Background
Fall-related injuries are the largest cause of accidental death in older people across Europe [
1] and the second leading cause of accidental death amongst older people globally [
2]. Over 30% of community-dwelling people aged 65 and older and 50% of people aged 80 and over fall at least once per year [
3,
4]. People living in retirement villages/assisted living facilities fall frequently [
5]. Those identified as frail fall more frequently than those who are classified as vigorous [
6,
7]. Falls are associated with admission to residential care homes, reduced functioning, psychological problems such as fear of falling and loss of confidence leading to social isolation and increased dependency. The direct and indirect costs of falls are substantial, for example, estimated costs in the UK NHS are in excess of £2.3 billion per year [
8].
There is strong evidence that strength and balance-based exercises reduce falls by up to 42% [
3,
9,
10] and that strength and balance exercise as a stand-alone intervention may be the most cost-effective approach to fall prevention at a population level [
11]. Although there are few studies in assisted living facilities, a cluster randomised controlled trial of group strength and balance exercise in retirement villages in Australia showed a reduction of 22% falls in the intervention group compared to the control [
5]. Exercise as a means of fall prevention and for the promotion of independence has been welcomed by older people, as a positive step that individuals can take for themselves [
12]. Reviews of community-based fall prevention indicates that strength and balance exercise need to be tailored, progressive and of adequate dose (50 h) [
3,
13,
14]. Sherrington et al. reveal that exercise programmes that are of a higher dose (more than 3 h/week) have larger effects [
14]. Such training can be costly and inaccessible to older adults [
15]. The repetitive nature of these exercises may also discourage older adults to exercise in the home setting, thereby rendering the intervention ineffective [
16]. Uptake and adherence to exercise programmes is low, and appropriate levels and progression are often not adequately prescribed [
5,
17]. Fear of falling can lead to restriction or avoidance of daily activities, loss of independence, depression and a reduction in quality of life [
18]. In frailer older adults and for those living in institutional settings, there is also the risk that unsupervised exercise can increase risk of falls [
16,
19]. A number of reviews of exercise to improve function in frailer older adults recommend supervision to ensure progression and effectiveness [
20,
21]. Thus, there are compelling reasons to find interventions that are both effective and safe for this population.
Exergaming (active video games which combine gameplay with physical exercise and may also incorporate types of virtual reality simulations) may be a feasible tool for older people to improve exercise uptake, challenge and progression [
22]. There is growing evidence that Exergaming may also improve function and adherence and provide other health outcomes [
4,
23] and that such technology-based approaches can be attractive to older people [
24]. The advantages of using gaming systems to deliver exercise are that they can be immersive, entertaining and enjoyable, potentially improving adherence and frequency/duration of the exercise programme [
25,
26]. The gamified elements of Exergames (levels, points, progress) may also encourage uptake and adherence to exercise [
27,
28]. The feedback on progress alongside comparison or competition with other players may be persuasive and motivate longer-term use [
29,
30]. A recent meta-analysis of effectiveness of virtual reality (VR) games for fall prevention in older people found positive effects on balance and fear of falling compared with no intervention; VR games were also concluded to be superior to conventional treatment [
31]. But a high risk of bias, small sample sizes and large variability between methods and interventions mean evidence remains inconclusive and further research is needed. Other systematic reviews of virtual reality exercise programmes, Exergames and technology-based exercise interventions for older people [
32‐
34] present similar conclusions that these interventions have potential, but larger and more rigorous studies are required to make more definitive conclusions regarding the effectiveness of Exergames to improve outcomes such as fall rate and fall risk.
The development and design of the Exergames used in this study were previously tested in a feasibility study [
25,
35]. We followed the UK Medical Research Council (MRC) Guidance for Developing and Evaluating Complex Interventions [
36] that recommends: identifying the evidence base and relevant theory; modelling process and outcomes; and then testing through feasibility or pilot studies prior to a full-scale evaluation [
36].
Exergame programmes were planned to be carried out on a one-to-one basis (i.e. one person playing the Exergames at a time, supervised for research purposes by a physiotherapist or a physiotherapist assistant) either as part of a group setting or individually. Tailoring the Exergame programme and setting realistic, person-centred goals that are continuously reassessed to ensure personalisation and progression were also deemed important [
37‐
39]. Understanding the health benefits of exercise and having self-belief in one’s ability to exercise (self-efficacy) are also necessary [
41,
42]. There are also practical considerations for the delivery of the intervention such as ease of access to the exercise, particularly for frailer older adults unwilling or unable to travel [
15,
43].
