TY - JOUR AU - Mia, Raihan Md AU - Ahamed, Iqbal Sheikh AU - Nemanich, Samuel PY - 2025/2/28 TI - Gamified mHealth System for Evaluating Upper Limb Motor Performance in Children: Cross-Sectional Feasibility Study JO - JMIR Serious Games SP - e57802 VL - 13 KW - mobile health KW - mHealth KW - digital health KW - mobile apps KW - smartphones KW - iPad KW - gamification KW - serious games KW - digital interventions KW - digital technology KW - spatiotemporal KW - upper limb movement KW - motor performance KW - motor skills KW - pediatrics KW - toddler KW - children KW - youth N2 - Background: Approximately 17% of children in the United States have been diagnosed with a developmental or neurological disorder that affects upper limb (UL) movements needed for completing activities of daily living. Gold-standard laboratory assessments of the UL are objective and precise but may not be portable, while clinical assessments can be time-intensive. We developed MoEvGame, a mobile health (mHealth) gamification software system for the iPad, as a potential advanced technology to assess UL motor functions. Objective: This feasibility study examines whether MoEvGame can assess children?s whole-limb movement, fine motor skills, manual dexterity, and bimanual coordination. The specific aims were to (1) design and develop novel mHealth gamified software tools to examine theory-driven features of UL movement, (2) analyze spatiotemporal game data with new algorithms and statistical techniques to quantify movement performance as a parameter of speed, accuracy, and precision, and (3) validate assessment methods with healthy participants from schools. Methods: Elementary school children (N=31, median 9.0, IQR 4.0-14.0 years old) participated by playing 5 games. The game tasks were focused on key features of skilled motor control: (1) whole limb reaching, (2) fine motor control and manual dexterity, and (3) bilateral coordination. Spatiotemporal game data were transferred and stored in a cloud-based data management server for further processing and analysis. We applied change point detection (ie, the pruned exact linear time method), signal processing techniques, and other algorithms to calculate movement speed and accuracy from spatiotemporal parameters. Different statistical methods (ie, Pearson correlation, mean, standard deviation, P value, 95% confidence interval) were used to compare speed-accuracy tradeoffs and evaluate the relationship between age and motor performance. Results: A negative correlation was identified between speed and accuracy in the whole limb movement (r=?0.30 to ?0.42). Significant relationships between age and upper limb performance were found: older participants exhibited lower errors with faster completion times compared to younger participants. Significant differences in bimanual coordination were found related to phase synchronization (in-phase congruent [mean 28.85, SD 18.97] vs antiphase congruent [mean 112.64, SD 25.82] and in-phase mirrored [mean 23.78, SD 16.07] vs antiphase mirrored [mean 121.39, SD 28.19]). Moreover, the average speed (revolutions per second) and travel distance (m) of the in-phase mode were significantly higher than those of the antiphase coordination. Conclusions: Results of this feasibility study show that spatiotemporal data captured from the mHealth app can quantify motor performance. Moving beyond traditional assessments, MoEvGame incorporates gamification into ubiquitous and accessible technology as a fast, flexible, and objective tool for UL motor assessment. UR - https://games.jmir.org/2025/1/e57802 UR - http://dx.doi.org/10.2196/57802 UR - http://www.ncbi.nlm.nih.gov/pubmed/40053722 ID - info:doi/10.2196/57802 ER - TY - JOUR AU - Fang, Hao AU - Fang, Changqing AU - Che, Yan AU - Peng, Xinyuan AU - Zhang, Xiaofan AU - Lin, Di PY - 2025/2/24 TI - Reward Feedback Mechanism in Virtual Reality Serious Games in Interventions for Children With Attention Deficits: Pre- and Posttest Experimental Control Group Study JO - JMIR Serious Games SP - e67338 VL - 13 KW - serious games KW - virtual reality KW - attention deficit KW - inhibitory control ability KW - reward feedback N2 - Background: Virtual reality (VR) serious games, due to their high level of freedom and realism, influence the rehabilitation training of inhibitory control abilities in children with attention-deficit/hyperactivity disorder (ADHD). Although reward feedback has a motivating effect on improving inhibitory control, the effectiveness and differences between various forms of rewards lack empirical research. Objective: This study aimed to investigate the effectiveness of different forms of reward feedback on the inhibitory control abilities of children with attention deficits in a VR serious game environment. Methods: This study focuses on children who meet the diagnostic criteria for ADHD tendencies, using a 2 (material rewards: coin reward and token reward) × 2 (psychological rewards: verbal encouragement and badge reward) factorial between-subject design (N=84), with a control group (n=15) for pre- and posttest experiments. The experimental group received VR feedback reinforcement training, while the control group underwent conventional VR training without feedback. The training period lasted 0.5 months, with each intervention session lasting 25 minutes, occurring twice daily with an interval of at least 5 hours for 28 sessions. Before and after training, the Swanson, Nolan, and Pelham, Version IV Scale (SNAP-IV) Scale, stop signal task, inhibition conflict task, and Simon task were administered to assess the hyperactivity index and the 3 components of inhibitory control ability. The pretest included the SNAP-IV Scale and 3 task tests to obtain baseline data; the posttest involved repeating the above tests after completing all training. Data were entered and analyzed using SPSS (IBM) software. Independent sample t tests were performed on the experimental and control groups? pre- and posttest task results to determine whether significant differences existed between group means. Paired sample t tests were also conducted on the SNAP-IV Scale?s pre- and posttest results to assess the intervention effect?s significance. Results: Reward feedback was more effective than no reward feedback in improving behaviors related to attention deficits in children. Material rewards showed significant effects in the Stop-Signal Task (F1=13.04, P=.001), Inhibition Conflict Task (F1=7.34, P=.008), and SNAP-IV test (F1=69.23, P<.001); mental rewards showed significant effects in the Stop-Signal Task (F1=38.54, P<.001) and SNAP-IV test (F1=70.78, P<.001); the interaction between the 2 showed significant effects in the Stop-Signal Task (F1=4.47, P=.04) and SNAP-IV test (F1=23.85, P<.001). Conclusions: Combining material and psychological rewards within a VR platform can effectively improve attention-deficit behaviors in children with ADHD, enhancing their inhibitory control abilities. Among these, coin rewards are more effective than token rewards, and verbal encouragement outperforms badge rewards. The combined feedback of coin rewards and verbal encouragement yields the most significant improvement in inhibitory control abilities. UR - https://games.jmir.org/2025/1/e67338 UR - http://dx.doi.org/10.2196/67338 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/67338 ER - TY - JOUR AU - Peramalaiah, Kanakapura Mrudula AU - Parmar, Tejraj Sanjay AU - Sepehri, Nariman AU - Muthukumarana, Saman AU - Kanitkar, Anuprita AU - Hin, Kit-Fong Cherry AU - Szturm, Joseph Tony PY - 2025/2/18 TI - Evaluation of a Game-Based Mechatronic Device for Rehabilitation of Hand-Arm Function in Children With Cerebral Palsy: Feasibility Randomized Controlled Trial JO - JMIR Rehabil Assist Technol SP - e65358 VL - 12 KW - cerebral palsy KW - computer game?assisted rehabilitation KW - manual dexterity KW - repetitive task practice KW - robotic manipulandum N2 - Background: Children with neurodevelopmental disorders, such as cerebral palsy (CP), often experience motor impairments in manual dexterity, which hinder daily tasks and social interactions. Traditional rehabilitation methods require repetitive task practice, which can be difficult for children to sustain due to low engagement. Game-based rehabilitation devices and robots offer a promising alternative by combining therapy with digital play, improving motivation and compliance. However, many systems fail to incorporate actual object manipulation, which is essential for motor learning through sensory feedback. To address this limitation, a low-cost, easy-to-use robotic manipulandum device (RMD) was developed. The RMD enables real-time object manipulation during gameplay while providing assistive force, allowing the practice of a wide range of manual dexterity skills beyond gross reaching. This system offers an engaging and effective rehabilitation approach to enhance hand function in children with CP. Objective: This study aimed to provide evidence for the feasibility and therapeutic value of the RMD game?based exercise program for children with CP. Methods: In total, 34 children with CP, aged 4 to 10 years, were randomly assigned to the experimental group (XG) or the control group (CG). The XG received a computer game?based exercise program using the RMD, focusing on object manipulation tasks, while the CG received task-specific training similar to constraint-induced movement therapy. Both groups received their respective therapy programs 3 times per week for 8 weeks. Semistructured interviews with parents and children, along with qualitative analysis, were conducted to evaluate their experiences with the exercise program. The following outcome measures were used: (1) the Peabody Developmental Motor Scale-2 (PDMS-2) grasping and visual-motor integration subtests and (2) the computer game?based upper extremity (CUE) assessment of manual dexterity. Results: No dropouts occurred during the 8-week program. Both groups showed significant improvements in the PDMS-2 subtests (P<.001) and the CUE assessment of manual dexterity, including success rates (tennis ball: P=.001; cone: P<.001; medicine ball: P=.001; and peanut ball: P<.001) and movement errors (tennis ball: P=.01; cone: P<.001; medicine ball: P=.04; and peanut ball: P<.001). The XG outperformed the CG, showing greater improvements in PDMS-2 grasping (P=.002) and visual-motor integration (P=.01). In the CUE assessment, the XG demonstrated higher success rates (medicine ball: P=.001 and peanut ball: P=.02) and fewer movement errors (cone: P<.001). Parents reported an increase in the children?s independence in daily tasks. Conclusions: This study demonstrates the feasibility, acceptability, and positive outcomes of the RMD game?based exercise program for improving hand function in children with CP. The findings support further research and development of computer game?assisted rehabilitation technologies. Trial Registration: Clinical Trials Registry - India CTRI/2021/07/034903; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NTc4ODU UR - https://rehab.jmir.org/2025/1/e65358 UR - http://dx.doi.org/10.2196/65358 UR - http://www.ncbi.nlm.nih.gov/pubmed/39964707 ID - info:doi/10.2196/65358 ER - TY - JOUR AU - Herren, Silvia AU - Seebacher, Barbara AU - Mildner, Sarah AU - Riederer, Yanick AU - Pachmann, Ulrike AU - Böckler, Sonja Nija AU - Niedecken, Stephan AU - Sgandurra, Alicia Sabrina AU - Bonati, Leo AU - Hotz, Isabella AU - Schättin, Alexandra AU - Jurt, Roman AU - Brenneis, Christian AU - Lenfert, Katharina AU - Behrendt, Frank AU - Schmidlin, Stefan AU - Nacke, Lennart AU - Schuster-Amft, Corina AU - Martin-Niedecken, Lisa Anna PY - 2025/2/14 TI - Exergame (ExerG)-Based Physical-Cognitive Training for Rehabilitation in Adults With Motor and Balance Impairments: Usability Study JO - JMIR Serious Games SP - e66515 VL - 13 KW - exergame KW - rehabilitation KW - user-centered design KW - usability testing KW - mixed-methods KW - interdisciplinary research KW - concept functional model proofs KW - exercise KW - cognitive training KW - technology acceptance KW - motor KW - cognitive impairment KW - safety KW - user experience KW - balance impairments KW - balance N2 - Background: Exergames are increasingly used in rehabilitation, yet their usability and user experience for patients and therapists, particularly for functional model systems, are underresearched. The diverse needs and preferences of users make conducting usability studies challenging, emphasizing the need for further investigation in real-world settings. Objective: This study aimed to evaluate the usability, safety, and user experience of a novel exergame functional model, the ExerG, from the perspectives of patients and therapists in a rehabilitation setting. Methods: In this mixed methods study, 15 patients undergoing rehabilitation (primary end users [PEUs]) and 20 therapists (secondary end users [SEUs]) from 2 rehabilitation centers in Switzerland and Austria participated in exercising and observation sessions with the ExerG. SEUs received training on system use and technical issue management, enabling them to fulfill their therapist roles while treating patients or mock patients. Rapid Iterative Testing and Evaluation was used and the training software adjusted based on participant feedback. Usability was assessed with questionnaires, semistructured interviews, and through observations during the ExerG testing. System acceptability was evaluated using specific quantitative thresholds based on PEU performance and feedback. An observation protocol tracked SEUs? correct use, errors, hesitations, task completion time, and needed assistance across scenarios. Results: Patients and therapists reported overall good usability and positive experiences with the exergame. PEUs rated 23/29 (79%) instructions as acceptable, showed good-to-very-good exercise performance in 19/29 (65%) tasks, and completed 28/29 (97%) tasks. Patients reported no adverse events, showing improved performance and enjoyment across ExerG exercising rounds, with 79/90 (88%) expressing positive emotions and reporting median scores of 9 (IQR 7.5?10) on a 1?10 user satisfaction scale. Patients were willing to continue using the device if the graphic design was improved (5/15), tracking systems and projector quality were enhanced (each 3/15), instructions clarified (12/15), and the game variety increased (2/15). PEUs felt secure in the safety harness (15/15) but recommended swivel arm movement enhancements (5/15). SEUs effectively executed scenarios, with hesitation and difficulties observed in only 14/41 tasks and 2/41 tasks, across all 20 therapists, accounting for 1.7% and 0.2% of the 820 total task cases, respectively. Therapists? quantitative usability ratings were high (median System Usability Scale score 82.5, IQR 65?95). All SEUs expressed their willingness to use the ExerG (20/20) and reported being able to operate the system using the user handbook (20/20). They emphasized the motivation-enhancing effect of video-game based training (12/20) and considered the activities supportive for physical and cognitive skills (20/20). They suggested incorporating daily living task simulations (13/20), more customizable options (6/20), more targeted motivational feedback (9/20), clearer performance ratings (9/20), and more concise activity instructions (6/20). Conclusions: The interdisciplinary, iterative ExerG development approach shows promise. The findings will inform future optimizations. Future work will assess long-term impact. Trial Registration: ClinicalTrials.gov NCT05967078; https://clinicaltrials.gov/study/NCT05967078 and OSF Registries OSFCQ9AT; https://osf.io/cq9at UR - https://games.jmir.org/2025/1/e66515 UR - http://dx.doi.org/10.2196/66515 ID - info:doi/10.2196/66515 ER - TY - JOUR AU - Binyamin-Netser, Reut AU - Handelzalts, Shirley AU - Goldhamer, Noy AU - Avni, Inbar AU - Tayer Yeshurun, Adi AU - Koren, Yogev AU - Bibas Levy, Ofri AU - Kramer, Shilo AU - Bar Haim, Simona AU - Shmuelof, Lior PY - 2025/2/13 TI - Neurotechnology-Based, Intensive, Supplementary Upper-Extremity Training for Inpatients With Subacute Stroke: Feasibility Study JO - JMIR Serious Games SP - e56397 VL - 13 KW - stroke KW - rehabilitation KW - neurotechnology N2 - Background: Upper-extremity hemiparesis is a common and debilitating impairment after stroke, severely restricting stroke survivors? ability to participate in daily activities and function independently. Alarmingly, only a small percentage of stroke patients fully recover upper extremity function. Animal models indicate that high-dose upper extremity training during the early poststroke phase can significantly enhance motor recovery. However, translating such programs for human patients remains challenging due to resource limitations, patient compliance issues, and administrative constraints. Objective: This study aimed to assess the feasibility and potential efficacy of an intensive, video game?based upper-extremity training protocol designed to improve movement quality during inpatient stroke rehabilitation. Additionally, it evaluated the resources required for this intervention. Specifically, the protocol provides high-intensity, high-dose training to facilitate motor recovery by engaging patients in targeted interactive exercises. Methods: Twelve patients with upper-extremity hemiparesis completed a 4-week intensive training program comprising 40 sessions of 60 minutes; the training was conducted for 2 hours per day, 5 days per week. This was delivered in addition to standard care, which included 3 therapeutic sessions daily. Two video game?based platforms were used: one platform (tech 1) targeted proximal movements involving the shoulder and elbow, while the second platform (tech 2) emphasized distal movements of the wrist and fingers. Feasibility was assessed using the measure of time on task and measures of patients? motivation and engagement. Potential effectiveness was assessed using the Fugl-Meyer Assessment of the upper extremity (FMA-UE) scale, Action Research Arm Test (ARAT), and Stroke Impact Scale (SIS). Results: Of the 12 patients, 8 completed the full protocol, 3 completed 34?38 sessions, and 1 completed 27 sessions. On average, patients actively engaged in exercises for 35 (SD 4) minutes per hour on the proximal platform (tech 1) and 37 (SD 2) minutes on the distal platform (tech 2). Patients reported high motivation and enjoyment throughout the sessions, with an Intrinsic Motivation Inventory enjoyment score of 6.49 (SD 0.66) out of 7. Pain levels were minimal, with a visual analogue scale (VAS) mean score of 2.00 (SD 2.32). Significant improvements were observed in motor function assessments: the mean improvement in FMA-UE score was 16.5 (SD 10.2) points, ARAT scores increased by 22.9 (SD 13.1) points, and the SIS Hand Function and Recovery score showed a mean delta of 1.23 (SD 0.80) points and a 23.33% (SD 21.5%) improvement, respectively. Conclusions: These findings demonstrate that a high-dose, high-intensity, video game?based training protocol is feasible and can be successfully integrated into subacute stroke rehabilitation. Additionally, preliminary evidence suggests that this supplementary intervention may be effective in enhancing motor recovery. This approach holds promise for future stroke rehabilitation protocols by offering an engaging, high-dose, and high-intensity program during early recovery. Trial Registration: Clinicaltrials.gov NCT04737395, https://clinicaltrials.gov/study/NCT04737395 UR - https://games.jmir.org/2025/1/e56397 UR - http://dx.doi.org/10.2196/56397 ID - info:doi/10.2196/56397 ER - TY - JOUR AU - Chang, Chien-Hsiang AU - Wei, Chun-Chun AU - Lien, Wei-Chih AU - Yang, Tai-Hua AU - Liu, Bo AU - Lin, Yimo AU - Tan, Thong Poh AU - Lin, Yang-Cheng PY - 2025/1/21 TI - The Usability and Effect of a Novel Intelligent Rehabilitation Exergame System on Quality of Life in Frail Older Adults: Prospective Cohort Study JO - JMIR Serious Games SP - e50669 VL - 13 KW - frailty KW - exergame KW - older adults KW - intelligent rehabilitation KW - reminiscence therapy KW - eHealth care N2 - Background: Aging in older adults results in a decline in physical function and quality of daily life. Due to the COVID-19 pandemic, the exercise frequency among older adults decreased, further contributing to frailty. Traditional rehabilitation using repetitive movements tends not to attract older adults to perform independently. Objective: Intelligent Rehabilitation Exergame System (IRES), a novel retro interactive exergame that incorporates real-time surface electromyography, was developed and evaluated. Methods: Frail older adults were invited to use the IRES for rehabilitation using lower limb training twice per week for 4 weeks. Participants were required to have no mobility or communication difficulties and be willing to complete the 4-week study. The enrolled cohort had baseline scores ranging from 1 to 5 on the Clinical Frailty Scale, as described by Rockwood et al. Three major lower limb movements (knee extension, plantar flexion, and dorsiflexion) were performed 20 times for each leg within 30 minutes. The surface electromyography collected and analyzed muscle potential signals for review by health care professionals to customize the protocol for the next training. The System Usability Scale (SUS) and Taiwanese version of the EuroQol-5 Dimensions (EQ-5D) were administered after completing the first (week 1, baseline) and last training (week 4, one-month follow-up) to evaluate the usability of the IRES and its effects on the quality of life of participants. Results: A total of 49 frail older adults (mean age 74.6 years) were included in the analysis. The usability of the IRES improved according to the mean SUS score, from 82.09 (good) at baseline to 87.14 (good+) at 1-month follow-up. The willingness to use (t96=?4.51; P<.001), learnability (t96=?4.83; P<.001), and confidence (t96=?2.27; P=.02) in working with the IRES increased. After using the IRES for 1 month, significant improvements were observed in the ease of use (t47=2.05; P=.04) and confidence (t47=2.68; P<.001) among participants without previous rehabilitation experience. No sex-based differences in the SUS scores were found at baseline or 1-month follow-up. The quality of life, as assessed by the EQ-5D, improved significantly after 1 month of IRES training compared to that at baseline (t96=6.03; P<.001). Conclusions: The novel IRES proposed in this study received positive feedback from frail older adults. Integrating retro-style exergame training into rehabilitation not only improved their rehabilitation motivation but also increased their learning, system operability, and willingness to continue rehabilitation. The IRES provides an essential tool for the new eHealth care service in the post?COVID-19 era. UR - https://games.jmir.org/2025/1/e50669 UR - http://dx.doi.org/10.2196/50669 ID - info:doi/10.2196/50669 ER - TY - JOUR AU - Ramos, Aurélien AU - Boisvert, Maxence AU - Traverse, Elodie AU - Levac, Danielle AU - Lemay, Martin AU - Demers, Marika AU - Bordeleau, Martine AU - Ruest, Sarah-Maude AU - Périnet-Lacroix, Roxanne AU - Best, L. Krista AU - Robert, T. Maxime PY - 2025/1/17 TI - Bridging Needs and Expectations of Individuals With Physical Disabilities and Community Services Stakeholders for the Cocreation of an Adapted Physical Activity Platform in Virtual Reality: Qualitative Study JO - JMIR Serious Games SP - e59704 VL - 13 KW - virtual reality KW - physical activity KW - community organizations KW - accessibility KW - physical disability N2 - Background: Physical activity supports the health and well-being of individuals with physical disabilities. Despite the significance of engaging in physical activity, barriers faced by individuals with disabilities, such as limited access to adapted facilities and lack of transportation, can restrict their participation. Community organizations play a role in addressing these challenges, but virtual reality (VR) also offers a way to diversify adapted activities. In some situations, VR can help overcome the resource limitations of organizations by providing accessible, engaging, and highly personalized options for physical activity. Objective: The aim of this study was to explore the needs and expectations of individuals with physical disabilities and their interventionists for the use of a VR physical activity platform in a community organization. Methods: A descriptive qualitative study was conducted using semistructured interviews with individuals with physical disabilities and their interventionists, all associated with a nonprofit organization promoting physical activity among people with disabilities. Data were analyzed using an inductive thematic approach. Results: In total, 15 participants, including 8 people with physical disabilities and 7 interventionists, were interviewed. Through this discussion, we gained insights into the everyday challenges faced by individuals with disabilities and identified priorities for community organizations. Subsequently, we discussed key considerations for using VR, including adapting activities, the possibility of fostering a more positive perception of physical activity, and harnessing the potential of VR to improve access to physical activity. We also discussed the importance of supporting personal goals and creating inclusive experiences while recognizing challenges such as technical difficulties and connectivity issues. Conclusions: By exploring the needs and expectations regarding VR technology from individuals with physical disabilities and their interventionists, this study provided essential insights for integrating immersive and nonimmersive VR into community organizations, informing next steps for the design of adapted physical activities in VR. UR - https://games.jmir.org/2025/1/e59704 UR - http://dx.doi.org/10.2196/59704 ID - info:doi/10.2196/59704 ER - TY - JOUR AU - Su, Kuan-Chu AU - Wu, Ko-Chiu AU - Chou, Kuei-Ru AU - Huang, Chia-Hsu PY - 2025/1/9 TI - Tongue Muscle Training App for Middle-Aged and Older Adults Incorporating Flow-Based Gameplay: Design and Feasibility Pilot Study JO - JMIR Serious Games SP - e53045 VL - 13 KW - exergame KW - mobile app KW - flow KW - self-care KW - feasibility KW - older adults KW - dysphagia KW - tongue exercises N2 - Background: Complications due to dysphagia are increasingly prevalent among older adults; however, the tediousness and complexity of conventional tongue rehabilitation treatments affect their willingness to rehabilitate. It is unclear whether integrating gameplay into a tongue training app is a feasible approach to rehabilitation. Objective: Tongue training has been proven helpful for dysphagia treatment. Following the development of a tongue training app, a feasibility trial aimed to identify physiological and psychological factors that affect user and flow experience and explored whether training specialized muscles could produce a flow experience for optimal immersion. We aimed to provide a useful tool for medical rehabilitation so that older adults could retain tongue muscle flexibility. Methods: After consulting professional nurses, we developed a mobile gaming app for middle-aged and older adults to train their tongue muscles. This pilot study used an image recognition system to detect the tongue movements of 32 healthy middle-aged and older adults (7 males, 21.9%; 25 females, 78.1%) during 3 game training tasks, each requiring different reaction speeds. Their physiological and psychological signals, as well as the results of the Flow State Scale 2 (FSS2) questionnaire, were used for correlation analysis regarding relevant flow experiences to establish and evaluate the feasibility of our method. Results: Through exploratory factor analyses, a 2-factor (operation and immersion) structure was confirmed to have an adequate model fit (?²36=448.478; P<.001; Kaiser-Meyer-Olkin=0.757) and internal consistency reliability (Cronbach ?=0.802). The slow, medium, and fast levels all significantly affected the FSS2 score for operation (P=.001), the National Aeronautics and Space Administration Task Load Index (P<.001), and flow distance (P<.001). K-means clustering revealed that participants could be further categorized into 3 groups. Through the analysis of changes in the participants? physiological and psychological signals for each given task, Pearson correlation indicated that changes were primarily related to flow distance. For the 12 indicators measured in this study, the low, medium, and high operation groups showed significance in 58% (7/12), 50% (6/12), and 25% (3/12) of the indicators, respectively. Similarly, the low, medium, and high immersion groups had changes in 50% (6/12), 33% (4/12), and 17% (2/12) of indicators, respectively. Conclusions: Our research supports the further development of a gaming app to aid older adults with tongue muscle training and measure flow using physiological and psychological signals to enhance training accuracy and feasibility. Next, we aim to conduct a randomized pilot trial, improve app functions, offer alternative rehabilitation options, and encourage long-term participation. Future goals include enhancing long-term efficacy, diversifying training modes, and adding a multiuser interactive option for an added challenge. UR - https://games.jmir.org/2025/1/e53045 UR - http://dx.doi.org/10.2196/53045 ID - info:doi/10.2196/53045 ER - TY - JOUR AU - Funao, Hiroki AU - Momosaki, Ryo AU - Tsujikawa, Mayumi AU - Kawamoto, Eiji AU - Esumi, Ryo AU - Shimaoka, Motomu PY - 2024/12/30 TI - Virtual Reality?Applied Home-Visit Rehabilitation for Patients With Chronic Pain: Protocol for Single-Arm Pre-Post Comparison Study JO - JMIR Res Protoc SP - e58734 VL - 13 KW - chronic pain KW - homebound patient KW - home-visit rehabilitation KW - virtual reality KW - protocol KW - feasibility study KW - VR KW - pain KW - recurrent pain KW - home visit KW - rehabilitation KW - home rehabilitation KW - in-home KW - effective KW - screening KW - VR intervention KW - feasibility KW - alleviate pain N2 - Background: Pain inhibits rehabilitation. In rehabilitation at medical institutions, the usefulness of virtual reality (VR) has been reported in many cases to alleviate pain. In recent years, the demand for home rehabilitation has increased. Unlike in medical situations, the patients targeted for in-home rehabilitation often have chronic pain due to physical and psychosocial factors, and the environment is not specialized for rehabilitation. However, VR might be effective for in-home rehabilitation settings. Objective: This study aims to evaluate the feasibility of applying VR to home-visit rehabilitation for homebound patients with chronic pain. Methods: This study will test the feasibility of VR applied to home-visit rehabilitation for patients with chronic pain. A single-arm pre-post comparison will be conducted to evaluate its feasibility. Screening will be conducted on patients who have given consent to participate in the study, and those who have pain that persists or recurs for more than 3 months and receive home-visit rehabilitation will be enrolled in the study. Baseline measurements will be conducted on study participants before the start of the VR intervention. VR-applied home-visit rehabilitation will be conducted once a week for a total of 10 VR interventions. The primary endpoint is the change in pain from the baseline to the tenth intervention. Pain is a subjective symptom of the study participants and will be subjectively assessed by the Numerical Rating Scale of 11 levels from 0 to 10. Pain as the primary endpoint will be measured at 3-time points per rehabilitation session: before, during, and after the rehabilitation so that changes between time points can be evaluated. Secondary endpoints are heart rate variability, range of motion of the area in the musculoskeletal system where the pain occurs, motivation for rehabilitation, catastrophic thoughts of pain, mood state, quality of life, and interviews. Assessments will be conducted at the baseline, first, fifth, and tenth interventions. After completing the clinical study (10 VR interventions), patients will continue their regular home-visit rehabilitation as usual. Results: Recruitment of participants began on February 22, 2022, and data collection is ongoing as of November 2024. The research results will be published in international peer-reviewed journals and through presentations at national and international conferences. Conclusions: This study will contribute to the development of novel rehabilitation-based solutions for homebound patients who have had difficulty obtaining adequate relief from chronic pain. Future studies will consider conducting randomized controlled trials as clinical trials to validate the efficacy of VR during home-visit rehabilitation for patients with chronic pain. International Registered Report Identifier (IRRID): DERR1-10.2196/58734 UR - https://www.researchprotocols.org/2024/1/e58734 UR - http://dx.doi.org/10.2196/58734 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/58734 ER - TY - JOUR AU - Groenveld, D. Tjitske AU - Smits, GM Indy AU - Scholten, Naomi AU - de Vries, Marjan AU - van Goor, Harry AU - Stirler, MA Vincent PY - 2024/12/9 TI - Pulmonary and Physical Virtual Reality Exercises for Patients With Blunt Chest Trauma: Randomized Clinical Trial JO - JMIR Serious Games SP - e54389 VL - 12 KW - virtual reality KW - pain KW - pulmonary KW - chest trauma KW - blunt thorax trauma KW - pain relief KW - breathing KW - mobilization KW - randomized clinical trial KW - clinicians KW - rehabilitation KW - physical activity KW - exercise KW - interview N2 - Background: Adequate pain relief, early restoration of breathing, and rapid mobilization pose a clinical challenge in patients with blunt chest trauma. Virtual reality (VR) has the potential to achieve these 3 interrelated treatment objectives with enhanced self-efficacy and autonomy of patients and limited support by clinicians. Objective: This study aimed to assess the effectivity of breathing and physical exercises using VR on the pulmonary recovery of patients with blunt chest trauma at the ward. Methods: A pilot randomized controlled trial was performed. The control group received usual physiotherapy consisting of protocolized breathing exercises (8 times daily for 10 minutes) and physical exercises (2 times daily for 10 minutes). The VR group was instructed to perform these exercises using VR. The primary outcome was vital lung capacity at day 5 or earlier at discharge. Secondary outcomes were patient mobility (time standing, lying, and sitting), clinical outcomes (length of hospital stay, pulmonary complications, transfer to intensive care unit, and readmission within 30 days), pain, activities of daily living, patient-reported outcome measures (satisfaction and quality of recovery). Patient experiences and barriers and facilitators toward implementation were assessed through interviews. Results: The study was prematurely ended due to enrollment failure combined with poor protocol adherence to exercises in both groups. A total of 27 patients were included, of which 19 patients completed 3 or more days. Vital lung capacity at 5 days (or last measurement) was equal between groups with 1830 (SD 591) mL and 1857 (SD 435) mL in the control and VR groups, respectively. No marked differences were observed in secondary outcomes. Patient interviews showed positive attitudes toward the use of VR, describing that visualization of the exercises helped patients to perform the exercises correctly and to continue the exercises for a longer duration. Also, patients experienced the immersiveness of VR as an analgesic. However, patients did not experience added value over usual care and reported that better integration in treatment and the hectic hospital environment could improve the use of the VR exercises. Conclusions: The suitability of patients to use virtual reality therapy (VRx) in a hospital (trauma) ward setting is lower than generally expected. Effective application of VRx requires professional guidance and needs thorough alignment with clinical practice. For future research, we recommend to chart adherence to study protocol before designing a VR clinical trial. Patient-reported experiences need to be prioritized in evaluating VR acceptance, usability, and effectiveness. In line, we recommend performing a systematic analysis (eg, using the technology acceptance model) on the acceptance before pilot or main effectiveness studies. Finally, the eligibility of patients and exclusion of patients due to the inability to use VRx should be routinely reported. Trial Registration: ClinicalTrials.gov NCT05194176; https://tinyurl.com/2bzh4tzx UR - https://games.jmir.org/2024/1/e54389 UR - http://dx.doi.org/10.2196/54389 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54389 ER - TY - JOUR AU - Gnadlinger, Florian AU - Werminghaus, Maika AU - Selmanagi?, André AU - Filla, Tim AU - Richter, G. Jutta AU - Kriglstein, Simone AU - Klenzner, Thomas PY - 2024/12/3 TI - Incorporating an Intelligent Tutoring System Into a Game-Based Auditory Rehabilitation Training for Adult Cochlear Implant Recipients: Algorithm Development and Validation JO - JMIR Serious Games SP - e55231 VL - 12 KW - cochlear implant KW - eHealth KW - evidence-centered design KW - hearing rehabilitation KW - adaptive learning KW - intelligent tutoring system KW - game-based learning N2 - Background: Cochlear implants are implanted hearing devices; instead of amplifying sounds like common hearing aids, this technology delivers preprocessed sound information directly to the hearing (ie, auditory) nerves. After surgery and the first cochlear implant activation, patients must practice interpreting the new auditory sensations, especially for language comprehension. This rehabilitation process is accompanied by hearing therapy through face-to-face training with a therapist, self-directed training, and computer-based auditory training. Objective: In general, self-directed, computer-based auditory training tasks have already shown advantages. However, compliance of cochlear implant recipients is still a major factor, especially for self-directed training at home. Hence, we aimed to explore the combination of 2 techniques to enhance learner motivation in this context: adaptive learning (in the form of an intelligent tutoring system) and game-based learning (in the form of a serious game). Methods: Following the suggestions of the evidence-centered design framework, a domain analysis of hearing therapy was conducted, allowing us to partially describe human hearing skill as a probabilistic competence model (Bayesian network). We developed an algorithm that uses such a model to estimate the current competence level of a patient and create training recommendations. For training, our developed task system was based on 7 language comprehension task types that act as a blueprint for generating tasks of diverse difficulty automatically. To achieve this, 1053 audio assets with meta-information labels were created. We embedded the adaptive task system into a graphic novel?like mobile serious game. German-speaking cochlear implant recipients used the system during a feasibility study for 4 weeks. Results: The 23 adult participants (20 women; 3 men) fulfilled 2259 tasks. In total, 2004 (90.5%) tasks were solved correctly, and 255 (9.5%) tasks were solved incorrectly. A generalized additive model analysis of these tasks indicated that the system adapted to the estimated competency levels of the cochlear implant recipients more quickly in the beginning than at the end. Compared with a uniform distribution of all task types, the recommended task types differed (?