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

The effectiveness of real-life cognitive and physical interventions on cognitive functioning in healthy older adults: A systematic review of the effects of education and training duration

Physical and cognitive interventions are deemed the primary methods of improving cognitive functioning in healthy older adults. However, the effectiveness of these interventions is still debated. This systematic review, synthesised findings from the literature on four different types of interventions: physical activities, cognitive training, cognitive stimulation and a combined intervention. We searched six databases for each intervention category. Findings demonstrated that 65% of the studies across all intervention groups reported improvement in the experimental group following the intervention. Furthermore, memory, executive and global cognitive functions were the most reported improvements post-intervention. Additionally, participants with higher education benefited more from cognitive training (an intervention that targets a specific cognitive domain), while those with lower education gained more following cognitive stimulation (an intervention that targets general domains). Lastly, in sub-types of physical activity, cognitive stimulation and combined category, longer durations (more than 20 sessions) were associated with significant cognitive improvements. Conversely, in cognitive training, having less than 20 sessions led to significant results. Findings indicated an interaction of education and intervention duration with significant outcomes post-intervention. In conclusion, this review demonstrated the importance of intervention type, duration and education in understanding cognitive improvement post-intervention.

Acute effects of virtual reality exercise bike games on psychophysiological outcomes in college North-African adolescents with cerebral palsy: A randomized clinical trial

Background

Cerebral palsy (CP) is a neurological disorder that can affect motor skills and psychophysiological well-being. Virtual Reality Exercise (VRE) improves cognitive and physical outcomes in patients with CP. Therefore, this study aimed to investigate the effects of VRE on attention, vigor, and decision-making abilities in adolescents with CP.

Methods

A randomized controlled trial was conducted. The intervention consisted of a single 40-minute session of VRE compared to TE conducted in a controlled laboratory environment.

Results

Fourteen participants (42.9 % female) were included in this analysis. The results indicated that VRE had a statistically significant positive effect on attention and vigor compared to TE. While participants in the VRE group exhibited enhanced attention levels and reported elevated levels of vigor subsequent to the exercise sessions, the memory results did not reach statistical significance.

Conclusions

The findings suggest that VRE is an effective intervention for improving attention and vigor in adolescents with CP.

Registration

Pan African Clinical Trial Registry (PACTR202308598603482; 31/08/2023). The trial was reported in accordance with the CONSORT reporting guidelines.

Neurologic dance training and home exercise improve motor-cognitive dual-task function similarly, but through potentially different mechanisms, among breast cancer survivors with chemotherapy-induced neuropathy: Initial results of a randomized, controlled clinical trial

BACKGROUND

Dual-task function is compromised among individuals with prodromal Alzheimer's disease (AD) and others at risk of developing AD. While exercise has been studied as a therapeutic candidate, the activity of social dance might promote dual-task rehabilitation as well or better than conventional exercise.

OBJECTIVE

Compare effects of social dance versus home exercise on dual-task function and intervention adherence among individuals with increased risk of developing AD: survivors of breast cancer (BC) with chemotherapy-induced neuropathy (CIN).

METHODS

Fifty-two (n = 52) survivors of BC with CIN-related symptoms and functional deficits were randomized (1:1) to 8 weeks of biweekly physical activity that took the form of partnered AdapTango dance (20 min) or home exercise (45 min) (NCT05114005, registered 08/15/2021). Primary outcome: dual-task function (TUG-Cog counting backward by 3 s). Secondary outcome: adherence. Exploratory outcomes: participant rating of perceived exertion in physical versus cognitive domains and cognitive load during dual-task performance.

RESULTS

Both interventions improved Timed-Up-and-Go with cognitive task (TUGCog) after 4 weeks (p < 0.001); gains were maintained at 8 weeks of intervention (p < 0.001) and 1 month follow-up (p < 0.001). The dance intervention met adherence feasibility criteria for 8 weeks; exercise met criteria for 4 weeks. The ratio of cognitive to physical exertion was higher for dance (1 to 1) than exercise (0.8 to 1.0; p < 0.001). Dance, only, was associated with reduced cognitive load (p = 0.02).

CONCLUSIONS

Among survivors of BC with CIN, small doses of social dance improved dual-task function comparably to larger doses of home exercise, possibly due to differences in cognitive engagement.

Effects of immersive virtual reality stimulation and/or multicomponent physical exercise on cognitive and functional performance in hospitalized older patients with severe functional dependency: study protocol for a randomized clinical trial

BACKGROUND

Hospital-associated functional decline affects nearly one-third of the hospitalized older adults. The aim of this trial is to investigate the effect of a cognitive stimulation intervention provided via immersive virtual reality (IVR), with or without a multicomponent physical exercise intervention (ME) in hospitalized patients aged 75 or older with severe functional dependency at admission (Barthel Index < 60 points).

METHODS

This clinical randomized controlled trial will be conducted in the Acute Geriatric Unit of a tertiary hospital in Spain. A total of 212 acute patients will be enrolled according to the following criteria: age ≥ 75, Barthel Index < 60, able to collaborate, expected length of stay ≥ 5 days, absence of clinical instability and severe dementia (Global Deterioration Scale 7) or other end-stage disease. Patients will be randomly assigned to a control group (CG) or any of the three intervention groups (IG): IVR, ME, or IVR + ME. The IVR group will watch ad-hoc videos showing Spanish regional landscapes and villages, approximately 4 min per day for three consecutive days. The ME group will undergo aerobic and strength exercise for progressive training of the upper and lower limbs. The IVR + ME group will do both cognitive and physical intervention. The primary outcomes will be cognitive and physical measures at discharge. Mood, quality of life, isometric strength, and acceptance of IVR will be also assessed.

DISCUSSION

This project has the potential to enhance physical and psychological well-being of patients with severe functional dependency hospitalized for acute conditions, using technology. Virtual reality is expected to be favourably perceived by hospitalized older adults. This intervention represents a novelty in the geriatric patients' care, comprising IVR and/or ME dispensed within the patient's room, and including patients who are commonly excluded from research clinical trials.

TRIAL REGISTRATION

This study was approved by the Navarra Clinical Research Ethics Committee on May 17th, 2023 (PI_2023/60). The trial is registered at ClinicalTrials.gov, registration number NCT06340282, 24th May 2024.

Impact of Virtual Reality on Pain, ROM, Muscle Strength and Quality of Life among Breast Cancer Patients: An Integrative Review of Literature

BACKGROUND

Breast cancer is the most commonly diagnosed cancer among women globally, with significant impacts on physical, emotional, and functional well-being. Traditional rehabilitation methods may not fully address the multifaceted challenges faced by breast cancer survivors (BCSs), prompting exploration into innovative approaches such as Virtual Reality (VR) technology.

OBJECTIVE

The present review aims to assess the effectiveness of VR in alleviating pain, improving Range of Motion (ROM), enhancing muscle strength, and augmenting the overall quality of life in patients undergoing breast cancer rehabilitation.

METHODS

A comprehensive review of existing literature was conducted, focusing on studies investigating the use of VR in breast cancer rehabilitation. PubMed, Scopus, PEDro and Google scholar were searched for articles addressing VR interventions targeting pain management, ROM improvement, muscle strength enhancement, and quality of life enhancement in breast cancer patients.

RESULTS

Findings yielded total 12 articles matching the selection criteria. VR technology has shown promising results in addressing the multifaceted needs of breast cancer patients. VR also serves as a distraction tool, positively impacting psychological well-being and mitigating negative psychological symptoms associated with the disease.

CONCLUSION

VR represents a non-pharmacological approach to pain management and rehabilitation in breast cancer patients. Its ability to engage emotional, cognitive, and attention processes contributes to its effectiveness in enhancing overall quality of life. Further research is warranted to elucidate the long-term benefits and optimal utilization of VR technology in breast cancer rehabilitation programs.

