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

A scoping review of the feasibility, usability, and efficacy of digital interventions in older adults concerning physical activity and/or exercise

Background

The global population is aging, leading to significant health challenges among older adults, such as reduced muscle mass, increased risks of dementias, and chronic diseases. Physical activity (PA) is crucial for maintaining health and wellbeing in this demographic, yet participation tends to decrease with age due to various barriers. Digital technologies, including mobile health (mHealth) interventions, show promise in promoting PA among older adults, though their adoption remains limited due to intrinsic and extrinsic challenges.

Objectives

This scoping review aimed to systematically map existing evidence on digital PA interventions for older adults, assessing feasibility, usability, and efficacy, whilst providing recommendations for future research and practice.

Eligibility criteria

Original investigations concerning digital interventions in older adults (≥60 years of age) focusing on physical activity and/or exercise were considered. Sources of evidence: Four electronic databases [MEDLINE, CINAHL Ultimate, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL)] were searched.

Methods

A scoping review was conducted using the scoping review methodological framework. Review selection and characterisation were carried out by two independent reviewers.

Results

The 34 included studies were published between 2005 and 2023 across Europe, North America, Asia, and Oceania. Participants varied from healthy to frail individuals, with some diagnosed with dementia or cognitive impairment. Interventions were most commonly delivered via exergames, tablet apps, and videoconferencing. The most common exercise program type was multicomponent. Most studies assessed efficacy, feasibility, and usability, with many using a combination of these measures. Reminders were commonly utilised to enhance engagement through various digital and non-digital methods.

Conclusion

There was a notable lack of mobile health (mHealth) studies in the literature, with most research focusing on exergame and tablet interventions. More research on smartphone apps, particularly for muscle strengthening, is needed, and the growing ease of app development may drive innovation and research. Digital interventions are generally feasible, usable, and effective for older adults, offering a promising, scalable approach for promoting PA. This review identified several valuable lessons from the existent literature for future developments.

Balance Board or Motion Capture? A Meta-Analysis Exploring the Effectiveness of Commercially Available Virtual Reality Exergaming in Enhancing Balance and Functional Mobility Among the Elderly

Force platforms and motion capture are commonly used as feedback mechanisms in exergaming; nevertheless, their therapeutic effectiveness may vary. Therefore, the primary objective of this study was to evaluate the effectiveness of commercially available virtual reality (VR) exergaming systems on balance and functional mobility, with a supplementary analysis considering the administered dose of exergaming. The search was conducted in five databases. Commercially available exergaming platforms were classified into two categories: VR exergaming with a balance board (including Wii Balance Board) and motion capture (including Xbox Kinect). Two categories of control interventions (treatment as usual [TAU] and no treatment [NT]) were extracted. The meta-analysis was performed separately for static, dynamic, and proactive balance outcomes and for the aggregated results of all included outcomes with subgroup analysis of lower, moderate, and higher doses. In total, 28 studies with 1457 participants were included. Both exergaming systems were particularly effective in improving the single leg stance outcome. VR exergaming with motion capture was found to be more effective than TAU with a standardized mean difference (SMD) of 0.48 (P = 0.006) and NT (SMD = 0.86; P = 0.02). In conclusion, commercially available VR exergaming with a motion capture feedback mechanism has demonstrated effectiveness as an intervention for balance training when compared with NT. Specifically, high doses (above 134 minutes per week) appear to be more beneficial for healthy older adults. Moreover, the findings provide some weak evidence supporting the effectiveness of VR exergaming with a balance board for improving functional mobility, particularly when compared with NT.

A randomised controlled pilot study of a Nintendo Ring Fit Adventure™ balance and strengthening exercise program in community-dwelling older adults with a history of falls

OBJECTIVES

This pilot study examined the feasibility, acceptability, and effects of a Nintendo Ring Fit Adventure™-based balance and muscle strengthening exercise program in community-dwelling older adults with a history of falls.

