|A Scoping Review of Exergaming for Adults with Systemic Disabling
|Matthew A. Plow1*, Corey McDaniel2, Susan Linder3 and Jay L. Alberts4
|1Project Scientist, Department of Biomedical Engineering, Department of Physical Medicine and Rehabilitation, Cleveland Clinic Lerner Research
Institute, 9500 Euclid Ave, ND-20, Cleveland, OH 44195, USA
|2Graduate Student, Department of Biomedical Engineering, Department of Physical Medicine and Rehabilitation, Cleveland, USA
|3Clinical Specialist, Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, USA
|4Associate Staff, Department of Biomedical Engineering, Center for Neurological Restoration, Cleveland, USA
||Matthew A. Plow, PhD
Project Scientist, Department
of Biomedical Engineering
Department of Physical Medicine and Rehabilitation
Cleveland Clinic Lerner Research Institute, 9500 Euclid Ave
OH 44195, USA
Tel: 216 445 3288
Fax: 216 646 2599
|Received October 05, 2011; Accepted November 15, 2011; Published November
|Citation: Plow MA, McDaniel C, Linder S, Alberts JL (2011) A Scoping Review
of Exergaming for Adults with Systemic Disabling Conditions. J Bioengineer &
Biomedical Sci S1:002. doi:10.4172/2155-9538.S1-002
|Copyright: © 2011 Plow MA, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
|Background: Exergaming, or playing a game on a television, computer or projector screen with a motion-monitoring
system to enable control of on-screen action by bodily movements that result in a substantially greater expenditure of
energy compared to resting levels, may be particularly relevant for adults with systemic disabling conditions because
of its potential to increase health and function and improve adherence to rehabilitation/exercise programs. Thus, we
conducted a scoping review of the literature on examining the usability and utility of low-cost exergaming technology in
adults with systemic disabling conditions.
|Methods: Comprehensive strategies were used to search for studies published or in-press between 1980 and
July, 2011. Main inclusion-exclusion criteria were studies that examined the usability or utility of affordable exergaming
technology (e.g., excluding fully immersive virtual reality platforms) in adults with systemic disabling conditions. We
used the User-Orientation Evaluation Framework, GameFlow model, and Dobkin’s framework on the progressive
staging of pilot studies to determine the scope and quality of the existing literature.
|Results: We identified 25 studies, which reported on 346 adults with disabling conditions. Most participants were
male and stroke survivors. Only four studies employed a randomized controlled trial design and most studies were
classified in the consideration-of-concept stage, according to Dobkin’s framework. Few studies were comprehensive
in their usability assessment. Common exergaming technology platforms examined were Sony PlayStation EyeToy,
Nintendo Wii, and technology developed by the researchers of the study. Eight adverse events were reported across
the 25 studies.
|Conclusions: Research on exergaming using affordable exergaming technology platforms is still in its infancy.
We recommend that randomized controlled trials be conducted with a long-term follow-up that employs a mixed methods
approach to collecting data. Multidisciplinary collaborations among exercise physiologist, behavioral scientist,
rehabilitation scientist and neuromotor control experts are needed to advance the field and identify possible mechanisms
|Although not a new concept, exergaming, or playing a game on
a television, computer or projector screen with a motion-monitoring
system to enable control of on-screen action by bodily movements that
result in a substantially greater expenditure of energy compared to
resting levels, has received a great deal of media attention over the last
few years. This attention largely is the result of recent advances in video
game technology that have made exergames more realistic and readily available
to the general public [1-2]. Common platforms on which to
utilize exergames are virtual reality systems, computers mounted on
exercise equipment and commercially available home video game
consoles. The motion-monitoring system to enable control of onscreen
action can range from handheld accelerometers and gyroscopes
to haptic and video-capture technology . Exergaming is advocated
as an enjoyable way to meet physical activity guidelines to improve and
maintain health in a variety of population segments [4-6], including
adults with chronic systemic disabling conditions (i.e., a long-term
condition that affects multiple organ systems or the whole body and
limits participation in life roles) [7-10].
