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are serious games promoting mobility an attractive alternative to conventional self-training for elderly people?
- 1. GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS GameUp project is cofunded by the AAL Joint Programme (AAL-2011-4-090) COFUNDING PARTNERS
- 2. Page 2 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS ARE SERIOUS GAMES PROMOTING MOBILITY AN ATTRACTIVE ALTERNATIVE TO CONVENTIONAL SELF-TRAINING FOR ELDERLY PEOPLE? VIVIANE HASSELMANN MAS PT, PETER OESCH, PhD PT Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 3. Page 3 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Context Percentage of the population over 65 in Europe in 2010 Based on data from the CIA World Factbook. Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 4. Page 4 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Recommendations • Adults > 65 should practice aerobic physical activity for at least 150 minutes of moderate intensity or 75 minutes of high intensity per week (WHO, 2010) However, the compliance of elderly people to execute self-exercise programs varies considerably. These programs are often • Self-training programs: prematurely stopped. – improve significantly physical capacities, likewise therapist-assisted sessions (Olney, Nymark et al., 2006). (Phillips, Schneider et al., 2004; Burdea, 2002; Robertson et al., 2010; Rego et al., 2010). – serve as a proven efficient and cost-effective mean for inpatient rehabilitation settings. Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 5. • Valens Rehabilitation Clinic had already positive experiences manipulation of the Nintendo Wii® console (Wollersheim et al., 2010; Theng et Page 5 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Background with the use of serious games promoting mobility. • In a feasibility study, stroke patients were highly motivated to use Nintendo Wii® for training balance (Schnurr and Oesch, 2012). • However, some constraints and difficulties arose during the al., 2009; Anderson et al, 2010; Chao et al., 2013). Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 6. Page 6 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Study objectives • To determine whether elderly people in rehabilitation setting show higher adherence to self-exercise programs when using computer-based games than when performing conventional exercises. • To analyze mobility improvement according to the mode of exercising. Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 7. Page 7 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Study design • single blind, randomized controlled trial with two parallel-groups (conventional self-training exercises vs exergame self-training exercises). • double-site conducted study Valens Rehabilitation Clinics (Switzerland) O+Berri Instituto Vasco de Innovacion Sanitaria (Spain) Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 8. hampering the practice of computer-based games. Page 8 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Participants’ inclusion Inclusion Criteria • + 65 years old. • Ability to walk independently over 20 meters, with or without walking aids. • Self-training prescribed by the doctor. • Informed signed consent form. Exclusion Criteria • Cognitive impairment (MMSE score <26). • Other limiting disorders Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 9. Page 9 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Bias reduction • Stratification: participants are stratified in 4 groups according to their balance capacities (Berg Balance Score ≤ 44 or ≥ 45) and according to their computer skills (computer experience yes or no). • Randomization: Within the strata, patients are randomly assigned to one of the 2 groups (intervention vs control) with Microsoft Excel. • Single blinding: examiner is not informed of the group allocation. Independent dynamic mobility measurements. Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 10. Page 10 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Study flow Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 11. Page 11 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Outcome measures 1. Primary outcome: Intensity of the performed self-training program is collected in a logbook during the whole intervention phase. • frequency (quantity in number of sessions) • duration (time in minutes) of self- training sessions 2. Secondary outcomes: Mobility capacities are tested at pre- and post-intervention. • The Berg Balance Scale (BBS) • self-perceived Fall Efficacy Scale (FES-I) • ActiGraph Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 12. Page 12 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Measurement methods - 1 • pro forma logbook Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 13. • Falls Efficacy Scale measures the subjective level of Page 13 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Measurement methods - 2 • Berg Balance Scale measures the objective balance capabilities of the patient. It also serves as baseline for the exercise level. It tests the ability to keep balance in various standard activities (Berg et al., 1992). concern about falling during social and physical activities (Lomas-Vega et al., 2012; Dias et al., 2006). Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 14. Page 14 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Measurement methods - 3 • ActiGraph Mobility Tracker assesses mobility by a tri-axial accelerometer measuring Local Dynamic Stability (Wollerheim et al., 2010). • It has been advocated as an early indicator of risk for falls (Hilfiker et al., 2013). Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 15. Page 15 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Time flow of interventions Entry 1 day after entry 2 days for instructions Week 1 Week 2 1 2 3 4 5 6 7 8 9 10 End I 1 I 2 I 1 I 2 Test 1 T1 T2 Check inclusion criteria Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014 Test 2 Serious games promoting mobility Conventional self-training Logbook (from day 1 to day 10)
- 16. Page 16 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Level 1 self-training • Berg Balance Scale score < 45 • Exercises performed in sitting position Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 17. Page 17 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Level 2 self-training • Berg Balance Scale score between 45 and 56 • Exercises performed in standing position Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 18. Page 18 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Level 3 exercises • Berg Balance Scale score = 56 • Exercises performed in standing and walking Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 19. Page 19 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Discussion • To our knowledge this study is the first to compare conventional self-training programs with serious games among elderly persons. • Results of this study will provide insight into the effectiveness of serious games promoting mobility and contribute to our understanding of the motivational potential of serious games in elderly people. Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
- 20. Page 20 GAME-BASED MOBILITY TRAINING AND MOTIVATION OF SENIOR CITIZENS Thank you very much for your attention Questions? Project Number: AAL-2011-4-090 AAL Forum Bucarest September 2014
Editor's Notes
- This presentation will describe the study protocol of the clinical trial performed as part of our GameUp project.
