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Table 1 Data summary of randomized clinical trials using exergames with the Nintendo Wii gaming console

From: Virtual reality using games for improving physical functioning in older adults: a systematic review

Study

Sample

Trial Desing

Outcomes

Intervention

Effects Observed

Bieryla & Dold[9]

Healthy older adults from a local senior living community.

Randomized controlled trial with one month follow-up.

1) BBS.

EG: Wii Balance Board with Wii Fit.

- BBS scores significantly increased for EG participants. Post hoc analysis indicated a significant increase from pre-intervention to 1 month post-intervention but not a significant increase from pre-intervention to 1 week post-intervention. BBS score did not significantly change in the CG.

 

N = 12

 

2) FAB.

The intervention consisted of a series of exercises and activities chosen from the yoga (half moon, chair, warrior), aerobic (torso twists), and balance games (soccer heading, ski jump) modes.

- There was no significant improvement in FAB, FRT and TUG for either group.

 

81.5 ± 5.5 yrs

 

3) FRT.

Individual sessions 3x/week (30 min each session) for 3 weeks.

 
 

EG: n = 6 (withdraw = 1 during treatment and 1at follow-up)

 

4) TUG.

CG: No intervention.

 
 

CG: n = 6 (withdraw = 1)

    

Franco et al.[28]

Community dwelling elders at low-income senior housing facility.

Randomized controlled trial.

1) BBS.

EG1: Wii Fit.

- Balance tests (BBS and Tinetti) improved in all 3 groups after the intervention period. There was a significant main effect of time (pre- to post-intervention) but no interaction between time (pre and post) and groups (Wii Fit, MOB, Control).

 

N = 32

 

2) Tinetti-POMA

5 Wii Fit balance training games (soccer heading, ski jumping- slalom, tightrope, table tilt and balance bubble) with supplemental home exercises (balance and flexibility- daily).

 
 

78.27 ± 6 yrs

 

3) SF-36.

- Individual sessions 2x/week (10-15 min each session) for 3 weeks.

 
 

EG1: n = 11

 

4) Wii Fit Enjoyment Questionnaire.

EG2: Matter of Balance program (MOB). The program uses a cognitive restructuring for coping strategies, strength training exercises (elastic resistance band) for strength and balance tasks to reduce fall risk.

- The groups were different at pre-test in SF-36 scores. There was no significant time change in SF-36 scores and non-significant group-time interaction.

 

EG2: n = 11

  

Group sessions 2x/week (30-45 min each session) for 3 weeks.

- 81% of the EG1 participants reported high levels of enjoyment while playing the Wii games.

 

CG: n = 10

  

CG: No intervention.

 

Jorgensen et al.[7]

Community-dwelling older adults.

Randomized controlled trial.

1) Maximal voluntary contraction (MVC) of leg extensors.

EG: Nintendo Wii training.

- Between-group difference (pre-to-post changes) favoring the EG were evident in the MVC, RFD, TUG, FES-I, and Chair Stand Test. The CoP-VM did not differ between groups.

 

N = 58

 

2) Postural balance- center of pressure velocity moment (CoP-VM).

Each training session was designed to include balance exercise games followed by a muscle exercise sequence. The participants could choose freely between 5 balance games (table tilt, slalom ski, perfect 10, tight rope tension, penguin slide), whereas a single exercise (standing rowing squat) was used for muscle conditioning.

- EG participants either agreed or strongly agreed with the statement that Wii training was fun and motivating.

 

75 ± 6 yrs

 

3) Rapid force capacity (RFD).

- Individual sessions 2x/week (35 to 40 min each session) for 10 weeks

 
 

EG: n = 28 (withdraw = 7)

 

4) TUG.

CG: EVA insoles as placebo.

 
 

CG: n = 30 (withdraw = 2)

 

5) FES-I.

The participants in CG were instructed to wear EVA insoles in their shoes everyday for the entire duration of the trial. They received phone calls to check that problems with the EVA insoles had not emerged.

 
   

6) 30-sec repeated Chair Stand Test.

.

 
   

7) Likert scale regarding motivation toward Wii training.

  

Laver et al.[29]

Geriatric Hospital

Feasibility Randomized controlled trial.

1) TUG.

EG: Nintendo Wii training.

- There was no difference between groups on univariable analyses for any measures.

 

Rehabilitation

 

2) SPPB.

Treatment focused on balance tasks (weight shift on the balance board), strength exercises for the lower limb (sustained squats or single leg extension) and aerobic capacity (stepping on and off the balance board or walking on the spot).

Multivariable analyses (based on the number of intervention sessions) adjusting for length of stay, age, gender and baseline FIM showed that EG improved more on TUG and MBBS.

