Accepted Manuscript

The Effectiveness of Exergaming Training for Reducing Fall Risk and Incidenceamong the Frail Older Adults with a History of Falls

Amy S.N. Fu, PhD, Kelly L. Gao, MPT, K.K. Tung, DHS, William W.N. Tsang, PhD,Marcella M.S. Kwan, PhD

PII: S0003-9993(15)01155-7

DOI: 10.1016/j.apmr.2015.08.427

Reference: YAPMR 56304

To appear in: ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 14 January 2015

Revised Date: 30 July 2015

Accepted Date: 13 August 2015

Please cite this article as: Fu ASN, Gao KL, Tung KK, Tsang WWN, Kwan MMS, The Effectivenessof Exergaming Training for Reducing Fall Risk and Incidence among the Frail Older Adults with aHistory of Falls, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2015), doi: 10.1016/j.apmr.2015.08.427.

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The Effectiveness of Exergaming Training for Reducing Fall Risk and Incidence among the Frail Older Adults with a History of Falls

Amy S.N. Fu1, PhD, Kelly L. Gao1, MPT, K.K. Tung1, DHS, William W.N. Tsang1, PhD ( ),

Marcella M.S. Kwan2, PhD

1 Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China 2 Rural Clinical School, School of Medicine, The University of Queensland

Submitted to Archives of Physical Medicine and Rehabilitation

Running title: exergaming training prevents falls

( ) Correspondence addresses: William W.N. Tsang, PT, PhD Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong Phone: (852) 2766 6717 Fax: (852) 2330 8656 Email: William.Tsang@polyu.edu.hk

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ACKNOWLEDGMENTS

The authors thank all subjects who participated in this study and Mr. Bill Purves for his English

editorial advice.

Conflict of Interest: The authors declare that they have no conflicts of interest with respect to

the authorship or publication of this report. No funding was provided for its preparation.

Author Contributions: The authors have worked as a team on all aspects of this research from

design of the study through the implementation, analysis, and development of the manuscript.

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The Effectiveness of Exergaming Training for Reducing Fall Risk and Incidence among 1

the Frail Older Adults with a History of Falls 2

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ABSTRACT 8

9

Objective: To use Nintendo’s Wii Fit® balance board to determine the effectiveness of 10

exergaming training in reducing risk and incidence of falls among the older adults with a 11

history of falls. 12

Design: Randomized controlled clinical trial. 13

Setting: A nursing home for older adults. 14

Participants: Sixty older adults aged 65 or above. 15

Intervention: Participants who lived in a nursing home had six weeks of balance training 16

with either Wii Fit equipment or conventional exercise. 17

Main Outcome Measures: Physiological Profile Assessment (PPA) scores and incidence of 18

falls were observed with subsequent intention-to-treat statistical analyses. 19

Results: PPA scores and fall incidence improved significantly in both groups after the 20

intervention, but the subjects in the Wii Fit training group showed significantly greater 21

improvement in both outcome measures. 22

Conclusions: In institutionalized older adults with a history of falls, Wii Fit balance training 23

was more effective than conventional balance training in reducing the risk and incidence of 24

falls. 25

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Key words: virtual reality; exergame; older adults; falls; balance exercise 26

27

List of Abbreviations 28

COP – Center of Pressure 29

FAC – Functional Ambulatory Category 30

PPA – Physical Profile Assessment 31

SPSS – Statistical Package for the Social Sciences 32

VR – Virtual Reality 33

RCT – Randomized controlled clinical trial 34

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Falls are the second leading cause of accidental deaths worldwide,1,2 and adults older 35

than 65 suffer the greatest number of fatal falls. Even non-fatal falls can impact on one’s 36

quality of life as a result of severe fall-related injuries and fractures. Moreover, older people 37

who report a fall in the past year are likely to fall again.3 Falls can lead to fear of falling,4 38

which may lead to a debilitating spiral marked by loss of confidence and restriction of 39

activity, resulting ultimately in a loss of independence.5 Falls have also shown to be a strong 40

predictor of nursing home admission.6 Research showed that fall incidence in 41

institutionalized older people are about three times more than those living in the community.7-42