²6=86.713; P<.001), indicating that the system selected specific task types for each patient. This is underlined by the identified categories for the error proportions of the task types. Conclusions: This contribution demonstrates the feasibility of combining an intelligent tutoring system with a serious game in cochlear implant rehabilitation therapies. The findings presented here could lead to further advances in cochlear implant care and aural rehabilitation in general. Trial Registration: German Clinical Trials Register (DRKS) DRKS00022860; https://drks.de/search/en/trial/DRKS00022860 UR - https://games.jmir.org/2024/1/e55231 UR - http://dx.doi.org/10.2196/55231 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55231 ER - TY - JOUR AU - Fahr, Annina AU - Kläy, Andrina AU - Coka, S. Larissa AU - van Hedel, A. Hubertus J. PY - 2024/11/18 TI - Effectiveness of Game-Based Training of Selective Voluntary Motor Control in Children With Upper Motor Neuron Lesions: Randomized Multiple Baseline Design Study JO - JMIR Form Res SP - e47754 VL - 8 KW - neurorehabilitation KW - single-case design KW - interactive computer play KW - cerebral palsy KW - surface electromyography KW - motor control KW - mirror movements KW - involuntary movements N2 - Background: Selective voluntary motor control (SVMC) is the ability to control joint movements independently. Impairments in SVMC can affect functional activities, but only a few interventions directly target SVMC. Therefore, we developed a game-based intervention for children with upper motor neuron lesions to improve SVMC. The intervention trained selective activation of a muscle or joint movement while providing immediate feedback about involuntarily occurring muscle activations or movements in another joint. The intervention was provided in a playful manner with a custom-made game environment and a technology-based interface to capture muscle activation or joint movements. Objective: This study aimed to investigate the effectiveness of this game-based intervention and explore treatment response?related factors in children with impaired SVMC undergoing inpatient neurorehabilitation. Methods: We conducted a single-case research study with a randomized, nonconcurrent, multiple baseline design. The study consisted of a random-length baseline phase where no SVMC-specific intervention was provided and an intervention phase with additional SVMC training. Concurrently in both phases, children attended their individual multimodal rehabilitation program at our clinic, Swiss Children?s Rehab. During the intervention phase, participants completed ten 45-minute sessions with our game-based SVMC training. SVMC was measured repeatedly throughout both phases and at the 3-month follow-up with a short custom-made assessment. Results: Eighteen children with reduced SVMC from upper motor neuron lesions participated in the study. The mean age of the children was 12.7 (SD 2.9) years, and they mostly had spastic cerebral palsy. A linear mixed-effects model revealed a significant trend (P<.001) for improved SVMC already in the baseline phase. This trend did not change significantly (P=.15) when the game-based SVMC training was introduced in the intervention phase, suggesting no additional improvements due to the SVMC training. Although we could not find an overall treatment effect, we could explain 89.4% of the total random variation of the treatment effect by patient and therapy characteristics. Children with spasticity in the trained movement (20.1%), and those who trained the more affected side (23.5%) benefited most from the intervention. At the 3-month follow-up, SVMC had deteriorated compared to the end of the intervention but was still better than at the beginning of the study. Conclusions: The regular concomitant rehabilitation program already yielded improvements in SVMC, while the game-based SVMC training showed no additional effects. Although the intervention did not show a group effect, we could identify patient and therapy characteristics that determine who is likely to profit from the intervention. Trial Registration: German Clinical Trials Register DRKS00025184; https://tinyurl.com/msnkek9b UR - https://formative.jmir.org/2024/1/e47754 UR - http://dx.doi.org/10.2196/47754 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/47754 ER - TY - JOUR AU - Wei, Xijun AU - Zhou, Ping AU - Wei, Yixi AU - Wu, Dashuang AU - Qin, Ping AU - Zhang, Yingying AU - Zhu, Jing AU - Ren, Zhanbing AU - Li, Hai AU - Zhang, Yumei PY - 2024/11/15 TI - Comparison of Occupational Performance in Immersive Virtual and Real Environments Among Patients With Stroke: Observational Randomized Crossover Pilot Study JO - JMIR Serious Games SP - e58388 VL - 12 KW - instrumental activities of daily living KW - immersive virtual reality KW - occupational performance KW - stroke rehabilitation KW - occupational therapy N2 - Background: Conventional rehabilitation approaches involve therapists simulating various occupational tasks in health care settings or recreating real-life situations to assess and train patients in instrumental activities of daily living (IADLs). As an alternative, immersive virtual reality (IVR) has been widely used in stroke rehabilitation for years, but research comparing occupational performance between virtual and real environments is limited. Objective: This study aims to introduce a novel IVR shopping system designed for patients with stroke and to investigate the correlation of occupational performance in virtual and real environments among patients with stroke. Methods: Ten patients with stroke were recruited from the Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, who met the inclusion and exclusion criteria for this observational, randomized crossover study; the patients were predominantly male (n=7), had experienced ischemic stroke (n=9), were aged 14 to 73 years, and had a time since stroke of 1 to 42 months. All patients attempted shopping tasks in virtual and real environments. The Mini-Mental State Examination (MMSE), Timed Up and Go Test (TUGT), modified Barthel index (MBI), and Lawton index (LI) were used to assess cognition, ambulation, and activities of daily living. Memory capacity and duration in the virtual and real environments were recorded as the primary parameters of occupational performance. The Wilcoxon test and Spearman correlation coefficients were used to analyze the differences and correlations between the 2 environments. Results: The Wilcoxon test showed no significant differences between the virtual and real environments in memory capacity and duration of task completion (P>.99 and P=.99), and memory capacity in both environments correlated with the LI (?=0.81; P=.005). Memory duration had a relationship with the TUGT in the virtual environment (?=0.68; P=.03) and a borderline negative correlation with MMSE in the real environment (?=?0.58; P=.08). Conclusions: Considering the small sample size used in this study and the study?s limitations, despite the significant correlation between shopping performance in IVR and the real world, it is still too early to conclude that IVR is a noninferior approach, but it presents the potential to be an alternative for assessment and training in IADLs when resources are limited. However, further research is needed to investigate the psychometric properties, clinical effects, and impact of virtual training on real-world performance. The implications for practice might include the following: (1) occupational performance in virtual shopping might be the same as real-world shopping, and more virtual IADLs could thus be developed; (2) virtual IADL assessment and training systems could be used in remote locations or locations with limited resources; and (3) more objective parameters of IADLs could be extracted from virtual environments. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000041058; https://www.chictr.org.cn/showprojEN.html?proj=65714 UR - https://games.jmir.org/2024/1/e58388 UR - http://dx.doi.org/10.2196/58388 ID - info:doi/10.2196/58388 ER - TY - JOUR AU - Warlo, S. Leonie AU - El Bardai, Souraya AU - de Vries, Andrica AU - van Veelen, Marie-Lise AU - Moors, Suzan AU - Rings, HHM Edmond AU - Legerstee, S. Jeroen AU - Dierckx, Bram PY - 2024/10/17 TI - Game-Based eHealth Interventions for the Reduction of Fatigue in People With Chronic Diseases: Systematic Review and Meta-Analysis JO - JMIR Serious Games SP - e55034 VL - 12 KW - fatigue KW - chronic disease KW - eHealth KW - serious games KW - exergames N2 - Background: Fatigue is a common and debilitating side effect of chronic diseases, significantly impacting patients? quality of life. While physical exercise and psychological treatments have been shown to reduce fatigue, patients often struggle with adherence to these interventions in clinical practice. Game-based eHealth interventions are believed to address adherence issues by making the intervention more accessible and engaging. Objective: This study aims to compile empirical evidence on game-based eHealth interventions for fatigue in individuals with chronic diseases and to evaluate their effectiveness in alleviating fatigue. Methods: A comprehensive literature search was performed across Embase, MEDLINE ALL, PsycINFO, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar in August 2021. Study characteristics and outcomes from the included studies were extracted, and a random-effects meta-analysis was conducted. Sensitivity and subgroup analyses were performed to identify sources of heterogeneity. Results: Of 1742 studies identified, 17 were included in the meta-analysis. These studies covered 5 different chronic diseases: multiple sclerosis (n=10), cancer (n=3), renal disease (n=2), stroke (n=1), and Parkinson disease (n=1). All but 1 study used exergaming interventions. The meta-analysis revealed a significant moderate effect size in reducing fatigue favoring the experimental interventions (standardized mean difference [SMD] ?0.65, 95% CI ?1.09 to ?0.21, P=.003) compared with control conditions consisting of conventional care and no care. However, heterogeneity was high (I2=85.87%). Subgroup analyses were conducted for the 2 most prevalent diseases. The effect size for the multiple sclerosis subgroup showed a trend in favor of eHealth interventions (SMD ?0.47, 95% CI ?0.95 to 0.01, P=.05, I2=63.10%), but was not significant for the cancer group (SMD 0.61, 95% CI ?0.36 to 1.58, P=.22). Balance exercises appeared particularly effective in reducing fatigue (SMD ?1.19, 95% CI ?1.95 to ?0.42, P=.002). Conclusions: Game-based eHealth interventions appear effective in reducing fatigue in individuals with chronic diseases. Further research is needed to reinforce these findings and explore their impact on specific diseases. Additionally, there is a lack of investigation into interventions beyond exergaming within the field of game-based learning. UR - https://games.jmir.org/2024/1/e55034 UR - http://dx.doi.org/10.2196/55034 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55034 ER - TY - JOUR AU - Lo, Man Hermione Hin AU - Ng, Marques AU - Fong, Hugo Pak Yiu AU - Lai, Ki Harmony Hoi AU - Wang, Bo AU - Wong, Yeung-shan Samuel AU - Sit, Shan Regina Wing PY - 2024/9/27 TI - Examining the Feasibility, Acceptability, and Preliminary Efficacy of an Immersive Virtual Reality?Assisted Lower Limb Strength Training for Knee Osteoarthritis: Mixed Methods Pilot Randomized Controlled Trial JO - JMIR Serious Games SP - e52563 VL - 12 KW - virtual reality KW - VR KW - immersive KW - knee KW - joint KW - arthritis KW - arthritic KW - osteoarthritis KW - knee osteoarthritis KW - gerontology KW - geriatric KW - older adult KW - elder KW - elderly KW - older person KW - older people KW - aging KW - pain KW - function KW - acceptability KW - user experience KW - RCT KW - randomized KW - controlled trial KW - limb KW - strength KW - muscle KW - muscular KW - physiotherapy N2 - Background: Knee osteoarthritis prevalently causes significant pain, activity limitations, psychological distress, and reduced quality of life. Despite lower limb strength training being a core treatment for knee osteoarthritis, adherence remains a challenge, prompting the exploration of virtual reality (VR) to improve exercise compliance. Recent research suggests the potential of VR in providing enhanced pain management and functional outcomes for knee osteoarthritis, necessitating further exploration of immersive VR technology. Objective: We aimed to study the feasibility, acceptability, and preliminary efficacy of an immersive VR-assisted lower limb strength training for knee osteoarthritis (VRiKnee). Methods: A convergent, parallel, mixed methods study was conducted in 30 participants with knee osteoarthritis. After 1:1 randomization, the VRiKnee group (n=15) was assigned to perform repetitive concentric quadriceps and isometric vastus medialis oblique exercise in an immersive environment using a head-mounted display for 12 weeks. The control group (n=15) completed the same exercises without VRiKnee. VRiKnee participants were interviewed at week 12 to study VRiKnee acceptability and user experience. Quantitative data included feasibility outcomes such as recruitment, dropout, and exercise adherence rates, and effectiveness outcomes such as the numeric rating scale, the Western Ontario and McMaster Universities Osteoarthritis Index (100 points) pain and function subscales, and objective physical activity measured by metabolic equivalents of task using an ActivPAL accelerometer. Qualitative data were analyzed by thematic analysis, followed by integration with quantitative data using joint displays. Results: The recruitment rate was 100% (N=30), with enrollment of 30 participants in 7.57 weeks. The median age was 63.5 (IQR 61.8?66.3) years, with 76% (n=23) being female. The response rates were 80% and 93% for the VRiKnee and control groups. Dropout rates were 13% for VRiKnee and 7% for the control group. Median exercise adherence was 77% (IQR 37-104%) for VRiKnee and 62% (IQR 40-166%) for the control group, respectively, with adherence reduction over this study?s period and no significant intergroup differences (P=.82). No statistically significant differences were observed in primary and secondary outcomes, though positive trends were observed in pain and stiffness. Cybersickness was reported by 5 (33%) participants in the VRiKnee group. In the qualitative analysis, 4 themes, 11 subthemes, and 16 quotes were generated, identifying facilitators and barriers with practical suggestions to enhance the usability of VRiKnee. Conclusions: VRiKnee demonstrated feasibility, acceptability, and potential efficacy in managing knee osteoarthritis. Future trials of larger sample sizes and better VR designs will confirm its role in clinical practice. Trial Registration: Chinese Clinical Trial Registry CHiCTR2100046313; https://www.chictr.org.cn/showprojEN.html?proj=125404 UR - https://games.jmir.org/2024/1/e52563 UR - http://dx.doi.org/10.2196/52563 ID - info:doi/10.2196/52563 ER - TY - JOUR AU - Houzangbe, Samory AU - Lemay, Martin AU - Levac, E. Danielle PY - 2024/9/23 TI - Toward Physiological Detection of a ?Just-Right? Challenge Level for Motor Learning in Immersive Virtual Reality: Protocol for a Cross-Sectional Study JO - JMIR Res Protoc SP - e55730 VL - 13 KW - virtual reality KW - pediatric rehabilitation KW - physiological data KW - engagement KW - just-right challenge N2 - Background: Motor learning, a primary goal of pediatric rehabilitation, is facilitated when tasks are presented at a ?just-right? challenge level?at the edge of the child?s current abilities, yet attainable enough to motivate the child in persistent efforts for success. Immersive virtual reality (VR) may be ideally suited for ?just-right? task challenges because it enables precise adjustments of task parameters in motivating environments. Rehabilitation-specific VR tasks often use dynamic difficulty algorithms based on task performance to personalize task difficulty. However, these approaches do not consider relevant cognitive processes that could also impact ?just-right? challenges, such as attention and engagement. Objective physiological measurement of these cognitive processes using wearable sensors could support their integration within ?just-right? challenge detection and prediction algorithms. As a first step, it is important to explore relationships between objectively and subjectively measured psychophysiological states at progressively challenging task difficulty levels. Objective: This study aims to (1) evaluate the performance of wearable sensors in a novel movement-based motor learning immersive VR task; (2) evaluate changes in physiological data at 3 task difficulty levels; and (3) explore the relationship between physiological data, task performance, and self-reported cognitive processes at each task difficulty level. Methods: This study uses the within-participant experimental design. Typically developing children and youth aged 8-16 years will be recruited to take part in a single 90-minute data collection session. Physiological sensors include electrodermal activity, heart rate, electroencephalography, and eye-tracking. After collecting physiological data at rest, participants will play a seated unimanual immersive VR task involving bouncing a virtual ball on a virtual racket. They will first play for 3 minutes at a predefined medium level of difficulty to determine their baseline ability level and then at a personalized choice of 3 progressive difficulty levels of 3 minutes each. Following each 3-minute session, participants will complete a short Likert-scale questionnaire evaluating engagement, attention, cognitive workload, physical effort, self-efficacy, and motivation. Data loss and data quality will be calculated for each sensor. Repeated-measures ANOVAs will evaluate changes in physiological response at each difficulty level. Correlation analyses will determine individual relationships between task performance, physiological data, and self-reported data at each difficulty level. Results: Research ethics board approval has been obtained, and data collection is underway. Data collection was conducted on December 12, 2023, and April 12, 2024, with a total of 15 typically developing children. Data analysis has been completed, and results are expected to be published in the fall of 2024. Conclusions: Wearable sensors may provide insights into the physiological effects of immersive VR task interaction at progressive difficulty levels in children and youth. Understanding the relationship between physiological and self-reported cognitive processes is a first step in better identifying and predicting ?just-right? task challenges during immersive VR motor learning interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/55730 UR - https://www.researchprotocols.org/2024/1/e55730 UR - http://dx.doi.org/10.2196/55730 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55730 ER - TY - JOUR AU - Bevilacqua, Roberta AU - Benadduci, Marco AU - Barbarossa, Federico AU - Amabili, Giulio AU - Di Donna, Valentina AU - Martella, Clotilda AU - Pelliccioni, Giuseppe AU - Riccardi, Renato Giovanni AU - Maranesi, Elvira PY - 2024/9/9 TI - Effectiveness of Technological Interventions for Older Adults With Parkinson Disease: Systematic Review JO - JMIR Serious Games SP - e53431 VL - 12 KW - technological intervention KW - Parkinson disease KW - randomized controlled trail KW - older adults KW - efficacy N2 - Background: Among the older population, Parkinson disease (PD) stands out as a leading contributor to disability. Clinically, the foremost objectives in managing PD involve proactively delaying and preventing disability. Understanding the pivotal role of gait and balance in daily functionality holds substantial clinical significance, signaling imminent disability and prompting a reevaluation of management approaches. A key priority lies in identifying novel and effective interventions for symptoms that substantially contribute to disability. Objective: This paper presents a systematic review that critically examines the existing body of literature on the use of technology in the rehabilitation of older patients with PD. By synthesizing current evidence, we aim to provide insights into the state of the field, identify gaps in knowledge, and offer recommendations for future research and clinical practice. Methods: A systematic review of the literature was conducted in September 2023 analyzing manuscripts and papers of the last 5 years from the PubMed, Scopus, Embase, Web of Science, and CINAHL databases following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 14 papers were included. The inclusion criteria are as follows: (1) randomized controlled trial, (2) PD in people aged 65 years and older, and (3) use of technology in the rehabilitation training in the older population. Results: A large portion of effective interventions relies on the incorporation of technology, particularly through virtual reality exergames. This technology appears to have effects not only on the cognitive aspect but also on the physical domain. The analysis of the results clearly indicates that, in terms of gait and balance performance, the technological intervention outperforms the traditional approach, irrespective of the specific technology employed. Conclusions: This systematic review seeks to shed light on the evolving landscape of technology-assisted rehabilitation for older individuals with PD. As we delve into the available evidence, we will assess the extent to which technology can serve as a valuable adjunct to conventional therapy, offering new avenues for optimized care and improved outcomes in this growing patient demographic. As we sift through the existing evidence, our goal is to evaluate the potential of technology as a valuable supplement to traditional therapy, presenting fresh opportunities for enhanced care and better outcomes in this expanding patient demographic. UR - https://games.jmir.org/2024/1/e53431 UR - http://dx.doi.org/10.2196/53431 UR - http://www.ncbi.nlm.nih.gov/pubmed/39250193 ID - info:doi/10.2196/53431 ER - TY - JOUR AU - Bressler, Michael AU - Merk, Joachim AU - Gohlke, Tanja AU - Kayali, Fares AU - Daigeler, Adrien AU - Kolbenschlag, Jonas AU - Prahm, Cosima PY - 2024/8/27 TI - A Virtual Reality Serious Game for the Rehabilitation of Hand and Finger Function: Iterative Development and Suitability Study JO - JMIR Serious Games SP - e54193 VL - 12 KW - video games KW - virtual reality KW - exercise therapy KW - physical therapy KW - hand rehabilitation KW - finger rehabilitation N2 - Background: Restoring hand and finger function after a traumatic hand injury necessitates a regimen of consistent and conscientious exercise. However, motivation frequently wanes due to unchallenging repetitive tasks or discomfort, causing exercises to be performed carelessly or avoided completely. Introducing gamification to these repetitive tasks can make them more appealing to patients, ultimately increasing their motivation to exercise consistently. Objective: This study aims to iteratively develop a serious virtual reality game for hand and finger rehabilitation within an appealing and engaging digital environment, encouraging patient motivation for at least 2 weeks of continuous therapy. Methods: The development process comprised 3 distinct stages, each of which was subject to evaluation. Initially, a prototype was created to encompass the game?s core functionalities, which was assessed by 18 healthy participants and 7 patients with impaired hand function. Subsequently, version 1 of the game was developed and evaluated with 20 patients who were divided into an investigation group and a control group. On the basis of these findings, version 2 was developed and evaluated with 20 patients who were divided into an investigation group and a control group. Motivation was assessed using the Intrinsic Motivation Inventory (IMI), while the application?s quality was rated using the Mobile Application Rating Scale and the System Usability Scale. User feedback was gathered using semistructured interviews. Results: The prototype evaluation confirmed the acceptance and feasibility of the game design. Version 1 significantly increased motivation in 2 IMI subscales, effort (P<.001) and usefulness (P=.02). In version 2, a significant increase in daily performed exercises was achieved (P=.008) compared to version 1, with significantly higher motivation in the IMI subscale effort (P=.02). High Mobile Application Rating Scale scores were obtained for both versions 1 and 2, with version 2 scoring 86.9 on the System Usability Scale, indicating excellent acceptability. User feedback provided by the semistructured interviews was instrumental in the iterative development regarding improvements and the expansion of the playable content. Conclusions: This study presented a virtual reality serious game designed for hand and finger rehabilitation. The game was well received and provided an environment that effectively motivated the users. The iterative development process incorporated user feedback, confirming the game?s ease of use and feasibility even for patients with severely limited hand function. UR - https://games.jmir.org/2024/1/e54193 UR - http://dx.doi.org/10.2196/54193 UR - http://www.ncbi.nlm.nih.gov/pubmed/39190432 ID - info:doi/10.2196/54193 ER - TY - JOUR AU - Dalko, Katharina AU - Elsuson, Andri Hlynur AU - Kalter, Ivonne AU - Zilezinski, Max AU - Hofstetter, Sebastian AU - Stoevesandt, Dietrich AU - Paulicke, Denny AU - Jahn, Patrick PY - 2024/5/31 TI - Virtual Reality Applications for the Implementation of Domestic Respiratory Rehabilitation Programs for Patients With Long COVID and Post-COVID Condition: Scoping Review JO - JMIR Serious Games SP - e52309 VL - 12 KW - long COVID KW - post-COVID KW - rehabilitation KW - virtual reality KW - implementation KW - respiratory KW - respiratory rehabilitation KW - scoping review KW - development KW - accessibility KW - support KW - physical KW - psychological KW - motivation KW - compliance KW - usability KW - COVID-19 KW - COVID N2 - Background: Due to a high number of patients affected by long COVID or post-COVID condition, an essential step to address the long-term effects of COVID-19 lies in the development and implementation of flexible and accessible rehabilitation programs. Virtual reality (VR) technologies offer the potential to support traditional therapies with individualized at-home programs. Objective: This study aims to provide an overview of existing scientific evidence on the development and implementation of VR-assisted respiratory rehabilitation programs for patients with long COVID and post-COVID condition and to synthesize the results. Methods: We conducted a scoping review of studies from 6 databases. PubMed, CINAHL, Cochrane, ScienceDirect, Web of Science Social Sciences Citation Index, and PEDro were searched using an exploratory search strategy. The search, which was last updated in February 2024, included peer-reviewed studies on immersive VR applications providing respiratory rehabilitation programs for patients with chronic obstructive pulmonary disease and long COVID or post-COVID condition. Exclusion criteria were studies in clinical or inpatient settings, telemedicine, nonimmersive VR applications, and gray literature. Nine publications were included in this review. Findings were extracted and summarized from the studies according to the JBI (Joanna Briggs Institute) method and thematically categorized. Topics covered were study characteristics, physiotherapeutic concept, clinical parameters, as well as usability and acceptability. Results: The 9 publications included in the qualitative analysis were published in 2019-2023. Eight empirical studies were included: 4 followed a mixed methods design, 3 were qualitative studies, and 1 followed a quantitative method. One scoping review was included in the data analyses. Four of the included studies were on patients with chronic obstructive pulmonary disease. The 9 studies demonstrated that VR-supported respiratory rehabilitation programs result in positive initial outcomes in terms of physical as well as psychological parameters. Particularly noteworthy was the increased motivation and compliance of patients. However, adverse effects and lack of usability are the barriers to the implementation of this innovative approach. Conclusions: Overall, VR is a promising technology for the implementation of individualized and flexible respiratory rehabilitation programs for patients with long COVID and post-COVID condition. Nevertheless, corresponding approaches are still under development and need to be more closely adapted to the needs of users. Further, the evidence was limited to pilot studies or a small number of patients, and no randomized controlled trials or long-term studies were part of the study selection. The included studies were performed by 4 groups of researchers: 3 from Europe and 1 from the United States. UR - https://games.jmir.org/2024/1/e52309 UR - http://dx.doi.org/10.2196/52309 UR - http://www.ncbi.nlm.nih.gov/pubmed/38819890 ID - info:doi/10.2196/52309 ER - TY - JOUR AU - Webster, Amy AU - Poyade, Matthieu AU - Coulter, Elaine AU - Forrest, Lisa AU - Paul, Lorna PY - 2024/4/26 TI - Views of Specialist Clinicians and People With Multiple Sclerosis on Upper Limb Impairment and the Potential Role of Virtual Reality in the Rehabilitation of the Upper Limb in Multiple Sclerosis: Focus Group Study JO - JMIR Serious Games SP - e51508 VL - 12 KW - virtual reality KW - multiple sclerosis KW - upper limb rehabilitation KW - coproduction KW - activities of daily living KW - exercise games KW - upper limb impairment N2 - Background: Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Using virtual reality (VR) could be a solution to this challenge; however, there is a lack of reporting on the views of people with MS and clinicians on VR-based approaches and recommendations for games for rehabilitation. Objective: This study aims to identify common UL problems and their related current therapeutic approaches for people with MS, and to explore the opinions of people with MS and specialist clinicians on VR and obtain suggestions for the development and design of VR games. Methods: Separate focus groups were conducted with people with MS, recruited through the MS Society UK?s research network, and clinicians, recruited through the MS Trust Therapists in MS network. A total of 10 people with MS (2 focus groups) and 8 clinicians (5 physiotherapists, 2 occupational therapists, and 1 MS nurse in 2 focus groups) were involved. The focus groups were recorded and transcriptions were analyzed using theme-based content analysis. Results: People with MS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many people with MS neglected UL exercise and found strategies for adapting to the UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a solution, as it was convenient for people with MS to access and it could provide a more engaging and disguised approach to exercise. There were shared concerns with cybersickness and disengagement with using VR approaches. Both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and people with MS suggesting more abstract activities. Conclusions: VR was well received by both people with MS and clinicians for UL rehabilitation. Recommendations were made for the development of VR rehabilitation games which are personalized and customizable for the varying abilities of people with MS. UR - https://games.jmir.org/2024/1/e51508 UR - http://dx.doi.org/10.2196/51508 UR - http://www.ncbi.nlm.nih.gov/pubmed/38669680 ID - info:doi/10.2196/51508 ER - TY - JOUR AU - Lee, J. Edmund W. AU - Tan, W. Warrick AU - Pham, Phat Ben Tan AU - Kawaja, Ariffin AU - Theng, Yin-Leng PY - 2024/4/24 TI - Addressing Data Absenteeism and Technology Chauvinism in the Use of Gamified Wearable Gloves Among Older Adults: Moderated Usability Study JO - JMIR Serious Games SP - e47600 VL - 12 KW - wearables KW - exergames KW - older adults KW - active aging KW - rehabilitation KW - stroke N2 - Background: Digital health technologies have the potential to improve health outcomes for older adults, especially for those recovering from stroke. However, there are challenges to developing these technologies, such as data absenteeism (where older adults? views are often underrepresented in research and development) and technology chauvinism (the belief that sophisticated technology alone is the panacea to addressing health problems), which hinder their effectiveness. Objective: In this study, we aimed to address these challenges by developing a wearable glove integrated with culturally relevant exergames to motivate older adults to exercise and, for those recovering from stroke, to adhere to rehabilitation. Methods: We conducted a moderated usability study with 19 older adults, of which 11 (58%) had a history of stroke. Our participants engaged in a 30-minute gameplay session with the wearable glove integrated with exergames, followed by a quantitative survey and an in-depth interview. We used descriptive analysis to compare responses to the System Usability Scale between those who had a history of stroke and those who did not. In addition, we analyzed the qualitative interviews using a bottom-up thematic analysis to identify key themes related to the motivations and barriers regarding the use of wearable gloves for rehabilitation and exercise. Results: Our study generated several key insights. First, making the exergames exciting and challenging could improve exercise and rehabilitation motivation, but it could also have a boomerang effect, where participants may become demotivated if the games were very challenging. Second, the comfort and ease of use of the wearable gloves were important for older adults, regardless of their stroke history. Third, for older adults with a history of stroke, the functionality and purpose of the wearable glove were important in helping them with specific exercise movements. Conclusions: Our findings highlight the importance of providing contextual support for the effective use of digital technologies, particularly for older adults recovering from stroke. In addition to technology and usability factors, other contextual factors such as gamification and social support (from occupational therapists or caregivers) should be considered to provide a comprehensive approach to addressing health problems. To overcome data absenteeism and technology chauvinism, it is important to develop digital health technologies that are tailored to the needs of underserved communities. Our study provides valuable insights for the development of digital health technologies that can motivate older adults recovering from stroke to exercise and adhere to rehabilitation. UR - https://games.jmir.org/2024/1/e47600 UR - http://dx.doi.org/10.2196/47600 UR - http://www.ncbi.nlm.nih.gov/pubmed/38656778 ID - info:doi/10.2196/47600 ER - TY - JOUR AU - Guo, Qifan AU - Zhang, Liming AU - Han, Lianyi Leo AU - Gui, Chenfan AU - Chen, Guanghui AU - Ling, Chunyan AU - Wang, Wei AU - Gao, Qiang PY - 2024/4/24 TI - Effects of Virtual Reality Therapy Combined With Conventional Rehabilitation on Pain, Kinematic Function, and Disability in Patients With Chronic Neck Pain: Randomized Controlled Trial JO - JMIR Serious Games SP - e42829 VL - 12 KW - virtual reality KW - neck pain KW - disability KW - kinematic function KW - rehabilitation KW - physiotherapy KW - neck KW - pain KW - chronic KW - therapy KW - kinematic KW - efficacy KW - patient KW - effect N2 - Background: Neck pain is a common condition that leads to neck motor dysfunction and subsequent disability, with a significant global health care burden. As a newly emerging tool, virtual reality (VR) technology has been employed to address pain and reduce disability among patients with neck pain. However, there is still a lack of high-quality studies evaluating the efficacy of VR therapy combined with conventional rehabilitation for patients with chronic neck pain, particularly in terms of kinematic function. Objective: This study aims to investigate the effect of VR therapy combined with conventional rehabilitation on pain, kinematic function, and disability in patients with chronic neck pain. Methods: We conducted an assessor-blinded, allocation-concealed randomized controlled trial. Sixty-four participants experiencing chronic neck pain were randomly allocated into the experimental group that underwent VR rehabilitation plus conventional rehabilitation or the control group receiving the same amount of conventional rehabilitation alone for 10 sessions over 4 weeks. Pain intensity, disability, kinematic function (cervical range of motion, proprioception, and mean and peak velocity), degree of satisfaction, and relief of symptoms were evaluated at 3 timepoints (baseline, postintervention, and at 3 months follow-up). A 2*3 mixed repeated measures analysis of variance was utilized for analyzing the difference across indicators, with a significant difference level of .05. Results: Both groups demonstrated significant improvements in pain, disability, and kinematic functions (P<.05) at postintervention and at 3-month follow-up. The experimental group showed superior therapeutic outcomes compared to the control group in pain reduction (mean difference from the baseline: 5.50 vs 1.81 at posttreatment; 5.21 vs 1.91 at the 3-month follow-up, respectively; P<.001), disability improvement (mean difference from baseline: 3.04 vs 0.50 at posttreatment; 3.20 vs 0.85 at the 3-month follow-up, respectively; P<.001), and enhanced kinematic functions (P<.05). Moreover, participants in the experimental group reported better satisfaction and relief of symptoms than the control group (P<.05), with better initiative for exercising during the follow-up period. However, there was no between-group difference of improvement in proprioception. No adverse events were reported or observed in our research. Conclusions: The findings of our study support the efficacy of combining VR therapy with conventional rehabilitation in alleviating pain, enhancing kinematic function, and reducing disability of patients with chronic neck pain. Future research should focus on refining the therapeutic protocols and dosages for VR therapy as well as on optimizing its application in clinical settings for improved convenience and effectiveness. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000040132; http://www.chictr.org.cn/showproj.aspx?proj=64346 UR - https://games.jmir.org/2024/1/e42829 UR - http://dx.doi.org/10.2196/42829 UR - http://www.ncbi.nlm.nih.gov/pubmed/38656775 ID - info:doi/10.2196/42829 ER - TY - JOUR AU - Rhiel, Sophia AU - Kläy, Andrina AU - Keller, Urs AU - van Hedel, A. Hubertus J. AU - Ammann-Reiffer, Corinne PY - 2024/3/18 TI - Comparing Walking-Related Everyday Life Tasks of Children with Gait Disorders in a Virtual Reality Setup With a Physical Setup: Cross-Sectional Noninferiority Study JO - JMIR Serious Games SP - e49550 VL - 12 KW - adolescent KW - child KW - gait KW - head-mounted display KW - motion capture KW - neurological rehabilitation KW - noninferiority trial KW - physical therapy KW - virtual reality KW - walking N2 - Background: A frequent rehabilitation goal for children with gait disorders is to practice daily-life walking activities. Unfortunately, these are often difficult to practice in a conventional therapeutic setting. Virtual reality (VR) with head-mounted displays (HMDs) could be a promising approach in neurorehabilitation to train such activities in a safe environment. First, however, we must know whether obstacles in VR are indeed mastered as obstacles. Objective: This study aimed to provide information on whether VR is feasible and motivating to induce and practice movements needed to master real obstacles in children and adolescents with gait disorders. Furthermore, this project aims to evaluate which kinds of everyday walking activities are appropriate to be practiced in VR. Methods: In this cross-sectional study, participants stepped over a bar, crossed a gap, balanced over a beam, and circumvented stationary obstructions arranged in a course under real physical and virtual conditions wearing a VR HMD. We recorded the respective primary outcomes (step height, step length, step width, and minimal shoulder-obstacle distance) with motion capture. We then calculated the mean differences and 95% CI of the spatiotemporal parameters between the VR and physical setup and later compared them using noninferiority analysis with margins defined a priori by a clinical expert panel. Additionally, the participants responded to a standardized questionnaire while the therapists observed and evaluated their movement performance. Results: We recruited 20 participants (mean age 12.0, range 6.6-17.8 years) with various diagnoses affecting their walking ability. At 3.77 (95% CI 1.28 to 6.26) cm, the mean difference in step height of the leading foot in the overstepping task did not exceed the predefined margin of ?2 cm, thus signifying noninferiority of the VR condition compared to mastering the physical obstacles. The same was true for step length (?1.75, 95% CI ?4.91 to 1.41 cm; margin ?10 cm), step width (1.05, 95% CI 0.20 to ?1.90 cm; margin 3 cm), and the minimal shoulder-obstacle distance (0.25, 95% CI ?0.85 to 0.35 cm; margin ?2 cm) in the other tasks. Only the trailing foot in the overstepping task yielded inconclusive results. Conclusions: Children with gait disorders perform everyday walking tasks like overstepping, crossing, balancing, or circumventing similarly in physical and VR environments, suggesting that VR could be a feasible therapeutic tool to practice everyday walking tasks. UR - https://games.jmir.org/2024/1/e49550 UR - http://dx.doi.org/10.2196/49550 UR - http://www.ncbi.nlm.nih.gov/pubmed/38498048 ID - info:doi/10.2196/49550 ER - TY - JOUR AU - Prats-Bisbe, Alba AU - López-Carballo, Jaume AU - García-Molina, Alberto AU - Leno-Colorado, David AU - García-Rudolph, Alejandro AU - Opisso, Eloy AU - Jané, Raimon PY - 2024/3/18 TI - Virtual Reality?Based Neurorehabilitation Support Tool for People With Cognitive Impairments Resulting From an Acquired Brain Injury: Usability and Feasibility Study JO - JMIR Neurotech SP - e50538 VL - 3 KW - acquired brain injury KW - virtual reality KW - head-mounted display KW - neurorehabilitation KW - usability KW - feasibility KW - co-design KW - multidisciplinary experiences KW - immersive serious games N2 - Background: Acquired brain injury (ABI) is a prominent cause of disability globally, with virtual reality (VR) emerging as a promising aid in neurorehabilitation. Nonetheless, the diversity among VR interventions can result in inconsistent outcomes and pose challenges in determining efficacy. Recent reviews offer best practice recommendations for designing and implementing therapeutic VR interventions to evaluate the acceptance of fully immersive VR interventions. Objective: This study aims to evaluate the usability and feasibility of a co-designed VR-based neurorehabilitation support tool by conducting multiple proof-of-concept trials in a sample of patients with ABI within a hospital setting. Methods: A single session deploying custom immersive serious games to train cognitive functions using a new-generation head-mounted display was conducted among a sample of inpatients with ABI. Structured questionnaires were administered at the end of the session to evaluate the usability of the system and the intervention, participants? familiarity with the technology, and any adverse effects related to cybersickness. Additionally, the training duration while wearing the headset and the demographic characteristics of the participants were considered. Results: A total of 20 patients with ABI participated in a 1-hour proof-of-concept trial. The mean usability score was 37 (SD 2.6) out of 40, the technology familiarity level was 9.2 (SD 2.9) out of 12, and the Simulator Sickness Questionnaire total score was 1.3 (SD 2). On average, participants wore the headset for approximately 25.6 (SD 4.7) minutes during the intervention. There were no substantial differences in usability and technology familiarity levels based on patients? etiology or age, with no notable symptoms of cybersickness reported. Significantly strong correlations were noted between cybersickness symptoms and various usability categories, including exposure, motivation, interactivity, task specificity, and immersion aspects. Further, there was a significant association between the intervention time and the number of tasks performed (P<.001). Furthermore, patients who derived enjoyment from VR sessions expressed a heightened interest in incorporating VR into their daily neurorehabilitation practice (P<.001). Moreover, oculomotor issues were found to be highly sensitive to the onset of disorientation sickness symptoms (P<.001). Conclusions: Through a collaborative approach, this study showcases the usability and feasibility of a VR-based support tool for cognitive rehabilitation among inpatients with ABI. Key components of such interventions encompass a multidisciplinary array of immersive experiences integrating neurorehabilitation principles and serious games techniques. UR - https://neuro.jmir.org/2024/1/e50538 UR - http://dx.doi.org/10.2196/50538 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/50538 ER - TY - JOUR AU - Zhang, Tongtong AU - Li, Xin AU - Zhou, Xuan AU - Zhan, Lixia AU - Wu, Fan AU - Huang, Zefan AU - Sun, Yuxun AU - Feng, Yufei AU - Du, Qing PY - 2024/2/12 TI - Virtual Reality Therapy for the Management of Chronic Spinal Pain: Systematic Review and Meta-Analysis JO - JMIR Serious Games SP - e50089 VL - 12 KW - virtual reality KW - chronic spinal pain KW - inflammation-related pain KW - systematic review KW - meta-analysis N2 - Background: The effectiveness of virtual reality (VR) therapy in adults with chronic spinal pain (CSP) is unclear. Objective: This study was conducted to compare the effectiveness of VR therapy and other therapies in adults with CSP, especially patients with inflammation-related pain. Methods: PubMed, Web of Science, Cochrane Library, Embase, and CINAHL databases were searched up to November 11, 2023. Randomized controlled trials (RCTs) comparing adults with CSP receiving VR therapy with those receiving other therapies were included. The trial registration platform as well as the reference lists of included studies and previous systematic reviews and meta-analyses were manually searched. Two independent reviewers performed study selection, data extraction, risk-of-bias assessment, and evaluation of the quality of the evidence. The weighted mean difference (WMD) was used as the effect size used to synthesize the outcome measure. Results: In total, 16 RCTs involving 800 participants were included in this meta-analysis. The pooled data from 15 (94%) RCTs including 776 (97%) participants showed that VR therapy was superior in improving pain intensity (WMD=?1.63, 95% CI ?2.11 to ?1.16, P<.001, I2=90%) and reducing inflammatory markers, including C-reactive protein (WMD=?0.89, 95% CI ?1.07 to ?0.70, P<.001, I2=0%), tumor necrosis factor-alpha (WMD=?6.60, 95% CI ?8.56 to ?4.64, P<.001, I2=98%), and interleukin-6 (WMD=?2.76, 95% CI ?2.98 to ?2.53, P<.001, I2=0%). However, no significant differences were found in terms of the spinal range of motion (ROM), disability level, or fear of movement. In addition, 10 (63%) of the included RCTs had a high risk of bias. Conclusions: VR therapy may be an effective and safe intervention for reducing symptoms in patients with CSP, as it is shown to exert significant analgesic effects and beneficial improvements in inflammatory factor levels. However, this approach may not have significant effects on the spinal ROM, disability level, or fear of movement. Notably, the quality of the evidence from the RCTs included in this study ranged from moderate to low. Therefore, we recommend that readers interpret the results of this study with caution. Trial Registration: PROSPERO CRD42022382331; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=382331 UR - https://games.jmir.org/2024/1/e50089 UR - http://dx.doi.org/10.2196/50089 UR - http://www.ncbi.nlm.nih.gov/pubmed/38345832 ID - info:doi/10.2196/50089 ER - TY - JOUR AU - Brassel, Sophie AU - Brunner, Melissa AU - Campbell, Andrew AU - Power, Emma AU - Togher, Leanne PY - 2024/1/19 TI - Exploring Discussions About Virtual Reality on Twitter to Inform Brain Injury Rehabilitation: Content and Network Analysis JO - J Med Internet Res SP - e45168 VL - 26 KW - virtual reality KW - Twitter KW - brain injury KW - rehabilitation KW - cognitive communication KW - social networks KW - social media KW - brain injury rehabilitation KW - engagement KW - development KW - clinical practice KW - injury KW - users N2 - Background: Virtual reality (VR) use in brain injury rehabilitation is emerging. Recommendations for VR development in this field encourage end user engagement to determine the benefits and challenges of VR use; however, existing literature on this topic is limited. Data from social networking sites such as Twitter may further inform development and clinical practice related to the use of VR in brain injury rehabilitation. Objective: This study collected and analyzed VR-related tweets to (1) explore the VR tweeting community to determine topics of conversation and network connections, (2) understand user opinions and experiences of VR, and (3) identify tweets related to VR use in health care and brain injury rehabilitation. Methods: Publicly available tweets containing the hashtags #virtualreality and #VR were collected up to twice weekly during a 6-week period from July 2020 to August 2020 using NCapture (QSR International). The included tweets were analyzed using mixed methods. All tweets were coded using inductive content analysis. Relevant tweets (ie, coded as ?VR in health care? or ?talking about VR?) were further analyzed using Dann?s content coding. The biographies of users who sent relevant tweets were examined descriptively. Tweet data networks were visualized using Gephi computational analysis. Results: A total of 260,715 tweets were collected, and 70,051 (26.87%) were analyzed following eligibility screening. The sample comprised 33.68% (23,596/70,051) original tweets and 66.32% (46,455/70,051) retweets. Content analysis generated 10 main categories of original tweets related to VR (ie, advertising and promotion, VR content, talking about VR, VR news, general technology, VR industry, VR live streams, VR in health care, VR events, and VR community). Approximately 4.48% (1056/23,596) of original tweets were related to VR use in health care, whereas 0.19% (45/23,596) referred to VR in brain injury rehabilitation. In total, 14.86% (3506/23,596) of original tweets featured commentary on user opinions and experiences of VR applications, equipment, and software. The VR tweeting community comprised a large network of 26,001 unique Twitter users. Users that posted tweets related to ?VR in health care? (2124/26,001, 8.17%) did not form an interconnected VR network, whereas many users ?talking about VR? (3752/26,001, 14.43%) were connected within a central network. Conclusions: This study provides valuable data on community-based experiences and opinions related to VR. Tweets showcased various VR applications, including in health care, and identified important user-based considerations that can be used to inform VR use in brain injury rehabilitation (eg, technical design, accessibility, and VR sickness). Limited discussions and small user networks related to VR in brain injury rehabilitation reflect the paucity of literature on this topic and the potential underuse of this technology. These findings emphasize that further research is required to understand the specific needs and perspectives of people with brain injuries and clinicians regarding VR use in rehabilitation. UR - https://www.jmir.org/2024/1/e45168 UR - http://dx.doi.org/10.2196/45168 UR - http://www.ncbi.nlm.nih.gov/pubmed/38241072 ID - info:doi/10.2196/45168 ER - TY - JOUR AU - Villada Castillo, Felipe Julian AU - Montoya Vega, Fernanda Maria AU - Muñoz Cardona, Edison John AU - Lopez, David AU - Quiñones, Leonardo AU - Henao Gallo, Alberto Oscar AU - Lopez, Fernando Jose PY - 2024/1/11 TI - Design of Virtual Reality Exergames for Upper Limb Stroke Rehabilitation Following Iterative Design Methods: Usability Study JO - JMIR Serious Games SP - e48900 VL - 12 KW - stroke KW - user-centered design KW - exergame KW - design KW - virtual reality KW - playtest KW - upper limb rehabilitation N2 - Background: Since the early 2000s, there has been a growing interest in using exercise video games (exergames) and virtual reality (VR)?based interventions as innovative methods to enhance physical rehabilitation for individuals with multiple disabilities. Over the past decade, researchers and exercise professionals have focused on developing specialized immersive exercise video games for various populations, including those who have experienced a stroke, revealing tangible benefits for upper limb rehabilitation. However, it is necessary to develop highly engaging, personalized games that can facilitate the creation of experiences aligned with the preferences, motivations, and challenges communicated by people who have had an episode of stroke. Objective: This study seeks to explore the customization potential of an exergame for individuals who have undergone a stroke, concurrently evaluating its usability as a technological tool in the realm of physical therapy and rehabilitation. Methods: We introduce a playtest methodology to enhance the design of a VR exergame developed using a user-centered approach for upper limb rehabilitation in stroke survivors. Over 4 playtesting sessions, stroke survivors interacted with initial game versions using VR headsets, providing essential feedback for refining game content and mechanics. Additionally, a pilot study involving 10 stroke survivors collected data through VR-related questionnaires to assess game design aspects such as mechanics, assistance, experience, motion sickness, and immersion. Results: The playtest methodology was beneficial for improving the exergame to align with user needs, consistently incorporating their perspectives and achieving noteworthy results. The pilot study revealed that users had a positive response. In the first scenario, a carpenter presents a game based on the flexion-extension movement of the elbow; the second scenario includes a tejo game (a traditional Colombian throwing game) designed around game mechanics related to the flexion-extension movement of the shoulder; and in the third scenario, a farmer challenges the player to perform a movement combining elbow flexion and extension with internal and external rotation of the shoulder. These findings suggest the potential of the studied exergame as a tool for the upper limb rehabilitation of individuals who have experienced a stroke. Conclusions: The inclusion of exergames in rehabilitation for stroke-induced hemiparesis has significantly benefited the recovery process by focusing on essential shoulder and elbow movements. These interactive games play a crucial role in helping users regain mobility and restore practical use of affected limbs. They also serve as valuable data sources for researchers, improving the system?s responsiveness. This iterative approach enhances game design and markedly boosts user satisfaction, suggesting exergames have promising potential as adjunctive elements in traditional therapeutic approaches. UR - https://games.jmir.org/2024/1/e48900 UR - http://dx.doi.org/10.2196/48900 UR - http://www.ncbi.nlm.nih.gov/pubmed/38206670 ID - info:doi/10.2196/48900 ER - TY - JOUR AU - Chuadthong, Janya AU - Lekskulchai, Raweewan AU - Hiller, Claire AU - Ajjimaporn, Amornpan PY - 2023/12/20 TI - A Home-Based Exercise Program With Active Video Games for Balance, Motor Proficiency, Foot and Ankle Ability, and Intrinsic Motivation in Children With Chronic Ankle Instability: Feasibility Randomized Controlled Trial JO - JMIR Serious Games SP - e51073 VL - 11 KW - active video game KW - children KW - chronic ankle instability KW - motivation level KW - balance training KW - home-based exercise KW - video game KW - feasibility KW - ankle KW - instability KW - kinesiology KW - balance KW - exercise KW - exergame KW - exergaming N2 - Background: Children with chronic ankle instability (CAI) frequently experience ankle unsteadiness, causing trips, falls, and ankle sprain injuries resulting in poor quality of life. A specific exercise program focused on physical and psychological purposes in children with CAI is needed. Objective: The purpose of this study was to investigate the feasibility of a 4-week home-based exercise training program using active video games (AVGs) for balance, motor proficiency, foot and ankle ability, and intrinsic motivation in children with CAI. Methods: Sixty children with CAI (mean age 10, SD 2 years) were randomly assigned to an experimental group (AVG group; n=30) or a control group (CG; n=30). The AVG group played 2 selected video games, Catching Fish and Russian Block, while the CG received the traditional exercise program for CAI. Both programs were scheduled for 30 minutes per day, 3 times per week, for 4 weeks at home. The single-leg stance test was used to assess static balance. The walking forward on a line and standing long jump tests were used to assess motor proficiency. The Foot and Ankle Ability Measure (FAAM) and the Intrinsic Motivation Inventory questionnaire were used to assess foot and ankle ability and intrinsic motivation, respectively. Assessments were conducted at baseline and after 4 weeks. Results: In the AVG group, the single-leg stand test (eyes open; on floor and on foam conditions), the FAAM (activities of daily living subscale), and intrinsic motivation (interest/enjoyment, pressure/tension, and value/usefulness dimensions) were improved compared with the CG (all P<.05). Motor proficiency did not differ between the 2 groups at the end of the 4-week program (P=.31 for the walking forward on a line, P=.34 for the standing long jump test). Conclusions: A 4-week home-based exercise training program using AVGs can be beneficial and may be an effective approach for improving balance, foot and ankle ability, and enhancing positive motivation by increasing the interest/enjoyment and value/usefulness dimensions and lowering the pressure/tension dimension in children with CAI that require long-term rehabilitation sessions. Trial Registration: Thai Clinical Trials Registry TCTR20220727002; https://trialsearch.who.int/Trial2.aspx?TrialID=TCTR20220727002 UR - https://games.jmir.org/2023/1/e51073 UR - http://dx.doi.org/10.2196/51073 ID - info:doi/10.2196/51073 ER - TY - JOUR AU - Seinsche, Julia AU - de Bruin, D. Eling AU - Saibene, Enrico AU - Rizzo, Francesco AU - Carpinella, Ilaria AU - Ferrarin, Maurizio AU - Moza, Sotiria AU - Ritter, Tanja AU - Giannouli, Eleftheria PY - 2023/12/7 TI - A Newly Developed Exergame-Based Telerehabilitation System for Older Adults: Usability and Technology Acceptance Study JO - JMIR Hum Factors SP - e48845 VL - 10 KW - older adults KW - motor-cognitive intervention KW - exergame KW - telerehabilitation KW - information and communications technologies KW - user-centered design KW - usability KW - technology acceptance N2 - Background: Telerehabilitation has gained significance as a tool to deliver and supervise therapy and training as effective as traditional rehabilitation methods yet more accessible and affordable. An exergame-based telerehabilitation system has recently been developed within the scope of the international Continuum-of-Care (COCARE) project. The system comprises training devices for use in clinics (Dividat Senso) and at home (Dividat Senso Flex), an assessment system, and a rehabilitation cockpit, and its focus lies on home-based motor-cognitive training, which is remotely managed by health care professionals (HPs). Objective: This study aims to analyze the usability, acceptance, and enjoyment of the COCARE system from the perspective of primary (older adults [OAs]) and secondary (HPs) end users. Methods: At 3 trial sites (located in Switzerland, Italy, and Cyprus), participants engaged in a single-session trial of the COCARE system, including testing of exergames and assessments. Mixed methods encompassing qualitative approaches (eg, think aloud) and quantitative measures (eg, Exergame Enjoyment Questionnaire [EEQ], System Usability Scale [SUS], and Unified Theory of Acceptance and Use of Technology [UTAUT] questionnaire) were used to analyze participants? perceptions of the system and identify potential barriers to its implementation in a home setting. In addition, the associations of performance during gameplay and assessments, demographics, and training motivation (Behavioral Regulation in Exercise Questionnaire?3 [BREQ-3]) with usability, acceptance, and enjoyment were explored. Results: A total of 45 OAs and 15 HPs participated in this study. The COCARE system achieved good acceptance ratings (OAs: 83%, range 36%-100% and HPs: 81%, range 63.8%-93.3% of the maximum score), and OAs indicated high enjoyment (mean 73.3, SD 12.7 out of 100 points in the EEQ) during the exergame session. The system?s usability, assessed with the SUS, received scores of 68.1 (SD 18.8; OAs) and 70.7 (SD 12.3; HPs) out of 100 points, with substantial differences observed between the trial sites. Several requirements for improvement were identified. Commonly mentioned barriers to adoption included the movement-recognition sensitivity of the Senso Flex, its limited markings, and difficulties in understanding certain instructions for assessments and games. Performance in games and assessments showed the highest significant correlations with the SUS (Spearman ?=0.35, P=.02 to ?=0.52, P<.001). The BREQ-3 had significant correlations with all usability measures, thereby even large significant correlations with enjoyment (Spearman ?=0.58; P<.001). Age had moderately significant correlations with the SUS (Spearman ?=?0.35; P=.02) and the UTAUT total score (?=?0.35; P=.02) but no significant correlation with the EEQ. Concerning sex and years of education, no significant correlations were found. Conclusions: The study?s findings will inform the further development of the COCARE system toward a user-friendly and widely accepted version, enhancing cognitive and physical functions in OAs. Future randomized controlled trials should evaluate the system?s feasibility and effectiveness. UR - https://humanfactors.jmir.org/2023/1/e48845 UR - http://dx.doi.org/10.2196/48845 UR - http://www.ncbi.nlm.nih.gov/pubmed/38060283 ID - info:doi/10.2196/48845 ER - TY - JOUR AU - Baeza-Barragán, Rosa María AU - Labajos Manzanares, Teresa Maria AU - Amaya-Álvarez, Cristina Mercedes AU - Morales Vega, Fabián AU - Rodriguez Ruiz, Judit AU - Martín-Valero, Rocío PY - 2023/11/15 TI - Effectiveness of a 5-Week Virtual Reality Telerehabilitation Program for Children With Duchenne and Becker Muscular Dystrophy: Prospective Quasi-Experimental Study JO - JMIR Serious Games SP - e48022 VL - 11 KW - Duchenne muscular dystrophy KW - telerehabilitation KW - virtual reality KW - physical therapy KW - muscular dystrophy KW - mutation KW - muscle KW - degeneration KW - telehealth KW - motor function KW - digital health intervention KW - Becker muscular dystrophy KW - VR N2 - Background: Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are neuromuscular diseases. DMD is the most prevalent in children. It affects dystrophin production, reducing the patient?s mobility and quality of life. New technologies have become a part of physical therapy in DMD and BMD. During the COVID-19 pandemic, conducting telerehabilitation through virtual reality?based games could help these children maintain their physical abilities. Objective: This study examined if the use of a virtual platform in a multimodal intervention program changes the results of the 6-minute walk test (6MWT) in children with DMD and BMD. The main objective was to test whether children with DMD and BMD obtain different results on the 6MWT after completing 10 telerehabilitation treatment sessions. The secondary objective was to measure whether other specific motor scales also produce different results after the 10 defined sessions. Methods: This was a descriptive, open, and quasi-experimental study with a prospective A-B (control-intervention) design. A sample of 12 participants who fulfilled the inclusion criteria followed the program for 5 weeks with 10 telerehabilitation sessions. During the sessions, the participants used virtual reality glasses to train for the treatment goals. All participants were assessed in person before and after the intervention. Analysis was performed using R software according to the different functional assessments performed for each test. Results: The participants showed a 19.55-meter increase in the 6MWT. Motor function also remained stable according to other scales used to assess it. The North Start Ambulatory Assessment scores were stable in both treatment conditions (P=.20). Furthermore, the timed up and go test results were 0.1 seconds faster in the telerehabilitation condition, and the Motor Function Measure in all of the 3 dimensions showed no significant differences (P=.08). Finally, the Effort Perception Infant scale showed that during the training, fatigue increased in the middle and decreased by the end of the sessions, but the perception throughout the sessions was lower even as the exercise intensity increased. Conclusions: There were no differences between conventional and telerehabilitation treatments, so the telerehabilitation tool could be used without harming children with DMD and BMD, facilitating their access to therapies and stimulating learning to maintain their functional capacity. Therefore, telerehabilitation in general may be helpful in maintaining motor function in children with DMD and BMD. The learning effect helped reduce the feeling of fatigue in the children during the program. Trial Registration: ClinicalTrials.gov NCT03879304; https://clinicaltrials.gov/study/NCT03879304 UR - https://games.jmir.org/2023/1/e48022 UR - http://dx.doi.org/10.2196/48022 ID - info:doi/10.2196/48022 ER - TY - JOUR AU - Vaezipour, Atiyeh AU - Aldridge, Danielle AU - Koenig, Sebastian AU - Burns, Clare AU - Baghaei, Nilufar AU - Theodoros, Deborah AU - Russell, Trevor PY - 2023/10/31 TI - Rehabilitation Supported by Immersive Virtual Reality for Adults With Communication Disorders: Semistructured Interviews and Usability Survey Study JO - JMIR Rehabil Assist Technol SP - e46959 VL - 10 KW - communication disorders KW - speech and language therapy KW - rehabilitation KW - virtual reality KW - human-computer interaction KW - technology acceptance KW - acceptance KW - communication KW - therapy KW - usefulness KW - usability KW - survey KW - barrier KW - mobile phone N2 - Background: Individuals who have acquired communication disorders often struggle to transfer the skills they learn during therapy sessions to real-life situations. Immersive virtual reality (VR) technology has the potential to create realistic communication environments that can be used both in clinical settings and for practice at home by individuals with communication disorders. Objective: This research aims to enhance our understanding of the acceptance, usefulness, and usability of a VR application (SIM:Kitchen), designed for communication rehabilitation. Additionally, this research aims to identify the perceived barriers and benefits of using VR technology from the perspective of individuals with acquired communication disorders. Methods: Semistructured interviews and usability surveys were conducted with 10 individuals with acquired neurogenic communication disorders aged 46-81 (mean 58, SD 9.57) years after trialing an immersive VR application. The audio-recorded interviews were transcribed and analyzed to identify themes. Results: The quantitative data regarding the usability of the system associated with participants? immersion experience in the VR application were promising. Findings from semistructured interviews are discussed across five key thematic areas including (1) participant?s attitude toward VR, (2) perceived usefulness of the VR system, (3) perceived ease of use of the VR system, (4) their willingness to continue using VR, and (5) the factors they perceived as challenges or facilitators to adopting this VR technology. Conclusions: Overall, participants in this study found the VR experience to be enjoyable and were impressed by the realism of the VR application designed for communication rehabilitation. This study highlighted personally relevant, immersive VR interventions with different levels of task difficulty that could enhance technology uptake in the context of communication rehabilitation. However, it is essential that VR hand controller technology is refined to be more naturalistic in movement and able to accommodate user capabilities. UR - https://rehab.jmir.org/2023/1/e46959 UR - http://dx.doi.org/10.2196/46959 UR - http://www.ncbi.nlm.nih.gov/pubmed/37906228 ID - info:doi/10.2196/46959 ER - TY - JOUR AU - Pinos Cisneros, Veronica Tamara AU - Brons, Annette AU - Kröse, Ben AU - Schouten, Ben AU - Ludden, Geke PY - 2023/10/16 TI - Playfulness and New Technologies in Hand Therapy for Children With Cerebral Palsy: Scoping Review JO - JMIR Serious Games SP - e44904 VL - 11 KW - technology KW - cerebral palsy KW - play KW - children KW - hand therapy N2 - Background: Innovative technologies such as game consoles and smart toys used with games or playful approaches have proven to be successful and attractive in providing effective and motivating hand therapy for children with cerebral palsy (CP). Thus, there is an increased interest in designing and implementing interventions that can improve the well-being of these children. However, to understand how and why these interventions are motivating children, we need a better understanding of the playful elements of technology-supported hand therapy. Objective: This scoping review aims to identify the playful elements and the innovative technologies currently used in hand therapy for children with CP. Methods: We included studies that design or evaluate interventions for children with CP that use innovative technologies with game or play strategies. Data were extracted and analyzed based on the type of technology, description of the system, and playful elements according to the Lenses of Play, a play design toolkit. A total of 31 studies were included in the analysis. Results: Overall, 54 papers were included in the analysis. The results showed high use of consumer technologies in hand therapy for children with CP. Although several studies have used a combination of consumer technologies with therapeutic-specific technologies, only a few studies focused on the exclusive use of therapeutic-specific technologies. To analyze the playfulness of these interventions that make use of innovative technologies, we focused our review on 3 lenses of play: Open-ended Play, where it was found that the characteristics of ludus, such as a structured form of play and defined goals and rules, were the most common, whereas strategies that relate to paidia were less common. The most commonly used Forms of Play were physical or active form and games with rules. Finally, the most popular Playful experiences were control, challenge, and competition. Conclusions: The inventory and analysis of innovative technology and playful elements provided in this study can be a starting point for new developments of fun and engaging tools to assist hand therapy for children with CP. UR - https://games.jmir.org/2023/1/e44904 UR - http://dx.doi.org/10.2196/44904 UR - http://www.ncbi.nlm.nih.gov/pubmed/37843886 ID - info:doi/10.2196/44904 ER - TY - JOUR AU - Vidal, Elizabeth AU - Castro-Gutierrez, Eveling AU - Arisaca, Robert AU - Paz-Valderrama, Alfredo AU - Albiol-Pérez, Sergio PY - 2023/10/3 TI - Serious Game for Fine Motor Control Rehabilitation for Children With Epileptic Encephalopathy: Development and Usability Study JO - JMIR Form Res SP - e50492 VL - 7 KW - serious game KW - virtual motor rehabilitation KW - ecologic virtual system KW - fine motor rehabilitation KW - virtual reality KW - rare diseases KW - children with epileptic encephalopathy N2 - Background: Epileptic encephalopathy (EE) is defined as the presence of frequent epileptiform activity that adversely impacts development, typically causing the slowing or regression of developmental skills, and is usually associated with frequent seizures. One of the main disturbances in EE is in the coordination of the upper extremities and hands. Traditional rehabilitation for this type of pathology focuses on the alleviation of gross or fine motor disability. In the last few years, the use of low-cost devices together with customized serious games has shown improvements in motor disorders and enrichments in activities of daily living. Objective: This study aims to explore the feasibility of a new serious game for improving fine motor control in children with EE. Methods: The participants were 4 children with EE (male: n=2, 50%; female: n=2, 50%) who were classified as belonging to level 1 in the Gross Motor Classification System. The children were tested over 10 sessions during the intervention period (before and after treatment). The clinical tests performed were the Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition and Pittsburgh Rehabilitation Participation Scale. The subscales of the Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition were fine motor precision, fine motor integration, manual dexterity, and upper-limb coordination. At the end of the first session, we used the User Satisfaction Evaluation Questionnaire to analyze user satisfaction. Results: The significance outcomes for a Student t test (1-tailed) were as follows: P=.009 for fine motor precision, P=.002 for fine motor integration, P=.56 for manual dexterity, and P=.99 for upper-limb coordination. The participation rate as measured using the Pittsburgh Rehabilitation Participation Scale was between good and very good, which means that, based on the therapist?s evaluation, interest, independence, and motivation were achieved by each participant. The mean User Satisfaction Evaluation Questionnaire score was close to 30, which is the maximum value. Conclusions: The results support the use of the proposed serious game as a complement in therapeutic sessions during the rehabilitation processes for children with EE. Significant improvements in fine motor control and activities of daily living revealed that the proposed serious game is beneficial for fine motor disorders of this pathology. UR - https://formative.jmir.org/2023/1/e50492 UR - http://dx.doi.org/10.2196/50492 UR - http://www.ncbi.nlm.nih.gov/pubmed/37788071 ID - info:doi/10.2196/50492 ER - TY - JOUR AU - Huang, Houqiang AU - Huang, Min AU - Chen, Qi AU - Hayter, Mark AU - Watson, Roger PY - 2023/9/25 TI - Effects of Serious Games for Patients With Chronic Obstructive Pulmonary Disease: Systematic Literature Review JO - JMIR Serious Games SP - e46358 VL - 11 KW - chronic obstructive pulmonary disease KW - COPD KW - serious game KW - rehabilitation KW - review KW - mobile phone N2 - Background: The use of serious games for rehabilitation has been an emerging intervention in health care fields, referred to as an entertaining and positive activity. Although related studies have been conducted on patients with chronic obstructive pulmonary disease (COPD), a more comprehensive study that summarizes and evaluates its effects in this area is needed. Objective: This review aimed to systematically evaluate the effects of serious games in promoting rehabilitation and related outcome measures of serious game?based engagement in patients with COPD. Methods: This review adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Searches were performed in the following databases: PubMed, Scopus, Embase (via Ovid), CINAHL, Science Direct, and China Biology Medicine disc. Only quantitative studies were included in this review, and the methodological quality and bias of the included studies were evaluated using related tools. Several outcomes, including clinical outcomes and serious game?based engagement outcomes, were ultimately collected in this review. The results were summarized and evaluated using descriptive methods due to significant heterogeneity. Results: In total, 11 studies were included. Serious games played a potentially positive effect on pulmonary function and exercise capacity. However, no consistent findings were reported on dyspnea and psychological status. Additionally, serious game engagement showed favorable findings on adherence, enjoyment, and acceptability. Furthermore, no serious adverse effects were identified in all included studies. Conclusions: This review preliminarily indicated the potential benefits of serious games in promoting rehabilitation for patients with COPD, despite the limited quality of the included studies. More studies with high methodological quality are needed to further explore the effects of serious games in this field. UR - https://games.jmir.org/2023/1/e46358 UR - http://dx.doi.org/10.2196/46358 UR - http://www.ncbi.nlm.nih.gov/pubmed/37747768 ID - info:doi/10.2196/46358 ER - TY - JOUR AU - Erten, Bü?ra Ay?e AU - Tarakç?, Devrim AU - Çaçan, Akif Mehmet PY - 2023/9/11 TI - The Effectiveness of Video-Based Game Exercise Therapy Applications in Pes Planus Rehabilitation: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e51772 VL - 12 KW - exergame KW - pes planus KW - rehabilitation KW - serious game KW - video-based game therapy N2 - Background: Pes planus is one of the most common foot deformities. Although there are many studies on the effectiveness of various exercise methods in pes planus rehabilitation, the number of studies on video-based game exercise therapy applications is very limited. Objective: This study aims to evaluate the effectiveness of 2 video-based game exercise therapies and structured exercise practices in pes planus rehabilitation. Methods: This study is a 3-arm, parallel-group, single-blinded randomized controlled trial. The study will include 69 patients with flexible pes planus aged between 18 and 25 years who attend the orthopedics and traumatology clinic and meet the inclusion criteria. The primary outcomes are measures of navicular drop and pedobarographic analysis before and after the intervention, and the secondary outcomes include balance, femoral anteversion, and lower extremity muscle strength. Participants will be evaluated with a navicular drop test for medial longitudinal arch height, a pedobarographic analysis system for plantar pressure analysis, a Craig test for femoral anteversion, the Becure Balance System for balance measurement, and a myometer device for lower extremity muscle strength measurement. Participants will be randomly assigned to a structured exercise group, an exergame group, or a serious game group according to their order of arrival. The structured exercise group will use a short foot exercise, a towel-picking exercise, and various walking and balance