We appreciate the insightful comments and reflections regarding our study on the impact of serious games on executive functions and their application in neurodiverse populations [1]. The suggestion to consider pinball machines as a tool within the serious games paradigm presents an interesting avenue for further exploration. At the time of our study, our focus was primarily on conventional and emerging digital technologies, such as virtual reality, mobile devices, and sensor-based interactions. However, we acknowledge that pinball, with its unique combination of physical and digital interactions, may offer valuable cognitive and therapeutic benefits, particularly in the context of executive function training. The references provided in the letter highlight historical and recent research supporting its potential applications in various populations, reinforcing the idea that this arcade technology could play a role in future serious game developments. Given the evidence presented on pinball’s ability to engage attention, impulse control, cognitive flexibility, and problem-solving skills, we recognize its potential as a tool to enhance executive function training. Future work in this area could explore the adaptation of pinball mechanics within digital serious games or investigate its direct application as a therapeutic tool in controlled settings. Additionally, we acknowledge that the development of assistive technologies for neurodiverse populations often encounters blind spots, where certain tools or approaches are overlooked. Our intention with the published article is to provide a roadmap for researchers, highlighting that there remains substantial work to be done in this area. By identifying these gaps, we aim to offer a starting point for ongoing and future investigations. Several studies have underscored the challenges and opportunities in designing technologies for neurodiverse users. For instance, Frauenberger et al. discuss the importance of involving neurodiverse children in the technology design process to ensure that their unique needs are met [2]. Similarly, Benton and Johnson highlight lessons from neurodiverse communities, emphasizing the necessity of tailored technological interventions [3]. These perspectives reinforce the need for comprehensive research and development efforts to address the diverse requirements of neurodiverse populations. We thank the authors of the letter for broadening the discussion on serious game technologies. Their insights open the door to new interdisciplinary research possibilities that could further enrich this field.

This article (letter to the editor) discusses an overlooked, long-established technology within serious games research: the pinball machine. Pinball is a game that engages multiple cognitive processes, enhancing executive functions, as explored in the accompanying article. Its enduring presence in the gaming industry—spanning gameplay design, mechanics, electronics, and both kinetic and digital formats—raises important questions: Could pinball's unique format, rooted in both physical and digital realms, bridge the gap between traditional and modern approaches to serious gaming? Could it offer a more tangible, interactive experience as a promising therapeutic tool (or adjunct) compared to conventional serious games? Despite decades of studies examining the use of pinball machines as an intervention for individuals with various conditions, the role of pinball in serious game research remains underexplored. Why is this technology not more widely investigated, including its theoretical potential, even as it continues to evolve? Is pinball less adaptable or perhaps too costly compared to other technologies? While traditionally viewed as entertainment, the cognitive challenges pinball presents to players may provide an effective means to exercise executive function skills. To fully unlock its potential as a serious game, researchers must broaden their scope, integrating arcade technologies like the pinball machine into the increasingly digital-centric landscape of serious gaming.

