Recommendations for Developing User-Centered Games for Balance Rehabilitation in Multiple Sclerosis: An Interdisciplinary Approach
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Abstract
Background: In recent years, exergames have emerged as a potential rehabilitation tool to address balance dysfunction in patients with multiple sclerosis (PwMS). Although preliminary findings have shown promise, their overall effectiveness remains inconclusive, primarily due to their reliance on commercial games. This underscores the critical need for user-centered games tailored to the specific needs of patients. Despite this necessity, existing literature lacks established frameworks that guide the development of such games, highlighting a gap in literature. Therefore, the objective of this research was to propose the first evidence-based framework to guide the development of user-centered games for balance rehabilitation in PwMS.
Materials and Methods: A two-step method was used to achieve this objective. The first step involved the examination of commercial games used in clinical studies, identifying their mechanics and limitations. The second step involved reviewing the literature to identify relevant findings that could inform the development of user-centered games.
Results: A set of targeted recommendations was proposed, emphasizing the necessity of developing adaptable games with focused therapeutic designs to effectively address the distinct balance impairments observed in PwMS. A game prototype was also presented to illustrate the practical applications of these recommendations.
Conclusion: This research establishes the first structured framework to guide the design of user-centered exergames for balance rehabilitation in PwMS. Beyond its theoretical insights, this framework provides actionable guidelines for developing clinically effective exergames aligned with patient impairments and therapeutic needs. Ultimately, this will contribute to improved therapeutic outcomes, enhanced patient care, and advancements in both rehabilitation and game design fields.
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6. Taylor M, Griffin M. The use of gaming technology for rehabilitation in people with multiple sclerosis. Mult Scler J. 2015 Apr 1;21(4):355–71.
7. Calafiore D, Invernizzi M, Ammendolia A, Marotta N, Fortunato F, Paolucci T, et al. Efficacy of Virtual Reality and Exergaming in Improving Balance in Patients With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Front Neurol. 2021 Dec 10;12:773459.
8. Belchior P, Marsiske M, Leite WL, Yam A, Thomas K, Mann W. Older Adults’ Engagement During an Intervention Involving Off-the-Shelf Videogame. Games Health J. 2016 Jun 1;5(3):151–6.
9. Massetti T, da Silva TD, Crocetta TB, Guarnieri R, de Freitas BL, Bianchi Lopes P, et al. The Clinical Utility of Virtual Reality in Neurorehabilitation: A Systematic Review. J Cent Nerv Syst Dis. 2018 Nov 27;10:1179573518813541.
10. Vieira C, Ferreira da Silva Pais-Vieira C, Novais J, Perrotta A. Serious Game Design and Clinical Improvement in Physical Rehabilitation: Systematic Review. JMIR Serious Games. 2021 Sep 23;9(3):e20066.
11. Pau M, Coghe G, Corona F, Leban B, Marrosu MG, Cocco E. Effectiveness and Limitations of Unsupervised Home-Based Balance Rehabilitation with Nintendo Wii in People with Multiple Sclerosis. BioMed Res Int. 2015;2015:916478.
12. Gatica-Rojas V, Méndez-Rebolledo G. Virtual reality interface devices in the reorganization of neural networks in the brain of patients with neurological diseases. Neural Regen Res. 2014 Apr 15;9(8):888–96.
13. Robert PH, König A, Amieva H, Andrieu S, Bremond F, Bullock R, et al. Recommendations for the use of Serious Games in people with Alzheimer’s Disease, related disorders and frailty. Front Aging Neurosci. 2014 Mar 24;6:54.
14. Wiemeyer J, Deutsch J, Malone LA, Rowland JL, Swartz MC, Xiong J, et al. Recommendations for the Optimal Design of Exergame Interventions for Persons with Disabilities: Challenges, Best Practices, and Future Research. Games Health J. 2015 Feb 1;4(1):58–62.
15. Caruso F, Peretti S, Barletta VS, Pino MC, Mascio TD. Recommendations for Developing Immersive Virtual Reality Serious Game for Autism: Insights From a Systematic Literature Review. IEEE Access. 2023;11:74898–913.
16. Paraskevopoulos IT, Tsekleves E, Craig C, Whyatt C, Cosmas J. Design guidelines for developing customised serious games for Parkinson’s Disease rehabilitation using bespoke game sensors. Entertain Comput. 2014 Dec 1;5(4):413–24.
17. Allen DD, Gadayan J, Hughes R, Magdalin C, Jang C, Schultz A, et al. Patterns of balance loss with systematic perturbations in Parkinson’s disease and multiple sclerosis. Neurorehabilitation. 49(4):607–18.
18. Arpan I, Fling B, Powers K, Horak FB, Spain RI. Structural Neural Correlates of Impaired Postural Control in People with Secondary Progressive Multiple Sclerosis. Int J MS Care. 2020;22(3):123–8.
19. Zackowski KM, Smith SA, Reich DS, Gordon-Lipkin E, Chodkowski BA, Sambandan DR, et al. Sensorimotor dysfunction in multiple sclerosis and column-specific magnetization transfer-imaging abnormalities in the spinal cord. Brain J Neurol. 2009 May;132(Pt 5):1200–9.
20. Abdel-Aziz K, Schneider T, Solanky BS, Yiannakas MC, Altmann DR, Wheeler-Kingshott CAM, et al. Evidence for early neurodegeneration in the cervical cord of patients with primary progressive multiple sclerosis. Brain. 2015 Jun;138(6):1568.
