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Ann Geriatr Med Res > Volume 27(1); 2023 > Article
Park and Shin: Effectiveness of an Exercise Program for Older Adults Using an Augmented Reality Exercise Platform: A Pilot Study

Abstract

Background

With the rapid progression of population aging worldwide, the health management of older adults is emerging as an important topic. To help prevent declines in physical and cognitive function due to aging, older adults must maintain consistent physical activity. The development of digital technology has recently allowed the optimization of exercise programs for older adults using augmented reality (AR) game technology.

Methods

Fifteen older adult females were enrolled in an AR-based exercise program. The program was conducted for 30 minutes, three times weekly, for a total of 6 weeks. To verify the effectiveness of the program and assess physical function before and after exercise, the following tests were performed: timed up-and-go test, five times sit-to-stand test, 1-minute sit-to-stand test, lung capacity test, respiratory muscle strength test, and bioelectrical impedance analysis. The Trail Making Test was used to evaluate cognitive function. For statistical analysis, a paired t-test was used to verify the effects on physical and cognitive function before and after exercise.

Results

The study results confirmed improved overall physical and cognitive function. The timed up-and-go test, maximal inspiratory pressure, and Trail Making Test part B scores showed significant increases.

Conclusion

This study verified the effectiveness of AR exercise in community-dwelling older adult women. In the future, exercise programs with game elements that increase the interest and motivation of participants to engage in exercise routines should be developed and applied.

INTRODUCTION

The global population is aging rapidly, with 73 million people aged 65 years or older in 2019. This figure is expected to double to 1.5 billion by 2050.1) As the older adult population increases, there is increasing interest in aging. Aging reduces physical function and activity and affects muscle strength.2) If muscle strength decreases, motor skills such as walking and balancing become difficult, thereby increasing the risk of falls.3,4) In Korea, 80.9% of older adults who visited the emergency room because of a fall reported moderate or higher degrees of physical injury that required medical intervention.5) Therefore, falls are a dangerous concern for older adults.
To prevent a decline in physical and cognitive function due to aging, older adults must maintain regular physical activity. Various exercise programs are used to increase physical activity in older adults. Studies have shown that older adults who participate in exercise programs have improved walking ability, lower-extremity muscle strength, grip strength, and cognitive function.6,7) Therefore, maintaining a high level of physical function by increasing physical activity can reduce the risk of falls in this population.8)
Various attempts have been made to improve physical function in older adults through strength, aerobic, and Pilates exercise programs geared towards this population.9,10) With progressive technological advances, exercise programs for older adults have been developed in the form of games. Among these programs, exercise routines developed using virtual reality (VR) technology can create interest and increase exercise participation in older adults.11) However, VR adaptation in older adults is severely limited by the inconvenience of wearing VR equipment on the face.
An alternative technology in game development is augmented reality (AR), which has an advantage over VR because of its ease of use in older adult populations.12) However, most existing AR-based exercise programs prompt users to exercise by capturing movements using cameras, which are then viewed on a display monitor.12) This limits the range of movement during exercise and reduces the amount of physical activity expended. Recently developed AR technology allows the exercise to be performed in a wider space because the beam is projected from the AR equipment onto the floor. This facilitates a broader range of motion and more intense physical activity through various exercises. Therefore, this study applied a recently developed exercise program using AR technology to older adult women and verified its effects on their physical and cognitive functions.

MATERIALS AND METHODS

Participants

This study included 15 community-dwelling older adult women aged 65 years or older (Table 1). The selection criteria included participants who could walk unassisted and had no problems accomplishing tasks of daily living. Participants with nervous system and musculoskeletal diseases who were unable to walk were excluded from the study. The ideal number of study participants was computed using an effect size of 0.7, an alpha error of 0.05, and a power of 0.80, according to previous studies. G*Power 3.1.9.4 was used for sample size calculation.13) The study purpose and content were explained to all participants who voluntarily consented to participate. All participants consented to the use of their exercise photographs. This study was approved by the Institutional Review Board of the Pusan National University Hospital Ethics Review Committee (IRB No. 2209-007-118) and registered with the Clinical Research Information Service on the World Health Organization International Clinical Trials Registry Platform (Clinical Research Information Service No. KCT0008115). Also, this study complied the ethical guidelines for authorship and publishing in the Annals of Geriatric Medicine and Research.14)

Procedure

This study enrolled 15 older women in an exercise program using an AR exercise platform (DIDIM; Twohands Interactive, Busan, Korea) (Fig. 1). The exercise sessions ran for 30 minutes, three times weekly, for a total of 6 weeks. The exercise was facilitated using an AR game projected on the floor. The participants played the game by touching the floor controls with their feet. Before and after each exercise session, physical function was evaluated to confirm the effects of AR-based exercise.

