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Development of an Exergame to Deliver a Sustained Dose of High-Intensity Training: Formative Pilot Randomized Trial

Development of an Exergame to Deliver a Sustained Dose of High-Intensity Training: Formative... Background: Sport science can play a critical role in reducing health inequalities. The inverse relationship between life expectancy, cardiorespiratory fitness, and socioeconomic status could be addressed by performing high-intensity training (HIT), delivered in a class salient and accessible approach. Commercially available exergames have shown encouraging compliance rates but are primarily designed for entertainment purposes rather than focusing on health-related outcomes. A serious game tailored toward delivering an exercise stimulus, while reducing the aversive protocols associated with HIT, could be beneficial to engage and improve health outcomes in socially deprived males. Objective: The aims of this study were to develop an exergame capable of delivering HIT and evaluate the effect on selected health outcomes in men recruited in regions of socioeconomic deprivation. Methods: We conducted an exploratory trial in our target population, and participants were allocated to intervention (n=14) or control groups (n=10) by third-party minimization. The intervention was a 6-week training program consisting of three sessions of exergaming per week. The sessions involved a structured warm-up, then brief intermittent repetitions in the form of boxing rounds (10 s, 20 s, and 30 s) against their peers with a work/rest ratio of 0.25. Results: Retention to the intervention was 87.5% (21/24). Over the duration of the intervention, session attendance was 67.5% (170/252); repetition mean and peak heart rates (% of maximal) and session ratings of perceived exertion (AU, arbitrary units) were 86.3 (5.4%), 89.9 (6.1%), and 7.5 (2.2 AU), respectively. The effect of the intervention, when compared with the control, was a likely small beneficial improvement in predicted maximum oxygen consumption (VO max, 3.0; 90% confidence limits ±2.6%). Effects on body mass, waist circumference, and blood pressure were either trivial or unclear. Conclusions: Over the 6-week intervention, the exergame delivered a consistent and sustained dose of HIT, with some beneficial effects on aerobic fitness in the target population. Trial Registration: ClinicalTrials.gov NCT03477773; https://clinicaltrials.gov/ct2/show/NCT03477773 (Archived by WebCite at http://www.webcitation.org/6yDLgVs35) (JMIR Serious Games 2018;6(1):e4) doi: 10.2196/games.7758 http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al KEYWORDS high-intensity interval training; video games; heart rate; boxing; metabolic syndrome known to deliver, at best, low to moderate levels of exercise Introduction [18], our first aim was to describe the development of a serious exergame for this purpose. Our second aim was to quantify its The latest government audit of university-based research in the real-world fidelity and potential to improve fitness and health United Kingdom has highlighted the need for more sport and outcomes in males recruited in regions of socioeconomic exercise research to target health inequalities that persist in deprivation over a 6-week intervention. society [1]. There are strong inverse relationships between life expectancy, cardiorespiratory fitness, and socioeconomic status Methods [2-4]. As these trends are exacerbated in males, improving fitness in men living in regions of socioeconomic deprivation Development of the Game and Intervention could be important for addressing health inequalities. During the preintervention period, we held regular focus groups High-intensity training (HIT) is a time-efficient way to improve comprising in-house participants, computer programmers, and fitness over a short duration [5], and a growing body of evidence exercise scientists with specialisms in delivering HIT. Together, advocates this form of exercise for public health interventions we explored opportunities to gamify HIT protocols. Boxing [6]. HIT is known to stimulate a combination of central and was an obvious theme for gamification as it involves peripheral adaptations promoting an enhanced availability, high-intensity exercise [19], and the subculture already exists extraction, and utilization of oxygen [7,8]. Although these within our target population of lower working-class males of findings are encouraging, these previous studies have tended the North-East of England [20,21]. The complete set of hardware to prescribe exercise with a focus on cycling and running [9-12]. used in the trials comprised a single computer with a dedicated Some argue that the psychologically aversive nature of graphics card (GeForce GTX 960, [22]), two standard 23-inch high-intensity exercise means that this training will not be monitors, two Kinect for Windows sensors, four wrist-mounted adopted or maintained by many people [13]. Thus, although the wireless inertial measurement units (developed in-house to physiological benefits of HIT are unequivocal, there is ongoing reduce latency in the Kinect datastream), and two wireless debate about its relevance across populations, particularly for chest-worn heart-rate monitors (Polar RS400, Polar Electro Oy, those less-motivated individuals. Finding ways to improve its Kempele, Finland). In addition, the participants wore acceptability could be the key to improve the wider acceptance boxing-specific resistance bands (ShadowBoxer Pty, Australia) of HIT. to increase levels of exertion and reduce eccentric muscle The concept of exergaming, or active video gaming, has been contractions during the deceleration phase of punching. The around since the 1980s and affords unrivalled opportunities to movement data from the sensors were streamed to our gaming reward exercise through visual, audio, haptic, and mental engine [23] via a User Datagram Protocol with a latency of stimuli. Exergaming-based interventions have understandably approximately 15 ms. Input from the skeletal tracking module shown improved rates of compliance, adherence, and social of the Kinect system and inertial measurement units were inclusion (eg, see [2]). Despite this, however, and after nearly converted to a digital avatar using purpose-written functions to a decade of research, the potential for exergaming to improve convert each body segment long-axis (19 in total) into levels of fitness on a population level has not been realized [14]. three-dimensional quaternions, as can be seen with the hardware A possible reason is that most of the research is based on setup in Figure 1. The C# programming language was used commercially available exergames that are designed primarily throughout to create scripts for gameplay (Figure 2). for entertainment. In other areas of health research, such as Commercial games are primarily designed for entertainment physiotherapy, researchers have overcome these shortfalls by and recreation for younger populations and tend to have colorful creating their own exergames specifically geared to the and visually busy game and user interfaces [24]. Furthermore, physiological needs of the clinical or at-risk population. These commercially available games are mostly designed for serious games are purposively designed to train physiological enjoyment and not based on basic exercise principles. For games systems at a level that is sufficient to cause positive adaptation. to promote beneficial changes in health, they need to engage Importantly, these serious exergames have succeeded in physiological systems in a meaningful manner that is relevant improving health-related outcomes (eg, balance and falls risk) for the function being trained [25]. Our philosophy was to ensure and demonstrate their potential for use in other health that the gameplay was simple and, where possible, true to the professions [15]. rules of boxing. Each avatar was assigned collision objects with A major challenge with improving HIT and exergaming is to inertial characteristics on the trunk, head, and hands, thus translate positive laboratory-based findings into interventions enabling the physics engine to superimpose realistic joint that can directly affect those individuals who need it most and movements in response to being hit. As in real boxing, the can also be administered on a larger scale [16,17]. Whether or primary mechanism for scoring was to successfully land a punch not the concept of serious exergaming can contribute in this on either the trunk or head of the opponent. The number of regard requires, first, that a game is tailored toward reducing points awarded per punch was the product of the current heart the aversive protocols associated with HIT and second, that the rate (expressed as a percentage of maximal) and speed of impact intervention is capable of improving fitness in our target -1 (ms ). population. Given that the commercially available games are http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al Figure 1. The exergaming system comprising hardware and software with real-time avatar mapping. Thus, for example, a punch landing to the head with a relative of allowable close-up punching. Specifically, after 1 s of -1 close-up punching, the referee interrupted the fight (shown in speed of 9 ms and at 95% of maximal heart rate (ie, 95% the striped shirt in Figure 3) and ordered both participants to HRmax) was awarded 8.55 points (ie, 9 x 0.95). Each participant race back to their respective corners (ie, 3 m backwards of was provided with biofeedback in the form of a partial arc backwards stepping). The winner of each mini race received an positioned around the opponent’s head; the