Effects of active video games on physical function in independent community-dwelling older adults: A systematic review and meta-analysis

J Adv Nurs. 2021;00:1–17. | 1wileyonlinelibrary.com/journal/jan Received: 21 May 2021 | Revised: 25 August 2021 | Accepted: 9 December 2021 DOI: 10.1111/jan.15138 REVIEW Effects of active video games on physical function in independent communitydwelling older adults: A systematic review and metaanalysis Nora SuleimanMartos1 | Rubén GarcíaLara2 | Luis AlbendínGarcía3 | José L. RomeroBéjar4 | Guillermo A. CañadasDe La Fuente1 | Carolina MonsalveReyes5 | José L. GomezUrquiza1 This is an open access article under the terms of the Creat ive Commo ns Attri bution-NonCo mmercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2021 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 1Nursing Department, University of Granada, Granada, Spain 2GranadaNortheast Health Management Area, Andalusian Health Service, Granada, Spain 3GranadaMetropolitano Health District, Andalusian Health Service, Granada, Spain 4Statistics and Operational Research Department, University of Granada, Granada, Spain 5Social Sciences Department, Catholic University of La Santísima Concepción, Concepción, Chile Correspondence José L. RomeroBéjar. Statistics and Operational Research Department, University of Granada, Avda. Fuentenueva S/N, 18071 Granada, Spain. Email: [email protected] Abstract Aim: To analyse the effects of active video games on physical function in independent communitydwelling older adults. Design: Systematic review and metaanalysis of randomized controlled trials. Data sources: The CINAHL, LILACS, Medline, Proquest and Scopus databases were consulted, with no restriction by year of publication. Review methods: Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines were followed. The metaanalysis was performed using RevMan software. Results: The analysis included 22 randomized controlled trials with a total of 1208 participants (all ≥55 years old). In our metaanalyses, the effects produced by playing the active video games (mean differences) were statistically significant for the variables Gait speed and Timed upandgo. The differences between the control and experimental groups were not significant in the following tests: 6minute walk, 30second chair stand, balance (measured with the Berg Balance Scale), cadence, grip strength, knee extension strength, 8Foot UpandGo or velocity. Conclusions: Physical exercise from participation in active video games has beneficial effects on two clinical parameters (Gait speed and Timed upandgo) in independent communitydwelling older adults. However, the effects on other parameters do not differ from those obtained with conventional exercise training. Therefore, the clinical significance of these benefits is limited. Impact: Older adults usually perform little physical activity. In consequence, researchers have increasingly considered alternatives to traditional forms of exercise. One such is that provided by active video games, which can be a source of stimulation, encouraging adherence and motivation in exercise programmes. Our review shows that active video games can improve gait speed and mobility, but in other respects obtain no differences from conventional exercises. Further tailored randomized clinical trials 2 | SULEIMANMARTOS ET AL. 1 | INTRODUCTION With global ageing, it is expected that 20% of the population will be over 50 years of age by 2050 (World Health Organization, 2017). However, this rising life expectancy is associated with a parallel increase in the incidence of agerelated diseases, meaning greater overall morbidity and mortality (Cao et al., 2020). In addition, ageing causes physiological changes that may compromise functional performance (Nicholson et al., 2015). However, lifestyle is an important determinant of functional levels in old age, and studies have highlighted the important benefits offered by regular physical exercise (Gopinath et al., 2018). 1.1 | Background Inactivity is said to be the fourth leading cause of death worldwide, and older people are at particular risk in this respect (Kohl et al., 2012). Therefore, behavioural strategies to promote healthy ageing should include the regular practice of physical exercise (Xiong et al., 2021). Physical activity can delay the functional decline effects of ageing, in areas such as physical performance, balance, mobility and muscle strength (Nakano et al., 2014), thus helping preserve independence and autonomy. The evaluation of physical function is a critical element in assessing the status of older persons and should be performed using standard, commonlyavailable tools in order to ensure objectivity (Patrizio et al., 2021). The definition of physical function usually refers to concepts (and the tools for measuring them) such as gait and balance (Berg Balance Scale, Tinetti Test, 8Foot UpandGo or Unipedal Stance Test), mobility and the risk of falling (Timed UpandGo Test), endurance (6minute walk test and 30second chair stand) and muscle strength (Patrizio et al., 2021). Among other positive effects, physical exercise benefits the cardiovascular and respiratory systems, metabolism, the immune system and body composition (Su & Yu, 2019). Furthermore, it is associated with a higher quality of life, greater strength, improved balance and coordination and reduced cognitive impairment (MonteroAlía et al., 2019; Song et al., 2018). The World Health Organization (WHO), in its report on ageing and health (WHO, 2016), recommended the development of healthy ageing strategies to involve older people while they still have a high and relatively stable functional capacity. Such strategies, however, require a change in attitudes towards the prevention of agerelated diseases and the adoption of innovative solutions that would allow older adults to remain independent for longer and thus actively