.4 years, range = 65–90 years, 16 female) completed the study. Inhibition and working memory significantly improved post-intervention in favor of the intervention group [inhibition: F₍₁₎ = 2.537, p = 0.046, np2 = 0.11, working memory: F₍₁₎ = 5.872, p = 0.015, np2 = 0.02]. Two measures of short-term attentional span showed improvements after training in favor of the control group [F₍₁₎ = 4.309, p = 0.038, np2 = 0.03, F₍₁₎ = 8.504, p = 0.004, np2 = 0.04]. No significant training effects were evident for physical functions or brain volume. Both groups exhibited a significant decrease in gray matter volume of frontal areas and the hippocampus over time. The findings indicate a positive influence of exergame training on executive functioning. No improvements in physical functions or brain volume were evident in this study. Better adapted individualized training challenge and a longer training period are suggested. Further studies are needed that assess training-related structural brain plasticity and its effect on performance, daily life functioning and healthy aging.

Cognitive-behavioral intervention via interactive multimedia online video game for active aging: study protocol for a randomized controlled trial

BACKGROUND

Due to the progressive aging of the population, programs to promote active aging have been recommended. However, older adults have difficulty accessing them. Interventions administered through online video games may increase their accessibility, and complementing these with a smartphone app will likely increase adherence and allow for ongoing professional monitoring. The objective of this study is to evaluate the efficacy of a cognitive-behavioral intervention for active aging administered through an online interactive multimedia video game that includes a smartphone app companion. The secondary objectives are to analyze the moderators and mediators of the change in the outcome variables and to evaluate the adherence to the intervention.

METHODS/DESIGN

A randomized controlled clinical trial will be conducted. Adults 45 years and older will be randomly assigned to a cognitive-behavioral intervention administered through an online multimedia video game that includes a smartphone app companion or to a control group that will receive online information on active aging (274 participants per group). The intervention will be administered in eight weekly 45-min modules. An investigator-blinded evaluation will be conducted using online self-administered tests at baseline, post-intervention, and 6- and 12-month follow-ups. The primary outcome will be mental health status as evaluated using the 36-item Short-Form Health Survey (SF-36) at post-intervention. Secondary outcomes will be emotional well-being, depressive symptoms, reinforcement, negative thoughts, self-reported memory, cognitive task performance, sleep hygiene behaviors, physical activity, eating habits, body mass index, social support, dropout, treatment adherence, and satisfaction with the intervention.

DISCUSSION

If the results are favorable, this study would involve the development of the first evidence-based active aging promotion intervention based on a video game that includes a smartphone app companion, providing evidence on its efficacy, accessibility, and clinical utility.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03643237. Registered 27 August 2018.

Exergame-Driven High-Intensity Interval Training in Untrained Community Dwelling Older Adults: A Formative One Group Quasi- Experimental Feasibility Trial

Purpose

To investigate the feasibility of an exergame-driven high-intensity interval training (HIIT) and its effects on cardiovascular fitness in untrained community dwelling older adults.

Methods

Twelve older participants [10 women, age 72.3 (SD: 4.44) years] performed a high-intensity interval exergame intervention three times a week for 4 weeks. Data was acquired during two baseline and one final measurement. Feasibility outcomes included attrition, adherence, acceptability [Technology Acceptance Model Questionnaire (TAM)], usability [System Usability Scale (SUS)], and enjoyment of exergaming. Furthermore, participants' physical activity levels pre and post intervention were compared to physical activity levels for similar types of training. The secondary outcome was exercise capacity [heart rate at rest (HRrest), heart rate variability (HRV), maximum heart rate (HRmax), and maximum workload (W, in watt)] evaluated through maximal exercise testing.

Results

Eleven participants completed the study (8% attrition), without any adverse events. Adherence to the HIIT intervention was 91% and participants showed high acceptance of the intervention with TAM scores between 5.8 and 6.7 points. User satisfaction was rated as excellent (SUS total score: 93.5 of 100) and the overall enjoyment of exergaming scored 4.5 of 5 possible points. Total exercise time ranged from 19 to 35 min with a mean of 30.8 (SD: 3.6) min. Actual high-intensity exercise time showed consistency with the target exercise time in 98% percent of trainings. Eighty-six percent of high-intensity intervals met the targeted intensity range (>70-90% of HRmax). Thirty-six percent of the recovery periods were completed with a heart rate above the target range of 50-70% of HRmax. Maximum workload (W) during the incremental exercise test post-training increased significantly compared to the baseline measurements one and two (p = 0.032, effect size r = 0.77 and p = 0.012, r = 0.87).

