A O o D P B M o R ( T s C E © K I t b i w c 7 ( i m m 0 h Physiotherapy 98 (2012) 205–210 Active video games as a form of exercise and the effect of gaming experience: a preliminary study in healthy young adults� C. O’Donovan ∗, J. Hussey Discipline of Physiotherapy, School of Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin 8, Ireland bstract bjectives To examine the energy expenditure and heart rate response while playing active video games, and the effect of gaming experience n energy expenditure. esign Cross-sectional study. articipants and interventions Twenty-eight healthy participants (18 male, age 19 to 27 years) played either Wii Sports Boxing, Tennis and aseball, or Wii Sports Boxing and Wii Fit Free Jogging. ain outcome measures Percentage maximal heart rate (%HRmax) and metabolic equivalents (METs) were measured during 15 minutes f rest and during each game. esults Mean %HRmax and METs while playing each of the four games were as follows: Wii Fit Free Jogging 71% [standard deviation SD) 13%], 5.9 (SD 1.8); Wii Sports Boxing 58% (SD 13%), 3.2 (SD 1.1); Wii Sports Baseball 42% (SD 6%), 2.0 (SD 0.5); and Wii Sports ennis 42% (SD 7%), 2.0 (SD 0.4). Subjects with gaming experience achieved a lower heart rate playing Wii Sports Tennis compared with ubjects without gaming experience. onclusions Wii Sports Boxing, Tennis and Baseball are light-intensity activities, and Wii Fit Free Jogging is a moderate-intensity activity. xperience of gaming may affect the exercise intensity of games requiring controller skill. 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. eywords: Video games; Energy metabolism; Metabolic equivalent p t a c p t t s J w ntroduction Physical activity is a major factor in the prevention and reatment of obesity, cardiovascular disease and other mor- idities [1]. It is recommended that adults should participate n at least 30 minutes of moderate activity at least 5 days per eek [1]. For healthy young adults, moderate-intensity exer- ise is that which results in an energy expenditure of 4.8 to .1 metabolic equivalents (METs), or a maximal heart rate %HRmax) of 64% to 76% [1]. Examples of moderate activ- ty for young adults include walking for exercise, dancing or owing the lawn [2]. Activity levels have been shown to decline below recom- ended levels in early adulthood [3]. Watching television and � This paper is based on a paper presented at WCPT in Amsterdam 2011. ∗ Corresponding author. Tel.: +353 (0)1 8963613; fax: +353 (0)1 453 1915. E-mail address: odonovc@tcd.ie (C. O’Donovan). m i c s p t 031-9406/$ – see front matter © 2012 Chartered Society of Physiotherapy. Publis ttp://dx.doi.org/10.1016/j.physio.2012.05.001 laying computer and video games are thought to contribute o sedentary behaviour in adults [4]. However, video games ppeal to young adults [5] and their use is increasing [6]. With the development of active video games (AVGs), omputer gaming has the potential to become a more active astime [7]. An AVG, or interactive game, is defined as elec- ronic media that allows players to actively interface with he game by physical manipulation of equipment [8]. One uch AVG console is the WiiTM (Nintendo Co Ltd., Tokyo, apan). The Wii is primarily operated through a handheld ireless controller (Wii RemoteTM). Players simulate move- ents with this controller, and the on-screen character moves n the same way. This allows players to move freely while ontrolling characters as they engage in activities such as winging a racket. Theoretically, if the exercise intensity reached while laying the Wii is moderate, such participation may con- ribute to the achievement of physical activity guidelines [1]. hed by Elsevier Ltd. All rights reserved. dx.doi.org/10.1016/j.physio.2012.05.001 mailto:odonovc@tcd.ie dx.doi.org/10.1016/j.physio.2012.05.001 2 Physiot F g e i S t p a M g t i u m r b a m p s e m u t a B s H l p l i F p c t a u q a t [ a M r s a p e h n T F [ p a o u t e t w e e p b w l b f e h t [ a o h t g e r M R y n d 3 c p o i a p p S 06 C. O’Donovan, J. Hussey / urthermore, the visual and auditory stimulation from these ames may provide augmented feedback which can be an ffective addition to exercise therapy [9]. A number of studies have investigated the exercise ntensity associated with playing the Wii [5,10–16]. Wii ports is the most common Wii game as it is provided with he console when purchased. Several simulations can be layed on Wii Sports, including baseball, golf and bowling, ll which result in energy expenditure of just below 3 ETs; these are generally considered to be light-intensity ames [13,14,16]. Although studies have consistently shown hat Wii Sports Boxing (hereinafter known as ‘Boxing’) s the most active of the Wii Sports simulations, there is ncertainty about whether or not it can be considered a oderate-intensity activity. Some studies found that Boxing equired a higher or comparable energy expenditure to risk walking [11,12,17], while others [13,14] reported it s a light-intensity activity. Differences in methodologies ay explain the variations