Adapting the Wii Fit Balance Board to Enable Active Video Game Play by Wheelchair Users: User-Centered Design and Usability Evaluation

Perceptions of stroke survivors regarding factors affecting adoption of technology and exergames for rehabilitation

BACKGROUND

Task-specific motor training and repetitive practice are essential components of clinical rehabilitation. Emerging evidence suggests that incorporating gaming interfaces (also referred to as "exergames"), including virtual reality and augmented reality (VR/AR)-based interfaces for motor training, can enhance the engagement and efficacy of poststroke rehabilitation.

OBJECTIVE

To investigate perceptions of individuals with stroke regarding technology and exergames for rehabilitation.

DESIGN

This qualitative phenomenological study included a convenience sample of 11 individuals with stroke (61.7 ± 12.4 years, 6 women and 5 men, 63.5 ± 41.2 months post stroke).

SETTING

Community.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Semistructured open-ended focus-group interviews to understand their perceptions on technology and exergames to improve recovery were coded using thematic content analysis.

RESULTS

Individuals with stroke were comfortable using smartphones, computers, and rehabilitation technologies but had limited experiences using exergames and VR/AR devices. Individuals with stroke were motivated to use technologies and exergames to improve their functional recovery. Participants identified facilitators (eg, enhancing functional recovery, feedback, therapist supervision) and barriers (eg, safety, inaccessibility, inadequate knowledge) to adopting exergames in their daily lives. Participants wanted the exergames to be customizable, goal oriented, and enjoyable to maintain their engagement. They were willing to use exergames to improve their functional recovery but indicated that these games could not replace the therapist's supervision.

CONCLUSIONS

Despite having limited experiences with exergames, people post stroke perceived that exergames could promote functional recovery. The perspectives gained from the present study can inform user-centered game design for neurorehabilitation.

The Usability of a Touchpad Active Video Game Controller for Individuals With Impaired Mobility: Observational Study

BACKGROUND

Video games are a popular sedentary activity among people with impaired mobility; however, active video game hardware typically lacks accessibility and customization options for individuals with mobility impairments. A touchpad video game system can elicit moderate physical activity in healthy adults; however, it is unclear if this system is usable by adults with impaired mobility.

OBJECTIVE

The purpose of this study was to assess the usability of a touchpad video game controller system adapted for adults with impaired mobility. Additional outcomes explored were enjoyment, perceived exertion, self-efficacy, participant feedback, and researcher observations of gameplay.

METHODS

Participants played several video game titles for 20 minutes with a touchpad video game controller as they stood or sat in a chair or their wheelchair. Usability was assessed with the System Usability Scale (SUS) and the Health Information Technology Usability Evaluation Scale (Health-ITUES) surveys after gameplay. After each video game, participants reported enjoyment using a visual analog scale (0 to 100 mm) and a rating of perceived exertion using the OMNI 0 to 10 scale. Self-efficacy was measured before and after gameplay. Participants provided feedback at the end of their session.

RESULTS

In total, 21 adults (6 females and 15 males) with a mean age of 48.8 (SD 13.8) years with various mobility impairments participated in this study. The touchpads received mean usability scores on the SUS 80.1 (SD 18.5) and Health-ITUES 4.23 (SD 0.67).

CONCLUSIONS

The SUS scores reported suggest the touchpad system is "usable"; however, the Health-ITUES scores were slightly below a suggested benchmark. Participants reported moderate to high enjoyment but perceived the exertion as "somewhat easy." Self-efficacy was moderate to high and did not differ pre- to postgame play. The participants regarded the touchpads as novel, fun, and entertaining. The generalizability of our results is limited due to the heterogenous sample; however, our participants identified several areas of improvement for future iteration.

Usability of the GAIMplank Video Game Controller for People With Mobility Impairments: Observational Study

BACKGROUND

Replacing sedentary behaviors during leisure time with active video gaming has been shown to be an enjoyable option for increasing physical activity. However, most off-the-shelf active video gaming controllers are not accessible or usable for individuals with mobility impairments. To address this requirement, a universal video game controller (called the GAIMplank) was designed and developed.

