The Use and Implementation of Commercial Video Gaming in Rehabilitation: A Scoping Review

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The Use and Implementation of Commercial Video Gaming in Rehabilitation:

A Scoping Review

Malin Knudtzon Neergaard

Master Thesis

Department of Psychology University of Oslo

April 2016

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The Use and Implementation of Commercial Video Gaming in Rehabilitation:

A Scoping Review

Malin Knudtzon Neergaard http://www.duo.uio.no

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Abstract

Gamification is an emerging field of research with a focus on motivation that is presenting promising results in many contexts. Submitting gamification into a rehabilitation setting could potentially be beneficial for individuals undergoing rehabilitation, as a motivational

component is key in this context. The global need for rehabilitation is great and there are several disabilities that should be targeted when looking for more efficient and beneficial treatments. The following research questions were answered in this study:

1) What is the current state of the field of research on the use and implementation of commercial video gaming in rehabilitation?

2) How have rehabilitative interventions utilising commercial video gaming been implemented in regards to the three most prevalent illnesses in this field – MS, CP, and stroke?

The current state of the field of research on gamification in rehabilitation is inconclusive. A scoping study was therefore conduced to provide an overview and to summarise the current findings. The search strategy resulted in 631 relevant articles. Nine categories were developed after a content analysis was conducted, and each category covered a separate topic on the field of research on commercial video gaming in rehabilitation settings. This scoping review also investigated how rehabilitative interventions utilising commercial video gaming have been implemented in regards to the three most prevalent illnesses in this field, namely stroke, Cerebral Palsy, and Multiple Sclerosis. The findings suggest that while there are a range of validated measures in these studies, the majority of the articles are characterised by poor reporting of both their methods and their findings. There is a need for more consistent

research in the future, and this study provides the ground work on which a framework can be built on.

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Acknowledgements

I would like to thank my supervisor Cato A. Bjørkli for his feedback, guidance and support throughout this last year. Thank you for your time, dedication and encouragement even through the darkest of times. Also, thank you for your movie analogies. Some were excellent, others were like Jar Jar Binks; well-meaning but far off the mark.

I would also like to thank the practitioners at Sunnaas Sykehus. Your excitement towards this project and the work you have conducted has been of great relevance, as well as motivating, in conducting this scoping review.

Hege Kristin Ringnes must be acknowledged for her efforts and enthusiasm, as she managed to explain and teach me how to carry out such a complicated search.

My dear friends, Charlotte B. Pollen and Karoline H. Kannelønning, I honour you for keeping up with me this past year. Thank you for always cheering on me and believing in me, even when I did not do so myself. To maintain a friendship through (at times) three different time zones is not an easy task, but we somehow manage. I would also like to extend my gratitude towards my friend, dive instructor and language exchange partner, Martijn

Landman. Without your massive support, numerous dive sites explorations and conjugations of verbs, I would not have made it.

Last, but also the most, I would like to extend my gratitude towards Pernille

Lappegård. Without you, writing this thesis would have been impossible. You reminded me that the force is strong with this one, and did not find my lack of faith disturbing. Rather, you encouraged me, reminded me that fear is the path to the dark side, and helped me when you were my only hope. I will ignore that time you commented on me being a little short for a researcher. I truly hope this is a collaboration that will, in terms of both academic and personal character continue to the infinity and beyond.

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1. Introduction

1.1 Gamification – A diverse tool

Gamification is an emerging field of research showing promising results in many contexts. Over the recent years, gamification has been used in different settings such as education, health related settings, work contexts, and for behavioural change (Borges, Reis, Durelli, & Isotani, 2014; Hamari, Koivisto, & Sarsa, 2014; Aparico, Vela, Sánches, Montes, 2012). Gamification has also been used in education for different outcomes such as

motivation, improving skills, and maximising learning (Borges et al., 2014). Seen in a work context, gamification can be used as a strategic tool, to influence behaviour, enhancing performance and productivity, and as a feedback mechanism (Singh, 2013). It also has the potential to be used as a behavioural change tool towards sustainable consumption (Huber, &

Hilty, 2015) and exercise (Pereira, Duarte, Rebelo, & Noriega, 2014).

