# Gamification of Upper Limb Rehabilitation in Mixed-Reality Environment
## 6 Conclusions  
Repetitive tasks of the same complexity fail to generalize the improvement of UE motor functions. Therefore, increasing the complexity of different tasks and actions to complete them can be judged by the different achievement levels in a game. In such an assessment, patients' in-game levels better reflect their engagement and intention to improve their situation. Another way of evaluation is the number of badges a patient collects in the game. A badge is a visual marker of success that can be unlocked by completing tasks or achieving levels, and the player can add them to their profile. Similarly to that, milestones or checkpoint crossing shows the patient's involvement and improvement by playing the game. However, currently, those games are not open source. They will be publicly released after further testing and evaluation. A novel approach to upper extremity rehabilitation by developing a gamified MR-based solution for the Microsoft HoloLens 2 is proposed in this study, which is an MR application with game levels that can measure the ranges of motion of the arm joints. Ten adults with no history of arm injuries served as test subjects for the proposed rehabilitation system, along with two occupational therapists. During rehabilitation sessions, the system can simulate the actions of the upper limb without needing external sensors. It integrates arm joint data in real-time into the application while remaining standalone, making it unique among technologically-based rehabilitation methods. By comparing and contrasting, we find that the spatial awareness feature of the mixed-reality environment, which provides safety to the users, makes this system superior to earlier VR-based rehabilitation techniques. Furthermore, it is significantly more relevant and accurate than the existing MR-based rehabilitation. The overall experimental results obtained from the participants indicate a promising solution that can be used for individuals with UE motor dysfunctions. Although participants provided positive feedback about the proposed MR game for its user-friendly design, we acknowledge that it is difficult to make generalized statements about the findings with only the healthy participants. In future studies, people with upper limb mobility impairments are necessary to derive robust conclusions about the proposed system. Furthermore, there are some uncertainties with the participants' feedback as it is not objective. The next step will be to test the system in a clinical setting with individuals with upper extremity dysfunctions. Conceptualization, methodology, software, A.P. ; validation, investigation, formal analysis, A.P., M.S.H.S., M.T.S. and N.B. ; resources, supervision, project administration, M.H.R. ; writing--original draft preparation, A.P., M.S.H.S. and M.H.R. ; visualization, A.P. and M.S.H.S., writing--review and editing, A.P., N.B., M.S.H.S. and M.H.R. All authors have read and agreed to the published version of the manuscript. This research received no external funding. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of the University of Wisconsin-Milwaukee (protocol UWM IRB 22.220 and the approval date is August 08/01/2022). Informed Consent Statement: Informed consent was obtained from all participants involved in the study. Written informed consent has been obtained from the participants to publish this paper. The data generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request. The authors declare no conflict of interest. The following abbreviations are used in this manuscript: