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Background: Visuospatial neglect due to stroke is characterized by the inability to perceive stimuli emerging in the area opposite to the side of brain damage. Besides adopting conventional rehabilitation methods to treat neglect symptoms, the use of virtual reality (VR) is becoming increasingly popular. We designed a series of 9 exergames aimed to improve exploration of the neglected side of space. When new VR interventions are designed, it is important to assess the usability aspects of such management strategies within the target population. To date, most studies used questionnaires to assess user satisfaction with the intervention or product being tested. However, only a combination of both quantitative and qualitative data allows a full picture of user perspective. Objective: The purpose of this study was to quantitatively and qualitatively assess patient and therapist perspectives of a VR intervention based on the series of 9 exergames designed to explore hemineglected space. Specifically, we wanted to evaluate (1) perceived-user friendliness of the exergames, (2) attitude towards using the exergames, and (3) intention to use the exergames in the future. Methods: A total of 19 participants (7 patients, 12 therapists) evaluated the exergames they had used 5 times a week during 3 weeks. The Technology Acceptance Model (TAM) questionnaire was filled out after the intervention. Based on those responses, we conducted focus group interviews (with therapists) and individual interviews (with patients). To analyze the TAM questionnaires, we used descriptive statistics. We adopted content and comparative analysis to analyze the interviews and drew illustration maps to analyze the focus group interviews. Results: The therapists took a more critical stance with a mean TAM questionnaire total score of 48.6 (SD 4.5) compared to the patients who had a mean total score of 56.1 (SD 12.3). The perceived user-friendliness score was 5.6 (SD 1.4) for patients and 4.9 (SD 1.4) for therapists. The attitude towards using the exergames was rated 4.8 (SD 1.9) by patients and 3.6 (SD 1.4) by therapists, respectively. The intention to use the exergames in the future was rated 3.9 (SD 2.1) by patients and 3.7 (SD 1.8) by therapists. We gained information on how to improve the exergames in the interviews. http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al Conclusions: Patients and therapists perceived the exergames as user-friendly; however, using the games further with the actual test version was not perceived as conceivable. The therapists were generally more critical towards future use than the patients. Therefore, involving both users to achieve acceptable and user-friendly versions of game-based rehabilitation for the future is deemed crucial and warranted. Trial Registration: Clinicaltrials.gov NCT02353962; https://clinicaltrials.gov/ct2/show/NCT02353962 (Archived by WebCite at http://www.webcitation.org/6soxIJlAZ) (JMIR Serious Games 2017;5(3):e18) doi: 10.2196/games.8013 KEYWORDS usability; user perspective; mixed-methods; exergames; visuo-spatial neglect; stroke interface was reduced to a minimum by designing a game menu Introduction with large and clear icons to select a game, difficulty level, and playing time (Figure 1), and (3) the costs of the VR systems are Stroke-related visuospatial neglect (VSN) due to a right-sided relatively low, as the exergames are played on a personal brain lesion (RBL) is characterized by the inability to perceive computer, using the Novint Falcon haptic device (Novint stimuli emerging in the area opposite to the side of brain damage Technologies) to control the games  (Figure 2). The Novint [1,2]. VSN patients usually have lower scores on disability tests Falcon enables people to experience a realistic sense of touch and require longer rehabilitation periods compared to stroke by providing force and haptic feedback when reaching for and patients without neglect [3,4]. Thus, VSN influences most grasping virtual objects . Furthermore, it can be operated activities of daily living such as eating, reading, and getting with one hand only, thus permitting VSN patients to play the dressed [2,5]. exergames with their unaffected upper limb. Besides adopting conventional rehabilitation methods to treat When new VR interventions are designed, it is important to stroke-related VSN symptoms, the use of virtual reality (VR) follow a phased iterative approach, wherein the usability aspects in their assessment and treatment is becoming increasingly of such a management strategy, within the target population, popular [6-8]. VR is defined as “an advanced form of are first assessed . Usability is defined by the International human-computer interface that allows the user to ‘interact’ with Organization for Standardization (ISO) as “the extent to which and become ‘immersed’ in a computer-generated environment a product can be used by specified users to achieve specified in a naturalistic fashion” . Reasons for this increasing goals with effectiveness, efficiency and satisfaction in a popularity might be found in the many advantages attributed to specified context of use” . “Specified users” do not only VR, for example, the ability to provide a safe but engaging include patients but also therapists, as their requirements for environment , immediate feedback on performance, and the use of such games may differ from those of the patients . repetitive task training with quantifiable continuous progression Therapists may, for example, need an easy startup and of training . For example, VR training in isolation or in configuration procedure, or stress that the games should be combination with conventional therapy approaches proved to supportive not only for the patient during play but also for the be superior for the improvement of lower extremity function in therapist in tracking a patient’s performance . It is therefore stroke patients . However, despite this, evidence for VR important to assess both the therapists’ and patients’ opinions, therapies being superior to conventional intervention methods as they will use the exergames at least as often as a patient. for treating VSN is so far somewhat limited [6-8]. Evidence shows that VR has the capacity both to enhance current methods Assessing opinions from users can be done by using for the assessment and rehabilitation of VSN and to provide questionnaires or by means of interviews. The former has the new ones. Tsirlin et al  presented three major challenges for advantage to assess many opinions of a representative sample successful implementation of VR systems in VSN therapy: (1) but cannot tell us about the meaning behind a response. The ergonomic aspects in the sense that mobile, lightweight VR latter is usually applied in a smaller sample but provides systems are required for rehabilitation, (2) the complexity of personal thoughts from an insider’s perspective . To date, VR systems insofar as treating clinic staff do not necessarily most studies used questionnaires to assess users’ satisfaction have programming skills, and (3) the prohibitive costs of VR with the