Use of Active-Play Video Games to Enhance Aerobic Fitness in Schizophrenia: Feasibility, Safety, and Adherence

Sedentary lifestyles are highly prevalent among individuals with schizophrenia, with rates in this population far exceeding those in the general population (1). Extensive literature has linked a sedentary lifestyle to multiple cardiometabolic comorbidities (2,3) along with poor neurocognition and daily dysfunction (4,5). Consequently, in recent years there have been increased efforts to address sedentary lifestyles among people with serious mental health illnesses by developing aerobic exercise (AE) interventions to increase aerobic fitness, typically by using traditional AE equipment. A search of PubMed indicated that the number of publications focusing on sedentary lifestyles and AE interventions grew nearly eightfold in recent years, from seven in 1999 to 54 in 2013. Yet a number of barriers limit the broad implementation of AE programs among persons with serious mental illnesses, key among them are boredom and limited interest in training (6).

Technological advances over the past decade have led to the development of active-play video game systems, for example, Nintendo Wii and Xbox 360 with Kinect, that promote active lifestyles by making physical activity more fun (7). They have become mainstream tools for enhancing aerobic fitness, as evident from their endorsement by the American Heart Association (7). To date, however, only one small study has evaluated the use of such systems among persons with schizophrenia (8). Although the study provided preliminary support for use of such game systems with this population, the conclusions were limited by the sample’s narrow age range (>55), use of a single light-intensity active-play video game (bowling), and a relatively brief program (30 minutes per week for six weeks). Thus our aim was to characterize the feasibility, acceptability, safety, and adherence associated with using active-play video games as part of an AE training program for individuals with schizophrenia.

Methods

The data were collected between May 2012 and July 2014 as part of a single-blind randomized clinical trial assessing the impact of AE on neurocognition in schizophrenia (5). The study was conducted at the New York State Psychiatric Institute (NYSPI), an affiliate of Columbia University Medical Center, and was approved by the NYSPI’s institutional review board. Participants were recruited from outpatient mental health clinics in greater New York City, and all provided written informed consent.

The inclusion criteria were a DSM-IV diagnosis of schizophrenia or a related disorder; age between 18 and 55 years, English speaking, use of antipsychotic medication for at least eight weeks and the current dose for four weeks or use of injectable depot antipsychotics with no change in dose in the past three months, and medical clearance by a physician to take part in AE training. The exclusion criteria were a DSM-IV diagnosis of alcohol or drug abuse within the past month or alcohol or drug dependence within the past six months; recent use of street drugs (confirmed by a urine toxicology test); a history of seizures or head trauma resulting in cognitive sequelae or rehabilitation; significant clinical abnormalities in physical examination, electrocardiogram, or lab assessments; a neurological or general medical disorder that could interfere with study participation; untreated hyper- or hypothyroidism; extreme obesity (BMI ≥40); being pregnant or nursing; having suicidal or homicidal risk; presence of moderate or more severe positive formal thought disorder (score of ≥3 on the Scale for the Assessment of Positive Symptoms [SAPS]); depressive symptoms of more than mild severity (score of >18 on the Beck Depression Inventory [BDI]; and participation in a study involving neurocognitive assessment in the previous three months.

Diagnoses were established by using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Clinical symptoms were assessed by using the SAPS, the Scale for the Assessment of Negative Symptoms, the BDI, and the Beck Anxiety Inventory. Aerobic fitness was determined by a cardiopulmonary exercise test to establish maximal oxygen consumption, or VO₂peak (ml/kg/min). Familiarity with and acceptability of active-play video games were measured with a self-report questionnaire adapted from previous studies of individuals with schizophrenia assessing use of off-the-shelf technologies (9). A detailed description of the aerobic fitness assessments and randomization procedures used in the study has been published elsewhere (5).

The AE program involved three one-hour sessions of AE training per week for 12 weeks. The sessions were informed by guidelines from the American College of Sports Medicine and the federal government (10) and led by an exercise trainer with a B.S. in therapeutic recreation and four years of AE training experience. Each session opened with a joint ten-minute warm-up, after which participants exercised individually using the AE equipment for a minimum of 45 minutes, ending with a five-minute cooldown. The trainer was present during the AE sessions for guidance and support, along with a research assistant who recorded AE behavioral data (for example, time spent using the various exercise equipment). The AE equipment included two Xbox 360 video game consoles with Kinect motion sensing devices for playing Your Shape Fitness Evolved 2012, an interactive whole-body fitness activity software designed by Ubisoft, along with two treadmill machines, a stationary bike, and an elliptical machine.

During the 45 minutes of active AE, participants were free to use any AE equipment. Similarly, when using Your Shape Fitness Evolved 2012, they were free to play any of the 18 AE games. Typically, the games start at a beginner level and become progressively more intense as the player achieves greater compliance at more intense AE levels. Participants were encouraged to change equipment every 15 to 20 minutes as well as to hydrate and take breaks as needed. This routine allowed participants to use all equipment types during each session as well as to diversify physical exercise routines.

