Posts Tagged Exergames

[Abstract] Exergames in people with major neurocognitive disorder: a systematic review


To systematically evaluate the efficacy of exergames in individuals with major neurocognitive disorder.

Materials and methods

PubMed, EMBASE and PEDro were systematically searched from inception until October 2019 for randomised and clinical controlled trials. Methodological quality of the trials was assessed with the PEDro rating scale or Risk of Bias in Nonrandomised Studies of Interventions-I (ROBINS-I), when appropriate. Grading of Recommendations Assessments, Development and Evaluation (GRADE) was used to assess the overall quality of the evidence.


Eight trials, all of moderate to high methodological quality (i.e., PEDro score of 6 or higher or a Robins-I moderate quality score) were included. The overall quality of evidence was moderate to high according to the GRADE criteria. Improvements in gait, mobility and balance and beneficial effects on activities of daily living performance, cognitive function, fear of falls, quality of life and mood following exergaming were reported. Heterogeneity in outcome measures, intervention characteristics and included participants precluded a meta-analysis.


The current literature is of moderate to high quality and demonstrates that exergames have a wide range of physical and mental benefits in people with major neurocognitive disorder. More controlled trials are however needed to confirm the existing evidence before exergames can be recommended in treatment guidelines for people with major neurocognitive disorder.

Implications for rehabilitation

  • Exergames have many physical and mental benefits in people with major neurocognitive disorder

  • Exergaming can enhance gait, mobility and balance in people with major neurocognitive disorder

  • Evidence for beneficial cognitive effects of exergaming is emerging

via Exergames in people with major neurocognitive disorder: a systematic review: Disability and Rehabilitation: Assistive Technology: Vol 0, No 0

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[PhD Thesis] The Design Of Exergaming Systems For Autonomous Rehabilitation

A PhD thesis by Michele Pirovano (Politecnico di Milano, Italy), studying the feasibility of at-home rehabilitation using exergames for stroke patients. It includes the results of a 3-months pilot test using an original exergaming system developed by the author.

Download the thesis for free at

via PhD Thesis: The Design Of Exergaming Systems For Autonomous Rehabilitation – Gabriele Ferri’s research blog

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[ARTICLE] Does a novel exergame challenge balance and activate muscles more than existing off-the-shelf exergames? – Full Text



Novel balance-targeting exergames controlled with off-the-shelf hardware, were developed based on current recommendations for balance training in healthy older adults and documented shortcomings of existing games. The aim of this study was to explore the feasibility of these novel exergames as training tool for elderly and, more specifically whether these games can elicit more challenging weight shifts and higher levels of muscle activity compared to existing off-the-shelf exergames. Furthermore, the motivational pull in these new games was studied.


Sixteen healthy older adults were recruited to play the novel games and two reference games that were found to be the most challenging ones in terms of weight shifts or muscle activity in previous studies. Weight shifts were expressed relative to participants’ Functional Limits of Stability (FLOS). Muscular challenge of the games was quantified by dividing the signal into 200 ms blocks and determining the average muscle activity within these blocks. The muscle activity was normalized to maximal voluntary contractions (MVC) to categorize the blocks in zones of < 40, 40–60, 60–80 and > 80% MVC. Subsequently, the number of blocks per intensity level and the number of consecutive blocks above 40% were determined. Motivation to play the games was assessed using the Intrinsic Motivation Inventory (IMI) and scores between the games were analyzed using Generalized Estimated Equations (GEE).


The novel exergames successfully elicited center of mass (COM) displacements with medians of around 80% of FLOS or higher for all directions. Furthermore, the COM displacements in the novel games were larger for each direction than in the reference games, although for one game the sideward left direction reached significance only at the third trial. Compared to the existing games, longer blocks of muscle activation above 40% MVC were found, but overall intensity remained low. IMI scores were high on all subscales, indicating that older adults experienced the games as motivating.


We conclude that affordable hardware can be used to create challenging and enjoyable balance training programs using exergames. The exergames that were successful in eliciting challenging weight shifts and muscle activity should now be further studied in longitudinal randomized controlled interventions, to assess effects on balance, muscle strength and eventually fall risk in healthy older adults.


Studies report that 30–40% of people older than 65 will fall at least once per year and about 10–20% of these falls will result in hospitalization [12]. The number of people aged 65 and older will increase due to the demographic developments worldwide, which will further increase the total number of falls [3]. Major risk factors for falling are an age-related decrease in functional capabilities, especially in balance control and muscle strength [45]. Multidimensional training programs have been shown to ameliorate these risk factors and reduce fall risk in older adults. This is especially the case when strength training and sufficiently challenging balance exercises are provided for at least 3 h per week [1267]. However, ongoing participation in a training program is needed to prevent fading of the benefits due to the progressive strength and balance decline caused by aging [26]. As long-term, structural supervised training is costly, home-based training appears most promising for long-term effects. Sadly, adherence to traditional home-based training programs is low due to the repetitive nature of the exercises, lack of perceived usefulness and therefore motivation [89].

