Can video games help older people with back pain?

Low back pain is the leading cause of disability worldwide [1] and up to 90% of people will experience low back pain at some point in their life [2]. The small percentage of people who develop chronic and disabling symptoms account for most of the burden of low back pain, and these are mostly older people [3].

Low back pain becomes more severe and disabling as people age [4], and substantially affects older people’s physical functioning, such as their strength, balance and walking speed. Despite this, most of the treatment options we have for low back pain have not been tested on older people. This is particularly problematic given the rapidly aging population.

People with chronic low back pain are encouraged to exercise, but compliance with unsupervised home-exercise is poor [5]. To complicate matters, older people with poor physical functioning often prefer home-based exercise as accessing treatment facilities can be difficult and costly [6].

Video-game exercise programs could be a solution to this problem, as they include features that could increase motivation to perform home-exercise. These features include video and audio exercise instructions, feedback on technique and a scoring system that provides feedback on overall performance. Video-game exercise programs are also low-cost and could reduce the need to travel to treatment facilities for supervised exercise. These programs could therefore be a valuable self-management strategy for older people with chronic low back pain.

What we did

We conducted a randomised controlled trial that investigated the effectiveness of a home-based video-game exercise program for older people with chronic low back pain [7]. To be included, patients had to be over 55 years old, report non-specific low back pain that had lasted for at least three months, report a usual pain intensity of 3/10 or greater on a numeric rating scale, and be able to mobilise independently without a walking aid.

We recruited 60 participants from the community and waiting list of an outpatient physiotherapy department in Western Sydney, Australia. Participants were randomised to receive home-based video-game exercises for 8 weeks (video-game exercise group) or continue their usual activities and care-seeking behaviours (control group).

Participants in the video-game exercise group performed a range of flexibility, strength, aerobic and balance exercises at home using the Nintendo Wii-Fit-U program. Participants were encouraged to perform video-game exercises for 60 minutes, 3 times per week, and could select which exercises they wanted to perform. The only extra contact participants in the video-game exercise group had with the research team was during the first session – when they were instructed how to use the program – and during fortnightly telephone calls – where they could report any technical issues encountered.

We were interested in determining whether video-game exercises could help older people with chronic low back pain self-manage their condition and reduce their need for formal treatment. As a result, our primary outcomes were pain self-efficacy (assessed using the 10-item Pain Self-Efficacy Questionnaire, PSEQ) and care seeking behaviours at 3 and 6 months. Higher scores on the PSEQ indicated a greater ability to continue with daily activities despite pain. Care seeking behaviours included current care seeking (e.g. general practitioner, physiotherapist, chiropractor, etc.) and medication use.

We also collected data on pain, function, disability, physical activity, fear of movement/re-injury and falls efficacy, but only at baseline and immediately post-intervention (8 weeks). This reduced the burden on participants and helped us achieve a high rate of follow-up at 6 months (95%). Participants tracked the duration and frequency of their exercise sessions in a paper exercise diary because it is simple and likely appropriate for an older population. Statistical tests were performed to identify differences in outcomes between the video-game exercise and control group.

What we found

Participants in the video-game exercise group had significantly higher pain self-efficacy compared to the control group at 6 months (5.2 points higher on a 0-60 scale, 95% Confidence Interval, CI: 0.5 to 9.8, p=0.03), but not at 3 months (4.3 points higher, 95% CI: -0.2 to 8.8, p=0.06) or immediately post-intervention (1.2 points higher, 95% CI: -3.2 to 5.6, p=0.59). There were no differences between the groups for care seeking behaviours.

Participants in the video-game exercise group experienced significantly greater post-intervention reductions in pain (1.1 points lower on a 0-10 scale, 95% CI: -2.1 to 0.0, p=0.04) and improvements in function (1.2 points higher on a 0-10 scale, 95% CI: 0.1 to 2.3, p=0.03) compared to the control group. However, there was no difference between the groups for the remaining outcomes.

