Effectiveness and acceptability of exergaming in people with mild cognitive impairment: protocol for an overview of systematic reviews and network meta-analysis.

Introduction

A new case of dementia will be diagnosed every 3 s around the world [ 1 ]. It is estimated that the global prevalence of dementia will almost double every 20 years, from 46.8 million in 2015 to 131.5 million in 2050, most of which will occur in low-income and middle-income countries [ 1 ]. This has a negative impact on families, communities, and health care systems around the world [ 2 ]. The combined cost of health care and income loss due to this disease has reached US $81 billion per year and is expected to increase to US $2 trillion by 2030 [ 1 ].

At present, there is no treatment to cure dementia, so many researchers have focused their research on delaying the preclinical stage of dementia patients, that is, mild cognitive impairment (MCI). MCI is a critical stage in delaying or preventing the transition to dementia [ 3 ]. The risk of dementia in patients with MCI is 5–10% higher than those without MCI [ 4 ]. The conversion rate of MCI to dementia within 3 years was 46%, while the conversion rate of people without MCI was only 3% [ 5 ]. However, MCI is reversible to a certain extent, and early intervention will help delay or prevent the progression of the disease and effectively reduce the risk of adverse health outcomes such as dementia [ 6 , 7 ].

Exergaming is a combination of exercise and gaming that allows people to physically interact with a web-based game scene on a screen [ 8 ]. It requires the player’s physical performance, as the technology used in the game system tracks the player’s movements to control those in the game, thus immersing the player [ 9 ]. Previous systematic reviews have shown that exergaming is one of the most effective exercise interventions to improve the cognitive and functional health outcomes of the elderly [ 10 , 11 ]. Exergaming has shown promising results in studies of patients with MCI, suggesting that it can improve physical and cognitive function in patients with MCI [ 12 , 13 ].

However, there are several uncertainties. The first is that there have been conflicting results on the effectiveness of existing exergaming in people with MCI. A systematic review and meta-analysis of 10 randomized controlled trials (RCTs) showed that exergaming improved executive function and memory in people with MCI, but were not statistically significant in improving attention [ 12 ]. However, a meta-analysis of nine studies showed that exergaming improved global cognitive function in people with MCI, but were not statistically significant in improving attention, executive function, and memory [ 14 ]. Second, there is no research to investigate which exergaming is the most effective. Third, there is no overview of systematic reviews using exergaming in patients with MCI, making the methodological quality of these systematic reviews unclear. Fourth, there is no study investigating the acceptability of exergaming in MCI patients. This indicates that the acceptability of exergaming in people with MCI needs to be considered. The uncertainties described above will affect the credibility of the research results and limit the application of exergaming in clinical practice.

The objectives of this protocol are as follows: (1) Provide an overview of systematic reviews to synthesize and critically evaluate current systematic reviews and (2) conduct a pairwise meta-analysis, followed by a network meta-analysis using RCTs extracted from eligible systematic reviews to explore the comparative effectiveness and acceptability of each exergaming in MCI patients.

Methods and analysis

An overview of systematic reviews will be conducted according to the general principles of systematic review methodology [ 15 ]. A network meta-analysis will be conducted to compare the effectiveness of different exergames. A Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) checklist [ 16 , 17 ] has been completed. The study protocol was registered with PROSPERO—CRD42023421052.

Eligibility criteria

Studies must be in the English language and meet the criteria for participants, interventions, comparisons, outcomes, and study designs listed below to identify multiple systematic reviews of relevant research questions in the same topic area. After including all eligible systematic reviews, embedded RCTs will be extracted and assessed for eligibility criteria as well, which is a common approach used in network meta-analysis [ 18 ].

