The Effects of VR Interactive Games on Balance and Quality of Life Enhancement for Elderly in the Community
Phase: NA
Conditions: Virtual Reality
Sponsor: Taipei Medical University

The Effects of VR Interactive Games on Balance and Quality of 
Life Enhancement for Elderly in the Community
Unique Protocol ID: N202210004 
Document Date: June 26, 2023

I 
Abstract 
Thesis title: Examining the effectiveness of a virtual reality interactive 
game on physical fitness and quality of life in community-dwelling 
elderly people 
Name of degree and program: Master’s program in Long-term Care, 
Taipei Medical University 
Graduate student: Yu-Ching Tseng 
Thesis directed by: Chueh-Ho Lin, Associate Professor International 
Ph.D. Program in Gerontology and Long-term Care, Taipei Medical 
University 
Background: Currently, community exercise courses are mostly guided 
by nurses and there are few opportunities for participating elderly people 
to interact with others during exercise. An interactive game was 
developed to allow elderly people participating in community activities to 
use game feedback to increase enjoyment and competitiveness in team 
games. Besides improving physical fitness, and increasing motivation and 
willingness to continue participating in exercise, this can also improve the 
quality of life. 
Objective: To examine whether a virtual reality interactive game exercise 
can help improve the physical fitness and quality of life of elderly people. 
Methods: Elderly people aged 65 years and above who participate in 
community activities were recruited and randomized into the 
experimental group and control group. The experimental group 
completed 36 episodes of exercise intervention using the interactive game, 
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spread over 12 weeks, while the original routine exercise was used as the 
course content in the control group. Both groups underwent 36 episodes 
of intervention of one hour each time, thrice a week for 12 consecutive 
weeks. Assessments of functional physical fitness and satisfaction with 
quality of life were performed before and after intervention and the 
statistical significance was set as p<0.05. 
Results: After 36 weeks of virtual reality interactive game interaction, the 
post-test scores for 2-minute step test (p<0.001), right chair sit-and-reach 
test (p=0.010), left chair sit-and-reach test (p=0.002), psychological 
quality of life (p=0.033), and environmental quality of life (p=0.048) of 
the experimental group were all significantly higher than those of the 
control group. 
Conclusion: A 36-week course of virtual reality interactive game could 
significantly improve the physical fitness and psychological and 
environmental quality of life of community-dwelling elderly. 
 
Keywords: virtual reality, interactive game, community-dwelling elderly, 
physical fitness, quality of life 
 
 
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Catalog 
Abstract ..................................................................................... I 
Chapter One Introduction ...................................................... 1 
Section 1  Research Background ............................................................ 1 
Section 2  Research Purpose ................................................................... 5 
Section 3  Research Questions and Hypotheses ...................................... 5 
Section 4  Conceptual Architecture ........................................................ 6 
Chapter 2 Literature Discussion ............................................. 7 
Section 1  Falls and prevention in the elderly ......................................... 7 
Section 2 The impact of exercise training on the balance ability of the 
lower limbs of the elderly ...................................................................... 10 
Section 3 Interactive games are used in exercise prescriptions for the 
elderly .................................................................................................... 12 
Section 4  Literature Summary ............................................................. 17 
Chapter 3 Research Methods ................................................ 18 
Section 1  Research Design .................................................................. 18 
Section 2  Research Places, Objects and Ethical Considerations ........... 19 
Section 3  Intervention Tools ................................................................ 20 
Section 4  Intervention Methods ........................................................... 21 
Section 5  Assessment Tools ................................................................ 27 
Section 6  Data Processing and Statistical Analysis .............................. 30 
Chapter 4  Research Results ............................................... 32 
Section 1  Basic Information of Subjects .............................................. 32 
Section 2  Functional fitness analysis and comparison .......................... 37 
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Section 3  Analysis and Comparison of Quality of Life Scale .............. 42 
Chapter 5  Discussion .......................................................... 43 
Section 1  Discussion on the application of virtual reality interactive 
games in sports courses at community care centers ................................ 43 
Section 2  The impact of virtual reality interactive game intervention on 
the physical fitness of the elderly ........................................................... 46 
Section 3  The impact of virtual reality interactive game intervention on 
the quality of life of the elderly .............................................................. 48 
Section 4  Research Limitations and Future Suggestions ...................... 50 
Chapter 6  Conclusion ......................................................... 52 
Chinese references.................................................................................. 52 
English references .................................................................................. 60 
Appendix ................................................................................ 65 
Appendix 1 TMU-JIRB .......................................................................... 65 
Appendix 2 Subject Consent Form ......................................................... 66 
 
 
 
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Chart list 
Figure catalog 
Figure 1. Conceptual architecture diagram……………………………..7 
Figure 2. Research architecture diagram….……………………………19 
Figure 3. Research equipment laptop and touch tablet connected to 
projector………………………………………………………………..27 
Figure 4. Virtual reality interactive game system startup screen….……28 
Figure 5. Virtual reality interactive game activity screen………………29 
Figure 6: Photos of the elderly participating in activities and using chair 
backs to prevent falls……………………………...…………………….30 
Figure 7. Photos of elders in the control group participating in 
activities…………………………………………………………………32 
Figure 8. Case collection flow chart…………………………………….40 
Figure 9. Presentation and ranking of scores after the elders participated 
in the activity……………………………………………………………59 
 
 
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Table directory 
Table 1. Functional fitness….………………………………………….36 
Table 2. Basic information table of elderly subjects of VR interactive 
games……………………………………………………………………42 
Table 3. Descriptive statistics…………………………………………..44 
Table 4. Functional fitness pre-test……………………………………...46 
Table 5. Intra-group pre- and post-test comparison between the 
experimental group and the control group…..………...………………47 
Table 6. Post-test comparison between the experimental group and the 
control group……………………….…………………..……………….49 
Table 7. Analysis and comparison of pre- and post-test quality of life 
within the group after the experiment………………..……………….…51 
 
 
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Introduction 
Section 1 Research Background 
The global phenomenon of population aging has become a 
universal trend and a future development. The World Health 
Organization (WHO) defined an "aging society" in 2002 as a society 
where the proportion of the population aged 65 and over reaches 7% of 
the total population. According to the statistics from the Population 
Division of the World Health Organization, the population of elderly 
individuals aged 65 and over has reached 720 million, accounting for 
approximately 9% of the global population. It is estimated that by the 
year 2050, the global population of elderly individuals will exceed 
17% (WHO, 2020).In contrast, Taiwan has entered an aging society 
since 1993 when the proportion of elderly individuals reached 7% of 
the total population. By 2018, this proportion had reached 14%, 
transitioning into an aged society. According to the National 
Development Council of the Executive Yuan, it is estimated that by the 
year 2025, the proportion of elderly individuals will reach 20%, 
making Taiwan a super-aged society member. This indicates that 
within the next decade, one out of every five individuals in Taiwan will 
be elderly (National Development Council, 2020). 
Comparing with other countries, France took 155 years 
(1864-2019) to transition from an aging society to a super-aged society, 
while Taiwan accomplished this transition in just 32 years (Economic 
Development Committee of the Executive Yuan, 2013). This is mainly 
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due to the increase in life expectancy, decline in birth rates, and the 
increasing prevalence of late marriage and non-marriage among the 
population. Therefore, coping with the multiple problems caused by 
aging and the changes in social structure leading to increased demand 
for long-term care poses a serious challenge for rapidly aging Taiwan. 
According to global population statistics, approximately 30% of 
individuals aged 65 and above experience at least one fall annually (Bjerk 
et al., 2019). In Taiwan, the statistical report on the main causes of death 
among the population in 2020 revealed that falls were the second leading 
cause of mortality among individuals aged 65 and above (Department of 
Statistics, Ministry of Health and Welfare, 2020). In the health discourse 
of aging societies, fall prevention and management are among the most 
crucial topics. Falls among the elderly are associated with various risk 
factors such as poor posture control, diminished balance, muscle 
weakness, postural hypotension, underlying diseases, cognitive decline, 
medication use, environmental factors, and a history of previous falls 
(Wu et al., 2019; Huang et al., 2015). The occurrence of falls can lead to 
disability, hospitalization, long-term institutionalization, and even death. 
To prevent the increase of future financial burden on the country and to 
maintain national competitiveness, the Department of Health has set 
active aging and disability prevention as the main goals of elderly health 
policies. These policies include promoting physical fitness among the 
elderly, fall prevention strategies, encouraging social participation, 
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preventive healthcare, and screening services (Ministry of Health and 
Welfare, 2020). 
   Recognizing that most elderly individuals live in communities, the 
government announced the Long-term Care 2.0 Ten-Year Plan in 2018, 
which includes the establishment of venues and bases in communities to 
provide services such as activities to prevent disability, health promotion, 
and exercise training courses for the elderly. This initiative actively 
promotes successful active aging with the goal of reducing the social 
costs associated with long-term care resulting from falls and ultimately 
improving the quality of life (Ministry of Health and Welfare, 2016; 
Chang & Chen, 2020). Scholars suggest that active participation in leisure 
activities and social engagement helps increase physical activity and 
interaction with the external environment, thereby enhancing the quality 
of life for the elderly (Chen et al., 2020; Lin, 2021; Bashkireva et al., 
2018). Section 3 Analysis and Comparison of Quality of Life Scale   
Increase itionally, through the establishment of community-based 
exercise programs, various forms of exercise can improve physical 
function and maintain fitness. For example, balance and resistance 
exercises conducted 2-3 times a week for 15-90 minutes each time have 
been proven effective in improving muscle strength, balance, and fall 
prevention among the elderly (Chung et al., 2016; Lewis, Peiris, Shields, 
2016; Sherrington et al., 2019).However, traditional structured exercises 
led by instructors can often be monotonous. Therefore, many scholars 
actively research interactive games that utilize physical and visual 
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feedback to complement each other. These games provide training for 
coordination, enhance reaction movements, and improve balance abilities, 
thereby increasing the willingness of the elderly to engage in physical 
activities. It has been found that these interventions are beneficial in 
preventing falls among community-dwelling elderly individuals. 
Constructing simple task-based games not only motivates the elderly but 
also enhances their enjoyment and morale, and even reduces anxiety (Lim 
et al., 2015; Chen et al., 2015; Llorens et al., 2016; Neri et al., 2017; 
Chen, Hu, Wang, & Lin, 2018; Huang et al., 2019; Hsu & Lin, 2020). 
However, current interactive games on the market are limited by space 
constraints, allowing only 1-2 individuals to engage simultaneously in the 
same space. Therefore, establishing an interactive game mode using 
virtual reality that enables multiple participants to engage in exercise 
together fosters interaction and communication among participants. 
Through cooperation, support, competition, and communication, this 
approach not only increases the frequency of interactions between the 
elderly and others but also enhances the willingness of the elderly to 
participate in exercise, effectively training balance abilities, and 
maintaining the overall satisfaction of their quality of life. 
 
 
 
 
 
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Section 2 Research Objectives 
The purpose of this study is to validate the effectiveness of virtual reality 
interactive gaming exercises in improving the physical fitness of the 
elderly and enhancing their quality of life. 
Section 3 Research Questions and Hypotheses 
Research Questions: 
Does intervention with virtual reality interactive gaming exercises 
effectively improve physical fitness and quality of life among 
community-dwelling elderly individuals? 
Hypotheses: 
The use of virtual reality interactive gaming exercises contributes to 
improving physical fitness and quality of life among the elderly. 
 
 
 
 
 
 
 
 
 
 
 
 
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Section 4 Conceptual Architecture 
 
 
 
 
 
 
 
 
 
 
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Literature Review 
Section 1: Falls and prevention among the elderly 
The World Health Organization defines "health" not only as the 
absence of disease or physical impairments but also encompasses 
physiological, psychological well-being, and happiness as integral 
components of overall health (WHO, 2022). However, numerous studies 
have indicated that as individuals age, their sensory-motor functions and 
neuromuscular systems gradually decline, leading to increased fatigue in 
lower limb muscles, reduced endurance for walking, and poor balance 
performance among elderly individuals. The decline in balance not only 
directly impacts their daily lives and independence but also increases the 
risk of falls, resulting in injuries, disability, and escalating healthcare 
costs and social burdens, and in severe cases, even death (Senefeld et al., 
2017; Henry & Baudry, 2019; Li et al., 2018; Wu, 2021). Beyond 
physical injuries, the fear of falling and subsequent loss of confidence in 
walking and engaging in activities independently can also have 
psychological impacts on the elderly, leading to reduced quality of life. 
This issue has garnered significant attention from public health and 
geriatric medicine sectors worldwide, making fall prevention and 
effective maintenance of physiological functions essential for overall 
health and successful aging (Garatachea & Lucia, 2013; Shi et al., 2015; 
Noradechanunt et al., 2017; Steckhan et al., 2021). 
Regarding the definition of falls, the Health Promotion 
Administration describes them as incidents occurring in any situation or 
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setting where an individual unexpectedly loses balance and sits or falls to 
the ground, regardless of whether it results in physical injury (Chou, 
2020). Increase itionally, the Ministry of Health and Welfare, in its 
"Health Promotion Administration: 2020 Healthy People White Paper," 
lists the prevention and treatment of falls and fractures among the elderly 
as one of its objectives (Ministry of Health and Welfare, 2020). The risk 
factors for falls can be categorized into four major factors: biological, 
behavioral, environmental, and socioeconomic. Biological factors include 
age, gender, balance ability, muscle strength decline, weakened protective 
reflexes, chronic diseases, and skeletal changes. Behavioral factors refer 
to factors that lead to falls due to behavior, such as medication use, 
alcohol consumption, and lack of exercise. Environmental factors include 
indoor and outdoor environments, such as damaged stairs, poor lighting, 
and lack of handrails or assistive devices. Socioeconomic factors include 
education level and social support (Chen et al., 2013). Among these, the 
primary reasons for falls among the elderly are often related to biological 
factors, particularly inadequate balance and muscle strength. These 
factors are also critical predictors of fall incidents among the elderly, 
underscoring the importance of appropriate exercise training in fall 
prevention. Additionally, the decline in physical function, insufficient 
physical activity, and increased sedentary behavior among the elderly are 
closely associated with falls. After experiencing a fall, individuals may 
restrict their activities due to fear of falling again, which further impacts 
their quality of life (Schoene et al., 2014). 
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Quality of life is a broad and complex concept that encompasses all 
factors affecting an individual's life, not just the prolongation of life, but 
also includes physiological, psychological, and social dimensions (Cai, 
Verza, & Bjerklund Johansen, 2021; M. Choi, Lee, Lee, & Jung, 2017). 
In recommendations for promoting health, delaying aging, and adapting 
to role changes among the elderly while enhancing quality of life, social 
participation is considered one of the best options. High levels of social 
participation have been associated with higher quality of life and life 
satisfaction (Dai et al., 2016; Hsu & Chu, 2022). Long-term and regular 
exercise has multiple benefits for the elderly, including improving 
cardiovascular function, maintaining independence, enhancing flexibility 
and balance, and improving psychological and cognitive function. 
Making new friends during exercise also promotes intergenerational 
interaction, thereby enhancing positive image and quality of life (Chou, 
2020). The American College of Sports Medicine's exercise guidelines 
for older adults recommend diverse exercise programs, including aerobic 
exercise, flexibility training, balance exercises, and resistance training, to 
effectively maintain the fitness of older adults, prevent falls due to frailty, 
and avoid the crisis of disability and bed confinement. Therefore, how to 
maintain the physical function of the elderly, prevent and delay disability, 
reduce medical and social costs, and enhance quality of life has become 
an extremely important issue (Su, Hu, & Wu, 2020). 
 
 
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Section 2: Impact of Exercise Training on Elderly Lower Limb Balance 
    In Taiwan, it is well understood that regular exercise is the optimal 
strategy for improving the sensory motor system of the body and 
maintaining balance to prevent falls. With the aging process, balance 
ability gradually declines with age. Balance stability is controlled by the 
cerebral cortex and cerebellum, which interact through the central 
nervous system and sensory motor nerves (Rogge et al., 2018). Balance 
can be divided into dynamic and static balance. Dynamic balance refers 
to the ability to maintain balance while performing movements such as 
standing up, walking, and running. Static balance refers to the ability to 
maintain a specific posture without losing balance while stationary. 
Among these, dynamic balance, agility, and flexibility are most closely 
related to the risk of falls in older adults (Rikli & Jones, 2013). 
In clinical practice, there are many simple and rapid scales used to detect 
balance function, such as the Timed Up and Go (TUG) test, Tinetti test, 
single-leg balance test, functional fitness, Berg Balance Scale, and 
Functional Reach Test (FRT). Among these, functional fitness, also 
known as the health-related fitness of older adults, is a common tool used 
in the community to assess the fitness of the elderly. It includes testing 
muscle endurance and strength, agility, flexibility, and body balance, 
aiming to assess whether the elderly have the basic physical activity 
ability to independently handle daily life functions. The test includes four 
directions with seven items: (1) Muscle endurance and strength testing: 
including sitting-to-standing and arm curls. (2) Flexibility testing: 
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including seated forward bend and back scratch. (3) Balance testing: 
including agility and dynamic balance testing, and static balance testing. 
(4) Cardiopulmonary endurance testing. The higher the level of physical 
activity, the better the health-related fitness, indicating a greater ability to 
manage daily life independently. 
    Several scholars have conducted research on introducing fitness, 
resistance band, and rehabilitation exercises into community centers. The 
results show significant benefits for elderly participants in terms of 
muscle strength, balance, flexibility, walking, and cardiopulmonary 
function. Therefore, intervention measures involving exercise training for 
older adults to strengthen balance, muscle strength, and flexibility are 
crucial for fall prevention (Chang et al., 2013; Ma et al., 2017; Chen et al., 
2019; Jiang et al., 2020). The Health Promotion Administration of the 
Ministry of Health and Welfare also issued the "Falling Prevention Tips 
for Seniors" handbook in 2014. In addition to promoting fall prevention 
knowledge, the chapter on fall prevention exercise prescriptions 
introduces seven strength exercises, five balance exercises, three 
flexibility training, and three stretching exercises (Health Promotion 
Administration, Ministry of Health and Welfare, 2021), all of which help 
to train lower limb strength and improve balance. A complete exercise 
prescription design for the elderly. Domestic scholars have researched the 
correlation between walking in the elderly and quality of life, finding that 
older adults with higher levels of physical activity and better 
cardiopulmonary fitness have better quality of life. Therefore, it is 
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recommended that older adults increase their physical activity to improve 
cardiopulmonary fitness, which helps promote physical and mental health 
and enhance quality of life (Lai et al., 2021). However, effective exercise 
must be integrated into daily life and sustained. Although community 
centers have relevant course content recommendations in the Long-Term 
Care 2.0 plan, there is a lack of consistent exercise training standards due 
to different funding sources and community attributes. Designing a set of 
virtual reality interactive games combined with exercise for use in 
community care centers can create a positive atmosphere through group 
activities, increasing the fun and competitiveness of participation, which 
helps older adults become more willing to participate in society, interact 
with others, and ultimately improve their quality of life. 
 
