Using commercial video games for falls prevention in older adults: the way for the future?

Systematic Review Using Commercial Video Games for Falls Prevention in Older Adults: The Way for the Future? Eva Pietrzak, PhD; Cristina Cotea, BSc (Hons), LCDR; Stephen Pullman, RAN ABSTRACT

INTRODUCTION

Background and Purpose: Falls in older adults are an increasingly costly public health issue. There are many fall prevention strategies that are effective. However, with an increasing population of older people and ever-decreasing availability of health practitioners and health funding, novel modes of intervention are being developed, including those relying on computer technologies. The aim of this article was to review the literature on the use of exergaming to prevent falls in older adult persons living in the community. Methods: The Cochrane, Medline, and Embase databases were searched using prespecified search terms. To be included, studies had to investigate the effect of using commercially available consoles and video games on outcome measures such as a decrease in falls, improvements in balance control or gait parameters, decreased fear of falling, and attitude to exercise in older adult persons living in the community. All study designs with the exception of single-person case studies were included. Articles had to be published in peer-reviewed journals in the English language. Results: Nineteen studies fulfilled the inclusion criteria. The following outcomes were observed: (1) using computer-based virtual reality gaming for balance training in older adults was feasible; (2) the majority of studies showed a positive effect of exergaming on balance control; (3) some studies showed a positive effect on balance confidence and gait parameters; (4) the effect was seen across the age and sex spectrum of older adults, including those with and without balance impairment. Conclusions: There is as yet no evidence that using virtual reality games will prevent falls, but there is an indication that their use in balance training may improve balance control, which in turn may lead to falls prevention. Key Words: balance training, falls prevention, older adults, video games, virtual reality

Each year, 1 in every 3 adults aged 65 years and more falls.1 Among this age group, falls are the leading cause of injury death and the most common cause of nonfatal injuries and hospital admissions for trauma.2 In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments throughout the United States, and more than 662,000 of these patients were hospitalized.1 The direct medical cost of falls was estimated at $30 billion.3 Falls without associated injuries that may be undetected by health services may result in fear of falling, decreased activity, functioning, and quality of life of older persons.4 The most important risk factors associated with falls are increased age, history of falls, chronic medical conditions such as stroke or Parkinson’s disease, multiple medications such as benzodiazepines, impaired balance and mobility, reduced muscle strength, sensory problems (mainly visual), impaired cognition, depression, low level physical activity, low body mass and osteoporosis, fear of falling, and female sex.4 Some of the most important risk factors for falling such as age, sex or chronic medical conditions are not modifiable; others, such as impaired balance and mobility, reduced muscle strength, low level physical activity or fear of falling may be modified by a suitable intervention.4 A systematic review, which rated the intervention to reduce falls on the basis of the strength of evidence, found that exercise had the strongest evidence of effectiveness.4 Among various types of exercises, the most effective in falls reduction were tai chi (reduced falls by 35%), multiple-component home-based exercise (reduced falls by 23%), and multiple-component group exercise (reduced falls by 17%).5 Historically, for people with balance problems, interventions for the examination and treatment of balance have included high-cost force plate and virtual reality (VR) systems in clinical settings. Recently, owing to its low cost, ease of use, and portability, the Nintendo Wii platform is being used in physical therapy clinics and skilled nursing facilities as a popular substitute for the expensive and complicated force plates to improve dynamic strength and balance.6 Nintendo Wii’s validity and reliability as an intervention tool has been confirmed. The study has found that, compared with “gold standard” laboratory-grade force platform, the

(J Geriatr Phys Ther 2014;37:166–177.) Centre for Military and Veterans’ Health, Research Coordination Unit, Mayne Medical School, The University of Queensland, Herston, Queensland, Australia. This review was undertaken on behalf of and funded by the E-Health Research Unit, UQ Node, CMVH. The authors declare no conflicts of interest. Address correspondence to: Stephen Pullman, RAN, Centre for Military and Veterans’ Health, Research Coordination Unit, Mayne Medical School, Herston Rd, The University of Queensland, Herston, Queensland 4006, Australia ([email protected]) Decision Editor: Kevin Chui DOI: 10.1519/JPT.0b013e3182abe76e 166

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Systematic Review Wii Balance Board demonstrates excellent concurrent validity (intraclass correlation coefficient [ICC] 0.77-0.89) and test–retest reliability (ICC 0.66) when assessing the center of pressure (a measure of standing balance parameter, also called a measure of sway).7 For those people who have limited access to physical therapy clinics with expensive equipment, using the Wii Fit as a means of balance exercise exhibits 2 undisputable advantages over traditional clinical balance exercise techniques. First, there is a reduced cost of up to several hundreds of dollars in savings compared with up to $100,000 for the traditional system. Second, there is an improved ease of use and portability, with the Wii Fit system can be plugged into any television monitor and requiring about 3 minutes to set up, and the entire system being compact and weighing approximately 5 kg, allowing easy transport and setup in community settings or in patients’ homes.8 The aim of this review was to examine the latest literature on the effectiveness of using commercially available gaming consoles and off-the-shelf video games in improving risk factors associated with falls in older adults.

