The authors have declared that no competing interests exist.
Conceived and designed the experiments: MST AGL JPC RCC RM SJHB SL. Performed the experiments: MST AGL JPC AM DT RCC RM SJHB SL. Analyzed the data: MST AGL JPC AM DT RCC RM SJHB SL. Wrote the paper: MST AGL JPC AM DT RCC RM SJHB SL.
Active video games (AVGs) have gained interest as a way to increase physical activity in children and youth. The effect of AVGs on acute energy expenditure (EE) has previously been reported; however, the influence of AVGs on other health-related lifestyle indicators remains unclear.
This systematic review aimed to explain the relationship between AVGs and nine health and behavioural indicators in the pediatric population (aged 0–17 years).
Online databases (MEDLINE, EMBASE, psycINFO, SPORTDiscus and Cochrane Central Database) and personal libraries were searched and content experts were consulted for additional material.
Included articles were required to have a measure of AVG and at least one relevant health or behaviour indicator: EE (both habitual and acute), adherence and appeal (i.e., participation and enjoyment), opportunity cost (both time and financial considerations, and adverse events), adiposity, cardiometabolic health, energy intake, adaptation (effects of continued play), learning and rehabilitation, and video game evolution (i.e., sustainability of AVG technology).
51 unique studies, represented in 52 articles were included in the review. Data were available from 1992 participants, aged 3–17 years, from 8 countries, and published from 2006–2012. Overall, AVGs are associated with acute increases in EE, but effects on habitual physical activity are not clear. Further, AVGs show promise when used for learning and rehabilitation within special populations. Evidence related to other indicators was limited and inconclusive.
Controlled studies show that AVGs acutely increase light- to moderate-intensity physical activity; however, the findings about if or how AVG lead to increases in habitual physical activity or decreases in sedentary behaviour are less clear. Although AVGs may elicit some health benefits in special populations, there is not sufficient evidence to recommend AVGs as a means of increasing daily physical activity.
The majority of children and youth around the world do not meet current physical activity guidelines and are considered to be inactive
High levels of habitual sedentary time (especially via screen-based activities) are associated with a range of negative health and behavioural indicators including poorer measures of body composition, fitness, self-esteem, self-worth, pro-social behaviour, and/or academic achievement
An electronic or computerized game played seated by manipulating images on a video display or television screen, using a conventional gamepad controller (e.g. a conventional hand-held game). | |
A video game that requires physical activity beyond that of a passive game (i.e. conventional hand-held games). Active video games rely on technology that tracks body movement or reaction for the game to progress. | |
Any bodily movement produced by skeletal muscles that requires energy expenditure without the use of an electronic gaming system or display device. |
AVGs have the potential to increase habitual PA and improve measures of cardiometabolic health among children and youth who would otherwise be spending time in sedentary, screen-based activities. Manipulating the gaming environment as an intervention tool for increasing PA is reinforced by recent findings showing that playing AVGs acutely increases EE compared to sedentary video games
The GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework was used to guide our review including
To be included, studies needed to have a specific measure of time spent using AVGs using direct (e.g., accelerometer, pedometer or computer memory) or indirect (e.g., self- or parent-report) measurement, and a measure of at least one relevant health or behaviour indicator. Relevant health and behaviour indicators were chosen
Outcome | Priority |
Physical Activity and Energy Expenditure | Critical |
- Physical activity (light, moderate, vigorous intensity) | |
- Sedentary behaviour (EE ≤1.5 METs and a sitting or reclining posture) | |
- Activity compensation (i.e., is active video gaming replacing another activity, are children more/less likely to be physically active/sedentary as a result of playing active video games) | |
Adherence and appeal | Critical |
- Adherence to a program focused on an active video gaming vs. traditional physical activity | |
- Adherence and appeal of active video games vs. passive games | |
- Appeal (e.g., values and preferences for those who don't enjoy traditional physical activity) | |
Opportunity cost | Critical |
- Financial cost associated with traditional physical activity (e.g., equipment and registration of hockey, soccer etc.) vs. active video gaming (e.g., updating gaming console, games, accessories) | |
- Time spent on active video games instead of traditional physical activity (i.e., does one replace the other) | |
- Injury related to video game playing (e.g., injury due to over-exertion, accident, improper use) | |
Adiposity | Important |
- Body composition and measures of overweight or obesity (e.g., body mass index (BMI), waist circumference, skin-folds, bio-impedance analysis (BIA), dual-energy X-ray absorptiometry (DXA or DEXA)) | |
Cardiometabolic health indicators | Important |
- Measures of cardiometablolic health (e.g., plasma lipids, lipoprotein concentrations (e.g. LDL-cholesterol, triglycerides), hypertension, fasting glucose, insulin resistance, inflammatory markers (e.g., C-reactive protein)) | |
Energy intake | Important |
- Does EI increase/decrease when playing active video games | |
- Differences in EI between passive and active video gamers | |
Adaptation | Important |
- Learned behaviour (i.e., tricks/tactics that change overall EE) | |
- Controlled lab conditions vs. uncontrolled real life conditions (i.e., do EE, enjoyment, adherence differ?) | |
Learning and rehabilitation | Important |
- Rehabilitation (i.e., to help children with either chronic or acute conditions increase EE, movement acquisition or skills relevant to independence and tasks of daily living) | |
- Effectiveness to teach new (or develop) fundamental movement skills (i.e., are active video games effective and feasible) | |
Video game evolution | Important |
- Do outcomes differ between types of active video games (e.g., is EE, EI or adherence different between consoles or gaming systems) | |
- With respect to available technology (i.e. are active video games sustainable) |
All published, peer-reviewed studies were eligible for inclusion; no date limits were imposed, but due to feasibility, studies in languages other than English or French were excluded. Studies were excluded if the mean age of participants was greater than 17.99 years; if the study examined only passive video games; if there was more than one aspect to the intervention that may have confounded the results (e.g., an intervention that included both AVG and diet components); or if the outcome of interest was not included in our list of relevant health and behavioural indicators.
