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Patients who receive rehabilitation after hip replacement surgery are shown to have increased muscle strength and better functional performance. However, traditional physiotherapy is often tedious and leads to poor adherence. Exercise games, provide ways for increasing the engagement of elderly patients and increase the uptake of rehabilitation exercises.
The objective of this study was to evaluate Fietsgame (Dutch for
This paper describes a pilot study that evaluates the usability of the Fietsgame. The study was conducted in a rehabilitation center with 9 participants, including 2 physiotherapists and 7 patients. The patients were asked to play 6 exercise games, each lasting about 5 min, under the guidance of a physiotherapist. The mean age of the patients was 74.57 years (standard deviation [SD] 8.28); all the patients were in the recovery process after hip surgery. Surveys were developed to quantitatively measure the usability factors, including presence, enjoyment, pain, exertion, and technology acceptance. Comments on advantages and suggested improvements of our game system provided by the physiotherapists and patients were summarized and their implications were discussed.
The results showed that after successfully playing the games, 75% to 100% of the patients experienced high levels of enjoyment in all the games except the squats game. Patients reported the highest level of exertion in squats when compared with other exercise games. Lunges resulted in the highest dropout rate (43%) due to interference with the Kinect v2 from support chairs. All the patients (100%) found the game system useful and easy to use, felt that it would be a useful tool in their further rehabilitation, and expressed that they would like to use the game in the future. The therapists indicated that the exercise games highly meet the criteria of motor rehabilitation, and they intend to continue using the game as part of their rehabilitation treatment of patients. Comments from the patients and physiotherapists suggest that real-time corrective feedback when patients perform the exercises wrongly and a more personalized user interface with options for increasing or decreasing cognitive load are needed.
The results suggest that Fietsgame can be used as an alternative tool to traditional motor rehabilitation for patients with hip surgery. Lunges and squats are found to be more beneficial for patients who have relatively better balance skills. A follow-up randomized controlled study will be conducted to test the effectiveness of the Fietsgame to investigate how motivating it is over a longer period of time.
Elderly people consume a large part of the health care and social services, especially in developed countries [
Due to the engaging, entertaining, and thus motivating properties of exercise games, gaming has been proposed as a valuable instrument to encourage patients’ participation in rehabilitation and improve patients’ adherence to therapy programs [
Exercise games have shown equal or superior effectiveness compared with conventional physiotherapy in rehabilitation in patients over 16 years of age [
Compared with traditional rehabilitation, exercise games allow for task-specific exercises to be delivered at different difficulty levels. This allows the patient to start at an appropriate level and then proceed, based on a set of goals, with a gradual progression of difficulty. However, according to Skjaeret et al [
Achieving the goal of rehabilitation after hip surgery requires accurate and appropriate tracking and feedback. Therefore, we developed Fietsgame using Microsoft Kinect as an off-the-shelf three-dimensional (3D) depth camera. Kinect v2 offers marker-free full-body tracking on a conventional personal computer (PC). It has a wide field- of-view to provide full-body control of animated virtual characters. This allows the virtual character on the screen to mirror the movements of the user in real time. Earlier studies concluded that Kinect v2 has the potential to be used as a reliable and valid clinical measurement tool [
To the best of our knowledge, only a few Kinect games offer exercises with full-body animated virtual characters and configurable level of difficulties, which are required for rehabilitation after hip surgery. Earlier studies using Kinect to design rehabilitation exercise games either focus on rehabilitation of the upper body [
In general, applications supporting the management of illnesses or providing assistance in daily living activities for the elderly showed good usability and high acceptance [
In this pilot study, we were interested in getting an insight into the point of view from the physiotherapists, in particular whether the exercise games satisfy the nature of a motor rehabilitation program for elderly patients after hip surgery (Research question 1) and whether they have the intention to use the exercise games to treat the patients in the future (Research question 2). Furthermore, we investigated whether the patients experienced a high level of presence and enjoyment and an expected level of exertion and pain (Research question 3), and whether they found the games easy to use and wanted to continue using the exercise games to do further rehabilitation (Research question 4).
