Geriatric urinary incontinence (UI) is often related to impaired mobility, balance and cognition (1). This study aimed to assess the usability of a newly designed exergame and wearable sensors for the treatment of geriatric UI.

An international research consortium from Belgium, Canada, Portugal and Switzerland developed a geriatric rehabilitation exergame that uses wearable sensors and a web-based interface to provide evidence-based training for geriatric UI. The present mixed method study is the first evaluation loop of an iterative design approach comprising design, prototyping and user evaluation. 

Participants were older community-dwelling women with mixed or urgency UI, as defined by the questionnaire for UI diagnosis (QUID) (2). To be included in the study, participants had to be:  ≥ 65 years, experiencing at least three incontinences per week on the seven-day bladder diary, able to contract their pelvic floor muscles (PFMs) (as confirmed by vaginal assessment), able to maintain a standing position for at least 30 minutes without assistance and have sufficient visual acuity to view the games on a television screen.

After signing the informed consent form, participants completed a demographic questionnaire, the Montreal Cognitive Assessment (MoCA), the Short Physical Performance Battery (SPPB) and the Questionnaire on UI Diagnosis (QUID). Then, a trained PFM physiotherapist placed an intravaginal PFM force sensor into the participant’s vaginal cavity to monitor PFM force during the game. Two inertial sensors assessing movement were attached to the participant’s feet to monitor steps. 

Women played the exergame, which included 30-minutes of cognitive and physical activities during one try-out session. They performed maximal PFM contractions and/or steps in different directions to control the video game scenario presented on a frontal screen. During the exergame, acceptability and game experience were qualitatively assessed using the think out loud method and field notes were taken by the observer. Following the exergame, participants completed the System Usability Scale (SUS), a reliable and valid 10-item scale (3). This commonly used scale provides a global view of subjective usability of a product/system. Total scores ranged from 0 to 100, with scores between 25 to 39 corresponding to poor game usability; 39 to 52 corresponding to ok; 52 to 73 corresponding to ok to good; 73 to 85 corresponding to good to excellent, and 85 to 100 corresponding to excellent game usability. Finally, women took part in a semi-structured in-depth interview to document usability based on their personal experience. Think out loud data, field notes and interviews were coded and analysed.

From February to October 2020, 10 women participated in the study (five from Switzerland and five from Canada). Participants’ mean age was 72.4 ± 9.08 years, mean weight was 66.28 ± 12.59 kilograms, mean height was 1.62 ± 0.39 meters, and mean years of education was 12.1 ± 2.4 years. Mean values for the MoCA was 26.6/30 ± 2.4, SPPB 10.4/12 ± 1.26 and the total QUID score was 11.5/30 ± 6.2.  All participants completed the try-out session. All but one participant accepted using the vaginal sensor. No adverse events were reported during or after the exergame session.

The SUS score was 67.00/100 ± 18.77, corresponding to a ‘marginally high’ acceptability range. The analysis of the qualitative data revealed six main themes describing the experiences of the participants: 1- overall experience, 2- game environment 3- game interaction; 4- sensors usability, 5- training intensity, 6- risk and limitations.

Overall experience: All participants liked the exergame and experienced ‘joy’, ‘fun’ or ‘happiness’ while playing the game (n= 10; 100%). 

Game environment: 70% of participants appreciated the overall platform design, the game versatility and enjoyed the music played, using words such as ‘motivating’ and ‘entertaining’. A few, however, found the game environment ‘somewhat childish’ (n=2; 20%). 

Game interaction: 40 % of participants had difficulty understanding game instructions and needed explanation from the physiotherapist to understand game goals/rules and navigation. Verbal guidance was needed for most participants, particularly at the beginning, regarding the goal of each game and how to navigate through the games using steps. This misunderstanding of the game led to wider leg movements and more displacement of the participant in the room, leading to frustration (n =4; 40%). 

Sensor usability: Foot sensors were accepted by all. Participants used words like ‘easy to use’ and ‘comfortable’ to qualify them. Although many (n = 7; 78%) appreciated the feedback given by the vaginal sensor during the game, some reported technical issues with the vaginal sensor, such as ‘discomfort’ (n = 4; 44%) and ‘displacement’ (n = 2; 22%), respectively, while playing the game. 

Training intensity: Most participants stated that the game was of 'adequate' intensity (n = 8; 80%). Most reported that the games required ‘concentration’, particularly in games where both foot and vaginal sensors were used.  All participants said that the duration of the exergame session was good. 

Risk and limitation: Only one participant reported a fear of falling when stepping backward. 

The overall qualitative findings were supported by the SUS score corresponding to a ‘marginally high acceptability’ range. Most issues identified by the study participants regarding the game and sensors were resolved. Difficulty with instruction and navigation in the game were addressed. Additionally, two PFM sensor sizes were made to accommodate different vaginal hiatus sizes and help prevent discomfort during the game.

Based on this study findings, it can be concluded that VITAAL exergame was not only acceptable by study participants, but it was also experienced as a fun, entertaining and motivating. Game and sensor improvements will be studied in the next evaluation loop of our iterative design, which will be an RCT assessing of this exercise solution for geriatric UI. Overall, the findings of this study underscore the value of end users’ involvement in the development of exergames.

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