8 A recent study found that 89% of preventable deaths of nursing home residents were due to 43

falls.9 A fall prevention program aimed at this frail elderly population is therefore important. 44

Exercise have been shown to be effective in reducing falls in the community,10 however it has 45

failed to reduce the rate of falls or risk of falling as a single intervention in nursing care 46

facilities.11 47

Virtual reality (VR) and exergaming technologies have been used as an assessment and 48

treatment tool in rehabilitation.12,13 Some VR training environments have been enhanced by 49

the addition of video games, increasing participants’ motivation and enjoyment.14-16 Nintendo 50

released the Wii Fit® platform that includes a built-in center of pressure (COP) sensor which 51

can enhance yoga, strength training, aerobics, and balance games. The system offers feedback 52

to the participants, enabling them to identify improved balance capabilities. 53

Although there is some evidence of the effectiveness of virtual reality and the use of 54

video games in enhancing balance control,17 empirical evidence in falls prevention 55

particularly with a randomized controlled clinical trial (RCT) design is still lacking.18 While 56

there is research on exergaming in patients with chronic stroke19 and multiple sclerosis20, but 57

still little research on the effectiveness of the Wii Fit apparatus in the treatment of balance 58

dysfunction among the frail elderly who are at risk of falls. This study was therefore designed 59

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to investigate the effect of interactive exergaming training exercise on balance control, fall 60

risk factors and the incidence of falls among frail elderly persons living in a nursing home. 61

62

METHODS 63

64

Study Design 65

This was a single-blinded, RCT with a control group (a conventional balance training 66

group) and an intervention group (the Wii Fit balance training group). 67

68

Participants 69

Sixty participants aged 65 or over living in a nursing home were recruited. Each was 70

assessed with a Functional Ambulatory category (FAC) of grade 2 or 3. The FAC grade 2 71

subjects required manual contact with one person during ambulation on a level surface to 72

prevent falling. The manual contact usually consisted of continuous or intermittent light 73

touches to assist balance or coordination. The FAC grade 3 subjects could walk on a level 74

surface without such contact, but for safety’s sake they required a guard standing by because 75

of either poor judgment, questionable cardiac status, or a need for verbal cueing. All of the 76

participants were alert and medically stable and able to follow instructions. Each had history 77

of falls in the previous year. A fall was defined as “inadvertently coming to rest on the ground 78

or other lower level with or without loss of consciousness, and other than as a consequence of 79

sudden onset of paralysis, epileptic seizure, excess alcohol intake or overwhelming external 80

force”.21 Residents who had visual problems which might affect their training, who were 81

unable to follow instructions or who had any history of seizure, stroke, Parkinsonism or 82

uncontrolled cardiovascular disease were excluded. 83

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Approval from the nursing home was obtained prior to conducting the study, and ethical 85

clearance was obtained before the study began from the ethics committees of both the nursing 86

home and The Hong Kong Polytechnic University. Informed voluntary consent was obtained 87

from each participant after thorough explanation. 88

89

Procedures 90

Subjects were randomly assigned to the conventional or Wii Fit balance training group 91

by using a random number produced by the computerized method of minimization (Figure 1). 92

The conventional balance exercise regime used was that developed by Campbell and 93

colleagues specifically for fall prevention among elderly women.22 It has been shown to be 94

effective in reducing falls incidence in an elderly population. The exercise regime included 95

lower limb muscles strengthening exercises, tandem standing exercises in parallel bars, 96

tandem walking exercises in parallel bars, sideways and turn round walking exercise in 97

parallel bars, stepping exercise, sitting to standing exercise, and half-squats. Subjects were 98

rested for one to two minute between sets. The exercise was organized in one-hour sessions, 99

which were held on three days a week for six weeks. A physiotherapist conducted the whole 100

training regime for all conventional and Wii Fit subjects during this six-week period. 101

Subjects who were randomized to the Wii Fit balance training group received balance 102

training using a Nintendo’s Wii Fit® balance board.a Three balance training games—namely 103

