Ruivo, Jorge A. MD
Recently, entertainment software has become a valuable partner in public health. For disease prevention, the new “health games” are specifically designed to encourage participants to engage in healthy behaviors, helping patients adhere to their treatments more effectively and providing them greater understanding of their health status. This is achieved, for example, by delivering facts about nutrition and exercise, by rewarding diabetic patients for their consistent glycemia monitoring practice,1 or even by promoting real-time energy expenditure (EE).2 The latter new generation of active video games (AVGs) allows the person to interact with the game by performing intricate movements that are fast paced, involving certain skills, which might, in theory, contribute to physical fitness. These devices with the latest motion sensing technology are revolutionary in featuring a sensor that detects movements in all directions, thus enabling the human player to direct the avatar movements with his own. Usually, the console receives input from a hand controller, which contains gyroscopes and accelerometers. In combination with infrared detectors, this allows its position in 3-dimensional space to be detected. Further innovation lead to the development of interactive stepping platforms, which contain multiple pressure sensors. For instance, in sports AVG, players are required to simulate the limb motions similar to playing the actual sport, which translate into the animated caricature screen movements.
The medical community is embracing the concept. AVGs are used for fighting pediatric obesity,3 in long-term care facilities to prevent the social isolation effects,4 to improve seniors physical performance,5 and to facilitate poststroke motor rehabilitation.6 To our knowledge, there is no available research regarding the use of this opportunity in the cardiac rehabilitation (CR) setting. Therefore, this literature review aims to establish a rationale in using AVGs as a complement to the comprehensive CR program.
To ensure a comprehensive inclusion of relevant studies about this topic, a dual-search strategy was adopted. First, the author conducted a systematic literature search, using the following title search string in PubMed: (Wii[Title] OR exergam*[Title] OR video*gam* [Title] OR videogam*[Title]) AND (aerobic[Title] OR fitness[Title] OR expenditure[Title] OR energy[Title] OR MET[Title] OR metabolic[Title] OR activity[Title] OR physical[Title] OR fall[Title] OR balance [Title] OR stability [Title] OR old*[Title] OR elder*[Title] OR randomized [Title] OR Clinical[Title] OR rehabilitation[Title]). Filters activated: full text available, publication date from August 31, 2002, to August 11, 2012. Second, reference lists from the retrieved articles were examined to identify any additional relevant studies missed by the electronic search. Authors were not contacted for disclosure of any unpublished work.
Abstracts of all the retrieved studies were reviewed to identify potentially relevant studies for further analysis. To determine relevance, we focused on AVG benefits for human health promotion or disease rehabilitation through an exercise component, which could translate into the CR population. To be a considered an AVG, the intervention was required to (1) be screened in some form of video display, (2) lead to physical exertion, (3) have a system of reward or incentive, (4) be interactive and/or competitive, and (5) be designed for recreational use.
We then obtained and assessed the full transcripts of the potentially relevant studies to ascertain whether they met the inclusion criteria. The studies were selected if they were human trials, where participants had at least moderate hand and arm functional autonomy to perform the exergames. We excluded studies where participant age was exclusively less than 30 years, if there was cognitive inability to participate autonomously or nonlocomotion. We did not consider indirect interventions, that is, if the AVG had an effect on health care providers that was likely to improve outcomes in patients. We also disqualified studies where self-reported outputs or staff perception was the sole outcome. Furthermore, studies in which the applied AVGs were not commercially available or were not used as a part of a strategy to promote clinical improvement were also left out.
Data Collection Process
Information on authorship, year of publication, country where the study was conducted, conflicts of interest, study design, sample characterization, AVG type, duration, intensity and metabolic equivalents (METs) achieved, AVG and control intervention protocols, outcome measures used and key results, and gender results differences was collected. The trials were further classified according to the control over external variables as laboratory studies (artificial environment, high degree of control over extraneous variables) or field studies (real environment, low degrees of control over extraneous variables, but the results have more ecological validity). Information from the selected field studies on trial design, adequacy of randomization, degree of allocation concealment, blinding, among others, was also extracted so as to independently score their methodological quality by using predeveloped scales. According to the study design, either the PEDro scale7 for randomized controlled trials (RCTs) or a quality scale suggested by Romeiser Logan et al8 for single-subject design trials was used. Inclusion of the studies for further analysis warranted a score of at least 5 of 10 points in the RCT scale, and at least 7 of 14 points in the single-subject design trials. Performing a ratio calculation allowed for a percentage quality classification.
