Introduction
Due to the increase in life expectancy in different countries and, thus, the increase in the number of aged people and the prevalence of physical problems related to old age, it is of great importance to investigate low-risk methods that can lead to the improvement of the physical fitness and daily living activities of the elderly. One of these methods is exercise. Studies have shown that various exercises have many benefits for the elderly, including reduced mortality and health costs. Due to increased tendency towards new technologies and video games, technology-based exercises have recently been considered as an alternative method. This study aims to investigate the effect of technology-based sports on physical fitness and activities of daily living (ADLs) of the elderly with impaired balance living in nursing homes in Iran.

Methods
This is a clinical trial that was conducted on 60 older people with balance disorders living in nursing homes in Shiraz, Iran. Their balance was first measured using the timed up & go test, and the people whose test time was 14-20 seconds were selected based on the inclusion criteria. They were randomly divided into intervention and control groups. The participants in the intervention group received a technology-based exercise program at two sessions of 30-45 minutes every week for 6 weeks using the Xbox Kinect sensor. The selected sports games included penalty kicks, goalkeeping, skiing, and darts, each session covering different aspects to improve physical fitness and ADLs of the elderly. All the selected sports required the use of the upper and lower limbs in a standing position. In the control group, the elderly received the routine programs of the nursing home, which included walking, playing table tennis, and doing some art and music activities. After 6 weeks, physical fitness and daily life activities were measured and compared in two groups using the senior fitness test (SFT) and the ADL questionnaire.

Results
The two groups were similar to each other in terms of mean ADL score before the intervention, but increased significantly in the intervention group (from 87.1±10.4 to 92.6±9.1) compared to the control group (from 86.5±11.3 to 85.1±1.2) after the intervention (P=0.001). Also, before the intervention, the two groups were similar to each other in terms of all SFT tests except in the chair sit and reach test. Performing technology-based sports in the intervention group led to an increase in the mean scores of chair stand test (P<0.001), arm curl test (P<0.001), chair sit and reach test (P=0.001), back scratch test (P=0.007) and 8-foot up & go test (P=0.001), while no significant changes were observed in the control group. Between-groups comparisons showed significant differences in SFT tests (except for the 2-minute step in place test) after the intervention. Regarding the chair sit and reach test, since the pre-test scores were significantly different between the two groups, ANCOVA test was performed to investigate the intervention effect. The results showed that, after controlling the effect of pre-test score, the effect of technology-based intervention on the chair sit and reach test score was still significant (P=0.001).

Conclusion
Performing 6 weeks of technology-based sports can improve physical fitness and ADLs in elderly people with balance disorders living in nursing homes and can replace group sports when necessary. Considering the effectiveness of this intervention and its benefits such the ease of use, cost-effectiveness, and high acceptance by people, and the emphasis of the World Health Organization (WHO) on providing innovative and attractive solutions to increase independence and prevent illness and dependency of the elderly, it can be used in the nursing homes. However, more studies are still needed to investigate the different types of virtual sports and their impact on the physical and mental conditions of the elderly, compared to traditional sports.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Shiraz University of Medical Sciences (Code: IR.SUMS.REC.1398.573) and was registered by Iranian Registry of Clinical Trials (Code: IRCT20190727044347N1).

Funding
This study was extracted from the MSc thesis of Noorolla Zahedian-Nasab and was financially supported by Shiraz University of Medical Sciences (Grant No.: 97- 01-08-18699).


Authors' contributions
The authors equally contributed in preparation of this article.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors would like to express their sincerest gratitude to Shiraz University of Medical Sciences for the support. The authors would also like to appreciate the authorities of Yas-hay-eSepid and Farzanegan Nursing Homes in Shiraz and all the participants who cooperated in the study.

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