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Modelo - EXG
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Article history: Introduction: Exercise through video or virtual reality games (i.e. exergames) has grown in popularity
Received 6 June 2018 among older adults; however, there is limited evidence on efficacy of exergaming on well-being related to
Received in revised form 23 January 2019 health in this population. This systematic review examined the effectiveness of exergaming on health-
Accepted 24 January 2019
related quality of life in older adults.
Methods: PRISMA guidelines for this systematic review. Several databases were searched using keywords
Keywords: to identify peer-reviewed journal articles in English. Randomized control trials that evaluated the effect
Aged
of exergaming on health-related quality of life in older adults when compared to a control group and
Exergaming
Exercise health
published between January 2007 to May 2017 were included.
Quality of life Results: Nine articles that in total included 614 older adults with varying levels of disability, mean age
Virtual reality 73.6 + 7.9 years old, and 67% female were analyzed. Significant improvements in health-related quality of
Well-being life of older adults engaged in exergaming were reported in three studies. Sample sizes were small in 7 of
the studies (N < 60). The study participants, exergaming platforms, health-related quality of life
instruments, study settings and length, duration and frequency of exergaming varied across studies.
Conclusion: Exergaming is a new emerging form of exercise that is popular among older adults. However,
findings from this analysis were not strong enough to warrant recommendation due to the small sample
sizes and heterogeneity in the study participants, exergaming platforms, health-related quality of life
instruments, length, duration and frequency of the intervention and study settings. Further research is
needed with larger sample sizes and less heterogeneity to adequately explore the true effects of
exergaming on health-related quality of life of older adults.
© 2019 Elsevier Ltd. All rights reserved.
* Corresponding author.
E-mail address: cacciatm@uci.edu (M. Cacciata).
https://doi.org/10.1016/j.ijnurstu.2019.01.010
0020-7489/© 2019 Elsevier Ltd. All rights reserved.
M. Cacciata et al. / International Journal of Nursing Studies 93 (2019) 30–40 31
unclear or high risk across 7 categories: random sequence (Morone et al., 2016), and Denmark (Smaerup et al., 2016). The 9
generation, allocation concealment, blinding of participants and studies provided a total of 614 participants, 309 in the intervention
personnel, blinding of outcome assessor, incomplete outcome group and 305 in the control group. Varying health-status were
data, selective outcome reporting and a category of “other bias”. noted among study participants including healthy and ambulatory
(Franco et al., 2012; Padala et al., 2017; Karahan et al., 2015),
3. Results Alzheimer’s disease (Padala et al., 2012), and with functional
impairments, such as stroke (Adie et al., 2017), gait instability
3.1. Search result (Haines et al., 2009), vestibular dysfunction (Smaerup et al., 2016),
bone loss condition affecting balance (Morone et al., 2016) and
A flow diagram (Fig. 1) for study selection outlined the steps in semi-ambulatory post hospital discharges (Laver et al., 2012). Both
choosing the articles. The search generated 213 citations, for which genders were included, with a higher proportion of women in the
61 articles were fully assessed for eligibility and 9 studies were majority of the studies (67%); one study was exclusively female
selected for the final review and analysis. Because of the (Morone et al., 2016). The participants’ mean age was 73.6 + 7.9
heterogeneity of the publications, exergaming devices and instru- years old years old. The comparison or control groups were
ments used to measure outcomes, a meta-analysis is not feasible. allocated to no intervention (Franco et al., 2012; Haines et al.,
2009), tailored arm exercise + usual rehabilitation therapy (Adie
3.2. Study characteristics et al., 2017), home-based balance exercise (Karahan et al., 2015),
walking (Padala et al., 2012), conventional therapy (Laver et al.,
The studies were conducted worldwide, with three from the U. 2012), standard of care (Morone et al., 2016), cognitive program
S. (Franco et al., 2012; Padala et al., 2012,2017), two from Australia (Padala et al., 2017) and printed instructions (Smaerup et al., 2016).
(Haines et al., 2009; Laver et al., 2012), one each from the United All studies included in this review were reviewed and approved by
Kingdom (Adie et al., 2017), Turkey (Karahan et al., 2015), Italy the appropriate Institutional Review Board.