Synthesis of Results
A semiquantitative/qualitative description of the appraised studies is reported, as it was not possible to use formal techniques of meta-analysis because of the wide diversity in study designs, interventions, and outcome measures. To understand if AVG can meet CR guideline physical activity (PA) level demands, the laboratory studies were further ranked by the intensity of the AVG, according to the reported/estimated EE. Randomized controlled trials, considered the only controlled field intervention studies with clear AVG isolation, were ranked by whether the AVG protocol resulted in clinical improvement, according to the study primary outcome measures. For future reference, age groups were defined as follows: young age (<21 years), adults (21-65 years), and older people/elders/seniors (>65 years).
We identified 134 studies from our search, of which 91 studies were found to be potentially relevant. Full copies were retrieved, and according to inclusion and exclusion criteria, 26 studies were selected and more detailed methodological evaluation done. Only 21 studies were finally identified as complete trials and meeting the required methodological quality (the Figure; Tables 1 and 2).
The total number of subjects reported in the studies was 633, with the largest study including 1009 and the smallest only 7.10 Women were more represented than men (58% vs 42%, respectively) in the combined total. The majority of the sample population was adults or older people (96%). Most studies were conducted in the United States (57%), followed by Australia and Canada (9% each). Despite the broad publication date search filters, the included studies were all from 2009 onward. There were no conflicts of interest reported in all studies, but 3.11–13 The trials were classified into 2 categories: laboratory (n = 10) and field intervention (n = 11) studies.
There were 308 subjects recruited, with sample sizes ranging from 109 to 10011 participants. Male gender participation was estimated to be 56% overall. Only 1 study examined single-gender sample (male),13 while all other included both. All studies were aimed at adults or older people, while simply 2 used a mixed population with youngsters included.14,15 Infants represented only 11% of the tested individuals. Nine studies (90%) used a single-subject repeated measures design. Most of the laboratory studies consisted of multiple conditions for each participant to play various types of AVGs (3-15 minutes on each game) and control/alternative conditions.
The most commonly used AVGs were part of Nintendo Wii Sports (6 studies) and Wii Fit (4 studies) packages, followed by games relying on alternative AVG systems such as the dance pad–based console,11 band simulation peripherals,11,13 or isometric hand-controller13 (1 study each), for the Microsoft Xbox 360. In almost all studies, the difficulty setting began with the easiest skill level of competition. AVGs progress resulted in fluctuations in the game intensity, difficulty, and/or length, because personal skills, fitness, type of game, and desire were taken in consideration.
Field Intervention Studies
A total of 325 subjects were recruited. The highest-participated trial enrolled 84 participants16 through a multicenter approach, while the smallest sample corresponded to 7 individuals.10 Male-gender participation was estimated at 29%, with the majority obtained in the laboratorial trials. Only 1 study involved female-only participants,17 while all others included both genders. One study used a mixed children and adult population (9%),18 whereas all others were aimed at adults and seniors (91%). Seven studies (64%) used a between-subjects design (6 were RCTs), and the remaining 4 studies used a within-subject design (36%). The design quality of the studies ranged from 57%18,19 to 80%,20 with a mean score of 64.8 ± 6.8%. Most of the trials consisted in index participants playing 1 or various types of AVGs (25-60 minutes per session) throughout an intervention period, and then being compared in terms of certain outcomes with their controls (RCTs). Except for 1 trial with variable time length,20 the planned duration of all other intervention studies ranged from 6 to 12 weeks, with an average of 8.6 ± 3.2 weeks. Only 1 study included a followup period.19 Four of the interventions were run from home, 6 from a laboratory/training facility, and 1 based at a hospital ward.20 The most commonly used AVGs were from the Nintendo Wii Fit collection (8 studies), followed by Wii Sports (3 studies).
