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Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. Patients with MS experience a wide range of physical and cognitive dysfunctions that affect their quality of life. A promising training approach that concurrently trains physical and cognitive functions is video game–based physical exercising (ie, exergaming). Previous studies have indicated that exergames have positive effects on balance and cognitive functions in patients with MS. However, there is still a need for specific, user-centered exergames that function as a motivating and effective therapy tool for patients with MS and studies investigating their usability and feasibility.
The aim of this interdisciplinary research project is to develop usable and feasible user-centered exergames for the pressure-sensitive plate Dividat Senso by incorporating theoretical backgrounds from movement sciences, neuropsychology, and game research as well as participatory design processes.
Focus groups (patients and therapists) were set up to define the user-centered design process. This was followed by the field testing of newly developed exergame concepts. Two sequential usability and feasibility studies were conducted on patients with MS. The first study included a single exergaming session followed by measurements. Between the first and second studies, prototypes were iterated based on the findings. The second study ran for 4 weeks (1-2 trainings per week), and measurements were taken before and after the intervention. For each study, participants answered the System Usability Scale (SUS; 10 items; 5-point Likert Scale; score range 0-100) and interview questions. In the second study, participants answered game experience–related questionnaires (Flow Short Scale [FSS]: 13 items; 7-point Likert Scale; score range 1-7; Game Flow questionnaire: 17 items; 6-point Likert Scale; score range 1-6). Mixed methods were used to analyze the quantitative and qualitative data.
In the first study (N=16), usability was acceptable, with a median SUS score of 71.3 (IQR 58.8-80.0). In the second study (N=25), the median SUS scores were 89.7 (IQR 78.8-95.0; before) and 82.5 (IQR 77.5-90.0; after), and thus, a significant decrease was observed after training (z=−2.077; P=.04;
The project revealed that the newly developed, user-centered exergames were usable and feasible for patients with MS. Furthermore, exergame elements should be considered in the development phase of user-centered exergames (for patients with MS). Future studies are needed to provide indications about the efficacy of user-centered exergames for patients with MS.
Globally, approximately 2.3 million people have multiple sclerosis (MS) [
In general, physical exercise is a safe method that can yield beneficial effects such as depending on the training content, muscular strength, and aerobic capacity and, consequently, it improves mobility, fatigue, and quality of life in patients with MS [
An upcoming training method that concurrently combines the training of physical and cognitive functions is exergaming [
In recent years, researchers have started to evaluate exergames as a rehabilitation tool for patients with MS. Exergames proved to be an acceptable, feasible, safe, enjoyable, challenging, and self-motivating tool [
Human-computer interaction research, sports science, and human movement sciences offer numerous guidelines and frameworks aiming for more attractive and effective full-body motion games for different target populations [
In summary, there is a huge potential for developing effective and attractive user-centered exergames that combine training principles with elements of game design and focus on disease-specific deficits to increase motivation and performance and thus to ensure the possibility of successful training. The overall aim of the interdisciplinary research and development work presented here is to develop and evaluate user-centered exergames for the game controller Dividat Senso by incorporating a theoretical background from movement sciences, neuropsychology, and game research, as well as participatory design processes with patients with MS and their therapists. This work aims to contribute specifically to the following: (1) research-based, iterative, co-designed user-centered exergames for patients with MS and (2) the usability and feasibility testing of newly developed exergames by field testing and study trials.
As a first step, the iterative and research-based development process of the exergame concepts considered the knowledge gained from different user perspectives (patients with MS and therapists) and disciplines (human movement science and neuropsychology as well as game design and research) to holistically generate a potentially attractive and effective user-centered exergame training for cognitive-motor therapy in patients with MS (
Iterative and research-based development process.
This interdisciplinary research and development project developed new exergame concepts for the game controller Dividat Senso (Dividat;
Original setup of the Dividat Senso.
The design process started by analyzing the existing system and determining its technical opportunities, focusing on the Dividat Senso plate and the game collection, as they were not designed with or for the specific requirements of patients with MS. In this context, the project team visited certain therapy settings (rehabilitation center and physiotherapy) with neurologically impaired patients (MS and Parkinson disease) using the existing system in a therapy session. Furthermore, project members tested the plate and existing games themselves.