3.3. Quality assessment and bias et al., 2016; Franco et al., 2012; Padala et al., 2017) and two studies
for use of participant self-reports (Haines et al., 2009; Adie et al.,
Overall, studies varied across bias domain (see Table 1 and Fig. 2). 2017). Two studies were assessed for other risk of bias: 1) one
All studies were assessed as low risk for random sequence generation study lacked blinding after enrollment (Laver et al., 2012) that may
bias utilizing computerized random number generator, random resulted in prediction of future allocations, hence threatening
permuted blocks and randomization through coin flipping for patient assignment, and 2) a threat to validity related to a
participant’s study selection. Likewise, all but three studies participant’s confusion in completing the quality of life survey
described allocation concealment (Franco et al., 2012; Padala questionnaire and following the Wii Fit instructions due to
et al., 2012; Karahan et al., 2015). Random sequence and allocation language barrier, thus, inaccurate data affected study outcomes
concealment prevent foreknowledge of the forthcoming allocation; (Franco et al., 2012).
these are important factors in study reliability and validity (Higgins All studies lacked adequate information to assess for reporting
and Green, 2011). Blinding of participants and personnel was bias using the criteria established by Higgins et al. (Higgins and
somewhat challenging due to the nature of the intervention, Green, 2011) except for one study that was deemed high risk
however, outcome assessors were blinded in four studies (Smaerup (Karahan et al., 2015) for excluding the attrition rate in the final
et al., 2016; Haines et al., 2009; Laver et al., 2012; Adie et al., 2017). analysis. Overall, these biases influenced generalizability and
Majority of the studies were assessed as low risk for attrition publication bias.
bias due to participants’ dropout rate of less than 20% (Smaerup
et al., 2016; Padala et al., 2012; Haines et al., 2009; Laver et al., 3.4. Description of exergaming
2012; Adie et al., 2017; Karahan et al., 2015), or a sensitivity
analysis was conducted to investigate bias due to missing data for The Nintendo Wii Fit games comprised soccer heading, ski
subjects dropped out (Padala et al., 2017), and the use of intention jumping, ski slalom, tightrope, table tilt, strength training, yoga,
to treat analysis (Padala et al., 2012, 2017; Laver et al., 2012). table tilt, tilt city, penguin slide, soccer heading, basic run, obstacle
Common reasons for dropouts include illness, losing interest, lack course, basic step and balance games. These games required
of transportation, lack of time to complete sessions, patient participants to use their arms or body motions to simulate actions
deterioration and death. These reasons were similar across the performed in real sports. The Nintendo Wii Balance requires a
studies. Furthermore, high risk for detection bias were assessed in balance board where participants used certain body parts to
four studies for not blinding the outcomes assessors (Smaerup simulate actions. The Nintendo Wii Sports included bowling,
Table 1
Bias Risk Assessment within Studies following the Cochrane Handbook methodology.
Citation Random Allocation Blinding of participants, Incomplete Blinding of participant, Selective Other
sequence concealment personnel and outcomes Outcome personnel and outcome Reporting potential
generation (selection assessor (performance Data (attrition assessors (detection bias) (reporting threats to
(selection bias) bias) bias) bias) bias) validity
(Adie et al., 2017) ❍ ❍ ❍ ❍ ✢ ? ❍
(Franco et al., 2012) ❍ ? ✢ ✢ ✢ ? ✢
(Haines et al., 2009) ❍ ❍ ❍ ❍ ✢ ? ❍
(Karahan et al., 2015) ❍ ? ? ❍ ? ✢ ❍
(Laver et al., 2012) ❍ ❍ ❍ ❍ ❍ ? ✢
(Morone et al., 2016) ❍ ❍ ? ? ? ? ❍
(Padala et al., 2012) ❍ ? ✢ ❍ ✢ ? ❍
(Padala et al., 2017) ❍ ? ✢ ❍ ✢ ? ❍
(Smaerup et al., 2016) ❍ ? ❍ ❍ ✢ ? ❍
Citation, Design/Setting Sample size; % Participants Type of Intervention and Comparative Frequency and Adherence Dropouts Quality Findings
Country Female; age (years) Physical Mobility Format Duration of Life
(SD) Measures
(Adie Randomized N = 235 Stroke patients Arm exercise Tailored arm exercise Every day for 45 Exercise adherence I = 6 (5%) SIS, No significant improvement in I
et al., Control Trial with arm weakness minutes group when compared to C
2017) group at 6 weeks and 6 months
follow up
United Multicenter I = 117; C = 118 6 weeks I = 82% C = 9 (7%) EQ-5D 3L
Kingdom
Two groups Female Wii Sports C = 71% Lost to
follow
up = 6
(3%)
Home-based I = 51%; C = 53% Games: bowling, tennis, 6 months follow
35
36
Table 2 (Continued)
Citation, Design/Setting Sample size; % Participants Type of Intervention and Comparative Frequency and Adherence Dropouts Quality Findings
Country Female; age (years) Physical Mobility Format Duration of Life
(SD) Measures
(Padala Randomized N = 22 Older adults with Balance and gait exercise Walking 30 min/day, 5 Exercise time 11.5 (+ I = 1 (9%) QOL-AD No significant difference in the I
et al., Control Trial mild Alzheimer days /week 3.5) hours - 37% group but significant difference
2012) Pilot in the C group (p = .03)
United Two groups I = 11; C = 11 8 weeks C = 1 (9%)
States
Assisted living Female Uses cane or Wii Fit
facility walkers for
ambulation
I = 73%; C = 73% Games: strength training, No follow up
yoga and balance games post
intervention
Mean age
I = Intervention; C = Control (PPT); SIS = Stroke Impact Scale; EQ5D = EuroQol 5 Dimensions; SF = Short Form; QOL-AD = Quality of Life - Alzheimer's Disease.
M. Cacciata et al. / International Journal of Nursing Studies 93 (2019) 30–40 37
tennis, boxing, golf and baseball games (Adie et al., 2017). The posttest at six weeks after playing the Xbox 360Kinect when
Microsoft Xbox 360Kinect included Kinect adventures, Kinect compared to the control group using home-based balance exercise
sports and Kinect sports season (i.e. football, tennis, table tennis, regime (Karahan et al., 2015). Non-commercial video-based device,
skiing, golf, volleyball and bowling) (Karahan et al., 2015). Kitchen Table Exercise Program was not significant (Euroqol 5D)
The non-commercial, video-based devices were the low among older adults with gait instability at 6 months follow up
technology "Kitchen Table Exercise Program," and “Move It to when compared to the control group (i.e. no intervention) (Haines
Improve It (Mitti). The "Kitchen Table Exercise Program" involved et al., 2009). Likewise, the Mitti program had no significant impact
a video based Digital Video Device and workbook with six types of on the quality of life in older adults with vestibular dysfunction
exercises each with different levels of difficulty that challenged after 12 weeks of intervention versus the control group using
both muscle strength and standing balance (Haines et al., 2009). printed instructions (Smaerup et al., 2016). Studies that showed
In the Mitti program, participants watched and followed move- statistical significance involved healthy participants with high
ments shown in the video. The program included drag-and-drop adherence to exergaming and conducted in a center-based setting.
and follow- the- leader games where the participants manipu- Exergaming was less effective in improving health-related quality
lated the virtual object on the video screen by grabbing and of life among participants with disabilities, low adherence and
dragging to different locations or to another virtual object exergaming at home. Five studies reported no intervention related
(Smaerup et al., 2016). adverse events (Padala et al., 2012; Adie et al., 2017); four studies