Section 3: Application of Interactive Games in Exercise Prescription for 
the Elderly 
    In recent years, the development of interactive games has provided 
users with a variety of sensory simulations, including visual, auditory, 
and tactile sensations. This not only creates an immersive experience but 
also motivates continuous participation in activities through engaging and 
enjoyable means (Hsieh, 2014). Interactive gaming combines the 
concepts and characteristics of games with physical activities, leveraging 
multimedia functions such as images, graphics, text, and music. By 
integrating cognitive psychology training, it effectively enhances the 
attention of older adults. Through feedback provided by the system, 
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learners are continually encouraged to change their behaviors, ultimately 
achieving learning goals (Lin & Lin, 2020). Virtual digital gaming 
involves generating three-dimensional virtual environments using 
computers, projected onto screens or large screens. By utilizing dynamic 
images, clear rules, and objectives, users can experience changes in 
different scenarios in a safe environment. This not only increases the 
motivation of the elderly to learn but also enhances their learning interest 
and motivation through game feedback mechanisms (Lin & Lin, 2020). 
   Virtual Reality (VR) utilizes integrated graphics, sound, images, 
animations, and interactive devices, possessing three main characteristics: 
1. Creating a virtual space through computer-generated images and 
audio-visual effects, allowing users to immerse themselves in imaginary 
scenarios; 2. Enabling user interaction with virtual scene objects, 
providing real-time feedback through different input devices 
(head-mounted displays, data gloves, position trackers), enhancing 
interactivity; 3. Combining virtual scenes with various input devices to 
fulfill sensory needs, creating an immersive experience that connects and 
resonates with users. Semi-immersive virtual reality scenes, 
complemented by projection display systems, multi-channel sound, and 
multi-dimensional interactive systems, satisfy users' visual, auditory, and 
tactile sensory requirements. This often requires 2-3 or even multiple 
projection channels seamlessly stitched together to form a large 
projection surface, providing high-resolution two-dimensional or 
three-dimensional images and creating a semi-immersive virtual reality 
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system experience environment. Flight simulators are examples of 
semi-immersive virtual scenes that rely on large-screen displays and 
powerful projection systems and monitors to provide an immersive 
atmosphere while allowing users to remain aware of the existence of the 
real world (Zhang, 2018). Clinically, virtual reality has been proven to be 
an effective device for treating patients with balance disorders (Griswold 
et al., 2014). It simulates various sensory perceptions of humans and 
images and sound effects similar to real environments, and uses sensors 
to detect physiological responses feedback to the simulator. This creates 
real-time interaction between humans and machines, allowing users to 
control virtual characters' actions through movements similar to actual 
exercise, providing interactive experiences with audiovisual feedback 
gaming. The complementary functions of objects and image feedback can 
enhance and improve users' balance abilities (Huang et al., 2022). During 
the process, users perform actions in front of receivers (infrared, heat 
sensing, etc.) facing the screen, allowing the receivers to send feedback to 
the cloud to identify identities and detect positions. Through sensing 
movements and measuring physical activity performance, interactive and 
operational effects are achieved. Currently available interactive games on 
the market, such as commercial developments like Wii Fit, Nintendo, 
Xbox, etc., can provide specific balance training for users. The system of 
interactive games can promote better posture control than traditional 
exercises, and the energy expended by participating in games is 
equivalent to light to rate-intensity activities. It can incorporate various 
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exercise control challenges into games, allowing participants to move 
their bodies interactively with the game. In addition to maintaining the 
original context and spatial perception, functional fitness training, 
maintaining correct physical movements, and improving social 
interaction with others are also enhanced through gaming. This 
effectively increases motivation and enjoyment, improves the activity and 
balance abilities of the elderly, reduces the risk of falls, and maintains 
independence (Hsieh, 2014; Hupin et al., 2015; Nicholson et al., 2015; 
Chen & Yu, 2016; Taylor et al., 2018; Chen & Gong, 2019; Lai, 2020; 
Phirom et al., 2020). 
   In recent years, recognizing Taiwan's gradual aging population, 
efforts have been made in communities to promote physical fitness 
activities for the elderly. With rapid technological advancements, activity 
designs should evolve accordingly. By integrating VR interactive games 
as a medium, the willingness of the elderly to participate in activities can 
be increased, along with enhanced interaction with others and the 
achievement of confidence and satisfaction through completing tasks (Lin 
& Lin, 2020). Several scholars have conducted research on interventions 
with virtual reality or interactive games for elderly residents in 
institutions (day care centers, rehabilitation homes) or patients with stroke 
or muscular dystrophy, and found that these interventions are helpful for 
improving balance and lower limb posture (Donath et al., 2016; Xu, 2020; 
Zhong, 2020; Du, 2021). However, there is limited research on the 
elderly in community care centers. Observing existing exercise programs 
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in community centers, they typically involve small group sessions with 
one instructor demonstrating exercises to the elderly. This method does 
not allow the elderly to see if their movements are correct and lacks 
interaction with other participants. If VR interactive games can be 
introduced into exercise programs, allowing the elderly to participate in 
exercise games and interact with others, it not only increases the 
willingness of the elderly to continue exercising but also boosts their 
confidence and sense of fulfillment through game achievements, thereby 
achieving the goal of healthy aging. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Section 4: Literature Summary 
    From the synthesis of the above literature, it is evident that the 
primary goal of "healthy aging" is to maintain and enhance the physical 
function of the elderly population, enabling them to lead happy, satisfying, 
and fulfilling lives. The decline in functional abilities and the increase in 
sedentary behavior among the elderly are closely related, making it 
crucial to address how to maintain their physical function, prevent or 
delay disability, reduce medical and social costs, and improve quality of 
life. Regular exercise is recognized as the best strategy for improving the 
sensory-motor system and maintaining balance to prevent falls. By 
designing group activities that increase the atmosphere of group activities 
and incorporating game feedback and interactive processes with others, 
participants can become highly engaged and focused within the social 
group. They can feel relaxed, relieved of stress, and experience mood 
changes during facility activities. This increases motivation and 
willingness to continue participating in exercise and accomplishing tasks 
during the game, boosting confidence among the elderly and 
consequently enhancing their quality of life by redefining the value and 
meaning of life. 
 
 
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Chapter 3: Research Methodology 
Section 1: Research Design 
    This study adopts an experimental design with a pre-test and 
post-test for two groups. Convenience sampling is utilized as the 
sampling method, and data collection is conducted through questionnaires 
and measurement evaluation scales. The research investigates the 
intervention of integrating VR interactive games to assist in improving 
balance function and lower limb strength among the elderly, thereby 
enhancing their quality of life. The proposed intervention research 
framework is depicted below (Figure 2). 
 
 
 
 
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Section 2: Research Site, Participants, and Ethical Considerations 
Research Site: 
This study will be conducted among community-based activities and 
voluntary participants aged 65 and above. 
Research Participants: 
The sample size for this study is calculated using G-power 3.1.9.7 
statistical software to determine the effect size. According to Cohen 
(1988), effect sizes are categorized as large (0.80), medium (0.50), and 
small (0.20). Since most research results have an effect size of 0.50, this 
study sets the criterion of at least a medium effect size. With α=0.05, 
statistical power (power)=0.80, and effect size set at 0.5, the estimated 
sample size is 60 individuals. Considering potential changes in the elderly 
or refusal to participate, a dropout rate of 15% is estimated. Therefore, a 
total of 70 elderly individuals from community-based activities will be 
recruited for this study. The inclusion criteria for this study are as follows: 
(1) aged 65 and above, (2) able to communicate in Mandarin or 
Taiwanese and willing to complete interviews or self-administered 
questionnaires, (3) no mobility impairments (e.g., stroke, Parkinson's 
disease, motor neuron diseases), (4) no severe cardiovascular diseases, (5) 
no degenerative joint diseases or acute attacks in the past three months, (6) 
lower limb joint surgery performed more than three months ago, and (7) 
no dizziness or any unstable health conditions that hinder exercise. 
During the study period, participants who do not engage in physical 
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activity for more than three weeks or have missing pre-test or post-test 
data will be excluded from the statistical analysis. 
Ethical Considerations: 
Prior to conducting the study, the research proposal will be submitted to 
the Institutional Review Board (IRB) for review and approval. Approval 
was obtained from the Taipei Medical University Joint Institutional 
Review Board (TMU-JIRB) on November 24, 2022, with the approval 
letter numbered N202210004 (see Appendix 1). This study aims to 
investigate the effects of VR interactive games as part of exercise 
prescriptions on the balance function and lower limb strength of elderly 
participants. 
Section 3: Intervention Tools 
Hardware Setup: 
The study utilizes four main devices, including Bluetooth-enabled 
three-axis inertial sensors (Inertial Measurement Unit, IMU), an LED 
projector, a tablet computer, and a laptop computer to interface between 
the tablet and projector. The virtual airplane game, designed by the 
researchers, is downloaded onto the tablet and projected onto a blank wall 
using the projector. Participants wear a waist protector embedded with 
IMU sensors, which are connected via Bluetooth to control the aircraft in 
the virtual game. The sensors collect data on the maximum displacement 
of the participant's body midline and angles, which are used to determine 
the participant's movements and position. By moving their body in 
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different directions, participants complete various game tasks to engage 
in balance training. 
 
Section 4 Intervention Methods 
Virtual reality (VR) technology is employed to simulate normal 
functional limb movements, with motion sensing systems using infrared 
sensors to detect and provide feedback on body movements for kinematic 
analysis. The system calculates the position and velocity of the body to 
generate kinematic values for clinical functional assessment forms. 3D 
scenes and interactions are designed, with researchers guiding the elderly 
participants through large joint body movements. During the process, 
data on force distribution or behavioral patterns are identified and 
analyzed. The game training is divided into three stages based on 
different body weight distributions: 
Stage 1 (first four weeks): Participants stand with feet parallel and 
perform forward leaning, backward leaning, left bending, and right 
bending according to the game content. 
Stage 2 (middle four weeks): Participants stand with feet parallel in a 
slight squatting position and perform forward leaning, back 
Stage 3 (last four weeks): Participants stand with feet apart and perform 
forward leaning, backward leaning, and left-right bending. 
The balance game training plan is divided into three difficulty levels: low, 
medium, and high. The system continuously records the angle of body 
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movement during each exercise session, and pre- and post-training data 
results are analyzed and compared at the end of the training period. 
  The study spanned three months, with pre-tests conducted within the 
first two weeks befor the first session and post-tests within two weeks 
after the 36th session. Functional physical fitness and quality of life 
assessments were conducted for both groups befor and after each session. 
Upon completion of the overall program, the researchers provided 
comprehensive feedback on the study's results. 
Exercise Protocol: 
Both groups initially engaged in modal rate-intensity exercise. The 
experimental group underwent a 12-week intervention program, 
consisting of 3 sessions per week, totaling 36 sessions. Each session 
lasted 60 minutes and included the following components: 
Warm-up exercises (10-15 minutes) 
Main exercise activity (30 minutes) 
Cool-down exercises (5-10 minutes), with a 10-minute break in between 
To mitigate potential risks associated with exercise training, blood 
pressure measurements were taken befor each session. Participants 
engaged in exercises under the guidance of research personnel. If 
participants felt unwell on a given day, they were allowed to skip the 
session. In case of any discomfort during the activity, the training was 
immediately halted. 
Hardware and Software Setup: 
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The intervention utilized a touch-enabled 11-inch tablet computer loaded 
with the research game system, serving as the interface for participants to 
interact with the VR interactive game. A laptop computer facilitated the 
connection between the tablet and projector. The game content could only 
be downloaded and used on the tablet or Android smartphones. To allow 
elderly participants to see the game's effectiveness during the activity, the 
tablet was wirelessly connected to the laptop and projected onto a white 
wall in the same Wi-Fi environment. 
Game Implementation: 
The game design included four aircraft, each representing a participant in 
the group. Before starting the game, the game and sensors were paired via 
Bluetooth. The sensors were securely placed on the waist belt at the 
lumbar spine level. Participants underwent posture corrections, including 
left-right bending, forward bending, and backward leaning, to ensure 
accurate sensor data capture. Once all participants completed the 
calibration, the game training for that session began, with three game 
records per activity. 
     During the game, coins and meteors appeared in eight directions on 
the screen. Participants earned points by moving their bodies to collect 
coins and avoid meteors. After each session, scores were summarized and 
ranked to motivate participants. The recorded body angle data were 
stored in the backend cloud platform for post-game analysis. 
   During the VR interactive game training, participants were instructed 
to stand with their feet shoulder-width apart and move their upper bodies 
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according to the music and game screen cues. They were encouraged to 
stretch and bend their arms along with their bodies' forward, backward, 
left, and right movements to increase upper body activity and effectively 
maintain body balance. Participants with weaker lower limbs could use 
the backrest of a chair for support to prevent accidents. 
 
