Usability Test of Exercise Games Designed for Rehabilitation of Elderly Patients After Hip Replacement Surgery: Pilot Study

Yun Ling; Louis P Ter Meer; Zerrin Yumak; Remco C Veltkamp

doi:10.2196/games.7969

Ling, Yun; Meer, Louis P Ter; Yumak, Zerrin; Veltkamp, Remco C

2017-10-12 00:00:00

Background: Patients who receive rehabilitation after hip replacement surgery are shown to have increased muscle strength and better functional performance. However, traditional physiotherapy is often tedious and leads to poor adherence. Exercise games, provide ways for increasing the engagement of elderly patients and increase the uptake of rehabilitation exercises. Objective: The objective of this study was to evaluate Fietsgame (Dutch for cycling game), which translates existing rehabilitation exercises into fun exercise games. The system connects exercise games with a patient’s personal record and a therapist interface by an Internet of Things server. Thus, both the patient and physiotherapist can monitor the patient’s medical status. Methods: This paper describes a pilot study that evaluates the usability of the Fietsgame. The study was conducted in a rehabilitation center with 9 participants, including 2 physiotherapists and 7 patients. The patients were asked to play 6 exercise games, each lasting about 5 min, under the guidance of a physiotherapist. The mean age of the patients was 74.57 years (standard deviation [SD] 8.28); all the patients were in the recovery process after hip surgery. Surveys were developed to quantitatively measure the usability factors, including presence, enjoyment, pain, exertion, and technology acceptance. Comments on advantages and suggested improvements of our game system provided by the physiotherapists and patients were summarized and their implications were discussed. Results: The results showed that after successfully playing the games, 75% to 100% of the patients experienced high levels of enjoyment in all the games except the squats game. Patients reported the highest level of exertion in squats when compared with other exercise games. Lunges resulted in the highest dropout rate (43%) due to interference with the Kinect v2 from support chairs. All the patients (100%) found the game system useful and easy to use, felt that it would be a useful tool in their further rehabilitation, and expressed that they would like to use the game in the future. The therapists indicated that the exercise games highly meet the criteria of motor rehabilitation, and they intend to continue using the game as part of their rehabilitation treatment of patients. Comments from the patients and physiotherapists suggest that real-time corrective feedback when patients perform the exercises wrongly and a more personalized user interface with options for increasing or decreasing cognitive load are needed. Conclusions: The results suggest that Fietsgame can be used as an alternative tool to traditional motor rehabilitation for patients with hip surgery. Lunges and squats are found to be more beneficial for patients who have relatively better balance skills. A follow-up randomized controlled study will be conducted to test the effectiveness of the Fietsgame to investigate how motivating it is over a longer period of time. (JMIR Serious Games 2017;5(4):e19) doi: 10.2196/games.7969 KEYWORDS rehabilitation exercise; computer games; hip replacement; elderly; physical therapists http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Achieving the goal of rehabilitation after hip surgery requires Introduction accurate and appropriate tracking and feedback. Therefore, we developed Fietsgame using Microsoft Kinect as an off-the-shelf Background three-dimensional (3D) depth camera. Kinect v2 offers Elderly people consume a large part of the health care and social marker-free full-body tracking on a conventional personal services, especially in developed countries [1]. Hip fracture is computer (PC). It has a wide field- of-view to provide full-body considered a major problem for elderly people because of its control of animated virtual characters. This allows the virtual high incidence [2,3] and the related high mortality and morbidity character on the screen to mirror the movements of the user in [4,5], and as a consequence the decreased quality of life visible real time. Earlier studies concluded that Kinect v2 has the in reduced physical movement [6], and finally the increased potential to be used as a reliable and valid clinical measurement costs of health care involved in the treatment of patients [1,2]. tool [17-19]. Hence, the physiotherapists can set the range of The most commonly used treatment method is surgery, which knee angle and hip angle as they usually do in the traditional helps patients recover more quickly [7]. Besides, fracture hip rehabilitation training when they use the exercise games. replacement is a treatment for patients with abrasion of the hip Objectives joints to reduce pain and increase mobility. Establishing rehabilitation programs after hip surgery improves the quality To the best of our knowledge, only a few Kinect games offer of life of elderly patients [6]. Earlier studies with patients who exercises with full-body animated virtual characters and received outpatient rehabilitation showed increased strength configurable level of difficulties, which are required for and better functional performance such as self-care ability and rehabilitation after hip surgery. Earlier studies using Kinect to mobility after 3 months and 1 year, respectively, compared with design rehabilitation exercise games either focus on those without rehabilitation [5,8]. However, conventional rehabilitation of the upper body [20-23] or use simple balance physiotherapy is often experienced as boring by the patient, training exercises [24-27]. These games are lacking the variety leading to poor adherence [9]. of exercises with a very limited range of difficulty levels. We, therefore, have developed a series of immersive and motivating Due to the engaging, entertaining, and thus motivating properties exercise games with real-time feedback and a configurable wide of exercise games, gaming has been proposed as a valuable range of difficulty levels. instrument to encourage patients’ participation in rehabilitation and improve patients’ adherence to therapy programs [10]. For In general, applications supporting the management of illnesses example, Pichierri et al [11] and Uzor and Baillie [12] showed or providing assistance in daily living activities for the elderly better adherence in exercise gaming groups than in the controlled showed good usability and high acceptance [28,29]. For conventional groups. Furthermore, playing an exercise game example, Arnhold et al [28] showed that applications for elderly can be used to distract patients’ attention from pain resulting diabetes patients have moderate to good usability. Hossain and from their surgery or movement, and it thus contributes to the Ahmed [29] found that elderly participants interacted with the patients’ motivation to use exercise games [13,14]. virtual caregiver easily and were highly satisfied with its assistance during their daily activities. Exercise games are Exercise games have shown equal or superior effectiveness designed to elicit motivation for rehabilitation training. Studies compared with conventional physiotherapy in rehabilitation in testing the usability of exercise games among the elderly patients over 16 years of age [15,16]. A meta-analysis suggests population showed that the games that were specifically that exercise games are equally effective to improve balance, designed for the elderly were positively evaluated by the elderly when considering the aspects of balance and walking speed participants with respect to their usability, user acceptance, [15]. Warburton et al [16] showed that, because of improved enjoyment, and its rehabilitation effect [30-32]. engagement of the patient, cycling exercise games result in significant improvements in physical fitness, including muscular In this pilot study, we were interested in getting an insight into strength and flexibility, compared with conventional cycling the point of view from the physiotherapists, in particular whether exercise training. the exercise games satisfy the nature of a motor rehabilitation program for elderly patients after hip surgery (Research question Compared with traditional rehabilitation, exercise games allow 1) and whether they have the intention to use the exercise games for task-specific exercises to be delivered at different difficulty to treat the patients in the future (Research question 2). levels. This allows the patient to start at an appropriate level Furthermore, we investigated whether the patients experienced and then proceed, based on a set of goals, with a gradual a high level of presence and enjoyment and an expected level progression of difficulty. However, according to Skjaeret et al of exertion and pain (Research question 3), and whether they [10], the majority of the studies used commercially available found the games easy to use and wanted to continue using the gaming technologies such as the Nintendo Wii game console, exercise games to do further rehabilitation (Research question Sony PlayStation II, X-Box360, and Dance Dance Revolution. 