 

Unit.

 

3) Modified BBS.

Individual sessions 5x/week (25 min each session) for the duration of the participant’s stay on the unit.

- No statistically significant differences were found between groups for the SPPB, Timed IADL Test, ABC Scale or EQ5D.

 

N = 44

 

4) TIADL.

CG: Conventional physiotherapy.

- In either groups, participants reported some discomfort, being musculoskeletal pain the most frequent one. Within the CG, 1 serious adverse event (conscious collapse- vasovagal). Three participants from the EG fell while on the unit in comparison to one fall reported from CG.

 

84.9 ± 4.5 yrs

 

5) FIM.

Treatment sessions included walk, transfers practice, walk up and down steps, balance tasks (standing on a foam block, tapping a balloon or reaching for objects), strength (e.g. use of light weights or stretches), aerobic and flexibility exercises.

 
 

EG: n = 22 (withdraw = 2)

 

6) ABC Scale.

- Individual sessions 5x/week (25 min each session) for the duration of the participant’s stay on the unit.

 
 

CG: n = 22

 

7) EQ5D.

  
   

8) Participant reports of discomfort and adverse events.

  

Maillot & Perrot[6]

Independent older adults.

Randomized controlled trial.

1) Physical Measures:

EG: Nintendo Wii training.

- Follow-up tests showed greater improvement in the EG than in the CG for all the physical measures except the Back-Scratch upper-right and the Borg Scale ratings.

 

N = 32

 

- chair-stand test;

Each session began with a warm-up and finished with a cool-down. The main session comprises games from the Wii Sports, Wii Fit, and Mario & Sonic on Olympic Games. The participants’ pairs change at each session with the intention of making the exergame playing more enjoyable and motivating adherence to the regimen.

- The comparisons for measures of executive function and processing speed show that improvement was significantly greater in the EG than in the CG.

 

65 to 78 yrs

 

- arm curl test;

Pairs sessions 2x/week (30 min each session) for 12 weeks.

- For measures of visuospatial function, the difference between the EG and CG was not significant.

 

EG: n = 16 (withdraw = 1)

 

- 6 MW (meters, borg scale max and mean HR);

CG: No intervention.

- 80% of EG participants agreed that the exergame training was manageable for seniors. All participants reported that they would like to continue with exergame activity, however only 40% considered acquiring a game console.

 

CG: n = 16 (withdraw = 1)

 

- chair-sit-and-reach test;

  
   

- back-scratch test;

  
   

- 8 ft UG.

  
   

2) Cognitive battery:

  
   

- executive control tasks (Trail- Making test, Stroop Color Word Interference test, Letter Sets test, Matrix Reasoning test2, Digit Symbol Substitution test);

  
   

- visuospatial tasks (Spatial Span test, Directional Headings test, Mental Rotation test)

  
   

- processing-speed tasks subdivided into two categories: perceptual speed (Cancellation test and Number Comparison test) and psychomotor speed (the Reaction Time test and Plate Tapping test).

  
   

3) Impression questionnaire of the exergame program.

  

Pluchino et al.[10]

Independent seniors.

Randomized controlled trial- pilot study.

1) TUG.

EG 1: Standardized Balance Exercise. Program consisted of 14 functional activities with a pronounced demand for balance (stepping on a compliant surface, walking forward 10 steps and pivoting 180°, alternately moving a weight between a high and low shelf situated just beyond 1 arm’s length and more).

- Significant increase in COP area across time (pre to post-test) was seen for the three groups. Differences were detected for the COP anterior-posterior excursion (max/ min/ SD) and velocity (max/min); and COP medial-lateral excursion (min) and velocity (max). No significant group X time interactions were detected for any COP measurements.

 

N = 40

 

2) OLS.

EG 2: Tai Chi program.

- For dynamic posturography, significant improvements in the overall score (dynamic movement analysis score), and in 2 of the 3 linear and angular measures were seen for the sample.

 

72.5 ± 8.40 yrs

 

3) FRT.

The program was based on the Tai Chi Sun-style. The program consisted of 12 movements using small forward and backward steps, as well as weight transfers from one leg to the other. The form also focused on posture alignment, slight bending of the knees and moving slowly with a gentle resistance.

- No significant differences were seen on time or group (EG1, EG2, EG3) X time (pre-post) interaction for any field test or questionnaire.

 

EG1: n = 14 (withdraw = 6)

 

4) Tinetti- POMA.

EG 3: Wii Fit Balance Program.

 
 

EG2: n = 14 (withdraw = 3)

 

5) Postural Sway Test (force plate): COP area and velocity for medial-lateral/ anterior-posterior directions.