The use of computer games to aid in balance training for older adults, also called exergames balance training, receives increasing attention [10,11,12]. In this study, exergames are defined as computer games using commercial consoles as the Wii and the Kinect console and that are controlled with body movements. Different commercial games are already available that might have a balance training potential [10,11,12]. Potential benefits of exergames over conventional training are: an increase in motivation and thereby adherence [13], the option to offer dual task training [14], the option to provide different forms of feedback [15] and to adapt the training intensity to the skill level of the player so that individualized progression is possible. However, the latter is not always possible in commercial games. Despite these promising features, systematic reviews report varying results on balance [10,11,12], possibly due to the wide variability in games that have been studied and the fact that these games were not specifically developed with the aim to improve balance in older adults. In conventional balance training, strength and specific balance training were shown to be key elements in preventing falls [261617]. It is recommended that balance training is sufficiently challenging by requiring weight-shifts to the limits of stability, by reducingthe base of support (BOS) [6], or by adding a cognitive task. For strength training, it is recommended in literature that the muscles are sufficiently challenged by increasing the intensity of the exercises or the number of repetitions, so that the muscles will fatigue [18]. The American College of Sports Medicine defined the threshold for hypertrophy and strength gains to be 60% of the one-repetition maximum [19]. However, exercises with external weights are unpractical in VR training, which is often performed at home. Recent research showed that strength exercises at low loads, but with high velocities, can induce muscle activations comparable to training with high loads [20]. Furthermore, these low-load exercises also seem to induce benefits for strength and balance in older adults [21]. Finally, ongoing participation in the training program is recommended to prevent fading of the gained benefits [6]. A study that analysed the challenge of balance provided by off-the-shelf games showed that balance is challenged to a varying extent, but that ample room for improvements is left. Moreover, it was found that adaptation to or learning the game, as trials advanced, resulted in a decreasing challenge in some games [2223]. From the analysis of muscle activity in seven off-the shelf games, it was concluded that overall muscle activation was low and that longer periods of muscle activation were scarce [24]. Only the games that required faster movements elicited some muscle activity that seemed challenging enough to be considered as a training impulse [24].

The motivational pull of exergame balance training with off-the-shelf games, was assessed in older adults and results showed that playing exergames can lead to strong intrinsic motivation [25]. Especially games that provide positive feedback resulted in high intrinsic motivation. Furthermore, physically active games containing variation seemed to be the preferred game mechanics [25].

Based on the above summarized recommendations for balance training (e.g. sufficiently challenging balance tasks and strength exercises that lead to muscle fatigue), an exergame package for balance training for older adults was developed [246]. The aim of the current study was to evaluate whether the novel set of exergames (called Virbal), which are controlled with off-the-toy-shelf technologies, are feasible and well-suited from a content perspective for balance training in elderly. The novel games were evaluated to see whether they were more challenging in terms of balance movements and muscle activity than existing off-the shelf games. Furthermore, the novel exergames were evaluated on how motivating they are for older adults. Games were compared regarding the challenge imposed to balance in terms of magnitude of center of mass (COM) displacements and regarding the muscle activation elicited in terms of intensity and duration of muscle activation. Motivation was evaluated using questionnaires on motivation.



via Does a novel exergame challenge balance and activate muscles more than existing off-the-shelf exergames? | Journal of NeuroEngineering and Rehabilitation | Full Text


Screenshots of the mini games of the Virbal game. The overarching game is presented in the middle. From this overarching game different mini games are chosen

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[ARTICLE] Feasibility, Safety and Efficacy of a Virtual Reality Exergame System to Supplement Upper Extremity Rehabilitation Post-Stroke: A Pilot Randomized Clinical Trial and Proof of Principle – Full Text


(1) Background: Increasing the amount of therapy time has been shown to improve motor function in stroke survivors. However, it is often not possible to increase the amount of therapy time provided in the current one-on-one therapy models. Rehabilitation-based virtual reality exergame systems, such as Jintronix, can be offered to stroke survivors as an adjunct to traditional therapy. The goal of this study was to examine the safety and feasibility of providing additional therapy using an exergame system and assess its preliminary clinical efficacy.
(2) Methods: Stroke survivors receiving outpatient rehabilitation services participated in this pilot randomized control trial in which the intervention group received 4 weeks of exergaming sessions in addition to traditional therapy sessions.
(3) Results: Nine subjects in the intervention and nine subjects in the control group completed the study. The intervention group had at least two extra sessions per week, with an average duration of 44 min per session and no serious adverse events (falls, dizziness, or pain). The efficacy measures showed statistically meaningful improvements in the activities of daily living measures (i.e., MAL-QOM (motor activity log-quality of movement) and both mobility and physical domains of the SIS (stroke impact scale) with mean difference of 1.0%, 5.5%, and 6.7% between the intervention and control group, respectively) at post-intervention.
(4) Conclusion: Using virtual reality exergaming technology as an adjunct to traditional therapy is feasible and safe in post-stroke rehabilitation and may be beneficial to upper extremity functional recovery.

