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

A Serious Game for Performing Task-Oriented Cervical Exercises Among Older Adult Patients With... Background: There is sparse research on the effectiveness of therapeutic exercise for the treatment of neck pain in older adult populations. Moreover, there is a lack of research on the use of serious games or virtual reality for the treatment of neck pain in this population. Objective: The primary aim of this study was to develop and assess the suitability of a serious game for performing task-oriented cervical exercises in patients with neck pain. Methods: A serious game was designed based on the key features identified by previous studies that designed serious video games for physical and cognitive rehabilitation or exercise. The game in this study was designed to provide an interactive scenario, with the main functionality of the software solution to control a virtual airplane to reach targets using head motions. At the end of the exercise, the application stores the targets reached and missed and the airplane’s trajectory. A crossover pilot study was carried out for preliminary evaluation of the suitability of the technology in the older adult population. Men and women over 65 years of age with chronic neck pain were included. Subjects were randomly assigned to two study arms; each arm consisted of a sequence of two 4-week treatments with an intermediate washout period of 4 weeks. The total study duration was 16 weeks due to a final follow-up measure 4 weeks after the end of all treatments. Treatment A consisted of the use of the serious game developed in this study, and treatment B consisted of conventional exercises. Subjects allocated to the A-B study arm received treatment A first, followed by treatment B, and vice versa in the B-A arm. The following variables were assessed: Suitability Evaluation Questionnaire (SEQ) scores, Visual Analog Scale scores, and the number of targets reached in the serious game. Results: A total of 18 subjects were assessed for eligibility. A total of 13 subjects, aged between 71 and 92 years (mean 81.85, SD 6.82), were finally included and completed the study protocol. The global mean SEQ score was 50.38 (SD 5.35) out of 65 https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al points, showing good suitability of the serious game. Most patients considered the experience very enjoyable and “real” in terms of the virtual environment and found the information provided to be clear. Also, they believed that the game could be very helpful for their rehabilitation. None of the patients felt any neck pain or discomfort when playing the game, and only 2 patients out of 13 (15%) reported some degree of dizziness, eye discomfort, or disorientation, which did not limit their capacity to finish the session. Conclusions: The serious game developed in this study showed good suitability for use in adults over 70 years of age with chronic neck pain. The game was a safe method for performing task-oriented cervical exercises, and patients reported very high levels of satisfaction and acceptance after the use of this technology. (JMIR Serious Games 2022;10(1):e31404) doi: 10.2196/31404 KEYWORDS video games; neck pain; aged; virtual reality; exercise therapy; physical therapy modalities; technology [15] but recommended further focused, high-quality research Introduction due to the low-quality evidence available [14]. Neck pain is a highly prevalent musculoskeletal disorder among Previous research studies have developed serious games or VR populations of developed societies that leads to considerable systems and investigated their use in terms of assessment of pain, disability, and economic burden [1]. The 1-year prevalence neck kinematics [16,17] and exercise prescription for the of neck pain in the general population has been shown to be treatment of patients with neck pain [18,19]; these treatments 25.8% (range 4.8%-79.5%) on average, with a point prevalence showed good psychometric properties [17] and effectiveness in of 14.4% (range 0.4%-41.5%) [2]. It has been ranked as the neck pain, disability, satisfaction, or cervical motion kinematics 4th-greatest contributor to overall global disability and 21st in [18]. However, to the authors’ knowledge, no previous research terms of overall burden [3]. Between 50% and 85% of the has investigated the suitability of the use of similar technologies general population who experience neck pain at some point in in the performance of task-oriented neck exercises in older adult their lives will report it again 1 to 5 years later [4]. Neck pain populations with chronic neck pain. has been shown to be higher in females and to increase with There is sparse research on the effectiveness of therapeutic age, up to 70 to 74 years, then to decrease with older age [1]. exercise for the treatment of neck pain in older adult populations However, results from the Spanish National Health Survey [8]. Moreover, there is a lack of research on the use of serious showed that the age group of individuals older than 75 years games or VR for the treatment of neck pain in this population had a higher prevalence of chronic neck pain (17.32% of males [14]. Previous research has suggested that VR technology could and 34.60% of females) compared to other age groups [5]. improve variables such as functional mobility through improving Clinical guidelines recommend therapeutic exercise as one of gait quality and resistance in older populations [20]. A recent the main therapeutic options for patients with neck pain [6]. systematic review also suggested that VR interventions have However, recent systematic reviews have highlighted the need the potential to improve health outcomes in older adults. for further research, as there has only been low- or However, factors including frailty as well as usability or moderate-quality evidence to support its effectiveness [7,8]. acceptability of this technology need to be explored in future research in this population [21]. The use of technology in the context of the prescription or performance of therapeutic exercise in patients with neck pain The use of serious video games with motion capture sensors has become more popular in recent years. Serious gaming has has become popular in physical treatments in the last decade. been described as the use of computer games where the primary Some pieces of commercial equipment, mainly Wii or Kinect, goal is not pure entertainment [9]. Serious games have shown have been applied for clinical purposes among older adult positive clinical results in physical rehabilitation [10] and pain people, especially for balance training [22,23] or pain management contexts [11]; they are believed to increase management [24]. Most of these studies demonstrated that motivation and engagement in health care contexts, in which functions such as walking, muscle strength, and other motor patients are required to undergo repetitive or mundane tasks functions improved. Despite their potential, these kinds of that can be perceived as boring or nonmotivating. These games commercial devices have not been designed to monitor and involve participation in challenging game environments that register relevant parameters, such as range of motion (ROM) can potentially help patients to be more adherent to treatment or movement velocity, which would be useful for quantifying regimens, as well as focus their attention on an engaging the progress of the intervention. In addition, they are usually distraction away from aversive symptoms [9,12]. designed to train functional movements of the lower and upper limbs. The use of serious games for neck pain has been evaluated in various investigations, normally described in terms of immersive The video game in this study is controlled by the ENLAZA virtual reality (VR) serious games using head-mounted displays sensor (Werium Solutions), which consists of an inertial sensor or using nonimmersive flat-screen computer games [13-15]. that translates the cervical ROM into mouse pointer Recent systematic reviews reported that existing evidence of displacements. The ENLAZA interface has previously been VR effectiveness in patients with chronic neck pain is promising used for the following purposes: as an input device [25], for https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al physical rehabilitation [26], and for biomechanical assessment may be critical to motor learning. The number of targets, [27-29]. These previous studies show the potential of the use the target size, and the airplane speed are customizable. of the device in the rehabilitation of cervical movement in These targets are shown randomly every time the game people with neurological disorders, such as cerebral palsy. starts. However, this device has never been tested in the population Cervical ROM. The distance between targets is being investigated in this paper. customizable as a function of the cervical ROM required to reach them. The primary objective of this study was to develop and assess Cognitive challenge. The video game presents a simple and the suitability of a serious game for performing task-oriented understandable goal-directed task. cervical exercises in patients with neck pain. The secondary Sensitivity to auditory and visual limitations of the target objective was to compare the effects of the serious game with population. There is high contrast between the different those of conventional therapeutic exercises among older adult elements of the scene and representative sounds when an patients with chronic neck pain. event occurs. Biofeedback. The airplane moves according to the user’s Methods head movement, and the video game offers visual and auditive stimuli when the user succeeds and fails. Sensor Description Meaningful play. To provide an incentive to keep playing, The sensor development was based on previous work focused besides perceiving the immediate result of the reached target on head-mounted interfaces in the field of augmentative and via visual and auditive stimuli, a final score of the reached alternative communication for children with cerebral palsy targets is shown. [30,31]. The ENLAZA sensor (Werium Solutions) has also been The control algorithm follows absolute mapping, which means validated to measure the ROM of different body regions, such that a given angular orientation of the head always corresponds as the neck, knee, elbow, and wrist [27-29,32]. to the same position of the virtual airplane. Absolute mapping The core of the sensor is the MPU-9250 microelectromechanical is more interesting than relative mapping (ie, based on a relative systems sensor (InvenSense), which integrates a 3D variable, such as movement speed or acceleration) for accelerometer, a 3D gyroscope, and a 3D magnetometer. The rehabilitation purposes, because the system demands an upright information from these three sensors is combined to estimate posture to control the game successfully. the angular rotation of the sensor [3]. The three degrees of freedom of the cervical joint (ie, 3D space), The wearable