The Use of Commercial Health Video
Games to Promote Physical Activity in
ISSN: 1524-7929 VOLUME: 18 PUBLICATION DATE: May 20 2010
Volume 18-Issue 5-May 2010
Tiffany E. Shubert, PhD, MPT
Over the past 18 months, sales of the Nintendo Wii™, Electronic Arts Sports Active™,
and Konami’s Dance Dance Revolution (DDR)™ totaled $2 billion worldwide.1
Gamers today represent a broad range of ages and backgrounds. The average gamer is
39 years old, 40% are women, and more than 25% are age 50 and over.2 It was
estimated that by the end of 2009, 68% of American households would have a gaming
console in the home.2
Older persons have not missed out on this trend, with several media reports of entire
nursing home chains and senior centers purchasing gaming systems and offering games
as a part of their programming. Game developers have also expanded their
demographics by focusing on developing and marketing games with greater appeal to
the general public. Over 84% of the games available on the market today are labeled
“E,” meaning they are appropriate for everyone, and these “E” games accounted for the
largest market share of all games sold in 2008.2
Why the surge in interest and participation in video games by older adults? One major
reason is the fun factor. Innovative technologies such as motion sensors and smart
homes have been developed to facilitate healthy aging or aging in place, but these
technologies are not interactive or engaging. Virtual reality and spatial 3D user
interfaces have been utilized as effective adjuncts to or components of rehabilitation for
the past 20 years, but until recently these technologies were quite expensive and not
portable. Through recent technological innovations, off-the-shelf gaming consoles can
replicate several aspects of a costly virtual reality system, and these systems can be
played in an individual’s home.
The combination of improved technology, cheaper price, and age-appropriate games has
captured the interest of older adults. These games offer fun and convenient activities
that are cross-generational, social, and could have health benefits. Commercially
available health games have the potential to be a health promotion intervention to
increase an older adult’s physical activity levels; however, these types of games have
only been available since 2007, and several questions remain unanswered about the
efficacy, feasibility, and safety of these games for older persons. The purpose of this
review article is to provide an overview of the commercial health video games available
that could promote physical activity, review the research being done with these games,
and discuss future directions.
A Brief History of Health Video Games
The video game industry began in the mid-1970s with the advent of the video arcade.
During the 1980s and 1990s, the technology and graphics improved, prices dropped,
and video games effectively moved out of the arcade and into the home. Few
individuals purchased the first home games with their large and expensive consoles and
rudimentary graphics. Games from that period through today typically consisted of a
console connected to a television or computer to display the game and a controller that
the player manipulated to interact with the game. Some would say that the technology
may have evolved too much during this period, as the games and controllers became
quite complicated, and market share was lost due to lack of interest from the general
The current generation of games and gamers are quite different. The games incorporate
advanced technologies, but they couple those technologies with relatively simple user
interfaces and easy-to-manipulate controllers. Gamers now can use their entire body to
play the games developed for the Sony PlayStation® 2 EyeToy™, perfect a real yoga
move using Wii Fit, or manipulate real physical props like guitars and drums to play
The gaming industry has evolved as well, with entirely new areas of research and
development in “Health Games” to best meet the demands of the ever growing market.