1. Introduction

Hemiplegia, weakness of one side of the body, is a common consequence of stroke that can lead to significant functional impairments, including loss of arm function that occurs in up to 85% of stroke survivors [1]. The impact of arm-related limitations on activities of daily living, leisure activities, or work is significant as the arm plays a central role in a person’s life from the ability to perform basic activities of daily life to carrying out family and social roles. Guidelines indicate that rehabilitation can improve upper extremity (UE) motor control and functional status post-stroke [2]. Intense and repetitive training post-stroke is widely recognized as being essential to maximize recovery and promote plasticity in the central nervous system [2,3,4,5,6]. However, in reality, the feasibility of providing intensive rehabilitation may be limited in a rehabilitation setting by a lack of resources or motivation from the patient [7]. Furthermore, stroke survivors discharged from acute care receive physical and occupational therapy services primarily in rehabilitation centers, on an in- and out-patient basis or at home, but budgetary constraints and shortage of specialized health care professionals limit accessibility to much needed rehabilitation services.
New models of service delivery and maximizing the use of existing resources are therefore essential. With the emergence of interactive technologies or “gamified” products, innovative treatment strategies are being developed. Virtual reality (VR) and computer games are recent technologies that, as they become more accessible and affordable [8], are increasingly being used in rehabilitation to allow patients to engage in repetitive practice of specific tasks. The so-called exergames or exergaming reflect the idea of exercising through computer games. A number of published reviews and meta-analyses have examined the use of VR and video games for post-stroke rehabilitation, focusing on or including UE rehabilitation [3,4,6,8,9,10,11].
Saposnik and his colleagues [9] examined the effectiveness of rehabilitation using VR on UE motor function post-stroke in a meta-analysis study. In total, 11 of the 12 included studies (5 randomized controlled trials and 7 pre-post interventions) showed a benefit on the primary outcome, with the pooled randomized controlled trials showing a 4.9 higher chance of improvement in motor impairment when VR was used in comparison to control. Similarly, another meta-analysis study included a subgroup of studies related to UE function [6] and showed that VR had a significant effect on arm function (seven studies) and activities of daily living (ADL) (three studies) in comparison to control groups. The updated Cochrane Review of the meta-analysis concluded that virtual reality has a statistically significant effect on upper limb function (based on 12 studies) and ADL outcome (based on 8 studies) [12]. Another meta-analysis looked at the effect of virtual environments and commercial games on each category of the International Classification of Function, Disability, and Health (ICF), i.e., body function, activity, and participation, in post-stroke rehabilitation [11]. The authors reported that there was a significant effect of using virtual environments in improving all three ICF categories and that these outcome improvements by VR rehabilitation are moderately higher than conventional therapy [11]. However, there is still insufficient evidence regarding the best dose of therapy, timing, and types of programs. In addition, few studies report the users’ perception of these technologies, for both patients and therapists, although Lange and her colleagues [4] discussed the importance of activity enjoyment in their review. Celinder and Peoples [13] studied patients’ experiences through interviews and observation of patients using the Wii Sports for in-patient rehabilitation post-stroke. Most patients reported that the Wii provides them with variety, more stimulation, and more meaningful activities in their rehabilitation. Overall, studies agree that there is limited but promising findings that VR and video games, when combined with conventional rehabilitation, have a positive impact on recovery post-stroke. Furthermore, the literature in the field of technology adoption suggests that the user’s perception plays an important role in the actual use of the technology [14].
The Jintronix system (Jintronix Inc.,, based on the Microsoft Kinect technology, is one such product that allows patients who have had a stroke to train UE movements independently using challenging and engaging programs tailored to their level of ability. This exergame system allows therapists to objectively track patients’ activities during their recovery process and to adjust, as required, the training program. Graded tasks that challenge and provide feedback to the patient can optimize motor learning [2,15]; this system has embedded this concept in their exergames. In addition, eventually, the tracking functionality that the exergame system offers could allow patients to train without direct therapist supervision, thereby offering interesting opportunities for increased dosage of in-clinic rehabilitation as well as for home-based tele-rehabilitation. In other words, following a stroke, people could participate in a more intensive rehabilitation training without increasing staffing. That being said, prior to using this exergame system in a clinical setting when used as an adjunct to conventional therapy, its feasibility, safety, and efficacy must be assessed.
The goals of this pilot study were to assess the feasibility and safety of the rehabilitation exergaming system and to provide preliminary evidence regarding its clinical efficacy for UE functional recovery post-stroke as a supplement to conventional rehabilitation services, as proposed by Saposnik and colleagues [9]. The results of this study will serve as a basis for a larger multicenter trial, in order to determine the effectiveness of exergame systems as a supplement to UE therapy post-stroke.[…]

Continue —->  IJERPH | Free Full-Text | Feasibility, Safety and Efficacy of a Virtual Reality Exergame System to Supplement Upper Extremity Rehabilitation Post-Stroke: A Pilot Randomized Clinical Trial and Proof of Principle | HTML

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Figure 1. The Jintronix rehabilitation exergaming system.


