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Results and Guidelines From a Repeated-Measures Design Experiment Comparing Standing and Seated Full-Body Gesture-Based Immersive Virtual Reality Exergames: Within-Subjects Evaluation

Results and Guidelines From a Repeated-Measures Design Experiment Comparing Standing and Seated... Background: Although full-body seated exercises have been studied in a wide range of settings (ie, homes, hospitals, and daycare centers), they have rarely been converted to seated exergames. In addition, there is an increasing number of studies on immersive virtual reality (iVR) full-body gesture-based standing exergames, but the suitability and usefulness of seated exergames remain largely unexplored. Objective: This study aimed to evaluate the difference between playing a full-body gesture-based iVR standing exergame and seated exergame in terms of gameplay performance, intrinsic motivation, and motion sickness. Methods: A total of 52 participants completed the experiment. The order of the game mode (standing and sitting) was counterbalanced. Gameplay performance was evaluated by action or gesture completion time and the number of missed gestures. Exertion was measured by the average heart rate (HR) percentage (AvgHR%), increased HR%, calories burned, and the Borg 6-20 questionnaire. Intrinsic motivation was assessed with the Intrinsic Motivation Inventory (IMI), whereas motion sickness was assessed via the Motion Sickness Assessment Questionnaire (MSAQ). In addition, we measured the fear of falling using a 10-point Likert scale questionnaire. Results: Players missed more gestures in the seated exergame than in the standing exergame, but the overall miss rate was low (2.3/120, 1.9%). The analysis yielded significantly higher AvgHR%, increased HR%, calories burned, and Borg 6-20 rating of perceived exertion values for the seated exergame (all P<.001). The seated exergame was rated significantly higher on peripheral sickness (P=.02) and sopite-related sickness (MSAQ) (P=.004) than the standing exergame. The score of the subscale “value/usefulness” from IMI was reported to be higher for the seated exergame than the standing exergame. There was no significant difference between the seated exergame and standing exergame in terms of intrinsic motivation (interest/enjoyment, P=.96; perceived competence, P=.26; pressure/tension, P=.42) and the fear of falling (P=.25). Conclusions: Seated iVR full-body gesture-based exergames can be valuable complements to standing exergames. Seated exergames have the potential to lead to higher exertion, provide higher value to players, and be more applicable in small spaces compared with standing exergames. However, gestures for seated exergames need to be designed carefully to minimize motion sickness, and more time should be given to users to perform gestures in seated exergames compared with standing exergames. (JMIR Serious Games 2020;8(3):e17972) doi: 10.2196/17972 KEYWORDS exergames; immersive virtual reality; standing exergame; seated exergame; exercising http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al motivation than standard televisions or monitors [8,25], where Introduction enjoyment and motivation are, in turn, linked to increased adherence to physical exercises in general [26-28]. Background Full-body gesture-based exergames have been widely explored Physical inactivity has been identified as the fourth leading with people in standing positions in iVR [20,22,23]. However, cause of death globally [1]. It is now well established that a they have not been adapted and explored in seated versions. sedentary lifestyle is a unique risk factor for several illnesses, Seated iVR exergames could have the following benefits: (1) such as type 2 diabetes and cardiovascular diseases, which suitability for users with a sedentary lifestyle (eg, university account for about 30% of global mortality [2]. Exergames students [29]); (2) feasibility for mobility-impaired users (eg, represent a promising approach that has been widely examined elderly users and wheelchair users [5,30]); (3) possibility of for various population groups (ie, children [3], young individuals reducing the risk of injuries due to falls or motion sickness [4], and older adults [5]) to promote regular exercise (defined [31,32]; and (4) avoidance of injury from hitting other objects as planned, structured, repetitive, and intentional movement (eg, furniture) when the space is small or surroundings are intended to improve or maintain physical fitness) in unmotivated cluttered, because players are not required to walk around. or inactive target groups [6,7]. Motivation can be divided into intrinsic (enjoyment of the In recent years, exergames have been proven to have the activity) and extrinsic (driven by external outcomes, eg, losing potential to improve enjoyment, motivation, and long-term weight and improving fitness) [33]. Intrinsic motivation (ie, engagement when compared with other conventional exercises motivation derived from enjoyment and satisfaction gained from (eg, cardiovascular exercises like biking [8,9]), and as such, an activity) plays an essential role in long-term adherence to they can be effective in promoting both physical and mental exercising [26,27,33], whereas extrinsic motivation, such as health [10,11]. Various nonimmersive virtual reality (VR) [12] competitive pressure, may lead to tension and feelings of (like using interfaces such as a flat-screen television/monitor) compulsion, and can diminish intrinsic motivation [34,35]. exergames have been designed to encourage people to be more There is evidence that exergames increase enjoyment and active [5] and promote a positive lifestyle [13] and self-care intrinsic motivation compared with conventional exercises (eg, [14]. Previous literature has shown that exergames could bring biking) and distract from uncomfortable bodily sensations physical and health outcomes to players. For example, Peng et [25,36-39]. al [15] performed a meta-analysis of energy expenditure in exergames, and their main finding suggests that exergames are A sedentary lifestyle is a problem for older adults and people as effective as traditional exercises in facilitating light- and with physical disabilities and is a serious health problem among moderate-intensity physical exertion. Huang et al [16] reported university students [40]. Most of the research on exergames has that participants who were enthusiastic about exercising showed been targeted at older adults or disabled people [5,30,41] but positive changes in happiness, perceived energy levels, and not university students, who are underrepresented in such relaxation in a 2-week exergame intervention. Sapi et al [17] studies. Research has shown that lack of time and not liking reported that participants showed improvements in balance exercising are the major barriers for university students [29]. following a 6-week exergame intervention, and the These barriers could be overcome by using full-body improvements were in favor of using the exergame than gesture-based exergames that can be played either standing or conventional balance training. da Silva Alves et al [18] found seated at any time and in small spaces because exergames are that participants showed improvements in functional well-being perceived to be more enjoyable and preferred by university and physical well-being after 10 sessions of exergaming. In the students than other conventional exercises (eg, cardiovascular study by Garcia et al [19], participants showed improvements exercises like biking [8,9]). in stepping, standing balance, gait speed, and mobility following Goal of the Study a 12-week exergame intervention. The focus of this research was to evaluate the playability and With the recent advances in immersive virtual reality (iVR) user experience of a seated iVR exergame compared with a head-mounted displays (HMDs), an increasing number of iVR similar standing exergame among university students in terms exergames [20-22] are being developed. They have opened the of gameplay performance (ie, action completion time and possibility of altering more radically how we engage users in number of gestures missed) and user experience (ie, motion performing exercises. Studies have shown that iVR has the sickness, intrinsic motivation, and fear of falling). potential to produce benefits that other types of displays (ie, a standard display like television) cannot offer. For instance, iVR Methods exergames can offer users the illusion of more exceptional physical capabilities than they have. As such, iVR may increase Experiment Design motivation for exercising in general [23]. Moreover, iVR games We employed a one-way within-subjects experiment design can offer benefits such as increased perceived competence and where the independent variable was game mode with two levels the feeling of body movements that are more in line with how (standing and sitting). The order of the game mode was we perform exercise in the real world. Participants have counterbalanced to compensate for any learning effects. The described exaggerated movements to be natural, fun, and whole experiment lasted between 30 and 40 minutes for each empowering [24]. Furthermore, exercising in iVR has been participant depending on their tiredness level and resting heart found to be an effective intervention to increase enjoyment and rate (RestHR). http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Participants Rules and Logic Participants were recruited from a local