# Exercise as it relates to Disease/Virtual Reality Improves Physical Function in Elderly Adults

This Wikibooks page is a fact sheet and critique of the journal article "Unsupervised Virtual Reality-Based Exercise Program Improves Hip Muscle Strength and Balance Control in Older Adults: A Pilot Study" by Kim et al. (2013)

### Background

Australia is experiencing an ageing population. In 2016, 15% of the Australian population was reported as being over the age of 65. Older Australians lose over 1.8 million years of healthy life to due premature death or living with disability or disease. Leading causes of burden include cardiovascular disease, respiratory disease, cancer and musculoskeletal conditions. Despite the benefits of physical activity in these conditions, 65% of older Australians are insufficiently active.
Promoting exercise in the elderly will limit an increase in burden of disease. Kim and colleagues sought to determine if virtual reality (VR) would be a safe and effective method of promoting exercise in an elderly population.

### Source of the Research

This study was conducted by the Korea University Department of Physical Therapy. Measurements and interventions were performed at the Korea University research laboratory. Participants were volunteers from a local Korean community.
Korea is a reasonable comparison to an Australian population. Korea has a high standard of living, a high average income and an aging population. By 2050, the elderly will contribute to 38% of the Korean population. The leading causes of death for Korean elderly are similar to Australia and include cancer, heart diseases, cerebrovascular diseases, pneumonia and diabetes mellitus.
The authors have been involved in other high-quality studies collectively and as individuals. They have collaborated on several studies of the effects of VR in elderly and neuromuscular populations.

### Research Design

This pilot study was an 8-week randomised control trial with one experimental group. The aim of this study was to assess the effects of a virtual-reality exercise program on hip muscle strength and reactive balance in community dwelling elderly adults. A secondary aim of this study was the assess the feasibility of virtual-reality as an unsupervised means of home based exercise.
This study has received a confirmed Physiotherapy Evidence Database (PEDro) score of 7/10. A high PEDro score indicates strong experiment design.. As a pilot study, this research is designed to guide future study rather than directly influence practice.
PEDro Scoring :
| Random Allocation | Y |
| Concealed Allocation | N |
| Baseline Comparability | Y |
| Subjects Blinded | N |
| Therapists Blinded | N |
| Assessors Blinded | Y |
| Adequate Follow-up | Y |
| Intention-to-treat Analysis | Y |
| Between-group Analysis | Y |
| Point Estimates & Variability | Y |

### Methodology

Groups were randomly created from thirty-six elderly adults. Those with a history of orthopaedic or neurological surgery, altered mental state, cardiovascular disease, dizziness or headache were excluded from participating in this study. Participants could walk independently and could perform a single leg stance for more than 15 seconds.
Intervention :
| | Sample Size (f:m) | Mean Age | Intervention |
| Experimental Group | 12:4 | 68.28 ± 3.74 | 3x 1hr/week sessions for 8 weeks using Xbox KINECT exercise program. Exercise program involved 4x tai-chi inspired movements. Real time feedback provided by on-screen avatar. Sessions were unsupervised and performed at the university laboratory. |
| Control Group | 17:1 | 66.21 ± 3.87 | Instructed to continue daily routine for 8 weeks. |
Outcome Measures :
| Measure | Method |
| Strength Hip flexors/extensors Hip abductors/adductors | Performed in standing using a dynamometer. Best of 3 attempts for each muscle recorded. |
| Reactive Balance Backwards/sideways Vision/vision occluded | Performed on a force plate. Ground reaction force value for each direction recorded. |
There are limitations in this methodology which impacted results. Small sample size may have inflated improvements. Participants were volunteers and more likely to adhere to treatment than randomly selected subjects. The inclusion criteria included only healthy participants whereas more than 50% of Australian elderly live with disability. Despite claims that interventions were unsupervised, required attendance to the university laboratory may have increased adherence. Balance and strength outcomes were appropriate however adherence was not measured.