intervention or product being tested [19-22]. Currently, devices (eg, for immersive VR systems with head-mounted there is a lack of evidence from studies examining the users’ displays or cyber gloves) [7,8,12]. For these reasons, VR perspective via application of qualitative methodologies . rehabilitation platforms have been mainly restricted to King et al  and Lewis et al , for example, used focus laboratories and to prototypical systems  and have not been group and semistructured interviews to assess patients’ widely implemented in patients’ homes. satisfaction with their game intervention. All participants enjoyed playing the computer games. However, all stroke A European research group, Rehabilitative Wayout In patients were in the chronic stage of recovery and none were Responsive Home Environments (REWIRE), developed a diagnosed with VSN symptoms. Another qualitative report game-based VR rehabilitation intervention trying to account explored the perceptions and personal experiences of stroke for those challenges : (1) the exergame station was designed survivors regarding a leisure-based VR program , reporting as a computer workplace, allowing the patient to practice the improved self-efficacy belief in leisure activities after the VR exergames in a seated position, (2) the complexity of the user http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al experience in in-depth interviews. However, the reported full picture of user perspectives, as it is done in mixed methods evidence was based on a single game session only. research . Therefore, the purpose of this study was to quantitatively and qualitatively assess the patients’ and Results of a recent systematic review state that in the posttest therapists’ user perspective when using REWIRE exergames stage of usability evaluation, performing interviews to evaluate for rehabilitation of VSN symptoms due to a stroke. Specifically, user perceptions of games is recommended, whereas the use of we wanted to evaluate the (1) perceived-user friendliness of the questionnaires is considered useful for evaluating user exergames, (2) attitude towards using the exergames, and (3) acceptance and satisfaction . As a consequence, only a intention to use the exergames in the future. combination of both quantitative and qualitative data allows a Figure 1. Game menu of the 9 neglect exergames. Figure 2. REWIRE exergames training station. http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al side of the computer monitor at a distance allowing the patients Methods ease of reach with their nonaffected hand. A height-adjustable chin rest (Novavision GmbH) was mounted on the table to avoid Study Design compensatory head movements while playing the exergames. For this usability study, we used a mixed methods design REWIRE Visuospatial Neglect Exergames adopting the “sequential explanatory” design strategy . This design strategy is characterized by an initial collection of We designed a series of 9 exergames aimed to improve quantitative data followed by a collection and analysis of exploration of the neglected side of space. During the qualitative statements. The purpose of this strategy is to use the development of the exergames, we regularly tested them in qualitative results to assist in explaining and interpreting the healthy controls prior to implementing them in a clinical setting. findings of the quantitative data. Their feedback was constantly integrated in the development process until consensus was reached. In order to maintain Participants principles of training, game progression was individually There were 2 groups of users involved in this study: patients as adjustable through the selection of appropriate different levels end users and therapists as experts. of difficulty (more demanding meant more exploration towards the hemineglected side was required) . The exergames The patient group included 7 adults with an ischemic (n=5 men) content aimed to imitate activities of daily living (ADL), such or hemorrhagic (n=2 women) RBL due to a first stroke with as cooking a meal, following a recipe, gathering apples, walking accompanying VSN symptoms as measured with the Catherine a dog, and doing a puzzle. An overview of the 9 games and Bergego Scale (CBS) . The CBS includes direct observation corresponding short instructions supporting their independent of the patient’s functioning in 10 real-life situations. The use are shown in Multimedia Appendix 1. A detailed description functioning is rated from 0-30, where 0 indicates no neglect of the exergames can be found elsewhere . symptoms. These patients simultaneously participated in a feasibility study in which the exergames were evaluated, while Intervention taking part in this usability evaluation . Their mean age was Both therapists and patients had the opportunity to test the 68.6 (SD 8.9) years. Their stroke incidence took place 46.3 (SD exergames before entering the study, followed by a training 30.8) days before study entry. All patients were right-handed. event organized by the research team to learn, for example, how Three participants were able to walk, while the others used a to handle the game menu and Falcon Novint haptic device. wheelchair for locomotion. Their CBS mean score was 9.4 (SD During the whole intervention phase, the research staff provided 5.1) points. All but one of these 7 patients identified themselves telephone or personal support whenever needed, for example, as having a computer at home prior to participating in the study. to handle technical problems with the training station. The The expert group consisted of therapists responsible for the exergames intervention lasted 3 weeks and included 15 training treatment of the stroke patients during their inpatient stay. The sessions each of approximately 30 minutes duration. Patients 12 therapists (6 occupational therapists from one rehabilitation exercised with the games under supervision of the therapists clinic and 6 neuropsychologists from another clinic) supervised depending on their required level of support, for example, to and trained the patients in the use of the REWIRE exergames start a new game. The neuropsychologists included exergames during the 3-week intervention phase. Their mean age was 33.3 playing in their computer group, meaning that participating (SD 5.7) years (range 27-45) with a mean work experience of patients played the REWIRE exergames while other group 6.8 (SD 5.8) years (range 0.5-20). All therapists stated being members performed alternative computer tasks. The familiar with the use of computers, rating their computer occupational therapists (OTs) supervised their patients in a knowledge as excellent (n=3), good (n=8), and poor (n=1). All one-to-one setting during individual therapy sessions. 