1. Introduction
More than one billion people have different disabilities around the globe, according to the World Health Organization (WHO) [1]. Neurological disorders rank highly among the factors that contribute to disability [2]. Approximately 20 million individuals worldwide experience a stroke each year, and in 45% of such cases, the patient will always be permanently disabled in the upper body [3]. Additionally, many people have neurological diseases that result in lower limb disability or momentary mobility limitations [4]. Although there are several innovative and advanced therapies for neurological rehabilitation, many users are not compatible with them, and the effectiveness of restoration is still relatively low [5].
The use of technology to assist people with severe brain injuries or disorders in their daily activities is growing [6,7,8,9]. According to Berardi et al. [10], of the 3,775,920 disabled individuals in Canada, 95% require the assistance of one or more aids or devices for everyday tasks, communication, mobility, or education [11]. These figures highlight the importance of increasing access to assistive technologies and improving the quality of life of people with brain illnesses or disorders [12].
Effective neurorehabilitation requires innovative assistive methods and technology that can support patients unable to produce autonomous movement in generating the necessary functional patterns of brain activity and motor behavior [13,14]. These therapies are required to increase the likelihood of functional recovery and hasten the brain’s natural healing processes [15,16]. However, accessibility and efficiency remain important considerations when creating and using these technologies.
1.1. Brain–Computer Interface and Brain–Machine Interface
BCIs [4] and BMIs [15] have the potential of leading technologies, in recent years, for those suffering from neurological conditions or trauma for quick healing and enhancing the quality of life [15,16]. BCI enables communication with a signal-processing device by translating brain signals into a format the device can understand without involving bodily movements [17,18,19]. The researchers use an electroencephalogram (EEG) or electrodes implanted in the cortical neurons to record signals from the scalp, while the system can also use signals from both sources [20,21]. BCIs offer an alternate form of communication to conventional input devices like keyboards or mice that necessitate physical touch. They enable people to operate objects or machinery outside them purely by using their brain activity [22]. Further developments in BCI technology include improvements in signal-processing techniques [23] and adaptive systems to enhance usability and reliability in neurorehabilitation applications and systems [24,25].
On the other hand, a BMI is the implantation of electrodes or sensors directly into the brain tissue, enabling more precise and direct brain activity recording and motivation compared to non-invasive techniques like scalp EEG [26]. When a higher spatial and temporal resolution level is required, such as for advanced prosthesis control or neurorehabilitation applications, invasive BMIs are often used [27,28]. BMIs have become highly interdisciplinary, including research from many other academic fields. The multidisciplinary nature of BMI research has significantly improved our understanding of brain and machine interaction. It provides new opportunities for strengthening human-machine interactions and enhancing the lives of disabled individuals [29,30].
1.2. Challenges in Implementation
BCIs and BMIs in assistive technology applications have several significant challenges that should be overcome to guarantee their effectiveness and usability. In developing reliable BCIs, irregularity and noise in brain signals are substantial barriers that impact physical and cognitive impairments [31,32]. Disabled people require more time and effort to improvise their mental exercises or motor imagery in operating the interface and to change their cognitive processes to generate reliable and distinct brain signals [33,34]. For instance, it would be tough for Cerebral Palsy (CP) patients to generate consistent motor imagery (MI) signals, resulting in high error rates and reduced device usability [35]. Similarly, rural-dwelling stroke survivors often face difficulties due to the limited access to the professionals needed for configurations of BCIs, making these technologies less practical for home use [36]. For individuals with disabilities, BCIs need to be user-friendly, compatible with currently available assistive equipment, and relatively simple to set up.
Accessibility and usability are two main factors when using BCIs [37]; furthermore, ethical concerns about informed permission, data security, and privacy must also be considered [38,39]. BCIs must be dependable, efficient, and long-lasting. Although electrode stability, device lifetime, and responsiveness to changing environmental circumstances are significant concerns [40].
More considerations and surgical skills are required to ensure minimum risk and safety of a patient, as direct implantation of electrodes or sensors into the brain tissue is the most risky and one of the significant challenges [38,41]. These risks include infection, tissue damage, hardware failure, and neurological problems. For people with Amyotrophic Lateral Sclerosis (ALS), this procedure may reduce the quality of life and provide limited advantages due to its progressive nature [42]. Another challenge is the BMI system’s stability and reliability. Factors affecting the BMI’s functionality and durability are electrode deterioration, tissue response, and device longevity, which demand continuous evaluation and development [43]. While considering noise and signal unpredictability, interpreting brain signals and decoding user intentions from recorded brain activity accurately and efficiently is the most challenging task for BMI technology [44]. To use the interface efficiently, disabled people must develop the ability to generate precise neural signals or adjust their brain activity, as training and user education are essential aspects of BMI utilization. Developing training regimens that enhance user learning and adaptation while sustaining efficiency is a constant struggle [45].
Recent advancements in these technologies have shown the potential to address these challenges as in January 2024, two essential breakthroughs were reported: Telepathy emerging from Neuralink and BCI Neural Electronic Opportunity (NEO) device completed the first implantable BCI human trail, which significantly improved the stability of the electrode and reduced the risk of infections and tissue damage [46]. Similarly, the integration of virtual reality (VR) with BCIs has the potential to provide engaging environments to enhance motor and cognitive recovery [47]. However, further research is required so researchers and developers can improve the accessibility of assistive technology for disabled people and overcome the obstacles to successfully implementing BCIs and BMIs in these circumstances.
1.3. Introduction to Gamification
A learning strategy called gamification, which integrates game elements into non-game contexts to increase users’ interest, has emerged as a potential solution to overcome the challenges and surge user motivation and engagement in assistive technology applications for users to improve their knowledge and experience [48]. Gamification has become increasingly popular as a study topic, with applications in corporate business transformation, education, and health [41,49]. Gamified BCIs and BMIs have much potential for overcoming the difficulties in neurorehabilitation for people with disabilities [50,51]. Gamification in training increases user engagement and enjoyment because it simulates real-world situations and uses engaging game material [52]. Gamification can potentially increase user involvement by adding it to therapeutic activities. Increasing accessibility and simplifying complex tasks using well-designed gamified elements can overcome the challenges of neurorehabilitation discussed in Section 1.2, such as improving usability and engagement, improving users’ focus and motivation, skill acquisition, and sustaining interest in learning tasks [53,54,55]. Users can practice and improve specific cognitive and motor abilities through game-based challenges and activities while obtaining immediate feedback on their performance.
Iterative learning and adaptation processes are vital in enhancing brain plasticity and encouraging functional recovery in people with disabilities [56,57]. Using gamification, disabled people can develop specific cognitive, motor, and communicative skills more quickly, providing practical and encouraging experiences. According to Mubin and Cai, assistive technologies with gamification elements can improve their quality of life and maintain general health than traditional tech environments [58,59].
1.4. Significance
The evolution of gamified BCIs and BMIs has to be remarkable, offering valuable support in various learning domains for disabled people [60]. By integrating game-like elements, these technologies enhance learning processes and provide numerous advantages [61]. Gamification primarily increases user motivation and engagement by offering challenges, rewards, and interactive interfaces, making learning more enjoyable and engaging [62,63]. These technologies provide significant results in neurorehabilitation, such as increased brain plasticity, recovery of motor function in people with disabilities, and introduction of stimulating and enjoyable tasks through consistent practice and task-specific training [64]. Gamified systems provide people with severe speech or physical deficiencies with different modes of interaction with others [65]. In addition, these innovative technologies enable individuals to express themselves, control external devices, and participate in social events, thus significantly increasing their lives and encouraging independence [66]. Similarly, setup with assistive devices for rehabilitation through VR is another domain that facilitates disabled people to be involved in the immersive world. Participation in relaxation activities generally increases their quality of life [67].
1.5. Problem Statement
Neurological disabilities significantly affect motor and cognitive functions; however, traditional rehabilitation techniques fail to engage users and provide eternal improvements. Although BCIs and BMIs offer significant potential for neurorehabilitation, the effectiveness of these technologies is restricted by technical limitations, ethical concerns, and challenges in user involvement. Despite its potential to improve user motivation, learning, and functional recovery, gamification remains an underexplored approach in BCI and BMI. This paper highlights the potential of gamified neurotechnologies to rejuvenate rehabilitation results and enhance the quality of lives of disabled people.
1.6. Objective of This Study
The advantages and disadvantages of incorporating gamification components into BCI and BMI technology applications are examined in this study. The objective is to determine how gamification can increase learning abilities by encouraging motivation, engagement, and skill enhancement, including gaming interfaces, prizes, and feedback systems, from assistive technology perspectives while considering previous research and literature. This study highlights significant developments, difficulties, and possibilities in the growth and use of gamified BCI and BMI technologies. The information collected from this study will spur more progression and innovation in assistive technology, improving the individuality and quality of life for disabled ones.