Background: Alzheimer disease (AD) is the leading cause of dementia worldwide. With aging populations and limited access to effective treatments, there is an urgent need for innovative markers to support timely preventive interventions. Emerging evidence highlights spatial cognition (SC) as a valuable source of cognitive markers for AD. This study presents NavegApp, a serious game (SG) designed to assess 3 key components of SC, which show potential as cognitive markers for the early detection of AD. Objective: This study aimed to determine the content validity and usability perception of NavegApp across multiple groups of interest. Methods: A multistep process integrating methodologies from software engineering, psychometrics, and health measurement was implemented to validate the software. Our approach was structured into 3 stages, guided by the software life cycle for health and the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations for evaluating the psychometric quality of health instruments. To assess content validity, a panel of 8 experts evaluated the relevance and representativeness of tasks included in the app. In addition, 212 participants, categorized into 5 groups based on their clinical status and risk level for AD, were recruited to evaluate the app’s digital ergonomics and usability at various stages of development. Complementary analyses were performed to identify group differences and to explore the association between task difficulty and user agreeableness. Results: NavegApp was validated as a highly usable tool by both experts and users. The expert panel confirmed that the tasks included in the game were representative (Aiken V=0.96-1.00) and relevant (Aiken V=0.96-1.00) for measuring SC components. Both experts and nonexperts rated NavegApp’s digital ergonomics positively, with minimal differences between groups (r_rb 0.08-0.29). Differences in usability perceptions were observed among participants with sporadic mild cognitive impairment compared to cognitively healthy individuals (r_rb 0.26-0.29). A moderate association was also identified between task difficulty and user agreeableness (Cramér V=0.37, 95% CI 0.28-0.54). Conclusions: NavegApp is a valid and user-friendly SG designed for SC assessment, developed by integrating software engineering and psychometric evaluation methodologies. While the results are promising, further studies are warranted to evaluate its diagnostic accuracy and construct validity. This work outlines a comprehensive framework for SG development in cognitive assessment, emphasizing the importance of incorporating psychometric validity measures from the outset of the design process.

Background: Virtual reality (VR) active gaming is growing in popularity but little is known about physical activity during gameplay. Two popular VR games are Gorilla Tag and Beat Saber. Little is known about physical activity during these games in youth. Objective: The purpose of this study was to investigate the enjoyment, intensity, and amount of physical activity while playing Gorilla Tag and Beat Saber in early adolescent youth. Methods: Sixteen participants, 13 males and 3 females with an average age of 10.7±0.34 years played two VR games (Gorilla Tag and Beat Saber) in a single session. Both games followed the same procedure: a max of 10-minute familiarization period, 5 minutes of rest, 15 minutes of gameplay, and 10 minutes of rest. Participants wore a heart rate monitor to track heart rate reserve (% HRR) and accelerometers on the wrist and waist to monitor time in sedentary activity, light physical activity , and moderate to vigorous physical activity of the arm and whole-body. The Physical Activity Enjoyment Scale-child version (PACES) and ratings of perceived exertion were completed after each game. Dependent t-tests compared measures between games. Results: The results revealed that average and maximum %HRR were significantly higher during Gorilla Tag than Beat Saber, with heart rate-based physical activity intensity reaching light for Beat Saber and moderate for Gorilla Tag. Arm moderate to vigorous physical activity and whole-body moderate to vigorous physical activity and light physical activity were greater during Gorilla Tag than Beat Saber. Arm and whole-body sedentary time were significantly lower during Gorilla Tag than Beat Saber. Gorilla Tag and Beat Saber were rated as highly enjoyable. There were no differences between games for maximum (p=.352) or average (p=.362) ratings of perceived exertion. Both games were rated as light intensity for average ratings of perceived exertion (GT: 4.3±1.9; BS: 4.7±2.3) and moderate intensity for maximum ratings of perceived exertion (GT: 5.4±1.9; BS: 5.8±2.4). Conclusions: These results suggest that Beat Saber produced light intensity physical activity and Gorilla Tag produced light to moderate-intensity physical activity in early adolescent youth, with both games rated as highly enjoyable.