sensor unit is connected to the computer through corresponding to flexion-extension, right-left inclination, and Bluetooth connection, following the classic serial port profile right-left rotation, have to be translated into the vertical and of the RN42 wireless module (Microchip Technology Inc). horizontal coordinates of the virtual airplane (ie, 2D space). The Once the wearable sensor is paired with the computer, the sensor vertical coordinate (y) is always controlled by the angle of streams orientation data, which can be read through a virtual flexion-extension, and the horizontal coordinate (x) can be serial communication port. controlled by the angular inclination or rotation of the head. The software solution integrates a graphical user interface to Video Game Description: Active Airlines configure the following options (Multimedia Appendix 2): The video game in this study has been designed based on the key features identified by previous studies involving the design Control of the horizontal coordinate using inclination or of serious video games for physical and cognitive rehabilitation rotational movement. or exercise. Previous research has shown that the most relevant Control of the virtual airplane in 1D (ie, vertical or key feature is to keep players engaged with a challenge adapted horizontal axis) or 2D (ie, vertical and horizontal axes). to the skills of a particular user [33-35]. This is a critical point Number of targets to reach. when the users are older adult people, due to their physical and Required cervical ROM to reach the targets (ie, angular cognitive skills. sensibility). Level of difficulty (eg, speed of target appearance). Based on the key features described by the literature, we developed the software component of the solution, called Active Absolute mapping uses the Euler angles generated from the Airlines. This is a Windows-based application, using the C# direction cosine matrix (DCM) using the YZX Euler convention. language in Unity’s integrated development environment, The x and y coordinates of the airplane were calculated designed to provide an interactive scenario for assessment and according to the following formulas: exercise of cervical ROM. The main functionality of the software solution was to control a virtual airplane to reach targets using head motions (Multimedia Appendix 1). The key factors described in the literature were adapted to fulfill the physical and cognitive skills of our target population, following these criteria: Motor control. The user performs a specific movement that requires the anticipation of feedback; as a result, outcomes https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al where R is the result of multiplying the R matrix (ie, the the outcome evaluators were blinded to patients’ group T cal assignments. The evaluators were in charge of recording the DCM in neutral posture) by R (ie, the DCM in every sample). initial selection data and verifying that participants were eligible The x and y values represent the horizontal and vertical to participate in the study. At the end of each treatment block, coordinates of the airplane (pixels), respectively. R and R H V they collected the data obtained from the participants. All represent the horizontal and vertical distance between targets participants were asked not to discuss the treatments they were (pixels), respectively. α and β represent the required ROM T T undergoing with the evaluators so as not to influence the records. to reach the targets (angular degree). In the case of noncompliance, patients were excluded from the Before starting the exercise, a calibration process is required to trial. establish the R matrix. The subject maintains a neutral posture cal Randomization: Sequence Generation (ie, head in the upright position) for 2 seconds, and the All subjects who fulfilled the study selection criteria were physiotherapist calibrates the device by clicking a specific button randomly assigned to one of two study arm groups (see on the software application. Interventions section below). Randomization was performed Finally, the software application includes a database to register using the online computer program Prism (version 5; GraphPad the subjects’ data. At the end of the exercise, the application Software) to assign participants to the serious game group or stores the targets reached and missed and the airplane’s the conventional exercise group. trajectory (Multimedia Appendix 3). The number of reached Primary Outcomes and missed targets together represents the performance score, which is directly related to the motor control of the head. The Suitability Evaluation Questionnaire (SEQ) was designed to test items such as satisfaction, acceptance, and security of Pilot Study Design use in virtual rehabilitation systems. It is an easy-to-understand The usability analysis and preliminary evaluation of the effects questionnaire, with a reasonable number of straightforward and were carried out through a randomized, single-blind, crossover clear questions that are evaluated on a scale from 1 (“not at all” clinical pilot study. Subjects were recruited from the Residencia or “very easy”) to 5 (“very much” or “very difficult”). The Municipal de Griñón, a nursing home in Madrid, Spain. The questionnaire addresses different items related to virtual trial was conducted under the criteria of the CONSORT rehabilitation systems, with 14 questions on feeling, satisfaction, (Consolidated Standards of Reporting Trials) statement [36]. and realism; the last question is open ended, where patients, if This study was approved by the Ethics Committee of the Centro they felt uncomfortable, were asked the reasons why. The Superior de Estudios Universitarios La Salle, Universidad minimum score is 13 points, and the maximum score is 65 Autónoma de Madrid (approval code: CSEULS-PI-181/2017). points. Previous research has used the SEQ to evaluate the All participants provided signed informed consent before suitability of virtual rehabilitation in older adults [38]. participation. Secondary Outcomes As the primary objective of this study was to develop a serious Number of Targets Reached in the Serious Game game and then assess its suitability, and not to measure the outcome of the intervention through a randomized controlled The number of targets reached by each user in the serious game trial, the study was not retrospectively registered. group was evaluated as a percentage in order to compare the proportion of hits across sessions, representing the performance Participants of the craniocervical motor control. This outcome was only Men and women over 65 years of age with chronic neck pain registered during the serious game experimental group sessions; were included. Subjects selected for this study had to meet the in addition, this outcome was used as complementary data following inclusion criteria: be at least 65 years of age; regarding whether the older adults included in the study could understand, write, and speak Spanish fluently; have suffered improve their game performance over 4 weeks of consecutive from neck pain for more than 12 weeks [37]; scored more than sessions. Therefore, this outcome did not allow for any 5 points on the Neck Disability Index (NDI); have no cognitive comparison between groups nor for analysis that would evaluate impairment below 20 points, as assessed by the Mini–Mental whether improvements in the game scores were associated with State Examination (MMSE) scale; and be willing to undergo changes in pain or disability. treatment. In addition, the following exclusion criteria were Visual Analog Scale used: red-flagged medical history (ie, tumor, fracture, metabolic diseases, and rheumatoid arthritis), fibromyalgia syndrome, The Visual Analog Scale (VAS) is a horizontal line used to previous neck surgery, or neck pain accompanied by vertigo grade the intensity of pain, from no pain to the maximum caused by vertebrobasilar insufficiency. The subjects were possible pain. Poor pain control is considered to be above 3 recruited by word of mouth, through individual interviews with points on the VAS [39], and the minimum detectable change is patients. 2 points [40]. This scale was used to measure neck pain intensity at baseline and at each of the follow-up points of the pilot study Research Team by asking each patient to mark a vertical line on the scale The research team was composed of three physiotherapists, representing the intensity of neck pain in the last 24 hours. which included two evaluators and one person who administered the treatment and was in charge of assigning the groups so that https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al was placed approximately in a straight line with the xiphoid Control Variables process. Within the Active Airlines application, parameters Neck Disability Index could be set, such as difficulty, degrees of rotation, movement The NDI is a self-completed questionnaire with 10 items: to be treated, and number of objects to be picked up. An “easy” intensity of neck pain, self-care, lifting, reading, headache, difficulty level was selected for all subjects, with a marked ability to concentrate, ability to work, ability to drive, sleep maximal mobility of 20º to 30º in order to cover the entire screen activities, and leisure activities. Each of the items has six (ie, flexion-extension movements moved the plane down or up, possible responses representing six progressive levels of respectively, and lateral inclinations moved the plane to the functional ability, with scores ranging from 0 to 5. The total sides), leaving rotation unworked in this study. The location of score is expressed in percentage terms with respect to the each of the targets was shown on the screen randomly, and the maximum possible score. The completion time is reasonably time elapsed between targets was 5 seconds. The participant short, and a validated Spanish version was used [41]. The NDI performed the exercise twice (ie, two series) in each session, has been shown to be a responsive scale among older adult and the application was set up so that the participant aimed to patients with nonspecific neck pain [42]. The minimum pick up 21 targets per series, for a total of 42 points. Considering detectable change is 5 out of 50 points, and a change of 7 points that the patient had to perform a combined movement (ie, is recommended for achieving a clinically relevant difference flexion-extension combined with right-left lateral flexion) to [43]. reach each of the targets, the total number of combined movements performed by patients in each session was 42 (ie, Mini–Mental State Examination one per target), and the total game duration was 210 seconds To measure cognitive impairment, we used an adapted and (ie, 5 seconds per target). At the end of each series, the targets validated Spanish version of the Folstein MMSE [44]. This is picked up were counted and recorded as a percentage value (ie, a screening test for dementia that is also useful in the the score for the day was recorded as the total percentage from evolutionary