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Journal Description

JMIR Serious Games (JSG, ISSN 2291-9279; Impact Factor: 2.226) is a multidisciplinary journal devoted to computer/web/virtual reality/mobile applications that incorporate elements of gaming, gamification or novel hardware platforms such as virtual reality headsets or Microsoft Kinect to solve serious problems such as health behavior change, physical exercise promotion (exergaming), medical rehabilitation, diagnosis and treatment of psychological/psychiatric disorders, medical education, health promotion, teaching and education, or social change. The journal also considers commentary and research in the fields of video games violence and video games addiction.

The journal is indexed in PubMed, PubMed Central, DOAJ, and SCIE/Web of Science, and JCR (Journal Citation Reports) where it received an official impact factor by Clarivate. In June 2018, JSG received an official inaugural journal impact factor of 2.226 (Journal Citation Reports 2017, Clarivate Analytics), ranking JSG at the top of all gaming related academic journals, ahead of (for example) more established competitor journals such as the Games for Health Journal. 


Recent Articles:

  • Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review


    Background: Although traditional forms of therapy for anxiety-related disorders (eg, cognitive behavioral therapy, CBT) have been effective, there have been long-standing issues with these therapies that largely center around the costs and risks associated with the components comprising the therapeutic process. To treat certain types of specific phobias, sessions may need to be held in public, therefore risking patient confidentiality and the occurrence of uncontrollable circumstances (eg, weather and bystander behavior) or additional expenses such as travel to reach a destination. To address these issues, past studies have implemented virtual reality (VR) technologies for virtual reality exposure therapy (VRET) to provide an immersive, interactive experience that can be conducted privately and inexpensively. The versatility of VR allows various environments and scenarios to be generated while giving therapists control over variables that would otherwise be impossible in a natural setting. Although the outcomes from these studies have been generally positive despite the limitations of legacy VR systems, it is necessary to review these studies to identify how modern VR systems can and should improve to treat disorders in which anxiety is a key symptom, including specific phobias, posttraumatic stress disorder and acute stress disorder, generalized anxiety disorder, and paranoid ideations. Objective: The aim of this review was to establish the efficacy of VR-based treatment for anxiety-related disorders as well as to outline how modern VR systems need to address the shortcomings of legacy VR systems. Methods: A systematic search was conducted for any VR-related, peer-reviewed articles focused on the treatment or assessment of anxiety-based disorders published before August 31, 2017, within the ProQuest Central, PsycINFO, and PsycARTICLES databases. References from these articles were also evaluated. Results: A total of 49 studies met the inclusion criteria from an initial pool of 2419 studies. These studies were a mix of case studies focused solely on VRET, experimental studies comparing the efficacy of VRET with various forms of CBT (eg, in vivo exposure, imaginal exposure, and exposure group therapy), and studies evaluating the usefulness of VR technology as a diagnostic tool for paranoid ideations. The majority of studies reported positive findings in favor of VRET despite the VR technology’s limitations. Conclusions: Although past studies have demonstrated promising and emerging efficacy for the use of VR as a treatment and diagnostic tool for anxiety-related disorders, it is clear that VR technology as a whole needs to improve to provide a completely immersive and interactive experience that is capable of blurring the lines between the real and virtual world.

  • Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Patterns Among 754 Gamification Cases: Content Analysis for Gamification Development


