Bandura’s [
1] Self-Efficacy Theory states that it is our perceived, rather than actual, capabilities which determine the actions we select. However, an accurate awareness of our physical abilities—both our strengths and our weakness—is critical to ensuring that we avoid taking any unnecessary risks when navigating our environment. For example, before deciding which walking path to select—a shorter, ‘risky’ path covered in ice, or a longer, ‘safer’ path—we need to appraise our physical capabilities. However, approximately one-third of older adults misjudge their balance abilities, either over- or under-estimating their physical capabilities [
2].
Disparities between perceived and actual balance abilities
A discrepancy between perceived and actual capabilities will likely lead to these individuals engaging in either unduly cautious or risky behaviours; both of which may increase the likelihood of a fall occurring. For example, a cautious approach will likely lead to activity avoidance, which in turn is associated with a reduction in physical activity and increased risk of falls [
3], while an overly risky approach may increase the likelihood that an individual will attempt a task which they are unable to safely complete. As elderly falls are the leading cause of injury, and mortality from injury, in those aged 65 years and older [
4], the development of cost-effective methods to reduce falls is an important public health challenge. One potential method for reducing falls may be through addressing the inaccurate perceptions of fall-risk made by elderly people. While physical training is a commonplace method to target falls in the elderly, modifying inappropriate levels of confidence relative to physical ability is both novel and theoretically achievable through employing principles of motor learning, such as augmented feedback.
Fear of falling is negatively associated with numerous markers of wellbeing in older adults, including a restriction in physical activities, social isolation, decreased quality of life and increased fall-risk [
2,
3,
5‐
7]. These attributes have led to the common view that fear of falling is maladaptive and should be reduced through interventions. However, fear of falling may not always be associated with an increased risk of falling, particularly if this fear represents an accurate appraisal of one’s balance abilities. In these cases, this fear may even reduce the risk of falls by encouraging the individual to avoid exposing themselves to unnecessary risk [
8]. Therefore, designing interventions to indiscriminately reduce this fear of falling may have a detrimental effect on actual falls. Furthermore, while approximately 10% of the older adults in the sample studied by Delbaere and colleagues [
2] were under-confident in relation to their balance abilities, 20% over-estimated their physical capabilities. Therefore, reducing fear of falling in individuals who have either accurate or over-confident perceptions of their balance abilities may even increase the risk of falls by encouraging these individuals to perform tasks beyond their physical capabilities.
As a result, it might be more important for “intervention programmes to help elderly people develop a realistic appraisal of fall risk or improve physical functioning in concert with addressing fear, rather than just reduce fear of falling” ([
2], p.1). Yet, the majority of interventions that address fear of falling in older adults are designed to indiscriminately reduce fear (i.e. [
9]), rather than attempting to ‘recalibrate’ these individuals’ perceptions of their balance abilities. Therefore, the aim in this present research is to determine if it is possible to recalibrate perceptions amongst older adults of their balance capabilities through a carefully designed, short-term exergaming intervention.
Exergaming as a means to deliver augmented feedback
Exergaming (portmanteau of “exercise” and “videogaming”) was selected as the most appropriate means through which to deliver this present intervention due to the ease in which accurate augmented feedback relating to task performance can be provided to the participant. Specifically, we utilised the Nintendo Wii Balance Board (WBB; Nintendo, Kyoto, Japan) to deliver this intervention, due to the device’s reliability in monitoring centre of pressure (COP; [
10‐
12]). Used in conjunction with the Nintendo Wii Fit technology, the Wii Balance Board allows users to shift their body movement to control a virtual avatar in a variety of different videogames. Real-time visual and auditory feedback is used to monitor and control COP.
While commercially available exergames may successfully challenge and train aspects of balance associated with fall-risk, and provide relevant augmented feedback on performance, we are unaware of any commercially available exergames specifically designed to do so. Therefore, it was necessary to design a bespoke, novel exergame for this specific purpose. Scientists have demonstrated that it is possible to interface the WBB with virtual-reality software to create bespoke interactive games designed for specific training needs of older adults [
13,
14]. We developed a novel game in this manner. This exergame was based on the classic videogame, PONG. In this modified version of the game, individuals had to use their COP, moving in the anterior-posterior (forwards and backwards) plane to move a paddle to intercept a ball. In this game, the same physical task is repeated approximately 15 times a minute (at varying degrees of difficulty), with augmented performance feedback provided after each attempted movement.