|Since the 1980s, there have been a growing number of research
studies in the rehabilitation literature on developing and evaluating
virtual reality systems among adults with systemic disabling conditions
[11-12]. Many rehabilitation studies have focused on examining the
benefits of virtual reality systems that use video-capture technology and create fully immersive environments with large screen projections,
head-mounted displays or concave projection screens . These
studies involve research subjects (e.g., stroke survivors) engaging in
therapeutic exercises, sport and leisure activities and/or functional
tasks within a virtual environment. Although this line of research
has shown potential in improving health and function, cost and the
expertise required to operate virtual reality systems have impeded its
widespread distribution in clinical rehabilitation practices . Thus,
using commercially available home video game consoles is an appealing
alternative to expensive virtual reality systems . Occupational and
physical therapists have suggested that incorporating exergaming utilized on home video game consoles into the rehabilitative care of
patients with disabling conditions could lead to improved health
outcomes by improving quality of care and exercise adherence [9-10].
|Several studies have documented that adults with systemic
disabling conditions do not receive quality rehabilitation care. Reasons
for inadequate care include issues related to accessibility, affordability
and continuity in services [16-20]. One way to increase accessibility and
affordability of rehabilitation services is through web-based telehealth
communication . Exergames could be discussed in telehealth
communications between a physical or occupational therapist and
patient. For example, exergames can enable individuals to keep track
of their personalized exercise program online and monitor progress
towards meeting fitness goals, which could be sent to the therapist for
review and feedback. Exergames could also be used within a clinical
setting to reduce costs. For example, exergames can be used to help
patients achieve the required practice to learn a new motor skill.
With proper safety precautions in place, the therapist’s time from
supervising this low-skilled service could be reduced to focus on
higher-skilled services, such as gait training and improving quality of
movement . Exergames used on home video game counsels could
facilitate continuity in rehabilitation services by providing a common
therapeutic modality to use across rehabilitation settings (i.e., acute,
post-acute and home setting).
|Exergaming may also improve patient compliance with both
therapeutic and preventive/maintenance exercise programs .
Exergaming has the potential to be engaging and fun to play, which
is important for people with disabling conditions that may experience
many disincentives for engaging in physical activity and exercise. It is
now generally accepted that routine engagement in physical activity can
improve physical function, decrease utilization of healthcare services
and improve quality of life in adults with disabling conditions [24-27].
However, adults with disabling conditions experience many healthrelated
barriers to physical activity and can subsequently become
extremely inactive [28-29]. Inactivity can lead to de-conditioning,
secondary conditions (e.g., obesity, diabetes and cardiovascular
disease) and ultimately further disability and increased utilization
of healthcare services [30-31]. Exergaming may be able to break this
disabling cycle by increasing motivation and influencing psychosocial
constructs (e.g., self-efficacy) related to increased physical activity
levels . Exergaming in the home could remove common barriers
that adults with disability often experience in going to a gym [32-33],
while allowing for the possibility of social interactions in the home.
|Given these potential benefits, the research literature on
exergaming in adults with systemic disabling conditions is rapidly
growing. Furthermore, non-profit organizations and federal granting
agencies have a renewed interest in funding healthy gaming research
. Thus, there is a critical need to examine how best to advance the
research literature on exergaming. While there have been recent review
articles on utilizing healthy gaming technology, to the best of our
knowledge, these reviews have primarily focused on expensive virtual
reality systems or only reviewed research studies in narrowly-defined
population segments (e.g., healthy adults or individuals with a particular
condition/disease) [13,34-37]. Furthermore, many of these reviews
have not used a conceptual framework to guide search methodology
and make research recommendations. Using a conceptual framework
can help ensure a thorough review of the literature and can provide a
classification system to organize studies and identify knowledge gaps
|In summary, exergaming may be particularly relevant for adults with systemic disabling conditions because of its potential to increase
health and function, improve rehabilitation services and decrease
rates of inactivity. However, exergaming technology and studies
that evaluate such technology are growing rapidly across different
scientific disciplines. To help avoid superfluous and redundant studies
that fail to substantially advance the field towards evidence-based
rehabilitation practice, we conducted a scoping review of the literature
on examining the usability, benefits and risks of exergaming in adults
with chronic systemic disabling conditions. The objective of the review
was to identify gaps within the existing literature and make future
research recommendations. We focused our review to exergames
played on a television or computer screen with exercise equipment
(e.g., bike or treadmill) or commercially available home video game
consoles (i.e., Nintendo Wii or Sony PlayStation Eye Toy). See the
following cited review articles for details on the potential benefits of
virtual reality systems that use more expensive technologies (e.g., large
screen projections, cave systems, head-mounted displays, robotics or
|We used the following three conceptual frameworks to
operationalize definitions, identify gaps in the literature and make
future research recommendations: (a) User-Orientation Evaluation
Framework , (b) GameFlow model for evaluating enjoyment in video
games  and (c) Dobkin’s  progressive staging of pilot studies for
motor interventions in rehabilitation. We used the User-Orientation
Evaluation Framework and GameFlow model to help determine both
the extent and quality of the existing research literature to examine the
accessibility, usability and utility of exergaming. Both of these models
identify and define a set of constructs (e.g., accessibility, usability, utility
and playability) that should be considered when examining how an
individual will respond and react to interactive computer technology
(i.e., User-orientation) and whether they will have fun playing it (i.e.,
GameFlow). It will be important to examine such constructs when
determining the feasibility of incorporating exergaming into clinical
rehabilitation practice and whether exergaming can realistically be
used to increase exercise adherence in adults with systemic disabling
conditions. We used Dobkin’s framework on the progressive staging
of pilot studies for motor/rehabilitation interventions to guide
methodological recommendations for future research.
