Table 1.

Overview technologies and results of studies evaluating exergames for balance training in elderly and adults

	Sample characteristics & Study type	Technologies used	Game elements and tasks	Intervention design	Internal outcome measures	External outcome measures	Results
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Studenski [30]	E: Healthy elderly (N = 36) Age: 80.1 ± 5.4 Study type: UCT	Dance pad containing four panels	Dance game (DancetownTM) controlled by stepping movements in forward, backward left and right directions.	24 x 30 min sessions over 3 months. Total = 720 min.	Not used FB user: Game performance	- BMI - blood pressure - Pulse - SPPB - NWT - Digit symbol substitution test - SF36 PMC - ABC scale	SF 36 PMC, NWT and ABC scale improved (p < 0.05) No significant effects on other outcome measures
Smith [31]	E 1: Healthy elderly (N = 26) Age: 78.9 ± NR E 2 and E 3: Healthy elderly (N = 20) Age: 79.6 ± NR C: Young adults (N = 20) Age: 28.4 ± NR Study type: CT	Dance mat containing four panels	E 1: Stepping to the left, right, left forward or right forward on panels corresponding to arrows shown on a display. Arrow drift speed varied. E 2: Same game with constant arrow speed. E 3: Manipulated arrow speed and appearance	E 1: 4 min E 2 and E 3: 5 x 4 min trials < 1 hr. Total Studies 2 and 3 = 80 min.	-Step timing -% missed targets FB user: not reported	Not used	Step timing improved (p < 0.05) after multiple trials & group effect; young outperformed elderly (p < 0.05). % missed targets decreased after multiple trials (p < 0.05) & group effect; young adults outperformed elderly (p < 0.05).
Kosse [33]1	E: Healthy elderly (N = 9) Age: 77 ± 5.0 Study type: ITS	Wobble board	Moving a ball through a maze using weight shifts without lifting the feet	18 x 20 min. over 6 weeks Total =360 min.	Not used FB user: Game performance	- BBS - FOE - TS EO and EC - OLS EO and EC	BBS and FOE improved (p < 0.01) TS and OLS EC & EO did not improve
Fitzgerald [24]	E: Healthy adults (N = 11) Age: 25.4 ± 2.1 C: Healthy adults (N = 11) Age: 26.9 ± 3.2 Study type: RCT	Wobble board	E: Controlling a ball using weight shifts without lifting the feet C: Postural stability training on a wobble board.	3 x 15 min. p/wk for 4 weeks Total = 180 min.	Not used FB user: Game performance	- DPSI - SEBT - Intrinsic motivation inventory	DPSI and SEBT: no group effects. Intrinsic motivation: higher (p < 0.01) score on interest/enjoyment category
Lamoth [25]1	E: Healthy elderly (N = 9) Age: 77 ± 5.0 Study type: ITS	Wobble board	Moving a ball through a maze using weight shifts without lifting feet.	18 x 20 min over 6 weeks Total = 360 min.	Not used FB user: Game performance	- DT - Standing FP& TS: trunk acceleration patterns in AP and ML: variability, regularity, smoothness.	Performance on DT improved (p < 0.05), Postural control indexed by variability, regularity and smoothness improved (P < 0.05)
Betker [23]	Healthy Adults (N = 8) Neurological patients (N = 7) Age: 15 – 72 Study type: CT	Pressure mat, 53 × 53 cm, 256 pressure sensors.	Weight shifts in AP and ML direction with cognitive tasks.	3 × 10 min. Total = 30 min.	During gameplay: game performance, COP position After gameplay total ROM ML & AP directions.	- Questionnaire: 9 questions about enjoyment, motivation to exercise, game difficulty	Internal outcome measures: NR Questionnaire: Games are challenging, attractive and more appealing than traditional exercises.
Bisson [38]	E 1: Healthy elderly (N = 12) Age: 74.4 ± 3.65 E 2: Healthy elderly (N = 12) Age: 74.4 ± 4.92 Study type: ITS	Camera tracks red gloves, player projected in Virtual Environment. Force platform measures COP.	E 1: Moving cursor using weight shifts E 2: Catch 'Falling’ balls by reaching the arms without lifting feet	2 x 30 min. p/wk for 10 weeks Total = 600 minutes	Not used FB user: Game performance	- Sway variability AP and ML - CB&M - RT	Sway variability: no significant group effect. CB&M and RT: both groups improved (P < 0.05)
