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

Learn More →

Software Engineering Frameworks Used for Serious Games Development in Physical Rehabilitation: Systematic Review

Software Engineering Frameworks Used for Serious Games Development in Physical Rehabilitation:... Background: Serious games are a support in the rehabilitation process for treating people with physical disabilities. However, many of these serious games are not adapted to the patient’s needs because they are not developed with a software engineering framework with a set of activities, actions, and tasks that must be executed when creating a software product. Better serious games for rehabilitation will be developed if the patient and therapist requirements are identified, the development is planned, and system improvements and feedback are involved. The goal is that the serious game must offer a more attractive environment, while maintaining patient interest in the rehabilitation process. Objective: This paper submits the results of a systematic review of serious games in physical rehabilitation identifying the benefits of using a software engineering framework. Methods: A systematic research was conducted using PubMed, PEDro (Physiotherapy Evidence Database), IEEE Xplore, ScienceDirect, ACM Digital Library, Mary Ann Liebert, Taylor & Francis Online, Wiley Online Library, and Springer databases. The initial search resulted in 701 papers. After assessing the results according to the inclusion criteria, 83 papers were selected for this study. Results: From the 83 papers reviewed, 8 used a software engineering framework for its development. Most of them focused their efforts on 1 or more aspects, such as data acquisition and processing, game levels, motivation, therapist supervision. Conclusions: This systematic review proves that most of the serious games do not use a software engineering framework for their development. As a result, development systems overlook several aspects and do not have a standardized process, eventually omitting important implementation aspects, which impact the patient’s recovery time. (JMIR Serious Games 2021;9(4):e25831) doi: 10.2196/25831 KEYWORDS serious game; physical rehabilitation; framework; methodology https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al The concept of framework is widely used in the field of Introduction computer science. However, there is some confusion between the software engineering framework and the application Overview framework. The former provides a skeletal abstraction of a According to the World Health Organization, over 1 billion solution to several problems that have some similarities. A people have some form of disability [1], with up to 200 million software engineering framework will generally outline the steps people having loss or decrease in movement, which limits their or phases that must be followed in implementing a solution ability to perform activities of daily living. To overcome it, they without getting into the details of what activities are done in must undergo a rehabilitation program to gradually regain each phase [7]. The goal is for developers to use the framework movement and consequently, improve their quality of life. as a guide to creating software systems by applying “building blocks” depending on the problem domain; by contrast, However, the traditional rehabilitation process is often slow application framework is an integrated set of software artifacts and presents problems such as lack of motivation, boredom, (such as classes, objects, and components) that collaborate to and others; as a result, many patients consider the exercises provide a reusable architecture for a family of related stressful, and therefore abandon the therapy [2]. applications [8]. They are used to facilitate the development To avoid these situations, new ways of conventional therapy process of applications, reducing time, effort, and costs. support have been used in recent years, such as medicinal Software engineering framework and application framework treatments, robotics, video games (known as serious games), should not be confused. The latter is composed of and others [3], which have contributed to faster rehabilitation pre-established source codes (eg, data access routines, form when performing exercises in a fun way, allowing the patients validation, templates) that the programmer uses to reduce to forget their conditions and concentrate on the game. workload and do not start the project from scratch. For this reason, new interaction modes, such as serious games One of the main motivations for applying a software engineering [4], have the potential to provide more attractive, motivating, framework in serious game development is to design an efficient and enriching experiences for patients who suffer from decreases and satisfactory system for the patient. in movement. Currently, serious game–based physical rehabilitation is an area of research in constant evolution, and Software Engineering Frameworks and Serious Games therefore, there is the need for developing guidelines adapted The use of software engineering frameworks for the from other research fields. development of serious games allows the application of a variety Despite the potential benefits of serious games in physical of concepts, models, techniques, and artifacts at a high level of rehabilitation, many available platforms are inflexible and abstraction. Being an interdisciplinary field, an orientation on limited in their scope. Many developments do not follow a the developed tasks is required. Besides, it is flexible to adapt process involving a set of activities, actions, or tasks that must to changing conditions or personalization according to the final be executed when a software product is to be created. As a approach of the video game (rehabilitation, education, etc.). result, essential elements to the patient’s improvement process Serious games like other software developments require a are ignored within the video game. Some of these elements are “systematic, disciplined, and quantifiable” approach. Every motivation, play levels, player commitment, challenges aspect of production, from early stages of system specification according to the patient’s level, clinical evaluation, assessment to maintenance after its operation, must be established. Below scales, among others [5,6]. is a set of related activities that lead to the development of a This work aims to describe the software engineering frameworks software product [9-12]. used in serious games development and their benefits in the Structural Activities in Software Development physical rehabilitation process. In software engineering, 5 generic structural activities are used Background during software development [9-12]: communication, planning, modeling, construction, and deployment. The software process A Note on Frameworks details will be different in each case, but the structural activities The term framework has several meanings depending on the are the same. The definitions of the structural activities are field. For example, it may refer to a model, prescription, presented in Textbox 1. guidelines underlying a design and analysis, among others. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Textbox 1. Definitions of the structural activities in software development. Communication Defining the software characteristics and functions is particularly important to communicate and collaborate with the client and other participants. This activity aims to understand the project objectives of the participants and meet the requirements. Planning Once the requirements are obtained, this activity presents an estimate of the resources; establishes a software project plan; and describes technical tasks, probable risks, and program activities. Modeling Its objective is to help understand the requirements through models. The models’ aim is to affirm the understanding of the work and give technical guidance to those who will implement the software, establishing, for example, the database model, the software architecture, user screen prototypes, and others. In some developments, this activity is the equivalent of the design stage. Construction This activity consists of the code generation and tests required to discover bugs in the software product. Deployment Once the software is created (completely or an increment), it is delivered to the client who will evaluate it and give feedback for system improvement. gamification in the rehabilitation of patients with Gamification musculoskeletal disorders of the shoulder. They concluded that According to Kumar [13] gamification applies game design gamification is essential in health care to enhance motivation principles and mechanics to nongame environments. In the and support therapy in general, especially in chronic diseases rehabilitation process, gamification can increase motivation and and rehabilitation. Other advantages are motivation, avoiding engagement through rewards, game levels, accessibility, boredom, and distraction from pain and anxiety. feedback, and challenge. Therefore, the software engineering Related Works framework for serious game development must incorporate gamification. Various gamification elements include immersion, A systematic review of literature is a method to identify, support for different roles, flow enhancement, visual evaluate, and interpret all available and relevant research of a enhancement, support for different learning stages and particular research question, subject area, or phenomenon of experience levels, design for interactivity, and progress [14]. interest. The individual studies that contribute to the systematic By contrast, Vermeir et al [15] identified the following elements: review are called primary studies. A systematic review is also avatar, challenge, competition, difficulty adjustment, feedback considered a form of secondary study [18]. loops, levels, progress, rewards, social interaction, sound effects, This systematic review includes literature work on developing and story/theme. serious games in physical rehabilitation using a software engineering framework. To identify existing secondary research Benefits of Gamification in Rehabilitation in the same field, we searched the following electronic de Castro-Cros et al [16] analyzed the effects of gamification databases: IEEE Xplore, ACM Digital Library, Wiley Digital on the mental imagery brain–computer interface in rehabilitation Library, PubMed, ScienceDirect, Taylor & Francis, Mary Ann functional assessments in 10 patients with stroke with Liebert, and Springer. Besides, we used Google Scholar as a hemiparesis in the upper limb and 6 healthy individuals. The web source to broaden our results. authors concluded that user opinions about the game level of entertainment, clarity of rules, narrative, and visual The search was realized using the following search string: A1 attractiveness were all positive. The patients were consensus AND B1 AND (C1 OR C2 OR C3 OR C4 OR C5 OR C6). about the interest in gamifying stroke rehabilitation sessions. Textbox 2 shows the terms included in the search string. By contrast, Steiner et al [17] performed a scoping review of https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Textbox 2. Search terms to identify related secondary studies. A term A1. Serious games B term B1. Framework C term C1. Review C2. Systematic review C3. Systematic literature review C4. Systematic mapping C5. Mapping study C6. Systematic mapping study When this search was performed in the electronic databases, no questions focused on discovering if quality has been constant related secondary studies were identified. Therefore, we sought throughout the software development cycle or in some stages. systematic reviews focused on software engineering frameworks The authors showed that 97% of the literature reviewed applied in any field. Table 1 summarizes the secondary studies found. quality in the final phase (product). Only 7.14% focused on quality in the design phase and 1.79% in the requirement phase. Mubin et al [19] performed a review on gamification design This study was included because it identified the phases in which framework and its application for children with autism. This quality was applied: requirement, design, code, and final review aimed to offer gamification solutions for interaction product. skills. They identified the framework phases in 5 papers and target users/audience/focus. The authors concluded that Tomalá-Gonzáles et al [21] reported on methodologies, game frameworks have been analyzed from an in-game context but engines currently used in serious games development in various did not emphasize on children with autism. In the literature, areas (education, cognitive disabilities, and physical studies show that gamification is very effective in the areas of rehabilitation), and criteria for game engine selection. From the therapy and education for children with autism. The most 27 papers, 8 used a defined methodology such as XP, Cascade, important contribution of this review is the development of and others, while 3 proposed their own model. The authors interaction skills. This review identified phases of the concluded that although several software development development process in some studies (eg, planning, designing). methodologies can be adapted to serious game development, However, it does not explain how users benefit from the process the best option was the SUM methodology because it is based interaction. on Scrum (fast, precise, optimized, and adaptable programming characteristics). However, this review did not make distinctions Vargas et al [20] developed a systematic mapping study on between framework and methodology. It also did not identify serious game quality. The aim was to discover the current state methodology phases nor the benefits of applying a methodology of serious games quality initiatives. One of the research in the learning or rehabilitation process. Table 1. Summary of secondary studies. Study Type Year of publication Target users/audience Benefit of framework Phases of process devel- /focus opment identified? Mubin et al [19] Review 2019 Children with autism Interaction skills in Yes children with autism Vargas et al [20] Systematic 2014 Serious games quality Quality Yes mapping study Tomalá-Gonzáles et al [21] Review 2020 Identifies methodologies No and game engines Not available. Although our work shares similarities with the aforementioned activities proposed by Pressman [9], who states that “The studies, the literature review presented in this paper is different software process details will be different in each case, but the because this review (1) focuses on serious games for physical structural activities are the same”; (3) identifies contributions rehabilitation, (2) identifies the software development stages in of software engineering frameworks to the rehabilitation process; each software engineering framework according to the structural and (4) identifies if the proposed software engineering https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al framework provides objective monitoring of the rehabilitation The first phase consists of the following steps: (1) describe the process. main reasons for the literature review, (2) specify a set of research questions, and (3) review the protocol. The second Methods phase comprises 4 steps: (1) identify important research, (2) select primary studies, (3) extract data from primary studies, Research Methodology and (4) synthesize data. Finally, the third phase consists of 3 steps: (1) obtain results, (2) identify the validity threats, and (3) The systematic literature review process proposed by Brereton conclusions. Figure 1 shows the literature review process. In et al [22] was applied for this systematic review. Figure 1 shows the following subsections, we describe the activities carried out the process and steps for each phase. The process consists of 3 in each phase of this systematic literature review. main phases: plan review, conduct review, and document review. Figure 1. Literature review process. elements. It allows transforming obstacles into positive and fun Research Questions reinforcements, thereby encouraging patients. In this subsection, we present the 9 research questions that RQ5 and RQ6 are centered on applicability and serious game guided this study through the investigation to meet the objectives characteristics for rehabilitation using a software engineering of the systematic review. Table 2 presents these questions. framework. These questions identify relevant data such as target The research questions can be classified into 4 fields of interest. audience, interaction technology for data acquisition, main RQ1 and RQ2 study serious games evaluated in software modalities, among others. engineering. These questions identify the number of serious Finally, RQ7, RQ8, and RQ9 studied important aspects to games developed with a software engineering framework and evaluate and provide follow-up of rehabilitation progress the set of activities, actions, and tasks required. depending on the type of exercise. RQ3 and RQ4 describe framework contributions to the rehabilitation process and implementation of gamification https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Table 2. Research questions. Research question Question 1 What framework is used in the development of the serious game? 2 What are the generic structural activities used in frameworks? 