Fitness game, Exergaming or exer-gaming (a portmanteau of "exercise" and "gaming") is a term used for video games that are also a form of exercise. Exergaming relies on technology that tracks body movement or reaction. The genre has been credited with upending the stereotype of gaming as a sedentary activity, and promoting an active lifestyle. Research indicates that exergames can produce real improvements in fitness. Exergames are seen as evolving from technology changes aimed at making video games more fun.
The genre's roots can be found in games released in the late eighties, including the Foot Craz, which was the first such device, released for the Atari 2600 in 1987, and the Power Pad (or Family Trainer), released for the Nintendo Entertainment System (NES) in 1988, although both had limited success. Konami's Dance Dance Revolution was cited as one of the first major successes of exergaming; when it was ported from the arcade to PlayStation, it sold over three million copies. In the 2000s, a number of devices and games have used the exergame style to much success: the EyeToy camera has sold over ten million units, while Nintendo's Wii Fit has sold in excess of 21 million copies. By June 2009, health games were generating revenues of $2 billion, largely due to Wii Fit's 18.22 million sales at the time. The term exergaming entered the Collins English Dictionary in 2007.
The genre has been mooted as a way to improve users' health through exercise, but few studies have been undertaken to measure the health benefits. Smaller trials have yielded mixed results and have shown that the respective traditional methods of exercise are superior to their video game equivalents.
Exergaming contains elements that were developed in the virtual reality community during the 1980s. The pioneer in this area was Autodesk, which developed two systems, the HighCycle and Virtual Racquetball. The HighCycle was an exercise bike that a user would pedal through a virtual landscape. If the user pedaled fast enough, the virtual bike would take off and fly over the landscape. Virtual Racquetball tracked the position and orientation of an actual racquet that was used to hit a virtual ball in a virtual environment. This environment was shared with another user equipped with another tracked racquet, allowing the two users to play each other over phone lines. In both systems, the users could wear the VPL eyephones, an early Head-mounted display (HMD), that would provide more immersion for the user.
The first true attempt at what would later be called Exertainment was the Atari Puffer project (1982). This was an exercise bike that would hook up to an Atari 400/800 or 5200 system. Forward speed was controlled by pedaling while steering and additional gameplay was handled by a handlebar-mounted Gamepad. The machine was nearly ready for production with several games (Tumbleweeds and Jungle River Cruise) when Atari declared bankruptcy and the Puffer project was abandoned. Nintendo also dabbled in this space with the Power Pad in the late 1980s.
The first exergaming system released to the market was the 1986 Computrainer. Designed as a training aid and motivational tool, the Computrainer allowed users to ride through a virtual landscape generated on a Nintendo NES, while monitoring data such as power output and pedaling cadence. The product had a price that was far too high to be considered as an entertainment product, but was affordable by dedicated athletes. The product continues to this day, where it now runs using Microsoft Windows compatible software with extensive graphic and physiological capabilities.
About the same time as the Computrainer, Concept II introduced a computer attachment for their rowing machine. This has become their eRow product and is used for both individual motivation as well as competition in "indoor rowing leagues"
During the 1990s, there was a surge of interest in the application of "virtual reality" technologies to high-end gym equipment. Life Fitness and Nintendo partnered to produce the Exertainment System; Precor had an LCD-based bike product, and Universal had several CRT-based systems. The Netpulse system provided users with the ability to browse the web while exercising. Fitlinxx introduced a system that used sensors attached to weight machines in order to provide automated feedback to users.
The most sophisticated of these entries was the Tectrix VR Bike. Developed originally by CyberGear Inc., The VR Bike allowed users to pedal through a number of virtual environments as well as engage in single and multiplayer games. It was joined later by the VR Climber. The VR Bike software is now distributed alongside Trixter bikes.
Three issues combined to ensure the failure of these systems in the marketplace. First, they were significantly more expensive than the equivalent models that did not have all the additional electronics. Second, they were harder to maintain, and were often left broken. Lastly the additional expertise required to operate the software was often intimidating to the users, who shied away from the machines out of fear that they would look foolish while trying to master the machine.