19 participants signed informed written consent before study Additionally, the supervising therapist individually adjusted the entry. We obtained ethical approval for the study from the local intensity of playing the exergames. This was done, for example, Ethics Committees (Zurich No. 2014-0543 and Bern No. by changing the difficulty level or game duration in the game 389/2014) as well as from Swissmedic (2015-MD-0003). The menu or by implementing short breaks between each game if study is registered with ClinicalTrials.gov. needed. Each patient selected up to four REWIRE VSN exergames from the game menu to be played in a gaming Setup of the Exergames Training Stations session. The choice was based on personal interest of the patient, We installed 2 exergames training stations, one in each of the which was assumed to enhance motivation while playing. collaborating clinics (Figure 2). The games were played at a Therefore, during the 3-week intervention time, the patient was table in a seated position either in a chair or wheelchair also allowed to change games if they wanted to test another depending on the patient’s motor skills. We used a 21-inch game or felt bored with the previously played one. However, computer monitor at a distance of 60-65 cm to display the games we suggested the patients test all of the 9 games at least once. and the haptic Falcon Novint device to control the games. The Rehabilitation continued during the study intervention, our haptic feedback enabled the patients to experience a realistic exergames serving as an additional therapy option to the sense of touch, for example, by feeling some resistance standard program comprising daily occupational, physical, and simulating the weight of the currently held virtual object in the neuropsychological therapy. virtual hand displayed on the screen (force feedback of the Falcon ) or a vibration when dropping, for example, a virtual apple in a virtual basket. The Falcon Novint was placed at the http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al mean score of more than 4 points on the Likert scale, where 1-3 Outcome Measurements points meant no agreement, 4 points neutral, and 5-7 points Both patients and therapists completed a questionnaire at the agreement. The maximum achievable score was 84 points, end of the intervention. This included 12 questions with a indicating perfect agreement. For the individual and focus group 7-point Likert scale (1 point=strongly disagree; 7 interviews, we hypothesized that the users (therapists and points=strongly agree), evaluating (1) perceived patients) would have experienced the VR-based neglect training user-friendliness of the exergames, (2) attitude towards using as supportive in treating VSN. the exergames, and (3) intention to use the exergames in the future. The questionnaire design was based on an abridged Data Analysis version of the Technology Acceptance Model (TAM). TAM is To analyze the TAM questionnaires, we used descriptive an intention-based model developed specifically for explaining statistics in SPSS software version 23. We calculated means, user acceptance of computer technology  that we considered standard deviations, medians, and interquartile range values as useful for evaluating user acceptance and user satisfaction . appropriate. Patients received physical assistance from clinic staff to complete the questionnaire when incapable of writing or reading We transcribed the individual interviews verbatim. due to neglect. The therapists filled in their questionnaires Subsequently, we selected text passages from the entire independently. We analyzed the completed questionnaire conversation in which the interviewer (BC-T-A) and the patient responses and thereafter used them as a basis to prepare the discussed the use of the exergames and stored them separately. individual interview  with the patients and the focus group We used content and comparative analysis to analyze those interviews  with the therapists. passages [35,36], taking the following analysis steps: (1) reading the interview passages’ transcriptions, (2) highlighting BC-T-A performed the audio-recorded individual interviews significant statements that provide an understanding of how the during the follow-up assessment planned for the feasibility study patient experienced the use of the exergames, (3) comparing 4 weeks post-intervention. They focused on the patients’ those statements with the TAM questionnaire answers and everyday life experiences with right hemispheric stroke and assigning them to the three subcategories (user-friendliness, VSN symptoms during active rehabilitation and served as an attitude, and intention to use in the future), and (4) writing a opportunity to deepen, clarify, or confirm answers that were composite description of the patients’ perspectives of using the given in the TAM questionnaire. BC-T-A, who is an exergames, while using quotes to underpin the interpretation. occupational therapist, took an active role during the interviews, aiming to build a relationship with the participants based on We analyzed the two focus group interviews by drawing “Focus confidence and co-creation. Thanks to the many opportunities group Illustration Maps” (FIMs) . The aim was to to meet the patients in the past (eg, while introducing the summarize the complex variety of statements and opinions exergames to the patients or during data generation for the without losing information or knowledge. Therefore, capturing simultaneously running feasibility study ), a good basis to the whole range of group knowledge is the essence of knowledge achieve this aim was already established. mapping, rather than highlighting the single statements of individuals. We took the following analysis steps: (1) listening We conducted the two focus group interviews in the to the audio recording while watching the video and taking collaborating rehabilitation clinics after the last patient had notes, (2) comparing the notes and audio recordings together finished the REWIRE exergames intervention. We with the flipchart notes, (3) drawing the FIMs, re-watching the audio-recorded and filmed them. In comparison to individual video to check the accuracy of the FIMs, (4) sending the FIMs interviews, focus groups represented group opinions influenced to the participants for member checking, (5) incorporating by social interactions and team dynamics, as therapists already feedback from participants into the FIMs if representative for knew each other well . Therefore, they were an important the whole group, and (6) merging FIMs from both clinics into complement to individually given answers via TAM one FIM per subcategory from the TAM questionnaires, questionnaires and served as a means for therapists to gain, representing the opinions from all 12 participating therapists. share, or dispute experiences made with those exergames from their perspectives. During each interview, the moderator Results (BC-T-A) summarized the given answers on a flip chart, allowing therapists to add, complement, or change statements We summarized the answers from the TAM questionnaires in if needed. Additionally, the role of the moderator was (1) to Table 1 for patients and in Table 2 for therapists. Generally, the balance the therapists’ statements in terms of therapists took a more critical stance with a mean TAM allowing/encouraging everybody to speak, while intervening questionnaire total score of 48.6 (SD 4.5) compared to the when someone would have claimed too much time to speak and patients with a mean