JMIR Publications

ABSTRACT

Background:

Fatigue is one of the most common and underrecognized consequences of pediatric acquired brain injury, often expressed behaviorally rather than verbally. Traditional rehabilitation programs are frequently static and cognitively demanding, limiting engagement and therapeutic outcomes. Extended Reality (XR) technologies offer new opportunities to address these challenges by enabling interactive, adaptive, and motivating therapy environments. However, few XR systems are designed to detect fatigue or are co-developed with children and therapists.

Objective:

This study explores how XR rehabilitation can be designed to increase engagement and support the detection of fatigue-related symptoms in children with brain injuries.

Methods:

A qualitative case study approach was employed, combining co-design workshops, interviews with healthcare professionals, observational data, and iterative user testing with children aged 8–16. The XR prototype was developed using Unity, Cognitive3D, and the Meta Quest 3 headset. Engagement and fatigue were evaluated using adapted versions of the User Engagement Scale (UES) and the Virtual & Mixed Reality Fatigue Scale (VMRFS), supplemented by thematic analysis of qualitative data.

Results:

Children demonstrated higher engagement with short, modular XR sessions (3–10 minutes) that included interactive game mechanics and preserved visibility of their surroundings. Fatigue was inferred through behavioral cues such as gaze, posture, and responsiveness. Therapists emphasized the importance of adaptive difficulty, personalization, and simplified environments. A therapist-facing dashboard was developed to visualize behavioral indicators of fatigue

Conclusions:

This study demonstrates that XR-based rehabilitation, when co-designed with children and therapists, can effectively support engagement and behavioral fatigue detection in pediatric brain injury contexts. By integrating adaptive difficulty, personalized interaction, and simplified environments, the prototype addressed key limitations in prior XR systems. Findings reinforce the importance of short, modular sessions and emotionally supportive gamification to sustain motivation without overstimulation. The use of AR over VR minimized disorientation, while behavioral tracking provided actionable insights for therapists. Together, these contributions offer a fatigue-sensitive, engagement-driven framework for XR design in pediatric neurorehabilitation.