A target for AE training intensity was set individually for each participant on the basis of his or her maximal heart rate (HR_max), as determined during a baseline VO₂peak test. Minimal AE intensity was set at 60% of HR_max in week 1, 65% in week 2, 70% in week 3, and 75% in weeks 4–12. To assess in-session training intensity, participants wore a wrist-style heart rate monitor (Polar RS400 HR) and a chest strap to record their heart rate during each session. The monitors were programmed to emit a soft beep if a participant’s heart rate fell below the individually targeted AE intensity level for a particular week of training. If a participant’s AE intensity fell below the designated intensity goal, the trainer encouraged him or her to achieve their target goal. Data on participants’ AE intensity were uploaded to a personal computer at the end of each AE session. Information about the intensity of the AE has been described elsewhere (5). The statistical package IBM SPSS, version 22, was employed in all data analyses.

Results

As part of the clinical trial, 33 of 41 participants completed the baseline assessment and were randomly assigned to AE (N=16) or a control group (N=17). Thirteen participants (81%) randomly assigned to the AE arm completed the 12-week AE training program (in addition to standard psychiatric care), and 13 (76%) participants in the control group completed 12 weeks of standard psychiatric care. All three AE noncompleters dropped out of AE training during the first week; reasons included loss of contact (N=1), long commute time to AE site (N=1), and not liking the AE program (N=1). Four participants in the control group dropped out; reasons included relocation (N=1), hypomanic episode (N=1), and protocol violations (N=2).

Table 1 describes the AE participants’ clinical and demographic characteristics. More than one-third of participants reported that they owned an exercise video game system. At follow-up, participants indicated that they had few difficulties operating the AE program’s system or understanding the on-screen instructions. Likewise, the displays of self-avatars on the screen were acceptable. Participants rated the use of the system as a very pleasant and entertaining experience that they considered somewhat challenging but not stressful. Finally, participants stated that they would favorably consider using exercise video game systems in future AE training and would strongly recommend them to others.

The AE participants attended a mean±SD of 28.5±2.4 of the 36 scheduled sessions over the 12-week program (79%; 2.4 sessions per week), exercising for an average of 42.7±3.51 minutes per session. There were no adverse events associated with the AE training program. The highest proportion of AE session time (N=15,820 minutes) was spent using the Xbox 360 with Kinect (N=6,170, 39%), followed by the treadmill (N=5,062, 32%), stationary bike (N=2,057, 13%), elliptical machine (N=2,057, 13%), and trainer-led AE (N=475, 3%). On average, the participants’ mean heart rate while using the Xbox 360 was 133.31±16.46. The mean heart rate during use of traditional equipment was 133.75±16.39. When using the Xbox 360, participants played an average of 2.24±1.59 games per session, with Cardio Workout (used in 60% [N=499] of all sessions [N=832] involving the use of Xbox), Wall Breaker (41%, N=341,), and Jump Rope (15%, N=125) being most popular.

Discussion and Conclusions

This study is the first systematic characterization of the use of active-play video games as part of an AE training program for individuals with schizophrenia. Our results provide preliminary support for the integration of such technologies into AE training programs for this population. Participants with schizophrenia living in the community reported high acceptability and enjoyment rates related to use of the exercise video game system, recommended use of such systems to others, and endorsed future plans to use active-play video games. In addition, the Xbox 360 was the most popular AE equipment among the participants, as indexed by the proportion of AE session time devoted to its use over the 12-week program. These findings were consistent with the high training completion and attendance rates (81% and 79%, respectively), given that previous reports indicate that use of active-play video games resulted in a higher degree of enjoyment and may lead to higher AE engagement (7). Related to these findings, participants in the AE group significantly increased their aerobic fitness, whereas there was virtually no change in the aerobic fitness of the control group (5). Notably, previous reports of similarly structured AE training programs using traditional AE equipment reported a lower average attendance rate (64%) (11). Altogether, these data indicated strong attendance and excellent in-session engagement.

Our AE program was designed with high ecological validity in mind, electing to use exercise equipment, facilities, training routines, and human resources that are relatively inexpensive and likely available in mental health clinics. Consistent with this aim, we elected to use the Xbox 360 with Kinect because it provides a number of advantages, including requiring a relatively small indoor space, a modest financial investment (about $350), and minimal storage space. In addition, exercise video game systems promote an active lifestyle by making physical activity more fun, offering a high degree of entertainment and greater variety of AE that minimize boredom and that may increase long-term engagement. Furthermore, such systems utilize interval training (multiple high-intensity short training segments), which are more effective than continuous AE in enhancing aerobic fitness and reducing metabolic complications (12–14), with preliminary evidence suggesting a similar trend in schizophrenia (15). Finally, the Kinect sensor is a motion-sensing input device that allows tracking of a participant’s body movements and provides visual feedback on the screen regarding the accuracy of the participant’s form and movements.

Our study had a number of potential limitations. First, the sample size was rather modest. Second, although previous reports indicate that active-play video games could enhance aerobic fitness in a range of clinical and nonclinical populations (7), our study did not address this issue directly, and there were no comparisons with control participants without mental illness. Finally, we did not compare the effectiveness of active-play video games and traditional AE equipment in increasing aerobic fitness. Future studies should aim to address these questions directly. However, on the basis of the program’s feasibility, acceptability, and adherence, overall our results provided preliminary support for integrating active-play video games into AE training programs to enhance aerobic fitness in people with schizophrenia.