Play to move: A mixed-methods prospective observational study of exergaming versus traditional exercise interventions in children with Down syndrome

Abstract

Objective

Children with Down syndrome often face challenges associated with physical activity engagement and motor skill development. This study examined the effectiveness of an augmented reality exergaming application compared with that of traditional paper-based exercise recommendations for promoting physical activity in children with Down syndrome.

Methods

Using a mixed-methods design, this prospective, observational study investigated the experiences of participants in a 6-week exercise intervention by comparing the effectiveness of an exergaming application (n = 3) with the provision of a paper handout with recommended exercises (n = 2). Five children with Down syndrome participated in the study, with physical assessments conducted pre- and post-intervention via telehealth, weekly interviews, and activity tracking.

Results

Thematic analysis revealed that the exergaming application provided initial novelty and motivation that decreased over time; however, session duration increased. Paper handouts served as reminders but not motivators. Participants preferred activities involving upper-body movements over more challenging, whole-body movements, and familiar, simplified movements over novel complex tasks. All application group participants demonstrated improvement in the 2-min step test.

Conclusion

Exergaming may help improve physical fitness in children with Down syndrome; however, it requires specific design considerations to sustain long-term engagement and activity initiation.

Introduction

Down syndrome (DS) is a genetic condition caused by the addition of an extra copy of chromosome 21, affecting approximately one in 640 individuals worldwide. ¹ Key characteristics of DS include developmental delays, intellectual disability, and distinct physical features. To help individuals with DS thrive, it is important to consider the various health challenges that often accompany this condition. Managing a healthy lifestyle with diet and exercise poses unique challenges for individuals with DS compared with the general population, and comorbidities such as obesity and diabetes are common. ² Children with DS experience unique physical and cognitive challenges that can impact their engagement in regular physical activity. Physiological impairments common to DS such as low peak oxygen uptake, joint laxity, and muscle hypotonia lead to reduced exercise capacity, making regular exercise participation inefficient and challenging, whereas motor skill deficits and slower reaction times, which are common in this population, can make traditional exercise programs frustrating.^3,4 Additionally, parents of children with DS have reported that although their children do participate in physical activity once encouraged, they lack the motivation to initiate the activity themselves. ⁵ Furthermore, traditional approaches to promoting physical activity in this population often rely on structured therapy sessions or paper-based exercise programs, which may lack the engaging elements necessary to maintain long-term participation.

Exergaming, which combines video game elements with physical exercise, has emerged as a promising intervention for various populations. Although only minimal research has been done on exergaming in the DS community, initial findings conclude that exergaming has the potential to improve balance, functional mobility, and muscle strength in this population.^4,6 The gamification of physical activity can potentially address motivation and motor learning challenges while providing structured, measurable physical activity opportunities. Some commonly used gaming systems for a pediatric population include Wii Fit, Microsoft Xbox Kinect, Wii Sports software, and Dance Dance Revolution. Although these exergaming systems have demonstrated positive effects on physical fitness and activity levels, most require a specific game console and/or wearable controllers. ⁷ Additionally, these exergaming systems were not intentionally designed for individuals with special needs, learning differences, or undergoing rehabilitation therapy. Augment Therapy^® has developed an exergaming platform to address these gaps by creating an application (app) accessible using commercially available devices, which requires no wearables for gameplay, and was designed by physical therapists to deliver therapeutic exercise with settings options to make the software accessible for children with disabilities, individuals undergoing rehabilitation, and complex care patients.

To best serve children with DS, a thorough understanding of their motivations and experiences with physical activity and exergaming is crucial. To gain this insight, this study aimed to compare the experiences and outcomes associated with the use of an augmented reality exergaming app versus traditional paper-based exercise recommendations over a 6-week intervention period in children with DS.

Methods

Study design

This study was designed as a prospective, mixed-methods observational study. It was conducted as a small-scale exploratory study focusing primarily on user experience and feasibility rather than an officially registered clinical trial; therefore, the study protocol was not pre-registered on public trial registries. Data collection points and the intervention timeline were structured as follows. Pre-intervention physical assessments were conducted via telehealth at week 0, followed by a 6-week intervention period (weeks 1–6) during which participants completed weekly structured qualitative interviews. Post-intervention physical assessments were repeated at the end of week 6; detailed flowchart has been presented in Figure 1. Owing to the nature of the interventions (app vs. paper handout), participants and their families could not be blinded to group allocation. Additionally, the telehealth assessments and interviews were conversational in nature to best support the participants; therefore, assessor blinding was not performed. The reporting of this study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. ⁸

Figure 1.

