The aim of this study was to investigate the effects of exergaming comparing GestureTek’s Interactive Rehabilitation and Exercise System (IREX™) [32] with traditional gym-based exercise, with no virtual stimuli (TGB), for older people with chronic musculoskeletal pain on the sensory, emotional and motivational dimensions of pain, pain intensity, postural control, technology acceptance and Flow State experience.
Before considering any comparison, of any outcome measures, between groups (TGB versus exergaming) it is essential to consider if the physical demands on participants, in each group, were matched, or not. To facilitate this, we recorded both objective and subjective measures of physiological demand.
There were no significant differences, between the groups, in either objective (% of APMHR), or subjective (RPE and SMEQ) measures of the physiological demand of exercising. Therefore, the premise is supported that the exercises were successfully matched and hence any differences, between the groups, could be attributed, with some confidence, to the different modes of exercise they undertook.
It is also important to consider if the intensity and load of the exercise was sufficient to meet current recommendations - and - if it changed over the intervention period. HR did not alter significantly, for either group over the intervention period; being stable and similar, for both groups, at 77% of APMHR. This places exercise intensity, in both groups, (just) within the Vigorous classification (77–95% of HR Max) of the ACSM [51]. Both RPE and SMEQ increased over the intervention period in both groups. The increases in SMEQ were significant in both groups. RPE increased significantly in the TGB group and the increase in the IREX® group was approaching significance (at p < 0.10). These significant increases over time in perceived physical exertion and expended subjective mental effort in both groups suggest that our participants invested more physical effort and concentration into their respective exercise sessions as they progressed. Barry et al. [39], however, reported significantly lower post-intervention physical exertion scores in their study comparing Xbox Kinect™ with traditional gym-based exercise in healthy younger active adults. Their findings suggested that their exergaming group perceived the Xbox Kinect™ to be less physically demanding and of lower intensity compared to traditional gym-based exercise.
Participants’ RPE levels, both before and after the intervention, while increased, remained associated with light exercise (at approximately 10). Therefore, while our participants rated their exertion levels higher after the exercise period, they remained underrated, compared to normative values and expectations for RPE. In essence while both groups were, objectively, exercising at a high aerobic physiological demand, which did not alter (as reflected by % of APMHR), participants felt the exercise was somewhat easier than that throughout the intervention period, in both groups. Despite increasing over the intervention period, perceived exertion remained below levels normally associated with vigorous exercise (RPE 14–17) [51]. This would be encouraging for the likely efficacy of both forms of exercise, as working harder (objectively), when exercising, than it feels, can be beneficial.
Pain
In our study, participants reported pain intensity, at the end of the intervention, was reduced in both groups. The reduction was significantly greater, however, in those in the exergaming group. This broadly echoes the existing (limited) body of previous evidence; despite evidence of therapeutic benefits from exergaming [21, 24, 52], published studies on the effects of exergaming on pain are varied and inconsistent [53]. Many suggest an association between exergaming and pain reduction [54] but few previous studies have reported significant changes in pain after exergaming [54, 55]. Kim et al. [56] found significant improvements in the Oswestry low-back pain disability index (ODI) scores amongst middle-aged women with low back pain after a three-times weekly 4-week exergaming intervention using Wii Fit Yoga. Sobral Monteiro-Junior et al. [54] found significant reductions in chronic low back pain amongst older women after a three-times weekly 8-week using both exergaming and strength exercises, but failed to find an intervention effect.
We are the first to use the MAPS questionnaire across exergaming and standard exercise. In terms of the multidimensional aspects of pain, we observed significant improvement in thermal pain (pain related to heat sensations) and feelings of physical engagement (active, vigorous) in the exergaming group. This suggests that exergaming alleviated these particular aspects of pain experience. Significant improvements in depressed mood and affiliative feelings also were observed in our exergaming group. The TGB group also showed improvements in depressed mood over time; the reduction was significantly higher in the exergaming group. Therefore, meaningful increases occurred in our participants’ feelings of being active and vigorous and benefits in emotional well-being after exergaming. Again, these findings accord with the premise that exergaming may induce positive mood states in users [57, 58].
It would seem logical to consider that the virtual-reality aspect of exergaming may alter pain perception to some extent through active distraction [59, 60]. It would also seem logical to speculate that the distraction and consequent improvement in pain perception, with exergaming, may encourage people who do not exercise, to take it up, or, those who do exercise, to exercise more.
Postural control
While decreases occurred, in all postural control variables, under the eyes open Condition, in both groups, over the intervention period (with the sole exception of CoP Velocity - which increased in the TGB group), these changes (bar the increase in CoP Velocity in the TGB group) were positive, in that they indicated improved postural control (reduced sway). There were no significant between-group effects observed under either condition (eyes open or closed). In our study, we did not find significant post-intervention differences between the exergaming and standard exercise groups for either condition (eyes open, or closed). The across-the-board improvement in postural control (and hence balance) observed here, is similar to that reported by Sobral Monteiro-Junior et al. [54] and Bisson et al. [61].