3 How the framework contributes to the rehabilitation process? 4 What gamification elements does the framework use? 5 What is the targeted disability contemplated in the frameworks? 6 If the framework includes a case study, which part of the body is rehabilitated? What is the modality of the serious game? Which interaction technology is used? 7 What type of evaluation and number of patients are involved in the clinical trials? 8 Does the framework contemplate a standardized scale to evaluate the patient’s rehabilitation progress? 9 Does the framework contemplate adaptability? were identified by searching in the following databases: Search Strategy PubMed, PEDro (Physiotherapy Evidence Database), IEEE The objective of the search strategy was to identify all relevant Xplore, ScienceDirect, ACM Digital Library, Mary Ann Liebert, primary studies. A literature search was conducted to answer Taylor & Francis Online, Wiley Online Library, and Springer. the proposed research questions. To build the search string, a list of keywords and their synonyms were identified. Logical operators (AND and OR) and words The search strategy is an adaptation of Guidelines for related to rehabilitation, serious games, and framework were Performing Systematic Literature Reviews in Software used. The final search strings consisted of the following Boolean Engineering [18] and Preferred Reporting Items for Systematic expressions: “(A1 AND (B1 OR B2)) AND (C1 OR C2 OR Reviews and Meta-Analyses (PRISMA) [23]. Relevant papers C3) AND D1”. The search terms are shown in Textbox 3. Textbox 3. Search terms for the final search string. A term A1. Serious B term B1. Game B2. Games C term C1. Rehabilitation C2. Disability C3. Disabilities D term D1. Framework using serious games, serious games for educational purposes, Inclusion Criteria and serious games for cognitive rehabilitation were excluded The systematic review is focused on serious games for physical from the study. rehabilitation; clear inclusion criteria were established to Study Selection determine the eligibility of papers for inclusion in the review. Only studies with the following criteria were considered eligible First, the search string was used in different databases. for inclusion: serious game papers for physical rehabilitation, Potentially relevant papers were identified after reading the title papers published in English, and all serious games regardless and abstract. Duplicate papers were removed. Subsequently, an of the year of development. exhaustive verification of compliance with the inclusion and exclusion criteria was carried out to select the papers. Figure 2 Exclusion Criteria shows the item selection process. In the systematic review, 701 Papers duplicated, papers regarding opinion pieces, existing papers were included. Table 3 shows the number of documents literature reviews, papers that are not related to rehabilitation retrieved from each database. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Figure 2. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)–based flowchart. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Table 3. Search results. Databases Results, n PubMed 14 PEDro 12 IEEE Xplore 103 ScienceDirect 88 ACM Digital Library 166 Mary Ann Liebert 27 Taylor & Francis Online 50 Wiley Online Library 43 Springer 198 Two types of data were extracted for each study: bibliographic Extract Data From Primary Studies (title, author name, country, year, database) and content data, After identification, the primary papers were rigorously analyzed which are used to answer the research questions. Table 4 shows in accordance with the following considerations: (1) only the the concentration of the bibliographic data of the primary papers. authors of this review can participate in the data collection Multimedia Appendix 1 shows the percentage of primary studies process; (2) each primary paper should be reviewed with at least from each electronic database. IEEE Xplore presented more two reviewers; (3) each reviewer will collect a set of data from primary studies than the rest. The following section presents an each primary study, then meet with another reviewer to reach analysis of the data collected. an agreement on the data obtained. Table 4. Bibliographic data of the primary papers. Study Year Country Database Baranyi et al [24] 2013 Austria IEEE Xplore Pirovano et al [25] 2016 Italy ScienceDirect Amengual Alcover et al [26] 2018 Spain PubMed Baranyi et al [27] 2019 Austria IEEE Xplore Zain et al [28] 2012 Malaysia IEEE Xplore Noveletto et al [29] 2018 Brazil ScienceDirect Afyouni et al [30] 2017 Cyprus ACM Digital Library Maggiorini et al [31] 2012 Switzerland ACM Digital Library virtualization, game design, and secondary goals. In exercise Results definition, a set of exercises is proposed to cover therapy needs. Each exercise is structured into primary and secondary goals. RQ1: What Framework Is Used in the Development During virtualization, the team identifies primary goals, and of the Serious Game? they are implemented into a virtual exercise by defining input Only 8 (10%) out of the 83 papers related to physical (tracking) and output (feedback) requirements through simple rehabilitation using a software engineering framework graphical elements and specifying interaction mechanisms. (Multimedia Appendix 2). Through game design, the virtual exercise is converted into a true exergame. In the last step, there are 2 functionalities. The In Baranyi et al [24,27], the proposed studies were based on the first is to analyze motion data and identify wrong movements. user-centered design framework. The physiotherapist is The second provides feedback to the patients. important because s/he identifies the needs and limitations of the patients in the rehabilitation process. There are 3 phases: In Amengual Alcover et al [26], the serious game development research, design, and evaluation. In research, a physiotherapist framework follows an iterative process flow structured into 2 conducts brainstorming with the work team and identifies the dimensions: activities and incremental development. The first requirements. Afterward, in the design phase, the team creates dimension is based on 3 approaches: Scrum, the web application mock-ups and a prototype. Finally, the physiotherapist evaluates development model, and a clinical trial. The activities dimension the application. includes a project initiation activity, an iterative flow composed of 4 basic development activities (planning and control, Pirovano et al [25] proposed a 4-step procedure to create safe modeling, construction, and evaluation), and a final clinical exergames for rehabilitation therapies: exercise definition, https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al study to evaluate the rehabilitation process of the patient through Every study established a communication activity to obtain the the serious game. Incremental development includes 3 different requirements. Baranyi et al [24] brainstormed with a increments: interaction mechanism, interaction elements, and physiotherapist to identify relevant problems and needs for serious game. In the first increment, an existing device on the patients undergoing rehabilitation. Pirovano et al [25] defined market is identified to capture the movements of patients exercises addressing the primary and secondary objectives of according to their needs. In the second increment, the rehabilitation. To achieve maximum effectiveness, the exercises development team must design the interaction elements that are defined in collaboration with therapists. In Amengual force patients to perform the therapy correctly. The final Alcover et al [26], the communication began by identifying the increment is aimed at designing a serious game that motivates context, operational objectives, restrictions, and requirements. the patient to perform therapy to obtain the best results. Baranyi et al [27] established communication with the therapist to obtain the requirements. Zain et al [28] identified the user Zain et al [28] proposed a conceptual framework for people abilities, limitations, and behavior, which become requirements with motor impairment, so they can enjoy the experience of for the serious game. Noveletto et al [29] considered experts in playing serious games. The framework’s main elements were the field (health personnel, therapists, etc.) and patients to obtain player skills, challenge, concentration, feedback, immersion, the requirements. Afyouni et al [30] established the type of learning opportunities, accessibility, and adaptivity. The game through patient needs, preferences, and limitations, proposed framework will help the game designer and developer allowing custom game features. Finally, Maggiorini et al [31] create a serious game that combines the game’s technology with analyzed the most diffused issues present in elders’ homes (eg, the learning environment. This framework is based on the game size of rooms, habits) to explore requirements and limitations flow model. through an immersive approach. Noveletto et al [29] presented a conceptual model for the design The planning activity was implemented in Amengual Alcover or development of serious games to rehabilitate people with et al [26]. The goal of this activity was to determine the tasks stroke. The framework establishes a relationship between experts to perform during the development by identifying the end and patients to obtain the requirements, considering that the products and the people who will do the work. The activity biomedical device and the video game score are used to design includes 3 tasks: planning, scheduling, and tracking. serious games. The modeling activity was performed in several papers. For Afyouni et al [30] proposed a framework consisting of a example, Baranyi et al [24] called it design, elaborating basic therapy-driven 3D environment augmented with a natural user models discussed with a therapist. Pirovano et al [25] interface based on movement. The framework incorporated transformed the exercise requirements into a true exergame by different adaptation techniques to adjust patient’s needs. Patient adding all the elements and characteristics of a game and a good preferences and limitations were considered key parameters for game design for the patients. Amengual Alcover et al [26] changing the game, thereby creating personalized games for created models that helped the development team to understand each patient. the requirements obtained and the game design. By contrast, Maggiorini et al [31] presented a framework for serious game Baranyi et al [27] contemplated the use of prototypes to refine development that allows the therapist to remotely control the user requirements. Finally, Maggiorini et al [31] established a video game home activities. The objective was to create a more list of technical characteristics (desired) for the prototype attractive game for the elderly with easily adjustable parameters creation. for therapy adaptability. The framework includes 3 phases of The construction activity was implemented in every study. serious game development: requirements definition, empirical Developments produce executable software units that will be validation of requirements list, and design and prototyping. used by users, through the creation of prototypes to improve the software [24-27,30,31], or the final product [28,29]. RQ2: What Are the Generic Structural Activities Used in Frameworks? Finally, the user evaluates and provides feedback on the serious The objective of this research question was to identify generic game in the deployment stage. In the primary papers, Pirovano structural activities in primary studies (see the “Background” et al [25] and Baranyi et al [27], patients were asked to give section). Table 5 summarizes the structural activities and their opinion to improve the game design and change some Multimedia Appendix 3 shows the frequency of occurrence of aspects of the application. each structural activity in primary studies. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Table 5. Structural activities in primary studies. Study Communication Planning Modeling Construction Deploy Baranyi et al [24] X X X — Pirovano et al [25] X — X X X Amengual Alcover et al [26] X X X X — Baranyi et al [27] X — X X X Zain et al [28] X — — X — Noveletto et al [29] X — — X — Afyouni et al [30] X — — X — Maggiorini et al [31] X — X X — Not available. For users with motor impairment, Zain et al [28] used flow RQ3: How the Framework Contributes to the theory [32] to propose user interface design factors that make Rehabilitation Process? their experience enjoyable when playing serious games. This Baranyi et al [24,27] applied a user-centered design approach framework includes user interface design factors and aims to to establish constant communication with the physiotherapist establish a conceptual model that can be used by a game who has the experience to identify the needs and limitations of designer for efficient game development or an educational the final user. Serious games are developed with entertainment practitioner when designing enjoyable serious games for users elements such as levels, rewards, challenges, and adaptability with motor impairment. to the patient need, considering special conditions. Noveletto et al [29] established a relationship among key Pirovano et al [25] proposed the creation of safe exergames, stakeholders (experts and patient) and elements (biomedical identifying the needs of real exercise besides therapy goals. device and game score) for serious game design. The framework These needs are incorporated into a video game considering the states that a correlation between the game score and clinical primary objectives (what a user should do) and secondary tests can aid treatment and evaluation through the biomedical objectives (how user actions should be carried out). The former system. is easily integrated into the gameplay, while the latter aids the Afyouni et al [30] proposed a framework for video game patient with corrections or prevention of compensatory development with an adaptive and user-centered approach. The movement through analysis of the flow of movement data and framework embeds different adaptation techniques to tailor to wrong movements in real time, thereby providing immediate patients’ needs. The video game adapts to the difficulty level feedback to patients to correct themselves during the exercise. based on the patient’s profile and performance in real time. Amengual Alcover et al [26] proposed an iterative, Other aspects such as patient preferences and constraints are prototype-oriented, systematized serious game development considered as key game-changing parameters. process. The proposed process guarantees that products based Finally, in Maggiorini et al [31], the framework allowed serious on this framework are developed and validated by following a game development with telerehabilitation allowing the therapist coherent and systematic method that leads to high-quality to remotely control the video game home activities. It supports serious games. parameter adjustments for therapy adaptability. Table 6 summarizes framework contributions. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Table 6. Framework contributions in primary studies. Framework contribution to rehabilitation Utility Primary studies Communication with health expert A physiotherapist establishes communications with patients Baranyi et al [24], Pirovano et al [25], undergoing rehabilitation to identify the problems and needs. Baranyi et al [27], Noveletto et al [29] Exercise definition Exercise can be defined as a sequence of different actions Pirovano et al [25] needed to complete it to achieve maximum effectiveness. Analyzes the stream of motion data and Provides immediate feedback to the patients for correct ex- Pirovano et al [25] identifies in real time wrong movements ercising. Iterative and prototyping Visualize prototypes of serious games from early stages. The Baranyi et al [24], Pirovano et al [25], therapist or patients identify additional requirements or Baranyi et al [27], Noveletto et al [29], modify them. Afyouni et al [30], Maggiorini et al [31] User interface design factors Motivation and immersion Baranyi et al [24], Pirovano et al [25], Amengual Alcover et al [26], Baranyi et al [27], Zain et al [28], Noveletto et al [29] The correlation between game score and Aids in patient treatment and evaluation Noveletto et al [29] clinical tests Adaptive approach Adapts difficulty level according to the patient’s profile and Baranyi et al [24], Pirovano et al [25], Zain performance in real time et al [28] Afyouni et al [30], Maggiorini et al [31] Telerehabilitation Therapists can remotely control the video game for home Maggiorini et al [31] activities and provide adjustable parameters to improve therapy gamification elements. The papers identified the following RQ4: What Gamification Elements Does the elements: feedback, motivational factor, adaptability, challenge, Framework Use? levels, immersion, rewards, concentration, and avatar. Table 7 shows the gamification elements in primary studies, and Overview Multimedia Appendix 4 shows the frequency of occurrence of Gamification allows the transformation of obstacles into positive each gamification element. and fun reinforcement, encouraging users to make the right The gamification elements of primary studies are described decisions for their health and well-being [33]. It is essential to below. keep the patient motivated in physical rehabilitation. For this reason, the software engineering framework is required to use Table 7. Gamification elements in primary studies. Gamification element Study Feedback Pirovano et al [25], Amengual Alcover et al [26], Baranyi et al [27], Zain et al [28], Noveletto et al [29], Afyouni et al [30], Maggiorini et al [31] Motivational factor Baranyi et al [24], Pirovano et al [25], Amengual Alcover et al [26], Baranyi et al [27], Noveletto et al [29] Adaptability Baranyi et al [24], Pirovano et al [25], Zain et al [28], Afyouni et al [30], Maggiorini et al [31] Challenge Baranyi et al [24], Zain et al [28], Afyouni et al [30] Levels Baranyi et al [24], Amengual Alcover et al [26], Baranyi et al [27], Afyouni et al [30] Immersion Zain et al [28] Rewards Pirovano et al [25] Concentration Zain et al [28] Avatar Pirovano et al [25] screen at all times. In Baranyi et al [27], the feedback provided Feedback was either visual, aural, or haptic. In Zain et al [28], users with In Pirovano et al [25], the feedback mechanisms were designed motor impairment received feedback on their progress, and to show the outcome of actions to patients. For instance, whether when they lose the game, feedback is provided to continue in a target is met or a movement has been successfully performed. the right direction. Noveletto et al [29] established that serious Amengual Alcover et al [26] used “mirror feedback,” which same should reward players with feedback on progress. Afyouni consists of projecting the user onto the screen and simulating a et al [30] used a scoring system that was designed to keep track mirror in such a way that the users can see themselves on the of the number of times the patient successfully passed through https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al the targets. Finally, in Maggiorini et al [31], a skeleton Immersion wireframe is drawn in red to provide immediate visual feedback, Zain et al [28] considered that immersive games draw players and an alarm is raised on the screen. into the game and affect their senses through elements such as audio and narrative. Motivational Factor Baranyi et al [24] used “goals.” The gameplay was based on Reward achieving goals that should act as motivation factors. Pirovano Pirovano et al [25] used a scoring system, and at the end of each et al [25] established that extrinsic motivational effects can be exergame, a virtual reward is presented to the patients. achieved through careful use of verbal praise, scoring Concentration mechanisms, and virtual reward systems. In Amengual Alcover et al [26], the development of new serious games allowed the Zain et al [28] considered that the more concentration a task inclusion of motivational elements to increase engagement. requires in terms of attention and workload, the more absorbing Baranyi et al [27] used rewards in serious games for the user. it will be. The games should grab the player’s attention quickly Finally, Noveletto et al [29] used the “motivational score” to and maintain it throughout the game. improve attention during rehabilitation sessions. Avatar Adaptability Pirovano et al [25] used an avatar for feedback on wrong Baranyi et al [24] proposed an adaptive system with the movements, changing the color of the associated avatar opportunity to adapt the game difficulty. Pirovano et al [25] segments. When wrong movements persist for a long time, the established that virtual exercises should use dynamic difficulty game is paused, and a virtual therapist avatar pops up to advise adaptation, thus further increasing the flexibility of serious patients. games. For Zain et al [28], an adaptive factor was important to RQ5: What Is the Targeted Disability Contemplated design and develop serious games for users with motor in the Frameworks? impairment because the application, aware of the users’ current cognitive load and physical limitations, can change its response, This specifies whether a study focuses on a particular pathology presentation, and interaction flow to improve users’ experience with loss or decrease in movement. The papers established the and their task performance. In Afyouni et al [30], the framework following target pathology: 4 defined strokes [24,25,27,29], 2 embeds different adaptation techniques to adapt to the patients’ defined neuromotor disorder [26,30], 1 defined users with motor needs. Key game-changing parameters such as patient impairment [28], and 1 defined rehabilitation of the elderly [31]. preferences and constraints are considered. This allows the Stroke is mainly targeted in studies because it is the second creation of personalized game features for every patient. cause of death and the third cause of disability worldwide [34]. Maggiorini et al [31] proposed that remotely controlled serious Multimedia Appendix 5 shows the target disability percentage. games may also provide easily tunable parameters to better RQ6: If the Framework Includes a Case Study, Which adapt the game therapy to the actual patient recovery. Part of the Body Is Rehabilitated? What Is the Challenge Modality of the Serious Game? Which Interaction Baranyi et al [24] proposed the challenge as a “key fact.” They Technology Is Used? considered that the game should not be too easy nor too hard As Table 8 reports, Baranyi et al [24] presented a prototype that to manage. The game should be sufficiently challenging and rehabilitates patients with lower limb disabilities with balance match the player’s skill level. Zain et al [28] proposed that and strength exercises using the Wii Fit Balance Board. Pirovano serious games should also vary the level of difficulty and keep et al [25] developed serious games for upper limb motor an appropriate pace. Afyouni et al [30] generated therapy-aware rehabilitation therapy using Microsoft Kinect and lower limb navigational movements with multiple levels of difficulty. with the Wii Fit Balance Board. Amengual Alcover et al [26] also rehabilitated the lower limb by allowing patients to perform Levels repetitions in a video game controlled with Microsoft Kinect, Baranyi et al [24] stated that the purpose of the serious game with each repetition varied according to the participant’s developed is to have a rehabilitation system containing different tolerance and the physiotherapist’s recommendations. Baranyi levels that were adapted and created for the individual needs of et al [27] performed hand rehabilitation using gesture exercises, the patients and to fit their impairments. Amengual Alcover et touch, and patient movement levels using mobile phone sensors. al [26] considered that serious games must have a definition of Zain et al [28] and Noveletto et al [29] did not report any case different levels in the game. In Baranyi et al [28], when the studies. Afyouni et al [30] developed a serious game for hand game is started for the first time, a diagnostic routine is rehabilitation using leap motion. Game instructions can be visual performed; using these data, a baseline for the exercises can be (shown on the screen) or voice, depending on the perception defined by the therapist to get an initial idea about how easy or capacity of the patient. Finally, Maggiorini et al [31] developed complex a level might be for a patient. Afyouni et al [30] a prototype for rehabilitation using Microsoft Kinect. It only presented different levels of difficulty based on therapeutic presents the skeleton tracking by a sensor and does not mention gestures and patient performance. whether the video game implements another form of communication with the patient. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al The modality is a way in which information is transmitted from Amengual Alcover et al [26], Baranyi et al [27], and Afyouni the computer to the participants [35]. Baranyi et al [24,27], et al [30] used audio effects such as music or voice instructions. Pirovano et al [25], Amengual Alcover et al [26], Afyouni et al Baranyi et al [27] used haptic modality to control the video [30], and Maggiorini et al [31] used a visual modality, presenting game through a touch screen. Zain et al [28] and Noveletto et a graphical interface for user interaction. Pirovano et al [25], al [29] did not report modalities. Table 8. Rehabilitated limb, serious game modality, and data-acquisition device in primary studies. Study Rehabilitation/extremity Modality Interaction technology Baranyi et al [24] Lower limbs Visual Wii Fit Balance Board Pirovano et al [25] Lower and upper limbs Visual, auditory Wii Fit Balance Board and Microsoft Kinect Amengual Alcover et al [26] Lower limbs Visual, auditory Microsoft Kinect Baranyi et al [27] Hand Visual, auditory, haptic iOS platform sensors Zain et al [28] Not reported Not reported Open Noveletto et al [29] Not reported Not reported Open Afyouni et al [30] Hand Visual, auditory Leap motion Maggiorini et al [31] Full body Visual Microsoft Kinect (mean 29.5 [SD 3.9] and after (mean 34.1 [SD 2.2]) the RQ7: What Type of Evaluation and Number of intervention. The Functional Reach Test revealed significant Patients Are Involved in the Clinical Trials? differences in functional balance before and after the The objective of this research question was to identify clinical intervention: right upper limb, before (mean 8.6 [SD 1.4]) and validation of the studies and the number of patients involved. after intervention (mean 10.1 [SD 2.0]; P=.007); and left upper In clinical trials, participants receive specific interventions limb, before (mean 8.3 [SD 2.0]) and after intervention (mean according to the research plan or protocol created by the 10.1 [SD 3.7]; P=.052). Finally, a significant difference between researchers to determine the safety and efficacy of the the pre- and post-assessment scores for the Tinetti Balance Test interventions through the measurements of the outcomes [36]. was observed at the end of the 24-week intervention period. Table 9 shows these data. Amengual Alcover et al [26] The average score rose from 16 to 21 points on a scale of 28 conducted a clinical trial and observed a significant difference points. Afyouni et al [30] reported that patients showed between before and after scores. They used the Berg Balance improved hand movement using a range of motion. They were Scale and their results showed a significant functional able to document 66% of the elements in the video game. No improvement (P=.002) in comparison with assessments before other study reported a clinical trial. Table 9. Type of evaluation and number of patients in the primary studies. Study Evaluation Number of patients Baranyi et al [24] No clinical validation N/A Pirovano et al [25] No clinical validation N/A Amengual Alcover et al [26] Clinical trial 9 Baranyi et al [27] No clinical validation N/A Zain et al [28] No clinical validation N/A Noveletto et al [29] No clinical validation N/A Afyouni et al [30] Clinical trial 5 Maggiorini et al [31] No clinical validation N/A NA: not applicable. on the type of exercise applied. During the analysis of primary RQ8: Does the Framework Contemplate a papers, we identified 3 studies with assessment instruments: Standardized Scale to Evaluate the Patient’s Pirovano et al [25], Amengual Alcover et al [26], and Afyouni Rehabilitation Progress? et al [30]. An assessment instrument allows to objectively quantify the RQ9: Does the Framework Contemplate Adaptability? disability degree of the patient and measure the progress of Adaptability is the ability to dynamically adapt difficulty in a rehabilitation [37,38]. The evaluation scales in the framework video game according to the patient’s performance [39]. Five are used to quantify the improvement in rehabilitation depending https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al primary studies use this characteristic. In Baranyi et al [24], the Conclusions physiotherapist designed the level of difficulty of the video The objective of this study was to identify the software game. Pirovano et al [25] established that for every exercise, engineering frameworks used in the development of serious quality parameters are necessary to define movement properties. games through a literature review of 8 primary studies. The This will allow one to determine the challenge degree of the conclusions of this study are as follows: exercises and adapt the difficulty to the patient’s needs. Zain et About 75% (6/8) of the primary papers proposed a framework al [28] mentioned that adaptability must consider the following [25,26,28-31], whereas the rest were adaptations of the elements: (1) user motivation, (2) experience and abilities, and user-centered design framework (RQ1). Regarding the structural (3) detection, which identifies necessary changes. Afyouni et activities, 100% (8/8) of the papers applied the communication al [30] adapted the difficulty level based on the patient’s profile and construction activity [24-31], 63% (5/8) used modeling and performance in real time. In Maggiorini et al [31] the (known as a design in some developments) [24-27,31], 25% therapist can remotely adapt the game therapy to the patient’s (2/8) considered user feedback to improve the serious games actual recovery. Amengual Alcover et al [26], Baranyi et al [25,27], and only 13% (1/8) included the planning phase [26] [27], and Noveletto et al [29] did not specify how adaptability (RQ2). is incorporated into their game. Multimedia Appendix 6 shows the percentage of frameworks contemplating adaptability. Each primary study contributes in one or more aspects to the rehabilitation process. Baranyi et al [24,27] applied a Threats to Validity of Primary Studies Selected user-centered design using which the physiotherapist can Although we used search strategies and techniques to personalize individual needs in the serious game. Pirovano et systematically find papers by using keywords in the selected al [25] proposed ease of play and assisted help during the databases, these words may vary within papers, so