Lange [40]	E: Healthy adults (N = 7) Age: 16-43 Study type: UCT	Webcams, LED markers, custom step-based game.	Dance and step-based exercises in forward, backward, left, right and diagonal directions	Not specified	Not used FB user: Not reported	- Semi-structured interviews about game experience	All participants reported enjoying the experience
Nitz [41]	E: Healthy adults (N = 8) Age: 46.6 ± 9.9 Study type: UCT	Wii balance board	WiiFit: Yoga, balance, aerobic and strength pre-programmed activities.	2 x 30 min p/wk for 10 weeks. Total = 600 min.	Not used FB user: Game performance	- 6MWT - TUG - TUGcognitive - Step test - BS (foam, EC) - OLS (EO) - LOS - RT - Ankle dorsiflexion - LLS - Body weight	OLS for both limbs and lower limb strength improved (P < 0.05) Other outcome measures: no significant improvement.
Williams [42]	E: Elderly with increased fall risk (N = 15) Age: 76.8 ± 5.2 C: Elderly with increased fall risk (N = 6) Age: 76.5 ± 4.8 Study type: CT	Nintendo Wii, Wii balance board, walking frame.	E: WiiFit, balance and aerobic exercises controlled using stepping on the board, shifting weight and performing poses. C: Standard care exercise/education programme	E: 2 game sessions per week for 12 weeks. Total = Not reported C: 12 week exercise/education programme	Wii Age; number calculated by the Nintendo Wii based on game results. FB user: Game performance, Wii Age.	- BBS - TBA - FES-I	No group effect on BBS and TBA. Control group improved on FES-I (P < 0.05). Game group improved on Wii-age (P < 0.05)
Young [43]	E: Healthy elderly (N = 6) Age: 84.1 ± 5.1 Study type: ITS	Wii balance board, custom games.	Catching apples and popping balloons using COP shifts without lifting feet.	10 x 20 min. over 4 weeks Total = 200 min.	Not used FB user: Real-time visual FB of current COP position	- Sway variability AP EO & EC - Sway variability ML EO & EC - FES	Sway variability AP EC improved (p < 0 .05) Other sway measures and FES showed trend towards improvement.
Heiden [44]	E: Healthy elderly (N = 9) C: Healthy elderly (N = 6) Age : 77 ± NR Study type: CT	2 Force plates (25x10x1.5 cm)	E: Playing tennis game 'Pong’ controlled using weight shifts in AP and ML directions and a dynamic stepping routine + chair exercise program. C: Chair exercise program.	E: 2x (16 x 60 min. chair exercises + 30 min. exergaming) p/wk for 8 weeks. Total exercise = 1440 min. and gaming = 480 min. C: 16 x 60 min. over 8 weeks Total = 960 min	Not used FB user: Real time visual FB of COP movement	- Postural sway AP - Postural sway ML - RT dual task - CB&M - 6MWT	RT during dual task and CB&M improved (p < 0.05) in intervention group Both groups improved on the 6MWT (p < 0.05).
Agmon [75]	E: Balance impaired elderly (N = 7) Age: 84 ± 5 Study type: ITS	Nintendo Wii, Wii balance board	4 balance games controlled using weights shifts and stepping on the balance board	3x30 min p/w for 3 months. Total = 1170 min	Not used FB user: Game performance	- BBS - Timed 4-meter walk test - PACES	BBS and walking speed improved (P < 0.05). No effect on PACES.

E = Experimental group; C = Control group; N = Number of participants; RCT = Randomized controlled trial; UCT = Uncontrolled trial; CT = Controlled trial; ITS = Interrupted time series design. When no p values are presented in the table, they were not provided in the paper, ¹=Same data set; NR = Not reported; ROM = Range of movement; ML = Medio-lateral; AP = Anterior-posterior; COP = Centre of pressure; SF36 PMC = SF 36 physical & mental component; NWT = Narrow walk time; DPSI = Dynamic postural stability index; SEBT = Star excursion balance test; FOE = Figure of eight; EO = Eyes open; EC = Eyes closed; DT = Dot task; RT = Reaction time; LLS = Lower limb strength; TUG = Timed-up-and-go; 6MWT = 6 minute walk test; LOS = Limits of stability; BMI = Body mass index; SPPB = Short physical performance battery; FES-I = Falls efficacy scale international; ABC scale = Activities specific balance confidence scale; BBS = Berg balance scale; TBA = Tinetti balance assessment; FES = Falls efficacy scale; CB&MS = Community balance and mobility scale; FP = Feet parallel; TS = Tandem stance; OLS = One-leg stance; BS = Bilateral stance; PACES = Physical activity enjoyment scale.