4). These commercial games are originally designed for entertainment, targeted at younger people, and not based on Methods exercise principles. Commercial games are also too difficult and not engaging enough for elderly. Therefore, effective Participants exercise games that are specific to the needs of the elderly are In total, 2 physiotherapists (a male aged 31 years and a female needed. aged 29 years) and 7 patients (5 females and 2 males) with age http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al range of 60 to 82 years (mean 74.57, SD 8.28) from Aafje muscular strength as well as endurance. The system has the Rehabilitation Center in Rotterdam, The Netherlands, following two components: the exercise games and Community participated in this study. The patients were recovering from Care 360 (CC360) with a therapist control interface and the hip joint replacement (hip arthroplasty) or (unipolar) short-stem patient’s medical record. The exercise games and CC360 are hemiarthroplasty surgery. The inclusion criteria of the patients connected by the Internet of Things (IoT) server from were that they should be capable of performing the exercises Consultants to Government and Industries (CGI) [33]. The and understanding the instructions of the exercise game. Patients games were run on a PC with Windows 10 software and with acute illness in the past 3 weeks, with mental disorders, or displayed on a 48-inch TV. A Raspberry Pi device was used to with poor visual acuity (not capable of seeing the visual features connect the PC to the IoT platform. on the TV screen) were excluded. Figure 1 shows the architecture of the Fietsgame. The system All participants provided written informed consent before their works as follows: first, basic information such as the age, the participation in the experiment. After completing the experiment date of intake, and a photo of the patient is fed into the patient’s and answering the questions, they received a compensation gift. medical record in CC360 and sent to the IoT server. Then, the The exercise games imposed the same risk as a regular therapy patient logs into the system through a face recognition session, because the patients performed the same exercises as technology embedded in the exercise game using Kinect v2. part of their normal treatment. Whenever the patient was playing We used face recognition to identify the user because of the the game, a physiotherapist was always present. The load of the following two reasons: first, it allows natural interaction with exercise games was comparable with the normal treatment for the system, with high recognition accuracy [34-37], and second, both the patients and the therapists, according to the in the future, we can extend the exercise game system with physiotherapists. This study has been approved by the board of emotion recognition using the camera [38-40]. directors of the rehabilitation center of Aafje and the ethical After the exercise game recognizes the identity of the patient, committee of Utrecht University. assigned workout is automatically retrieved from the server using the Raspberry Pi. When the patient completes the exercise The Fietsgame game, his or her workout data such as the number of exercises, The Fietsgame has been designed by a consortium of knee or hip angles, and game scores are sent to the IoT platform physiotherapists, game designers, researchers, and an and stored for further analysis. Both the patient and the information technology company with the goal of improving physiotherapist can read the patient’s workout data through the rehabilitation process. The specific aim was to increase the CC360. mobility of the joints and surrounding soft tissues and to increase Figure 1. The Fietsgame system. physiotherapists to improve the usability issues of the earlier The Exercise Games version of the exercise games. This paper presents the results The purpose of hip rehabilitation is to reduce symptoms such of testing the beta version of the exercise games. as pain and inflammation and improve hip joint function The games are implemented using the Unity 3D game engine. approached through a systematic progression, depending on the There are 6 exercise games with 6 different balance exercises: patient’s present pathology and functional needs. The patients cycling in a life-like virtual village for stepping, dancing under must understand the related precautions and the recommended the spotlight with fellow dancers for sidestepping, ringing the progression for their individual situations. The physiotherapists bell in a church for squats, picking up apples for lunges, playing advise a suitable exercise program by defining frequency, football for back kicks, and fishing on a boat for single leg duration, and range of motion after considering the patient’s stance (Figures 2-7). The participant’s avatar is presented from level of discomfort and physical status of the hip joints [41]. In a third person perspective. The therapist can adapt the difficulty our case, we created the exercise games based on the level of the exercise games according to the patient’s physical physiotherapists’ advice and requirements over a period of 4 condition and level of discomfort. Possible configuration years. The physiotherapists gave their suggestions and parameters for each game are shown in Figures 2-7. In addition requirements to the design team regarding the exercises they to the final scores, the games consist of motivational elements need to have and what parameters the design team needs to such as awards and sounds. The interface of the game is in configure in the rehabilitation program. Before the pilot test, Dutch. In the following paragraphs, we summarize the play of we did 2 usability tests with 2 real patients and 2 each game. http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Figure 2. The cycling game—stepping; left: virtual environment, right: configurable variables. Figure 7. The dancing game—sidestepping; left: virtual environment, right: configurable variables. game are the number of steps and required knee angle with Cycling mean and SD. In the cycling game (Figure 2), the player is instructed to finish Dancing stepping exercises with the minimum required knee angle. When the player performs the exercises correctly, the bike goes The dancing game (Figure 3) works as follows: the player is forward smoothly. If not, the bike stops going forward. There expected to do the sidestepping exercises with the minimum are gift boxes and pedestrians on the road. An arrow indicates required step width. The arrow in the interface indicates which when the player comes to the end of the road. The player needs side the player should take a step. When the exercise is to put out his/her left (or right) hand to turn left (or right). If the performed successfully, the avatars in the virtual environment player follows the direction of the arrow, she/he can get to the give feedback by dancing and clapping their hands. The avatars destination faster. The player can pick up the gift box to earn stay in the standing pose if the player does not perform the money by running over it and can wave to the pedestrians to exercise correctly. The configurable variables are the number earn social points. When the player waves at the pedestrians, of steps and minimum step width. the bell of the bike rings. The configurable variables in this http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Figure 3. The ringing the bell game—squats; left: virtual environment, right: configurable variables. bright and the bell rings, indicating the accomplishment of the Ringing the Bell exercise. When the patient fails in doing the squat correctly, the During the ringing the bell game (Figure 4), the player is progress