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Virtual reality using games for improving physical functioning in older adults: a systematic review
Journal of NeuroEngineering and Rehabilitationvolume 11, Article number: 156 (2014)
The use of virtual reality through exergames or active video game, i.e. a new form of interactive gaming, as a complementary tool in rehabilitation has been a frequent focus in research and clinical practice in the last few years. However, evidence of their effectiveness is scarce in the older population. This review aim to provide a summary of the effects of exergames in improving physical functioning in older adults. A search for randomized controlled trials was performed in the databases EMBASE, MEDLINE, PsyInfo, Cochrane data base, PEDro and ISI Web of Knowledge. Results from the included studies were analyzed through a critical review and methodological quality by the PEDro scale. Thirteen studies were included in the review. The most common apparatus for exergames intervention was the Nintendo Wii gaming console (8 studies), followed by computers games, Dance video game with pad (two studies each) and only one study with the Balance Rehabilitation Unit. The Timed Up and Go was the most frequently used instrument to assess physical functioning (7 studies). According to the PEDro scale, most of the studies presented methodological problems, with a high proportion of scores below 5 points (8 studies). The exergames protocols and their duration varied widely, and the benefits for physical function in older people remain inconclusive. However, a consensus between studies is the positive motivational aspect that the use of exergames provides. Further studies are needed in order to achieve better methodological quality, external validity and provide stronger scientific evidence.
The use of virtual reality (VR) using interactive games, as a complementary tool in rehabilitation has been a frequent focus of research since the late 1990′s, with a considerable increase in the number of publications in the last few years . VR makes it possible to practice activities within enriched, secure and challenging environments, thereby favoring motor learning and neural plasticity [1, 2]. In addition, it is considered to be a feasible strategy for intervention and an alternative complement to conventional exercises .
Exercise is well recognized as a beneficial intervention to enhance physical functioning in older adults, ultimately improving overall health . Some studies suggest that exercise using VR in elderly patients promotes improvements in mobility [5, 6], in muscular strength of the lower limbs , in cognition, mainly of executive functions , in balance control [1, 8–11], in reaction time  and also helps to prevent falls [1, 12, 13]. Although these studies might be compelling, there is not enough evidence to support that exercises using VR would promote better or even similar improvements in physical functioning, when compared with regular exercise programs.
Older people present diminished mobility and balance control as a result of morphological and functional changes in the central and peripheral nervous system related to age , to the presence of illnesses and to disuse. In order to overcome these negative changes, challenging, intensive and repetitive motor training through specific therapeutic exercises, such as those involving multi-segment coordination, anticipatory postural adjustments and tasks with divided attention can be used to enhance neuroplasticity [15, 16]. However the use of exergaming could optimize motor learning by combining physical and cognitive demands in an attractive and interactive way, motivating players to focus their attention not on the movements itself, but on the outcome of the movements in the game [2, 17].
There is a greater interest in the use of VR for therapeutic purposes [14, 17–25]. Systematic reviews concerning VR have been carried out in populations with specific health conditions, such as post-stroke patients and those with balance disturbances or falls [18, 20, 22–24], within different therapeutic settings  and in samples covering a range of age groups [14, 17]. Minor or inconclusive positive improvements have been demonstrated with the use of VR in individual studies. However, systematic reviews reveal notable lack of significant methodological quality studies and reinforce that there is insufficient information to recommend interventions with exercise using VR [14, 21]. Particularly, the evidence is scarce regarding the efficacy and effectiveness of using VR through games, on an isolated basis or in addition to conventional motor therapies in the older population. Thus, the aim of this systematic review is to investigate the effectiveness of exercises using interactive games (exergames) in improving physical functioning in older adults.