The most important finding was that patients often showed similar interaction patterns while playing on the Dividat Senso; patients first focused on the screen to receive the visual game stimuli and then tended to look down at the plate to step on the plate area to trigger the respective game input. This process seems to be important for patients with MS, as the motor learning process can be triggered via cognitive and motor information processing and realization [
Rethinking the Dividat Senso plate. Concepts for more intuitive and natural input movements and flow are shown.
Moreover, some of the existing games did not necessarily follow a
On the basis of the above reflections (usage and interaction patterns), the existing training concepts were also reconsidered, focusing on MS-specific motor and cognitive disabilities (eg, balance and coordination) and disease-specific deficits (eg, degeneration of myelin). Overall, the training concepts were developed and integrated by considering the following specific training principles: (1) type and specificity, (2) intensity, (3) progression, (4) variability, and (5) feedback [
In this process, some motor functions were considered that seem to be beneficial for patients with MS. Patients with MS often experience, to a variable extent, muscle weakness, diminished dexterity, spastic paresis, sensory dysfunction, gait disturbances, and fall risk, as well as fatigue and depression [
Input movements, including existing patterns (A, B, and C) and rethought patterns (D, E, and F). Input movements are presented as body models and as patterns that are registered by the pressure-sensitive plate.
A further training concept for exergames that must be mentioned is the dual-task approach. Study findings indicate that patients with MS have impaired dual- or multi-task performances that could result from their deficits in divided attention, resource capacity overload, or differential neural activation [
Furthermore, the reconsidered training concepts considered both games that endorse motor learning [
Following the rethinking process, new exergame scenarios were designed. To ensure that the concepts were user-centered, the target group (patients with MS and their therapists) was involved from the outset. A semistructured interview guideline was developed based on questions about all elements of the exergame environment (eg, body, controller, and virtual game scenarios). The aim of the focus group interviews was to explore the target group’s experiences with exergames and technology in the context of therapy, as well as to define needs, preferences, and expectations for an optimal exergame setup and its integration into an MS therapy setting. The focus group surveys took approximately 90 minutes and were carried out with 4 physiotherapists experienced in MS therapy, 9 patients with MS, and 2 specialists in neuropsychology. In addition to a list of specific questions, participants’ thoughts and specific wishes for the look and feel of future exergames were assessed using 3 different sketches of potential game scenarios (
Three sketches of potential game scenarios. Different gameplay options, game mechanics, and perspectives served as inspiration during focus groups. The Puddle Jump sketch (A), the Gentle Giant sketch (B), and the Owl Flight sketch (C).
On the basis of the results of the focus groups, personas for the 2 target audiences were developed. The primary aim was to provide patients with MS (predominantly adult females of all ages, ranging from high to low fitness) an attractive and effective training. The secondary aim was to provide physiotherapists (who are open to the use of technology in movement therapy) with a flexible supplementary tool to their traditional therapy methods. Among other outcomes, the focus groups revealed that the design should not be restricted to a specific age or gender group nor to a single game style and input movement concept, because the MS disease pattern is very heterogeneous. Therefore, different exergame scenarios were designed, including different game mechanics, narratives, perspectives, and input movements with the Dividat Senso. Each scenario provided slightly different cognitive and motor challenges and aimed at patients with MS aged around 30-85 years who fulfilled further requirements (see the study criteria in
In total, 6 box prototypes (
Unity 3D box prototypes. Based on the input from the focus groups, different game scenarios and mechanics were designed. A and D: Two playful, toy-like 2D prototypes allowing the feet to move freely on the Dividat Senso plate to draw and play with a face. E: 2D scenario allowing free steps or weight shifting. B and C: Two 3D images of the Dividat Senso plate acting as a virtual playground, allowing free steps and jumps. F: 3D Racer scenario with a weight shifting input.
Following the preliminary field research, 3 exergame concepts were designed, including different virtual game scenarios and game mechanics, each demanding other input movements on the Dividat Senso plate. The specific descriptions of the video games, visualization of the input movements, and visual progression overview can be found in
Game concepts for the game controller Dividat Senso.
