JMIR Publications

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  Research Letter

  Jan 15, 2026

  RedMan-GreenMan: Co-Designed Pedestrian Safety Game Prototype for Children With Autism

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  Authors List:

  • Jason Carter Stanton  
  • Nicole L Peel  
  • Caroline J Mills  
  • Paul P Breen  

  Abstract:

  This research letter presents the conceptualization, design, and in-situ evaluation of the RedMan-GreenMan game co-developed with carers to help children with Autism Spectrum Disorder (hereafter autism) acquire pedestrian safety skills.

  • JMIR Serious Games 2026;14(1):e69260

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  Serious Games for Health and Medicine

  Jan 13, 2026

  Usability Study of Augmented Reality Visualization Modalities on Localization Accuracy in the Head and Neck: Randomized Crossover Trial

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  Authors List:

  • Yao Li  
  • Gijs Luijten  
  • Christina Gsaxner  
  • Kim Grunert  
  • Alexis Bader  
  • Frank Hölzle  
  • Rainer Röhrig  
  • Matías de la Fuente  
  • Jan Egger  
  • Kunpeng Xie  
  • Behrus Hinrichs-Puladi  

  Abstract:

  Background: Augmented reality (AR) head mounted displays (HMDs) could overcome the spatial dissociation between medical imaging and the surgical field, which may be particularly important in anatomically dense regions such as the head and neck. Although many HMDs offer markerless inside-out tracking at a fraction of the cost of navigation systems, their overlay accuracy with superimposition (SI) modality onto the surgical field remains limited. The virtual twin (VT), displaying holography adjacent to the surgical field, may offer a viable alternative. However, its performance is still unclear. Objective: To compare the accuracy and efficiency of the two visualization modalities SI and VT for anatomical localization in the head and neck region. Methods: In a randomized crossover trial to compare two AR visualization modalities (SI and VT), 38 participants used a HoloLens 2 (HL2) to localize point, line, and volume-based anatomical structures on head phantoms. Their performance was evaluated with respect to accuracy, workload, time, and user experience. Results: SI achieved significantly better point localization accuracy than VT both in absolute (14.4 ± 4.2 mm vs. 15.8 ± 5.5 mm; P=.003) and relative accuracy (3.4 ± 2.2 mm vs. 6.0 ± 5.0 mm; P<.001). In line-based structures, accuracy was comparable between SI (ASD: 23.4 mm; HD 31.5 mm) and VT (ASD: 23.0 mm, P=.51; HD 31.0 mm, P=.57). However, SI showed significantly higher deviation than VT in volume-based structure (ASD: 37.1 mm vs. 34.1 mm, P=.01; HD: 52.0 mm vs. 49.1 mm, P=.03). Subjects were faster with SI (P=.02), while workload NASA-TLX scores did not demonstrate a significant difference (P=.79). Conclusions: Given that SI did not clearly outperform VT under overlaid soft tissue and viewing challenges, VT remains a viable alternative in certain surgical scenarios where high accuracy is not required. Future research should focus on optimizing viewing angles guidance and the linkage between anatomical target and the skin surface. Clinical Trial: German Clinical Trial Register DRKS00032835; https://drks.de/search/en/trial/DRKS00032835

  • JMIR Serious Games 2026;14(1):e75962

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  Serious Games for Health and Medicine

  Jan 5, 2026

  Efficacy and Safety of a Video Game–Like Digital Therapy Intervention for Chinese Children With Attention-Deficit/Hyperactivity Disorder: Single-Arm,...