Participants in the video-game exercise group completed, on average, 85% of the recommended sessions and the mean total exercise time was 71% of our recommendation for the 8-week period.

What this means

Home-based video-game exercises can improve pain self-efficacy, and may improve pain and function in older people with chronic low back pain, but the magnitude of these effects are small. For example, participants completing home-based video-game exercises experienced a 27% reduction in pain and 23% increase in function by the end of the 8-week trial. To put this in perspective, small effects are very common when treating chronic pain, and the beneficial effects of video-game exercises were comparable to supervised exercise programs.

Home-based video-game exercises provide a unique solution to increase older people’s motivation to self-manage their chronic low back pain through home-exercise. These programs have potential because supervised physiotherapy visits can be costly and people who live in remote or rural areas can face barriers accessing these services. Video-game exercises could also be implemented under the current Medical Benefit Scheme chronic pain care pathway in Australia, with only one session needed to set up the program and teach patients how to use it. Traditional exercise programs usually require many more sessions than are funded by the Medical Benefit Scheme.

Our study found high compliance to home-based video-game exercises, with participants completing on average 85% of recommended sessions. This is much higher than compliance to unsupervised exercise reported in other studies [8], but many of the exercise sessions in our trial failed to last for 60 minutes. These findings suggests older people with chronic low back pain might be more suited to shorter exercise sessions.

Participants rarely had issues or questions regarding how to use the equipment. Future trials should therefore consider removing scheduled telephone contact between participants and the research team. This would better match the patient-therapist interaction time between the groups. Effectiveness in this context would further support usefulness of this novel approach to self-management that has the potential to reduce care seeking among older people with chronic low back pain.

Take away message

Home-based video-game exercises can improve pain self-efficacy, and may reduce pain and increase physical functioning in older people with chronic low back pain. These effects are small but comparable to supervised exercise program. Video-game exercises should therefore be considered a valuable treatment option for older people with chronic low back pain that is low cost and could reduce reliance on a healthcare system with scarce resources.

About Joshua Zadro

Joshua is a Physiotherapist and Postdoctoral Research Fellow at the Institute for Musculoskeletal Health, The University of Sydney. He is currently investigating strategies to replace low-value physiotherapy with high-value physiotherapy in partnership with the Australian Physiotherapy Association, Choosing Wisely Australia and Wiser Healthcare. He completed his PhD at the end of 2017, with a research focus on chronic back pain, physical activity and the role of shared familial factors. He has published his work in high-impact spine and physiotherapy journals and presented at leading conferences in his field (e.g. World Congress on Pain, International Back & Neck Pain Forum, Preventing Overdiagnosis). He continues to work clinically and over the past few years has taught in musculoskeletal physiotherapy units at The University of Sydney.

References

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[2] Australian Institute of Health and Welfare 2018. Back problems snapshot. Cat. no: PHE 231.

[3] Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North Am. 1991;22(2):263-71.

[4] Buchbinder R, Blyth FM, March LM, Brooks P, Woolf AD, Hoy DG. Placing the global burden of low back pain in context. Best Practice & Research in Clinical Rheumatology. 2013;27(5):575-89.

[5] van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Practice & Research in Clinical Rheumatology. 2010;24(2):193-204.

[6] Franco MR, Howard K, Sherrington C, Ferreira PH, Rose J, Gomes JL, et al. Eliciting older people’s preferences for exercise programs: a best-worst scaling choice experiment. J Physiother. 2015;61(1):34-41.

[7] Zadro JR, Shirley D, Simic M, Mousavi SJ, Ceprnja D, Maka K, et al. Video Game-Based Exercises for Older People With Chronic Low Back Pain: A Randomized Controlled Trial (GAMEBACK). Phys Ther. 2018.

[8] Friedrich M, Gittler G, Halberstadt Y, Cermak T, Heiller I. Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 1998;79(5):475-87.