The Benefits of Virtual Reality in Preventing Falls in Older Adults: Literature Review

Author for correspondence:

Franjo Liška

Sestre milosrdnice University Hospital Center, Zagreb, Croatia

E-mail: franjo.liska@hotmail.com

https://doi.org/10.24141/2/7/2/5

Keywords: virtual reality, exergames, falls, fall prevention, older adults, elderly

Abstract

Introduction. The aging of the human organism brings with it a decrease in bodily functions, both motor and cognitive, and the probability of develop- ing numerous diseases and conditions increases. The most common difficulties faced by the elderly are re- duced ability to control balance and control gait due to muscle weakness and reduced coordination. The con- sequences of falls in elderly population are increase in mortality and morbidity and effects on quality of life, and work is needed to prevent falls in this popu- lation. Over the past few decades, the integration of information and communication technology (ICT) into healthcare has given rise to a novel research field. One prominent aspect within this field is the widespread adoption of virtual reality (VR) and/or exergaming in various medical areas. This study aims to explore the potential usability of virtual reality and exergames as a preventive measure against falls in older adults.

Methods. A search of literature was conducted through PubMed and Scopus databases, using search strings and inclusion and exclusion criteria.

Results. A total of 330 papers were identified through databases search, and after study selection process, 8 studies were included in this review.

Conclusion. The use of these interventions has a promising effect on improving the balance, gait, mo- tor, and cognitive functions of the older adults, which are all factors that are correlated with a reduction in the risk of falls in the studied population.

Introduction

In recent decades, there has been a notable shift in the demographic makeup of the global population, primarily driven by advancements in healthcare and medical services, as well as broader societal factors. This transformation is characterized by an increas- ing proportion of older individuals worldwide, ac- companied by a simultaneous decline in the younger population. The World Health Organization (WHO) re- ported in 2020 that the number of individuals aged 60 years and above outnumbered children under the age of 5. Furthermore, projections indicate that be- tween 2020 and 2050, the global population aged 60 years or older is expected to double from 1 billion to 2.1 billion (1).

The stated development of today’s society brings more than just advantages. The aging of the human organism inevitably leads to a decrease in bodily functions, both motor and cognitive, and the prob- ability of developing numerous diseases and condi- tions increases (2). According to Owino, the most common difficulties faced by the elderly are reduced ability to control balance and control gait due to mus- cle weakness and reduced coordination (3). Due to this decline, elderly individuals often experience various complex health conditions, with falls being one of the most prevalent (4). The combination of re- duced cognitive functions and the factors mentioned earlier contributes to the heightened susceptibility of the elderly population to falls. Additionally, falls in this population often result in more significant consequences and impacts on overall well-being. Ac- cording to previous research, every third person aged 65 or more experiences at least one fall every year (5, 6). According to the World Health Organization (WHO), individuals aged 60 years and above experi- ence the highest number of fatal falls (1). Addition- ally, Marschollek’s research emphasizes that falls are the primary cause of non-fatal injuries among older adults (7).

The consequences of falls in elderly population are various, including increase in mortality and morbid- ity, but also psychological, such as reduction of qual- ity of life due to loss of independence and fear of falling which can lead to depression and social iso- lation (8). In addition, falls represent a great socio-

economic burden on health care systems all around the globe.

Due to all the above, work is needed to prevent falls in this population. Among the many ways to conduct measures of prevention, one of the most effective would be promoting individuals physical activity in order to slow down the decline of motor functions.

As time progresses, the activity levels of most indi- viduals tend to decline. However, extensive research has consistently demonstrated that participating in physical activity positively impacts coordination, bal- ance, and the likelihood of falls in this population (9- 12). In fact, increased physical activity can potential- ly decrease the risk of falls by up to 50% (13). Taylor cites that the WHO recommends daily physical activ- ity and combining balance and muscle-strengthening exercise to reduce the impairment of physical func- tions in people aged over 65 (14). However, here we encounter the problem of cooperation. Namely, older adults may have difficulty in mobility and are unable to regularly attend, for example, organized classical exercise programs. Furthermore, a major aggravating circumstance is the lack of motivation in this popula- tion, and according to de Groot and Fagerström, older people must see a certain potential in carrying out physical activity, such as a potential increase in in- dependence or a potential better balance, which is difficult to achieve through classic exercise programs (15).