participate in their own health care (Foster et al., 2013). Technological advances may offer viable alternatives to traditional exercise programmes, for example, through gamebased interventions. The use of games in the learning process, or gamification, provides players with continuous feedback and entertainment (DeSmet et al., 2014). Interventions devised for this purpose may be based on video games originally developed purely for entertainment or take a directly physical approach, as is the case with ‘exergames’, designed to improve physical and cognitive functions and/or facilitate rehabilitation (Pirovano et al., 2016). Physically active video games include virtual reality programmes (CorregidorSánchez et al., 2020) and those combining video interaction with physical exercise, by means of appropriate devices (such as the Nintendo Wii or Microsoft Xbox 360 Kinect consoles) (Vieira et al., 2016). Both types of intervention are based on virtual experiences, mixing physical exercise and video stimuli and providing attractive audio/visual feedback, in order to involve and motivate the participant (Nyman & Victor, 2012). Furthermore, these video games can respond to changes in the frequency, direction, speed and acceleration of movement, encouraging the player to complete the task set and to achieve the goals desired (Meekes & Stanmore, 2017). Personalized interventions fostering healthier behaviour can promote active, healthy ageing and thus lead people to live independently longer (Li et al., 2018), and for some of those concerned a technologybased approach may be very attractive (Helbostad et al., 2017). Studies have shown that interventions with exergames can improve cognitive and physical functions in older people (Zhao et al., 2020). Some authors have studied game modalities such as ‘cybercycle’ for patients with diabetes (AndersonHanley et al., 2012) or ‘cybergolfing’ (Chow & Mann, 2015), and have reported improvements in clinical parameters such as cognition, executive function and balance. The use of active video games is also associated with a reduced risk of falls by older people (Chan et al., 2021; Zeng et al., 2017), with the alleviation of depressive symptoms (Drazich et al., 2020; Fang et al., 2020), with an enhanced quality of life (Cacciata et al., 2019) and with better motor function in patients with Parkinson's disease (Dockx et al., 2016). In addition, studies have assessed the effects of exergames on parameters of physical function in older adultslike balance, the Timed UpandGo test and the 30second sittostand test (Pacheco et al., 2020; Taylor et al., 2018). An older systematic review, based on fewer studies and lacking a should be undertaken with diverse populations of older adults to evaluate different physical function variables to determine the most appropriate training approach and its optimal design and duration. KEYWORDS ageing, exergame, health game, nursing, older adults, physical function | 3 SULEIMANMARTOS ET AL. metaanalysis, reported inconclusive results about the effectiveness of virtual reality games for enhancing physical function in older adults (Molina et al., 2014). However, these studies omitted some parameters that are objectively measurable and sensitive to change in the assessment of physical function in older adults, such as handgrip strength, the 6minute walk test, gait speed and walk distance (Patrizio et al., 2021). By addressing the largest possible number of functional parameters, using reliable, widely available measures, researchers could better analyse the improvements to be gained by exergamebased approaches to physical outcomes and functional status in independent communitydwelling older adults. With these considerations in mind, we conducted the following systematic review and metaanalysis. 2 | THE REVIEW 2.1 | Aims The aim of this systematic review and metaanalysis is to analyse the effects of interventions based on interactive games (exergames or virtual reality) on physical function in independent communitydwelling older adults. 2.2 | Design This systematic review and metaanalysis was performed in accordance with the guidelines of the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Metaanalyses) (Moher et al., 2015). 2.3 | Search methods The following databases were consulted: CINAHL, LILACS, Medline, Proquest and Scopus, using the search equation: ‘(game OR gamification) AND (aged OR elderly OR adult OR senior) AND (exercise OR sport OR physical activity OR physical functional performance OR physical fitness OR health) AND (RCT OR randomised controlled trial)’. The search started in March 2021 and was completed in April 2021 using the PICO strategy. The search and selection process were performed independently by NSM and JLGU. The eligibility criteria applied to the studies included are shown in Table 1. 2.4 | Search outcomes The following inclusion criteria were applied: (1) randomized controlled trial; (2) communitydwelling older adults; (3) independence in ambulatory functions with or without a walking support; (4) no severe motor functional impairment in terms of mobility, postural balance or musculoskeletal function that would prevent participation in the training programme; (5) capable of understanding and following the game; (6) use of video games or interactive experiences (rulesbased games providing interaction and feedback and focused on the achievement of specific objectives); (7) analysis of the impact of the intervention on clinical outcomes related to physical condition; (8) measurement of the effect produced by the intervention in terms of altered muscle strength, balance, mobility, gait and speed, using a validated instrument; (9) publication of data describing the effect of the intervention. No restrictions were placed on the language or year of publication. Any studies matching the following criteria were excluded: (1) pilot