total score of 56.1 (SD 12.3). Their (2) to take care that all therapists’ TAM answers were discussed statements are presented according to the three subcategories that needed clarification while keeping the time set for the focus of the TAM questionnaire. These are “perceived group interview. user-friendliness,” “attitude towards using the exergames,” and “intention to use the exergames in the future.” We expected the acceptance of and satisfaction with the neglect exergame intervention to be good, which we defined as a total http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al Table 1. Postintervention patients’ TAM questionnaire responses. a b Statement P2 P3 P4 P5 P6 P7 Mean (SD) Mean (SD) P1 Median (Q /Q ) 1 3 Perceived user-friendliness The exergames were easy to use. 5 6 7 7 7 6 5 6.1 (0.9) 6 (5/7) 5.6 (1.4) The exergames manual was clear and under- 5 6 7 5 7 7 6 6.1 (0.9) 6 (5/7) standable. Learning to use the exergames independently 3 5 6 4 7 2 5 4.6 (1.7) 5 (3/6) would be easy for me. Attitude towards using the exergames I generally have a positive attitude towards 5 7 2 6 7 1 6 4.9 (2.4) 6 (2/7) 4.8 (1.9) using the exergames. I enjoyed exercising with the exergames. 4 6 2 6 7 5 3 4.7 (1.8) 5 (3/6) Exercising with the exergames… was motivating. 4 6 2 7 7 4 5 5.0 (1.8) 5 (4/7) was exhausting. 3 7 1 3 4 7 2 3.9 (2.3) 3 (2/7) was a stupid idea. 5 7 4 6 7 5 4 5.4 (1.3) 5 (4/7) Intention to use the exergames in the future: If I had access to the exergames from at home, … I would use them in the future. 5 5 1 4 1 4 1 3.0 (1.9) 4 (1/5) 3.9 (2.1) I would use them regularly. 4 5 1 4 1 3 1 2.7 (1.7) 3 (1/4) I’m convinced that my family/friends would 5 3 2 6 7 4 6 4.7 (1.8) 5 (3/6) support me using the exergames. I would recommend the exergames to other 6 7 1 6 7 2 6 5.0 (2.5) 6 (2/7) patients. Total score 54 70 36 64 69 50 50 56.1 (12.3) 54 (50/69) Mean (SD) 4.5 5.8 3 5.3 5.8 4.2 4.2 (0.9) (1.2) (2.4) (1.3) (2.4) (2.0) (2.0) Q 4 5 1 4 4.8 2.3 2.3 Median 5 6 2 6 7 4 5 Q 5 7 5.5 6 7 5.8 6 Patient Quartile 1=Q ; Quartile 3=Q 0.25 0.75 Positive statements: 1=strongly disagree / 7=strongly agree; Negative statements: 1=strongly agree / 7=strongly disagree http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al Table 2. Postintervention therapists’ TAM questionnaire responses . b c d State- T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 Mean Median Mean T1 Q Q 1 3 ment (SD) (SD) Perceived user-friendliness a) 6 5 6 7 7 5 5 5 5 6 6 4 5.6 (0.9) 5 5.5 6 4.9 (1.4) b) 5 6 7 7 7 4 5 5 4 5 3 4 5.2 (1.3) 4 5 6.8 c) 5 4 6 5 7 6 4 4 2 2 2 4 4.3 (1.7) 2.5 4 5.8 d) 5 5 7 5 7 6 4 4 4 3 3 3 4.7 (1.4) 3.3 4.5 5.8 Attitude towards using the exergames e) 5 4 4 4 3 4 4 3 3 4 2 6 3.8 (1.0) 3 4 4 3.6 (1.4) f) 4 3 2 4 2 4 3 4 4 3 4 3 3.3 (0.8) 3 3.5 4 g) 7 5 7 3 3 5 4 6 3 2 6 5 4.7 (1.7) 3 5 6 h) 1 3 1 1 2 3 1 4 1 3 2 3 2.1 (1.1) 1 2 3 i) 4 5 3 3 2 4 3 4 4 4 5 5 3.8 (0.9) 3 4 4.8 Intention to use the exergames in the future j) 2 3 1 2 2 2 2 3 3 4 2 3 2.4 (0.8) 2 2 3 3.7 (1.8) k) 7 6 7 7 6 7 6 5 6 5 5 5 6.0 (0.9) 5 6 7 l) 2 4 2 2 2 4 2 3 3 4 2 3 2.8 (0.9) 2 2.5 3.8 Total 53 53 53 50 50 54 43 50 42 45 42 48 48.6 (4.5) 42.3 50 51 scores Mean 4.4 4.4 4.4 4.2 4.1 4.5 3.9 4.2 3.5 3.8 3.5 4.0 (SD) (1.9) (1.1) (2.5) (2.1) (2.4) (1.4) (1.4) (0.9) (1.3) (1.2) (1.6) (1.0) Q 2.5 3.25 2 2.25 2 4 2.25 3.25 3 3 2 3 Median 5 4.5 5 4 3 4 4 4 3.5 4 3 4 Q 5.75 5 7 6.5 7 5.75 4.75 5 4 4.75 5 5 Positive statements: 1=strongly disagree / 7=strongly agree; Negative statements: 1=strongly agree / 7=strongly disagree. Statements: Perceived user-friendliness a) The exergames manual was clear and understandable. b) I was easily able to train my patients for using the exergames. c) Learning to use the exergames independently was easy for my patients. d) I experienced learning to use the exergames as easy. Attitude towards using the exergames e) I generally have a positive attitude towards using the exergames. f) The exergames were a gain for my patients. g) The exergames were an unnecessary burden for my patients. h) The exergames were a relief of responsibility for me. i) The supervision of my patients was a pleasure for me. Intention to use the exergames in the future j) I can imagine using the exergames regularly as a training for my patients. k) I generally believe that my workplace supports the use of VR training possibilities for my patients. l) I would recommend using the exergames to other colleagues. T=Therapist Quartile 1=Q 0.25 Quartile 3=Q 0.75 the poor general computer knowledge that both patients Perceived User-Friendliness identified. Thus there were associated uncertainties of what to This subcategory was the most positively judged among patients do when sudden difficulties arose while playing, as stated by with a mean 5.6 (SD 1.4) points and therapists with a mean 4.9 P6: “Sometimes I had difficulties in discharging the apples, and (SD 1.4). All patients agreed on the clarity of the manual and when I wasn’t able to keep them steady over the basket, then the ease of use of the exergames, while learning to use the the apples refused to drop into the basket” (P6). P2 had the same exergames independently would not have been easy for patients experience in another game with the “faulty pieces”: 1 and 6 (P1 and P6; see Table 1). A possible explanation was http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al Yes, they [the exergames] sometimes weren’t responsibility for the therapists, which negatively influenced technically well set. You touched it [the fruit], but it their attitude towards using the exergames (Figure 4). They didn’t stick [to the virtual hand] [P2] further reported that some patients had difficulty understanding the purpose of the games. Therapists’ reasons for this were given To solve those difficulties in game control, P6 and P2 indicated as being either (1) due to patients’ poor self-awareness of their that they contacted the supervising therapist for help. Using the actual skills, making it difficult for them to explain to the Novint Falcon as haptic device to play the games was perceived patients the necessity of exercising their visuospatial exploration as good by all patients. Patient P3 described that the device skills, or (2) due to the game design, which was experienced as “acted up” now and then (not running smoothly or skidding of being unappealing by both patients and therapists in combination the whole device while playing), suggesting use of the mouse with the abstract game control. The breakdown susceptibility instead of the Novint Falcon as input device in order to solve of the software and the suboptimal posture, especially the use this problem. of the chin rest, were major critique points mentioned by most The therapists all agreed on the game manual’s good therapists (Figure 3). The former explained why therapists understandability (Figure 3). They rated themselves as being reported experiencing loss of valuable therapy time, as they capable of introducing the exergames to their patients (Table often had to re-boot the system, keeping patients waiting while 2). However, they also stated that only the fitter patients were the computer restarted. Thus the