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Perspectives on Active Video Gaming as a New Frontier in Accessible Physical Activity for Youth With Physical Disabilities

Jennifer L. Rowland, Laurie A. Malone, Cali M. Fidopiastis, Sangeetha Padalabalanarayanan, Mohanraj Thirumalai, James H. Rimmer
DOI: 10.2522/ptj.20140258 Published 1 April 2016

Abstract

This perspective article explores the utility of active video gaming as a means of reducing sedentary behavior and increasing physical activity among youth with physical disabilities and limitations in lower extremity function who typically are excluded from mainstream exercise options. Youth with physical disabilities are disproportionately affected by health problems that result from sedentary behavior, lack of physical activity, and low fitness levels. Physical, programmatic, and attitudinal barriers have a synergistic and compounded impact on youths' ability to participate in physical activity. A recent health and wellness task force recommendation from the American Physical Therapy Association's Section on Pediatrics supports analyzing individualized health behaviors and preferences that are designed to improve fitness, physical activity, and participation in pediatric rehabilitation. This recommendation represents an opportunity to explore nontraditional options to maximize effectiveness and sustainability of pediatric rehabilitation techniques for youth with disabilities who could best benefit from customized programming. One new frontier in promoting physical activity and addressing common physical activity barriers for youth with physical disabilities is active video games (AVGs), which have received growing attention as a promising strategy for promoting health and fitness in children with and without disabilities. The purpose of this article is to discuss the potential for AVGs as an accessible option to increase physical activity participation for youth with physical disabilities and limitations in lower extremity function. A conceptual model on the use of AVGs to increase physical activity participation for youth with physical disabilities is introduced, and future research potential is discussed, including a development project for game controller adaptations within the Rehabilitation Engineering Research Center on Interactive Exercise Technologies and Exercise Physiology for People With Disabilities (RERC RecTech) at the University of Alabama at Birmingham (UAB)/Lakeshore Foundation Research Collaborative.

The most recent US Census data reported that approximately 5.2 million (8.4%) of children under age 15 years had a disability.1 Half of children with a disability (2.6 million children) were classified as having severe disabilities.1 Obesity prevalence and physical inactivity are significantly higher among youth with physical and intellectual disabilities compared with youth who are nondisabled.2–5 A recent report indicates that obesity rates among youth with disabilities are 38% higher than for children without disabilities.6 An analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2002 revealed that 80.6% of children with functional limitations affecting participation in physical activity were classified as being either overweight or obese.7 In ambulatory youth with cerebral palsy (CP), the prevalence of obesity has been reported to be 16.5%, with increasing rates since the mid-1990s.8 Children with spina bifida have the highest rate of obesity at 50%.9

High obesity prevalence, combined with lower levels of physical fitness, limits the ability of youth with disabilities to lead healthy and independent lifestyles.10 The long-term consequences of physical inactivity and eventual severe deconditioning can be costly in developing a higher risk for secondary conditions such as obesity, pain, fatigue, and other health conditions such as heart disease and type 2 diabetes.4,11

Because of barriers, youth with physical disabilities are less likely than youth without disabilities to participate in physical activity.12–14 Physical activity guidelines recommend that youth aged 6 to 17 years should engage in 60 minutes or more of physical activity each day.14 For youth with physical disabilities, however, numerous barriers make it extremely difficult to meet this goal.15 Physical, programmatic, and attitudinal barriers to physical activity have a compounded effect on participation.16–18 Such barriers include playgrounds and ball fields that are inaccessible to wheelchair users (ie, uneven or grass surfaces) and lack of knowledgeable staff who understand or desire to implement adaptations to sports and physical activity programs.19,20 Likewise, sports fields, parks, playgrounds, and physical education classes are often used for competitive games and sports.16 For many youth with physical disabilities, costs associated with program fees and transportation also are barriers to physical activity participation.21 Children and youth with physical limitations in balance, strength, coordination, power, and aerobic fitness have a difficult time keeping up with their peers in community- and school-based physical activities, sports, and recreation, which may lead to decreased interest of parents in encouraging physical activity in their children.22 With fewer opportunities to participate in sports, recreation, and fitness, youth with disabilities are more likely to spend available leisure time in sedentary behaviors.23

