Implementation of Virtual Reality Motivated Physical Activity via Omnidirectional Treadmill in a Supported Living Facility for Older Adults: A Mixed-Methods Evaluation.: Virtual reality to motivate physical activity for older adults

The ongoing demographic shift towards older populations as a consequence of increasing life expectancy globally means that a growing proportion of adults are at retirement age or above [1]. These changes continue to put pressure on health and social care (H&SC) resources [2] due to the physical and mental deterioration associated with advanced age [3]. Frailty is one syndrome associated with ageing, defined as clinically notable increases in vulnerability associated with decline due to ageing [4]. This challenge is exacerbated further through diminishing numbers of care workers to provide required support [1]. To counter this, policy-makers have called for research and innovation focusing on technologies that support healthy ageing [5], thereby promoting longer healthy, independent living with less reliance on H&SC.

Virtual Reality (VR) is one technology of interest with potential to support the wellbeing of ageing adults [6, 7]. VR systems can be useful through a range of mechanisms; they can allow users to engage with immersive physical activities in virtual spaces that can facilitate reminiscence [8] or incorporate social activity remotely [6], or be used for improvements in physical functioning such as balance [9]. One such example described in the literature is of a VR based application using a stationary bike for older adults living independently at home to explore VR worlds while peddling [7]. The VR technologies under investigation in this study have been designed by MOTUS VR (formerly known as ROVR Systems) and include an omnidirectional treadmill for interaction with VR worlds (MOTUS Adventure) and a static 360° VR experience (MOTUS Relieve). In this study, we therefore gained feedback not only on standard VR experiences for relaxation and wellbeing, but also the VR motivated treadmill designed to increase levels of physical activity. The Adventure system has been designed to exploit the benefits of VR in engaging users in interacting with immersive environments to promote physical activity (PA), while also incorporating social connectedness and reminiscence for older adults. Regarding PA, the MOTUS VR developers recognised the physical deconditioning experienced by older adults and those in residential care settings. Research has shown care home residents spend most of their day sedentary [10]. Remaining physically active is a significant and well documented challenge for the older population, who are generally not able to sustain engagement with exercise over time on their own [11]. This is problematic as PA through the life course has clear benefits, including PA sustained over 6 months being associated with reduced falls [12]. Further, there are numerous health benefits for older adults, with exercise providing a protective factor against diseases including cancer, diabetes, cardiovascular disease and stroke, and delaying dementia onset [11]. Therefore, there has been increasing interest in reablement strategies to support older adults engaging in PA [10]. Regarding the social interaction on the MOTUS VR platform, the potential for technologies to aid with social connectedness is of significant interest for supporting older adults but is particularly relevant for those in residential care who are principally vulnerable to feelings of isolation and loneliness [13]. The Relieve system has been designed to provide meaningful activity and opportunity for mindfulness and reminiscence. Meaningful activity is an important aim within care, contributing towards physical and mental health, further to quality of life [14], however, one challenge is a lack of high-quality activities available. Consequently, many care home residents’ days are characterised by apathy and lack of activity [14]. As such, both systems aim to improve health and wellbeing for older adults.

Beyond increasing PA motivation, social connectedness and meaningful activity, VR has also generated research interest as a vehicle to engaging with culture and heritage [15]. Heritage is an often-overlooked contributor to wellbeing, personal happiness and social connectedness. Interaction with heritage sites supports these components of wellbeing by providing remote access to both physical locations and online resources [16, 17, 18]. The restrictions in place during the COVID-19 pandemic limited access to heritage sites, and the wellbeing benefits associated with heritage access [19]. Heritage resources are thought to support wellbeing through facilitating connectedness with places of cultural importance, motivating PA, and facilitating reminiscence [17]. Further benefits arise from heritage-based opportunities to engage with a shared identity and take part in social contact [17]. Access to heritage resources has been shown to support improvements to several markers of mental wellbeing, including empowerment, social connectivity, sense of belonging, worth, confidence, and social inclusion [20]. Older adults are often the age group most invested in heritage [21], yet they can also experience the greatest barriers to access due to combinations of reduced mobility and the heritage sites physical accessibility issues (e.g., uneven ground, lack of accessibility features due to conservation) [21]. The use of heritage sites within VR experiences could therefore also aid inclusivity for older adults, particularly those with physical or sensory barriers [22].

Considering these potential outcomes of VR innovations, and the requirement for research into technological innovations for healthy ageing [5], this study aimed to contribute through evaluation of VR systems with potential in this area. In other work, the authors explored professional health and care stakeholder perceptions towards the MOTUS Adventure system, and documented perceived benefits, challenges and design requirements [23]. However, the prior work did not engage older adults themselves and was based on short-term interactions (60 minutes), gaps we respond to here.