All studies queried the effect of AVG playing on EE through indirect calorimetric measurement (Table 1). The totality succeeded in demonstrating a significant increase in mean EE of AVG compared with rest or sedentary videogames. Some trials also compared AVG playing EE against actual sports EE and found out that similar metabolic rates to walking, yoga, and mild resistance training12,21 could be achieved with some of the Nintendo Wii Sports and Wii Fit games, but these were not comparable to actual running, tennis, or boxing.12 Among the 10 studies testing the association between EE and AVG play intensity, 2 (20%) reported gameplay intensity levels that could be classified as moderate PA9,21 (Table 3). Three studies (30%) found that the AVGs tested equaled light PA.13,14,22 The remaining 50% presented intensities that ranged from light to moderate PA.11,12,15,23,24
Exercise heart rate (HR) was screened in 6 studies,13,15,21–24 with variable results when compared to baseline. Three studies measured participant enjoyment of AVGs.11,15,21 According to these participants, enjoyment was significantly greater with AVG playing than other exercise conditions like treadmill walking or jogging,15 although the games requiring greater METS were perceived to be less pleasant than less demanding sedentary games.11 Five studies also measured participant perceived exertion while playing AVGs, which was allegedly overall reported to be low. Just 2 of the studies reported gender differences on 1 of the dependent variables.21,23
Field Intervention Studies
Altogether, these trials investigated the effects of AVG playing on health outcomes for adults/seniors, such as EE, PA, walking ability, postural control, fall risk, quality of life (QOL), depression/anxiety levels, emotional experience, social facilitation, etc (Table 2). Balance, followed up in 8 studies, was among the most popular outputs, evidencing an improvement trend after AVG intervention against no exercise, but nonsuperiority compared with already-established balance training regimes. Considering the RCTs only, the AVG treatment was considered to be more effective than the control group in 7 occasions at achieving clinical improvement as defined by the measured outcome (Table 4). No difference was found between the AVG intervention group and the control group in 8 instances. No studies reported gender differences in outcomes or adverse events.
Some of the identified benefits and risks of AVGs are discussed here.
AVGs' Cardiometabolic Benefits
Physical Activity and Energy Expenditure
The use of exergames among children and adolescents for obesity prevention is much more established than in the adult population. With this purpose in mind, recent reviews have assessed EE in youngsters while using movement-based consoles.25 The EE levels of adolescents when playing AVGs are documented to be equivalent to moderate PA intensity.2 Despite studying an older population, our literature review found similar EE results, with 2 studies reporting gameplay intensity levels that could also be considered as moderate PA,9,21 while 5 presented intensities that ranged from light to moderate PA.11,12,15,23,24 The research by Miyachi et al,12 in particular, merits further analysis. Twelve men and women (25 to 44 years old) were recruited to pantomime basic moves of sports and physical activities (Wii Sports and Wii Fit Plus). Each activity was continued for at least 8 minutes to obtain a steady-state EE, allowing MET value calculation from resting EE. From the 40 different activities included in Wii Fit, the most effective exercise was the single-arm stand (5.6 METs), and boxing was the most effective in Wii Sports (4.5 METs). Although, there were no vigorous-intensity activities (>6.0 METs), one-third of the AVGs required an EE of 3.0 METs or more, which exceeds the cutoff for moderate intensity PA (>3.0 METs). However, the large majority of authentic versions of the active sports still used substantially more energy than the AVGs.12,21
Heart rate and oxygen uptake (
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O2) are other ways to assess exercise intensity. Researchers in 2009 expressed the intensity of each AVG activity as a percentage of predicted
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O2peak and actual HRpeak and found out that the most active games, Wii Step and Wii Boxing, were played at 40% and 48% of predicted
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O2peak and 52% and 75% of actual HRpeak, respectively.26 This is sufficient to maintain cardiovascular fitness, on the basis of current exercise prescription guidelines for CR.27 There is also the general impression that playing against other people rather than playing against the machine may result in increased exertion. Bonetti et al13 demystified that, by reporting that there were no significant differences for both the physiological measures.
AVGs' Noncardiometabolic Benefits
The literature analysis revealed AVG's superior effectiveness20,28 or noninferiority16,29 at improving balance compared with control established interventions. The nonsuperiority results comparing to no structured balance training at all reported by Nilsagard et al16 were more intriguing. The lack of control over activities performed outside the protocol may account for the outlier result. The extra PA levels relied on self-report only, and several participants in the nonexercise group commented on how they had found motivation to spontaneously exercise on their own, which was possibly emphasized by the fact that they were to be followed up 2 months later. The nonexercise group reported twice the frequency of unsupervised exercise during the study period compared with the balance exercise group. This difference between the groups just had not been anticipated and was not adjusted for when calculating the sample size.
