Exergames as Coping Strategies for Anxiety Disorders During the COVID-19 Quarantine Period

Introduction

The history of humanity is marked by the negative impact of several frightening epidemics of infectious disease, such as severe acute respiratory syndrome (SARS). ¹ Currently, many countries around the world are fighting a novel coronavirus (SARS-CoV-2), which typically causes mild infection but can develop into a severe and even fatal communicable disorder named COVID-19. As COVID-19 has a high infection potential and mortality rate, ² many affected countries have been using quarantine to contain and control the spread of SARS-CoV-2.^3,4

Based on previous epidemics of infectious diseases,^1,5 although quarantine can segregate people potentially exposed to the SARS-CoV-2 and thus at risk for COVID-19, the quarantine in place today may be causing considerable financial, psychological, and emotional problems for some.^6,7 By its nature, quarantine increases self-isolation; thus it may lead to an increase in mood disorders, such as higher anxiety levels. ⁷ Therefore, strategies to prevent and reduce anxiety levels are fundamental to reduce the likelihood of such disorders increasing during the COVID-19 quarantine period.

In this vein, physical exercise^8–13 and dance ¹⁴ appear to be feasible nonpharmacological treatments. However, people might not be able to access exercise facilities or to exercise outdoors during this period. Therefore, home-based exercise training may be important for both maintaining physical fitness and establishing long-term adherence to exercise ¹⁵ —the latter is fundamental since adherence is important if the health benefits of exercise are to be realized. Thus, exergames (active videogames) appear to be an enjoyable and interesting example of home-based exercise. Exergames are perceived to be easy to set up and to use, and appear to be safe for most clinical populations. ¹⁶ These characteristics are crucial for increasing motivation and self-efficacy, as well as for possibly keeping people physically active. ¹⁷ Previous studies have shown that exergame interventions are able to improve the following: physical activity levels, ¹⁸ the performance of daily activities,^19,20 heart rate,^21–25 oxygen consumption,^21,23,25 and energy expenditure in various populations^21,23,25,26; improvements in body composition in children ²⁷ ; and postural balance ²⁸ and cognitive function in older adults. ²⁹ Moreover, it has already been demonstrated that a single session of a dance exergame reduced anxiety levels in young adult women. ²²

Taking all the points already mentioned together, this article offers a critical appraisal of the opportunities and challenges of exergames as a coping strategy for preventing and treating anxiety disorders in a home-based environment during the COVID-19 quarantine period.

Exergames and Anxiety Disorders During COVID-19 Quarantine: The Challenges and Opportunities

In a recent systematic review and meta-analysis, ³⁰ overall, exergames demonstrated within-group improvements in anxiety levels across various clinical populations (e.g., patients with Parkinson's disease, enrolled in cardiac rehabilitation, with fibromyalgia, and with systemic lupus erythematosus); however, the effects were no greater than those of nonexercise control interventions. Notwithstanding this, exergames are more advantageous because they induce acute and chronic beneficial physiological changes that are not typically found after nonexercise control interventions. Although there is some heterogeneity among studies, these can mostly be explained by differences in methods employed.^31,32

Exergames comprise many different modalities (walking, running, climbing stairs, cycling, rowing, swimming, baseball, ping-pong, tennis, balance training, frisbee, boxing, canoeing, stretching exercises, bowling, golf, resistance exercises, yoga, dancing, etc.)^{21–23,26,30} and are based on the idea of integrating physical activity and exercise with appealing digital games. ³³ We believe that some modalities may be better than others at reducing anxiety levels, especially those classified as being of moderate intensity.^7,8 In this context, a single session (20 minutes) of the exergame Zumba Fitness performed at moderate intensity seems to significantly reduce state anxiety levels in healthy young women. ²² Also, an 8-week (2 days per week, 60 minutes per session) exergames intervention (dance steps, postural control, co-ordination, and walk training) seems to provide superior effects on anxiety levels in patients with fibromyalgia, compared with a nonexercise control group. ³¹ In addition, participants enrolled in a dance-based exergaming intervention ³² appear to report a higher perceived competence in performing regular exercise, and exergames seem to provide a positive effect on overall psychological adjustment in obese adolescents. ³² Moreover, unpublished data from our laboratory show that when performed at the same intensity, 40 minutes of moderate-intensity dance exergames appears to achieve a similar reduction in state anxiety and higher enjoyment in young women, compared with a traditional aerobic exercise protocol (moderate-intensity continuous exercise).

As most people do not have access to exercise facilities during this quarantine period, exergames can be considered a useful tool for coping with anxiety. In addition, as people who suffer from high levels of anxiety can experience impaired quality of life, autoimage, and personal relationships, ³⁴ exergames could be an enjoyable way of overcoming common barriers to physical exercise (e.g., motivation, ¹⁷ adherence, ³² and lack of compliance ³⁵ ) during the current quarantine period. Furthermore, exergames can easily be shared with peers and families ³⁶ in social isolation situations and can be a tool for maintaining physical activity levels and, consequently, physical fitness.