exergames were rated as being able to use the exergame station independently. For the more somewhat impractical, although therapists recognized that they severely affected ones, guidance of the arm was necessary to were testing in a pilot phase. play the games. This was experienced as no relief of Figure 3. Focus group illustration map: perceived user-friendliness. http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al Figure 4. Focus group illustration map: attitude toward using the exergames. The patients experienced conventional methods as more Attitude Toward Using the Exergames effective than the VR intervention: The general attitude of the patients toward the use of the I didn’t have the impression that it [the exergames exergames was 4.8 (SD 1.9) points (Table 1). The therapists intervention] did yield much. I experienced it as being rated it a mean total score of 3.6 (SD 1.4) points (Table 2). The a bit silly. I had the impression that the other things patients experienced exercising with the games to be motivating simply helped me much, much more. […] The eyes and interesting and also as a “welcome change" to the were not equally challenged to move back and forth. conventional therapy methods provided in the Rehabilitation [P6] clinics: “Those games were a welcome diversion to normal The content of the games was judged as “not bad” (P4). P4 neuropsychology, where you just sit face-to-face and have to perceived the exergame “puzzle” as being difficult because the do exhausting things all the time” (P5). puzzle template was displayed only once at the beginning, However, most patients preferred the conventional therapy requiring the player to piece together the puzzle out of memory. methods over the exergames intervention, as they described it The speed of the games and the related short reaction time was difficult to understand the purpose of the games: another difficulty mentioned by most patients as being experienced during play. They described being initially very In the beginning, I didn’t really understand what all motivated to play the games, but over the course of the 3-week this meant; for what the games were good for. Then intervention, their enthusiasm decreased, as they started to they [the therapists] explained it to me. After they perceive playing the games as “boring” (P1, P4) and even had told me what aspects I had to pay attention to, “childish” (P1, P3): then it was all good. [P2] I couldn’t make sense out of it [the exergames]. I You know, piling the ABC can be done by a first- or always had the feeling that the things there—those second-former! And to burst balloons that pop up out tests—were meant for ones with very severe brain of a hole isn’t very demanding either” (P3); and damage, who weren’t back on their feet yet. […] But “Boring! In the beginning, it was good. But most not for me—I don’t have such severe damage! [P3] recently…it was complicated to look through this thing [chin rest], you know. The other games they I don’t know what they [the exergames] would have had were more interesting in a way. [P4] been useful for. And no matter how much you have scored, you couldn’t see the progress you had made. [P6] http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al Using the chin rest while playing was the main reason why most Well, maybe tests that are more related to practice. patients experienced the exergames as exhausting (mean 3.9 You know, where you see: “Ah, this could be useful!” [SD 2.3]): […] For example doing an exercise you will need in the future when you want to drive a car again. This [chin rest] wasn’t useful! I couldn’t sit in an Reaction or such things…which will help me to go upright position and look through [the chin rest] to ahead. [P3] scan the whole computer screen. This was exhausting. For some patients, the games could have been more challenging You also weren’t able to turn your head. [P4] and entertaining. P7 did not experience much pleasure while The suboptimal posture of the patients while using the playing: exergames was also problematic for the therapists (Figures 3 and 4). It was the main reason why some therapists rated them Not really…well, when I was successful, then I felt as an unnecessary burden. They described observing their pleasure anyhow. Then I thought: ‘Indeed, I am not patients sitting tilted to the left side in their wheelchair due to as dull as I thought!’ […] It simply worked out their VSN symptoms, watching past the chin rest instead of somehow, but not as good that I would have felt looking through it while playing. Furthermore, the therapists pleasure to play more. [P7] expressed reservations regarding the therapeutic use of the Remarkably, most patients were nevertheless convinced that exergames. Those reservations were based on their uncertainty their family and friends would support them using the exergames of achieving a carryover effect of visuospatial room exploration at home. The patients also stated that they would recommend skills trained in a virtual environment into the real world. the exergames to other patients (Table 1). Reasons might be Additionally, they had difficulties in perceiving the VR that the support of their relatives is taken for granted—no matter intervention as supportive to achieve the patient’s rehabilitation what they were doing to get better—and that they believe that goal, namely to regain independence in daily life as well as trying everything to get better is the best rehabilitation strategy, possible. The therapists further described that their patients fully including novel therapy methods like the exergames: “One trusted them in the choice of therapy intervention to improve should leave nothing undone, and try out everything!” (P7). their skills (Figure 4). This blind trust gave the therapists a The therapists were not yet ready either to use the exergames dilemma: on the one hand, they wished to use conventional in the future or to recommend their use to other colleagues—at therapy methods instead which they knew to be effective, but least in the version used for this study—although all therapists on the other hand, they recognized that the patients had agreed were convinced that their workplace supports the use of VR (and were eager) to participate in the study using this novel training methods (Table 2). The neuropsychologists in particular intervention. Despite this rather negative attitude towards were experienced in using the computer as a means of therapy exergames use, some therapists rated them as being a motivating and therefore accustomed to high-tech VR methods. The OTs, alternative for fit patients to exercise independently, although however, were rather restrained towards VR methods, some they also rated them as being too easy for some patients. even fearful of being replaced by computers in the future (Figure Intention to Use the Exergames in the Future 5). Barriers to future use of exergames were diverse and numerous; for example, the benefits of virtual versus equivalent Using the exergames regularly in the future was not viewed as real-life tasks was mentioned by the OTs, who expressed conceivable yet, either among patients (mean 