Jan 29, 2015
Game Theory

In more and more athletic training rooms, video game systems are being used for active rehab and injury prevention. This author has found creative ways to make gaming both fun and functional.

By Dr. Kirk Brumels

Kirk Brumels, PhD, ATC, is Associate Professor of Kinesiology and Director of the Athletic Training Program at Hope College. He can be reached at: [email protected].

During a typical day in our athletic training program, some injured athletes snowboard down huge mountains as part of their rehab. Some compete in intense dance competitions. And others use their feet to stomp on moles as they emerge from their holes.

Sound ridiculous? It would be, if these activities occurred in actual reality instead of virtual reality. Here at Hope College, we use video gaming as an integral part of our athletic training and rehabilitation programs.

There are no video games on the general market today that specifically target rehabbing athletes. But with some creativity and willingness to experiment, many commercially available games can be adapted to add value to an athletic training program. The technology in today’s systems has brought gaming far beyond the days when it was only a workout for the thumbs–with some games out there today, playing is truly a total-body experience.

Of course, there’s more to it than buying the latest game console, setting it up with a TV in the corner, and telling your athletes to have at it. But with clear goals in mind, video gaming can be fun and functional at the same time.


The goals of typical injury prevention and rehab exercises are relatively simple. They need to improve flexibility, strength, endurance, and functional characteristics such as balance, agility, and coordination. Every athletic trainer knows a battery of exercises and movements that can do all of those things, but sometimes the very best exercises are, for a lack of a better word, boring.

Repetitive drills can be laborious for even the most dedicated athlete, despite our efforts at inspiration. When attention wanders, form and mechanics deteriorate and effort is less than we want. Thus, making an exercise fun and engaging is about more than helping the athletes have a good time. It’s an important way of promoting compliance, and getting athletes to view rehab as something they want to do instead of something they have to do.

Video games are designed for entertainment, and there’s no denying they’re very good at that. But when using them as a rehabilitation tool, the main goal isn’t for the user to have fun–though that’s a pleasant side effect. Video games in the rehab setting must be evaluated just like any new exercise or piece of equipment, with a few key questions in mind:

• Do they help meet our rehab objectives? • Do they provide a challenge for the injured athlete that he or she is physically capable of handling? • Do they present minimal risk for re-injury or injury aggravation? • Do they achieve a specific benefit, and do so more effectively than other available methods?

In my experience, a well-designed rehab protocol incorporating video games can answer “yes” to all those questions.

In particular, I have found video games can help bridge the gap between static and functional movements and specifically target weight acceptance, muscular control, balance, coordination, core stability, strength, endurance, and proprioception. In addition, video game-based rehabilitation offers great versatility, as it can be modified for both the athletic training room and the athlete’s home or dorm.

I recently conducted a study along with several of my athletic training students at Hope College to compare the effectiveness of video game-based rehabilitation exercises and traditional exercises. We looked specifically at lower-leg and ankle balance programs, and found that athletes who participated in the video game program not only showed a statistically significant improvement in ability relative to the non-video game users, but also reported that their training was “more enjoyable” and “less strenuous,” even though both groups performed the same amount of work.

This backs up our growing body of anecdotal evidence showing that–big surprise here–college students enjoy working with video games. Light-hearted competition for high scores develops among athletes who are prescribed similar activities during their rehab programs. And though they often don’t realize it, they push themselves harder and perform the exercises with greater precision as a result. Some even come in for extra rehab and injury prevention work, in order to defend their “record high score” against another rehabbing athlete.


We have been using video game-based rehabilitation exercises in our athletic training program for nearly five years. Our first foray into this method utilized the game Dance Dance Revolution (DDR) as a way to improve balance and agility in healthy athletes and those rehabbing from injury.

DDR was at the forefront of the “active gaming” movement, being one of the first games to require weight bearing physical activity instead of the typical handheld controller. The interface is a floor mat with a grid of pressure-sensitive pads activated by the user’s feet.

During play, visual commands are presented on a television screen accompanied by auditory cues. The player must respond to a scrolling series of arrows pointing left, right, up, or down by moving their feet and touching the corresponding arrow on the game mat at just the right time.

The tempo and difficulty of the patterns increase as the player progresses through the levels, ultimately leading to an experience that stimulates metabolism, creates general and specific body fatigue, and facilitates performance improvement. We’ve modified game play in many ways to achieve specific training results, sometimes mimicking the demands and benefits of well-known exercises and movements such as the Star Excursion Balance Test. See “DDR Breakdown” below for several examples.

The 2008 introduction of another gaming platform, the Nintendo Wii Fit bundle, greatly enhanced our options for video gaming in rehabilitation. Anyone who has used a Wii knows it’s different from any other gaming experience. The controller is handheld like with older game consoles, but it is highly sensitive to motion and acceleration in all directions. Depending on the game, it can be swung like a golf club or tennis racket, thrust like a boxing glove, or tilted and turned like a steering wheel.

The Wii Fit system comes with a balance board, which is critical to many of the exercises and features we use with our athletes. It’s essentially a force plate that responds to changes in body position and center of balance, providing constant feedback about the player’s performance.

When we purchased the Wii gaming system and the Wii Fit bundle, we immediately found several applications for them. Many Wii games provide auditory and visual stimulation and competitive situations that force the user to concentrate on changing body position and performing challenging movements.

And because these exercises require minimal supervision once learned, there are countless opportunities to fit them in. For instance, we encourage athletes who are waiting for ankle taping to participate in Wii-assisted balance improvement exercises for extra injury prevention at a time when they’d otherwise sit around and socialize.

