INTERNATIONAL JOURNAL OF HUMAN–COMPUTER INTERACTION 2019, VOL. 35, NO. 2, 140–167 https://doi.org/10.1080/10447318.2018.1441253

Older Adults’ Physical Activity and Exergames: A Systematic Review Dennis L. Kappen a, Pejman Mirza-Babaei a, and Lennart E. Nacke b aUXR Lab, University of Ontario Institute of Technology, Oshawa, Canada; bHCI Games Group, Games Institute, University of Waterloo, Waterloo, Canada

ABSTRACT Exertion games, also referred to as exergames, have become popular because they combine physical activity (PA) with game mechanics, such as actions, challenges, and achievements. Exergames have been also used to encourage PA among older adults, as technological interventions to help achieve the latters’ health and wellness goals and as aids to rehabilitation. To the best of our knowledge, no systematic review of empirical studies on exergaming and older adults’ PA has been reported in the literature. Our review indicates that exergames make a measurable contribution to the improvement of health and wellness goals of older adults. Our systematic review identifies 9 categories and 19 themes of exergame applications in the domain of older adults’ PA. We aggregate these categories and themes into three broader exergaming clusters, of “training,”“rehabilitation,” and “wellness.” Additionally, we outline pathways for future empirical research into applying exergames as health and wellness inter- ventions for older adults through physical activities.

1. Introduction Marsiske, Sisco, Yam, & Mann, 2012), improvement in range of motion (ROM) (Bobeth, Schmehl, Kruijff, Given advances in technology and healthcare, it is estimated that Deutsch, & Tscheligi, 2012), and mental stimulation the number of US adults aged 65 and older will more than (Ijsselsteijn, Nap, De Kort, & Poels, 2007; Marston, 2013; double to 71 million by 2030 (Centers for Disease Control and Siriaraya, Ang, & Bobrowicz, 2012), to feelings of social Prevention, 2012). Technological interventions are helping older connectedness in their peer groups (Pedell, Vetere, Kulik, adults improve their general health and wellness, as well as Ozanne, & Gruner, 2010;Waycottetal.,2013). providing them with effective rehabilitation mechanisms. Older While older adults participate in aerobic activity classes, adults face increasing cognitive and physical challenges in their dancing, yard work or gardening, swimming and water lives, and exertion games or exergames are a way of encouraging aerobics (Elsawy & Higgins, 2010), or even Tai Chi physical activity (PA), with clear anticipated benefits. (Pigford, 2010), the cognitive and physical deterioration Exergames are innovative and interactive digital games that associated with aging tends to reduce older adults’ cap- combine exercise and video games (Sinclair, Hingston, & abilities to participate in playing digital games or video Masek, 2007). These digital games may track and react to game exercising (Lin, Mamykina, Lindtner, Delajoux, & body movements. Exergaming for older adults, whose range Strub, 2006). However, playful applications, such as of PA is often delimited, demands a greater understanding of motion-based video games, hold the promise of providing the complexities of human interaction. A systematic review of accessible PA for older adults (Gerling, Livingston, Nacke, exergames in this context is needed to advance our knowledge &Mandryk,2012). Prior research focused on an older of the development of interactive systems, from a human demographic has demonstrated the benefits to physical perspective that is specific to older adults. and emotional well-being of these game applications (Jung,Li,Janissa,Gladys,&Lee,2009;Schutzer& 1.1. Exergame applications Graves, 2004). Motivational characteristics, such as purpo- seful interactions, customization of activities, fostering Participation in recreational activities, such as playing independence, building relationships, sharing, and accom- digital games or exercising as a recreational activity, modating preferences (Kappen, Nacke, Gerling, & Tsotsos, improves older adults’ quality of life (QOL) (Marston, 2016), are common for older adults, which relate to their 2013). Video games as playful technology applications lifestyle attitudes. Significant increase in wellness scores provide entertainment (Gamberini et al., 2008; measured by the Wellness Evaluation of Lifestyle inven- Smeddinck, Gerling, & Tiemkeo, 2013)forthisdemo- tory was indicated due to decreased sedentary time and graphic. The benefits of playing range from focusing increased PA (Barwais, Cuddihy, & Tomson, 2013). players’ attention (Hwang, Hong, Jong, Lee, & Chang Additionally, prescriptive interventions using casual video 2009) increased gameplay engagement (Belchior,

CONTACT Dennis L. Kappen [email protected] © 2018 Taylor & Francis Group, LLC INTERNATIONAL JOURNAL OF HUMAN–COMPUTER INTERACTION 141 games indicated an improvement in participants’ mood of technology (Wagner, Hassanein, & Head, 2010). A and reduced stress (Russoniello, O’Brien, & Parks, 2009). review of custom-designed motion-based games for older adults (Gerling & Mandryk, 2014) indicated the need to accommodate exergaming interaction activities to address 1.2. Current systematic reviews age-related changes due to cognitive, psychological, and Research on exergames has dramatically increased in the psychomotor impairments. last decade (Kharrazi, Lu, Gharghabi, & Coleman, 2012). Systematic reviews have also been undertaken that focus on This scoping review established the positive influence of the health benefits of exergames. A review of studies relating exergames in health contexts with specific focus on num- to simultaneous physical and cognitive exercises highlighted ber of publications per clinical contexts such as PA and the role of functional brain connectivity work and multimodal nutrition. This review concluded the need to include training to understand and train the aging brain through females and elderly in studies, increase the number of exergames (Bamidis et al., 2014). Review of studies using participants, increase the intervention period and user– exergames in Parkinson’s disease (PD) rehabilitation indicated game interaction, and expand the application of health improvements in balance, reduction in severity of motor games to clinical contexts other than PA and nutrition symptoms, and rehabilitate motor skills (Barry, Galna, & (Kharrazi et al., 2012). Previous reviews of the literature Rochester, 2014). Furthermore, a scoping review of exergames have also addressed specific health contexts relating exer- and implementation potential for patients with heart failure games as interventions for older adults. Review of exer- indicated that there was improved balance, improved cogni- games used as interventions to help cope with effects of tive function, enjoyment of the exergames, reduction of ageing indicated that this technology could be used as a depressive symptoms, thus improving the QOL for such therapeutic tool (Velazquez et al., 2014). Their review patients (Verheijden Klompstra, Jaarsma, & Strömberg, conducted assessments of 52 articles and concluded that 2014). Another systematic review on the training of muscu- exergames could serve as a diagnostic tool to find or loskeletal functions using exergames showed evidence of evaluate a health condition or as a therapeutic tool to delayed functional and muscle loss in the aged and helped modify a health condition (Velazquez et al., 2014). to overcome decline in motor skills (Rodrigues, Valderramas, However, this review did not focus on the PA outcome Rossetin, & Gomes, 2014). A systematic review on the percep- of using exergames. A review article of sedentary behavior tions of the efficacy of exergames and falls prevention sug- of older adults (56 articles) established the need to over- gested that these games facilitated intrinsic factors such as come sedentariness through PA and its relationship with independence, control, and the perceived need of safety to health outcomes such as mortality, metabolic syndrome, continue using exergame technologies (Hawley-Hague, cardiometabolic markers, triglycerides, high-density lipo- Boulton, Hall, Pfeiffer, & Todd, 2014). A narrative literature protein cholesterol, blood pressure, abdominal obesity, review looked at adults’ motivation to play exergames and the obesity, and cancer (Fornias, Rezende, Rey-Lopez, experience of playing such games which indicated that differ- Matsudo, & Luiz, 2014). The use of technology to help ences in older adults (e.g., age, gender, education) and game- improve these health outcomes is also critical from the play in natural setting would enable hedonic aspects of integration of technology and health contexts. In this vein, playing exergames (Loos, 2017). using mobile phones as health interventions to stimulate Themes such as mental, physical, and social health factors PA, medicine management, falls detection, dermatology, emerged in a systematic review on health benefits of digital and exercise monitoring for heart patients contributed to video games (Hall, Chavarria, Maneeratana, Chaney, & the overall improvement in the QOL of older adults (Joe Bernhardt, 2012). Similarly, research on the effectiveness and & Demiris, 2013). A review of seven randomized con- efficiency of digital games indicated that social, psychological, trolled trials (RCTs) using validated scales indicated the physiological, and sensory-motor themes facilitate in the pre- effectiveness of exergames in physical outcomes for vention and rehabilitation dimensions for older adults healthy older adults by improving balance performance, (Wiemeyer & Kliem, 2012). Systematic review relating virtual improved stepping action, and increased muscle strength reality (VR) and gaming systems to encourage PA indicated (Larsen, Schou, Lund, & Langberg, 2013). However, this that such systems helped to address physical impairments and article only addressed the physical outcome aspect of bal- limitations (Miller et al., 2014). Another review on the usage ance training within the health context as a result of of exergames and physical functioning indicated the motiva- exergame intervention with older adults and was limited tional aspect of such games to facilitate PA (Molina, Ricci, De to RCTs. Review of older adults’ interaction techniques Moraes, & Perracini, 2014) and the promotion of PA (Molina relevant to input devices, gestures, and visual displays et al., 2014). A review of Nintendo Wii exergame usage indicated that more studies relating age-related changes, indicated positive effects such as improved physical function- prior experience with technologies, and characteristics of ing, decrease in depression, improved cognition, improved devices and use situations were needed (Motti, Vigouroux, socialization, and increased motivation to exercise (Chao, &Gorce,2013). A multi-disciplinary review of computer Scherer, & Montgomery, 2014). use by older adults used the social cognitive theory as a Despite this plethora of literature reviews on exergames, lens to analyze the literature which indicated that the while the prior systematic reviews focused on separate out- triangulation of person, behavior and environmental fac- comes such as rehabilitation, physical functioning, and tors contributed to adaptability, usability, and acceptance encouraging PA, our systematic review focusses on exergames 142 D. L. KAPPEN ET AL. and older adults’ PA from the context of training, rehabilita- exercising (Silva & Saddik, 2011), exergaming (Mackenzie, tion, and wellness. Our review is tightly focused on the rele- 2006), exertion games (Mueller, Agamanolis, Vetere, & vance of exergames and their direct implications on older Gibbs, 2009), active gaming (Mears & Hansen, 2009), health adults’ PA and examines research conducted in areas of reha- games (Kharrazi et al., 2012), active video games (Altamimi & bilitation, physical and cognitive training, and leisure or Skinner, 2012), embodied interactive video games (Hwang entertainment with a health and wellness dimension. et al., 2009), and interactive computer games (Bleakley et al., The purpose of this systematic review is to provide a high- 2015). While many terms for the combination of PA and level overview of the current state of research on exergames, gaming technologies have been indicated above, we define in relation to digital games that encourage PA in older adults. exergaming within this review as “the combination of gaming We discuss the research completed on the PA engaged in by technologies and exercise routines to motivate physical activ- older adults through digital games. Our first contribution in ity among individuals or groups.” this article is to compare different research on exergames for From an older adult’s perspective, the degree of difficulty older adults. Second, we propose taxonomy of research in engaging in a PA is determined by their age-related impair- themes in that field. Third, we identify three major clusters ments (decreased motor skills, balance issues, poor posture) of research themes, where exergames have provided empirical and health related challenges (coronary disease, osteoporosis, evidence toward improving older adults’ health and wellness arthritis, emotional loneliness, minimized cognitive func- through PA. Finally, we identify pathways for future research. tions). Taking into account these age-related impairment, a context-aware adaptive game engine (Silva & Saddik, 2011) that is flexible enough to accommodate the needs of older 2. Related work adults and adapt to the users’ exertion capabilities is highly Games that include an element of PA, such as Dance Dance desirable. Our systematic review investigates the relevance of Revolution (DDR), Pump it Up, and In the Groove (Hoysniemi, exergames to the domain of older adults’ PA with a health and 2006), have become very popular. Additionally, interactive and wellness focus. To relate older adults and their attitudes to immersive technologies used in the Nintendo Wii Fit and PA, we investigate studies that have used exergaming as Microsoft Xbox Kinect gaming devices have led to much- interventions for physical and cognitive training, rehabilita- increased market penetration of motion-based video gaming. tion, and improving health and wellness.

