Improving Patient Motivation in Game Development
for Motor Deficit Rehabilitation
Eletha Flores1, Gabriel Tobon1, Ettore Cavallaro2, Francesca I. Cavallaro2, Joel C. Perry2, Thierry Keller2
1Massachusetts Institute of Technology – EECS Dept.
Box 38-401, 77 Massachusetts Avenue
Cambridge, MA 02139- 4307 USA
+1 617 253 4600
2Fatronik Foundation – Biorobotics Department
Paseo Mikeletegi, 7
20009 Donostia-San Sebastian - Spain
+34 934 00 55 00
<ejflores, yehagt>@mit.edu, <ecavallaro, fcavallaro, jperry, tkeller>@fatronik.com
It has been stated repeatedly that actively participating in
rehabilitation programs increases the benefits and the
effectiveness of the therapy. In developing robotic devices for
stroke rehabilitation, the existing use of boring task interfaces
produces a significant reduction in elderly patient motivation. To
combine robot-aided therapy with appealing games, then, is not
only a matter of creating entertainment, but a real necessity for
motor recovery. Besides emphasizing a lack of attention to elderly
patients in conceiving games for post-stroke rehabilitation, this
paper suggests a tool that consolidates the gaming scenario
criteria for both rehabilitation and elderly entertainment.
Conclusions are then formed from the adaptability of existing
games to identify the direction of future game development.
Categories and Subject Descriptors
K.4.2 [Computers and Society]: Social Issues
Measurement, Performance, Design, Human Factors, Theory
Rehabilitation Gaming, Computer Games, Serious Games,
Assistive Technologies, Motivation, Biofeedback, Skill
Assessment, Motor Rehabilitation, Elderly, Stroke.
Over the past 3 decades, the field of computer entertainment
technology has seen substantial improvements in both the
complexity and realism of games produced. The increased
prevalence and availability of games and gaming platforms has
made accessible these advances for their application to new
audiences and new fields. A relatively new audience of particular
interest is the population of aging adults who suffer from
variations of muscular, neuromuscular, and orthopedic
impairments. While a few prototype systems for this population
exist, games remain simplistic and often unanalyzed in terms of
effectiveness and appropriateness for the rehabilitation process.
At present, serious games exist for a variety of educational
and training purposes. For the field of rehabilitation, research has
shown that games and related virtual technology can provide
significant motivation to post-stroke patients [5, 14, 6, 20].
Understandably, the greater the motivation to participate in
rehabilitation tasks, the more likely patients will be to continue
active participation. Additionally, it is known that longer
therapeutic sessions lead to greater functional outcomes over the
course of treatment. Acknowledging that participation is a
prerequisite to increased treatment, it follows that increases in
sustained participation will lead to greater motor recovery during
the rehabilitation process .
Despite the existence of a growing number of robotic
systems for rehabilitation, a thorough understanding of the
association between the design of the task-oriented interface, or
gaming scenario, and the overall effectiveness of the rehabilitation
system is yet to be achieved. This gap in the literature represents a
significant weakness in the current state of rehabilitation-oriented
gaming. In the awareness of this gap, the research effort reported
in this paper will present the following: 1) a summary of the
pertinent literature to date on rehabilitation-oriented gaming, 2) a
guide map of the critical factors in designing gaming scenarios for
motor impairment rehabilitation and elderly-specific adherence,
and 3) some example of how to use this map in developing new
games and/or adapting existing games for the purpose of
rehabilitation, particularly for aging adults.
2. RELATED WORK
To date, there have been many systems created and tested,
from exoskeleton robotic arms that aid with arm movement to
highly immersive virtual reality interfaces that provide task-
oriented environments. Among the work, different task-oriented
scenarios have been implemented to incorporate more motivating
and interactive patient-device interfaces using VR or related
technology. The interfaces commonly use high or low immersion
methods and are implemented both with and without robot aided
therapy. A number of existing robotic systems were reviewed,
including MIT-Manus (8), Gentle/s system (2, 14), ARMIn (17),
CADEN-7 (19), MIME (16), and the T-WREX (20), all of which
are devices that support the arm and many of which provide
movement assistance during arm exercises.
Permission to make digital or hard copies of all or part of this work for
personal or classroom use is granted without fee provided that copies
are not made or distributed for profit or commercial advantage and that
copies bear this notice and the full citation on the first page. To copy
otherwise, or republish, to post on servers or to redistribute to lists,
requires prior specific permission and/or a fee.
Conference’04, Month 1–2, 2004, City, State, Country.
Copyright 2004 ACM 1-58113-000-0/00/0004…$5.00.