In total, 2 physiotherapists (a male aged 31 years and a female aged 29 years) and 7 patients (5 females and 2 males) with age range of 60 to 82 years (mean 74.57, SD 8.28) from Aafje Rehabilitation Center in Rotterdam, The Netherlands, participated in this study. The patients were recovering from hip joint replacement (hip arthroplasty) or (unipolar) short-stem hemiarthroplasty surgery. The inclusion criteria of the patients were that they should be capable of performing the exercises and understanding the instructions of the exercise game. Patients with acute illness in the past 3 weeks, with mental disorders, or with poor visual acuity (not capable of seeing the visual features on the TV screen) were excluded.
All participants provided written informed consent before their participation in the experiment. After completing the experiment and answering the questions, they received a compensation gift. The exercise games imposed the same risk as a regular therapy session, because the patients performed the same exercises as part of their normal treatment. Whenever the patient was playing the game, a physiotherapist was always present. The load of the exercise games was comparable with the normal treatment for both the patients and the therapists, according to the physiotherapists. This study has been approved by the board of directors of the rehabilitation center of Aafje and the ethical committee of Utrecht University.
The Fietsgame has been designed by a consortium of physiotherapists, game designers, researchers, and an information technology company with the goal of improving the rehabilitation process. The specific aim was to increase the mobility of the joints and surrounding soft tissues and to increase muscular strength as well as endurance. The system has the following two components: the exercise games and Community Care 360 (CC360) with a therapist control interface and the patient’s medical record. The exercise games and CC360 are connected by the Internet of Things (IoT) server from Consultants to Government and Industries (CGI) [
After the exercise game recognizes the identity of the patient, assigned workout is automatically retrieved from the server using the Raspberry Pi. When the patient completes the exercise game, his or her workout data such as the number of exercises, knee or hip angles, and game scores are sent to the IoT platform and stored for further analysis. Both the patient and the physiotherapist can read the patient’s workout data through CC360.
The Fietsgame system.
The purpose of hip rehabilitation is to reduce symptoms such as pain and inflammation and improve hip joint function approached through a systematic progression, depending on the patient’s present pathology and functional needs. The patients must understand the related precautions and the recommended progression for their individual situations. The physiotherapists advise a suitable exercise program by defining frequency, duration, and range of motion after considering the patient’s level of discomfort and physical status of the hip joints [
The games are implemented using the Unity 3D game engine. There are 6 exercise games with 6 different balance exercises: cycling in a life-like virtual village for stepping, dancing under the spotlight with fellow dancers for sidestepping, ringing the bell in a church for squats, picking up apples for lunges, playing football for back kicks, and fishing on a boat for single leg stance (
The cycling game—stepping; left: virtual environment, right: configurable variables.
The dancing game—sidestepping; left: virtual environment, right: configurable variables.
In the cycling game (
The dancing game (
The ringing the bell game—squats; left: virtual environment, right: configurable variables.
During the ringing the bell game (
The apple picking game—lunges; left: virtual environment, right: configurable variables.
The apple picking game (
The football playing game—back kicks; left: virtual environment, right: configurable variables.
The goal of the football game (
The fishing game—one leg stance; left: virtual environment, right: configurable variables.
The objective of the fishing game (
CC360 is a patient-centric health platform that allows the patients, health care professionals, and other stakeholders to monitor and manage the patients’ health. CC360 provides applications for both the therapists and the patients. The configuration interface (
Top: the physiotherapist control interface; bottom: the patient interface showing patient’s medical record in CC360. The configuration parameter vissen_aantal means the number of fishing exercises.