Types of participants

MCI patients were diagnosed by Peterson [ 19 ] (self-reported or insider-reported memory declines; scores based on the Montreal Cognitive Assessment scale [ 20 ] were ≤ 13 points for the illiterate group, ≤ 19 points for the primary school group, and ≤ 24 points for the junior high school group and above; the score of the Activity of Daily Living scale was ≤ 23 points; no clinical diagnosis of dementia), the National Institute of Aging, the Alzheimer’s Association, and other criteria. Studies were excluded if they focused on cognitive decline in patients with dementia, Parkinson’s disease, stroke, Huntington’s disease, epilepsy, multiple sclerosis, diabetes, or psychiatric illnesses (e.g. schizophrenia). Systematic reviews involving mixed populations (e.g. MCI and dementia) were only included if they provided separate analyses for MCI patients.

Types of interventions

At least one intervention group was required to be an exergaming intervention for patients with MCI. Exergames include the following categories: (i) dance and step video games, (ii) commercial home video game consoles (the Nintendo Wii, Xbox Kinect), and (iii) interactive virtual ergometers (cybercycles, virtual kayak ergometer).

Comparisons

Systematic reviews can provide any type of control, including exercise, rehabilitation, and placebo. Regardless of the control treatment, the trial must allow for the evaluation of the net effect of exergaming.

Outcomes

To be included in a network meta-analysis, trials must include one of the following two outcome measures: (1) Effectiveness (cognitive function) or (2) acceptability. When measuring cognitive function using multiple standard rating scales within the same study, we will use the predefined hierarchical structure to maintain consistency in the use of the included trails. Acceptability is defined as the direct or indirect measurement through qualitative assessment of acceptability, satisfaction, and experience or indirect measures via compliance, completion, adherence, attrition, or dropout rate [ 21 ].

Study designs

We included systematic reviews and meta-analyses that meet the eligibility criteria, as well as the RCTs included in them.

Search strategy

We will systematically search six English databases including PubMed, Web of Science, Embase, Cochrane Library, CINAHL, and PsycINFO from inception to January 2025. We will use a combination of medical topic headings (MeSH) and keywords in the search method. Grey literature and reference lists of all included studies will also be reviewed for further research. If we need more information about the study, we will contact the first author.

At the same time, we will keep in touch with authors and researchers active in the field and use citation search, such as Web of Science and PubMed, to track important articles. There is no limitation on the publication data of the included RCTs. Only studies published in English will be included. The search process will be completed independently by two researchers (X. C. and Y. F. C.). Any disagreement will be resolved through discussion and consensus between the two researchers (X. C. and Y. F. C.). Table 1 summarizes the search strategies that will be used in PubMed.

Study selection and data extraction

After removing duplicate studies, all titles and abstracts will be reviewed independently by two reviewers (X. C. and Y. F. C.), and potential studies will be identified according to the inclusion criteria. A list of included RCTs will be retrieved from eligible systematic reviews. We acknowledge that the included systematic reviews may address similar research questions and include many of the same preliminary studies. We will use the corrected coverage area to evaluate the overlap of included studies [ 22 ]. A corrected coverage area value of 0–5% is considered “slight overlap”, 6–10% is “moderate overlap”, 11–15% is “high overlap”, and above 15% is “very high overlap” [ 23 ]. Additionally, we will create a citation matrix to resolve overlap issues.

Any differences will be resolved by discussion and consensus between the two authors or, if necessary, by consulting a third author (H. T. N.) to reach a consensus. We will record all reasons for excluding studies. Two researchers (X. C. and Y. F. C.) will use NoteExpress 4.0 software to manage the literature. The results will be recorded in detail using the PRISMA flowchart (Fig. 1 ).

After systematic reviews and/or meta-analysis are included, the full text will be independently read by two authors (X. C. and Y. F. C.), and data will be collected independently by two authors (X. C. and Y. F. C.) using a data extraction table in the Covidence that has been discussed by all authors. And the extracted data will be rigorously compared to ensure consistency.