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To analyze the literature on the effectiveness of exergames in physical education classes and in the acquisition and development of motor skills and abilities.

Data source:

The analyses were carried out by two independent evaluators, limited to English and Portuguese, in four databases: Web of Science, Science Direct, Scopus and PubMed, without restrictions related with year. The keywords used were: “Exergames and motor learning and motor skill” and “Exergames and motor skill and physical education”. The inclusion criteria were: articles that evaluated the effectiveness of exergames in physical education classes regarding the acquisition and development of motor skills. The following were excluded: books, theses and dissertations; repetitions; articles published in proceedings and conference summaries; and studies with sick children and/or use of the tool for rehabilitation purposes.

Data synthesis:

96 publications were found, and 8 studies were selected for a final review. The quality of the articles was evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) scale and the Physiotherapy Evidence Database (PEDro) scale. Evidence was found on the recurring positive effects of exergames in both motor skills acquisition and motor skills development.


Exergames, when used in a conscious manner – so as to not completely replace sports and other recreational activities -, incorporate good strategies for parents and physical education teachers in motivating children and adolescents to practice physical exercise.


As an indispensable factor for success in sports activities, games and other physical activities, basic motor skills in childhood are determinant for a healthy and active lifestyle. 1 On the other hand, physical inactivity in childhood may result in the inability to acquire and develop motor skills and abilities, which leads to posterior deficit in learning and in the perfection of specialized motor abilities. 2 Some variables make it difficult to practice physical activity in school environments, such as: limited time, large number of students per class and lack of adequate spaces. Besides, throughout the years there has been a change in the behavior of children, leading to the removal of games that involve the movement of several body segments, and to the approximation with technology and entertainment using a screen. Facing this phenomenon, new strategies are required to keep the children motivated for the practice of physical activity. 3

Aiming at allying technology and physical activity, the active games came up – or exergames, name given to the technologies that require the whole body to move, combining physical exercises and videogames. 4 These tools convert the real movements to the virtual environment, allowing the users to be more active 5 , practicing virtual sports, fitness exercises and/or other ludic and interactive physical activities, using movements that are similar to real life tasks. 6 The exergames are different from sedentary videogames 7due to the physical effort and motor skills and abilities required during the games. 5

The insertion of exergames in the daily life may help children and adolescents to reach the recommended levels of physical activity, and, probably, have a positive impactive on the lives of children, since this is a useful way to acquire and develop motor skills and abilities. 4 ,, , 10 Even if exergames are a reality in the lives of children and adolescents – and some researchers have been studying their applicability for the motor performance -, identifying evidence in the scientific literature that indicates the successful or little efficient initiatives in relation to their use for the acquisition and development of motor skills and abilities is essential to formulate new proposals for its broad application in the school context.

In this context, the objective of this study was to analyze the literature as to the efficacy of the use of exergames in Physical Education classes and in the acquisition and development of motor skills and abilities.[…]



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Figure 1:
Flowchart of the articles found .

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[Abstract] Active exergames to improve cognitive functioning in neurological disabilities: a systematic review and meta-analysis.

Exergames represent a way to perform physical activity through active video games, serving as potentially useful tool in the field of neurorehabilitation. However, little is known regarding the possible role of exergames in improving cognitive functions in persons suffering from neurological disabilities.A search for relevant articles was carried out on PubMed/Medline, Scopus, PEDro, and Google Scholar. Only randomized controlled studies and non-randomized but controlled studies were retained. The following additional inclusion criteria were applied: studies focused on physical activity interventions carried out by means of exergames; populations targeted were affected by neurological disabilities; and reported results were related to cognitive outcomes. We calculated standardized mean differences (SMD) and pooled results using a random effects meta-analysis.Of 520 abstracts screened, thirteen studies met the criteria to be included yielding a total of 465 participants, 233 randomized to exergames, and 232 allocated to the alternative or no intervention. The included studies varied in terms of studied populations (e.g., multiple sclerosis, post-stroke hemiparesis, Parkinson’s disease, dementia, dyslexia, Down syndrome), type and duration of interventions, and cognitive outcome measures. Exergames significantly improved executive functions (SMD=0.53, p=0.005; 8 studies, n=380) and visuo-spatial perception (SMD=0.65, p<0.0001; 5 studies, n=209) when compared to the alternative or no intervention. There were no significant differences for attention (SMD=0.57, p=0.07; 7 studies, n=250) and global cognition (SMD=0.05, p=0.80; 6 studies, n=161).Exergames are a highly-flexible tool for rehabilitation of both cognitive and motor functions in adult populations suffering from various neurological disabilities and developmental neurological disorders. Additional high-quality clinical trials with larger samples and more specific cognitive outcomes are needed to corroborate these preliminary findings.Exergames could be considered either as a supplemental treatment to conventional rehabilitation, or as strategy to extend benefits of conventional programs at home.

via Active exergames to improve cognitive functioning in neurological disabilities: a systematic… – Abstract – Europe PMC

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Samreen Sadiq, Lahore College of Physical therapy,

Iqra khan, University Institute of Physical Therapy, University of Lahore


The consumption of gaming technology has recently gain unexpected significance in medical health care for neurological rehabilitation. With increasing interest in exergames study, numerous definitions and terminology have been introduced to describe this term. Researchers from health-related background acknowledged the fact that engaging in video gaming was not always sedentary and might act as a means to ensure more physical work. Simplifying the terminology exergames are those types of gaming technology or multimedia communications that necessitate the player to perform physical activity during play.