Until 1998, nothing significant happened in the field of videogame exercise. Hardware was still too expensive for the average home consumer, and the health clubs were gun-shy about adopting any new technology. As high-performance game console capabilities improved and prices fell, manufacturers once more started to explore the fitness market.
In 2000, UK startup Exertris introduced an interactive gaming bike to the commercial fitness market.
Exergaming came to the mass media attention at the Consumer Electronics Show when Bill Gates showcased the Exertris Interactive Gaming Bike in 2003, and the following year the same show hosted a pavilion dedicated to video game technology that also worked as sports and exercise equipment.
The 2005 release of the EyeToy: Kinetic, brought the first—multi-function—exergame hardware into the home market. Making the players physical movements into the game's controller. 2006 Saw the launch of Gamercize, combining traditional fitness equipment with games consoles. The minimalist approach allows game play to continue only when exercising, turning all game titles into potential exergames.
Nintendo's Wii in 2006 brought acceleration detection with the Wii Remote. In late 2007, Nintendo released the exergame Wii Fit, which utilized a new peripheral, the Wii Balance Board. Various approaches to exergames have been documented and compared by VideoJug in an information film.
The PCGamerBike appeared at CES in 2007 where it received an Honoree Award. It differs from other exergaming devices in that its pedal motion can be mapped to any key on the keyboard. It also has an optical encoder which detects forward and reverse pedal motion. The Fisher-Price Smart Cycle was another entry in the field.
Other examples of exergaming products include: Positive Gaming iDANCE, iSTEP, Cobalt Flux Blufit, Cyber coach, NeoRacer, Gymkids exercise equipment with interactive technology, some Wii titles such as EA Sports Active, Cybex TRAZER, Powergrid Fitness Kilowatt, Lightspace Play Floor, PlayMotion, Yourself!Fitness, Expresso Fitness S2, i.play, Cyber ExerCycle, VEQTOR Sport Trainer and Sportwall.
Exergaming in the lab
In order to better understand exergaming’s relationship with physical activity, laboratory studies have compared exergames to both traditional seated video games and other physical activities, for example, treadmill walking. Consistent evidence demonstrates exergaming requires more energy and has the potential to raise heart rate in comparison to traditional seated video games and rest. Overall, most exergames are equivalent to light-to-moderate activity for both adults and children. For example, Electronic Arts commissioned a 2010 study by the University of Wisconsin that found that EA Sports Active passed fitness guidelines for an "effective workout" put forth by the American College of Sports Medicine. However, while the Wii has been seen as being more physically demanding than sedentary game consoles, a study published in the British Medical Journal found that while playing the Wii uses significantly more energy than playing sedentary computer games, the energy used when playing active Wii games is not of high enough intensity to contribute towards the recommended daily amount of exercise in children. Based on a systematic review on active video games for youth, none of the games elicited an average energy expenditure above 6 MET threshold for vigorous energy expenditure.
When used at intermediate or high intensity, exergaming can improve fitness.
- Energy expenditure
Energy expenditure during exergames differs only slightly from other traditional light-to-moderate intensity physical activities. Most exergames elicit energy expenditures between light and moderate intensities, although in some studies a ‘sizeable percentage’ of players have performed at vigorous activity levels. Exergames which only require upper body movement typically result in energy expenditures equivalent to light physical activity, while lower and whole body movement games provide activity of at least a moderate intensity.
Several studies have been done to see what types of exercise gamers get while playing these types of games and to see if children really benefit from the activities. Over all the research indicates exergaming has the potential to increase physical activity which is always a benefit. Anytime physical activity is an improvement over sedentary time on the couch. 
- Heart rate
Exergames increase heart rate compared to resting. Those which require whole/lower body movement produce a greater increase in heart rate than those which use only upper body movements. Different games requiring similar movements for game play do not necessarily have the same impact on heart rate. For example, games played on dance mats have increased heart rates to levels similar to those of moderate and even vigorous intensities; whereas games played using a balance board have produced heart rates less than that of a brisk walking pace, although both require lower body movement. It has been argued that heart rate is not a good proxy for energy expenditure for exergames as several studies have shown heart rate to increase for sedentary video games.