Some Wii games can be used just as designed by the manufacturer. For instance, the yoga, strength, and balance activities in the Wii Fit and Wii Fit Plus game bundles provide ample challenge just by following the on-screen prompts and directions. However, we have also increased the difficulty by adding dumbbells, tubing, or other implements and rehabilitative tools. Some other games can be used simply to promote movement and diversion during traditional exercises, such ankle and knee stability work.


So what exactly do our video game-based exercises look like? One of our (and our athletes’) favorites is performing step-up, wall sit, or squatting exercises on a BOSU apparatus while playing a game like the Duck Hunt game from the Wii Play program (Duck Hunt is just what it sounds like–the player aims the controller like a gun at small ducks flying against a sky background on the screen).

To make this exercise more difficult, the athlete plays while performing wall sits or squats and squeezing a Pilates ring or weighted ball between their distal thighs.

That’s just one way we get the most out of a game. Here are some more examples of successful adaptions we’ve used.

• Shaun White Snowboarding and Wii Fit balance games both use the Wii’s balance platform, which we place on an upside-down BOSU. We sometimes have athletes play Snowboarding while in a plank position, with their hands instead of their feet on the balance platform.

• Both DDR and Mole Stomper from the Active Life Outdoor Challenge program are based on foot movement patterns (though we don’t only use them for foot work). They can be played with surgical tubing around the ankles to add resistance.

We’ve also had athletes play these games with their hands. The athlete places their feet are on a physioball or has them held and perturbed by a practitioner, which indeed is just as hard as it looks.

• Various Wii games, including boxing and tennis, can be played while the athlete performs pike exercises on a BOSU.

• In Wii boxing, which involves holding a game controller in each hand and “punching” an on-screen opponent with full arm extension, we have attached surgical tubing to an athlete’s hands or given them dumbbells to hold in addition to the controller.

• For various Wii games that require manipulating the handheld controller either through punching or swinging, we have the athlete play while performing different exercises on a physioball. This is a “freestyle” form of exercise that varies greatly based on the chosen game, our rehab or conditioning goal fort he athlete, and any injury limitations they may have. It can also include balance or strengthening work specific to the injury rehab program they have been given.

We’re very pleased with the new dimension video gaming has added to our bag of tools for our athletes’ rehabilitation and skill development. Besides getting athletes excited about coming to the athletic training room, which we all know can be quite a challenge at times, it has produced functional benefits for the many of them who have embraced using it. And as we continue experimenting with new games and new ways to adapt video gaming to our training and rehabilitation goals, it will only get better. Play on.


What equipment is necessary to add video game protocols to your athletic training room? Here’s the rundown:

Television. You definitely don’t need a fancy wall-mounted big-screen HDTV. We use an old TV set discarded by our school’s Information Technology office, and the only thing fancy about it is the exquisite faux wood veneer on the sides. If your set doesn’t have the correct audio/visual jacks to connect the game console, you can usually find an inexpensive adapter.

Our television is on the top shelf of a rolling cart for easy movement, storage, and visibility during both “high” (standing) and “low” (near the floor) exercises. For extra visibility, we’ve added a second, smaller set on the lower shelf of the cart. This way, an athletic trainer or other observer can follow the activity on the larger screen while the athlete in a low position looks at the smaller one.

Gaming System. We started out with the Nintendo Game Cube system, but we now use the Nintendo Wii. Our old Game Cube games (such as the Mario Mix version of Dance Dance Revolution) are still usable because they’re compatible with the Wii. In my opinion, the Wii is by far the most suitable gaming system for athletic training use.

Games. The possibilities are extensive and continually growing. The ones I most highly recommend for the Wii are Dance Dance Revolution, Wii Fit or Wii Fit Plus (this game is packaged with the pressure-sensitive balance platform), Wii Play, and Outdoor Life Challenge.

Memory Device. This is critical for storing data created by each user’s participation in various games. Many games have certain activities or levels that need to be “unlocked” via repetition or obtaining a high score. Once they are unlocked, you want the ability to save them for future use and play. In addition, a memory device makes it easier for athletes to repeat a previously used routine.

Accessories. Most of the implements we use to add an extra challenge to the games can be found in any athletic training room or rehab center. We’ve used surgical tubing, physioballs, dumbbells, cuff weights, step-up platforms, and unstable surfaces.


As we have grown more sophisticated using the Dance Dance Revolution (DDR) game, we’ve learned to improvise by adding implements and “activity distracters” to make the game more demanding. Here are some ways we’ve applied DDR to assist with specific aspects of rehab:


Weight Shifting • Stand on both feet in the middle of the control pad. Step onto direction arrows as directed by game, then return to the middle (normal game play).

• Same as above, but instead of returning to the middle, stay on each direction arrow until the next movement command.

Single-Leg Balance • Use a single-leg stance in the middle of the pad with the knee slightly bent. Respond to game commands with the opposite foot, without unloading the standing leg.

• Increase difficulty by utilizing an unstable surface for the standing leg, such as a foam roller, foam disc, wobble board, or balance disc.

• Same as above, but also engage the upper extremities with matrix patterns using dumbbells, tubing, or a BodyBlade, or with partner-assisted catching, throwing, or swinging activities.

• With a single-leg stance on an elevated platform at the center of the pad, use squat movements to touch the directional arrows with the non-standing heel as directed by the game. Mini-squats can be performed while waiting for the next directional prompt.


• Starting in a push-up position, respond to game commands by tapping the correct directional arrow with either arm. Use this progression to increase difficulty:

1. Begin with knees in “modified push-up” position 2. Progress to full push-up position 3. Elevate the legs onto a platform, table, or physioball

• While performing the above, do push-ups in between directional arrow commands and tap the arrows with one hand when prompted.

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