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

Safety, feasibility, and acceptability of physiotherapy combined with strength training using active video games for older patients with musculoskeletal conditions

PURPOSE

This study aimed to determine the safety, feasibility, and acceptability of physiotherapy (PT) combined with strength training using active video games (AVG) for older patients with musculoskeletal conditions.

METHODS

Sixteen patients underwent AVG + PT on day 1 and only conventional physiotherapy (CPT) on day 2. The AVG was conducted in 6 upper- and lower-limb training performed in standing position using Ring Fit Adventure (RFA) on Nintendo Switch. Outcome measured adverse events and deviant movements associated with the AVG as safety, execution rate of each AVG programme as feasibility, and questionnaires (4-point Likert scale) regarding enjoyment, motivation to continue, and feeling of efficacy as acceptability.

RESULTS

The berg balance scale/functional independence measure indicated 45 ± 8/90 ± 16. No adverse events occurred. Some of deviant movements were observed that could be an injury risk, such as a slight forward movement during the stepping exercise. The execution rate for each AVG programme ranged from 81% to 100%. The categories of enjoyment, motivation to continue, and feeling of efficacy had >90% of positive responses (strongly agree, slightly agree) in AVG + PT, and enjoyment tended to be higher in AVG + PT than in CPT.

CONCLUSIONS

Strength training using RFA was considered to be a safe and feasible exercise tool enough to be applicable as part of a rehabilitation programme in older patients with musculoskeletal conditions. However, should be supervised, at least during the introductory phase. It was also positively accepted by older adults, suggesting enhanced enjoyment.IMPLICATIONS FOR REHABILITATIONActive video games (AVG) training with Ring Fit Adventure (RFA) was found to be safe enough to be considered for application as part of a rehabilitation programme for older patients with musculoskeletal conditions, but should be supervised, at least during the introductory phase.AVG training comprising strength training with RFA was found to be a highly feasible exercise tool for rehabilitation in older patients with musculoskeletal conditions.Physiotherapy combined with AVG training using RFA was also well received, suggesting enhanced enjoyment for older patients with musculoskeletal conditions.

Comparison of Nonimmersive Virtual Reality and Task-Oriented Circuit Training on Gait, Balance and Cognition Among Elderly Population: A Single-Blind Randomized Control Trial

Purpose: The purpose of this study was to determine the effects of nonimmersive virtual reality (VR) and task-oriented circuit training on gait, balance, cognitive domains, and quality of life among the elderly population. Methods: This is a single-blind randomized control trial in which 28 elderly individuals between 60 and 75 years were selected. The participants were divided into two groups, task-oriented circuit training and the other receiving nonimmersive VR treatment, with 14 participants in each group. To analyze the effects of both training on balance and gait time up and go test (TUGT), dynamic gait index (DGI), measures were used and for cognitive domains Montreal cognitive assessment (MoCA) scale was used. Short form 12 (SF-12) (along with two domains, Physical Component Summary and Mental Component Summary) was used for the measurement of quality of life. The treatment duration was 8 weeks for both groups. Both the pre-test and post-test readings were analyzed and compared. Results: The mean age of participants was 66.91 ± 3.79 years. Within-group comparison between the pre-test and post-test indicated that significant differences (P < 0.05) existed in all the outcome measures (TUGT, DGI, MoCA, and SF-12) in both groups. However, between-group comparison, significant differences were only found in TUGT and DGI in nonimmersive VR group. Conclusion: This study concluded that both interventions nonimmersive VR and task-oriented circuit training were beneficial for improving balance, gait, quality of life, and cognitive domains like memory, attention spans, executive functions, and so on in elderly population. However nonimmersive virtual reality training is a more effective, feasible, and safe alternative and can be proposed as a form of fall prevention exercise for the older adults. ClinicalTrials.gov Identifier: NCT05021432.

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.

Current status and clinical perspectives of extended reality for myoelectric prostheses: review

Training with "Extended Reality" or X-Reality (XR) systems can undoubtedly enhance the control of the myoelectric prostheses. However, there is no consensus on which factors improve the efficiency of skill transfer from virtual training to actual prosthesis abilities. This review examines the current status and clinical applications of XR in the field of myoelectric prosthesis training and analyses possible influences on skill migration. We have conducted a thorough search on databases in the field of prostheses using keywords such as extended reality, virtual reality and serious gaming. Our scoping review encompassed relevant applications, control methods, performance evaluation and assessment metrics. Our findings indicate that the implementation of XR technology for myoelectric rehabilitative training on prostheses provides considerable benefits. Additionally, there are numerous standardised methods available for evaluating training effectiveness. Recently, there has been a surge in the number of XR-based training tools for myoelectric prostheses, with an emphasis on user engagement and virtual training evaluation. Insufficient attention has been paid to significant limitations in the behaviour, functionality, and usage patterns of XR and myoelectric prostheses, potentially obstructing the transfer of skills and prospects for clinical application. Improvements are recommended in four critical areas: activities of daily living, training strategies, feedback, and the alignment of the virtual environment with the physical devices.

Physical and Affective Physical Literacy Domains Improved After a Six-Week Exergame Exercise Program in Older Adults: A Randomized Controlled Clinical Trial

Introduction: We investigated the effects of an exergames-based exercise program for older adults, and its benefits on their physical literacy (PL) domains, such as physical (mobility skills), affective (motivation and confidence), cognitive (knowledge about physical activity [PA]), and behavioral (daily exertion) when compared with a conventional exercise program and no training (NT) (control). Material and Methods: Forty older adults (mean age 72 years) volunteered and were randomized within three groups-exergame training (ET; n = 15), conventional training (CT; n = 14), and NT (n = 11). ET group performed training sessions based on a commercially available exergame console, while the CT group enrolled in a convention exercise program (aerobic, strength, balance, and flexibility exercises). The training program was conducted three times a week for 6 weeks. The Timed Up and Go Test (TUG), Exercise Confidence Survey (ECS), Motives for Physical Activity Measure-Revised (MPAM-R), Knowledge and Understanding Questionnaire (K&UQ), and total PA tracking (using wearable technology) were used as the study's outcomes. Outcome variables were measured at preintervention (week 0), postintervention (week 6), and at the time of final follow-up (week 9). Results: We observed a reduction in the ET TUG time at postintervention and follow-up. Also, a significant main effect for group and moment of measurement was observed for the Fitness-Health subscore, derived from MPAM-R. The values demonstrated by ET and CT were statistically different (P = 0.01) and a within-group comparison revealed significant differences in the ET from preintervention to both postintervention and follow-up (both, P = 0.01). We did not observe any other significant difference. Conclusion: Our results suggest that a 6-week exergame-based training program may have the potential in improving the physical and affective domains of PL in community-dwelling older adults. The topics related to fitness and health seem to be of interest in this population and programs can make use of them to improve the PL domains.

Age-specific biomechanical challenges and engagement in dynamic balance training with robotic or virtual real-time visual feedback

Challenging balance training that targets age-related neuromuscular and motor coordination deficits is needed for effective fall prevention therapy. Goal-directed training can provide intrinsically motivating balance activities but may not equally challenge balance for all age groups. Therefore, the purpose of this research was to quantify age-specific effects of dynamic balance training with real-time visual feedback. Kinematics, muscle activity, and user perceptions were collected for forty healthy adults (20 younger, 18-39 years; 20 older, 58-74 years), who performed a single balance training session with or without real-time visual feedback. Feedback involved controlling either a physical mobile robot or screen-based virtual ball through a course with standing tilt motions from an instrumented wobble board. Dynamic balance training was more challenging for older compared to younger adults, as measured by significantly higher dorsiflexor and knee extensor muscle activity and ankle co-contractions (50%-80%, p<0.05). Older participants also performed more motion while training without feedback compared to younger adults (22%-65%, p<0.05). Robotic and virtual real-time visual feedback elicited similar biomechanical adaptations in older adults, reducing motions to similar levels as younger adults and increasing ankle co-contractions (p<0.05). Despite higher muscular demand, perceived physical exertion and high enjoyment levels (Intrinsic Motivation Inventory >0.80) were consistent across groups. However, robotic visual feedback may be more challenging than virtual feedback based on more frequent balance corrections, lower perceived competence, and lower game scores for older compared to younger adults. These findings collectively support the feedback system's potential to provide engaging and challenging at-home balance training across the lifespan.

