JMIR Serious Games

A Tangible Multimodal Sensing Interface for Collaborative Task Engagement in Children With Autism Spectrum Disorder: Cross-Sectional Mixed Methods Feasibility Study

2026-10-15T16:15:18-04:00

Background: Social engagement is critical for the developmental progress of children with autism spectrum disorder (ASD). While tangible technologies and serious games (SGs) show promise, a dual-purpose platform that both facilitates collaborative interaction and enables sensing of collaborative task engagement is required. Existing tangible interfaces often lack integrated sensing capabilities, while devices designed for complex input are typically not optimized for the sensory and interaction needs of this population. Objective: This study aims to present InteractiSense, a tangible prototype designed to support collaborative play while enabling engagement estimation for children with ASD through embedded multimodal sensing. Our primary objectives were twofold: (1) to evaluate the prototype’s preference, usability, and workload, and (2) to assess the feasibility of its embedded sensor data in generating valid inputs for preliminary machine learning (ML)-based engagement classification. Methods: We developed InteractiSense, a spherical, soft-textured prototype embedded with 7 physio-behavioral sensors, alongside a collaborative SG promoting key social skills, and evaluated it against a familiar Xbox controller as a practical baseline. Fifteen children with ASD (mean age 11, SD 3 years; 10 males and 5 females) participated in a cross-sectional feasibility evaluation using a within-subjects mixed methods design. Preference data were analyzed using the McNemar test and Bayesian analysis, and usability and workload scores were compared using 2-tailed paired tests. Qualitative caregiver interviews on InteractiSense and the SG were analyzed using thematic analysis, with device-related themes contextualizing quantitative findings during interpretation. To validate sensing feasibility, we analyzed the signal-to-noise ratio (SNR) of the sensor data and trained a preliminary extreme gradient boosting (XGBoost) model, comparing it with baseline models to classify binary engagement states using video-coded ground truths. Results: InteractiSense showed a tendency toward higher preference and comparable usability and workload metrics relative to the Xbox controller. Caregivers associated its round shape, soft texture, and simplified configuration with favorable perceptions and noted peer collaboration during the SG and interest in home use. Signal quality varied across sensing modalities: selected modalities provided analyzable data, whereas audio quality was low and pressure data were excluded from SNR and ML analyses. XGBoost achieved 83% (CI 0.76-0.90) balanced accuracy in binary engagement classification, exceeding random and majority-class baselines. Conclusions: These findings provide initial evidence that InteractiSense can serve as a dual-purpose platform supporting collaborative play and engagement-aware sensing within the same tangible interface. Unlike prior systems focused on either interaction support or separate monitoring, InteractiSense combines embedded multimodal sensing with a social play interface in one platform for children with ASD. This study offers a proof-of-concept for extending tangible play systems toward engagement-related sensing and inference, with implications for future therapeutic and educational tools that monitor play and support adaptive intervention. However, feasibility was shown only at a preliminary level, requiring validation in larger cohorts and over longer observation periods.

Effects of Active Video Games on Cardiometabolic Health in Children and Adolescents: Systematic Review and Meta-Analysis of Randomized Controlled Trials

