Content area
Background
Serious games and gaming are increasingly used as therapeutic interventions in the rehabilitation of the upper extremities (UE) among individuals with musculoskeletal (MSK) conditions.
Purpose
To describe and summarize the characteristics of gaming technology used for UE rehabilitation of MSK conditions.
Study Design
Scoping review.
Methods
We searched four databases. Three reviewers screened articles and included articles that i) had at least one participant with an MSK condition, ii) used a gaming intervention, and iii) focused on UE rehabilitation, indicated by using an UE outcome measure. Reviewers extracted data on the study, patient, and gaming characteristics, and descriptively summarized the data. Stakeholder consultations were conducted with experts and therapists to receive feedback on the results and on reporting them.
Results
We included 41 articles. Gaming technology was reported to have participation (eg, to motivate, increase adherence) and therapeutic (eg, improving range of motion, muscle strength) benefits. The conditions included fractures ( n = 8), amputation ( n = 8), arthritis ( n = 5), shoulder impingement syndrome ( n = 3), hand injuries, etc. Gaming technologies such as Myo ( n = 4), Leap Motion ( n = 4), Nintendo Wii ( n = 4), Kinect ( n = 6), and Oculus ( n = 5) were frequently used. Gaming was used as an adjunct in 49% of the articles and as a standalone intervention in 51%. Joint range of motion and muscle power were commonly evaluated, along with other constructs related to activities, participation, quality of life, compliance, and adherence. Limitations of gaming technology were related to the technology, hardware, games, therapeutics, and costs.
Conclusions
A variety of gaming technology has been used for UE rehabilitation of MSK conditions. This review summarizing the characteristics of these gaming technology can help therapists and researchers make decisions on which ones to use, although some may be currently unavailable.
Introduction
Musculoskeletal (MSK) conditions are typically characterized by limitations in movement, dexterity, and pain influencing functioning and participation. 1 Gaming technology is increasingly used in the conservative management of the upper extremities (UE) among individuals with MSK conditions. Gaming, gaming technology, or commercial games refer to games created primarily for entertainment but retrofitted with another use, for example, a therapeutic purpose. In contrast, serious gaming refers to games that have been created primarily for a purpose other than pure entertainment, for example, purpose-designed virtual environments for therapeutic use. 2 In this article, we use the term gaming to refer to any games used therapeutically (inclusive of both games created with, ie, serious games, or without a therapeutic purpose, ie, commercial gaming) in rehabilitation. 2 Evidence from a scoping review supports that gaming technology has a positive effect on pain relief, joint mobility, and motor functions among people with chronic MSK conditions. 3 Clients also reported high motivation and satisfaction because they can interact and engage with gaming technology through a variety of mechanisms such as mouse, joystick, cameras, sensory, or haptic (touch) feedback devices, and receive feedback through visual display, hearing, touching, movement, and balance. 3
Extensive research and reviews have been conducted on the efficacy of gaming technology in UE neurorehabilitation, 4 particularly in individuals with cerebral palsy, spinal cord injury, 5 Parkinson's disease, 6 and especially stroke. 7,8 Systematic reviews on MSK conditions do not report on characteristics of the gaming technology 3,9,10 or focus only on a specific type of technology (eg, Tokgöz et al 11 and Lin et al 3 report only on virtual reality [VR] gaming interventions). Though Steiner et al 12 and Koutsiana et al 2 provide detailed information on the characteristics of gaming technology, they have a narrow focus on MSK conditions of the shoulder and serious games, respectively. 12 Hence, there are gaps in the literature syntheses regarding the characteristics (eg, the type of hardware and software used, specific games played, intervention intensity, frequency and duration, and clinical settings) and different types of gaming technology used for rehabilitation of MSK conditions. Thus, to address these gaps, this scoping review aims to describe and summarize the characteristics of gaming technology used for UE rehabilitation of MSK conditions. By synthesizing the available evidence, this review will contribute to a deeper understanding of the practical application of gaming technology, ultimately informing clinical practice and future research directions.
Methods
To answer the research question, we followed the six-step Arksey and O'Malley framework for scoping reviews and the PRISMA_Scoping Review flowchart. 13,14
Stage 1: Identifying the research question
The research question guiding this review is “What are the characteristics of gaming technology used for UE rehabilitation of MSK conditions?”.
In this review, we are using the World Health Organization’s definition of MSK conditions, which refers to conditions that affect any anatomical areas or structures in the UE (eg, fractures, peripheral nerve injuries, repetitive use injuries, postsurgical repairs, etc), as well as conditions involving multiple body areas or systems (eg, generalized weakness in fibromyalgia, weakness following surgical removal of cancerous tissue) that result in limitations in dexterity and overall functioning of the UE. 1 We chose this definition because it is broad and captures conditions with an MSK-level impairment without a central nervous system involvement. The UE includes the areas and related anatomical structures of the shoulder, elbow, forearm, wrist, and hand complex. The term gaming interventions covers all types of games that use technology and have a user interface, such as VR, augmented reality (AR), video games, and mobile games with health applications (mHealth). VR games include games that simulate the real world in three-dimensional virtual environments using computer graphics. 2 AR games refer to games showing a real environment where some objects are enhanced by computer-generated perceptual information or games with a virtual world that includes a real limb of the user (eg, capturing the upper limb using cameras). 2 Video games refer to two-dimensional games, and mHealth apps are health applications that can be used on a mobile phone or a tablet. 2
Stage 2: Identifying the relevant studies
An initial search was conducted in February 2022, and the search was updated in September 2023 and November 2024. The search strategy was developed through an iterative process with the research team (one senior researcher in MSK conditions, one researcher on hand therapy, two graduate students with a background in physical therapy, and one graduate student with a background in occupational therapy) and a health sciences librarian. The initial and the updated search strategies are provided in Appendix A. We searched four databases (Medline Ovid, Embase, CINAHL, and PubMed). No year limits were set in the initial search in 2022.
Step 3: Selection of studies
Two independent reviewers screened the titles and abstracts, and those that met the criteria were advanced to full-text review. A third reviewer resolved conflicts. The research team iteratively developed the selection criteria in
Step 4: Charting the data
We extracted information on the study (eg, author, year of publication, country, aim, and study design) and participant (eg, diagnosis, age range, sex, and gender ratio) characteristics, evaluation (eg, outcomes, time points of assessment), the intervention provided (eg, purpose, frequency, and duration) and details on gaming (eg, characteristics, hardware, software, games, number of players, availability, and patient feedback), and the use of reporting guidelines such as (Consensus on Exercise Reporting Template [CERT] and Template for Intervention Description and Replication) by authors.
Step 5: Collating, summarizing, and reporting the results
We performed descriptive analyses of both numerical and thematic data. We descriptively summarized the extracted information on the study and participant characteristics using numerical summaries such as percentages, frequencies, and counts. The gaming characteristics were analyzed thematically, and the results are reported based on existing classifications for gaming technology.
