Exergaming in older adults: Use, user experiences, and the relationship between game elements and movement characteristics

Abstract

NORSK SAMMENDRAG: Exergaming for eldre Bruk, brukervennlighet og forholdet mellom spill elementer og bevegelseskarakteristikker - Etter introduksjonen av det Playstation-baserte spillet Dance Dance Revolution (DDR) i 2004 og Nintendo Wii i 2006, har bruken av videospill som et middel for å fremme fysisk aktivitet økt kraftig i popularitet. Disse bevegelses-kontrollerte spillene, som blir kalt exergames eller trenings spill på norsk, ble raskt anerkjent som et mulig verktøy for å tilby artig og lett tilgjengelig trening i både generell treningssammenheng og spesifikk rehabilitering. Selv om disse spillene har vist seg å ha et stort potensiale, er det fortsatt begrenset kunnskap om bruken og brukervennligheten av disse spillene for eldre, og om de er egnet for å opprettholde fysisk aktivitet, eller til bruk ved opptrening etter sykdom eller skade. Målet med denne avhandlingen er å evaluere bruken, brukervennligheten og forholdet mellom spill elementer og bevegelseskarakteristikker hos eldre, med spesielt fokus på spill som er designet for å ta steg for å få poeng. Resultatene viser at eldre synes at spill er en artig og spennende form for trening, men de påpekte en del mangler i forhold til tilbakemeldinger de fikk fra spillene, samt ønske om gradvis økning av vanskelighetsnivået. Eldre viser også forskjeller i bevegelsene de gjennomfører når de spiller ulike spill på ulike vanskelighetsnivå, noe som illustrerer viktigheten av å se på bevegelsene til spilleren, samt se på de ulike egenskapene som spillene innehar, før man tar i bruk spill i spesifikk trening og rehabilitering for eldre. Økt vanskelighetsgrad kan øke glede og gjøre spillet mer lystbetont, men kan samtidig redusere bevegelseskvalitet. Det er derfor viktig å velge spill ut i fra hva man ønsker at utfallet skal være.

Older adults represent the single largest group of people requiring healthcare in modern-day society. As the number of healthcare personal is projected to decrease in the years to come, it is important that elderly stay healthy and independent as long as possible. Falls and fall-related injuries are a major cause for loss of independence, and physical activity aimed at improving balance that includes stepping movements with weight shifting tasks has been shown to decrease fall risk. After the promotion of the Playstation-based Dance Dance Revolution (DDR) videogames as a weight loss tool in 2004 and the introduction of Nintendo Wii in 2006 for general, active entertainment, the use of body movements to control video games gained momentum rapidly and almost overnight became the favoured mode for a player to interact with a game station. These movement-controlled games, referred to as exergames, were quickly recognized as a potential tool to provide enjoyable, easy access, low threshold exercise and before long, exergaming was implemented in both general exercise and specific rehabilitation settings. Soon after, the first scientific studies appeared in the literature about the usability of exergames for elderly and the potential effect of balance and stepping exercises on fall risk reduction and prevention. After a decade with increasing research activity, several studies have reported that exergames have a great potential and positive, if weak, effects on physical activity in older adults. However, there is still a lack of in-depth descriptions of different game technologies, physical functions targeted, and safety issues related to older adults playing exergames, as well as of knowledge about older adults’ user experiences and preferences of exergame technologies to exercise balance and stepping abilities. Furthermore, little attention has been paid to the actual movements older adults display when playing step-based exergames, leading to uncertainty whether these exergames actually elicit the specific movements considered important for improving balance and stepping abilities in older adults. The overall aim of this thesis is to evaluate the use of exergames among older adults, with special focus on exergames designed for stepping activities. Specifically, the thesis aims to provide an overview of the technologies, safety and efficacy of exergames, to explore whether this technology is a safe and effective exercise and rehabilitation tool for older adults, to provide insight into the potential usefulness of exergames by evaluating user experiences and preferences of exergame technologies, and to assess movement characteristics displayed by older adults and map these to game elements during game play of step-based exergames. Results of the research reported in this thesis show that a variety of game technologies has been utilized to offer weight-bearing exercises to older adults, and that these exergames seem promising as an intervention tool to improve balance and gait parameters in older adults, with only a few reported adverse events. However, large differences between studies in terms of intervention protocols, outcome measures, and methodological limitations makes it challenging to compare the different studies and to draw definite conclusions regarding the effect of the interventions. Regarding user experiences and preferences, older adults expressed that they want exergames to focus on challenging tasks, provide feedback on how to perform the correct movements in a game, and provide progression in the game by rewarding correct movements and gradually increasing difficulty. As both movements displayed and game elements varied across all three exergames, mapping movement characteristics to game elements, illustrated the value of including analyses of movement characteristics of the player during game play when developing guidelines for designing exergames for fall prevention. Three-dimensional motion analysis demonstrated that movement characteristics displayed during game play are affected by the specifics of the step-based exergames as well as by the difficulty level of each game. Although players appreciated the increased level of difficulty, it had an unexpected negative effect on almost all movement characteristics, such as shorter steps with less variation in length and velocity, and less weight shift within a smaller movement area. This thesis provides new insight into the field of exergaming by providing a more thorough understanding of the use of exergames by older adults, particularly with respect to the preferences of older adults, movements displayed during game play, and the relationship between movements and game elements. The results of this thesis indicate that specific characteristics of the games influence how older adults move during game play. Gaining knowledge about game elements and movement characteristics is therefore important when designing and choosing exergames to exercise specific functions, such as balance and stepping abilities, in older adults. Exergames need to be selected and designed with care, taking into account the preferences of older adults, as well as the movement characteristics aimed for during game play by mapping the different elements in the game against the resulting movements of the players. Exergaming has great potential to become an important part of future personalized medical technology. However, to realize more fully the potential of exergames as an exercise and rehabilitation tool for older adults, there is a need for further understanding the movements displayed during game play, as well as establishing the safety of unsupervised exergaming, ensuring ease of use by older adults, achieving long-term adherence to the games, and gaining understanding about which technology to use for which exercise or rehabilitation purpose. The current thesis has provided several important steps towards gaining this understanding.