Zahedian-Nasab et al.

BMC Geriatrics (2021) 21:509

https://doi.org/10.1186/s12877-021-02462-w

RESEARCH Open Access

Effect of virtual reality exercises on balance

and fall in elderly people with fall risk: a
randomized controlled trial
Noorolla Zahedian-Nasab1, Azita Jaberi2, Fatemeh Shirazi3* and Somayyeh Kavousipor4

Abstract
Background: Deficient balance and fear of falling in elderly people can lead to disturbed daily activities, falling, and
finally reduced quality of life. Therefore, evaluation of low-risk methods that might partially improve balance in this
group of people is of utmost importance. The present study aimed to investigate the impact of Virtual Reality (VR)
exercises based on Xbox Kinect on balance and fear of falling among elderly people.
Methods: This clinical trial was performed on 60 elderly individuals living in nursing homes divided into two
groups of control and Xbox. The participants in the intervention group received VR exercises based on Xbox Kinect
in form of two 30–45-min sessions held on a weekly basis for 6 weeks. The individuals in the control group, on the
other hand, received routine exercises of the nursing homes. The research tools used in this study included a
demographic questionnaire, the Berg Balance Scale (BBS), the Timed Up and Go (TUG) test, and the Falling Efficacy
Scale (FES).
Results: The findings of the current study demonstrated that the scores of BBS and TUG test as the indices of
balance among elderly people improved significantly in the Xbox group after the intervention (p < 0.001 for both
BBS and TUG test). Moreover, the score of fear of falling diminished significantly in the intervention group
compared to the control group (p < 0.001).
Conclusion: According to the results of the present investigation, 6 weeks of VR balance exercises could enhance
balance and fear of falling among elderly people living in nursing homes.
Trial registration: Code:IRCT20190727044347N1, Date: 17-8-2019.
Keywords: Aged, Exercise, Virtual reality, Postural balance, Fall, Nursing homes, Xbox

Background has in turn led to a diminished mortality rate, an aug-

In the recent decades, advances have been made in mented lifetime, and problems concerning the quality of
medicine, technology, and public health and the know- life among elderly people [2]. One of the problems asso-
ledge of people about health, nutrition, and education ciated with a longer lifetime is falling. Falling is among
has improved. As a result, life expectancy has increased the reasons for injury and death in elderly individuals, as
throughout the world and the world population has one out of every three people over 65 years old and one
moved towards getting old [1]. Elevated life expectancy out of every two individuals over 80 years old experience
falling during a year [3–5]. According to the literature,
* Correspondence: [email protected]
falling among elderly people imposes heavy expenses
3
Community Based Psychiatric Care Research Center, School of Nursing and both directly (medical) and indirectly (non-medical) on
Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran people and the society [6, 7]. Fracture, performance
Full list of author information is available at the end of the article

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Zahedian-Nasab et al. BMC Geriatrics (2021) 21:509 Page 2 of 9

