Exergaming for people with major neurocognitive disorder: a qualitative study

Exergame (ExerG)-Based Physical-Cognitive Training for Rehabilitation in Adults With Motor and Balance Impairments: Usability Study

Background

Exergames are increasingly used in rehabilitation, yet their usability and user experience for patients and therapists, particularly for functional model systems, are underresearched. The diverse needs and preferences of users make conducting usability studies challenging, emphasizing the need for further investigation in real-world settings.

Objective

This study aimed to evaluate the usability, safety, and user experience of a novel exergame functional model, the ExerG, from the perspectives of patients and therapists in a rehabilitation setting.

Methods

In this mixed methods study, 15 patients undergoing rehabilitation (primary end users [PEUs]) and 20 therapists (secondary end users [SEUs]) from 2 rehabilitation centers in Switzerland and Austria participated in exercising and observation sessions with the ExerG. SEUs received training on system use and technical issue management, enabling them to fulfill their therapist roles while treating patients or mock patients. Rapid Iterative Testing and Evaluation was used and the training software adjusted based on participant feedback. Usability was assessed with questionnaires, semistructured interviews, and through observations during the ExerG testing. System acceptability was evaluated using specific quantitative thresholds based on PEU performance and feedback. An observation protocol tracked SEUs' correct use, errors, hesitations, task completion time, and needed assistance across scenarios.

Results

Patients and therapists reported overall good usability and positive experiences with the exergame. PEUs rated 23/29 (79%) instructions as acceptable, showed good-to-very-good exercise performance in 19/29 (65%) tasks, and completed 28/29 (97%) tasks. Patients reported no adverse events, showing improved performance and enjoyment across ExerG exercising rounds, with 79/90 (88%) expressing positive emotions and reporting median scores of 9 (IQR 7.5-10) on a 1-10 user satisfaction scale. Patients were willing to continue using the device if the graphic design was improved (5/15), tracking systems and projector quality were enhanced (each 3/15), instructions clarified (12/15), and the game variety increased (2/15). PEUs felt secure in the safety harness (15/15) but recommended swivel arm movement enhancements (5/15). SEUs effectively executed scenarios, with hesitation and difficulties observed in only 14/41 tasks and 2/41 tasks, across all 20 therapists, accounting for 1.7% and 0.2% of the 820 total task cases, respectively. Therapists' quantitative usability ratings were high (median System Usability Scale score 82.5, IQR 65-95). All SEUs expressed their willingness to use the ExerG (20/20) and reported being able to operate the system using the user handbook (20/20). They emphasized the motivation-enhancing effect of video-game based training (12/20) and considered the activities supportive for physical and cognitive skills (20/20). They suggested incorporating daily living task simulations (13/20), more customizable options (6/20), more targeted motivational feedback (9/20), clearer performance ratings (9/20), and more concise activity instructions (6/20).

Conclusions

The interdisciplinary, iterative ExerG development approach shows promise. The findings will inform future optimizations. Future work will assess long-term impact.

The "FitBrain" program: implementing exergaming & dual-task exercise programs in outpatient clinical settings

Dual-task training and exergaming interventions are increasingly recognized for their potential to enhance cognitive, physical, and mood outcomes among older adults and individuals with neurological conditions. Despite this, clinical and community programs that use these interventions are limited in availability. This paper presents the "FitBrain" program, an outpatient clinical model that combines dual-task and exergaming interventions to promote cognitive and physical health. We review the scientific rationale supporting these methods, detail the structure and methodology of the FitBrain program, and provide examples of session designs that integrate dual-tasking through exergaming. The paper also addresses implementation considerations, such as tailoring interventions to specific populations, ensuring user-centered design, and leveraging accessible technologies. We discuss key challenges, including limited research on programs utilizing multiple technologies and cost constraints, and propose directions for future research to refine best practices and evaluate the comparative effectiveness of multimodal vs. singular interventions. This paper aims to inform clinicians and program developers on implementing dual-task and exergaming interventions within diverse clinical and community settings by offering a structured model and practical guidelines.

Dementia and Video Games: Systematic and Bibliographic Review

BACKGROUND/OBJECTIVES

This systematic and bibliographic review examines publications in the field of dementia and video game research from 2004 to 2023. The main objective is to assess developments and trends in video game technology for dementia care and detection.

METHODS

The PubMed database was the primary source for publications. PRISMA guidelines were applied to structure this review. Ten variables were defined, investigated, and split into three main categories: bibliographic, medical, and technical.