Researchers have reported that the provision of performance feedback can have a positive effect on both self-efficacy/balance confidence and task selection. For example, Lamarche, Gionfriddo, Cline, Gammage and Adkin [
15] found that younger adults who received positive feedback (i.e., feedback which praised their performance on a balance task) reported greater levels of balance confidence and subsequently selected more challenging balance tasks, while those who received negative feedback demonstrated task selection evident of reduced risk-taking. It, therefore, seems logical to assume that: (1) under-confident individuals with excessive levels of fear who receive feedback that their balance abilities are better than previously assumed will experience increases in balance confidence (moving their perceived balance abilities to better align with their actual capabilities), while; (2) over-confident individuals who under-estimate their physiological fall-risk and receive feedback that their balance abilities are worse than previously assumed will experience decreases in balance confidence (once again moving their perceived balance abilities to better align with their actual capabilities). However, given difficulties associated with categorising individuals as either under/over-confident (i.e., problems related to utilising a median/dichotomous split to classify individuals as having either low/high levels of balance confidence and physical functioning), we deemed it more appropriate to correlate perceived and actual balance abilities to determine the degree to which these align.
A recent meta-analysis presented by Lesinski, Hortobágyi, Muehlbauer, Gollhofer and Granacher [
16] concludes that an “effective BT [balance training] protocol for healthy older adults is characterized by a training period of 11–12 weeks, a training frequency of three sessions per week, a total number of 36–40 training sessions... and a total duration of 91–120 min of BT [balance training] per week” (p. 1737). However, research from the domain of motor learning demonstrates the profound effect that short-term (i.e., single-session) interventions utilising explicit, augmented feedback can have on perceptions of physical capabilities [
17‐
19]; with these altered perceptions persisting following both a 24-h and 1-week retention period following the feedback [
19]. Furthermore, Lamarche and colleagues [
15] observed altered perceptions about balance in individuals receiving a single piece of performance feedback. Consequently, these findings indicate that it may be possible to target psychological determinants of elderly fall-risk through interventions which are shorter in duration than those needed to target the physical determinants of fall-risk.
Given that the training dosage of the present intervention is substantially shorter than these recommendations (i.e. 8-sessions over a 4-week period), we do not expect (by design) to observe significant improvement in the balance assessments collected. We predict that this short-term intervention will result in psychological, rather than physical, changes. Specifically, we predict that this intervention will provide participants with an environment in which they can critically appraise their balance abilities, resulting in a recalibration of perceptions relating to physical capabilities. This recalibration will be evidenced by a stronger alignment (as represented by stronger correlations) between postural control and perceived balance abilities post-intervention, compared to pre-intervention. We do not expect this recalibration to be evidenced by significant global changes in perceived balance abilities. Instead, we expect to observe changes at both ends of the continuum (i.e., increased confidence in those individuals who were previously under-confident and decreased confidence in those who were previously over-confident). We therefore predicted to observe a significant correlation between pre-intervention perceptions and the change in perceived balance between pre- and post-intervention. This prediction suggests that the largest pre-post intervention increases in balance confidence will be observed in individuals previously reporting the lowest perceptions of their balance abilities. We also predict that this recalibration will also be evident in the qualitative focus group data. While these measures of ‘recalibration’ are the primary outcomes of the present research, the secondary outcomes are an evaluation of any changes in balance performance. While we do not expect to observe any significant post-intervention changes in postural control, if any improvements are observed, these will be specific to the movements performed in the gaming task, for which explicit, augmented feedback is provided (i.e., significant improvements in anterior-posterior measures of postural control, but not those assessing medial-lateral control). If this work is successful in recalibrating perceptions relating to balance abilities in older adults, it may be possible to target aspects of psychological functioning associated with increased fall-risk through carefully-designed, short-term interventions.