We will extract basic information such as the author’s name, year, country, study location, participant source, MCI diagnostic criteria, type of intervention, outcomes, and other basic information. For the network meta-analysis, we also will extract data from the RCTs in the included systematic reviews. If there is a lack of data or unclear information, we will contact the main authors included in the study.

Methodological quality assessment

AMSTAR 2 will be used for methodological quality assessment [ 24 ]. It consists of 16 evaluation items, and the quality scale has four levels: high, medium, low, and very low. AMSTAR-2 considers items 2, 4, 7, 9, 11, 13, and 15 as critical items that affect the production of systematic reviews and the validity of its results, while the rest are noncritical items [ 25 ]. If ≤ 1 noncritical item is not met, it is assessed as “high” quality. If > 1 noncritical item is not satisfied, it is rated as “medium” quality; if a critical item is not satisfied, the quality level is “low” regardless of whether there is a critical item or not. If more than one critical item is unsatisfactory, it will be rated as ‘”very low” quality regardless of whether there are noncritical items.

Methodological quality assessment of the included RCTs will be performed using “the Version 2 of the Cochrane tool for assessing risk of bias in RCTs” (RoB 2) [ 26 ]. The overall risk of bias for each RCT will be judged as low risk of bias, partial risk of bias, or high risk of bias based on the five domains (bias due to the randomization process, bias due to deviation from the intended intervention, bias due to missing outcome data, bias due to the measurement of the outcome, and bias due to selection of the reported result) [ 26 ]. The evaluation of methodological quality will be completed independently by two authors (X. C. & Y. F. C.). Any differences will be resolved through discussion and consensus between the two researchers (X. C. & Y. F. C.). If differences cannot be resolved, a third author (H. T. N.) will be consulted.

We will use the PRISMA statement to report quality evaluation [ 25 ], which encompasses 27 items. Reporting completeness was scored as follows: 1 point for full reporting, 0.5 points for partial reporting, and 0 point for no reporting. The maximum possible score is 27. Scores ≤ 15 imply a relatively serious information defect, scores between 15 and 21 indicate a certain defect, and scores of 21 to 27 signify a relatively complete reporting. The PRISMA statement serves solely as a descriptive tool for reporting quality evaluation and does not influence inclusion/exclusion decisions or quality grading.

Finally, the certainty of evidence that contributes to network estimation will be assessed through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework [ 27 ], respectively, for pairwise meta-analyses [ 28 ] and network meta-analyses [ 29 ]. The quality of evidence for each outcome was divided into four levels (high, medium, low, and very low) [ 29 , 30 ]. There is no evidence of any items being downgraded to high, one item is downgraded to medium, two items are downgraded to low, and three or more items are downgraded to very low [ 31 ].

Data analysis

Pairwise meta-analyses

In this study, we will adhere to the established methods for conducting pairwise meta-analyses, followed by a network meta-analysis, both of which are recognized as standard methodology [ 32 ]. We will conduct the pairwise meta-analysis and network meta-analysis to explore the effectiveness and acceptability. In pairwise meta-analysis, the data will be synthesized by comparison with the control group using a random-effect model. Data on cognitive function will be combined into standard mean differences (SMDs) with 95% confidence interval (CI). Acceptability data will be expressed as odds ratios (ORs) with 95% CI. The χ 2 test and I 2 statistics will be used to determine the heterogeneity between the studies. The I 2 < 25% is regarded as a low level, 25%–50% as a moderate level, and > 50% as a high level [ 33 ]. When the I 2 value exceeds 50%, a random effects model will be used to minimize the potential heterogeneity.

Network meta-analysis

Network meta-analysis will be used to rank the effectiveness and acceptability of different types of exergaming. A network plot will be used to illustrate the different types of each exergaming in the network. Direct and indirect evidence for any pair of exergaming will be combined to produce a combined effect size, expressed as SMDs with 95% CI [ 34 ]. If there is a closed loop of evidence in a network graph, the inconsistency analysis will be performed. The effectiveness level will be obtained by using the surface under the cumulative sorting curve (SUCRA). The larger the SUCRA, the higher the effectiveness ranking of the intervention will be. Data analysis will be performed using STATA version 14.1.