The measurements used in the experiment include psychometric tools, such as self-reported questionnaires, and objective behavioral measurements. Objective behavioral measures such as knee angle, step width, hip angle, and the number of successfully finished exercises were captured by Kinect v2 and sent to the IoT platform via the Raspberry Pi. The experiment was also video-recorded for further analysis of the comments of the therapists and the patients during the exercise game. Self-reported questionnaires were filled in by the therapists and were answered by the patients. The questionnaire for the patients was designed to measure the subjective feeling of presence, enjoyment, exertion, pain level, and technology acceptance, whereas the questionnaire for the physiotherapist was aimed to get an expert opinion on the usability of the game from the technology acceptance and rehabilitation point of view. More details about the questionnaires are given below, and the questionnaires for patients and physiotherapists are attached in
At the beginning of the experiment, patients were asked to fill in a questionnaire containing the following personal data: date of intake, the current number of daily exercise sessions, age, gender, mother tongue, gameplay experience, and social status. Visual acuity was measured using the Freiburg Visual Acuity Test at a distance of 3 m [
The concept of presence in virtual reality covers three aspects: spatial presence, social presence, and copresence [
Enjoyment was tested by using a 1-item question on a 7-point Likert scale, “Do you find the exercise game interesting?” [
The adapted Technology Acceptance Model (TAM) from Hu et al [
At the beginning of the experiment, the physiotherapists were asked to fill in a questionnaire, which recorded their age, gender, mother tongue, education, and gameplay experience. The experience of using the exercise game was investigated through questionnaires, including criteria for rehabilitation of the exercise game [
Regarding the usability of the game for motor rehabilitation, we used a revised version of the design criteria for stroke rehabilitation programs for elderly users from Flores et al [
Adaptability to the motor skill level of the patient. As motor impairments vary among patients and patients’ motor skills improve over time, the changeable level of difficulty in the exercise game is necessary.
Meaningful tasks. Tasks should be incorporated so that exercises in the game can be correlated with daily life activities.
Appropriate feedback for both the patient and the physiotherapist. The exercise game should provide real-time feedback on how well the patient is doing and how much she/he has been improving and provide encouraging feedback to stimulate the patient to adhere to the exercise game. Providing exercise record such as charting the history of patients’ exercise accomplishments can help the physiotherapist to better plan future therapy sessions.
Therapy appropriate range of motion. This refers to the extent the game demands the therapeutic motions needed for the rehabilitation program of patients after hip surgery.
Focus diverted from exercise. The game should be fun enough to divert patients’ attention from the exercises to the objectives of the gameplay.
Participants’ responses were rated on a 7-point Likert scale from −3 (strongly disagree) to 3 (strongly agree).
After playing each exercise game, all the participants were asked to give general feedback and comments on each game. At the end of the experiment, participants were asked to discuss their favorite and least favorite part of playing the exercise game in open questions.
To ensure high quality of recognition, we tested the exercise games in a controlled environment. To be more specific, the camera was set to track the closest person as long as possible, and only the player is within a distance of 2 to 3 m in front of the camera where the tracking accuracy is the best [
After obtaining consent and basic information from the patients and the physiotherapists, participants were introduced to the exercise games, including the Kinect v2 sensor and CC360. One of the experimenters took a picture of the patient and uploaded it to the IoT platform for facial recognition to start the exercise games. The therapist then assigned the exercises according to the patient’s recovery status through the configuration file on a PC. The patients were asked to play 6 different exercise games, each lasting about 5 min. The physiotherapist was always in the same room as a guide for the patient and answered all the questions the patient asked during the game. Each participant was assessed individually during the session, which in total lasted about 60 min. Patient’s behavior and the voice of the experimenters and the physiotherapist were recorded by a laptop camera for later transcription.
Before each exercise game, the physiotherapist showed how to play the exercise game correctly and explained the instructions on the screen. Participants, if applicable, wore their prescription glasses during the experiment. All the patients used chairs to prevent falling. The chairs were placed on the left or right and behind the player. After each exercise game, the patients were asked to report their experienced level of presence, enjoyment, perceived exertion, and pain level by one of the experimenters and their reported scores were noted in the printed hard copy of questionnaire; the physiotherapists were asked to fill in a short questionnaire, which measures whether the exercise game meets the criteria for rehabilitation. Both the patient and the physiotherapist were asked to give a general feedback and comments on the game that the patient just played. Objective behavioral measures, including knee angle, step width, and hip angle, and the number of successfully finished exercises, were captured by Kinect v2 during the gameplay.