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  Authors List:

  • Mengyi Bao  
  • Shang Feng  
  • Jiaheng Wang  
  • Jia Ye  
  • Jiangping Wang  
  • Wenyu Li  
  • Kewen Jiang  
  • Lin Yao  

  Abstract:

  Background: The digital therapy of attention-deficit/hyperactivity disorder (ADHD) based on a “self-adaptive multitasking training paradigm” has been developed to improve the cognitive functional impairments and attention deficits of children with ADHD. However, the efficacy and safety of such treatment for Chinese patients remain untested. Objective: This study aimed to preliminarily evaluate the actual intervention effects of a video game–like training software (ADHD-DTx) for children with ADHD aged 6-12 years as the first nationally certified digital therapeutics medical device for ADHD in China. We performed a single-arm, open-label efficacy and safety study. Methods: This is a single-arm, open-label, pre-post efficacy and safety study. A total of 97 participants were included in the analysis. Participants received digital therapy (ADHD-DTx) and basic behavioral parent training for 4 weeks (25 min/day, ≥5 times/week) without medication. The efficacy outcomes included the Test of Variables of Attention (TOVA), Swanson, Nolan, and Pelham Questionnaire, version 4 (SNAP-IV), Weiss Functional Impairment Rating Scale (WFIRS), and Conner’s Parent Symptom Questionnaire (PSQ). Safety-related events were monitored during and after the trial. Results: From day 0 (baseline) to day 28, the population TOVA Attention Performance Index exhibited statistically significant improvement (from mean –4.15, SE of the mean [SEM] 0.32 to mean –1.70, SEM 0.30; t₉₄=–8.78; n=95; P<.001); the population total, inattention (AD), hyperactivity/impulsivity (HD), and oppositional defiant disorder (ODD) scores of SNAP-IV all significantly improved (total: from mean 1.33, SEM 0.05 to mean 1.09, SEM 0.05; t₉₆=5.32; P<.001; AD: from mean 1.71, SEM 0.06 to mean 1.44, SEM 0.06; t₉₆=4.44; P<.001; HD: from mean 1.38, SEM 0.07 to mean 1.05, SEM 0.06; t₉₆=5.96; P<.001; ODD: mean 0.84, SEM 0.05 to mean 0.75, SEM 0.05; Z=2.47; P=.03; n=97); for WFIRS results, domains of “family” and “social activities” showed significant population improvement (family: from mean 0.75, SEM 0.05 to mean 0.65, SEM 0.04; Z=2.80; P=.01; social activities: from mean 0.56, SEM 0.05 to mean 0.45, SEM 0.05; Z=2.91; P=.01; n=97); for PSQ results, domains of “learning problem,” “psychosomatic problem,” “impulsivity-hyperactivity,” and “hyperactivity index” showed significant improvement (learning problem: from mean 1.72, SEM 0.06 to mean 1.57, SEM 0.06; Z=2.42; P=.03; psychosomatic problem: from mean 0.40, SEM 0.03 to mean 0.32, SEM 0.03; Z=2.66; P=.02; impulsivity-hyperactivity: from mean 0.94, SEM 0.06 to mean 0.80, SEM 0.06; Z=2.49; P=.03; hyperactivity index: from mean 1.06, SEM 0.05 to mean 0.92, SEM 0.05; Z=2.90; P=.01; n=97). No device-related adverse event or severe adverse event was observed or reported during or after the intervention. Conclusions: This study preliminarily suggested the significant improvements of ADHD symptoms and attention function after 4 weeks of ADHD-DTx digital therapy combining basic behavioral parent training with satisfying safety outcomes.

  • JMIR Serious Games 2026;14(1):e76114

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  Games for Cognitive Assessment

  Dec 30, 2025

  Shadow-Induced Forgetting in a Game-Based Paradigm on Nonclinical Adults and Its Effects on Consciousness, Emotional Valence, and Temporal Dynamics:...

