JMIR Serious Games

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

The Reciprocal Relationships Among Impulsivity, Self-Control, Gaming Time, and Internet Gaming Disorder Among Adolescents: Prospective Longitudinal Cohort Study

2026-09-23T15:45:10-04:00

Background: Gaming time, impulsivity, and self-control are known determinants of internet gaming disorder (IGD). However, their reciprocity has not been empirically tested. Objective: This study investigated the reciprocal relationships among gaming time, impulsivity, self-control, and IGD simultaneously within a single cross-lagged panel model among Chinese adolescents, hypothesizing that all 4 variables would be prospectively associated with each other. Methods: This 1-year, 2-wave prospective longitudinal cohort (observational) study recruited grade 7 and grade 8 students from a convenience sample of 6 junior high schools in Chengdu and Guangzhou, China. Students completed an identical self-administered questionnaire in classrooms (using paper and pencil, without teachers present) in December 2018 (wave 1 [W1]) and December 2019 (wave 2 [W2]). Impulsivity, self-control, gaming time, and IGD were assessed using validated scales. The 2238 students (mean age 12.60, SD 0.63 years, 95% CI 12.58‐12.63; male: n=1102, 49.24%, 95% CI 47.27%‐51.21%) who completed the W1 survey were included in the final data analysis, with multiple imputations addressing missing data from dropouts and unmatched assessments across the 2 study waves. Results: Adjusting for background characteristics, autoregressive correlations, and concurrent correlations, the cross-lagged panel model showed that (1) the prospective association between gaming time at W1 and IGD at W2 was statistically nonsignificant (β=0.02, 95% CI −0.04 to 0.08), but IGD at W1 was prospectively and positively associated with gaming time at W2 (β=0.08, 95% CI 0.01‐0.16; =.02); (2) self-control at W1 was prospectively and negatively associated with both gaming time at W2 (β=−0.13, 95% CI −0.19 to −0.07; <.001) and IGD at W2 (β=−0.11, 95% CI −0.17 to −0.05; <.001), and IGD at W1 was prospectively and negatively associated with self-control at W2 (β=−0.09, 95% CI −0.15 to −0.03; <.001), but gaming time at W1 was not associated with self-control at W2 (β=0.04, 95% CI −0.01 to 0.09); and (3) the prospective associations between impulsivity at W1 and IGD at W2 (β=0.03, 95% CI −0.03 to 0.09) and between impulsivity at W1 and gaming time at W2 (β=−0.04, 95% CI −0.10 to 0.03) were statistically nonsignificant; reciprocally, neither IGD at W1 (β=0.05, 95% CI −0.01 to 0.11) nor gaming time at W1 (β=−0.01, 95% CI −0.07 to 0.05) was prospectively associated with impulsivity at W2. Conclusions: This prospective longitudinal cohort study is the first to disentangle the reciprocal prospective associations among gaming time, impulsivity, self-control, and IGD simultaneously within a single cross-lagged panel model. Unlike prior studies, which examined these variables separately and largely cross-sectionally, this design clarified their bidirectionality and relative longitudinal importance. The findings revealed novel differential associations among the 4 variables, findings that promise to reorient the field from gaming time toward the cognitive and motivational processes regulating gaming behaviors. Practically, if replicated in studies with more robust designs, prevention and control programs for IGD should prioritize strengthening adolescents’ self-control rather than merely restricting their gaming time.

Two-Stage Gamified Digital Assessment for Autism Spectrum Disorder Screening and the Limits of Differentiating Social Communication Disorder in Children and Adolescents: Cross-Sectional Diagnostic Accuracy Study Using Explainable Machine Learning