study or protocol; (2) no randomization or control group; (3) mixed samples (young participants and adults) lacking independent data by age groups; (4) severe cognitive impairment (a test score <22 measured with the MiniMental State or the Montreal Cognitive Assessment); (5) mobility or cognitive impairments that prevented participation; (6) studies focused on participant samples including specific clinical conditions (stroke or epilepsy, Parkinson's disease, Alzheimer's disease or other forms of dementia, neurological disease, neurodegenerative disease, terminal illness or unstable chronic illness); (7) impaired vision or auditory function that impeded participation and/or monitoring of the intervention programme; (8) interventions with no form of physical activity. In the first stage of the selection process, two of the authors (NSM and RGL), working independently, reviewed the title and abstract of each article found. Then, the full text was read. A third author (JLRB) was consulted to resolve any disagreement (see Figure 1). 2.5 | Quality appraisal The quality of the studies was evaluated according to the levels of evidence and grades of recommendation stipulated by the OCEBM (Centre for EvidenceBased Medicine) (Howick et al., 2011) (see Table 2). The risk of bias was analysed by two of the authors (NSM and RGL), working independently, using the Cochrane Collaboration Risk of Bias tool (Higgins & Green, 2011). TABLE 1 PICO search strategy Participants Intervention Comparison Outcomes Independent communitydwelling older adults (≥55 years old) Interactive game or virtual game aimed at enhancing physical function, strength, balance, mobility, gait or velocity Control group (traditional intervention or no intervention) and Intervention group in order to test the efficacy of the intervention Evaluation of health measures, muscle strength, balance, mobility, gait or velocity, before and after intervention through measuring instruments 4 | SULEIMANMARTOS ET AL. 2.6 | Data abstraction All data were extracted on a coding sheet by two of the authors (NSM and GCDF). If there was any disagreement, a third author (JLRB) checked the data. The following variables were obtained for each of the articles: (1) author, year, country; (2) design; (3) sample; (4) aim; (5) type of intervention; (6) adherence rate; (7) duration of intervention; (8) measuring instruments used and main results obtained. The reliability of the researchers’ data coding was assessed by calculating the intraclass correlation coefficient and Cohen's kappa coefficient. 2.7 | Data synthesis and analysis For the descriptive analysis, the information reported in each study was classified into data tables and these results were categorized in a systematic review. The metaanalysis considered only those studies with sufficient outcomes, including appropriate statistical data (sample size, postintervention mean and standard deviation, for the control and intervention groups). Publication bias was assessed with a funnel plot. Heterogeneity was assessed by the I2 index. If it exceed 50%, a random effects metaanalysis was performed, otherwise a fixed effects metaanalysis was applied. The following random effects metaanalyses were performed on the outcomes: (1) 6minute walk test; (2) Berg Balance Scale; (3) Grip strength; (4) Knee extension strength; (5) 8Foot UpandGo. In addition, fixed effects metaanalyses were applied to the following outcomes: (6) 30second chair stand; (7) Cadence; (8) Gait speed; (9) Timed UpandGo; (10) Velocity. RevMan Web software was used for the metaanalysis. 3 | RESULTS 3.1 | Search process and study characteristics The initial search obtained 1612 papers. After reviewing the titles and abstracts, 1510 were excluded, because they were duplicates or did not meet the inclusion criteria. After reading the fulltext articles, the final sample was then reduced to 22 papers, all of which provided sufficient analytical quality according to the quality assessment tools applied. The intraclass correlation coefficient was 0.96 (minimum = 0.95; maximum = 1) and Cohen's kappa coefficient of the categorical variables was 0.96 (minimum = 0.92; maximum = 1). The search and selection process are illustrated in Figure 1. In the papers considered, the total sample size was n = 1208 participants, all of whom were aged 55 years or more. The majority were women. Of these 22 studies, 18 had information on one or more of the outcomes assessed in our metaanalysis. The publication dates ranged from 2012 to 2020. Five were performed in the USA, followed by three in Switzerland, two each in Korea, France FIGURE 1 Flow diagram of the publication search process Records identified through database searching (n = 1612) Records excluded after reading Title and Abstract (n = 1510) Articles excluded after full-text reading (n = 80) Exclusion criteria: not an intervention study, lack of quantitative data pre-post intervention, protocol study, not older adult sample (≥ 55 years old), not active video games, results of the control group not reported, not independent functional status Exclusion criteria: duplicates, not randomised controlled trials, not virtual or interactive games as intervention Records screened (n = 1612) IdentificationScreeningEligibilityIncluded Full-text articles assessed for eligibility (n = 102) Studies included in qualitative synthesis (systematic review) (n = 22) Studies included in metaanalysis (n = 18) | 5 SULEIMANMARTOS ET AL. and Brazil, and one each in Lebanon, Australia, Denmark, Turkey, Singapore, Taiwan, Japan and the UK. Fourteen of the articles described an intervention based on the use of active video games, either with the Nintendo Wii console (Bieryla & Dold, 2013; Fakhro et al., 2020; Franco et al., 2012; Jorgensen et al., 2013; Kwok & Pua, 2016; Lee et al., 2014; Maillot et al., 2012; Ray et al., 2012; Rendon et al., 2012; Toulotte et al., 2012; Whyatt et al., 2015) or with the Xbox 360 (Bacha et al., 2018; Karahan et al., 2015; Queiroz et al., 2017). In the remaining articles, the intervention was based on a simulation, with a virtual 3D television game (Adcock et al., 2020; Park & Yim, 2015), with dancetraining video games (Eggenberger et al., 2015; Pichierri et al., 2012), with Microsoft Kinect exergames (Gschwind et al., 2015; Liao et al., 2019; Sato et al., 2015) or with an interactive augmented reality 3D exercise (Ku et al., 2019). The main characteristics of all these studies are listed in Table 2. 