Studies that focused more on the virtual reality or related
technologies of their systems, such as the RGS (4), Broeren et al
(3), Two DoF (5), and Ma et al (15) were also reviewed. Many of
the interfaces used in these systems are not designed to be
entertaining or motivational for the users but present tasks in a
repetitive manner which leads one to question their ability to
sustain the interest of patients during extended exercise. Although
patient motivation for using the system was commonly evaluated
through questionnaires or mentioned as observations, none of the
papers reviewed provided follow-up studies that focused on the
impact their game design in particular had on patient outcome.
To our knowledge, there is a current lack of research
evaluating the effectiveness of rehabilitation regimes under a
standardized therapy (both technique and device) using different
virtual interfaces (i.e., gaming scenarios). The major question yet
to be addressed is to what degree patient outcome is influenced by
the design of the task environment. The only study reviewed that
focused on the central theme of game design for motor
rehabilitation presented a model for game design in general based
on the association between gaming patterns and the taxonomy of
stroke rehabilitation . In this model, only a subset of stroke
symptoms and treatments were discussed which suggest the need
to expand analysis of the taxonomy and verify the associations
between game patterns and treatments. On the other end of the
spectrum, one study reviewed focused almost purely on the
motivation of the users of the robot-aided rehabilitation system
Two-Dof using the Intrinsic Motivational Inventory questionnaire.
This study developed an evaluation metric to measure user
performance with their particular system, but does not present
designs for games based on factors that influence motivation .
On the other hand, some commercial video games, such as
Pong, have been utilized as task interfaces for rehabilitation,
which brings into consideration the features of these games for
therapy purposes. As the next step in this process, we suggest that
professional game developers should be involved in the design of
the interfaces. Whether creating new games for rehabilitation or
modifying existing games, additional studies are needed that
address the following questions:
•What are the design criteria that satisfy both the nature of
a motor rehabilitation program and the preferences of
most elderly users in order to create a motivational
program that promote patient adherence?
•Given the criteria for game design, are commercial video
games suitable for implementation with rehabilitation
systems, or do gaming scenarios need to be specifically
designed/tailored for use in elderly motor rehabilitation?
If existing games can be suitable or modifiable for these
purposes, this is a field that invites the contributions of today's
game developers to further advance the state of motor
A comprehensive search of the pertinent journals and
databases was performed in order to compile a set of criteria for
designing the important game characteristics for stroke
rehabilitation. The literature was reviewed for both criteria used to
design effective therapy for stroke patients as well as for criteria
used to design entertainment for the elderly population. For the
former, much of the literature focused on the analysis of new
types of therapy, not tailored to the design of a proper therapeutic
game, but many shared the same criteria needed for effective
motor skills’ training of stroke patients. The majority of the
elderly entertainment criteria were derived from the ElderGAMES
project [7,9], which works closely with older populations to find
the most motivating and enjoyable games for elderly. The
combined set of design criteria as collected from the literature is
shown in Table 1. Represented in the table are two sets of criteria
and the relationship of each criterion to the corresponding gaming
classification. The ideal game to be used for stroke rehabilitation
would satisfy all of the listed criteria.
Table 1. Gaming design criteria for stroke rehabilitation
programs serving elderly users
Criteria for Stroke
Rehabilitation Criteria for Elderly
•Adaptability to motor
•Focus diverted from
•Element of social activity
•Appropriateness of genre
•Creation of new learning
•Promotion of cognitive
capacities chosen by
experts of ElderGames
•Sensitivity to decreased
sensory acuity and slower
Games for Stroke Rehabilitation – Because of the extent to which
motor impairment varies from one patient to the next, successful
stroke rehabilitation requires that the game used with a robotic
device be able to adapt to a patient's motor level. Adaptability is
equally important for individuals so that the level of difficulty can
be raised as the patient's motor skills improve over time.
Meaningful tasks should be incorporated so that the patient can
have a direct correlation between use of their disabled limb during
therapy and use in activities of daily living (ADLs) . The
game must also provide appropriate feedback for both patient and
therapist. This feedback is used to determine how well the patient
is doing, how much he or she is improving, and provides some
encouragement to the patient to continue with the therapy.
Charting the history of recorded feedback can also help to steer
the direction of future therapy sessions. Therapy-appropriate
range-of-motion (ROM) refers to the extent the game demands the
therapeutic motions needed for the particular motor rehabilitation
program of each patient. Skills need to be practiced extensively,
requiring intensive repetition, according to neurobiological and
VR technology for stroke rehabilitation research [18, 22]. Other
studies on motor rehabilitation therapy suggest that patients with
hemiplegia need an environment where they can practice skills as
the demands of that environment change in a variety of ways, in
order to develop versatile motor schemata that will allow them to
perform ADLs . It follows that the game should divert the
focus away from the conscious effort to move the impaired arm,
and towards the objectives of game play, which can simulate the
varied demands of ADLs.