1.7. Contribution of This Study
Providing a comprehensive research review from 2015 to 2024 on the development and importance of gamified BCI and BMI technologies for disabled individuals, this research makes an essential contribution, aiming to answer the following questions:
What are the measurable impacts of integrating gamification into assistive technologies on cognitive and motor recovery?
How does gamification enhance user engagement and learning in BCI and BMI technologies for disabled individuals?
This study emphasizes the revolutionary potential of gamified BCI and BMI technologies in increasing the independence and quality of life of individuals with impairments. The merging of recent research, prototypes, and practical implementations makes this work a valuable resource for academics, professionals, and policymakers in assistive technology, highlighting the areas for future innovation and research needs. This project also increases awareness of the ethical issues and societal effects of implementing gamified BCI and BMI technologies, contributing to the continuing conversation at the intersection of gaming, neuroscience, and disability studies.
2. Materials and Methods
By reviewing gamified BCIs and BMIs for disabled people, we can learn more about how these technologies may improve their lives. We have conducted a preliminary review to ascertain whether our proposed assessment is viable. Much research on using gamified BCI and BMI systems as helpful aids for individuals with disabilities has been observed since our initial review. These technologies endeavor to offer alternate communication networks, control mechanisms, and rehabilitative interferences for people with limited mobility or communication skills. However, it is still compulsory to carefully observe the fields’ where disabled people have successfully used gamified BCI and BMI applications. Moreover, examining the results of studying the effects of various game elements, user interfaces, and interaction techniques on this population is still very important.
We suggest using a comprehensive review (CR) methodology to allow us to impartially evaluate and synthesize the available research to fill up these gaps. The goal of our CR approach is to give a thorough evaluation of the present status of gamified BCI/BMI technology for disabled people. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [68] criteria will be adhered to ensure the highest level of scientific rigor and transparency in our analysis, even though conducting a meta-analysis may be difficult given the small number of published studies and differences in methodologies.
2.1. Sources and Information Plan
An online search was carried out across numerous digital databases for the last 10 years (2015–2024), including IEEE Xplore, Frontiers, Scopus, PubMed, ScienceDirect, SAGE, Springer LINK, Web of Science, and Google Scholar, to compile pertinent material on gamified BCIs and BMIs for disabled people. This timeframe is intended to include the most recent BCI technological developments in the context of applications for disabilities. The primary keywords used for relevant literature were BCI, BMI, Gamified BCI, BMI, Disability, and Learning Abilities. A specific search strategy was used for each database to eliminate duplicates. Titles and abstracts were screened to find relevant studies. These articles’ full texts were located, read, and graded using predefined standards. A thorough selection method was achieved by using a cross-checking procedure by four reviewers to guarantee the inclusion of legitimate and significant papers in the review.
2.2. Selection Criteria
The inclusion criteria for this review were defined in two phases. Three main criteria were used in the first phase of the literature screening process: (1) publications written in English were taken into consideration since this language is commonly used in scientific research; (2) publications were restricted to those published between 2015 and 2024; and (3) to ensure high academic rigor and reliability, only peer-reviewed journal articles were included, excluding non-peer-reviewed sources like editorials, book chapters, theses, dissertations, and unpublished manuscripts. In the second phase, additional criteria were applied to refine the selection. These criteria included the following: (1) only empirical studies, which exclude conceptual and review-based papers and offer scientifically reliable data to address the research questions; (2) studies that concentrate on the gamification features of BCI and BMI to improve learning outcomes for people with disabilities; (3) studies that assess the influence of gamified BCI and BMI interventions on learning outcomes for people with disabilities; and (4) only full-text available studies.
Fifty-six studies that satisfied the criteria and were included in this critical evaluation were selected from the initial pool of eight hundred articles, as shown in Figure 1. Studies without full-text accessibility, papers written in languages other than English, research unrelated to the topic, and studies released before 2015 were also considered exclusion criteria.
2.3. Quality Appraisal Criteria
We used the standards for quality evaluation provided by [62] to evaluate the selected publications, quality critically. We used two sections in our quality appraisal process: one for assessing qualitative research (9 items), which was based on work by [63], and another for reviewing quantitative studies (7 items), which was based on the NICE checklist [64]. A scale from no mention (0) to substantial mention (3) was used to rate the appraisal criteria. We excluded studies having a mean score of fewer than two points, following the [62].
Adherence to PRISMA statement guidelines ensures a systematic approach that maintains transparency, comprehensiveness, and methodological rigor throughout the process of identifying, selecting, and analyzing research records. PRISMA statement’s widespread acceptance in the academic community highlights its credibility and efficiency in conducting systematic reviews. This compliance enhances the credibility and significance of research findings and fosters greater confidence and influence in the field.
Recommendation of registered Table 1 (PRISMA) presents the scoring results for both sections systematically. The table displays the extent to which the studies part of our review met each criterion, demonstrating our dedication to methodological precision.
3. Results
3.1. Gamified BCIs and Their Impact on Disabled People
Gamified BCIs have stirred up much interest due to their potential to improve the everyday routines and learning capacities of people with disabilities as shown in Table 2. In this section, we thoroughly evaluate several studies investigating the incorporation of gamification components into BCIs and their significant impacts on developing skills and rehabilitation in people with disabilities.
3.1.1. Stroke Rehabilitation and Upper Limb Functionality
Sebastián-Romagosa et al. [69] examined how a gamified BCI might benefit individuals with stroke-related deficits throughout their motor rehabilitation. The study involved 51 stroke patients with upper extremity hemiparesis. The researchers created a VR-based BCI game to focus on upper limb movements. Compared to conventional rehabilitation techniques, 84.3% of participants’ motor function was greatly improved by 4.68 points (SD = 4.92), according to the results, after they received the gamified BCI intervention. However, the study faced some limitations. First, some patients could not complete all the tests, resulting in a low sample size for statistical analyses. Moreover, the benefits of the therapy for a long duration as the effects of treatment were not investigated beyond 6 months. Lastly, they used a broad range of scales; however, various EEG quantitative approaches may offer additional perceptions.
Another relevant study by de Castro-Cros et al. [70] presented the game-based environment for upper limb rehabilitation after a stroke. A game was specifically created to match the goals and tempo of the rehabilitation procedure. Functional electro-stimulation and animation were employed in the rehabilitation process to animate the patient’s limbs as a virtual avatar. With the help of a control group of six volunteers and ten patients (seven were females and nine males), a pilot study was conducted with two rehabilitation sessions. The maximum and minimum age of the healthy group was 58 and 23 years old, while the stroked patients’ age was 79 and 26 years old. The results showed that gamified rehabilitation did not change MI effectiveness. Still, they enhanced the participants’ experience, making treatment more enjoyable; the study showed some limitations that need to be addressed for future research. First, the generalizability of the study could be impacted by small groups and age differences in the group. Also, it lacks the sessions to assess generalizability. Furthermore, excluding emotional variables in the user performance comparison could overlook the crucial factors influencing the results.
3.1.2. Neurorehabilitation and VR Integration
Wen et al. [71] analyzed the integration of VR with BCI technologies to aid in rehabilitating neurological illnesses. They examined the advantages and prospective uses of integrating these two cutting-edge technologies into neurorehabilitation. The study explained how BCIs could allow direct brain-to-device communication while VR can generate immersive settings for treatments by analyzing pertinent research and studies. The study emphasized the positive developments in neurological ailments, including spinal cord injury, stroke, and Parkinson’s disease. However, this study highlights several areas for improvement. First, the transmission rate of EEG signals needs to be enhanced for efficient communication. Additionally, there is a need to improve the accuracy and generalization performance of the EEG analysis algorithm to make it more reliable and applicable. Furthermore, a more natural brain-machine interaction mode based on P300 or SSVEP to improve the practical use of the BCI-VR system needs to be explored, enabling smoother and more intuitive user experiences.
An innovative rehabilitation program for people recovering from upper-limb disabilities caused by a stroke was introduced in the study by the authors of [72] using BCI-VR technologies. Twelve stroke patients (aged 30 to 70 years) were recruited for the study, and the experiments were performed at Taoyuan Chang Gung Memorial Hospital, China. The BCI system keeps track of the user’s concentration levels throughout the rehabilitation activities and gives them immediate feedback on their engagement. Findings indicate that the combined BCI and VR system is feasible and may help improve focus and concentration in stroke patients undergoing upper limb rehabilitation. However, the generalizability of the findings can be limited as the study focused on a specific group of post-stroke patients with certain criteria. The impact of performance accommodation mechanisms on perceived control and frustration in online BCI for stroke therapy/treatment was studied by [73]. Nineteen stroke victims (seven women and twelve men, mean age 27 ± 8 years) who undertook a BCI-based rehabilitation program with game-based interaction participated in the study and provided their informed consent before participation. The participants played a specially created fishing game where they had to capture as many fish as possible from a lake while controlling a fisherman. The results demonstrated that the performance accommodation methods enhanced user satisfaction and performance by 80% while lowering annoyance levels.