In recent decades, a novel research field has emerged that integrates information and ICT into healthcare, specifically through the widespread utilization of VR and/or exergaming across various medical areas.

VR technology can simulate a real exercise environ- ment, and its popularity has been growing because it is entertaining, enables the use of all senses and can provide feedback and results (16). Virtual reality is defined in the Encyclopaedia of multimedia as tech- nology that uses different multimedia technologies such as image, sound, video, text, as well as newer ones like touch, smell, taste, all to provide almost real experiences in a virtual way (17). Exergaming is actively playing videogames that includes physical movement (18).

The aim of this literature review was to investigate the benefits of virtual reality in preventing falls in older adults.

Methods

This study reviewed the scientific literature on the effect of virtual reality on fall prevention in the el- derly population published from 2018 to 2022. The search was conducted in two scientific databases, PubMed, and Scopus, on February 17, 2023. The fol- lowing keywords were used in various combinations when searching for titles, abstracts, and keywords of articles: virtual reality, exergame*, serious game*, fall*, fall prevention, preventing fall* older adult*, el- der*. Boolean operators were used to create search strings, as shown in Table 1. Regarding the inclusion and exclusion criteria, shown in Table 2, the search was limited to English-language articles, and the tar- get population were participants older than 65 years. Regarding the type of article, clinical trials and rand- omized clinical trials were included.

Results

By searching both databases, we obtained a total of 330 articles, of which 119 by searching the PubMed database and 211 by searching the Scopus database. After removing duplicates using Zotero, there were 221 articles left. After reading the title and abstract and following the inclusion and exclusion criteria listed in Table 2, another 209 articles were excluded (not randomized controlled trials - 195, articles not written in English - 5, population under 65 - 9). Ad- ditionally, 4 more articles were excluded due to con- tent irrelevance. There were 8 articles left that were included into the final review. The procedure for ex- tracting the final literature used for this literature review is shown in Figure 1 using the PRISMA flow diagram (19).

Records identified from Pubmed and Scopus databases. (n = 330)

Article after duplicate removed.

(n = 221)

Articles assessed for eligibility

(n = 221)

Articles included in review (n = 8)

Articles excluded by exclusion criteria

(n = 540)

Not in English (n = 5) Not RCT (n = 195)

Population ‹65(n = 9) Not eligible (n = 4)

Articles identified through Pubmed database.

(n = 119)

Articles identified through Scopus database.

(n = 211)

Included

Screening

Identification

Figure 1. PRISMA flow diagram for the literature research

Discussion

This literature review has identified a collection of randomized controlled studies that provide substan- tial evidence supporting the advantageous impact of incorporating virtual reality and exergames-con- ducted exercise programs on the balance, gait, motor skills, and cognitive functions of older adults.

Authors Zak et al. wanted to investigate if there were advantages in using a VR application enhanced physi- otherapy compared to classic programme. They con- ducted a double-blind study on a total of 60 participants randomly allocated into 4 groups (three VR enhanced groups and one classic programme group), where the sessions took place in the participants homes for 3 weeks. They concluded that the use of VR environments in the physiotherapy programme particularly improved

static balance. Also, they claim that VR enhanced physi- otherapy is good alternative to classic physiotherapeu- tic regimens (20). The above-mentioned results have been supported by similar studies, which further dem- onstrated superior improvements in gait among the VR group (21,22). Hauer et al. conducted research that also revealed notable enhancements in the performance of complex motor-cognitive stepping using exergames, which has potential relevance in fall prevention. The study involved fifty-eight older adults who participated in a 10-week intervention, engaging in strength and bal- ance exercises once a week, along with supplementary stepping exergame training. The control group, on the other hand, solely performed the strength and balance exercises without the additional exergame component

(23). Hassett et al. conducted research wherein they also demonstrated improvements in mobility among individu- als with various health conditions through the utilization of digitally enabled rehabilitation (24).

