Use of Stakeholder Feedback to Develop an App for Vestibular Rehabilitation-Input From Clinicians and Healthy Older Adults

Abstract

Close to half people over 60 years of age experience vestibular dysfunction. Although vestibular rehabilitation has been proven effective in reducing dizziness and falls in older adults, adherence to exercise programs is a major issue and reported to be below 50%. Therefore, this research aimed to develop an app with gaming elements to improve adherence to exercises that are part of vestibular rehabilitation, and to provide feedback to increase the accuracy during exercise performance. A clinician-informed design was used where five physical therapists were asked identical questions about the exercises they would like to see in the app, including their duration and frequency. Games were developed to train the vestibulo-ocular (VOR) reflex using VOR and gaze shifting exercises; and to train the vestibulo-spinal system using weight shifting and balance exercises. The games were designed to progress from simple to more complex visuals. The games were controlled by an Inertial Measurement Unit placed on the head or anterior waist. The app was tested on ten healthy females (69.1 ± 5.1 years) with no prior history of vestibular dysfunction or complaints of dizziness. Participants completed gaze stabilization and balance exercises using the app and provided feedback on the user interface, ease of use, usefulness and enjoyment using standardized questionnaires and changes they would like to see in the form of open-ended questions. In general, participants reported that they found the app easy to use, the user interface was friendly, and they enjoyed playing the games due to the graphics and colors. They reported that the feedback provided during the exercise session helped them recognize their mistakes and motivated them to do better. However, some elements of the app were frustrating due to incomplete instructions and inability to distinguish game objects due to insufficient contrast. Feedback received will be implemented in a revised version which will be trialed in older adults with dizziness due to vestibular hypofunction. We have demonstrated that the "Vestibular AppTM" created for rehabilitation with gaming elements was found to be enjoyable, useful, and easy to use by healthy older adults. In the long term, the app may increase adherence to vestibular rehabilitation.

Keywords: balance; dizziness; physical therapy; rehabilitation application; rehabilitation games; vestibular ocular reflex; vestibular rehabilitation.

Conflict of interest statement

NP, KM, TZ, and PR are employed by CFD Research Corporation and MR was employed by CFD Research Corporation at the time this research was conducted. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 DSilva, Skop, Pickle, Marschner, Zehnbauer, Rossi and Roos.

Figures

Figure 1

Four different levels of exercise for VOR in the pitch and yaw direction (left and right column respectively). The various levels of visual stimuli are tailored to the severity of symptoms due to vestibular dysfunction. Patients progress from simple backgrounds (top row), to a complex static background (2nd row), a complex dynamic background (3rd row–torches flicker), to a 3D background with texture and the character and background moving (bottom row). Note that although the background was static for the first two rows, the obstacles and character still moved over the screen.

Figure 2

Screenshots of the different vestibular rehabilitation exercise games: (A) gaze shifting, (B) single leg balance, and (C) weight shift with the character moving toward the coin and (D) weight shift with the character returning the coin.

Figure 3

Ratings of the different games, indicating the number of subjects agreeing or disagreeing with the statements.

Figure 4

Feedback summary on the User Interface Questionnaire. The triangles show the averages of all subjects and the bars show the standard deviation.

Figure 5

Rating for the six questions on the perceived ease of use questionnaire.

Figure 6

Overview of responses to the usefulness, motivation, and enjoyment questionnaire.