follow-up of dementia. This questionnaire explores the two series). Once the first series was finished, the exact short- and long-term memory, orientation, information about same procedure was performed again, thus ending the serious everyday events, and calculation capacity. Information was game session for that day. In this group, the sessions included collected by means of an auto-administered questionnaire. The only one participant at a time. results were evaluated according to the following number of Conventional Exercise: Treatment B errors: 0 to 2 (normal), 3 to 4 (mild cognitive impairment), 5 to 7 (moderate cognitive impairment), and 8 to 10 (severe cognitive Treatment B consisted of a therapeutic exercise protocol that impairment). When using this scale, it is important to consider was based on two weekly sessions of conventional physical the educational level of the person taking the test. In cases of therapy for 4 weeks; this consisted of an exercise program of low educational level (ie, elementary education), one additional about 30 to 45 minutes in length for groups of 2 to 4 patients. error is allowed for each category. In cases of high educational This program included 5 minutes of stairs, 10 minutes of level (ie, university level), one fewer error is allowed for each pedaling, 5 minutes of pulleys, and 5 minutes of obstacle category (35 points maximum). Two cutoff points are considered walking. In addition, three sets of 12 repetitions of cervical joint according to age: 24 points for those 65 years of age and older, mobility exercises in all ranges were added: cervical and 29 points for nongeriatric adults. The classification brackets flexion-extension, right-left lateral flexion, and cervical for points are as follows: 30 to 35 (normal), 24 to 29 rotations. The exercises were not performed with resistance, (borderline), 19 to 23 (mild), 14 to 18 (moderate), and less than but were only self-loading at the beginning of the ROM. 14 (severe) [44]. Procedure Interventions Once the informed consent forms were revised and signed by the participants, the VAS, NDI, and MMSE were administered Overview at baseline. The study had a total duration of 16 weeks. First, For the crossover study, subjects were randomly assigned to the therapist assigned each study group to one study arm. One one of two study groups. Group A-B started by testing the group followed the A-B sequence with an intermediate washout serious game for 4 weeks (8 sessions), followed by a 4-week period of 4 weeks. The other group received the treatment in washout period, after which they performed conventional the B-A order, also with a washout period of 4 weeks. Finally, exercises for 4 weeks (8 sessions). Group B-A started with the the last assessment of outcomes was carried out 4 weeks after conventional exercises and then tested the game after the the treatment finished. Thus, the distribution of the evaluators’ washout period. The total study duration was 16 weeks, measurements was as follows: baseline (0 weeks), after first including a final follow-up measure 4 weeks after the end of all intervention (4 weeks), washout period (8 weeks), after second treatments. intervention (12 weeks), and follow-up period (16 weeks). Serious Game: Treatment A In the washout and follow-up weeks, no exhaustive follow-up Treatment A consisted of the use of the Active Airlines serious was performed, and participants were simply reminded, game twice a week for 4 weeks. The sensor had to be held at sporadically, to keep up with the previously prescribed exercises. forehead level with an elastic band and Velcro, with a Windows These exercises were based on cervical joint mobility. computer in front of it in order to run the application correctly; the computer screen was placed at eye level, and the keyboard https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al The evaluation of the VAS was carried out at all follow-up measures after the first intervention (4 weeks) and after the periods, and the SEQ was included in the evaluation at the end second intervention (12 weeks). in order to assess the degree of suitability of the inertial sensor Finally, to test the sequence effect, the change produced in the and the Active Airlines game. variables of interest with each of the interventions was analyzed by comparing the A-B sequence and the B-A sequence. For Data Analysis example, if there was no sequence effect, the value obtained for All statistical tests were performed with SPSS Statistics for the VAS variable after having received the serious game Windows (version 27; IBM Corp) with a significance level of intervention should be the same, either in the first period or in P<.05. Demographic data were analyzed with descriptive the second period. Therefore, the difference between baseline statistics and were represented as mean (SD) for each of the and postintervention for each variable was calculated for each variables. The Shapiro-Wilk statistic was used to test the normal group and compared, based on whether the A-B or B-A sequence distribution of the data. Since this was a randomized crossover was followed. clinical trial, it was necessary to analyze the difference in the variables of interest between each of the interventions. For this In addition, for the study of the control variables and variables purpose, the Student t test was used for related measures, to related to the use of the technology, the Student t test for related compare between groups and within groups. measures and the repeated-measures analysis of variance (ANOVA) test were used. Also, based on the crossover design, other effects had to be analyzed, such as the residual effect, period effect, and sequence Results effect. In order to guarantee as high a quality as possible in the analysis, the following tests were performed, according to Overview previous recommendations [45]. A total of 18 subjects were evaluated for inclusion in the study. To verify that the interventions had an effect over time, the Of these, 14 subjects, aged between 71 and 92 years (mean residual effect of the interventions was analyzed by performing 81.85, SD 6.82), were finally included (Figure 1). There was 1 a Student t test for related samples, comparing the initial participant lost due to death in the B-A sequence study group measurement with the measurement after the washout period. during the first 4-week period of treatment. Demographic In the case of statistically significant results, the Wilcoxon variables and all baseline variables showed a normal distribution, signed-rank test was used to repeat the analysis, subdividing by with P values greater than .05 in the Shapiro-Wilk test. intervention group to identify the intervention that produced Descriptive data for the demographic variables are shown in the residual effect. The period effect was also analyzed by Table 1. performing a Student t test for related samples, comparing the https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al Figure 1. Participant flowchart. https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al Table 1. Baseline descriptive data and normality test. Variable Value (N=14) P value Sex (women), n (%) 9 (64) N/A Age (years), mean (SD) 81.85 (6.82) .31 Weight (kg), mean (SD) 68.16 (8.38) .82 Height (cm), mean (SD) 1.54 (0.07) .12 BMI, mean (SD) 28.65 (3.58) >.99 31.08 (3.01) .13 Mini–Mental State Examination score 15.77 (8.19) .98 Neck Disability Index score P values are based on the Shapiro-Wilk test, which measures the distribution of variables; variables showed a normal distribution. N/A: not applicable; the Shapiro-Wilk test cannot be performed on categorical data. The classification brackets for this scale are as follows: 30 to 35 (normal), 24 to 29 (borderline), 19 to 23 (mild), 14 to 18 (moderate), and less than 14 (severe). The minimum detectable change for this index is 5 out of 50 points, and a change of 7 points is recommended for achieving a clinically relevant difference. The results of the SEQ also showed that none of the patients Suitability of the Technology felt any neck pain or discomfort when playing the game, and The scores obtained in each of the items of the SEQ are only 2 patients out of 13 (12%) reported some degree of presented in Table 2. The global mean score for the SEQ was dizziness, eye discomfort, or disorientation. These two events 50.38 (SD 5.35) out of 65 points, showing good suitability of of dizziness were also recorded separately by researchers as the Active Airlines serious game. Most of the patients minor adverse effects. Both subjects were able to finish the considered the experience to be very enjoyable and “real” in session and kept participating in the study. No other adverse terms of the virtual environment, and found the information events occurred during any of the treatment sessions. provided to be clear. Also, most of them thought that the game Moreover, most patients considered the task to be difficult and could be very helpful for their rehabilitation. the system difficult to use, suggesting that the game presented a challenge for them across the different treatment sessions. Table 2. Suitability of the technology based on results from the Suitability Evaluation Questionnaire (SEQ). Question SEQ score, mean (SD) Q1. How much did you enjoy your experience with the system? 4.92 (0.277) Q2. How much did you sense being in the environment of the system? 3.92 (1.115) Q3. How successful were you in the system? 3.85 (1.214) Q4. To what extent were you able to control the system? 3.62 (1.261) Q5. How real is the virtual environment of the system? 4.62 (0.961) Q6. Is the information provided by the system clear? 4.31 (0.947) Q7. Did you feel discomfort during your experience with the system? 1.00 (0.000) Q8. Did you experience dizziness or nausea during your practice with the system? 1.54 (1.330) Q9. Did you experience eye discomfort during your practice with the system? 1.54 (1.330) Q10. Did you feel confused or disoriented during your experience with the system? 1.23 (0.832) Q11. Do you think that this system will be helpful for your rehabilitation? 4.69 (0.630) Q12. Did you find the task difficult? 