Kim and Cho’s research findings indicated that VR and motor imagery training (MIT) can effectively contribute to fall prevention among older adults. Fur- thermore, they recommended VR and MIT as viable alternatives to physical activity for older individuals who may be socially isolated (25).

However, it is important to note that not all studies included in this review demonstrated advantages of VR-enhanced exercise in comparison to traditional training. For instance, one study investigated the ef- fects of exergames played on Xbox Kinect platforms in the intervention group, while the control group en- gaged in their usual activities. The study, however, yielded no statistically significant improvements in the intervention group. But the authors emphasize that the attendance rate was high, which can be in- dicative of the motivational potential of exergames on older adults (26). Another study conducted by Moreira et al. did not demonstrate a significant ad- vantage of VR-aided training. In their study, they compared the impacts of exergaming and a tradition- al training program on cognitive and motor functions. The study enrolled a total of 66 participants who were randomly assigned to two groups. Surprisingly, both programs demonstrated equal effectiveness in reducing the fear of falling, enhancing fall risk awareness, and improving cognitive status, muscle function, and physical function (27).

Identified gaps

Most of the studies mentioned above have been con- ducted on a relatively small number of participants, so it is questionable if their results can be applied to the total population. However, this field of interest has been present for some time now. Many studies were conducted investigating the use of VR and exergam- ing in rehabilitating patients suffering from different diseases and conditions. A great majority of those studies concluded that using VR and exergaming can be a significant benefit, not only because they give better results but also because of the long-term cost- benefit. So, the question is not whether they are help- ful but how can we make them more useful in a specif- ic design and tailoring for certain groups of patients.

Furthermore, some of the research lack long-term follow-up, and we do not know if the immediate good results of VR-based training had a long-term impact and how long. This is therefore considered vital be- cause this data would greatly help to tailor and de- sign the VR mentioned above and exergames target- ing a specific population or group of patients.

Conclusion

Through a comprehensive review of the literature on this subject, the research findings consistently indicate that the implementation of VR and/or exer- gaming can have a positive impact on enhancing the balance, gait, motor skills, and cognitive functions of older adults. These improvements directly contrib- ute to reducing the risk of falls within this popula- tion. The results obtained from this study align with the majority of previously conducted research in this specific area of interest, reinforcing the coherence and validity of the findings. The common conclusion derived from all the studies conducted is that, con- sidering the fact that the ageing population, which is at the greatest risk of falls, and will be a great bur- den on health and socioeconomic systems globally, there is a need to develop instruments and methods for fall prevention, and exergaming or VR has shown great potential to do so. Further studies should be conducted on larger number of participants to better examine the mechanisms by which such technolo- gies can help in preventing falls. Also, further work is needed to identify the best ways to implement these technologies to be used by the said popula- tion, considering aggravating factors such as lack of motivation, inactivity, digital literacy, and aversion to the use of technology.

References

1. World Health Organization (WHO). Ageing and health. World Health Organization. 2022. Available from: https://www.who.int/news-room/fact-sheets/detail/ ageing-and-health Accessed: 11.01.2023.

2. Fernández-Argüelles EL, Rodríguez-Mansilla J, Antu- nez LE, Garrido-Ardila EM, Muñoz RP. Effects of dan- cing on the risk of falling related factors of healthy ol- der adults: A systematic review. Arch Gerontol Geriatr. 2015;60(1):1–8. doi: 10.1016/j.archger.2014.10.003.

3. Owino V, Yang SY, Goldspink G. Age-related loss of skeletal muscle function and the inability to express the autocrine form of insulin-like growth factor-1 (MGF) in response to mechanical overload. FEBS Lett. 2001;505(2):259-63. doi: 10.1016/s0014- 5793(01)02825-3.