RESULTS

The results were synthesized using a quantitative approach to reduce bias through interpretation. Of 209 initial results, 77 publications have been included in the investigation. More studies focus on rehabilitation over assessment and detection of dementia. Clinical trials are typically conducted with limited participants. The most populated trials rarely enrol over 300 subjects. On average, around 38 subjects were enrolled in the trials. These studies are commonly supervised by a trainer or technology specialist, suggesting a technology gap in familiarity in the trial demographic.

CONCLUSIONS

Most interventions assessed were custom-designed applications with a specific outcome, focusing on physical activity and cognitive exercises. As the first of its kind, this publication focuses on the technical aspects of applied technologies and development methods. Using video games to treat and detect patients with cognitive impairments like dementia can benefit healthcare professionals, caretakers, and patients.

Exergaming to Increase Physical Activity in Older Adults: Feasibility and Practical Implications

PURPOSE OF REVIEW

To evaluate the feasibility of exergaming among older adults, focusing on acceptability, demand, implementation, and practicality. Additionally, to offer practical implications based on the review's findings.

RECENT FINDINGS

Exergaming is a safe for older adults, potentially increasing physical activity, balance, cognition, and mood. Despite these possible benefits, barriers such as unfamiliarity with equipment, complex controls, and unclear instructions may challenge older adults in exergaming. Based on the experience of older adults, they found exergaming enjoyable, particularly the social interactions. Exergaming was perceived as physically and cognitively demanding, with technical and safety challenges. Introducing exergaming requires thorough familiarization, including written and video instructions, follow-up support, and home accessibility. To be able to follow improvements during exergaming as well as age-appropriate challenges are important for successful integration into daily life. Based on these findings, an ExerGameFlow model for older adults was developed which provides practical implications for future design of exergames and interventions.

Nurse-led physical activity interventions for people with dementia in nursing homes: A systematic review on intervention characteristics and implementation facilitators/barriers

BACKGROUND

Physical activities are important to maintain and promote physical functioning and activities of daily living in people with dementia. Nurses are in a key position to deliver physical activity interventions in nursing homes. However, synthesized strategies for sustainable implementation of physical activity interventions in nursing homes for people with dementia are lacking.

OBJECTIVE

We aimed at synthesizing the evidence on nurse-led physical activity interventions and at identifying facilitators and barriers to sustainable implementation of physical activity interventions for people with dementia.

DESIGN

Systematic review.

REVIEW METHODS

We performed a comprehensive literature search combining database searches (MEDLINE, CINAHL, CENTRAL, Web of Science Core Collection; last search: September 27, 2023) and supplementary search methods (citation tracking, web searching, clinical guideline database searching). We considered studies on nurse-led physical activity interventions for people with dementia living in nursing homes for eligibility; published as journal articles and related material in English, French, German language, without restrictions on primary study design and publication year. Independently and in duplicate, we assessed the references' eligibility and the quality of the included studies. We used the Mixed Methods Appraisal Tool to appraise quality of included studies. We piloted and double-checked data extractions, and summarized the results narratively and graphically (harvest plot). We prospectively registered our review (PROSPERO CRD42021271833).

RESULTS

We identified 24 studies (of which eleven were randomized trials) assessing various interventions that we categorized into physical exercise (n = 8), care-integrated physical activity (n = 6), outdoor or walking activity (n = 5), technology-supported physical exercise (n = 3), and dancing (n = 2). Types of outcomes and length of follow-up varied widely. Effects were inconclusive, except for outdoor or walking activities showing an overall positive impact on physical outcomes. For eight interventions, we identified evidence on implementation barriers (b) and facilitators (f), including staff shortage (b), staff time resources (b), or ease of implementation for staff (f) and adaptability of interventions (f) or refusal to participate of people with dementia (b).

CONCLUSIONS

The results of our review provide a comprehensive overview on types, characteristics and effects of nurse-led physical activity interventions for people with dementia in nursing homes. Based on evidence from a range of study designs and sources, we came to the conclusion that all stakeholders involved considered physical activity interventions for people with dementia as useful and relevant. Outcome measures varied widely and a clear conclusion on effectiveness remains open.