Exergames | Ladybug | Scooper | Cloudy |
Description | Navigation of a ladybug to collect randomly allocated flowers and avoid collisions with obstacles | Harvesting garden vegetables | Setting the position of the sun (Study 1) or a rain cloud (Study 2) to grow flowers |
Motor components | Static balance and coordination | Dynamic balance, coordination, accuracy, and strength | Static balance, coordination, accuracy, and strength |
Cognitive components | Information processing, anticipation, selective attention, and visual-spatial orientation | Information processing, planning, selective attention, and visual-spatial orientation | Information processing and selective attention |
Motor-level settings (Study 2) |
Level 1: Side stepping, tapping or weight shifting Level 2: Side stepping, tapping or weight shifting and stepping to the front to avoid obstacles (stones) Level 3: Side stepping, tapping or weight shifting and stepping to the front to avoid obstacles (caterpillars) |
Level 1: Walking and standing on objects for collection Level 2: Walking and squatting on objects for collection Level 3: Walking and jumping on objects for collection |
Level 1: Side stepping or tapping Level 2: Side stepping or tapping and squatting to make the cloud rain Level 3: Side stepping or tapping and jumping to make the cloud rain |
Cognitive-level settings (Study 2) |
Level 1: Pick all flowers Level 2: Pick bonus flower (2 colors) Level 3: Pick bonus flower (3 colors) |
Level 1: Pick all vegetables Level 2: Pick bonus vegetables (2 colors) Level 3: Pick bonus vegetables (3 colors) |
Level 1: Water all flowers Level 2: Water bonus flower (2 colors) Level 3: Water bonus flower (3 colors) |
Study setup and in-game screenshots of the tutorial and game tested in the first study (A, B, and C) and in the second study (D, E, and F).
Two usability studies were conducted to evaluate the usability and feasibility of the newly developed user-centered exergames in patients with MS. From January to February 2019, the measurements for the first study were taken, and from April to May 2019, the training sessions and measurements for the second study were conducted.
Project schedule.
In the first study, patients with MS tested each exergame concept (
In the second study, patients with MS played the redesigned exergame concepts (
The ethics committee of ETH Zurich, Switzerland, approved both study protocols (EK 2018-N-85 and EK 2018-N-124). Before any measurements were taken, all eligible patients provided written informed consent according to the Declaration of Helsinki. Withdrawal for no stated reason was permitted at any time during the study.
In the first study, potential participants were recruited by physiotherapists from a physiotherapy center (Physiotherapy Langmatten). In the second study, participants were recruited by physiotherapists and study investigators from specialized centers for neurological physiotherapy (Physiotherapy Langmatten) and rehabilitation (ZURZACH Care, Rehaklinik Bad Zurzach and Reha Rheinfelden). In both studies, all interested patients were fully informed about the study procedure and the inclusion criteria by physiotherapists and study investigators before screening. Patients who met the initial eligibility criteria and signed the informed consent form participated in a personal interview to screen for mental and physical health. Screened data included demographic data and medical information regarding MS (eg, MS type, leg spasticity, and fatigue). Furthermore, the following 2 questionnaires were assessed to define prevalent MS-related restrictions: the MS Impact Scale [
For the first and second study, the same eligibility criteria were set. Patients fulfilling all the following inclusion criteria were eligible: (1) female or male; (2) aged 25-80 years; (3) clinical diagnosis of MS, including all forms (relapsing or remitting, primary-progredient, secondary-progredient, and progressive-relapsing); (4) stationary and ambulant; (5) able to provide written informed consent and understand instructions; (6) able to stand at least for 10 minutes with the aid of a handrail; and (7) visual acuity including correction sufficient to work on a television screen. Any of the following criteria led to exclusion: (1) conditions that precluded stepping exercise (severe spasticity that prevents a person from taking a full step or severe musculoskeletal injury), (2) excessive fatigue that prevented training participation, and (3) exercise intolerance that prevented training participation.
Study assessments.
