The Effect of the Virtual Reality Games on the Muscle Activity and Balance in the Elderly Women.

Transcription

1 The Effect of the Virtual Reality Games on the Muscle Activity and Balance in the Elderly Women. Eun-Ja Kim, PT, Ph.D 1.Yong-Jin Jeon, PT, Ph.D 2. Kyoung-Bo Lee,, PT, Ph.D 3. 1,2, Department. of Physical therapy, Kyungdong University. 3 Department of Physcial Therapy, St.Vincent Hospital Abstract Purpose : The aim of this study is to investigate the effects of VRG on the muscle activity and balance in the elderly women. Methods : The subjects are the elderly women aging 65 or over (n=20). there were 10 subjects in the VBG and GE group, respectively. The intervention is performed for 40 mins per a session, twice a week, 8weeks. Results : BBS and FRT were showed no significant difference in the control group and a significant difference in the experimental group. Also, there is a significant difference between two groups. In the comparison of muscle activity of tibialis anterio and gastrocenemius medialis, there is no significant difference in the control group and a significant difference in the experimental group. Also, there is a significant difference between two groups. Conclusion : VRG is effective to improve muscle activity and balance in the elderly women aging 65 or over. Key Words: Elderly Women, Balance, SEMG, Virtual reality Ⅰ. Introduction The older people have occurred in physiological change as aging. among the those changes, It appears the sarcopenia by decreasing a skeletal muscle mass. The sarcopenia reduce a muscle strength and causes the disability of independent activity daily of living, which could increase the risk of motality in the eldery 1. The reducing of muscle strength could effect on balance and the decreasing of postural control has the pontential to induce the problems of basic and functional ADL, which lowers the quality of life 2. Balance makes ones to maintain the posture in exteral space and helps to perform the various tasks, which are accomplished by the complex process in the neuromusculoskeletal system. However, the elderly can not make a response rapidly by a body perturbation, and thus the improvement of balance is very important for the prevention of fall in older people 3. The fall can lead to the medial cost loss, which in turn develop the disability of the physical and psychological function, lowering the QOL in elderly people. In addition, they could be occurred in various environments during

2 the ADL. Though physical muscle strengthening exercises have been suggested for fall prevention, balance program using multiple tasks has been considered to be more appropriate 4. Virtual reality games have been recently used in exercise intervention through the various applications and developments of computer programs, and it has been used instead of traditional treatment or as a supplementary treatment in clinical settings 5. virtual reality games have been widely used in physical therapy and/or occupational therapy, and Improving balance and reducing falls have been attempted by treating individuals with multidisciplinary fall-prevention programs and specific exercises. Performing a number of physical activities could improve a QOL and prevent falling in ADL. However, even though virtual based game have an effectiveness for individual treatment in older people, it is too expensive to use regularly as a clinical application 6. Few studies provide evidence supporting the positive effects of virtual based game exercises on the balance and muscle activity of older adults. Therefore, this study evaluates the effects of VBG training on the balance and muscle activity of older adults. Ⅱ. Methods 1. Participants This study were conducted with the elderly women aging of 65 and over in S welfare center, Sungnamsi, South Korea. Incrulsion criteria includes ones who have no falling within one year, without central or peripheral disease, no orthopedic problems to complete our exercise programs, and with 24 or more of MMSE score. this study included the control group of general exercise(ge, n=10) and experimental group of virtual based game (VBG, n=10). All subjects provided written informed consent prior to participating in the study. The genreal characterisitcs of participants were in table 1.

3 Table 1. Genaral characteristics of the subjects General exercise(n=10) Virtual reality(n=10) t p Age(year) 75.00± ± Weight(kg) 55.14± ± Height(cm) ± ± ,57 Mean ± SD, *p< Intervention GE performed to move weight from side to side and forth to back, to stand on one leg, to squat, and to walk in place during standing on balance pad. VBG was conducted with Gymplate (TECHNO CONCEPT, France), and both group performed the program for 8 weeks, twice a week, 40 mins per a session. Gymplate has four directional pressure senses and translate the force of foot plate into computer system through USB, which can identify distribution of balance in top, bottom, left and right. the programs of VBG were shown in fig 1 and 2, which consists of the total of 6 grades and the subjects were performed gradually. Fig 1,2 3. Measure Several objective outcome measures were used to determine the effects of VBG training on the balance and muscle activity. (1) Surface electromyography(semg) We used the SEMG(MyoSystem 1400A, Noraxon, USA) to measure the muscle activity of tibialis anterior and gastrocnemius medialis. The details of muscle attachment outline in table 2. the participants skin was cleaned with alcohol and the electrodes were attached with tape and elastic strips. Electrode (Electrode2237, 3M, USA) placed over dominant leg. Maximal voluntary contraction(mvc) of each muscles were performed with manual resistance using a reference of Danieis and Worthingham. muscle activity on one leg standing(ols) was measured for 5 sec, 3 times, of which we calculated the data of intermediate 3 sec except of 1 sec before and after. The EMG activity was expressed by root mean squares, which were normalized by the MVC and were described in percentages.