- Body composition and BMI
Few exergaming studies have examined actual changes in body composition over time. Instead, estimates have been made based on laboratory game play. For example, it has been suggested that if exergaming were to take place at a similar intensity outside the laboratory, children would have the potential to lose 2.5 kg-6 kg over the course of a year with only 15–30 minutes of game play per day.
- Psychological outcomes
Children and young people report enjoying Wii Fit activities more than inactive games and treadmill exercise.
The evidence in adults is less abundant than in children. Studies tend to have only a small number of participants, which makes it difficult to generalise the findings to the whole population.
- Energy expenditure
Exergaming provides a form of light-to-moderate physical activity for adults. Wii Boxing has been shown to produce similar energy expenditure to a self-selected brisk walking pace, while Wii Aerobics results in lower energy expenditure. In general, exergames have less of an effect on energy expenditure than playing the actual sport. Energy expenditure does not increase by adding active elements to traditional games. For example, adding specialist motion sensing controllers to play shooting games was no more effective in increasing energy expenditure than using traditional hand held controllers.
- Heart rate
Exergamers experience a greater increase in heart rate after 30 minutes of Wii Fit’s Free Run than treadmill walking (at 3.5 mph), while Wii Boxing produces a heart rate similar to that of a self-selected brisk walking pace. In contrast, self-selected brisk treadmill walking results in a higher heart rate than what is obtained by participating in Wii Aerobics, Tennis or Baseball.
- Psychological outcomes
Research shows changes to psychological wellbeing from taking part in exergaming are mixed. In older women, positive changes to self-perception and social and psychological wellbeing have been noted after six weeks of game play. Alternatively, measurements of wellbeing decreased after a single session of Wii Fit Free Run compared with treadmill walking in young adults. These young adults did however perceive playing Wii Fit to be more intense than treadmill walking. Both younger and older adults rate exergaming as more enjoyable than inactive gaming and treadmill walking.
- Falls and balance in older adults
In healthy older adults there is some evidence that dance exergames can improve mental health (e.g. Dance! Don't Fall), improve measures of physical performance, e.g., the narrow walk time test and self-reported balance confidence. Additionally, anecdotal evidence suggests the Nintendo Wii can be used as part of a falls rehabilitation programme. Studies have demonstrated increases in dynamic balance, a reduction in Timed Up and Go scores, which measures mobility, and improvements in static balance after Wii usage. However most of these studies tend to be case studies. Additionally, few exergames have been designed specifically for elderly, and we lack knowledge about the characteristics of the movements elicited by exergames and thereby about their potential to train functions important for fall risk reduction. Moreover, exergames provide better user experience if games are developed specifically for older adults. More robust evidence is needed to warrant the inclusion of exergaming in falls prevention programmes.
- Upper extremity dysfunction
Upper extremity dysfunction results from a variety of different diseases and disorders. The degree of dysfunction ranges from the subject’s self-reported pain, weakness, and impairment of the shoulder, elbow, wrist, and hand, to larger symptoms such as debilitating post- stroke. Multiple studies have chosen to incorporate the Wii into both movement therapy and exercise regimens for patients displaying these symptoms, in order to test whether the use of Wii’s motion controller will benefit these patients. A study done by Hsu et al. examined the effect of Wii bowling on shoulder motion range. Elderly long-term care patients with upper extremity debilities supplemented their standard exercise regimen by playing Wii Sports bowling with the affected arm for 20 minutes at least twice a week, for one month. This resulted in an overall improvement of patients’ active range of shoulder motion, as well as better scores in the modified PACES (Physical Activity Enjoyment Scale) and the NHPPT (Nursing Home Physical Performance Test). Research has also shown a positive effect from Wii Sports movement therapy for stroke patients. Stroke patients with upper limb dysfunction underwent movement therapy consisting of monitored, intense Wii Sports gaming for two weeks. These patients displayed improved functional use of their dominantly affected arm and hand, along with an increase in joint range of motion. Furthermore, significant clinical improvement on test metrics such as the WMFT (Wolf Motor Function Test) and MAL-QOM (Motor Activity Log Quality of Movement) suggests that the skills gained from Wii-based movement therapy are transferable to daily-living activities.