For the purposes of this article, we are defining physical disability in terms of mobility limitations. Specifically, for our discussion on adaptations and development of game controllers, we are focusing on youth with lower extremity mobility disabilities (eg, youth with spina bifida, CP, muscular dystrophy, spinal cord injury, or other type of lower extremity mobility disability) with partial or full use of their upper extremities. One explanation for the higher rate of obesity and lower physical fitness may be related to the difficulty many youth with physical disabilities experience in their attempts to be physically active.24,25

Conceptual Model for Using Active Video Games (AVGs) as an Accessible Means of Physical Activity for Youth With Physical Disabilities

One promising approach to promoting physical activity and addressing common physical activity barriers in youth with physical disabilities is AVGs, also called “exergames,” which refer to a category of video games involving movement or in which movement is encouraged by the game controller that could involve motion-sensing cameras or handheld versions, mats, or boards.24 Active video games have garnered recent attention as a “gateway experience” to motivate players to increase the intensity and amount of daily physical activity. Specifically, a few years ago, the American Heart Association convened a planning committee to examine the influence AVGs might have on health promotion and health behaviors and described AVGs as a “gateway experience” to physical activity, meaning they open the door to interest and participation in other types of physical activity as a result of playing the games. The panel, which included health care providers, behavioral researchers, and professionals from the active-play game industry, concluded there is a promising future in developing games and technologies focused on increasing physical activity participation, energy expenditure, and the incorporation of abilities and interests of diverse and targeted populations.25

Given the emerging evidence supporting AVGs as a means of improving cardiovascular and functional outcomes in youth with physical disabilities, the application of AVGs as a tool for home- and community-based physical activity in this population represents a new frontier in accessible physical activity for youth with disabilities. Figure 1 provides a conceptual model focusing on AVGs and accessible options that can be used to increase health benefits for youth with disabilities in home- and community-based settings. This conceptual model is influenced by domains from the International Classification of Functioning, Disability and Health (ICF).26 Specifically, the conceptual model incorporates accessibility barriers that draw from the “Impairments” and “Activity and Participation” domains in addition to the contextual factors involving the “Person” and the “Environment.”

Figure 1.
Figure 1.

Conceptual model of active video gaming for youth with physical disabilities. RERC RecTech=Rehabilitation Engineering Research Center on Interactive Exercise Technologies and Exercise Physiology for People With Disabilities.

The far left column of the conceptual model represents “Accessibility” and the barriers (low cardiovascular endurance and decreased physical functioning) represented in the AVG literature for youth with disabilities.22,27–31 Adaptations to address these physical limitations are listed at the bottom of that column and represent the research being conducted by the Rehabilitation Engineering Research Center on Interactive Exercise Technologies and Exercise Physiology for People With Disabilities (RERC RecTech) at the University of Alabama at Birmingham (UAB)/Lakeshore Foundation Research Collaborative, including game controller adaptations, seated play, and differing levels of fitness enhancing play. The specific aspects of this project are described later in this article. The “Health-Related Outcomes” column of the conceptual model addresses behaviors such as motivation, exercise adherence, and enjoyment that may be influenced by AVGs. Other potential health-related outcome benefits include increased cardiovascular endurance, increased functional independence, and long-term outcomes such as decreased chronic disease and secondary condition risks.

The “Environment” and “Activity/Participation Outcomes” columns of the conceptual model represent settings and social outcome improvements that may result from AVG play. These are important aspects of application for adapted activities that involve settings (home, community) and social environments (social inclusion within peer groups).