The following electronic bibliographic databases were searched: MEDLINE, EMBASE, psycINFO, SPORTDiscus and Cochrane Central Database. The search strategy was created and run by AGL (see
Titles and abstracts of potentially relevant articles were screened by two independent reviewers (AM, and one of JPC, RCC, AGL, or DT), and full text copies were obtained for articles meeting initial screening criteria. Full text articles were screened in duplicate for inclusion in the review (AM and one of JPC, RCC, AGL or DT); any discrepancies were discussed, and resolved by the reviewers. In addition to our search, seven key content experts were contacted and asked to identify what they deemed important papers in the field.
Data extraction was completed by one reviewer and checked by another for accuracy (one of JPC, AGL or AM). One reviewer (AGL) independently assessed the quality of evidence for all studies
First Author | Year | Country | Study Design | Population ( |
Age group | Intervention or exposure | Outcome and measure |
Adamo |
2010 | Canada | Randomized controlled trial | 26Boys = 26Girls = 12 | Age range = 12–17 yrsMean = 14.5 yrs | GameBike for Playstation (2, 60 min sessions/week, 10 weeks) | Energy expenditure (peak HR, average kcal expended, distance)Adiposity (BMI, % BF, waist circumference)Cardiometabolic health indicators (total cholesterol, HDL, LDL, total cholesterol/HDL ratio, fasting blood glucose, fasting insulin, TG) |
Bailey |
2011 | USA | Intervention | 39Boys = 19Girls = 20 | Age range = 9–13 yrsMean = 11.5 yrs | DDR, LightSpace, Wii, Cybex Trazer, Sportwall, Xavix (10–15 mins/day) | Energy expenditure [indirect calorimetry]Adherence and appeal (enjoyment [10-point Likert scale])Adiposity (BMI) |
Baranowski |
2012 | USA | Randomized controlled trial | 78Boys = 40Girls = 38 | Age range = 9–12 yrsMean = 11.3 yrs | Wii (7 weeks) | Energy expenditure (PA [accelerometry-min/day])Adherence and appeal (qualitative self-report) |
Berg |
2012 | USA | Case report | 1 | 12 yrs | Wii (4, 20 min sessions/week, 8 weeks) | Learning and rehabilitation (Bruininks-Oseretsky Test of Motor Proficiency) |
Bethea |
2012 | USA | Intervention | 28Boys = 18Girls = 10 | Age range = 9–11 yrsMean = 9.9 yrs | DDR (3 days/week, 30 weeks) | Energy expenditure (physical activity [VO2max])Cardiometabolic (fasting metabolic profile [total cholesterol, LDL, HDL, TG, and glucose-mg/dL])Adiposity (BMI) |
Chang |
2011 | China | Case study | 2Boys = 1Girls = 1 | Age range = 16–17 yrsMean = 16.5 yrs | Kinerehab (2 sessions/day, 34 days), Microsoft Kinect | Learning and rehabilitation (number of correct movements) |
Chin A Paw |
2008 | Netherlands | Randomized controlled study | 16Boys = 2Girls = 14 | Age range = 9–12 yrsMean = 10.6 yrs | Interactive dance simulation video game (12 weeks) | Adherence and appeal [focus group discussions]Adiposity (aerobic fitness [shuttle run], BMI, PA [questionnaire]). |
Deutsch |
2008 | USA | Case study | 1Boys = 1Girls = 0 | Age = 13 yrs | Wii (11, 60–90 min sessions, 4 weeks) | Learning and rehabilitation (visual-perceptual processing [Test of Visual Perceptual Skills], postural control [weight distribution and sway measures], functional mobility [gait distance]). |
Dixon |
2010 | New Zealand | Cross sectional | 37Boys = 22Girls = 15 | Age range = 10–14 yrs | EyeToy, DDR (20–30 min/game) | Adherence and appeal (preference [focus group interviews]) |
Duncan |
2011 | England | Randomized controlled trial | 40Boys = 20Girls = 20 | Age range = 10–11 yrsMean = 10.8 yrs | Gamercize (2 sessions/week, 6 weeks) | Energy expenditure (PA, HR [pedometry-steps/min], [% MVPA]) |
Duncan |
2010 | England | Randomized controlled trial | 30Boys = 12Girls = 18 | Age range = 10–12 yrsMean = 10.4 yrs | Wii (2 sessions/week, 6 weeks) | Energy expenditure (PA, HR [pedometry-steps/min], [% MVPA]) |
Epstein |
2007 | USA | Randomized controlled trial | 35Boys = 18Girls = 17 | Age range = 8–12 yrsMean = 10.8 yrs | DDR (2 min/6 games, 2 sessions) | Adherence and appeal (7-point Likert scale) |
Errickson |
2012 | USA | Randomized controlled trial | 60Boys = 27Girls = 33 | Age range = 8–12 yrsMean = 7.5 yrs | DDR (120 min/week, 10 weeks) | Energy expenditure (accelerometry, DDR logs, and Playstation2 memory cards) |
Fawkner |
2010 | Scotland | Cross sectional | 19Boys = 0Girls = 19 | Age range = 13–15 yrsMean = 14.0 yrs | Zigzag Xer-Dance (30 mins, 4 sessions, 6 weeks) | Energy expenditure (REE, EE, HR) |
Fogel |
2010 | USA | Cross sectional | 4Boys = 2Girls = 2 | Age range = 9–11 yrsMean = 9 yrs | DDR, Gamercize, Three Rivers Game Cycle, Dog Fighter, Cateye, Wii, iTech Fitness XrBoard, Fit Interactive 3 Kick (30 min/game) | Energy expenditure (PA)Adherence and appeal (preference rating) |
Gao |
2011 | USA | Cross sectional | 280Boys = 156Girls = 124 | Age range = 12–15 yrsMean = 13.59 yrs | DDR (1 min bouts, 9 sessions) | Energy expenditure (PA [accelerometry]-MVPA)Adherence and appeal (7-point Likert scale) |
Getchell |
2012 | USA | Case-control | 30Boys = 18Girls = 12 | Age range = 15–20 yrsMean = 17.5 yrs w Autism, 17.23 yrs without | Wii, DDR (20 min bouts, 2 weeks) | Learning and rehabilitation (MVPA, EE [accelerometry]) |
Graf |
2009 | USA | Cross sectional | 23Boys = 14Girls = 9 | Age range = 10–13 yrsMean = 11.9 yrs | DDR, Wii (2, 30 min sessions, 4 weeks) | Energy expenditure (EE [indirect calorimetry-kJ/min], step rate [accelerometry-steps/min], RPE, HR [Borg Scale] |
Graves |
2010 | England | Randomized controlled trial | 42Boys = 28Girls = 14 | Age range = 8–10 yrsMean = 9.2 yrs | jOG (12 weeks) | Energy expenditure [accelerometry-counts/min]Adherence and appeal [behavior preference survey] |
Graves |
2010 | England | Cross sectional | 14Boys = 10Girls = 4 | Age range = 11–17 yrsMean = 15.8 yrs | Wii (1, 70 min session) | Energy expenditure (REE, RHR, VO2, EE, and HR)Adherence and appeal (modified Physical Activity Enjoyment Scale) |
Graves |
2008 | England | Cross sectional | 13Boys = 7Girls = 6 | Age range = 11–17 yrsMean = 15.1 yrs | Wii (1, 60 min session) | Energy expenditure (PA [accelerometry-J/kg/min]) |
Graves |
