GameTech

Stuart Smith

Videogames a “serious” health

technology

Monday, 11 July 2011

GameTech 2011

Background

Games for fall prevention

Games for stroke rehabilitation

Building an Australian Serious Games for Health industry


GameTech 2011

Video games have often received bad press with respect to health

increased aggression and violence

addiction to gameplay

increased sedentary behaviour

epileptic seizures

Wii knee, haemothorax and ruptured tendons

But before all of that......


GameTech 2011

However..... games can be seriously considered


GameTech 2011

Exergames for neuroplasticity


GameTech 2011

spinal cord rehabilitation


GameTech 2011

Technology Research for Independent Living

Develop technology for in-home monitoring of factors associated with falls, cognitive function and social connectivity in older adults

Falls

Cog

nitiv

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Soci

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Ethnography

Technology Platform


GameTech 2011

Australian TRIL

Use of technology for monitoring health and promoting independent living in older adults.

Regional, rural and remote areas


GameTech 2011

Can existing technology facilitate independent living in

older adults?


GameTech 2011

Everyday objects are digital

Television most familiar of all.


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Can we use the television to facilitate independent living?


GameTech 2011

Here’s a significant health issueFalls are a major factor

for reduced independence in older adults

1/3 community dwelling older adults fall each year

!"#$%&'()#&'#$*&)$+,-.$,/$$0*11-$%&2345$67,&8$91)#4$:#,;1#$$

(&$<#=$>,3."$?*1#-$@AABCADE!"#$%&'("(&")*+",$-.(/

Total health cost to NSW alone in 2006/2007 $553M

$18,454 per hospital admission


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Interventions for preventing falls in older people living in thecommunity (Review)

Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2009, Issue 4

http://www.thecochranelibrary.com

Interventions for preventing falls in older people living in the community (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

We know fall risk can be reduced by exercise

Effective Exercise for the Prevention of Falls: A Systematic Reviewand Meta-Analysis

Catherine Sherrington, PhD,!wz Julie C. Whitney, MSc,§ Stephen R. Lord, DSc,w

Robert D. Herbert, PhD,! Robert G. Cumming, PhD,z and Jacqueline C. T. Close, MDwk

OBJECTIVES: To determine the effects of exercise on fallsprevention in older people and establish whether particulartrial characteristics or components of exercise programs areassociated with larger reductions in falls.

DESIGN: Systematic review with meta-analysis. Random-ized controlled trials that compared fall rates in older peo-ple who undertook exercise programs with fall rates inthose who did not exercise were included.

SETTING: Older people.

PARTICIPANTS: General community and residential care.

MEASUREMENTS: Fall rates.

RESULTS: The pooled estimate of the effect of exercisewas that it reduced the rate of falling by 17% (44 trials with9,603 participants, rate ratio (RR)50.83, 95% confidenceinterval (CI)5 0.75–0.91, Po.001, I2562%). The great-est relative effects of exercise on fall rates (RR5 0.58, 95%CI50.48–0.69, 68% of between-study variability ex-plained) were seen in programs that included a combina-tion of a higher total dose of exercise (450 hours over thetrial period) and challenging balance exercises (exercisesconducted while standing in which people aimed to standwith their feet closer together or on one leg, minimize use oftheir hands to assist, and practice controlled movements ofthe center of mass) and did not include a walking program.

CONCLUSION: Exercise can prevent falls in older people.Greater relative effects are seen in programs that includeexercises that challenge balance, use a higher dose of ex-ercise, and do not include a walking program. Service pro-viders can use these findings to design and implementexercise programs for falls prevention. J Am Geriatr Soc56:2234–2243, 2008.

Key words: falls; exercise; meta-analysis

The development and implementation of effective andcost-efficient strategies to prevent falls in older people

is an urgent global health challenge. In developed countries,life expectancy for people aged 65 years old is approxi-mately 17 years for men and 21 years for women. At leastone-third of people aged 65 and older fall at least onceannually,1 and falls account for more than half of the injury-related hospitalizations for older people.2 Fall rates in thegeneral older population are reported to be 1.2 falls perperson year.3

Falls in older people are not purely random events butcan be predicted by assessing a number of risk factors.4,5

Some of these risk factors (e.g., reduced muscle strength andimpaired balance and gait) can be modified using exercise,whereas others (e.g., poor vision, psychoactive medicationuse) require different intervention approaches. Exercisecan be used as a stand-alone falls prevention intervention oras a component of a multifaceted program. Multifacetedinterventions can prevent falls in the general community,in those at greater risk of falls, and in residential carefacilities.4,6

Many trials have sought to establish the specific effectof exercise on fall rates, but a large proportion of these trialshave been underpowered. The best way to interpret thesetrials may be to pool their data in a meta-analysis, but trialsof the effects of exercise on fall rates vary in their quality,have been conducted on a range of populations, and employexercise programs that differ greatly in their aims and con-tent. Meta-analysis should therefore involve exploration ofwhether these factors ‘‘explain’’ (are associated with) esti-mates of the effect of exercise programs.7,8