To verify the range of publications on interventions through exercises using VR games in older people, searches were made on the following data bases: EMBASE, MEDLINE, PsyInfo, Cochrane data base, PEDro and ISI Web of Knowledge. Four thematic blocks were used with a series of synonyms and variants related to 1) virtual reality with games, 2) exercises/physiotherapy, 3) aged and 4) randomized clinical trial. The words in a single block were combined among themselves with the use of the OR boolean operator and the interaction between blocks with the AND operator, in accordance with the example: ((user-computer interface) OR (computers or microcomputers or computer systems or software) OR (computer simulation or computer-assisted instruction or therapy computer-assisted) OR (computer graphics or video games or touch) OR (virtual reality* or virtual-reality* or VR) OR (computer game* or computer interact*) OR (computer assist* therap* or computer assist* treat*) OR (computer generat* environment* or computer generat* object) OR (video game*) OR (haptics or haptic device*) OR (user computer interface)) AND ((exercise) OR (exercise movement techniques) OR (exercise therapy) OR (biofeedback) OR (exercis* or training or biofeedback ) OR (physical fitness) OR (exercise tolerance) OR (sports) OR (physical endurance) OR (exertion*) OR (exercis*) OR (sport*) OR (physical fitness or motion fitness or physical therap*) OR (physical* endur*) OR (strength* or isometric* or isotonic* or isokinetic* or aerobic* or endurance or weight*) OR (train*) OR (physical therapy modalities) OR (physiotherap*) OR (kinesiotherap*) OR (rehabilitation or rehab*) OR (resistance training) OR (exercis* or training)) AND ((older adult or older people or older person* or elderly or seniors or geriatric or frail or aged)) AND ((randomized controlled trial*) or (controlled clinical trial) or (random allocation) or (double-blind method) or (single-blind method) or (clinical trial) or (placebo) or (random*) or (blind*)).
The search was conducted from July to October 2013 being limited to scientific articles and with no restrictions regarding language and publication year. In addition, a manual search was carried out to complement the strategy of looking up research on the topic.
This review included randomized controlled clinical trials with a sample of older adults (≥60 years old) and main intervention of VR with physical exercises by way of interactive games that aimed at rehabilitation. The VR exergames treatment could be on an isolated basis or combined with other interventions. For comparison, the control could be either with no intervention or conventional treatment (physical exercises, functional training or education). To be considered a game was necessary to fill out at least some of the following characteristics: interactivity, entertainment, rules, presence of an opponent or the objective to win points, and the possibility of winning or losing.
Studies were excluded if they had only cognitive outcomes, samples composed of participants with specific clinical conditions (i.e. stroke, Parkinson, dementias, diabetes mellitus, vestibulopathy), game performed in sit position, VR just provides visual information and insufficient description of statistical analysis.
For the selection of studies, the publications resulting from the searches had their titles and abstracts analyzed by two independent assessors. The articles selected for reading were once again analyzed in terms of criteria for eligibility. In the case of discordances, in any phase of the selection process, a third reviewer was called in for a consensus analysis. The studies included for the final review were analyzed in terms of methodology with the extraction of data regarding the sample composition, interventions and outcomes description, and the effects of the interventions.
The primary outcomes considered were mobility-related physical functioning measures. Emphasis was placed on measurements for physical mobility and body balance through objective and/or subjective tests and instruments that are easily interpreted and used in clinical practice. Secondary outcomes included measurements relating to body structure and function, such as laboratorial posture control (ie. postural sway test and dynamic posturography), muscle strength (ie. maximal isometric muscle force and grip strength), reaction time and laboratory gait measurement.
Methodological analysis and quality
The methodological quality of the studies was assessed using the PEDro scale. This scale analyses 11 items for the interpretation of research relating to the internal and external validity of clinical trials in physiotherapy . The PEDro total score varies from zero to 10, with no score for the first item and the higher the score the better the methodological quality of the clinical trial. The ranking of the studies is available in the PEDro database . In the absence of this ranking at PEDro database two assessors conducted the ranking on an independent basis and if there was disagreement, a third assessor was called in to reach a consensus.