Effects of virtual reality on the balance performance of older adults: a systematic review and meta-analysis

[Purpose] Virtual reality has been increasingly used to improve the balance performance of older adults; however, the effect remains inconclusive. This study aimed to examine the effects of virtual reality on the balance performance of older adults through a systematic review and meta-analysis. [Methods] The PubMed, MEDLINE, CINAHL, Cochrane Library, and PEDro electronic databases were searched. Only randomized clinical trials published in English from January 1st, 1980, to September 30, 2022, were included and reviewed. Outcome measures included the Berg Balance Scale, Timed Up and Go Test and Activity-specific Balance Confidence scale. [Results] The results showed that virtual reality training for older adults led to significant improvements in Berg Balance Scale scores and Timed Up and Go Test times compared with non-virtual reality training. However, such an outcome was not observed with regard to the Activity-specific Balance Confidence scale. [Conclusion] Virtual reality training is effective in improving both static and dynamic balance among older adults. However, its effect on their self-confidence regarding balance is not significant.

Components of effective exergame-based training to improve cognitive functioning in middle-aged to older adults - A systematic review and meta-analysis

BACKGROUND

Exergame-based training is currently considered a more promising training approach than conventional physical and/or cognitive training.

OBJECTIVES

This study aimed to provide quantitative evidence on dose-response relationships of specific exercise and training variables (training components) of exergame-based training on cognitive functioning in middle-aged to older adults (MOA).

METHODS

We conducted a systematic review with meta-analysis including randomized controlled trials comparing the effects of exergame-based training to inactive control interventions on cognitive performance in MOA.

RESULTS

The systematic literature search identified 22,928 records of which 31 studies were included. The effectiveness of exergame-based training was significantly moderated by the following training components: body position for global cognitive functioning, the type of motor-cognitive training, training location, and training administration for complex attention, and exercise intensity for executive functions.

CONCLUSION

The effectiveness of exergame-based training was moderated by several training components that have in common that they enhance the ecological validity of the training (e.g., stepping movements in a standing position). Therefore, it seems paramount that future research focuses on developing innovative novel exergame-based training concepts that incorporate these (and other) training components to enhance their ecological validity and transferability to clinical practice. We provide specific evidence-based recommendations for the application of our research findings in research and practical settings and identified and discussed several areas of interest for future research.

PROSPERO REGISTRATION NUMBER

CRD42023418593; prospectively registered, date of registration: 1 May 2023.

The Effects of Virtual Reality Training on Cognition in Older Adults: A Systematic Review, Meta-Analysis, and Meta-Regression of Randomized Controlled Trials

The aim of this systematic review, meta-analysis, and meta-regression was to examine the effects of virtual reality-based training on global cognition and executive function compared with conventional training or information-based treatment in older adults, regardless of cognitive level. A systematic literature search was conducted using four databases. A total of 31 randomized controlled trials were identified. Pooled effect sizes were calculated, the risk of bias was assessed, and evidence was graded. The primary analyses showed a small but statistically significant effect of virtual reality-based training compared with control on global cognition (Hedges' g 0.42, 95% confidence interval [0.17, 0.68], I2 = 70.1%, n = 876, 20 randomized controlled trials, low evidence) and executive function (Hedges' g 0.35, 95% confidence interval [0.06, 0.65], I2 = 68.4%, n = 810, 16 randomized controlled trials, very low evidence). Meta-regression yielded inconclusive results. Virtual reality-based training may be more effective than control in improving cognition in older adults; however, more high-quality studies are needed.

Effectiveness of sensor-based interventions in improving gait and balance performance in older adults: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Sensor-based interventions (SI) have been suggested as an alternative rehabilitation treatment to improve older adults' functional performance. However, the effectiveness of different sensor technologies in improving gait and balance remains unclear and requires further investigation.

METHODS

Ten databases (Academic Search Premier; Cumulative Index to Nursing and Allied Health Literature, Complete; Cochrane Central Register of Controlled Trials; MEDLINE; PubMed; Web of Science; OpenDissertations; Open grey; ProQuest; and Grey literature report) were searched for relevant articles published up to December 20, 2022. Conventional functional assessments, including the Timed Up and Go (TUG) test, normal gait speed, Berg Balance Scale (BBS), 6-Minute Walk Test (6MWT), and Falling Efficacy Scale-International (FES-I), were used as the evaluation outcomes reflecting gait and balance performance. We first meta-analyzed the effectiveness of SI, which included optical sensors (OPTS), perception sensors (PCPS), and wearable sensors (WS), compared with control groups, which included non-treatment intervention (NTI) and traditional physical exercise intervention (TPEI). We further conducted sub-group analysis to compare the effectiveness of SI (OPTS, PCPS, and WS) with TPEI groups and compared each SI subtype with control (NTI and TPEI) and TPEI groups.

RESULTS

We scanned 6255 articles and performed meta-analyses of 58 selected trials (sample size = 2713). The results showed that SI groups were significantly more effective than control or TPEI groups (p < 0.000) in improving gait and balance performance. The subgroup meta-analyses between OPTS groups and TPEI groups revealed clear statistically significant differences in effectiveness for TUG test (mean difference (MD) = - 0.681 s; p < 0.000), normal gait speed (MD = 4.244 cm/s; p < 0.000), BBS (MD = 2.325; p = 0.001), 6MWT (MD = 25.166 m; p < 0.000), and FES-I scores (MD = - 2.036; p = 0.036). PCPS groups also presented statistically significant differences with TPEI groups in gait and balance assessments for normal gait speed (MD = 4.382 cm/s; p = 0.034), BBS (MD = 1.874; p < 0.000), 6MWT (MD = 21.904 m; p < 0.000), and FES-I scores (MD = - 1.161; p < 0.000), except for the TUG test (MD = - 0.226 s; p = 0.106). There were no statistically significant differences in TUG test (MD = - 1.255 s; p = 0.101) or normal gait speed (MD = 6.682 cm/s; p = 0.109) between WS groups and control groups.

CONCLUSIONS

SI with biofeedback has a positive effect on gait and balance improvement among a mixed population of older adults. Specifically, OPTS and PCPS groups were statistically better than TPEI groups at improving gait and balance performance, whereas only the group comparison in BBS and 6MWT can reach the minimal clinically important difference. Moreover, WS groups showed no statistically or clinically significant positive effect on gait and balance improvement compared with control groups. More studies are recommended to verify the effectiveness of specific SI. Research registration PROSPERO platform: CRD42022362817. Registered on 7/10/2022.

Virtual reality exergames for improving physical function, cognition and depression among older nursing home residents: A systematic review and meta-analysis

OBJECTIVE

To explore the effectiveness of virtual reality (VR) exergames on physical function, cognition and depression among older nursing home residents.

METHODS

A systematic review and meta-analysis were conducted. The PubMed, Ovid, Embase, Cochrane, CINAHL, and Web of Science databases were searched for relevant studies from inception until June 1, 2023. The reviewers independently completed the study selection, data extraction and quality assessment. Subgroup analyses were conducted to explore the sources of between-study heterogeneity and to determine whether participant or intervention characteristics influenced effect sizes.

RESULTS

Eighteen studies met the inclusion criteria and were selected for qualitative and quantitative synthesis. The overall methodological quality was relatively high, and the overall evidence grade was moderate. VR exergames had a large effect on physical function, including mobility [SMD=-0.66, P < 0.001], balance [SMD=0.95, P < 0.001], and lower limb strength [SMD=0.53, P = 0.0009]; and a moderate effect on cognition [SMD=0.48, P = 0.02] and depression [SMD=-0.72, P = 0.03]. Subgroup analyses revealed that a training frequency of 2 sessions per week and coordinating with physiotherapists yielded greater improvements in mobility (P = 0.009; P = 0.0001). VR exergames had especially beneficial effects on balance for physically fit participants (P = 0.03) and on cognition for participants with cognitive impairment (P = 0.01). Additionally, regarding the improvement of depression, commercial VR exergames were superior to self-made systems (P = 0.03).

