Exercise and rehabilitation delivered through exergames in older adults: An integrative review of technologies, safety and efficacy

Background: There has been a rapid increase in research on the use of virtual reality (VR) and gaming technology as a complementary tool in exercise and rehabilitation in the elderly population. Although a few recent studies have evaluated their efficacy, there is currently no in-depth description and discussion of different game technologies, physical functions targeted, and safety issues related to older adults playing exergames. Objectives: This integrative review provides an overview of the technologies and games used, progression, safety measurements and associated adverse events, adherence to exergaming, outcome measures used, and their effect on physical function. Methods: We undertook systematic searches of SCOPUS and PubMed databases. Key search terms included “game”, “exercise”, and “aged”, and were adapted to each database. To be included, studies had to involve older adults aged 65 years or above, have a pre-post training or intervention design, include ICT-implemented games with weight-bearing exercises, and have outcome measures that included physical activity variables and/or clinical tests of physical function. Results: Sixty studies fulfilled the inclusion criteria. The studies had a broad range of aims and intervention designs and mostly focused on community-dwelling healthy older adults. The majority of the studies used commercially available gaming technologies that targeted a number of different physical functions. Most studies reported that they had used some form of safety measure during intervention. None of the studies reported serious adverse events. However, only 21 studies (35%) reported on whether adverse events occurred. Twenty-four studies reported on adherence, but only seven studies (12%) compared adherence to exergaming with other forms of exercise. Clinical measures of balance were the most frequently used outcome measures. PEDro scores indicated that most studies had several methodological problems, with only 4 studies fulfilling 6 or more criteria out of 10. Several studies found positive effects of exergaming on balance and gait, while none reported negative effects. Conclusion: Exergames show promise as an intervention to improve physical function in older adults, with few reported adverse events. As there is large variability between studies in terms of intervention protocols and outcome measures, as well as several methodological limitations, recommendations for both practice and further research are provided in order to successfully establish exergames as an exercise and rehabilitation tool for older adults.© 2015 Elsevier Ireland Ltd. All rights reserved. This is the authors' accepted and refereed manuscript to the article. Locked until januar 2017-01-01 due to the copyright restrictions

How Effective Is “Exergamification”? A Systematic Review on the Effectiveness of Gamification Features in Exergames

Physical activity is very important to public health and exergames represent one potential way to enact it. The promotion of physical activity through gamification and enhanced anticipated affect also holds promise to aid in exercise adherence beyond more traditional educational and social cognitive approaches. This paper reviews empirical studies on gamified systems and serious games for exercising. In order to gain a better understanding of these systems, this review examines the types and aims (e.g. controlling body weight, enjoying indoor jogging…) of the corresponding studies as well as their psychological and physical outcomes. This paper particularly reviews the deployed motivational affordances and the effectiveness of incorporating gamification features in exergames. The review shows overall positive psychological outcomes (e.g. enjoying exercise) as well as behavioral ones (e.g. decreasing sedentariness) about exergames. Its findings inform about the current state of the research on the topic, based on which, suggestions for further research are outlined

Motivational strategies and approaches for single and multi-player exergames: A social perspective

Background: Exergames have attracted the interest of academics, practitioners, and designers, in domains as diverse as health, human-computer interaction, psychology, and information technology. This is primarily because exergames can make the exercise experience more enjoyable and entertaining, and in turn, can increase exercise levels. Despite the many benefits of exergames, they suffer from retention problems. Thus, the objective of this article was to review theories and game elements that have been empirically examined or employed in an attempt to make exergames more motivating so people engage in sustained physical activity (duration of physical activity) in a repeating pattern over time (frequency of physical activity). Methodology: A literature search and narrative review were conducted. Results: Five major theories and elements were prevalent in the exergaming literature: (1) self-determination theory, (2) gamification, (3) competition and cooperation, (4) situational interest, and (5) social interaction. These theories and elements are important for encouraging long-term play and show promise for designing exergames to promote sustained engagement and motivate physical activity. We discuss their strengths and weaknesses throughout the paper. Conclusions: The long-term effectiveness of exergame interventions is unclear mainly because of the limited amount of long-term studies. Better metrics are also needed to evaluate this effectiveness. We also identified particular attention to social factors and group dynamics, such as multi-player exergames and more effective player matchmaking strategies for increasing social connectedness, as a key area of future research

