Comparison of three interactive video games for youth with visual impairments

Abstract

There is a current trend toward using innovative interventions, such as active video gaming to increase physical activity levels among youth with visual impairments. Therefore, the purpose of this study was to compare three video games (Dance, Dance, Revolution [DDR]; EyeToy Kinetic; and Wii Boxing) in allowing youth with visual impairments to achieve time (seconds spent during a 10-min bout) in moderate-to-vigorous physical activity (MVPA). Participants with complete data were youth (N = 5) with visual impairments aged 10–16 years who played three games for 10-min bouts. Heart rate monitors measured physical activity intensity. A Friedman’s analysis of variance (ANOVA) was used to determine differences between the three interactive video games. Most players were able to achieve time in MVPA in all three games and there was a significant difference in time spent in MVPA, χ²(2) = 7.4, p = .024, with the most time in MVPA from playing EyeToy Kinetic. This study demonstrated that EyeToy Kinetic, Wii Boxing, and DDR are capable of helping youth with visual impairments accrue time in MVPA.

Keywords

Active gaming physical activity video games visual impairments

Introduction

One of the major goals of physical activity researchers and Healthy People 2020 is to identify ways to increase physical activity levels among underrepresented groups, such as individuals with disabilities (U.S. Department of Health and Human Services, 2012). The U.S. Department of Health and Human Services (2008a) recommended that all youth participate in at least 60 min of moderate-to-vigorous physical activity (MVPA) daily. A review of the literature by Haegele and Porretta (2015) found that physical activity levels among youth with visual impairments tend to be significantly lower when compared to same age peers without a disability.

This disparity is also implied that youth with a severe visual impairment are potentially less physically active than youth with less severe visual impairments (Stuart, Lieberman, & Hand, 2006). Additionally, there is evidence that implies that older youth with visual impairments are not as physically active as younger youth with visual impairments (Ayvazoglu, Oh, & Kozub, 2006; Longmuir & Bar-Or, 2000). Consequently, researchers have highlighted that youth with visual impairments have shown decreased levels of physical activity and these decreases in physical activity have contributed to lower daily MVPA percentages (Ayvazoglu et al., 2006; Kozub, 2006; Kozub & Oh, 2004; Oh, Ozturk, & Kozub, 2004). The low levels of physical activity are important to note because a number of youth with visual impairments may not be meeting the current MVPA guidelines which are an essential element in keeping them healthy (U.S. Department of Health and Human Services, 2008b).

Stuart and colleagues (2006) attribute intrinsic and extrinsic barriers to lower physical activity levels. These barriers, which may be limiters to the participation in physical activity, may include the following: personal barriers (e.g. level of visual impairment; Stuart et al., 2006), teacher-related barriers (e.g. knowing how to modify activities; Conroy, 2012; Perkins, Columna, Lieberman, & Bailey, 2013), and parental-related barriers (e.g. overprotection; Ayvazoglu et al., 2006; Stuart et al., 2006). This is problematic because youth who have low physical activity levels are at risk for becoming adults who do not adopt active lifestyles (Telama et al., 2005).

Unfortunately, youth and adults with disabilities are at risk of secondary conditions such as obesity due to their lack of participation in physical activities and their adoption of sedentary behavior (Rimmer, Rowland, & Yamaki, 2007). Vandewater and Huang (2006) further suggest that youth’s weight status is directly related to their sedentary behavior of screen time habits. This pattern has been observed in adults with visual impairments and is most likely the case with youth with visual impairments (Lenz, Starkoff, Lieberman, & Foley, 2015). As cost of consumer-based technology decreases, it is inevitable that screen-based technology, such as video games, will continue to increase among youth with and without disabilities.