exercises. Patients in the serious play group will play the lower extremity games in the Becure Balance System. Patients in the exergame group will play balance games on the Nintendo Wii game console. All participants will participate in 18 exercise sessions (3 days a week for 6 weeks). After the treatment, the initial measurements will be repeated. Results: The study started in January 2023. It is expected to be completed in June 2024. Conclusions: This study will be the first randomized controlled study to evaluate the effectiveness of 2 different video-based game exercise therapy applications in pes planus rehabilitation. Through this study, the use of video-based game exercise therapy in pes planus rehabilitation, together with the developing technology, will be a guide. In addition, a new exercise protocol, including serious game exercises, will be added to the literature. In the future, it is expected that our study on the development of different game systems, especially for the ankle, will provide pioneering feedback. Trial Registration: ClinicalTrials.gov NCT05679219; https://clinicaltrials.gov/study/NCT05679219 International Registered Report Identifier (IRRID): DERR1-10.2196/51772 UR - https://www.researchprotocols.org/2023/1/e51772 UR - http://dx.doi.org/10.2196/51772 UR - http://www.ncbi.nlm.nih.gov/pubmed/37695657 ID - info:doi/10.2196/51772 ER - TY - JOUR AU - Mendonca, J. Christen AU - Malone, A. Laurie AU - Mohanraj, Sangeetha AU - Thirumalai, Mohanraj PY - 2023/8/3 TI - The Usability of a Touchpad Active Video Game Controller for Individuals With Impaired Mobility: Observational Study JO - JMIR Rehabil Assist Technol SP - e41993 VL - 10 KW - active video games KW - exergames KW - usability KW - enjoyment KW - disability KW - mobility limitation KW - mobility impairment N2 - Background: Video games are a popular sedentary activity among people with impaired mobility; however, active video game hardware typically lacks accessibility and customization options for individuals with mobility impairments. A touchpad video game system can elicit moderate physical activity in healthy adults; however, it is unclear if this system is usable by adults with impaired mobility. Objective: The purpose of this study was to assess the usability of a touchpad video game controller system adapted for adults with impaired mobility. Additional outcomes explored were enjoyment, perceived exertion, self-efficacy, participant feedback, and researcher observations of gameplay. Methods: Participants played several video game titles for 20 minutes with a touchpad video game controller as they stood or sat in a chair or their wheelchair. Usability was assessed with the System Usability Scale (SUS) and the Health Information Technology Usability Evaluation Scale (Health-ITUES) surveys after gameplay. After each video game, participants reported enjoyment using a visual analog scale (0 to 100 mm) and a rating of perceived exertion using the OMNI 0 to 10 scale. Self-efficacy was measured before and after gameplay. Participants provided feedback at the end of their session. Results: In total, 21 adults (6 females and 15 males) with a mean age of 48.8 (SD 13.8) years with various mobility impairments participated in this study. The touchpads received mean usability scores on the SUS 80.1 (SD 18.5) and Health-ITUES 4.23 (SD 0.67). Conclusions: The SUS scores reported suggest the touchpad system is ?usable?; however, the Health-ITUES scores were slightly below a suggested benchmark. Participants reported moderate to high enjoyment but perceived the exertion as ?somewhat easy.? Self-efficacy was moderate to high and did not differ pre- to postgame play. The participants regarded the touchpads as novel, fun, and entertaining. The generalizability of our results is limited due to the heterogenous sample; however, our participants identified several areas of improvement for future iteration. UR - https://rehab.jmir.org/2023/1/e41993 UR - http://dx.doi.org/10.2196/41993 UR - http://www.ncbi.nlm.nih.gov/pubmed/37535411 ID - info:doi/10.2196/41993 ER - TY - JOUR AU - Specht, Julian AU - Stegmann, Barbara AU - Gross, Hanna AU - Krakow, Karsten PY - 2023/7/21 TI - Cognitive Training With Head-Mounted Display Virtual Reality in Neurorehabilitation: Pilot Randomized Controlled Trial JO - JMIR Serious Games SP - e45816 VL - 11 KW - cognitive rehabilitation KW - virtual reality KW - neurorehabilitation KW - psychology KW - stroke N2 - Background: Neurological rehabilitation is technologically evolving rapidly, resulting in new treatments for patients. Stroke, one of the most prevalent conditions in neurorehabilitation, has been a particular focus in recent years. However, patients often need help with physical and cognitive constraints, whereby the cognitive domain in neurorehabilitation does not technologically exploit existing potential. Usually, cognitive rehabilitation is performed with pen and paper or on a computer, which leads to limitations in preparation for activities of daily living. Technologies such as virtual reality (VR) can bridge this gap. Objective: This pilot study investigated the use of immersive VR in cognitive rehabilitation for patients undergoing inpatient neurorehabilitation. The goal was to determine the difference in rehabilitation effectiveness between a VR serious game that combines everyday activities with cognitive paradigms and conventional computerized cognitive training. We hypothesized the superiority of the VR serious game regarding cognitive abilities and patient-reported outcomes as well as transfer to daily life. Methods: We recruited 42 patients with acute brain affection from a German neurorehabilitation clinic in inpatient care with a Mini Mental Status Test score >20 to participate in this randomized controlled trial. Participants were randomly assigned to 2 groups, with 1 receiving the experimental VR treatment (n=21). VR training consisted of daily life scenarios, for example, in a kitchen, focusing on treating executive functions such as planning and problem-solving. The control group (n=21) received conventional computerized cognitive training. Each participant received a minimum of 18 treatment sessions in their respective group. Patients were tested for cognitive status, subjective health, and quality of life before and after the intervention (Alters-Konzentrations-Test, Wechsler Memory Scale?Revised, Trail Making Test A and B, Tower of London?German version, Short Form 36, European Quality of Life 5 Dimensions visual analog scale, and Fragebogen zur Erfassung der Performance in VR). Results: Repeated-measures ANOVA revealed several significant main effects in the cognitive tests: Tower of London?German version (P=.046), Trail Making Test A (P=.01), and Wechsler Memory Scale?Revised (P=.006). However, post hoc tests revealed that the VR group showed significant improvement in the planning, executive control, and problem-solving domains (P=.046, Bonferroni P=.02). In contrast, no significant improvement in the control group between t0 and t1 was detected (all P>.05). Furthermore, a nonsignificant trend was observed in visual speed in the VR group (P=.09, Bonferroni P=.02). Conclusions: The results of this pilot randomized controlled trial showed that immersive VR training in cognitive rehabilitation had greater effectiveness than the standard of care in treating patients experiencing stroke in some cognitive domains . These findings support the further use and study of VR training incorporating activities of daily living in other neurological disorders involving cognitive dysfunction. Trial Registration: Federal Registry of Clinical Trials of Germany (DRKS) DRKS00023605; https://drks.de/search/de/trial/DRKS00023605 UR - https://games.jmir.org/2023/1/e45816 UR - http://dx.doi.org/10.2196/45816 UR - http://www.ncbi.nlm.nih.gov/pubmed/37477957 ID - info:doi/10.2196/45816 ER - TY - JOUR AU - De Miguel-Rubio, Amaranta AU - Alba-Rueda, Alvaro AU - Millán-Salguero, María Elena AU - De Miguel-Rubio, Dolores M. AU - Moral-Munoz, A. Jose AU - Lucena-Anton, David PY - 2023/6/30 TI - Virtual Reality for Upper Limb Rehabilitation in Patients With Obstetric Brachial Palsy: Systematic Review and Meta-Analysis of Randomized Controlled Trials JO - J Med Internet Res SP - e47391 VL - 25 KW - neonatal brachial plexus palsy KW - virtual reality KW - rehabilitation KW - upper extremity KW - review KW - meta-analysis N2 - Background: Obstetric brachial palsy (OBP) is a pathology caused by complications during childbirth because of cervical spine elongation, affecting the motor and sensory innervation of the upper limbs. The most common lesion occurs on the C5 and C6 nerve branches, known as Erb-Duchenne palsy. The least common lesion is when all nerve roots are affected (C5-T1), which has the worst prognosis. Virtual reality (VR) is commonly used in neurological rehabilitation for the evaluation and treatment of physical deficits. Objective: This systematic review aims to assess the efficacy of VR in the rehabilitation of upper limb function in patients with OBP. Methods: A search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines in several scientific databases?PubMed, Web of Science, PEDro, Cochrane, MEDLINE, Scopus, and CINAHL?without language or date restrictions and including articles published up to April 2023. The inclusion criteria were established according to the population, intervention, comparison, outcome, and study (PICOS) design framework: children aged <18 years diagnosed with OBP, VR therapy used in addition to conventional therapy or isolated, VR therapy compared with conventional therapy, outcomes related to OBP rehabilitation therapy, and randomized controlled trials (RCTs). The PEDro scale was used to assess the methodological quality of the RCTs, and the Cochrane Collaboration tool was used to assess the risk of bias. The Review Manager statistical software (version 5.4; The Cochrane Collaboration) was used to conduct the meta-analysis. The results were synthesized through information extraction and presented in tables and forest plots. Results: In total, 5 RCTs were included in this systematic review, with 3 (60%) providing information for the meta-analysis. A total of 138 participants were analyzed. All the studies used semi-immersive or nonimmersive VR systems. The statistical analysis showed no favorable results for all outcomes except for the hand-to-mouth subtest of the Mallet scoring system (functional activity; standardized mean difference ?0.97, 95% CI ?1.67 to ?0.27; P=.007). Conclusions: The evidence for the use of VR therapy for upper limb rehabilitation outcomes in patients with OBP was insufficient to support its efficacy and strongly recommend its use. Nevertheless, scientific literature supports the use of VR technologies for rehabilitation as it provides several advantages, such as enhancing the patient?s motivation, providing direct feedback, and focusing the patient?s attention during the intervention. Thus, the use of VR for upper limb rehabilitation in patients with OBP is still in its first stages. Small sample sizes; limited long-term analysis; lack of testing of different doses; and absence of International Classification of Functioning, Disability, and Health?related outcomes were present in the included RCTs, so further research is needed to fully understand the potential of VR technologies as a therapeutic approach for patients with OBP. Trial Registration: PROSPERO CRD42022314264; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=314264 UR - https://www.jmir.org/2023/1/e47391 UR - http://dx.doi.org/10.2196/47391 UR - http://www.ncbi.nlm.nih.gov/pubmed/37389922 ID - info:doi/10.2196/47391 ER - TY - JOUR AU - Ersin, Kerem AU - Gürlek, Emre AU - Güler, Hakan AU - Kalayc?k Ertugay, Çi?dem AU - ?erbetçio?lu, Bülent Mustafa PY - 2023/4/13 TI - Appropriate Image Selection With Virtual Reality in Vestibular Rehabilitation: Cross-sectional Study JO - JMIR Serious Games SP - e40806 VL - 11 KW - balance KW - computerized dynamic posturography KW - stress KW - vestibular rehabilitation KW - vestibular system KW - virtual reality N2 - Background: While vestibular rehabilitation with virtual reality (VR) is becoming more popular every day, the disadvantages of this method are not yet clear. Objective: The aim of this study is to examine the effect of the image to be used in vestibular rehabilitation with VR on the systems that provide body posture. Methods: The study was carried out with 36 participants (18 women and 18 men) aged 18 to 30 years. To assess balance control components separately, a sensory organization test was administered to the participants in the presence of stressful and relaxing environment images with VR technology. The State-Trait Anxiety Inventory survey was also used to measure the stress values in the created environments. Results: The State-Trait Anxiety Inventory survey revealed that while stressful videos significantly increased stress, relaxing videos reduced stress. Among measurements obtained in the presence of VR, significant decreases were observed mostly in the visual system data. A significant increase in vestibular system data (P=.01) was observed with a decrease in visual system data (P<.001) when the relaxing image was presented. Additionally, there was a significant difference in the somatosensory (P=.001), composite (P=.002), and visual system (P<.001) data in the presence of stressful videos. Conclusions: Although the use of a VR system for vestibular rehabilitation is relatively new, no extant studies have examined how the image type used in VR can affect the integration of visual system data. Therefore, this study is unique in terms of showing the effects of the stress created by the change in the type of the image used in VR. When VR technology is used for therapeutic vestibular rehabilitation for patients whose balance disorder is due to the vestibular system, stress-free videos should be used. However, the use of stressful videos in VR technology will be beneficial in the rehabilitation of those with balance disorders due to the somatosensory system. UR - https://games.jmir.org/2023/1/e40806 UR - http://dx.doi.org/10.2196/40806 UR - http://www.ncbi.nlm.nih.gov/pubmed/37052976 ID - info:doi/10.2196/40806 ER - TY - JOUR AU - Stammler, Britta AU - Flammer, Kathrin AU - Schuster, Thomas AU - Lambert, Marian AU - Karnath, Hans-Otto PY - 2023/2/27 TI - Negami: An Augmented Reality App for the Treatment of Spatial Neglect After Stroke JO - JMIR Serious Games SP - e40651 VL - 11 KW - spatial neglect KW - gamification KW - augmented reality KW - visual exploration training KW - stroke rehabilitation KW - serious games KW - rehabilitation KW - stroke N2 - Background: A widely applied and effective rehabilitation method for patients experiencing spatial neglect after a stroke is ?visual exploration training.? Patients improve their ipsilesional bias of attention and orientation by training exploration movements and search strategies toward the contralesional side of space. In this context, gamification can have a positive influence on motivation for treatment and thus on the success of treatment. In contrast to virtual reality applications, treatment enhancements through augmented reality (AR) have not yet been investigated, although they offer some advantages over virtual reality. Objective: This study aimed to develop an AR-based app (Negami) for the treatment of spatial neglect that combines visual exploration training with active, contralesionally oriented rotation of the eyes, head, and trunk. Methods: The app inserts a virtual element (origami bird) into the real space surrounding the patient, which the patient explores with the camera of a tablet. Subjective reports from healthy elderly participants (n=10) and patients with spatial neglect after stroke (n=10) who trained with the new Negami app were analyzed. Usability, side effects, and game experience were assessed by various questionnaires. Results: Training at the highest defined difficulty level was perceived as differently challenging but not as frustrating by the group of healthy elderly participants. The app was rated with high usability, hardly any side effects, high motivation, and entertainment. The group of patients with spatial neglect after stroke consistently evaluated the app positively on the dimensions of motivation, satisfaction, and fun. Conclusions: The Negami app represents a promising extension by adding AR to traditional exploration training for spatial neglect. Through participants? natural interaction with the physical surrounding environment during playful tasks, side effects as symptoms of cybersickness are minimized and patients? motivation appeared to markedly increase. The use of AR in cognitive rehabilitation programs and the treatment of spatial neglect seems promising and should receive further investigation. UR - https://games.jmir.org/2023/1/e40651 UR - http://dx.doi.org/10.2196/40651 UR - http://www.ncbi.nlm.nih.gov/pubmed/36848215 ID - info:doi/10.2196/40651 ER - TY - JOUR AU - Gallou-Guyot, Matthieu AU - Perrochon, Anaick AU - Marie, Romain AU - Bourgeois, Maxence AU - Mandigout, Stephane PY - 2023/2/2 TI - Measured and Perceived Exercise Intensity During the Performance of Single-Task, Cognitive-Motor Dual-Task, and Exergame Training: Transversal Study JO - JMIR Serious Games SP - e36126 VL - 11 KW - exergame KW - dual-task KW - exercise intensity KW - heart rate KW - cognitive load KW - active video game KW - physical activity N2 - Background: The physical and cognitive loads borne during exergaming may differ from more conventional cognitive-motor dual-task trainings. Objective: The aim of this pilot transversal study was to compare objectively measured and perceived exercise intensity during exergame, cognitive-motor dual-task, and single-task training sessions. Methods: We recruited apparently healthy young adults who carried out one session of each type of training: exergaming, cognitive-motor dual-tasking, and single-tasking. We used a custom-made exergame as support. The sessions lasted 30 minutes, were spaced at least 24 hours apart, and took place in random order for each group of 4 participants. We used heart rates to assess exercise intensity and the modified Borg scale to assess perception of intensity. In all, 16 apparently healthy young participants carried out all sessions. Results: There was no difference between the different types of training in mean heart rates (P=.27), peak heart rates (P=.50), or Borg scale scores (P=.40). Our custom-made exergame?s objectively measured and perceived physical load did not differ between cognitive-motor dual-task and single-task training. Conclusions: As a result, our exergame can be considered to be as challenging as more traditional physical training. Future studies should be conducted in older adults with or without cognitive impairments and incorporate an assessment of cognitive performance. UR - https://games.jmir.org/2023/1/e36126 UR - http://dx.doi.org/10.2196/36126 UR - http://www.ncbi.nlm.nih.gov/pubmed/36729572 ID - info:doi/10.2196/36126 ER - TY - JOUR AU - Eckert, Martina AU - Domingo Soria, Beatriz AU - Terroso Gil, Noelia PY - 2023/1/13 TI - Finding Effective Adjustment Levels for Upper Limb Exergames: Focus Group Study With Children With Physical Disabilities JO - JMIR Serious Games SP - e36110 VL - 11 KW - rehabilitation KW - physical therapy KW - cerebral palsy KW - obstetric brachial plexus palsy KW - serious games KW - exergames KW - Kinect N2 - Background: We developed the Blexer system consisting of a database and a web interface for therapists that can host different types of adaptive and personally configurable virtual reality exergames based on Kinect (Microsoft Corp) motion capture to provide entertaining exercises for children with motor disabilities. It allows for parameter adjustment and the monitoring of results remotely, thereby providing a useful tool to complement traditional physical therapy sessions with home exercises. Objective: The aim of this study was to observe the motor benefits achieved through the use of a video exergame and the importance and implications of correctly setting the game?s difficulty parameters. Methods: This was an observational case study of 6 children with different physical disabilities receiving physical therapy at school combined with the use of a fully configurable exergame under research that forms a part of the Blexer environment. The game integrates 4 repeatedly appearing upper limb exercises with individually adjustable difficulties (intermittent arm rising, arm forward and backward movement, rising and holding of one arm, and trunk control in all directions). The outcomes were 3 assessments of 2 efficacy measures: Box and Block Test and Jebsen Taylor Hand Function Test. Results: A total of 5 children with cerebral palsy (mean 8.4, SD 2.7 years; Gross Motor Function Classification II?2/5, 40%; III?2/5, 40%; and IV?1/5, 20%) and 1 child with obstetric brachial plexus palsy (aged 8 years; Mallet Classification III) received between 8 and 11 sessions of training (10-20 minutes per session), depending on age, motivation, and fatigue. Significant associations were observed between game parameter settings and improvements in motor function, on the one hand, and between the type of improvement and disability severity, on the other: with adjusted game parameters goal and time in the range of 70% to 100%, only less affected children improved in the Box and Block Test (+11 blocks vs ?1 block), and more affected children improved more in the Jebsen Taylor Hand Function Test (+90 seconds vs +27 seconds). Conclusions: When defining the difficulty parameters for an exergame, we suggest a classification in levels ranging from very easy to very hard. For practical use, we suggest setting the difficulty for the player to an easy or medium level rather than high-commitment goals, as this leads to a longer playtime with more fun and, therefore, seems to improve the results of the game and, consequently, mobility. UR - https://games.jmir.org/2023/1/e36110 UR - http://dx.doi.org/10.2196/36110 UR - http://www.ncbi.nlm.nih.gov/pubmed/36637882 ID - info:doi/10.2196/36110 ER - TY - JOUR AU - Aartolahti, Eeva AU - Janhunen, Maarit AU - Katajapuu, Niina AU - Paloneva, Juha AU - Pamilo, Konsta AU - Oksanen, Airi AU - Keemu, Hannes AU - Karvonen, Mikko AU - Luimula, Mika AU - Korpelainen, Raija AU - Jämsä, Timo AU - Mäkelä, Keijo AU - Heinonen, Ari PY - 2022/11/28 TI - Effectiveness of Gamification in Knee Replacement Rehabilitation: Protocol for a Randomized Controlled Trial With a Qualitative Approach JO - JMIR Res Protoc SP - e38434 VL - 11 IS - 11 KW - knee arthroplasty KW - serious game KW - gamification KW - therapeutic exercise KW - rehabilitation KW - physical therapy KW - Kinect KW - mixed methods KW - randomized controlled trial N2 - Background: Exergames can provide encouraging exercise options. Currently, there is limited evidence regarding home-based exergaming in the postoperative phase of total knee replacement (TKR). Objective: This study aimed to investigate the effects of a 4-month postoperative home-based exergame intervention with an 8-month follow-up on physical function and symptoms among older persons undergoing TKR compared with home exercise using a standard protocol. In addition, a concurrent embedded design of a mixed methods study was used by including a qualitative component within a quantitative study of exergame effects. Methods: This was a dual-center, nonblinded, two-arm, parallel group randomized controlled trial with an embedded qualitative approach. This study aimed to recruit 100 patients who underwent their first unilateral TKR (aged 60-75 years). Participants were randomized to the exergame or standard home exercise arms. Participants followed a custom-made exergame program independently at their homes daily for 4 months. The primary outcomes at 4 months were function and pain related to the knee using the Oxford Knee Score questionnaire and mobility using the Timed Up and Go test. Other outcomes, in addition to physical function, symptoms, and disability, were game user experience, exercise adherence, physical activity, and satisfaction with the operated knee. Assessments were performed at the preoperative baseline and at 2, 4, and 12 months postoperatively. Exergame adherence was followed from game computers and using a structured diary. Self-reported standard exercise was followed for 4 months of intervention and physical activity was followed for 12 months using a structured diary. Qualitative data on patients? perspectives on rehabilitation and exergames were collected through laddering interviews at 4 and 12 months. Results: This study was funded in 2018. Data collection began in 2019 and was completed in January 2022. The COVID-19 pandemic caused an unavoidable situation in the study for recruitment, data collection, and statistical analysis. As of November 2020, a total of 52 participants had been enrolled in the study. Primary results are expected to be published by the end of 2022. Conclusions: Our study provides new knowledge on the effects of postoperative exergame intervention among older patients with TKR. In addition, this study provides a new understanding of gamified postoperative rehabilitation, home exercise adherence, physical function, and physical activity among older adults undergoing TKR. Trial Registration: ClinicalTrials.gov NCT03717727; https://clinicaltrials.gov/ct2/show/NCT03717727 International Registered Report Identifier (IRRID): RR1-10.2196/38434 UR - https://www.researchprotocols.org/2022/11/e38434 UR - http://dx.doi.org/10.2196/38434 UR - http://www.ncbi.nlm.nih.gov/pubmed/36441574 ID - info:doi/10.2196/38434 ER - TY - JOUR AU - He, Danni AU - Cao, Shihua AU - Le, Yuchao AU - Wang, Mengxin AU - Chen, Yanfei AU - Qian, Beiying PY - 2022/10/19 TI - Virtual Reality Technology in Cognitive Rehabilitation Application: Bibliometric Analysis JO - JMIR Serious Games SP - e38315 VL - 10 IS - 4 KW - virtual reality KW - cognitive rehabilitation KW - bibliometric analysis KW - CiteSpace KW - gCLUTO KW - rehabilitation KW - cognitive disorder KW - visual content analysis N2 - Background: In recent years, with the development of computer science and medical science, virtual reality (VR) technology has become a promising tool for improving cognitive function. Research on VR-based cognitive training has garnered increasing attention. Objective: This study aimed to investigate the application status, research hot spots, and emerging trends of VR in cognitive rehabilitation over the past 20 years. Methods: Articles on VR-based cognitive rehabilitation from 2001 to 2021 were retrieved from the Web of Science Core Collection. CiteSpace software was used for the visual analysis of authors and countries or regions, and Scimago Graphica software was used for the geographic visualization of published countries or regions. Keywords were clustered using the gCLUTO software. Results: A total of 1259 papers were included. In recent years, research on the application of VR in cognitive rehabilitation has been widely conducted, and the annual publication of relevant literature has shown a positive trend. The main research areas include neuroscience and neurology, psychology, computer science, and rehabilitation. The United States ranked first with 328 papers, and Italy ranked second with 140 papers. Giuseppe Riva, an Italian academic, was the most prolific author with 29 publications. The most frequently cited reference was ?Using Reality to Characterize Episodic Memory Profiles in Amnestic Mild Cognitive Impairment and Alzheimer?s Disease: Influence of Active and Passive Encoding.? The most common keywords used by researchers include ?virtual reality,? ?cognition,? ?rehabilitation,? ?performance,? and ?older adult.? The largest source of research funding is from the public sector in the United States. Conclusions: The bibliometric analysis provided an overview of the application of VR in cognitive rehabilitation. VR-based cognitive rehabilitation can be integrated into multiple disciplines. We conclude that, in the context of the COVID-19 pandemic, the development of VR-based telerehabilitation is crucial, and there are still many problems that need to be addressed, such as the lack of consensus on treatment methods and the existence of safety hazards. UR - https://games.jmir.org/2022/4/e38315 UR - http://dx.doi.org/10.2196/38315 UR - http://www.ncbi.nlm.nih.gov/pubmed/36260388 ID - info:doi/10.2196/38315 ER - TY - JOUR AU - Hernandez, Alejandro AU - Bubyr, Liudmila AU - Archambault, S. Philippe AU - Higgins, Johanne AU - Levin, F. Mindy AU - Kairy, Dahlia PY - 2022/9/27 TI - Virtual Reality?Based Rehabilitation as a Feasible and Engaging Tool for the Management of Chronic Poststroke Upper-Extremity Function Recovery: Randomized Controlled Trial JO - JMIR Serious Games SP - e37506 VL - 10 IS - 3 KW - rehabilitation KW - serious game KW - stroke KW - telerehabilitation KW - upper extremity KW - virtual reality?based rehabilitation KW - virtual reality KW - virtual care N2 - Background: A growing number of stroke survivors are left with little to no rehabilitation services upon discharge from stroke rehabilitation, although arm deficits may persist or develop from disuse once rehabilitation services have ceased. Virtual reality (VR)?based rehabilitation, combined with new technologies such as telerehabilitation, including serious games using VR environments that encourage users to practice functional movements from home with minimal supervision, may have an important role to play in optimizing and maintaining upper extremity (UE) function. Objective: The primary objective of this study is to determine the extent to which a 1-month intervention using a VR-based serious game is effective in improving UE function compared with an evidence-based home exercise program. A secondary objective is to assess the feasibility of implementing the intervention for chronic stroke rehabilitation in participants? homes. Methods: A total of 51 chronic stroke participants were randomized to treatment (n=26, 51%; Jintronix system) or standard care (n=25, 49%; standardized Graded Repetitive Arm Supplementary Program kit home program) groups. The participants were evaluated at baseline (before), immediately after the intervention (after), and at follow-up (4 weeks). The primary outcome measure was the Fugl-Meyer Assessment for UE (FMA-UE). Secondary outcome measures included the Stroke Impact Scale and an abridged version of the Motor Activity Log-14. Self-reported number of sessions was logged for the standard care group. Results: No statistically significant differences between groups were found across measures. Overall time effects were found for the FMA-UE (P=.045), specifically between preintervention and postintervention time points for both groups (P=.03). A total of 9 participants in the treatment group reached or surpassed the minimal clinically important difference in scores for the FMA-UE, with 7 (78%) of them having baseline low or moderate arm function, compared with 3 (33%) participants in the standard care group. Furthermore, 56% (9/16) of the participants in the treatment group who actively engaged with the system reached the minimal clinically important difference for the FMA-UE, compared with none for the 0% (0/10) less-active participants. Conclusions: These findings suggest that UE training for chronic stroke survivors using virtual rehabilitation in their home may be as effective as a gold standard home exercise program and that those who used the system the most achieved the greatest improvement in UE function, indicating its relevance to being included as part of ongoing rehabilitation services. Trial Registration: ClinicalTrials.gov NCT02491203; https://clinicaltrials.gov/ct2/show/NCT02491203 International Registered Report Identifier (IRRID): RR2-10.1016/j.cct.2015.12.006 UR - https://games.jmir.org/2022/3/e37506 UR - http://dx.doi.org/10.2196/37506 UR - http://www.ncbi.nlm.nih.gov/pubmed/36166289 ID - info:doi/10.2196/37506 ER - TY - JOUR AU - Kalron, Alon AU - Frid, Lior AU - Fonkatz, Iliya AU - Menascu, Shay AU - Dolev, Mark AU - Magalashvili, David AU - Achiron, Anat PY - 2022/9/12 TI - The Design, Development, and Testing of a Virtual Reality Device for Upper Limb Training in People With Multiple Sclerosis: Single-Center Feasibility Study JO - JMIR Serious Games SP - e36288 VL - 10 IS - 3 KW - virtual reality KW - rehabilitation KW - feasibility KW - upper limb KW - multiple sclerosis N2 - Background: Multiple sclerosis (MS) is a common nontraumatic, neurological, disabling disease that often presents with upper limb dysfunction. Exercise training has resulted in improvement for patients; however, there can be a lack of compliance due to access because of location and lack of MS experts. Virtual reality (VR) is a promising technology that can offer exercise therapy/rehabilitation at a distance. This type of remote training can be motivational and effective for patients with MS and can improve range of motion and muscle strength for those with upper limb dysfunction. Objective: The aim of this study is to evaluate the safety and feasibility of the XRHealth software and the Oculus Rift Station for patients with MS with upper limb motor dysfunction. Methods: A single-center, prospective, feasibility study was conducted with patients with MS who had upper limb motor dysfunction. Patients participated in a single 45-minute digital environment session with VR and completed a questionnaire about the quality of the training and fatigability. The clinician also completed a questionnaire to evaluate the suitability and safety of the training. Results: Overall, 30 patients were enrolled between the ages of 20 and 81 years. Patients reported that the training sessions within the digital environment were helpful, challenging, fun, and simple to understand, and that they would be willing to repeat the sessions again. The physical therapist that oversaw the patients reported that the training was suitable for 87% (n=26) of the patients. Anticipated adverse events were fatigue, temporary dizziness, and temporary nausea. The operator complications included that the cable of the head-mounted display interrupted the training (n=2, 7%) and fatigue that caused cessation of the VR training session (n=2, 7%). No serious adverse events were reported. Conclusions: These preliminary results demonstrated that the use of the XRHealth software and Oculus Rift Station platform is feasible, safe, and engaging for patients, and has the potential to improve the functionality of the upper limbs in patients with MS. This study provides support for future studies of implementing a series of training sessions with virtual reality in a home-based environment. UR - https://games.jmir.org/2022/3/e36288 UR - http://dx.doi.org/10.2196/36288 UR - http://www.ncbi.nlm.nih.gov/pubmed/36094809 ID - info:doi/10.2196/36288 ER - TY - JOUR AU - Mena-Moreno, Teresa AU - Munguía, Lucero AU - Granero, Rosario AU - Lucas, Ignacio AU - Sánchez-Gómez, Almudena AU - Cámara, Ana AU - Compta, Yaroslau AU - Valldeoriola, Francesc AU - Fernandez-Aranda, Fernando AU - Sauvaget, Anne AU - Menchón, M. José AU - Jiménez-Murcia, Susana PY - 2022/9/9 TI - Cognitive Behavioral Therapy Plus a Serious Game as a Complementary Tool for a Patient With Parkinson Disease and Impulse Control Disorder: Case Report JO - JMIR Serious Games SP - e33858 VL - 10 IS - 3 KW - Parkinson disease KW - impulse control disorder KW - hypersexuality KW - multidisciplinary approach KW - serious game N2 - Background: Impulse control disorders (ICDs) are commonly developed among patients who take dopamine agonist drugs as a treatment for Parkinson disease (PD). Gambling disorder and hypersexuality are more frequent in male patients with PD, with a prevalence over 4% in dopamine agonists users. Although impulsive-compulsive behaviors are related to antiparkinsonian medication, and even though ICD symptomatology, such as hypersexuality, often subsides when the dopaminergic dose is reduced, sometimes ICD persists in spite of drug adjustment. Consequently, a multidisciplinary approach should be considered to address these comorbidities and to explore new forms of complementary interventions, such as serious games or therapies adapted to PD. Objective: The aim of this study is to present the case of a patient with ICD (ie, hypersexuality) triggered by dopaminergic medication for PD. A combined intervention was carried out using cognitive behavioral therapy (CBT) for ICD adapted to PD, plus an intervention using a serious game?e-Estesia?whose objective is to improve emotion regulation and impulsivity. The aim of the combination of these interventions was to reduce the harm of the disease. Methods: After 20 CBT sessions, the patient received the e-Estesia intervention over 15 sessions. Repeated measures, before and after the combined intervention, were administered to assess emotion regulation, general psychopathology, and emotional distress and impulsivity. Results: After the intervention with CBT techniques and e-Estesia, the patient presented fewer difficulties to regulate emotion, less emotional distress, and lower levels of impulsivity in comparison to before the treatment. Moreover, the frequency and severity of the relapses also decreased. Conclusions: The combined intervention?CBT and a serious game?showed positive results in terms of treatment outcomes. UR - https://games.jmir.org/2022/3/e33858 UR - http://dx.doi.org/10.2196/33858 UR - http://www.ncbi.nlm.nih.gov/pubmed/36083621 ID - info:doi/10.2196/33858 ER - TY - JOUR AU - Ardern, L. Clare AU - Hooper, Nicholas AU - O'Halloran, Paul AU - Webster, E. Kate AU - Kvist, Joanna PY - 2022/8/9 TI - A Psychological Support Intervention to Help Injured Athletes ?Get Back in the Game?: Design and Development Study JO - JMIR Form Res SP - e28851 VL - 6 IS - 8 KW - sports KW - medicine KW - rehabilitation KW - sports injury KW - psychological support KW - mental health KW - postoperative medicine KW - feasibility KW - eHealth KW - mobile phone N2 - Background: After a serious knee injury, up to half of athletes do not return to competitive sport, despite recovering sufficient physical function. Athletes often desire psychological support for the return to sport, but rehabilitation clinicians feel ill-equipped to deliver adequate support. Objective: We aimed to design and develop an internet-delivered psychological support program for athletes recovering from knee ligament surgery. Methods: Our work for developing and designing the Back in the Game intervention was guided by a blend of theory-, evidence-, and target population?based strategies for developing complex interventions. We systematically searched for qualitative evidence related to athletes? experiences with, perspectives on, and needs for recovery and return to sport after anterior cruciate ligament (ACL) injury. Two reviewers coded and synthesized the results via thematic meta-synthesis. We systematically searched for randomized controlled trials reporting on psychological support interventions for improving ACL rehabilitation outcomes in athletes. One reviewer extracted the data, including effect estimates; a second reviewer checked the data for accuracy. The results were synthesized descriptively. We conducted feasibility testing in two phases?