university campus A game is an activity that requires at least one player, has rules, through posters, social media platforms, and a mailing list. The and has a victory condition [45]. The design of our game study included university students with the ability to speak followed this definition and was inspired by the game called English, who were not disabled, were not pregnant (because of Just Dance, which requires users to follow and imitate the the physical exertion required to play the game), and had not dancing gestures one by one and has been used in some prior consumed any alcohol during the day (blood alcohol level of studies [46]. However, the level of our program consists of a approximately 0.07% could reduce symptoms of cybersickness sequence of exercise gestures instead of dance movements. As [42], which might affect the results of our study). the game starts, the player needs to follow the body gestures of the instructor in the VR system to move his/her body Participants were excluded from the experiment if they (1) accordingly. For ease of reproducing the gestures, a gesture is answered “yes” to any of the Physical Activity Readiness deemed completed if specific joint positions (eg, head, Questionnaire (PAR-Q) [43] questions, (2) had a resting blood controllers, and trackers) of the player meet the predefined pressure higher than 140/90 mmHg, and (3) had a RestHR level variables of corresponding gestures based on a simple rule-based that was too low (ie, RestHR <62 beats/min for a 16 to system and if the player can keep the pose for 0.4 seconds, 19-year-old female, RestHR <60 beats/min for a 20 to which was determined from the results of a pilot study with 10 39-year-old female, RestHR <56 beats/min for a 16 to participants, where we found that a short pose hold time could 19-year-old male, or RestHR <55 beats/min for a 20 to lead to gesture misrecognitions and a long pose hold time could 39-year-old male) or too high (ie, RestHR >94 beats/min for a lead to player fatigue easily. In addition, this time of 0.4 seconds 16 to 19-year-old female, RestHR >89 beats/min for a 20 to was informed from the literature in other fields (eg, text entry 39-year-old female, RestHR >87 beats/min for a 16 to [47]). A badge [48] is given to players when they complete 19-year-old male, or RestHR >84 beats/min for a 20 to every 10 actions as an in-game achievement to motivate them 39-year-old male) [44]. to follow and replicate the gestures carefully. The victory All participants received drinks and snacks for their participation condition was to successfully follow the instructor’s gestures after they finished the experiment. The University Ethics and not fail to follow these gestures three times in a row. In Committee at Xi’an Jiaotong-Liverpool University approved addition, our game warned users when they were not paying the experiment. All participants signed informed consent forms attention to the virtual instructor by tracking the rotation data prior to taking part in the study, and the research protocol was from the HMD. Both visual and auditory feedback were approved by the University Ethics Committee. provided to encourage players to continue playing. To determine the sample size for the study, a statistical power Game Procedure analysis was performed. This statistical power analysis was not The game starts with a calibration phase (Figure 1A) for the based on data from prior studies owing to limited similar work. system to take into account the individual differences of players. It was based on general considerations about the trade-offs The player needs to lift the hands midair and confirm having between the ability to detect certain effects and the feasibility finished the calibration by pressing a button on the controllers. to acquire a sufficiently large sample. We used a sample size The system then records the position data of the head, hands, calculation software program (G*Power version 3.1.9.2 for and feet. After the calibration phase, the game progresses to the Windows), with an effect size of 0.5 (Cohen d), statistical power training (warm-up) phase (Figure 1B), where the player needs of .90, and statistical level of significance of .05. The sample to follow the virtual instructor to perform two rounds of six size was established at 44 participants, and we decided to recruit gestures with a fixed order to become familiar with the gestures an additional 10 participants in the case of dropouts. that need to be performed. The gameplay phase (Figure 1C) starts after the training phase, where the player needs to follow Game the virtual instructor who performs gestures presented in a The game was implemented in Unity3D with the SteamVR random manner. plugin to enable positional tracking of the HTC VIVE trackers and controllers. Figure 1. (A) Calibration, (B) training, and (C) game phases for the seated version; the process for the standing version is the same, except the instructor is standing instead of sitting. http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al the sitting and standing versions of the exergame. The selection Included Gestures process of gestures and the intensity values were informed by Table 1 shows the intensity of the gestures selected for our the results of a pilot study (Multimedia Appendix 1). game. Figure 2 shows the final pose of the gestures involved in Table 1. Intensity level of the gestures used in the experiment. Gesture Intensity (%) Sitting gesture Hands up 32.30 Knees up 32.27 Feet up + hands up 35.10 Feet up + hands stretched 34.75 Knees up + hands up 42.39 Knees up + hands stretched 44.03 Standing gesture Hands up 31.00 Hands stretched 37.20 Left/right kick 27.25 Squat 50.69 Hand stretched + kick 43.88 Hands up + kick 46.05 Figure 2. Seated gestures: (A) Hands up + knees up; (B) Hands up; (C) Knees up; (D) Feet up + hands up; (E) Hands stretched + knees up; (F) Hands stretched + feet up. Standing gestures: (G) Left/right kick; (H) Squat; (I) Hands up; (J) Left/right kick + hands up; (K) Left/right kick + hands stretched; (L) Hands stretched. increased HR%, which was the difference between the HR% at Outcome Measurements the beginning and the end of the game phase, for a direct comparison of both versions. Calories burned were calculated Exertion using the Polar Beat mobile app with the activity set as other We measured participants’ exertion based on HR and calories indoor activity and the user profile of the app calibrated to each burned using a Polar OH1 wrist-strap monitor. Average HR participant. We started recording the HR and calories burned (AvgHR%) was expressed as a percentage of a participant’s as soon as the participants finished the training phase. estimated maximum HR (MaxHR), where MaxHR was Furthermore, the Borg CR 6-20 [50] rating of perceived exertion estimated as 220 minus age [49]. This measure is commonly (RPE) was used to measure the participants’ perceived exertion used in exercise studies to confirm that participants are working level. It describes the physical efforts involved in completing at a required level of exertion. Additionally, we measured the the game as perceived by the participants, with “6” indicating http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al “no exertion,” “13” indicating “somewhat hard exertion,” and the perceived competence and pressure/tension subscales “20” indicating “maximum exertion.” Borg RPE is frequently because they are positive and negative predictors of intrinsic used in exercise sciences as a quantitative measure of perceived motivation, respectively. In addition, the subscale exertion when exercising [50,51], and it has been applied to value/usefulness has been used in internalization studies [57] studies with iVR exergames [4,20]. and can provide us with an idea about how people internalize and self-regulate themselves with respect to the activities that Gameplay Data they experience as useful or valuable for themselves. The IMI We collected several types of data in the background, including has gained widespread acceptance as a multidimensional (1) the action completion time of every successfully performed measure of intrinsic motivation in the context of sports and gesture, which was equal to the time spent by the user to perform exercising [58,59] and has been widely used in studies dealing the same pose and hold the pose for 0.4 seconds, (2) the number with iVR exergames [23,60,61]. Each item was rated on a of gestures missed for each gesture type, and (3) the real-time severity scale ranging from 1 (not at all) to 7 (very). A higher HR data from the Polar OH1 optical HR sensor for every 0.2 score indicates a more internally motivated self-regulated seconds in the actual experiment stage. Therefore, we analyzed physical activity behavior. (1) the average action completion time, (2) the total number of We measured fear of falling by asking participants “how missed gestures, and (3) the plot profile of real-time HR. concerned are you about the possibility of falling during the Motion Sickness experiment?” using a 10-point Likert scale from 1 to 10, with 1 indicating “very slightly or not at all” and 10 indicating Motion sickness was assessed using the self-reported 16-item “extremely.” Motion Sickness Assessment Questionnaire (MSAQ) [52], which is a valid descriptor of motion sickness in the general After completing the above questionnaires, participants were population that covers the following four dimensions of motion asked to answer the following open-ended question in the sickness: gastrointestinal (stomach sick, queasy, nauseated, and questionnaire: “What do you think about this version of the vomit), central (faint-like, lightheaded, dizzy, spinning, and game?” They responded by typing into a text box. There was disoriented), peripheral (sweaty, clammy, and hot/warm), and no limit for the length of participants’ responses. A full list of sopite-related (annoyed, drowsy, tired, and uneasy). The results questions used after each condition can be found in Multimedia from the MSAQ were correlated strongly with the overall scores Appendix 2. from the Pensacola diagnostic index (r=0.81; P<.001) and the Apparatus and Setup nausea profile (r=0.92; P<.001) [52]. It has been found that the MSAQ is a valid evaluation tool and that it is advantageous to The experiment was conducted using HTC VIVE Pro Eye use this multidimensional questionnaire rather than the connected to an HP Z workstation (i7 CPU, 16 GB RAM, and one-dimensional form [52]. The questionnaire has been widely Nvidia Quadro P5200 GPU). Two HTC VIVE handheld used in studies dealing with virtual environments [53-55]. The controllers, two HTC VIVE trackers, and two base stations were scale ranges from 1 (not at all) to 9 (severely). A lower score used to enable hand and feet motion tracking. A stable chair is associated with lower motion sickness. with two handles was used in the sitting condition. The HR was monitored by a Polar OH1 optical HR sensor, which has been Intrinsic Motivation proved to be able to capture good HR data when compared with Intrinsic motivation was measured using the self-reported the gold standard of HR measurement with an 25-item version of the Intrinsic Motivation Inventory (IMI) electrocardiography device [62,63]. The experiment was [56], which covers the following four subscales: conducted in an indoor laboratory room that could not be seen interest/enjoyment, perceived competence, pressure/tension, from the outside. The room temperature was always set to be and value/usefulness. Although IMI includes seven subscales, 23 to 24°C during the experiment. Figure 3 depicts the only interest/enjoyment measures intrinsic motivation and is experiment setup and devices used in the experiment. considered the primary self-reporting measure. We included http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Figure 3. Standing (A) and seated (B) experiment setup, and the devices used in the experiment: (1) the HTC VIVE base stations, the locations of the two base stations can be found in the vertical view in the left bottom corner; (2) the two VIVE trackers attached to the legs; (3) the VIVE controllers used to track the player’s hand positions; (4) HTC VIVE Pro Eye; (5) the HP Z backpack; (6) the chair; and (7) Polar OH1. performance, IMI, MSAQ, fear of falling, and exertion Procedure measurements. For the percentage of missed gesture types for Before filling in the pre-experiment questionnaire that gathered sitting/standing gesture type, we used one-way repeated analysis demographic information (eg, age, gender, and experience with of variance (ANOVA) with the sitting/standing gesture type as the VR device), we obtained participants’ consent to participate the within-subjects variables, respectively. We also examined in the experiment and collected their RestHR and resting blood and reported if there were any significant gender differences in pressure. They were also asked to enter their age, gender, height, our measurements by using one-way between-subjects ANOVA. and weight into the Polar Beat app. Before each condition We set the α level at .05 in our analyses. We further reported started, a researcher would help them to wear the VIVE Pro the effect sizes using Cohen suggestion to classify the effect Eye headset with two VIVE handheld controllers and two VIVE size, where Cohen suggested that d=0.2 represents a “small” trackers. Participants were then given 3 minutes to get familiar effect size, 0.5 represents a “medium” effect size, and 0.8 with the corresponding condition of the iVR exergame. Once represents a “large” effect size [64]. Analyses were performed their HR reached the equivalent RestHR level, they proceeded using the Statistical Package for the Social Sciences (IBM Corp). to the experiment stage, beginning with calibrating the game, training, and testing. In each condition, they needed to perform Results 120 gestures, requiring 5 minutes (120 gestures × 2.5 seconds). We fixed the number of gestures to allow for comparing the Participant Characteristics two games. After each condition, they were asked to fill in Fifty-four individuals were interested in participating in the postexperiment questionnaires. They proceeded to the next experiment. Two were excluded owing to their high RestHR. condition when they felt rested and their HR was at the rest At the end, a total of 52 participants were eligible to participate level. in the study. The characteristics of the study participants are shown in Table 2. Statistical Analysis We used the paired t test to understand the difference between the seated exergame and standing exergame regarding gameplay http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Table 2. Characteristics of the study participants. Characteristic Value Number of students, n 52 Age (years), mean (SD) 18.81 (1.70) 77.71 (8.78) RestHR , mean (SD) Height (cm), mean (SD) 170.11 (7.75) Weight (kg), mean (SD) 60.84 (10.79) 20.93 (2.87) Body mass index (kg/m ), mean (SD) Self-reported exercise time per week (min), mean (SD) 87.88 (66.55) Normal or corrected-to-normal, n 52 Self-reported experience with seated exercise regimes No b c Self-reported experience with VR HMDs , n Frequent user, n 1 Self-reported experience with full-body gesture-based video games, n 28 Frequent player, n 4 RestHR: resting heart rate. VR: virtual reality. HMD: head-mounted display. completion time. However, the analysis showed that players Gameplay Data missed more gestures in the seated exergame than in the standing Gameplay data and analysis results are reported in Table 3. The exergame. analysis showed that game mode did not influence action Table 3. Gameplay data and exertion measures. Variable Standing exergame, mean (SD) Seated exergame, mean (SD) 51 P value Cohen d Gameplay Action completion time 1.48 (0.14) 1.53 (0.18) 1.87 .07 N/A Missed gestures 1.65 (1.71) 2.33 (1.83) 2.40 .02 0.332 Exertion 51.9% (4.6%) 54.3% (5.0%) 4.66 <.001 0.646 AvgHR% 6.9% (4.4%) 11.8% (5.3%) 5.86 <.001 0.813 Increased HR% Calories 21.83 (6.76) 24.67 (7.25) 4.44 <.001 0.615 Borg 6-20 9.02 (2.15) 10.25 (2.59) 3.96 <.001 0.548 Significant at .05. N/A: not applicable. AvgHR%: average heart rate percentage. HR%: heart rate percentage. gesture type (F =1.058, P=.38) on the percentage of 5,255 Percentage of Missed Gesture Types corresponding missed gestures. The missed rate for sitting and The results of one-way repeated ANOVA yielded no significant standing gesture types can be found in Figure 4. effect of the sitting gesture type (F =1.98, P=.08) or standing 5,255 http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Figure 4. Missed rates for (A) seated gestures and (B) standing gestures. Error bars indicate ±2 standard errors. exergame was rated as “very light” exercise according to the Exertion Borg 6-20 RPE scale. Exertion (AvgHR%, increased HR%, calories burned, and Borg To aid the visualization of the AvgHR% behavior of both 6-20) data and analysis results are presented in Table 3. The exergames, Figure 5 shows the AvgHR% data from all analysis yielded significantly higher AvgHR%, increased HR%, participants during the 5 minutes of gameplay, averaged over calories burned, and Borg 6-20 RPE for the seated exergame the whole session. The seated exergame had a higher AvgHR% (all P<.001). Our results suggest that the seated exergame was than the standing exergame after 0.34 minutes. rated as “very light” to “light” exercise and the standing Figure 5. Mean AvgHR% during gameplay for both versions of the exergame; the interaction between two lines occurs at 0.38 minutes. At 2.64 minutes, AvgHR% of the seated exergame reached the moderate physical intensity level. AvgHR%: average heart rate percentage. sickness (P=.02) and sopite-related sickness (P=.004) for the Experience seated exergame. We did not find a significant difference Data analysis of the MSAQ included the overall MSAQ score between the seated exergame and standing exergame in terms and its subscale scores (gastrointestinal, central, peripheral, and of central (P=.81), gastrointestinal (P=.81), and overall sickness sopite-related). The MSAQ data and analysis results are reported (P=.06). in Table 4. The analysis showed significantly higher peripheral http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Regarding IMI, there was no significant difference for The one-way between-subjects ANOVA showed that interest/enjoyment (P=.96), perceived competence (P=.26), and interest/enjoyment was rated significantly higher by females pressure/tension (P=.42). However, the analysis yielded a (mean 5.20, SD 1.23) than males (mean 4.38, SD 41.16), with significantly higher value/usefulness for the seated exergame a medium effect size (F =6.01, P=.02). 