Leg Muscle Activity and Joint Motion during Balance Exercise Using a Newly Developed Weight-Shifting-Based Robot Control System

A novel and fun exercise robot (LOCOBOT) was developed to improve balance ability. This system can control a spherical robot on a floor by changing the center of pressure (COP) based on weight-shifting on a board. The present study evaluated leg muscle activity and joint motion during LOCOBOT exercise and compared the muscle activity with walking and sit-to-stand movement. This study included 10 healthy male adults (age: 23.0 ± 0.9 years) and examined basic LOCOBOT exercises (front-back, left-right, 8-turn, and bowling). Electromyography during each exercise recorded 13 right leg muscle activities. Muscle activity was represented as the percentage maximal voluntary isometric contraction (%MVIC). Additionally, the joint motion was simultaneously measured using an optical motion capture system. The mean %MVIC differed among LOCOBOT exercises, especially in ankle joint muscles. The ankle joint was primarily used for robot control. The mean %MVIC of the 8-turn exercise was equivalent to that of walking in the tibialis anterior, and the ankle plantar flexors were significantly higher than those in the sit-to-stand motion. Participants control the robot by ankle strategy. This robot exercise can efficiently train the ankle joint muscles, which would improve ankle joint stability.

Exergaming in older adults: the effects of game characteristics on brain activity and physical activity

Introduction

Exergames are increasingly used in rehabilitation settings for older adults to train physical and cognitive abilities. To meet the potential that exergames hold, they need to be adapted to the individual abilities of the player and their training objectives. Therefore, it is important to know whether and how game characteristics affect their playing. The aim of this study is to investigate the effect of two different kinds of exergame (step game and balance game) played at two difficulty levels on brain activity and physical activity.

Methods

Twenty-eight older independently living adults played two different exergames at two difficulty levels each. In addition, the same movements as during gaming (leaning sideways with feet in place and stepping sideways) were performed as reference movements. Brain activity was recorded using a 64-channel EEG system to assess brain activity, while physical activity was recorded using an accelerometer at the lower back and a heart rate sensor. Source-space analysis was applied to analyze the power spectral density in theta (4 Hz-7 Hz) and alpha-2 (10 Hz-12 Hz) frequency bands. Vector magnitude was applied to the acceleration data.

Results

Friedman ANOVA revealed significantly higher theta power for the exergaming conditions compared to the reference movement for both games. Alpha-2 power showed a more diverse pattern which might be attributed to task-specific conditions. Acceleration decreased significantly from the reference movement to the easy condition to the hard condition for both games.

Discussion

The results indicate that exergaming increases frontal theta activity irrespective of type of game or difficulty level, while physical activity decreases with increasing difficulty level. Heart rate was found to be an inappropriate measure in this population older adults. These findings contribute to understanding of how game characteristics affect physical and cognitive activity and consequently need to be taken into account when choosing appropriate games and game settings for exergame interventions.

Exercise-Boosted Mitochondrial Remodeling in Parkinson's Disease

Parkinson's disease (PD) is a movement disorder characterized by the progressive degeneration of dopaminergic neurons resulting in dopamine deficiency in the striatum. Given the estimated escalation in the number of people with PD in the coming decades, interventions aimed at minimizing morbidity and improving quality of life are crucial. Mitochondrial dysfunction and oxidative stress are intrinsic factors related to PD pathogenesis. Accumulating evidence suggests that patients with PD might benefit from various forms of exercise in diverse ways, from general health improvements to disease-specific effects and, potentially, disease-modifying effects. However, the signaling and mechanism connecting skeletal muscle-increased activity and brain remodeling are poorly elucidated. In this review, we describe skeletal muscle-brain crosstalk in PD, with a special focus on mitochondrial effects, proposing mitochondrial dysfunction as a linker in the muscle-brain axis in this neurodegenerative disease and as a promising therapeutic target. Moreover, we outline how exercise secretome can improve mitochondrial health and impact the nervous system to slow down PD progression. Understanding the regulation of the mitochondrial function by exercise in PD may be beneficial in defining interventions to delay the onset of this neurodegenerative disease.

Tele-Medicine Based and Self-Administered Interactive Exercise Program (Tele-Exergame) to Improve Cognition in Older Adults with Mild Cognitive Impairment or Dementia: A Feasibility, Acceptability, and Proof-of-Concept Study

Improved life expectancy is increasing the number of older adults who suffer from motor-cognitive decline. Unfortunately, conventional balance exercise programs are not tailored to patients with cognitive impairments, and exercise adherence is often poor due to unsupervised settings. This study describes the acceptability and feasibility of a sensor-based in-home interactive exercise system, called tele-Exergame, used by older adults with mild cognitive impairment (MCI) or dementia. Our tele-Exergame is specifically designed to improve balance and cognition during distractive conditioning while a telemedicine interface remotely supervises the exercise, and its exercises are gamified balance tasks with explicit augmented visual feedback. Fourteen adults with MCI or dementia (Age = 68.1 ± 5.4 years, 12 females) participated and completed exergame twice weekly for six weeks at their homes. Before and after 6 weeks, participants' acceptance was assessed by Technology Acceptance Model (TAM) questionnaire, and participants' cognition and anxiety level were evaluated by the Montreal Cognitive Assessment (MoCA) and Beck Anxiety Inventory (BAI), respectively. Results support acceptability, perceived benefits, and positive attitudes toward the use of the system. The findings of this study support the feasibility, acceptability, and potential benefit of tele-Exergame to preserve cognitive function among older adults with MCI and dementia.

Fully Immersive Virtual Reality Game-Based Training for an Adolescent with Spastic Diplegic Cerebral Palsy: A Case Report

BACKGROUND

Recently, virtual reality-based training (VR-based training) is receiving attention as greater emphasis is placed on the importance of interest and motivation in participation. However, studies investigating the effects of fully immersive VR-based training are insufficient.

CASE PRESENTATION

We report a case of using a fully immersive VR game-based training in a patient with cerebral palsy. A 15-year-old girl was diagnosed with spastic diplegia cerebral palsy Gross Motor Function Classification System level II. A six-week intervention (18 sessions) phase was performed with one fully immersive VR game using PlayStation^®VR in three sessions per week. After 18 sessions of training, the scores on the gross motor function measure-88 (Gross Motor Function Measure-88-GMFM-88), pediatric balance scale (PBS), timed up and go test (TUG), functional gait assessment (FGA), and 10 m walking test (10MWT) were improved: GMFM-88, 91.56 points (9.31 points increase); PBS, 45 points (6 points increase); TUG, 8.23 s (6.9 s decrease); FGA, 11 points (3 points increase); the 10 MWT, 5.27 s (6.59 s decrease).

CONCLUSIONS

This study found that a fully immersive VR game-based training using PlayStation^®VR may be an effective intervention for GMFCS level II adolescent, leading to some improvement of motor function, balance and gait skills in adolescents with cerebral palsy.