Kapp (2012) defines gamification as “game-based mechanics, aesthetics, and game thinking to engage people, motivate action, promote learning and solve problems”. This is based on what he defines as game systems: contexts that consists of one or more players, interactivity, quantifiable outcomes, challenges, rules, and even an emotion reaction in abstract game realities (Kapp, 2012). Another definition which is often used is that

gamification “is the use of game design elements in non-game contexts” (Deterding, Dixon, Khaled, & Nacke, 2011). Applying game elements to unrelated context is not just for entertainment, as the term gamification might indicate. However, research on gamification can investigate how to use game elements that are motivating and entertaining, and how they have a transmissible effect in more serious matters.

Gamification is first and foremost utilised as a motivational tool, and aims to activate a person’s intrinsic motivation. This refers to the act of undertaking an activity for its own sake, for the enjoyment it proves, the learning it permits, or the feeling of accomplishment it evokes (Kapp, 2012). Intrinsic motivation is seen in comparison to extrinsic motivation, which is in regards to behaviour undertaken in order to obtain some reward or avoid punishment (Kapp, 2012). Gamification it is most frequently applied to encourage learning environments and solving different problems, and it is especially applicable to settings or tasks that are not necessarily engaging or motivating in themselves (Kapp, 2012; McGonigal, 2011).

Putting gamification into good use with the correct context can not only be effective in terms of learning and engaging people, but it can provide necessary and cost-efficient

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influences on society. Submitting gamification into a rehabilitation setting could potentially not only help larger communities, but also be especially beneficial for individuals undergoing rehabilitation, as a motivational component is key in this context.

1.2 Recognising Rehabilitation

According to WHO (World Health Organization) rehabilitation of people with

disabilities is” a process aimed at enabling them to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels. Rehabilitation provides disabled people with the tools they need to attain independence and self-determination”.

Rehabilitation often focus on physical therapy which helps individuals with their strength, mobility, and fitness. There is also a focus on occupational therapy to help with daily activities, and language therapy to help with speaking, understanding, reading, and writing.

Rehabilitative interventions are also used in the treatment of pain. There are several illnesses and disabilities that are highly relevant in terms of the need of effective rehabilitation

treatments, and three of these are Multiple Sclerosis, and Cerebral Palsy, and stroke.

Fifteen million people suffer from stroke each year, and five million of these are permanently disabled (The world health report, 2002). The burden of morbidity and healthcare costs of post stroke patients are very high (Leal, Luengo-Fernandez, Gray, Petersen, & Rayner, 2006), and stroke is the leading cause of adult disability worldwide.

There is therefore a large need of rehabilitative services (Stroke Association, Impact of stroke).

At least 700,000 people in Europe are affected by Multiple Sclerosis (MS), with more than one million people being affected through their role as care takers and/or family

members. MS most frequently affect people between the age of 20 and 40, but can occur at any time in life (European Multiple Sclerosis Platform, Living with multiple sclerosis in Europe). MS is a neurodegenerative disease, one of the most common long-term conditions affecting the central nervous system, and is the prime cause of non-traumatic disability in young adults (European Multiple Sclerosis Platform, MS facts). MS can affect people differently, ranging from mild symptoms to major disability issues. There is still no cure (European Multiple Sclerosis Platform, MS facts), and therefore it is important to look at proper rehabilitation alternatives which can generate positive outcomes for patients.

Cerebral Palsy (CP) is a condition which affects movement, posture and coordination, and the most common cause of significant physical impairment in children (Surveillance of Cerebral Palsy in Europe, Cerebral Palsy). It occurs as a result of brain impairment during

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pregnancy, birth or early childhood, and it is estimated that about two in every 1000 children is affected by the condition (Surveillance of Cerebral Palsy in Europe, Cerebral Palsy). Like MS, is can affect people in many different ways, and range from mild to severe impairments with difficulties of hearing, intellect, vison, feeding and communication (Surveillance of Cerebral Palsy in Europe, Cerebral Palsy). The disorder is permanent, but not unchanging, and it is therefore important to look at rehabilitation possibilities which can improve the wellbeing of the patient and ability to participate fully in life.