Step 6: Stakeholder consultation
Stakeholder consultations are important for scoping reviews conducted for knowledge users such as clinicians. 17 Two virtual stakeholder consultations were conducted with committees from a tertiary hospital in Ontario, Canada, with the intention of obtaining feedback on the results and recommendations on ways to report the results. These committees comprised six bioengineering experts and eight clinicians working with individuals with MSK conditions. We presented preliminary results to the two committees, discussed the relevance of the results for clinicians, and received feedback on reporting the results. The preliminary results included data on the participant characteristics, study characteristics, and the gaming characteristics (eg, game type, duration, etc). During the meeting, we also discussed multiple ways to categorize the information for the infographic summarizing the gaming technology (eg, based on the anatomical area affected, rationale for using gaming technology, diagnosis, or a tree for each gaming software). We chose not to categorize the games based on the impairments or functions addressed by the gaming intervention, as the authors of the included articles did not often explicitly state it, and would require making assumptions on what they intended to target. Due to multiple constructs and corresponding outcome measures being used in each article, summarizing based on this criterion was difficult as well. Due to the variety in gaming hardware and software, using these features as a starting point would result in numerous infographics. Hence, we made the decision to broadly categorize based on the areas involved and related anatomical structures, as this information was more often mentioned by the authors or could be easily ascertained from the diagnosis. The stakeholders requested information on the features of games that were reported in the articles to help them make decisions on which games to use. They also recommended providing information on what the game requires the client to do or the requirements for success, what the game achieves from a clinical standpoint (such as improving sensation, isolation of movement, range of motion, and proprioception). The bioengineering experts added that identifying these features could help implement them in games on other platforms if the existing hardware became obsolete. We did not present the infographics back to these committees for further feedback.
Results
We screened 7890 abstracts, 240 full texts, and included 41 articles.
18-57 The Preferred Reporting Items for Systematic Reviews and Meta Analysis_Scoping Review flow diagram is provided in
The stakeholders’ suggestions were incorporated into the reporting and presentation of results. For the infographic (
As rightly noted by the stakeholders, often the choice of which gaming technology to use is also mediated by the hardware, software, and games available to the clinician in the rehabilitation setting. As the stakeholders described their experiences with the hardware being obsolete by the time it is implemented in clinical settings, we checked the availability of the gaming technology reported by the included articles. The Kinect, Leap Motion, Wii, and Oculus Rift that have been used in the included articles have been formally discontinued by their developers and therefore might not be compatible with the newer consoles. Oculus Meta Quest 2 and Myo are commercial gaming devices that are still available. We also summarized some of the commonly seen games and their features in a table.
Study characteristics
Among the included articles, there were six (17%) each from Turkey, the United Kingdom, and India, four (11%) from Italy, three from the United States, and two each from Taiwan, Brazil, the Netherlands, and Spain. Other articles were from China, Hong Kong, Malaysia, Austria, Pakistan, Germany, and Romania. One study was a multisite study with participants recruited from Sweden and Slovenia. 28
The earliest included article was published in 2007 ( n = 1). Most of the articles were published in the last 5 years, with the highest number in 2020 ( n = 7), followed by 2021 ( n = 6), and five articles each in 2024, 2022, and 2019.
Characteristics of participants
Among the included articles, fractures (eg, of distal radius) were the most seen diagnosis ( n = 8), followed by amputation (including joint disarticulation) and related sequelae like phantom limb pain ( n = 8), arthritis (juvenile idiopathic arthritis, n = 3; rheumatoid arthritis, n = 2), shoulder impingement syndrome ( n = 3), and upper extremity weakness following breast cancer ( n = 2). Other diagnoses included fibromyalgia ( n = 1), sarcopenia ( n = 1), osteopenia ( n = 1), traumatic hand injury ( n = 1), atraumatic shoulder instability ( n = 1), post-Carpal tunnel syndrome surgery ( n = 1), humerus tuberosity symptoms ( n = 1), acromioclavicular joint sprain ( n = 1), and rotator cuff injury ( n = 1). Six articles included a mix of participants with different diagnoses, such as rheumatoid arthritis, fractures, osteoarthritis, joint dislocation, tendinopathy, hand injuries, etc. About 63.4% of the articles had adult participants, 14.6% were pediatric (<18 years), 5% had both adults and children, and 17% did not report the age of their sample.
Appendix B provides information on the sex of the participants in the included articles. Thirteen articles did not report the sex or gender of the participants. 21,24,28,33,38,41,45,49,51-53,55,56 Also, the terms relating to sex (eg, male, female) and gender (eg, man, woman) were used interchangeably in the included articles.
Study design and intervention features
Study design
Among the included articles, randomized controlled trials (RCTs) were the most frequent ( n = 17; 13 RCTs, 1 multicenter RCT, 2 pilot RCTs, and 1 pilot crossover RCT), followed by prospective trials with two groups ( n = 12). Three articles had single-group pre-post-intervention designs; four articles were case reports, and two were observational studies. Other included articles were an observational retrospective study, a validation study, and a feasibility study.
Rationale
Most articles described the therapeutic benefits of using gaming technology, and the benefits of participation, which are provided in
Outcomes evaluated
The constructs evaluated based on International Classification of Functioning, Disability and Health and the respective outcome measures used in the included articles focused on body functions (eg, joint position sense, and range of motion [ROM]), body structures (eg, skeletal muscle mass), activities (eg, patient-rated wrist evaluation, functional independence measure), participation (eg, Canadian Occupational Performance Measure), and quality of life (QOL) (eg, Short Form 36 [SF-36]). Some of the included articles also evaluated compliance and adherence to therapy using patient logs, diaries, tracking on gaming software, and qualitative questions or surveys. The authors also evaluated the enjoyment or ease of use of the games. Joint range of motion and muscle power were the most frequently evaluated constructs.
Intervention duration and frequency
Appendix B provides information on the duration of the intervention that ranged from 2 hours to <30 minutes. Most frequently, each intervention session lasted for an hour ( n = 8) followed by 45 and 30 minutes or less.
Setting
Among the 41 included articles, 28 articles mention an outpatient setting, a clinic, or a hospital, four report an inpatient setting (including acute inpatient units and inpatient rehabilitation units), and two report the setting as home. Articles also had a mix of participants in multiple settings, such as nursing homes and daycare ( n = 1), and an outpatient unit and a retirement home ( n = 1). Five articles did not specify the setting in which the intervention was provided.
Rehabilitation professionals
The gaming interventions were provided by physical therapists ( n = 26), occupational therapists ( n = 2), and multidisciplinary teams ( n = 2). Eleven articles did not report on which professionals provided the intervention.
Guidelines
None of the included articles reports following or using the CERT or TIDIER guidelines.
Characteristics of gaming intervention used in the included articles
Figure 2 is an infographic that provides an overview of the gaming hardware, software, and games used for the areas and anatomical structures around the hand, wrist, elbow, forearm, shoulder, and entire upper limb.
Frameworks used for intervention
The authors of the included articles used different theories to guide the intervention and rationalize the use of gaming technology. Some of these theories focus on pain (eg, neuro-matrix theory and gate control theory 31), progressive resistance training, 22 task-oriented activities, 57 and motor learning (eg, Gentile’s motor learning theory 22).
Game type
Games were played for therapeutic purposes using different technologies, such as VR, immersive VR with head-mounted displays, AR, and mobile health applications on Android cell phones.