Games used for the balance program were: soccer heading, ski slalom, ski jump, table tilt, tightrope walk, river bubble, penguin slide, snowboard slalom and lotus focus. The games were based on the control of an on-screen avatar using body movements that are detected by the balance board. The training starts with participants playing each game for 7 min. During the second day they played 5 out of the 8 games for 10 min each. The 5 games played were chosen as follows: the 3 games in which they scored the lowest on the first day of training, and 2 games of their choice. For the duration of the study, the participants played 5 out of the 8 games per session for 10 minutes each. They first played the 3 games that were not played during the previous session. These were then followed by the 2 games in which they produced their lowest cumulative scores.

 
 

EG3: n = 12 (withdraw = 4)

 

6) Dynamic posturography

EG1, 2, 3: 5 min warm-up, 50 min of specific training, and 5 min of cool-down.

 
   

- DMA (dynamic motion analysis)

2x/ week (60 minutes each session) for 8 weeks.

 
   

- up and down, side to side, and anterior/posterior;

  
   

- translational and rotational movements including flexion/extension, lateral flexion, and core rotation.

  
   

7) FROP-Com.

  
   

8) FES.

  

Rendon et al.[8]

Outpatient geriatric orthopaedic and balance physical therapy clinic

Randomized controlled trial.

1) 8 ft UG.

EG: Wii Fit balance games.

- Post-intervention measurements showed significant improvements for the EG in the 8 ft UG and ABC scale when compared with CG.

 

N = 40

 

2) ABC scale.

Treatment comprises 8 min warm-up (stationary bicycle), 3 different balance games (lunges, single leg extensions and twists) and 8-min cool-down. Participants alternated the exercise game sequence week-to-week.

- Both groups scored in the ‘normal’ classification of depression scoring by the GDS (0–9 = normal). No significant between groups differences were seen for GDS.

 

60 to 95 yrs

 

3) GDS.

Individual sessions 3×/week (35-45 min each session) for 6 weeks.

 
 

EG: n = 20 (withdraw = 4)

  

CG: No intervention.

 
 

CG: n = 20 (withdraw = 2)

    

Toulotte et al.[31]

Healthy elderly living independently.

Randomized controlled trial.

1) OLS with EO/ EC.

EG1: Adapted Physical Activities. Participants undertook exercises to increase step length, step height, the mobility of the cervical rachis and ocular mobility in order to develop muscular strength, proprioception, flexibility, static balance with EO/ EC and dynamic balance. The difficulty of the exercises was increased at each session.

- After training subjects in EG1 and EG3 improved significantly in the Tinetti- POMA test and the scores of EG2 improved significantly only in the static part of the test.

 

N = 36

 

2) Tinetti- POMA.

EG2: Wii Fit training.

- The number of times the suspended foot touched the floor during the OLS in EO/EC conditions decreased significantly after training for EG1 and EG3.

 

75.09 ± 10.26 yrs

 

3) Wii Fit tests (center of gravity).

The participants used the Nintendo standardized video games (heading soccer, ski jumping, yoga, downhill skiing, game balls and tightrope walker). The training was personalized because the progress in training was based on the different levels into each video game.

- The percentage difference between right and left (center of gravity position) was significantly modified for EG3 and EG2, but no significant difference appeared in EG1 after treatment.

 

EG1: n = 9

  

EG3: Adapted Physical Activities (30 min) + Wii Fit Training (30 min).

- There was no significant difference between pre and post-tests for the CG.

 

EG2: n = 9

  

Training for EG3 were the same, but the number of repetitions was lower than the EG1 and EG 2.

 
 

EG3: n = 9

  

EG1/EG2/EG3: All subjects trained 1x/week (1 hour each session) for 20 weeks.

 
 

CG: n = 9

  

CG: The subjects watched television, played board games but no physical training was done.

 
  1. 6 MW = 6 minute walk test; 8 ft UG = 8 foot Up and Go; ABC Scale = The Activities-specific Balance Confidence Scale; BBS = Berg Balance Scale; CG = Control Group; COP = Center of Pressure; DMA = Dynamic Motion Analysis; EG = Experimental Group; EQ5D = EuroQOL Five Dimensions Questionnaire; FAB = Fullerton Advanced Balance; FES-I = Falls Efficacy Scale International; FIM = Functional Independence Measure; FROP-Com = Falls Risk for Older People-Community Setting; FRT = Functional Reach Test; GDS = Geriatric Depression Scale; MBBS = Modified Berg Balance Scale; OLS = One Leg Stance SF-36 = SF-36 health survey; SPPB = Short Physical Performance Battery; TUG = Timed Up and Go; TIADL = Timed Instrumental Activities of Daily Living; Tinetti-POMA = Tinetti Performance Oriented Mobility Assessment.