Design Recommendations for User-Centered Games for Multiple Sclerosis Balance Rehabilitation: An Evidence Review
Abstract
Introduction: 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 held promises, their overall effectiveness remains inconclusive, primarily because they rely on commercial games. This issue underscores the critical need for user-centered games tailored to patients’ specific needs. Despite this necessity, the existing literature lacks established frameworks to develop such games, highlighting a gap. Therefore, the objective of this research was to propose the first evidence-based framework to create 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 examining commercial games used in clinical studies, identifying their mechanics and limitations. The second step involved reviewing the literature to identify relevant findings that could help the development of user-centered games.
Results: A set of targeted recommendations was proposed, emphasizing the need to develop adaptable games with focused therapeutic designs and to address the distinct balance impairments observed in PwMS effectively. A game prototype was also presented to illustrate the practical applications of these recommendations.
Conclusion: This research establishes the first structured framework to design user-centered exergames for balance rehabilitation in PwMS. In addition to its theoretical insights, this framework provides actionable guidelines for developing clinically effective exergames that align with patient impairments and therapeutic needs. Ultimately, this work will contribute to improved therapeutic outcomes, enhanced patient care, and advancements in both rehabilitation and game design fields.
Anders P, Bengtson EI, Grønvik KB, Skjæret-Maroni N, Vereijken B. Balance training in older adults using exergames: game speed and cognitive elements affect how seniors play. Frontiers in Sports and Active Living. 2020; 2:54. [DOI:10.3389/fspor.2020.00054] [PMID]
Hoffmann K, Wiemeyer J. Physical and motivational effects of exergames in healthy adults-Protocol for a systematic review and meta-analysis. Plos One. 2022; 17(4):e0266913. [DOI:10.1371/journal.pone.0266913] [PMID]
Pirovano M, Surer E, Mainetti R, Lanzi PL, Alberto Borghese N. Exergaming and rehabilitation: A methodology for the design of effective and safe therapeutic exergames. Entertainment Computing. 2016; 14:55-65. [DOI:10.1016/j.entcom.2015.10.002]
Mat Rosly M, Mat Rosly H, Davis Oam GM, Husain R, Hasnan N. Exergaming for individuals with neurological disability: A systematic review. Disability and Rehabilitation. 2017; 39(8):727-35. [DOI:10.3109/09638288.2016.1161086] [PMID]
Baigi SFM, Sarbaz M, Sobhani-Rad D, Mousavi AS, Dahmardeh F, Kimiafar K. Investigating the effects of telerehabilitation on improving the physical activity of individuals with multiple sclerosis: A systematic review of randomized controlled trial . Journal of Modern Rehabilitation. 2024; 18(1):1-14. [DOI: 10.18502/jmr.v18i1.14724]
Taylor M, Griffin M. The use of gaming technology for rehabilitation in people with multiple sclerosis. Multiple Sclerosis. 2015; 21(4):355-71. [DOI:10.1177/1352458514563593] [PMID]
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. Frontiers in Neurology. 2021; 12:773459. [DOI:10.3389/fneur.2021.773459] [PMID]
Belchior P, Marsiske M, Leite WL, Yam A, Thomas K, Mann W. Older adults’ engagement during an intervention involving off-the-shelf videogame. Games for Health Journal. 2016; 5(3):151-6. [DOI:10.1089/g4h.2015.0049] [PMID]
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. Journal of Central Nervous System Disease. 2018; 10:1179573518813541. [DOI:10.1177/1179573518813541] [PMID]
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; 9(3):e20066. [DOI:10.2196/20066] [PMID]
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 Research International. 2015; 2015:916478. [DOI:10.1155/2015/916478] [PMID]
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 Regeneration Research. 2014; 9(8):888-96. [DOI:10.4103/1673-5374.131612] [PMID]
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. Frontiers in Aging Neuroscience. 2014; 6:54. [DOI:10.3389/fnagi.2014.00054] [PMID]