limitations, traumatic injuries to the brain, disability, video exercises might improve physical performance and
extra expenses, and mortality are among the most im- balance [25, 31], eventually leading to a reduction in the
portant sequels of falling [8]. fear of falling [12, 15, 32]. For instance, Bieryla (2016)
Falling in elderly individuals is affected by diverse fac- conducted a pilot study on healthy elderly individuals
tors, some of which can be balanced, while some cannot. from living communities and an intervention group
Fear of falling and impaired balance are known as the trained with the Kinect for Xbox 360 for 3 weeks. The
adjustable risk factors of falling in old people [9]. Fear of results showed significant changes in Berg Balance Scale
falling is one of the common problems in elderly people (BBS) and Fullerton Advanced Balance (FAB) [31]. An-
and is more frequently observed in individuals with an other systematic review also showed the positive effects
experience of falling, impaired balance, low social activ- of Kinect systems on rehabilitation for elderly people
ities, depression, and weak autonomy [10, 11]. Studies suffering from stroke and falling risk [33]. However,
have indicated that about half of elderly individuals have most of these studies were pilot investigations with small
experienced falling at least once [12, 13]. Fear of falling sample sizes and short intervention durations. Moreover,
results in limitations in physical activities, which might studies conducted in Iran have assessed the effect of
be followed by falling. Consequently, the quality of life video games on elderly people with stroke [34]. Elderly
decreases and a low-mobility lifestyle occurs [14]. In people living in nursing homes, on the other hand, may
addition to the fear of falling, impaired balance is one of suffer from balance disorders and fear of falling for rea-
the most prevalent reasons for falling amongst elderly sons other than stroke. Therefore, studying the effect of
people [15]. Disturbed balance results in the fear of fall- these methods among elderly people with various disor-
ing in elderly people, which can lead to impaired daily ders could provide a more appropriate conclusion about
activities and diminished quality of life [3, 5]. Disturbed this type of exercise for researchers. According to Neil
balance, which is another reason for falling in elderly et al., there are significant differences in the physical
people [15], has been defined as the disability for main- interaction and therapeutic emphasis of diverse games
taining balance and alterations in body consistency at [35].
the center [16]. Nurses have an important role in ensuring the safety
There are various methods for maintaining or enhan- of their clients and face many challenges in this regard
cing balance and some of the common therapeutic tech- [35]. Given that lack of balances and falls are threatening
niques include tango dance [17, 18], yoga [19, 20], tai factors for the safety of the elderly, it is necessary for
chi [21–23], and video games. Considering the tendency nurses to investigate the impact of various interventions
of modern society towards computer and video games on reducing these threats. Considering the importance
played by smart computers [24–28], video games have of this issue and the lack of investigations in this regard,
been recently noted as a substitute for the rehabilitation the present study aims to evaluate the impact of Virtual
of disabled people. Some of the benefits of using smart Reality (VR) exercises on balance and fear of falling
computers for improving balance entail the possibility of among the elderly people living in the nursing homes.
easy application at home, lower costs compared to other
therapeutic methods, and better acceptance of the inter- Methods
vention by individuals due to being interesting [25]. Study design and setting
Xbox Kinect is a smart computer that can simulate bal- This clinical trial with a pretest-posttest design was per-
ance exercises. This computer can recognize people’s formed in the nursing homes of Shiraz, Iran in 2019.
movements by a camera and infrared motion sensors
and helps people perform movements correctly in case Participants
they are wrong. Moreover, this smart computer allows The participants of the current study were males and fe-
people to move freely and have diverse positions [27]. males aged over 60 years living in nursing homes. First,
The Xbox Kinect can be used for rehabilitation purposes all interested elderly people were invited to participate
as well as for exercising (also termed “exergames”) [29]. in the research. Afterwards, the interested individuals
Considering the elevated population of elderly people were tested using the Timed Up and Go (TUG) test, and
in modern societies and the high prevalence of falling in 60 people with TUG scores of 14–20 were selected [36]
this group, exercises that can promote the physical per- based on the inclusion and exclusion criteria. The initial
formance of these people and decrease the risk of falling TUG test scores of the participants were recorded for
have been taken into consideration by health caretakers. comparison to post-intervention scores.
Therefore, it is highly important to evaluate low-risk The inclusion criteria of the study entailed the ability
methods, which can partially improve the balance of to walk with or without assisting tools and the permis-
these individuals and finally enhance their quality of life sion of the doctor at the nursing home. The exclusion
[30]. Some studies in this regard have demonstrated that criteria included a history of acute and chronic physical,
Zahedian-Nasab et al. BMC Geriatrics (2021) 21:509 Page 3 of 9