|A scoping review involves the synthesis and analysis of existing
research literature with the aim of providing greater conceptual clarity
about a specific phenomenon. Although a relatively new methodology
in healthcare research, its use and recognized utility is growing across
research disciplines. Davis  suggested that a scoping review “provides
a comprehensive and panoramic overview that not only illuminates its
extent and context but also has the potential to influence policy and
practice developments.” Unlike a systematic review of the literature,
evaluating quality of evidence is not the primary focus of a scoping
review. Instead, the main purpose is to map existing literature by time
(history of literature), location (where are the studies being conducted)
and origin (highlight disciplines/theoretical underpinnings) to identify
research gaps and make recommendations for future research [42,43].
Arksey and O’Malley  outline five stages in a scoping review: (1)
identifying the research question and operationalizing the definitions;
(2) identifying relevant studies through electronic databases, reference
lists and hand-searching of key journals; (3) establishing inclusionexclusion
criteria for the selection of studies; (4) charting the data
through a narrative review; (5) collating, summarizing and reporting
|Step 1: Identify Research Question and Operationalize
|The questions we aimed to answer from the existing literature in
adults with systemic disabling conditions: (1) What are the benefits
and risks of exergaming? (2) What strategies are being implemented to
evaluate and promote the use of exergaming? (3) What are the usability
barriers to exergaming? The User-Orientation Evaluation Framework
, GameFlow model , and Dobkin’s  progressive staging of
pilot studies were used to operationalize definitions and classify studies
included in the review. Tables 1 and 2 outline important constructs and
definitions in each framework/model.
||Table 1: Dobkin’s progressive staging of pilot studies for motor interventions.
||Table 2: Definition of constructs for the user-orientation framework and game flow model.
|The User-Orientation Evaluation Framework is based on the
principle of universal access (i.e., the accessibility, usability and
acceptance of technology irrespective of social status and functional
level) and draws upon theories from sociology, social psychology and
information systems/computer science (e.g., Innovation Diffusion
Theory, Theory of Reasoned Action and Technology Acceptance
Model). The framework summarizes six universal access constructs/
measures (i.e., visibility, perceived usefulness and ease of use, availability/
approachability, quality of interaction, relationship maintainability
and competitiveness) that should be considered within the context
of the user’s goals and characteristics. The GameFlow model outlines
eight constructs (i.e., concentration, challenge, player skills, control,
clear goals, feedback, immersion and social interaction) that seek to
guide the evaluation of player enjoyment in video games. We used both
the User-Orientation Evaluation Framework and GameFlow model to
identify research gaps in the evaluation of exergaming technology and
to provide guidance on making substantive research recommendations.
