Are active videogames a challenge
to the fitness industry?

Vaughan Nicholson examines current understanding of the energy expenditure associated with active video games (AVGs) and the impact such gaming can have on balance and physical functioning.

A continuing challenge for health and fitness professionals is how to initiate physical activity in the sedentary and, once initiated, how to help them maintain an active lifestyle1. Despite an abundance of effective exercise options available to both young and older adults, compliance is often poor, with up to 50 per cent of individuals dropping out of an exercise program within six months of starting2. The development of active video games (AVGs), also known as ‘exergames’, that stimulate greater activity during game play by requiring players’ body movement to interact with the game have the potential to encourage physical activity and improve balance and function in certain populations.

The public has embraced AVGs, evidenced by over 94 million global sales of the Nintendo WiiTM since its inception in 20063. There has also been a concomitant growth of research into AVGs in recent years, with various studies examining the effect of AVGs on physiological, psychological and functional outcomes.

Energy expenditure

Energy expenditure associated with the Nintendo Wii and game play from Nintendo WiiFitTM and WiiSports games has received considerable attention to date (Peng et al. 2011). Although the quality of studies varies greatly within AVG research, the following studies have each used a form of indirect calorimetry to determine energy expenditure that provides an accurate assessment of energy expenditure and allows for some inter-study comparison.

Graves and colleagues compared the physiological cost of exergaming of WiiFitTM with aerobic exercise in adolescents, young and older adults (Graves et al. 2010). Oxygen consumption (VO2), heart rate and energy expenditure were measured while performing 10 minutes on each of seven tasks which included sedentary gaming, WiiFitTM game play, treadmill walking and jogging. Oxygen consumption, heart rate and energy expenditure for WiiFitTM were greater than for handheld gaming and less than treadmill walking or running. Based on established boundaries for physical activity intensity classification (Light < 3, Moderate 3-6, Vigorous >6 METs)4 all activities were classified as light except Wii aerobics and brisk treadmill walking (moderate), and treadmill jogging (vigorous). These results compare well with research in adults that reported moderate exercise intensity during Nintendo WiiFitTM gaming5.

Miyachi and colleagues determined the energy expenditure during WiiFitTM Plus and Wii Sports game activities in an open-circuit metabolic chamber6. Twelve Japanese adults performed all the activities within each game for at least eight minutes to obtain steady state energy expenditure. The mean MET values of all activities ranged from 1.3 METs to 5.6 METs with 67 per cent of activities classified as low intensity, and 33 per cent classified as moderate intensity. In agreement with Graves (Graves et al. 2010), there were no vigorous-intensity activities in either game. The authors concluded that time spent playing games that elicited a moderate intensity can count toward the daily amount of exercise required according to the guidelines provided by the ACSM and AHA7.

Worley and colleagues determined the effectiveness of selected Nintendo WiiFitTM games by assessing the percentage VO2 max and energy expenditure during game play in eight healthy young women8. Participants attended two gaming testing sessions after the assessment of their VO2 max via a graded treadmill protocol. At these gaming sessions participants played for 10 minutes at each level of two different games. Percentage VO2 max ranged from 30.6 per cent to 39.4 per cent. Using standard equations that predict oxygen consumption from walking speed9, the authors determined that the Nintendo WiiFitTM hula game produced similar metabolic stress to walking >5.6 km/h.

AVGs do not necessarily demonstrate significant increases in energy expenditure compared to traditional moderate-intensity physical activity such as brisk walking or sports play. Variations in the walking speed tested have an obvious influence on energy expenditure, so too does the age of the population tested and the measures used to assess energy expenditure. For example, Graf and colleagues (Graf et al. 2009) reported that walking at 5.7km/h elicited similar levels of energy expenditure as playing Wii boxing in 10- to 13-year-old children. Graves (Graves et al. 2010) found that energy expenditure during WiiFitTM was less than that elicited by treadmill walking at self selected speeds of 4.8-6.1km/h, while Barkley and Penko10 found that playing Wii boxing produced higher heart rates and oxygen consumption than walking at 4km/h in adults.

