Boureaud, Justine

Charles, DK

Holmes, Dominic

McClean, S

McDonough, S M

Morrow, PJ

Games are increasingly used by physiotherapists in rehabilitation and the gamification of rehabilitation processes is an increasingly common practice. A key motivation for injecting playful or gameful activities into rehabilitation is to enhance engagement for home rehabilitation exercises by making them more fun. Multi-disciplinary cooperation is important to designing gameful activities. However, system design and development can be challenging between software engineers, health professionals, and academics due to terminology and knowledge differences. Sometimes skill and knowledge levels are also not optimal within the team. In both cases a comprehensive Rehabilitation Game Model (RGM) built on established principles, with an associated tool, can facilitate an effective design process. Factors that can be missed without use of a structured process include the potential impact of symptoms and variation in user demographic, personality or interaction preference. Our RGM helps game designers put a greater focus on variations between people in designing rehabilitation games. In this paper we provide an overview of the RGM and extending it to include rehabilitation aspects. We apply it to upper arm stroke rehabilitation. We present a representation of the output from the RGM that can form the basis for advice and guidance to serious game designers of upper arm stroke rehabilitation games

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Application of a rehabilitation game model for assistive technology software designJ Boureaud1, D E Holmes2, D K Charles2, S McClean2, PJ Morrow2 1Faculty of Science and Technique, University of Limoges,123 Avenue Albert Thomas, Limoges, FRANCE2School of Computing and Information Engineering, University of Ulster,Cromore Rd, Coleraine, NORTHERN IRELANDjustine.boureaud@etu.unilim.fr, Holmes-D2@email.ulster.ac.uk, {dk.charles, si.mcclean, pj.morrow}@ulster.ac.ukABSTRACTGame design is increasingly influencing physiotherapist practice. A key motivation for injecting playful or gameful activities into rehabilitation is to enhance engagement by making them more fun. Multi-disciplinary cooperation is important to designing gameful activities. However, system design and development can be challenging between software engineers, health professionals, and academics due to terminology and knowledge differences. Sometimes skill and knowledge levels are also not optimal within the team. In both cases a comprehensive Rehabilitation Game Model (RGM) built on established principles, with an associated tool, can facilitate an effective design process. Factors that can be missed without use of a structured process include the potential impact of symptoms and variation in user demographic, personality or interaction preference. Our RGM helps game designers put a greater focus on variations between people in designing rehabilitation games. In this paper we provide an overview of the RGM and apply it to upper arm stroke rehabilitation. We present a representation of the output from the RGM that can form the basis for advice and guidance to serious game designers of upper arm stroke rehabilitation games.1. INTRODUCTIONThe creation of serious games for use in assistive technologies is becoming increasingly popular. Physiotherapy is particularly applicable to games and gamification since physical rehabilitation programmes can potentially be mundane, are often challenging, and require adherence to prescribed schedules. Gamification is the application of game-design elements and game principles in non-game contexts (Deterding et al, 2011) so as to improve processes and systems in relation to a broad range of contexts including physical exercise. Recently, gamification has been used in rehabilitation to help people become more engaged in their rehabilitation (Szaniawski et al, 2015), and to encourage them to complete their exercises more regularly and consistently. Gamification can embed principles of psychology in the form of reinforcement of positive behaviours and rewards mechanisms to improve adherence through motivational techniques. Games and virtual reality (VR) can be used to add fun to the process through structuring the exercises in entertaining contexts and embedded gamification features. To have an effective rehabilitation game, the game design needs to be adapted to the type of exercise and also to the people who will play it. Designing and creating effective assistive technologies can be difficult and time consuming due to the complexity of rehabilitation requirements. Development of games and VR rehabilitation systems is especially challenging as it adds another dimension to the expertise required of the multidisciplinary team; requiring knowledge of game design, game asset creation, technical game development skills, software engineering, physiotherapy and end user experience. This is a challenging process, even for experienced designers, and so we have developed the Rehabilitation Game Model (RGM) (Holmes et al., 2015) to guide the process. 