July 2018 Issue

Update on Exergaming
By Jennifer Van Pelt, MA
Today's Dietitian
Vol. 20, No. 7, P. 26

The use of gaming technologies such as Nintendo Wii and Xbox Kinect for exercise has been dubbed exergaming. The concept originated in the late 1980s but didn't become popular until the introduction of the game Dance Dance Revolution in the late 1990s. The term "exergaming" was added to dictionaries in 2007 and has since expanded as new technologies have been introduced; it now encompasses not only video games but also gaming technologies integrated with exercise equipment, mobile exergaming apps, and virtual reality technologies.

The American College of Sports Medicine defines and describes exergaming as "technology-driven physical activities that require participants to be physically active or exercise to play the game. These game-based physical activities go beyond simple hand and finger movements as the primary interface and require the user to apply full body motion to participate in virtual sports, in group fitness exercise, or other interactive physical activities."1 Depending on the game design, exergames can improve balance and coordination, sensorimotor control, and/or cardiorespiratory fitness. Exergaming originally was proposed as a way to encourage increasingly sedentary and overweight adolescents to exercise by engaging them with the gaming technologies responsible for excessive screen time and lack of physical activity. Although dance-based exergames and Wii Fit competitive sports exergames are popular and have gotten adolescents moving at home and at school, exergaming is proving to be more beneficial for the elderly and individuals with movement limitations.

Today's Dietitian last covered the exergaming trend in late 2010 and late 2013. In the last five years, exergaming research has been vigorous. Based on a PubMed search, hundreds of studies have been published on its use for a wide variety of applications. Medical uses of commercially available and proprietary systems have increased substantially, and rehabilitative benefits for several diseases and conditions have been reported. This article will review recently published studies on emerging medical applications of exergaming, as well as briefly discuss developments in exergaming technologies for the future.

Exergaming and the Elderly
A surprising development in exergaming is its rapid and enthusiastic uptake in the elderly population, given the fear or dislike of computers and other newer technologies that many older adults have. Senior centers, assisted living facilities, and other facilities serving the elderly have embraced the Wii, forming competitive Wii bowling, tennis, and golf tournaments and leagues for seniors. For the first time, those in wheelchairs and walkers, and with other movement limitations, can participate with their more mobile friends from the comfort of home, a senior center, or a care facility, playing sports they used to enjoy in their younger, more active years.

This unexpected appeal and convenience of exergaming for the elderly led researchers to investigate its value not only as entertainment and exercise but also as a therapeutic modality. PubMed searches on exergaming revealed that the most researched exergaming applications are for the elderly, with more studies published on exergaming and the elderly than any other population. Research has focused on improving balance and fall prevention, motor function, and quality of life for the elderly.

A 2015 study compared Xbox Kinect exergames vs traditional home-based balance exercises in 90 adults aged 65 or older. Both groups exercised at home five days per week for six weeks and had significant improvements in balance at the end of the study. However, the exergaming group's scores on balance tests were better; the exergaming group also showed improvements in functional walking, while the traditional exercise group didn't. The exergaming elders also reported significant improvements in quality of life parameters, and they found exergaming to be "very entertaining."2 A second 2015 study of the Kinect found significant improvements not only in balance but also in muscular strength and walking when the elderly used it once or twice weekly for exergaming.3

Another 2015 study found that balance training with exergaming was more effective than conventional balance training for reducing the risk and incidence of falls in frail older adults with a history of falls. Adults aged 65 and older living in a nursing home setting participated in balance training using a Wii Fit or conventional balance exercises. Although balance and incidence of falls improved significantly in both groups after six weeks of training, the Wii Fit group had significantly greater improvements in both.4

A 2015 systematic review and meta-analysis evaluated 11 studies on the use of exergaming for improving balance and postural control in healthy older adults, as well as those with Parkinson's disease. Nine studies reported improvements in static balance, dynamic balance, and postural control for healthy older adults participating in exergaming. Two smaller studies reported some balance and postural control improvements in older adults with Parkinson's disease, indicating that exergaming may be promising as a neurorehabilitation tool.5 A May 2018 study supported that conclusion, finding that exergaming with the Kinect system improved walking capacity, ability to stand from sitting, and quality of life in elderly individuals with Parkinson's disease. Outcomes with exergaming were similar to those of traditional functional training and stationary cycling in Parkinson's disease management.6

Most exergaming applications for the elderly use existing commercial technologies such as Wii and Kinect, but exergames designed for and dedicated to the elderly are being developed and researched. A December 2017 study reported initial results of exergaming with five new games with topics, difficulties, and interfaces designed specifically for the elderly population. In comparison with traditional exercise, elderly exergamers reported significantly greater enjoyment of exercise.7 Ongoing research is focusing on making exergames more senior friendly and beneficial for not only physical but also psychosocial health in the elderly.

