We already discussed and presented the development of computer and technologies related to the games in the last decades (see Chap. 1). Therefore, it is not surprising to observe an important increase of the number of studies and publications since 2010 (the Wii was released in 2007 and the Kinect sensor in 2010). Before the commercialization of those popular commercial devices, the creation of serious games required development of both hardware and software.

Thanks to the large availability, and affordable price, of the sensors developed by and for gaming purposes, researchers and developers can easily develop specific games and solution for physical rehabilitation.

Since 2010, approximately one third of the tested games are specially developed exergames (Fig. 4.1).

Figure 4.1 presents the use of commercial (black) and specific games (white). 212 studies were included in this review. The repartition is two third about commercial video games (140 studies) and one third for specific solutions (72 studies). From a theoretical point of view both systems have advantages and disadvantages that are summarized in Table 4.1.

Six main pathologies/conditions were discussed individually because there were enough studies in the literature in this field: aging, obesity and weight management, stroke, balance impairment, cerebral palsy (CP), and Parkinson’s disease (PD). The repartitions of the patients included in those studies are presented in Tables 4.2 and 4.3.

Although there is almost the same number of studies about aging, for stroke rehabilitation the number of patients included is much more important for aging. The second most studied population are obese and overweighed subjects. Those numbers are relatively coherent and reflect the prevalence of these conditions/pathologies (see Table 7.​1).

The repartition of the patients in the different studies between commercial and specific games is presented in Table 4.2, in Fig. 4.2 for commercial video games, in Fig. 4.3 for specific games, and for both approaches in Fig. 4.4.

Depending on the pathologies, and the severity of the disease, the duration of the rehabilitation varies a lot. Except for the management of obesity that required longer intervention for the other pathologies the mean duration is approximately 18 sessions which correspond more or less to the duration of the conventional rehabilitation treatment.

Of course, aging is not a pathology by itself but aging is associated with physiological decline of various systems and functions.

The two main problems related to the elderly are: a significant increase of risk of fall and a natural decline of cognitive functions.

Since the population of developed countries is getting older, a lot of efforts are done and must be done to improve autonomy and decreased risk of fall. A dramatic statistic illustrates the importance of avoiding falls: the most common fractures in case of fall are wrist and femoral neck. In case of femoral neck fracture, the mortality rate after 1, 6, 12, and 24 months are 5%, 16%, 21%, and 30%, respectively (Meessen et al. 2014). Hip fracture incidence per 1000 persons of above 70 years old is 8.4 in women and 3.7 in men (Meessen et al. 2014).

Therefore, decreasing risk of fall and cognitive decline of the elderly is a major health care problem.

In order to prevent risk of falls, different approaches are possible in physiotherapy and rehabilitation: to increase coordination between legs, to increase the proprioception (i.e., sense of relative position of joints in space), to maintain “normal,” or at least functional, range of motion of the most important joints (e.g., hip and knee).

Dual-task training is another popular approach in physiotherapy to decrease risk of falls. Dual-task training consists in performing simultaneously two tasks—often a motor task and a cognitive task: the best-known case is to ask the patient to walk while counting.

Occupational therapists have also an important role to modify the living environment in order to be as safe as possible (e.g., avoid carpet, sufficient lights).

The vision, in particular the visual field, must also be checked since a lot of elderly patients have a visual field loss (i.e., scotoma due to macular degeneration).

Obesity by itself is not a pathology but is a very important health-related problem that can lead to several pathologies such as hypertension, and hypercholesterolemia and therefore drastically increase the risk of stroke, myocardial infarction, diabetes, cancers, etc. Recent studies also demonstrated a link between obesity and Alzheimer’s disease probably due to the accumulation of fat tissues and the role of fat tissue on the hormonal system.

Overweight and obesity are defined as abnormal or excessive fat accumulation in the body that presents a risk to health. Simple indicator of obesity is the body mass index (BMI) that is equal to the weight (in kilograms) divided by the square of the height (in meters). A person with a BMI of 30 or more is considered obese. A person with a BMI equal to or more than 25 is considered overweight (WHO).

Obesity is a huge health care problem in the world; according to the WHO, it is estimated that 12% of the people (aged 20 and over) are obese and 35% are overweight¹. Obesity is not any more a problem related to high-income countries; the prevalence of obesity and overweight exploding in emerging countries (Table 7.​1) presents the prevalence of obesity in different region of the world.

In some particular cases (2–3%), obesity is caused by endocrinal troubles (hypothyroidism, adrenal gland disease), but in most cases, it is caused by an excess of energy intake and insufficient energy expenditure (exercises).

