According to the WHO [77], health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (p.1). This definition includes behavioural, physical, mental and social aspects of health and well-being. Besides control of nutrition and drug consumption, performing an active lifestyle including adequate, continuous, and enduring participation in physical activity, exercise or sport is an important issue (e.g. [4]). In this section, we differentiate endurance training, resistance training, training of sensory–motor functions and further effects relevant to prevention.
Endurance training
One goal of PA and RE is to raise the additional energy expenditure above a minimum of 600–800 kcal per week, with an optimum of about 3,000 kcal per week [57]. According to the proposed theory of planned behaviour and its extensions or modifications, SG may offer a good option for PA because of their positive effects on attitude, emotions, motivation, intention and self-efficacy.
The new generation of digital games, especially video games, works on interfaces that demand whole-body movements to control the game, like Konami Dance Dance Revolution, Sony EyeToy Kinetics, XaviX Sports, Nintendo Wii Sports and Wii Fit and Microsoft Xbox Kinect. Specific sensors like cameras, motion sensors and force sensors measure the movements of the players and integrate this information into the control of the respective game.
Numerous studies have been published showing great differences concerning the applied research methods (see [5, 36, 39, 74] for recent reviews). Concerning the rise of energy expenditure (EE), Fig. 4 shows the results of the available studies [3, 7, 11, 22, 37, 54, 59, 65, 75]. The impact of playing games on energy expenditure highly depends on the gaming device, game type and intensity of gaming. Energy expenditure in “virtual” sport games is always below the respective “real” sports activity (e.g. [3, 22]). At best, an EE of above 400 kcal/h can be achieved. This means that in order to meet the minimum requirements for health-enhancing PA, one has to play at least 2 h/week; for the optimum, at least 7.5 h are required. From long-term SG studies, we know that the participants have difficulties to meet this challenging criterion (e.g. [42]). Unfortunately, all the above-mentioned studies have analysed children, youth or young adults, and study quality is often low (e.g. lack of experimental control in gaming). Therefore, it is not clear whether the reported EE increases hold for elderly people.
Wollersheim et al. [78] investigated the physical and psychosocial effects of exergaming with the Wii Sports in community-dwelling older women (N = 11; mean age, 73.5 ± 9.0 years). The treatment consisted of a 6-week training period with two sessions a week (average duration of one session, 51 min; range, 9–130 min). The participants played individually or in groups of up to four in a planned activity group offered by a community health service. Quantitative accelerometer data showed that the exergaming did not have substantial physical effects. The qualitative data reveal that the participants on the one hand had difficulties in getting familiar with the game technology, were embarrassed and needed continuous extrinsic positive feedback by the experimenters and on the other hand experienced fun, challenge, motivation, as well as social and psychological well-being. It is noteworthy that two participants left the programme because of “embarrassment about using the Wii” ([78], p.88). Another woman dropped out on advice of her physician. The quality of this study is low because of a missing control group and lack of treatment control. The results clearly show that the SG was a motivating experience with additional benefit only for a part of the sample. According to the EMPB, perceived control and self-efficacy was supported by playing the game, enhancing the intention to continue playing in some women. According to the 4LM, SG effects were mainly confirmed on the psychological and social level, i.e. the “sensing body” and the “relating body”. One important conclusion can be drawn from the results: Older SG players prefer individualised gaming, i.e. gaming corresponding to their individual needs, experiences and physical conditions, within social gaming contexts.
Resistance and strength training
Some studies addressing strength training have included older subjects. King [33] showed in a clinical laboratory study with 146 patients (age range, 16–78 years) that embedding gaming contexts into strength exercises increased the number of repetitions of strength exercises (training volume) significantly. However, the study quality is low because of the confounding of game and task requirements. The authors did not assess psychological, physiological and social parameters.