This trial investigated the effectiveness of a suite of Exergames that were developed with, and for, older people to improve function and reduce the risk of falls [
25]. A series of games were co-created with older adults, therapists and software designers [
25], which are based on OTAGO and FaME exercises for older people (strength and balance exercises with demonstrated effectiveness to reduce falls) [
44‐
46]. The Exergames draw on self-determination theory and gamification to aid uptake, motivation and adherence to the Exergame programme [
40]. Evaluation of this intervention is particularly timely given the current emphasis on healthy ageing and prevention [
46,
47]. A cluster randomised trial design was adopted as individual randomisation within assisted living facilities would have been open to contamination bias. The research hypothesis was that a 12-week tailored programme of strength and balance Exergames will improve balance in people aged 55 years and older, in assisted living facilities.
Study objectives
The primary objective of this study was to evaluate the effectiveness of a tailored 12-week fall prevention Exergame programme on balance in adults aged 55 years or older as assessed by the Berg Balance Scale [
48].
The secondary objectives were to investigate the effectiveness of the Exergame programme on fear of falling, lower limb function, self-reported physical activity, fall risk, pain, mood, fatigue, cognition, healthcare utilisation, health-related quality of life (HRQoL) and fall rates during a 3-month follow-up.
Discussion
This is the first cluster RCT of Exergames in community-based, assisted living facilities. Provision of Exergames for strength and balance exercises over 12 weeks to residents aged 55 years and older of these facilities significantly improved balance (as measured by the BBS), pain (VAS) and fear of falling (Short FES-I). Furthermore, an IRR = 0.31 for falls over a 3-month follow-up indicates an unexpected significant effect for this fall reduction.
The trial was powered on the minimum detectable change (MDC) of 8 points on the BBS from a trial of dependent older people (living in residential care homes) of somewhat older age than those in this trial [
68]. However, other studies have found that the MDC for more physically independent older people receiving physiotherapy was rather less (3.2 points [
80] and 4.9 points [
81]). Furthermore, it has recently been advised that studies should not be powered on distribution-based statistics, such as the MDC [
82], but should primarily use anchor-based methods and/or expert opinion to estimate the minimally important difference (MID).
There has been no research to determine the MID for the BBS on a population similar to ours, but Saso et al. [
81] found an MID of 6 points for people early after stroke and Godi et al. [
83] found an MID of 7 points for a groups of older people with balance deficits undergoing rehabilitation. Given the nature of the population in our trial, the MID would be expected to be not greater than 6 and perhaps a little smaller. The estimated difference in change between the groups for balance (BBS 6.2 points) is therefore plausible as an important difference, if only slightly exceeding the likely MID. However, the 95% confidence interval for this effect is relatively wide (2.4 to 10.0) so further research is recommended to provide further evidence as to the magnitude of the effect.
The results of our economic evaluation imply that Exergames are likely to be cost-effective compared to control (physio advice and the Otago Exercise Programme leaflet). These findings were robust, controlling for baseline characteristics using multiple imputation or complete case analysis, and choice of methodology to derive utility values from the EQ-5D-5L instrument. In the primary analysis, the ICER was £15,209.80 per QALY, and there was a 61–73% probability of Exergames being cost-effective at NICE thresholds [
78] of £20,000–£30,000 per QALY. It should be noted that the full Otago Exercise Programme consists of a set of three times per week progressive exercises, over a 12-month period and a walking plan with multiple home visits by an instructor [
45]. Therefore, traditional Otago Exercise Programme costs would be much higher than those proposed in this current 12-week study due to the additional labour costs, on-going training, travel, telephone calls and overhead costs.
This study demonstrated consistent findings between the locations indicating the potential transferability of the Exergame system. Retention of the Exergame participants was high (87%) compared to other exercise programmes for older people [
84], with a mean attendance at Exergame sessions of around two thirds (69%). Although there is no current consensus on the cut-off points for levels of high, moderate or low adherence [
85], this may be considered a beneficial level of attendance that resulted in improvements in balance, the primary outcome measure and also falls. Participants also reportedly liked the Exergames and found them easy to use (albeit, after it had been set up by the therapists, so this may refer to their understanding and playing of the Exergames). These are important factors when considering not just the effectiveness of the intervention but also whether people will actually want to use it in the long term [
86]. We recorded no adverse events related to the 12-week intervention.