CONCLUSION

VR exergames can provide a positive impact on physical function, cognition and depression among older nursing home residents. The study also demonstrated the different benefits of exergames between participants who were physically fit and those with cognitive impairment, which is considered as an innovative, cost-efficient and sustainable approach. Specifically, commercial VR exergame programs with a frequency of 2 sessions per week and coordinating with physiotherapists may be the most appropriate and effective option.

Effects of combined cognitive and resistance training on physical and cognitive performance and psychosocial well-being of older adults ≥65: study protocol for a randomised controlled trial

INTRODUCTION

With increasing life expectancy of older adult population, maintaining independence and well-being in later years is of paramount importance. This study aims to investigate the impact of three distinct interventions: cognitive training, resistance training and a combination of both, compared with an inactive control group, on cognitive performance, mobility and quality of life in adults aged ≥65 years.

METHODS AND ANALYSIS

This trial will investigate healthy older adults aged ≥65 years living independently without cognitive impairments. Participants will be randomly assigned to one of four groups: (1) cognitive training, (2) resistance training, (3) combined cognitive and resistance training, and (4) control group (n=136 participants with 34 participants per group). The interventions will be conducted over 12 weeks. The cognitive training group will receive group-based activities for 45-60 min two times a week. The resistance training group exercises will target six muscle groups and the combined group will integrate cognitive tasks into the resistance training sessions. Primary outcomes are: Short Physical Performance Battery, Sit-to-Stand Test, Montreal Cognitive Assessment, Trail Making Test and Stroop Test combined with gait on a treadmill (dual task). Life satisfaction will be measured by the Satisfaction With Life Scale. Secondary outcomes encompass hand grip strength and the Functional Independence Measure.

ETHICS AND DISSEMINATION

Ethical approval was provided by the local Ethics Committee at the University of Hamburg (no. 2023_009). Informed consent will be obtained from all study participants. The results of the study will be distributed for review and discussion in academic journals and conferences.

TRIAL REGISTRATION NUMBER

DRKS00032587.

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.

Examining technology-assisted rehabilitation for older adults' functional mobility: a network meta-analysis on efficacy and acceptability

Technological advancements facilitate feedback adaptation in rehabilitation through virtual reality (VR) exergaming, serious gaming, wearables, and telerehabilitation for older adults fall prevention. Although studies have evaluated these technologies, no comparisons of their effectiveness have been conducted to date. Thus, this study aims to assess the differences in effectiveness of these interventions on balance and functional mobility in the older adults. A systematic review and network meta-analysis (NMA) were conducted to identify the most effective interventions for improving balance and functional mobility in adults aged 60 and over. The search was conducted in five databases (PubMed, Embase, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science) up to June 10, 2023. The eligibility criteria were: (1) older adults, (2) functional mobility, balance, or gait as the primary outcome, (3) new technology intervention, and (4) randomized study design. New technology interventions were classified into five categories: exergaming with balance platforms or motion capture technologies, other serious gaming, interventions with wearables, and telerehabilitation. Additionally, two categories of control interventions (conventional exercises and no treatment) were extracted. The NMA was performed for the aggregated results of all outcomes, and separately for clinical functional scales, functional mobility, and gait speed results. Fifty-two RCTs with 3081 participants were included. Exergaming with motion capture was found to be statistically significant in producing a better effect than no treatment in the analysis of the functional mobility with an SMD of -0.70 (P < 0.01). The network meta-analysis revealed that exergaming with motion capture offers greater therapeutic benefits for functional mobility and balance compared to no treatment control. The effectiveness of this approach is similar to that of conventional exercises. Further RCTs are needed to provide a more definitive conclusion, particularly with respect to the effectiveness of serious games, telerehabilitation, and interventions with wearables.

The Importance of Technology in the Combined Interventions of Cognitive Stimulation and Physical Activity in Cognitive Function in the Elderly: A Systematic Review

BACKGROUND

Numerous studies have been developed in an attempt to understand which factors best predict improvements in cognitive function in the elderly such as exergaming. The aim of this study was to investigate and systematize literature on intervention programs that simultaneously include cognitive stimulation and physical activity, understand the importance of the use of new technology, including exergaming or computer programs, and understand their impact on cognitive function in older adults, giving indications about their contribution to healthy aging.

METHODS

A narrative approach was used for extraction and synthesis of the data. Relevant studies were identified from electronic databases such as PubMed, Scopus, Web of Science, and Academic Search Complete.

RESULTS

Thirty-two articles, involving 2815 participants, were identified. All selected studies were randomized controlled studies. The studies were published between 2011 and 2020. All studies included a combination of cognitive and physical interventions. Many of the studies used technology to administer the cognitive stimulation program.

CONCLUSIONS

Most of the analyzed studies used exergaming in physical and cognitive interventions, demonstrating that this new form of intervention exerts lasting and stable benefits in cognition. However, we concluded that more studies are needed to compare interventions that use exergaming or computer programs with traditional interventions.

Effect of Exercise Cognitive Combined Training on Physical Function in Cognitively Healthy Older Adults: A Systematic Review and Meta-Analysis

This study aimed to evaluate the effects of exercise cognitive combined training (ECCT) compared with non-ECCT on physical function in cognitively healthy older adults. Databases were searched for randomized controlled trials from inception to December 2, 2021, and 22 studies (1,091 participants, Mage = 74.90) were included in the meta-review. The Cochrane Risk of Bias and Grading of Recommendations Assessment, Development, and Evaluation tools were used for quality assessments. ECCT improved gait speed (mean difference: 0.06 m/s, 95% CI [confidence interval] [0.02, 0.11]; 446 participants, 11 studies) and balance (standardized mean difference: 0.38, 95% CI [0.14, 0.61]; 292 participants, seven studies). Simultaneous ECCT, but not nonsimultaneous ECCT, improved gait speed (mean difference: 0.11 m/s, 95% CI [0.07, 0.15]), balance (standardized mean difference: 0.40, 95% CI [0.16, 0.64]), and functional mobility (mean difference: -0.85 s, 95% CI [-1.63, -0.07]; 327 participants, nine studies). Future research should focus on the duration and form of ECCT intervention optimal for improving the functional activities of older individuals.

Application of Immersive Virtual-Reality-Based Puzzle Games in Elderly Patients with Post-Stroke Cognitive Impairment: A Pilot Study

Background: The society is aging in China, and the cognitive level of elderly post-stroke patients gradually declines. Face-to-face cognitive functional training is no longer sufficient. Immersive virtual reality (IVR) is a promising rehabilitation training device. In this study, we developed an IVR-based puzzle game to explore its effectiveness, feasibility, and safety in elderly stroke patients with cognitive dysfunction. Methods: A total of 30 patients with mild post-stroke cognitive impairment after stroke were randomly assigned to a control or IVR group. Patients in both groups received routine rehabilitation therapy. Patients in the control group received traditional cognitive training, and those in the IVR group received IVR-based puzzle game therapy. Before and after treatment, Montreal cognitive assessment (MOCA), trail-making test-A (TMT-A), digit symbol substitution test (DSST), digital span test (DST), verbal fluency test (VFT), and modified Barthel index (MBI) were evaluated in both groups. In addition, the IVR group was administered a self-report questionnaire to obtain feedback on user experience. Results: There was no significant difference in the baseline data between the two groups. After six weeks of treatment, the cognitive assessment scores were improved in both groups. Moreover, the IVR group showed more improvements than the control group in the DSST (Z = 2.203, p = 0.028 < 0.05, η2 = 0.16); MOCA (T = 1.186, p = 0.246 > 0.05, d = 0.44), TMT-A (T = 1.791, p = 0.084 > 0.05, d = 0.65), MBI (T = 0.783, p = 0.44 > 0.05, d = 0.28), FDST (Z = 0.78, p = 0.435 > 0.05, η2 = 0.02), BDST (Z = 0.347, p = 0.728 > 0.05, η2 = 0.004), and VFT(Z = 1.087, p = 0.277 > 0.05, η2 = 0.039) did not significantly improve. The significant difference in DSST represents an improvement in executive function and visual−spatial cognitive characteristics. The other assessment scores did not show such features. Therefore, we did not observe significant differences through this measure. According to the results of the self-report questionnaire, most of the patients were satisfied with the equipment stability and training content. Several individuals reported mild adverse reactions. Conclusions: This pilot study suggests that IVR-based puzzle games are a promising approach to improve post-stroke cognitive function, especially executive cognitive function, and visual−spatial attention in older adults.