   
   

   
   

4. World Health Organization. Falls. World Health Organiza- tion. 2021. Available from: https://www.who.int/news- room/fact-sheets/detail/falls Accessed: 11.01.2023.

5. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35 Suppl 2:ii37-ii41. Available from: https://aca- demic.oup.com/ageing/article/35/suppl_2/ii37/15775

6. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for pre- venting falls in older people living in the community. Co- chrane Database Syst Rev. 2012;2012(9):CD007146. doi: 10.1002/14651858.cd007146.pub3.

7. Marschollek M, Rehwald A, Wolf KH, Gietzelt M, Nemitz G, zu Schwabedissen HM, et al. Sensors vs. experts - a performance comparison of sensor-based fall risk assessment vs. conventional assessment in a sam- ple of geriatric patients. BMC Med Inform Decis Mak. 2011;11:48. doi:10.1186/1472-6947-11-48.

8. Choi SD, Guo L, Kang D, Xiong S. Exergame techno- logy and interactive interventions for elderly fall pre- vention: A systematic literature review. Appl Ergon. 2017;65:570-81. doi:10.1016/j.apergo.2016.10.013.

9. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cum- ming RG, Close JC. Effective exercise for the preven- tion of falls: a systematic review and meta-anal- ysis. J Am Geriatr Soc. 2008;56(12):2234-43. doi: 10.1111/j.1532-5415.2008.02014.x.

10. Avin KG, Hanke TA, Kirk-Sanchez N, McDonough CM, Shubert TE, Hardage J, et al; Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Management of falls in community- dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Phys Ther. 2015;95(6):815-34. doi: 10.2522/ptj.20140415.

11. Kobayashi R, Nakadaira H, Ishigami K, Muto K, Anesaki S, Yamamoto M. Effects of physical exercise on fall risk fac- tors in elderly at home in intervention trial. Environ Health Prev Med. 2006;11(5):250-5. doi: 10.1007/bf02898014.

12. Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA, Gold R; US Preventive Services Task Force. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Pre- ventive Services Task Force. Ann Intern Med. 2010 Dec 21;153(12):815-25. doi: 10.7326/0003-4819- 153-12-201012210-00008.

13. Bembom O, van der Laan M, Haight T, Tager I. Leisure- time physical activity and all-cause mortality in an el- derly cohort. Epidemiology. 2009;20(3):424-30. doi: 10.1097/ede.0b013e31819e3f28.

14. Taylor D. Physical activity is medicine for older adults. Postgrad Med J. 2014;90(1059):26-32. doi: 10.1136/

    postgradmedj-2012-131366.

15. de Groot GC, Fagerström L. Older adults’ motivat- ing factors and barriers to exercise to prevent falls. Scand J Occup Ther. 2011;18(2):153-60. doi: 10.3109/11038128.2010.487113.

16. Hall CD, Clevenger CK, Wolf RA, Lin JS, Johnson TM 2nd, Wolf SL. Feasibility of a low-cost, interactive gaming system to assess balance in older women. J Aging Phys Act. 2016;24(1):111-8. doi:10.1123/japa.2014-0184.

17. Virtual Reality. In: Furht, B., editor. Encyclopedia of Mul- timedia. Boston, MA: Springer; 2008. doi: 10.1007/978- 0-387-78414-4_255.

18. Oh Y, Yang S. Defining exergames & exergaming. Pro- ceedings of meaningful play. 2010;2010:21-23.

19. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoff- mann TC, Mulrow CD, et al. The PRISMA 2020 state- ment: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71.

20. Zak M, Sikorski T, Krupnik S, Wasik M, Grzanka K, Cour- teix D, et al. Physiotherapy Programmes Aided by VR Solutions Applied to the Seniors Affected by Function- al Capacity Impairment: Randomised Controlled Trial. Int J Environ Res Public Health. 2022;19(10):6018. doi:10.3390/ijerph19106018.