Hardware and software
Some of the commonly used gaming technologies were the Myogames ( n = 6, including Myo ArmBand, 24 Myogesture, 26 MyoBoy, 33 Myo electric bracelet, 39 Myobox, 27 MyRio 58), Leap Motion 22,34,52,53 ( n = 4), Nintendo Wii ( n = 4, including Wii, Wii Fit, and Wii Sports), Kinect ( n = 6, including Xbox 360 Kinect and Microsoft Kinect), and Oculus ( n = 5, including Oculus Quest 21,35,36, Meta Quest 2, 20 and Rift 22). Other gaming interventions used an Android phone with Android OS games, 32 RehabRelive Glove with Android OS, 19 Pablo system, 55 Brando 29 etc. A few articles used the gaming technologies in combination with other equipment, such as the Kinect sensor with the Play Ball 46, Kinect with the Myo arm band, 24 or the Nintendo Wii Fit with the Balance board. 49 Some custom-made technologies include the RehabRelive Glove with Android OS, 19 and the technology by Ortiz-Catalan et al, 28 which was on the open-source platform BioPatRec. 28 The Wii, Kinect, Oculus, and Myo are commercial gaming systems that are available off the shelf.
Games and their features
The content of the games included sport or play-related (eg, boxing, bowling, beach volleyball, table tennis, and archery), leisure (eg, whitewater rafting, skiing, shooting, and dancing), or curated scenarios (eg, flying a rocket, bursting balloons, and climbing). Some common features of the games were scoring based on completing levels, grading based on duration or difficulty, and encouraging audiovisual cues. Real-time audiovisual feedback from the games was frequently reported in addition to haptic and proprioceptive feedback. The characteristics of some games with their hardware, software, the game features, and the movements required for playing the game are provided in
Number of players
One article reported using a multiplayer game, 51 35 articles reported using a single-player game, and five articles did not report the number of players. Single-player games also involved games in which the participant played against the computer or the technology.
Use of gaming as an adjunct modality
In 21 articles, gaming was used as a standalone intervention, and in 20 articles, it was used as an adjunct. Among these articles, 16 utilized gaming as an adjunct for physical therapy, which included manual therapy, cryotherapy, isometric and isotonic exercises, stretches, mobilization, etc. Additionally, in three articles, gaming was used as an adjunct to multidisciplinary conventional rehabilitation, including physical and occupational therapy. In a case study of an individual with right wrist disarticulation, gaming was used along with nerve block. 39
Use of gaming software for evaluation
Gaming technology was used for evaluation in nine articles. 19,25,29,41,43,46,52,55,56 It was used to evaluate constructs like range of motion, joint position sense, the velocity of movement, etc.
Commercial availability
About 56% of the articles reported that the games were commercially available, while 37% were lab prototypes. About 7% of the included articles did not report the game's availability. Among the commercially available gaming technologies, six articles mentioned that the games were affordable. However, none of the articles mentioned the costs of the gaming technology. The commercially available gaming technology, such as Nintendo Wii, Oculus Rift, Leap Motion, and Kinect, has been formally discontinued; however, these older models can be purchased through other vendors. Oculus Quest 2 and MyoBoy are still sold by their developers.
Gaming session duration and frequency
The sessions ranged from 10 to 90 minutes. The most frequent duration was 30 minutes ( n = 10 articles), 45 minutes ( n = 5), an hour or more ( n = 5), and 20 minutes or less ( n = 4). Information on the duration of the gaming intervention is provided in Appendix B. The number of sessions ranged from once only, twice a day (10 sessions/week), and daily ( n = 3 articles), to twice/week ( n = 13) with the highest frequency, thrice/week ( n = 5 articles), and five times/week ( n = 2 articles). The intervention was provided once 29,33 to 24 weeks. 51 Most articles provided the intervention for six weeks, followed by 4 weeks ( n = 5), 8 weeks ( n = 3), and 12 weeks.
Limitations of gaming technology
Most articles ( n = 27) did not report specific limitations of gaming technology itself. We thematically categorized some of the limitations mentioned by the authors.
A) Technology and hardware-related limitations include the lack of force feedback for supination and pronation 29 and difficulties with Xbox Kinect in mapping limb rotations in specific orientations, especially when obstacles like mobility aids obscure the patient's view. 25 Patients also reported that the software was too sensitive and detected finger movements or arm spasms. 25 A study reported the need for controllers with relevant button presses for individuals with thumb fracture injuries. 31 The authors also raised concerns about the durability and security of hardware. 31 Among patients with amputations, predicting phantom movements requires sufficient voluntary muscle control signals at the stump, and the sensors may not work in shoulder disarticulation amputees. 28 Lastly, among amputees experiencing phantom limb pain, finger movements are preanimated and cannot be replicated by the opposite hand, as in a digital glove. 23
B) Therapeutic limitations include the following: time taken for calibration and setup 41; limited possible shoulder movements based on the available Wii games 45; and risk of injury if played improperly or excessively 45 and reduced clinician control over patient access and game usage. 31 Also, one article noted that the Wii remotes are lightweight with no additional resistance, so it may not improve strength as much as heavier weights/resistance. 45 An author also described that exergames involving patients viewing themselves on the display screen generally had a negative response. 25 Also, Chau et al 39 noticed that when the Myo band synchronization was erroneous (occurred during one session), less engagement and pain relief were reported.
C) Game-related limitations included the following: lack of age-appropriate content, 25 the need for additional game scenarios and increased levels of difficulty, 31 the primitive nature of some game software that lacks esthetics and variety, 32 and the need for more multiuser games. 31
D) Cost-related limitations were mentioned in one article as the technology (including the hardware and software) might not be affordable for patients to buy and have at home. 57
Discussion
This scoping review described the available evidence on gaming technology for UE rehabilitation of patients with a wide range of MSK conditions. Various hardware, software, and games utilized are reported and summarized. Different gaming technologies, including Myo, Leap Motion, Nintendo Wii, Kinect, and Oculus, were used for therapeutic purposes through virtual, augmented, and mobile health applications. Furthermore, this review notes that gaming was used both as an adjunct to conventional therapies and as a standalone intervention. It also addresses the limitations of gaming technologies, such as hardware durability, software sensitivity, therapeutic efficacy, game design, and cost issues, emphasizing the need for improvements in these areas. Additionally, this review provides data on session duration, frequency, and commercial availability of gaming technologies.
Characteristics of participants
While we did not directly assess the effectiveness of these interventions, this work has implications for patients, healthcare providers, and researchers. The diverse patient populations in the included articles (eg, fractures, peripheral nerve injuries, amputations, arthritis, weakness following breast cancer, fibromyalgia, and sarcopenia) suggest that interventions can be tailored to address specific needs, enhancing therapeutic gaming in rehabilitation settings.