3.1.3. Gamified Approaches for Various Disabilities
Pires et al. [74] proposed a unique error-monitoring BCI that uses gamification to increase cognitive and behavioral flexibility in people with autism spectrum disorders (ASD). Ten healthy participants, including five men and five women with a mean age of 28.1 ± 4.43 years, and one 33-year-old autistic male participated in the experiments. The gamified task aims to improve the user’s performance and learning, with an online balance accuracy of 81.6% and 77.1% in ErrPs detection for two game modes. According to the results, the gamified interface’s efficacy in error identification and correction suggests its potential as a therapeutic tool for people with ASD. However, the patients expressed irritation by receiving rewards only for identifying errors rather than for performing well overall. Moreover, the study did not track patients’ eye movement, limiting the insights into decision-making processes; it is also challenging to determine whether the findings apply to broader populations. In a Mercado et al. [75] study, a BCI video game for 12 children with ASD autism-specific neurofeedback training was generated and evaluated. The aim was to determine whether integrating BCI technology into a gaming environment could enrich the outcomes of neurofeedback training for patients with ASD. Through the game’s BCI technology, players can utilize their brain activity to control and manipulate various games, thereby improving their emotional regulation abilities. The study findings revealed that autistic individuals improved their capacity for focus, interpersonal communication, and emotional regulation abilities. However, the study showed limitations, including focusing on attention issues and neglecting symptoms like language impairments and social interactions. Moreover, the game did not facilitate posture control to reduce movement-related noise, indicating the necessity of developing reliable posture detection methods for further research.
A study by the authors of [76] focused on the co-design approach to develop a VR game teaching kids with ASD how to cross the street using head-mounted displays (HMDs). The game immersed players in a virtual street-crossing scenario, aided by HMD, and guided through various obstacles and interactions with fictional pedestrians and vehicles. The results revealed the effectiveness of co-designed VR games in enhancing street crossing skills among children with ASD. Participants improved decision-making skills, awareness of traffic lights, and social interactions related to street crossing. The immersive and dynamic features of the game increased engagement and motivation, facilitating the efficient development of new skills/abilities. The small sample size, a brief intervention period, an emphasis on particular outcome measures, possible uncontrolled variables in the control group, a lack of extended follow-up, restricted generalizability to other populations, and the application of specific measurement instruments are some limitations of this study that need to be considered for future research.
A study conducted by the authors of [77] examined the difficulties, solutions, and lessons discovered in creating mobile EEG (electroencephalography) neurofeedback games, such as the “Starkids” and “Zodiac Animals” game series, to offer successful and enjoyable interventions for children with ASD. The research emphasized the value of industry standards in creating mobile EEG neurofeedback games for autistic children. Nineteen ASD children (aged 3–6) participated in the experiment. Children showed a high level of acceptance and enjoyed the fun. The study contributed to ongoing attempts to create therapies that tap into the promise of technology to meet the needs of children on the autism spectrum by exploring difficulties, methods, and lessons learned using the Nintendo® Wii-Fit training system, Urgen et al. [78] examined the effects of VR games on children with CP and their superior motor skills and balance. Forty-seven children attended a session; however, only thirty-seven participated in the training program, while the informed consent was collected only from thirty-four children. They showed significant improvements in their ability to do leg jumps, especially on the hemiplegic side, compared to the children who had traditional rehabilitation therapy. Improving the motor skills of hemiplegic people, reducing the need for helpful movements, and encouraging muscle activation to increase balance maintenance, sports such as racing and ski jumping, have shown significant outcomes. They also encourage them to incorporate game-based therapies within the treatment for possible advantages.
Researchers examined the effectiveness and feasibility of gamified BCI systems for computer control in patients with CP. A group of CP patients with limited motor function communicated with computer programs using a BCI device to evaluate the BCI system’s efficiency, usability, and user satisfaction. The findings demonstrated BCI technology’s effectiveness in aiding CP patients’ navigating computer programs using gamified interfaces. However, the lack of recording of the raw EEG data provides information on signal patterns and artifacts. Additionally, the lack of transparency in proprietary algorithms of the Emotive BCI device, making training improvement complicated and declining users’ performance, are also drawbacks of the study. Twenty percent of users cannot generate classifiable brain signals. The inherent variability in motor imagery-based brain activity classification performance needs to improve the efficacy of BCIs for people with CP [79].
Combining a BCI training system with a jigsaw puzzle game was another innovative strategy presented by [80]. The primary goal was to improve CP patients’ motivation and learning results by offering a dynamic and inspiring learning environment for BCI applications. The findings indicated that the game has effectively elevated user engagement and improved motor and cognitive abilities during BCI sessions.
BCI training game ideas and implementations enhance to balance the data quality with user acceptability. A similar study by the authors of [81] focused on creating and valuing a training program incorporating gaming components for CP patients utilizing BCI technology. The goal was to determine the usefulness of game-based training in CP patients, helping them improve their motor and cognitive abilities and encouraging successful rehabilitation methods for such patients.
The attentional skills of CP children using EEG technology and serious games were assessed by [82]. The study’s main objective was to determine the feasibility and effectiveness of an integrated approach to attention assessment by data evaluation and comparison with established attention measures. The results exhibited the method’s ability to assess CP children’s attentional skills, recognize attentional patterns, and identify areas needing support. A VR-based BCI system (including games and exercises to enhance spatial working memory) was developed by Liu et al. [83]. While receiving real-time feedback on their brain activity, participants completed spatial memory tasks using the BCI system during training sessions. According to the results, the gamified BCI system significantly improved spatial working memory performance compared to a control group, and using gamification elements such as rewards and interactive games enriched cognitive performance and increased awareness of training tasks. A low-cost BCI-VR system (unique method) for stroke treatment was introduced in a study by the authors of [84]. The primary goal was implementing a gamified VR environment to improve motor recovery in stroke patients with severe upper limb motor injuries. The REINVENT system’s feasibility, use, and initial results were assessed in a pilot study with a small number of stroke survivors. Promising results showed optimistic user experiences and improvements in upper limb motor function. The study’s drawbacks include limited sample size, poor generalizability, lack of diversity, short length, deficiency of a control group, and dependency on self-reported measures. Future research should consider these limitations to thoroughly examine REINVENT’s effectiveness and long-term benefits for stroke rehabilitation.
3.1.4. Advancements in Technology and Rehabilitation
Aamer et al. [47] conducted a study on the effectiveness of VR and BCI technologies in treating severe disorders such as stroke, spinal cord injuries, and neurodegenerative diseases. The study found that combining BCI and VR provides a viable and efficient strategy to help neurorehabilitation and accelerate the healing process for people suffering from various neurological disorders.
Employing a 3D learning environment with gamified elements, BCI technology, and interactive attention-training exercises, Ali and Puthusserypady [38] introduced an approach to improve attention in attention deficit hyperactivity disorder (ADHD) patients. The aim was to discover whether utilizing BCI technology in a gamified situation can successfully train attention in those with ADHD. A group of individuals with ADHD were examined to ascertain the efficiency of this training system, and the result shows that integrating a 3D learning playground with BCI helps patients with ADHD develop more practice at paying attention. The study’s drawbacks include the small sample of just healthy participants, no testing on actual ADHD patients, and its limited focus on attention training at the expense of other cognitive domains affected by ADHD.
The reactions of ADHD children to a neurofeedback video game using BCI technology were examined by Blandón et al. [85]. The primary purpose was to provide children feedback based on how their brains are working, promoting self-control and improving focus. Therefore, a group of ADHD children participated by playing the BCI neurofeedback game while using an EEG to track their brain activity. According to the findings, the BCI neurofeedback game illustrated significant improvements in the brain activity of children with ADHD. Utilization of mobile games as a technique to improve behavioral and cognitive results in ADHD children, a scoping study was presented by Jiang et al. [86]. According to them, playing mobile games can increase working memory, retention, and treatment for ADHD patients.
Similarly, researchers in another study [86] created a BCI system that successfully involves ADHD children in a training program based on games to increase their attention abilities. The participants’ EEG signals are captured and analyzed during gameplay sessions to identify attentional states. The results demonstrated the great potential of BCI gaming as a training technique for improving sustained attention in children with ADHD. Improvements in task completion rates and attention performance scores among the participants suggest enhanced sustained attention abilities. The children stated that they were engaged and happy while playing. Some limitations need to be considered for future research: the validity of the assessment is compromised by inadequate study design, small sample sizes, and the lack of a control group diminishes reliability.
Additionally, Understanding the long-term impact is hampered by a lack of follow-up. K Park et al. [87] Introduced a motion sensing and training system that utilizes games and is controlled through BCI for ADHD children. The training system’s creation and design included the result of a virtual world with fantasy features, defining game scenarios requiring focus and motor control, and integrating BCI and motion sensor interfaces. BCI technology was used to track the participants’ attention levels during gameplay sessions, and motion-sensing equipment records their body movements. The results demonstrate gains in motor control precision and attention performance ratings, indicating better motor control and coordination skills.
