Rehabilitation-Oriented Serious Game Development and Evaluation Guidelines for Musculoskeletal Disorders

Gamified Physical Rehabilitation for Older Adults With Musculoskeletal Issues: Pilot Noninferiority Randomized Clinical Trial

BACKGROUND

Resource-rich countries are facing the challenge of aging societies, a high risk of dependence, and a high cost of care. Researchers attempted to address these issues by using cost-efficient, innovative technology to promote healthy aging and regain functionality. After an injury, efficient rehabilitation is crucial to promote returning home and prevent institutionalization. However, there is often a lack of motivation to carry out physical therapies. Consequently, there is a growing interest in testing new approaches like gamified physical rehabilitation to achieve functional targets and prevent rehospitalization.

OBJECTIVE

The purpose of this study is to assess the effectiveness of a personal mobility device compared with standard care in the rehabilitation treatment of patients with musculoskeletal issues.

METHODS

A total of 57 patients aged 67-95 years were randomly assigned to the intervention group (n=35) using the gamified rehabilitation equipment 3 times a week or to the control group (n=22) receiving usual standard care. Due to dropout, only 41 patients were included in the postintervention analysis. Outcome measures included the short physical performance battery (SPPB), isometric hand grip strength (IHGS), functional independence measure (FIM), and the number of steps.

RESULTS

A noninferiority related to the primary outcome (SPPB) was identified during the hospital stay, and no significant differences were found between the control and intervention groups for any of the secondary outcomes (IHGS, FIM, or steps), which demonstrates the potential of the serious game-based intervention to be as effective as the standard physical rehabilitation at the hospital. The analysis by mixed-effects regression on SPPB showed a group×time interaction (SPPB_I_t1=-0.77, 95% CI -2.03 to 0.50, P=.23; SPPB_I_t2=0.21, 95% CI -1.07 to 0.48, P=.75). Although not significant, a positive IHGS improvement of more than 2 kg (Right: 2.52 kg, 95% CI -0.72 to 5.37, P=.13; Left: 2.43 kg, 95% CI -0.18 to 4.23, P=.07) for the patient from the intervention group was observed.

CONCLUSIONS

Serious game-based rehabilitation could potentially be an effective alternative for older patients to regain their functional capacities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03847454; https://clinicaltrials.gov/ct2/show/NCT03847454.

Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING)

BACKGROUND

In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so.

OBJECTIVE

This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions.

METHODS

We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field.

RESULTS

Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions.

CONCLUSIONS

Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions.

Adaptive Rehabilitation Bots in Serious Games

In recent years, we have witnessed a growing adoption of serious games in telerehabilitation by taking advantage of advanced multimedia technologies such as motion capture and virtual reality devices. Current serious game solutions for telerehabilitation suffer form lack of personalization and adaptiveness to patients' needs and performance. This paper introduces "RehaBot", a framework for adaptive generation of personalized serious games in the context of remote rehabilitation, using 3D motion tracking and virtual reality environments. A personalized and versatile gaming platform with embedded virtual assistants, called "Rehab bots", is created. Utilizing these rehab bots, all workout session scenes will include a guide with various sets of motions to direct patients towards performing the prescribed exercises correctly. Furthermore, the rehab bots employ a robust technique to adjust the workout difficulty level in real-time to match the patients' performance. This technique correlates and matches the patterns of the precalculated motions with patients' motions to produce a highly engaging gamified workout experience. Moreover, multimodal insights are passed to the users pointing out the joints that did not perform as anticipated along with suggestions to improve the current performance. A clinical study was conducted on patients dealing with chronic neck pain to prove the usability and effectiveness of our adjunctive online physiotherapy solution. Ten participants used the serious gaming platform, while four participants performed the traditional procedure with an active program for neck pain relief, for two weeks (10 min, 10 sessions/2 weeks). Feasibility and user experience measures were collected, and the results of experiments show that patients found our game-based adaptive solution engaging and effective, and most of them could achieve high accuracy in performing the personalized prescribed therapies.