- The European population is getting older. Due to these demographic changes, the need for adapted medical services for this specific age group has become critical.
- In order to improve cardiorespiratory and muscular functions, and to reduce the risk of non-communicable diseases, depression and cognitive decline, the WHO recommends that adults aged over 65 practice aerobic physical activity for at least 150 minutes of moderate intensity or 75 minutes of high intensity per week. Moreover, elderly people should perform strengthening exercises minimum twice a week and balance exercises minimum thrice a week. In this manner, to increase therapy intensity and thus independence in activities of daily living, older patients admitted to rehabilitation are often instructed customized self-training exercises. These self-training programs, likewise therapist-assisted sessions, improve significantly physical capacities, and thus serve as a proven efficient and cost-effective mean for rehabilitation settings. However, the compliance of elderly people to execute self-exercise programs varies considerably. These programs are often considered as tedious and boring, hence prematurely stopped. An alternative to increase patient’s motivation for self-exercising is using serious games promoting mobility.
- Some studies indicated constraints and difficulties during the manipulation of the commercial Nintendo Wii®: games are designed for the young and healthy audience and so older users need a lot of technical help, motions and interactions through a console make it more difficult to manipulate, scores and progress measurements are too generic for rehabilitation use. Due to their lack of computer skills, serious games intended for elderly people should reproduce as much as possible activities of daily living (Gerling, Livingston et al., 2012) with little simultaneous information and few options but with enough time for assimilation (Burmeister, 2010). These requirements are usually not met by standard commercial serious games.
- Hence these questions emerge: do elderly people train more frequently with serious games promoting mobility than with conventional self-training exercises? and thereby achieve a greater improvement in balance and mobility capacities? Therefore the primary objective of our clinical trial is to determine whether elderly people in rehabilitative settings show higher adherence to self-training when using serious learning games than when performing conventional exercises. Secondly it explores balance and mobility performances according to the mode of self-training. In this presentation, I will focus on the study protocol.
- Inclusion Criteria • + 65 years old • Ability to walk independently over 20 meters, with or without walking aids • Self-training is prescribed by the doctor • Sufficient written and spoken knowledge of German to fill out the questionnaires, with or without help. • Informed signed consent form. Exclusion Criteria • Cognitive impairment, defined as a Mini Mental State Examination (MMSE) score <26 • Other limiting disorders hampering the practice of computer-based games (e.g. visual impairment, numbness, vertigo) Based on our observations from the Wii® study, we assume that serious games promoting mobility lead to higher motivation and therefore patients tend to train more often and longer. We assume a statistical power of 0.80 and a medium effect size (d = 0.5). With this magnitude of the effect of interest in the population, a sample size of 64 subjects per group is necessary to prove any statistical significance.