Prior work more broadly includes a study by Campo-Prieto et al. [24], who acknowledged the importance of PA for healthy ageing, and explored the use of VR to motivate exercise for older adults. The study had a small sample, with only four healthy men recruited (ages 65-77), who completed exergaming programs and measures of usability and adverse effects. Participants reported high levels of satisfaction and no adverse effects or sickness, suggesting general feasibility of the VR intervention. However, all participants were healthy and independent, limiting understanding of VR exercise for older adults in supported or care home accommodation, which by definition implies some physical or mental impairments, requiring greater understanding of feasibility and person characteristics for safe use. Campo-Prieto et al. [24] also relied on upper-body movements with use of a VR headset and handheld controllers, for games such as boxing.

In a recent editorial on VR exercise for health and wellbeing of older adults [25], the authors conclude that VR exercise could be an effective intervention for fall prevention, but suggested further research was needed to understand the effect of VR exercise on a range of outcomes, and understanding of which types of VR-based exercise are most effective, to support future technology developments. A literature review by Piech et al. [26] also notes the potential for VR exercise in fall prevention, having reviewed 21 randomised controlled trials using VR dancing and exergames. In another review, Baragash et al. [27] reviewed literature classifying VR and AR for improved quality of life for older adults. The authors identified 57 studies, finding motion based exergames and augmented reality systems the most common. Ali et al. [28] also recently published a systematic review of VR-based techniques for human exercises and health improvement but focused on studies of visual and mental exercises, rather than physical, but did conclude the use of VR for health has not yet been thoroughly explored. In a systematic review by Zheng et al. [29], the authors identified seven RCTs with 243 pre-frail and frail older adults using physical outcomes including muscle strength, balance ability, mobility function, gait and falls, as well as subjective feeling outcomes, feasibility, attendance. Exergames improved balance and mobility function of frail elderly, and showed a tendency to increase muscle strength when combined with resistance training. As far as the limited evidence was concerned, exergames were feasible and generally accepted by participants. There remains much exploration in the area of VR exercise for older adults, and based on the prior work, there is particularly limited research among frailer older adults not living independently, such as those in care homes or supported living facilities. The prior work does suggest potential for VR for reduced falls, improved wellbeing and health, but further work is necessary on feasibility and safety across a range of person characteristics. We respond here with a longitudinal implementation study with older adults residing in supported living. Studies such as this are essential for novel technologies with potential positive implications for health and social care. To consider real world use of these devices to support exercise of older adults in care settings, research should first seek to understand suitability and the person characteristics required for safe use, while also exploring user perceptions and initial indications of impacts.

This study aimed to explore the physical abilities necessary to use the standing VR treadmill and static VR experience. We were able to recruit a residential home and seven residents to trial a new treadmill approach for VR motivated exercise, alongside the more ‘traditional’ seated VR for relaxation and reminiscence. Six out of the seven were able to use both treadmill and the seated VR even though they had many physical impairments and limited physical ability. The oldest user was 103 and participants with knee and hip surgeries, mobility issues and complex illnesses felt able to use the standing treadmill, albeit with supervision and support. The one wheelchair user was not able to use the treadmill. This suggests VR motivated exercise on devices such as the MOTUS VR treadmill could be appropriate interventions to enhance activity levels in aged care settings.

Few other studies have included such participants in using VR and certainly not in using a treadmill. Campo-Prieto et al [24] used only upper body movements in their exploration of VR exercise. The prior work by Campo-Prieto et al [24] on exergaming involved only healthy and independent adults, which does not add to understanding of suitability of such devices to various person characteristics, particularly when considering older adults in supported living or care settings who therefore are likely to have some form of physical or cognitive limitations.

Participants thought that within the range of people able to use the treadmill it would be of more benefit to those who were less physically able, those with restricted mobility who were unable to leave the home, and therefore would benefit from virtual access to experiences and a method of being more active. Those more active and able to engage freely in outdoor experiences felt the technology may be less relevant to them. In a small sample we cannot conclude anything from the senior fitness scores but note that two participants with the best physical ability scores interacted with the standing MOTUS VR system less often than the other four that used the treadmill. It seems possible that those least able to go out and experience real-world walking will use a VR-linked treadmill more for exercise and to access to virtual heritage/nature experiences. Future research with a larger sample would be worthwhile to test this hypothesis, as the small number of participants in the present study limit generalisability of this finding.

