A systematic review and meta-analysis to determine effectiveness of exergames for improving mobility and balance in older adults.

Exergames are effective and safe in improving the gait, functional mobility and postural balance associated with falls in older adults.

Systemic changes associated with aging causes various impairments in mobility and postural balance in older adults. Reduction in proprioceptive sense, decline in visual acuity and slowness in responses of center of mass are some instances of findings that combine, compromise dynamic and static balance, movement precision and dynamic balance. These series of events increases the risk of falls, which is the major health problem in older adults. Injuries related to falls are a leading cause of disability, increasing health care costs and death. It is estimated that approximately one-third of older adults (age ≥ 65 years) fall once a year and half of them are likely to fall again in the subsequent year. Also there occurs a variation in incidence of falls in various countries.  For instance, the percentage of falls in older adults each year is 34% in Chile, 22% in Barbados, 20% in Japan, and 6-31% in China.

The outcomes of falls reflect a reduction in quality of life and social interactions and physical impairments of older adults. Therefore, it is essential to maintain gait and balance adjustments for mobility and independence. A wide variety of interventions are developed to restore gait balance in older adults. Low adherence to physical activity and traditional exercise in older adults is also associated with lack of motivation, fear of injury and kinesiophobia. Most of the approaches for restoring balance and gait in older adults include the use of virtual reality (VR)-based exercises. Exergames is one of the most integral virtual reality (VR)-based exercises which involve self correction, gait and balance recovery, stimulation of executive function and multitask training. The user interacts with game scenario during exergames while stimulating psychological, sensorial and motor functions. Interactive and engaging form of exercise helps to improve adherence of exergames in older adults. It also helps to overcome various barriers of traditional exercise such as negative perception of exercise outcomes and lack of outcomes.

Several low cost and commercial exergames are available in healthcare settings for utility in older adults. An exergame named as Microsoft Xbox in Washington, USA uses motor control and kinetic sensors so that player succeeds in game if movements are performed appropriately. Another exergame named as Nintendo Wii in Kyoto, Japan uses exergame platform for balance training in older adults. A study demonstrated significant improvement in balance in Nintendo Wii users.

A variety of exergames have been developed for therapeutic purposes called as serious games in addition to the popularity of commercial exergames in rehabilitation settings. These exergame combine features which provide high concentration and immersion for greater involvement of participant, thereby creating a balance between challenges and skills and personal experiences. It also provides a state of perception of an individual’ needs for mastery, autonomy, arousal, connectedness, challenge, fun or fantasy. Some studies have reported the effect of exergaming on postural balance in older adults. Some evidences also reported the effectiveness of exergames in improving balance in neurological conditions when used as a supplement therapy for standard rehabilitation of stroke and Parkinson disease patients.

Several studies have been developed for older adults without neurological disorders but these studies yielded inconsistent results. An analysis reported the effects of exergames combined to other therapies on the Activities-Specific Balance Confidence (ABC), Falls Efficacy Scale (FES), and Timed Up and Go test (TUG). A latest study also described the exergaming effects on population of frail older adults.

Rationale behind research:

As evidenced from the previous studies there occurs variability and inconsistency in selection criteria in studies, therefore this systematic review was conducted to study the effects of exergame on older adults.

Objective:

The objective of present systematic review was to determine the effects of exergame on the balance and mobility in older adults without neurological conditions compared to no exercise or health education.

A systematic literature search was performed from MEDLINE, PEDro, EMBASE, INSPEC, CINAHL and Cochrane Central Register of Controlled Trials. Trial registries were also searched from ReBEC (http://www.ensaiosclinicos.gov.br), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization International Clinical Trials Registry Platform (www.who.int/trialsearch). PICO strategy was used to conduct search strategy. The search terms used were (“Older adult” OR senior OR elder OR elderly OR aged OR “older person” OR “older people” OR gerontological OR geriatric) AND (“Virtual reality” OR exergames OR “videogame” OR “video game” OR Wii OR Kinect OR “balance board”) AND (Mobility OR “physical disability” OR “physical function” OR “physical performance” OR balance OR gait OR motor OR walk OR dizziness OR vertigo OR posture OR postural OR “physical fitness” OR “physical health”). The reference lists of included trials and any relevant systematic reviews were searched for additional trials. Additional information on relevant trials were obtained by contacting experts and organizations.

Inclusion criteria

This systematic review included studies if they:

• Were randomized controlled trials
• Were conducted in women aged 60 and older and community-dwelling men
• Included older adults without neurological conditions such as stroke, Parkinson’s disease, peripheral neuropathies, or neuromuscular diseases
• Used exergames to improve mobility or balance in older adults
• Compared the effects of the exergames to no intervention or to health education, or cognitive exercises with no physical activity
• Reported mobility and/or balance measures as primary outcomes.

The studies which had combined conventional exercise and exergames in control or experimental group and were performed in long-term care facilities were excluded.

Study selection

The abstracts, titles, full-text articles and identified trials identified from search were independently screened by two review authors (TP and CM). A third review author resolved the disagreements. Duplicate trials and multiple reports of same trials were identified and excluded.

Data extraction

Information from included trials was extracted by authors and transferred into Review Manager 5.3. Using a sample of studies, the extracted data was piloted to identify any unclear or missing items. A standardized data extraction form was filled to record the following items: age (mean and range), sex,  authors, sample size, study duration,  method of recruitment, characteristics of the exergame, intervention duration,  comparability of groups, outcomes measures (balance and functional mobility), safety/adverse events,  adherence funding source and notable conflicts of interest.