Experiences of older adults participating in dance exergames: A systematic review and meta-synthesis

BACKGROUND

Interventions to encourage adequate physical activity amongst older adults have had limited long-term success. Dancing and exergames, two beneficial and enjoyable physical activities for older adults, may make regular exercise more interesting and effective. Dance exergames are physical exercises that integrate sensory, cognitive, psychological, and physical functions by requiring users to interact with game scenarios through deliberate body motions and receive real-time feedback. They provide an inherently enjoyable gaming and workout experience, which may boost exercise adherence. However, little is known about older adults' experiences with dance exergames.

OBJECTIVE

To synthesise the qualitative experiences of older adults participating in dance exergames.

DESIGN

Systematic review and meta-synthesis.

METHODS

Dance exergame studies (peer-reviewed and grey literature) involving older adults in any setting published in English from inception to 17 August 2023 were included. Qualitative or mixed-method studies must use immersive or non-immersive virtual-reality platforms. PubMed, Scopus, CINAHL, The Cochrane Library, ProQuest Dissertations & Theses Global, Google Scholar, and reference lists of relevant studies and reviews were searched for eligible studies. The search strategy for Scopus was: (TITLE-ABS-KEY (danc*) AND TITLE-ABS-KEY (exergames OR exergame OR video AND games OR virtual AND reality) AND TITLE-ABS-KEY (older AND adults OR elderly OR seniors OR geriatrics)). Thematic synthesis by Thomas and Harden was used for meta-synthesis.

RESULTS

Eleven studies (n = 200 older adults) were included. Three themes and 14 subthemes were synthesised: 1) Dance exergames as dual-task training for physical, cognitive, and psychological well-being, 2) Concerns on usability issues, and 3) Possible enhancements of dance exergames. Older adults recognised that dance exergames could improve their physical, cognitive, and psychological well-being. Existing dance exergame systems had several usability issues. For example, some older adults were unfamiliar with using new technology and had trouble in navigating the game systems. The older adults also provided various suggestions for adaptation to their age group, such as ensuring a variety of dances, difficulty levels suited for older adults' cultural backgrounds, and physical and cognitive capabilities.

CONCLUSIONS

Dance exergames may be an attractive way to encourage older adults to exercise, but appropriate modifications are needed. When designing/selecting dance exergames for older persons, researchers, healthcare professionals, and senior care centres should consider using exergames that have simple designs, varied dances that are locally adapted, and appeal to a large proportion of older adults.

REGISTRATION

PROSPERO CRD42023395709.

Impact of AI-Powered Solutions in Rehabilitation Process: Recent Improvements and Future Trends

Rehabilitation is an important and necessary part of local and global healthcare services along with treatment and palliative care, prevention of disease, and promotion of good health. The rehabilitation process helps older and young adults even children to become as independent as possible in activities of daily life and enables participation in useful living activities, recreation, work, and education. The technology of Artificial Intelligence (AI) has evolved significantly in recent years. Many activities related to rehabilitation have been getting benefits from using AI techniques. The objective of this review study is to explore the advantages of AI for rehabilitation and how AI is impacting the rehabilitation process. This study aims at the most critical aspects of the rehabilitation process that could potentially take advantage of AI techniques including personalized rehabilitation apps, rehabilitation through assistance, rehabilitation for neurological disorders, rehabilitation for developmental disorders, virtual reality rehabilitation, rehabilitation of neurodegenerative diseases and Telerehabilitation of Cardiovascular. We presented a survey on the newest empirical studies available in the literature including the AI-based technology helpful in the Rehabilitation process. The novelty feature included but was not limited to an overview of the technological solutions useful in rehabilitation. Seven different categories were identified. Illustrative examples of practical applications were detailed. Implications of the findings for both research and practice were critically discussed. Most of the AI applications in these rehabilitation types are in their infancy and continue to grow while exploring new opportunities. Therefore, we investigate the role of AI technology in rehabilitation processes. In addition, we do statistical analysis of the selected studies to highlight the significance of this review work. In the end, we also present a discussion on some challenges, and future research directions.

Older adults' needs and requirements for a comprehensive exergame-based telerehabilitation system: A focus group study

Introduction

Telerehabilitation in older adults using information and communication technologies (ICTs) provides therapy, which is potentially equally effective as traditional rehabilitation, yet more accessible. This study aimed to analyze the needs and requirements of older adults (OA) and healthcare-professionals (HP) toward ICTs and telerehabilitation in general as well as toward a specific novel exergame-based telerehabilitation system (COCARE system, Dividat).