Background: In collaboration with clinical domain experts, we developed a prototype of immersive virtual reality (VR) cognitive remediation for major depressive disorder (bWell-D). In the development of a new digital intervention, there is a need to determine the effective components and clinical relevance using systematic methodologies. From an implementation perspective, the effectiveness of digital intervention delivery is challenged by low uptake and high noncompliance rates. Gamification may play a role in addressing this as it can boost adherence. However, careful consideration is required in its application to promote user motivation intrinsically. Objective: We aimed to address these challenges through an iterative process for development that involves co-design for developing content as well as in the application of gamification while also taking into consideration behavior change theories. This effort followed the methodological framework guidelines outlined by an international working group for development of VR therapies. Methods: In previously reported work, we collected qualitative data from patients and care providers to understand end-user perceptions on the use of VR technologies for cognitive remediation, reveal insights on the drivers for behavior change, and obtain suggestions for changes specific to the VR program. In this study, we translated these findings into concrete representative software functionalities or features and evaluated them against behavioral theories to characterize gamification elements in terms of factors that drive behavior change and intrinsic engagement, which is of particular importance in the context of cognitive remediation. The implemented changes were formally evaluated through user trials. Results: The results indicated that feedback from end users centered on using gamification to add artificial challenges, personalization and customization options, and artificial assistance while focusing on capability as the behavior change driver. It was also found that, in terms of promoting intrinsic engagement, the need to meet competence was most frequently raised. In user trials, bWell-D was well tolerated, and preliminary results suggested an increase in user experience ratings with high engagement reported throughout a 4-week training program. Conclusions: In this paper, we present a process for the application of gamification that includes characterizing what was applied in a standardized way and identifying the underlying mechanisms that are targeted. Typical gamification elements such as points and scoring and rewards and prizes target motivation in an extrinsic fashion. In this work, it was found that modifications suggested by end users resulted in the inclusion of gamification elements less commonly observed and that tend to focus more on individual ability. It was found that the incorporation of end-user feedback can lead to the application of gamification in broader ways, with the identification of elements that are potentially better suited for mental health domains.

Background: The exponential growth of new technologies has meant that the educational field has had to update itself. From the educational point of view, there are some studies that have promoted the implementation of new technologies. These facts have raised the need to implement augmented reality in the university environment, especially among students of health sciences. The use of augmented reality can mean a new approach to teaching by teachers and better learning by students. Objective: To compare the degree of usability of the two augmented reality applications and to analyse the academic performance of the control group and the experimental group at the Universities of Cadiz and Malaga. The existence of significant differences and relationships between the two variables were observed. Methods: This is a quasi-experimental design with post-test as the only evaluation measure that has followed the SPIRIT statement and the ethical and legal aspects of the Principles of the Declaration of Helsinki. An intervention was carried out using two augmented reality applications in the subject of General Procedures in Physiotherapy II at the Universities of Malaga and Cadiz. Results: A total of 199 participants took part in the study. Demographic variables, ratings and usability were analysed, as well as the statistical analysis of the study with the presentation of the results and their interpretation. Significant differences (p<0.001) were found in the ratings at both universities. In addition, significant differences (p<0.001) were found between the experimental group and the control group. Regarding the degree of usability in the univariate analysis, no significant differences were found (p=0.049). A multiple regression analysis of the rating and usability was performed. Rating was found significant differences, with a beta of 1.4 (p<0.001) and usability was also significant (p=0.029) in favour of Aumentaty group. Conclusions: Significant differences were observed in those who used augmented reality compared to the control group being higher in the University of Malaga. There are no correlations between the variables of usability and qualifications. Clinical Trial: NTC05798468

Background: Physical activity (PA) is vital for physical and mental health, but many college students fail to meet recommended levels. AI-powered gamification interventions through mobile application (app) have the potential to improve PA levels among Chinese college students. Objective: To assess the feasibility and usability of an AI-powered gamification intervention. Methods: A quasi-experimental study spanning two months was conducted on a sample of college students aged 18 to 25 from 18 universities in Beijing. PA data were recorded using the ShouTi Fitness app, and participant engagement was evaluated through surveys. User satisfaction was gauged via the System Usability Scale (SUS), while the intervention's feasibility was assessed through Spearman rank correlation analysis, Mann-Whitney tests, and additional descriptive analyses. Results: As of July 2023, we enrolled 456 college students. In total, 18,073 PA sessions were recorded, with men completing 8,068 sessions and women 10,055 sessions. The average PA intensity was 7 METs per session. Most participants preferred afternoon sessions and favored short-duration sessions, with men averaging 66 seconds per session and women 42 seconds. The SUS score for the intervention based on app is 65.2. Users responded positively to the integration of AI and gamification elements, including personalized recommendations, action recognition, smart grouping, dynamic management, collaborative, and competition. Specifically, 341 users (75%) found the AI features very interesting, 365 (80%) were motivated by the gamification elements, 364 (80%) reported that the intervention supported their fitness goals, and 365 (80%) considered the intervention reliable. A significant positive correlation was observed between the duration of individual PA and intervention duration for men (rho = 0.510, P < .001), although the correlation was weaker for women (rho = 0.258, P = .046). However, the frequency of PA declined after 35 days. Conclusions: This study provides pioneering evidence of the feasibility and usability of the AI-powered gamification intervention. While adherence was successfully demonstrated, further studies or interventions are needed to directly assess the impact on PA levels and focus on optimizing long-term adherence strategies and evaluating health outcomes.

