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Effectsofbalance-focusedinteractivegames
comparedtotherapeuticbalanceclassesforolder
women
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CLIMACTERIC 2013;16:141–146
Effects of balance-focused interactive games
compared to therapeutic balance classes for
older women
D. K. A. Singh, B. S. Rajaratnam*, V. Palaniswamy, V. P. Raman, P. S. Bong and H. Pearson†
Universiti Kebangsaan Malaysia, Faculty of Health Sciences, Kuala Lumpur, Malaysia; *Nanyang Polytechnic, Singapore;
†Pantai Integrated Rehab Services Sdn Bhd, Pandan Indah, Kuala Lumpur, Malaysia
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Key words: VIRTUAL REALITY, BALANCE, AGILITY, FUNCTIONAL MOBILITY, COMMUNITY-DWELLING OLDER WOMEN
ABSTRACT
Objective The prospective pre–post control study was designed to evaluate the effect of introducing balancefocused interactive virtual-reality games to community-dwelling older women to improve their agility, balance
and functional mobility.
Method The study was set in a senior citizens’ club in Cheras, Kuala Lumpur, Malaysia. The participants were
36 community-dwelling older women. Participants were randomly divided into either a group undertaking
balance-focused virtual-reality games or a group doing therapeutic balance exercises. The program lasted
6 weeks and was conducted twice a week for 40 min during each session. As the main outcome measures,
the results of the Ten Step Test (TST), postural sway (overall performance index, OPI) and the Timed Up and
Go test (TUG) were measured pre- and post-intervention to evaluate agility, balance and functional mobility,
respectively.
Results Although both groups improved in OPI (F ⫽ 4.63, p ⬍ 0.001), TST (F ⫽ 46.15, p ⬍ 0.001) and TUG
(F ⫽ 52.57, p ⫽ 0.03), combined time and group interaction only improved in the TUG (F ⫽ 4.54, p ⬍ 0.05).
No significant differences between the two groups were found in terms of TST (F ⫽ 0.02, p ⫽ 0.86), OPI
(F ⫽ 0.66, p ⫽ 0.42), and TUG (F ⫽ 0.11, p ⫽ 0.74).
Conclusion Older people could improve their agility, balance and functional mobility by complementing
therapeutic balance exercises with active participation in interactive virtual-reality games at home or in the
community.
INTRODUCTION
By 2050, the world is expected to have 2 billion older adults
aged 60 years or more and 54% of them will be residing in
Asia1. The older adult who adopts a sedentary lifestyle has
poorer agility, balance and impairment in mobility compared
to the aged-matched individual who exercises regularly at
moderate intensity for 30 min at least 5 days a week2–8. Thus,
a regular exercise program for older adults should include
balance and agility training components1,9.
Balance training is important as the sensorimotor system
starts to decline early in the fourth decade of life9. Tai-Chi
and golf are exercises that activate the sensorimotor system
to improve balance, knee joint proprioception and limits of
stability in the stance of older adults10–13. Older adults are
more likely to comply and adhere to physical activities that
are engaging, interesting, motivating, and easy to perform
compared to activities such as jogging, cycling and strength
training14,15. Performing exercises indoors may also be preferred so as to avoid the impact of outdoor weather.
Interactive virtual-reality games performed in the comfort
of one’s own home and in the community present an opportunity for the older adult to keep agile and physically fit independently. The Wii FitTM is a new-generation, interactive,
virtual-reality game tool that immerses the user in a stimulating ‘real exercises’ environment. It is worth noting that 25%
of today’s gamers are above the age of 60 years16. Interactive
virtual-reality games have varied levels of challenges and
Correspondence: Dr D. K. A. Singh, Universiti Kebangsaan Malaysia, Faculty of Health Sciences, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur,
Malaysia
ORIGINAL ARTICLE
© 2013 International Menopause Society
DOI: 10.3109/13697137.2012.664832
Received 29-11-2011
Revised 31-01-2012
Accepted 04-02-2012
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Interactive virtual-reality games and older women
provide real-time visual feedback to improve older adults’
balance and lower limb muscle strength15,17. Interactive virtual-reality games can be performed at any time and at any
location and are known to increase practice volume and
attention span18–21. Interactive virtual-reality games and
robot-assisted movement training have been shown to improve
upper limb motor function after stroke22,23. Communitydwelling older women who participated in interactive virtualreality games improved their balance15,18,24–26 and attention
span, hand–eye coordination, motor skills, short-term memory,
problem solving and reaction time27.
