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Results from the EU-project iStoppFalls: feasibility, effectiveness, user
experience and acceptance of a new technology based approach for fall
prevention
Sabine Eichberg1, Konstantin Aal2, Daryoush Vaziri2 & Rainer Wieching2
1German Sport Univiersity Cologne, 2University Siegen,
Key words: Exergame, fall risk, usability, dual task, living lab, older adults
Introduction
Falls are mostly associated with loss of individual independence and high burden of
costs. The prevention of falls and related disability is one of the public health chal-
lenges (World Health Organization, 2007). The fall risk is multifactorial and com-
prises factors like gait instability, muscle weakness, balance difficulties, and cogni-
tive decline (American Geriatrics Society & British Geriatrics Society, 2011). Sys-
tematic reviews and meta-analyses show the evidence of multicomponent interven-
tions with a focus on balance and strength training that last at least six months in
preventing falls (Gillespie et al., 2012). The challenge is to provide forms of exer-
cises which increase the longer-term compliance on such programs (Uzor & Baillie,
2014). Exergames are a promising pathway to increase the appeal of and engage-
ment in exercise. It can be utilized to monitor exercise and deliver performance
feedback (Schoene et al., 2014).
Therefore, the consortium, including University Siegen, German Sport University
Cologne, University Polytechnic of Valencia, Philips Research Europe, Austrian In-
stitute of Technology, Neuroscience Research Australia, developed a new Infor-
mation and Communication (ICT)-based system for fall prevention and fall risk as-
sessment in community-dwelling older people at home. The objectives of the
iStoppFalls project were
1) to reduce risk of falls, and thus improve quality of life
2) to offer improved fall prediction & prevention measures
3) to fit very well inside basic daily behavioral settings
4) to provide self-learning solutions with advanced reasoning
5) to provide advanced HCI technologies (usability & accessibility).
In this paper we want to show some selected results. We hypothesized that the
iStoppFalls exercise program would reduce the physiological fall risk, increase
quality of life, and dual task interference. In addition this ICT-based exercise pro-
gram is feasible for older people in terms of exercise adherence, acceptability and
safety.
Method
One hundred fifty-three community-dwelling older people aged 65 years and older
took part in this international, multicenter, single-blinded, two-group randomized
trial. Study sites were located in Germany (Cologne), Spain (Valencia) and Austral-
ia (Sydney).
2 presentations and poster
Living Lab
Another part of the study was conducted in a Living Lab (Ogonowski et al., 2013)
with the aim to investigate the integration of ICT-based preventive exergames into
the daily routines of older adults in the long term (six months), to gain a better un-
derstanding of appropriation processes, and how exergames affect participants’
usage behavior. The Living Lab approach enabled the project consortium to use
qualitative methods and gave participants an active role in the evaluation process.
Over the six-month period researchers worked very closely with the participants
and gained data from semi-structured interviews with additional observations proto-
cols, usability tests and workshops. All data were supplemented by notes with indi-
vidual experiences and observations from home visits, the social event and regular
exchanges with participants via email, instant messaging and phone as well as by
logging data of system usage.
System Overview
The iStoppFalls system consists of several technical components: a set-top box
with controller, a Mini-PC with the exergame, a Microsoft Kinect for movement de-
tection and gesture/voice control, a Senior Mobility Monitor (SMM) for mobility
tracking, a tablet PC as an alternative input/output device for the iTV system, an a
TV with the iTV program. A more detailed description of the system is provided in
the work of Marston et al. (2015).
Figure 1. iStoppFalls exergames: balance games (upper panel) and strength training (lower panel) (retrieved
and modified from Marston et al., 2015).
Intervention
The training program consists balance and strength exercises in the form of video
games using exergame technology (see Figure 1). The three Balance Exergames
were based on the Weight-bearing Exercise for Better Balance (WEBB) program
(www.webb.org.au) and focus on weight shifting, knee bending, and/or stepping in
different directions. Cognitive tasks targeting semantic and working memory were
3
added at higher levels (dual-task). Strength exercises for the lower extremities in-
cluding knee extension, knee flexion, hip abduction, calf raises, and toe raises were
based on the strength exercise component of the Otago exercise program (Camp-
bell et al., 1997). Progression was achieved by increasing the number of repetitions
and sets, and adding 1-3 kg ankle cuff weights). Participants conducted a 16-week
exercise program based on recommendations by Sherrington and colleagues
(2011); 180 min per week with at least three balance sessions (40 min each) and
three strength sessions (20 min each).
Assessment
Primary outcomes: The short version of the Physiological Profile Assessment (PPA)
estimated individual fall risk based on five sensorimotor tests, indicated in five cate-
gories from mild to marked (Lord et al., 2003). The European Quality of Life 5 Di-
mensions (EQ-5D) questionnaire was used to assess quality of life
(www.euroqol.org).