Management of obesity and overweight problem is complex and requires a multidisciplinary team: nutritionist and food specialists to modify food habits, psychologists to modify body image and perception of the body, physiotherapists to promote physical activities, and medical doctors to control the associated disorders.

The aim of rehabilitation is obvious with obese patients: patients need to move in order to burn calories, physical activity also stimulates these patients and improves proprioception, the perception of the body, and increases self-esteem.

The power and strength of the group should also be considered in physical rehabilitation. It is important for the patients to work together, share their difficulties, and visualize their progresses. Group session are organized under the supervision of a multidisciplinary team to help those patients. Group therapy is also commonly proposed for patients suffering from low back pain, fibromyalgia, multiple sclerosis, cancers, etc.

Obesity problem has been, partly, addressed by the industry of commercial video games since a lot of fitness games have been developed in order to make patients more active. Specific games have been created to develop fitness skills (e.g., Nintendo Wii Fit™) and thanks to the development of new way of controlling the games (mainly Nintendo Wii™ and Microsoft Xbox Kinect™) the energy expenditure have been increasing when playing video games (see Sect. 3.​1.​2.​2).

Summary of the different studies included are presented in Tables 4.6 and 4.7 for commercial video games and specific ones, respectively. 22 studies were found in the literature. Repartitions of devices and approaches are presented in Fig. 4.6.

It is interesting to note that 40% solutions are specific games. Actually in this case, it is more accurate to speak of teaching and monitoring programs (in most cases via the Internet) for controlling and modifying eating behavior rather than developing solutions to make the patients more active (e.g., Wagener et al. 2012; Christison and Khan 2012).

The first question to answer is whether or not the active video games induce an increase of energy expenditure and if yes what is the level of physical activity reached during this kind of training. Many studies have been conducted in this field.

The level of energy expenditure reached is estimated between 2.7 and 5.4 metabolic equivalents (i.e., moderate intensity level of physical activity) when children and teenagers play active games. A study compared the levels of energy expenditure in an obese population and in a control group, surprisingly the author found that obese children burnt fewer calories than the control group (O’Donovan et al. 2014).

We already mentioned that playing active video games correspond to the same energy expenditure level as the level reached during walking and are therefore not enough to fulfill WHO recommendation (60 min per day of moderate physical activity) (White et al. 2011). Another study compared the energy expended during a fitness game and a balance game. 100 people, including 55 overweight people, participated in this study. The same levels of physical activity were found when playing the fitness game (still below the WHO recommendations) that in previous studies but lower energy expenditure for balance games but the patients preferred to play balance games instead of fitness games (Lyons et al. 2012).

Although we saw that the levels of energy expenditure reached are relatively low, could these games still be successfully integrated into the management of obesity and overweight?

The first large study was conducted in 2012, 171 obese students were included. They were separated into two groups: 63 people were included in the group playing video games and the other 108 in a control group. After 9 weeks of training, the level of physical activity was higher in the intervention group and patients had lost between 1.5 and 2 kg after this intervention (Johnston et al. 2012). An important point of the rehabilitation, besides weight loss, is to change the behavior of patients and empower them in the self-management of their disease. The previous study also shows that patients are more active after the intervention, proof that they have realized the importance of performing physical activity in order to control their weights. This effect was also demonstrated in another study where games were introduced in physical education classes. The authors showed that 86 obese children who participated in this study were more active after this intervention (Quinn 2013).

Another interesting study was conducted to compare which kind of games, competitive games and cooperative games, was the most effective. 31 obese subjects participated in this study. After 6 months of training (5 sessions per week), the authors found that patients who were playing games in cooperative mode had a higher intrinsic motivation and the level of intrinsic motivation was directly correlated with the level of energy expenditure (Staiano et al. 2012a, b). The same authors conducted another study with a control group. Patients in cooperative games group lost significantly more weight than both patients in the control group and those playing competitive games. Surprisingly, patients in the competitive group games did not lose weight (Staiano et al. 2013)!

It is also interesting to note that games can be used to help patients to control weight during temporary situations such as sports injuries, pregnancy, or postpartum (LeBlanc et al. 2013).

A study has been conducted on 34 women during the postpartum period. Subjects were divided into an intervention group and a control group. After 40 days of games, the authors observed a significant decrease in weight but also of the circumferences of the waist and thighs and the percentage of fat only in the intervention group. The authors also observed a significant decrease in calorie intake. The games could therefore lead to both an increase in energy expenditure and a decrease of energy intake. There is, naturally, a positive correlation between the amount of hours spent on the games and the weight loss. The authors concluded by stating that playing has fortunately (!) no influence on how the mother took care of their babies. (Tripette et al. 2014).