some relevant rehabilitation exercise. Amengual Alcover et al [26] developed studies may have been omitted. a framework for motor rehabilitation therapies using a systematized process. Zain et al [28] embraced immersion and Discussion fun in the game to maintain flow interest. Noveletto et al [29] used game scores for patient assessment. Afyouni et al [30] Preliminary Findings developed games with dynamic adaptability that were patient We found only few studies that used a systematic process for centered. Finally, Maggiorini et al [31] incorporated serious game development. Each framework analyzed in the telerehabilitation and adaptability for the elderly to perform primary papers highlighted a different feature. rehabilitation exercises at home (RQ3). Every study applies gamification elements that allow patients to transform Planning was the structural activity least implemented. This rehabilitation obstacles into positive and fun reinforcements. activity is essential because it allows goal definition, objectives, Feedback was the gamification element most applied (7/8, 88%) and path to follow in the software development [9,10,40,41]. [25-31]. Other elements frequently implemented were Regarding applicability, most studies focused on the treatment adaptability [24,25,28,30,31] and motivational factor [24-27,29] of stroke sequelae using various modalities such as visual and (5/8, 63%) for both; RQ4. auditory. The latter should also be implemented to provide Stroke is the primary pathology on which serious games are feedback on patient performance. Lastly, test cases directly use focused. This pathology is the third cause of disability playable commercial platforms such as Microsoft Kinect and worldwide, and a characteristic symptom is the sudden, Leap motion as interaction technology. generally unilateral, loss of muscle strength in the arms, legs, There were a few clinical trials, and the type of improvement or face (RQ5). Regarding the case studies of limb rehabilitation, reported varies from one study to another. Amengual Alcover 2 studies [24,26] included the lower limb, 1 [25] included lower et al [26] used the Berg Balance Scale and Tinetti Balance Test and upper limbs, 2 [27,30] included hand, 1 [31] full body, and measurements and reported significant functional improvement 2 [28,29] did not report case studies. The most used video game from previous results. Afyouni et al [30] also reported modality was visual (6/8, 75%) [24-27,30,31], followed by improvements using range of motion evaluation in hand auditory (4/8, 50%) [25-27,30]. Although each case study used movement. No other studies used clinical trials to evaluate the a different motion acquisition technology, every framework framework. Clinical evaluation is essential to objectively allowed a wide variety of the interaction style to obtain the validate the patient’s rehabilitation progress [36]. patient’s movement and control the serious game (RQ6). Pirovano et al [25], Amengual Alcover et al [26], and Afyouni Of the primary papers, 25% (2/8) applied a clinical evaluation et al [30] used an evaluation scale to assess the patient’s to assess patient improvement when the serious game is used progress. It should also be used as an alternative to adaptability, [26,30] (RQ7). To objectively evaluate progress and identify which is essential for progress and motivation [42]. It is also a abilities and deficits, only 38% (3/8) of the primary studies used technique that can be used to advance game levels [5]. Game an assessment instrument [25,26,30] (RQ8). The assessment levels help engage in the game and could increase treatment used standardized procedures indicating how a patient of any compliance. given age and intelligence level would perform. Adjusting the video game difficulty to the patient’s rehabilitation needs is essential to avoid frustration or boredom, and 63% (5/8) of the primary studies used adaptability [24,25,28,30,31] (RQ9). https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Finally, we recommend that all serious games have to be We propose the following recommendations for future studies: developed with a framework or methodology. If for some reason • Carry out a study of the papers that propose a methodology this is not possible, they should at least involve the therapist to for serious game development. define requirements. It is also important to include evaluation • Study software engineering framework proposals in serious scales to measure the patient’s progress and gamification games from other fields, such as education. elements. Besides, the video game development must be an • Develop a software engineering framework applying all iterative and incremental process based on generic structural the structural activities and gamification elements for the activities and the patient should be considered in the validation creation of serious games for physical rehabilitation. and feedback phases. Acknowledgments The authors thank the National Council of Science and Technology (CONACyT) for their support of this study. Additionally, this work was supported by Secretariat of Public Education (SEP) through PRODEP (Programa para el Desarrollo Profesional Docente). Conflicts of Interest None declared. Multimedia Appendix 1 Percentage of primary studies provided by each electronic database. [PNG File , 18 KB-Multimedia Appendix 1] Multimedia Appendix 2 Percentage of serious games that used a software engineering framework. [PNG File , 21 KB-Multimedia Appendix 2] Multimedia Appendix 3 Frequency of occurrence of structural activities in primary studies. [PNG File , 7 KB-Multimedia Appendix 3] Multimedia Appendix 4 Frequency of occurrence of each gamification element. [PNG File , 11 KB-Multimedia Appendix 4] Multimedia Appendix 5 Target disability contemplated in frameworks. [PNG File , 15 KB-Multimedia Appendix 5] Multimedia Appendix 6 Frameworks contemplating adaptability. [PNG File , 17 KB-Multimedia Appendix 6] References 1. World Report on Disability 2011. Geneva, Switzerland: World Health Organization; 2011. URL: https://apps.who.int/iris/ handle/10665/44575 [accessed 2021-01-31] 2. Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Man Ther 2010 Jun;15(3):220-228 [FREE Full text] [doi: 10.1016/j.math.2009.12.004] [Medline: 20163979] 3. Hatem SM, Saussez G, Della Faille M, Prist V, Zhang X, Dispa D, et al. Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery. Frontiers in Human Neuroscience 2016;10:1-22 [FREE Full text] [doi: 10.3389/fnhum.2016.00442] [Medline: 27679565] 4. Michael D, Chen S. Serious Games: Games That Educate, Train, and Inform. Boston, MA: Thomson Course Technology; 2005:287. 5. Baranowski MT, Belchior PP, Chamberlin B, Mellecker R. Levels in Games for Health. Games Health J 2014 Apr;3(2):60-63. [doi: 10.1089/g4h.2014.0019] [Medline: 26196044] https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al 6. Cortegiani A, Absalom AR. Importance of proper conduct of clinical trials. Br J Anaesth 2021 Feb;126(2):354-356. [doi: 10.1016/j.bja.2020.09.030] [Medline: 33121749] 7. Mnkandla E. About software engineering frameworks and methodologies. New York, NY: IEEE; 2009 Presented at: AFRICON 2009; September 23-25, 2009; Nairobi, Kenya. [doi: 10.1109/afrcon.2009.5308117] 8. Schmidt DC, Gokhale A, Natarajan B. Leveraging Application Frameworks. Queue 2004 Jul;2(5):66-75. [doi: 10.1145/1016998.1017005] 9. Pressman R. Software Engineering: A Practitioner's Approach. New York, NY: McGraw Hill; 2014:941. 10. Sommerville I. Software Engineering. London, UK: Pearson; 2015:816. 11. Vliet H. Software Engineering: Principles and Practice. Hoboken, NJ: Wiley; 2008:552. 12. Schmidt R. Software Engineering Architecture-Driven Software Development. St Louis, MO: Elsevier/Morgan Kaufmann; 2013:376. 13. Kumar J. Gamification at work: designing engaging business software. In: Marcus A, editor. Design, User Experience, and Usability. Health, Learning, Playing, Cultural, and Cross-Cultural User Experience. DUXU 2013. Berlin, Germany: Springer; 2013:528-537. 14. Schulz R, Martinez S, Hara T. Towards a Game-Design Framework for Evidence-Based Clinical Procedure Libraries. New York, NY: IEEE; 2019 Presented at: IEEE 7th International Conference on Serious Games and Applications for Health (SeGAH); August 5-7, 2019; Kyoto, Japan. [doi: 10.1109/SeGAH.2019.8882474] 15. Vermeir JF, White MJ, Johnson D, Crombez G, Van Ryckeghem DML. The Effects of Gamification on Computerized Cognitive Training: Systematic Review and Meta-Analysis. JMIR Serious Games 2020 Aug 10;8(3):e18644 [FREE Full text] [doi: 10.2196/18644] [Medline: 32773374] 16. de Castro-Cros M, Sebastian-Romagosa M, Rodríguez-Serrano J, Opisso E, Ochoa M, Ortner R, et al. Effects of Gamification in BCI Functional Rehabilitation. Front Neurosci 2020;14:882 [FREE Full text] [doi: 10.3389/fnins.2020.00882] [Medline: 32973435] 17. Steiner B, Elgert L, Saalfeld B, Wolf K. Gamification in Rehabilitation of Patients With Musculoskeletal Diseases of the Shoulder: Scoping Review. JMIR Serious Games 2020 Aug 25;8(3):1-12 [FREE Full text] [doi: 10.2196/19914] [Medline: 32840488] 18. Kitchenham B. Systematic review in software engineering: where we are and where we should be going. New York, NY: Association for Computing Machinery; 2012 Presented at: 2nd International Workshop on Evidential Assessment of Software Technologies; September 22, 2012; New York, NY. [doi: 10.1145/2372233.2372235] 19. Mubin S, Wee APM. A Review on Gamification Design Framework: How They Incorporated for Autism Children. New York, NY: IEEE; 2019 Presented at: 2019 4th International Conference and Workshops on Recent Advances and Innovations in Engineering; November 27-29, 2019; Kedah, Malaysia. [doi: 10.1109/icraie47735.2019.9037765] 20. Vargas J, García-Mundo L, Genero M, Piattini M. A systematic mapping study on serious game quality. New York, NY: ACM Press; 2014 Presented at: 18th International Conference on Evaluation and Assessment in Software Engineering; May 2014; London, UK. [doi: 10.1145/2601248.2601261] 21. Tomala-Gonzales J, Guaman-Quinche J, Guaman-Quinche E, Chamba-Zaragocin W, Mendoza-Betancourt S. Serious Games: Review of methodologies and Games engines for their development. New York, NY: IEEE; 2020 Presented at: 15th Iberian Conference on Information Systems and Technologies (CISTI); June 24-27, 2020; Sevilla, Spain. [doi: 10.23919/cisti49556.2020.9140827] 22. Brereton P, Kitchenham BA, Budgen D, Turner M, Khalil M. Lessons from applying the systematic literature review process within the software engineering domain. Journal of Systems and Software 2007 Apr;80(4):571-583. [doi: 10.1016/j.jss.2006.07.009] 23. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021 Mar 29;372:1-9 [FREE Full text] [doi: 10.1136/bmj.n71] [Medline: 33782057] 24. Baranyi R, Willinger R, Lederer N, Grechenig T, Schramm W. Chances for serious games in rehabilitation of stroke patients on the example of utilizing the Wii Fit Balance Board. 2013 Presented at: 2nd International Conference on Serious Games and Applications for Health (SeGAH); May 2-3, 2013; Vilamoura, Portugal. [doi: 10.1109/segah.2013.6665319] 25. Pirovano M, Surer E, Mainetti R, Lanzi PL, Alberto Borghese N. Exergaming and rehabilitation: A methodology for the design of effective and safe therapeutic exergames. Entertainment Computing 2016 May;14:55-65. [doi: 10.1016/j.entcom.2015.10.002] 26. Amengual Alcover E, Jaume-I-Capó A, Moyà-Alcover B. PROGame: A process framework for serious game development for motor rehabilitation therapy. PLoS One 2018;13(5):1-18 [FREE Full text] [doi: 10.1371/journal.pone.0197383] [Medline: 29768472] 27. Baranyi R, Czech P, Walcher F, Aigner C, Grechenig T. Reha@Stroke - A Mobile Application to Support People Suffering from a Stroke Through Their Rehabilitation. New York, NY: IEEE; 2019 Presented at: IEEE 7th International Conference on Serious Games and Applications for Health (SeGAH); August 5-7, 2019; Kyoto, Japan. [doi: 10.1109/segah.2019.8882447] https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al 28. Zain N, Jaafar A, Razak F. SGameFlow framework: how to experience enjoyment in serious game (SG) for motor impaired users (MIU). 2012 Presented at: International Conference on Computer Information Science (ICCIS); June 12-14, 2012; Kuala Lumpur, Malaysia. [doi: 10.1109/iccisci.2012.6297175] 29. Noveletto F, Hounsell M, Soares A, Eichinger F, Sagawa Y, Bertemes Filho P. Stronger: A serious game framework for post-stroke rehabilitation. Annals of Physical and Rehabilitation Medicine 2018 Jul;61:e487. [doi: 10.1016/j.rehab.2018.05.1135] 30. Afyouni I, Qamar A, Hussain S, Ur RF, Sadiq B, Murad A. Motion-based serious games for hand assistive rehabilitation. New York, NY: Association for Computing Machinery; 2017 Presented at: 22nd International Conference on Intelligent User Interfaces Companion; March 13-16, 2017; New York, NY. [doi: 10.1145/3030024.3040977] 31. Maggiorini D, Ripamonti L, Zanon E. Supporting seniors rehabilitation through videogame technology: a distributed approach. New York, NY: IEEE Press; 2012 Presented at: 2012 Second International Workshop on Games and Software Engineering: Realizing User Engagement with Game Engineering Techniques (GAS); June 9, 2012; Zurich, Switzerland. [doi: 10.1109/gas.2012.6225920] 32. Csikszentmihalyi M. The flow experience and its significance for human psychology. In: Optimal Experience Psychological Studies of Flow in Consciousness. Cambridge, UK: Cambridge University Press; 1988:15-35. 33. Pereira P, Duarte E, Rebelo F, Noriega P. A review of gamification for health-related contexts. In: Marcus A, editor. Design, User Experience, and Usability. User Experience Design for Diverse Interaction Platforms and Environments. DUXU 2014. Cham, Switzerland: Springer International Publishing; 2014:742-753. 34. Feigin V, Forouzanfar M, Krishnamurthi R, Mensah G, Connor M, Bennett D, et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. The Lancet 2014 Jan;383(9913):245-255. [doi: 10.1016/s0140-6736(13)61953-4] 35. Laamarti F, Eid M, El Saddik A. An Overview of Serious Games. International Journal of Computer Games Technology 2014;2014:1-15. [doi: 10.1155/2014/358152] 36. Wright B. Introduction to clinical trials. In: A Comprehensive and Practical Guide to Clinical Trials. Waltham, MA: Academic Press; 2017. 37. Shamley D, Wright B. A Comprehensive and Practical Guide to Clinical Trials. USA: Academic Press; 2017:210. 38. Martinez R. Clinical Trial Outcomes: What Matters to Patients. JACC Heart Fail 2019 Mar;7(3):272-273 [FREE Full text] [doi: 10.1016/j.jchf.2018.12.003] [Medline: 30819384] 39. Rego P, Moreira P, Reis L. Architecture for Serious Games in Health Rehabilitation. Berlin, Germany: Springer International Publishing; 2014 Presented at: World Conference on Information Systems and Technologies (WorldCIST); April 15-18, 2014; Funchal, Portugal p. 307-317. [doi: 10.1007/978-3-319-05948-8_30] 40. Rook P. Project planning and control. In: Software Engineer's Reference Book. Oxford, United Kingdom: Butterworth-Heinemann; 1991. 41. Rook P. Controlling software projects. Software Engineering Journal 1986;1(1):7-16. [doi: 10.1049/sej.1986.0003] 42. De Lope RP, Medina-Medina N. A Comprehensive Taxonomy for Serious Games. Journal of Educational Computing Research 2016 Dec 12;55(5):629-672. [doi: 10.1177/0735633116681301] Abbreviations PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Edited by N Zary; submitted 17.11.20; peer-reviewed by G Alor-Hernández, U Juárez-Martínez; comments to author 08.01.21; revised version received 05.04.21; accepted 22.07.21; published 11.11.21 Please cite as: Ambros-Antemate JF, Beristain-Colorado MDP, Vargas-Treviño M, Gutiérrez-Gutiérrez J, Hernández-Cruz PA, Gallegos-Velasco IB, Moreno-Rodríguez A JMIR Serious Games 2021;9(4):e25831 URL: https://games.jmir.org/2021/4/e25831 doi: 10.2196/25831 PMID: ©Jorge Fernando Ambros-Antemate, María Del Pilar Beristain-Colorado, Marciano Vargas-Treviño, Jaime Gutiérrez-Gutiérrez, Pedro Antonio Hernández-Cruz, Itandehui Belem Gallegos-Velasco, Adriana Moreno-Rodríguez. Originally published in JMIR Serious Games (https://games.jmir.org), 11.11.2021. 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 https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 18 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Loading next page...