Study design and intervention features
Despite the large variability in the outcomes evaluated, which could be attributed to variability in the diagnoses, we still recommend that experts in gaming technology consider developing a consensus statement on evaluation or condition-specific gold standard measures for consistency. 59 Our results on the frequency of use of clinician-reported outcomes (eg, joint range of motion and muscle power) versus patient-reported outcomes (eg, quality of life) align with evidence in stroke rehabilitation, where VR has shown limited influence on International Classification of Functioning, Disability and Health participation-level outcomes. 59-61 We recommend using patient-rated and participation-focused outcomes to provide a holistic view of gaming technology's impact on MSK rehabilitation.
Theoretical frameworks and game design
The included articles reported using theories such as motor learning, pain gate theory, and Gentile’s classification. Gentile’s skill categories, also previously used in stroke rehabilitation, 62 can guide the design of MSK-specific games, enabling personalized therapy goals and plans. We propose that when reporting the nature of the games, the authors structure the game characteristics based on skill level, inter-trial variability (eg, the environment changes from one task trial to the next), and object manipulation (eg, a joystick) to play the game.
Gaming technology and evaluation
In addition to the commonly used hardware, such as gaming consoles, monitors, joysticks, controllers, etc., articles also include equipment, such as the Kinect sensor with the Play Ball or the Nintendo Wii with the Balance board. A strength of using additional equipment is that it increases the scalability and the therapeutic benefits by addressing other impairments caused by MSK conditions, and can also change the game's immersion level. For example, using haptic gloves in combination with semi-immersive VR as an intervention strategy for UE rehabilitation after stroke produced significant improvements. 63
In addition to being used as an intervention strategy, gaming technology and sensors have also been used to evaluate constructs like muscle power, range of motion, joint position sense, the velocity of movement, etc. (eg, sand technology such as using a Gyko inertial sensor and Kinect-MIRA system and Fizyosoft extremity range of motion). Leveraging gaming technology and sensors for assessment has the undeniable advantage of potentially reducing errors. However, more research is imperative to establish convergent validity (using gaming technology for evaluation) with other existing methods like goniometry, manual muscle testing, etc, and to compare outcome measures using different gaming technologies to evaluate the inter-rater reliability of the various technologies (eg, measurement using Kinect vs Xbox).
Challenges in gaming technology implementation
In this review, the commonly used hardware and software for UE rehabilitation of MSK conditions are Myo, along with electromyography, Leap Motion, Nintendo Wii, Kinect, and Oculus, which are similar to those used in UE rehabilitation of stroke, Parkinson’s disease, and in lower extremity MSK disorders. 64 Due to the gaming field’s fast-paced nature, technology often becomes outdated quickly, making it difficult to predict its effectiveness. By the time the technology and the games become commercially available, and hospitals purchase them, the games or their parts and repairs are obsolete. We found that the majority of the commercially available devices used (eg, Wii, Kinect, Leap Motion, and Oculus Rift) in 20 included articles have been formally discontinued and are not currently on the market. This concern was reinforced by clinicians and researchers during the stakeholder consultations. For example, the Kinect sensor (used in six articles) had large rehabilitation potential owing to its precise motion capture and interactivity features but was discontinued in 2017, and is no longer compatible with the more recent Xbox. 65 The short life span of commercial devices poses challenges for long-term clinical use. To mitigate these issues, researchers should explore ways to extend the usability and life span of existing technology or create more durable and adaptable gaming equipment for clinical environments.
Games were played for therapeutic purposes using different technologies, such as VR, immersive VR with head-mounted displays, AR, and mobile health applications on Android cell phones. As seen in Table 4, the games' descriptions and features were inconsistently reported in the included articles. There is a lack of clarity about which components of the gaming technology are contributing to improvement, that is, is it the game itself, features of the hardware or software, nature of feedback or dosage, etc. We recommend that the authors provide more detailed descriptions of their gaming technology because of the diversity in interfaces, input provided, movement patterns expected of the participant, augmented feedback, settings, etc. For instance, varying elements and features such as scaling levels or feedback types could allow researchers to isolate their impact on recovery outcomes and could improve our understanding of each feature's therapeutic value. 59 Also, none of the included studies compared different gaming technologies (eg, Leap Motion vs MIRA) or games to compare effectiveness or feedback on user interface.
Barriers to the use of gaming technology reported are high costs, need for clinician training, limited accessibility, absence of clinical decision-making framework to guide the selection of gaming technology, games, grading, and medical documentation. 66 To address these, it is crucial to provide training on its use, develop protocols, and clinical frameworks to guide the selection and grading of gaming interventions. 67 Through this review, we have created an infographic summarizing the gaming technology to serve as a starting point to guide decision-making by providing different options. We foresee that clinicians can use the infographic in two ways. Firstly, clinicians can identify which anatomical areas (eg, wrist, hand complex, and shoulder) are impaired and then within the subsection ( Figs. 2A-2E) follow along horizontally to see the different options for hardware, software, games, and the reference article. Alternatively, they can follow along vertically (across the entire infographic) in the hardware or software column to locate the gaming technology present in their setting, then determine which diagnosis it has been utilized for, and the reference article. Once they have identified the article that uses the gaming technology of their choice, they can refer to the study characteristics table in Appendix B to get more information on the setting, intervention duration, frequency, etc. Although the infographic does not explicitly mention the rationale for the games (eg, improve range of motion, strength, etc), the game settings can often be adapted to address different patient needs. Clinicians can also use Table 3 to make decisions on which tests to use along with the gaming intervention. For example, if they want to evaluate patient-reported impairment, they can refer to Table 3 to determine the different outcome measures that have been used and the population for which it was used. During documentation, we recommend that clinicians should broadly report on the rationale for using the game (eg, improving ROM, muscle strength), grading (eg, in terms of difficulty, duration, or inter-trial variability), supervision provided, and the technology used. If clinicians use gaming technology for evaluation, they should also document this to track progress over time.
Home use and supervision considerations
As most of the included articles administered gaming interventions under supervision, more research exploring unsupervised home rehabilitation is required. Home-based gaming interventions raise concerns about patient training, especially for choosing difficulty levels of the game and monitoring progress. Gaming technology’s tracking capabilities could allow clinicians to remotely assess patient adherence and effectiveness, offering an alternative to in-person sessions and increasing access to therapy for patients. However, there is a need to ensure safe usage at home to minimize risks of improper or excessive use and improve these technologies to be more accessible, simplified, and adaptable to engage the patient. 68
Gaming modes and multiplayer potential
This review noted that most games were single-player, with limited exploration of multiplayer or competitive modes. Expanding multiplayer options could facilitate group therapy, thereby providing social support and increasing clinician efficiency. Additionally, multiplayer games may enhance patient engagement and adherence to rehabilitation programs.
Dosage and duration
The included studies demonstrated considerable variability in session duration, frequency, and therapy program duration, highlighting the need for standardized protocols for gaming interventions in MSK rehabilitation. Other reviews also describe variability in the average dose of gaming sessions, with Aminov et al, 59 reporting 40-60-minute sessions delivered 3-5 days per week for 6 weeks (total ranging from 18 to 36 sessions) in stroke, Crosbie and colleagues reporting three times per week for 1-1.5 hours, over a 2-4-week period (ie, 6-18 hours total) for people with stroke, and Palma et al 60 reporting the average dose of VR was 17.6 hours for upper limb motor function rehabilitation and 13.2 hours for motor activity rehabilitation. 69 Consistency in implementation parameters could improve comparability across studies and enhance the evidence base for gaming technology.