2026-09-23T15:15:09-04:00

Background: Distinguishing autism spectrum disorder (ASD) from social communication disorder (SCD) is clinically challenging because both conditions present with overlapping social communication deficits. Standard caregiver-reported instruments capture surface-level behavioral similarities rather than underlying cognitive differences, motivating the development of digital gamified assessments that measure social cognitive processes directly. Objective: This study developed and evaluated a 2-stage gamified digital pipeline: stage 1 (Buddy Plan, a self-report module) for high-sensitivity ASD screening, and stage 2 (Buddy Drill, story-based social-judgment scenarios), which was examined with a leakage-controlled analysis, for assessing whether ASD can be differentiated from SCD. Methods: In this cross-sectional diagnostic accuracy study, 275 children and adolescents aged 6‐18 years (mean 11.07, SD 3.13 years; 175/275, 63.6% male) were recruited by convenience sampling from 5 clinical and community sites in the Republic of Korea (May 2024 to February 2025) across 5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) groups: ASD (n=51), SCD (n=54), attention-deficit/hyperactivity disorder (n=23), high risk (n=52), and neurotypically developing (ND; n=95). Diagnoses were established by board-certified child psychiatrists. Participants completed 2 tablet-based modules: Buddy Plan (52 self-report items; stage 1) and Buddy Drill (153 story-based scenarios; stage 2). The primary outcome was diagnostic accuracy (area under the receiver operating characteristic curve [AUC], sensitivity, and specificity). Four machine learning algorithms were trained with nested cross-validation (5×5 folds). For stage 2, item selection and imputation were performed within each training fold. Explainability used Shapley Additive Explanations (SHAP). Significance was set at α=.05 (2-sided) with bootstrap 95% CIs. Results: Group differences were tested by 1-way ANOVA. For stage 1 (ASD vs ND; n=146), random forest achieved a nested AUC of 0.912 (95% CI 0.856‐0.953). At a threshold of 0.200, sensitivity was 96.1% (49/51; 95% CI 86.8%‐99.5%) and specificity was 58.9% (56/95; 95% CI 48.4%‐68.9%), with 2 false negatives. For stage 2 (ASD vs SCD; n=100), the fully nested pipeline yielded only chance-level discrimination: regularized logistic regression achieved a nested AUC of 0.62 (95% CI 0.51‐0.74), and no feature configuration (self-report: 0.55, objective: 0.62, combined: 0.63) exceeded chance. SHAP identified 5 cross-algorithm stage 1 biomarkers with significant ASD-versus-ND differences (all <.01) and no evidence of sex bias. Conclusions: The gamified Buddy Plan module shows promise for high-sensitivity ASD screening. In contrast, once feature-selection leakage was removed with a fully nested pipeline, the Buddy Drill module did not robustly differentiate ASD from SCD, and the apparent advantage of objective features over self-report features seen in leaky analyses did not persist. Because the results derive from internal cross-validation in a single, predominantly male Korean cohort without external validation or IQ matching, they represent preliminary evidence of screening feasibility rather than validated clinical differentiation. Prospective, externally validated, IQ- and language-matched studies are required.

Gameful Experience and Perceived Educational Value in a Student-Designed Medical Escape Room for Preclinical Medical Education: Cross-Sectional Study

2026-09-21T16:15:11-04:00

Background: Educational escape rooms are increasingly used in medical education to promote engagement, collaboration, and active problem-solving. However, existing literature varies considerably in theoretical grounding and evaluation methodology, and limited evidence exists regarding how specific dimensions of gameful experience may relate to learners’ perceived educational value. Objective: This study aimed to evaluate preclinical medical students’ perceptions of a student-designed medical escape room and to examine associations between dimensions of gameful experience and perceived educational value. Methods: A cross-sectional study was conducted during the 2023-2024 and 2024-2025 academic years among 144 preclinical medical students participating in a student-designed educational escape room. The intervention integrated foundational medical sciences, collaborative problem-solving, and simulation-based procedural tasks. Participants completed anonymous questionnaires after the activity. Perceived educational value was assessed using the Diabetes Escape Room Perception Scale (DERPS), while gameful experience was measured using the Gameful Experience Scale (GAMEX). Descriptive statistics, reliability analyses, principal component analysis with Varimax rotation, Spearman correlation analyses, one-sample Wilcoxon signed-rank tests, and multiple linear regression models were performed using IBM SPSS Statistics version 29. Statistical significance was set at an α level of .05. Results: Of the 144 participants, 140 (97.2%) completed all questionnaires. The sample was 52.1% (73/140) female, with a mean age of 20.8 (SD 1.5) years. Participants reported favorable perceptions of the escape room, with DERPS scores exceeding the neutral midpoint (mean 4.00, SD 0.50; =35.50; <.001). The GAMEX showed high internal consistency (Cronbach α=0.89), and factor analysis supported the original 6-factor structure. Enjoyment (mean 4.75, SD 0.41), Creative Thinking (mean 4.33, SD 0.56), Activation (mean 3.99, SD 0.63), Absorption (mean 3.70, SD 0.76), and Dominance (mean 3.48, SD 0.81) were above the scale midpoint (all <.001). Scores on the Absence of Negative Affect dimension (mean 2.11, SD 1.12; <.001) were below the midpoint, indicating that participants reported some degree of challenge-related negative emotions during the activity. Spearman correlation analyses demonstrated positive associations between DERPS scores and Enjoyment (ρ=0.534; <.001), Creative Thinking (ρ=0.467; <.001), and Absorption (ρ=0.319; <.001). In multivariable regression analyses, Enjoyment was associated with both overall perception scores (β=0.385; <.001; ²=.442) and educational efficacy scores (β=0.279; =.004; ²=.350). Dominance was related to educational efficacy scores (β=0.194; =.04). Conclusions: This study extends existing research on educational escape rooms by combining a relatively large preclinical medical student sample with validated measures of learner perception and gameful experience. Unlike previous studies that primarily assessed satisfaction, the present study identified specific experiential dimensions—enjoyment and dominance—associated with perceived educational value. These findings contribute to a theory-informed understanding of game-based learning in medical education and provide practical guidance for designing immersive, learner-centered activities. These findings support the use of student-designed, digitally enriched escape rooms as engaging educational activities in preclinical medical education.