Games for Elderly Entertainment – Entertaining and motivating
elderly users means that the game must be challenging enough to
keep the interest and attention of the player. Elderly video game
players prefer simple games in thought-based genres such as
history and word trivia. Moreover, they enjoy the social aspects of
video games, both in side by side multiplayer games on the same
console and in large multiplayer games played over a network
. Games designed for the elderly should also take into
consideration a decreased sensory acuity and longer response time
(i.e. using large font size, allow delayed responses, etc.) .
Based on the collection of criteria described above, the
information in Table 1 has been used to analyze a set of existing
games. The set contains games designed specifically for use with
stroke rehabilitation devices (Driver's SEAT and Whack-a-
Mouse), a game that has been used, although not designed, for
rehabilitation (Pong), as well as a few popular games that could be
adapted for this purpose (Tetris, Computer Chess, and Trivial
Pursuit). The existing stroke rehabilitation games were chosen
subjectively as the most entertaining for the elderly according to
our criteria. The popular games were chosen as examples of
games that have distinct advantages over existing games for
stroke rehabilitation against our complete set of criteria but have
not been adapted for stroke rehabilitation.
Table 2 provides a summary of a subjective analysis of six
games, where three of the games have been used for stroke
rehabilitation and three are popular games not currently used in
rehabilitation. The table illustrates the deficiencies present in both
sets of existing games. Additionally, an approximate rating is
given to the overall appropriateness of each game for elderly
rehabilition based on weighting values assigned to each of the
criteria. As seen in the Table, all of the games designed for stroke
rehabilitation fail to be cognitively challenging, to create new
learning, and to promote cognitive capacity for elderly users.
They also lack a social aspect that could allow the patients to
enjoy the interaction and encouragement from others playing the
same game. The games designed for entertainment, on the other
hand, are untested for efficacy in rehabilitation, lack meaningful
tasks, and do not provide thorough feedback about the user’s
It is no surprise that by design, the games that are currently
used for stroke rehabilitation have qualities that make them
effective for therapy when used with a corresponding robotic
device. Compared to popular games that are designed to be
engaging and fun, current therapeutic games lack the qualities
required to be entertaining and are thus less motivating for
patients. On the other hand, the popular games have not been
thoroughly analyzed with the criteria of stroke rehabilitation in
mind and thus lack essential components for therapeutic
At present, one major criticism worth noting is that existing
gaming scenarios for rehabilitation have been designed solely by
engineers, scientists, and health professionals whose purpose is to
build and test the overall functionality of the developed hardware.
Careful attention must be given to the way in which we design the
patient-system interface to incorporate motivation for active
participation. Reviewing existing scenarios, it seems possible to
use certain games for elderly users in post-stroke motor
rehabilitation therapy. While some games can be modified to
better suit exercise programs, others can serve as models for the
creation of a specific motor rehabilitation game.
Table 2. Comparison assessment of existing gaming scenarios using the criteria of Table 1.
CRITERIA (WEIGHT: 1-3)
Adaptability to motor skill level (3)
Meaningful tasks (2)
Appropriate feedback (2)
Therapy-appropriate ROM (3)
? ? ?
Focus diverted from exercise (2)
Appropriate cognitive challenge (3)
Simple objective/interface (2)
Element of social activity (1)
Appropriateness of genre (1)
Creation of new learning (1)
Multiple levels of difficulty (3)
Sensitivity to decreased sensory acuity (2)
Sensitivity to slower responses (2)
Stroke Rehabilitation Criteria Score 10/12 12/12 10/12 2/12 2/12 2/12
Elderly Entertainment Criteria Score 10/16 10/16 9/16 14/16 16/16 16/16
Total Score 20/28 22/28 19/28 16/28 18/28 18/28
ü ü ü
ü ü ü
ü ü ü
ü ü ü ü ü ü
ü ü ü
ü ü ü ü ü ü
ü ü ü ü ü
ü ü ü ü ü ü
Promotion of the cognitive capacities
chosen by the experts (1) ü ü ü
ü ü ü ü ü ü
ü ü ü ü ü ü
In the results of this study, it is clear that the weighting
assigned to the design criteria is necessarily subjective rather than
indicative of a definitive study. However, the reported game
scores may serve as general indicators for the appropriateness or
adaptability of each game for use in elderly rehabilitation. It is
anticipated that these and other games can be modified in order to
satisfy a larger number of criteria from the above tables and
become more functional tools for therapy.
Further research is needed to fully assess the effectiveness of
games designed to combine elderly game preferences and
requirements of motor rehabilitation programs. The need for
serious games aimed at rehabilitation programs and elderly
audiences invites current game developers to contribute their
skills and imagination to this growing population of potential
 Aison, C, Davis, G, et al. 2002. Appeal and Interest of Video
Game Use Among the Elderly. Harvard Graduate School of
Education, (May 2002), i-28. DOI=http://www.jrmilner.com/
 Amirabdollahian, F., et al., 2007. Multivariate analysis of
the Fugl-Meyer outcome measures assessing the
effectiveness of GENTLE/S robot-mediated stroke therapy.