2008 | England | Cross sectional | 11Boys = 6Girls = 5 | Age range = 13–15 yrsMean = 14.6 yrs | Wii (1, 45 min session) | Energy expenditure [indirect calorimetry-kJ/kg/min] |
Jannink |
2008 | Netherlands | Randomized controlled trial | 10Boys = 9Girls = 1 | Age range = 7–16 yrsMean = 11.75 yrs | EyeToy (6 weeks) | Learning and rehabilitation (user satisfaction [post exercise questionnaire], functional outcome [Melbourne Assessment scores]) |
Jones |
2009 | USA | Cross sectional | 21Boys = 8Girls = 13 | Age range = birth – 30+ (separated by groups ie: birth-5, 6–10, 11–15 yrs)Mean = 16 yrs | Wii | Opportunity cost (injury [self-reported]) |
Lam |
2011 | China | Cross sectional | 79Boys = 40Girls = 39 | Age range = 9–12 yrsMean = 10.85 yrs | XaviX (2, 60 min sessions) | Energy expenditure (PA [accelerometry], HR) |
Lanningham-Foster |
2009 | USA | Cross sectional | 22Boys = 11Girls = 11 | Age range = 10–14 yrsMean = 12.1 yrs | Wii (1, 10 min session) | Energy expenditure [indirect calorimetry-kcal/hr/kg] |
Lanningham-Foster |
2006 | USA | Cross sectional | 25Boys = 12Girls = 13 | Age range = 8–12 yrsMean = 9.7 yrs | EyeToy, DDR (2, 15 min sessions) | Energy expenditure [indirect calorimetry-kJ/hr/kg] |
Maddison |
2012 | USA | Randomized controlled trial | 322Boys = 160Girls = 162 | Age range = 10–14 yrsMean = 11.6 yrs | EyeToy (3 months) | Energy expenditure (MVPA [accelerometry], VO2max)Adiposity (BMI-kg/m2)Energy intake (snack frequency) |
Maddison |
2007 | New Zealand | Cross sectional | 21Boys = 11Girls = 10 | Age range = 10–14 yrsMean = 12.4 yrs | EyeToy (1, 25–40 min session) | Energy expenditure (HR [indirect calorimetry] |
Maddison |
2011 | New Zealand | Randomized controlled trial | 322Boys = 160Girls = 162 | Age range = 10–14 yrs | EyeToy (1, 25–40 min session, 3 months) | Energy expenditure (MVPA, VO2max [20-m shuttle run, accelerometry])Adiposity (BMI, % body fat)Energy Intake [self-reported food snacking] |
Madsen |
2007 | USA | Randomized controlled trial | 30Boys = 12Girls = 18 | Age range = 9–18 yrsMean = 13.0 yrs | DDR (6 months) | Adiposity (BMI)Adherence and appeal |
Maloney |
2008 | USA | Randomized controlled trial | 60Boys = 30Girls = 30 | Age range = 7–8 yrsMean = 7.5 yrs | DDR (4 sessions, 28 weeks) | Energy expenditure (MVPA [accelerometry-min/day])Adiposity (BMI)Adherence and appeal [satisfaction survey] |
Maloney |
2012 | USA | Randomized controlled trial | 65Boys = 31Girls = 34 | Age range = 9–17 yrsMean = 12.32 yrs | DDR (12 weeks) | Energy expenditure (PA [self-reported-frequency, pedometry-steps/day, accelerometry-min/day]) |
Mellecker |
2010 | China | Intervention | 27Boys = 10Girls = 17 | Age range = 9–13 yrsMean = 11.0 yrs | X-BOX 360 on an adapted treadmill (4, 60 min sessions) | Energy intake [kcal intake] |
Mellecker |
2008 | China | Cross sectional | 18Boys = 11Girls = 7 | Age range = 6–12 yrsMean = 9.6 yrs | XaviX (10 min session) | Energy expenditure (REE, EE [indirect calorimetry- kcal/min], HR [beats/min]) |
Mitre |
2011 | USA | Cross sectional | 19Boys = 11Girls = 8 | Age range = 8–12 yrsMean = 10 yrs | Wii (10 min bouts) | Energy expenditure [indirect calorimeter]Adiposity (BMI) |
Murphy |
2009 | USA | Randomized controlled trial | 35Boys = 18Girls = 17 | Age range = 7–12 yrsMean = 10.21 yrs | DDR (12 weeks) | Energy expenditure (HR, VO2peak [cycle ergometer])Cardiometabolic health indicators (HDL, LDL, TG, insulin, glucose)Adiposity (BMI) |
Ni Mhurchu |
2008 | New Zealand | Randomized controlled trial | 20Boys = 12Girls = 8 | Age range = 10.5–13.5 yrsMean = 12 yrs | EyeToy (12 weeks) | Energy expenditure [accelerometry, Physical Activity Questionnaire for Children, activity log]Adiposity (BMI, waist circumference) |
Owens |
2011 | USA | Intervention | 12Boys = 6Girls = 6 | Age range = 8–13 yrsMean = 10 yrs | Wii (12 weeks) | Energy expenditure (MVPA [accelerometry] muscular fitness [push-ups], aerobic fitness [VO2] and flexibility [trunk flexion])Adiposity (BMI, %BF) |
Paez |
2009 | USA | Randomized controlled trial | 60Boys = 31Girls = 29 | Age range = 7–8 yrsMean = 7.5 yrs | DDR (4, 120 min sessions/week, 10 weeks) | Energy expenditure (PA [accelerometry], BMI)Adherence and appeal [PA logs] |
Penko |
2010 | USA | Cross sectional | 24Boys = 12Girls = 12 | Age range = 8–12 yrsMean = 10.4 yrs | Wii (10 min bouts +) | Energy expenditure (HR [telemetry monitor], VO2 [indirect calorimetry])Adherence and appeal (Relative Reinforcing Value [RPE scale, likeability scale]) |
Perron |
2011 | USA | Cross sectional | 30Boys = 19Girls = 11 | Age range = 7–12 yrsMean = 9.4 yrs | Wii, EA SPORTS Active (1, 20–25 min session) | Energy expenditure (RPE [OMNI scale], HR, PA [accelerometry]) |
Roemmich |
2012 | USA | Cross sectional | 44Boys = 22Girls = 22 | Age range = 8–12 yrsMean = 10.15 yrs | Wii (1, 60 min session) | Energy Expenditure (PA/MVPA [accelerometry], HR)Adherence and appeal (likert scale likeability ratings, choice of video game) |
Rubin |
2010 | USA | Case report | 4Boys = 3Girls = 1 | Age range = 3–9 yrsMean = 6.75 | Wii | Opportunity cost (injury [self-reported pain]) |
Shih |
2011 | China | Intervention | 2Boys = 1Girls = 1 | Age range = 17–18 yrsMean = 17.5 yrs | Wii (4–6, 3 min sessions/day, 51–63 sessions) | Learning and rehabilitation (number of correct responses) |
Shih |
2011 | China | Intervention | 4Boys = 3Girls = 1 | Age range = 14–17 yrsMean = 15.25 yrs | Wii (4–6, 3 min sessions/day, 60–63 sessions) | Learning and rehabilitation (number of correct responses) |
Sit |
2010 | China | Cross sectional | 70Boys = 35Girls = 35 | Age range = 9–12 yrsMean = 10.87 yrs | XAviX , Aerostep (2, 60 min sessions) | Energy expenditure (HR, minute ventilation, VO2)Adherence and appeal (time spent on chosen game) |
Smallwood |
2012 | England | Cross sectional | 18Boys = 10Girls = 8 | Age range = 11–15 yrsMean = 13.4 yrs | Kinect | Energy expenditure (HR, VO2, EE (kcal/min)) |
Straker |
2007 | Australia | Cross sectional | 20Boys = 12Girls = 8 | Age range = 9–12 yrs | EyeToy | Energy expenditure (HR, EE (kcal/min/kg) [indirect calorimetry], minute ventilation (L/min), O2 uptake (ml/min/kg)) |
White |
2010 | New Zealand | Cross sectional | 26Boys = 26Girls = 0 | Age range = 10–13 yrsMean = 11.4 yrs | Wii (2 sessions) | Energy expenditure (RMR, EE, V02 peak) |
