Exergames in In-patient Rehabilitation

This pilot trial aims to evaluate the feasibility and effectiveness of a technology-based intervention for cognitive-motor training in rehabilitation clinics with geriatric, neurological and cardiac patients.

The primary objective of this pilot study is to evaluate the feasibility of exergame-based cognitive-motor training in in-patient rehabilitation settings.

The secondary objective of this pilot trial is to evaluate the effectiveness of an expanded rehabilitation treatment (combining exergame training with conventional care) on physical and cognitive functioning in different patient groups.

This study is a pilot trial with two arms: an intervention group where the conventional treatment during the stay in the in-patient rehabilitation clinic is extended with a technology-based cognitive-motor intervention and a control group following just the conventional treatment. Participants will be randomly allocated to one of the two groups. The selected methods to evaluate the primary and secondary endpoints include quantitative and qualitative measures. This national study will be conducted in Switzerland in a multicentre setup; three rehabilitation clinics are involved as study centres.

The study will include at least 40 patients in each of the rehabilitation clinics involved as study centres (20 patients in the intervention group, 20 patients in the control group), resulting in a total sample size of 120 patients. At clinic entry, patients potentially fulfilling all inclusion criteria will be informed in oral and written about the study and asked if they wish to participate. All interested participants will then be screened for eligibility. The included participants will then undergo a baseline assessment battery and will be subsequently randomly allocated to the intervention or the control group using a block randomization.

Screening as well as baseline measurements (T1-measurements) are conducted within the first two days upon entry at the rehabilitation clinic. T1-measurements will last around 60-70 minutes. One day after T1- measurements, the intervention will begin (for patients in the intervention group). The intervention period will be equal to the length of the stay in the rehabilitation clinic (between 2-3 weeks, according to each cantonal/regional regulations and insurance coverage) and will include short daily training sessions using the Dividat Senso (5x/week à 10-15min), resulting in 10 to 15 training sessions in total. The training sessions will be supervised by a qualified study investigator (carefully observing patients while training and also preventing/aiding in case of adverse events). At the last two days before discharge from the clinic, post-measurements (T2-measurements) will be performed with all (intervention \& control) study participants. T2-measurements last around 70-80 minutes.

Intervention group:

The patients allocated to the intervention group will conduct simultaneously combined cognitive- motor training on a technological device providing exergames, the Dividat Senso. Both, the hardware (Dividat Senso) and the software (exergames) are specifically developed considering the needs and requirements of older adults but also clinicians/therapists.

The Dividat Senso is a platform for the dynamic recording of steps, weight shifts and other body movements producing forces. The platform includes 20 sensors (strain gauges), 5 vibration motors and an light-emitting diode (LED) control. It is certified as a medical device class 1 and used by clinics, hospitals and nursing and care homes in 15 countries worldwide. It is connected to a small computer (running the software) and a large screen.

The Dividat exergames specifically target all cognitive functions relevant for the successful mastering of activities of daily living such as executive and attentional functions and physical functions such as balance and coordination. The games are played by conducting body movements, mainly steps in four directions (front, right, left, back) but also body weight shifting.

The Dividat software is a web-based environment that includes data backing (Dividata), an administrative interface (Dividat Manager) and an intelligent, adaptable training environment with the exergames for motor-cognitive training (Dividat Play). In the Dividat Manager, participants can be registered as users and their training program can be managed. The training software (Dividat Play) contains an algorithm for automatic, real-time adaptation of the difficulty of a training game to the skills of a user. Moreover, the training applied in this study is progressive in the course of the intervention period; patients start with the easier games in the first week, progressing to more difficult games in the second week and so on. Therapists and study investigators have the opportunity to individually adapt the training plan to meet each patient's functional capacity in the Dividat Manager. Thus, personalized training and optimal challenge for each patient are ensured.

The intervention period in the rehabilitation setting will be equal to the length of the stay in the rehabilitation clinic (between 2-3 weeks, according to each cantonal/regional regulations and insurance coverage) and will include short daily training sessions using the Senso (5x/week à 10- 15min), resulting in 10 to 15 training sessions in total.

Each session contains various combinations of the Dividat exergames (each of the games lasts around 2-3min).

Control group:

The patients of the control group follow the standard rehabilitation procedure including per week: 3x 30min physiotherapy, 8x 30min group therapy, 3x 45min group therapy (group therapy includes body- focused therapy, mindfulness therapy, respiratory therapy, gymnastics, hiking etc.).

Eligibility Criteria:
Inclusion Criteria:

* Patients with prescription for rehabilitation\*
* ≥ 50 years old
* Able to score ≥ 20 at the Mini Mental State Examination (MMSE)
* Able to provide a signed informed consent
* Physically able to stand for at least 3min without external support (self-report)

Exclusion Criteria:

* Mobility or cognitive limitations or comorbidities which impair the ability to use the training games and overall system
* Conservatively treated osteoporotic fractures
* Previous or current major psychiatric illness (e.g. schizophrenia, bipolar disorder, recurrent major depression episodes)
* History of drugs or alcohol abuse
* Terminal illness
* Severe sensory impairments (mainly visual, auditory, color blindness)
* Insufficient knowledge of German to understand the instructions/games

  * \*In the rehabilitation clinics involved as study centres, mainly persons suffering from cardiovascular diseases (clinic Seewis), persons suffering from neurological diseases (esp. Parkinson's Disease according to the United Kingdom Brain Bank criteria) (clinic Zihlschlacht) and geriatric patients (clinic Dussnang) will be included in this study.