METHODS Search The Cochrane, Medline, Embase, and Google databases were searched for articles on falls prevention in older adults, using prespecified search terms. Three strings of terms were used in combination: (1) falls prevention, fear of falling, balance, and balance training; (2) VR, exergames, video-based games, Nintendo Wii, and dance mat; and (3) older people and elderly. In addition, reference lists were searched for relevant articles. Search was performed in August 2012 and updated in May 2013.

Inclusion and Exclusion Criteria The detection of changes in the rate of falls requires large and long-term studies. The novelty of the area of research investigating the use of commercial video games in falls prevention may explain the limited evidence currently available because of a predominance of studies with a small sample size and of short duration. Therefore, we have included studies that investigated substitute outcomes, such as changes in the risk factors (ie, increased balance and decreased fear of falling). The population of interest involved older adults, living in the community or in assisted living facilities, with or without diagnosed balance problems, but essentially without specifically diagnosed mobility or mental impairments. Studies of all design types, with the exception of single-person case studies, published in peerreviewed journals in the English language were included. To be included, studies had to investigate VR video games and measure outcomes such as a decrease in falls, increased balance, decreased fear of falling, and the attitude toward exercise in older adults.

According to the review typology found in Grant and Booth,9 this review can be characterized as a scoping review; it provides a preliminary assessment of the potential size and scope of available research literature, and it aims to identify the nature and extent of research evidence. A higher level systematic review and meta-analysis of the benefits of interventions was not undertaken. For a metaanalysis to be valid, included studies had to be sufficiently similar regarding characteristics such as the population studied, the intervention explored, and most importantly, outcomes measured in the same way at the same intervals.9 A higher level systematic review and meta-analysis was not performed in this review, due predominantly to the preliminary nature of the majority of included studies and their variability, especially in the study design and duration of the intervention.

RESULTS The search resulted in 21 articles investigating the effect of using video games to improve balance control.6,10-29 An overview of the individual study characteristics and outcomes is presented in Table 1. The design of 8 studies was quasiexperimental with only 1 group of participants and a pre-/postcomparison. Nine studies were randomized control trials (RCTs) and 3 were of a comparative design with groups assigned without randomization. All studies were published in the past 4 years (2010-2013). They were performed in the United States (n = 11), the Netherlands (n = 3), Australia (n = 2), and in Scotland, Malaysia, Germany, Denmark, and Switzerland (n = 1 each). The largest RCTs numbered between 13 and 21 participants per group12,13,20,27,29 and smaller RCTs had between 5 and 7 participants.17,21,26 Comparative studies had between 4 and 19 participants per group.14,15,22,24,28 Observational studies numbered generally between 8 and 14 participants,6,11,16,18,25 but 2 studies had 22 and 36 participants.19,23 In 6 studies, the subject population involved older adults living in the community and performing individual exercises6,10-14 and 2 studies had group exercises.15,29 In 9 studies, the subjects were recruited from various retirement settings or residential living facilities and performed either individually based exercises16-19 or group exercises.20-24,28 In 2 studies, the subject age range was wider (18-67 years),25,26 and in 1 study, participants were temporarily hospitalized.27 The participants in 5 studies had either a balance impairment6,16,18 or a history of falling.10,14 In the remaining studies, participants reported no unusual balance problems, or the balance status of participants was not provided by the study. One study compared participants with and without balance impairment.18 The duration of the interventions ranged from 4 weeks to 3 months. Controls ranged from no intervention17,21,22,24,28,29 to active controls with intervention that included standard 167

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Study Characteristics

N=8 Participants: older adults, mean age 75 yrs, with a perceived balance deficit, living in the community; USA Design: quasiexperimental, singlegroup, pre-/postcomparison; duration 6 wks

N = 17, 3 groups Participants: aged 53-91 yrs, living in the community, no diagnosed balance problem, but history of at least 2 falls, recruited by a clinician referral (PW and PT) and volunteers (Wii); USA Design: RCT/comparative (PW and PT groups randomized, Wii volunteers); duration 4 wks

N=9 Participants: healthy older adults, older than 65 yrs, living in the community; the Netherlands Design: Quasiexperimental, singlegroup, pre-/postcomparison; duration 6 wks

N = 40, 3 groups Participants: healthy, independent seniors, mean age 72 yrs, no impairments, recruited in community; USA Design: RCT; duration 8 wks; 27 completed

Bainbridge et al6

Bateni10

Lamoth et al11

Pluchino et al12

Intervention and Outcome Measures

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• Performance on the dot task improved within the first 2 wk of training (P < .05) • Postural control improved during the intervention (P < .05) • After the intervention period, task performance and balance were better than before the intervention. • Subjects were highly motivated to exercise balance because they found gaming challenging and enjoyable