Using a cybathlete with tetraplegia as an example, Korik et al. [88] investigated the viability and efficacy of BCI training for people with severe motor impairments (as shown in Figure 2). The cybathlete experienced BCI training to participate in the Cybathlon championship (Brain Driver), a competition designed for disabled people using assistive technology to control virtual avatars. The findings indicated significant improvements in cybathlete abilities following the intensive BCI training. With the assistance of the BCI system, the cybathlete successfully participated in the Cybathlon competition, signifying the potential of BCI technology to enable those with severe motor disabilities to participate in gaming activities. However, the classifier, “task vs. relax” (TX), struggles to stay stable after issuing the proper commands and quickly fixing errors. Also, the classifier exhibits higher variability in brain frequency contributions and inconsistent performance between training and competition than other classifiers, resulting in lower accuracy and faster speed. The participation of two tetraplegic users in the BCI race at Cybathlon was also reported by Perdikis et al. [89], an event for disabled people using assistive technology. The study highlighted the significance of improving the BCI system and users’ performance over time, emphasizing the importance of collaborative learning and association between participants and researchers. Both users demonstrated excellent control and completed the race successfully, suggesting promising outcomes.
A popular video game was used in a pilot study by the authors of [90] to help people with Multiple Sclerosis (MS) with sustained attention and executive functioning. MS patients participated in frequent training sessions, including game-based exercises, to improve their cognitive capabilities. The objective was to improve overall sustained attention and mental agility. According to the results, playing video games might help MS patients increase their mental health and quality of life as a cost-effective and efficient cognitive rehabilitation treatment. Some drawbacks were limited sample size, a small follow-up period, minimal control intervention, inadequate cognitive tests, and a possible partial design. More research is required to validate the advantages of cognitive programs at home for MS patients.
A VR avatar to explore the potential of combining BCI technology with VR to assist gait adaptation to changes in visual kinematics was reviewed by [91]. The applicants were trained to study the avatar’s walking pattern and mentally adjust their stride to mirror the changes displayed by the avatar. The findings showed that the applicants successfully changed their walk in response to visual kinematic disturbances affected by the BCI system. The improved walking-to-avatar synchronization recommends that the BCI-mediated VR intervention successfully persuaded gait adaptation. In another study, to evaluate the effects of motor priming in VR, ref. [92] examined the efficiency of motor-imagery training in restorative BCI. The aim was to determine whether combining motor priming with motor imagery training can speed up the recovery of motor function in those who use BCI technology. Accuracy, speed, and smoothness of avatar control are metrics used to assess each condition’s effectiveness. The findings illustrated that when motor-imagery training and motor priming are used together in VR, the results are better than when using motor-imagery training alone. During the combined training conditions, participants display greater precision, quicker and more fluid movements, and enhanced activation in motor-related brain areas. The small sample size of 9 participants may impact statistical power and generalizability.
Further research is needed for validation because stroke patients may not benefit directly from the concentration on healthy volunteers. Only eight electrodes are employed to record EEG data, which limits spatial resolution and enhances the possibility of more accuracy with more electrodes. While interpreting the results, cautiousness is essential. In addition, it highlights the necessity of more significant sample numbers and improved techniques in future research to ensure solid and valuable findings.
The studies by [93,94] examined the viability and efficacy of using EEG signals to steer serious video games created with people with Alzheimer’s and dementia. The objective was to make it possible for people with cognitive impairments to gain something from these games as part of their therapy and cognitive rehabilitation. The therapeutic goals of the severe games included memory enhancement, mental stimulation, and emotional well-being. Participants played while their EEG signals were tracked and converted into game commands. The study showed that people with Alzheimer’s and dementia can successfully interact with serious games employing EEG-based control. This technology can potentially give users a more engaging and accessible experience. The paper presented by [95] introduced a revolutionary mobile healthcare system solution that allows doctors to remotely check on patients’ neurocognitive ability with cognitive impairment and recommend potential therapies. The method employed BCI technology and a semantic-based approach to game adaptation to increase accuracy by learning from the subject’s performance in a game or test. A time-constrained application would benefit most from the system’s ability to rectify the variables that could affect the P300. The study included a limited group of people, which may hamper the generalizability of the findings. The authors conclude that the suggested method is useful for suggesting potential therapies and remotely monitoring the neuro-cognitive processes of people with impairments. However, the accuracy and reliability of EEG signals could produce uncertainties. Moreover, The P300 amplitudes and latencies may need to be interpreted wisely, and various users or physicians may interpret them differently.
Using a BCI in conjunction with deep learning classification and a VR game for neuro-rehabilitation purposes was examined by [96] to determine how well this integrated strategy supported people with neurological impairments in rehabilitation. Participants were instructed to hit the subject. After hitting the issue, the hand or foot movement was imagined and executed successfully. Task performance, functional progress, and subjective input from the participants and their caregivers were metrics used to gauge how well the system worked. The study’s findings show that the BCI-VR system is helpful for neurorehabilitation.
Participant performance on tasks improves, pointing to improved motor or cognitive ability. Pinheiro et al. [97] Introduced a game that simulates a wheelchair to increase wheelchair mobility skills, individuality, and standard of living for people with severe disabilities by managing their virtual wheelchair with input devices like joysticks or adaptable switches thanks to the game’s interface mimicking wheelchair controls. The findings showed the wheelchair simulator game’s potential to teach those with severe disabilities wheelchair mobility techniques. Improvements in task completion efficiency and accuracy among the participants indicate improved wheelchair control. However, the limited spatial resolution of EEG data was a significant restriction that can make it challenging to record and interpret brain activity accurately.
Furthermore, people with severe disabilities might find it challenging to use traditional interfaces like joysticks, which would restrict their ability to use technologies like motorized wheelchairs effectively. Although methods for recognizing patterns in EEG signals have advanced, accurately interpreting various brain signal frequency bands is still tricky. Furthermore, there are risks and ethical issues associated with the use of invasive methods, such as placing electrodes directly on the cerebral cortex.
The research by the authors of [98] described a pilot study on applying a BCI for flight simulation to explore the viability and potential of using BCI technology to operate flight simulations, providing a fresh method for developing pilot abilities. The participant was a quadriplegia patient. The participant was advised to control the flight simulation’s navigation, altitude, and speed, making training more engaging and participatory using brain signals. The results showed that using BCI technology for flight simulation control was technically feasible. However, focusing exclusively on assessing the successful control of dynamic systems restricts the evaluation of the BCI-controlled flight system. The assessment procedure is limited by specific metrics, such as response times of the controlled system and physical constraints, as well as by factors like neural signal reaction times.
Moreover, tests do not account for situations in which the aircraft veers, of course, and require the operator to adjust, which limits the number of real-world scenarios that can be evaluated. In a study by the authors of [99], a specifically designed controller consisting of sensors, switches, or additional inputs controlled by voice commands, breathing control, or body signals was introduced for a quadriplegia person, enabling hands-free video gaming and allowing them to play using alternate control methods. According to the experimental design and evaluation, using a hands-free controller, quadriplegic persons can vigorously participate in video games. Results demonstrated that participants showed keen interest and happiness in interacting with the games and exploiting the alternative control choices presented by the controller. Similarly, to detect flexion and grip, [100] presented a review to assess an electronic device worn on the hand. According to the findings, these devices can potentially improve two aspects of BCI rehabilitation: closed-loop techniques and thorough experimental assessments of hand function.
Botrel, L. et al. presented Brain Painting V2, a P300-based BCI proposed to support imagination using a user-centered design approach [101]. The primary purpose of this study was to evaluate the system’s usability and effectiveness by allowing users to create art with restricted motor control to produce artwork by selecting colors, shapes, and brushstrokes using their brain signals. The results illustrated the inspired and practical creative outlet for people with limited motor control. Using brain signals, participants chose colors and changed their brushstrokes on virtual canvases. The study included only one participant, which affected its generalizability; however, recommending involving more individuals with comparable problems may benefit from the findings, also highlighting the need for more reliable BCI technology for better performances and results. Researchers examined combining interactive games with motion-based interfaces to increase hand rehabilitation and motor recovery in another research [102]. For traditional rehabilitation methods, serious motion-based games were introduced as a feasible substitute, including exercises and activities designed to enhance hand movement, coordination, and accuracy. User feedback surveys and standardized evaluation tools tracked and evaluated participants’ progress. According to the findings, motion-based serious games significantly improved hand-healing performance, range of motion, and functionality. Games’ cooperative and attractive abilities stimulated higher motivation, satisfaction, and healing adherence.