cognitive, and mental diseases that might hinder exercis- researchers, and one of them performed the
ing, participation in other exercises similar to the inter- randomization accordingly.
vention, having problems leading to problematic
exercises, unmodified hearing and seeing problems, and Interventions
balance disorders due to the problems of the vestibular The participants were asked to fill out the demographic
system and cerebellum diagnosed by a doctor. questionnaire, Falling Efficacy Scale (FES), and TUG test.
It should be noted that the TUG test results were col-
Ethical consideration lected at the stage of sample selection. Afterwards, the
The present study was approved by theEthics Committee balance of all participants was measured and recorded.
of Shiraz University of Medical Sciences (IR.SUMS.- Next, the intervention group received simulated balance
REC.1398.573). It was registered in Iranian Registry of exercises in the form of two 30–60-min sessions on a
Clinical Trials (IRCT) with registration number of weekly basis for 6 weeks. For simulated balance exer-
IRCT20190727044347N1 on 2019-08-17. All necessary cises, Xbox Kinect was applied, which is a game console
permissions for conducting the research were obtained simulating balance exercise in the game environment
from the relevant administrators and all methods were and allows a person to move freely and have diverse po-
performed in accordance with the relevant guidelines sitions. This computer recognizes and executes the
and regulations. Furthermore, a session was held after movements of people via a camera and infrared motion
the selection of participants for explaining the study ob- sensors. This smart computer contains a variety of
jectives and procedures. Written informed consent games. In this study, suitable games for improving the
forms were also taken from all participants. balance of elderly people were selected in a meeting with
the professors of the Rehabilitation Department. The se-
Sample size lected games (Kinect Sports 1 and 2) included penalty,
According to the research by Park et al. (2017), using goalkeeping, ski, and darts, and each session covered a
the equation for the difference of BBS means (mean of different aspect of enhancing balance. All selected exer-
50 ± 6.27 for the intervention group and 44.7 ± 7.47 for cises required the application of upper and lower organs
the control group), and considering type 1 error of 0.05 while standing (Table 1).
and power of 80%, the sample size was calculated as 27 In order to perform simulated exercises in each ses-
for each group. Considering dropout, 30 participants sion, first, the position of the individual was set at 1.5–2
were allocated to each group, making a total sample size m from the computer and the exercise was explained to
of 60 [37]. the person. Prior to the exercises, permission was taken
from the doctor of the nursing home. Exercises were
Randomization stopped in case of fatigue, pain, or dyspnea. During the
The participants were divided into an intervention group game, the participants were encouraged by the re-
(i.e., exercise by Xbox Kinect) and a control group (i.e., searcher. It is worth mentioning that special mats were
routine programs of the nursing homes) through ran- used in order to prevent injury to the elderly people.
dom allocation using double randomized permutation The exercises were continued for 30–60 min each ses-
block with foursome blocks. The random list was gener- sion and all participants in the intervention group played
ated by a statistician using the “Random Allocation” all specified games for 6 weeks.
software, and 15 blocks were selected for forming the In the control group, the elderly individuals received
two study groups. The list was then provided to the the routine programs of nursing homes, including

Table 1 Description of each game in the Xbox Kinect sports pack

Ski Weight shifting to the right and left or up and down is trained. – Active movement of the lower extremity (flexion, abduction, and
The screen demonstrates a virtual slope and players should follow external-internal rotation of hip; flexion and extension of knees;
the slope without crashing into the barriers. dorsiflexion and plantar flexion of ankles)
– Trunk rotation
– Training weight-shifting and weight-bearing
– Training balance
Penalty The usage of lower extremities, head, neck, and trunk while – Active movement of the lower extremities (flexion, abduction,
and standing and kicking a ball in a virtual soccer field is practiced. and external-internal rotation of hip; flexion and extension of
goalkeeper knees; dorsiflexion and plantar flexion of ankles)
– Training weight-shifting and weight-bearing
– Training balance
Darts Players throw small missiles known as darts at a circle-shaped dart- The upper limb has unilateral movements along with static
board. Three darts are utilized per visit at the board to reduce 501 standing.
to 0.
Zahedian-Nasab et al. BMC Geriatrics (2021) 21:509 Page 4 of 9