Wii Fit training seems to improve static and dynamic balance, and combined Wii and physical therapy is more effective than Wii Fit training alone • All subjects showed improvement in the BBS and bubble test scores. • Groups that included physical therapy tended to perform better: the PT and PW groups had greater improvements on BBS than the WI group (by 8, 6, and 3 points, respectively) • None of the differences reached statistical significance

Overall, no significant changes were found for any outcome measure • However, a trend toward improvement (P = .66) was seen on the BBS; 1 participant improved by 5 points, and 3 improved by 1-2 points

Results

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System: Wii; games: soccer heading, ski slalom, ski jump, table tilt, tightrope walk, • At postintervention, there were no differences between the groups river bubble, penguin slide, snowboard slalom, lotus focus • Within the groups, there were no significant Intervention: exercised supervised, in a laboratory differences after the intervention compared with • Three groups: { standard balance exercise program baseline on any functional test or questionnaire { Tai chi • All groups improved on COP (P = .000) mea{ Wii sure and some other laboratory tests Outcomes: Various functional and laboratory measures of static and dynamic balance and fear of falling, including TUG, one-leg stance, FR, Tinetti test, COP, and FES

System: balance control platform (sense balance fitness board), game involved using body tilt to guide ball through the maze into a target hole Intervention: individual exercises, practiced in a senior center • Three 20-min sessions per week for 6 wks Outcomes: • Balance performance (using the clinical measuring device) • Postural control (using the dot test) • Pleasure in activity • Motivation for the game-based training

System: Wii Fit; games: ski slalom, ski jump and table tilt Intervention: exercised supervised, not at home • Three sessions per week for 4 wks • Three groups: { Physical therapy and Wii Fit training (PW group) { Wii Fit training alone (WI group) { Physical therapy training alone (PT group) Outcomes: Static and dynamic balance: • BBS, all groups • Postural control (bubble test, PW, and WI groups)

System: Wii Fit balance board, soccer heading, ski jump, ski slalom, table tilt, tightrope walk, and penguin slide Intervention: exercised supervised, not at home • 30-min sessions 2 times per week for 6 wks • Each session began and ended with 5 min of yoga poses • All games were played in the respective order for 5 min per game Outcomes: • Balance (BBS) • Balance confidence (ABC scale) • Limits of stability (multidirectional reach test)

Older adults recruited in community—exercises were performed on individual basis

Study

Table 1. Characteristics and Outcomes of Studies on Using Exergaming for Falls Prevention

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N = 21, 2 groups (15 intervention, 6 control) Participants: older adults, aged over 70 yrs, with a history of falls, living in the community; UK Design: comparative; duration 12 wks

Williams et al14

Hermes et al15

N = 12, 3 groups Participants: older females, mean age 71 yrs, no cognitive or motor impairment, living in the community; USA Design: qualitative between groups comparison, because numbers were too small for quantitative analysis Duration 8 wks


System: Wii Fit; games: aerobic: jogging, step basics; balance: tilt table, ski slalom, heading, ski jump, hula hoop; yoga: breathing exercise • Intervention (individual exercises, with 1:1 supervision, not at home), sessions twice weekly for 12 wks • Control: standard care attended the local falls group, which is an exercise/education program supervised by NHS physiotherapists Outcomes: • Balance: BBS, TT • Fear of falling: FES • Acceptability of intervention: attitude to falls-related interventions scale • A qualitative interview

System: Wii; games: balance bubble, ski slalom, table tilt, soccer heading, and tight rope walk Intervention (individual exercises, with 1:1 supervision): • A 40-min session twice per week for 6 wks; each session included 10 min of warm-up and cool-down exercises • Two groups: { VR balance games { Conventional balance exercises Outcomes: • Risk of falling, physiological profile approach • Fear of falls (ABC-6)

System: Wii Fit; games: balance games Intervention: • 40-min Wii Fit sessions 2 times per week for 8 wks • Sessions offered at a local senior center, with supervision to ensure safety and correct performance • Each session included flexibility (yoga), strength training and balance training and cardiorespiratory training Control 1: traditional physical activity program Control 2: no intervention Outcomes: • Functional fitness, percentage change (chair stand, arm curl, timed up and go, and a 12-min walk) • Balance measures (end point excursion, maximum excursion, movement velocity, directional control, and reaction time)

Older adults recruited in community—exercises were performed in groups

N = 36, 2 groups Participants: women aged 56 and above, living in the community; Malaysia Design: RCT; duration 6 wks


Singh et al13

Study

Table 1. Characteristics and Outcomes of Studies on Using Exergaming for Falls Prevention (Continued ) Results

(continues )

Compared with baseline both Wii and traditional groups showed improvements in balance • However, the Wii group showed larger improvement on balance measures such as leaning backward, on endpoint excursion, maximum excursion, and directional control compared with the traditional and control groups • The traditional group improved more on strength measures, although Wii exhibited little change in functional fitness measures