3.1.5. Innovation and Inclusivity in Gaming
An overview of the 2019 BCI Game Jam findings that focused on the Calgary competition’s investigation of kid-friendly gaming possibilities was presented by Kelly et al. [103]. The primary purpose was to provide children with disabilities with engaging and inclusive gaming experiences using BCI technology. Using BCI technology, children operated various game elements using their brain signals, encouraging involvement, creativity, and engagement. According to the outcomes, BCI has the potential in emerging accessible games to improve children’s ability to play. Based on children’s feedback, prototypes created during the match involved advanced and broad aspects such as brain signal control for items or characters, increasing engagement, enjoyment, and promising gaming experiences. The use of gamification techniques to improve motor imagery-based BCI learning was reviewed by [5]. Gamification in BCI applications can enhance user performance and the learning process. According to the review, gamification maximizes the learning level in the BCI approach in the motor imagery tasks. Research has shown that adding interactive aspects and game components to BCI training improves user motivation, engagement, and learning outcomes. Gamification in BCI applications can improve user happiness, speed up training, and improve performance.
Another study examined a BCI-based action observation rehabilitation game to improve the mirror neuron system (MNS) using flickering action video. In this experiment, fifteen healthy participants viewed short video clips of picking a ball, and their EEG data were collected to measure mu suppression (the brain’s way of responding and observing movements, areas related to motor control). The criteria of the game fall into four conditions: flickering video stimuli only (S_only), a game with interactive feedback (G + I), a non-flickering video with a game background (NonF), and a game without interaction (G − I). The results demonstrated significant improvements in the G + I condition as compared to others. The study also suggests using BCI-based games for effectiveness and attentiveness in rehabilitation programs [104].
Moreover, conducting an extensive literature review, Cortes-Perez et al. [105] observed the effectiveness of video game-based therapy using a Leap Motion controller (LMC) for patients with central nervous system (CNS) syndromes. This therapy offers an immersive rehabilitation experience through motion-sensing technology and VR. This systematic review and meta-analysis concluded that LMC video game-based therapy significantly enhanced upper extremity control among patients with CNS disorders. Numerous outcome measures such as mobility, motor function, and activities of daily living exhibited significant improvements. In another study, Wu et al. [106] examined a meta-analysis of randomized controlled trials (RCTs) to evaluate the therapeutic effects of VR games in young patients on balancing abilities with CP. VR games offer modified training and response to improve balance, coordination, and control in virtual environments. The outcomes indicated that playing VR games has the potential to enhance the balancing abilities of kids with CPs.
3.1.6. Synthesis and Implications
According to the surveyed studies, gamified BCIs have drastically improved the quality of life and rehabilitation results for disabled individuals. Gamified approaches provide new opportunities for enhancing motor and cognitive performance across extensive populations through modified and engaging treatments. However, more thorough research is necessary to maximize the efficiency and inclusivity of neurorehabilitation activities by designing and implementing gamified BCIs.
3.2. BMI Applications and Impact on Disabled People
3.2.1. Potential of BMI Technology for Rehabilitation and Functional Restoration
The practical usage of BMI has considerably changed the lives of disabled people [107]. Exciting opportunities for regaining lost talents, strengthening communication, and raising general quality of life are presented by BMI devices, which create a direct connection between the brain and external devices [108]. To enhance the performance of neuroprosthetic arms during grasping. Ref. [109] investigated using a shared control system that combined BMI and vision-guided autonomous robotics. People with tetraplegia who participated in the study moved objects with and without shared control using a robotic arm. The shared control system was designed to balance the intention obtained from BMI and computer help. Objects were recognized, tracked, and defined stable grasp locations by an autonomous robotic grasping system. The study concludes that enhanced performance on object transfer tasks resulted from integrating BMI control with vision-guided mechanical assistance. BMI systems will appeal more to potential users if support is provided while preserving generalizability. However, neuroprosthetic control performance optimization is hampered by the limitations imposed by intracortical BMIs. These restrictions include the restricted number of neurons that can be recorded at once, which would limit the quantity of data available to control the robotic arm, and the gradual deterioration in signal quality, which could compromise the reliability of the BMI control.
An epidural wireless BMI was used in another experiment [110] to demonstrate how a tetraplegic patient might use an exoskeleton. According to the study, people with severe paralysis can restore their motor abilities by using BMI technology. The epidural wireless BMI allowed the patient to control the exoskeleton’s movements, which captured brain impulses from the motor cortex, enabling more directionality and reducing the need for wires. Individuals with paralysis or spinal cord damage may be able to restore their movement and freedom with exoskeletons, representing a significant development in BMI technology.
To implant a motor neuroprosthetic through neuro-interventional surgery using BMI technology to decode brain signals and generate commands for the device, Oxley et al. [111] presented their research. Two patients were included in the study, one with tetraplegia and the other with ALS. According to the results, motor neuroprosthesis makes it easier and safer for severely paralyzed patients to do daily tasks. Also, it is a promising technique that might significantly improve the quality of life of such patients. However, limited sample size may affect generalization, and considering the variety of paralysis causes, it is crucial to apply a consistent methodology for assessing task performance in various situations. Utilizing a fully implanted BCI in an ALS patient who is unable to speak or move was studied by MJ Vansteensel et al. [112]. The usefulness and safety of the implanted BCI for enabling patients to type letters on a computer screen while thinking of communicating was assessed in the study. According to the results, implanted BCI could be beneficial as a long-term treatment for ALS patients and other diseases that severely hinder motor function. The authors emphasize the extended use of these reliable and secure technologies, which considerably improve the lives of severely disabled people.
In another study, using a portable fully implanted BCI on a male patient (21-year-old) with complete cervical quadriplegia, allowing him to acquire voluntary control of hand grasp in the house context was presented by [113]. The technology used the neural signals obtained from the patient’s motor cortex to generate an electrical stimulation device that triggered grasping hands problems to interpret the intended hand motions of the subject. Various functional tasks were performed by patients, such as eating, drinking, and brushing teeth, and the study discovered that the device was secure and reliable for constant use. However, the applicability of the study remains unclear as it focused on one participant only. Therefore, the participant’s difficulty with intricate movements demonstrated that the regained movement was not always functioning. Correspondingly, Cajigas et al. [114] explained how a fully implanted portable BMI was used at home by a male subject, age 21, after a spinal cord injury to acquire a volitional hand grasp with total cervical quadriplegia. The study proved some gains in self-care, pain perception during home use, and the subject’s ability to establish intentional control of hand grasp when using the implantable BCI.
3.2.2. Advancement in Speech Neuroprosthetic for Communication
A remarkable advancement in neuroprosthetics was presented by [115] by allowing a paralyzed person with anarthria (inability to articulate speech) to communicate via a neuroprosthesis. Researchers implanted electrodes into his brain to monitor cerebral activity while the subject tried to talk. The recorded brain impulses were first deciphered using machine learning techniques to produce synthesized speech. This discovery has significant ramifications with the potential to help people with speech impairments regain communication skills. The study demonstrates the potential of neuroprosthetics to restore speech function, providing confidence for people suffering from anarthria and other speech-related syndromes. A similar research study was conducted by [116], focusing on a paralyzed person unable to move or speak. Researchers interpreted neural signals connected to spelling intentions through implanting brain electrodes, and then these decoded signals were used to generate speech through voice neuroprosthesis. The results revealed that participants accurately spelled words and chose letters using voice neuroprosthesis. Users perceive them as less natural compared to using letters, while code words develop neural discriminability. Moreover, since participants must spell at a certain pace, they face restrictions in user control and naturalness.
The system demonstrated remarkable accuracy and flexibility, highlighting the potential of speech neuroprosthetics to help patients with severe speech and quadriplegia regain the ability to communicate through various vocabulary and spelling challenges.
3.2.3. Surgical Interventions and Neurostimulation Therapies
A surgical treatment proposed to restore mobility in people with spinal cord injuries as an outcome of the LION procedure, a case series, was published by the authors of [117]. The LION therapy was conducted on eighteen people, and it involved identifying and activating pelvic nerves to improve lower limb function. The results demonstrated that this method was an efficient therapeutic approach for patients with spinal cord injuries to regain sovereignty and movement. Wagner et al. [118] conducted a study for people with spinal cord injuries with total limb paralysis to restore their ability to walk. The researchers combined non-invasive stimulation technologies with invasive electrodes to target spinal cord regions. According to the study’s outcomes, the training treatment facilitated people restoring voluntary control and coordination of their leg motions combined with specific spinal cord electrical stimulation. Different research scrutinized the application and design of a real-time ECG-controlled neuroprosthesis for paralyzed patients [119]. The participants were the people who had lost their motor abilities due to neurodegenerative disorders like ALS. Artificial intelligence (AI) algorithms and signal-processing techniques were used to interpret brain activity and generate control commands. The results showed the feasibility and practicality of ECoG in real-time BMI to allow paralyzed patients to control external devices retrieved from ECoG signals. Using their brain activity, participants mastered various tasks, such as gripping objects and typing on a virtual keyboard. The study highlighted more research as ECoG-based interfaces’ possible invasiveness and safety risks are not adequately addressed.