As evident, the global need for rehabilitation is great and there are several disabilities that should be targeted when looking for more efficient and beneficial treatments. For example, a study showed that 76% of stroke victims who were discharged have still not returned to working society 12 months later (Hanger, Wilkinson, & Mears, 2010). There is especially a need to rehabilitate balance (Bower, Clark, McGinley, Martin, & Miller, 2014) and upper limbs (Langhorne, Coupar, & Pollock, 2009) for post stroke individuals. For individuals with MS the need for rehabilitation is crucial. Half of the patients that are diagnosed with MS leave their jobs after three years (EMSP, European Mulitple Sclerosis Platform, 2016). Rehabilitation purposes involve reducing the impairments in terms of physical fitness (Monteiro Junior, Dantas, Souza, & Silva, 2012) and balance (Nilsagård, Forsberg, & von Koch, 2012). Further, there is no cure for MS and individuals with the diagnosis should initialise rehabilitation as soon as possible, thus helping them achieve optimal functioning in everyday life (Race Against Multiple Sclerosis, Multiple Sclerosis).

The need for rehabilitation in CP patients is largely concerned with physical activity

(Howcroft et al, 2012) and motor function of the arm and hand (Jannink et al, 2008). The act of rehabilitating can often be tedious and less engaging, and methods for improving the rehabilitation settings are sorely needed.

1.3 Reinventing Rehabilitation

With the current need for more efficient rehabilitation interventions, there has recently been a focus on developing new approaches. Researchers and health care personnel are currently attempting to develop fun, engaging, and cost-efficient ways to rehabilitate.

Submitting gamification into a rehabilitation setting could assist in establishing such methods.

Furthermore, gamification seems applicable in achieving the goals in accordance to WHO’s global disability action plan, 2014- 2021, which aims “to strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation.” (WHO, Rehabilitation).

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Due to the fact that gamification has shown promising results in many other areas, it has also been applied to rehabilitation settings. Currently, gamification is being used in the rehabilitation of different illnesses and disabilities, such as stroke, balance, heart related illnesses, burn victims and traumatic brain injuries, with positive outcomes (Hung et al., 2014;

Booth, Masrud, Connell, & Bath-Hextall, 2013; Yohannan et al., 2012; Pietrzak, Pullman, &

McGuire, 2014). Gamification, and especially serious games have often been used for balance rehabilitation, here serious games refers to games that are developed for specific purposes other than entertainment (Kapp, 2012). For example, the study conducted by Bonnechére, Omelina, Jansen, and Jan (2014) was successful in improving clinical balance scores in children with CP after an intervention with a serious game. Furthermore, serious games have also been successful in rehabilitating upper limbs (Hocine et al., 2014) and cognitive deficits (Vourvopoulos, Faria, Ponnam, & Badia, 2014). A gamification system has also shown a potential in rehabilitating motor functions (Faria, Silva, & Campilho, 2013). As evident from these studies, there are a range of positive results from the use of gamification in

rehabilitation settings. However, this field of research is still quite new and this is evident in the studies that have been conducted. There are still no conclusive results about the long-term effects of the use of gamification in rehabilitation and there is a need for an overview of this field.

1.4 Commercial video games in rehabilitation

The field of research on gamification in rehabilitation is still in the early stages, however, there are clear indications that it can yield positive outcomes. Even so, there is no conclusions about the effectiveness of the interventions. Gamification is an extensive field in terms of the methods of implementing game design element in non-game contexts, and a big part of the field is the use of commercially available video games. The expertise of creating engaging, and even emotional, game experiences exists in the commercial market with commercial consoles and games, and the technology is easily transferable to a home setting for patients undergoing rehabilitation. As Kapp (2012) states, gamification involves game thinking and experiences in terms of exploration, story-telling, competition, and cooperation.

These elements are frequently present in commercial video gaming, which might translate to a greater engagement in the rehabilitation process. Furthermore, being able to use commercial video games in rehabilitation settings is also more cost efficient for both the patient and the health care sector.

