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Table 2 Data summary of randomized clinical trials using exergames with other devices

From: Virtual reality using games for improving physical functioning in older adults: a systematic review

Study Sample Trial Desing Outcomes Intervention Effects Observed
Duque et al.[12] Community-dwelling elderly whit history of falls from the Falls and Fractures Clinic. Randomized controlled trial. 1) Posturography (BRU) at six different conditions: EG: Balance Rehabilitation Unit (BRU). - After 6 weeks of intervention the EG showed significant increase in LOS and smaller elliptical areas of the EC on hard surface/ foam, optokinetic stimuli, and vertical/ horizontal visual-vestibular condition.
  N = 60   - LOS; Treatment is consisted of visual-vestibular rehabilitation while standing and postural training virtual reality games (maze, breakfast and surfing) with increasing levels of complexity as the individual reported higher confidence and demonstrated learning of the correct postural control techniques required to pass to a higher level (maximum of 15 levels). - After 9 months, as compared with the CG, the EG showed significantly higher level of LOS, and significantly smaller COP areas in the optokinetic stimuli and both vertical/ horizontal visual-vestibular condition. Elliptical areas of the EC on hard surface/ foam returned to the baseline values for EG.
  EG: n = 30 (withdraw = 2)   - COP EO/ EC on hard surface; - Individual sessions 2x/week (at least 30 min each session) for 6 weeks. After 6 weeks participants received the usual care until complete 9 months. - EG subjects reported a significantly lower number of falls and lower SAFFE score as compared with the CG.
  79.3 ± 10 yrs   - COP EC on foam; CG: Usual care.  
  CG: n = 30 75 ± 8 yrs   - COP optokinetic stimuli; All participants were given general recommendations and an evidence-based care plan on falls prevention.  
    - COP horizontal/ vertical visual-vestibular condition; - 9 months.  
    2) Fall history.   
    3) Gait pattern (GAIT Rite® instrumented walkway): velocity, cadence, stride length and double support time.   
    4) Grip strength using a hand dynamometer.   
    5) Venous blood.   
    6) GDS.   
    7) SAFFE.   
Schoene et al.[13] Residents at independent-living units. Randomized controlled trial- pilot study. 1) CSRT using a step pad: reaction time, movement time and total response time. EG: A computer unit and step pad at home.  
  N = 37   2) PPA: The game required participants to synchronize their stepping with instructions presented on the screen. For each step, score and feedback was given in the center of the screen (perfect, good, miss). To introduce an additional cognitive load, a ‘bomb’, was randomly presented. If participants failed to avoid it the bomb ‘exploded’ as an indication of the error and points were correspondingly deducted from their game score. Participants were instructed how to use the system and play the stepping game in one (90 min) session in their homes and received a manual. - Compared to the CG, the EG significantly improved their CSRT, PPA composite scores, as well as the postural sway and contrast sensitivity PPA sub-component scores. In addition, the EG improved significantly in the TUG dual-task.
  78 ± 5 yrs   - contrast sensitivity, proprioception of the lower extremities (knee joint position sense); - Home individual sessions 2–3x/week (15–20 min each session) for 8 weeks. - There were no differences between groups for any of the other outcome measures.
  EG: n = 18 (withdraw = 3)   - lower extremity strength (isometric knee extension); CG: No intervention. - EG participants played a median of 2.7 sessions/week and no adverse events were reported.
  CG: n = 19 (withdraw = 2)   - standing balance (postural sway on a compliant surface);   
    - simple hand reaction time.   
    3) TUG and TUG dual task.   
    4) 5STS.   
    5) AST.   
    6) TMT.   
    7) INHIB.   
    8) FES.   
Pichierri et al. [[30] Participants from hostels for the aged. Randomized controlled trial. 1) Foot placement test: EG: Dance video game with pad. - On foot placement performance, within-group comparison resulted in a significant improvement in ML deviation and walking velocity condition 2 in EG and no changes in the CG. Between-group comparisons revealed significant differences walking velocity condition 2 in favor of EG.
  N = 31   Condition 1: self-selected pace and place the right foot into target 1 (T1)/ Condition 2: place the right foot into target 1 and the left foot into target 2 (T2)/ Condition 3: step over an obstacle lying between the two targets. EG received the CG program and in addition they performed a progressive video game dancing intervention. - The within-group comparison revealed significant walking performance improvements throughout all the walking conditions for the EG. In contrast, in the CG improvements in walking performance were only observable for the normal and normal cognitive conditions. Significant between-group differences where observed in the fast cognitive condition. The EG showed a significant increase in walking speed and a decrease in single support time compared to the CG. Significant between-group differences for DTC were observed for the parameter single support time for both normal and fast walking speed favoring EG.
  86.2 ± 4.6 yrs   - M-L/ A-P deviation; The dance video game was projected on a white wall and performed on metal dance pads. A scrolling display of arrows moving upwards across the screen cued each move, and the participants were asked to execute the indicated steps (forward, backward, right, or left) when the arrows reached the fixed raster graphic at the top of the screen, and in time with different songs. As the levels increased additional distracting visual cues, e.g., “bombs,” were presented and participants had to ignore these cues and focused on the arrows. - FES-I questionnaire showed a reduction of concerns about falling in both groups after treatment. Between-group comparison resulted in no significant differences.
  EG: n = 15 (withdraw = 4)   - walking velocity condition 2 and 3; Group sessions 2x/ week (40 min each physical program session) and in addition individual video game sessions (10-15 min) training for 12 weeks.  