Stroke occurs when part of the brain is suddenly deprived of blood supply. This deficit causes a loss of function of the affected area of the brain. The severity of the disability and the degree of recovery depend on the extent, the localization of the lesions, and the time. Time is the key factor in the management of stroke. It is estimated that brain cells cannot survive for more than 3 min being deprived of oxygen without causing irreversible damage. Stroke is the third leading cause of death in the world and the leading cause of disability and long-term serious complications. It is estimated that 33 million of new cases of stroke are occurring each year (Samai and Martin-Schild 2015). Among the new cases about 10% of the patients will recover completely, 25% with mild deficits, 40% with moderate to severe deficits, 10% of these patients must be placed in specialized centers because of the functional impact, and 15% die shortly after stroke.

There are two types of strokes: ischemic and hemorrhagic.

Ischemic strokes are the most common (about 80% of cases); they are due to blood clots migration from peripheral artery to a clotted artery in the brain which will therefore become clogged when the diameter is too narrow. Most frequently, these clots are due to atherosclerosis: the accumulation of body fat (mainly cholesterol) in the arterial walls. This slowly causes loss of elasticity of the artery walls, a decrease in the light of the arteries (stenosis), and therefore blood flow reduction. This reduction may be up to the complete obliteration of the vessel (thrombosis) resulting in the death of the tissue located downstream of the thrombosis. Finally, the clot may crack and be released into the bloodstream.

The risk factors for ischemic stroke are age (75% of strokes occur after age 65), gender (incidence was 1.25 times higher for men), hypertension (80% of strokes occur in patients with hypertension [blood pressure greater than 140/90 mmHg]), diabetes (increasing the risk of a factor of 3.5 in women and 2.1 in men), hyperlipidemia and high cholesterol (HDL), smoking, sleep apnea, alcohol and drug use, and physical inactivity (low levels of physical activity) (Samai and Martin-Schild 2015).

Despite the fact that the majority of these risk factors are modifiable, and that awareness campaigns provide information on these risk factors, a significant increase in the new case of stroke is still observed (Stroebele et al. 2011). This increase is approximately 15% over the last 10 years.

Hemorrhagic strokes are due to a rupture of a cerebral artery. The major risk factor for hemorrhagic stroke is high blood pressure (Biffi et al. 2015).

Primary care, management, and rehabilitation after stroke are best examples of teamwork in physical rehabilitation. The first goal of rehabilitation is the autonomy.

Autonomy is defined as the right and/or the ability of a person to lead his life according to his free judgment. The second objective is to coordinate all measures to prevent or minimize the related functional potential consequences of the disease from a physical, psychological, social and economic point of view. The aim is to exploit and maximize the residual capacity of the patient. This approach differs from curative medicine by its multidisciplinary nature: the medical doctor has the role of coordinator of functional rehabilitation team, centered around participatory patient. The multidisciplinary rehabilitation team may consist of nurses, physiotherapists, occupational therapists, psychologists, speech therapists, social workers, dieticians, and neuropsychologists (Heuschling et al. 2013) (see Sect. 2.​1.​1).

Damages in the central nervous system causes spasticity in the limbs. Spasticity is an exaggeration of the tendon reflex activity. In case of voluntary contraction and motion, the muscle-tendon reflex activity is over exaggerated, muscles are too contracted, and therefore no more motion is possible.

During the rehabilitation, it is important to differentiate the acute phase (less than 3 months after the accident) and the chronic state. Treatment and recovery possibilities are indeed different.

In the acute phase, it is essential to start the rehabilitation process as soon as possible to avoid adverse effect as much as possible that could affect the function and limit the disability. The first month after the stroke is a crucial period during which brain plasticity and thus recovery capabilities are maximized.

One of the main objectives of the stroke care unit is to minimize the impact of the induced spasticity from a functional point of view. Spasticity is also responsible for vicious postures because the muscles do not relax sufficiently. Reduction of the spasticity can be obtained with oral medication (e.g., Baclofen), by muscular injection of Botulinum toxin, with intrathecal Baclofen (directly into the spinal canal), with casting or orthoses and physiotherapy. These approaches can, and should, be combined.

Summary of the different studies included are presented in Tables 4.8 and 4.9 for commercial video games and specific ones, respectively. 53 studies were found in the literature. Repartitions of devices and approaches are presented in Fig. 4.7.

The most used systems are the Nintendo Wii and some specific solutions. Only three studies were performed using the PlayStation, including the first study in this area in 2008 (Yavuzer et al. 2008). Kinect was available only 5 years after the Nintendo Wii; therefore, there are fewer studies conducted with this device but there is a significant increase since 2013 and currently the recent studies are conducted with both devices equally.