Health games are specifically designed to encourage the participant to engage in
healthful behaviors.4 This may be physical activity (Wii or Dancetown Fitness
System®), improving eating habits, stopping smoking, or even engaging in a virtual
world in which recovering substance abusers can practice and reinforce relapse-
The health video gaming industry has expanded significantly over the past few years
and is supported by several foundations looking to develop better health promotion
dissemination vehicles. The Robert Wood Johnson Foundation has funded 20
researchers during the past two years to pursue studies developing or modifying health
games to improve physical activity or some aspect of self-care. Senior-specific topics
include: “Commercially Available Interactive Video Games for Individuals with
Chronic Mobility and Balance Deficits Post-Stroke” at the University of South
Carolina; “Seniors Cyber-Cycling with a Virtual Team: Effects on Exercise Behavior,
Neuropsychological Function and Physiological Outcomes” at Union College
Department of Psychology; and “Action Video Games to Improve Everyday Cognitive
Function in Older Adults” at the University of Florida.4
Current and Future Research
The research in this area is in the early stages. This new generation of technology has
the potential to effectively facilitate increasing physical activity or other behavioral
changes; however, published studies to date have been done only in children and
adolescents.5-8 Currently, no published research addresses the effect of these gaming
systems on energy expenditure, behavioral change, or health benefits in older adults. In
general, children and adolescents who engage in interactive video games expend more
energy than playing more traditional video games,5, 6 but the amount of expenditure is
typically less as compared to playing the actual game.5,7 Researchers have also reported
that with certain games, as skill level increases, so does the energy expenditure.7 No
studies have been published in the pediatric or geriatric literature on the effect of
playing these games on physical or functional performance in healthy individuals. In the
rehabilitation literature, there has been one case study of an adolescent with cerebral
palsy who incorporated Wii as part of his rehabilitation intervention with positive
Health Video Games for Older Adults
The three most popular health video games that have the potential to be appropriate for
seniors and incorporate physical activity are Dancetown, EyeToy, and Nintendo Wii.
There are no publications to date that assess relationships between older adults playing
these games and levels of physical activity.
Dancetown Fitness System®
The only game designed specifically for seniors is Touchtown’s Dancetown Fitness
System® (Figure 1), the more “mature” version of DDR.10 This gaming system utilizes
a dancepad marked with directional arrows. The pad is connected to a personal
computer that drives a display device (a television or a computer screen). When the
player is ready, graphics appear on the screen to guide the dance step movements. At
first, movements are slow, but progress in speed and complexity as the player becomes
more skilled. Whereas DDR features quick steps to rock and roll and hip hop,
Dancetown incorporates a more senior-friendly design, slower dance steps, and safety
features like grab bars. An additional innovative feature of Dancetown is the
incorporation of validated, senior-specific assessment tools such as the Senior Fitness
Test, The Timed Up and Go, the Tinetti Balance and Gait Test, and the Six-Minute
Dancetown records performance and generates results that could be utilized by a
physical therapist or a physician.10 To date, there are no published studies on
Dancetown, although a few have been published studying DDR as a potential
intervention to increase physical activity in children.5-8,11 These studies suggest that
children age 8-10 years will increase total weekly physical activity and decrease
sedentary activity time when they have access to DDR.8,11 One other study compared
energy expenditure of adolescents playing DDR, Wii, and walking at 5.7 miles per hour,
and determined that playing DDR was the equivalent of moderate-intensity
walking.5The authors concluded that DDR played at the appropriate level could be an
effective intervention to promote physical activity in children. The findings from this
research could be applied to older adults who may enjoy participating in this type of
activity in their home or at a senior facility.
The Sony PlayStation® 2 EyeToy™
The EyeToy (Figure 2) is a low-cost, off-the-shelf, video-capture system. It consists of a
camera connected to the PlayStation 2 gaming system, which is connected to a
television. To interact with the system, the camera is turned on, and an image of the
player appears on the screen. The system works best if the individual is alone in a well-
lit room so that the character on the screen is clearly delineated.12 When the player
moves his/her body, the image on the screen mirrors the actual movements. Players
move their bodies to “play” different virtual games, such as popping bubbles, painting a
rainbow, or even completing a do-it-yourself project. Sony has plans to release the next
version of the EyeToy in the PlayStation Move game to be released in Fall 2010. The
PlayStation Move is Sony’s response to the Wii and has the potential to be easier to
manipulate and provide better feedback to older adult players.13
Three articles have been published assessing whether the EyeToy is a feasible and
effective adjunct to rehabilitation post-stroke.13-15 Yavuzer et al13 compared Functional
Independence Measure (FIM) scores among 20 patients with hemiparesis who added 30
minutes of EyeToy play to conventional therapy to a control group receiving
conventional therapy and a placebo treatment. The intervention group demonstrated
significant improvements in FIM scores as compared to controls. Researchers reported
that participants had high adherence rates and enjoyed the activity.
