Virtual fitness gets real

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Virtual fitness gets real

Video games - once associated with health problems - are now becoming

part of the solution

By J. Light

http://biomech.com/current_full_article/?ArticleID=151

America's younger population today finds itself in the grip of a

battle involving several health problems, such as obesity and type 2

diabetes, which were once associated mainly with older adults. In an

effort to help patients stave off these conditions, fitness

researchers and experts are now reaching for the most unlikely of

solutions to motivate youth to get off the couch and get fit: a video

game remote.

A new wave of fitness video games may be key to combating sedentary

behaviors that are at the heart of assorted health problems,

according to recent research.

Video games have in the past been demonized for encouraging

inactivity among youth. In an unusual about-face, however, a new

type of video game system has become part of the solution. So-called

fitness video gaming systems, which require more physical activity

than traditional sedentary systems, can actually lead to better

health, according to some recent research.

" Exergaming " is the buzzword used to describe video games that—beyond

their inherent entertainment value—demand a certain amount of

physical activity by those playing them. This new wave of interactive

video games may be just the type of thing to induce youth to spend

more time exercising and less time sitting, according to research

presented in May at the 55th Annual Meeting of the American College

of Sports Medicine.

In fact, these games have been found to increase heart rate, oxygen

consumption, and energy expenditure (EE) in children by two to three

times when compared with sitting quietly or playing traditional

handheld games, according to a study from the University of Nebraska

at Kearney presented at the ACSM Meeting.

" If someone is going to play video games, physically active video

games are better than just sitting on the couch moving your fingers, "

said lead author Brown, PhD, graduate program committee chair

of the health, physical education, recreation, and leisure department

at UNK.

Brown and his colleagues found that while a child was engaged in

virtual play, his or her average heart rate increased about 33%—from

80 beats per minute to 120 bpm—about what one could expect when

walking or dancing slowly, according to Brown.The research team

studied 25 children from the local community (15 boys, 10 girls)

whose average age was 11. All participants were assessed for body

composition using dual-energy x-ray absorptiometry. Aerobic fitness

was measured with a

treadmill and a ParvoMedics TrueOne metabolic measurement system.

The children played three video games that demanded physical activity

and one sedentary game for 15 minutes each in random order. The

active games were Wii Boxing and Wii Tennis, by Nintendo, and Dance

Dance Revolution, by Konami, a game where participants stand in front

of a monitor and dance in step to instructions and graphics on the

screen. The sedentary game was Grand Turismo 4, by Polyphony Digital.

The children rested for five minutes between game sessions. Heart

rate, oxygen consumption, and EE were measured during play using the

same instruments that were used for the aerobic fitness assessment.

Researchers analyzed the data using a two-factor (gender x

intervention) repeated measures ANOVA. Researchers combined the data

for boys and girls because they did not find gender-related

differences in any measured variable.

The investigators discovered that the children's heart rates were

higher while they played Dance Dance Revolution than while playing

Wii Tennis. Heart rates were highest, however, during sessions of Wii

Boxing. Oxygen consumption relative to body mass was higher while

playing all three active video games than at rest or while playing a

sedentary video game. Fur­thermore, there was no difference in

relative oxygen consumption between the three video games demanding

physical activity (Wii Tennis elicited 25.3% ± 2.9% V02 max; Wii

Boxing, 32.5% ± 2.7% V02 max; and Dance Dance Revolution, 31.5% ±

3.8% V02 max).

" The energy expenditure of playing active video games is still not

what one would expend while really playing sports, " Brown

said. " These video games are not a substitute for exercise. " A

similar study, also reported at the ACMS meeting, showed that

children burn two to three times as many calories while playing

active video games as they do when watching a DVD or playing a

traditional hand-controlled video game. Thirteen 10-year-olds

participated in the study from the University of Glasgow, in the

U.K., which compared the effects of playing two active games with

playing a handheld game or watching a Simpsons DVD. When the children

played Dance Mat Mania (Senario Entertainment) and Eye Toy Boxing

(Sony Computer Entertainment), their heart rates jumped from 80 bpm

to 160 bpm, which is equivalent to what one might experience while

walking briskly or even jogging.

Children's accelerometer counts of total movements per minute were

more than four times higher while playing active video games than

during DVD-watching and sedentary handheld gaming activities. In

fact, researchers from this study found that when the children

watched a DVD or played a traditional hand-controlled video game,

they did not burn any more calories than they would by reading a book.

