[ARTICLE] Competitive and cooperative arm rehabilitation games played by a patient and unimpaired person: effects on motivation and exercise intensity – Full Text



People with chronic arm impairment should exercise intensely to regain their abilities, but frequently lack motivation, leading to poor rehabilitation outcome. One promising way to increase motivation is through interpersonal rehabilitation games, which allow patients to compete or cooperate together with other people. However, such games have mainly been evaluated with unimpaired subjects, and little is known about how they affect motivation and exercise intensity in people with chronic arm impairment.


We designed four different arm rehabilitation games that are played by a person with arm impairment and their unimpaired friend, relative or occupational therapist. One is a competitive game (both people compete against each other), two are cooperative games (both people work together against the computer) and one is a single-player game (played only by the impaired person against the computer). The games were played by 29 participants with chronic arm impairment, of which 19 were accompanied by their friend or relative and 10 were accompanied by their occupational therapist. Each participant played all four games within a single session. Participants’ subjective experience was quantified using the Intrinsic Motivation Inventory questionnaire after each game, as well as a final questionnaire about game preferences. Their exercise intensity was quantified using wearable inertial sensors that measured hand velocity in each game.


Of the 29 impaired participants, 12 chose the competitive game as their favorite, 12 chose a cooperative game, and 5 preferred to exercise alone. Participants who chose the competitive game as their favorite showed increased motivation and exercise intensity in that game compared to other games. Participants who chose a cooperative game as their favorite also showed increased motivation in cooperative games, but not increased exercise intensity.


Since both motivation and intensity are positively correlated with rehabilitation outcome, competitive games have high potential to lead to functional improvement and increased quality of life for patients compared to conventional rehabilitation exercises. Cooperative games do not increase exercise intensity, but could still increase motivation of patients who do not enjoy competition. However, such games need to be tested in longer, multisession studies to determine whether the observed increases in motivation and exercise intensity persist over a longer period of time and whether they positively affect rehabilitation outcome.

Trial registration

The study is not a clinical trial. While human subjects are involved, they participate in a single-session evaluation of a rehabilitation game rather than a full rehabilitation intervention, and no health outcomes are examined.


Rehabilitation ,Virtual reality ,Multiplayer games, Interpersonal rehabilitation games ,Social interaction ,Motivation ,Exercise intensity


Home rehabilitation technology

Diseases such as stroke have a massively debilitating effect on people’s lives. It is estimated that one in six people will experience a stroke in their lifetime [1], and 88% of survivors report some impairment of their limb function [2]. In the United States, approximately 795,000 individuals suffer a new or recurrent stroke every year, leading to an estimated combined direct and indirect cost of $68.9 billion [3]. Intensive training delivered by a therapist soon after the injury can effectively restore motor functions needed for independent life. However, even top hospitals only devote a limited amount of time to rehabilitation of motor functions [4]. The situation is even worse in most other hospitals and health centers, where patients are idle for most of the day due to a shortage of qualified medical staff [4]. After leaving the hospital, patients thus need to exercise at home without therapist supervision in order to fully regain their abilities.

Several technologies, ranging from consumer devices such as the Microsoft Kinect [5] to complex exoskeletons [6], have been deployed for motor rehabilitation at home. These technologies usually combine limb tracking with virtual environments presented on a personal computer, which allow patients to perform a variety of simulated activities of daily living [7]. Furthermore, they incorporate game-like elements such as automated difficulty adaptation, score displays and cognitive challenges [8, 9, 10, 11]. However, despite promising technical achievements, the effectiveness of home rehabilitation technology remains limited. A recent study showed that, even if a therapist prescribes a technology-supported exercise, only about 30% of unsupervised patients will comply with the rehabilitation regimen [12].

This lack of compliance is due to lack of motivation for rehabilitation, which is known to be a key determinant of rehabilitation outcome: patients who are unmotivated will not exercise frequently or intensely enough [13, 14]. Studies outside rehabilitation have already shown that motivational interventions improve compliance with the therapy regimen [15], and recent home rehabilitation studies have emphasized the importance of motivational elements that would increase the duration and intensity of exercise [16, 17]…

Continue —> Competitive and cooperative arm rehabilitation games played by a patient and unimpaired person: effects on motivation and exercise intensity | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 1 The BiMeo used unimanually without support (top left), unimanually on a table (top right), bimanually without support (bottom left), and bimanually on a table (bottom right)


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