2.1. Defining exergaming 2.2. Exergaming and physical and cognitive training An illustrated review of exergaming dates the advent of this Full-body movement exergames lead to behavior change, concept to 1982, with the introduction of the Atari-Joyboard increased engagement, and participation in PA (Lieberman (Johnson, 2008), which was a simple four-switch balance et al., 2011) on the part of older adults due to gesture-based board controller for the Atari 2600. An early definition com- interactions. Gestures for selection and moving the cursor on bining PA and games postulated that PA must actually influ- the screen in place of mouse actions helped older adults in ence the game outcome by the use of motor skills in pursuit of simplifying certain actions, encouraging PA and allowing for a pre-lusory goal of the game (Vossen, 2004). While the easier repetition of actions. Attitudes of older adults toward concept of fitness gaming has been around since the intro- gesture-based interaction have changed because of the pre- duction of the “Foot Craz,” a pad controller for the Atari sence of new products like the Nintendo Wii Remote and 2600, in 1989 (Bogost & Montfort, 2009), “exergaming” as a Microsoft Xbox Kinect sensor. The performance and accep- term representing a genre of gaming for fitness is a relatively tance of freehand gestures through a variety of techniques new area of research which has gained in popularity over the were investigated in a study (Bobeth et al., 2012) of 24 older past few years. A simplified definition of exergaming is “the adults that particularly look at performance issues of several use of videogames in an exercise activity” (Sinclair et al., implemented freehand gesture techniques related to control of 2007). a TV menu. The authors explored gesture-based TV control Inconsistencies in the use of terminologies and uncertainty methods instead of a standard hand-held remote to investi- over definitions of what constitutes the “combination of PA gate controlling the TV through gestures as a form of PA. and gaming” among health-related researchers and non- However, we still do not know whether full-body gestures as a health-related researchers have been tabulated (Oh & Yang, way of interaction would increase the cognitive load on older 2010). This tabulation helped to redefine exergames to be “a adults because they would have to remember more items. In combination of exertion and video games incorporating digital games, we need to prioritize capability before strength training, balance and flexibility activities.” The mechanics to make games more accessible to a larger audi- authors also challenged usage of the term “exercise” in the ence, including older adults (Gerling et al., 2012). Meanwhile, exergame definition because of the inherent repetitive nature robot games (Hansen, 2011) encouraging older adults to imi- of the exercise activity, whereas a PA could also be performed tate movements of a mobile robot has developed into a per- for its experiential nature. This definition helped to extend suasive tool for promoting PA among older adults. The exergaming to the domain of experiential physical activities. authors investigated the learning of a robot and its adaptabil- The following terminologies have been used by researchers to ity to older adult players with differing degrees of challenged categorize games that involve PA, fun, and exercise: active- mobility. Changes in the interactions between older adults play video games (Lieberman et al., 2011), game-based and the mobile robot, the former using required assistive INTERNATIONAL JOURNAL OF HUMAN–COMPUTER INTERACTION 143 tools such as crutches, wheelchairs, or walkers, also provided adults. Rehabilitation strategies can be monotonous and information on play styles. Adaptable gameplay and controls, time-consuming (Kamkarhaghighi, Mirza-Babaei, El-Khatib, as well as adjustable calibration parameters in digital games & Gerling, 2017). A combination of human–computer inter- for physical therapy, were found to be critical in developing action (HCI) modalities and games for health can improve the games for older adults with motor disabilities (Geurts et al., attitudes of older adults toward participating in PA, which in 2011). Improved sense of physical, social, and psychological turn leads to positive behavior change and improved QOL. well-being in older women resulted from the use of Wii video Furthermore, the entertainment and leisure value of exergam- games because of increased confidence in using technology, ing can help older adults adhere to their exercise routines. the benefits of improved connectedness with family members, This also improves older players’ confidence in their ability to and positive changes to their self-image (Wollersheim et al., perform repetitive tasks. Exergames can also improve a per- 2010). Feedback on gesture-based games features higher rat- son’s motivation to participate in a rehabilitation program, ings for physical well-being among older adults because of the where routine PA sessions are made more engaging by intuitiveness of the games, the ease of the gestures themselves, exergames. and the increased movement demanded by the games (Rice Video games with true-to-life scenarios, game preferences, et al., 2011). Studies using Nintendo Wii Fit Balance Board and with motivations to play tailored to older adults, can games indicated improvements in balance among older adults provide cognitive training and improvement in reflexes (Young, Ferguson, Brault, & Craig, 2010). The independently (Nap, Kort, & IJsselsteijn, 2009). The fields of rehabilitation created SilverBalance exertion game using the Nintendo Wii and entertainment technology both contribute to improving Fit Balance Board reported positive engagement and enjoy- the lifestyles of older adults: For example, games have been ment amongst older adults because of improvements in self- created for older adults undergoing stroke rehabilitation efficacy and the perception of the game’s user-friendliness (Flores et al., 2008) and to improve motivation among (Gerling, Schild, & Masuch, 2011). patients undergoing motor deficit rehabilitation. Others Encouraging older adults to participate in PA through persua- (Alankus, Proffitt, Kelleher, & Engsberg, 2011) have evaluated sive technology interventions provides the additional benefit of the use of motion-based digital games, such as Helicopter, being able to track user activity. One study showed that over- Pong, and Baseball Catch in stroke therapy, where the games coming sedentary lifestyles can be achieved through systems like were customized to measure improvements in patients’ ROM. UbiFit Garden (Consolvo et al., 2008) where the authors used on- Other research topics have included motivating mobility for body sensing and machine learning to track PA. The authors upper limb rehabilitation of stroke patients (Balaam et al., incorporated rewards and tracking functions to encourage older 2011), use of physical therapy to improve postural balance adults to participate in PA. A separate study (Albaina, Visser, van (Bateni, 2011), dynamic balance and coordination (A. S. Billis der Mast, & Vastenburg, 2009) used Flowie, a persuasive virtual et al., 2010), rehabilitation of PD patients (Siegel & coaching game, to encourage PA in the elderly by encouraging Smeddinck, 2012), and rehabilitation strategies (S. T. Smith, them to walk using motivational cues. Other researchers (Fan, Talaei-Khoei, Ray, & Ray, 2009). Embodied interactions, Forlizzi, & Dey, 2012) found that overcoming barriers to PA investigated in video games not requiring precision controls through technology interventions must support the needs of or fine motor skills (Hwang et al., 2009), facilitated both older adults. The authors identified awareness of personal limita- engagement and gameplay. Sensor-based physical activities tions, social motivation, establishing and adapting to routines, and using 3D depth sensors and 3D accelerometers combined finding enjoyable activities to be four consistent themes that with exergame technology demonstrated performance differ- technology interventions could address to help older adults over- ences between fallers and non-fallers (Ejupi et al., 2014). come barriers to PA. SilverPromenade, a custom video game, These studies evince the relevance of exergames as interven- simulated real-life activities rendered inaccessible due to age- tions for rehabilitation of older adults by motivating them to related changes (Gerling, Schulte, Smeddinck, & Masuch, 2012). participate in boring rehabilitation routines, improve their One study (Brox, Fernandez-Luque, Evertsen, & González- motor skills, and enhance their balance. Hernández, 2011) found that social exergaming was an effective strategy to engage older adults in PA and helped to reduce lone- 2.4. Exergaming and health and wellness goals liness by promoting social interaction. By the same token, digital games can use cognitive challenges Exergames have also been studied in the context of PA and therapeutically. Some of the many examples of this genre are older adults’ health and wellness goals. Suitability of exer- games for people with dementia (Astell, 2010), games to enhance games for senior citizens, keeping in mind age-related changes brain fitness in senior citizens (Baecker et al., 2010), games used (Gerling et al., 2011), is critical in the development of safe and to understand social disengagement (Bassuk, Glass, & Berkman, usable exergames for this demographic. Gerling, Schulte, and 1999), and games used to improve social interactions (Casey, Masuch (2011) investigated the possibility of designing exer- Kirman, & Rowland, 2007). Exergames also afforded temporary games for elderly adults with flexibility of use in sitting and improvements in concentration (Gao & Mandryk, 2012). standing positions, avoidance of sudden rapid movements, customizable game speed, level of difficulty, and input device sensitivity; and also with cognizance of prior technological 2.3. Exergaming and rehabilitation experience. Engaging in sports and physical fitness activities Much research has investigated the use of motion-based (Cho, Jun, & Cho, 2002) facilitates an active, dynamic, and games in occupational therapy and rehabilitation for older healthy QOL. Curious Companion (Wu, Miao, Tao, & 144 D. L. KAPPEN ET AL.

Helander, 2012) integrated a Chinese water-painting game for the term “exergames and ageing,” and 1770 results for encouraging movements and variable speed of motion to terms “exergames and ageing adults.” We used the search complete a digital Chinese poem. The game helped to create terms “Exergames” and “Older Adults,”“Exergames” [All interpersonal relationships and overcome social isolation; Fields] AND (“aged” [MeSH Terms] OR “aged” [All Fields] Walk 2 Win (Mubin, Shahid, & Mahmud, 2008), an inter- OR “elderly” [All Fields] AND “Motivations”). We used addi- active mobile game for older adults, motivated players to tional terms, such as “digital games” and “older adult fitness,” spend more time in community centers in a more engaging “older adult PA,” along with the keyword terms of “active older and socially active manner. Positive effects on the overall well- adults” and “fitness games” and “PA” and “motivations.” being of older adults through improved self-esteem, affect, and reduced loneliness (Jung et al., 2009) are indicative of 3.1.1 Databases searched the physical and psychosocial benefits of exergames. Exergames are HCI technologies that are researched in multi- Furthermore, improved socialization and motivation (Chao, ple disciplines, such as information technology, health inter- Scherer, Montgomery, Lucke, & Wu, 2014) indicated the ventions, and science. This diversity of exergame applications advantages of exergames as technological interventions to led to the selection of the following databases for a detailed meet health and wellness goals. search to cover literature published in engineering and infor- mation technology, medicine and life science, and science databases: ACM Digital Library, IEEE Xplore, ScienceDirect, 2.5. Research questions PubMed, EBSCOhost, SpringerLink, Web of Science, and The term “exergaming” has evolved over time to include Scopus. multidisciplinary elements in digital gaming, interaction design, PA and health, and rehabilitation. The purpose of 3.2. Inclusion criteria this systematic review is to identify the current state of research into exergames for older adults in the specific context The aim of this systematic review was to survey the broadest of PA. The following research questions drove our systematic possible domain in which exergames have been used as tech- research: nological interventions in health and wellness applications specific to older adults’ fitness. Our focus was on older adults’ RQ1: Does empirical evidence support the usage of exergames fitness, whereby key inclusion criteria were (1) exergaming as technological interventions in older-adult physical activity research targeted toward adults aged 50 years and over; (2) situations? literature comprising original, peer-reviewed empirical research; (3) research involving human participants and RQ2: What age-related impairments were addressed by these using validated instruments; and (4) research into PA with a exergames? health and wellness focus. Research that did not adhere to the above four conditions were excluded from the current review. RQ3: Is there evidence of improvements in older adults’ physical activity resulting from their usage of exergames? 3.3. Data analysis The selected articles were reviewed across the “research qual- ity” dimension and the “research methodology” dimension 3. Methods because the study of technological interventions to improve We used a systematic review method based on the Cochrane older adults’ PA is conducted differently in different research guidelines for systematic reviews (Higgins & Green, 2011; van disciplines. The 49 resulting articles were coded to establish Tulder, Furlan, Bombardier, & Bouter, 2003). Systematic the relevance of the research studies within the older adults’ review methodology for software engineering (Connolly, PA domain along these two distinct dimensions. Based on Boyle, MacArthur, Hainey, & Boyle, 2012; Kitchenham, additional reviews, we added six additional RCT articles from 2004) was also referenced this review. We used a systematic the systematic review which focused on physical outcomes review to identify, filter, and analyze peer-reviewed literature (Larsen et al., 2013). This resulted in a total of 55 articles indicating empirical evidence from studies of exergames and for the systematic review. older adults’ physical activities. Since the publications we reviewed were from separate fields and disciplines and thus 3.3.1. “Research quality” dimension heterogeneous in their content, we did not conduct a meta- This dimension was further disaggregated into two sub- analysis. We also referred to the systematic review conducted dimensions: “exergame themes and categories” and “metho- on computer games and serious games (Connolly et al., 2012) dological quality of studies.” The identification of themes and as a frame of reference for our own systematic review. categories was based on the research focus presented in each article and the methodological rigor of the study designs helped us identify the methodological quality of the reported 3.1. Literature search terms studies. In February 2015, a search in Google Scholar indicated 2630 results for the search term “exergames,” 1960 results for the 3.3.1.1. Exergame themes and categories dimension. Two combinatory terms “exergames and older adults,” 492 results primary reviewers independently reviewed the 49 selected INTERNATIONAL JOURNAL OF HUMAN–COMPUTER INTERACTION 145 articles to identify themes and overarching categories. added to this set of 49 articles were not included in the Additionally, two secondary independent reviewers (total reliability calculations. reviewers = 4) coded the selected articles again for themes and overarching categories. The last six articles added to the 3.3.2. “Research methods” dimension existing set of 49 articles that made the set of 55 selected Two primary reviewers coded this dimension for the selected articles were coded by the primary researcher. articles according to the following sub-dimensions. While the “themes” represented the primary outcomes of the article, the “categories” represented the overarching out- comes of the research study. “Themes” and “categories” 3.3.2.1. Study design. Selected articles were coded based on dimensions coded by each reviewer for each article were the empirical research methods used in the study design. Key reviewed and discussed to determine agreement or disagree- terms indicative of the research method were “qualitative,” ment of the themes and categories. In this coding process, “quantitative,”“mixed-method,”“case studies,” and “surveys” each article received four themes and four categories (each and were coded accordingly. generated by one of the four independent reviewers). These themes and categories were then reduced to a single unifying 3.3.2.2. Participant sample. The age, gender demarcation, theme and a unifying category by the process of inductive number of participants, and time frame of the study design analysis. were coded.