All fitness games are not created equal

Most people would agree that any active game is better for a child

than a handheld one. But not all fitness video games promote the same

level of exercise intensity, according to a study from the

Netherlands presented at the ACSM meeting. The researchers found that

children did not burn as many calories playing Wii Tennis and Eye Toy

Volleyball as they did while playing four other interactive games:

Dance Dance Revolution, Xerbike (Motion Kids), Lasersquash (Laserpro

Games), and Apartgame (O-dynamic Games).

The investigators sought to assess the EE of six active computer

games in relation to the Netherlands' physical activity guidelines.

Twelve children (six boys, six girls; ages seven to 13 years)

participated in the study. The Cortex Vmas ST system for oxygen

consumption measurement and the Actigraph accelerometer (attached on

each subject's wrist and hip) were simultaneously used for estimating

EE. Heart rate was measured using Finnish heart rate monitoring

equipment. The measurements lasted five minutes, and the last four

minutes of time spent playing the video games were used for analyses.

Direct measurement of oxygen consumption showed that four of the six

interactive computer games promote a sufficient level of exercise

intensity to meet the Dutch physical activity intensity level

guidelines for children (five to eight metabolic equivalents [METS]

for moderate-intensity activities). However, the games did not meet

the ACSM recommendations for moderate-intensity physical activity.

Wii Fit offers biofeedback

The Wii Fit system, released by Nintendo in May, offers 40 games in

four categories: yoga, aerobics, balance, and strength training. Each

of these categories offers just four or five choices at first, but

the longer a user exercises, the more options he or she " unlocks. "

New exercises are " opened " once a player performs at a certain level.

For example, there are two tightrope activity levels: basic and

advanced. A player has to get across the tightrope within a certain

time to reach the more advanced level. In other situations, if a

player performs well on a yoga pose, a new pose opens. The more

experienced a player becomes, the more yoga poses he or she gets to

choose from.

The system features a motion-sensitive controller that looks like a

television remote control and that can quickly sense the user's

movements and translate them into onscreen action. When a player

holds a remote in hand and makes a swing motion as if he or she is

hitting a tennis ball, for example, the character on screen mimics

the player's movement in real-time. The Wii Fit's main accessory,

however, is a 12 x 20-inch plastic balance board that looks like a

smaller version of the steps used in aerobics classes.

The biofeedback component measures how steadily the player holds each

pose in addition to proper weight distribution. The Wii Fit acts as a

force plate that measures a player's weight distribution and sway.

That information is provided after completion of an exercise to help

a player understand his or her performance and—hopefully—improve it

the next time.

If a user selects strength training, he or she can choose between

single-leg extensions, torso twists, lunges, jackknifes, and a push-

up/side-plank combo. The balance board can't tell the user if he or

she is doing the exercise correctly. It can only count how many times

a user does it (when he or she touches the board). " I think that some

of the instructions are better than others, " said Judith Deutsch,

PhD, a professor of developmental and rehabilitative sciences at the

University of Medicine and Dentistry of New Jersey, who, in addition

to observing adult stroke patients use the Wii Fit, has used it

herself.

" Instructions for some of the balance activities, like the tightrope

walk, were not very clear to me, which made it difficult to achieve

success. In contrast, the aerobic activity of walking was very clear

and made it easy to succeed in that activity, " she said. Deutsch has

also tested all of the Wii fitness exercise categories herself. She

says that she found some of the biofeedback information useful at

times and a little distracting at others. " The information on how to

shift your weight during the sky jump made it easier for me to get a

longer jump. However, this was not the case when I was doing the sun

salutation in yoga, " Deutsch said. " When I would bend down, I could

not see the center-of-pressure measurement and I wondered how I was

doing. "

The summary feedback, which tells the user where his or her center of

pressure was for the whole exercise, was very useful for the sun

salutation, according to Deutsch. However, she could not use it to

make any corrections during the exercise.

Overall, Deutsch feels that the human engagement the Wii Fit program

promotes with the games and biofeedback is its biggest benefit. The

Wii Fit could be improved, however, if it were to incorporate a

customization option for specific rehabilitation

applications.

" It is a new toy, but I am sure that [fitness experts] are trying it

out, " Deutsch said. " We are learning how to use it to help stroke

patients improve their mobility and balance. "

Wii knees and other injuries

As with any real sport, there is a risk of injury while playing

virtual sports. Among the types of injuries being reported, some are

caused by repeated overuse while others are caused by overexertion.

In one case, a 16-year-old boy injured his knee while playing

Nintendo Wii. When the boy showed up at the emergency room of Leeds

Teaching Hospitals in the U.K., the knee was acutely swollen and

painful, according to the article published in the May issue of

Skeletal Radiology.

Initial radiographs revealed effusion and an osteochondral fracture.

Magnetic resonance imaging showed evidence of lateral patella

dislocation with medial patellofemoral ligamentous damage and a large

femoral osteochondral fracture. The patient was successfully treated

with surgical fixation of the osteochondral fragment and medial

patellofemoral ligament repair.

In another case, acute " wii-itis " of the upper extremity was

reportedly caused by prolonged participation in a physically

interactive virtual video game. The case report, published in

Emergency Radiology in March, reported that an unenhanced MRI

demonstrated marked abnormality within several muscles of the

shoulder and upper arm, without evidence of macroscopic partial- or

full-thickness tearing of the muscle or of intramuscular hematoma.

Arthur Rettig, MD, an orthopedic surgeon from the Methodist Sports

Medicine Center in Indianapolis, believes that clinicians will begin

to see more overuse injuries like these due to the Wii Fit games.

However, he doesn't think that wii-itis will be a common occurrence

because virtual exercise is not as stressful as performing an actual

sport.

" I doubt that the risks of virtual exercise will outweigh the

benefits in the long haul, " he said. " However, it is probably a good

idea to educate Wii players about such risks. " To avoid virtual

fitness game injuries, Rettig suggests limiting play to a couple of

hours at any given time. He also advises players to take breaks

between gaming sessions. " If you start feeling soreness and pain in

any area, rest and stretch the muscles that are involved in play

prior to the activity, " he said. " This could help virtual fitness

gamers avoid overuse injuries. " Icing the muscles used after

activities may help as well.

Mark , PhD, a staff radiology consultant in the

musculoskeletal division of the diagnostic radiology department at

the Mayo Clinic in Rochester, MN, and one of the authors of the case

study, said that, in simple terms, the upper extremity injury

resulted from the patient playing the game too vigorously for too

long.

" I imagine it is pretty easy to get caught up in these entertaining

games and not realize the types of excessive awkward movements you

are doing, " said. " The mind thinks you are bowling with the

typical resistance of a 10-pound or heavier bowling ball, but you are

really exerting forces against a much lighter resistance, which can

cause some awkward deceleration forces. "

said that he cannot make any specific recommendations to

avoid injury with use of the Wii or virtual fitness exercise in

general. Injuries do occur, he pointed out, and are usually the

product of excessive repetitions with excessive awkward forces. " I

doubt any specific training or stretching would prevent this injury, "

he said. His advice is to simply not play too forcefully for too

long.

Virtual fitness becomes a reality

Recent research suggests that the more one plays a virtual game, the

more fit one becomes. Results from this study, conducted at Hofstra

University in Hempstead, NY, were published in the March-April issue

of the Journal of American College Health.Nineteen male college

students—12 experienced Dance Dance Revolution players and seven

inexperienced ones—completed maximal oxygen uptake assessments and a

30-minute Dance Dance Revolution gaming session. Experienced video

game players showed a higher exercise heart rate, perceived exertion

rate, respiratory exchange rate, oxygen consumption, total and

relative EE, and exercise intensity than did inexperienced players.

They also took less time and fewer steps to expend 150 kilocalories

(P <.05) than less adept players.

Researchers concluded that participants with greater playing

experience can work at higher intensities, which can promote greater

energy expenditure.

" Exertainment " video games may still have a way to go before they

earn a solid reputation as a respectable source for exercise in the

fitness arena. Although most experts agree that there is still no

substitute for playing the sport itself, it seems clear that computer-

based fitness systems like the Nintendo Wii are clearly appealing to

a population of Americans that is in desperate need of a fitness

regime adjustment. Active video games may be a successful tool to

promote physical activity among children.

But fitness experts, like scientific researcher Simons, a

researcher from the Organization for Applied Scientific Research in

Delft, the Netherlands, still recommend that children play regular

sports outdoors. " The feeling of playing real sports, the social

interaction, and getting fresh air and sunshine cannot be reached by

playing computer games, " Simon said. " But for children who are not

interested in sports or don't have the possibility to play outside,

active computer games could be a successful tool to promote physical

activity. Active gaming should not replace regular sports but should

serve as a replacement for sedentary activities, like watching

television and playing conventional inactive computer games. "