AR Exercise

The dedicated space for the AR game measured 4.5 m×2.5 m. The AR equipment employs LiDAR sensors to detect and operate foot movements. The exercise program was configured for physical and cognitive function training and consisted of six routines. Tap steps, balloon pathfinding, catching bugs, speed cards, shape-stepping bridges, and random squares were performed sequentially (Fig. 2). Specifically, the tap steps involved moving both feet sequentially and rapidly in the direction of each foot, in a straight standing position (Fig. 2A). Balloon pathfinding required the participants to remember the order in which the balloons sparkled to step on and pop them (Fig. 2B). Catching bugs involved catching bugs projected onto the game floor by stepping on them (Fig. 2C). Speed cards required participants to use their feet to position the card displayed on the screen appropriately, either in the left or right direction (Fig. 2D). The shape-stepping bridge routine required the participants to memorize the shapes presented, culminating in crossing the bridge by stepping on the correct shapes (Fig. 2E). Finally, random square was an exercise in which the participants were instructed to find randomly marked tiles with their feet (Fig. 2F). Each exercise was conducted for 5 minutes. When one exercise was completed, the next exercise was performed after a 1-minute break. As two people could exercise simultaneously, the participants were competitively motivated to improve their respective scores.

Evaluation

To observe the effect of improving physical function in the study participants, lower extremity and respiratory functions were evaluated. In addition, bioelectrical impedance analysis was performed. The timed up-and-go test (TUG), five times sit-to-stand test (5TSTS), and 1-minute sit-to-stand test (1MSTS) were used to measure lower extremity function. TUG is an evaluation method that can identify the risk of falling in older adults by evaluating their balance ability.15) This method measures the time required to stand up from a chair, move 3 m, and return to sit on the chair. The 5TSTS evaluates lower-extremity muscle strength.16) The participants were asked to stand up and sit as fast as possible, five times. Both tests were performed twice and the minimum value was used. The 1MSTS can also evaluate lower-extremity muscle strength and function.17) The evaluation is a measure of how many times the subject can stand up and sit on a chair in 1 minute.
Respiratory function was evaluated to assess lung capacity and respiratory muscle strength. Respiratory function was evaluated by a physiotherapist with 8 years of experience, trained according to guidelines from the American Thoracic Society/European Respiratory Society Task Force.18,19) The lung capacity of the participants was measured for forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) using spirometry equipment (Pony FX; COSMED Srl, Rome, Italy). The respiratory muscle strength of the study participants was measured for maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) using respiratory strength measurement equipment (Pony FX). All evaluations were repeated three times after a 1-minute break after each. The highest values were used in this study.
In addition, bioelectrical impedance analysis (BIA) (InBody S10; InBody Co. Ltd., Seoul, Korea) was used to confirm the participants’ body composition.20) The Trail Making Test (TMT) was also used to evaluate cognitive function. The TMT is divided into Parts A and B, wherein visual perceptual ability, complex visual scanning, and agility are comprehensively required.21) Part A required connecting the displayed numbers by drawing a line through them in sequential order. Part B required the participants to alternately connect numbers and letters by drawing lines sequentially. Compared with Part A, Part B requires the additional ability to alternate between the use of cognitive functions and backward inhibition and maintain two types of parallel thinking.22) The participants were encouraged to draw the lines at high speeds, and the time at which the inspection was completed was recorded.

Statistical Analysis

The data collected in this study were analyzed using IBM SPSS Statistics for Windows, version 19.0 (IBM Corp., Armonk, NY, USA). The study data satisfied normality and the effects before and after exercise were compared using the paired t-test. The significance level α was set at 0.05.