However, health related researchers were hesitant to use the terminology of exergaming, their descriptions shared a mutual purpose of enhancing physical activity level. Two similar terms were defined to explain that concept known as activity promotion and active video gaming. For instance, videogames that promote physical activity were described as those video games that have capability to enhance physical movements during screen period whereas active video gaming may give new opportunities to transform the conventional sedentary attitude into physical active behavior. The chief impression of using such terminology is to discriminate engaging in video gaming that encourage active attitude from those resulting in inactive behavior.’

The growing utilization of exergaming and the expansion of diverse software’s by ground breaking minds in gaming industry have inadvertently opened new ways to address goals of neurological rehabilitation. The common aims of rehabilitation include improvement in balance, enhancing functional movements as well as to promote flexibility. The chief reason for integrating video gaming in neurological rehabilitation is to enhance patient motivation, strict adherence to treatment procedure and to ignore boring training.

An important question which rises in mind is could those clients who are involved in neurological rehabilitation through gaming technology capitalize on its entertainment value? Motivating a person’s interest is probably a key to strict exercise adherence. The utilization of gaming technology is limitless. A research was done to evaluate efficacy of Wii Ninetedo in Parkinson’s disease patients and the impact of integrating exergaming for the management of childhood obesity. Case reports utilizing exergaming have been described for improving balance and gait parameters in patients suffering from neurological condition known as stroke. The practice of exergames were found to be effective in improving exercise tolerance and adherence in Multiple Sclerosis patients. A study on efficacy of Wii Fit was also conducted to evaluate the balance problems among Cerebral palsy children and the results suggested that Nintendo Wii provides entertaining, safe and effective means in conjunction with traditional management to improve balance of cerebral palsy children.

The safety of these emergent devices as medical equipment is questionable and whether there is need to give approval to these devices by governing authorities before using them. The concerned issue should be emphasized keeping in consideration the risks, dangers and adverse effects associated with the use of this exergames technology. Several case reports of injuries have been identified with utilization of this gaming technology for example shoulder joint dislocation, pulmonary disorder, tendon and ligamentous tear. Another case was reported about primary spontaneous pneumothorax in an old man with initial presentation following prolonged period of playing Nintendo Wii. Commonly reported injuries include overuse strain injuries, joint injuries and has been named as Wiiitis by authors. Terminology mostly used to describe such injuries associated to to Wii-habilitation include Wii Shoulder, Wii Knee and Nintendinitis.

Worldwide utilization of this novel technology has been implemented and various international scholars showed strong interest in integrating the use of exergaming for neurological rehabilitation. Global attention has been focused to this technology and paper based work has been presented in World Confederation for Physical Therapy. A lot of document based work displayed in Amsterdam was also put together on this specific topic, some were initial researches but they depict a worldwide interest in this emergent technology. Previous literature have focused the remarkable and extraordinary effects of exergaming on upper extremity function, daily living activities and posture control. This novel technology can efficiently provide opportunity to neuro patients to accomplish maximal repetition of movement and tasks and provide a better possibility in comparison to traditional techniques. In Pakistan, a similar paper highlighted the application of exergaming as an effective and innovative tool for stroke rehabilitation. It was suggested that this tool offers a collaborative activity and the cost of video games is less as well as ensure easier implementation. So, it is the chief responsibility of concerned professionals to deliver a complete rehabilitation protocol so that optimal functioning level can be achieved. It enables the person to perform activities of daily living independently. This novel technology lessens the full time help of physical therapist and home-based management can also be manageable in future. Therefore, it is correct time to use this technological advancement for assistance in neurological rehabilitation to attain best outcome in small period.

The debate on emergent technologies is relatively noteworthy in rehabilitation and physical therapy practice. This forward technology shift and use of other analogous devices offer countless choices for rehabilitation extending from heart rate measuring and respiratory rate monitoring tools, to diagnostic and education applications. It now seems possible to foresee the effect and impact of this emergent technology in rehabilitation fields. It is pretty clear that technology has substantially improved the delivery of rehabilitation services and exer-gaming is likely to positively influence neurological rehabilitation in the future.

