2026-04-01
Mareike Kuehn, Lena Wypyrsczyk, Francesca Lanfranconi, Adriana Cristina Balduzzi, Hayley Marriott, Alba Solera-Sanchez, Joachim Wiskemann, Nikolai Bauer, Nina Karguth, Barbara Heißerer, Norbert W Paul, Rodolf Mongondry, Wilhelm Bloch, Katie Rizvi, Martin Kaj Fridh, Eva S C Ramos, Carmen Fiuza-Luces, Miriam Götte, Gabriele Gauß, Filippo Spreafico, Barbara Konda, Milica Stefanović, Elias Dreismickenbecker, Marie A Neu, Joerg Faber, FORTEe Consortium
Background: As survival rates for children, adolescents, and young adults with cancer improve, managing treatment-related side effects is increasingly important. Enhancing physical activity levels has been shown to be effective in reducing some of these effects. Digital interventions, such as mobile apps, offer engaging tools to promote physical activity in young populations. Objective: This article introduces the “FORTEe Get Strong” app (Nurogames GmbH) and presents a formative evaluation of its acceptability among children, adolescents, and young adults with cancer. Methods: The “FORTEe Get Strong” app was developed within the multicenter FORTEe trial. Grounded in behavior change theories, the app uses gamification to deliver a child-friendly platform promoting physical activity and health-related knowledge. An embedded mixed methods design, with qualitative insights contextualizing quantitative findings, was applied. User experience was assessed using a self-developed questionnaire combining Likert scale items (1‐5: “not at all satisfied” to “very satisfied,” 1‐3 for participants aged <8 y) and open-ended questions. Quantitative data were analyzed descriptively and inferentially, including chi-square tests for differences in app usage by age, sex, and diagnosis, and Kruskal-Wallis tests to compare app feature ratings between age groups. Free text responses underwent qualitative content analysis. Results: The app was published in May 2023; it integrates gamified features to teach health knowledge. Exercise videos address endurance, strength, flexibility, coordination, and gait. Feedback on user experience was provided by 53 patients aged 5‐19 years (mean 11.4, SD 3.8 years, 95% CI 10.4‐12.5; 27/53, 51% male). App use did not differ significantly by age groups (²=5.1; =.16; Cramer V=0.135), sex (²=3.4; =.06; =0.110), or diagnosis (=.54; Cramer V=0.168). The app was generally well-received, with a mean Likert scale score of 4.14 (SD 1.04, 95% CI 3.84‐4.43). For individual components, mean scores ranged from 3.52 (SD 1.44, 95% CI 3.09‐3.95) for exercise content to 4.37 (SD 0.82, 95% CI 4.14‐4.60) for design. Kruskal-Wallis tests revealed no significant differences among age groups. Qualitative analysis identified key categories regarding overall app evaluation, specific features, target group perception, usability, and suggestions for improvement. While participants highlighted the app’s design and gamification, concerns arose regarding age-appropriateness, lack of supervision, and adaptability of exercises. Conclusions: This study provides novel insights into user experience of children, adolescents, and young adults with cancer with a gamified exercise and health education app. Unlike previous studies focusing on survivorship, this evaluation offers a comprehensive understanding of how digital tools can support patients in maintaining physical activity during intensive treatment. Apps with interactive, gamified elements may complement clinical care by providing low-threshold access to exercise and health education. The findings advance the field by identifying key facilitators and barriers to engagement. Future research should assess adherence, behavioral outcomes, and effectiveness in larger samples to inform clinical implementation. Trial Registration: ClinicalTrials.gov NCT05289739; https://clinicaltrials.gov/study/NCT05289739
2026-03-31
Sylwia Starzec, Sławomir Śpiewak, Jolanta Starosta, Paweł Strojny
Background: Gaming disorder (GD) is an emerging issue that leads to significant impairment, yet existing tools for measuring withdrawal symptoms in GD are limited and often fail to capture its multidimensional nature. Most current measures rely on single-item assessments or adapted tools from substance use disorders, overlooking cognitive, behavioral, and physiological components. A comprehensive, multidimensional questionnaire is needed to more accurately assess withdrawal in GD, aiding in early detection and intervention. Objective: The objective of this study was to develop and psychometrically validate a comprehensive measurement tool, the Gaming Withdrawal Symptoms Questionnaire (GWSQ), capturing the multidimensional nature of withdrawal symptoms in GD, including affective, cognitive, behavioral, and physiological components. Methods: A multistage psychometric approach was used, starting with item generation from a scoping literature review. Exploratory factor analysis and confirmatory factor analysis were conducted to refine the questionnaire. Reliability and validity were assessed using 2 cross-sectional studies. Data were collected anonymously via an online survey platform. Participants were recruited from gaming-related platforms and social media (eg, Discord, Reddit, and Facebook) and restricted to actively engaged adult gamers who passed attention check questions to ensure data quality. Results: Study 1 involved 480 adults (mean age 23, SD 4.96 years; n=327, 68.1% male). Study 2 included 565 adults (mean age 25, SD 5.55 years; n=245, 43% male). Exploratory factor analysis revealed a 3-factor model of withdrawal symptoms: (1) motivational and cognitive