Perspectives on the Gamification of an Interactive Health Technology for Postoperative Rehabilitation of Pediatric Anterior Cruciate Ligament Reconstruction: User-Centered Design Approach

Abstract

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.

A scoping review of portable sensing for out-of-lab anterior cruciate ligament injury prevention and rehabilitation

“…In contrast to the subjective verbal feedback from human observations, the visual feedback enabled by portable sensors is tangible, quantifiable, and more importantly, objective 59 – 61 . Further, the capabilities for automatic tracking of training and progress provided by portable sensing technologies could also open the door to new strategies, such as gamification, to motivate and engage athletes in completing injury prevention programs 96 , 97 .…”

Towards Out-of-Lab Anterior Cruciate Ligament Injury Prevention and Rehabilitation Assessment: A Review of Portable Sensing Approaches

“…In contrast to the subjective verbal feedback from human observations, the visual feedback enabled by portable sensors is tangible, quantifiable, and more importantly, objective [44, 53, 56]. Further, the capabilities for automatic tracking of training and progress provided by portable sensing technologies could also open the door to new strategies, such as gamification, to motivate and engage athletes in completing injury prevention programs [121, 122].…”

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts

“…They require closer guidance and rigid objective targets of recovery which could be achieved through novel and innovative solutions such as with the use of artificial intelligence and virtual reality. 99 It is not only the surgical technique that requires modification from the adult norm.…”