This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included.
The pandemic has highlighted the importance of low-threshold opportunities for exercise and physical activity. At the beginning of 2020, the COVID-19 pandemic led to many restrictions, which affected seniors in care facilities in the form of severe isolation. The isolation led, among other things, to a lack of exercise, which has led to a multitude of negative effects for this target group. Serious games can potentially help by being used anywhere at any time to strengthen skills with few resources.
The aim of this study is to evaluate the effectiveness of a serious game to strengthen motor skills (study 1) and the influence of pandemic restrictions (study 2) on seniors in care facilities.
The data on motor skills (measured by the Tinetti test) originated from an intervention study with repeated measurements that was interrupted by the pandemic conditions. Data were collected 4 times every 3 months with an intervention group (IG, training 3 times for 1 hour per week) and a control group (CG, no intervention). There were 2 substudies. The first considered the first 6 months until the pandemic restrictions, while the second considered the influence of the restrictions on motor skills.
The sample size was 70. The IG comprised 31 (44%) participants, with 22 (71%) female and 9 (29%) male seniors with an average age of 85 years. The CG comprised 39 (56%) participants, with 31 (79%) female and 8 (21%) male seniors with an average age of 87 years. In study 1, mixed-design ANOVA showed no significant interaction between measurement times and group membership for the first measurements (
During the first 6 months, the IG showed increased motor skills, whereas the motor skills of the CG slightly deteriorated and showed a statistically significant difference after 6 months. The pandemic restrictions leveled the difference and showed a significant negative effect on motor skills over 3 months. As our results show, digital games have the potential to break down access barriers and promote necessary maintenance for important skills. The pandemic has highlighted the importance of low-threshold opportunities for exercise and physical activity. This potentially great benefit for the challenges of tomorrow shows the relevance of the topic and demonstrates the urgent need for action and research.
Deutsches Register klinischer Studien DRKS00016633; https://tinyurl.com/yckmj4px
By the spring of 2020, the rapid spread of coronavirus led several German states to implement drastic measures in order to protect their population. Many of these measures included restrictions on movement and social contact, which particularly impacted groups that were already affected by multimorbidity, restricted functionality, and the need for care [
Compared to the results from a survey study conducted in 2017, the pandemic-related measures led to a sharp reduction in physical activity [
Even before the outbreak of the COVID-19 pandemic, the German health care system was faced with major challenges related to demographic change. Among those were the growing number of aging individuals in need of care (22% of 60-80-year-olds) [
The positive effect of physical activities [
The overall positive effect of serious games with a special focus on promoting motor movement sequences in older individuals has already been investigated and reported in several meta-analyses [
Initial studies conducted during the pandemic show the usefulness and positive effects of digital exercise on physical well-being [
Despite the positive effects of physical activity and the preliminary evidence that serious games have a positive impact on health and physical well-being, new digital technologies [
In 2014, MemoreBox was developed in response to the need for promoting prevention and health relative to the cognitive, motor, and psychosocial skills of senior citizens and, in particular, nursing home residents. MemoreBox is a health game that includes a gesture-controlled game console, which records the participants' movement data by means of a Kinect camera (Microsoft Corporation) and an individual quick response (QR) code. Games can be played when sitting or standing, individually and in groups, and the therapeutic training program can be used preventively and independently of any indications. There are currently 6 games (motorcycling, bowling [
Exemplary Bowling module in the serious game MemoreBox.
As part of a large, applied research study, the data used here for the analysis came from an intervention study that was set up as a quasi-experimental design with repeated measurements. The overarching goal of this intervention study was to test the effectiveness of MemoreBox. To evaluate the game’s effectiveness, we designed a large-scale study with 100 German nursing homes. Over the course of 1 year, we recorded and examined a total of 1000 seniors in an intervention group (IG) and a control group (CG). The intervention, training by playing, was carried out 3 times per week for 1 hour in a group using a fixed training plan that was developed in advance by occupational therapists. Data were collected over the course of 1 year during which participants were asked to complete standardized questionnaires 8 times. The standardized questionnaires on cognition, motor skills, and psychosocial health were administered every 3 months and thus 4-5 times in total. In this paper, we focus on the participants’ motor skills, which were recorded at 4 points over the course of 9 months using the Tinetti test [
Due to the global COVID-19 pandemic, which has also caused major changes in Germany, at least since March 2020, the research could not be carried out as originally planned. Protection of and care for the target population, that is, vulnerable senior citizens who are dependent on care due to physical or psychological frailties, is the top priority. For a large majority of the participating nursing homes, this situation led to an inevitable interruption of the study and thus of the planned data collection (also due to a lack of appropriate facilities) starting at the beginning of March 2020. However, the situation and the respective restrictions caused by COVID-19 differed greatly from 1 nursing home to the next. Given that such a large number of facilities were originally recruited throughout Germany, a few nursing homes emerged that were able to continue with the study and data collection due to their particular local setups and conditions within the respective facilities. These 11 nursing homes were able to continue the training plan unaltered, which ultimately led to a sample size of 70 participants (IG n=31, 44%, vs CG n=39, 56%).