Intervention flow chart.

“App” group refers to the ARWell intervention group, “Paper” group refers to the paper-handout control group.

This mixed-methods design investigates the experiences of participants who underwent a 6-week exercise intervention in the home setting, comparing those who used an exergaming app with those who used a paper handout with suggested exercises. The study employed both quantitative measures (physical assessments and activity tracking) and qualitative data collection (weekly interviews) to comprehensively evaluate participant experiences and outcomes. All data were deidentified prior to analysis.

Participants

On enrolment, study participants were assigned either to the intervention (app) or the control (paper handout) group based on an alternating schedule. The study protocol was approved on 5 October 2023 by the Institutional Review Board of the University of California Santa Cruz (HS-FY2024-71). This study adhered to the principles in the Declaration of Helsinki (as revised in 2024). Written informed consent was obtained from all participants parents/legal guardians.

Recruitment, enrolment, and screening

Participants were recruited through partnerships with DS support organizations. Inclusion criteria included confirmed DS diagnosis; age, 6–18 years; ability to participate in physical activity as confirmed by parent/guardian; and access to technology (tablet/smartphone) to enable participation in app-based intervention activities. Exclusion criteria included recent injuries preventing physical activity or inability to complete telehealth assessments.

Measures

Exercise adherence was defined as the proportion of completed exercise sessions relative to the target goal of three sessions per week over the 6-week period. Missing qualitative data from weekly interviews were addressed by noting the absence during thematic coding without imputation. Missing or lost quantitative app logging data (arising from software reinstallation anomalies) were excluded from aggregate mathematical calculations and were used solely as descriptive trend vectors to triangulate and support parent-reported activity patterns.

Survey. Weekly structured interviews administered to participants and their parents included the following six survey questions:

1. What exercises or physical activities did you do this week?

2. What exercises from the app/handout did you complete?

3. Did the app/handout motivate you to exercise this week?

4. Did you enjoy specific exercises or activities?

5. Were there specific exercises you found difficult or didn’t like?

6. Besides the app/handout, what other physical activities did you do?

Physical assessments. A licensed physical therapist conducted standardized assessments via telehealth at the beginning and end of the 6-week study. These assessments included the 5x sit-to-stand test, the 30-s arm curl test, and the 2-min step test.^9–11 These tests were chosen for feasibility of implementation for individuals with intellectual disabilities/DS in a telehealth setting. To ensure that all assessments were performed similarly, the same physical therapist conducted all assessment testing.

Exercise participation. Activity tracking was performed to record the frequency of performing the assigned activity, duration of exercise sessions, and types of activities chosen.

Procedure

Participants completed physical assessments with a licensed physical therapist via Zoom video chat both prior to and upon completion of their assigned intervention. App group participants received access to an exergaming app (ARWell), whereas paper group participants received a handout with suggested exercises and physical activities. Certain activity types were similar between both groups, such as squats, while some were different; for example, the “countertop pushups” activity was included only for the paper group, whereas the “flying” (arms out horizontally, leaning side to side) activity was only included in the ARWell app. Both groups were assigned the goal of exercising 3 days per week. No other parameters were predefined in the study design; therefore, participants could choose which games to play/exercises to complete, when, and for how long. The study coordinator conducted weekly interviews with participants and their parent(s), including the six survey questions described above.

Interventions

ARWell app. ARWell is a tablet-based augmented-reality app that promotes physical activity through interactive, movement-based activities. Using the tablet's camera, it projects virtual objects and games onto the real environment, targeting mobility, balance, strength, coordination, and cognitive challenge (Figure 2). Motion-tracking technology enables the user's body to function as the game controller, with mirrored images and animated avatars providing real-time feedback. The app tracks performance data (e.g. time and repetitions) which is deidentified and stored in compliance with Health Insurance Portability and Accountability Act (HIPAA) and privacy standards. Within the ARWell app, a variety of accessibility settings allow players with significant cognitive or physical disabilities to successfully interact with and complete games and exercises.

Figure 2.

Example ARWell game.

Screenshot of the “Goal Kick” game where a player kicks their leg forward to allow their avatar to “kick” the ball into the goalpost.