3.3.1.2. Methodological quality of studies. The methodologi- cal rigor of each study was assessed according to the Cochrane 3.3.2.3. Research instruments. The type of data-collection guidelines for quality assessment (Higgins & Green, 2011; instrument used to measure improvements or decrements, Kitchenham, 2004) and accorded with assessments undertaken where PA games were used as a technological intervention, in previous systematic reviews (Galna, Peters, Murphy, & was coded. Morris, 2009). Based on this prior research, the articles were “ ” scored on their level of evidence (LoE) (van Tulder et al., 3.3.2.4. Physical activity. Articles were coded to identify the 2003)asshowninTable 1. The studies reported in the articles type of PA undertaken in the (PA) games. were rated for methodological quality, data extraction, and data analysis. Additionally, each study design (qualitative and/or quantitative) was rated as shown in Table 1. 4. Literature search results The scores for each of the sub-criteria provided under methodological quality, data extraction, and data analysis This systematic review provides a comprehensive review of items were averaged to create nominal scores for each of the current literature relevant to the use of exergames as inter- three criteria. This was done for both the coders, resulting in ventions relating older adults and their health and fitness pairs of scores for each criterion. To ensure inter-rater relia- goals. We reviewed the selected 55 articles across the dimen- bility for the quality assessment, the ratings provided by the sions indicated in Section 3 and report our analysis specific to coders for all the 49 selected articles were compared for literature search, as well as to the research quality dimension consistency by one primary coder. The six articles that were and research methods dimension.

Table 1. Level of evidence (LoE). Criteria Sub-criteria Rating (yes = 2, no = 1, don’t know = 0) Methodological quality assessment Assessment blinded for authors, institutions, journal 2, 1, 0 Assessment by content expert and non-expert 2, 1, 0 Pilot test of quality assessment 2, 1, 0 Consensus method to solve disagreement 2, 1, 0 Use of recommended criteria list 2, 1, 0 Explicit operationalization of criteria 2, 1, 0 Data extraction Extraction blinded for authors, institutions, journal 2, 1, 0 Use of standardized form 2, 1, 0 Pilot test the data extraction form 2, 1, 0 Consensus method to solve disagreements 2, 1, 0 Contact author for additional information 2, 1, 0 Data analysis Explicit description of comparisons 2, 1, 0 Analysis of clinical heterogeneity 2, 1, 0 Statistical test for heterogeneity 2, 1, 0 Use of random effects model 2, 1, 0 Subgroup analysis related to review objectives 2, 1, 0 Study design (quantitative) RCTs QUAN-4 Controlled studies QUAN-3 Case studies, pretest/posttest QUAN-2 Surveys QUAN-1 Study design (qualitative) Consistent findings in RCT High = 4 (QUAL-4) Consistent findings in low quality RCTs and/or CCT Moderate = 3 (QUAL-3) Limited Limited = 2 (QUAL-2) Low quality RCT or CCT Conflicting = 1 (QUAL-1) RCTs: randomized control trials. 146 D. L. KAPPEN ET AL.

Table 2. Results from searched databases, filtered according to our inclusion criteria. selected articles. After further screening, we excluded articles Database Total number Merged list Filtered results that did not involve human participants and articles that did ACM 158 33 8 not have a qualitative, quantitative, or a mixed-method study IEEE Xplore 47 15 8 ScienceDirect 85 8 2 design. The screening of articles to be selected for final quality PubMed 31 12 12 review was done by two reviewers according to their adher- EBSCOhost 13 9 3 ence to the inclusion criteria. This resulted in a selection of 55 SpringerLink 124 41 9 Web of Science 46 3 4 articles in the filtered results as shown in the third column of Scopus 26 19 9 Table 2, which were selected for further quality review. 530 140 55 After the quality review of the studies, one article was deleted from the collection because it was a future study 4.1. Search results protocol on exergaming (Gschwind et al., 2014) for older Using each search term, an independent list of literature was adults. Two additional articles discovered in a secondary created specific to each of the searched databases (all of which search were added into the collection; they were to take the are relevant to and used in HCI research). After cross-refer- count to 51 articles. The initial screening excluded these encing, article repetitions found in multiple databases were articles because they were categorized as short articles. We eliminated. An initial merged list of articles was created included these short articles because they reported quantita- resulting in 140 documents. The middle column in Table 2 tive analyses of empirical research. shows the initial merged list, which was based on the search The detailed quality analysis of these 51 articles resulted in terms. 2 being deleted from the collection, one article because, while The basic flow diagram indicating the exclusions of articles addressing exergaming for older adults, it discussed the devel- from the original selection of 530 articles is shown in Figure 1 opment of a game system (Garcia, Navarro, Scheone, Smith, and is based on the criteria outlined in Section 3.2. While & Pisan, 2012) and thus did not include any study design. The many articles researched the multi-disciplinary applicability of second article was removed because it purportedly discussed exergames in the field of technology, science, and medical exergaming for older adults but performed the study design applications, studies that were conceptual, theoretical, or defi- with participants whose mean age was 37 years (Van Diest nitive of frameworks were eliminated from the original list of et al., 2014) and thus did not fit the inclusion criteria. Furthermore, we added 6 articles from a prior systematic review (Larsen et al., 2013) which resulted in a revised total of 55 articles for the systematic review.

4.2. Research quality dimensions Research in the broad domain of exergaming has addressed a diverse range of age-related challenges and fitness goals. We decided to classify the articles according to “thematic areas” and “overarching categories.” This research quality classifica- tion helped us to analyze the “research methods” dimension more effectively. The thematic focus of exergame articles focused on PA is shown in Table 3.

Table 3. Thematic focus of exergame articles. Article categories Articles Balance training 19 Increased physical activity 7 Cognitive training 4 Rehabilitation (Parkinson) 3 Wellness 3 Rehabilitation 2 Rehabilitation (balance) 2 Cognitive–physical training 2 Physical training (wellness) 2 Physical training 2 Rehabilitation (Stroke) 1 Wellness (psychosocial) 1 Wellness (cognitive) 1 Wellness (motivation) 1 Wellness (QOL) 1 Physical training (visual) 1 Physical training (heart) 1 Mental health (depression) 1 Design 1 Figure 1. Search results. Total 55 INTERNATIONAL JOURNAL OF HUMAN–COMPUTER INTERACTION 147

4.2.1. Exergame themes and categories dimension (Lamoth, Alingh, & Caljouw, 2012)andVRinterventions The N = 55 articles were organized into 19 exergame themes improved gait and balance-related physical performance depending on the type of research focus of the study design, (Wüest et al., 2014). Additionally, increased attention to exercise the type of exergames being considered, and the goals of the during gameplay, along with increased discussion of perfor- intervention. To distinguish the research instruments, find- mance while watching other participants play, was also reported ings, and exergames used within each exergame theme, we are (Fang,Sheu,Lin,Lee,&Chen,2015). We provide detailed reporting each exergame theme separately. coding in Table 4 of these 19 articles investigating balance training for older adults using exergames as technological inter- 4.2.2. Exergame articles on balance training ventions. In the table, exergames developed specifically for a The majority of articles (n = 19, 35%) in the selected group of study, or those that are not available for commercial purchase 55 literature samples were empirical research focused on are indicated as noncommercial (NC). Table 4 also includes addressing challenges in balance training for older adults. further details of these studies. NIH Senior Health (“Falls and Older Adults,” 2014) indicated that more than one-third of older adults over the age of 65 are 4.2.3. Exergame articles on increased PA prone to balance coordination problems serious enough to Our next major theme focuses on using exergames as inter- cause falls. Exergaming studies indicated older adults’ eager- ventions for increased PA (n = 7). These studies focused on ness to participate in exergames (Gerling, Schild, & Masuch, encouraging PA per se and overcoming older adults’ seden- 2010) and provided insights into the effectiveness of sensor- tary lifestyles. Motion-based games had a positive effect on based technologies in using exergames (Schwenk et al., 2014) mood and, by extension, improved the emotional well-being as balance training interventions. Sensor-based “stepping test” of older adults (Gerling et al., 2012). While age-related exergames found significant performance differentials (Ejupi impairments limited the performance of active and frail par- et al., 2014) between fallers and non-fallers in unsupervised ticipants, differences in mobility and physical ability affect home assessments. exergames as a medium for PA (Gerling et al., 2011). During balance training, the performance levels of older Irrespective of age-related impairments, this study revealed adults decreased as stimulus speed and step rate were increased engagement and enjoyment of exergames in all increased (Smith, Sherrington, Studenski, Schoene, & Lord, participants. Outdoor exergames on mobile phones improved 2011). Balance training was found to depend on dynamic and user engagement and satisfaction and heightened participants’ postural stability (Duclos, Miéville, Gagnon, & Leclerc, 2012). interest in PA (Birn, Holzmann, & Stech, 2014). Dynamic balance performance (Kosse, Caljouw, Vuijk, & Additionally, studies using the Nintendo Wii as an exer- Lamoth, 2011) showed improvements arising from the game intervention for older adults (Kirk, Macmillan, Rice, & dynamic movements afforded by exergames. While the use Carmichael, 2013) showed that in addition to heart rate, use of commercial Wii Fit exergames was assessed to be safe and of rate of perceived exertion is an appropriate measure of feasible (Agmon, Perry, Phelan, Demiris, & Nguyen, 2011) for exertion. Furthermore, Wii Fit appeared to be enjoyable for a supervised, in-home balance training program, combining all groups of participants (adolescents, young adults, and physical therapy training with Wii Fit training provided better older adults) (Graves et al., 2010) and indicated the effective- balance training (Bateni, 2012). A 3-week RCT study indi- ness of cardiorespiratory and enjoyment measurements in cated that there was no significant improvement in the bal- comparison to hand-held inactive video gaming. ance with the intervention group and postulated the need for Elsewhere, interactive computer games increased PA and studies with longer durations (Franco, Jacobs, Inzerillo, & exergames were deemed a catalyst to healthier lifestyle beha- Kluzik, 2012). Comparison of the Wii balance training with viors (Lin et al., 2006). Active video games provided light- a balance board and Tai Chi revealed similar effectiveness intensity exergames in community-dwelling older people with improvement in balance, increasing the possibility of (Taylor et al., 2012) and resulted in improved PA benefits in-home Wii interventions (Pluchino, Lee, Asfour, Roos, & whether played in a seated or standing position. The details Signorile, 2012). Additionally, improvements in dynamic bal- are outlined in Table 5. ance and balance confidence (Rendon et al., 2012), improve- ments in standing balance with limited improvements to the 4.2.4. Exergame articles on rehabilitation gait function (Szturm, Betker, Moussavi, Desai, & Goodman, This theme categorizes studies into interventions for general 2012), and evidence of limiting the decline in sensorial func- rehabilitation (n = 2), rehabilitation for Parkinson’s patients tions while improving balance (Toulotte, Toursel, & Olivier, (n = 3), rehabilitation for stroke patients (n = 1), and rehabi- 2012) were seen in older adults in these RCTs. litation for postural or balance issues (n = 2). While the article More recent articles reported improvement in mobility and on rehabilitation of patients with balance issues used exer- quality of movement (Uzor & Baillie, 2014) resulting from long- games as interventions for balance training (Maillot, Perrot, term usage of exergames. The use of exergaming in the form of Hartley, & Do, 2014), we grouped this article under the interactive modular tiles for improving balance in older adults rehabilitation theme as opposed to balance training because lowered their health risk level to a better level (Lund & Jessen, of the focus on overcoming balance issues as opposed to more 2014). Older players’ movement characteristics afforded guide- general balance training. Improved step action and balance lines for designing exergames (Skjæret et al., 2015)soasto were seen in the intervention group compared to the control improve subjects’ quality of movement in fall-prevention exer- group with dance video game (Pichierri, Coppe, Lorenzetti, cises. Exergames with visual feedback enhanced postural control Murer, & De Bruin, 2012). 148

Table 4. Exergames for balance training (NC = noncommercial, RCT = randomized controlled trial). Exergame articles on balance training