angle subtended by additional 50 points; equivalent to approximately 6 to 7 this arc was linked to the current heart rate (Figure 3). well-timed punches. After several iterations of observing For example, when player 1 was working at 50% of maximal kinematics, heart rates, and tactics during gameplay, we prepared heart rate, an arc of 180 was displayed around the head of the exergaming system (ie, both hardware and software) for use player 2. The players were made aware that the angle of the arc in the target settings. was proportional to their current training intensity, which in Participants turn contributed strongly to punch power and points scoring. We conducted a 6-week exploratory controlled trial designed They were also aware that large global displacements of their to assess the fidelity of the game in terms of delivering the center of mass (eg, bouncing up and down) would increase this intended training stimulus and to examine the effect of the intensity but with a lag of approximately 20 to 30s [26]. This intervention on selected health outcomes. As appropriate for an arc was visible in their monitor only and was active throughout exploratory trial, we did not conduct formal sample size the exergaming session (ie, during both repetitions and rest), estimation a priori, rather the CIs would be used to inform future essentially allowing the participants to self-regulate training trials. Men are commonly referred to as a hard-to-reach intensity per the oncoming requirements of the game. Although population to engage in health promotion activities [27], where we kept on-screen text to a minimum, we elected to display a a targeted recruitment approach at locations predominantly countdown timer during some periods. These were during the attended by men may facilitate uptake of participants. Therefore, final 30 s of active recovery to encourage the elevation of to maximize recruitment within our intended population, training intensity in preparation for a repetition and during the relevant gatekeepers were approached at institutions positioned latter 10 s of each repetition to encourage all-out punching right within regions of social deprivation. Thus, two settings used up until the bell. Following preliminary tests, we removed the for recruitment and the trials were a social club and mosque, ability to block punches as this was observed to be energetically both situated within deprived regions of Middlesbrough, United undemanding; thus, the only forms of defense were to attack Kingdom (TS1 and TS4). Recruitment in the social club relied before being hit or to dodge the oncoming punch using whole heavily on the gatekeeper (club secretary), whereas uptake of body movements. For similar reasons, we limited the periods http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al South Asian men from a local mosque was more straightforward; Participants were given a £15 shopping voucher upon all 9 mosque participants were recruited from a single completion of follow-up measures (week 7) irrespective of their demonstration (and we had similar experiences in previous adherence to the intervention protocol or group allocation. The iterations). Presumably, the intervention was culturally salient intervention took place from November 2014 to December 2014 in this population; the North of England has developed some (social club) and March 2015 to April 2015 (mosque). Postcode famous prominent Muslim boxers (eg, Amir Kahn and Naseem data were analyzed to match against indices of multiple Hamed) in recent years, and when delivered in the safe form, deprivation in lower-layer super output areas to check whether was acceptable to the respected leaders of the religious groups the cohort fell within our target population. Two participants (ie, the Imam of the mosque). A total of 24 males were recruited (8%, 2/24) lived in the least deprived 20% (decile 8), 20 into the trial (Figure 4) using relevant gatekeepers at institutions participants (83%, 20/24) lived in the most deprived 20% areas positioned within regions of social deprivation. Two recruitment in England (decile 2), and 1 participant (6%, 1/24) lived in the drives (October 2014 and February 2015) took place, and these most deprived 1% of areas (decile 1). The participants were involved live demonstrations of the technology followed by broadly split between white (58%, 14/24) and South Asian word-of-mouth and snowballing approaches. The exergaming (42%, 10/24). Body mass index [29] and waist circumference system was important in this recruitment process because it [30] cut-points were adjusted for ethnicity. Accordingly, 63% provided something tangible and interesting to engage potential (15/24) had abdominal obesity, 37.5% (9/24) were overweight, participants. and 42% (10/24) were obese. Within this group, the 45 to 50 years category was most common (33%, 8/24), followed by 18 Inclusion criteria were deliberately broad to maximize to 24 years (29%, 7/24), 25 to 34 years (17%, 4/24), 35 to 44 recruitment, that is, apparently healthy, as defined by ACSM years (17%, 4/24), and 51 to 55 years (4%, 1/24) categories. guidelines and in the age range of 18 to 55 years [28]. Figure 2. Machine state variables used in controlling the game. http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al Figure 3. The three visual outputs communicating instructions and actual game play to the users. A third-party minimization process using baseline measures of upper arm blood pressure monitor (Omron MX13). Measures age, waist circumference, and predicted maximum oxygen were made at least three times at 3-min intervals, where an consumption (VO max) was used to remove bias in group average of the two lowest measures was used for analysis [31]. Waist circumference was measured using the World Health allocation. The control group was instructed to maintain their Organization guidelines [32]. Predicted VO max was obtained current physical activity levels and inform the researchers should 2 any changes arise during the intervention period. One of the by performing a submaximal 8-min ramped step test [33]. Heart participants in the control group decided to embark on his own rate response (Polar T34; PolarElectro OY, Kempele, Finland) fitness program following the preintervention tests but was and simultaneous breath-by-breath expired gas were collected included in the data analysis. Participant flow through the trials using a portable indirect calorimeter (Cosmed K4 b2; Rome, is shown in Figure 4, whereby 3 participants were lost to Italy), calibrated per the manufacturer’s guidelines. Individual follow-up (control=2, intervention=1). Overall retention to the HRmax was estimated [34] and plotted against VO data for intervention that encompassed baseline and follow-up measures the determination of predicted VO max. was 87.5% (21/24). Intervention Delivery To explore perceptions of the exergame and the HIT regime, Evidence recommends a minimum duration of 12 weeks for a semistructured interviews were conducted with 5 intervention HIT protocol to promote favorable changes in blood pressure participants following the 6-week training period, which were and anthropometric measurements of obesity [35]. However, a analyzed semantically. The study was approved by the ethics 6-week intervention was selected, as a minimum of 13 sessions committee of Teesside University, United Kingdom, and written (0.16 work/rest ratio) is sufficient to elicit moderate informed consent was obtained from all participants. improvements in VO max in sedentary individuals [5]. Measures Additionally, there is still ambiguity regarding the optimal work-to-rest ratio when designing HIT interventions, particularly Participants’ baseline characteristics (mean [SD]) are shown in in populations with varied age, baseline fitness, and training Table 1. All measures were assessed pre and post intervention. experience [36]. Therefore, longer duration HIT models (1-4 Blood pressure was collected on the left arm positioned at heart min) were deemed unsuitable for our target population [37]. height with the subjects in a seated position by an automatic http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al Figure 4. Participant flow though the trial. Furthermore, minigames (such as the current exergame) have were followed by 40, 80, or 120-s of active recovery. short life spans, where adherence to a longer intervention (eg, Participants were instructed to perform the repetitions at an 12 weeks) may diminish over time and influence health intensity ≥85% HRmax. Each exergaming session took outcomes. This was evident from a 12-week pilot study approximately 30 to 40 min to complete, including equipment (unpublished data) using an exergame in the same population set-up, warm-up with additional enjoyment, and task immersion that saw attendance drop from 53% during week 2 to 16% during questionnaires upon completion of the HIT bouts (not reported week 12. here). Heart rate responses were taken within repetitions and therefore, did not include any of the recovery period. This, Participants allocated to the intervention group were invited to therefore, avoided an overestimation of physiological load, attend three sessions of exergaming per week. At the beginning which can occur when heart rate continues to rise after exercise of the exergaming session, participants were required to cessation [26]. complete a 6-min structured warm-up consisting of a series of exercises on a 210 mm step until both participants reached >70% Statistical Analysis HRmax. Session workloads with volumetric progression were Data are presented as mean (SD). Exergaming session set automatically once the user’s identifying information was