Seven trials compared AVGs with no intervention25,30,33,36–38 or usual care32; 5 trials compared AVGs with conventional exercise (ie, strength, balance, mobility, and/or balance exercises that did not use video game technology)28,29,31,35,39 and 3 trials compared AVGs with both conventional exercise and a no intervention control.26,34,40 The remaining trial compared AVGs with a placebo shoe insole.27
Risk of Bias
Four of the 18 trials were assessed as low risk of bias across 3 or more of the 6 items assessed.27,28,38,39 The remainder had 4 or more items assessed as either high or unclear risk because there was insufficient information reported for evaluation (Table 2).23–26,30–32,33–37,40
For all outcomes analyzed, there was no indication that outcome measures were influenced either positively or negatively by the risk of bias scores.
The duration of AVG programs for community dwellers was 3 to 20 weeks, with most offered for 8 weeks, usually 2 to 3 times weekly for approximately 40 minutes each session. For hospitalized older people, the program ran daily for the duration of the patient's stay (usually 7 days).
With the exception of 1 trial, delivered in the home environment,38 all trials were supervised programs conducted in a gymnasium or research center setting. Most were delivered on an individual basis, although 2 trials used either game play with a partner30 or in small groups.31
Eleven trials used Nintendo Wii,23,24,26–30,34–36,40 5 used pressure-sensitive mat systems,25,31,33,38,39 1 used the Kinect motion sensor,37 and the remaining trial used a virtual reality head set.32
The focus of all trials except 130 was to improve balance. Nine trials used solely AVGs.23–25,28,30,34,37–39 Eight trials combined the AVGs with conventional exercise to develop balance, strength, or aerobic capacity.26,27,29,31–33,35,36 One 3-arm trial compared AVGs alone with exercise alone and a third intervention group that combined AVGs with exercise.40
There was no clear indication that trials that combined exercise and AVGs programs had better or worse outcomes and trials that used AVGs alone.
Participants were mostly community-dwelling older people. The exception was 1 trial conducted in an acute hospital setting,28 and 2 trials that recruited from care homes.31,33 The average age of community-dwelling participants was 75.6 (6.9) years (n = 675) and of hospitalized or nursing home older participants was 85.3 (4.5) years (n = 90).
Inclusion and Exclusion Criteria
Thirteen trials limited inclusion to higher functioning older people24–26,30,31,33–38,40 (ie, those with no major cardiovascular, neuromuscular, or vestibular impairments, who were independent in ambulatory function). Three trials targeted people with balance limitations or falls risk.27,32,39 One trial did not report exclusion criteria29 and the remaining trial recruited hospitalized older people.28
Twelve trials excluded those with cognitive impairment.24–26,28,31–34,37–40 Cognitive impairment was not specified as an exclusion criterion in 1 trial, but baseline cognitive scores indicated normal cognition for all participants.24 Cognitive status was not specified in the remaining 5 trials.23,27,29,35,36
Physical Performance (Mobility) Measures
Changes in physical performance measures were assessed in 10 trials.23,25,27,28,30,34–36,38,39 The most frequently used mobility measure was the Timed Up and Go (TUG)41 and its modification, the 8-ft Up and Go.42 Seven trials used the TUG23,25,27,28,34,38,39 and 3 trials used the 8-ft Up and Go.30,35,36
One trial43 used the Short Physical Performance Battery44 and 2 trials30,35 used the Senior Fitness Test, which includes the 30-second chair stand test.45
The mean baseline TUG score for trials that used this measure was 10.3 (4.1) seconds (n = 169),23,25,27,34,38 which was within the expected range of 7 to 15 seconds for healthy older people.46,47 The mean baseline 8-ft TUG score was 7.9 (1.6) seconds (n = 159)30,36 which was also within the normal range for healthy older people.48 In participants with balance and mobility limitations, baseline TUG scores were higher (20.9 (3.5) seconds; n = 30)39 and in the only inpatient-based study,28 baseline TUG group means were considerably higher (36.7 (18.7) seconds; n = 44).