Sample size AL. ET KAPPEN L. D. Exergame physical (female), mean Challenges in Study Study design Study duration activity age Research instrument Findings implementation Guidelines LoE Agmon et al. Case study, single- Play exergames for 30 min/ Wii Fit exergames 7 (4 F), 84 Paper log, Berg Balance Scale, Supervised balance training is Feeling of fatigue Reviewing progress and QUAN-2 (2011) group, pre–post session, 3 times/week, semi-structured interviews, 4- feasible for select sample of older during exercise visible improvement in design 3 months meter times walk test, PAES adults sessions scores is useful Weekly telephone interviews Increased Follow-ups provide (5–10 min) cardiovascular reinforcement to the demand participants Closer guidance and supervision is needed with older adults and Wii fit Safety concerns and muscle strain Bateni (2012) Controlled study, Three sessions/week for Wii Fit exergames 17 (9 F), 72 Berg Balance Scale (all groups) and Combination of Wii Fit and Initially, adjusting Review the scores QUAN-3 three groups 4 weeks bubble test physical therapy improves balance balance and weight achieved which indicated to play the games a measure of was difficult performance Duclos et al. Five tasks, repeated Three 15-s periods for each Wii Fit exergames 7 (5 F), 66.6 Stability assessment via kinematic Stabilizing/Destabilizing forces Older adults’ Use exergames for static QUAN-3 (2012) measures design game (task) data recorded in motion analysis model can be used to rate level of difficulty in adjusting balance tasks lab at 60 Hz using an Optotrak balance requirements during the weight transfers 3020 system (Northern Digital Inc.) different tasks such as gait or between both feet exergames were evident Ejupi et al. RCT 15 min per participant (2 Sure Step (NC) 104 (70 F), 80.7 Microsoft Kinect Software Mean stepping reaction time and More time required Use exergames to assess QUAN-4 (2014) stepping trials, 40 steps/trial, Development Kit with a sampling total step time in the fallers group for fallers to regain older adults in clinical 1-min break time after 20 rate of 30 Hz were significantly slower than in their balance and unsupervised home repetitions) the non-fallers group. Fallers situations needed significant longer to recover their balance after taking a step compared to non-fallers Fang et al. Six exercises/ 15 min/participant to a total EFS (NC) 13 (11 F), 68 PAR-Q; PAES; semi-structured Seniors paid more attention to More training was Use sceneries and travel QUAN-3 (2015) participant, of 3 hr interview exercises during game play and needed to practice themes to encourage repeated measures engaged in social activity of certain movements participation design comparing their performance with Some steps appeared Incorporate relevant to others to be visually life themes (e.g., challenging needing gardening and more explanations calligraphy) Franco et al. RCT 3 weeks, two sessions/week Wii Fit, MOB 32 (25 F), 78.2 Berg Balance Scale and the Tinetti Interventions failed to increase Technology training Provide greater duration QUAN-4 (2012) Gait and Balance Assessment balance significantly within the 3- had to be provided to of exergame activity to week period the Wii Fit and MOB enable improvements in group balance Gerling et al. One focus group No data on duration SilverBalance (NC) 9 (5 F), 84 Focus groups Positive eagerness to participate, Lack of confidence to Provide simple body QUAL-3 (2010) session using Nintendo Wii minimalistic design increased be able to stand for a movements Balance Board focus on games, social interaction long period of time Encourage the flexibility due to comparisons of other Dependency on of play in sit or stand players results assistive devices positions inhibited play Minimize sudden body Impairments such as movements stiffness of joints and Provide for adjusting lack of attention level of difficulty inhibited play (Continued) Table 4. (Continued).

Exergame articles on balance training Sample size Exergame physical (female), mean Challenges in Study Study design Study duration activity age Research instrument Findings implementation Guidelines LoE Kosse et al. Repeated measures, 6-week program, 20-min SensBalance Fitness 9 (5 F), 77 Figure-of-eight, Berg Balance Balance improvement was Training sessions had Tailor balance programs QUAN-3 (2011) single subject sessions, three times a week Board (NC) Scale, tandem one-leg stance dependent on level of to be provided to to be short and intensive design performance at start of training, help older adult get activities participants with lower scores familiar with the Focus on exergames that improved more across time than game system help to improve highest scoring participants performance Lamoth et al. Three tasks, No data on duration Miniboard; 12(7 F), 69 Mean Hilbert amplitude, number Exergame feedback conditions Mental and physical Incorporate feedback to QUAN-4 (2012) controlled Sensamove® (NC) of oscillations, fluency of the ensured a more controlled fatigue of older increase engagement experiment, movement indexed by dividing the movement technique on the participants Provide a mix of exercise randomized, power spectral density of the wobble board and increased Slower movements of intensities to improve repeated measures fundamental oscillatory frequency experienced workout intensity older adults concentration and design by that of the entire signal variety Lund and Nine group sessions, 1–1.5 hr/week, 12-week Modular interactive 14 (9 F), 73 6MWT, the 8-foot TUG test, and Significant improvement in the Older adults were Provide low dose QUAN-3 Jessen one intervention intervention tiles (Entertainment the CS test; senior fitness test health status of the elderly from somewhat frail with (intensity) of exercise (2014) group Robotics) (NC) one health risk level to a better low gait speed training to facilitate level was reported Training was needed interest and better effort to familiarize older However, add higher adults with the new dose for better technology improvement in abilities Pluchino et al. RCT 8 weeks Wii Balance Board, 40 (25 F), 72.5 TUG, one-leg stance, functional Similar improvements between the Initial training with Provide the possibility of QUAN-4 (2012) Tai Chi reach, Tinetti performance- Wii group and the Tai Chi group the balance board adjusting the exercise oriented mobility assessment, took time intensity based on force plate COP and time to physical and cognitive boundary, dynamic posturography needs HUMAN OF JOURNAL INTERNATIONAL (DP), Falls Risk for Older People– Community Setting, and Falls Efficacy Scale Rendon et al. RCT, pre- and 6-week intervention, Nintendo® Wii Fit 40 (26 F), 84.5 Eight-foot up and go, Activities- Virtual reality gaming does aid in Loss of interest Provide cues that help QUAN-4 (2012) posttest evaluations 35–45 min/session, three specific Balance Confidence Scale, the improvement of dynamic caused four maintain interest in the sessions/week Geriatric Depression Scale balance participants to drop exergame, which, in turn, out can help with exercise adherence Schwenk et al. Two groups, single- 4-week study (twice a week, Step Training (NC) 17 (10 F), 84.6 Changes in CoM sway, ankle and Sway of CoM, hip, and ankle were Back pain for a few Incorporate simple steps QUAN-4 (2014) blinded, RCT each session 45 min) hip joint sway measured during EO reduced. Improvement was participants to help with and EC balance test at baseline obtained for AST, no significant Exercise fatigue memorability and post-intervention. Ankle–hip change in RCI, and positive Errors in repeating Provide movements that postural coordination was training experience with a sensor- the steps in a correct consider range of motion

quantified by a RCI. Physical feedback-based exergame sequence of older adults – OPTRINTERACTION COMPUTER performance was quantified by the Provide movements that AST, TUG, and gait assessment consider functional impairments of older adults Skjæret et al. Three games, 3 min per game × three DDR, Mole 14 (9 F), 73 Video observations and five 3D avatars and game narrative Increased game Provide possibilities to QUAN-4 (2015) controlled games (SilverFit), LightRace movement characteristics (weight improved enjoyment of balance speed caused achieve high scores experiment, in YourShape shift; variation in step length, training exergames difficulty in upkeep of Facilitate the use of randomized, (UbiSoft) speed, and movement direction; steps and timing known gestures related repeated measures, visual independency) Training to overcome to daily life counterbalanced difficulty in following Provide game diversity to game visual elements increase autonomy on the screen 149 (Continued) 150 .L APNE AL. ET KAPPEN L. D.

Table 4. (Continued).

Exergame articles on balance training Sample size Exergame physical (female), mean Challenges in Study Study design Study duration activity age Research instrument Findings implementation Guidelines LoE Smith et al. Five sessions, Two group studies, 1 hr each DDR (Konomi): Step 46 (29 F), 78.9 Average step timing, percentage Significant linear relationships Difficulty in gauging Provide options for QUAN-3 (2011) repeated measures, training system of missed targets, or percentage between stepping performance the speed of adjusting the speed of four locations. Two correctly made steps (mean SEM and stimulus characteristics were interaction elements interaction elements group studies reported throughout) were observed Difficulty in hitting computed as outcome measures of targets stepping performance Szturm et al. RCT, two arm 16 sessions, two sessions/ Under Pressure 30 (19 F), 80.5 Berg Balance Scale, TUG test, Intervention group showed Training was needed Provide visual feedback QUAN-4 (2012) week, 45 min/session (NC), Memory Activities-specific Balance improvement in dynamic balance for the intervention on gait and posture to Match (NC) Confidence Scale, Clinical Test of over control group groups help raise self-efficacy Sensory Interaction and Balance, spatio-temporal gait variables Toulotte et al. RCT, four arm 20 weeks, 1 hr/week Adapted Physical 36 (22 F), 75.1 Tinetti test, unipedal tests, and the Improvement in dynamic balance No implementation Add movement routines QUAN-4 (2012) Activities and Wii Wii Fit® tests in the intervention groups challenges were and walking routines to Fit® reported help increase dynamic balance Uzor and Baillie Two-arm RCT, 9 12-week duration Pigeon Express, 17 (14 F), 72 TUG, SUS Adherence to exergame Fear of falling Convenience in using the QUAN-4 (2014) exercises/session for River Gems Game, rehabilitation program is better Challenges with exergame should be easy the intervention Game, Panda Peek than instructional booklet, operating the system Provide scores as a group Game (NC) improvement in balance Problems with the measure of progress sensor equipment Wüest et al. Five exergames, Three sessions/week, 12 weeks Scare Crow, Tractor 13 (10 F), 73.5 Berg Balance Scale, 7-m TUG, Short Significant improvements in Berg Lack of time Use a variety of games to QUAN-3 (2014) repeated measures, for a total of 36 sessions, each Driver, Fruit Physical Performance Battery, force Balance Scale, TUG, and Short Fear of injury maintain interest controlled study one-on-one session was Catcher, Worm platform stance tests, and gait Physical Performance Battery Use a combination of partitioned in three parts: Hurdler, Mix Soup analysis scores were observed difficulty levels to 10 min training, 10 min break, (IGER Games) (NC) promote effort and 10 min training LoE: Level of evidence; PAES: Physical Activity Enjoyment Scale; EFS: Evergreen Fitness System; PAR-Q: Physical Activity Readiness Questionnaire; MOB: matter of balance; 6MWT: 6-Minute Walk Test; TUG: Timed Up & Go; CS: Chair-Stand; CoP: center of pressure; CoM: center of mass; EO: eyes open; EC: eyes closed; RCI: reciprocal compensatory index; AST: Alternate-Step-Test; DDR: Dance Dance Revolution; SUS: System Usability Scale. Table 5. Exergame articles on increased PA (NC = noncommercial, RCT = randomized controlled trial). Exergame articles on increased physical activity Sample size (female), mean Study Study design Study duration Exergame physical activity age Research instrument Findings Challenges in implementation Guidelines LoE Birn et al. Four game tasks/ 3 min/participant Mobile outdoor exergame 8 (5 F), 65.8 SUS Combining physical exertion Interface design issues Encourage the preference for QUAL-3 (2014) Participant, talk (NC) and cognitive training into a Difficulty in picking points of audio feedback aloud protocol and mobile exergame improved interest on the map Provide a simpler user feedback satisfaction amongst users for interface PA Gerling et al. Two groups, two No data on SilverPromenade (NC) using 18 (14 F), 80.5 GEQ, ISO-Norm Questionnaire Age-related impairments Physical impairments limited Limit player action to one QUAN-3 (2011) levels/participant duration Nintendo Wii Remote 9241/10, player performance limited the walker mode for motor movements role (gameplay) to minimize metrics some participants Challenges with remembering cognitive load steps Reduce game design to fewer tasks Incorporate a multiplayer mode for supporting each other Gerling et al. Two studies, Study 1: no data Gesture Movements (NC) Study 1: 15 (7 F), Questionnaire-PANAS- Positive interaction experience Different time requirements to Design exergames to adapt QUAN-3 (2012) repeated measures on duration Kinect 73.72 descriptive stats, player but recall of gestures was too complete gestural interactions to physical and cognitive Study 2: no data Study 2: 12 (5 F), performance metrics challenging due to cognitive Kinect system had difficulty impairments on duration 76.7 load with participants in Accommodate different wheelchairs range of motion of different Inaccuracy of gesture participants recognition between Design for fatigue and participants due to differences exertion, simplicity of in range of motion routines, feedback and easy recall of steps Graves et al. Three groups, Seven activities/ Wii Fit activities (inactive 13 (3 F), 57.5 MetaMax 3B, PACES, oxygen Energy expenditure/HR Physical limitations of Provide intensity QUAN-3 HUMAN OF JOURNAL INTERNATIONAL (2010) seven activities participant for game, yoga, muscle consumption (VO2), greater than inactive gaming participants prevented a few adjustments with increasing 10 min conditioning, balance, electrocardiogram, HR but lower than treadmill, Wii from jogging on the treadmill Provide for fatigue and intensity aerobics, brisk treadmill Aerobics failed to meet exertion management walking, and treadmill recommended intensity in all jogging) groups, Enjoyment was higher in Wii Aerobics Kirk et al. Experimental 120 min/session Wii sports and Wii Fit games 20 (14 F), 61 PANAS, test of non-verbal Indicated overall physiological Relating heart rate and effort Incorporate visual feedback QUAN-3 (2013) study, single group intelligence (TONI-IQ) and benefits in using the Wii, to determine the level of for participants on perceived trail B tests, HR, RPE which will not be constant for exertion of participants while exertion and desired all the games. As such, there is monitoring safety intensity levels likely to be a degree of considerations for variation in the physical overexertion were a big intensity depending on games challenge

