Exergaming for balance training of elderly: state of the art and future developments

Abstract

Fall injuries are responsible for physical dysfunction, significant disability, and loss of independence among elderly. Poor postural control is one of the major risk factors for falling but can be trained in fall prevention programs. These however suffer from low therapy adherence, particularly if prevention is the goal. To provide a fun and motivating training environment for elderly, exercise games, or exergames, have been studied as balance training tools in the past years. The present paper reviews the effects of exergame training programs on postural control of elderly reported so far. Additionally we aim to provide an in-depth discussion of technologies and outcome measures utilized in exergame studies. Thirteen papers were included in the analysis. Most of the reviewed studies reported positive results with respect to improvements in balance ability after a training period, yet few reached significant levels. Outcome measures for quantification of postural control are under continuous dispute and no gold standard is present. Clinical measures used in the studies reviewed are well validated yet only give a global indication of balance ability. Instrumented measures were unable to detect small changes in balance ability as they are mainly based on calculating summary statistics, thereby ignoring the time-varying structure of the signals. Both methods only allow for measuring balance after the exergame intervention program. Current developments in sensor technology allow for accurate registration of movements and rapid analysis of signals. We propose to quantify the time-varying structure of postural control during gameplay using low-cost sensor systems. Continuous monitoring of balance ability leaves the user unaware of the measurements and allows for generating user-specific exergame training programs and feedback, both during one game and in timeframes of weeks or months. This approach is unique and unlocks the as of yet untapped potential of exergames as balance training tools for community dwelling elderly.

Figures

Figure 1

Summary of results of uncontrolled studies evaluating training effect of exergames on balance ability of elderly. The vertical axis represents the percentage improvement between pre- and post-intervention on the outcome measure provided on the horizontal axis. The bars on the left side of the solid vertical line indicate clinical measures, the bars on the right side instrumented measures. BBS = Berg Balance Scale, FOE = Figure of Eight, CB&M = Community Balance and Mobility scale, E1 = experimental group 1, E2 = experimental group 2, FES = Fall Efficacy Scale, WS = Walking speed, TS = tandem stance time, OLS = one-leg stance time (both TS and OLS are measured in seconds), DTM = Dot gaming Task Mean, DTV = Dot gaming Task Variability, SR = Sway Root mean square values, EO = eyes open, EC = eyes closed, SE = sample entropy, AP = antero-posterior direction, ML = medio-lateral direction, MPF = mean power frequency, RT = reaction time, SR = Sway Root mean square values, * indicates a significance of P < 0.05.

Figure 2

Summary of results of controlled studies evaluating training effect of exergames on balance ability of elderly. The vertical axis represents the percentage improvement between pre- and post-intervention on the outcome measure provided on the horizontal axis. Dark bars indicate the experimental group, light bars the control group. Note that [42] found an improvement in the control group where the experimental group did not improve. The bars on the left side of the solid vertical line indicate clinical measures, the bars on the right side instrumented measures. BBS = Berg Balance Scale, TBA = Tinetti Balance Assessment, FES-I = Fall Efficacy Scale International, CB&M = Community Balance and Mobility scale, 6MWT = 6 Minute Walk Test, SR = Sway Root mean square values, AP = antero-posterior direction, ML = medio-lateral direction, RT = reaction time. * indicates a significance of P < 0.05.