Improving personalized elderly care: an approach using cognitive agents to better assist elderly people

Tesis por compendio de publicaciones[ES]El envejecimiento de la población a nivel global es una constante cada vez más presente en el día a día y las consecuencias derivadas de este problema son cada vez más impactantes para el correcto funcionamiento y estructuración de la sociedad. En este contexto, hablamos de consecuencias a nivel de crecimiento económico, estilos de vida (y jubilación), relaciones familiares, recursos disponibles por el gobierno a la franja etaria más anciana e inevitablemente la prevalencia de enfermedades crónicas. Es ante esta realidad que surge la necesidad de desarrollo y promoción de estrategias eficaces en el acompañamiento, prevención y estímulo al envejecimiento activo y saludable de la población para garantizar que las personas ancianas continúen teniendo un papel relevante en la sociedad en lugar de someterse al aislamiento y fácil deterioro de las capacidades físicas, cognitivas, emocionales y sociales. De esta forma, tiene todo el sentido aprovechar todos los desarrollos tecnológicos verificados en los últimos años, principalmente en lo que se refiere a avances en las áreas de dispositivos móviles, inteligencia artificial y sistemas de monitoreo y crear soluciones capaces de brindar apoyo diariamente al recopilar datos e indicadores del estado de salud y, en respuesta, proporcionar diversas acciones personalizadas que motiven la adopción de mejores hábitos de salud y medios para lograr este envejecimiento activo y saludable. El desafío consiste en motivar a esta población a conciliar su día a día con el interés y la voluntad de utilizar aplicaciones y sistemas que brinden este apoyo personalizado. Algunas de las abordajes recientemente explorados en la literatura con este objetivo y que han alcanzado resultados prometedores se basan en la utilización de técnicas de gamificación e incentivo al cumplimiento de desafíos a nivel de salud (como si la persona estuviera jugando un juego) y la utilización de interacciones personalizadas con objetos (ya sean físicos como robots o virtuales como avatares) capaces de brindar feedback más personal, creando así una conexión más cercana entre ambas entidades. El trabajo aquí presentado combina estas ideas y resulta en un enfoque inteligente para la promoción del bienestar de la población anciana a través de un sistema de cuidados de salud personalizado. Este sistema incorpora diversas técnicas de gamificación para la promoción de mejores hábitos y comportamientos, y la utilización de un asistente virtual cognitivo capaz de entender las necesidades e intereses del usuario para posibilitar un feedback e interacción personalizados con el fin de ayudar y motivar al cumplimiento de los diferentes desafíos y objetivos que se identifiquen. El enfoque propuesto fue validado a través de un estudio con 12 usuarios ancianos y se lograron resultados significativos en términos de usabilidad, aceptación y efectos de salud. Específicamente, los resultados obtenidos permiten respaldar la importancia y el efecto positivo de combinar técnicas de gamificación e interacción con un asistente virtual cognitivo que traduzca el progreso del estado de salud del usuario, ya que se lograron mejoras significativas en los resultados de salud después de la intervención. Además, los resultados de usabilidad obtenidos mediante la cumplimentación de un cuestionario de usabilidad confirmaron la buena adhesión a el enfoque presentado. Estos resultados validan la hipótesis de la investigación estudiada en el desarrollo de esta disertación

CorpOperatio: Game-inspired App for Encouraging Outdoor Physical Activity for People with Intellectual Disabilities

This thesis presents a serious mobile exergame for people with intellectual disabilities, to help people with intellectual disability be more physically active. Exergames are games with the purpose of physically engaging the user in the gameplay, and intervenes with sedentariness and repetitive behavior. The game is based around the use of augmented reality, which is described as bringing 3D virtual objects into a 3D real environment in real time. As the field of physical activity in people with intellectual disabilities is a low-research field, the project aims to create a technical solution to them improve their physical health. There are few solutions tailored for people with intellectual disabilities to aid in physical exercise, something we wanted to change. A physical activity mobile game was created using the Unity game engine and augmented reality. Requirements and design choices came through literature review, reference meetings and meetings with professional psychologists. The game was tested by intellectually disabled users in a controlled, randomized trial over the course of four days, with interviews after testing to get results. While evaluation of the application rvealed areas of potential improvement, the application is already usable for people with intellectual disabilities. Augmented reality proved to be challenging to understand initially, but also fun, once the concept was understood. We have created an application for encouraging physical activity for people with intellectual disabilities. The application shows promise, but also improvement points for it to be deployed to the public market