1,50 (P=.04). IMI data and analysis results can be found in Table 4. Table 4. Motion Sickness Assessment Questionnaire and Intrinsic Motivation Inventory test measures. Variable Standing exergame, mean (SD) Sitting exergame, mean (SD) P value Cohen d MSAQ Peripheral 22.7% (12.9%) 27.7% (14.3%) −2.41 0.334 Sopite-related 18.8% (11.3%) 23.9% (15.4%) −3.06 0.424 Central 19.2% (11.1%) 18.8% (10.7%) 0.24 .81 N/A Gastrointestinal 13.5% (5.7%) 13.7% (5.2%) −0.24 .81 N/A Overall 17.4% (7.3%) 19.4% (8.4%) −1.91 .061 N/A IMI Interest/enjoyment 4.73 (1.30) 4.72 (1.30) 0.05 .96 N/A Competence 4.99 (1.12) 4.85 (1.20) 1.14 .26 N/A Pressure/tension 2.90 (0.95) 2.99 (1.04) −0.82 .42 N/A Value/usefulness 5.12 (1.28) 5.38 (1.12) −2.11 0.292 Significant at .05. MSAQ: Motion Sickness Assessment Questionnaire. N/A: not applicable. IMI: Intrinsic Motivation Inventory. exercising in the seated position (none of them had previous Fear of Falling experience of seated exercising; Table 2). There was no significant difference in the fear of falling ratings Regarding motion sickness, previous studies [31,32] have between the standing exergame (mean 2.10, SD 1.58) and seated suggested that the seated exergame might result in a lower level exergame (mean 2.40, SD 1.78) (t =−1.16, P=.25). of motion sickness. However, this was not supported by our findings. We observed that participants felt sicker (ie, peripheral Discussion and sopite-related motion sickness) in the seated exergame. However, the reason was beyond the scope of this study; a Overview further investigation is required to understand why motion With the limited exploration of seated exergames in the literature sickness was higher in the seated exergame than in the standing of iVR exergames, this study is the first to explore the difference exergame. We suggest that future designers and researchers between full-body gesture-based seated exergames and standing should carefully design full-body gestures for iVR seated exergames in iVR among university students regarding exergames to minimize motion sickness. playability (ie, gameplay performance) and user experience (ie, As for intrinsic motivation, we did not observe any significant intrinsic motivation and motion sickness). Our results suggest difference between the seated exergame and standing exergame that participants perceived higher value in the seated exergame (ie, interest/enjoyment, P=.96; perceived competence, P=.26; than in the standing exergame. However, the seated exergame pressure/tension, P=.42). However, there was a gender effect was associated with a worse gameplay performance (ie, the on participants’ intrinsic motivation toward exergames, where number of missed gestures) and a higher rating of motion we found that females had a significantly higher intrinsic sickness than the standing exergame. motivation (ie, interest/enjoyment) than males (P=.02). This Although we observed that participants missed a significantly could be because the exergame involved in our study was more higher number of gestures in the seated exergame than in the like a dance game, which was inspired by Just Dance, and prior standing exergame (P=.02), this rate was as low as 1.9% research [65] has shown that females tend to be more physically (2.3/120). Further analysis of the type of gestures missed in the active in dance exergames. Aside from this difference between seated exergame confirmed that these misses were in the early male and female participants, no other differences were found stages of the experiment, and as such, the main reason for the in our experiment. misses could be because of participant unfamiliarity with http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al In most cases, standing exercises have a higher exercise intensity Third, warning signs should be provided for standing exergames (in traditional exercises [66,67] and exergames [68,69]). We if users have left (or are about to leave) the calibration position found that our seated exergame led to a higher exertion (ie, and are too far to keep them protected. This is because players AvgHR%, increased HR%, calories burned, and Borg 6-20) tend to move around during gameplay, which we encountered than the standing exergame, possibly because the seated in our study and has been reported previously [23]. It could lead exergame involved more whole-body movements that required to potentially dangerous situations (eg, hitting objects that are increased energy expenditure during gameplay [70-73]. in the environment and going out of the safe tracking area) or decrease the recognition performance of the sensors (eg, tracking Design Guidelines may not work when they are too close to or far from the In this section, we provide design guidelines that are based on sensors). suggestions provided by Wiemeyer et al [74] for future game Limitations and Future Work designers who are interested in building iVR full-body standing or seated gesture-based exergames. Our study only focused on one sedentary lifestyle user group (university students). Future work could focus on investigating First, practice should be provided for each gesture during the two versions of the exergame with different population warm-up. A warm-up session before exercising is essential [75], groups (eg, older adults and users who have physical and it should be included in exergames as well. One way to disabilities). To minimize players’ cognitive workload, we set perform warm-up for full-body gesture-based exergames is to both exergames to include only 6 out of the 10 gesture types practice the gestures involved in the game, which will not only that we measured during the pilot study. In the future, we could help players reduce the risk of injures but also make them add more gestures to increase the complexity of the game (as familiar with the in-game gestures. stated by participants 13, 20, 30, and 37). A further limitation Second, the difficulty level of the game should be adapted to is that our experiment did not measure which types of gestures the current state of the individual. Regarding an offline approach, caused the unwanted level of motion sickness in the seated players might have difficulty in performing certain gestures exergame. Future experiments could be conducted to check during gameplay. Therefore, to match the difficulty of the game issues related to motion sickness based on specific gestures and to the current state of the individual, it would be necessary for types of gestures. players to experience and select gestures they are comfortable Conclusions performing before playing the game. Regarding an online Our contributions to the field of iVR exergaming regarding approach, one of the adaptive methods that has been used and gameplay performance and user experience are as follows: (1) pro v en to be suitable in e x er g ames is the iVR seated exergame could result in higher exertion and proportional–integral–derivative (PID) control [76]. Designers provide higher value to players than the standing exergame; (2) can use PID control to modify the transition time between participants might feel sicker in the iVR seated exergame than gestures or select the gestures based on the player’s real-time in the standing exergame, and as such, full-body gestures for HR and gameplay performance (ie, the number of gestures seated exergames need to be designed carefully to help minimize missed). PID control is also useful to avoid overly vigorous the feeling of motion sickness; and (3) participants might miss exercise, which might put the exerciser at risk of eliciting more gestures in the iVR seated exergame than in the standing unwanted coronary issues [77]. exergame. Therefore, designers should allow more time for performing gestures in the seated exergame. Acknowledgments This research was supported by Xi’an Jiaotong-Liverpool University Key Program Special Fund (grant no. KSF-A-03) and Xi’an Jiaotong-Liverpool University Research Development Fund. The authors thank all the participants who volunteered for the study and the reviewers for their suggestions that helped improve this article. Conflicts of Interest None declared. Multimedia Appendix 1 Approach for measuring the intensity of gestures. [PDF File (Adobe PDF File), 122 KB-Multimedia Appendix 1] Multimedia Appendix 2 Questionnaire used in the study. 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[doi: 10.1093/eurheartj/ehn163] [Medline: 18426850] Abbreviations ANOVA: analysis of variance AvgHR%: average heart rate percentage HMD: head-mounted display HR: heart rate IMI: Intrinsic Motivation Inventory iVR: immersive virtual reality MaxHR: maximum heart rate MSAQ: Motion Sickness Assessment Questionnaire PAR-Q: Physical Activity Readiness Questionnaire PID: proportional–integral–derivative RestHR: resting heart rate RPE: rating of perceived exertion VR: virtual reality Edited by G Eysenbach; submitted 25.01.20; peer-reviewed by A Duhamel, E Dove; comments to author 16.03.20; revised version received 27.04.20; accepted 03.06.20; published 27.07.20 Please cite as: Xu W, Liang HN, He Q, Li X, Yu K, Chen Y Results and Guidelines From a Repeated-Measures Design Experiment Comparing Standing and Seated Full-Body Gesture-Based Immersive Virtual Reality Exergames: Within-Subjects Evaluation JMIR Serious Games 2020;8(3):e17972 URL: http://games.jmir.org/2020/3/e17972/ doi: 10.2196/17972 PMID: 32716004 ©Wenge Xu, Hai-Ning Liang, Qiuyu He, Xiang Li, Kangyou Yu, Yuzheng Chen. Originally published in JMIR Serious Games (http://games.jmir.org), 27.07.2020. 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 http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al 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/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | 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