being played – OPTRINTERACTION COMPUTER Lin et al. (2006) Single group, two Pre-intervention Fish ‘n’ Steps (NC) 19 (11 F), 63 TTM of behavioral change Encouragement showed an Intrusiveness of the devices Provide multiple levels of QUAL-3 conditions (4 weeks) increase in long term and pedometers were incentives Intervention behavioral change as opposed reported Provide options for (6 weeks) to negative reinforcement, cooperation or competition Post-intervention four participants showed (4 weeks) permanent positive behavior change Taylor et al. Repeated measures 5 min per session Nintendo Wii and Xbox 360 19 (11 F), 70.7 METs, Balance confidence No significant difference in Interpretation of interaction Minimize high bone-loading QUAN-4 (2012) with a cumulative Kinect: Active Video Games scale, mini-BESTest, Activities- energy expenditure or with the exergames differed impact activities play time of specific Balance Confidence perceived exertion between between participants 45 min Scale; TUG equivalent games played while standing and seated LoE: Level of evidence; SUS: system usability cale; HR: heart rate; RPE: rate of perceived exertion; TTM: transtheoretical model; METs: metabolic equivalents; TUG: Timed Up and Go. 151 152 D. L. KAPPEN ET AL.

Wheelchair-accessible motion-based games enabled posi- 4.2.7. Exergame articles on mental health (depression) tive engagement of older adults using wheelchairs (Gerling, We report a single article separately in this section that used Mandryk, & Kalyn, 2013). Wii games as interventions to favor exergames as an intervention for mental health (to alleviate progress over challenge, prevent overexertion, prevent health depression). This article indicated that the participation in risks, and decrease reaction times provided criteria for reha- exergames contributed to significant reduction of depressive bilitation and treatment of age-related diseases (Barenbrock, symptoms, improvement in mental health-related quality of Herrlich, & Malaka, 2014). life (HRQOL), and improvement in cognitive performance For PD rehabilitation, dynamic difficulty adjustments in an (Rosenberg et al., 2011). This study indicated the benefits of exergame tailored for PD patients provided automatic adjust- exergames on older adults with subsyndromal symptomatic ment of amplitude parameter (Siegel & Smeddinck, 2012). A depression. The details are shown in Table 9. similar sample of participants reported improved game experi- ence when using “kinesiatric” digital games (Smeddinck, Siegel, 4.2.8. Exergame articles on wellness &Herrlich,2013) or exergames as interventions for PD. Player In contrast to cognitive training, cognitive–physical training, enjoyment and immersion improved; however, difficulty and mental health interventions, exergames have also been increased when players were required to multitask (Galna studied in the context of a person’s overall “wellness.” This et al., 2014). refers to an overall uplifting of the mind and body image of For stroke patients, exergames as an intervention in the the individual or a group of people. We report studies under form of Wii Sports (tennis and boxing) at moderate intensity the wellness themes (n = 3) and further classification into were sufficient for maintaining and improving health subthemes for psychosocial wellness (n = 1), cognitive well- (Hurkmans, Ribbers, Streur-Kranenburg, Stam, & Van Den ness (n = 1), wellness as applied to motivation (n = 1), and Berg-Emons, 2011). The details are shown in Table 6. wellness as associated with QOL. Increased motivation for exergames and willingness to play again suggested that older adults are more open to 4.2.5. Exergame articles on cognitive training the overall physical and mental benefits of exergames Cognitive training formed another theme pertaining to exer- (Brauner, Valdez, Schroeder, & Ziefle, 2013). During the games as technology interventions. Wii Bowling was enjoyed exergame, raising arms to pause or resume game, grabbing by the most participants with mild cognitive impairment motion in reaction to falling apples, timed events, and (Hughes et al., 2014) and was rated highest for cognitive train- reaction time provided fun and affective engagement to ing, social, and physical stimulation. Dual-Task Tai Chi train- the participants. Facilitating affective technology to create ing was effective in improving cognitive functions (Kayama joy and surprise as motivational elements during gameplay et al., 2013); better cycling function was indicated using the produced a greater inclination to participate in exergames cybercycle in contrast to a traditional exerciser (Anderson- (Fukuda, 2011). Gesture-based exergames afforded the Hanley et al., 2012) indicating that motion-based exergames potential for heightened physical well-being and social combining physical and cognitive exercises helped to improve engagement (Rice et al., 2011). cognitive functions. Dynamic game content and highly signifi- The potential of exergames to increase social connections cant predictive value of affective, usability, and satisfaction (Wollersheim et al., 2010) within the participant sample pro- states highlighted the potential of exergaming in improving vided a basis for intergenerational fitness and playful activ- affective states of older adults (Billis, Konstantinidis, Ladas, ities. While this study reported significantly higher maximum Tsolaki, & Bamidis, 2011). The details are listed in Table 7. energy expenditure than baseline, the difference in overall energy expenditure was not significant. This study was speci- 4.2.6. Exergame articles on cognitive–physical training fically geared toward examining the physical and psychosocial Although we review articles on cognitive training in the above effects of Wii Sports among older women and reported section, we decided to form a separate category for studies improved outlook toward fitness activities. focusing on exergame benefits for cognitive and physical Improved cognition was indicated through increased training and report these as a separate thematic section. ability to efficiently control game elements in a motion- These two studies focused more on the advantages of exer- based game (Gerling, Dergousoff, & Mandryk, 2013). The gaming in improving the cognitive functioning of older adults age and type of controllers used impacted user perfor- through the medium for physical training. This distinction mance. Overall well-being from the usage of exergames was the reason for creating a separate theme for the following affected the comfort level and enjoyment level of older two studies. adults. This rationale allowed us to report this article Significant improvements in measures of physical func- under this section as opposed to under the earlier section tion and cognitive measures of executive control and pro- related to the benefits of cognitive training from cessing speed were reported (Maillot, Perrot, & Hartley, exergames. 2012). Furthermore, improvement in motivation to exer- The relationship between usability and dependability of the cise and the importance of expert supervision of older exergames in the context of older adults’ flow experience adults when using Wii therapy constituted a distinct indicated that in-game challenges (Hwang et al., 2009) played focus on exergames as interventions for cognitive and an important role in motivating older adults to engage in such physical training (Portela, Correia, Fonseca, & Andrade, games. Overall QOL was measured using HRQOL, SF-8 2011). The details are in Table 8. (Quality Metric) which reported that somatosensory video Table 6. Exergame articles on rehabilitation (NC = noncommercial, RCT = randomized controlled trial). Sample size Exergame (female), mean Study Study design Study duration physical activity age Research instrument Findings Challenges in implementation Guidelines LoE Exergame articles on rehabilitation Gerling et al. Single study design 10 min Cupcake-Heaven: 10 (6 F), 75 Gesture Analysis Tool Coordinating multiple Participants needed more time When designing exergames, QUANT-3 (2013) (NC) Kinect- based on Kinect movements was difficult for for wheelchair based gestural consider the strength of the Wheels Wheels older adults; gesture recall input participant challenges Training was needed to Consider the effort needed familiarize participants with the for wheelchair based exergame interaction inputs Barenbrock Field study, nine games 3 days/person Wii Games 4 (2 F), 78.5 Field study, GEQ and Risk perception measures for Evaluation of physical ability of Incorporate challenges and QUAL-3 et al. (2014) interviews older adults were lowered and participants to participate took progress feedback elements improved confidence time Provide for fatigue Safety aspects during gameplay management and health conditions took time Provide for risk to evaluate management of safety aspects to prevent injuries through supervised sessions Exergame articles on rehabilitation (Parkinson) Galna et al. Single study session Three-hour session/person Nintendo Wii and 9 (6 F), 68.2 Flow State Scale, Improvement in balance; Safety issues of participants Incorporate progressive QUAL-3 (2014) Microsoft Xbox semi-structured difficulty in discriminating Tiredness of participants led to intensity levels to cater to Kinect interviews between different types and cessation of progression exertion levels orientations of visual information and challenges with multi-tasking Siegel and Pre–post study design Five sessions/person, 16 game Sterntaler 3 (0 F), 72 DDA measured using Exergames for PD are viable No challenges were reported Provide vertical movements QUAN-2 Smeddinck rounds/person, 3 weeks/ (WuppDi!) amplitude adaptation and appreciated by therapists with large range of motion (2012) person exergames (NC) with improved flexibility so that balance is not NENTOA ORA FHUMAN OF JOURNAL INTERNATIONAL compromised Address individual strengths and weakness Allow for adjustable and fine-grained controls Smeddinck Multiple session study Five 30-min sessions, Sterntaler 3 (0 F), 71.33 Performance metrics Flexibility of system provided Calibrating equal reach for both Provide varying difficulty QUAL-1 et al. (2013) 15–20 min of gameplay/ (WuppDi!) using performance in appropriate challenge suitable arms was difficult levels to cater to differences session exergames (NC) collecting time and to PD subjects Participants had different range in ability of older adults amplitude of motion Increase challenges to maintain interest Exergame articles on rehabilitation (Stroke) Hurkmans et al. Randomized, repeated 15 min/session, two sessions, Wii Sports tennis 10 (4 F), 53 Measuring oxygen Patients were able to play at Physical impairments like severe Provide simplicity of steps QUAN-4 (2011) measures 10-min break in between and boxing uptake (VO2), METs moderate intensity to meet spasticity prevented in holding and routines health requirements the Wiimote and the Nanchuck –

in both hands INTERACTION COMPUTER Stroke induced deficits caused issues with timing Exergame articles on rehabilitation (balance) Maillot et al. RCT, pretest-training- 14-week study Walking/Braking 34 (12 F), 72.5 Senior Fitness Test, Exergames appear to be an Gait challenges were different for Provide strength training QUAN-4 (2014) posttest design (Wii system) (NC) Medical Outcomes effective way to train postural participants and balance exercises to Survey Short Form 36 control in older adults improve flexibility (SF-36) Pichierri et al. RCT 60 min and consisted of a Dance video 15 (9 F), 84.9 Step action arrow Under dual task conditions, Of the 25 initial participants, only Provide step action for QUAN-4 (2012) warm-up (5 min), resistance game sequences using a participants showed improved 19 completed the study, because improvement in balance training (25 min), balance MATLAB script, step time of falls and being too frail and postural control exercises (10 min), and the sensors dance video gaming (20 min) 153 LoE: Level of evidence; DDA: Dynamic Difficulty Adjustments; METs: metabolic equivalents. Table 7. Exergame articles on cognitive training (NC = noncommercial, RCT = randomized controlled trial). 154 Sample size Exergame physical (female), mean Challenges in Study Study design Study duration activity age Research instrument Findings implementation Guidelines LoE .L APNE AL. ET KAPPEN L. D. Exergame articles on cognitive training Anderson- Multi-site cluster 3 months Cyber-cycle with 102 (62 F) 75.7 Stationary Ergometer, control and Simultaneous cognitive and Training in Provide combination of cognitive QUAN-4 Hanley et al. RCT virtual reality tours randomized groups, plasma test; ACLS- physical exercise had greater cybercycling and physical exercise (2012) (NC) PAQ potential for preventing was needed Provide a combination of visual cognitive decline and dynamic exercises Billis et al. Experimental 2-week period FitForAll Exergame 14 (8 F), 69.2 QUIS, Software Usability Measurement Strong evidence that dynamic Training was Provide for ease of use and QUAN-3 (2011) session (NC) Inventory game content adaptation needed learnability according to one’s affective Provide for adjustability of state would result into better gameplay based on the training adherence and experiential states of the user seniors’ reinforcement of motivation Hughes et al. RCT 90 min each week for Wii Sports games 20 (14 F), 77.35 CAMCI, Cognitive Self-Report Interactive video gaming (with No difficulties Consider incorporating QUAN-4 (2014) 24 weeks (bowling, golf, Questionnaire-25, Timed Instrumental moving of arms) is feasible for were reported exergames that provide tennis, and Activities of Daily Living, game scores older adults with mild cognitive, social, and physical baseball) cognitive impairment stimulation Kayama et al. Experimental 15 min of moderate-intensity Full-body motion 41 (17 F), 72 TMT and VFT Physical training using DTTC Training on Provide longer time to familiarize QUAN-3 (2013) study design, aerobic exercise, 15 min of Suduko with Kinect improved executive cognitive control devices with control devices and action repeated progressive strength training, sensors (NC) functions was needed sequences measures 10 min of flexibility and balance exercises, and 10 min of cool-down activities/session LoE: Level of evidence; RCT: randomized clinical trial; ACLS-PAQ: Aerobics Center Longitudinal Study Physical Activity Questionnaire; QUIS: Questionnaire for User Interaction Satisfaction; CAMCI: Computerized Assessment of Mild Cognitive Impairment; TMT: trail-making test; VFT: verbal fluency test; DTTC: Dual-Task Tai Chi.