Dobkin’s progressive staging of pilot studies details a four-stage
pathway (i.e., consideration-of-concept, development-of-concept,
demonstration-of-concept and proof-of-concept) in which research
methodology should progress to generate evidence-based rehabilitation
interventions. Thus, this framework provides guidance on making
methodological research recommendations.
|Step 2: Identify Relevant Studies
|Multiple search strategies were used to identify studies on
exergaming in adults with systemic disabling conditions. Four databases
were searched – Pubmed, CINHAL, Web of Science and Scopus. The
following MeSH and/or subject terms were used: virtual reality, video
games, Wii, Kinect and EyeToy in combination with rehabilitation,
physical activity, exergaming or exercise. In addition, the reference list
of relevant review articles was searched to identify additional studies,
and Google Scholar was scanned using relevant search phrases. The
following journals were also hand-searched between 1980 and July, 2011 (including in-press articles that were available for review): Clinical
Rehabilitation, Disability and Rehabilitation, Archives of Physical
Medicine and Rehabilitation, American Journal of Occupational
Therapy, Physical Therapy and Cyberpsychology, Behavior, & Social
|Step 3: Inclusion-Exclusion Criteria
|Inclusion-exclusion criteria were implemented to help ensure
that we only reviewed exergames that are or could potentially be
commercially available to the general public and be readily used in
the home or clinical setting. Inclusion criteria were English language
articles that examined the usability or utility of exergames in adults
with chronic systemic disabling conditions (e.g., cardiopulmonary
diseases, neurological conditions, developmental disability, polyarthritis
and other ailments of old age, such as mobility and balance
problems) and were published or in-press between 1980 and July, 2011.
Exclusion criteria were (1) conference proceedings and abstracts, (2)
review articles that described ongoing research, (3) studies on children,
healthy adults, adults in long-term care facilities and individuals with
orthopedic injuries, single joint inflammation, amputations, burns,
mental health disorders (not excluded if co-morbid condition) or
non-disabling risk factors for cardiovascular disease (e.g., high blood
pressure or cholesterol), (4) examination of technology (i.e., goggles
and ear piece) that provide visual or audio cues during gait training, (5)
validation studies for assessing motor function or ability to engage in
activities of daily living, (6) studies focusing on cognitive rehabilitation,
re-learning daily skills in a “real-life” virtual environment (i.e., grocery
store, train platform, ATM machine) or mimicking movements of
a therapist from a remote location. We also excluded articles that
described using fully immersive virtual reality technology or playing
exergames using large screen projections, cave systems, head-mounted
displays, advanced haptic or force-plate technology (i.e., beyond
commercially available joysticks with vibration and Wii Board),
electroencephalography, electromyography and robotics. If it was not
clear whether the technology used in the study met inclusion-exclusion
criteria (e.g., whether advanced robotic or haptic technology was
used), there needed to be an explicit discussion about the cost of the
technology or about the potential of it being commercially available to
the general public.
|We first scanned titles to determine whether the study potentially
examined exergaming in adults with systemic disabling conditions. In
this initial search, we felt that it was important to include any article
that could potentially describe a study examining the use of virtual
reality/video game technology in adults with systemic disabling We first scanned titles to determine whether the study potentially
examined exergaming in adults with systemic disabling conditions. In
this initial search, we felt that it was important to include any article
that could potentially describe a study examining the use of virtual
reality/video game technology in adults with systemic disabling of technology met study criteria, the study was moved to the final
phase of review. In the final phase of review, we scanned the entire
article to confirm inclusion-exclusion criteria. Thus, the final set of
studies examined the usability and/or benefits of low-cost exergaming
technology in adults with systemic disabling conditions.
|Step 4: Charting Data
|Coding of data: For the remaining pool of articles, sample
characteristics (e.g., gender, age, type of disabling condition and mobility
level), description of research design and outcomes (i.e., type of design,
number of subjects and Dobkin ‘s  methodological classification
framework) and characteristics of the exergaming interactions
(i.e., location and frequency of exergaming, type of exergaming and
description of the video game platform) were extracted from the articles.
Articles were also coded as to whether they considered or examined the
constructs specified in the User-Orientation Evaluation Framework or
GameFlow model. Articles were coded as considering or examining
the construct regardless of whether the construct was described from
the perspective of the researcher (e.g., administering health outcomes)
or the patient (e.g., asking the patient whether they had fun playing
the exergame). The first and second authors independently coded each
article. Disagreements were discussed until consensus was reached.
|Step 5: Collating, Summarizing and Reporting Results
|We had an initial pool of 1,074 articles that had the potential to
describe the examination of exergaming technology in adults with
systemic disabling conditions. Of these articles, we excluded 1,047
articles (see Figure 1). We first identified and excluded 569 conference
abstracts/proceedings and review articles (including review articles that
described ongoing research). We then categorized and excluded 104
articles for not meeting criteria on sample characteristics, 33 articles
for focusing on validating an assessment or activities of daily living
(ADL) training and 34 for articles for focusing on cognitive training.
