Exergame Efficacy in Clinical and Non-Clinical Populations: A Systematic Review and Meta-Analysis

Background: Exergames are video games that involve exercise. Many exergames have been commercial successes, beginning with Dance Dance Revolution in 1998, and exergames are available on all three main consoles sold today. Wii Fit has sold over 22 million copies worldwide, while exergames predominated in the first year of titles on Microsoft’s Kinect. Metabolic studies confirm that exergames can produce exertion equivalent to at least moderate exercise. They have been increasingly used to promote fitness and in clinical contexts, like rehabilitation, but it has been unclear whether exergames can deliver real improvements in health. Objective: To assess the effects of exergames on health outcomes. Methods: A systematic review of English-language articles using PubMed and Web of Science. Only studies with a sample size greater than 5 were used. Short term, laboratory-only studies were excluded. Both commercial and bespoke exergames were included, as were clinical and non-clinical populations. Before/after studies and randomised controlled trials were included in the discursive analysis, and only RCTs in the meta-analyses. Results: We identified 18 RCTs and 9 before/after studies. These covered a range of software, including Dance Dance Revolution, Wii Fit, EyeToy games and systems connected to exercise bikes. All pooled analyses were based on random effects models. Six RCTs measuring BMI or weight (n = 463) showed exergame use associated with a reduced BMI (pooled effect size, -0.26; 95% CI, -0.45 to -0.07). Three RCTs measuring VO2max (n = 371) showed an increase that did not quite reach statistical significance (pooled effect size, 0.72; 95% CI, -0.03 to 1.47). Four RCTs measuring general physical activity (n = 453) showed no difference (pooled effect size, 0.17; 95% CI, -0.26 to 0.60). Five RCTs measuring adherence or attendance (n = 122) showed no difference (pooled effect size, 0.35; 95% CI, -0.57 to 1.27), but there is a significant improvement if we exclude one outlier. Three RCTs (n = 136) show exergames are enjoyed more (pooled effect size, 0.78; 95% CI, 0.16 to 1.39). Studies on balance were usually on older adults using the Wii console. Three RCTs (n = 62) conducted equivalence trials and showed no significant difference with standard balance exercises. Three RCTs (n = 107) compared against control conditions, but found no significant difference (pooled effect size, 0.97; 95% CI, -0.39 to 2.33). Before/after studies generally gave results concordant with the RCTs. Conclusions: The papers found contained a heterogeneous selection of technology and were on varied populations. Many of the studies were very small and reported large numbers of outcome measures. How the exergame was made available and the choice of control varied. It was difficult to assess whether there has been publication bias. No studies using the Kinect and meeting our inclusion criteria have yet been published. Although many exergames have different interfaces and methods of working, there is evidence that exergames can improve fitness and may improve adherence to exercise and, in the elderly, balance. However, there is a need for larger and better trials, in particular looking at long-term outcomes.