attendance was calculated using descriptive statistics. Training entered. The session workloads were 120s-, 150-s, and 180-s data (heart rate [repetition mean and peak], rating of perceived of work during weeks 1 and 2, weeks 3 and 4, and weeks 5 and exertion [RPE]) were analyzed using a mixed linear model with 6, respectively. a random intercept (Statistical Package for the Social Sciences [SPSS] version 23 [IBM Corp]). To avoid staleness, the repetition lengths (10, 20, or 30-s) were randomly selected at the beginning of each round. We set the work-to-rest ratio at 1:4, and thus, the respective repetitions http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al This approach enabled us to calculate (1) the within-participant declaring an effect clinically beneficial being <0.5% (most variability in the training dose [38], expressed as an SD; (2) the unlikely) for harm and >25% (possibly) for benefit [42]. effect of HIT repetition duration (entered as a fixed effect) on heart rate and RPE; and (3) the change in heart rate and RPE Results across the 6-week HIT intervention, with session number (1-18) Measures entered as a fixed effect. A priori, we defined a minimal practically important difference (MPID) in training heart rates When compared with the control group, the effect of the as two percentage points, given that when training at exergaming intervention was a likely small beneficial high-intensity, this difference influences the adaptive response improvement in predicted VO max. The SD of the individual [39]. responses in predicted VO max to the exergaming intervention was 3.4 (90% CLs ±3.1). All other effects were either most The MPID for RPE was set at one arbitrary unit (AU) on the likely trivial (body mass and waist circumference) or unclear Borg CR10 Scale, representing a full increment change on the (systolic blood pressure and diastolic blood pressure; Table 1). scale. Inferences were then based on the disposition of the 90% confidence limits (CLs) for the mean difference to these MPID; Intervention Delivery the probability (percent chances) that differences in heart rate Mean session attendance was 67.5% (170/252; range 0%-100%). and RPE between HIT repetitions of different durations or across Of the 14 intervention participants, 9 attended at least 75% of the 6-week intervention were substantial (>2 percentage points, the prescribed exergaming sessions. The total number of >1 AU) or trivial was calculated as per the magnitude-based repetitions performed was 1268 (range 6-136 per participant), inference approach described by Batterham and Hopkins [40], and the descriptive training data for the exergaming intervention an approach that has been advocated within user research [41]. are presented in Table 2. The magnitude of the within-participant These percent chances were qualified via probabilistic terms variability in all intensity measures was moderate. assigned using the following scale: 25 to 75%, possibly; 75 to Mean exercise intensity data for the 10-s, 20-s, and 30-s 95%, likely; 95 to 99.5%, very likely; and >99.5%, most likely repetitions are presented in Table 3. The effect of repetition [42]. To determine the magnitude of the within-participant duration on mean heart rate was substantially higher heart rates variability in our training heart rate and RPE, the values were during the 30-s repetitions when compared with the 20-s (2.2 doubled and then interpreted against aforementioned MPID. percentage points; ±90% CLs 0.5 percentage points) and 10-s All training data effects were evaluated mechanistically, repetitions (3.5 percentage points; ±0.5 percentage points). Peak whereby if the 90% CL overlapped the thresholds for the heart rates were also substantially higher for the 30-s repetitions smallest worthwhile positive and negative effects, the effect when compared with the 20-s (3.6 percentage points; ±0.6 was deemed unclear [42]. The effect of HIT on our outcome percentage points) and 10-s repetitions (6.4 percentage points; measures was determined using a custom-made spreadsheet ±0.6 percentage points). The effect of repetition duration on [43], with the baseline value of the dependent variable used as RPE was most likely trivial. The mean exercise intensity scores a covariate to control for baseline between-group imbalances. per exercise session along with the individual data points to Following this, standardized thresholds for small, moderate, illustrate the variability around the mean score are presented in and large changes (0.2, 0.6, and 1.2, respectively) [42] derived Figure 5. Across the intervention, the regression slope revealed from between-subject SDs of the baseline values were used to most likely trivial changes in mean heart rate (0.1 percentage assess the magnitude of all effects, with magnitude-based points; ±90% CLs 0.2 percentage points), peak heart rate (0.1 inferences subsequently applied. Here, all inferences were percentage points; ±0.2 percentage points), and RPE (0.1 AU; categorized as clinical, with the default probabilities for ±0.1 AU) across the duration of the 6-week HIT intervention. Table 1. Outcome measures at baseline along with the analysis of covariance adjusted change scores and the between-group comparisons of the change scores. Outcome measures Intervention group (n=13) Control group (n=8) Group comparison Baseline values, Change score, Baseline values, Change score, Difference between groups, mean (SD) mean (SD) mean (SD) mean (SD) % mean; ±90% CL Body mass (kg) 87 (22) −1.1 (2.0) 88 (20) −0.5 (1.6) −0.5; ±1.4 Waist circumference 97 (15) −0.6 (1.6) 100 (14) −0.3 (1.6) −0.3; ±1.3 43.7 (8.8) 3.2 (4.1) 39.5 (8.5) 0.2 (2.4) 3.0; ±2.6 Predicted VO max (mL/kg/min) Systolic blood pressure 130 (9) −5.9 (5.5) 134 (12) −2.7 (6.7) −3.2; ±5.2 Diastolic blood pressure 80 (10) −5.1 (5.7) 86 (9) −5.1 (7.1) −0.1; ±5.8 High-intensity training (HIT) control. CL: confidence limit. VO max: maximal oxygen consumption. http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al Table 2. Exercise intensity data for the high-intensity training (HIT) intervention. Intensity measure Mean (SD) Within-subject variability; ±90% CL Mean heart rate (%) 86.3 (5.4) 4.7; ±0.2 Peak heart rate (%) 89.9 (6.1) 5.7; ±0.2 b c 7.5 (2.2) 1.6; ±0.1 Session RPE (AU ) CL: confidence limit. RPE: rating of perceived exertion. AU: arbitrary unit. Table 3. Exercise intensity data for the high-intensity training (HIT) repetition duration. Intensity measure 10-s repetitions 20-s repetitions 30-s repetitions Mean heart rate (%) 84.7 ± 5.3 85.9 ± 6.6 88.2 ± 3.5 Peak heart rate (%) 86.8 ± 4.9 89.5 ± 7.7 93.2 ± 3.4 a b Session RPE (AU ) 7.4 ± 2.2 7.5 ± 2.4 7.6 ± 2.0 RPE: rating of perceived exertion. AU: arbitrary unit. Figure 5. Group mean (large open squares) and individual (small closed triangles) heart rates (session mean and session peak) and ratings of perceived exertion (RPE) across the 6-week exergaming intervention period (session numbers 1-18). AU: arbitrary unit. http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al like finished, then you had to wait about 30 seconds Qualitative Findings before a 20 second one started or something like that. Participants who engaged in interviews ranged between 25 and I loved the 30 second ones. I thought that was great, 50 years and attended between 60% and 100% of the exercise that was just enough, like 30 seconds in that one sessions. Data revealed that participants found the exergame to round and that was just more than enough sort of be challenging but rewarding, as illustrated in the following thing, you know? [Participant 4, 45 years, hotel quotes: worker] At the start you think this is too hard but as you go Finally, some gameplay elements such as heart rate integration on and it does get easier, I say it gets easier but you and visual feedback of a successful punch were encouraging extend the time don’t you so you’re doing more. Half for participants, as illustrated in the following quote: way through the second week I started to appreciate All I knew that if I see the ring go round the head, the that, what you’re doing is making it harder to keep further round it is, if I hit him the more points I’d get, testing me, do you know what I mean? And you can so I knew that and I knew every time it flashed I’d feel it, you can feel it that you are getting better at caught him. I knew my heart rate was there and I the game. I think it still knacks you out [exhausts you] knew the timer was ticking down at the bottom. But because you start trying harder as it goes on. the movements and everything else were excellent. [Participant 1, 50 years, social club worker] [Participant 1, 50 years, social club worker] At the beginning it was killing me [exhausting me], but as I carried it on it was still killing me and then Discussion it started to get like, better, my heart wasn’t working as hard and I was getting more fit to the point where Principal Findings I coped well, to the point where I was actually still This study developed a novel HIT intervention using working my hardest at the level I wanted to. exergaming. Obtaining information about whether the game [Participant 4, 25 years, hospital worker] was used as intended by the target population is a fundamental Participants found that the competitive aspects resulted in a stage in the development cycle. We evaluated its use in men changing game scenario between players and rounds for each recruited from regions of socioeconomic deprivation, a training session, which facilitated motivation to attend and population predisposed to low life expectancy. The training engage, as illustrated in the following quotes: data is indicative of a consistent and progressive dose of HIT (>85% of