An additional aim of this study was to explore (for those who could safely use the devices) the user-experience, feasibility and acceptability of the standing or seated VR experiences, further to use and impact. Both the VR-treadmill and the seated VR were seen to be acceptable by this group of relatively frail older adults. They clearly enjoyed the experience, feeling benefits for their activity, access to heritage, nature and experiences and therefore wellbeing. Both the more novel treadmill as well as the more usual seated VR were acceptable. Although this will require further research and validation, technologies that enhance access to experiences have the potential to improve inclusivity and wellbeing [16, 17, 18], while methods of motivating physical activity have clear implications for health outcomes [11]. Technologies such as those studies here, if routinely implemented longitudinally, could therefore have societal benefits for remaining independent as we age and reducing the burden on health and social care services.

In terms of content, participants in this study much preferred realistic VR experiences, criticising more cartoonish and unrealistic models and requesting finer details and virtual visits to real world locations. There was particular interest in heritage locations such as museums, as could be expected due to older adults’ particular investment in history and heritage [21]. Our prior work documented many health and care stakeholders reporting concerns of negative effects such as dizziness and motion sickness. However, the short interaction period of our prior work limited validity of participant assessment of these effects, as there was limited time for participants to familiarise themselves with the VR systems and overcome any initial motion sickness. These types of reactions are common among all VR systems, and work is underway to generally reduce cybersickness experiences for users of head mounted displays [40]. Repeated exposure to the same VR content has been shown to reduce severity of motion sickness [40], thus a longitudinal study would more accurately report the extent to which motion sickness is a barrier to the use of VR. This is supported in this study, where residents reported feeling better when using the devices over time, suggesting for future implementations, facilitators should encourage perseverance with VR experiences where possible. One factor to consider in future implementations would be ethical considerations, when considering the target population of older adults, and ensuring comfort and familiarisation before trying technologies, as well as capacity to consider any risks of negative effects of the VR or treadmill for informed choices on using the technologies.

As an interesting finding, participants here voiced desire for a seated version of the treadmill. Participants discussed a compromise between the low-friction, slippery treadmill (Adventure) and static 360 VR (Relieve) experience, where they could remain seated without risking a fall, but also move and explore VR worlds as opposed to passively watching video footage. It could be possible that the motivated movement of a seated treadmill could provide an answer to the suitability issue we have presented, that less physically able people are more motivated to use such technologies but less suited to the standing treadmill. As such, a seated treadmill could act as a facilitating exercise, to support leg movement and strengthening, and perhaps increase confidence and ability ahead of using the standing treadmill. MOTUS VR has responded to the findings of this study with a redeveloped seated treadmill which is currently undergoing trials. A seated treadmill provides an alternative, but congruent approach to seated VR cycling, as used by D'Cunha et al [41]. Future research could seek to explore the level of activity and muscle activation achieved using both treadmill and cycle methods.

This study also aimed to document and report on the implementation process, and any barriers important to consider. We had approached a number of care homes before we found one able to carry out the study, with other homes noting limitations including lack of staff and physical space to accommodate the equipment. Although the treadmill was felt advantageous in increasing physical activity, for use in care homes there is a requirement for staff supervision, physical space to host the treadmill and investment potential to buy and maintain the equipment. The standard seated VR system was felt easier to use and implement, and was perceived as safer for the frailer residents, therefore, as suggested by care staff in prior work [23], a seated treadmill was noted as a potential solution to increase confidence in being active and using a treadmill, perhaps before graduating to the standing treadmill. The space requirement for technologies within care settings is a consideration with implications for future developments and studies. One suggested improvement was being able to fold or pack the treadmill down when not in use, the site manager did feel the treadmill was a considerable size to occupy space in the resident's home.

The site manager in the current study raised further interesting practical considerations, one of which was cost. The social care sector has very limited investment potential, something for technology developers aiming products at the market will need to consider. A key finding of this study is also that staff and residents reported not being comfortable or confident enough to use the devices without researchers present. We left devices in situ and gave training demonstrations to staff so that use could be facilitated in our absence. However, further research will need to explore what would be required to allow end-users the confidence for real-world use without researchers present for facilitation and for stakeholders to feel comfortable with independent use, in order for future end-users to receive any real-world benefits of the increased PA. It is possible that as the technology was not ‘owned’ by the site, there were latent concerns of damage or breakages to the equipment. It is also possible the training given did not give the staff ample confidence in use. However, this is an important outcome with implications for any real-world implementations of such technology, thus deserving additional attention in future research, potentially taking a behaviour change approach to examine predictors of use and facilitate the impact of staff training on uptake.

As subsidiary aims of this study, we also hoped to comment on the feasibility and validity of the senior fitness data. There should be further exploration of various fitness tests used in this regard, as the missing data in the present study could suggest easier fitness measures are required, or additional time and resources are required to ensure a full data set considering the time commitment of conducting all of the senior fitness test measures. For the data that was collected, the measures appeared to provide useful and accurate indicators of participants physical functioning, based on congruence between physical fitness scores and qualitative feedback on ability and health conditions, and could be useful measures for future research of this kind.