Paper handout. The paper handout contained illustrated exercise recommendations for cardiovascular activities (walking, running, dancing), strength exercises (squats, pushups, chair exercises), balance activities, flexibility and stretching routines, and recreational activities.

Analyses

Thematic analysis of qualitative data was performed using interview data, following the methods outlined by Naeem et al. ¹² The analysis focused on identifying patterns in motivation, preferences, and barriers to exercise engagement.

Descriptive analysis was performed using quantitative data, including physical testing outcomes. Due to missing exercise participation data, the remaining available data were used only to support parent-reported activity patterns from the qualitative surveys. Trends uncovered from the quantitative data were used in conjunction with the qualitative results to formulate conclusions about participants’ experiences throughout the study.

Results

Participants

A convenience sample of five children with DS, ages 10–17 years was enrolled in the study, with three allocated to the exergame intervention group (app) and two to the paper-handout group (paper) (Table 1).

Table 1.

Demographic characteristics of the study population.

Participant	Group	Sex	Age (years)
P01	App	F	16
P02	Paper	F	10
P04	Paper	F	17
P05	App	F	17
P06	App	F	12

“App” group refers to the ARWell intervention group, and “Paper” group refers to the paper-handout control group. Participant P03 withdrew from the study, and their data were not included in the analyses.

Qualitative results

Thematic analysis was completed for two primary topics, motivation (survey question #3) and likes/dislikes pertaining to the intervention (survey questions #4 and #5). Initial codes were generated inductively and clustered into overarching themes regarding motivation, barriers, and preferences. Inter-rater agreement was assessed through iterative peer debriefing sessions until 100% consensus on the final thematic structure was achieved.

Motivation themes. App group:

1. Initial novelty effect. All three app participants showed high initial excitement and motivation (weeks 1–2), with comments such as “very excited about the app” and “made her more motivated, was excited at first.”

2. Declining motivation over time. By weeks 3–4, motivation decreased as the novelty wore off, with participants showing “less interest over time” and “has lost interest over time.”

   “First day, the participant was very excited; second day slowed down a little bit, and third day, the excitement waned a little bit.” (P05)

3. Sustained engagement during sessions. Despite reduced initiation motivation, the session duration increased over time when they did engage.

   “Once she is on the app she has fun.” (P06)

Paper group:

1. Reminder function. Paper handouts served as reminders rather than motivators, with parents noting “reminds of her exercises” and “helps her remember workouts to do.”

   “Does not motivate her to do it independently, keeps her focused on a completed task.” (P04)

2. External support required. Success required consistent parental supervision and encouragement.

3. Limited independent motivation. Participants showed little autonomous motivation from paper materials alone.

   “Does not help much with her motivation, too abstract for her, but helps her mom to keep her motivated/knowing that we are tracking.” (P02)

Activity preferences.

Preferred activities (both groups):

1. Upper-body exercises (arm exercises, tennis, and tracing games);

2. Game-based activities with clear objectives;

3. Activities with immediate feedback;

4. Shorter duration, focused exercises.

Disliked activities:

1. Whole-body movements requiring running or jumping;

   “(Dislikes) Anything to do with running, her stamina runs out.” (P06)

2. High-intensity cardiovascular exercises;

   “Some of the workouts were too hard to keep motivation up.” (P05)

3. Activities perceived as “workouts” rather than games;

4. Complex multistep exercises.

Quantitative results

Physical fitness metrics. The 2-min step test demonstrated an average increase of 112% in the number of steps after the intervention in the app group and an 8.5% average increase in the paper group. For the 5x sit-to-stand test, all three app group participants and one paper group participant had worse post-intervention scores (longer time) compared with pre-intervention scores, and one paper group participant demonstrated improved post-intervention scores (less time). There were no noticeable patterns in the results of the 30-s arm curl test (Figure 3).

Figure 3.

Changes in physical assessment outcomes before and after intervention.

“App” group refers to the ARWell intervention group, “Paper” group refers to the paper-handout control group.

Activity participation. Significant inconsistencies were present between self-reported data and app-collected data. Some details were also missing among the self-report data such as frequency and duration of exercises completed. Additionally, due to app reinstallation errors and lack of appropriate labeling, some app data may have been lost. Therefore, the quantitative analysis of session frequency and duration, and resultant adherence data, was limited to the available app-collected data and was used to support the overall activity trends reported by participants’ parents.