    Background: Gamification is one of the techniques that applies game elements, such as game mechanics and dynamics, to a nongame context (eg, management, education, marketing, and health care). A variety of methodologies have been published for developing gamification. However, some of these are only usable by people with a certain level of gamification knowledge. People who do not have such knowledge face difficulty in using game mechanics and experiencing enjoyment. To ease their difficulties, a gamification methodology should provide directions for using game mechanics. Objective: This study aimed at collecting global gamification cases and determining patterns or differences among the collected cases. Methods: In total, 754 cases were collected based on 4F process elements, such as play type, playful user experience (PLEX)–based fun factors, and game mechanics. In addition, the collected cases were classified into 6 categories. From the data analysis, basic statistics and correlation analyses (Pearson and Kendall) were conducted. Results: According to the analysis results in PLEX-based fun factors, challenge and completion fun factors formed a large proportion among the 6 categories. In the results of the game mechanics analysis, point, leaderboard, and progress accounted for a large proportion among the 6 categories. The results of the correlation analysis showed no difference or specific patterns in game mechanics (Pearson r>.8, Kendall τ>.5, P<.05) and PLEX-based fun factors (Pearson r>.8, Kendall τ>.7, P<.05). Conclusions: On the basis of the statistical findings, this study suggests an appropriate number of PLEX-based fun factors and game mechanics. In addition, the results of this study should be used for people who do not have gamification knowledge and face difficulty using game mechanics and PLEX-based fun factors.

  • In-game welcome screen from OU Brainwave app (montage). Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    A Mobile App Delivering a Gamified Battery of Cognitive Tests Designed for Repeated Play (OU Brainwave): App Design and Cohort Study


    Background: Mobile phone and tablet apps are an increasingly common platform for collecting data. A key challenge for researchers has been participant “buy-in” and attrition for designs requiring repeated testing. Objective: The objective of this study was to develop and assess the utility of 1-2 minute versions of both classic and novel cognitive tasks using a user-focused and user-driven mobile phone and tablet app designed to encourage repeated play. Methods: A large sample of app users (N=13,979 at first data collection) participated in multiple, self-paced sessions of classic working memory (N-back), spatial cognition (mental rotation), sustained attentional focus (persistent vigilance task), and split attention (multiple object tracking) tasks, along with the implementation of a comparatively novel action-learning task. The “OU Brainwave” app was designed to measure time-of-day variation in cognitive performance and did not offer any training program or promise any cognitive enhancement. To record participants’ chronotype, a full Morningness-Eveningness questionnaire was also included, which measures whether a person's circadian rhythm produces peak alertness in the morning, in the evening, or in between. Data were collected during an 18-month period. While the app prompted re-engagement at set intervals, participants were free to complete each task as many times as they wished. Results: We found a significant relationship between morningness and age (r=.298, n=12,755, P<.001), with no effect of gender (t13,539=−1.036, P=.30). We report good task adherence, with ~4000 participants repeatedly playing each game >4 times each—our minimum engagement level for analysis. Repeated plays of these games allowed us to replicate commonly reported gender effects in gamified spatial cognition (F1,4216=154.861, P<.001, η2ρ=.035), split attention (F1,4185=11.047, P=.001, η2ρ=.003), and sustained attentional focus (F1,4238=15.993, P<.001, η2ρ=.004) tasks. We also report evidence of a small gender effect in an action-learning task (F1,3988=90.59, P<.001, η2ρ=.022). Finally, we found a strong negative effect of self-reported age on performance, when controlling for number of plays, in sustained attentional focus (n=1596, F6,1595=30.23, P<.001, η2=.102), working memory (n=1627, F6,1626=19.78, P<.001, η2=.068), spatial cognition (n=1640, F6,1639=23.74, P<.001, η2=.080), and split attention tasks (n=1616, F6,1615=2.48, P=.02, η2=.009). Conclusions: Using extremely short testing periods and permitting participants to decide their level of engagement—both in terms of which gamified task they played and how many sessions they completed—we were able to collect a substantial and valid dataset. We suggest that the success of OU Brainwave should inform future research oriented apps—particularly in issues of balancing participant engagement with data fidelity.

