Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

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

Rehabilitation-Oriented Serious Game Development and Evaluation Guidelines for Musculoskeletal... Background: The progress in information and communication technology (ICT) led to the development of a new rehabilitation technique called “serious game for functional rehabilitation.” Previous works have shown that serious games can be used for general health and specific disease management. However, there is still lack of consensus on development and evaluation guidelines. It is important to note that the game performance depends on the designed scenario. Objective: The objective of this work was to develop specific game scenarios and evaluate them with a panel of musculoskeletal patients to propose game development and evaluation guidelines. Methods: A two-stage workflow was proposed using determinant framework. The development guideline includes the selection of three-dimensional (3D) computer graphics technologies and tools, the modeling of physical aspects, the design of rehabilitation scenarios, and the implementation of the proposed scenarios. The evaluation guideline consists of the definition of evaluation metrics, the execution of the evaluation campaign, the analysis of user results and feedbacks, and the improvement of the designed game. Results: The case study for musculoskeletal disorders on the healthy control and patient groups showed the usefulness of these guidelines and associated games. All participants enjoyed the 2 developed games (football and object manipulation), and found them challenging and amusing. In particular, some healthy subjects increased their score when enhancing the level of difficulty. Furthermore, there were no risks and accidents associated with the execution of these games. Conclusions: It is expected that with the proven effectiveness of the proposed guidelines and associated games, this new rehabilitation game may be translated into clinical routine practice for the benefit of patients with musculoskeletal disorders. (JMIR Serious Games 2017;5(3):e14) doi: 10.2196/games.7284 KEYWORDS rehabilitation exercise; virtual rehabilitation; rehabilitation; user computer interface; musculoskeletal diseases well-being of the involved people [1,2]. Age-related Introduction deficiencies, sport and transport accidents, and genetic conditions are the main sources of these disorders. In the United Context States, billions of dollars have been spent for treatment and Musculoskeletal disorders lead to high medical costs all over patient management. In Europe, the ageing effect of the the world. These disorders affect the working performance and population requires significant efforts for medical experts and http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al infrastructures. Research studies have been performed to provide to reach and step as far and as fast as possible. Patients are better diagnosis and treatment of these disorders. Among the required to execute repetitive and variable tasks in order to learn most common routine practices, functional rehabilitation plays new movement patterns and to perform the transition from one a key role in the recovery of mechanical functions of the human movement to another by performing mixed and multiple tasks. body. This specific treatment helps recover the functionality of A virtual avatar is shown on the screen that mimics the patient’s the musculoskeletal system by improving the ranges of motion movements. However, the system was never tested on Parkinson as well as the muscle strengths. Current physical therapy disease patients. Assad et al (2011) also investigated the use of programs are performed by patients and supervised by medical serious games for Parkinson disease patients, and they doctors over a long period of time in hospitals or clinics [3,4]. implemented a series of games that use the Sony PlayStation This traditional rehabilitation scheme requires permanent EyeToy as a motion capture tool [14]. Four different Parkinson involvement of different medical actors (eg, physiotherapists disease adapted games were developed and tested by 13 and medical doctors) during the program, leading to a high cost Parkinson disease patients. The system was rated using a for medical human resources. Moreover, due to the repetitive questionnaire completed by the patients after performing the nature of the rehabilitation exercises, the motivation of the exercises. This study concluded that the patients enjoyed the patient decreases rapidly during the execution of the program. exercises. Paraskevopoulos et al (2014) developed serious games Recently, the progress in information and communication adapted to Parkinson disease patients [15]. They defined a technology (ICT) led to the development of a new rehabilitation guideline to successfully design serious games adapted to scheme called “serious game for functional rehabilitation” [5-7]. Parkinson disease through a detailed literature review of related In fact, the coupling of the game technologies and functional works, and developed 2 games using the Wii Mote and the rehabilitation allows a better interaction between patient and Kinect camera. They tested the games on 5 Parkinson disease the rehabilitation program [8]. Moreover, the use of serious patients and concluded that serious games have the potential to game scenarios may be a potential solution to improve the increase the level of engagement for such patients. patient’s motivation in future rehabilitation sessions. Another rehabilitation field that has been studied is stroke rehabilitation. Cho et al (2014) developed a proprioception State of the Art rehabilitation system for stroke patients [16]. The user moves Some research studies focused on games that could improve a connected cylinder to interact with the game. The objective general health for adults and elders. Chen et al (2012) developed was to hold the connected cylinder under a table to move the a lower limb power rehabilitation system. Each user needs to virtual cylinder from an initial position to a destination position. execute a squat motion, with sufficient power, to correctly build The study was tested with 10 healthy subjects and 10 stroke a virtual tower made of blocks [9]. The system was tested with patients and showed significant improvement in patients. 20 participants, whereas 20 control participants executed normal However, this improvement might have been attributed to exercises for 6 weeks. The results showed that the participants patients becoming accustomed to the game. Another system using the developed system achieved greater improvements in used a commercial Wii Fit game and 2 Wii balance boards to power and velocity of movement. Sun et al (2013) presented a adapt the games to stroke survivors [17]. Each balance board balance rehabilitation system using Kinect and a force plate captures the center of pressure of the leg. The weak leg’s signal [10]. The objective of this game was to fit an avatar in a specific is multiplied by a higher weight than the healthy leg’s signal frame indicated on the screen, while standing on the force plate. so that the patient applies more load on the weak leg. The system In total, 23 healthy subjects tested this system, but the results was tested on 3 stroke survivors (2 participants and 1 control) showed that different evaluation methods could lead to different and showed that after 7 to 12 sessions, the patients began to interpretation of the player experience. Chatzitofis et al (2015) rely more on their weak legs and began to tend to normal load [11] implemented a home-based rehabilitation system for cardio ratios observed in healthy subjects. Ibarra Zannatha et al (2013) vascular diseases using Kinect and body worn inertial sensors. also developed a serious for game stroke rehabilitation using The users need to start the game by warming up, and then they the Kinect camera, electromyography (EMG) sensors, and a need to execute the assigned movement. Visual feedback is humanoid robot [18]. The system consists of 4 games for the generated on the screen to help the user to optimize the upper limbs. This system was not tested on stroke patients. movement. The system was evaluated with 6 patients. Finally, Lozano-Quilis et al (2014) [12] implemented an augmented Literature showed that serious games have been intensively reality system for multiple sclerosis using the Kinect. The developed for general health and specific disease management. system is called RemoviEM and includes 3 game exercises One of the most important aspects of serious games is the game (TouchBall, TakeBall, and StepBall). In total, 11 patients tested playing scenario to motivate the patient. Moreover, user the ability of the system to encourage players to perform acceptability also plays an important role in promoting this new exercises. The results were collected through a questionnaire technology to clinical practice. Finally, the user security aspect and showed that patients accepted the system and felt safe and needs particular attention to avoid new clinical complications secure while playing. for patients. Different game systems have been developed and tested. There is still lack of development and evaluation Parkinson disease has been a subject of interest among serious consensus guidelines to achieve these important aspects. It is game projects. Yu et al (2011) [13] developed a real-time important to note that the game performance depends on the Parkinson mediated rehabilitation environment. They designed scenario. Some authors have attempted to propose implemented a system applied in a clinical space to treat specific guidelines for game development-based learning [19] Parkinson disease symptoms by improving the patient’s ability http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al or for Parkinson disease rehabilitation [15]. However, the proposed scenario. This workflow aims to design fun but methodologies and best practices related to the development of useful game scenarios to motivate end users to perform customized serious games for musculoskeletal disorders to functional rehabilitation tasks. The evaluation guideline consists recover complex joint and muscle functions are still lacking. of the definition of the evaluation metrics, the execution of the Thus, the objective of this work was to develop specific game evaluation campaign, the analysis of user results and feedbacks, scenarios and to evaluate them with a panel of musculoskeletal and the improvement of the designed game. Finally, the patients, to propose game development and evaluation improved game is reevaluated in a closed-loop technique. This guidelines. In particular, specific games for the functional user-centered game design approach allows different users (eg, rehabilitation of musculoskeletal disorders were developed and patients and medical experts) to participate actively in the design evaluated using the proposed approach. Hence, the usefulness and evaluation stages. Note that the second workflow focuses of the developed games was quantified. Discussion on the on the evaluation of user acceptability and security aspects when usefulness of the proposed guidelines according to the literature using this new technology. The development of these guidelines was also provided. was performed using determinant framework [20]. This theoretical approach has been commonly used to determine Methods what important factors influence implementation outcomes. Thus, eight determinants (3D computer graphics technologies, Development of Serious Games physics modeling, scenario design, implementation, evaluation metrics definition, evaluation campaign, user result and feedback The development of serious games for functional rehabilitation analysis, and game improvement) were hypothesized to of musculoskeletal disorders is a complex engineering task. To influence the implementation outcomes of the development and deal with such complexity, a two-stage workflow was proposed. evaluation of rehabilitation-oriented serious games. In fact, The first workflow relates to the development guideline (Figure these components aim to cover necessary methodologies and 1), whereas the second workflow concerns the evaluation best practices for developing customized serious games for guideline (Figure 2). The development workflow includes the musculoskeletal disorders and evaluating them. The choice of selection of three-dimensional (3D) computer graphics these components is based on our experiences gained from technologies and tools, the modeling of physical aspects, the literature analysis and also from our preliminary studies on design of rehabilitation scenarios, and the implementation of functional rehabilitation using serious game technologies [7,8]. Figure 1. Rehabilitation-oriented serious game: development guideline. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 2. Rehabilitation-oriented serious game: evaluation guideline. during the motion [21]. Game environments and interaction Case Study for Musculoskeletal Disorders objects were also designed and implemented using Blender design software. Rehabilitation-Oriented Serious Game: Development Guideline Games with 3D interactive objects need to establish interaction rules between them. An algorithm was designed and This subsection describes the work done using a proposed implemented to detect collisions between objects within the development guideline for creating specific serious games for scene. The challenge was to find a way to differentiate between functional rehabilitation of musculoskeletal disorders. the detection between different avatar bones and 3D objects; Three-Dimensional (3D) Computer Graphics Technologies therefore, we created spheres around each bone of the body and Tools (Figure 3. Note that the radius and positions of these spheres The selection of available computer graphics technologies and are adjustable to a specific subject body. The assessment of the tools plays a crucial role in the success of the rehabilitation collisions is done by calculating the distance between the spheres game. To ensure a user-friendly, human-system interaction, of objects and bones (Figure 3). cutting-edge technologies benefiting the most recent progress Let S be a sphere with a 3D center C (C , C , C ) and a 1 1 1x 1y 1z of ICT solutions need to be used. In this study, open source radius r , and S another sphere with center C (C , C , C ) Blender design software (Neo Geo) was selected for human 1 2 2 2x 2y 2z body modeling. XNA Game Studio (Microsoft) was selected and radius r . The distance between the 2 centers of the 2 spheres as game engine. Microsoft Kinect camera was selected as human is d drawn in Figure 3 and is computed using the following motion capture tool. Computer screen was used as equation: human-system interface. The pertinence of these technological 2 2 2 1/2 d=[(C -C ) +(C -C ) +(C -C ) ] choices has been proven in our previous studies [7-8,21]. 1x 2x 1y 2y 1z 2z This distance is computed between every 2 objects at each Physics Modeling updated iteration during the game. If d is found to be less than A 3D avatar model was developed using Blender design the sum of the 2 radiuses r and r , a collision is detected, and 1 2 software to represent the human body. This is a 3D surface mesh the game reacts to it by a certain preprogramed reaction. model including a collection of vertices, edges, and faces that defines the external shape of the human body. Moreover, an Scenario Design internal skeleton structure was also created to define body Two task-oriented game scenarios (football and object segments (eg, thigh and leg) and their interaction (eg, joint) manipulation) were designed and implemented. The football http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al game aims at practicing body orientation and lower limb since the patient has to kick the ball. It is noted that a soccer motions, allowing the rehabilitation of spinal and lower limb stadium was designed for this specific rehabilitation game. systems. The object manipulation aims to practice the upper Object Manipulation Game limb and lower limb motions with a focus on the detailed hand In this scene, the user needs to take a flower from the given skill. The description of each game is given in the following vase and put it in the other one (Figure 4). They repeat the same paragraphs. actions from right to left until the game-time expires. Three Football Game levels of difficulty (easy, medium, and hard) are defined. In the This game requires the player to execute many consecutive first level, the virtual avatar is fixed between 2 tables and can gestures. First, players have to stand in front of the Kinect and only move their hands. In particular, the player is rewarded 4 the computer screen. Then, they need to target the left or right points for a combination of 3 successive gestures: take the cones by pivoting their body (Figure 4). Once the target is flower with the first hand from the first vase, switch the flower reached, the player has to verify that the pointer in the bottom to the second hand, and put the flower in the second vase. The right corner of the screen is in the green zone. If the pointer is second level of this game requires the player to move left and green, they kick the ball to hit the cone and score one point. right while a certain distance separates the tables. Therefore, Otherwise, if they kick while the pointer is red, the ball will players have to move one step left and then get the flower. They miss. When the cone is hit, the user needs to pivot back to the switch it to the other hand and then move one step to the right original position to get another ball. A point is awarded for in order to put the flower in the other vase. Finally, the third every cone hit. We developed three levels of difficulty because level of difficulty is similar to the second one but the challenge patients playing the game might be in different phases of their is to put the flower in the other vase before the expiration of a rehabilitation. Using the different developed levels, experts can timer that appears on the bottom of the screen. This game targets configure the difficulty of the exercises to be executed by their several parts of the body. The upper limbs are targeted in all patients according to the rehabilitation progress. In the easy the levels, whereas the lower limbs are targeted only by the level, the cones are big and the green or red pointer is slow. The second and third levels. Moreover, the third level targets lower medium level decreases the size of the cones. Finally, to make limb movement speed recovery, since the timer would force the it harder, the pointer will move faster on the hard level. Experts users to move quicker. It is noted that a surrounding living room can also define the duration for each exercise, which gives them was designed for this specific rehabilitation game. more control over the rehabilitation program. This game aims Implementation at the rehabilitation of several parts of the body. It targets Visual Studio.Net, with C# programming language, was adopted balance, since the users rotate to target a cone. In addition, it for image acquisition and processing, body tracking, object includes a decision-making action, since players have to verify manipulation, as well as for the development of graphical user the pointer position. Finally, the lower limbs are also affected, interfaces (GUIs). Figure 3. Illustrations of the association of collision spheres to avatar bones (a) and object collision detection principle (b). http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 4. Football game (easy level) (a) and object manipulation game (hard level) (b). level of difficulty of each game, which means a total of 6 trials Rehabilitation-Oriented Serious Game: Evaluation per subject. Some patients were not able to try all levels or even Guideline one of the two games due to the severity of their state This part presents the work done, as well as outcomes issued (amputation, leg prosthesis, and paralyses). Medical experts from the application of the proposed evaluation guideline for were given the decision to accept or decline the participation assessing the developed games. of their patient in a game or a level of a certain game. Therapists accompanied their patients by standing behind them and Definition of Evaluation Metrics supporting them, to ensure their security. The duration of each The game-playing performance was evaluated by the points game level was around 60 seconds. A rest time of around 2 min acquired at the end of each scenario. For the usage acceptability was also allowed for each participant when necessary (ie, aspect of the designed games, a questionnaire was defined. At recovery from fatigue) after each game execution. The total the end of each game scene, players were required to fill out a time of the test for one subject was equal to 20 min questionnaire. The questionnaire consists of 13 questions for approximately. each specific game scenario. The feedback focuses on the game, exercise, and user aspect. For the game, the objective, the level Results of difficulty, the ignorance of achievement, the attractiveness of the 3D environment and GUI, and the game management User Result and Feedback Analysis (begin, end) were investigates. For the exercise, the game For the control group, the scores did not change so much when instructions, the variation of scenarios, the suitability of the increasing the level of difficulty for the football scenario game to the goal, and the clearness of the feedback were (Figures 5-7). The mean and SD scores of the easy, medium, examined. For the user, the motivating challenge, the possibility and hard levels were 8.5 (SD 1.8), 8.5 (SD 2.2), and 8.5 (SD to make mistakes, and the security feeling were investigated. 2.7), respectively. Maximal scores were 11, 12, and 13 for the easy, medium, and hard levels of difficulty, respectively. Note Evaluation Campaign that when a score is achieved, this means that the player finished The developed game scenarios were evaluated by a normal a game with all requirements. Statistical test (t-test, implemented healthy group (10 subjects: 6 males and 4 females with a mean in Matlab R2010b software [The MathWorks Inc.]) showed no age of 26.8 [standard deviation, SD 5.65]), to ensure the security significant difference. In particular, some subjects (ID4 or ID6) condition, and then evaluated by a population of 20 pathological increased their score when enhancing the level of difficulty. subjects (13 males and 7 females with a mean age of 49.75 [SD According to the healthy control group, the performance of the 18.68]) at the “Centre Hospitalier Universitaire de Limoges” pathological population was significantly (t-test, P<.005) lower (France). The patient group included different musculoskeletal for all levels of difficulty (Figures 5-7). The mean and SD scores disorders (3 amputee patients, 8 hemiplegia patients, 1 hereditary of the easy, medium, and hard levels were 2.7 (SD 1.3), 2.5 (SD spastic paraplegia patient, 1 patient with ankle arthrodesis, 1 1.7), and 3.9 (SD 1.8), respectively. Maximal scores were 6, 6, stroke patient, 1 patient with shoulder capsulitis, 1 patient with and 7 for the easy, medium, and hard levels of difficulty, low back pain, 1 patient with carpal tunnel, 1 patient with respectively. In particular, some patients (ID17 or ID24) prosthesis, 1 patient with muscle disease, and 1 patient with increased their score when enhancing the level of difficulty. walking difficulty due to a car accident). Each participant signed However, the number of the patients able to perform on harder an informed consent agreement before playing the rehabilitation levels was reduced from 19 patients for easy level to 8 patients games. It is important to note that the execution of rehabilitation for the hard level. serious game was monitored by clinicians, to ensure the ability and the security of the patients when using this new Regarding the object manipulation game, the same results were rehabilitation tool. Each healthy subject was asked to play every noted (Figures 8-10). The normal population showed mean and http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al SD scores of 51.6 (SD 13.3), 59.2 (SD 14), and 60.4 (SD 25) Regarding the user acceptability of the evaluated games, all for the easy, medium, and hard levels, respectively. Maximal healthy subjects found the 2 developed games motivational, scores were 72, 88, and 116 for the easy, medium, and hard attractive, and challenging. A synthesis of the patients’ responses levels of difficulty, respectively. The pathological population to the football game questionnaire is depicted in Table 1. showed mean and SD scores of 22.8 (SD 12.3), 22 (SD 12.2), Moreover, they enjoyed all the levels of difficulty. Note that and 25.3 (SD 21.7) for the easy, medium, and hard levels, the answers about the accuracy of the human movements’ respectively. Maximal scores were 52, 44, and 68 for the easy, detection varied. That can be interpreted by the limitations of medium, and hard levels of difficulty, respectively. Thus, the the Kinect due to occlusion of limbs, which could affect the performance of the pathological population was significantly accuracy of movement detection. Most of the participants (t-test, P<.05) lower than that of the normal population. The assumed that they were comfortable with the system, whereas number of the patients able to perform harder levels was also some patients, having balance disorders, worried about some reduced from 17 patients for the easy level to 5 patients for the levels of difficulty. Finally, there were no risks and accidents hard level. associated with the execution of these 2 games not only for the normal population but also for the pathological population. For the responses to the questionnaires, 29 users (patients and healthy subjects) rated the football game, and 27 rated the object manipulation game. Figure 5. Game performance: patient group vs. healthy control group: easy level of the football scenario. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 6. Game performance: patient group vs. healthy control group: medium level of the football scenario. Figure 7. Game performance: patient group vs. healthy control group: hard level of the football scenario. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 8. Game performance: patient group vs. healthy control group: easy level of the object manipulation scenario. Figure 9. Game performance: patient group vs. healthy control group: medium level of the object manipulation scenario. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 10. Game performance: patient group vs. healthy control group: hard level of the object manipulation scenario. The project is very fun, helps in performing Game Improvement rehabilitation while enjoying it. It should please young Finally, players were asked to give some specific comments on and old people. this project and the developed games. Comments and Very attractive games. suggestions from the patient groups are summarized as follows: Very interesting project for movement coordination. Interesting game and this game needs to be developed The avatar's movements should be improved. in bigger scales. Difficult but interesting. More games need to be The games are amusing, motivational and not bad at all. It made developed. me really move my legs. Based on these suggestions, our game scenarios were updated The football scene is excellent. I am a football fan to take them into consideration. Note that only technical and I watch all the games. improvement feedbacks were considered in the updated version. In particular, the order of the football game, as suggested in the I recommend you to force the player to hit the left third comment above, was redefined to adapt to the rehabilitation cone at first and then rotate towards the right cone. of spinal patients. Moreover, avatar’s movement has been This improves the efficacy of spine rehabilitation. improved by using multi-sensor fusion approach [22]. Some In my opinion this can really help patients. Even if I patients did not try the football game because they could not am not a florist! stand up on their feet. This could be an initiative to create The exercises are adapted to rehabilitation at the exercises for patients sitting on wheelchairs in the future version final stages. of our serious game system. The project is suitable for younger players. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Table 1. Patients’ responses to the football game questionnaire. Criteria Rank 1 2 3 4 5 Game: Objective/goal 1   1 2 15 Unclear (1) → Clear (5) Game: Level of difficulty 3 4 7 2 3 Low (1) → High (5) Game: Ignorance of achievement     3 2 14 Unawareness (1) → Awareness (5) Game: Environment 1   1 5 12 Unattractive (1) → Attractive (5) Game: User Interface     3 2 14 Not user-friendly (1) → User-friendly (5) Game: Beginning and end 1   1 3 14 Unclear (1) → Clear (5) Exercises: Instructions 1     1 17 Unclear (1) → Clear (5) Exercises: Variation   3 1 6 9 Low (1) → High (5) Exercises: Suitable for game goal   2 5 3 9 Low (1) → High (5) Exercises: Feedback   1 3 4 11 Unclear (1) → Clear (5) User: Motivating challenge 2 2 1 4 10 Low (1) → High (5) User: Mistake permission 6 2 7 1 3 Impossible (1) → Possible (5) User: Security feeling     3   16 Uncomfortable (1) → Comfortable (5) Total 15 14 36 32 144 and Wii Mote cameras tied in first place among motion capture Discussion tools. Serious game for functional rehabilitation has become a potential solution to improve the traditional rehabilitation Principal Findings practice [29-32]. Generally speaking, user acceptability was Serious gaming technologies target audience ranging from young high for some developed games [31]. Clinical improvements to adults to the elderly population. The objective of this work over time were also noted [30-32]. However, this new was to propose development and evaluation guidelines of serious rehabilitation scheme needs to be used with caution because of games for musculoskeletal disorders. The simplicity and some negative results. For example, Bower et al (2015) reported challenging aspect are the main advantages of this new minor increases in pain for some participants. Particular attention technology. Research studies have proposed some interesting was also noted for cognitive function and motor impairment solutions over the past decade for the “gamification” approach patients when using virtual reality rehabilitation games [31]. [23-26]. Seaborn and Fels (2015) reviewed and defined Thus, the development of rehabilitation games should be done “gamification” as the use of game elements to execute nongame in a well-controlled manner. In previous works, there is no tasks in a game-like environment [27]. In particular, available development guideline for this new rehabilitation Wattanasoontorn et al (2013) conducted a survey on serious scheme. In this study, we proposed a specific task-oriented games for health, and they showed that general health was the development guideline to create attractive, motivational, and most targeted by serious games, whereas stroke disease comes safe rehabilitation games. The experience that we got from the in second place [28]. Furthermore, the mouse was the most used case study of musculoskeletal disorders showed the usefulness interaction tool, mostly used for cognitive rehabilitation. Kinect http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al and applicability of the established task-oriented development development and evaluation processes. This study proposes guideline. Furthermore, an evaluation guideline was also useful guidelines to achieve this objective. Thus, the established to propose the common steps toward an objective development and evaluation of the 2 developed games (football and quantitative evaluation process. The case study showed the and object manipulation) followed the proposed guidelines. In applicability and usefulness of the proposed guidelines in real general, a guideline is defined as a principle to determine a set condition. It is expected that this study may contribute in the of actions in a standard way. This study aimed to propose a definition of customized guidelines for developing and coherent set of development and evaluation steps for evaluating serious games for musculoskeletal disorders. rehabilitation-oriented serious games for musculoskeletal disorders. It is expected that this proposition may help define Regarding our case study, patients’ scores were lower than those a development and evaluation consensus in the health-oriented of the healthy group. Some of them were not able to play the serious games community. It is important to note that some football scene because of their amputation. Others could not try published works already followed these guidelines [9,10,12] the object manipulation scene because they cannot move their but other works did not conduct some important steps like the hands at all. In general, all of them accepted the challenge and improvement of game from user feedback [16] or the evaluation wanted to participate in this study. Hemiplegic patients were on patients [18]. Thus, this study may serve to highlight the the top testers among all patients. Medical doctors and important steps to develop and evaluate a serious game for physiotherapists thought that these task-oriented games were musculoskeletal disorders. more adapted to this particular disorder. Previous study came to the same conclusion about the use of the task-oriented games Our developed system used the Kinect camera as motion capture for these patients [16,17]. We can see that all hemiplegic patients sensor. Currently, the virtual avatar imitates player movements were able to try at least one level of difficulty from each game, correctly. However, clinical experts require more precision in and their achieved scores depended largely on the severity of analyzing the joint behavior during the exercise. It is well known their disorder. Amputees tried our system and showed great that the accuracy of this device is limited for joint angle motivation even though they failed to achieve high scores; they estimation. A deviation range of 11° to 14° was noted for the felt the challenge even in the absence of any achievement. knee joint motion [8,33]. To overcome this drawback, a fusion Moreover, the Kinect had some difficulty recognizing the shape process between the Kinect and inertial sensors, placed on the of their body, which might influence the virtual avatar’s part of the body where experts require more precision, was behavior. Overall, patients’ results depend on the state of each investigated in another work to achieve a better estimation of patient. Moreover, even though the difficulty of the games joint angles [22]. However, the use of only Kinect camera leads increased, some patients and healthy subjects achieved higher to the feasible and potential translation of such a rehabilitation scores even at the hard level of difficulty. This might be game into clinical routine practice, especially in a home-based explained by the fact that the designed games stimulated the setting thanks to the low cost and portable nature of this specific user motivation. Thus, they felt the challenge to perform better device. More complex sensors need to be optimized before they when they got familiar with the game. However, more are used in a clinical setting. In particular, within the context quantitative measurements on user’s motivation need to be of a “game,” the precision may be sacrificed for the portability performed to confirm this finding. Moreover, the increasing and ease-of-use criteria. scores occurred for the favorite game for each patient. Thus, Limitations the choice of the game scenario for the profile of each patient The main limitation of the 2 developed games is the lack of may potentially enhance the achieved scores. evident cognitive actions, which could maximize the effect of The design of rehabilitation game scenarios plays a crucial role game outcomes to better manage the functional rehabilitation in the success of the serious game for health. The game scenario of musculoskeletal disorders with cognitive impairment [34,35]. must not only be attractive but also needs to be clinically useful. Thus, a new rehabilitation game will be investigated to integrate In this study, a task-oriented rehabilitation game scenario was clear cognitive aspects into the game scenario. Thus, cognitive proposed. The football and object manipulation games respond actions may help detect visuo-spatial memory and propose an to the challenging objective: patient practices rehabilitation appropriate rehabilitation program [36]. Moreover, the exercises without recognizing that it is a rehabilitation exercise evaluation of the effectiveness of these serious games will be when playing the game. Thus, the football game allows the performed during a long-term campaign to confirm their clinical player to practice the two motor tasks (body rotation motion relevance. Finally, in this study, the user questionnaire was and the leg motion) and two decision-making actions based on the one defined previously [8]. This questionnaire (observation of time and identification of right moment). The covers many aspects including the game, the exercise, and the object manipulation game allows the