Soccer Heading, Table Tilt and Balance Bubble—were selected. In Soccer Heading, the 104

subjects mimicked soccer players and took turns kicking soccer balls, cleats, or panda heads 105

at each other. Subjects scored a point if their head butted a soccer ball, but lost a point if a 106

cleat hit them and three points if they were nailed by a panda head. To perform these 107

maneuvers the subjects had to shift their body weight left or right while standing on the 108

platform. In the Table Tilt game the subjects tilted a board to roll marbles into holes by 109

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shifting their body weight. They had to carefully manipulate the board to roll the balls into 110

the holes without dropping a ball off the table. In Balance Bubble the players were required to 111

steer the bubble through a hazard-filled course, again by shifting their body weight while 112

standing on the balance board. The farther the subjects leaned, the faster the bubble traveled 113

in that direction. Subjects progress to the harder mode of the game at their own pace. This 114

pace was determined through the game’s “star system” that rates the player’s performance on 115

each individual game. Subjects were rested while each game was being restarted. 116

These activities exercised various components of the balance control system including 117

the musculoskeletal components, the sensory system, neuromuscular strategies and 118

anticipatory control. The Wii Fit training was also for one hour per session, three sessions a 119

week for six weeks. Since all the participants had history of falls, they were accompanied by 120

a rehabilitation assistant who provided immediate manual support when necessary during 121

both the Wii Fit and the conventional balance exercises. 122

After the six-week intervention period, both groups resumed the routine mobilizing and 123

strengthening exercises without receiving either the Wii Fit or the conventional balance 124

training. 125

126

Outcome measures 127

Falls incidence was recorded by the nursing staff according to the aforementioned 128

definition and reported to the investigator for each subject monthly over the 12-month period 129

after randomization. Nurses at the nursing home who documented falls were unaware of 130

subjects’ group allocation. 131

Fall risk was determined using the short-form physiological profile assessment (PPA) 132

composed of five validated measures of physiological function.23 Weighted combinations of 133

these measures can provide a falls risk score that can predict people at risk of multiple falling 134

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with 75% accuracy.23 The five measures used were contrast sensitivity, proprioception, 135

quadriceps strength, simple reaction time and postural sway. Visual contrast sensitivity was 136

assessed using the Melbourne Edge Test.24 Proprioception was measured using a lower limb-137

matching task. Errors in degrees were recorded using a protractor inscribed on a vertical clear 138

acrylic sheet (60cm x 60cm x 1cm) placed between the legs. Quadriceps strength in both legs 139

was measured isometrically in kilograms while the participants were seated with the hip and 140

knee flexed at 90 degrees. Simple reaction time in milliseconds was measured using a light as 141

the stimulus and a finger-press as the response. Postural sway while subjects stood on foam 142

with double legs and eyes open was measured using a sway meter recording displacements of 143

the body at the level of the pelvis. A research assistant blinded to the subjects’ allocation was 144

responsible for the PPA assessment. Fall risk was assessed before and after the six-week 145

training program. 146

147

Statistical Analysis 148

The data were analysed using version 19 of the Statistical Package for the Social 149

Sciences (SPSS) software package (IBM Corp. 2010) and Stata v12 (StataCorp. 2011). 150

Independent t-tests and chi-square tests were conducted to compare the two groups in terms 151

of age, height, weight, BMI, as well as the distribution of genders and functional ambulation 152

categories. For the PPA z-scores, independent t-tests were used to compare the between- 153

group difference, while paired t-tests were performed to compare the within group 154

measurements. For the numbers of falls, negative binomial regression models were employed 155

to estimate the difference in rates of falls between the two groups. Additional models adjusted 156

for sex, age and number of falls in previous year before the intervention were used. The 157

intention-to-treat was employed in the statistical analyses and the alpha level was set at 0.05. 158

159

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RESULTS 160

All 60 subjects completed the six-week training and the post-intervention assessment 161

