Editors Note: This article was produced in cooperation with the National Athletic Trainers' Association (NATA), the professional membership association for certified athletic trainers and those who support the athletic training profession. For more information on the NATA, visit www.nata.org
When athletes or patients experience an injury, what do they need to do to safely and effectively return to activity? They must be strong, regain their range of motion, maintain their cardiovascular conditioning, and be able to perform sport-specific and physical activity skills. To be at the top of their game and to prevent re-injury, the individual must have good balance, proprioception and core strength.
Accomplishing these goals usually means many hours in the athletic training room or a rehabilitation clinic counting reps and sets, and doing the same exercises over and over again. Are there better or alternate ways to meet these goals?
In some athletic training rooms and clinics today, athletic trainers or other health professionals may suggest their patients "warm up with tightrope walking, move to the hula hoop, head some soccer balls, box for 20 minutes, then cool down with some yoga and try to beat each of your previous scores." Patients often bypass the traditional techniques of weightlifting and stationery bike riding, and head to a television attached to a video game to begin their rehabilitation.
The Growth of Video Gaming
Video games, or exergames, are gaming devices with an additional component of physical activity. Some of the most popular ones include the Nintendo Wii and Wii Fit, Dance Dance Revolution, PlayStation 2's EyeToy, and Xbox 360. There are several others just entering the market.
These exergames are being used more frequently in athletic training rooms, sports medicine or rehabilitation clinics, nursing homes and even in Veterans and Shriners hospitals as a fun way to motivate clients to rehabilitate, improve their conditioning, or just enjoy controlled physical activity. One popular video game, the Nintendo Wii, is based on computer technology that utilizes a handheld controller with an accelerometer.
The Wii games are followed visually on a screen, and the sport or activity is played by moving the remote to mimic specific skills of the sport or activity. The Wii Fit is a force platform placed on the floor that involves the athlete or patient shifting their weight or stepping on and off to a mirror, replicating the movements of many activities, from ski jumping to dancing to yoga. The other devices are based on similar technology.
The Role of Exergaming
The potential benefits of exergames are numerous. The weightbearing exercises utilizing the force platform can very effectively improve range of motion, core strength, and balance. Weight shift and balance exercises performed while watching the screen improve proprioception, employing the visual component traditional exercises often lack.
The visual component is particularly positive for athletes returning to a sport in which visual mirroring is part of the skill set. Initially the visual cues can be limited to varying bar graphs, indicating the amount of weight across each extremity while standing on the Wii Fit platform. These exercises can be used effectively for the first phase of rehabilitation of a post operative knee or ankle when weight bearing is allowed, but the range of motion is limited.
As function improves, a variety of games can be added to the rehabilitation protocol. Side to side and front to back weight shift to try to maneuver a ball into a hole on the screen sounds very simple, but can challenge the most accomplished athlete. Heading a virtual soccer ball or avoiding a shoe aimed at your head takes timing and control.
Weight bearing, closed-chain, functional exercises are what athletic trainers and other health care professionals try to include in all phases of rehabilitation. Video games do an excellent job of creating those types of movements, while encouraging the natural competitiveness athletes possess.
The upper body motions used with the hand-held controller can imitate the movements for each sport or activity. This imitation of movement can be used to improve range of motion and actually promote neurological improvements, including hand-eye coordination. This has been proven especially effective for patients suffering from strokes and closed head injuries.
The military is seeing positive benefits of exergaming with returning veterans who are rehabilitating after head injuries, spinal cord injuries and amputations. Using the gaming controllers often encourages movement in a range of motion that pain would otherwise prevent. Games like Guitar Hero promote finger movement and dexterity in joints frozen from lack of use.
Nursing homes and senior citizen centers are using gaming to motivate their patients to get moving and participate in physical activity. The benefit of play has been shown to decrease depression and improve overall morale.
Exergames are also being used with patients recovering from joint replacements, Parkinson's and Alzheimer's diseases. Older and recovering patients can play their favorite sports again from their wheelchair or walker. Bowling for example has become a favorite game for many older patients. Some facilities have even hosted their own "Olympics" or tournaments to coincide with the timing of major sporting events.