 
/lp/jmir-publications/software-engineering-frameworks-used-for-serious-games-development-in-fbbqOYd0UC

References (56)

Publisher
JMIR Publications
Copyright
Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
ISSN
2291-9279
DOI
10.2196/25831
Publisher site
See Article on Publisher Site

Abstract

Background: Serious games are a support in the rehabilitation process for treating people with physical disabilities. However, many of these serious games are not adapted to the patient’s needs because they are not developed with a software engineering framework with a set of activities, actions, and tasks that must be executed when creating a software product. Better serious games for rehabilitation will be developed if the patient and therapist requirements are identified, the development is planned, and system improvements and feedback are involved. The goal is that the serious game must offer a more attractive environment, while maintaining patient interest in the rehabilitation process. Objective: This paper submits the results of a systematic review of serious games in physical rehabilitation identifying the benefits of using a software engineering framework. Methods: A systematic research was conducted using PubMed, PEDro (Physiotherapy Evidence Database), IEEE Xplore, ScienceDirect, ACM Digital Library, Mary Ann Liebert, Taylor & Francis Online, Wiley Online Library, and Springer databases. The initial search resulted in 701 papers. After assessing the results according to the inclusion criteria, 83 papers were selected for this study. Results: From the 83 papers reviewed, 8 used a software engineering framework for its development. Most of them focused their efforts on 1 or more aspects, such as data acquisition and processing, game levels, motivation, therapist supervision. Conclusions: This systematic review proves that most of the serious games do not use a software engineering framework for their development. As a result, development systems overlook several aspects and do not have a standardized process, eventually omitting important implementation aspects, which impact the patient’s recovery time. (JMIR Serious Games 2021;9(4):e25831) doi: 10.2196/25831 KEYWORDS serious game; physical rehabilitation; framework; methodology https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al The concept of framework is widely used in the field of Introduction computer science. However, there is some confusion between the software engineering framework and the application Overview framework. The former provides a skeletal abstraction of a According to the World Health Organization, over 1 billion solution to several problems that have some similarities. A people have some form of disability [1], with up to 200 million software engineering framework will generally outline the steps people having loss or decrease in movement, which limits their or phases that must be followed in implementing a solution ability to perform activities of daily living. To overcome it, they without getting into the details of what activities are done in must undergo a rehabilitation program to gradually regain each phase [7]. The goal is for developers to use the framework movement and consequently, improve their quality of life. as a guide to creating software systems by applying “building blocks” depending on the problem domain; by contrast, However, the traditional rehabilitation process is often slow application framework is an integrated set of software artifacts and presents problems such as lack of motivation, boredom, (such as classes, objects, and components) that collaborate to and others; as a result, many patients consider the exercises provide a reusable architecture for a family of related stressful, and therefore abandon the therapy [2]. applications [8]. They are used to facilitate the development To avoid these situations, new ways of conventional therapy process of applications, reducing time, effort, and costs. support have been used in recent years, such as medicinal Software engineering framework and application framework treatments, robotics, video games (known as serious games), should not be confused. The latter is composed of and others [3], which have contributed to faster rehabilitation pre-established source codes (eg, data access routines, form when performing exercises in a fun way, allowing the patients validation, templates) that the programmer uses to reduce to forget their conditions and concentrate on the game. workload and do not start the project from scratch. For this reason, new interaction modes, such as serious games One of the main motivations for applying a software engineering [4], have the potential to provide more attractive, motivating, framework in serious game development is to design an efficient and enriching experiences for patients who suffer from decreases and satisfactory system for the patient. in movement. Currently, serious game–based physical rehabilitation is an area of research in constant evolution, and Software Engineering Frameworks and Serious Games therefore, there is the need for developing guidelines adapted The use of software engineering frameworks for the from other research fields. development of serious games allows the application of a variety Despite the potential benefits of serious games in physical of concepts, models, techniques, and artifacts at a high level of rehabilitation, many available platforms are inflexible and abstraction. Being an interdisciplinary field, an orientation on limited in their scope. Many developments do not follow a the developed tasks is required. Besides, it is flexible to adapt process involving a set of activities, actions, or tasks that must to changing conditions or personalization according to the final be executed when a software product is to be created. As a approach of the video game (rehabilitation, education, etc.). result, essential elements to the patient’s improvement process Serious games like other software developments require a are ignored within the video game. Some of these elements are “systematic, disciplined, and quantifiable” approach. Every motivation, play levels, player commitment, challenges aspect of production, from early stages of system specification according to the patient’s level, clinical evaluation, assessment to maintenance after its operation, must be established. Below scales, among others [5,6]. is a set of related activities that lead to the development of a This work aims to describe the software engineering frameworks software product [9-12]. used in serious games development and their benefits in the Structural Activities in Software Development physical rehabilitation process. In software engineering, 5 generic structural activities are used Background during software development [9-12]: communication, planning, modeling, construction, and deployment. The software process A Note on Frameworks details will be different in each case, but the structural activities The term framework has several meanings depending on the are the same. The definitions of the structural activities are field. For example, it may refer to a model, prescription, presented in Textbox 1. guidelines underlying a design and analysis, among others. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Textbox 1. Definitions of the structural activities in software development. Communication Defining the software characteristics and functions is particularly important to communicate and collaborate with the client and other participants. This activity aims to understand the project objectives of the participants and meet the requirements. Planning Once the requirements are obtained, this activity presents an estimate of the resources; establishes a software project plan; and describes technical tasks, probable risks, and program activities. Modeling Its objective is to help understand the requirements through models. The models’ aim is to affirm the understanding of the work and give technical guidance to those who will implement the software, establishing, for example, the database model, the software architecture, user screen prototypes, and others. In some developments, this activity is the equivalent of the design stage. Construction This activity consists of the code generation and tests required to discover bugs in the software product. Deployment Once the software is created (completely or an increment), it is delivered to the client who will evaluate it and give feedback for system improvement. gamification in the rehabilitation of patients with Gamification musculoskeletal disorders of the shoulder. They concluded that According to Kumar [13] gamification applies game design gamification is essential in health care to enhance motivation principles and mechanics to nongame environments. In the and support therapy in general, especially in chronic diseases rehabilitation process, gamification can increase motivation and and rehabilitation. Other advantages are motivation, avoiding engagement through rewards, game levels, accessibility, boredom, and distraction from pain and anxiety. feedback, and challenge. Therefore, the software engineering Related Works framework for serious game development must incorporate gamification. Various gamification elements include immersion, A systematic review of literature is a method to identify, support for different roles, flow enhancement, visual evaluate, and interpret all available and relevant research of a enhancement, support for different learning stages and particular research question, subject area, or phenomenon of experience levels, design for interactivity, and progress [14]. interest. The individual studies that contribute to the systematic By contrast, Vermeir et al [15] identified the following elements: review are called primary studies. A systematic review is also avatar, challenge, competition, difficulty adjustment, feedback considered a form of secondary study [18]. loops, levels, progress, rewards, social interaction, sound effects, This systematic review includes literature work on developing and story/theme. serious games in physical rehabilitation using a software engineering framework. To identify existing secondary research Benefits of Gamification in Rehabilitation in the same field, we searched the following electronic de Castro-Cros et al [16] analyzed the effects of gamification databases: IEEE Xplore, ACM Digital Library, Wiley Digital on the mental imagery brain–computer interface in rehabilitation Library, PubMed, ScienceDirect, Taylor & Francis, Mary Ann functional assessments in 10 patients with stroke with Liebert, and Springer. Besides, we used Google Scholar as a hemiparesis in the upper limb and 6 healthy individuals. The web source to broaden our results. authors concluded that user opinions about the game level of entertainment, clarity of rules, narrative, and visual The search was realized using the following search string: A1 attractiveness were all positive. The patients were consensus AND B1 AND (C1 OR C2 OR C3 OR C4 OR C5 OR C6). about the interest in gamifying stroke rehabilitation sessions. Textbox 2 shows the terms included in the search string. By contrast, Steiner et al [17] performed a scoping review of https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Textbox 2. Search terms to identify related secondary studies. A term A1. Serious games B term B1. Framework C term C1. Review C2. Systematic review C3. Systematic literature review C4. Systematic mapping C5. Mapping study C6. Systematic mapping study When this search was performed in the electronic databases, no questions focused on discovering if quality has been constant related secondary studies were identified. Therefore, we sought throughout the software development cycle or in some stages. systematic reviews focused on software engineering frameworks The authors showed that 97% of the literature reviewed applied in any field. Table 1 summarizes the secondary studies found. quality in the final phase (product). Only 7.14% focused on quality in the design phase and 1.79% in the requirement phase. Mubin et al [19] performed a review on gamification design This study was included because it identified the phases in which framework and its application for children with autism. This quality was applied: requirement, design, code, and final review aimed to offer gamification solutions for interaction product. skills. They identified the framework phases in 5 papers and target users/audience/focus. The authors concluded that Tomalá-Gonzáles et al [21] reported on methodologies, game frameworks have been analyzed from an in-game context but engines currently used in serious games development in various did not emphasize on children with autism. In the literature, areas (education, cognitive disabilities, and physical studies show that gamification is very effective in the areas of rehabilitation), and criteria for game engine selection. From the therapy and education for children with autism. The most 27 papers, 8 used a defined methodology such as XP, Cascade, important contribution of this review is the development of and others, while 3 proposed their own model. The authors interaction skills. This review identified phases of the concluded that although several software development development process in some studies (eg, planning, designing). methodologies can be adapted to serious game development, However, it does not explain how users benefit from the process the best option was the SUM methodology because it is based interaction. on Scrum (fast, precise, optimized, and adaptable programming characteristics). However, this review did not make distinctions Vargas et al [20] developed a systematic mapping study on between framework and methodology. It also did not identify serious game quality. The aim was to discover the current state methodology phases nor the benefits of applying a methodology of serious games quality initiatives. One of the research in the learning or rehabilitation process. Table 1. Summary of secondary studies. Study Type Year of publication Target users/audience Benefit of framework Phases of process devel- /focus opment identified? Mubin et al [19] Review 2019 Children with autism Interaction skills in Yes children with autism Vargas et al [20] Systematic 2014 Serious games quality Quality Yes mapping study Tomalá-Gonzáles et al [21] Review 2020 Identifies methodologies No and game engines Not available. Although our work shares similarities with the aforementioned activities proposed by Pressman [9], who states that “The studies, the literature review presented in this paper is different software process details will be different in each case, but the because this review (1) focuses on serious games for physical structural activities are the same”; (3) identifies contributions rehabilitation, (2) identifies the software development stages in of software engineering frameworks to the rehabilitation process; each software engineering framework according to the structural and (4) identifies if the proposed software engineering https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al framework provides objective monitoring of the rehabilitation The first phase consists of the following steps: (1) describe the process. main reasons for the literature review, (2) specify a set of research questions, and (3) review the protocol. The second Methods phase comprises 4 steps: (1) identify important research, (2) select primary studies, (3) extract data from primary studies, Research Methodology and (4) synthesize data. Finally, the third phase consists of 3 steps: (1) obtain results, (2) identify the validity threats, and (3) The systematic literature review process proposed by Brereton conclusions. Figure 1 shows the literature review process. In et al [22] was applied for this systematic review. Figure 1 shows the following subsections, we describe the activities carried out the process and steps for each phase. The process consists of 3 in each phase of this systematic literature review. main phases: plan review, conduct review, and document review. Figure 1. Literature review process. elements. It allows transforming obstacles into positive and fun Research Questions reinforcements, thereby encouraging patients. In this subsection, we present the 9 research questions that RQ5 and RQ6 are centered on applicability and serious game guided this study through the investigation to meet the objectives characteristics for rehabilitation using a software engineering of the systematic review. Table 2 presents these questions. framework. These questions identify relevant data such as target The research questions can be classified into 4 fields of interest. audience, interaction technology for data acquisition, main RQ1 and RQ2 study serious games evaluated in software modalities, among others. engineering. These questions identify the number of serious Finally, RQ7, RQ8, and RQ9 studied important aspects to games developed with a software engineering framework and evaluate and provide follow-up of rehabilitation progress the set of activities, actions, and tasks required. depending on the type of exercise. RQ3 and RQ4 describe framework contributions to the rehabilitation process and implementation of gamification https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Table 2. Research questions. Research question Question 1 What framework is used in the development of the serious game? 2 What are the generic structural activities used in frameworks? 