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  Exergames, Active Games and...

  Feb 2, 2026

  Effects of Exergaming Tennis on Players’ Tennis Skills and Mental State Compared to Regular Tennis in Adult Players: Quasi-Experimental Study

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  Authors List:

  • Jia Sheng Ngo  
  • See Ziau Hoe  
  • Maziah Mat Rosly  

  Abstract:

  Background: Exergaming, which combines physical activity with interactive gaming, has been shown to improve motor skills and fitness. However, exergaming’s potential in complex, open-skill sports such as tennis, which require real-time coordination, decision-making, and technical precision, remains underexplored. Furthermore, only a few studies have evaluated the impact of exergaming on both technical skill development and psychological outcomes such as motivation and confidence, especially among novice players. This study addresses these gaps by comparing the combination of exergame-based tennis training and on-court tennis training (EBTT+OCTT) with on-court tennis training alone (OCTT×2) in improving technical skills, grip strength, confidence, and motivation. Objective: This study aims to assess the effect of exergaming tennis in developing tennis technical skills, grip strength, confidence level, and motivation level. Methods: In a 12-week quasi-experimental trial, 66 novices were randomized to either the EBTT+OCTT or the OCTT×2 group. Participants consisted of 22 males and 44 females, with the mean BMI and age of approximately 22 (SD 2.9) kg/m² and 26 (SD 7) years, respectively. The EBTT+OCTT group had 1 weekly session of OCTT and 1 session of exergaming training using Virtual Tennis (PlayStation 3 Move), while the OCTT×2 group completed 2 weekly on-court sessions. Outcomes included tennis technical skills such as groundstroke technique, service speed, and service accuracy (assessed using the Hewitt tennis test), grip strength (using a handheld dynamometer), confidence (using the Sports Confidence Inventory), and motivation (using the Sport Motivation Scale). Mean differences (MDs) between pre- and postintervention were collected and analyzed using repeated-measures ANOVA (α=.05) and Pearson correlation analysis. Effect sizes were calculated using partial eta squared (ηp²), where values ≥0.14 indicated large effects. Results: After 12 weeks of training, both EBTT+OCTT and OCTT×2 groups showed significant improvements (P<.001) in tennis technical skills (MD=17.06-22.62), grip strength (MD=9.59-11.04 kg), and confidence levels (MD=23.29-26.28). These outcome measures have large effect sizes (ηp²=0.84-0.92); however, they did not significantly differ (P>.05) across the groups when compared, with P_{grip strength}=.24, P_hit=.97, P_accuracy=.86, P_speed=.72, and P_confidence=.31. In terms of motivation, EBTT+OCTT retained intrinsic motivation (IM) better than OCTT×2, with significant reductions in IM, mainly IM-to-know (MD=7, SD 2.95) and IM-to-accomplish (MD=5, SD 3.77) observed in the OCTT×2 group (P<.001). Grip strength, confidence, and motivation levels (except amotivation) showed positive correlations with tennis technical skills (r=0.39-0.80). Conclusions: EBTT+OCTT and OCTT×2 significantly improve tennis skills and confidence levels in novice players, although no significant differences were found between the two. However, EBTT+OCTT appeared to better sustain IM. Thus, EBTT+OCTT may serve as a supplementary tool for novice players to better learn tennis.

  • JMIR Serious Games 2026;14(1):e73732

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  Exergames, Active Games and...

  Feb 2, 2026

  Gamified Physical Education and Cognitive Performance Among Chinese Secondary School Students: Cross-Sectional Moderation Mediation Study

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  Authors List:

  • Jingtong Zhang  
  • Sae-Sook Oh  
  • Yaru Xu  

  Abstract:

  Background: Educators are exploring new methods to educate beyond the classroom as global concerns about students’ cognitive, emotional, and social well-being grow. Physical education (PE) has been demonstrated to boost cognitive and psychological outcomes in several studies. Most research has neglected the benefits of gamification and artificial intelligence (AI)–based feedback in PE, focusing instead on conventional PE formats. The impacts of technologically enhanced PE settings on students’ cognitive performance through feedback and reward mechanisms remain understudied. Objective: This study aimed to investigate how intrinsic motivation and AI-based feedback moderated the effects of gamified PE on students’ cognitive performance. Methods: The study used a cross-sectional design. In Beijing, Shanghai, Chengdu, and Guangzhou, a total of 1029 public high school students completed a standardized questionnaire. Students in secondary school (male: n=490, 47.6% and female: n=539, 52.4%) aged 10-18 years, were recruited from urban, suburban, and rural locales. Participants were sourced from public, private, and semigovernment schools, reflecting a range of academic achievement levels and access to technology. Students participating in standard PE sessions were included, whereas those with medical conditions that restricted physical exercise were excluded. Data were gathered via standardized questionnaires during designated PE sessions. Gamified PE, cognitive performance, intrinsic motivation, teacher support, collaboration, and AI feedback were examined using standardized instruments. Trained facilitators helped younger participants understand and follow ethical norms. The study used maximum likelihood estimation for structural equation modeling. Bootstrapping was used to analyze mediation and moderation effects at a 5% significance level (α=.05). Results: According to structural equation modeling, gamified PE highly predicts cognitive performance (β=.34; P<.001). Other significant factors were teacher support (β=.31; P<.001), physical exercise enjoyment (β=.28; P<.001), and teamwork (β=.26; P<.001). AI-based feedback strengthened the link between gamified PE and cognitive performance under moderation analysis (β=.18; P<.001). Mediation analysis indicated that intrinsic motivation partially mediated the relationship, resulting in a significant indirect effect (β=.21, 95% CI 0.12-0.31; SE=0.05). Conclusions: This research integrates gamified PE with AI-based feedback mechanisms to evaluate students’ cognitive outcomes, a domain that has been rarely investigated experimentally. This study highlights the combined effect of intrinsic motivation and AI-generated feedback in a technology-enhanced PE context, in contrast to previous research that primarily focuses on traditional PE methods or isolated gamification elements. The findings enhance the field by demonstrating that student-centered, feedback-rich PE environments may improve cognitive abilities through social interaction, enjoyment, and instructor support. AI-assisted, gamified PE programs may enhance learning outcomes and academic performance among secondary school students.

  • JMIR Serious Games 2026;14(1):e81086

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  Game Design and Efficacy of Game...

  Jan 30, 2026

  A Haptic-Driven Serious Game for Cognitive Stimulation and Visual Impairment Mitigation in Older Adults Based on the Design-Play-Experience Framework:...

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  Authors List:

  • Xin Huang  
  • Nazlena Mohamad Ali  
  • Shafrida Sahrani  
  • Yue Zhang  

  Abstract:

  Background: In the context of global aging, cognitive decline among older adults has become a prevalent issue, significantly impacting their daily lives. Serious games have demonstrated potential in enhancing cognitive abilities in this population. However, most existing serious games designed for older adults rely heavily on visual interfaces, which are often potentially detrimental for those with pre-existing visual impairments. Objective: This study had two primary objectives: (1) to design a theoretical prototype for a haptic-driven serious game for older adults based on the Design-Play-Experience (DPE) framework, aiming to enhance cognitive abilities, including attention, logical reasoning, and decision-making while simultaneously mitigating challenges associated with visual impairment, and (2) to conduct a pilot study evaluating the prototype’s usability, accessibility, and user experience within the target population. Methods: We used a cross-sectional, mixed methods pilot study with a single-group observational design, comprising a theoretical design and a pilot user study. First, the DPE framework was systematically applied to develop a game prototype by integrating haptic feedback technology (using built-in smartphone vibration motors) across its 3 core dimensions: design (haptic symbol system, accessible interface), play (dynamic difficulty adjustment), and experience (emotional engagement). Subsequently, a pilot study was conducted with 10 older adults recruited via convenience sampling (mean age 62.9, SD 3.35 years; 5 male, 5 female; all with self-reported mild visual impairments, such as presbyopia). Following interaction with the prototype, data were collected remotely using the System Usability Scale (SUS) and semistructured interviews administered via videoconferencing. Quantitative data from the SUS were analyzed using descriptive statistics, while qualitative data from the interviews were processed using thematic analysis. Results: Pilot user studies showed that the game prototype had good usability, with an average SUS score of 89.5 (SD 2.72; 95% CI 87.6-91.4), which is considered “excellent.” Thematic analysis of the interviews revealed three significant themes. The first theme was intuitive haptic feedback, which reflected that participants were able to quickly grasp and value the vibrational cues used to identify cards. The second theme was based on reduced eye strain, in which the combination of large fonts, high-contrast interfaces, and haptic feedback was praised for its effectiveness in relieving eye strain. The third theme was simplicity, where the simplified card game mechanics were considered both fun and challenging. Conclusions: This study developed and validated a haptic, serious game for older adults. Its innovation lies in the systematic application of the DPE framework to achieve “haptic substitution for vision,” which differs from previous research that focused on general immersive experiences. The main contribution of this study is providing a reusable design blueprint for creating easy-to-use cognitive training tools. These findings have practical implications in the real world, providing a feasible approach for deploying low visual load interventions in communities and care facilities.