4.69 (0.855) Q13. Did you find the devices of the system difficult to use? 4.77 (0.599) Total for all questions 50.38 (5.35) Questions were scored on a 5-point Likert scale, ranging from 1 (“not at all”) to 5 (“very much”). Reverse scoring was performed for Q7-Q10, Q12, and Q13, ranging from 1 (“very easy”) to 5 (“very difficult”). https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al session. The results showed statistically significant effects over Number of Targets Reached in the Serious Game time (F =22.14; P<.01), as the percentage of targets reached A repeated-measures ANOVA showed that the number of targets during the game progressively increased in each session (Table reached during serious game–playing increased with each 3). Table 3. Success in the serious game during each treatment session. Session Success (%), mean (SD) 1 68.86 (24.87) 2 71.06 (24.63) 3 82.05 (19.50) 4 82.96 (21.14) 5 85.16 (15.25) 6 83.51 (13.31) 7 86.44 (16.02) 8 89.74 (12.95) Percentage change from session 1 to 8 24.90 (20.85) The serious game software only returns the percentage of success in the game. A statistically significant residual effect was found. The Pilot Study Results for Pain Wilcoxon signed-rank test, used as a secondary analysis There were no significant differences between the effects of the subdividing by group, showed a statistically significant residual serious game and conventional exercises when considering all effect only for the conventional exercise intervention (baseline: subjects who received each treatment, independent of the study mean 5.36, SD 1.84; washout: mean 3.21, SD 2.45; Z=–2.38, group sequence, but both treatments showed improvements in P=.02). neck pain intensity (Table 4). Table 4. Comparison between treatments, intratreatment changes, and residual effect. a b c c Posttreatment VAS score, mean Washout period VAS score Treatment Baseline VAS score, mean P value P value (SD) (residual effect), mean (SD) (SD) Serious game 4.92 (1.88) 3.77 (1.92) <.001 3.69 (2.13) .01 Conventional exercise 4.92 (1.88) 3.46 (2.22) <.001 3.69 (2.13) .01 No statistically significant differences between treatments were detected in the measurement after the intervention (serious game vs conventional exercise). VAS: Visual Analog Scale. P values are based on the Student t test. Period effect analysis revealed that there were statistically with the B-A sequence (VAS score mean difference –1.64, SD significant differences between the end of the first period and 0.75) than with the A-B sequence (VAS score mean difference the end of the second period. The mean VAS score at baseline –0.58, SD 0.49). On the other hand, for the conventional exercise was 4.92 (SD 1.88), the score after the first treatment was 4.15 treatment, pain was reduced to a greater extent with the A-B (SD 1.57), and the score after the second treatment was 3.08 sequence (VAS score mean difference –2.08, SD 1.02) than (SD 2.36; P=.003). with the B-A sequence (VAS score mean difference –0.93, SD 0.45). Table 5 shows the changes in pain that occurred after Finally, the sequence effect analysis for the serious game treatment in each of the study group sequences. intervention showed that pain was reduced to a greater extent https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al Table 5. Sequence effect analysis. a b c d Treatment and sequence VAS score, mean difference (SD) P value Serious game A-B –0.58 (0.49) .01 B-A –1.64 (0.75) Conventional exercise A-B –2.08 (1.02) .04 B-A –0.93 (0.45) Sequence A-B is serious game followed by conventional exercise; sequence B-A is conventional exercise followed by serious game. VAS: Visual Analog Scale. This value represents the mean difference between baseline and posttreatment measures. P values are based on the Student t test. P values for each group are reported in the top row of that group. The main clinical findings of the pilot study are as follows: (1) Discussion both conventional exercise and the use of the serious game had the same effect in reducing neck pain in the older adult Principal Findings population and (2) the A-B sequence (ie, playing the serious This study allowed for the development of a serious game to game first followed by conventional exercise) reduced pain provide a suitable solution for the performance of task-oriented more than the B-A sequence (ie, conventional exercise first cervical exercises for people with neck pain. followed by playing the serious game). The older adult population included in the study showed very On the one hand, the results of this study appear to support the good results in terms of satisfaction, acceptance, and security findings of another recent study that suggested that performing when using this technology. Moreover, minor adverse events exercises with immersive VR is not superior to exercises alone were scarce in the pilot population sample included in the study. without VR among young adult patients with neck pain [48]. Therefore, the older adult population aged over 80 years with On the other hand, the results of this research are not supported chronic pain might benefit from this intervention, but some by those found in another study that compared nonimmersive factors would need further research, such as technological VR exercises with proprioceptive training in patients with neck acceptance, visual and hearing disorders, and cognitive pain, using eight sessions over a period of 4 weeks. That study impairments, among others, which can become barriers for the observed that patients in the VR group improved more in terms success of the intervention. of pain and disability than the group that performed proprioceptive exercises [49]. Although the design of the study did not allow for measuring treatment adherence, the playful approach and integrated Another study in which VR was added to neck exercises in one technology used may be capable of increasing adherence to the group and compared to a group that performed exercises alone exercise treatment. Further research is needed to investigate during four to six treatment sessions found that only the group whether these technologies are associated with higher adherence that included VR improved more in terms of disability and ROM or patient motivation compared with conventional exercise in rotation. However, there was no improvement over the programs, which can sometimes be considered more repetitive exercise-only group in terms of pain intensity. Those results or boring [12]. support the ones obtained in this study; although we did not measure the ROM variable, patients improved in accuracy when The main clinical implication from this study is that patients playing the video game in successive sessions [18]. with neck pain could safely use this serious game with high levels of satisfaction and acceptance. Although the clinical The results of this study were novel in terms of the use of a findings from the pilot study are limited and do not allow for serious game in a population of adults over 70 years of age, but medium- or long-term evaluation of its effects, it can be we must analyze a series of important limitations for their hypothesized that patients’ satisfaction and adherence to exercise possible applicability in clinical practice. First, the may be increased when performing therapeutic exercise through characteristics of the pilot study with a reduced sample size the serious game. Moreover, this serious game has the potential limit the generalizability of the results in terms of the suitability to be used in a telerehabilitation context by physiotherapists; of the serious game in this older adult population and its effects this could result in important advantages regarding on the treatment of neck pain. Second, the study had a crossover cost-effectiveness [46] and the possibility to perform therapeutic versus parallel design; therefore, it is more difficult to exercise at home, without having to make tiring journeys [47], demonstrate the isolated effects of each therapy. Third, a control which could be especially relevant at some stages of group was not included to investigate whether the therapies physiotherapy treatment in the older adult population with neck used had a greater effect than the natural evolution of neck pain. pain. Fourth, psychological variables such as kinesiophobia or anxiety, which have been shown to influence the effects of interventions https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al for neck pain in other studies with VR, were not measured. The age with chronic neck pain. It was a safe method for performing fifth limitation is that the washout period was shown to be task-oriented cervical exercises, and patients reported very good ineffective according to the statistical analysis of this study; for levels of satisfaction and acceptance after the use of this future studies, washout periods longer than 4 weeks should be technology. Although preliminary results on the effects of using considered. the serious game showed short-term improvements in pain intensity, further research with larger samples is needed. Conclusions The serious game developed in this study showed good suitability when used in a population of adults over 70 years of Acknowledgments This study was supported by the Fundación Universitaria San Pablo CEU and Banco Santander (grant FUSPBS-PPC20/2017); the Spanish Ministry of Science, Innovation and Universities (PID2019-108616RA-I00/AEI/10.13039/501100011033); and Project RTI2018-097122-A-I00, which is funded by the Fondo Europeo de Desarrollo Regional, the Ministry of Science and Innovation, and the Agencia Estatal de Investigación. Part of HBA’s salary is financed by the European Regional Development Fund (2020/5154). The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; and in the decision to publish the results. Conflicts of Interest RR is the CEO of Werium Solutions. Multimedia Appendix 1 Screenshot of the Active Airlines serious game. [PNG File , 1397 KB-Multimedia Appendix 1] Multimedia Appendix 2 Settings for the graphical user interface of the Active Airlines serious game. [PNG File , 156 KB-Multimedia Appendix 2] Multimedia Appendix 3 Subjects' data regarding targets reached and missed in the Active Airlines serious game. [PNG File , 135 KB-Multimedia Appendix 3] References 1. Safiri S, Kolahi A, Hoy D, Buchbinder R, Mansournia MA, Bettampadi D, et al. Global, regional, and national burden of neck pain in the general population, 1990-2017: Systematic analysis of the Global Burden of Disease Study 2017. BMJ 2020 Mar 26;368:m791 [FREE Full text] [doi: 10.1136/bmj.m791] [Medline: 32217608] 2. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol 2010 Dec;24(6):783-792. [doi: 10.1016/j.berh.2011.01.019] [Medline: 21665126] 3. Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, et al. 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A novel virtual reality technique (Cervigame®) compared to conventional proprioceptive training to treat neck pain: A randomized controlled trial. J Biomed Phys Eng 2019 Jun;9(3):355-366 [FREE Full text] [doi: 10.31661/jbpe.v0i0.556] [Medline: 31341881] Abbreviations ANOVA: analysis of variance CONSORT: Consolidated Standards of Reporting Trials DCM: direction cosine matrix MMSE: Mini–Mental State Examination NDI: Neck Disability Index ROM: range of motion SEQ: Suitability Evaluation Questionnaire VAS: Visual Analog Scale VR: virtual reality Edited by N Zary; submitted 21.06.21; peer-reviewed by M Eckert, G Dermody; comments to author 24.09.21; revised version received 15.10.21; accepted 13.11.21; published 01.02.22 Please cite as: Beltran-Alacreu H, Navarro-Fernández G, Godia-Lledó D, Graell-Pasarón L, Ramos-González Á, Raya R, Martin-Pintado Zugasti A, Fernandez-Carnero J A Serious Game for Performing Task-Oriented Cervical Exercises Among Older Adult Patients With Chronic Neck Pain: Development, Suitability, and Crossover Pilot Study JMIR Serious Games 2022;10(1):e31404 URL: https://games.jmir.org/2022/1/e31404 doi: 10.2196/31404 PMID: ©Hector Beltran-Alacreu, Gonzalo Navarro-Fernández, Daniela Godia-Lledó, Lucas Graell-Pasarón, Álvaro Ramos-González, Rafael Raya, Aitor Martin-Pintado Zugasti, Josue Fernandez-Carnero. Originally published in JMIR Serious Games (https://games.jmir.org), 01.02.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 14 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