A feasibility study was conducted to determine whether an older adult post-stroke could
successfully interact with the user interface and to identify appropriate games for
seniors.14 A 76-year-old woman, 17 months post-stroke, independently played with the
EyeToy for 20 one-hour sessions distributed over four and a half weeks. The EyeToy
sessions were not supervised, although the patient’s companion was present for each
session. Researchers reported that the subject enjoyed playing the games but found that
several games were either too difficult or just not interesting to the subject. However,
five of the 15 games were played repeatedly by the subject. Researchers reported that
after the initial orientation, the subject could independently set up and play the system.
After the intervention period, the subject demonstrated significant improvements on the
Dynamic Gait Index, as well as trends toward improvements on several balance
measures. The subject reported that she would continue to play after the study period.14
Rand et al15 investigated the feasibility of the EyeToy as compared to the IREX®
Virtual Reality Exercise system as an intervention for healthy older adults and those
with disability. Results from the study indicate that the EyeToy was a feasible
intervention for individuals with acute and chronic stroke, it was suitable and easy to
operate for older adults, and older adults enjoyed interacting with the EyeToy as much
as younger adults, but they enjoyed playing different games.
Preliminary research indicates that the EyeToy may be an effective intervention to
increase physical activity and improve physical fitness in healthy older adults. Lotan
and colleagues16 reported that middle-aged adults (mean age, 52.3 ± 5.8 yr) did improve
on measures of physical fitness after playing the EyeToy for two 30-minute sessions per
week for six weeks. The EyeToy appears to be a feasible option for healthy older adults
and those with impairments. The user interface is simple, and older persons have
reported that the games are enjoyable.14,15 Adherence rates for studies have been high,
and this is especially important for those individuals recovering from stroke or other
impairments. Adherence rates to home exercise programs are traditionally low. If the
EyeToy can improve those rates and improve physical function, then it follows that
physical activity levels may increase.
The Wii gaming system was released by Nintendo in November 2006. The name “Wii”
was chosen to emphasize the “we” aspect of the game, meaning that it is meant for
everyone to play.16 According to Nintendo and the popular press, older persons have
embraced Wii. Nintendo has specifically included seniors in a broad-based marketing
campaign launched in 2006,16 and there have been reports of people in their 90s and
100s playing the game.17 In 2007, Erickson Living partnered with Nintendo to host a
series of Wii Bowling Championships across the nation. Seniors created teams at their
local assisted living facilities and participated in a “virtual bowling championship” with
other teams across the nation. Highlights of the competition were posted on
www.youtube.com, creating much positive press for the gaming system. Shortly after
the first championship, several newspapers and websites reported about the surge in
nursing homes and senior centers purchasing Wiis.
The original Wii includes a “Wiimote,” the primary remote controller for the console.
