The effect of visual biofeedback on balance in elderly population: a systematic review Hammad Alhasan,1 Victoria Hood,2 Frederick Mainwaring2 1Physiotherapy Department, Faculty of Applied Medical Science, Umm al-Qura University, Mecca, Kingdom of Saudi Arabia; 2School of Health Science, University of Nottingham, Nottingham, Nottinghamshire, UK Background: Balance is commonly affected by multiple factors, especially among the elderly population. Visual biofeedback (VBF) is an intervention tool that can be used in balance rehabilitation. Aim: This study aimed to systematically review randomized controlled trials that examine whether VBF training is effective in improving balance in an elderly population.Data sources: Three databases were searched: CIAHL, EMBASE, and MEDLINE. The searches were limited to the period from 2010 to 2016.Eligibility criteria: Healthy adults, aged â?¥65 years, with no specific disorders were included. Interventions were any VBF intervention with the aim of improving balance and were compared to no intervention, traditional exercises, placebo, or standard care. The outcome measures were balance as measured by any validated outcome measure.Studies appraisal method: The Physiotherapy Evidence Database quality assessment tool and The Cochrane Collaboration tool for assessing risk of bias were used by two independent authors (HA and FM) in order to appraise the included studies.Results: The database search resulted in 879 articles, of which five papers were included. VBF was compared to no intervention, a placebo, and traditional exercise. The total number of participants in all the five included studies was 181, with a mean age of 74.3 years (standard deviation 6.7). Two studies were rated as high-quality studies, and three were rated as fair quality.Conclusion: Engaging elderly people living in the community in VBF training was found to be effective and could improve their balance ability. However, the variation between studies in methodology, intervention protocol, and outcomes utilized made it difficult to inform a definitive statement regarding the potential application of VBF for balance training with the elderly. Furthermore, high-quality randomized control trials are required. The systematic review level of evidence is moderate, and the strength of recommendation is that VBF is likely to be beneficial. Keywords: visual feedback, exergames, older adult, postural balance

Background: Interactive videogames (IVGs) have been used to reduce risk of falls in the older adult and improve postural control (PC) outcomes. Objective: To systematically review trials that examine whether IVGs training is effective in improving PC and managing falls in frail and pre-frail older adults. Data Sources: Four databases were searched, Scopus, Web of science, PubMed, and MEDLINE, from January 2007 to March 2019. Eligibility Criteria: Frail and pre-frail older adults aged 65+. Interventions were any Nintendo^® Wii™ training. The outcome measures were PC and risk of falls as measured by any validated outcome measure. Studies Appraisal Method: The PEDro (Physiotherapy Evidence Database) scale and Cochrane risk-of-bias tool were used by two independent authors. Results: Eleven papers were included, involving 388 participants, with a mean age of 79 ± 5.7 years. The mean duration of IVGs sessions was 8.8 ± 3.8 weeks, the mean total number of sessions was 20 ± 11.1 session, and the mean length of training was 44 ± 15.7 minutes. Meta-Analysis: IVGs achieved better results compared with traditional exercises and control on the Berg Balance Scale (mean difference [MD] 2.80; 95% confidence interval [CI] 1.21 to 4.39; P < 0.001; I² = 16%), as well as in the short term on Timed Up and Go (MD −1.23; 95% CI −2.37 to −0.09; P = 0.03; I² = 0%). Limitation: Definitive judgement could not be made due to the variability in training, training duration and outcomes measurement. Conclusion: IVGs is a promising modality that has a positive effect on PC but not on the outcome of falls, so it should be prescribed with caution among frail older adults. Systematic Review Registration: PROSPERO registration number: CRD42019129611.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Frailty is a geriatric syndrome associated with increased risk of falls, hospitalization, and reduced quality of life. Traditional exercises may be unsuitable for frail older adults due to mobility issues and accessibility barriers. Virtual reality (VR) offers an engaging, home-based alternative by providing interactive training with real-time feedback. VR interventions have shown potential benefits for improving balance, strength, and mobility Objective: To systematically evaluate the effectiveness of VR-based home training programs in improving balance, strength, and mobility among frail and pre-frail older adults. Methods: A systematic search was conducted in PubMed, Scopus, and Web of Science from inception to November 1, 2023, using terms related to older adults, frailty, virtual reality, balance, mobility, and strength. Eligible studies included randomized and non-randomized trials involving frail or pre-frail adults aged ≥65 years who received home-based VR interventions aimed at improving balance, strength, or functional mobility. Comparator groups included no intervention, traditional exercise, or standard care. Studies involving participants with neurological or cognitive disorders were excluded. Study quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. A random-effects meta-analysis was performed to calculate pooled mean differences (MD) and 95% confidence intervals (CI) for three primary outcomes Berg Balance Scale (BBS), Timed Up and Go (TUG), and Chair Stand (CS). Results: A total of 1063 records were identified, with 1023 screened after duplicate removal. Six studies met the inclusion criteria, involving 407 participants (mean age 75.2 ± 6.4 years), of whom 198 were allocated to VR interventions and 159 to control groups. VR interventions lasted a mean of 13.3 ± 7.7 weeks, with an average of 39.6 ± 5.2 sessions lasting 25.3 ± 5 minutes. Methodological quality was high in five studies (mean PEDro score = 5.6 ± 1.3). Four studies were included in the meta-analysis. Significant improvements were observed in balance, as measured by the BBS (mean difference = 3.62; 95% CI 2.29–4.95; P < 0.001; I² = 0%). No significant effects were found for mobility (TUG: MD = -0.37; 95% CI -1.16 to 0.41; P = 0.35; I² = 0%) or strength (Chair Stand: MD = -0.20; 95% CI -1.70 to 1.29; P = 0.79; I² = 21%). Conclusions: VR-based training appears effective in improving balance in frail and pre-frail older adults, but its impact on strength and mobility remains inconclusive. These inconsistencies may be attributed to differences in intervention type, progression, and outcome measures. Future research should focus on optimizing VR program design and exploring long-term adherence and functional outcomes. Clinical Trial: https://www.crd.york.ac.uk/PROSPERO/view/CRD42023478330