Materials and methods

The COCARE telerehabilitation system enables individual training based on exergames, as well as an assessment system and a digital centralized case management. Six focus groups with in total 34 participants were conducted. A mixed-methods approach was used comprising questionnaires and semi-structured interviews.

Results

Both OA and HP would engage to an exergame-based telerehabilitation program. Major motivating factors are the relevance of such a training for health and the entertainment component of exergames. Main requirements are simplification of the system, variety, a personalized training, a constantly available contact person, and comprehensive instructions for use. Besides, HP praised the system's motivational effect, but remained concerned about risk of falls and social isolation.

Conclusion

ICTs for telerehabilitation are accepted by OA and HP but should be adapted hardware- and software-wise to address OA' age-stemming vulnerabilities (e.g., risk of falls) and low ICT literacy.

Design Considerations for an Exergame-Based Training Intervention for Older Adults With Mild Neurocognitive Disorder: Qualitative Study Including Focus Groups With Experts and Health Care Professionals and Individual Semistructured In-depth Patient Interviews

BACKGROUND

Exergames have attracted growing interest in the prevention and treatment of neurocognitive disorders. The most effective exergame and training components (ie, exercise and training variables such as frequency, intensity, duration, or volume of training and type and content of specific exergame scenarios) however remain to be established for older adults with mild neurocognitive disorders (mNCDs). Regarding the design and development of novel exergame-based training concepts, it seems of crucial importance to explicitly include the intended users' perspective by adopting an interactive and participatory design that includes end users throughout different iterative cycles of development.

OBJECTIVE

This study aimed to determine the capabilities, treatment preferences, and motivators for the training of older adults with mNCD and the perspectives of individuals on training goals and settings and requirements for exergame and training components.

METHODS

A qualitative study including expert focus groups and individual semistructured in-depth patient interviews was conducted. Data were transcribed to a written format to perform qualitative content analysis using QCAmap software.

RESULTS

In total, 10 experts and health care professionals (80% females) and 8 older adults with mNCD (38% females; mean age 82.4, SD 6.2 years) were recruited until data saturation was observed.

CONCLUSIONS

The psychosocial consequences of patients' self-perceived cognitive deterioration might be more burdensome than the cognitive changes themselves. Older adults with mNCD prefer integrative forms of training (such as exergaming) and are primarily motivated by enjoyment or fun in exercising and the effectiveness of the training. Putting the synthesized perspectives of training goals, settings, and requirements for exergames and training components into context, our considerations point to opportunities for improvement in research and rehabilitation, either by adapting existing exergames to patients with mNCDs or by developing novel exergames and exergame-based training concepts specifically tailored to meet patient requirements and needs.

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

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

The VITAAL Stepping Exergame Prototype for Older Adults With Major Neurocognitive Disorder: A Usability Study

Purpose: This study investigates the usability of a stepping exergame in older adults with major neurocognitive disorder (MNCD) residing in a long-term care facility.

Materials and Methods: A mixed methods study was conducted. Participants played exergames for 30 min on one try-out session. During the exergames, the think aloud method was used, and field notes were taken by the facilitator. Following the exergames, participants completed the System Usability Scale (SUS) and a semi-structured in-depth interview about usability including their personal experiences. Audio files were transcribed and a thematic content analysis of the think aloud data, field notes and interviews were performed using NVivo 12.

Results: Twenty-two participants with MNCD were included [mean age = 84.3 ± 5.5 (70–95) years; 81.8% women; Short Physical Performance Battery score = 7.5 ± 3.2 (1–12), Montreal Cognitive Assessment score = 11.9 ± 4.4 (2–19)]. System usability was rated “ok to good” with a mean SUS score of 57.8 (SD = 12.3) with scores ranging from 37.5 to 90.0. Five main themes emerged from the thematic content analysis: (1) perceived user friendliness and acceptability of the exergames; (2) interactional experience; (3) motivational factors; (4) training modalities; and (5) risks. There were no adverse events nor dropouts.

Conclusion: Participants evaluated the usability of the exergames positively. The results indicate that the stepping exergame is usable in older adults with MNCD.

The efficacy of exergaming in people with major neurocognitive disorder residing in long-term care facilities: a pilot randomized controlled trial

BACKGROUND

It is currently unknown whether exergaming is efficacious in people with major neurocognitive disorder (MNCD) residing in long-term care facilities. This pilot randomized controlled trial (RCT) explored the efficacy of a stepping exergame program on gait speed, balance, mobility, reaction time, cognitive and neuropsychiatric outcomes, quality of life, and daily life functioning in people with MNCD residing in long-term care facilities.