Research of AVGs has also extended its scope to take into account the emotional and psychological aspects of gaming. Three of the reviewed laboratory studies measured participant enjoyment of AVGs,11,15,21 reporting significantly greater pleasure with AVG playing than other exercise conditions like treadmill walking or jogging,15 which may be a good predictor of future activity involvement.
Playing AVGs in groups seems to foster social interaction, as Kahlbaugh et al30 found lower loneliness levels and greater positive mood among engaged participants. The act of playing together cooperatively or competitively in a game thus can help enhance interaction and facilitate the social networking.31
The work of Rosenberg et al19 on the feasibility, acceptability, short-term efficacy, and safety of an intervention using exergames for depression in older adults provide support to the findings of Kahlbaugh et al30 on positive mood modulation by AVGs. Community-dwelling older adults with subsyndromal depression participated in a 12-week pilot study of Nintendo's Wii Sports and revealed an important improvement in depressive symptoms and an improvement in mental health–related QOL and cognitive performance.
Quality of Life
Three field intervention studies assessed QOL as an outcome and produced discouraging results, since they failed to evidence significant improvement after AVG intervention, compared with the controls. These results should be considered with reservations, since 2 studies had an 8-week intervention duration,6,28 and 1 other, on hospitalized patients, presumably shorter,20 which might have been insufficient to change participant perception of their life conditions. Moreover, EVREST trial was only a pilot study with a small sample size, originally designed as a feasibility study and not powered to detect a difference between groups.6 Moreover, these studies screened QOL in different populations (survivors of stroke,6 hospitalized geriatric patients,20 and patients with Alzheimer disease28) by using distinct QOL setting-specific scales, making these results unlikely comparable among themselves. There is an empirical sense that entertainment-based exercise strategies should improve QOL, but whether that applies to exergames in specific disease contexts still remains to be demonstrated.
Despite AVG injuries reported in the past, such as acute tendonitis, hand laceration/bruising, or other minor traumatic injuries,32 none of the reviewed trials reported any adverse events, which suggests that this is a safe intervention. In fact, according to the American Electronic Injury Surveillance System, only 92 AVG-associated injuries were reported from 2004 to 2009,33 contrasting with the millions of users.
This review reveals a lack of data concerning the use of AVGs in patients with heart disease. Therefore, the discussion was based on the presumption that the reported AVG benefits in other adult subpopulations are probably transposable to the CR population. Another issue relates to the fact that the retrieved studies' conclusions were limited by small sample sizes. This fact likely reflects the low participation rate in exercise rehabilitation programs among older people and the substantial obstacles to recruiting these individuals for research studies, such as social, cognitive, and cultural barriers, the presence of comorbidities, and impaired capacity to provide informed consent.34 Another possible limitation concerned the data selection methodology. The present review included only laboratory or field intervention trials, therefore experimental studies in nature. This inclusion criterion was kept to evaluate a higher level of evidence for the usefulness of AVG to improve health outcomes than prior reviews on this topic, which also made use of weaker observational approaches. We could not, however, limit our review to RCTs, given the small number of hits yielded after applying such criteria on the already-challenging age filters. The major criticism of single-subject designs, though, is possible carry-over and order effects. Also, we have excluded non–off-the-shelf AVGs studies, possibly quite valid, in the name of allowing for a more consensual generalization.
Application to Practice
Research documents numerous positive health benefits attributed to exergames, which can, in theory, be particularly promising if translated into the CR setting. Nevertheless, before its application, future research should carefully assess the feasibility, efficacy, and safety of such strategy in light of the specificities of the cardiac population.
Although most studies to date concerning exergames have been done in children and adolescents, there is evidence that some of the gaming benefits are also verified among older populations, including individuals with high-risk cardiovascular diseases, such as patients with stroke.6 Since their release, AVGs are mobilizing a substantial following among seniors.35 Twenty-five percent of today's gamers are aged 60 years or older.36 Encouraging evidence comes from the fact that prior gaming experience and aerobic fitness levels do not influence the physiological responses during active gaming, including the amount of energy expended.26 Nevertheless, some seniors cannot easily navigate AVGs, since certain games may be too fast, too difficult, lacking support for task customization/grading, leading to negative performance feedback,37,38 which may be detrimental. Specially, the feasibility of home rehabilitation may be jeopardized, if left unattended. But in the class setting, this problem is easily overcome, since the therapists typically set up the games and may help in developing the correct technique.