3.2 | Duration of intervention and adherence by participants The duration of the intervention programmes ranged from 3 weeks (Franco et al., 2012) to 24 weeks (Eggenberger et al., 2015) and that of individual activities from 15 min (Franco et al., 2012) to 120 min (Gschwind et al., 2015). Compliance rates were high, ranging from 70% (Adcock et al., 2020) to 100% (Franco et al., 2012). The characteristics of each intervention are shown in Table 2. 3.3 | Metaanalysis of the effect size produced by each intervention on physical function Sufficient data information were obtained to perform a metaanalysis of 10 variables: the 6min walk test (metres), 30s chair stand (repetitions), balance (measured on the Berg Balance Scale), cadence (steps/minute), gait speed (metres/second), grip strength (kg), knee extension strength (kg), Timed UpandGo (seconds), 8Foot UpandGo and velocity (cm/second). The variable most commonly included was Timed UpandGo (in nine articles) while the least common were cadence, gait speed, knee extension strength and 8Foot UpandGo (each were present in two articles). The largest sample size corresponded to the Timed UpandGo metaanalysis, with 233 participants in the intervention group and 241 in the control group. The heterogeneity index (I2), illustrated in Figure 2a,b, were high for the following tests: 6minute walk, balance, grip strength, knee extension strength and 8Foot UpandGo; low values were recorded for the 30second chair stand, cadence, gait speed, Timed UpandGo and velocity. The overall effect size of the intervention was statistically significant for two variables: gait speed and Timed UpandGo (in favour of the experimental group in both cases). For gait speed, the difference was – 0.10 metres/second (95%CI: – 0.16, – 0.05), and for Timed UpandGo it was – 0.34 s (95%CI: – 0.56, – 0.12). For the following tests, the differences between the control and experimental groups following the intervention were not statistically significant (p > .05): the 6minute walk test (26.04: 95%CI: – 0.58, 52.67); the 30second chair stand (0.54: 95%CI: – 0.65, 1.74); balance (1.69: 95%CI: – 0.68, 4.07), cadence (0.54: 95%CI: – 3.79, 4.87); grip strength (3.73: 95%CI: 0.07, 7.38); knee extension (– 1.32: 95%CI: – 7.73, 5.10), 8Foot UpandGo (– 0.15: 95%CI: – 2.13, 1.82) and velocity (2.05: 95%CI: – 1.11, 5.21). The forest plot for each variable is shown in Figure 2a,b, and the risk of bias is shown in Figure 3. The funnel plots did not reflect the presence of publication bias. 3.4 | Participants' perception of the intervention In general, the participants were satisfied with the intervention programmes, with up to 81% reporting high levels of enjoyment and satisfaction (Bacha et al., 2018; Franco et al., 2012). Similarly, a high proportion of participants indicated that the Nintendo Wii was fun and motivating, and would consider buying one (Jorgensen et al., 2013). In the study by Karahan et al. (2015), 42.8% of participants rated the use of the Xbox 360 console as moderately pleasant, while for 21.4% it was fairly pleasant. Significant improvements were also observed in quality of life, social role functioning and body awareness (Karahan et al., 2015; Maillot et al., 2012). Furthermore, greater confidence in functional activities led to a reduced fear of falls (Kwok & Pua, 2016; Rendon et al., 2012). 4 | DISCUSSION This systematic review and metaanalysis were undertaken to consider the effects produced by the use of active video games on parameters related to physical and motor function in independent communitydwelling older adults. A previous systematic review, with fewer studies and no metaanalysis, reported inconclusive results on the effectiveness or otherwise of virtual reality games in improving physical function in older adults (Molina et al., 2014). However, our own metaanalysis revealed a positive effects on clinical parameters such as gait speed and Timed UpandGo in older adults, corroborating previous metaanalyses in this respect (Pacheco et al., 2020; Taylor et al., 2018), which also reported that exergames were more effective than conventional exercise programmes for balance and the 30s chair stand. On the other hand, our analysis revealed no such prepost intervention improvement, possibly due to the inclusion of fewer studies in the previous metaanalyses, or because some of the studies included did not use the postintervention mean score of each group, or because postintervention statistical information was not shown in the forest plot, or because the studies considered were focused on older dependent people, who are at greater risk of falls (Pacheco et al., 2020; Taylor et al., 2018). Previous research has also observed beneficial results for the Timed UpandGo outcome, although only three studies addressed this parameter (Pacheco et al., 2020). This result was confirmed by our metaanalysis, which 6 | SULEIMANMARTOS ET AL. TABLE 2 Characteristics of the included studies (n = 22) Authors (year) country Sample Aim and Setting Intervention Duration Adherence rate Instruments/ Main outcomes M (SD) EL/RGBaseline (CG/IG) Followup (CG/IG) Adcock et al. (2020) Switzerland n = 31 n CG = 16 n IG = 15 Mean age = 73.9 years Female = 51.6% To analyse physical functions Clinic and research institute CG: No intervention (Active@Home