A number of research studies have suggested that long bouts of non-active video games and computer usage may decrease physical activity levels of youth (Boone, Gordon-Larsen, Adair, & Popkin, 2007; Nelson, Neumark-Stzainer, Hannan, Sirard, & Story, 2006; Phillips, Rolls, Rouse, & Griffiths, 1995; Vandewater, Shim, & Caplovitz, 2004), that said, there is evidence of positive outcomes through active video game play (Foley & MacDonald, 2012; Yang & Foley, 2011). Studies involving video games have reported outcomes that can be assistive to youth with and without disabilities. Some of the reported outcomes include the following: increased visual field (Green & Bavelier, 2003), increased reaction time (Castel, Pratt, & Drummond, 2005), increased attention (Boot, Kramer, Simons, Fabiani, & Gratton, 2008), increased energy expenditures (Wang & Perry, 2006), and increased enjoyment levels of game play (Boffoli, Foley, Gasperetti, Yang, & Lieberman, 2011; Wood, Griffiths, & Parke, 2007).

Technology has started to move from non-active gaming to active or interactive gaming, which requires players to be physically active (Maddison et al., 2007). Active video games require full body movements to be the controller rather than them just moving thumbs on a controller. Some examples of active video games require the player to be the controller by reflecting the player onto the screen though a camera or by the player moving their feet on a pad in order to control the game. This trend is being embraced by the gaming world and researchers who are modifying gaming systems for individuals who are blind (Morelli, Foley, & Folmer, 2010; Morelli, Folmer, Foley, & Lieberman, 2011). However, little research has been done on commercially available systems for youth with visual impairments.

Most commercially available games have relied heavily on a graphic user interface for feedback and little on auditory and haptic interfaces. For a person with a visual impairment, this could be a barrier to engaging in game that might be played by friends and peers. While many individuals with visual impairments learn to modify or adapt when playing games, little is known whether commonly played active video games could successfully elicit MVPA in an individual with a visual impairment. Therefore, the purpose of this study was to compare three commonly used active video games in allowing youth with visual impairments to achieve time (seconds spent during a 10-min bout) in MVPA. The active video games that the youth played were Dance, Dance, Revolution (DDR) Extreme 2 (Playstation 2), EyeToy Kinetic (Playstation 2), and Wii Boxing (Nintendo Wii). These three games were chosen based on the following factors: (1) a review of the research indicated that players without disabilities are able to achieve over three metabolic equivalents (METs) of energy expenditure in all three games (Foley & MacDonald, 2012); (2) with a large screen, these games can be successfully played by youth with visual impairment (Gasperetti et al., 2010); (3) all games provide auditory feedback; (4) youth with visual impairments have shown high levels of enjoyment playing the three games (Boffoli et al., 2011); and (5) all three games were mainstream games that could be easily purchased. Foley and MacDonald (2012) list the MET values for the three games between 3 and 4 METs, with Wii Boxing having highest MET value. However, discrepancies in the literature exist; work by Whitehead, Johnston, Nixon, and Welch, (2010) suggested that playing DDR would produce higher energy expenditure than Wii Boxing.

The following two research questions were set forth based on the purpose of this study to compare of three commonly used active video games in allowing youth with visual impairments to achieve time in MVPA. The first question could youth with a visual impairment achieve MVPA while playing a commercially available active video games? It was hypothesized that all three games would allow players to achieve MVPA during play. The second question would there be a significant difference in time spent in MVPA between the three commercially available active video games? It was hypothesized that there would be no significant difference in time spent in MVPA between the three games.

Method

Participants

The participants in the study attended a 1 week overnight sports camp for youth with visual impairments. Prior to the arrival to camp, 15 youth were identified as being qualified to participate in the study based on level of visual impairment. To limit confounding factors that might adversely influence the results, the following inclusion criteria for the study were no orthopedic impairment, no intellectual disability, and the U.S. Association of Blind Athletes (2009) classification of B2 or B3. Athletes with a B2 classification have the ability to recognize the shape of a hand up to visual acuity of 20/600 and athletes with a B3 have a visual acuity between 20/600 and 20/200. Participants also had to be willing to wear a heart rate monitor while playing each video game.

Of the 15 possible candidates, 12 individuals initially decided to participate in the study. Two persons decided not to wear the heart rate monitor after the first session and therefore they were not included in the final study. The final number of participants (N = 10) were six males and four females with visual impairments who ranged in ages from 10 to 16 years. Because of a technical malfunction caused by human error during the data transfer with a heart rate monitor, some data were lost which resulted in five participants with incomplete data and five participants with complete data. Additional participant information is included in Table 1. Parents/guardians and the participants were informed about the study. The parents/guardians signed consent forms and the participants signed an assent document that was offered in large print and braille. All forms and procedures were approved by the Institutional Review Boards of the researcher’s universities.

Table 1.

Anthropometric data and descriptive classification of children.

Participant	Sex	Age (years)	VI Classification	Height (cm)	Weight (kg)	BMI (kg/m²)
1^a	M	11	B3	140.95	34.29	17.3
2^a	M	13	B3	166.05	50.82	18.4
3^a	F	15	B2	148.5	48.83	22.2
4^a	F	10	B3	134.1	35.11	19.5
5^a	M	11	B3	143	40.46	19.8
6	F	14	B3	152.95	51.46	22.0
7	M	10	B3	127.8	28.26	17.3
8	M	12	B2	164.5	73.71	27.2
9	M	16	B3	170.7	55.02	18.9
10	F	15	B3	147.5	47.47	21.8
M	−	12.7	−	149.61	46.54	20.44
SD	−	2.21	−	14.10	12.95	2.99

BMI: body mass index; SD: standard deviation.

Participants with complete data.

Procedures

Participants were accompanied by a counselor while being fitted and assigned a Polar heart rate monitor (model E600). An ultrasound gel was applied to the heart rate monitors to allow for better conductivity. Youth were asked to wear the heart rate monitors while playing all three of the interactive video games. Additionally, to determine resting heart rate, they had to wear the heart rate monitor once for 20 min while they were resting on their bed. The heart rate monitors were programmed to record heart rate every 15 s and were started at the beginning of the activity and stopped at the end of 10 min or the completion of the interactive video game. Additional measurements included height and weight and that were recorded with a stadiometer and digital scale, respectively.

Modifications to DDR, Wii Boxing, and EyeToy Kinetic were made based upon a 1 week field study completed a year prior to this study using the recommendations of Gasperetti et al. (2010). The authors found that modifying these games would allow for enhanced usability of the games by all youth, specifically youth with visual impairments. Modifications included the following: (1) using a 6 ft × 6 ft projector screen, (2) placing the projector 8 ft high to prevent shadowing, (3) placing the DDR pads close to the screen, (4) reduce the room lighting to allow better contrast, and (5) allow youth time to practice.

The participants were assigned to play three interactive video games (DDR Extreme 2, EyeToy Kinetic, and Wii Boxing) in a random order. DDR is an interactive video game that uses a touch-sensitive dance pad to step on in sync with arrows scrolling up on the display screen. The arrows that appear on the screen could be up, down, left, and right or a combination of two of them. When the arrows reach a set of stationary shadowed/target arrows that are at the top of the screen, the player stepped on the matching arrow on the dance pad. Each time a step was to be taken, there was a visual and sometimes auditory feedback given. The visual feedback was a dancer in the background making the same movements as the player and the auditory feedback would be good, great, perfect, or almost.

EyeToy Kinetic is a Sony Playstation 2 interactive video game that uses a USB web camera to incorporate the player onto the screen. The camera places a live moving video of the player on screen, and as such, the movements they make are reflected on screen. In essence, the camera provides a type of virtual reality that allows the player and their movements to be the controller. EyeToy Kinetic has several games suitable for youth with visual impairments (Gasperetti et al., 2010). The game Breakspeed was chosen for this study since Boffoli et al. (2011) found youth with visual impairments experienced high levels of enjoyment while playing this game. The objective of the game is to break as many bricks as possible located in the upper right, upper left, lower right, and lower left areas of the screen. The bricks appear in the four areas, and the harder the players punch or kick, the more bricks they break (explode). Each time a brick was hit, there was a visual (breaking of bricks) and an auditory (sound of breaking bricks) feedback.