  • The Delirium Experience serious game (montage). Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    A Web-Based Serious Game on Delirium as an Educational Intervention for Medical Students: Randomized Controlled Trial


    Background: Adequate delirium recognition and management are important to reduce the incidence and severity of delirium. To improve delirium recognition and management, training of medical staff and students is needed. Objective: In this study, we aimed to gain insight into whether the serious game, Delirium Experience, is suited as an educational intervention. Methods: We conducted a three-arm randomized controlled trial. We enrolled 156 students in the third year of their Bachelor of Medical Sciences degree at the University Medical Centre Groningen. The Game group of this study played Delirium Experience. The Control D group watched a video with explanations on delirium and a patient’s experience of delirious episodes. The Control A group watched a video on healthy aging. To investigate students’ skills, we used a video of a delirious patient for which students had to give care recommendations and complete the Delirium Observations Screening Scale and Delirium Rating Scale R-98. Furthermore, students completed the Delirium Attitude Scale, the Learning Motivation and Engagement Questionnaire, and self-reported knowledge on delirium. Results: In total, 156 students participated in this study (Game group, n=51; Control D group, n=51; Control A group, n=55). The Game group scored higher with a median (interquartile range) of 6 (4-8) for given recommendations and learning motivation and engagement compared with the Control D (1, 1-4) and A (0, 0-3) groups (P<.001). Furthermore, the Game group scored higher (7, 6-8) on self-reported knowledge compared with the Control A group (6, 5-6; P<.001). We did not find differences between the groups regarding delirium screening (P=.07) and rating (P=.45) skills or attitude toward delirious patients (P=.55). Conclusions: The serious game, Delirium Experience, is suitable as an educational intervention to teach delirium care to medical students and has added value in addition to a lecture.

  • Virtual reality head-mounted display in use. Source: B Garrett, University of British Columbia; Copyright: B Garrett, University of British Columbia; URL:; License: Licensed by JMIR.

    Virtual Reality Clinical Research: Promises and Challenges


    Background: Virtual reality (VR) therapy has been explored as a novel therapeutic approach for numerous health applications, in which three-dimensional virtual environments can be explored in real time. Studies have found positive outcomes for patients using VR for clinical conditions such as anxiety disorders, addictions, phobias, posttraumatic stress disorder, eating disorders, stroke rehabilitation, and for pain management. Objective: This work aims to highlight key issues in the implementation of clinical research for VR technologies. Methods: A discussion paper was developed from a narrative review of recent clinical research in the field, and the researchers’ own experiences in conducting VR clinical research with chronic pain patients. Results: Some of the key issues in implementing clinical VR research include theoretical immaturity, a lack of technical standards, the problems of separating effects of media versus medium, practical in vivo issues, and costs. Conclusions: Over the last decade, some significant successes have been claimed for the use of VR. Nevertheless, the implementation of clinical VR research outside of the laboratory presents substantial clinical challenges. It is argued that careful attention to addressing these issues in research design and pilot studies are needed in order to make clinical VR research more rigorous and improve the clinical significance of findings.

  • Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Digital Gaming to Improve Adherence Among Adolescents and Young Adults Living With HIV: Mixed-Methods Study to Test Feasibility and Acceptability


    Background: An estimated 50% of adolescents and young adults (AYA) living with HIV are failing to adhere to prescribed antiretroviral treatment (ART). Digital games are effective in chronic disease management; however, research on gaming to improve ART adherence among AYA is limited. Objective: We assessed the feasibility and acceptability of video gaming to improve AYA ART adherence. Methods: Focus group discussions and surveys were administered to health care providers and AYA aged 13 to 24 years living with HIV at a pediatric HIV program in Washington, DC. During focus group discussions, AYA viewed demonstrations of 3 game prototypes linked to portable Wisepill medication dispensers. Content analysis strategies and thematic coding were used to identify adherence themes and gaming acceptance and feasibility. Likert scale and descriptive statistics were used to summarize response frequencies. Results: Providers (n=10) identified common adherence barriers and strategies, including use of gaming analogies to improve AYA ART adherence. Providers supported exploration of digital gaming as an adherence intervention. In 6 focus group discussions, 12 AYA participants identified disclosure of HIV status and irregular daily schedules as major barriers to ART and use of alarms and pillboxes as reminders. Most AYA were very or somewhat likely to use the demonstrated game prototypes to help with ART adherence and desired challenging, individually tailored, user-friendly games with in-game incentives. Game prototypes were modified accordingly. Conclusions: AYA and their providers supported the use of digital games for ART adherence support. Individualization and in-game incentives were preferable and informed the design of an interactive technology-based adherence intervention among AYA living with HIV.