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 For Health Journal. 2015; 4(1):58-62. [DOI:10.1089/g4h.2014.0078] [PMID]
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. [DOI:10.1109/ACCESS.2023.3296882]
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. Entertainment Computing. 2014; 5(4):413-24. [DOI:10.1016/j.entcom.2014.10.006]
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. 2021; 49(4):607-18. [DOI:10.3233/NRE-210200] [PMID]
Arpan I, Fling B, Powers K, Horak FB, Spain RI. Structural neural correlates of impaired postural control in people with secondary progressive multiple sclerosis. International Journal of MS Care. 2020; 22(3):123-8. [DOI:10.7224/1537-2073.2019-004] [PMID]
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. 2009; 132(Pt 5):1200-9. [DOI:10.1093/brain/awp032] [PMID]
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; 138(6):1568. [DOI:10.1093/brain/awv086] [PMID]
Fling BW, Dutta GG, Schlueter H, Cameron MH, Horak FB. Associations between proprioceptive neural pathway structural connectivity and balance in people with multiple sclerosis. Frontiers in Human Neuroscience. 2014; 8:814. [DOI:10.3389/fnhum.2014.00814] [PMID]
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. 2019; 13(1):59-64. [Link]
Cameron MH, Horak FB, Herndon RR, Bourdette D. Imbalance in multiple sclerosis: A result of slowed spinal somatosensory conduction. Somatosensory & Motor Research. 2008; 25(2):113-22. [DOI:10.1080/08990220802131127] [PMID]
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. Magnetic Resonance Imaging. 2020; 66:226-31. [DOI:10.1016/j.mri.2019.11.004] [PMID]
Ganesan M, Kanekar N, Aruin AS. Direction-specific impairments of limits of stability in individuals with multiple sclerosis. Annals of Physical and Rehabilitation Medicine. 2015; 58(3):145-50. [DOI:10.1016/j.rehab.2015.04.002] [PMID]
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. Archives of Physical Medicine and Rehabilitation. 2014; 95(7):1390-7. [DOI:10.1016/j.apmr.2014.01.004] [PMID]
Ibrahim H, Diab A, Khalil M, Guardiola E. Personalized game design for balance rehabilitation in multiple sclerosis: Insights from neuroimaging and neurophysiological test. Paper presented at: 2024 International Conference on Smart Systems and Power Management (IC2SPM). 2025 January 22; Beirut, Lebanon. [DOI:10.1109/IC2SPM62723.2024.10841339]
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. Journal of Medical Internet Research. 2024; 26:e49692. [DOI:10.2196/49692] [PMID]
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; 7(2):e11565. [DOI:10.2196/11565] [PMID]
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 Science, Medicine & Rehabilitation. 2015; 7:8. [DOI:10.1186/s13102-015-0001-1] [PMID]
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. Medicine and Science in Sports and Exercise. 2020; 52(5):1007-14. [DOI:10.1249/MSS.0000000000002228] [PMID]
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. Neurorehabilitation and Neural Repair. 2013; 27(6):516-25. [DOI:10.1177/1545968313478484] [PMID]
Nilsagård YE, Forsberg AS, von Koch L. Balance exercise for persons with multiple sclerosis using Wii games: A randomised, controlled multi-centre study. Multiple Sclerosis. 2013; 19(2):209-16. [DOI:10.1177/1352458512450088] [PMID]
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. Multiple Sclerosis. 2013; 19(9):1219-21. [DOI:10.1177/1352458512472747] [PMID]
Plow M, Finlayson M. Potential benefits of nintendo Wii fit among people with multiple sclerosis: A longitudinal pilot study. International Journal of MS Care. 2011; 13(1):21. [DOI:10.7224/1537-2073-13.1.21] [PMID]
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. Multiple Sclerosis and Related Disorders. 2020; 39:101902. [DOI:10.1016/j.msard.2019.101902] [PMID]
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. Digital Health. 2024; 10:20552076241287874. [DOI:10.1177/20552076241287874] [PMID]
Gutiérrez RO, Galán Del Río F, Cano de la Cuerda R, Alguacil Diego IM, González RA, et al. A telerehabilitation program by virtual reality-video games improves balance and postural control in multiple sclerosis patients. NeuroRehabilitation. 2013; 33(4):545-54. [DOI:10.3233/NRE-130995] [PMID]