### Results

There was a withdrawal rate of 0% in the experimental group and 22% in the control group. Statistical analysis was performed to determine change within and difference between groups. The control group did not demonstrate significant change in measured outcomes. The VR group had a significant improvement in strength of the hip muscles and ground reaction force for all stepping tests.
Kim et al draw sensible conclusions and do not overestimate results. They state that further investigation into VR use in less healthy individuals is needed before changing practice. The authors overvalue the impact of VR in increasing subject adherence. They attribute participation to be due to "motivation and joy" without considering the influence of voluntary subjects or limited equipment access.

### Conclusions

It is reasonable to conclude that VR exercise is a safe and independent method of improving hip strength and reactive balance in healthy elderly. The degree of these increases or the effect in the presence of comorbidities cannot be determined without further study. The effect of VR programs on adherence cannot yet be determined.
These results are aligned with studies of similar populations. When used for motor learning, VR has positive and equal effect compared to general rehabilitation in healthy elderly. When used in conjunction with games, VR appeared to be as effective as active controls and more effective than non-active controls at improving balance, strength and gait. While VR was associated with high adherence and enjoyment, current validity of VR research is limited due to small sample sizes and poor methodology </ref>.

### Practical Advice

When designing an exercise program to improve function for healthy people aged 65+ a dosage of 8-weeks of 3 hour long sessions weekly is effective. VR programs are safe for this population and appear to provide adequate feedback for correct performance when performed independently. If targeting hip strength and reactive balance, include balance and strengthening exercises such as those used in tai-chi.

### Further Reading

Follow the links below for further information:
* Motor learning through VR in elderly - a systematic review
* VR using games for improving physical functioning in older adults: a systematic review
* The Effects of VR-based Balance Training on Balance of the Elderly

### References

* 1 2 3 4 Kim J, Son J, Ko N, Yoon B. Unsupervised virtual reality-based exercise program improves hip muscle strength and balance control in older adults: a pilot study. Arch Phys Med Rehabil. 2013;94(5):937-43.
* 1 2 3 4 5 Australian Institute of Health and Welfare. Older Australians at a glance. 2017; AIHW web cat. Available from: https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/health-and-aged-care-service-use
* 1 2 Howe N, Jackson R, Nashima K. The Aging of Korea: Demographics and Retirement Policy in the Land of the Morning Calm. Washington DC: The Centre for Strategic and International Studies; 2007.
* ↑ Statistics Korea. 2016 Statistics on the Aged. 2016; Available from: http://kostat.go.kr/portal/eng/pressReleases/1/index.board?bmode=read&aSeq=358082
* ↑ Lee M, Son J, Kim J, Yoon B. Individualized feedback-based virtual reality exercise improves older women's self-perceived health: a randomized controlled trial. Arch Gerontol Geriatr. 2015;61(2):154-60
* ↑ Lee M, Pyun SB, Chung J, Kim J, Eun SD, Yoon B. A Further Step to Develop Patient-Friendly Implementation Strategies for Virtual Reality-Based Rehabilitation in Patients With Acute Stroke. Phys Ther. 2016;96(10):1554-64
* ↑ Lee M, Suh D, Son J, Kim J, Eun SD, Yoon B. Patient perspectives on virtual reality-based rehabilitation after knee surgery: Importance of level of difficulty. J Rehabil Res Dev. 2016;53(2):239-52
* ↑ Physiotherapy Evidence Database. PEDro Statistics. 2017; Available from: https://www.pedro.org.au/english/downloads/pedro-statistics/
* 1 2 Cochrane Methods. Assessing Risk of Bias in Included Studies. 2017; Available from: http://methods.cochrane.org/bias/assessing-risk-bias-included-studies#The%20Cochrane%20Risk%20of%20Bias%20Tool
* ↑ Ribeiro-Papa D, Massetti T, Crocetta TB, Menezes LDCd, Antunes T, Bezerra I, et al. Motor learning through virtual reality in elderly - a systematic review. Medical Express. 2016;2(3).
* 1 2 3 Molina KI, Ricci NA, de Moraes SA, Perracini MR. Virtual reality using games for improving physical functioning in older adults: a systematic review. J Neuroeng Rehabil. 2014;11:156.