maximal heart rate) over the duration of the 6-week There was always something else that kept you intervention. Given that our protocol for measuring training interested, kept you wanting to do more. If you go for intensity is conservative [38], we are confident that the game a run, its more like “I’m just running,” that’s it. The was used by the participants as intended. Furthermore, we also fact that you were fighting someone, a different found clear beneficial effects on predicted VO max, and these opponent—you had to change, you either didn’t have 2 findings together demonstrate the potential usefulness of to work as hard [or you should be] or you had to work exergaming for the future delivery of HIT. harder than you could. [Participant 4, 45 years, hotel worker] Despite the respective popularities of both HIT and video I just thought it was a fun way to exercise. If it wasn’t gaming, there have been no previous attempts to combine these competition, it would be hard to be doing that 2-3 concepts in the form of an exercise intervention. As such, there times a week to train at that intensity. Like you would are no studies against which to directly compare our training go the odd time training that intense but if it’s against data, although the intensity levels are clearly greater than those someone you’re more likely to put 100% in. You know, measured for commercially available exergames [18]. In fact, if my heart rate had have got that high just doing it our training data are more comparable to those from a recent by myself, maybe once or twice but not on a consistent high-intensity exercise programs delivered via traditional means thing like that, in a competition against someone else and described as a high-quality dose of HIT [38]. For example, it does push you to train harder, it did me, it did push our repetition peak heart rates of 89% of maximal when me to train harder. [Participant 2, 25 years, averaged over the duration of the 6-week intervention were only unemployed] two percentage points below their levels. Although we cannot pinpoint the specific mechanisms underpinning this success, The variance in the allocated workload was a motivating factor we suggest the feedback and point-scoring made a strong but highlighted that repeated 30-s bursts may have discouraged contribution. Specifically, by matching point-scoring to current one participant from attending exercise sessions, as illustrated training intensity and enabling users to self-regulate and in the following quotes: maximize their intensity, it was possible to deliver a consistent It was probably just right, just right really and I liked dose of HIT. Furthermore, given that these levels were based how it varied 10, 20, 30—I didn’t want to do 30 on their own individual maximal levels (ie, relative to maximal seconds all the time. [Participant 3, 34 years, heart rate), the participants were also aware that these were community worker] attainable (eg, [44]). Accordingly, after the first session during I always felt as though the 10 seconds were mad which users became familiar with the game concepts, intensity [hard] to be honest, because no sooner than you were http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al levels remained consistent throughout the 6-week intervention, protocols (IPs) and greater bandwidth, these exergaming indicative of a high-quality dose of HIT. sessions could be delivered over the internet. Further work into the acceptability of delivering exercise in this manner may need When our outcome data are compared with those from other to be undertaken, but the benefits of doing exercise at work or HIT programs, however, our improvements in fitness were at home would most probably appeal to some of our participants. relatively modest. For example, the effect on predicted VO Furthermore, by using these technologies effectively, it may be max was only half the pooled effect for untrained males of 6.2% possible to exploit other opportunities to further motivate, such [5]. This relatively smaller improvement could be because of a as social media to improve competitiveness and camaraderie range of factors (eg, age), although given that we analyzed the [50]. outcome data on an intention-to-treat (ITT) basis, nonattendance was the most probable cause. Specifically, our attendance of Limitations 68% is much lower than is typical for lab-based studies and There were several limitations to this study that need to be more similar to other community-based trials involving HIT. overcome in a larger trial. First, our sample only included white For example, our attendance data was similar to other boxing Europeans and South Asian males recruited from regions of themed interventions (79%, [45]), mixed-gender HIT programs socioeconomic deprivation. The acceptability of this intervention (75% for maximal volitional intensity training; [46]), obese across different ethnicities and other socioeconomic groups is males (57%, [47]), and community-based HIT interventions therefore not known. Second, we administered a submaximal using adult populations (58%-77%, [48]). Thus, although there fitness test despite it being known that such tests are prone to were some positive findings related to this HIT intervention errors [51]. Third, minigames such as this usually have a short (eg, ease of recruitment in the target population and training at lifespan [52,53], and it is not known how much longer the the intended dose), some of the usual problems associated with exergame could maintain interest beyond this 6-week conducting exercise interventions in the community remained. intervention. Future studies are needed to explore the Despite favorable changes in VO max, there were no clear 2 acceptability of a maximal VO max test within this population. beneficial effects for body mass, waist circumference, and blood Fourth, participant blinding was not possible in this study, and pressure when compared with our control group. We suspect we therefore cannot rule out cluster contamination and that our ITT analysis and shorter intervention period (<12 participant allocation resentment. Fifth, we did not perform an weeks) influenced these outcome measures when compared economic evaluation of this intervention. Whether these benefits, with other HIT studies [35,49]. given the costs of treating symptoms associated with lack of exercise, set against the costs of developing and delivering the In summary, we have established that HIT can be delivered via intervention, requires formal evaluation in future research. exergaming but that the usual problems of attendance remain. Clearly, finding strategies to improve attendance will be Conclusions important in future development cycles. One of the appealing Exergaming can be configured to deliver a sustained and features of HIT among our participants was the time-efficient consistent dose of high-intensity exercise, resulting in improved nature of HIT. However, the delivery of our exergaming sessions fitness in a group of males living in regions of socioeconomic in many cases required travel to and from the venue on a status over a 6-week program. Furthermore, class-salient thrice-weekly basis. This could add hours onto a relatively brief interventions delivered to specific populations have the potential period of HIT, and for some, this was a major disincentive to to facilitate adherence and attendance. Exergaming is inherently attend. On a more positive note, however, online gaming is now scalable and has good reach into our population, although future a major part of the gaming industry, and through internet strategies using IPs could improve the real-world effectiveness. Acknowledgments This work was sponsored by the Research Councils Digital Economy Programme. CH was a fully funded staff member of Fuse the Centre for Translational Research in Public Health, a UKCRC Public Health Research Centre of Excellence. Funding for Fuse from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, is gratefully acknowledged. The authors would also like to acknowledge Alan Batterham for his help in the early stages of this project and their gatekeepers at Central Masjid Middlesbrough Mosque, Beechwood and Easterside Social Club, and Eden—Easterside Church Group for helping with the delivery of the intervention and the participants involved. Conflicts of Interest None declared. Editorial notice: This randomized study was only retrospectively registered. The editor granted an exception of ICMJE rules for prospective registration of randomized trials because the risk of bias appears low and the study was considered formative. 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JMIR Serious Games 2014 Aug;2(2):e9 [FREE Full text] [doi: 10.2196/games.3413] [Medline: 25654660] Abbreviations AU: arbitrary unit CL: confidence limit HIT: high-intensity training HRmax: maximal heart rate IP: internet protocol MPID: minimal practically important difference RPE: rating of perceived exertion VO max: maximal oxygen consumption Edited by G Eysenbach; submitted 27.03.17; peer-reviewed by P Lau, A Billis; comments to author 22.07.17; revised version received 15.09.17; accepted 19.12.17; published 27.03.18 Please cite as: McBain T, Weston M, Crawshaw P, Haighton C, Spears I JMIR Serious Games 2018;6(1):e4 URL: http://games.jmir.org/2018/1/e4/ doi: 10.2196/games.7758 PMID: 29588271 ©Thomas McBain, Matthew Weston, Paul Crawshaw, Catherine Haighton, Iain Spears. Originally published in JMIR Serious Games (http://games.jmir.org), 27.03.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 13 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Development of an Exergame to Deliver a Sustained Dose of High-Intensity Training: Formative Pilot Randomized Trial

