Active Videogaming Interventions in Adults with Neuromuscular Conditions: A Scoping Review

Introduction

There is substantial evidence that regular participation in physical activity, including exercise training, improves health and functional outcomes (e.g., improved mobility, cardiovascular endurance, muscular strength, balance, fatigue, depression) in people with disabilities, including neuromuscular conditions.^1,2 However, the majority of people with neuromuscular conditions do not engage in adequate amounts of physical activity for acquiring health benefits.^3–6 Although the causes of neuromuscular conditions vary, many possess a mobility limitation that may exacerbate physical inactivity.^3,4 In addition, the low level of physical activity may be attributed in part to fewer opportunities and numerous personal and environmental barriers that restrict their physical activity participation in the community (e.g., lack of transportation, poor facility access, fitness staff inexperienced with mobility limitations).^7–12 These barriers make it much more challenging for people with neuromuscular conditions to achieve the U.S. public health guideline of at least 150 minutes/week of moderate intensity physical activity.^5,6

Research efforts have focused on physical activity promotion for people with neuromuscular conditions through the delivery of traditional exercise training programs (e.g., treadmill walking, weight lifting) and/or recreation, leisure, and sport activities (e.g., yoga, martial arts). ² Over the past two decades, studies incorporating interactive technology such as active videogaming (AVG) have demonstrated acceptance as an enjoyable leisure time option for improving health outcomes and physical activity for individuals with a neuromuscular condition.^13,14 AVGs are typically played using trunk and limb movements while the system reflects participants' movements in space using a wireless controller. Participants can mimic use of real-world objects (e.g., tennis racquet) and perform leisure time physical activities. Physical activity can be defined as bodily movement that results in increases in energy expenditure above resting level while performing sports, conditioning, exercise, household tasks, and other daily activities. ¹⁵ Previous studies among people with mobility limitations have reported that AVG is perceived as an enjoyable activity^16,17 and can produce moderate-intensity exercise,^16,18–22 thereby helping individuals meet the recommended physical activity guidelines.^5,6

It is estimated that 46 million persons with disabilities (PWD) in the U.S. engage in videogame play. ²³ Previous studies have reported increased levels of energy expenditure in persons with a mobility limitations during AVG^16,18 and may replace typical sedentary play with health-promoting physical activity.^24,25 Collectively, AVG has the potential to serve as an alternative form of leisure time physical activity for individuals with a neuromuscular condition mitigating common environmental barriers to physical activity participation such as transportation and facility access. ⁹

Recent literature reviews have reported that home and clinic-based AVG interventions can improve functional health (e.g., mobility, balance) and physical activity among adults with neuromuscular conditions, including multiple sclerosis (MS), stroke, and Parkinson disease (PD).^26–28 Yet, the current trends and benefits of the AVG interventions may be underestimated from a small number of carefully selected studies (i.e., inclusion of home-based interventions and/or randomized controlled trials [RCT] only) and limited to functional health outcomes. Although functional health is an important therapeutic measure for people with neuromuscular conditions, data are limited that can illustrate the effectiveness of AVG interventions on other important outcomes, such as musculoskeletal, cardiorespiratory and secondary conditions, physical activity, and quality of life (QOL). It is imperative that we expand the review of existing literature to identify gaps and advance the knowledge base regarding AVG.

To better understand the use of AVG as a health-promoting activity in young and middle-aged adults (18–64 years) with neuromuscular conditions, this scoping review explored the characteristics of AVG interventions (e.g., research design, gaming technology, setting, intervention dose) over a 10-year period. The review included the following neuromuscular conditions, namely stroke, MS, PD, spinal cord injury (SCI)/dysfunction, post-polio syndrome, and traumatic brain injury (TBI) as classified by the American College of Sports and Medicine (ACSM). ²⁹ In addition, the review aimed to describe the influence of AVG interventions on changes in broad outcome areas, including health-related secondary conditions, physical activity, and QOL.

Methods

This scoping review followed the Arksey and O'Malley methodological framework for conducting a scoping review. ³⁰ Scoping reviews aim to address broad, overarching views of the existing literature and research questions that can further provide a foundation for investigating more specific research questions for systematic review and/or meta-analyses.^30,31 This review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement as a guideline for reporting. ³² Using systematic review procedures, intervention studies that incorporated AVG to change health, physical activity, secondary condition, or QOL-related outcomes for people with neuromuscular conditions were identified, reviewed, and synthesized by disability type.

Results

The results of the study selection process are provided in a PRISMA flowchart in Figure 1. The search strategy returned 4033 studies from the electronic databases, and four studies were located through additional resources (review articles and journals) related to the topics of interest (e.g., game, rehabilitation, and disability). After removing duplicates, 3519 studies were screened at the abstract level based on the eligibility criteria, and 631 studies were retained and reviewed at the full-text level. Collectively, 40 studies^34–73 that met the eligibility criteria were included in the final review. The summary characteristics of all studies are presented in Table 1. The characteristics of the studies included in the quantitative synthesis are provided in Table 2.

OPEN IN VIEWER

FIG. 1.

PRISMA flow diagram. From: Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Internal Med 2009; 151:264–269. DOI: 10.7326/0003-4819-151-4-200908180-00135.