Sana: A Gamified Rehabilitation Management System for Anterior Cruciate Ligament Reconstruction Recovery

The anterior cruciate ligament (ACL) provides stabilization support for the back and forth motion of the knee joint. ACL ruptures account for 50% of all sports-related knee injuries with approximately 76.6% of them requiring reconstructive surgery, necessitating long-term patient rehabilitation. Compliance with rehabilitation management programs, following ACL reconstruction, is fundamental for the successful restoration of the knee’s kinematics and reducing the risk of secondary osteoarthritis. Existing recovery programs are often paper-based and require patients to perform exercises at home, unsupervised, resulting in a low level of self-efficacy; by promoting self-efficacy in home-based settings, rehabilitation outcomes can improve. This paper reports the design development of the Sana system, a mobile and wearable application that adopts behavioral design principles and gamification theory to improve long-term post-operative outcomes for ACL reconstruction recovery. A feasibility study was conducted from 15 October 2019–13 May 2020, employing the double diamond framework and a human-centered design approach (BS EN ISO 9241-210: 2019). Eighteen participants were recruited, including eight domain experts (in fields such as user experience design, human factors, and physiotherapy), and ten representative users who had undergone long-term rehabilitation for musculoskeletal injuries.

Hospital-to-Home Transition for Older Patients: Using Serious Games to Improve the Motivation for Rehabilitation – a Qualitative Study

Traditional physiotherapy is often perceived as repetitive and boring by patients, leading to issues in maintaining their interest and performing the required exercises. This paper investigates older patients’ engagement and motivation for physical activity using a serious game-based rehabilitation compared to a control group using a standard care therapy, during hospitalization. We conducted a randomized clinical trial with 57 geriatric patients and demonstrated that the serious game-based rehabilitation was as efficient as the standard rehabilitation program in terms of improving their functional capacity. In this paper, we mainly focus on reporting qualitative analysis of the patient’s behavior change thorough the intervention. The intervention lasted 3 weeks. Semi-structured interviews, including all the participants, were conducted before and after the intervention. Patients’ attitudes towards rehabilitation process, physical activity and innovation technology were investigated. Motivation to be active following the intervention were explored. Participants admitted feeling bored at the hospital and only following along the care process routine. Enthusiasm towards the progress brought by technological solution was observed. At the end of the hospital stay, the serious game-based rehabilitation received positive feedback. Patients felt more active and observed significant improvement of their general condition. The analysis suggests that patients participating in the gamified rehabilitation are more motivated. Several recommendations on designing serious game for elderly rehabilitation are proposed.

Improving Maximal Strength in the Initial Postoperative Phase After Anterior Cruciate Ligament Reconstruction Surgery: Randomized Controlled Trial of an App-Based Serious Gaming Approach

Background

Anterior cruciate ligament reconstruction surgery is one of the most common orthopedic procedures. One of the main factors that influence the outcome is regaining strength in the postoperative phase. Because anterior cruciate ligament reconstruction surgeries are often performed in young patients, we combined the concept of prehabilitation with an app-based serious gaming approach to improve maximal strength postoperatively.

Objective

Our objective was to conduct a prospective randomized trial to evaluate whether an app-based active muscle training program (GenuSport Knee Trainer) can improve postoperative strength by starting rehabilitation immediately after primary anterior cruciate ligament reconstruction surgery.

Methods

We designed a pilot study in which we randomly assigned patients receiving primary anterior cruciate ligament reconstruction to either the serious gaming training (intervention) group or a conventional rehabilitation (control) group. Except for the serious gaming-based training, both groups followed the same postoperative treatment protocol. Outcome parameters were absolute and relative change in maximal strength, as well as the International Knee Documentation Committee Subjective Knee evaluation form, Knee Injury and Osteoarthritis Outcome Score, and Lysholm Knee Score.

Results

In total 26 patients agreed to participate (14 patients in the intervention group and 12 patients in the control group, 1 of whom was lost to follow-up). We noted a difference in absolute maximum strength between the exergaming intervention and the control groups. Mean maximum strength preoperatively was 155.1 (SD 79.2) N in the intervention group (n=14) and 157.0 (SD 40.8) N in the control group (n=11). Postoperative mean maximum strength was 212.8 (SD 78.5) N in the intervention group and 154.5 (SD 27.1) N in the control group. Mean absolute change in maximum strength was 57.7 (SD 95.2) N in the intervention group and –4.8 (22.2) N in the control group. The analysis of covariance model with absolute change as the dependent variable and treatment group and baseline maximum strength as covariates showed a relevant difference in relative change between treatment groups (intervention – control) of 59.7 N (95% CI 10.1-109.3; P=.02). Similarly to the absolute increase, the relative change in maximum strength was relevantly higher in the exergaming group. The mean relative change in maximum strength was 1.7 (SD 1.17) in the intervention group and 1 (SD 0.13) in the control group. No adverse events or problems were reported during the study period.