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A range of commercial video games and consoles have been used for rehabilitation purposes. Nintendo Wii, Xbox Kinect as well as the PlayStation with their corresponding games are most frequently used in this context. Pietzak, Cotea and Pullman (2014) reviewed the use of commercial video gaming for the rehabilitation of post stroke patients. They reported promising results for the improvement in mobility of these patients, but could not conclude about the effect on a long term basis. They also reported that the studies in this area were characterised by poor reporting and inconclusive results. Further on, in their review, Cyarto, Kuys, Henwood, and Blackberry (2011) found that Nintendo Wii is feasible for use in rehabilitation and age care settings, however there is a need for further research. Revenek, Wolfe, & Hitzig (2015) carried out a scoping review which aimed to gather all research in the field of commercial video gaming for rehabilitation purposes. However, their study only yielded 30 articles due to their search strategy, thereby excluding a considerable amount of research conducted in the field. Their scoping review was not able to conclude about the effectiveness of these interventions, due to the small number of studies, as well as the poor methodology of the included studies.

The three most researched illnesses in terms of utilising commercial video gaming in rehabilitation are MS, CP and stroke, and there is extensive research conducted. For example, a study by Hurkmans, van den Berg-Emons and Stam (2010) concluded that Wii Sports, more specifically the games tennis and boxing, were able to provide at least moderate activity levels in CP patients. On the other hand, they were not able to provide conclusions about the effectiveness of this intervention. Similar studies looking at fitness levels for individuals with MS concluded, via physical assessments, that using the Wii Fit may improve impairments relevant for these patients (Plow & Finlayson, 2011). This study also suggest that future studies should research the safety associated with these kind of interventions. Finally, Flynn, Palma and Bender (2007) looked at the use of PlayStation 2 EyeToy in rehabilitation for stroke patients. They found the intervention to be effective in improving clinically relevant measures, and concluded that it may be used in association with standard therapy.

These are just a few examples of the studies investigating the use of gamified

interventions for these illnesses and even though the research shows a lot of promising results, there are not many long term conclusions. The research is characterised by poor reporting, in terms of both measurements and methods. It is therefore necessary to create an overview of the field, in order for future research to build on a framework and properly investigate the effectiveness of these interventions. This is also imperative when considering the growing need for rehabilitation for individuals with disabilities.

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1.5 Why scoping review?

This field of research is in the early stages and is therefore characterised by scattered and enthusiastic research, an overview at this point can be very valuable for future research.

Due to the large range of studies with an array of inconsistencies choosing the appropriate method in which to create this overview is vital. There are a range of methods to choose from, but large scale literature reviews or meta-analyses are not viable at this stage. Initially the aim of this study was to conduct a summarisation of effect sizes, however this was not possible as the research in this field is not consistent enough. It was therefore found necessary to carry out a scoping review. A scoping review is a process which has the aim of mapping existing literature or evident base in a specific field (Arksey and O’Malley’s, 2005). It can be used in different ways, such as summarizing findings of the research and identifying research gaps.

This does not necessary include describing findings in detail, but it can help inform systematic reviews, more specifically in terms of exploring the extent of the literature in a particular field and help identifying appropriate parameters. These may include a specific population, intervention, comparison, or outcome. A scoping review can also help to identify the potential scope of a systematic review and estimate the associated costs in doing so (Arksey and O’Malley’s, 2005). The aim of this study is to map the field of research while simultaneously identifying gaps.

1.6 Aim of this study

The aim of this study is to summarise all the existing literature that focuses on the use and implementation of commercial video gaming in rehabilitation. Moreover, this study aims to evaluate the implementation of commercial video gaming interventions in the rehabilitation of Multiple Sclerosis, Cerebral Palsy, and stroke. This study will investigate methods, results and conclusions from the studies concerning this topic. This is done in order to assemble information as regards to the knowledge of implementation of video gaming for rehabilitation purposes. This will include scrutinising the methodology in terms of the participants, study design and the conclusions. This review will identify and give suggestions as to how the research should move forward in order to implement commercial video gaming in rehabilitation in a safe and efficient manner.