between studies. The study opulations varied from children [14] to adults [16], and ome studies used electronic devices to estimate energy xpenditure [13] while others used indirect calorimetry [14]. AVGs that require whole body movement are likely to be ore metabolically demanding than AVGs that only require pper body movement [19]. Wii FitTM is a game designed o incorporate lower limb movement. Many Wii Fit games re played using a pressure sensitive platform (Wii Balance oardTM). On-screen characters can be controlled by players hifting their body weight while standing on this platform. owever, it is not capable of supporting the weight of a human anding on it with momentum, and therefore it is not used to lay Wii Fit Jogging. Players’ movements for jogging simu- ations are detected through the Wii Remote, which is placed n the player’s pocket while they jog. There are four choices of jogging simulations on the Wii it Plus game. Basic Jogging and Jogging Plus are computer- aced games, 2P Wii Jogging allows two players’ on-screen haracters to jog through the same virtual landscape simul- aneously, and Free Jogging is paced by the player and lasts set time of either 10 or 20 minutes. Wii Fit Free Jogging is nique among Wii simulations in that it has both the desired ualities of being continuous for a minimum of 10 minutes, nd necessitates whole body movement. To the authors’ knowledge, three studies have examined he energy expenditure associated with playing Wii Fit games 5,10,16], but none of them used Wii Fit Free Jogging. Miy- chi et al. reported energy expenditure of 5.1 METs and 4.0 ETs during Wii Fit Plus Basic Jogging and Jogging Plus, espectively, in healthy adults aged 25 to 44 years [16]. As uch, these games were considered to be moderate-intensity ctivities in this population [16]. These jogging games were aced by a computer-generated guide. Graves et al. [5] and Guderian et al. [10] examined the nergy expenditure associated with playing Wii Fit games; owever, they grouped different simulations together and did ot report the energy expenditure for individual simulations. t p t herapy 98 (2012) 205–210 he combined mean energy expenditure for playing six Wii it games among middle-aged and older adults was 3.5 METs 10]. Similarly, the combined mean energy expenditure for laying Wii Fit Hula Hoop, step aerobics and jogging games mong young adults was 3.6 METs [5]. Another limitation f these studies was that the trial versions of the games were sed, which are shorter and require a lower level of skill than he full versions. It is not clear whether gaming experience is related to nergy expenditure when playing AVGs. Sell et al. found hat players with gaming experience expended more energy hen playing AVGs compared with those without gaming xperience [18]. However, some researchers believe that xperienced players may adapt their movement patterns while laying to conserve energy [19]. Video games can be played at different levels, either y selection or progress. A methodological difficulty arises hen comparing energy expenditure across computer game evels, as these levels can lead to the playing experience eing inherently different. A game that is paced by the player rom the beginning is therefore preferable when comparing xperienced gamers with inexperienced gamers. Research as shown that when children had the opportunity to modify he intensity of an AVG, they accrued more physical activity 8]. No studies examining the exercise intensity reached by dults playing the Wii have investigated the possible effect f gaming experience on energy expenditure. This study aimed to examine the energy expenditure and eart rate response while playing four Wii simulations, and o compare these results with moderate-intensity exercise uidelines [1]. In addition, the effect of gaming experience on nergy expenditure while playing AVGs of different energy equirements was examined. ethods ecruitment and design Twenty-eight young non-smoking adults (mean age 22 ears, 18 male) were recruited through posters on university otice boards. Those with a history of cardiac or respiratory isease, musculoskeletal injury, low back pain in the previous months, taking prescribed medication other than the oral ontraceptive pill, and pregnant women were excluded from articipation. All testing took place in the exercise laboratory f the Trinity Centre for Health Sciences, Dublin. Written nformed consent was received from all participants. Participants were divided into a Wii Sports group (n = 12) nd a Wii Fit group (n = 16). All Wii Sports simulations were layed at the most basic level. Participants in both groups layed Boxing. Those in the Wii Sports group also played Wii ports Baseball and Wii Sports Tennis (hereinafter referred o as ‘Baseball’ and ‘Tennis’). Those in the Wii Fit group also layed self-paced Wii Fit Free Jogging (hereinafter referred o as ‘Jogging’). Physiotherapy 98 (2012) 205–210 207 P f n t W b G t t m a H F v t w T 1 d t b m o o p h h e D o t B a P o i c p t t t a 1 m w p t i Table 1 Participants’ characteristics. Group Wii Sports, n = 12, 8 male Wii Fit, n = 16, 10 male Age (years) 23 (1) 22 (3) Height (cm) 178 (8) 180 (6) Weight (kg) 73.0 (7.0) 75.1 (10.8) Body mass index (kg/m2) 23.2 (1.8) 23.1 (2.8) Experienced gamers 5, all male 5, all male D S i 1 s i 2 t H e l u d K I o n e m i l w c G R r e i m k c n q f C. O’Donovan, J. Hussey / rotocol On arrival at the laboratory, participants, who had fasted or 3 hours, completed a physical activity readiness question- aire [20]. Height was measured with a Seca stadiometer o the nearest 1 cm (Seca Mod 220, Hamburg, Germany). eight (shoes removed) was measured with a Seca balance eam scale to the nearest 0.1 kg (Seca Mod 220, Hamburg, ermany). The familiarisation period included a demonstra- ion of Wii use, but the participants were not permitted to play he games as this could have affected their subsequent perfor- ance. Participants were fitted with a face mask, which was ttached to the Oxycon Mobile (Jaeger, Viasys Healthcare, oechberg, Germany), and a Polar heart rate monitor (Polar S1 fitness, Kempele, Finland). The Oxycon Mobile is a alid and reliable [21] lightweight portable indirect calorime- er. Oxygen consumption (VO2), energy expenditure and HR ere measured during supine rest and while playing AVGs. he game order was randomised. Each game was played for 5 minutes with a 5-minute seated rest between games. A uration of 15 minutes was chosen to allow energy expendi- ure to reach a steady state. Little research has been undertaken on the time required to ecome skilled at playing computer games requiring move- ent and coordination. Research has shown that 30 minutes f computer simulation practice improves the performance f participants performing simulated surgery [22]. Therefore, articipants were considered to be experienced gamers if they ad previously played all the Wii simulations in this study, or ad played any of these simulations for an accumulated time xceeding 30 minutes. etails on AVGs Tennis is a doubles game. Participants have no control ver where their on-screen characters move on court, con- rolling only when and how characters swing their rackets. aseball involves a team of virtual players that compete in three-innings game against a computer-controlled team. layers control batting and pitching, but do not control utfielders, infielders or runners, who run automatically. Box- ng consists of three 1-minute rounds, unless an on-screen haracter is knocked out. Players control their characters’ unches by simulating punching movements while holding he Wii Remote in their hand. In all Wii Sports simula- ions, the duration varies depending on the player’s ability o score points. Participants were asked to choose to play gain after each game until they had played for a total of 5 minutes. Jogging involves jogging on the spot. The player’s move- ents are detected by the console through the Wii Remote hich, to standardise its position, was kept in a small back- ack worn by participants. When small quick steps are taken, he on-screen character falls over; therefore, participants were nstructed not to shuffle their feet. a e g ( ata presented as mean (standard deviation). tatistical analysis METs were calculated as gaming VO2 divided by rest- ng VO2. VO2 and HR were averaged over minutes 9 to 4 for each condition. Energy expenditure in joules was ummed for the entire 15 minutes of each condition. Partic- pants’ age-related predicted maximal HR was calculated as 08 − (0.7 × age) [23]. Single sample t-tests were conducted o investigate whether energy expenditure and maximum R differed significantly from recommendations for mod- rate activity [1]. Differences between groups, sexes and evel of gaming experience within groups were assessed sing repeated measures analysis of variance and indepen- ent t-tests. Data were checked for normality using the olmogorov–Smirnov test. JMP Version 7.0.1 (SAS Institute nc. North Carolina, USA) was used to analyse the results. For a power of 0.95 with alpha set at 0.05, an a pri- ri power calculation revealed that eight participants were eeded in each group to adequately compare the METs xpended during Boxing with the minimal accepted require- ent for moderate activity (4.8 METs). To detect differences n VO2 between experienced and inexperienced gamers, at east five participants with experience and five participants ithout experience were required in each group. Power cal- ulations were performed using G*Power Version 3.1.2 (Kiel, ermany). esults There were no significant differences in anthropomet- ic variables between sexes, groups and level of gaming xperience. Data were therefore pooled for sex and gam- ng experience (Table 1). Five participants in each group (all ale) were considered to be experienced gamers. Data were normally distributed, with the exception of ilojoules expended when playing Baseball and Tennis. A ommon outlier was found for these variables. Laboratory otes recorded during testing reported that the participant in uestion felt ‘uncomfortable and claustrophobic’ wearing the ace mask. Data pertaining to this outlier were excluded in ll subsequent analyses. As there were no significant differ- nces in cardiovascular responses to rest or Boxing between roups, combined data are presented for these conditions Table 2). 