Balance Therapy With Hands-Free Mobile Robotic Feedback for At-Home Training Across the Lifespan

Providing aging adults with engaging, at-home balance therapy is essential to promote long-term adherence to unsupervised training and to foster independence. We developed a portable interactive balance training system that provides real-world visual cues on balance performance using wobble board tilt angles to control the speed of a robotic car platform in a three-dimensional environment. The goal of this study was to validate this mobile balance therapy system for home use across the lifespan. Twenty younger (18-39 years) and nineteen older (58-74 years) healthy adults performed balance training with and without visual feedback while standing on a wobble board instrumented with a consumer-grade inertial measurement unit (IMU) and optical motion tracking markers. Participants performed feedback trials based on either the robotic car's movements or a commercially-available virtual game. Wobble board tilt measurements were highly correlated between IMU and optical measurement systems ( [Formula: see text]), with high agreement in outcome metrics ( [Formula: see text]) and small bias ( [Formula: see text]). Both measurement systems identified similar aging, feedback, and stance type effects including (1) altered movement control when older adults performed tilting trials with either robotic or virtual feedback compared to without feedback, (2) two-fold greater wobble board oscillations in older vs. younger adults during steady standing, (3) no difference in board oscillations during steady standing in narrow vs. wide double support, and (4) greater wobble board oscillations for single compared to double support. These findings demonstrate the feasibility of implementing goal-directed robotic balance training with mobile tracking of balance performance in home environments.

The role of motivation factors in exergame interventions for fall prevention in older adults: A systematic review and meta-analysis

Balance disorders and falls are common in the elderly population. Regular balance exercises are an evidence-based physical intervention to prevent falls in older adults, while patient motivation and adherence are important factors for intervention outcome. Exergames are a relatively new, alternative intervention for physical rehabilitation as they improve balance and strength in older adults. The aims of this systematic review and meta-analysis were to assess the (1) effect of motivation factors as per the Capability, Opportunity and Motivation model of Behavior change (COM-B) on the effectiveness of exergame interventions in healthy older adults, (2) effectiveness of exergames to improve balance in older healthy adults and, (3) impact of exergames on cognitive outcomes. Results show that motivation and capability components influence the general outcome of the exergame training. Motivational factors should thus be considered when setting-up an exergame intervention. Furthermore, exergame intervention appears to be a promising training method in comparison to traditional exercise training. However, exergame training in itself might not be sufficient to improve fall risk and cognitive performance.

Risk of falls using the Biodex Balance System in non-faller patients with Parkinson Disease

PURPOSE

Biodex Balance System (BBS) is a low-cost platform used to assess balance in different populations. However, no study has used this tool to evaluate the risk of falls related to balance changes in non-faller individuals with Parkinson Disease (PD).

OBJECTIVE

The aim of this study was to determine the changes in the balance in non-faller individuals with mild to moderate PD compared to healthy elders.

METHODS

Forty-six PD patients at stages 2 and 3 were assessed in the 'on' state (fully medicated) as well as 31 age-matched healthy controls. They were submitted to the fall risk protocol of BBS and performed three 20-s trials and a 60-s rest interval between the trials.

RESULTS

Non-faller PD patients had an increased instability when compared to the healthy controls in the anteroposterior (controls: 1.54 ± 1.00 vs. PD patients: 2.91 ± 0.93) and mediolateral directions (controls: 1.21 ± 0.57 vs. PD patients: 1.42 ± 0.46), resulting in a great overall instability in the PD patients (controls: 1.28 ± 0.61 vs. PD patients: 4.09 ± 1.22). A significant correlation between overall instability and UPDRS-III (motor symptoms) in individuals with PD was observed.

CONCLUSION

BBS was able to identify the risk of falls in non-fallers, showing that PD patients have a greater risk of falls in unstable conditions than age-matched healthy elders, mainly due to the large sway in the anteroposterior direction. Furthermore, the severity of motor symptoms was related to overall instability which can increase the risk of falls in PD patients.

Does regularly playing serious gaming improve cognitive functioning of seniors in care facilities? Controlled Effectiveness Trial on a Representative German Sample

Background

Serious games have been found to have enhancing and preventative effects on cognitive abilities in healthy older adults. Yet, there are few results on the effects in older seniors with age-related low cognitive impairments. Their special needs were considered when designing and using innovate technology in the area of prevention, which is especially relevant owing to the continuously aging population.

Objective

The objective of this study was to evaluate the impact of a serious game on the cognitive abilities of seniors in order to potentially implement innovative resource-oriented technological interventions that can help to meet future challenges.

Methods

In this controlled trial, we tested the serious game MemoreBox, which features modules specifically designed for seniors in nursing homes. Over a period of 1 year, we tested the cognitive abilities of 1000 seniors at 4 time points using the Mini-Mental Status Test. Only half of the participating seniors engaged with the serious game.

Results

The study included an intervention group (n=56) and a control group (did not play; n=55). Based on the in-game data collection, a second intervention group (n=38) was identified within the original intervention group, which exactly followed the planned protocol. There were no noteworthy differences between the demographic and main variables of the overall sample. The large reduction in the sample size was due to the effects of the COVID-19 pandemic (drop-out rate: 88.9%). The CI was set at 5%. Mixed analysis of variance (ANOVA) between the cognitive abilities of the intervention and control groups did not show a statistically significant difference between time and group (F_{2.710,295.379}=1.942; P=.13; partial η²=0.018). We noted approximately the same findings for mixed ANOVA between the cognitive abilities of the second intervention and control groups (F_3,273=2.574; P=.054; partial η²=0.028). However, we did observe clear tendencies and a statistically significant difference between the 2 groups after 9 months of the intervention (t_88.1=−2.394; P=.02).

Conclusions

The results of this study show similarities with the current research situation. Moreover, the data indicate that the intervention can have an effect on the cognitive abilities of seniors, provided that they regularly play the serious game of MemoreBox. The small sample size means that the tendency toward improvement cannot be proven as statistically significant. However, the tendency shown warrants further research. Establishing an effective prevention tool as part of standard care in nursing homes by means of an easy-to-use serious game would be a considerable contribution to the weakened health care system in Germany as it would offer a means of activating senior citizens in partially and fully inpatient care facilities.

Trial Registration

German Clinical Trials Register DRKS00016633; https://tinyurl.com/2e4765nj

Effects and Feasibility of a Memory Exergame Training in Older Adults: A Randomized Controlled Trial

Objective: The aim of the study is to assess the feasibility, sustainability, and effectiveness of task-specific memory exergame training on motor-cognitive performance in older adults. Materials and Methods: Fifty older adults (age: 78.8 ± 7.0 years) participated in a randomized controlled trial with a 10-week intervention and 3-month follow-up period. Both the intervention group (IG: n = 29) and control group (CG: n = 21) underwent a once-weekly exercise program, including strength and balance exercises, while the IG performed an additional exergame training, combining dynamic balance with visuospatial memory tasks. Outcome measures were completion time for distinct levels of memory exergame tasks without (condition 1) and with procedural support (condition 2) and (sub)-total game scores documented by a game-specific assessment strategy. Results: Significant improvements in the IG compared with the CG over the intervention period were found for completion times in most of the analyzed levels of condition 1 (P < 0.001-0.047; η_p² = 0.238-0.335) and one level of condition 2 (P < 0.001, η_p² = 0.267), for the subtotal game score of condition 1 (P = 0.002; η_p² = 0.186), and for the total game score (P = 0.005; η_p² = 0.162). Improvements were partially sustained 3 months after training cessation (P = 0.008-0.039, η_p² = 0.095-0.174). Completion rates for initial levels were 86%-98%. No clinical events or safety issues were observed during the training. Conclusion: The study demonstrates that additional memory exergame training effectively, and sustainably, improves performance in complex motor-cognitive tasks involving dynamic balance and visuospatial memory in older adults.

