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Serious games have been used as supportive therapy for traditional rehabilitation. However, most are designed without a systematic process to guide their development from the phases of requirement identification, planning, design, construction, and evaluation, which reflect the lack of adaptation of rehabilitation requirements and thus the patient’s needs.
The aim of this study was to propose a conceptual framework with standardized elements for the development of information systems by using a flexible and an adaptable process centered on the patient’s needs and focused on the creation of serious games for physical rehabilitation.
The conceptual framework is based on 3 fundamental concepts: (1) user-centered design, which is an iterative design process focused on users and their needs at each phase of the process, (2) generic structural activities of software engineering, which guides the independent development process regardless of the complexity or size of the problem, and (3) gamification elements, which allow the transformation of obstacles into positive and fun reinforcements, thereby encouraging patients in their rehabilitation process.
We propose a conceptual framework to guide the development of serious games through a systematic process by using an iterative and incremental process applying the phases of context identification, user requirements, planning, design, construction of the interaction devices and video game, and evaluation.
This proposed framework will provide developers of serious games a systematic process with standardized elements for the development of flexible and adaptable software with a high level of patient commitment, which will effectively contribute to their rehabilitation process.
Human motor skills can be affected by numerous adverse situations such as trauma, stroke, and degenerative diseases. Rehabilitation exercises play a fundamental role in reducing the degree of disability. The traditional assisted rehabilitation model consists of daily supervised exercise sessions with a therapist [
Previous studies have developed serious game frameworks in various areas such as physical rehabilitation and education. The following papers were obtained when reviewing the existing literature.
Amengual et al [
Ushaw et al [
Olszewski et al [
Pirovano et al [
The main differences between our framework and that mentioned in similar studies are as follows: (1) our framework contains 5 structural activities of software engineering applied to a UCD; (2) physical rehabilitation–oriented gamification elements were included and classified into 3 groups (flow enhancement, immersion, and progress), which are implemented in the design phase to motivate the patient and to generate an immersive environment, thereby preventing dropouts; and (3) we propose a phase to develop a data acquisition interface to process the patient’s movements when commercial devices do not adapt to the rehabilitation process.
Summary of the related studies.
Framework | Structural activity | Gamification elements | Information on interaction device |
Amengual et al [ |
Project initiation |
Levels | No |
Ushaw et al [ |
Serious goal and game-play mechanic (communication and planning) |
Benefit delivery mechanic: repetition, exploration, strategy, reward, measurement | No |
Olszewski et al [ |
Preparation (communication) |
—a | No |
Pirovano et al [ |
Exercise definition (communication) |
Feedback and motivational factors | No |
aNot available.
Our conceptual framework is based on 3 fundamental concepts: (1) software engineering because serious games are based on the principles of information systems; (2) UCD, which is an iterative design process that focuses on users and their needs in each phase of the project; and (3) gamification, which allows the transformation of obstacles into positive and fun reinforcements, thereby encouraging patients in their rehabilitation process. The concepts used in our framework proposal are shown in
Conceptual elements of the framework.
The software engineering framework establishes a high level of abstraction for software development, applying concepts, models, and other elements. It provides solutions to a series of similar problems, generally describing the phases that must be followed to fix them without further detail of the activities in each phase [
The work associated with the development of information systems in software engineering is classified into generic structural activities [
Communication: This activity focuses on identifying the context and key requirements of the system through collaboration between the client and the development team. This phase determines the information processed, developed interfaces, design restrictions, and validation criteria.
Planning: This activity identifies requirements and develops resource estimates. Development tasks are identified and a work plan is created. Then, techniques are applied to define a work path and the strategic goal of the project.
Modeling: With a multidisciplinary team, the models must understand the real entity and represent the characteristics that the users need in addition to the information obtained and transformed with the software. The models must meet these objectives at different abstraction levels, including the illustration of software from the user perspective and on a technical level for the development team.
Construction: In this activity, models are coded in a programming language, errors are detected through tests, and they are corrected, resulting in a smart operating software for the client or end user.
Deployment: The prototype is delivered to the end user. The customer must provide feedback on the project for improvements. The software development process is iterative and incremental, and as a result, several deployments are made until the software development is completed.
