Parkinsonism and Related Disorders 41 (2017) 66e72

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Parkinsonism and Related Disorders

journal homepage: www.elsevier.com/locate/parkreldis

An interactive videogame for arm and hand exercise in people with

Parkinson's disease: A randomized controlled trial
Natalie E. Allen a, *, Jooeun Song a, b, Serene S. Paul a, c, Stuart Smith d, e, Jonathan O'Duffy f,
Matthew Schmidt e, Rachelle Love a, Catherine Sherrington c, Colleen G. Canning a
a
The University of Sydney, Faculty of Health Sciences, Sydney, Australia
b
University of Technology Sydney, Graduate School of Health, Sydney, Australia
c
The University of Sydney, Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, Sydney, Australia
d
Southern Cross University, Coffs Harbour, Australia
e
University of Tasmania, School of Health Sciences, Hobart, Australia
f
Temper Tantrum, Hobart, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: People with Parkinson's disease (PD) have difficulty performing upper extremity (UE) ac-
Received 19 January 2017 tivities. The aim of this study was to investigate if exergames targeting the UE improve arm and hand
Received in revised form activities and impairments and to establish the acceptability and feasibility of these games in people with
12 April 2017
PD.
Accepted 14 May 2017
Methods: Two tablet-based exergames were developed which were controlled with finger movements or
unimanual whole arm movements. Participants with PD were randomized to an exergame (n ¼ 19) or
Keywords:
control (n ¼ 19) group. The exergame group performed UE exergames at home, 3 times per week for 12
Parkinson's disease
Upper extremity
weeks. The primary outcome measure was the nine hole peg test. Secondary outcomes included mea-
Motor learning sures of UE activities and impairments, including the tapping test [speed (taps/60s), and error (weighted
Rehabilitation error score/speed)].
Exergame Results: There were no between group differences in the nine hole peg test, or in any secondary outcome
measures except for the tapping test. Horizontal tapping test results showed that exergame participants
improved their speed (mean difference ¼ 10.9 taps/60s, p < 0.001) but increased error (mean
difference ¼ 0.03, p ¼ 0.03) compared to the control group. Participants enjoyed the games and improved
in their ability to play the games. There were no adverse events.
Conclusion: The UE exergames were acceptable and safe, but did not translate to improvement in
functional activities. It is likely that the requirement of the games resulted in increased movement speed
at the detriment of accuracy. The design of exergames should consider task specificity.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction reduced health-related quality of life [8].

People with Parkinson's disease (PD) experience upper ex-
tremity (UE) impairment, often early in the disease process [1].
These impairments include bradykinesia [2,3], UE ‘freezing’ [4],
abnormal force modulation [5], difficulty making individual finger
movements [2] and difficulty performing repetitive or sequential
movements [6]. UE impairments contribute to difficulties per-
forming daily activities [7], leading to a loss of independence and
* Corresponding author. Faculty of Health Sciences, The University of Sydney, PO
Box 170, Lidcombe, NSW 1825, Australia.
E-mail address: natalie.allen@sydney.edu.au (N.E. Allen).
Despite these difficulties, there is a paucity of research exploring
potential interventions. Pharmacological trials indicate that diffi-
culties with dexterous hand movements respond poorly to dopa-
minergic medications [3,6], as do difficulties with balance and falls
[9]. However, while balance and falls have been shown to improve
with exercise in people with mild to moderate PD [10,11], only two
randomized controlled trials have focused on the potential for ex-
ercise targeting the UE to improve activity performance. Improve-
ments in UE activities were reported following a modified
constraint-induced movement therapy administered 3 h/day, 5
days/week over 4 weeks [12]. However, longer term effects and the
acceptability of this intensive program were not addressed. A