(Figure 1). Two subjects from the Wii Fit balance training group and three from the 162

conventional training group could not complete the full year of surveillance due to illness or 163

death, so the completion rates were 93.3% for the Wii Fit group and 90% for the conventional 164

balance training group. 165

The demographic data are shown in Table 1. There was no statistically significant 166

difference in average age, gender, height, weight, BMI, FAC distribution or number of falls 167

over the previous year between the two groups. 168

169

Fall risk 170

Table 2 presents the means and standard deviations of the five items of the PPA short 171

form and PPA z-scores before and after intervention. Independent t-tests showed that there 172

was no statistically significant difference in the average pre-test PPA values of the two 173

groups. Within both the Wii Fit and conventional balance training groups, paired t-tests 174

showed that there were significant differences in their PPA z-scores before and after the 175

respective interventions. However, independent t-test showed that there was statistically 176

significant difference in the post-test PPA z-scores between the two groups. Subjects who had 177

received the Wii Fit balance training achieved significantly greater muscle strength (p < 178

0.001), faster reaction times (p <0.001), and less body sway (p = 0.013) when compared with 179

those who had received conventional balance training (Table 2). 180

Figure 2 shows the fall risks of the participants between the Wii Fit balance and 181

conventional balance training groups, with the higher the z-score, the greater a person’s fall 182

risk. It also shows the fall risk scores before and after the intervention. Prior to intervention, 183

the mean z-score for both groups was 3.7, in the marked risk category. After training, the 184

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mean z-score of the conventional training group was 3.3 while it was 2.4 for the Wii Fit 185

training group. The decrease in fall risk was more marked in the Wii Fit training group than 186

the conventional exercise group (p = 0.004). 187

188

Falls 189

The overall incidence of falls in the intervention group was 0.54 per person years (range 0-1) 190

compared with 1.52 per person years in the control group (range 0-3) (Table 2). The 191

incidence rate ratio (IRR) adjusted for age and sex (common confounders though not 192

significant in univariate analysis) was 0.35 (95% confidence interval (CI) 0.20 to 064, p = 193

0.001). Inclusion of previous falls in the model resulted in an improved IRR of 0.31 (95% CI 194

0.17 to 0.57, p<0.001). 195

196

DISCUSSION 197

Wii Fit games in reducing falls & fall risk 198

This study is the first RCT utilizing Wii Fit balance games or exergame as a training 199

technique for fall prevention in older adults. The Wii Fit balance training has shown to reduce 200

falls by 69% compared to the conventional exercise. In terms of fall risk, the Wii Fit balance 201

training has a 35% improvement in the fall risk z-score, significantly higher than 11% in the 202

conventional exercise group. The findings echo the results of Campbell and colleagues22 203

whose exercise regime was adopted for the control group of this study. 204

205

Wii Fit games as balance training 206

Wii Fit games have been shown to improve balance in patient groups such as those who 207

suffered chronic stroke and multiple sclerosis,19,20 but no RCT has been conducted in the 208

context of fall prevention. Clark and Kraemer25 reported a case study investigating the 209

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clinical use of Wii games as therapy exercise with elderly nursing home residents at risk of 210

falling. They report that clinical outcomes such as Berg Balance Scale scores, timed up and 211

go test times and dynamic gait index ratings were improved. Another case study was 212

conducted by Hakin and colleagues26 in a community-dwelling older adults suffering from 213

bilateral peripheral neuropathy. There were improvements found in tests conducted by the 214

computerized dynamic posturography as well as clinical tests. 215

Rendon and colleagues27 adopted a RCT design for a total of 40 community-dwelling 216

older adults. The Wii Fit balance group received an intensity of intervention of 3x/week for 6 217

weeks while the control group received no intervention. The clinical tests using 8-foot Up & 218

Go test and Activities-specific Balance Confidence showed significant improvement in the 219

Wii Fit group. Another RCT was conducted by Jorgensen and colleagues28 investigating the 220

Wii Fit training on muscle strength and postural control in community-dwelling older adults. 221

The investigators found an 18% increase in maximum muscle strength after the intervention 222

in comparison to the control group who wore shoe insoles. This increase was comparatively 223

higher than ours (14%) possibly due to the younger mean age of their group 75 years and a 224

passive intervention mode in the control group. However, there was no difference in the 225

bilateral static stance in term of COP velocity moment whereas we found a lower body sway 226

area (21.7%) in the Wii Fit group when subjects were standing on a foam with eyes open. 227

