Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible respiratory condition characterized by persistent airflow limitation, which collectively reduces patients’ physical capabilities and impairs their quality of life (QoL). COPD affects >300 million individuals worldwide and ranks as the third leading cause of death, underscoring an urgent need for innovative, accessible management solutions [1]. COPD management typically focuses on symptom alleviation and preventing disease progression through pulmonary rehabilitation (PR; defined as a multidisciplinary, evidence-based intervention for chronic respiratory diseases such as COPD, combining exercise training, education, and behavioral therapy to reduce symptoms, improve physical and psychological well-being, and enhance long-term health behaviors), pharmacological interventions, and behavior modification (such as smoking cessation and dietary change) [1]. However, adherence to these programs is often low, due in part to a lack of patient engagement, access barriers, and the need for long-term ongoing use of the interventions [2]. Recent advances in digital health, particularly gamified interventions, show promise to enhance adherence and self-management in patients with COPD by incorporating engaging, game-like elements into COPD management programs.

Gamification in health care, defined as using game design elements in nongame contexts, is emerging as a valuable tool in managing chronic diseases, particularly in PR and home-based COPD management [3]. Gamified interventions leverage mechanisms such as rewards, competitive elements, real-time feedback, and immersive virtual environments to enhance motivation; foster active participation; and sustain adherence, particularly to exercise-focused regimens [4]. Recent systematic reviews indicate that gamified eHealth interventions can improve physical activity levels in adults with chronic diseases and significantly enhance physical outcomes, adherence, and QoL [1,5]. In COPD, where symptoms often lead to a sedentary lifestyle, these elements can provide a sense of accomplishment and motivation, addressing common barriers to physical activity and rehabilitation.

A systematic review by Chang et al [5] highlighted the potential of gamified interventions to enhance exercise endurance and QoL among patients with COPD, especially those incorporating telemonitoring, web-based tools, and virtual reality (VR). VR as a vehicle for PR has a growing evidence base; for example, Liu et al [2] conducted a meta-analysis to explore VR’s role in COPD management and found that VR-assisted PR can improve lung function and exercise capacity. By making exercise engaging and immersive, delivery via VR potentially mitigates the monotony associated with traditional exercise–focused PR, encouraging regular participation and improving outcomes. In addition, a systematic review and meta-analysis by Obrero-Gaitán et al [3] found supportive evidence for the effectiveness of VR-based PR in COPD, reporting significant improvements in physical performance and mobility.

Such immersive, game-like platforms not only aid in physical rehabilitation but also enhance patient engagement. In a scoping review, Dalko et al [6] found supportive evidence for VR in rehabilitation for patients recovering from post–COVID-19 condition who had chronic respiratory problems [6]. These findings support the idea that VR’s engaging nature may appeal to patients with COPD facing similar challenges of motivation and compliance.

While these studies found promising results, most gamified interventions are in the early stages of development. As the recent systematic reviews highlight, there is a need for larger, long-term rigorous studies to validate their effectiveness, cost-effectiveness, acceptability, and sustained use for different populations. This review synthesizes existing literature to assess the impact of gamified interventions on COPD management and PR, focusing not only on physical outcomes and QoL improvements but also on engagement and adherence. By consolidating these findings, this study aims to provide a comprehensive understanding of gamification’s potential role in enhancing care for patients with COPD.

The primary objective of this study was to systematically review and evaluate the impact of gamified interventions on the management of COPD, including PR. Specifically, this study aimed to assess how gamification influences key outcomes in COPD management, such as patient adherence to treatment regimens, physical activity, symptom management, and QoL. In addition, we sought to assess the accessibility, usability, and patient satisfaction associated with these interventions, considering whether gamification supports long-term behavior change and self-management. By synthesizing findings from recent studies, this study aimed to provide valuable insights into the current evidence, limitations, and the potential of gamified approaches in enhancing COPD care, as well as to offer recommendations for future research directions in this emerging area of digital health.

The search strategy targeted studies on gamified interventions for COPD management, emphasizing recent advancements over the past 10 years (January 2014-October 2024) to maintain relevance in this rapidly evolving field. We searched 7 databases—PubMed, Scopus, Web of Science, Embase, IEEE Xplore, Cochrane Library, and China National Knowledge Infrastructure—capturing a broad range of research in biomedical and digital health.

The search terms in Table 1 were identified for 3 domains: “chronic obstructive pulmonary disease,” “gamification,” and “condition management” as well as “rehabilitation,” with terms within each domain connected by the Boolean operator “OR” and domains linked by “AND.” Detailed search strategies for each database are shown in Multimedia Appendix 1.

The searches included studies published in English and Chinese to capture a more global perspective than reviews relying solely on English-language databases. Boolean operators were used to ensure comprehensive coverage, and all retrieved studies were imported into EndNote 20 (Clarivate) to facilitate screening, deduplication, and data extraction.