Widman |
2006 | USA | Intervention | 8Boys = 4Girls = 4 | Age range = 15–19 yrsMean = 16.48 yrs | GameCycle (16 weeks) | Learning and rehabilitation (peak V02 [arm ergometer] peak HR, max work output, aerobic endurance, RPE [Borg scale], user satisfaction [survey]) |
Wuang |
2010 | China | Randomized control trial | 115 | Age range = 7–12 yrs | Wii (2, 60 min sessions/week, 24 weeks) | Learning and rehabilitation ([Bruininks–Oseretsky Test of Motor Proficiency, The Developmental Test of Visual Motor Integration, The Test of Sensory Integration Function]) |
Maddison and Maddison used participant data from the same study but presented in two manuscripts.
AVG, active video games; BMI, body mass index; EE, energy expenditure, DDR, Dance Dance Revolution; HR, heart rate, HDL, high-density lipoprotein; LDL, low-density lipoprotein; MVPA, moderate- to vigorous-intensity physical activity; PA, physical activity, REE, resting energy expenditure; RMR, resting metabolic rate; RPE, rating of perceived exertion; TG, triglycerides.
Quality assessment | No of participants | Absolute effect (confidence interval, standard error) | Quality | Importance | ||||||
No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | ||||
11 | RCT | No serious risk of bias | Serious inconsistency |
No serious indirectness | No serious imprecision | None | 725 |
146.40±37.86 min/day, 16.37±12.26 min/day |
⊕⊕⊕Ο MODERATE | CRITICAL |
MD = 2.97±4.99, p = 0.013 |
||||||||||
MD = −18.98, p = 0.003 |
||||||||||
29.5±4.5 ml/kg/min, p<0.01 |
||||||||||
6 | Observational study |
No serious risk of bias | No serious inconsistency |
No serious indirectness | No serious imprecision | None | 296 | F 1, 28 = 15.6, p = 0.0001 |
⊕⊕ΟΟ LOW | CRITICAL |
F(2, 558) = 352.45, p<0.01 |
||||||||||
2 | RCT | No serious risk of bias |
No serious inconsistency |
No serious indirectness | No serious imprecision | None | 50 | 11.7±3.1 ml/kg/min |
⊕⊕⊕Ο MODERATE | CRITICAL |
18 | Observational |
No serious risk of bias |
No serious inconsistency | No serious indirectness | No serious imprecision | None | 493 | 16.7–28.1 kJ/min |
⊕⊕ΟΟ LOW | CRITICAL |
190.6±22.2; 202.5±31.5; 198.1±33.9 |
||||||||||
182.1±41.3; 200.5±54.0; 267.2±115.8 |
||||||||||
190.8±34.6; 236.8±36.4; 188.2±31.0; 348.1±44.7; | ||||||||||
384.9±81.1; 697.7±89.9 |
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141±20 bpm |
||||||||||
108±40%, 172±68 |
||||||||||
5.14±1.71(329%) |
||||||||||
6.5±1.7, 5.9±1.8, 4.9±1.3, 2.9±0.3, 3.6±1.1 |
||||||||||
0.01 kcal/kg/min (39%), 0.03 kcal/kg/min (98%), | ||||||||||
0.12 kcal/kg/min (451%) |
||||||||||
0.63±0.011, p<0.001 kcal/kg/min |
||||||||||
3.05±0.93 |
||||||||||
144.0±8.0 bpm, 136.5±9.6 bpm |
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118bpm, 131bpm |
||||||||||
F(1, 10) = 4.37, p<0.03; F(1, 40) = 20.73, p<0.001 |
||||||||||
38.9% MVPA, 0.13 kcal.kg/min; 52.9%MVPA, | ||||||||||
0.18 kcal/kg/min |
||||||||||
0.125 kcal/kg/min, p<0.001 |
||||||||||
63–190%, p≤0.001; 56–184%, p≤0.001 |
No significant difference in objectively measured time spent engaging in PA between children who were given inactive video games and those that were given active video games
No significant different in total physical activity 12 weeks post intervention between active gaming and sedentary gaming group
Intervention had no effect on time spent engaging in MVPA (measured by accelerometer) or level of physical fitness (measured through VO2max test)
Twelve week DDR intervention had no effect on fitness test results post-intervention (step test), physical activity (light, moderate, or vigorous intensity measured by accelerometer) or step counts (measured by pedometer)
No significant difference in overall physical activity or MVPA between intervention and control groups at the end of a 12 week active video game intervention
To meet eligibility criteria, participants had to be overweight or obese as per International Obesity Task Force criteria.\
Time spent in moderate and vigorous intensity PA respectively, compared to 112.1±36.7 min/day of moderate intensity activity and 12.7 min/day of vigorous intensity activity for control group. No significance given
Represents the main effect of heart rate to explain percentage of time spent in MVPA was significantly lower in the intervention group, compared to the control group, across the intervention period
Children in the active gaming intervention group had significantly fewer steps per day that those in the control group after 6 weeks
Increase in vigorous physical activity in DDR intervention group at week 10
Peak VO2 in the exercise group following a 12 week DDR intervention was significantly higher than the control group (24.3±4.8 ml/kg/min)
Includes 5 intervention
Three month at home Wii Fit intervention had no effect on measures of peak VO2, balance, flexibility, muscular strength, or time spend engaging in PA
Mean difference in VO2max (ml/kg/min) at 30-wks compared to baseline
Mean minutes of physical activity per session (compared to 1.6 min in physical education class)
Students spend more time in MVPA in fitness class (40.46%) and football (37.09%) class than playing DDR (7.91%)
Participants included obese individuals or overweight individuals with at least one co-morbidity (i.e. BMI>95th% or BMI>85th% + elevated glucose, triglycerides, LDL cholesterol or decreased HDL cholesterol)
No significant difference in average time spent pedaling (min/session), EE (kcal/session), time spent in moderate intensity PA (60–79% peak HR), or average distance pedaled (km) between GameBike intervention group and music only control group. Music only control group spent significantly more time in vigorous intensity PA (80–100% peak HR), (24.9±20.0) than the Game bike intervention group (13.7±12.8), p = 0.05
VO2 during Wii Boxing was significantly higher than at rest, while playing sedentary video games and during treadmill walking (at 1.5 mph) (P<0.05). Data was also presented for mean heart rate and RPE but not presented here
Includes 7 intervention studies
Participants were chosen from their physical education class because they were inactive, overweight, had low fitness scores, and good behaviour and attendance