did not report adverse events (Smaerup et al., 2016; Franco et al.,
3.5. Frequency, duration and adherence to exergaming 2012; Karahan et al., 2015; Morone et al., 2016).
The majority of the randomized control trials were pilot or The three studies that showed statistical significance in health-
feasibility studies. Therefore, generalizability was compromised related quality of life reported high to 100% adherence rate with
and at least in one study, it was not a priori powered to address all interventions conducted at rehabilitation clinics and outpatient
outcomes (Padala et al., 2017). Another factor that may have clinics (Padala et al., 2017; Karahan et al., 2015; Morone et al.,
contributed to inconsistent findings in health-related quality of life 2016). These findings suggest that adherence is an important factor
outcome was the variability in the length, frequency and duration in improving exercise regimen and may result in increased physical
of the interventions. The shortest intervention was three weeks function and health-related quality of life. Notably, study settings
and the longest was 12 weeks. The prescribed frequency ranged may have influence on exercise adherence. Settings such as
from two to seven days a week and for 20–100 min per session. The rehabilitation centers and outpatient clinics have clinicians and
Global Recommendations directive on Physical Activity for Health other staff available to provide support and guidance. Also,
(WHO, 2010) recommended that older adults engage in moderate exercising with other individuals provide social support, interac-
aerobics physical activity for at least 150 min or at least 75 min of tion and connectedness (Agmon et al., 2011), that may result in an
vigorous aerobic exercise over a course of a week. However, with increased motivation to exercise, thus improving adherence.
exergaming or video based interactive exercise games, there have Therefore, these findings call for the question of why other
been no established guidelines with intervention times needed for forms of exercise have positive impact on older adults health-
functional or physical improvement (Molina et al., 2014). Increased related quality of life but not exergaming? A systematic review that
functional and physical capacities have been associated with reported on other types of exercise with positive impact on health-
improved health-related quality of life in older adults (Tavares related quality of life included strength training, tai chi, combined
et al., 2014; Ostman et al., 2017). exercise (strength, aerobic, balance and flexibility) but in
Most importantly, findings from the studies demonstrated varying individuals with depression (Tavares et al., 2014). Likewise, a
degrees of adherence to exergaming in the interventions group. The systematic review on aerobic exercise and resistance training with
variability in adherence may result in inconsistent or non-significant varying intensities in patients with heart failure also showed
findings. Adherence to exergaming is important as it affects study positive effect on health-related quality of life (Ostman et al., 2017).
outcomes. The three studies that showed statistical significance in Another study that reported a positive effect of exercise on health-
health-related quality of life reported high to 100% adherence rate related quality of life among patients with heart failure involved
even though the dose and frequency of exergaming differed. exercise intensity; greater improvement in exercise capacity and
However, exergaming sessions were conducted at rehabilitation intensity is strongly associated with increased health-related
centers and outpatient clinic. Indeed, study settings or exercise quality of life (Evangelista et al., 2017). Both systematic reviews
venues may be an important factor in determining exercise and the study conducted by Evangelista and colleagues (Evangel-
adherence. In this review, exergaming sessions were held in different ista et al., 2017) reported that moderate to high intensity exercise is
settings: rehabilitation centers, outpatient clinics, senior housing and associated with improved health-related quality of life in older
assisted living facilities, and at participants home. Findings from these adults. In this systematic review, exergaming intensity was not
studies demonstrated that adherence to the prescribed time, length evaluated suggesting the need to explore and evaluate exergaming
and duration of exergaming were high in the rehabilitation centers intensity in order to determine the impact of this intervention on
and the outpatient clinic and lowest in home-based setting. One can health-related quality of life.
ascertain that the high adherence rate in the rehabilitation centers
and clinics can be attributed to the interventionist or clinicians on site 4.1. Strength and limitations
where assistance and support were readily available. These findings
also suggest that exergaming is more efficient in group activities such The major strength of this systematic review is the use of
as those occurring at rehabilitation centers where individuals PRISMA guidelines (i.e., comprehensive search strategy including
exercise with other people. This may result in social interaction hand searching and checking reference lists, duplicate and
and connectedness, a motivating factor to engage in exercise independent screening, methodological data extraction and
(Klompstra et al., 2014). In contrast, home-based exercise had the quality assessment). Next, only randomized control trials were
lowest adherence rate. This may be due to participants’ lack of included in the analysis using validated instruments to measure
motivation to engage in exercise regimen or lack of support from outcomes. Although this review chose only randomized control
family members. Exergaming provide opportunities for social trials, the studies included in the analysis presented methodologi-
interactions and connectedness with family members and peers cal limitations; these limitations pose biases in generating
(Agmon et al., 2011), however, for those individuals with no family evidence regarding the efficacy of intervention with exergaming.
