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8/10/2019 Exergaming Evidence Briefing
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Exergaming1
Costs ofPhysical Inactivity
E v i d en c e
B
r i ef n g
ExergamingAn evidence brieng on active video games
Funded by
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Contents
Summary 1
Introduction 1
Exergaming in the lab 2
Children 2
Adults 3
Changes to physical activity levels 4
Children 4
Adults 5
Exergaming in practice 6
Limitations 6
Recommendations 6
The purpose of this brieng is to provide an overview of the evidence related to the role of exergaming in promoting
physical activity to help policy makers, commissioners and practitioners inuence work in this eld. It summarises
what is known about exergaming in both laboratory and ‘real life’ settings and provides recommendations on the use
of exergaming as a physical activity intervention. Any bias to a particular manufacturer or gaming console is purely
due to the availability of the current research.
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1
Making physical activity a priority
Exergaming
Making physical activity a priority
SummaryThe evidence reviewed in this document indicates:
• Exergaming refers to screen-based activities which
combine video game play with exercise and require
participants to use bodily movements to control and
play the games.
• Most exergames are considered to be a light-to-
moderate intensity activity for both adults and
children. In older adults, most games are likely to
be a light intensity activity.
• Exergames provide an alternative to sedentary
behaviours, but they only contribute a small amountto daily moderate-to-vigorous physical activity.
• More high quality research is needed to assess
exergaming’s potential for providing long term
changes to levels of physical activity and sedentary
behaviour.
• When designing interventions that incorporate
exergaming, guidelines on frequency and duration
of usage should be given to participants.
IntroductionScreen-based entertainment is a popular form of
leisure time activity. For example, in Scotland adults
spend on average over three hours per day on TV
viewing and other screen-based entertainment; while
in children 50% of boys and 19% of girls report more
than two hours of computer or console game play per
day (1, 2). (More information and data for the other
home countries is provided in the BHFNC Sedentary
behaviour evidence brieng (3)).
Key term – exergaming
A screen-based activity which combines video gameplay with exercise and requires participants to use
bodily movements to control and play games.
In recent years there has been a re-emergence of
active video gaming, or exergaming, which provides
participants with an active way to take part in a
traditionally sedentary pursuit. Exergaming can be
undertaken in a variety of ways. For some games,
players use lower body movements to control game play
using dance pads and balance boards. Alternatively,
handheld controllers such as the Nintendo Wii Nunchucks use upper body movements to control game play.
In rudimentary forms exergaming has been available
to consumers for over 30 years. However, it wasn’t
until the early 21st century, with the emergence
of Dance Dance Revolution (DDR), the Sony EyeToy
and in particular the Nintendo Wii, that the idea of
exergaming really took hold.
As the consumer exergaming market continues to boom,
there has been growing interest in the use of these
games in public health to inuence levels of physicalactivity and sedentary behaviour. This evidence brieng
outlines the current research surrounding exergaming
and provides information on the potential for its use as a
physical activity intervention. Research considering game
play which requires movement to provide power to the
consoles, exercise bikes which provide riders with visual
simulation, educational games involving knowledge of
physical activity and specialised rehabilitation games will
not be considered in this brieng.
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Exergaming2
Exergaming in the labIn order to better understand exergaming’s
relationship with physical activity, laboratory studies
have compared exergames to both traditional
seated video games and other physical activities, for
example, treadmill walking.
Consistent evidence demonstrates exergaming requires
more energy and has the potential to raise heart rate
in comparison to traditional seated video games and
rest. Overall, most exergames are equivalent to light-
to-moderate activity for both adults and children (4).
ChildrenEnergy expenditure
Energy expenditure during exergames differs only
slightly from other traditional light-to-moderate
intensity physical activities (4).
Most exergames elicit energy expenditures between
light and moderate intensities, although in some
studies a ‘sizeable percentage’ of players have
performed at vigorous activity levels (5, 6).