EE for active video games (Wii boxing, DDR thirteen, Cybex Trazer Goalie Wars, LightSpace Bug Invasion, Sportwall, Xavix J-mat) compared to 4.6 kJ/min at rest
EE (kcal/min) compared to rest (1.18±0.5 kcal/min)
Increase in EE (kcal/hr/kg) of DDR and Will boxing (in boys and girls respectively) above rest compared to 3.0 times increase in EE associated with walking at 5.7 km/hr
EE (kj/kg/min) for Wii bowling, Wii tennis and Wii boxing respectively compared to 125.5±13.7 for sedentary video games (XBOX360). For all games, EE was less than traditional version Graves
EE (kj/kg/min) for Wii bowling, Wii tennis and Wii boxing respectively compared to 115.8±18.3 for sedentary video games (XBOX360). Boxing was associated with greater EE than the other games (p<0.05). Data also presented (but not reported here) for VO2 (l/min) and HR (bpm)
EE (kj/kg/min) for Wii yoga, Wii conditioning, Wii balance, Wii aerobics, treadmill walking and treadmill running respectively compared to 111.7±22.7 at rest and 113.526.3 for handheld gaming.
Data also presented (but not reported here) for VO2 (l/min) and HR (bpm)
Cardiovascular effort per hour of play (in beats per minute) compared to 104±17 bpm when playing a seating internet game (p<0.01). Results were not significant for girls or for bowling type games
Percent increase in EE above rest compared to 138±40% for treadmill walking at 1.5mph and 22±12% for sedentary video games
Increase in EE (kcal/hr/kg) above rest when playing Nintendo Wii Sports compared to playing sedentary video games (1.67±0.37(40%)), p<0.0001
EE (kcal/min) playing ‘knockout’, ‘homerun’, ‘dance UK’, ‘Groove’ and AntiGrav respectively compared to 1.6±0.2 kcal/min playing a sedentary games and 1.3±0.2 at rest. VO2, HR, METs and activity monitor counts also measured but not reported here
Increased in EE (kcal/kg/min and percent increase) above rest for seated bowling, XaviX bowling, and XaviX J-Mat respectively
EE while using a walking media station was significantly higher than rest and while playing a seated video game. Study reports similar results for V02 and heart rate but not reported here
Increase in EE (kcal/kg/min) above rest. This was higher in lean (3.50±0.71 kcal/kg/hr) than overweight/obese participants (2.42±0.85 kcal/kg/min)
Mean heart rate during activities using EA SPORTS Active and Wii Fit respectively were significantly higher than baseline measures of 107.1±18.6 bpm (with EA SPORTS Active) and 109.2±16.9 bpm (with Wii Fit)
Mean heart rate during Dance Central and Kinect Sports Boxing respectively. Heart rates were 53% and 70% higher than rest, respectively (p<0.001) and 34% and 48% higher than during sedentary video game play respectively (p<0.001)
Rate of EE while playing each of the traditional games was greater than the corresponding exergame; significant main effect as average intensity was 107% greater when children had access to traditional indoor games (basketball, boxing, golf, hockey) versus same version of exergame (Wii)
Percent of time children engaged in MVPA during 57.7min XaviX bowling session and 55.3 min Aerostep running session
EE while playing with EyeToy interactive video game was significantly higher than when using a handheld game, a gamepad, a keyboard or a wheel. Heart rate, minute ventilation, and oxygen uptake were also significantly higher (results presented in manuscript but not here)
Percent increase in EE when participating in Wii bowling, boxing, tennis, Wii fit, skiing and step compared to rest and to sedentary video games respectively. Treadmill running (8.7±1.2 km/hr) was associated with a significantly greater increase in EE from rest than all active video games (442%). Results were also given for VO2peak, METs and HR but not presented here
Quality assessment | No of participants | Absolute effect (confidence interval, standard error) | Quality | Importance | ||||||
No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | ||||
8 | RCT | No serious risk of bias | No serious inconsistency |
No serious indirectness | No serious imprecision | None | 208 | MD = 9.95, p = 0.01, MD = 9.96, p = 0.01 |
⊕⊕⊕⊕ HIGH | CRITICAL |
MD = −14.02, p = 0.05, MD = −18.98, p = 0.003 |
||||||||||
0.14 hr/d; 0.25 hr/d; 0.37 hr/d; 0.25 hr/d |
||||||||||
week 1 = 147±145 mpw, week 10 = 60±61 mpw |
||||||||||
MD = −52 min/day CI:−101, −2, p = 0.04 |
||||||||||
4 | Observational study |
No serious risk of bias | No serious inconsistency |
No serious indirectness | No serious imprecision | None | 158 |
45% |
⊕⊕ΟΟ LOW | CRITICAL |
2 | RCT | No serious risk of bias | No serious inconsistency |
No serious indirectness | No serious imprecision | None | 138 | ⊕⊕⊕Ο MODERATE | CRITICAL | |
7 | Observational study |
No serious risk of bias |
No serious inconsistency | No serious indirectness | No serious imprecision | None | 440 | F(5, 30) = 19.68, p<0.001 |
⊕⊕ΟΟ LOW | CRITICAL |
78.6±15.0; 78.8±16.9; 84.3±15.1; 90.4±9.8; 65.5±17.1; 59.8±24.8 |
||||||||||
F(1, 40) = 17.8, p<0.001; F(1, 40) = 10.81, p<0.002); F(1, 40) = 43.57, 8.5±1.8 cm |
||||||||||
p<0.001 |
Playing time for both an interactive dance video game decreased in both the home and multiplayer groups over the 12 week intervention but the change didn't reach significance; qualitative reports suggest that kids had technical problems with the game and found that it became boring
Children in the intervention and control group both decreased their time spent playing sedentary games, but the children in the control group decreased this time more, but did not reach significance (29.39 min; 95% CI: 219.38, 0.59 min; P = 0.06)
Size of TV, absence or other (sedentary) video games, and participation by others (parents, siblings, friends) were not significant predictors for time spent playing DDR or engaging in PA after 10-week intervention
For the first week of the intervention, children in the active gaming group had more steps than children in the control group (52.9 steps/min compared to 46.5 steps/min). At the midpoint and end of study children in the intervention group had significantly fewer steps per day than during the first week)
