JMIR Publications

ABSTRACT

Background:

Hospitalization, especially when it involves prolonged bed rest, is associated with muscle weakness, loss of independence in activities of daily living (ADLs), and higher mortality. Conventional inpatient rehabilitation often struggles with low engagement, particularly among patients with depressive symptoms, anxiety, or reduced motivation. Immersive virtual reality (VR) serious games can deliver repetitive, task-oriented, and contextualized training, but most ADL-oriented systems have been tested in outpatient, neurological, or laboratory settings rather than in acute hospital wards.

Objective:

This study presents the design, development and evaluation of Life in Play, an immersive VR serious game for ADL training in hospitalized adults, and to evaluate its usability among physical therapists and its acceptability and safety among inpatients.

Methods:

We conducted a methodological pilot study in the wards of a Brazilian infectious disease reference hospital. The game was co-designed by physical therapists and VR developers in Unity and deployed on a Meta Quest 3 headset with hand tracking, simulating ADLs in 5 home environments (bedroom, bathroom, kitchen, living room, and backyard). Usability was assessed with the System Usability Scale (SUS) among physical therapists after approximately 1 hour of use of the alpha version. Patients with ADL limitations (Modified Barthel Index 0-99) and preserved cognition (Montreal Cognitive Assessment >25) were offered 15-minute sessions 3 times per week for up to 3 weeks. Acceptability was assessed with the Brazilian version of the Intrinsic Motivation Inventory–Task Evaluation Questionnaire (IMI-TEQ-Br). Safety was assessed with the Simulator Sickness Questionnaire (SSQ) and with blood pressure, heart rate, peripheral oxygen saturation (SpO2), and the modified Borg scale before, during, and after each session. Pre-post differences were tested with the Wilcoxon signed-rank test and associations with Spearman correlation.

Results:

A total of 33 physical therapists rated usability with a mean SUS score of 82.0 (SD 8.0; range approximately 65-95), corresponding to excellent usability. Of 13 screened patients, 6 were enrolled, 1 withdrew in the first session because of claustrophobia, and 5 (mean age 47 years) completed the protocol, contributing 12 analyzed sessions. IMI-TEQ-Br scores showed high interest/enjoyment (mean 6.33, SD 0.12) and low pressure/tension (mean 2.95, SD 0.87). Mean SSQ total score rose from 5.92 (SD 10.67) before to 16.52 (SD 18.49) after sessions (P=.002), driven mainly by the oculomotor subscale (P=.004); eye strain was the most frequent symptom (38.5% of sessions). Systolic blood pressure (111 to 132 mm Hg; P<.001), diastolic blood pressure (70 to 82 mm Hg; P=.001), heart rate (91 to 100 beats/min; P=.007), and Borg rating (0 to 2; P=.008) increased, whereas SpO2 remained stable (P=.86). No clinically relevant adverse events occurred. After sessions, perceived exertion correlated with diastolic blood pressure (ρ=0.59) and SSQ total score (ρ=0.52).

Conclusions:

Life in Play was rated as highly usable by rehabilitation professionals and was well accepted and tolerated by hospitalized adults under supervised conditions, eliciting a moderate physiological response and predominantly mild oculomotor symptoms. These findings support its feasibility as an adjunct to inpatient ADL rehabilitation and justify larger controlled trials with functional outcomes. Clinical Trial: Brazilian Clinical Trials Registry (ReBEC); Registration number: RBR-7b6t4mk; Universal Trial Number (UTN): U1111-1343-2293.