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  Authors List:

  • Yoon Jin Cho  
  • Ka Hyun Kim  
  • Da Won Suh  
  • In Seong Baek  
  • Jung Hun Phee  
  • Jae Yong Yu  
  • Kyung Min Kim  
  • Yu Rang Park  

  Abstract:

  Background: Memory suppression transiently disrupts hippocampal activity, leading to suppression-induced forgetting (SIF), especially for negative stimuli. However, traditional paradigms like Think/No-Think rely on explicit control and lack ecological validity. This study introduces a game-based task that implicitly elicits suppression through reversed motor mappings, providing a naturalistic approach to studying memory inhibition. Objective: To examine how shadow-induced forgetting (ShIF) varies across short-term and long-term intervals (0h, 24h, 72h), under conscious versus unconscious exposure, and between positive and negative emotional stimuli. Methods: This single-center, within-subjects experimental study involved 56 university students (mean age = 23.37 ± 1.84 years) and was conducted between December 1, 2023, and March 1, 2024. Participants learned 36 cue–target image pairs varying in emotional valence (positive, negative). They underwent a game-based paradigm where habitual motor responses were disrupted through reversed key mappings to induce an amnesic shadow. During gameplay, selected cues were presented either consciously or unconsciously, while others served as controls. Memory performance was assessed using METEOR scores (semantic similarity) immediately after intervention (0 h), and again at 24 h and 72 h. Electroencephalography (EEG) was recorded in a subset of 40 participants to examine neural correlates of memory suppression. Results: Shadow-Induced Forgetting (ShIF) effects were short-term, conscious-dependent, and selective for negative memories. A significant interaction between exposure condition and time (F₃.₆₂,₁₉₉.₃₃ = 2.7, P=.037, η²ₚ = 0.05, 95% CI [0.00, 1.00]) indicated that the effect varied across time points. Specifically, a significant ShIF effect emerged immediately after the intervention (0h) in the conscious condition (t = −2.86, P= .018, d = 0.38) but was absent in the unconscious condition, and dissipated by 72 hours. Robust main effects of time (F₂,₁₀₉.₉₉ = 102.91, P<.001, η²ₚ = 0.65, 95% CI[0.57,1.00]) and emotional valence (F₁,₅₅ = 42.43, P<.001, η²ₚ = 0.44, 95% CI [0.27, 1.00]) showed that overall recall declined over time and was consistently lower for negative images. EEG analyses revealed enhanced right frontal beta (FC6, F4, F8: P< .001) and posterior gamma (O1, O2, P8: P<.002) activity during suppression of negative cues, reflecting neural inhibition processes underlying ShIF. Conclusions: ShIF occurs primarily for consciously processed negative memories and diminishes over several days, highlighting the temporal and emotional boundaries of intentional forgetting. This study introduces a game-based approach that extends traditional suppression paradigms and offers an ecologically valid framework for investigating memory control. Importantly, we demostrate that suppression can be induced through a game-based paradigm. By examining emotional valence, exposure condition, and temporal dynamics, we extend previous work, focused only on transient effects, and clarifies the potential for practical implementation in digital therapeutic applications such as PTSD treatment. Clinical Trial: CRIS KCT0009516; https://cris.nih.go.kr/cris/search/detailSearch.do?seq=29053&search_page=L

  • JMIR Serious Games 2025;13(1):e76946

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  Serious Games for Health and Medicine

  Dec 19, 2025

  Super Mario Bros. and Yoshi Games’ Affordance of Childlike Wonder and Reduced Burnout Risk in Young Adults: In-Depth Mixed Methods Cross-Sectional Study

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  Authors List:

  • Winze Tam  
  • Congcong Hou  
  • Andreas Benedikt Eisingerich  

  Abstract:

  Background: Unrelenting pressure and an “always-on” culture can leave no time for genuine rest among young adults. While playing video games has been noted to afford cognitive escapism and relaxation, critical questions remain about the influence of popular video games, such as Super Mario Bros., and their potential effects on young adults’ burnout risk. Objective: This study examined the extent to which, if at all, popular video games such as Super Mario Bros. and Yoshi could foster childlike wonder. It also investigated the potential of these games to reduce burnout risk among young adults. Methods: We used a mixed methods approach. First, qualitative data were collected through 41 exploratory, in-depth interviews (women: n=19, 46.3%; men: n=21, 51.2%; prefer not to disclose sex: n=1, 2.4%; mean age 22.51, SD 1.52 years) with university students who had experience playing Super Mario Bros. or Yoshi. Second, quantitative data were collected in a cross-sectional survey (N=336) of players of Super Mario Bros. and Yoshi to examine the games’ affordance of childlike wonder, overall happiness in life, and burnout risk. Results: Insights from in-depth interviews showed that players appreciated the ability of Super Mario Bros. and Yoshi games to instill childlike wonder, enhance happiness in life, and reduce burnout risk. Quantitative analyses showed that the games’ affordance of childlike wonder positively affected young adults’ happiness (b=0.30, SE=0.04, t=6.80, 95% CI 0.21-0.38; P<.001). In turn, overall happiness significantly reduced the risk of burnout (b=–0.48, SE=0.05, t=–9.55, 95% CI –0.572 to –0.377). Results showed that happiness fully mediated the impact of childlike wonder on burnout, as the direct effect of childlike wonder on burnout risk became insignificant (b=–0.08, SE=0.04, t=–1.88, 95% CI –0.16 to 0.01; P=.06), while the indirect effect of childlike wonder on burnout risk was significant (b=–0.14, bootstrapped SE=0.03, 95% CI –0.20 to –0.09). Conclusions: The findings showed the significant positive effect of popular video games such as Super Mario Bros. and Yoshi on fostering players’ childlike wonder, increasing happiness, and reducing burnout risk. This study was among the first to identify childlike wonder as an emotional pathway through which mainstream video games could enhance well-being and reduce burnout. By moving beyond escapism and nostalgia, it offers a new perspective on how well-designed, globally familiar games can function as accessible, resilience-building digital microenvironments. These findings contributed to research bridging gaming and mental health and have practical implications for game designers, educators, and health professionals interested in promoting mental wellness through everyday play. Trial Registration:

  • JMIR Serious Games 2025;13(1):e84219

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  Serious Games for Health and Medicine

  Dec 17, 2025

  Serious Games Integrating Perceptual Learning and Stereopsis Training in Children With Amblyopia: Single-Arm Pre-Post Feasibility Study

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  Authors List:

  • Yiwei Mo  
  • Peng Chen  
  • Manting Hou  
  • Fang Cui  
  • Chao Luo  
  • Chao Deng  
  • Jinkang Lin  
  • Qi Wu  

  Abstract:

  Background: Amblyopia, a leading cause of preventable childhood blindness, often remains inadequately addressed by traditional treatment methods such as refractive correction and occlusion therapy, which can be non-interactive and lead to poor adherence. Objective: This study aimed to design and assess the efficacy of a serious game intervention that merges perceptual learning (PL) with stereopsis training in children diagnosed with amblyopia. Methods: We evaluated visual acuity, accommodative sensitivity, binocular accommodation, and stereopsis in a cohort of amblyopic children aged 7 to 12 years before and after a 3-month intervention. Participants engaged in visual training via a serious game, attending sessions four times weekly for 30 minutes each. Results: The intervention resulted in statistically significant improvements in visual acuity, accommodative sensitivity, binocular accommodation, and stereoscopic function (p < 0.01). Notably, adjustment sensitivity (Cohen's d = 1.216) and binocular accommodation (Cohen's d = 1.112) exhibited large effect sizes. Conclusions: The integration of gamified elements into amblyopia treatment not only improved treatment adherence but also significantly enhanced visual function in children. This interactive approach effectively combines perceptual learning with stereopsis training, presenting a promising alternative to conventional therapies. Clinical Trial: The research protocol adhered to the principles of the Declaration of Helsinki and received approval from the Human Research Ethics Committee of the Faculty of Psychology, Shenzhen University（SZU_PSY_2024_100）

  • JMIR Serious Games 2025;13(1):e77402

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  Gamification

  Dec 16, 2025

  Long-Term Usage of Breeze, a Gamified Breathing Training App, and Its Effect on Momentary Relaxation in People With Cancer: Cohort Study

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  Authors List:

  • Anja Yvonne Bischof  
  • Tobias Budig  
  • Sonja Schläpfer  
  • Yanick Xavier Lukic  
  • Fabian Schneider  
  • Prabhakaran Santhanam  
  • Jürgen Barth  
  • Claudia M Witt  
  • Tobias Kowatsch  

  Abstract:

  Background: People with cancer often experience stress. Digital health interventions (DHIs) can help individuals increase momentary relaxation. Breeze is a gamified breathing training that can be embedded into DHIs. Its effectiveness in controlled cross-sectional studies was shown. However, adherence to Breeze and its effect on momentary relaxation in longitudinal interventional studies has yet to be investigated. Objective: This work aims to assess the use of Breeze and its effect on momentary relaxation in people with cancer. Methods: Breeze was one of seven relaxation techniques included in the CanRelax 2.0 app, designed specifically for individuals diagnosed with cancer. Participants could select any of the seven techniques to promote momentary relaxation. The intervention was designed to last 10 weeks. However, participants were allowed to use the CanRelax 2.0 app after that period. Participants were adults diagnosed with cancer in the last five years recruited across Switzerland, Germany, and Austria. Momentary relaxation was measured pre- and post-exercise using an 11-point visual analog scale, while Breeze was assessed through objective usage metrics. Statistical analyses included linear mixed-effects models and effect size calculations. Results: Out of 352 participants, 118 (33.5%) used Breeze at least once. The 118 participants engaged in 754 breathing sessions with Breeze. Momentary relaxation was assessed and calculated for 249 (33.0%) Breeze sessions. The use of Breeze remained stable even after the formal intervention period. Participants also followed the pre-defined breathing rates of Breeze. On average, a small effect on momentary relaxation was observed for 2-minute breathing sessions (d = .20), while a large effect (d = .74) resulted from breathing sessions >=4 minutes. Conclusions: This study shows the potential of Breeze to reduce acute stress in individuals with a chronic condition, such as cancer. By combining gamification with evidence-based breathing techniques, Breeze fosters sustained user engagement and momentary relaxation. Future research aims to assess the impact of Breeze on other populations and chronic conditions. Clinical Trial: German Clinical Trials Register DRKS00027546; registered on 23 February 2022

  • JMIR Serious Games 2025;13(1):e70297

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  Exergames, Active Games and...

  Dec 15, 2025

  Effects of Competitive Exergaming–Based Esports on Older Adults in Hong Kong: Nonrandomized Controlled Pilot Study

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  Authors List:

  • Ka Man Leung  
  • Yuchen Shi  

  Abstract:

  Background: Hong Kong faces a rapidly aging population, with many older adults not meeting recommended physical-activity levels and struggling to maintain long-term exercise adherence. Exergaming offers an accessible, technology-supported way to promote health conditions while providing immediate feedback and task variability among older adults. Objective: This study aimed to evaluate the effects of an 8-week competitive exergaming intervention on functional fitness, cognition, loneliness, physical activity (PA) enjoyment, and quality of life among community-dwelling older adults in Hong Kong. Methods: We conducted a pragmatic, nonrandomized, 2-group pilot with community participants allocated to either a competitive exergaming group (EG) or a passive control group (CG). EG attended 16 instructor-led 90-minute sessions playing Fitness Boxing (Nintendo Switch), including head-to-head bouts and a bracketed tournament. Outcomes were assessed at baseline and postintervention. Primary analyses used repeated-measure analysis of covariance (time: pre and post; group: EG and CG) adjusted for age, sex, education, marital status, employment, financial status, and housing. Partial η² was used to quantify effect sizes. Given the pilot nature, P values are unadjusted for multiplicity and interpreted cautiously. Results: A total of 48 older adults completed assessments (EG: n=24; mean age 69.50, SD 4.77 years; CG: n=24; mean age 71.50, SD 6.74 years). Significant group × time interactions favored EG for lower-body strength (30-second chair stand: F_{1, 48}=12.39; P<.001; partial η²=0.22), aerobic endurance (2-minute step: F_{1, 48}=4.89; P=.03; η²=0.10), and PA enjoyment (Physical Activity Enjoyment Scale: F_{1, 48}=9.36; P<.001; η²=0.18). For the Number Comparison Test (processing speed), the group × time interaction was not significant (P=.08); however, an exploratory main effect of group indicated higher performance in EG across time (P=.04). Executive function (Trail Making Test parts A and B), loneliness, and Short Form-36 Health Survey subscales showed no significant effects. Conclusions: Competitive exergaming was feasible and produced small to moderate improvements in lower-body strength, aerobic endurance, and enjoyment of PA. Cognitive effects were inconclusive and should not be overinterpreted given the nonrandomized design, passive control, small sample, and multiple outcomes. Future randomized trials with active comparators and longer duration are warranted.