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

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Abstract

Background: There is sparse research on the effectiveness of therapeutic exercise for the treatment of neck pain in older adult populations. Moreover, there is a lack of research on the use of serious games or virtual reality for the treatment of neck pain in this population. Objective: The primary aim of this study was to develop and assess the suitability of a serious game for performing task-oriented cervical exercises in patients with neck pain. Methods: A serious game was designed based on the key features identified by previous studies that designed serious video games for physical and cognitive rehabilitation or exercise. The game in this study was designed to provide an interactive scenario, with the main functionality of the software solution to control a virtual airplane to reach targets using head motions. At the end of the exercise, the application stores the targets reached and missed and the airplane’s trajectory. A crossover pilot study was carried out for preliminary evaluation of the suitability of the technology in the older adult population. Men and women over 65 years of age with chronic neck pain were included. Subjects were randomly assigned to two study arms; each arm consisted of a sequence of two 4-week treatments with an intermediate washout period of 4 weeks. The total study duration was 16 weeks due to a final follow-up measure 4 weeks after the end of all treatments. Treatment A consisted of the use of the serious game developed in this study, and treatment B consisted of conventional exercises. Subjects allocated to the A-B study arm received treatment A first, followed by treatment B, and vice versa in the B-A arm. The following variables were assessed: Suitability Evaluation Questionnaire (SEQ) scores, Visual Analog Scale scores, and the number of targets reached in the serious game. Results: A total of 18 subjects were assessed for eligibility. A total of 13 subjects, aged between 71 and 92 years (mean 81.85, SD 6.82), were finally included and completed the study protocol. The global mean SEQ score was 50.38 (SD 5.35) out of 65 https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al points, showing good suitability of the serious game. Most patients considered the experience very enjoyable and “real” in terms of the virtual environment and found the information provided to be clear. Also, they believed that the game could be very helpful for their rehabilitation. None of the patients felt any neck pain or discomfort when playing the game, and only 2 patients out of 13 (15%) reported some degree of dizziness, eye discomfort, or disorientation, which did not limit their capacity to finish the session. Conclusions: The serious game developed in this study showed good suitability for use in adults over 70 years of age with chronic neck pain. The game was a safe method for performing task-oriented cervical exercises, and patients reported very high levels of satisfaction and acceptance after the use of this technology. (JMIR Serious Games 2022;10(1):e31404) doi: 10.2196/31404 KEYWORDS video games; neck pain; aged; virtual reality; exercise therapy; physical therapy modalities; technology [15] but recommended further focused, high-quality research Introduction due to the low-quality evidence available [14]. Neck pain is a highly prevalent musculoskeletal disorder among Previous research studies have developed serious games or VR populations of developed societies that leads to considerable systems and investigated their use in terms of assessment of pain, disability, and economic burden [1]. The 1-year prevalence neck kinematics [16,17] and exercise prescription for the of neck pain in the general population has been shown to be treatment of patients with neck pain [18,19]; these treatments 25.8% (range 4.8%-79.5%) on average, with a point prevalence showed good psychometric properties [17] and effectiveness in of 14.4% (range 0.4%-41.5%) [2]. It has been ranked as the neck pain, disability, satisfaction, or cervical motion kinematics 4th-greatest contributor to overall global disability and 21st in [18]. However, to the authors’ knowledge, no previous research terms of overall burden [3]. Between 50% and 85% of the has investigated the suitability of the use of similar technologies general population who experience neck pain at some point in in the performance of task-oriented neck exercises in older adult their lives will report it again 1 to 5 years later [4]. Neck pain populations with chronic neck pain. has been shown to be higher in females and to increase with There is sparse research on the effectiveness of therapeutic age, up to 70 to 74 years, then to decrease with older age [1]. exercise for the treatment of neck pain in older adult populations However, results from the Spanish National Health Survey [8]. Moreover, there is a lack of research on the use of serious showed that the age group of individuals older than 75 years games or VR for the treatment of neck pain in this population had a higher prevalence of chronic neck pain (17.32% of males [14]. Previous research has suggested that VR technology could and 34.60% of females) compared to other age groups [5]. improve variables such as functional mobility through improving Clinical guidelines recommend therapeutic exercise as one of gait quality and resistance in older populations [20]. A recent the main therapeutic options for patients with neck pain [6]. systematic review also suggested that VR interventions have However, recent systematic reviews have highlighted the need the potential to improve health outcomes in older adults. for further research, as there has only been low- or However, factors including frailty as well as usability or moderate-quality evidence to support its effectiveness [7,8]. acceptability of this technology need to be explored in future research in this population [21]. The use of technology in the context of the prescription or performance of therapeutic exercise in patients with neck pain The use of serious video games with motion capture sensors has become more popular in recent years. Serious gaming has has become popular in physical treatments in the last decade. been described as the use of computer games where the primary Some pieces of commercial equipment, mainly Wii or Kinect, goal is not pure entertainment [9]. Serious games have shown have been applied for clinical purposes among older adult positive clinical results in physical rehabilitation [10] and pain people, especially for balance training [22,23] or pain management contexts [11]; they are believed to increase management [24]. Most of these studies demonstrated that motivation and engagement in health care contexts, in which functions such as walking, muscle strength, and other motor patients are required to undergo repetitive or mundane tasks functions improved. Despite their potential, these kinds of that can be perceived as boring or nonmotivating. These games commercial devices have not been designed to monitor and involve participation in challenging game environments that register relevant parameters, such as range of motion (ROM) can potentially help patients to be more adherent to treatment or movement velocity, which would be useful for quantifying regimens, as well as focus their attention on an engaging the progress of the intervention. In addition, they are usually distraction away from aversive symptoms [9,12]. designed to train functional movements of the lower and upper limbs. The use of serious games for neck pain has been evaluated in various investigations, normally described in terms of immersive The video game in this study is controlled by the ENLAZA virtual reality (VR) serious games using head-mounted displays sensor (Werium Solutions), which consists of an inertial sensor or using nonimmersive flat-screen computer games [13-15]. that translates the cervical ROM into mouse pointer Recent systematic reviews reported that existing evidence of displacements. The ENLAZA interface has previously been VR effectiveness in patients with chronic neck pain is promising used for the following purposes: as an input device [25], for https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al physical rehabilitation [26], and for biomechanical assessment may be critical to motor learning. The number of targets, [27-29]. These previous studies show the potential of the use the target size, and the airplane speed are customizable. of the device in the rehabilitation of cervical movement in These targets are shown randomly every time the game people with neurological disorders, such as cerebral palsy. starts. However, this device has never been tested in the population Cervical ROM. The distance between targets is being investigated in this paper. customizable as a function of the cervical ROM required to reach them. The primary objective of this study was to develop and assess Cognitive challenge. The video game presents a simple and the suitability of a serious game for performing task-oriented understandable goal-directed task. cervical exercises in patients with neck pain. The secondary Sensitivity to auditory and visual limitations of the target objective was to compare the effects of the serious game with population. There is high contrast between the different those of conventional therapeutic exercises among older adult elements of the scene and representative sounds when an patients with chronic neck pain. event occurs. Biofeedback. The airplane moves according to the user’s Methods head movement, and the video game offers visual and auditive stimuli when the user succeeds and fails. Sensor Description Meaningful play. To provide an incentive to keep playing, The sensor development was based on previous work focused besides perceiving the immediate result of the reached target on head-mounted interfaces in the field of augmentative and via visual and auditive stimuli, a final score of the reached alternative communication for children with cerebral palsy targets is shown. [30,31]. The ENLAZA sensor (Werium Solutions) has also been The control algorithm follows absolute mapping, which means validated to measure the ROM of different body regions, such that a given angular orientation of the head always corresponds as the neck, knee, elbow, and wrist [27-29,32]. to the same position of the virtual airplane. Absolute mapping The core of the sensor is the MPU-9250 microelectromechanical is more interesting than relative mapping (ie, based on a relative systems sensor (InvenSense), which integrates a 3D variable, such as movement speed or acceleration) for accelerometer, a 