Background: Retention capacities depend on the learning context. The optimal interval between two learning sessions to maintain the learner’s knowledge is often a subject of discussion, as well as the methodology used. Screen-based simulation could represent an easy alternative for re-training in neonatal resuscitation. Objective: The aim of the study was to evaluate the benefits of a 3-month recall in high-fidelity simulation or screen-based simulation, 6 months after an initial neonatal resuscitation training in simulation among anesthesia and intensive care residents. Methods: All anesthesia and intensive care residents who participated were volunteers and they were trained in the same session (theoretical course and a high-fidelity simulation). Then, attendees were randomized in three groups: a first group with no 3-month recall, a second one with a high-fidelity simulation recall (HF), and a last group with a screen-based simulation recall (SG). In order to reassess the skills of each participant, a high-fidelity simulation has been performed at 6 months. The evaluation included expert assessment of technical skills using the NRPE score, and non-technical skills assessed by the ANTS score as primary outcomes and some knowledge quiz, self-assessment of confidence as secondary outcomes. We compared the results between groups and intragroup progressions. Results: Twenty-eight participants were included in the study. No differences were observed between groups at the 6-month evaluation. However, we observed a significant improvement in theoretical knowledge and self-confidence among students over time. Concerning non-technical skills evaluated by the ANTS score, there was a significant improvement between the initial training and the session at 6 months in both groups that had a recall session (16 vs 12.8, p=.012 in HF group, 16 vs 13.9, p=.05 in SG group, 14.7 vs 15.1, p=.498 in control group). Regarding technical skills assessed by the NRPE score, there was a non-significant trend toward improvement in the two groups with recall, while a regression was observed in the control group. The increase of students' self-confidence was significant for each group, but it remained higher in the two groups that had a 3-month recall. Conclusions: Initial training for anesthesia and intensive care residents in neonatal resuscitation leads to improved knowledge and self-confidence that persists at 6 months. A 3-month recall, whether through high-fidelity simulation or screen-based simulation, is showing better results on non-technical (such as situation management and team communication) and technical skills. Screen-based simulation, while saving time and resources, seems to be an effective educational method for recall after initial training. The study’ outcomes are justifying the need of further studies, with larger attendance, to confirm the promising results of the serious games role in the educational programs for students. Clinical Trial: CERAR (Ethics Committee for Research in Anesthesia Resuscitation) IRB 00010254-2021-048;