  • Source:; Copyright: Jamie McInall; URL:; License: Licensed by JMIR.

    The Untapped Potential of the Gaming Community: Narrative Review


    Background: Video gamers are a population at heightened risk of developing obesity due to the sedentary nature of gaming, increased energy intake, and the disruption caused to their sleep. This increases their risk of developing a number of noncommunicable diseases. To date, research seeking to improve health behaviors has focused on developing novel video games to promote behavior change. Although positive results have emerged from this research, large-scale success has been limited due to the lack of transferability to mainstream games and the focus on children and adolescents. The gaming community has a number of unique aspects, which have received comparatively less attention than the development of new video games. Objective: The purpose of this paper is to highlight under-researched areas that have the potential to encourage positive health behavior among this community. Methods: A narrative review of the lay and academic literature was conducted to provide context and support to our claims that further research could be beneficial in this area. Results: Research has found that advertising can have implicit effects on an individual’s memories, which could influence later decisions. However, the effect of the exponential growth of in-game advertisements and the brand sponsorship of gaming events and professional gamers have not been explored in the gaming community. The possibility of using advertising techniques to encourage positive health behaviors within games or at these events has also not been explored. Research suggests that virtual communities can be effective at disseminating health information, but the efficacy of this needs to be explored using known community influencers within the gaming community. Conclusions: This paper has highlighted a number of potential avenues for the development of interventions within the gaming community. Further research must be conducted alongside game developers to ensure that any in-game developed interventions do not deter gameplay and gamers to ensure that potential approaches are acceptable.

  • Participant playing the video game, Lifeguard (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Investigating the Relationship Between Eye Movement and Brain Wave Activity Using Video Games: Pilot Study


    Background: All eye movements are related in one way or another to our mental processes with lateral eye movements being associated with the different hemispheres of the brain. Eye movement techniques form the basis of eye movement desensitization and reprocessing therapy, wherein forced eye movements activate neurological pathways to treat the subject. Objective: The objective of our study was to examine the relationship between players' eye movements and their brain wave activities using a video game. Methods: We used similar eye movement techniques in the form of a video game called Lifeguard that could potentially stimulate different eye movement mode and create a more engaging experience for the user. By designing an experiment, we further explored the differences in electroencephalogram spectral power activity for the alpha, beta, theta, delta, and gamma frequency bands in Lifeguard and Tetris. Results: The game based on eye movement technologies resulted in decreased delta power and increased beta power, but significant difference between 2 games was not found. Conclusions: The applied uses of this research could mean that eye movement desensitization and reprocessing can be conducted in a more fun and engaging way through the use of gaming technology.

  • Participant wearing the Oculus Rift headset. Source: Image created by the Authors; Copyright: Megan Applegate; URL:; License: Creative Commons Attribution (CC-BY).

    Determining Physiological and Psychological Predictors of Time to Task Failure on a Virtual Reality Sørensen Test in Participants With and Without Recurrent...


