JMIR Publications

ABSTRACT

Background:

Impaired motor function and balance deficits place People with Stroke (PwS) at increased risk of falls, which may lead to injury and reduced physical activity. Perturbation-based balance training (PBT), which exposes individuals to repeated balance disturbances, has demonstrated strong potential for fall prevention but is typically limited to specialized rehabilitation clinics. Extending this approach to home environments could improve accessibility and long-term adherence. Action Observation combined with Motor Simulation (AOMS) has been shown to enhance reactive stepping responses and may provide a safe and feasible pathway to translate key element of PBT to the home environment. When integrated with exergames, which combine exercise with gaming elements, it can further enhance motivation and engagement in neurological rehabilitation.

Objective:

To design a home-based exergame that integrates AOMS principles to train reactive stepping responses and support perturbation-based balance training for PwS. In addition, to evaluate the user experience in terms of game experience, usability and safety perception.

Methods:

Using a user-centered design methodology, we iteratively developed the HEROES exergame to support home based rehabilitation by promoting practice of reactive stepping responses. The exergame combines physical exercise with cognitive tasks in a gamified virtual environment where the player needs to imagine and mimic the stepping responses of an avatar in response to virtual perturbations. The prototype was evaluated by PwS (n=8) with a single play-test session conducted in a simulated home environment. Game experience was assessed by the Game Experience Questionnaire (GEQ), usability with the eHealth Usability Benchmarking Instrument (HUBBI) and safety perception by a custom questionnaire, all using 5-point Likert scales. In addition, observations and comments from participants and physiotherapists were collected using a think aloud approach to gain deeper insights.

Results:

Eight PwS participated in the play-test. GEQ scores showed high median ratings for Competence (4.2), Flow (3.9), and Positive Affect (4.7), Tension (1.0), Negative Affect (1.6), and Challenge (2.3) were low. HUBBI results revealed strong Task–Technology Fit (4.25), Interface Design (4.25), and Navigation (4.0), but lower Basic System Performance (2.12), indicating technical issues, such as error in the tracking recognition, that could hinder usability. Safety perception ratings were high: Physical Safety medians were 5.0 (PwS) and 5.0 (physiotherapist), Trust medians were 4.37 and 4.8, while Psychological Safety (the feeling of falling while playing the game) was lower (3.6 for both groups).

Conclusions:

The HEROES exergame demonstrates that integrating Action Observation and Motor Simulation principles into a home-based perturbation-based balance training approach is feasible. PwS perceived the system as engaging, usable, and physically safe, though improvements in technical robustness and task challenge may be required to sustain long-term engagement. Future work should explore longer-term use and clinical effectiveness to determine whether it can improve reactive stepping performance and reducing falls.