May 2015

Exergaming: therapeutic benefits in older adults

5exergaming-iStock20678158-copyIncreasing numbers of studies are suggesting that exergaming can help improve strength, balance, and other variables in older adults, but clinicians also need to be aware that some aspects of exergaming can present challenges in this patient population.

By Ying-Yu Chao, RN, GNP-BC, PhD

People older than 65 years in the US numbered 39.6 million in 2009 and accounted for about 12.9% of the population, a percentage that is expected to grow to 19% by 2030.1 A sedentary lifestyle is a common phenomenon among older adults.2 A systematic review, for example, found that approximately 60% of older adults reported sitting at least four hours daily, and more than 55 % reported watching television for more than two hours a day. Studies with objective measurements have found that 67% of older adults were sedentary for at least 8.5 hours a day.3

This type of sedentary behavior is associated with multiple adverse health outcomes, such as coronary heart disease, type 2 dia­betes, and certain types of cancer. It is also a significant risk factor for mortality. On the other hand, regular physical activity can reduce disease occurrence and symptoms, optimize physical and emotional health, maintain function, and improve quality of life.4 However, many older adults do not adhere to exercise over time because traditional repetitive motion exercises are often perceived as boring and not motivating.

Many older adults do not adhere to exercise over time because traditional repetitive motion exercises are often perceived as boring and not motivating.

Virtual reality has been defined as a computer-generated 3D interactive environment in which users can experience sensory information in much the same way as they would in the real world. Virtual reality technology is often designed around hierarchical tasks that can be delivered and titrated based on an individual’s interactive performance. Virtual reality also supports the precise capture of data related to complex responses, such as assessments of kinematics, speed, accuracy, timing, and consistency.

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Exergames, a type of virtual reality experience, are entertaining video games that combine game play with exercise. Exergame programs are designed to detect changes in direction, speed, and acceleration. They also offer visual and audio feedback, which may engage and motivate individuals to use the programs. Overall, exergames provide meaningful, enjoyable, and purposeful activities as an alternative to sedentary pastimes. As individuals engage in various gaming activities, therapists can evaluate their accomplishments in real time. In addition, exergames provide opportunities for social interaction and connections with peers and family members.5

A look at exergames

There are different types of exergames in the market. In recent years, researchers have used exergames to encourage older adults to engage in physical activity in the interest of improving their health.

Nintendo Wii. Nintendo Wii (eg, Wii Sports, Wii Fit) are popular accessible exergames that can be used in rehabilitation and long-term care settings. The gaming system offers different activity levels, and can be played while standing or sitting. Studies have reported that using Wii exergames is associated with improved cognition, balance, balance confidence, mobility, strength, flexibility, fitness, and health-related quality of life, as well as decreased anxiety and depression in older adults.6-11

One study, for example, compared Wii Fit exergame training with conventional physiotherapy in 44 hospitalized older adults (80% women) with a mean age of 85 years.12 There were no significant differences between groups, but multivariate analysis suggested the Wii Fit group improved more on the Timed Up and Go test compared with the conventional therapy group.12

Another small study looked at use of the Wii Fit in residents of community care retirement facilities.13 Seven older adults (mean age 84 years) with impaired balance showed significantly improved balance and increased walking speed after playing four exergames (basic step, soccer heading, ski slalom, table tilt) for at least 30 minutes, three times per week, for three months.13

Esculier et al published a study in 2012 in which 10 participants with moderate Parkinson disease and eight healthy older adults used a Nintendo Wii Fit and balance board at home for approximately 40 minutes a day, three days per week, for six weeks. They recorded measures of balance, mobility, and function at baseline and after three and six weeks of training. At six weeks, the participants with Parkinson disease significantly improved from baseline on measures on static and dynamic balance, mobility, and functional abilities.14

A noted limitation is that Wii exergames are not sensitive enough to measure certain levels of functional ability. In other words, older individuals may not be able to move fast enough for some of the gaming activities, which may lead the system to give negative auditory and visual feedback.10

Interactive video dance games. Interactive video dance games (eg, Dance Town, Dance Dance Revolution) require players to make rapid step responses to a randomly presented visual stimulus, sometimes using a dance pad on the floor marked with directional arrows.

A 2010 study of 25 healthy older adults (mean age 80.1 ± 5.4 years, 83% women) in senior living settings showed that three months of using video dance games was associated with gains in balance (narrow walk time), self-reported balance confidence, and mental health.15 A randomized controlled trial16 of 22 older adults (mean age 86.2 ± 4.6 years, 82% women) living in a hostel for the elderly in Switzerland placed the seniors into two groups. Both groups received twice-weekly, 40-minute sessions of progressive balance and strength training, while the dance group supplemented this training with 10 to 15 minutes of dance video gaming. Those in the dance group had significant improvements on fast walking performance (velocity, double support time, step length) compared with those who did progressive strength and balance training alone.16

Despite these noted improvements, it’s important to note that older adults often have challenges with fast-paced music, frequent jumping, and screens overloaded with color and information. For example, older players often decrease stepping performance on dance games’ fast stimulus speed due to physical changes they have experienced with aging.17

Sony PlayStation 2 Eye Toy. The Sony PlayStation 2 Eye Toy uses computer vision and gesture recognition to process images taken by a webcam-like camera. The camera and built-in microphone allow users to play games using their body movements and sounds.

Researchers have reported that in older adults the gaming system enhances sensorimotor function, balance, postural control, mobility, and functional gait abilities and decreases depressive symptoms.18,19 Researchers have also reported limitations with the Eye Toy in its response to players with severely involved motor impairments; one study, for example, found that players with severe hand mobility problems could not interact with the system.20

Our research team developed an intervention incorporating self-efficacy theory into an exergaming program for residents of assisted living facilities.

Microsoft Kinect. The Microsoft Kinect (XBox One, XBox 360) is a motion-sensing input device that allows users to control and interact with the device through gestures and spoken commands.21 The Kinect delivers adaptable stepping exercises and simultaneously measures step performance. The system has been used in older adults to improve balance, flexibility, strength, and endurance, with the aim of reducing fall risk and improving performance of daily activities.22,23

A recent pilot study evaluated the effect of an investigator-developed automated interactive exercise coaching system used with the Microsoft Kinect on bradykinesia in older adults with Parkinson disease. The coaching system guides users through a series of video exercises aimed at improving balance, flexibility, strength, and endurance. It tracks and measures their movements, provides real-time feedback, and records their performance over time. The investigators trained six participants to perform whole body reaching movements at different elevations in different directions. After training, participants had improvements in acceleration and movement speed.24

The Microsoft Kinect’s limitations include complex performance measures for older users, a lack of tracking accuracy in small exercise spaces, and small text on the screen.23

Literature reviews

The most common apparatus for exergaming interventions in the medical literature is the Nintendo Wii gaming system. A literature review10 found that the effects of Nintendo Wii exergames in older adults have been studied in different settings (hospitals, rehabilitation institutes, nursing homes, assisted living facilities, community care retirement facilities, and private homes) across different countries (Australia, Canada, Denmark, France, Singapore, the UK, and the US). The studies reported positive physical and psychological benefits, socialization, and motivation to exercise.10 However, there was great variation among study exercise protocols; among 20 reviewed studies, the frequency and duration of exergaming interventions varied from two- to 20-week programs done two to five times a week for 10 to 60 minutes per session.

Another systematic review25 examined 13 studies on the effects of exergames on physical function in older adults. Again, exergame protocols varied across the reviewed studies. The review found inconclusive evidence for the benefits of exergames for improving physical function in older adults.25

The transferability of skills from exergaming to real-world application is of major practical relevance. Most studies report the specific training effects, but few examine the transfer effects between different devices and different training modes.16,26 One recent study suggested that skills needed with one exergame are highly specific, and do not transfer to other exergames for different tasks.26 The authors postulated that the transferability of skills is associated with long-term and real-life experience. Further studies are needed to clarify the transferability of skills from exergaming to real-world applications.26

Our research

Exergames offer a venue to help increase exercise and exercise adherence of older adults. An individual’s self-efficacy is associated with his or her motivation to perform a specific task, and individuals with higher exercise self-efficacy commit to and engage more in exercise.27 Researchers have suggested that interventions based on self-efficacy theory may be the most effective way to change exercise behavior in older adults.28 Hence, our research team designed and developed an intervention incorporating self-efficacy theory into a Wii Fit exercise program to encourage assisted living residents to engage in exercise.

In our intervention, which was utilized in two pilot studies, we used four strategies of self-efficacy theory to enhance participants’ exercise self-efficacy, including enactive mastery experiences (eg, goal setting, discussion of performance and progress), vicarious experiences (eg, role modeling, storytelling), verbal persuasion (eg, education, support, encouragement), and physiological and affective feedback (eg, monitoring emotional and physical burden, managing discomfort). We also distributed an exercise-related poster and health education booklet to each participant. The health education topics included the benefits of exercise, how to get started with exercising, safety issues, and how to stay active.29 We discussed each topic with participants at each session.

We used six Wii Fit gaming activities—jogging, lunge, penguin slide, table tilt, chair, and deep breathing—involving four types of exercise in the program. The intervention was designed to take about 30 minutes per session. Participants were paired and took turns playing games against each other. The actual game difficulty levels and time spent depended on each individual’s physical tolerance and performance. A walker was placed around the Wii balance board for stability.

One of our pilot studies implemented a twice-weekly, eight-week supervised intervention among seven residents in an assisted living facility. After eight weeks, participants demonstrated statistically significant improvement in balance, and improvement trends for cognition, mobility, walking endurance, and fear of falling.30,31

Another pilot study implemented the intervention twice a week for four weeks in 32 participants in two different assisted living facilities. We compared the effects of the Wii Fit group with those of a group whose intervention included only education. Wii Fit participants had significant improvements in balance, mobility, and depression after the four-week intervention; in comparison there was no significant improvement in any of the assessed outcomes in the education group. At baseline, there were no significant between-group differences for any of the outcome measures. However, at post-test, there was a significant difference between groups for the Short Form 8 (SF-8) mental-health related quality of life subset (p < .05).32

Differences in the diagnoses and overall condition between the groups of older adults in the two pilot studies are the likely reasons for the greater mobility improvements seen in participants in the four-week program.

We conducted studies in only three assisted living facilities, so our results cannot be generalized to all older adults. Overall, the exergaming interventions showed promise as a potential tool to improve and maintain physical and psychosocial health for older adults. During the study period, we often saw participants talking about their performance and comparing their scores. They were extremely happy when they achieved top scores. On the other hand, some participants felt upset when they did not perform well. Most participants said they enjoyed exergaming and would like to continue to use it to exercise after the study’s end. A couple of participants suggested to the facility administrator that the exergames should be continued in the facility. However, two participants thought that exergames were more like games, not exercise, and said they would prefer to do other types of exercise, such as walking.

Implications

There are advantages and disadvantages associated with different types of exergames. Researchers and healthcare providers should recognize the benefits and limitations of each exergaming system in order to choose the most appropriate device for senior players. For example, older adults with visual impairments may not be suitable to play games with fast-moving images (eg, snowboarding, skiing).

In addition, appropriate instructions and encouragement should be given to those with certain levels of physical impairment (eg, survivors of stroke and traumatic brain injury, those with Parkinson disease) to offset negative performance feedback from exergaming systems. In our pilot studies, for example, it was unsafe for some older, physically impaired adults to stand and move on the balance board, and to ensure safety, participants held onto a walker while playing games.

Another consideration is that some features of current exergames (eg, small fonts, distractingly colorful images, complex menu structures) may have a negative effect on the gaming experience of senior players. Hence, designing and inventing senior-friendly exergames will be important for making gaming activities more user-friendly for older adults.

Future studies should include evaluations of different exergaming systems, implementation of different gaming activities for older adults who require different levels of care and assisted living, randomized controlled trials with larger sample sizes, longitudinal studies, and the use of theoretical frameworks (eg, self-efficacy theory, self-determination theory, behavioral inoculation theory) to provide stronger scientific evidence on which to base clinical interventions.10

Ying-Yu Chao, RN, GNP-BC, PhD, is a clinical assistant professor in the Division of Nursing Science at Rutgers University—Newark in New Jersey.

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