We also excluded 73 articles for describing the use of fully immersive
virtual reality technology or advanced robotics, and 114 articles for
focusing on miscellaneous topics that were not about exergaming.
For the remaining pool of 147 articles (i.e., third and final round of
review), we excluded an additional 34 articles for not meeting criteria
on sample characteristics, 44 articles for focusing on validating an
assessment or ADL training, three articles for focusing on cognitive
training, 20 articles for focusing on miscellaneous topics that were not
about examining the utility or usability of exergaming and 19 articles
for describing using advanced technology and not discussing the
affordability of the technology. The remaining 27 articles were described
as using six different technology platforms for playing a variety of
different exergames. Two of the articles outlined the methodology of
the study or described a subset analysis of a larger study [45-46]. Thus,
25 different studies were coded from the 27 articles.
||Figure 1: Flow of articles through the study.
|Characteristics of the research samples: Table 3 (Data included
as supplementary) provides an overall summary of the characteristics
of the 25 research samples. The 25 research samples had 346 adults
with disabling conditions. Most research subjects were male. Research
subjects’ ages ranged from 19 to 91 years old, with eleven studies having
a mean age 55 years or below. Thirteen studies were conducted on
people with stroke who had mild to moderate upper- or lower-extremity
mobility impairments. The remaining studies included people with
spinal cord injury, traumatic brain injury, older adults with balance
problems, multiple sclerosis, developmental disabilities and across
different disabling conditions (e.g., multiple sclerosis, arthritis, and
fibromyalgia). Four studies were conducted in individuals who were
ambulatory or used a mobility aid. Eight studies involved individuals
who used a wheelchair, one study involved both wheelchair users
and mobility aid users, and two studies involved adults with balance
problems. Ten studies focused on people with mild to moderate upperextremity
|Research design & outcomes: Only four studies employed
a randomized controlled trial design. According to Dobkin 
classification framework, 24 studies were classified as being in the
consideration-of-concept stage and one study was classified as being in
the demonstration-of-concept stage. However, it did not report effect
sizes. The most common types of outcomes were on upper-extremity
function, followed by objective evaluation of physical function, selfreported
physical function and mobility, and balance. Eight studies
conducted open-ended or semi-structured interviews. All studies
reported positive findings: either improvements in health and function
outcomes or positive reports about accessibility and usability. The
most commonly reported positive findings were improvements in
upper-extremity function. Eight adverse events were reported across
the 25 studies. However, six studies noted limitations/problems in the
usability of the technology platform to engage in exergaming. The most
commonly reported limitation was being unable to adjust the intensity
of the game to the functional level of the patient and/or having difficulty
using/controlling the technology.
|Characteristics of the exergaming interaction: The most common
technology platforms to play exergames were on the commercially
available Sony PlayStation EyeToy and Nintendo Wii. Eleven studies
where on technology that was developed by the researchers of the
study; three studies were on the development of exergames, six were
on the development of technology platforms to play exergames,
and two developed both the platform and exergame. Eight studies
examined Wii Sports (i.e., boxing, tennis, baseball and bowling),
while fourteen studies examined games requiring users to reach and
manipulate floating objects, such as popping a balloon. Exergaming
training protocols were usually short in duration (i.e., 2 to 8 weeks),
but consisted of several sessions per week (i.e., 4 times a week ranging
from 15 to 180 minute sessions). Five studies examined patients using
exergaming in their home environment.