There are a range of implications from this work, principally, these findings have implications for developers of VR motivated exercise technologies for older adults, in providing user-centered understanding of design requirements, challenges and barriers to consider. The MOTUS VR treadmill has been designed specifically for older adults, and the design is notably different to more gaming-oriented treadmills on the market. Gaming treadmills are much more commonplace than those targeting older adults [42], but the findings of this study may be useful for developers going forwards as the older generations of the future may be more accustomed to varied gaming experiences, and gaming for older adults is a developing market [43]. The study is also useful for developers and researchers within this field to gain initial insight into the potential suitability and person characteristics that make this type of technology useful and feasible, with implications for future research and implementations of such devices. Finally, this work has implications for stakeholders within the aged care sector, in demonstrating the potential usefulness (in terms of physical activity, accessibility of experiences and engagement) of VR and technology generally in the support of older adults.

Although there are useful implications and contributions from this work, there are a number of limitations to acknowledge due to this being a preliminary study. The first is the small sample size, meaning we can draw limited conclusions from the quantitative pre and post data, other than the indications of person characteristics for device use, when understood alongside the qualitative data. A further limitation is the reasonably limited number of technology interactions which again inhibits any potential to quantitively measure impact of device use, although this was not a key aim of this study. Future research should consider a comparative study with a control group and larger sample size to directly measure any impact of VR treadmill use on activity levels and health outcomes. While our participants had access to the technologies over six weeks, they did not use the VR without researchers present. The finding that residents were not confident enough to use the VR without researchers to facilitate is a key outcome of this work with implications for future developments. As such, future devices will need to provide thorough digital or in-person training to overcome this barrier.

Overall, our results suggest promising potential for technologies such as the MOTUS VR aimed at increasing physical activity and supporting wellbeing. We found that older frail people were able to use this technology. Further research will be required to fully explore the impact of interventions such as these with larger samples, and over longer time periods, to establish any significant quantitative impact on physical function in older adults.

On behalf of the GOALD project: Catherine H. Hennessy, Faculty of Social Sciences, University of Stirling; Ray B. Jones, Faculty of Health, University of Plymouth; Richard Haynes, Faculty of Arts & Humanities, University of Stirling; Anna C. Whittaker, Faculty of Health Sciences & Sport, University of Stirling (Core Management Team); Sheena Asthana, Plymouth Institute for Health and Care Research (PIHR), University of Plymouth; Rory Baxter, Faculty of Health, University of Plymouth; Hannah Bradwell, Faculty of Health, University of Plymouth; Arunangsu Chatterjee, Faculty of Medicine and Health, University of Leeds; Pete Coffee, School of Social Sciences, Heriot-Watt University; Leonie Cooper, Faculty of Health, University of Plymouth; Alison Dawson, Faculty of Social Sciences, University of Stirling; Katie Edwards, Faculty of Health, University of Plymouth; Swen Gaudl, Faculty of Science & Engineering, University of Plymouth; Tanja Krizaj, Faculty of Health, University of Plymouth; Gregory Mannion, Faculty of Social Sciences, University of Stirling; Gemma Ryde, Institute of Cardiovascular and Medical Sciences, University of Glasgow; Alejandro Veliz Reyes, Faculty of Arts, Humanities and Business, University of Plymouth; John Ritchie, Faculty of Arts & Humanities, University of Stirling; Simone Tomaz, Faculty of Health Sciences & Sport, University of Stirling; Alison Warren, Faculty of Health, University of Plymouth; Karen Watchman, Faculty of Health Sciences & Sport, University of Stirling; Katherine Willis, Faculty of Arts, Humanities and Business, University of Plymouth, and partners—Active Stirling Ltd., Generations Working Together, Hearing Loss Cornwall, Nudge Community Builders, South Asian Society (Devon and Cornwall), Sporting Heritage, Sports Heritage Scotland, St. Breward Community, iSightCornwall, UKActive. With thanks to the supported living organization who hosted our research and made us so welcome when visiting their home. Thanks also to Rose Wilmot and Hannah Hobbs for their Media and Admin support on GOALD.

This paper is also on behalf of Katherine Willis, Daniel Maudlin, Chunxu Li, Sheena Asthana, Kerry Howell, Shangming Zhou, Emmanual Ifeachor as ICONIC co-applicants and Lauren Tenn (Media and Administration officer). With thanks to the ICONIC project on which HB is a co-applicant, which has benefited from these earlier works in developing their methods and approaches, for the support in funding this publication. ICONIC (Intergenerational co-creation of novel technologies to reconnect digitally excluded people with community & cultural landscapes in coastal economies) is funded by UKRI EPSRC Grant Ref: EP/W024357/1.

To see further information from MOTUS Ltd please see [44].

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