VR exergame interventions among older adults living in long-term care facilities: A systematic review with Meta-analysis

BACKGROUND

To improve the motivation toward exercise in older adults, exergames have shifted from entertainment to rehabilitation.

OBJECTIVES

To review the training focus of exergames and analyze the effectiveness of exergame training on physical, psychological, or cognitive outcomes among older adults in long-term care facilities (LTCFs).

METHODS

This review followed the PRISMA guidelines. By searching 7 electronic databases up to April 30, 2022, studies were included if they 1) involved adults ≥65 years old residing in LTCFs, 2) were randomized controlled trials (RCTs) with virtual reality-based exergames as the intervention, 3) compared the effects of exergames to usual care or conventional exercises, and 4) reported physical, psychological, or cognitive outcomes. The Cochrane Risk-of-Bias tool for randomized trials version 2 (RoB 2) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) were used to evaluate the methodological quality of studies and levels of evidence for outcomes. The meta-analysis was conducted with Review Manager 5.4. Results are presented as standardized mean differences (SMDs) and 95% confidence intervals (CIs).

RESULTS

A total of 12 RCTs were included in the systematic review and meta-analysis. For overall methodological quality, 10 studies showed some concerns and 2 studies showed high risk. Levels of evidence for outcomes were assessed as low (n = 8) and very low (n = 4). The studies involved a total of 482 older adults. Most studies implemented balance exercise as the exergame intervention. Older adults who completed exergame interventions showed improvements in cognitive outcomes (SMD 0.90, 95%CI 0.61-1.19, p<0.001) and in balance self-efficacy (SMD 1.04, 95%CI 0.47-1.61, p<0.001) as compared with those in usual care. They also showed improvements in balance (SMD 0.49, 95%CI 0.20-0.78, p<0.001) as compared with those in conventional exercise programs. Overall, exergames had a positive effect on balance (SMD 0.62, 95%CI 0.29-0.95, p<0.001).

CONCLUSION

This review revealed that exergames can improve the balance ability of older adults in LTCFs.

Therapeutic Application of Virtual Reality in the Rehabilitation of Mild Cognitive Impairment: A Systematic Review and Meta-Analysis

This review aimed to quantify the effect of therapeutic application of virtual reality (VR) on cognitive function in individuals with mild cognitive impairment (MCI). We searched for randomized controlled trials involving VR in the interventions provided to individuals with MCI. After searching four international electronic databases, we analyzed six studies involving 279 individuals with MCI. RevMan 5.4 was used for quality assessment and quantitative analysis. Therapeutic application of VR in individuals with MCI resulted in a significant improvement in cognitive function (mean difference = -1.46; 95% confidence interval: -2.53 to -0.39; heterogeneity: χ² = 970.56, df = 18, I² = 98%; and overall effect: Z = 2.67, p = 0.008). However, there was no significant improvement in the subcategories such as global cognition, working memory, executive function, memory function, and attention. In conclusion, feedback stimulation through VR has a potential value in improving cognitive function in individuals with MCI. However, on the basis of the results of the subcategories, a personalized VR program is required for the individual subcategories of cognitive function.

Clinical Perspectives on Cardiac Rehabilitation After Heart Failure in Elderly Patients with Frailty: A Narrative Review

The purpose of this narrative review is to examine rehabilitation modalities for patients with heart failure and Frailty who require comprehensive intervention. Ischemic heart disease is the leading cause of death worldwide, accounting for 16% of global mortality. Due to population growing and aging, the total number of heart failure patients continues to rise, a condition known as the heart failure pandemic. Furthermore, frailty has been associated with an increased risk for heart failure and increased morbidity and mortality. The 2021 update of the 2017 ACC expert consensus decision pathway for optimization of HF treatment has become more concerning, citing frailty as one of the 10 most important issues associated with heart failure with reduced ejection fraction (HFrEF). Frailty and heart failure share common pathological mechanisms and are associated with poor clinical outcomes. Most studies of frailty in patients with heart failure primarily focus on physical frailty, and associations between psycho-psychological and social factors such as cognitive dysfunction and social isolation have also been reported. These results suggest that a more comprehensive assessment of frailty is important to determine the risk in patients with heart failure. Therefore, mechanisms of the three domains, including not only physical frailty but also cognitive, psychological, spiritual, and social aspects, should be understood. In addition to interventions in these three domains, nutritional and pharmacological interventions are also important and require tailor-made interventions for the widely varied conditions associated with heart failure and frailty. Although several studies have shown a relationship between frailty and prognosis in patients with heart failure, interventions to improve the prognosis have not yet been established. Further information is needed on frailty intervention by a multidisciplinary team to improve the prognosis.

A Pilot Study of Virtual Reality (VR) Tai Chi Program on Mental Health among Older Adults during the COVID-19 Pandemic

OBJECTIVES

Tai Chi, an ancient Chinese martial art, has been credited for improving the physical and mental health of community-dwelling older adults. Virtual reality (VR) has developed as a therapeutic technique for improving health and well-being in older adults. Previous research on exercise-based VR interventions in older adults has focused primarily on the physical and cognitive health effects. The extent to which a program integrating the ancient practice of Tai Chi with virtual reality might benefit older individuals' physical and mental health is an unknown entity. In this pilot study, we examined potential advantages of the virtual Tai Chi program in terms of health outcomes, as well as to gather qualitative data on the barriers to VR program participation.

METHODS

We conducted semi-structured, in-depth interviews with 5 participants who had participated at least 5 years in traditional Tai Chi.

RESULTS

Three key salient themes emerged as beneficial results of VR experiences: (1) mindfulness/ meditation, (2) enjoyment, and (3) physical exercise. Participants also reported 3 main challenges: (1) some difficulties with controllers and functions, (2) cybersickness/pain, and (3) absence of group synergy.

CONCLUSIONS

These challenges suggest further avenues of investigation for researchers in refining this approach.

Virtual Reality and Exercise Training Enhance Brain, Cognitive, and Physical Health in Older Adults with Mild Cognitive Impairment

We investigated the effectiveness of virtual-reality-based cognitive training (VRCT) and exercise on the brain, cognitive, physical and activity of older adults with mild cognitive impairment (MCI).

METHODS

This study included 99 participants (70.8 ± 5.4) with MCI in the VRCT, exercise, and control groups. The VRCT consisted of a series of games targeting different brain functions such as executive function, memory, and attention. Twenty-four sessions of VRCT (three days/week) were performed, and each session was 100 min long. Exercise intervention consisted of aerobic and resistance trainings performed in 24 sessions for 60 min (2 times/week for 12 weeks). Global cognitive function was measured using the Mini-Mental State Examination (MMSE) test. Resting-state electroencephalography (EEG) of the neural oscillatory activity in different frequency bands was performed. Physical function was measured using handgrip strength (HGS) and gait speed.

RESULTS

After the intervention period, VRCT significantly improved the MMSE scores (p < 0.05), and the exercise group had significantly improved HGS and MMSE scores (p < 0.05) compared to baseline. One-way analysis of variance (ANOVA) of resting-state EEG showed a decreased theta/beta power ratio (TBR) (p < 0.05) in the central region of the brain in the exercise group compared to the control group. Although not statistically significant, the VRCT group also showed a decreased TBR compared to the control group. The analysis of covariance (ANCOVA) test showed a significant decrease in theta band power in the VRCT group compared to the exercise group and a decrease in delta/alpha ratio in the exercise group compared to the VRCT group.