    Background: Sørensen trunk extension endurance test performance predicts the development of low back pain and is a strong discriminator of those with and without low back pain. Performance may greatly depend on psychological factors, such as kinesiophobia, self-efficacy, and motivation. Virtual reality video games have been used in people with low back pain to encourage physical activity that would otherwise be avoided out of fear of pain or harm. Accordingly, we developed a virtual reality video game to assess the influence of immersive gaming on the Sørensen test performance. Objective: The objective of our study was to determine the physiological and psychological predictors of time to task failure (TTF) on a virtual reality Sørensen test in participants with and without a history of recurrent low back pain. Methods: We recruited 24 individuals with a history of recurrent low back pain and 24 sex-, age-, and body mass index–matched individuals without a history of low back pain. Participants completed a series of psychological measures, including the Center for Epidemiological Studies-Depression Scale, Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and a self-efficacy measure. The maximal isometric strength of trunk and hip extensors and TTF on a virtual reality Sørensen test were measured. Electromyography of the erector spinae, gluteus maximus, and biceps femoris was recorded during the strength and endurance trials. Results: A two-way analysis of variance revealed no significant difference in TTF between groups (P=.99), but there was a trend for longer TTF in females on the virtual reality Sørensen test (P=.06). Linear regression analyses were performed to determine predictors of TTF in each group. In healthy participants, the normalized median power frequency slope of erector spinae (beta=.450, P=.01), biceps femoris (beta=.400, P=.01), and trunk mass (beta=−.32, P=.02) predicted TTF. In participants with recurrent low back pain, trunk mass (beta=−.67, P<.001), Tampa Scale for Kinesiophobia (beta=−.43, P=.01), and self-efficacy (beta=.35, P=.03) predicted TTF. Conclusions: Trunk mass appears to be a consistent predictor of performance. Kinesiophobia appears to negatively influence TTF for those with a history of recurrent low back pain, but does not influence healthy individuals. Self-efficacy is associated with better performance in individuals with a history of recurrent low back pain, whereas a less steep median power frequency slope of the trunk and hip extensors is associated with better performance in individuals without a history of low back pain.

  • The 3MD (Model for Motivational Mobile-health Design) model for chronic conditions. Source: Image created by the Author; Copyright: The Author; URL:; License: Creative Commons Attribution (CC-BY).

    3MD for Chronic Conditions, a Model for Motivational mHealth Design: Embedded Case Study

    Authors List:


    Background: Chronic conditions are the leading cause of death in the world. Major improvements in acute care and diagnostics have created a tendency toward the chronification of formerly terminal conditions, requiring people with these conditions to learn how to self-manage. Mobile technologies hold promise as self-management tools due to their ubiquity and cost-effectiveness. The delivery of health-related services through mobile technologies (mobile health, mHealth) has grown exponentially in recent years. However, only a fraction of these solutions take into consideration the views of relevant stakeholders such as health care professionals or even patients. The use of behavioral change models (BCMs) has proven important in developing successful health solutions, yet engaging patients remains a challenge. There is a trend in mHealth solutions called gamification that attempts to use game elements to drive user behavior and increase engagement. As it stands, designers of mHealth solutions for behavioral change in chronic conditions have no clear way of deciding what factors are relevant to consider. Objective: The goal of this work is to discover factors for the design of mHealth solutions for chronic patients using negotiations between medical knowledge, BCMs, and gamification. Methods: This study uses an embedded case study research methodology consisting of 4 embedded units: 1) cross-sectional studies of mHealth applications; 2) statistical analysis of gamification presence; 3) focus groups and interviews to relevant stakeholders; and 4) research through design of an mHealth solution. The data obtained was thematically analyzed to create a conceptual model for the design of mHealth solutions. Results: The Model for Motivational Mobile-health Design (3MD) for chronic conditions guides the design of condition-oriented gamified behavioral change mHealth solutions. The main components are (1) condition specific, which describe factors that need to be adjusted and adapted for each particular chronic condition; (2) motivation related, which are factors that address how to influence behaviors in an engaging manner; and (3) technology based, which are factors that are directly connected to the technical capabilities of mobile technologies. The 3MD also provides a series of high-level illustrative design questions for designers to use and consider during the design process. Conclusions: This work addresses a recognized gap in research and practice, and proposes a unique model that could be of use in the generation of new solutions to help chronic patients.

  • Source: Wikicommons; Copyright: Rama; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    The Modification of Vital Signs According to Nursing Students’ Experiences Undergoing Cardiopulmonary Resuscitation Training via High-Fidelity Simulation:...


    Background: High-fidelity simulation represents a primary tool in nursing education, especially when hands-on practical training is involved. Objective: We sought to determine the influence of high-fidelity clinical simulation, applied during cardiopulmonary resuscitation (CPR) training, on blood pressure, heart rate, stress, and anxiety levels in 2 groups of nursing students. One group had experience in health contexts, whereas the other group had none. Methods: We performed a quasi-experimental study. Data were collected between May and June 2015 and included measurements of all the resting values, before and after participation in CPR clinical simulations regarding the 2 groups of university students (ie, with and without experience). Results: An increase in vital signs was observed in students after participating in a clinical simulation scenario, especially the heart rate. In all students, increased stress and anxiety levels were observed before the first simulation case scenario. Also, in all study groups, a decrease in vital signs, stress levels, and anxiety was observed throughout the study. Conclusions: Participation in high-fidelity simulation experiences has both physiological and psychological effects on students.