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In order to investigate this, these two research questions will be answered:

3) What is the current state of the field of research on the use and implementation of commercial video gaming in rehabilitation?

4) How have rehabilitative interventions utilising commercial video gaming been implemented in regards to the three most prevalent illnesses in this field – MS, CP, and stroke?

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2. Method

This scoping study is part of a larger project at Sunnaas Sykehus. Their aim is to incorporate commercial video gaming in rehabilitation processes. This scoping review was conducted by two master students at the University of Oslo (UiO), including the author of this study, in cooperation with the academic staff at UiO, namely Cato A. Bjørkli, and health practitioners at Sunnaas Sykehus. The scoping review was conducted by the students, in terms of the development of search strategy and the screening and coding process, while consulting with a University librarian and the stakeholders both in academia and at Sunnaas Sykehus.

2.1 Scoping framework

The framework of Arksey and O’Malley’s (2005) is composed of five main stages, and a sixth optional one. The objective of these six stages is to generate a more transparent process of conducting a scoping review. The first step is to determine the research question, which in turn will generate the appropriate search strategy. Step two is identifying the studies that are relevant. This is done by sifting different sources and determining the limits of the scoping review. Arksey and O’Malley’s (2005) suggest going through relevant databases, screening the reference list of important articles, and conferences, as well as finding relevant information through organisations and networks. Step three is to determine the inclusion and exclusion criteria, based upon the selection of focus area. Step four is identifying and

outlining articles from the search, based on key issues and themes. In this step it is necessary to determine what information you want to target. The final step, step five, is concerned with summarising and addressing the results, as well as providing an overview of the gathered literature. The sixth and optional step is consulting with stakeholders. This step is included in the present scoping review, as recommended by both Levac et al. (2010) and Daudt et al.

(2013). Whether or not one should include quality assessment in a scoping review is debated upon (Grant & Booth, 2009; Levac et al., 2010; Wagman, Håkansson, & Jonsson, 2015).

Some researchers support the inclusion of such an assessment, while others argue the fact that it is not significant when conducting a scoping review. When considering how this field of research should move forward, and seeing as it is an essential aspect of the research field, this study will to some extent evaluate the quality of the research thus far.

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2.2 Search strategy

The research question this study aims to answer, in broad terms “What is the current state of the field of research on the use and implementation of commercial video gaming in rehabilitation?”. This is done by outlining and summarising the existing literature in this field of research. Five databases were selected for the article search, in collaboration with a

librarian. These databases included PubMed (Medline), PSYCinfo, ERIC, Scopus, and Web of Science. The search string was tested and developed in collaboration with the practitioners at Sunnaas Sykehus and stakeholders at University of Oslo. As it was necessary to make the search string not too broad or too narrow, numerous combinations of words and phrases were attempted (See Appendix 1 for a full overview of the process). Consequently, the eventual search string was developed to include different words and phrases, which would yield the appropriate research. This would include everything in the field of gamification, and more specifically commercial video gaming and rehabilitation. The first section of the search string aimed to cover all variations of terms that are relevant in gamification. The second section of the search string consisted of phrases that included the field of rehabilitation. Section three of the search string excluded categories that were not relevant for this scoping review.

The final search string was as follows:

("video game*" or gaming or videogame* or "commercial game*" or "entertainment game*" or "video rehabilitation*" or xbox or kinect or Nintendo or wii or playstation) and (rehab* or neurorehab* or cognitive or cognition or "brain injur*" or "spinal cord injur*" or stroke or "multiple sclerosis" or "cerebral palsy") not ("serious games" or app or apps or gambl* or aggress* or addiction or "gaming disorder" or radio)

The final search was conducted on the 29.09.2015. There were no constraints on the search, neither language nor year of publication, other than that the article had to be published before the aforementioned date. A manual search was completed including the reference list of reviews and analyses in the databases and the most relevant articles and journals, in order to uncover all relevant articles.