2026-10-13T11:30:22-04:00

Background: Cardiometabolic risk factors emerging during childhood and adolescence may persist into adulthood and increase the risk of cardiovascular disease. Although physical activity improves cardiometabolic health, maintaining regular participation remains challenging. Active video games (AVG), which combine physical activity with video game enjoyment, may provide an engaging approach to promote physical activity participation. Objective: This study aims to evaluate the effects of AVG on cardiometabolic health in children and adolescents and to explore potential moderators of these effects. Methods: PubMed, Web of Science, the Cochrane Library, and Embase were searched from database inception to July 2026. Eligible randomized controlled trials (RCTs) evaluating AVG in children and adolescents aged 4‐18 years were included, with comparisons against no intervention, sedentary video games, or regular physical activity. Random-effects meta-analyses were conducted to estimate pooled effects. Subgroup analyses explored potential moderators. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool (RoB 2; Cochrane), sensitivity analyses examined robustness, and small-study effects were evaluated when feasible. Certainty of evidence was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Results: A total of 14 RCTs involving 942 children and adolescents were included. AVG were associated with a small but significant reduction in BMI (Hedges =−0.23, 95% CI −0.35 to −0.10; 95% prediction interval [PI] −0.43 to −0.01; =.002). SBP (Hedges =−0.18, 95% CI −0.36 to −0.001; 95% PI −0.43 to 0.07; =.0497) showed a small statistically significant reduction, although the 95% PI crossed the null. No significant effects were observed for diastolic blood pressure (DBP) (Hedges =−0.11, 95% CI −0.86 to 0.63; 95% PI −2.09 to 1.75; =.59), high-density lipoprotein cholesterol (HDL) (Hedges =0.05; 95% CI −0.21 to 0.31; 95% PI −0.54 to 0.57; =.65), low-density lipoprotein cholesterol (LDL) (Hedges =−0.26, 95% CI −0.64 to 0.13; 95% PI −1.18 to 0.69; =.15), total cholesterol (TC) (Hedges =−0.96, 95% CI −3.79 to 1.88; 95% PI −5.71 to 3.86; =.37), triglycerides (Hedges =−0.20, 95% CI −0.70 to 0.31; 95% PI −1.41 to 0.99; =.38), heart rate (HR) (Hedges =−0.14, 95% CI −1.74 to 1.46; 95% PI −4.23 to 5.38; =.47), or glucose (Hedges =−0.17, 95% CI −0.37 to 0.02; 95% PI −0.42 to 0.07; =.07) following AVG. No significant BMI subgroup differences were observed by gender, intervention type, or nutritional status. Conclusions: This review extends previous evidence by providing an updated RCT-only evaluation of a broader pediatric population and a wider range of cardiometabolic outcomes. AVG were associated with small reductions in BMI and systolic blood pressure (SBP), although evidence for other cardiometabolic outcomes remains uncertain. By clarifying both potential benefits and remaining evidence gaps, this review provides a broader basis for future research and intervention development. AVG may serve as an engaging adjunct to support physical activity participation among children and adolescents. Trial Registration: PROSPERO CRD420261303390; https://www.crd.york.ac.uk/PROSPERO/view/CRD420261303390

Association Between Embodiment of a Muscular Avatar and Muscle Performance in Virtual Reality for Chronic Low Back Pain: Exploratory Pre-Post Study