Secondary outcomes: Dual-task ability was assessed by asking participants to
count backwards by three starting from a random 3-digit number while walking over
a 10 m distance. For this analysis participants were divided into fallers (at least one
fall in the last 12 months) and non-fallers (no fall). Usability and enjoyment was as-
sessed by the 10-item System Usability Scale (SUS; Mullen et al., 2011) and the 8-
item Physical Activity Enjoyment Scale (PACES; Borsci et al., 2009). The Dynamic
Acceptance Model for the Re-evaluation of Technologies (DART; Amberg et al.,
2005) was used for the analysis and evaluation of user acceptance of products or
services.
Results
At baseline intervention and control group were comparable regarding socio-
demographic factors, health status, leisure time activities and computer experience.
Adherence
The intervention group played the balance exergames 96 times for an overall net
duration (without instructions) of four hours. Strength exercises were performed 224
times for an overall net duration of five hours. On average 20 exergames were
played per week and person with an average duration of 35 minutes per week. Dur-
ing the observation period no adverse events occurred while playing the exergame.
Fall risk
After 16 weeks of intervention fall risk was significantly reduced in the intervention
group compared to the control group (F1,127=4.54, p<.05), see figure 2.
4 presentations and poster
Figure 2.Fall risk score of intervention vs. control group (per-protocol analysis).
In addition, the intervention group was divided into high-adherence (>90 min exer-
cise per week) and low-adherence group (<90 min exercise per week). The sub-
group analyses show the highest reduction in fall risk in the high-adherence group
compared to low-adherence group and control group (F2,125=3.12, p<0.05).
Dual task
Another subgroup analysis concerns the difference between fallers and non-fallers
regarding gait speed, counting backwards, dual task interference and dual task
costs at baseline.
Fallers did not have slower gait speed and poorer cognitive function under single
and dual task condition (all p>.05). Video-based physical training slightly improved
gait speed (F1,128=4.022, p<.05) and cognitive function (F2,128=3.60, p<0.06) under
dual task condition. However, fallers did not profit more from training than non-
fallers (all p>.05).
Acceptance and usability
Older adults enjoyed using the system and playing the exergames. System usability
was perceived as good. The participants showed a high acceptance rate, although
they rated a high System-/ IT-complexity. In addition, it seems the system attracts
specific subgroups; female, young-old, and IT-literate participants. E.g. women
played more games than men, women preferred balance games, whereas men pre-
ferred strength training.
Discussion
The iStoppFalls system was developed for fall prevention in older adults. It is feasi-
ble and safe for use at home; adverse events did not occur while playing the exer-
game. Physiological fall risk was reduced in the intervention group with the highest
p< 0.05
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reduction in persons who trained 90 min and more per week. Also gait speed and
cognitive function both under dual task condition were improved. However, there
was no difference between falls and non-fallers. These benefits may be small and
the clinical relevance should be confirmed in further analyses.
The study had certain limitations. Overall adherence to the intervention was rea-
sonable, but did not reach the recommended dose of exercise (180 min per week;
Sherrington et al., 2011) and the low progression of level of difficulty. These factors
could be the reason of the small positive changes in fall risk and the dual task inter-
ference.
The older adults in this sample were healthy and show relatively high fitness (ex-
pressed in high levels of quality of life and a mild fall risk). Further studies should
include individuals with rather low physical and low cognitive abilities, a high fall
risk, and several experienced falls, respectively. Like demented older adults for ex-
ample, on which a new German national research project with members of the
iStoppFalls consortium will focus on in the future.
One could also suppose that the training intensity was too low for the rather fit
study group included in the iStoppFalls study as described here. Therefore, for fur-
ther research, several approaches could be pursued. One the one hand, a closer
screening of adherence and more reminder functions could be included in the sys-
tem. One the other hand, more and different types of games could be provided to
match individual preferences.
In our study population balance games were more seen as a warm-up, and the
OTAGO based strength training as the “real” training. Higher levels were more mo-
tivating. Combined physical exercises and cognitive task were highly valued. A
weakness of the iStoppFalls system was the limited number of different games, like
dancing or others. Older adults would like to have more variety here.
Analysis of motivational effects comprised that the opportunity of self-monitoring,
was a very important aspect for the older adults involved in our study. Very active
older adults were more looking for competition; active older adults were predomi-
nately interested in their personal health status. An increased awareness of health,
fitness and fall risk related issues was reported by the older adults themselves, and
thus improved health literacy could be observed. Participants felt more confident
and safe during physical indoor and outdoor activities, and were more motivated to
engage in physical activities. Finally, increased IT-literacy could be achieved, as
older adults learned to use new devices and applications.
Conclusions
The newly developed ICT-based fall prevention and risk assessment program
iStoppFalls is feasible and safe for unsupervised use at home by community-
dwelling older adults. The use of iStoppFalls significantly reduced the physiological
fall risk of the intervention group vs. control in a 4 months international randomized
controlled trial with 153 participants in three countries (Gschwind et al. 2015).
Those participants with the highest fall risk and best adherence benefitted most
from the program. Putting the individual fall risk under older adults own control was
an important measure of success.
6 presentations and poster
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