Delayed onset muscle soreness can occur in untrained individuals who suddenly begin to exercise and even in athletes who exceed their limits of training. The phenomenon appears approximately 12 to 48 hours after strenuous eccentric exercises that are high in intensity or performed in an unaccustomed manner.1–3 Because of the presence of pain and other possible debilitating performance factors (eg, stiffness of adjacent joints or reduced range of motion and strength) in response to delayed onset muscle soreness, preventing or minimizing the effects of delayed onset muscle soreness is a concern for patients, athletic trainers, and other sport medicine personnel. The literature indicates that an acute bout of exercise provides an analgesic effect known as exercise-induced hypoalgesia.4 However, few studies have investigated the nature of exercise-induced hypoalgesia for delayed onset muscle soreness and pain. Zainuddin et al.5 indicated that light concentric exercise of the sore muscles had a temporary hypoalgesic effect on delayed onset muscle soreness-related pain, but did not affect recovery from muscle damage. Because most athletes will continue to train despite muscle soreness and pain, more research is needed to determine the most effective methods or practices to alleviate this type of pain.6
One such modality of exercise (active gaming) has become a common tool in many health care facilities, including athletic training facilities. Gaming devices such as the Wii (Nintendo Co., Ltd., Kyoko, Japan) allow an individual to be physically active during video game play and add a certain level of entertainment value. Generally, research shows that active gaming has the potential to improve postural control, increase heart rate and energy expenditure when compared to rest, and improve compliance to exercise programs due to the fun aspect of competitive games.7 Because exercise can reduce pain sensitivity and perception,4 research is warranted to investigate the potential use of active gaming as a tool for pain management, including the management of delayed onset muscle soreness. Therefore, the purpose of this study was to determine whether active recovery using the Wii gaming system, specifically the Wii Sports Boxing game (Nintendo Co., Ltd.), is more effective than other treatments to reduce pain and increase range of motion following an induced bout of delayed onset muscle soreness.
Previous studies have shown that the Wii Sports Boxing game played at a self-selected intensity produces exercise intensity of approximately 40% of heart rate reserve,8 thus providing an opportunity to exercise at a light to moderate intensity. We compared the effects of the Wii Sports Boxing game to a standardized form of light concentric exercise of the sore muscles, a traditional treatment for delayed onset muscle soreness (ie, ice therapy), and no treatment. We hypothesized that active recovery through light exercise would reduce pain similar to ice therapy following an induced bout of delayed onset muscle soreness.
A convenience sample of 49 healthy adults (45 women, 4 men; average age: 20.00 ± 1.90 years; age range: 18 to 27 years; body mass index: 23.06 ± 3.5 kg/m2) enrolled in this study and 48 participants completed the entire study. Participants were recruited from the University of Florida campus and surrounding community. All participants read and signed the informed consent form that was approved by the University's Institutional Review Board. Exclusion criteria included: engagement in regular (two to three times per week) resistance training exercise, any injury to the neck or upper extremity in the past 6 months that would prevent participants from performing the exercises in this study, and currently taking nutritional supplements or anti-inflammatory medication on a daily basis. Additionally, participants completed the Physical Activity Readiness Questionnaire (PAR-Q) to screen for any potential health conditions that would prohibit them from participating in physical activity.9
All participants completed three testing sessions that were held on three separate but consecutive days; baseline (day 0), 24 hours from baseline (day 1), and 48 hours from baseline (day 2). During the first session (day 0), participants read and signed the informed consent form, completed questionnaires asking for demographic data including age, height, and weight, and completed the PAR-Q. Participants also completed baseline assessments of muscle pain and function, pain sensitivity, and psychological risk factors. Participants then performed an eccentric exercise protocol designed to induce delayed onset muscle soreness on the non-dominant arm. At the end of the first session, participants were randomly assigned to one of three intervention groups (the Wii Boxing, ice therapy, or standardized light concentric exercise groups) or a control group (ie, no intervention performed). A random numbers table was used to assign the participants to the groups. Each intervention group consisted of 12 participants.