AVG Accessibility to Improve Health-Related Outcomes

The third column of the conceptual model focuses on health-related outcomes. Currently, AVG accessibility is limited for youth with physical disabilities, given this population's generally low cardiovascular endurance and physical limitations, such as decreased motor control, range of motion, muscle strength, ambulatory status, and balance.16,22 Many AVGs offer limited play options for youth who are unable to stand, have balance problems or poor motor control, or cannot use their lower body to perform game movements.24 Active video game adaptations to game controllers and provisions for seated play offer youth with physical disabilities accessible options for using AVGs for moderate-to-vigorous exercise in environments such as their homes and communities. Personal factors (eg, age, sex) and cultural factors play a role in game selection and potential satisfaction. The resulting health-related outcomes include improved health behaviors, such as exercise motivation, that are increased by game enjoyment and potentially lead to increased exercise adherence. Health benefits include increased cardiovascular endurance and functional independence, and long-term benefits include decreased chronic disease and secondary condition risks.22,27–31 Activity and participation outcomes also are potentially affected by game play that involves more than one player, and adapted games can increase social inclusion for these youth among family, peers, and community groups.

Figure 2 represents an example of the RERC RecTech conceptual model applied to a youth with CP. Specific information about ways in which the model can be applied to these youth is provided in the (1) “Accessibility” column (barriers and adaptations sections), (2) “Environment” column (person section), (3) “Activity/Participation Outcomes” column (social inclusion section), and (4) RERC RecTech game controller adaptation sections.

Figure 2.
Figure 2.

Example of the conceptual model of active video gaming applied to a youth with cerebral palsy. RERC RecTech=Rehabilitation Engineering Research Center on Interactive Exercise Technologies and Exercise Physiology for People With Disabilities, UE=upper extremity, LE=lower extremity.

AVG Accessibility Solutions

Within the conceptual model are adaptations to address barriers for AVG play in addition to the newly developed game controller adaptations from the RERC RecTech. In examining these adaptations, it is useful to consider the current state of AVG accessibility. Exploring the usefulness of AVGs as an accessible option for exercise is part of the emerging applications for these exergames. The “Adaptations” section of the model offers provisions for game controller and seated play adaptations that will allow for moderate-to-vigorous game play to best determine the dose-response effects for each participant. Over the past decade, AVGs using floor pad controllers (ie, Dance Dance Revolution [DDR], El Monte, California) have been popular. Recent research by Rowland and Rimmer22 examined the accessibility of adapted DDR game pads that considered reachability and sensitivity of the pads, which were adapted into tabletop versions for participants who are nonambulatory. More recently, however, the introduction of motion-controlled AVGs (ie, Nintendo Wii [Nintendo, Redmond, Washington], Sony PlayStation 3 Move [Sony Corporation of America, New York, New York], Microsoft Xbox One [Microsoft Corp, Redmond, Washington]) that allow a much greater variety of physically active games have increased their popularity. These games hold promise for promoting higher levels of energy expenditure, weight management, and fitness among youth and are recognized by the President's Council on Fitness, Sports & Nutrition as tools to reduce childhood obesity.32 Accelerometer-based hand controllers such as those used by the PlayStation Move and Nintendo Wii platforms often require rapid and precise movements for successful play. Active video games using the camera-based controller of Microsoft Kinect (Microsoft Corp) typically require the player to be standing for proper game function.

Within the past several years, there has been an emergence of a variety of creative and successful adaptations to game controllers and interfaces that enable youth with disabilities to play video games. For example, Figure 3 represents a wheelchair platform that was developed for use on top of the Wii Fit balance board. The individual sits in his or her wheelchair on top of the balance board and is able to shift his or her weight from side to side and from front to back. Using these movements, the person controls the cursor on the screen as required for the game. The “floor-board” is made of lightweight black ABS plastic for use with manual wheelchairs and a maximum weight of 49.6 kg (330 lb) (http://www.lifelivelyactive.com). Other game adaptations and accessibility information is available on the following websites: (1) http://atwiki.assistivetech.net/index.php/Wii_accessibility (includes general discussion of the Nintendo Wii system, along with various controller interfaces for accessibility, and a list of games that work with modified controllers); (2) http://www.acpoc.org/assets/pdf/AdaptedGameControllers.pdf (a document produced by Shriners Hospitals for Children, with a list of adapted game controllers websites); and (3) http://www.apparelyzed.com/forums/forum/67-accessible-video-gaming-xbox-nintendo-wii-playstation/ (a support forum for individuals with spinal cord injury and cauda equina syndrome, which includes a section on accessible video gaming).

