Exergames as a rehabilitation modality to improve postural control and risk of falls in frail and pre-frail older adults

Given the serious influence of frailty on older adults, and the rising concern around its consequences, along with the increased rate and prevalence of frailty, and the sedentary lifestyle adopted by the majority of older adults, the aim of this research was to design a training protocol for frail and pre-frail older adults using exergames - exercise video games - as a rehabilitation modality, and to test the effectiveness of the protocol on postural control and risk of fall outcomes. In addition, the thesis aimed to understand how healthcare practitioners (i.e., physiotherapists and occupational therapists) perceive the use of exergames, to what extent they are familiar with it, and what can prevent them or encourage them to utilise exergames in rehabilitation. This was achieved by conducting several studies: a narrative synthesis was accomplished by a systematic review and meta-analysis, an experimental study, a questionnaire study, and the cultural adaptation and translation of the questionnaire.

First, to summarise and synthesise the evidence related to the use of exergames (Nintendo Wii™) and frail older adults, a systematic review and meta-analysis was conducted. Eleven papers were included, involving 388 participants, with a mean age of 79 ± 5.7 years. Findings from the meta-analysis showed that exergames have a significant effect on postural control but not on risk of falls. Exergames achieved better results compared to traditional exercises and control on the Berg Balance Scale [mean difference (MD) 2.80; 95% CI 1.21 to 4.39; p>0.01; I²=16%], as well as in the short-term on Timed Up and Go test (MD -1.23; 95% CI -2.37 to -0.09; p =0.03; I²=0%). However, a definitive judgement could not be arrived at due to the variability in training and outcome measurement. Findings indicated that continued work in this field is required, and several limitations were apparent; the need of quantitative and objective assessment of postural control and the lack of studies that investigate the use of multicomponent exergaming.

Second, a multicomponent exergames training protocol was developed based on the findings from the systematic review and from the literature review. Findings from the non- randomised controlled experimental study on 12 pre-frail older adults showed that 8 weeks of multicomponent exergames training using Nintendo Wii fit-plus™, twice a week for 30 minutes, had a significant effect on postural control objective outcomes (Centre of pressure mean velocity  1.62 ± 0.09 95% CI 1.41 to 1.83; p<0.01} and sway area  2.39 ± 0.18 95% CI 1.97 to 2.80; p<0.01} measured with the use of a force platform) and functional outcomes (Berg Balance Scale 41 ± 1.08 38.58 to 43.41 p<0.01} and timed up and go 14.85 ± 0.80 [13.05 to 16.64 p<0.01}) compared to a control group (p<0.01). However, no significant improvement was observed for subjective outcomes (activity balance confidence scale and falls efficacy scale international) (p≥ 0.283). These findings support the use of multicomponent exergaming using Nintendo Wii fit plusTM as a supplement to traditional exercises.

Third, to understand issues around the successful implementation of exergames in rehabilitation settings, a questionnaire specifically designed to capture how healthcare practitioners (physiotherapists and occupational therapists) perceive the use of exergames, the extent to which they are familiar with them, and the perceived advantages and barriers regarding using this modality was developed and validated then distributed. 244 responses were obtained (completion rate= 59%). To validate that the items in the questionnaire were related to each construct a factorial validity analysis was conducted. Correlations were compact and yielded distinct and reliable factors for advantages (KMO= 0.89) and barriers (KMO= 0.76) constructs which indicated that the items were related. Cronbach’s alpha value for the survey items was 0.81, which indicated that the questionnaire had an adequate level of inter-item reliability. The findings revealed that exergames use is limited, and such use is not prevalent among healthcare practitioners from different disciplines with only 17 % (n = 42/244) of the total sample using it. However, there was a positive attitude toward exergames. The most common advantage of exergames reported by participants was ‘’Make the training more motivating’’ (n=231/244, 95%), The most common barrier of exergames reported by participants was ‘’ Cost of purchasing the device and its games’’ (n=186/244, 76%). Workshops and online material should be provided to familiarise healthcare practitioners with exergames, and to overcome the lack of familiarity barrier.

Finally, to further allow non-English speakers to take part in the questionnaire, a translation and cultural adaptation of the questionnaire to Arabic by following guidelines for cross-cultural adaptation was conducted. The findings showed the Arabic version of the exergames questionnaire is reliable and culturally appropriate for use among healthcare practitioners who speaks Arabic in Arabic countries. In terms of psychometric properties of the Arabic questionnaire, internal consistency for the whole questionnaire was (Cronbach’s α= 0.84). Regarding advantages and barriers sub-scales, Cronbach’s α was 0.75 and 0.88 respectively. The test-retest reliability of the Arabic version over a 10- to 14-day period was good (ICC(19)= 0.87 values of 9.5, 95% CI (0.79 to 0.94)). A significant correlation was found between the average score on the advantages’ sub-scale from the first and second administration of the questionnaire (rho= 0.93, p>0.01). Similar findings were observed for the average score of barriers sub-scale (rho= 0.91, p>0.01).

In summary, the work carried out in this thesis extends the knowledge on the importance of multicomponent exergames as a training modality for pre-frail older adults. Furthermore, the findings from this thesis provide healthcare practitioners with a multicomponent intervention that could encourage pre-frail older adults to become physically active and improves their postural control. Additionally, healthcare practitioners showed positive attitudes toward using exergames with their patients.