Kramer A, Dettmers C, Gruber M. Exergaming with additional postural demands improves balance and gait in patients with multiple sclerosis as much as conventional balance training and leads to high adherence to home-based balance training. Archives of Physical Medicine and Rehabilitation. 2014; 95(10):1803-9. [DOI:10.1016/j.apmr.2014.04.020] [PMID]
Molhemi F, Monjezi S, Mehravar M, Shaterzadeh-Yazdi MJ, Salehi R, Hesam S, Mohammadianinejad E. Effects of virtual reality vs conventional balance training on balance and falls in people with multiple sclerosis: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2021; 102(2):290-9. [DOI: 10.1016/j.apmr.2020.09.395] [PMID]
Cimino V, Chisari CG, Raciti G, Russo A, Veca D, Zagari F, et al. Objective evaluation of Nintendo Wii Fit Plus balance program training on postural stability in Multiple Sclerosis patients: A pilot study. International Journal Of Rehabilitation Research. 2020; 43(3):199-205. [DOI:10.1097/MRR.0000000000000408] [PMID]
Yazgan YZ, Tarakci E, Tarakci D, Ozdincler AR. Treatment of balance problems with Nintendo Wii-Fit games in multiple sclerosis patients: A pilot study. Paper presented at: 31st Congress of the European Committee for Treatment and Research in Multiple Sclerosis. 2024 November 21; Barcelona, Spain. [DOI:10.1177/1352458515602642]
Eftekharsadat B, Babaei-Ghazani A, Mohammadzadeh M, Talebi M, Eslamian F, Azari E. Effect of virtual reality-based balance training in multiple sclerosis. Neurological Research. 2015; 37(6):539-44. [DOI:10.1179/1743132815Y.0000000013] [PMID]
Behrouz Jazi AH, Rasti J, Etemadifar M. Balance rehabilitation for patients with Multiple Sclerosis using a Kinect®-based virtual training program. Journal of Clinical Neuroscience. 2023; 116:104-11. [DOI:10.1016/j.jocn.2023.08.026] [PMID]
Schättin A, Häfliger S, Meyer A, Früh B, Böckler S, Hungerbühler Y, et al. Design and evaluation of user-centered exergames for patients with multiple sclerosis: Multilevel usability and feasibility studies. JMIR Serious Games. 2021; 9(2):e22826. [DOI:10.2196/22826] [PMID]
Lozano-Quilis JA, Gil-Gómez H, Gil-Gómez JA, Albiol-Pérez S, Palacios-Navarro G, Fardoun HM, et al. Virtual rehabilitation for multiple sclerosis using a kinect-based System: Randomized controlled trial. JMIR Serious Games. 2014; 2(2):e12. [DOI:10.2196/games.2933] [PMID]
Thomas S, Fazakarley L, Thomas PW, Collyer S, Brenton S, Perring S, et al. Mii-vitaliSe: A pilot randomised controlled trial of a home gaming system (Nintendo Wii) to increase activity levels, vitality and well-being in people with multiple sclerosis. BMJ Open. 2017; 7(9):e016966. [DOI:10.1136/bmjopen-2017-016966] [PMID]
Manser P, Adcock-Omlin M, de Bruin ED. Design considerations for an exergame-based training intervention for older adults with mild neurocognitive disorder: Qualitative study including focus groups with experts and health care professionals and individual semistructured in-depth patient interviews. JMIR Serious Games. 2023; 11:e37616. [DOI:10.2196/37616] [PMID]
Nachmani H, Paran I, Salti M, Shelef I, Melzer I. Examining different motor learning paradigms for improving balance recovery abilities among older adults, random vs. block training-study protocol of a randomized non-inferiority controlled trial. Frontiers in Human Neuroscience. 2021; 15:624492. [DOI:10.3389/fnhum.2021.624492] [PMID]
Mansfield A, Peters AL, Liu BA, Maki BE. A perturbation-based balance training program for older adults: Study protocol for a randomised controlled trial. BMC Geriatrics. 2007; 7:12. [DOI:10.1186/1471-2318-7-12] [PMID]
Brincks J, Dalgas U, Franzén E, Callesen J, Wallin A, Johansson S. Unwrapping the “black box” of balance training in people with multiple sclerosis - A descriptive systematic review of intervention components, progression, and intensity. Multiple Sclerosis And Related Disorders. 2023; 69:104412. [DOI:10.1016/j.msard.2022.104412] [PMID]
Cameron MH, Lord S. Postural control in multiple sclerosis: Implications for fall prevention. Current Neurology and Neuroscience Reports. 2010; 10(5):407-12. [DOI:10.1007/s11910-010-0128-0] [PMID]