Commercial availability
Commercially available games referring to “off-the-shelf” devices like Wii and Xbox are readily accessible, therefore increasing their utilization in rehabilitation, but they often lack specific features for therapeutic efficacy, as they were designed for general entertainment. 7 As a result, they may not consider the physiological, motor, and cognitive aspects of recovery in rehabilitation and may lack the scalability of purpose-designed serious gaming systems. 59 These limitations of commercial gaming are congruent with the gaming and technology-related limitations reported by this review, such as the absence of relevant buttons for individuals with thumb fracture injuries, lack of force feedback for supination and pronation, 29 and difficulties with Xbox Kinect in mapping limb rotations in specific orientations. Future research should compare various gaming technologies and document user feedback on the effectiveness of interfaces (eg, commercially available vs custom-developed interface).
Though we extracted information on reporting guidelines, none of the included articles reported using them. We recommend that the authors use the CERT or TIDIER guidelines for more uniform reporting of intervention studies regarding the technology, software, game, and game description, or target of the game.
In conclusion, this review summarizes the potential of gaming interventions for UE rehabilitation of MSK conditions but highlights the need for more detailed reporting, standardized implementation protocols, and extended usability of gaming hardware. As the field advances, these improvements can make gaming interventions more accessible, effective, and adaptable in diverse rehabilitation settings.
Limitations of the review
Some of this review's limitations include excluding articles in a language other than English. The information discovered and reported by this review is not necessarily a direct reflection of the clinical use of gaming interventions, as the review design is limited to what has been researched and reported, rather than day-to-day practice itself. We did not critically appraise the quality of included studies because it is not necessary for scoping reviews and does not align with the research questions. We also did not search gray literature or theses. We did not conduct follow-up stakeholder consultation meetings to present the revisions suggested.
Conclusion
The review provides an overview of gaming technology used for UE rehabilitation of MSK conditions and its characteristics that can guide therapists and researchers in deciding which ones to use. However, due to the fast-paced nature of technology, some of the gaming technology reported in the included articles may be currently unavailable.
Funding
No funding was received to conduct this review.
Author Contributions
Catherine Mariam George: Writing – review & editing, Writing – original draft, Visualization, Project administration, Methodology, Formal analysis, Data curation. Javad Raeesi: Writing – original draft, Visualization, Methodology, Formal analysis, Data curation. Armaghan Dabbagh: Writing – original draft, Methodology, Formal analysis, Data curation. Mike Szekeres: Writing – review & editing, Supervision, Conceptualization. Joy C. MacDermid: Writing – review & editing, Visualization, Supervision, Resources, Methodology, Conceptualization.
Declaration of Generative AI and AI-assisted technologies in the writing process
Canva was used to create the images in the “Results.” Grammarly was used to check for grammatical errors.
Declaration of Competing Interest
The authors have no competing interests to declare.
Supporting information
Supplementary data associated with this article can be found in the online version at
Supplementary material
Supplementary material
.Table 1
| Criterion | Inclusion criteria | Exclusion criteria |
| Population | Articles with at least one participant diagnosed with a musculoskeletal condition (eg, fractures, post surgery, amputation, peripheral nerve injuries, etc) as defined by the WHO, resulting in limitations in dexterity or overall functioning of the UE | Articles involving only participants
• without an MSK diagnosis, except for burns • with conditions involving the central nervous system, such as stroke, spinal cord injury, multiple sclerosis, etc • with congenital conditions such as cerebral palsy, Erb's palsy • Who are healthy individuals • Who are older adults without an MSK condition |
| Concept | Gaming interventions with a user interface (eg, virtual reality, augmented reality, etc.) | Gaming interventions without a user interface or technology
Gaming used for leisure instead of a therapeutic function |
| Context | Focuses on UE rehabilitation as indicated by using at least one UE outcome measuring function or pain (can be primary or secondary outcomes) | Only evaluating outcomes such as participant adherence, patient/user experience, and feedback on gaming |
| Article type | Randomized controlled trials (RCTs), observational studies, case reports, and case series published in English | Reviews, editorials, conference abstracts, and theses |
Table 2
| Concept/term | Description |
| Medical condition or diagnosis | The MSK condition affecting UE and for which therapeutic intervention is required. |
| Type | The type or broad category of gaming technology used. Examples include virtual reality, augmented reality, mobile health apps, immersive reality, etc. |
| Hardware | The use of any devices such as the robotic arm, glove, sensors, immersive helmets, etc. along with the game. |
| Software | The gaming technology that was used, along with its specific details such as version, year, etc. |
| Games | The name and descriptive details of the specific games that were used. Examples include bowling, volleyball, archery, etc. |
| Joints focused on | The joints and the related anatomical structures that were the focus of the therapeutic intervention. These joints can be synonymous with the joints affected by the diagnosis. |
| Commercially available | The commercial availability of gaming hardware, software, and games. Some games and gaming software were prototypes or custom-created and, therefore, are not commercially available. Also, addresses whether it was adapted or used off-shelf and whether it is still commercially available. |
| Duration of the session | The duration of the therapeutic session (if gaming was an adjunct, then the duration of the gaming session as well). |
| Setting | The location where the intervention was provided. Examples include inpatient, outpatient unit, home, etc. |
| Study design | The processes used in the study for data collection and analysis. |
| Rationale | The reasoning provided for using the gaming technology for the rehabilitation of UE in MSK conditions. |
Table 3
| Construct | Outcomes | Diagnosis of the participants |
| Performance-based and clinician-rated outcomes | ||
| Arm function ( n = 1) | Joint mobility tests such as Scapular Retraction Test, Scapular Assistance Test, Lateral Scapular Slide Test, and Neer and Hawkins Test | Subacromial impingement syndrome and scapular dyskinesis |
| Whole-body function ( n = 1) | Sit and Reach test 51 | Fibromyalgia |
| Dexterity ( n = 6) | Nine Hole Peg test 53,54 | Juvenile idiopathic arthritis, traumatic hand injuries involving bone and/or flexor tendon |
| Clothespin relocation test 27 | Amputation | |
| Purdue Pegboard test 34 | Fractures and rheumatoid arthritis | |
| Jebsen Taylor Hand Function 53 | Juvenile idiopathic arthritis | |
| Box and Block test 22,39 | Sarcopenia, fracture | |
| Muscle strength ( n = 16) | Grip strength (using JAMAR dynamometer, Saehan hydraulix hand dynamometer, Biometrics Kit, and Upper extremity evaluation software or unspecified tests) 32,34-37,48,50,53-57 | Juvenile idiopathic arthritis, metacarpal fracture, post-traumatic hand surgery sequalae, amputations, rheumatoid arthritis, traumatic hand injuries involving bone and/or flexor tendon, breast cancer, and post-Carpal tunnel release surgery |