Due to the variability between the interventions proposed and small study sample sizes it was not possible to conduct a metanalysis. A critical review analysis of the contents was performed.
As shown in Figure 1, a total of 2,940 references were found via the data base and manual searches. After the removal of duplicated references, the titles and abstracts were analyzed for 2,802 studies, with 28 articles being pre-selected for full reading. Of these, 15 were excluded because they failed to fit the inclusion criteria for this review, resulting in 13 articles for critical analysis of content. The synopsis of the articles analyzed can be found in Tables 1 and 2, in accordance with the type of device used (Wii console or others). The great majority of these articles (n = 11) [6–10, 12, 13, 28–31] was published in the last 2 years.
The samples composition of the 13 studies varied from 12 to 58 participants divided between control group and intervention group. The samples included both sexes, with a higher proportion of women [6–12, 28–32]. Just one of the studies failed to report the proportion of sexes in the sample . Five studies presented a sample size calculation [7, 10, 12, 13, 29] and among these just one had its data analyzed with the initially calculated sample size .
Four studies were conducted with community-dwelling elders [9, 13, 28, 30], four with older people from a housing facility/ senior living community [6, 7, 10, 31], three studies took their samples from outpatient clinics (falls and balance clinic/ orthopedic and balance) [8, 12, 32], one study recruited inpatients from a geriatric hospital rehabilitation unit , and other older adults attending day hospital . Despite being in different therapeutic settings, the inclusion criteria were similar in all the studies analyzed, demonstrating a relative degree of functional independence and cognitive capacity in the participants. The survey conducted by Laver et al.  followed the same criteria for inclusion as the other studies, however, the sample is different because the participants were hospitalized due to acute conditions or health complications such as falls, fractures, medical and surgical problems.
All studies presented some type of measurement related to the primary outcome of this review, be it through the analysis of mobility [6–11, 13, 29, 32], body balance [9–11, 13, 28, 29, 31, 32] or questionnaires on self-efficacy in activities involving risk of falls [7, 8, 11–13, 29, 30, 32]. For the mobility outcome, the most frequently used instrument was the Timed Up and Go test (TUG) [7, 9–11, 13, 29, 32], while for body balance it was the Berg Balance Scale (BBS) [9, 11, 28, 29, 32] and for self-efficacy it was the Falls Efficacy Scale (FES/ FES-I) [7, 13, 30, 32]. Other tests and instruments related to the primary outcome, were Sit to Stand 5 (STS) or Chair Stand Test [6, 7, 13, 32], The Activities-specific Balance Confidence Scale (ABC scale) [8, 11, 29], Tinetti Performance Oriented Mobility Assessment (POMA) [10, 28, 31], One Leg Stance (OLS) [10, 31, 32], Functional Reach Test (FR) [9, 10], The Survey of Activities and Fear of Short Physical Battery (SPPB) , Dynamic Gait Index (DGI) , Physiological Profile Assessment (PPA)  and Falling in the Elderly (SAFFE) .
With regard to the secondary outcomes of this review, the most frequently assessed measures were muscle strength [7, 12, 32]; gait [11, 12, 30], postural control [7, 10, 12, 31] and other parameters [13, 30] through the use of laboratory equipment. Outcomes assessed with lesser degree of representation in the studies were questionnaires on daily living activities , quality of life [28, 29], cognition [6, 13], depression [8, 12], aerobic capacity  and history of falls. In some studies, the participants in the exergames group were asked about discomfort and adverse events , impressions of the game , enjoyment  and motivation .
Study design and methodological quality
Ten studies described themselves as Randomized Controlled Trials [6–9, 11, 12, 28, 30–32] and three studies as Randomized Controlled Trial – Pilot Studies [10, 13, 29]. Just one study performed analysis of the short-term follow-up (one month after the intervention period) . In the study by Duque et al.  during the follow-up, the participants in the exergame group continued to receive their usual care. Thus, no long-term follow-up was performed in any of the studies.