A recent RCT conducted by Cone and colleagues29 on young healthy adults (18-35 228

years) using the dosage of six weeks (2-4 x/week, 30-45 min/day). They found that the Wii 229

Fit group achieved better in condition 5 of the sensory organization test (condition where the 230

visual input is occluded with inaccurate somatosensory input) and better spatial and temporal 231

domains in the limits of stability test. The investigators suggested that improved postural 232

control when subjects relied on vestibular input to maintain postural control might be due to 233

the frequent movement of head during the game play. The game also challenged the players 234

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in their reaction time and stability limit and these improvements were being reflected in the 235

limits of stability test. 236

All of these studies were either single subject case reports or studies recruiting healthy 237

elderly persons.17 There has been no RCT performed with an elderly population at risk of 238

falls, especially frail elderly persons with functional disability (FAC grade 2 or 3). 239

240

Is Wii Fit balance training better than conventional balance training? 241

The five test items of the PPA short form are i) contrast sensitivity, ii) proprioception, iii) 242

quadriceps strength, iv) reaction time, and v) body sway. In Wii Fit groups, significant 243

improvements after training were observed in reaction time; quadriceps strength and body 244

sway while improvements in reaction time and quadriceps were only found in the control 245

subjects. Any changes in proprioception and contrast sensitivity were not significant. The 246

significantly better performance in these test items observed in Wii Fit group over the 247

conventional exercise group may be explained by the different training modes and 248

environments of the two protocols. 249

During the Wii Fit training, the trainees had to shift their body quickly in different 250

directions with appropriate timing in order to gain points and not lose in the games. Such 251

training would be expected to strengthen the legs, improve the reaction time in response to 252

external cues, and improve control of body sway. Moreover, exergaming provides real-time 253

performance feedback, cuing stimuli to support error-free learning. Performance feedback as 254

to the status and outcome of a response is generally accepted to be necessary for most forms 255

of learning or skill acquisition, including the learning process that underlies rehabilitation.30 256

So the real time visual feedback to the subjects would be expected to enhance the training 257

process compared with conventional training. Moreover, the exergaming environment allows 258

dynamic stimulus delivery and control. This also allows for the presentation of cuing stimuli 259

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that could be used for “error-free” learning approaches in rehabilitation scenarios.31 Unlike 260

the participants in Wii Fit group, control subjects only improved in reaction time and 261

quadriceps strength, but not in the postural sway. In the PPA, it assesses the body sway during 262

standing on foam with eyes open. However, the exercise regime designed by Campbell and 263

colleagues22 consists of more dynamic balance training, such as tandem walking, sideways 264

and turn around exercises. Due to training specificity, the effect of a more dynamic balance 265

could not be reflected on a static standing assessment. 266

267

Study Limitations 268

We acknowledge the study has certain limitations. Firstly, the difficulty level of the 269

games might be too hard for frailer adults, as they were originally designed for people of 270

relatively younger age. Subsequently, each game lasts only few minutes, so they had to be re-271

started regularly, which could potentially decrease the efficiency of the training. Although 272

Wii Fit games have been used and accepted by other high fall risk population such as 273

multiple sclerosis, studies often recruited younger age group as in Kramer and colleagues’ 274

study with mean age of 47.20 These limitations arose due to the commercial nature of the 275

games, therefore, balance training games targeting the older adults need to be designed 276

specifically for clinical application. Secondly, the amount of rest time in each subject was not 277

recorded. This might result in inconsistency between the two groups in training duration. 278

Thirdly, the physiological outcome measures were only re-assessed post intervention, how 279

much training effect is maintained throughout the follow-up period is not known. However, 280

any deficits in the physiological function would be reflected by number of falls occurred.3,23 281

Finally, as the trial was undertaken in a nursing home setting, we acknowledge our findings 282

may not be generalizable to older people living in the community. 283

284

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CONCLUSIONS 285

Wii Fit balance training was demonstrated to be significantly more effective than 286

conventional balance training for reducing falls among the institutionalized, frail, elderly 287

people most at high risk of recurrent falls. 288

289

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291

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379

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Figure Legends: 381

Figure 1. Study Flowchart 382

Figure 2. A scatter plot showing the PPA z-scores pre and post-intervention between the Wii 383

Fit balance and conventional balance training groups 384

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385

Supplier’s List: 386

a Nintendo, Redmond, Washington, US 387

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Table 1. Baseline characteristics of subjects in both groups. Values are mean ± SD unless otherwise stated.