Background: Proper donning and doffing of personal protection equipment (PPE) and hand hygiene in the correct spatial context of a health facility is important for the prevention and control of nosocomial infections. On-site training is difficult due to the potential infectious risks and shortages of PPE, whereas video-based training lacks immersion which is vital for the familiarization of the environment. Virtual reality (VR) training can support repeated practice of PPE donning and doffing in an immersive environment that simulates a realistic configuration of a health facility. Objective: The aim is to develop and evaluate a VR simulation focusing on the correct event order of PPE donning and doffing, i.e., the item and hand hygiene order in the donning and doffing process but not the detailed steps of how to don/doff an item, in an immersive environment that replicates the spatial zoning of a hospital. The VR method should be generic and support customizable sequencing of PPE donning and doffing. Methods: An immersive VR PPE training tool was developed by computer scientists and medical experts. The effectiveness of the immersive VR method versus video-based learning was tested in a pilot study as a randomized controlled trial (N=32: VR group N=16, video-based training N=16) using questionnaires on spatial-aware event order memorization questions, usability, and task workload. Trajectories of participants in the immersive environment were also recorded for behavior analysis and potential improvements of the real environment of the health facility. Results: Comparable sequence memorization scores (VR: \mu=\ 79.38,\ \sigma=12.90 vs. Video: \mu=74.38,\ \sigma=17.88,\ p=0.372) as well as NASA-TLX scores (VR: \mu=42.9,\ \sigma=13.01 vs. Video: \mu=51.50,\ \sigma=20.44,\ p=0.168) were observed. The VR group had an above average usability in the System Usability Scale (\mu=\ 74.78\ >\ 70.0) and was significantly better (VR: \mu=74.78,\ \sigma=13.58 vs. Video: \mu=57.73,\ \sigma=21.13,\ p=0.009) than the video group. The analysis and visualization of trajectories revealed a positive correlation between the length of trajectories and the completion time, but neither correlated to the accuracy of the memorization task. Further user feedback indicated a preference for the VR method over the video-based method. Limitations of and suggestions for improvements in the study were also identified. Conclusions: A new immersive VR PPE training method was developed and evaluated against the video-based training. Results of the pilot study indicate that the VR method provides comparable training quality to the video-based training with better usability. In addition, the immersive experience of realistic settings and the flexibility of training configurations make the VR method a promising alternative to video instructions.

Background: Pediatric patients undergoing surgery frequently experience significant anxiety, which can result in adverse effects such as prolonged sedation and behavioral changes associated with pharmacological interventions like oral midazolam. Video games offer a nonpharmacological distraction method that shows promise in alleviating procedural anxiety without significant side effects. However, the effectiveness of video games compared to midazolam in managing perioperative anxiety remains uncertain. Objective: This study aimed to evaluate the effectiveness of video game interventions in reducing perioperative anxiety in pediatric patients undergoing general anesthesia. Methods: We conducted a comprehensive search across PubMed, Embase, Web of Science, and the Cochrane Library, supplemented by reference screening. Primary outcomes included anxiety levels assessed during parent separation and mask induction procedures, while secondary outcomes encompassed emergence delirium (ED), postoperative behavior, and length of stay in the Post-Anesthesia Care Unit (PACU). The risk of bias was assessed using the Risk of Bias 2 (ROB 2) scale. Data were synthesized descriptively and through meta-analysis, with the certainty of the evidence evaluated using GRADE criteria. Results: Six randomized controlled trials involving 612 participants were included in the analysis. Children who participated in video game interventions reported significantly lower anxiety levels during parent separation (standardized mean difference [SMD] −0.31, 95% CI −0.50 to −0.12; P = .001), with high certainty, and during mask induction (SMD −0.29, 95% CI −0.52 to −0.05; P = .02), with moderate certainty, compared to those receiving oral midazolam. Additionally, significant differences in postoperative behavior changes in children were observed compared to oral midazolam (SMD −0.35, 95% CI −0.62 to −0.09; P = .008). Children in the video game intervention groups also had a shorter length of stay in the PACU (MD −19.43 minutes, 95% CI −31.71 to -7.16; P = .002). However, no significant differences were found in ED (MD −2.01, 95% CI −4.62 to 0.59; P = .13). Conclusions: Video game interventions were more effective than midazolam in reducing perioperative anxiety among pediatric patients, improving postoperative behavior, and shortening length of stay in the PACU. However, video games alone did not outperform midazolam in managing ED. Further high-quality research is needed for more conclusive results. Clinical Trial: PROSPERO CRD42023486085; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=486085