Scenario-Based Serious Game for Screening Mild Cognitive Impairment in Older Adults: Cross-Sectional Preliminary Validation Study

2026-09-16T16:15:11-04:00

Background: Many existing digital cognitive assessments rely on isolated or abstract tasks, and primarily use accuracy-based outcome measures, despite recent advances in the field. Few have been culturally adapted to reflect the familiar daily-life experiences of Korean older adults. Integrating culturally meaningful scenarios with task-specific accuracy and reaction time (RT) measures may provide a more ecologically grounded approach to mild cognitive impairment (MCI) screening. Objective: This study aimed to develop and preliminarily evaluate a tablet-based, scenario-based serious game for community-based MCI screening among Korean older adults. Methods: In this cross-sectional diagnostic accuracy study, community-dwelling adults aged 60‐84 years were recruited through convenience sampling from a senior welfare center in Daejeon, South Korea, between July 2024 and June 2025. Of 87 participants who underwent eligibility assessment, 67 participants were included in the analysis: 47 cognitively normal participants, and 20 participants with MCI. Clinical classification was determined according to Petersen criteria based on the Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease battery, second edition, structured clinical interviews, and clinician judgment blinded to the serious game results. The serious game initially comprised 5 culturally familiar and ecologically grounded daily-life tasks, from which task-specific accuracy and RT features were extracted. A reduced 4-task model informed by exploratory misclassification analysis served as the primary classification model and was evaluated using random forest classification with out-of-bag validation. A full 5-task model and a demographic-adjusted model were also evaluated. Convergent validity and perceived workload were assessed. Results: The group with MCI was older (77.3 vs 74.5 y; =.002) and had fewer years of education (9.4 vs 11.2 y; =.04). The primary 4-task model achieved an overall accuracy of 82.1% (55/67), balanced accuracy of 80.1%, sensitivity of 75% (15/20), specificity of 85.1% (40/47), and an area under the receiver operating characteristic curve of 0.787 (95% CI 0.643‐0.932). The demographic-adjusted model showed broadly comparable discrimination (area under the receiver operating characteristic curve 0.794, 95% CI 0.654‐0.934). Accuracy and RT measures from the sale items task ranked among the most important predictors. Digital composite scores were significantly correlated with the Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease battery, second edition total score (=.655 and =.447; both <.001). Perceived workload did not significantly differ between groups (=.97). Conclusions: This study provides preliminary evidence for the diagnostic utility and feasibility of a tablet-based serious game integrating culturally familiar daily-life scenarios with task-specific accuracy and RT measures, thereby capturing both performance accuracy and potential differences in processing efficiency. The automated format may offer a scalable and accessible screening option for community settings without specialized equipment. Independent, multisite, and longitudinal validation is required to establish its generalizability and predictive utility.

