Background: Individuals with physical disabilities have fewer opportunities to participate in enjoyable physical activity. One option for increasing physical activity is playing active video games (AVG), however, many are inaccessible or offer limited play options. Objective: To examine energy expenditure and enjoyment in adults with mobility impairment during AVG play using off-the-shelf (OTS) and adapted versions of the Wii Fit balance board. Methods: During visit 1, participants completed a functional assessment and familiarization period. For visit 2, metabolic data were collected during a 20-minute baseline and four 10-minute bouts of Wii Fit Plus game play, two bouts on each of the boards. During rest participants completed the Physical Activity Enjoyment Scale (PACES). Statistical analyses were computed using SPSS. Data were analyzed separately for individuals who were able to play standing on both boards (StdStd), those who could not play standing on the OTS board, but were able to play standing on the adapted board (aStd), and for those who could only play seated on the OTS board (aSit). Results: Data were collected for 58 participants (StdStd, n=17; aStd, n=10; aSit, n=31). Sample included 31 men, 27 women with a mean age of 41.21 (±12.70) years. Energy expenditure (METs) during game play was significantly greater than rest for all players. Only 17 participants (StdStd group) were able to play using OTS board. During game play on adapted board average MET values for the two game sets were: aSit = 2.261±0.718, 2.233±0.751 kcal/kg/hour; aStd = 3.151±1.034, 2.990±1.121; StdStd = 2.887±0.823, 2.881±0.898. For game play on the adapted board, self-reported rating of perceived exertion (RPE) on a 0-10 scale suggested greater exercise intensity levels, with median RPE scores ranging from moderate (3) to very hard (7). PACES scores indicated that all players enjoyed using the adapted board with median scores of 4 on a 5-point scale. Conclusions: The adapted Wii Fit balance board provided an opportunity for those with mobility impairments, including wheelchair users, to engage in AVG. All participants were able to utilize the adapted controller and enjoyed the AVG activity. Although average MET values achieved during AVG represented light intensity exercise (<3 METs), 16% of seated participants and 41% of standing participants achieved moderate intensity (3-6 METs) exercise on at least one of the games. Factors not accounted for that may have influenced intensity of exercise include: 1) game selection, 2) limited familiarization period, and 3) discomfort wearing COSMED system for oxygen consumption measurement. Accessible AVG controllers offer an innovative approach to overcoming various barriers to participation in physical activity. Next steps include assessment of an AVG intervention using an adapted board gaming controller on health and fitness outcomes. Trial Registration: ClinicalTrials.gov NCT02994199