2026-10-09T16:15:09-04:00

Background: Chronic low back pain (CLBP) is associated with impaired muscle performance, including reduced trunk strength, as well as disturbances in body perception. Virtual reality (VR) enables modulation of body representation, and the Proteus effect suggests that embodying a stronger avatar may influence perceived bodily capability and behavior. Although preliminary CLBP studies have reported short-term improvements in pain and beliefs, it remains unclear whether avatar-based embodiment can acutely modify muscle strength or relate to subjective embodiment. Objective: This study aimed to examine immediate changes in muscle strength and pain after a VR-based squat task with a progressively muscular avatar in individuals with CLBP and explore associations between strength changes and subjective embodiment. Methods: In this exploratory pre-post proof-of-concept study, 16 individuals with CLBP and 16 age- and sex-matched healthy controls performed a VR-based squat task with a progressively muscular avatar. Muscle strength (handgrip, trunk extension, and knee extension) was assessed before and after VR. Pain and fear were assessed in CLBP only. Subjective embodiment was assessed using the Virtual Embodiment Questionnaire (VEQ). Group × time effects were analyzed using repeated-measures ANOVA, and associations were analyzed using Spearman correlations with false discovery rate correction. All participants completed the VR-based task and assessments, and no missing data were observed in variables included in the analyses. Results: Significant time effects were observed for handgrip strength (=.04), trunk extension strength (<.001), and knee extension strength (<.001), whereas no significant group × time interactions were observed for handgrip, trunk extension, or knee extension strength (=.75, =.19, and =.28, respectively). Trunk extension strength significantly increased in healthy controls (mean difference 0.04 kgf/kg, 95% CI 0.03 to 0.05; Bonferroni-adjusted <.001) but not in individuals with CLBP (mean difference 0.02 kgf/kg, 95% CI 0.001-0.05; Bonferroni-adjusted =.08). Knee extension strength increased in both the CLBP group (mean difference 0.06 kgf/kg, 95% CI 0.02-0.11; Bonferroni-adjusted =.02) and healthy controls (mean difference 0.09 kgf/kg, 95% CI 0.06-0.12; Bonferroni-adjusted <.001). In the CLBP group, pain intensity decreased during VR compared with pre-VR levels (=.02), whereas post-VR pain did not differ from pre-VR levels. Changes in trunk extension strength were positively correlated with VEQ change in the CLBP group (ρ=0.76, 95% CI 0.41-0.94; false discovery rate–adjusted =.006). Conclusions: Trunk and knee extension strength showed time-related increases without significant group × time interactions, and trunk extension strength change was associated with VEQ change in the CLBP group. These findings suggest that avatar-based modulation of body perception may relate to individual variability in motor output. However, without a neutral-avatar control condition, the observed changes cannot be attributed specifically to the progressive muscular transformation of the avatar. Further research is needed to clarify the role of avatar-based embodiment in exercise-based rehabilitation.

Haptic Virtual Reality Training for Combined Spinal-Epidural Anesthesia in Anesthesiology Trainees: Prospective Randomized Controlled Pilot Trial

2026-10-08T17:15:20-04:00

Background: Combined spinal-epidural (CSE) anesthesia is a complex psychomotor skill requiring precise tactile discrimination. Traditional manikin-based training may be limited by degraded haptic fidelity and inconsistent tissue feedback. Whether skills acquired through haptic virtual reality (VR) training transfer to supervised clinical procedures remains uncertain. Objective: This study assessed the feasibility and early clinical application of CSE skills after high-fidelity haptic VR training in junior anesthesiology trainees vs traditional manikin-based training. Methods: We conducted a single-center, prospective, parallel-group, randomized, and outcome assessor-blind pilot trial. A total of 20 fifth-year anesthesiology interns with minimal neuraxial experience were randomly assigned (1:1) by an independent investigator using a card draw to a standardized 7-day curriculum with either a traditional manikin (control group [CG], n=10) or a haptic-VR simulator (simulator group [SG], n=10). SG trainees performed repeated punctures on the haptic-VR CSE Teaching Platform, whereas the CG trainees practiced the CSE procedure on a lumbar puncture manikin. Both interventions were delivered face-to-face in a simulation laboratory by experienced instructors. During training, each trainee performed 1 supervised CSE on a patient. Clinical performance was video recorded and assessed by blinded experts. The primary outcome was the 0 to 100 total clinical performance score, rated by 2 assessors. Secondary outcomes included domain-specific scores, procedural time, puncture-angle adjustments, first-attempt success rate, and adverse events within 24 hours. Results: All 20 trainees completed training and clinical assessments and were included in the intention-to-treat analysis. Overall scores were higher in the SG than in the CG (mean difference 4.50 points, 95% CI 1.85-7.15; =.002). The SG had higher scores for tactile-dependent skills, including recognition by bubble compression (mean difference 1.90 points, loss of resistance 95% CI 1.14-2.66; <.001) and ligamentum flavum penetration (mean difference 1.90 points, 95% CI 1.18-2.62; <.001), but lower aseptic technique compliance (mean difference −1.40 points, 95% CI −2.00 to −0.80; <.001). The SG trainees had a shorter time to ligamentum flavum breakthrough, fewer passive angle adjustments, and more active adjustments. The first-attempt success rate was higher but imprecisely estimated. Primary-outcome interrater reliability was excellent (average-measures intraclass correlation coefficient of 0.977). No significant adverse events occurred. Conclusions: Compared with traditional manikin training, haptic-VR training yielded higher overall clinical performance and better tactile-dependent CSE skills during the first supervised patient procedure, whereas manikin training better supported aseptic practice. By evaluating posttraining performance in patients rather than only in simulation, this study extends VR research toward early clinical skill transfer and suggests that the 2 modalities may develop complementary components of procedural competence. In practice, these findings support a blended CSE curriculum in which VR is used for repeated tactile and needle-control training and manikin-based simulation for aseptic preparation and procedural workflow; this approach should be evaluated in larger trials. Trial Registration: Chinese Clinical Trial Registry ChiCTR2100043952; https://tinyurl.com/yc497byy