symptoms, (2) affective symptoms, and (3) physical symptoms, explaining 54% of the variance. Confirmatory factor analysis confirmed adequate model fit ( χ 2 227 =887.8; P <.001; comparative fit index=0.91; Tucker‐Lewis index=0.90; root-mean-square error of approximation=0.072). The GWSQ demonstrated high internal consistency, with Cronbach α ranging from 0.89 (motivational and cognitive symptoms) to 0.90 (affective symptoms and physical symptoms). Correlations with related constructs (Internet Gaming Disorder Scale-Short Form [IGDS9-SF], Patient Health Questionnaire-9 items, and Generalized Anxiety Disorder-7 items) confirmed convergent validity with moderate associations (eg, IGDS9-SF: r =0.48, 95% CI 0.32-0.61) and discriminant validity, and normative data (sten scores) were established for the general population. Conclusions: The GWSQ is the first validated multidimensional tool specifically designed to assess withdrawal symptoms in GD, representing a conceptual and methodological innovation. It addresses critical gaps in GD diagnosis and research by capturing a broader spectrum of symptoms beyond affective distress. The questionnaire’s tripartite structure provides a framework for advancing theoretical models and informing etiological studies of GD. The GWSQ offers a robust measure for clinical research and enables differentiated assessment of symptom clusters. In real-world contexts, it can serve as a reliable patient-reported outcome tool in forthcoming clinical trials of GD interventions, enabling precise monitoring of treatment effects . Nevertheless, given the nonclinical sample, further cultural validation and studies involving clinical populations are required.
2026-03-30
Isabel Neumann, Stefan Lindner, Yevgeniya Nedilko, Ralitsa Zhivova, Michael Gödde, Tobias Tischer-Zeitz, Heike L Rittner, Ivo Käthner
Background: Virtual reality (VR) has proven effective in delivering nonpharmacological interventions to reduce acute and chronic pain. For the treatment of nonspecific chronic low back pain (CLBP), it offers benefits over traditional treatment options, such as the possibility of gamified movement exercises with real-time performance feedback and virtual embodiment. We implemented a novel immersive VR intervention (a serious game) that combined these elements. Objective: This study evaluated the feasibility, tolerability, and initial clinical efficacy of the gamified VR intervention. Methods: Patients with CLBP (n=20; mean age 47, SD 14 years; symptom duration >3 months to ≤5 years; convenience sample) took part in a prospective, single-arm, and preregistered trial over 9 weeks. The VR therapy phase lasted 3 weeks, and there were 2 VR sessions per week conducted at the University Hospital Wuerzburg (Germany). Before the therapy phase, there was a 2-week baseline phase, and the posttherapy phase lasted 4 weeks. During the sessions, patients wore a head-mounted display. In VR, they embodied a virtual avatar and performed gamified movement exercises. Participants were immersed in a virtual toy factory, and they had the task of teaching 5 different toys how to move. They received real-time feedback on performance through a hologram overlaying their avatar. Based on performance, movements to be performed became gradually more difficult (graded exposure). Primary outcome measures were adherence and side effects for assessing feasibility and tolerability (Simulator Sickness Questionnaire), and pain intensity ratings (numerical rating scale 0‐10) were used for assessing initial clinical efficacy. Secondary outcomes included back- and task-specific functioning and questionnaires to further test initial clinical efficacy and assess fear-avoidance beliefs. Results: Adherence was high (18/20, 90%). Participants indicated lower pain in the posttherapy phase compared with baseline levels (mean difference 0.73, CI 0.27-1.19; =3.38; =.004; =0.82). There were only few and minor side effects. Task- and back-specific functioning improved (ie, performing daily life activities; Back Performance Scale: =4.53; =.02; η=0.04; Roland-Morris Disability Questionnaire: =4.73; =.02; η=0.08), and movement restrictions decreased (=10.82; <.001; η=0.06). There were no changes in the psychological outcome measures (eg, fear avoidance beliefs). Across all VR sessions, study participants reported high levels of fun (mean 8.07, SD 1.99). Conclusions: We implemented a gamified immersive VR intervention for the treatment of CLBP. The combination of gamified movement exercises and virtual body illusions is unique, and for the first time, it included real-time feedback via a hologram overlaying the virtual avatar of the user. The study demonstrated the feasibility and safety of the intervention. Initial tests of the clinical efficacy revealed positive effects on pain, physical functioning, and daily activities. However, these did not reach the thresholds of clinical importance. A randomized controlled trial is needed to test the specificity of the effects. Trial Registration: German Clinical Trials Register DRKS00031535; https://drks.de/search/en/trial/DRKS00031535
2026-03-26
Jijia Liu, Meijun Ou, Mengyao Yan, Xianghua Xu, Li Qin