At the end of the experiment, both the patients and the therapists were asked to fill in the questionnaire for the TAM and to give their general comments about the exercise games. The patients were also asked whether they felt any discomfort before they left the room. They were requested to rest until they feel better when they experienced any discomfort. After completing the experiment, participants were debriefed and given a gift of 10 euros for their contribution. As CC360 is a widely used commercial product [
All the behavioral data and self-reported scores of the questionnaires were analyzed with SPSS statistics package version 24. To answer our research questions, the measured data, including behavioral and self-reported data, were analyzed using descriptive statistics for all the 6 exercise games, and 2 trained researchers coded the qualitative feedback from patients and physiotherapists separately. Under the broad question, themes emerged from the coded data. The researchers discussed and refined the codes, that is, codes with similar meanings were grouped together, and the more frequently a code appeared, the more the theme was strengthened. We then analyzed the codes addressing gaming experience, game design, system operation, usefulness, and intention to use the exercise games.
A summary of demographic data and personal information of the patients is provided in
Median and interquartile ranges of workout assignments in the configuration from the guiding physiotherapist are provided in
All the patients used chairs to keep balance during the exercises.
Demographic and personal data of the patients.
Patient | Planned exercises per day | Age | Gender | Native language | Visual acuity | Sport | Frequency of playing computer games | Living status |
1 | 2 | 70 | Female | Dutch | 0.69 | Physio-training | Occasionally | Alone |
2 | 3 | 82 | Female | Dutch | 0.48 | Fitness and physio-training | Everyday | With partner |
3 | 6 | 82 | Male | Dutch | 0.66 | Physio-training | Never | With partner |
4 | 3 | 60 | Female | Dutch | 0.73 | Swimming, walking, and physio-training | Never | Alone |
5 | 4 | 81 | Female | Danish | 0.64 | Nordic walking and physio-training | Never | Alone |
6 | 2 | 77 | Female | Hungarian | 0.53 | Physio-training | Never | Alone |
7 | 4 | 70 | Male | Dutch | 0.53 | Coordinating football in the field and physio-training | Never | Alone |
Patients’ workout assignments in the exercise games (medians and interquartile ranges).
Games | Behavioral measurements | Median | Interquartile range |
Repeated number of steps | 40 | 56 | |
Mean knee angle (degree) | 45 | N/A | |
Knee angle standard deviation (degree) | 10 | N/A | |
Repeated number of steps | 10 | N/A | |
Minimum step width (cm) | 30 | 10 | |
Repeated number of squats | 5 | N/A | |
Squats timer (second) | 2 | 1 | |
Knee angle minimum (degree) | 40 | N/A | |
Knee angle maximum (degree) | 100 | N/A | |
Repeated number of lunges | 5 | N/A | |
Time to hold the lunges (second) | 2 | 0 | |
Foremost minimum knee angle (degree) | 30 | 0 | |
Repeated number of back kicks | 10 | N/A | |
Standing timer (second) | 3 | 0 | |
Mean knee angle (degree) | 30 | N/A | |
Knee angle standard deviation (degree) | 10 | N/A | |
Repeated number of one leg stance | 10 | N/A | |
Standing timer (second) | 3 | 1 | |
Minimum hip angle (degree) | 80 | 20 |
Number of participants who successfully played the game, who dropped out of the game, and who could not finish the assignments because of the unsuccessful recognition of their movements.