circle does not fully turn to a bright color. Furthermore, expected to do squats with the required knee angle and duration the brightened part of the circle disappears if the player fails to as defined in the configuration file. When the squat pose is hold the correct squat pose for the required duration and needs correct, the avatar mimics the player and a circle indicating the to start again. The configurable variables are the number of progress starts to fill with brighter colors to count for the squats, squat duration, and knee angle range (minimum and duration of the squat. When the patient manages to stay in maximum). balance for the required duration of the squat, the circle is fully Figure 4. The apple picking game—lunges; left: virtual environment, right: configurable variables. circle is fully bright and the apple is picked up and thrown into Apple Picking the basket. When the patient fails in doing the exercise correctly, The apple picking game (Figure 5) asks the player to perform the yellow circle does not start to fill with brighter colors to lunges with a required minimum front knee angle. An apple count the duration of holding the lunge. The brightened part of falls from the left/right side of the avatar, and the player should the circle disappears if the player fails to hold the correct pose step the mirrored left/right leg forward to perform lunges. The for the required duration. The basket shown in the front of the function of the yellow circle works similar to the one in the avatar in the game is to show the award by playing lunges ringing the bell game. The avatar mimics the player’s movement, successfully. It has no other function in the game. The and the circle starts to fill with brighter colors to count for the configurable variables are the number of lunges, lunge duration, duration of the lunge when the lunge pose is correct. When the minimum foremost knee angle, and the frequency of exercises patient manages to stay in balance for the required duration, the for the left or right leg. http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Figure 5. The football playing game—back kicks; left: virtual environment, right: configurable variables. do the back kicks. The real-time feedback function of the yellow Football Playing circle is the same as the ones in the ringing the bell and the The goal of the football game (Figure 6) is to kick the ball to apple picking games. Once this duration of back kick is one of the 5 holes. At each turn, the number assigned to the completed, feedback is provided by showing the avatar kicking holes is changed, and when the user aims at the hole with a the football out. No kicking actions of the avatar will be shown higher number, he/she scores higher. The player raises one of when the player does not perform the exercise correctly. The the legs to prepare for a back kick and holds the leg in that configurable variables are number of back kicks, back kick position for the duration defined in the settings. The user turns duration, knee angle (mean and SD), and the frequency of his/her upper body to left/right to aim for the hole while keeping exercises for the left or right leg. the leg raised. An arrow indicates which leg should be used to Figure 6. The fishing game—one leg stance; left: virtual environment, right: configurable variables. applications for both the therapists and the patients. The Fishing configuration interface (Figure 8 top, originally in Dutch; see The objective of the fishing game (Figure 7) is to perform single also Multimedia Appendix 1) allows the physiotherapists to set leg stance. The player is required to perform one-leg stance the goals of the game according to the patients’ conditions and exercise with a configured minimum hip angle and holding the rehabilitation goals. The therapist can specify the treatment time. A fish is caught and put into the boat when the player for each patient such as the required range of the knee and hip performs the exercise correctly in each turn. An arrow indicates angles during the game, depending on the patient’s physical which leg should do the one leg stance. The real-time feedback capabilities. Thus, the therapist application allows the function of the yellow circle is the same as the ones in the physiotherapists to work more effectively, following whether ringing the bell, the apple picking, and the football playing a patient is following the treatment plan and being prepared for games. No fish will be caught if the player fails in doing one consultations. In the patient application (Figure 8 bottom, leg stance. The configurable variables are the number of one originally in Dutch; see also Multimedia Appendix 2), the leg stances, stance duration, minimum hip angle, and the patient can see the exercises assigned to him/her by his/her frequency of exercises for the left or right hip. physiotherapist and play the exercise games by performing the required therapeutic movements. The game software assesses Community Care 360 the performance of the patient by analyzing the data captured CC360 is a patient-centric health platform that allows the by Kinect v2. The final results, such as the number of patients, health care professionals, and other stakeholders to successfully accomplished movements, knee angle, hip angle, monitor and manage the patients’ health. CC360 provides and start and end time of the exercises, will be recorded and http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al sent to the IoT platform and can be accessed through the the patient receives no assignment from the physiotherapist therapist and patient applications in CC360. The exercises can through CC360. also be assigned through a local configuration file on a PC when Figure 8. Top: the physiotherapist control interface; bottom: the patient interface showing patient’s medical record in CC360. The configuration parameter vissen_aantal means the number of fishing exercises. http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al The adapted Technology Acceptance Model (TAM) from Hu Measures et al [48] was used in this study for measuring patients’ and The measurements used in the experiment include psychometric physiotherapists’ intention to use the game system. It was tools, such as self-reported questionnaires, and objective suggested that ΤΑΜ was able to provide a reasonable depiction behavioral measurements. Objective behavioral measures such of physicians’ intention to use telemedicine technology [48]. as knee angle, step width, hip angle, and the number of TAM consists of 21 items with the following 4 subscales: successfully finished exercises were captured by Kinect v2 and perceived ease of use, perceived usefulness of the technology, sent to the IoT platform via the Raspberry Pi. The experiment attitude toward using the technology, and intention to use the was also video-recorded for further analysis of the comments technology. The participants’ responses were rated on a 7-point of the therapists and the patients during the exercise game. Likert scale from −3 (strongly disagree) to 3 (strongly agree). Self-reported questionnaires were filled in by the therapists and were answered by the patients. The questionnaire for the patients Self-Reported Questionnaires for the Physiotherapists was designed to measure the subjective feeling of presence, At the beginning of the experiment, the physiotherapists were enjoyment, exertion, pain level, and technology acceptance, asked to fill in a questionnaire, which recorded their age, gender, whereas the questionnaire for the physiotherapist was aimed to mother tongue, education, and gameplay experience. The get an expert opinion on the usability of the game from the experience of using the exercise game was investigated through technology acceptance and rehabilitation point of view. More questionnaires, including criteria for rehabilitation of the details about the questionnaires are given below, and the exercise game [49] and the adapted TAM from Hu et al [48]. questionnaires for patients and physiotherapists are attached in The questions in the TAM questionnaires were virtually the Multimedia Appendices 3 and 4, respectively. same for both the patients and the physiotherapists, but the terms used were rehabilitation and patient care for patients and Self-Reported Questionnaires for the Patients physiotherapists, respectively. At the beginning of the experiment, patients were asked to fill in a questionnaire containing the following personal data: date Regarding the usability of the game