Wii Boxing is an interactive video game that uses the Nintendo Wii system. The player holds two controllers in their hands, a Wii controller which is connected to an additional “nunchuk controller.” The controls represent the hands of the player’s avatar through the various sensors in the controllers; thus, relaying the player’s movements to the on-screen avatar. The player has to throw, dodge, and block punches in order to beat their opponent. The objective of the game is to knock out their opponent as quickly as they can within three 1-min rounds. Throughout the game, there was visual feedback as each detected move of the player results in corresponding on-screen movement. There was also auditory feedback when the player or opponent was hit, and there were also cheers and clapping. Additionally, haptic feedback was provided through the vibrating Wii controller when the player’s on-screen avatar makes contact with the opponent or gets hit by the opponent.

Data collection

Participants followed a previously established protocol from Morelli and Colleagues (2010) of playing one game a night; each game had a 5-min warm-up before participants played for a period of at least 10 min. During DDR, the youth were allowed to choose the songs and level of their choice. Each participant played at least five songs while wearing the heart rate monitor. During EyeToy Kinetic, the youth played the game Breakspeed for 10 min which included at least 3 bouts of the game that lasted 3 min on the same level. During Wii Boxing, the youth were handed the controllers and they played as many games as they could in the 10-min allotted time. In all cases, players played each game at least 10 min. After 10 min of playing, players were allowed to finish the game before stopping. Data were used from the first 10 min of game play.

After each playing session, the heart rate data were downloaded via an infrared USB device into the Polar PE Manager software and then exported to an Excel spreadsheet. The heart rate data are described in Table 2. Extreme values of heart rate are any numbers that were above maximal heart rate and below resting heart rate. These extreme values were eliminated due to an illogical sequence and they were replaced with averages of heart rate values around the eliminated heart rate. The Karvonen method for determining target heart rate was used to determine maximal heart rate, heart rate reserve, and target heart rate (Karvonen & Vuorimaa, 1988); 60% of heart rate reserve and 80% of heart rate reserve were determined to be the target heart rate range (Powers & Howley, 2007) and the threshold values for MVPA (Gilson, Cooke, & Mahoney, 2001). All heart rate data were reported in beats per minute. MVPA were reported in seconds spent in MVPA during a 10-min period.

Table 2.

Average heart rates in beats per minute (bpm).

Participant	Resting (bpm)	Kinetic (bpm)	Wii (bpm)	DDR (bpm)
1^a	89	144	129	119
2^a	79	162	134	114
3^a	95	133	148	136
4^a	95	154	153	117
5^a	91	164	153	152
6	108	165	−	150
7	94	128	116	−
8	90	−	132	112
9	72	−	91	94
10	88	159	−	121
M	90.1	151.13	132	123.89
SD	9.66	14.45	21	18.81

SD: standard deviation; DDR: Dance, Dance, Revolution.

(–) missing data.

Participants with complete data.

Data analyses

For the five participants who had complete heart rate data to calculate MVPA for all three games (participants 1–5), a Friedman’s analysis of variance (ANOVA) was used to analyze whether there was a difference in time spent in MVPA between the three games. Post hoc tests for Friedman’s ANOVA were performed by comparing the differences between the mean ranks of the different groups (Games 1–2, Games 1–3, Games 2–3; Siegel & Castellan, 1988). If the mean difference is larger than the critical Z, then there is a significant difference between the groups. A critical Z score of 1.51 was determined and compared to the mean ranks for each activity. Alpha was set at .05 to test for statistical significance in the analysis. Effect size was calculated by (r = ^z/_√n) in order to measure the strengths of the two variables being compared – interpretation of the effect size: .1–.29 = small effect, .3–.49 = medium effect, and .5 and greater = large effect (Field, 2005).