Sohnsmeyer, Gilbrich and Weisser [56] performed a randomized control trial study with 40 subjects above 70 years. The subjects of the game group (age, 76.95 ± 4.84 years) played an activity-promoting video game (Wii Bowling) for 6 weeks (two 20-min sessions per week). The control group (age, 77.75 ± 8.69 years) did not exercise. After training, strength of the left and right quadriceps increased significantly compared to the control group. The authors on the one hand report high acceptance by the participants but on the other hand emphasize that exergames are very demanding and include some risk of injury. One issue of this study is the lack of treatment control.
Both studies examining the effects of strength training cannot be related to the EMPB or 4LM because the respective variables have either not been assessed or not been reported in detail. However, both studies confirm psychological effects on motivation.
Sensory–motor training
The reviews by Lager and Bremberg [36] and Ijsselsteijn et al. [31] reveal positive effects of SG on the reaction time of older people. The age of the participants ranges from 57 to 90 years.
Kliem and Wiemeyer [34] compared a game-based balance training programme with a traditional programme using a convenient sample of 22 members in a health-care centre (age: range = 18–67 years; M = 47.36 years, SD = 13.14). After a period of 3 weeks (three 10- to 12-min sessions per week), both groups improved significantly in four of five balance tests. On the one hand, subjects improved their performance in tests that were part of their training programme; on the other hand, subjects were able to transfer training effects to new balance tasks. Self-efficacy and enjoyment of PA did not change. Overall, the traditional training programme was more effective than the game-based programme. In contrast to Brumels et al. [12] who examined younger subjects, no motivational benefit was found for older adults. In the original publication, a no-treatment control group is missing; therefore, the learning effects cannot unequivocally be attributed to the intervention. According to the EMPB, the results indicate that because of the lack of differential effects on self-efficacy and enjoyment, the proposed SG intervention will not lead to enhanced intention and behaviour changes in older people. Due to the individual training procedure, social effects were not examined. Concerning the 4LM, only two levels have been analysed: the psychological and the behavioural level.
Williams et al. [76] performed a pilot and feasibility study with subjects above 70 years who had suffered from falls. The intervention group (N = 15) underwent a structured individual 12-week training with two training sessions a week using the Wii fit console, while the control group (N = 6) performed a conventional 12-week exercise and training programme. While the intervention group showed a transient improvement of balance (week 4) and a terminal improvement of Wii-fit age (week 12), the control group did not improve balance skill. Furthermore, two subjects dropped out in each group. There were no differences concerning the attendance of the programme. Members of the intervention group reported enjoyment (100%), adequate length and frequency of exercise (69%), low barrier for participation (77%) and the strong desire to continue Wii training (92%). Unfortunately, the members of the control group were not interviewed. Based on the EMPB, positive attitude and perceived control increased the intention to continue training. Concerning the 4LM, only the behavioural and psychological levels have been investigated.
Harley et al. [27] conducted a qualitative 1-year study with 30 players (age, 60 to 94 years) using the Wii console for bowling competitions. Participant observations of ten gaming sessions and interviews revealed that the older people easily adopted the new technology, had a lot of fun and gradually established and broadened social connections with their peers. Playing the Wii offered a safe place for learning the new technology enhanced by mutual support. The quality of this study is low because of the lack of treatment control and missing standardised tests and surveys. Concerning the 4LM, three levels of effects confirmed surplus effects of SG: psychological, behavioural and social levels.
Young et al. [80] developed two games based on the Wii balance board: The centre of pressure was measured to control the position of a basket for catching apples or the position of an avatar to pop rising bubbles. In a pilot study, after a 4-week training period including ten sessions of 20 min game play, a sample of six healthy elderly people (mean age, 84.1 ± 5.1 years) showed both increased balance skill and self-efficacy. In addition, all participants confirmed to be ready to continue game training for the next 6 months. Due to the missing control group, these effects must not be attributed to the game treatment. According to the EMPB, sustainable game training can be expected because of the positive impact of self-efficacy on intention. According to the 4LM, only two levels have been addressed: the psychological and the behavioural levels.