Results and Guidelines From a Repeated-Measures Design Experiment Comparing Standing and Seated Full-Body Gesture-Based Immersive Virtual Reality Exergames: Within-Subjects Evaluation

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Background: Although full-body seated exercises have been studied in a wide range of settings (ie, homes, hospitals, and daycare centers), they have rarely been converted to seated exergames. In addition, there is an increasing number of studies on immersive virtual reality (iVR) full-body gesture-based standing exergames, but the suitability and usefulness of seated exergames remain largely unexplored. Objective: This study aimed to evaluate the difference between playing a full-body gesture-based iVR standing exergame and seated exergame in terms of gameplay performance, intrinsic motivation, and motion sickness. Methods: A total of 52 participants completed the experiment. The order of the game mode (standing and sitting) was counterbalanced. Gameplay performance was evaluated by action or gesture completion time and the number of missed gestures. Exertion was measured by the average heart rate (HR) percentage (AvgHR%), increased HR%, calories burned, and the Borg 6-20 questionnaire. Intrinsic motivation was assessed with the Intrinsic Motivation Inventory (IMI), whereas motion sickness was assessed via the Motion Sickness Assessment Questionnaire (MSAQ). In addition, we measured the fear of falling using a 10-point Likert scale questionnaire. Results: Players missed more gestures in the seated exergame than in the standing exergame, but the overall miss rate was low (2.3/120, 1.9%). The analysis yielded significantly higher AvgHR%, increased HR%, calories burned, and Borg 6-20 rating of perceived exertion values for the seated exergame (all P<.001). The seated exergame was rated significantly higher on peripheral sickness (P=.02) and sopite-related sickness (MSAQ) (P=.004) than the standing exergame. The score of the subscale “value/usefulness” from IMI was reported to be higher for the seated exergame than the standing exergame. There was no significant difference between the seated exergame and standing exergame in terms of intrinsic motivation (interest/enjoyment, P=.96; perceived competence, P=.26; pressure/tension, P=.42) and the fear of falling (P=.25). Conclusions: Seated iVR full-body gesture-based exergames can be valuable complements to standing exergames. Seated exergames have the potential to lead to higher exertion, provide higher value to players, and be more applicable in small spaces compared with standing exergames. However, gestures for seated exergames need to be designed carefully to minimize motion sickness, and more time should be given to users to perform gestures in seated exergames compared with standing exergames. (JMIR Serious Games 2020;8(3):e17972) doi: 10.2196/17972 KEYWORDS exergames; immersive virtual reality; standing exergame; seated exergame; exercising http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al motivation than standard televisions or monitors [8,25], where Introduction enjoyment and motivation are, in turn, linked to increased adherence to physical exercises in general [26-28]. Background Full-body gesture-based exergames have been widely explored Physical inactivity has been identified as the fourth leading with people in standing positions in iVR [20,22,23]. However, cause of death globally [1]. It is now well established that a they have not been adapted and explored in seated versions. sedentary lifestyle is a unique risk factor for several illnesses, Seated iVR exergames could have the following benefits: (1) such as type 2 diabetes and cardiovascular diseases, which suitability for users with a sedentary lifestyle (eg, university account for about 30% of global mortality [2]. Exergames students [29]); (2) feasibility for mobility-impaired users (eg, represent a promising approach that has been widely examined elderly users and wheelchair users [5,30]); (3) possibility of for various population groups (ie, children [3], young individuals reducing the risk of injuries due to falls or motion sickness [4], and older adults [5]) to promote regular exercise (defined [31,32]; and (4) avoidance of injury from hitting other objects as planned, structured, repetitive, and intentional movement (eg, furniture) when the space is small or surroundings are intended to improve or maintain physical fitness) in unmotivated cluttered, because players are not required to walk around. or inactive target groups [6,7]. Motivation can be divided into intrinsic (enjoyment of the In recent years, exergames have been proven to have the activity) and extrinsic (driven by external outcomes, eg, losing potential to improve enjoyment, motivation, and long-term weight and improving fitness) [33]. Intrinsic motivation (ie, engagement when compared with other conventional exercises motivation derived from enjoyment and satisfaction gained from (eg, cardiovascular exercises like biking [8,9]), and as such, an activity) plays an essential role in long-term adherence to they can be effective in promoting both physical and mental exercising [26,27,33], whereas extrinsic motivation, such as health [10,11]. Various nonimmersive virtual reality (VR) [12] competitive pressure, may lead to tension and feelings of (like using interfaces such as a flat-screen television/monitor) compulsion, and can diminish intrinsic motivation [34,35]. exergames have been designed to encourage people to be more There is evidence that exergames increase enjoyment and active [5] and promote a positive lifestyle [13] and self-care intrinsic motivation compared with conventional exercises (eg, [14]. Previous literature has shown that exergames could bring biking) and distract from uncomfortable bodily sensations physical and health outcomes to players. For example, Peng et [25,36-39]. al [15] performed a meta-analysis of energy expenditure in exergames, and their main finding suggests that exergames are A sedentary lifestyle is a problem for older adults and people as effective as traditional exercises in facilitating light- and with physical disabilities and is a serious health problem among moderate-intensity physical exertion. Huang et al [16] reported university students [40]. Most of the research on exergames has that participants who were enthusiastic about exercising showed been targeted at older adults or disabled people [5,30,41] but positive changes in happiness, perceived energy levels, and not university students, who are underrepresented in such relaxation in a 2-week exergame intervention. Sapi et al [17] studies. Research has shown that lack of time and not liking reported that participants showed improvements in balance exercising are the major barriers for university students [29]. following a 6-week exergame intervention, and the These barriers could be overcome by using full-body improvements were in favor of using the exergame than gesture-based exergames that can be played either standing or conventional balance training. da Silva Alves et al [18] found seated at any time and in small spaces because exergames are that participants showed improvements in functional well-being perceived to be more enjoyable and preferred by university and physical well-being after 10 sessions of exergaming. In the students than other conventional exercises (eg, cardiovascular study by Garcia et al [19], participants showed improvements exercises like biking [8,9]). in stepping, standing balance, gait speed, and mobility following Goal of the Study a 12-week exergame intervention. The focus of this research was to evaluate the playability and With the recent advances in immersive virtual reality (iVR) user experience of a seated iVR exergame compared with a head-mounted displays (HMDs), an increasing number of iVR similar standing exergame among university students in terms exergames [20-22] are being developed. They have opened the of gameplay performance (ie, action completion time and possibility of altering more radically how we engage users in number of gestures missed) and user experience (ie, motion performing exercises. Studies have shown that iVR has the sickness, intrinsic motivation, and fear of falling). potential to produce benefits that other types of displays (ie, a standard display like television) cannot offer. For instance, iVR Methods exergames can offer users the illusion of more exceptional physical capabilities than they have. As such, iVR may increase Experiment Design motivation for exercising in general [23]. Moreover, iVR games We employed a one-way within-subjects experiment design can offer benefits such as increased perceived competence and where the independent variable was game mode with two levels the feeling of body movements that are more in line with how (standing and sitting). The order of the game mode was we perform exercise in the real world. Participants have counterbalanced to compensate for any learning effects. The described exaggerated movements to be natural, fun, and whole experiment lasted between 30 and 40 minutes for each empowering [24]. Furthermore, exercising in iVR has been participant depending on their tiredness level and resting heart found to be an effective intervention to increase enjoyment and rate (RestHR). http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Participants Rules and Logic Participants were recruited from a local university campus A game is an activity that requires at least one player, has rules, through posters, social media platforms, and a mailing list. The and has a victory condition [45]. The