METHODS

Participants were randomly assigned to 8 weeks, three times weekly, 15 min of exergaming versus watching preferred music videos. The exergame device consisted of a pressure-sensitive step training platform on which participants performed stepping movements to play the games. The device automatically adapted the training level to the participants' capabilities. The Short Physical Performance Battery (SPPB), step reaction time test (SRTT), Montréal Cognitive Assessment (MoCA), Neuropsychiatric Inventory (NPI), Cornell Scale for Depression in Dementia (CSDD), Dementia Quality of Life (DQoL), and Katz Activities of Daily Living (Katz ADL) were assessed at baseline and post-intervention. A Quade's non-parametric ANCOVA controlling for baseline values with post hoc Bonferroni correction (p < 0.00625) was used to analyze pre- and post-differences between the groups. Partial eta-squared (η²p) effect sizes were calculated.

RESULTS

Forty-five of 55 randomized inpatients with mild to moderate MNCD (Mini-Mental State Examination score = 17.2 ± 4.5; aged 70-91; 35 women) completed the study. The exergame group (n = 23) demonstrated improvements in gait speed (p < 0.001, η²_p = 0.41), total SPPB (p < 0.001, η²_p = 0.64), SRTT (p<0.001, η²_p = 0.51), MoCA (p<0.001, η²_p = 0.38), and reductions in CSDD (p<0.001, η²_p = 0.43) compared to the control group (n = 22). There were no differences in NPI (p = 0.165, η²_p = 0.05), DQoL (p = 0.012, η²_p = 0.16), and ADL (p = 0.008, η²_p = 0.16) post-intervention scores between the experimental and control group, albeit DQol and ADL measures showed large effect sizes in the exergame group. The mean attendance rate was 82.9% in the exergame group and 73.7% in the music control group. There were no study-related adverse events reported by the participants, nor observed by the research team.

CONCLUSIONS

The findings of this pilot RCT suggest that an individually adapted exergame training improves lower extremity functioning, cognitive functioning and step reaction time and symptoms of depression in inpatients with MNCD residing in long-term care facilities.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04436302.

Combining Stochastic Resonance Vibration With Exergaming for Motor-Cognitive Training in Long-Term Care; A Sham-Control Randomized Controlled Pilot Trial

Purpose: Physical and mental functions allow classifying older adults as “Go-Go” (independent functioning); “Slow-Go” (in need of care with a slight handicap); and “No-Go” (in need of care with severe functional limitation). The latter group exhibits reduced exercise tolerance. More recently technology-based motor-cognitive types of training services emerged as a possible training service. This study examined the use of technology including stochastic resonance whole-body vibration and Exergame-dance training for motor-cognitive training in care home dwelling adults.

Methods: Seventeen older adults (10 women, 7 men, age range: 79–98) were randomly assigned to the intervention (IG, n = 9) or the sham group (SG, n = 8). IG performed five sets of 1-min whole-body vibration with 1-min rest in between, three times a week for the first 4 weeks of the training period with varying frequency. From weeks five to eight the Exergame-dance training was conducted after the vibration sessions. SG performed a stochastic resonance whole-body vibration training with the same terms applied, however, with a fixed frequency of 1 Hz, Noise 1. From weeks five to eight a passive trampoline-programme of 5 min was applied following the vibration sessions. Primary outcome was the Short Physical Performance Battery (SPPB). Secondary outcomes were the Trail Making Test A and B (TMT A & B) and the Falls Efficacy Scale–International (FES-I). Outcomes were measured at baseline, after 4 and 8 weeks of intervention and at follow-up (4 weeks after the intervention). The non-parametric Puri and Sen rank-order test was applied, followed by an ANOVA for repeated measures to analyse main and interaction effects. Mann–Whitney U-Test was used to determine differences between the groups.

Results: The post-hoc analysis showed significant effects on the SPPB total score with large effect sizes from baseline to 8 weeks (+72%, p = 0.005, η² = 0.423). The TMT part B displayed significant improvements with large effect sizes from baseline to 8 weeks (+17.5%, p = 0.002, η² = 0.779) and to follow-up (+21%, p = 0.001, η² = 0.827).

Conclusion: The technology based 8-week training programme consisting of a combination of stochastic resonance whole-body vibration and Exergame-dance training showed beneficial effects on both physical and cognitive performance in older care home dwelling adults.