Figure 3.
Figure 3.

A large platform that sits on top of the Wii Balance Board as an example of an adaptation to allow wheelchair users to play games that require use of the balance board.

Use of Active Video Gaming in Youth With Disabilities

The concepts within the conceptual model are supported by a review of the literature on AVGs and youth with disabilities.22,27–31,33,34 To date, most of the AVG or “games for health” literature has involved youth and young adults without disabilities,35–45 including games based on factors such as physical activity or health behavior education as a weight loss mechanism.46–54 More recently, video games have been examined as a potential rehabilitation tool for adults with disabilities,55–59 including an emerging body of literature examining their use in clinical and community settings for youth with disabilities. Researchers have begun to examine the use of AVGs for cardiorespiratory, functional rehabilitation, and satisfaction outcomes in youth with disabilities.22,27–31,33 These studies are described in more detail below, with a summary presented in the Table. The Table reviews 8 studies and includes a short description of each study, including information on the sample, gaming platform, measures, key findings, and strength of the evidence.60

View this table:
Table.

Summary of Studies That Explored the Use of AVGs for Youth With Disabilitiesa

Exercise Intensity and Energy Expenditure Outcomes

Exercise has proven to be an important component in the health and fitness of youth with physical disabilities. For example, studies have shown that youth with CP are able to achieve and sustain moderate-intensity exercise and are able to improve health-related fitness outcomes through structured exercise training.61,62 A systematic review that included 23 studies suggests that youth with spina bifida also are able to achieve exercise benefits, such as cardiorespiratory endurance and muscle strength through aerobic (eg, running, wheeling) and strength (eg, isotonic exercises) training regimens.63 A review of the literature that examined the role of exercise in managing juvenile idiopathic arthritis indicates that structured aerobic exercise training leads to benefits, including improved exercise capacity, functional ability, and quality of life.64

O'Donovan et al27 measured energy cost and exercise intensity of AVG play among children with and without cystic fibrosis (n=30 in each group) while playing Nintendo Wii Sports Boxing and Wii Fit Free Jogging. The researchers found no significant difference between the groups (mean age=12.3 years, SD=2.6; 17 boys, 13 girls; age- and sex-matched controls). The participants with cystic fibrosis were reported to have relatively high pulmonary function and to be relatively healthy. Both groups were able to attain light- to moderate-intensity levels of aerobic activity during AVG play. Wii Boxing was found to be a light-intensity activity (2.46 metabolic equivalents [METs]), and Wii Fit Free Jogging was found to be a moderate-intensity activity (4.44 METs). As suggested by the authors, Wii Fit Free Jogging, when played regularly, could be of sufficient intensity for youth with and without cystic fibrosis to achieve cardiovascular health benefits.

Robert et al28 compared exercise intensity levels between age-matched children with spastic diplegic CP and children with typical development while playing Wii Fit games. Participants played 4 games (Skiing, Jogging, Snowboarding, and Bicycling), 10 minutes per game. Heart rate (HR) measurements taken during game play were used to calculate heart rate reserve (maximum HR − resting HR) as a measure of exercise intensity. Secondary measures included muscle spasticity, joint passive range of motion, and isometric muscle strength. Lower body kinematics also were assessed during the Jogging and Bicycling games. Rate of perceived exertion (RPE) was measured at the end of each game, as was degree of motivation. Results indicated no difference between groups in terms of exercise intensity levels during game play, thus suggesting that children with CP who are ambulatory could potentially benefit from AVG exercise in ways similar to children who are developing typically.