Exergames which only require upper body movement
typically result in energy expenditures equivalentto light physical activity, while lower and whole
body movement games provide activity of at least a
moderate intensity (7).
Heart rate
Exergames increase heart rate compared to resting.
Those which require whole/lower body movement
produce a greater increase in heart rate than those
which use only upper body movements (7-9).
Different games requiring similar movements for game
play do not necessarily have the same impact on heartrate. For example, games played on dance mats have
increased heart rates to levels similar to those of
moderate and even vigorous intensities (9); whereas
games played using a balance board have produced
heart rates less than that of a brisk walking pace (8),
although both require lower body movement.
Body composition and BMI
Few exergaming studies have examined actual changes
in body composition over time. Instead, estimateshave been made based on laboratory game play. For
example, it has been suggested that if exergaming
were to take place at a similar intensity outside the
laboratory, children would have the potential to lose
2.5kg-6kg over the course of a year with only 15-30
minutes of game play per day (7).
One randomised controlled trial (RCT) demonstrated
exergames, when used as a substitute for traditional
video games or other time spent inactive, result in
smaller increases in BMI over six months compared
with continued traditional game play in 10-14 year
olds. The exergame group also had a larger decrease
in body fat compared with the control group (10).
Key term – randomised controlled trial (RCT)
A form of experimental research that has the
potential to provide robust evidence of a cause and
effect relationship.
In an RCT participants will be randomly put into
either a group involved in the intervention or in
a control group who operate under their usual
conditions. Both groups would then be followed
over time to assess the differences between the
two groups’ responses.
Psychological outcomes
Children and young people report enjoying Wii
Fit activities more than inactive games and
treadmill exercise
(8)
.
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Exergaming
Adults
The evidence in adults is less abundant than in
children. Studies tend to have only a small number ofparticipants, which makes it difcult to generalise the
ndings to the whole population.
Energy expenditure
Exergaming provides a form of light-to-moderate
physical activity for adults (5, 11). Wii Boxing has
been shown to produce similar energy expenditure
to a self-selected brisk walking pace, while Wii
Aerobics results in lower energy expenditure (8, 12). In
general, exergames have less of an effect on energy
expenditure than playing the actual sport (11).
Energy expenditure does not increase by adding
active elements to traditional games. For example,
adding specialist motion sensing controllers to play
shooting games was no more effective in increasing
energy expenditure than using traditional hand held
controllers (13).
Heart rate
Exergamers experience a greater increase in heart
rate after 30 minutes of Wii Fit’s Free Run than
treadmill walking (at 3.5 mph), while Wii Boxingproduces a heart rate similar to that of a self-selected
brisk walking pace (12). In contrast, self-selected brisk
treadmill walking results in a higher heart rate than
what is obtained by participating in Wii Aerobics,
Tennis or Baseball (8, 12).
Psychological outcomes
Research shows changes to psychological wellbeing
from taking part in exergaming are mixed. In older
women, positive changes to self-perception and social
and psychological wellbeing have been noted after six
weeks of game play (14). Alternatively, measurements of
wellbeing decreased after a single session of Wii Fit Free
Run compared with treadmill walking in young adults.
These young adults did however perceive playing Wii Fit
to be more intense than treadmill walking (15).
Both younger and older adults rate exergaming as more
enjoyable than inactive gaming and treadmill walking (8).
Falls and balance in older adults
In healthy older adults there is some evidence dance
exergames can improve mental health, improvemeasures of physical performance, eg, the narrow walk
time test and self-reported balance condence (16).
Additionally, anecdotal evidence suggests the Nintendo
Wii can be used as part of a falls rehabilitation
programme. Studies have demonstrated increases in
dynamic balance (17), a reduction in Timed Up and Go
scores, which measures mobility (11), and improvements
in static balance (18) after Wii usage. However most
of these studies tend to be case studies. More robust
evidence is needed to warrant the inclusion of
exergaming in falls prevention programmes (17, 19, 20).