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Abstract

Background: Sport science can play a critical role in reducing health inequalities. The inverse relationship between life expectancy, cardiorespiratory fitness, and socioeconomic status could be addressed by performing high-intensity training (HIT), delivered in a class salient and accessible approach. Commercially available exergames have shown encouraging compliance rates but are primarily designed for entertainment purposes rather than focusing on health-related outcomes. A serious game tailored toward delivering an exercise stimulus, while reducing the aversive protocols associated with HIT, could be beneficial to engage and improve health outcomes in socially deprived males. Objective: The aims of this study were to develop an exergame capable of delivering HIT and evaluate the effect on selected health outcomes in men recruited in regions of socioeconomic deprivation. Methods: We conducted an exploratory trial in our target population, and participants were allocated to intervention (n=14) or control groups (n=10) by third-party minimization. The intervention was a 6-week training program consisting of three sessions of exergaming per week. The sessions involved a structured warm-up, then brief intermittent repetitions in the form of boxing rounds (10 s, 20 s, and 30 s) against their peers with a work/rest ratio of 0.25. Results: Retention to the intervention was 87.5% (21/24). Over the duration of the intervention, session attendance was 67.5% (170/252); repetition mean and peak heart rates (% of maximal) and session ratings of perceived exertion (AU, arbitrary units) were 86.3 (5.4%), 89.9 (6.1%), and 7.5 (2.2 AU), respectively. The effect of the intervention, when compared with the control, was a likely small beneficial improvement in predicted maximum oxygen consumption (VO max, 3.0; 90% confidence limits ±2.6%). Effects on body mass, waist circumference, and blood pressure were either trivial or unclear. Conclusions: Over the 6-week intervention, the exergame delivered a consistent and sustained dose of HIT, with some beneficial effects on aerobic fitness in the target population. Trial Registration: ClinicalTrials.gov NCT03477773; https://clinicaltrials.gov/ct2/show/NCT03477773 (Archived by WebCite at http://www.webcitation.org/6yDLgVs35) (JMIR Serious Games 2018;6(1):e4) doi: 10.2196/games.7758 http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al KEYWORDS high-intensity interval training; video games; heart rate; boxing; metabolic syndrome known to deliver, at best, low to moderate levels of exercise Introduction [18], our first aim was to describe the development of a serious exergame for this purpose. Our second aim was to quantify its The latest government audit of university-based research in the real-world fidelity and potential to improve fitness and health United Kingdom has highlighted the need for more sport and outcomes in males recruited in regions of socioeconomic exercise research to target health inequalities that persist in deprivation over a 6-week intervention. society [1]. There are strong inverse relationships between life expectancy, cardiorespiratory fitness, and socioeconomic status Methods [2-4]. As these trends are exacerbated in males, improving fitness in men living in regions of socioeconomic deprivation Development of the Game and Intervention could be important for addressing health inequalities. During the preintervention period, we held regular focus groups High-intensity training (HIT) is a time-efficient way to improve comprising in-house participants, computer programmers, and fitness over a short duration [5], and a growing body of evidence exercise scientists with specialisms in delivering HIT. Together, advocates this form of exercise for public health interventions we explored opportunities to gamify HIT protocols. Boxing [6]. HIT is known to stimulate a combination of central and was an obvious theme for gamification as it involves peripheral adaptations promoting an enhanced availability, high-intensity exercise [19], and the subculture already exists extraction, and utilization of oxygen [7,8]. Although these within our target population of lower working-class males of findings are encouraging, these previous studies have tended the North-East of England [20,21]. The complete set of hardware to prescribe exercise with a focus on cycling and running [9-12]. used in the trials comprised a single computer with a dedicated Some argue that the psychologically aversive nature of graphics card (GeForce GTX 960, [22]), two standard 23-inch high-intensity exercise means that this training will not be monitors, two Kinect for Windows sensors, four wrist-mounted adopted or maintained by many people [13]. Thus, although the wireless inertial measurement units (developed in-house to physiological benefits of HIT are unequivocal, there is ongoing reduce latency in the Kinect datastream), and two wireless debate about its relevance across populations, particularly for chest-worn heart-rate monitors (Polar RS400, Polar Electro Oy, those less-motivated individuals. Finding ways to improve its Kempele, Finland). In addition, the participants wore acceptability could be the key to improve the wider acceptance boxing-specific resistance bands (ShadowBoxer Pty, Australia) of HIT. to increase levels of exertion and reduce eccentric muscle The concept of exergaming, or active video gaming, has been contractions during the deceleration phase of punching. The around since the 1980s and affords unrivalled opportunities to movement data from the sensors were streamed to our gaming reward exercise through visual, audio, haptic, and mental engine [23] via a User Datagram Protocol with a latency of stimuli. Exergaming-based interventions have understandably approximately 15 ms. Input from the skeletal tracking module shown improved rates of compliance, adherence, and social of the Kinect system and inertial measurement units were inclusion (eg, see [2]). Despite this, however, and after nearly converted to a digital avatar using purpose-written functions to a decade of research, the potential for exergaming to improve convert each body segment long-axis (19 in total) into levels of fitness on a population level has not been realized [14]. three-dimensional quaternions, as can be seen with the hardware A possible reason is that most of the research is based on setup in Figure 1. The C# programming language was used commercially available exergames that are designed primarily throughout to create scripts for gameplay (Figure 2). for entertainment. In other areas of health research, such as Commercial games are primarily designed for entertainment physiotherapy, researchers have overcome these shortfalls by and recreation for younger populations and tend to have colorful creating their own exergames specifically geared to the and visually busy game and user interfaces [24]. Furthermore, physiological needs of the clinical or at-risk population. These commercially available games are mostly designed for serious games are purposively designed to train physiological enjoyment and not based on basic exercise principles. For games systems at a level that is sufficient to cause positive adaptation. to promote beneficial changes in health, they need to engage Importantly, these serious exergames have succeeded in physiological systems in a meaningful manner that is relevant improving health-related outcomes (eg, balance and falls risk) for the function being trained [25]. Our philosophy was to ensure and demonstrate their potential for use in other health that the gameplay was simple and, where possible, true to the professions [15]. rules of boxing. Each avatar was assigned collision objects with A major challenge with improving HIT and exergaming is to inertial characteristics on the trunk, head, and hands, thus translate positive laboratory-based findings into interventions enabling the physics engine to superimpose realistic joint that can directly affect those individuals who need it most and movements in response to being hit. As in real boxing, the can also be administered on a larger scale [16,17]. Whether or primary mechanism for scoring was to successfully land a punch not the concept of serious exergaming can contribute in this on either the trunk or head of the opponent. The number of regard requires, first, that a game is tailored toward reducing points awarded per punch was the product of the current heart the aversive protocols associated with HIT and second, that the rate (expressed as a percentage of maximal) and speed of impact intervention is capable of improving fitness in our target -1 (ms ). population. Given that the commercially available games are http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al Figure 1. The exergaming system comprising hardware and software with real-time avatar mapping. Thus, for example, a punch landing to the head with a relative of allowable close-up punching. Specifically, after 1 s of -1 close-up punching, the referee interrupted the fight (shown in speed of 9 ms and at 95% of maximal heart rate (ie, 95% the striped shirt in Figure 3) and ordered both participants to HRmax) was awarded 8.55 points (ie, 9 x 0.95). Each participant race back to their respective corners (ie, 3 m backwards of was provided with biofeedback in the form of a partial arc backwards stepping). The winner of each mini race received an positioned around the opponent’s head; the angle subtended by additional 50 points; equivalent to approximately 6 to 7 this arc was linked to the current heart rate (Figure 3). well-timed punches. After