members, social support, or lacking motivation, adherence to home- One of the limitations is the relatively small sample size in most
based exergaming program may not be attainable. studies. Most studies were pilot or feasibilities studies that tested
All studies used validated instruments to assess health-related the efficacy of the interventions. Studies with a small sample size
quality of life, but the instruments vary. These variations may pose are at risk of being underpowered resulting in less reliable findings.
a challenge to compare studies and draw relevant conclusions. Since health-related quality of life was the secondary outcomes, if a
Also, health-related quality of life is a complex concept that sample size calculation was performed prior to the study it was for
involves several distinctions between measures and different the primary end-point. Finding statistically significant differences
dimensions (Kaplan and Ries, 2007). As mentioned earlier, health- using a generic health-related quality of life instrument often
related quality of life was measured using both generic and disease required larger sample sizes than most studies provided in this
specific instruments. One can argue that it is justified to include review. Also, health-related quality of life was measured using
studies with different assessment procedure for health-related different instruments and the heterogeneity in measurement tools
quality of life, however, it should be noted that the heterogeneity would make it challenging to do a meta-analysis. Due to the nature
may restrict the degree to which studies can be compared. In of the healthcare intervention, blinding participants and inter-
addition, multiple distinctions between instruments and the ventionist were not feasible leading to performance bias. However,
evaluation of different health dimensions to produce a single blinding of assessors was used in six studies. Most significantly, the
expression of health status makes health-related quality of life clinical heterogeneity of the studies included in this analysis
difficult to measure because different health problems are not of revealed diversity in study population, exergaming devices,
equal concern for different people (Kaplan and Ries, 2007). outcomes measure, outcomes instruments, study settings, and
M. Cacciata et al. / International Journal of Nursing Studies 93 (2019) 30–40 39
dose, frequency and duration of the interventions. Such limitations determine if exergaming is an effective health care intervention
pose challenges in drawing relevant conclusion for exergaming as to improve health-related quality of life in older adults.
an effective intervention to improve health-related quality of life in Furthermore, interventions were conducted in heterogeneous
older adult. Finally, the review was limited to studies in the past 10 patient population, exergaming devices, frequency, duration and
years. A search was conducted prior to 2007 for randomized length of the intervention, and study settings. Such factors do not
control trial studies on exergaming and health-related quality of allow for definitive conclusions to be made on the use of
life among older adults but unable to find articles that met criteria exergaming for improving health-related quality of life in this
for this systematic review. Studies not referenced in PubMed, patient population. Further research is needed with larger sample
CINAHL, Web of Science, PsychInfo or Cochrane and unpublished size and less heterogeneity in design and measurements to
studies were not identified; thus, this study is subject to explore the true effects of exergaming on the health-related
publication bias. quality of life in this patient population.
This systematic review appraised randomized control trials The authors declare that there is no conflict of interest.
that evaluate the effect of exergaming on health-related quality of
life in older adults. Of the 219 articles retrieved, 9 articles were Funding
reviewed in the final analysis after meeting the inclusion criteria.
At present, participants with high adherence to exergaming and None.
those in a center-based setting appear to have the most promising
effect. Overall, the evidence was not sufficiently strong to Appendix A
40 M. Cacciata et al. / International Journal of Nursing Studies 93 (2019) 30–40
References Ling, Z., Robyn, G., Lis, N., 2014. Health-related quality of life in atrial fibrillation
patients over 65 years: a review. Eur. J. Prev. Cardiol. 22 (8), 987–1002.
Addington-Hall, J., Kalra, L., 2001. Who should measure quality of life? BMJ 322 Mazzoleni, S., Montagnani, G., Vagheggini, G., et al., 2014. Interactive videogame as
(7299), 1417–1420. rehabilitation tool of patients with chronic respiratory diseases: preliminary
Adie, K., Schofield, C., Berrow, M., et al., 2017. Does the use of Nintendo Wii Sports results of a feasibility study. Respir. Med. 108 (10), 1516–1524.