CONCLUSION

Our findings suggest that VRCT and exercise training enhances brain, cognitive, and physical health in older adults with MCI. Further studies with a larger population sample to identify the effect of VRCT in combination with exercise training are required to yield peak benefits for patients with MCI.

Applicability of an Immersive Virtual Reality Exercise Training System for Office Workers during Working Hours

Virtual reality is a computer-generated simulation of a real or imaginary three-dimensional environment that has entered our lives, particularly for gaming. Lately, it has been permeating into many aspects of our everyday life, such as exercise. It is important to ascertain whether exercise in an immersive virtual reality environment can be accepted from employees and lead to positive outcomes for them. The aim of this exploratory study was to examine the acceptance, future adoption, interest/enjoyment and usability of an immersive virtual reality system for exercise training by office workers during breaks within their working hours. A total of 40 female employees participated in the study with a mean age of 42.58 years (SD 10.77). Participants were requested to complete two sequential 15-min dual task cycling sessions corresponding to two experimental conditions. The first, condition A, involved cycling in a virtual environment, wearing a virtual reality head mounted display, and responding to cognitive tasks by answering multiple choice questions—on a screen, using a joystick. The second, condition B, involved cycling on a static bicycle and simultaneously responding to cognitive tasks by answering multiple choice questions in a real environment. After completion of the two conditions, participants responded to a series of scales regarding each of the experimental conditions and to a semi-structured interview. The results showed that participants noted a significant preference for the immersive virtual reality exercise, condition A, compared to condition B (bike only); and their acceptance, interest/enjoyment, usability and intention for future use were high. The qualitative data showed increased intention for future use, feelings of control and presence and most of the participants did not encounter any difficulties or require extra help to understand the immersive virtual reality system. Overall, exercising during working hours with an immersive virtual reality exercise system was well perceived by office workers and applicable. However, the effects of the immersive virtual reality training system on physical and mental health and the employees’ adherence to the exercise program should be tested with a longer intervention program.

Effects of Tabletop Games on Cognition in Older Adults: A Systematic Review and Meta-Analysis

Studies have shown that leisure activities, such as tabletop games, not only increase social interactions and reduce depression among older adults, but also help improve their cognitive function. However, the effects of tabletop games on cognition in older adults are yet to be comprehensively analyzed. The purpose of this study was to review and examine the effects of tabletop games on cognition in older adults. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were searched in seven electronic databases from their inception to December 2020. A total of 3946 studies were retrieved, among which 11 studies were systematically reviewed and 10 were meta-analyzed. In older adults with intact cognition, tabletop games had positive effects on their global cognition (standardized mean differences [SMD] = 1.36, 95% confidence intervals [CI]: 0.37-2.34, P < 0.001) and executive function (SMD = 0.47, 95% CI: 0.12-0.83, P < 0.001). In older adults with cognitive impairment, significant differences were found in global cognition (SMD = 0.53, 95% CI: 0.09-0.98, P = 0.02). Tabletop games had the characteristics of cognitive training and interpersonal interactions. After receiving tabletop game interventions, the cognitive functioning in older adults with intact cognition and those with mild cognitive impairment or dementia was improved. For older adults, in addition to improving cognitive functioning, tabletop games also increased their social participation and interactions. Systematic Review Registration: This review has been registered in the PROSPERO (CRD42021254085).

Physiotherapy Programmes Aided by VR Solutions Applied to the Seniors Affected by Functional Capacity Impairment: Randomised Controlled Trial

Modern technologies are presently harnessed in response to a complex challenge of providing physiotherapeutic management in older adults. Fully immersive virtual reality (VR) solutions are acknowledged to viably enhance the overall effectiveness of traditional physiotherapeutic methods. A total of 60 community-dwelling older adults (over 75 years of age) were recruited for the study protocol. They were subsequently randomly split into four equally sized study groups (VR, CVR, OCULUS, and the classic programme group (OTAGO), and the physiotherapy sessions were pursued in the subjects’ homes for 3 weeks, 3 times a week, for 30 min in each group. At the first measurement point, respective study groups differed significantly in functional performance, as expressed in gait (POMA G) and individual static balance. The post hoc analysis indicated significantly higher scores in POMA G for the classic programme group vs. the results of the VR and CVR groups. On the other hand, the OCULUS group held significantly higher scores in individual balance and TUG, as compared to the other groups (p < 0.001). Making use of a virtual reality (VR) environment in the physiotherapeutic management of community-dwelling older adults appreciably enhanced individual functional performance, especially in terms of static balance. Physiotherapy management aided by VR technology solutions offers a viable alternative to traditional physiotherapeutic regimens (e.g., OTAGO programme) in enhancing individual functional performance. The innovatively self-designed VIRTUAL REALITY COMPREHENSIVE REHABILITATION ROOMS (VRCRR) solution may help out in pursuing a complex physiotherapy programme on an individual basis within one’s own home environment.

Optimal dose and type of exercise to improve cognitive function in older adults: A systematic review and bayesian model-based network meta-analysis of RCTs

OBJECTIVE

To examine the dose-response relationship between overall and specific types of exercise with cognitive function in older adults.

DESIGN

Systematic Review and Bayesian Model-Based Network Meta-Analysis.

DATA SOURCES

Systematic search of MEDLINE, Web of Science, Scopus, PsycINFO and SPORTDiscus.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomized controlled trials of exercise interventions in participants aged 50 years or over, and that reported on at least one global cognition outcome.

RESULTS

The search returned 1998 records, of which 44 studies (4793 participants; 102 different effect sizes) were included in this review with meta-analysis. There was a non-linear, dose-response association between overall exercise and cognition. We found no minimal threshold for the beneficial effect of exercise on cognition. The estimated minimal exercise dose associated with clinically relevant changes in cognition was 724 METs-min per week, and doses beyond 1200 METs-min per week provided less clear benefits. We also found that the dose-response association was exercise type dependent, and our results show that clinically important effects may occur at lower doses for many types of exercise. Our findings also highlighted the superior effects of resistance exercises over other modalities.

CONCLUSIONS

If provided with the most potent modalities, older adults can get clinical meaningful benefits with lower doses than the WHO guidelines. Findings support the WHO recommendations to emphasise resistance training as a critical component of interventions for older adults.

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.

The Effects of Combined Cognitive-Physical Interventions on Cognitive Functioning in Healthy Older Adults: A Systematic Review and Multilevel Meta-Analysis

Research has shown that both physical exercise and cognitive training help to maintain cognition in older adults. The question is whether combined training might produce additive effects when the group comparisons are equated in terms of exercise intensity and modality. We conducted a systematic electronic search in MEDLINE, PsycInfo, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify relevant studies published up to February 2021. Seven hundred and eighty-three effect sizes were obtained from 50 published intervention studies, involving 6,164 healthy older adults, and submitted to a three-level meta-analysis. Results showed that combined training produced a small advantage in comparison to single cognitive training on executive functions, whereas both types of training achieved similar effects on attention, memory, language, processing speed, and global cognition. Combined training achieved higher training gains in balance than single physical training, indicating a transfer from cognitive training to balance. Performing cognitive and physical exercise simultaneously, and interactive training (e.g., exergames, square stepping) produced the largest gains in executive functions, speed, and global cognition, as well as the largest improvements in physical functions. Aerobic training was associated with higher effects in attention and fitness, whereas non-aerobic training produced larger effects in global cognition and balance. For all cognitive and physical outcomes, training resulted more advantageous when performed in a social context, even though individual training obtained similar results in balance as group training.

Systematic Review Registration:www.crd.york.ac.uk/prospero/, identifier: CRD42020175632.

Is Virtual Reality Training More Effective Than Traditional Physical Training on Balance and Functional Mobility in Healthy Older Adults? A Systematic Review and Meta-Analysis

Objective

The studies showed the benefits of virtual reality training (VRT) for functional mobility and balance in older adults. However, a large variance in the study design and results is presented. We, thus, completed a systematic review and meta-analysis to quantitatively examine the effects of VRT on functional mobility and balance in healthy older adults.