Medians and interquartile ranges of patients’ perceived feelings of presence, enjoyment, exertion, and pain during each exercise game are shown in
Medians and interquartile ranges of patients’ perceived feeling of presence, enjoyment, exertion, and pain for all the 6 exercise games. Scoring of presence and enjoyment ranged from −3 to 3, scoring of exertion ranged from 6 to 20, and scoring of pain ranged from 0 to 10. The horizontal line represents the median and the distance between the top, and the bottom of the bar represents the interquartile range.
The scores on the 5 items about whether the exercise games satisfy the nature of a motor rehabilitation program from 2 physiotherapists are shown in
Evaluation of game design (scoring ranged from −3 to 3).
Game design evaluation | Cycling | Dancing | Ringing the bell | Apple picking | Football playing | Fishing | ||
Adaptability | 2 | 2 | 0 | 1 | 0 | 2 | ||
Meaningful tasks | 1 | 2 | 2 | 2 | 1 | 2 | ||
Appropriate feedback | 1 | 2 | 2 | 2 | 2 | 2 | ||
Range of motion | 2 | 2 | 2 | 2 | 2 | 2 | ||
Diverted focus | 2 | 2 | 2 | 2 | 2 | 2 | ||
Adaptability | 2 | 2 | 1 | 2 | 2 | 2 | ||
Meaningful tasks | 2 | 2 | 1 | 3 | 2 | 3 | ||
Appropriate feedback | 2 | 2 | 1 | 2 | 2 | 3 | ||
Range of motion | 2 | 2 | 1 | 2 | 2 | 2 | ||
Diverted focus | 3 | 3 | 1 | 3 | 1 | 3 |
Medians and interquartile ranges of evaluation of Technology Acceptance Model (TAM) from both the patients and the physiotherapists. Scoring ranged from −3 to 3. The horizontal line represents the median, and the distance between the top and the bottom of the bar represents the interquartile range.
Comments provided by the physiotherapists and the patients and their implications are presented in
For some players, the exercise games were too complicated because of the requirement of engaging in multiple activities simultaneously. For example, in the cycling game, the patients sometimes need to do the stepping exercise, collect gift boxes and wave to the virtual pedestrians, and indicate directions occasionally at the same moment. Some patients found it difficult to follow the instruction arrow indicating which leg they should practice in the football playing game. However, most of the patients thought the game interface was rather easy to understand. Minimizing the amount of information presented on the screen might allow older patients with poor cognitive skills to perceive information. Hence, older patients can follow the instruction and commands more easily [
Some patients were unsure of what action should take place at a particular time. Providing helpful information and feedback at the appropriate time throughout the game will be beneficial [
Some patients got confused when the movement of the representing avatar did not match their movements when playing the dancing and football games. The patients were asked to do sidestepping without clapping hands when playing the dancing game, and they do not need to shoot the ball when doing back kick in the football game. Instructions showing that movements such as clapping hands and shooting the ball are not compulsory should be given at the beginning of the games to help the patients understand how the games actually worked.
Patients at the beginning phase of their physiotherapy found some of the games more difficult. For example, it was difficult for them to do sidestepping in the dancing game. During the cycling game, waving to the avatars and indicating directions raising one of the hands were difficult for some of them because of impaired balance. Therefore, we suggest that the stepping exercise should not require the patient to go to the same side for more than once. Waving to the avatars can be optional in the game. Other ways for indicating directions such as turning the upper body or automatically changing directions should be configurable for patients with poor balance skills.
Patients complained that all the fishes looked similar and they prefer varieties in the game content.
The Kinect did not properly recognize squats and lunges played by a few of the female patients with a wide blouse or obesity. Chairs, mirrors, and other objects in the environment sometimes interfered with the Kinect tracking. Of the participants, 3 had to quit playing the apple picking game as their lunges were not recognized. We observed that Kinect v2 could recognize lunges for patients with relatively normal mass level even with support chairs; however, for patients with obesity, it did not recognize their lunges. Furthermore, we found that Kinect v2 could not recognize movements of patients with a wide blouse or trousers; it worked better when they changed their clothes to relatively tight ones. Hence, we suggest that players wear relatively tight clothes when playing Kinect exercise games.
