Exergaming Evidence Briefing

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



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.



1

Making physical activity a priority

Exergaming


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.



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).



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).



5


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).



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



7


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.



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

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Exergaming Evidence Briefing