METHODS

Older adults who have had at least one fall in the past year were randomly assigned to an experimental (n = 21) or control group (n = 21). The experimental group performed 16 exercise sessions in total, lasting 60 min each, twice a week for 8 weeks, whereas the control group received usual care. Feasibility was evaluated based on the scores of participants in the exercises. Acceptance was evaluated using a customised questionnaire examining participants' self-perceived enjoyment, feasibility and improvements. Clinical outcomes including balance (Mini-BESTest), lower limb muscle strength (Five-Time Sit-to-Stand test), mobility (Timed-Up and Go test), dual-task ability (Timed-Up and Go test-Dual Task), fear of falling (Icon-FES) and executive function (Color Trails Test) were evaluated at baseline and 8 weeks.

RESULTS

Thirty-one participants (74%) finished the 8-week assessment. The experimental group significantly improved their scores in six out of eight exercises (all p < .031). The mean scores of the self-perceived enjoyment, feasibility and improvement domains of the acceptability questionnaire were 3.46 ± .53, 3.08 ± .59, and 3.47 ± .57 respectively. A significant improvement in the anticipatory subscore of the Mini-BESTest was found in the experimental group compared to the control group (p = .02; Partial eta squared = .14).

CONCLUSIONS

The Nintendo Ring Fit Adventure™-based exercise program was feasible, acceptable, and potentially effective in community-dwelling older adults with a history of falls.

Effects of active exergames on physical performance in older people: an overview of systematic reviews and meta-analysis

This overview assessed the available body of published peer-reviewed systematic reviews and meta-analyses related to the effects of active exergames compared with active/passive control on physical performance outcomes in older people. The methodological quality and certainty of evidence were assessed using PRISMA, AMSTAR 2, and GRADE. The protocol was registered in PROSPERO (code: CRD42023391694). The main outcomes indicate that 4,477 records, five systematic reviews, and 10 meta-analyses were included. The AMSTAR-2 reported six meta-analyses with high methodological quality, four moderate quality, two systematic reviews with low quality, and three very-low quality. Meta-analysis was performed on balance using the Berg Balance Scale (BBS) and Timed Up-and-Go (TUG) tests, on cardiorespiratory fitness using the 6-min walk test, and on upper and lower limbs muscle strength using the handgrip strength, knee extension, and 30-s chair stand tests. Significant differences in favor of the active exergames groups concerning active/passive groups were reported in BBS (SMD = 0.85; 95% CI = 0.12-1.58; I2 = 96%; p = 0.02), TUG (SMD = 1.44; 95% CI = 0.71-2.16; I2 = 97%; p < 0.0001), and 30-s chair stand test (SMD = 0.79; 95% CI = 0.33-1.25; I2 = 88%; p = 0.0008). However, no significant differences were reported in favor of the active exergames groups in 6-min walk (SMD = 0.93; 95% CI = -0.64 to 2.50; I2 = 95%; p = 0.24), handgrip strength (SMD = 0.67; 95% CI = -0.04 to 1.38; I2 = 84%; p = 0.06), and knee extension tests (SMD = 0.20; 95% CI = -0.05 to 0.44; I2 = 95%; p = 0.12) compared to active/passive control. However, it was impossible to perform a meta-analysis for the variables of walking speed as a fall risk due to the diversity of instruments and the small number of systematic reviews with meta-analysis. In conclusion, interventions utilizing active exergames have shown significant improvements in the static and dynamic balance and lower limb muscle strength of apparently healthy older people, compared to control groups of active/inactive participants, as measured by BBS, TUG, and 30-s chair stand tests. However, no significant differences were found in the 6-min walk, HGS, and knee extension tests.

Systematic review registration

PROSPERO, CRD42023391694.