All participants were asked to return to the laboratory for sessions 2 (day 1) and 3 (day 2) within a 3-hour window from the completion of their delayed onset muscle soreness protocol on day 0. On days 1 and 2, participants completed 20 minutes of their assigned intervention. Outcome measures were taken immediately before and after the intervention (pretest and posttest) on the non-dominant arm. All treatments were administered by a certified athletic trainer (SC). An overview of the procedures can be seen in Figure 1.
Overview of the study design. DOMS = delayed onset muscle soreness
Exercise Protocol to Induce Delayed Onset Muscle Soreness
On day 0, participants completed an isotonic eccentric-only exercise protocol intended to induce delayed onset muscle soreness on the non-dominant arm.10 A one-repitition max test for elbow flexion (biceps curl) was performed on the dominant arm between 10 and 130 degrees on a standard biceps curls machine. Once the maximal load was determined, participants began the eccentric-only exercise protocol by lowering 140% of their one-repetition max load from full elbow flexion to the machine's resting placement for the weight with the non-dominant arm. During the exercise, the participant was asked to slowly lower the weight for a period of 6 seconds at a verbal count of 1 to 6. This eccentric-only exercise protocol was performed as 3 sets of 10 repetitions. The participant was assisted in returning the machine to the starting position by the researcher after each repetition and received 1 minute of rest between sets.10
Interventions and Control Groups
On days 1 and 2, participants completed a 20-minute session of one of the following interventions.
Ice Therapy. The ice therapy treatment consisted of the participant sitting with an ice bag placed on the biceps brachii area of the non-dominant arm. The application time of 20 minutes falls within the recommended range for ice treatment of muscle injuries.11
Wii Sports Boxing Active Game. The Wii active game intervention consisted of the participant playing the Wii Sports Boxing game. Wii Sports Boxing is an upper-extremity game that uses both upper extremities to mimic boxing movements. Participants held a video game controller in each hand while playing at a self-selected intensity for 20 minutes.
Standardized Exercise. The standardized exercise intervention consisted of active continuous elbow flexion and extension while holding a 1-lb weight for 20 minutes with the non-dominant arm. Participants performed the exercise at 2 seconds per elbow flexion-extension for 8 sets of 60 repetitions with 30 seconds of rest between each set (20 minutes total).
Control. Participants in the control group sat comfortably for 20 minutes and were allowed to read.
Outcome measures on the non-dominant arm were taken at baseline on day 0 and pretest and posttest on days 1 and 2. Measures of muscle function and pain included elbow range of motion, self-reported measures of disability (Quick Disabilities of the Arm, Shoulder, and Hand Outcome Measure [QuickDASH]), self-reported pain at rest (Brief Pain Inventory), activity-related pain during active elbow flexion and extension, and muscle tenderness at the biceps brachii as measured by pressure pain thresholds.
Active Total Range of Motion of the Elbow. Active total range of motion in elbow flexion and extension of the elbow joint was measured with a standard goniometer while the participant was in the supine position on a padded table. The participant was instructed to flex and extend the non-dominant arm at the elbow “as far as you could.” Elbow flexion and extension were assessed in the sagittal plane with the arm parallel to the trunk and in the anatomic position. The center fulcrum of the goniometer was placed over the lateral epicondyle of the humerus. The stationary arm of the goniometer was fixed along the lateral midline of the humerus in line with the acromion process and the moving arm was fixed along the lateral midline of the radius in line with the styloid. The normal elbow flexion active total range of motion values for adults range from 140 to 150 degrees, with greater numbers indicating greater flexion. The normal elbow extension active total range of motion value for adults is 0 degrees, with lower numbers indicating greater extension.12 Three measurements of active elbow flexion and extension were conducted at each assessment time point, with the average of the three measurements used as the outcome measure for each time point. All active total range of motion measurements were conducted by the same researcher (SC).
Pain-Free Range of Motion of the Elbow. The same procedures used for active total range of motion were used for pain-free range of motion, except participants were instructed to flex and extend the elbow to the point at which they first experienced pain.
