XXV.4 July - August 2018
Page: 24
Digital Citation

Games and exergames in rehabilitation

Gitte Lindgaard

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Following major surgery or a life-changing injury, the lengthy rehabilitation process requires adherence to a prescribed exercise regimen. Dropout rates of up to 70 percent indicate that many patients never fully regain their pre-injury health status. Clearly, rehabilitation is an ideal area in which HCI/UX game developers can make a huge difference. The popularity of rehabilitation VR exergames is increasing, but these remain largely ineffective. Most games provide temporary pain relief, but chronic pain management is rarely, if ever, addressed. You need an almost superhuman will to succeed in continued exercise when your body hurts badly. Yet few exergames even mention the essential goal of maintaining player motivation. The Abracadabra series invites us to wave a magic wand in fulfilment of one wish for the HCI/UX community. As a former nurse, my biggest wish is that future exergames be more informed by an understanding of player motivation and of the construct of pain than is currently the case.

back to top  Patient Motivation

One important element of motivation is one's beliefs about the locus of control. Patients with an internal locus of control believe they can perform the exercises effectively, that adherence will lead to health restoration, and that this will provide the positive reinforcement necessary to keep going. However, patients with an external locus of control believe that their health carers—or, in our case, an exergame—control the outcomes. They are unlikely to expect exercising to make them feel competent or to provide positive reinforcement; therefore, they are likely to stop exercising prematurely. The patient's psychological situation rather than the objective situation thus dictates how likely they are to adhere to the exercise regimen.

Self-determination theory (SDT) holds that motivation is considerably more complex than the crude distinction between intrinsic and extrinsic motivation [1]. It asserts that people who engage in an activity purely for pleasurable enjoyment are intrinsically motivated; the behavior is congruent with their values. But performing repetitive exercises that most likely also hurt is hardly done for pure enjoyment. So, although people with an internal locus of control regard exercising as essential to their health, adherence to a prescribed rehabilitation regimen is still an example of extrinsic motivation because it is imposed by an external agent.

Extrinsic motivation varies according to the degree to which a person internalizes a behavior. According to SDT, external regulation is initiated and controlled by contingencies of reward external to the person. Behaviors thus driven may be successfully performed, but they will not be maintained because they depend on external rewards. Patients in this category are unlikely to continue exercising, even if the supporting exergame provides ongoing entertainment value. By contrast, integrated regulation represents the most autonomous form of motivation, occurring when behavioral regulation and "personally endorsed values, goals, and needs that are already part of the self" [2] are congruent. As exercising is not sheer pleasurable enjoyment, integrated regulation is still extrinsically motivated, even though the exercises become congruent with the patient's values.

To enhance motivation, exergames should start with very easy exercises.

SDT outlines three basic psychological needs, two of which apply here: competence and autonomy. Frustration of these needs leads to negative affect [2], whereas mastering our environment makes us feel competent. To enhance motivation, exergames should thus start with very easy exercises. Allowing players to decide when and how much to exercise and adjust the difficulty level when they feel ready creates a sense of autonomy, of taking charge of exercising. Giving up on rehabilitation exercises is, according to SDT, due to an internalization failure because the patient's autonomy has been undermined, whereas supporting autonomy facilitates internalization.

The informational component of externally imposed goals confirms one's sense of autonomy; the controlling component pressures one to behave. A situation will likely satisfy the need for autonomy and competence if it is perceived mainly as informational, but not if it is perceived mainly as controlling. For patients at the external regulation stage, external agents (therapist, exergame) exert pressure. However, if patients at the integrated regulation stage exercise more than recommended, they risk being hurt because they exert excessive pressure on themselves. Exergames should thus enable therapists to set safe exercise ranges and also remind the patient to stop when getting close to the safe maximum. Studies assessing behavior internalized by such provisions have consistently found positive correlations with health outcomes [3].