 
 
 
 
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Control Group Intervention 
The control group maintained their regular aerobic exercise regimen, led 
by a fitness instructor, three times a week for 1 hour per session. The 
structure of each session was as follows: 
Warm-up Exercises: 10-15 minutes 
Main Exercise Activity: 30 minutes 
Cool-down Exercises: 5-10 minutes, including a 10-minute break 
Over the course of 36 sessions, the control group participated in a variety 
of exercises, including resistance band training for 12 sessions, chair yoga 
for 12 sessions, and aerobic exercise for 12 sessions. Apart from these 
structured exercise sessions, both groups did not engage in any other 
physical activities during the 36-week period. 
 
 
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Section 5 Evaluation Tools 
This study aims to understand the impact of intervention on the 
functional fitness and quality of life of elderly participants befor and after 
the intervention. The assessment tools used include functional fitness 
tests and a quality of life questionnaire, along with the collection of basic 
participant information. Both groups underwent pre-tests befor the 
intervention, which included a fall risk assessment, functional fitness 
assessment, and quality of life satisfaction survey. After completing the 
12-week, 36-session intervention, post-tests were conducted to measure 
the effectiveness of the intervention. 
1. Basic Participant Information: 
Includes gender, age, exercise habits, self-perceived health status 
questionnaire, and Body Mass Index (BMI). 
2. Functional Fitness Tests: 
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(a) Chair Stand Test: 
Measures lower body strength/endurance. 
Participants sit in a chair without armrests and stand up as many times as 
possible within 30 seconds. 
(b) Chair Sit and Reach Test: 
Assesses lower body flexibility. 
Participants sit on the edge of a chair with one knee bent at 90 degrees 
and try to reach their toes with their hands. The distance between the 
fingertips and toes is measured. 
(c) 8-Foot Up-and-Go Test: 
Evaluates agility and dynamic balance. 
Participants sit in a chair, stand up upon hearing a signal, walk around a 
designated point 8 feet away, and return to the chair. The time taken to 
complete the task is recorded. 
(d) 2-Minute Walk Test: 
Measures aerobic endurance. 
Participants walk in place for 2 minutes, and the number of times the 
knees are lifted to a specific height is counted. 
3. Quality of Life Questionnaire: 
Administered using the "Taiwanese version of the World Health 
Organization Quality of Life Questionnaire-Brief Form 
(WHOQOL-BREF Taiwanese version)." 
Consists of 28 questions divided into four domains: physical health, 
psychological health, social relationships, and environment. 
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Each question is scored on a Likert scale ranging from 1 (very poor) to 5 
(very good), with higher scores indicating better quality of life. 
Demonstrates good reliability with Cronbach's α and split-half reliability 
of 0.92 and 0.93, respectively. 
 
 
 
 
 
 
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Section 6 Data Processing and Statistical Analysis 
After data collection, the collected data will be coded, documented, 
and analyzed using the Statistical Package for the Social Sciences (SPSS) 
19.0 Chinese version software. Both descriptive and inferential statistics 
will be employed. A significance level of p < .05 will be used to 
determine statistical significance. 
 
1. Descriptive Statistics: 
Categorical variables of demographic data for both experimental and 
control groups will be presented as percentages, while continuous 
variables will be described using means and standard deviations. 
2. Inferential Statistics: 
(a) Independent t-test or Mann-Whitney U test: 
Analyze the differences between the experimental and control groups in 
variables such as balance function, muscle strength, flexibility, 
cardiovascular capacity, and quality of life befor intervention. A 
Shapiro-Wilk test will be conducted to check for normal distribution. If 
the data is normally distributed, an independent t-test will be used; 
otherwise, the Mann-Whitney U test will be employed. 
(b) Chi-Squared Test: 
Analyze the homogeneity of basic demographic characteristics (age, 
gender, education level, marital status), exercise habits, duration of each 
exercise session, and experience of falling in the past year between the 
two groups. 
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(c) Dependent Samples t-test or Wilcoxon Signed Rank Test: 
Analyze the differences in variables such as balance function, muscle 
strength, flexibility, cardiovascular capacity, and quality of life within 
each group 之前 and after the intervention. A Shapiro-Wilk test will be 
conducted to check for normal distribution. If the data is normally 
distributed, a dependent samples t-test will be used; otherwise, the 
Wilcoxon signed rank test will be employed. 
(d) ANCOVA Analysis using Intention-to-Treat Analysis: 
ANCOVA will be employed to compare the post-test scores between the 
experimental and control groups while controlling for pre-test scores. 
This analysis will utilize intention-to-treat principles. 
 
Figure 8. Flowchart of the application of virtual reality interactive games 
to the lower limb balance of community elders 
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Research Results 
This study involved the intervention of the experimental group using 
virtual reality interactive games, while the control group underwent 
exercise interventions led by original instructors. Both groups 
participated in modal rate-intensity sessions three times a week for 12 
weeks, totaling 36 sessions. Testing was conducted befor and three 
months after the completion of the program. A total of 84 participants 
were recruited from two community care activity centers in Taipei City, 
but 14 participants were excluded due to personal reasons or inability to 
consistently monitor data due to illness. Ultimately, data from 70 
participants who completed at least 30 sessions were analyzed. 
Regarding participant attrition, the experimental group initially 
recruited 35 participants. However, during the 12-week, 36-session 
program, five participants were absent for over one-third of the sessions 
(12 sessions) due to health issues or personal preferences, rendering their 
data unusable. The experimental group experienced a dropout rate of 
14.28%. The control group initially recruited 35 participants, but only 33 
completed the post-intervention assessment. Two participants were 
excluded from the analysis due to absence for over one-third of the 
sessions. The dropout rate for the control group was 8.57%. Both groups 
had dropout rates within the predetermined range of 15% set befor the 
study. 
The study spanned 36 sessions from February 13th to May 31st, [insert 
year]. Data from participants who attended less than 12 sessions were 
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excluded from statistical analysis. Thus, statistical analysis was 
conducted on data from 30 participants in the experimental group and 33 
participants in the control group. 
Section 1: Participant Demographics 
This study recruited a total of 70 participants, with 35 participants in both the 
experimental and control groups. Among them, 63 participants completed the entire 
study, with 30 participants in the experimental group and 33 participants in the control 
group. The average age of the experimental group (30 participants) was 77.7 years, 
with the majority being female (96.7%) and married (90.0%). See Table 4-1 for 
details. Assessment of demographic data in both groups showed no significant 
differences. Independent samples t-tests or Mann-Whitney U tests and chi-squared 
tests were used to analyze demographic data, revealing no significant differences 
between the two groups' demographic characteristics, as shown in Table 2. 
 
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Table 2 Basic information table of elderly subjects of virtual reality 
interactive games 
  
Test group (N=30) 
Control group 
(N=33) 
t value (p) or Z value (p) or 
Chi-square value (p)* 
Demographic 
variables 
 
 
 
age 
77.7 ± 5.8 
74.4 ± 8.3 
1.78 (0.080)‡ 
Gender: emale) 29 (96.7%) 
30 (90.9%) 
0.88 (0.614) 
marriage 
2.00 (0.615) 
unmarried 
0 (0%) 
2 (6.1%) 
Married 
27 (90.0%) 
27 (81.8%) 
Widowed 
3 (10.0%) 
4 (12.1%) 
BMI 
27.0 ± 3.5 
25.4 ± 3.8 
1.77 (0.077)§ 
height 
150.5 ± 5.2 
152.5 ± 7.0 
-1.29 (0.201)† 
weight 
61.0 ± 6.5 
59.2 ± 9.8 
0.86 (0.393)∫ 
‡Shapiro-Wilk test: P=0.055，Using independent sample t test 
 
 
 
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Based on descriptive statistics, it was confirmed that in the control 
group, the highest education level was junior high school graduation, with 
13 individuals (43.3%), followed by 11 individuals (36.7%) who 
graduated from elementary school. All elderly participants had a habit of 
exercising, with 30 individuals (100%) regularly attending exercise 
classes at the activity centers. Seven individuals (23.3%) reported 
experiencing falls in the past year. Regarding exercise frequency, 6 
individuals (20.0%) exercised fewer than three days per week, while 24 
individuals (80.0%) exercised at least three days per week. Moreover, all 
participants exercised for at least 30 minutes each time. In the control 
group, the highest education level was high school or vocational school 
graduation, with 14 individuals (42.4%), followed by 10 individuals 
(30.3%) who graduated from junior high school. Thirty-two individuals 
(97.0%) had a habit of exercising, primarily by attending exercise classes 
at the activity centers. Eight individuals (24.2%) reported experiencing 
falls in the past year. Regarding exercise frequency, 11 individuals 
(33.3%) exercised fewer than three days per week, while 22 individuals 
(66.7%) exercised at least three days per week. The majority, 30 
individuals (90.9%), exercised for at least 30 minutes each time. See 
Table 3 for details. 
 
