# Gamification of Upper Limb Rehabilitation in Mixed-Reality Environment
## 2 Related Works
In this RCT, among the fifty-two participants, the experimental group received two types of games from the functional category targeted for movement coordination and progressive-level difficulties. The in-person therapist performed the game assignments based on the patient's functional capacity. Several assessment scores suggested that properly designed and functionally adapted standalone gamified VR therapy can improve UE motor functions in acute and chronic stroke patients. User experience-centric research on gamification showed that it is effective in multiuser, support-group settings. The authors of [16] used the Jintronix Rehabilitation System with a Kinect camera for tracking limb movements where patients could choose exercises from the prescribed four to six games depending on the on-site presence of the physiotherapist. Based on the assessment scores, the work discussed that VR-based therapy is reliable, cheap, and effective even remotely monitoring a support-group scenario. Although a prior study in [17] claimed that Kinect-based therapy was ineffective compared to VR-based therapy, authors of [18] used a home-based therapeutic solution by utilizing a Kinect-enabled device to develop Unity3D-based gamified intervention for stroke patients. The games (ball bump, trajectory tracing, and food fight) involved manipulating virtual objects and providing hand movement to the patients. The results showed that multiuser VR therapy in the home environment is more effective than the single-user system. Gamified therapy showed improvements in different UE motor functions based on the standard Fugl-Meyer Assessment-Upper Extremity score (FMA-UE). A recent RCT in [19] used a Leap Motion Controller (LMC)-based device to play games targetingdifferent hand movements. The multilevel leap ball game was developed to provide hand grasp movements such as wrist and finger flexion-extension. The Pong game was used for wrist-elbow movements such as radial-ulnar deviation, elbow flexion-extension, and forearm pronation-supination. The results showed an increased range of motion to the overall hand and, specifically, wrist movements. However, the author claimed that although the VR-based approach improved FMA-UE and other scores, it was less effective in strengthening the grip. Contrary to that, work in [20] used an LMC device as hardware and the Unity3D game engine to develop the game to provide seven functional tasks in the hemiplegic UE. The effect of the gamified approach to UE functions on early-stage stroke patients showed satisfactory results [21]. Moreover, Nintendo Wi-based gamified therapy increased vision and motor performances, as shown in [22; 23]. However, the authors of [24] claimed the opposite when they performed RCT comparing Nintendo Wi-enabled VR-based therapeutic exercises with occupational therapy for early-stage stroke patients. The patients played three sports games (swordplay, table tennis, and canoe), and the experimental results showed that although it improved the UE functions and ADL, this device-dependent VR-based therapy is less effective during the early stage of stroke than conventional therapy. Incorporating VR-based gamified therapy into conventional therapy is considered effective in improving UE motor functions [25; 26; 27]. Authors in [28] claimed the same, where they included traditional therapy and VR game-based task-oriented therapy using the Armeo Spring device for chronic stroke patients. In another RCT for multiple sclerosis patients [29], authors developed six serious games using Unity3D with the clinician's guidelines reflecting activities commonly performed in traditional rehabilitation, such as hand pronation-supination and finger flexion-extension. Based on their assessment, LMC-based gamified UE therapy and conventional ones can enhance gross and fine manual dexterity and hand coordination. A combination of physiotherapy and Xbox Kinect-based VR training can improve UE for chronic stroke patients [30; 31].