The current study evaluated the effect of introducing balance-focused, interactive, virtual-reality games compared to
therapeutic balance exercise classes among communitydwelling older women to study the effect on their agility,
balance and functional mobility. This study also investigated
covariates of the pre-intervention physical status of older
adults as confounding or interacting factors. If interactive
virtual-reality games are found to improve the agility, balance and functional mobility of older adults, health-care
professionals can introduce these games to be undertaken as
exercises within the home as well as in rehabilitation units
for older adults with dysfunction. Computer-literate older
adults who are capable of exercising safely and in an unsupervised environment could also keep physically active
within the comfort of their homes and in the community. A
physically fit, older adult requires less medical services and
places less strain on medical and long-term care facilities28.
METHODS
Forty-six women aged 56 years and above, who could ambulate without a walking aid and were willing to attend twice-aweek exercise programs, were recruited from a senior citizens’
club in Kuala Lumpur, Malaysia. Participants were excluded
if they had severe cognitive impairments (Mini Mental State
Examination score ⬍ 23), vestibular and visual impairments
that were not corrected, an ear infection 2 weeks before the
intervention, were currently enrolled in a structured physical
activity program, or taking antipsychotic or antidepressants
that could affect their balance. Two participants were
excluded from the study based on the exclusion criteria. Six
participants voluntarily withdrew before the start of the
intervention.
The study was approved by the Faculty Research Ethics and
Governance Committee of Universiti Kebangsaan Malaysia
(NN-120 - 2010, NN-114 - 2010). Participants were informed
of details of the study and their written consent obtained.
The body mass index of each participant was calculated.
Agility was quantified with the Ten Step Test (TST), as reported
by Miyamoto and colleagues29. Participants stepped up and
down a 10-cm high stool with one foot first, followed by the
other foot. Participants performed step-ups and downs ten
times and as fast as possible. Each participant did the TST
twice with a 10-min rest between each attempt, and their
fastest time was recorded.
142
Singh et al.
An intelligent balance board, with perturbation features
and attached to a computer screen that has an intra-class correlation coefficient of r ⫽ 0.916 (Probalance, Lab Rehab Pte
Ltd., Singapore), quantified each participant’s postural sway30.
When participants stood on the Probalance, they were
instructed to keep their center of body mass within a circle
shown on the computer screen for 30 s. Their anterior–
posterior and medial–lateral sway scores were converted to
an overall performance index (OPI) by the Probalance software program. Lower OPI scores reflect better ability to regulate postural sway.
Functional mobility was quantified by performing the
Timed Up and Go (TUG) test. Participants were required to
stand up from an arm chair (46 cm seat height and 65 cm
arm height), walk 3 m as fast as possible, turn around and
walk back to sit on the chair; the time they took was recorded31.
The test–retest intra-class correlation coefficient of the TUG
is r ⫽ 0.9731,32. The assessor who measured TST, OPI and
TUG in weeks 1 and 7 was blinded to the type of intervention
that each participant experienced (Figure 1).
Procedure
Thirty-eight participants were randomly allocated to the
group undertaking the balance-focused, interactive, virtualreality games (experimental) or to the therapeutic balance
exercise group (control). One participant from each group
withdrew after the first session. Thirty-six participants completed the 6-week intervention. Table 1 lists the demographic
data of the 36 participants.
Both programs consisted of 5 min of warming-up exercises
followed by 30 min of either the experimental or the control
programs. The programs concluded with 5 min of coolingdown exercises. Sessions for both groups were conducted
twice weekly for six continuous weeks.
Participants in the experimental group performed the exercises using the Nintendo® Wii balance board. The virtualreality games selected for this study were Ski Slalom, Table
Tilt, Penguin Slide, Soccer Heading, Tight Rope Walk, Perfect
10 and Tilt City. Participants progressed within each game at
their own pace from the beginner level to the advanced level,
and then to the expert level.
Participants in the control group performed five balance
tasks adapted from the protocol of Seidler and Martin33. The
tasks were ‘one leg standing’, ‘free leg swinging’, ‘moving
objects forward, backwards and sideways’, and ‘walking in
place, sideways and backwards’. Participants progressed by
increasing their speed of performance and the complexity of
each task. For example, the complexity of ‘one leg standing’
progressed from standing with the eyes opened, to standing
with the eyes closed and finally standing on foam with eyes
opened.
Data was analyzed with a two-way repeated measure
(ANOVA) with time and group as the within- and betweensubject variables. SPSS software version 19 was utilized during
the analysis.