• Attendance: 80% of participants attended 75% or more of the exercise sessions • 100% of the Wii group found the intervention to be enjoyable and acceptable and preferred it to usual care • There was no significant change in balance scores or fear of falling (BBS, TT, or FES scores) at 12 wks compared with baseline in any of the groups

• Both groups had significant decrease in risk and fear of falling (P = .001 and .01, respectively) • There was no difference in the level of improvement between the groups

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al29

N = 58 Participants: community-dwelling older adults aged 75 ± 6 yrs, with self-reported balance poor to average; Denmark Design: RCT Duration: 10 wks Group size selected to achieve 80% statistical power; 82% competed training; analysis was performed on intention-to-treat basis, with adjustment for age, sex, and baseline level

Study Characteristics System: Wii sport; games: table tilt, slalom ski, perfect 10, tight rope tension, penguin slide Intervention: • 70-min sessions, 2 times per week for 10 wks • Each training session comprised of Wii balance exercises (a game of choice, 35 min) • Muscle conditioning (standing rowing squat (∼25 min) • Pauses between exercises, each of ∼10-min duration • All sessions included 2 participants supervised by a physiotherapist Control: daily use of EVA copolymer insoles Outcomes • Maximal muscle strength (maximal voluntary contraction) • Static postural balance (center of pressure velocity moment during bilateral static stance) • Rate of force development • TUG test • Falls Efficacy Scale–International (FIS-I); • 30-s repeated chair stand test • Measurement of training motivation (5-point Likert scale)


System: 4 Nintendo Wii Fit exergames: basic step, soccer heading, ski slalom, and table tilt; two games were modified to ensure participants’ safety Intervention (exercised unsupervised, at home): • Received individualized instructions (at least 5 home visits) and weekly telephone follow-up • Sessions: 30 min 3 times per week for 3 mos • Completed a log of game enjoyment rate after each session Outcomes: • Balance (BBS) • Walking speed (4-m timed walk test) • Enjoyment (physical activity enjoyment scale) System: Wii Fit, games not specified • Intervention group (not reported but probably individual exercises with supervision) • Sessions 3 times a week for 3 wks • Each session lasted ∼30 min • Included strength exercises, yoga poses, and balance games • Control group continued with their normal daily routine Outcomes: • Balance: BBS • FR • Gait parameters (TG)

N=7 Participants: older adults (mean age 84 yrs) with impaired balance, but no cognitive impairment, living in continuing care retirement communities; USA Design: Quasiexperimental, singlegroup, pre-/postcomparison; duration 3 mos

N = 11, 2 groups Participants: older adults, aged 70-92 yrs, recruited from a local senior living the community; USA Design: RCT; duration 3 wks; 1 wk and 1 mo follow-up after the end of intervention Used paired test for before and after comparison

Agmon et al16

Bieryla and Dold17

Older adults recruited in retirement setting, assisted living residential facilities—exercises were performed on individual basis

Jorgensen et

Study

Table 1. Characteristics and Outcomes of Studies on Using Exergaming for Falls Prevention (Continued )

(continues )

Wii Fit training seems to improve dynamic balance but not gait parameters: • In the experimental group, BBS scores increased significantly at 1 wk and 1 mo after training compared to baseline; there was no change in BBS for the control group • TUG and FR were not different

• Balance was improved significantly (BBS rose from 49 to 53 points) • Walking speed increased significantly from 1.04 to 1.33 m/s • Participants rated enjoyment of games as high and expressed desire to play exergames with their grandchildren

Compared to controls, greater improvements were seem in the WII group in the following outcomes: • Mechanical lower limb muscle function (maximal voluntary contraction strength was higher by 18%, P = .001) • The rate of force development (P = .03) • TUG test (P = .01) • FIS (P = .03) • 30-s repeated chair stand test (P = .01) • Participants rated the Wii training highly motivating at 5 and 10 wks into the intervention • Interestingly, static postural balance deteriorated in both groups to a similar degree (between group difference 1%, P = 0.92) • Safety: no adverse events were reported

Results

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N = 22 Participants: older adults in reasonably good health, living in retirement communities; USA Design: quasiexperimental, singlegroup pre-/postcomparison; duration 4 wks

Williams et al19


System: Wii Fit; games: participants could choose games from the balance and aerobic categories, which involved leaning 4 ways, and jogging in place, step aerobics, swaying of hips, and boxing Intervention (exercised supervised, at their facility): • Twelve 20-min sessions, 3 per week, over 4 wks • Each session included 10 min of balance training and 10 min of aerobic activity Outcomes: Balance (BBS)