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[ARTICLE] The effect of active video games on cognitive functioning in clinical and non-clinical populations: A meta-analysis of randomized controlled trials – Full Text


Physically-active video games (‘exergames’) have recently gained popularity for leisure and entertainment purposes. Using exergames to combine physical activity and cognitively-demanding tasks may offer a novel strategy to improve cognitive functioning. Therefore, this systematic review and meta-analysis was performed to establish effects of exergames on overall cognition and specific cognitive domains in clinical and non-clinical populations. We identified 17 eligible RCTs with cognitive outcome data for 926 participants. Random-effects meta-analyses found exergames significantly improved global cognition (g = 0.436, 95% CI = 0.18–0.69, p = 0.001). Significant effects still existed when excluding waitlist-only controlled studies, and when comparing to physical activity interventions. Furthermore, benefits of exergames where observed for both healthy older adults and clinical populations with conditions associated with neurocognitive impairments (all p < 0.05). Domain-specific analyses found exergames improved executive functions, attentional processing and visuospatial skills. The findings present the first meta-analytic evidence for effects of exergames on cognition. Future research must establish which patient/treatment factors influence efficacy of exergames, and explore neurobiological mechanisms of action.

1. Introduction

Cognition can be broadly defined as the actions of the brain involved in understanding and functioning in our external environment (Hirschfeld and Gelman, 1994). As it is generally accepted that cognition requires multiple mental processes, this broader concept has been theoretically separated into multiple ‘cognitive domains’ (Hirschfeld and Gelman, 1994). Although definitions vary, and the boundaries between domains often overlap, examples of distinct areas of cognitive functioning include the processes for learning and remembering verbal and spatial information, attentional capacities, response speed, problem-solving and planning (Strauss et al., 2006).

Various neuropsychological tests have been developed as tools for assessing and quantifying an individual’s overall cognitive functioning (or ‘global cognition’) along with their performance within the separable domains of cognition (Strauss et al., 2006). Performance in these various cognitive tests has been found to be relatively stable over time in healthy adults, and moderately accurate predictors of real-world functioning and occupational performance (Chaytor and Schmitter-Edgecombe, 2003 ;  Hunter, 1986). Furthermore, neuropsychological tests can detect the deficits in cognitive functioning which arise as a consequence of various psychiatric and neurological diseases (Mathuranath et al., 2000 ;  Nuechterlein et al., 2004). For example, people with Parkinson’s disease show marked impairments in planning and memory tasks (Dubois and Pillon, 1996), whereas those with schizophrenia have cognitive pervasive deficits, 1–2 standard deviations below population norms, which also predict the severity of disability in this population (Green et al., 2000). Additionally, cognitive abilities decline naturally in almost all people during healthy ageing (Van Hooren et al., 2007). In an ageing population, the functional consequences of cognitive decline may ultimately have a severe social and economic impact. Thus, interventions which improve cognition hold promise for the treatment of psychiatric and neurological diseases, an have positive implications for population health.

Fortunately, interventions which stimulate the brain and/or body can improve cognition, or attenuate decline. For instance, physical exercise has been shown to significantly improve global cognition, along with working memory and attentional processes, in both clinical and healthy populations (Firth et al., 2016Smith et al., 2010 ;  Zheng et al., 2016). Interventions can also be designed to target cognition directly, as computerized training programs for memory and other functions have been found to provide significant cognitive benefits, at least in the short term (Hill et al., 2017 ;  Melby-Lervåg and Hulme, 2013). Furthermore, ‘gamification’ of cognitive training programs can maximize their clinical effectiveness, as more complex and interesting programs are capable of better engaging patients in cognitively-demanding tasks while also training multiple cognitive processes simultaneously (Anguera et al., 2013).

Previous studies have found that providing both aerobic exercise and cognitive training together may have additive effects, preventing ageing-related cognitive decline more effectively (Shatil, 2013). This may be due to aerobic and cognitive activity stimulating neurogenesis through independent but complementary pathways; as animal studies show that while exercise stimulates cell proliferation, learning tasks support the survival of these new cells (Kempermann et al., 2010), such that combining these two types of training results in 30% more new neurons than either task alone (Fabel et al., 2009).

Rather than delivering aerobic and cognitive training in separate training sessions, recent advances in technology has presented an opportunity for combining physical activity with cognitively-challenging tasks in a single session through ‘exergames’. Exergames are considered as interactive video-games which require the player to produce physical body movements in order to complete set tasks or actions, in response to visual cues (Oh and Yang, 2010). Common examples include the ‘Nintendo Wii’ (along with ‘Wii Fit’ or ‘Wii Sports software’) or the ‘Microsoft Xbox Kinect’. Additionally, virtual reality systems which use exercise bikes and/or treadmills as a medium for players to interact with three-dimensional worlds have also been developed to provide immersive training experiences (Sinclair et al., 2007).

Along with their popular usage for leisure and entertainment, there is growing interest in the application of exergame systems to improve clinical outcomes. Recent systematic reviews and meta-analyses of this growing literature have provided preliminary evidence that exergames can improve various health-related outcomes, including reducing childhood obesity, improving balance and falls risk factors in elderly adults, facilitating functional rehabilitation in people with parkinson’s disease, and even reduce depression (Barry et al., 2014Li et al., 2016 ;  van’t Riet et al., 2014). However, the effects of exergames on cognitive functioning have not been systematically reviewed, despite many individual studies in this area.