|User-orientation & GameFlow Constructs: All studies considered
or examined at least one User-Orientation construct. Thirteen articles
examined three or more constructs from the model. The most common
construct examined was quality of interaction followed by perceived
usefulness and ease, relationship maintainability and availability/
approachability. No studies examined visibility and few studies
examined competitiveness. The quality of interaction construct was
primarily evaluated by administering health outcomes pre- and posttest,
while relationship maintainability was primarily evaluated by
adherence measures. Alternatively, fourteen studies did not evaluate
GameFlow constructs. The few studies that did evaluate GameFlow
constructs were primarily focused on developing a videogame specific
to people with disabling conditions. The most common construct
examined was feedback followed by immersion, player skills, and clear
goals. Social interactions, concentration, challenge and control were
|In spite of the promising potential of exergaming technology to
increase health and function, improve rehabilitation services and
decrease rates of inactivity in adults with systemic disabling conditions,
we found that research on exergaming using affordable technology
platforms is still in its infancy. The lack of pervasiveness of exergaming
in the rehabilitation literature is probably in part because affordable
technology platforms have only become readily available over the
last couple of years. However, the absence of randomized controlled
trials and rigorous research methodology to enlist the perceptions
and attitudes of adults with disabilities has impeded the advancement towards evidence-based rehabilitation practice for exergaming.
Furthermore, few studies in this review were comprehensive in the
examination of constructs from the User-Orientation Framework or
GameFlow model. As a result, many fundamental questions remain
about the usability and utility of exergaming technology among adults
with systemic disabling conditions. For example, questions remain
about perceptions and attitudes that influence the use of exergaming in
adults with systemic disabling conditions (i.e., mediators), who is likely
to benefit from exergaming (i.e., moderators), the safety precautions
that should be implemented to reduce risk of injury, the strategies
needed to promote use of exergaming in the home and whether
exergaming can achieve equivalent or even better health outcomes than
traditional therapeutic exercise programs.
|Several studies in this review used objective assessments or
questionnaires to report on the positive health benefits of exergaming
in a clinical setting over a short period of time (i.e., pre- and posttest)
among adults with a moderate or high level of function or
with a condition expected to get better or not progress. While these
studies help provide some rationale for using exergaming in clinical
rehabilitation practice, these positive findings are not surprising in light
of existing research that indicates that physical activity improves health
and function in adults with systemic disabling conditions [24,25].
Furthermore, supervised exercise sessions tend to result in better
compliance and subsequently better outcomes [25,47]. Thus, studies
that examine exergaming in supervised sessions without collecting
data on perceptions or mechanisms of action are somewhat redundant
with the existing exercise and rehabilitation literature in adults with
systemic disabling conditions [25,48].
|There is a need to conduct research that examines exergaming in
an ecologically-valid approach in order to facilitate evidence-based
rehabilitation practice guidelines. For example, examining exergaming
in patients who transition from inpatient and outpatient to residential
and community settings (i.e., exploring how exergaming can facilitate
continuity in different rehabilitation settings), and conducting research
on subjects who have more moderate impairments or who are expected
to decline in function over time (i.e., multiple sclerosis and Parkinson’s
disease) will be important. Many of the studies in this review only
included patients with a high level of function and/or a non-progressive
condition. While inclusion of these types of patients makes for “cleaner
science”, individuals with more moderate impairments or who have
conditions that are expected to progress may have unique barriers
to exergaming that will need to be identified and addressed before
exergaming can be readily used in clinical rehabilitation practices.
|User-Orientation and GameFlow Constructs
|Most studies examined at least one construct from the User-
Orientation Framework. However, few studies evaluated constructs
from the GameFlow model. Few studies examined the visibility
construct from the User-Orientation Framework as well as social
interaction, concentration, challenge and control constructs from
the GameFlow model. Nonetheless, examining these constructs will
be important because adults with systemic disabling conditions may
experience health-related barriers that make it difficult to access and
control exergaming technology or make the games too challenging to
play. Furthermore, social interactions may be an important construct
to consider, as it may be a powerful incentive to promote exergaming
adherence in adults with systemic disabling conditions .
|Although several studies examined User-Orientation constructs,
many of the studies did so informally or “in passing.” Thus, while it is noteworthy to find that most studies indicated that research
participants generally had favorable attitudes towards exergaming, data
on attitudes and perceptions that are collected informally or in passing
should be considered preliminary. Mixed-methods research (i.e., using
both qualitative and quantitative research methodology) is needed to
rigorously examine User-Orientation constructs. An example of such
research was the study conducted by Lange . This study explored
the usability of the Sony PlayStation EyeToy and Nintendo Wii. Both
focus groups and standardized questionnaires were used in the study.
