Results of the risk of bias assessment are provided in Table 2. The conference abstract by Makhabah et al29 was unclear in all categories of bias assessment, with no further information obtained from the authors. Of the remaining 5 studies, 4 were determined to be unclear in the blinding of study participants. Other sources of bias included limited washout periods and short exercise sessions in crossover trials. The majority of studies used appropriate randomization and reported all outcomes.
Table 3 describes the characteristics of the active video games discussed in this review. Four studies used Nintendo Wii25,27–29 and 2 used the Xbox Kinect gaming consoles.24,26 Wii Fit, a game consisting of yoga, strength, and aerobic exercises, was used in 2 studies for participants with COPD29 or mixed respiratory diseases.27 Two crossover studies for participants with COPD28 or CF25 used the EA Sports Wii Active game, consisting of jogging on the spot, dance, boxing, and other sports. Both studies using the Xbox system chose 1 mini-game from the Xbox Kinect Adventures game.
Of the randomized controlled trials, 2 studies delivered the video game intervention twice weekly for a period of 629 to 824 wk, and 1 study delivered the intervention once daily for 7 d during the last week of PR.27 The length of the video game intervention ranged from 40 min24 to 1 hr.27 This differs from the 3 crossover studies, 2 of which included only a single 15-min session,25,26 the third being a single 20-min session.28
PRIMARY OUTCOME-EXERCISE CAPACITY
All 6 studies included outcome measures related to exercise capacity (Table 1). These included constant treadmill time and distance,24 6-min walk distance (6MWD),27,29 cycle ergometry,27 and measures of HR.24–26,28
Treadmill time and distance were compared for children with moderate to severe asthma following 8 wk of training using a treadmill or the “Reflex Ridge” mini-game.24 Both groups showed significant improvement in treadmill time and distance. Between-group differences favored the conventional training group (P < .05).
The addition of Wii Fit training to the final week of a standard PR program was associated with significant improvements in 6MWD compared with control (P = .028) but no difference in measures of incremental arm (P = .361) or leg cycle ergometry (P = .776) between groups.27 Another study using Wii Fit noted significant improvements in 6MWD from baseline for both groups,29 with no between-group differences reported.
Maximal HR levels during active video game training were comparable to or higher than those achieved by the control group in all studies.24–26,28 Kuys et al25 reported significantly higher minimum and maximal training HR in the video game group, although there was no difference in average HR between groups (95% CI, 3-9 beats/min).25 A significantly higher percentage of predicted maximal HR during active video game training compared with treadmill training was also reported in patients with asthma (P < .05).24
SECONDARY OUTCOME MEASURES
Secondary outcome measures included measures of Spo2,25,26,28 dyspnea rating,25–29 rating of perceived exertion,25,26 energy expenditure,24–26 HRQOL,27,29 enjoyment, and preference for exercise modality.25,26,28
SECONDARY OUTCOME MEASURES: TRAINING
Spo2 was similar during training between all intervention and control groups and remained >90%, or was maintained with supplemental oxygen at safe levels during training.25,26,28 Dyspnea levels were recorded during training using the Borg scale25,26 and a visual analog scale28 in the crossover studies. The Transition Dyspnea Index,27,29 and the Medical Research Council dyspnea scale27 were used for the randomized controlled trials. Dyspnea levels and rating of perceived exertion between groups were comparable in all studies.25,28,29 Fatigue was measured in 2 studies using a visual analog scale25,28; in 1 study, Wii training resulted in similar fatigue levels compared with control25; in a second study, Xbox Kinect training was associated with significantly lower fatigue levels during training (P < .001).28
Total energy expenditure, as measured continuously during training by a portable activity monitor, was higher than conventional exercise training only when playing the Xbox Kinect Adventure “Reflex Ridge” mini-game than during treadmill training (P < .01),24 with no differences noted with EA Sports Wii Active training.25,26
SECONDARY OUTCOME MEASURES: CLINICAL
Only 1 study27 reported significant differences in dyspnea rating using the Transition Dyspnea Index, with the video game group reporting less breathlessness than the control group (P < .001). Two studies27,29 measured HRQOL using the St George's Respiratory Questionnaire. Both groups had significant improvement in their St George's Respiratory Questionnaire scores only from baseline to the end of the study.27,29
Enjoyment and preference for exercise modality were reported in the 3 crossover studies.25,26,28 Adults with CF expressed higher levels of enjoyment for the EA Wii Sports Active games compared with treadmill exercise (95% CI, 1.6-3.6).25 Children and adolescents with CF preferred the Xbox Kinect Adventures mini-game “River Rush” to stationary cycle exercise (P < .001)28 while individuals with COPD equally enjoyed treadmill/cycle training and Nintendo Wii training.26
A variety of active video games and gaming systems were used in the studies included in this review. These games varied in their exercise intensity, as reflected by the percent predicted maximum HR determined for each population.24,25,28 Compared with treadmill or cycling training, active video games induced similar maximal HR24–26,28 and dyspnea levels.25,26,28,29 Although 1 study27 reported between-group differences in 6MWD in favor of the video game intervention, the short (1 wk) intervention period limits any meaningful interpretation of the result beyond a 3-wk inpatient PR program.