To take full advantage of all the data from all 10 participants (5 with complete data and 5 with missing data) in the study, a second analysis was completed. A series of repeated measures using multiple regressions with robust standard errors, to account for the lack of independence, were used to determine whether a significant difference exist between games (Blackwell, Mendes de Leon, & Miller, 2006). Three separate multiple regressions were run with MVPA as the dependent variable. The games played were coded as 1/0 binary independent variables to compare MVPA of one interactive video game to the MVPA of the other two interactive video games. The Holm’s sequential Bonferroni method was used for adjusting multiple comparisons, where the p values are ordered from smallest to largest. After they are ordered, those values are then compared against the threshold values (Holm, 1979). Data were analyzed using SPSS for Windows v.16 (SPSS Inc., Chicago, IL, USA) for the Friedman’s ANOVA and Stata v. 11 (StataCorp LP, College Station, TX, USA) for the regressions.

Results

The Friedman’s ANOVA test revealed a significant difference in time spent in MVPA, χ²(2) = 7.4, p = .02. Post hoc analysis revealed that time spent in MVPA for EyeToy Kinetic (M = 264.00 s) was significantly greater than time spent in MVPA for DDR (M = 63.00 s), p < .05, and r = –.64. Although time spent in MVPA for Wii Boxing (M = 156.00 s) was greater than time spent in MVPA for DDR (M = 63.00 s), it was found to be not significant. Similarly, time spent in MVPA for EyeToy Kinetic (M = 264.00 s) was greater than time spent in MVPA for Wii Boxing (M = 156.00 s) and it again was found to be not significant.

The results obtained from the multiple linear regressions (second analysis with the full sample) mirror the results from the above-mentioned analysis. Time spent in MVPA for EyeToy Kinetic (M = 256.88 s) was significantly greater than time spent in MVPA for DDR (M = 40.00 s), p = .03. Even though time spent in MVPA for Wii Boxing (M = 103.13 s) was greater than time spent in MVPA for DDR (M = 40.00 s), it was found to be not significant. Similarly, time spent in MVPA for EyeToy Kinetic (M = 256.88 s) was greater than time spent in MVPA for Wii Boxing (M = 103.13 s) and it was found to be not significant. Table 3 displays the amount of time for each participant spent in MVPA for each active video game. The results showed that 8 out of 10 of the youth with visual impairments were able to get some MVPA from at least one of the three active video games. The activity that showed the most amount of time spent in MVPA was EyeToy Kinetic.

Table 3.

Time spent in MVPA (seconds/percentage).

Participant	Kinetic MVPA	Wii MVPA	DDR MVPA
1^a	135/22.5	0/0	0/0
2^a	495/82.5	60/10	0/0
3^a	15/2.5	135/22.5	0/0
4^a	195/32.5	285/47.5	30/5
5^a	480/80	300/50	285/47.5
6	315/52.5	−	45/7.5
7	0/0	0/0	−
8	−	45/7.5	0/0
9	−	0/0	0/0
10	420/70	−	0/0
M	256.88/42.81	103.13/17.19	40/6.67
SD	199.87/33.31	125.35/20.89	93.37/15.56

SD: standard deviation; MVPA: moderate-to-vigorous physical activity.

(–) Missing data.

0/0 indicates no time achieved in MVPA.

Participants with complete data.