Overall, it appears that WiiTM-based gaming can significantly increase heart rate, oxygen consumption and energy expenditure above resting levels and above values found for sedentary gaming. This is confirmed by a recent meta-analysis that reported playing of AVGs provides energy expenditure equivalent to light to moderate intensity physical activity (Peng et al. 2011).

The ever-expanding field of AVGs will continue to provide exercise options for various population groups. The research results to date are promising, particularly for sedentary and inactive individuals in terms of increased energy expenditure. More longitudinal research still needs to be completed and factors associated with long-term adherence such as enjoyment and safety need to be further explored.

Balance and physical functioning

Significant improvements in balance have been noted in trials of exercise interventions involving gait, balance, functional exercises and muscle strengthening (Howe et al. 2008), however, compliance with such interventions is often disappointing (Forkan et al. 2006). One method by which compliance with exercise interventions could be improved involves the use of AVGs that combine player movement, immediate performance feedback and high levels of enjoyment11. In contrast to research assessing energy expenditure, which has explored effects across the lifespan, the majority of research assessing the effectiveness of WiiTM-based interventions on balance and function has targeted older adults and special populations.

Identified benefits of WiiFitTM-based programs in older adults include improvements in walking speed12 and balance13,14. The Wii Balance Board (WBB) – the peripheral that detects changes in centre of pressure – has been compared to a laboratory grade force platform with findings suggesting that the WBB is a valid tool for assessing standing balance23. Agmon and colleagues concluded that the use of WiiFitTM for balance training in the home was safe and feasible for a selected sample of older adults12. The study involved only seven older adults with impaired balance (Berg Balance Scale score < 52 points) that completed three months of WiiFitTM game play. Participants safely and independently played a mean of 50 sessions, median session duration of 31 minutes. Berg Balance Scores increased significantly (p=0.017) from 49 (2.1) to 53 (1.8) points and walking speed increased from 1.04 (0.2) to 1.33 (0.84) m/s (p =0.018).

In one of the few WiiTM-based studies with a sample size over 20, Crotty14 compared the effect of a WiiFitTM program with conventional physiotherapy among 44 older adults recruited from a Geriatric Evaluation and Management (GEM) unit. Results showed that both groups improved, however there was a small significant difference between groups on balance and the Timed Up and Go Test, with the WiiFitTM appearing to be a more effective approach to balance and mobility training in hospitalised older people.

In one of the few studies examining the benefits of Wii-based training in a healthy geriatric (aged 74 to 94) population, Williams13 found a significant improvement in balance (Berg Balance Scale) after four weeks of WiiFitTM training, although these improvements diminished by week 12.

Although results appear promising, many studies to date have had small subject numbers or have lacked a control or comparison group. Results have been generally positive in the few studies that have included a comparison group, with Wii intervention groups being as effective or better than traditional care14,15, although others have found traditional care16 or combined interventions to be more favourable than WiiFitTM training alone17.

Despite the ever-increasing amount of exergaming research, there is still much to be learned about its safety and effectiveness in improving the balance, strength and falls risk in older adults living independently in unsupervised settings. Furthermore, the level of enjoyment and likelihood of ongoing participation in such activities should be determined to gauge whether long-term adherence is likely.

IMPLICATIONS FOR THE FITNESS PROFESSIONAL
  • Oxygen consumption, heart rate and energy expenditure for WiiFitTM are greater than for handheld gaming, but less than for treadmill walking or running.
  • No WiiFitTM Plus and Wii Sports activities are classified as vigorous, based on established boundaries.
  • WiiTM-based gaming can significantly increase heart rate, oxygen consumption and energy expenditure above resting levels and above values found for sedentary gaming.
  • WiiFitTM-based programs can improve walking speed and balance in older adults, although long term benefits are unproven.
  • WiiFitTM has been found to improve lateral reach, functional reach and single leg balance in older adults.
  • Wii-based interventions have had positive results for balance measures in those with Parkinson’s disease, lower limb amputations and cerebral palsy.
  • Other benefits typically associated with exercise, such as increased muscle mass and bone density, have not been demonstrated in AVG research to date.