1.1 	The Rehabilitation Game Model (RGM)Having a structured tool that aids the creation and evaluation of personalised games is important for communication between non-professionals and professionals across multiple disciplines during the design and development process. Facilitating interaction between disciplines as early as possible helps focus efforts on a game that accounts for personality – rehabilitation guidelines and exercises – as user gaming preferences to encourage enjoyment. Thus allowing all parties to clearly understand and quickly define a personalised game idea ready for development.The RGM has guides the design and implementation of effective rehabilitation games and consists of mappings three core aspects (Fig 1): a gamification typology, a comprehensive set of game design patterns, and core behaviour change techniques from psychology. The RGM is applied to a rehabilitation context such as upper arm stroke rehabilitation. A gamification typology (such as Marczewski, 2015b) takes into account variation between types of people and the ways that they may be motivated. In the RGM, gamification types are based on Marczewski’s (2015a) Hexad. The Hexad gamification types are in part based on well-known player types, and in part on other psychological personality models including Self-Determination Theory. In our application of the RGM these are mapped to a set of game design patterns by Bjork & Holopainen (2004) containing 300 game mechanics that can be used in a number of combinations to design novel gameplay suited to Marczewski’s Hexad gamification types. Behaviour change techniques (Michie et al, 2014) are also integrated and mapped against the game mechanics in order to shape behaviour and help tailor games to encourage improved adherence to exercise. The six Hexad gamification user types are:Disruptor–motivated by change they want to disrupt the system directly or through others with a positive or negative outcome.Free Spirit–motivated by autonomy they want to explore, be creative and have choices.Achiever–motivated by mastery they are all about self-improvement and like to be challenged in order to better themselves.Player–motivated by rewards they are selfish and do what is necessary to win or be better than others.Socializer–motivated by relatedness they want to create a social connection with others.Philanthropist–motivated by purpose to interact and are also altruistic towards others.Figure 1 provides an operational illustration of the RGM, integrating the well-known MDA (mechanics, dynamics, aesthetics) model of a game. The core component is the game and respective game mechanics are constructed from fundamental game design patterns. A model of player motivation is embedded using gamification types (in this instance Hexad types). Player behaviour is modelled using COM-B (Michie et al, 2014) (Capability, Opportunity, Motivation for Behaviour change) and in particular key behaviour change techniques which are mapped to a particular group of game mechanics and thus player type (see colour coding). Player interactions on the game mechanics (Dynamics) result in change of game state and the provision of feedback to the player. Feedback to the player can be visual, auditory, or haptic and is central to the user experience (Aesthetics). Game mechanics can promote certain behaviour changes according to the challenges brought about by the particular player type’s interactions on the games mechanics. For example, Achievers may want to fight (interact) against a boss monster (game mechanic) to test their learnt skills and knowledge, giving a sense of progression when achieving this high level goal (feedback, behaviour technique (Goal setting) & aesthetics).Figure 1. The RGM comprises: player motivational, game design patterns, and user behaviour.2. APPLICATION OF THE RGM TO UPPER ARM STROKE REHABILITATIONOur RGM and initial online prototype tool was constructed over a six-month period and links core game mechanics from around three hundred game design patterns to core gamification types.  An appropriately designed tool can embed much of the multi-disciplinary expert knowledge, logical processing and decision making required to support a less experienced team to make good design decisions (Fig 2). In this way rehabilitation games may be created that are more usable, user friendly, functional and fun, thus ensuring patients who will use it will be more motivated and more inclined to engage in regular, high quality rehabilitation. Our system enables a physiotherapist to input data and tailor system parameters based on patient requirements. For example, symptoms or comorbidities that the game designer needs to take into account to create effective games for a given population and health condition. As well as the specific rehabilitation requirements, demographics factors such as age, gender and culture are also taken into account. In this way we can use available statistical population information to guide design guidance outcome from the tool. Figure 2. Visualisation of the RGM in action. 