Rowland and Rimmer22 conducted a feasibility study of AVGs as a means for increasing energy expenditure in young adults with disabilities who are nonambulatory. They tested 3 young adults with differing upper extremity functional levels on Wii Fit and DDR games and found that, with appropriate modifications, the AVGs showed clinically significant increases in energy expenditure for all 3 participants. All participants were nonambulatory wheelchair users with differing upper extremity function. Participant 1 (severe limitation) was a 21-year-old woman with spastic quadriplegic CP and bilateral upper extremity limitations, participant 2 (moderate limitation) was a 19-year-old man with spastic diplegic CP and unilateral upper extremity limitations, and participant 3 (no limitations) was a 21-year-old man with spina bifida and no upper extremity limitations. For participants with severe and moderate limitations, there was a higher percentage increase in energy expenditure for the Wii games (severe limitation, 25.6%; moderate limitations, 30.8%) compared with the DDR (severe limitations, 10.8%; moderate limitations, 29.1%), whereas the participant with no limitations had a greater increase for the DDR (173.5%) compared with the Wii (59.5%).

Howcroft et al29 examined energy expenditure, muscle activation, and quality of movement in children with CP (N=17; mean age=9.43 years, SD=1.51) during play of 4 AVGs (Wii Bowling, Wii Tennis, Wii Boxing, and DDR Disney Dance Grooves). The children also completed the Physical Activity Enjoyment Scale. The results indicated the potential for youth with CP to achieve light-to-moderate physical activity levels during AVG play (DDR Disney Dance Grooves: X̅=3.20 METs, SD=1.04; Boxing: X̅=3.36 METs, SD=1.50) as well as the ability of AVGs to provide rehabilitative effects such as joint motion and promotion of bilateral limb use. The children also reported a high level of enjoyment with the games, an important factor for continued participation.

Widman et al34 used the GameCycle upper extremity exercise device (Out-Front, Mesa, Arizona) and a video game that controls a car in a racing game to measure peak oxygen consumption, maximum work output, aerobic endurance, peak HR, RPE, and user satisfaction among 8 youth with spina bifida (aged 14–18 years). Results indicated 6 of the 8 participants reached 50% of their oxygen consumption reserve (V̇o2R), 7 of 8 reached an HR of 50% of heart rate reserve, and 7 of 8 participants increased maximum work capacity during a maximal arm crank ergometer test.

Functional and Rehabilitation Outcomes

The impact of AVGs on functional rehabilitation represents another area of research. Li et al30 tested the effectiveness of a relatively low-cost (<$700) home-based virtual reality therapy system to promote upper extremity movement for children with hemiplegic CP. The system included a Sony PlayStation 2 with EyeToy and a video signal control subsystem. The researchers found that targeted hand and arm movements of the hemiplegic limb were improved through use of the virtual reality-based system, and it provided an enjoyable outlet for performing the rehabilitative arm movements at home.

Deutsch et al31 studied one 13-year-old child with CP using the Test of Visual Perceptual Skills, third edition (TVPS-3); a posture scale analyzer; and functional mobility measurements during 11 sessions over 4 weeks. They found that visual processing improved in all domains except visual memory. Postural control also improved, and ambulation with crutches increased from 4.6 m (15 ft) to 45.7 m (150 ft) during training and up to 76.2 m (250 ft) after training.

Jannink et al33 performed a 2-part study to examine unilateral upper limb function and game satisfaction for the EyeToy on PlayStation 2 among youth with CP aged 7 to 16 years. These youth played the EyeToy games 30 minutes twice per week for 6 weeks and experienced increased upper limb function as measured using the Melbourne Assessment of Unilateral Upper Limb Function. These youth also rated the game to be visually interesting and reported that they were motivated by the game.

