2026-10-21
Hyein Jeong, Hyunsuk Park, Junmoo Ahn, Kyeong Han Kim, Hojung Lee, Taehoon Bang, Min Jun Kang, Sangjun Lee, Youngju Rhee, Seung Kyu Kim, Seong-Gyu Ko
Background: Acupuncture training requires precise acupoint localization and needle control, yet peer-to-peer practice raises safety concerns and physical phantoms offer limited anatomical fidelity. Extended reality (XR) is increasingly used in health professions education, but immersive and semi-immersive XR training systems for acupuncture have not been mapped. Objective: This scoping review aimed to map the applications, hardware modalities, and reported technical and educational outcomes of immersive and semi-immersive XR training systems in acupuncture education. Methods: This review followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) and the five-stage scoping review framework of Arksey and O’Malley, as refined by Levac and colleagues. On September 19, 2026, we searched PubMed, Embase, Scopus, IEEE Xplore, CNKI, RISS, ScienceOn, and OASIS. No language or date restrictions were applied. Backward and forward citation searching supplemented the database search. Eligible sources were peer-reviewed original studies or full conference papers describing virtual reality (VR; either fully immersive [IVR] or semi-immersive [SIVR]), augmented reality (AR), or mixed reality (MR) systems for acupuncture training. Two reviewers independently screened records and charted the study design, hardware, training task, and outcomes. Each study was assigned an evidence tier. Results: Of 6176 records, 3378 were screened after removal of duplicates and ineligible document types, 80 reports were assessed in full text, and 26 studies were included (25 from databases and 1 from citation searching). Most studies came from East Asia (25/26, 96.2%), mainly China (n=18), and 20 (76.9%) were published between 2020 and 2026. Systems used VR (n=15), AR (n=5), or MR (n=6); 19 were IVR and 7 were SIVR. Training tasks addressed acupoint localization (n=13), needling skills (n=11), and clinical reasoning (n=2). Localization errors were reported with different metrics and were not directly comparable across systems. In a randomized comparison, a VR group scored higher on practical skills than a conventional instruction group (32.52, SD 2.28 vs 28.62, SD 2.77 points; <.001). In an MR simulator with depth-responsive vibrotactile feedback active in both sessions, mean depth error decreased from 6.41 mm in the first practice session to 3.58 mm in the second. Of the 26 studies, 7 used a comparative design; the rest were technical validation (n=6), system development (n=10), or case and survey reports (n=3). Reported barriers included headset weight, narrow field of view, tracking instability, and limited tactile fidelity. Conclusions: Immersive and semi-immersive XR systems for acupuncture training have been developed mainly for acupoint localization and needling. Randomized comparisons reported higher test scores than conventional instruction, but most evidence came from system development reports and small feasibility studies. Randomized trials comparing XR-based and conventional training on objective localization and needling outcomes are needed before these systems are adopted for competency assessment. Trial Registration: OSF Registries PVU8E; https://osf.io/pvu8e/overview
2026-10-20
Yong Hoe Koo, Woo Chul Son, In Ho Woo, Ye Ji Kim, Soo Hoon Yoon, Ji Hye Kim, Young Cheon Song, Ho Cheol Kim, Dong-Hwan Jung, Jiwon Ryu, Gwanseob Shin, Jaesoon Choi, Won Kim
Background: Early rehabilitation is important after transplantation and critical illness, but profound weakness, fatigue, and motivational, psychological, and safety barriers may limit participation. Exergaming may facilitate rehabilitation, but the feasibility of full-body in-bed exergaming in this population remains unclear. Objective: We evaluated the feasibility and observed safety of individually prescribed in-bed exergaming using Nintendo Ring Fit Adventure (NFA; Nintendo Co, Ltd) in posttransplant inpatients after intensive care unit (ICU) care. Methods: This prospective, single-center, single-arm interventional feasibility study (October 2024-October 2025) enrolled 26 posttransplant adults with prior ICU care and Functional Ambulation Category (FAC) scores ≤3. Participants