Inclusion criteria were as follows: (1) languages—studies published in English and Chinese were included to capture a breadth of global research; (2) duration—publications from the last 10 years (January 2014-October 2024) were included to reflect recent advances in gamification and digital health; and (3) study types—only original studies involving trials (both randomized controlled trials [RCTs] and non-RCTs), intervention studies, feasibility studies, cross-sectional surveys, or qualitative studies were included. Studies published solely as protocols or conference proceedings were excluded due to limited information on outcomes and intervention efficacy. Studies that did not incorporate gamification elements and those not addressing COPD as the primary health condition were also excluded.

Data extraction and analysis were conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines to ensure thorough and transparent reporting [7]. The PRISMA checklist is presented in Multimedia Appendix 2. Using a standardized data extraction form, 2 independent reviewers extracted relevant information from each study, reducing the risk of bias and enhancing data reliability. Key data collected included study design, sample size, population characteristics, intervention details (such as the type of gamification, platform, and duration), outcomes (eg, physical function, adherence, engagement metrics, and QoL), and any limitations reported. Multimedia Appendix 3 provides the template used for the data extraction and analysis form. Data on primary and secondary outcomes—such as physical activity levels, lung function, and QoL metrics—were specifically targeted to assess the effectiveness of gamified interventions in COPD management. A third reviewer addressed any discrepancies between the 2 primary reviewers. Once extracted, data were tabulated and summarized to facilitate cross-study comparisons. Given the diversity in gamification strategies and outcome measures, a narrative synthesis approach was used to identify common themes, potential correlations, and patterns across studies. Each study’s methodological quality and risk of bias were assessed using criteria aligned with the PRISMA guidelines. The risk-of-bias assessment was conducted using a qualitative approach, given the diverse study designs (both RCTs and non-RCTs) included in this review. For each study, the review evaluated methodological limitations and potential sources of bias, including risk-of-bias assessment, risk-of-bias findings, and limitations. The assessment framework considered several key domains that could potentially influence study validity: randomization procedures (eg, control group presence and characteristics, as well as blinding methods), sample characteristics (eg, sample size adequacy, dropout rates, and selection procedures), and implementation quality (eg, study duration, follow-up assessment, and intervention adherence). On the basis of these criteria, studies were classified as low risk, moderate risk, or high risk.

The study identified 29 studies published between January 2014 and October 2024 that investigated the impact of gamified interventions on COPD management. The studies examined a range of gamification approaches, including VR-based rehabilitation, mobile apps, and digital games designed to enhance patient engagement, physical activity, or symptom management. Multimedia Appendix 4 [8-36] provides a detailed summary of the data extraction and analysis for each included study. The PRISMA flowchart (Figure 1) outlines the study selection process.

Most of the studies (10/29, 35%) were RCTs, reflecting the focus on evaluating intervention effectiveness [8,9]. Sample sizes ranged from small-scale feasibility trials with as few as 4 participants to larger studies with up to 106 participants [10,11]. Intervention durations varied substantially from single sessions to long-term studies lasting more than a year. Settings varied widely, including clinical, home-based, and hybrid models, with home-based approaches being common for virtual and gamified interventions [12,13].

Table 2 provides a summary of the study design, setting, sample size, and intervention duration for each reviewed study, capturing the diversity in research approaches across this field.

The reviewed studies applied various gamified interventions to support COPD management, ranging from VR programs to wearable activity trackers. Platforms included VR headsets, gaming consoles, and smartphone apps, each incorporating gamification elements such as motivational cues, real-time feedback, and rewards for progress [8,14,15]; for example, the Condition Coach COPD telehealth program used wearable devices and daily feedback tailored by physiotherapists [8], while BreathCoach provided real-time biofeedback for respiratory exercises [24].

Several interventions offered individualized tailoring to enhance relevance and usability, adapting exercise intensity or integrating patient preferences into their design. Integration with health care systems varied, with some interventions offering telemonitoring and health care provider supervision, such as the SmokeFreeBrain project [18]. Table 3 shows the details of the interventions, the platform, game elements, details of tailoring if included, and integration with health care.

Gamified interventions showed positive impacts on COPD management outcomes, particularly in improving exercise tolerance and physical fitness; for instance, Mazzoleni et al [14] found a significant increase in 6-minute walk test distance among participants using exergames, with the experimental group improving by 97.4 meters. Similarly, Rutkowski et al [11] observed increased exercise performance in the VR groups compared to the traditional exercise group, as shown in Table 4.

Regarding behavioral outcomes, gamified interventions were effective in increasing motivation and adherence to exercise; for example, LeGear et al [16] noted high participant enjoyment and engagement with Wii-based exergames, enhancing exercise adherence. Furthermore, Hoaas et al [12] reported long-term adherence to telerehabilitation, showing improved self-management and coping skills among patients with COPD.