- Stratification: participants are stratified in 4 groups according to their balance capacities (Berg Balance Score ≤ 44 or ≥ 45) and according to their computer skills (computer experience or no computer experience). This stratification is important to reduce bias in relation to the primary study question: firstly, it should be avoided that more computer experienced participants are included in the Kinect group and secondly participants with poor balanced capacities should be equally distributed in both groups. Randomization: These tables were then randomized in Microsoft Excel (with the Random function), so that each patient is randomly assigned to one of the 2 groups. Blinding: The examiner reports after the stratification process to an independent body which possesses the randomization tables. On the basis of these 4 stratification tables, patients are randomly assigned to one of the 2 groups (serious games or conventional exercises). The examiner is not informed in which group the patient is finally allocated. Whereas the physiotherapist is aware of it in order to be able to instruct the appropriate self-training program to the patient.
- Primary outcome: The primary outcome measures the intensity in which the patient performs self-training exercises individually and without being asked. The intensity is based on the frequency (quantity) and duration (time in minutes) of self- training sessions, and is recorded in a logbook by the patient. 2. Secondary outcomes: Secondary outcomes are the balance improvement, which are measured with a pre- and post-test method. The used assessment tools are the Berg Balance Scale (BBS) and the self-perceived Fall Efficacy Scale-International version (FES-I) and the ActiGraph.
- Logbook measures the intensity of the performed self-training exercises (for both groups). Before the intervention phase, each participant receives a pro forma logbook from the physiotherapist. The participant records himself daily frequency and duration of each performed self-training session. Data collected are: date, total number of sessions performed, duration in minutes of each self-training, Number of steps and floors walked and motivation. The logbook contains predefined fields to fill out.
- - The Berg Balance Scale (BBS) is collected in a pre/post-test method, and measures the balance capabilities of the patient performed by the examiner. It also serves as baseline for the exercise level. The BBS measures the ability to keep balance in 14 standard activities. The assessment is divided into the following 3 subcategories: stability, postural reactions and equilibrium reactions. These three categories are divided into 14 items. The items are organized following a progression from the simplest ("free sitting " ) to the most difficult (" standing on one leg "). For each item, the score is evaluated on a five-point scale, ranging from 0-4. “0” indicates the lowest level of function and “4” the highest level of function or in other words, from “not possible” to “independent”. The maximum total score is 56. The higher the score, the better are balance capabilities. The BBS is considered the gold standard for assessment of balance. - The Falls Efficacy Scale - International Version (FES -I) is used as a structured self-administered questionnaire filled by the patient at pre- and post-intervention. The FES-I is a short, easy to administer tool that measures the subjective level of concern about falling during social and physical activities inside and outside the home whether or not the person actually does the activity. It consists of 16 Items and the level of concern is measured on a four-point scale (1=not at all concerned to 4=very concerned).
- Actigraph Mobility Tracker assesses mobility by a tri-axial accelerometer measuring Local Dynamic Stability. LSD is a non-linear gait stability index quantified by calculating Lyapunov exponent. It has been advocated as an early indicator of risk for falls.The triaxial accelerometer is attached to the lower back at the level of the third lumbar vertebra and measured trunk acceleration in mediolateral (ML), vertical (V) and anteroposterior (AP) directions. Lyapunov Exponent definition (Wikipedia): Dans l'analyse d'un système dynamique l'exposant de Lyapunov permet de quantifier la stabilité ou l'instabilité de ses mouvements1. Un mouvement instable a un exposant de Lyapunov positif, un mouvement stable, un exposant de Lyapunov négatif. Les mouvements bornés d'un système linéaire ont un exposant de Lyapunov nul. L'exposant de Lyapunov peut servir à étudier la stabilité (ou l'instabilité) des points d'équilibre des systèmes non linéaires.
- Participants are entitled to 2 time-slots à 30min per day, from Monday to Friday, dedicated to self-training in addition to the usual rehabilitation services, and this during the 10 days of the intervention period. Self-training programs are instructed by a trained physiotherapist and appropriate balance exercises are selected according to the patient’s balance capacities. BBS is used as a cutoff point: A BBS score < 45 indicates a risk of falling, and thus patients scoring less than 45 points perform the balance exercises in sitting position only. Patients scoring between 45 and 56 points perform the balance exercises in static standing position, whereas patients reaching the maximum score of 56 points perform exercises in dynamic standing position. During the instruction, patients are told the following: "From Monday to Friday, you can use every available free time to carry out the self-training program. Perform the self-training exercises as intensively as possible, and as often as you want.” Additionally patients are encouraged to walk and climb stairs instead of using the lift, in order to improve their endurance.