several iterations of observing For example, when player 1 was working at 50% of maximal kinematics, heart rates, and tactics during gameplay, we prepared heart rate, an arc of 180 was displayed around the head of the exergaming system (ie, both hardware and software) for use player 2. The players were made aware that the angle of the arc in the target settings. was proportional to their current training intensity, which in Participants turn contributed strongly to punch power and points scoring. We conducted a 6-week exploratory controlled trial designed They were also aware that large global displacements of their to assess the fidelity of the game in terms of delivering the center of mass (eg, bouncing up and down) would increase this intended training stimulus and to examine the effect of the intensity but with a lag of approximately 20 to 30s [26]. This intervention on selected health outcomes. As appropriate for an arc was visible in their monitor only and was active throughout exploratory trial, we did not conduct formal sample size the exergaming session (ie, during both repetitions and rest), estimation a priori, rather the CIs would be used to inform future essentially allowing the participants to self-regulate training trials. Men are commonly referred to as a hard-to-reach intensity per the oncoming requirements of the game. Although population to engage in health promotion activities [27], where we kept on-screen text to a minimum, we elected to display a a targeted recruitment approach at locations predominantly countdown timer during some periods. These were during the attended by men may facilitate uptake of participants. Therefore, final 30 s of active recovery to encourage the elevation of to maximize recruitment within our intended population, training intensity in preparation for a repetition and during the relevant gatekeepers were approached at institutions positioned latter 10 s of each repetition to encourage all-out punching right within regions of social deprivation. Thus, two settings used up until the bell. Following preliminary tests, we removed the for recruitment and the trials were a social club and mosque, ability to block punches as this was observed to be energetically both situated within deprived regions of Middlesbrough, United undemanding; thus, the only forms of defense were to attack Kingdom (TS1 and TS4). Recruitment in the social club relied before being hit or to dodge the oncoming punch using whole heavily on the gatekeeper (club secretary), whereas uptake of body movements. For similar reasons, we limited the periods http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al South Asian men from a local mosque was more straightforward; Participants were given a £15 shopping voucher upon all 9 mosque participants were recruited from a single completion of follow-up measures (week 7) irrespective of their demonstration (and we had similar experiences in previous adherence to the intervention protocol or group allocation. The iterations). Presumably, the intervention was culturally salient intervention took place from November 2014 to December 2014 in this population; the North of England has developed some (social club) and March 2015 to April 2015 (mosque). Postcode famous prominent Muslim boxers (eg, Amir Kahn and Naseem data were analyzed to match against indices of multiple Hamed) in recent years, and when delivered in the safe form, deprivation in lower-layer super output areas to check whether was acceptable to the respected leaders of the religious groups the cohort fell within our target population. Two participants (ie, the Imam of the mosque). A total of 24 males were recruited (8%, 2/24) lived in the least deprived 20% (decile 8), 20 into the trial (Figure 4) using relevant gatekeepers at institutions participants (83%, 20/24) lived in the most deprived 20% areas positioned within regions of social deprivation. Two recruitment in England (decile 2), and 1 participant (6%, 1/24) lived in the drives (October 2014 and February 2015) took place, and these most deprived 1% of areas (decile 1). The participants were involved live demonstrations of the technology followed by broadly split between white (58%, 14/24) and South Asian word-of-mouth and snowballing approaches. The exergaming (42%, 10/24). Body mass index [29] and waist circumference system was important in this recruitment process because it [30] cut-points were adjusted for ethnicity. Accordingly, 63% provided something tangible and interesting to engage potential (15/24) had abdominal obesity, 37.5% (9/24) were overweight, participants. and 42% (10/24) were obese. Within this group, the 45 to 50 years category was most common (33%, 8/24), followed by 18 Inclusion criteria were deliberately broad to maximize to 24 years (29%, 7/24), 25 to 34 years (17%, 4/24), 35 to 44 recruitment, that is, apparently healthy, as defined by ACSM years (17%, 4/24), and 51 to 55 years (4%, 1/24) categories. guidelines and in the age range of 18 to 55 years [28]. Figure 2. Machine state variables used in controlling the game. http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al Figure 3. The three visual outputs communicating instructions and actual game play to the users. A third-party minimization process using baseline measures of upper arm blood pressure monitor (Omron MX13). Measures age, waist circumference, and predicted maximum oxygen were made at least three times at 3-min intervals, where an consumption (VO max) was used to remove bias in group average of the two lowest measures was used for analysis [31]. Waist circumference was measured using the World Health allocation. The control group was instructed to maintain their Organization guidelines [32]. Predicted VO max was obtained current physical activity levels and inform the researchers should 2 any changes arise during the intervention period. One of the by performing a submaximal 8-min ramped step test [33]. Heart participants in the control group decided to embark on his own rate response (Polar T34; PolarElectro OY, Kempele, Finland) fitness program following the preintervention tests but was and simultaneous breath-by-breath expired gas were collected included in the data analysis. Participant flow through the trials using a portable indirect calorimeter (Cosmed K4 b2; Rome, is shown in Figure 4, whereby 3 participants were lost to Italy), calibrated per the manufacturer’s guidelines. Individual follow-up (control=2, intervention=1). Overall retention to the HRmax was estimated [34] and plotted against VO data for intervention that encompassed baseline and follow-up measures the determination of predicted VO max. was 87.5% (21/24). Intervention Delivery To explore perceptions of the exergame and the HIT regime, Evidence recommends a minimum duration of 12 weeks for a semistructured interviews were conducted with 5 intervention HIT protocol to promote favorable changes in blood pressure participants following the 6-week training period, which were and anthropometric measurements of obesity [35]. However, a analyzed semantically. The study was approved by the ethics 6-week intervention was selected, as a minimum of 13 sessions committee of Teesside University, United Kingdom, and written (0.16 work/rest ratio) is sufficient to elicit moderate informed consent was obtained from all participants. improvements in VO max in sedentary individuals [5]. Measures Additionally, there is still ambiguity regarding the optimal work-to-rest ratio when designing HIT interventions, particularly Participants’ baseline characteristics (mean [SD]) are shown in in populations with varied age, baseline fitness, and training Table 1. All measures were assessed pre and post intervention. experience [36]. Therefore, longer duration HIT models (1-4 Blood pressure was collected on the left arm positioned at heart min) were deemed unsuitable for our target population [37]. height with the subjects in a seated position by an automatic http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al Figure 4. Participant flow though the trial. Furthermore, minigames (such as the current exergame) have were followed by 40, 80, or 120-s of active recovery. short life spans, where adherence to a longer intervention (eg, Participants were instructed to perform the repetitions at an 12 weeks) may diminish over time and influence health intensity ≥85% HRmax. Each exergaming session took outcomes. This was evident from a 12-week pilot study approximately 30 to 40 min to complete, including equipment (unpublished data) using an exergame in the same population set-up, warm-up with additional enjoyment, and task immersion that saw attendance drop from 53% during week 2 to 16% during questionnaires upon completion of the HIT bouts (not reported week 12. here). Heart rate responses were taken within repetitions and therefore, did not include any of the recovery period. This, Participants allocated to the intervention group were invited to therefore, avoided an overestimation of physiological load, attend three sessions of exergaming per week. At the beginning which can occur when heart rate continues to rise after exercise of the exergaming session, participants were required to cessation [26]. complete a 6-min structured warm-up consisting of a series of exercises on a 210 mm step until both participants reached >70% Statistical Analysis HRmax. Session workloads with volumetric progression were Data are presented as mean (SD). Exergaming session set automatically once the user’s identifying information was attendance was calculated using descriptive statistics. Training entered. The session workloads were 120s-, 150-s, and 180-s data (heart rate [repetition mean and