Pain During Elbow Flexion and Extension. Participants performed the following elbow movements: moving from a fully flexed starting position through active total range of motion to full extension and moving from a fully extended starting position through active total range of motion to full flexion. Ratings of muscle pain intensity were assessed following each contraction using a scale from 0 to 100, with 0 indicating “no pain” and 100 indicating the “most intense pain imaginable.”
QuickDASH. The QuickDASH focuses on the participant's ability to use the affected arm during activities of daily living. Participants rated their symptoms and ability to perform specific tasks using a 5-point hierarchical Likert scale. Scores were obtained by summing circled responses, dividing the total by the number of items answered, subtracting 1, and then multiplying that figure by 25. A score of 0 represents no dysfunction at all, whereas higher scores represent more limitations in self-reported function (range: 0 to 100). A minimum of 10 questions had to be answered to score the QuickDASH. The QuickDASH is comparable to the full DASH (r = 0.98) and its construct validity and responsiveness suggest that the QuickDASH scores should give views of disability and symptoms that are relatively similar to scores provided by the full DASH.13,14
Brief Pain Inventory. The Brief Pain Inventory asks participants to rate their pain in four different conditions: (1) “worst” pain in the previous 24 hours, (2) “least” pain in the previous 24 hours, (3) average pain in the previous 24 hours, and (4) current pain. The Brief Pain Inventory uses a scale from 0 to 10, with 0 representing “no pain” and 10 representing “pain as bad as you can imagine.” Pain was assessed specific to the biceps of the affected arm. For the current study, only “current pain” was used in the statistical analyses. This provided an index of pain while the affected arm was at rest.
Pressure Pain Threshold. Pressure pain threshold is defined as the point at which a pressure stimulus first becomes painful. Using a hand-held, clinical grade pressure algometer (Wagner Instruments, Greenwich, CT), pressure was applied to the biceps brachii muscle of the affected (non-dominant) arm while the arm was stationary at approximately 90 degrees of elbow flexion. Pressure was increased at a rate of approximately 1 kg/s until the participant first reported feeling pain. The pressure (kg) at threshold was recorded as the dependent variable.
Descriptive characteristics were calculated for age, height, and weight. These measures were analyzed with a one-way analysis of variance (ANOVA) test with the type of intervention as the between-subject factor. The effectiveness of the delayed onset muscle soreness protocol was assessed with 4 intervention × 2 time (day 0, day 1 pretest) mixed-model ANOVA tests conducted on the outcome measures. The effect of the interventions on the outcome measures was assessed with 4 intervention × 2 day (day 1, day 2) × 2 time (pretest, posttest) mixed-model ANOVA tests with repeated measures on the last two factors. If the sphericity assumption was violated, the Greenhouse-Geisser degrees of freedom corrections were applied to obtain the critical P value. Post-hoc analyses were conducted using the Tukey honest significant difference procedure and simple effects tests for significant main effects and interactions, respectively. For all analyses, the probability value was set a-priori (α = 0.05).
No significant differences existed between intervention groups at baseline in height, weight, and age (P > .05).
Effectiveness of Delayed Onset Muscle Soreness Protocol
The two-way ANOVA test conducted on the outcome measures demonstrated that the delayed onset muscle soreness protocol was successful at inducing muscle soreness, pain, and functional limitations in the affected arm at the day 1 pretest compared to baseline (before delayed onset muscle soreness protocol). Table 1 shows the scores for all outcome measures at baseline and the day 1 pretest. No differences in the effectiveness of the delayed onset muscle soreness protocol were observed between the intervention groups (P > .05).
Effectiveness of Delayed Onset Muscle Soreness Protocol on Outcome Measures
Active Total Range of Motion of the Elbow
The analysis on elbow flexion active total range of motion showed a significant intervention × day interaction (P = .01). Follow-up tests revealed that elbow flexion range of motion was greater for the Wii Boxing group on day 1 (150.67 ± 1.16 degrees) compared to the standardized exercise group on day 1 (148.33 ± 1.16 degrees). No other main effects or interactions were significant (P > .05).