Interaction Preference Differences between Elderly and Younger Exergame Users

Existing motion capture technology can efficiently track whole-body motion and be applied to many areas of the body. This whole-body interaction design has gained the attention of many researchers. However, few scholars have studied its suitability for elderly users. We were interested in exercise-based whole-body interactive games, which can provide mental and physical exercise for elderly users. We used heuristic evaluation to measure participants' actions during exergame tasks and analyzed preference differences between elderly and younger users through the distribution of actions in four dimensions. We found that age affected the actions performed by users in exergame tasks. We discuss the mental model of elderly users during the process of performing these tasks and put forward some suggestions for interactive actions. This model and these suggestions theoretically have guiding significance for the research and application of exergame design for elderly users and may help designers develop more effective exergames or other whole-body interaction interfaces suitable for elderly users.

The Effects of Exergames on Muscle Architecture: A Systematic Review and Meta-Analysis

Muscle architectural parameters play a crucial role in the rate of force development, strength, and sports performance. On the other hand, deteriorated muscle architectural parameters are associated with injuries, sarcopenia, mortality, falls, and fragility. With the development of technology, exergames have emerged as a complementary tool for physical therapy programs. The PRISMA 2020 statement was followed during the systematic review and meta-analysis. CENTRAL, CINAHL, PROQUEST, PubMed, and OpenGrey databases were searched last time on 22 September 2021. In total, five controlled trials were included in the systematic review. Twelve weeks of virtual dance exercise (Dance Central game for Xbox 360®) showed a medium effect on the improvement of hamstrings (g = 0.55, 95% CI (−0.03, 1.14), I2 = 0%) and the quadriceps femoris muscle cross-sectional area (g = 0.58, 95% CI (0.1, 1.00), I2 = 0%) in community-dwelling older women. Additionally, a four-week virtual balance-training program (the ProKin System) led to significant increments in the cross-sectional areas of individual paraspinal muscles (14.55–46.81%). However, previously investigated exergame programs did not show any medium or large effects on the architectural parameters of the medial gastrocnemius muscle in community-dwelling older women. Distinct exergame programs can be used as a complementary therapy for different prevention and rehabilitation programs.

Effects of 8 Weeks of Balance Training, Virtual Reality Training, and Combined Exercise on Lower Limb Muscle Strength, Balance, and Functional Mobility Among Older Men: A Randomized Controlled Trial

BACKGROUND

Poor muscle strength, balance, and functional mobility have predicted falls in older adults. Fall prevention guidelines recommend highly challenging balance training modes to decrease falls; however, it is unclear whether certain modes are more effective. The purpose of this study was to determine whether traditional balance training (BT), virtual reality balance training (VR), or combined exercise (MIX) relative to a waitlist control group (CON) would provoke greater improvements in strength, balance, and functional mobility as falls risk factor proxies for falls in older men.

HYPOTHESIS

We hypothesized that 8 weeks of MIX will provoke the greatest improvements in falls risk factors, followed by similar improvements after BT and VR, relative to the CON.

STUDY DESIGN

Single-blinded randomized controlled trial NCT02778841 (ClinicalTrials.gov identifier).

LEVEL OF EVIDENCE

Level 2.

METHODS

In total, 64 community-dwelling older men (age 71.8 ± 6.09 years) were randomly assigned into BT, VR, MIX, and CON groups and tested at baseline and at the 8-week follow-up. The training groups exercised for 40 minutes, 3 times per week, for 8 weeks. Isokinetic quadriceps and hamstrings strength on the dominant and nondominant legs were primary outcomes measured by the Biodex Isokinetic Dynamometer. Secondary outcomes included 1-legged stance on firm and foam surfaces, tandem stance, the timed-up-and-go, and gait speed. Separate one-way analyses of covariance between groups were conducted for each outcome using baseline scores as covariates.

RESULTS

(1) MIX elicited greater improvements in strength, balance, and functional mobility relative to BT, VR, and CON; (2) VR exhibited better balance and functional mobility relative to BT and CON; and (3) BT demonstrated better balance and functional mobility relative to CON.

CONCLUSION

The moderate to large effect sizes in strength and large effect sizes for balance and functional mobility underline that MIX is an effective method to improve falls risk among older adults.

CLINICAL RELEVANCE

This study forms the basis for a larger trial powered for falls.

The Effect of Physical Exercise on Cognitive Impairment in Neurodegenerative Disease: From Pathophysiology to Clinical and Rehabilitative Aspects

Neurodegenerative diseases are a group of pathologies that cause severe disability due to motor and cognitive limitations. In particular, cognitive impairment is a growing health and socioeconomic problem which is still difficult to deal with today. As there are no pharmacologically effective treatments for cognitive deficits, scientific interest is growing regarding the possible impacts of healthy lifestyles on them. In this context, physical activity is gaining more and more evidence as a primary prevention intervention, a nonpharmacological therapy and a rehabilitation tool for improving cognitive functions in neurodegenerative diseases. In this descriptive overview we highlight the neurobiological effects of physical exercise, which is able to promote neuroplasticity and neuroprotection by acting at the cytokine and hormonal level, and the consequent positive clinical effects on patients suffering from cognitive impairment.

An Interactive Physical-Cognitive Game-Based Training System Using Kinect for Older Adults: Development and Usability Study

BACKGROUND

Declines in physical and cognitive functions are recognized as important risk factors for falls in older adults. Promising evidence suggests that interactive game-based systems that allow simultaneous physical and cognitive exercise are a potential approach to enhance exercise adherence and reduce fall risk in older adults. However, a limited number of studies have reported the development of a combined physical-cognitive game-based training system for fall risk reduction in older adults.

OBJECTIVE

The aim of this study is to develop and evaluate the usability of an interactive physical-cognitive game-based training system (game-based exercise) for older adults.

METHODS

In the development phase (Part I), a game-based exercise prototype was created by integrating knowledge and a literature review as well as brainstorming with experts on effective fall prevention exercise for older adults. The output was a game-based exercise prototype that covers crucial physical and cognitive components related to falls. In the usability testing (Part II), 5 games (ie, Fruits Hunter, Where Am I?, Whack a Mole, Sky Falls, and Crossing Poison River) with three difficulty levels (ie, beginner, intermediate, and advanced levels) were tested in 5 older adults (mean age 70.40 years, SD 5.41 years). After completing the games, participants rated their enjoyment level while engaging with the games using the Physical Activity Enjoyment Scale (PACES) and commented on the games. Descriptive statistics were used to describe the participants' characteristics and PACES scores.

RESULTS

The results showed that the average PACES score was 123 out of 126 points overall and between 6.66 and 7.00 for each item, indicating a high level of enjoyment. Positive feedback, such as praise for the well-designed interactions and user-friendly interfaces, was also provided.

CONCLUSIONS

These findings suggest that it is promising to implement an interactive, physical-cognitive game-based exercise in older adults. The effectiveness of a game-based exercise program for fall risk reduction has yet to be determined.