Strengths and limitations
Baseline assessment was undertaken pre-randomisation, thus limiting the potential for selection bias. Sample sizes were achieved and high retention rates suggest little effect of attrition bias. Recruitment across multiple locations provides some evidence of generalisability across assisted living facilities and should reduce risks of performance bias. The Exergames were tested with people aged 55 years or older using rigorous methods in a ‘real-world’ context in communal areas in assisted living facilities rather than in a controlled laboratory-type setting, and the physiotherapists and assistants had no prior experience of this type of technology. Benefits of the intervention were that the Exergames were co-designed with older people and therapists and are based on evidence-based exercises (FaME and OTAGO) and gamification health psychology [
27] and can be tailored to a participant’s level of ability, preference and progression (i.e. different upper and lower limb exercises could be matched to different games and changed throughout the intervention period to maintain interest).
Cluster randomisation was essential to ensure that intervention contamination did not occur, but this also made blinding of the assessors difficult. Therefore, despite the use of objective measures and standardised participant instructions, it is possible that some of the improvements at follow up may have resulted from detection bias and so the results should be interpreted with caution. Blinding of the data analysts would also have been difficult, although there is sparse evidence that this may have affected outcomes [
87]. An a priori analysis plan was agreed and executed to minimise risk of reporting bias.
The incidence rate ratio for falls over the 3-month follow up (IRR = 0.31) significantly favours the Exergame group and this is in line with community-based RCTs testing the exercises that the Exergames were based on [
3,
9,
52]. But falls were only followed up for 3 months, and falls were self-reported by the participants. Recall bias could be present, and it is recommended in future studies that falls are prospectively followed up for 1 year as per the ProFaNE consensus guidelines [
70]. A further limitation is that the majority of the participants were women and of white, British ethnic origin. Future studies need to target ethnic groups and more men. Changes in physiotherapy staffing (one change in Manchester, two changes in Glasgow) could have also affected the delivery of the intervention, as it was observed that it took around 2 weeks for the therapists to become confident in setting up and delivering the Exergames to the intervention group. There tended to be more remote technology support required during these early weeks to ensure the sessions ran smoothly. These support issues caused short delays in the delivery of the Exergames which could have reduced both the duration of the session and the enjoyment level of the participants.
Attendance at the Exergame sessions was generally good, but the amount of time spent exercising (mean 33 min per week) was well below the recommended level of 150 min per week of moderate aerobic activity for adults and older people [
46]. This appears to be an issue, even in well-designed community exercise RCTs [
88]. However, in one recent cluster RCT, increased levels of physical activity were self-reported, albeit below the recommended levels, and the fall rate was reduced [
89].
Future studies are needed to investigate the optimum intensity, progression and long-term adherence to Exergame programmes. Moreover, such studies should investigate improvements in balance using clinical measures (e.g. BBS) with also include an instrumental measurement of static and dynamic balance (e.g. posturography) and include other outcomes such as lower limb muscle strength [
14], fall rates, fall risk, fatigue and habitual physical activity. In particular, a definitive trial is recommended to evaluate the cost-effectiveness of the implementation of the Exergames with a primary outcome of fall rates, and costs per QALY along with a process evaluation comparing traditional delivery of exercise [
86]. More research is also required to test the effectiveness of Exergames in other settings such as care homes, within early hospital discharge schemes, or to top-up or continue longer-term rehabilitation at home under remote monitoring by clinicians. This is particularly important as, in frailer older adults, unsupervised home exercise may be risky [
19].
Acknowledgements
The authors would like to acknowledge the contributions of Ms Kelly Banham, Ms Margaret Clarke, Ms Tina Duckworth, Ms Megan Lloyd, Dr Katie Thomson, Dr Calum Leask, Trafford Housing Trust, Pennine Care NHS Falls Service (Ms Debra Maloney, Dr Jay Chillala, Ms Angela Easdon), Mr Bibhas Roy, Dr Richard Deed, Prof Jackie Oldham, Dr Mark Pilling, Ms Joanne Thomas, Ms Bernadette O’Dowd.
We would like to thank all participants in this study and the management and staff of the assisted living facilities for their help and participation.