The ACE of Hearts Serious Game for Young People With Adverse Childhood Experiences: Experience-Based Co-Design and Agile Development Study

2026-10-05T16:15:14-04:00

Background: Young people exposed to adverse childhood experiences (ACEs) are at risk of poor mental and physical health across the life course, yet many struggle to access timely help. Serious games offer an engaging, scalable, and stigma-reducing support, but few are co-designed with young people who have lived experience of ACEs, and methodological accounts of how participatory design is operationalized alongside software delivery are scarce. Objective: We aimed to (1) develop and apply a novel methodological framework integrating experience-based co-design (EBCD) with agile game development to co-design a serious game with young people affected by ACEs, (2) describe the co-designed game prototype and the design decisions shaped by youth participation, and (3) examine the ethical and safeguarding considerations arising from co-designing digital mental health interventions with trauma-exposed young people. Methods: We conducted a participatory co-design study comprising 12 workshops across 8 iterative co-design sprints, involving 18 diverse young people (aged 12‐24 years) with lived experience of ACEs, 5 professional stakeholders, and a multidisciplinary game development team. Young people were recruited across England through partner youth organizations and regional Young People’s Advisory Groups. Co-design ran from June 2022 to April 2024 in hybrid and online formats. Baseline characteristics include demographics, and mental health and well-being measures. EBCD activities were mapped onto agile practices (sprint planning, sprint reviews, and retrospectives); all feedback was logged in a “you said, we did” form. Analyses were descriptive, and reporting followed the GRIPP2-LF (Guidance for Reporting Involvement of Patients and the Public, long-form) checklist. Results: The resulting prototype, ACE of Hearts, comprised a central “cozy den” hub and 4 mini-games addressing bereavement and caregiving, trauma and disability, gender dysphoria, and poverty. Youth feedback directly shaped 47 documented feedback and design decisions. Co-design participants (14 of 18 participants) were diverse in gender (8/14, 57% men or boys; 3/14, 21% women or girls; 1/14, 7% nonbinary; 2/14, 14% another identity; and 3/14, 21% transgender), ethnicity (5/14, 36% from minoritized ethnic backgrounds), sexuality (6/14, 43% bisexual or pansexual), and neurodivergence (7/14, 50% autistic), with elevated levels of depression (mean Patient Health Questionnaire 9-item scale 8.8, SD 4.5) and anxiety (mean Generalized Anxiety Disorder 7-item scale 8.4, SD 3.9). Mean posttraumatic stress symptom severity (Children's Revised Impact of Event Scale, 8-item; n=13) was 22.5 (SD 7.7). Design innovations included metaphoric storytelling, integration of narrative exposure therapy principles into gameplay, and an embedded ethics framework addressing representation, agency, and emotional safety. Conclusions: Integrating EBCD with agile development is a feasible and transparent method for coproducing trauma-informed serious games with young people who have lived experience of ACEs. The approach is transferable to other participatory digital-health projects involving vulnerable populations. Future work would evaluate acceptability, feasibility, and clinical outcomes.