4 Table 2. electomyography attechment position Muscle tibialis anterio attechment position The percentage distance from the tuberosity of tibia to the inter-malleoli line, starting frome the tuberosity of tibia The percentage distance from the medial side of the popliteus cavity to gastrocenemius medialis the medial side of the Achilles tendon insertion starting frome the Achilles tendon (2) Berg Balance Scale(BBS) Balance ability was tested using the Berg Balance Scale (BBS), which includes 14 functional balance items, with scores ranging from 0 to 56 points; better balance is indicated by a higher score. within- and between-reliability is 0.98 and 0.97 respectively 7. (3) Functional Rech Test (FRT) FRT is to measure dynamic balance ability, during which the subject is positioned on standing, putting heel on the floor, to reach his arm forward maximally. the distance is measured using a tapeline 4. Statistical Analysis A statistical analysis of the data was conducted with SPSS version 18. The demographic data between groups was calculated using T-test. the change of variables before and after intervention were compared with Wilcoxon's sign ranks test, and Mann-Whitney U test was used to compared the changes between groups. A p-value < 0.05 was considered to indicate significance. Ⅲ. Results 1. Comparison of balance ability between groups While there was not a significant difference of FRT after intervention in GE group(p>.05), VBG group showed the significant change (P<.05). Additionally, for the variable of BBS, there was a significant difference in VBG group but not in GE group. Both of BBS and FRT were showed a significant difference between groups.table 3

5 Table 3. Comparison of balance ability between groups GE c (n=10) VR d (n=10) t p Pre 10.40±2.54 e 10.40± FRT a (cm) Post 10.40± ± Change.90± ± t p Pre 48.80± ± BBS b (score) Post 49.80± ± Change 1.00± ± t p a FRT: Functional Rech Test, b BBS:Berg Balance Scale. c GE:General exercise, d VR;Virtual reality, e Mean ± SD, 2. Comparison of muscle activity between groups There was not a significant difference of TA muscle activity after training in GE group, but showed a meaningful change in VBG group. For GCM muscle, there was a significant change in VBG group but not in GE group. the difference between groups was occurred only in GCM. Table 4 Table 4. Comparison of muscle activity between groups (Unit:%MVIC) GE a (n=10) VR b (n=10) t p Pre 28.20±5.78 c 39.30± tibialis anterio Post 28.70± ± Change 1.00± ± t p Pre 40.20± ± gastrocene -mius medialis Post 41.30± ± Change 1.10± ± t p a GE:General exercise, b VR;virtual reality, c Mean ± SD

6 Ⅳ. Discussion The aim of this study was to explore the effect of VBG and GE on the muscle activity and balance. VBG group showed a significant change of muscle activity and balance after training, but there was no significant difference in GE group. Difference between the groups revealed in both muscle activity and balance. In the previous study, which conducted to compare the balance ability with Wii-Fit program for 8 weeks in the elderly woman aging of 65 or more. they showed the decrease of body sway in a situation of both eye open and closed and presented the increase of FRT distance 8. They suggested that this virtual based game could be useful for the increase of dynamic and static balance. It has also been shown that training with Wii-fit program in the older people aging from 65 or more to 90 improved the dynamic and static balance through the demands of postural control in various tasks, and this effects could reduce the fall risk 9. Moreover, it was demonstrated that for subject aging of 65 or more, limit of stability(los) and center of pressure(cop) were increased after training using a virtual reality game and it affected on a decrease of the fear of falling and the fall rate 10. This study revealed that BBS and FRT were significantly improved in the eldery women aging of above 65 after training of virtual based games. this results were consistent with the previous studies. the fall of older people would influence on an increase of medical cost and has an adverse effect on independent ADL. Most of exercise programs for the elderly have been designed to prevent a fall. Our study used the device able to run a virtual reality game applicable individually. the virtual based game program has several advantages. the one is to be applied individually to prevent the fall of elderly, and the other is to complement the drawbacks to being easily bored in general physical therapy programs. Therefore, It could be suggested as an supplementary intervention to increase balance and prevent the fall risk. Old people may be more reliant on visual stimui compensating for a lack of proprioceptive sense, and thus a visual stimuli in VBG and performing tasks in various supporting surfaces have been known to