Quality assessment

The quality assessment of pooled studies is essential as studies with a variety of methodological approaches and different study designs.  A validated and reproducible checklist approach was used for evaluation of selected studies as it was effective and feasible in distinguishing research studies with high precision and less bias. It also assigns a quality score assessment for each study.  This approach assessed the quality of studies using 14 questions for external and internal assessment and statistical analysis. One question accounted for prognostic factors who tailored to accommodate the requirements of study. A prognostic score was developed to balance indicators affecting outcome of T2D across exposure groups. Various prognostic scores were age, sex, body mass index (BMI), dyslipidemia, hypertension, RA duration, physical inactivity, family history of T2D and CV disease, and use of other medications such as cDMARDs, bDMARDs, folic acid and corticosteroids.

A score of 1 was given to study balancing ≥5 of these indicators whereas a score of 0.5 and 0 was given to study reporting 3 or 4 indicators and study with no evidence of any of these prognostic factors. After assigning scores to individual studies and critically reading of each study, the total points were added to obtain a Qi score. A Qi score of ≥10 was defined as a high-quality score whereas a score of ≤9 was defined as a low-quality score.

Statistical Analysis and Risk of Bias

Review Manager 5.3 was used to calculate effects of intervention. I² statistic and Chi² test within the forest plot was used to determine the heterogeneity of trials. Forest plots were used to determine the summary value for each study. The actual effects of intervention were evaluated using a random effect model.

The risk of bias was assessed using recommendations of the Cochrane Handbook for Systematic Reviews of Interventions by two independent researchers. Based on the sequence generation, blinding of participants,  blinding of outcome assessment, allocation concealment, selective outcome and other bias, the risk of bias was classified as “high,” “low,” or “unclear”.

Study outcomes

The primary outcomes of the study included assessment of:

• functional mobility measured using physical performance instruments such as the Functional Reach Test (FRT), the Short Physical Performance Battery (SPPB), the Functional Gait Assessment (FGA), the 30-s chair stand, the 8-ft up and go test, and the Timed Up and Go test (TUG)
• postural balance calculated using valid instruments such as Berg Balance Scale (BBS), Tinetti balance test, Activities-Specific Balance Confidence (ABC), Balance Master System and center of pressure (CoP) parameters assessed by force platform

The secondary outcomes included evaluation of:

• motivation using questionnaire or self-reported impression
• safety using self-reported impression
• adherence using questionnaire or self-report that described the level of adherence to virtual therapies
• adverse effects described in the studies including motion sickness, pain, injury, falls, and death
• quality of life using questionnaire or self-report

Outcomes

Study and participant characteristics:

• A total of 12 trials comparing exergames with no intervention were included after screening 822 records
• 1520 older adults were enrolled in study with a mean age of 76 ± 6 years for the experimental group and 76 ± 5 years for the control group
• The mean of time of exposure to exergames was calculated as 825 ± 342 min (number of sessions × duration of each session), ranging from 360 to 1440 min
• The mean number of sessions were calculated as 21 ± 10 varying from 8 to 48, and duration varied from 4 to 16 weeks

Effect of intervention on outcome:

• There were significant improvements in balance and mobility as calculated on the center of pressure sway, Berg Balance Scal and on Timed Up and Go test
• No adverse events of exergames were reported in this systematic review and meta-analysis
• Quantitative evaluation also described significant improvement in adherence, quality of life, motivation and enjoyment reported with the use of various exegames in different studies

The present systematic review determined the effectiveness of exergames in older adults with disturbances in balance and found that exergames can improve balance and mobility in older adults. Using exergames also helps to keep older adults physically active and prevents fragility and impair functional mobility associated with other conditions.

A study conducted using visual biofeedback and virtual exercises showed improvements in reaction time and functional abilities of older people due to the attention demand required in virtual environments. Sensorial perception is also increased in older adults when they interact using different game scenarios and the action-observation of the avatar movements provides sensorial perception. Therefore, multisensory approach using various components may help in better processing of sensory affordance to maintain balance.

A favorable evidence for maintaining balance was shown in a study conducted by Jogersan et al. The study findings were associated with challenging environments of posture in which older adults finds it difficult to control their CoP in multidirections. Sensitivity of exergames in integrating various sensory modalities necessary for balance was represented by favorable results for exergames in regard to Cop.

In this study, 58% of heterogeneity is observed with no overlap of confidence intervals in graph. BBS data also showed heterogeneity. Some significant differences have been reported related to baseline changes, unclear bias, high value in Chi² test and absence of overlap among confidence intervals which may lead to additional heterogeneity in effects of intervention and statistic among studies.

The study also evaluated mobility using TUG which found the positive effects of exergames in older adults. The risk of falls is lower in older adults which are able to complete TUG in less than 10 s. The International Functional Classification (ICF) domain “Activity and Participation” regarding gait independence presents the essentiality of maintaining a good timing for executing TUG. Exergames can also play a relevant role in gait as they are effective in recovering functional mobility as represented by TUG. Functional mobility is also essential for maintaining control in posture, transfers, gait and independence of carrying out daily activities. The consistent findings of present study related to heterogeneity in BBS and Cop & TUG represent the use of exergames as a good strategy to improve functional abilities, mobility and posture balance in older adults. Exergames also keep older adults active, with positive effects on motivation and physical activity enjoyment. It also improves adherence with no adverse events.