Gamified Assessment of Medication Literacy in School-Aged Children: Instrument Development and Validation Study

2026-10-02T16:00:03-04:00

Background: Assessing medication literacy in children is essential for evaluating school-based health education, yet traditional measurement tools often fail to engage children, compromising data quality. Gamified assessments offer an alternative, but their psychometric properties, comparability to conventional formats, and responsiveness to intervention effects require systematic evaluation. Objective: This study developed and evaluated a gamified assessment tool for measuring medication literacy across 4 domains (knowledge, attitude, perceived behavioral control, and behavioral intention) in elementary school children through 3 sequential phases: psychometric validation, methodological comparison with a paper-based questionnaire, and application to interventions. Methods: Three independent cohorts were recruited from a single elementary school in Nanjing, China, using cluster random sampling of intact classes (grades 4-6). We adapted the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) framework. Phase 1 (40/81, 49.4% female) includes content validity via 2 rounds of expert review, construct validity using Rasch analysis, and 1-month test-retest reliability. Phase 2 (42/85, 49.4% female) includes a randomized crossover design (10-minute washout), equivalence assessed with an intraclass correlation coefficient (ICC), Bland-Altman analysis, decision consistency, and superiority using the chi-square test (data quality) and 2-tailed independent t tests (enjoyment and preference on 5-point Likert scales). Phase 3 (41/85, 48.2% female) includes a single-group pre-post design, with responsiveness evaluated using generalized linear mixed models (GLMMs) with random intercepts. Analyses used R software with an α of .05. Results: Phase 1 had perfect content validity (scale-level content validity index/average [S-CVI/Ave]=1.00), and the Rasch analysis supported unidimensionality (eigenvalues 2.14-2.25, ratios 0.34-0.40) and item fit (mean infit/outfit mean-square [MNSQ] 0.83-1.23). The test-retest ICCs were 0.76 to 0.92 (95% CI 0.64-0.95). Phase 2 equivalence was confirmed (ICC 0.94-0.99, 95% CI 0.90-0.99; κ=0.87-0.97). Validity rates were 100% (42/42, 95% CI 91.6%-100%) for gamified vs 90.7% (39/43, 95% CI 77.4%-96.9%) for paper (P=.13). The gamified tool yielded higher enjoyment (mean 4.26, SD 0.94 vs mean 2.46, SD 0.85; Cohen d=2.00, 95% CI 1.46-2.55; P<.001) and preference (mean 4.29, SD 0.83 vs mean 2.82, SD 0.97; Cohen d=1.62, 95% CI 1.11-2.13; P<.001). Phase 3 GLMMs showed time effects for attitude (β=1.74, 95% CI 1.25-2.22; P<.001), perceived behavioral control (β=2.86, 95% CI 2.18-3.53; P<.001), behavioral intention (β=2.33, 95% CI 1.51-3.15; P<.001), and knowledge (incidence rate ratio [IRR]=1.52, 95% CI 1.22-1.89; P<.001); time × class interactions were nonsignificant (all P≥.19), indicating consistent changes across classes. Effect sizes were moderate to large (Cohen d=0.70-1.53, 95% CI 0.36-1.97). Conclusions: This study develops and validates a gamified assessment tool for children’s medication literacy across 3 independent phases, including a randomized crossover comparison with a paper-based format. Unlike child health measures relying on adult proxy reports or adapted adult scales, our child-centered tool was directly validated with students and designed to enhance engagement. The psychometrically sound tool achieves measurement equivalence while offering a pediatric health-promotion outcome measure. The tool can support school-based medication literacy programs and advance health equity by detecting consistent improvements across diverse classrooms.