RESULTS

The results of applying the AR exercise program in older women are shown in Table 2. The TUG decreased from 7.05±0.88 to 6.24±0.58 (p<0.05), the 5TSTS decreased from 8.11±2.03 to 7.21±1.05, and the 1MSTS increased from 39.60±9.24 to 42.13±8.37. In addition, the respiratory muscle strength MIP increased from 64.87±18.97 to 68.87±16.60 (p<0.05) and the MEP increased from 79.00±18.00 to 84.53±16.54. The weight increased from 58.36±6.64 to 59.38±6.20 kg (p<0.05), and body mass index (BMI) changed from 23.99±2.75 to 24.43±2.60 kg/m2 (p<0.05). In the case of BIA, the percent body fat (PBF) changed from 31.84%±5.77% to 32.29%±5.86%, skeletal muscle mass (SMM) changed from 21.21±2.49 to 21.57±2.52 kg (p<0.05), skeletal muscle mass index (SMI) changed from 7.08±0.69 to 7.09±0.71 kg/m2, and fat-free mass (FFM) changed from 39.59±4.06 to 40.06±4.09 kg (p<0.05). Finally, regarding cognitive function, TMT_A decreased from 30.52±6.52 to 27.34±12.85 seconds, and TMT_B decreased from 76.25±53.71 to 66.76±60.55 seconds (p<0.05).

DISCUSSION

The results of this study confirmed the effects of improving physical function by applying a 6-week AR-based indoor exercise program to older adult women. The participants in this study showed significantly increased TUG and MIP scores. In addition, significant changes in SMM and BMI were observed in BIA results. However, no significant changes in the numerical values of BIA were observed. Additionally, cognitive function also improved significantly.
The community-dwelling older adult women who participated in this study had healthy physical function. Previous studies on TUG, 5TSTS, and 1MSTS have confirmed that physical health status can be predicted using physical function tests before applying an exercise program.16,23-26) The physical function of community-based older adult women was improved after 6 weeks of an AR-based physical exercise intervention. These results suggest that AR exercise programs should be considered to improve and maintain the physical health of healthy older adults.
In this study, only TUG improved significantly among the administered lower extremity function tests such as TUG, 5TSTS, and 1MSTS. The current exercise program was composed mainly of lower-extremity agility exercises and not muscle exercises. Therefore, the TUG test score, which contains the gait ability test component, increased significantly. However, no significant changes were observed in the 5TSTS and 1MSTS, both of which focused on lower extremity muscle strength. One explanation for the lack of significant changes in lower extremity muscle strength may be the low intensity and short intervention period of the exercise program. A previous study that applied exercise programs for 20 weeks in community-dwelling older adults reported no significant change in the sit-to-stand evaluation in the first 10 weeks but observed a significant change by the 20th week.27) In addition, a previous study that conducted high-intensity exercise in older adult women for 12 weeks showed significant improvement in the sit-to-stand evaluation after exercise.28) The results of these previous studies suggest that significant changes in 5TSTS and 1MSTS may occur with longer intervention periods and higher-intensity exercises using AR content.
In this study, the respiratory function did not change significantly based on the lung capacity; however, MIP indicated a significant increase in respiratory muscle strength. While the MEP also increased, the results were not significant. Although the AR exercise program required increased levels of activity, we believe that it did not significantly impact lung capacity because the exercise was not of high enough intensity to increase lung capacity. Previous studies on aerobic exercises in young adult women suggested that lung capacity does not increase with short-term interventions.29) However, previous studies have shown that lung capacity increases with high-intensity interval training.30) Future studies are needed to test the hypothesis that providing sufficient high-intensity training, even for a short time, will affect lung capacity. However, a significant increase in respiratory muscle strength, indicated by MIP, in a state of unchanged lung capacity suggests that the inspiratory pressure of the thorax has increased without a change in the volume of the chest thorax.31) This would have affected the respiratory muscle strength due to structural changes in the diaphragm caused by an increase in diaphragmatic activity, corresponding to an increased number of breaths during exercise.
Increased muscle mass is a positive factor in older adults.32) The participants in this study had significantly increased weights and BMI after the exercise program. In the BIA results, only the SMM increased significantly. The PBF, SMI, and FFM did not differ significantly, while both muscle mass and fat mass increased. Sarcopenia is a risk factor for older adults and should be prevented by increasing or maintaining muscle mass through exercise programs.
This study assessed cognitive function using TMT. While TMT Part A showed an improvement, the change was not statistically significant. However, Part B exhibited a significant improvement. The marked improvement in cognitive function in older adult participants who engaged in this study’s exercise program was similar to those reported previously.7) Older adults who exercise regularly have better cognitive function due to continual blood, oxygen, and nutrient supply to brain cells due to physical activity.33) Moreover, a study that conducted a mid-intensity exercise program for older adults with good cognition twice weekly for 16 weeks reported significant improvements in attentive concentration, immediate memory, and delayed memory among the cognitive functions of the frontal lobe.34)
Over time, exercise programs for older adults have continually been developed and applied. Existing exercise programs have proven to be effective and exert positive effects on the quality of life and physical and cognitive functions of older adults.9,35,36) However, the continuous repetition of simple exercises results in eventual disinterest. Therefore, it is crucial to add game elements to the exercise so that participants can continually experience the novelty of different exercises. Various digitalized equipment has been developed and applied in the field of exercise and will continue to be used in the future. In this increasingly digital environment, an exercise program that uses organized and easy-to-use digital equipment can allow consistent participation among older adults. The participants in this study remained interested in exercising using the AR exercise program with many game elements. In addition, the participants commented that they wanted to continue participating in the AR exercise program even after the end of the study. In the future, AR exercise programs should be implemented to improve the health of older adults.
This study has several limitations. First, the number of participants was small, as this was a pilot study. Future studies should recruit more community-dwelling older adults. Moreover, the exercise effect should be verified not only in older adult women but also in older adult men. Furthermore, an exercise program should be designed and conducted to improve muscle strength by adding muscle strength exercises content. Moreover, the exercise intervention period should be extended to obtain new results. Finally, because there was no control group, we could not compare the effects of other exercises. Future studies should verify the effectiveness of the AR-based exercise program by using a control group.
The results of this study confirmed changes in the physical and cognitive functions of older adult women who participated in a 6-week AR-based exercise program. The exercise program was confirmed to be effective even with the short intervention period of 6 weeks. In the future, more community-based exercise programs for older adults should be conducted, based on the AR exercise equipment used in this study. It is important to keep community-dwelling older adults interested in participating in exercise programs to manage their health.