Virtual and augmented reality in the vestibular rehabilitation of peripheral vestibular disorders: systematic review and meta-analysis

Vestibular rehabilitation therapy is an established treatment for patients with vestibular dysfunction. Virtual reality (VR) and augmented reality (AR) can be utilised in vestibular rehabilitation. Evidence of the efficacy of VR and AR delivered rehabilitation in patients with peripheral vestibular disorders is reviewed. MEDLINE, EMBASE, CENTRAL, CINAHL, PsychInfo, PsychBITE, OTSeeker, Ei Compendex, IEE, Clinical trials.gov and WebofScience databases were searched. Reduction in vestibular dysfunction symptoms 0-3 months post-intervention was the primary outcome. Secondary outcomes included long-term symptom improvement and side effects. Risk of bias assessment and meta analyses were planned. Five studies meeting eligibility criteria were included. Dizziness Handicap Inventory (DHI) scores 0-3 months post-intervention were reported by four studies. Meta-analysis identified a 1.13 (95% CI, - 1.74, - 0.52) standardized mean difference reduction in DHI in VR and AR treated patients compared to controls. Side effects reported by two studies were reduced by week four of VR intervention. Bias assessment identified DHI scores and side effects to be at high risk or of some concern. Adjunct VR interventions reduced patient DHI significantly more than vestibular rehabilitation alone 0-3 months post-intervention in adult patients diagnosed with unilateral vestibular disease. High quality studies are needed.

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.

Enhancement of Anticipatory Postural Adjustments by Virtual Reality in Older Adults with Cognitive and Motor Deficits: A Randomised Trial

BACKGROUND

Postural activities involved in balance control integrate the anticipatory postural adjustments (APA) that stabilize balance and posture, facilitating arm movements and walking initiation and allowing an optimal coordination between posture and movement. Several studies reported the significant benefits of virtual reality (VR) exercises in frail older adults to decrease the anxiety of falling and to induce improvements in behavioural and cognitive abilities in rehabilitation processes. The aim of this study was thus to test the efficiency of a VR system on the enhancement of the APA period, compared to the use of a Nintendo Wii system.

METHODS

Frail older adults (n = 37) were included in this study who were randomized and divided into a VR exercises group (VR group) or a control group using the Nintendo Wii system (CTRL group). Finally, 22 patients were included in the data treatment. APA were studied through muscular activation timings measured with electromyographic activities. The functional reach test, the gait speed, and the time up and go were also evaluated before and after a 3-week training phase.

RESULTS AND DISCUSSION

As the main results, the training phase with VR improved the APA and the functional reach test score along the antero-posterior axis. Together, these results highlight the ability of a VR training phase to induce neuromuscular adaptations during the APA period in frail older adults. Then, it underlines the effective transfer from learning carried out during the VR training movements to control balance abilities in a more daily life context.

Effectiveness of virtual reality in children and young adults with cerebral palsy: a systematic review of randomized controlled trial

BACKGROUND

Cerebral palsy (CP) is one of the main causes of disability in childhood. Virtual reality (VR) has been used as a treatment option in this population, however its effectiveness is unclear.

OBJECTIVE

To evaluate the effectiveness of VR in patients with CP.

METHODS

We conducted electronic searches in EMBASE, MEDLINE, Cochrane library, PEDro, AMED, PsycoINFO, and LILACS databases and trial site registries such as ClinicalTrials.gov and ICTRP. We included randomized controlled trials that tested the use of VR alone or in combination with other interventions compared to more conventional rehabilitation or usual care in individuals with CP. The primary outcomes were upper and lower limb function, postural control, and balance. The secondary outcomes included global motor function, perception, cognition and spatial functions, motivation, motor learning, and adverse events. Two independent reviewers extracted and assessed included articles for risk of bias using the Cochrane risk of bias tool. We use a meta-analysis with random effect model whenever possible. We analyzed the quality of evidence using theGRADE approach.

RESULTS

We included 38 trials (pooled n = 1233 participants) in this review. There is very low quality of evidence that VR plus conventional rehabilitation is better than conventional rehabilitation for upper limb function. There is also very low quality evidence that VR alone is no better than conventional rehabilitation for upper and lower limb function. No adverse events were observed among the 10 trials that provided information on this outcome.

CONCLUSION

At present we have very limited to limited confidence in effect estimation for utilization of VR in this population. Future studies may change our confidence in results and effect estimates.

PROTOCOL REGISTRATION

PROSPERO CRD 42018102759.

Proof of Concept of Novel Visuo-Spatial-Motor Fall Prevention Training for Old People

Falls in the geriatric population are one of the most important causes of disabilities in this age group. Its consequences impose a great deal of economic burden on health and insurance systems. This study was conducted by a multidisciplinary team with the aim of evaluating the effect of visuo-spatial-motor training for the prevention of falls in older adults. The subjects consisted of 31 volunteers aged 60 to 92 years who were studied in three groups: (1) A group under standard physical training, (2) a group under visuo-spatial-motor interventions, and (3) a control group (without any intervention). The results of the study showed that visual-spatial motor exercises significantly reduced the risk of falls of the subjects.

User training for machine learning controlled upper limb prostheses: a serious game approach

BACKGROUND

Upper limb prosthetics with multiple degrees of freedom (DoFs) are still mostly operated through the clinical standard Direct Control scheme. Machine learning control, on the other hand, allows controlling multiple DoFs although it requires separable and consistent electromyogram (EMG) patterns. Whereas user training can improve EMG pattern quality, conventional training methods might limit user potential. Training with serious games might lead to higher quality EMG patterns and better functional outcomes. In this explorative study we compare outcomes of serious game training with conventional training, and machine learning control with the users' own one DoF prosthesis.

METHODS

Participants with upper limb absence participated in 7 training sessions where they learned to control a 3 DoF prosthesis with two grips which was fitted. Participants received either game training or conventional training. Conventional training was based on coaching, as described in the literature. Game-based training was conducted using two games that trained EMG pattern separability and functional use. Both groups also trained functional use with the prosthesis donned. The prosthesis system was controlled using a neural network regressor. Outcome measures were EMG metrics, number of DoFs used, the spherical subset of the Southampton Hand Assessment Procedure and the Clothespin Relocation Test.

RESULTS

Eight participants were recruited and four completed the study. Training did not lead to consistent improvements in EMG pattern quality or functional use, but some participants improved in some metrics. No differences were observed between the groups. Participants achieved consistently better results using their own prosthesis than the machine-learning controlled prosthesis used in this study.

CONCLUSION

Our explorative study showed in a small group of participants that serious game training seems to achieve similar results as conventional training. No consistent improvements were found in either group in terms of EMG metrics or functional use, which might be due to insufficient training. This study highlights the need for more research in user training for machine learning controlled prosthetics. In addition, this study contributes with more data comparing machine learning controlled prosthetics with Direct Controlled prosthetics.

A Langevin-Based Model With Moving Posturographic Target to Quantify Postural Control

Falls are a major concern of public health, particularly for older adults, as the consequences of falls include serious injuries and death. Therefore, the understanding and evaluation of postural control is considered key, as its deterioration is an important risk factor predisposing to falls. In this work we introduce a new Langevin-based model, local recall, that integrates the information from both the center of pressure (CoP) and the center of mass (CoM) trajectories, and compare its accuracy to a previously proposed model that only uses the CoP. Nine healthy young participants were studied under quiet bipedal standing conditions with eyes either open or closed, while standing on either a rigid surface or a foam. We show that the local recall model produces significantly more accurate prediction than its counterpart, regardless of the eyes and surface conditions, and we replicate these results using another publicly available human dataset. Additionally, we show that parameters estimated using the local recall model are correlated with the quality of postural control, providing a promising method to evaluate static balance. These results suggest that this approach might be interesting to further extend our understanding of the underlying mechanisms of postural control in quiet stance.

