Exergaming to improve balance and decrease the risk of falling in individuals with knee osteoarthritis

Abstract

Background: The benefits of exercise to improve balance and reduce the risk of falls is well-recognised in the older-adult literature. However, little attention is paid to people with osteoarthritis (OA) of the knee. While there is evidence of an increasing number of falls in adults with knee OA, the contributing factors for falling has not been substantially investigated. Exergaming (exercise and gaming) is useful in improving balance in a range of health conditions, yet there is limited research regarding its application to people with knee OA. Aim: The primary aim of this thesis was to investigate the feasibility and acceptability of exergaming using Nintendo Wii Fit™ to improve balance and reduce the risk of falls in individuals with knee OA. Secondary aims were to identify the risk factors for falls in adults with knee OA and to examine the strength of relationship between falling and clinical characteristics such as dynamic balance, pain, instability, muscle strength, and physical function in adults with knee OA. Methods: The main study utilised a mixed-methods, explanatory sequential study design (quantitative followed by qualitative design) to determine the feasibility of exergaming. Nested in this thesis were two literature reviews and a cross-sectional study, all conducted to inform the design of the main study. A systematic review was conducted to identify published evidence on the risk factors for falls in adults with knee OA. The findings from the systematic review informed the risk factors for falls explored in the cross-sectional study. A narrative synthesis of exergaming literature using Nintendo Wii Fit™ was conducted to determine dosage and parameters of the exergaming intervention in the main study. Results: Findings from the systematic review included moderate evidence for impaired balance, decreased knee muscle strength, an increasing number of symptomatic joints, and the presence of comorbidities as risk factors for falls in individuals with knee OA Conflicting evidence was found for knee pain. Impaired proprioception, knee instability, and use of walking aids had limited evidence for being significantly associated with increasing risk for falls. In the cross-sectional study, 31 out of 63 (49%) participants with knee OA reported at least one fall in the previous 12 months. For participants with knee OA and history of falling, dynamic balance, knee muscle strength, and performance of physical function were significantly reduced when compared to participants with knee OA and no history of falling (p<0.05). Lower dynamic balance measured by the Composite Score (OR 0.86, 95% CI 0.73–0.98, p=0.049) and weaker quadriceps muscles strength (OR 0.70, 95% CI 0.44–0.91, p=0.028) showed positive association with an increased risk of falling. Whereas, poorer physical function measured with the Timed Up and Go test, showed increased risk of falling by almost two-fold (OR=1.65, 95% CI 1.85–4.21, p=0.006). The main study found that it is feasible and acceptable to use Nintendo Wii Fit™ as an exergaming tool to improve balance and decrease the risk of falling in adults with knee OA. The pre-defined feasibility criteria such as recruitment, retention, and compliance were successfully met. This was affirmed by the participants’ views on the procedures of the study in terms of the frequency and duration of the assessment and intervention sessions, which they reported to be acceptable. The study demonstrated that it is safe to use Nintendo Wii Fit™ as an exergaming tool as there were no adverse events reported throughout the study period. There were encouraging results in the key outcome measures such as increasing muscle strength, balance, and performance of physical function sufficient to support the conduct of a future randomised controlled trial (RCT). Participants enjoyed playing Wii Fit™ games and found exergaming motivating and interactive in spite of some barriers with the use of technology. Conclusion: This thesis highlights the risk factors for falls and the potential of exergaming to improve balance and decrease the risk of falling in individuals with knee OA. It is essential to understand the mechanism underlying the occurrence of falls in knee OA by identifying modifiable risk factors which can be mitigated. The potential use of exergaming as a balance tool and the assessment of knee OA symptoms that are critical to increasing falls risk can provide valuable information for both clinicians and fall prevention program developers. Findings coming from feasibility study are encouraging, and support the need to conduct a full-scale RCT