https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-017-0467-7 Exergames versus self-regulated exercises with instruction leaflets to improve adherence during geriatric rehabilitation: a randomized controlled trial

1. Exergames versus self-regulated exercises with
instruction leaflets to improve adherence during
geriatric rehabilitation: a randomized controlled trial
Peter Oesch, Jan Kool,
Luis Fernandez-Luque
Ellen Brox, Gunn Evertsen, Anton Civit, Roger Hilfiker
and Stefan Bachmann
BMC Geriatrics 201717:77
DOI: 10.1186/s12877-017-0467-7
1lluque@hbku.edu.qa

2. 2
BACKGROUND
Mobility and physical activity
Aging is associated with a decline in mental function, reduced motivation for physical activities, a decline in
motor skills, mobility impairment and a higher risk of falling
Self-regulated exercise and exergames
In order to increase the
quantity and duration of
therapy during
rehabilitation, self-
regulated exercise is
prescribed
Exergames may be an
attractive alternative for
increasing the
motivation of elderly
people performing self-
regulated exercises.
Exergames are
designed for a primary
purpose other than
pure entertainment.
During exergames the
user performs physical
exercises to control the
game.

3. 3
BACKGROUND – EXERGAME ACTIVITIES

4. 4
BACKGROUND – EXERGAME ACTIVITIES

5. 5
BACKGROUND
Effectiveness of exergames
There is limited evidence regarding the effectiveness of exergames in increasing adherence to exercise
recommendations in rehabilitation settings.
A review of exergames for stroke rehabilitation found moderate improvements in activity outcomes and highlighted
the need for larger studies.
The present study was conducted within the GameUp project [21], which addressed these specific challenges by
developing new exergames promoting mobility in elderly people, using well-documented user-centered design
methods.
Aim
The primary aim of this study in a geriatric rehabilitation setting was to compare adherence to self-regulated training
when playing exergames or using information leaflets for self-regulated exercises.
Secondary outcomes enjoyment, motivation and balance skills.

6. 6
METHODS
Design
A single-center randomized
controlled clinical trial was
performed comparing self-regulated
conventional exercises with self-
regulated exergames
Figure shows the study design and
patient flow.

7. 7
RESULTS
Recruitment and baseline characteristics

8. 8
OUTCOMES
The primary outcome of the study was adherence to prescribed self-regulated exercise evaluated by self-
reported exercise time
Adherence to prescribed self-regulated
exercise (min/d) for 10 days of treatment
Patient ratings of enjoyment during
exercise over 10 days of treatment
Patient ratings of motivation during
exercise over 10 days of treatment

9. 9
MAIN RESULTS
This study compared the effect on adherence,
motivation, enjoyment and balance abilities of
conventional self-regulated exercises with
exergames older people in a geriatric rehabilitation
setting.
Contrary to our expectations, no benefit was found
for self-regulated exergames compared with self-
regulated conventional exercises regarding
adherence, measured as daily training volume.
Exercise time and frequency of exercise sessions
on the first self-regulated training day were
comparable in both groups, but changed
significantly over the 10-day period in favor of self-
regulated conventional exercises.
The significant difference in training volume over
the 10-day intervention period between both
groups was accompanied by a significant
decrease in motivation and enjoyment in the self-
regulated exergames group compared with the
self-regulated conventional exercises group.

10. 10
STRENGTHS OF THIS STUDY
To our knowledge, this is the first study to
compare exergames with conventional self-
regulated exercises in persons over 65
years of age in a rehabilitation setting.
Other available studies focus on older adults,
either with brain injury or with cognitive
impairment, living in the community.
Although recruitment was more than 50%
below expectations, the effects were larger
than expected and were therefore
significant (Cohen’s d > 0.5).
In addition, by making repeated measures over
a period of ten consecutive days the power of
between-group statistical analyses was
increased over that of comparing two
measurements before and after a treatment
phase.
1 2
3 4

11. 11
FUNDING
The present study is part of an international research project (GameUp Project) focusing on game-based
mobility training and motivation of elderly persons, and is co-funded by the European research and
development joint program “Ambient Assisted Living” (Ref. AAL-2011-4-090)

12. 12
LIMITATIONS
We did not evaluate frailty at baseline. A higher level of frailty in
the exergame group might have contributed to the higher drop-
out rate in this group. However, groups were comparable for age,
diagnosis, multimorbidity, cognition, balance and fear of falling
A further limitation of the study design is the short duration of the
intervention (ten working days). This limitation is due to the length
of hospitalization (2 to 3 weeks).
The use of a self-report logbook to measure daily training volume
can be considered a further limitation of the design. A systematic
error in self-reporting cannot be excluded, but, as participants in
both treatment groups used the same logbook, we assume that
such error was comparable in the two groups.

13. 13
CONCLUSIONS
In a geriatric rehabilitation setting, conventional self-regulated
exercise using printed instruction leaflets were superior to self-
regulated exercise using exergames with respect to adherence,
enjoyment and motivation.
Computer-based exergames were initially associated with
higher motivation and enjoyment, but this difference reversed
over a period of 2 weeks.
Balance skills during walking measured with accelerometers
remained unchanged in both groups.
Improvements in exergames, and randomized controlled trials
evaluating their effectiveness compared with other methods of
providing self-regulated exercise, are needed before general
use in a geriatric rehabilitation setting can be considered.