Mobile exergaming in Type 2 Diabetes mellitus – innovative ways to overcome physical inactivity and increase exercise adherence

Background Type 2 diabetes has developed into a worldwide pandemic in recent years that is associated with vast comorbidity and mortality and has created an enormous financial strain on health care systems all around the globe. Physical inactivity is known to be one of the most important risk factors for the development of type 2 diabetes and responsible for much of the diabetes‐related comorbidity. An increase in regular physical activity is therefore an essential component of a successful type 2 diabetes treatment. However, despite the proven benefits of regular physical activity, the vast majority of patients with type 2 diabetes remain inactive – often due to low motivation and lack of physical activity enjoyment. A recent and promising approach to motivate sedentary individuals to be more physically active and sustainably adhere to regular physical activity is exergames. These games integrate physical activity and personal health information into a game or game‐like setting and thereby promote physical activity through playful and enjoyable challenges. Aims The aims of this Ph.D. project were: (1) to systematically review the current evidence for the effectiveness of exergaming in overweight and type 2 diabetes and (2) to evaluate the suitability of the Wii Fit Plus exergame to improve cardiorespiratory fitness in individuals with type 2 diabetes. The aim was further (3) to develop a behavior change technique‐based smartphone game that delivers individualized exercise and physical activity promotion with the intention to motivate inactive type 2 diabetes patients to become sustainably physically active and to plan a 24‐week randomized controlled trial evaluating the game’s effectiveness. In addition, it was aimed (4) to assess the accuracy of a commercial activity wristband and of iOS and Android smartphones to measure steps during various walking conditions as those devices were intended to be used to measure the primary outcome (steps per day) in the 24‐week randomized controlled trial. Finally, the aims were (5) to examine the effectiveness of the smartphone game to increase daily physical activity and improve glycemic control and aerobic capacity as well as (6) to evaluate the game’s suitability to increase the intrinsic physical activity motivation and elicit sustained improvements in physical activity adherence in inactive individuals with type 2 diabetes over a 24‐week period. Methods In this Ph.D. project, one systematic review and three studies were conducted. In the systematic review, electronic bibliographic databases (PubMed, Embase, Web of Science, OpenGrey, and the Cochrane Central Register of Controlled Trials) were searched up to March 2015. Randomized controlled trials and cross‐sectional studies published in English in peer‐reviewed journals were included. Included studies were required to have analyzed the effects of exergames on objectively measured intensity parameters of physical activity (oxygen uptake, energy expenditure, and heart rate) in overweight adults with and without type 2 diabetes. In study 1, data collected from a study conducted by Prof. Schmidt‐Trucksäss before the start of my Ph.D. was analyzed to evaluate the cardiorespiratory exertion (maximum and mean oxygen uptake) of 12 elderly individuals with type 2 diabetes during 10‐minute bouts of different Wii Fit Plus exercises. Oxygen uptake values were compared to the maximally reached values during a previously conducted cardiopulmonary exercise test on a treadmill. Correlations between oxygen uptake values reached during exergame activity and those reached during the all‐out exercise test were analyzed using Spearman’s rank correlation coefficient. Following this preparatory work and considering its results, I collaborated with an international team consisting of sports scientists, gamification researchers, professional game developers, and clinical professionals in developing an innovative smartphone game with the aim to encourage a healthier, more active lifestyle through gamified physical activity in inactive type 2 diabetes patients. To evaluate the effectiveness of the game to sustainably increase physical activity in the target group, I planned a 24‐week randomized controlled trial with daily physical activity (steps per day) as the primary outcome. To verify the validity of the