The analysis on elbow extension active total range of motion revealed a main effect of day (P = .021) and time (P = .004). Elbow extension active total range of motion grew worse from day 1 (−3.06 ± 1.34 degrees) to day 2 (−0.79 ± 1.80 degrees). Additionally, elbow extension active total range of motion improved from pretest (−1.28 ± 1.60 degrees) to posttest (−2.49 ± 1.45 degrees) on days 1 and 2 with all interventions. No other main effects or interactions were significant (P > .05).
Pain-Free Range of Motion of the Elbow
Analysis on elbow flexion pain-free range of motion revealed significant day × intervention (P = .001) and time × intervention (P = .014) interactions. Follow-up analyses indicated that elbow flexion pain-free range of motion significantly decreased from day 1 (146.95 ± 2.18 degrees) to day 2 (144.15 ± 2.25 degrees) for the Wii Boxing group. Although the clinical significance of this could be questioned, the changes show that a trend to improve range of motion is occurring and could be further studied. Additionally, the control group showed reduced elbow flexion pain-free range of motion on both days (144.18 ± 2.18 and 144.00 ± 2.25 degrees on days 1 and 2, respectively) compared to the Wii Boxing group on day 1 and the ice therapy group on day 2 (146.86 ± 2.05 degrees). However, the time × intervention interaction indicated that elbow flexion pain-free range of motion improved from pretest to posttest for the Wii Boxing group (Figure 2). The Wii Boxing group also demonstrated greater elbow flexion pain-free range of motion at the posttest compared to the control group at pretest and posttest.
Elbow (A) flexion pain-free range of motion and (B) extension pain-free range of motion at pretest and posttest for each intervention on days 1 and 2. LCE = light concentric arm exercise
The three-way ANOVA test conducted on elbow extension pain-free range of motion showed a main effect of time (P = .021). Across all interventions and days, elbow extension pain-free range of motion improved from pretest (9.31 ± 1.96 degrees) to posttest (6.48 ± 1.89 degrees). No other interactions or main effects were significant (P > .05).
Pain During Flexion and Extension Movement
The three-way ANOVA test on pain ratings during elbow flexion showed a time × intervention interaction (P = .036). Pain ratings significantly decreased from pretest to posttest for the Wii Boxing group only (Figure 3). The Wii Boxing group at pretest also demonstrated significantly higher pain ratings compared to the ice therapy group at posttest and light concentric exercise group at pretest. No other main effects or interactions were significant (P > .05).
Pain ratings during (A) flexion and (B) extension of the elbow at pretest and posttest for each intervention on days 1 and 2. LCE = light concentric arm exercise
The ANOVA test conducted on pain ratings during elbow extension also showed a significant time × intervention interaction (P = .045). Again, pain ratings during elbow extension significantly decreased from pretest to posttest for the Wii Boxing group only. Additionally, the Wii Boxing group at pretest had significantly higher pain ratings compared to the ice therapy and light concentric exercise groups at all time points. The control group also had significantly higher pain ratings at posttest compared to the ice therapy group at posttest.
Pressure Pain Threshold
The analysis revealed a significant time × intervention interaction (P = .006). Pressure pain thresholds significantly increased from pretest to posttest for the Wii Boxing and ice therapy groups (Figure 4). The Wii Boxing group also had greater pressure pain thresholds at posttest compared to the control group at pretest and posttest.
Pressure pain thresholds (PPT) at the biceps of the affected arm at pretest and posttest for each intervention on days 1 and 2. LCE = light concentric arm exercise
The ANOVA test showed a main effect of day (P = .009) that was superseded by a day × intervention interaction (P = .001). The follow-up analyses revealed no significant differences between groups on day 1. However, the Wii Boxing group had significantly higher QuickDASH scores on day 2 compared to the ice therapy group on day 2. Figure 5 shows the QuickDASH scores for each day and time point by intervention.
QuickDASH (Quick Disabilities of the Arm, Shoulder, and Hand Outcome Measure) score at pretest and posttest for each intervention on days 1 and 2. LCE = light concentric arm exercise
Brief Pain Inventory (Current Pain)
The three-way ANOVA test conducted on the Brief Pain Inventory (current pain) showed a significant day × intervention interaction (P = .005). Follow-up analyses revealed that the Wii Boxing group reported higher pain on day 2 (current pain = 3.27 ± 0.54) compared to the ice therapy and control groups on day 2 (1.45 ± 0.54 and 1.16 ± 0.60, respectively).