 
 
 
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Table 3 Descriptive Statistics 
 
Test group (N=30) 
Control group 
(N=33) 
Chi-square value (p) 
Education level 
 
 
11.742 (0.014) 
Not reading 
0 (0%) 
2 (6.1%) 
 
Elementary school 
11 (36.7%) 
4 (12.1%) 
 
Junior high school 
13 (43.3%) 
10 (30.3%) 
 
High school 
6 (20.0%) 
14 (42.4%) 
 
University 
0 (0%) 
3 (9.1%) 
 
Exercise habits 
 
 
1.949 (0.321) 
No habit 
0 (0%) 
1 (3.0%) 
 
Less than 3 times a week 
6 (20.0%) 
10 (30.3%) 
 
More than 3 times a week 
24 (80.0%) 
22 (66.7%) 
 
Each exercise time 
 
 
6.326 (0.039) 
less than 30 minutes 
0 (0%) 
3 (9.1%) 
 
more than 30 inutes 
22 (73.3%) 
15 (45.5%) 
 
30-60 minutes 
8 (26.7%) 
15 (45.5%) 
 
Falls experience in the past 
year 
 
 
1.034 (0.669) 
No falls 
23 (76.7%) 
25 (75.8%) 
 
≤3 次 
6 (20.0%) 
5 (15.2%) 
 
>3 次 
1 (3.3%) 
3 (9.1%) 
 
 
 
 
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Section 2: Comparison of Functional Fitness 
1. Analysis of Demographic Data 
Before the intervention of virtual reality interactive gaming, the 
participants' functional fitness, including height, weight, lower limb 
muscle endurance, lower limb flexibility, and agility, were assessed 
descriptively. 
In the pre-test assessment, there were no significant differences 
between the experimental group and the control group in terms of fitness 
and quality of life, as indicated by independent samples t-tests, as shown 
in Table 4. 
2. Comparison of Pre-test and Post-test within the Experimental and 
Control Groups 
The results of dependent samples t-tests (Table 5) showed 
statistically significant improvements in four assessment outcomes in the 
experimental group, including the 2-minute step test (p < 0.001), left and 
right chair sit and reach (p < 0.001, p = 0.003), and psychological quality 
of life (p = 0.008). 
In the control group, there was a statistically significant 
improvement in one assessment outcome, the 30-second chair stand test 
(p = 0.001). 
 
 
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Table 4  Functional fitness pre-test of the experimental group and the 
control group 
 
Test group (N=30) 
Control group 
(N=33) 
t value (p) or  
Z value (p) 
pretest assessment 
 
 
 
BMI 
27.0 ± 3.5 
25.4 ± 3.8 
1.77 (0.077)§ 
30 seconds sit and 
stand 
16.3±4.6 
17.7±5.2 
-1.19 (0.234)§ 
2 minutes to step 
96.0±20.7 
92.5±25.4 
0.60 (0.548)‡ 
The seat body bends 
forward (right) 
2.9±10.1 
2.6±12.0 
0.25 (0.799)§ 
The seat body bends 
forward (left) 
1.2±11.2 
1.4±13.4 
-0.08 (0.935)‡ 
Get up and walk 
Around at 2.4 meters 
8.5±3.2 
8.4±3.6 
0.70 (0.483)§ 
Physiological quality of 
life 
10.8±1.4 
11.4±1.5 
-1.75 (0.086)‡ 
Psychological quality 
of life 
11.1±1.8 
11.7±1.8 
-1.28 (0.200)§ 
Quality of social life 
11.2±1.9 
11.4±1.1 
-0.652 (0.515)§ 
Environment quality of 
life 
10.6±2.2 
10.3±2.0 
0.090 (0.928)§ 
‡ Using independent sample t test 
§Using the Mann-Whitney U test 
 
 
 
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Table 5 Intra-group pre- and post-test comparison between the 
experimental group and the control group 
  
Test group (N=30) 
Control group (N=33) 
 
pretest 
posttest 
score 
difference 
(Pre-test-P
ost-test) 
t value (p) 
或 
S value (p) 
pretest 
posttest 
score 
difference 
(Pre-test-P
ost-test) 
t value (p) 
or 
S value (p) 
Mean ± standard deviation 
Mean ± standard deviation 
BMI 
27.0 ± 3.5 26.9±3.
6 
0.1±1.0 
16.5 (0.741) 25.4 ± 3.8 25.3±3.7 
0.1±0.4 
75 (0.071) 
30 seconds sit and 
stand 
16.3±4.6 17.1±4.
4 
-0.9±3.1 -56.5 (0.174) 17.7±5.2 18.5±4.9 
-0.8±1.5 -83.5 (0.001) 
The seat body 
bends forward 
(right) 
96.0±20.7 
121±25.
7 
-26.6±31.2 
-4.67(<0.001
)§ 
92.5±25.4 98±20.2 -3.8±15.0 
-1.47(0.151)
§ 
The seat body 
bends forward 
(left) 
2.9±10.1 7.3±9.6 
-4.4±7.4 
-140 
(<0.001) 
2.6±12.0 2.9±12.3 
-0.3±2.8 
0 (1.000) 
Get up and walk 
Around at 2.4 
meters 
1.2±11.2 5.9±9.6 
-4.9±8.1 
-3.29 (0.003) 
§ 
1.4±13.4 2.9±13.2 
-0.2±1.5 
-0.79(0.433)
§ 
Physiological 
quality of life 
8.5±3.2 8.3±2.4 
0.2±2.9 
33 (0.507) 
8.4±3.6 
8.2±3.4 
0.1±0.7 
39 (0.384) 
Psychological 
quality of life 
10.8±1.4 
11.1±1.
4 
-0.1±0.4 
-1.31 (0.202) 
§ 
11.4±1.5 11.3±1.4 
0.0±0.1 
1.00(0.325)§ 
Quality of social 
life 
11.1±1.8 11.3±1.
7 
-0.2±0.3 
-18 (0.008) 11.7±1.8 11.7±1.9 
-0.0±0.1 
-0.5 (1.000) 
Environment 
quality of life 
11.2±1.9 11.3±1.
8 
-0.1±0.4 
-1.5 (0.500) 11.4±1.1 11.4±1.1 
0.0±0.0 
-* 
The seat body 
bends forward 
(right) 
10.6±2.2 
10.6±2.
2 
-0.0±0.1 
-1.5 (0.500) 10.3±2.0 10.3±2.0 
0.0±0.0 
-* 
§The Wilcoxon sign test is used, and the rest uses the dependent sample t test. 
 
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3. Comparison of Post-test between Experimental and Control Groups 
Due to significant differences in demographic data and pre-test 
assessments between the experimental and control groups, particularly in 
the education level variable, and considering age as an important control 
variable, analysis of covariance (ANCOVA) was conducted to compare 
the post-test scores between the experimental and control groups. Age, 
education level, and pre-test scores were controlled for in the analysis. 
Intention-to-treat analysis was used. 
The results of ANCOVA analysis (Table 6) revealed that the post-test 
scores of the experimental group were significantly higher than those of 
the control group in five assessment outcomes, including the 2-minute 
step test (p < 0.001), right chair sit and reach (p = 0.010), left chair sit and 
reach (p = 0.002), psychological quality of life (p = 0.033), and 
environmental quality of life (p = 0.048). Additionally, the differences in 
fitness (except for the 30-second chair stand test) and quality of life had 
effect sizes (partial eta squared) ranging from 0.011 to 0.267, indicating 
moderate to substantial intervention effects. These results suggest that the 
intervention in this study was more effective in improving the 
aforementioned fitness and quality of life compared to regular community 
activities. 
 
 
 
 
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Table 6  Post-test comparison between the experimental group and the 
control group 
 
StatisticsF /(p) 
effect size (partial eta 
squared) 
BMI 
0.195 (0.661) 
0.003 
30 seconds sit and stand 
0.015 (0.904) 
0.000 
The seat body bends forward (right) 
21.154 (<0.001) 
0.267 
The seat body bends forward (left) 
7.091 (0.010) 
0.109 
Get up and walk Around at 2.4 meters 
10.294 (0.002) 
0.151 
Physiological quality of life 
0.667 (0.418) 
0.011 
Psychological quality of life 
0.956 (0.332) 
0.016 
Quality of social life 
4.766 (0.033) 
0.076 
Environment quality of life 
1.405 (0.241) 
0.024 
The seat body bends forward (right) 
4.080 (0.048) 
0.066 
Note:This analysis uses ANCOVA to control the pretest scores and other significant influencing factors 
in the pretest. The control variables include: age, education level, and pretest scores of each variable. 
 
 
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Section 3: Analysis and Comparison of Quality of Life Questionnaire 
Upon statistical analysis of pre-test and post-test scores (Table 7), it 
was found that in the experimental group, there was a difference of 0.4 
points in the physical domain (p = 0.202), no difference in the 
psychological domain (p = 0.008), a difference of 0.2 points in the social 
relationships domain (p = 0.500), and no difference in the environmental 
domain (p = 0.500). In contrast, in the control group, there was a 
difference of 0.4 points in the physical domain (p = 0.325), no difference 
in the psychological domain (p = 1.000), and no difference in the social 
relationships and environmental domains. The results indicate a 
significant change in the quality of life in the physical domain for the 
experimental group. 
Table 7 Analysis and comparison of pre- and post-test on the quality of 
life within the group after the experiment 
  