jogging in the nursing home, table tennis, and some art- Independent t-test and chi-square test were applied for
istic activities, for 6 weeks. After 6 weeks of intervention, comparing the two groups regarding the demographic
balance, physical performance, and fear of falling were variables. Moreover, the pre- and post-intervention
assessed in the participants of both control and interven- scores were compared in the two groups via paired t-
tion groups and were compared to the data recorded test. To compare the difference between the scores of
previously. the two groups, independent t-test and Analysis of Co-
variance (ANCOVA) were utilized.
Outcome measures and follow-up
Data collection tools in the present study included a Results
demographic questionnaire, FES, Berg Balance Scale A total of 150 elderly people were candidate for par-
(BBS), and the TUG test. The demographic question- ticipating in the current study, among whom 112
naire encompassed age, gender, previous employment people expressed a tendency for participation. The
status, education level, marital status, duration of stay at TUG test was conducted for these individuals, 65 of
the nursing home (direct question from elderly people), whom had a test time of over 14 s and could be en-
and a record of the number of fallings during the previ- rolled into the study. Afterwards, these people were
ous year. evaluated in terms of other inclusion criteria and fi-
Fear of falling was evaluated using FES, which ad- nally, 60 (16 females and 44 males) were selected and
dressed the rate of fear of falling during different daily divided into a control and an intervention group
activities. The answers ranged from “I am worried a lit- through random allocation (Fig. 1). After 6 weeks of
tle” [1] to “I am worried very much” [4]. Thus, the scores intervention, balance, physical performance, and fear
of the survey could range from 16 to 64, with higher of falling were assessed in the participants of both
scores showing a greater fear of falling. The validity and control and intervention groups and were compared
reliability of the English and Persian versions of this tool to the data recorded previously.
have been evaluated and confirmed in the previous The mean age of the participants was 70.83 ± 7.79
studies. years and most of them were male (73.3%) and single
The participants’ balance was assessed utilizing BBS, (45%). The demographic characteristics of the partici-
which is a clinical test for evaluating people’s static and pants have been presented in Table 2. Accordingly, no
dynamic balance. This survey contained 14 items significant difference was found between the two groups
responded based on a five-point Likert scale, in which in terms of age, gender, marital status, education level,
four indicated the best execution and zero demonstrated occupation, duration of stay at the nursing home, and
the worst execution. The total score of the scale could number of falls before the intervention (p > 0.05).
range from zero to 56 and was obtained by summing up Comparison of the study variables, including pre- and
all 14 items. The psychometric characteristics of this in- post-test balance, TUG test, and FES, has been summa-
strument were investigated and confirmed in the previ- rized in Table 3. Accordingly, the mean score of balance
ous studies in Iran [38]. significantly augmented in the intervention group post
The participants’ balance in walking was evaluated by intervention (p < 0.001), while this elevation was not ob-
applying the TUG test that examined distinct aspects of served in the control group (p = 0.687). In addition, the
static and dynamic balance during daily activities. This mean balance changes were significantly different be-
test included three stages of standing up, walking three tween the control and intervention groups (p < 0.001).
meters, turning around, and returning. The time of the Considering the results showing that the two groups
test, as the dependent variable, was measured by a timer. were not similar in this regard before the intervention,
When the participants announced that they were ready, ANCOVA was used. The impact of the intervention on
the timer was started and when they returned and their balance in the intervention group was significant even
backs touched the chair, the timer was stopped. The val- with the pre-test effect control (p < 0.001).
idity and reliability of this tool have been assessed and The study findings revealed that the mean of the post-
confirmed in various studies [39, 40]. intervention TUG test reduced by about 2.33 s in the
intervention group (p < 0.001), while the two groups
Statistical analysis were not significantly different (p = 0.88). Considering
The normality of the data was assessed using the the difference between the two groups at the beginning,
Kolmogorov-Smirnov test, and the results indicated that ANCOVA was utilized. The influence of the intervention
all demographic data and other study variables had nor- on this factor was found to be significant with the pre-
mal distribution. Descriptive statistics were used for the test effect control (p < 0.001).
demographic data and the variables were reported as The results indicated that the mean score of FES was
mean, standard deviation, frequency, and percentage. similar in the two groups prior to the intervention.
Zahedian-Nasab et al. BMC Geriatrics (2021) 21:509 Page 5 of 9

Fig. 1 CONSORT flow diagram of the clinical trial

However, the mean score of this factor decreased signifi- However, Ki-hun-cho et al. demonstrated that al-
cantly following the exercises (p < 0.001), but did not though video exercises enhanced dynamic balance, no
change in the control group (p = 0.217). significant impact was noted on the static balance of the
individuals under investigation [42]. Virtual games are
mentally and physically challenging for people and the
Discussion direction, rate, and speed of movements alter constantly
According to the results of the present investigation, during the games. As a result, rapid mental processing
simulated balance exercises could lead to the enhance- and body balance control along with fast changes are re-
ment of balance, TUG test, and FES among the elderly quired [43].
people with impaired balance. The findings revealed that Most of the games used in the current study needed
virtual exercises resulted in the improvement of the the active movements of the hip joint, knees, ankles, and
mean score of balance in the participants, as BBS was different muscles. A higher rate of using these joints and
enhanced. Other studies also showed that utilization of muscles along with more efforts of elderly people to
Xbox smart computer could promote balance and re- concentrate on games could enhance balance among the
duce the risk of falling in old people [24], video games participants. Moreover, receiving real-time and individ-
could improve motor function in patients with cerebral ual feedbacks from the system based on balance status
infarction [37] and enhance dynamic balance in children resulted in the participants’ more focus on their balance
with ataxia [41]. A meta-analysis on elderly people indi- and further attempts to enhance their balance in future
cated that sport interventions could diminish the fear of games. It is worth mentioning that exercise might result
falling at a low to moderate level [15]. in diminished fallings and fear through improving
Zahedian-Nasab et al. BMC Geriatrics (2021) 21:509 Page 6 of 9