7 improve the balance of old people 11. Moreover, in the study of Parkinson's disease and old people, it has been shown that virtual reality game could improved the response to visual stimulus in various environments 12. Virtual reality game was designed with eye and head tracking technology and has been shown to increase individual's interest in performing related exercise. this virtual based game system provides an interactive environment and instant feedback to participants. Additionally, Positive results were also seen when video games were incorporated into virtual environments, and thus it provides a purposeful and challenging exercise 13. It has been also revealed that virtual based game in standing could positively affect on postural control and muscle strength 14.. The results of this study, which showed the improvement of balance after training to response to a visual stimuli and to perform a task on standing, was consistent with the previous study. However, we did not assessed a visual stimuli and a future study would be needed in this area. An ankle strategy used to control balance is critical for the displacement of COG. In the previous study of subjects aging from 65 to 80 with Wii-Fit program, the muscle activities of TA and GCM were shown to be increased and they controlled COG of body through the ankle strategy. It also had a effect on preventing falls 15. In this study, there were increases of the muscle activity for TA and GCM in VBG group, and this results is in accordance with the previous research. In my opinion, an increase of the muscle activity of TA and GCM could influence on improving balance ability in standing as well as make them adjust rapidly for body perturbation, which would prevents the falls. There were several limitation in this study. this study was conducted with small samples and had an limitation of external validity due to including only the elderly women in the welfare center. A further limitation was that fall statuses of participants were not measured. However, balance statuses were objectively assessed using several outcome measures that have been clinically demonstrated to predict falls. Ⅴ. Conclusion

8 The VBG intervention significantly improved BBS and FRT in 40 mins per a session, twice a week, 8 weeks. Moreover, there were significant difference of the muscle activities on TA and GCM. There would be a need to investigate the long term beneficial effects and a better method in a clinical setting. References 1. Park SW. Sarcopenia of the old age. Endocrinology and Metabolism. 2007;22(1): Kim HR. Causality analysis of muscle activation, physical strength and dality living abilities change among the elderly the to a health promotion exercise program. J Kor Soc Phys Ther. 2010;22(4): Lin SI, Woollacott MH.Postural muscle responses following changing balance threats in young, stable older, and unstable older adults. J Mot Behav ;34(1): Park IS. Analysis of Risk Factors for Falls in Older Adults. THe Kor Enter Indus asso. 2016;11: Kwon JS. Effects of Computer Based Virtual Reality Program on Clinical Rehabilitation in Korea : A Meta-analysis. J Digital Convergence. 2015;13(7); Skjæret N, Nawaz A, Morat T, et al. Exercise and rehabilitation delivered through exergames in older adults: An integrative review of technologies, safety and efficacy. Int J Med Inform. 2016;85(1): Berg KO, Wood-Dauphinee SL, Williams JI, et al. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83(2): Lee JH, Park SU, Kang JI et al. Effects of Virtual Reality Exercise Program on Muscle Activity and Balance Abilities in Elderly Women. J Kor Phys Ther. 2011;23(4): Rendon AA, Lohman EB, Thorpe D, et al. The effect of virtual reality gaming on dynamic balance in older adults. Age Ageing. 2012;41(4): Duque G, Boersma D, Loza-Diaz G, et al. Effects of balance training using a virtual-reality system in older fallers. Clin Interv Aging. 2013;8: Kim JJ, Shin SJ, An SG, et al. Comparison of the Effects of Virtual Reality and Task-Oriented Programs of Balance for the Elderly. J Kor Soci Comm Based Occupat Ther. 2013;3(2): Gallagher R, Damodaran H, Werner WG, et al. Auditory and visual cueing modulate cycling speed of older adults and persons with Parkinson's disease in a Virtual Cycling (V-Cycle) system. J Neuroeng Rehabil. 2016;13(77):1-11.

9 13. Zito GA, Cazzoli D, Scheffler L, et al. Street crossing behavior in younger and older pedestrians: an eye- and head-tracking study. BMC Geriatr. 2015;15(176): Lai CH, Peng CW, Chen YL, et al. Effects of interactive video-game based system exercise on the balance of the elderly. Gait Posture. 2013;37(4): Cho GH, Shin HS. The Effect of Virtual Reality Training on Lower Extremity Muscle Activation in Elderly. J Kor Soc Phys Med. 2014;9(1):55-62.

10