Test group (N=30) 
Control group (N=33) 
 
pretest 
posttest 
score 
difference 
(Pre-test- 
Post-test) 
t value (p) 
pretest 
posttest 
score  
difference 
(Pre-test- 
Post-test) 
t value (p) 
Mean ± standard deviation 
Mean ± standard deviation 
Physiological 
quality of life 
10.8±1.4 11.1±1.4 
-0.1±0.4 
-1.31 
(0.202) 
11.4±1.5 11.3±1.4 
0.0±0.0 
1.00 
(0.325) 
Psychological 
quality of life 
11.1±1.8 11.3±1.7 
-0.2±0.3 
-18 
(0.008) 
11.7±1.8 11.7±1.9 
0.0±0.0 
   -0.5 
  (1.000) 
Quality of 
social life 
11.2±1.9 11.3±1.8 
-0.1±0.4 
-1.5 
(0.500) 
11.4±1.1 11.4±1.1 
0.0±0.0 
-* 
Environment 
quality of life 
10.6±2.2 
10.±2.2 
0.0±0.1 
-1.5 
(0.500) 
10.3±2.0 10.3±2.0 
0.0±0.0 
-* 
*Since all subjects have the same score, the t test cannot be performed. 
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Chapter 5: Discussion 
Section 1: Exploration of the Application of Virtual Reality 
Interactive Games in Community Care Centers 
Virtual reality interactive games have become increasingly popular 
across all age groups, with more and more seniors incorporating 
interactive gaming into their daily lives or leisure activities. Apart from 
entertainment, these games also address the health care needs of seniors, 
representing the latest trend in digital game development. Through digital 
technology environments, games are designed to immerse seniors in 
experiences that allow them to fully engage and resonate. Numerous 
studies have demonstrated that virtual reality game training can improve 
balance ability. Currently, Kinect, Wii, and VR interactive sensory games 
are widely used for strength, balance, and muscle training, all of which 
have shown significant effects. For instance, researchers such as 
Nicholson et al. (2015) conducted studies on community elders using 
unsupervised Wii balance games three times a week for 30 minutes each, 
and researchers like Chen, Zhang, Wang, and Lu (2019) have trained 
special populations such as individuals with cerebral palsy, chronic stroke 
patients, and depression patients using sensory games, all with consistent 
results showing improvements or maintenance of balance. In 2016, HTC 
Corporation and Valve Corporation demonstrated through immersive 
virtual reality game training that users could experience a virtual world as 
if they were actually there. By making the games enjoyable, participation 
and motivation are increased, achieving effects that are not easily 
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achieved through traditional exercise, thereby fostering a habit of regular 
exercise. Increase itionally, by forming alliances with others through 
interactive virtual reality games, not only is the fun increased, but also the 
sense of accomplishment upon completing game objectives, thereby 
enhancing quality of life and achieving the goal of healthy aging. 
This study initially targeted websites and platforms specifically 
designed for or targeted at older adults to find digital games 
recommended on these platforms. Subsequently, games suitable for older 
adults recommended on non-elderly websites were also collected. Finally, 
a virtual reality interactive game suitable for use by older adults aged 65 
and above in community centers was innovatively created by integrating 
popular games currently available in the market. The study designed a 
virtual airplane game, allowing for interactive and group gameplay, 
enabling four older adults to simultaneously participate in competitive 
activities. After 36 sessions, significant changes were observed in the 
experimental group in the 2-minute step test (p<0.001), left and right 
chair stands (p<0.001, p=0.003), and psychological well-being (p=0.008). 
During the exercise, older adults experienced feelings of happiness, 
excitement, nervousness, and anticipation. However, if the game ended 
with unsatisfactory scores or due to delays caused by network 
connectivity issues, feelings of confusion, dissatisfaction, complaints, and 
low mood emerged. Each gaming session prompted older adults to 
remember their scores and engage in discussions with others. Through 
continuous self-challenges in the game, participants not only increased 
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their willingness to engage in exercise but also enhanced their confidence 
and positive feelings by achieving game objectives. The game content 
was based on the recommendations of the American College of Sports 
Medicine for older adults engaging in regular physical activity, including 
strength training, balance exercises, flexibility exercises, and aerobic or 
endurance activities. In the game, older adults were required to stand with 
their feet stationary while moving their upper body in response to music 
and game elements such as coins and asteroids on the screen. They also 
had to raise their hands and perform stretching, bending, twisting, 
bending forward, arching backward, and leaning side to side to hit coins 
and asteroids. This not only increased the frequency and opportunities for 
upper body movement but also trained flexibility and balance. 
Considering the economic benefits and sustainability of exercise 
execution, the integration of the virtual airplane game created in this 
study with exercise programs provides a necessary measure for older 
adults in community centers to engage in regular health-promoting 
exercise and prevent or mitigate disability. Additionally, the system 
required participants to perform maximum body movements in all 
directions before each intervention session. The purpose was to record the 
maximum range of individual body movements and use them in training 
to achieve personalized and precise exercise interventions, thereby 
maximizing the benefits of improving physical fitness. 
 
 
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Section 2 The impact of virtual reality interactive game intervention 
on the physical fitness of the elderly 
Although there is existing literature on interactive games for elderly 
training, most studies focus on residents of institutions such as day care 
centers, nursing homes, and rehabilitation centers (Hsieh, 2014; Chung, 
2020; Du, 2021). Nowadays, community centers typically offer exercise 
programs led by sports professionals or instructors for elderly participants, 
including activities like Ba Duan Jin, chair yoga, step aerobics, fitness, 
resistance band exercises, and rehabilitation exercises (Chen et al., 2019; 
Jiang et al., 2020). However, these activities often involve older adults 
lining up facing the instructor and following instructions, which may not 
foster a positive and engaging group atmosphere. 
This study primarily utilized virtual reality interactive games for training. 
It employed a three-axis inertial sensor to monitor body angle changes 
during exercise. Older adults wore a waist protector embedded with 
sensors, which connected via Bluetooth to control a virtual aircraft in the 
game. Participants moved their bodies forward, backward, left, and right 
to collide with asteroids and coins in different directions, challenging 
their balance with varying levels of difficulty such as standing with feet 
parallel, slightly squatting with feet parallel, and standing with feet apart. 
增加itionally, participants were required to raise their hands and perform 
stretching and bending movements in sync with body movements in the 
game. This not only increased upper body movement opportunities but 
also effectively maintained body balance, reducing the risk of falls during 
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the game. Researchers like Fang et al. (2016) found that using virtual 
reality Wii Fit games for training for more than 6 weeks can improve 
dynamic balance ability in older adults. 
In this study, a custom-designed virtual airplane game allowed elderly 
participants in community center activities to effectively train balance 
and improve flexibility during exercise. By following game instructions 
for forward and backward movements, participants could earn scores and 
complete tasks successfully. After 36 sessions, significant improvements 
were observed in elderly participants who engaged in virtual reality 
interactive games, particularly in the 2-minute step test (p<0.001) and left 
and right chair stands (p<0.001, p=0.003). ANCOVA analysis revealed 
differences in physical fitness (except for the 30-second chair stand) and 
quality of life, with effect sizes (partial eta squared) ranging from 0.011 
to 0.267, indicating moderate to substantial intervention effects. These 
findings demonstrate that the virtual reality intervention in this study 
outperformed conventional center-based activities in enhancing physical 
fitness and quality of life. 
 
 
 
 
 
 
 
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Section 3: The impact of virtual reality interactive game intervention on 
the quality of life of the elderly 
After 12 weeks and 36 sessions of intervention using the virtual 
reality interactive game designed in this study, elderly participants were 
able to increase their willingness to engage in physical activity and social 
interaction through participation in the game, thereby expanding their 
interpersonal relationships and interactions with the community 
environment. The research results also revealed that the experimental 
group had significantly higher post-test scores in psychological 
well-being (p=0.033) and environmental well-being (p=0.048) compared 
to the control group. This aligns with literature suggesting that the quality 
of life of older adults is influenced by their health status, activities, and 
functional status. Active social participation and positive interactions 
with others can contribute to a satisfying and happy old age (Chen et al., 
2018; Chou, 2020).Although virtual reality interactive games currently 
available on the market can target specific balance training for users, they 
are limited to single-player or multiplayer models. In contrast, the game 
software developed in this study allowed up to four elderly individuals to 
exercise simultaneously, forming a small group activity. At the end of 
each game, the results were provided, motivating participants to engage 
in the game through competition and evaluation among themselves. This 
not only satisfied their sense of honor but also encouraged them to 
continue participating in the game activities. From the 6th week onwards, 
the stability of elderly participants' engagement in the activities was 
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49 
 
generally established. They tended to form groups with friends to play the 
game and would inquire about and remind each other of the next activity 
time. Peer encouragement and invitations played a crucial role in 
sustaining their participation. Increase itionally, participants became more 
interested in the activity as they interacted with peers, forming 
friendships and forming small groups. Even those who were initially 
reluctant to participate or found the activity uninteresting eventually 
became regular participants due to peer invitations and increased interest. 
This program not only provided balance training for community-dwelling 
elderly but also created a pleasant and positive atmosphere through the 
design of virtual reality interactive games, promoting high engagement 
and focus on the activities. This is consistent with scholars' suggestions 
that community centers can increase participants' engagement and 
relaxation through the design of group activities, leading to changes in 
mood and stress relief during center activities (Chuang et al., 2021). 
 
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Section 4: Study limitations and Future Recommendations 
Virtual reality interactive game training can utilize changes in 
position control and audiovisual stimulation to enhance activity 
performance, allowing the elderly to focus their attention on experiencing 
the game during training and strive to achieve game objectives. In this 
process, virtual reality interactive games provide a rich, stimulating, and 
challenging environment that helps maintain dynamic and static balance 
and agility. Most elderly participants in the study found this to be an 
enjoyable activity. 
    This study involved collaboration between a gaming company, a 
company providing hardware sensors, and participants in community 
activity programs to innovate a team-based game software suitable for the 
elderly. During the process, several limitations were identified: 
Sensor and Game Identification Pairing:The pairing of sensors and game 
identities via Bluetooth was random, leading to complaints from the 
elderly about the inability to select their preferred colors for their aircraft. 
Setup Process:Prior to activities, setting up the game required connecting 
a tablet to a laptop and projecting it onto a wall approximately 1 meter 
away. The colors of the four aircraft in the game were too similar, making 
it difficult for participants to identify their own color during rapid body 
movements. 
Technical Issues:Connectivity issues and delays between the game 
system and sensors were common. Testers had to ensure that the module 
vibrated during pairing, leading to delays and frustrations among the 
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elderly participants, especially when community activity schedules were 
tight. 
To address these issues, a user-friendly model with enhanced motivation 
and ease of operation should be developed for the elderly. Developing a 
community-based digital learning support system is a worthwhile future 
direction. Although age-related decline in physical function is inevitable, 
weekly VR interactive game exercise training can improve strength, 
flexibility, and balance in the elderly, enhancing their activity capacity 
and quality of life.Furthermore, integrating virtual reality interactive 
games into regular community activity programs led by professionals can 
foster enthusiasm and motivation among the elderly through peer 
companionship and encouragement. The innovative and visually 
engaging feedback exercise in the virtual reality interactive game 
designed in this study offers a novel direction and mindset for exercise 
training tailored to community-dwelling seniors. 
 