  • JMIR Serious Games 2025;13(1):e77655

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  Exergames, Active Games and...

  Dec 15, 2025

  Effects of an Immersive Virtual Reality–Based Exercise Intervention on Psychological and Physiological Outcomes in College Students: Randomized Controlled...

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  Authors List:

  • Wenxi Liu  
  • Daniel J McDonough  
  • John Oginni  
  • Jessh Mavoungou  
  • Zan Gao  

  Abstract:

  Background: Physical inactivity is a major public health issue among college students, often exacerbated by academic pressures and lifestyle shifts. Traditional exercise interventions often face challenges with adherence due to low motivation and engagement. Immersive virtual reality (VR)–based exercise interventions may address these barriers by providing interactive and motivating experiences, yet empirical evidence regarding their psychological and physiological benefits remains scarce. Objective: This study aims to evaluate the effects of a 4-week immersive VR-based exercise intervention on psychological and physiological health outcomes in college students. Methods: A randomized controlled trial was conducted involving 36 college students randomized into either a VR exercise group (n=17, 47%) or a no-intervention control group (n=19, 53%). Participants in the VR group engaged in immersive VR cycling sessions (two 60-minute sessions weekly) using the VirZoom VR system, while the control group continued their normal routines. Psychological outcomes were assessed during preintervention and postintervention assessments, including exercise motivation (Behavioral Regulation in Exercise Questionnaire-2), mood states (Brunel Mood Scale), and depressive symptoms (Beck Depression Inventory). Physiological outcomes assessed were cardiovascular fitness (3-Minute Step Test) and body composition (bioelectrical impedance analysis). We used a 2-way repeated measures ANOVA to analyze the effects of the intervention. Results: Significant time×group interactions indicated enhanced intrinsic motivation (P=.02; η²=0.25); improved mood states with increased vigor (P=.01; η²=0.18); and decreased confusion (P=.01; η²=0.17), fatigue (P=.02; η²=0.16), and tension (P=.003; η²=0.24) in the VR group. Depressive symptoms were also significantly reduced (P=.03; η²=0.14). Physiological outcomes showed significant improvements in the VR group, including decreased body fat percentage (P<.001; η²=0.34) and enhanced cardiovascular fitness (P<.001; η²=0.47) compared to the control group. Conclusions: This study indicated that a 4-week immersive VR-based exercise intervention may confer short-term psychological and physiological benefits among college students compared to the no-intervention control group under COVID-19 pandemic–related constraints. Future studies should adopt active control designs and be conducted in real-world settings, incorporating objectively determined intensity monitoring and follow-up to further investigate effectiveness and real-world scalability. Trial Registration: ClinicalTrials.gov NCT06902727; https://clinicaltrials.gov/study/NCT06902727

  • JMIR Serious Games 2025;13(1):e75777

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  Game Development

  Dec 12, 2025

  Development and Evaluation of a Monocular Camera–Based Mobile Exergame for at-Home Intervention in Individuals at High Risk of Type 2 Diabetes: Randomized...