Virtual Reality–Based Mirror Guidance for Indirect Vision Training in Minimally Invasive Endodontic Access Cavity Preparation Among Dental Students: Randomized Controlled Crossover Trial

2026-10-01T15:30:35-04:00

Background: Minimally invasive endodontics requires precise visualization to preserve tooth structure, often relying on indirect vision with a dental mirror—a challenging skill for dental students. Although virtual reality (VR) simulators provide immersive environments for dental training, most existing systems primarily focus on procedural simulation and haptic feedback, with limited capabilities for real-time mirror positioning and indirect visual guidance. Objective: The aim of this study was to evaluate verbal, visual, and haptic VR-based mirror guidance for indirect vision during minimally invasive endodontic access cavity preparation. Methods: Eligible fourth-year preclinical dental students were recruited through institutional email invitations and public announcements. A randomized controlled crossover trial was conducted with 30 participants, who completed all VR sessions in a simulation laboratory under direct investigator supervision to ensure standardized implementation of the training protocol. Participants performed simulated maxillary first molar access cavity preparations under 4 VR mirror guidance conditions—verbal guidance, visual guidance, haptic guidance, and no guidance—following a randomized 4 × 4 Latin square sequence with a 48-hour washout period between sessions. The primary outcome was outcome error score. Exploratory secondary outcomes included operating area visibility, operating area obstruction, operator posture error, task completion time, and Virtual Reality System Usability Questionnaire score. Outcomes were analyzed using linear mixed-effects models accounting for the crossover design. Estimated marginal mean differences (MDs) with 95% CIs and partial eta-squared (ηp²) effect sizes were reported, with Bonferroni-adjusted pairwise comparisons used to account for multiple comparisons. Results: Guidance modality significantly affected the primary outcome, outcome error score (F_3,84=20.34; P<.001; ηp²=0.421). Compared with no guidance, outcome error scores were significantly lower with verbal (MD −0.50, 95% CI −0.76 to −0.24), visual (MD −0.68, 95% CI −0.94 to −0.42), and haptic guidance (MD −0.63, 95% CI −0.89 to −0.37; all adjusted P<.001). Guidance modality also significantly affected operating area visibility (F_3,84=12.31; P<.001; ηp²=0.305). Compared with no guidance, visibility duration was significantly greater with verbal (MD 37.79, 95% CI 11.15-64.43 seconds; adjusted P=.001), visual (MD 59.15, 95% CI 32.51-85.79 seconds; adjusted P<.001), and haptic guidance (MD 31.52, 95% CI 4.90-58.15 seconds; adjusted P=.01). No significant differences were detected for operating area obstruction, operator posture error, task completion time, or usability. Conclusions: VR-based mirror guidance improved the outcome error score and increased operating area visibility during minimally invasive endodontic access cavity preparation. Verbal, visual, and haptic guidance resulted in fewer outcome errors and greater operating area visibility than no guidance, while no significant differences were detected in other performance measures or usability. These findings demonstrate the potential of diverse feedback modalities to provide effective guidance for indirect vision and inform future development of adaptive VR training systems using 1 or more modalities to suit learner needs. Trial Registration: Thai Clinical Trials Registry TCTR20260126008; https://www.thaiclinicaltrials.org/show/TCTR20260126008

Exergame Intervention for Habit Formation, Lifestyle Adjustment, and Health Ownership Enhancement Among Hong Kong’s Older Adults: Multisession, Single-Group, Pre-Post Pilot Study