ACKNOWLEDGMENTS

CONFLICT OF INTEREST

The researchers claim no conflicts of interest.

FUNDING

None.

AUTHOR CONTRIBUTIONS

Conceptualization, TSP, MJS; Data curation, TSP; Methodology, TSP; Project administration, MJS; Supervision, MJS; Writing–original draft, TSP.

Fig. 1.
The augmented reality (AR) exercise platform.
agmr-23-0016f1.jpg
Fig. 2.
The augmented reality (AR) exercise configuration involves the following games: (A) tap step, (B) balloon pathfinding, (C) catching bugs, (D) speed cards, (E) shape-stepping bridge movement, and (F) random square.
agmr-23-0016f2.jpg
Table 1.
General characteristics of the study participants
Characteristic Value
Age (y) 70.47±3.54
Height (cm) 156.27±3.69
Weight (kg) 58.36±6.64

Values are presented as mean±standard.

Table 2.
Exercise program application results
Pre Post p-value
TUG (s) 7.05±0.88 6.24±0.58 0.001*
5TSTS (s) 8.11±2.03 7.21±1.05 0.072
1MSTS 39.60±9.24 42.13±8.37 0.270
FVC (L) 2.25±0.34 2.28±0.30 0.446
FEV1 (L) 1.79±0.27 1.83±0.25 0.200
FEV1/FVC (%) 79.40±4.70 79.73±4.50 0.511
FVC% 102.27±14.14 103.40±12.92 0.476
FEV1% 99.40±14.98 101.33±15.72 0.217
MIP (cmH2O) 64.87±18.97 68.87±16.60 0.016*
MEP (cmH2O) 79.00±18.00 84.53±16.54 0.186
Weight (kg) 58.36±6.64 59.38±6.20 0.003*
BMI (kg/m2) 23.99±2.75 24.43±2.60 0.003*
PBF (%) 31.84±5.77 32.29±5.86 0.432
SMM (kg) 21.21±2.49 21.57±2.52 0.040*
SMI (kg/m2) 7.08±0.69 7.09±0.71 0.856
FFM (kg) 39.59±4.06 40.06±4.09 0.122
TMT_A (s) 30.52±6.52 27.34±12.85 0.233
TMT_B (s) 76.25±53.71 66.76±60.55 0.031*

Values are presented as mean±standard.

TUG, timed up and go test; 5TSTS, five sit-to-stand test; 1MSTS, one-minute sit-to-stand test; FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second; MIP, maximum inspiratory pressure; MEP, maximal expiratory pressure; BMI, body mass index; PBF, percent body fat; SMM, skeletal muscle mass; SMI, skeletal muscle mass index; FFM, fat-free mass; TMT, trail making test.

* p<0.05, significant difference between pre- and post-exercise.

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