player to practice two user. However, the user engagement aspect is still simple in the motor tasks (leg and arm motion) and two decision-making used questionnaire. Thus, the use of a validated questionnaire actions (localization of rose or vase, and observation of time). that focuses more on the user aspects to analyze the game This study suggests that rehabilitation game scenarios should engagement will be performed in the future [37]. be designed, implemented, and evaluated with similar strategies. In summary, this study is an explanatory work aiming to show The outcome of the case study confirmed the robustness and the usefulness and applicability of the proposed guidelines and effectiveness of this strategy. associated serious games for functional rehabilitation of The design of a motivating, challenging, and safe serious games musculoskeletal disorders. However, more investigations such for functional rehabilitation requires particular attention on the http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al as a long-term evaluation campaign for effectiveness analysis environment scenes (football and object manipulation). Healthy and a more quantitative analysis on the user‘s engagement in subjects and patients enjoyed the games and found them the games are needed to fully validate these guidelines [38]. challenging and amusing. In this work, we concentrated on the assessment data of the developed games. In perspective, the Conclusions effectiveness and clinical relevance of these games will be Development and evaluation guidelines dedicated to serious studied through a long-term evaluation campaign. And, in the games for health were established in this study. The case study case of positive outcomes, this new rehabilitation game may be showed the effectiveness and usefulness of these guidelines and translated into clinical routine practice in the near future for the associated games. The developed serious game system used the benefit of patients with musculoskeletal disorders. Kinect camera to allow users to interact with two 3D Acknowledgments This work was funded within the framework of EBIOMED Chair–IUIS (Institut Universitaire d’Ingénierie en Santé). This work was carried out in the framework of the Labex MS2T, which is funded by the French Government. The authors would like to thank F Chaouche and E Kleinpeter for their useful comments and help on the questionnaire development. Conflicts of Interest None declared. References 1. Aroui H, Merchaoui I, Adnène HM, Rassas I, Belhadj N, Chaari N, et al. Musculoskeletal disorders of the hand and wrist and population attributable fraction of risk of exposure to biomechanical constraints. Ann Phys Rehabil Med 2016 Sep;59S:e113-e114. [doi: 10.1016/j.rehab.2016.07.255] [Medline: 27676734] 2. Cox J, Varatharajan S, Côté P. Effectiveness of acupuncture therapies to manage musculoskeletal disorders of the extremities: a systematic review. J Orthop Sports Phys Ther 2016 Jun;46(6):409-429. [doi: 10.2519/jospt.2016.6270] 3. Chen CM, Yang YH, Chang CH, Chen CC, Chen PC. The utilization of rehabilitation in patients with hemophilia A in Taiwan: a nationwide population-based study. PLoS ONE 2016 Sep 30;11(9):e0164009. [doi: 10.1371/journal.pone.0164009] 4. Serra MV, Camargo PR, Zaia JE, Tonello MG, Quemelo PR. Effects of physical exercise on musculoskeletal disorders, stress and quality of life in workers. Int J Occup Saf Ergon 2016 Oct 06:1-6 Epub ahead of print. [doi: 10.1080/10803548.2016.1234132] [Medline: 27690286] 5. Amado I, Brénugat-Herné L, Orriols E, Desombre C, Dos Santos M, Prost Z, et al. A Serious Game to Improve Cognitive Functions in Schizophrenia: A Pilot Study. Front Psychiatry 2016 Apr 20;7:64. [doi: 10.3389/fpsyt.2016.00064] [Medline: 27148093] 6. Levac D, Nawrotek J, Deschenes E, Giguere T, Serafin J, Bilodeau M, et al. Development and reliability evaluation of the movement rating instrument for virtual reality video game play. JMIR Serious Games 2016 Jun 01;4(1):e9. [doi: 10.2196/games.5528] [Medline: 27251029] 7. Tannous H, Istrate D, Ho Ba Tho MC, Dao TT. Serious game and functional rehabilitation for the lower limbs. European Research in Telemedicine / La Recherche Européenne en Télémédecine 2016 Jun;5(2):65-69. [doi: 10.1016/j.eurtel.2016.05.001] 8. Tannous H, Istrate D, Ho Ba Tho MC, Dao TT. Feasibility study of a serious game based on Kinect system for functional rehabilitation of the lower limbs. European Research in Telemedicine / La Recherche Européenne en Télémédecine 2016 Sep;5(3):97-104. [doi: 10.1016/j.eurtel.2016.05.004] 9. Chen PY, Wei SH, Hsieh WL, Cheen JR, Chen LK, Kao CL. Lower limb power rehabilitation (LLPR) using interactive video game for improvement of balance function in older people. Arch Gerontol Geriatr 2012 Nov;55(3):677-682. [doi: 10.1016/j.archger.2012.05.012] 10. Sun TL, Lee CH. An Impact study of the design of exergaming parameters on body intensity from objective and gameplay-based player experience perspectives, based on balance training exergame. PLoS ONE 2013 Jul 26;8(7):e69471. [doi: 10.1371/journal.pone.0069471] 11. Chatzitofis A, Monaghan D, Mitchell E, Honohan F, Zarpalas D, O’Connor NE, et al. HeartHealth: a cardiovascular disease home-based rehabilitation system. Procedia Comput Sci 2015;63:340-347. [doi: 10.1016/j.procs.2015.08.352] 12. Lozano-Quilis JA, Gil-Gómez H, Gil-Gómez JA, Albiol-Pérez S, Palacios-Navarro G, Fardoun HM, et al. Virtual rehabilitation for multiple sclerosis using a kinect-based system: randomized controlled trial. JMIR Serious Games 2014 Nov 12;2(2):e12. [doi: 10.2196/games.2933] 13. Yu W, Vuong C, Ingalls T. An interactive multimedia system for Parkinson's patient rehabilitation. Lecture Notes in Computer Science 2011 Jul;6774:129-137. 14. Assad O, Hermann R, Lilla D, Mellies B, Meyer R, Shevach L, et al. Motion-based games for Parkinson's disease patients. Lecture Notes in Computer Science 2011 Oct;6972:47-58. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al 15. Paraskevopoulos IT, Tsekleves E, Craig C, Whyatt C, Cosmas J. Design guidelines for developing customised serious games for Parkinson’s disease rehabilitation using bespoke game sensors. Entertain Comput 2014 Dec;5(4):413-424. [doi: 10.1016/j.entcom.2014.10.006] 16. Cho S, Ku J, Cho YK, Kim IY, Kang YJ, Jang DP, et al. Development of virtual reality proprioceptive rehabilitation system for stroke patients. Comput Methods Programs Biomed 2014 Jan;113(1):258-265. [doi: 10.1016/j.cmpb.2013.09.006] 17. Ding Q, Stevenson IH, Wang N, Li W, Sun Y, Wang Q, et al. Motion games improve balance control in stroke survivors: a preliminary study based on the principle of constraint-induced movement therapy. Displays 2013 Apr;34(2):125-131. [doi: 10.1016/j.displa.2012.08.004] 18. Ibarra Zannatha JM, Tamayo AJ, Sánchez AD, Delgado JE, Cheu LE, Arévalo WA. Development of a system based on 3D vision, interactive virtual environments, ergonometric signals and a humanoid for stroke rehabilitation. Comput Methods Programs Biomed 2013 Nov;112(2):239-249. [doi: 10.1016/j.cmpb.2013.04.021] 19. Wu B, Wang AI. A guideline for game development-based learning: a literature review. IJCGT 2012;2012:1-20. [doi: 10.1155/2012/103710] 20. Nilsen P. Making sense of implementation theories, models and frameworks. Implementation Sci 2015 Apr 21;10(1):10. [doi: 10.1186/s13012-015-0242-0] 21. Dao TT, Tannous H, Pouletaut P, Gamet D, Istrate D, Ho Ba Tho MC. Interactive and connected rehabilitation systems for e-Health. IRBM 2016 Nov;37(5-6):289-296. [doi: 10.1016/j.irbm.2016.02.003] 22. Tannous H, Istrate D, Benlarbi-Delai A, Sarrazin J, Gamet D, Ho Ba Tho MC, et al. A new multi-sensor fusion scheme to improve the accuracy of knee flexion kinematics for functional rehabilitation movements. Sensors 2016 Nov 15;16(11):1914. [doi: 10.3390/s16111914] 23. Fleming TM, Bavin L, Stasiak K, Hermansson-Webb E, Merry SN, Cheek C, et al. Serious games and gamification for mental health: current status and promising directions. Front Psychiatry 2017 Jan 10;7:215. [doi: 10.3389/fpsyt.2016.00215] 24. Lumsden J, Edwards EA, Lawrence NS, Coyle D, Munafò MR. Gamification of cognitive assessment and cognitive training: a systematic review of applications and efficacy. JMIR Serious Games 2016 Jul 15;4(2):e11. [doi: 10.2196/games.5888] 25. McCallum S. Gamification and serious games for personalized health. Stud Health Technol Inform 2012;177:85-96. [Medline: 22942036] 26. Anderson J, Rainie L. Gamification and the internet: experts expect game layers to expand in the future, with positive and negative results. Games Health J 2012 Aug;1(4):299-302. [doi: 10.1089/g4h.2012.0027] 27. Seaborn K, Fels DI. Gamification in theory and action: A survey. Int J Hum Comput Stud 2015 Feb;74:14-31. [doi: 10.1016/j.ijhcs.2014.09.006] 28. Wattanasoontorn V, Boada I, García R, Sbert M. Serious games for health. Entertain Comput 2013 Dec;4(4):231-247. [doi: 10.1016/j.entcom.2013.09.002] 29. Labruyère R, Gerber CN, Birrer-Brütsch K, Meyer-Heim A, van Hedel HJ. Requirements for and impact of a serious game for neuro-pediatric robot-assisted gait training. Res Dev Disabil 2013 Nov;34(11):3906-3915. [doi: 10.1016/j.ridd.2013.07.031] [Medline: 24025439] 30. Jaume-i-Capó A, Martínez-Bueso P, Moyà-Alcover B, Varona J. Interactive rehabilitation system for improvement of balance therapies in people with cerebral palsy. IEEE Trans Neural Syst Rehabil Eng 2014 Mar;22(2):419-427. [doi: 10.1109/TNSRE.2013.2279155] [Medline: 24122561] 31. Bower K, Louie J, Landesrocha Y, Seedy P, Gorelik A, Bernhardt J. Clinical feasibility of interactive motion-controlled games for stroke rehabilitation. J NeuroEngineering Rehabil 2015 Aug 2;12(1):12. [doi: 10.1186/s12984-015-0057-x] 32. Soares AV, Borges Júnior NG, Hounsell MS, Marcelino E, Rossito GM, Sagawa Júnior Y. A serious game developed for physical rehabilitation of frail elderly. European Research in Telemedicine / La Recherche Européenne en Télémédecine 2016 Jun;5(2):45-53. [doi: 10.1016/j.eurtel.2016.05.003] 33. Bonnechère B, Jansen B, Salvia P, Bouzahouene H, Omelina L, Moiseev F, et al. Validity and reliability of the kinect within functional assessment activities: comparison with standard stereophotogrammetry. Gait Posture 2014 Jan;39(1):593-598. [doi: 10.1016/j.gaitpost.2013.09.018] 34. Manera V, Petit PD, Derreumaux A, Orvieto I, Romagnoli M, Lyttle G, et al. 'Kitchen and cooking,' a serious game for mild cognitive impairment and Alzheimer's disease: a pilot study. Front Aging Neurosci 2015 Mar;7:24 [FREE Full text] [doi: 10.3389/fnagi.2015.00024] [Medline: 25852542] 35. Lumsden J, Edwards EA, Lawrence NS, Coyle D, Munafò MR. Gamification of cognitive assessment and cognitive training: a systematic review of applications and efficacy. JMIR Serious Games 2016 Jul 15;4(2):e11. [doi: 10.2196/games.5888] 36. Perrochon A, Kemoun G, Dugué B, Berthoz A. Cognitive impairment detection of visuo-spatial memory using a modified walking Corsi test with the « magic carpet ». Dement Geriatr Cogn Disord Extra 2014;4:1-13. [doi: 10.1159/000356727] 37. Brockmyer JH, Fox CM, Curtiss KA, McBroom E, Burkhart KM, Pidruzny JN. The development of the game engagement questionnaire: a measure of engagement in video game-playing. J Exp Soc Psychol 2009 Jul;45(4):624-634. [doi: 10.1016/j.jesp.2009.02.016] 38. Cook DA, Bordage G, Schmidt HG. Description, justification, and clarification: a framework for classifying the purposes of research in medical education. Med Educ 2008;42(2):128-133. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Abbreviations 3D: three-dimensional EMG: electromyography GUI: graphical user interface ICT: information and communication technology SD: standard deviation Edited by A McDougall; submitted 09.01.17; peer-reviewed by T Chang, D Rojas; comments to author 24.02.17; revised version received 28.02.17; accepted 04.04.17; published 04.07.17 Please cite as: Idriss M, Tannous H, Istrate D, Perrochon A, Salle JY, Ho Ba Tho MC, Dao TT JMIR Serious Games 2017;5(3):e14 URL: http://games.jmir.org/2017/3/e14/ doi: 10.2196/games.7284 PMID: 28676468 ©Mohamad Idriss, Halim Tannous, Dan Istrate, Anaick Perrochon, Jean-Yves Salle, Marie-Christine Ho Ba Tho, Tien-Tuan Dao. Originally published in JMIR Serious Games (http://games.jmir.org), 04.07.2017. 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 http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 15 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

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

Download PDF
15 pages

Loading next page...