Importance of the Literature on Physical Activity and Active Video Gaming for Youth With Disabilities

As a whole, the current body of literature has explored the effects of AVGs on cardiovascular and functional outcomes with some secondary analyses involving other variables such as enjoyment. Taken together, these contributions allow for projections of the potential benefit of AVGs on health-related outcomes as well as activity and participation outcomes for youth with traditionally few exercise options.

RERC RecTech Project's Approach to Addressing AVG Accessibility for Youth With Physical Disabilities

After examining the current research on AVGs and their utility for youth with disabilities, it is clear that further research and development are needed to examine the usefulness of AVGs in promoting physical activity in youth with physical disabilities. Future research will involve: (1) developing and testing the accessibility of gaming systems, (2) examining the benefits of AVGs in improving cardiorespiratory fitness in youth with physical disabilities at various levels of function, and (3) determining the potential positive effects of AVGs on social inclusion and motivation involved in physical activity participation. As represented in the bottom section of the conceptual model (Fig. 1), the RERC RecTech development project to adapt game controllers to increase their accessibility for youth with physical disabilities offers a potential solution to traditional accessibility barriers. By increasing game controller accessibility through development and testing and examining the benefits of adapted game play on health outcomes, the potential long-term effects on activity and participation can be measured.

User-Centered Design of AVGs and Controller Limitations

The RERC RecTech adaptations involve the use of user-centered design (UCD). This is the design process typically followed to guide the development of any product that needs to optimize human performance, such as how well the targeted user population interacts with the product.65 The UCD process is an iterative process that takes into account the performance goals, characteristics of the users, their environment, required tasks, and workflow into the design of a product. The primary goal of UCD is to enhance the usability of products while providing a more productive and enjoyable experience. Active video games are prime examples of human-in-the-loop systems that include computer hardware, software, and a gamer. The game developer must first understand how the user will interact with the hardware and software of the gaming system in order to create an entertaining experience that also meets the goal of providing a fitness benefit. The interactivity of the gamer with the computer technology (eg, joystick) and gaming elements (eg, action codes for movement) is a key issue that also determines the accessibility of the exergame for all players. Because gaming systems are developed with people who are able-bodied as the target user population, a primary goal is to design game controllers to be accessible for youth with different levels of functional ability.

Traditional game controllers (eg, mouse and keyboard, joystick) provide a simple means to direct an avatar or figure representing a person in computer games. The game controller is an essential component of the gaming experience, yet currently receives little attention as an aspect of designing AVGs for accessibility. For example, the Kinect, developed by Microsoft, uses the body motion of the gamer as the controller for their popular Xbox gaming system. This controller does not recognize gamers in wheelchairs, nor does it have the capability of coding for body motions used by people with disabilities. The unique challenges of AVG design is the expectation of physical fitness benefit for the player regardless of his or her ability level. The goals for a controller that will meet these expectations must be those that provide seamless interactivity, high levels of immersion, and, more importantly, appropriate physical effort.

Most conventional controllers provide limited options for adapting to a player's current ability level.66 Due to lack of accessibility, the option to use off-the-shelf gaming controllers typically is limited when designing AVGs for the diverse needs of youth with disabilities. International Organization of Standardization (ISO) standards for the overall design and development of interactive computer-based systems, which includes AVGs, exist (ISO 13407, now ISO 9241-210) and are successfully used within the exergames design cycle.67 Following a UCD ensures the appropriate usability, effectiveness, efficiency, and satisfaction of the AVG as a whole. However, as Fidopiastis et al68 suggest, satisfying the recommended ISO guidelines is subjective to the designer, who may not address valid usability testing specifically for people with disabilities when testing how these gamers interact with their product. These standards also do not specifically address game controller design and gaming system integration. Therefore, most conventional controllers are not flexible (eg, enable a range of action codes) for adapting to a player's current ability levels.66 To expand the benefit of AVGs to adults and youth with disabilities, the AVG design cycle must go beyond usability testing to include a scalable mapping of ability levels and fitness outcomes to the controller functionality.