Exergaming With Disabilities
Exergaming also is being investigated and developed for use by individuals with physical limitations. Maria Swartz, PhD, MPH, RD, LD, an assistant professor in the department of nutrition and metabolism at the Center for Recovery, Physical Activity and Nutrition at the University of Texas Medical Branch, has four years of research experience tailoring exergames for individuals with physical function limitations. In 2015, she coauthored an article in Games for Health Journal, the first peer-reviewed publication dedicated to advancing the impact of gaming research and technologies and their applications for health and well-being.8

Swartz and her coauthors discussed adaptations of exergaming to better suit individuals with disabilities (eg, in a wheelchair) so this population can enjoy the benefits of exergaming. A few commercially available exergames, such as the Kinect Zumba and Your Shape fitness games, can be easily adapted for those who must remain seated while exercising, Swartz notes. "Some of the off-the-shelf Xbox 360 Kinect games are more suitable for individuals with disabilities. These games allow play to continue even when the exerciser is only doing partial movements with just their arms," she explains.

However, most of the exergames best suited for individuals with disabilities were developed in the research lab setting, she says, and may have availability limited to a research study or specialty therapeutic setting.

Depending on their disability, those who'd like to try exergaming may need to adapt hand controllers and other handheld or standing exergaming equipment to better suit their condition, according to Swartz. For example, a Wii balance board could be placed on a chair and used with the person seated on it.

Swartz and her coauthors recommend that exergaming technology in development for these applications consider the physiological, psychological, social, and therapeutic needs of the intended population. Certain populations may have physical challenges, such as operating a game controller with smaller buttons, as well as processing or comprehension difficulties, such as understanding visual and acoustic feedback during the game. The challenge, she and her colleagues noted, is retaining the fun and entertaining exergame experience while also incorporating technological modifications for disabilities.

"Our exergaming research participants often commented on how much fun they had while exergaming, without feeling like they were exercising. Conventional (off-the-shelf) exergames may not be as fun or motivating for those with disabilities as specially designed exergames," Swartz says.

Ongoing research on exergaming for this population is primarily focused on individuals in wheelchairs. Some researchers are modifying features of the Kinect to tailor exergames to be more functional and fun for those with disabilities.9 There appears to be increasing demand for exergaming applications for both therapy and fun, and, within a few years, a wider availability of better-designed exergames is expected.

Exergaming in the Clinical Setting
Clinical exergaming applications include use in poststroke recovery, physical therapy/rehabilitation, pain relief, and depression.

An October 2017 systematic review and meta-analysis evaluated exergaming for improving cognitive functioning in neurological disabilities. The researchers analyzed 13 studies that included 465 participants randomized to either exergaming or an alternative. Clinical conditions for which exergaming was used as therapy included multiple sclerosis, Parkinson's disease, dementia, poststroke hemiparesis, dyslexia, and Down syndrome. Exergaming was found to significantly improve executive functioning and visual-spatial perception compared with conventional exercise or other interventions. The researchers concluded that exergames should be considered as a supplemental therapy to conventional rehabilitation modalities or for use as home-based therapy in patients with neurological conditions requiring rehabilitation.10

Positive results also have been reported for exergaming as rehabilitation for inflammatory conditions. A 2016 randomized controlled trial found that exergaming increased physical activity and reduced pain in patients with ankylosing spondylitis.11 A 2017 randomized study evaluated the effects of exergaming on women with fibromyalgia. After an eight-week exergaming program with two to three sessions per week focusing on postural control, coordination, aerobic conditioning, strength, and mobility, pain, anxiety, stiffness, and overall quality of life significantly improved. The researchers concluded that exergaming is an effective intervention for women with fibromyalgia.12 However, exergaming wasn't compared with any other exercise-based intervention in this study, and additional research comparing it with other types of exercise is necessary.