  CG: n = 16 (withdraw = 5)   - M-L/ A-P contact with leading foot; CG: Physical exercise program with progressive resistance and postural balance. The training session consisted of a warm-up (5 min), resistance training (25 min), and balance exercises (10 min).  
    - contact with subsequent foot; Group sessions 2x/ week (40 min each session) training for 12 weeks.  
    - wrong foot.   
    2) Gait analysis: (GAITRiteW Platinum Version 4.0 software and the electronic walkway)   
    - Normal/ Fast/ Normal cognitive/ Fast cognitive: velocity, cadence, step time, cycle time, stance time, single/double support time, step length;   
    - dual task costs (DTC) of walking: percentage of loss relative to the single task walking performance (normal and fast walking).   
    3) Gaze behavior   
    4) FES-I.   
Szturm et al.[11] Community-dwelling older adults attending at day hospital. Randomized controlled trial. 1) BBS. EG: Program coupled to computer games. - Significant within-group and between group improvements in BBS scores were observed. Significant reductions in LOB counts on the foam surface and ABC scores were observed for the EG, but not for the CG.
  N = 30   2) TUG. Participants received a program of dynamic balance exercises coupled with video game play, using a center-of-pressure position signal as the computer mouse. The tasks were performed while standing on a fixed floor surface, with progression to compliant foam. Three games were developed for use (under pressure, memory match and balloon burst) - The EG exhibited significantly greater improvements in change scores for the BBS, ABC, LOB than the CG.
  EG: n = 14 (withdraw = 1)   3) Spatial-temporal gait pattern (gait speed, swing time, stance duration, double support, single support times, step length and step width). Individual sessions 2x/ week (45 min each session) for 4 weeks. - No significant within-group or between-group effect on spatiotemporal gait parameters and for the composite LOB on normal surface.
  80.5 ± 6 yrs    CG: Typical rehabilitation program at day hospital. - At baseline there was a significant group difference in TUG time, with a worse time among the EG. Although improvements in TUG time did occur in both groups, the differences between groups were not significant.
  CG: n = 13 (withdraw = 2)   4) ABC scale. Thera-Band and leg weights were used for strength exercises, and a cycle ergometer was used for endurance exercise. Balance exercises included hip flexion, side-leg raises, squats, and standing up from a chair and sitting down in the chair without using hands. Along with these exercises, there was an assessment of walking aids and a gait re-education program. Participants also were involved in an unsupervised walking program.  
  81 ± 7 yrs   5) MCTSIB - composite loss of balance (LOB) count for stability tasks performed on a fixed floor and on a compliant surface. Individual sessions 2x/ week, (45 min each session) for 4 weeks.  
    - standing EO/ EC;   
    - cyclic L/R head rotation;   
    - cyclic arm lifting and lowering task;   
    - cyclic L/R trunk rotations;   
    - cyclic forward trunk bending.   
Hagedorn & Holm[32] Patients from a geriatric falls and balance clinic. Randomized controlled trial. 1) Maximal isometric muscle force: knee extensor/ flexor muscle and ankle dorsiflexion. Both: Both groups received progressive resistance muscle strength training whit high intensity, training in step machine, cycling (at least 15 min and minimum of 3 km) and ball games (dribbling, rolling and throwing). Patients were also instructed to train endpoints at home when they scored low in a pre-training test. - Within group analyses showed significant improvement after the intervention period on knee extension for both groups. CG had significant improvement on STS and EG for walking distance (6 MW test).
  N = 35   2) STS (in 30s). EG: Computer Feedback System- Personics. - Comparisons between groups showed significant change in time standing on a foam with EC in favoring of EG. There were no differences between groups for others outcomes.
  81.3 ± 6.9 yrs (withdraw = 8)    Four games were used and controlled through weight shifts. Games:  
  EG: n = 15   3) Arm curl test (in 30s). 1- Building a tower used lifting a leg.  
  CG: n = 12   4) TUG. 2- Bursting a balloon with alternated movements for normal standing to toe.  
    5) 6 MW. 3- Controlling a tray with a drink by shifting the body position while standing on medium dense foam.  
    6) MCTSIB: firm and foam surface with EO/ EC. 4- Catching fruits in a bucket.  
    7) OLS. Two games were allowed at each training session if they did not exceed about 10 minutes. As patients progressed, the surface was changed to a more difficult one.  
    8) Tandem test. Individual session 2/week (1.5 hour each session) for 12 weeks.  
    9) BBS. CG: Traditional balance training.  
    10) DGI. Treatment was composed of exercises standing on different surfaces (foam, tilting platforms and pillows) EO/EC, one leg balance training, walking on a line and passing an obstacle course.  
    11) FES-I. Individual session 2/week (1.5 hour each session) for 12 weeks.  
  1. 6 MW = 6 minute walk test; ABC Scale = The Activities-specific Balance Confidence Scale; AST = Alternate Step Test; A-P = Antero – Posterior; BBS = Berg Balance Scale; CG = Control Group; COP = center of pressure; CSRT = Choice Stepping Reaction Time; EC = Eyes Closed; EO = Eyes Opened; EG = Experimental Group; FES-I = Falls Efficacy Scale International; FRT = Functional Reach Test; DGI = Dynamic Gait Index; GDS = Geriatric Depression Scale; INHIB = Inhibitory Component; L/R = Left/Right; LOS = Limit of Stability; MCTSIB = Modified Clinical Test of Sensory Interaction and Balance; M-L = Medio- Lateral; OLS = One Leg Stance; PPA = Physiological Profile Assessment; SAFFE = The Survey of Activities and Fear of Falling in the Elderly; STS = Sit to Stand; TUG = Timed Up and Go; TMT = Trail Making Test; VRE = Virtual Reality Environment.