System: Wii Fit; games: table tilt, balance bubble, ski slalom, penguin fishing, snowboard slalom, and soccer heading (the latter only for advanced players); games have adjustable difficulty levels Intervention (exercised supervised by 2 people): • A 20-min session, 3 times per week for 4 (NE) or 6 wks (MC) • Each session began with yoga simulation for 4 min Outcomes: • Balance abilities measured by BBS, TT, and COPM • Gait mechanics measured by the gait score

Pichierri et al20

N = 31 Participants: residents of 2 hostels for the aged, mean age 86 yrs, no cognitive or motor impairment; Switzerland Design: RCT; duration 12 wks

System: StepMania (Version 3.9) software, modified for the study to allow the control of speed, metal dance pads (Version of DDR) Control: • Progressive strength and balance training • 40-min sessions 2 times per week for 12 wks • Sessions conducted in groups of 3-4 participants • Each session consisted of a 5-min warm-up, 25-min resistance training. and 10 min of balance exercises Intervention: • As above, plus additional dance video gaming for 10-15 min • Each dancing session included 4 songs, each 2-3 min long, with a 30-s break between them • Progression of performance was controlled through adjusting the beats per minute and the difficulty level Outcomes: • Foot placement accuracy • Gait analysis (performance under single and dual task conditions) • Fear of falling

Older adults recruited in retirement setting, assisted living residential facilities—exercises were performed in groups

N = 14 Participants: recruited from 2 local assisted living communities; mean age = 85 yrs; USA Divided into 2 subgroups, with and without balance problems: • NE, n = 8, with no balance concerns • MC, n = 6 Design: Quasiexperimental, 2 subgroups, pre-/postcomparison; duration 4 and 6 wks


Bomberger18

Study


(continues )

• The improvements in step time were significantly larger in the dance video game group than in controls • The fast walking performance under dual task conditions (velocity, double support time, step length) improved significantly in the dance video game group only • The foot placement accuracy and fear of falling improved in both groups compared with baseline, to the similar degree

• Average posttest balance scores were significantly improved compared with baseline (by about 10 points) • Participants reported enjoyment and possible improvements in quality of life

Balance abilities increased in both groups but only the improvement was more marked in the group without balance problems; the gait mechanics improved only in the group without balance problems • BBS scores increased by 3.8% in the NE group and by 0.41% in the MC group • TT scores increased by 1.80% in the NE group and by 0.76% in the MC group • COPM analysis: the radius of movement and the velocity of movement decreased in both groups, but the changes in the NE group were more marked • The gait score increased by 5.3% in the NE group

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N = 21, 3 groups Participants: prefrail volunteers, who exhibited 1-2 characteristics of frailty, recruited from residential living facility, mean age 77 yrs; USA Design: RCT, duration 15 wks

N = 39, 2 groups Participants: older volunteers from 2 seniors’ homes, aged 80-89 yrs, stable medical condition and a BBS test score between 22 and 55; the Netherlands Design: comparative; duration 6 wks

N = 36 Participants: healthy older (±80 yrs) adults, recruited from senior living settings; no history of falling; USA Design: quasiexperimental, 1 group pre-/postcomparison; duration 3 mos

N = 21, 3 groups Participants: older than 60 yrs or more, no physical or mental impairment, living at 3 assisted living facilities; USA Design: quasiexperimental, comparative, 3-group, pre-post comparison; duration 8 wks

Tange et al22

Studenski et al23

Bell et al24


Daniel21

Study

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System: Wii Fit; game: bowling • Intervention (supervised, group exercises): 1. Warm-up exercises, Nintendo Wii bowling, and fall prevention education 2. Warm-up exercises and Nintendo Wii bowling (no education) • Control: no intervention • The confidence in the ability to prevent falls (M-FES) • Quality of life (CASP-19 scale) • Social relationships and support (SPA scale)

System: DancetownTM, a video dance game designed for older people • Intervention: group exercises with a trained coordinator • 30-min supervised dance sessions, twice weekly for 3 mos • Participants danced singly or in pairs using a proprietary game Outcomes: • Balance confidence • Physical and mental function (SF36) • Self-reported quality of life

System: Wii Fit; game: tilt table • Intervention: games played in 5 groups of 2-5 people, supervised; 1-hr sessions, twice a week for 6 wks • Control: no intervention Outcomes: • Balance control: BBS at 0, 3, and 6 wks • Quantitative data on the satisfaction with the game were collected

System: Wii Fit; games: bowling, tennis, and boxing • Intervention 1 (supervised, group exercise): 45-min sessions of Wii Fit training 3 times per week; wore a weight vest to strengthen core and quadruples muscles • Intervention 2 (supervised, group exercise): seated exercise, 45-min sessions of seated aerobic program, 3 times per week • control: no intervention Outcomes: • Balance confidence (balance efficacy scale) • TUG • Measures of fitness and functionality • Attendance



(continues )

• In the quantitative data outcomes, results were scattered and no valid conclusions could be drawn • In the qualitative data, there were some signs of overall satisfaction, fall awareness, and increased participation

