Immersive Virtual Reality as a Novel Physical Therapy Approach for Nonagenarians: Usability and Effects on Balance Outcomes of a Game-Based Exercise Program
Campo-Prieto P, Carral JMC, Alsina-Rey B, Fuentes GR. Immersive Virtual Reality as a Novel Physical therapy Approach for Nonagenarians: Usability and Effects on Balance Outcomes of a Game-Based Exercise Program. Journal of Clinical Medicine. 2022;11(13):3911. doi:10.3390/jcm11133911Link to Original Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9267554/
Key Points
1. Physical exercise has been recognized as an important strategy for promoting healthy aging, especially in improving motor ability and balance in older adults.
2. The use of immersive virtual reality (IVR) technology, specifically a commercial IVR exergame, was found to be feasible and effective in enhancing balance and reducing the risk of falls in community-dwelling nonagenarian women.
3. The study included 12 nonagenarian women, with the experimental group (EG) undergoing a 10-week IVR exercise program using an exergame, while the control group (CG) received usual therapy programs.
4. Results showed that the EG significantly improved balance parameters and total Tinetti test scores, while maintaining total Timed Up and Go (TUG) test times, as compared to the CG, which exhibited worsening balance scores and increased TUG test times.
5. Usability of the IVR system was rated as good, with no adverse effects reported, and the System Usability Scale (SUS) score was 78.33, indicating good usability.
6. The study demonstrated that IVR training with a commercial head-mounted display (HMD) and exergame is a feasible, effective, and personalized method for improving balance and reducing the risk of falls in nonagenarian women, showcasing the potential of IVR technology in promoting physical activity and rehabilitation in older adults.
Introduction
The research paper emphasizes the importance of physical exercise in promoting healthy aging and addressing the functional decline associated with aging. Older adults often face decreased motor ability, muscle strength, and balance, leading to an increased risk of falls, fractures, and hospitalization. Compared to older people of younger age, nonagenarians participate less in physical activity that leads to decreased functional independence. Virtual reality (VR)-integrated exercise is emerging as a promising intervention strategy as it engages the motor skills and sensorimotor learning of older adults to improve their motor ability. Immersive virtual reality (IVR) is a computer-generated, multi-sensory, three-dimensional world where individuals can interact with the virtual environment. IVR typically involves the use of a head-mounted device or a room that encloses the user. Non-immersive VR, on the other hand, uses a computer-generated virtual world on a screen. VR exercise, particularly IVR, has shown positive effects on motor ability and has the potential to enhance sensorimotor integration and improve physical and functional abilities in older adults.
The paper highlights the scarcity of scientific evidence on the effects of exercise programs in nonagenarian older adults and the relatively unexplored applications of IVR-based exercise programs targeting this age group. The gap in research presents an opportunity for further investigation into the usability and balance effects of IVR personalized exercise programs in nonagenarians. Consequently, the study aims to explore the potential benefits of IVR-integrated exercise for nonagenarian older adults and address the current gaps in scientific evidence in this field.
Materials and Methods
Participants
The research paper recruited a community of elderly residents from an old people’s home in Pontevedra, Spain. Inclusion criteria were aged greater than 90 years, able to stand up and walk independently without aids, and able to sign informed consent. Exclusion criteria were cognitive deficit according to the clinician’s judgment, the presence of cardiovascular, pulmonary, or musculoskeletal conditions based on physical therapist’s judgment, the presence of severe visual loss, and the presence of vertigo, epilepsy, or psychosis. A total of 12 nonagenarian women participated in the study and were randomly assigned to either an experimental group (EG) or a control group (CG). The participants were all women with average age of 91.67 years in EG and 90.83 years in CG.
Intervention
The EG underwent 30 immersive virtual reality (IVR) exercise sessions over ten weeks with three sessions held each week. A session of IVR training lasted 6 minutes. In addition, both EG and CG received a 45 minute group session, 5 times per week that included occupational therapy to work on general mobility and stretching as well as functional skills and cognitive stimulation workshop. The IVR system utilized the HTC Vive Pro TM device and a 6m2 play area. One week before the trial, participants were introduced to the IVR and participated in a virtual environment experience to evaluate acceptability and symptoms of cybersickness. The participants in the IVR training engaged in boxing techniques in a virtual gym (BOXVR) to encourage physical movement and its resemblance to activities in a traditional physical therapy session.
Figure 4.
Real gym and virtual gym: (a) Participant during an exergame session, (b) Screenshot of the exergame proposed (BOXVR)
Assessments
The study evaluated balance, motor ability, and usability of IVR sessions using various assessment tools such as the Tinetti test, the Timed Up and Go test, the Simulator Sickness Questionnaire (SSQ), and the System Usability Scale (SUS). The Tinetti test assessed gait and balance, the TUG test measured functional mobility, and the SSQ and SUS gauged participant experiences and usability. Heart rate, demographic data, and the number of completed exergaming sessions were also recorded.
Statistical Analysis
The study used statistical analyses such as the Shapiro-Wilk test, Wilcoxon test, and Kruskal-Wallis test to compare group effects and program outcomes. The results were assessed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) for MAC version 26.0 with a significance level set at <0.05.
