The aim of this systematic review was to explore whether exergaming is a safe, feasible and effective rehabilitation tool for people with PD. Exergaming as a method of rehabilitation for people with PD is still very novel, as seen by the small number of studies included in this review. These preliminary studies indicate that exergaming is feasible for PD however games may need to be tailored towards specific clinical populations, and safety and feasibility as a home-based rehabilitation tool is yet to be fully established.
More evidence is needed regarding the safety of people with PD playing exergames before it can be recommended for wide spread clinical use, particularly in home-based settings. For this reason, we recommend future studies report both objective and subjective measures of safety. Importantly, six of the seven studies we reviewed used the Nintendo Wii and Wii fit balance board [19–24]. The Wii fit is a raised platform and so may present a trip risk for people with PD, particularly when they are focused on the television screen. New commercial exergaming systems are now available, such as the XBOX Kinect™, that do not require a raised platform. Using these systems may improve the safety of exergaming for people with PD, however this remains to be tested, as does the clinical efficacy of these new exergaming systems.
Three studies reported improvement in gameplay performance in PD participants using commercial Nintendo Wii exergames [20–24], suggesting commercial games are feasible. Two studies that sought participant feedback about gameplay and reported that people with PD enjoyed playing the games and were motivated to play them [19, 25]. Despite these promising results and the potential of commercial exergames as a means of low-cost home-based exercise, there is concern that the commercial games are too difficult for some people with PD . This reflects the need for appropriate game selection and design. A key advantage of exergames is that they can provide immediate biofeedback of performance. This is a useful attribute that may be exploited to improve motor learning in people with PD, especially given their increased reliance on visual cues. Setting an appropriate threshold of difficulty is essential. If feedback is too negative, for example when playing games that are too fast or complex, motivation, adherence and safety may suffer. This was particularly highlighted when Mendes et al. assessed motor and cognitive ability of game play using the Nintendo Wii for PD and healthy elderly adults , and showed that PD participants failed to improve on games that required fast decision making and movements to avoid virtual obstacles.
Of the reviewed papers, Assad and colleagues were the only authors to design their own exergame specifically tailored towards people with PD (WuppDi) . Five games were developed to rehabilitate upper body movements and elements of cognition. Games were played, either with a hand held marker (wooden stick) or with no markers. The results showed that the majority of the participants enjoyed the experience and gained positive feedback from playing the games, and would enjoy playing with others especially their grandchildren. However, the authors noted some of the games were too complex and needed to be made easier for people with PD. Some participants also had difficulty with the hand held controllers. Hand held devoices may not be appropriate for people with severe tremor or dyskinesia who could find it difficult to keep a hold of and manipulate the controller.
There is also little known regarding the efficacy of exergaming as compared to traditional rehabilitation. Pompeu et al. has conducted the only randomised controlled trial of exergaming for people with PD . The findings of the study suggest that 14 sessions (over 7 weeks) of playing the Nintendo Wii™ can improve clinical measures of balance to the same extent as traditional balance training in people with PD. A potential confounder to this study was that participants in both groups also received stretching, strengthening and axial mobility exercises before each session. As such, it is difficult to conclude whether changes in the clinical tests can be ascribed to the balance training (either traditional or exergaming). Bateni found similar results when analysing the effects of the Wii on balance in healthy elderly adults, in that a combination of the Wii and standard balance training had the greatest improvement in balance outcomes at post test compared to Wii or balance training alone . Therefore, it is possible that exergaming may be more useful for PD as an adjunct to standard clinical treatment than as a stand alone intervention.
Six of the seven studies examined whether people with PD improved on clinical tests after an exergaming intervention [19–24]. All six showed that people with PD improved on various clinical measures of balance (Berg balance score, single leg stand, functional reach test), motor function (Sit to stand, Timed up and go, 10 m walk, timed tapping) and severity of PD motor symptoms (UPDRS II). Two of these studies also showed that improvements in clinical tests were retained 60 days after the intervention [20, 21]. With Hertz et al. showing improvements were attained 4 weeks post intervention for PDQ-39 ADL and emotion, and motor scores for UPDRS . These results indicate that exergaming may be effective for the rehabilitation of motor and balance symptoms in people with PD. However, more rigorous research designs need to be adopted in future trials to confirm whether improvements in these tests are clinically meaningful and are not due to increased familiarity with the clinical tests.
One of the potential benefits of exergaming interventions is that they can be administered in the home . Although not formally tested, the resources required for exergaming are likely to be less than those required by formal rehabilitation services. To date, there has only been one home-based exergaming intervention reported in people with PD . The authors were able to show that people with PD improved on several clinical tests and on gameplay over the 6 week training period. Questions remain, however, whether home-based exergaming interventions are safe and as effective as traditional clinic based interventions for people with PD.
We included only full articles in this review, which resulted in the exclusion of two relevant abstracts relating to exergaming and PD [30, 31]. Dos Santos et al., showed that 14 sessions of dance based exergaming using a balance board resulted in improved balance and reduced motor symptoms (UPDRS) in people with PD . Alvarez et al. trained 12 people with PD using three commercial XBOX Kinect™ games. Twenty-four sessions over eight weeks resulted in improvements in the UPDRS (II&III) and Tinetti scale for gait and balance . Another limitation of this review was the heterogeneity of the different exergames included in each intervention limited our ability to distinguish which particular games, and which aspects of those games, are useful for rehabilitation of specific symptoms in PD.
This systematic review indicates that exergaming appears feasible for people with PD, however it also highlights the current paucity of evidence for exergaming as a rehabilitation tool. The studies we reviewed adopted relatively weak designs and small sample sizes. As such, we can not state with confidence whether or not exergaming is a safe and effective rehabilitation tool until larger randomised controlled trails are conducted, especially in a home-based setting. In addition, exergaming has only been tested in people with mild PD. To address these concerns, we recommend that large, robust randomised controlled trials be conducted in order to establish the safety and effectiveness of exergaming for rehabilitation in people with PD with a range of disease severity. In addition, to facilitate future reviews and meta-analysis of exergaming in PD we recommend i) future studies should report standard measures of disease severity (Hoehn and Yahr, and UPDRS III), medication status (levodopa equivalent daily dosage) and cognitive status (MMSE or MoCA); and ii) objective and subjective measures of safety, and the participants’ ability to play the games should be reported.
This review has also identified several important considerations when designing games for people with PD. To improve the effectiveness and adherence to exergaming interventions in people with PD, we recommend games designed for PD should: i) target specific clinical features of PD; ii) be easier than commercial games; iii) avoid negative feedback; iv) include very clear instructions and goals; iv) introduce cognitively demanding aspects slowly and sparingly; and v) examine the use of new exergaming systems that do not require balance platforms or handheld controller.