For the first week of the intervention, children in the active gaming group had more steps than children in the control group (52.9 steps/min compared to 46.5 steps/min). At the midpoint and end of study children in the intervention group had significantly fewer steps per day than during the first week)
Adjusted change score between intervention and control groups showing a decrease in sedentary video games and an increase in active video games at 6 and 12 weeks; decrease in sedentary video game playing at 6 weeks (score increased at 12 weeks showing a detrimental effect of the intervention, data not reported); decrease in TV viewing at 12 weeks; increase in total video game playing at 6 and 12 weeks
Mean use (minutes per week) of DDR at week 1 (peak usage) and week 10. Usage never reached ‘prescribed’ level of 120 minutes per week
Mean difference in average time spent playing active games (compared to inactive games) between intervention and control groups. Children in the intervention group also tended to spend less total time playing video games, but this did not reach significance (MD = −44 min/day, CI: −92, 2,
Includes 2 intervention studies
Only qualitative data available and not included in this table
On average, no significant difference in time spent playing interactive versus online bowling or running game; however, non-overweight children spent more time on both interactive bowling (p>0.05) and running (p>0.01) than overweight participants
Number of participants at 30 weeks reported here. Number of participants at baseline = 28 and at 12 weeks = 25
Percentage of children who had ‘lost interest’ in DDR by 3 months
Children reported that they like AVG because they “didn't have to go outside” and “doing activities that you wouldn't normally be able to do”. Things they didn't like were related to specific games such as “computer competitor would scream things”, “I couldn't understand a character”, “didn't have anyone to play with” or “didn't like difficulty level”. No specific data reported
Includes 6 intervention studies
Specific data not presented in paper. Boys enjoyed Wii boxing, Xavix J-mat more than girls (p≤0.05). Those with higher BMI enjoyed Sportwall more than those with a lower BMI (p≤0.05)
Data not reported, but the students preferred Wii bowling, boxing and DDR. The teacher reported that the exergaming was beneficial to the students, that it resulted in more student engagement, and they listened to instructions
Participants were chosen from their physical education class because they were inactive, overweight, had low fitness scores, and good behaviour and attendance
Children liked DDR or DDR+video controller more than dance+music or dance+video conditions
Students reported higher intrinsic motivation and identified regulation towards fitness class than DDR
Scores on the Physical Activity Enjoyment Scale (PACES) for Wii conditioning, Wii balance, Wii aerobics, treadmill walking and treadmill running respectively compared to 60.8±18.8 for handheld gaming. Scores were significantly higher for Wii balance, Will conditioning, and Will aerobics (p≤0.003) and Wii Fit (p = 0.029) compared to handheld games. Treadmill walking was significantly different from Wii balance, Wii aerobics (p≤0.05). Treadmill running was significantly different from Wii balance, Wii aerobics (p≤0.035)
Rating of ‘liking’ on a visual analog scale. Participants rated Wii Boxing significantly higher than sedentary video games or treadmill walking (p<0.05)
Children liked traditional mini indoor basketball more than the exergame version. Liked the exergame version of golf more than indoor
mini golf. Children spent an average of 87% more time in free play given access to exergames than indoor traditional games
Quality assessment | No of participants | Absolute effect (confidence interval, standard error) | Quality | Importance | ||||||
No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | ||||
3 | Observational study |
Serious risk of bias |
No serious inconsistency |
No serious indirectness | No serious imprecision |
None | 25 |
7, 6, 4, 19, 1, 1 |
⊕ΟΟΟ VERY LOW | CRITICAL |
Includes 1 intervention study
All 4 participants were regular clients in the author's chiropractic clinic; they were all given a brief examination when they presented new symptoms and treated accordingly
Of 8 serious adverse events reported during the three month study, none were deemed related to the study intervention (EyeToy)
Participants were briefly examined when they presented with new symptoms, possible that new symptoms were not directly related to Wii, no quantitative data presented
Represents cases (i.e. number) of injury associated with active video games as reported in the National Electronic Injury Surveillance System (representing emergency room visits from across the U.S.). Of 21 cases, 13 were in those were from birth to 15 years and 8 in those aged 16–30+ years
Represents number of injuries from being hit or hitting another object during the game (33%); strains or sprains (29%); contusions or abrasions (19%); lacerations (19%); factures (5%); and concussions (5%) respectively
Quality assessment | No of participants | Absolute effect (confidence interval, standard error) | Quality | Importance | ||||||
No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | ||||
7 | RCT |
No serious risk of bias | No serious inconsistency |
No serious indirectness | No serious imprecision | None | 508 |
42.111.7 %BF, 43.5±7.8 %BF |
⊕⊕⊕⊕ HIGH | IMPORTANT |
3 | Observational study |
No serious risk of bias | No serious inconsistency |
No serious indirectness | No serious imprecision | None | 53 |
⊕⊕ΟΟ LOW | IMPORTANT |
Randomized trials
Maddison
There was no significant difference between change in BMI in intervention and control group after a 10-week DDR intervention
Participants included obese individuals or overweight individuals with at least one co-morbidity (i.e. BMI>95th% or BMI>85th% + elevated glucose, triglycerides, LDL cholesterol or decreased HDL cholesterol)
Post-intervention % body fat in music and GameBike group, respectively. GameBike group had a larger decrease in body fat (%) than group that exercised to music alone (pre-intervention body fat % = 45.2±9.6 and 43.7±11.8, respectively)