back to top  Notes on Pain

VR games can successfully distract patients from pain associated with many medical procedures. Snow World [4], for example, created to reduce the excruciating pain that burn patients endure during wound-care procedures, is so successful that patients require substantially fewer analgesics than they would without the game. In the game, the player hurls snowballs at snowmen and penguins while traveling through an icy canyon. Such relatively passive distraction is, however, insufficient for encouraging rehabilitating patients to exercise. And unfortunately, many patients will suffer chronic pain, thus requiring longitudinal adherence to an exercise regimen. Barriers to successful adherence include worsening pain while exercising and boredom with endlessly repetitive exercises. Exergames should thus aim to minimize initial pain to promote an experience of competence and provide an engaging, evolving storyline. Along with providing a record of effort expended, exergames should encourage the patient to try the next level of difficulty while allowing them to decide when to do so, thereby supporting autonomy.


The fear of upcoming pain strongly influences the pain experience. Pain thus depends on expectations of the apparent danger to bodily tissues rather than the true danger of tissue damage. Merely seeing a painful limb being touched can evoke pain and swelling for people with chronic pain, even if the limb is not actually being touched. Imagined movement of a painful limb can also increase pain and swelling without any detectable muscle activity or limb movement [5]. Chronic pain can spread and swap location, sides, or limbs, suggesting perceptual and regulatory dysfunctions not attributable to tissue injury. As pain persists, the central nervous system (CNS) and the brain undergo measurable changes, making the pain-tissue link tenuous [5]. The more tenuous this link is, the more an exergame must look beyond physical-tissue damage and cater to the pain experience as well. Cognitive-behavioral treatment, for example, aims to establish a sense of control over pain; it teaches patients techniques to deal with pain episodes rather than distracting from them. Such coping strategies can change pain-related cognition and reverse CNS/brain dysfunction. Studies of long-term meditation practitioners reveal that it also alters anticipatory pain evaluation, suggesting that meditation increases attention to the sensory pain experience while reducing emotional and evaluative responses [6].

In conclusion, the above discussion suggests that exergames for rehabilitation should include pain-management goals other than mere pain distraction, and also consider patients' motivation to adhere to a long-term rehabilitation exercise regimen.

back to top  References

1. Deci, E.L. and Ryan, R.M. Intrinsic Motivation and Self-Determination in Human Behavior. Plenum Press, New York, NY, 1985.

2. Deci, E.L. and Ryan, R.M. Handbook of Self-Determination Research, University of Rochester Press. Rochester NY, 2002.

3. Campbell, R., Vansteenkiste, M., Delesie, L.M., Mariman, A.N, Soenens, B., Tobback, E., van der Kaap-Deeded, J., and Vogelaers, D.P. Examining the role of psychological need satisfaction in sleep: A self-determination theory perspective. Personality and individual differences 77 (2015), 190–204.

4. Hoffman, G.H., Patterson, D.R., Carrougher, G.J., Nakamura, D., Moore, M., Garcia-Palacios, A., and Furness, A. The effectiveness of virtual reality pain control. With multiple treatments of longer durations: A case study. International Journal of Human-Computer Interaction 13, 1 (2010), 1–12.

5. Atlas, L.Y., Lindquist, M.A., and Wager, T.D. Brain mediators of predictive cue effects on perceived pain. The Journal of Neuroscience 30, 9 (2010), 12964–12977.

6. Solomons, T.V. and Kucyi, A. Does meditation reduce pain through a unique neutral mechanism? The Journal of Neuroscience 31, 36 (2011), 12705–12707.

back to top  Author

As an experimental psychologist, Gitte Lindgaard held the Canadian NSERC/Cognos Senior Industry Research UCD Chair (11 years), prior to which she was principal scientist at the Telstra Research Laboratories and chair of the Australian CHISIG. She has served in numerous editorial positions at HCI journals and has authored approximately 250 peer-reviewed international publications. [email protected]

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