| Pinch strength (using dynamometer, Biometrics Kit, and Upper Extremity Evaluation Software, and unspecified tests) 37,53-57 | Juvenile idiopathic arthritis, post-traumatic hand surgery sequelae, fractures, traumatic hand injuries involving bone and/or flexor tendon, and post-Carpal tunnel release surgery | |
| Shoulder joint muscle strength (using digital scale and dynamometer) 45,47 | Shoulder impingement syndrome, breast cancer | |
| Isometric muscle strength 22,48,50 | Rheumatoid arthritis, breast cancer, and sarcopenia | |
| Hand function using virtual ball squeezing and Digikey exercises 56 | Post carpal tunnel release surgery | |
| Strength assessment of maximal voluntary contractions/maximal isometric strength using the Playball 46 | Shoulder pathologies: impingement syndrome, capsulitis, tendon injuries, and degenerative joint or tendon pathologies | |
| Arm curl test 51 | Fibromyalgia | |
| Upper limb muscle strength (unspecified) 57 | Juvenile idiopathic arthritis | |
| Joint position sense ( n = 1) | Fizyosoft extremity ROM 40 | Rotator cuff partial rupture |
| Approximation force ( n = 1) | Fizyosoft Balance system 40 | Rotator cuff partial rupture |
| Joint range of motion (ROM) ( n = 17) | Video analysis of ROM 45 | Shoulder impingement syndrome |
| ROM (using composite finger ROM using a standardized ruler and goniometry) 22,29-32,34-36,47,48,55 | Fractures, post-traumatic hand surgery sequelae, breast cancer, rheumatoid arthritis, sarcopenia, and amputation | |
| Functional ROM tests such as Back Scratch test, Arm lift angle 41,51 | Fibromyalgia, humerus tuberosity symptoms | |
| ROM degree using sensors and technology (such as using a Gyko inertial sensor and Kinect-MIRA system, and Fizyosoft extremity ROM) 40,42,46 | Impingement syndrome, rotator cuff partial rupture | |
| Physical function ( n = 1) | Physical function test 50 | Rheumatoid arthritis |
| Muscle and movement-related attributes ( n = 5) | Electromyography parameters: maximum voluntary contraction, proportional precision control, electrode separation, muscle endurance, muscular activation, and Electromyography signals on patient’s muscle activity 24,27,33 | Upper limb amputations, forearm injuries, including wrist and elbow fractures affecting pronation/supination and flexion/extension |
| Motion-related attributes like Constant Murley Score scale, completion time, exercise efficiency, Root Mean Square of motion, maximum acceleration, velocity of movements, and motion tracking 29,41 | Humerus tuberosity symptoms, forearm injuries including wrist and elbow fractures affecting pronation/supination and flexion/extension | |
| Function with prosthesis ( n = 1) | Number of Degrees of Freedom (DoF) 27 | Amputation |
| South Hamptom Hand Assessment 27 | Amputation | |
| Pain ( n = 1) | Algometer for pain threshold 40 | Rotator cuff partial rupture |
| Skeletal muscle mass | Appendicular skeletal muscle mass index (ASMMI) 22 | Sarcopenia |
| Patient-rated outcomes | ||
| Pain ( n = 15) | Pain (not specified) 30,31 | Fractures of the upper limb; UE or hand injuries (burns or fractures) |
| Visual Analog scale (VAS) 23,34-36,39,40,44,47,48,55 | Fractures of the upper limb, subacromial impingement syndrome and scapular dyskinesis, post-traumatic hand surgery sequelae, breast cancer, rotator cuff partial rupture, rheumatoid arthritis, phantom limb pain in the UE, and wrist disarticulation after a traumatic injury | |
| McGill Pain Questionnaire (short and long form) 23,39 | Phantom limb pain in UE amputations, wrist disarticulation after a traumatic injury | |
| Wong-Baker faces measurement 39 | Wrist disarticulation after a traumatic injury | |
| Subjective feedback on pain relief and function pre and post intervention 39 | Wrist disarticulation after a traumatic injury | |
| Pain rating scales such as weighted pain distribution scale, pain rating index, pain frequency scale, and Numeric Pain rating scale 28,57 | Phantom limb pain, juvenile idiopathic arthritis | |
| Pain questionnaire | Atraumatic shoulder instability | |
| Engagement ( n = 1) | Physical Activity Enjoyment Scale (PACES)—short 46 | Shoulder pathologies: impingement syndrome, capsulitis, tendon injuries, and degenerative joint or tendon pathologies |
| Self-efficacy ( n = 1) | Self-efficacy scale 46 | Shoulder pathologies: impingement syndrome, capsulitis, tendon injuries, and degenerative joint or tendon pathologies |
| Fear of movement ( n = 1) | Tampa Kinesiophobia Scale 48 | Breast cancer |
| Occupational measure ( n = 1) | Canadian Occupational Performance Measure 57 | Juvenile idiopathic arthritis |
| Independence in daily activities ( n = 1) | Functional Independence Measure 55 | Post-traumatic hand surgery sequelae |
| Health condition--related impairments and activity limitations ( n = 20) | Childhood Health Assessment Questionnaire 2 53,57 | Juvenile idiopathic arthritis |
| Duruoz Hand Index 53,57 | Juvenile idiopathic arthritis | |
| Michigan score 55 | Post-traumatic hand surgery sequelae | |
| Michigan Hand Questionnaire 34 | Fractures and rheumatoid arthritis | |
| Patient-Rated Wrist Evaluation 37 | Distal radius fracture | |
| Patient-Rated Wrist and Hand Evaluation 32 | Metacarpal fractures | |
| Upper extremity functional index 54 | Traumatic hand injuries involving bone and/or flexor tendon | |
| Disabilities of the Arm, Shoulder and Hand (DASH) 35-37,40,42,48,55 | Post-traumatic hand surgery sequelae, rotator cuff partial rupture, DRF, impingement syndrome, breast cancer, amputations, and proximal humeral fractures | |
| Oxford Shoulder Score 42 | Impingement syndrome | |
| Oxford Shoulder Instability Score 25,26 | Atraumatic shoulder instability (bilateral or unilateral) | |
| PENN shoulder score 46 | Shoulder pathologies: impingement syndrome, capsulitis, tendon injuries, and degenerative joint or tendon pathologies | |
| Shoulder Pain and Disability Index (SPADI) 21 | Subacromial impingement syndrome and scapular dyskinesis, proximal humeral fractures | |
| Patient-rated severity ( n = 3) | Disease Activity Score-28 49 | Rheumatoid arthritis |
| Stanmore Percentage of Normal Shoulder assessment 25,26 | Atraumatic shoulder instability (bilateral or unilateral) | |
| Quality of Life ( n = 5) | Western Rotator Cuff Index 45 | Shoulder impingement syndrome |
| Rotator cuff Quality of life index 40 | Rotator cuff partial rupture | |
| Generic Quality of Life (QOL) measures like Short Form-36 (SF-36), EuroQOL-Visual Analog Scale (EQ-VAS) 42,50 | Rheumatoid arthritis, impingement syndrome | |
| Health Assessment Questionnaire 49,50 | Rheumatoid arthritis | |
| Functional Assessment of Chronic Illness Therapy (FACIT) 49 | Rheumatoid arthritis | |
| Patient’s Global Assessment using a VAS 50 | Rheumatoid arthritis | |
| Fatigue | Modified Borg Scale 47 | Breast cancer |
| Fatigue questionnaire 25 | Atraumatic shoulder instability | |
| Prosthesis use ( n = 1) | Prosthesis use 28 | Phantom limb pain |
| Medication ( n = 1) | Medication intake 28 | Phantom limb pain |
| Pleasure of exercise (n = 1) | Modified Visual Analog scale 47 | Breast cancer |
| Feasibility ( n = 6) | Questionnaire ratings on experience, intrinsic motivation, enjoyment/ happiness, pressure, competence, effort, usefulness, difficulty, usability, feedback on training, acceptability, 29,31,33,38,43 and the System Usability Scale 46 | UE or hand injuries (burns or fractures), traumatic upper limb amputation, and shoulder pathologies: impingement syndrome, capsulitis, tendon injuries, degenerative joint or tendon pathologies, fractures, forearm injuries including wrist and elbow fractures affecting pronation/supination and flexion/extension joint dislocation, tendinopathy, humerus fracture, calcification, osteoarthritis, and shoulder impingement |
| Compliance/ adherence ( n = 2) | Self-reported using a diary (used for nongaming controls) 32 | Metacarpal fractures |
| Activity logging software on device (used for gaming group) 32 | Metacarpal fractures | |
| Attitudes to train at home (one-item questionnaire) 46 | Shoulder pathologies: impingement syndrome, capsulitis, tendon injuries, and degenerative joint or tendon pathologies | |
| Intention to train at home (one-item questionnaire) 46 | Shoulder pathologies: impingement syndrome, capsulitis, tendon injuries, and degenerative joint or tendon pathologies | |
| Pablo system 55 | Post-traumatic hand surgery sequelae—burns, amputations, electric lesions, and work-related accidents |
Table 4
| Type of gaming system | Hardware and its description | Motion capture | Feedback to users | Examples of games with descriptions and its features | Rationale | Movements focused on |
| VR | Leap Motion:
34,52
The Leap Motion software combines its sensor data with an internal model of the human hand to help cope with challenging tracking conditions. It consists of an optical sensor that works with computer interaction. Hardware: Leap Motion Controller device (including an optical sensor, two monochromatic IR cameras, and three infrared LEDs), computer |
Leap Motion Controller is a motion-based device specially designed for the acquisition of 3D positions and orientations of hands and fingers. | NR | A musical game with a mechanic similar to Guitar Hero7 (Commercial), Flappybird (Commercial), Clone8 (Commercial), Arcade game (Commercial), and 3D game (a simplified flight simulator).
All the games had the same features Features: Control the exercises of the games implemented, record all the patient’s actions, replay, and analyze the sessions. |
NR | Wrist range of motion |
| VR | Nintendo Wii
30,44,45
Hardware: Nintendo Wii System/console, Wii remote, Wii Nunchuck, digital scale for strength measurement, and video camera for range of motion analysis Additional hardware: Balance board 50 |
Reflective markers for video-based motion capture and analysis.
Wii remote: a handheld pointing device that detects movement in three dimensions. |
Visual, auditory | Boxing (Commercial): “dodging” exercise that was used to train shoulder internal and external rotation. Clients held their upper arms to their sides and rotated the forearms side-to-side to “dodge” virtual punches. The Wii boxing game also has a punching exercise where clients punch with one hand and then switch, repeating punches across the body. This was used to train shoulder coordination. | Train the scapular stabilizers | Shoulder movements, scapular stabilization, shoulder internal and external rotation, shoulder coordination, elbow, and forearm |
| Bowling (Commercial): swinging the arm back into shoulder retraction to swing the virtual ball, then swinging forward into protraction to release the ball.
Features: Scoring |
NR | Scapular retraction and protraction, elbow, and forearm | ||||
| Tennis (Commercial) | NR | Elbow, forearm | ||||
| Balance games | NR | Full body | ||||
| VR | Nintendo Wii Fit:
49
The Nintendo Wii Fit system is an interactive and movement-based gaming system in which the player is represented as an avatar within the virtual environment. The system uses a handle game controller and a pressure-sensitive platform on which the player can stand and actively shift his/her weight during playing. Moreover, to perform digit/hand training, the balance platform can be set for slight weights, simulating activities of manual dexterity. A television display is used to output the game being played. Hardware: Wii Fit console, balance board, discs with game software, and television |
NR | NR | Wii fit games such as running, skiing, balloon shooting, bike salon, and balls moving through the labyrinth | NR | Shoulder flexion, abduction, extension, internal and external rotation, elbow flexion, extension, forearm supination, pronation, hand digit motion, weight shift back and from side-to-side, and knee and ankle flexion/ extension. |
| VR | Robotic arm VR game
29
Hardware: Custom robotic arm with passive support, handle with buttons, and VR display. Arm support counterbalances weight. |
End-effector position tracked | Visual, proprioceptive, and haptic force feedback. | Ringing bells, hitting balls, bursting balloons in all the games, and targets appeared at different locations and sequences | NR | Flexion/extension and pronation/supination movements of the forearm |
| VR | Custom VR
54
Hardware: desk-top computer, a handmade joystick handle with seven force sensing resistors, and a data processing module. |
NR | Real-time visual feedback on game performance, such as targets hit, force applied, and positive feedback, and force sensing resistors on the joystick handle | Shooting (Custom-developed): gripping handle, moving forearm, and wrist to hit targets in the game.
Features: Adjustable difficulty levels, encouraging audio/visual cues |
NR | Wrist and hand functions simultaneously: gripping, wrist flexion/extension, and forearm pronation/supination to move handle and aim/shoot in the game. |
| VR | Kinect v2
41
Additional hardware: Bluetooth Ball |
Kinect skeleton tracking, Bluetooth ball sensors | Real-time visual feedback on gameplay performance | Whitewater rafting (Custom-developed): avoid obstacles by moving the ball side-to-side | NR | Arm swinging, lifting, and side-to-side motions |
| Collision pinball (Custom-developed): hit pinball targets by swinging the ball | ||||||
| VR | Xbox 360 Kinect Sports 1 48 | NR | NR | Kinect Sports 1 (darts, bowling, boxing, beach volleyball, and table tennis) and Fruit Ninja | NR | NR |
| VR | Xbox 360 Kinect
57
Xbox Kinect can track joint movements, relatively inexpensive, portable, does not require players to hold a controller, increase motivation when adherence is low, reduce the amount of pain, and provides real-time feedback when exercises are not performed correctly. |
NR | NR | Dance Central 3: Macarena Kinect Sports I: beach volleyball, table tennis, boxing, darts, and bowling | NR | NR |
| VR | Xbox Kinect with MIRA Medical Interactive Recovery System
25,26,42
Xbox Kinect: The Medical Interactive Recovery Assistant (MIRA) is a gaming software, owned by MIRA Rehab (London), which uses the Xbox Kinect for targeted training of the shoulder joint. MIRA enables clinicians to create individual patient exercise schedules by selecting games based on specific shoulder movements. MIRA also allows clinicians to view patients’ progress and adherence to a prescribed rehabilitation schedule. For each patient profile, data such as moving time within any given session, points won, and total time spent using the MIRA are collected. |
Kinect sensor | Real-time feedback | Serious games: Flight Control, Follow, Forest leaves, Grab, Izzy the bee, Jugger, Memory Scape, Move, NBack, Piano, Powerhouse Bid, Seasons, Range of Motion Drills, Star Find, and Task Swap (Commercial)
Features: Score, time spent moving, can be graded on duration, difficulty level, and sequence to create personalized program. |
ROM, control, activation of the kinetic chain, arm velocity, and strength | Shoulder movements |
| VR | KineActiv 43 | RGBD (Red, Green, Blue, Depth) sensor (MS-Kinect V2) | Real-time feedback | Exergames
Features: Motions of the patient’s limbs are automatically tracked, goals are set in advance, and records exercise data and makes it available to the physiotherapist through a client-server architecture |
NR | Upper limb motion (abduction, flexion) and the two dynamics (isometric, concentric). |
| Android | Android Phone
32
Hardware: Android smartphones with front-facing cameras and touchscreens. Custom motion tracking mobile game app, color-coded gloves |
Smartphone camera captured finger motions aided by the color-coded gloves that enhanced motion tracking. | Visual | Grab It! (Custom-developed): manipulating puzzle pieces on screen by finger motions detected via mobile camera.