Research recently conducted at the University of the Sunshine Coast (Nicholson VP, unpublished observation) attempted to address some of the above issues by assessing the effectiveness of an unsupervised Wii-based balance training program in independent community-dwelling older adults (aged 65-84). An intervention group played WiiFitTM balance games for 30 minutes three times a week for six weeks. A control group of age- and balance-matched peers were compared to the WiiFitTM group in a variety of balance and mobility measures pre- and post-intervention. The WiiFitTM group improved significantly in measures of lateral reach, functional reach and single leg balance compared to controls. Importantly, there were no adverse events associated with the unsupervised program and generally high levels of enjoyment were reported throughout.

Research examining Nintendo Wii-based interventions in special populations has also revealed positive results for balance measures in various groups including those with Parkinson’s disease18, lower limb amputations19 and cerebral palsy20. Despite the promising results, it should be noted that the majority of studies in special populations have, to date, been case studies or included very small subject numbers. Furthermore, exergames are not without their dangers, as evidenced by Wii-related injuries cited in the literature21,22.

There is no doubt that AVGs, such as those developed for the Nintendo WiiTM, provide an attractive exercise option for those in which light-to-moderate intensity exercise is desired. The benefits of such devices (apart from increased energy expenditure and improved balance) include: immediate performance feedback; variety to provide novel experiences and possibly limit staleness; and reported moderate-to-high levels of enjoyment across a range of age groups. It should be noted that other benefits typically associated with exercise, such as increased muscle mass and bone density, have not been demonstrated in AVG research to date.

So, are active videogames a challenge to the fitness industry?

Many in the fitness industry may not appreciate the potential loss of clients to the user-friendly exergaming market, but the competition from exergaming is likely to become even tougher as motion capture technology improves, becomes more adaptable and less expensive. And although AVGs may lack the ability to correct poor technique, encourage exercise adherence and elicit higher intensity workouts, perhaps they can remind us of what clients want in a trainer or a program: tangible improvement, variety and – maybe most importantly – enjoyment.