There are examples of applying systematic design guidelines to determine AVG controller limitations as they pertain to effort levels for people without a disability. Park et al,69 for example, evaluated speed-based exergame controllers that required continuous effort (eg, stationary bike) and mapped linear or angular speed to intensity of activity. For unmodified game use, the controller evaluation pointed to several areas of concern that limited game play and impeded attaining functional effort levels. These controller limitations included: (1) lack of appropriate speed ranges to support controllability at different levels of the game, (2) game activity that polarized effort levels (ie, either too challenging or too easy), and (3) lack of training prior to game play. For youth with disabilities, these types of evaluations provide more information on how to adapt the controller than solely focusing on what type of physical input is necessary for accessibility. These studies highlight the necessity for a safe, yet standardized, methodology to evaluate not only the controllers but also how the overall AVG design can support youth with disabilities.

Dose Mapping

Exercise dosing refers to the prescribed intensity and duration of exercises performed. We are mapping the exercise dose of cardiovascular measurement assigned to the AVG game activity to that of the newly designed controller. There is an explicit need for more detailed AVG design guidelines to address issues of appropriate exercise dose mapping to the controller accounting for player level. The dose mapping is critical for successful implementation of AVGs to fitness outcomes when considering people with disabilities as end users. In addition to a module on how to perform the exercise appropriately, there is a necessity for safety guidelines addressing repetitive strain injuries and negative training. There are systematic design guidelines to speed-based exergame controllers that require continuous effort (eg, stationary bike) and that map linear or angular speed to intensity of activity.69

When creating AVGs, several features must be considered for youth with disabilities: (1) currently, game designers do not set appropriate speed ranges that support controllability at different levels of the game; (2) game activity intended to affect the player's effort level is either too exhausting or not challenging enough; and (3) training is not provided to the player such that the appropriate user action was known prior to game play. The RERC RecTech study addresses adaptation for youth with disabilities by highlighting the explicit need for more detailed AVG design guidelines to address issues of appropriate exercise dose mapping to the controller accounting for player level. The dose mapping is critical for successful implementation of AVGs to fitness outcomes when considering persons with disabilities as end users.

Testing Adapted Game Controllers

To address the barriers for AVG participation among youth with lower extremity mobility disabilities, the RERC RecTech research team aims to first identify the barriers these youth encounter in using gaming controllers for AVG play and then develop accessible controllers that enable AVG participation. For this project, we are recruiting youth with lower extremity mobility disabilities (eg, spina bifida, CP, muscular dystrophy, spinal cord injury) and with partial or full use of their upper extremities to play AVGs on all systems (Nintendo Wii, Sony PlayStation 3 Move, and Microsoft Xbox One). Heart rate will be monitored, and the Children's OMNI Scale of Perceived Exertion70 will be used to collect the participant's RPE. Participants will complete the Active Video Gaming Session Feedback sheet to document aspects pertaining to use of the system (eg, Did they experience pain or loss of balance?) and 16 Active Video Game Enjoyment questions. The investigator will complete an Active Game Observation Sheet to document quality of game play and the ability of the participants to use the controllers.

Once barriers to successful AVG play are identified, a team of engineers will adapt current technology or develop new technologies to overcome these barriers and open a new engaging avenue for physical activity participation. A primary strategy will be to develop technology that sits between the standard controller and the console, reading a specific remapped or adapted interface. Although some adaptations may require only simple re-engineering, others are likely to require complicated reverse engineering, which will be utilized as deemed feasible or necessary.

We also will determine the dose-response relationship involved in playing AVGs in youth with mobility impairments, with the resultant outcome being a listing of energy expenditure values in METs for each AVG. Currently, there are no guidelines for energy expenditure of various types of AVGs for youth with physical disabilities. The following game protocol design will provide information necessary to gather energy expenditure for the games and to determine the capacity of each participant prior to use of the AVGs. Games will be categorized into low, moderate, or vigorous intensity based on the participants' HR during game play and measure of V̇o2R (V̇o2 peak − V̇o2 resting) using a portable gas analyzer: light intensity=20% to 39% V̇o2R; moderate intensity=40% to 59% V̇o2R; and vigorous intensity=60% to 84% V̇o2R.71 The energy expenditure exercise protocol will include 2 sessions of 24 minutes of AVG play (3 games, 8 minutes per game) while connected to the portable analyzer for each gaming system. The long-term goals are to make AVGs accessible and to develop an evidence base for the use of AVGs as an exercise modality for improving cardiorespiratory fitness and strength in youth with physical disabilities.