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Interactive virtual-reality games and older women
Singh et al.
Recruitment and screening tests
(n = 46)
2 participants excluded
6 participants withdrew
Baseline evaluation of TST, OPI, TUG
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Randomization
(n= 38)
Week 1: Experimental
Week 6: Completed intervention
(n = 18)*
Week 1: Control
Week 6: Completed intervention
(n = 18)*
Week 7: Post-intervention evaluation of TST, OPI, TUG
Figure 1 Flow chart depicting total participants and the methodology of the study. *, One participant from each group withdrew after the fi rst
session. Reasons given were travelling overseas and illness. TST, Ten Step Test; OPI, overall performance index; TUG, Timed Up and Go
the virtual-reality game group and the therapeutic balance
exercise group post-intervention.
RESULTS
The demographic data of the participants are shown in
Table 1. There were no significant differences in age and body
mass index between the groups.
The results indicated significant within-group improvement
in TST, OPI and TUG due to the intervention (TST, F ⫽ 46.15,
p ⬍ 0.001; TUG, F ⫽ 52.57, p ⬍ 0.001; OPI, F ⫽ 4.63,
p ⫽ 0.03). The between-group effect showed no significant
difference in TST (F ⫽ 0.02, p ⫽ 0.86), OPI (F ⫽ 0.66, p ⫽ 0.42)
and TUG (F ⫽ 0.11, p ⫽ 0.74). Analysis of time and group
interaction showed significant effect in TUG (F ⫽ 4.54,
p ⫽ 0.04) (Table 2). No significant effects were demonstrated
for TST (F ⫽ 1.17, p ⫽ 0.29) and OPI (F ⫽ 1.32, p ⫽ 0.26)
(Table 2). Figure 2 depicts the percentage improvement in
DISCUSSION
This study demonstrated that community-dwelling older
women who participated in regular, interactive, virtual-reality
games could improve their agility, balance and functional
mobility. The improvements were similar to the outcomes of
older women who participated in a therapeutic balance exercise program. Thus, therapists working in community settings
can introduce interactive virtual-reality games to communitydwelling older adults to improve their balance and minimize
their risk of falls.
Table 1 Demographic data of participants. Data are given as mean ⫹
⫺ standard deviation
Age (years)
Body mass index (kg/m2)
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Experimental group
(n ⫽ 18)
Control group
(n ⫽ 18)
61.12 ⫹
⫺ 3.72
29.54 ⫹
⫺ 5.01
64.00 ⫹
⫺ 5.88
27.31 ⫹
⫺ 4.31
Analysis of covariance
0.08
0.10
143
Interactive virtual-reality games and older women
Singh et al.
Table 2 Comparison of time and group interaction effects on TST, OPI and TUG in the balance-focused,
interactive, virtual-reality games group (experimental) and therapeutic balance exercise group (control). Data
are given as mean ⫹
⫺ standard deviation
Variable
TST pre-intervention (s)
TST post-intervention (s)
OPI pre-intervention (score)
OPI post-intervention (score)
TUG pre-intervention (s)
TUG post-intervention (s)
Experimental group
(n ⫽ 18)
Control group
(n ⫽ 18)
19.96 ⫹
⫺ 4.20
16.35 ⫹
⫺ 4.37
1.43 ⫹
⫺ 0.56
0.99 ⫹
⫺ 0.42
9.55 ⫹
⫺ 1.48
8.27 ⫹
⫺ 1.64
20.86 ⫹
⫺ 5.37
15.89 ⫹
⫺ 2.88
1.40 ⫹
⫺ 0.79
1.27 ⫹
⫺ 0.64
10.24 ⫹
⫺ 1.88
7.90 ⫹
⫺ 1.30
Analysis of
covariance
F (d.f.)†
p
1.17
0.29
1.32
0.26
4.54
0.04*
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†, Time and group interaction effect; *, p ⬍ 0.05
TST, Ten Step Test; OPI, overall performance index; TUG, Timed Up and Go
Agility is the ability to change positions and directions
quickly, with accuracy and without loss of balance34. Regular
participation in virtual-reality games requires repetitive performance of visual neuromotor actions that are quick and
precise to respond effectively to disturbances of body equilibrium during activities35. Our results indicated an 18%
improvement in agility after participating in the balancefocused, interactive, virtual-reality games for 6 weeks compared with therapeutic balance exercises (Figure 2). To the
best of our knowledge, this is the first study that has quantified agility improvement among community-dwelling older
women after they participated in a regular, balance-focused,
interactive, virtual-reality games-based program.