http://dx.doi.org/10.1016/j.parkreldis.2017.05.011
1353-8020/© 2017 Elsevier Ltd. All rights reserved.
 N.E. Allen et al. / Parkinsonism and Related Disorders 41 (2017) 66e72
recent randomized controlled trial [13] investigated the effect of 6
weeks of handwriting exercises emphasizing increased writing
amplitude on micrographia in people with PD. Results showed that
participants who undertook the exercises improved their micro-
graphia compared to a sham control group, with evidence of
transfer and automization of the improvements, as well as reten-
tion for 6 weeks after practice ceased. Taken together, these trials
indicate that further exploration of interventions to improve UE
activities in people with PD is warranted.
Interactive, exercise-based videogames (exergames) have
recently attracted attention for their potential to provide a prag-
matic, sustainable and engaging form of therapeutic exercise [14].
Overall, the use of exergames with people with PD appears to be
feasible, though the efficacy of such games, particularly when
delivered in the home environment, remains unclear [14].
Furthermore, commercially available games may not be suitable for
use with people with PD [14] with some people reporting diffi-
culties with fast and complex games and with using hand-held
controllers [15]. In the current study we developed a home-based
exergame program specifically designed for people with PD and
with a focus on UE exercises. The primary aim of this randomized
controlled trial was to determine if use of this exergame program
improved UE activity performance and impairments in people with
PD. The secondary aim was to establish the feasibility and accept-
ability of this intervention. We hypothesized that the exergame
intervention would lead to improvements in UE activity perfor-
mance and impairments, and that the intervention would be
feasible to deliver and acceptable to people with PD.
2. Methods
2.1. Design
A randomized controlled trial of a 12 week, home-based UE
exergame intervention for people with PD was undertaken during
2014e2106. Participants were recruited from Sydney, Australia. The
study was approved by the relevant Human Research Ethics Com-
mittee and all participants gave written informed consent. The trial
was registered in the Australian and New Zealand Clinical Trials
Registry (ACTRN12614001048673) and trial reporting adhered to
the CONSORT guidelines [16].
Assessments were conducted in participants' homes at baseline
and on completion of the 12-week intervention period. Participants
were assessed while ON, typically around 1 h after taking their
usual PD medication. Post-intervention assessments were con-
ducted by a physiotherapist who was blinded to participants' group
allocation. Following the baseline assessment, participants were
randomly allocated to the exergame or the control group using a
computer-generated randomization schedule with randomly
permuted block sizes. Randomization was stratified according to
each participant's level of UE impairment, as determined by the
total score of the 6 UE items of the Movement Disorders Society
Unified Parkinson's Disease Rating scale (MDS-UPDRS) motor ex-
amination [17] [i.e. items 3.4e3.6 and 3.15e3.17 (UE only)], using a
threshold value of 13. The randomization schedule was developed
and held by an investigator not involved in recruitment, assessment
or intervention i.e. a concealed allocation system.
2.2. Participants
Participants were recruited via Parkinson's NSW newsletters
and support groups and through the research teams' database of
people with PD who have requested to be contacted regarding
67
research participation. People who volunteered for the trial were
included if they had a diagnosis of idiopathic PD, were aged 40
years, and had been on a stable medication regime for at least two
weeks prior to commencing the trial. Volunteers were excluded if
they had UE pain or injuries which would preclude performance of
the exergames, cognitive impairment (Mini-mental state exami-
nation <24) [18], or any other health condition that would interfere
with safe conduct of the testing or training protocol. All participants
were required to provide written medical clearance to certify their
suitability for participation in the trial prior to randomization.
Background information was collected at baseline. This included
demographic information, medical history, medications and the
MDS-UPDRS motor examination [17].
2.3. Intervention
Participants randomized to the exergame group were asked to
perform the exergames 3 times per week for 12 weeks, while ON
medication. Participants received two initial home visits and a third
visit at six weeks to ensure they were able to set up the equipment,
play the games and make appropriate progressions. Extra home
visits were permitted if the participant required further instruction.
Participants were contacted fortnightly for the duration of the trial
to provide support, guide progression and monitor adverse events.
Participants recorded games played, as well as any unwanted ef-
fects of the exergame (eg muscle soreness) in a logbook. The control
group received usual care and continued with their usual activities.
Two exergames (i.e. a ‘marshmallow’ game and a ‘chicken’
game) focusing on coordinated movements of the arm and hand,
were specifically designed and developed by the research team for
the trial using Unity game development software (www.unity3d.
com). The set-up of the equipment and a screenshot from each
game is shown in Fig. 1. Both games were played with one UE at a
time, and were played with either the whole arm or the hand. A full
exergame session comprised of playing each game under six con-
ditions (right and left arms both in the near and far settings plus
right and left hands), so that 12 games were played per session.
Details about the exergames are outlined in the supplementary
information. The two exergames required different movement
strategies, with the ‘marshmallow’ game focusing on correct timing
of responses, and the ‘chicken’ game focusing on rapid movement.
In both games, participants were provided with auditory and visual
feedback designed to assist them to improve their performance.
Each game had four levels of difficulty to choose from. The phys-
iotherapist prescribed the starting level and participants were
encouraged to progress to harder levels when they were successful
in the game most of the time.
2.4. Outcome measures
The primary outcome measure was the time to complete the
nine hole peg test [19]. This was chosen as it is easily administered,
requires coordinated movements of the arm and hand, has high
test-retest reliability and is likely to be a responsive measure of
change in people with PD [20].
Secondary outcome measures were tests of UE impairments and
activities. Movement speed and accuracy were measured with
horizontal and vertical tapping tests, where participants alternately
tapped two pre-designated keys (the ‘s’ and the ‘; ’) with their index
finger on a standard English computer keyboard as quickly and as
accurately as possible for 60 s. Keystrokes were recorded by a
computer running a word processing program. The tests were
conducted with the keyboard aligned vertically and horizontally,
68 N.E. Allen et al. / Parkinsonism and Related Disorders 41 (2017) 66e72

