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!

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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

-