Comments made by the physiotherapists, the patients, and the implications. Note that feedbacks from the physiotherapists are in
Exercise games | Positive comments | Negative comments | Implications |
Cycling | “I like this game a lot!” | Picking gift boxes and waving to the other virtual humans should be optional in the game. | |
“I like the beautiful village in the virtual environment.” | “The bike runs too fast and it made me dizzy.” | The speed of the bike should be configurable. | |
“I tried not to run over the gift boxes on the street.” | Other ways for indicating directions such as turn the upper body should be configurable. | ||
Dancing | “The game is nice. It is much better than the boring exercises we normally do.” | For patients who need support for balance, stepping exercise should not require the patient to go to the same side for more than once. | |
“The music is good.” | “My movements did not match with the movements of the dancing avatars on the screen.” | Patients should be told that they could clap their hands if they want, but it is not required in the exercise. | |
“I really looked forward to dancing and it was even better than I expected.” | |||
“The game looks easier than it really is.” | |||
Ringing the bell | “It is a nice game.” | It is a difficult game for the patients, and it is more suitable for patients who have better balance skills. | |
“The rewarding music brings in enjoyment in the player.” | Patients should wear relatively tight clothes to ensure more accurate movement recognition by Kinect v2. | ||
“I was disappointed that the game did not recognize my squats while I was wearing my wide blouse.” | |||
Picking apples | “It is a nice game.” | “ |
The chairs interfere with tracking for lunges. |
“The game does not respond to my correct movements.” | It is more suitable for patients who are at a later stage of their rehabilitation, that is, patients who can do lunges without balance support. | ||
Football playing | “It is a very useful game for balance training, and it reacts very well to the movements of the player.” | To reduce cognitive load, let the patient play the game by doing back kicks using their left and right legs alternatively. | |
“It is a great game. It made me feel like that I was playing a real football game.” | “It is difficult for me to pay attention to the arrows indicating which leg I should use.” | Instructions should tell the patients that they do not have to shoot the ball. | |
Fishing | “It is a nice game. I had a feeling that I had a real therapy.” | “I focused on the timer, and the virtual environment was not noticeable for me.” | Different types/sizes of fish need to be created in the game. |
“This game would help a lot in my rehabilitation.” | “All the fishes looked similar. It would be nice if I could catch a different fish.” | ||
“The virtual environment is beautiful and I like it a lot!” | |||
General comments | |||
“You have to be clever enough to play the games as it requires paying attention to multiple things at the same time.” | To satisfy personal preferences, interfaces and virtual environments should be configurable to meet the needs of different cognitive challenges. | ||
“ |
“I am very smart, so the game could be made slightly more difficult for me.” | ||
“These are very nice and useful games and I would like to play them again.” | |||
“You could play the game at home, but you would still need the physiotherapists’ feedback on how well you are doing with your rehabilitation by using the games.” | |||
“It is good to receive feedback on the exercises from the games. It prevents you from doing the exercises in the wrong way.” | |||
“After you get used to playing the exercise games, you have a lot of fun.” |
This study assessed the usability of the exercise games in terms of the experienced level of presence, enjoyment, exertion, pain, and technology acceptance among patients, and game design and technology acceptance among physiotherapists. The results showed that, in general, the patients experienced a high level of enjoyment, a moderate to high level of presence, and a low to moderate level of exertion and pain. The physiotherapists rated the exercise games as highly satisfying the nature of a motor rehabilitation program for elderly patients after hip surgery. Finally, both the patients and the therapists found the exercise games useful and easy to use and intended to use the exercise game system in the future.