Table 8. Exergame articles on cognitive–physical training (NC = noncommercial, RCT = randomized controlled trial). Exergame Sample size Study physical (female), mean Challenges in Study Study design duration activity age Research instrument Findings implementation Guidelines LoE Exergame articles on cognitive–physical training Maillot et al. Pretest-training–posttest 24 × 1 hr Wii Games 32 (27 F), 73.47 Functional fitness testing, Significant improvement to Physical trainer was Provide a combination of QUAN-4 (2012) design, experimental and of training Stroop test; cognitive tests experimental group in needed for each session to cognitive and physical control group using executive control physical and cognitive supervise older adults routines tasks, visuospatial tasks function and processing –speed tasks Portela et al. Randomized controlled 50 min/ Wii therapy 65 (40 F), 79 Balance (Berg Scale), Daily Improved the physical No implementation issues Provide for activities to QUAN-4 (2011) trial session Activities (Barthel Daily), component of the elderly and were reported focus on different muscle Cognitive Status (MMSe), it also can be a motivating groups with increasing Perceived Health (SF-36) factor for exercise practice intensity LoE: Level of evidence. INTERNATIONAL JOURNAL OF HUMAN–COMPUTER INTERACTION 155

games (SVG) (Chen, Huang, & Chiang, 2012) had great potential as a health promotion tool for the disabled elderly. This indicated the relevance of exergames within the QOL QUAN-2 subtheme. The details are in Table 10. – 4.2.9. Exergame articles on physical training ” This section focuses on articles which provided empirical thinking “ evidence of the benefits of exergaming on physical training. feeling – We have also initiated subthemes where the exergaming was specifically geared toward physical training (n = 2), cardio- Provide for independent activity through exergames Provide for gaming leading to moving vascular training (n = 1), visual training (n = 1), and wellness training (n = 2). Augmentation of existing exercises using VR technology is also a form of exergame. A study using VR as an assistive technology for physical therapy to augment existing exercises

Challenges in tailored for retirement home residents (Bruun, Søndergaard, implementation Guidelines LoE Serafin, & Kofoed, 2014) reported increased motivation to Setting up and training of participants was required uphold a regular exercise routine. Comparison of the results of traditional measures of muscle strength using a clinical dynamometer with those obtained using the video game indi- cated an increase in grip strength in older adults (Zavala- Ibarra & Favela, 2012). Increase in exercise capacity and daily PA was reported in a study of heart failure patients (Klompstra, Jaarsma, &

Preliminary indication of the benefits of exergames in seniors with Subsyndromal Depression was noted Strömberg, 2014), indicating the benefits of exergames as a form of intervention for these older adult patients. Hand– eye coordination and reaction times improved (Chiang, Tsai, & Chen, 2012) through the use of Xbox games as a mode of intervention. This provided evidence of the ben- efits of exergames in the subtheme of physical training with the goal of enhancing visual acuity. Self-efficacy-based intervention using Wii exergames in assisted living residents (Chao, Scherer, Wu, Lucke, & enjoyment questionnaire, performance logs Montgomery, 2013) reported exergames to be an acceptable, safe, and effective medium to promote PA in older adults. Furthermore, use of Nintendo Wii as an exergame interven-

(female), tion indicated that participants developed a sense of empow- mean age Research instrument Findings Sample size erment and achievement after some initial reluctance and anxiousness (Keogh, Power, Wooller, Lucas, & Whatman, 2014). The details are shown in Table 11. activity physical Exergame Wii Sports 19 (13 F) 78.7 QIDS, MOS SF-36, RBANS, 4.2.10. Exergame articles on design for PA While this systematic review focuses on fitness outcomes of exergaming when used as a technological intervention, we decided to include one study with a focus on exergame design (Velazquez, Martinez-Garcia, Favela, Hernandez, & Ochoa, 2013) because of the empirical nature of the study design

24 weeks); three 35- and the relevance of its findings to the PA characteristics of – min sessions per week 12-week pilot study (with follow-up at 20 older adults. The study (Table 12) described insights into the design of full-body exergames for older adults with an empha- sis on monitoring physical characteristics of older adults in adapting to gameplay and spectator-centered design.

Single study design 4.2.11. Methodological quality of studies The nominal values of the ratings from each coder against the methodological quality assessment, data extraction, ) Exergame articles on mental health (depression) (NC = noncommercial, RCT = randomized controlled trial). and data analysis criteria (shown in Table 1)resultedin 2011 ( pairs of scores. Pair-wise comparisons of these scores for Study Study design Study duration Exergame articles on mentalRosenberg health et (depression) al. Table 9. LoE: Level of evidence; QIDS: Quick Inventory of Depressive Symptoms; RBANS: Repeatable Battery for Assessment of Neurocognitive Status. each variable were calculated for inter-rater reliability. We 156

Table 10. Exergame articles on wellness (NC = noncommercial, RCT = randomized controlled trial). Sample size Exergame physical (female), mean Research Challenges in .L APNE AL. ET KAPPEN L. D. Study Study design Study duration activity age instrument Findings implementation Guidelines LoE Exergame articles on wellness Brauner et al. (2013) Controlled experiment, Did not report GrabApple, 21 (11 F), 68 NPS, Bartle Exergames had a positive effect on Participants had difficulty in Provide initial levels to be QUAN-3 three levels, pretest– FruitSalad (NC) Player Types perceived level of pain in older understanding the relation easy to use posttest evaluation, scale adults between their posture and in Increase the level of quantitative and game setting causing the intensity and difficulty qualitative methods game to pause progressively (interviews) Fukuda (2011) Pretest/Posttest Trial, 4-week continuous use, Personal Trainer 8 (3 F), 73.5 POMS Possibility of older adults utilizing Participants were conscious Provide for continuous QUAN-2 and final evaluation Walking; Brain Age exergaming technologies by about their walk and the and frequent usage of the Express: Math, Brain facilitating through affectiveness wearable devices system to help with Age Express: Arts & familiarity Letters (NC) Rice et al. (2011) Within-subjects design, 2 hr/session Silhouette and 36 (29 F), 62.9 PE, PEOU, PU, Exergames associated with Interference with the screen Simplify exercise routines QUAN-3 six groups, six swatting Game (NC) and SI physical well-being was rated and participants hands incorporating stationary participants/group higher and affirmed the caused errors exercises or simplified importance of monitoring exercise exercises parameters to determine any difference between perceived and actual heart rate Exergame articles on wellness (psychosocial) Wollersheim et al. Repeated measures, post- 6 weeks Wii Sports 11 (11 F), 73.5 RT3 Qualitative data revealed that the Mobility issues inhibited play Provide feedback and QUAN-3 (2010) intervention focus group Accelerometers participants perceived an encouragement to sessions measuring improved sense of physical, social support participants intensity and and psychological well-being during gameplay duration Exergame articles on wellness (cognitive) Gerling et al. (2013) Randomized, repeated 6 min to complete three tasks Collecting flowers, 17 (11 F), 71.5 ISO 9241-?9 Results showed that older adults No implementation Increase the frequency of QUAN-4 measures navigating the maze and NASA-TLX could apply motion-based game challenges were reported feedback for older adults and following the questionnaires controls efficiently and that they Provide hands-free input flower (NC) enjoyed motion-based interaction Provide reasonable game pacing to help with overcoming fatigue Exergame articles on wellness (motivation) Hwang et al. (2009) Observational study Did not report DDR 30 (16 F), 65 Interviews Usability and dependability were No implementation Provide a feeling of being QUAL-3 identified as critical factors for the challenges were reported safe during gameplay elders to use computer technology Create a combination of due to the cognitive ageing challenges, categorizations such as sorting, identifying countries and shared experiences Exergame articles on wellness (QOL) Chen et al. (2012) Quasi-experimental Trainings of three sessions per SVG (NC) 61 (43 F), 78.5 HRQOL, SF-8 Results of HRQOL showed that Training sessions for the Provide for social QUAN-3 design with a control week, for 30 min each session (Quality Metric) general health, physical function, participants took time functions such as sharing group which included 5-min warm role physical, and body pain in because of different and interaction up, 20-min interactive gaming, physical component summary and experiences with gaming Provide immediate and 5-min cool down during social functioning in mental technology feedbacks their free time component summary were significantly improved after the intervention LoE: Level of evidence; NPS: Net Promoter Score; POMS: profile of mood status; PE: physical engagement; PEOU: perceived ease of use; PU: perceived usefulness; SI: social interaction; SVG: somatosensory video games; HRQOL: health-related quality of life. Table 11. Exergame articles on fitness—physical training (NC = noncommercial, RCT = randomized controlled trial). Sample size Exergame (female), mean Challenges in Study Study design Study duration physical activity age Research instrument Findings implementation Guidelines LoE Exergame articles on physical training Bruun et al. (2014) Interviews One-day session, stop the Exerbike (VR 10 (8 F), 82.9 Semi-structured interview Majority of subjects reported Fatigue of participants Provide for virtual QUAL-3 intervention at will augmentation) to support the VR environments of a diverse (NC) augmentation and preferred nature the VR based exercise Provide realism in the experience to the virtual environments conventional exercise Empower curiosity and exploratory interest to travel to unknown places Zavala-Ibarra and Controlled study, two 45-min playtesting session Xbox and Wii 5 (2 F), 72 Measurement of grip strength Reported an increase in grip Lack of experience with Provide simple rules, easy to QUAN-3 Favela (2012) groups, and with games (clinical dynamometer) strength to assist in the technology inhibited learn steps for reduced focus group session detection of early signs of play, caused anxiety cognitive effort dynapenia and insecurity Facilitate skill building, mastery, and performance improvement Exergame articles on fitness—physical training (heart) Klompstra et al. Pretest/posttest 12-weeks, 20 min/day Wii games 32 (10 F), 63 Borg’s RPE; Dairy Log, SEE; Reported that although the Motor disabilities and Provide for continuous QUAN-2 (2014) HADS; EMI daily physical activity did not range of motion usage to improve exercise change over time, exergaming inhibited play capacity was feasible for heart failure Issues with technology patients and might be a such as working of rehabilitation option for controllers and battery patients with heart failure issues stalled the

program HUMAN OF JOURNAL INTERNATIONAL Exergame articles on fitness—physical training (visual) Chiang et al. (2012) Quasi-experimental Trainings three times per Somatosensory 53 (37 F), 73.5 The Vienna Test System and the Interventions significantly Training sessions for Provide for social functions QUAN-3 design week, for 30 min each session video games Soda Pop test improved the visual the participants took such as sharing and which included 5-min warm performance improved time because of interaction up, 20-min interactive gaming, significantly on the reaction different experiences Provide immediate and 5-min cool down test (p < 0.001) and eye–hand with gaming feedbacks coordination (p < 0.001) technology Exergame articles on fitness—physical training (wellness) Chao et al. (2013) Single-group pre– 8-week study Wii Fit 7 (5 F), 86 Berg Balance Scale (BBS-14), TUG Supported the applications of No implementation Provide for safe gameplay QUAN-2 post design test, 6MWT, FES, SEE scale, OEE integrating self-efficacy theory challenges were environment scale into exergames as a reported Interject scores to help mechanism to encourage build confidence of players older adults to engage in Limit negative feedback exercise because it tends to cause – frustration with players with INTERACTION COMPUTER “functional disability or physical intolerance” Keogh et al. (2014) Mixed-methods, 8 weeks, 5 min/participant/ Wii Sports 34 (30 F), 83 Semi-structured group interview; Intervention group had No implementation Provide exercise routines to QUAN-2 quasi-experimental day, 3 days a week functional ability (bicep curl and significantly greater increases challenges were help increase upper body pilot study FSST), physical activity (RAPA), in bicep curl muscular reported strength and quality of life (World Health endurance, physical activity Organization Quality of Life levels, and psychological Questionnaire—Brief Australian quality of life than the control version [WHOQOL-Brief]) group LoE: Level of evidence; RPE: Rating of Perceived Exertion; SEE: self-efficacy questionnaire; HADS: Hospital Anxiety and Depression Scale; EMI: Exercise Motivation Index; TUG: Timed up and go; 6MWT: 6-minute Walk Test; FES: falls efficacy scale; SEE: self-efficacy for exercise; OEE: outcome expectations for exercise; FSST: Four-Square Step Test; RAPA: Rapid Assessment of Physical Activity. 157 158 D. L. KAPPEN ET AL.

took the ratings for the 50 articles which included the study design for younger and older participants (Van Diestetal.,2014) as opposed to the final selection of 55 QUAL-3 articles. While the ratings needed to be compared only for a subsample of at least 20% of the total number of articles, as reported by Swert (2012),weusedtheentiresampleof 50 articles for inter-rater reliability testing. We added six articles to this set and did not include these in the relia- bility calculations because the inter-rater reliability was already established for more than 20% of the dataset. The inter-rater reliability was established by calculating Krippendrorff’s alpha (Kalpha). For each of the variable pairs, Kalpha >0.8 indicated good agreement between the

exertion for older adultsrequire does high not intensity exercises Provide for longer timeand to play understand the exergame Provide for socialization and interaction two coders for each of the three criteria (A, B, and C) as shown in Table 13. Regarding the methodological quality of studies assess- ment, the LoE reported by each study was rated for the LoE within quantitative and qualitative studies as indi- Challenges in

implementation Guidelines LoE cated, respectively, by dimensions (D) and (E) (Table 1).