Category | Explanation | ||
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Training adherence and attrition rate |
Compliance with training sessions Participants lost at follow-up (dropouts) |
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System Usability Scale |
Reliable and valid tool providing a global view of subjective usability [ A score of at least 70 for an “acceptable” solution, below 50 is “unacceptable,” and 50-70 is “marginally acceptable” [ 10 items (5-point Likert Scale), score range 0-100 |
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Flow Short Scale |
Used to retrospectively get a typical flow-score for specific kinds of actions or situations [ 13 items (7-point Likert Scale), score range 1-7 Dimensions: flow (items 1-10), fluency (item 2, 4, 5, 7, 8, and 9), absorption (items 1, 3, 6, and 10), and perceived importance (items 11-13) |
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Game Flow questionnaire |
Derived from the Sweetser and Wyeth [ 17 items (6-point Likert Scale), score range 1-6 7 main items (items 1-7) building the dimension Game Flow and 10 additional explorative exergame-specific items (items 8-17) |
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Guideline-based interview |
Qualitative evaluation of the user’s game play experiences Categories: (1) overall experience, (2) game scenario, (3) Dividat Senso plate (game controller), (4) body and mind, (5) motivation, (6) training, (7) comparison to conventional movement therapy, and (8) others |
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Video recording and monitoring protocol |
Exergame performance Same categories as for the interview |
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Physical and cognitive exertion |
Modified Borg Scale from 1 to 10 [ |
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Number of trainings |
Range from 4 to 8 trainings |
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Training time |
How long participants trained per session |
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Play preferences |
How often each exergame was played |
For quantitative data, statistical analysis was conducted using SPSS (IBM SPSS 26). The level of significance was set at P<.05. The data were compared using the Wilcoxon signed-rank test, as the assumptions for parametric statistics were not met (nonnormally distributed data). The effect size (
An effect size of 0.10–0.29 indicates a small effect, an effect size of 0.30–0.49 indicates a medium effect, and
The participant characteristics are shown in
Baseline and training data characteristics.
Characteristics | Study 1 (N=16) | Study 2 (N=25) | |||
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Female | 10 (62) | 15 (60) | ||
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Male | 6 (38) | 10 (40) | ||
Age (years), mean (SD) | 62.1 (13.0) | 57.3 (11.2) | |||
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RRb | 7 (44) | 11 (44) | ||
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SPc | 2 (12) | 10 (40) | ||
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PPd | 7 (44) | 3 (12) | ||
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Not applicable | 0 (0) | 1 (4) | ||
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Ambulant | 16 (100) | 19 (76) | ||
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Stationary | 0 (0) | 6 (24) | ||
Diagnosis since (years), mean (SD) | 22.73 (13.1) | 16.6 (11.7) | |||
MSISe, mean (SD) | 33.2 (16.7) | 34.3 (15.0) | |||
MSIS physical, mean (SD) | 34.2 (20.1) | 36.2 (15.5) | |||
MSIS psychological, mean (SD) | 29.7 (23.0) | 32.1 (19.2) | |||
ABCf, mean (SD) | 74.7 (11.7) | 69.4 (18.2) | |||
Exergame experience, n (%) | 2 (13) | 10 (40) | |||
Number of trainings per participant, mean (SD) | 1 (0) | 4.8 (1.1) | |||
Training time per session (min), mean (SD) | 15 (0) | 19.1 (3.9) | |||
Borg motor, mean (SD) | 3.3 (1.2) | 3.8 (1.8) | |||
Borg cognitive, mean (SD) | 4.0 (1.8) | 3.5 (1.9) |
aMS: multiple sclerosis.
bRR: relapsing-remitting.
cSP: secondary-progressive.
dPP: primary-progressive.
eMSIS: multiple sclerosis impact scale.
fABC: Activities-specific Balance Confidence scale.
In the first study, the median SUS score was 71.3 (IQR 58.8-80.0). The SUS and questionnaire pre-post comparisons of the second study are presented in
Questionnaire data (N=25).