While all bar one of the balance measures decreased over time in both groups, with eyes open and closed, statistically significant reductions over time were observed on ML SD, AP SD and the CoP excursion in the anterior-posterior and medio-lateral direction in the exergaming group with vision, indicating better postural control. These improvements in balance measures are suggestive of benefit from exergaming, as was reported by Barry et al. [39]. They found significant improvements over time in ML SD, ML range and CoP velocity in healthy adults who had participated in a three-times weekly exergaming intervention for four weeks. Our findings are also consistent with those of Whyatt et al. [62] who found significant increases in Berg Balance Scale (BBS) scores, higher balance confidence and increased performance in levels of CoP displacement in the anterior, right and left CoP test locations after exergaming.
We also found significant reductions over time in the CoP excursion in the medio-lateral direction for the TGB group, under eyes closed condition, similar to those of Nicholson et al. [63], who reported significant reductions in the medio-lateral CoP range in older people following twelve weeks of balance training. ML postural sway is associated more with fall risks in older people compared to AP postural sway [64]. It is accepted that any effect of exercise, on balance, is likely to be more apparent when the balance task is performed under eyes closed condition [65]. When the eyes are closed, balance relies on solely on efferent neuromuscular and sensorimotor input [66], which can be improved with exercise [67].
Our findings reinforce the premise that exercise, of many types, has the potential to improve balance in older people if performed safely. There were no adverse events or reactions in our study and both forms of exercise appeared to yield some benefit. We did not explore the postural control mechanisms affected, nor observe anything other than a trend to greater benefit from exergaming. It would appear, though that exercising using exergames can potentially contribute to improving balance and reducing fall risks in older people with chronic musculoskeletal pain [65].
Technology acceptance
Our results showed that all UTAUT scores increased in both groups but significant increase occurred only in social influence and behavioural intention in the TGB group. The increase in all UTAUT scores indicates high acceptance for both forms of exercise and favourable response from participants in both groups. This could be due to several factors. Firstly, the affective state of a user plays an important role in their acceptance of a new activity or technology [68]. How users feel when they perform the exercises determines their appraisal of the exercise and whether they would continue with it [69]. Kwan and Bryan [70] found that affective response influenced exercise behaviour, particularly intention to exercise. In the case of exergaming, Billis et al. [71] found that game content in exergames adapted according to older people’s affective states would influence their acceptance of exergaming. Secondly, if older people found the type of exercise to be both useful and easy to follow, they were more likely to express intention to continue the activity [72]. Thirdly, verbal or non-verbal social behaviour nurtures change in any particular behaviour [73, 74]. This would include encouragement, feedback or supervision and even the mere presence of the researcher during the sessions [75].
The higher scores observed in effort expectancy in the TGB group may arise from the absence of any active distraction (the activity did not involve interaction with an external source). The standard exercise routine comprised planned and structured repetitive physical movements [76]. Therefore, the participants were exercising with themselves instead of having to engage with visual or auditory stimuli (as in exergaming). While this could have made mastering the movements initially easier, the absence of distraction may not encourage concordance over the longer term.
We also observed that the change in behavioural intention was larger in the exergaming group although it did not reach significance. It may be that the group experienced positive affect and engagement during exergaming, which could have brought on the larger increase in behavioural intention [77].
Flow
We found significant between-group differences in the concentration aspect of flow state, favouring the TGB group. Two other dimensions, autotelic experience, and paradox of control approached significance, also favouring the TGB group of standard exercise. While our results showed a trend of increased scores in all flow dimensions from baseline to the end of the intervention, significance increases over time were achieved in eight of the nine dimensions of flow state in both groups, except transformation of time, supporting the notion of the flow phenomenon in sport [78, 79].
Regarding the observation on the significant increase in transformation of time for the exergaming group, similar results have been reported in previous studies [26, 39]. This suggests that the immersive environment during exergaming can facilitate distortion of time amongst users. Distortion of time during exercise implies that users experience deep involvement when exercising and become fully invested in the exercise experience [80]. The largest effect size was observed in the significant increase in unambiguous feedback in the exergaming group suggests that the exergaming group received more direct and immediate feedback when exercising in an immersive environment compared to performing standard exercises. This feedback is akin to successes and failures during exergame play, so that a clear idea and continuity of feedback is provided for the next action [81].
Limitations
We acknowledge that our results are based on a limited number of participants and may lack sufficient power to provide fully definitive results from some of the compared outcomes. As this research was conducted as part of the completion of a PhD, it was also restricted by staffing, time and funding. For practical reasons, neither the researcher nor the participants were blind to the conditions being tested. In future, this research would benefit from further verification from a larger sample.