Fig. 1. Panel A: Set up of equipment for the arm exercises. The distance from the participant to the targets was adjustable, with targets in the figure shown in the ‘far’ position. The
white markers indicate the ‘near’ target position. The computer keyboard was used for the hand exercises. Panel B: Screen shots of the two exergames, showing visual feedback
received when successful in the game. The ‘marshmallow’ game (left) required participants to remove the correct marshmallow (here indicated by the number 10) at the correct
moment. The ‘chicken’ game (right) required participants to catch the eggs by moving the vessel to the correct location as quickly as possible once the previous egg had been caught.

and under single and dual cognitive task conditions. The dual
cognitive task involved counting backwards by 3, beginning at a
randomly chosen number between 80 and 100. A speed score (total
number of keystrokes in 60s) and an error score (derived from the
number and location of incorrect keystrokes divided by the speed
score) were recorded [21]. Hand reaction time was measured using
a hand-held electronic timer, with participants depressing a switch
with their index finger as quickly as possible in response to a light
stimulus [22].
Hand dexterity was measured with the coin rotation task [3] and
UE dexterity was measured with the box and block test [23]. Par-
ticipants' subjective ratings of their ability to perform everyday UE
activities were measured with the Manual Ability Measure-36
questionnaire [24], and their perception of any change in their
arm and hand function over the 12 week period was measured at
post-test using an 11-point global perceived effect scale ranging
from 5 (very much worse) to 5 (very much better).
Cognition was measured with the Montreal Cognitive Assess-
ment [25] as well as the Trail Making Tests, Part A and B [26].
Disease-related quality of life was measured with the Parkinson's
Disease Questionnaire (PDQ-39) [27].
Adherence and unwanted effects of the exercise (e.g., muscle
soreness, fatigue) were monitored through participant log books.
On completion of the 12 week intervention period, participants
completed a questionnaire regarding their experiences of playing
the exergames.
2.5. Sample size and data analysis
Calculations of statistical power based on previously published
measures of the nine hole peg test in people with PD [20] showed
that a sample size of 19 participants per group was required to
detect a 20% between-group difference in the nine hole peg test
time (mean 29.9 s, SD 10.2, power 0.8, alpha 0.05, pre/post corre-
lation 0.8), allowing for a 10% drop-out rate.
Differences between the groups at the end of the 12 week
intervention period were assessed using linear regression analysis
adjusted for baseline scores. Where data were not normally
distributed, the difference between post-test and pre-test scores
was calculated and this difference score was used in the linear
regression. Between-group differences in participants' perception
of overall change in arm and hand function during the trial period
were assessed with an independent samples t-test (two-sided tail).
All analyses were conducted using an intention to treat approach.
As motor learning is enhanced by higher levels of practice, a post-
hoc analysis was also conducted including only participants who
completed 80% of the prescribed exergames. Data were analyzed
using SPSS v22 (IBM Corp, Armonk NY).
 N.E. Allen et al. / Parkinsonism and Related Disorders 41 (2017) 66e72
3. Results
3.1. Participant flow and characteristics
A total of 38 participants were randomized to the exergame
group (n ¼ 19) and the control group (n ¼ 19), with follow-up data
available for 95% (n ¼ 18) of exergame and 100% (n ¼ 19) of control
participants. The flow of participants through the trial is shown in
Fig. 2. Demographic characteristics of the participants at baseline
are presented in Table 1. The daily levodopa equivalent dose [28] at
baseline was a mean of 939 mg (SD 531) for the intervention group
and 711 mg (SD 703) for the control group. At post-test it was a
mean of 955 mg (SD 538) for the intervention group and 719 mg
(SD 700) for the control group, indicating that both groups had
similar, small overall increases in daily levodopa equivalent dose
which was unlikely to affect trial results.
3.2. Efficacy of the exergames