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22. Aliabadi S, Khanmohammadi R, Olyaei G, Ghotbi N, Talebian S, Moghadasi AN. Comparison of the Position Sense of the Knee Joint in Patients With Multiple Sclerosis and Healthy Controls | Journal of Modern Rehabilitation. [cited 2025 Apr 18]; Available from: https://jmr.tums.ac.ir/index.php/jmr/article/view/230
23. Cameron MH, Horak FB, Herndon RR, Bourdette D. Imbalance in Multiple Sclerosis: A Result of Slowed Spinal Somatosensory Conduction. Somatosens Mot Res. 2008;25(2):113–22.
24. Lee CY, Huisinga JM, Choi IY, Lynch SG, Lee P. Correlation between spinal cord diffusion tensor imaging and postural response latencies in persons with multiple sclerosis: A pilot study. Magn Reson Imaging. 2020 Feb;66:226–31.
25. Ganesan M, Kanekar N, Aruin AS. Direction-specific impairments of limits of stability in individuals with multiple sclerosis. Ann Phys Rehabil Med. 2015 Jun;58(3):145–50.
26. Huisinga JM, St. George RJ, Spain R, Overs S, Horak FB. Postural response latencies are related to balance control during standing and walking in patients with multiple sclerosis. Arch Phys Med Rehabil. 2014 Jul;95(7):1390–7.
27. Ibrahim H, Diab A, Khalil M, Guardiola E. Personalized Game Design for Balance Rehabilitation in Multiple Sclerosis: Insights from Neuroimaging and Neurophysiological Test. In: 2024 International Conference on Smart Systems and Power Management (IC2SPM) [Internet]. 2024 [cited 2025 Jan 22]. p. 17–22. Available from: https://ieeexplore.ieee.org/document/10841339/references#references
28. Sarasmita MA, Lee YH, Chan FY, Chen HY. Digital Serious Games to Promote Behavior Change in Children With Chronic Diseases: Scoping Review and Development of a Self-Management Learning Framework. J Med Internet Res. 2024 Aug 19;26:e49692.
29. Verschueren S, Buffel C, Stichele GV. Developing Theory-Driven, Evidence-Based Serious Games for Health: Framework Based on Research Community Insights. JMIR Serious Games. 2019 May 2;7(2):e11565.
30. Robinson J, Dixon J, Macsween A, van Schaik P, Martin D. The effects of exergaming on balance, gait, technology acceptance and flow experience in people with multiple sclerosis: a randomized controlled trial. BMC Sports Sci Med Rehabil. 2015 Apr 17;7:8.
31. Tollár J, Nagy F, Tóth BE, Török K, Szita K, Csutorás B, et al. Exercise Effects on Multiple Sclerosis Quality of Life and Clinical-Motor Symptoms. Med Sci Sports Exerc. 2020 May;52(5):1007–14.
32. Prosperini L, Fortuna D, Giannì C, Leonardi L, Marchetti MR, Pozzilli C. Home-based balance training using the Wii balance board: a randomized, crossover pilot study in multiple sclerosis. Neurorehabil Neural Repair. 2013 Aug;27(6):516–25.
33. Nilsagård YE, Forsberg AS, von Koch L. Balance exercise for persons with multiple sclerosis using Wii games: a randomised, controlled multi-centre study. Mult Scler Houndmills Basingstoke Engl. 2013 Feb;19(2):209–16.
34. Brichetto G, Spallarossa P, de Carvalho MLL, Battaglia MA. The effect of Nintendo® Wii® on balance in people with multiple sclerosis: a pilot randomized control study. Mult Scler Houndmills Basingstoke Engl. 2013 Aug;19(9):1219–21.
35. Plow M, Finlayson M. Potential Benefits of Nintendo Wii Fit Among People with Multiple Sclerosis: A Longitudinal Pilot Study. Int J MS Care. 2011 Spring;13(1):21.
36. Yazgan YZ, Tarakci E, Tarakci D, Ozdincler AR, Kurtuncu M. Comparison of the effects of two different exergaming systems on balance, functionality, fatigue, and quality of life in people with multiple sclerosis: A randomized controlled trial. Mult Scler Relat Disord. 2020 Apr;39:101902.
37. Alba-Rueda A, Lucena-Anton D, De Miguel-Rubio A. Effectiveness of two different exergaming systems in addition to conventional treatment for physical therapy in patients with multiple sclerosis: A study protocol for a multicenter, assessor-blind, 24-week, randomized controlled trial. Digit Health. 2024 Oct 18;10:20552076241287874.
38. Gutiérrez RO, Galán Del Río F, Cano de la Cuerda R, Alguacil Diego IM, González RA, Page JCM. A telerehabilitation program by virtual reality-video games improves balance and postural control in multiple sclerosis patients. NeuroRehabilitation. 2013;33(4):545–54.
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| Issue | Articles in Press | |
| Section | Review Article(s) | |
| Keywords | ||
| Postural Balance, User-Centered Design, Exergaming, Rehabilitation, Multiple Sclerosis | ||
| Rights and permissions | |
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Ibrahim H, Guardiola E, Diab A. Recommendations for Developing User-Centered Games for Balance Rehabilitation in Multiple Sclerosis: An Interdisciplinary Approach. jmr. 2025;(-).
