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 (AVGs); however, many AVGs are inaccessible or offer limited play options. Objective: This study aimed 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 (Nintendo). Methods: During visit 1, participants completed a functional assessment and the familiarization period. During visit 2, metabolic data were collected during a 20-minute baseline and four 10-minute bouts of Wii Fit Plus game play, with two bouts on each of the boards. During the resting period, participants completed the Physical Activity Enjoyment Scale (PACES). Statistical analyses were computed using SPSS software. Data were analyzed separately for individuals who were able to play while standing on both boards (StdStd); those who could not play while standing on the OTS board, but were able to play while standing on the adapted board (aStd); and those who could only play while sitting on the adapted board (aSit). Results: Data were collected for 58 participants (StdStd, n=17; aStd, n=10; aSit, n=31). The sample included 31 men and 27 women with a mean age of 41.21 (SD 12.70) years. Energy expenditure (metabolic equivalent [MET]) during game play was significantly greater than that during rest for all players. Only 17 participants (StdStd group) were able to play using the OTS board. During game play on the adapted board, the average MET values for the two game sets were 2.261 (SD 0.718) kcal/kg/hour and 2.233 (SD 0.751) kcal/kg/hour for the aSit group, 3.151 (SD 1.034) and 2.990 (SD 1.121) for the aStd group, and 2.732 (SD 0.655) and 2.777 (SD 0.803) for the StdStd group. For game play on the adapted board, self-reported ratings of perceived exertion on a 0-10 scale suggested greater exercise intensity levels, with median scores ranging from moderate (3) to very hard (7). The PACES scores indicated that all players enjoyed using the adapted board, with a median score of 4 on a 5-point scale. Conclusions: The adapted Wii Fit balance board provided an opportunity for individuals 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 the average MET values achieved during AVG represented light-intensity exercise (<3 METs), 16% of sitting participants and 41% of standing participants achieved moderate-intensity exercise (3-6 METs) in at least one of the games. Factors not accounted for, which may have influenced the intensity of exercise, include game selection, limited familiarization period, and discomfort wearing the COSMED portable metabolic system for measurement of oxygen consumption. Accessible AVG controllers offer an innovative approach to overcome various barriers to participation in physical activity. The next steps include assessment of an AVG intervention using an adapted board gaming controller on health and fitness outcomes.