References
  1. Cox, KL, Burke, V., Gorely, TJ, Beilin, LJ, & Puddey, IB. (2003). Controlled Comparison of Retention and Adherence in Home-vs Center-Initiated Exercise Interventions in Women Ages 40-65 Years: The SWEAT Study (Sedentary Women Exercise Adherence Trial)* 1. Preventive Medicine, 36(1), 17-29.
  2. Dishman, R.K. (1988). Exercise adherence: Its impact on public health. Champaign, Illinois: Human Kinetics Books
  3. Nintendo. (2012). Consolidated Sales Transition by Region  Retrieved 7/2/2012, from http://www.nintendo.co.jp/ir/library/historical_data/pdf/consolidated_sales_e1112.pdf
  4. Ainsworth, B.E., Haskell, W.L., Whitt, M.C., Irwin, M.L., Swartz, A.M., Strath, S.J., . . . Emplaincourt, P.O. (2000). Compendium of physical activities: an update of activity codes and MET intensities. Medicine & Science in Sports & Exercise, 32(9 Suppl), S498.
  5. Guderian, B., Borreson, LA, Sletten, LE, Cable, K., Stecker, TP, Probst, MA, & Dalleck, LC. (2010). The cardiovascular and metabolic responses to Wii Fit video game playing in middle-aged and older adults. Journal of Sports Medicine and Physical Fitness, 50(4), 436-442.
  6. Miyachi, M., Yamamoto, K., Ohkawara, K., & Tanaka, S. (2010). METs in adults while playing active video games: A metabolic chamber study. Medicine & Science in Sports & Exercise, 42(6), 1149.
  7. Haskell, W.L., Lee, I., & Pate, R.R. (2007). Physical activity and public health. Updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation, 116.
  8. Worley, J.R., Rogers, S.N., & Kraemer, R.R. (2011). Metabolic Responses to Wii Fit Video Games at Different Game Levels. The Journal of Strength & Conditioning Research, 25(3), 689
  9. Whaley, MH, Brubaker, PH, & Otto, RM (Eds.). (2006). ACSM's Guidelines for Exercise Testing and Prescription. Philadelphia, PA: Lippincott Williams and Wilkins.
  10. Barkley, J.E., & Penko, A. (2009). Physiologic responses, perceived exertion, and hedonics of playing a physical interactive video game relative to a sedentary alternative and treadmill walking in adults. Journal of Exercise Physiology Online, 12(3), 12-22.
  11. Warburton, D., Bredin, S., Horita, L., Zbogar, D., Scott, J., Esch, B., & Rhodes, R. (2007). The health benefits of interactive video game exercise. Applied Physiology, Nutrition, and Metabolism, 32(4), 655-663.
  12. Agmon, M., Perry, C.K., Phelan, E., Demiris, G., & Nguyen, H.Q. (2011). A Pilot Study of Wii Fit Exergames to Improve Balance in Older Adults. Journal of Geriatric Physical Therapy.
  13. Williams, M., Soiza, R., Jenkinson, A., & Stewart, A. (2010). EXercising with Computers in Later Life (EXCELL)-pilot and feasibility study of the acceptability of the Nintendo WiiFitTM in community-dwelling fallers. BMC Research Notes, 3(1), 238.
  14. Crotty, M., Laver, K., Quinn, S., Ratcliffe, J., George, S., Whitehead, C., & Davies, O. (2011). Is use of the Nintendo Wii Fit in physiotherapy as effective as conventional physiotherapy training for hospitalised older adults? Paper presented at the 2011 International Conference of Virtual Rehabilitation, Zurich.
  15. Rogers, NL, Slimmer, ML, Amini, SB, & Park, EY. (2010). Wii Fit for older adults: Comparison to a traditional program. Medicine & Science in Sports & Exercise, 42(5), S419.
  16. Bateni, H. (2011). Changes in balance in older adults based on use of physical therapy vs the Wii Fit gaming system: a preliminary study. Physiotherapy.
  17. Toulotte, C., Toursel, C., & Olivier, N. (2012). Wii Fit training vs. Adapted Physical Activities: which one is the most appropriate to improve the balance of independent senior subjects? A randomized controlled study. Clinical Rehabilitation.
  18. Esculier, J.F., Vaudrin, J., Beriault, P., Gagnon, K., & Tremblay, L.E. (2012). Home-Based Balance Training Programme Using Wii Fit with Balance Board for Parkinson's Disease: A Pilot Study. Journal of Rehabilitation Medicine, 44(2), 144-150.
  19. Miller, C.A., Hayes, D.M., Dye, K., Johnson, C., & Meyers, J. (2011). Using the Nintendo Wii Fit and Body Weight Support to Improve Aerobic Capacity, Balance, Gait Ability, and Fear of Falling: Two Case Reports. Journal of Geriatric Physical Therapy.
  20. Deutsch, J.E., Borbely, M., Filler, J., Huhn, K., & Guarrera-Bowlby, P. (2008). Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Physical Therapy, 88(10), 1196.
  21. Cowley, A.D., & Minnaar, G. (2008). New generation computer games: watch out for Wii shoulder. BMJ: British Medical Journal, 336(7636), 110.
  22. Peek, AC, Ibrahim, T., Abunasra, H., Waller, D., & Natarajan, R. (2008). White-out from a wii: Traumatic haemothorax sustained playing Nintendo Wii. Annals of the Royal College of Surgeons of England, 90(6), 532.
  23. Clark, R.A., Bryant, A.L., Pua, Y., McCrory, P., Bennell, K., & Hunt, M. (2010). Validity and reliability of the Nintendo Wii Balance Board for assessment of standing balance. Gait & Posture, 31(3), 307-310

 


Vaughan Nicholson, BHMS (Hons) MPhtySt
Vaughan is a physiotherapist and PhD student at USC supported by Australian Fitness Network studying ‘The value of group fitness exercise for at risk populations (older adults)’.