Therefore, the aim of this study was to systematically review all existing trials of exergames for cognition, and apply meta-analytic techniques to establish the effects of exergames on global cognition along with individual cognitive domains. We also sought to (i) examine the effects of exergames on cognition in healthy and clinically-impaired populations, and (ii) investigate if the effects of exergames differed from those of aerobic exercise alone, by comparing exergames to traditional physical activity control conditions.

Fig. 1

Fig. 1. PRISMA flow diagram of systematic search and study selection.

Continue —> The effect of active video games on cognitive functioning in clinical and non-clinical populations: A meta-analysis of randomized controlled trials

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[ARTICLE] New Approaches to Exciting Exergame-Experiences for People with Motor Function Impairments – Full Text


The work presented here suggests new ways to tackle exergames for physical rehabilitation and to improve the players’ immersion and involvement. The primary (but not exclusive) purpose is to increase the motivation of children and adolescents with severe physical impairments, for doing their required exercises while playing. The proposed gaming environment is based on the Kinect sensor and the Blender Game Engine. A middleware has been implemented that efficiently transmits the data from the sensor to the game. Inside the game, different newly proposed mechanisms have been developed to distinguish pure exercise-gestures from other movements used to control the game (e.g., opening a menu). The main contribution is the amplification of weak movements, which allows the physically impaired to have similar gaming experiences as the average population. To test the feasibility of the proposed methods, four mini-games were implemented and tested by a group of 11 volunteers with different disabilities, most of them bound to a wheelchair. Their performance has also been compared to that of a healthy control group. Results are generally positive and motivating, although there is much to do to improve the functionalities. There is a major demand for applications that help to include disabled people in society and to improve their life conditions. This work will contribute towards providing them with more fun during exercise.

1. Introduction

For a number of years, the possibility of applying serious games for rehabilitation purposes has been thoroughly investigated [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28]. It is often claimed that serious games reduce health system costs and efforts as they enable in-home rehabilitation without loss of medical monitoring, and in so doing provide an additional fun factor for patients [22,23,24]. Multiple reviews have summarized the very powerful contributions and reveal that the systems are generally evaluated as feasible, but no state of general applicability has yet been reached [2,3,5,7,11,13].
Most studies are quite specialised and tend to cover the same groups of largely elderly patients (e.g., stroke and Parkinson’s), which do not constitute a credible target group per se for gaming among the population. In addition, the impression is that the same functionalities are being tested repeatedly, without any evolution. Above all, other groups like children and adolescents with chronic diseases are rarely addressed, even though they are an excellent target group and would probably benefit greatly from using exergames as they need to move like any other child but are mostly limited to performing their exercises with a physiotherapist. This is generally boring, time-consuming and prevents them from playing with friends during this time. If instead they could play games involving physical exercises, without it feeling like rehabilitation, due to proper immersion and motivation, they would possibly need fewer sessions with the therapist, which may in turn improve their social life. Commercially available games would be good enough for many children with physical disabilities, if only they were configurable and adaptive to their potential and needs. Remote controls (RC) are typically not sufficiently configurable (button functions cannot be changed or the RC cannot be used with one hand) and are only made for hands (why not for feet or the mouth?) Some RCs are not sufficiently precise in detection, and so the user ends up tired and loses motivation. Motion capture devices like the Kinect sensor seem to provide better prerequisites for exergaming purposes but feature important limitations too, (e.g., detection of fine movements and rotations) such that the needs of many people are still not be covered by commercial solutions.
However, this is not due to the sensors, but rather the software, which lacks configurability for special needs, such as simple adjustments of level difficulties or the option of playing while seated. For the latter, some Kinect games are available [29], but those are hardly the most liked ones, as has been stated by affected users [30]. Therefore, more complex solutions are required to adapt a game to problems like muscle weaknesses (most games require wide or fast movements), spasticity (“strange” movements are not recognized) or the available limbs (for instance configuring a game to be controlled with the feet for players without full hand use).
To fill these gaps, the authors of the work presented here are pursuing the overall aim (as part of a long-term project) of creating an entertaining exergaming environment for adventure games that immerses the players into a virtual world and makes them forget their physical impairments. Knowledge of the gaming industry is applied to create motivating challenges that the users have to solve, which are sufficiently addictive to make the exercises pass to an unconscious plane. The gaming environment is configurable to the user’s potential and requirements. Challenges will be programmable by a therapist and will also adapt themselves to the players automatically real-time, by observing their fatigue or emotional state (lowering the difficulty or switching to more relaxing exercises when needed)…

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Figure 8. Different scenes while the volunteers were playing. (a) “The Paper-Bird”, (b) “The Ladder”, (c) “The Boat” and (d) “Whack-a-Mole”.