for motor rehabilitation, of intake, the current number of daily exercise sessions, age, we used a revised version of the design criteria for stroke gender, mother tongue, gameplay experience, and social status. rehabilitation programs for elderly users from Flores et al [49]. Visual acuity was measured using the Freiburg Visual Acuity It includes the following five criteria: Test at a distance of 3 m [42]. The experience of playing the Adaptability to the motor skill level of the patient. As motor exercise game was measured through standard questionnaires, impairments vary among patients and patients’ motor skills including feelings of presence, enjoyment, exertion, pain level, improve over time, the changeable level of difficulty in the and technology acceptance. exercise game is necessary. The concept of presence in virtual reality covers three aspects: Meaningful tasks. Tasks should be incorporated so that spatial presence, social presence, and copresence [43]. In this exercises in the game can be correlated with daily life study, we are interested in testing whether patients’ attention activities. can be distracted by the real world. Therefore, spatial presence Appropriate feedback for both the patient and the where patients’ feeling of being present in the virtual physiotherapist. The exercise game should provide real-time environment instead of being aware of the real world is feedback on how well the patient is doing and how much important. Schubert et al [44] created an Igroup presence she/he has been improving and provide encouraging questionnaire (IPQ), which consists of 14 items rated on a feedback to stimulate the patient to adhere to the exercise 7-point Likert scale to measure spatial presence. The scores on game. Providing exercise record such as charting the history the 14 IPQ items are mapped onto 3 subscales: spatial presence of patients’ exercise accomplishments can help the (the relation between the virtual reality and the physical real physiotherapist to better plan future therapy sessions. world), involvement (the awareness devoted to the virtual Therapy appropriate range of motion. This refers to the reality), and experienced realism (the sense of reality attributed extent the game demands the therapeutic motions needed to the virtual reality). It also includes one general item that for the rehabilitation program of patients after hip surgery. assesses the general feeling of being in the virtual reality. To Focus diverted from exercise. The game should be fun lower the burden of answering questions for the elderly, we enough to divert patients’ attention from the exercises to measured presence using only the general item. the objectives of the gameplay. Enjoyment was tested by using a 1-item question on a 7-point Participants’ responses were rated on a 7-point Likert scale from Likert scale, “Do you find the exercise game interesting?” [45]. −3 (strongly disagree) to 3 (strongly agree). The Perceived Exertion Scale [46] was used as a measure of Qualitative Feedback perceived exertion. It is a 15-point scale ranging from 6 (very light exertion) to 20 (very hard exertion). The Perceived After playing each exercise game, all the participants were asked Exertion Scale is widely used and has adequate reliability and to give general feedback and comments on each game. At the validity. The perceived pain level was measured using the Visual end of the experiment, participants were asked to discuss their Analogue Scale (VAS) [47]. The VAS contains 11 brief pain favorite and least favorite part of playing the exercise game in severity descriptions. Scores on the VAS ranged from 0 (no open questions. pain) to 10 (very severe pain). http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al left the room. They were requested to rest until they feel better Procedure when they experienced any discomfort. After completing the To ensure high quality of recognition, we tested the exercise experiment, participants were debriefed and given a gift of 10 games in a controlled environment. To be more specific, the euros for their contribution. As CC360 is a widely used camera was set to track the closest person as long as possible, commercial product [33], we did not ask the patients or and only the player is within a distance of 2 to 3 m in front of physiotherapists to use and evaluate CC360 itself. the camera where the tracking accuracy is the best [50]. No objects or other persons are between the player and the Kinect Data Analyses v2 camera. There were 3 experimenters, 1 for the technical All the behavioral data and self-reported scores of the support of CC360 and making notes of the comments given by questionnaires were analyzed with SPSS statistics package the patients and the physiotherapists, 1 for the technical support version 24. To answer our research questions, the measured of the exercise game and also for making notes of the comments data, including behavioral and self-reported data, were analyzed from the participants, and 1 for administrating the consent, using descriptive statistics for all the 6 exercise games, and 2 questionnaires, and debriefing of the experiment. trained researchers coded the qualitative feedback from patients After obtaining consent and basic information from the patients and physiotherapists separately. Under the broad question, and the physiotherapists, participants were introduced to the themes emerged from the coded data. The researchers discussed exercise games, including the Kinect v2 sensor and CC360. and refined the codes, that is, codes with similar meanings were One of the experimenters took a picture of the patient and grouped together, and the more frequently a code appeared, the uploaded it to the IoT platform for facial recognition to start more the theme was strengthened. We then analyzed the codes the exercise games. The therapist then assigned the exercises addressing gaming experience, game design, system operation, according to the patient’s recovery status through the usefulness, and intention to use the exercise games. configuration file on a PC. The patients were asked to play 6 different exercise games, each lasting about 5 min. The Results physiotherapist was always in the same room as a guide for the Patient Descriptions patient and answered all the questions the patient asked during the game. Each participant was assessed individually during A summary of demographic data and personal information of the session, which in total lasted about 60 min. Patient’s the patients is provided in Table 1. All the patients had their behavior and the voice of the experimenters and the intake after hip surgery at Aafje Rehabilitation Centre between physiotherapist were recorded by a laptop camera for later January and November in 2016. The pilot test was conducted transcription. in December 2016. Patients’ visual acuities were sufficient for playing the exercise games, which were rendered on a 48-inch Before each exercise game, the physiotherapist showed how to TV placed at a distance of 3 m in front of them. play the exercise game correctly and explained the instructions on the screen. Participants, if applicable, wore their prescription Median and interquartile ranges of workout assignments in the glasses during the experiment. All the patients used chairs to configuration from the guiding physiotherapist are provided in prevent falling. The chairs were placed on the left or right and Table 2. Some of the configured variables such as the required behind the player. After each exercise game, the patients were knee angle in the cycling game were the same for all the patients. asked to report their experienced level of presence, enjoyment, To keep the configuration of the knee angle more consistent perceived exertion, and pain level by one of the experimenters between different exercise games, we need to change the mean and their reported scores were noted in the printed hard copy and SD of the knee angle into minimum and maximum knee of questionnaire; the physiotherapists were asked to fill in a angles for the cycling game and the football playing game in short questionnaire, which measures whether the exercise game the next version of the games. meets the criteria for rehabilitation. Both the patient and the All the patients used chairs to keep balance during the exercises. physiotherapist were asked to give a general feedback and Figure 9 shows the number of participants who successfully comments on the game that the patient just played. Objective accomplished assignments from the physiotherapist, who behavioral measures, including knee angle, step width, and hip dropped out because of personal reasons, and who could not angle, and the number of successfully finished exercises, were finish the exercise because of recognition errors. Of the patients, captured by Kinect v2 during the gameplay. 