Methods

We systematically reviewed the publications in five databases. Studies that examine the effects of VRT on the measures of functional mobility and balance in healthy older adults were screened and included if eligible. Subgroup analyses were completed to explore the effects of different metrics of the intervention design (e.g., session time) on those outcomes related to functional mobility and balance.

Results

Fifteen studies of 704 participants were included. The quality of these studies was good. Compared to traditional physical therapy (TPT), VRT induced greater improvement in TUG (MD = -0.31 s, 95% CI = -0.57 to -0.05, p = 0.02, I 2 = 6.34%) and one-leg stance with open eyes (OLS-O) (MD = 7.28 s, 95% CI = 4.36 to 10.20, p = 0.00, I 2 = 36.22%). Subgroup analyses revealed that immersive VRT with more than 800 min of total intervention time over 8 weeks and at least 120 min per week and/or designed by the two motor-learning principles was optimal for functional mobility and balance.

Conclusion

Virtual reality training can significantly improve functional mobility and balance in healthy older adults compared to TPT, and the findings provided critical knowledge of the optimized design of VRT that can inform future studies with more rigorous designs.

Systematic Review Registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021297085].

Frailty Syndrome-Fall Risk and Rehabilitation Management Aided by Virtual Reality (VR) Technology Solutions: A Narrative Review of the Current Literature

Frailty, a physiological syndrome (FS) affecting primarily the older adults, manifests itself through significantly depleted bodily reserves, and appreciably higher (up to over threefold) individual exposure to fall risk. Concomitant medical conditions such as balance impairment, reduced visual acuity, limited mobility, and significantly diminished daily functional performance further exacerbate the patients' condition. Their resultant susceptibility to frequent hospitalisations makes their prognosis even worse. This narrative review aimed to provide an overview of published studies focused on rehabilitation management approaches aided by virtual reality (VR) technology in frail older adults. The authors had it also augmented with their own, evidence-based body of experience in rehabilitation. Making use of technologically advanced exercise machinery, specially adapted for rehabilitating frail older adults, combined with a structured exercise regimen, further aided by the application of select virtual reality (VR) technology solutions, clearly proved effective. Consequently, the patients were helped to move back from the frail to the pre-frail stage, as well as had their motor and cognitive functions appreciably enhanced. The application of modern technology in rehabilitating older adults over 65, affected by FS, when specifically aided by the select VR technology solutions, was also proven to complement successfully the conventional rehabilitation management. The overall versatility of the VR technology solutions, e.g., adaptation for home use allowing remote supervision, also makes this novel approach to rehabilitation far more appealing to the patients. They find it both very attractive and far more mentally engaging. Its considerable potential lies mostly in being appreciably more effective in bringing in desirable therapeutic outcomes.

Comparison between the effects of exergame intervention and traditional physical training on improving balance and fall prevention in healthy older adults: a systematic review and meta-analysis

OBJECTIVE

Physical training (PT, e.g., Tai Chi and strength training) has been demonstrated to improve balance control and prevent falls. Recently, exergame intervention (EI) has emerged to prevent falls by enhancing both physical and cognitive functions in older adults. Therefore, we aim to quantitatively assess and compare the effects of PT and EI on the performance of balance control and fall prevention in healthy older adults via meta-analysis.

METHODS

A search strategy based on the PICOS principle was used to find the publication in the databases of PubMed, EMBASE, Web of Science, Cochrane Library, and MEDLINE. The quality and risk of bias in the studies were independently assessed by two researchers.

RESULTS

Twenty studies consisting of 845 participants were included. Results suggested that as compared to PT, EI induced greater improvement in postural control (sway path length, SMD = - 0.66, 95% CI - 0.91 to - 0.41, P < 0.001, I2 = 0%; sway speed, SMD = - 0.49, 95% CI - 0.71 to - 0.27, P < 0.001, I2 = 42%) and dynamic balance (SMD = - 0.19, 95% CI - 0.35 to - 0.03, P = 0.02, I2 = 0%) in healthy older adults. The EI with 90-119 min/week for more than 8-week significantly reduced falls. Subgroup analyses revealed that exergames, which were designed by the two principles of repeatedly performing diversified tasks and gradually increase the difficulty of the task, induced significant effects in improving balance control and falls prevention respectively (P = 0.03, P = 0.009). In addition, intervention that combines EI and PT induced significant improvement in postural control (P = 0.003).

CONCLUSION

The exergame intervention, especially the combination of EI and PT, is a promising strategy to improve balance control and reduce falls in healthy older adults. Future studies with rigorous design, larger sample size, and follow-up assessments are needed to further assess the effectiveness of diverse exergame interventions in fall prevention and to quantify the "dose-effect" relationship, as well as the carry-over effect of such intervention, which will ultimately help optimize the rehabilitative strategies to improve balance control and prevent falls.

Benefits of VR Physical Exercise on Cognition in Older Adults with and without Mild Cognitive Decline: A Systematic Review of Randomized Controlled Trials

It is well known that physical exercise has beneficial effects on cognitive function in older adults. Recently, several physical exercise programs with virtual reality (VR) have been proposed to support physical exercise benefits. However, it is still unclear whether VR physical exercise (VR-PE) has positive effects on cognitive function in older adults. The purpose of this study was to conduct a systematic review (SR) of the effects of VR-PE on cognitive function in older adults with and without cognitive decline. We used academic databases to search for research papers. The criteria were intervention study using any VR-PE, participants were older adults with and without mild cognitive decline (not dementia), and cognitive functions were assessed. We found that 6 of 11 eligible studies reported the significant benefits of the VR-PE on a wide range of cognitive functions in aging populations. The SR revealed that VR-PE has beneficial effects on the inhibition of executive functions in older adults with and without mild cognitive decline. Moreover, VR-PE selectively leads to improvements in shifting and general cognitive performance in healthy older adults. The SR suggests that VR-PE could be a successful approach to improve cognitive function in older adults with and without cognitive decline.

The Effect of Mixed Reality Technologies for Falls Prevention Among Older Adults: Systematic Review and Meta-analysis

BACKGROUND

Falling is one of the most common and serious age-related issues, and falls can significantly impair the quality of life of older adults. Approximately one-third of people over 65 experience a fall annually. Previous research has shown that physical exercise could help reduce falls among older adults and improve their health. However, older adults often find it challenging to follow and adhere to physical exercise programs. Interventions using mixed reality (MR) technology could help address these issues. MR combines artificial augmented computer-generated elements with the real world. It has frequently been used for training and rehabilitation purposes.

OBJECTIVE

The aim of this systematic literature review and meta-analysis was to investigate the use of the full spectrum of MR technologies for fall prevention intervention and summarize evidence of the effectiveness of this approach.

METHODS

In our qualitative synthesis, we analyzed a number of features of the selected studies, including aim, type of exercise, technology used for intervention, study sample size, participant demographics and history of falls, study design, involvement of health professionals or caregivers, duration and frequency of the intervention, study outcome measures, and results of the study. To systematically assess the results of the selected studies and identify the common effect of MR interventions, a meta-analysis was performed.

RESULTS

Seven databases were searched, and the initial search yielded 5838 results. With the considered inclusion and exclusion criteria, 21 studies were included in the qualitative synthesis and 12 were included in meta-analysis. The majority of studies demonstrated a positive effect of an MR intervention on fall risk factors among older participants. The meta-analysis demonstrated a statistically significant difference in Berg Balance Scale score between the intervention and control groups (ES: 0.564; 95% CI 0.246-0.882; P<.001) with heterogeneity statistics of I2=54.9% and Q=17.74 (P=.02), and a statistical difference in Timed Up and Go test scores between the intervention and control groups (ES: 0.318; 95% CI 0.025-0.662; P<.001) with heterogeneity statistics of I2=77.6% and Q=44.63 (P<.001). The corresponding funnel plot and the Egger test for small-study effects (P=.76 and P=.11 for Berg Balance Scale and Timed Up and Go, respectively) indicate that a minor publication bias in the studies might be present in the Berg Balance Scale results.