The longest duration of active video game training was 8 wk with training twice weekly,24 the minimum time generally recommended for exercising populations.6,31,32 Only 2 of the 3 randomized controlled trials reported 6 to 8 wk of active video games versus the alternative traditional exercise training. The third randomized controlled trial had only a 1-wk add-on to a short (3-wk) PR program. Other studies varied in intervention length, the shortest 2 being a single 15-min session.
Both active video games such as Nintendo Wii EA Sports Active26 and the Xbox Kinect Adventures “Reflex Ridge” and “River Rush” mini-games24,28 can achieve exercise intensities similar to those achieved using treadmill or cycle training. These findings are consistent with the recent review of active video game training in patients with CF.33 The style of video game training, using short, 3-5 min mini-games, with approximately 15-30 sec rest while the next game loads,26 is similar to interval training, an approach used for patients with chronic respiratory diseases who may be unable to tolerate continuous exercise.34 Further information is required regarding the relative intensity of exercise prescription for this approach due to the variation of games used in this review.
The specificity of training within the active video game may influence outcome measures. For example, one would not expect changes in arm cycle ergometry from a video game that was predominantly focused on lower limb training.27 Similarly, the improvement in treadmill time in the control group in the study by Gomes et al24 is not surprising, despite the higher training energy expenditure and HR in the video game group, as the latter involved a program of jumps, squats, and arm movements to avoid obstacles whereas the former used treadmill training. In addition, the study by Mazzoleni et al27 included a measurement of HRQOL after a 1-wk long trial. This highlights the importance of evaluation studies selecting outcomes appropriate to the intervention. In addition, the comparator exercise was variable between studies both in duration and intensity and did not reflect the interval style of the video games.
The majority of active video games on the market are designed to appeal to children and young adults, but studies with older adults have demonstrated that they too can enjoy these games.11,20,26 In this review, children and adults with asthma or CF clearly preferred video game training24,28 whereas adults with COPD enjoyed both training modalities.26 Active video games are a unique exercise training option as they offer the enjoyment and competitive aspect of video games but are controlled by the player's movement and, therefore, are also a form of physical activity. By immersing the player in a virtual reality, active video games also serve to distract the player from symptoms such as fatigue or dyspnea, common among the respiratory population25,26,28,29
While the collective results demonstrating similar training maximal HR, dyspnea levels and positive enjoyment are encouraging, longer-term studies, with a consistent intervention in a homogeneous population, are required to establish the clinical impact of active video game training. In addition, personnel should be blinded to group allocation when evaluating outcome measures to reduce the risk of bias in future studies. Given the nature of the intervention, it would be difficult to blind participants. An important limitation of this review is the small number of studies identified, which reflects the novelty of video game training in respiratory rehabilitation. Had this review been expanded to include a cardiac population, there would have been more studies included; however, a comprehensive review of “exergames” in cardiac rehabilitation has been previously published.35 The small number of studies identified included methodological limitations relating to the small sample size, heterogeneity, and duration of exercise training. Such variations in the study design, population, intervention, and outcome measures prevented grouping of data in a meta-analysis. Therefore, current evidence is insufficient to establish the role of active video game training for individuals with chronic respiratory diseases. However, this review will help inform further studies in this area. If shown to be a clinically useful component of exercise, active video games could provide additional variety to standard PR exercise training, increasing motivation and promoting adherence17,20 both in a hospital setting20,24,27 and at home.14,17,18
Active video games can induce similar physiological demands such as maximal HR, dyspnea levels, and energy expenditure during training as traditional exercise modalities. The evidence of enhanced clinical outcomes provided in this review is of low quality with small sample sizes and brief intervention periods. Larger randomized controlled trial of homogeneous design and longer-term follow-up will determine whether active video game training can result in long-term improvements in exercise capacity and HRQOL among those with chronic respiratory conditions.
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