This study investigated the hypoalgesic effects of active gaming on delayed onset muscle soreness and pain. Three key findings emerged from this study. First, the Wii Sports Boxing game was the most effective intervention for temporarily reducing pain sensitivity and pain perception during movement of the affected arm. Second, despite the acute hypoalgesic effect of the Wii Sports Boxing game, pain and functional limitations appeared to be enhanced on day 2 compared to day 1 for the individuals in the Wii Boxing group. Third, ice therapy was the most effective intervention for preventing an increase in functional limitations and pain from day 1 to day 2.
Prior research suggests that moderate and vigorous aerobic exercises produce a temporary analgesic effect on experimentally induced pain, with larger effects found for vigorous exercise.4 However, minimal exercise-induced hypoalgesic-related research has focused on delayed onset muscle soreness pain. In one of the few studies examining exercise for pain related to delayed onset muscle soreness, light concentric exercise temporarily reduced delayed onset muscle pain and tenderness caused by strenuous eccentric exercise.5 Our results are in partial agreement with these findings. The Wii Sports Boxing game, which can be considered a light to moderate form of aerobic activity,8 resulted in improved pain-free range of motion, reduced pain during active elbow flexion and extension, and increased pressure pain thresholds. This analgesic effect was consistent across days 1 and 2. The application of the Wii gaming system or active gaming provides the necessary motivation to come to the rehabilitation setting and have fun in addition to conditioning or reducing pain.
Conversely, the standardized light concentric exercise did not reduce pain or improve function on any of the outcome measures. Both exercise conditions in the current study involved continuous elbow flexion and extension activity of the arms. However, a few key differences between the two exercise conditions could have resulted in the contrasting effects. First, the standardized exercise condition involved flexion/extension activity with a 1-lb weight that was slightly heavier than the Wii gaming system controller held by the affected arm during play of the Wii Sports Boxing game. This leads to the question of whether a higher intensity creates a negative effect, specifically for recovery related to delayed onset muscle soreness. Second, the standardized exercise condition involved constant activity of the affected arm, whereas participants boxed with both arms during the Wii Sports Boxing game and could have minimized movement of the affected arm. Third, the Wii Sports Boxing game condition likely induced a greater cardiorespiratory response compared to the standardized exercise condition. Aerobic exercise-induced hypoalgesia reduces pain through central mechanisms and does not need to involve the body site experiencing pain. Future research should determine whether the intensity of the exercise condition and use of the affected versus unaffected arm plays a role in determining the hypoalgesic effect of a bout of exercise on delayed onset muscle soreness and pain.
Several different mechanisms could have been responsible for the hypoalgesic effect of the Wii Sports Boxing game. The most commonly ascribed mechanism for exercise-induced hypoalgesia involves activation of the endogenous opioid system during aerobic exercise. Animal studies show that exercise of sufficient intensity and duration results in the release of central and peripheral beta endorphins, which have been associated with reductions in pain sensitivity.15,16 However, it is possible that the Wii Sports Boxing game was not played at a high enough intensity to induce this mechanism. Another potential mechanism involves an increase in blood flow and lymphatic drainage by the active gaming that could have modified the threshold or response patterns of nociceptors. Additionally, the activation of groups III and IV muscle afferents in skeletal muscle during exercise could have induced hypoalgesia.17 Animal studies show that activation of these afferents increases pain thresholds.18,19 Nonetheless, future research is needed to determine the possible mechanisms through which the Wii Sports Boxing game acutely reduces delayed onset muscle soreness.
Delayed onset muscle soreness is considered to peak at 48 hours after exercise. Although play in the Wii Sports Boxing game was able to temporarily decrease pain and improve range of motion immediately following the treatment session, an increase in both pain and disability were noted on day 2. No current research has identified whether an ideal time frame exists for how long a treatment session of active gaming should last. Although the active gaming provided immediate relief, potentially due to an increase in blood flow and lymphatic drainage, the length of time on day 1 for active gaming may have been too long and contributed to an increase in delayed onset muscle soreness symptoms on day 2. Alternately, ice therapy was able to regulate the inflammatory process, prevent an increase in delayed onset muscle soreness symptoms from day 1 to day 2, and provide analgesia immediately before and after exercise, thus implying that ice therapy combined with the Wii Sports Boxing game may be a viable option for pain management of delayed onset muscle soreness.