Of the available app-collected data, analysis of session duration over time in the app group demonstrated a trend of decreasing session frequency; however, the session duration increased. This trend was similar to parent-reported usage.

Discussion

The primary purpose of this mixed-methods observational study was to compare the motivation, physical activity experiences, and functional outcomes of children with DS utilizing an augmented reality exergaming app versus traditional paper-based recommendations. We successfully uncovered distinct behavioral patterns regarding novelty-driven engagement, user preferences, and the practical utility of paper handouts as structured reminders within this population.

Key findings

Three dominant themes emerged from this study:

Novelty-driven initial motivation with temporal decline. The ARWell app demonstrated a clear novelty effect that increased motivation to initiate physical activity in the first 2–3 weeks. However, this motivation decreased over time. Although a decline in participation is common in new exercise programs as 50% of the general population will quit a new exercise regimen within the first 6 months, our findings suggest that once participants began a session, their engagement was sustained. ¹³ Although session frequency decreased over time, participants played multiple games during each session. This pattern suggests that initial participation was driven by extrinsic motivation (novelty); however, the sustained duration during sessions indicates the presence of an emerging intrinsic motivation or enjoyment of competence once engaged. Future iterations should incorporate design elements, such as adaptive difficulty and personalized feedback, to transition users from novelty-based engagement to motivation aligned with the principles of the Self-Determination Theory, which emphasizes autonomy and competence. ¹⁴ This pattern also indicates that although the app may not be a sufficiently strong driver of long-term initiation, it is capable of maintaining engagement once a session has started.

Paper materials as reminders, not motivators. The paper handout intervention served primarily as a reminder system rather than a motivation tool. Participants and parents reported that although the handout helped them remember to exercise and provided structure, it did not generate intrinsic motivation for physical activity. These findings align with previous studies, according to which, paper handouts were less motivating than technology-based home exercise programs.^15–17 Success with paper-based interventions required consistent external support and supervision. Since familial support and facilitation is critical for physical program participation in a pediatric DS population, it is important to consider methods that support parents and caregivers. ⁵ If a paper handout can serve as a reminder to engage in physical activity, providing it as an adjunct to a digital regimen may help encourage regular participation, although it may not provide sufficient motivation when used alone.

Activity type preferences impact engagement. A clear preference emerged for upper-body–focused activities over whole-body movements. Participants consistently reported enjoying activities that isolated arm movements (tennis and tracing games) while expressing dislike for activities requiring running, jumping, or full-body coordination. This preference could be related to the physiological characteristics of children with DS, where joint laxity and low muscle tone often complicate whole-body movements and balance tasks, leading to the selection of activities where they feel more successful and competent. ⁴ There was a general dislike for activities which were deemed “too hard” because they were perceived to cause cardiovascular exertion or involved complicated coordination. Despite the differences in activities in the app and those listed in the paper handout, both groups chose activities that were simple to execute or were most similar to an activity they were already familiar with, suggesting that familiarity is a stronger factor than novelty, regardless of the exercise modality.

This observation acts as important feedback that should be considered when designing interventions or programs for DS populations since their ability to perform certain physical and cognitive tasks differs from that of a general pediatric population. Although exergaming has shown similar physical benefits as traditional exercise in this population in a controlled setting, different motivational and participatory factors need to be considered to encourage sustained participation. ¹⁸ Inclusion of activities that can help create a sense of success among individuals with DS is an important factor that would encourage participant enjoyment and continued participation. ⁵ The results of this study suggest that the difficulty of playing games with complex movements outweighed the motivational factors; this is in contrast to results of a previous exergaming interventions study, according to which, participants with DS overcame the physical challenges owing to the motivation for gameplay. ¹⁹ The themes from this study add to the emerging body of work that has investigated exergaming interventions in individuals with DS by highlighting unique considerations that may affect motivation and participation in this population. Understanding how perceptions of challenges, both cognitive and physical, affect participation in a DS population and how they differ from those in the general pediatric population is critical for creating physical activities that will provide adequate fitness benefits while remaining accessible.