The controller is a handheld device with a few buttons that allows users to navigate the
games. It has an accelerometer and utilizes infrared technology that tracks and translates
real motion into the virtual game, allowing players to swing a virtual tennis racquet or
golf club. Players receive feedback about performance through their “Mii,” or virtual
self. When players first interact with the game, they create a Mii, which appears on the
screen to translate a player’s real motions into virtual motions and track performance.16
The Wii Fit (Figure 3) was the first interactive video game incorporating a balance
board designed specifically for the Wii system. The Fit was released in December 2007
and has become the second best selling video game in history. The balance board is able
to calculate body mass index, track center-of-pressure movements, and provide
feedback on performance. By including a performance tracking and education
component, Wii Fit shifts away from playing games and toward an innovative health
and fitness focus. When players first interact with Wii Fit they complete several balance
tests conducted by the game. Based on the game’s assessment of performance, the
system calculates a “Wii Fit Age,” which can be a player’s actual age, or significantly
younger or older. The system tracks time between sessions, weight lost/gained, and
overall performance. The system will reassess balance performance at specified times
and generate graphs for a visual display of progress. It also allows users to track
physical activities outside of the game. Wii Fit includes a “virtual trainer” who
demonstrates the strength and yoga exercises, provides feedback on performance, and
educates users about the importance of posture, strength, and balance. The Fit offers
four categories of games: balance, strength, yoga, and aerobic. As users progress,
exercises are “unlocked,” for a total of 47 activities.17
Criticisms about Wii Fit include that it is limited in providing a “real workout.”18 Each
exercise lasts approximately one to two minutes, and there is a break while users choose
the next exercise. In 30-45 minutes of Wii time, a user may engage in only 20 minutes
of actual physical activity or exercise.
The next generation of health video games is already lining up to remedy this problem.
Electronic Arts released Sports Active in May 2009. It is an interactive workout DVD
that uses Wii and Wii Fit to lead a participant through 30-45 minutes of physical
activity. Sports Active also does brief “health assessment” questionnaires that allow
players to track their sleep habits, eating habits, and how much water they have drunk
that day. Nintendo is also developing new games, and in June 2009 announced it would
include technology to monitor such vital signs as heart rate and oxygen levels in the
next generation of Wii.
Although more popular than the EyeToy, less published research exists on Wii and Wii
Fit. Early publications focused on injuries associated with younger people playing Wii.
There were several reports of adolescents and young adults with wrist and shoulder
injuries due to too much play19, 20 or becoming too involved in the game and losing
awareness of the environment, resulting in fractures and falls.21,2223,24
The most recent reports have focused on assessing the energy expenditure associated
with playing the various Wii games. In Wii Sports Pack, boxing appears to have the
highest energy expenditure for children and adults.5,25,26 The most popular game with
seniors is bowling; however, bowling has been shown to have the smallest increase in
energy expenditure of all the Wii Sport Games.5 In addition, the bowling game can be
played while sitting, which makes it a great social opportunity; however, it may not
have the health benefits of a standing game.
Over the coming year, more will be understood about the role of Wii to increase
physical activity or as an adjunct to therapy. A few case reports presented in early 2009
supported the assertion that Wii might facilitate the achievement of certain physical
therapy goals.28,29 One case presented an 89-year-old woman who played the bowling
game standing as a component of therapy.28 The authors reported improvements in
balance and balance confidence. Another study assessed the effect of Wii and Wii Fit as
an adjunct to traditional therapy with a 69-year-old woman with balance impairments.29
Outcomes suggest that including Wii and Wii Fit as part of therapy may have
contributed to the patient’s compliance with therapy and improved performance on
balance and coordination assessments.
There is much interest in determining whether playing Wii can improve function and
mobility in patients with movement disorders. The National Institutes of Health has
funded two studies using Wii. Researchers at Vanderbilt University are assessing
movement data collected from the Wiimote.30 Their purpose is to determine whether the
Wiimote produces reliable and valid data to study individuals with movement disorders.
Researchers at St. Michael’s Hospital in Toronto are examining the effectiveness of Wii
gaming versus recreational activity in patients receiving standard rehabilitation after
stroke.27 Other funded studies include a pilot study assessing the effect of playing Wii
on movement and depression in individuals with Parkinson’s disease at the Medical
College of Georgia,28 and the effects of Wii Fit on strength and balance in healthy older
adults at the University of Aberdeen, Scotland.29
Of the three most accessible and popular health video games for seniors, Wii has
generated the greatest popular interest. It has senior-appropriate options, and older
persons need to be educated on how to play the games to get the greatest health benefits.