 
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Chapter 6 Conclusion 
The 36-week course activities of virtual reality interactive games can 
significantly improve the physical fitness, psychological and 
environmental quality of life of the elderly in the community. 
 
Chinese references 
Fang, J., Chen, S., Li, W., & Cheng, S. (2016). "Effects of Wii Fit Virtual 
Reality Training on Static and Dynamic Balance Abilities and 
Vestibular Function in Community-Dwelling Elderly People." Hong 
Kong Journal of Sports Science, 78, 1-14. 
Shih, F., Hsu, H., Lin, Y., She, C., Wu, C., Lin, N., & Shih, S. (2015). 
"Analysis of Elderly Patients Presenting to the Emergency 
Department Due to Falls." Journal of Geriatric Medicine and 
Gerontology, 10(1), 16-27. DOI：
10.29461/TGG.201502_10(1).0002 
Executive Yuan, Council for Economic Planning and Development. 
(2013, February 27). "Population Projection for the Republic of 
China (Taiwan) from 2012 to 2060." Retrieved from 
http://www.cepd.gov.tw/m1.aspx?sNo=0000455 
Jiang, J., Chien, N., Wei, P., Yu, C., & Chang, S. (2020). Characteristics 
of physical performance and pre-frailty risk factors in middle-aged 
and older adults in the community. Journal of Chinese Biomechanics, 
17(2), 11-19. DOI: 10.3966/207332672020091702002 
Document Date: June 26, 2023

53 
 
Du, Y. H. (2021). The effectiveness of using interactive motion sensing 
games to improve physical and mental functions in elderly 
individuals with muscular dystrophy (Master's thesis). Retrieved 
from: https://ndltd.ncl.edu.tw/cgi-bin 
Wu, P. Y., Su, J. J., Li, M. Z., & Ling, X. (2019). A review of the 
effectiveness of home exercise in preventing falls in older adults. 
Taipei City Medical Journal, 16(4), 291-304. 
DOI:10.6200/TCMJ.201912_16(4).0002 
Wu, P. Y. (2021). A Study on the Functional Fitness of Older Adults 
through Diverse Exercise Programs: A Case Study of Older Adults 
in Chiayi County Communities. Journal of Physical Education, 
Health, and Recreation, 20(2), 16-27. 
DOI:10.6169/NCYUJPEHR.202112_20(2).02 
Li, H. C., Tsai, F. W., Lin, H. J., Liu, J. Y., & Hsieh, C. J. (2018). A 
Prospective Study on Balance Function and Falls in Elderly 
Residents of Long-Term Care Facilities. New Taipei Journal of 
Nursing, 20(1), 11-25. DOI:10.6540/NTJN.2018.1.002 
Li, Y. P., & Chen, Q. H. (2016). The Impact of Widowhood on the 
Health and Life of the Elderly and Nursing Care. Nursing Journal, 
63(4), 19-24. 
Li, H. Y., Sun, J. H., & Lin, C. Y. (2015). The Impact of Multifaceted 
Circuit Training on Physical Function and Balance Ability in 
Elderly Residents of Urban and Rural Communities. Physical 
Therapy, 40(2), 53-65. 
Document Date: June 26, 2023

54 
 
Lin, D. Y., & Lin, H. J. (2020). Journal of Ergonomics Studies, 22(1),  
33-44.DOI: 10.6273/JES.202012_22(1).0003 
Zhou, D. J. (2020). The Effect of Functional Exercise Intervention on 
Muscle Fitness, Fall Risk, and Quality of Life in the Elderly 
(Master's thesis). Retrieved from: https://ndltd.ncl.edu.tw/cgi-bin 
Hsu, J. R., & Lin, C. C. (2020). Evaluation of the Effects of Contextual 
Sensory Game Intervention on Balance Ability in the Elderly. 
Journal of Welfare Technology and Service Management, 8(2), 
193-206. DOI: 10.6283/JOCSG.202006_8(2).193 
Chuang, J. R., Tsai, C. L., Tsai, M. J., & Lu, C. T. (2021). The 
Relationship between Social Participation, Organizational 
Playfulness Climate, and Functional Deprivation among the Elderly. 
Journal of Management Practice and Theory Research, 15(2), 
113-127. DOI: 10.29916/JMPP.202112_15(2).0008 
Chen, C. Y. (2009). Healthy People 2020 White Paper. Taipei City: 
Department of Health. 
Chen, B. L., Hu, H. Y., Wang, S. Y., & Lin, K. C. (2018). The impact of 
leisure games program on social participation and happiness among 
older adults living alone or widowed. Taiwan Journal of Healthcare 
Management Research, 18, 13-34. 
Ma, C. L., Kuo, C. Y., & Lu, J. F. (2017). The impact of fitness programs 
in community care centers on the physical and mental health of the 
elderly. Journal of Social Development Studies, 20, 1-38. 
DOI: 10.6687/JSDS.2017.20.1 
Document Date: June 26, 2023

55 
 
Hsu, C. J. (2020). The impact of context-aware motion-sensing game 
intervention on the learning benefits of elderly balance ability 
(Master's thesis). Retrieved from 
https://js.gerontechnology.org.tw/csgj/index.php/JGSM/article/vie
w/615 
Hsu, Y. C., & Chu, M. C. (2022). Exploring the Relationship between 
Social Capital, Social Participation, and Well-being among the 
Elderly. Taiwan Journal of Health Care Management, 25, 74-99. 
National Development Council. (2020). Republic of China Population 
Projections (2020-2070) Annual Report. Retrieved from 
https://pop-proj.ndc.gov.tw. 
Zhang, Y. Q., & Chen, Y. M. (2020). The current situation, challenges, 
and opportunities of integrated care in C-grade alley long-term care 
stations: Perspectives from the World Health Organization's 
Integrated Care for Older People (ICOPE) service levels. 
Long-Term Care Journal, 24(2), 93-109. 
DOI:10.6317/LTC.202008_24(2).0002 
Zhang, Q. H., Cheng, Y. F., Jin, H. Z., & Li, X. N. (2013). Validation and 
reliability study of the Taiwan version of the World Health 
Organization Quality of Life Brief questionnaire 
(WHOQOL-BREF) in a sample of severely visually impaired 
adults. Journal of Educational Psychology, 44(5), 521-536. 
Zhang, Q. X., Liang, Z. Z., Lin, C. H., Wei, Y. J., Xu, W. J., & Chen, J. Q. 
(2013). Effects of physical therapy intervention on physical 
Document Date: June 26, 2023

56 
 
performance, balance, and walking ability of older adults in 
community care centers. Physical Therapy, 38(3), 201-209. 
Zhang, X. (2018). Challenges of using virtual reality in educational 
settings. Taiwan Educational Review Monthly, 7(11), 120-125. 
Chen, M. F., Lin, C. A., & Tsai, C. T. (2013). Exploring the related or 
risk factors of falls among community-dwelling elderly in Taiwan: 
A systematic literature review. Taiwan Journal of Public Health, 32, 
403-423. DOI: 10.6288/TJPH2013-32-05-01 
Chen, Y. J., Chang, C. H., Wang, M. H., & Lu, L. T. (2019). A literature 
review on the application of motion-sensing games in physical 
activity. Chung Yuan Physical Education Journal, (13), 17-27. DOI: 
10.6646/CYPEJ.201907_(13).0003 
Chen, M. C., & Gong, X. H. (2019). Enhancing attention in the elderly 
through virtual reality games. Journal of Welfare Technology and 
Services Management, 7(2), 150-166. DOI: 
10.6283/JOCSG.201906_7(2).150 
Chen, S. W., Liao, M. W., & Hsu, C. L. (2015). Design and user 
acceptance of a smart health fitness system. Journal of Medical 
Informatics, 24(3), 1-15. 
Chen, L. J., & She, Y. J. (2016). Using motion-sensing video game 
consoles to improve compliance with treadmill training among 
junior high school students with intellectual disabilities in special 
education schools. Journal of Disability Research Quarterly, 14(3), 
180-194. 
Document Date: June 26, 2023

57 
 
Chen, Y. A., Yu, H. W., Chu, D. H., & Chen, Y. M. (2018). Evaluation of 
the effectiveness of a disability prevention care module on 
community-dwelling older adults in Nantou County: Impact on 
physical fitness, health-related quality of life, and exercise 
self-efficacy. Long-term Care Journal, 22(2), 119-134. 
Chen, C. C., Chang, C. H., Hsieh, C. G., Huang, Y. H., Yen, C. F., Lo, C. 
H., & Liang, C. Z. (2019). A pioneering study on the impact of 
combining environmental conservation activities with rehabilitation 
exercise models on the physical activity performance of older 
adults in community care centers. Journal of Geriatrics, 
Gerontology, and Geriatric Medicine, 14(2), 82-97. 
DOI:10.29461/TGGa.201905_14(2).0003 
Huang, T. Y., Tu, M. H., Chen, H. Y., & Chen, H. C. (2015). Assessment 
and prevention of falls in older adults. Family Medicine and 
Primary Care Review, 30(1), 2-8. 
Huang, H. N., Chou, W. H., Ou, C. C., Chen, S. H., Lin, S. L., & Jia, C. L. 
(2019). The integration relationship between human standing 
balance and interactive gaming systems. Journal of Sport and 
Recreation Research, 14(1), 17-27. DOI: 
10.29423/JSRR.201909_14(1).02 
Huang, H. N., Chen, J. W., Chen, S. H., Ou, C. C., & Jia, C. L. (2022). 
The effects of six-week interactive gaming balance training on 
human body sway. Journal of Sport and Recreation Research, 16(3), 
25-36. DOI: 10.29423/JSRR.202203_16(3).03 
Document Date: June 26, 2023