The sample consisted of an IG that played regularly and a CG that did not play. All participants are residents of nursing homes in Germany. We started with 10 participants per nursing home (IG n=5 and CG n=5, 50% each), that is, N=1000. The assignment of groups was voluntary for practical and ethical reasons, which required a final parallelization of the data. Exclusion criteria for both groups were severe mental or neurological illnesses and age below 60 years. In addition, the state of health, comorbidities, and medications of both groups were surveyed.
All data collection was carried out by scientifically trained nursing staff. The data collection instruments were designed to suit the target population, and age-related restrictions in the process were considered. This paper deals with the results of the Tinetti test [
The enormously high dropout rate was largely a result of the outbreak of the COVID-19 pandemic (see description before). Given the length of the study and the target population examined, a high dropout rate was generally assumed. Illnesses and deaths, as well as lack of motivation, were the other main reasons for dropping out. The weightings shown in
Survey times, periods of operationalization, and dropout reasons. CG: control group; IG: intervention group.
At the beginning of the data analysis, the 2 study groups were compared with regard to their characteristics in the dependent variables at baseline (T0). The reason for this was the nonrandomized group assignment, which made
This study was approved by the Ethics Committee of Charite Berlin (Ethikausschuss am Campus Benjamin Franklin; review number: EA4/035/19).
Due to the lack of randomization of the study groups, independent sample
Mean values, SDs, and statistical differences of the examined variables: IGa and CGb at measurement time T0.
Variables | IG (N=31), mean (SD) | CG (N=39), mean (SD) | Statistics | 95% CI |
|
|
|
|
|
|
|
||
Age (years) | 85.45 (4.99) | 86.66 (8.76) | .718 (60.5) | .48 | –0.311 to 0.639 |
|
Level of care neededc | 2.34 (0.974) | 2.47 (0.71) | .592 (61) | .56 | –0.347 to 0.645 |
|
State of healthd | 2.33 (1.07) | 3.16 (1.22) | –.623 (66) | .54 | –0.631 to 0.328 |
|
Health behaviore | 2.42 (0.720) | 2.54 (0.97) | .570 (68) | .57 | –0.335 to 0.609 |
|
Health self-assessmentf | 2.84 (0.735) | 2.92 (0.81) | .452 (68) | .65 | –0.364 to 0.580 |
|
Tinetti mean | 1.15 (0.37) | 1.05 (0.41) | –.974 (68) | .33 | –0.707 to 0.240 |
|
Tinetti total sum | 18.16 (5.88) | 16.67 (6.58) | –.989 (68) | .33 | –0.710 to 0.236 |
|
aIG: intervention group (playing regularly).
bCG: control group.
c0=no need for care to 5=most severe impairment.
d0= healthy to 5=chronically ill.
e0=does not take care of health to 5=strongly focuses on health.
f0=“I rate my health as very bad” to 5=“I rate my health as very good.”
The analysis sample was part of the total sample and included those participants who were present at all measurement times and throughout the entire intervention. Therefore, this study included 70 participants. The IG (participants who played regularly) comprised 31 (44%) participants, of which 22 (71%) were female and 9 (29%) male. Participants in the IG ranged were aged from 74 to 97 (mean 85.45, SD 4.99) years. The CG included 31 (79%) females and 8 (21%) males, who were aged from 61 to 102 (mean 86.66, SD 8.76) years. The distribution of age (mean 86.06, SD 8.2 years) and gender (female n=53, 76%, male n=17, 24%) in the total sample roughly corresponded to the findings on the need for care in Germany [
Next, the results of the Tinetti data collected from the 70 participants over the course of 1 year were analyzed separately in 2 study sections. Study 1 looked at the first 6 months of the intervention, which analyzed the situation before the outbreak of the pandemic. The second study then dealt with the analysis of the data collected during the pandemic with its severe restrictions for the participants. Both studies looked at the CG in comparison to the IG, which carried out the study plan consistently despite massive, pandemic-related restrictions.
Mixed-design ANOVA showed no statistically significant interaction between measurement times and group membership:
Results of the Tinetti total score for the IG and CG over 6 months of intervention. T0: IG (mean 18.16, SD 5.88), CG (mean 16.67, SD 6.58); T1: IG (mean 19, SD 6.77), CG (mean 16.62, SD 7.93); T2: IG (mean 19.81, SD 6.34), CG (mean 16.23, SD 7.14); CG: control group; IG: intervention group.