devices used to measure the primary outcome (steps per day) in the 24‐week intervention study, I conducted a validation study in an additional investigation of this Ph.D. project. In the study, 20 participants were equipped with 3 iPhone SE smartphones (placed in pants pocket, shoulder bag, and backpack), 1 Samsung Galaxy S6 Edge (pants pocket), 1 Garmin Vivofit 2 wristband, and 2 ActiGraph wGTX+ devices (worn at wrist and hip) and instructed to walk for five minutes at four predefined walking speeds (1.6, 3.2, 4.8, and 6.0 km/h) and to complete an outdoor walking course. Video observation was used as gold standard. Validity was evaluated by comparing each device with the gold standard using mean absolute percentage errors. In the main study (ClinicalTrials.gov identifier NCT02657018) of this Ph.D. project, 36 inactive, overweight type 2 diabetes patients between 45 and 70 years of age were randomly assigned to either the intervention group or the control group. Participants in the intervention group received the self‐developed smartphone game, and participants in the control group were instructed to implement the recommendations from the baseline lifestyle counseling autonomously during the 24‐week intervention period. Before and after the intervention period, steps per day were objectively measured during six consecutive days. In addition, glycemic control (HbA1c) was measured by analysis of venous blood, and aerobic capacity (oxygen uptake at the first ventilatory threshold) was assessed during an all‐out exercise test on a bike ergometer. Intrinsic physical activity motivation was assessed with an abridged 12‐item version of the Intrinsic Motivation Inventory (IMI). In the intervention group, adherence to the game‐proposed physical activity recommendations during the intervention period was additionally assessed via the phonerecorded game usage data. Analyses of covariance with adjustment for the respective preintervention values were used to compare changes in outcome parameters (steps per day, HbA1c, oxygen uptake at the first ventilatory threshold, and IMI score) between the two groups. Correlations between game use (min) and change in steps per day as well as change in workload (W) at the first ventilatory threshold were analyzed using Spearman’s rank correlation coefficient, and a linear regression model was used to assess the relationship between total in‐game training (min) and change in IMI total score. Results Publication 1: Effects of Exergaming on Physical Activity in Overweight Individuals. [1] The systematic review showed that exergames are able to increase physical activity among overweight individuals. However, the magnitude of this increase as well as the intensity of the exergame‐related physical activity and consequently their suitability to offer a guidelineconcordant training is greatly dependent on the console and the game mode as well on the duration of play. The majority of the included studies were of poor or moderate methodological quality. No studies exist that objectively assess the effect of exergames on daily physical activity in type 2 diabetes, and the cross‐sectional nature of all included studies does not permit judgement on whether exergames are suitable to increase physical activity in the long term. A general lack of adequate individualization of the intensity and difficulty level was noted for all exergames, making most game modes unsuitable for an effective training and potentially unsafe for inactive individuals with chronic diseases and a likely reduced fitness level. Publication 2: Cardiorespiratory Exertion While Playing Video Game Exercises in Elderly Individuals With Type 2 Diabetes. [2] In elderly type 2 diabetes patients, carefully selected Wii Fit Plus exercises elicit peak values in oxygen uptake that correspond to 60% of the maximally reached values during an all‐out treadmill test. Mean values were just above 40% for all exercises and were thus in a range that corresponds to current exercise guidelines. A moderate‐to‐strong positive correlation between the peak oxygen uptake during exergame play and the maximal value reach during the exercise test was found, indicating that subjects with a higher fitness level were able to exercise at a higher intensity during exergame play than individuals with a lower fitness level. Publication 3: Mobile Exergaming for Health – Effects of a Serious Game Application for Smartphones on Physical Activity and Exercise