Contrary to most traditional exercise options used in CR, which require a great deal of space and costly equipment, AVG platforms have the extra advantages of being small, light, and portable. Practical advantages of exergaming also include the ability to train selected patients at home with online supervision, thus reducing health care costs. In fact, strategies are already in place to incorporate automated telemanagement in home-based CR programs.39 The prototype system is designed to run by using an internet connection and communicate all patient data to a central server implementing real-time clinical decision support.
The average values attained during Nintendo Wii boxing shed light on the efficacy of some AVGs moderate-intensity activities being part of a CR exercise program, as an alternative or a complement to brisk-walking exercise. Nevertheless, exercise protocols that are low-intensity and result in little EE may also be sufficient to derive the established clinical benefits in specific high-risk CR groups. Therefore, analyzing HR might be a more useful measure of intensity than using the MET values. However, when using HR in exergaming as a method to predict activity intensity, note that there is a disassociation between HR and
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O2 during the lowest-intensity activities40 because of the emotional responses to AVG. Other external contributors to HR variation should be taken in consideration when applying AVGs in the CR class. Following the data of Lanningham-Foster et al,14 exercise leaders should pay attention to some patient-inflated competitiveness and their means to obtain success. Contrary to children, adults motivated to win the challenge may use a strategy that involves reducing their movements to what is necessary, thus spending less energy. In AVGs, one does not need to swing one's arm with force. It is sufficient to make a small, precise movement from the wrist in the right timing to achieve a higher score. Down to the CR class, an exercise leader should recognize and discourage the simplistic technique among participants.
There is a growing body of evidence supporting that AVG noncardiovascular benefits, altogether, might contribute to a more comprehensive CR experience. Using AVG might increase standing and activity tolerance and coordination,41 and reduce anxiety and risk of falls among the elderly patients.17,42 Cardiovascular disease and failure in carrying out activities of daily living are found to trigger depression among elderly people, a condition often seen in CR patients. Exergames may improve depressive symptoms by increasing levels of enjoyment, self-efficacy, self-esteem, cognitive performance, and social interaction,19 which when transferred to the CR setting, may result higher adherence to the protocols43 and a more sustained behavioral change.
Regarding the safety of implementing these platforms in CR, the likelihood of an AVG-related injury should be very low. Nevertheless, new strategies are being sought to contribute to the safety of these apparatus, making them more suitable for clinical populations. Some AVG platforms already include technology to monitor vital signs such as HR and oxygen saturation levels, steering the gamer toward recommended intensity levels and determining higher levels of safety in training high-risk patients. Particular postsurgical care should be taken when applying AVGs to patients with coronary artery bypass graft, to not cause incisional discomfort and jeopardize tissue healing. Historically, precautions during early CR of these patients included marked restrictions in lifting and arm/shoulder motion until the sternotomy wound was completely dry.44 Presently, it is argued that delaying full range-of-motion exercise can decrease the likelihood of full recovery of strength and range of motion due to inactivity, impairing functional capacity.45 Therefore, the use of AVG in select cases at conservative intensities may, in fact, be indicated.
On the basis of this review, AVGs' usefulness to improve PA, cardiorespiratory fitness, and motor function in older adults appears to be poorly described. Particularly, data on the impact of AVGs on the CR population seem inexistent. Nevertheless, we have described reasons to believe that exergaming benefits may prove important to address the health and well-being concerns of this population. Specifically, most AVG studies reported gameplay intensity levels that could be classified as moderate or light-moderate PA. AVGs also revealed superior effectiveness or noninferiority at improving balance and motor function compared with control interventions. Additionally, its interactivity aspect fostered enhanced socialization and improved mood among the players. More research in the specific setting of CR is obviously warranted, but it seems fair to assume that AVGs may be a feasible supplementation exercise strategy, meeting the specificities of these patients. Clinicians could borrow several concepts incorporated in AVGs to come up with a CR intervention that is effective, safe, fun, and engaging to improve adherence.
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cardiac rehabilitation; exergames; Wii program