Effects and Moderators of Exergaming on Glucose and Lipid Metabolism in Children and Adolescents: Systematic Review and Meta-Analysis

2026-09-15T11:45:10-04:00

Background: Exergaming, or active video gaming, may make physical activity more engaging for children and adolescents. Earlier reviews have focused on activity, adiposity, fitness, or psychosocial outcomes, leaving effects on glycemic and lipid biomarkers uncertain. Their cardiometabolic relevance warrants synthesis. Objective: This systematic review and meta-analysis evaluated the effects of exergaming on glucose and lipid metabolism in children and adolescents, and explored potential moderators. Methods: Following PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), we searched PubMed, Embase, Scopus, Web of Science, the Psychology and Behavioral Sciences Collection, and CENTRAL from inception to April 27, 2026, with backward and forward citation searching. Eligible controlled interventions enrolled participants aged ≤18 years and compared exergaming with nonexergaming controls. Outcomes were glucose, insulin, total cholesterol (TC), triglycerides, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C). Standardized mean differences (Hedges ) were pooled with inverse-variance random-effects models and the Hartung-Knapp-Sidik-Jonkman adjustment. We reported 95% CIs, heterogeneity, 95% prediction intervals (PIs), risk of bias, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) certainty; subgroup analysis, meta-regression, and leave-one-out sensitivity analyses explored moderators and estimate stability. Results: Ten controlled intervention studies involving 732 participants were included. Pooled effects were nonsignificant for glucose (9 studies, 528 participants; Hedges =−0.16, 95% CI −0.57 to 0.24; PI −1.12 to 0.79), insulin (5 studies, 308 participants; Hedges =−0.06, 95% CI −0.35 to 0.23; PI −0.39 to 0.27), TC (9 studies, 510 participants; Hedges =−0.39, 95% CI −1.11 to 0.33; PI −1.70 to 0.93), triglycerides (9 studies, 510 participants; Hedges =−0.17, 95% CI −0.50 to 0.17; PI −0.88 to 0.55), and HDL-C (9 studies, 510 participants; Hedges =−0.14, 95% CI −0.34 to 0.06; PI −0.35 to 0.07; effect sizes were reverse-oriented so that negative values favored exergaming). LDL-C showed a small favorable pooled average reduction (9 studies, 510 participants; Hedges =−0.29, 95% CI −0.55 to −0.04; PI −0.73 to 0.14), but its PI crossed the null. All PIs crossed the null; heterogeneity was substantial for glucose, considerable for TC, moderate for triglycerides, and low for insulin, HDL-C, and LDL-C. Subgroup signals were exploratory, no significant meta-regression moderators were identified, and leave-one-out analyses did not materially alter the glucose, TC, or triglycerides estimates. Most randomized trials had risk-of-bias concerns; the nonrandomized study had serious risk of bias. These limitations reduce confidence in the LDL-C signal. GRADE certainty was very low for glucose and TC and low for the remaining outcomes. Conclusions: This review provides a synthesis of pediatric glycemic and lipid biomarkers and potential moderators, extending earlier broader exergaming reviews. Exergaming may be an engaging complementary strategy for physical activity and lipid health, including LDL-C, in schools, families, and community settings. However, heterogeneous protocols, risk-of-bias concerns, very low-to-low certainty, and PIs crossing the null mean that the magnitude and generalizability of any metabolic benefit remain uncertain. Trial Registration: OSF Registries osf.io/64fus; https://osf.io/64fus

Dynamic Adoption of Immersive Tai Chi Training Among Older Adults: Exploratory Qualitative-Dominant Longitudinal Mixed Methods Follow-Up Study of Virtual and Mixed Reality Delivery