A meta-analysis on pooled TUG scores from 6 trials (n = 206) that compared AVGs with conventional exercise or no intervention failed to reach significance (REM, MD = −2.29; 95% CI, −5.20 to 0.64).
A meta-analysis on pooled 30-second chair stand scores from 4 trials (n = 188)27,30,35,37 showed a significant effect in favor of AVGs (REM, MD = 3.99; 95% CI, 1.92-6.05) (Figure 2). No significant effect was found for the 5 times sit-to-stand used in 1 trial.38
Changes in direct measures of balance were assessed in 5 trials.24,25,32,34,35 Two trials reported significant within-group differences in center of pressure (COP) in the intervention group,24,25 but no significant difference between intervention and control (no intervention) groups. The 3 trials that compared AVGs with conventional exercise reported significant within-group differences in COP34,35 and limits of stability32,35 measures for both AVG and conventional exercise groups, but no significant difference between groups for COP measures. This suggests AVGs were as effective as conventional exercise at improving COP measures.32,34,35
Finally, 2 trials measured stepping reaction time in response to visual cues.33,38 Both reported significant between-group differences in favor of AVGs over the control group.
Indirect measures of balance, including 1 legged standing, the forward reach test, the Berg Balance Scale (BBS),49 and the Tinetti Performance-Oriented Mobility Assessment (the Tinetti POMA),50 were assessed in 9 trials.23,25,26,28,34,36,37,39,40 Five trials used the BBS,23,25,26,37,39 1 used a modified BBS,28 and 3 used versions of the Tinetti POMA.26,34,40
The mean baseline BBS score for trials that used this measure was 51.7 (5.2) points (n = 126),23,25,26,37 or for trials that used the Tinetti POMA,23,34 the mean baseline score was 26.4 (0.9) points (n = 72) indicating normal balance.50,51 For participants with limited balance and mobility, baseline BBS scores were in the low to medium fall risk category (range 37-42 points).39
Mean BBS scores from 3 trials in community-dwelling participants25,26,37 (n = 105) that compared AVGs with no intervention on BBS scores were pooled for meta-analyses (Figure 3). A significant difference in favor of AVGs over no intervention was demonstrated (MD = 0.73; 95% CI, 0.17-1.29). Pooled data (n = 49) that compared active video game BBS scores with conventional exercise26,39 also showed an effect in favor of AVGs (MD = 4.33; 95% CI, 2.93-5.73) (Figure 2). In addition, Laver et al28 also reported a significant improvement in the modified BBS scores in hospitalized inpatients in favor of AVGs compared with conventional exercise (MD = 0.59; 95% CI, 0.02-1.16).
For trials that used the Tinetti POMA, no significant between-group changes in balance scores were reported.26,34,40
Other individual item balance measures used were the single-legged stance25,34 and the forward reach test.23,34,37 One trial reported a significant change in the forward reach score for the AVG group over the control,37 but no significant findings were reported for the single-legged stance.
Self-Report Balance Confidence Measures
Three trials used the Activities-Specific Balance Confidence Scale28,36,39 and 5 trials used a Falls Efficacy Scale (FES).25,27,31,34,38
Significant change scores in favor of the AVGs were reported for the Activities-Specific Balance Confidence Scale in 236,39 of the 3 trials.28
Differences in study participants and variation in a FES used precluded combined analyses of the subjective balance measures. Of the 5 trials that used an FES, 2 showed significant between-group differences favoring AVGs25,27 and 3 showed no significant differences between groups.31,34,38
Two trials monitored adverse events.28,38 Of these, 1 reported adverse events that were minor in nature (musculoskeletal strain, feeling giddy) and occurred in both control (conventional exercise) and intervention groups.28
Trial Completion and Program Adherence Rates
Trial completion rate was defined as the number of participants who completed the trial. The median trial completion rate was 89% (interquartile range, 80-100).