Table 2 Demographic data of the participants

Variable Intervention Control P-value
(n = 30) (n = 30)
Age (year) (Mean ± SD) 69.67 ± 7.725 72 ± 7.808 0.249
Duration of stay at nursing homes (month) (Mean ± SD) 22.34 ± 20.43 16.97 ± 18.34 0.514
Number of falls during the previous year (Mean ± SD) 2.10 ± 1.49 2 ± 1.46 0.794
Gender 1
Male 22 (73.3) 22 (73.3)
Female 8 (26.7) 8 (26.7)
Marital status n (%) 0.209
Single 12 (40) 15 (50)
Married 11 (36.7) 4 (13.3)
Widowed 6 (20) 9 (30)
Divorced 1 (3.3) 2 (6.7)
Education level n (%) 0.342
Illiterate 9 (30) 10 (33.3)
Primary school 12 (40) 7 (23.3)
Junior high school and high school 5 (16.7) 11 (36.7)
Academic degree 4 (13.3) 2 (6.7)
Previous occupation n (%) 0.658
Employee 6 (20) 10 (33.3)
Worker 7 (23.3) 5 (16.7)
Freelance 11 (36.6) 10 (33.3)
Homemaker 6 (20) 5 (16.7)

power, stepping, balance, and mood [12]. Furthermore, decreased significantly in the intervention group after
receiving visual feedbacks in simulated exercises could the intervention. These results were in line with those of
lead to the elevation of the participants’ awareness of the research by Htut et al. [44] concerning the effect of
their balance control and enhancement of their self- virtual exercises on the physical, cognitive, and func-
efficacy [44]. tional status of elderly people. These authors reported
In the present study, the TUG test that consisted of that the TUG test was significantly reduced in the inter-
three stages and was another index of balance was over vention group compared to the control group. More-
14 s in both groups at the beginning, demonstrating bal- over, Park et al. [37] indicated that simulated exercises
ance disorder in both groups. However, the TUG test by smart Xbox Kinect could improve the TUG test

Table 3 Comparison of the two groups regarding the mean scores of BBS, TUG test, and FES
Variable Groups Baseline Six weeks Change P-valuea
(Mean ± SD) (Mean ± SD) (Mean ± SD) (within-group)
BBS Intervention 36.9 ± 8.6 40.4 ± 7.7 3.4 ± 2.76 < 0.001
Control 31.7 ± 9 31.9 ± 7.8 0.2 ± 2.6 0.68
P-value (between-group) 0.026 b
< 0.001 c
< 0.001 c
–
Balance state (TUG test) Intervention 15.3 ± 1.9 13.0 ± 2.6 −2.3 ± 1.6 < 0.001
Control 16.6 ± 2.7 16.7 ± 2.6 0.06 ± 2.5 0.88
P-value (between groups) 0.04b < 0.001 c < 0.001 c –
FES Intervention 37.6 ± 11.2 33.5 ± 9.9 −4.0 ± 4.4 < 0.001
Control 41.4 ± 11.6 42.3 ± 9.6 0.8 ± 3.6 0.217
P-value (between groups)
b
0.195 0.001 < 0.001
BBS Berg Balance Scale, TUG Timed Up and Go, FES Falling Efficacy Scale
a
Paired t-test for within-group comparisons; bIndependent t-test; c ANCOVA for between-group comparisons
Zahedian-Nasab et al. BMC Geriatrics (2021) 21:509 Page 7 of 9

among people with hemiplegia. Yang et al. [45] also a disturbance in the sensor of the Xbox Kinect in some
stated that VR exercises had impacts similar to those of situations, which caused the researcher to be mistaken
real exercises, and might enhance balance. They con- by a participant in some situations and made him keep
cluded that virtual exercises could be a suitable substi- the distance to solve this problem. The difficulty of exer-
tute for real training. However, Bieryla et al. [31] showed cises for some participants at the beginning was another
that video games promoted balance among elderly study limitation. Additionally, Kinect systems are not
people based on BBS and Fullerton Advanced Balance suitable for patients with severe disabilities [29]. Consid-
Scale, while TUG and functional tests did not change. ering the fact that there were no severely disabled pa-
According to the results, virtual exercises might improve tients in the present study, the effect of the VR on theses
walking performance and tolerance through increasing patients’ outcomes could not be measured. One other
people’s activity and engagement in games [37]. study limitation was the lack of traditional exercises,
The current study results demonstrated that simulated such as Otago and tango dance, for comparison of their
exercises significantly diminished the fear of falling efficiency to that of the exercises used in the research.
amongst elderly participants in addition to improving This might be taken into consideration in future studies.
their balance. The latter finding was consistent with that Furthermore, some researchers have pointed out some
of the study by Levy et al. and Singh et al. who showed limitations of this type of intervention, including the
that virtual exercises enhanced the fear of falling among fixed location of the sensor with a range of capture of
elderly people [43, 46]. However, in the Kwok et al. roughly 10 meters, difficulty in fine movements capture,
study, these exercises did not diminish the fear of falling and indirect fall-risk assessment [29]. Given that re-
in elderly individuals in 12 weeks, but reduced the fear searchers in most studies have focused on improving the
after 24 weeks [47]. Nonetheless, Rodriguez et al. mobility of patients and advantages of this intervention,
assessed the influence of dance by Xbox Kinect on the it is necessary to consider more realistic and specific re-
fear of falling in elderly people and revealed that dancing sults. Moreover, rehabilitation objectives, including fine
with video games did not affect the fear of falling among motor skills, cannot be evaluated by Kinect alone, and
these people [48]. In justifying these inconsistent results, these results should be accompanied by those of other
Hornyak et al. believed that the fear of falling in old evaluation methods. Of course, games were not used as
people depended on their physical performance, and a rehabilitation strategy in the present study. However, if
older age resulted in increased fear of falling due to de- they are used for rehabilitation, other evaluation
clined physical performance [49]. methods, such as elderly people’s opinions, should be
Participating or memory of participating in challenging used.
activities, such as virtual sports, might promote balance
confidence and decrease the fear of falling [48]. No im- Conclusion
provement in the balance and fear of falling in the con- The findings of the present study demonstrated that
trol group in the present study highlighted the necessity simulated balance exercises could lead to the enhance-
for elderly people to be physically active. The lack of ment of balance, TUG test, and FES in elderly individ-
sports activities in these people might cause impaired uals with balance disorder. Considering the efficacy of
balance and augmented fear of falling, leading to a virtual balance exercises in improving the balance of eld-
higher rate of falling [30]. erly people and some positive features of such exercises,
Overall, the results of the present study showed that they can be utilized in nursing homes. Some of these
video exercises could improve elderly people’s balance positive points include easiness to use and lower costs
and fear of falling. The impact of video exercises, as an compared to some therapeutic methods. Nonetheless,
interesting tool [14, 50], could provide a guide for the further investigations for evaluating diverse virtual exer-
treatment team for the enhancement of these variables. cises and their impacts on different physical and psycho-
As a result, the most is made of small spaces in insti- logical aspects compared to traditional exercises are
tutes, which do not have sufficient space for other exer- warranted.
cises or when elderly individuals are not interested in
Abbreviations
other sports. ANCOVA: Analysis of Covariance; BBS: Berg Balance Scale; FES: Falling Efficacy
Scale; TUG: Timed Up and Go; VR: Virtual Reality
Strong points and limitations
Acknowledgments
The tendency of elderly individuals for participating in This study was extracted from a master’s thesis by Noorolla Zahedian-Nasab.
the exercises in the current study was among the strong The authors would like to express their sincerest gratitude to Shiraz Univer-
points of the research. Moreover, the participants stated sity of Medical Sciences for financially supporting the research (grant No. 97-
01-08-18699). They would also like to appreciate the authorities of Yas-hay-e-
that these exercises resulted in competition and happi- Sepid and Farzanegan nursing homes in Shiraz and all the participants who
ness. Nevertheless, a limitation for this investigation was cooperated in the study. Finally yet importantly, they would like to thank Ms.
Zahedian-Nasab et al. BMC Geriatrics (2021) 21:509 Page 8 of 9

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