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An Interactive Physical-Cognitive Game-Based Training System Using Kinect for Older Adults: Development and Usability Study

An Interactive Physical-Cognitive Game-Based Training System Using Kinect for Older Adults:... Background: Declines in physical and cognitive functions are recognized as important risk factors for falls in older adults. Promising evidence suggests that interactive game-based systems that allow simultaneous physical and cognitive exercise are a potential approach to enhance exercise adherence and reduce fall risk in older adults. However, a limited number of studies have reported the development of a combined physical-cognitive game-based training system for fall risk reduction in older adults. Objective: The aim of this study is to develop and evaluate the usability of an interactive physical-cognitive game-based training system (game-based exercise) for older adults. Methods: In the development phase (Part I), a game-based exercise prototype was created by integrating knowledge and a literature review as well as brainstorming with experts on effective fall prevention exercise for older adults. The output was a game-based exercise prototype that covers crucial physical and cognitive components related to falls. In the usability testing (Part II), 5 games (ie, Fruits Hunter, Where Am I?, Whack a Mole, Sky Falls, and Crossing Poison River) with three difficulty levels (ie, beginner, intermediate, and advanced levels) were tested in 5 older adults (mean age 70.40 years, SD 5.41 years). After completing the games, participants rated their enjoyment level while engaging with the games using the Physical Activity Enjoyment Scale (PACES) and commented on the games. Descriptive statistics were used to describe the participants’ characteristics and PACES scores. Results: The results showed that the average PACES score was 123 out of 126 points overall and between 6.66 and 7.00 for each item, indicating a high level of enjoyment. Positive feedback, such as praise for the well-designed interactions and user-friendly interfaces, was also provided. Conclusions: These findings suggest that it is promising to implement an interactive, physical-cognitive game-based exercise in older adults. The effectiveness of a game-based exercise program for fall risk reduction has yet to be determined. (JMIR Serious Games 2021;9(4):e27848) doi: 10.2196/27848 KEYWORDS digital game; interactive game-based training; physical-cognitive training; exergaming; Kinect sensors; older adults; falls; PACES; user-centered design; game-based exercise https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al improving cognitive abilities (eg, executive function, speed of Introduction processing), and reducing the risk of falls among older adults [35-42]. However, in most existing training programs available Declines in multiple physiological systems with ageing for fall prevention, research concerning simultaneous training contribute to balance and gait deficits, leading to an increased of physical and cognitive functions (dual tasking) with the use risk of fall [1]. Fall is a serious public health problem, and its of exergames has remained scarce. consequences have a marked adverse impact on physical and psychological aspects such as injuries, activity restriction, fear Among interactive game-based technology for training, the of falling, and loss of autonomy [2-4]. Given the substantial Kinect motion sensor (Microsoft Corporation) has been impact of falls on health, as well as their medical and economic considered as a high-potential approach because it provides a burden, an effective strategy to prevent falls in older adults is markerless full-body 3D motion tracker and enables users to warranted. virtually interact hands-free with a computer system. Additionally, several examiners have demonstrated that among Several investigators have consistently reported a strong positive interactive game-based technology for exercising, Microsoft effect of physical exercise on fall prevention among older adults Kinect has an advantage in that it allows individuals to interact [5-9]. Researchers have also identified a critical role of with games using their own body in a natural way [43,44]; this cognition, especially executive function, attention, and memory, enhances the natural form of human-computer interaction [45]. on balance and gait control [10-13]. Many examiners have In addition, the Microsoft Kinect motion sensor is an accurate demonstrated that cognitive training, which is an intervention input device; thus, it allows precise tracking and real-time program aimed at improving, maintaining, or restoring cognitive feedback of user performance [46]. The Microsoft Kinect sensor function via the repeated and structured practice of tasks, can is proposed to be a feasible and effective tool for training improve balance and gait and reduce fall risk [14-17]. Taken concurrent physical and cognitive components in older adults, together, incorporating a cognitive component into physical with the aim of reducing the intrinsic causes (ie, physical and exercise may augment its benefits in fall prevention cognitive) of falls [47-51]. [11-13,18-20]. A growing number of investigators have documented the effects of combined physical-cognitive exercise Based on the usability challenges faced by older adults, training in a simultaneous form (dual-tasking) among older programmers should develop user interfaces that are adults. Combined physical-cognitive exercise training programs user-friendly for older adults and specific for training purposes. have resulted in greater improvement in physical and cognitive A previous investigator has suggested that older adults accept performance than either type of single training alone [21-25]. innovative technology when they recognize its benefit and find it meaningful for their lives [52]. As technology advances, a new alternative of rehabilitation approach targeting training of various physical and cognitive Therefore, this study focused on developing a prototype of a components in the form of interactive game-based exercises game-based exercise that accounts for the target user’s (exergames) is becoming available [26]. These interactive expectation and requirement (eg, enjoyment, attractiveness, user game-based exercises use technology-driven platforms that skill-challenge balance, and benefit for training cognitive and require users to move their body in order to complete assigned physical components). In particular, following a user-centered tasks via video game interface elements [27]. The interactive design approach, acceptability and training adherence in future game-based exercises have advantages in terms of gamification empirical studies were established. features. Researchers have demonstrated that exergames are attractive because they provide real-time interaction and Methods feedback to users, which enhances motivation and training adherence [28,29]. In addition, game-based exercises allow Study Design users to be active with repetitive practice and track progression, The present study consists of two parts: (1) the development of which is beneficial for training outcomes [30]. Another a game-based exercise prototype, and (2) evaluation of target advantage of exergames is that they can offer an experience for users’ feedback, response, and satisfaction regarding the daily-life task requirements based on concurrent training of developed game-based exercise prototype. The concept of physical and cognitive components [31-33]. Moreover, development and evaluation of the target user’s experience for game-based exercises can be applied either in rehabilitation producing a final prototype followed a user-centered design centers or community and home settings [33,34]. Several (UCD) approach [27,46,53-62]. UCD is a user interface design researchers have shown that game-based training using Nintendo process in which designers focus on gaining a target user’s Wii Fit, and Microsoft Kinect sensors were effective in perspective to create a product with a high degree of usability. improving physical abilities (eg, balance, gait performance), The UCD cycle is depicted in Figure 1. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Figure 1. Schematic of the user-centered design cycle [27]. prototype using the Unity 3D game engine software with Kinect Part I: Development of a Game-Based Exercise Sensor V2 for Windows. In the third phase, user feedback to Prototype improve the game-based exercise prototype was provided by end users using a think-aloud method [68]. Finally, the fourth Development Process phase concentrated on assessing physical activity enjoyment In this part, the 4-phase UCD process was applied [27,46,53-62]. during game engagement. The Physical Activity Enjoyment The first phase, the design development process of a game-based Scale (PACES) questionnaire [69,70], an 18-item scale exercise prototype, was conducted in the brainstorming phase. questionnaire, was used to analyze physical activity enjoyment. A total of 7 team members, including 3 physical therapists and Moreover, the usability of the game-based exercise prototype 1 physician (3-20 years of experience in geriatric and cognitive was determined with a structured interview (feedback about the rehabilitation), 2 game programmers (5 years of experience in game, themes, user interface, sound effect, graphics, and the Unity 3D game engine), and 1 game designer (10 years of interaction). Feedback from all participants was considered by experience in game design and game theory), participated in the research team to improve the game-based exercise prototype. the brainstorming session. This phase involved generating potential core game ideas by integrating the knowledge and Characteristics of the Game-Based Exercise Prototype literature review of previous physical and cognitive training The characteristics of the game-based exercise prototype are programs and interactive exergame interventions for fall presented in Table 1. The game can be described as individual prevention in older adults [16,63-65]. In the present study, the interactive game-based training using Kinect. The prototype of core game was composed of two training elements: (1) a the game-based exercise comprised 5 games, including (1) Fruits physical element, including stepping and balance training, and Hunter, (2) Where Am I ?, (3) Whack a Mole, (4) Sky Falls, (2) a cognitive element related to balance and falls in older and (5) Crossing Poison River. The games had three different adults, including executive function, attention, and memory levels: beginner, intermediate, and advanced. The level of game [18,66,67]. To ensure that the difficulty of the games was complexity progressed by increasing the difficulty of physical appropriate for each individual user, the progression of game demand (ie, movement speed, distance, duration, base of difficulty was considered. The game-based training program support) and cognitive demand (ie, number of stimuli, underwent critical appraisal by the physical therapists and complexity of the game’s rules, and amount of cognitive load). physician. In the second phase, after consensus, proven game The estimated play time was 45 to 60 minutes. ideas were used to create a game-based digital exercise game https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Table 1. Summary of the characteristics of the developed game-based exercise prototype. Characteristic Description Basic characteristics Health topic A game-based exercise prototype Targeted age group Older adults (age ≥65 years) Short description of the game idea The game-based exercise is a virtual, interactive game-based training system using Microsoft Kinect motion sensor technology. The game-based exercise comprises 5 games that include physical and cognitive components associated with balance and falls in older adults. Target player Individual Behavior change procedure used A game-based exercise is used to enhance motivation and engagement in older adults. Clinical support needed Physical therapist and geriatric physicians Data shared with clinician Data are saved and stored in the hard disk. However, reaction time, error, and score are given as feedback on the display screen (ie, the rubber mat) at the end of each game. Type of game Physical, action, real-time strategy Game components Player’s game goal/objective Physical components Improve static and dynamic balance Improve stepping reaction and response time Improve lower limb muscle strength Cognitive components Fruits Hunter: improves response ability and speed of processing via a stepping task. Where am I ?: improves semantic memory and visuospatial ability via visual sense Whack a Mole: improves selective attention ability, visual attention performance, speed of processing, and inhibition ability Sky Falls: improves sequencing and planning ability Crossing Poison River: improve episodic memory via auditory sense Rules Fruits Hunter: step on the presented fruits as fast as possible within a limited time. Where am I ?: step to the presented objects and remember as many as of them possible. The recall questions are provided at the end of the game. Whack a Mole: respond correctly to different rules of this game as follows: Mole or rabbit: steps on the target 1 time Mole or rabbit with helmet: steps on the target 2 times Bomb: do not step on the target Sky Falls: step with alternating feet to collect as many dropping objects in the basket as possible Crossing Poison River: listen to a short story and remember the content of the story while standing on one leg Game mechanics The game-based exercise system allows users to interact with the virtual games by stepping on the presented targets in different directions in pursuit of the game’s goals. The game-based exercise also provides audio and visual feedback to the users while they are playing the games. Virtual environment A forest with fruits, animals, vegetables, and a river Setting The game-based exercise can be set in a room environment Device requirements Personal computer/notebook/laptop with LED projector Sensors used Microsoft Kinect Sensor V2 Estimated play time 45-60 minutes an assistive device for at least 10 m, and (4) ability to step in Part II: Evaluation of Target User’s Experience all directions independently and safely. Exclusion criteria were (1) depressive symptoms (determined by a Thai Geriatric Recruitment and Participants Depression Scale-15 [72] score >6 points), (2) orthopedic A total of 5 community-dwelling older adults were enrolled as deficits, neurological deficits, and/or other significant health representative target users. The inclusion criteria were (1) age problems that precluded the participant from completing the 65 years or older, (2) had normal cognitive function (determined testing protocol, and (3) uncorrected visual and hearing by a Mental State Examination T10 [71] score ≥24 points or impairment. The study protocol was approved by the Human depending on the level of education), (3) ability to walk without https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Ethical Review Board of the principal investigator’s institute The Kinect Sensor V2 is a depth sensor camera manufactured (AMSEC-61EX-078). All participants gave written informed by Microsoft that provides information about the depth, color, consent prior to participating in the study. The demographic and skeleton of a user who is standing in front of the sensor. data of the participants, which consisted of age, height, weight, The Kinect sensor and LED projector were set on a portable medication use, and history of falls in the previous 12 months, metal storage rack at a height of 0.8 m and 2.0 m from the floor, were recorded. respectively. The laptop computer that contained the developed game software was set near the Kinect sensor. The game was Hardware Configuration projected on a rubber mat (2.0 m width × 1.2 m height) that was To set up the system, the capture volume of the system was placed on the floor; thus, the participants could virtually interact configured using the three main devices: Kinect Sensor V2 [73], by stepping. The center of the rubber mat was set 2.5 m from LED projector, and laptop computer. In the present study, the the Microsoft Kinect sensor and LED projector. The Kinect Sensor V2 was used because it provides greater precision configuration of hardware for playing the game-based exercise and more stable results compared to the Kinect Sensor V1 [74]. is illustrated in Figure 2. Figure 2. Environment configuration of the game-based exercise system. After completing the game-based exercise, participants were Protocol asked to rate their enjoyment using the PACES questionnaire The game-based exercise was connected with the Microsoft [69,70]. The PACES is an 18-item scale questionnaire that Kinect sensor, an LED projector, and the laptop computer. After assesses physical activity enjoyment during game engagement that, the system was calibrated by moving four markers in the with a 7-point Likert scale (1, strongly disagree, to 7, strongly game-based training system over the four corner marks on the agree). A higher PACES score reflects a greater level of rubber mat. For individualized body position calibration, each enjoyment. Moreover, using a structured interview, participants participant was asked to perform a T-pose stand for were interviewed about their impressions of the game-based approximately 5 seconds at the center of the rubber mat (Figure exercise features in terms of rules, mechanics, interfaces, and 2). After the calibration process, each participant received a scoring, as well as their physical and cognitive involvement comprehensive description of the rules of the games, including while playing the games. a demonstration, and was requested to play the game-based Data Analysis exercise. The American College Sport of Medicine exercise guidelines recommend that older adults should participate in Descriptive statistics were used to describe both the participants’ aerobic activities for a minimum of 30 minutes per session to characteristics and their scores on the 18-item PACES promote and maintain their health-related outcomes [75]. In questionnaire. All data were analyzed using SPSS 21.0 (IBM this study, the exercise duration ranged between 30 and 50 Corporation). minutes, with a rest interval of between 10 and 15 minutes, depending on the participant performance; this resulted in a total time of 45 to 60 minutes. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Game programmers: the specialists who generated the Results digital game using the computer programming language and game engine software (the Unity 3D game engine Part I: Development of a Game-Based Exercise software with Microsoft Kinect sensor V2 for Windows). Prototype Domain knowledge: the experts having core knowledge The framework of the game-based exercise comprised 6 and experience of physical and cognitive training programs components (Figure 3), including: for fall prevention in older adults. Game-based training system: the digital game system, which The Microsoft Kinect sensor: the depth sensor that was comprised 5 games (Games I-V) with 3 levels (levels 1-3) used to track and monitor full-body movements in 3D and feedback (ie, score, response time, and error). coordinates (ie, the x-, y-, and z-axes). The tracking data User and laptop computer: a system operator who was were then converted to the 24 points of the Joint ID Map responsible for controlling the game-based training system (body skeleton model). In this study, 4 points of the Joint while participants were playing the games. ID Map [43] (ANKLE_RIGHT, FOOT_RIGHT, Graphical user interface: a form of user interface that allows ANKLE_LEFT and FOOT_LEFT) were used for the participants to interact with the game-based exercise (Figure interaction between the user and the game. 4). An example of a participant training with the game-based exercise prototype is displayed in Figure 5. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Figure 3. Framework of the game-based exercise system. GUI: graphical user interface. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Figure 4. Screenshots of the 5 games in the game-based exercise system: (A) Fruits Hunter, (B) Where Am I ?, (C) Whack a Mole, (D) Sky Falls, and (E) Crossing Poison River. Figure 5. Examples of a participant playing the game-based exercise: (A) Whack a Mole, (B) Sky Falls, and (C) Crossing Poison River. years (range 65-79 years). No participants had any experience Part II: Evaluation of the Target Users’ Experience with using exergames. They had low incidence rate of falls in the past 12 months, and they either did not take medication or Participant Characteristics took only one type. The participants’ characteristics are A total of 5 community-dwelling older adults participated in summarized in Table 2. the usability testing phase. Their mean age was 70.40 (SD 5.41) Table 2. Characteristics of the study participants. Characteristic Value Median Range Age (years), mean (SD) 70.40 (5.41) 68 65-79 Height (cm), mean (SD) 155.20 (6.06) 156 149-164 Weight (kg), mean (SD) 53.40 (8.62) 55 39-60 22.08 (2.63) 22.21 17.60-24.30 BMI (kg/m ), mean (SD) Education (years), mean (SD) 14.40 (5.90) 16 4-18 Types of medication, mean (SD) 0.20 (0.45) 0 0-1 Falls in the past year, n 1 0 0-1 https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al answered the PACES questionnaire. The average score on each User Experience in Using the Game-Based Exercise item was between 6.66 and 7.00, which indicated greater levels System of enjoyment. The 18-item PACES scores are illustrated in All 5 participants completed the game-based exercise and Table 3. Table 3. Physical Activity Enjoyment Scale (PACES) rating scores (n=5). All items were rated on a 7-point scale from 1, strongly disagree, to 7, strongly agree. Question Participants Response rating, mean (SD) S01 S02 S03 S04 S05 1. I enjoy it; I hate it 7 6 7 7 6 6.80 (0.20) 2. I feel interested; I feel bored 7 6 7 7 7 7.00 (0.00) 3. I like it; I dislike it 7 7 7 7 7 7.00 (0.00) 4. I find it pleasurable; I find it unpleasurable 7 7 7 6 6 6.66 (0.24) 5. I am very absorbed in this activity; I am not at all absorbed in this 6 7 7 7 7 6.80 (0.20) activity 6. It’s a lot of fun; it’s no fun at all 7 7 7 7 7 7.00 (0.00) 7. I find it energizing; I find it tiring 7 6 7 7 7 6.80 (0.20) 8. It makes me happy; it makes me depressed 7 7 7 7 7 7.00 (0.00) 9. It’s very pleasant; it’s very unpleasant 7 7 7 7 6 6.80 (0.20) 10. I feel good physically while doing it; I feel bad physically while 7 7 7 7 7 7.00 (0.00) doing it 11. It’s very invigorating; it’s not at all invigorating 7 7 7 6 7 6.80 (0.20) 12. I am not at all frustrated by it; I am very frustrated by it 7 7 7 7 7 7.00 (0.00) 13. It’s very gratifying; it’s not at all gratifying 7 7 7 6 6 6.66 (0.24) 14. It’s very exhilarating; it’s not at all exhilarating 7 7 7 7 6 6.80 (0.20) 15. It’s very stimulating; it’s not at all stimulating 7 7 7 6 7 6.80 (0.20) 16. It give me a strong sense of accomplishment; it does not give 7 7 7 6 7 6.80 (0.20) me any sense of accomplishment 17. It’s very refreshing; it’s not at all refreshing 7 7 6 6 7 6.66 (0.24) 18. I felt as though there was nothing else I would rather be doing; 7 7 7 7 6 6.80 (0.20) I felt as though I would rather be doing something else Rating scale of all items (total points: 126) 125 123 125 120 120 123.00 (1.26) User Feedback and Suggestions The feedback and suggestions provided by the users are presented in Table 4. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Table 4. Feedback and suggestions provided by the study participants for the game prototype. Type of feedback or suggestion Feedback Feedback Positive “The games’ feature and appearance were very attractive and enhanced my motivation to complete the games.” “The games provided my performance with visible outcomes and scores which motivated me to try harder to get a better score in the next trial.” “The difficultly of each game was optimal; it was not too easy and not too difficult.” “The games had variety of forms and rules that challenged my physical and cognitive abilities.” “The games had a meaningful sound effect which helped me to identify my right or wrong responses.” “The games’ systems were quite simple to set up and easy to manage, thus it appeared to be feasible to use in the community or home settings.” Negative “In the Whack a Mole, sometimes I did not step on the bomb, but it eventually blew up.” “In the Sky Falls, sometimes it was quite hard to control the movement of the bamboo basket even though I tried to alternate my stepping rhythmically.” Suggestions Game rules Clearly state the game instructions and rules at the beginning Level design Reduce the speed of dropping objects in the beginner level of Sky Falls Use different types of animals and vegetables for each difficulty level of Where Am I? Graphics/look and feel Adjust the distance of each presented object in Whack a Mole Audio Increase the display volume Use different background music for each game the behavior of HIV service uptake among a key population. Discussion Lange et al [27] established an interactive game-based program constructed on a UCD design process for training the dynamic Principal Findings balance of individuals who have previously experienced a stroke. In this study, we aimed to develop and test the usability of a Howes et al [79] also used UCD to develop the bespoke Active virtual, interactive game-based training system that is focused Computer Gaming system to deliver strength and balance on simultaneously training the physical and cognitive function exercise programs for older adults. Together, the present and (dual-tasking) of community-dwelling older adults. The core previous findings consistently suggest that the UCD approach games were formulated by integrating the principal