3.9 [SD 2.1] preference for the latter therapy option. The nonadaptiveness points) or therapists (mean 3.7 [SD 1.8] points). Most patients of the software was another barrier highlighted by the perceived the exergames as a good pastime and diversion that neuropsychologists, as they were used to exergames with this helped shorten the long days in the rehabilitation clinic (P4, P6, feature. P7) but indicated that they would prefer doing activities other than gaming once back at home: “Up there [in the rehabilitation The therapists proposed suggestions for improvements for all clinic], I thought that it is way better to do this [playing the mentioned barriers (see Figure 6), which, given that those exergames] than lying in bed or sitting on a chair while doing improvements are implemented in a new version of the nothing” (P6). P5 and P7 described themselves as not being “a exergames, indicates that a new version of those exergames computer freak” (P7) or “a gamer” (P5) and therefore not would be used in the future. wanting to use the games further at home. P3 missed the relevance to real life of the games, making the following suggestion for improvements: http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al Figure 5. Focus group illustration map: intention to use the exergames in the future. Figure 6. Focus group illustration map: suggestions for improvements of the game-based virtual reality intervention. http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al complexity is no guarantee of constant use and engagement Discussion over time. Other studies testing different VR interventions with patients with cerebral palsy also described a reduction in Principal Findings engagement over time [41,42]. Therefore, reasons for this This usability study aimed to quantitatively and qualitatively decreasing enthusiasm other than a suboptimal balance of assess user perspectives (patients and therapists) of using providing a challenge while still enabling success might be the REWIRE exergames as a novel rehabilitation intervention to time point of the intervention and the lack of feedback in the treat VSN symptoms due to stroke. The findings showed that achieved game scores. Compared to other stroke samples the patients as end users generally rated the use of the exergames [24,25,37,39], our patients were still in the early stage of more highly than did the therapists. Most patients experienced recovery and were still hospitalized, therefore in the situation the games as motivating, interesting, and a welcome diversion of receiving daily therapy sessions with which they could in their daily routine during their inpatient stay in the compare the REWIRE exergames. In this context, it is perhaps rehabilitation clinic. The feeling of joy and motivation while understandable that the exergames—still a test version—fell playing was also described in other studies assessing user behind other VR therapy options that are long-established in perspective in stroke patients testing a novel VR intervention the market. Furthermore, testing a novel therapy option with [23,37,38]. Those studies tested games aiming to improve motor stroke patients in their chronic stage, when regular therapy often control in the affected arm due to hemiparesis following stroke might have stopped, evokes hope for further motor or cognitive without VSN symptoms. In our study, the patients controlled improvements and therefore increases motivation . Another the games with a haptic device using their unaffected arm, in reason for the decreasing interest might be seen in the fact that order to focus on improvement of cognitive skills. Most our games did not display the achieved results after each training participants liked using the Novint Falcon instead of the mouse session, unlike Lewis et al’s  submarine game, for example. to control the games. However, some patients described having Although this option was provided by the software, we had difficulties in grasping and releasing virtual objects. They decided not to activate it, as the achieved scores after each confirmed that in one game, they had to touch an object with game/session were not yet storable. This prevented the patients the index finger of the virtual hand to grasp it and in another seeing progression over time. We were aware that being unable game with the palm of the hand. This discrepancy was to see the achieved scores equaled a lack of feedback regarding experienced as being misleading. In order to standardize the the patient’s personal progress. However, positive feedback and game control, Mainetti et al  suggest optimizing the degree measures of success are critical components to enhance of overlap between the virtual hand collision region and the engagement [23,24]. There was a rewarding system after each target collision region. REWIRE game (Figure 7), but as this was random and not performance-based, patients did not care for it. Our sample, however, suffered from neglect and a certain related level of anosognosia . They nevertheless experienced The lack of feedback experienced by fitter patients, combined pleasure while playing. This is in line with other findings from with their perceptions of being insufficiently challenged while a satisfaction questionnaire where stroke participants with playing the exergames, might be reasons why they indicated neglect symptoms indicated enjoyment of the VR experience preference for conventional therapy methods with a “real” . Despite having fun while playing, the presence of therapist over this VR intervention. Their experiences of the anosognosia in our sample negatively influenced their games as “a good pastime and diversion” suggests that most understanding of the purpose of the exergames. Inability to fully patients did not see this as a rehabilitation intervention per se, understand the purpose of the intervention was also a topic in supporting their preference for conventional therapy. This is in a focus group interview with stroke patients without VSN line with other findings, where stroke survivors experienced symptoms . It is important to make sure that patients the novel games as supplementary to conventional therapy, the understand the game purpose, so as to meet their expectations latter being viewed as providing beneficial rehabilitation . and to avoid frustration . Although we paid weekly visits Conversely, the majority of patients in another study reported to participating rehabilitation clinics to discuss progress and experiencing VR interventions as useful as conventional therapy progression of the exergaming with patients and therapists, it . The nature of play that is inherent to games may be nevertheless seemed difficult for some of the former group to perceived differently among adult patients, as the therapeutic understand the purpose of the treatment strategy. This was benefit may not be as obvious as during conventional therapy, particularly the case for the more severely affected patients. also depending greatly on how the virtual environments were designed . It might be that having prepared a predefined set Mainetti et al  tested exergames in a single patient with of games