Effects of Balance-Based Exergame Training With Variable Difficulty on Balance and Spatiotemporal Gait Outcomes in Adults With Mild Cognitive Impairment: Randomized Controlled Trial

Abstract

Background: Exergame balance training integrates cognitive and motor challenges, potentially enhancing neuroplasticity, postural control, and gait stability in mild cognitive impairment (MCI). However, whether modulating the task difficulty of a balance-based exergame training may influence posture- and gait-related outcomes remains unknown. Objective: We compared balance and gait improvements across exergame training groups performing exercise with different difficulty levels and a Wii Fit group in adults with MCI. Methods: This 4-armed, parallel design, double-blinded, randomized clinical trial included 97 participants with MCI (Montreal Cognitive Assessment score=18-25). Participants were convenience-sampled from the Railway General Hospital, Rawalpindi, Pakistan, and randomized to one of 4 intervention groups: low-difficulty, moderate-difficulty, high-difficulty exergame training or a Wii Fit training group. Each participant completed 24 sessions (40 min, 3/week) supervised by physical therapists. Gait and balance were assessed using time up and go (TUG), cognitive time up and go (C-TUG), and the Gait & Balance mobile app at baseline and after 4 and 8 weeks. Although the calculated sample size was 80, 97 were recruited to offset attrition. Eighty-seven participants completed the study (94% adherence) (attrition: low-difficulty 1, moderate 3, high 2, Wii Fit 2; 10% total). Data were analyzed using mixed-model analysis of covariance with baseline values as covariates to assess time×group interactions. Bonferroni-adjusted post hoc comparisons revealed between-group differences. Results: High-difficulty training showed the greatest TUG gains (–0.71, SD 0.32; P=.03, anteroposterior (AP) steadiness with eyes open (EO) on firm surface (0.04, SD 0.02; P=.04), step time variability head forward (HF; 0.06, SD 0.09; P=.02), walking speed HF (0.08, SD 0.04; P=.05), step time head turn (HT; –0.04, SD 0.02; P=.04), step time variability HT (–0.35, SD 0.09; P.05). Conclusions: Balance-based exergame training improves balance and gait in adults with MCI, with no significant differences across difficulty levels, while the high- and low-difficulty training outperformed Wii Fit in several outcomes. High-difficulty training yielded the most consistent improvements in TUG, postural steadiness, gait variability, and walking speed. These results support graded cognitive-motor exergaming as an effective strategy for enhancing postural control and walking stability in MCI, potentially aiding fall prevention and mobility preservation in aging populations.