Exergaming beyond the lab
One primary goal of exergaming is to get children or adults "off the couch" and more active. Laboratory studies showing brief increases in physical fitness as a result of exergaming may not translate to real world improvements. A 2013 systematic review of randomised controlled trials and before/after studies of exergames beyond the lab showed that exergames are associated with a better outcome in BMI/weight, with some evidence for improvements in VO2 max and adherence to exercise. The review called for more research on the mechanisms that make exergames effective.
Individual studies vary in their findings. One study of children in actual homes over an extended period did not show lasting changes to their exercise habits. This study revealed “no evidence that children receiving the active video games were more active in general, or at any time, than children receiving the inactive video games.” Exercise physiologist Anthony Barnett suggested the results of the study are predictable. He said that children compensate for the increased activity of exergaming by reducing their exercise in other parts of their lives, resulting in no net gain. When designing interventions that incorporate exergaming, guidelines on frequency and duration of usage should be given to participants.
Benefits of exercise on mental ability and productivity are in the early stages of research, but indications from using Gamercize with a computer have been reported as providing a 17% productivity improvement. Combining cardiovascular exercise and balance practice has been shown to increase academic success among students in grades K-12. According to the 2009 Active Healthy Kids Canada Report Card on PhysicalActivity for Children and Youth, children who are physically active perform better in school than those who are not. Interestingly, academic performance improves even when academic learning time is reduced to allow time for physical activity.
A different question is whether exergaming effects beliefs about and attitudes toward physical activity. For example, in a 6 week program incorporated into 5th grade physical education lessons in Singapore, children who were exposed to threat-framed messages about physical activity and who also played Wii exergames developed more positive attitudes and higher perceived behavioral control than children who were only exposed to the messages. The effectiveness of maintaining interest in exercise using traditional fitness machines has been examined with Gamercize and found to be six times more sustainable than exercise alone.
When making an exergaming system, the manufacturer of a consumer product must make the decision as to whether the system will be usable with off-the-shelf games or if custom software must be written for it. Because it takes longer for a user to move their entire body in response to stimulation from the game, it is often the case that dedicated software must be written for the game to playable. An example of this is Konami's Dance Dance Revolution. Though designed to be played by users moving about on a specially designed dancepad, that game can alternatively be played by pushing buttons with one's fingers using a standard hand-held gamepad. When played with the dancepad at higher levels the game can be quite challenging (and physically exhausting), but if the game is played using the buttons on the hand controller, none of the sequences are physically limited.
Newer systems such as Xbox 360, PlayStation 3 and Wii use alternative input devices such as the Kinect and PlayStation Move. The Move uses image analysis to extract the motion of the user against a background and uses these motions to control the character in the game. A specifically designed exercise game Kinetic, superimposes animated objects to be punched, kicked, or otherwise interacted with over a video image of the user. The Wii and PlayStation 3 both incorporate motion sensors such as accelerometers and gyroscopes into the hand-held controllers that are used to direct behaviors within the game.
Research projects such as Exertion Interfaces that investigate the design aspects of these games explore how the technological augmentation that comes with the digital gameplay component can be nurtured for additional benefits, such as utilizing the social power of exercising together even though players are connected only over a network or scaling the amount of players, enabling novel exercise experiences not available without the technological augmentation.
Exergame resellers have developed fitness centers and specialist room designs with programmes that focus entirely on creating environments for young people using exergaming for fitness. Group fitness programmer Les Mills International has recently launched "Immersive Fitness" studios around the globe which combine exergaming with live group fitness classes.
One of the newest trends is using virtual reality immersion utilizing an omnidirectional treadmill, such as the Infinadeck. Such a system allows the user to virtually be in the game while allowing 360 degrees of movement. While the technology is new, it is showing promising results in weight management as well as in high participation rates.
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