Feasibility, safety, and effects of a Nintendo Ring Fit Adventure™ balance and strengthening exercise program in community-dwelling older adults with a history of falls: A feasibility randomized controlled trial

AIM

This pilot study examined the feasibility, safety, and effects of a Nintendo Ring Fit Adventure™-based exercise program to enhance balance and lower limb muscle strength in community-dwelling older adults with a history of falls.

METHODS

In total, 42 older adults who experienced at least one fall in the past year were randomly assigned to an experimental or control group. Participants in the experimental group performed 60-min sessions of the exercise program twice per week for 8 weeks. The control group received usual care. We assessed the feasibility (retention and adherence to the exercise program), safety (number of adverse events), and clinical outcomes: (1) balance (Mini-BESTest); (2) functional lower limb muscle strength (Five-Time Sit-to-Stand test); (3) mobility (Timed-Up and Go test); (4) dual-task ability (Timed-Up and Go test - Dual Task); (5) fear of falling (Icon-FES); and (6) executive function (Color Trails Test).

RESULTS

Thirty-one participants (74%) completed the 8-week assessment. No adverse event associated with the exercise program was reported. There was a significant interaction in the anticipatory domain score of the Mini-BESTest between the experimental and control groups over the 8 weeks (P = 0.019).

CONCLUSIONS

The Nintendo Ring Fit Adventure™-based exercise program was feasible, safe, and potentially effective in improving anticipatory balance in community-dwelling older fallers. Geriatr Gerontol Int 2024; 24: 334-341.

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

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

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.

Exergames in Older Adult Community Centers and Nursing Homes to Improve Balance and Minimize the Risk of Falls in Older Adults: A Systematic Review and Meta-Analysis

There is a substantial gap in our knowledge regarding the efficacy of exergames on the reduction of fall risk in older adults. This systematic review analyzes the findings of clinical trials describing the efficacy of exergames to improve balance or reduce the risk of falls in individuals above 60 years of age who are residents in community centers or nursing homes. We searched Google Scholar, PubMed, and Embase up to January 2023. Initially, 52,294 records were screened. After applying the inclusion and exclusion criteria, 20 studies were included in this systematic review. Meta-analyses revealed statistically significant reductions in the risk of falls and improvements in balance. Exergaming tended to produce positive benefits according to the results obtained using different instruments (TUG, PPA, BBS, and others), control groups, and times of intervention. Nevertheless, a substantial proportion of studies exhibited a high risk of bias and only one had a long follow-up period. Although a large body of evidence supports the view that exergaming is suitable for reducing fall risk and improving balance in older adults, some gaps remain in our knowledge about such benefits.

Effectiveness of virtual reality games in improving physical function, balance and reducing falls in balance-impaired older adults: A systematic review and meta-analysis

BACKGROUND

In recent years, sports games based on virtual reality (VR) have been widely used in the prevention and treatment of diseases related to the elderly. However, there seems to be no consensus on the improvement and comparison of physical function, balance and falls in elderly people with balance impairment.

OBJECTIVE

This study aims to explore the effects of VR intervention on physical function, balance and falls in elderly people with balance impairment.

METHODS

Systematic literature searches of the PubMed, Web of Science, Elsevier, Cochrane, CNKI, and Wanfang databases were performed for VR games-related randomized controlled trials or comparison studies among elderly participants with impaired balance, published in English or Chinese until March 20, 2022. The Cochrane collaboration risk of bias tool was used to evaluate the methodological quality of the studies. A meta-analysis was performed to calculate the standardized mean deviation or mean difference of the sample and its 95% confidence interval (CI) in VR games.