• 70% of participants completed the study • Completers were healthier than noncompleters • Completers showed significant gains in: • Narrow walk time • Self-reported balance confidence • Mental health • There were no serious adverse events; 4 people withdrew due to musculoskeletal complaints

• There was no significant effect on balance in the intervention group • Participants enjoyed competitive and social aspect of gaming • Participants noted that the exertion level of Wii sports is between sedentary activities and real physical training • Participants suggested that vendors make navigation speed of games adjustable

There was no difference between groups in the level of improvement • Compared with the control group, in both physical activity groups there was trend to improvement on several of the fitness measures, including chair stands, arm curls, step 2, 6-min walk, sit and reach, and the timed up and go, but none of the differences reached statistical significance • Several participants from the Wii group bought the game for their own home use

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N = 29 (3 groups, 2 interventions, n = 8 each, and control, n = 13) Participants: older adults living in a nursing home, average age over 80 yrs (65-90 yrs); the Netherlands Group 1 had regular experience with the Nintendo “Wii Fit” for at least 1 yr; group 2 were novices Design: comparative Duration: 12 wks Assessment was performed by a physiotherapist blinded to allocation


System: Wii Fit; games: not specified • Intervention (not clear where sessions took place and if supervised) • A 30-min session, twice weekly for 10 wks • Regimen determined for age and physical ability was preprogrammed by the manufacturer for each participant Outcomes: Various balance measures, muscle strength flexibility. and cardiovascular fitness System: Wii Fit; games: ski slalom, table tilt, and tightrope walk. Intervention: • Group exercise • 10-12 min of sessions 3 times per week for 3 wks • Each session involved each the games played 3 times for about 3 min • The difficulty level was chosen by participants Control: traditional balance exercises Outcomes: • Balance: 5 tests (SEBT; ball-handling; 2 video games: ski slalom and balance bubble; dynamic balance) • Psychological effects of the interventions: a questionnaire concerning mood state, self-efficacy, physical activity enjoyment, flow and subjective experience

N = 10 Participants: healthy women aged between 30 and 60 yrs; Australia Design: quasiexperimental, 1 group pre-/postcomparison; duration 10 wks

N = 22 Participants: volunteers, age range 18-67 yrs, mean 47 yrs, living in the community; recruited at a health center-–specializing in rehabilitation; no additional details about participants’ health were provided; Germany Design: RCT Duration 3 wks

Kliem and Wiemeyer26

System: Wii Fit Plus; games: table tilt and at least 2 other games Intervention: • Sessions 2 times per week for 12 wks • Sessions lasted 1 hr per group, giving a play time of 10-15 min per participant per session • Each participant played the game 3 times per session • There were 2 sets of devices installed, so 2 players could play at the same time; they were closely supervised by 2 people (the researcher and a volunteer) • A chair was put in front of each Wii Balance Board as a safeguard for participants who were afraid of falling from the board Control: usual activities Outcomes: • Balance (BBS) • Physical activity (LASA physical activity questionnaire); measured in minutes per day

Nitz et al25

Special subject population

Janssen et al28

Study


(continues )

Wii Fit seems to improve balance in adults, but to the lesser degree than traditional balance exercises • Compared with baseline, posttest measures for both groups showed significant improved in balance performance (in 4 of 5 tests each) • In between groups comparison, the Wii group showed a significantly greater improvement in 1 test (ski slalom), whereas the traditional group showed a significantly greater improvement in 2 tests (SEBT and ball-handling) • There were no significant pre-/posteffects nor between the groups differences in psychological effects of the interventions

• Balance and lower limb muscle strength showed significant improvement • There were no other significant changes

Compared with baseline: • Balance improved for all 3 groups to the same degree, but there was no effect of playing “Wii Fit Plus” (P = .89) • Intervention had a positive effect on physical activity (P = .005); activity increased by 54 and 61 min/d in intervention groups 1 and 2, respectively

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N = 42, 2 groups Participants: hospitalized patients recruited from a geriatric rehabilitation unit, mean age of 85 yrs, ambulatory and relatively high functioning: no cognitive impairment and medically fit to participate; Australia Design: RCT, randomization concealed, outcome assessment blinded, none lost to follow-up, ITT analysis Duration: mean of 12 d

Abbreviations: ABC, Activities-specific and Balance Confidence Scale; BBS, Berg Balance Scale; CASP, Control, Autonomy, Satisfaction, Pleasure scale; COP, Centre of pressure; COPM, Centre of pressure movement; DDR, Dance Dance Revolution; EVA, ethylene vinyl acetate; FES, Falls Efficacy Scale; FR, functional reach; MC, mild to moderate balance concerns; NE, normal elders; PT; PW; RCT, randomized control trial; SEBT, Star Excursion Balance Test; SPA, Social relationships and support; TT, Tinetti Test; TUG, timed up and go; WI, Wii intervention; WII, Wireless inter-interface; VR, virtual reality.