All studies included in this review had their PEDro score retrieved from the PEDro website, since they had been ranked previously (Table 3). Studies scores show that most of the studies presented methodological problems, with a high proportion of scores below 5 [6, 9, 10, 12, 28, 30–32].
The exergames groups used games through Nintendo Wii gaming console [6–10, 28, 29, 31] (Table 1), games created on computers [11, 32], Dance video game with pad [13, 30] and the Balance Rehabilitation Unit (BRU™)  (Table 2).
Some studies added to the exergames group recommendations for falls prevention , warm-up and cool-down exercises , adapted physical activity , home exercises , exercises for balance, muscle resistance and strengthening [30, 32].With the exception of one study that administered the games in pairs , the other studies performed the exergames individually. Pichierri et al.  combined the exergames performed individually with a group intervention using conventional exercises. In only one study, the participants were instructed to use the exergames at home, with no professional supervision during the sessions .
In six studies there was a control group with no type of intervention [6, 8, 9, 13, 28, 31]. The study by Jorgensen et al.  had a placebo control group, using EVA insoles with no therapeutic effect. When the control group was active, the therapies performed involved physical activity, conventional physiotherapy, traditional balance training and usual care [10–12, 29–32]. Also with regard to the control group, specific protocols and techniques were used, such as Matter of Balance (MOB)  and Tai Chi . Three studies delivered group interventions as control [10, 28, 30].
The time of exergames intervention varied from 10 minutes to an hour, with a predominance of therapies with an average time of 30 minutes. For the studies involving some type of intervention in the control group, the time varied from 25 minutes to an hour. The total duration of treatment varied from 3 to 20 weeks and the frequency of the sessions was from 1 to 5 times a week.
Effects of the intervention
For the studies that compared exergames and active control, no difference was observed between groups in two of the studies [10, 28]. The other studies demonstrated improvements favoring the exergame group in some of the outcomes assessed, such as laboratory outcomes related to gait and posture control [12, 30, 31], balance [11, 29], mobility  and self-efficacy for falls [11, 12].
In the study with the placebo control (EVA insole), there was improvement in the parameters relating to muscle strength, mobility and self-efficacy for falls . The studies that used comparison with non-active control group observed differences only in some specific parameters related to balance [8, 9], mobility [6, 8, 13], muscle strength , reaction time  and physiological functions involved in postural stability  in favor of the exergame group. In one study with three arms: a group using Wii Fit games, an MOB intervention group and a non-active control group it was observed a balance improvement in all groups with no difference between them .
For the TUG, the instrument most used by the studies included in this review, three studies indicated improvement in favor of the exergame group [7, 13, 29], one study did not observed a superiority in favor of the exergame group  and the others studies did not observed any improvement in any of the groups [9, 10, 32]. With regard to the BBS, three studies obtained significant improvement from interactive game group in comparison with the control group [9, 11, 29], being that Bieryla & Dold  observed this improvement only in the follow-up analysis after one month. In the study by Franco et al.  there was an increase in the BBS score for the three groups analyzed, but with no significant difference between them. There was no improvement in the results for the BBS in older outpatients from the geriatric and balance clinic .
The older adults responded positively in terms of enjoyment and their perception of improvement in functional aspects after practicing the exergames [6, 13, 28]. Four articles demonstrated high levels of adherence to the treatments [6, 12, 13, 30]. Two studies reported that there were no adverse effects during intervention with the use of games [7, 13] while Laver et al.  reported cases of discomfort for the exergames group and for the control group that used conventional therapy.
The use of technologies that allow the creation of interactive environments and that provide a form of treatment for the older population by way of VR is spreading worldwide. However, as shown in this review, there is still no substantial evidence of improvement in physical functioning among older adults through the use of exergames, either as a complementary form or as an alternative to other types of intervention.
