Exergames May Improve Balance Better Than Standard Rehab

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by Steve Bryson, PhD |

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Exergames — playing video games that involve physical exercise — may be more effective at improving balance in people with multiple sclerosis (MS) than conventional rehabilitation, a review of current studies suggested.

The study, “Efficacy of Virtual Reality and Exergaming in Improving Balance in Patients With Multiple Sclerosis: A Systematic Review and Meta-Analysis,” was published in the journal Frontiers in Neurology.

Some of the most common manifestations of MS include spasticity (abnormal muscle stiffness that affects walking), fatigue, and muscle weakness, all of which contribute to significant balance problems and a risk of falling.

While conventional rehabilitation and physiotherapy programs help ease these balance difficulties, technological devices such as virtual reality (VR) have shown promise when integrated into several programs for neurological disease rehabilitation.

VR enables an enhanced interaction with an artificial environment, and allows for multisensorial feedback training that may make rehabilitation more effective.

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To complement virtual reality, patients can also engage in exergames.

“Commercially available exergames (e.g., Nintendo Wii and Microsoft Kinect) have successfully transformed living rooms into playful training environments for about 10 years,” the researchers wrote, adding that active video gaming may reduce the boredom associated with rehabilitation, increase motivation, and provide direct feedback.

While clinical and home trials have investigated the impact of exergames and VR on balance and gait in people with MS, results have been inconsistent.

For this reason, researchers at several academic sites in Italy conducted a systematic review and meta-analysis of recently published studies evaluating the efficacy of VR and exergames on balance in MS patients. They compared the findings to conventional rehabilitation approaches.

Researchers searched for studies in adults with MS that compared VR and/or exergames to conventional rehabilitation, and that assessed changes in balance using the Berg Balance Scale (BBS), a widely used test of static and dynamic balance.

Seven randomized controlled trials, published from 2013 to 2020, were selected for this analysis. Four were conducted in European countries, and the other three in Iran, Israel and Jordan.

The trials enrolled 209 MS patients in total, with 97 assigned to VR or exergaming as part of their balance training, and 112 to conventional balance training as a control group. Their mean age ranged from 34.9 to 48.3 years.

Among the five trials that examined the impact of exergames, three showed significant improvements in BBS scores among patients in the exergame group compared with the control group.

Although the other two trials found patients’ balance improved after both exergames and conventional balance training, the differences in BBS scores between the two groups in these studies were not statistically significant, meaning the difference could be random chance.

One of the two trials investigating VR reported a significant improvement in BBS scores in patients using the VR approach compared with the control group. The other study reported a non-statistically significant difference between groups after their assigned programs.

A pooled analysis of all studies — called a meta-analysis — demonstrated a significant benefit for exergames and VR in improving balance. However, a subgroup analysis indicated that only exergaming had a significant effect on balance.

Assessments of biases that may affect study outcomes showed low publication bias — the tendency to publish studies with significant results. There was also low selection bias in six selected studies, indicating the proper randomization of study participants.

Five studies excluded performance bias, suggesting that some of their participants did not receive more attention than others during balance training. Six studies guaranteed that the outcomes were assessed by someone other than its investigators (a blinded study), and six adequately examined attrition bias — in which some participants may have discontinued the study.

“Taken together, these findings suggested that balance rehabilitation using exergames appears to be more effective than conventional rehabilitation in patients affected by MS,” the researchers wrote.

“Our systematic review considered only a small number of [randomized clinical trials] due to the limited evidence available in the literature,” they continued, adding that “further high-quality studies investigating exergames and VR effects in improving balance in patients with MS compared with conventional rehabilitation treatment are still warranted.”

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