Adherence in Type 2 Diabetes Mellitus – Study Protocol for a Randomized Controlled Trial. [3] The self‐developed and innovative game takes the proven motivational benefit of exergames into consideration and further extends them by integrating established behavior change techniques into an elaborate storyline. Shortcomings with regard to the suitability and effectiveness of the exercise regimen of current exergames are addressed by offering a fitness level‐adjusted training with an individualized rate of intensity progression that is based on the performance in established and in‐game‐conducted exercise tests. Publication 4: Validity of Activity Trackers, Smartphones, and Phone Applications to Measure Steps in Various Walking Conditions. [4] The Garmin Vivofit 2 and iPhone SE showed good accuracy for treadmill walking ≥3.2 km/h (<3% deviation from video recordings) and for free walking thus being suitable to measure steps at normal, fast, and even slow walking speeds. The Samsung Galaxy S6 Edge showed good accuracy (<3% deviation from video recordings) for treadmill walking ≥4.8 km/h and for free walking, demonstrating suitability to measure steps during normal and fast walking. The good validity of the iPhone SE was found independently of the phone’s position (pants pocket, backpack, shoulder bag), suggesting a broad versatility of the device for physical activity measurement in various settings. Publication 5: Publication 5 Behavior Change Technique‐based Smartphone Game Sustainably Increases Daily Physical Activity in Type 2 Diabetes Patients – A Randomized Controlled Trial. [5] In persistently inactive type 2 diabetes patients, a novel self‐developed smartphone game that follows a cognitive/behavioral approach and incorporates individualized exercise regimens and physical activity recommendations elicited significant and clinically meaningful increases in daily physical activity (+4,000 steps per day) over a 24‐week period, classifying the participants as sufficiently active post‐intervention (average of 9,782 steps per day). The increase in daily physical activity was accompanied by an increase in aerobic capacity with a significantly higher oxygen uptake and workload at the first ventilatory threshold. Total duration of in‐game training was positively correlated with the change in steps per day and the change in workload at the first ventilatory threshold. Glycemic control (HbA1c) did not change during the intervention period; however, as indicated by the significant adjusted difference in HbA1c of ‐0.9 percentage points in favor of the intervention group, there is reason to assume that regular use of the game supports the stabilization of glycemic control in medically well‐controlled patients. In the control group, none of the outcome parameters changed significantly during the intervention period. Publication 6: Effectiveness of a Behavior Change Technique‐based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Type 2 Diabetes Patients: A Randomized Controlled Trial. [6] The 24‐week randomized controlled trial further showed that participants in the intervention group significantly increased their IMI‐measured intrinsic physical activity motivation during the intervention period. Participants in the control group did not show any significant changes in their intrinsic physical activity motivation. The analysis of the usage data revealed that participants in the intervention group used the game for an average of 143.1 (SD 59.1) minutes of in‐game training per week, which underlines the game’s potential in motivating formerly inactive type 2 diabetes patients to meet and sustainably adhere to established physical activity recommendations. Conclusions A novel smartphone game that incorporates established motivational elements and personalized physical activity recommendations into an elaborate storyline elicits clinically relevant increases in daily physical activity and aerobic capacity and contributes to a medically well‐regulated glycemic control in persistently inactive type 2 diabetes patients. The game is therefore a suitable treatment option to motivate inactive individuals to increase daily physical activity that may be relevant for other inactive target groups with and without chronic diseases. Future research should further refine the game design as well as the motivational and physical activity‐related content to make it an even more comprehensive treatment tool for various target groups