to be played during several training sessions while chronic stroke who had VSN symptoms. This patient liked the only progressing difficulty levels within the same games—as exergames and was not bored while playing them. Most of our it was suggested by some of the therapists—might have helped patients, however, experienced a decreasing enthusiasm during patients perceiving the exergames as a (repetitive) rehabilitation the 3-week intervention and started to perceive the activity as intervention. However, we preferred letting them choose and boring, even though games regularly and individually progressed switch games according to their individual preferences to (1) and were designed according to therapeutic principles . It keep motivation as high as possible and (2) give them the seems that basing the selection of games on personal interest opportunity to test all exergames during the intervention. of the patient could not enhance motivation while playing either. Paying attention to the diversity and progression of game http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al Figure 7. Rewarding system of REWIRE exergames. The REWIRE game design was rated as having limited appeal effects of VR interventions into real life is limited [45,46]. For by both therapists and patients. The therapists in particular example, Gruskin et al  observed increased awareness of wished to have games that would be self-adaptive to patient the involved extremity as well as greater carryover into ADL progress in order to experience ease of responsibility. For when using an auditory feedback device to alert a patient with example, they missed the opportunity to prepare a series of left hemineglect when his flaccid upper extremity was in a games that would then automatically run through during an dependent position. Gates et al  compared walking intervention session. The lack of facility within software for overground and on a treadmill surrounded by a virtual patients to save and return to previously achieved difficulty environment that applied optic flow in individuals with and levels between sessions was also noted. Those features would without transtibial amputation. They found that both groups allow the patient to start directly at the right difficulty level and walked with similar overall kinematics (eg, knee subsequently play the game independently without the therapist flexion/extension) and kinematic variability (ankle, knee, or needing to adjust the settings before and during the training hip) on the treadmill as they did overground. Their results session. Although the goal of such VR interventions is to create suggest that treadmill training in a virtual environment should a game menu that patients can run themselves with little input be sufficiently similar to overground walking in the real world from others, it is nonetheless imperative that an expert (ie, that changes carry over. therapist) guides progression of the games to maintain the Further reasons why the therapists would have preferred use of therapeutic basis of the intervention. In one study, where game rehabilitation time for conventional therapy rather than for speed and progression advanced automatically, the users were testing the novel VR intervention was the breakdown overwhelmed, which negatively influenced motivation and susceptibility of the software—giving them the feeling of engagement in the game intervention . wasting too much therapy time. Additionally, the use of the Some of our patients indicated that they missed the exergames’ chin rest forced the patients to sit in a nonergonomic posture. relevance to real-life tasks—feedback also given by other stroke This posture was also the reason why many patients got tired patients testing similar interventions . This is despite the while playing, rather than because of cognitive challenge. When fact that we had tried to design them to be as much alike as planning this study, we did not expect the chin rest to be a major possible. Male patients in particular perceived being able to problem when playing the exergames. Its use was precipitated drive a car as very important to them and therefore wished to by a need to avoid compensatory movements of the head. be able to train those driving skills on the computer. Such However, according to the feedback of all participants, the use conflicts with real-life expectations have also been described of the chin rest for a whole therapy session of approximately by Lewis and Rosie , suggesting a selection of environments 30 minutes was too exhausting. We therefore recommend the that are deliberately unreal. Such simple environments have the use of a chin rest for short assessments only rather than for a advantage of avoiding unnecessary distractors by providing a whole therapy session . Such technology limitations have restricted amount of stimulation, thus targeting the required also been described in other studies testing VR interventions rehabilitation effect. On the other hand, they comprise a risk of [42,48]. For example, Wille et al  found a correlation boredom and a related reduction in engagement for both patients between software failures and reduced ratings of fun while and therapists. playing. Li et al  have described difficulties in positioning patients with postural impairments so that they were able to When supporting patients to play the REWIRE exergames, operate the VR system. Not surprisingly, such technology some OTs expressed uncertainty in achieving carryover effects limitations are associated with negative feedback from the users, into real-life tasks. This uncertainty was one of the reasons why as was the case in our sample. Those limitations were also they would have preferred to use time for the training of real determinative of participants’ ratings of limited intention to use ADL rather than game play to achieve the rehabilitation goals exergames in the future. Other perceived barriers were not being set for their patients. Indeed, evidence for positive carryover a “gamer” (patients), as well as the fear of being replaced by http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al computers in the future (OTs). The neuropsychologists did not Future Work share this fear, as they were more used to computer-based Lewis and Rosie  were entirely correct in their statement interventions than the OTs. As a consequence, the that “it may appear impossible to design a system that appeals neuropsychologists as computer experts were the most critical to all users” (p. 1884). However, we should not overlook the users of our exergames. fact that, despite all the critiques mentioned by users, most patients enjoyed playing the exergames. The criticisms identified Limitations are a motivator to improve the existing game design in order to Some limitations of this study should be discussed. First, most achieve an optimal rehabilitation effect. Therefore, before of the stroke patients needed assistance in completion of the thinking about testing the REWIRE exergames in a larger TAM questionnaire, either in retaining the paper-based controlled trial of stroke patients with VSN, for example, the questionnaire while it was on the table due to their hemiparesis, game design should first be modified according to the suggested or in being helped to read the questions due to their VSN improvements. Decisions should be made regarding the degree symptoms. Both of these issues may have influenced their of realism of the virtual environments: should we design responses. A touch-screen version on a tablet fixed on a table environments as unreal as possible , or as real as possible to avoid side slipping for those stroke patients who suffer from by using a tool such as Google Street View , for example? hemiparesis would allow questionnaire completion with one Immediate feedback of the achieved game scores should be hand only. A button placed on the right margin of the tablet implemented together with a graphical overview of the changes could be designed to audio-display the questions, making over time to enhance engagement and motivation. The flexibility reading of the questions unnecessary. Second, the fact that the of the software should be increased, for example, by creating a therapists participating in the focus group were working function to save the chosen difficulty level for each game. Future colleagues from the same team might also have influenced their work could examine if the frequency and time of game play—in interactions and utterances during the interview. For example, our study on a daily basis over 3 weeks—or if providing a in both interview groups, the team leader was also present, predefined set of exergames to be played instead of having free which might have inhibited some participants in expressing choice of game selection, influences user perspectives on the what they really thought about the exergames. We therefore exergames. Results have shown that the use of a chin rest to chose focus group illustration maps for data analysis. Together control compensatory movements of the head is not with the flip chart notes taken directly during the interview, recommended for a whole therapy session. Furthermore, those FIMs allowed a precise summary of the group statements evidence is needed to explore possible carryover effects of such without exposing someone through using quotes, where they VR interventions into real life in order to enhance acceptance might recognize the person who had said that. Third, the fact of such interventions among therapists. that the main researcher (BC-T-A) knew all participants quite well at the time point of the interview influenced her way of Conclusion conducting the individual and focus group interviews. Holding This study provided insight into user perspectives based on preunderstanding about the patients’ life from former meetings quantitative and qualitative statements of stroke patients during data acquisition for the feasibility study might have suffering from VSN and therapists using novel exergames to influenced her way of formulating questions differently than explore the hemineglected left space in an inpatient setting. The when she would have met the patient for the first time. However, results showed that all users perceived the REWIRE exergames the interview quality probably had improved thanks to the as user-friendly, but that they would not necessarily entertain already established relationship. Being an occupational therapist their use in their current format. The general attitude toward like half of the participating therapists further influenced the using the exergames was more positive among the patients than flow and conduct of the focus group interviews. However, among the therapists. Recommendations for improvements of speaking the same professional language might have facilitated the exergames were mainly formulated by the therapists. formulating experiences made with the patients and exergames. Feedback suggests that once those recommendations could be Fourth, the recruitment of stroke patients with VSN symptoms realized, then the REWIRE exergames intervention could be in a clinical setting who were fit enough to test the game-based explored using further trials. It is therefore of the utmost VR intervention was quite difficult. Testing such an intervention importance that end users (patients) and experts (therapists) are in a later, chronic stage where most patients are in a better health involved in order to achieve acceptable and user-friendly VR condition might have been easier. However, all patients were game-based rehabilitation methods. excited to take part in a research project during their inpatient stay and they cherished being asked for their personal opinion not only in a questionnaire, but also in a face-to-face interview. Acknowledgments This work was partially supported by the Rehabilitative Wayout in Responsive Home Environment (REWIRE) project (www.rewire-project.eu), funded by the European Commission under the FP7 framework with contract 287713, and by the Occupational Therapy Association of Switzerland [no grant number available]. We warmly thank the 19 participants who were willing to share their time and opinions with us to realize this study. Further thanks go to the two collaborating clinics where the study took place, namely the Zürcher Reha Zentrum Wald, Canton of Zurich, http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann et al Switzerland, and the Klinik Bethesda, Tschugg, Canton of Berne, Switzerland. Further thanks go to Laura Wiederkehr, former masters student of the ETH Zurich, for her invaluable help in this research project, and to Martin J. 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[doi: 10.1080/17518420902773117] [Medline: 19283533] Abbreviations ADL: activities of daily living CBS: Catherine Bergego Scale FIM: Focus group Illustration Map OT: occupational therapist RBL: right-sided brain lesion REWIRE: Rehabilitative Wayout in Responsive Home Environments TAM: Technology Acceptance Model VR: virtual reality VSN: visuospatial neglect Edited by G Eysenbach; submitted 10.05.17; peer-reviewed by S Yang, N Skjaeret; comments to author 31.05.17; revised version received 12.07.17; accepted 27.07.17; published 25.08.17 Please cite as: Tobler-Ammann BC, Surer E, Knols RH, Borghese NA, de Bruin ED User Perspectives on Exergames Designed to Explore the Hemineglected Space for Stroke Patients With Visuospatial Neglect: Usability Study JMIR Serious Games 2017;5(3):e18 URL: http://games.jmir.org/2017/3/e18/ doi: 10.2196/games.8013 PMID: 28842390 ©Bernadette C Tobler-Ammann, Elif Surer, Ruud H Knols, N Alberto Borghese, Eling D de Bruin. Originally published in JMIR Serious Games (http://games.jmir.org), 25.08.2017. 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 http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tobler-Ammann 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 http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2017/3/e18/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e18 | p. 18 (page number not for citation purposes) XSL FO RenderX
JMIR Serious Games – JMIR Publications
Published: Aug 25, 2017
Keywords: usability; user perspective; mixed-methods; exergames; visuo-spatial neglect; stroke
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