3 How the framework contributes to the rehabilitation process? 4 What gamification elements does the framework use? 5 What is the targeted disability contemplated in the frameworks? 6 If the framework includes a case study, which part of the body is rehabilitated? What is the modality of the serious game? Which interaction technology is used? 7 What type of evaluation and number of patients are involved in the clinical trials? 8 Does the framework contemplate a standardized scale to evaluate the patient’s rehabilitation progress? 9 Does the framework contemplate adaptability? were identified by searching in the following databases: Search Strategy PubMed, PEDro (Physiotherapy Evidence Database), IEEE The objective of the search strategy was to identify all relevant Xplore, ScienceDirect, ACM Digital Library, Mary Ann Liebert, primary studies. A literature search was conducted to answer Taylor & Francis Online, Wiley Online Library, and Springer. the proposed research questions. To build the search string, a list of keywords and their synonyms were identified. Logical operators (AND and OR) and words The search strategy is an adaptation of Guidelines for related to rehabilitation, serious games, and framework were Performing Systematic Literature Reviews in Software used. The final search strings consisted of the following Boolean Engineering [18] and Preferred Reporting Items for Systematic expressions: “(A1 AND (B1 OR B2)) AND (C1 OR C2 OR Reviews and Meta-Analyses (PRISMA) [23]. Relevant papers C3) AND D1”. The search terms are shown in Textbox 3. Textbox 3. Search terms for the final search string. A term A1. Serious B term B1. Game B2. Games C term C1. Rehabilitation C2. Disability C3. Disabilities D term D1. Framework using serious games, serious games for educational purposes, Inclusion Criteria and serious games for cognitive rehabilitation were excluded The systematic review is focused on serious games for physical from the study. rehabilitation; clear inclusion criteria were established to Study Selection determine the eligibility of papers for inclusion in the review. Only studies with the following criteria were considered eligible First, the search string was used in different databases. for inclusion: serious game papers for physical rehabilitation, Potentially relevant papers were identified after reading the title papers published in English, and all serious games regardless and abstract. Duplicate papers were removed. Subsequently, an of the year of development. exhaustive verification of compliance with the inclusion and exclusion criteria was carried out to select the papers. Figure 2 Exclusion Criteria shows the item selection process. In the systematic review, 701 Papers duplicated, papers regarding opinion pieces, existing papers were included. Table 3 shows the number of documents literature reviews, papers that are not related to rehabilitation retrieved from each database. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Figure 2. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)–based flowchart. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Table 3. Search results. Databases Results, n PubMed 14 PEDro 12 IEEE Xplore 103 ScienceDirect 88 ACM Digital Library 166 Mary Ann Liebert 27 Taylor & Francis Online 50 Wiley Online Library 43 Springer 198 Two types of data were extracted for each study: bibliographic Extract Data From Primary Studies (title, author name, country, year, database) and content data, After identification, the primary papers were rigorously analyzed which are used to answer the research questions. Table 4 shows in accordance with the following considerations: (1) only the the concentration of the bibliographic data of the primary papers. authors of this review can participate in the data collection Multimedia Appendix 1 shows the percentage of primary studies process; (2) each primary paper should be reviewed with at least from each electronic database. IEEE Xplore presented more two reviewers; (3) each reviewer will collect a set of data from primary studies than the rest. The following section presents an each primary study, then meet with another reviewer to reach analysis of the data collected. an agreement on the data obtained. Table 4. Bibliographic data of the primary papers. Study Year Country Database Baranyi et al [24] 2013 Austria IEEE Xplore Pirovano et al [25] 2016 Italy ScienceDirect Amengual Alcover et al [26] 2018 Spain PubMed Baranyi et al [27] 2019 Austria IEEE Xplore Zain et al [28] 2012 Malaysia IEEE Xplore Noveletto et al [29] 2018 Brazil ScienceDirect Afyouni et al [30] 2017 Cyprus ACM Digital Library Maggiorini et al [31] 2012 Switzerland ACM Digital Library virtualization, game design, and secondary goals. In exercise Results definition, a set of exercises is proposed to cover therapy needs. Each exercise is structured into primary and secondary goals. RQ1: What Framework Is Used in the Development During virtualization, the team identifies primary goals, and of the Serious Game? they are implemented into a virtual exercise by defining input Only 8 (10%) out of the 83 papers related to physical (tracking) and output (feedback) requirements through simple rehabilitation using a software engineering framework graphical elements and specifying interaction mechanisms. (Multimedia Appendix 2). Through game design, the virtual exercise is converted into a true exergame. In the last step, there are 2 functionalities. The In Baranyi et al [24,27], the proposed studies were based on the first is to analyze motion data and identify wrong movements. user-centered design framework. The physiotherapist is The second provides feedback to the patients. important because s/he identifies the needs and limitations of the patients in the rehabilitation process. There are 3 phases: In Amengual Alcover et al [26], the serious game development research, design, and evaluation. In research, a physiotherapist framework follows an iterative process flow structured into 2 conducts brainstorming with the work team and identifies the dimensions: activities and incremental development. The first requirements. Afterward, in the design phase, the team creates dimension is based on 3 approaches: Scrum, the web application mock-ups and a prototype. Finally, the physiotherapist evaluates development model, and a clinical trial. The activities dimension the application. includes a project initiation activity, an iterative flow composed of 4 basic development activities (planning and control, Pirovano et al [25] proposed a 4-step procedure to create safe modeling, construction, and evaluation), and a final clinical exergames for rehabilitation therapies: exercise definition, https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al study to evaluate the rehabilitation process of the patient through Every study established a communication activity to obtain the the serious game. Incremental development includes 3 different requirements. Baranyi et al [24] brainstormed with a increments: interaction mechanism, interaction elements, and physiotherapist to identify relevant problems and needs for serious game. In the first increment, an existing device on the patients undergoing rehabilitation. Pirovano et al [25] defined market is identified to capture the movements of patients exercises addressing the primary and secondary objectives of according to their needs. In the second increment, the rehabilitation. To achieve maximum effectiveness, the exercises development team must design the interaction elements that are defined in collaboration with therapists. In Amengual force patients to perform the therapy correctly. The final Alcover et al [26], the communication began by identifying the increment is aimed at designing a serious game that motivates context, operational objectives, restrictions, and requirements. the patient to perform therapy to obtain the best results. Baranyi et al [27] established communication with the therapist to obtain the requirements. Zain et al [28] identified the user Zain et al [28] proposed a conceptual framework for people abilities, limitations, and behavior, which become requirements with motor impairment, so they can enjoy the experience of for the serious game. Noveletto et al [29] considered experts in playing serious games. The framework’s main elements were the field (health personnel, therapists, etc.) and patients to obtain player skills, challenge, concentration, feedback, immersion, the requirements. Afyouni et al [30] established the type of learning opportunities, accessibility, and adaptivity. The game through patient needs, preferences, and limitations, proposed framework will help the game designer and developer allowing custom game features. Finally, Maggiorini et al [31] create a serious game that combines the game’s technology with analyzed the most diffused issues present in elders’ homes (eg, the learning environment. This framework is based on the game size of rooms, habits) to explore requirements and limitations flow model. through an immersive approach. Noveletto et al [29] presented a conceptual model for the design The planning activity was implemented in Amengual Alcover or development of serious games to rehabilitate people with et al [26]. The goal of this activity was to determine the tasks stroke. The framework establishes a relationship between experts to perform during the development by identifying the end and patients to obtain the requirements, considering that the products and the people who will do the work. The activity biomedical device and the video game score are used to design includes 3 tasks: planning, scheduling, and tracking. serious games. The modeling activity was performed in several papers. For Afyouni et al [30] proposed a framework consisting of a example, Baranyi et al [24] called it design, elaborating basic therapy-driven 3D environment augmented with a natural user models discussed with a therapist. Pirovano et al [25] interface based on movement. The framework incorporated transformed the exercise requirements into a true exergame by different adaptation techniques to adjust patient’s needs. Patient adding all the elements and characteristics of a game and a good preferences and limitations were considered key parameters for game design for the patients. Amengual Alcover et al [26] changing the game, thereby creating personalized games for created models that helped the development team to understand each patient. the requirements obtained and the game design. By contrast, Maggiorini et al [31] presented a framework for serious game Baranyi et al [27] contemplated the use of prototypes to refine development that allows the therapist to remotely control the user requirements. Finally, Maggiorini et al [31] established a video game home activities. The objective was to create a more list of technical characteristics (desired) for the prototype attractive game for the elderly with easily adjustable parameters creation. for therapy adaptability. The framework includes 3 phases of The construction activity was implemented in every study. serious game development: requirements definition, empirical Developments produce executable software units that will be validation of requirements list, and design and prototyping. used by users, through the creation of prototypes to improve the software [24-27,30,31], or the final product [28,29]. RQ2: What Are the Generic Structural Activities Used in Frameworks? Finally, the user evaluates and provides feedback on the serious The objective of this research question was to identify generic game in the deployment stage. In the primary papers, Pirovano structural activities in primary studies (see the “Background” et al [25] and Baranyi et al [27], patients were asked to give section). Table 5 summarizes the structural activities and their opinion to improve the game design and change some Multimedia Appendix 3 shows the frequency of occurrence of aspects of the application. each structural activity in primary studies. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Table 5. Structural activities in primary studies. Study Communication Planning Modeling Construction Deploy Baranyi et al [24] X X X — Pirovano et al [25] X — X X X Amengual Alcover et al [26] X X X X — Baranyi et al [27] X — X X X Zain et al [28] X — — X — Noveletto et al [29] X — — X — Afyouni et al [30] X — — X — Maggiorini et al [31] X — X X — Not available. For users with motor impairment, Zain et al [28] used flow RQ3: How the Framework Contributes to the theory [32] to propose user interface design factors that make Rehabilitation Process? their experience enjoyable when playing serious games. This Baranyi et al [24,27] applied a user-centered design approach framework includes user interface design factors and aims to to establish constant communication with the physiotherapist establish a conceptual model that can be used by a game who has the experience to identify the needs and limitations of designer for efficient game development or an educational the final user. Serious games are developed with entertainment practitioner when designing enjoyable serious games for users elements such as levels, rewards, challenges, and adaptability with motor impairment. to the patient need, considering special conditions. Noveletto et al [29] established a relationship among key Pirovano et al [25] proposed the creation of safe exergames, stakeholders (experts and patient) and elements (biomedical identifying the needs of real exercise besides therapy goals. device and game score) for serious game design. The framework These needs are incorporated into a video game considering the states that a correlation between the game score and clinical primary objectives (what a user should do) and secondary tests can aid treatment and evaluation through the biomedical objectives (how user actions should be carried out). The former system. is easily integrated into the gameplay, while the latter aids the Afyouni et al [30] proposed a framework for video game patient with corrections or prevention of compensatory development with an adaptive and user-centered approach. The movement through analysis of the flow of movement data and framework embeds different adaptation techniques to tailor to wrong movements in real time, thereby providing immediate patients’ needs. The video game adapts to the difficulty level feedback to patients to correct themselves during the exercise. based on the patient’s profile and performance in real time. Amengual Alcover et al [26] proposed an iterative, Other aspects such as patient preferences and constraints are prototype-oriented, systematized serious game development considered as key game-changing parameters. process. The proposed process guarantees that products based Finally, in Maggiorini et al [31], the framework allowed serious on this framework are developed and validated by following a game development with telerehabilitation allowing the therapist coherent and systematic method that leads to high-quality to remotely control the video game home activities. It supports serious games. parameter adjustments for therapy adaptability. Table 6 summarizes framework contributions. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Table 6. Framework contributions in primary studies. Framework contribution to rehabilitation Utility Primary studies Communication with health expert A physiotherapist establishes communications with patients Baranyi et al [24], Pirovano et al [25], undergoing rehabilitation to identify the problems and needs. Baranyi et al [27], Noveletto et al [29] Exercise definition Exercise can be defined as a sequence of different actions Pirovano et al [25] needed to complete it to achieve maximum effectiveness. Analyzes the stream of motion data and Provides immediate feedback to the patients for correct ex- Pirovano et al [25] identifies in real time wrong movements ercising. Iterative and prototyping Visualize prototypes of serious games from early stages. The Baranyi et al [24], Pirovano et al [25], therapist or patients identify additional requirements or Baranyi et al [27], Noveletto et al [29], modify them. Afyouni et al [30], Maggiorini et al [31] User interface design factors Motivation and immersion Baranyi et al [24], Pirovano et al [25], Amengual Alcover et al [26], Baranyi et al [27], Zain et al [28], Noveletto et al [29] The correlation between game score and Aids in patient treatment and evaluation Noveletto et al [29] clinical tests Adaptive approach Adapts difficulty level according to the patient’s profile and Baranyi et al [24], Pirovano et al [25], Zain performance in real time et al [28] Afyouni et al [30], Maggiorini et al [31] Telerehabilitation Therapists can remotely control the video game for home Maggiorini et al [31] activities and provide adjustable parameters to improve therapy gamification elements. The papers identified the following RQ4: What Gamification Elements Does the elements: feedback, motivational factor, adaptability, challenge, Framework Use? levels, immersion, rewards, concentration, and avatar. Table 7 shows the gamification elements in primary studies, and Overview Multimedia Appendix 4 shows the frequency of occurrence of Gamification allows the transformation of obstacles into positive each gamification element. and fun reinforcement, encouraging users to make the right The gamification elements of primary studies are described decisions for their health and well-being [33]. It is essential to below. keep the patient motivated in physical rehabilitation. For this reason, the software engineering framework is required to use Table 7. Gamification elements in primary studies. Gamification element Study Feedback Pirovano et al [25], Amengual Alcover et al [26], Baranyi et al [27], Zain et al [28], Noveletto et al [29], Afyouni et al [30], Maggiorini et al [31] Motivational factor Baranyi et al [24], Pirovano et al [25], Amengual Alcover et al [26], Baranyi et al [27], Noveletto et al [29] Adaptability Baranyi et al [24], Pirovano et al [25], Zain et al [28], Afyouni et al [30], Maggiorini et al [31] Challenge Baranyi et al [24], Zain et al [28], Afyouni et al [30] Levels Baranyi et al [24], Amengual Alcover et al [26], Baranyi et al [27], Afyouni et al [30] Immersion Zain et al [28] Rewards Pirovano et al [25] Concentration Zain et al [28] Avatar Pirovano et al [25] screen at all times. In Baranyi et al [27], the feedback provided Feedback was either visual, aural, or haptic. In Zain et al [28], users with In Pirovano et al [25], the feedback mechanisms were designed motor impairment received feedback on their progress, and to show the outcome of actions to patients. For instance, whether when they lose the game, feedback is provided to continue in a target is met or a movement has been successfully performed. the right direction. Noveletto et al [29] established that serious Amengual Alcover et al [26] used “mirror feedback,” which same should reward players with feedback on progress. Afyouni consists of projecting the user onto the screen and simulating a et al [30] used a scoring system that was designed to keep track mirror in such a way that the users can see themselves on the of the number of times the patient successfully passed through https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al the targets. Finally, in Maggiorini et al [31], a skeleton Immersion wireframe is drawn in red to provide immediate visual feedback, Zain et al [28] considered that immersive games draw players and an alarm is raised on the screen. into the game and affect their senses through elements such as audio and narrative. Motivational Factor Baranyi et al [24] used “goals.” The gameplay was based on Reward achieving goals that should act as motivation factors. Pirovano Pirovano et al [25] used a scoring system, and at the end of each et al [25] established that extrinsic motivational effects can be exergame, a virtual reward is presented to the patients. achieved through careful use of verbal praise, scoring Concentration mechanisms, and virtual reward systems. In Amengual Alcover et al [26], the development of new serious games allowed the Zain et al [28] considered that the more concentration a task inclusion of motivational elements to increase engagement. requires in terms of attention and workload, the more absorbing Baranyi et al [27] used rewards in serious games for the user. it will be. The games should grab the player’s attention quickly Finally, Noveletto et al [29] used the “motivational score” to and maintain it throughout the game. improve attention during rehabilitation sessions. Avatar Adaptability Pirovano et al [25] used an avatar for feedback on wrong Baranyi et al [24] proposed an adaptive system with the movements, changing the color of the associated avatar opportunity to adapt the game difficulty. Pirovano et al [25] segments. When wrong movements persist for a long time, the established that virtual exercises should use dynamic difficulty game is paused, and a virtual therapist avatar pops up to advise adaptation, thus further increasing the flexibility of serious patients. games. For Zain et al [28], an adaptive factor was important to RQ5: What Is the Targeted Disability Contemplated design and develop serious games for users with motor in the Frameworks? impairment because the application, aware of the users’ current cognitive load and physical limitations, can change its response, This specifies whether a study focuses on a particular pathology presentation, and interaction flow to improve users’ experience with loss or decrease in movement. The papers established the and their task performance. In Afyouni et al [30], the framework following target pathology: 4 defined strokes [24,25,27,29], 2 embeds different adaptation techniques to adapt to the patients’ defined neuromotor disorder [26,30], 1 defined users with motor needs. Key game-changing parameters such as patient impairment [28], and 1 defined rehabilitation of the elderly [31]. preferences and constraints are considered. This allows the Stroke is mainly targeted in studies because it is the second creation of personalized game features for every patient. cause of death and the third cause of disability worldwide [34]. Maggiorini et al [31] proposed that remotely controlled serious Multimedia Appendix 5 shows the target disability percentage. games may also provide easily tunable parameters to better RQ6: If the Framework Includes a Case Study, Which adapt the game therapy to the actual patient recovery. Part of the Body Is Rehabilitated? What Is the Challenge Modality of the Serious Game? Which Interaction Baranyi et al [24] proposed the challenge as a “key fact.” They Technology Is Used? considered that the game should not be too easy nor too hard As Table 8 reports, Baranyi et al [24] presented a prototype that to manage. The game should be sufficiently challenging and rehabilitates patients with lower limb disabilities with balance match the player’s skill level. Zain et al [28] proposed that and strength exercises using the Wii Fit Balance Board. Pirovano serious games should also vary the level of difficulty and keep et al [25] developed serious games for upper limb motor an appropriate pace. Afyouni et al [30] generated therapy-aware rehabilitation therapy using Microsoft Kinect and lower limb navigational movements with multiple levels of difficulty. with the Wii Fit Balance Board. Amengual Alcover et al [26] also rehabilitated the lower limb by allowing patients to perform Levels repetitions in a video game controlled with Microsoft Kinect, Baranyi et al [24] stated that the purpose of the serious game with each repetition varied according to the participant’s developed is to have a rehabilitation system containing different tolerance and the physiotherapist’s recommendations. Baranyi levels that were adapted and created for the individual needs of et al [27] performed hand rehabilitation using gesture exercises, the patients and to fit their impairments. Amengual Alcover et touch, and patient movement levels using mobile phone sensors. al [26] considered that serious games must have a definition of Zain et al [28] and Noveletto et al [29] did not report any case different levels in the game. In Baranyi et al [28], when the studies. Afyouni et al [30] developed a serious game for hand game is started for the first time, a diagnostic routine is rehabilitation using leap motion. Game instructions can be visual performed; using these data, a baseline for the exercises can be (shown on the screen) or voice, depending on the perception defined by the therapist to get an initial idea about how easy or capacity of the patient. Finally, Maggiorini et al [31] developed complex a level might be for a patient. Afyouni et al [30] a prototype for rehabilitation using Microsoft Kinect. It only presented different levels of difficulty based on therapeutic presents the skeleton tracking by a sensor and does not mention gestures and patient performance. whether the video game implements another form of communication with the patient. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al The modality is a way in which information is transmitted from Amengual Alcover et al [26], Baranyi et al [27], and Afyouni the computer to the participants [35]. Baranyi et al [24,27], et al [30] used audio effects such as music or voice instructions. Pirovano et al [25], Amengual Alcover et al [26], Afyouni et al Baranyi et al [27] used haptic modality to control the video [30], and Maggiorini et al [31] used a visual modality, presenting game through a touch screen. Zain et al [28] and Noveletto et a graphical interface for user interaction. Pirovano et al [25], al [29] did not report modalities. Table 8. Rehabilitated limb, serious game modality, and data-acquisition device in primary studies. Study Rehabilitation/extremity Modality Interaction technology Baranyi et al [24] Lower limbs Visual Wii Fit Balance Board Pirovano et al [25] Lower and upper limbs Visual, auditory Wii Fit Balance Board and Microsoft Kinect Amengual Alcover et al [26] Lower limbs Visual, auditory Microsoft Kinect Baranyi et al [27] Hand Visual, auditory, haptic iOS platform sensors Zain et al [28] Not reported Not reported Open Noveletto et al [29] Not reported Not reported Open Afyouni et al [30] Hand Visual, auditory Leap motion Maggiorini et al [31] Full body Visual Microsoft Kinect (mean 29.5 [SD 3.9] and after (mean 34.1 [SD 2.2]) the RQ7: What Type of Evaluation and Number of intervention. The Functional Reach Test revealed significant Patients Are Involved in the Clinical Trials? differences in functional balance before and after the The objective of this research question was to identify clinical intervention: right upper limb, before (mean 8.6 [SD 1.4]) and validation of the studies and the number of patients involved. after intervention (mean 10.1 [SD 2.0]; P=.007); and left upper In clinical trials, participants receive specific interventions limb, before (mean 8.3 [SD 2.0]) and after intervention (mean according to the research plan or protocol created by the 10.1 [SD 3.7]; P=.052). Finally, a significant difference between researchers to determine the safety and efficacy of the the pre- and post-assessment scores for the Tinetti Balance Test interventions through the measurements of the outcomes [36]. was observed at the end of the 24-week intervention period. Table 9 shows these data. Amengual Alcover et al [26] The average score rose from 16 to 21 points on a scale of 28 conducted a clinical trial and observed a significant difference points. Afyouni et al [30] reported that patients showed between before and after scores. They used the Berg Balance improved hand movement using a range of motion. They were Scale and their results showed a significant functional able to document 66% of the elements in the video game. No improvement (P=.002) in comparison with assessments before other study reported a clinical trial. Table 9. Type of evaluation and number of patients in the primary studies. Study Evaluation Number of patients Baranyi et al [24] No clinical validation N/A Pirovano et al [25] No clinical validation N/A Amengual Alcover et al [26] Clinical trial 9 Baranyi et al [27] No clinical validation N/A Zain et al [28] No clinical validation N/A Noveletto et al [29] No clinical validation N/A Afyouni et al [30] Clinical trial 5 Maggiorini et al [31] No clinical validation N/A NA: not applicable. on the type of exercise applied. During the analysis of primary RQ8: Does the Framework Contemplate a papers, we identified 3 studies with assessment instruments: Standardized Scale to Evaluate the Patient’s Pirovano et al [25], Amengual Alcover et al [26], and Afyouni Rehabilitation Progress? et al [30]. An assessment instrument allows to objectively quantify the RQ9: Does the Framework Contemplate Adaptability? disability degree of the patient and measure the progress of Adaptability is the ability to dynamically adapt difficulty in a rehabilitation [37,38]. The evaluation scales in the framework video game according to the patient’s performance [39]. Five are used to quantify the improvement in rehabilitation depending https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al primary studies use this characteristic. In Baranyi et al [24], the Conclusions physiotherapist designed the level of difficulty of the video The objective of this study was to identify the software game. Pirovano et al [25] established that for every exercise, engineering frameworks used in the development of serious quality parameters are necessary to define movement properties. games through a literature review of 8 primary studies. The This will allow one to determine the challenge degree of the conclusions of this study are as follows: exercises and adapt the difficulty to the patient’s needs. Zain et About 75% (6/8) of the primary papers proposed a framework al [28] mentioned that adaptability must consider the following [25,26,28-31], whereas the rest were adaptations of the elements: (1) user motivation, (2) experience and abilities, and user-centered design framework (RQ1). Regarding the structural (3) detection, which identifies necessary changes. Afyouni et activities, 100% (8/8) of the papers applied the communication al [30] adapted the difficulty level based on the patient’s profile and construction activity [24-31], 63% (5/8) used modeling and performance in real time. In Maggiorini et al [31] the (known as a design in some developments) [24-27,31], 25% therapist can remotely adapt the game therapy to the patient’s (2/8) considered user feedback to improve the serious games actual recovery. Amengual Alcover et al [26], Baranyi et al [25,27], and only 13% (1/8) included the planning phase [26] [27], and Noveletto et al [29] did not specify how adaptability (RQ2). is incorporated into their game. Multimedia Appendix 6 shows the percentage of frameworks contemplating adaptability. Each primary study contributes in one or more aspects to the rehabilitation process. Baranyi et al [24,27] applied a Threats to Validity of Primary Studies Selected user-centered design using which the physiotherapist can Although we used search strategies and techniques to personalize individual needs in the serious game. Pirovano et systematically find papers by using keywords in the selected al [25] proposed ease of play and assisted help during the databases, these words may vary within papers, so some relevant rehabilitation exercise. Amengual Alcover et al [26] developed studies may have been omitted. a framework for motor rehabilitation therapies using a systematized process. Zain et al [28] embraced immersion