Outcome data at baseline and 12 weeks for both the exergame
and control groups are presented in Table 2. There was no differ-
ence between the exergame and the control groups in the time to
complete the nine hole peg test. Participants in the exergame group
displayed significantly faster movement speed in the horizontal
tapping test (speed score) at post-test compared to the control
Fig. 2. Flow of participants through the trial. *The 4 exergame participants who discontinued intervention includes 1 participant lost to follow-up for both primary and secondary
outcomes.
69
group under single-task conditions. However, participants in the
exergame group significantly deteriorated in their accuracy at post-
test compared to the control group as measured by the horizontal
and vertical tapping test error scores, under both single and dual
cognitive task conditions. Participants in the exergame group did
not perceive any overall improvement in their arm and hand
function on the global perceived effect scale [mean change exer-
game group 0.53 (SD 1.8), control group 0.42 (SD 0.9); between
group difference 0.11 (95% CI -1.06 to 0.84, p ¼ 0.8)].
Outcome data for participants who completed at least 80% of
prescribed exergames and the control group are presented in
supplementary table S1. This post-hoc analysis also shows no
difference between the groups in the nine hole peg test (mean
difference 1.3 s, p ¼ 0.41). However, participants in the exer-
game group showed improved movement speed compared to the
control group with higher speed scores in both the horizontal
and vertical tapping test under single and dual cognitive task
conditions (mean difference ranged from 10.2 to 15.9 taps/60s, p
ranged from <0.001 to 0.03). The increased error remained for
the exergame group compared to the control group in the ver-
tical tapping test with dual cognitive task (mean difference
0.063, p ¼ 0.003). Participants completing the exergame protocol
improved their time compared to the control group for the Trail
Making Test Part A, but not for Part B.
70 N.E. Allen et al. / Parkinsonism and Related Disorders 41 (2017) 66e72
Table 1
Participant characteristics at baseline.
Variable
Age (y)
Gender (men)
MMSE (range, 0 to 30)
Dominant hand (right)
Hand most affected by PD (right)
Disease duration (y)
MDS-UPDRS motor exam (range, 0 to 132)
MDS-UPDRS upper extremity subscore (range, 0 to 56)
Daily levodopa equivalent dose, mg
The values are either mean (SD) or number and (percentage).
a
One participant in the control group was ambidextrous.
b
Three intervention (15.8%) and nine control (47.4%) participants reported both hands as equally affected by PD; MMSE, Mini-Mental State
Examination; MDS-UPDRS, Movement Disorders Society Unified Parkinson's Disease Rating Scale.
3.3. Acceptability and adherence
All participants (except three of the four participants who
dropped out) progressed to harder levels of difficulty in the games.
By the end of the 12 weeks of intervention, 3 of the 15 completers
(20%) had reached the hardest (i.e. ‘insane’) level of difficulty for 4
out of the 12 conditions, 3 (20%) for 8 conditions, and 4 (27%) for 10
conditions. The remaining 5 participants (33%) reached the ‘hard’
level for at least 4 conditions.
Analysis of participants' log books showed that they completed
an average of 34.9 (97%) of the prescribed 36 exergame sessions
(range 4e52 sessions), and 478 (111%) of the 432 prescribed games
(range 38e1137). Ten participants (53%) completed more than the
prescribed number of sessions, and 12 participants (63%)
completed more than the prescribed number of games. When
maximum adherence was capped at 100%, then an average of 83%
(SD 32.9) of prescribed exergame sessions and 82% (SD 34.1) of
prescribed games were completed. One participant required an
extra two initial home visits in order to learn how to use the sys-
tem. No adverse events (e.g., muscle soreness, undue fatigue) were
reported. However, one participant reported an exacerbation of a
previously existing chronic pain condition and withdrew during
week 2. As this participant experienced regular exacerbations, it
was unclear if this was related to trial participation.
Sixteen participants (84.2%) from the exergame group
completed the post-intervention questionnaire. Eleven (68.8%) re-
ported that they enjoyed the exergames, while 2 (12.5%) did not