Fatigue of players Understand that the perceived We compared the quality of evidence reported by 55 articles using qualitative research methods (n =9)and quantitative research methods (n = 34). Out of the results of the evidence assessment of articles using qualitative research methodology, one article (2%) was evaluated as of very low quality (QUAL-2), while eight articles (15%) were rated as QUAL-3. The results were based on the LoE reported by the qualitative research method used in the studies. Furthermore, out of the results of the evidence assessment of the articles using quantitative research methodology, 7 articles (13%) were rated as QUAN-2, 19 including measure arcs ofestablish motion limits to and identifyamong levels players beyond frailty condition articles (35%) were rated as QUAN-3, and 20 articles (36%) were rated as high as QUAN-4. The articles cate- gorized based on this LoE reported by study designs are Research

Instrument Findings indicated in Table 14. Furthermore, many studies using small sample sizes, lack of control groups, use of non-validated research instruments, and short study duration stood out as major challenges of empirical studies evaluated in this systematic review. Mean Age Sample Size (Female), 18(12 F), 70 CAR Identified need to level skill challenge, 4.3. Research methods dimension The research methods dimension was further extrapolated into the sub-dimensions of study designs, participant sample, research instruments, and fitness activity and these were

Exergame coded as indicated below. Physical Activity Motion-based exergames 4.3.1. Study design The spectrum of research methods used in the 55 articles Study

Duration adapting exergames in older adults’ activity and PA lead- Weekly, 2 hr/ session ing to health improvements can be seen in Table 15.We use “fitness” as an overarching term to denote the domain encompassing health and wellness goals for older adults. Of the 55 articles under quality review, 34 articles

Focus group sessions (62%) used quantitative measures to extrapolate the use- ) fulness of exergames for older adult’s fitness, 10 articles Exergame articles on design (NC = noncommercial, RCT = randomized controlled trial). 2013 (18%) used qualitative methods, 10 articles (18%) reported mixed methods, and 1 article (2%) was identified as using et al. ( case study and survey in its study design. Exergame articles on designVelazquez for physical activity Study Study Design LoE: Level of evidence; CAR: Canonical Action Research. Table 12. INTERNATIONAL JOURNAL OF HUMAN–COMPUTER INTERACTION 159

Table 13. Krippendorff’s alpha. Variable (pairs) Percentage agreement Krippendorff’s alpha N agreements N disagreements Cases N decisions Methodological quality assessment 94 0.86 47 3 50 100 Data extraction 92 0.84 46 4 50 100 Data analysis 94 0.88 47 3 50 100

Table 14. Level of evidence (LoE) based on study design. LoE based on study design LoE No of articles % Article reporting studies Type of studies QUAL-2 1 2% Smeddinck et al. (2013) Case Study QUAL-3 8 15% Barenbrock et al. (2014), Bruun et al. (2014), Gerling et al. Interviews (2010), Velazquez et al. (2013), Birn et al. (2014), Galna et al. (2014), Hwang et al. (2009), Lin et al. (2006) QUAN-2 7 13% Agmon et al. (2011), Chao et al. (2013), Fukuda (2011), Keogh Case study, pretest/posttest et al. (2014), Klompstra et al. (2014), Rosenberg et al. (2011), Siegel and Smeddinck (2012) QUAN-3 19 34% Billis et al. (2011), Bateni (2012), Brauner et al. (2013), Chen Controlled studies et al. (2012), Chiang et al. (2012), Duclos et al. (2012), Fang et al. (2015), Gerling et al. (2011), Gerling et al. (2012), Gerling et al. (2013), Graves et al. (2010), Kosse et al. (2011), Kayama et al. (2013), Kirk et al. (2013), Lund and Jessen (2014), Smith et al. (2011), Wollersheim et al. (2010), Wüest et al. (2014), Zavala-Ibarra and Favela (2012) QUAN-4 20 36% Anderson-Hanley et al. (2012), Ejupi et al. (2014), Gerling RCT, randomized Latin et al. (2013), Hughes et al. (2014), Hurkmans et al. (2011), square study design Lamoth et al. (2012), Maillot et al. (2012), Maillot et al. (2014), Portela et al. (2011), Rice et al. (2011), Schwenk et al. (2014), Skjæret et al. (2015), Taylor et al. (2012), Uzor and Baillie (2014), Franco et al. (2012), Pichierri et al. (2012), Pluchino et al. (2012), Rendon et al. (2012), Szturm et al. (2012), Toulotte et al. (2012) Total 55 100% LoE: Level of evidence; RCT: randomized controlled trials.

of exergames for balance training. Additionally, the highest Table 15. Research method used. reported participant ages (84.6 ± 6.8) were reported in a study Research method Number of articles Percentage (Schwenk et al., 2014), indicating the benefits of balance Survey 1 2 training through exergames. Qualitative 9 16 Quantitative 34 62 Mixed Methods 10 18 4.3.3. Research instruments Case Study 1 2 – 55 As indicated in Tables 4 12, many studies used validated research instruments such as the Berg Balance Scale, TUG, SUS, PANAS, HRQOL, and SF-8. However, a few studies 4.3.2. Participant sample reported semi-structured interviews and used their own ques- This systematic review reports on the participant sample size tionnaires which resulted in their lower rating in the metho- and the mean age of the participants recruited for each study dological quality assessment. as indicated in Tables 4–12. Within this systematic review of empirical evidence 4.3.4. Exergame PA relating to the benefits or disadvantages of exergames in Exergame physical activities used in the studies are reported the context of older adults’ fitness, a major shortcoming in Tables 4–12. From these tables, 25 articles (51%) reported that emerged was the identification of small participant the use of their own independently developed NC motion- sample sizes in many studies. Of the 55 articles, 24 articles based games as exergames for their studies. Three studies (49%) reported empirical evidence based on small partici- (6%) reported the use of DDR for evaluating the benefits of pant sizes (Nparticipants < 15). This also indicated the diffi- exergame as an intervention. Fifteen studies (30.6%) used culty of recruiting from the older adult population, Nintendo Wii games for their experiments. Three articles especially with such a heterogeneous range of age-related (6%) reported the use of Microsoft Xbox and Nintendo Wii impairments affecting this demographic. games for their study purposes and two articles (4%) reported The smallest sample size (Nparticipants = 3) was in a quali- the use of SVG for their experimental setup. tative study (Smeddinck et al., 2013) and in a corresponding quantitative study (Siegel & Smeddinck, 2012) reporting 5. Discussion results of the effectiveness of exergames for rehabilitation in patients with PD. The largest cohort (Nparticipants = 104) was in Our systematic review identified a broad range of use con- a study (Ejupi et al., 2014) which reported on the effectiveness texts for exergames: from using NC digital game mechanics 160 D. L. KAPPEN ET AL.

Table 16. Main exergame categories. The balance training category on its own represented a Exergame categories Number of articles major area of exergame interventions for older adults. Design for physical activity 1 Empirical evidence from articles in this category indicated Physical training 6 Wellness 7 that supervised balance training is feasible (Agmon et al., Mental health (depression) 1 2011) and efficacious. A combination of Wii Fit and physical Cognitive physical training 2 therapy provided positive results when using exergames as Cognitive training 4 Rehabilitation 8 interventions for older adults’ balance training (Bateni, Balance training 19 2012). Studies of balance training for older adults using exer- Increased physical activity 7 “ ” Total 55 games showed improvement in stepping reaction time (Ejupi et al., 2014), level of balance requirements (Duclos et al., 2012), and level of performance (Kosse et al., 2011). Balance training exergames also allowed people to compare that enable PA among older adults to commercial interac- their own performance with others (Fang et al., 2015); provide tive video games (DDR, Wii Sports, Wii Fit) that enable PA feedback (Lamoth et al., 2012); encouraged subjects to parti- among older adults. This systematic review focused on cipate eagerly (Gerling et al., 2010); and improved health articles reporting empirical evidence. Our review included parameters like balancing, mobility, and agility (Lund & data on methodological quality; ratings for LoE provided by Jessen, 2014). Sensor-based exergames (Schwenk et al., 2014) the studies; and databases from science, engineering, and improved the experience of balance training. It also helped if technology. The inclusion criteria provided us with a selec- they incorporated 3D avatars and game narratives (Skjæret tion of 55 articles. A detailed quality review of these articles et al., 2015) as well as other stimuli (S. Smith et al., 2011). revealed 19 themes (Table 3) which were further reduced to Exercise adherence (Uzor & Baillie, 2014) and improvement 9 exergame categories (Table 16)withafocusofthese in balance training (Wüest et al., 2014) were also attributed to exergame studies on technological interventions for older exergames. adults’ PA. Increased PA was experienced by older adults playing mobile exergames combining physical and cognitive training (Birn et al., 2014). They also experienced reduced cognitive 5.1. Exergame themes and categories load (Gerling, Livingston, et al., 2012) and felt encouraged by physical gameplay (Lin et al., 2006). Studies indicated overall Based on the above thematic groupings, we developed a physiological benefits in increased PA using the Wii console taxonomy, categorizing 55 articles into 19 themes, shown in (Kirk et al., 2013), increased enjoyment and greater energy Figure 2. These 19 themes were further reduced to 9 major expenditure and heart rate (Graves et al., 2010), with categories, which are shown in Table 16. This table indicates increased engagement and enjoyment (Gerling et al., 2011). that “balance training” formed the theme of 28.6% (n = 14) of The differential energy expenditure in older adults playing the selected articles. The main groupings also showed that exergames in seated and standing position was not significant. increased PA, rehabilitation, and wellness each formed 14.3% Exergames as interventions for rehabilitation indicated (n = 7 each) of the selected articles. This was followed by the challenges for older adults in gesture-based games because physical training group at 12.2% (n = 6), the cognitive train- of gesture recall difficulty (Gerling et al., 2013), lower risk ing theme at 8.2% (n = 4), and the cognitive physical training perception (Barenbrock et al., 2014), and the challenge of theme at 4.1% (n = 2). At the low end of the frequency scale multi-tasking (Galna et al., 2014). However, the flexibility of were the exergame articles on the mental health (depression) adapting exergames to PD rehabilitation (Siegel & Smeddinck, theme and the exergame on the theme of design for older 2012; Smeddinck et al., 2013) provided advantages for imple- adults, each with 2% (n = 1). This distribution also helps to menting exergames as interventions for rehabilitation. indicate the hierarchy of importance of these exergame Improvements in postural control (Maillot et al., 2014) for themes and categories. patients needing balance training and stroke patients

Figure 2. Taxonomy of 19 exergame themes. INTERNATIONAL JOURNAL OF HUMAN–COMPUTER INTERACTION 161