Questionnairesa | Pre, median (IQR) | Post, median (IQR) | z | P value |
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System Usability Scale | 89.7 (78.8-95.0) | 82.5 (77.5-90.0) | −2.077 | .04b | 0.42 | ||||||
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5.9 (4.6-6.4) | 5.8 (5.4-6.2) | −0.400 | .69 | 0.08 | ||||||
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Fluency | 5.7 (4.4-6.6) | 5.6 (4.8-6.6) | −0.325 | .75 | 0.07 | |||||
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Absorption | 5.8 (5.1-6.5) | 6.0 (5.1-6.6) | −0.485 | .63 | 0.10 | |||||
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Perceived importanced | 2.0 (1.5-3.8) | 1.3 (1.0-3.5) | −2.118 | .03b | 0.42 | |||||
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5.0 (4.7-5.3) | 5.1 (4.9-5.3) | −0.473 | .64 | 0.09 | ||||||
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Concentration | 5.0 (5.0-6.0) | 6.0 (5.0-6.0) | −0.775 | .44 | 0.16 | |||||
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Challenge | 4.0 (2.5-4.5) | 4.0 (3.0-4.8) | −0.210 | .83 | 0.04 | |||||
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Skills or abilities | 5.0 (4.0-5.0) | 5.0 (4.0-5.0) | −0.277 | .78 | 0.06 | |||||
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Control | 5.0 (4.5-5.0) | 5.0 (4.5-6.0) | −0.732 | .46 | 0.15 | |||||
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Aim | 6.0 (6.0-6.0) | 6.0 (6.0-6.0) | −0.816 | .41 | 0.16 | |||||
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Feedback | 6.0 (5.0-6.0) | 6.0 (6.0-6.0) | −1.030 | .30 | 0.21 | |||||
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Immersion | 5.0 (5.0-6.0) | 5.0 (5.0-6.0) | −0.811 | .42 | 0.16 | |||||
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Pleasure and liking | 6.0 (5.0-6.0) | 6.0 (5.0-6.0) | −0.264 | .79 | 0.05 | |||||
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Dual flow over—challenged | 1.0 (1.0-2.5) | 1.0 (1.0-2.0) | −0.577 | .56 | 0.12 | |||||
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Dual flow under—challenged | 1.0 (1.0-3.0) | 2.0 (1.0-2.8) | −0.418 | .68 | 0.08 | |||||
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System control | 5.0 (4.3-5.0) | 5.0 (5.0-6.0) | −1.604 | .11 | 0.32 | |||||
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Movement | 5.0 (5.0-6.0) | 5.0 (5.0-6.0) | −0.351 | .73 | 0.07 | |||||
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Motivation | 6.0 (5.0-6.0) | 6.0 (5.0-6.0) | −0.816 | .41 | 0.16 | |||||
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Physical exertione | 4.0 (2.0-5.0) | 4.0 (2.0-5.0) | −0.158 | .88 | 0.03 | |||||
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Cognitive exertione | 3.0 (2.0-4.5) | 3.0 (2.0-4.0) | −0.042 | .97 | 0.01 | |||||
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Optimal challenge | 5.0 (4.0-5.0) | 4.0 (4.0-5.0) | −0.842 | .40 | 0.17 | |||||
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Spatial presence | 5.0 (3.5-6.0) | 5.0 (4.0-6.0) | −0.361 | .72 | 0.07 |
aData were analyzed using Wilcoxon signed-rank test.
bP<.05.
cThe higher the scores, the better the results. This counts for all items that are not specifically marked.
dThe lower the scores, the better the results.
eThe more in the middle field, the better the results.
Findings from the guideline-based interviews of both studies are reported for
In summary, all participants reported an enjoyable, motivating, varied, and fun experience with the exergames, which was a completely new thing for most of them (
Interview data focusing on overall experience. (Some and minority = at least 30% of the participants; many = at least 50% of the participants; most and majority = at least 80% of the participants).
Interview data focusing on body and mind. (Some and minority = at least 30% of the participants; many = at least 50% of the participants; most and majority = at least 80% of the participants).
Interview data focusing on games, gameplay experience, and hardware. (Some and minority = at least 30% of the participants; many = at least 50% of the participants; most and majority = at least 80% of the participants).
Interview data focusing on motivation. (Some and minority = at least 30% of the participants; many = at least 50% of the participants; most and majority = at least 80% of the participants).
Interview data focusing on the comparison of exergames with conventional therapy. (Some and minority = at least 30% of the participants; many = at least 50% of the participants; most and majority = at least 80% of the participants).
This project aimed to contribute specifically to (1) develop research-based, iterative, and co-designed user-centered exergames for patients with MS and (2) determine the usability and feasibility of the newly developed exergames. This was only possible by incorporating the theoretical background from human movement sciences, neuropsychology, and game research, as well as practical skills from game design. Furthermore, this iterative and participatory design process was carried out in close collaboration with patients with MS and their therapists.
In the following sections, the quantitative and qualitative results of the user studies are discussed and set in the context of related work and knowledge in game research and movement science, as well as research in the field of MS. Quantitative and qualitative data revealed certain exergame elements that are specific to patients with MS and can become key features for the further development of user-centered exergames for this heterogeneous target group. An outlook on future approaches in user-centered MS-specific exergame development and research will be provided.