Conventional balance

training group

(N=30)

Wii Fit balance training group

(N=30)

p

Age (Years) 82.3 ± 4.3 82.4 ± 3.8 0.975

Gender (Male/Female) 10 / 20 11 / 19 0.995

Height (m) 1.58 ± 0.5 1.55 ± 0.3 0.657

Weight (kg) 59.7 ± 0.5 59.4 ± 0.6 0.542

BMI (kg/m2) 23.9 ± 0.5 24.7 ± 0.4 0.481

Functional Ambulatory Category (grade 2 / 3)

16 / 14 14 / 16 0.797

No. of falls over previous one year (range)

2.2 ± 0.9

(1 - 4)

2.5 ± 1.1

(1 - 5) 0.307

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Table 2. Comparison of outcome measurements between the conventional balance training group and Wii Fit balance training group

Conventional balance training group (N=30)

Wii Fit balance training group (N=30)

p Value

Pre-test Post-test Pre-test Post-test

Pre-test

(between groups)

Post-test

(between groups)

Contrast sensitivity (db)

17.3±1.5 17.3±1.5 17.4±1.6 17.4±1.6 0.986 0.986

Proprioception (degree)

2.6±1.0 2.6±1.0 2.3±1.2 2.2±1.0 0.894 0.809

Quadriceps strength (kg)

4.1±0.4 5.1±0.6 a 4.3±0.5 5.8±0.8 a 0.637 <0.001 b

Reaction time (ms)

346.6±89.0 338.9±87.6 a 344.3±77.3 315.5±74.2 a 0.785 <0.001 b

Postural sway (mm2)

1213.5±390.7 1330.8±510.4 1364.0±372.5 1042.0±317.2 a 0.146 0.013 c

PPA z-scores 3.7 ± 1.2 3.3 ± 1.2 a 3.7 ± 1.0 2.4 ± 1.0 a 0.896 0.004 b

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No. of falls 2.2 ± 0.9 1.5 ± 0.6 a 2.5 ± 1.1 0.5 ± 0.5 a 0.330 <0.001 b

Note. Values are mean ± SD or p values.

Within group:

a Denotes a difference at the alpha = 0.01 significance level when compared with the pre-test values.

Between the two groups:

b Denotes a difference at the alpha = 0.01 significance level.

c Denotes a difference at the alpha = 0.05 significance level.

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Assessed for eligibility (n=82)

Excluded (n=22):

No fall in previous year (n=5)

Unable to follow instruction (n=4)

Visual problem (n=3)

FAC grade<2 (n=4)

Declined (n=6)

Randomised (n=60)

Wii Exercise Group (n=30) Conventional Exercise Group (n=30)

Pre-intervention assessment on PPA

Wii balance exercise X6 weeks,

3x/ week, 1h/ session

Received allocated intervention (n=30)

Conventional exercise X6 weeks,

3x/ week, 1h/ session

Received allocated intervention (n=30)

Post-intervention assessment on PPA

(n=30)

Post-intervention assessment on PPA

(n=30)

Completed 12 month follow-up on

falls surveillance (n=28)

Did not complete (n=2):

Illness (n=2)

Death (n=0)

Completed 12 month follow-up on

falls surveillance (n=27)

Did not complete (n=3)

Illness (n=2)

Death (n=1)

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A s

core

Pos

t Int

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ntio

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PPA score Pre Interventiion

Conventional

Wii

Figure 2. A scatter plot showing the PPA z-scores pre and post-intervention between the Wii Fit balance and conventional balance training groups

Group