knowledge is a core process that should be embedded in health games to and existing evidence from the literature related to effective fall ensure usability and acceptability. Therefore, the target users prevention exercise programs for older adults as well as by may benefit fully from exergames technology. subjecting the games to critical appraisal from experts. We also To our knowledge, our game-based exercise is the first game assessed older adults’ experiences in terms of enjoyment and prototype that was mainly designed to support older adults in game features using the PACES questionnaire and a structured combined physical-cognitive exercising using the Microsoft interview. Kinect motion sensor. In particular, the game-based exercise Several intervention studies have reported high dropout rates focused on the core impairment aspects that are related to falls and limited use of technology-supported platforms for delivering in older adults, including balance and stepping performance as exercise training programs [76-78]. Interactive game-based well as executive function, attention, and memory. Several training may be considered as a more efficient approach for investigators have consistently reported that the most important empowering user engagement, which contributes to positive component of exercise programs for fall prevention is balance outcomes of an intervention. However, many older adults tend training [6,7]. In addition, stepping training, a form of highly to be less engaged with modern digital technology, and not all specific balance training, has shown to be an effective fall are accepting of it. To overcome this limitation, the UCD prevention strategy [80]. Thus, balance and stepping training approach, which incorporates game design principles (ie, goals, were included in the game-based exercise. Regarding cognition, rules, feedback, points, time, reward structures, levels, and declined executive function, attention, and memory have been aesthetics), was used in the process of designing and developing identified as crucial contributors to falls [11-13,19]. Thus, a game-based exercise prototype with an aim to motivate and adding these cognitive components to physical training may engage older adults in exercising [54-60]. Researchers have potentially enhance the efficacy of fall prevention programs for identified the potential benefits of using the UCD concept for older adults. In addition, age-related perception and sensation developing exergames for older adults with and without decline in older adults were considered. Therefore, visual and health-related problems. For example, Hemingway et al [53] audio presentations, such as the size and distance of target used the UCD process to develop a mobile game to influence https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al objects as well as the level of sound volume, were included. enjoyment and experiences of using the game-based exercise Findings from the study demonstrated that the target users prototype were obtained from a single training session. Thus, viewed the game-based exercise prototype as an enjoyable and the findings should be considered preliminary and interpreted practical intervention approach for their physical and cognitive with caution. Future studies with larger sample sizes, a balanced training at home and in community settings. This may be gender ratio, and data obtained from multiple training sessions because the development of the game-based exercise prototype are warranted. Another limitation concerns the hardware incorporated the current knowledge regarding the key specification of the Microsoft Kinect sensor. In this study, the contributing factors for training continuation by using exergames capture volume of the Kinect sensor was restricted to 0.5 to 4.5 among older adults. These factors gradually increase the level m, which partly limited the design of the configurations of the of game difficulty, provide clearer feedback, and offer a simple games. Further studies should consider using multiple Kinect setup [81]. In this way, we expected that the newly developed sensors to cover a greater capture volume. Moreover, our game exergames would overcome the barrier to exercise in older system was designed for the individual player. Exergames adults. This enjoyment (determined by PACES scores) and systems that allow group players should be considered for positive feedback from the users may be, at least in part, due to promoting social interaction. Finally, this study investigated the fundamental elements of the game-based exercise, which the enjoyment during game engagement using the 18-item feature a real-time interface display and feedback. Consistent PACES questionnaire. In future studies, the 8-item version of with previous studies, our games system provides feedback, PACES would be an appropriate questionnaire to reduce the including scores and performance outcomes (ie, response time, completion time. error), which enhances the motivation of the users [82-84]. Conclusions Moreover, the positive responses from older learners who are This preliminary study demonstrated a prototype of a unfamiliar with new technologies can be attributed to the design game-based exercise for older adults using the Microsoft Kinect features of the game-based exercise prototype, such as having sensor. The game-based exercise prototype contained combined a user-friendly interface and providing optimal levels of task physical and cognitive training elements with different levels difficulty [85]. Nevertheless, some comments indicated that of difficulty. The developed game-based exercise was well further refinements are required prior to implementation of the accepted by the target users, with prominent enjoyment and game-based exercise among older adults in a realistic context. positive feedback. Thus, the game-based exercise appears to be Limitations a promising tool for enhancing older adults’ motivation to This study has certain limitations that need to be acknowledged. engage in physical-cognitive exercise with the aim to reduce This study is a preliminary study that involved a small number the risk of falls. of participants who were all female. Further, results on the Acknowledgments This research was supported by the Research and Researchers for Industries (RRI) Project, Thailand Science Research and Innovation (TSRI) Grant MSD61I0015 and TSRI Grant RSA6180023 (SS). Moreover, this research was partially supported by Chiang Mai University and with the collaboration of a research group of Modern Management and Information Technology, College of Arts, Media and Technology, and the Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand. In addition, the authors would like to thank K Intanon, P Sirinual, T Kunthadech, and S Korpraphan for their contributions to the development of the games. Authors' Contributions TK, SB, and SS share first authorships, conducted a major part of the methods and experimental design, developed the software, and contributed to the majority of the writing and reviewing of the manuscript. KP conducted a major part of the methods and experimental design, and commented on the manuscript and reviewed the final manuscript. Conflicts of Interest None declared. References 1. Osoba MY, Rao AK, Agrawal SK, Lalwani AK. Balance and gait in the elderly: a contemporary review. Laryngoscope Investig Otolaryngol 2019 Feb 04;4(1):143-153. [doi: 10.1002/lio2.252] [Medline: 30828632] 2. Coutinho EDSF, Silva SDD. Uso de medicamentos como fator de risco para fratura grave decorrente de queda em idosos. Cad Saúde Pública 2002 Oct;18(5):1359-1366. [doi: 10.1590/s0102-311x2002000500029] 3. 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[doi: 10.3389/fpsyg.2017.01837] [Medline: 29089914] Abbreviations PACES: Physical Activity Enjoyment Scale UCD: user-centered design Edited by N Zary; submitted 10.02.21; peer-reviewed by M Jordan-Marsh, Y Zhang, DR Colombo Dias, R Dörner, C Sik-Lanyi; comments to author 17.04.21; revised version received 08.09.21; accepted 24.09.21; published 27.10.21 Please cite as: Kamnardsiri T, Phirom K, Boripuntakul S, Sungkarat S JMIR Serious Games 2021;9(4):e27848 URL: https://games.jmir.org/2021/4/e27848 doi: 10.2196/27848 PMID: https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al ©Teerawat Kamnardsiri, Kochaphan Phirom, Sirinun Boripuntakul, Somporn Sungkarat. Originally published in JMIR Serious Games (https://games.jmir.org), 27.10.2021. 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An Interactive Physical-Cognitive Game-Based Training System Using Kinect for Older Adults: Development and Usability Study