Proceedings of the 50th Hawaii International Conference on System Sciences

Physical activity is very important to public health and exergames represent one potential way to enact it. The promotion of physical activity through gamification and enhanced anticipated affect also holds promise to aid in exercise adherence beyond more traditional educational and social cognitive approaches. This paper reviews empirical studies on gamified systems and serious games for exercising. In order to gain a better understanding of these systems, this review examines the types and aims (e.g. controlling body weight, enjoying indoor jogging…) of the corresponding studies as well as their psychological and physical outcomes. This paper particularly reviews the deployed motivational affordances and the effectiveness of incorporating gamification features in exergames. The review shows overall positive psychological outcomes (e.g. enjoying exercise) as well as behavioral ones (e.g. decreasing sedentariness) about exergames. Its findings inform about the current state of the research on the topic, based on which, suggestions for further research are outlined.</p

Contribution of Exergaming Behaviour to Physical Activity: Toward Better Understanding the Role of Motivation

Physical activity (PA) is associated with numerous health benefits. Because PA patterns established early in life track into adulthood, it is important that children develop and sustain healthy PA habits. Current guidelines recommend that youth accumulate ≥ 60 minutes of moderate to vigorous intensity PA daily, but many youth do not attain this level. Evaluation of public health interventions that aim to promote PA provide little evidence of sustained positive effects over time. This could relate, at least in part, to interventions lacking a strong conceptual foundation and, in particular, to a lack of underpinnings that recognize the central role of motivation in PA. It is important that effective strategies to increase and sustain healthy PA levels in youth are identified. The Self-Determination Theory is used to explain why people adopt and maintain healthy PA behaviors and posits that sustained PA relates to natural or intrinsic tendencies or motivations to behave in healthy and effective ways. Positive PA experiences in school, at home and in community settings may foster an internal desire or motivation to sustain PA participation simply for its challenges or for enjoyment. Lack of sustained PA among youth could reflect a scarcity of enjoyable PA options that fit with the sophisticated technetronic expectations of youth today. PA interventions must “keep up with the times,” by acknowledging young peoples’ prevailing interests and by incorporating advancements in technology that heighten interest and motivation for PA. Exergaming, a type of non-sedentary videogame that requires players to be physically active in order to attain a series of incrementally challenging goals, is increasingly viewed as an enjoyable PA option among today’s technology-immersed youth. However, although critical to informing the design, implementation and sustainability of exergaming interventions, evidence on exergaming-related motivation, preferences, intentions and sustainability is lacking. Research in this domain is needed to ascertain whether exergaming interventions can help youth become and remain physically active, and which facets of exergaming hold the most promise in sustaining positive PA change. More specifically, using “gamified augmented reality” such as exergaming could help youth attain recommended PA levels and promote sustainable healthy behaviour, while at the same time contributing to enjoyment of PA. The three studies described in this thesis examine motivation and exergaming in-depth using SDT and its tenants as a theoretical guide and a common theme across studies. Thus, the role of motivation and intentions in exergaming behaviour and how they contribute to PA in the general population of youth is a key contribution of this dissertation. Study 1, a review of reviews on exergaming, provides background for the next two studies, each of which was conducted in population-based (as opposed to clinical or experimental) settings. Twenty-five reviews spanning 2009 to 2016 were retained, each of which incorporated between 5 and 100 articles. A positive relationship between exergaming and energy expenditure (EE) was well-documented, but whether exergaming increases PA or changes body composition was not established. There is however, evidence that exergaming (i.e., as a non-sedentary use of screens) is a healthy alternative to sedentary behaviour, that it improves cognitive function, that it is an interesting and enjoyable pastime in youth, that it shows promise as a PA option by adding variety and alternative PA forms in health and dietary interventions and finally that it is likely more health-promoting than traditional videogames because of higher EE and possibly improved physical fitness, body composition and cognitive health. However, more research and specifically, longitudinal studies are needed to assess whether exergaming can be sustained to obtain these benefits over time. Study 2 identified correlates of sustained exergaming. We reported that almost 50% of grade 9 students sustained exergaming for 2-3 years. Study results suggest that in non-clinical settings, exergaming may be a practical approach to help adolescents maintain PA during adolescence. Study 3 examined the psychometric properties of a new scale to assess reasons for exergaming (i.e., the Reasons to Exergame (RTEX) scale). This study also examined whether and how the scale relates to the timing, intensity and duration of past-month exergaming. RTEX items were developed in consultation with PA and exergaming experts and using key exergaming constructs, including PA, general interest in videogames and enjoyment of exergaming. RTEX was found to be a reliable and valid assessment of reasons to exergame. However, further studies should replicate these initial findings in larger, more diverse samples

Information technology for active ageing: A review of theory and practice

Active Ageing aims to foster a physically, mentally and socially active lifestyle as a person ages. It is a complex, multi-faceted problem that involves a variety of different actors, such as policy makers, doctors, care givers, family members, friends and, of course, older adults. This review aims to understand the role of a new actor, which increasingly plays the role of enabler and facilitator, i.e., that of the technology provider. The review specifically focuses on Information Technology (IT), with a particular emphasis on software applications, and on how IT can prevent decline, compensate for lost capabilities, aid care, and enhance existing capabilities. The analysis confirms the crucial role of IT in Active Ageing, shows that Active Ageing requires a multidisciplinary approach, and identifies the need for better integration of hardware, software, the environment and the involved actors