2 dropped out of cycling and fishing because of personal At the end of the experiment, both the patients and the therapists schedules, and 3 participants had to give up playing apple were asked to fill in the questionnaire for the TAM and to give picking to do lunges because the exercise game could not their general comments about the exercise games. The patients recognize their movement even though they exercised correctly were also asked whether they felt any discomfort before they according to the guiding physiotherapist. http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Table 1. Demographic and personal data of the patients. Patient Planned exer- Age Gender Native lan- Visual Sport Frequency of play- Living status cises per day guage acuity ing computer games 1 2 70 Female Dutch 0.69 Physio-training Occasionally Alone 2 3 82 Female Dutch 0.48 Fitness and physio-training Everyday With partner 3 6 82 Male Dutch 0.66 Physio-training Never With partner 4 3 60 Female Dutch 0.73 Swimming, walking, and physio-training Never Alone 5 4 81 Female Danish 0.64 Nordic walking and physio-training Never Alone 6 2 77 Female Hungarian 0.53 Physio-training Never Alone 7 4 70 Male Dutch 0.53 Coordinating football in the field and Never Alone physio-training Table 2. Patients’ workout assignments in the exercise games (medians and interquartile ranges). Games Behavioral measurements Median Interquartile range Cycling Repeated number of steps 40 56 Mean knee angle (degree) 45 N/A Knee angle standard deviation (degree) 10 N/A Dancing Repeated number of steps 10 N/A Minimum step width (cm) 30 10 Ringing the bell Repeated number of squats 5 N/A Squats timer (second) 2 1 Knee angle minimum (degree) 40 N/A Knee angle maximum (degree) 100 N/A Apple picking Repeated number of lunges 5 N/A Time to hold the lunges (second) 2 0 Foremost minimum knee angle (degree) 30 0 Football playing Repeated number of back kicks 10 N/A Standing timer (second) 3 0 Mean knee angle (degree) 30 N/A Knee angle standard deviation (degree) 10 N/A Fishing Repeated number of one leg stance 10 N/A Standing timer (second) 3 1 Minimum hip angle (degree) 80 20 http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Figure 9. Number of participants who successfully played the game, who dropped out of the game, and who could not finish the assignments because of the unsuccessful recognition of their movements. enjoyment score >0). Most of the participants found apple Patients’ Gaming Experience picking (75%) and fishing (80%) enjoyable to use, but only Medians and interquartile ranges of patients’ perceived feelings 43% of the participants rated ringing the bell enjoyable. All the of presence, enjoyment, exertion, and pain during each exercise participants (100%) experienced low to moderate exertion game are shown in Figure 10. The score of each game was only (exertion ≤13) in cycling and dancing. The majority of the from those participants who successfully accomplished the participants also indicated low to moderate levels of exertion assignment as assigned by the physiotherapist in the exercise in apple picking (75%), football (57%), and fishing (60%), and game. The majority of the participants reported high levels of a high level of exertion (exertion >13) in ringing the bell (57%). presence (with presence score >0) in cycling (60%), apple Most of the participants had low to moderate pain (score ≤5) picking (75%), football (71%), and fishing (60%) but a low while playing the exercise games such as cycling (80%), dancing level of presence in dancing (57% of the participants scored (100%), ringing the bell (71%), apple picking (75%), football enjoyment below 0). Presence score for ringing the bell was (86%), and fishing (80%). Very few participants reported a pain evenly distributed over the score range. All the participants score above 5 during their exercises. (100%) found cycling, dancing, and football enjoyable (with http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Figure 10. Medians and interquartile ranges of patients’ perceived feeling of presence, enjoyment, exertion, and pain for all the 6 exercise games. Scoring of presence and enjoyment ranged from −3 to 3, scoring of exertion ranged from 6 to 20, and scoring of pain ranged from 0 to 10. The horizontal line represents the median and the distance between the top, and the bottom of the bar represents the interquartile range. therapy-appropriate range of motion, and (5) diverting the Physiotherapists’ Evaluation of Game Design patient’s consciousness from exercise toward game playing. The scores on the 5 items about whether the exercise games Technology Acceptance Model satisfy the nature of a motor rehabilitation program from 2 physiotherapists are shown in Table 3. Both physiotherapists Figure 11 presents the medians and interquartile ranges of TAM expressed positive attitudes toward the exercise games on all items that were evaluated by both the patients and the the 5 items: (1) adaptability of the game to the motor skill level physiotherapists. The exercise games were considered to be of patients, (2) providing meaningful tasks to promote quality useful and easy to use. The participants expressed positive of life, (3) giving appropriate feedback for both the patient and attitudes toward using the exercise games, as well as an intention the physiotherapist to encourage adherence to the game and to continue using the exercise games in their future rehabilitation keep track of the patient’s recovery status, (4) staying within or patient care. http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Table 3. Evaluation of game design (scoring ranged from −3 to 3). Game design evaluation Cycling Dancing Ringing the bell Apple picking Football playing Fishing Physiotherapist 1 Adaptability 2 2 0 1 0 2 Meaningful tasks 1 2 2 2 1 2 Appropriate feedback 1 2 2 2 2 2 Range of motion 2 2 2 2 2 2 Diverted focus 2 2 2 2 2 2 Physiotherapist 2 Adaptability 2 2 1 2 2 2 Meaningful tasks 2 2 1 3 2 3 Appropriate feedback 2 2 1 2 2 3 Range of motion 2 2 1 2 2 2 Diverted focus 3 3 1 3 1 3 http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Figure 11. Medians and interquartile ranges of evaluation of Technology Acceptance Model (TAM) from both the patients and the physiotherapists. Scoring ranged from −3 to 3. The horizontal line represents the median, and the distance between the top and the bottom of the bar represents the interquartile range. on the gaming experience, usefulness, and intention for future Qualitative Feedback and Implications for Design use, we also encountered some issues relating to game design Guidelines and movement recognition by Kinect v2. We discuss the main Comments provided by the physiotherapists and the patients issues revealed from the negative comments and the and their implications are presented in Table 4. In general, we corresponding implications for future work below. The received very positive feedback. The patients liked and enjoyed requirements and implications hold for all the Kinect exercise the games a lot, and sometimes they were genuinely excited. games targeting the elderly population. The game design, for example, the beautiful virtual environment, Game Design background music, and rewarding sound, brought in enjoyment to the patients. The patients can quickly exercise on their own Cognitive Load in the exercise games. The players found the gameplay For some players, the exercise games were too complicated experience comparable with real physiotherapy and expressed because of the requirement of engaging in multiple activities intention to play again. Despite the overall positive comments http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al simultaneously. For example, in the cycling game, the patients sidestepping without clapping hands when playing the dancing sometimes need to do the stepping exercise, collect gift boxes game, and they do not need to shoot the ball when doing back and wave to the virtual pedestrians, and indicate directions kick in the football game. Instructions showing that movements occasionally at the same moment. Some patients found it such as clapping hands and shooting the ball are not compulsory difficult to follow the instruction arrow