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[ARTICLE] “FIND Technology”: investigating the feasibility, efficacy and safety of controller-free interactive digital rehabilitation technology in an inpatient stroke population: study protocol for a randomized controlled trial – Full Text HTML



Stroke results in significant disability, which can be reduced by physical rehabilitation. High levels of repetition and activity are required in rehabilitation, but patients are typically sedentary. Using clinically relevant and fun computer games may be one way to achieve increased activity in rehabilitation.


A single-blind randomized controlled trial will be conducted to evaluate the feasibility, efficacy and safety of novel stroke-specific rehabilitation software. This software uses controller-free client interaction and inertial motion sensors. Elements of feasibility include recruitment into the trial, ongoing participation (adherence and dropout), perceived benefit, enjoyment and ease of use of the games. Efficacy will be determined by measuring activity and using upper-limb tasks as well as measures of balance and mobility. The hypothesis that the intervention group will have increased levels of physical activity within rehabilitation and improved physical outcomes compared with the control group will be tested.


Results from this study will provide a basis for discussion of feasibility of this interactive video technological solution in an inpatient situation. Differences in activity levels between groups will be the primary measure of efficacy. It will also provide data on measures of upper-limb function, balance and mobility.


In the US alone, one person per minute has a stroke, and although death rates have declined over the last decade, the burden of disease remains high [13]. Physical rehabilitation has the potential to positively impact functional outcomes and improve this burden; however, this requires a high dose of therapy. A significant factor limiting rehabilitation outcomes is low levels of patient activity [10]. Observational studies in different countries have found that patients after stroke in rehabilitation are surprisingly inactive for the vast majority of the waking day. For example, only 13 % of a stroke unit patient’s day is typically spent in activities related to functional outcome, such as active therapy or walking practice [2]. Many rehabilitation activities, aimed at stimulating neuroplasticity, are by their very nature repetitive and tend to be tedious [19]. One method by which engagement with rehabilitation programs and levels of activity could be improved involves the use of fun and engaging video games.

Commercial, off-the-shelf devices such as the Microsoft Xbox Kinect (Microsoft Corporation, Redmond, WA, USA) are relatively inexpensive and use motion capture and feedback technologies with potential for use in rehabilitation. Interactive video games increase adherence to and enjoyment of exercise in the general population [1] and have the potential to increase the dose of repetitive exercise completed by people with reduced mobility. Exercise-based video games could be used to increase exercise dose during therapy and to enable exercise outside of therapy hours. This is true both in inpatient and outpatient rehabilitation settings as well as at home after discharge from hospital.

In particular, the Kinect for Xbox 360, or simply Kinect, is a “controller-free gaming and entertainment experience” by Microsoft for the Xbox 360 video-game platform and is now also supported by PCs via Windows 8. It enables users to control and interact with the Xbox 360 without the need to touch a game controller, through a user interface using gestures and spoken commands. Kinect enables full-body depth-based three-dimensional motion-capture, facial recognition and voice recognition capabilities. This differentiates it from previous generations of interactive technologies that have been used in rehabilitation.

Despite the promise of such low-cost, consumer-based technologies, many, if not all, off-the-shelf video-game solutions are inappropriate for individuals with functional impairment [16]. There is an opportunity for purpose-built, clinically relevant video game-based rehabilitation to add significant value to current rehabilitation practice. Jintronix, a Montreal-based company, has recently launched a Kinect-based rehabilitation system, Jintronix Rehabilitation System (JRS), which provides an easy-to-use software solution (JRS WAVE) for patients to use. The software solution has been designed in collaboration with physical and occupational therapists and draws upon the motor relearning recommendations by Carr and Shepard [5]. As such, upper limb, sitting balance, standing balance and stepping rehabilitation tasks have been programmed in the JRS WAVE as fun and engaging video games that can be played at a number of different levels of complexity and speed. The system is also capable of automatically measuring changes in the range, speed and quality of motion to give patients instant feedback on their progress.

A second feature of the JRS WAVE is a cloud-based client management telehealth system for clinicians to recommend rehabilitation tasks and track and record performance of those tasks (JRS PORTAL). The PORTAL allows clinicians to provide patients regular updates and information on what has happened to them with daily, weekly or monthly progress reports on their rehabilitation, either face-to-face or remotely.

The proposed project will evaluate the feasibility, efficacy and safety of the JRS WAVE for use in an Australian stroke inpatient rehabilitation context. Elements of feasibility include recruitment into the trial, ongoing participation (adherence and dropout), perceived benefit, and enjoyment and ease of use of the games. Efficacy will be determined by measuring physical activity (using an accelerometer) and using upper-limb tasks as well as measuring changes in balance and mobility over time between the two groups. Adverse events will be monitored and changes in pain and fatigue with the interventions will be used to determine safety of the system. We will test the hypothesis that the intervention group will have increased levels of physical activity within rehabilitation and improved physical outcomes compared with the control group.

Continue —> “FIND Technology”: investigating the feasibility, efficacy and safety of controller-free interactive digital rehabilitation technology in an inpatient stroke population: study protocol for a randomized controlled trial | Trials | Full Text


Fig. 1 Feasibility Interactive Digital (FIND) technology protocol flow diagram

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