3D gyroscope, and a 3D magnetometer. The rehabilitation purposes, because the system demands an upright information from these three sensors is combined to estimate posture to control the game successfully. the angular rotation of the sensor [3]. The three degrees of freedom of the cervical joint (ie, 3D space), The wearable sensor unit is connected to the computer through corresponding to flexion-extension, right-left inclination, and Bluetooth connection, following the classic serial port profile right-left rotation, have to be translated into the vertical and of the RN42 wireless module (Microchip Technology Inc). horizontal coordinates of the virtual airplane (ie, 2D space). The Once the wearable sensor is paired with the computer, the sensor vertical coordinate (y) is always controlled by the angle of streams orientation data, which can be read through a virtual flexion-extension, and the horizontal coordinate (x) can be serial communication port. controlled by the angular inclination or rotation of the head. The software solution integrates a graphical user interface to Video Game Description: Active Airlines configure the following options (Multimedia Appendix 2): The video game in this study has been designed based on the key features identified by previous studies involving the design Control of the horizontal coordinate using inclination or of serious video games for physical and cognitive rehabilitation rotational movement. or exercise. Previous research has shown that the most relevant Control of the virtual airplane in 1D (ie, vertical or key feature is to keep players engaged with a challenge adapted horizontal axis) or 2D (ie, vertical and horizontal axes). to the skills of a particular user [33-35]. This is a critical point Number of targets to reach. when the users are older adult people, due to their physical and Required cervical ROM to reach the targets (ie, angular cognitive skills. sensibility). Level of difficulty (eg, speed of target appearance). Based on the key features described by the literature, we developed the software component of the solution, called Active Absolute mapping uses the Euler angles generated from the Airlines. This is a Windows-based application, using the C# direction cosine matrix (DCM) using the YZX Euler convention. language in Unity’s integrated development environment, The x and y coordinates of the airplane were calculated designed to provide an interactive scenario for assessment and according to the following formulas: exercise of cervical ROM. The main functionality of the software solution was to control a virtual airplane to reach targets using head motions (Multimedia Appendix 1). The key factors described in the literature were adapted to fulfill the physical and cognitive skills of our target population, following these criteria: Motor control. The user performs a specific movement that requires the anticipation of feedback; as a result, outcomes https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al where R is the result of multiplying the R matrix (ie, the the outcome evaluators were blinded to patients’ group T cal assignments. The evaluators were in charge of recording the DCM in neutral posture) by R (ie, the DCM in every sample). initial selection data and verifying that participants were eligible The x and y values represent the horizontal and vertical to participate in the study. At the end of each treatment block, coordinates of the airplane (pixels), respectively. R and R H V they collected the data obtained from the participants. All represent the horizontal and vertical distance between targets participants were asked not to discuss the treatments they were (pixels), respectively. α and β represent the required ROM T T undergoing with the evaluators so as not to influence the records. to reach the targets (angular degree). In the case of noncompliance, patients were excluded from the Before starting the exercise, a calibration process is required to trial. establish the R matrix. The subject maintains a neutral posture cal Randomization: Sequence Generation (ie, head in the upright position) for 2 seconds, and the All subjects who fulfilled the study selection criteria were physiotherapist calibrates the device by clicking a specific button randomly assigned to one of two study arm groups (see on the software application. Interventions section below). Randomization was performed Finally, the software application includes a database to register using the online computer program Prism (version 5; GraphPad the subjects’ data. At the end of the exercise, the application Software) to assign participants to the serious game group or stores the targets reached and missed and the airplane’s the conventional exercise group. trajectory (Multimedia Appendix 3). The number of reached Primary Outcomes and missed targets together represents the performance score, which is directly related to the motor control of the head. The Suitability Evaluation Questionnaire (SEQ) was designed to test items such as satisfaction, acceptance, and security of Pilot Study Design use in virtual rehabilitation systems. It is an easy-to-understand The usability analysis and preliminary evaluation of the effects questionnaire, with a reasonable number of straightforward and were carried out through a randomized, single-blind, crossover clear questions that are evaluated on a scale from 1 (“not at all” clinical pilot study. Subjects were recruited from the Residencia or “very easy”) to 5 (“very much” or “very difficult”). The Municipal de Griñón, a nursing home in Madrid, Spain. The questionnaire addresses different items related to virtual trial was conducted under the criteria of the CONSORT rehabilitation systems, with 14 questions on feeling, satisfaction, (Consolidated Standards of Reporting Trials) statement [36]. and realism; the last question is open ended, where patients, if This study was approved by the Ethics Committee of the Centro they felt uncomfortable, were asked the reasons why. The Superior de Estudios Universitarios La Salle, Universidad minimum score is 13 points, and the maximum score is 65 Autónoma de Madrid (approval code: CSEULS-PI-181/2017). points. Previous research has used the SEQ to evaluate the All participants provided signed informed consent before suitability of virtual rehabilitation in older adults [38]. participation. Secondary Outcomes As the primary objective of this study was to develop a serious Number of Targets Reached in the Serious Game game and then assess its suitability, and not to measure the outcome of the intervention through a randomized controlled The number of targets reached by each user in the serious game trial, the study was not retrospectively registered. group was evaluated as a percentage in order to compare the proportion of hits across sessions, representing the performance Participants of the craniocervical motor control. This outcome was only Men and women over 65 years of age with chronic neck pain registered during the serious game experimental group sessions; were included. Subjects selected for this study had to meet the in addition, this outcome was used as complementary data following inclusion criteria: be at least 65 years of age; regarding whether the older adults included in the study could understand, write, and speak Spanish fluently; have suffered improve their game performance over 4 weeks of consecutive from neck pain for more than 12 weeks [37]; scored more than sessions. Therefore, this outcome did not allow for any 5 points on the Neck Disability Index (NDI); have no cognitive comparison between groups nor for analysis that would evaluate impairment below 20 points, as assessed by the Mini–Mental whether improvements in the game scores were associated with State Examination (MMSE) scale; and be willing to undergo changes in pain or disability. treatment. In addition, the following exclusion criteria were Visual Analog Scale used: red-flagged medical history (ie, tumor, fracture, metabolic diseases, and rheumatoid arthritis), fibromyalgia syndrome, The Visual Analog Scale (VAS) is a horizontal line used to previous neck surgery, or neck pain accompanied by vertigo grade the intensity of pain, from no pain to the maximum caused by vertebrobasilar insufficiency. The subjects were possible pain. Poor pain control is considered to be above 3 recruited by word of mouth, through individual interviews with points on the VAS [39], and the minimum detectable change is patients. 2 points [40]. This scale was used to measure neck pain intensity at baseline and at each of the follow-up points of the pilot study Research Team by asking each patient to mark a vertical line on the scale The research team was composed of three physiotherapists, representing the intensity of neck pain in the last 24 hours. which included two evaluators and one person who administered the treatment and was in charge of assigning the groups so that https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al was placed approximately in a straight line with the xiphoid Control Variables process. Within the Active Airlines application, parameters Neck Disability Index could be set, such as difficulty, degrees of rotation, movement The NDI is a self-completed questionnaire with 10 items: to be treated, and number of objects to be picked up. An “easy” intensity of neck pain, self-care, lifting, reading, headache, difficulty level was selected for all subjects, with a marked ability to concentrate, ability to work, ability to drive, sleep maximal mobility of 20º to 30º in order to cover the entire screen activities, and leisure activities. Each of the items has six (ie, flexion-extension movements moved the plane down or up, possible responses representing six progressive levels of respectively, and lateral inclinations moved the plane to the functional ability, with scores ranging from 0 to 5. The total sides), leaving rotation unworked in this study. The location of score is expressed in percentage terms with respect to the each of the targets was shown on the screen randomly, and the maximum possible score. The completion time is reasonably time elapsed between targets was 5 seconds. The participant short, and a validated Spanish version was used [41]. The NDI performed the exercise twice (ie, two series) in each session, has been shown to be a responsive scale among older adult and the application was set up so that the participant aimed to patients with nonspecific neck pain [42]. The minimum pick up 21 targets per series, for a total of 42 points. Considering detectable change is 5 out of 50 points, and a change of 7 points that the patient had to perform a combined movement (ie, is recommended for achieving a clinically relevant difference flexion-extension combined with right-left lateral flexion) to [43]. reach each of the targets, the total number of combined movements performed by patients in each session was 42 (ie, Mini–Mental State Examination one per target), and the total game duration was 210 seconds To measure cognitive impairment, we used an