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2.3 Screening process

According to the framework of Arksey and O’Malley (2005), the next step was screening the articles. This included titles, abstracts and keywords, to decide whether or not they met the inclusion criteria. The inclusion criteria were stated as: the article must have commercial video gaming incorporated in a rehabilitation setting, either directly with the patients or testing whether it is possible. Due to the fact that the term virtual reality is used inconsistently throughout the field of research on gamification, articles using this term was included. In this process, articles in other languages besides English were included, but later eliminated. Meta-analyses and reviews were also included.

The exclusion criteria were stated as: rehabilitation of mental illness, including Alzheimer`s and dementia. Articles that included participants who were obese, but other than that healthy. As to narrow the search, articles that focused on gaming apps were also

eliminated. Two raters screened the articles manually and independently. They decided whether to include them in the further analysis, by applying the inclusion and exclusion criteria. The agreement was measured by calculating Cohen`s Kappa. The articles the two raters disagreed on were reviewed and discussed until it was determined whether or not they were relevant. To guarantee that the articles were screened and categorised correctly, the raters met frequently. This also established a thorough process where both raters were updated on all articles and could examine possible disagreements.

2.4 Coding process

According to the framework, the next step was to code the relevant articles. Full-text versions of the articles were assessed, then coded based on the inclusion and exclusion criteria. All articles that did not meet the criteria at this stage were now eliminated. A content analysis of the remaining articles was conducted in order to categorise them. Content analysis refers to a process in which to analyse a body of text and extract meaning from it

(Krippendorff, 2004; Neuendorf, 2002). At this point the scoping review was narrowed down.

The final areas of focus for this scoping review ended up being what kind of consoles and games were used, what measures were utilised, as well as the results and conclusions in each study. Other contributions to the field of research on gamification were also recognised.

The following research question will be addressed, and the next part of this scoping review will attempt to answer: “How have rehabilitative interventions utilising commercial video gaming been implemented in regards to the three most prevalent illnesses in this field – MS, CP, and stroke?”

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3. Results

The search resulted in 14262 articles and later 9691 articles after duplicates were removed. The duplicates were removed using the reference manager program EndNote X7.

1529 articles remained after the screening, when applying the inclusion and exclusion criteria.

A Cohen`s Kappa of .840 (CI 95% .824 – .856) p<.001 was achieved during this process.

Landis & Koch (1977) classifies this as almost perfect. To assure that the specified criteria were accurate enough for the raters to be in correspondence with each other, Cohen`s Kappa was calculated from beginning to end.

Development of the Kappa values in the initial screening process is presented below (Table 1).

Range calculated Kappa value Confidence interval Significance

1-35 .268 -.057 – .593 p=.110

36-70 .400 .010 – .790 p=.016

71-100 .783 .373 – 1.193 p<.001

101-200 .851 .702 – .992 p<.001

201-300 .831 .700 – .962 p<.001

301-500 .669 .542 – .796 p<.001

501-1000 .800 .743 – .857 p<.001

1001-4846 .878 .856 – .900 p<.001

4847-9691 .827 .802 – .852 p<.001

Table 1: Cohen’s kappa- values development during the screening process

In the beginning of the process the agreement was not satisfactory. However, after the two raters reviewed the individual articles and discussed the inclusion and exclusion criteria, the Cohen`s Kappa rapidly increased to acceptable values, and later an almost perfect value was reached.

The manual search revealed that of the 9691 articles 1529 were relevant. It was then discovered that 371 of them were duplicates. 165 articles were not able to obtain in full-text versions.

After manually searching 49 reviews and meta-analysis, 4 more articles were found. A conference paper was also found in the reference list of the database, which generated 23 additional relevant articles.

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After examining the full-text versions of the relevant references, 347 references were eliminated due to the fact that they did not include commercial video gaming, or were not relevant in another way. Lastly, 42 articles were eliminated due to language limitations. A total of 631 articles were left for further analysis.

The whole process is illustrated in figure 1 below.

