Hands up who has bought a for use Should in falls research/practice? we ?

an overview of the exerciseexergaming gaming approach to falls research Keep them up it works the way you’d like it to Stuart Smith Smith, ANZFPS, Dunedin 2010

What are exergames? What are exergames?

Why use them?

Who is using them in a health (falls) context?

Where to from here?

Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010

What are exergames? Amiga/Atari Joyboard What are exergames? (1982)

Sensors used to transduce body movements into control of play

Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010 Why use video games? Why use video games?

Video games have often received bad press with respect to health EffectiveBecause Exercise for the Preventionthey of Falls: A Systematic Review and Meta-Analysis

Ãw § w increased aggression and violence Catherine Sherrington,are PhD, FUNz Julie C. Whitney, MSc, Stephen R. Lord, DSc, Ã w Robert D. Herbert, PhD, Robert G. Cumming, PhD,z and Jacqueline C. T. Close, MD k addiction to gameplay

OBJECTIVES: To determine the effects of exercise on falls Key words: falls; exercise; meta-analysis increased sedentary behaviour prevention in older people and establish whether particular trial characteristics or components of exercise programs are associated with larger reductions in falls. DESIGN: Systematic review with meta-analysis. Random- epileptic seizures ized controlled trials that compared fall rates in older peo- ple who undertook exercise programs with fall rates in those who did not exercise were included. he development and implementation of effective and Wii knee, haemothorax and ruptured tendons SETTING: Older people. Tcost-efficient strategies to prevent falls in older people PARTICIPANTS: General community and residential care. is an urgent global health challenge. In developed countries, life expectancy for people aged 65 years old is approxi- MEASUREMENTS: Fall rates. mately 17 years for men and 21 years for women. At least RESULTS: The pooled estimate of the effect of exercise one-third of people aged 65 and older fall at least once Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010 was that it reduced the rate of falling by 17% (44 trials with annually,1 and falls account for more than half of the injury- 9,603 participants, rate ratio (RR) 5 0.83, 95% confidence 2 2 related hospitalizations for older people. Fall rates in the interval (CI) 5 0.75–0.91, Po.001, I 5 62%). The great- general older population are reported to be 1.2 falls per est relative effects of exercise on fall rates (RR 5 0.58, 95% person year.3 CI 5 0.48–0.69, 68% of between-study variability ex- Falls in older people are not purely random events but plained) were seen in programs that included a combina- can be predicted by assessing a number of risk factors.4,5 tion of a higher total dose of exercise (450 hours over the Some of these risk factors (e.g., reduced muscle strength and trial period) and challenging balance exercises (exercises impaired balance and gait) can be modified using exercise, conducted while standing in which people aimed to stand whereas others (e.g., poor vision, psychoactive medication with their feet closer together or on one leg, minimize use of use) require different intervention approaches. Exercise their hands to assist, and practice controlled movements of can be used as a stand-alone falls prevention intervention or the center of mass) and did not include a walking program. as a component of a multifaceted program. Multifaceted CONCLUSION: Exercise can prevent falls in older people. interventions can prevent falls in the general community, Greater relative effects are seen in programs that include in those at greater risk of falls, and in residential care exercises that challenge balance, use a higher dose of ex- facilities.4,6 ercise, and do not include a walking program. Service pro- Many trials have sought to establish the specific effect viders can use these findings to design and implement of exercise on fall rates, but a large proportion of these trials exercise programs for falls prevention. J Am Geriatr Soc have been underpowered. The best way to interpret these 56:2234–2243, 2008. Why use video games? trials mayInterventions be to pool their for preventing data in falls a meta-analysis, in older people living but trials in the Promote adherence Why use video games? of the effects of exercise oncommunity fall rates (Review) vary in their quality, From the ÃMusculoskeletal Division, The George Institute for International have been conducted on a range of populations, and employ Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH Health and zSchool of Public Health, University of Sydney, Sydney, Australia; exercise programs that differ greatly in their aims and con- wFalls and Balance Research Group, Prince of Wales Medical Research tent. Meta-analysis should therefore involve exploration of § Institute, University of New South Wales, Sydney, Australia; Clinical Age whether these factors ‘‘explain’’ (are associated with) esti- ResearchWe Unit,know Kings College fall Hospital, risk London, can United Kingdom; and mates of the effect of exercise programs.7,8 kDepartment of Geriatric Medicine, Prince of Wales Hospital, Sydney, 6 Australia.be reduced by exercise A Cochrane review of fall prevention strategies con- Address correspondence to Dr. Catherine Sherrington, The George Institute ducted separate meta-analyses on different forms of exer- for International Health, PO Box M201, Missenden Road, Sydney NSW cise and concluded that some exercise programs can prevent Effective2050, Australia. Exercise E-mail: [email protected] for the Prevention of Falls: A Systematicfalls in Review community dwellers (e.g., home exercise program of andDOI: 10.1111/j.1532-5415.2008.02014.x Meta-Analysis balance and strength training, a Tai Chi group program) but