Conclusion

High-intensity interval training through exergaming is feasible, safe, and shows high usability and acceptance in community dwelling older people. Exergame-driven HIIT had a significant effect on maximum power output on an incremental exercise test. A more extensive exergame intervention period, higher work to recovery ratios as well as a higher-intensity activity should be considered in future projects.

User-centred design of an active computer gaming system for strength and balance exercises for older adults

Purpose

Active computer gaming (ACG) is a way for older people to participate in strength and balance exercise. Involving older adults in the development of a bespoke ACG system may optimise its usability and acceptability. The purpose of this paper is to employ user-centred design to develop an ACG system to deliver strength and balance exercises, and to explore its safety, usability and acceptability in older adults.

Design/methodology/approach

This paper describes user involvement from an early stage, and its influence on the development of the system to deliver strength and balance exercise suitable for display on a flat screen or using an Oculus Rift virtual reality (VR) headset. It describes user testing of this ACG system in older adults.

Findings

Service users were involved at two points in the development process. Their feedback was used to modify the ACG system prior to user testing of a prototype of the ACG system by n=9 older adults. Results indicated the safety, usability and acceptability of the system, with a strong preference for the screen display.

Research limitations/implications

The sample size for user testing was small; however, it is considered to have provided sufficient information to inform the further development of the system.

Practical implications

Findings from user testing were used to modify the ACG system. This paper identified that future research could explore the influence of repeated use on the usability and acceptability of ACG in older adults.

Originality/value

There is limited information on the usability and acceptability VR headsets in this population.

Physical Activity, Injurious Falls, and Physical Function in Aging: An Umbrella Review

PURPOSE

To review and update the evidence of the relationship between physical activity, risk of fall-related injury, and physical function in community-dwelling older people that was presented in the 2018 Physical Activity Guidelines Advisory Committee Scientific Report (PAGAC Report).

METHODS

Duplicate independent screenings of 1415 systematic reviews and meta-analyses published between 2006 and 2016 identified from PubMed®, Cochrane Library, and CINAHL databases yielded 111 articles used for the PAGAC Report. The PAGAC Aging Subcommittee members graded scientific evidence strength based upon a five-criteria rubric and assigned one of four grades: strong, moderate, limited, or not assignable. An updated search of 368 articles published between January 2017 and March 2018 yielded 35 additional pertinent articles.

RESULTS

Strong evidence demonstrated that physical activity reduced the risk of fall-related injuries by 32% to 40%, including severe falls requiring medical care or hospitalization. Strong evidence also supported that physical activity improved physical function and reduced the risk of age-related loss of physical function in an inverse graded manner among the general aging population, and improved physical function in older people with frailty and with Parkinson's disease. Aerobic, muscle-strengthening, and/or multicomponent physical activity programs elicited the largest improvements in physical function in these same populations. Moderate evidence indicated that for older adults who sustained a hip fracture or stroke, extended exercise programs and mobility-oriented physical activity improved physical function.

CONCLUSIONS

Regular physical activity effectively helps older adults improve or delay the loss of physical function and mobility while reducing the risk of fall-related injuries. These important public health benefits underscore the importance of physical activity among older adults, especially those living with declining physical function and chronic health conditions.