Participants in the study reported that exergaming would help keep
them motivated to stay physically active and that the exergames offered
a distraction from their disability. However, it was also observed that
some participants had difficulty navigating through the menu and that
game play was sometimes too fast. The authors noted that commercially
developed exergaming technology is not entirely applicable to
rehabilitation practice and individuals with disability.
|Thus, some researchers have taken it upon themselves to develop
and/or improve the usability of exergaming technology. We found
that the studies in this review that described the development of new
exergaming technology were more likely to consider constructs from
the GameFlow model. Fitztgerald [51-52], O’Connor [53-55], Guo
, Lange  and Gil-Gomez and Gonzalez-Fernandez [45,58] are
all examples of such studies. Fitztgerald O’Connor and Guo developed
a technology platform that enabled wheelchair users to control the onscreen
action of several commercially developed video games with an
upper-body ergometer or wheelchair. The series of studies conducted
by this research group indicate that the Gamewheel and Gamecycle can
increase motivation to exercise and subsequently improve fitness levels
in adults who use wheelchairs. Gonzalez-Fernadez , Gil-Gomez
 and Lange  all developed Nintendo Wii exergames designed
specifically for use in people with disabilities and rehabilitation practice.
These studies focused on evaluating health outcomes and GameFlow
model constructs, and concluded that these developed exergames are
fun to play, improve health outcomes and can be incorporated into
rehabilitation practice. Because these researchers examined GameFlow
model constructs, they were able to modify and adapt it to the needs of
adults with disabilities.
|We note that although exergaming technology developed by
academic researchers may be able to address many of the problems with
commercially developed exergaming technology, questions still remain
as to whether it will be possible to widely disseminate this technology
. Researchers who have developed exergaming technology will
need to demonstrate that their technology is more cost-effective than
commercially developed technology and that the technology can be
widely disseminated to rehabilitation clinicians and their patients. It
seems that the best solution would consist of a partnership between
academia and video game corporations with the goal of developing
and distributing exergaming technology that meets the needs of
rehabilitation clinics and adults with disabilities.
|Potential Mechanisms of Action
|Few of the reviewed studies explored mechanisms of action
(i.e., why exergaming may be effective), which will be essential
for improving the usability and utility of exergaming technology.
Mechanisms of action need to be explored by experts in the field of
exercise physiology, behavioral science and neuromotor control. From
an exercise physiology perspective, research indicates that playing
commercially available exergames does not always meet recommended
intensity guidelines for moderate physical activity . However,
even light-intensity physical activity can result in some health benefits; particularly, in adults who are highly inactive, which is the
case with many adults with systemic disabling conditions [28,29,61].
Furthermore, Hurkmans [62,63] concluded that playing some Wii
Sports games can reach moderately intense levels of physical activity in
stroke survivors and adults with cerebral palsy. Further research should
identify the characteristics of low, moderate and vigorous exergames
so that a classification system can be developed to categorize newly
developed exergames. This will help clinicians decide which exergames
are most appropriate for their patients and negate the need to conduct
research every time a new exergame is developed.
|From a behavioral science perspective, it will be important to
utilize behavior change theories (e.g., Theory of Planned Behavior 
and Social Cognitive Theory ) and measure constructs from these
theories (e.g., self-efficacy, outcome expectations, social norms, past
experiences, etc.) to help determine why patients may or may not be
adherent to an exergaming program and whether there are particular
user characteristics that will make it more likely to be adherent to an
exergaming program. The assumption that exergaming will lead to
increased adherence because it is fun should be brought into question.