Ãw § w Catherine Sherrington, PhD, z Julie C. Whitney, MSc, Stephen R. Lord, DSc, Tectrix VR bike à w Robert D. Herbert, PhD, Robert G. Cumming, PhD,z and Jacqueline C. T. Close, MD k JAGS 56:2234–2243, 2008 r 2008, Copyright the Authors 39 participants (21-60yo) Journal compilation r 2008, The American Geriatrics Society 0002-8614/08/$15.00 OBJECTIVES: To determine the effects of exercise on falls Key words: falls; exercise; meta-analysis prevention in older people and establish whether particular trial characteristics or components of exercise programs are This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library VR vs standard exercise bikes (upright, recumbent) associated with larger reductions in falls. 2009, Issue 4 http://www.thecochranelibrary.com DESIGN: Systematic review with meta-analysis. Random- ized controlled trials that compared fall rates in older peo- pleHigh who undertook dosage exercise programs withof fall exercise rates in is required (eg > 50 hrs those who did not exercise were included. he development and implementation of effective and Exercise 3x/week for 14 weeks, 20-30 mins/session SETTING: Older people. Tcost-efficient strategies to prevent falls in older people PARTICIPANTS:or twice/weekGeneral community and residential for care. 25is anweeks). urgent global health challenge. In developed countries, life expectancy for people aged 65 years old is approxi- Attendance greater for VR over standard bike exercise MEASUREMENTS: Fall rates. mately 17 years for men and 21 years for women. At least RESULTS: The pooled estimate of the effect of exercise one-third of people aged 65 and older fall at least once was that it reduced the rate of falling by 17% (44 trials with 1 Interventions for preventing falls in older people living inthecommunity(Review) annually, and falls account for more than half of theCopyright injury- © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 9,603 participants, rate ratio (RR) 5 0.83, 95% confidence related hospitalizations for older people.2 Fall rates in the (F6,32 = 6.01, p <0.02) 2 interval (CI) 5 0.75–0.91, Po.001, I 5 62%). The great- general older population are reported to be 1.2 falls per est relative effects of exercise on fall rates (RR 5 0.58, 95% person year.3 CI 5 0.48–0.69, 68%Video of between-study variabilitygames ex- Falls in older might people are not purely random offer events but a way to plained) were seen in programs that included a combina- can be predicted by assessing a number of risk factors.4,5 tion of a higher total dose of exercise (450 hours over the Some of these risk factors (e.g., reduced muscle strength and trial period) and challenging balance exercises (exercises impaired balance and gait) can be modified using exercise, 83% adherence for VR, 61% recumbent, 57% upright conducted while standing in which people aimed to stand ensure compliancewhereas others (e.g., poor vision, psychoactive with medication exercise with their feet closer together or on one leg, minimize use of use) require different intervention approaches. Exercise their hands to assist, and practice controlled movements of can be used as a stand-alone falls prevention intervention or the center of mass) and did not include a walking program. as a component of a multifaceted program. Multifaceted Smith, ANZFPS, Dunedin 2010 Smith,CONCLUSION: ANZFPS,Exercise Dunedin can prevent2010 falls in older people. interventions can prevent falls in the general community, Greater relative effects are seen in programs that include in those at greater risk of falls, and in residential care exercises that challenge balance, use a higher dose of ex- facilities.4,6 ercise, and do not include a walking program. Service pro- Many trials have sought to establish the specific effect viders can use these findings to design and implement of exercise on fall rates, but a large proportion of these trials exercise programs for falls prevention. J Am Geriatr Soc have been underpowered. The best way to interpret these 56:2234–2243, 2008. trials may be to pool their data in a meta-analysis, but trials of the effects of exercise on fall rates vary in their quality, From the ÃMusculoskeletal Division, The George Institute for International have been conducted on a range of populations, and employ Health and zSchool of Public Health, University of Sydney, Sydney, Australia; exercise programs that differ greatly in their aims and con- wFalls and Balance Research Group, Prince of Wales Medical Research tent. Meta-analysis should therefore involve exploration of § Institute, University of New South Wales, Sydney, Australia; Clinical Age whether these factors ‘‘explain’’ (are associated with) esti- Research Unit, Kings College Hospital, London, United Kingdom; and mates of the effect of exercise programs.7,8 kDepartment of Geriatric Medicine, Prince of Wales Hospital, Sydney, 6 Australia. A Cochrane review of fall prevention strategies con- Address correspondence to Dr. Catherine Sherrington, The George Institute ducted separate meta-analyses on different forms of exer- for International Health, PO Box M201, Missenden Road, Sydney NSW cise and concluded that some exercise programs can prevent 2050, Australia. E-mail: [email protected] falls in community dwellers (e.g., home exercise program of DOI: 10.1111/j.1532-5415.2008.02014.x balance and strength training, a Tai Chi group program) but