RESULTS

The systematic review included 23 studies. The results showed that VR intervention had significant effects on hand grip strength (MD:1.30, P = 0.040), knee extension strength (MD:-6.27, P<0.001), five times sit-to-stand test scores (MD:1.13, P = 0.030), timed up-and-go test scores (MD:-1.01, P = 0.001), berg balance scale scores (MD:2.37, P<0.001), and falls efficacy scale scores (SMD:-0.28, P = 0.020). Subgroup analysis results showed that VR intervention was more effective on improving TUG and BBS scores than the conventional exercise group (MD=-0.54, P = 0.004; MD=3.24, P<0.001) and the non-intervention group (MD=-0.98, P = 0.001; MD=3.30, P < 0.001). The balance training-based VR had a significant effect on improving TUG (MD=-1.03, P = 0.004) and BBS (MD=2.93, P<0.001), and 20-45 min intervention, ≥3 times/wk, 5-8 wk cycles were significant in improving TUG (MD=-0.89, P<0.001; MD=-0.75, P = 0.0003; MD=-1.54, P<0.0001). VR intervention significantly improved TUG (MD=-2.27, P<0.0001) and BBS (MD=3.41, P<0.0001) in older adults in the hospital or nursing home compared with those residing in communities.

CONCLUSION

VR interventions can help the elderly with impaired balance to overcome traditional sports obstacles and improve physical function, balance and minimize falls. Balance training-based VR intervention is more effective in balance recovery and fall prevention compared with game program. An intervention plan comprising 20-45 min, 5-8 wk cycles, and ≥3 times/wk frequency has significantly higher effects for high-risk elderly populations living in hospitals or nursing homes.

Home-Based Exergame Program to Improve Physical Function, Fall Efficacy, Depression and Quality of Life in Community-Dwelling Older Adults: A Randomized Controlled Trial

This study aimed to investigate the effects of home-based exergame programs on physical function, fall efficacy, depression, and health-related quality of life in community-dwelling older adults. Fifty-seven participants aged 75 years or older were divided into control and experimental groups. The experimental group received a home-based exergame program that included balance and lower-extremity muscle strength for 8 weeks. The participants exercised at home for 50 min three times a week and were monitored through a video-conference application. Both groups received online education on musculoskeletal health once a week, whereas the control group did not exercise. Physical function was assessed using the one-leg standing test (OLST), Berg balance scale (BBS), functional reaching test (FRT), timed up-and-go test (TUGT), and five-times sit-to-stand (FTSTS). Fall efficacy was assessed using the modified falls efficacy scale (MFES). Depression was assessed using the geriatric depression scale (GDS). Health-related quality of life was assessed using a 36-item short-form health survey (SF-36). The experimental group showed an overall improvement in OLST, BBS, FRT, TUGT, and FTSTS (p < 0.05). MFES was significantly increased in the experimental group after the intervention (p < 0.05). The GDS significantly decreased in the experimental group after the intervention (p < 0.05). In SF-36, role limitations due to physical health, general health, and fatigue (energy and fatigue) items improved in the experimental group after intervention (p < 0.05). An 8-week home-based exergame program improved physical function, fall efficacy, depression, and health-related quality of life in older adults. The study was registered on ClinicalTrials.gov (NCT05802537).

Feasibility and Effectiveness of a Novel Intervention Integrating Physical Therapy Exercise and Dance Movement Therapy on Fall Risk in Community-Dwelling Older Women: A Randomized Pilot Study

This pilot study presents a novel fall prevention intervention that integrates physical therapy exercise (PTE) and dance movement therapy (DMT) to address both physical and emotional fall risk factors, as well as factors influencing adherence to treatment. The aim of this study was to examine the feasibility and effectiveness of the intervention in a sample of eight older women (median = 86 [81.25-90.75] years) from a day center for senior citizens. The intervention, based on the Otago Exercise Program and DMT techniques, aimed to address the emotional experience during physical exercise. Participants were randomly assigned to either a PTE+DMT intervention group (n = 5) or a PTE control group (n = 3). A pre-post intervention battery of physical and emotional fall risk assessments, therapist-patient bond, and home exercise adherence was conducted. Non-parametric tests results showed significant improvement in the PTE+DMT group in measures of balance and fear of falling compared to the PTE group. However, no other significant differences were found between the groups in terms of falls-related psychological concerns, self-perceived health status, therapist-patient bond, and home exercise adherence. These findings demonstrate the feasibility and potential benefits of an intervention that integrates both physical and emotional aspects to reduce fall risk in older adults, and provide a basis for further studies and modifications in the research protocol.