(1) technical assessment and (2) feasibility and usability testing. For phase 1, we recruited clinicians and people with lived experience of ACL injury. For phase 2, we recruited patients aged between 15 and 30 years who were within 8 weeks of ACL reconstruction surgery. Participants completed a 10-week version of the intervention and semistructured interviews for evaluating acceptability, demand, practicality, and integration. This project was approved by the Swedish Ethical Review Authority (approval number: 2018/45-31). Results: The following three analytic themes emerged from the meta-synthesis (studies: n=16; participants: n=164): (1) tools or strategies for supporting rehabilitation progress, (2) barriers and facilitators for the physical readiness to return to sport, and (3) barriers and facilitators for the psychological readiness to return to sport. Coping strategies, relaxation, and goal setting may have a positive effect on rehabilitation outcomes after ACL reconstruction (randomized controlled trials: n=7; participants: n=430). There were no trials of psychological support interventions for improving the return to sport. Eleven people completed phase 1 of feasibility testing (technical assessment) and identified 4 types of software errors, which we fixed. Six participants completed the feasibility and usability testing phase. Their feedback suggested that the intervention was easy to access and addressed the needs of athletes who want to return to sport after ACL reconstruction. We refined the intervention to include more multimedia content and support access to and the use of the intervention features. Conclusions: The Back in the Game intervention is a 24-week, internet-delivered, self-guided program that comprises 7 modules that complement usual rehabilitation, changes focus as rehabilitation progresses, is easy to access and use, and includes different psychological support strategies. UR - https://formative.jmir.org/2022/8/e28851 UR - http://dx.doi.org/10.2196/28851 UR - http://www.ncbi.nlm.nih.gov/pubmed/35943769 ID - info:doi/10.2196/28851 ER - TY - JOUR AU - Ammann-Reiffer, Corinne AU - Kläy, Andrina AU - Keller, Urs PY - 2022/7/14 TI - Virtual Reality as a Therapy Tool for Walking Activities in Pediatric Neurorehabilitation: Usability and User Experience Evaluation JO - JMIR Serious Games SP - e38509 VL - 10 IS - 3 KW - rehabilitation KW - pediatric KW - child KW - adolescent KW - walking KW - feasibility study KW - virtual reality KW - head-mounted display KW - therapy KW - tool KW - user KW - usability KW - visual KW - auditory KW - feedback KW - youth N2 - Background: Many essential walking activities in daily life, such as crossing a street, are challenging to practice in conventional therapeutic settings. Virtual environments (VEs) delivered through a virtual reality (VR) head-mounted display (HMD) would allow training such activities in a safe and attractive environment. Furthermore, the game-like character and high degree of immersion in these applications might help maintain or increase children?s motivation and active participation during the rehabilitation process. Objective: This study aimed to investigate the usability, user experience, and acceptability of an immersive VE experienced through a VR HMD to train everyday life walking activities in pediatric neurorehabilitation. Methods: In a cross-sectional study, 21 youths (median age 12.1 years; range 6.8-17.7 years) with a neuromotor impairment undergoing inpatient or outpatient neurorehabilitation tested a VE experienced through the VR HMD Oculus Quest. The participants, accompanied by their physiotherapists, moved freely around a 4.4 by 10-meter VE, displaying a magical forest and featuring various gamified everyday activities in different game designs. Using their hands, represented in the VE, the participants could interact with the virtual objects placed throughout the VE and trigger visual and auditory feedback. Symptoms of cybersickness were checked, and usability, user experience, and acceptability were evaluated using customized questionnaires with a visual analog scale for youths and a 5-point Likert scale for their therapists. Results: None of the participants reported any signs of cybersickness after 20 minutes of VR HMD exposure time. They rated comfort (median 10/10) and movement ability (median 10/10) with the VR HMD as high. The VE was perceived as being really there by the majority (median 8/10), and the participants had a strong feeling of spatial presence in the VE (median 9.5/10). They enjoyed exploring the virtual world (median 10/10) and liked this new therapy approach (median 10/10). Therapists? acceptance of the VR HMD was high (4/5). There were 5 patients that needed more support than usual, mainly for supervision, when moving around with the VR HMD. Otherwise, therapists felt that the VR HMD hardly affected their patients? movement behavior (median 4.75/5), whereas it seemed to increase their level of therapy engagement (median 4/5) compared to conventional physiotherapy sessions. Conclusions: This study demonstrates the usability of an immersive VE delivered through a VR HMD to engage youths in the training of everyday walking activities.The participants? and therapists? positive ratings on user experience and acceptance further support the promising application of this technology as a future therapeutic tool in pediatric neurorehabilitation. UR - https://games.jmir.org/2022/3/e38509 UR - http://dx.doi.org/10.2196/38509 UR - http://www.ncbi.nlm.nih.gov/pubmed/35834316 ID - info:doi/10.2196/38509 ER - TY - JOUR AU - Chang, Chien-Hsiang AU - Yeh, Chung-Hsing AU - Chang, Chien-Cheng AU - Lin, Yang-Cheng PY - 2022/7/14 TI - Interactive Somatosensory Games in Rehabilitation Training for Older Adults With Mild Cognitive Impairment: Usability Study JO - JMIR Serious Games SP - e38465 VL - 10 IS - 3 KW - dementia KW - elderly KW - usability KW - gesture recognition KW - card recognition rehabilitation KW - interactive somatosensory game N2 - Background: In aging societies, dementia risk increases with advancing age, increasing the incidence of dementia-related degenerative diseases and other complications, especially fall risk. Dementia also escalates the care burden, impacting patients, their families, social welfare institutions, and the social structure and medical system. Objective: In elderly dementia, traditional card recognition rehabilitation (TCRR) does not effectively increase one?s autonomy. Therefore, from the usability perspective, we used the Tetris game as a reference to develop an interactive somatosensory game rehabilitation (ISGR) with nostalgic style for elders with mild cognitive impairment (MCI). Through intuitive gesture-controlled interactive games, we evaluated subjective feelings concerning somatosensory game integration into rehabilitation to explore whether the ISGR could improve the willingness to use and motivation for rehabilitation among elders with MCI. Methods: A total of 15 elders with MCI (7 males and 8 females with an average age of 78.4 years) underwent 2 experiments for 15 minutes. During experiment 1, TCRR was performed, followed by completing the questionnaire of the System Usability Scale (SUS). After 3-5 minutes, the second experiment (the ISGR) was conducted, followed by completing another SUS. We used SUS to explore differences in impacts of TCRR and ISGR on willingness to use among elders with MCI. In addition, we further investigated whether the factor of gender or prior rehabilitation experience would affect the rehabilitation willingness or not. Results: The novel ISGR made the elderly feel interested and improved their willingness for continuous rehabilitation. According to the overall SUS score, the ISGR had better overall usability performance (73.7) than the TCRR (58.0) (t28=?4.62, P<.001). Furthermore, the ISGR individual item scores of ?Willingness to Use? (t28=?8.27, P<.001), ?Easy to Use? (t28=?3.17, P<.001), ?System Integration? (t28=?5.07, P<.001), and ?Easy to Learn? (t28=?2.81, P<.001) were better than TCRR. The somatosensory game was easier to learn and master for females than for males (t13=2.71, P=.02). Besides, the ISGR was easier to use (t12=?2.50, P=.02) and learn (t14=?3.33, P<.001) for those without prior rehabilitation experience. The result indicates that for elders with no rehabilitation experience ISGR was easier to use and simpler to learn than TCRR. Conclusions: Regardless of prior rehabilitation experience, the ISGR developed in this study was easy to learn and effective in continuously improving willingness to use. Furthermore, the adoption of a nostalgic game design style served the function of cognitive training and escalated interest in rehabilitation. The ISGR also improved user stickiness by introducing different game scenarios and difficulties, increasing long-term interest and motivation for rehabilitation. For future research on the adoption of interactive somatosensory games in rehabilitation, additional rehabilitation movements can be developed to benefit the elderly with MCI. UR - https://games.jmir.org/2022/3/e38465 UR - http://dx.doi.org/10.2196/38465 UR - http://www.ncbi.nlm.nih.gov/pubmed/35834303 ID - info:doi/10.2196/38465 ER - TY - JOUR AU - Leng, Yan AU - Lo, Ambrose Wai Leung AU - Mao, Rong Yu AU - Bian, Ruihao AU - Zhao, Li Jiang AU - Xu, Zhiqin AU - Li, Le AU - Huang, Feng Dong PY - 2022/7/8 TI - The Impact of Cognitive Function on Virtual Reality Intervention for Upper Extremity Rehabilitation of Patients With Subacute Stroke: Prospective Randomized Controlled Trial With 6-Month Follow-up JO - JMIR Serious Games SP - e33755 VL - 10 IS - 3 KW - stroke KW - motor function of upper extremity KW - virtual reality KW - cognitive function N2 - Background: Stroke is among the leading causes of long-term disability worldwide. Motor impairments after stroke not only impact the individuals quality of life but also lay substantial burdens on the society. Motor planning is a key component of cognitive function that impacts motor control. Hand movements such as grasping or reaching to grasp require the application of correct force and the coordination of multiple limb segments. Successful completion of hand motor task requires a certain degree of cognitive function to anticipate the requirement of the task. Cognitive function may thus be a confounding factor to rehabilitation outcomes. Objective: This study aims to explore the impact of cognitive function on functional outcomes in people with subacute stroke after VR intervention. Methods: Patients with stroke were first stratified into cognitively normal (CN) and cognitively impaired (CI), followed by allocation to the VR or control group (CG). Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Barthel Index (BI), and Instrumental Activities of Daily Living (IADL) were recorded at baseline, 3 weeks after the intervention, and 3 and 6 months after the intervention. The between-group and within-group differences were assessed by repeated-measures analysis of variance (ANOVA). Results: The between-group comparison indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) scores improved significantly in both groups after the intervention. Repeated-measures ANOVA indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) were significantly different in each subgroup after the intervention. For BI score, the ANOVA results showed obvious interaction effects (treatment × time × cognitive effect, P=.04). Conclusions: VR intervention was as effective as traditional conventional therapy in improving upper limb function regardless of the cognitive functional level. Patients with stroke with impaired cognitive function may gain more improvement in upper limb function and independency in performing activities of daily living after a VR-based intervention. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IOC-15006064; https://tinyurl.com/4c9vkrrn UR - https://games.jmir.org/2022/3/e33755 UR - http://dx.doi.org/10.2196/33755 UR - http://www.ncbi.nlm.nih.gov/pubmed/35802415 ID - info:doi/10.2196/33755 ER - TY - JOUR AU - Allegue, Rakia Dorra AU - Higgins, Johanne AU - Sweet, N. Shane AU - Archambault, S. Philippe AU - Michaud, Francois AU - Miller, William AU - Tousignant, Michel AU - Kairy, Dahlia PY - 2022/6/22 TI - Rehabilitation of Upper Extremity by Telerehabilitation Combined With Exergames in Survivors of Chronic Stroke: Preliminary Findings From a Feasibility Clinical Trial JO - JMIR Rehabil Assist Technol SP - e33745 VL - 9 IS - 2 KW - stroke KW - rehabilitation KW - virtual reality KW - video games KW - telerehabilitation KW - upper extremity KW - motivation KW - mHealth KW - mobile health KW - personalized care KW - stroke rehabilitation N2 - Background: Exergames are increasingly being used among survivors of stroke with chronic upper extremity (UE) sequelae to continue exercising at home after discharge and maintain activity levels. The use of virtual reality exergames combined with a telerehabilitation app (VirTele) may be an interesting alternative to rehabilitate the UE sequelae in survivors of chronic stroke while allowing for ongoing monitoring with a clinician. Objective: This study aimed to determine the feasibility of using VirTele in survivors of chronic stroke at home and explore the impact of VirTele on UE motor function, quantity and quality of use, quality of life, and motivation in survivors of chronic stroke compared with conventional therapy. Methods: This study was a 2-arm feasibility clinical trial. Eligible participants were randomly allocated to an experimental group (receiving VirTele for 8 weeks) or a control group (receiving conventional therapy for 8 weeks). Feasibility was measured from the exergame and intervention logs completed by the clinician. Outcome measurements included the Fugl-Meyer Assessment-UE, Motor Activity Log-30, Stroke Impact Scale-16, and Treatment Self-Regulation Questionnaire-15, which were administered to both groups at four time points: time point 1 (T1; before starting the intervention), time point 2 (after the intervention), time point 3 (1 month after the intervention), and time point 4 (T4; 2 months after the intervention). Results: A total of 11 survivors of stroke were randomized and allocated to an experimental or a control group. At the onset of the COVID-19 pandemic, participants pursued the allocated treatment for 3 months instead of 8 weeks. VirTele intervention dose was captured in terms of time spent on exergames, frequency of use of exergames, total number of successful repetitions, and frequency of videoconference sessions. Technical issues included the loss of passwords, internet issues, updates of the system, and problems with the avatar. Overall, most survivors of stroke found the technology easy to use and useful, except for 9% (1/11) of participants. For the Fugl-Meyer Assessment-UE and Motor Activity Log-30, both groups exhibited an improvement in >50% of the participants, which was maintained over time (from time point 3 to T4). Regarding Stroke Impact Scale-16 scores, the control group reported improvement in activities of daily life (3/5, 60%), hand function (5/5, 100%), and mobility (2/5, 40%), whereas the experimental group reported varied and inconclusive results (from T1 to T4). For the Treatment Self-Regulation Questionnaire-15, 75% (3/4) of the experimental group demonstrated an increase in the autonomous motivation score (from T1 to time point 2), whereas, in the control group, this improvement was observed in only 9% (1/11) of participants. Conclusions: The VirTele intervention constitutes another therapeutic alternative, in addition to conventional therapy, to deliver an intense personalized rehabilitation program for survivors of chronic stroke with UE sequelae. International Registered Report Identifier (IRRID): RR2-10.2196/14629 UR - https://rehab.jmir.org/2022/2/e33745 UR - http://dx.doi.org/10.2196/33745 UR - http://www.ncbi.nlm.nih.gov/pubmed/35731560 ID - info:doi/10.2196/33745 ER - TY - JOUR AU - Knobel, Johannes Samuel Elia AU - Kaufmann, Charlotte Brigitte AU - Geiser, Nora AU - Gerber, Moreno Stephan AU - Müri, M. René AU - Nef, Tobias AU - Nyffeler, Thomas AU - Cazzoli, Dario PY - 2022/5/25 TI - Effects of Virtual Reality?Based Multimodal Audio-Tactile Cueing in Patients With Spatial Attention Deficits: Pilot Usability Study JO - JMIR Serious Games SP - e34884 VL - 10 IS - 2 KW - virtual reality KW - search task KW - stroke KW - neglect, multimodal cueing KW - bird search task N2 - Background: Virtual reality (VR) devices are increasingly being used in medicine and other areas for a broad spectrum of applications. One of the possible applications of VR involves the creation of an environment manipulated in a way that helps patients with disturbances in the spatial allocation of visual attention (so-called hemispatial neglect). One approach to ameliorate neglect is to apply cross-modal cues (ie, cues in sensory modalities other than the visual one, eg, auditory and tactile) to guide visual attention toward the neglected space. So far, no study has investigated the effects of audio-tactile cues in VR on the spatial deployment of visual attention in neglect patients. Objective: This pilot study aimed to investigate the feasibility and usability of multimodal (audio-tactile) cueing, as implemented in a 3D VR setting, in patients with neglect, and obtain preliminary results concerning the effects of different types of cues on visual attention allocation compared with noncued conditions. Methods: Patients were placed in a virtual environment using a head-mounted display (HMD). The inlay of the HMD was equipped to deliver tactile feedback to the forehead. The task was to find and flag appearing birds. The birds could appear at 4 different presentation angles (lateral and paracentral on the left and right sides), and with (auditory, tactile, or audio-tactile cue) or without (no cue) a spatially meaningful cue. The task usability and feasibility, and 2 simple in-task measures (performance and early orientation) were assessed in 12 right-hemispheric stroke patients with neglect (5 with and 7 without additional somatosensory impairment). Results: The new VR setup showed high usability (mean score 10.2, SD 1.85; maximum score 12) and no relevant side effects (mean score 0.833, SD 0.834; maximum score 21). A repeated measures ANOVA on task performance data, with presentation angle, cue type, and group as factors, revealed a significant main effect of cue type (F30,3=9.863; P<.001) and a significant 3-way interaction (F90,9=2.057; P=.04). Post-hoc analyses revealed that among patients without somatosensory impairment, any cue led to better performance compared with no cue, for targets on the left side, and audio-tactile cues did not seem to have additive effects. Among patients with somatosensory impairment, performance was better with both auditory and audio-tactile cueing than with no cue, at every presentation angle; conversely, tactile cueing alone had no significant effect at any presentation angle. Analysis of early orientation data showed that any type of cue triggered better orientation in both groups for lateral presentation angles, possibly reflecting an early alerting effect. Conclusions: Overall, audio-tactile cueing seems to be a promising method to guide patient attention. For instance, in the future, it could be used as an add-on method that supports attentional orientation during established therapeutic approaches. UR - https://games.jmir.org/2022/2/e34884 UR - http://dx.doi.org/10.2196/34884 UR - http://www.ncbi.nlm.nih.gov/pubmed/35612894 ID - info:doi/10.2196/34884 ER - TY - JOUR AU - Wu, Wen-Lan AU - Huang, Yu-Ling AU - Liang, Jing-Min AU - Chen, Chia-Hsin AU - Wang, Chih-Chung AU - Ho, Wen-Hsien PY - 2022/4/15 TI - Interactive Digital Game for Improving Visual?Perceptual Defects in Children With a Developmental Disability: Randomized Controlled Trial JO - JMIR Serious Games SP - e34756 VL - 10 IS - 2 KW - interactive digital game KW - visual?perceptual defect KW - developmental disability KW - Children KW - Test of Visual Perceptual Skills KW - rehabilitation N2 - Background: Visual?perceptual defects in children can negatively affect their ability to perform activities of daily living. Conventional rehabilitation training for correcting visual?perceptual defects has limited training patterns and limited interactivity, which makes motivation difficult to sustain. Objective: We aimed to develop and evaluate an interactive digital game system for correcting visual?perceptual defects and evaluate its effectiveness. Methods: Participants were children aged 5 to 10 years with a diagnosis of visual?perceptual defect associated with a developmental disability. The children were randomized into a digital game group who received the traditional course of rehabilitation combined with an interactive digital game intervention (n=12) and a standard rehabilitation group (n=11) who only received the traditional course of rehabilitation. Each group underwent rehabilitation once a week for 4 weeks. Overall improvement in Test of Visual Perceptual Skills 3rd edition (TVPS-3) score and overall improvement in performance in the interactive digital game were evaluated. Parents and therapists were asked to complete a satisfaction questionnaire. Results: After 4 weeks, the TVPS-3 score had significantly increased (P=.002) in the digital game group (pre: mean 41.67, SD 13.88; post: 61.50, SD 21.64). In the standard rehabilitation group, the TVPS-3 score also increased, but the increase was not statistically significant (P=.58). Additionally, TVPS-3 score increases were significantly larger for the digital game group compared with those for the standard rehabilitation group (P=.005). Moreover, both parents and therapists were highly satisfied with the system. All 5 themes of satisfaction had mean scores higher than 4 in a 5-point scale questionnaire (mean 4.30, SD 0.56). Conclusions: The system has potential applications for improving visual?perceptual function in children undergoing medical rehabilitation for developmental disability. Trial Registration: ClinicalTrials.gov NCT05016492; http://clinicaltrials.gov/ct2/show/NCT05016492 UR - https://games.jmir.org/2022/2/e34756 UR - http://dx.doi.org/10.2196/34756 UR - http://www.ncbi.nlm.nih.gov/pubmed/35436215 ID - info:doi/10.2196/34756 ER - TY - JOUR AU - Peebles, T. Alexander AU - van der Veen, Susanne AU - Stamenkovic, Alexander AU - France, R. Christopher AU - Pidcoe, E. Peter AU - Thomas, S. James PY - 2022/3/23 TI - A Virtual Reality Game Suite for Graded Rehabilitation in Patients With Low Back Pain and a High Fear of Movement: Within-Subject Comparative Study JO - JMIR Serious Games SP - e32027 VL - 10 IS - 1 KW - virtual reality KW - reaching KW - intervention KW - rehabilitation KW - exergaming KW - biomechanics KW - serious games KW - gamification KW - movement KW - physiotherapy KW - lumbar N2 - Background: Complex movement pathologies that are biopsychosocial in nature (eg, back pain) require a multidimensional approach for effective treatment. Virtual reality is a promising tool for rehabilitation, where therapeutic interventions can be gamified to promote and train specific movement behaviors while increasing enjoyment, engagement, and retention. We have previously created virtual reality?based tools to assess and promote lumbar excursion during reaching and functional gameplay tasks by manipulating the position of static and dynamic contact targets. Based on the framework of graded exposure rehabilitation, we have created a new virtual reality therapy aimed to alter movement speed while retaining the movement-promoting features of our other developments. Objective: This study aims to compare lumbar flexion excursion and velocity across our previous and newly developed virtual reality tools in a healthy control cohort. Methods: A total of 31 healthy participants (16 males, 15 females) took part in 3 gamified virtual reality therapies (ie, Reachality, Fishality, and Dodgeality), while whole-body 3D kinematics were collected at 100 Hz using a 14-camera motion capture system. Lumbar excursion, lumbar flexion velocity, and actual target impact location in the anterior and vertical direction were compared across each virtual reality task and between the 4 anthropometrically defined intended target impact locations using separate 2-way repeated measures analysis of variance models. Results: There was an interaction between game and impact height for each outcome (all P<.001). Post-hoc simple effects models revealed that lumbar excursion was reduced during Reachality and Fishality relative to that during Dodgeality for the 2 higher impact heights but was greater during Reachality than during Fishality and Dodgeality for the lowest impact height. Peak lumbar flexion velocity was greater during Dodgeality than during Fishality and Reachality across heights. Actual target impact locations during Dodgeality and Fishality were lower relative to those during Reachality at higher intended impact locations but higher at lower intended impact locations. Finally, actual target impact location was further in the anterior direction for Reachality compared to that for Fishality and for Fishality relative to that for Dodgeality. Conclusions: Lumbar flexion velocity was reduced during Fishality relative to that during Dodgeality and resembled velocity demands more similar to those for a self-paced reaching task (ie, Reachality). Additionally, lumbar motion and target impact location during Fishality were more similar to those during Reachality than to those during Dodgeality, which suggests that this new virtual reality game is an effective tool for shaping movement. These findings are encouraging for future research aimed at developing an individualized and graded virtual reality intervention for patients with low back pain and a high fear of movement. UR - https://games.jmir.org/2022/1/e32027 UR - http://dx.doi.org/10.2196/32027 UR - http://www.ncbi.nlm.nih.gov/pubmed/35319471 ID - info:doi/10.2196/32027 ER - TY - JOUR AU - Wiskerke, Evelyne AU - Kool, Jan AU - Hilfiker, Roger AU - Sattelmayer, Martin Karl AU - Verheyden, Geert PY - 2022/3/22 TI - Determining the Optimal Virtual Reality Exergame Approach for Balance Therapy in Persons With Neurological Disorders Using a Rasch Analysis: Longitudinal Observational Study JO - JMIR Serious Games SP - e30366 VL - 10 IS - 1 KW - digital therapeutics KW - virtual reality KW - exergaming KW - balance KW - stroke KW - multiple sclerosis KW - neurorehabilitation KW - Rasch analysis N2 - Background: Virtual reality (VR) exergames have gained popularity in the rehabilitation of persons with neurological disorders as an add-on therapy to increase intensity of training. Intensity is strongly dependent on the motivation of the patient. Motivation can be increased by delivering variation within training and challenging exercises. However, patients are often underchallenged, as exergame difficulty often does not match the patient?s ability. A Rasch analysis can establish hierarchy of exergame items in order to assist the delivery of patient-centered therapy. Objective: The aim of this study was to apply the Rasch model to create a hierarchical order of existing VR balance exergames and to relate these exergames to the abilities of persons with neurological disorders, in order to deliver challenge and variation. Methods: A total of 30 persons with stroke and 51 persons with multiple sclerosis (MS) were included in the study. All participants performed a training program, lasting 3 weeks for persons with MS and 4 weeks for persons with stroke, in which they performed VR balance exergames with a movement recognition?based system (MindMotion GO; MindMaze SA). VR exercise scores, Berg Balance Scale scores, and clinical descriptive data were collected. Berg Balance Scale and device scores were analyzed with the Rasch model using a repeated-measures approach to examine whether the distribution of exercise scores fitted the Rasch model. Secondly, a person-item map was created to show the hierarchy of exercise difficulty and person ability. Results: Participants completed a selection of 56 balance exercises (ie, items), which consisted of a combination of various balance tasks and levels (ie, exercises). Using repeated measures, this resulted in a count of 785 observations. Analysis showed strong evidence for unidimensionality of the data. A total of 47 exercises (ie, items) had a sufficiently good fit to the Rasch model. Six items showed underfit, with outfit mean square values above 1.5. One item showed underfit but was kept in the analysis. Three items had negative point-biserial correlations. The final model consisted of 47 exercises, which were provided for persons with low to moderate balance ability. Conclusions: The VR exercises sufficiently fitted the Rasch model and resulted in a hierarchical order of VR balance exercises for persons with stroke and MS with low to moderate balance ability. In combination with the Berg Balance Scale, the results can guide clinical decision-making in the selection of patient-focused VR balance exercises. Trial Registration: ClinicalTrials.gov NCT03993275; https://clinicaltrials.gov/ct2/show/NCT03993275 UR - https://games.jmir.org/2022/1/e30366 UR - http://dx.doi.org/10.2196/30366 UR - http://www.ncbi.nlm.nih.gov/pubmed/35315785 ID - info:doi/10.2196/30366 ER - TY - JOUR AU - Sawa, Ryuichi AU - Saitoh, Masakazu AU - Morisawa, Tomoyuki AU - Takahashi, Tetsuya AU - Morimoto, Yuh AU - Kagiyama, Nobuyuki AU - Kasai, Takatoshi AU - Dinesen, Birthe AU - Daida, Hiroyuki PY - 2022/3/18 TI - The Potential Application of Commercially Available Active Video Games to Cardiac Rehabilitation: Scoping Review JO - JMIR Serious Games SP - e31974 VL - 10 IS - 1 KW - active video game KW - cardiac rehabilitation KW - physical exercise KW - rehabilitation KW - serious games KW - CVD KW - AVG KW - cardiovascular disease KW - exercise KW - safety KW - adherence N2 - Background: Commercially available active video games (AVGs) have recently been used for rehabilitation in some specific patient populations but rarely in those with cardiovascular disease (CVD). Commercially available AVGs are designed to increase motivation for continuous play, which could be applicable to the long-term cardiac rehabilitation process. Objective: The objective of this scoping review was to assess the effectiveness of AVG-induced physical exercise, safety management, and patient adherence by applying commercially available AVGs to cardiac rehabilitation. Methods: Four databases (CINAHL, MEDLINE, PubMed, and SPORTDiscus) were searched for all years up to August 12, 2020. Articles were retained if they were written in English, included patients with CVD who were aged 18 years or older, and used AVGs as part of a physical exercise program. The included studies were then evaluated from the viewpoints of effectiveness as physical exercise, safety, and adherence management. Results: Among 120 nonduplicate articles reviewed, 5 (4.2%) were eligible for inclusion, of which 3 (2.5%) were reported by the same research group. The AVG consoles used were Xbox Kinect and Nintendo Wii, and sports-related programs were adopted for the intervention. No adverse cardiac events occurred in the identified studies, and dropout rates tended to be low. Conclusions: AVGs appear to be safe and feasible for promoting an active lifestyle in patients with CVD. However, the effectiveness of AVGs alone as a therapeutic exercise to improve physical function may be limited. UR - https://games.jmir.org/2022/1/e31974 UR - http://dx.doi.org/10.2196/31974 UR - http://www.ncbi.nlm.nih.gov/pubmed/35302503 ID - info:doi/10.2196/31974 ER - TY - JOUR AU - Barak Ventura, Roni AU - Stewart Hughes, Kora AU - Nov, Oded AU - Raghavan, Preeti AU - Ruiz Marín, Manuel AU - Porfiri, Maurizio PY - 2022/2/10 TI - Data-Driven Classification of Human Movements in Virtual Reality?Based Serious Games: Preclinical Rehabilitation Study in Citizen Science JO - JMIR Serious Games SP - e27597 VL - 10 IS - 1 KW - motion analysis KW - principal component analysis KW - telerehabilitation KW - virtual reality N2 - Background: Sustained engagement is essential for the success of telerehabilitation programs. However, patients? lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science?based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR). Objective: This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert. Methods: In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users? range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software?s response to their movements. During calibration, the time series of the users? movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements. Results: The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%). Conclusions: Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation. UR - https://games.jmir.org/2022/1/e27597 UR - http://dx.doi.org/10.2196/27597 UR - http://www.ncbi.nlm.nih.gov/pubmed/35142629 ID - info:doi/10.2196/27597 ER - TY - JOUR AU - Vinolo Gil, Jesus Maria AU - Gonzalez-Medina, Gloria AU - Lucena-Anton, David AU - Perez-Cabezas, Veronica AU - Ruiz-Molinero, Carmen María Del AU - Martín-Valero, Rocío PY - 2021/12/15 TI - Augmented Reality in Physical Therapy: Systematic Review and Meta-analysis JO - JMIR Serious Games SP - e30985 VL - 9 IS - 4 KW - augmented reality KW - physical therapy KW - rehabilitation KW - functionality N2 - Background: Augmented reality (AR) is a rapidly expanding technology; it comprises the generation of new images from digital information in the real physical environment of a person, which simulates an environment where the artificial and real are mixed. The use of AR in physiotherapy has shown benefits in certain areas of patient health. However, these benefits have not been studied as a whole. Objective: This study aims to ascertain the current scientific evidence on AR therapy as a complement to physiotherapy and to determine the areas in which it has been used the most and which variables and methods have been most effective. Methods: A systematic review registered in PROSPERO (International Prospective Register of Systematic Reviews) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta?Analyses) recommendations. The search was conducted from July to August 2021 in the PubMed, PEDro, Web of Science, Scopus, and Cochrane Library scientific databases using the keywords augmented reality, physiotherapy, physical therapy, exercise therapy, rehabilitation, physical medicine, fitness, and occupational therapy. The methodological quality was evaluated using the PEDro scale and the Scottish Intercollegiate Guidelines Network scale to determine the degree of recommendation. The Cochrane Collaboration tool was used to evaluate the risk of bias. Results: In total, 11 articles were included in the systematic review. Of the 11 articles, 4 (36%) contributed information to the meta-analysis. Overall, 64% (7/11) obtained a good level of evidence, and most had a B degree of recommendation of evidence. A total of 308 participants were analyzed. Favorable results were found for the Berg Balance Scale (standardized mean change 0.473, 95% CI ?0.0877 to 1.0338; z=1.65; P=.10) and the Timed Up and Go test (standardized mean change ?1.211, 95% CI ?3.2005 to 0.7768; z=?1.194; P=.23). Conclusions: AR, in combination with conventional therapy, has been used for the treatment of balance and fall prevention in geriatrics, lower and upper limb functionality in stroke, pain in phantom pain syndrome, and turning in place in patients with Parkinson disease with freezing of gait. AR is effective for the improvement of balance; however, given the small size of the samples and the high heterogeneity of the studies, the results were not conclusive. Future studies using larger sample sizes and with greater homogeneity in terms of the devices used and the frequency and intensity of the interventions are needed. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020180766; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=180766 UR - https://games.jmir.org/2021/4/e30985 UR - http://dx.doi.org/10.2196/30985 UR - http://www.ncbi.nlm.nih.gov/pubmed/34914611 ID - info:doi/10.2196/30985 ER - TY - JOUR AU - Li, Chong AU - Song, Xinyu AU - Chen, Shugeng AU - Wang, Chuankai AU - He, Jieying AU - Zhang, Yongli AU - Xu, Shuo AU - Yan, Zhijie AU - Jia, Jie AU - Shull, Peter PY - 2021/11/23 TI - Long-term Effectiveness and Adoption of a Cellphone Augmented Reality System on Patients with Stroke: Randomized Controlled Trial JO - JMIR Serious Games SP - e30184 VL - 9 IS - 4 KW - stroke KW - augmented reality KW - serious game KW - upper limb motor function KW - cognitive function KW - home-based rehabilitation N2 - Background: A serious game?based cellphone augmented reality system (CARS) was developed for rehabilitation of stroke survivors, which is portable, convenient, and suitable for self-training. Objective: This study aims to examine the effectiveness of CARS in improving upper limb motor function and cognitive function of stroke survivors via conducting a long-term randomized controlled trial and analyze the patient?s acceptance of the proposed system. Methods: A double-blind randomized controlled trial was performed with 30 poststroke, subacute phase patients. All patients in both the experimental group (n=15) and the control group (n=15) performed a 1-hour session of therapy each day, 5 days per week for 2 weeks. Patients in the experimental group received 30 minutes of rehabilitation training with CARS and 30 minutes of conventional occupational therapy (OT) each session, while patients in the control group received conventional OT for the full 1 hour each session. The Fugl-Meyer Assessment of Upper Extremity (FMA-UE) subscale, Action Research Arm Test (ARAT), manual muscle test and Brunnstrom stage were used to assess motor function; the Mini-Mental State Examination, Add VS Sub, and Stroop Game were used to assess cognitive function; and the Barthel index was used to assess activities of daily living before and after the 2-week treatment period. In addition, the User Satisfaction Evaluation Questionnaire was used to reflect the patients? adoption of the system in the experimental group after the final intervention. Results: All the assessment scores of the experimental group and control group were significantly improved after intervention. After the intervention. The experimental group?s FMA-UE and ARAT scores increased by 11.47 and 5.86, respectively, and were both significantly higher than the increase of the control group. Similarly, the score of the Add VS Sub and Stroop Game in the experimental group increased by 7.53 and 6.83, respectively, after the intervention, which also represented a higher increase than that in the control group. The evaluation of the adoption of this system had 3 sub-dimensions. In terms of accessibility, the patients reported a mean score of 4.27 (SD 0.704) for the enjoyment of their experience with the system, a mean 4.33 (SD 0.816) for success in using the system, and a mean 4.67 (SD 0.617) for the ability to control the system. In terms of comfort, the patients reported a mean 4.40 (SD 0.737) for the clarity of information provided by the system and a mean 4.40 (SD 0.632) for comfort. In terms of acceptability, the patients reported a mean 4.27 (SD 0.884) for usefulness in their rehabilitation and a mean 4.67 (0.617) in agreeing that CARS is a suitable tool for home-based rehabilitation. Conclusions: The rehabilitation based on combined CARS and conventional OT was more effective in improving both upper limb motor function and cognitive function than was conventional OT. Due to the low cost and ease of use, CARS is also potentially suitable for home-based rehabilitation. Trial Registration: Chinese Clinical Trial Registry ChiCTR1800017568; https://tinyurl.com/xbkkyfyz UR - https://games.jmir.org/2021/4/e30184 UR - http://dx.doi.org/10.2196/30184 UR - http://www.ncbi.nlm.nih.gov/pubmed/34817390 ID - info:doi/10.2196/30184 ER - TY - JOUR AU - Ambros-Antemate, Fernando Jorge AU - Beristain-Colorado, Pilar María Del AU - Vargas-Treviño, Marciano AU - Gutiérrez-Gutiérrez, Jaime AU - Hernández-Cruz, Antonio Pedro AU - Gallegos-Velasco, Belem Itandehui AU - Moreno-Rodríguez, Adriana PY - 2021/11/11 TI - Software Engineering Frameworks Used for Serious Games Development in Physical Rehabilitation: Systematic Review JO - JMIR Serious Games SP - e25831 VL - 9 IS - 4 KW - serious game KW - physical rehabilitation KW - framework KW - methodology N2 - Background: Serious games are a support in the rehabilitation process for treating people with physical disabilities. However, many of these serious games are not adapted to the patient?s needs because they are not developed with a software engineering framework with a set of activities, actions, and tasks that must be executed when creating a software product. Better serious games for rehabilitation will be developed if the patient and therapist requirements are identified, the development is planned, and system improvements and feedback are involved. The goal is that the serious game must offer a more attractive environment, while maintaining patient interest in the rehabilitation process. Objective: This paper submits the results of a systematic review of serious games in physical rehabilitation identifying the benefits of using a software engineering framework. Methods: A systematic research was conducted using PubMed, PEDro (Physiotherapy Evidence Database), IEEE Xplore, ScienceDirect, ACM Digital Library, Mary Ann Liebert, Taylor & Francis Online, Wiley Online Library, and Springer databases. The initial search resulted in 701 papers. After assessing the results according to the inclusion criteria, 83 papers were selected for this study. Results: From the 83 papers reviewed, 8 used a software engineering framework for its development. Most of them focused their efforts on 1 or more aspects, such as data acquisition and processing, game levels, motivation, therapist supervision. Conclusions: This systematic review proves that most of the serious games do not use a software engineering framework for their development. As a result, development systems overlook several aspects and do not have a standardized process, eventually omitting important implementation aspects, which impact the patient?s recovery time. UR - https://games.jmir.org/2021/4/e25831 UR - http://dx.doi.org/10.2196/25831 UR - http://www.ncbi.nlm.nih.gov/pubmed/34762052 ID - info:doi/10.2196/25831 ER - TY - JOUR AU - Garske, Alexander Christian AU - Dyson, Matthew AU - Dupan, Sigrid AU - Morgan, Graham AU - Nazarpour, Kianoush PY - 2021/11/8 TI - Serious Games Are Not Serious Enough for Myoelectric Prosthetics JO - JMIR Serious Games SP - e28079 VL - 9 IS - 4 KW - rehabilitation KW - serious games KW - engagement KW - transfer KW - upper limb KW - arm prosthesis KW - virtual training KW - virtual games UR - https://games.jmir.org/2021/4/e28079 UR - http://dx.doi.org/10.2196/28079 UR - http://www.ncbi.nlm.nih.gov/pubmed/34747715 ID - info:doi/10.2196/28079 ER - TY - JOUR AU - Thorarinsdottir, Kristjana AU - Holmes, A. Emily AU - Hardarson, Johann AU - Hedinsdottir, Unnur AU - Kanstrup, Marie AU - Singh, Laura AU - Hauksdottir, Arna AU - Halldorsdottir, Thorhildur AU - Gudmundsdottir, Berglind AU - Valdimarsdottir, Unnur AU - Thordardottir, Bjork Edda AU - Gamble, Beau AU - Bjornsson, Andri PY - 2021/11/4 TI - Reducing Intrusive Memories of Childhood Trauma Using a Visuospatial Intervention: Case Study in Iceland JO - JMIR Form Res SP - e29873 VL - 5 IS - 11 KW - psychological trauma KW - intrusive memories KW - case report KW - visuospatial interference task KW - Tetris gameplay KW - mental imagery KW - mobile phone N2 - Background: Additional interventions are needed for survivors of psychological trauma because of several barriers to and limitations of existing treatment options (eg, need to talk about the trauma in detail). Case studies are an important step in exploring the development of novel interventions, allowing detailed examination of individual responses to treatment over time. Here, we present a case study that aims to test a novel intervention designed to disrupt memory reconsolidation, taking a single-symptom approach by focusing on intrusive memories of a traumatic event. Objective: This study aims to examine a novel brief cognitive intervention to reduce the number of intrusive memories of trauma in an Icelandic setting and to extend previous studies by examining long-term effects for up to 3 months. The intervention was guided by a clinical psychologist and comprised a brief memory reminder, followed by Tetris gameplay with mental rotation, targeting one memory at a time in each session. Methods: This was a single case study in Iceland with a woman in her 50s (drawn from an epidemiological study of trauma) with subthreshold posttraumatic stress disorder and a diagnosis of obsessive-compulsive disorder and social anxiety disorder. The participant had four different intrusive memories from a traumatic event that happened in her childhood. The primary outcome was the change in the number of intrusive memories from baseline to intervention phase and to follow-ups. The number of intrusions was monitored in a daily diary for 4 weeks preintervention, 8 weeks during the intervention, and 1 week at 1-month and 3-month follow-ups. Intrusions were targeted one by one over six intervention sessions, creating four repetitions of an AB design (ie, length of baseline A and intervention phase B varied for each memory). We examined changes in both the total number of intrusions (summed across all four memories) and individually for each memory. In addition, we explored whether having fewer intrusive memories would have an impact on functioning, posttraumatic stress, and depression or anxiety symptoms. Results: The total number of intrusions per week was 12.6 at baseline, 6.1 at the intervention phase (52% reduction from baseline), 3.0 at the 1-month follow-up (76% reduction), and 1.0 at the 3-month follow-up (92% reduction). Reductions in the symptoms of posttraumatic stress and depression were observed postintervention. Sleep, concentration, stress, and functioning improved. The participant considered the gameplay intervention acceptable and helpful in that she found that the memories disappeared while she was playing. Conclusions: This guided brief cognitive intervention reduced the number of intrusive memories over the intervention phase and follow-ups. The brief memory reminder was well tolerated, removing the need to discuss trauma in detail. The next steps require an extension to more cases and exploring remote delivery of the intervention. UR - https://formative.jmir.org/2021/11/e29873 UR - http://dx.doi.org/10.2196/29873 UR - http://www.ncbi.nlm.nih.gov/pubmed/34734830 ID - info:doi/10.2196/29873 ER - TY - JOUR AU - Gagnon Shaigetz, Vincent AU - Proulx, Catherine AU - Cabral, Anne AU - Choudhury, Nusrat AU - Hewko, Mark AU - Kohlenberg, Elicia AU - Segado, Melanie AU - Smith, D. Michael S. AU - Debergue, Patricia PY - 2021/11/3 TI - An Immersive and Interactive Platform for Cognitive Assessment and Rehabilitation (bWell): Design and Iterative Development Process JO - JMIR Rehabil Assist Technol SP - e26629 VL - 8 IS - 4 KW - virtual reality KW - clinical psychology KW - cognitive assessment KW - neuropsychology KW - mental health KW - cognitive rehabilitation KW - digital therapeutics KW - mobile phone KW - cognitive training N2 - Background: Immersive technologies like virtual reality can enable clinical care that meaningfully aligns with real-world deficits in cognitive functioning. However, options in immersive 3D environments are limited, partly because of the unique challenges presented by the development of a clinical care platform. These challenges include selecting clinically relevant features, enabling tasks that capture the full breadth of deficits, ensuring longevity in a rapidly changing technology landscape, and performing the extensive technical and clinical validation required for digital interventions. Complicating development, is the need to integrate recommendations from domain experts at all stages. Objective: The Cognitive Health Technologies team at the National Research Council Canada aims to overcome these challenges with an iterative process for the development of bWell, a cognitive care platform providing multisensory cognitive tasks for adoption by treatment providers. Methods: The team harnessed the affordances of immersive technologies while taking an interdisciplinary research and developmental approach, obtaining active input from domain experts with iterative deliveries of the platform. The process made use of technology readiness levels, agile software development, and human-centered design to advance four main activities: identification of basic requirements and key differentiators, prototype design and foundational research to implement components, testing and validation in lab settings, and recruitment of external clinical partners. Results: bWell was implemented according to the findings from the design process. The main features of bWell include multimodal (fully, semi, or nonimmersive) and multiplatform (extended reality, mobile, and PC) implementation, configurable exercises that pair standardized assessment with adaptive and gamified variants for therapy, a therapist-facing user interface for task administration and dosing, and automated activity data logging. bWell has been designed to serve as a broadly applicable toolkit, targeting general aspects of cognition that are commonly impacted across many disorders, rather than focusing on 1 disorder or a specific cognitive domain. It comprises 8 exercises targeting different domains: states of attention (Egg), visual working memory (Theater), relaxation (Tent), inhibition and cognitive control (Mole), multitasking (Lab), self-regulation (Butterfly), sustained attention (Stroll), and visual search (Cloud). The prototype was tested and validated with healthy adults in a laboratory environment. In addition, a cognitive care network (5 sites across Canada and 1 in Japan) was established, enabling access to domain expertise and providing iterative input throughout the development process. Conclusions: Implementing an interdisciplinary and iterative approach considering technology maturity brought important considerations for the development of bWell. Altogether, this harnesses the affordances of immersive technology and design for a broad range of applications, and for use in both cognitive assessment and rehabilitation. The technology has attained a maturity level of prototype implementation with preliminary validation carried out in laboratory settings, with next steps to perform the validation required for its eventual adoption as a clinical tool. UR - https://rehab.jmir.org/2021/4/e26629 UR - http://dx.doi.org/10.2196/26629 UR - http://www.ncbi.nlm.nih.gov/pubmed/34730536 ID - info:doi/10.2196/26629 ER - TY - JOUR AU - Jacobs, Jonathan AU - Heymann, Reolyn AU - Greeff, Jacobus Jacob PY - 2021/11/1 TI - A Telehealth System Incorporating a Serious Game Intervention to Aid Occupational Therapists in Identifying and Treating Children With Difficulty Crossing the Body?s Midline: Key Informant Interviews Among Occupational Therapists JO - JMIR Serious Games SP - e27761 VL - 9 IS - 4 KW - serious games KW - input device KW - telehealth KW - occupational therapy KW - midline crossing N2 - Background: The midline is an imaginary line that isolates the left and right parts of the body. Crossing the midline infers that a body part (eg, hand or foot) can spontaneously move over to the opposite side of the body to perform an action. A child who has difficulty crossing the midline can physically perform actions that cross the center of the body; however, they do not intuitively cross the midline when challenged with a task that requires this movement, as their perceptual components prevent them from engaging on the contralateral side. This requires treatment from an occupational therapist. Owing to the recent COVID-19 pandemic, access to therapeutic sessions was not possible or reduced, putting the responsibility for treatment on caretakers at home. Caretakers do not have the knowledge and skills to provide treatment, and occupational therapists do not receive adequate feedback from caretakers on the child?s progress. Objective: The first objective is to adapt a simple serious game, or applied game, into a telehealth solution. Children will play the game at home under the supervision of a caretaker, and the results will be stored on the web. Occupational therapists can monitor progress via a web-based dashboard, receive additional valuable feedback about the child?s behavior during treatment, and easily adapt the game to target specific needs. The second objective is to evaluate whether the implemented telehealth solution is feasible as a treatment option for midline crossing difficulties and thus fit for purpose. Methods: To meet the first objective, engineering and game development stakeholders formed a team with an occupational therapist, and through a collaborative design process combined with an agile programming approach, a telehealth solution was designed to assist remote monitoring of the serious gameplay. For the second objective, 6 different occupational therapists were introduced to the game, had the opportunity to play the game, and then provided feedback regarding the feasibility, benefits, and applicability of the system during structured interviews. Results: A telehealth system was designed aimed to address this problem. All results are saved on the web and accessed by occupational therapists via a dashboard. In addition, observed behavioral information is also saved. During the interviews, occupational therapists indicated that the dashboard would support their treatment plan and was indeed a feasible solution. Conclusions: The feedback from the occupational therapists for this telehealth solution suggests a feasible method to treat midline crossing problems remotely. The therapists commented on the convenience of integrating both assessment and treatment into the same application, as it assists them when grading a child. The therapists collectively agreed that the quantitative aspect the serious game creates by providing measurable and standardized data proves advantageous when compared with traditional methods of assessment and treatment. UR - https://games.jmir.org/2021/4/e27761 UR - http://dx.doi.org/10.2196/27761 UR - http://www.ncbi.nlm.nih.gov/pubmed/34723821 ID - info:doi/10.2196/27761 ER - TY - JOUR AU - Vieira, Catarina AU - Ferreira da Silva Pais-Vieira, Carla AU - Novais, João AU - Perrotta, André PY - 2021/9/23 TI - Serious Game Design and Clinical Improvement in Physical Rehabilitation: Systematic Review JO - JMIR Serious Games SP - e20066 VL - 9 IS - 3 KW - serious games KW - physical rehabilitation KW - systematic review KW - physical impairment KW - game design KW - game characteristics KW - stroke KW - multiple sclerosis KW - cerebral palsy N2 - Background: Serious video games have now been used and assessed in clinical protocols, with several studies reporting patient improvement and engagement with this type of therapy. Even though some literature reviews have approached this topic from a game perspective and presented a broad overview of the types of video games that have been used in this context, there is still a need to better understand how different game characteristics and development strategies might impact and relate to clinical outcomes. Objective: This review assessed the relationship between the characteristics of serious games (SGs) and their relationship with the clinical outcomes of studies that use this type of therapy in motor impairment rehabilitation of patients with stroke, multiple sclerosis, or cerebral palsy. The purpose was to take a closer look at video game design features described in the literature (game genre [GG], game nature [GN], and game development strategy [GDS]) and assess how they may contribute toward improving health outcomes. Additionally, this review attempted to bring together medical and game development perspectives to facilitate communication between clinicians and game developers, therefore easing the process of choosing the video games to be used for physical rehabilitation. Methods: We analyzed the main features of SG design to obtain significant clinical outcomes when applied to physical rehabilitation of patients recovering from motor impairments resulting from stroke, multiple sclerosis, and cerebral palsy. We implemented a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) database-adjusted electronic search strategy for the PubMed, IEEE Xplore, and Cochrane databases. Results: We screened 623 related papers from 2010-2021 and identified 12 that presented results compatible with our inclusion criteria. A total of 512 participants with stroke (8 studies, 417 participants), cerebral palsy (1 study, 8 participants), and multiple sclerosis (2 studies, 46 participants) were included; 1 study targeting the elderly (41 participants) was also included. All studies assessed motor, sensory, and functional functions, while some also measured general health outcomes. Interventions with games were used for upper-limb motor rehabilitation. Of the 12 studies, 8 presented significant improvements in at least one clinical measurement, of which 6 presented games from the casual GG, 1 combined the casual, simulation, and exergaming GGs, and 2 combined the sports and simulation GGs. Conclusions: Of the possible combinations of game design features (GG, GN, and GDS) described, custom-made casual games that resort to the first-person perspective, do not feature a visible player character, are played in single-player mode, and use nonimmersive virtual reality attain the best results in terms of positive clinical outcomes. In addition, the use of custom-made games versus commercial off-the-shelf games tends to give better clinical results, although the latter are perceived as more motivating and engaging. UR - https://games.jmir.org/2021/3/e20066 UR - http://dx.doi.org/10.2196/20066 UR - http://www.ncbi.nlm.nih.gov/pubmed/34554102 ID - info:doi/10.2196/20066 ER - TY - JOUR AU - Seol, Yoon Hye AU - Kang, Soojin AU - Lim, Jihyun AU - Hong, Hwa Sung AU - Moon, Joon Il PY - 2021/8/31 TI - Feasibility of Virtual Reality Audiological Testing: Prospective Study JO - JMIR Serious Games SP - e26976 VL - 9 IS - 3 KW - hearing loss KW - virtual reality KW - speech performance KW - real-world performance KW - hearing KW - audiology N2 - Background: It has been noted in the literature that there is a gap between clinical assessment and real-world performance. Real-world conversations entail visual and audio information, yet there are not any audiological assessment tools that include visual information. Virtual reality (VR) technology has been applied to various areas, including audiology. However, the use of VR in speech-in-noise perception has not yet been investigated. Objective: The purpose of this study was to investigate the impact of virtual space (VS) on speech performance and its feasibility to be used as a speech test instrument. We hypothesized that individuals? ability to recognize speech would improve when visual cues were provided. Methods: A total of 30 individuals with normal hearing and 25 individuals with hearing loss completed pure-tone audiometry and the Korean version of the Hearing in Noise Test (K-HINT) under three conditions?conventional K-HINT (cK-HINT), VS on PC (VSPC), and VS head-mounted display (VSHMD)?at ?10 dB, ?5 dB, 0 dB, and +5 dB signal-to-noise ratios (SNRs). Participants listened to target speech and repeated it back to the tester for all conditions. Hearing aid users in the hearing loss group completed testing under unaided and aided conditions. A questionnaire was administered after testing to gather subjective opinions on the headset, the VSHMD condition, and test preference. Results: Provision of visual information had a significant impact on speech performance between the normal hearing and hearing impaired groups. The Mann-Whitney U test showed statistical significance (P<.05) between the two groups under all test conditions. Hearing aid use led to better integration of audio and visual cues. Statistical significance through the Mann-Whitney U test was observed for ?5 dB (P=.04) and 0 dB (P=.02) SNRs under the cK-HINT condition, as well as for ?10 dB (P=.007) and 0 dB (P=.04) SNRs under the VSPC condition, between hearing aid and non?hearing aid users. Participants reported positive responses across almost all items on the questionnaire except for the weight of the headset. Participants preferred a test method with visual imagery, but found the headset to be heavy. Conclusions: Findings are in line with previous literature that showed that visual cues were beneficial for communication. This is the first study to include hearing aid users with a more naturalistic stimulus and a relatively simple test environment, suggesting the feasibility of VR audiological testing in clinical practice. UR - https://games.jmir.org/2021/3/e26976 UR - http://dx.doi.org/10.2196/26976 UR - http://www.ncbi.nlm.nih.gov/pubmed/34463624 ID - info:doi/10.2196/26976 ER - TY - JOUR AU - Allegue, Rakia Dorra AU - Kairy, Dahlia AU - Higgins, Johanne AU - Archambault, S. Philippe AU - Michaud, Francois AU - Miller, C. William AU - Sweet, N. Shane AU - Tousignant, Michel PY - 2021/8/31 TI - A Personalized Home-Based Rehabilitation Program Using Exergames Combined With a Telerehabilitation App in a Chronic Stroke Survivor: Mixed Methods Case Study JO - JMIR Serious Games SP - e26153 VL - 9 IS - 3 KW - stroke KW - rehabilitation KW - virtual reality KW - video games KW - telerehabilitation KW - upper extremity KW - motivation N2 - Background: In Canada, only 11% of stroke survivors have access to outpatient and community-based rehabilitation after discharge from inpatient rehabilitation. Hence, innovative community-based strategies are needed to provide adequate postrehabilitation services. The VirTele program, which combines virtual reality exergames and a telerehabilitation app, was developed to provide stroke survivors with residual upper extremity deficits, the opportunity to participate in a personalized home rehabilitation program. Objective: This study aims to determine the feasibility of VirTele for remote upper extremity rehabilitation in a chronic stroke survivor; explore the preliminary efficacy of VirTele on upper extremity motor function, the amount and quality of upper extremity use, and impact on quality of life and motivation; and explore the determinants of behavioral intention and use behavior of VirTele along with indicators of empowerment. Methods: A 63-year-old male stroke survivor (3 years) with moderate upper extremity impairment participated in a 2-month VirTele intervention. He was instructed to use exergames (5 games for upper extremity) for 30 minutes, 5 times per week, and conduct videoconference sessions with a clinician at least once per week. Motivational interviewing was incorporated into VirTele to empower the participant to continue exercising and use his upper extremities in everyday activities. Upper extremity motor function (Fugl-Meyer Assessment?upper extremity), amount and quality of upper extremity use (Motor Activity Log-30), and impact on quality of life (Stroke Impact Scale-16) and motivation (Treatment Self-Regulation Questionnaire-15) were measured before (T1), after (T2) VirTele intervention, and during a 1- (T3) and 2-month (T4) follow-up period. Qualitative data were collected through logs and semistructured interviews. Feasibility data (eg, number and duration of videoconference sessions and adherence) were documented at the end of each week. Results: The participant completed 48 exergame sessions (33 hours) and 8 videoconference sessions. Results suggest that the VirTele intervention and the study protocol could be feasible for stroke survivors. The participant exhibited clinically meaningful improvements at T2 on the Fugl-Meyer and Stroke Impact Scale-16 and maintained these gains at T3 and T4. During the follow-up periods, the amount and quality of upper extremity use showed meaningful changes, suggesting more involvement of the affected upper extremity in daily activities. The participant demonstrated a high level of autonomous motivation, which may explain his adherence. Performance, effort, and social influence have meaningful weights in the behavioral intention of using VirTele. However, the lack of control of technical and organizational infrastructures may influence the long-term use of technology. At the end of the intervention, the participant demonstrated considerable empowerment at both the behavioral and capacity levels. Conclusions: VirTele was shown to be feasible for use in chronic stroke survivors for remote upper extremity rehabilitation. Meaningful determinants of behavioral intention and use behavior of VirTele were identified, and preliminary efficacy results are promising. International Registered Report Identifier (IRRID): RR2-10.2196/14629 UR - https://games.jmir.org/2021/3/e26153 UR - http://dx.doi.org/10.2196/26153 UR - http://www.ncbi.nlm.nih.gov/pubmed/34132649 ID - info:doi/10.2196/26153 ER - TY - JOUR AU - McClincy, Michael AU - Seabol, G. Liliana AU - Riffitts, Michelle AU - Ruh, Ethan AU - Novak, E. Natalie AU - Wasilko, Rachel AU - Hamm, E. Megan AU - Bell, M. Kevin PY - 2021/8/27 TI - Perspectives on the Gamification of an Interactive Health Technology for Postoperative Rehabilitation of Pediatric Anterior Cruciate Ligament Reconstruction: User-Centered Design Approach JO - JMIR Serious Games SP - e27195 VL - 9 IS - 3 KW - IHT KW - pediatric KW - sports medicine KW - ACL KW - orthopaedics KW - rehabilitation KW - health technology KW - gamification N2 - Background: Pediatric and adolescent athletes are a large demographic undergoing anterior cruciate ligament reconstruction (ACL-R). Postoperative rehabilitation is critical, requiring patients to complete home exercise programs (HEPs). To address obstacles to HEP adherence, we developed an interactive health technology, interACTION (iA), to monitor knee-specific rehabilitation. iA is a web-based platform that incorporates wearable motion sensors and a mobile app that provides feedback and allows remote monitoring. The Wheel of Sukr is a gamification mechanism that includes numerous behavioral elements. Objective: This study aims to use a user-centered design process to incorporate behavioral change strategies derived from self-management theory into iA using the Wheel of Sukr, with the aim of influencing patient behavior. Methods: In total, 10 athletes aged 10-18 years with a history of ACL-R were included in this study. Patients were between 4 weeks and 1 year post?ACL-R. Participants underwent a 60-minute triphasic interview. Phase 1 focused on elements of gaming that led to high participation and information regarding surgery and recovery. In phase 2, participants were asked to think aloud and rank cards representing the components of the Wheel of Sukr in order of interest. In phase 3, the patients reviewed the current version of iA. Interviews were recorded, transcribed, and checked for accuracy. Qualitative content analysis segmented the data and tagged meaningful codes until descriptive redundancy was achieved; next, 2 coders independently coded the data set. These elements were categorized according to the Wheel of Sukr framework. The mean age of participants was 12.8 (SD 1.32) years, and 70% (7/10) were female. Most participants (7/10, 70%) reported attending sessions twice weekly. All patients were prescribed home exercises. Self-reported HEP compliance was 75%-100% in 40% (4/10), 50%-75% in 40% (4/10), and 25%-50% of prescribed exercises in 20% (2/10) of the participants. Results: The participants responded positively to an app that could track home exercises. Desirable features included exercise demonstrations, motivational components, and convenience. The participants listed sports specificity, competition, notifications, reminders, rewards, and social aspects of gameplay as features to incorporate. In the Wheel of Sukr card sort exercise, motivation was ranked first; self-management, second; and growth, esteem, and fun tied for the third position. The recommended gameplay components closely followed the themes from the Wheel of Sukr card sort activity. Conclusions: The participants believe iA is a helpful addition to recovery and want the app to include exercise movement tracking and encouragement. Despite the small number of participants, thematic saturation was reached, suggesting the sample was sufficient to obtain a representative range of perspectives. Future work will implement motivation; self-management; and growth, confidence, and fun in the iA user experience. Young athlete ACL-R patients will complete typical clinical scenarios using increasingly developed prototypes of the gamified iA in a controlled setting. UR - https://games.jmir.org/2021/3/e27195 UR - http://dx.doi.org/10.2196/27195 UR - http://www.ncbi.nlm.nih.gov/pubmed/34448715 ID - info:doi/10.2196/27195 ER - TY - JOUR AU - Meinke, Anita AU - Peters, Rick AU - Knols, Ruud AU - Karlen, Walter AU - Swanenburg, Jaap PY - 2021/8/26 TI - Exergaming Using Postural Feedback From Wearable Sensors and Exercise Therapy to Improve Postural Balance in People With Nonspecific Low Back Pain: Protocol for a Factorial Pilot Randomized Controlled Trial JO - JMIR Res Protoc SP - e26982 VL - 10 IS - 8 KW - low back pain KW - exercise therapy KW - postural balance KW - postural feedback KW - motor control KW - fear of movement KW - exergame KW - randomized controlled trial KW - physical activity KW - smartphone KW - sensors KW - activity tracker KW - mobile phone N2 - Background: Physical exercise is a common treatment for people with low back pain (LBP). Wearable sensors that provide feedback on body movements and posture during exercise may enhance postural balance and motor control in people with LBP. Objective: This study aims to investigate whether physical exercising with postural feedback (EPF) improves postural balance, motor control, and patient-reported outcomes in people with LBP. Methods: The study was an assessor-blinded 2×2 factorial trial. We planned to recruit 80 participants with nonspecific LBP who did not receive treatment for LBP. In addition, we aimed to recruit 40 patients with chronic, nonspecific LBP who were receiving exercise therapy (ET) at the University Hospital Zurich. Both ET patients and participants without treatment were randomized to receive either an additional EPF intervention or no additional intervention. This resulted in four different combinations of interventions: ET+EPF, ET, EPF, and no intervention. The participants underwent outcome assessments at inclusion (T1); 3 weeks later, at randomization (T2); after an intervention period of 3 weeks with a predefined exercise schedule for participants receiving EPF (T3); and after an additional 6 weeks, during which participants assigned to the EPF groups could exercise as much as they wished (T4). Patients receiving ET completed their regularly prescribed therapies during the study period. Balance was assessed during quiet standing on a force platform, and motor control was assessed during a lifting task and a waiter?s bow task. Physical activity was recorded using an activity tracker and the participants? mobile phones during the study. The predefined EPF schedule consisted of nine sessions of 20 minutes of exercise with a tablet and inertial measurement unit sensors at home. Participants performed a series of trunk and hip movements and received feedback on their movements in a gamified environment displayed on the tablet. Results: The first participant was recruited in May 2019. Data collection was completed in October 2020, with 3 patients and 32 eligible people without therapy who passed the eligibility check. Conclusions: Although it will not be possible to investigate differences in patients and people without other therapies, we expect this pilot study to provide insights into the potential of EPF to improve balance in people with LBP and adherence to such interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/26982 UR - https://www.researchprotocols.org/2021/8/e26982 UR - http://dx.doi.org/10.2196/26982 UR - http://www.ncbi.nlm.nih.gov/pubmed/34435954 ID - info:doi/10.2196/26982 ER - TY - JOUR AU - Lapierre, Nolwenn AU - Um Din, Nathavy AU - Igout, Manuella AU - Chevrier, Joël AU - Belmin, Joël PY - 2021/8/26 TI - Effects of a Rehabilitation Program Using a Patient-Personalized Exergame on Fear of Falling and Risk of Falls in Vulnerable Older Adults: Protocol for a Randomized Controlled Group Study JO - JMIR Res Protoc SP - e24665 VL - 10 IS - 8 KW - older adult KW - fall KW - fear of falling KW - exergame KW - randomized controlled trial KW - psychomotor therapy KW - rehabilitation KW - fear KW - risk KW - elderly KW - protocol KW - therapy N2 - Background: Older adults often experience physical, sensory, and cognitive decline. Therefore, they have a high risk of falls, which leads to severe health and psychological consequences and can induce fear of falling. Rehabilitation programs using exergames to prevent falls are being increasingly studied. Medimoov is a movement-based patient-personalized exergame for rehabilitation in older adults. A preliminary study showed that its use may influence functional ability and motivation. Most existing studies that evaluate the use of exergames do not involve an appropriate control group and do not focus on patient-personalized exergames. Objective: This study aims to evaluate the effects of Medimoov on risk of falls and fear of falling in older adults compared with standard psychomotor rehabilitation. Methods: This is a serial, comparative, randomized controlled group study. Both groups (n=25 in each) will receive psychomotor rehabilitation care. However, the methods of delivery will be different; one group will be exposed to the Medimoov exergame platform, and the other only to traditional means of psychomotor rehabilitation. The selection criteria will be (1) age of 65 years or older, (2) ability to answer a questionnaire, (3) ability to stand in a bipedal position for at least 1 minute, (4) score of 13 or greater on the Short Fall Efficacy Scale, and (5) stable medical condition. An evaluation will be made prior to starting the intervention, after 4 weeks of intervention, and at the end of the intervention (after 8 weeks), and it will focus on (1) risk of falls, (2) fear of falling, and (3) cognitive evaluations. Physical activity outside the session will also be assessed by actimetry. The outcome assessment will be performed according to intention-to-treat analysis. Results: The protocol (2019-11-22) has been approved by the Comité de Protection des Personnes Nord-Ouest I?Université de Rouen (2019-A00395-52), which is part of the French national ethical committee. The study received funding in February 2020. As of October 2020 (submission date), and due to the context of the COVID-19 pandemic, a total of 10 participants out of 50 had been enrolled in the study. The projected date for the end of the data collection is December 2021. Data analyses have not been started yet, and publication of the results is expected for Spring 2022. Conclusions: The effects of psychomotor rehabilitation using the Medimoov exergame platform on the risk and fear of falls will be evaluated. This pilot study will be the basis for larger trials. Trial Registration: ClinicalTrials.gov NCT04134988; https://clinicaltrials.gov/ct2/show/NCT04134988 International Registered Report Identifier (IRRID): DERR1-10.2196/24665 UR - https://www.researchprotocols.org/2021/8/e24665 UR - http://dx.doi.org/10.2196/24665 UR - http://www.ncbi.nlm.nih.gov/pubmed/34435968 ID - info:doi/10.2196/24665 ER - TY - JOUR AU - Brassel, Sophie AU - Power, Emma AU - Campbell, Andrew AU - Brunner, Melissa AU - Togher, Leanne PY - 2021/7/30 TI - Recommendations for the Design and Implementation of Virtual Reality for Acquired Brain Injury Rehabilitation: Systematic Review JO - J Med Internet Res SP - e26344 VL - 23 IS - 7 KW - virtual reality KW - acquired brain injury KW - traumatic brain injury KW - rehabilitation KW - systematic review KW - recommendations KW - cognitive communication KW - mobile phone N2 - Background: Virtual reality (VR) is increasingly being used for the assessment and treatment of impairments arising from acquired brain injuries (ABIs) due to perceived benefits over traditional methods. However, no tailored options exist for the design and implementation of VR for ABI rehabilitation and, more specifically, traumatic brain injury (TBI) rehabilitation. In addition, the evidence base lacks systematic reviews of immersive VR use for TBI rehabilitation. Recommendations for this population are important because of the many complex and diverse impairments that individuals can experience. Objective: This study aims to conduct a two-part systematic review to identify and synthesize existing recommendations for designing and implementing therapeutic VR for ABI rehabilitation, including TBI, and to identify current evidence for using immersive VR for TBI assessment and treatment and to map the degree to which this literature includes recommendations for VR design and implementation. Methods: This review was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive search of 11 databases and gray literature was conducted in August 2019 and repeated in June 2020. Studies were included if they met relevant search terms, were peer-reviewed, were written in English, and were published between 2009 and 2020. Studies were reviewed to determine the level of evidence and methodological quality. For the first part, qualitative data were synthesized and categorized via meta-synthesis. For the second part, findings were analyzed and synthesized descriptively owing to the heterogeneity of data extracted from the included studies. Results: In the first part, a total of 14 papers met the inclusion criteria. Recommendations for VR design and implementation were not specific to TBI but rather to stroke or ABI rehabilitation more broadly. The synthesis and analysis of data resulted in three key phases and nine categories of recommendations for designing and implementing VR for ABI rehabilitation. In the second part, 5 studies met the inclusion criteria. A total of 2 studies reported on VR for assessment and three for treatment. Studies were varied in terms of therapeutic targets, VR tasks, and outcome measures. VR was used to assess or treat impairments in cognition, balance, and anxiety, with positive outcomes. However, the levels of evidence, methodological quality, and inclusion of recommendations for VR design and implementation were poor. Conclusions: There is limited research on the use of immersive VR for TBI rehabilitation. Few studies have been conducted, and there is limited inclusion of recommendations for therapeutic VR design and implementation. Future research in ABI rehabilitation should consider a stepwise approach to VR development, from early co-design studies with end users to larger controlled trials. A list of recommendations is offered to provide guidance and a more consistent model to advance clinical research in this