Forsberg A, von Koch L, Nilsagård Y. Effects on balance and walking with the coduse balance exercise program in people with multiple sclerosis: A multicenter randomized controlled trial. Multiple Sclerosis International. 2016; 2016:7076265. [DOI:10.1155/2016/7076265] [PMID]
Cattaneo D, Jonsdottir J, Coote S. Targeting dynamic balance in falls-prevention interventions in multiple sclerosis. International Journal of MS Care. 2014; 16(4):198-202. [DOI:10.7224/1537-2073.2014-062] [PMID]
Aruin AS, Kanekar N, Lee YJ. Anticipatory and compensatory postural adjustments in individuals with multiple sclerosis in response to external perturbations. Neuroscience Letters. 2015; 591:182-6. [DOI:10.1016/j.neulet.2015.02.050] [PMID]
Gera G, Fling BW, Horak FB. Cerebellar white matter damage is associated with postural sway deficits in people with multiple sclerosis. Archives of Physical Medicine and Rehabilitation. 2020; 101(2):258-64. [DOI:10.1016/j.apmr.2019.07.011] [PMID]
Doty RL, MacGillivray MR, Talab H, Tourbier I, Reish M, Davis S, et al. Balance in multiple sclerosis: Relationship to central brain regions. Experimental Brain Research. 2018; 236(10):2739-50. [DOI:10.1007/s00221-018-5332-1] [PMID]
Odom AD, Richmond SB, Fling BW. White matter microstructure of the cerebellar peduncles is associated with balance performance during sensory re-weighting in people with multiple sclerosis. Cerebellum. 2021; 20(1):92-100. [DOI:10.1007/s12311-020-01190-y] [PMID]
Memarmoghadam M, Shahraki M, Orangi BM, Correale L, Peyré-Tartaruga LA. The effect of sensorimotor synchronization on gait spatiotemporal parameters in women with multiple sclerosis. Journal of Modern Rehabilitation. 2024; 19(1):71-9. [Link]
Gouglidis V, Nikodelis T, Hatzitaki V, Amiridis IG. Changes in the limits of stability induced by weight-shifting training in elderly women. Experimental Aging Research. 2011; 37(1):46-62. [DOI:10.1080/0361073X.2010.507431] [PMID]
Khallaf ME. Effect of task-specific training on trunk control and balance in patients with subacute stroke. Neurology Research International. 2020; 2020:5090193. [DOI:10.1155/2020/5090193] [PMID]
Teasell RW, Foley NC, Salter KL, Jutai JW. A blueprint for transforming stroke rehabilitation care in Canada: the case for change. Archives of Physical Medicine and Rehabilitation. 2008; 89(3):575-8. [DOI:10.1016/j.apmr.2007.08.164] [PMID]
Wiskerke E, Kool J, Hilfiker R, Sattelmayer KM, Verheyden G. determining the optimal virtual reality exergame approach for balance therapy in persons with neurological disorders using a rasch analysis: Longitudinal observational study. JMIR Serious Games. 2022; 10(1):e30366. [DOI:10.2196/30366] [PMID]
Willaert J, De Vries AW, Tavernier J, Van Dieen JH, Jonkers I, Verschueren S. Does a novel exergame challenge balance and activate muscles more than existing off-the-shelf exergames? Journal of Neuroengineering and Rehabilitation. 2020; 17(1):6. [DOI:10.1186/s12984-019-0628-3] [PMID]
Melzer I, Benjuya N, Kaplanski J, Alexander N. Association between ankle muscle strength and limit of stability in older adults. Age and Ageing. 2009; 38(1):119-23. [DOI:10.1093/ageing/afn249] [PMID]
Kanekar N, Aruin AS. The role of clinical and instrumented outcome measures in balance control of individuals with multiple sclerosis. Multiple Sclerosis International. 2013; 2013:190162. [DOI:10.1155/2013/190162] [PMID]
Callesen J, Cattaneo D, Brincks J, Kjeldgaard Jørgensen ML, Dalgas U. How do resistance training and balance and motor control training affect gait performance and fatigue impact in people with multiple sclerosis? A randomized controlled multi-center study. Multiple Sclerosis. 2020; 26(11):1420-32. [DOI:10.1177/1352458519865740] [PMID]
Amiri Z, Sekhavat YA, Goljaryan S. A Framework for rehabilitation games to improve balance in people with multiple sclerosis (MS). Paper presented at: 2018 2nd National and 1st International Digital Games Research Conference: Trends, Technologies, and Applications (DGRC). 2025 April 25; Tehran, Iran. [DOI:10.1109/DGRC.2018.8712038]
| Issue | Vol 20 No 1 (2026) | |
| Section | Review Article(s) | |
| DOI | https://doi.org/10.18502/jmr.v20i1.21022 | |
| Keywords | ||
| Postural balance User-Centered design Exergaming Rehabilitation Multiple sclerosis | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |

