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 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
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 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.
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, 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 follow-up, 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.
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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Keywords:Copyright © 2014 the Section on Geriatrics of the American Physical Therapy Association
balance training; falls prevention; older adults; video games; virtual reality