If they are sitting and bowling, they will probably not be improving balance and
strength, but they may be socially engaged. Social engagement is an important and
meaningful activity, even if it is not actually physical activity. However, if they are
patients who are recovering from strokes or diagnosed with Parkinson’s disease, then
Wii games played sitting or standing may be an option to improve range of motion and
Wii Fit poses the greatest questions. The Fit board is quite narrow, 20 inches wide by 12
inches long and 2 inches high, and does pose a fall risk, especially for an older adult
with slower reaction times and difficulty with dual tasks. In addition, the games can be
quite challenging, and several are not appropriate for older adults with physical or
cognitive impairments. Informal queries with staff at senior centers and assisted living
facilities indicate that older adults can lose their balance while playing Wii Fit and are
always supervised. Finally, Wii Fit does provide feedback on performance, but often
that feedback can be discouraging. If an individual does not perform well, the virtual
trainer or the Mii looks sad and disappointed. This is not the feedback one would want a
new exerciser to have, and may impede behavioral change.
Our own research addresses aspects of how video gaming technology can be
appropriately modified to appeal to older persons and be utilized as an effective health
promotion intervention. One question not yet addressed in the literature is that of user
interface and usability. Although Nintendo has made great efforts at simplifying the
console to improve the access and usability of Wii, there are no data supporting that
seniors can easily navigate the system. Discussion from a presentation entitled “The Use
of the Wii and Related Technology in Physical Therapy” at the American Physical
Therapy Association’s Combined Sections Meeting in February 2009 indicated that
therapists typically set up the games instead of the patients. Discussions with staff at
several senior facilities support that activity directors or technicians set up the systems
for older adults to play.
We have conducted several focus groups composed of both senior Wii veterans and
novices to assess user interface design and feasibility, and with physical therapists using
the Wii as part of therapy with geriatric patients. Results from focus groups indicate that
seniors are very interested in playing the Wii, especially if there is a particular health
benefit that can be achieved with play.30 However, both older adults and therapists
report that several of the games are too fast for older adults, and the feedback too
negative.30,31 One researcher studied a group of older adults learning to play Wii
bowling and reported several issues with the ability to press and release the correct
button at the correct time in order to successfully play the game.32 These results all
support the need to develop senior-appropriate fun games, and suggest that this may be
a potential venue to deliver health promotion interventions.
Our current research is focused on modifying current gaming technologies to develop a
senior-friendly video game. This game could be played in any setting—the home, gym,
or senior center—and could potentially deliver programming to improve strength or
balance to be used as an adjunct to traditional physical therapy. We are borrowing
several concepts currently incorporated in gaming consoles to see if we can make the
intervention fun and engaging to improve adherence. If successful, this format may be a
safe, reliable, and valid way to increase physical activity among seniors.
Gaming, and in particular, “exergames,” has captured the public’s attention and will
continue to grow as a part of our culture. While these games show great promise as an
introduction to physical activity, the virtual game still has a long way to go before
replacing actual activity. Few of these games are tailored for older adults, and some
games may put an older adult at increased risk of a fall. However, adherence rates for
games appears to be high, which supports the possibility of health video games as an
effective intervention to promote physical activity in older adults. The EyeToy and
Dancetown are probably better options for older persons at this time due to ease of use,
functionality of games, and specificity to the geriatric population.
That being said, health video gaming has great potential for both healthy older adults
and those with impairments. As the games are modified to increase their appeal and
appropriateness for older adults, and as researchers determine what participating in
these games translates to for function and mobility, we may see health video games as
an effective and safe venue to increase physical activity in a fun and meaningful way for
This project was supported by the “Bringing Basic Scientist to Aging” pilot grants
program through the University of North Carolina Institute of Aging. Funding for this
grant program was provided by The UNC-CH Office of the Vice Chancellor for
Research and Economic Development.
The author reports no relevant financial relationships.
Dr. Shubert is a Research Scientist, The University of North Carolina Institute on
Aging, and Adjunct Assistant Professor, The UNC Division of Physical Therapy, Chapel
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