This systematic review included studies that used different VR technologies to administer the therapies with interactive games. The Nintendo™ Wii (Nintendo; Redmond, WA, USA) console was the one most frequently used to apply the games [6–10, 28, 29, 31] with variations depending on the package and accessories used such as the Wii Sports package with the associated handheld remotes and the balance, fitness and strength games in the Wii Fit package with the accompanying Wii balance board. Some studies used more sophisticated VR systems, such as the computer feedback system (Personics, ÄbyhØj Denmark) coupled to sensors that register body position , BRU™ a force platform used to assess (posturography) and train balance , and computer games coupled to the flexible pressure mat (FSA pressure mat, Vista Medical td, Winnipeg.) developed exclusively for the study . Another VR option was the use of step pads with the modified Dance Dance Revolution (DDR) Stepmania game [13, 30].
With the exception of BRU, which requires specific training for implementation, has a high cost and depends on ample space and safety accessories, even those that make use of specific computer programs represent a relatively simple form of intervention with virtual games. It is notable that the studies give priority to the games available on commercial consoles that facilitate their use in therapeutic environments and participant access to the equipment if they wish to continue the activities after the study.
According to the World Health Organization , the regular practice of physical activities among older adults can prevent against diseases and disability, including tasks of transportation (e.g. walking or cycling), occupational, household chores, play, games, sports or planned exercise, in the context of daily, family and community activities. The use of interactive games through VR can be, therefore, considered as a form of physical activity and this way should obey recommendations related to period and length of practice, to bring the desired benefits to the health of the older person.
The directives of the Global Recommendations on Physical Activity for Health  recommend that older people practice at least 150 minutes of moderately aerobic physical activity or at least 75 minutes of vigorously aerobic physical activity over the course of a week. Also according to this guideline, the elderly should carry out activities for muscular strengthening involving large major muscle groups twice a week or more. In the case of older individuals with reduced mobility, an exercise program should be followed three times a week, aimed at improving balance and preventing falls. However, in the case of interactive games there are still no references with regard to the time of intervention needed for functional improvement.
In the studies analyzed in this review, the interventions demanded movements in an orthostatic position which we considered to represent moderately intense physical activity. This being so, none of the studies attained the minimum length of practice time recommended for the older population. This data corroborates the findings of other systematic reviews on VR subject, testifying the lack of standardization in dosage for this type of intervention for therapeutic purposes [21, 34].
The VR games were administered on an isolated basis [6–9, 11, 13, 29] or combined with conventional physical activities [10, 12, 28, 30–32]. Concepts related to learning and motor control consider that practice involving functional tasks that are identifiable through variable practices and with the presence of contextual interferences ensure greater transfer of the task practiced to new tasks and new environments . Interventions that bring together several components such as strength training, resistance, balance exercises, cognitive elements and education stimulate the older person on a broader level and prevent disability . Ultimately, the use of exergames associated with multiple components and variable practice may result in improved functionality and greater gains in the process of rehabilitation compared with practices conducted on a single basis.
With regard to the assessment instruments, a large part of the studies included in this review chose methods that are widely used in the older population, such as BBS, TUG, FR and POMA. These instruments can be applied in a range of therapeutic environments; they do not require complex materials, extended lengths of time for administration and they are low-cost. These characteristics facilitate their use in clinical practice. Nevertheless, some of these instruments might have problems with responsiveness. This fact may be caused, in some of the studies by a ceiling effect on the scores in the baseline assessment, justifying the lack of significant difference between the game intervention group and the control group [9, 28].