 
/lp/jmir-publications/rehabilitation-oriented-serious-game-development-and-evaluation-Ws5W3VkWF1
Publisher
JMIR Publications
Copyright
Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
ISSN
2291-9279
DOI
10.2196/games.7284
Publisher site
See Article on Publisher Site

Abstract

Background: The progress in information and communication technology (ICT) led to the development of a new rehabilitation technique called “serious game for functional rehabilitation.” Previous works have shown that serious games can be used for general health and specific disease management. However, there is still lack of consensus on development and evaluation guidelines. It is important to note that the game performance depends on the designed scenario. Objective: The objective of this work was to develop specific game scenarios and evaluate them with a panel of musculoskeletal patients to propose game development and evaluation guidelines. Methods: A two-stage workflow was proposed using determinant framework. The development guideline includes the selection of three-dimensional (3D) computer graphics technologies and tools, the modeling of physical aspects, the design of rehabilitation scenarios, and the implementation of the proposed scenarios. The evaluation guideline consists of the definition of evaluation metrics, the execution of the evaluation campaign, the analysis of user results and feedbacks, and the improvement of the designed game. Results: The case study for musculoskeletal disorders on the healthy control and patient groups showed the usefulness of these guidelines and associated games. All participants enjoyed the 2 developed games (football and object manipulation), and found them challenging and amusing. In particular, some healthy subjects increased their score when enhancing the level of difficulty. Furthermore, there were no risks and accidents associated with the execution of these games. Conclusions: It is expected that with the proven effectiveness of the proposed guidelines and associated games, this new rehabilitation game may be translated into clinical routine practice for the benefit of patients with musculoskeletal disorders. (JMIR Serious Games 2017;5(3):e14) doi: 10.2196/games.7284 KEYWORDS rehabilitation exercise; virtual rehabilitation; rehabilitation; user computer interface; musculoskeletal diseases well-being of the involved people [1,2]. Age-related Introduction deficiencies, sport and transport accidents, and genetic conditions are the main sources of these disorders. In the United Context States, billions of dollars have been spent for treatment and Musculoskeletal disorders lead to high medical costs all over patient management. In Europe, the ageing effect of the the world. These disorders affect the working performance and population requires significant efforts for medical experts and http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al infrastructures. Research studies have been performed to provide to reach and step as far and as fast as possible. Patients are better diagnosis and treatment of these disorders. Among the required to execute repetitive and variable tasks in order to learn most common routine practices, functional rehabilitation plays new movement patterns and to perform the transition from one a key role in the recovery of mechanical functions of the human movement to another by performing mixed and multiple tasks. body. This specific treatment helps recover the functionality of A virtual avatar is shown on the screen that mimics the patient’s the musculoskeletal system by improving the ranges of motion movements. However, the system was never tested on Parkinson as well as the muscle strengths. Current physical therapy disease patients. Assad et al (2011) also investigated the use of programs are performed by patients and supervised by medical serious games for Parkinson disease patients, and they doctors over a long period of time in hospitals or clinics [3,4]. implemented a series of games that use the Sony PlayStation This traditional rehabilitation scheme requires permanent EyeToy as a motion capture tool [14]. Four different Parkinson involvement of different medical actors (eg, physiotherapists disease adapted games were developed and tested by 13 and medical doctors) during the program, leading to a high cost Parkinson disease patients. The system was rated using a for medical human resources. Moreover, due to the repetitive questionnaire completed by the patients after performing the nature of the rehabilitation exercises, the motivation of the exercises. This study concluded that the patients enjoyed the patient decreases rapidly during the execution of the program. exercises. Paraskevopoulos et al (2014) developed serious games Recently, the progress in information and communication adapted to Parkinson disease patients [15]. They defined a technology (ICT) led to the development of a new rehabilitation guideline to successfully design serious games adapted to scheme called “serious game for functional rehabilitation” [5-7]. Parkinson disease through a detailed literature review of related In fact, the coupling of the game technologies and functional works, and developed 2 games using the Wii Mote and the rehabilitation allows a better interaction between patient and Kinect camera. They tested the games on 5 Parkinson disease the rehabilitation program [8]. Moreover, the use of serious patients and concluded that serious games have the potential to game scenarios may be a potential solution to improve the increase the level of engagement for such patients. patient’s motivation in future rehabilitation sessions. Another rehabilitation field that has been studied is stroke rehabilitation. Cho et al (2014) developed a proprioception State of the Art rehabilitation system for stroke patients [16]. The user moves Some research studies focused on games that could improve a connected cylinder to interact with the game. The objective general health for adults and elders. Chen et al (2012) developed was to hold the connected cylinder under a table to move the a lower limb power rehabilitation system. Each user needs to virtual cylinder from an initial position to a destination position. execute a squat motion, with sufficient power, to correctly build The study was tested with 10 healthy subjects and 10 stroke a virtual tower made of blocks [9]. The system was tested with patients and showed significant improvement in patients. 20 participants, whereas 20 control participants executed normal However, this improvement might have been attributed to exercises for 6 weeks. The results showed that the participants patients becoming accustomed to the game. Another system using the developed system achieved greater improvements in used a commercial Wii Fit game and 2 Wii balance boards to power and velocity of movement. Sun et al (2013) presented a adapt the games to stroke survivors [17]. Each balance board balance rehabilitation system using Kinect and a force plate captures the center of pressure of the leg. The weak leg’s signal [10]. The objective of this game was to fit an avatar in a specific is multiplied by a higher weight than the healthy leg’s signal frame indicated on the screen, while standing on the force plate. so that the patient applies more load on the weak leg. The system In total, 23 healthy subjects tested this system, but the results was tested on 3 stroke survivors (2 participants and 1 control) showed that different evaluation methods could lead to different and showed that after 7 to 12 sessions, the patients began to interpretation of the player experience. Chatzitofis et al (2015) rely more on their weak legs and began to tend to normal load [11] implemented a home-based rehabilitation system for cardio ratios observed in healthy subjects. Ibarra Zannatha et al (2013) vascular diseases using Kinect and body worn inertial sensors. also developed a serious for game stroke rehabilitation using The users need to start the game by warming up, and then they the Kinect camera, electromyography (EMG) sensors, and a need to execute the assigned movement. Visual feedback is humanoid robot [18]. The system consists of 4 games for the generated on the screen to help the user to optimize the upper limbs. This system was not tested on stroke patients. movement. The system was evaluated with 6 patients. Finally, Lozano-Quilis et al (2014) [12] implemented an augmented Literature showed that serious games have been intensively reality system for multiple sclerosis using the Kinect. The developed for general health and specific disease management. system is called RemoviEM and includes 3 game exercises One of the most important aspects of serious games is the game (TouchBall, TakeBall, and StepBall). In total, 11 patients tested playing scenario to motivate the patient. Moreover, user the ability of the system to encourage players to perform acceptability also plays an important role in promoting this new exercises. The results were collected through a questionnaire technology to clinical practice. Finally, the user security aspect and showed that patients accepted the system and felt safe and needs particular attention to avoid new clinical complications secure while playing. for patients. Different game systems have been developed and tested. There is still lack of development and evaluation Parkinson disease has been a subject of interest among serious consensus guidelines to achieve these important aspects. It is game projects. Yu et al (2011) [13] developed a real-time important to note that the game performance depends on the Parkinson mediated rehabilitation environment. They designed scenario. Some authors have attempted to propose implemented a system applied in a clinical space to treat specific guidelines for game development-based learning [19] Parkinson disease symptoms by improving the patient’s ability http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al or for Parkinson disease rehabilitation [15]. However, the proposed scenario. This workflow aims to design fun but methodologies and best practices related to the development of useful game scenarios to motivate end users to perform customized serious games for musculoskeletal disorders to functional rehabilitation tasks. The evaluation guideline consists recover complex joint and muscle functions are still lacking. of the definition of the evaluation metrics, the execution of the Thus, the objective of this work was to develop specific game evaluation campaign, the analysis of user results and feedbacks, scenarios and to evaluate them with a panel of musculoskeletal and the improvement of the designed game. Finally, the patients, to propose game development and evaluation improved game is reevaluated in a closed-loop technique. This guidelines. In particular, specific games for the functional user-centered game design approach allows different users (eg, rehabilitation of musculoskeletal disorders were developed and patients and medical experts) to participate actively in the design evaluated using the proposed approach. Hence, the usefulness and evaluation stages. Note that the second workflow focuses of the developed games was quantified. Discussion on the on the evaluation of user acceptability and security aspects when usefulness of the proposed guidelines according to the literature using this new technology. The development of these guidelines was also provided. was performed using determinant framework [20]. This theoretical approach has been commonly used to determine Methods what important factors influence implementation outcomes. Thus, eight determinants (3D computer graphics technologies, Development of Serious Games physics modeling, scenario design, implementation, evaluation metrics definition, evaluation campaign, user result and feedback The development of serious games for functional rehabilitation analysis, and game improvement) were hypothesized to of musculoskeletal disorders is a complex engineering task. To influence the implementation outcomes of the development and deal with such complexity, a two-stage workflow was proposed. evaluation of rehabilitation-oriented serious games. In fact, The first workflow relates to the development guideline (Figure these components aim to cover necessary methodologies and 1), whereas the second workflow concerns the evaluation best practices for developing customized serious games for guideline (Figure 2). The development workflow includes the musculoskeletal disorders and evaluating them. The choice of selection of three-dimensional (3D) computer graphics these components is based on our experiences gained from technologies and tools, the modeling of physical aspects, the literature analysis and also from our preliminary studies on design of rehabilitation scenarios, and the implementation of functional rehabilitation using serious game technologies [7,8]. Figure 1. Rehabilitation-oriented serious game: development guideline. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 2. Rehabilitation-oriented serious game: evaluation guideline. during the motion [21]. Game environments and interaction Case Study for Musculoskeletal Disorders objects were also designed and implemented using Blender design software. Rehabilitation-Oriented Serious Game: Development Guideline Games with 3D interactive objects need to establish interaction rules between them. An algorithm was designed and This subsection describes the work done using a proposed implemented to detect collisions between objects within the development guideline for creating specific serious games for scene. The challenge was to find a way to differentiate between functional rehabilitation of musculoskeletal disorders. the detection between different avatar bones and 3D objects; Three-Dimensional (3D) Computer Graphics Technologies therefore, we created spheres around each bone of the body and Tools (Figure 3. Note that the radius and positions of these spheres The selection of available computer graphics technologies and are adjustable to a specific subject body. The assessment of the tools plays a crucial role in the success of the rehabilitation collisions is done by calculating the distance between the spheres game. To ensure a user-friendly, human-system interaction, of objects and bones (Figure 3). cutting-edge technologies benefiting the most recent progress Let S be a sphere with a 3D center C (C , C , C ) and a 1 1 1x 1y 1z of ICT solutions need to be used. In this study, open source radius r , and S another sphere with center C (C , C , C ) Blender design software (Neo Geo) was selected for human 1 2 2 2x 2y 2z body modeling. XNA Game Studio (Microsoft) was selected and radius r . The distance between the 2 centers of the 2 spheres as game engine. Microsoft Kinect camera was selected as human is d drawn in Figure 3 and is computed using the following motion capture tool. Computer screen was used as equation: human-system interface. The pertinence of these technological 2 2 2 1/2 d=[(C -C ) +(C -C ) +(C -C ) ] choices has been proven in our previous studies [7-8,21]. 1x 2x 1y 2y 1z 2z This distance is computed between every 2 objects at each Physics Modeling updated iteration during the game. If d is found to be less than A 3D avatar model was developed using Blender design the sum of the 2 radiuses r and r , a collision is detected, and 1 2 software to represent the human body. This is a 3D surface mesh the game reacts to it by a certain preprogramed reaction. model including a collection of vertices, edges, and faces that defines the external shape of the human body. Moreover, an Scenario Design internal skeleton structure was also created to define body Two task-oriented game scenarios (football and object segments (eg, thigh and leg) and their interaction (eg, joint) manipulation) were designed and implemented. The football http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al game aims at practicing body orientation and lower limb since the patient has to kick the ball. It is noted that a soccer motions, allowing the rehabilitation of spinal and lower limb stadium was designed for this specific rehabilitation game. systems. The object manipulation aims to practice the upper Object Manipulation Game limb and lower limb motions with a focus on the detailed hand In this scene, the user needs to take a flower from the given skill. The description of each game is given in the following vase and put it in the other one (Figure 4). They repeat the same paragraphs. actions from right to left until the game-time expires. Three Football Game levels of difficulty (easy, medium, and hard) are defined. In the This game requires the player to execute many consecutive first level, the virtual avatar is fixed between 2 tables and can gestures. First, players have to stand in front of the Kinect and only move their hands. In particular, the player is rewarded 4 the computer screen. Then, they need to target the left or right points for a combination of 3 successive gestures: take the cones by pivoting their body (Figure 4). Once the target is flower with the first hand from the first vase, switch the flower reached, the player has to verify that the pointer in the bottom to the second hand, and put the flower in the second vase. The right corner of the screen is in the green zone. If the pointer is second level of this game requires the player to move left and green, they kick the ball to hit the cone and score one point. right while a certain distance separates the tables. Therefore, Otherwise, if they kick while the pointer is red, the ball will players have to move one step left and then get the flower. They miss. When the cone is hit, the user needs to pivot back to the switch it to the other hand and then move one step to the right original position to get another ball. A point is awarded for in order to put the flower in the other vase. Finally, the third every cone hit. We developed three levels of difficulty because level of difficulty is similar to the second one but the challenge patients playing the game might be in different phases of their is to put the flower in the other vase before the expiration of a rehabilitation. Using the different developed levels, experts can timer that appears on the bottom of the screen. This game targets configure the difficulty of the exercises to be executed by their several parts of the body. The upper limbs are targeted in all patients according to the rehabilitation progress. In the easy the levels, whereas the lower limbs are targeted only by the level, the cones are big and the green or red pointer is slow. The second and third levels. Moreover, the third level targets lower medium level decreases the size of the cones. Finally, to make limb movement speed recovery, since the timer would force the it harder, the pointer will move faster on the hard level. Experts users to move quicker. It is noted that a surrounding living room can also define the duration for each exercise, which gives them was designed for this specific rehabilitation game. more control over the rehabilitation program. This game aims Implementation at the rehabilitation of several parts of the body. It targets Visual Studio.Net, with C# programming language, was adopted balance, since the users rotate to target a cone. In addition, it for image acquisition and processing, body tracking, object includes a decision-making action, since players have to verify manipulation, as well as for the development of graphical user the pointer position. Finally, the lower limbs are also affected, interfaces (GUIs). Figure 3. Illustrations of the association of collision spheres to avatar bones (a) and object collision detection principle (b). http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 4. Football game (easy level) (a) and object manipulation game (hard level) (b). level of difficulty of each game, which means a total of 6 trials Rehabilitation-Oriented Serious Game: Evaluation per subject. Some patients were not able to try all levels or even Guideline one of the two games due to the severity of their state This part presents the work done, as well as outcomes issued (amputation, leg prosthesis, and paralyses). Medical experts from the application of the proposed evaluation guideline for were given the decision to accept or decline the participation assessing the developed games. of their patient in a game or a level of a certain game. Therapists accompanied their patients by standing behind them and Definition of Evaluation Metrics supporting them, to ensure their security. The duration of each The game-playing performance was evaluated by the points game level was around 60 seconds. A rest time of around 2 min acquired at the end of each scenario. For the usage acceptability was also allowed for each participant when necessary (ie, aspect of the designed games, a questionnaire was defined. At recovery from fatigue) after each game execution. The total the end of each game scene, players were required to fill out a time of the test for one subject was equal to 20 min questionnaire. The questionnaire consists of 13 questions for approximately. each specific game scenario. The feedback focuses on the game, exercise, and user aspect. For the game, the objective, the level Results of difficulty, the ignorance of achievement, the attractiveness of the 3D environment and GUI, and the game management User Result and Feedback Analysis (begin, end) were investigates. For the exercise, the game For the control group, the scores did not change so much when instructions, the variation of scenarios, the suitability of the increasing the level of difficulty for the football scenario game to the goal, and the clearness of the feedback were (Figures 5-7). The mean and SD scores of the easy, medium, examined. For the user, the motivating challenge, the possibility and hard levels were 8.5 (SD 1.8), 8.5 (SD 2.2), and 8.5 (SD to make mistakes, and the security feeling were investigated. 2.7), respectively. Maximal scores were 11, 12, and 13 for the easy, medium, and hard levels of difficulty, respectively. Note Evaluation Campaign that when a score is achieved, this means that the player finished The developed game scenarios were evaluated by a normal a game with all requirements. Statistical test (t-test, implemented healthy group (10 subjects: 6 males and 4 females with a mean in Matlab R2010b software [The MathWorks Inc.]) showed no age of 26.8 [standard deviation, SD 5.65]), to ensure the security significant difference. In particular, some subjects (ID4 or ID6) condition, and then evaluated by a population of 20 pathological increased their score when enhancing the level of difficulty. subjects (13 males and 7 females with a mean age of 49.75 [SD According to the healthy control group, the performance of the 18.68]) at the “Centre Hospitalier Universitaire de Limoges” pathological population was significantly (t-test, P<.005) lower (France). The patient group included different musculoskeletal for all levels of difficulty (Figures 5-7). The mean and SD scores disorders (3 amputee patients, 8 hemiplegia patients, 1 hereditary of the easy, medium, and hard levels were 2.7 (SD 1.3), 2.5 (SD spastic paraplegia patient, 1 patient with ankle arthrodesis, 1 1.7), and 3.9 (SD 1.8), respectively. Maximal scores were 6, 6, stroke patient, 1 patient with shoulder capsulitis, 1 patient with and 7 for the easy, medium, and hard levels of difficulty, low back pain, 1 patient with carpal tunnel, 1 patient with respectively. In particular, some patients (ID17 or ID24) prosthesis, 1 patient with muscle disease, and 1 patient with increased their score when enhancing the level of difficulty. walking difficulty due to a car accident). Each participant signed However, the number of the patients able to perform on harder an informed consent agreement before playing the rehabilitation levels was reduced from 19 patients for easy level to 8 patients games. It is important to note that the execution of rehabilitation for the hard level. serious game was monitored by clinicians, to ensure the ability and the security of the patients when using this new Regarding the object manipulation game, the same results were rehabilitation tool. Each healthy subject was asked to play every noted (Figures 8-10). The normal population showed mean and http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al SD scores of 51.6 (SD 13.3), 59.2 (SD 14), and 60.4 (SD 25) Regarding the user acceptability of the evaluated games, all for the easy, medium, and hard levels, respectively. Maximal healthy subjects found the 2 developed games motivational, scores were 72, 88, and 116 for the easy, medium, and hard attractive, and challenging. A synthesis of the patients’ responses levels of difficulty, respectively. The pathological population to the football game questionnaire is depicted in Table 1. showed mean and SD scores of 22.8 (SD 12.3), 22 (SD 12.2), Moreover, they enjoyed all the levels of difficulty. Note that and 25.3 (SD 21.7) for the easy, medium, and hard levels, the answers about the accuracy of the human movements’ respectively. Maximal scores were 52, 44, and 68 for the easy, detection varied. That can be interpreted by the limitations of medium, and hard levels of difficulty, respectively. Thus, the the Kinect due to occlusion of limbs, which could affect the performance of the pathological population was significantly accuracy of movement detection. Most of the participants (t-test, P<.05) lower than that of the normal population. The assumed that they were comfortable with the system, whereas number of the patients able to perform harder levels was also some patients, having balance disorders, worried about some reduced from 17 patients for the easy level to 5 patients for the levels of difficulty. Finally, there were no risks and accidents hard level. associated with the execution of these 2 games not only for the normal population but also for the pathological population. For the responses to the questionnaires, 29 users (patients and healthy subjects) rated the football game, and 27 rated the object manipulation game. Figure 5. Game performance: patient group vs. healthy control group: easy level of the football scenario. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 6. Game performance: patient group vs. healthy control group: medium level of the football scenario. Figure 7. Game performance: patient group vs. healthy control group: hard level of the football scenario. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 8. Game performance: patient group vs. healthy control group: easy level of the object manipulation scenario. Figure 9. Game performance: patient group vs. healthy control group: medium level of the object manipulation scenario. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Figure 10. Game performance: patient group vs. healthy control group: hard level of the object manipulation scenario. The project is very fun, helps in performing Game Improvement rehabilitation while enjoying it. It should please young Finally, players were asked to give some specific comments on and old people. this project and the developed games. Comments and Very attractive games. suggestions from the patient groups are summarized as follows: Very interesting project for movement coordination. Interesting game and this game needs to be developed The avatar's movements should be improved. in bigger scales. Difficult but interesting. More games need to be The games are amusing, motivational and not bad at all. It made developed. me really move my legs. Based on these suggestions, our game scenarios were updated The football scene is excellent. I am a football fan to take them into consideration. Note that only technical and I watch all the games. improvement feedbacks were considered in the updated version. In particular, the order of the football game, as suggested in the I recommend you to force the player to hit the left third comment above, was redefined to adapt to the rehabilitation cone at first and then rotate towards the right cone. of spinal patients. Moreover, avatar’s movement has been This improves the efficacy of spine rehabilitation. improved by using multi-sensor fusion approach [22]. Some In my opinion this can really help patients. Even if I patients did not try the football game because they could not am not a florist! stand up on their feet. This could be an initiative to create The exercises are adapted to rehabilitation at the exercises for patients sitting on wheelchairs in the future version final stages. of our serious game system. The project is suitable for younger players. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Table 1. Patients’ responses to the football game questionnaire. Criteria Rank 1 2 3 4 5 Game: Objective/goal 1   1 2 15 Unclear (1) → Clear (5) Game: Level of difficulty 3 4 7 2 3 Low (1) → High (5) Game: Ignorance of achievement     3 2 14 Unawareness (1) → Awareness (5) Game: Environment 1   1 5 12 Unattractive (1) → Attractive (5) Game: User Interface     3 2 14 Not user-friendly (1) → User-friendly (5) Game: Beginning and end 1   1 3 14 Unclear (1) → Clear (5) Exercises: Instructions 1     1 17 Unclear (1) → Clear (5) Exercises: Variation   3 1 6 9 Low (1) → High (5) Exercises: Suitable for game goal   2 5 3 9 Low (1) → High (5) Exercises: Feedback   1 3 4 11 Unclear (1) → Clear (5) User: Motivating challenge 2 2 1 4 10 Low (1) → High (5) User: Mistake permission 6 2 7 1 3 Impossible (1) → Possible (5) User: Security feeling     3   16 Uncomfortable (1) → Comfortable (5) Total 15 14 36 32 144 and Wii Mote cameras tied in first place among motion capture Discussion tools. Serious game for functional rehabilitation has become a potential solution to improve the traditional rehabilitation Principal Findings practice [29-32]. Generally speaking, user acceptability was Serious gaming technologies target audience ranging from young high for some developed games [31]. Clinical improvements to adults to the elderly population. The objective of this work over time were also noted [30-32]. However, this new was to propose development and evaluation guidelines of serious rehabilitation scheme needs to be used with caution because of games for musculoskeletal disorders. The simplicity and some negative results. For example, Bower et al (2015) reported challenging aspect are the main advantages of this new minor increases in pain for some participants. Particular attention technology. Research studies have proposed some interesting was also noted for cognitive function and motor impairment solutions over the past decade for the “gamification” approach patients when using virtual reality rehabilitation games [31]. [23-26]. Seaborn and Fels (2015) reviewed and defined Thus, the development of rehabilitation games should be done “gamification” as the use of game elements to execute nongame in a well-controlled manner. In previous works, there is no tasks in a game-like environment [27]. In particular, available development guideline for this new rehabilitation Wattanasoontorn et al (2013) conducted a survey on serious scheme. In this study, we proposed a specific task-oriented games for health, and they showed that general health was the development guideline to create attractive, motivational, and most targeted by serious games, whereas stroke disease comes safe rehabilitation games. The experience that we got from the in second place [28]. Furthermore, the mouse was the most used case study of musculoskeletal disorders showed the usefulness interaction tool, mostly used for cognitive rehabilitation. Kinect http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al and applicability of the established task-oriented development development and evaluation processes. This study proposes guideline. Furthermore, an evaluation guideline was also useful guidelines to achieve this objective. Thus, the established to propose the common steps toward an objective development and evaluation of the 2 developed games (football and quantitative evaluation process. The case study showed the and object manipulation) followed the proposed guidelines. In applicability and usefulness of the proposed guidelines in real general, a guideline is defined as a principle to determine a set condition. It is expected that this study may contribute in the of actions in a standard way. This study aimed to propose a definition of customized guidelines for developing and coherent set of development and evaluation steps for evaluating serious games for musculoskeletal disorders. rehabilitation-oriented serious games for musculoskeletal disorders. It is expected that this proposition may help define Regarding our case study, patients’ scores were lower than those a development and evaluation consensus in the health-oriented of the healthy group. Some of them were not able to play the serious games community. It is important to note that some football scene because of their amputation. Others could not try published works already followed these guidelines [9,10,12] the object manipulation scene because they cannot move their but other works did not conduct some important steps like the hands at all. In general, all of them accepted the challenge and improvement of game from user feedback [16] or the evaluation wanted to participate in this study. Hemiplegic patients were on patients [18]. Thus, this study may serve to highlight the the top testers among all patients. Medical doctors and important steps to develop and evaluate a serious game for physiotherapists thought that these task-oriented games were musculoskeletal disorders. more adapted to this particular disorder. Previous study came to the same conclusion about the use of the task-oriented games Our developed system used the Kinect camera as motion capture for these patients [16,17]. We can see that all hemiplegic patients sensor. Currently, the virtual avatar imitates player movements were able to try at least one level of difficulty from each game, correctly. However, clinical experts require more precision in and their achieved scores depended largely on the severity of analyzing the joint behavior during the exercise. It is well known their disorder. Amputees tried our system and showed great that the accuracy of this device is limited for joint angle motivation even though they failed to achieve high scores; they estimation. A deviation range of 11° to 14° was noted for the felt the challenge even in the absence of any achievement. knee joint motion [8,33]. To overcome this drawback, a fusion Moreover, the Kinect had some difficulty recognizing the shape process between the Kinect and inertial sensors, placed on the of their body, which might influence the virtual avatar’s part of the body where experts require more precision, was behavior. Overall, patients’ results depend on the state of each investigated in another work to achieve a better estimation of patient. Moreover, even though the difficulty of the games joint angles [22]. However, the use of only Kinect camera leads increased, some patients and healthy subjects achieved higher to the feasible and potential translation of such a rehabilitation scores even at the hard level of difficulty. This might be game into clinical routine practice, especially in a home-based explained by the fact that the designed games stimulated the setting thanks to the low cost and portable nature of this specific user motivation. Thus, they felt the challenge to perform better device. More complex sensors need to be optimized before they when they got familiar with the game. However, more are used in a clinical setting. In particular, within the context quantitative measurements on user’s motivation need to be of a “game,” the precision may be sacrificed for the portability performed to confirm this finding. Moreover, the increasing and ease-of-use criteria. scores occurred for the favorite game for each patient. Thus, Limitations the choice of the game scenario for the profile of each patient The main limitation of the 2 developed games is the lack of may potentially enhance the achieved scores. evident cognitive actions, which could maximize the effect of The design of rehabilitation game scenarios plays a crucial role game outcomes to better manage the functional rehabilitation in the success of the serious game for health. The game scenario of musculoskeletal disorders with cognitive impairment [34,35]. must not only be attractive but also needs to be clinically useful. Thus, a new rehabilitation game will be investigated to integrate In this study, a task-oriented rehabilitation game scenario was clear cognitive aspects into the game scenario. Thus, cognitive proposed. The football and object manipulation games respond actions may help detect visuo-spatial memory and propose an to the challenging objective: patient practices rehabilitation appropriate rehabilitation program [36]. Moreover, the exercises without recognizing that it is a rehabilitation exercise evaluation of the effectiveness of these serious games will be when playing the game. Thus, the football game allows the performed during a long-term campaign to confirm their clinical player to practice the two motor tasks (body rotation motion relevance. Finally, in this study, the user questionnaire was and the leg motion) and two decision-making actions based on the one defined previously [8]. This questionnaire (observation of time and identification of right moment). The covers many aspects including the game, the exercise, and the object manipulation game allows the player to practice two user. However, the user engagement aspect is still simple in the motor tasks (leg and arm motion) and two