Exergaming is a rehabilitation tool that can be shared with the patient's family and easily be continued at home. The most important advantage is that the games are fun and competitive, and motivate the patient to comply with their rehabilitation program.
Children, Teens and Elite Athletes
Exergaming may have its greatest effect on children and teenagers. Childhood obesity affects millions of kids across the country. Television, computers, and videogames are often blamed for the sedentary lifestyles of today's children. Overweight and out-of-shape children and teens are suffering from more related medical conditions than ever before.
Videogaming in which the child must physically participate is certainly healthier than other popular sedentary gaming activities. Exergaming may be a useful tool to enact a transition from the common sedentary lifestyle to a more active one. Exergames may assist with maintenance of conditioning, or may elicit improvement in people who are in poor condition. For example, Dance Dance Revolution is a popular activity for teenagers and has been shown to benefit cardiovascular conditioning and strength training of the large muscle groups of the lower body.
Although highly trained and conditioned athletes will not generally improve their skills and conditioning through exergaming, they may be able to maintain their skills by practicing with a videogame that provides immediate and specific feedback.
A golfer may still be able to swing a video controller to mirror the motion of a golf swing while virtually playing some of the most amazing courses in America. A skier may work on the timing of turns and weight shift maneuvers when they aren't quite ready to hit the slopes.
Specific sport skills must be consistently monitored in skilled athletes to prevent them from developing bad habits or improper technique. This is particularly true of the footwork required for effective sport participation. Close monitoring of footwork will be necessary for optimal use of exergaming as a rehabilitation technique.
Play Safe and Smart
There are some risks associated with exergaming. Even too much fun can be hazardous. Athletic trainers and other rehab specialists must be familiar with the games to determine the benefits for the patient, the physical demands of the game, and skill levels required to play them.
Much like any therapeutic exercise, it must be appropriate for the patient's condition and the specific phase of rehabilitation they're in. For example, a patient may be ready for a certain game that requires weight shifting, but may not physically be ready to progress past a certain level without risk of re-injury. When utilizing exergaming as part of a rehabilitation program, patients must be educated on which exergames are safe and how long they should play.
Repetitive motions and poor technique can lead to overuse or chronic injuries. The shoulder, wrist and elbow are particularly vulnerable to the vicious swing of a tennis racket, bat or foil during a ferocious virtual competition that may last for hours. Along with tendonitis and bursitis, facial injuries have been documented as self-inflicted injuries or accidents caused by a zealous opponent. Television and computer screens have also been the victims of a handheld controller that was not properly attached to the player's wrist. Patients should be reminded about safety when using exergaming.
Research is on the Rise
Research is consistently investigating the effectiveness of interactive videogaming in rehabilitation, fitness, and special needs domains. The Robert Wood Johnson Foundation is one of several organizations that specifically fund health games research. Grants are awarded for advancing the effectiveness of interactive games for health, examining the role of exergaming in patient motivation, Parkinson's disease, obese children, cognitive health, and health-related behaviors.
Degree programs in videogaming are becoming a popular major at many colleges and universities. Videogaming has become a billion dollar industry across a wide variety of game genres. The ability to process motion data from a wireless accelerometer has launched the exergame genre into a potential profit center that may also be beneficial for a wide variety people of all activity levels.
Exergaming is an intriguing new addition to the repertoire of the rehabilitation professional. The current niche seems to function as a motivator and transition tool. The competitive nature of gaming will entice patients to participate in rehabilitation protocols in a consistent and vigorous basis. Exergaming can encourage sedentary youth to participate in increasing levels of physical activity.
Innovation and imaginative use of various games can accentuate transitions from the resumption of weightbearing through return to play. "How can I get to the next level?" is the over-riding question for all gamers, whether you're talking about varsity athletes or computer jocks.
For an athlete or patient to meet all the goals for their return to play or just to improve everyday life, they must work hard and have a positive outlook. Exergames can make a challenging and often frustrating rehabilitation program a little more fun and make it possible to successfully meet their goals.
Sue Stanley-Green is director of the athletic training education program at Florida Southern College in Lakeland, FL.