peak], rating of perceived of work during weeks 1 and 2, weeks 3 and 4, and weeks 5 and exertion [RPE]) were analyzed using a mixed linear model with 6, respectively. a random intercept (Statistical Package for the Social Sciences [SPSS] version 23 [IBM Corp]). To avoid staleness, the repetition lengths (10, 20, or 30-s) were randomly selected at the beginning of each round. We set the work-to-rest ratio at 1:4, and thus, the respective repetitions http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al This approach enabled us to calculate (1) the within-participant declaring an effect clinically beneficial being <0.5% (most variability in the training dose [38], expressed as an SD; (2) the unlikely) for harm and >25% (possibly) for benefit [42]. effect of HIT repetition duration (entered as a fixed effect) on heart rate and RPE; and (3) the change in heart rate and RPE Results across the 6-week HIT intervention, with session number (1-18) Measures entered as a fixed effect. A priori, we defined a minimal practically important difference (MPID) in training heart rates When compared with the control group, the effect of the as two percentage points, given that when training at exergaming intervention was a likely small beneficial high-intensity, this difference influences the adaptive response improvement in predicted VO max. The SD of the individual [39]. responses in predicted VO max to the exergaming intervention was 3.4 (90% CLs ±3.1). All other effects were either most The MPID for RPE was set at one arbitrary unit (AU) on the likely trivial (body mass and waist circumference) or unclear Borg CR10 Scale, representing a full increment change on the (systolic blood pressure and diastolic blood pressure; Table 1). scale. Inferences were then based on the disposition of the 90% confidence limits (CLs) for the mean difference to these MPID; Intervention Delivery the probability (percent chances) that differences in heart rate Mean session attendance was 67.5% (170/252; range 0%-100%). and RPE between HIT repetitions of different durations or across Of the 14 intervention participants, 9 attended at least 75% of the 6-week intervention were substantial (>2 percentage points, the prescribed exergaming sessions. The total number of >1 AU) or trivial was calculated as per the magnitude-based repetitions performed was 1268 (range 6-136 per participant), inference approach described by Batterham and Hopkins [40], and the descriptive training data for the exergaming intervention an approach that has been advocated within user research [41]. are presented in Table 2. The magnitude of the within-participant These percent chances were qualified via probabilistic terms variability in all intensity measures was moderate. assigned using the following scale: 25 to 75%, possibly; 75 to Mean exercise intensity data for the 10-s, 20-s, and 30-s 95%, likely; 95 to 99.5%, very likely; and >99.5%, most likely repetitions are presented in Table 3. The effect of repetition [42]. To determine the magnitude of the within-participant duration on mean heart rate was substantially higher heart rates variability in our training heart rate and RPE, the values were during the 30-s repetitions when compared with the 20-s (2.2 doubled and then interpreted against aforementioned MPID. percentage points; ±90% CLs 0.5 percentage points) and 10-s All training data effects were evaluated mechanistically, repetitions (3.5 percentage points; ±0.5 percentage points). Peak whereby if the 90% CL overlapped the thresholds for the heart rates were also substantially higher for the 30-s repetitions smallest worthwhile positive and negative effects, the effect when compared with the 20-s (3.6 percentage points; ±0.6 was deemed unclear [42]. The effect of HIT on our outcome percentage points) and 10-s repetitions (6.4 percentage points; measures was determined using a custom-made spreadsheet ±0.6 percentage points). The effect of repetition duration on [43], with the baseline value of the dependent variable used as RPE was most likely trivial. The mean exercise intensity scores a covariate to control for baseline between-group imbalances. per exercise session along with the individual data points to Following this, standardized thresholds for small, moderate, illustrate the variability around the mean score are presented in and large changes (0.2, 0.6, and 1.2, respectively) [42] derived Figure 5. Across the intervention, the regression slope revealed from between-subject SDs of the baseline values were used to most likely trivial changes in mean heart rate (0.1 percentage assess the magnitude of all effects, with magnitude-based points; ±90% CLs 0.2 percentage points), peak heart rate (0.1 inferences subsequently applied. Here, all inferences were percentage points; ±0.2 percentage points), and RPE (0.1 AU; categorized as clinical, with the default probabilities for ±0.1 AU) across the duration of the 6-week HIT intervention. Table 1. Outcome measures at baseline along with the analysis of covariance adjusted change scores and the between-group comparisons of the change scores. Outcome measures Intervention group (n=13) Control group (n=8) Group comparison Baseline values, Change score, Baseline values, Change score, Difference between groups, mean (SD) mean (SD) mean (SD) mean (SD) % mean; ±90% CL Body mass (kg) 87 (22) −1.1 (2.0) 88 (20) −0.5 (1.6) −0.5; ±1.4 Waist circumference 97 (15) −0.6 (1.6) 100 (14) −0.3 (1.6) −0.3; ±1.3 43.7 (8.8) 3.2 (4.1) 39.5 (8.5) 0.2 (2.4) 3.0; ±2.6 Predicted VO max (mL/kg/min) Systolic blood pressure 130 (9) −5.9 (5.5) 134 (12) −2.7 (6.7) −3.2; ±5.2 Diastolic blood pressure 80 (10) −5.1 (5.7) 86 (9) −5.1 (7.1) −0.1; ±5.8 High-intensity training (HIT) control. CL: confidence limit. VO max: maximal oxygen consumption. http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al Table 2. Exercise intensity data for the high-intensity training (HIT) intervention. Intensity measure Mean (SD) Within-subject variability; ±90% CL Mean heart rate (%) 86.3 (5.4) 4.7; ±0.2 Peak heart rate (%) 89.9 (6.1) 5.7; ±0.2 b c 7.5 (2.2) 1.6; ±0.1 Session RPE (AU ) CL: confidence limit. RPE: rating of perceived exertion. AU: arbitrary unit. Table 3. Exercise intensity data for the high-intensity training (HIT) repetition duration. Intensity measure 10-s repetitions 20-s repetitions 30-s repetitions Mean heart rate (%) 84.7 ± 5.3 85.9 ± 6.6 88.2 ± 3.5 Peak heart rate (%) 86.8 ± 4.9 89.5 ± 7.7 93.2 ± 3.4 a b Session RPE (AU ) 7.4 ± 2.2 7.5 ± 2.4 7.6 ± 2.0 RPE: rating of perceived exertion. AU: arbitrary unit. Figure 5. Group mean (large open squares) and individual (small closed triangles) heart rates (session mean and session peak) and ratings of perceived exertion (RPE) across the 6-week exergaming intervention period (session numbers 1-18). AU: arbitrary unit. http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al like finished, then you had to wait about 30 seconds Qualitative Findings before a 20 second one started or something like that. Participants who engaged in interviews ranged between 25 and I loved the 30 second ones. I thought that was great, 50 years and attended between 60% and 100% of the exercise that was just enough, like 30 seconds in that one sessions. Data revealed that participants found the exergame to round and that was just more than enough sort of be challenging but rewarding, as illustrated in the following thing, you know? [Participant 4, 45 years, hotel quotes: worker] At the start you think this is too hard but as you go Finally, some gameplay elements such as heart rate integration on and it does get easier, I say it gets easier but you and visual feedback of a successful punch were encouraging extend the time don’t you so you’re doing more. Half for participants, as illustrated in the following quote: way through the second week I started to appreciate All I knew that if I see the ring go round the head, the that, what you’re doing is making it harder to keep further round it is, if I hit him the more points I’d get, testing me, do you know what I mean? And you can so I knew that and I knew every time it flashed I’d feel it, you can feel it that you are getting better at caught him. I knew my heart rate was there and I the game. I think it still knacks you out [exhausts you] knew the timer was ticking down at the bottom. But because you start trying harder as it goes on. the movements and everything else were excellent. [Participant 1, 50 years, social club worker] [Participant 1, 50 years, social club worker] At the beginning it was killing me [exhausting me], but as I carried it on it was still killing me and then Discussion it started to get like, better, my heart wasn’t working as hard and I was getting more fit to the point where Principal Findings I coped well, to the point where I was actually still This study developed a novel HIT intervention using working my hardest at the level I wanted to. exergaming. Obtaining information about whether the game [Participant 4, 25 years, hospital worker] was used as intended by the target population is a fundamental Participants found that the competitive aspects resulted in a stage in the development cycle. We evaluated its use in men changing game scenario between players and rounds for each recruited from regions of socioeconomic deprivation, a training session, which facilitated motivation to attend and population predisposed to low life expectancy. The training engage, as illustrated in the following quotes: data is indicative of a consistent and progressive dose of HIT (>85% of maximal heart rate) over the duration of the 6-week There was always something else that kept you intervention. Given that our protocol for measuring training