Balance gaming: Video game balance training in elderly

The expanding aging population has ignited a growing interest in the prevention
of balance problems to reduce the risk of falling as falling can result in loss
of independence, significant morbidity or death. Physical activity has an
important influence on health status, especially for older adults. Especially
balance training can be of help to enhance the recovery of function and/or
long-term maintenance of postural control in the normal aging population. While
there are many health and social benefits from a range of exercise regimes, it
is primarily balance training that has been shown to impact significantly on
reducing falls in older adults. Balance training could not only improve
function, but also the confidence of elderly patients and they will be more
likely to maintain healthy levels of physical activity, which in turn will help
to enhance their balance control and prevent fall incidents. New
technology-based techniques, such as exergames (exercise and video games)
appear quite promising for balance training, Especially because these systems
motivate people to practice and become more and more cost-effective, portable
and user-friendly.
Recovery of function and long-term maintenance are strongly influenced by
matching training and environmental conditions to function. By playing a
balance game people do not pay attention to their movements but on the outcome
of their movements in the projected environment. This environmental focus might
facilitate the learning process. Lack of interest or attention span can also
impair the potential effectiveness of the therapeutic exercise. Attention and
motivation to practice can be enhanced by using exergames for balance training.
Playing videogames while exercising motivates people to practice simple
movements over and over again because they want to improve their high score to
progress to the next game level. Finally, research indicated the importance of
adapting the exercise interventions to the performance level of the older
adults, that is to provide individualized training. Especially exergames can be
adapted easily to the performance level of individual users. Notwithstanding
the recently increased attention in the gaming industry and media for the use
of computer games as a form of exercise (e.g. Nintendo Wii-balance board),
evidence for its beneficial effect on postural control and stability is still
scarce.

The objective is 1) to examine the effect of an exergaming balance
intervention in older adults; 2) evaluate the intrinsic or extrinsic motivation
in older adults to join a training intervention using an interactive gaming
device.

The study is an exploraty study. Subject data will be analysed by means of an
interrupted ABA time series design (ITS) .In this desging, a numer of baseline
measurements (baseline time-serie) isfollowed by an intervention period, and
again followed by a period of no intervention with only measurements. In this
desging, a numer of baseline measurements (baseline time-serie) isfollowed by
an intervention period, and again followed by a period of no intervention with
only measurements . Although an ITS is a within-subject design, it should not
be confused with a cross-over design where a carry-over or
treatment-interaction can severely weaken the power of a trial. In the ITS
design, data are collected at many consecutive points in time before, during
and after a treatment is introduced. Analyis of these measurements or so-called
time-series data, praticular the direction of the time-series for each phase
provide information about the origin of the change. Separating potential
reasons for effects into those essentially related to the intervention and
those only accidentally related is the principal task in analyzing time-series
experiments. The time-series experimental design can be regarded as an
extension in both directions (the past and the future).of the pretest-posttest
experiment. The pretest-posttest design, however is disreputable because so
many influences other than the treatment can account for a change in scores
from pre to post. A great advantage of the interrupted time-series experiment
is that it includes preintervention and postintervention observations and thus
permits separating intervention effects from other trends in a time series.
Repeated measurements of the dependent variables under baseline
condition are required to obtain a stable baseline pattern. In the baseline A1
we expect a fluctuation around a fixed level over time because our participants
are healthy subjects who do not receive treatment and will not naturally cure
or decline over such a short period, but random fluctuations or cyclical
effects in level over time can always occur. Generally, the greatest threat to
validity is that an event other than the balancetraining occurs at the same
time as the intervention, thereby making causal inferences impossible. To
control for this, we will ask participants to report their daily physical
activity.
The established baseline trends (A1 and A2) are used to assess whether the
intervention (B1) has an effect significantly greater than the underlying trend
which is observed at baseline. This involves specific statistical analyses to
separate the unaccountable variation of indices across time from the
determinant effects of the intervention. We will apply linear regression
analysis and the autocorrelation function will be estimated to adjust for
trends in combination with maximum likelihood methods. In addition different
contrast analysis of the phases will be performed.
Baseline phases: Before the intervention, in the baseline phase (A1), a
secular trend is established based on 6 measurements to detect a period trend.
The baseline phases (A1 and A2) before and after the intervention will last 3
weeks. Each week, 2 measurements will take place with 2 days in between.
Intervention phase includes a 6 week exergaming training program on the
SensBalance Board, with three times a week a session of 20-min. In addition
each week one measurement session is performed before the training session
using the same tests as during the baseline phase. With exception of the first
session which also includes an intake, none of the training and measurement
sessions will last longer then 30 minutes.

The intervention will include three 20 min exergaming sessions per week for a
period of 6 weeks. The sessions will be performed on the SensBalance Board
(Sensamove®, Utrecht, Netherlands). The balance board provides real time
feedback about balance performance on a screen in front of the participant in
the form of a labyrinth or maze game. By shifting weight on the board the maze
presented on the screen can be tilted and a ball can be moved through the maze
on the screen (see Fig 2).
During the first session the basic level will be used. In the following
sessions, like in regular computer games the program will be adjusted to the
participant*s level by increasing the difficulty of the gaming level (there are
10 levels of difficulty). These individual training adjustments ensure that the
training will be challenging for all individual participants during the whole
program. The SensBalance Board will be situated at the Hoornse Heem 100m from
the service apartment complex.

Risk assessment: The measurements and training are non-invasive. The apparatus
is used in physical therapy rehabilitation practice. Physical therapists
working for over a year with older patients (e.g. parkinson patients) on this
apparatus ensured safety and reported minimal cardiovascular load for patients
using this apparatus. Therefore, the risks associated with participation of
healthy elderly can be considered negligible and also the burden can be
considered minimal. We ask people to visit us regularly (2 to 3 times a week)
in a period of 12 weeks. Our experience (and that of other people working with
exergames) is that people enjoy playing the video games and working with new
technology, in addition to the social aspect. To minimize the effort to attend
we will plan the visits with the participants and organized a location on a
walking distance of only 100m from the participant*s home. The measurements
consist of a functional performance test battery which assesses balance. These
are standardized clinical tests, easy to administer within 30 minutes.
Reliability and validity of these tests have been established for healthy
elderly. In addition trunk sway is measured during these functional performance
tests with a light small sensor module (64x64x13 mm) which is fixed with an
elastic belt over the clothes at the trunk at the level of segment L3.

Benefits: The intervention is an exercise intervention. In general, elderly
benefit from moderate exercise both in terms of physical improvement and social
participation. The computer assisted exercise (exergaming) is a new form of
exercise. Preliminary results of a similar study in Aberdeen shows a trend in
improving balance after a 4-week intervention with the Wii-fit. In addition,
based on interviews, it was shown that elderly were more motivated to exercise
with the computer assisted apparatus. Based on these results we expect elderly
to benefit from the intervention, resulting in an improved balance.