training was provided to enable voluntary training) IG: Active@Home Exergame (Tai Chi exercises +dancing + stepbased cognitive games instructed by an avatar) 3 sessions per week (30– 40 min) for 16 weeks 70% Gait Speed mean (m/s) 1.4 (0.2)/1.2 (0.2) 30second chairstand (repetitions) 16.5 (6)/13 (4.5) 2min stepping test (repetitions) 74.5 (26)/66 (22.5) Gait Speed mean (m/s) 1.4 (0.2)/1.2 (0.1) 30second chairstand (repetitions) 15.5 (6)/13 (2.5) 2min stepping test (repetitions) 78.5 (7.7)/76 (14) 1b/A Bacha et al. (2018) Brazil n = 46 n CG = 23 n IG = 23 Mean age = 69.3 (5.3) years Female = 73.9% To analyse dynamic balance and cardiorespiratory fitness Clinic hospital CG: Traditional physical therapy exercises (endurance and strength same duration as intervention group) IG: Xbox 360 (Kinect Adventures games) 14 sessions (60 min) for 4 weeks 91% 6min step test (repetitions) 121.3 (24.6)/122.6 (23) MiniBalance Evaluation Systems Test (score) 27.6 (2.6)/26.5 (3.2) Functional Gait Assessment (score) 27.3 (2.1)/26.6 (2.4) 6min step test (repetitions) 144.7 (19.1)/134.3 (25.4) MiniBalance Evaluation Systems Test (score) 29.8 (2)/29.6 (2.8) Functional Gait Assessment (score) 29.3 (0.9)/28.1 (2) 1b/A Bieryla et al. (2013) USA n = 12 n CG = 6 n IG = 6 Mean age = 81.5 (5.5) years Female = 88.3% To improve clinical measures of balance Local senior living community CG: No intervention (normal daily activities) IG: Nintendo's Wii Fit (yoga +aerobic + balance games) 3 sessions per week (30 min) for 3 weeks - Berg Balance Scale (score) 51 (10)/50 (4) Timed UpandGo Test (s) 10.8 (10)/12.8 (2.7) Berg Balance Scale (score) 54(11.5)/53 (2) Timed UpandGo Test (s) 10.1 (7.8)/11.2 (3.7) 1b/A Eggenberger et al. (2015) Switzerland n = 47 n CG = 15 n IG1 = 15 n IG2 = 17 Mean age = 78.9 years Female = 64.8% To analyse gait and physical training Geriatric clinic CG: Treadmill walking IG1: Virtual reality video game dancing (DANCE) IG2: Treadmill walking with simultaneous verbal memory training (MEMORY) 52 sessions (60 min) for 26 weeks 79.8% Velocity (cm/s) 115.8 (5.4)/123 (5.3)/109.4 (3.8) 6minute walk test (m) 506 (18)/505 (25)/489 (16) Velocity (cm/s) 131.1 (4.7)/133.4 (5.2)/126.3 (5.4) 6minute walk test (m) 538 (21)/560 (21)/530 (20) 1b/A Fakhro et al. (2020) Lebanon n = 60 n CG = 30 n IG = 30 Mean age = 74.3 years Female = no data To analyse dynamic and static balance Communitydwelling elders at lowincome senior housing CG: No intervention (normal daily activities) IG: Nintendo Wii Fit (‘Soccer Heading’ + ‘Table Tilt’ game) 40 min session for 8 weeks - Timed UpandGo Test (s) 19.5 (9)/15.4 (4.6) Centre of pressure (%) 6.7/13.3 Timed UpandGo Test (s) 21.8 (9)/14.1 (4.4) Centre of pressure (%) 6.7/33.3 1b/A Franco et al. (2012), USA n = 32 n CG = 10 n IG1 = 11 n IG2 = 11 Mean age = 78.2 years Female = 78.1% To analyse balance and functional mobility Independent living senior housing CG: No intervention (normal daily activities) IG1: Nintendo Wii Fit games (balance games, yoga, aerobic +strength activities) IG2: Traditional exercise program (strength + balance training) in group sessions 2 sessions per week (10– 15 min) for 3 weeks 100% Berg Balance Scale (score) 50.3 (3.7)/48.5 (9.1)/47.3 (8) Tinetti Gait and Balance (score) 25.8 (1.8)/25.8 (4.3)/25 (4.1) Berg Balance Scale (score) 51.4 (2.9)/52 (5.4)/50.7 (6) Tinetti Gait and Balance (score) 26.8 (1.8)/26.7 (2.4)/26.4 (3.2) 1b/A Gschwind et al. (2015) Australia n = 124 n CG = 61 n IG1 = 24 n IG2 = 39 Mean age = 80.9 years Female = 65.8% To improve balance and lower extremity strength Participants’ homes CG: No intervention (educational booklet about health and fall prevention) IG1: Microsoft Kinect (strength +balance exergames) IG2: Step mat training (exergames by stepping) 120 min per week for 16 weeks - Timed UpandGo Test (s) 12.4 (3.7)/11.5 (3.5)/11.5 (3.1) Knee extension strength (kg) 21.9 (8.6)/20.8 (9.4)/24.2 (10.3) Timed UpandGo Test (s) 12.6 (4.4)/11.1 (3.3)/11.5 (2.6) Knee extension strength (kg) 23.8 (9.1)/26.2 (10.3)/25.8 (9.2) 1b/A Jorgensen et al. (2013) Denmark n = 57 n CG = 30 n IG = 27 Mean age = 75 (6) years Female = 69% To analyse improvements of muscle function, static postural balance and functional performance Geriatric research clinic CG: ethylene vinyl acetate copolymer shoe insoles for 10 weeks IG: Nintendo Wii Fit (balance +muscle exercise games) 2 sessions per week (35– 40 min) for 10 weeks - Rate force development (N/s) 3704 (2627)/3266 (2271) Timed UpandGo Test (s) 11 (5)/10.3 (3.8) 30second chairstand (repetitions) 11.2 (3)/11.5 (3.8) Rate force development (N/s) 3622 (2423)/4143 (2831) Timed UpandGo Test (s) 10.9 (5.1)/9 (3.2) 30second chairstand (repetitions) 12.1 (3)/13.3 (3.2) 1b/A Karahan et al. (2015) Turkey n = 90 n CG = 42 n IG = 48 Mean age = 71.5 years Female = 43.3% To analyse balance and functional mobility Outpatient clinic CG: Home exercise (balance, stretching +strength) IG: Xbox 360 (Kinect Adventures +Kinect Sports) 30 exercise sessions (30 min) for 6 weeks 90% Berg Balance Scale (score) 49.4 (3.7)/49.8 (3.8) Timed UpandGo Test (s) 8.6 (1.7)/8.7 (1.7) Berg Balance Scale (score) 51.1 (4.1)/54.9 (2.6) Timed UpandGo Test (s) 8.6 (1.8)/8.1 (1.4) 1b/A Ku et al. (2019) Korea n = 34 n CG = 16 n IG = 18 Mean age = 64.8 years Female = 50% To assess balance and movement parameters Hospital CG: Conventional physical fitness program (lowerextremity strengthening and endurance) IG: Interactive augmented reality. 