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  Authors List:

  • Jianan Zhao  
  • Dian Zhu  
  • Yanan Wang  
  • Yaqin Xia  
  • Zeshi Zhu  
  • Jihong Yu  

  Abstract:

  Background: Exergames have emerged as effective interventions for promoting physical activity and preventing type 2 diabetes (T2D). Kinect-based exergames have demonstrated improvements in exercise adherence and health outcomes, but their high cost and reliance on specialized hardware hinder widespread home-based adoption. Recent advances in computer vision now enable monocular-camera-based systems, offering a potentially cost-effective and scalable alternative for promoting physical activity at home. Objective: This study aimed to evaluate the feasibility and user experience of monocular-camera-based exergames as a home-based intervention for individuals at risk for T2D. Methods: Forty-five community-dwelling individuals at high risk for T2D (mean age = 47.12, SD = 6.92) were recruited and randomized into three groups (n = 15 each): (1) Control group (traditional offline exercise), (2) Kinect group (Kinect-based exergame), and (3) Monocular group (Monocular-camera-based exergame). Participants engaged in a 10-minute intervention once per week for 7 weeks. Data were collected at three time points: baseline (exercise performance: heart rate and perceived fatigue), post-intervention (exercise performance and user experience, including game experience and intrinsic motivation), and follow-up (user engagement and qualitative feedback). One-way ANOVA was used for data analysis. Results: Exercise performance was comparable across all groups, with no significant differences in heart rate (p = 0.757) or fatigue levels (p = 0.248). However, participants in the monocular group reported significantly lower fatigue compared to the control group (p = 0.035). Intrinsic motivation was significantly higher in both the Kinect (M = 35.13, SD = 3.20) and monocular (M = 34.00, SD = 4.41) groups compared to the control group (M = 26.06, SD = 1.87; p < 0.001), with no significant difference between the two exergame groups (p = 0.443). While most user experience measures showed no significant differences, the monocular group reported a higher perceived challenge (M = 3.45) compared to the Kinect group (M = 2.96; p = 0.092). Additionally, the monocular group exhibited higher engagement, as evidenced by more frequent use, fewer challenges, and a greater intention to continue using the system. Conclusions: Monocular-camera-based exergame is a feasible and effective solution for promoting physical activity in individuals at risk for T2D. It offers motivational and experiential benefits similar to Kinect-based systems but require less costly and more accessible equipment. These findings suggest that monocular systems have strong potential as scalable tools for home-based chronic disease prevention. Clinical Trial: The trial was registered in ClinicalTrials.gov (NCT06950528); https://clinicaltrials.gov/study/NCT06950528.

  • JMIR Serious Games 2025;13(1):e75823

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  Usability of Games and Gamification

  Dec 1, 2025

  Immersive Virtual Reality–Assisted Therapy for Distressing Voices in Psychosis: Qualitative Study of Participants’ and Therapists’ Experiences in the...

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  Authors List:

  • Mads Juul Christensen  
  • Matilde Poulsen Rydborg  
  • Rikke Jørgensen  
  • Cecilie Dueholm Nielsen  
  • Jan Mainz  
  • Imogen H Bell  
  • Neil Thomas  
  • Lisa Charlotte Smith  
  • Lise Sandvig Mariegaard  
  • Thomas Ward  
  • Merete Nordentoft  
  • Louise Birkedal Glenthøj  
  • Ditte Lammers Vernal  

  Abstract:

  Background: Immersive virtual reality-assisted therapy (VRT) is a relational therapy for distressing voices in psychosis. Like AVATAR therapy (AT), VRT centres on therapist-facilitated dialogues with a digital avatar representing a voice. Unlike AT, VRT employs immersive virtual reality (VR). While participant experiences of AT have been explored, therapist perspectives remain unexamined, and for VRT, neither participant nor therapist experiences have been studied. Understanding these perspectives is essential to inform optimization of therapy, future research, and implementation. Objective: The objective of this qualitative study was to explore both trial participants’ and therapists’ experience of VRT in the Challenge trial. Methods: Semi-structured interviews were conducted with 10 trial participants and 8 therapists across three Challenge trial sites. Trial participants were purposively sampled to ensure site representation and variation in voice-hearing duration. Individual interviews were conducted with trial participants, while therapists participated in site-based groups with 2–3 in each. Interviews were audio-recorded, transcribed, and subjected to reflexive thematic analysis from a critical realist position. Coding and theme development were inductive. People with lived experience were invited to initial focus groups for topic guide development and a later theme validation workshop. Reporting followed Standards of Reporting Qualitative Research (SRQR). Results: Five overarching themes were generated: (1) Using technology to meet the voice, (2) A different approach to voice-hearing and treatment, (3) On a tight schedule, (4) A toolbox for transformation, and (5) A price to pay. Trial participants and therapists generally found VRT acceptable, appropriate, and feasible. Highlights included the acknowledging approach to the voice(s), facilitation of engagement with the voice(s), and opportunity to share the otherwise private experience of voice-hearing. Externalizing and embodying the voice(s) in VR supported avatar role-plays and was seen as a key affordance. Positive outcomes included increased trial participant empowerment and self-worth, enabling or improvement of voice dialogue, new understanding of voice intentions, and changes in voice frequency or content. Challenges included instances of participant anxiety, exhaustion, or suboptimal sense of presence; adverse voice reactions; technological malfunctions and limitations to avatar design; measurement insensitivity; tensions between assertiveness and compassion; difficulties with reproducing negative voice-content; and the demanding nature of the therapy and the non-traditional skills required of therapists. Conclusions: The study provided comprehensive insights into trial participants’ and therapists’ experience of VRT in the Challenge trial. Findings share several similarities with qualitative research on other relational therapies for distressing voices and highlight VRT’s potential for positive change. Key considerations for future research and implementation include monitoring anxiety and voice reactions, ensuring operational reliability of hard- and software, and addressing the additional effort required by therapists, which may be unsustainable in routine practice. As a demanding intervention, successful implementation of VRT will require adequate training, supervision, and structural support.

  • JMIR Serious Games 2025;13(1):e77920

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  Game Addiction and Other Unintended...

  Nov 28, 2025

  Effects of Progressive Aerobic Training on Executive-Reward Network Connectivity and Symptoms of Internet Gaming Disorder: Randomized Controlled Trial

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  Authors List:

  • Shaoyu Cui  
  • Xuefeng Xu  
  • Xin Luo  
  • Meiting Wei  
  • Guang-Heng Dong  

  Abstract:

  Background: Background: Internet gaming disorder (IGD) causes neurocognitive deficits and brain functional. Traditional interventions require specialists and incur high costs, while progressive aerobic training (PAT) shows more practical. But its effect on IGD and the underlying neural mechanism remains unclear. Objective: This pre-registered, randomized controlled, single-blind study examined the efficacy of a novel non-pharmacological intervention by elucidating the neurocognitive mechanisms in IGD. Methods: Methods: A total of 72 IGD participants were recruited and randomly assigned to a PAT group or a free training (FT) group. Sixty-four participants completed the experiment (PAT:33; FT: 31), which included pre- and post-treatment fMRI scans and 20 PAT sessions in a month. Regional homogeneity and degree centrality are calculated, and the overlapping brain regions were used as seed points for FC analysis. The correlation between FC and behavioral data and neurotransmitters were also evaluated. Results: Results: Compared with the FT group, the PAT group showed decreased addiction severity and craving after the intervention. FC analysis showed that PAT increased the FC within the executive control network (ECN) and between the ECN and the reward network (RN). FC was significantly associated with cannabinoid receptors CB1 and type-5 metabotropic glutamate receptor (mGluR5). Conclusions: Conclusions: This study suggests that PAT is effectively in treating IGD by improving the FC between the ECN and the RN, enhancing the top-down control. These results are supported by the correlation between FC and behavior and neurotransmitters, indicating that PAT is a very promising intervention approach. Clinical Trial: The protocol of the trial had been registered at the Chinese clinical trial registry (http://www.chictr.org.cn; ChiCTR2400090834).

  • JMIR Serious Games 2025;13(1):e83597

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