Multiplayer games have emerged as a promising approach to increase the motivation of patients involved in rehabilitation therapy. In this systematic review, we evaluated recent publications in health-related multiplayer games that involved patients with cognitive and/or motor impairments. The aim was to investigate the effect of multiplayer gaming on game experience and game performance in healthy and non-healthy populations in comparison to individual game play. We further discuss the publications within the context of the theory of flow and the challenge point framework.
A systematic search was conducted through EMBASE, Medline, PubMed, Cochrane, CINAHL and PsycINFO. The search was complemented by recent publications in robot-assisted multiplayer neurorehabilitation. The search was restricted to robot-assisted or virtual reality-based training.
Thirteen articles met the inclusion criteria. Multiplayer modes used in health-related multiplayer games were: competitive, collaborative and co-active multiplayer modes. Multiplayer modes positively affected game experience in nine studies and game performance in six studies. Two articles reported increased game performance in single-player mode when compared to multiplayer mode.
The multiplayer modes of training reviewed improved game experience and game performance compared to single-player modes. However, the methods reviewed were quite heterogeneous and not exhaustive. One important take-away is that adaptation of the game conditions can individualize the difficulty of a game to a player’s skill level in competitive multiplayer games. Robotic assistance and virtual reality can enhance individualization by, for example, adapting the haptic conditions, e.g. by increasing haptic support or by providing haptic resistance. The flow theory and the challenge point framework support these results and are used in this review to frame the idea of adapting players’ game conditions.
Robotic assistance and virtual reality in neuromuscular therapy
Neurological deficits can result in impaired motor function that affect a person’s quality of life. Researchers have been working to restore the nervous system and reduce the neurological deficits of people suffering from stroke, spinal cord injury, or traumatic brain injury . For people with neurological deficits, impaired motor function is among the most prominent factors limiting the quality of life . Motor neurorehabilitation can lead to permanent improvements in motor function . Robotic assistance and virtual reality have the potential to enhance rehabilitation of neuromuscular deficits beyond the levels possible with conventional training strategies [4, 5].
Game experience and task performance in multiplayer games
Robot- and virtual reality-assisted single-player games are well integrated in neurorehabilitation schedules. Recently, multiplayer games have been tested to complement neuromuscular therapy. Multiplayer games are expected to motivate the patients and increase the potential of robot- and virtual reality-assisted neuromuscular therapy.
Multiplayer games incorporate social interaction to promote the enjoyment of the involved players. The additional player adds new possibilities to the game environment, generally missed in single-player gaming against preprogrammed challenges or artificially controlled opponents. The multiplayer environment and related game mechanics can facilitate social interaction, ranging from conversation to haptic interaction. Due to the this added social interaction, the game experience is thought to be better in multiplayer compared to single-player gaming .
The mode of the game specifies whether the players compete or cooperate with one another . In line with the flow theory, a competitive mode requires opponents of similar skill level to achieve enjoyment as the task difficulty experienced by one opponent . Comparable skill levels prevent boredom or stress and result in a meaningful challenge level that leads to a flow state when training . In such training conditions the players have a positive game experience.
In positive game experience players increase their game performance [9, 10]. Increased game performance facilitates the general idea of serious games, i.e., playing for a primary purpose other than pure entertainment . If enhanced game performance is achieved by increased physical activity, training intensity is also increased. In neuromuscular therapy, training intensity – alongside early treatment, user-centered, and task-oriented training – is one of the key factors in neurorehabilitation [12, 13]. Therefore, multiplayer gaming has great potential to further increase the benefits of robot-assisted neuromuscular and virtual reality-assisted therapy [14, 15].
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