interested, kept you wanting to do more. If you go for intensity is conservative [38], we are confident that the game a run, its more like “I’m just running,” that’s it. The was used by the participants as intended. Furthermore, we also fact that you were fighting someone, a different found clear beneficial effects on predicted VO max, and these opponent—you had to change, you either didn’t have 2 findings together demonstrate the potential usefulness of to work as hard [or you should be] or you had to work exergaming for the future delivery of HIT. harder than you could. [Participant 4, 45 years, hotel worker] Despite the respective popularities of both HIT and video I just thought it was a fun way to exercise. If it wasn’t gaming, there have been no previous attempts to combine these competition, it would be hard to be doing that 2-3 concepts in the form of an exercise intervention. As such, there times a week to train at that intensity. Like you would are no studies against which to directly compare our training go the odd time training that intense but if it’s against data, although the intensity levels are clearly greater than those someone you’re more likely to put 100% in. You know, measured for commercially available exergames [18]. In fact, if my heart rate had have got that high just doing it our training data are more comparable to those from a recent by myself, maybe once or twice but not on a consistent high-intensity exercise programs delivered via traditional means thing like that, in a competition against someone else and described as a high-quality dose of HIT [38]. For example, it does push you to train harder, it did me, it did push our repetition peak heart rates of 89% of maximal when me to train harder. [Participant 2, 25 years, averaged over the duration of the 6-week intervention were only unemployed] two percentage points below their levels. Although we cannot pinpoint the specific mechanisms underpinning this success, The variance in the allocated workload was a motivating factor we suggest the feedback and point-scoring made a strong but highlighted that repeated 30-s bursts may have discouraged contribution. Specifically, by matching point-scoring to current one participant from attending exercise sessions, as illustrated training intensity and enabling users to self-regulate and in the following quotes: maximize their intensity, it was possible to deliver a consistent It was probably just right, just right really and I liked dose of HIT. Furthermore, given that these levels were based how it varied 10, 20, 30—I didn’t want to do 30 on their own individual maximal levels (ie, relative to maximal seconds all the time. [Participant 3, 34 years, heart rate), the participants were also aware that these were community worker] attainable (eg, [44]). Accordingly, after the first session during I always felt as though the 10 seconds were mad which users became familiar with the game concepts, intensity [hard] to be honest, because no sooner than you were http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES McBain et al levels remained consistent throughout the 6-week intervention, protocols (IPs) and greater bandwidth, these exergaming indicative of a high-quality dose of HIT. sessions could be delivered over the internet. Further work into the acceptability of delivering exercise in this manner may need When our outcome data are compared with those from other to be undertaken, but the benefits of doing exercise at work or HIT programs, however, our improvements in fitness were at home would most probably appeal to some of our participants. relatively modest. For example, the effect on predicted VO Furthermore, by using these technologies effectively, it may be max was only half the pooled effect for untrained males of 6.2% possible to exploit other opportunities to further motivate, such [5]. This relatively smaller improvement could be because of a as social media to improve competitiveness and camaraderie range of factors (eg, age), although given that we analyzed the [50]. outcome data on an intention-to-treat (ITT) basis, nonattendance was the most probable cause. Specifically, our attendance of Limitations 68% is much lower than is typical for lab-based studies and There were several limitations to this study that need to be more similar to other community-based trials involving HIT. overcome in a larger trial. First, our sample only included white For example, our attendance data was similar to other boxing Europeans and South Asian males recruited from regions of themed interventions (79%, [45]), mixed-gender HIT programs socioeconomic deprivation. The acceptability of this intervention (75% for maximal volitional intensity training; [46]), obese across different ethnicities and other socioeconomic groups is males (57%, [47]), and community-based HIT interventions therefore not known. Second, we administered a submaximal using adult populations (58%-77%, [48]). Thus, although there fitness test despite it being known that such tests are prone to were some positive findings related to this HIT intervention errors [51]. Third, minigames such as this usually have a short (eg, ease of recruitment in the target population and training at lifespan [52,53], and it is not known how much longer the the intended dose), some of the usual problems associated with exergame could maintain interest beyond this 6-week conducting exercise interventions in the community remained. intervention. Future studies are needed to explore the Despite favorable changes in VO max, there were no clear 2 acceptability of a maximal VO max test within this population. beneficial effects for body mass, waist circumference, and blood Fourth, participant blinding was not possible in this study, and pressure when compared with our control group. We suspect we therefore cannot rule out cluster contamination and that our ITT analysis and shorter intervention period (<12 participant allocation resentment. Fifth, we did not perform an weeks) influenced these outcome measures when compared economic evaluation of this intervention. Whether these benefits, with other HIT studies [35,49]. given the costs of treating symptoms associated with lack of exercise, set against the costs of developing and delivering the In summary, we have established that HIT can be delivered via intervention, requires formal evaluation in future research. exergaming but that the usual problems of attendance remain. Clearly, finding strategies to improve attendance will be Conclusions important in future development cycles. One of the appealing Exergaming can be configured to deliver a sustained and features of HIT among our participants was the time-efficient consistent dose of high-intensity exercise, resulting in improved nature of HIT. However, the delivery of our exergaming sessions fitness in a group of males living in regions of socioeconomic in many cases required travel to and from the venue on a status over a 6-week program. Furthermore, class-salient thrice-weekly basis. This could add hours onto a relatively brief interventions delivered to specific populations have the potential period of HIT, and for some, this was a major disincentive to to facilitate adherence and attendance. Exergaming is inherently attend. On a more positive note, however, online gaming is now scalable and has good reach into our population, although future a major part of the gaming industry, and through internet strategies using IPs could improve the real-world effectiveness. Acknowledgments This work was sponsored by the Research Councils Digital Economy Programme. CH was a fully funded staff member of Fuse the Centre for Translational Research in Public Health, a UKCRC Public Health Research Centre of Excellence. Funding for Fuse from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, is gratefully acknowledged. The authors would also like to acknowledge Alan Batterham for his help in the early stages of this project and their gatekeepers at Central Masjid Middlesbrough Mosque, Beechwood and Easterside Social Club, and Eden—Easterside Church Group for helping with the delivery of the intervention and the participants involved. Conflicts of Interest None declared. Editorial notice: This randomized study was only retrospectively registered. The editor granted an exception of ICMJE rules for prospective registration of randomized trials because the risk of bias appears low and the study was considered formative. 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JMIR Serious Games 2014 Aug;2(2):e9 [FREE Full text] [doi: 10.2196/games.3413] [Medline: 25654660] Abbreviations AU: arbitrary unit CL: confidence limit HIT: high-intensity training HRmax: maximal heart rate IP: internet protocol MPID: minimal practically important difference RPE: rating of perceived exertion VO max: maximal oxygen consumption Edited by G Eysenbach; submitted 27.03.17; peer-reviewed by P Lau, A Billis; comments to author 22.07.17; revised version received 15.09.17; accepted 19.12.17; published 27.03.18 Please cite as: McBain T, Weston M, Crawshaw P, Haighton C, Spears I JMIR Serious Games 2018;6(1):e4 URL: http://games.jmir.org/2018/1/e4/ doi: 10.2196/games.7758 PMID: 29588271 ©Thomas McBain, Matthew Weston, Paul Crawshaw, Catherine Haighton, Iain Spears. Originally published in JMIR Serious Games (http://games.jmir.org), 27.03.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/1/e4/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e4 | p. 13 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Mar 27, 2018

Keywords: high-intensity interval training; video games; heart rate; boxing; metabolic syndrome

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