Results
The study reported high adherence to the intervention program, with 100% of participants completing the virtual reality (VR) exercise sessions. Baseline characteristics were similar between the experimental group (EG) and control group (CG). The EG showed significant improvements in Tinetti test scores for balance (10.97%), gait (9.23%), and total score (10.20%). However, the turning time in the TUG test increased significantly in the EG. In contrast, the CG exhibited worsened Tinetti scores for balance, gait, and total score, as well as increased total times for the TUG test, with particularly significant worsening in the turning section. Statistically significant differences between the groups were found in the Tinetti test scores for balance and total score.
Additionally, the usability of the VR sessions for the EG was reported to be good, with no cybersickness symptoms recorded.
Table 2.
Balance scores (static and dynamic metrics) in the sample.
In summary, the EG demonstrated improved balance and gait measures as indicated by the Tinetti test, while the CG experienced declines in these measures. The VR-integrated exercise was well-received in terms of usability and did not result in cybersickness for the participants. These findings highlight the potential benefits of VR-integrated exercise for nonagenarian older adults, although the study also identified challenges, such as the increased turning time in the TUG test.
Discussion
The study aimed to investigate the usability and balance effects of a 10-week virtual reality (IVR) exercise program for nonagenarian women. The findings demonstrated that the IVR protocol was feasible with good usability and maximum adherence, without adverse effects. The population involved in the study consisted of community-dwelling nonagenarians, and it was highlighted that women outnumber men in the 90+ age groups globally and in the study region. The importance of exercise for promoting active aging in both genders was emphasize to reduce the risk of falling.
The study showed that the virtual exercise program led to significant improvements in balance, as indicated by the Tinetti scores, and it was considered as feasible as conventional exercise training. The IVR program resulted in participants being placed in the minimum risk stratum for falls. The study also suggested the potential of IVR technology for fall prevention in nonagenarians and other age-related conditions.
The usability ratings of the IVR system were positive, and the study recommended future research with a larger and more representative sample, including both genders.
Limitations
The study had limitations in terms of the briefness of the intervention and the lack of follow-up post-intervention. It is necessary to conduct a study with a larger sample size that accurately represents the nonagenarian population. Moreover, it is important to note that all participants in this study were female, indicating a need for further research on gender variations in the impact of the IVR intervention.
Implications of Using Immersive Virtual Reality in Clinical Practice
The study supports the use of IVR for increasing motivation and training effects in clinical practice. Virtual reality enables therapists to access a wide range of resources, which would be unattainable in a real environment. Additionally, IVR provides various options for specific strategies targeted towards different populations.
Conclusions
The research paper's conclusion highlights the successful demonstration of the feasibility and effectiveness of IVR (Interactive Virtual Reality) training using a commercial HMD (Head Mounted Display) and an exergame in enhancing balance and reducing the risk of falls in female nonagenarian residents of old people's homes. The IVR training can complement other fall prevention intervention programs and offers a safe and well-accepted intervention with high effectiveness and adherence. The proposed exergame could potentially provide personalized treatment for fall prevention in community-dwelling older adults in the future. This study's findings suggest the potential for IVR training to be integrated into fall prevention interventions and personalized treatment for older adults, indicating a significant advancement in the field. However, further research is needed to explore the generalizability of these findings to male nonagenarian adults and other populations. Moreover, future studies should delve into the long-term effects of IVR training on balance and fall prevention, addressing existing gaps in scientific evidence and paving the way for advancements in promoting healthy aging through virtual reality-integrated exercise.
Opportunities for Future Research
1. Investigate the long-term effects: Conduct a follow-up study to assess the maintenance of improvements in balance and the risk of falls in nonagenarian women after an extended period following the completion of the IVR exercise program.
2. Gender-specific effects: Explore the potential gender differences in the effectiveness of IVR exercise programs on balance and fall risk in nonagenarian individuals. Research the impact of IVR technology on the motor abilities and fall risk of nonagenarian males.
3. Comparison with conventional exercise programs: Compare the effects of IVR-based exercise programs with conventional physical therapy interventions on balance and fall risk in nonagenarian populations. Investigate the relative effectiveness of IVR technology in promoting sensorimotor learning and cortical plasticity compared to traditional exercise modalities.
4. Role of immersive virtual environments: Investigate the specific aspects of immersive virtual environments that contribute to the effectiveness of the IVR exercise program in improving balance and reducing the risk of falls in nonagenarian individuals. Determine the optimal design elements and sensory stimulation levels for IVR interventions targeting healthy aging.
5. Expansion to diverse populations: Extend the research on IVR exercise programs to include nonagenarian populations from diverse demographic backgrounds and geographic locations. Investigate the cultural, socioeconomic, and environmental factors that may influence the usability and effectiveness of IVR training for healthy aging.
6. Comparison of different IVR exergames: Evaluate the comparative effects of different types of exergames within the IVR environment on balance, motor ability, and fall risk in nonagenarian individuals. Explore the potential of various IVR exergames to provide personalized and effective methods for enhancing balance in community-dwelling older adults.