As presented in the results, the studies included in this review registered specific improvements in some measures relating to physical functioning. Studies that use assessment based on posturography and gait analysis detected improvements in quantitative laboratorial parameters [12, 30, 31]. These parameters are more sensitive to change, but these gains are not always transferred to the activities assessed in the functional capacity tests. Also, little is known about the differences that are clinically relevant for these instruments. With regard to the instruments, of the seven studies analyzed that had their outcomes assessed by the TUG [7, 9–11, 13, 29, 32], just two of them revealed significant improvement in the group that had intervention of exergames in relation to the control group [7, 29]. In the study by Laver et al.  the group that had intervention with Nintendo Wii obtained better results than the traditional hospital therapy group after adjustments to hospital length of stay, age, sex and baseline functional independence measure. Jorgensen et al.  compared intervention through Nintendo Wii Training with a placebo. It is worth pointing out that for those who encountered no significant differences between the groups post-intervention, or the test result was within the normal range prior to intervention [9, 10, 13], or the groups presented differences in the baseline [11, 32]. With regard to the BBS, just one study encountered an improvement in favor of the exergame group in comparison with the control group . Franco et al. , observed improvement both in the intervention group and in the control group, without any significant difference between them. In the other studies there was no significant difference in the BBS scores between exergame and the control group in the post-intervention period [9, 32]. However, one point that appears to be a consensus is the motivation that the use of VR through interactive games provides [6, 13, 28]. Because it involves tasks that combine physical and cognitive demands in an attractive and challenging way, interactive games may represent an option that is both viable and well-accepted by older people, thereby expanding the therapeutic strategies used in conventional physiotherapy.
Although this review has only chosen randomized clinical trials, aiming to attain better scientific evidence, the studies selected present methodological limitations, and consequently restricting their capacity for generating evidence regarding the efficacy of intervention with VR games. The most frequent limitation is related to the sample size and its characteristics. In order to render the use of interactive games viable, inclusion criteria were applied to ensure a relative degree of physical and cognitive independence of the older adults. This not only makes it more difficult to recruit such participants but also limits the representativeness of the sample, portraying a very specific parcel of the older population within the chosen therapeutic scenarios. The absence of sample size calculation may culminate in systematic errors [37, 38] and the small sample size along with the restrictions in the inclusion criteria reduce the external validity of the study, i.e. that the results of the surveys studies are limited for population generalization. Only three studies performed the intention-to-treat analysis [7, 8, 29] which protects the randomization and preserves compatibility between groups, thereby reducing the chance of bias . Also, the studies used in this review cannot categorically state that the gains observed would lead to lasting benefits for the participants, since no follow-up analysis was performed.
These limitations have been quantified and are expressed by low scores on the PEDro scale. Although the criteria for eligibility, random allocation, baseline comparability, point estimates and variability have been adopted; the absence of intention-to-treat analysis, blinding and follow-up in a large part of the studies result in low scores and indicate poor methodological quality. The other reviews published on VR come up against similar problems [17, 21, 23, 34].
This manuscript brings a critic view of studies involving the use of exercises using interactive games (exergames) in improving physical functioning in older. Resources involving VR are growing in interest and the use of exergames has shown the potential to represent an option that is both viable and well-accepted by older people. However the results discussed in this review show that evidence to support the effectiveness of using exergames for improving physical functioning in older adults remains inconclusive.
In order to achieve better methodological quality and provide stronger scientific evidence, it is necessary that future studies use more responsive instruments with clear minimal clinically important difference, as well as conduct appropriate statistical analyses and sample size calculations. We observed that there was a wide variability in exercise prescription regarding the use of exergames, ultimately making a suitable dosage of training still inconceivable. It is recommended that RCTs should follow the Consolidated Standards of Reporting Trials , since it was challenging to retrieve relevant information in some studies. Therefore, it is still not possible to recommend the use of exergames as an isolated or combined intervention for improving physical functioning in older people.
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CONSORT Statement Website. http://www.consort-statement.org/
In this review everyone involved in conception, design, search and analysis or interpretation of data were involved in drafting or revising the manuscript, and were considered as co-authors. Therefore, we don’t have anyone else to acknowledge.
The authors declare that they have no competing interests.
KIM, NAR and MRP were involved in the conception and design of the review, the search and analysis and interpretation of the studies, and the writing of the manuscript. SAM was the second reviewer to carry out the quality assessment on the relevant articles with KIM and was involved in revising of the manuscript. The final manuscript has been seen and approved by all author.