OBJECTIVE

This study aimed to assess the usability of the GAIMplank video game controller for playing PC video games among individuals with mobility impairments. Measures of enjoyment, perceived exertion, and qualitative data on the user experience were also examined.

METHODS

Adults (aged 18-75 years) with a mobility impairment were recruited to participate in a single testing session in the laboratory. Before testing began, basic demographic information, along with minutes of weekday and weekend physical activity, minutes of weekday and weekend video game play, and video game play experience were collected. The GAIMplank was mapped to operate as a typical joystick controller. Depending on their comfort and functional ability, participants chose to play seated in a chair, standing, or in their own manual wheelchair. Leaning movements of the trunk created corresponding action in the game (ie, lean right to move right). The participants played a total of 5 preselected video games for approximately 5 minutes each. Data were collected to assess the usability of the GAIMplank, along with self-efficacy regarding execution of game play actions, rating of perceived exertion and enjoyment for each game, and overall qualitative feedback.

RESULTS

A total of 21 adults (n=15, 71% men; n=6, 29% women) completed the usability testing, with a mean age of 48.8 (SD 13.8; range 21-73) years. Overall, 38% (8/21) of adults played while standing, 33% (7/21) of adults played while seated in a chair, and 29% (6/21) played in their own manual wheelchair. Scores from the System Usability Scale indicated above average (74.8, SD 14.5) usability, with scores best for those who played seated in a chair, followed by those standing, and then individuals who played seated in their own wheelchairs. Inconsistencies in the responsiveness of the controller and general feedback for minor improvements were documented. Rating of perceived exertion scores ranged from light to moderate intensity, with the highest scores for those who played seated in a chair. Participants rated their experience with playing each game from above average to very enjoyable.

CONCLUSIONS

The GAIMplank video game controller was found to be usable and accessible, providing an enjoyable option for light-to-moderate intensity exercise among adults with mobility impairments. Minor issues with inconsistencies in controller responsiveness were also recorded. Following further development and refinement, the next phase will include a pilot exercise intervention using the GAIMplank system.

Use and subjective experience of the impact of motor-assisted movement exercisers in people with amyotrophic lateral sclerosis: a multicenter observational study

Motor-assisted movement exercisers (MME) are devices that assist with physical therapy in domestic settings for people living with ALS. This observational cross-sectional study assesses the subjective experience of the therapy and analyzes users' likelihood of recommending treatment with MME. The study was implemented in ten ALS centers between February 2019 and October 2020, and was coordinated by the research platform Ambulanzpartner. Participants assessed symptom severity, documented frequency of MME use and rated the subjective benefits of therapy on a numerical scale (NRS, 0 to 10 points, with 10 being the highest). The Net Promotor Score (NPS) determined the likelihood of a participant recommending MME. Data for 144 participants were analyzed. Weekly MME use ranged from 1 to 4 times for 41% of participants, 5 to 7 times for 42%, and over 7 times for 17%. Particularly positive results were recorded in the following domains: amplification of a sense of achievement (67%), diminution of the feeling of having rigid limbs (63%), diminution of the feeling of being immobile (61%), improvement of general wellbeing (55%) and reduction of muscle stiffness (52%). Participants with more pronounced self-reported muscle weakness were more likely to note a beneficial effect on the preservation and improvement of muscle strength during MME treatment (p < 0.05). Overall, the NPS for MME was high (+ 61). High-frequency MME-assisted treatment (defined as a minimum of five sessions a week) was administered in the majority of participants (59%) in addition to physical therapy. Most patients reported having achieved their individual therapeutic objectives, as evidenced by a high level of satisfaction with MME therapy. The results bolster the justification for extended MME treatment as part of a holistic approach to ALS care.