indicating which leg should be given at the beginning of the games to help the they should practice in the football playing game. However, patients understand how the games actually worked. most of the patients thought the game interface was rather easy Balance Skills to understand. Minimizing the amount of information presented Patients at the beginning phase of their physiotherapy found on the screen might allow older patients with poor cognitive some of the games more difficult. For example, it was difficult skills to perceive information. Hence, older patients can follow for them to do sidestepping in the dancing game. During the the instruction and commands more easily [28]. To tailor our cycling game, waving to the avatars and indicating directions exercise games to individual needs of cognitive challenges, raising one of the hands were difficult for some of them because picking gift boxes and waving to the other virtual humans should of impaired balance. Therefore, we suggest that the stepping be optional in the cycling game. We believe that as the patients exercise should not require the patient to go to the same side become more experienced with the games and their for more than once. Waving to the avatars can be optional in performances improve, the cognitive load of the games can be the game. Other ways for indicating directions such as turning made more challenging by introducing levels. In this way, the upper body or automatically changing directions should be patients can be mentally challenged over a longer period, thus configurable for patients with poor balance skills. maintaining long-term exercise habits. Indistinguishable Objects Lack of Real-Time Feedback on Wrong Movements Patients complained that all the fishes looked similar and they Some patients were unsure of what action should take place at prefer varieties in the game content. a particular time. Providing helpful information and feedback at the appropriate time throughout the game will be beneficial Kinect Tracking [51]. For example, a real-time instruction such as how far away The Kinect did not properly recognize squats and lunges played the patients’ knee angle is from the required knee angle should by a few of the female patients with a wide blouse or obesity. be given when the patient is performing the cycling game. How Chairs, mirrors, and other objects in the environment sometimes far the patients are away from achieving the minimum step interfered with the Kinect tracking. Of the participants, 3 had width should be shown on the screen while playing the dancing to quit playing the apple picking game as their lunges were not game. Similarly, instructions such as how far away the patient’s recognized. We observed that Kinect v2 could recognize lunges knee/hip angles are from the required knee/hip angles and how for patients with relatively normal mass level even with support much time is left for the required duration should be given when chairs; however, for patients with obesity, it did not recognize the patient is performing the rest of the games. their lunges. Furthermore, we found that Kinect v2 could not Mismatched Movements recognize movements of patients with a wide blouse or trousers; it worked better when they changed their clothes to relatively Some patients got confused when the movement of the tight ones. Hence, we suggest that players wear relatively tight representing avatar did not match their movements when playing clothes when playing Kinect exercise games. the dancing and football games. The patients were asked to do http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Table 4. Comments made by the physiotherapists, the patients, and the implications. Note that feedbacks from the physiotherapists are in italic. Exercise Positive comments Negative comments Implications games Cycling “I like this game a lot!” “It is difficult for the patients who are at the Picking gift boxes and waving to the beginning phase of their physiotherapy to other virtual humans should be optional wave to other virtual humans or to put out a in the game. hand to indicate direction.” “I like the beautiful village in the virtual “The bike runs too fast and it made me The speed of the bike should be config- environment.” dizzy.” urable. “I tried not to run over the gift boxes on the Other ways for indicating directions such street.” as turn the upper body should be config- urable. Dancing “The game is nice. It is much better than “As the patients were using chairs to support For patients who need support for bal- the boring exercises we normally do.” balance, it was difficult to go to the same side ance, stepping exercise should not re- for 2 or more side steps.” quire the patient to go to the same side for more than once. “The music is good.” “My movements did not match with the Patients should be told that they could movements of the dancing avatars on the clap their hands if they want, but it is not screen.” required in the exercise. “I really looked forward to dancing and it was even better than I expected.” “The game looks easier than it really is.” Ringing the “It is a nice game.” “It is a difficult game; hence, patients’ plea- It is a difficult game for the patients, and bell sure is lost.” it is more suitable for patients who have better balance skills. “The rewarding music brings in enjoyment “It is a difficult exercise and patients intend- Patients should wear relatively tight in the player.” ed to do a wrong performance.” clothes to ensure more accurate move- ment recognition by Kinect v2. “I was disappointed that the game did not recognize my squats while I was wearing my wide blouse.” Picking ap- “It is a nice game.” “ The supporting chairs interfere with The chairs interfere with tracking for ples Kinect’s recognition of the movements.” lunges. “The game does not respond to my correct It is more suitable for patients who are movements.” at a later stage of their rehabilitation, that is, patients who can do lunges without balance support. Football “It is a very useful game for balance train- “Patients intended to shoot the ball.” To reduce cognitive load, let the patient playing ing, and it reacts very well to the move- play the game by doing back kicks using ments of the player.” their left and right legs alternatively. “It is a great game. It made me feel like that “It is difficult for me to pay attention to the Instructions should tell the patients that I was playing a real football game.” arrows indicating which leg I should use.” they do not have to shoot the ball. Fishing “It is a nice game. I had a feeling that I had “I focused on the timer, and the virtual envi- Different types/sizes of fish need to be a real therapy.” ronment was not noticeable for me.” created in the game. “This game would help a lot in my rehabil- “All the fishes looked similar. It would be itation.” nice if I could catch a different fish.” “The virtual environment is beautiful and I like it a lot!” http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Exercise Positive comments Negative comments Implications games General “Playing games distracted patients’ atten- “Some patients were unsure of what action Real-time feedbacks on how far the pa- comments tion from exercise and pain.” was supposed to take place at a particular tients are away from the required range time. When the patients fail in doing the exer- of motion should be provided on the cise successfully, they do not get feedback on screen when the patients are performing how to do it correctly.” the exercises. “You can use the game for fun besides the “You have to be clever enough to play the To satisfy personal preferences, inter- physiotherapy.” games as it requires paying attention to mul- faces and virtual environments should tiple things at the same time.” be configurable to meet the needs of different cognitive challenges. “ Patients have enjoyment and they can ex- “I am very smart, so the game could be made ercise by their own quickly by using the ex- slightly more difficult for me.” ercise games.” “These are very nice and useful games and I would like to play them again.” “You could play the game at home, but you would still need the physiotherapists’ feed- back on how well you are doing with your rehabilitation by using the games.” “It is good to receive feedback on the exer- cises from the games. It prevents you from doing the exercises in the wrong way.” “After you get used to playing the exercise games, you have a lot of fun.” Patients experienced moderate to high levels of presence during