Cheer for me: effect of non-player character audience feedback on older adult users of virtual reality exergames

The presence of an audience and its feedback could affect people's performance and experience during an event, especially related to sports such as tennis or boxing. Similarly, in videogames, players' gameplay could be affected if there is an audience and its feedback in response to players' performance in the environment. The inclusion of an audience with non-player characters (NPC) is common in videogames in general. However, there is a limited exploration of the use of an NPC audience in virtual reality (VR) exergames, especially focusing on elderly players. To fill this gap, this work examines the effect of an NPC audience and its associated feedback (with/without) on elderly users of VR exergames. In a user study, we used 120 NPC in a virtual audience. Results showed that the presence of the NPC audience with responsive feedback led to higher performance (with a higher success rate of performing gesture actions, more successful combinations of actions (or combos for short) performed, and more opponent's combos prevented) and better gameplay experience (with higher levels of competence, autonomy, relatedness, immersion, and intuitive controls) of elderly players. Our results can help frame the design and engineering of VR exergames that are targeted at elderly users to help them have an enhanced gameplay experience and improve their health.

Evaluation of Arm Swing Features and Asymmetry during Gait in Parkinson's Disease Using the Azure Kinect Sensor

Arm swinging is a typical feature of human walking: Continuous and rhythmic movement of the upper limbs is important to ensure postural stability and walking efficiency. However, several factors can interfere with arm swings, making walking more risky and unstable: These include aging, neurological diseases, hemiplegia, and other comorbidities that affect motor control and coordination. Objective assessment of arm swings during walking could play a role in preventing adverse consequences, allowing appropriate treatments and rehabilitation protocols to be activated for recovery and improvement. This paper presents a system for gait analysis based on Microsoft Azure Kinect DK sensor and its body-tracking algorithm: It allows noninvasive full-body tracking, thus enabling simultaneous analysis of different aspects of walking, including arm swing characteristics. Sixteen subjects with Parkinson's disease and 13 healthy controls were recruited with the aim of evaluating differences in arm swing features and correlating them with traditional gait parameters. Preliminary results show significant differences between the two groups and a strong correlation between the parameters. The study thus highlights the ability of the proposed system to quantify arm swing features, thus offering a simple tool to provide a more comprehensive gait assessment.

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

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

A Pilot Study Comparing the Effects of Concurrent and Terminal Visual Feedback on Standing Balance in Older Adults

While balance training with concurrent feedback has been shown to improve real-time balance in older adults, terminal feedback may simplify implementation outside of clinical settings. Similarly, visual feedback is particularly well-suited for use outside the clinic as it is relatively easily understood and accessible via ubiquitous mobile devices (e.g., smartphones) with little additional peripheral equipment. However, differences in the effects of concurrent and terminal visual feedback are not yet well understood. We therefore performed a pilot study that directly compared the immediate effects of concurrent and terminal visual feedback as a first and necessary step in the future design of visual feedback technologies for balance training outside of clinical settings. Nineteen healthy older adults participated in a single balance training session during which they performed 38 trials of a single balance exercise including trials with concurrent, terminal or no visual feedback. Analysis of trunk angular position and velocity features recorded via an inertial measurement unit indicated that sway angles decreased with training regardless of feedback type, but sway velocity increased with concurrent feedback and decreased with terminal feedback. After removing feedback, training with either feedback type yielded decreased mean velocity, but only terminal feedback yielded decreased sway angles. Consequently, this study suggests that, for older adults, terminal visual feedback may be a viable alternative to concurrent visual feedback for short duration single-task balance training. Terminal feedback provided using ubiquitous devices should be further explored for balance training outside of clinical settings.

