Dr Emma Stanmore, University of Manchester
User centred, OTAGO based Exergames for Falls
Prevention
• How the MIRA exergames were developed
• The clinical testing – feasibility and Cluster RCT
• Case examples• Lessons learned and next steps
Clinical perspectives
EXERGAMES
WHY?
Current system untenable with increasing incidence of falls
Robust evidence that specific strength/balance exercises
reduce falls but……..
Low uptake and adherence
Barriers to exercise – health problems, slow return, low motivation, other priorities
Need to improve access, uptake and adherence
Evidence based exergames for Falls Prevention 2012 - 2017
FUNDING
MICRACMFT
SBRI NHS England
TEAM
ACADEMICCLINICALHOUSINGAGE UK
PENNINE CARE NHS COMMERCIAL
USERS
PRE AND POST FOCUS GROUPS, INTERVIEWS
FEASIBILITY STUDY
CLUSTER RCT STUDY
Project plan
PRE DESIGN USER CENTERED DESIGN EVALUATION
- 3 PHASE PROJECT -
12 EXERGAMES
(14 exercises)
FOCUS GROUPS,
INTERVIEWSCLINIC SETTING
frequent feedback
PILOT FEASIBILITY n=24
CLUSTER RCT n=120
20 Sheltered Housing facilities in Manchester & Glasgow
TALK AND EXERGAME
DEMONSTRATIONS
QUESTIONS AND FEEDBACK
Pre-design and USD
MIRA REHAB DESIGNED SOFTWARE -- 12 GAMES, 14 EXERCISES
Liked the conceptEnjoyed the exergames
Wanted to be able to tailor to their health needs & level
Wanted exergames to be slower & simpler
Slower music or more suitable music Didn’t like the young perfect avatar!
Your
Shap
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erga
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Based on OTAGO/FaME strength & balance exercises Input from 2 Falls prevention teams (geriatrician, physios, OTs,
rehab nurse) Input from patients & healthy older people
Motivators and awardsControlled movements with balance support if needed
(chair/person)MIRA platform – captures patient stats in real time
Used with Kinect 1 and 2 Remote monitoring, online and offline use
MIRA exergames APPROVED
Patient management dashboardTracks progress and monitors real time adherenceOther validated measures: Pain levels, fatigue and
e.g. fear of falling (Short FES-I)
MIRA Platform
Time Spent % Involvement Point Tally Graph
Time spent in latest day of activity
% involvement (i.e. % of time spent in movements)
Points gathered in latest day of
activity
Graph of pts per day of
activity
Total time in all days of activity
Average % involvement across all days of activity
Total points gathered in all days of activity
MIRA is capable of tracking adherence data on:
Time spent in rehab/therapy per day of activity;Percentage of the time spend moving during each exergaming session; and
Points gathered during each exergaming session.
Parameters Tracked and Measured by the MIRA Software
- T IME S TAT I S T I C S -
Movements Attempted Parameters Graph
Squats
Sit to Stand
Hip Abduction
Side Steps
Knee Flexion
Full Body Turn
Repetition in latest day of activity
Total repetition in all days of activity
Variations of movement
Percentages of movement
Graphical display of each type of movement per days of activity
Parameters Tracked and Measured by the MIRA Software
- MOVEMENT S TAT I S T I C S -
Joints Tracked Parameters Parameters Graph
Spine
Right Ankle
Left Ankle
Right Shoulder
Left Shoulder
Right Wrist
Left Wrist
Distance moved in the joint for each day of
activity
Distance moved in the joint in all days of activity
Average joint speed for each day
Average joint speed across all days
Acceleration in the joint for each
day
Acceleration in the joint across all
days
Graphical display of variation
across days of activity
Parameters Tracked and Measured by the MIRA Software
- JO INT S TAT I S T I C S -
Used in clinic setting x2 weekly
In-depth health assessment
Demo & instruction, supervision
Goal setting and progressive
Social contact
Use projector to increase screen size
Feedback from users and therapists
Initial testing in falls prevention clinic
• Users very positive • Enjoyed the exergames, lost
track of time• Less waiting around• Therapists - data monitoring
useful• Works well in clinical
environment under supervision
• Microsoft Kinect does not like mirrors, long skirts and shorts!