QoL improvements were also observed, with several interventions enhancing emotional well-being and reducing anxiety; for example, Pancini et al [32] reported reduced anxiety and stress in participants using VR relaxation interventions, contributing to overall QoL. Such findings suggest that gamified approaches can not only support physical health but also promote psychological resilience and well-being in patients with COPD [8,13].

The reviewed studies demonstrated strong engagement and satisfaction among patients with COPD using gamified interventions, with many participants expressing enjoyment and adherence to the programs; for instance, studies involving VR and exergames, such as the one by Rutkowski et al [9], showed high engagement due to immersive environments and interactive features, leading to consistent participation. Satisfaction metrics varied, with studies such as the one by Baxter et al [27] noting that visual rewards and timers within apps were especially motivating.

Adaptations to improve usability included simplified interfaces and controls, particularly for older adults with limited technological experience [29,30]. However, technical challenges were present, such as synchronization issues in Fitbit devices [25] and discomfort from equipment such as VR headsets [31]. Cultural adaptations were minimal but occasionally tailored to suit specific populations, as seen in the studies by Pardos et al [33] and Colombo et al [34], which adapted VR for older adults with COPD.

Table 5 provides detailed insights into engagement, satisfaction, and technical adjustments across the reviewed studies.

The reviewed studies presented varying levels of bias and limitations. For the RCTs, additional considerations included randomization procedures and blinding, while the non-RCT studies were evaluated based on their specific study design characteristics. Many of the studies (28/29, 97%), particularly early-stage trials, did not formally assess the risk of bias, often resulting in moderate risk due to factors such as small sample sizes and a lack of long-term follow-up [8,14]. Only a few studies (1/29, 3%), such as the one by Rutkowski et al [9], used formal tools and structured randomization to minimize bias, resulting in a lower risk profile.

Common limitations included a reliance on small sample sizes and subjective data, particularly in studies using self-reported outcomes, which may introduce reporting bias [25]. Technical challenges, such as issues with device accuracy and system usability, also affected study outcomes, as seen in the studies by Tabak et al [8] and Oberschmidt et al [28]. Furthermore, most of the studies (13/29, 45%) lacked long-term follow-up, limiting their ability to evaluate sustained effects of the interventions.

Table 6 provides a detailed breakdown of each study’s risk-of-bias assessment, findings, and limitations.

Digital health technologies and gamification hold considerable potential as transformative approaches for managing chronic respiratory diseases such as COPD. By making rehabilitation more interactive and accessible, these interventions can support sustained patient engagement between medical presentations for exacerbations and beyond traditional clinical settings, addressing key challenges in long-term COPD care [5]. The ability of gamified interventions to integrate with real-time monitoring and provide personalized feedback aligns well with the goals of self-managed, home-based COPD care, making it easier for patients to monitor their symptoms and manage exacerbations effectively [24,29]. In addition, gamification encourages continuous engagement, which is crucial for adherence to exercise routines in COPD rehabilitation [6]. As research advances, digital health and gamification could become essential tools in the COPD management toolkit, offering a scalable, patient-centered approach to chronic respiratory care.

This systematic review highlights the positive impact of gamified interventions on COPD management, demonstrating improvements in physical outcomes, patient engagement, and QoL. Various studies have shown that gamified tools—ranging from exergames to VR-based PR—enhance patients’ adherence to exercise routines and promote self-management [8,9]. In particular, features such as real-time feedback, interactive guidance, and personalized adjustments make these interventions highly engaging and effective, aligning with the chronic, self-managed nature of COPD care. However, the studies also reveal challenges, such as technological barriers and limitations in sample size and duration, suggesting that more robust trials are needed to confirm the efficacy of gamified interventions in COPD management.

The integration of gamified interventions into COPD care presents significant opportunities for patients, health care providers, and policy makers. Gamified interventions empower patients with interactive and flexible tools for managing COPD symptoms, promoting independence and engagement in their care. These tools offer a novel approach to supporting patient adherence to home-based rehabilitation, reducing the reliance on in-clinic visits. Policy makers can leverage this approach to address the rising costs of COPD management by supporting digital health policies that encourage the development and use of gamified COPD interventions. Such policies could also promote accessibility to these tools across various populations, making COPD care more equitable and scalable.

Future research should focus on addressing the identified limitations of many of the studies in this review by conducting larger, long-term RCTs to assess the sustained impact of gamified interventions on COPD outcomes. Developing culturally relevant and adapted gamified tools can enhance the global applicability of these interventions. Collaborating with gaming companies could facilitate the integration of advanced game mechanics and elements, making interventions more engaging and effective. Furthermore, integrating personalized gamification approaches that cater to individual patient needs and preferences into health care could enhance adherence. Finally, exploring the long-term effects of gamified interventions will be essential for establishing their place in the chronic management of COPD and similar conditions.