A study [120] investigated the possibility of using handwriting to help paralyzed people communicate brain-to-text. Electrodes were surgically implanted in the brain regions of two paraplegic patients to enable hand motions. The brain activities were captured through these electrodes as the patients visualized writing words and letters. Several tests, such as exercises in free speech, spelling, and phrase creation, were considered to evaluate the accuracy and performance of the system while the participant mouthed words. The system created text or sound from decoded data by precisely decoding speech-related brain activity. The machine learning algorithm translated brain signals into text from recorded data. According to the findings, high-performance text input with low error rates was achieved through handwriting-based brain-to-text communication. Moreover, the study emphasizes more research into the advancements of such an approach for more successful results for paralyzed people. However, several limitations were highlighted, such as continuous retraining of the decoder for optimal performance, matching of calibration data online error rates, more extensive and diverse datasets required to train the decoding algorithms and prevent overfitting, and accommodating a large vocabulary size for general use. These limitations need to be addressed to improve efficacy and usefulness.
In research by Bercu et al. [121], the effectiveness of responsive neurostimulation (RNS) as a therapeutic method for drug-resistant focal epilepsy in pediatric patients was observed. In this RNS therapy, six participants (aged 8 to 17) were treated. Even with a small patient cohort, the study showed encouraging results in improving quality of life and reducing medical seizures. According to survey results, implementing responsive stimulation early in conjunction with lowering seizure frequency early may result in notable improvements in cognitive and functional development, ultimately improving pediatric patients’ quality of life. This method is believed to be secure and efficient treatment for children.
Somers et al. [122] presented the cochlear implant fitting method using EEG-based auditory system diagnostics. The study provided a scientifically sound and practical approach for cochlear implant implantation by showing that continuous EEG signals may be recorded from the implanted intracochlear electrode array in humans. Three adults with experimental cochlear implants with percutaneous connectors participated in the trial. The findings showed that this approach might open the door to neuro-steered hearing prostheses and chronic neuro-monitoring of deaf and hard-of-hearing users in their regular listening environment.
3.2.4. Advancements in Assistive Technologies
In a study, Handelman et al. [123] presented a research paper on using BMIs to operate bimanual robotic limbs for self-feeding. The technique of using a BMI for shared control of bimanual robotic arms in the context of self-feeding is described in Figure 3. Based on the ongoing self-feeding job, a collaborative control method is used to map these decoded movements onto the degrees of freedom of the robotic arms. In addition to the participant performing semi-autonomous tasks, robotic limbs may perform specific tasks independently. With these semi-autonomous tasks, they can direct their attempted motions to control a particular portion of the limb’s movement. In this study, subjects with specific spinal cord injuries fed themselves using a robotic arm with several moving elements controlled by the brain. They could chop their food, take up a fork and knife, and carry it to their mouths with the assistance of this robotic arm, as shown in Figure 4. The 49-year-old male participant in the study used a collaborative approach to control. Electrodes (NeuroPort) were inserted into their brains’ left and right sides to track brain activity and make this possible. The findings demonstrated that the robot’s behavior might be adjusted to match the user’s intent thanks to the shared control strategy. The BMI user could effectively accomplish the task with high precision and efficiency.
3.2.5. Long-Term Evaluation of Prosthetic Devices
Yue et al. presented a durable investigation of the outcomes of a blind patient who had chronic implantation with the Argus I epiretinal prosthesis (a device for restoring some vision for people with severe retinal degenerative illnesses) [124]. Patients’ visual insight, functional vision, and general health over ten years were comprehensively examined, providing information about visual performance through several visual tests, such as visual acuity, object recognition, and motion awareness. The ten-year follow-up results showed that the Argus I prosthesis improved the patients’ visual perception and functional vision, and they could recognize giant letters, find objects, and detect movement. However, protocol alterations during the study and difficulties compared with prior data may hinder practical analysis. Furthermore, a lack of ability to evaluate the stability of movement and orientation functions due to the lack of previous data restricts our ability to comprehend long-term results.
3.2.6. Baseline, Experimental Design, and Ethical Considerations
In this paper, some studies used conventional methods for stroke rehabilitation while experimental groups followed gamified BCIs, enabling researchers to evaluate the efficacy of gamified interventions [69]. Other studies adopted different methodologies, such as comparing the neurorehabilitation outcomes of both healthy participants and disabled people. Control groups are essential in comparing the effectiveness of BCIs and BMIs with traditional systems, allowing researchers to assess the usability of gamified methods and establish performance benchmarks [70]. Furthermore, by highlighting gamification, some studies compare the results of user engagement and performance using gamified and non-gamified BCIs [57,58].
Baseline metrics are vital in evaluating the results objectively. This paper deploys various metrics, such as motor function score, to assess the effects of gamified interventions with conventional techniques [69,79,84,93,125]. Some studies evaluated the efficiency of gamified BCIs with traditional methods using time taken to complete motor tasks [86,97], while other studies used error rates to measure the accuracy and reliability of gamified BCIs [35,120]. Surveys were utilized in different studies to assess user satisfaction and engagement in gamified environments [102,121]. Moreover, cognitive performance metrics were deployed by some studies to improve memory, attention, and problem-solving skills in gamified BCIs for ADHD and neurorehabilitation environments [38,86,87,126].
This comprehensive review employed well-structured control groups and utilized vigorous baseline metrics to measure the accuracy and efficiency of gamified BCIs and BMIs. Furthermore, all studies followed strict ethical guidelines to ensure the safety of participants obtaining informed consent from participants. Researchers highlighted user privacy and safety by implementing secure data protocols, obtaining institutional approval, and providing open communication with participants.
Table 2A comprehensive overview of gamified BCI and BMI advances for disabilities.
| No. | Methodology | Main Findings | Limitations | Ref. |
|---|---|---|---|---|
| 1 | BCI is an innovative technology that allows the human brain to communicate with computers and other electronic devices without using the usual brain information output pathways. | Thanks to it, patients with significant motor impairment may find interacting with the outside world more accessible. | Using BCI-VR, the transmission rate of EEG signals needs to be improved. | [71] |
| 2 | A game-based environment for post-stroke upper limb rehabilitation was created. | The results showed that gamified rehabilitation enhanced the participants’ experience, making treatment more enjoyable. | The small sample size used in the study and age differences between groups may impact generalizability. | [70] |
| 3 | The effectiveness of BCI training for a cybathlete with tetraplegia was examined. | Cybathletes showed significantly better results due to extensive BCI training. | The BCI system regulates when commands are issued using the “task vs. relax” (TX) classifier. | [88] |
| 4 | A jigsaw puzzle game for CP patients was presented. | Findings showed positive effects of the game, which effectively encourages user involvement and enhances cognitive and motor skills in BCI training. | Although the patients accepted the technology, the data quality was lacking. | [80] |
| 5 | A flight simulation was developed to explore the viability and potential of using BCI technology to operate flight simulations for a quadriplegia patient. | The results showed that using BCI technology for flight simulation control was technically feasible. | Focusing exclusively on assessing the successful control of dynamic systems places limitations on evaluating the BCI-controlled flight system. | [98] |
| 6 | A game-based training program in a BCI system was created for children with ADHD to improve their attention abilities. | The findings showed that BCI gaming is a potential training tool for enhancing attention in ADHD children. | Assessment validity is compromised by inadequate study design. | [126] |
| 7 | A unique error-monitoring gamified BCI to increase cognitive and behavioral flexibility in people with ASD was evaluated. | The gamified interface can be a useful therapeutic tool for people with ASD. | As so few people participated, it is difficult to determine whether the findings apply to everyone. | [74] |
| 8 | A P300-BCI game, Brain Painting V2, was created for people with limited motor control. | The game proves to be a valuable and practical creative activity. | The results might not apply to others because only one person was studied. Therefore, the findings may benefit people with conditions identical to the participants. | [101] |
| 9 | The implantation of a motor neuroprosthetic through neuro-interventional surgery was presented. | Motor neuroprosthesis could help people do daily activities more safely and effectively. | It is difficult to generalize the results due to the small number of participants. | [111] |
| 10 | A voice neuroprosthesis was used for a paralyzed person who could not speak or move their limbs to produce speech using the decoded neural signals. | Neuroprosthesis allowed the participant to choose letters using brain impulses to spell words correctly. | While code words improve neural discriminability, users find them less natural when using them instead of letters. | [116] |
| 11 | A portable, fully implanted BCI allows patients with total cervical quadriplegia to regain voluntary control of the hand. | The patient could perform several functions, like eating, drinking, and brushing teeth. | It is unclear whether the study’s conclusions apply to others because it only looked at one subject. | [113] |
| 12 | A controlled neuroprosthesis was developed for ALS patients. | It is feasible and practical to let paralyzed patients operate external devices. | Given the narrow focus on patient populations, such as ALS patients, there are concerns regarding the generalizability of the results. | [115] |
| 13 | A thorough examination of a blind patient who had chronic implantation was presented. | A ten-year follow-up showed that the patient’s visual perception and functional vision were enhanced. | The results can only be applied to a smaller group based solely on one case report. | [124] |
4. Discussion
The potential for improving the learning outcomes and experiences of disabled individuals through the integration of gamified BCI and BMI technologies is enormous as described in Table 2. Traditional neurological disease rehabilitation techniques frequently involve inactive participation, which results in laborious, repetitive processes with unpredictable outcomes. By incorporating game principles and interactive feedback mechanisms, gamified techniques address these limitations by promoting improved user engagement, motivation, and skill learning [127]. Although gamified BCI and BMI technologies are gaining popularity, few comprehensive evaluations concentrate on these topics. Though several studies have explored the use of BCIs in neurorehabilitation, especially gamified BCIs, there are not many systematic reviews that discuss how BMIs are used by people with disabilities [128]. The aforementioned highlights the necessity of concerted efforts to gather and examine the abundance of information and data on BMI functions, difficulties, and prospective innovations within disabled groups [129].