adapted and (ie, 5 seconds per target). At the end of each series, the targets validated Spanish version of the Folstein MMSE [44]. This is picked up were counted and recorded as a percentage value (ie, a screening test for dementia that is also useful in the the score for the day was recorded as the total percentage from evolutionary follow-up of dementia. This questionnaire explores the two series). Once the first series was finished, the exact short- and long-term memory, orientation, information about same procedure was performed again, thus ending the serious everyday events, and calculation capacity. Information was game session for that day. In this group, the sessions included collected by means of an auto-administered questionnaire. The only one participant at a time. results were evaluated according to the following number of Conventional Exercise: Treatment B errors: 0 to 2 (normal), 3 to 4 (mild cognitive impairment), 5 to 7 (moderate cognitive impairment), and 8 to 10 (severe cognitive Treatment B consisted of a therapeutic exercise protocol that impairment). When using this scale, it is important to consider was based on two weekly sessions of conventional physical the educational level of the person taking the test. In cases of therapy for 4 weeks; this consisted of an exercise program of low educational level (ie, elementary education), one additional about 30 to 45 minutes in length for groups of 2 to 4 patients. error is allowed for each category. In cases of high educational This program included 5 minutes of stairs, 10 minutes of level (ie, university level), one fewer error is allowed for each pedaling, 5 minutes of pulleys, and 5 minutes of obstacle category (35 points maximum). Two cutoff points are considered walking. In addition, three sets of 12 repetitions of cervical joint according to age: 24 points for those 65 years of age and older, mobility exercises in all ranges were added: cervical and 29 points for nongeriatric adults. The classification brackets flexion-extension, right-left lateral flexion, and cervical for points are as follows: 30 to 35 (normal), 24 to 29 rotations. The exercises were not performed with resistance, (borderline), 19 to 23 (mild), 14 to 18 (moderate), and less than but were only self-loading at the beginning of the ROM. 14 (severe) [44]. Procedure Interventions Once the informed consent forms were revised and signed by the participants, the VAS, NDI, and MMSE were administered Overview at baseline. The study had a total duration of 16 weeks. First, For the crossover study, subjects were randomly assigned to the therapist assigned each study group to one study arm. One one of two study groups. Group A-B started by testing the group followed the A-B sequence with an intermediate washout serious game for 4 weeks (8 sessions), followed by a 4-week period of 4 weeks. The other group received the treatment in washout period, after which they performed conventional the B-A order, also with a washout period of 4 weeks. Finally, exercises for 4 weeks (8 sessions). Group B-A started with the the last assessment of outcomes was carried out 4 weeks after conventional exercises and then tested the game after the the treatment finished. Thus, the distribution of the evaluators’ washout period. The total study duration was 16 weeks, measurements was as follows: baseline (0 weeks), after first including a final follow-up measure 4 weeks after the end of all intervention (4 weeks), washout period (8 weeks), after second treatments. intervention (12 weeks), and follow-up period (16 weeks). Serious Game: Treatment A In the washout and follow-up weeks, no exhaustive follow-up Treatment A consisted of the use of the Active Airlines serious was performed, and participants were simply reminded, game twice a week for 4 weeks. The sensor had to be held at sporadically, to keep up with the previously prescribed exercises. forehead level with an elastic band and Velcro, with a Windows These exercises were based on cervical joint mobility. computer in front of it in order to run the application correctly; the computer screen was placed at eye level, and the keyboard https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al The evaluation of the VAS was carried out at all follow-up measures after the first intervention (4 weeks) and after the periods, and the SEQ was included in the evaluation at the end second intervention (12 weeks). in order to assess the degree of suitability of the inertial sensor Finally, to test the sequence effect, the change produced in the and the Active Airlines game. variables of interest with each of the interventions was analyzed by comparing the A-B sequence and the B-A sequence. For Data Analysis example, if there was no sequence effect, the value obtained for All statistical tests were performed with SPSS Statistics for the VAS variable after having received the serious game Windows (version 27; IBM Corp) with a significance level of intervention should be the same, either in the first period or in P<.05. Demographic data were analyzed with descriptive the second period. Therefore, the difference between baseline statistics and were represented as mean (SD) for each of the and postintervention for each variable was calculated for each variables. The Shapiro-Wilk statistic was used to test the normal group and compared, based on whether the A-B or B-A sequence distribution of the data. Since this was a randomized crossover was followed. clinical trial, it was necessary to analyze the difference in the variables of interest between each of the interventions. For this In addition, for the study of the control variables and variables purpose, the Student t test was used for related measures, to related to the use of the technology, the Student t test for related compare between groups and within groups. measures and the repeated-measures analysis of variance (ANOVA) test were used. Also, based on the crossover design, other effects had to be analyzed, such as the residual effect, period effect, and sequence Results effect. In order to guarantee as high a quality as possible in the analysis, the following tests were performed, according to Overview previous recommendations [45]. A total of 18 subjects were evaluated for inclusion in the study. To verify that the interventions had an effect over time, the Of these, 14 subjects, aged between 71 and 92 years (mean residual effect of the interventions was analyzed by performing 81.85, SD 6.82), were finally included (Figure 1). There was 1 a Student t test for related samples, comparing the initial participant lost due to death in the B-A sequence study group measurement with the measurement after the washout period. during the first 4-week period of treatment. Demographic In the case of statistically significant results, the Wilcoxon variables and all baseline variables showed a normal distribution, signed-rank test was used to repeat the analysis, subdividing by with P values greater than .05 in the Shapiro-Wilk test. intervention group to identify the intervention that produced Descriptive data for the demographic variables are shown in the residual effect. The period effect was also analyzed by Table 1. performing a Student t test for related samples, comparing the https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al Figure 1. Participant flowchart. https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al Table 1. Baseline descriptive data and normality test. Variable Value (N=14) P value Sex (women), n (%) 9 (64) N/A Age (years), mean (SD) 81.85 (6.82) .31 Weight (kg), mean (SD) 68.16 (8.38) .82 Height (cm), mean (SD) 1.54 (0.07) .12 BMI, mean (SD) 28.65 (3.58) >.99 31.08 (3.01) .13 Mini–Mental State Examination score 15.77 (8.19) .98 Neck Disability Index score P values are based on the Shapiro-Wilk test, which measures the distribution of variables; variables showed a normal distribution. N/A: not applicable; the Shapiro-Wilk test cannot be performed on categorical data. The classification brackets for this scale are as follows: 30 to 35 (normal), 24 to 29 (borderline), 19 to 23 (mild), 14 to 18 (moderate), and less than 14 (severe). The minimum detectable change for this index is 5 out of 50 points, and a change of 7 points is recommended for achieving a clinically relevant difference. The results of the SEQ also showed that none of the patients Suitability of the Technology felt any neck pain or discomfort when playing the game, and The scores obtained in each of the items of the SEQ are only 2 patients out of 13 (12%) reported some degree of presented in Table 2. The global mean score for the SEQ was dizziness, eye discomfort, or disorientation. These two events 50.38 (SD 5.35) out of 65 points, showing good suitability of of dizziness were also recorded separately by researchers as the Active Airlines serious game. Most of the patients minor adverse effects. Both subjects were able to finish the considered the experience to be very enjoyable and “real” in session and kept participating in the study. No other adverse terms of the virtual environment, and found the information events occurred during any of the treatment sessions. provided to be clear. Also, most of them thought that the game Moreover, most patients considered the task to be difficult and could be very helpful for their rehabilitation. the system difficult to use, suggesting that the game presented a challenge for them across the different treatment sessions. Table 2. Suitability of the technology based on results from the Suitability Evaluation Questionnaire (SEQ). Question SEQ score, mean (SD) Q1. How much did you enjoy your experience with the system? 4.92 (0.277) Q2. How much did you sense being in the environment of the system? 3.92 (1.115) Q3. How successful were you in the system? 3.85 (1.214) Q4. To what extent were you able to control the system? 3.62 (1.261) Q5. How real is the virtual environment of the system? 4.62 (0.961) Q6. Is the information provided by the system clear? 4.31 (0.947) Q7. Did you feel discomfort during your experience with the system? 1.00 (0.000) Q8. Did you experience dizziness or nausea during your practice with the system? 1.54 (1.330) Q9. Did you experience eye discomfort during your practice with the system? 1.54 (1.330) Q10. Did you feel confused or disoriented during your experience with the system? 1.23 (0.832) Q11. Do you think that this system will be helpful for your rehabilitation? 4.69 (0.630) Q12. Did you find the task difficult? 