Results

Wii Fit seems to improve balance and functional mobility parameters at least as well as traditional balance exercises • Participants in the Wii group improved significantly more in the functional mobility (TUG) and balance (BBS) tests than in the conventional physiotherapy group • Changes on other effectiveness tests were similar in both groups • There were no serious adverse events in any group • Adherence to therapy was high in both groups (90% and 91%) • Consent rates were low; many did not want to participate in case they were assigned to the Wii group


System: Wii Fit; games: balance games, strength and light aerobic tasks Intervention: • 25-min sessions 5 times per week for duration of stay (average 12 d and 6 sessions) • Setup and operation of the Wii Fit program was performed by the treating physiotherapist, who provided close standby assistance • Games were played individually with the physiotherapist present Control: conventional physiotherapy to maximize functional mobility (walking and transfers), 25 min, 5/wk, but a mean of 8 sessions Outcomes: • Functional mobility, TUG test) • Balance and balance confidence • Physical function, activities of daily living, functional independence and healthrelated quality of life • Safety, adherence levels, eligibility, and consent rates


Laver et al27

Study

Table 1. Characteristics and Outcomes of Studies on Using Exergaming for Falls Prevention (Continued )

Systematic Review balance exercise programs12-15,20,21,26,27 and tai chi.12 In 3 studies, intervention consisted of video games combined with physical balance training compared with physical balance training alone.10,20,27 The exergaming system used in most studies was Nintendo Wii Fit balance platform, although 1 study used an equivalent commercial balance platform of a different brand.11 Two studies used a system with a dance pad controller.20,23 The majority of the studies used several games per session to achieve comprehensive balance exercises. The games used were available commercially and were not modified. In 1 study only the commercial game was modified to allow for control of the game speed.20 The outcome investigated most often was a dynamic balance control measured by the Berg Balance Scale. Other outcomes included parameters of gait, postural control, balance confidence, fear of falling, lower limb muscle strength, and level of physical activity. Validated score tests were generally used to measure outcomes. Some studies collected qualitative data on game enjoyment and motivation to perform VR exercises. The following outcomes were observed: (1) Compared with the baseline, postintervention balance and postural control parameters improved significantly in 12 studies,10,11,15-20,25-27 and did not improve in 7 studies.6,12,14,22,28,29 (2) In 5 randomized trials with active controls, game-based balance training resulted in similar improvements in balance scores as physical balance training.12,14,21,26,27 (3) In 3 randomized trials, the combined effect of physical balance training and video games had a stronger effect on improvement of balance scores than physical balance training alone.10,20,27 (4) Balance confidence had mixed outcomes, improving in 1 study23 and not improving in another.24 (5) Fear of falling improved in 1 study.13 (6) Gait parameters improved in 5 studies. Improvements were seen in subjects who were balance impaired16 and not impaired.20,21,23 In 1 study that compared the 2 groups, the gait score improved only in the group of balance-unimpaired subjects and did not improve in balance-impaired subjects.18 Single studies showed no improvements in the gait parameters17 and significant improvements in lower limb muscle strength29 and level of physical activity.28 (7) Participants reported that they enjoyed the games,11,14,16,19 were motivated to play,11,29 preferred gaming over traditional exercises,14 and had a possible improvement in the quality of life.19

DISCUSSION Evidence of Effectiveness The majority of the studies, investigating the use of VR gaming for balance training in older adults, generally showed a positive effect on balance control, although some showed a positive effect on balance confidence and gait parameters. The effect was seen not only across the spectrum of older adult populations, including those living independently in


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Systematic Review the community and in a retirement setting, both with and without balance impairment, but also in the middle-aged population and the hospitalized frail older adults. In studies that did not show improvements, no clear association could be seen between lack of improvement and design of the study, its sample size, or duration of intervention. However, definitive conclusions about the benefits of the interventions could not be drawn due to the methodological limitation of the studies. The most common limitations were as follows: (1) With the lack of a control group in many of the studies, it is difficult to claim conclusively that changes in balance and gait occurred as a result of the Wii Fit intervention. (2) Studies that used another active intervention as a comparison were not powered to detect differences between the groups conclusively. (3) The relatively short-term duration of follow-up did not enable assessment of the permanence of improvement with the continuing intervention, or whether there is any dose–response effect. (4) With 1 exception, study samples were self-selected and may not be representative of the entire spectrum of older adults. (5) In all studies but 1, the exercises were carried out under supervision and often participants attended sessions in a research setting. It is not clear whether the outcomes would be similar if the exercises were performed at home without supervision.