58 
 
Lai, H. J. (2020). Exploring factors influencing the use of digital 
game-based learning among elderly learners. Journal of 
Gerontechnology and Service Management, 8(1), 58-71. 
DOI: 10.6283/JOCSG.202003_8(1).58 
Chung, H. Y. (2020). The effect of eight weeks of virtual reality game 
training on balance ability in middle-aged and elderly individuals. 
Master's thesis, Department of Physical Education, National 
Taichung University of Education. 
Hsieh, H. J. (2014). The effectiveness of virtual reality motion 
rehabilitation device on upper limb movement training for children 
with cerebral palsy. Journal of Liberal Arts and Social Sciences, 
National Taiwan University of Science and Technology, 10(3), 
203-223. DOI: 10.29506/JLASS 
Lai, H. J., Zhang, Q. X., Hsu, J. Z., & Su, H. X. (2021). Can smart 
wristbands influence walking ability and quality of life in elderly 
individuals living alone? Journal of Medicine and Health, 10(3), 
1-16. 
Department of Health Promotion, Ministry of Health and Welfare 
(November 24, 2016). 2020 National Health White Paper. 
Retrieved from:https://www.mohw.gov.tw/cp-26-36493-1.html 
Ministry of Health and Welfare Statistics Office - Analysis of National 
Mortality Statistics for the Year 109 (2020, June 18)." Retrieved 
from: https://dep.mohw.gov.tw/dos/lp-5069-113-xCat-y109.html 
Document Date: June 26, 2023

59 
 
Ministry of Health and Welfare - Long-term Care 2.0 Ten-Year Plan 
(November 14, 2016). Retrieved from: 
https://1966.gov.tw/LTC/cp-5200-42415-201.html 
Ministry of Health and Welfare, Health Promotion Administration - 
National Fall Prevention Tips Handbook (February 2021). 
Retrieved from :. 
https://www.hpa.gov.tw/Pages/EBook.aspx?nodeid=1193 
Ministry of Health and Welfare. (September , 2015). Health statistics 
information network. Retrieved from http:// 
www.mohw.gov.tw/cht/DOS/Statistic.aspx?f_list_n 
o=312&fod_list_no=4176.〕 
Su, Y.-C., Hu, C.-H., & Wu, Y.-T. (2020). The impact of progressive 
exercise modules on functional fitness of older adults. Journal of 
Sport and Recreation Research, 14(3), 17-31. DOI: 
10.29423/JSRR.202003_14(3).02 
Dai, S.-M., Huang, P.-L., & Chu, M.-J. (2016). Active aging in place and 
the sense of security among older adults: A case study of Miaoli 
County. In Proceedings of the 1st Cross-Strait Emergency 
Management Summit Forum (pp. 1-10). Taipei, Taiwan: 
Cross-Strait Emergency Management Association. 
 
 
 
 
Document Date: June 26, 2023

60 
 
English references 
American College of Sports Medicine, Chodzko-Zajko, W. J., Proctor, D. 
N., Fiatarone Singh, M. A., Minson, C. T., Nigg, C. R., Salem, G. 
J., & Skinner, J. S. (2009). American College of Sports Medicine 
position stand. Exercise and physical activity for older adults. 
Medicine and Science in Sports and Exercise, 41(7), 1510-1530. 
https://doi.org/10.1249/MSS. 0b013e3181a0c95c 
Bjerk, M., Brovold, T., Skelton, D. A., Liu-Ambrose, T., & Bergland, A. 
(2019). Effects of a falls prevention exercise programme on 
health-related quality of life in older home care recipients: a 
randomised controlled trial. Age and ageing, 48(2), 213-219.  
Bashkireva, A. S., Bogdanova, D. Y., Bilyk, A. Y., Shishko, A. V., 
Kachan, E. Y., & Arutyunov, V. A. (2018).Quality of life and 
physical activity among elderly and old people.Adv Gerontol,30(5), 
743-750. 
Chung, C. L., Thilarajah, S., & Tan, D. (2016). Effectiveness of 
resistance training on muscle strength and physical function in 
people with Parkinson's disease: A systematic review and 
meta-analysis. Clinical Rehabilitation, 30(1), 11-23. 
https://doi.org/10.1177/0269215515570381 
Cai, T., Verze, P., & Bjerklund Johansen, T. E. (2021). The Quality of 
Life Definition: Where Are We Going? Uro, 1(1), 14–
22. doi:10.3390/uro1010003  
Document Date: June 26, 2023

61 
 
Choi, M., Lee, M., Lee, M.-J., & Jung, D. (2017). Physical activity, 
quality of life and successful ageing among community-dwelling 
older adults. International Nursing Review, 64(3), 396–
404. doi:10.1111/inr.12397  
Chou, W.C.; Tinetti, M.E.; King, M.B.; Irwin, K.; Fortinsky, R.H. 
Perceptions of physicians on the barriers and facilitators to 
integrating fall risk evaluation and management into practice. J. 
Gen. Intern. Med. 2006, 21, 117–122 
Donath, L., Rössler, R., & Faude, O. (2016). Effects of Virtual Reality 
Training (Exergaming) Compared to Alternative Exercise Training 
and Passive Control on Standing Balance and Functional Mobility 
in Healthy Community-Dwelling Seniors: A Meta-Analytical 
Review. Sports Medicine, 46(9), 1293–
1309. doi:10.1007/s40279-016-0485-1  
Garatachea, N., & Lucia, A. (2013). Genes, physical fitness and ageing. 
Ageing research reviews, 12(1), 90-102.  
Griswold, D., Rockwell, K., Killa, C., Maurer, M., Landgraff, N., & 
Learman, K. (2014). Establishing the reliability and concurrent 
validity of physical performance tests using virtual reality 
equipment for community-dwelling healthy elders. Disability and 
Rehabilitation, 37(12), 1097–
1101. doi:10.3109/09638288.2014.952451  
Henry, M., & Baudry, S. (2019). Age-related changes in leg 
proprioception: implications for postural control. Journal of  
Document Date: June 26, 2023

62 
 
Hupin, D., Roche, F., Gremeaux, V., Chatard, J.-C., Oriol, M., Gaspoz, 
J.-M., . . . Edouard, P. (2015). Even a low-dose of 
moderate-to-vigorous physical activity reduces mortality by 22% in 
adults aged≥ 60 years: a systematic review and meta-analysis. 
British journal of sports medicine, 49(19), 1262-1267.  
Lim, D., Kim, C., Jung, H., Jung, D., & Chun, K. J. (2015). Use of the 
Microsoft Kinect system to characterize balance ability during 
balance training. Clinical interventions in aging, 10, 1077.  
Llorens, R., Latorre, J., Noé, E., & Keshner, E. A. (2016). Posturography 
using the Wii Balance Board™: a feasibility study with healthy 
adults and adults post-stroke. Gait & posture, 43, 228-232.  
Lewis, M., Peiris, C. L., & Shields, N. (2017). Long-term home and 
community-based exercise programs improve function in 
community-dwelling older people with cognitive impairment: A 
systematic review. Journal of Physiotherapy, 63(1), 23-29. 
https://doi.org/10.1016/j.jphys.2016.11.005 
Neri, S. G., Cardoso, J. R., Cruz, L., Lima, R. M., De Oliveira, R. J., 
Iversen, M. D., & Carregaro, R. L. (2017). Do virtual reality games 
improve mobility skills and balance measurements in 
community-dwelling older adults? Systematic review and 
meta-analysis. Clinical Rehabilitation, 31(10), 1292-1304.  
Nicholson, V. P., McKean, M., Lowe, J., Fawcett, C., & Burkett, B. 
(2015). Six weeks of unsupervised Nintendo Wii Fit gaming is 
Document Date: June 26, 2023

63 
 
effective at improving balance in independent older adults. Journal 
of aging and physical activity, 23(1), 153-158.  
Noradechanunt, C., Worsley, A., & Groeller, H. (2017). Thai Yoga 
improves physical function and well-being in older adults: A 
randomised controlled trial. Journal of Science and Medicine in 
Sport, 20(5), 494–501. doi:10.1016/j.jsams.2016.10.007  
Organization, W. H. (2020). Decade of healthy ageing: baseline report.  
Phirom, K., Kamnardsiri, T., & Sungkarat, S. (2020). Beneficial Effects of 
Interactive Physical-Cognitive Game-Based Training on Fall Risk 
and Cognitive Performance of Older Adults. International Journal 
of Environmental Research and Public Health, 17(17), 
6079. doi:10.3390/ijerph17176079  
Rikli, R. E., & Jones, C. J. (2013). Senior fitness test manual: Human 
kinetics. 
Rogge, A. K., Röder, B., Zech, A., & Hötting, K. (2018). 
Exercise-induced neuroplasticity: balance training increases 
cortical thickness in visual and vestibular cortical regions. 
Neuroimage, 179, 471– 479 
Steckhan, G. M. A., Warner, L. M., & Fleig, L. (2021). Preventing Falls 
Together: Social Identification Matters for Engaging Older Adults 
in a Group-based Exercise Program. Activities, Adaptation & 
Aging, 1–16. https://doi.org/10.1080/01924788 
Senefeld, J., Yoon, T., & Hunter, S. K. (2017). Age differences in 
dynamic fatigability and variability of arm and leg muscles: 
Document Date: June 26, 2023

64 
 
Associations with physical function. Experimental gerontology, 87, 
74-83.  
Sherrington, C., Fairhall, N. J., Wallbank, G. K., Tiedemann, A., 
Michaleff, Z. A., Howard, K., ... Lamb, S. E. (2019). Exercise for 
preventing falls in older people living in the community. The 
Cochrane Database of Systematic Reviews, 1(1), CD012424. 
https://doi.org/10.1002/14651858. CD012424. pub2 
Schoene, D., Valenzuela, T., Lord, S. R., & de Bruin, E. D. (2014). The 
effect of interactive cognitive-motor training in reducing fall risk in 
older people: a systematic review. BMC Geriatrics, 
14(1). doi:10.1186/1471-2318-14-107  
Taylor, L. M., Kerse, N., Frakking, T., & Maddison, R. (2018). Active 
Video Games for Improving Physical Performance Measures in 
Older People. Journal of Geriatric Physical Therapy, 41(2), 108–
123. doi:10.1519/jpt.0000000000000078 
World Health Organization.(2007).WHO Global report on falls 
Prevention in older Age. Retrieved from 
https://extranet.who.int/agefriendlyworld/wp-conte 
nt/uploads/2014/06/WHo-Global-report-on-falls-pr 
evention-in-older-age.pdf 
WHO. WHO remains firmly committed to the principles set out in the 
preamble to the Constitution. Available at: 
https://www.who.int/about/who-we-are/ constitution. Accessed 
June 22, 2022. 
Document Date: June 26, 2023

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Appendix1-TMU-JIRB  
 
 
 
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