4.69 (0.855) Q13. Did you find the devices of the system difficult to use? 4.77 (0.599) Total for all questions 50.38 (5.35) Questions were scored on a 5-point Likert scale, ranging from 1 (“not at all”) to 5 (“very much”). Reverse scoring was performed for Q7-Q10, Q12, and Q13, ranging from 1 (“very easy”) to 5 (“very difficult”). https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al session. The results showed statistically significant effects over Number of Targets Reached in the Serious Game time (F =22.14; P<.01), as the percentage of targets reached A repeated-measures ANOVA showed that the number of targets during the game progressively increased in each session (Table reached during serious game–playing increased with each 3). Table 3. Success in the serious game during each treatment session. Session Success (%), mean (SD) 1 68.86 (24.87) 2 71.06 (24.63) 3 82.05 (19.50) 4 82.96 (21.14) 5 85.16 (15.25) 6 83.51 (13.31) 7 86.44 (16.02) 8 89.74 (12.95) Percentage change from session 1 to 8 24.90 (20.85) The serious game software only returns the percentage of success in the game. A statistically significant residual effect was found. The Pilot Study Results for Pain Wilcoxon signed-rank test, used as a secondary analysis There were no significant differences between the effects of the subdividing by group, showed a statistically significant residual serious game and conventional exercises when considering all effect only for the conventional exercise intervention (baseline: subjects who received each treatment, independent of the study mean 5.36, SD 1.84; washout: mean 3.21, SD 2.45; Z=–2.38, group sequence, but both treatments showed improvements in P=.02). neck pain intensity (Table 4). Table 4. Comparison between treatments, intratreatment changes, and residual effect. a b c c Posttreatment VAS score, mean Washout period VAS score Treatment Baseline VAS score, mean P value P value (SD) (residual effect), mean (SD) (SD) Serious game 4.92 (1.88) 3.77 (1.92) <.001 3.69 (2.13) .01 Conventional exercise 4.92 (1.88) 3.46 (2.22) <.001 3.69 (2.13) .01 No statistically significant differences between treatments were detected in the measurement after the intervention (serious game vs conventional exercise). VAS: Visual Analog Scale. P values are based on the Student t test. Period effect analysis revealed that there were statistically with the B-A sequence (VAS score mean difference –1.64, SD significant differences between the end of the first period and 0.75) than with the A-B sequence (VAS score mean difference the end of the second period. The mean VAS score at baseline –0.58, SD 0.49). On the other hand, for the conventional exercise was 4.92 (SD 1.88), the score after the first treatment was 4.15 treatment, pain was reduced to a greater extent with the A-B (SD 1.57), and the score after the second treatment was 3.08 sequence (VAS score mean difference –2.08, SD 1.02) than (SD 2.36; P=.003). with the B-A sequence (VAS score mean difference –0.93, SD 0.45). Table 5 shows the changes in pain that occurred after Finally, the sequence effect analysis for the serious game treatment in each of the study group sequences. intervention showed that pain was reduced to a greater extent https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al Table 5. Sequence effect analysis. a b c d Treatment and sequence VAS score, mean difference (SD) P value Serious game A-B –0.58 (0.49) .01 B-A –1.64 (0.75) Conventional exercise A-B –2.08 (1.02) .04 B-A –0.93 (0.45) Sequence A-B is serious game followed by conventional exercise; sequence B-A is conventional exercise followed by serious game. VAS: Visual Analog Scale. This value represents the mean difference between baseline and posttreatment measures. P values are based on the Student t test. P values for each group are reported in the top row of that group. The main clinical findings of the pilot study are as follows: (1) Discussion both conventional exercise and the use of the serious game had the same effect in reducing neck pain in the older adult Principal Findings population and (2) the A-B sequence (ie, playing the serious This study allowed for the development of a serious game to game first followed by conventional exercise) reduced pain provide a suitable solution for the performance of task-oriented more than the B-A sequence (ie, conventional exercise first cervical exercises for people with neck pain. followed by playing the serious game). The older adult population included in the study showed very On the one hand, the results of this study appear to support the good results in terms of satisfaction, acceptance, and security findings of another recent study that suggested that performing when using this technology. Moreover, minor adverse events exercises with immersive VR is not superior to exercises alone were scarce in the pilot population sample included in the study. without VR among young adult patients with neck pain [48]. Therefore, the older adult population aged over 80 years with On the other hand, the results of this research are not supported chronic pain might benefit from this intervention, but some by those found in another study that compared nonimmersive factors would need further research, such as technological VR exercises with proprioceptive training in patients with neck acceptance, visual and hearing disorders, and cognitive pain, using eight sessions over a period of 4 weeks. That study impairments, among others, which can become barriers for the observed that patients in the VR group improved more in terms success of the intervention. of pain and disability than the group that performed proprioceptive exercises [49]. Although the design of the study did not allow for measuring treatment adherence, the playful approach and integrated Another study in which VR was added to neck exercises in one technology used may be capable of increasing adherence to the group and compared to a group that performed exercises alone exercise treatment. Further research is needed to investigate during four to six treatment sessions found that only the group whether these technologies are associated with higher adherence that included VR improved more in terms of disability and ROM or patient motivation compared with conventional exercise in rotation. However, there was no improvement over the programs, which can sometimes be considered more repetitive exercise-only group in terms of pain intensity. Those results or boring [12]. support the ones obtained in this study; although we did not measure the ROM variable, patients improved in accuracy when The main clinical implication from this study is that patients playing the video game in successive sessions [18]. with neck pain could safely use this serious game with high levels of satisfaction and acceptance. Although the clinical The results of this study were novel in terms of the use of a findings from the pilot study are limited and do not allow for serious game in a population of adults over 70 years of age, but medium- or long-term evaluation of its effects, it can be we must analyze a series of important limitations for their hypothesized that patients’ satisfaction and adherence to exercise possible applicability in clinical practice. First, the may be increased when performing therapeutic exercise through characteristics of the pilot study with a reduced sample size the serious game. Moreover, this serious game has the potential limit the generalizability of the results in terms of the suitability to be used in a telerehabilitation context by physiotherapists; of the serious game in this older adult population and its effects this could result in important advantages regarding on the treatment of neck pain. Second, the study had a crossover cost-effectiveness [46] and the possibility to perform therapeutic versus parallel design; therefore, it is more difficult to exercise at home, without having to make tiring journeys [47], demonstrate the isolated effects of each therapy. Third, a control which could be especially relevant at some stages of group was not included to investigate whether the therapies physiotherapy treatment in the older adult population with neck used had a greater effect than the natural evolution of neck pain. pain. Fourth, psychological variables such as kinesiophobia or anxiety, which have been shown to influence the effects of interventions https://games.jmir.org/2022/1/e31404 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e31404 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Beltran-Alacreu et al for neck pain in other studies with VR, were not measured. The age with chronic neck pain. It was a safe method for performing fifth limitation is that the washout period was shown to be task-oriented cervical exercises, and patients reported very good ineffective according to the statistical analysis of this study; for levels of satisfaction and acceptance after the use of this future studies, washout periods longer than 4 weeks should be technology. Although preliminary results on the effects of using considered. the serious game showed short-term improvements in pain intensity, further research with larger samples is needed. Conclusions The serious game developed in this study showed good suitability when used in a population of adults over 70 years of Acknowledgments This study was supported by the Fundación Universitaria San Pablo CEU and Banco Santander (grant FUSPBS-PPC20/2017); the Spanish Ministry of Science, Innovation and Universities (PID2019-108616RA-I00/AEI/10.13039/501100011033); and Project RTI2018-097122-A-I00, which is funded by the Fondo Europeo de Desarrollo Regional, the Ministry of Science and Innovation, and the Agencia Estatal de Investigación. Part of HBA’s salary is financed by the European Regional Development Fund (2020/5154). The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; and in the decision to publish the results. Conflicts of Interest RR is the CEO of Werium Solutions. Multimedia Appendix 1 Screenshot of the Active Airlines serious game. 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A novel virtual reality technique (Cervigame®) compared to conventional proprioceptive training to treat neck pain: A randomized controlled trial. J Biomed Phys Eng 2019 Jun;9(3):355-366 [FREE Full text] [doi: 10.31661/jbpe.v0i0.556] [Medline: 31341881] Abbreviations ANOVA: analysis of variance CONSORT: Consolidated Standards of Reporting Trials DCM: direction cosine matrix MMSE: Mini–Mental State Examination NDI: Neck Disability Index ROM: range of motion SEQ: Suitability Evaluation Questionnaire VAS: Visual Analog Scale VR: virtual reality Edited by N Zary; submitted 21.06.21; peer-reviewed by M Eckert, G Dermody; comments to author 24.09.21; revised version received 15.10.21; accepted 13.11.21; published 01.02.22 Please cite as: Beltran-Alacreu H, Navarro-Fernández G, Godia-Lledó D, Graell-Pasarón L, Ramos-González Á, Raya R, Martin-Pintado Zugasti A, Fernandez-Carnero J A Serious Game for Performing Task-Oriented Cervical Exercises Among Older Adult Patients With Chronic Neck Pain: Development, Suitability, and Crossover Pilot Study JMIR Serious Games 2022;10(1):e31404 URL: https://games.jmir.org/2022/1/e31404 doi: 10.2196/31404 PMID: ©Hector Beltran-Alacreu, Gonzalo Navarro-Fernández, Daniela Godia-Lledó, Lucas Graell-Pasarón, Álvaro Ramos-González, Rafael Raya, Aitor Martin-Pintado Zugasti, Josue Fernandez-Carnero. 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Published: Feb 1, 2022

Keywords: video games; neck pain; aged; virtual reality; exercise therapy; physical therapy modalities; technology

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