2.1 	RGM Applied to Stroke RehabilitationFigure 3 provides a graphical illustration of the RGM applied to physical therapy for stroke survivors. The process proceeds as follows and may be implemented with an online tool or offline with guidance documentation: Key symptoms are identified: For stroke we may consider ataxia, visual problems, spasticity, focus and thinking problems and aphasia. Links are generated between these symptoms and design challenges for game designers: For example, aphasia is a communication disorder that results from damage or injury to language parts of the brain. Aphasia gets in the way of a person's ability to use or understand words (Lava 2014). They may also have problems understanding conversation, reading and comprehending written words, writing words, and using numbers. So the challenge to the game designer would be to use images rather than words for tutorials and gameplay. User demographics are specified: Statistics of people who have suffered a stroke, as well as age and gender. For example, typically people afflicted by a stroke tend to be from the older population and that there are almost identical numbers of men and women. Culture and ethnic group can also have an impact on rehabilitation game design.Consider motivation through expected gamification user types for the target population. From Figure 3 it can be seen that several of the bubbles are larger than others and the size of these bubbles is specific to the target population. Within the same style of bubble, a larger bubble indicates a larger impact on the game design. For example, for stroke survivors the socialiser gamification type is considered to be important due to typical population age, positive mental health, and the need for able bodied support. Also we can see the bubble of visual problems is larger, because up to 66% of people who had a stroke are affected by such problems and only 33% have aphasia; this is why the bubble of aphasia are smaller.3. CONCLUSIONIn this paper we have outlined our Rehabilitation Game Model and provided an illustration of its application to stroke rehabilitation. From this illustration, we can see a paper based or online tool embedding the RGM can aid the design process and safeguard against designer play preference or experience bias. It encourages the designer not to just consider the core physiotherapy requirements based on an average patient but take in consideration a wide range of factors and demographics. The approach supports experts (and non-experts) with different background to work effectively on the same rehabilitation game project, reducing project risks related to difficulty in communication. We are currently using this RGM online tool to design upper arm rehabilitation games for stroke survivors. This will enable us to evaluate the approach more fully. It is also our intention to develop the tool further so that it can be made available online for other designers.Figure 3. Rehabilitation Game Model (RGM) to serious game design for stroke physical therapy.4. REFERENCESBjork, S, and Holopainen, J, (2004), Patterns in Game Design. Charles River Media Game Development, p. 423.Deterding, S, Sicart, M, Nacke, L, O’Hara, K, and Dixon, D, (2011),  Gamification: using game-design elements in non-gaming contexts,  CHI EA '11 CHI '11 Extended Abstracts on Human Factors in Computing Systems, Vancouver, pp.2425-2428.Holmes, D, Charles, D, Morrow, P, McClean, S, and McDonough, S, (2015), Rehabilitation Game Model for Personalised Exercise, IEEE Intl. Conf. on Interactive Technologies and Games , Nottingham, pp.41-48.Lava, NS, (2014), An Overview of Aphasia, WebMD Medical Reference. [Online]. Available : http://goo.gl/bVsTEQ.Marczewski, A, (2015). User Types. In Even Ninja Monkeys Like to Play: Gamification, Game Thinking and Motivational Design, 1st ed., pp. 65-80.Marczewski, A, (2015), 47 Gamification elements, mechanics and ideas. [Online]. Available: http://www.gamified.uk/2015/02/04/47-gamification-elements-mechanics-and-ideas/.Michie, S, Atkins, L, West, R, (2014), The Behaviour Change Wheel : A Guide to Designing Interventions, Silverback Publishing, London p. 329.Szaniawski, M, Boess, S, Kraan, G, and Goossens, R, (2015), Enhancing engagement with motor rehabilitation therapy through gamified rehabilitation interactions. Third European Conference in Design4Health, Sheffield UK4Proc. 11th Intl Conf. Disability, Virtual Reality & Associated Technologies Los Angeles, California, USA, 20–22 Sept. 2016©2014 ICDVRAT; ISBN 978-0-7049-1547-33Proc. 11th Intl Conf. Disability, Virtual Reality & Associated Technologies Los Angeles, California, USA, 20–22 Sept. 20162016 ICDVRAT; ISBN 978-0-7049-1547-3

Application of a Rehabilitation Game Model to Assistive Technology Design

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