208 C. O’Donovan, J. Hussey / Physiotherapy 98 (2012) 205–210 Table 2 Cardiovascular response to rest and active video game play. Condition (group) Heart rate (beats/minute) %HRmax Oxygen consumption (ml/minute kg) Energy expenditure (kJ/15 minutes) n Rest (both) 59.9 (10.9) n/a 4.3 (0.9) 94.7 (19.1) 27 Boxing (both) 112.4 (24.4) 58 (13) 13.5 (4.1) 305.5 (96.5) 27 Tennis (Wii Sports) 79.9 (12.8)a 42 (7)a 7.7 (1.6) 171.9 (27.3) 11 Baseball (Wii Sports) 80.4 (11.3) 42 (6) 8.0 (2.4) 179.0 (50.5) 11 Jogging (Wii Fit) 137.7 (24.9) 71 (13) 25.7 (5.5) 594.2 (155.1) 16 D imum h B f t 1 c w i % i d g b r e i g p u B a s n B a w a p i ( T F ata presented as mean (standard deviation). %HRmax, percentage of max a Significant difference between experienced and inexperienced gamers. Mean %HRmax reached playing Baseball, Tennis and oxing were significantly lower than the accepted description or moderate activity (>64%) [1]. When engaging in Jogging, he participants reached a moderate %HRmax [mean 71 (SD 3)%; Table 2]. METs reached while playing AVGs are presented graphi- ally in Fig. 1. The mean METs playing Tennis and Baseball ere in the very-light-intensity range. Mean MET levels dur- ng Boxing were in the light-intensity range [1]. Similar to HRmax results, MET values recorded during Jogging were n the moderate-intensity range. A significant difference was found between gaming con- itions for both groups (F = 4.45, P = 0.002 for Wii Sports roup; F = 18.38, P < 0.001 for Wii Fit group). Interactions etween gaming condition, sex and previous gaming expe- ience were all non-significant. Tests of between-subject ffects revealed no significant effect for sex or previous gam- ng experience; the interaction between sex and previous aming experience was not conducted as all participants with revious gaming experience were male. Post-hoc analysis D w ig. 1. Energy expenditure while playing active video games in metabolic equivalen eart rate; n/a, not applicable. sing Bonferonni’s correction factor revealed that playing oxing resulted in significantly higher responses for all vari- bles measured compared with both Tennis and Baseball imulations (P < 0.05). Similarly, Jogging resulted in sig- ificantly higher responses for all variables measured than oxing (P < 0.05). As this was a preliminary study, independent t-tests were lso performed to gain further insight into the results. Results ere similar to those reported from the repeated-measures nalysis. However, %HRmax and HR reached by experienced layers (37%, 72 beats/minute) during Tennis were signif- cantly lower than those reached by inexperienced players 45%, 86 beats/minute; P = 0.038 and P = 0.036, respectively; able 2). iscussion For any exercise prescription, the FITT principles apply, hereby there is a need to determine the frequency, intensity, ts (METs). Exercise intensity guidelines are shown. CI, confidence interval. Physiot t w c i e u s A n m f l m J d % i p e e i r n t t p t g b e a 3 b e e v [ m h t w s c p b a m a d i t a t A a o a n T b b 2 X t t w w A w t t e e n t t f l A e t p d r C i t w p W e t C. O’Donovan, J. Hussey / ime and type of exercise. It is not possible to prescribe AVGs ithout knowledge of their exercise intensity. For AVGs to ontribute towards an individual’s daily recommended activ- ty, they must require appropriate HRs or levels of energy xpenditure [1]. Energy expenditure and HR while playing Wii Sports sim- lations were comparable with those obtained in previous tudies, and add to the body of knowledge in this area [5,16]. s Wii Sports simulations were of a light intensity, they can- ot be advocated as partial fulfilment of the 30 minutes of oderate-intensity activity recommended on 5 days per week or young adults. This is the first study to examine the cardiovascu- ar response to Jogging. Participants consistently reached oderate-intensity HR and MET values while playing ogging, which may be considered as part of an adult’s aily recommended physical activity. Furthermore, the mean HRmax approached levels where, theoretically, an increase n cardiovascular fitness could be achieved with continuous lay [1]. To the authors’ knowledge, this is higher than the nergy requirements of any other AVG. Although continuous whole body movement would be xpected to result in high energy expenditure and HR, the ntensity of Jogging was surprisingly high, with one player eaching %HRmax of 88%. There are several potential expla- ations for this. Firstly, although it is not a competitive game, here are on-screen characters that the player can overtake if hey increase their step rate. This may have motivated some layers. Secondly, as most people would not be accustomed o jogging on the spot, this movement may have required reater energy expenditure than expected. An energy expenditure of approximately 1255 kJ/day