2026-09-15T11:45:10-04:00

Background: Immersive exercise systems may support guided movement practice and physical activity among older adults, but adoption of head-mounted systems cannot be inferred from single-session usability or intention ratings. Older adults must negotiate unfamiliar equipment, movement safety, comfort, perceived control, trust, and perceived benefit. Virtual reality (VR) and mixed reality (MR) are often grouped as extended reality despite different sensory and safety affordances. Objective: This study examined how older adults’ barriers and facilitators evolved during repeated immersive Tai Chi training and how VR and MR delivery appeared to shape immersion, control, trust, safety appraisal, and conditional willingness to continue use. Methods: We conducted an exploratory, qualitative-dominant longitudinal mixed methods follow-up study in Hunan, China. Community-dwelling adults aged 60 years or older completed guided Tai Chi training in VR or MR while retaining parent-study allocation; comparisons were descriptive and hypothesis-generating. The completed-protocol quantitative sample and the main qualitative denominator each included 34 participants (VR: n=16; MR: n=18). Data sources comprised semistructured interviews, Game Experience Questionnaire dimensions, Virtual Reality Sickness Questionnaire (VRSQ) scores, safety observations, and task performance logs from days 1, 3, and 6. Qualitative data were coded using a Dynamic Barrier Framework–informed codebook and integrated with descriptive quantitative summaries. Results: Adoption unfolded as a staged process. During entry, unfamiliarity, competence concerns, and mild physical discomfort shaped responses. Initial uncertainty was endorsed by 7 of 16 (43.8%, 95% CI 23.1‐66.8) VR participants and 6 of 18 (33.3%, 95% CI 16.3‐56.3) MR participants. During adaptation, participants described practice, feedback, social reinforcement, and environmental experience; accuracy improved from day 1 to day 6 by 0.083 (95% CI 0.024‐0.142) in VR and 0.103 (95% CI 0.037‐0.169) in MR. Late-stage willingness remained conditional on comfort, safety, content variety, and usefulness. VR accounts more often emphasized environmental immersion and affective value, whereas MR accounts more often emphasized reality grounding, perceived control, and trust. Standardized VRSQ scores were low overall (VR 8.65 and MR 5.65, on a 0‐100 scale), with no falls, serious adverse events, or session terminations. Conclusions: This study combines repeated qualitative accounts with symptom, safety, and performance evidence while holding the Tai Chi content constant across VR and MR delivery. Unlike single-session acceptance studies, broad extended reality comparisons, or endpoint-only evaluations, it shows adoption as a phase-sensitive and conditional process rather than a one-time decision. The Dynamic Barrier Framework explains how entry barriers may soften, persist, or change meaning and how modality-sensitive affordances shape experience without implying device superiority. In practice, immersive exercise should combine gradual orientation, monitored exposure, comfort and safety safeguards, understandable feedback, social support, and modality-sensitive design. Longer community or home follow-up remains necessary before inferring sustained adherence or unsupervised safety.

Development of a Mixed-Reality Application for Volitional Step Training in People With Multiple Sclerosis: Cross-Sectional Qualitative User-Centered Co-Design Study

2026-09-14T17:00:03-04:00

Background: People with multiple sclerosis (MS) are at high risk of falls, with approximately half experiencing at least 1 fall within 6 months. Multidirectional step training has shown potential for fall prevention, but evidence in people with MS remains inconsistent. Mixed reality (MR) offers adaptive and home-based rehabilitation opportunities. However, successful implementation of MR-based serious games requires structured co-design processes integrating patient, clinician, and technical perspectives. Objective: This qualitative study describes the co-design and prototyping of a home-based MR serious game called Head Your Limits for volitional step training in people with MS, aiming to identify patient-, clinician-, and technology-driven design requirements and translate them into an MR rehabilitation application. Methods: We implemented a cross-sectional qualitative user-centered co-design process. Phase 1 involved 2 online focus groups with people with MS to identify experiential and design preferences related to MR-based training. Phase 2 included a focus group with 4 clinicians and 1 engineer to define clinical and technical requirements. Phase 3 consisted of in-person hands-on testing of 2 MR prototypes (“clock” and “grapes”), developed in Unity and deployed on Meta Quest 3. Twenty people with MS were purposively screened from among individuals referred for motor rehabilitation; 14 participated in the online focus groups and 9 in in-person prototype testing (mean age 56.2, SD 7.0 years; mean Expanded Disability Status Scale score 5.1, SD 1.3; 6/9, 66.7% female). Iterative refinement followed each phase, translating stakeholder-derived requirements into architectural modifications of the MR application. Focus group recordings and moderator notes were reviewed to identify themes and design requirements guiding iterative prototype refinement. Results: Five primary patient-derived requirements emerged: multisensory feedback, gamification, progress tracking, visual accessibility, and ergonomic comfort. Clinicians emphasized adaptive difficulty, cognitive-motor integration, biomechanical validity, and caregiver compatibility. Prototype comparison showed that floor-level targets induced cervical discomfort and postural compensation, whereas auditory guidance reduced head flexion. The final application repositioned targets at eye level and implemented head-mounted display tracking to ensure appropriate center-of-mass displacement, preserve proprioceptive engagement, enable caregiver proximity, and integrate gamified feedback and performance reporting. Conclusions: Iterative stakeholder engagement resolved key design tensions related to ergonomics, sensory reliance, biomechanical validity, and motivation. The transition to eye-level, head-mediated interaction emerged as a core solution integrating therapeutic and user-experience goals. Through a rigorous user-centered co-design process, aligned with contemporary human-centered development models, we developed an MR serious game for volitional step training in people with MS. This study contributes to the field by providing a transparent methodological framework integrating biomechanical validity, usability, and engagement. Although clinical effectiveness remains to be tested, these findings may inform the design of accessible, personalized home-based rehabilitation for people with MS and other neurological populations.