A crucial aspect of our discussion is the possible influence of gamified BCI and BMI technologies on enhancing the results of neurorehabilitation for people with disabilities. With the use of immersive VR environments and robot therapy (RT) applications, recent developments in BCI technology, such as movement-related cortical potential (MRCP)-based systems, offer promise for improving motor function rehabilitation [125]. An illustrative study conducted between 2001 and 2020 investigated the training viability of a gamified, noninvasive motor imagery (MI)-brain–computer interface (BCI) system. The study achieved an average accuracy of 74.35%.
Furthermore, in a systematic investigation, ref. [12] examined the advanced pediatric BCIs, focusing on evolving innovative technologies to help kids and teenagers with low physical dexterity or communication issues. The information was collected between 2008 and 2020 to create guidelines for pediatric BCI clinical translation. In enhancing the functioning and rehabilitation of individuals with disabilities, a different study examined integrating VR systems with BCI programs. Data between 2000 and 2018 was compiled, and an analysis was offered, contrasting VR-BCI with traditional BCI methods [71]. Similarly, a systematic review (2002 to 2022) presented an overview of non-invasive hand-worn devices for rehabilitating hand functions [100].
The presented comprehensive review covered the unexplored topic of the use of gamified BCIs and BMIs for people with disabilities. This study aimed to explore assistive technology and neurorehabilitation treatments for disabled people further after analyzing data from several sources from 2015 to 2024. Our primary objective was to fully understand the unexploited potential of gamified BCIs and BMIs to increase the quality of life for disabled individuals.
Gamified BCIs and BMIs showed more significant potential as innovative assistive technologies in improving the lives of disabled victims significantly [17,18]. Adding video game principles and components enhances user motivation, engagement, and skill acquisition. These technologies provide a more effective, engaging, and therapeutic platform by providing an immersive and interactive environment for exploring and interacting with their surroundings [55].
Most studies showed that gamified BCIs for motor imagery tasks can significantly increase motor skills and memory [34]. In contrast, VR-based gamified systems can reduce mental fatigue and enhance concentration during training sessions [130], enabling users to track their performance and make necessary adjustments. In a similar vein, BMIs can improve rehabilitation results and motor function. In a BMI system for upper limb rehabilitation, users can mimic real-world actions, including reaching, grabbing, and handling things [87,91]. Users may also engage with a virtual environment and obtain real-time performance feedback by modifying their brain signals. This method promotes the development of motor skills and applying such abilities in practical settings. Integrating gamification into assistive technologies provides faster skill development and significantly encourages users to improve motor and cognitive recovery for disabled individuals [131].
Increasing user engagement is one of the main advantages of gamified BCIs and BMIs [53]. Traditional rehabilitation approaches reduce compliance and motivation levels as repetitive and tedious activities characterize them. Furthermore, new learning skills are developed in disabled people using gamified BMIs and BCIs by participating in game-based activities to improve their motor and cognitive abilities, allowing users to monitor their performance and make essential modifications through the real-time feedback provided by these systems. The iterative learning and adaption process is highly needed to enhance functional recovery and brain plasticity for disabled individuals [132].
The gamification approach provides various applications in BCIs, including cognitive training, better motor control, and improved communication. As proven by [133], disabled people were given a user-friendly platform that aided their learning and skill development. The combination of game-based treatment with BCI technology provides a novel approach to rehabilitation and skill development for people with impairments, assisting them in improving their learning experiences and overall quality of life [134]. Using a gamified BCI communication system, users may train their brain impulses to control the selection of letters or words from a virtual keyboard. These strategies allow us to communicate successfully without utilizing regular speech. The UI is meant to resemble a game and contains feedback systems, which enhances learning by making it more exciting and user-friendly [102]. Furthermore, gamified BCI helps disabled people enhance their action observation (AO), a technique to improve and increase the rehabilitation results in patients with stroke. According to the study, the BCI-AO game paradigm with peripheral electrical stimulation (PES) has shown significant effects in the motor-evoked potential for rehabilitation purposes, especially for stroke patients [135,136,137].
Gamified BCIs and BMIs may resolve some of the issues with conventional rehabilitation techniques. Not every traditional therapy is inspiring or customized for each patient. User engagement and motivation can be enhanced by integrating interactive gaming elements such as real-time feedback, rewards, and challenges. On the other hand, these technologies provide distinct and adaptable experiences to improve learning and offer a more personalized approach to rehabilitation by monitoring user performance and adjusting game features accordingly. Furthermore, by introducing game features such as challenges, rewards, and interactive feedback, gamified BCIs, and BMIs can enhance excitement and satisfaction in rehabilitation sessions [66,67]. Two critical outcomes for enhancing neurorehabilitation are increased engagement in neurorehabilitation, which results in longer therapy sessions, and increased motivation levels [138]. Thus, gamified BCIs and BMIs have significant potential for enhancing learning and rehabilitation using personalized feedback with user-centric design moralities [139].
However, these approaches may have some limitations that must be addressed for better performance and results. Ensuring reliable and precise signal processing is a significant challenge when real-time feedback is involved. Improved hardware and signal processing methods are required to guarantee accurate signal processing in the presence of noise and interference [34,37,48]. Moreover, to develop user-friendly interfaces and game elements to accommodate a variety of disabilities, careful consideration of individual preferences, user-centered design strategy, and cognitive capacity are mandatory [103].
Individual preferences, mobility restrictions, and cognitive ability should be considered carefully during the design phase. User-centered design techniques for gamified BCIs and BMIs must be used to manage accessibility and alignment with the requirements and capabilities of individuals with disabilities [140,141]. Additionally, ethical considerations should be considered when developing and implementing gamified BCIs and BMIs. Privacy and security should be addressed when working with neurological data to avoid unauthorized access to private data. Evaluating the possible effects of gamified BCIs and BMIs on user autonomy and decision-making requires users’ control over their interactions and experiences [142].
In summary, gamified BCI and BMI technology can significantly improve disabled people’s lives and revolutionize neurological rehabilitation. These technologies offer a practical approach to enhancing learning outcomes and promoting independence among disabled people by providing modified rehabilitative experiences, increasing user engagement, and supporting skill development. However, technical obstacles and ethical problems need to be overcome to realize the potential of these approaches in the realm of assistive technology.
5. Conclusions and Future Work
The presented CR examined the impact of gamified BCIs and BMIs on people with disabilities, highlighting the potential of these technologies for neurorehabilitation and skill development. Gamification can significantly expand opportunities for those with disabilities through participation, customization, and immersive rehabilitation experiences.
This study presents strong proof of the transformative potential of gamified neurotechnologies, demonstrating significant improvements in speech, motor abilities, and cognitive function of disabled people. The gamified method offers continuing evolution and improved results by increasing the satisfaction of rehabilitative activities and promoting regular and reliable use. However, recognizing the drawbacks of this research is still very important. We may not have included all necessary research in our review, given the fast advancement of gamified BCIs and BMIs. Moreover, the study might have included bias or missed some research, which could have affected the overall results during the selection process criteria and search techniques. Further research and development in various sectors will also be required.
BCIs face challenges due to noise and unpredictability in brain signals despite progress, which highly affects the system’s reliability. For increasing the overall performance of gamified BCIs and BMIs, improved accuracy and giving real-time feedback through enhanced signal processing techniques should also be considered by developing advanced signal processing algorithms, improving real-time data interpretation, and minimizing latency for rehabilitation sessions. Considering a wide range of individual preferences and limits, user interfaces must be developed with accessibility to assure inclusiveness.
Moreover, comprehensive research is necessary to study the long-term impact of gamified BCIs and BMIs on neurorehabilitation results and overall quality of life. Traditional BCI and BMI systems fail to provide engaging, immersive gaming experiences that maintain users’ focus. More dynamic, personalized, and adaptive gaming environments must be considered for future developments to increase motivation and engagement. Careful consideration of ethical problems such as user privacy and data security is required for protecting sensitive brain signals while retaining user autonomy. Additionally, the publication lacks a specific part to discuss gaps or limitations in the present state of research. Highlighting the review’s contribution to the field and recognizing areas that need further investigation by addressing these gaps and challenges through collaborative research projects with scientists, medical specialists, and people with disabilities is crucial.