Discussion

Active video games

This study sought answer the following two questions: (1) could youth with a visual impairment achieve MVPA while playing a commercially available active video games? And (2) would there be a significant difference in time spent in MVPA between the three commercially available active video games? For the first research question, it was hypothesized that all three games would allow players to achieve moderate-to-vigorous activity during play. The results of this study confirm the hypothesis that most youth with visual impairments can achieve MVPA while playing commercially available active video games. For the second research question, there was a significant difference in time spent in MVPA between the three active video games. It was hypothesized that there would be no difference in time spent in MVPA between the three games. The results indicated otherwise, playing EyeToy Kinetic provided greater time in MVPA than DDR.

The findings of this study suggested that participating in active video games such as EyeToy Kinetic, Wii Boxing, and DDR may increase time spent in MVPA, with the EyeToy Kinect video game resulting in a greater percentage of time in MVPA than DDR. This result may be partially explained by the movement of the upper and lower extremities required to play EyeToy Kinect. These interactive video games may be beneficial to increasing physical activity and obtain important health benefits (Foley & MacDonald, 2012; U.S. Department of Health and Human Services, 2008b). Initially, active video games which started out in arcades have slowly integrated into different environments, leading researchers to investigate its’ uses for physical education, fitness, and rehabilitation (Yang, Smith, & Graham, 2008). Active video games have also been used in schools and communities to promote physical activity, working together, and social skills (Street, Lacey, & Langdon, 2017). This study provides evidence that active video games enable the players with visual impairments to move their bodies to play the games, thereby allowing them to accumulate time in MVPA.

Professionals in charge of the promotion of physical activity for youth with visual impairments can utilize the results of this study to justify the usefulness of active video games. Furthermore, by incorporating these types of games into sport camps, afterschool programs, or physical education programs, professionals may trigger curiosity and interest of youth with and without visual impairments to play together. This may provide youth with visual impairments a much needed outlet for common socialization and interests. To maximize social and physical benefits of active gaming, instructors may need to be selective in terms of types of video games and modifications made before including all students.

Limitations

Because of the small sample size in this study, the results may not be representative of all youth with visual impairments and limits the generalization of results to all youths with visual impairments. However, since other studies have shown youth without visual impairments achieve MVPA while playing these games it provides confidence in our results (Alsac, Johnson, & Swan, 2007; Tan, Aziz, Chua, & Teh, 2002; Thin, Howey, Murdoch, & Crozier, 2007). A limitation of this study may be that the amount of true MVPA might have been underestimated due to fatigue associated with attending an overnight sports camp and an evening collection. That said, differences between games most likely were not influenced by fatigue because of the randomly assigned counterbalanced design of the study. Another limitation is the missing data from participants 6–10. Finally, players were given the choice to self-select songs when playing DDR, and this may have affected the intensity of the game play. That said, this was more realistic to how the games would be played at home.

Recommendations for future research

Future research studies on this topic should include more participants and be conducted over a longer amount of time. In addition, it would be beneficial to investigate the sustainability of using active video games in the home environment. There is a need for more research on the design aspects of the game, such as the influence of different types of auditory feedback during gaming or the way a person’s avatar is portrayed in the game (ideal vs actual self).

Recommendations for practice

The three active video games in this study are consumer friendly and may provide opportunities that enable peers to work and play together, thereby promoting socialization which is imperative for youth with visual impairments (Hoysniemi, 2006; van Schie & Wiegman, 1997). Additionally, peers may form communities based on interest in video games that will help expand their social network (Hoysniemi, 2006). Furthermore, these games can be used to motivate students with visual impairments to sustain an active lifestyle (Lieberman, Ponchillia, & Ponchillia, 2013). The more motivated a student is to exercise, the more likely they will increase their time in physical activity.

Implications for practitioners and families are that interactive video games are commercially available and can be found in many places including electronics department in department stores, electronic stores, video game stores, on the Internet, and at yard sales. Interactive video games and video game systems range in prices from inexpensive to expensive depending on the age and the version of the video game system. The current research study found that with proper modifications, interactive video games such as Kinetic, Wii Boxing, and DDR are capable of allowing this particular sample of youth with visual impairments to attain time in MVPA.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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