21. Liao YY, Chen IH, Lin YJ, Chen Y, Hsu WC. Effects of vir- tual reality-based physical and cognitive training on executive function and dual-task gait performance in older adults with mild cognitive impairment: a random- ized control trial. Front Aging Neurosci. 2019;11:162. doi:10.3389/fnagi.2019.00162.

22. Lee K. Virtual reality gait training to promote balance and gait among older people: a randomized clinical trial. Geriatrics (Basel). 2020;6(1):1. doi: 10.3390/ge- riatrics6010001.

23. Hauer K, Litz E, Günther-Lange M, Ball C, de Bruin ED, Werner C. Effectiveness and sustainability of a motor-cognitive stepping exergame training on step- ping performance in older adults: a randomized con- trolled trial. Eur Rev Aging Phys Act. 2020;17:17. doi:10.1186/s11556-020-00248-4.

24. Hassett L, van den Berg M, Lindley RI, Crotty M, Mc- Cluskey A, van der Ploeg HP, Smith ST, et al. Digitally enabled aged care and neurological rehabilitation to enhance outcomes with Activity and MObility UsiNg Technology (AMOUNT) in Australia: A randomised con- trolled trial. PLoS Med. 2020;17(2):e1003029. doi: 10.1371/journal.pmed.1003029.

25. Kim SH, Cho SH. Benefits of virtual reality program and motor imagery training on balance and fall effi- cacy in isolated older adults: a randomized controlled trial. Medicina. 2022;58(11):1545. doi:10.3390/me- dicina58111545.

26. Taylor L, Kerse N, Klenk J, Borotkanics R, Maddison R. Exergames to improve the mobility of long-term care residents: a cluster randomized controlled trial. Games Health J. 2018;7(1):37-42. doi:10.1089/g4h.2017.0084.

27. Moreira NB, Rodacki ALF, Costa SN, Pitta A, Bento PCB. Perceptive-cognitive and physical function in prefrail older adults: exergaming versus traditional multicom- ponent training. Rejuvenation Res. 2021;24(1):28-

36. doi: 10.1089/rej.2020.2302.

PREDNOSTI VIRTUALNE STVARNOSTI U PREVENCIJI PADOVA KOD STARIJIH ODRASLIH: PREGLED LITERATURE

Sažetak

Uvod. Starenje ljudskog organizma sa sobom nosi smanjenje tjelesnih funkcija, kako motoričkih tako i kognitivnih, te se povećava vjerojatnost razvoja broj- nih bolesti i stanja. Najčešće su poteškoće s kojima se susreću starije osobe smanjena sposobnost kontrole ravnoteže i kontrole hoda zbog slabosti mišića i sma- njene koordinacije. Posljedice su pada u starijoj po- pulaciji povećanje mortaliteta i morbiditeta te utjecaj na kvalitetu života te je potrebno raditi na prevenciji padova u ovoj populaciji. Tijekom posljednjih nekoliko desetljeća integracija informacijske i komunikacijske tehnologije (IKT) sa zdravstvenom skrbi dovela je do novoga istraživačkog polja. Jedan od aspekata u ovom području je široko prihvaćanje virtualne stvar- nosti (VR) i/ili exergaminga u različitim područjima medicine. Ova studija ima za cilj istražiti potencijalnu upotrebljivost virtualne stvarnosti i exergaminga kao preventivne mjere protiv padova kod starijih osoba.

Metode. Pretraživanje literature provedeno je kroz baze podataka PubMed i Scopus, primjenom nizova za pretraživanje te kriterija uključivanja i isključivanja.

Rezultati. Pretraživanjem baza podataka identifici- rano je ukupno 330 radova, a nakon postupka odabi- ra studija, u ovaj pregled literature uključeno je osam studija.

Zaključak. Primjena ovih intervencija ima obećavaju-

ći učinak na poboljšanje ravnoteže, hoda, motoričkih i       

kognitivnih funkcija starijih odraslih osoba, što su sve čimbenici koji su u korelaciji sa smanjenjem rizika od

Ključne riječi: virtualna stvarnost, exergaming, padovi, prevencija pada, starije osobe

padova u proučavanoj populaciji.