At 24 weeks, active gaming intervention group had significant decreases in BMI and zBMI (−0.06 CI: −0.12, 0.00; P = 0.04)
Difference in BMI and %body fat respectively between intervention and control group when controlled for aerobic fitness level
Weight gain in intervention and control groups after 12 week DDR physical activity intervention
Mean difference in waist circumference from baseline to end of 12 week active gaming intervention between intervention and control groups
Includes 3 intervention studies
No significant effect of 30-wk DDR intervention on BMI
When adjusted for baseline BMI z-score, DDR ise was not associated with change in BMI from baseline at either 3 or 6 months
Three month at home Wii Fit intervention had no effect on measures of body fat % or BMI
Number of participants at 30 weeks included here (number of participants at baseline = 28 and at 12 weeks = 25)
Quality assessment | No of participants | Absolute effect (confidence interval, standard error) | Quality | Importance | ||||||
No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | ||||
2 | RCT | No serious risk of bias | Serious inconsistency | No serious indirectness | No serious imprecision | None | 61 |
3.8±0.6 mmol/L, 4.1±0.9 mmol/L |
⊕⊕⊕Ο MODERATE | IMPORTANT |
1 | Observational study |
No serious risk of bias | No serious inconsistency |
No serious indirectness | No serious imprecision | None | 23 |
⊕⊕ΟΟ LOW | IMPORTANT |
Randomized trials
Participants included obese individuals or overweight individuals with at least one co-morbidity (i.e. BMI>95th% or BMI>85th% + elevated glucose, triglycerides, LDL cholesterol or decreased HDL cholesterol)
Post-intervention total cholesterol (mmol/L) in music and GameBike group, respectively. GameBike group had a larger decrease in total cholesterol than group that exercised to music alone (pre-intervention total cholesterol = 4.0±0.7 and 4.5±0.7, respectively). No difference on HDL, LDL, total cholesterol to HDL ration, fasting blood glucose, fasting insulin or triglycerides
Significant decrease in mean arterial pressure in exercise group (no change in control group). However, there was no significant difference between blood pressure (DBP, SBP), resting heart rate, cholesterol (HDL, LDL, total CHL, triglycerides) or measures of insulin sensitivity (insulin, HOMA) between intervention and control groups after a 12 week DDR intervention
Includes 1 prospective cohort study
No effect of 30-week DDR intervention on measures of blood pressure, fasting glucose, total, HDL, or LDL cholesterol or triglycerides post intervention
Number of participants at 30 weeks reported here. Number of participants at baseline = 28 and at 12 weeks = 25
Quality assessment | No of participants | Absolute effect (confidence interval, standard error) | Quality | Importance | ||||||
No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | ||||
1 | RCT | No serious risk of bias | No serious inconsistency |
No serious indirectness | No serious imprecision | None | 322 | ⊕⊕⊕⊕ HIGH | IMPORTANT | |
1 | Observational | No serious risk of bias | No serious inconsistency |
No serious indirectness | No serious imprecision | None | 27 | ⊕⊕ΟΟ LOW | IMPORTANT |
Randomized trial
Average self-reported daily total energy consumed from snack food decreased in the active video game intervention group (compared to the sedentary video game control group), but change was not significant
No significant difference in energy intake between active gaming session (383±266 kcal/hr) versus seated gaming session (374±192 kcal/hr)
Quality assessment | No of participants | Absolute effect (confidence interval, standard error) | Quality | Importance | ||||||
No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | ||||
2 | RCT | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 120 |
0–15% |
⊕⊕⊕⊕ HIGH | IMPORTANT |
7 | Observational study |
Serious risk of bias |
No serious inconsistency | No serious indirectness | No serious imprecision | None | 33 |
2, -3 |
⊕ΟΟΟ VERY LOW | IMPORTANT |
41.1m |
||||||||||
98.5; 93.8; 76.4; 32.6; 25.9 |
||||||||||
P<0.01 |
||||||||||
p<0.01 |
||||||||||
Pre: 65.5±9.7 W, post 77.7±7.1 W (P<0.015) |
Randomized trials
Includes 5 children in the control group (continuing normal physiotherapy for cerebral palsy) and 5 in the intervention group
Includes children with diagnosed down syndrome but no other serious disease (n = 110)
Percent change of Melbourne Assessment if Unilateral Upper Limb Function in the intervention group compared to −1–4% change in the control group (p-value not reported)
Children in the intervention (Wii) group performed significantly better on all follow-up analyses than the control group. BOT-2 Bruininks–Oseretsky Test of Motor Proficiency-Second Edition; VMI, Developmental Test of Visual Motor Integration; TSIF, Test of Sensory Integration Function
Includes 4 intervention studies
Case study of 1 participant diagnosed with Down Syndrome. Recruitment procedures were explained but difficult to generalize findings
Study was case control (15 participants with autism spectrum disorder, 15 apparently healthy). Only data from case (i.e. autism group) is presented here
Change in BOT-2 composite score after 8 week intervention for manual and body coordination respectively. Both changes exceed the minimum detectable change that would be statistically significant when comparing different samples and the minimum important difference that represents a clinically significant difference
Both participants significantly increased correct movements when playing Kinect during the intervention
Increase in functional mobility (with forearm crutches) after training. This continued to increase post-intervention
Percent time spent in MVPA (during a 30 minute exercise bout) while walking, running, playing DDR, playing Wii Fit and playing Wii Sport respectively
Both groups significantly increased the number of correct answers they provided after the intervention (using Wii balance board to follow instructions)
Both participants increased the number of correct responses during the two intervention periods (first intervention = 51 weeks, second intervention = 63