Complex training intervention
Homma [30] performed a one-group pre-post study including elderly people (age, M = 87.3 years; SD = 4.2; range, 80–94 years.). After 6 weeks of training (three sessions of 30 min per week), hand and quadriceps strength improved significantly. However, endurance, joint flexibility and coordination (stand up and reaction) did not improve. Furthermore, all participants experienced enjoyment and flow whereas one person reported problems with the handling of the numerous buttons of the Wiimote interface. Only two participants perceived physical improvements. Unfortunately, Homma neither controlled training sufficiently nor included a control group. Furthermore, the variables indicating an additional benefit were assessed only by qualitative methods (interview). Attitude was positive, whereas self-efficacy was low leading to antagonistic effects in the EMPB.
Neufeldt [46] performed a qualitative study with six participants. After introduction to the video game (Wii sport), the attitude of the participants changed from scepticism to curiosity and enjoyment. On the other hand, the participants experienced severe control problems with the Wii interface leading to the covering of the unused buttons. An important side effect was the spontaneous development of new player communities. According to the EMPB, by change of attitude and enhanced self-efficacy and sense of control, the intention to engage in PA may be positively affected. There is also a significant interaction of the sense of control and enjoyment [40]. Concerning the 4LM, three levels show an additional benefit of SG: the psychological, the behavioural and the social level.
Voida, Carpendale and Greenberg [70] (see also [69]) examined 12 playing groups including two groups of three female residents of a retirement community (age, 68–84 years) and a family group including two mature adults (age, 52–59 years). The qualitative studies reveal the great importance of social gaming for older people: Particularly, mutual encouragement was observed in the game groups. Fun and enjoyment seemed to be elicited primarily by the collective game experience rather than the game design.
Further preventive effects
Other application fields of serious games are perception, sensory–motor control, asthma prevention, prevention of drug abuse, smoking prevention, HIV prevention, prevention of violence, and nutrition [5, 36, 39]. Most of the studies find positive short-term effects of serious gaming on attitude, knowledge, motivation, volition and behaviour.
Almost nothing is known about long-term effects and dose–response relationships. According to the EMPB, positive effects can be expected because of the positive impact of SG on attitude, volition and behaviour. Concerning the 4LM, studies neglected two levels: the physiological and the social level. With very few exceptions, all studies tested children, youth or young adults.
Summary: prevention
Summing up the existing evidence, the following effects of exergames and games for health have received at least partial support:
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Rise of EE (to be confirmed in elderly persons)
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Improvement of strength
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Improvement of basic motor control (e.g. simple reactions, balance)
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Improvement of health-related knowledge
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Improvement of self-efficacy and other motivational, emotional and volitional components
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Improvement of social interactions and communication
On the one hand, research shows encouraging results concerning the effectivity and additional benefits of SG; in general, relevant factors in the EMPB and 4LM seem to be positively affected. However, in the studies, the complex concept of game experience has not been completely examined. On the other hand, SG also provoke new barriers. One important aspect that needs to be considered is the usability of the game technology. In most studies with older people, at least some subjects experienced difficulties with the interface. Therefore, appropriate user interfaces have to be developed for the specific target group of older gamers. Usability of the game controller seems to be an important contributor to game experience [20, 40].
Another important issue is the setting. Almost nothing is known on which gaming settings favour long-term use of SG. The generally positive effect of SG on game experience, which is normally found in young people, seems not to hold for older gamers. Playing in communities (e.g. peer groups or family) seems to be an important option for older people (e.g., [27, 46, 69, 70]). In this regard, the EMPB needs to be further extended to social variables relevant to sustained PA and RE (e.g. [64, 71]). Furthermore, the quality of most studies is low, and studies with older people have rarely been published.
What are the particular challenges for science? Some key issues should be addressed in the future:
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The development of appropriate game concepts for the effective and enduring enhancement of all components of health behaviour games should be tailored for specific target groups (e.g. older people with or without specific sensory–motor disabilities; see also [31])
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Performing more randomized controlled studies as the gold standard for evidence-based interventions (e.g. [2]) covering the complete range of effects
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Investigating the appropriate dose–response relationship for exergames and games for health
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Searching for the appropriate settings for intervention based on sound theoretical foundations