design of our game study included university students with the ability to speak followed this definition and was inspired by the game called English, who were not disabled, were not pregnant (because of Just Dance, which requires users to follow and imitate the the physical exertion required to play the game), and had not dancing gestures one by one and has been used in some prior consumed any alcohol during the day (blood alcohol level of studies [46]. However, the level of our program consists of a approximately 0.07% could reduce symptoms of cybersickness sequence of exercise gestures instead of dance movements. As [42], which might affect the results of our study). the game starts, the player needs to follow the body gestures of the instructor in the VR system to move his/her body Participants were excluded from the experiment if they (1) accordingly. For ease of reproducing the gestures, a gesture is answered “yes” to any of the Physical Activity Readiness deemed completed if specific joint positions (eg, head, Questionnaire (PAR-Q) [43] questions, (2) had a resting blood controllers, and trackers) of the player meet the predefined pressure higher than 140/90 mmHg, and (3) had a RestHR level variables of corresponding gestures based on a simple rule-based that was too low (ie, RestHR <62 beats/min for a 16 to system and if the player can keep the pose for 0.4 seconds, 19-year-old female, RestHR <60 beats/min for a 20 to which was determined from the results of a pilot study with 10 39-year-old female, RestHR <56 beats/min for a 16 to participants, where we found that a short pose hold time could 19-year-old male, or RestHR <55 beats/min for a 20 to lead to gesture misrecognitions and a long pose hold time could 39-year-old male) or too high (ie, RestHR >94 beats/min for a lead to player fatigue easily. In addition, this time of 0.4 seconds 16 to 19-year-old female, RestHR >89 beats/min for a 20 to was informed from the literature in other fields (eg, text entry 39-year-old female, RestHR >87 beats/min for a 16 to [47]). A badge [48] is given to players when they complete 19-year-old male, or RestHR >84 beats/min for a 20 to every 10 actions as an in-game achievement to motivate them 39-year-old male) [44]. to follow and replicate the gestures carefully. The victory All participants received drinks and snacks for their participation condition was to successfully follow the instructor’s gestures after they finished the experiment. The University Ethics and not fail to follow these gestures three times in a row. In Committee at Xi’an Jiaotong-Liverpool University approved addition, our game warned users when they were not paying the experiment. All participants signed informed consent forms attention to the virtual instructor by tracking the rotation data prior to taking part in the study, and the research protocol was from the HMD. Both visual and auditory feedback were approved by the University Ethics Committee. provided to encourage players to continue playing. To determine the sample size for the study, a statistical power Game Procedure analysis was performed. This statistical power analysis was not The game starts with a calibration phase (Figure 1A) for the based on data from prior studies owing to limited similar work. system to take into account the individual differences of players. It was based on general considerations about the trade-offs The player needs to lift the hands midair and confirm having between the ability to detect certain effects and the feasibility finished the calibration by pressing a button on the controllers. to acquire a sufficiently large sample. We used a sample size The system then records the position data of the head, hands, calculation software program (G*Power version 3.1.9.2 for and feet. After the calibration phase, the game progresses to the Windows), with an effect size of 0.5 (Cohen d), statistical power training (warm-up) phase (Figure 1B), where the player needs of .90, and statistical level of significance of .05. The sample to follow the virtual instructor to perform two rounds of six size was established at 44 participants, and we decided to recruit gestures with a fixed order to become familiar with the gestures an additional 10 participants in the case of dropouts. that need to be performed. The gameplay phase (Figure 1C) starts after the training phase, where the player needs to follow Game the virtual instructor who performs gestures presented in a The game was implemented in Unity3D with the SteamVR random manner. plugin to enable positional tracking of the HTC VIVE trackers and controllers. Figure 1. (A) Calibration, (B) training, and (C) game phases for the seated version; the process for the standing version is the same, except the instructor is standing instead of sitting. http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al the sitting and standing versions of the exergame. The selection Included Gestures process of gestures and the intensity values were informed by Table 1 shows the intensity of the gestures selected for our the results of a pilot study (Multimedia Appendix 1). game. Figure 2 shows the final pose of the gestures involved in Table 1. Intensity level of the gestures used in the experiment. Gesture Intensity (%) Sitting gesture Hands up 32.30 Knees up 32.27 Feet up + hands up 35.10 Feet up + hands stretched 34.75 Knees up + hands up 42.39 Knees up + hands stretched 44.03 Standing gesture Hands up 31.00 Hands stretched 37.20 Left/right kick 27.25 Squat 50.69 Hand stretched + kick 43.88 Hands up + kick 46.05 Figure 2. Seated gestures: (A) Hands up + knees up; (B) Hands up; (C) Knees up; (D) Feet up + hands up; (E) Hands stretched + knees up; (F) Hands stretched + feet up. Standing gestures: (G) Left/right kick; (H) Squat; (I) Hands up; (J) Left/right kick + hands up; (K) Left/right kick + hands stretched; (L) Hands stretched. increased HR%, which was the difference between the HR% at Outcome Measurements the beginning and the end of the game phase, for a direct comparison of both versions. Calories burned were calculated Exertion using the Polar Beat mobile app with the activity set as other We measured participants’ exertion based on HR and calories indoor activity and the user profile of the app calibrated to each burned using a Polar OH1 wrist-strap monitor. Average HR participant. We started recording the HR and calories burned (AvgHR%) was expressed as a percentage of a participant’s as soon as the participants finished the training phase. estimated maximum HR (MaxHR), where MaxHR was Furthermore, the Borg CR 6-20 [50] rating of perceived exertion estimated as 220 minus age [49]. This measure is commonly (RPE) was used to measure the participants’ perceived exertion used in exercise studies to confirm that participants are working level. It describes the physical efforts involved in completing at a required level of exertion. Additionally, we measured the the game as perceived by the participants, with “6” indicating http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al “no exertion,” “13” indicating “somewhat hard exertion,” and the perceived competence and pressure/tension subscales “20” indicating “maximum exertion.” Borg RPE is frequently because they are positive and negative predictors of intrinsic used in exercise sciences as a quantitative measure of perceived motivation, respectively. In addition, the subscale exertion when exercising [50,51], and it has been applied to value/usefulness has been used in internalization studies [57] studies with iVR exergames [4,20]. and can provide us with an idea about how people internalize and self-regulate themselves with respect to the activities that Gameplay Data they experience as useful or valuable for themselves. The IMI We collected several types of data in the background, including has gained widespread acceptance as a multidimensional (1) the action completion time of every successfully performed measure of intrinsic motivation in the context of sports and gesture, which was equal to the time spent by the user to perform exercising [58,59] and has been widely used in studies dealing the same pose and hold the pose for 0.4 seconds, (2) the number with iVR exergames [23,60,61]. Each item was rated on a of gestures missed for each gesture type, and (3) the real-time severity scale ranging from 1 (not at all) to 7 (very). A higher HR data from the Polar OH1 optical HR sensor for every 0.2 score indicates a more internally motivated self-regulated seconds in the actual experiment stage. Therefore, we analyzed physical activity behavior. (1) the average action completion time, (2) the total number of We measured fear of falling by asking participants “how missed gestures, and (3) the plot profile of real-time HR. concerned are you about the possibility of falling during the Motion Sickness experiment?” using a 10-point Likert scale from 1 to 10, with 1 indicating “very slightly or not at all” and 10 indicating Motion sickness was assessed using the self-reported 16-item “extremely.” Motion Sickness Assessment Questionnaire (MSAQ) [52], which is a valid descriptor of motion sickness in the general After completing the above questionnaires, participants were population that covers the following four dimensions of motion asked to answer the following open-ended question in the sickness: gastrointestinal (stomach sick, queasy, nauseated, and questionnaire: “What do you think about this version of the vomit), central (faint-like, lightheaded, dizzy, spinning, and game?” They responded