J. Neuroeng. and Rehabil. (Feb. 4 2007), 4:4.
 Broeren, J., et al., 2008. Virtual rehabilitation after stroke.
Studies in Health Tech. and Informatics, (2008) 136:77-82.
 Cameirao, M. S., et al., 2007. The Rehabilitation Gaming
System: a Virtual Reality Based System for the Evaluation
and Rehabilitation of Motor Deficits. Virtual Rehabilitation,
2007 (September 27-29) 29-33.
 Colombo, et al., 2007. Design strategies to improve patient
motivation during robot-aided rehabilitation. Journal of
NeuroEngineering and Rehabilitation (February, 2007),
 Crosbie, J. H., Lennon, S., Basford, J. R., McDonough,
S. M., 2007. Virtual reality in stroke rehabilitation: Still
more virtual than real. Disabil. Rehabil. (2007),
 Fabregat, M., 2006. D1.2 - Game Typologies to be
developed and their relationship with the parameters to
measure. Development of High Therapeutic Value IST-based
Games for Monitoring and Improving the Quality of the Life
of Elderly People. Information Society Technologies project
CN 034552. ElderGames Project, final report version.
 Fasoli, S., Krebs, H., Stein, J.,Frontera, W., Hogan, N., 2003.
Effects of robotic therapy on motor impairment and recovery
in chronic stroke, Arch. Phys. Med. Rehabil., 84(4), 477-482,
 Gamberini L., et al., 2006. Cognition, technology and games
for the elderly: An introduction to ELDERGAMES Project.
PsychNology Journal, (December. 2006), 4(3):285 -308.
 Goude, D., Björk, S., Rydmark, M. 2007. Game Design in
Virtual Reality Systems for Stroke Rehabilitation. Stud
Health Technol. and Inform. 125:146-148.
 Griffiths M, Davies M, Chappell D. Online computer
gaming: a comparison of adolescent and adult gamers.
Journal of Adolescence. Video Games and Public Health,
(February 2004) 27(1):87-96.
 Ijsselsteijn W, Nap H, de Kort Y, Poels K, Digital game
design for elderly users. Future Play: Proc. of the 2007
Conf. on Future Play. ACM Press. New York, NY, 17-22.
 Johnson M, et al., 2006. Systems that Rehabilitate as well as
Motivate: Three Strategies for Motivating Impaired Arm
Use. The First IEEE/RAS-EMBS Intl. Conf. on Biomed.
Robotics and Biomechatronics, 2006. BioRobotics. (Feb.
20-22, 2006), 254-9.
 Loureiro, R.C.V., Collin, C.F., Harwin, W.S., 2004. Robot
aided therapy: challenges ahead for upper limb stroke
rehabilitation. In Proc. of 5th Intl. Conf. of Disability, VR
& Assoc. Tech. (Sep. 20-22 2004), 4(1):7-11.
 Ma, M., et al., 2007. Adaptive Virtual Reality Games for
Rehabilitation of Motor Disorders. Universal Access in
Human-Computer Interaction. Ambient Interaction, (August
 Masiero, S., Celia, A., Rosati, G., Armani, M., 2007.
Robotic-assisted rehabilitation of the upper limb after acute
stroke. Arch. Phys. Med. Rehabil., (Feb. 2007) 88(2):142-9.
 Nef, T., Mihelj, M., Colombo, G., Riener, R., 2006. ARMin -
robot for rehabilitation of the upper extremities. In
Proceedings of IEEE Intl. Conf. on Robotics and
Automation, (May 15-19 2006) 3152 – 3157.
 Nelles G., Jentzen W, et al. 2001. Arm Training Induced
plasticity in stroke studied with serial positron emission
tomography. Neurological Image 2001; 13; 1146-1154.
 Perry, J.C., Rosen, J., Burns, S., 2007. Upper-Limb Powered
Exoskeleton Design. IEEE-ASME Trans. on Mechatronics
(Aug 2007) 12(4):408-417. DOI=http://doi.acm.org/10.1109/
 Reinkensmeyer, D.J., Housman S.J., 2007. “If I can´t do it
once, why do it a hundred times?”: Connecting volition to
movement success in a virtual environment motivates people
to exercise the arm after stroke. Virtual Rehabil.. (Sept.
27-29 2007) 44 – 48.
 Sabari J: Motor learning concepts applied to activity-based
intervention with adults with hemiplegia. Amer. J. of Occup.
Therapy (1991), 45:523-530.
 Small S, Solodkin A. 1998. The Neurobiology of stroke
rehabilitation. Neuroscientist (1998), 4:426-434.