  • Source: US Department of Defence (John J Kruzel); Copyright: US Department of Defence; URL:; License: Public Domain (CC0).

    Video Games as a Potential Modality for Behavioral Health Services for Young Adult Veterans: Exploratory Analysis


    Background: Improving the reach of behavioral health services to young adult veterans is a policy priority. Objective: The objective of our study was to explore differences in video game playing by behavioral health need for young adult veterans to identify potential conditions for which video games could be used as a modality for behavioral health services. Methods: We replicated analyses from two cross-sectional, community-based surveys of young adult veterans in the United States and examined the differences in time spent playing video games by whether participants screened positive for behavioral health issues and received the required behavioral health services. Results: Pooling data across studies, participants with a positive mental health screen for depression or posttraumatic stress disorder (PTSD) spent 4.74 more hours per week (95% CI 2.54-6.94) playing video games. Among participants with a positive screen for a substance use disorder, those who had received substance use services since discharge spent 0.75 more days per week (95% CI 0.28-1.21) playing video games than participants who had not received any substance use services since discharge. Conclusions: We identified the strongest evidence that participants with a positive PTSD or depression screen and participants with a positive screen for a substance use disorder who also received substance use services since their discharge from active duty spent more time playing video games. Future development and evaluation of video games as modalities for enhancing and increasing access to behavioral health services should be explored for this population.

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  • Augmented reality app in ultrasound training A prospective trial to demonstrate the effect of an augmented reality ultrasound trainer application on the motorical skills needed for a kidney ultrasound.

    Date Submitted: Nov 8, 2018

    Open Peer Review Period: Nov 9, 2018 - Jan 4, 2019

    Background: Medical education is currently evolving from 'learning by doing' to simulation based hands on tutorials. Objective: The aim of this prospective 2-armed study is to evaluate a newly develop...

    Background: Medical education is currently evolving from 'learning by doing' to simulation based hands on tutorials. Objective: The aim of this prospective 2-armed study is to evaluate a newly developed augmented reality ultrasound application and its effect on educational training and diagnostic accuracy. Methods: 66 medical students were recruited and using imaging and measuring a kidney as quality indicator were tested on the time they needed for imaging. Both groups used text books as preparation; in addition, the study group had access to a virtual ultrasound simulation application for mobile devices (APP). Results: There was no significant difference between the study arms regarding age, gender and previous ultrasound experience. The time needed to complete the kidney measurements also did not differ significantly. However, the results of the longitudinal kidney measurements differed significantly between study and control group, with larger more realistic values in the study group (study group: medianright 105.3 mm, range 86.1 mm – 127.1 mm, control group: medianright 92 mm, range 50.4 mm – 112.2 mm; p < .01; study group: medianleft 100.3 mm, range 81.7 mm – 118.6 mm, control group: medianleft 85.3 mm, range 48.3 mm – 113.4 mm; p < .01). Furthermore, whilst all students of the study group obtained valid measurements, students of the control group failed to obtain valid measurements of one or both kidneys in seven cases. Conclusions: To summarize, the newly developed augmented reality ultrasound simulator APP provides a useful add-on for ultrasound education and training. Our results indicate that the use of the APP for training purposes results in improved quality of kidney measurements in medical students. Clinical Trial: The Trial was registered with the local ethics commission

  • EpiduroSIM: Epiduroscopy simulator based on serious game for spatial cognitive training

    Date Submitted: Nov 5, 2018

    Open Peer Review Period: Nov 5, 2018 - Dec 31, 2018

    Background: Performing high-level surgeries with endoscopy are challenging, and hence, an efficient surgical training method or system is required. Serious-game-based simulators can provide a trainee-...