These 5 generic structural activities are used during software development. The process details will be different in each case, but the structural activities remain the same.
UCD is an iterative design process that focuses on users and their needs in each phase of the design process. Users are involved during the design process through research and design techniques to create highly usable and accessible products for them [
UCD is an iterative process that includes the following key principles [
User-centered design process.
Helander and Landauer [
Gamification is a relatively new concept. Its objective is to apply game mechanics in different contexts to attract users to mundane but fun activities with motivational and cognitive benefits [
Cheek et al [
Zain et al [
Specifically, Schulz et al [
Vermeir et al [
Bergeron [
From the gamification elements mentioned before, we chose those shared in every study and those that were convenient in a serious game for physical rehabilitation, and we classified the elements into 3 groups: flow enhancement, immersive factors, and progress. These concepts may appear in more than one group. For example, the element “rewards” is included in flow enhancement and progress. The shared gamification elements are shown in
Classification of gamification elements.
Challenge: According to Zain et al [
Accessibility: This element refers to the capacity to adapt to the patient’s disabilities. For example, when identifying hand movements in a patient who cannot hold an object, a camera can be used to track movements or a device that can be held by the patient.
Adaptability: According to Zain et al [
Player skill: The skill must be consistent with the serious game. As the game progresses, the patient develops more skills that motivate him/her to continue the rehabilitation process.
Rewards: Use indicators of the patient’s progress such as points, virtual coins, badges, or any virtual object to motivate the user to continue with the rehabilitation process.
Real-life simulation: Games simulating real-life activities allow patients with physical disabilities to immerse themselves in the game.
Concentration: A serious game is motivating when the patients can fully focus on the game. Zain et al [
Feedback: There are different ways to provide feedback to the patient: (1) through progress, when the patient has correctly performed the exercise and must be motivated; (2) when indicating how to correctly perform an exercise; (3) through rewards with badges or virtual gifts when completing a challenge.
Difficulty adjustment: The serious game must be developed such that it allows the therapist to indicate the start level and make the necessary adjustments to the rehabilitation exercises.
Few studies use a framework to develop serious games systematically. Therefore, our objective was to propose a conceptual framework based on UCD. Our framework consists of the adequate application of gamification elements and structural activities and guidance of meaningful, pleasant, relevant, and motivating serious games for physical rehabilitation. We use certain phases of the original UCD process, including a planning phase to establish estimates and priorities of the requirements and a modified designing phase to identify between creating an interaction device or using a commercial one.
Proposed conceptual framework for the development of serious games for physical rehabilitation.
The framework begins in the phase of context and user understanding, and then the user requirements are identified. When new requirements are needed in the planning stage, it is necessary to return to the previous phase and include them in the user requirements. From planning to designing solutions, there are 2 possible scenarios shown in
Contemplated scenarios.
When developing a system or product, certain characteristics must be considered, such as context and user population with specific goals and tasks. Other conditions are technical, physical, social, or organizational that may affect its use. The quality of use of a system, user-friendliness, user health, and safety will depend on having an adequate understanding of the context. Identifying the correct context will help specify the user requirements and provide a solid foundation for subsequent evaluation activities. For well-known systems, the identification of stakeholders and context use review is sufficient. Further analysis of context and a study of existing users is required for more complex systems.
The identification of direct and indirect users (people who influence or are affected by the system) ensures that every need is met and is tested as its construction progresses. User Mapping is a tool to identify users, as proposed by Taylor et al [
There are structured methods that obtain detailed information to understand the context of system use as a foundation for subsequent usability activities, particularly the specification and evaluation of user requirements. Some methods for context analysis have been proposed by Maguire [
This stage identifies and documents the potential user requirements derived from the context information. Establishing and documenting user requirements will lead to the design process of a system [
An essential requirement in physical rehabilitation is checking the patient progress and matching their levels. For example, the Wolf motor function test [
Several authors [
Once the user requirements are established, they must be divided by iterations to obtain a prototype in each cycle, as shown in
Initial planning of user requirements.