Program adherence was defined as the percentage of prescribed exercise sessions completed over the program duration. For the 10 trials that reported program adherence, the range was 77% to 100% in the intervention (AVG) group and 87% to 100% in the control group,26,27,30–34,37,38,43 which is at the higher end of previously reported adherence rates for exercise RCTs.52 On the basis of the reported reasons for participant dropouts, there was no indication that completion or adherence rates were associated with any dislike of the intervention (AVG) itself.
Five trials evaluated participants' perceptions of game appeal.26,27,30,38,43 Of these, 4 reported positive feedback, noting that participants found AVGs to be motivating and enjoyable,27,38 manageable and comparable or preferable to other physical activity.26,30 The fifth trial, which used hospital inpatients,28,43 reported no strong preference for the way in which their therapy was delivered before therapy commencement. However, after using the AVGs, respondents reported a preference for conventional therapy, citing they felt it to be more effective, despite having not received the other approach.43
This review included 18 RCTs that compared AVGs with conventional exercise or with no intervention or usual care in older people. Active video games were found to be more effective than conventional exercise and no intervention for improving balance (BBS) and mobility (30-second sit to stand) in community-dwelling older people. In addition, the only trial that enrolled hospitalized older people reported that AVGs were more effective at improving balance and mobility scores when compared with conventional rehabilitation.
Strengths and Limitations
This is the first systematic review of AVGs that has included a meta-analysis of RCTs for improving physical performance measures in older people. Limitations of this review include the relatively high risk of bias scores of some of the trials included in the meta-analysis. The diversity in trial design and outcome measures limited the extent to which study results could be pooled. To minimize this heterogeneity, only studies with the same outcome measures were pooled. For this reason analyses were undertaken on a small number of studies, which increased the CIs for pooled data. Furthermore, the conservative assumptions made for pooled data regarding standard deviations may have influenced the calculated effect size effects.
Participant eligibility criteria of included trials were strict, with exclusion of people with cognitive impairment and mobility limitations, with the exception of 1 trial in an acute hospital environment.28 Because of this, it is unclear whether AVGs are equally suitable for older people with significant cognitive impairments or with balance or mobility limitations.
Interestingly, the high baseline mobility and balance scores of participants in some trials might have masked clinically relevant improvements that may be seen in a more mobility-limited group of older people. Although the improvement in BBS scores for AVGs compared with conventional exercise shown in the meta-analyses was above the 4-point change considered clinically meaningful,53 some trials noted that participants scored near the ceiling of the baseline balance tests, making it difficult to measure improvement.26,27,34
Program Usability and Safety
With the exception of 1 trial conducted in the home environment,38 game play was supervised and offered to individuals rather than groups. Whether participants other than high-functioning individuals could manage the AVGs without supervision has not been adequately explored. Nevertheless, there were few adverse events reported, suggesting the AVGs are safe when supervised.
The program adherence rates were good, but the intervention durations were short. Hence, the high adherence was likely related to the novelty factor; and the sustained effect of AVG use is unclear.
In terms of game appeal, community dwellers enjoyed the games. However, the hospitalized older people who received AVGs reported a preference for conventional therapy.43 This variance of opinion may be due to both an older person's perception of using AVGs for rehabilitation, and the suitability of the game for the older person, in terms of the visual display and the ease of use of the control devices. Some trials modified the AVGs to suit the older person, in terms of reduction of onscreen information, selection of age-appropriate music, and speed of play.31,37,54 Future development of AVGs for older people may need to consider these aspects of game play.
Lastly, whether AVGs can be used with groups rather than individuals requires investigation. Environments such as care homes do not always have the capacity to supervise individual exercise programs. On this basis, AVGs may be unsuitable for a group exercise program, unless combined with other activities as part of an activity circuit.
Active video games are a useful intervention for improving physical performance measures of balance and mobility in older people. Future work may consider monitoring adherence to an AVG program combined with conventional exercise, offered over longer period (12 months), to older people with a broader range of physical and cognitive abilities.
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Keywords:© 2018 Academy of Geriatric Physical Therapy, APTA
aged; exercise; older adult; video games