I really hate the weasel words used. 'potential','more appropriate','more'.
We'll never get; 'Do this and get these results' until researchers are instructed to deliver objective starting points and objective protocols.
The use of game modes to promote engagement and social involvement in multi-user serious games: a within-person randomized trial with stroke survivors
Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 62 (2021)
Abstract
Background
Serious games are promising for stroke rehabilitation, with studies showing a positive impact on reducing motor and cognitive deficits. However, most of the evidence is in the context of single-user rehabilitation, and little is known concerning the impact in multi-user settings. This study evaluates the impact that different game modes can have on engagement and social involvement during a two-user game. Specifically, we want to understand the benefits of game modalities based on competition, co-activation, and collaboration and analyze the influence of different motor and cognitive deficits and personality traits.
Methods
We developed a two-player setup—using tangible objects and a large screen interactive table—for upper limb rehabilitation purposes. We implemented a game that, while keeping the same basic mechanics, can be played in the three different modes (Competitive, Co-active, and Collaborative). We ran a within-person randomized study with 21 stroke survivors that were paired and played the game in its three versions. We used the Game Experience Questionnaire—Core Module to assess engagement and the Social Presence Module to assess Social Involvement. For personality, motor, and cognitive function, users answered the International Personality Item Pool (short version), Fugl-Meyer Assessment—Upper Extremity, Modified Ashworth Scale, and Montreal Cognitive Assessment, respectively.
Results
The Collaborative mode promoted significantly more Behavioral Involvement. The Competitive mode promoted more Flow and Challenge than the Co-active mode with participants with better cognitive performance, with low extraversion, or with higher motor skills. Participants with higher cognitive deficits reported more Competence with the Co-active mode.
Conclusions
Our results indicate that, for multi-user motor rehabilitation settings, the collaborative mode is the more appropriate gaming approach to promote social involvement, showing a high potential for increasing adherence and effectiveness of therapy. Additionally, we show that a player's motor and cognitive ability and personality should be considered when designing personalized tasks for multiplayer settings.
Introduction
The use of novel technologies for neurorehabilitation has increased during the last years, leading to new rehabilitation methods with multifold benefits [1]. Depending on the technology, we can benefit from personalization to individual patients' specific needs, the ability to measure with objectivity, or provide visual, haptic, or auditory real-time feedback [2]. Additional benefits emerge with the use of Virtual Reality (VR), which can provide enriched environments for stroke survivors to engage in problem-solving challenges and therefore develop new skills [3]. VR combined with serious gaming offers attractive rehabilitation options because motor learning principles underlying neuroplasticity, such as practice, augmented feedback, motivation, and observational learning [4], are inherent features of VR systems [5]. Moreover, VR allows us to define goal-oriented tasks and promotes more task repetitions than conventional therapy, which have been shown to be essential for neurological rehabilitation [6, 7]. Finally, the engagement with VR based approaches has been shown to lead to high treatment adherence, with patients reporting that it is more interesting and enjoyable than standard care [1, 8, 9].
Despite the many benefits of technology-mediated rehabilitation approaches, other aspects such as the environment, changes in assistive devices, individual preferences, and interaction with peers can modulate the delivered experience and its impact on the users [2, 3]. For instance, multi-user user technology-mediated rehabilitation approaches have been shown to influence rehabilitation outcomes, highlighting the potential positive effects of social interaction in rehabilitation settings [10]–[12]. However, features like the way players interact between themselves to achieve success in a task or game, i.e., the interaction mode (competitive, cooperative, or collaborative), can influence the social impact and engagement experienced by the users [10, 11]. In fact, Baur et al. identified nine studies where different multiplayer modes had a different effect on game experience [12]. In general, competitive games have been shown to lead to higher enjoyment [13]–[15]. Specifically, competitive game modes seem to be related to higher physical effort and usually require more skills, at least more than the opponent, to produce performance satisfaction when compared to modalities that require collaboration or cooperation [16,17,18,19]. However, there is no consensus on this matter, as there is literature suggesting that cooperative modes lead to greater efforts than their competitive counterparts [20]. Collaborative modes have been less addressed in the literature, and therefore the evidence on their specific impact is still scarce [12, 21,22,23,24]. Also, to our best knowledge, only two recent studies compared the three game modes (competitive, cooperative, and collaborative) [10, 11], with most studies comparing cooperative with competitive modes [12].
When reviewing the specific impact of cooperative and collaborative modes, we found that Roschelle et al. define collaboration as "to work together," which requires coordination of efforts to solve a problem and establish a synergic relationship [25] and cooperation as "to operate together," which means to divide the work among different operators, each one being responsible for a portion of a problem. In contrast, a recent review study defines cooperation as "playing in the same team with different roles according to own individual skills; thus, a role being either "supported" or "supportive"” [12]. These authors go further and suggest that in a substantial number of studies, modes termed as cooperative should have been termed as co-active instead because the individual player can solve the task by itself without depending on the co-player [12]. In our here presented study, we adopted this renaming of cooperative to co-active mode as we believe that the therapeutic impact of a game can be very different if players have the same or different tasks on a multi-user game.
We developed a multi-user interactive table with a custom-made serious game intended to enhance the social impact and improve self-efficacy during motor rehabilitation of stroke survivors. In this study, we aim to understand what the impact on engagement and social involvement of stroke survivors is of having the game presented in three different modes, namely, Competitive, Co-active, and Collaborative. For this purpose, we recruited a sample of stroke survivors who were paired to play a game in those three game modes. We investigated competitive, cooperative, and collaborative modes in a previous study with community-dwelling older adults using a different experimental setup (a vertical screen with indirect interaction with VR), identifying some positive effects in collaborative interaction [10]. However, it is not sure to what extent the previously observed results generalize to a stroke population with motor deficits, a different interaction modality (direct interaction with VR), and different technology and interfaces. We hypothesize that engagement will be higher in the Competitive mode than Co-active and Collaborative modes, as the literature suggests that competitive modes are usually more motivating [26]. Also, we expected social involvement to be higher in the Collaborative game mode when compared to Competitive and Co-active modes because this specific mode requires dependence on the co-player to reach the goal. Finally, we want to understand how the results are affected by different levels of motor and cognitive function, spasticity, and personality.
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