  • JMIR Serious Games 2026;14(1):e86290

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  Serious Games for Health and Medicine

  Jan 30, 2026

  Co-Designing Mobile Serious Games to Support Patients With Psoriatic Arthritis and Chronic Pain: Mixed Methods Study

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  Authors List:

  • Bárbara Ramalho  
  • Samuel Gomes  
  • Marta Silva Vicente  
  • Filipa Magalhães  
  • Rodolfo Gonçalves Costa  
  • Sandra Gama  
  • Vasileios Charisis  
  • Leontios Hadjileontiadis  
  • Sofia B Dias  
  • iPROLEPSIS Consortium

  Abstract:

  Background: Serious games present a promising avenue for clinical care, enhancing patient engagement while delivering therapeutic benefits. Pain is present in many diseases, notably in Psoriatic Arthritis (PsA), and it can cause emotional distress while negatively impacting function and ability to work, ultimately leading to an overall reduction in a patient's well-being. Objective: This study, within the scope of the iPROLEPSIS Horizon Europe project, introduces NoPain Games, specifically designed to assist people with PsA in managing chronic pain. These games utilize repetitive, soothing, and cognitively stimulating mechanics to provide pain distraction and opportunities for cognitive engagement. Methods: The study emphasizes the co-design process of the proposed NoPain Games, adhering to an agile-based methodology and involving 14 experts, including clinicians, researchers, and game developers, from three European countries to refine game requirements, storyboards, and mechanics. They all participated in a 90-minute online co-design session. Results: Thematic analysis of the transcribed dialogues identified three core themes, each examined through their respective subthemes. Therapeutic Benefits (Theme 1) highlight pain distraction, memory enhancement, cognitive stimulation, stress reduction, and creative engagement, showcasing the games' potential to support PsA patients in overcoming both mental and physical challenges. Game Difficulty (Theme 2) focuses on balancing and dynamically adapting game duration and complexity, to sustain engagement without causing fatigue or diminishing therapeutic efficacy. Accessibility and Interaction (Theme 3) aim to address physical limitations, optimize touchscreen usability, and ensure inclusive design tailored to PsA patients' specific needs. Additionally, the feedback collected during the co-design process was integrated into the creation of two NoPain Game prototypes. Conclusions: Our findings provide essential insights into the design of NoPain Games for PsA patients, paving the way for their potential implementation as digital health interventions. Future work will focus on the technical development of the game prototypes while refining their mechanics and incorporating adaptive difficulty features. Afterwards, clinical trials will be conducted to validate the effectiveness of the prototyped games in improving the quality of life for PsA patients.

  • JMIR Serious Games 2026;14(1):e75072

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  Usability of Games and Gamification

  Jan 28, 2026

  Immersive Tai Chi for Home-Based Exercise in Older Adults: Usability and Feasibility Study

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  Authors List:

  • XiaCheng Song  
  • Nazlena Mohamad Ali  
  • Mohamad Hidir Mhd Salim  
  • Muhammad Yudhi Rezaldi  

  Abstract:

  Background: Longer life expectancy makes physical exercise crucial for active aging, however, adherence to traditional exercise among community-dwelling older adults is generally low. Virtual Reality (VR) and Mixed Reality (MR) Tai Chi exergames show significant potential as novel health promotion tools, particularly for older adults exercising in a home setting. While promising, usability and safety issues such as cybersickness are significant barriers that must be addressed before these technologies can be widely implemented for unsupervised home use. Objective: This study aimed to evaluate the usability and feasibility of a VR/MR Tai Chi exergame for community-dwelling older adults. The primary focus was on assessing subjective experience, physiological comfort, and objective interaction performance. The study also sought to explore the relationships between key usability factors and to quantify the links between objective accuracy and subjective experience to inform design choices for display mode, feedback, and session length. Methods: Study Design: This was a pilot study utilizing a 2x2 factorial design (Display Mode: VR/MR × Feedback: Soothing/Intense). Participants: 86 community-dwelling older adults were initially recruited. After screening, 16 participants (18.6%) were excluded due to issues with VR adaptation. Data from the final sample of 70 participants were analyzed. Participants were sequentially assigned in a rotating order to one of the four experimental conditions. Intervention: Using a Meta Quest 3 head-mounted display (HMD), each participant performed two formal 5-minute gameplay sessions under their assigned condition. The better performance of the two sessions was retained for analysis. Outcome Measures: The primary outcome measures included the Game Experience Questionnaire (GEQ) to assess subjective experience, the Virtual Reality Sickness Questionnaire (VRSQ) to quantify physiological comfort, and objective gameplay logs for performance data. Results: 1. The VR/MR Tai Chi game demonstrated good overall usability and acceptability among the screened participants. 2. Subjective experience was highly positive, with median scores for "Positive Affect" (Mdn=4.0) and "Competence" (Mdn=3.8) being significantly high, while the median for "Challenge" (Mdn=1.4) was significantly low (P<.001 for all). 3. Physiological comfort in the post-screening sample was acceptable. However, a noteworthy finding was the initial exclusion of 18.6% of participants due to VR discomfort. The most common mild symptoms reported were dizziness with eyes closed (20.0%) and vertigo (18.6%). 4. A significant positive correlation was found between movement accuracy and flow (ρ=.342) and competence (ρ=.322). The VRSQ total score was significantly negatively correlated with positive affect (ρ=−.334, P=.005). Conclusions: Immersive technology-based Tai Chi exergames offer a feasible and attractive pathway for promoting physical exercise among community-dwelling older adults, supporting the goal of aging in place. The high satisfaction reported may be influenced by a novelty effect, and longer-term, home-based follow-ups are needed to assess durability. The analysis provides guidance for design choices, but the high initial exclusion rate due to cybersickness highlights a major barrier to wider, unsupervised home-based adoption.

  • JMIR Serious Games 2026;14(1):e79453

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  Gamification

  Jan 19, 2026

  Effects of Game-Based Learning on Piano Music Knowledge Among Elementary School Pupils: Pretest-Posttest Quasi-Experimental Study

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  Authors List:

  • Yun Wang  
  • Wee Hoe Tan  
  • Qiaoling Ye  
  • Tingting Gu  

  Abstract:

  Background: Music education is central to holistic child development; yet, traditional piano instruction in China often emphasizes rote memorization at the expense of meaningful understanding. Elementary school pupils, particularly novices, frequently struggle with rhythm, melody, and music theory. Game-based learning (GBL), which applies game elements to teaching, may address these challenges by enhancing engagement, providing immediate feedback, and fostering long-term learning. Objective: This study aimed to examine the effects of a GBL module for piano education on elementary school pupils’ music knowledge in Anhui Province, China, compared to traditional instruction. Methods: A quasi-experimental, nonequivalent control group pretest-posttest design was used. Participants were allocated nonrandomly to experimental and control groups based on scheduling feasibility and teacher availability. A total of 60 novice piano learners (mean age 8.8 years, SD 1.16 years; 16 boys and 44 girls) from 3 elementary schools were assigned to either the GBL group (n=30) or the control group (n=30). Music knowledge was measured using the standardized Level 1 Basic Music Written Test before and after an 8-week intervention. Nonparametric analyses were applied, including Mann-Whitney U, Wilcoxon signed-rank, and McNemar item-level analyses. Rank-based effect sizes (r) and 95% CIs were reported where applicable. Results: Baseline differences were present, with the control group scoring higher at pretest (median 52, IQR 24-76) than the GBL group (median 28, IQR 16-64; Mann-Whitney U=265.50; r=–0.35; 95% CI –0.39 to –0.32; P=.006). After the intervention, the GBL group significantly outperformed controls (median 100, IQR 88-100 vs median 60, IQR 40-92; Mann-Whitney U=4.0; r=–0.87; 95% CI –0.90 to –0.83; P<.001). Within-group analyses confirmed significant pre-post improvements for both groups (control Z=–3.24; r=–0.59; P=.001; and GBL Z=–4.81; r=–0.88; P<.001). Item-level McNemar tests showed significant improvements (P<.05) in 5 of 25 items for the GBL group. Missing data were negligible (<2%) and handled via listwise deletion after Little’s missing completely at random (MCAR) confirmation (P=.08). Conclusions: The GBL module significantly improved pupils’ music knowledge, overcoming baseline disparities and producing posttest score gains with consistent mastery. The innovation of the study lies in the systematic integration of gamification with Orff and Dalcroze pedagogy through the Sidek Module Development Model, which distinguishes it from previous music education studies that examine gamification in isolation. By providing a validated, cost-effective, and scalable instructional module, the study contributes empirical evidence to the field of game-based music education and other practical implications for improving piano instruction in resource-constrained elementary school settings.

  • JMIR Serious Games 2026;14(1):e80766

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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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