has een shown to be effective for weight loss [29]. Provided nergy intake remained constant, substituting a sedentary ctivity for Jogging would achieve this goal in approximately 2 minutes. Although engaging in Wii Sports games may not e prescribed as a means of obtaining moderate-intensity xercise, the benefits of light exercise should be acknowl- dged [24]. If playing computer games is already part of an indi- idual’s lifestyle, which is the case for many young adults 6], converting screen time to exercise could be an effective eans of introducing exercise into daily life [24]. Studies ave shown that the use of AVGs to reduce sedentary screen ime has proven successful [25,26]. It has been shown that atching television can contribute to adiposity by increasing nacking [4], so playing AVGs instead of watching television ould reduce this behaviour. In order to improve or maintain cardiovascular fitness, hysical activity of any type, including playing AVGs, must e performed on a regular basis. Interventional studies on dults have shown that the addition of an interactive ele- ent to an exercise programme has beneficial effects on ttendance, adherence and risk factors associated with car- iovascular disease [27,28]. As this study was cross-sectional n nature, this was not examined. a a m t herapy 98 (2012) 205–210 209 Sex has been shown to have an effect on energy expendi- ure while playing AVGs among children [8,13,15] but not dults [12,16]. In this study, no significant difference between he sexes was found in the cardiovascular response to playing VGs. The lack of a relationship between gaming experience nd the energy cost of playing AVGs is consistent with ther studies [14,15]. It is hypothesised that the lower HR nd %HRmax seen among experienced gamers playing Ten- is may have been due to more efficient controller skill. ennis requires more controller skill than Boxing, Base- all or Jogging as the players are required to alternate etween controlling two on-screen characters rapidly. In 010, Microsoft released a controller-free AVG console: the box KinectTM. When playing an AVG on this console, con- roller skill would not be a confounding variable. Research on he potential use of the Xbox Kinect as a form of exercise is arranted. Interestingly, no difference was found between subjects ith and without gaming experience playing a self-paced VG (Jogging). A limitation is that only one self-paced game as examined. Furthermore, no controller skill was needed o play Jogging. It is hypothesised that games requiring con- roller skill may be more useful in exposing differences in nergy expenditure between those with and without gaming xperience. Having two groups, such that all of the participants did ot play all of the games, could be viewed as a limita- ion. This design reflects the fact that two separate studies ook place that were similar in nature, and were there- ore analysed and reported as one preliminary study. Other imitations are that the criteria for being an experienced VG player were basic, and participants’ fitness was not xamined. All measurements were taken by the same investiga- or, who was not blinded. However, to minimise bias, articipants were not encouraged, instructions were stan- ardised, and the indirect calorimeter used was valid and eliable. onclusions To the authors’ knowledge, this is the first study to exam- ne the energy requirements of a self-paced Wii game without ransition periods. It is also the first study to investigate hether gaming experience affects energy expenditure while laying Wii games. The results of this study can guide the clinical use of the ii, and inform its prescription. The Wii may be useful to ncourage sedentary adults who enjoy playing video games o become more active. Tennis and Baseball were classed s very-light-intensity activities, and Boxing was classed as light-intensity activity. Finally, Jogging was classed as a oderate-intensity activity and should be encouraged for hose wishing to use AVGs to contribute to their daily activity 2 Physiot r n o a a w E m F T m C R [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ 10 C. O’Donovan, J. Hussey / ecommendations. This simulation may represent a welcome, ovel method of exercising. AVGs should be encouraged ver sedentary activities, but should not replace more intense ctivities such as sports. Neither sex nor gaming experience ppeared to have a significant effect on energy expenditure hile playing AVGs. thical approval: Faculty of Health Sciences Ethics Com- ittee, Trinity College Dublin, Ireland. unding: Irish Research Council for Science Engineering and echnology (Grant G30372). 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Med Sci Sports Exerc 2001;33: S521–7. ciencedirect.com http://www.sciencedirect.com/science/journal/00319406 Active video games as a form of exercise and the effect of gaming experience: a preliminary study in healthy young adults Introduction Methods Recruitment and design Protocol Details on AVGs Statistical analysis Results Discussion Conclusions References