were referred after ward transfer by transplant-team advanced practice nurses, and the principal investigator confirmed eligibility based on prespecified inclusion and exclusion criteria. Ten individually prescribed, supervised in-bed NFA sessions, each scheduled for 30 minutes, including setup and operation, were planned alongside usual physical therapy. Data were obtained from medical records, standardized session logs, and prespecified clinical and questionnaire assessments. Outcomes included retention; session delivery, completion, and interruptions; exercise-item completion and interruptions; session-terminating adverse events; net exercise time; satisfaction; and exploratory strength, mobility, and health-related quality-of-life changes. Results: Participants (mean age 53.0, SD 12.4 y; 14 men) included 23 liver and 3 bilateral lung transplant recipients. Mean ICU stay and mechanical ventilation duration were 24.3 (SD 11.0) days and 21.3 (SD 11.6) days, respectively; median baseline FAC and Medical Research Council Sum Score were 0.5 (IQR 0.0-1.0) and 38.0 (IQR 30.5-42.0), respectively. None had an FAC score above 2. Twenty completed the final assessment (20/26, 76.9%, 95% CI 57.9%-89%). Of 227 delivered sessions, 223 (98.2%, 95% CI 95.8%-100%) were completed. Of 2161 prescribed exercise items, 2072 (95.9%, 95% CI 93.4%-97.9%) were completed. No session-terminating adverse events were observed (0/227, 0%, 95% CI 0%-1.6%). Median within-participant net exercise time increased by 159.0 (IQR 35.5-296.3) seconds from sessions 1 to 10 (95% CI 81.0-284.0; Wilcoxon signed-rank test, <.001). Friedman tests followed by Bonferroni-adjusted Wilcoxon signed-rank tests (2-sided α=.05) showed baseline-to-final median within-participant changes of 8.0 Medical Research Council Sum Score points (IQR 2.3-10.3; 95% CI 4.0-10.0, =.004), 2.0 Intensive Care Unit Mobility Scale points (IQR 1.0-4.3; 95% CI 1.0-3.5, <.001), and 15.0 EQ-VAS points (IQR 0.0-30.0; 95% CI 5.0-25.0, =.009). Questionnaire responses were favorable. Conclusions: Under therapist supervision, the individually prescribed in-bed NFA program showed favorable operational feasibility, with no session-terminating adverse events. By combining the accessibility of a commercial off-the-shelf exergame with individualized exercise prescription, the program extended bedside exergaming to posttransplant inpatients with substantial functional impairment after ICU care who had not achieved independent ambulation. Trial Registration: ClinicalTrials.gov NCT06937463; https://clinicaltrials.gov/study/NCT06937463
2026-10-15
Won Kim, Chaeyeon Lim, Minwoo Seong, SeungJun Kim
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.
2026-10-13
Wenqi Liu, Yuxin Wang, Tianle Wang, Chunji Zhao, Jun Li, Weixin Chen, Fanhao Meng
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
2026-10-09
Yuichiro Nakaso, Yong-Hao Hu, Yukiko Shiro, Masayuki Inoue, Takafumi Kanaya, Takuto Nakamura, Takuji Narumi, Takahiro Ushida
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.
2026-10-08
Huihong Xie, Weiwei Lin, Yinjie Zheng, Mingxue Lin, Xiaobin Fang, Simeng Ma, Fu-Shan Xue, Xiaochun Zheng, Danfeng Wang, Fei Gao
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
2026-10-05
Haiou Zhu, Natalie Bisal, Minhua Ma, Harsimran Sansoy, Isabelle Butcher, Kamaldeep Bhui
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.
2026-10-02
Qingqing Liu, Lihua Cheng, Guanfu Liu, Jieli Peng, Zhiyu Wang
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 d =1.62, 95% CI 1.11-2.13; P β =1.74, 95% CI 1.25-2.22; P β =2.86, 95% CI 2.18-3.53; P β =2.33, 95% CI 1.51-3.15; P P 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.
2026-10-01
Unthitar Suranin, Metasit Getrak, Siriwan Suebnukarn, Peter Haddawy, Myat Su Yin, Rene Weller, Panuroot Aguilar, Kamon Budsaba, Andre Mühlenbrock, Gabriel Zachmann
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 (ηp 2 ) 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 2 =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 F 3,84 =12.31; P 2 =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 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
2026-09-25
Siqiang Wang, Yi Sun, Chun Yin Chung, Yin-Leng Theng
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.
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.