3D environment displayed on a large screen (balloon game, cave game +rhythm game) 12 sessions (30 min) for 4 weeks 75% Berg Balance Scale (score) 55.1 (1.1)/ 54.5 (1.5) Timed UpandGo Test (s) 7.9 (0.5)/7.8 (0.7) Berg Balance Scale (score) 55.5 (0.8)/ 55.5 (0.9) Timed UpandGo Test (s) 7.7 (0.6)/7.3 (0.6) 1b/A (Continues) | 7 SULEIMANMARTOS ET AL. TABLE 2 Characteristics of the included studies (n = 22) Authors (year) country Sample Aim and Setting Intervention Duration Adherence rate Instruments/ Main outcomes M (SD) EL/RGBaseline (CG/IG) Followup (CG/IG) Adcock et al. (2020) Switzerland n = 31 n CG = 16 n IG = 15 Mean age = 73.9 years Female = 51.6% To analyse physical functions Clinic and research institute CG: No intervention (Active@Home training was provided to enable voluntary training) IG: Active@Home Exergame (Tai Chi exercises +dancing + stepbased cognitive games instructed by an avatar) 3 sessions per week (30– 40 min) for 16 weeks 70% Gait Speed mean (m/s) 1.4 (0.2)/1.2 (0.2) 30second chairstand (repetitions) 16.5 (6)/13 (4.5) 2min stepping test (repetitions) 74.5 (26)/66 (22.5) Gait Speed mean (m/s) 1.4 (0.2)/1.2 (0.1) 30second chairstand (repetitions) 15.5 (6)/13 (2.5) 2min stepping test (repetitions) 78.5 (7.7)/76 (14) 1b/A Bacha et al. (2018) Brazil n = 46 n CG = 23 n IG = 23 Mean age = 69.3 (5.3) years Female = 73.9% To analyse dynamic balance and cardiorespiratory fitness Clinic hospital CG: Traditional physical therapy exercises (endurance and strength same duration as intervention group) IG: Xbox 360 (Kinect Adventures games) 14 sessions (60 min) for 4 weeks 91% 6min step test (repetitions) 121.3 (24.6)/122.6 (23) MiniBalance Evaluation Systems Test (score) 27.6 (2.6)/26.5 (3.2) Functional Gait Assessment (score) 27.3 (2.1)/26.6 (2.4) 6min step test (repetitions) 144.7 (19.1)/134.3 (25.4) MiniBalance Evaluation Systems Test (score) 29.8 (2)/29.6 (2.8) Functional Gait Assessment (score) 29.3 (0.9)/28.1 (2) 1b/A Bieryla et al. (2013) USA n = 12 n CG = 6 n IG = 6 Mean age = 81.5 (5.5) years Female = 88.3% To improve clinical measures of balance Local senior living community CG: No intervention (normal daily activities) IG: Nintendo's Wii Fit (yoga +aerobic + balance games) 3 sessions per week (30 min) for 3 weeks - Berg Balance Scale (score) 51 (10)/50 (4) Timed UpandGo Test (s) 10.8 (10)/12.8 (2.7) Berg Balance Scale (score) 54(11.5)/53 (2) Timed UpandGo Test (s) 10.1 (7.8)/11.2 (3.7) 1b/A Eggenberger et al. (2015) Switzerland n = 47 n CG = 15 n IG1 = 15 n IG2 = 17 Mean age = 78.9 years Female = 64.8% To analyse gait and physical training Geriatric clinic CG: Treadmill walking IG1: Virtual reality video game dancing (DANCE) IG2: Treadmill walking with simultaneous verbal memory training (MEMORY) 52 sessions (60 min) for 26 weeks 79.8% Velocity (cm/s) 115.8 (5.4)/123 (5.3)/109.4 (3.8) 6minute walk test (m) 506 (18)/505 (25)/489 (16) Velocity (cm/s) 131.1 (4.7)/133.4 (5.2)/126.3 (5.4) 6minute walk test (m) 538 (21)/560 (21)/530 (20) 1b/A Fakhro et al. (2020) Lebanon n = 60 n CG = 30 n IG = 30 Mean age = 74.3 years Female = no data To analyse dynamic and static balance Communitydwelling elders at lowincome senior housing CG: No intervention (normal daily activities) IG: Nintendo Wii Fit (‘Soccer Heading’ + ‘Table Tilt’ game) 40 min session for 8 weeks - Timed UpandGo Test (s) 19.5 (9)/15.4 (4.6) Centre of pressure (%) 6.7/13.3 Timed UpandGo Test (s) 21.8 (9)/14.1 (4.4) Centre of pressure (%) 6.7/33.3 1b/A Franco et al. (2012), USA n = 32 n CG = 10 n IG1 = 11 n IG2 = 11 Mean age = 78.2 years Female = 78.1% To analyse balance and functional mobility Independent living senior housing CG: No intervention (normal daily activities) IG1: Nintendo Wii Fit games (balance games, yoga, aerobic +strength activities) IG2: Traditional exercise program (strength + balance training) in group sessions 2 sessions per week (10– 15 min) for 3 weeks 100% Berg Balance Scale (score) 50.3 (3.7)/48.5 (9.1)/47.3 (8) Tinetti Gait and Balance (score) 25.8 (1.8)/25.8 (4.3)/25 (4.1) Berg Balance Scale (score) 51.4 (2.9)/52 (5.4)/50.7 (6) Tinetti Gait and Balance (score) 26.8 (1.8)/26.7 (2.4)/26.4 (3.2) 1b/A Gschwind et al. (2015) Australia n = 124 n CG = 61 n IG1 = 24 n IG2 = 39 Mean age = 80.9 years Female = 65.8% To improve balance and lower extremity strength Participants’ homes CG: No intervention (educational booklet about health and fall prevention) IG1: Microsoft Kinect (strength +balance exergames) IG2: Step mat training (exergames by stepping) 120 min per week for 16 weeks - Timed UpandGo Test (s) 12.4 (3.7)/11.5 (3.5)/11.5 (3.1) Knee extension strength (kg) 21.9 (8.6)/20.8 (9.4)/24.2 (10.3) Timed UpandGo Test (s) 12.6 (4.4)/11.1 (3.3)/11.5 (2.6) Knee extension strength (kg) 23.8 (9.1)/26.2 (10.3)/25.8 (9.2) 1b/A Jorgensen et al. (2013) Denmark n = 57 n CG = 30 n IG = 27 Mean age = 75 (6) years Female = 69% To analyse improvements of muscle function, static postural balance and functional performance Geriatric research clinic CG: ethylene vinyl acetate copolymer shoe insoles for 10 weeks IG: Nintendo Wii Fit (balance +muscle exercise games) 2 sessions per week (35– 40 min) for 10 weeks - Rate force development (N/s) 3704 (2627)/3266 (2271) Timed UpandGo Test (s) 11 (5)/10.3 (3.8) 30second chairstand (repetitions) 11.2 (3)/11.5 (3.8) Rate force development (N/s) 3622 (2423)/4143 (2831) Timed UpandGo Test (s) 10.9 (5.1)/9 (3.2) 30second chairstand (repetitions) 12.1 (3)/13.3 (3.2) 1b/A Karahan et al. (2015) Turkey n = 90 n CG = 42 n IG = 48 Mean age = 71.5 years Female = 43.3% To analyse balance and functional mobility Outpatient clinic CG: Home exercise (balance, stretching +strength) IG: Xbox 360 (Kinect Adventures +Kinect Sports) 30 exercise sessions (30 min) for 6 weeks 90% Berg Balance Scale (score) 49.4 (3.7)/49.8 (3.8) Timed UpandGo Test (s) 8.6 (1.7)/8.7 (1.7) Berg Balance Scale (score) 51.1 (4.1)/54.9 (2.6) Timed UpandGo Test (s) 8.6 (1.8)/8.1 (1.4) 1b/A Ku et al. (2019) Korea n = 34 n CG = 16 n IG = 18 Mean age = 64.8 years Female = 50% To assess balance and movement parameters Hospital CG: Conventional physical fitness program (lowerextremity strengthening and endurance) IG: Interactive augmented reality. 3D environment displayed on a large screen (balloon game, cave game +rhythm game) 12 sessions (30 min) for 4 weeks 75% Berg Balance Scale (score) 55.1 (1.1)/ 54.5 (1.5) Timed UpandGo Test (s) 7.9 (0.5)/7.8 (0.7) Berg Balance Scale (score) 55.5 (0.8)/ 55.5 (0.9) Timed UpandGo Test (s) 7.7 (0.6)/7.3 (0.6) 1b/A (Continues) 8 | SULEIMANMARTOS ET AL. Authors (year) country Sample Aim and Setting Intervention Duration Adherence rate Instruments/ Main outcomes M (SD) EL/RGBaseline (CG/IG) Followup (CG/IG) Kwok and Pua (2016) Singapore n = 80 n CG = 40 n IG = 40 Mean age = 70.1 years Female = 85% To analyse physical functions Outpatient centre CG: Standard Gymbased exercise IG: Nintendo Wii Fit (cardiovascular training, resistance, strengthening +balance) 12 sessions once weekly (60 min) for 12 weeks 80% Timed UpandGo Test (s) 12.3 (5.7)/11.7 (4.5) 6minute walk test (m) 290.8 (85.3)/297.1 (69.9) Gait speed (4m walk test) (m/s) 0.8 (0.3)/0.8 (0.2) Knee extension strength (kg) 24.9 (9.4)/24.5 (8.6) Timed UpandGo Test (s) 9.1 (1.2)/9.1 (1.1) 6minute walk test (m) 335.9 (26.3)/323.7 (25.9) Gait speed (4m walk test) (m/s) 1.2 (0.1)/1.1 (0.1) Knee extension strength (kg) 34.6 (2.3)/30.4 (2.3) 1b/A Lee et al. (2014) USA n = 82 n CC = 42 n IG = 40 Mean age = 75.2 (6.6) years Female = 70.7% To analyse benefit on gait parameters Centre for healthy living and longevity CG: Traditional fitness (strength +balance training) IG: Nintendo Wii Fit (sport +balance) 3 sessions per week (45 min) for 10 weeks - Velocity (cm/s) 121.4 (18.4)/120.7 (21.5) Stride length (cm) 129 (13.2)/126 (16.7) Cadence (steps/min) 112.9 (9.8)/115.2 (14.3) Velocity (cm/s) 128.2 (22.1)/128.1 (21.3) Stride length (cm) 130(19.2)/131 (16.3) Cadence (steps/min) 119.4 (19)/117.5 (11.9) 1b/A Liao et al. (2019) Taiwan n = 52 n CC = 25 n IG = 27 Mean age = 81.8 years Female = 69.2% To assess the improvement in frailty status and physical performance Senior centre CG: Traditional fitness (balance exercise + resistance + aerobic exercises) IG: Balance game virtual 3D fullbody map + Taichi exercise +resistance + aerobic exercises 36 sessions (60 min) for 12 weeks - 30second sittostand test (times) 8.9 (4.9)/9.9 (5.1) Timed UpandGo Test (s) 16.6 (9.9)/17 (8.4) Velocity (cm/s) 62 (24)/61 (33) Grip strength (kg) 13.7 (5.5)/17 (5.6) 30second sittostand test (times) 11.8 (5.4)/13 (5.8) Timed UpandGo Test (s) 15.4 (8.2)/15.1 (8.7) Velocity (cm/s) 68 (27)/74 (29) Grip strength (kg) 15.4 (5)/18.2 (5.4) 1b/A Maillot et al. (2012) France n = 32 n CC = 16 n IG = 16 Mean age = 73.5 (6) years Female = 84.4% To analyse an exergame training as a mode of physical activity Community senior centre CG: No intervention (commitment to not modify their sedentary lifestyle over 14 weeks) IG: Nintendo Wii Fit (games of physically simulated sport) 24 sessions (60 min) for 14 weeks 97.50% Mean Heart Rate 6Min Walk (bpm) 100.2 (15.1)/106.8 (11.6) 6minute walk test (m) 429.8 (61.5)/411.1 (84.6) 8Foot Up and Go (s) 7.1 (1.6)/7.4 (1.3) Mean Heart Rate 6Min Walk (bpm) 96.4 (11.6)/114.2 (13.5) 6minute walk test (m) 432.9 (26.5)/469.2 (40.4) 8Foot Up and Go (s) 7.6 (1.1)/6.4 (0.6) 1b/A Park et al. (2015) Korea n = 72 n CG = 36 n IG = 36 Mean age = 73.5 years Female = 94.4% To improve the cognitive function, muscle strength and balance Senior centre CG: Conventional exercise program with stepping, walking, oneleg standing and cup tapping (30 min) IG: Virtual reality kayak program 50 min session for 6 weeks - Grip strength (Right) (kg) 20.3 (5.5)/21.3 (5.6) Grip strength (Left) (kg) 18.3 (5.1)/20.1 (6.8) Grip strength (Right) (kg) 17.7 (5.1)/23.3 (4.8) Grip strength (Left) (kg) 15.2 (4.5)/23.1 (5.1) 1b/A Pichierri et al. (2012) Switzerland n = 31 n CG = 16 n IG = 15 Mean age = 86.2 (4.6) years Female = 81.8% To investigate the effects of training programs on physical parameters Hostels for the aged CG: Conventional exercise program (progressive resistance +postural balance) IG: Exercise +video game dancing program 40 min sessions twice weekly for 12 weeks 75% Medians (interquartile ranges) Velocity (cm/s) 69 (61.1– 82.7)/80.4 (72.9– 89.1) Cadence (steps/min) 93.9 (80.2– 99.9)/95.5 (93.3– 102.5) Medians (interquartile ranges) Velocity (cm/s) 82.2 (73.8– 101.8)/88.3 (69.2– 106.2) Cadence (steps/min) 104.2 (89.9– 112.3)/97.5 (96– 111.8) 1b/A Queiroz et al. (2017) Brazil n = 27 n CG = 14 n IG = 13 Mean age = 60.4 years Female = 59.2% To compare the effects of exergame on the functional fitness Laboratory CG: Aerobic exercise program (same duration as intervention) IG: Xbox 360 (Kinect sports games) 36 sessions (60 min) for 12 weeks 90.6% Timed UpandGo Test (s) 5.7 (0.6)/5.3 (0.8) 30second chairstand (repetitions) 13.5 (2.1)/14.3 (3.2) 2min stepping test (repetitions) 87.2 (0.2)/92.9 (19.9) Timed UpandGo Test (s) 5.1 (0.5)/4.8 (0.3) 30second chairstand (repetitions) 17.9 (4.5)/18.2 (3.2) 2min stepping test (repetitions) 93.7 (22.8)/110.5 (16.1) 1b/A Ray et al. (2012) USA n = 87 n CG = 18 n IG1 = 29 n IG2 = 40 Mean age = 75 years Female = 66.6% To analyse the ability to maintain postural control Laboratory CG: No intervention (no exercise prescribed) IG1: Nintendo Wii Fit (balance, bowling +boxing games) IG2: Fitness group 3 sessions per week (45 min) for 15 weeks - 6minute walk test (m) 529.1 (111.3)/462 (101.9)/416 (157.1) 8Foot Up and Go (s) 6.3 (1.2)/8 (1.5)/7.4 (1.4) Grip strength (kg) 27.3 (6.1)/23.4 (8.6)/25.9 (8.6) BMI 29.4 (1.4)/28 (4.7)/26.6 (6.2) 6minute walk test (m) 409.6 (245.1)/508.3 (81)/441.9 (167.7) 8Foot Up and Go (s) 6.2 (2)/7.1 (1.2)/6.8 (1) Grip strength (kg) 28.2 (9)/24.7 (7.7)/25.4 (9.8) BMI 29 (1.9)/27.5 (5.2)/26.4 (5.7) 1b/A Rendon et al. (2012) USA n = 40 n CG = 20 n IG = 20 Mean age = 84.5 (5.2) years Female = 65% To analyse the improvement of dynamic balance Outpatient geriatric clinic CG: No intervention (instructed to not alter their normal daily activities) IG: Nintendo Wii Fit (balance games+postural stability) 18 sessions (35– 45 min) for 6 weeks - Median (min– max) 8Foot Up and Go (s) 8.5 (5.1– 17.3)/9.1 (5.6– 