• Initial demonstration to users important
• Training and ongoing support required
• Minimal set up needed • Cognitive as well as physical
assessment needed
Clinic setting - F E E D B AC K & L E S S O N S L E A R N E D -
Feasibility & Cluster RCTCLINICAL ASSESSMENT QUESTIONNAIRE
Lower limb muscle strength (TUG) & balance (Berg)
Cognition (ACE III) Medication
PMH (surgery, joint replacements, fractures &
co-morbidities)
History of falls/injuriesFRAT
Short FES-I (fear of falling)VAS pain & fatigue
Health status (EQ-5D)Vision
Usability (SUS)Physical activity (PASE)
Demographics
• Feasibility - 6 wks Exergame group vs. usual activities – 2 housing facilities (n = 24)
• Interviews, focus groups & observation • Cluster RCT - Randomised 20 sheltered housing facilities - 12 wks
Exergames + FP lnfo vs. usual activities + FP info (n = 120, Manchester & Glasgow)
What features of usual routines/activities need consideration for successful implementation?
Is it possible to recruit and retain sufficient numbers of eligible older adults for a full scale definitive trial?
How can the exergames be tailored for sheltered home use for older adults?
What are the most effective outcome measurements to detect meaningful changes resulting from the Exergame programme?
What training and support needs are required to maximise the use of the exergame technology?
Research questions
Feasibility study results(n=24)
Mean usability & acceptability scores good Mean balance, pain, fatigue, cognition & global health scores
increased, Fear of falling decreased after 6 weeks
Adherence good, lots of interest but pts frail, cognitive issues, hospital visits, holidays
Not powered for statistical significanceConclusion: Older people can safely use exergames in the
community setting with support, worth pursuing a RCT
Case examples
“I feel more fit and confident to go out”
No longer stooped and using 2 sticks to walk, went on holiday with another resident and uses
exergames independently at home
“I was skeptical at first but then I started to improve
and saw how all the other people improved”
Started driving again after 4 years, can stand to wash
up and no longer uses mobility scooter indoors
“It improved my hip and back pain and things like that. It
helps you.”
Beryl - 83 Mary - 79 Bert aged 90
Exciting, fun, competitive, challenging Initial concerns about use of technologySome familiar (grandchildren & iPads)
Good that they don’t have to go outsideCosts – who pays
Some wanted as social activity, others privacy
Unsure about use due to health issuesSome had not participated in any exercise or activities previously
Need to be flexible about useNeed reminding about sessions
Social element and fun is importantPersonal goal setting & feedback important
More motivating than conventional exercise
Could use to extend physio programme Physios want to assess & tailor the
programme only
Community setting - F E E D B AC K -
Training for users (staff and older people): amount, type,
sensory deficits
Trainer: experienced and motivated
Technical: passwords, updates, 9-5pm support, calibration, default
setting, saved programmes,
Practical: remote support, internet, cables, posture, safety, (space,
environment, lighting, clothing, footwear), game preferences, flexibility.
Group dynamics and/or individual: competition, progression, +ve/-ve
outlook.
Lessons learnt
Are the exergame programmes challenging and progressive Cost effectiveness
Rolling out – How does the system integrate into existing pathways of care and organisations
Stakeholder support & buy inEngagement with clinicians – real world use
Simplifying interfaceRemote support – internet access??
Most effective approach – public health? high risk groups?
Challenges for the future
• Co-Investigators: Prof. Chris Todd, Prof. Dawn Skelton, Dr Alex Mavroedi, Dr Lex de Jong, Prof Matt Sutton, Dr Jay Chillala (CMFT), Mr Bibhas Roy (CMFT), Ms Debra Maloney (Pennine Care), Ms Angela Easdon (Pennine Care).
• Project Assistants: Ms Wytske Meekes, Ms Victoria Bell, Ms Kelly Hagan (Physio, Pennine Care), Mrs Margaret Clarke (Patient Support Worker, CMFT), Mrs Tina Duckworth (Patient Support Worker, AGE UK Tameside).
• Clinical Trials Unit: Dr Chris Sutton, University of Central Lancashire.
Research team
Any Questions?
- therapists able to support larger numbers of patients more effectively?
Questions and opportunities
- reduction in falls, fractures, fear of falling, osteoporosis- better quality of life for patients
- more responsive service – early alerts and disease markers
- more accessible evidence based therapy – isolated areas?
Other areas - Pre/post knee/hip/ankle surgery, arthritis, stroke recovery, Parkinsons, multiple sclerosis, etc. General fitness
-