decision-making used questionnaire. Thus, the use of a validated questionnaire actions (localization of rose or vase, and observation of time). that focuses more on the user aspects to analyze the game This study suggests that rehabilitation game scenarios should engagement will be performed in the future [37]. be designed, implemented, and evaluated with similar strategies. In summary, this study is an explanatory work aiming to show The outcome of the case study confirmed the robustness and the usefulness and applicability of the proposed guidelines and effectiveness of this strategy. associated serious games for functional rehabilitation of The design of a motivating, challenging, and safe serious games musculoskeletal disorders. However, more investigations such for functional rehabilitation requires particular attention on the http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al as a long-term evaluation campaign for effectiveness analysis environment scenes (football and object manipulation). Healthy and a more quantitative analysis on the user‘s engagement in subjects and patients enjoyed the games and found them the games are needed to fully validate these guidelines [38]. challenging and amusing. In this work, we concentrated on the assessment data of the developed games. In perspective, the Conclusions effectiveness and clinical relevance of these games will be Development and evaluation guidelines dedicated to serious studied through a long-term evaluation campaign. And, in the games for health were established in this study. The case study case of positive outcomes, this new rehabilitation game may be showed the effectiveness and usefulness of these guidelines and translated into clinical routine practice in the near future for the associated games. The developed serious game system used the benefit of patients with musculoskeletal disorders. Kinect camera to allow users to interact with two 3D Acknowledgments This work was funded within the framework of EBIOMED Chair–IUIS (Institut Universitaire d’Ingénierie en Santé). This work was carried out in the framework of the Labex MS2T, which is funded by the French Government. The authors would like to thank F Chaouche and E Kleinpeter for their useful comments and help on the questionnaire development. Conflicts of Interest None declared. References 1. Aroui H, Merchaoui I, Adnène HM, Rassas I, Belhadj N, Chaari N, et al. Musculoskeletal disorders of the hand and wrist and population attributable fraction of risk of exposure to biomechanical constraints. Ann Phys Rehabil Med 2016 Sep;59S:e113-e114. [doi: 10.1016/j.rehab.2016.07.255] [Medline: 27676734] 2. Cox J, Varatharajan S, Côté P. Effectiveness of acupuncture therapies to manage musculoskeletal disorders of the extremities: a systematic review. J Orthop Sports Phys Ther 2016 Jun;46(6):409-429. [doi: 10.2519/jospt.2016.6270] 3. Chen CM, Yang YH, Chang CH, Chen CC, Chen PC. The utilization of rehabilitation in patients with hemophilia A in Taiwan: a nationwide population-based study. PLoS ONE 2016 Sep 30;11(9):e0164009. [doi: 10.1371/journal.pone.0164009] 4. Serra MV, Camargo PR, Zaia JE, Tonello MG, Quemelo PR. Effects of physical exercise on musculoskeletal disorders, stress and quality of life in workers. Int J Occup Saf Ergon 2016 Oct 06:1-6 Epub ahead of print. [doi: 10.1080/10803548.2016.1234132] [Medline: 27690286] 5. Amado I, Brénugat-Herné L, Orriols E, Desombre C, Dos Santos M, Prost Z, et al. A Serious Game to Improve Cognitive Functions in Schizophrenia: A Pilot Study. Front Psychiatry 2016 Apr 20;7:64. [doi: 10.3389/fpsyt.2016.00064] [Medline: 27148093] 6. Levac D, Nawrotek J, Deschenes E, Giguere T, Serafin J, Bilodeau M, et al. Development and reliability evaluation of the movement rating instrument for virtual reality video game play. JMIR Serious Games 2016 Jun 01;4(1):e9. [doi: 10.2196/games.5528] [Medline: 27251029] 7. Tannous H, Istrate D, Ho Ba Tho MC, Dao TT. Serious game and functional rehabilitation for the lower limbs. European Research in Telemedicine / La Recherche Européenne en Télémédecine 2016 Jun;5(2):65-69. [doi: 10.1016/j.eurtel.2016.05.001] 8. Tannous H, Istrate D, Ho Ba Tho MC, Dao TT. Feasibility study of a serious game based on Kinect system for functional rehabilitation of the lower limbs. European Research in Telemedicine / La Recherche Européenne en Télémédecine 2016 Sep;5(3):97-104. [doi: 10.1016/j.eurtel.2016.05.004] 9. Chen PY, Wei SH, Hsieh WL, Cheen JR, Chen LK, Kao CL. Lower limb power rehabilitation (LLPR) using interactive video game for improvement of balance function in older people. Arch Gerontol Geriatr 2012 Nov;55(3):677-682. [doi: 10.1016/j.archger.2012.05.012] 10. Sun TL, Lee CH. An Impact study of the design of exergaming parameters on body intensity from objective and gameplay-based player experience perspectives, based on balance training exergame. PLoS ONE 2013 Jul 26;8(7):e69471. [doi: 10.1371/journal.pone.0069471] 11. Chatzitofis A, Monaghan D, Mitchell E, Honohan F, Zarpalas D, O’Connor NE, et al. HeartHealth: a cardiovascular disease home-based rehabilitation system. Procedia Comput Sci 2015;63:340-347. [doi: 10.1016/j.procs.2015.08.352] 12. Lozano-Quilis JA, Gil-Gómez H, Gil-Gómez JA, Albiol-Pérez S, Palacios-Navarro G, Fardoun HM, et al. Virtual rehabilitation for multiple sclerosis using a kinect-based system: randomized controlled trial. JMIR Serious Games 2014 Nov 12;2(2):e12. [doi: 10.2196/games.2933] 13. Yu W, Vuong C, Ingalls T. An interactive multimedia system for Parkinson's patient rehabilitation. Lecture Notes in Computer Science 2011 Jul;6774:129-137. 14. Assad O, Hermann R, Lilla D, Mellies B, Meyer R, Shevach L, et al. Motion-based games for Parkinson's disease patients. Lecture Notes in Computer Science 2011 Oct;6972:47-58. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al 15. Paraskevopoulos IT, Tsekleves E, Craig C, Whyatt C, Cosmas J. Design guidelines for developing customised serious games for Parkinson’s disease rehabilitation using bespoke game sensors. Entertain Comput 2014 Dec;5(4):413-424. [doi: 10.1016/j.entcom.2014.10.006] 16. Cho S, Ku J, Cho YK, Kim IY, Kang YJ, Jang DP, et al. Development of virtual reality proprioceptive rehabilitation system for stroke patients. Comput Methods Programs Biomed 2014 Jan;113(1):258-265. [doi: 10.1016/j.cmpb.2013.09.006] 17. Ding Q, Stevenson IH, Wang N, Li W, Sun Y, Wang Q, et al. Motion games improve balance control in stroke survivors: a preliminary study based on the principle of constraint-induced movement therapy. Displays 2013 Apr;34(2):125-131. [doi: 10.1016/j.displa.2012.08.004] 18. Ibarra Zannatha JM, Tamayo AJ, Sánchez AD, Delgado JE, Cheu LE, Arévalo WA. Development of a system based on 3D vision, interactive virtual environments, ergonometric signals and a humanoid for stroke rehabilitation. Comput Methods Programs Biomed 2013 Nov;112(2):239-249. [doi: 10.1016/j.cmpb.2013.04.021] 19. Wu B, Wang AI. A guideline for game development-based learning: a literature review. IJCGT 2012;2012:1-20. [doi: 10.1155/2012/103710] 20. Nilsen P. Making sense of implementation theories, models and frameworks. Implementation Sci 2015 Apr 21;10(1):10. [doi: 10.1186/s13012-015-0242-0] 21. Dao TT, Tannous H, Pouletaut P, Gamet D, Istrate D, Ho Ba Tho MC. Interactive and connected rehabilitation systems for e-Health. IRBM 2016 Nov;37(5-6):289-296. [doi: 10.1016/j.irbm.2016.02.003] 22. Tannous H, Istrate D, Benlarbi-Delai A, Sarrazin J, Gamet D, Ho Ba Tho MC, et al. A new multi-sensor fusion scheme to improve the accuracy of knee flexion kinematics for functional rehabilitation movements. Sensors 2016 Nov 15;16(11):1914. [doi: 10.3390/s16111914] 23. Fleming TM, Bavin L, Stasiak K, Hermansson-Webb E, Merry SN, Cheek C, et al. Serious games and gamification for mental health: current status and promising directions. Front Psychiatry 2017 Jan 10;7:215. [doi: 10.3389/fpsyt.2016.00215] 24. Lumsden J, Edwards EA, Lawrence NS, Coyle D, Munafò MR. Gamification of cognitive assessment and cognitive training: a systematic review of applications and efficacy. JMIR Serious Games 2016 Jul 15;4(2):e11. [doi: 10.2196/games.5888] 25. McCallum S. Gamification and serious games for personalized health. Stud Health Technol Inform 2012;177:85-96. [Medline: 22942036] 26. Anderson J, Rainie L. Gamification and the internet: experts expect game layers to expand in the future, with positive and negative results. Games Health J 2012 Aug;1(4):299-302. [doi: 10.1089/g4h.2012.0027] 27. Seaborn K, Fels DI. Gamification in theory and action: A survey. Int J Hum Comput Stud 2015 Feb;74:14-31. [doi: 10.1016/j.ijhcs.2014.09.006] 28. Wattanasoontorn V, Boada I, García R, Sbert M. Serious games for health. Entertain Comput 2013 Dec;4(4):231-247. [doi: 10.1016/j.entcom.2013.09.002] 29. Labruyère R, Gerber CN, Birrer-Brütsch K, Meyer-Heim A, van Hedel HJ. Requirements for and impact of a serious game for neuro-pediatric robot-assisted gait training. Res Dev Disabil 2013 Nov;34(11):3906-3915. [doi: 10.1016/j.ridd.2013.07.031] [Medline: 24025439] 30. Jaume-i-Capó A, Martínez-Bueso P, Moyà-Alcover B, Varona J. Interactive rehabilitation system for improvement of balance therapies in people with cerebral palsy. IEEE Trans Neural Syst Rehabil Eng 2014 Mar;22(2):419-427. [doi: 10.1109/TNSRE.2013.2279155] [Medline: 24122561] 31. Bower K, Louie J, Landesrocha Y, Seedy P, Gorelik A, Bernhardt J. Clinical feasibility of interactive motion-controlled games for stroke rehabilitation. J NeuroEngineering Rehabil 2015 Aug 2;12(1):12. [doi: 10.1186/s12984-015-0057-x] 32. Soares AV, Borges Júnior NG, Hounsell MS, Marcelino E, Rossito GM, Sagawa Júnior Y. A serious game developed for physical rehabilitation of frail elderly. European Research in Telemedicine / La Recherche Européenne en Télémédecine 2016 Jun;5(2):45-53. [doi: 10.1016/j.eurtel.2016.05.003] 33. Bonnechère B, Jansen B, Salvia P, Bouzahouene H, Omelina L, Moiseev F, et al. Validity and reliability of the kinect within functional assessment activities: comparison with standard stereophotogrammetry. Gait Posture 2014 Jan;39(1):593-598. [doi: 10.1016/j.gaitpost.2013.09.018] 34. Manera V, Petit PD, Derreumaux A, Orvieto I, Romagnoli M, Lyttle G, et al. 'Kitchen and cooking,' a serious game for mild cognitive impairment and Alzheimer's disease: a pilot study. Front Aging Neurosci 2015 Mar;7:24 [FREE Full text] [doi: 10.3389/fnagi.2015.00024] [Medline: 25852542] 35. Lumsden J, Edwards EA, Lawrence NS, Coyle D, Munafò MR. Gamification of cognitive assessment and cognitive training: a systematic review of applications and efficacy. JMIR Serious Games 2016 Jul 15;4(2):e11. [doi: 10.2196/games.5888] 36. Perrochon A, Kemoun G, Dugué B, Berthoz A. Cognitive impairment detection of visuo-spatial memory using a modified walking Corsi test with the « magic carpet ». Dement Geriatr Cogn Disord Extra 2014;4:1-13. [doi: 10.1159/000356727] 37. Brockmyer JH, Fox CM, Curtiss KA, McBroom E, Burkhart KM, Pidruzny JN. The development of the game engagement questionnaire: a measure of engagement in video game-playing. J Exp Soc Psychol 2009 Jul;45(4):624-634. [doi: 10.1016/j.jesp.2009.02.016] 38. Cook DA, Bordage G, Schmidt HG. Description, justification, and clarification: a framework for classifying the purposes of research in medical education. Med Educ 2008;42(2):128-133. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Idriss et al Abbreviations 3D: three-dimensional EMG: electromyography GUI: graphical user interface ICT: information and communication technology SD: standard deviation Edited by A McDougall; submitted 09.01.17; peer-reviewed by T Chang, D Rojas; comments to author 24.02.17; revised version received 28.02.17; accepted 04.04.17; published 04.07.17 Please cite as: Idriss M, Tannous H, Istrate D, Perrochon A, Salle JY, Ho Ba Tho MC, Dao TT JMIR Serious Games 2017;5(3):e14 URL: http://games.jmir.org/2017/3/e14/ doi: 10.2196/games.7284 PMID: 28676468 ©Mohamad Idriss, Halim Tannous, Dan Istrate, Anaick Perrochon, Jean-Yves Salle, Marie-Christine Ho Ba Tho, Tien-Tuan Dao. Originally published in JMIR Serious Games (http://games.jmir.org), 04.07.2017. 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 http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2017/3/e14/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e14 | p. 15 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious Games – JMIR Publications

Published: Jul 4, 2017

Keywords: rehabilitation exercise; virtual rehabilitation; rehabilitation; user computer interface; musculoskeletal diseases

There are no references for this article.