Discussion

This scoping review focused on describing the characteristics of AVG interventions that aimed to improve health, secondary conditions, physical activity, and QOL outcomes for adults with neuromuscular conditions. After screening, this review included 40 studies between the years of 2010 and 2020 that met our eligibility criteria. Studies underrepresented a few disability groups (e.g., TBI, SCI, PD) and people with severe mobility limitation. Also, a smaller number of studies focused on secondary conditions, cardiorespiratory, musculoskeletal, metabolic, as well as physical activity outcomes.

These limitations in the existing AVG intervention literature can serve as a framework for designing and developing a future research agenda. In addition, 26 studies (65%) incorporated an RCT intervention design. The remaining studies used quasiexperimental designs or pre- and post-intervention designs without a comparison group (Table 1). These less rigorous designs may limit the potential translation of study findings into clinical practice. The following sections discuss major observations of this scoping review regarding intervention characteristics and targeted outcomes, in conjunction with recommendations for future AVG research that addresses gaps in the literature.

The majority of studies included in this review reported on adults with MS and stroke, and this is most likely due to the incidence rate of these conditions compared with other disability groups, such as Huntington's and post-polio. The study participants had mostly mild-to-moderate mobility disability who were able to play games in a standing position. This is not surprising because most commercially available games require the player to stand, which limits the options available to persons with neuromuscular conditions and other physical disabilities. Considering the nature of disability severity, there is a likelihood of excluding people with limited ability to stand or walk in utilizing AVG for exercise. ⁷⁴ However, children and adults with cerebral palsy can achieve moderate-to-vigorous physical activity during AVG both in standing^75,76 and seated ¹⁹ positions.

Recognizing the potential for AVG to elicit adequate exercise intensity among people with limited ability to stand, efforts have been made to adapt AVG for seated play such as an upper-extremity Dance, Dance Revolution gaming mat, ¹⁹ an adapted version of the Wii Fit balance board for seated players,^18,77 and an adapted Wii gaming mat for seated play. ¹⁷ Adapted videogame controllers may also facilitate a higher dose of exercise training by increasing the amount of time a person with a disability is able to play by creating a game environment where an individual can play standing or sitting with minimal interruption to the experience.

The 2 most popular forms of AVG that were incorporated into interventions were Nintendo Wii and Xbox Kinect (83%), such as Wii Sports and Kinect Sports Rivals. The remaining studies used proprietary games not available to the public. Unfortunately, this may be problematic for future research because these two AVG devices have been discontinued (Nintendo Wii, October 2013 and Microsoft Kinect, October 2017) and may not be readily available or compatible with advancing technology. However, there is still potential to use AVG in future interventions by adapting technology and videogame controllers. The Microsoft Kinect device can still be used to control current PC games using applications such as the Flexible Action Articulating Skeletal Toolkit. ⁷⁸ Recent studies have adapted AVG input devices or created adaptive controllers to incorporate physical activity into a wide array of sedentary videogames for PWD and provide more opportunities to include participants with less functional ability in future research.^{16–18,77,79}

Our study findings indicated that the existing AVG studies have mainly targeted balance and mobility as primary health-related outcomes, and other important outcomes, such as changes in fitness and mitigation of secondary conditions, are vital to understanding AVG for PWD. While an increase in cardiorespiratory fitness was demonstrated for AVG among individuals with MS and stroke, other studies have shown that PWD can improve their cardiorespiratory capacity and increase their muscle strength with exercise training.^79–82 Only one study reported a reduction in pain during AVG; however, research has demonstrated a reduction in pain with exercise training among PWD.^83–86 Even though an increase in QOL and reduction in depression following an AVG intervention was reported for adults with MS, stroke, and Parkinson's (reduction in depression only), exercise training can improve QOL and reduce depression for other PWD.^{82,84,85,87–89} The use of AVG needs to be expanded beyond therapeutic use to facilitate improvement in physical fitness, functional ability, and QOL outcomes.

Among the studies reviewed, all but one reported a positive change in at least one of the outcomes assessed. Although there was a wide variation in the dose implemented within the interventions, 12 of the studies provided at least 150 minutes of activity per week. These parameters suggest that in some cases the dose of AVG is consistent with current physical activity guidelines. ⁶

The findings represent a promising potential to facilitate health-promoting activity that features AVG programming inclusive of people with mobility limitations; however, several trends emerged that future research should address. Researchers should include more underrepresented populations such as cerebral palsy, TBI, and SCI in AVG interventions. There exists a need for more AVG interventions to focus on physical activity and fitness improvements among PWD. In addition to using expert recommendations to dose an AVG intervention, efforts should be made by researchers to elicit appropriate exercise intensities in positions, such as sitting, that are inclusive to those with a mobility limitation. Because none of the included studies measured the participant's attitudes and perceptions of AVG, improvements can be made by surveying perceptions through focus groups and measuring task self-efficacy. Importantly, researchers can refine the AVG experience for PWD through usability testing and understanding the experience of the players themselves.

Conclusions

This scoping review described the characteristics of AVG interventions over a 10-year period and illustrated that AVG can produce positive changes in functional ability, health, fitness, physical activity, secondary conditions, and QOL for PWD, specifically those with neuromuscular conditions. The review suggests there is a need to recruit more underrepresented disability groups and dedicate additional attention to examining the possible benefits of AVG on physical activity and fitness, secondary conditions (e.g., pain), and QOL. Future research should include AVG equipment that is commercially available or implement adaptive devices that can facilitate play for PWD that possess a limited ability to stand.