Active Videogaming Interventions in Adults with Neuromuscular Conditions: A Scoping Review

This review synthesized active videogaming (AVG) intervention literature over a 10-year period (2010-2020) for people with neuromuscular conditions (18-64 years of age), examining interventions that aimed to improve health and secondary conditions, physical activity, and outcomes quality of life (QOL). Systematic searches yielded 40 eligible studies. The major groups were multiple sclerosis (40%) and stroke (33%), and the study participants had mostly mild-to-moderate disability who were able to play games in a standing position. Research designs primarily involved randomized controlled trials (65%) and pre/post-trial design without a control group (28%). The majority of interventions used commercial off-the-shelf gaming systems, such as Nintendo Wii and Microsoft Kinect. Studies reported significant improvements in health outcomes, specifically in balance (n = 30/36), mobility (n = 24/27), and cardiorespiratory fitness (n = 6/8). Positive changes were also seen in secondary conditions (n = 8/12), physical activity (n = 3/4), and QOL outcomes (n = 8/16). AVG research for people with neuromuscular conditions has grown in both quantity and quality but several gaps remain. Study findings provide a roadmap for future AVG trials on understudied populations, and highlight technology and targeted outcomes as drivers of future intervention research.

Development of Surface EMG Game Control Interface for Persons with Upper Limb Functional Impairments

In recent years, surface Electromyography (sEMG) signals have been effectively applied in various fields such as control interfaces, prosthetics, and rehabilitation. We propose a neck rotation estimation from EMG and apply the signal estimate as a game control interface that can be used by people with disabilities or patients with functional impairment of the upper limb. This paper utilizes an equation estimation and a machine learning model to translate the signals into corresponding neck rotations. For testing, we designed two custom-made game scenes, a dynamic 1D object interception and a 2D maze scenery, in Unity 3D to be controlled by sEMG signal in real-time. Twenty-two (22) test subjects (mean age 27.95, std 13.24) participated in the experiment to verify the usability of the interface. From object interception, subjects reported stable control inferred from intercepted objects more than 73% accurately. In a 2D maze, a comparison of male and female subjects reported a completion time of 98.84 s. ± 50.2 and 112.75 s. ± 44.2, respectively, without a significant difference in the mean of the one-way ANOVA (p = 0.519). The results confirmed the usefulness of neck sEMG of sternocleidomastoid (SCM) as a control interface with little or no calibration required. Control models using equations indicate intuitive direction and speed control, while machine learning schemes offer a more stable directional control. Control interfaces can be applied in several areas that involve neck activities, e.g., robot control and rehabilitation, as well as game interfaces, to enable entertainment for people with disabilities.

Active Video Gaming Using an Adapted Gaming Mat in Youth and Adults With Physical Disabilities: Observational Study

Background

A common leisure-time activity amongst youth and adults in the United States is video gameplay. Playing video games is typically a sedentary endeavor; however, to encourage an increased level of physical activity in an engaging and enjoyable way, active video gaming has become popular. Unfortunately, the accessibility of gaming controllers is often an issue for persons with disabilities. A commercial off-the-shelf (OTS) gaming mat was adapted to facilitate use by individuals with mobility impairments to address this issue.

Objective

Our study aimed to examine energy expenditure, enjoyment, and gameplay experience in youth and adults with mobility impairment during active video gaming using an OTS and adapted versions of a gaming mat.

Methods

The study used an observational design. During visit 1, physical function was assessed, and participants were given a familiarization period with the gaming system. For visit 2, based on observation during the physical function tests and discussion with the participant, it was decided whether the participant would play in a standing or seated position. For standing gameplay, the mat was placed on the floor, and for seated play, the mat was placed on a height-adjustable and tilt-adjustable tabletop. Metabolic data were collected during a 20-minute baseline and four 10-minute bouts of Wii Fit Plus gameplay, with 2 bouts on each of the mats (adapted and OTS). During gameplay, the research staff observed and rated participants’ ability to use the game controller (mat) and the quality of gameplay. At the end of each game set, participants reported their rating of perceived exertion on a scale from 0 to 10. During rest, participants completed the physical activity enjoyment scale. Participants also answered additional questions regarding the system's usability with each controller (adapted mat and OTS mat). Statistical analyses were computed using Stata 16 (version 16.1; StataCorp). Linear mixed-effects maximum likelihood regression was performed separately for individuals who could play standing and for those who played seated.