2026-09-25T15:30:13-04:00

Background: Regular physical activity is critical for healthy aging, yet older adults face persistent barriers to exercise adherence. Exergames, such as video games that require physical movement, have emerged as a promising tool to engage older adults in regular exercise. However, most existing research focuses on physical and cognitive outcomes, with limited understanding of whether exergames are associated with behavioral changes, including sustained exercise habits, healthier lifestyles, and a sense of health ownership, which underpin older adults’ environmental mastery and self-management of their health. Objective: This pilot study investigated how participation in a community-based exergame program was associated with exercise habits, healthy lifestyles, and health ownership and examined the motivational factors driving longer-term adherence. Methods: This study used a single-group, pre-post pilot design. It involved 33 older adults participating in an exergame program across 2 community centers in Hong Kong. The program was meticulously designed to include 12 supervised training sessions (6 wk), followed by a 4-week free-play period to assess long-term adherence. A package of exergames, covering physical, social, and cognitive health, was selected. Each exergame session lasted 30 minutes. During this time, older adults played 3 different games, with each game taking 10 minutes. Changes in health status, well-being, physical activity level, exercise habits, healthy lifestyles, health ownership, and motivations to play exergames at 4 stages were continuously measured. We applied repeated-measures generalized linear model for health and habit outcomes, Mann-Whitney to examine the relationship between motivational factors and adherence, and Spearman correlation to test links between motivation and play frequency during the free-play period. Results: The linear mixed model results suggest that participation in the exergame program was positively associated with older adults’ healthy lifestyles (mean difference 0.70, 95% CI 0.14 to 1.25, =6.52; <.001, η=0.17), exergame play habits (mean difference 0.50, 95% CI −0.03 to 1.03, =4.88; =.004, η=0.13), total physical activity metabolic equivalent of task levels (mean difference 2100.83, 95% CI −249.16 to 4450.82, =3.15; =.04, η=0.09), and health ownership (mean difference 0.24, 95% CI 0 to 0.48, =4.23; =.03, η=0.12). Posttraining adherence was high at 75.80% (25/33). Further, Spearman rank correlation analysis indicated positive associations between adhered gameplay frequency and social (coefficient=0.41; =.02) and enjoyment motivations (coefficient=0.39; =.02). Conclusions: This pilot study examines exergames as an innovative approach to healthy aging by encouraging sustained behavioral change. Unlike prior research that emphasized health outcomes, these findings suggest potential benefits in formulating physical activity habits, lifestyle adjustment, and health ownership. Enjoyment and social connection emerged as key motivational factors. The study indicates potential for nongovernmental organization–led community programs to foster active aging, lifestyle adjustment, and social cohesion.

Balance Wood, a Bilateral Ankle-Controlled Serious Game for Healthy Adults: 2-Stage Cross-Sectional Development and Usability Study

2026-09-25T15:00:17-04:00

Background: Ankle mobility and control contribute to balance and everyday movement throughout adulthood, yet are usually assessed through repetitive, abstract tasks that reveal little about movement production. Serious games can make repeated tasks engaging, but most report only end point scores rather than continuous gameplay signals, and few establish system usability. Developing and evaluating such a system in healthy adults is a necessary first step. Objective: This study aimed to develop Balance Wood, a bilateral ankle-controlled serious game in which seated players tilt a device through ankle flexion-extension to control on-screen play, to describe the system and the signals it records, and to evaluate its usability, safety, and user experience in healthy adults. Methods: In this two-stage cross-sectional development and usability study, healthy adults without lower-limb injury or balance-affecting neurological or vestibular disorders completed single-session repeated-measures procedures. In stage 1, a total of 40 adults—20 older (mean age 73.0, SD 5.9 y; 10 women) and 20 younger (mean age 28.1, SD 3.2 y; 4 women) adults—completed 3 fixed-order difficulty levels in 1 session (exploratory signal analysis). In stage 2, a total of 18 younger adults (mean age 24.6, SD 3.9 y; 5 women) completed the levels in counterbalanced order. Usability was assessed with the System Usability Scale (0‐100); use impressions and consciously used body parts with Likert and open-ended items; and device tilt-angle accuracy against a digital goniometer. Results: The mean System Usability Scale score was 81.5 (SD 11.2; 95% CI 76.0‐87.1; Cronbach α=.74), above the benchmark of 68, indicating good perceived usability. Mean ratings were 2.11 (SD 1.32) for safety concern (95% CI 1.45‐2.77) and 1.67 (SD 1.03) for pain (95% CI 1.15‐2.18). Ankle use was highest at 4.94 (SD 0.24), exceeding knee 2.50 (SD 1.29), hip 2.00 (SD 1.24), and trunk 2.17 (SD 1.15) by Wilcoxon signed-rank tests (<.001). Device readings agreed closely with the goniometer, with a mean absolute error of 0.66°, an intraclass correlation coefficient of 0.999, and 95% limits of agreement of −0.68 to 1.70°. In stage 1, all measures were computable for the 40 participants, with typical amplitudes of 20.5° to 27.2° and stable speed in both groups. In stage 2, repeated-measures analyses (α=.05) did not detect statistically significant differences across difficulty conditions or presentation positions (all >.13). Conclusions: In healthy adults, Balance Wood was usable, well-accepted, low-risk, and provided accurate device-level tilt measurement with predominantly ankle-based control while continuously recording gameplay signals. It is a low-cost, bilateral, ankle-specific control interface with continuous signal capture into 1 easy-to-use device. Its contribution is a reproducible, usability-tested platform with characterized device accuracy, and formally defined candidate measures awaiting validation. Once validated, it could support home- or community-based recording; in the near term, it is a research tool.