One of the most significant challenges to overcome is ensuring the availability of these systems at home. Many systems are restricted to laboratories or clinical settings. Portable, affordable, and user-friendly systems should be developed for implementation at home to be easily accessible to the user during daily activities. Furthermore, the integration of BCI and BMI with other modalities, such as VR and AR, is underutilized. Future research should focus on integrating multiple modalities to improve comprehensive rehabilitation results.
Furthermore, they integrated gamified components into invasive BMIs to address user adaptation and device stability while increasing user engagement and control. This approach promises a new path for advancing neurotechnologies. Intuitive gaming situations can maintain long-term motivation and cognitive engagement, while adaptive learning strategies supporting players’ brain signals can potentially enhance skill development. For stroke or accident recovery, gamified invasive BMIs may offer high potential in rehabilitation perspectives, providing motivating platforms that socially engage BMI users by playing cooperative and competitive games. However, to make these gamified interfaces practical, properly sound, and user-focused, long-term usability, user-centric design, and ethical concerns should be considered in the future.
To conclude, it has been observed that gamified BCIs and BMIs have a high potential to transform assistive technology by allowing disabled people, encouraging self-confidence, and improving general health. These innovative methods can address problems such as mobility restrictions and communication difficulties encountered by people with disability and revolutionize the traditional rehabilitation process into stimulating and engaging experiences by integrating gamification ideas. These technologies have diverse effects on people rather than on a particular one. Gamified BCIs and BMIs influence society’s opinions about disability by highlighting its strength and potential, which encourages those people to live everyday lives and allows them to adjust to society.
This paper focuses explicitly on integrating gamification into BCIs and BMIs to address cognitive and motor recovery for disabled individuals. Although previous studies focus on the technical advancements of BCIs and BMIs, this paper emphasizes how gaming elements such as rewards, real-time feedback, and adaptive challenges increase user engagement and satisfaction during therapeutic sessions. Furthermore, this paper provides a comprehensive review of implementation challenges, highlighting the recent developments of gamified neurorehabilitation systems. This paper offers innovative perspectives on increasing accessibility and efficacy for people with disabilities.
Conceptualization, B.A., S.K., H.L. and J.K.; methodology, B.A., S.K. and H.L.; software, B.A. and J.K.; validation, B.A., S.K., H.L. and J.K.; formal analysis, S.K. and J.K.; investigation, B.A., S.K. and J.K; resources, B.A. and H.L.; data curation, B.A. and J.K.; writing—original draft preparation, S.K.; writing—review and editing, B.A.; visualization, H.L. and J.K.; supervision, J.K.; project administration, B.A. and J.K.; funding acquisition, J.K. All authors have read and agreed to the published version of the manuscript.
The gathered research data used and/or analyzed for this study are available at reasonable request from the corresponding author. The data are not publicly available due to privacy.
The authors declare no conflicts of interest. The funders had no role in the design of the study, the collection, analysis, or interpretation of data, the writing of the manuscript, or the decision to publish the results.
Footnotes
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Enlarge this image.Figure 1. A visual representation of the study selection process from registered databases using the PRISMA statement.
![View Image - Figure 2. A participant with tetraplegia: (a) displays gameplay driven by BCI; (b) displays the Cybathlon Event game [88].](https://media.proquest.com/media/hms/THUM/4/ZAVYb?_a=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%2BgIBWYIDA1dlYooDHENJRDoyMDI1MDQzMDA1NDIwMTMxNDozNzk1Mjk%3D&_s=q2ZbR3lj%2BduSUFhdBX2xFSBeQjg%3D "View Image - Figure 2. A participant with tetraplegia: (a) displays gameplay driven by BCI; (b) displays the Cybathlon Event game [88].")
Enlarge this image.Figure 2. A participant with tetraplegia: (a) displays gameplay driven by BCI; (b) displays the Cybathlon Event game [88].
![View Image - Figure 3. A schematic representation of BMI-assisted shared control for bimanual robotic arms in self-feeding tasks. (A) Two robotic limbs are controlled by BMI using brain inputs, utilizing cooperative strategies to accomplish coordinated bimanual activities during self-feeding tasks. (B) Electrode arrays (NeuroPort) are surgically inserted into the left and right hemispheres’ somatosensory and motor regions to record neural activity. (C) To enable the smooth operation of the robotic arms, cortical implant-derived brain input is analyzed and decoded to retrieve pertinent information [123].](https://media.proquest.com/media/hms/THUM/6/ZAVYb?_a=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%2BgIBWYIDA1dlYooDHENJRDoyMDI1MDQzMDA1NDIwMTMxNDozNzk1Mjk%3D&_s=e5k4viQSq04EzgkTACyH4OT0e%2BA%3D "View Image - Figure 3. A schematic representation of BMI-assisted shared control for bimanual robotic arms in self-feeding tasks. (A) Two robotic limbs are controlled by BMI using brain inputs, utilizing cooperative strategies to accomplish coordinated bimanual activities during self-feeding tasks. (B) Electrode arrays (NeuroPort) are surgically inserted into the left and right hemispheres’ somatosensory and motor regions to record neural activity. (C) To enable the smooth operation of the robotic arms, cortical implant-derived brain input is analyzed and decoded to retrieve pertinent information [123].")
Enlarge this image.Figure 3. A schematic representation of BMI-assisted shared control for bimanual robotic arms in self-feeding tasks. (A) Two robotic limbs are controlled by BMI using brain inputs, utilizing cooperative strategies to accomplish coordinated bimanual activities during self-feeding tasks. (B) Electrode arrays (NeuroPort) are surgically inserted into the left and right hemispheres’ somatosensory and motor regions to record neural activity. (C) To enable the smooth operation of the robotic arms, cortical implant-derived brain input is analyzed and decoded to retrieve pertinent information [123].
![View Image - Figure 4. Images showing the process of self-feeding. A knife is attached to the robotic left hand, while a fork is held in the right hand. (Step 1) The task begins when the user activates the robot’s right hand. (Step 3) Users can align with the intended food item by moving the fork horizontally [123].](https://media.proquest.com/media/hms/THUM/8/ZAVYb?_a=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%2BgIBWYIDA1dlYooDHENJRDoyMDI1MDQzMDA1NDIwMTMxNDozNzk1Mjk%3D&_s=dWKeIyJ1%2B88PnRoHq4ZI3gdwBWM%3D "View Image - Figure 4. Images showing the process of self-feeding. A knife is attached to the robotic left hand, while a fork is held in the right hand. (Step 1) The task begins when the user activates the robot’s right hand. (Step 3) Users can align with the intended food item by moving the fork horizontally [123].")
Enlarge this image.Figure 4. Images showing the process of self-feeding. A knife is attached to the robotic left hand, while a fork is held in the right hand. (Step 1) The task begins when the user activates the robot’s right hand. (Step 3) Users can align with the intended food item by moving the fork horizontally [123].
Quality appraisal criteria.
| Criteria | Not to | Some | Good Mention (2) | Extensive Mention (3) |
|---|---|---|---|---|
| Criteria for Qualitative Studies | ||||
| Study methodologically is clear | 1 | 4 | 9 | 3 |
| Study theoretically substantiated | 2 | 5 | 6 | 4 |
| Ethical process transparent | 6 | 6 | 4 | 1 |
| The researcher(s) relationship with the participants is clear | 4 | 5 | 6 | 2 |
| Researchers’ relation to the data is clear | 3 | 7 | 5 | 2 |
| Researchers take a critical stance toward their research | 5 | 7 | 3 | 2 |
| Congruence between methodology and methods used for data collection, analysis, and interpretation | 4 | 8 | 3 | 2 |
| Participant involvement in data interpretation | 6 | 7 | 3 | 1 |
| Limitations voiced | 4 | 8 | 4 | 1 |
| Criteria for Quantitative Studies | ||||
| Is the source population or source area well-described? | 2 | 6 | 5 | 4 |
| Were interventions and comparisons well-described? | 1 | 7 | 6 | 3 |
| Were outcome measures reliable? | 3 | 5 | 6 | 3 |
| Were outcomes relevant? | 2 | 7 | 5 | 3 |
| Were the analytical methods appropriate? | 1 | 6 | 7 | 3 |
| Are the study results internally valid (i.e., unbiased)? | 2 | 5 | 7 | 3 |
| Are the findings generalizable to the source population? | 3 | 6 | 5 | 3 |
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; Khan, Sumbal 2 ; Lim, Hyunmi 1
; Ku, Jeonghun 1 1 Department of Biomedical Engineering, Keimyung University, Daegu 42601, Republic of Korea;
2 Department of Computer Science, Capital University of Science & Technology (CUST), Islamabad 45740, Pakistan;