CONCLUSIONS

The literature review and meta-analysis demonstrate that the use of MR interventions can have a positive effect on physical functions in the elderly. MR has the potential to help older users perform physical exercises that could improve their health conditions. However, more research on the effect of MR fall prevention interventions should be conducted with special focus given to MR usability issues.

Can Exergames Be Improved to Better Enhance Behavioral Adaptability in Older Adults? An Ecological Dynamics Perspective

Finding effective training solutions to attenuate the alterations of behavior and cognition in the growing number of older adults is an important challenge for Science and Society. By offering 3D computer-simulated environments to combine perceptual-motor and cognitive exercise, exergames are promising in this respect. However, a careful analysis of meta-analytic reviews suggests that they failed to be more effective than conventional motor-cognitive training. We analyzed the reasons for this situation, and we proposed new directions to design new, conceptually grounded, exergames. Consistent with the evolutionary neuroscience approach, we contend that new solutions should better combine high level of metabolic activity with (neuro)muscular, physical, perceptual-motor, and cognitive stimulations. According to the Ecological Dynamics rationale, we assume that new exergames should act at the agent-environment scale to allow individuals to explore, discover, and adapt to immersive and informationally rich environments that should include cognitively challenging tasks, while being representative of daily living situations.

A Clinical Decision-Making Framework for the Use of Video Gaming as a Therapeutic Modality

Virtual reality and video gaming offer modulation of more exercise and motor learning parameters simultaneously than other modalities; however, there is a demonstrated need for resources to facilitate their effective use clinically. This article presents a conceptual framework to guide clinical-decision making for the selection, adaptation, modulation, and progression of virtual reality or gaming when used as a therapeutic exercise modality, and two cases as exemplars. This framework was developed by adapting the steps of theory derivation, whereby concepts and parent theories are brought together to describe a new structure or phenomenon of interest. Specifically, motor learning theory, integrated motor control theory, Gentile's Taxonomy of Tasks, and therapeutic exercise principles were integrated to develop this framework. It incorporates person (body segment), environmental, and task demands; each demand is comprised of realm, category, choice, and continuum parameters as motor training considerations and alternatives for decision-making. This framework: (1) provides structure to guide clinical decisions for effective and safe use of virtual reality or gaming to meet therapeutic goals and requirements, (2) is a concise and organized method to identify, document, and track the therapeutic components of protocols and client progression over time; (3) can facilitate documentation for reimbursement and communication among clinicians; and, (4) structures student learning, and (5) informs research questions and methods.

Virtual Reality Rehabilitation and Exergames—Physical and Psychological Impact on Fall Prevention among the Elderly—A Literature Review

The present review is aimed at the effectiveness of virtual reality (VR) and exergames in the prevention of falls among the elderly. Falls become a significant problem in the aging population and lead to psychological, social, and physical impairment. Prevention of falls is crucial to the well-being of the elderly population and is one of the challenges of contemporary rehabilitation. Recently, in view of the threat of the SARS-CoV-2 pandemic, contactless methods of rehabilitation, including telerehabilitation, appear as valuable rehabilitation tools. This review is based on the PRISMA guidelines and was carried out in five databases: PubMed, Medline, Web of Science, Scopus, and PEDro. Twenty-one randomized controlled trials, focused on the application of VR and exergames in the prevention of falls, were included. This review suggests that VR training in rehabilitation appears to be a promising complement to traditional techniques of physiotherapy to improve specific physical outcomes. VR and exergames could be considered as a complement of standard physiotherapy and its possible continuation at home for elderly. However, further high-quality studies, with carefully designed protocols and proper blinding, are needed.

Effects of physical-cognitive training on physical and psychological functions among older adults with type 2 diabetes and balance impairment: a randomized controlled trial

Risks of falls among older adults are multifactorial in nature. A combined training program might be beneficial on fall-related outcomes. This study aimed to explore the effects of group-based physical-cognitive trainings on physical and psychological outcomes among older adults with type 2 diabetes mellitus (T2DM) and balance impairment. Fall incidence were also determined. Thirty-seven older adults with T2DM and balance impairment were randomly assigned to control and intervention groups. The intervention program comprised of 24 training sessions of 45–60 min exercise for 8 weeks. The exercise consisted of warm-up, aerobic exercise by nine square stepping, resistance exercise combined with cognitive training and cool down. All participants were assessed at baseline, 4 and 8 weeks after intervention, and 1-year follow-up. Both groups reported similar rates of falls. Global cognition, depressive symptoms, and fear of falling did not differ between groups at any time. The Timed Up & Go (TUG) test, alternate stepping test (AST), knee extensors, ankle plantarflexors, and dorsiflexors strength differed at 4 weeks. TUG, AST, hip abductors, knee flexors, ankle plantarflexors, and dorsiflexors strength differed at 8 weeks. The activity of daily living (ADL), TUG test (P=0.002) and AST, hip extensors and abductors, knee extensors and flexors, ankle plantarflexors and dorsiflexors were different at 1-year follow-up. The group-based physical-cognitive training could benefit older adults with T2DM in terms of maintaining ADL. The intervention could reduce fall risk factors by improving balance and lower limb muscle strength among older adults with T2DM and balance impairment.

A pilot study of aquatic prehabilitation in adults with knee osteoarthritis undergoing total knee arthroplasty - short term outcome

BACKGROUND

Knee osteoarthritis (KOA) is increasingly more prevalent and significant number of patients require knee arthroplasty. Although knee arthroplasty is generally successful, it takes months to recover physical function. Preoperative physical function is known to predict postoperative outcomes and exercise can improve preoperative physical function. However, patients with KOA have difficulty exercise on land due to pain and stiffness, while water exercise can be better tolerated. We hypothesized that preoperative water exercise to improve preoperative physical function will improve postoperative outcomes after total knee arthroplasty (TKA).

METHODS

We enrolled 43 participants who were scheduled for elective TKA in 4-8 weeks and scored at or below 50th percentile in mobility assessment tool-sf (MAT-sf). All enrolled participants were assessed on 1) clinical osteoarthritis symptom severity using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 2) physical function using Short Physical Performance Battery (SPPB), 3) self-reported mobility using Mobility Assessment Tool-short form (MAT-sf), 4) depression using Geriatric Depression Scale-short form (GDS-sf), 5) cognitive function using Montreal Cognitive Assessment (MoCA). Blood samples for high-sensitivity-C-reactive protein (hs-CRP), tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) were stored at - 80 °C then all samples were analyzed together. All the enrolled participants were randomly assigned to the aquatic exercise intervention (AEI) or usual care group. Sixty minute sessions of AEI was conducted three times a week for 4-8 weeks. Participants in both groups were evaluated within 1 week before their scheduled surgery, as well as 4 weeks after the surgery.

RESULTS

The mean age was 67.1 (±6.2), 44% were female, 74% were White. There is no statistically significant difference in combined outcome of any complication, unscheduled ER visit, and disposition to nursing home or rehab facility by AEI. However, AEI was associated with more favorable outcomes: WOMAC scores (p < 0.01), chair-stand (p = 0.019), MAT-sf as well as improved depression (p = 0.043) and cognition (p = 0.008).

CONCLUSION

4-8 weeks of aquatic exercise intervention resulted in improved functional outcomes as well as improved depression and cognition in elderly patients undergoing TKA. A larger study is warranted to explore the role of water exercise in clinical and functional outcomes of TKA.

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

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

Virtual Reality Exergames for Improving Older Adults' Cognition and Depression: A Systematic Review and Meta-Analysis of Randomized Control Trials

OBJECTIVES

Virtual reality (VR) exergames are an innovative approach to promote older adults' mental health. VR exergames are active video games controlled by bodily movements in a safe surrounding with advantages of physical activity engagement and interactions. The purpose of this study was to explore the effectiveness of VR exergames in improving older adults' cognition and ameliorating depressive outcome by a systematic review, meta-analysis, subgroup analysis, and meta-regression.