by typing into a text box. There was disoriented), peripheral (sweaty, clammy, and hot/warm), and no limit for the length of participants’ responses. A full list of sopite-related (annoyed, drowsy, tired, and uneasy). The results questions used after each condition can be found in Multimedia from the MSAQ were correlated strongly with the overall scores Appendix 2. from the Pensacola diagnostic index (r=0.81; P<.001) and the Apparatus and Setup nausea profile (r=0.92; P<.001) [52]. It has been found that the MSAQ is a valid evaluation tool and that it is advantageous to The experiment was conducted using HTC VIVE Pro Eye use this multidimensional questionnaire rather than the connected to an HP Z workstation (i7 CPU, 16 GB RAM, and one-dimensional form [52]. The questionnaire has been widely Nvidia Quadro P5200 GPU). Two HTC VIVE handheld used in studies dealing with virtual environments [53-55]. The controllers, two HTC VIVE trackers, and two base stations were scale ranges from 1 (not at all) to 9 (severely). A lower score used to enable hand and feet motion tracking. A stable chair is associated with lower motion sickness. with two handles was used in the sitting condition. The HR was monitored by a Polar OH1 optical HR sensor, which has been Intrinsic Motivation proved to be able to capture good HR data when compared with Intrinsic motivation was measured using the self-reported the gold standard of HR measurement with an 25-item version of the Intrinsic Motivation Inventory (IMI) electrocardiography device [62,63]. The experiment was [56], which covers the following four subscales: conducted in an indoor laboratory room that could not be seen interest/enjoyment, perceived competence, pressure/tension, from the outside. The room temperature was always set to be and value/usefulness. Although IMI includes seven subscales, 23 to 24°C during the experiment. Figure 3 depicts the only interest/enjoyment measures intrinsic motivation and is experiment setup and devices used in the experiment. considered the primary self-reporting measure. We included http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Figure 3. Standing (A) and seated (B) experiment setup, and the devices used in the experiment: (1) the HTC VIVE base stations, the locations of the two base stations can be found in the vertical view in the left bottom corner; (2) the two VIVE trackers attached to the legs; (3) the VIVE controllers used to track the player’s hand positions; (4) HTC VIVE Pro Eye; (5) the HP Z backpack; (6) the chair; and (7) Polar OH1. performance, IMI, MSAQ, fear of falling, and exertion Procedure measurements. For the percentage of missed gesture types for Before filling in the pre-experiment questionnaire that gathered sitting/standing gesture type, we used one-way repeated analysis demographic information (eg, age, gender, and experience with of variance (ANOVA) with the sitting/standing gesture type as the VR device), we obtained participants’ consent to participate the within-subjects variables, respectively. We also examined in the experiment and collected their RestHR and resting blood and reported if there were any significant gender differences in pressure. They were also asked to enter their age, gender, height, our measurements by using one-way between-subjects ANOVA. and weight into the Polar Beat app. Before each condition We set the α level at .05 in our analyses. We further reported started, a researcher would help them to wear the VIVE Pro the effect sizes using Cohen suggestion to classify the effect Eye headset with two VIVE handheld controllers and two VIVE size, where Cohen suggested that d=0.2 represents a “small” trackers. Participants were then given 3 minutes to get familiar effect size, 0.5 represents a “medium” effect size, and 0.8 with the corresponding condition of the iVR exergame. Once represents a “large” effect size [64]. Analyses were performed their HR reached the equivalent RestHR level, they proceeded using the Statistical Package for the Social Sciences (IBM Corp). to the experiment stage, beginning with calibrating the game, training, and testing. In each condition, they needed to perform Results 120 gestures, requiring 5 minutes (120 gestures × 2.5 seconds). We fixed the number of gestures to allow for comparing the Participant Characteristics two games. After each condition, they were asked to fill in Fifty-four individuals were interested in participating in the postexperiment questionnaires. They proceeded to the next experiment. Two were excluded owing to their high RestHR. condition when they felt rested and their HR was at the rest At the end, a total of 52 participants were eligible to participate level. in the study. The characteristics of the study participants are shown in Table 2. Statistical Analysis We used the paired t test to understand the difference between the seated exergame and standing exergame regarding gameplay http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Table 2. Characteristics of the study participants. Characteristic Value Number of students, n 52 Age (years), mean (SD) 18.81 (1.70) 77.71 (8.78) RestHR , mean (SD) Height (cm), mean (SD) 170.11 (7.75) Weight (kg), mean (SD) 60.84 (10.79) 20.93 (2.87) Body mass index (kg/m ), mean (SD) Self-reported exercise time per week (min), mean (SD) 87.88 (66.55) Normal or corrected-to-normal, n 52 Self-reported experience with seated exercise regimes No b c Self-reported experience with VR HMDs , n Frequent user, n 1 Self-reported experience with full-body gesture-based video games, n 28 Frequent player, n 4 RestHR: resting heart rate. VR: virtual reality. HMD: head-mounted display. completion time. However, the analysis showed that players Gameplay Data missed more gestures in the seated exergame than in the standing Gameplay data and analysis results are reported in Table 3. The exergame. analysis showed that game mode did not influence action Table 3. Gameplay data and exertion measures. Variable Standing exergame, mean (SD) Seated exergame, mean (SD) 51 P value Cohen d Gameplay Action completion time 1.48 (0.14) 1.53 (0.18) 1.87 .07 N/A Missed gestures 1.65 (1.71) 2.33 (1.83) 2.40 .02 0.332 Exertion 51.9% (4.6%) 54.3% (5.0%) 4.66 <.001 0.646 AvgHR% 6.9% (4.4%) 11.8% (5.3%) 5.86 <.001 0.813 Increased HR% Calories 21.83 (6.76) 24.67 (7.25) 4.44 <.001 0.615 Borg 6-20 9.02 (2.15) 10.25 (2.59) 3.96 <.001 0.548 Significant at .05. N/A: not applicable. AvgHR%: average heart rate percentage. HR%: heart rate percentage. gesture type (F =1.058, P=.38) on the percentage of 5,255 Percentage of Missed Gesture Types corresponding missed gestures. The missed rate for sitting and The results of one-way repeated ANOVA yielded no significant standing gesture types can be found in Figure 4. effect of the sitting gesture type (F =1.98, P=.08) or standing 5,255 http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Figure 4. Missed rates for (A) seated gestures and (B) standing gestures. Error bars indicate ±2 standard errors. exergame was rated as “very light” exercise according to the Exertion Borg 6-20 RPE scale. Exertion (AvgHR%, increased HR%, calories burned, and Borg To aid the visualization of the AvgHR% behavior of both 6-20) data and analysis results are presented in Table 3. The exergames, Figure 5 shows the AvgHR% data from all analysis yielded significantly higher AvgHR%, increased HR%, participants during the 5 minutes of gameplay, averaged over calories burned, and Borg 6-20 RPE for the seated exergame the whole session. The seated exergame had a higher AvgHR% (all P<.001). Our results suggest that the seated exergame was than the standing exergame after 0.34 minutes. rated as “very light” to “light” exercise and the standing Figure 5. Mean AvgHR% during gameplay for both versions of the exergame; the interaction between two lines occurs at 0.38 minutes. At 2.64 minutes, AvgHR% of the seated exergame reached the moderate physical intensity level. AvgHR%: average heart rate percentage. sickness (P=.02) and sopite-related sickness (P=.004) for the Experience seated exergame. We did not find a significant difference Data analysis of the MSAQ included the overall MSAQ score between the seated exergame and standing exergame in terms and its subscale scores (gastrointestinal, central, peripheral, and of central (P=.81), gastrointestinal (P=.81), and overall sickness sopite-related). The MSAQ data and analysis results are reported (P=.06). in Table 4. The analysis showed significantly higher peripheral http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al Regarding IMI, there was no significant difference for The one-way between-subjects ANOVA showed that interest/enjoyment (P=.96), perceived competence (P=.26), and interest/enjoyment was rated significantly higher by females pressure/tension (P=.42). However, the analysis yielded a (mean 5.20, SD 1.23) than males (mean 4.38, SD 41.16), with significantly higher value/usefulness for the seated exergame a medium effect size (F =6.01, P=.02). 