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Abstract

Background: Declines in physical and cognitive functions are recognized as important risk factors for falls in older adults. Promising evidence suggests that interactive game-based systems that allow simultaneous physical and cognitive exercise are a potential approach to enhance exercise adherence and reduce fall risk in older adults. However, a limited number of studies have reported the development of a combined physical-cognitive game-based training system for fall risk reduction in older adults. Objective: The aim of this study is to develop and evaluate the usability of an interactive physical-cognitive game-based training system (game-based exercise) for older adults. Methods: In the development phase (Part I), a game-based exercise prototype was created by integrating knowledge and a literature review as well as brainstorming with experts on effective fall prevention exercise for older adults. The output was a game-based exercise prototype that covers crucial physical and cognitive components related to falls. In the usability testing (Part II), 5 games (ie, Fruits Hunter, Where Am I?, Whack a Mole, Sky Falls, and Crossing Poison River) with three difficulty levels (ie, beginner, intermediate, and advanced levels) were tested in 5 older adults (mean age 70.40 years, SD 5.41 years). After completing the games, participants rated their enjoyment level while engaging with the games using the Physical Activity Enjoyment Scale (PACES) and commented on the games. Descriptive statistics were used to describe the participants’ characteristics and PACES scores. Results: The results showed that the average PACES score was 123 out of 126 points overall and between 6.66 and 7.00 for each item, indicating a high level of enjoyment. Positive feedback, such as praise for the well-designed interactions and user-friendly interfaces, was also provided. Conclusions: These findings suggest that it is promising to implement an interactive, physical-cognitive game-based exercise in older adults. The effectiveness of a game-based exercise program for fall risk reduction has yet to be determined. (JMIR Serious Games 2021;9(4):e27848) doi: 10.2196/27848 KEYWORDS digital game; interactive game-based training; physical-cognitive training; exergaming; Kinect sensors; older adults; falls; PACES; user-centered design; game-based exercise https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al improving cognitive abilities (eg, executive function, speed of Introduction processing), and reducing the risk of falls among older adults [35-42]. However, in most existing training programs available Declines in multiple physiological systems with ageing for fall prevention, research concerning simultaneous training contribute to balance and gait deficits, leading to an increased of physical and cognitive functions (dual tasking) with the use risk of fall [1]. Fall is a serious public health problem, and its of exergames has remained scarce. consequences have a marked adverse impact on physical and psychological aspects such as injuries, activity restriction, fear Among interactive game-based technology for training, the of falling, and loss of autonomy [2-4]. Given the substantial Kinect motion sensor (Microsoft Corporation) has been impact of falls on health, as well as their medical and economic considered as a high-potential approach because it provides a burden, an effective strategy to prevent falls in older adults is markerless full-body 3D motion tracker and enables users to warranted. virtually interact hands-free with a computer system. Additionally, several examiners have demonstrated that among Several investigators have consistently reported a strong positive interactive game-based technology for exercising, Microsoft effect of physical exercise on fall prevention among older adults Kinect has an advantage in that it allows individuals to interact [5-9]. Researchers have also identified a critical role of with games using their own body in a natural way [43,44]; this cognition, especially executive function, attention, and memory, enhances the natural form of human-computer interaction [45]. on balance and gait control [10-13]. Many examiners have In addition, the Microsoft Kinect motion sensor is an accurate demonstrated that cognitive training, which is an intervention input device; thus, it allows precise tracking and real-time program aimed at improving, maintaining, or restoring cognitive feedback of user performance [46]. The Microsoft Kinect sensor function via the repeated and structured practice of tasks, can is proposed to be a feasible and effective tool for training improve balance and gait and reduce fall risk [14-17]. Taken concurrent physical and cognitive components in older adults, together, incorporating a cognitive component into physical with the aim of reducing the intrinsic causes (ie, physical and exercise may augment its benefits in fall prevention cognitive) of falls [47-51]. [11-13,18-20]. A growing number of investigators have documented the effects of combined physical-cognitive exercise Based on the usability challenges faced by older adults, training in a simultaneous form (dual-tasking) among older programmers should develop user interfaces that are adults. Combined physical-cognitive exercise training programs user-friendly for older adults and specific for training purposes. have resulted in greater improvement in physical and cognitive A previous investigator has suggested that older adults accept performance than either type of single training alone [21-25]. innovative technology when they recognize its benefit and find it meaningful for their lives [52]. As technology advances, a new alternative of rehabilitation approach targeting training of various physical and cognitive Therefore, this study focused on developing a prototype of a components in the form of interactive game-based exercises game-based exercise that accounts for the target user’s (exergames) is becoming available [26]. These interactive expectation and requirement (eg, enjoyment, attractiveness, user game-based exercises use technology-driven platforms that skill-challenge balance, and benefit for training cognitive and require users to move their body in order to complete assigned physical components). In particular, following a user-centered tasks via video game interface elements [27]. The interactive design approach, acceptability and training adherence in future game-based exercises have advantages in terms of gamification empirical studies were established. features. Researchers have demonstrated that exergames are attractive because they provide real-time interaction and Methods feedback to users, which enhances motivation and training adherence [28,29]. In addition, game-based exercises allow Study Design users to be active with repetitive practice and track progression, The present study consists of two parts: (1) the development of which is beneficial for training outcomes [30]. Another a game-based exercise prototype, and (2) evaluation of target advantage of exergames is that they can offer an experience for users’ feedback, response, and satisfaction regarding the daily-life task requirements based on concurrent training of developed game-based exercise prototype. The concept of physical and cognitive components [31-33]. Moreover, development and evaluation of the target user’s experience for game-based exercises can be applied either in rehabilitation producing a final prototype followed a user-centered design centers or community and home settings [33,34]. Several (UCD) approach [27,46,53-62]. UCD is a user interface design researchers have shown that game-based training using Nintendo process in which designers focus on gaining a target user’s Wii Fit, and Microsoft Kinect sensors were effective in perspective to create a product with a high degree of usability. improving physical abilities (eg, balance, gait performance), The UCD cycle is depicted in Figure 1. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Figure 1. Schematic of the user-centered design cycle [27]. prototype using the Unity 3D game engine software with Kinect Part I: Development of a Game-Based Exercise Sensor V2 for Windows. In the third phase, user feedback to Prototype improve the game-based exercise prototype was provided by end users using a think-aloud method [68]. Finally, the fourth Development Process phase concentrated on assessing physical activity enjoyment In this part, the 4-phase UCD process was applied [27,46,53-62]. during game engagement. The Physical Activity Enjoyment The first phase, the design development process of a game-based Scale (PACES) questionnaire [69,70], an 18-item scale exercise prototype, was conducted in the brainstorming phase. questionnaire, was used to analyze physical activity enjoyment. A total of 7 team members, including 3 physical therapists and Moreover, the usability of the game-based exercise prototype 1 physician (3-20 years of experience in geriatric and cognitive was determined with a structured interview (feedback about the rehabilitation), 2 game programmers (5 years of experience in game, themes, user interface, sound effect, graphics, and the Unity 3D game engine), and 1 game designer (10 years of interaction). Feedback from all participants was considered by experience in game design and game theory), participated in the research team to improve the game-based exercise prototype. the brainstorming session. This phase involved generating potential core game ideas by integrating the knowledge and Characteristics of the Game-Based Exercise Prototype literature review of previous physical and cognitive training The characteristics of the game-based exercise prototype are programs and interactive exergame interventions for fall presented in Table 1. The game can be described as individual prevention in older adults [16,63-65]. In the present study, the interactive game-based training using Kinect. The prototype of core game was composed of two training elements: (1) a the game-based exercise comprised 5 games, including (1) Fruits physical element, including stepping and balance training, and Hunter, (2) Where Am I ?, (3) Whack a Mole, (4) Sky Falls, (2) a cognitive element related to balance and falls in older and (5) Crossing Poison River. The games had three different adults, including executive function, attention, and memory levels: beginner, intermediate, and advanced. The level of game [18,66,67]. To ensure that the difficulty of the games was complexity progressed by increasing the difficulty of physical appropriate for each individual user, the progression of game demand (ie, movement speed, distance, duration, base of difficulty was considered. The game-based training program support) and cognitive demand (ie, number of stimuli, underwent critical appraisal by the physical therapists and complexity of the game’s rules, and amount of cognitive load). physician. In the second phase, after consensus, proven game The estimated play time was 45 to 60 minutes. ideas were used to create a game-based digital exercise game https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Table 1. Summary of the characteristics of the developed game-based exercise prototype. Characteristic Description Basic characteristics Health topic A game-based exercise prototype Targeted age group Older adults (age ≥65 years) Short description of the game idea The game-based exercise is a virtual, interactive game-based training system using Microsoft Kinect motion sensor technology. The game-based exercise comprises 5 games that include physical and cognitive components associated with balance and falls in older adults. Target player Individual Behavior change procedure used A game-based exercise is used to enhance motivation and engagement in older adults. Clinical support needed Physical therapist and geriatric physicians Data shared with clinician Data are saved and stored in the hard disk. However, reaction time, error, and score are given as feedback on the display screen (ie, the rubber mat) at the end of each game. Type of game Physical, action, real-time strategy Game components Player’s game goal/objective Physical components Improve static and dynamic balance Improve stepping reaction and response time Improve lower limb muscle strength Cognitive components Fruits Hunter: improves response ability and speed of processing via a stepping task. Where am I ?: improves semantic memory and visuospatial ability via visual sense Whack a Mole: improves selective attention ability, visual attention performance, speed of processing, and inhibition ability Sky Falls: improves sequencing and planning ability Crossing Poison River: improve episodic memory via auditory sense Rules Fruits Hunter: step on the presented fruits as fast as possible within a limited time. Where am I ?: step to the presented objects and remember as many as of them possible. The recall questions are provided at the end of the game. Whack a Mole: respond correctly to different rules of this game as follows: Mole or rabbit: steps on the target 1 time Mole or rabbit with helmet: steps on the target 2 times Bomb: do not step on the target Sky Falls: step with alternating feet to collect as many dropping objects in the basket as possible Crossing Poison River: listen to a short story and remember the content of the story while standing on one leg Game mechanics The game-based exercise system allows users to interact with the virtual games by stepping on the presented targets in different directions in pursuit of the game’s goals. The game-based exercise also provides audio and visual feedback to the users while they are playing the games. Virtual environment A forest with fruits, animals, vegetables, and a river Setting The game-based exercise can be set in a room environment Device requirements Personal computer/notebook/laptop with LED projector Sensors used Microsoft Kinect Sensor V2 Estimated play time 45-60 minutes an assistive device for at least 10 m, and (4) ability to step in Part II: Evaluation of Target User’s Experience all directions independently and safely. Exclusion criteria were (1) depressive symptoms (determined by a Thai Geriatric Recruitment and Participants Depression Scale-15 [72] score >6 points), (2) orthopedic A total of 5 community-dwelling older adults were enrolled as deficits, neurological deficits, and/or other significant health representative target users. The inclusion criteria were (1) age problems that precluded the participant from completing the 65 years or older, (2) had normal cognitive function (determined testing protocol, and (3) uncorrected visual and hearing by a Mental State Examination T10 [71] score ≥24 points or impairment. The study protocol was approved by the Human depending on the level of education), (3) ability to walk without https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Ethical Review Board of the principal investigator’s institute The Kinect Sensor V2 is a depth sensor camera manufactured (AMSEC-61EX-078). All participants gave written informed by Microsoft that provides information about the depth, color, consent prior to participating in the study. The demographic and skeleton of a user who is standing in front of the sensor. data of the participants, which consisted of age, height, weight, The Kinect sensor and LED projector were set on a portable medication use, and history of falls in the previous 12 months, metal storage rack at a height of 0.8 m and 2.0 m from the floor, were recorded. respectively. The laptop computer that contained the developed game software was set near the Kinect sensor. The game was Hardware Configuration projected on a rubber mat (2.0 m width × 1.2 m height) that was To set up the system, the capture volume of the system was placed on the floor; thus, the participants could virtually interact configured using the three main devices: Kinect Sensor V2 [73], by stepping. The center of the rubber mat was set 2.5 m from LED projector, and laptop computer. In the present study, the the Microsoft Kinect sensor and LED projector. The Kinect Sensor V2 was used because it provides greater precision configuration of hardware for playing the game-based exercise and more stable results compared to the Kinect Sensor V1 [74]. is illustrated in Figure 2. Figure 2. Environment configuration of the game-based exercise system. After completing the game-based exercise, participants were Protocol asked to rate their enjoyment using the PACES questionnaire The game-based exercise was connected with the Microsoft [69,70]. The PACES is an 18-item scale questionnaire that Kinect sensor, an LED projector, and the laptop computer. After assesses physical activity enjoyment during game engagement that, the system was calibrated by moving four markers in the with a 7-point Likert scale (1, strongly disagree, to 7, strongly game-based training system over the four corner marks on the agree). A higher PACES score reflects a greater level of rubber mat. For individualized body position calibration, each enjoyment. Moreover, using a structured interview, participants participant was asked to perform a T-pose stand for were interviewed about their impressions of the game-based approximately 5 seconds at the center of the rubber mat (Figure exercise features in terms of rules, mechanics, interfaces, and 2). After the calibration process, each participant received a scoring, as well as their physical and cognitive involvement comprehensive description of the rules of the games, including while playing the games. a demonstration, and was requested to play the game-based Data Analysis exercise. The American College Sport of Medicine exercise guidelines recommend that older adults should participate in Descriptive statistics were used to describe both the participants’ aerobic activities for a minimum of 30 minutes per session to characteristics and their scores on the 18-item PACES promote and maintain their health-related outcomes [75]. In questionnaire. All data were analyzed using SPSS 21.0 (IBM this study, the exercise duration ranged between 30 and 50 Corporation). minutes, with a rest interval of between 10 and 15 minutes, depending on the participant performance; this resulted in a total time of 45 to 60 minutes. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Game programmers: the specialists who generated the Results digital game using the computer programming language and game engine software (the Unity 3D game engine Part I: Development of a Game-Based Exercise software with Microsoft Kinect sensor V2 for Windows). Prototype Domain knowledge: the experts having core knowledge The framework of the game-based exercise comprised 6 and experience of physical and cognitive training programs components (Figure 3), including: for fall prevention in older adults. Game-based training system: the digital game system, which The Microsoft Kinect sensor: the depth sensor that was comprised 5 games (Games I-V) with 3 levels (levels 1-3) used to track and monitor full-body movements in 3D and feedback (ie, score, response time, and error). coordinates (ie, the x-, y-, and z-axes). The tracking data User and laptop computer: a system operator who was were then converted to the 24 points of the Joint ID Map responsible for controlling the game-based training system (body skeleton model). In this study, 4 points of the Joint while participants were playing the games. ID Map [43] (ANKLE_RIGHT, FOOT_RIGHT, Graphical user interface: a form of user interface that allows ANKLE_LEFT and FOOT_LEFT) were used for the participants to interact with the game-based exercise (Figure interaction between the user and the game. 4). An example of a participant training with the game-based exercise prototype is displayed in Figure 5. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Figure 3. Framework of the game-based exercise system. GUI: graphical user interface. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Figure 4. Screenshots of the 5 games in the game-based exercise system: (A) Fruits Hunter, (B) Where Am I ?, (C) Whack a Mole, (D) Sky Falls, and (E) Crossing Poison River. Figure 5. Examples of a participant playing the game-based exercise: (A) Whack a Mole, (B) Sky Falls, and (C) Crossing Poison River. years (range 65-79 years). No participants had any experience Part II: Evaluation of the Target Users’ Experience with using exergames. They had low incidence rate of falls in the past 12 months, and they either did not take medication or Participant Characteristics took only one type. The participants’ characteristics are A total of 5 community-dwelling older adults participated in summarized in Table 2. the usability testing phase. Their mean age was 70.40 (SD 5.41) Table 2. Characteristics of the study participants. Characteristic Value Median Range Age (years), mean (SD) 70.40 (5.41) 68 65-79 Height (cm), mean (SD) 155.20 (6.06) 156 149-164 Weight (kg), mean (SD) 53.40 (8.62) 55 39-60 22.08 (2.63) 22.21 17.60-24.30 BMI (kg/m ), mean (SD) Education (years), mean (SD) 14.40 (5.90) 16 4-18 Types of medication, mean (SD) 0.20 (0.45) 0 0-1 Falls in the past year, n 1 0 0-1 https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al answered the PACES questionnaire. The average score on each User Experience in Using the Game-Based Exercise item was between 6.66 and 7.00, which indicated greater levels System of enjoyment. The 18-item PACES scores are illustrated in All 5 participants completed the game-based exercise and Table 3. Table 3. Physical Activity Enjoyment Scale (PACES) rating scores (n=5). All items were rated on a 7-point scale from 1, strongly disagree, to 7, strongly agree. Question Participants Response rating, mean (SD) S01 S02 S03 S04 S05 1. I enjoy it; I hate it 7 6 7 7 6 6.80 (0.20) 2. I feel interested; I feel bored 7 6 7 7 7 7.00 (0.00) 3. I like it; I dislike it 7 7 7 7 7 7.00 (0.00) 4. I find it pleasurable; I find it unpleasurable 7 7 7 6 6 6.66 (0.24) 5. I am very absorbed in this activity; I am not at all absorbed in this 6 7 7 7 7 6.80 (0.20) activity 6. It’s a lot of fun; it’s no fun at all 7 7 7 7 7 7.00 (0.00) 7. I find it energizing; I find it tiring 7 6 7 7 7 6.80 (0.20) 8. It makes me happy; it makes me depressed 7 7 7 7 7 7.00 (0.00) 9. It’s very pleasant; it’s very unpleasant 7 7 7 7 6 6.80 (0.20) 10. I feel good physically while doing it; I feel bad physically while 7 7 7 7 7 7.00 (0.00) doing it 11. It’s very invigorating; it’s not at all invigorating 7 7 7 6 7 6.80 (0.20) 12. I am not at all frustrated by it; I am very frustrated by it 7 7 7 7 7 7.00 (0.00) 13. It’s very gratifying; it’s not at all gratifying 7 7 7 6 6 6.66 (0.24) 14. It’s very exhilarating; it’s not at all exhilarating 7 7 7 7 6 6.80 (0.20) 15. It’s very stimulating; it’s not at all stimulating 7 7 7 6 7 6.80 (0.20) 16. It give me a strong sense of accomplishment; it does not give 7 7 7 6 7 6.80 (0.20) me any sense of accomplishment 17. It’s very refreshing; it’s not at all refreshing 7 7 6 6 7 6.66 (0.24) 18. I felt as though there was nothing else I would rather be doing; 7 7 7 7 6 6.80 (0.20) I felt as though I would rather be doing something else Rating scale of all items (total points: 126) 125 123 125 120 120 123.00 (1.26) User Feedback and Suggestions The feedback and suggestions provided by the users are presented in Table 4. https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al Table 4. Feedback and suggestions provided by the study participants for the game prototype. Type of feedback or suggestion Feedback Feedback Positive “The games’ feature and appearance were very attractive and enhanced my motivation to complete the games.” “The games provided my performance with visible outcomes and scores which motivated me to try harder to get a better score in the next trial.” “The difficultly of each game was optimal; it was not too easy and not too difficult.” “The games had variety of forms and rules that challenged my physical and cognitive abilities.” “The games had a meaningful sound effect which helped me to identify my right or wrong responses.” “The games’ systems were quite simple to set up and easy to manage, thus it appeared to be feasible to use in the community or home settings.” Negative “In the Whack a Mole, sometimes I did not step on the bomb, but it eventually blew up.” “In the Sky Falls, sometimes it was quite hard to control the movement of the bamboo basket even though I tried to alternate my stepping rhythmically.” Suggestions Game rules Clearly state the game instructions and rules at the beginning Level design Reduce the speed of dropping objects in the beginner level of Sky Falls Use different types of animals and vegetables for each difficulty level of Where Am I? Graphics/look and feel Adjust the distance of each presented object in Whack a Mole Audio Increase the display volume Use different background music for each game the behavior of HIV service uptake among a key population. Discussion Lange et al [27] established an interactive game-based program constructed on a UCD design process for training the dynamic Principal Findings balance of individuals who have previously experienced a stroke. In this study, we aimed to develop and test the usability of a Howes et al [79] also used UCD to develop the bespoke Active virtual, interactive game-based training system that is focused Computer Gaming system to deliver strength and balance on simultaneously training the physical and cognitive function exercise programs for older adults. Together, the present and (dual-tasking) of community-dwelling older adults. The core previous findings consistently suggest that the UCD approach games were formulated by integrating the principal knowledge is a core process that should be embedded in health games to and existing evidence from the literature related to effective fall ensure usability and acceptability. Therefore, the target users prevention exercise