Another promising clinical application is in depression management. The incidence of depression is increasing, and finding an effective treatment or combination of treatments often is challenging. Exercise is recommended for those with depression, but lack of motivation or issues with exercising in public may affect compliance. A 2016 systematic review and meta-analysis found that exergaming was effective in alleviating depression, especially for women and older adults with good physical mobility.13

Studies included in the review and analysis primarily used Wii Fit and Sports exergames. Wii Fit exergames included yoga, aerobic, strength, and other workouts; exergaming workout options may be more appealing and convenient, and thus more effective, because adherence is higher than for gym workouts for those with depression. The researchers noted that more "playful" exergames (sports, adventures) had a significantly larger effect on improving depression symptoms compared with workout-based exergames. Exergaming for depression is an emerging research area, and larger studies are necessary to better evaluate outcomes.

Research and development of exergaming is vigorous and ongoing. Look for expanding clinical indications for exergaming, as well as new and specialized games for the elderly and those with disabilities, in the near future.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.

1. American College of Sports Medicine. ACSM information on … exergaming. http://healthysd.gov/wp-content/uploads/2014/11/exergaming.pdf

2. Karahan AY, Tok F, Taşkın H, Kuçuksaraç S, Başaran A, Yildirim P. Effects of exergames on balance, functional mobility, and quality of life of geriatrics versus home exercise programme: randomized controlled study. Cent Eur J Public Health. 2015;23 Suppl:S14-S18.

3. Sato K, Kuroki K, Saiki S, Nagatomi R. Improving walking, muscle strength, and balance in the elderly with an exergame using Kinect: a randomized controlled trial. Games Health J. 2015;4(3):161-167.

4. Fu AS, Gao KL, Tung AK, Tsang WW, Kwan MM. Effectiveness of exergaming training in reducing risk and incidence of falls in frail older adults with a history of falls. Arch Phys Med Rehabil. 2015;96(12):2096-2102.

5. Harris DM, Rantalainen T, Muthalib M, Johnson L, Teo WP. Exergaming as a viable therapeutic tool to improve static and dynamic balance among older adults and people with idiopathic Parkinson's disease: a systematic review and meta-analysis. Front Aging Neurosci. 2015;7:167.

6. Ferraz DD, Trippo KV, Duarte GP, Neto MG, Bernardes Santos KO, Filho JO. The effects of functional training, bicycle exercise, and exergaming on walking capacity of elderly patients with Parkinson disease: a pilot randomized controlled single-blinded trial. Arch Phys Med Rehabil. 2018;99(5):826-833.

7. Li J, Xu X, Pham TP, Theng YL, Katajapuu N, Luimula M. Exergames designed for older adults: a pilot evaluation on psychosocial well-being. Games Health J. 2017;6(6):371-378.

8. Wiemeyer J, Deutsch J, Malone LA, et al. Recommendations for the optimal design of exergame interventions for persons with disabilities: challenges, best practices, and future research. Games Health J. 2015;4(1):58-62.

9. Eckert M, Gómez-Martinho I, Meneses J, Martínez JF. New approaches to exciting exergame-experiences for people with motor function impairments. Sensors (Basel). 2017;17(2):E354.

10. Mura G, Carta MG, Sancassiani F, Machado S, Prosperini L. Active exergames to improve cognitive functioning in neurological disabilities: a systematic review and meta-analysis [published online October 25, 2017]. Eur J Phys Rehabil Med. doi: 10.23736/S1973-9087.17.04680-9.

11. Karahan AY, Tok F, Yildirim P, Ordahan B, Turkoglu G, Sahin N. The effectiveness of exergames in patients with ankylosing spondylitis: a randomized controlled trial. Adv Clin Exp Med. 2016;25(5):931-936.

12. Collado-Mateo D, Dominguez-Muñoz FJ, Adsuar JC, Garcia-Gordillo MA, Gusi N. Effects of exergames on quality of life, pain, and disease effect in women with fibromyalgia: a randomized controlled trial. Arch Phys Med Rehabil. 2017;98(9):1725-1731.

13. Li J, Theng YL, Foo S. Effect of exergames on depression: a systematic review and meta-analysis. Cyberpsychol Behav Soc Netw. 2016;19(1):34-42.