After the second study, patients often reported a
The heterogeneity of patients with MS, including the individual course of the disease (eg, wide range of symptoms and unpredictable flare-ups), as well as demographic details (eg, wide range of age), was also reflected in the interviews. Patients reported that game content, challenge, and progression should always be adaptable to their
Most patients were motivated to train by exergames and enjoyed the requirement of physical activity for playing them. This is in line with a previous study that interviewed patients with MS about Nintendo Wii Fit [
An exergame should be able to adapt to the individual patient at a physical and cognitive level to meet the heterogeneous and individual requirements of patients with MS and to allow for an
Interviews showed a strong acceptance of the exergames by patients (even in the first study). The majority would
As a next step, further research and development work will deepen the knowledge of design principles in MS exergames and reveal additional insights. To meet the heterogeneous spectrum of MS and to provide an individually attractive and effective training and therapy tool, the newly developed exergames will be further iterated and extended based on the findings of the usability and feasibility studies. Furthermore, new types of use will be implemented, such as playing a multitask version of the exergames that involve upper-body input movements or sitting in a wheelchair. Moreover, further balancing game mechanics will be implemented, as well as extending the types of input, movement ranges, and tracking zone.
There are some limitations that can be reported for this study. In the first study, participants were trained only once with the exergames, whereas they trained multiple times in the second study. Therefore, participants might have had the chance to reflect more on and better familiarize themselves with the games in the second study, while they had only one attempt in the first study. Additionally, their feedback might have been influenced by the novelty effect. Furthermore, study testing was conducted at various clinics and institutions and it did not focus on measures of effectiveness. However, it should be emphasized that these studies should be conducted in the context of developing a complex intervention for health care settings. Within this context, intervention development contains different mandatory steps that should be taken in a sequential order [
The aim of the presented research and development work was to take the first step in the new field of user-centered exergames for patients with MS, to evaluate the usability and feasibility of the newly developed exergame concepts, to learn from the findings, and to derive design guidelines for future research and development projects in this field.
The quantitative and qualitative results of this project showed that the developed exergames were usable, feasible, well accepted, and enjoyable for patients with MS. Furthermore, the results indicated preliminary positive effects regarding the attractiveness of the newly developed, user-centered exergames. Participants enjoyed the motivating, varied, and fun experience with the exergames, which were both fun and physically as well as cognitively challenging and allowing them to forget their everyday worries (often associated with the disease) for the moment. Moreover, specific exergame elements were identified: control mechanisms through audio-visual design, adaptation of the individual difficulty level, game concept diversity addressing the patients’ heterogeneity, involvement of training principles, and considerations of the interaction of physical and cognitive impairments, especially brain-body communication.
Considering the points of discussion and design guidelines, user-centered exergames can be a promising training approach to improve physical and cognitive functions, especially brain-body communication in patients with MS. Thus, user-centered exergames might have positive effects on quality of life by reducing the risk of falling, mobility restrictions, and social isolation. Furthermore, the strengthening of body functions such as balance, coordination, and cognition seems to be a promising way to break the vicious circle of deconditioning. The evaluation of the effects of a user-centered exergame will show how far a user-centered exergame might complement or even surpass the results of conventional (exergame) approaches in patients with MS.
central nervous system
Flow Short Scale
multiple sclerosis
System Usability Scale
The authors want to thank the Swiss Innovation Agency Innosuisse for funding the project (grant number: 41968.1 IP-LS). Furthermore, they thank their postgraduate student Tiziana Schwarz for instructing trainings and helping with data acquisition. Finally, the authors thank all the patients with MS for their participation in this project and the physiotherapists who supported the studies.
AMN and AS conceptualized, designed, and drafted the manuscript. EDB and SF contributed substantially to the conception and design of the manuscript. AMN, AS, SB, SH, and YH created the study design, compiled the training protocols, and selected the assessment methods for the first study. SH conducted the study (supervised by AMN, AS, and RS). For the second study, AMN, AM, AS, BF, SB, and YH created the study design, compiled the training protocols, and selected the assessment methods. AM and BF conducted the study (supervised by AMN, AS, RS, and SF). SB and YH designed the exergame environments for both studies (supported by AMN, RB, and UG). AMN and AS led data analysis and interpretation; EDB and SF contributed to the latter. All authors critically reviewed and approved the final manuscript.
EDB was a cofounder of Dividat, the spin-off company that developed the exergame plate used in this study, and is associated with the company as an external advisor. No revenue was paid (or promised to be paid) directly to EDB or his institution over the 36 months before the submission of the work.