Comparison of a Deep Learning-Based Pose Estimation System to Marker-Based and Kinect Systems in Exergaming for Balance Training

Using standard digital cameras in combination with deep learning (DL) for pose estimation is promising for the in-home and independent use of exercise games (exergames). We need to investigate to what extent such DL-based systems can provide satisfying accuracy on exergame relevant measures. Our study assesses temporal variation (i.e., variability) in body segment lengths, while using a Deep Learning image processing tool (DeepLabCut, DLC) on two-dimensional (2D) video. This variability is then compared with a gold-standard, marker-based three-dimensional Motion Capturing system (3DMoCap, Qualisys AB), and a 3D RGB-depth camera system (Kinect V2, Microsoft Inc). Simultaneous data were collected from all three systems, while participants (N = 12) played a custom balance training exergame. The pose estimation DLC-model is pre-trained on a large-scale dataset (ImageNet) and optimized with context-specific pose annotated images. Wilcoxon's signed-rank test was performed in order to assess the statistical significance of the differences in variability between systems. The results showed that the DLC method performs comparably to the Kinect and, in some segments, even to the 3DMoCap gold standard system with regard to variability. These results are promising for making exergames more accessible and easier to use, thereby increasing their availability for in-home exercise.

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.

The Acute Effects of Cognitive-Based Neuromuscular Training and Game-Based Training on the Dynamic Balance and Speed Performance of Healthy Young Soccer Players: A Randomized Controlled Trial

Objective: The aim of this study was to investigate the acute effects of cognitive and game-based trainings (GBT) on dynamic balance (DB) and speed performance (SP) in healthy young soccer players. Materials and Methods: Forty-nine male soccer players were divided into three groups: cognitive-based neuromuscular training (CBNT; n = 16; age = 16.93 ± 1.18 years; body mass index [BMI] = 21.37 ± 1.57 kg/m²) group, GBT (n = 17; age = 17.05 ± 1.39 years; BMI = 21.10 ± 0.97 kg/m²) group, and control group (n = 16; age = 16.75 ± 1.12 years; BMI = 21.95 ± 1.36 kg/m²). The athletes in CBNT and GBT groups took part in one session lasting 1 hour. The Star Excursion Balance Test and the Speed Dribbling Test were used to evaluate DB and SP, respectively. The measurements were taken just before and after the trainings. Statistical analysis of the study was performed using SPSS 22.0 software (Statistical Package for Social Sciences, Inc., Chicago, IL). The Paired Student's t-test and Wilcoxon test were used. For in-group evaluation the ANOVA test was used for comparisons between the three groups. The Tukey's test was used for post hoc analysis. Results: DB significantly improved in all directions in the GBT group (P < 0.05). Also, significant improvements were observed in DB in all directions except anterior, anterolateral, and anteromedial in the CBNT group, and except anterior, medial, and anteromedial directons in the control group (P < 0.05). SP significantly developed just in the CBNT and GBT groups (P = 0.001, P = 0.003, respectively). CBNT and GBT improved the DB of soccer players by 9.6% and 9.5%, respectively. Also, trainings improved the SP by 3.1% and 2.6%, respectively. Conclusion: CBNT and GBT are promising trainings that can improve DB and SP of healthy young soccer players. Trial number: NCT03739658 (ClinicalTrials.gov Identifier).

Effects of the degree of freedom and assistance characteristics of powered ankle-foot orthoses on gait stability

We studied the use of powered ankle-foot orthoses (PAFOs) and walking stability of the wearers, focusing on the ankle joint, which is known to play a critical role in gait stability. Recognizing that the subtalar joint is an important modulator of walking stability, we conducted the walking experiment on a treadmill by applying varying assistance techniques to the 2-degree-of-freedom (DOF) PAFO, which has the subtalar joint as the rotating axis, and the commonly used 1-DOF PAFO. The participants were 8 healthy men (mean±SD: height, 174.8±7.1 cm; weight, 69.8±6.5 kg; and age, 29.1±4.8 years) with no history of gait abnormality. Center of pressure (COP) was measured with an in-shoe pressure sensor, and stability was estimated on the basis of the angular acceleration measured with the inertial measurement unit attached to the trunk. The experimental results of the 2-DOF PAFO, with or without assistance, showed a significantly higher stability than those of the 1-DOF PAFO (up to 23.78%, p<0.0326). With the 1-DOF PAFO, the stability deteriorated with the increase in the degree of assistance provided. With the 2-DOF PAFO, this tendency was not observed. Thus, the importance of the subtalar joint was proven using PAFOs. The mean position analysis of the COP during the stance phase confirmed that the COP highly correlated with stability (Pearson correlation coefficient: −0.6607). Thus, we conclude that only the 2-DOF PAFO can maintain walking stability, regardless of the assistance characteristics, by preserving the COP in the medial position through eversion. Awareness regarding the role of the subtalar joint is necessary during the manufacture or use of PAFOs, as lack of awareness could lead to the degradation of the wearer’s gait stability, regardless of effective assistance, and deteriorate the fundamental functionality of PAFO.

Effect of exergames on physical outcomes in frail elderly: a systematic review

AIM

The aim of this systematic review was to understand the exergames that can be applied to the pre-frail and frail elderly people, to evaluate whether these games have a positive impact on physical outcomes in pre-frail and frail older adults, and to explore user's subjective feelings and compliance.

METHODS

PubMed, EMBASE, CINAHL, Web of Science, and the Cochrane Library were searched until January 15, 2019. Only randomized controlled trials published in English for human beings were eligible. The review included studies which examined the effects of exergames on physical outcomes, feasibility and/or subjective feelings of pre-frail and frail older adults. Two researchers assessed the risk bias of all articles independently using the Cochrane collaboration's tool for assessing risk of bias.

RESULTS

Seven randomized controlled trials with 243 pre-frail and frail older adults met inclusion criteria and were included in this review. Results of the studies were heterogeneous. Physical outcomes (included muscle strength, balance ability, mobility function, gait and falls), subjective feeling outcomes, feasibility, attendance and some other functional outcomes were reported.

CONCLUSION

Exergames improved balance and mobility function of frail elderly, and it showed a tendency to increase muscle strength when combined with resistance training. As far as the limited evidence was concerned, exergames were feasible and generally accepted by participants.

Personalized Balance and Fall Risk Visualization with Kinect Two

When we face a super-aging society, there is a drastically increased need for efficient systems in terms of time and cost that can improve rehabilitation standards for the elderly people and other motor-impaired subjects. Human balance ability depends largely on the control of the full body center of mass (CoM), fall risks can be evaluated by estimating the subject-specific CoM displacement over the support polygon relating to the foot tracking. The CoM position is often estimated using what are known as anthropometric tables in biomechanics field. However, the parameters have been obtained from a standard population and will differ between subjects. Current existing fall risk assessment usually relies on the generic anthropometric table or need the center of pressure (CoP) recordings which are to be evaluated for the risk of fall. CoP measurements require force platform, wii board or specialized shoes, which limits the practical usage in the daily life environment. This work represents a personalized measure of balance that considers subject-specific body mass variations along with the motion tracking by Kinect Two. Based on our previous developments, we firstly verified the system with Kinect Two recording, and with adaptive support polygon extraction process, it realizes a real-time system for evaluating the personalized balance and fall risk visualization for unknown disturbance without needing force platform.

Effectiveness and sustainability of a motor-cognitive stepping exergame training on stepping performance in older adults: a randomized controlled trial

Background

Training effects reported for stepping exergames on stepping performances in older adults often based on not comprehensively validated outcomes measures, and follow-up data on their sustainability are lacking. The aim of this study is to evaluate the effectiveness and sustainability of a motor-cognitive stepping exergame training on the stepping performance in older adults.