    Background: Performing high-level surgeries with endoscopy are challenging, and hence, an efficient surgical training method or system is required. Serious-game-based simulators can provide a trainee-centered educational environment unlike the traditional teacher-centered education environments because serious game provides a high level of interaction (feedback that induces learning). Objective: We herein propose an epiduroscopy simulator, EpiduroSIM, based on a serious game for spatial cognitive training. Methods: The proposed EpiduroSIM is designed based on a serious game. For spatial cognitive training, the virtual environment of the proposed EpiduroSIM is modeled based on a cognitive map. The proposed EpiduroSIM is developed considering user accessibility, to provide various functions. The experiment for the validation of the proposed EpiduroSIM focused on the psychological fidelity and repetitive training effects. The experiments were conducted by dividing 16 specialists into 2 groups of 8 surgeons. The group was divided into the beginner and the expert, based on their epiduroscopy experience. Results: The psychological fidelity of the proposed EpiduroSIM was confirmed through the training results of the expert group rather than the beginner group. In addition, the repetitive training effect of the proposed EpiduroSIM was confirmed by improving the training results in the beginner group. Conclusions: The proposed EpiduroSIM may be useful for beginner surgeons to train epiduroscopy. Clinical Trial: N/A

  • Development of CliniPup®, a serious game for health aimed at reducing perioperative anxiety and pain in children

    Date Submitted: Oct 5, 2018

    Open Peer Review Period: Oct 9, 2018 - Dec 4, 2018

    Background: Increasing numbers of children undergo ambulatory surgery each year and a significant proportion experiences substantial preoperative anxiety and postoperative pain. The management of peri...

    Background: Increasing numbers of children undergo ambulatory surgery each year and a significant proportion experiences substantial preoperative anxiety and postoperative pain. The management of perioperative anxiety and pain remains challenging in children and is inadequate, which negatively impacts physical, psychosocial, and economic outcomes. Existing non-pharmacological interventions are costly, time consuming, vary in availability, and lack benefits. Therefore, there is a need for an evidence-based, accessible, non-pharmacological intervention as an adjunct to existing pharmacological alternatives to reduce perioperative anxiety and pain in children undergoing ambulatory surgery. Technology-enabled interventions have been proposed as a method to address the unmet need in this setting. In particular, serious games for health (SGHs) hold unique potential to change health beliefs and behaviors in children. Objective: The objective of this research was to describe the rationale, scientific evidence, design aspects, and features of CliniPup, an SGH aimed at reducing perioperative anxiety and pain in children undergoing ambulatory surgery. Methods: The SERES framework for SGH development was used to create the SGH, CliniPup. In particular, a mixed-methods approach was applied that consisted of a structured literature review supplemented with ethnographic research, such as expert interviews and a time-motion exercise. The resulting scientific evidence base was leveraged to ensure that the resulting SGH was relevant, realistic, and theory-driven. A participatory design approach was applied wherein clinical experts qualitatively reviewed several versions of the SGH and an iterative creative process was used to integrate the applicable feedback. Results: CliniPup, an SGH, was developed to incorporate (1) scientific evidence base from a structured literature review, (2) realistic content collected during ethnographic research such as expert interviews, (3) explicit pedagogical objectives from scientific literature, and (4) game mechanics and user interface design that address key aspects of the evidence. Conclusions: This report details the systematic development of CliniPup, an SGH aimed at reducing perioperative anxiety and pain in children undergoing ambulatory surgery. Clinical experts validated CliniPup’s underlying scientific evidence base and design foundations, suggesting that it was well designed for preliminary evaluation in the target population. An evaluation plan is proposed and briefly described.

  • CliniPup®, a web-based serious game for health to reduce perioperative anxiety and pain in children: a Pilot Study

    Date Submitted: Oct 5, 2018

    Open Peer Review Period: Oct 9, 2018 - Dec 4, 2018

    Background: As pediatric ambulatory surgeries are rising and existing methods to reduce perioperative anxiety and pain are lacking in this population, a serious game for health (SGH), CliniPup, was de...