programs for older adults as well as by may benefit fully from exergames technology. subjecting the games to critical appraisal from experts. We also To our knowledge, our game-based exercise is the first game assessed older adults’ experiences in terms of enjoyment and prototype that was mainly designed to support older adults in game features using the PACES questionnaire and a structured combined physical-cognitive exercising using the Microsoft interview. Kinect motion sensor. In particular, the game-based exercise Several intervention studies have reported high dropout rates focused on the core impairment aspects that are related to falls and limited use of technology-supported platforms for delivering in older adults, including balance and stepping performance as exercise training programs [76-78]. Interactive game-based well as executive function, attention, and memory. Several training may be considered as a more efficient approach for investigators have consistently reported that the most important empowering user engagement, which contributes to positive component of exercise programs for fall prevention is balance outcomes of an intervention. However, many older adults tend training [6,7]. In addition, stepping training, a form of highly to be less engaged with modern digital technology, and not all specific balance training, has shown to be an effective fall are accepting of it. To overcome this limitation, the UCD prevention strategy [80]. Thus, balance and stepping training approach, which incorporates game design principles (ie, goals, were included in the game-based exercise. Regarding cognition, rules, feedback, points, time, reward structures, levels, and declined executive function, attention, and memory have been aesthetics), was used in the process of designing and developing identified as crucial contributors to falls [11-13,19]. Thus, a game-based exercise prototype with an aim to motivate and adding these cognitive components to physical training may engage older adults in exercising [54-60]. Researchers have potentially enhance the efficacy of fall prevention programs for identified the potential benefits of using the UCD concept for older adults. In addition, age-related perception and sensation developing exergames for older adults with and without decline in older adults were considered. Therefore, visual and health-related problems. For example, Hemingway et al [53] audio presentations, such as the size and distance of target used the UCD process to develop a mobile game to influence https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al objects as well as the level of sound volume, were included. enjoyment and experiences of using the game-based exercise Findings from the study demonstrated that the target users prototype were obtained from a single training session. Thus, viewed the game-based exercise prototype as an enjoyable and the findings should be considered preliminary and interpreted practical intervention approach for their physical and cognitive with caution. Future studies with larger sample sizes, a balanced training at home and in community settings. This may be gender ratio, and data obtained from multiple training sessions because the development of the game-based exercise prototype are warranted. Another limitation concerns the hardware incorporated the current knowledge regarding the key specification of the Microsoft Kinect sensor. In this study, the contributing factors for training continuation by using exergames capture volume of the Kinect sensor was restricted to 0.5 to 4.5 among older adults. These factors gradually increase the level m, which partly limited the design of the configurations of the of game difficulty, provide clearer feedback, and offer a simple games. Further studies should consider using multiple Kinect setup [81]. In this way, we expected that the newly developed sensors to cover a greater capture volume. Moreover, our game exergames would overcome the barrier to exercise in older system was designed for the individual player. Exergames adults. This enjoyment (determined by PACES scores) and systems that allow group players should be considered for positive feedback from the users may be, at least in part, due to promoting social interaction. Finally, this study investigated the fundamental elements of the game-based exercise, which the enjoyment during game engagement using the 18-item feature a real-time interface display and feedback. Consistent PACES questionnaire. In future studies, the 8-item version of with previous studies, our games system provides feedback, PACES would be an appropriate questionnaire to reduce the including scores and performance outcomes (ie, response time, completion time. error), which enhances the motivation of the users [82-84]. Conclusions Moreover, the positive responses from older learners who are This preliminary study demonstrated a prototype of a unfamiliar with new technologies can be attributed to the design game-based exercise for older adults using the Microsoft Kinect features of the game-based exercise prototype, such as having sensor. The game-based exercise prototype contained combined a user-friendly interface and providing optimal levels of task physical and cognitive training elements with different levels difficulty [85]. Nevertheless, some comments indicated that of difficulty. The developed game-based exercise was well further refinements are required prior to implementation of the accepted by the target users, with prominent enjoyment and game-based exercise among older adults in a realistic context. positive feedback. Thus, the game-based exercise appears to be Limitations a promising tool for enhancing older adults’ motivation to This study has certain limitations that need to be acknowledged. engage in physical-cognitive exercise with the aim to reduce This study is a preliminary study that involved a small number the risk of falls. of participants who were all female. Further, results on the Acknowledgments This research was supported by the Research and Researchers for Industries (RRI) Project, Thailand Science Research and Innovation (TSRI) Grant MSD61I0015 and TSRI Grant RSA6180023 (SS). Moreover, this research was partially supported by Chiang Mai University and with the collaboration of a research group of Modern Management and Information Technology, College of Arts, Media and Technology, and the Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand. In addition, the authors would like to thank K Intanon, P Sirinual, T Kunthadech, and S Korpraphan for their contributions to the development of the games. Authors' Contributions TK, SB, and SS share first authorships, conducted a major part of the methods and experimental design, developed the software, and contributed to the majority of the writing and reviewing of the manuscript. KP conducted a major part of the methods and experimental design, and commented on the manuscript and reviewed the final manuscript. Conflicts of Interest None declared. References 1. Osoba MY, Rao AK, Agrawal SK, Lalwani AK. Balance and gait in the elderly: a contemporary review. Laryngoscope Investig Otolaryngol 2019 Feb 04;4(1):143-153. [doi: 10.1002/lio2.252] [Medline: 30828632] 2. Coutinho EDSF, Silva SDD. Uso de medicamentos como fator de risco para fratura grave decorrente de queda em idosos. Cad Saúde Pública 2002 Oct;18(5):1359-1366. [doi: 10.1590/s0102-311x2002000500029] 3. 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[doi: 10.3389/fpsyg.2017.01837] [Medline: 29089914] Abbreviations PACES: Physical Activity Enjoyment Scale UCD: user-centered design Edited by N Zary; submitted 10.02.21; peer-reviewed by M Jordan-Marsh, Y Zhang, DR Colombo Dias, R Dörner, C Sik-Lanyi; comments to author 17.04.21; revised version received 08.09.21; accepted 24.09.21; published 27.10.21 Please cite as: Kamnardsiri T, Phirom K, Boripuntakul S, Sungkarat S JMIR Serious Games 2021;9(4):e27848 URL: https://games.jmir.org/2021/4/e27848 doi: 10.2196/27848 PMID: https://games.jmir.org/2021/4/e27848 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27848 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kamnardsiri et al ©Teerawat Kamnardsiri, Kochaphan Phirom, Sirinun Boripuntakul, Somporn Sungkarat. Originally published in JMIR Serious Games (https://games.jmir.org), 27.10.2021. 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Published: Oct 27, 2021

Keywords: digital game; interactive game-based training; physical-cognitive training; exergaming; Kinect sensors; older adults; falls; PACES; user-centered design; game-based exercise

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