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Exergaming4
In a separate study when exergaming was offered
twice a week for six weeks as an alternative to
traditional breaks, children in the exergaminggroup accumulated more steps per minute during
the rst week of the intervention than children at
traditional break. However, by weeks three and six
the exergaming group accumulated fewer steps than
the traditional break group. Overall, children in the
exergaming group spent a lower proportion of their
time in MVPA (22).
Home
When exergames were introduced to the home
environment for natural play for three or more months
they had a relatively small impact on increasing
physical activity levels in children who were already
sufciently active (23).
Alternatively, one RCT found that introducing Dance
Dance Revolution (DDR) into the home setting for 12
weeks helped reduce the decline in moderate-to-
vigorous physical activity (MVPA) typically seen in
children aged 9-17 years old. Those in the exergaming
group received both a DDR game and a pedometer to
encourage physical activity, while the control group
only received a pedometer to track their steps. The
results demonstrated that children who had access
to the DDR exergame tended to have a smaller
decline in MVPA than the control group. Self-report
data indicated that children in the exergaming group
perceived they were more active after 12 weeks
while those in the control group perceived they were
less active (24). A similar study which also introduced
a dance mat to a family setting for 28 weeks showed
non-signicant increases to children’s vigorous physical
activity (25)
.
Changes to physicalactivity levelsFew studies have assessed changes to physical
activity during opportunities for sustained exergaming
outside the laboratory. This section provides
research ndings from interventions which have
assessed changes in physical activity during ‘real
life’ game play. Interventions have ranged from
short PE-based activities to six months of home use.
Most interventions allowed for natural game play,
ie, allowing participants to play for as long and as
frequently as they choose. Only a few provided strict
‘prescriptions’ for exergaming use, eg, instructions to
play the games for 30 minutes on ve days each week.
Children
School
Although schools provide a potential location for
running studies to assess changes in physical activity,
very few interventions have been evaluated in this
setting. One study has looked at the value of using
exergaming to promote physical activity compared
to traditional PE lessons. Over the course of ve
to eight 30 minute exergaming sessions, studentsrotated through 11 exergaming activities, spending ten
minutes on each activity. In this study of a very small
sample of inactive students time spent in moderate-
to-vigorous physical activity (MVPA) increased
when exergaming was offered as an alternative for
traditional PE lessons (21).
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Making physical activity a priority
Exergaming
Although physical activity may not have been
specically measured, some studies have highlighted
important components which inuence exergaminguse. For example, when a structured multi-player DDR
session was included for one hour a week in addition
to unregimented home use, children were less likely
to drop out of the 12 week activity programme. These
children also used the DDR system twice as much as
those children who were not invited to the weekly
multi-player group (26). Notably, children were more
likely to stick to exergaming programmes when strict
instructions on usage were given and when ‘signicant
others’ (for example, parents or peers) participated
alongside them (26-28).
Most studies to date have evaluated specic
exergames as part of the intervention. One study,
did offer children free choice of games within their
assigned group, ie, those in the intervention group
were offered a choice of which exergame they wanted
to play. Despite this, it was found even when children
picked their preferred games, physical activity levels
of those in the exergaming group did not change in
comparison to those playing only traditional sedentary
video games (29).
While exergaming shows inconsistent results for
increasing physical activity levels, it does provide a
potential platform for decreasing sedentary time.
During interventions lasting six or more months, the
use of exergames in the home environment resulted
in slight decreases in sedentary time and the use of
traditional seated games (10, 25, 30, 31).
Adults
Fewer exergaming intervention studies have been
conducted in adults compared to children.
Home
One study conducted in the home setting over three
months found when a Wii Fit was introduced for
natural play, ie, no recommendations were provided
on frequency or duration of usage, the whole family
only used it for an average of 12 minutes per day and
no changes in MVPA were noted. However, participants
in this study were already relatively active, with
adults averaging 44 minutes of MVPA per day (23).