Gamification Elements in Physical Activity Interventions: Scoping Review and Taxonomy Based on the Octalysis Framework

2026-09-25T14:15:11-04:00

Background: Physical inactivity affects approximately 1.4 billion adults globally, representing a major public health challenge. Gamification shows potential in addressing global inactivity by boosting motivation. The widely recognized Gamification Octalysis Framework, which emphasizes human motivation over mere functionality, can be used to summarize gamification elements in physical activity (PA) applications. However, previous reviews have mainly examined the effectiveness of gamified PA interventions, with limited attention to how gamification elements are linked to motivational mechanisms and behavior change techniques (BCTs). Additionally, the integration of identified BCTs can help connect game elements and health behavior change. Objective: This scoping review aimed to map and categorize gamification elements used in PA interventions according to the Octalysis Framework, identify associated BCTs, and describe reported outcome domains and design gaps to inform future gamified PA intervention development. Methods: The review protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251077817). The scoping review was conducted according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). A total of seven databases (ie, PubMed, Embase, Cochrane Library, Web of Science, CINAHL, SPORTDiscus, and Psychological Information) were selected and searched for relevant randomized controlled trials (RCTs) published in English from inception to July 7, 2026. Two reviewers (SJL and LQ) independently conducted study selection and gamification-element coding. Data charting was performed by one reviewer (SJL) and verified by another (LQ). Results: A total of 53 RCTs and 34 unique interventions were included in this review. The studies reported a variety of outcomes, including user retention, behavioral changes, psychological impacts, and health-related indicators. The most frequently adopted BCT elements were “2.2 feedback on behavior” and “1.1 goal setting (behavior).” Moreover, using the Octalysis framework, a taxonomy was developed, identifying 48 gamification elements (eg, narrative, mentoring, and points loss) across 8 core motivational drives. The majority of BCTs were mapped to 2 core motivations (ie, empowerment and accomplishment), while some BCTs were not supported by gamification elements. Conclusions: This scoping review complements previous effectiveness-focused reviews by examining how gamified PA interventions are designed and which motivational and behavior change functions they target. By developing an Octalysis-based taxonomy of 48 gamification elements and mapping these elements against BCTs, this review provides a descriptive, design-oriented evidence map of commonly used design patterns and underrepresented behavior change functions. The findings may support more deliberate and transparent selection, combination, and reporting of gamification elements in future PA interventions. However, they should not be interpreted as evidence of the effectiveness of individual gamification elements, and further research is needed to evaluate how specific design configurations influence engagement and PA outcomes. Trial Registration: PROSPERO CRD420251077817; https://www.crd.york.ac.uk/PROSPERO/view/CRD420251077817