Additional Areas of Future Research

In addition to the current and future research being conducted by the RERC RecTech on developing and testing accessible game controllers, another important area for future research involving AVGs and accessible physical activity options for youth with physical disabilities is the social inclusion and motivational aspects of peer and competitive game play. Examining the combinations of AVGs as a social activity that can be played between youth with and without disabilities using the same system, thus promoting full inclusion, is an area of research that has not yet been fully explored. Early research in this area has shown that multiplayer modes of game play have increased enjoyment and future play motivation that also are associated with high physical intensity.72 A recent study by Howcroft et al73 showed that children with unilateral CP enjoyed multiplayer game play more than solo play, and they speculate that this enjoyment may translate into more frequent participation in game play.

Another research focus is examining ways to maximize independence in game play for youth with physical disabilities. As outlined in the conceptual model, decreased physical functioning is often a barrier to physical activity participation among this population.4,10,11,74,75 Examining ways of promoting independence in the initiation of game play could include training caregivers or other assistants to work with the youth to set up an environment in which equipment is reachable and easy to access, position, and advance when needed.

Conclusion

Active video games have the potential to offer an accessible and motivational means of increasing physical activity participation in youth with physical disabilities. Although there is certainly a need to continue to emphasize more inclusive play, sport, and recreation opportunities for youth with all types of disabilities, there is an equally important need to increase physical activity in these underserved populations. Some organizations (eg, Lakeshore Foundation, Special Olympics, BlazeSports) provide model programs with the adaptations necessary to engage youth with disabilities in physical activity and sport; however, more such programs are needed. Until the barriers associated with physical activity participation for youth with physical disabilities are addressed, these youth will continue to be limited in their exercise options. Active video games offer a new frontier in promoting physical activity and addressing common physical activity barriers for youth with physical disabilities.

Footnotes

  • Dr Rowland, Dr Malone, Dr Fidopiastis, Mrs Padalabalanarayanan, Mr Thirumalai, and Dr Rimmer provided concept/idea/project design. All authors provided writing. Mrs Padalabalanarayanan provided project management. Dr Rimmer provided facilities/equipment.

  • The contents of this manuscript were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90RE5009-01-00) and from an NIDILRR Field Initiated Grant (NIDILRR grant number H133G080120) and a Quality of Life Grant awarded by the Christopher and Dana Reeve Foundation. NIDILRR is a center within the Administration for Community Living (ACL), US Department of Health and Human Services (HHS). The contents of this manuscript do not necessarily represent the policy of NIDILRR, ACL, or HHS, and endorsement by the federal government should not be assumed.

  • Received June 14, 2014.
  • Accepted August 18, 2015.

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Perspectives on Active Video Gaming as a New Frontier in Accessible Physical Activity for Youth With Physical Disabilities
Jennifer L. Rowland, Laurie A. Malone, Cali M. Fidopiastis, Sangeetha Padalabalanarayanan, Mohanraj Thirumalai, James H. Rimmer
Physical Therapy Apr 2016, 96 (4) 521-532; DOI: 10.2522/ptj.20140258

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Perspectives on Active Video Gaming as a New Frontier in Accessible Physical Activity for Youth With Physical Disabilities
Jennifer L. Rowland, Laurie A. Malone, Cali M. Fidopiastis, Sangeetha Padalabalanarayanan, Mohanraj Thirumalai, James H. Rimmer
Physical Therapy Apr 2016, 96 (4) 521-532; DOI: 10.2522/ptj.20140258
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