The results of the evaluation of the game design are encouraging. The physiotherapists found all the exercise games meet the requirements for rehabilitation exercises [
Patients experienced moderate to high levels of presence during the experiment with the lowest level of presence while playing the dancing game. During the dancing game, because of impaired balance skills, the patients used chairs to prevent fall. Hence, their attention was divided between the virtual and the real environment [
According to the qualitative feedback, both the patients and the physiotherapists found squats the most difficult. Patients also reported the lowest enjoyment but highest exertion while doing squats in ringing the bell game. In an exercise game named Astrojumper, Finkelstein et al [
Patients scored high on the technology acceptance scale, which was comparable with the scores in Wuest et al [
In general, people are more inclined to use a system if they perceive it as useful, easy to use, and enjoyable [
Apart from the contributions, there are still a number of limitations to this study. First, this study recruited a small sample of patients and physiotherapists because of limited availability of participants. Usability test with a larger group of elderly patients would be beneficial and allow exploration of usability within different subgroups, for example, patients who are at different recovery phases. It has been shown that with a pilot study of 4 or 5 participants, it is already possible to find 80% of the usability problems [
Second, most of the exercises had to be performed while holding onto a chair, which sometimes influenced the tracking accuracy for exercises such as squats and lunges. Similarly, Ofli et al [
Third, some user aspects of the game design such as high cognitive load and lack of real-time feedback on wrong movements and mismatched movements would pose barriers to future use. To address these issues, we plan to include the customization of the user interface and virtual environment according to personal preferences for cognitive challenges by providing real-time feedback on how far the patients are away from the required range of motion when they are performing the exercises and by giving informative instructions at the beginning of each exercise game. Furthermore, there are still some minor problems with the games that need to be fixed; for example, the setting of going to the same direction for more than once in dancing should be configurable in the therapist interface.
Finally, in this pilot test, we focused on the usability of the exercise games. However, it would be interesting to assess the usability of the CC360 and find ways to improve it according to elderly people’s abilities and preferences when the system is ready in the rehabilitation center or at homes.
The social aspect is known to affect exercise adherence [
As a next step, the effectiveness of the exercise games will be tested in a randomized controlled trial with 15 patients in each group, that is, an experimental group combining traditional exercises with playing exercise games versus control group with traditional exercises. The study will be conducted in the rehabilitation center and can shed some light on how motivating the game system is over a period of time.
We created Fietsgame, an engaging and motivating exercise game system, which translates traditional rehabilitation exercises into playful exercises. The performance of the users was automatically tracked using a 3D depth camera and stored for further analysis by the physiotherapists. The results indicate that the game can be used by patients as a new rehabilitation tool after hip surgery, and both the patients and the physiotherapists expressed positive attitudes toward using the game in the future. Although this study had a limited number of participants, it provides sufficient insights on the usability of the system and suggests improvements in the future. The qualitative feedback revealed that exercise games designed for elderly patients should be challenging enough to keep their interest and attention, but also should take into account their impaired motor, sensory, and cognition functions. We will improve the game by including real-time corrective feedback when patients are performing the exercises, by providing a customizable user interface allowing adjustments to cognitive load and by creating more varieties of game content. A randomized controlled clinical trial will be conducted covering a longer time period, testing the effectiveness of the game. The final goal is to provide elderly patients with a game that can be used in nursery houses or at homes to achieve improved physical functions and maintain independent living.
The original physiotherapist control interface of CC360.
The original patient interface showing the patient’s medical record in CC360.
Questionnaires answered by the patients.
Questionnaires answered by the physiotherapists.
Community Care 360
Consultants to Government and Industries
Internet of Things
Igroup presence questionnaire
personal computer
standard deviation
Technology Acceptance Model
Visual Analogue Score
This study is supported by the COMMIT project “Virtual worlds for well-being.” The authors would like to thank the other project team members, namely, Arjan Egges for his input on design of this study; Jan Kooijman, Eline van Vliet, and other physiotherapists from Aafje rehabilitation center for their suggestions in the design of the game; Cho Lie Tam, Jacob Mulder, Marten Eisma, and Pieter Goossen from CGI for their support to the project and their efforts to connect the games to the CC360 system; and Maarten Stevens and Meint Span from 8D games for designing and developing the exercise games.
None declared.