In this study, we investigated the effectiveness of a 12-week virtual reality exercise program using the Nintendo Wii console (Wii) in improving balance, emotion, and quality of life among patients with cognitive decline.
The study included 30 patients with cognitive decline (12 female, 18 male) who were randomly assigned to an experimental (n=15) and control groups (n=15). All subjects performed a traditional cognitive rehabilitation program and the experimental group performed additional three 40-minute virtual reality based video game (Wii) sessions per week for 12 weeks. The berg balance scale (BBS) was used to assess balance abilities. The short form geriatric depression scale-Korean (GDS-K) and the Korean version of quality of life-Alzheimer’s disease (KQOL-AD) scale were both used to assess life quality in patients. Statistical significance was tested within and between groups before and after treatment, using Wilcoxon signed rank and Mann-Whitney u-tests.
After 36 training sessions, there were significant beneficial effects of the virtual reality game exercise on balance (BBS), GDS-K, and KQOL-AD in the experimental group when compared to the control group. No significant difference was observed within the control group.
These findings demonstrate that a virtual reality-training program could improve the outcomes in terms of balance, depression, and quality of life in patients with cognitive decline. Long-term follow-ups and further studies of more efficient virtual reality training programs are needed.
Dementia is a degenerative disease of the nervous system, which is prevalent in the elderly population. It involves deterioration in cognitive function and ability to perform everyday activities. As the early diagnosis and treatment of dementia is delayed, its economic costs and burden on families and society are gradually increasing and becoming a social problem.1 Older people with dementia have an increased risk of falls and lower levels of everyday activities being performed due to cognitive decline and decreased muscle mass. This is a result of reduced physical activity, which further deteriorates their quality of life.2 Therapeutic interventions to improve cognitive function and to increase activities of daily living (ADL) in patients with dementia are divided into pharmacological and non-pharmacological treatments. For pharmacological treatment, acetylcholinesterase inhibitors and N-methyl-D-aspartate receptor antagonists are the most widely used in clinical practice.3 However, because pharmacological treatment alone cannot prevent the progression of cognitive decline and ADL deterioration in patients with dementia, various non-pharmacological treatments including cognitive therapy or physical exercise are used as additional treatments.4
Recent reports have stated that regular exercise was effective in delaying cognitive impairment in people with dementia.5 In a three-year follow-up study of healthy older people, a combination of cognitive activity and physical activity was found to be effective in reducing the risk for mild cognitive impairment.6 However, physical activity was found to be more important than cognitive activity in order to further reduce the risk for cognitive decline.6 When older people with dementia performed regular physical exercise, there was an improvement in the mini-mental state examination (MMSE) score.7 Physical exercise prevented the deterioration of ADL.8 The mechanism of the benefit of physical exercise on patients with dementia is thought to be that it can facilitate neuroplasticity, promote injury recovery mechanisms at a molecular level and facilitate self-healing of the brain through its neuroprotective effect.9
However, unless individuals perform exercise in the long run, such beneficial effects of exercise may wear off, leading to impaired brain function and worsened disease.10 Therefore, patients with dementia should continue exercise under the supervision of professional physical therapists in order to stop the progression of cognitive impairment for a long time. In order to achieve this, it is required to keep patients interested in the exercise therapy allowing them to maintain adherence. However, it is difficult to execute exercise treatment continuously in patients with dementia because of space, time, and cost issues in Korea. Patients get easily bored and tired of passive and simply repetitive forms of exercise treatment. In general, 20-50% of older people who start an exercise program will stop within six months.11 Patients with dementia are expected to be more likely to discontinue exercise program due to lowered levels of patience and self-regulation abilities. Therefore, exercise programs utilizing media, including games, attempt to keep patients interested in exercise programs and to improve therapeutic effects. With recent advances in scientific technologies and computer programs, exercise and rehabilitation interventions using virtual reality are being introduced in the medical field.12 Virtual reality refers to a computer-generated environment that allows users to have experiences similar to those in the real world. It is an interactive simulation characterized by technology that provides reality through various feedbacks.13 While performing predetermined tasks such as playing a game in virtual reality, users manipulate objects as if they were real and can control their movements by giving and receiving various feedbacks via numerous senses such as sight and hearing.14
The virtual reality-enhanced exercise consisting of exercise with computer-simulated environments and interactive videogame features allows patients to enjoy performing tasks, encourages competition, and creates motivation and interest in their treatment.15 Participation in a virtual reality-enhanced exercise was reported to lead to higher exercise frequency and intensity and enhanced health outcomes when compared with traditional exercise.16
However, despite these advantages, conventional virtual reality systems could not be widely available for patients in clinical settings due to several limitations including high costs and a large size.17 Therefore, it is necessary to develop virtual reality exercise programs that are easy to follow in hospitals and at home. As an alternative, the use of computer-based individual training programmes is becoming increasingly popular due to the low cost, independence and ease of use in the home. One such system that is increasing in popularity for use in exercise training is the Nintendo Wii (Wii; Nintendo Inc., Kyoto, Japan) personal game, which became commercially available. Wii is a video gaming console with a simple method, as its virtual reality system is implemented via a television monitor. It combine physical exercise with computer-simulated environments and interactive videogame features. Because the Wii console is inexpensive and small in size, it is easy to install or move it in hospitals or at home. This gaming console is designed to be controlled using a wireless controller, allowing user to interact with his/her own avatar, which is displayed on the screen through a movement sensing system. The controller is provided with an acceleration sensor that responds to acceleration changes recognizing direction and velocity changes.18 Wii-balance board is being used when playing a Wii Fit game. It is a force plate collecting movement information in the center of pressure of the standing user, enabling reflection of movements in a virtual environment on the monitor and thus constantly resending visual feedback to the user. Through this process, the user can adjust his/her postural responses. Studies have shown that the Wii balance board can be helpful in postural control training.19 Because Wii is a typical example of virtual reality applications and is simple, inexpensive, and easily accessible, Wii is expected to create interest among patients encouraging them to put more efforts in exercise via games and thus augmenting effects of the treatment.
Domestic studies on the use of Wii have reported its effects on the upper extremity function, visual perception and sense of balance in chronic stroke patients,20 spinal cord injury patients,21 Parkinson’s disease patients,22 and multiple sclerosis patients.23 However, there have been only a few controlled research studies about the effects of Wii on patients with cognitive decline. The present study aimed to analyze effects of virtual reality exercise program on balance function, emotions, and quality of life (QOL) in patients with cognitive decline.