(Hurkmans et al., 2011) increased the range of applications of articles (36%) were rated as a QUANT-4 study, which repre- exergames for rehabilitation. sented a RCT in examining the benefits of exergames as Dynamic game content (Antonis S. Billis et al., 2011) led to interventions for PA for older adults. increased adherence to exergames, while a combination of A number of studies from the science databases (Table 14) cognitive and physical exercise (Anderson-Hanley et al., rated higher on the methodological quality assessment and the 2012; Hughes et al., 2014) facilitated cognitive training. LoE provided, in contrast to the engineering- and technology- Combining tasks (Kayama et al., 2013) improved the cognitive themed articles. The reason for this could be that exergames training of older adults. Empirical evidence also points to were studied in the former context as a therapeutic or a benefits of combining cognitive and physical training diagnostic tool in articles on clinical intervention (Velazquez (Maillot et al., 2012; Portela et al., 2011). Additionally, using et al., 2014). Wii Sports as an intervention for older adults with subsyn- Further challenges reported in the studies include the small dromal depression (Rosenberg et al., 2011) suggested benefits participant sample sizes (Nparticipants < 15) in 24 (49%) studies. of exergames for mental health, specifically depression. Age-related impairments resulted in some participants not Exergames for older adults also led to improvements in the being able to complete some of the tasks, which led to their perceived level of pain (Brauner et al., 2013), affective engage- data being discarded from the study analysis. Some studies ment (Fukuda, 2011), and monitoring of exercise parameters were also single-session observational studies, which limit the (Rice et al., 2011). The cognitive benefits of exergames from a applicability of their results. wellness perspective included improved psychosocial wellness (Wollersheim et al., 2010) and greater enjoyment of motion- based exergames (Gerling et al., 2013). Additionally, semi- 5.3. Age factor with exergames structured interviews revealed advantages of exergames from Based on the systematic review, Tables 4–12 also indicates a dependability and usability perspective (Hwang et al., 2009) various challenges to implementation of the studies for older in the motivation-themed category. Exergames benefit the adults. The common challenges encountered by researchers general health (Chen et al., 2012) and improve overall QOL with study implementation with respect to physiological con- of older adults. texts were feeling of fatigue during exergames, higher levels of From a physical training perspective, older adults’ fitness exertion through higher cardiovascular demand, more time formed the next major category. Augmenting physical exer- required for fallers to regain their posture, slower movements cises through VR (Bruun et al., 2014) provided better experi- of older participants, back pain, lower gait speed, difficulty in ence and increased desire to engage in exergames, while also keeping up with the speed of the game, and feeling of mental being indicators of early signs of dynapenia (Zavala-Ibarra & and physical fatigue to mention a few. From a psychological Favela, 2012). Specific health studies investigated exergames perspective, a few of the many challenges faced by researchers as beneficial interventions for heart failure patients in the implementation of exergames for older adults were fear (Klompstra et al., 2014) and as tools for improving visual of falling during a routine, failing at a routine, lack of con- acuity (Chiang et al., 2012). Furthermore, the integration of fidence to try out routines, fear of injury, and fearful of their self-efficacy theory with exergames (Chao et al., 2013) and own safety. Furthermore, lack of experience with technology increased muscular endurance (Keogh et al., 2014) contribu- inhibited play, caused anxiety and insecurity among partici- ted to the wellness theme. The challenges of age-related pants. Within the cognitive context, a few of the many chal- impairments were also a factor in deciding between super- lenges faced by the researchers were loss of interest in the vised and unsupervised exergame interventions for PA. exergame routine, difficulty in remembering steps and rou- The above categorization of exergame interventions as PA tines, difficulty in performing the steps in the correct for older adults (into categories and themes) helps us recog- sequence, difficulty in hitting game targets, training needed nize the diversity of exergame applications. This answers RQ1 to help increase confidence with doing the routines, and about using exergames as technological interventions for memorizing the correctness of steps and form. older adult PA. This systematic categorization shows that The above challenges, while not limited to younger and certain thematic areas and groups (balance training, increased middle-aged adults, are more prevalent among older adults PA, and rehabilitation) are better researched than other health because these are related to physical and cognitive impair- domains such as cognitive training, mental health, and overall ments that come with aging. Within the spectrum of 55 wellness, a finding that answers RQ2. Additionally, the LoE studies reviewed in the systematic review, the lowest average mapping of these studies indicated increased motivation and age of the participants was 53 (Hurkmans et al., 2011). This engagement of older people in PA resulting from usage of further indicates the prevalence of age-related challenges with exergames (RQ3). participating in exergames (Ijsselsteijn et al., 2007; Marston, 2013; Siriaraya et al., 2012). 5.2. Methodological quality of studies The present systematic review identified the potential chal- 5.4. Pathways for future research lenges in study design which emerge from small participant sample sizes. Lack of control groups and the prevalence of Our findings from this systematic review helped us to identify observational study design (QUAL-2, QUAN-2) also added to 9 categories and 19 themes of exergame applications for older the limitations of some studies. As indicated in Table 14,20 adults’ PA. These categories and themes can be further 162 D. L. KAPPEN ET AL.

Figure 3. Three clusters of exergaming articles. aggregated into three broader exergaming clusters of “train- older adults’ intheroutinesprovidedbyspecific ing,”“rehabilitation,” and “wellness,” as shown in Figure 3. exergames. These three clusters, centered on older adults’ PA and exergames, included overlaps of articles across these three groups. Training related to postural control in balance 5.4.2. Exertion specificity rehabilitation (Maillot et al., 2014) overlapped with 14 Comparing physical ability, health benefits, usability, and age- (n = 19) articles from the “training” group. Improved related challenges will provide more success in mitigating ’ mental health through exergames with older adults older adults physical impairments. The development of indi- (Rosenberg et al., 2011) overlapped with articles related vidualized programs tailored to address unique barriers faced to wellness, and articles related to training benefits in the by older adults requires customization and personalization of “training” cluster overlapped with those relating to cogni- exergame interventions. tive training. Articles from the “wellness” cluster reporting enhanced wellness due to cognitive training overlapped 5.4.3. Customization specificity “ ” with those in the training cluster that reported benefits Tailoring exertion levels to specific goals as well as to the from cognitive training and cognitive physical training limitations of older adults can help in customizing and per- (Gerling, Dergousoff, et al., 2013). sonalizing exergame routines. The challenges of exertion can Benefits indicated in the wellness (QOL) article (Chen then also be adjusted to the desired activity level of older “ ” et al., 2012)fromthe wellness cluster overlapped with adults, taking into account their individual abilities. wellness benefits derived from physical training in the “training” cluster. This mapping of articles, through clus- tering into three major groups, indicated potential overlap 5.4.4. Method specificity of the benefits of exergames with PA of older adults. We While the study designs reviewed had a wide range of sample outline several potential opportunities for future research sizes and quantitative methods, in many articles, sample sizes based on observations related to the following. were small. Therefore, we have to question the generalizability of some results. While 14 studies indicated the presence of control groups comparing exergame to non-exergame condi- 5.4.1. Context specificity tions, more rigor and better evidence of efficacy of exergame While our systematic research indicates overlaps between interventions can be achieved through RCTs. However, “ ”“ ” “ the three major clusters ( training, wellness, and reha- recruitment of older adults and the difficulties of isolating ” bilitation ), it is critical to isolate benefits from exergames specific health conditions pose ongoing challenges in gather- targeted to specific age-related challenges. Training as a ing empirical evidence. preventive measure to attenuate the impacts of aging can Mapping these future research areas with the three clusters help to reduce the burden of rehabilitation by educating of exergames is shown in Figure 4. INTERNATIONAL JOURNAL OF HUMAN–COMPUTER INTERACTION 163

Figure 4. Mapping future research areas and exergame categories.

5.5. Strengths and limitations of this systematic review increases and more studies are likely to be undertaken on the applications of technology in the context of older adults. We This review incorporated the Cochrane guidelines on sys- have contributed a taxonomy of exergames for older adults tematic reviews (Higgins & Green, 2011; van Tulder et al., which contains 19 themes, 9 major categories, and 3 clusters, 2003), adopted the methodological quality assessment of the and in which using exergames provided facilitated PA beneficial empirical studies reviewed, and reported on the LoE provided to health and wellness. While exergaming as a research area is in by the results. This systematic review enabled us to create a its infancy, our categorization of current exergame research taxonomy of exergame themes (Figure 2) for exergame inter- provides us with a useful map of the applications of exergames ventions currently adopted in facilitating PA among older specific to PA among older adults. This taxonomy helps to adults. This provides us with a distinct mapping of the diver- identify potential gaps in the diverse research field of older sity of research being done in PA exergames for older adults adults’ QOL, ranging from leisure and entertainment to physical within the science and technology domains. and mental fitness to rehabilitation domains. Limitations to this review include the following: With some articles (n = 3), we had to contact the authors separately in the context of this systematic review, to determine the ORCID gender diversity in the participant sample, as this was not Dennis L. Kappen http://orcid.org/0000-0003-4815-153X reported in Section 3 of the study designs. Second, our study Pejman Mirza-Babaei http://orcid.org/0000-0002-8248-5392 reported on articles published between 2006 and 2015, and a Lennart E. Nacke http://orcid.org/0000-0003-4290-8829 few more articles may have been published after the latter date. Our review did not differentiate between the usage of NC exergames and commercial exergames, and this could be a References potential evaluation bias in our review. Additionally, we Agmon, M., Perry, C. K., Phelan, E., Demiris, G., & Nguyen, H. Q. included only those articles published in the English language. (2011). A pilot study of Wii Fit exergames to improve balance in older adults. Journal of Geriatric Physical Therapy (2001), 34(4), 161– 167. doi:10.1519/JPT.0b013e3182191d98 6. Conclusion Alankus, G., Proffitt, R., Kelleher, C., & Engsberg, J. (2011). Stroke therapy through motion-based games. ACM Transactions on This systematic review identifies a taxonomy of exergames Accessible Computing, 4(1), 1–35. doi:10.1145/2039339.2039342 being used as technological interventions addressing the PA Albaina, I. M., Visser, T., van der Mast, C. A. P. G., & Vastenburg, M. H. (2009). Flowie: A persuasive virtual coach to motivate elderly indivi- of older adults. While older adults get help to overcome a duals to walk. In Proc. of the 3d International ICST Conference on sedentary lifestyle, we believe that exergames for older adults Pervasive Computing Technologies for Healthcare (pp. 1–7). Icst. could also be described as “PA games” for health and wellness. doi:10.4108/ICST.PERVASIVEHEALTH2009.5949 The methodological quality assessment and LoE of the Altamimi, R., & Skinner, G. (2012). A survey of active video game literature. – reported studies also provide insights into how researchers can International Journal of Computer and Information Technology, 1(1), 20 35. Anderson-Hanley,C.,Arciero,P.J.,Brickman,A.M.,Nimon,J.P.,Okuma, in future improve the study design methodology of observa- N.,Westen,S.C.,...Zimmerman,E.A.(2012). Exergaming and older tional studies of older adults’ PA. This is a field of growing adult cognition: A cluster randomized clinical trial. American Journal of importance in HCI, as the median age of numerous populations Preventive Medicine, 42(2), 109–119. doi:10.1016/j.amepre.2011.10.016 164 D. L. KAPPEN ET AL.

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Archives of Physical Medicine and About the Authors Rehabilitation, 93(12), 2281–2286. doi:10.1016/j.apmr.2012.03.034 Toulotte, C., Toursel, C., & Olivier, N. (2012). Wii Fit ® training vs. Dennis L. Kappen has a PhD in Computer Science from the University Adapted Physical Activities: Which one is the most appropriate to of Ontario Institute of Technology which was supervised by Dr. Lennart improve the balance of independent senior subjects? A randomized E. Nacke and Dr. Pejman Mirza-Babaei. His specialization and expertise controlled study. Clinical Rehabilitation, 26(9), 827–835. doi:10.1177/ is in the application of gameful strategies in health and wellness domains 0269215511434996 with a focus on assistive technology for the older adult demographic. Uzor, S., & Baillie, L. (2014). Investigating the long-term use of exer- Pejman Mirza-Babaei is an Assistant Professor for Human-Computer games in the home with elderly fallers. In Proceedings of the 32nd Interaction at UOIT. He has been involved with the games research annual ACM conference on Human factors in computing systems - CHI community since 2009, where he has published more than 50 articles. ’14 (pp. 2813–2822). New York, New York, USA: ACM Press. He has contributed to more than 22 commercial games, including award- doi:10.1145/2556288.2557160 winning titles such as Pewdiepie Legend of the Brofist. Van Diest, M., Stegenga, J., Wörtche, H. J., Postema, K., Verkerke, G. J., & Lamoth, C. J. C. (2014). Suitability of Kinect for measuring whole Lennart E. Nacke is the Director of the HCI Games Group and an body movement patterns during exergaming. Journal of Biomechanics, Associate Professor for Human-Computer Interaction and Game Design 47(12), 2925–2932. doi:10.1016/j.jbiomech.2014.07.017 at the University of Waterloo. His research focuses on people and van Tulder, M., Furlan, A., Bombardier, C., & Bouter, L. (2003). Updated technology in the wider context of digital games, specifically gamifica- method guidelines for systematic reviews in the cochrane collabora- tion, user experience, and games user research. He is one of the founders tion back review group. Spine, 28(12), 1290–1299. doi:10.1097/01. of the CHI PLAY conference series and currently serves as the chair of BRS.0000065484.95996.AF the CHI PLAY steering committee.