(TM) improve arm function? Trial of Wii(TM) in Stroke: a randomized Molina, K.I., Ricci, N.A., de Moraes, S.A., Perracini, M.R., 2014. Virtual reality using
controlled trial and economics analysis. Clin. Rehabil. 31 (2), 173–185. games for improving physical functioning in older adults: a systematic review. J.
Agmon, M., Perry, C.K., Phelan, E., Demiris, G., Nguyen, H.Q., 2011. A pilot study of Neuroeng. Rehabil. 11, 156.
Wii Fit exergames to improve balance in older adults. J. Geriatr. Phys. Ther. 34 Mora, J.C., Valencia, W.M., 2018. Exercise and older adults. Clin. Geriatr. Med. 34 (1),
(4), 161–167. 145–162.
Anderson-Hanley, C., Snyder, A.L., Nimon, J.P., Arciero, P.J., 2011. Social facilitation in Morone, G., Paolucci, T., Luziatelli, S., et al., 2016. Wii Fit is effective in women with
virtual reality-enhanced exercise: competitiveness moderates exercise effort of bone loss condition associated with balance disorders: a randomized controlled
older adults. Clin. Interv. Aging 6, 275–280. trial. Aging Clin. Exp. Res. 28 (6), 1187–1193.
Bize, R., Johnson, J.A., Plotnikoff, R.C., 2007. Physical activity level and health-related Murphy, R.A., Patel, K.V., Kritchevsky, S.B., et al., 2014. Weight change, body
quality of life in the general adult population: a systematic review. Prev. Med. 45 composition, and risk of mobility disability and mortality in older adults: a
(6), 401–415. population-based cohort study. J. Am. Geriatr. Soc. 62 (8), 1476–1483.
Bocalini, D., dos, S.L., Serra, A., 2008. Physical exercise improves the functional Nelson, M.E., Rejeski, W.J., Blair, S.N., Duncan, P.W., Judge, J.O., King, A.C., Macera, C.
capacity and quality of life in patients with heart failureClinics (Sao Paulo, A., Castaneda-Sceppa, C., 2007. Physical activity and public health in older
Brazil) 63 (4), 437–442. . (Accessed 31 May 2017) http://onlinelibrary.wiley. adults. Recommendation from the american college of sports medicine and the
com/o/cochrane/clcentral/articles/503/CN-00700503/frame.html. american heart association. Med. Sci. Sports Exerc. 116 (9), 1094–1105.
Dang, M.T., 2010. Walking away the blues: exercise for depression in older adults. Ostman, C., Jewiss, D., Smart, N.A., 2017. The effect of exercise training intensity on
Nursing 40 (11), 33–36. quality of life in heart failure patients: a systematic review and meta-analysis.
Erickson, K.I., Voss, M.W., Prakash, R.S., et al., 2011. Exercise training increases size of Cardiology 136 (2), 79–89.
hippocampus and improves memory. Proc. Natl. Acad. Sci. U. S. A. 108 (7), 3017– Padala, K.P., Padala, P.R., Malloy, T.R., et al., 2012. Wii-fit for improving gait and
3022. balance in an assisted living facility: a pilot study. J. Aging Res. 2012, 597573.
Evangelista, L.S., Cacciata, M., Stromberg, A., Dracup, K., 2017. Dose-response Padala, K.P., Padala, P.R., Lensing, S.Y., et al., 2017. Efficacy of wii-fit on static and
relationship between exercise intensity, Mood States, and quality of life in dynamic balance in community dwelling older veterans: a randomized
patients with heart failure. J. Cardiovasc. Nurs. 32 (6), 530–537. controlled pilot trial. J. Aging Res. 2017, 4653635.
Franco, J.R., Jacobs, K., Inzerillo, C., Kluzik, J., 2012. The effect of the Nintendo Wii Fit Peng, W., Lin, J.H., Crouse, J., 2011. Is playing exergames really exercising? A meta-
and exercise in improving balance and quality of life in community dwelling analysis of energy expenditure in active video games. Cyberpsychol. Behav. Soc.
elders. Technol. Health Care 20 (2), 95–115. Netw. 14 (11), 681–688.