Results

A convenience sample of 78 individuals with mobility impairments between the ages of 12 and 60 years (mean 39.6, SD 15.8) participated in the study. Of the sample, 48 participants played the video games in a seated position, while 30 played the games standing. Energy expenditure and heart rate tended to be higher in the OTS mat condition for seated players, while values were similar for both conditions among standing players. However, seated participants reported greater gameplay experience, and both groups exhibited a higher quality of gameplay during the adapted mat condition.

Conclusions

Active video gaming using an adapted gaming mat provided an enjoyable exercise activity for individuals with mobility impairments. The use of the adapted controller provides a means by which this population can engage in light to moderate intensity active video gaming, thereby reducing sedentary leisure time.

Trial Registration

ClinicalTrials.gov NCT02994199; https://clinicaltrials.gov/ct2/show/NCT02994199

Exergames to Prevent the Secondary Functional Deterioration of Older Adults during Hospitalization and Isolation Periods during the COVID-19 Pandemic

The COVID-19 pandemic is having an intense impact on the functional capacity of older adults, making them more vulnerable to frailty and dependency. The development of preventive and rehabilitative measures which counteract the consequences of confinement or hospitalization is an urgent need. Exergaming can promote physical activity, prevent falls, and maintain functional and cognitive capacity. However, although the use of exergames in health programs for the elderly is promising, their widespread use should not be considered without the supervision of a social health professional. Therefore, the objective of this work was to evaluate and analyze three video game consoles (Nintendo Wii®, Xbox-Kinect® and Play Station 4®) and 26 commercial exergames with the aim of identifying their usefulness for the prevention of functional deterioration. Three occupational therapists analyzed the data independently, and subsequently agreed on the results. The examination of the commercial consoles met three criteria: components, interaction channels and the type of the exergame. Each exergame was analyzed taking into account its ability to train postural control, balance, upper limb functionality and cognitive function. The results of the evaluation showed that exergames contain game activities that can be part of the rehabilitative treatment aimed at the prevention of the functional impairment of older people affected by COVID.

Does exergaming drive future physical activity and sport intentions?

We studied how usability and playability of sport exergames affect future intentions of participation in physical activity or actual sport. We employed questionnaires to measure participants' enjoyment, usability, game-experience, and future intentions of physical activity and real sport. We compared the outcomes based on players' gender, previous real-swimming, and exergame experience. Psychological parameters were not different between groups but players without exergame experience enjoyed the game more. Physical activity intentions increased for all participants but not swimming intentions. The limitations of current gaming systems and their effects on players' gaming experience and intentions are discussed.

Exploring an Existing Weight Management App for Use With Adolescents and Young Adults With Spina Bifida: Usability Study

BACKGROUND

Adolescents and young adults with spina bifida (AYA-SBs) have unique user needs, given their variable and complex symptom profile. Owing to multiple barriers to prevention and intervention treatments for secondary conditions (eg, obesity), AYA-SBs may benefit from the use of behavioral intervention technologies (BITs). However, as BITs are often designed and tested with typically developing individuals, it is unclear if existing BITs may be usable for AYA-SBs.

OBJECTIVE

This study aimed to evaluate the usability of a high-quality, publicly available, weight management-focused mobile BIT (smartphone app) for AYA-SBs.

METHODS

Overall, 28 AYA-SBs attending a Young Men's Christian Association-based summer camp completed 4 structured usability tasks using a weight management app designed for the general public called My Diet Coach (Bending Spoons). Learnability was measured by (1) time to complete task, (2) number of user errors, and (3) correct entry of data when requested by the app. Satisfaction and general usability were measured via self-reported questionnaires and qualitative feedback following interactions with the app.