The purpose of this study was to examine whether interactive video game (IVG) training is an effective way to improve postural control outcomes and decrease the risk of falls. A convenience sample of 12 prefrail older adults were recruited and divided into two groups: intervention group performed IVG training for 40 minutes, twice per week, for a total of 16 sessions. The control group received no intervention and continued their usual activity. Outcome measures were centre of pressure (COP), mean velocity, sway area, and sway path. Secondary outcomes were Berg Balance Scale, Timed Up and Go (TUG), Falls Efficacy Scale International (FES-I), and Activities-Specific Balance Confidence (ABC). Assessment was conducted with preintervention (week zero) and postintervention (week eight). The intervention group showed significant improvement in mean velocity, sway area, Berg Balance Scale, and TUG (p<0.01) compared to the control group. However, no significant improvement was observed for sway path (p=0.35), FES-I (p=0.383), and ABC (p=0.283). This study showed that IVG training led to significant improvements in postural control but not for risk of falls.

Background/Objectives: Frailty is a multidimensional syndrome characterized by diminished physiological reserves, reduced mobility, and increased fall risk. While clinical assessments are commonly used to screen for frailty, they may not capture minor deficits in postural control. Center-of-pressure (CoP) metrics from force plates provide objective markers of postural control, yet their role in frailty screening remains underexplored. This study aimed to investigate the associations between functional performance measures and CoP-based metrics to identify predictors of frailty among older adults. Methods: Eighty-three adults aged ≥ 55 years with a history of falls were classified as frail or pre-frail based on modified Fried criteria. Functional assessments (Timed Up and Go (TUG), grip strength, Berg Balance Scale [BBS], Falls Efficacy Scale [FES]) and CoP metrics (mean velocity, sway path; eyes open/closed) were evaluated. Both unadjusted and age-adjusted logistic regression models were used to identify independent predictors of frailty. Results: Increased TUG time and number of falls were the strongest risk factors for frailty, while increased sway path and CoP velocity were protective. In particular, sway path under eyes-closed conditions showed the strongest protective association (OR = 0.323, p < 0.001). Additionally, fear of falling (OR = 1.078, p = 0.013) emerged as a significant psychological factor, consistently associated with increased frailty risk regardless of physical performance. Correlation analysis supported these findings, showing that better functional performance was linked to lower frailty risk. Conclusions: CoP sway path and mean velocity independently predict frailty status and offer added value beyond traditional clinical tools. These findings highlight the importance of incorporating instrumented balance assessments into frailty screening to capture nuanced postural control deficits and guide early intervention strategies.

Physical activity, sedentary behaviour, sleep quality, and anxiety are interrelated factors that play a critical role in physical and mental health. However, limited evidence exists on their associations within the Saudi Arabian context. This study aimed to investigate the relationships between physical activity, sedentary behaviour, sleep quality, and anxiety symptoms among healthy, pain-free adults in Saudi Arabia. A cross-sectional online survey was conducted between December 2024 and April 2025 using validated Arabic versions of the Global Physical Activity Questionnaire (GPAQ), the Brief Pittsburgh Sleep Quality Index (B-PSQI), and the Generalised Anxiety Disorder-7 (GAD-7). The data were analysed using descriptive statistics and multivariable linear regression models. A total of 185 participants (mean age = 33.99 ± 12.57 years; 69.73% female) were included. The average total physical activity was 1730.02 ± 2109.24 MET min/week, and the mean sedentary time was 6.77 ± 4.69 h/day. No significant associations were found between physical activity and either sleep quality or anxiety symptoms. Similarly, sedentary behaviour time was not significantly associated with sleep quality or anxiety symptoms. However, poorer sleep quality was significantly associated with higher anxiety levels. These findings highlight the importance of sleep quality in mental health strategies for healthy adults in Saudi Arabia.