    Background: As pediatric ambulatory surgeries are rising and existing methods to reduce perioperative anxiety and pain are lacking in this population, a serious game for health (SGH), CliniPup, was developed to address this unmet need. CliniPup was generated using the SERES framework for serious game development. Objective: To clinically evaluate CliniPup, an SGH, as an adjunct therapy to existing pharmacological interventions aimed at reducing perioperative anxiety and pain in children undergoing ambulatory surgery. Methods: CliniPup was evaluated in a prospective, randomized, controlled pilot trial in 20 children aged 6-10 years who underwent elective surgery, and their parents. Study participants were randomly assigned to the test (n=12) or control group (n=8). Children in the test group played CliniPup 2-days prior to surgery and children in the control group received standard of care. On the day of surgery, pediatric anxiety was measured with the modified Yale Preoperative Anxiety Scale (mYPAS) and parental anxiety was assessed with the State-Trait Anxiety Inventory (STAI). Pediatric postoperative pain was assessed by the Wong-Baker Faces Pain Rating Scale (WBFPRS). Child and parent user experience and satisfaction was also evaluated in the test group using structured questionnaires. Results: Despite the small sample, preoperative anxiety scores were significantly lower (P = .01) in children who played CliniPup prior to surgery, compared to controls. Parental preoperative anxiety scores were also lower in the test group (P = .10), but did not reach significance. No significant differences were observed in postoperative pain scores between groups (P = .54). The evaluation of user experience and satisfaction revealed that both children and parents were satisfied with CliniPup and would recommend the game to peers. Conclusions: Results of the pilot trial introduce CliniPup as a potentially effective and attractive adjunct therapy, to reduce preoperative anxiety in children undergoing ambulatory surgery, with a trend towards positive impact on parental preoperative anxiety. These results support the use of the SERES framework to generate an evidence-based SGH, which results in positive health outcomes for patients. Based on these preliminary findings, we propose a research agenda to further develop and investigate this tool.

  • Building up Trunk Muscles 2.0? Full Body Exergaming in Virtual Reality

    Date Submitted: Sep 27, 2018

    Open Peer Review Period: Oct 1, 2018 - Nov 26, 2018

    Background: In recent years many studies have associated the long time spent sedentary in front of screens with health problems in infants, children, and adolescents. Yet options for exergaming – pl...

    Background: In recent years many studies have associated the long time spent sedentary in front of screens with health problems in infants, children, and adolescents. Yet options for exergaming – playing video games that require rigorous physical exercise – seem to fail short of the physical activity levels recommended by the WHO. Objective: Here we test a full immersive VR-based training system designed to improve its users’ cardiorespiratory and muscular fitness while providing an enjoyable workout. Methods: A cross-sectional experiment design was used to analyze muscle activity (sEMG), heart rate, perceived rate of exhaustion (RPE) as well as cybersickness symptoms (SSQ), perceived workload, and physical activity enjoyment (PACES) from 33 participants performing a 5-min VR-simulated flight on a new training device. Results: The participants’ attempt to hold the planking position required to play the game resulted in moderate aerobic intensity (108 bpm ± 18.69). Due to the mainly isometric contraction of the dorsal muscle chain (with a mean activation between 20.6% (± 10.57) and 26.7% MVC (± 17.39)) they described the exercise as a moderate to vigorous activity (RPE 14.6 ± 1.82). The majority of the participants reported that they enjoyed the exercise (PACES 3.74 ± 0.16). However, six participants had to drop out because of cybersickness symptoms. Conclusions: Our findings suggest that fully immersive VR training systems can contribute to muscle-strengthening activities for healthy users. However, the drop-out rate highlights the need for technological improvements in both software and hardware. In prevention and therapy, movement quality is a fundamental element in providing effective resistance training that benefits health. Exergaming on a regular basis has the potential to develop strong muscles and a healthy back. It is essential that future VR-based training systems take into account the recommendations of sport and exercise science.