There are several limitations to this study. Although the exercise-induced muscle injury model does have some clinical validity, results must be translated with caution to clinical populations. Also, this study only assessed outcomes for individuals experiencing arm pain and disability. Therefore, generalizations to other injury locations should be done with prudence. In addition, exercise intensity during active gaming was not measured, so individuals' self-selected intensities could have been different. A set time was given for how long individuals would play the active gaming; however, some may have benefited from playing for a shorter duration. The sample in this study comprised primarily females and may not generalize to males. This resulted from a high percentage of males actively partaking in resistance training. Finally, the timing of the pain-free range of motion after the active total range of motion could have contributed to the increase in positive outcome (increase in range of motion) for the pain-free range of motion measures.
Implications for Clinical Practice
Active gaming is a fun and alternative method to decrease pain and increase functional ability following injury. Active recovery has long been found to be beneficial in recovering from delayed onset muscle soreness and is much more motivating than sitting with a bag of ice.5 An intervention that allows interaction and employs technology may benefit individuals who lack motivation to partake in traditional therapies. Furthermore, the ability of active gaming to produce cardiovascular outcomes may make the Wii Sports Boxing game a great method for both pain reduction and cardiovascular maintenance, thereby creating efficiency in treatment settings.8 Future studies are necessary to examine whether the current findings hold true in a clinical population. In addition, various forms of active gaming should be investigated to see whether they can produce the same benefits as the Wii Sports Boxing game. Finally, identifying an ideal range of time for active gaming during each treatment session should be established.
Wii active gaming is an enjoyable form of active recovery that can have an immediate reduction in symptoms for delayed onset muscle soreness. Active gaming had immediate effects similar to traditional ice therapy and was significantly better than light concentric exercise and no exercise (control group) when it came to decreasing pain and improving functional ability.
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- Naugle KM, Fillingim RB, Riley JL 3rd, . A meta-analytic review of the hypoalgesic effects of exercise. J Pain. 2012;13:1139–1150. doi:10.1016/j.jpain.2012.09.006 [CrossRef]
- Zainuddin Z, Sacco P, Newton M, Nosaka K. Light concentric exercise has a temporarily analgesic effect on delayed-onset muscle soreness, but no effect on recovery from eccentric exercise. Appl Physiol Nutr Metab. 2006;31:126–134. doi:10.1139/h05-010 [CrossRef]
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- Thomas S, Reading J, Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Can J Sport Sci. 1992;17:338–345.
- Parr JJ, Yarrow JF, Garbo CM, Borsa PA. Symptomatic and functional responses to concentric-eccentric isokinetic versus eccentric-only isotonic exercise. J Athl Train. 2009;44:462–468. doi:10.4085/1062-6050-44.5.462 [CrossRef]
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- Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord. 2006;7:44. doi:10.1186/1471-2474-7-44 [CrossRef]
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Effectiveness of Delayed Onset Muscle Soreness Protocol on Outcome Measures
|Outcome Measure||Baseline Score (Day 0)||Day 1 Pretest Score||P|
|Flexion active total range of motion (degrees)||150.90 ± 0.54||144.86 ± 1.12||< .001|
|Extension active total range of motion (degrees)||−4.40 ± 0.84||9.23 ± 2.39||< .001|
|Pressure pain threshold (kg)||2.84 ± 0.19||2.25 ± 0.17||< .001|
|Flexion pain (0 to 100)||0.23 ± 0.22||16.43 ± 2.26||< .001|
|Extension pain (0 to 100)||0.05 ± 0.05||16.13 ± 1.97||< .001|
|QuickDASH (0 to 100)||2.93 ± 0.51||16.15 ± 1.63||< .001|
|Brief Pain Inventory (current) (0 to 10)||0.04 ± 0.03||1.99 ± 0.23||< .001|