Features: Scoring based on completing levels/goals. |
Track finger motions | Finger movements |
| Commercial touch control games used: Zombie Smacker, Flash Finger, Finger Glow Hockey, Sensei's Flies, Cut the Buttons, Finger Run: Volcano Escape, Magic Tiles 3. | Improving finger range of motion, dexterity, and eye-hand coordination | Tapping, swiping, and coordination | ||||
| VR | Pablo system from Tyromotion 55 | Hand sensors to measure hand grip strength, pinch force, and range of motion of the upper limb. | Audiovisual and haptic feedback | Balloon (Commercial)
Features: Parameters adapt to person’s status |
NR | Eye-hand coordination |
| Firefighters (Commercial)
Features: Parameters adapt to person’s status |
Mobility and strength | |||||
| Videogame/VR | Xbox 360 Kinect 47 | Kinect motion sensor | Real-time visual feedback | Beach volleyball (Commercial) Bowling (Commercial) Boxing (Commercial) Fruit Ninja (Commercial) No description provided for the games | NR | Shoulder joint range of motion—flexion, abduction, and internal and external rotation |
| VR | Fizyosoft Extremity ROM
40
Capable of objective measurement of joint ROM by detecting reference points during extremity movements with its camera and sensors |
Camera and sensors | Visual feedback | Arm Rotate (Commercial) U-Ball (Commercial) No description provided for the games | ROM of shoulder | NR |
| Fizyosoft Balance
40
The subject puts both hands on the balance board and then applies downward force without using bodyweight |
Balance board with sensors | Visual feedback | Balance Surf (Commercial) Balance adventure (Commercial) No description provided for the games | Proprioception and pain in the shoulder | NR | |
| Immersive VR | Oculus Quest
35,36
The games used were 3D immersive representations of contour, position, and movement combined with gestural control in the sensor motion virtual environment. Hardware: Head-mounted display with handheld sensor |
Oculus headset, handheld controllers with sensors | NR | Racket (Commercial) Holofit (Commercial) Until you fall (Commercial) No description provided for the games | NR | Across all axes and planes, namely pronation and supination of the forearm, flexion/extension, and radial/ulnar deviation of the wrist, and flexion/extension, and thumb abduction/adduction of fingers. |
| NR | ||||||
| NR | ||||||
| VR | Oculus Rift
22
The Oculus Rift headset is portable and lightweight and equipped with an organic light-emitting diode panel for each eye. Constellation is the position tracking system of Oculus Rift and is used to track the position of a user’s head and other VR devices. It comprises external infrared tracking sensors that optically track specially designed VR devices. Hardware: one computer, one Oculus Rift headset, one constellation, and one Leap Motion sensor. |
Leap Motion sensor and the Oculus Rift headset | Real-time feedback | Leap Motion Blocks: Subjects can play freely with blocks; they can create blocks, grab, push, pile, and throw blocks around. The subjects are guided to perform a sequence of actions in the game. First, they need to pinch and stretch with both of their hands to create several blocks. Then, they need to push, pile, and throw blocks around | NR | NR |
| Slum Ball VR Tournament: Objects such as tin cans and balls will keep flying toward the player, and the player needs to hit the upcoming objects back to a specific location | ||||||
| VR Super Sports Basketball 10th edition: The player needs to keep grabbing a basketball and throwing it out into the basket | ||||||
| VR Super Sports Soccer 10th edition: The participant becomes the goalkeeper of a soccer game and needs to use both of their hands to block the upcoming ball. | ||||||
| Immersive VR | Custom-made
31
HMD-VR (Head-mounted display-virtual reality) is a fully immersive form of VR, delivered by a head-mounted display unit, which delivers sights and sounds, and in which users engage with the scenario using handheld controls. Hardware: VR headset with touch controllers, and software with two gaming environments using Unreal Engine 4.20, 3ds Max 2019, and Substance Designer 2018.3 software. |
Touch controllers | Real-time sensory visual and audio | Archery game: involves using a bow and arrow to target balloons and gnomes. The subject had to reach out with their noninjured arm to grab a bow floating in front of them, then lift up the injured arm, and bend the elbow behind the back to grab a narrow from a quiver. Afterward, the subject brought the arrow in line with the bow string to attach it, holding the bow outstretched and pulling back the injured arm holding the arrow. | HMD-VR is considered to reduce pain perception through its engagement of the user's attention, emotion, concentration, and senses | Overhead arm movements, gripping and grabbing, and flexion and extension of the elbow |
| Climbing game: The subject had to climb up to the top by performing an overhead arm raise exercise. Highlighted bricks and ropes were presented. Once the brick was grabbed, the subject lowered their arm to climb up. If the subject failed to grab the brick, s/he fell off the climbing wall. To minimize discouragement after falls and preserve some previous progress, several checkpoints were developed at different levels for the subject to land on. | ||||||
| VR | Play ball
46
PlayBall (Playwork, Alon 10, Ness Ziona, Israel) is a digital therapy gaming system with possible motivational assets. PlayBall is a smart exercise ball functioning as a performance-measuring tool and a videogame controller. Hardware: Play ball system, Play ball, and iPad |
Interactive ball allows measuring both movement and pressure applied to it. Smart integrated sensors objectively measure and track the performance. | Real-time visual feedback. | Real-time force: The subject was required to perform subsequent isometric contractions on the Playball with the elbow flexed at 90°. The subject was asked to push down and release the Playball with sets of contraction and relaxation. “Real-time force” exercise was also performed from the standing position with the elbow extended. The Playball was placed on a wedge and under the subject’s arm | NR | Guiding the ball with the hand, elbow extension, and rotating the ball simultaneously, rotating the ball with the elbow flexed, rotating the ball with the palm, and pushing and releasing the ball |
| Flying rocket: The subject was required to guide a spaceship, pushing down and releasing the Playball, aiming to hit stars and avoid asteroids |
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