and the remaining 3 (18.8%) neither enjoyed or disliked the expe-
rience. Eleven participants (68.8%) found the system easy to use
and all reported that the level of instruction from the physiother-
apist was sufficient for independent play. Seven (43.8%) reported
that they would continue playing the exergames if they had access
to them. Open-ended responses indicated that participants liked
the feedback provided by the system and were motivated to try to
beat their previous scores. They preferred the challenge of the fast
movements required in the ‘chicken’ game over the slower, care-
fully timed movements required by the ‘marshmallow’ game.
However, participants tired of playing the same two games for the
12 weeks. Most participants did not have space in their home to
leave the equipment set up between sessions, and some reported
that setting up and connecting the table-top mat, keyboard and
tablet for each session was awkward.
4. Discussion
This randomized controlled trial of an exergame intervention
targeting movements of the UE showed that the intervention was
Exergame group Control group
(n ¼ 19) (n ¼ 19)
67.5 (7.3) 68.4 (8.5)
12 (63.2%) 11 (57.9%)
28.8 (1.0) 28.6 (1.1)
15 (79%) 18 (95%)a
7 (36.8%)b 4 (21.0%)b
7.9 (3.9) 8.7 (6.1)
41.3 (16.0) 38.8 (11.3)
16.5 (5.9) 16.0 (4.5)
939 (531) 711 (703)
safe and feasible for cognitively intact people with mild to mod-
erate PD, and that participants were able to progress the level of
gameplay over the 12 weeks. However, the intervention did not
improve the ability of the exergame participants to complete UE
activities when compared to control group participants. Further-
more, tapping test results showed that while participants demon-
strated faster movement speeds after training, there was a
corresponding decrement in movement accuracy.
Our results, taken together with results from previous studies,
highlight the importance of specificity of task practice. The exer-
game intervention did not lead to improvements in the nine hole
peg test, or in secondary measures of hand/UE dexterity, subjective
abilities to perform UE activities or in disease-related quality of life.
The lack of improvement in UE activity performance following the
exergames is in contrast with previous findings [12,13]. Two pre-
vious trials both reported improvements specific to the tasks
trained, that is, improvements in arm and hand function following
modified constraint-induced movement therapy [12] and im-
provements in the size of handwriting following practice of writing
with increased amplitude [13]. In the present trial, participants
improved in their ability to play the games, and the improved speed
of movement measured in the tapping test closely resembles the
movements trained in the exergames. Moreover, the increase in the
error score on the tapping test may also be a consequence of the
exergame training. The exergames did not have a high accuracy
requirement, as there was no feedback about, or penalty for, hitting
the wrong button or key. The only consequence of such an error was
a momentary delay in making the correct response. This may have
encouraged participants to prioritize speed of response over the
accuracy of the response, leading to improved movement speed
with decreased accuracy. Participants in the present trial therefore
demonstrated improvements specific to what they practiced in the
exergames.
The results of this trial have implications for the use of exer-
games in the rehabilitation of people with PD. Exergames have the
potential to facilitate motor learning as they can provide engaging
practice of activities with augmented feedback, which often in-
cludes knowledge of results and/or knowledge of performance in
the form of visual, auditory and sensory feedback [29]. However, a
review of motor learning in PD [29] concluded that people with PD
demonstrate reduced flexibility and efficiency of learning and
require increased context specificity. Furthermore, people with PD
have demonstrated deficits in motor learning when testing condi-
tions vary from those used during practice [30]. Evidence suggests
therefore that exercise aimed at improving activity performance in
people with PD should closely resemble the activity the training is
aiming to improve. The results of the present trial further support
 N.E. Allen et al. / Parkinsonism and Related Disorders 41 (2017) 66e72 71