A Cochrane review of fall prevention strategies6 con-ducted separate meta-analyses on different forms of exer-cise and concluded that some exercise programs can preventfalls in community dwellers (e.g., home exercise program ofbalance and strength training, a Tai Chi group program) but

Address correspondence to Dr. Catherine Sherrington, The George Institutefor International Health, PO Box M201, Missenden Road, Sydney NSW2050, Australia. E-mail: [email protected]

DOI: 10.1111/j.1532-5415.2008.02014.x

From the !Musculoskeletal Division, The George Institute for InternationalHealth and zSchool of Public Health, University of Sydney, Sydney, Australia;wFalls and Balance Research Group, Prince of Wales Medical ResearchInstitute, University of New South Wales, Sydney, Australia; §Clinical AgeResearch Unit, Kings College Hospital, London, United Kingdom; andkDepartment of Geriatric Medicine, Prince of Wales Hospital, Sydney,Australia.

JAGS 56:2234–2243, 2008r 2008, Copyright the AuthorsJournal compilation r 2008, The American Geriatrics Society 0002-8614/08/$15.00

Effective Exercise for the Prevention of Falls: A Systematic Reviewand Meta-Analysis

Catherine Sherrington, PhD,!wz Julie C. Whitney, MSc,§ Stephen R. Lord, DSc,w

Robert D. Herbert, PhD,! Robert G. Cumming, PhD,z and Jacqueline C. T. Close, MDwk

OBJECTIVES: To determine the effects of exercise on fallsprevention in older people and establish whether particulartrial characteristics or components of exercise programs areassociated with larger reductions in falls.

DESIGN: Systematic review with meta-analysis. Random-ized controlled trials that compared fall rates in older peo-ple who undertook exercise programs with fall rates inthose who did not exercise were included.

SETTING: Older people.

PARTICIPANTS: General community and residential care.

MEASUREMENTS: Fall rates.

RESULTS: The pooled estimate of the effect of exercisewas that it reduced the rate of falling by 17% (44 trials with9,603 participants, rate ratio (RR)50.83, 95% confidenceinterval (CI)5 0.75–0.91, Po.001, I2562%). The great-est relative effects of exercise on fall rates (RR5 0.58, 95%CI50.48–0.69, 68% of between-study variability ex-plained) were seen in programs that included a combina-tion of a higher total dose of exercise (450 hours over thetrial period) and challenging balance exercises (exercisesconducted while standing in which people aimed to standwith their feet closer together or on one leg, minimize use oftheir hands to assist, and practice controlled movements ofthe center of mass) and did not include a walking program.

CONCLUSION: Exercise can prevent falls in older people.Greater relative effects are seen in programs that includeexercises that challenge balance, use a higher dose of ex-ercise, and do not include a walking program. Service pro-viders can use these findings to design and implementexercise programs for falls prevention. J Am Geriatr Soc56:2234–2243, 2008.

Key words: falls; exercise; meta-analysis

The development and implementation of effective andcost-efficient strategies to prevent falls in older people

is an urgent global health challenge. In developed countries,life expectancy for people aged 65 years old is approxi-mately 17 years for men and 21 years for women. At leastone-third of people aged 65 and older fall at least onceannually,1 and falls account for more than half of the injury-related hospitalizations for older people.2 Fall rates in thegeneral older population are reported to be 1.2 falls perperson year.3

Falls in older people are not purely random events butcan be predicted by assessing a number of risk factors.4,5

Some of these risk factors (e.g., reduced muscle strength andimpaired balance and gait) can be modified using exercise,whereas others (e.g., poor vision, psychoactive medicationuse) require different intervention approaches. Exercisecan be used as a stand-alone falls prevention intervention oras a component of a multifaceted program. Multifacetedinterventions can prevent falls in the general community,in those at greater risk of falls, and in residential carefacilities.4,6

Many trials have sought to establish the specific effectof exercise on fall rates, but a large proportion of these trialshave been underpowered. The best way to interpret thesetrials may be to pool their data in a meta-analysis, but trialsof the effects of exercise on fall rates vary in their quality,have been conducted on a range of populations, and employexercise programs that differ greatly in their aims and con-tent. Meta-analysis should therefore involve exploration ofwhether these factors ‘‘explain’’ (are associated with) esti-mates of the effect of exercise programs.7,8

A Cochrane review of fall prevention strategies6 con-ducted separate meta-analyses on different forms of exer-cise and concluded that some exercise programs can preventfalls in community dwellers (e.g., home exercise program ofbalance and strength training, a Tai Chi group program) but

Address correspondence to Dr. Catherine Sherrington, The George Institutefor International Health, PO Box M201, Missenden Road, Sydney NSW2050, Australia. E-mail: [email protected]

DOI: 10.1111/j.1532-5415.2008.02014.x

From the !Musculoskeletal Division, The George Institute for InternationalHealth and zSchool of Public Health, University of Sydney, Sydney, Australia;wFalls and Balance Research Group, Prince of Wales Medical ResearchInstitute, University of New South Wales, Sydney, Australia; §Clinical AgeResearch Unit, Kings College Hospital, London, United Kingdom; andkDepartment of Geriatric Medicine, Prince of Wales Hospital, Sydney,Australia.