RESULTS

The majority of the sample were able to complete the tasks, with increased completion rates and improved times on second attempts of the tasks (Ps<.05). Errors were common, and discrepancies emerged between quantitative and qualitative feedback such that self-reported measures indicated dissatisfaction but qualitative feedback was generally positive. Suggested improvements to the app included (1) tutorials, (2) simplifying the design, (3) more activity options for those who ambulate by wheelchair, and (4) notifications to prompt use.

CONCLUSIONS

AYA-SBs were able to learn how to complete specific tasks independently on a weight management app, but design changes consistent with previously proposed user needs were recommended. Rather than designing entirely new BITs, it may be possible to adapt existing technologies to personalize BITs for specific populations such as AYA-SBs.

Energy Expenditure and Enjoyment During Active Video Gaming Using an Adapted Wii Fit Balance Board in Adults with Physical Disabilities: Observational Study

Background

Individuals with physical disabilities have fewer opportunities to participate in enjoyable physical activity. One option for increasing physical activity is playing active video games (AVGs); however, many AVGs are inaccessible or offer limited play options.

Objective

This study aimed to examine energy expenditure and enjoyment in adults with mobility impairment during AVG play using off-the-shelf (OTS) and adapted versions of the Wii Fit balance board (Nintendo).

Methods

During visit 1, participants completed a functional assessment and the familiarization period. During visit 2, metabolic data were collected during a 20-minute baseline and four 10-minute bouts of Wii Fit Plus game play, with two bouts on each of the boards. During the resting period, participants completed the Physical Activity Enjoyment Scale (PACES). Statistical analyses were computed using SPSS software. Data were analyzed separately for individuals who were able to play while standing on both boards (StdStd); those who could not play while standing on the OTS board, but were able to play while standing on the adapted board (aStd); and those who could only play while sitting on the adapted board (aSit).

Results

Data were collected for 58 participants (StdStd, n=17; aStd, n=10; aSit, n=31). The sample included 31 men and 27 women with a mean age of 41.21 (SD 12.70) years. Energy expenditure (metabolic equivalent [MET]) during game play was significantly greater than that during rest for all players. Only 17 participants (StdStd group) were able to play using the OTS board. During game play on the adapted board, the average MET values for the two game sets were 2.261 (SD 0.718) kcal/kg/hour and 2.233 (SD 0.751) kcal/kg/hour for the aSit group, 3.151 (SD 1.034) and 2.990 (SD 1.121) for the aStd group, and 2.732 (SD 0.655) and 2.777 (SD 0.803) for the StdStd group. For game play on the adapted board, self-reported ratings of perceived exertion on a 0-10 scale suggested greater exercise intensity levels, with median scores ranging from moderate (3) to very hard (7). The PACES scores indicated that all players enjoyed using the adapted board, with a median score of 4 on a 5-point scale.

Conclusions

The adapted Wii Fit balance board provided an opportunity for individuals with mobility impairments, including wheelchair users, to engage in AVG. All participants were able to utilize the adapted controller and enjoyed the AVG activity. Although the average MET values achieved during AVG represented light-intensity exercise (<3 METs), 16% of sitting participants and 41% of standing participants achieved moderate-intensity exercise (3-6 METs) in at least one of the games. Factors not accounted for, which may have influenced the intensity of exercise, include game selection, limited familiarization period, and discomfort wearing the COSMED portable metabolic system for measurement of oxygen consumption. Accessible AVG controllers offer an innovative approach to overcome various barriers to participation in physical activity. The next steps include assessment of an AVG intervention using an adapted board gaming controller on health and fitness outcomes.

Trial Registration

ClinicalTrials.gov NCT02994199; https://clinicaltrials.gov/ct2/show/NCT02994199 (Archived by Webcite at http://www.webcitation.org/75fc0mN39).