18.3) Median (min– max) 8Foot Up and Go (s) 8.3 (5.2– 19.5)/8.5 (5.1– 16.5) 1b/A TABLE 2 (Continued) (Continues) | 9 SULEIMANMARTOS ET AL. Authors (year) country Sample Aim and Setting Intervention Duration Adherence rate Instruments/ Main outcomes M (SD) EL/RGBaseline (CG/IG) Followup (CG/IG) Kwok and Pua (2016) Singapore n = 80 n CG = 40 n IG = 40 Mean age = 70.1 years Female = 85% To analyse physical functions Outpatient centre CG: Standard Gymbased exercise IG: Nintendo Wii Fit (cardiovascular training, resistance, strengthening +balance) 12 sessions once weekly (60 min) for 12 weeks 80% Timed UpandGo Test (s) 12.3 (5.7)/11.7 (4.5) 6minute walk test (m) 290.8 (85.3)/297.1 (69.9) Gait speed (4m walk test) (m/s) 0.8 (0.3)/0.8 (0.2) Knee extension strength (kg) 24.9 (9.4)/24.5 (8.6) Timed UpandGo Test (s) 9.1 (1.2)/9.1 (1.1) 6minute walk test (m) 335.9 (26.3)/323.7 (25.9) Gait speed (4m walk test) (m/s) 1.2 (0.1)/1.1 (0.1) Knee extension strength (kg) 34.6 (2.3)/30.4 (2.3) 1b/A Lee et al. (2014) USA n = 82 n CC = 42 n IG = 40 Mean age = 75.2 (6.6) years Female = 70.7% To analyse benefit on gait parameters Centre for healthy living and longevity CG: Traditional fitness (strength +balance training) IG: Nintendo Wii Fit (sport +balance) 3 sessions per week (45 min) for 10 weeks - Velocity (cm/s) 121.4 (18.4)/120.7 (21.5) Stride length (cm) 129 (13.2)/126 (16.7) Cadence (steps/min) 112.9 (9.8)/115.2 (14.3) Velocity (cm/s) 128.2 (22.1)/128.1 (21.3) Stride length (cm) 130(19.2)/131 (16.3) Cadence (steps/min) 119.4 (19)/117.5 (11.9) 1b/A Liao et al. (2019) Taiwan n = 52 n CC = 25 n IG = 27 Mean age = 81.8 years Female = 69.2% To assess the improvement in frailty status and physical performance Senior centre CG: Traditional fitness (balance exercise + resistance + aerobic exercises) IG: Balance game virtual 3D fullbody map + Taichi exercise +resistance + aerobic exercises 36 sessions (60 min) for 12 weeks - 30second sittostand test (times) 8.9 (4.9)/9.9 (5.1) Timed UpandGo Test (s) 16.6 (9.9)/17 (8.4) Velocity (cm/s) 62 (24)/61 (33) Grip strength (kg) 13.7 (5.5)/17 (5.6) 30second sittostand test (times) 11.8 (5.4)/13 (5.8) Timed UpandGo Test (s) 15.4 (8.2)/15.1 (8.7) Velocity (cm/s) 68 (27)/74 (29) Grip strength (kg) 15.4 (5)/18.2 (5.4) 1b/A Maillot et al. (2012) France n = 32 n CC = 16 n IG = 16 Mean age = 73.5 (6) years Female = 84.4% To analyse an exergame training as a mode of physical activity Community senior centre CG: No intervention (commitment to not modify their sedentary lifestyle over 14 weeks) IG: Nintendo Wii Fit (games of physically simulated sport) 24 sessions (60 min) for 14 weeks 97.50% Mean Heart Rate 6Min Walk (bpm) 100.2 (15.1)/106.8 (11.6) 6minute walk test (m) 429.8 (61.5)/411.1 (84.6) 8Foot Up and Go (s) 7.1 (1.6)/7.4 (1.3) Mean Heart Rate 6Min Walk (bpm) 96.4 (11.6)/114.2 (13.5) 6minute walk test (m) 432.9 (26.5)/469.2 (40.4) 8Foot Up and Go (s) 7.6 (1.1)/6.4 (0.6) 1b/A Park et al. (2015) Korea n = 72 n CG = 36 n IG = 36 Mean age = 73.5 years Female = 94.4% To improve the cognitive function, muscle strength and balance Senior centre CG: Conventional exercise program with stepping, walking, oneleg standing and cup tapping (30 min) IG: Virtual reality kayak program 50 min session for 6 weeks - Grip strength (Right) (kg) 20.3 (5.5)/21.3 (5.6) Grip strength (Left) (kg) 18.3 (5.1)/20.1 (6.8) Grip strength (Right) (kg) 17.7 (5.1)/23.3 (4.8) Grip strength (Left) (kg) 15.2 (4.5)/23.1 (5.1) 1b/A Pichierri et al. (2012) Switzerland n = 31 n CG = 16 n IG = 15 Mean age = 86.2 (4.6) years Female = 81.8% To investigate the effects of training programs on physical parameters Hostels for the aged CG: Conventional exercise program (progressive resistance +postural balance) IG: Exercise +video game dancing program 40 min sessions twice weekly for 12 weeks 75% Medians (interquartile ranges) Velocity (cm/s) 69 (61.1– 82.7)/80.4 (72.9– 89.1) Cadence (steps/min) 93.9 (80.2– 99.9)/95.5 (93.3– 102.5) Medians (interquartile ranges) Velocity (cm/s) 82.2 (73.8– 101.8)/88.3 (69.2– 106.2) Cadence (steps/min) 104.2 (89.9– 112.3)/97.5 (96– 111.8) 1b/A Queiroz et al. (2017) Brazil n = 27 n CG = 14 n IG = 13 Mean age = 60.4 years Female = 59.2% To compare the effects of exergame on the functional fitness Laboratory CG: Aerobic exercise program (same duration as intervention) IG: Xbox 360 (Kinect sports games) 36 sessions (60 min) for 12 weeks 90.6% Timed UpandGo Test (s) 5.7 (0.6)/5.3 (0.8) 30second chairstand (repetitions) 13.5 (2.1)/14.3 (3.2) 2min stepping test (repetitions) 87.2 (0.2)/92.9 (19.9) Timed UpandGo Test (s) 5.1 (0.5)/4.8 (0.3) 30second chairstand (repetitions) 17.9 (4.5)/18.2 (3.2) 2min stepping test (repetitions) 93.7 (22.8)/110.5 (16.1) 1b/A Ray et al. (2012) USA n = 87 n CG = 18 n IG1 = 29 n IG2 = 40 Mean age = 75 years Female = 66.6% To analyse the ability to maintain postural control Laboratory CG: No intervention (no exercise prescribed) IG1: Nintendo Wii Fit (balance, bowling +boxing games) IG2: Fitness group 3 sessions per week (45 min) for 15 weeks - 6minute walk test (m) 529.1 (111.3)/462 (101.9)/416 (157.1) 8Foot Up and Go (s) 6.3 (1.2)/8 (1.5)/7.4 (1.4) Grip strength (kg) 27.3 (6.1)/23.4 (8.6)/25.9 (8.6) BMI 29.4 (1.4)/28 (4.7)/26.6 (6.2) 6minute walk test (m) 409.6 (245.1)/508.3 (81)/441.9 (167.7) 8Foot Up and Go (s) 6.2 (2)/7.1 (1.2)/6.8 (1) Grip strength (kg) 28.2 (9)/24.7 (7.7)/25.4 (9.8) BMI 29 (1.9)/27.5 (5.2)/26.4 (5.7) 1b/A Rendon et al. 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L., CañadasDe La Fuente, G. A., MonsalveReyes, C., & GomezUrquiza, J. L. (2021). Effects of active video games on physical function in independent communitydwelling older adults: A systematic review and metaanalysis. Journal of Advanced Nursing, 00, 1– 17. https://doi.org/10.1111/jan.15138 The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers. 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