Methods

Fifty-eight older adults (78.3 ± 6.5 years) participated in the randomized controlled trial with a 10-week intervention and 10-week follow-up period. The intervention group (IG: n = 29) took part in a once-weekly exercise program including strength and balance exercises supplemented with an additional stepping exergame training. The control group (CG: n = 29) only performed the strength and balance exercises. Outcome measures included stepping reaction times (SRTs) and games scores for individual stepping exergame levels and for the overall exergame performance, as measured by an assessment strategy previously validated in older adults.

Results

SRTs and/or games scores for 7 out of 10 levels and the overall exergame performance significantly improved in the IG compared to the CG during the intervention (p ≤ 0.001–0.039, η_p² = 0.090–0.445). Training gains were sustained for 2 levels and for the overall exergame performance (p = 0.017–0.033, η_p² = 0.127–0.193).

Conclusion

The study demonstrates that the additional stepping exergame training effectively and sustainably improves the performance in complex motor-cognitive stepping exergame tasks in older adults, which can be relevant for preventing falls. Future research is needed to evaluate the effectiveness of such training on reducing the number of falls.

Trial registration

ISRCTN registry, ISRCTN14855620, 06/06/2019 (retrospectively registered).

Balance training monitoring and individual response during unstable vs. stable balance Exergaming in elderly adults: Findings from a randomized controlled trial

OBJECTIVE

Exercise-based fall prevention programs mainly refer to multimodal and challenging balance exercises. Individual load monitoring and interpretations are crucial to enable adequate adaptation responses on the individual level. Thus, assessing internal responses to external stimuli throughout an intervention period need to be adequately addressed. The aim of this secondary analysis of a 3-armed randomized controlled trial was to analyze internal and external loads of unstable vs. stable balance Exergame training in healthy seniors. We intended to elucidate whether differences of external and internal load criteria occur over the intervention period.

METHODS

A total of 51 healthy seniors (females: n = 34; males: n = 17; age: 69 ± 6 years; BMI: 27 ± 5) were allocated to either volitional stepping (VOL), volitional stepping under unstable conditions (VOL + US) or an inactive control group (CON). VOL and VOL + US completed 8 weeks of Exergame based step training (three weekly sessions, 45 min each) using the Dividat Senso device. Twelve different balance Exergames were used, consisting of virtual reality like video games. The original nonswinging, stable platform was employed for VOL, whereas VOL + US used an adapted Senso mounted on a swinging Posturomed Rack. The instability level was increased for VOL + US only every second week. External (game scores) and internal (perceived efforts, using the rated perceived exertion scale (RPE)) load measures were individually recorded for every session. Statistical analysis was carried out using linear mixed-effects modelling.

RESULTS

Although VOL + US completed similar games at identical training volumes under unstable conditions, the achieved game scores did not significantly differ between both training groups (p = 0.71). Both intervention groups notably improved their game scores over the 8 training weeks (p < 0.01). A significant time x group interaction effect was observed for perceived effort (p < 0.01), serving as an internal load measure. Subsequent post-hoc testing revealed significant greater perceived exertion values in each of the first 7 weeks (p < 0.05) in VOL + US compared to VOL. No between-group differences were found for RPE in week 8. Whereas RPE values in VOL + US decreased over time (week 1: 4.6 ± 1.9; week 8: 3.1 ± 1.6), VOL indicated similar RPE values for all weeks (week 1: 3.1 ± 1.3; week 8: 2.9 ± 1.4). A detailed analysis of all twelve games revealed that differences in perceived exertion depend on the game content: in 75% of the involved games the RPE level was significantly higher in VOL + US compared to VOL (p < 0.05).

CONCLUSION

Monitoring internal and external loads on individual level are paramount for gaining adequate training adaptations. Our results indicate that between-group differences in perceived efforts a) can funnel over time, b) depend on game content and c) do not necessarily affect overall scoring. Future studies should individually employ and monitor measures of perceived efforts to guarantee an adequate challenge to the balance system within exercise-based fall prevention programs.

The Chongchong Step Master Game for Gait and Balance Training

Exercise can help to improve health, strengthen vitality and prevent brain disease, especially for the elderly. Exercise games, or exergames, which combine both exercise and video gaming, train people in a fun and competitive manner to lead a healthy lifestyle. Exergames promote more physical effort and have the potential to contribute to physical education. This research presents a full-body virtual reality exercise game called the Chongchong Step Master, which is designed to improve gait and balance function and prevent dementia in the elderly. This system used Kinect sensors to accurately recognize the user’s body movements and the stepping board mat to recognize and guide the user’s walking motion. It aims to help the elderly exercise more easily and independently with the virtual physical trainer.

Effects of Whole Body Electromyostimulation on Physical Fitness and Health in Postmenopausal Women: A Study Protocol for a Randomized Controlled Trial

Background: Age-related problems such as chronic diseases, functional limitation and dependence, reduce the quality of life in the elderly, and increase public spending in health. It has been established that physical activity plays a fundamental role in the health of the elderly. The whole body electromyostimulation (WB-EMS) could be a successful methodology as high-intensity training to improve the physical fitness of older people. Methods: A minimum of 13 women between 55 and 70 years old will be randomized in two groups. The exercise with WB-EMS group (EX + WB-EMS) will conduct a resistance strength training program with superimposed WB-EMS while the exercise group (EX) will perform only resistance strength and aerobic training. Balance, strength, flexibility, agility, speed, and aerobic performance (EXERNET battery and progressive resistance test), as well as body composition, blood parameters and physical activity reporting (IPAQ-E) will be assessed to analyze the effects of whole body electromyostimulation in the physical fitness and the health in postmenopausal women. Discussion: Innovative and scientifically well-designed protocols are needed to enhance the knowledge of the body's responses within this training methodology which is being used by a big quantity of population. This trial will provide evidence on the effectiveness of whole-body electromyostimulation in physical fitness and health in elderly women. Trial Registration: ISRCTN15558857 registration data: 27/11/2019 (retrospectively registered).

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 Immersion in Healthy Individuals: Ellipse Sway Area of an Electrical Shuttle Balance

To assess indirectly the effects of virtual reality (VR) immersion on postural sway in thirteen healthy individuals. The ellipse sway area was recorded with an accelerometer coupled to an electrical shuttle balance under six conditions, varying Romberg and single leg stance (SLS) position with eyes open and eyes closed. The length of the ellipse traveled over 10 s was measured and Romberg and single leg stance (SLS) ratios were calculated. Ellipse sway area was reduced in all positions after VR intervention. Statistical differences were observed in the left SLS ratio 24 hr after comparison to the baseline. A single VR session could reduce ellipse sway area and decrease the visual dependency of posture control indicating increased ability to maintain stable body sway over the shuttle.

The Role of Virtual Reality in Improving Health Outcomes for Community-Dwelling Older Adults: Systematic Review

Background

Virtual reality (VR) delivered through immersive headsets creates an opportunity to deliver interventions to improve physical, mental, and psychosocial health outcomes. VR app studies with older adults have primarily focused on rehabilitation and physical function including gait, balance, fall prevention, pain management, and cognition. Several systematic reviews have previously been conducted, but much of the extant literature is focused on rehabilitation or other institutional settings, and little is known about the effectiveness of VR apps using immersive headsets to target health outcomes among community-dwelling older adults.

Objective

The objective of this review was to evaluate the effectiveness of VR apps delivered using commercially available immersive headsets to improve physical, mental, or psychosocial health outcomes in community-dwelling older adults.