JAGS 56:2234–2243, 2008r 2008, Copyright the AuthorsJournal compilation r 2008, The American Geriatrics Society 0002-8614/08/$15.00

High dosage of exercise is required (eg > 50 hrs or twice/week for 25 weeks).

Video games might offer a way to ensure compliance with exercise


GameTech 2011

Will older adults play video games?

1034 individuals aged 36-50, 58% play video games

912 aged 51-65 52% play video games

“Interactive Australia 2009” Brand (2009)

National survey of 1614 households

221 aged 65+, 51% play video games


GameTech 2011

like Dance Dance Revolution


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Dance Dance Revolution to reduce fall risk and increase

physical activity


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Fall

risk

Date

Mrs Smith, it looks like you have been a bit unsteady on your feet lately. Is there anything we can

do for you?

Use DDR to measure fall risk over time

Provide health information feedback to older person and their

support network

Videogames as a telehealth technology


GameTech 2011

Where to from here?

difficulty. Subjects were asked to rate their confidence level inperforming each of the 14 activities on a continuous scale from0 (no confidence) to 100 (completely confident). A compositescore of the average level of confidence was used for analysis.The possible range of the ABC score is 0 to 100. The ABC hasbeen shown to have a good test-retest reliability.28(p36)

Quality of life was assessed by the SF-36 Questionnaire, acondition-generic tool composed of 36 questions measuringfunctional health and well being in 8 domains including Phys-ical Functioning, Role Functioning, Bodily Pain, GeneralHealth, Vitality, Social Functioning, Mental Health, and RoleEmotional.29 This instrument has been extensively studied, hasbeen validated in healthy adult outpatients and elderly patients,and has shown minimal floor or ceiling effects.30

SLS measures the amount of time a person can maintain SLSwithout support. Subjects were asked to stand on 2 forceplates,c1 under each foot, and to lift 1 foot whenever ready, with EO,unsupported, for up to 30 seconds. They were asked to repeatthis 3 times with each leg, and the repetition with the longesttime for each leg was chosen for analysis. The stance time wasdetermined by the vertical force from the corresponding forceplatebeing 0, with a timing resolution of .02 seconds. The SLS time isshown to correlate strongly with falls.31

Timed Up and Go measures the amount of time a personneeds to complete a well defined task. Subjects were asked tostand up from a chair, walk a 3-m distance, turn around, return,and sit down again.32 The time to complete this task wasrecorded by a digital timer with a resolution of .02 seconds.Each subject was asked to repeat this 3 times, and the repetitionwith the shortest time was used for analysis. This test has highinterrater and intrarater reliability (99%).32

Body sway in the medial-lateral direction during quiet stance isdefined as the displacement of the COP under the feet (normalizedby the width of the base of support) and is shown to be asignificant predictor for future falls in elders.33 Subjects wereasked to stand on a force platform, as still as possible, for 1 minutewith feet touching and EO, and then EC. The data from the forceplatform were collected by a personal computer with a samplingfrequency of 50Hz and were used to compute the COP in themedial-lateral and anterior-posterior directions, respectively.

Data AnalysisOutcome measures were examined to detect outliers and

other data anomalies. Group effect was tested for baseline andfor the change between pretest and posttest using 1-wayANOVA. If a significant group effect was found, pairwisecomparisons of the 3 groups were performed using the Tukeytest to adjust for multiple comparisons. Training effect wastested for each group using the paired t test. A significantdifference was set at a P value of .05. All analysis was doneusing intention to treat. Analyses were conducted using theSPSSd and SASe statistical programs.

RESULTS

Subject InformationA total of 112 subjects responded to the calls for recruitment,

94 were screened, and 64 enrolled in the study on a first-come,first-served basis. Main reasons for exclusion were health prob-lems and unwillingness to be randomized (including preferenceto one type of exercise over another, conflict with the class

Fig 1. A schematic illustra-tion of the Tele-ex set-up forthe exercise instructor andsubjects. The DocBox is alsoshown. Abbreviation: TV,television; MCU, multipointcontrol unit.

851TELE BASED TAI CHI FOR ELDERS, Wu

Arch Phys Med Rehabil Vol 91, June 2010

Instructor


GameTech 2011

Phys

ical

Cog

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Soci

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DDR

strategy, memory logic games

casual, online games

Video Games for Independent Living: An NBN Technology

ViGIL:ANT

Older adults/ people with health issues

Videogame designers/developers/publishers

Phys

ical

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A recent example

Upper limb function following stroke is a major barrier to independence


GameTech 2011

How do we build a Games for Health industry?

blah blah blah

WTF?

Health researchers

Game developers


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Market sizeThe number of people in NSW alone aged 65 and older is estimated to be just over 931,000

Every year more than 60,000 Australians have a stroke,

The cost of strokes to the Australian economy is in excess of $2 billion per annum

Distribution?

Certification?

Revenue model?


GameTech 2011

[email protected]

Thank you for hanging on till the bitter end.


mailto:[email protected]




GameTech

Health & Medicine

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