Discussion the experiment with the lowest level of presence while playing the dancing game. During the dancing game, because of Principal Findings impaired balance skills, the patients used chairs to prevent fall. This study assessed the usability of the exercise games in terms Hence, their attention was divided between the virtual and the of the experienced level of presence, enjoyment, exertion, pain, real environment [52], which might explain the low level of and technology acceptance among patients, and game design presence in dancing. However, patients had quite a lot of and technology acceptance among physiotherapists. The results enjoyment and little pain. Presence has been found to be showed that, in general, the patients experienced a high level associated with enjoyment. Earlier studies have found that of enjoyment, a moderate to high level of presence, and a low participants experiencing high levels of enjoyment also show to moderate level of exertion and pain. The physiotherapists high levels of presence [53,54]. Being engaged in playing the rated the exercise games as highly satisfying the nature of a game can also cause a decreased perception of pain [55]. motor rehabilitation program for elderly patients after hip Therefore, we expect that patients who can play the games surgery. Finally, both the patients and the therapists found the without the support chair will experience a higher level of exercise games useful and easy to use and intended to use the presence and enjoyment and less pain. In our experiment, all exercise game system in the future. the patients used chairs as support. The results of the evaluation of the game design are encouraging. According to the qualitative feedback, both the patients and the The physiotherapists found all the exercise games meet the physiotherapists found squats the most difficult. Patients also requirements for rehabilitation exercises [49]. The exercise reported the lowest enjoyment but highest exertion while doing games had a high level of adaptability to the patients’ motor squats in ringing the bell game. In an exercise game named skills, which is in line with the evenly distributed exertion levels Astrojumper, Finkelstein et al [56] found that participants’ experienced by the patients. The games were beneficial to the ratings of perceived exertion positively correlated with their patients’ daily life activities such as walking, sitting, and level of motivation. However, Rhodes et al [57] suggested that standing. The games provided appropriate feedback on whether activities based on relatively moderate to low exertion and the patients exercise correctly and provided encouragement to maximum enjoyment should be provided to increase adherence the patients to continue with the therapy. The required range of for elderly adults. Therefore, we suggest that to motivate the motion such as step width, knee angle, and hip angle can be patients to use the game, squats should be used for patients who configured properly in the games. Furthermore, patients had have relatively better balance skills. high levels of enjoyment while exercising in the game. Patients scored high on the technology acceptance scale, which Therefore, the results suggest that the physiotherapists can was comparable with the scores in Wuest et al [32]. Patients devise novel rehabilitation programs by using our exercise found the exercise games understandable and easy to use. They games. found the exercises meaningful and useful for balance training. http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al All the patients showed positive attitudes toward using the game the exercises and by giving informative instructions at the in the rehabilitation center or at homes. Patients also expressed beginning of each exercise game. Furthermore, there are still that they would like to continue to use the exercise games in some minor problems with the games that need to be fixed; for their rehabilitation routinely. Our patients showed high example, the setting of going to the same direction for more acceptance of exercise games that were designed according to than once in dancing should be configurable in the therapist their cognitive and physical limitations. This finding is in line interface. with the high acceptance rating of games that were specifically Finally, in this pilot test, we focused on the usability of the designed for patients, such as exercise games for home-based exercise games. However, it would be interesting to assess the stroke rehabilitation [30,32]. usability of the CC360 and find ways to improve it according In general, people are more inclined to use a system if they to elderly people’s abilities and preferences when the system is perceive it as useful, easy to use, and enjoyable [30]. ready in the rehabilitation center or at homes. Furthermore, earlier studies found that elderly participants The social aspect is known to affect exercise adherence [62]. strongly preferred virtual exercise gaming to traditional physical In general, social support can increase self-efficacy and then exercises [58,59]. Similarly, our system is designed to elicit enhance adherence [64]. In this study, as a first step, the exercise increased motivation for rehabilitation, and the participants games will be used in the rehabilitation center, where different showed positive attitudes with regard to their gaming experience patients exercise in a common area. Thus, the patients can share and the usability of the game system. Hence, we expect that the their scores with others, forming a healthy competitive exercise adherence rate of using our exercise games is higher than the environment among the elderly patients. Future work such as traditional exercises, and participants will continue using our creating leader boards and score-based achievements will also games when this system is implemented in the rehabilitation help foster competition with the possibility of cooperation center or at homes. among patients and enabling social engagement during the exercise. Furthermore, CC360 provides accomplished exercise Limitations and Future Work record of patients. In this way, the patients can be monitored Apart from the contributions, there are still a number of by physiotherapists and other caregivers and encouraged to limitations to this study. First, this study recruited a small sample adhere to the exercises by playing the game. of patients and physiotherapists because of limited availability of participants. Usability test with a larger group of elderly As a next step, the effectiveness of the exercise games will be patients would be beneficial and allow exploration of usability tested in a randomized controlled trial with 15 patients in each within different subgroups, for example, patients who are at group, that is, an experimental group combining traditional different recovery phases. It has been shown that with a pilot exercises with playing exercise games versus control group with study of 4 or 5 participants, it is already possible to find 80% traditional exercises. The study will be conducted in the of the usability problems [60,61]. There were also 2 rehabilitation center and can shed some light on how motivating physiotherapists who got involved in the design of the exercise the game system is over a period of time. games, and 2 other physiotherapists evaluated the exercise Conclusions games, which gives us confidence about the usability about our system at the level of therapists. We created Fietsgame, an engaging and motivating exercise game system, which translates traditional rehabilitation exercises Second, most of the exercises had to be performed while holding into playful exercises. The performance of the users was onto a chair, which sometimes influenced the tracking accuracy automatically tracked using a 3D depth camera and stored for for exercises such as squats and lunges. Similarly, Ofli et al further analysis by the physiotherapists. The results indicate [62] reported that the highest tracking errors were found in hip that the game can be used by patients as a new rehabilitation and ankle joints while using Kinect. Hence, we suggest that tool after hip surgery, and both the patients and the patients who are at the beginning phase of physiotherapy after physiotherapists expressed positive attitudes toward using the hip surgery should use the exercise games such as cycling, game in the future. Although this study had a limited number dancing, football, and fishing, which are not affected by of