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].

Physical Activity and Exergames Among Older Adults: A Scoping Review

Recently, exergames have been widely applied as exercise platforms among older adults. However, studies on the influence of exergames on older adults' physical activity remain scarce. The review article highlights the potential benefit of exergames as a physical activity tool for older adults. The literature search followed the PRISMA guidelines on databases PubMed (Public/Publisher MEDLINE), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, and Scopus. The literature included studies that evaluated the influence of exergames on older adults' physical activity. Articles were excluded if the mixed intervention was used, emphasizing specific limbs, improving specific tasks, or not mentioning intervention. The review article identified 25 studies that reported on 855 older adults 55 years of age and older. In addition, the common exergaming technology platforms examined were Microsoft Kinect™, Nintendo® Wii™, cybercycling, and interactive video dance games. Meanwhile, 11 studies used a pretest/post-test design and randomized controlled trial design in 14 studies. The review found that exergames significantly impacted the older adults' physical activity level as participants experienced improved balance and cognitive function, and enjoyed playing exergame, thus prolonging their game engagement. Although research on exergames is still new, current evidence showed a significant potential benefit of exergames as a physical activity tool for older adults. To overcome the limitation on various parameters that showed different effects and outcomes of exergames, the study recommends implementing randomized controlled trials with long-term observation using a mixed-method approach. Moreover, a multidisciplinary method involving exercise and neuromotor control experts could determine potential mechanisms of action that benefited from the exercises.

Efficacy of Virtual Reality and Exergaming in Improving Balance in Patients With Multiple Sclerosis: A Systematic Review and Meta-Analysis

Multiple sclerosis (MS) is one of the most common causes of neurological progressive disease and can lead to loss of mobility, walk impairment, and balance disturbance. Among several rehabilitative approaches proposed, exergaming and virtual reality (VR) have been studied in the recent years. Active video game therapy could reduce the boredom of the rehabilitation process, increasing patient motivation, providing direct feedback, and enabling dual-task training. Aim of this systematic review was to assess the efficacy of exergaming and VR for balance recovery in patients with MS. PubMed, Scopus, and Web of Science were systematically searched from the inception until May 14, 2021 to identify randomized controlled trials (RCTs) presenting: patients with MS as participants, exergaming and VR as intervention, conventional rehabilitation as comparator, and balance assessment [Berg Balance Scale (BBS)] as outcome measure. We also performed a meta-analysis of the mean difference in the BBS via the random-effects method. Out of 93 records, this systematic review included and analyzed 7 RCTs, involving a total of 209 patients affected by MS, of which 97 patients performed exergaming or VR and 112 patients underwent conventional rehabilitation. The meta-analysis reported a significant overall ES of 4.25 (p < 0.0001), showing in the subgroup analysis a non-significant ES of 1.85 (p = 0.39) for the VR and a significant ES of 4.49 (p < 0.0001) for the exergames in terms of the BBS improvement. Taken together, these findings suggested that balance rehabilitation using exergames appears to be more effective than conventional rehabilitation in patients affected by MS.

Wii or Kinect? A Pilot Study of the Exergame Effects on Older Adults' Physical Fitness and Psychological Perception

Exergames are now often implemented among older adults for health purposes. This study aimed to investigate whether playing Kinect and Wii exergames has effects on older adults’ physical fitness and psychological perceptions towards exergames. A total of 23 older participants aged above 60 years were recruited and randomly assigned into two groups, in which they played either Kinect or Wii Bowling exergames for three sessions in one week. Physiological and psychological measures were collected including heart rate, blood pressure, shoulder flexibility, as well as perceived benefits and intentions for future use. Findings indicated that exergames are equivalent to light-intensity exercises, and hence pose no or minimal risk to older adults. Older adults had a positive attitude towards exergames and have a strong willingness to engage in exergaming on a regular basis. Although no significant platform difference was identified, observation and qualitative findings suggested that Wii might provide a more intense physical activity than Kinect, while Kinect might obtain a higher perception among older adults than Wii. The study has several practical implications for both health professionals and exergame designers targeting the ageing population.