3.1 Overview of publication years

An overview of the distribution of publication years was created, in order to illustrate how the popularity of this topic has developed. The first publication on the topic of this study was in 1984. As one can see from the graph the peak year was 2014. This is likely due to the fact that the final search date in this study was before the end of 2015. The graph is found below in figure 2.

Figure 1: Screening process

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3.2 Categories

A content analysis was carried out, categorising the 631 relevant articles. A brief summary of categories is presented below (Table 2). One researcher originally carried out the coding process, and it was later checked by the second researcher.

1982 1984 1987 1989 1991 1995 1999 2001 2003 2005 2007 2009 2011 2013 2015

Year of publication

Figure 2: Overview of published articles by year

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Relevance These articles show how extensive the research on gamification in rehabilitation is, as both researchers and the individuals involved directly in rehabilitation can evaluate its value.

The reference lists of these articles were manually searched. The term tele-rehabilitation is loosely applied and some of the articles in this category could be included in other categories. Some use of commercial video gaming, but not consistent. This is extended to how commercial video gaming can be used in rehabilitation.

Content This category includes articles where researchers in several fields have evaluated whether or not gamification should be used in rehabilitation. It also includes the views of patients, their caretakers, and health personnel on gamification in rehabilitation. Meta-analyses, systematic reviews, literature reviews, etc. of gamification in rehabilitation. The articles in this category focus on tele-rehabilitation in combination with commercial video gaming. The articles in this category use commercial video gaming in combination with robotic rehabilitation. These articles evaluate and test how commercial video gaming can be made accessible for people with disabilities.

No. of articles 92 49 26 4 13

Category Evaluations Analyses/ reviews Tele- rehabilitation Robotics Developing accessibility

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Relevance This research creates a grounding on which gamification in rehabilitation could be justified. Although these articles often use games designed by researchers rather than commercial games, the consoles are still commercially available. Several diagnoses and games are represented here. This category, while broad, shows that commercial video gaming has been extensively researched in terms of rehabilitation.

Content This category is divided into three subcategories: assessment of the console, assessment of diagnosis, and assessment of movements. Concerning respectively assessing the reliability of consoles, the feasibility of using commercial video gaming to assess diagnoses and the consoles ability to facilitate movements. The articles in this category only use commercial video game consoles and not their respective games in rehabilitation. The research in this category only uses commercial video games in combination with a computer in rehabilitation. This category of research includes every article that uses both commercial consoles and games in rehabilitation of any kind of diagnosis or illness.

No. of articles 69 157 16 205

Category Measurements Commercial consoles only Commercial games only Commercial consoles and games

Table 2: Categories of articles

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3.3 MS, CP and stroke

In the next part of this analysis, there will be a summarisation of the studies done on the three most prevalent illnesses found in the data on the use on commercial video consoles and games. The tables presented in this analysis will illustrate the conclusions given by the different studies and whether or not they are positive to the use of gamification in

rehabilitation. Furthermore, the types of studies conducted will be presented, as well as the number of participants in each study. The analysis will also present the outcome and measures utilised. Whether or not these are validated will be discussed at a later point. Firstly, this analysis will start by presenting the illness with least amount of studies, MS. Secondly, CP will be investigated further, and lastly, the illness with the largest amount of studies, stroke, will be presented. The measures used in the studies and mentioned in the tables are

abbreviated, and a full list of these abbreviations can be found in appendix 2.

3.3.1 Multiple Sclerosis

Of the 12 published articles on MS, 11 of them use Nintendo Wii as their commercial video game console. The last one used the Nintendo DS. The first published article was in 2011, with a peak in number of published articles in 2012. The table/figure below illustrates the distribution of published articles on gamification in rehabilitation on MS with the use of commercial video games and consoles.

Figure 3: distribution of published articles on MS

Table 3 will present the studies investigating the use of commercial video gaming in relation to MS. A description of the methods and results of all of the studies that investigate MS in commercial rehabilitation settings will be given. Also, all findings will be summarised after the table is presented.

1 4 3 1 3

2 0 0 7 2 0 0 8 2 0 0 9 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5

The Use and Implementation of Commercial Video Gaming in Rehabilitation: A Scoping Review