Community settingsWhen exergaming was added to an existing twice
weekly activity group for older women, total physical
activity between the rst session and follow-up did
not differ. While the women spent more time in higher
intensity activities during the exergaming sessions,
they also spent more time being inactive (14).
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Exergaming6
Exergaming in practiceLimitations
The evidence base for using exergaming as a public
health intervention is growing; however it is difcult
to make any strong recommendations regarding its use
at this stage.
To date, there is inconsistent evidence on the
effectiveness of using exergaming to promote
MVPA. Evidence is strongest for children, but most
ndings have come from two RCTs and a pilot
study. Furthermore, most studies only have of a
small number of participants and use a variety of
measurements which makes comparing studies
and generalising the outcomes to the whole
population difcult.
Concerns have been expressed by both children
and parents as to the longevity of the games with
suggestions the novelty factor might wear off
quickly (32). The reality of these concerns has been
demonstrated during interventions, as a clear
trend towards decreasing game use after a few
weeks was observed (5, 6).
There is conicting evidence regarding the usefulness
and acceptability of exergaming as a therapy tool in
older adults. Some older adults have found gaming
sessions to be a positive experience and had high
engagement levels when participating in exergaming
interventions. Others cited they prefer traditional
therapy approaches (14, 17, 33).
Recommendations
Despite the above limitations, current evidence
suggests exergames are valuable for making a once
sedentary pursuit more active. To make the most of
exergaming’s potential to increase physical activity,
games which have the greatest energy expenditures
should be promoted and recommendations made by
practitioners about appropriate levels of game play.
Games which have been found to produce moderate
levels of activity include*:
• Dance Dance Revolution (DDR)
• Wii Boxing
• Play 2 Knockout (boxing) and Homerun (baseball)
• Eye Toy Groove and Kinetic Cascade
• XaviX J-mat Jackie’s Action Run and Jackie Chan
Studio Fitness (34).
*To date, no studies have reported on use of the
Xbox Kinect.
It is important for practitioners to provide instructions
for exergame use, eg, use in place of traditional
video games or use ve times a week for 30 minutes.
Practitioners should consider conducting interventions
in schools or community centres to allow for more
prescriptive and tightly controlled use.
In children, the benets of exergaming do not seem
limited to any specic sub-population. While there
is some evidence adolescent boys tend to engage in
more screen-based activities than girls (35, 36), there
is no consistent evidence that when girls take part
in exergaming they play at a lower intensity than
boys. Equally, there is no evidence to date that
overweight children reap a larger benet than thoseat a healthy weight (5, 7).
Although further research is needed to examine the
effects of exergaming on body composition, initial
studies show it may have the potential to slow weight
gain and positively affect body composition. In order
for this potential effect to be maximised, food intake
during exergaming may also need to be addressed.
Even though exergaming results in a lower energy
surplus than traditional video games and television
time, players may still take on extra calories duringexergame play (37).
While commercially available exergames encourage
improvements in balance, strength and tness, they
are not designed for rehabilitation. Exergaming is seen
as a supplement to existing rehabilitation programmes
but requires additional resources for use in these
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Making physical activity a priority
Exergaming
settings. Future work in this area should focus on
designing bespoke exergames which can be used in a
rehabilitation setting (11, 33)
.
Evidence suggests gaming related injuries or adverse
effects, specically in older adults, are usually a
consequence of excessive game play. In older adults
with balance deciencies, supervision is recommended
when using exergames that are designed to challenge
balance in order to ensure a safe and successful
experience (38). Healthy older adults should be able to
perform these games independently (11, 16).
As with any intervention, it is recommended future
exergaming interventions are based on the currentevidence and an appropriate programme evaluation
is put in place prior to beginning delivery of
the intervention.
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Exergaming8
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The British Heart Foundation is a registered charity in
Published by
British Heart Foundation National Centre (BHFNC)
for Physical Activity and Health, Loughborough University
T: 01509 226421 F: 01509 226420
www bhfactive org uk @BHFactive
Last updated October 2012
T 5 2 5 4 8 / D P S / O C T 1 2
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