DESIGN

This is a systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Adults over 60 years old.

METHODS

Four electronic databases, including PubMed, Embase, Medline, and Cochrane, were searched for related articles. After evaluation, 18 randomized control trials were selected for qualitative and quantitative synthesis.

RESULTS

The meta-analytical results found moderate effects of VR exergames on overall cognitive function and memory, and a large effect on depressive outcomes in older adults. Commercial VR games had more-significant and larger effects on depressive outcomes than exergames with VR devices. The meta-regression results revealed that the total intervention duration had a significant effect on depressive outcomes. A higher intervention duration had greater effects on depressive outcomes.

CONCLUSIONS AND IMPLICATIONS

This meta-analytical study suggests that VR exergames can provide potential positive influences on cognition, memory, and depression in older adult populations. VR exergames could be an interesting strategy for active aging and a good mental health status.

Comment on: Problematic online gaming and the COVID-19 pandemic - The role of exergames

Although significant increases in gaming may not always be beneficial, exergames (a new generation of video games also known as exergaming or active video games) appear as an alternative, feasible, attractive, and safe way to perform physical exercise for most clinical and nonclinical populations. Therefore, it is important to recognize that exergames can be considered a useful tool for coping with the COVID-19 outbreak and the recommended social distancing period.

Combined physical and cognitive training for older adults with and without cognitive impairment: A systematic review and network meta-analysis of randomized controlled trials

Combining physical exercise with cognitive training is a popular intervention in dementia prevention trials and guidelines. However, it remains unclear what combination strategies are most beneficial for cognitive and physical outcomes. We aimed to compare the efficacy of the three main types of combination strategies (simultaneous, sequential or exergaming) to either intervention alone or control in older adults. Randomized controlled trials of combined cognitive and physical training were included in multivariate and network meta-analyses. In cognitively healthy older adults and mild cognitive impairment, the effect of any combined intervention relative to control was small and statistically significant for overall cognitive (k = 41, Hedges' g = 0.22, 95 % CI 0.14 to 0.30) and physical function (k = 32, g = 0.25, 95 % CI 0.13 to 0.37). Simultaneous training was the most efficacious approach for cognition, followed by sequential combinations and cognitive training alone, and significantly better than physical exercise. For physical outcomes, simultaneous and sequential training showed comparable efficacy as exercise alone and significantly exceeded all other control conditions. Exergaming ranked low for both outcomes. Our findings suggest that simultaneously and sequentially combined interventions are efficacious for promoting cognitive alongside physical health in older adults, and therefore should be preferred over implementation of single-domain training.

Current Cognition Tests, Potential Virtual Reality Applications, and Serious Games in Cognitive Assessment and Non-Pharmacological Therapy for Neurocognitive Disorders

As the global population ages, the incidence of major neurocognitive disorders (major NCDs), such as the most common geriatric major NCD, Alzheimer's disease (AD), has grown. Thus, the need for more definitive cognitive assessment or even effective non-pharmacological intervention for age-related NCDs is becoming more and more pressing given that no definitive diagnostics or efficacious therapeutics are currently unavailable for them. We evaluate the current state of the art of cognitive assessment for major NCDs, and then briefly glance ahead at potential application of virtual reality (VR) technologies in major NCD assessment and in cognition training of visuospatial reasoning in a 3D environment, as well as in the alleviation of depression and other symptoms of cognitive disorders. We believe that VR-based technologies have tremendous potentials in cognitive assessment and non-pharmacological therapy for major NCDs.

Effectiveness of Virtual Reality Systems to Improve the Activities of Daily Life in Older People

(1) This review aims to evaluate the effectiveness of treatments with virtual reality systems (VRSs) on the functional autonomy of older adults versus conventional treatment. (3) Methods: Systematic review and meta-analysis. An electronic data search was carried out, following the PRISMA statement, up to February 2020. We combined results from clinical trials using VRSs for the improvement of basic and instrumental activities of daily living. The guidelines of the Cochrane Handbook for Systematic Reviews of Interventions were followed for calculations and risk of bias. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence. (4) Results: The final analysis included 23 studies with a population of 1595 participants. A moderate, but clinically significant, effect was found for basic activities of daily living (BADLs), (Standard Medium Deviation, SMD 0.61; 95% CI: -0.15-1.37; P < 0.001). A small effect was found for instrumental ADLs (Instrumental Activities of daily living, IADLs) (SMD -0.34; 95% CI: -0.82-0.15; P < 0.001). Functional ambulation was the BADL which improved the most (SMD -0.63; 95% CI: -0.86, -0.40; P < 0.001). (5) Conclusion: The use of VRSs is an innovative and feasible technique to support and improve the functional autonomy of community-dwelling older adults. Due to the very low quality of the evidence for our main outcomes, the effects of a VRS on the BADLs and IADLs are uncertain. Clinical trials of a higher methodological quality are necessary to increase the level of knowledge of its actual effectiveness.

The Effect of a Virtual Reality-Based Intervention Program on Cognition in Older Adults with Mild Cognitive Impairment: A Randomized Control Trial

This study aimed to investigate the association between a virtual reality (VR) intervention program and cognitive, brain and physical functions in high-risk older adults. In a randomized controlled trial, we enrolled 68 individuals with mild cognitive impairment (MCI). The MCI diagnosis was based on medical evaluations through a clinical interview conducted by a dementia specialist. Cognitive assessments were performed by neuropsychologists according to standardized methods, including the Mini-Mental State Examination (MMSE) and frontal cognitive function: trail making test (TMT) A & B, and symbol digit substitute test (SDST). Resting state electroencephalogram (EEG) was measured in eyes open and eyes closed conditions for 5 minutes each, with a 19-channel wireless EEG device. The VR intervention program (3 times/week, 100 min each session) comprised four types of VR game-based content to improve the attention, memory and processing speed. Analysis of the subjects for group-time interactions revealed that the intervention group exhibited a significantly improved executive function and brain function at the resting state. Additionally, gait speed and mobility were also significantly improved between and after the follow-up. The VR-based training program improved cognitive and physical function in patients with MCI relative to controls. Encouraging patients to perform VR and game-based training may be beneficial to prevent cognitive decline.

Is Xbox 360 Kinect-based virtual reality training as effective as standard physiotherapy in patients undergoing breast cancer surgery?

PURPOSE

Breast cancer surgery may be associated with pain and physical symptoms in the upper limbs. Functional impairment and pain-related avoidance of movement may further increase disability level. This study aimed to investigate the potential effects of early postoperative virtual reality (VR) therapy on pain, range of motion (ROM), muscle strength, functionality, and fear of movement.

METHODS

Forty women with breast cancer who had undergone unilateral mastectomy with axillary lymph node dissection and who were receiving adjuvant therapy were included in the study and randomly assigned to two groups: the Kinect-based rehabilitation group (KBRG) and the standardized physical therapy group (SPTG). The KBRG (n = 20) received VR therapy using Xbox Kinect-based games and the SPTG (n = 20) received standard physiotherapy. Study subjects were assessed at baseline and after the 6-week treatment. Outcome measures were pain (visual analogue scale), grip strength (dynamometer), functionality (disabilities of the arm shoulder and hand questionnaire), muscle strength (handheld dynamometer), ROM (digital goniometer), and fear of movement (Tampa kinesiophobia scale (TKS)).

RESULTS

Both groups detected significant changes in pain, ROM, muscle strength, grip strength, functionality, and TKS scores after the treatment (p < 0.01). Fear of movement was significantly improved in the KBRG and the SPTG displayed more improvement in functionality (p < 0.05). There were no differences in ROM, muscle strength, grip strength, and pain between the groups after the treatment (p > 0.05).

CONCLUSION

Kinect-based VR therapy resulted in significant outcomes that were comparable to those obtained under standard physiotherapy in the early postoperative phase in patients who had undergone breast cancer surgery.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov ( ClinicalTrials.gov identifier: NCT03618433).