Interestingly, despite stated preferences against lower-body activities, the 2-min step test showed the most consistent improvement across app group participants, suggesting that some physical benefits can occur even when activities that are deemed “too hard” are avoided. Although exercises including lower-extremity movement were not preferred, sufficient motivation was present among participants to complete those activities anyway. Consequently, the limited participation in activities involving movement of lower-body extremities may have provided enough benefit to elicit improvements in the 2-min step test results. Alternatively, the improvement in the 2-min step test may be a product of the additional physical activity participation using the ARWell app, regardless of the type of activity completed. This reasoning suggests that even activities that do not target cardiovascular fitness still provide those benefits in this population. Future studies are needed to establish whether improvements associated with ARWell use in individuals with DS are reproducible and clinically significant.

Clinical implications

Several important considerations for designing physical activity interventions for children with DS emerge. Simplified, familiar activities may help increase adoption and participation. Focus on upper-body and isolated movement activities may improve initial acceptance and participation as these simpler types of movement may be perceived as easier and more enjoyable. Combining the structure of traditional exercise programs or familiar movements with gamified elements may optimize outcomes by shortening the learning curve. This strategy leverages preferred activity types to increase adherence frequency, even if the underlying physiological benefits are subtle. In addition to tailoring programs to the pediatric participants, the families and their involvement must also be considered. Most exercise programs for children with DS will require family support and supervision for success. Considering this and minimizing the input required from parents and caregivers to encourage participation by the beneficiaries could enhance the success of such programs. Interventions should minimize the required parental workload while providing tools (such as the reminder function identified in the paper group) that effectively facilitate family involvement. Finally, similar to a general pediatric population, children with DS require thoughtful motivational techniques to encourage repeat usage. Technology-based interventions show promise; however, they require further gamification development to incentivize individuals to return to the app and initiate a physical activity session (e.g. external rewards, social goals, and adaptive challenges).

Limitations

Certain study limitations should be considered when interpreting these results. Most notably, the sample size of this study was relatively small (five participants), limiting the generalizability of these results. Additionally, group allocation was alternated, not randomized, thereby limiting true group comparisons. Participants were not categorized based on any distinctive physical traits, developmental or cognitive levels, associated medical conditions, or other diagnoses that can be related to DS, and the experiences and outcomes of these five children may not be representative of the broader population of children with DS. However, the ARWell app can be used by individuals with a wide variety of cognitive levels and involves settings that allow players to access the games even if they have significant cognitive or physical disabilities. Additionally, there may be selection bias among this small sample. All participants were already performing various physical activities, which might have limited the intervention's impact on their behavior since they already lead active lifestyles. Additionally, this excludes the experiences and results that might have been observed in a more sedentary population. The relatively short 6-week duration of the intervention may have been insufficient to capture long-term behavior change patterns. It 's difficult to determine whether the initial novelty effect of the app would have persisted, or if a different, more lasting motivational pattern would have emerged in time. The technology utilized for this study also poses its own limitations. The study required access to tablets and reliable internet, which may not be available to all families, and the telehealth physical assessments may have reduced measurement precision compared with in-person evaluations.

Future research directions

Based on these findings, future research should explore longer intervention times with a larger sample size. This would allow us to determine if the novelty effect of exergaming can be overcome with the use of a more engaging and adaptive platform and larger, more diverse samples, including sedentary children with DS to better understand the potential of these interventions in a wider range of individuals. Additionally, comparisons with other technology-based interventions could help determine which platforms or approaches are most effective in this population. Future development should focus on different motivational factors appropriate for a DS population. The integration of reward systems could help incentivize users to come back to the app and initiate future exercise sessions, thereby addressing the observed decline in motivation.

Conclusion

Gamification through augmented reality exergaming holds potential as an intervention for promoting physical activity in children with DS, a indicated by the initial motivation and sustained session engagement. However, the temporal decline in novelty-driven motivation indicates that current exergaming software requires refinement to maintain long-term activity initiation and participation.

The study reveals important insights about activity preferences in this population, highlighting the need for interventions that balance activity preferences with comprehensive physical fitness goals. Traditional paper-based approaches provide structure and reminders; however, they may lack the motivational elements necessary for independent engagement.

Future development of exergaming interventions should focus on adaptive and accessible content delivery, sustained engagement strategies, and integration of preferred movement patterns while continuing to address comprehensive fitness needs. The combination of technology-enhanced motivation with evidence-based exercise programming may offer the most promising approach for supporting exergaming physical activity engagement in children with DS.