Mixed-design ANOVA used to investigate motor skills before and after the outbreak of the pandemic between the groups did not reveal any statistically significant interaction between measurement times and group membership:
Significant differences after 9 months of intervention between IG and CG and between measurement times. CG: control group; IG: intervention group.
Senior citizens were particularly affected by the COVID-19 pandemic, which led to far-reaching and extensive measures of isolation. These resulted in a significant reduction in physical activity, which is counterproductive for an independent life and disease prevention. The WHO states that high physical activity is essential for an independent life and disease prevention. Physical inactivity not only leads to deterioration and dependency in physical, psychological, and social areas, it also accelerates the need for nursing and health care services [
The goal of this paper was to investigate whether the use of the serious game MemoreBox has a positive impact on the motor skills of seniors in nursing home facilities. Additionally, the data collected provide insights into the effects of COVID-19 restrictions (especially isolating measures) on the development of motor skills of the participants.
The data analysis of study I clearly shows that during the first 6 months of the study, the IG had increased motor skills, whereas the motor skills of the CG slightly deteriorated. After 6 months, there was a statistically significant difference in motor skills between the 2 groups (
After 6 months of intervention, the outbreak of the COVID-19 pandemic led to severe restrictions in nursing home facilities, which essentially led to isolation and separation, resulting in an overall strong reduction in physical activity. The effects can be clearly seen in the collected data, which show a significant decrease in the motor skills previously gained, resulting in the IG almost falling back to the initial level (
Based on these findings, we conclude that serious games can have a positive influence on the motor skills of seniors. However, despite continued use, other severe motor restrictions (in this case, isolation and separation) can counteract the gain in motor skills. Moreover, regardless of the examined intervention, the data clearly show that COVID-19-related restrictions had a significantly negative influence on the motor skills of the participating seniors. Despite the subsequent limitations, the longitudinal data underlying this study offered a valuable and rare opportunity to examine the direct effects the isolating measures implemented during the COVID-19 pandemic have on senior citizens’ health and mobility. Regarding the reported results on the effectiveness of MemoreBox, this intervention certainly provides a complementary measure to already established prevention programs.
The data collection instrument designed by the study and the examined data have clear limitations. The design limitations, which were analyzed in detail in Kleschnitzki et al [
The most important limitation of this study, however, is the sample size, which implies that the results cannot necessarily be generalized. However, there were at least 30 participants in each study group, which allowed for statistical methods. Furthermore, this population is difficult to reach. This stems from limitations (motor, cognitive, social) with regard to their location. Additionally, the longitudinal design of this study (most studies examine a period of 3 months) also posed great challenges for the participants and led to high dropout rates due to illnesses and deaths. Furthermore, there were large variances within the groups and thus among the participants. This variability, which had a similar range at all measurement times, also posed challenges to making possible significant differences visible. However, the examination of smaller, more homogeneous groups in regard to identifying potential statistically significant differences relative to certain characteristics did not provide any conclusive evidence. The G*Power analysis revealed an a priori minimum sample size of >260 (study 1) and >224 (study 2).
The outbreak of the COVID-19 pandemic undoubtedly had the greatest negative impact on the sample size. It led to high dropout rates among participants and created new challenges for data collection. Nevertheless, it also allowed us to collect data on COVID-19-related changes and associated limitations.
These limitations and analyzed consequences, in terms of their sustainability, cannot be fully foreseen at the moment and will certainly need to be examined more. The considerable variability in study designs and foci (eg, game applications, data collection instruments, target populations) makes it challenging to compare results from different studies that have examined the effectiveness of serious games [
Our results show that digital games can be deployed to promote health in a variety of contexts. They have the potential to break down access barriers and promote social engagement and interaction. The pandemic has highlighted the importance of low-threshold opportunities for exercise and physical activity, especially when conventional recreational programs are either greatly reduced or temporarily not available.
The results of this study help to further establish this new research area by (1) identifying that serious games can have a positive effect on motor skills of senior citizens and (2) revealing critical insights into the effects of COVID-19 on the motor development of seniors in isolation (physical inactivity, increased risk of falling, etc). Additionally, the results are discussed relative to the critical need for action and further research in that area. Lastly, our study contributes to identifying future global health-related challenges as well as potential preventive measures that could be developed and implemented in order to enable seniors, a consistently increasing population, to lead a healthier, independent, and more active lives.
control group
intervention group
World Health Organization
We acknowledge the tremendous support from the RetroBrain and the BARMER team. They not only developed the product with a lot of dedication but also played a key role in the organization, communication, and implementation of the rollout. We also acknowledge Janik Traunspurger, who actively supported us with the data material. Another thanks goes to Kara Grote for graphical support.
A big thank-you also goes to all the nursing staff and the seniors who, under difficult conditions (at least since the pandemic), fulfilled the project with their effort and commitment.
None declared.