Conclusions

Implementation of an app-based active muscle training program in the early postoperative therapy scheme was associated with an improvement in maximal strength. Therefore, we considered the use of GenuSport training after anterior cruciate ligament reconstruction to be a helpful complement to rehabilitation after anterior cruciate ligament reconstruction surgery to improve strength in the early postoperative phase. To our knowledge this was the first study to analyze immediate postoperative serious gaming-based training with the GenuSport device based on strength improvement.

Interactive serious game for shoulder rehabilitation based on real-time hand tracking

BACKGROUND

Virtual reality is becoming popular in the rehabilitation field thanks to the several advantages it can offer to patients and physicians. Indeed, serious games can: motivate and engage the patient; offer different levels of challenge and difficulty based on the patient baseline, and integrate objective measures of the patient's performance during each rehabilitation session.

OBJECTIVE

We designed and implemented a serious game for shoulder rehabilitation based on real-time hand tracking. The aim was to maintain the medical benefits of traditional rehabilitation, while reducing human resources and costs and facilitating active patient participation.

METHODS

Our software application provides the user with a shoulder horizontal adduction exercise. This exercise takes place in a 2D interactive game environment, controlled by hand movements on a desk pad. The hardware includes a standard desktop computer and screen, and the Leap Motion Controller: a hand tracking system. Changing the desk pad material allows the physiotherapist to vary the friction between the user hand and the supporting surface.

RESULTS

Fourteen healthy volunteers and six rehabilitation experts tested our serious game. The results showed that the application is attractive, ergonomic and clinically useful.

CONCLUSION

Despite promising results, clinical validation is necessary to demonstrate the efficacy of the serious game.

Interaction Modalities Used on Serious Games for Upper Limb Rehabilitation: A Systematic Review

This systematic review aims to analyze the state-of-the-art regarding interaction modalities used on serious games for upper limb rehabilitation. A systematic search was performed in IEEE Xplore and Web of Science databases. PRISMA and QualSyst protocols were used to filter and assess the articles. Articles must meet the following inclusion criteria: they must be written in English; be at least four pages in length; use or develop serious games; focus on upper limb rehabilitation; and be published between 2007 and 2017. Of 121 articles initially retrieved, 33 articles met the inclusion criteria. Three interaction modalities were found: vision systems (42.4%), complementary vision systems (30.3%), and no-vision systems (27.2%). Vision systems and no-vision systems obtained a similar mean QualSyst (86%) followed by complementary vision systems (85.7%). Almost half of the studies used vision systems as the interaction modality (42.4%) and used the Kinect sensor to collect the body movements (48.48%). The shoulder was the most treated body part in the studies (19%). A key limitation of vision systems and complementary vision systems is that their device performances might be affected by lighting conditions. A main limitation of the no-vision systems is that the range-of-motion in angles of the body movement might not be measured accurately. Due to a limited number of studies, fruitful areas for further research could be the following: serious games focused on finger rehabilitation and trauma injuries, game difficulty adaptation based on user's muscle strength and posture, and multisensor data fusion on interaction modalities.

Do-It-Yourself Gamified Cognitive Training: Viewpoint

Cognitive decline is an important nonmotor symptom in Parkinson disease (PD). Unfortunately, very few treatment options are available. Recent research pointed to small positive effects of nonpharmacological cognitive training in PD. Most of these trainings are performed under supervision and solely computerized versions of (traditional) paper-pencil cognitive training programs, lacking rewarding gamification stimulants that could help to promote adherence. By describing 3 different self-invented ways of cognitive gaming in patients with PD, we aimed to raise awareness for the potential of gamified cognitive training in PD patients. In addition, we hoped to inspire the readers with our case descriptions, highlighting the importance of both personalization and cocreation in the development of games for health. In this viewpoint, we have presented 3 PD patients with different ages, with different disease stages, and from various backgrounds, who all used self-invented cognitive training, including elements of personalization and gamification. To indicate generalization into a larger PD population, the recruitment results from a recent cognitive game trial are added. The presented cases show similarities in terms of awareness of their cognitive decline and the ways this process could potentially be counteracted, by looking for tools to train their cognition. On the basis of the response of the recruitment procedure, there seems to be interest in gamified cognitive training in a larger PD population too. Gamification may add to traditional therapies in terms of personalization and adherence. Positive results have already been found with gamified trainings in other populations, and the cases described here suggest that PD is also an attractive area to develop and test gamified cognitive trainings. However, no results of gamified cognitive trainings in PD have been published to date. This suggests an unmet need in this area and may justify the development of gamified cognitive training and its evaluation, for which our considerations can be used.