participants, it provides sufficient insights on the usability supporting objects. Furthermore, we did meet problems with of the system and suggests improvements in the future. The Kinect v2 recognizing obese patients for playing apple picking qualitative feedback revealed that exercise games designed for lunges. Patients with obesity may not be recognized as correctly elderly patients should be challenging enough to keep their as patients with an average body mass [63]. Future research interest and attention, but also should take into account their should look into the difference in tracking accuracy and impaired motor, sensory, and cognition functions. We will reliability comparing people with different levels of body mass. improve the game by including real-time corrective feedback Third, some user aspects of the game design such as high when patients are performing the exercises, by providing a cognitive load and lack of real-time feedback on wrong customizable user interface allowing adjustments to cognitive movements and mismatched movements would pose barriers load and by creating more varieties of game content. A to future use. To address these issues, we plan to include the randomized controlled clinical trial will be conducted covering customization of the user interface and virtual environment a longer time period, testing the effectiveness of the game. The according to personal preferences for cognitive challenges by final goal is to provide elderly patients with a game that can be providing real-time feedback on how far the patients are away used in nursery houses or at homes to achieve improved physical from the required range of motion when they are performing functions and maintain independent living. http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 18 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al Acknowledgments This study is supported by the COMMIT project “Virtual worlds for well-being.” The authors would like to thank the other project team members, namely, Arjan Egges for his input on design of this study; Jan Kooijman, Eline van Vliet, and other physiotherapists from Aafje rehabilitation center for their suggestions in the design of the game; Cho Lie Tam, Jacob Mulder, Marten Eisma, and Pieter Goossen from CGI for their support to the project and their efforts to connect the games to the CC360 system; and Maarten Stevens and Meint Span from 8D games for designing and developing the exercise games. Conflicts of Interest None declared. Multimedia Appendix 1 The original physiotherapist control interface of CC360. [PNG File, 124KB-Multimedia Appendix 1] Multimedia Appendix 2 The original patient interface showing the patient’s medical record in CC360. [PNG File, 124KB-Multimedia Appendix 2] Multimedia Appendix 3 Questionnaires answered by the patients. [PDF File (Adobe PDF File), 78KB-Multimedia Appendix 3] Multimedia Appendix 4 Questionnaires answered by the physiotherapists. [PDF File (Adobe PDF File), 60KB-Multimedia Appendix 4] References 1. Sernbo I, Johnell O. Consequences of a hip fracture: a prospective study over 1 year. Osteoporos Int 1993 May;3(3):148-153. [Medline: 8481591] 2. Mendonça TM, Silva CH, Canto RS, Morales ND, Pinto RD, Morales RR. Evaluation of the health-related quality of life in elderly patients according to the type of hip fracture: femoral neck or trochanteric. Clinics (Sao Paulo) 2008;63(5):607-612. 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The relationship between individual characteristics and experienced presence. Comput Human Behav 2013 Jul;29(4):1519-1530 [FREE Full text] [doi: 10.1016/j.chb.2012.12.010] 53. IJsselsteijn WA, de Kort YA, Westerink J, de Jager M, Bonants R. Virtual fitness: stimulating exercise behavior through media technology. Presence: Teleoperators Virtual Environ 2006 Dec;15(6):688-698. [doi: 10.1162/pres.15.6.688] 54. Lyons EJ, Tate DF, Ward DS, Ribisl KM, Bowling JM, Kalyanaraman S. Engagement, enjoyment, and energy expenditure during active video game play. Health Psychol 2014 Feb;33(2):174-181 [FREE Full text] [doi: 10.1037/a0031947] [Medline: 23527520] 55. Hoffman HG, Sharar SR, Coda B, Everett JJ, Ciol M, Richards T, et al. Manipulating presence influences the magnitude of virtual reality analgesia. Pain 2004 Sep;111(1-2):162-168. [doi: 10.1016/j.pain.2004.06.013] [Medline: 15327820] 56. Finkelstein S, Suma EA. Astrojumper: motivating exercise with an immersive virtual reality exergame. Presence Teleoperators Virtual Environ 2011 Feb;20(1):78-92. [doi: 10.1162/pres_a_00036] http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 21 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Ling et al 57. Rhodes RE, Martin AD, Taunton JE, Rhodes EC, Donnelly M, Elliot J. Factors associated with Eeercise adherence among older adults. Sports Med 1999;28(6):397-411. [doi: 10.2165/00007256-199928060-00003] [Medline: 10623983] 58. Van Schaik P, Blake J, Pernet F, Spears I, Fencott C. Virtual augmented exercise gaming for older adults. Cyberpsychol Behav 2008 Feb;11(1):103-106. [doi: 10.1089/cpb.2007.9925] [Medline: 18275322] 59. Proffitt R, Lange B, Chen C, Winstein C. A comparison of older adults' subjective experiences with virtual and real environments during dynamic balance activities. J Aging Phys Act 2015 Jan;23(1):24-33 [FREE Full text] [doi: 10.1123/japa.2013-0126] [Medline: 24334299] 60. Virzi RA. Refining the test phase of usability evaluation: how many subjects is enough? Hum Factors 1992;34(4):457-468. [doi: 10.1177/001872089203400407] 61. Nielsen J. Nngroup. How many test users in a usability study? URL: https://www.nngroup.com/articles/how-many-test-users/ [accessed 2017-10-08] [WebCite Cache ID 6u3fzudF2] 62. Ofli F, Kurillo G, Obdržálek Š, Bajcsy R, Jimison HB, Pavel M. Design and evaluation of an interactive exercise coaching system for older adults: lessons learned. IEEE J Biomed Health Inform 2016 Jan;20(1):201-212 [FREE Full text] [doi: 10.1109/JBHI.2015.2391671] [Medline: 25594988] 63. Xu X, McGorry RW. The validity of the first and second generation Microsoft KinectTM for identifying joint center locations during static postures. Appl Ergon 2015 Jul;49:47-54. [doi: 10.1016/j.apergo.2015.01.005] [Medline: 25766422] 64. McAuley E, Jerome GJ, Marquez DX, Elavsky S, Blissmer B. Exercise self-efficacy in older adults: Social, affective, and behavioral influences. Ann Behav Med 2003;25(1):1-7. [doi: 10.1207/S15324796ABM2501_01] [Medline: 12581930] Abbreviations CC360: Community Care 360 CGI: Consultants to Government and Industries IoT: Internet of Things IPQ: Igroup presence questionnaire PC: personal computer SD: standard deviation TAM: Technology Acceptance Model VAS: Visual Analogue Score Edited by A McDougall; submitted 03.05.17; peer-reviewed by E Brox, F Ofli, K Blondon, A Roundtree; comments to author 14.06.17; revised version received 07.08.17; accepted 28.08.17; published 12.10.17 Please cite as: Ling Y, Ter Meer LP, Yumak Z, Veltkamp RC JMIR Serious Games 2017;5(4):e19 URL: http://games.jmir.org/2017/4/e19/ doi: 10.2196/games.7969 PMID: 29025696 ©Yun Ling, Louis P Ter Meer, Zerrin Yumak, Remco C Veltkamp. Originally published in JMIR Serious Games (http://games.jmir.org), 12.10.2017. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2017/4/e19/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e19 | p. 22 (page number not for citation purposes) XSL FO RenderX

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Usability Test of Exercise Games Designed for Rehabilitation of Elderly Patients After Hip Replacement Surgery: Pilot Study

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Publisher: JMIR Publications
ISSN: 2291-9279
DOI: 10.2196/games.7969
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JMIR Serious Games – JMIR Publications

Published: Oct 12, 2017

Keywords: rehabilitation exercise; computer games; hip replacement; elderly; physical therapists

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Usability Test of Exercise Games Designed for Rehabilitation of Elderly Patients After Hip Replacement Surgery: Pilot Study

Usability Test of Exercise Games Designed for Rehabilitation of Elderly Patients After Hip Replacement Surgery: Pilot Study

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Usability Test of Exercise Games Designed for Rehabilitation of Elderly Patients After Hip Replacement Surgery: Pilot Study

Usability Test of Exercise Games Designed for Rehabilitation of Elderly Patients After Hip Replacement Surgery: Pilot Study

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