Franklin, N.C., 2015. Technology to promote and increase physical activity in heart Primack, B.A., Carroll, M.V., McNamara, M., et al., 2012. Role of video games in
failure. Heart Fail. Clin. 11 (1), 173–182. improving health-related outcomes: a systematic review. Am. J. Prev. Med. 42
Haines, T.P., Russell, T., Brauer, S.G., et al., 2009. Effectiveness of a video-based (6), 630–638.
exercise programme to reduce falls and improve health-related quality of life Pynoos, J., Cicero, C., Caraviello, R., 2008. Aging in place, housing, and the law. Elder
among older adults discharged from hospital: a pilot randomized controlled Law J. 16, 77–105.
trial. Clin. Rehabil. 23 (11), 973–985. Rumsfeld, J.S., Alexander, K.P., Goff, D.C., et al., 2013. Cardiovascular health: the
Higgins, J.P.T., Green, S., 2011. Cochrane Handbook for Systematic Reviews of importance of measuring patient-reported health status. A scientific statement
Interventions. Wiley. from the American Heart Association. Circulation 127 (22), 2233–2249.
Kaplan, R.M., Ries, A.L., 2007. Quality of life: concept and definition. COPD 4 (3), Skjaeret, N., Nawaz, A., Morat, T., Schoene, D., Helbostad, J.L., Vereijken, B., 2016.
263–271. Exercise and rehabilitation delivered through exergames in older adults: an
Karahan, A.Y., Tok, F., Taskin, H., Kucuksarac, S., Basaran, A., Yildirim, P., 2015. Effects integrative review of technologies, safety and efficacy. Int. J. Med. Inform. 85 (1),
of exergames on balance, functional mobility, and quality of life of geriatrics 1–16.
versus home exercise programme: randomized controlled study. Cent. Eur. J. Smaerup, M., Laessoe, U., Gronvall, E., Henriksen, J.J., Damsgaard, E.M., 2016. The use
Public Health 23 (Suppl), S14–S18. of computer-assisted home exercises to preserve physical function after a
Klompstra, L., Jaarsma, T., Stromberg, A., 2014. Exergaming to increase the exercise vestibular rehabilitation program: a randomized controlled study. Rehabil. Res.
capacity and daily physical activity in heart failure patients: a pilot study. BMC Pract. 2016, 7026317.
Geriatr. 14, 9. Tavares, B.B., Moraes, H., Deslandes, A.C., Laks, J., 2014. Impact of physical exercise
Laver, K., George, S., Ratcliffe, J., et al., 2012. Use of an interactive video gaming on quality of life of older adults with depression or Alzheimer’s disease: a
program compared with conventional physiotherapy for hospitalised older systematic review. Trends Psychiatry Psychother. 36 (3), 134–139.
adults: a feasibility trial. Disabil. Rehabil. 34 (21), 1802–1808. Vaapio, S.S., Salminen, M.J., Ojanlatva, A., Kivela, S.L., 2009. Quality of life as an
Li, J., Theng, Y.L., Foo, S., 2016. Effect of exergames on depression: a systematic outcome of fall prevention interventions among the aged: a systematic review.
review and meta-analysis. Cyberpsychol. Behav. Soc. Netw. 19 (1), 34–42. Eur. J. Public Health 19 (1), 7–15.
Liberati, A., Altman, D.G., Tetzlaff, J., et al., 2009. The PRISMA statement for reporting Verheijden Klompstra, L., Jaarsma, T., Stromberg, A., 2014. Exergaming in older
systematic reviews and meta-analyses of studies that evaluate health adults: a scoping review and implementation potential for patients with heart
care interventions: explanation and elaboration. Ann. Intern. Med. 151 (4) failure. Eur. J. Cardiovasc. Nurs. 13 (5), 388–398.
W-65-W-94. WHO, 2010. Global Recommendations on Physical Activity for Health. .