area. UR - https://www.jmir.org/2021/7/e26344 UR - http://dx.doi.org/10.2196/26344 UR - http://www.ncbi.nlm.nih.gov/pubmed/34328434 ID - info:doi/10.2196/26344 ER - TY - JOUR AU - Fahr, Annina AU - Kläy, Andrina AU - Keller, W. Jeffrey AU - van Hedel, A. Hubertus J. PY - 2021/7/28 TI - An Interactive Computer Game for Improving Selective Voluntary Motor Control in Children With Upper Motor Neuron Lesions: Development and Preliminary Feasibility Study JO - JMIR Serious Games SP - e26028 VL - 9 IS - 3 KW - virtual reality KW - game therapy KW - rehabilitation KW - augmented feedback KW - motivation KW - mobile phone N2 - Background: Computer game?based interventions are emerging in pediatric neurorehabilitation, as they can provide two key elements for motor learning?motivating environments that enable long-term compliance, which is particularly relevant for children, and augmented feedback for improving movement performance. Objective: The overall aim of this study is to develop an interactive computer play for children with upper motor neuron lesions to train selective voluntary motor control and give particular attention to motivation and feedback. We also aim to determine features that make games engaging, investigate which sensory feedback modality is noticed the fastest during play, develop an interactive game, and evaluate its feasibility. Methods: We identified engaging game features by interviewing 19 children and adolescents undergoing rehabilitation. By using a test version of the game, we determined the response times of 10 patients who had to react to visual, auditory, or combined feedback signals. On the basis of the results of these two subprojects, we developed and designed a game environment. Feasibility was studied in terms of the practicability and acceptability of the intervention among 5 children with upper motor neuron lesions. Results: The game features deemed the most important by pediatric patients were strategic gameplay (13/29, 45% of answers) and choice (6/29, 21%). While playing the game, an acoustic alarm signal (reaction time: median 2.8 seconds) was detected significantly faster (P=.01) than conditions with other feedback modalities (avatar velocity reduction: median 7.8 seconds; color desaturation: median 5.7 seconds). Most children enjoyed playing the game, despite some technical issues. Conclusions: The careful identification of game features that increase motivation and feedback modalities that inform children quickly led to the development of an interactive computer play for training selective voluntary motor control in children and adolescents with upper motor neuron lesions. UR - https://games.jmir.org/2021/3/e26028 UR - http://dx.doi.org/10.2196/26028 UR - http://www.ncbi.nlm.nih.gov/pubmed/34319236 ID - info:doi/10.2196/26028 ER - TY - JOUR AU - Louw, Gidion Jacobus AU - van Heerden, Alastair AU - Olivier, Leana AU - Lambrechts, Tersius AU - Broodryk, Mandi AU - Bunge, Liska AU - Vosloo, Martlé AU - Tomlinson, Mark PY - 2021/7/2 TI - Executive Function After Prenatal Alcohol Exposure in Children in a South African Population: Cross-sectional Study JO - JMIR Form Res SP - e20658 VL - 5 IS - 7 KW - fetal alcohol spectrum disorders KW - FASD KW - cognitive KW - executive function KW - experimental games KW - brain drug effects KW - child development KW - serious games KW - games KW - alcohol KW - training N2 - Background: Alcohol is a teratogen; its consumption during pregnancy can lead to negative birth outcomes, collectively referred to as fetal alcohol spectrum disorders. Neurodevelopmental delays in higher-order cognitive functions that affect development of executive functions are a common feature. Studies on executive function in children have focused on children diagnosed with fetal alcohol spectrum disorder, and there is a lack of information on the impact on children not diagnosed with fetal alcohol spectrum disorder but who had been exposed to alcohol. Objective: The aim of this study was to compare the development of executive function in children between 4 and 6 years of age with and without prenatal exposure to alcohol. Methods: Children both exposed and not exposed to alcohol were recruited as part of a feasibility RCT evaluating a computer-based cognitive training program for improving executive function development. The study was conducted in a low?socioeconomic status community in South Africa with a high prevalence of fetal alcohol spectrum disorder. Neurodevelopment was assessed in participating children; NEPSY-II standardized scores for executive function domains were compared using a multivariate analysis of variance with group membership as the predictor variable. Results: No significant differences in executive functions assessments (P=.39) were found between children in the alcohol-exposed group (n=76) and those in the nonexposed group (n=40). Both groups showed moderate to severe delays in domains. In all but one subtest, the average score for both groups was below the 25th percentile of expected norms. Conclusions: We expected that alcohol exposure would have a measurable impact on executive function development. The lack of differences highlights the prevalence of developmental delays in low?socioeconomic status communities in South Africa and suggests that children are exposed to various threats to cognitive development. International Registered Report Identifier (IRRID): RR2-10.2196/14489 UR - https://formative.jmir.org/2021/7/e20658 UR - http://dx.doi.org/10.2196/20658 UR - http://www.ncbi.nlm.nih.gov/pubmed/34255647 ID - info:doi/10.2196/20658 ER - TY - JOUR AU - Beristain-Colorado, Pilar María Del AU - Ambros-Antemate, Fernando Jorge AU - Vargas-Treviño, Marciano AU - Gutiérrez-Gutiérrez, Jaime AU - Moreno-Rodriguez, Adriana AU - Hernández-Cruz, Antonio Pedro AU - Gallegos-Velasco, Belem Itandehui AU - Torres-Rosas, Rafael PY - 2021/6/24 TI - Standardizing the Development of Serious Games for Physical Rehabilitation: Conceptual Framework Proposal JO - JMIR Serious Games SP - e25854 VL - 9 IS - 2 KW - serious game KW - physical rehabilitation KW - framework KW - software engineering KW - gamification N2 - Background: 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. Objective: 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. Methods: 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. Results: 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. Conclusions: 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. UR - https://games.jmir.org/2021/2/e25854/ UR - http://dx.doi.org/10.2196/25854 UR - http://www.ncbi.nlm.nih.gov/pubmed/34185003 ID - info:doi/10.2196/25854 ER - TY - JOUR AU - Kanitkar, Anuprita AU - Parmar, Tejraj Sanjay AU - Szturm, J. Tony AU - Restall, Gayle AU - Rempel, Gina AU - Sepehri, Nariman PY - 2021/5/31 TI - Parents' Perspectives on a Computer Game?Assisted Rehabilitation Program for Manual Dexterity in Children With Cerebral Palsy: Qualitative Analysis of Expectations, Child Engagement, and Benefits JO - JMIR Rehabil Assist Technol SP - e24337 VL - 8 IS - 2 KW - cerebral palsy KW - parents' expectations KW - fine motor function KW - object manipulation KW - computer game?based treatment protocol KW - parents KW - motor function KW - computer games, rehabilitation KW - game-based rehabilitation KW - gross movement KW - children N2 - Background: Children with motor impairments affecting the upper extremity benefit from task-specific therapy, such as constraint-induced movement therapy. However, there is a need to improve engagement and compliance with task-specific exercise programs that target manual dexterity for children with cerebral palsy (CP). A computer game?based rehabilitation (GRP) platform was developed that combines fine manipulation and gross movement exercises with engaging game activities appropriate for young children with CP. Objective: The objectives of this qualitative analysis were to compare parents? perspectives and opinions about expectations, challenges, and benefits between 2 interventions. Methods: A mixed methods, randomized controlled trial (RCT) was conducted to examine the feasibility and estimate the effect size of 2 exercise programs for rehabilitation of manual dexterity of children with CP using either GRP or conventional therapy. Parents of 26 of the children who completed the GRP program (n=33) and parents of 15 of the children who completed the conventional therapy program (n=27) participated in the interviews. A general conductive approach was used to analyze the data recorded during the parents? interviews. Results: Five themes captured the range of the parent?s experiences, viewpoints, and ideas: (1) parents? expectations, (2) child?s engagement with therapy, (3) positive effects of the interventions, (4) challenges, and (5) improving the protocol. Conclusions: Parents from both groups recognized that their expectations related to improving children?s object handling and manipulation skills including participation in activities of daily life were addressed during the 16-week therapy program. Parents perceived a change in the children?s level of independence in their daily tasks at home, school, and leisure activities. Trial Registration: ClinicalTrials.gov NCT02728375; https://clinicaltrials.gov/ct2/show/NCT02728375 UR - https://rehab.jmir.org/2021/2/e24337 UR - http://dx.doi.org/10.2196/24337 UR - http://www.ncbi.nlm.nih.gov/pubmed/34057424 ID - info:doi/10.2196/24337 ER - TY - JOUR AU - Lai, Byron AU - Powell, Maegen AU - Clement, Grace Anne AU - Davis, Drew AU - Swanson-Kimani, Erin AU - Hayes, Leslie PY - 2021/5/27 TI - Examining the Feasibility of Early Mobilization With Virtual Reality Gaming Using Head-Mounted Display and Adaptive Software With Adolescents in the Pediatric Intensive Care Unit: Case Report JO - JMIR Rehabil Assist Technol SP - e28210 VL - 8 IS - 2 KW - physical activity KW - active video gaming KW - exergaming KW - early mobility KW - rehabilitation N2 - Background: Early rehabilitative mobilization for adolescents is safe and feasible. However, there is a lack of published rehabilitation strategies and treatments that can maximize engagement and outcomes among adolescents in the pediatric intensive care unit (PICU). Virtual reality (VR) gaming using a head-mounted display (HMD) and adaptive software can allow active and nonactive gameplay at the bedside for people with limited arm mobility, making it a potentially inclusive and enjoyable treatment modality for adolescents in the PICU. Objective: The purpose of this brief case study is to report on the preliminary feasibility of incorporating adaptive VR gaming using an HMD with 2 adolescents who received early mobility treatment within the PICU. Methods: This study was a mini-ethnographic investigation of 2 adolescents (a 15-year-old male and a 13-year old male) in the PICU who underwent VR gaming sessions as part of their early mobilization care, using an Oculus Rift HMD and adaptive software (WalkinVR) that promoted full gameplay in bed. The Rift was plugged into a gaming laptop that was set up on a table within the patient?s room before each session. The intervention was delivered by an adapted exercise professional and supervised by a physical therapist. Patients had access to a variety of active games (eg, boxing, rhythmic movement to music, and exploratory adventure) and nonactive games (eg, racing and narrative adventure). Gaming sessions were scheduled between usual care, when tolerable and requested by the participant. The interventionist and therapists took audio-recorded and written notes after completing each gaming session. These data were analyzed and presented in a narrative format from the perspective of the research team. Results: Case 1 participated in 4 gaming sessions, with an average of 18 minutes (SD 11) per session. Case 2 participated in 2 sessions, with an average of 35 minutes (SD 7) per session. Both cases were capable of performing active gaming at a moderate level of exercise intensity, as indicated by their heart rate. However, their health and symptoms fluctuated on a daily basis, which prompted the gameplay of adventure or nonactive games. Gameplay appeared to improve participants? affect and alertness and motivate them to be more engaged in early mobilization therapy. Gameplay without the WalkinVR software caused several usability issues. There were no serious adverse events, but both cases experienced symptoms based on their condition. Conclusions: The findings of this study suggest that VR gaming with HMDs and adaptive software is likely a feasible supplement to usual care for adolescents within the PICU, and these findings warrant further investigation. Recommendations for future studies aimed at incorporating VR gaming during early mobilization are presented herein. UR - https://rehab.jmir.org/2021/2/e28210 UR - http://dx.doi.org/10.2196/28210 UR - http://www.ncbi.nlm.nih.gov/pubmed/34042602 ID - info:doi/10.2196/28210 ER - TY - JOUR AU - Chau, Hing Pui AU - Kwok, Jojo Yan Yan AU - Chan, Maggie Mee Kie AU - Kwan, Daniel Ka Yu AU - Wong, Lun Kam AU - Tang, Ho Ying AU - Chau, Peter Kan Lung AU - Lau, Matthew Sheung Wa AU - Yiu, Yannex Yan Yan AU - Kwong, Fanny Mei Yan AU - Lai, Thomas Wai Ting AU - Leung, Kit Mun PY - 2021/5/4 TI - Feasibility, Acceptability, and Efficacy of Virtual Reality Training for Older Adults and People With Disabilities: Single-Arm Pre-Post Study JO - J Med Internet Res SP - e27640 VL - 23 IS - 5 KW - virtual reality KW - rehabilitation KW - older adults, people with disabilities KW - evaluation N2 - Background: Unlike most virtual reality (VR) training programs that are targeted at homogenous populations, a set of VR games for rehabilitation purposes targeted at a heterogeneous group of users was developed. The VR games covered physical training, cognitive training (classification and reality orientation), community-living skills training, and relaxing scenery experiences. Special considerations for local older adults and people with disabilities were made in terms of hardware choice and software design. Objective: This study aimed to evaluate the feasibility, acceptance, and efficacy of VR training among users with varying abilities. Methods: A single-arm pretest-posttest evaluation study was conducted. The participants of the evaluation study were encouraged to undergo 30-minute VR training three times a week for 6 weeks. The 30-minute session consisted of 10 minutes of upper-limb motion games, 10 minutes of lower-limb motion games, and 10 minutes of cognitive games/community-living skills training/relaxing scenery experiences, as appropriate. On completion of each session, usage statistics were documented via the built-in VR software, whereas feedback on the experience of the VR games and adverse events was collected via self-reports and staff observations. Feasibility was reflected by usage statistics, and acceptance was reflected by positive feedback. In addition, health outcomes, including upper-limb dexterity, functional mobility, cognitive function, and happiness, were assessed at baseline, as well as 6 weeks and 3 months after baseline. The primary outcomes were upper-limb dexterity and acceptance of playing VR games. Results: A total of 135 participants with a mean age of 62.7 years (SD 21.5) were recruited from May 2019 to January 2020, and 124 (91.9%) completed at least one follow-up. Additionally, 76.3% (103/135) of the participants could attend at least 70% of the proposed 18 sessions, and 72.5% (1382/1906) of the sessions had a training time of at least 20 minutes. Linear mixed effect models showed statistically significant effects in terms of upper-limb dexterity (small effect) and cognitive function (moderate effect). Among the 135 participants, 88 provided positive comments. Additionally, 10.4% (14/135) reported mild discomfort, such as dizziness, and none reported severe discomfort. Conclusions: A set of VR training games for rehabilitation could be applied to users with heterogeneous abilities. Our VR games were acceptable to local older adults and those with different disabilities. Benefits in upper-limb dexterity and cognitive function were observed despite partial compliance to the training protocol. Service providers could refer to our experiences when developing VR training systems for their clients. UR - https://www.jmir.org/2021/5/e27640 UR - http://dx.doi.org/10.2196/27640 UR - http://www.ncbi.nlm.nih.gov/pubmed/33944795 ID - info:doi/10.2196/27640 ER - TY - JOUR AU - Yeo, Shi Pei AU - Nguyen, Ngoc Tu AU - Ng, Ern Mary Pei AU - Choo, Munn Robin Wai AU - Yap, Kiat Philip Lin AU - Ng, Pin Tze AU - Wee, Liang Shiou PY - 2021/4/27 TI - Evaluation of the Implementation and Effectiveness of Community-Based Brain-Computer Interface Cognitive Group Training in Healthy Community-Dwelling Older Adults: Randomized Controlled Implementation Trial JO - JMIR Form Res SP - e25462 VL - 5 IS - 4 KW - group-based computerized cognitive training KW - cognition KW - gait KW - community program implementation KW - healthy older adults KW - cognitive KW - community program KW - cognitive training KW - elderly KW - aging N2 - Background: Cognitive training can improve cognition in healthy older adults. Objective: The objectives are to evaluate the implementation of community-based computerized cognitive training (CCT) and its effectiveness on cognition, gait, and balance in healthy older adults. Methods: A single-blind randomized controlled trial with baseline and follow-up assessments was conducted at two community centers in Singapore. Healthy community-dwelling adults aged 55 years and older participated in a 10-week CCT program with 2-hour instructor-led group classes twice a week. Participants used a mobile app to play games targeting attention, memory, decision making, visuospatial abilities, and cognitive flexibility. Implementation was assessed at the participant, provider, and community level (eg, reach, implementation, and facilitators and barriers). Effectiveness measures were the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Color Trails Test 2 (CTT-2), Berg Balance Scale, and GAITRite walkway measures (single and dual task gait speed, dual task cost, and single and dual task gait variability index [GVI]). Results: A total of 94 healthy community-dwelling adults participated in the CCT program (mean age 68.8 [SD 6.3] years). Implementation measures revealed high reach (125/155, 80.6%) and moderate adherence but poor penetration of sedentary older adults (43/125, 34.4%). The effectiveness data were based on intention-to-treat (ITT) and per-protocol (PP) analysis. In the ITT analysis, single task GVI increased (b=2.32, P=.02, 95% CI [0.30 to 4.35]) and RBANS list recognition subtest deteriorated (b=?0.57, P=.01, 95% CI [?1.00 to ?0.14]) in both groups. In the PP analysis, time taken to complete CTT-2 (b=?13.5, P=.01, 95% CI [?23.95 to ?3.14]; Cohen d effect size = 0.285) was faster in the intervention group. Single task gait speed was not statistically significantly maintained in the intervention group (b=5.38, P=.06, 95% CI [?0.30 to 11.36]) and declined in the control group (Cohen d effect size = 0.414). PP analyses also showed interaction terms for RBANS list recall subtest (b=?0.36, P=.08, 95% CI [?0.75 to 0.04]) and visuospatial domain (b=0.46, P=.08, 95% CI [?0.05 to 0.96]) that were not statistically significant. Conclusions: CCT can be implemented in community settings to improve attention and executive function among healthy older adults. Findings help to identify suitable healthy aging programs that can be implemented on a larger scale within communities. Trial Registration: ClinicalTrials.gov NCT04439591; https://clinicaltrials.gov/ct2/show/NCT04439591 UR - https://formative.jmir.org/2021/4/e25462 UR - http://dx.doi.org/10.2196/25462 UR - http://www.ncbi.nlm.nih.gov/pubmed/33904819 ID - info:doi/10.2196/25462 ER - TY - JOUR AU - Demers, Marika AU - Fung, Karen AU - Subramanian, K. Sandeep AU - Lemay, Martin AU - Robert, T. Maxime PY - 2021/4/7 TI - Integration of Motor Learning Principles Into Virtual Reality Interventions for Individuals With Cerebral Palsy: Systematic Review JO - JMIR Serious Games SP - e23822 VL - 9 IS - 2 KW - virtual rehabilitation KW - upper limb KW - brain damage KW - feedback KW - active video games KW - learning N2 - Background: Increasing evidence supports the use of virtual reality systems to improve upper limb motor functions in individuals with cerebral palsy. While virtual reality offers the possibility to include key components to promote motor learning, it remains unclear if and how motor learning principles are incorporated into the development of rehabilitation interventions using virtual reality. Objective: The objective of this study was to determine the extent to which motor learning principles are integrated into virtual reality interventions targeting upper limb function in individuals with cerebral palsy. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was performed in 10 databases using a combination of keywords related to cerebral palsy, virtual reality, video games, and rehabilitation. Studies were divided into 2 categories: commercial video game platforms and devices and custom virtual reality systems. Study quality was assessed using the modified Downs and Black checklist. Results: The initial search yielded 1497 publications. A total of 26 studies from 30 publications were included, with most studies classified as ?fair? according to the modified Downs and Black checklist. The majority of studies provided enhanced feedback and variable practice and used functionally relevant and motivating virtual tasks. The dosage varied greatly (total training time ranged from 300 to 3360 minutes), with only 6 studies reporting the number of movement repetitions per session. The difficulty progression and the assessment of skills retention and transfer were poorly incorporated, especially for the commercial video games. Conclusions: Motor learning principles should be better integrated into the development of future virtual reality systems for optimal upper limb motor recovery in individuals with cerebral palsy. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020151982; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151982 UR - https://games.jmir.org/2021/2/e23822 UR - http://dx.doi.org/10.2196/23822 UR - http://www.ncbi.nlm.nih.gov/pubmed/33825690 ID - info:doi/10.2196/23822 ER - TY - JOUR AU - Xu, Yangfan AU - Tong, Meiqinzi AU - Ming, Wai-Kit AU - Lin, Yangyang AU - Mai, Wangxiang AU - Huang, Weixin AU - Chen, Zhuoming PY - 2021/3/24 TI - A Depth Camera?Based, Task-Specific Virtual Reality Rehabilitation Game for Patients With Stroke: Pilot Usability Study JO - JMIR Serious Games SP - e20916 VL - 9 IS - 1 KW - virtual reality KW - rehabilitation KW - stroke KW - lower extremity KW - rehabilitation game N2 - Background: The use of virtual reality is popular in clinical rehabilitation, but the effects of using commercial virtual reality games in patients with stroke have been mixed. Objective: We developed a depth camera?based, task-specific virtual reality game, Stomp Joy, for poststroke rehabilitation of the lower extremities. This study aims to assess its feasibility and clinical efficacy. Methods: We carried out a feasibility test for Stomp Joy within representative user groups. Then, a clinical efficacy experiment was performed with a randomized controlled trial, in which 22 patients with stroke received 10 sessions (2 weeks) of conventional physical therapy only (control group) or conventional physical therapy plus 30 minutes of the Stomp Joy intervention (experimental group) in the clinic. The Fugl-Meyer Assessment for Lower Extremity (FMA-LE), Modified Barthel Index (MBI), Berg Balance Scale (BBS) score, single-leg stance (SLS) time, dropout rate, and adverse effects were recorded. Results: This feasibility test showed that Stomp Joy improved interest, pressure, perceived competence, value, and effort using the Intrinsic Motivation Inventory. The clinical efficacy trial showed a significant time-group interaction effect for the FMA-LE (P=.006), MBI (P=.001), BBS (P=.004), and SLS time (P=.001). A significant time effect was found for the FMA-LE (P=.001), MBI (P<.001), BBS (P<.001), and SLS time (P=.03). These indicated an improvement in lower extremity motor ability, basic activities of daily living, balance ability, and single-leg stance time in both groups after 2 weeks of the intervention. However, no significant group effects were found for the FMA-LE (P=.06), MBI (P=.76), and BBS (P=.38), while a significant group interaction was detected for SLS time (P<.001). These results indicated that the experimental group significantly improved more in SLS time than did the control group. During the study, 2 dropouts, including 1 participant who fell, were reported. Conclusions: Stomp Joy is an effective depth camera?based virtual reality game for replacing part of conventional physiotherapy, achieving equally effective improvement in lower extremity function among stroke survivors. High-powered randomized controlled studies are now needed before recommending the routine use of Stomp Joy in order to confirm these findings by recruiting a large sample size. UR - https://games.jmir.org/2021/1/e20916 UR - http://dx.doi.org/10.2196/20916 UR - http://www.ncbi.nlm.nih.gov/pubmed/33759795 ID - info:doi/10.2196/20916 ER - TY - JOUR AU - Hashim, A. N. AU - Abd Razak, A. N. AU - Gholizadeh, H. AU - Abu Osman, A. N. PY - 2021/2/4 TI - Video Game?Based Rehabilitation Approach for Individuals Who Have Undergone Upper Limb Amputation: Case-Control Study JO - JMIR Serious Games SP - e17017 VL - 9 IS - 1 KW - box and block test KW - Intrinsic Motivation Inventory KW - maximum voluntary contraction KW - motor rehabilitation KW - upper limb amputee KW - video games N2 - Background: Brain plasticity is an important factor in prosthesis usage. This plasticity helps with brain adaptation to learn new movement and coordination patterns needed to control a prosthetic hand. It can be achieved through repetitive muscle training that is usually very exhausting and often results in considerable reduction in patient motivation. Previous studies have shown that a playful concept in rehabilitation can increase patient engagement and perseverance. Objective: This study investigated whether the inclusion of video games in the upper limb amputee rehabilitation protocol could have a beneficial impact for muscle preparation, coordination, and patient motivation among individuals who have undergone transradial upper limb amputation. Methods: Ten participants, including five amputee participants and five able-bodied participants, were enrolled in 10 1-hour sessions within a 4-week rehabilitation program. In order to investigate the effects of the rehabilitation protocol used in this study, virtual reality box and block tests and electromyography (EMG) assessments were performed. Maximum voluntary contraction was measured before, immediately after, and 2 days after interacting with four different EMG-controlled video games. Participant motivation was assessed with the Intrinsic Motivation Inventory (IMI) questionnaire and user evaluation survey. Results: Survey analysis showed that muscle strength and coordination increased at the end of training for all the participants. The results of Pearson correlation analysis indicated that there was a significant positive association between the training period and the box and block test score (r8=0.95, P<.001). The maximum voluntary contraction increment was high before training (6.8%) and in the follow-up session (7.1%), but was very small (2.1%) shortly after the training was conducted. The IMI assessment showed high scores for the subscales of interest, perceived competence, choice, and usefulness, but low scores for pressure and tension. Conclusions: This study demonstrated that video games enhance motivation and adherence in an upper limb amputee rehabilitation program. The use of video games could be seen as a complementary approach for physical training in upper limb amputee rehabilitation. UR - https://games.jmir.org/2021/1/e17017 UR - http://dx.doi.org/10.2196/17017 UR - http://www.ncbi.nlm.nih.gov/pubmed/33538698 ID - info:doi/10.2196/17017 ER - TY - JOUR AU - Garske, Alexander Christian AU - Dyson, Matthew AU - Dupan, Sigrid AU - Nazarpour, Kianoush PY - 2021/2/1 TI - Perception of Game-Based Rehabilitation in Upper Limb Prosthetic Training: Survey of Users and Researchers JO - JMIR Serious Games SP - e23710 VL - 9 IS - 1 KW - upper limb KW - rehabilitation KW - arm prosthesis KW - serious games KW - engagement KW - transfer N2 - Background: Serious games have been investigated for their use in multiple forms of rehabilitation for decades. The rising trend to use games for physical fitness in more recent years has also provided more options and garnered more interest for their use in physical rehabilitation and motor learning. In this study, we report the results of an opinion survey of serious games in upper limb prosthetic training. Objective: This study investigates and contrasts the expectations and preferences for game-based prosthetic rehabilitation of people with limb difference and researchers. Methods: Both participant groups answered open and closed questions as well as a questionnaire to assess their user types. The distribution of the user types was compared with a Pearson chi-square test against a sample population. The data were analyzed using the thematic framework method; answers fell within the themes of usability, training, and game design. Researchers shared their views on current challenges and what could be done to tackle these. Results: A total of 14 people with limb difference and 12 researchers participated in this survey. The open questions resulted in an overview of the different views on prosthetic training games between the groups. The user types of people with limb difference and researchers were both significantly different from the sample population, with ?25=12.3 and ?25=26.5, respectively. Conclusions: We found that the respondents not only showed a general willingness and tentative optimism toward the topic but also acknowledged hurdles limiting the adoption of these games by both clinics and users. The results indicate a noteworthy difference between researchers and people with limb difference in their game preferences, which could lead to design choices that do not represent the target audience. Furthermore, focus on long-term in-home experiments is expected to shed more light on the validity of games in upper limb prosthetic rehabilitation. UR - http://games.jmir.org/2021/1/e23710/ UR - http://dx.doi.org/10.2196/23710 UR - http://www.ncbi.nlm.nih.gov/pubmed/33522975 ID - info:doi/10.2196/23710 ER - TY - JOUR AU - Enciso, James AU - Variya, Dhruval AU - Sunthonlap, James AU - Sarmiento, Terrence AU - Lee, Mun Ka AU - Velasco, James AU - Pebdani, N. Roxanna AU - de Leon, D. Ray AU - Dy, Christine AU - Keslacy, Stefan AU - Won, Soonmee Deborah PY - 2021/1/19 TI - Electromyography-Driven Exergaming in Wheelchairs on a Mobile Platform: Bench and Pilot Testing of the WOW-Mobile Fitness System JO - JMIR Rehabil Assist Technol SP - e16054 VL - 8 IS - 1 KW - exergaming KW - gamercising KW - mobile health KW - wheelchair exercises KW - wireless electromyography KW - mobile phone N2 - Background: Implementing exercises in the form of video games, otherwise known as exergaming, has gained recent attention as a way to combat health issues resulting from sedentary lifestyles. However, these exergaming apps have not been developed for exercises that can be performed in wheelchairs, and they tend to rely on whole-body movements. Objective: This study aims to develop a mobile phone app that implements electromyography (EMG)-driven exergaming, to test the feasibility of using this app to enable people in wheelchairs to perform exergames independently and flexibly in their own home, and to assess the perceived usefulness and usability of this mobile health system. Methods: We developed an Android mobile phone app (Workout on Wheels, WOW-Mobile) that senses upper limb muscle activity (EMG) from wireless body-worn sensors to drive 3 different video games that implement upper limb exercises designed for people in wheelchairs. Cloud server recordings of EMG enabled long-term monitoring and feedback as well as multiplayer gaming. Bench testing of data transmission and power consumption were tested. Pilot testing was conducted on 4 individuals with spinal cord injury. Each had a WOW-Mobile system at home for 8 weeks. We measured the minutes for which the app was used and the exergames were played, and we integrated EMG as a measure of energy expended. We also conducted a perceived usefulness and usability questionnaire. Results: Bench test results revealed that the app meets performance specifications to enable real-time gaming, cloud storage of data, and live cloud server transmission for multiplayer gaming. The EMG sampling rate of 64 samples per second, in combination with zero-loss data communication with the cloud server within a 10-m range, provided seamless control over the app exergames and allowed for offline data analysis. Each participant successfully used the WOW-Mobile system at home for 8 weeks, using the app for an average of 146 (range 89-267) minutes per week with the system, actively exergaming for an average of 53% of that time (39%-59%). Energy expenditure, as measured by integrated EMG, was found to be directly proportional to the time spent on the app (Pearson correlation coefficient, r=0.57-0.86, depending on the game). Of the 4 participants, 2 did not exercise regularly before the study; these 2 participants increased from reportedly exercising close to 0 minutes per week to exergaming 58 and 158 minutes on average using the WOW-Mobile fitness system. The perceived usefulness of WOW-Mobile in motivating participants to exercise averaged 4.5 on a 5-point Likert scale and averaged 5 for the 3 participants with thoracic level injuries. The mean overall ease of use score was 4.25 out of 5. Conclusions: Mobile app exergames driven by EMG have promising potential for encouraging and facilitating fitness for individuals in wheelchairs who have maintained arm and hand mobility. UR - http://rehab.jmir.org/2021/1/e16054/ UR - http://dx.doi.org/10.2196/16054 UR - http://www.ncbi.nlm.nih.gov/pubmed/33464221 ID - info:doi/10.2196/16054 ER - TY - JOUR AU - Wittstein, William Matthew AU - Crider, Anthony AU - Mastrocola, Samantha AU - Guerena Gonzalez, Mariana PY - 2020/12/16 TI - Use of Virtual Reality to Assess Dynamic Posturography and Sensory Organization: Instrument Validation Study JO - JMIR Serious Games SP - e19580 VL - 8 IS - 4 KW - postural control KW - virtual reality KW - sensory organization test KW - intraclass correlations N2 - Background: The Equitest system (Neurocom) is a computerized dynamic posturography device used by health care providers and clinical researchers to safely test an individual?s postural control. While the Equitest system has evaluative and rehabilitative value, it may be limited owing to its cost, lack of portability, and reliance on only sagittal plane movements. Virtual reality (VR) provides an opportunity to reduce these limitations by providing more mobile and cost-effective tools while also observing a wider array of postural characteristics. Objective: This study aimed to test the plausibility of using VR as a feasible alternative to the Equitest system for conducting a sensory organization test. Methods: A convenience sample of 20 college-aged healthy individuals participated in the study. Participants completed the sensory organization test using the Equitest system as well as using a VR environment while standing atop a force plate (Bertec Inc). The Equitest system measures the equilibrium index. During VR trials, the estimated equilibrium index, 95% ellipse area, path length, and anterior-posterior detrended fluctuation analysis scaling exponent alpha were calculated from center of pressure data. Pearson correlation coefficients were used to assess the relationship between the equilibrium index and center of pressure?derived balance measures. Intraclass correlations for absolute agreement and consistency were calculated to compare the equilibrium index and estimated equilibrium index. Results: Intraclass correlations demonstrated moderate consistency and absolute agreement (0.5 < intraclass correlation coefficient < 0.75) between the equilibrium index and estimated equilibrium index from the Equitest and VR sensory organization test (SOT), respectively, in four of six tested conditions. Additionally, weak to moderate correlations between force plate measurements and the equilibrium index were noted in several of the conditions. Conclusions: This research demonstrated the plausibility of using VR as an alternative method to conduct the SOT. Ongoing development and testing of virtual environments are necessary before employing the technology as a replacement to current clinical tests. UR - http://games.jmir.org/2020/4/e19580/ UR - http://dx.doi.org/10.2196/19580 UR - http://www.ncbi.nlm.nih.gov/pubmed/33325830 ID - info:doi/10.2196/19580 ER - TY - JOUR AU - Koutsiana, Elisavet AU - Ladakis, Ioannis AU - Fotopoulos, Dimitris AU - Chytas, Achilleas AU - Kilintzis, Vassilis AU - Chouvarda, Ioanna PY - 2020/12/11 TI - Serious Gaming Technology in Upper Extremity Rehabilitation: Scoping Review JO - JMIR Serious Games SP - e19071 VL - 8 IS - 4 KW - serious gaming KW - gamification KW - upper extremity KW - upper limb KW - rehabilitation N2 - Background: Serious gaming has increasingly gained attention as a potential new component in clinical practice. Specifically, its use in the rehabilitation of motor dysfunctions has been intensively researched during the past three decades. Objective: The aim of this scoping review was to evaluate the current role of serious games in upper extremity rehabilitation, and to identify common methods and practice as well as technology patterns. This objective was approached via the exploration of published research efforts over time. Methods: The literature search, using the PubMed and Scopus databases, included articles published from 1999 to 2019. The eligibility criteria were (i) any form of game-based arm rehabilitation; (ii) published in a peer-reviewed journal or conference; (iii) introduce a game in an electronic format; (iv) published in English; and (v) not a review, meta-analysis, or conference abstract. The search strategy identified 169 relevant articles. Results: The results indicated an increasing research trend in the domain of serious gaming deployment in upper extremity rehabilitation. Furthermore, differences regarding the number of publications and the game approach were noted between studies that used commercial devices in their rehabilitation systems and those that proposed a custom-made robotic arm, glove, or other devices for the connection and interaction with the game platform. A particularly relevant observation concerns the evaluation of the introduced systems. Although one-third of the studies evaluated their implementations with patients, in most cases, there is the need for a larger number of participants and better testing of the rehabilitation scheme efficiency over time. Most of the studies that included some form of assessment for the introduced rehabilitation game mentioned user experience as one of the factors considered for evaluation of the system. Besides user experience assessment, the most common evaluation method involving patients was the use of standard medical tests. Finally, a few studies attempted to extract game features to introduce quantitative measurements for the evaluation of patient improvement. Conclusions: This paper presents an overview of a significant research topic and highlights the current state of the field. Despite extensive attempts for the development of gamified rehabilitation systems, there is no definite answer as to whether a serious game is a favorable means for upper extremity functionality improvement; however, this certainly constitutes a supplementary means for motivation. The development of a unified performance quantification framework and more extensive experiments could generate richer evidence and contribute toward this direction. UR - http://games.jmir.org/2020/4/e19071/ UR - http://dx.doi.org/10.2196/19071 UR - http://www.ncbi.nlm.nih.gov/pubmed/33306029 ID - info:doi/10.2196/19071 ER - TY - JOUR AU - Baeza-Barragán, Rosa Maria AU - Labajos Manzanares, Teresa Maria AU - Ruiz Vergara, Carmen AU - Casuso-Holgado, Jesús María AU - Martín-Valero, Rocío PY - 2020/12/8 TI - The Use of Virtual Reality Technologies in the Treatment of Duchenne Muscular Dystrophy: Systematic Review JO - JMIR Mhealth Uhealth SP - e21576 VL - 8 IS - 12 KW - Duchenne muscular dystrophy KW - virtual reality KW - upper limb KW - physical therapy KW - muscular dystrophy KW - mutation KW - muscle KW - degeneration N2 - Background: Duchenne muscular dystrophy is a serious and progressive disease affecting one in 3500-6000 live male births. The use of new virtual reality technologies has revolutionized the world of youth rehabilitation. Objective: We performed a systematic review to study the effectiveness of the use of virtual reality systems applied in the rehabilitation of the upper limbs of individuals with Duchenne muscular dystrophy. Methods: Between June 2018 and September 2019, we carried out a series of searches in 5 scientific databases: (1) PubMed, (2) Web of Science, (3) Scopus, (4) The Cochrane Library, and (5) MEDLINE via EBSCO. Two evaluators independently conducted the searches following the PRISMA recommendations for systematic reviews for articles. Two independent evaluators collated the results. Article quality was determined using the PEDro scale. Results: A total of 7 clinical trials were included in the final review. These studies used new technologies as tools for physiotherapeutic rehabilitation of the upper limbs of patients with Duchenne muscular dystrophy. Collectively, the studies showed improvement in functionality, quality of life, and motivation with the use of virtual reality technologies in the rehabilitation of upper limbs of individuals with Duchenne muscular dystrophy. Conclusions: The treatment of neuromuscular diseases has changed in recent years, from palliative symptom management to preventive methods for capacity building. The use of virtual reality is beginning to be necessary in the treatment of progressive diseases involving movement difficulties, as it provides freedom and facilitates the improvement of results in capacity training. Given that new technologies are increasingly accessible, rehabilitation and physiotherapy programs can use these technologies more frequently, and virtual reality environments can be used to improve task performance, which is essential for people with disabilities. Ultimately, virtual reality can be a great tool for physiotherapy and can be used for Duchenne muscular dystrophy rehabilitation programs to improve patient performance during training. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42018102548; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=102548 UR - http://mhealth.jmir.org/2020/12/e21576/ UR - http://dx.doi.org/10.2196/21576 UR - http://www.ncbi.nlm.nih.gov/pubmed/33289679 ID - info:doi/10.2196/21576 ER - TY - JOUR AU - Frost, Emily AU - Porat, Talya AU - Malhotra, Paresh AU - Picinali, Lorenzo PY - 2020/9/30 TI - A Novel Auditory-Cognitive Training App for Delaying or Preventing the Onset of Dementia: Participatory Design With Stakeholders JO - JMIR Hum Factors SP - e19880 VL - 7 IS - 3 KW - cognitive decline KW - mobile phone KW - hearing loss N2 - Background: Multiple gaming apps exist under the dementia umbrella for skills such as navigation; however, an app to specifically investigate the role of hearing loss in the process of cognitive decline is yet to be designed. There is a demonstrable gap in the utilization of games to further the knowledge of the potential relationship between hearing loss and dementia. Objective: This study aims to identify the needs, facilitators, and barriers in designing a novel auditory-cognitive training gaming app. Methods: A participatory design approach was used to engage key stakeholders across audiology and cognitive disorder specialties. Two rounds, including paired semistructured interviews and focus groups, were completed and thematically analyzed. Results: A total of 18 stakeholders participated, and 6 themes were identified to inform the next stage of app development. These included congruence with hobbies, life getting in the way, motivational challenge, accessibility, addictive competition, and realism. Conclusions: The findings can now be implemented in the development of the app. The app will be evaluated against outcome measures of speech listening in noise, cognitive and attentional tasks, quality of life, and usability. UR - http://humanfactors.jmir.org/2020/3/e19880/ UR - http://dx.doi.org/10.2196/19880 UR - http://www.ncbi.nlm.nih.gov/pubmed/32996884 ID - info:doi/10.2196/19880 ER - TY - JOUR AU - Hesam-Shariati, Negin AU - Newton-John, Toby AU - Singh, K. Avinash AU - Tirado Cortes, A. Carlos AU - Do, Nguyen Tien-Thong AU - Craig, Ashley AU - Middleton, W. James AU - Jensen, P. Mark AU - Trost, Zina AU - Lin, Chin-Teng AU - Gustin, M. Sylvia PY - 2020/9/29 TI - Evaluation of the Effectiveness of a Novel Brain-Computer Interface Neuromodulative Intervention to Relieve Neuropathic Pain Following Spinal Cord Injury: Protocol for a Single-Case Experimental Design With Multiple Baselines JO - JMIR Res Protoc SP - e20979 VL - 9 IS - 9 KW - EEG neurofeedback KW - neuropathic pain KW - spinal cord injury KW - thalamus KW - serious games KW - brain-machine interface KW - brain-computer interface KW - single-case experimental design N2 - Background: Neuropathic pain is a debilitating secondary condition for many individuals with spinal cord injury. Spinal cord injury neuropathic pain often is poorly responsive to existing pharmacological and nonpharmacological treatments. A growing body of evidence supports the potential for brain-computer interface systems to reduce spinal cord injury neuropathic pain via electroencephalographic neurofeedback. However, further studies are needed to provide more definitive evidence regarding the effectiveness of this intervention. Objective: The primary objective of this study is to evaluate the effectiveness of a multiday course of a brain-computer interface neuromodulative intervention in a gaming environment to provide pain relief for individuals with neuropathic pain following spinal cord injury. Methods: We have developed a novel brain-computer interface-based neuromodulative intervention for spinal cord injury neuropathic pain. Our brain-computer interface neuromodulative treatment includes an interactive gaming interface, and a neuromodulation protocol targeted to suppress theta (4-8 Hz) and high beta (20-30 Hz) frequency powers, and enhance alpha (9-12 Hz) power. We will use a single-case experimental design with multiple baselines to examine the effectiveness of our self-developed brain-computer interface neuromodulative intervention for the treatment of spinal cord injury neuropathic pain. We will recruit 3 participants with spinal cord injury neuropathic pain. Each participant will be randomly allocated to a different baseline phase (ie, 7, 10, or 14 days), which will then be followed by 20 sessions of a 30-minute brain-computer interface neuromodulative intervention over a 4-week period. The visual analog scale assessing average pain intensity will serve as the primary outcome measure. We will also assess pain interference as a secondary outcome domain. Generalization measures will assess quality of life, sleep quality, and anxiety and depressive symptoms, as well as resting-state electroencephalography and thalamic ?-aminobutyric acid concentration. Results: This study was approved by the Human Research Committees of the University of New South Wales in July 2019 and the University of Technology Sydney in January 2020. We plan to begin the trial in October 2020 and expect to publish the results by the end of 2021. Conclusions: This clinical trial using single-case experimental design methodology has been designed to evaluate the effectiveness of a novel brain-computer interface neuromodulative treatment for people with neuropathic pain after spinal cord injury. Single-case experimental designs are considered a viable alternative approach to randomized clinical trials to identify evidence-based practices in the field of technology-based health interventions when recruitment of large samples is not feasible. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000556943; https://bit.ly/2RY1jRx International Registered Report Identifier (IRRID): PRR1-10.2196/20979 UR - http://www.researchprotocols.org/2020/9/e20979/ UR - http://dx.doi.org/10.2196/20979 UR - http://www.ncbi.nlm.nih.gov/pubmed/32990249 ID - info:doi/10.2196/20979 ER - TY - JOUR AU - Lai, Byron AU - Davis, Drew AU - Narasaki-Jara, Mai AU - Hopson, Betsy AU - Powell, Danielle AU - Gowey, Marissa AU - Rocque, G. Brandon AU - Rimmer, H. James PY - 2020/9/3 TI - Feasibility of a Commercially Available Virtual Reality System to Achieve Exercise Guidelines in Youth With Spina Bifida: Mixed Methods Case Study JO - JMIR Serious Games SP - e20667 VL - 8 IS - 3 KW - physical activity KW - active video gaming KW - exergaming KW - disability KW - Oculus Quest N2 - Background: Access to physical activity among youth with spina bifida (SB) is much lower than it is for children without disability. Enjoyable home-based exercise programs are greatly needed. Objective: Our objective is to examine the feasibility of a virtual reality (VR) active video gaming system (ie, bundle of consumer-available equipment) to meet US physical activity guidelines in two youth with SB. Methods: Two youth with SB?a 12-year-old female and a 13-year-old male; both full-time wheelchair users?participated in a brief, 4-week exercise program using a popular VR head-mounted display: Oculus Quest (Facebook Technologies). The system included a Polar H10 (Polar Canada) Bluetooth heart rate monitor, a no-cost mobile phone app (VR Health Exercise Tracker [Virtual Reality Institute of Health and Exercise]), and 13 games. The intervention protocol was conducted entirely in the homes of the participants due to the coronavirus disease 2019 (COVID-19) pandemic. The VR system was shipped to participants and they were instructed to do their best to complete 60 minutes of moderate-intensity VR exercise per day. Exercise duration, intensity, and calories expended were objectively monitored and recorded during exercise using the heart rate monitor and a mobile app. Fatigue and depression were measured via self-report questionnaires at pre- and postintervention. Participants underwent a semistructured interview with research staff at postintervention. Results: Across the intervention period, the total average minutes of all exercise performed each week for participants 1 and 2 were 281 (SD 93) and 262 (SD 55) minutes, respectively. The total average minutes of moderate-intensity exercise performed per week for participants 1 and 2 were 184 (SD 103) (184/281, 65.4%) and 215 (SD 90) (215/262, 82.1%) minutes, respectively. One participant had a reduction in their depression score, using the Quality of Life in Neurological Disorders (Neuro-QoL) test, from baseline to postintervention, but no other changes were observed for fatigue and depression scores. Participants reported that the amount of exercise they completed was far higher than what was objectively recorded, due to usability issues with the chest-worn heart rate monitor. Participants noted that they were motivated to exercise due to the enjoyment of the games and VR headset as well as support from a caregiver. Conclusions: This study demonstrated that two youth with SB who used wheelchairs could use a VR system to independently and safely achieve exercise guidelines at home. Study findings identified a promising protocol for promoting exercise in this population and this warrants further examination in future studies with larger samples. UR - http://games.jmir.org/2020/3/e20667/ UR - http://dx.doi.org/10.2196/20667 UR - http://www.ncbi.nlm.nih.gov/pubmed/32880577 ID - info:doi/10.2196/20667 ER - TY - JOUR AU - LaPiana, Nina AU - Duong, Alvin AU - Lee, Alex AU - Alschitz, Leon AU - Silva, L. Rafael M. AU - Early, Jody AU - Bunnell, Aaron AU - Mourad, Pierre PY - 2020/9/2 TI - Acceptability of a Mobile Phone?Based Augmented Reality Game for Rehabilitation of Patients With Upper Limb Deficits from Stroke: Case Study JO - JMIR Rehabil Assist Technol SP - e17822 VL - 7 IS - 2 KW - augmented reality KW - stroke KW - upper limb rehabilitation KW - gamification KW - motor rehabilitation KW - motivation KW - participation N2 - Background: Upper limb functional deficits are common after stroke and result from motor weakness, ataxia, spasticity, spatial neglect, and poor stamina. Past studies employing a range of commercial gaming systems to deliver rehabilitation to stroke patients provided short-term efficacy but have not yet demonstrated whether or not those games are acceptable, that is, motivational, comfortable, and engaging, which are all necessary for potential adoption and use by patients. Objective: The goal of the study was to assess the acceptability of a smartphone-based augmented reality game as a means of delivering stroke rehabilitation for patients with upper limb motor function loss. Methods: Patients aged 50 to 70 years, all of whom experienced motor deficits after acute ischemic stroke, participated in 3 optional therapy sessions using augmented reality therapeutic gaming over the course of 1 week, targeting deficits in upper extremity strength and range of motion. After completion of the game, we administered a 16-item questionnaire to the patients to assess the game?s acceptability; 8 questions were answered by rating on a scale from 1 (very negative experience) to 5 (very positive experience); 8 questions were qualitative. Results: Patients (n=5) completed a total of 23 out of 45 scheduled augmented reality game sessions, with patient fatigue as the primary factor for uncompleted sessions. Each patient consented to 9 potential game sessions and completed a mean of 4.6 (SE 1.3) games. Of the 5 patients, 4 (80%) completed the questionnaire at the end of their final gaming session. Of note, patients were motivated to continue to the end of a given gaming session (mean 4.25, 95% CI 3.31-5.19), to try other game-based therapies (mean 3.75, 95% CI 2.81-4.69), to do another session (mean 3.50, 95% CI 2.93-4.07), and to perform other daily rehabilitation exercises (mean 3.25, 95% CI 2.76-3.74). In addition, participants gave mean scores of 4.00 (95% CI 2.87-5.13) for overall experience; 4.25 (95% CI 3.31-5.19) for comfort; 3.25 (95% CI 2.31-4.19) for finding the study fun, enjoyable, and engaging; and 3.50 (95% CI 2.52-4.48) for believing the technology could help them reach their rehabilitation goals. For each of the 4 patients, their reported scores were statistically significantly higher than those generated by a random sampling of values (patient 1: P=.04; patient 2: P=.04; patient 4: P=.004; patient 5: P=.04). Conclusions: Based on the questionnaire scores, the patients with upper limb motor deficits following stroke who participated in our case study found our augmented reality game motivating, comfortable, engaging, and tolerable. Improvements in augmented reality technology motivated by this case study may one day allow patients to work with improved versions of this therapy independently in their own home. We therefore anticipate that smartphone-based augmented reality gaming systems may eventually provide useful postdischarge self-treatment as a supplement to professional therapy for patients with upper limb deficiencies from stroke. UR - http://rehab.jmir.org/2020/2/e17822/ UR - http://dx.doi.org/10.2196/17822 UR - http://www.ncbi.nlm.nih.gov/pubmed/32876580 ID - info:doi/10.2196/17822 ER - TY - JOUR AU - Steiner, Bianca AU - Elgert, Lena AU - Saalfeld, Birgit AU - Wolf, Klaus-Hendrik PY - 2020/8/25 TI - Gamification in Rehabilitation of Patients With Musculoskeletal Diseases of the Shoulder: Scoping Review JO - JMIR Serious Games SP - e19914 VL - 8 IS - 3 KW - shoulder KW - upper extremity KW - musculoskeletal diseases KW - rehabilitation KW - gamification KW - serious games KW - exergames KW - scoping review N2 - Background: Gamification has become increasingly important both in research and in practice. Particularly in long-term care processes, such as rehabilitation, playful concepts are gaining in importance to increase motivation and adherence. In addition to neurological diseases, this also affects the treatment of patients with musculoskeletal diseases such as shoulder disorders. Although it would be important to assist patients during more than one rehabilitation phase, it is hypothesized that existing systems only support a single phase. It is also unclear which game design elements are currently used in this context and how they are combined to achieve optimal positive effects on motivation. Objective: This scoping review aims to identify and analyze information and communication technologies that use game design elements to support the rehabilitation processes of patients with musculoskeletal diseases of the shoulder. The state of the art with regard to fields of application, game design elements, and motivation concepts will be determined. Methods: We conducted a scoping review to identify relevant application systems. The search was performed in 3 literature databases: PubMed, IEEE Xplore, and Scopus. Following the PICO (population, intervention, comparison, outcome) framework, keywords and Medical Subject Headings for shoulder, rehabilitation, and gamification were derived to define a suitable search term. Two independent reviewers, a physical therapist and a medical informatician, completed the search as specified by the search strategy. There was no restriction on year of publication. Data synthesis was done by deductive-inductive coding based on qualitative content analysis. Results: A total of 1994 articles were screened; 31 articles in English, published between 2006 and 2019, were included. Within, 27 application systems that support patients with musculoskeletal diseases of the shoulder in exercising, usually at home but also in inpatient or outpatient rehabilitation clinics, were described. Only 2 application systems carried out monitoring of adherence. Almost all were based on in-house developed software. The most frequently used game components were points, tasks, and avatars. More complex game components, such as collections and teams, were rarely used. When selecting game components, patient-specific characteristics, such as age and gender, were only considered in 2 application systems. Most were described as motivating, though an evaluation of motivational effects was usually not conducted. Conclusions: There are only a few application systems supporting patients with musculoskeletal diseases of the shoulder in rehabilitation by using game design elements. Almost all application systems are exergames for supporting self-exercising. Application systems for multiple rehabilitation phases seem to be nonexistent. It is also evident that only a few complex game design elements are used. Patient-specific characteristic are generally neglected when selecting and implementing game components. Consequently, a holistic approach to enhance adherence to rehabilitation is required supporting patients during the entire rehabilitation process by providing motivational game design elements based on patient-specific characteristics. UR - http://games.jmir.org/2020/3/e19914/ UR - http://dx.doi.org/10.2196/19914 UR - http://www.ncbi.nlm.nih.gov/pubmed/32840488 ID - info:doi/10.2196/19914 ER - TY - JOUR AU - Shen, Jiabin AU - Xiang, Henry AU - Luna, John AU - Grishchenko, Alice AU - Patterson, Jeremy AU - Strouse, V. Robert AU - Roland, Maxwell AU - Lundine, P. Jennifer AU - Koterba, H. Christine AU - Lever, Kimberly AU - Groner, I. Jonathan AU - Huang, Yungui AU - Lin, Deborah En-Ju PY - 2020/8/25 TI - Virtual Reality?Based Executive Function Rehabilitation System for Children With Traumatic Brain Injury: Design and Usability Study JO - JMIR Serious Games SP - e16947 VL - 8 IS - 3 KW - traumatic brain injury KW - virtual reality KW - neurological rehabilitation KW - executive function KW - cognitive rehabilitation N2 - Background: Traumatic brain injury (TBI) poses a significant threat to children?s health. Cognitive rehabilitation for pediatric TBI has the potential to improve the quality of life following the injury. Virtual reality (VR) can provide enriched cognitive training in a life-like but safe environment. However, existing VR applications for pediatric TBIs have primarily focused on physical rehabilitation. Objective: This study aims to design and develop an integrative hardware and software VR system to provide rehabilitation of executive functions (EF) for children with TBI, particularly in 3 core EF: inhibitory control, working memory, and cognitive flexibility. Methods: The VR training system was developed by an interdisciplinary team with expertise in best practices of VR design, developmental psychology, and pediatric TBI rehabilitation. Pilot usability testing of this novel system was conducted among 10 healthy children and 4 children with TBIs. Results: Our VR-based interactive cognitive training system was developed to provide assistive training on core EF following pediatric TBI. Pilot usability testing showed adequate user satisfaction ratings for both the hardware and software components of the VR system. Conclusions: This project designed and tested a novel VR-based system for executive function rehabilitation that is specifically adapted to children following TBI. UR - http://games.jmir.org/2020/3/e16947/ UR - http://dx.doi.org/10.2196/16947 UR - http://www.ncbi.nlm.nih.gov/pubmed/32447275 ID - info:doi/10.2196/16947 ER - TY - JOUR AU - van der Veen, M. Susanne AU - Stamenkovic, Alexander AU - Applegate, E. Megan AU - Leitkam, T. Samuel AU - France, R. Christopher AU - Thomas, S. James PY - 2020/8/19 TI - Effects of Avatar Perspective on Joint Excursions Used to Play Virtual Dodgeball: Within-Subject Comparative Study JO - JMIR Serious Games SP - e18888 VL - 8 IS - 3 KW - virtual reality KW - avatar perspective KW - reaching KW - joint excursion KW - exergaming KW - exercise rehabilitation KW - head mounted display N2 - Background: Visual representation of oneself is likely to affect movement patterns. Prior work in virtual dodgeball showed greater excursion of the ankles, knees, hips, spine, and shoulder occurs when presented in the first-person perspective compared to the third-person perspective. However, the mode of presentation differed between the two conditions such that a head-mounted display was used to present the avatar in the first-person perspective, but a 3D television (3DTV) display was used to present the avatar in the third-person. Thus, it is unknown whether changes in joint excursions are driven by the visual display (head-mounted display versus 3DTV) or avatar perspective during virtual gameplay. Objective: This study aimed to determine the influence of avatar perspective on joint excursion in healthy individuals playing virtual dodgeball using a head-mounted display. Methods: Participants (n=29, 15 male, 14 female) performed full-body movements to intercept launched virtual targets presented in a game of virtual dodgeball using a head-mounted display. Two avatar perspectives were compared during each session of gameplay. A first-person perspective was created by placing the center of the displayed content at the bridge of the participant?s nose, while a third-person perspective was created by placing the camera view at the participant?s eye level but set 1 m behind the participant avatar. During gameplay, virtual dodgeballs were launched at a consistent velocity of 30 m/s to one of nine locations determined by a combination of three different intended impact heights and three different directions (left, center, or right) based on subject anthropometrics. Joint kinematics and angular excursions of the ankles, knees, hips, lumbar spine, elbows, and shoulders were assessed. Results: The change in joint excursions from initial posture to the interception of the virtual dodgeball were averaged across trials. Separate repeated-measures ANOVAs revealed greater excursions of the ankle (P=.010), knee (P=.001), hip (P=.0014), spine (P=.001), and shoulder (P=.001) joints while playing virtual dodgeball in the first versus third-person perspective. Aligning with the expectations, there was a significant effect of impact height on joint excursions. Conclusions: As clinicians develop treatment strategies in virtual reality to shape motion in orthopedic populations, it is important to be aware that changes in avatar perspective can significantly influence motor behavior. These data are important for the development of virtual reality assessment and treatment tools that are becoming increasingly practical for home and clinic-based rehabilitation. UR - http://games.jmir.org/2020/3/e18888/ UR - http://dx.doi.org/10.2196/18888 UR - http://www.ncbi.nlm.nih.gov/pubmed/32812885 ID - info:doi/10.2196/18888 ER - TY - JOUR AU - Hennessy, White Rebecca AU - Rumble, Deanna AU - Christian, Mike AU - Brown, A. David AU - Trost, Zina PY - 2020/8/10 TI - A Graded Exposure, Locomotion-Enabled Virtual Reality App During Walking and Reaching for Individuals With Chronic Low Back Pain: Cohort Gaming Design JO - JMIR Serious Games SP - e17799 VL - 8 IS - 3 KW - virtual reality KW - chronic low back pain KW - walking KW - rehabilitation KW - virtual reality exposure therapy N2 - Background: Chronic low back pain (cLBP) can interfere with daily activities, and individuals with elevated pain-related fear (also known as kinesiophobia or the fear of injury due to movement) can develop worse long-term disability. Graded exposure (GEXP) protocols use successive participation in avoided activities to help individuals overcome fearful movement appraisals and encourage activity. We sought to develop a series of GEXP virtual reality (VR) walking and reaching scenarios to increase the exposure and engagement of people with high kinesiophobia and cLBP. Objective: This study aims to (1) determine GEXP content validity of the VR application and (2) determine the feasibility of individuals with cLBP performing locomotion-enabled physical activities. Methods: We recruited 13 individuals with cLBP and high pain-related fear to experience six VR modules, which provide progressive movement exposure over three sessions in a 1 week period. At session 1, participants ranked each module by likelihood to avoid and assigned an expected pain and concern for harming their back rating to each module. Participants provided a rating of perceived exertion (RPE) after experiencing each module. To test feasibility, we administered the system usability scale (SUS) and treatment evaluation inventory (TEI) following the final session. In addition, we measured pain and pain-related fear at baseline and follow-up. Results: The 12 participants who completed the study period assigned higher avoidance (P=.002), expected pain (P=.002), and expected concern (P=.002) for session 3 modules compared with session 1 modules. RPE significantly increased from session 1 (mean 14.8, SD 2.3) to session 3 (mean 16.8, SD 2.2; P=.009). The VR application showed positive feasibility for individuals with cLBP through acceptable SUS (mean 76.7, SD 13.0) and TEI (mean 32.5, SD 4.9) scores. Neither pain (P=.20) nor pain-related fear (P=.58) changed significantly across sessions. Conclusions: The GEXP VR modules provided progressive exposure to physical challenges, and participants found the VR application acceptable and usable as a potential treatment option. Furthermore, the lack of significant change for pain and pain-related fear reflects that participants were able to complete the modules safely. UR - http://games.jmir.org/2020/3/e17799/ UR - http://dx.doi.org/10.2196/17799 UR - http://www.ncbi.nlm.nih.gov/pubmed/32773381 ID - info:doi/10.2196/17799 ER - TY - JOUR AU - Tacchino, Andrea AU - Veldkamp, Renee AU - Coninx, Karin AU - Brulmans, Jens AU - Palmaers, Steven AU - Hämäläinen, Päivi AU - D'hooge, Mieke AU - Vanzeir, Ellen AU - Kalron, Alon AU - Brichetto, Giampaolo AU - Feys, Peter AU - Baert, Ilse PY - 2020/4/16 TI - Design, Development, and Testing of an App for Dual-Task Assessment and Training Regarding Cognitive-Motor Interference (CMI-APP) in People With Multiple Sclerosis: Multicenter Pilot Study JO - JMIR Mhealth Uhealth SP - e15344 VL - 8 IS - 4 KW - tablet KW - mobile device KW - cognitive rehabilitation KW - cognitive impairment KW - dual-task training KW - cognitive-motor interference KW - dual-task cost KW - adherence KW - multiple sclerosis KW - walking N2 - Background: Dual tasking constitutes a large portion of most activities of daily living; in real-lifesituations, people need to not only maintain balance and mobility skills, but also perform other cognitive or motor tasks at the same time. Interest toward dual-task training (DTT) is increasing as traditional interventions may not prepare patients to adequately face the challenges of most activities of daily living. These usually involve simultaneous cognitive and motor tasks, and they often show a decline in performance. Cognitive-motor interference (CMI) has been investigated in different neurological populations, but limited evidence is present for people with multiple sclerosis (MS). The use of computerized tools is mandatory to allow the application of more standardized assessment and rehabilitation intervention protocols and easier implementation of multicenter and multilanguage studies. Objective: To describe the design and development of CMI-APP, an adaptive and interactive technology tablet-based app, and to present the preliminary results of a multicenter pilot study involving people with MS performed in several European centers for evaluating the feasibility of and adherence to a rehabilitation program based on CMI-APP. Methods: CMI-APP includes user-friendly interfaces for personal data input and management, assessment of CMI, and DTT. A dedicated team developed CMI-APP for Android tablets above API level 14 (version 4.0), using C# as the programming language and Unity and Visual Studio as development tools. Three cognitive assessment tests for working memory, information processing speed, and sustained attention and four motor assessment tests for walking at different difficulty levels were implemented. Dual cognitive-motor tasks were performed by combining single cognitive and motor tasks. CMI-APP implements exercises for DTT involving the following 12 cognitive functions: sustained attention, text comprehension, verbal fluency, auditory discrimination, visual discrimination, working memory, information processing speed, auditory memory, visual memory, verbal analog reasoning, visual analog reasoning, and visual spatial planning, which can be performed during walking or stepping on the spot. Fifteen people with MS (mean age 52.6, SD 8.6 years; mean disease duration 9.4, SD 8.4 years; mean Expanded Disability Status Scale score 3.6, SD 1.1) underwent DTT (20 sessions). Adherence to the rehabilitation program was evaluated according to the percentage of performed sessions, perceived exertion during the training (Borg 15-point Ratings of Perceived Exertion [RPE] Scale), and subjective experience of the training (Intrinsic Motivation Inventory [IMI]). Results: The adherence rate was 91%. DTT was perceived as ?somewhat difficult? (mean RPE Scale score 12.6, SD 1.9). IMI revealed that participants enjoyed the training and felt that it was valuable and, to some extent, important, without feelings of pressure. They felt competent, although they did not always feel they could choose the exercises, probably because the therapist chose the exercises and many exercises had few difficulty levels. Conclusions: CMI-APP is safe, highly usable, motivating, and well accepted for DTT by people with MS. The findings are fundamental for the preparation of future large-sample studies examining CMI and the effectiveness of DTT interventions with CMI-APP in people with MS. UR - http://mhealth.jmir.org/2020/4/e15344/ UR - http://dx.doi.org/10.2196/15344 UR - http://www.ncbi.nlm.nih.gov/pubmed/32343258 ID - info:doi/10.2196/15344 ER - TY - JOUR AU - Khalili-Mahani, Najmeh AU - Assadi, Atousa AU - Li, Kate AU - Mirgholami, Mahsa AU - Rivard, Marie-Eve AU - Benali, Habib AU - Sawchuk, Kim AU - De Schutter, Bob PY - 2020/3/26 TI - Reflective and Reflexive Stress Responses of Older Adults to Three Gaming Experiences In Relation to Their Cognitive Abilities: Mixed Methods Crossover Study JO - JMIR Ment Health SP - e12388 VL - 7 IS - 3 KW - silver gaming KW - serious games KW - stress KW - cognitive training KW - brain training games KW - exercise games KW - ICT N2 - Background: The gamification of digital health provisions for older adults (eg, for rehabilitation) is a growing trend; however, many older adults are not familiar with digital games. This lack of experience could cause stress and thus impede participants? motivations to adopt these technologies. Objective: This crossover longitudinal multifactorial study aimed to examine the interactions between game difficulty, appraisal, cognitive ability, and physiological and cognitive responses that indicate game stress using the Affective Game Planning for Health Applications framework. Methods: A total of 18 volunteers (mean age 71 years, SD 4.5; 12 women) completed a three-session study to evaluate different genres of games in increasing order of difficulty (S1-BrainGame, S2-CarRace, and S3-Exergame). Each session included an identical sequence of activities (t1-Baseline, t2-Picture encode, t3-Play, t4-Stroop test, t5-Play, and t6-Picture recall), a repeated sampling of salivary cortisol, and time-tagged ambulatory data from a wrist-worn device. Generalized estimating equations were used to investigate the effect of session×activity or session×activity×cognitive ability on physiology and cognitive performance. Scores derived from the Montreal Cognitive Assessment (MoCA) test were used to define cognitive ability (MoCA-high: MoCA>27, n=11/18). Kruskal-Wallis tests were used to test session or session×group effects on the scores of the postgame appraisal questionnaire. Results: Session×activity effects were significant on all ambulatory measures (?210>20; P<.001) other than cortisol (P=.37). Compared with S1 and S2, S3 was associated with approximately 10 bpm higher heart rate (P<.001) and approximately 5 muS higher electrodermal activity (P<.001), which were both independent of the movement caused by the exergame. Compared with S1, we measured a moderate but statistically significant drop in the rate of hits in immediate recall and rate of delayed recall in S3. The low-MoCA group did not differ from the high-MoCA group in general characteristics (age, general self-efficacy, and perceived stress) but was more likely to agree with statements such as digital games are too hard to learn. In addition, the low-MoCA group was more likely to dislike the gaming experience and find it useless, uninteresting, and visually more intense (?21>4; P<.04). Group differences in ambulatory signals did not reach statistical significance; however, the rate of cortisol decline with respect to the baseline was significantly larger in the low-MoCA group. Conclusions: Our results show that the experience of playing digital games was not stressful for our participants. Comparatively, the neurophysiological effects of exergame were more pronounced in the low-MoCA group, suggesting greater potential of this genre of games for cognitive and physical stimulation by gamified interventions; however, the need for enjoyment of this type of challenging game must be addressed. UR - http://mental.jmir.org/2020/3/e12388/ UR - http://dx.doi.org/10.2196/12388 UR - http://www.ncbi.nlm.nih.gov/pubmed/32213474 ID - info:doi/10.2196/12388 ER - TY - JOUR AU - Vugts, AP Miel AU - Zedlitz, MEE Aglaia AU - Joosen, CW Margot AU - Vrijhoef, JM Hubertus PY - 2020/3/9 TI - Serious Gaming During Multidisciplinary Rehabilitation for Patients With Chronic Pain or Fatigue Symptoms: Mixed Methods Design of a Realist Process Evaluation JO - J Med Internet Res SP - e14766 VL - 22 IS - 3 KW - serious gaming KW - eHealth KW - chronic pain KW - medically unexplained symptoms KW - implementation KW - realist evaluation N2 - Background: Serious gaming could support patients in learning to cope with chronic pain or functional somatic syndromes and reduce symptom burdens. Objective: To realize this potential, insight is needed into how, why, for whom, and when it works in actual treatment circumstances. Methods: Following a realist approach, process evaluations were performed before, during, and after a two-armed, natural quasi-experiment (n=275). A group of patients with interfering chronic pain or fatigue symptoms received a short additional blended mindfulness-based serious gaming intervention during a multidisciplinary rehabilitation program. A control group only received the regular rehabilitation program. During two sessions before and one session after the experiment, expectations about serious gaming processes were discussed in focus groups with local care providers, implementers, and experts. Patients participated in a survey (n=114) and in semistructured interviews (n=10). The qualitative data were used to develop tentative expectations about aspects of serious gaming that, in certain patients and circumstances, trigger mechanisms of learning and health outcome change. Hypotheses about indicative quantitative data patterns for tentative expectations were formulated before inspecting, describing, and analyzing?with regression models?routinely collected clinical outcome data. An updated program theory was formulated after mixing the qualitative and quantitative results. Results: Qualitative data showed that a subset of patients perceived improvement of their self-awareness in moments of daily social interactions. These results were explained by patients, who played the serious game LAKA, as a ?confrontation with yourself,? which reflected self-discrepancies. Important characteristics of serious gaming in the study?s context included innovation factors of relative advantage with experiential learning opportunity, compatibility with the treatment approach, and the limited flexibility in regard to patient preferences. Perceived patient factors included age and style of coping with stress or pain. Learning perceptions could also depend on care provider role-taking and the planning and facilitating (ie, local organization) of serious gaming introduction and feedback sessions in small groups of patients. Quantitative data showed very small average differences between the study groups in self-reported depression, pain, and fatigue changes (-.07