Exergame technology and interactive interventions for elderly fall prevention: A systematic literature review

Highlights

• We reviewed studies on exergaming and its applications for elderly fall prevention.

• The most common exergaming device was Nintendo Wii, followed by Xbox Kinect.

• Exergame interventions improved physical and/or cognitive functions in the elderly.

• Comparison between exergame interventions and physical therapy was inconclusive.

• The effect mechanism of exergaming on elderly's balance needs be further studied.

Abstract

Training balance and promoting physical activities in the elderly can contribute to fall-prevention. Due to the low adherence of conventional physical therapy, fall interventions through exergame technologies are emerging. The purpose of this review study is to synthesize the available research reported on exergame technology and interactive interventions for fall prevention in the older population. Twenty-five relevant papers retrieved from five major databases were critically reviewed and analyzed. Results showed that the most common exergaming device for fall intervention was Nintendo Wii, followed by Xbox Kinect. Even though the exergame intervention protocols and outcome measures for assessing intervention effectiveness varied, the accumulated evidences revealed that exergame interventions improved physical or cognitive functions in the elderly. However, it remains inconclusive whether or not the exergame-based intervention for the elderly fall prevention is superior to conventional physical therapy and the effect mechanism of the exergaming on elderly's balance ability is still unclear.

Introduction

Population ageing is a sign of success in the history of mankind, but nevertheless it also leads to a growing healthcare concern for society (World Health Organization, 2002). The global population is ageing as fertility declines and life expectancy increases (Ghadar, 2005). In 2015, 12% of the global population (901 million people) was aged 60 or over and this age group is growing the most rapidly. By 2050, 22% of the total population (2.1 billion people) will be aged 60 or over. Moreover, the older people are particularly prone to falls when compared with young adults (Lockhart et al., 2005, Schiller et al., 2007), probably due to the age-related deterioration in physical (e.g., muscle strength, endurance, range of motion) and cognitive (e.g., sensorimotor performance, reaction time, memory) capacities (Era et al., 2006, Isles et al., 2004, Keller and Engelhardt, 2013, Lord and Clark, 2009, Lord and Ward, 1994). About one third of community-dwelling people aged over 65 years have experienced at least one fall per year (Rubenstein, 2006). Falls are the leading cause of death and non-fatal injury in older people (Marschollek et al., 2011), they not only have devastating physical consequences for older people in terms of morbidity, mortality, and loss of independence, but also induce ‘post-fall syndrome’ such as fear of falling (Qiu and Xiong, 2015), social isolation and depression. Falls also present a considerable financial burden to the healthcare system. The annual costs of elderly falls and their consequences have been estimated to range from 0.85% to 1.5% of the total healthcare expenses (Hamacher et al., 2011, Stevens et al., 2006).

The negative physical, psychological and economic consequences resulting from falling has led to two fall management approaches (Howcroft et al., 2013). The first approach utilizes fall-detection technologies to detect falls and notify others for help when a fall event occurs. However, this approach is reactive since it can only mitigate the severity of irreversible consequences. In comparison with the first approach, the second one is proactive which prevents fall occurrences through interventions such as exercise, assistive devices, improved footwear, adaptation or modification of the home environment. Exercise has been shown to increase physical activities, enhance balance and thus reduce the risk of falling (Avin et al., 2015, Gillespie et al., 2012, Kobayashi et al., 2006, Li et al., 2005, Michael et al., 2010, Sherrington et al., 2008). Kobayashi et al. (2006) evaluated the efficacy of a three-month exercise program on motor functions of the elderly people. The intervention program included ten types of physical exercises and there were significant improvements on motor function measures such as step length, hip flexion torque after the intervention. Li et al. (2005) examined the effectiveness of a six-month Tai Chi intervention program for fall risk reduction in physically inactive older adults. At the end of the intervention period, Tai Chi group showed decreased number of falls, lower fear of falling, and improved balance and physical performance when compared with the control group. Shimada et al. (2004) reported the significant improvement in balance and reaction time using a bilateral separated treadmill exercise for the elderly. A perturbed gait exercise and training on the treadmill seemed to have a positive effect on physical functions in frail elderly people. Shimada also stated that in addition to gait training, walking on a treadmill helped increase mobility thus reducing falls in specific settings. Robitaille et al. (2005) assessed the effectiveness of a group exercise in improving balance and preventing falls. A structured group based exercise program offered by personnel and staff at older-adult community centers and health clinics increased static balance and mobility among older adults concerned about falls. Tiedemann et al. (2014) compared the older people's perceptions on a yoga-based program with two other established exercise programs (Tai Chi and Otago) for fall prevention. A large sample of community-dwelling people aged 60 or over participated in this study and 35% of them preferred yoga, followed by 33% on Tai Chi and 32% on Otago, indicating a yoga-based fall prevention program was as attractive to older people as other established fall prevention programs.