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Meta-analysis of the effects of game types and devices on older adults-video game interaction: Implications for video game training on cognition

Video game training can effectively improve the cognition of older adults. However, whether video game types and game devices influence the training effects of video games remains controversial. This meta-analysis aimed to access and evaluate the effects of video game types and game devices in video game training on the cognition of older adults. Interestingly, results indicated that mouse/keyboard was superior over other video game devices on perceptual-motor function. The effect size (Hedge's g) for perceptual-motor function decreased by 1.777 and 1.722 when the video game training device changed from mouse/keyboard to driving simulator and motion controller. The effects of cognitive training game and conventional video game were moderated by session length. More well-designed studies are required to clarify the unique efficacy of video game types and devices for older adults with video game training.

Effect of virtual reality exercises on balance and fall in elderly people with fall risk: a randomized controlled trial

BACKGROUND

Deficient balance and fear of falling in elderly people can lead to disturbed daily activities, falling, and finally reduced quality of life. Therefore, evaluation of low-risk methods that might partially improve balance in this group of people is of utmost importance. The present study aimed to investigate the impact of Virtual Reality (VR) exercises based on Xbox Kinect on balance and fear of falling among elderly people.

METHODS

This clinical trial was performed on 60 elderly individuals living in nursing homes divided into two groups of control and Xbox. The participants in the intervention group received VR exercises based on Xbox Kinect in form of two 30-45-min sessions held on a weekly basis for 6 weeks. The individuals in the control group, on the other hand, received routine exercises of the nursing homes. The research tools used in this study included a demographic questionnaire, the Berg Balance Scale (BBS), the Timed Up and Go (TUG) test, and the Falling Efficacy Scale (FES).

RESULTS

The findings of the current study demonstrated that the scores of BBS and TUG test as the indices of balance among elderly people improved significantly in the Xbox group after the intervention (p < 0.001 for both BBS and TUG test). Moreover, the score of fear of falling diminished significantly in the intervention group compared to the control group (p < 0.001).

CONCLUSION

According to the results of the present investigation, 6 weeks of VR balance exercises could enhance balance and fear of falling among elderly people living in nursing homes.

TRIAL REGISTRATION

Code: IRCT20190727044347N1 , Date: 17-8-2019.

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.

Beneficial Effects of Interactive Physical-Cognitive Game-Based Training on Fall Risk and Cognitive Performance of Older Adults

Physical and cognitive declines are significant risk factors for falls. Promising evidence suggests that combined physical-cognitive training would be an effective fall risk reduction and cognitive improvement intervention. However, a limited number of studies have been conducted and findings have been inconclusive. This study investigated the effects of interactive physical-cognitive game-based training on the fall risk and cognitive performance of older adults. Forty participants were randomly allocated to the intervention (n = 20) and control (n = 20) groups. Participants in the intervention group performed a 1 h session, 3 times a week for 12 weeks of the interactive physical-cognitive game-based training program. Fall risk (Physiological Profile Assessment, PPA; and Timed Up and Go, TUG) and cognitive outcome (Montreal Cognitive Assessment, MoCA) were assessed at pre- and post-intervention. Thirty-nine participants (mean age = 69.81 ± 3.78 years) completed the study (97.5%). At the end of the trial, participants in the intervention group demonstrated significant improvement in the PPA fall risk score (p = 0.015), postural sway (p = 0.005), MoCA score (p = 0.001), and TUG-dual task (p = 0.045) compared to controls. In conclusion, the interactive physical-cognitive, game-based training was effective in reducing physiological fall risk and improving cognitive function in community-dwelling older adults.