Table 2
Mean (SD) and mean (95% CI) differences between groups for the primary and secondary outcome measures for the intervention and control groups.

Outcome Groups Difference between groups

Pre-test Post-test
(12 weeks)

Intervention Control Intervention Control Intervention minus Controla

n ¼ 19 n ¼ 19 n ¼ 18 n ¼ 19

Nine hole peg testb (s) 28.8 29.9 29.0 30.4 0.3 (3.6e2.9)
(5.7) (7.3) (7.8) (7.5) p ¼ 0.84
Horizontal tapping test 124.1 119.0 130.1 114.6 10.9 (3.3e18.4)
speed score (taps/60 s)c (34.9) (29.4) (30.4) (26.3) p ¼ 0.006
Horizontal tapping test with cognitive task 76.7 87.2 84.6 87.4 6.6 (6.4e19.6)
speed score (taps/60 s) (36.7) (38.2) (46.4) (36.0) p ¼ 0.31
Horizontal tapping test 0.047 0.048 0.070 0.041 0.029 (0.004e0.054)
error scoreb,d (0.064) (0.042) (0.059) (0.037) p ¼ 0.02
Horizontal tapping test with cognitive task 0.063 0.055 0.098 0.043 0.044 (0.001e0.087)
error scoreb,d (0.086) (0.053) (0.097) (0.043) p ¼ 0.05
Vertical tapping test 124.8 117.3 127.8 114.0 6.5 (3.0e16.0)
speed score (taps/60 s) (40.9) (25.6) (41.5) (25.5) p ¼ 0.17
Vertical tapping test with cognitive task 82.9 92.1 91.3 88.8 10.0 (5.4e25.5)
speed score (taps/60 s) (47.5) (40.0) (57.6) (39.0) p ¼ 0.19
Vertical tapping test 0.057 0.056 0.080 0.050 0.028 (0.000e0.056)
error scoreb,d (0.080) (0.046) (0.068) (0.040) p ¼ 0.05
Vertical tapping test with cognitive task 0.048 0.070 0.094 0.056 0.059
error scoreb,d (0.067) (0.062) (0.098) (0.054) (0.023e0.096)
p ¼ 0.002
Coin rotation test 7.3 7.3 6.9 6.5 0.3 (1.3e1.9)
(number of half turns) (3.1) (3.2) (3.6) (4.2) p ¼ 0.68
Box and block test 41.6 40.6 42.3 39.7 1.3 (2.1e4.7)
(number of blocks moved) (10.6) (8.1) (9.7) (8.8) p ¼ 0.44
Hand reaction timeb,e (s) 0.28 0.27 0.27 0.27 0.01 (0.03e0.05)
(0.06) (0.07) (0.08) (0.05) p ¼ 0.65
Manual Ability Measuree 124.5 121.2 122.6 120.9 0.6 (5.9e4.6)
(range 0e144) (15.6) (15.4) (16.8) (15.1) p ¼ 0.81
PDQ_39b (%) 23.0 26.0 23.7 24.3 1.3 (4.2e6.8)
(12.3) (11.4) (14.9) (9.8) p ¼ 0.63
TMT Ab (s) 34.8 34.8 32.3 38.6 6.0 (12.5e0.5)
(10.2) (10.7) (10.7) (15.1) p ¼ 0.07
TMT Bb (s) 78.3 80.5 95.0 93.4 4.5 (21.6e30.6)
(34.8) (38.7) (88.1) (50.5) p ¼ 0.73
MOCA 26.8 26.8 27.8 28.2 0.4 (1.9e1.0)
(range 0e30) (1.6) (2.8) (3.0) (2.0) p ¼ 0.58
a
Values are change scores (post-test minus pre-test) and are adjusted for baseline (pre-test) score based on analysis of covariance ANCOVA.
b
High score reflects poor performance.
c
Significant outcome in favor of the exergame group.
d
Significant outcome in favor of the control group.
e
Analysis conducted using the difference between post-test and pre-test scores due to skewed data;
where the test is conducted on each hand individually, scores reflect the average performance of both hands; bold text ¼ statistically significant result; PDQ_39 ¼ Parkinson's
Disease Questionaire_39; TMT A ¼ Trail Making Test part A; TMT B ¼ Trail Making Test part B; MOCA ¼ Montreal Cognitive Assessment.

