Serious Game Design and Clinical Improvement in Physical Rehabilitation: Systematic Review

Abstract

Background Serious video games have now been used and assessed in clinical protocols, with several studies reporting patient improvement and engagement with this type of therapy. Even though some literature reviews have approached this topic from a game perspective and presented a broad overview of the types of video games that have been used in this context, there is still a need to better understand how different game characteristics and development strategies might impact and relate to clinical outcomes. Objective This review assessed the relationship between the characteristics of serious games (SGs) and their relationship with the clinical outcomes of studies that use this type of therapy in motor impairment rehabilitation of patients with stroke, multiple sclerosis, or cerebral palsy. The purpose was to take a closer look at video game design features described in the literature (game genre [GG], game nature [GN], and game development strategy [GDS]) and assess how they may contribute toward improving health outcomes. Additionally, this review attempted to bring together medical and game development perspectives to facilitate communication between clinicians and game developers, therefore easing the process of choosing the video games to be used for physical rehabilitation. Methods We analyzed the main features of SG design to obtain significant clinical outcomes when applied to physical rehabilitation of patients recovering from motor impairments resulting from stroke, multiple sclerosis, and cerebral palsy. We implemented a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) database-adjusted electronic search strategy for the PubMed, IEEE Xplore, and Cochrane databases. Results We screened 623 related papers from 2010-2021 and identified 12 that presented results compatible with our inclusion criteria. A total of 512 participants with stroke (8 studies, 417 participants), cerebral palsy (1 study, 8 participants), and multiple sclerosis (2 studies, 46 participants) were included; 1 study targeting the elderly (41 participants) was also included. All studies assessed motor, sensory, and functional functions, while some also measured general health outcomes. Interventions with games were used for upper-limb motor rehabilitation. Of the 12 studies, 8 presented significant improvements in at least one clinical measurement, of which 6 presented games from the casual GG, 1 combined the casual, simulation, and exergaming GGs, and 2 combined the sports and simulation GGs. Conclusions Of the possible combinations of game design features (GG, GN, and GDS) described, custom-made casual games that resort to the first-person perspective, do not feature a visible player character, are played in single-player mode, and use nonimmersive virtual reality attain the best results in terms of positive clinical outcomes. In addition, the use of custom-made games versus commercial off-the-shelf games tends to give better clinical results, although the latter are perceived as more motivating and engaging.

Use of an EMG-Controlled Game as a Therapeutic Tool to Retrain Hand Muscle Activation Patterns Following Stroke: A Pilot Study

“…This may have positively affected motivation. 27,28 After the training, the stroke survivors in both groups improved the ability to control the cursor on the screen through the creation of muscle activation patterns in the paretic limb. Across all participants, test completion time (16 targets) decreased by 5.3 minutes, a 46% reduction.…”

“…One means of implementing this direct training of muscle activation patterns is through "serious" computer games, 25,26 as they can improve participation, motivation, and enjoyment to promote the repetitive practice needed for rehabilitation. 27,28 Serious games have been increasingly used to address needs in stroke rehabilitation, 29,30 including with utilization of EMG control in an attempt to alleviate excessive coactivation between 2 proximal arm muscles. 31,32 However, these previous studies did not address control of more than 2 muscles simultaneously, as is needed for most functional tasks.…”

“…Training of activation patterns, such as through the use of electromyography (EMG)-triggered rehabilitation devices like neuromuscular electrical stimulators23 and arm and hand exoskeletons,24 has shown efficacy in stroke rehabilitation. One means of implementing this direct training of muscle activation patterns is through “serious” computer games,25,26 as they can improve participation, motivation, and enjoyment to promote the repetitive practice needed for rehabilitation 27,28…”

Embodiment Comfort Levels During Motor Imagery Training Combined With Immersive Virtual Reality in a Spinal Cord Injury Patient

“…Another relevant result from the present scenarios is that the participant’s choices revealed an overall preference for scenarios with multiple types of feedback, namely for mixed scenarios with a sequence of grass-stone-sand-water. In future studies it will be important to combine psychological evaluation ( Jeunet et al, 2015a ) and EEG activity to identify which type of scenarios are better suited for each participant ( Li et al, 2020 ; Vieira et al, 2021 ).…”

A Serious Game for Performing Task-Oriented Cervical Exercises Among Older Adult Patients With Chronic Neck Pain: Development, Suitability, and Crossover Pilot Study

“…Serious gaming has been described as the use of computer games where the primary goal is not pure entertainment [ 9 ]. Serious games have shown positive clinical results in physical rehabilitation [ 10 ] and pain management contexts [ 11 ]; they are believed to increase motivation and engagement in health care contexts, in which patients are required to undergo repetitive or mundane tasks that can be perceived as boring or nonmotivating. These games involve participation in challenging game environments that can potentially help patients to be more adherent to treatment regimens, as well as focus their attention on an engaging distraction away from aversive symptoms [ 9 , 12 ].…”