Methods

Peer-reviewed publications that included community-dwelling older adults aged ≥60 years residing in residential aged care settings and nursing homes were included. This systematic review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews of effectiveness evidence. The title of this review was registered with JBI, and the systematic review protocol was registered with the International Prospective Register of Systematic Reviews.

Results

In total, 7 studies that specifically included community-dwelling older adults were included in this review. VR apps using a head-mounted display led to improvements in a number of health outcomes, including pain management, posture, cognitive functioning specifically related to Alzheimer disease, and a decreased risk of falls. A total of 6 studies reported a statistically significant difference post VR intervention, and 1 study reported an improvement in cognitive function to reduce navigational errors. Only one study reported on the usability and acceptability of the interventions delivered through VR. While one study used a distraction mechanism for pain management, none of the studies used gaming technology to promote enjoyment.

Conclusions

Interventions to improve health outcomes through VR have demonstrated potential; however, the ability to synthesize findings by primary outcome for the older adult population is not possible. A number of factors, especially related to frailty, usability, and acceptability, also need to be explored before more substantial recommendations on the effectiveness of VR interventions for older adults can be made.

Trial Registration

PROSPERO CRD42019143504; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=143504

Balance Training in Older Adults Using Exergames: Game Speed and Cognitive Elements Affect How Seniors Play

Falls in older adults are a serious threat to their health and independence, and a prominent reason for institutionalization. Incorrect weight shifts and poor executive functioning have been identified as important causes for falling. Exergames are increasingly used to train both balance and executive functions in older adults, but it is unknown how game characteristics affect the movements of older adults during exergaming. The aim of this study was to investigate how two key game elements, game speed, and the presence of obstacles, influence movement characteristics in older adults playing a balance training exergame. Fifteen older adults (74 ± 4.4 years) played a step-based balance training exergame, designed specifically for seniors to elicit weight shifts and arm stretches. The task consisted of moving sideways to catch falling grapes and avoid obstacles (falling branches), and of raising the arms to catch stationary chickens that appeared above the avatar. No steps in anterior-posterior direction were required in the game. Participants played the game for eight 2 min trials in total, at two speed settings and with or without obstacles, in a counterbalanced order across participants. A 3D motion capture system was used to capture position data of 22 markers fixed to upper and lower body. Calculated variables included step size, step frequency, single leg support, arm lift frequency, and horizontal trunk displacement. Increased game speed resulted in a decrease in mean single support time, step size, and arm lift frequency, and an increase in cadence, game score, and number of error messages. The presence of obstacles resulted in a decrease in single support ratio, step size, cadence, frequency of arm lifts, and game score. In addition, step size increased from the first to the second trial repetition. These results show that both game speed and the presence of obstacles influence players' movement characteristics, but only some of these effects are considered beneficial for balance training whereas others are detrimental. These findings underscore that an informed approach is necessary when designing exergames so that game settings contribute to rather than hinder eliciting the required movements for effective balance training.

Effects of Exergaming on Balance of Healthy Older Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Balance is critical for older adults to perform daily activities. However, age-related declines in balance increase the risk of falls and severe injuries, such as bone fractures and head injuries. Exergames have been widely applied to improve health-related outcomes in older adults. This meta-analysis aims to quantify the effects of exergaming interventions on balance performance in healthy older adults. A literature search was performed using PubMed, ScienceDirect, SPORTDiscus, COCHRANE, EBSCO, and EMBASE. A total of 16 experimental studies met inclusion criteria for a full-text review. Data synthesis examined balance functions, including static, dynamic, proactive, and perceived balance abilities when performing daily activities. Intervention protocols of the reviewed studies included an average of two to three 40-minute exergaming sessions per week for 8 weeks. A random effects model identified significant effects in favor of the exergaming group, with moderate effect size in dynamic balance (Hedges' g = 0.36, 95% CI = 0.26-1.30, P < 0.001), and perceived balance (Hedges' g = 0.31, 95% CI = 0.04-0.58, P = 0.02); and considerable effect size in Chair Stand Test (Hedges' g = 0.78, 95% CI = 0.26-1.30, P = 0.003), and balance test batteries (Hedges' g = 0.72, 95% CI = 0.42-1.02, P < 0.001). No significant effect was found in the static balance (Hedges' g = 0.22, 95% CI = -0.31 to 0.76, P = 0.42), or proactive balance (Hedges' g = 0.54, 95% CI = -0.12 to 1.20, P = 0.11). Meta-analysis identified exergaming-associated benefits in older adults' balance function and confidence. This finding supports the feasibility of exergaming as a supplementary approach to improve balance for healthy older adults. Health professionals may optimize treatment effect by integrating exergaming sessions into a traditional balance exercise program.

The benefits and mechanisms of exercise training for Parkinson's disease

Parkinson's disease (PD) is a significantly progressive neurodegenerative disease characterised by both motor and nonmotor disorders. The main pathological characteristics of PD consist of the loss of dopaminergic neurons and the formation of alpha-synuclein-containing Lewy bodies in the substantia nigra. Currently, the main therapeutic method for PD is anti-Parkinson medications, including levodopa, madopar, sirelin, and so on. However, the effect of pharmacological treatment has its own limitations, the most significant of which is that the therapeutic effect of dopaminergic treatments gradually diminishes with time. Exercise training, as an adjunctive treatment and complementary therapy, can improve the plasticity of cortical striatum and increase the release of dopamine. Exercise training has been proven to effectively improve motor disorders (including balance, gait, risk of falls and physical function) and nonmotor disorders (such as sleep impairments, cognitive function and quality of life) in PD patients. In recent years, various types of exercise training have been used to treat PD. In this review, we summarise the exercise therapy mechanisms and the protective effects of different types of exercise training on PD patients.

Does a novel exergame challenge balance and activate muscles more than existing off-the-shelf exergames?

BACKGROUND

Novel balance-targeting exergames controlled with off-the-shelf hardware, were developed based on current recommendations for balance training in healthy older adults and documented shortcomings of existing games. The aim of this study was to explore the feasibility of these novel exergames as training tool for elderly and, more specifically whether these games can elicit more challenging weight shifts and higher levels of muscle activity compared to existing off-the-shelf exergames. Furthermore, the motivational pull in these new games was studied.

METHODS

Sixteen healthy older adults were recruited to play the novel games and two reference games that were found to be the most challenging ones in terms of weight shifts or muscle activity in previous studies. Weight shifts were expressed relative to participants' Functional Limits of Stability (FLOS). Muscular challenge of the games was quantified by dividing the signal into 200 ms blocks and determining the average muscle activity within these blocks. The muscle activity was normalized to maximal voluntary contractions (MVC) to categorize the blocks in zones of < 40, 40-60, 60-80 and > 80% MVC. Subsequently, the number of blocks per intensity level and the number of consecutive blocks above 40% were determined. Motivation to play the games was assessed using the Intrinsic Motivation Inventory (IMI) and scores between the games were analyzed using Generalized Estimated Equations (GEE).

RESULTS

The novel exergames successfully elicited center of mass (COM) displacements with medians of around 80% of FLOS or higher for all directions. Furthermore, the COM displacements in the novel games were larger for each direction than in the reference games, although for one game the sideward left direction reached significance only at the third trial. Compared to the existing games, longer blocks of muscle activation above 40% MVC were found, but overall intensity remained low. IMI scores were high on all subscales, indicating that older adults experienced the games as motivating.

CONCLUSION

We conclude that affordable hardware can be used to create challenging and enjoyable balance training programs using exergames. The exergames that were successful in eliciting challenging weight shifts and muscle activity should now be further studied in longitudinal randomized controlled interventions, to assess effects on balance, muscle strength and eventually fall risk in healthy older adults.