Our findings are in agreement with other studies that also
found improvement using virtual-reality games among participants with impaired balance25, neurological impairment36,
healthy older adults15,26 and young adults24. Balance-focused,
virtual-reality games require one to decrease one’s postural
sway to move safely and repeatedly in all directions. The
percentage of improvement in body sway among those who
participated in balance-focused, interactive, virtual-reality
games compared to therapeutic balance exercises was 21%
higher (Figure 2). The results suggest that older women,
who can exercise safely alone and are unable to attend
rehabilitation, can participate in regular, interactive, virtualreality games in their homes or in community settings.
Functional mobility to rise from sitting to standing, walk
a distance and turn around and return to sit also improved
after participation in balance-focused, interactive, virtualreality games. Our results concur with similar findings among
patients after stroke and the elderly who used the Wii Fit
system36,37. However, TUG scores of those in the therapeutic
balance exercise group improved 9.54% more than those in
the interactive, virtual-reality games group. One explanation
would be that balance-focused, interactive, virtual-reality
games confine one’s body sway within the Wii balance board
whereas therapeutic balance exercises allow one to move
around freely during exercise and thus the performance more
Figure 2 Percentage improvement after training on agility, balance and functional mobility. *, p ⬍ 0.05 in comparison with change between
virtual-reality balance games and therapeutic balance exercise group post-training. TST, Ten Step Test; OPI, overall performance index;
TUG, Timed Up and Go
144
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Interactive virtual-reality games and older women
closely resembles the functional mobility required in activities of daily living. Developers of interactive virtual games
should include safe functional mobility activities in their
design of future games for the older adult. Nevertheless,
older adults who regularly participate in balance-focused,
interactive, virtual-reality games can improve their functional mobility.
Health-care professionals could work with interactive digital media developers to design rehabilitation-focused games
to keep the growing number of older adults physically active
and disability-free. Rehabilitation-focused games must also
have features to measure therapeutic outcomes besides providing the older adult with immediate feedback to monitor
their own progress at home and in the community. The outcomes can be transmitted remotely to a virtual rehabilitation
therapist for analysis and progression of treatment. Besides
promoting physical activity and better therapeutic outcomes
among community-dwelling older adults, their collaborative
work can go one step further to design safe and beneficial
rehabilitation-focused fall-prevention games for the growing
number of older adults at risk of falls. The collaboration may
result in commercially available rehabilitation-focused, interactive, virtual-reality games in the future that would be
included within therapy sessions to reduce clinicians’ time in
implementing rehabilitation programs. In addition, rehabilitation-focused games may empower older adults to take
responsibility for their own physical and mental fitness and
well-being.
One of the limitations of this study is the therapeutic balance
program adapted from the study of Seidler and Martin33 which
was modified to mimic the exercises in the balance-focused,
interactive, virtual-reality games-based group. This may
explain why no significant differences were demonstrated
between the groups. Second, as the study was performed in
community-dwelling older women, the results of this study
may not be applied to institutionalized older adults.
Singh et al.
CONCLUSIONS
Participation in regular, balance-focused, interactive, virtualreality games improved the agility, balance and functional
mobility of community-dwelling older women. Collaboration
between heath-care professionals and virtual-reality game
developers should result in the development of simple yet
effective rehabilitation-focused, interactive, virtual-reality
games than can measure therapeutic outcomes for use in the
community, in rehabilitation centers and at home. Participation in rehabilitation-focused, interactive, virtual-reality games
could also be part of the overall preventative management
strategy to keep the mobility of older adults in the community,
and at lesser risk of falls and disability.
ACKNOWLEDGEMENTS
We thank the participants and management of Senior Citizens’
Club, Cheras, Kuala Lumpur for their support and assistance
rendered in the study. We also thank Nanyang Polytechnic,
Singapore and Pantai Integrated Rehab Services Sdn. Bhd.,
Malaysia for their active support of this study.
Conflict of interest
We certify that we have no affi liation with or fi nancial involvement (e.g. employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants and patents received or pending, royalties)
with any organization or entity with a fi nancial interest in,
or fi nancial confl ict with, the subject matter or materials
discussed in the manuscript and all such affi liations and
involvements are disclosed in the manuscript.
Source of funding
This study was funded by a Grant
from Universiti Kebangsaan Malaysia (UKM-HEJIMINDUSTRY-19-2010).
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