JAGS 56:2234–2243, 2008 r 2008, Copyright the Authors Journal compilation r 2008, The American Geriatrics Society 0002-8614/08/$15.00

Who is using exergames in a Who is using exergames in a Do older adults play health-related context? health-related context? video games?

Brand (2009) “Interactive Australia 2009” National survey of 1614 households

1034 individuals aged 36-50, 58% play video games

912 aged 51-65 52% play video games

221 aged 65+, 51% play video games

Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010 Exergames for Subsyndromal Depression in Older Adults: A Pilot Study of a Novel Intervention Who is using exergames in Who is using exergames in Check out our poster a FALL-related context? a FALL-related context? Dori Rosenberg, M.P.H., M.S., Colin A. Depp, Ph.D., Ipsit V. Vahia, M.D., Jennifer Reichstadt, M.S., Barton W. Palmer, Ph.D., Jacqueline Kerr, Ph.D., Greg Norman, Ph.D., Dilip V. Jeste, M.D.

Objectives: Subsyndromal depression (SSD) is several times more common than 89-year-old resident diagnosed with an unspecified major depression in older adults and is associated with significant negative health balance disorder and a history of multiple falls. outcomes. Physical activity can improve depression, but adherence is often poor. The authors assessed the feasibility, acceptability, and short-term efficacy and safety of a 6 Wii Bowling session, 1 hour/session, over 2 weeks novel intervention using exergames (entertaining video games that combine game play with exercise) for SSD in older adults. Methods: Community-dwelling older Outcome measures: adults (N ϭ 19, aged 63–94 years) with SSD participated in a 12-week pilot study Pre Post (with follow-up at 20–24 weeks) of ’s Wii sports, with three 35-minute Berg Balance Scale (49) 48 53 sessions a week. Results: Eight-six percent of enrolled participants completed the 12-week intervention. There was a significant improvement in depressive symptoms, But to give you a flavour..... Dynamic Gait Index (19) 19 21 mental health-related quality of life (QoL), and cognitive performance but not physical health-related QoL.3m There were no major adverse events, and improvement Timed Up and Go (13.5) 14.9 10.5 in depression was maintained at follow-up. Conclusions: The findings provide preliminary3m indication of the benefits of exergames in seniors with SSD. Randomized Activities-specific Balance controlled trials of exergames for late-life SSD are warranted. (Am J Geriatr Psychiatry Confidence (67%) 88% 90% 2010; 18:221–226) Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010 Key Words: Physical activity, aging, videogames, depression, quality of life, cognition

mong older people, subsyndromal depression safe, evidence-based interventions tailored to older per- A (SSD) is several times more common than major sons with SSD that can be delivered in the home.3 depression and is associated with substantial suffering, Physical activity is a key modifiable behavior for functional disability, increased use of costly medical improving physical health conditions and function- services, and higher mortality.1,2 There is a dearth of ing and reducing depressive symptoms in late life.4