Even though various conventional exercise intervention programs that train postural balance and muscle strength can help to prevent falls for the older people, poor program adherence and insufficient exercise intensity could seriously compromise the effectiveness of the intervention (Sohng et al., 2003, Tiedemann et al., 2014). Sohng et al. (2003) examined the effects of a fall prevention exercise program (FPEP) on the community-dwelling elderly in Korea. They reported that FPEP was beneficial for the older participants in the form of improvements on muscle strength, ankle flexibility, balance and geriatric depression. Although the positive effect from exercise is well-known, only around 30% of Korean older individuals perform the exercises regularly. A study done by Lee et al. (2013) obtained some compelling evidence. In their study, a multifactorial fall prevention program with exercise intervention was found to be effective for fall incidence and physical functions only at three months, not at one year. Okubo et al. (2016) reported that walking among community-dwelling older people can be more effective for fall prevention than balance training. However, since the frail older people are more susceptible to tripping and falling, walking should not be recommended for frail older people. Another study by Day et al. (2015) examined the effectiveness of Tai Chi in reducing falls among community-dwelling older people with the relatively good health and functional status. The experimental results indicated no evidence for any significant improvement on fall risk reduction and the authors pointed out that the lack of effectiveness may be due to low Tai Chi class attendance or insufficient exercise intensity. Overall, it is important that a fall prevention exercise program should be not only safe and effective, but also enjoyable and easy to perform, demonstrating the need of innovative fall prevention exercise modalities (Proffitt et al., 2015, Tiedemann et al., 2014, van Diest et al., 2013, Yardley et al., 2006).

Recently, virtual reality and game technologies are emerging and being used as effective tools to enhance balance and mobility in older adults (Bieryla and Dold, 2013, Griffin et al., 2012, Jorgensen et al., 2013, Larsen et al., 2013, Taylor et al., 2011, Williams et al., 2011). Exercises through video games (exergames), especially those utilize existing, relatively inexpensive game technology (e.g., Nintendo Wii), are gaining more and more interest in the field of fitness and mobility training (Nitz et al., 2010). Exergames have several advantages compared to conventional exercises: (1) Exergames can motivate people to practice through an attractive and interactive way and train both motor and cognitive skills when users performing dual tasks (Skjæret et al., 2016, van Diest et al., 2013); (2) The players can focus their attention on the outcome of the movements in the game, not on the movements itself (Proffitt et al., 2015); (3) The exergame can be undertaken at home, either alone or within a small group, which may make the activity more accessible to many older adults (Yardley et al., 2006). Although there is a rapid increase in research on the use of exergame technology and interactive interventions in the older population to increase physical activity and train balance function, there have been very rare in-depth reviews and discussion on the current state-of-the-art of exergame technologies, the design of exergame-based intervention, intervention effectiveness, and problems associated with current exergame-based interventions.

The aim of this study is to synthesize the available research on exergame technology and interactive interventions for fall prevention in the older population. The outcome of this study is expected to provide a systematic review on the current state-of-the-art of the exergame technologies and their applications in interactive fall interventions, along with the identification of associated problems.