Change in arm crank maximum work capacity (W) pre and post intervention using GameCycle
Studies were grouped depending on if they examined habitual activity (i.e., if AVG was associated with increased PA, decreased sedentary behaviour, or change in fitness), or acute EE (i.e., measured EE during a single bout of AVG play) (
Eleven randomized controlled trials (RCTs), and five observational studies examined the relationship between AVG play and habitual PA. The majority of the `RCTs reported that an AVG intervention had no effect on time spent engaging in total PA
The observational studies provided inconsistent results. Bethea et al.
Two RCTs examined the effect of AVG on acute EE. The first reported no significant difference in average time spent pedaling (min/session), EE (kcal/session), time spent in MVPA (60–79% peak heart rate/session), or average distance pedaled (km/session) between a GameBike intervention group and music only exercise group
Seven intervention studies and 12 cross-sectional studies examined the EE of AVGs compared to rest or to sedentary video games and all reported significant increases in EE
Studies were grouped depending on if they examined adherence to playing AVGs (i.e., children continued to use AVG in the long term, or if it dropped off quickly), or appeal of AVG (i.e., if children and/or their parents enjoyed AVGs) (
Of the eight RCTs that assessed adherence to AVG play, four reported high levels of adherence at the midpoint of the study, but significantly lower levels by the end of the interventions (interventions ranged from 10–12 weeks)
Two intervention studies and one cross-sectional study reported on adherence to AVG play. Bethea et al.
One RCT presented qualitative data reporting that in general, children like AVGs, and things they did not like were game-specific
This review identified one RCT and two observational studies reporting on adverse events associated with AVGs. The RCT reported that none of the adverse events that occurred during the study period were related to the AVG intervention (EyeToy)
Six RCTs (from seven papers), and three intervention studies were included.
Two RCTs and one prospective cohort study reported on the relationship between AVGs and cardiometabolic health. After a 12-week DDR intervention with overweight children, Murphy et al.
Two studies examined energy intake during AVG play
This review included two RCTs and seven observational studies examining the relationship between AVG and learning and rehabilitation. The first RCT used Nintendo Wii along with standard physiotherapy to treat those with cerebral palsy (compared to standard physiotherapy alone), and saw significant improvements in upper limb function
This systematic review is the first to provide a comprehensive understanding of the influence of AVGs on multiple health and behavioural indicators in children and youth. Existing evidence suggests that AVGs are able to increase EE above rest and when compared to playing passive video games. The studies included in the systematic review also showed that AVGs do not make a significant contribution to enable children and youth to meet guidelines of 60 minutes of moderate- to vigorous-intensity physical activity on a daily basis
The main strength of this study is the use of high, international standards of developing and conducting a systematic review. As many decisions as possible were made
The main limitation to our study, and an area for future research, relates to the relatively low quality of studies in this field of research. Most studies included in this review had small sample sizes and short intervention periods, making it difficult to elucidate the true effects of these technologies on health and behavioural outcomes. Further, since many studies were underpowered, some results were not statistically significant (and therefore not reported here) but showed a trend towards significance. Future work should aim to use larger sample sizes to avoid being underpowered, and focus on using both direct (e.g., accelerometer, pedometer, heart rate) and indirect (e.g., self-, parent-, caregiver-report) measures to assess total AVG use. Both measures are needed to reflect the nuances associated with capturing AVG play such as body position or intensity of play. Moreover, multiple follow-up measurements over longer time periods are required so the longitudinal effects of AVG use can be better understood. It is also important that future work aims to harmonize methods for data collection and analysis so that meta-analyses can be performed. Moreover, the review included studies that were largely based on what could be deemed “first generation” AVGs, as such there will be a need to re-evaluate the evidence in the future as AVGs evolve (and the quality of the research designs improve).
Other reviews in this area have shown similar results to ours in that some AVGs are able to acutely increase light- to moderate-intensity PA in some children and youth but unable to elicit PA of high enough intensity, or volume to enable children to meet physical activity guidelines
While controlled laboratory studies clearly demonstrate that a motivated player can obtain some light- to moderate-intensity PA from most AVGs, the findings are inconsistent about whether, or the circumstances under which, having an AVG results in sustained PA behaviour change, or for how long the behaviour change persists. Some of these games offer nuances on game play that could be related to increased PA or decreased sedentary behaviour. AVG technology is innovating at a rate that outpaces the related research. Higher quality research is needed that tests conceptual models of how different AVGs may relate to the initiation and maintenance of increased PA or decreased sedentary behaviour and understand their effects on health outcomes to resolve these inconsistencies.
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The authors are grateful to Dr. Margaret Sampson at the Children's Hospital of Eastern Ontario for her contributions to developing the search strategy for this project.