A Systematic Review on the Cognitive Benefits and Neurophysiological Correlates of Exergaming in Healthy Older Adults

Human aging is associated with structural and functional brain deteriorations and a corresponding cognitive decline. Exergaming (i.e., physically active video-gaming) has been supposed to attenuate age-related brain deteriorations and may even improve cognitive functions in healthy older adults. Effects of exergaming, however, vary largely across studies. Moreover, the underlying neurophysiological mechanisms by which exergaming may affect cognitive and brain function are still poorly understood. Therefore, we systematically reviewed the effects of exergame interventions on cognitive outcomes and neurophysiological correlates in healthy older adults (>60 years). After screening 2709 studies (Cochrane Library, PsycINFO, Pubmed, Scopus), we found 15 eligible studies, four of which comprised neurophysiological measures. Most studies reported within group improvements in exergamers and favorable interaction effects compared to passive controls. Fewer studies found superior effects of exergaming over physically active control groups and, if so, solely for executive functions. Regarding individual cognitive domains, results showed no consistence. Positive effects on neurophysiological outcomes were present in all respective studies. In summary, exergaming seems to be equally or slightly more effective than other physical interventions on cognitive functions in healthy older adults. Tailored interventions using well-considered exergames and intervention designs, however, may result in more distinct effects on cognitive functions.

Investigating the effect of physical games on the memory and attention of the elderly in adult day-care centers in Babol and Amol

Background: Physical activity is a behavioral strategy that increases general (public) health, including the mental performance of individuals. The goal of this study was to investigate the effect of group physical games on cognitive performance (memory, attention) of old people in adult day-care centers.

Methods: In this quasi-experimental study, 50 elderly people (aged >60 years) were selected from two adult day-care centers using available sampling and divided into two groups: control and intervention. As approval was received from the Babol Hamrah Salamat adult day-care center to modify the design of the center’s yard, this center was selected to conduct an intervention program. The intervention group received a physical activity program twice a week for 6 weeks. Questionnaires that were used for collecting data included demographic questions, a standard questionnaire for daily activities of living, and a short-term test, the Abbreviated Mental Test Score. Cognitive function was assessed with the Wechsler Memory Scale (WMS) (Form A), before and after the intervention. Statistical analysis of normal variables was performed using independent and paired t-tests and in non-standard cases with Mann–Whitney and Wilcoxon non-parametric tests at a significance level of P<0.05, using SPSS software (version 22).

Results: Statistical analysis showed that the scores of the subjects in the intervention group, compared to the control group, had significantly improved. The calculated mean differences in the intervention groupwere, for memory function d=8.4±3.3 (P=0.001), and for attention and concentration d=4.18±2.38 (P<0.001) (WMS). This level of change in the intervention group was significant.

Conclusion: The results of this study showed that a physical exercise program can improve the memory and attention/concentration of the elderly. Therefore, it seems that such activities are a useful method for maintaining cognitive function.

Digital behavior change interventions to promote physical activity and/or reduce sedentary behavior in older adults: A systematic review and meta-analysis

BACKGROUND

Physical activity and sedentary behavior are modifiable risk factors for non-communicable disease and healthy ageing, however the majority of older adults remain insufficiently active. Digital behavior change interventions (DBCI) have the potential to reach many older adults to promote physical activity and reduce sedentary time. This study aims to assess the efficacy of DBCI interventions in older adults (≥50 years) on physical activity and sedentary behavior.

METHODS

A systematic review of major databases from inception to 03/2018 was undertaken. Randomized controlled trials (RCT) or pre-post interventions assessing effects of DBCI on physical activity and/or sedentary behavior in older adults (≥50 years) were included. Random effects meta-analyses were carried out.

RESULTS

Twenty-two studies were included, including 1757 older adults (mean age = 67 years, %male = 41), 68% showed moderate-high risk of bias. Meta-analyses suggested that DBCI increased total physical activity among RCT studies (n = 8) (SMD = 0.28; 95%CI 0.01, 0.56; p = 0.04) and pre-post studies (n = 6) (SMD = 0.25; 95%CI 0.09, 0.41; p = 0.002), increased moderate-to-vigorous physical activity (SMD = 0.47; 95%CI 0.32, 0.62, p < 0.001; MD = 52 min/week) and reduced sedentary time (SMD = -0.45; 95%CI -0.69, -0.19; p < 0.001; MD = 58 min/day). Reductions in systolic blood pressure (-11 bpm; p = 0.04) and improvements in physical functioning (p = 0.03) were also observed.

CONCLUSIONS

DBCI may increase physical activity and physical functioning, and reduce sedentary time and systolic blood pressure in older adults, however more high-quality studies are required.