1,50 (P=.04). IMI data and analysis results can be found in Table 4. Table 4. Motion Sickness Assessment Questionnaire and Intrinsic Motivation Inventory test measures. Variable Standing exergame, mean (SD) Sitting exergame, mean (SD) P value Cohen d MSAQ Peripheral 22.7% (12.9%) 27.7% (14.3%) −2.41 0.334 Sopite-related 18.8% (11.3%) 23.9% (15.4%) −3.06 0.424 Central 19.2% (11.1%) 18.8% (10.7%) 0.24 .81 N/A Gastrointestinal 13.5% (5.7%) 13.7% (5.2%) −0.24 .81 N/A Overall 17.4% (7.3%) 19.4% (8.4%) −1.91 .061 N/A IMI Interest/enjoyment 4.73 (1.30) 4.72 (1.30) 0.05 .96 N/A Competence 4.99 (1.12) 4.85 (1.20) 1.14 .26 N/A Pressure/tension 2.90 (0.95) 2.99 (1.04) −0.82 .42 N/A Value/usefulness 5.12 (1.28) 5.38 (1.12) −2.11 0.292 Significant at .05. MSAQ: Motion Sickness Assessment Questionnaire. N/A: not applicable. IMI: Intrinsic Motivation Inventory. exercising in the seated position (none of them had previous Fear of Falling experience of seated exercising; Table 2). There was no significant difference in the fear of falling ratings Regarding motion sickness, previous studies [31,32] have between the standing exergame (mean 2.10, SD 1.58) and seated suggested that the seated exergame might result in a lower level exergame (mean 2.40, SD 1.78) (t =−1.16, P=.25). of motion sickness. However, this was not supported by our findings. We observed that participants felt sicker (ie, peripheral Discussion and sopite-related motion sickness) in the seated exergame. However, the reason was beyond the scope of this study; a Overview further investigation is required to understand why motion With the limited exploration of seated exergames in the literature sickness was higher in the seated exergame than in the standing of iVR exergames, this study is the first to explore the difference exergame. We suggest that future designers and researchers between full-body gesture-based seated exergames and standing should carefully design full-body gestures for iVR seated exergames in iVR among university students regarding exergames to minimize motion sickness. playability (ie, gameplay performance) and user experience (ie, As for intrinsic motivation, we did not observe any significant intrinsic motivation and motion sickness). Our results suggest difference between the seated exergame and standing exergame that participants perceived higher value in the seated exergame (ie, interest/enjoyment, P=.96; perceived competence, P=.26; than in the standing exergame. However, the seated exergame pressure/tension, P=.42). However, there was a gender effect was associated with a worse gameplay performance (ie, the on participants’ intrinsic motivation toward exergames, where number of missed gestures) and a higher rating of motion we found that females had a significantly higher intrinsic sickness than the standing exergame. motivation (ie, interest/enjoyment) than males (P=.02). This Although we observed that participants missed a significantly could be because the exergame involved in our study was more higher number of gestures in the seated exergame than in the like a dance game, which was inspired by Just Dance, and prior standing exergame (P=.02), this rate was as low as 1.9% research [65] has shown that females tend to be more physically (2.3/120). Further analysis of the type of gestures missed in the active in dance exergames. Aside from this difference between seated exergame confirmed that these misses were in the early male and female participants, no other differences were found stages of the experiment, and as such, the main reason for the in our experiment. misses could be because of participant unfamiliarity with http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al In most cases, standing exercises have a higher exercise intensity Third, warning signs should be provided for standing exergames (in traditional exercises [66,67] and exergames [68,69]). We if users have left (or are about to leave) the calibration position found that our seated exergame led to a higher exertion (ie, and are too far to keep them protected. This is because players AvgHR%, increased HR%, calories burned, and Borg 6-20) tend to move around during gameplay, which we encountered than the standing exergame, possibly because the seated in our study and has been reported previously [23]. It could lead exergame involved more whole-body movements that required to potentially dangerous situations (eg, hitting objects that are increased energy expenditure during gameplay [70-73]. in the environment and going out of the safe tracking area) or decrease the recognition performance of the sensors (eg, tracking Design Guidelines may not work when they are too close to or far from the In this section, we provide design guidelines that are based on sensors). suggestions provided by Wiemeyer et al [74] for future game Limitations and Future Work designers who are interested in building iVR full-body standing or seated gesture-based exergames. Our study only focused on one sedentary lifestyle user group (university students). Future work could focus on investigating First, practice should be provided for each gesture during the two versions of the exergame with different population warm-up. A warm-up session before exercising is essential [75], groups (eg, older adults and users who have physical and it should be included in exergames as well. One way to disabilities). To minimize players’ cognitive workload, we set perform warm-up for full-body gesture-based exergames is to both exergames to include only 6 out of the 10 gesture types practice the gestures involved in the game, which will not only that we measured during the pilot study. In the future, we could help players reduce the risk of injures but also make them add more gestures to increase the complexity of the game (as familiar with the in-game gestures. stated by participants 13, 20, 30, and 37). A further limitation Second, the difficulty level of the game should be adapted to is that our experiment did not measure which types of gestures the current state of the individual. Regarding an offline approach, caused the unwanted level of motion sickness in the seated players might have difficulty in performing certain gestures exergame. Future experiments could be conducted to check during gameplay. Therefore, to match the difficulty of the game issues related to motion sickness based on specific gestures and to the current state of the individual, it would be necessary for types of gestures. players to experience and select gestures they are comfortable Conclusions performing before playing the game. Regarding an online Our contributions to the field of iVR exergaming regarding approach, one of the adaptive methods that has been used and gameplay performance and user experience are as follows: (1) pro v en to be suitable in e x er g ames is the iVR seated exergame could result in higher exertion and proportional–integral–derivative (PID) control [76]. Designers provide higher value to players than the standing exergame; (2) can use PID control to modify the transition time between participants might feel sicker in the iVR seated exergame than gestures or select the gestures based on the player’s real-time in the standing exergame, and as such, full-body gestures for HR and gameplay performance (ie, the number of gestures seated exergames need to be designed carefully to help minimize missed). PID control is also useful to avoid overly vigorous the feeling of motion sickness; and (3) participants might miss exercise, which might put the exerciser at risk of eliciting more gestures in the iVR seated exergame than in the standing unwanted coronary issues [77]. exergame. Therefore, designers should allow more time for performing gestures in the seated exergame. Acknowledgments This research was supported by Xi’an Jiaotong-Liverpool University Key Program Special Fund (grant no. KSF-A-03) and Xi’an Jiaotong-Liverpool University Research Development Fund. The authors thank all the participants who volunteered for the study and the reviewers for their suggestions that helped improve this article. Conflicts of Interest None declared. Multimedia Appendix 1 Approach for measuring the intensity of gestures. [PDF File (Adobe PDF File), 122 KB-Multimedia Appendix 1] Multimedia Appendix 2 Questionnaire used in the study. 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[doi: 10.1093/eurheartj/ehn163] [Medline: 18426850] Abbreviations ANOVA: analysis of variance AvgHR%: average heart rate percentage HMD: head-mounted display HR: heart rate IMI: Intrinsic Motivation Inventory iVR: immersive virtual reality MaxHR: maximum heart rate MSAQ: Motion Sickness Assessment Questionnaire PAR-Q: Physical Activity Readiness Questionnaire PID: proportional–integral–derivative RestHR: resting heart rate RPE: rating of perceived exertion VR: virtual reality Edited by G Eysenbach; submitted 25.01.20; peer-reviewed by A Duhamel, E Dove; comments to author 16.03.20; revised version received 27.04.20; accepted 03.06.20; published 27.07.20 Please cite as: Xu W, Liang HN, He Q, Li X, Yu K, Chen Y Results and Guidelines From a Repeated-Measures Design Experiment Comparing Standing and Seated Full-Body Gesture-Based Immersive Virtual Reality Exergames: Within-Subjects Evaluation JMIR Serious Games 2020;8(3):e17972 URL: http://games.jmir.org/2020/3/e17972/ doi: 10.2196/17972 PMID: 32716004 ©Wenge Xu, Hai-Ning Liang, Qiuyu He, Xiang Li, Kangyou Yu, Yuzheng Chen. Originally published in JMIR Serious Games (http://games.jmir.org), 27.07.2020. 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 http://games.jmir.org/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Xu et al 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/2020/3/e17972/ JMIR Serious Games 2020 | vol. 8 | iss. 3 | e17972 | p. 15 (page number not for citation purposes) XSL FO RenderX

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Published: Jul 27, 2020

Keywords: exergames; immersive virtual reality; standing exergame; seated exergame; exercising

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