If possible, we will do some subgroup analyses based on heterogeneity and inconsistency of results, such as different types of control interventions. RCTs with at least one domain assessed as high risk of bias will be excluded from the pairwise meta-analysis, and sensitivity analysis will be performed to explore the robustness of the research results. We plan to use funnel plots to investigate publication bias.

Discussion

The current study aims to address key uncertainties about the effectiveness and acceptability of exergaming for individuals with MCI. Our study will provide a comprehensive and critical evaluation of existing research in this area, and we can provide evidence-based guidance to healthcare providers, investigators, and patients that will be important for clinical practice and future research directions.

First, by conducting an overview of systematic reviews, we will be able to evaluate the combined results of the effectiveness of exergaming for the MCI population and the methodological quality of the included systematic reviews. At the same time, by combining these studies, we will be able to identify any gaps or inconsistencies in current research and make recommendations for future research. In addition, our network meta-analysis will allow us to compare the effectiveness of different exergaming interventions, providing clearer guidance to healthcare providers, investigators, and patients to determine the most appropriate exergaming intervention. Lastly, our study will address the deficiencies in research on the acceptability of exergaming in patients with MCI, which is critical to ensuring its successful implementation in clinical practice, as this could significantly impact the use and effectiveness of exergaming interventions. The above information will be invaluable in developing strategies to promote the adoption and sustainability of exergaming interventions in clinical settings.

Regarding the feasibility of network meta-analysis, according to the previous systematic review [ 12 , 13 , 35 – 38 ], it can be expected that there will be sufficient relevant evidence allowing network meta-analysis. If it is not sufficient to conduct a network meta-analysis, a pairwise meta-analysis will be considered. Should a pairwise meta-analysis also not be possible, studies will be summarized narratively.

Future research should focus on standardizing exergaming interventions, conducting more high-quality randomized controlled trials with longer follow-up periods, and exploring potential mechanisms of how exergaming may benefit individuals with MCI. This will further improve the reliability and applicability of research results in this field.

Strengths and limitations of this study

This is the first protocol to overview the application of exergaming in a population with MCI. This overview will conduct a broad and comprehensive search and evaluate the methodological quality and level of evidence of included studies in order to provide a more reliable basis for the use of exergaming in people with MCI.

However, this protocol has two limitations. First of all, we only include studies published in English, and there may be information bias. Secondly, it must be admitted that the conclusion of this protocol may be influenced by the author’s professional background.

Acknowledgements

We are particularly grateful to the Central South University Library for providing search resources.

Patient and public involvement

None.

Authors' contributions

XC and DJ contributed equally. XC, DJ, and YFC conceived the study. HTN developed the search strategy. CX, YFC, HTN, and DJ performed the preliminary search. YSZ and HF reviewed the search strategy. XC, DJ, and HTN will oversee data extraction and analysis. CX, YFC, and HF produced the first draft of the manuscript. The definitive protocol was reviewed and approved by all authors (CX, YFC, HTN, DJ, YSZ, and HF).

Funding

This study is funded by the National Key Research & Development Program of China (grant number 2022YFC3601603) and Natural Science Foundation Project of Hunan Province(2025JJ60537). The funders did not and will not have a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

Not applicable.

Declarations

Ethics approval and consent to participate

The data for this study will be extracted from existing research; so, this study does not require ethical approval. Our findings will be published in peer-reviewed journals.

Consent for publication

All authors consented to the publication of this manuscript.

Competing interests

The authors declare that they have no competing interests.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Xi Chen and Dian Jiang contributed equally to this work.

Contributor Information

Hongting Ning, Email: Hongting4960@hnucm.edu.cn.

Hui Feng, Email: feng.hui@csu.edu.cn.

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Associated Data

Data Availability Statement

Not applicable.