and Discussion fun in the game to maintain flow interest. Noveletto et al [29] used game scores for patient assessment. Afyouni et al [30] Preliminary Findings developed games with dynamic adaptability that were patient We found only few studies that used a systematic process for centered. Finally, Maggiorini et al [31] incorporated serious game development. Each framework analyzed in the telerehabilitation and adaptability for the elderly to perform primary papers highlighted a different feature. rehabilitation exercises at home (RQ3). Every study applies gamification elements that allow patients to transform Planning was the structural activity least implemented. This rehabilitation obstacles into positive and fun reinforcements. activity is essential because it allows goal definition, objectives, Feedback was the gamification element most applied (7/8, 88%) and path to follow in the software development [9,10,40,41]. [25-31]. Other elements frequently implemented were Regarding applicability, most studies focused on the treatment adaptability [24,25,28,30,31] and motivational factor [24-27,29] of stroke sequelae using various modalities such as visual and (5/8, 63%) for both; RQ4. auditory. The latter should also be implemented to provide Stroke is the primary pathology on which serious games are feedback on patient performance. Lastly, test cases directly use focused. This pathology is the third cause of disability playable commercial platforms such as Microsoft Kinect and worldwide, and a characteristic symptom is the sudden, Leap motion as interaction technology. generally unilateral, loss of muscle strength in the arms, legs, There were a few clinical trials, and the type of improvement or face (RQ5). Regarding the case studies of limb rehabilitation, reported varies from one study to another. Amengual Alcover 2 studies [24,26] included the lower limb, 1 [25] included lower et al [26] used the Berg Balance Scale and Tinetti Balance Test and upper limbs, 2 [27,30] included hand, 1 [31] full body, and measurements and reported significant functional improvement 2 [28,29] did not report case studies. The most used video game from previous results. Afyouni et al [30] also reported modality was visual (6/8, 75%) [24-27,30,31], followed by improvements using range of motion evaluation in hand auditory (4/8, 50%) [25-27,30]. Although each case study used movement. No other studies used clinical trials to evaluate the a different motion acquisition technology, every framework framework. Clinical evaluation is essential to objectively allowed a wide variety of the interaction style to obtain the validate the patient’s rehabilitation progress [36]. patient’s movement and control the serious game (RQ6). Pirovano et al [25], Amengual Alcover et al [26], and Afyouni Of the primary papers, 25% (2/8) applied a clinical evaluation et al [30] used an evaluation scale to assess the patient’s to assess patient improvement when the serious game is used progress. It should also be used as an alternative to adaptability, [26,30] (RQ7). To objectively evaluate progress and identify which is essential for progress and motivation [42]. It is also a abilities and deficits, only 38% (3/8) of the primary studies used technique that can be used to advance game levels [5]. Game an assessment instrument [25,26,30] (RQ8). The assessment levels help engage in the game and could increase treatment used standardized procedures indicating how a patient of any compliance. given age and intelligence level would perform. Adjusting the video game difficulty to the patient’s rehabilitation needs is essential to avoid frustration or boredom, and 63% (5/8) of the primary studies used adaptability [24,25,28,30,31] (RQ9). https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al Finally, we recommend that all serious games have to be We propose the following recommendations for future studies: developed with a framework or methodology. If for some reason • Carry out a study of the papers that propose a methodology this is not possible, they should at least involve the therapist to for serious game development. define requirements. It is also important to include evaluation • Study software engineering framework proposals in serious scales to measure the patient’s progress and gamification games from other fields, such as education. elements. Besides, the video game development must be an • Develop a software engineering framework applying all iterative and incremental process based on generic structural the structural activities and gamification elements for the activities and the patient should be considered in the validation creation of serious games for physical rehabilitation. and feedback phases. Acknowledgments The authors thank the National Council of Science and Technology (CONACyT) for their support of this study. Additionally, this work was supported by Secretariat of Public Education (SEP) through PRODEP (Programa para el Desarrollo Profesional Docente). Conflicts of Interest None declared. Multimedia Appendix 1 Percentage of primary studies provided by each electronic database. [PNG File , 18 KB-Multimedia Appendix 1] Multimedia Appendix 2 Percentage of serious games that used a software engineering framework. [PNG File , 21 KB-Multimedia Appendix 2] Multimedia Appendix 3 Frequency of occurrence of structural activities in primary studies. [PNG File , 7 KB-Multimedia Appendix 3] Multimedia Appendix 4 Frequency of occurrence of each gamification element. [PNG File , 11 KB-Multimedia Appendix 4] Multimedia Appendix 5 Target disability contemplated in frameworks. [PNG File , 15 KB-Multimedia Appendix 5] Multimedia Appendix 6 Frameworks contemplating adaptability. [PNG File , 17 KB-Multimedia Appendix 6] References 1. World Report on Disability 2011. Geneva, Switzerland: World Health Organization; 2011. URL: https://apps.who.int/iris/ handle/10665/44575 [accessed 2021-01-31] 2. Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Man Ther 2010 Jun;15(3):220-228 [FREE Full text] [doi: 10.1016/j.math.2009.12.004] [Medline: 20163979] 3. Hatem SM, Saussez G, Della Faille M, Prist V, Zhang X, Dispa D, et al. Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery. Frontiers in Human Neuroscience 2016;10:1-22 [FREE Full text] [doi: 10.3389/fnhum.2016.00442] [Medline: 27679565] 4. Michael D, Chen S. Serious Games: Games That Educate, Train, and Inform. Boston, MA: Thomson Course Technology; 2005:287. 5. Baranowski MT, Belchior PP, Chamberlin B, Mellecker R. Levels in Games for Health. Games Health J 2014 Apr;3(2):60-63. [doi: 10.1089/g4h.2014.0019] [Medline: 26196044] https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al 6. Cortegiani A, Absalom AR. Importance of proper conduct of clinical trials. Br J Anaesth 2021 Feb;126(2):354-356. [doi: 10.1016/j.bja.2020.09.030] [Medline: 33121749] 7. Mnkandla E. About software engineering frameworks and methodologies. New York, NY: IEEE; 2009 Presented at: AFRICON 2009; September 23-25, 2009; Nairobi, Kenya. [doi: 10.1109/afrcon.2009.5308117] 8. Schmidt DC, Gokhale A, Natarajan B. Leveraging Application Frameworks. Queue 2004 Jul;2(5):66-75. [doi: 10.1145/1016998.1017005] 9. Pressman R. Software Engineering: A Practitioner's Approach. New York, NY: McGraw Hill; 2014:941. 10. Sommerville I. Software Engineering. London, UK: Pearson; 2015:816. 11. Vliet H. Software Engineering: Principles and Practice. Hoboken, NJ: Wiley; 2008:552. 12. Schmidt R. Software Engineering Architecture-Driven Software Development. St Louis, MO: Elsevier/Morgan Kaufmann; 2013:376. 13. Kumar J. Gamification at work: designing engaging business software. In: Marcus A, editor. Design, User Experience, and Usability. Health, Learning, Playing, Cultural, and Cross-Cultural User Experience. DUXU 2013. Berlin, Germany: Springer; 2013:528-537. 14. Schulz R, Martinez S, Hara T. Towards a Game-Design Framework for Evidence-Based Clinical Procedure Libraries. New York, NY: IEEE; 2019 Presented at: IEEE 7th International Conference on Serious Games and Applications for Health (SeGAH); August 5-7, 2019; Kyoto, Japan. [doi: 10.1109/SeGAH.2019.8882474] 15. Vermeir JF, White MJ, Johnson D, Crombez G, Van Ryckeghem DML. The Effects of Gamification on Computerized Cognitive Training: Systematic Review and Meta-Analysis. JMIR Serious Games 2020 Aug 10;8(3):e18644 [FREE Full text] [doi: 10.2196/18644] [Medline: 32773374] 16. de Castro-Cros M, Sebastian-Romagosa M, Rodríguez-Serrano J, Opisso E, Ochoa M, Ortner R, et al. Effects of Gamification in BCI Functional Rehabilitation. Front Neurosci 2020;14:882 [FREE Full text] [doi: 10.3389/fnins.2020.00882] [Medline: 32973435] 17. Steiner B, Elgert L, Saalfeld B, Wolf K. Gamification in Rehabilitation of Patients With Musculoskeletal Diseases of the Shoulder: Scoping Review. JMIR Serious Games 2020 Aug 25;8(3):1-12 [FREE Full text] [doi: 10.2196/19914] [Medline: 32840488] 18. Kitchenham B. Systematic review in software engineering: where we are and where we should be going. New York, NY: Association for Computing Machinery; 2012 Presented at: 2nd International Workshop on Evidential Assessment of Software Technologies; September 22, 2012; New York, NY. [doi: 10.1145/2372233.2372235] 19. Mubin S, Wee APM. A Review on Gamification Design Framework: How They Incorporated for Autism Children. New York, NY: IEEE; 2019 Presented at: 2019 4th International Conference and Workshops on Recent Advances and Innovations in Engineering; November 27-29, 2019; Kedah, Malaysia. [doi: 10.1109/icraie47735.2019.9037765] 20. Vargas J, García-Mundo L, Genero M, Piattini M. A systematic mapping study on serious game quality. New York, NY: ACM Press; 2014 Presented at: 18th International Conference on Evaluation and Assessment in Software Engineering; May 2014; London, UK. [doi: 10.1145/2601248.2601261] 21. Tomala-Gonzales J, Guaman-Quinche J, Guaman-Quinche E, Chamba-Zaragocin W, Mendoza-Betancourt S. Serious Games: Review of methodologies and Games engines for their development. New York, NY: IEEE; 2020 Presented at: 15th Iberian Conference on Information Systems and Technologies (CISTI); June 24-27, 2020; Sevilla, Spain. [doi: 10.23919/cisti49556.2020.9140827] 22. Brereton P, Kitchenham BA, Budgen D, Turner M, Khalil M. Lessons from applying the systematic literature review process within the software engineering domain. Journal of Systems and Software 2007 Apr;80(4):571-583. [doi: 10.1016/j.jss.2006.07.009] 23. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021 Mar 29;372:1-9 [FREE Full text] [doi: 10.1136/bmj.n71] [Medline: 33782057] 24. Baranyi R, Willinger R, Lederer N, Grechenig T, Schramm W. Chances for serious games in rehabilitation of stroke patients on the example of utilizing the Wii Fit Balance Board. 2013 Presented at: 2nd International Conference on Serious Games and Applications for Health (SeGAH); May 2-3, 2013; Vilamoura, Portugal. [doi: 10.1109/segah.2013.6665319] 25. Pirovano M, Surer E, Mainetti R, Lanzi PL, Alberto Borghese N. Exergaming and rehabilitation: A methodology for the design of effective and safe therapeutic exergames. Entertainment Computing 2016 May;14:55-65. [doi: 10.1016/j.entcom.2015.10.002] 26. Amengual Alcover E, Jaume-I-Capó A, Moyà-Alcover B. PROGame: A process framework for serious game development for motor rehabilitation therapy. PLoS One 2018;13(5):1-18 [FREE Full text] [doi: 10.1371/journal.pone.0197383] [Medline: 29768472] 27. Baranyi R, Czech P, Walcher F, Aigner C, Grechenig T. Reha@Stroke - A Mobile Application to Support People Suffering from a Stroke Through Their Rehabilitation. New York, NY: IEEE; 2019 Presented at: IEEE 7th International Conference on Serious Games and Applications for Health (SeGAH); August 5-7, 2019; Kyoto, Japan. [doi: 10.1109/segah.2019.8882447] https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al 28. Zain N, Jaafar A, Razak F. SGameFlow framework: how to experience enjoyment in serious game (SG) for motor impaired users (MIU). 2012 Presented at: International Conference on Computer Information Science (ICCIS); June 12-14, 2012; Kuala Lumpur, Malaysia. [doi: 10.1109/iccisci.2012.6297175] 29. Noveletto F, Hounsell M, Soares A, Eichinger F, Sagawa Y, Bertemes Filho P. Stronger: A serious game framework for post-stroke rehabilitation. Annals of Physical and Rehabilitation Medicine 2018 Jul;61:e487. [doi: 10.1016/j.rehab.2018.05.1135] 30. Afyouni I, Qamar A, Hussain S, Ur RF, Sadiq B, Murad A. Motion-based serious games for hand assistive rehabilitation. New York, NY: Association for Computing Machinery; 2017 Presented at: 22nd International Conference on Intelligent User Interfaces Companion; March 13-16, 2017; New York, NY. [doi: 10.1145/3030024.3040977] 31. Maggiorini D, Ripamonti L, Zanon E. Supporting seniors rehabilitation through videogame technology: a distributed approach. New York, NY: IEEE Press; 2012 Presented at: 2012 Second International Workshop on Games and Software Engineering: Realizing User Engagement with Game Engineering Techniques (GAS); June 9, 2012; Zurich, Switzerland. [doi: 10.1109/gas.2012.6225920] 32. Csikszentmihalyi M. The flow experience and its significance for human psychology. In: Optimal Experience Psychological Studies of Flow in Consciousness. Cambridge, UK: Cambridge University Press; 1988:15-35. 33. Pereira P, Duarte E, Rebelo F, Noriega P. A review of gamification for health-related contexts. In: Marcus A, editor. Design, User Experience, and Usability. User Experience Design for Diverse Interaction Platforms and Environments. DUXU 2014. Cham, Switzerland: Springer International Publishing; 2014:742-753. 34. Feigin V, Forouzanfar M, Krishnamurthi R, Mensah G, Connor M, Bennett D, et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. The Lancet 2014 Jan;383(9913):245-255. [doi: 10.1016/s0140-6736(13)61953-4] 35. Laamarti F, Eid M, El Saddik A. An Overview of Serious Games. International Journal of Computer Games Technology 2014;2014:1-15. [doi: 10.1155/2014/358152] 36. Wright B. Introduction to clinical trials. In: A Comprehensive and Practical Guide to Clinical Trials. Waltham, MA: Academic Press; 2017. 37. Shamley D, Wright B. A Comprehensive and Practical Guide to Clinical Trials. USA: Academic Press; 2017:210. 38. Martinez R. Clinical Trial Outcomes: What Matters to Patients. JACC Heart Fail 2019 Mar;7(3):272-273 [FREE Full text] [doi: 10.1016/j.jchf.2018.12.003] [Medline: 30819384] 39. Rego P, Moreira P, Reis L. Architecture for Serious Games in Health Rehabilitation. Berlin, Germany: Springer International Publishing; 2014 Presented at: World Conference on Information Systems and Technologies (WorldCIST); April 15-18, 2014; Funchal, Portugal p. 307-317. [doi: 10.1007/978-3-319-05948-8_30] 40. Rook P. Project planning and control. In: Software Engineer's Reference Book. Oxford, United Kingdom: Butterworth-Heinemann; 1991. 41. Rook P. Controlling software projects. Software Engineering Journal 1986;1(1):7-16. [doi: 10.1049/sej.1986.0003] 42. De Lope RP, Medina-Medina N. A Comprehensive Taxonomy for Serious Games. Journal of Educational Computing Research 2016 Dec 12;55(5):629-672. [doi: 10.1177/0735633116681301] Abbreviations PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Edited by N Zary; submitted 17.11.20; peer-reviewed by G Alor-Hernández, U Juárez-Martínez; comments to author 08.01.21; revised version received 05.04.21; accepted 22.07.21; published 11.11.21 Please cite as: Ambros-Antemate JF, Beristain-Colorado MDP, Vargas-Treviño M, Gutiérrez-Gutiérrez J, Hernández-Cruz PA, Gallegos-Velasco IB, Moreno-Rodríguez A JMIR Serious Games 2021;9(4):e25831 URL: https://games.jmir.org/2021/4/e25831 doi: 10.2196/25831 PMID: ©Jorge Fernando Ambros-Antemate, María Del Pilar Beristain-Colorado, Marciano Vargas-Treviño, Jaime Gutiérrez-Gutiérrez, Pedro Antonio Hernández-Cruz, Itandehui Belem Gallegos-Velasco, Adriana Moreno-Rodríguez. Originally published in JMIR Serious Games (https://games.jmir.org), 11.11.2021. 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 https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ambros-Antemate et al reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2021/4/e25831 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e25831 | p. 18 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious GamesJMIR Publications

Published: Nov 11, 2021

Keywords: serious game; physical rehabilitation; framework; methodology

There are no references for this article.