Who is using exergames in Who is using exergames in Received July 16, 2009; revised August 26, 2009; accepted August 31, 2009. From the Joint Doctoral Program in Clinical Psychology University of California San Diego (UCSD)/San Diego State University (SDSU) (DR); Department of Psychiatry, UCSD (CAD, IVV, BWP, DVJ); Sam and Rose a FALL-related context? a FALL-related context? Stein Institute for Research on Aging, UCSD (CAD, IVV, JR, DVJ); and Department of Family and Preventive Medicine, UCSD (JK, GN), San Diego, CA. Send correspondence and reprint requests to Dilip V. Jeste, M.D., Stein Institute for Research on Aging, Department of Psychiatry, University of California, 9500 Gilman Drive (MC 0664), La Jolla, CA 92093-0664. email: [email protected] © 2010 American Association for Geriatric Psychiatry

Am J Geriatr Psychiatry 18:3, March 2010 221 22 healthy older adults but presenting with SSD, 10 healthy women, aged 30-58, (8 completed) aged >60, (19 completed)

Two 30-min WiiFit sessions per week for 10 weeks Three 35-min Wii Sports sessions per week for 12 weeks

Yoga, balance, aerobic and strength options tennis, bowling, baseball, boxing and golf

Outcome measures: Outcome measures:

TUGcognitive speed improved Lower limb strength increased

Unilateral stance (Balance Master) improved

Weight loss observed

Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010

Who is using exergames in Who is using exergames in a FALL-related context? a FALL-related context?

Dance Dance Revolution Downloaded from bjsm.bmj.com on January 18, 2010 - Published by group.bmj.com BJSM Online First, published on November 29, 2009 as 10.1136/bjsm.2009.066845 Presents cognitively challenging, physical A novel Dance Dance Revolution (DDR) system for in- exercise to train stepping home training of stepping ability: Basic parameters of system use by older adults.

Downloaded from bjsm.bmj.com on January 18, 2010 - Published by group.bmj.com BJSM Online First, published on November 29, 2009 as 10.1136/bjsm.2009.066845 Stuart T Smith1§, Catherine Sherrington 2,1, 3 A novel Dance Dance Revolution (DDR) system for in- Stephanie Studenski , 1 home training of stepping ability: Basic parameters of Daniel Schoene , Stephen R Lord1 system use by older adults. Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010 Stuart T Smith1§, 1Prince of Wales Medical Research Institute, Sydney, Australia Catherine Sherrington 2,1, 2George Institute for International Health, University of Sydney, Sydney, Australia Stephanie Studenski 3, 3 Daniel Schoene 1, University of Pittsburgh, Pittsburgh, USA Stephen R Lord1 §Address for correspondence 1Prince of Wales Medical Research Institute, Sydney, Australia 2George Institute for International Health, University of Sydney, Sydney, Australia Stuart Smith, PhD 3University of Pittsburgh, Pittsburgh, USA Prince of Wales Medical Research Institute Barker Street §Address for correspondence Stuart Smith, PhD Randwick, NSW Australia 2031 Prince of Wales Medical Research Institute Phone: + 61 (0)2 9399 1629 Barker Street Fax: +61 (0)2 9399 1204 Randwick, NSW Australia 2031 Email: [email protected] Phone: + 61 (0)2 9399 1629 Fax: +61 (0)2 9399 1204 Email: [email protected] Keywords: Accidental falls, Exercise therapy, video games, telehealth

Keywords: Accidental falls, Exercise therapy, video games, telehealth Word count: 3134 Word count: 3134

Copyright Article author (or their employer) 2009. Produced by BMJ Publishing Group Ltd under licence.

Copyright Article author (or their employer) 2009. Produced by BMJ Publishing Group Ltd under licence. Where to from here? Where to from here? Expensive to develop age- appropriate games Challenges posed by off-the-shelf video game technology BUT the game development industry NEEDS a new market

Sensor resolution of the gaming system may be poor/ inappropriate for measuring movements in older adults

Interaction with off-the-shelf games not well suited to functional/cognitive limitations of older adults

Expensive to develop software titles for gaming consoles (Wii, Playstation, Xbox)

Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010

Where to from here? Where to from here? DDR,

We need to build collaborations with game developers

strategy, memory

logic games Falls Social Cognitive Connectivity Connectivity

casual, online games Video Games for Independent Living (ViGIL) Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010

Should we ?

We should certainly explore the use of ALL exergames

They’re fun

They facilitate engagement with exercise

They engage both physical and cognitive mechanisms

They employ levels of progression Thank you, if you’re so inclined, join our facebook group to learn more. They enable tracking of compliance for home-based exercise interventions (Games for Health Australasia) Smith, ANZFPS, Dunedin 2010 Smith, ANZFPS, Dunedin 2010