this, as the exergames did not resemble the activities assessed in
the outcome measures. Further research of the efficacy of exer-
games in this population may be enhanced by ensuring the exer-
game trains the target activity as closely as possible. This is likely to
be a challenge for UE activities, particularly dexterous activities,
where there is a wide variety of everyday activities that pose dif-
ficulties for people with PD. Gaming systems that can track player
movements in three dimensions may provide some solutions
worthy of further investigation.
Cognitive function, as measured by the Trail Making Test Part A,
showed a trend towards improvement in the exergame group in
the main analyses, which was statistically significant in post-hoc
analysis. This may indicate an improvement in visual scanning
and cognitive flexibility following the exergame training, possibly
due to the requirement to be constantly scanning for and
responding to random stimuli during the gameplay. However, a
limitation of the present trial is that people with significant
cognitive impairment were excluded. Nonetheless, it seems
possible that training of UE tasks (where there is a large number of
degrees of freedom and a complex range of activities) could
influence cognitive function. Further work is required to explore
any interaction between cognition and UE interventions.
The home-based exergame training was found to be feasible and
acceptable for cognitively intact people with PD. Feasibility was
similar to that reported for exergames involving the lower limbs
[14], with participants able to learn to use the system and play the
games within two home visits, progressing to more difficult levels
of game play, and enjoying playing the exergames. Overall adher-
ence was good and was similar to other minimally-supervised ex-
ercise-based interventions [11,13]. The equipment used was
reliable; however, some participants reported that it was awkward
to set up for each session, and participants tired of playing the same
two games for 12 weeks. A limitation of the present trial is that we
were unable to extend the trial beyond 12 weeks and so could not
evaluate the long term adherence or any potential long-term ben-
efits of the intervention. Nonetheless, our results suggest that if
exergames are to be used as an ongoing intervention, consideration
needs to be given to providing a variety of appropriate games in
order to facilitate long term interest and adherence.
In conclusion, this trial of an UE exergame intervention found
72 N.E. Allen et al. / Parkinsonism and Related Disorders 41 (2017) 66e72
the intervention did not lead to improvements in activity perfor-
mance. The intervention was feasible and acceptable, however
participants would have preferred more variety in the games pro-
vided. The results of this trial highlight the need to consider
specificity of task practice and long term adherence in the design of
future exergame interventions.
Funding
This work was supported by a Parkinson's NSW Bendigo Bank
Parkinson's Research Grant and a University of Sydney Bridging
Support Grant.
Documentation of author roles
Natalie Allen: study concept and design, participant recruit-
ment, delivery of the intervention, data collection, design and
execution of statistical analysis, manuscript writing; Jooeun Song:
study concept and design, participant recruitment, delivery of the
intervention, critical revision of the manuscript; Serene Paul: study
concept and design, critical revision of the manuscript; Stuart
Smith: study concept and design, critical revision of the manu-
script; Jonathan O'Duffy: study concept and design, critical revision
of the manuscript; Matthew Schmidt: study concept and design,
critical revision of the manuscript; Rachelle Love: data collection,
critical revision of the manuscript; Catherine Sherrington: study
concept and design, critical revision of the manuscript; Colleen
Canning: study concept and design, study supervision, critical
revision of the manuscript.
Disclosures
The authors report no disclosures.
Conflict of interest
None.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.parkreldis.2017.05.011.
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