Safety Issues Only 3 studies investigated safety as a separate outcome. These studies reported no adverse effects from playing video games.23,27,29 However, all studies included in this review provided supervision during individual exercises or exercise leaders for group exercises. Therefore, it is not clear whether it is safe for senior adults, especially those with a balance problem, to engage in unsupervised exergaming at home. The Wii Fit board is quite narrow (50 cm × 25 cm × 5 cm) and may pose a fall risk by itself, especially for an older adult with a balance problem and slower reaction times. However, a gradual introduction of exergaming in community centers, under supervision, may overcome these problems. A gaming fitness program is an option for seniors with limited access to a therapist in an organized class for balance training. This would allow those isolated seniors to have benefits of a socially engaging exercise activity. Although ideally an exercise leader should be available to supervise the exercise form, isolated seniors at home could gradually learn to exercise with only periodic supervision and thus become more independent.21 Virtual gaming interventions may offer an opportunity to provide classes for older adults who find it challenging to access and participate in real-person, group falls intervention activities. The Wii Fit has the potential to address common barriers to exercise: availability of well-designed interventions, cost, transportation, boredom/discomfort, and preference for home-based interventions. The gaming platform also

allows remote observation of user performance, obtains objective data, and provides real-time feedback.30

User Satisfaction With Video Game-Based Balance Training and Participants’ Preference for the Therapy To fully utilize the opportunity that the Wii platform presents in balance training for older adults, appropriate games have to be made available. The existing Wii Fit software was not designed specifically to improve balance and reduce fear of falling in older adults. Many of the activities have fast paced, moving graphics that are not age-appropriate and that older adults find distracting. Furthermore, the options in exercise progression and game speed control are limited.30 These features have been noted as essential by older subjects,22 and may be explained by a difference in basic performance capabilities between young and older players. In a study that evaluated the performance in a stepping game on a DanceDance Revolution mat, results showed that above certain optimal speed, the performance of older adults decreased and the number of mistakes increased proportionally to increasing speed of the game.31 As the enjoyment of exercise is an important factor promoting adherence to the activity, the ability to adjust the speed and difficulty of the game to the varying fitness entry levels of older participants and to cope with their improving ability has to be built into the games. This enables the games to function as a therapeutic tool of balance training, and to avoid participants’ frustration and keep their involvement in games at a high level. Overall, there seems to be an indication that patients’ enjoyment of the game and the preferences for the therapy are age-related. Brumels et al32 found that when young adults aged 18 to 24 years participated in traditional and video-based therapy, a larger proportion of them perceived video-based games as enjoyable compared with traditional balance training programs (88% vs 63%, respectively). Kliem and Wiemeyer,26 who investigated a group of mixed age (18-67 years old), found that only 35% of participants enjoyed the Wii group therapy, whereas enjoyment in the traditional exercise group was 55%, similar to that of young adults from the Brumels and colleagues’ study.32 In a supplementary study to the Laver et al’s trial,27 in which older adults hospitalized in a geriatric rehabilitation unit were randomized to Wii Fit or traditional therapy, the patients from the Wii Fit arm of the trial underwent additional testing. Their preference for the Wii Fit and traditional therapy was measured before and after undergoing the therapy using discrete choice experiment. This technique is designed to remove bias from the measure. This study showed that patients, who initially did not have a preference for the therapy, developed a preference for traditional therapy and perceived it as more effective after undergoing the Wii Fit therapy. The reasons for the aversion, such as potentially the games being more suitable for a younger group, were not investigated.33 Interestingly, 175


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Systematic Review the patients’ perception of the effectiveness of the therapy was not correct, as the main study showed that the participants in the Wii group improved significantly more in the functional mobility and balance tests than in conventional physiotherapy group.27 Contrary to the results of the Laver et al’s study,33 all older participants of another study14 preferred the Wii training to the traditional one. However, these participants were not randomized to the therapy and were self-selected to participate in the Wii therapy by media advertising recruitment.

Gaps in Knowledge and Research Opportunities The area of research on using VR video games to improve balance control in older adults is rapidly developing. First, it is based on conventional intervention with a known effectiveness; improving balance by “live” balance training has strong evidence for reducing falls. Second, virtual technology and, consequently, better VR games that train balance are being developed for commercial reasons, independent of health or science funding. Although more research is needed, it seems to be only a question of scale. It is not unreasonable to expect that better evidence will soon become available, regardless of whether exergaming improves balance in a way that is comparable with live balance training. To critically appraise the Nintendo Wii and other commercially available video games as a tool in occupational therapy practice, future research must incorporate the following conditions: (2) therapeutic benefits have to be investigated in statistically powered studies with a rigorous study design (ie, control, random assignment to groups, blinding, sufficient duration of the intervention and followup, and intention-to-treat analysis); (2) diverse populations of participants should be investigated to identify those that may potentially benefit most from the intervention; and (3) different Nintendo Wii Fit balance games should be studied separately to identify their comparative potential effectiveness.

CONCLUSIONS There is as yet no evidence that using video games in balance training will prevent falls. However, there is an indication that it may improve balance indicators, which in turn may lead to falls prevention. It is apparent that the games used should be modified, or at least carefully selected, to suit an older population.

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