We found in our study involving the evaluation of Nintendo Wii Fit
in the home over a 14-week period that individuals with MS stopped
playing once the novelty wore off and contacts had ceased with the
patient. We concluded that the Nintendo Wii Fit does not appear to be
the “magic pill” to promote long-term participation in physical activity,
and that user characteristics (e.g., gender, race, disability level, past
experiences and attitudes towards video games) might influence the
types of exergames that patients like to play and the type of strategies
that should be implemented to promote adherence . A “one-sizefits-
all” approach to delivering exergaming interventions may result in
non-adherence. For example, not all research participants will find it
appealing to utilize only sports-related exergames. The incorporation of
behavioral change theories into exergaming research will help identify
moderates and mediators that will help guide the implementation of
strategies that take into account user-specific characteristics to promote
|From a neuromotor control perspective, we have noticed that many
rehabilitation professionals have speculated that exergaming will lead
to improvements in physical function because the repetitive motions
required to play the game will result in motor learning. However, this
hypothesized mechanism of action (i.e., repetitive motions) does little
to describe the full potential of exergaming to promote motor learning
and neuroplasticity . In a review article by Carey , it was argued
that motor learning and neuroplasticity is best achieved through
contextual interference (CI). CI can be defined as the degree to which
practice situations promote cognitive engagement . Cognitive
engagement is increased through the incorporation of multiple and
complex tasks that happen at random practice intervals  and may
not be optimized simply by repeated execution of a movement without
complex and adaptive motor planning [70,71]. Carey  suggest that
higher CI during practice situations might lead to a greater release of
neurotrophins that induce neuroplastic changes (e.g., synaptogenesis,
synaptic efficacy, neurogenesis, and cortical re-mapping [70-73].
Exergaming may be an ideal method to promote CI and neuroplasticity.
This is because exergaming may be able to achieve a high degree of CI
(through incorporation of random, complex and continually adaptive
training) while causing an up-regulation of neurotrophic factors (e.g.,
Brain-Derived Neurotrophic Factor) from being physically active
. Thus, measurement models need to be developed on how best
to detect neuroplastic changes during exergaming (e.g., whether
it be from Functional Magnetic Resonance Imaging, Transcranial Magnetic Stimulation, electroencephalography and/or blood draws
for neurotrophic compounds). Such measurement models will help
identify the most optimal exergaming experience to promote CI
and neuroplasticity. It is likely that exergaming that only requires an
individual to repetitively reach for an object will not achieve a high
degree of CI and, therefore, not utilize the full potential of exergaming
to promote motor learning and neuroplasticity.
|In terms of limitations of this review, we acknowledge that our
review, although very comprehensive, may not have included all
exergaming studies that met our criteria. However, the purpose of a
scoping review is to summarize the breadth of existing literature to
identify overall gaps rather than identify all pertinent studies like in a
systematic review of the literature. It would not have been meaningful
to calculate effect sizes due to heterogeneity in intervention outcomes
and the small number of participants in the clinical trials. Another
limitation to this review is its reproducibility. Because both the
User-Orientation Framework and GameFlow model are conceptual
frameworks, and the exclusion criteria of advanced robotic technology,
fully immersive virtual reality and affordable technology are relative
terms, others may have operationalized definitions differently, which
could have led to differences in the inclusion and coding of articles.
Lastly, we acknowledge that the User-Orientation Framework and
GameFlow model might not have been relevant to all studies included
in this review. However, we contend that to advance exergaming
research in adults with disabling conditions will require comprehensive
assessments on the utility and usability of exergaming technology,
which can be facilitated with the frameworks/models used in this
|Advances in exergaming technology will unquestionably outpace
academic research on examining the utility and usability of exergaming.
Therefore, research that is generalizable across different exergaming
technology and/or can account for advances in exergaming technology
will have the greatest potential to advance existing knowledge and
generate evidence-based practice guidelines. It is encouraging to
note that only a few studies reported adverse events and that most
studies reported that patients generally liked to engage in exergaming.
However, these findings need to be confirmed with additional research.
We recommend that randomized controlled trials be conducted with
a long-term follow-up that employs a mixed-methods approach (i.e.,
collect both quantitative and qualitative data) to collecting data. To help
ensure the ecological-validity of the study, the control group should
receive a traditional exercise program and the study should follow
patients from the clinical setting into the home setting. Furthermore,
we recommend a multidisciplinary approach, which includes exercise
physiology, behavioral science and neuromotor control, to identify
possible mechanisms of action, who (i.e., user characteristics) will
benefit the most from an exergaming rehabilitation program, and
which types of exergames are most efficient in promoting motor
learning and fitness.
|This publication was made possible by the Case Western Reserve University/
Cleveland Clinic CTSA Grant Number UL1 RR024989 from the National Center
for Research Resources (NCRR), a component of the National Institutes of Health
and NIH roadmap for Medical Research. Its contents are solely the responsibility
of the authors and do not necessarily represent the official view of NCRR or NIH.”
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