Background: Dysphagia is a prevalent health issue affecting quality of life. Gamified swallowing exercises have the potential to enhance swallowing function and adherence in adults with dysphagia. Nevertheless, such evidence has not yet been systematically synthesized. Objective: This study aimed to systematically evaluate the effects of gamified swallowing exercises and promote their clinical application in swallowing rehabilitation. Methods: Eleven electronic databases were searched from inception to June 25, 2025. Randomized controlled trials (RCTs) that explored gamified swallowing exercises in adults with dysphagia, regardless of etiology, and reported on swallowing function, adherence, nutritional status, or quality of life were included. The Cochrane Risk of Bias tool 2.0 was applied to assess the methodological quality. We employed the Hartung-Knapp-Sidik-Jonkman method for random-effects model analysis to calculate effect sizes and 95% CIs. Subgroup analysis was conducted to explore potential causes of heterogeneity, and the overall quality of evidence was evaluated through GRADEpro GDT software. Results: Of 2400 initially identified records, 6 RCTs met the inclusion criteria, with 2 rated as low risk, 3 as some concerns, and 1 as high risk. These studies, conducted in China, South Korea, and Turkey between 2019 and 2025, enrolled a total of 330 poststroke patients with dysphagia. Interventions involved 1 to 3 games targeting the lips, tongue, and pharynx, with additional equipment. This meta-analysis indicated that gamified swallowing exercises improved swallowing function, as evidenced by enhanced swallowing performance (mean difference [MD]=1.1; 95% CI 0.9 to 1.3; =0; prediction interval [PI] 0.3 to 1.6), reduced dysphagia severity (standardized mean difference [SMD]=0.4; 95% CI 0.3 to 0.5; =0; PI 0.3 to 0.5), and increased adherence (MD=2.4; 95 % CI 1.8 to 2.9; =0; PI 1.2 to 2.7). However, no significant effects were observed on dysphagia screening (SMD=−1.8, 95% CI −5.4 to 1.8; =96.5%; PI −8.6 to 4.9) or quality of life (SMD=−2.30, 95% CI −9.6 to 5; =97.5%; PI −16.1 to 14.1). Overall, the quality of the included studies ranged from moderate to very low, which limits confidence in the pooled estimates. Conclusions: This study provides the first quantitative synthesis of the effects of gamified swallowing exercises. The results demonstrate that gamified swallowing exercises improve swallowing function and enhance adherence, suggesting that gamified swallowing exercises are a promising method for swallowing rehabilitation. However, the overall risk of bias across included studies and the suboptimal evidence quality reduce the certainty of the current evidence. Therefore, the findings should be interpreted with caution. The small number of high-quality RCTs, reliance on additional equipment, and limited standardization of gamified interventions further limit clinical generalizability. Future research should focus on large-scale, robustly designed RCTs, while designing etiology-specific games and developing more accessible rehabilitation equipment, such as smartphones, could enhance the overall effects and facilitate the widespread adoption of these interventions in remote and home care settings. Trial Registration: PROSPERO CRD42024617169; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024617169
2026-03-13
Yulin Zhang, Tianwu Lin, Yuefeng Tan, Xiaojin Shi, Yucheng Yang, Haibing Yang, Xiaona Na, Junhan Zhang, Ai Zhao
Background: Childhood and adolescent malnutrition, encompassing undernutrition and overnutrition, poses significant global health challenges, necessitating comprehensive dietary assessment tools. Existing dietary assessment methods, such as 24-hour dietary recalls (24HR), often fail to capture eating behaviors and food preferences. Objective: This study aims to compare a newly developed gamified dietary assessment tool (GDA) with a traditional 24HR and to explore its applicability in assessing dietary behavior tendencies among children and adolescents. Methods: A 2-phase study was designed, including an exploratory and an application study. The exploratory study included 30 school-aged participants, comparing the GDA with the 3-day 24HR. Nutrient and food intakes were analyzed using Pearson or Spearman correlation coefficients and Bland-Altman plots. The application study, conducted among 1541 adolescents (11‐18 y), assessed dietary intake and eating behavior tendencies. Differences in dietary intake across age, gender, socioeconomic status, and weight status were analyzed using the Kruskal-Wallis rank sum test. Multiple linear regression models were used to examine the associations of dietary intakes with emotional eating and with dining environment tendencies, respectively. Results: In the exploratory study (n=30), the GDA demonstrated moderate agreement with 24HR for energy (=0.46, =.01) and carbohydrates (=0.50, =.005). Bland-Altman plots indicated good agreement for energy and carbohydrate intake between methods (mean differences around 0). For fat intake, although the mean difference was close to 0, the correlation was not statistically significant. In contrast, the GDA substantially overestimated protein intake (mean difference around 25 g). In the application study (n=1541), higher emotional eating scores were associated with higher snack consumption (=0.438, 95% CI 0.035-0.840), and with lower protein (=−0.159, 95% CI −0.267 to −0.052), fruit (=−0.464, 95% CI −0.854 to −0.073), and nut consumption (=−0.183, 95% CI −0.304 to −0.062). Participants who chose solitary screen eating consumed significantly more carbohydrates than those who selected “eat with peers” (=4.2, 95% CI 1.2-7.1). Conclusions: This study demonstrates that the GDA effectively captures both dietary intake and contextual eating behaviors in young populations, providing data distinct from traditional methods, such as 24HR. As a complementary assessment approach, it offers valuable insights into food preferences and eating patterns through its interactive design.