Designing is a creative activity where components and their relationships are identified based on user requirements. The team approaches designing through different solutions, and every idea must go through iterative development. The product meets the potential user needs through its development with some design elements such as mock-ups or interface screens for interaction, visualization, or comments. Another formal modeling such as UML [
Two possible scenarios are established in this phase, which are described below:
Devices previously created from an iteration or commercial devices such as Microsoft Kinect, Leap Motion, and Novint Falcon Game Controller are used in many serious game developments. The development team must ensure that it is safe and meets the patient’s needs. Once the interaction device is selected, the creation phase of the video game is initiated.
Scenario A: Use of an existing or commercial device.
This scenario occurs when the commercial device does not allow complete customization, and there are limitations in the data processing. This requires an additional phase to create personalized devices (eg, exoskeletons, gloves with inertial sensors) that match the motor skills of the patient for game movement and control.
Scenario B: New device development.
In this phase, the video game prototype is developed, which is controlled by the interaction device of the previous phase. The previously analyzed and planned requirements are used in this phase. Regardless of the software’s scope, size, or complexity, the software design must include at least four of the following models: data or class design, architecture design, interface design, and component-level design [
In the Methods section, gamification was described and classified into 3 aspects: flow enhancement, immersive factors, and progress.
Different game genres include action, adventure, music, puzzle, role-playing game, simulation, and strategy. The genre must be appropriate to the age of the patient in rehabilitation. For example, Chesham et al [
According to Kuiper [
According to Bergeron [
Effectors are instruments that players have to interact with other game elements or to complete a mission. They are closely related with the interaction device (device that follows the patient’s movements) and used in the rehabilitation process. They must agree with the story and avatar.
Bergeron [
Baranowski et al [
Help shows game instructions to the user. It can be a small guide describing the movements to control the game or a document with frequently asked questions.
Define different sounds according to the game’s context. Bergeron [
According to Schulz et al [
Benefits of gamification through game design.
Game design | Gamification benefits |
Game genre | Flow enhancement, immersive factors |
Story or narrative | Flow enhancement, immersive factors, progress (challenge) |
Actors | Flow enhancement, immersive factors (simulate real life) |
Effectors | Immersion (simulate real life, accessibility), flow enhancement |
Screens and menus | Flow enhancement (challenge, accessibility, rewards), progress |
Levels | Flow enhancement, progress |
Help | Flow enhancement (player skills), immersive factors (accessibility) |
Sound and music | Immersive factors (adaptivity), feedback, rewards |
Visual enhancement | Immersive factors (simulate real life, concentration), player skills, rewards, feedback |
Software components, data, library, and other items are assembled at this stage to compile and link them to create an executable system.
Testing units may discover program defects before use. It has 2 distinct goals [
User-controlled testing is the most adequate method of assessment [
The development of serious games for physical rehabilitation is a multidisciplinary process involving several elements: software development, design aspects, and direct involvement of health care specialists, patients, and other nonprofessional health care personnel. Although multiple developments have used UCD [
The authors acknowledge the limitations of this conceptual framework, such as validation, which has to be applied to patients requiring physical rehabilitation, and the generality in its description. However, the latter has the objective to provide a generic framework for physical rehabilitation with an understandable approach to development teams of serious games.
This conceptual framework will be implemented in a serious game prototype application involving a health expert throughout the development process and validated by statistical analysis and clinical evaluation of patients.
Most serious games do not use a systematic process for their creation, thereby producing significant omissions in the rehabilitation process such as lack of rating scales to measure the patient’s progress, no feedback, and exercises that do not adapt to the patient’s disabilities. Therefore, this study provides a systematic process for the development of serious games for physical rehabilitation with the proposal of a conceptual framework. The framework applies 3 key concepts that increase the patient’s adherence to rehabilitation therapy: UCD to understand the specific needs of patients, structural activities of software engineering for their development, and gamification elements, which aim to influence the behavior and motivation of users through the experiences obtained in the game. Access to this type of framework will assist development teams in the creation of safer, fun, motivating serious games, thereby improving the participation and commitment of patients. Finally, it would be essential that every serious game published in a journal be developed through a standardized process applying a framework, thereby ensuring that the game meets the minimum requirements necessary to satisfy user needs.
user-centered design
The authors would like to thank the National Council of Science and Technology (CONACyT) for their support of this study.
None declared.