## 4 Discussion
Unlike conventional physical training, AVGs incorporate gamification elements, such as immediate feedback (visual, auditory, and haptic) and the opportunity to surpass scores, which can enhance confidence in one's abilities, satisfaction, and engagement with the intervention, generating positive emotions [18]. Additionally, AVGs have been shown to promote emotions like happiness and reduce symptoms of anxiety and depression, thereby improving subjective well-being and perceived self-efficacy [18]. On the other hand, some features, such as adaptive difficulty, immersion, and a sense of accomplishment, are key factors in motivating and sustaining older adults' participation in exergame interventions, underscoring the importance of these elements in maintaining commitment [63]. All of these factors are particularly relevant in patients with chronic joint pain, as psychological well-being and positive beliefs about pain can play a protective role and enhance coping capacity [64]. Thus, AVGs, by fostering positive emotions and a sense of control over pain, could contribute not only to improving emotional well-being but also to facilitating more effective pain management, promoting a better quality of life in this population. Our study is pioneering the reporting of MCID thresholds for WOMAC concerning the complementary use of AVGs in older adults with knee and/or hip OA. The MCID threshold is a fundamental tool for assessing treatment effectiveness, and its calculation can be performed using anchor-based, distribution-based, or sensitivity and specificity analysis approaches, each with its advantages and limitations [65]. In this study, the MCID was determined using a distribution-based Bayesian model, which allows for a better understanding of data variability and effect size, providing clinically relevant information even in the absence of statistical significance, complementing traditional tests, and minimizing the risk of errors due to exclusive reliance on \(p\)-values [43]. [PERSON] et al. (2005) reported an MCID of 9.1 for WOMAC-function in knee OA and 7.9 for hip OA, consistent with our MCID of \(\pm\)9.61 [66]. Meanwhile, the review by [PERSON] et al. (2019) on prosthetic replacements showed considerable variations depending on the calculation method. In the case of total knee arthroplasty (TKA), the MCIDs (on the original scale) ranged from 2.66 to 7.20 for WOMAC-pain and from 1.22 to 22.45 for WOMAC-function; for total hip arthroplasty (THA), the ranges were from 1.66 to 8.20 for pain and from 6.60 to 23.13 for function [67]. In addition to the MCID for WOMAC-function, we obtained values for WOMAC-stiffness, WOMAC-pain, and WOMAC-total, which expands the clinical applicability of our results; however, although the obtained values largely coincide with those previously reported, methodological and therapeutic variations highlight the need for further research. Various studies have attempted to stratify patients according to their WOMAC scores to identify specific patterns in knee and hip OA, assess their predictive validity, and classify responses to TKA, among other objectives [68; 69; 70]. However, these also emphasize the complexity of interpreting scores and the need for additional research. In this context, to deepen the clinical analysis, we stratified the sample according to the total WOMAC score using the 25 th, 50 th, and 75 th percentiles to generate four levels of increasing disability [71], and we visualized the trajectory of responses using Sankey diagrams, which have proven helpful in analyzing clinical evolutions [72]. To our knowledge, this is the first study to use this tool in patients with OA treated with AVGs. The diagrams show that incorporating AVGs yields greater clinical benefit (more transitions from higher quartiles to lower ones) and a broader positive response (more individuals improving quartiles) compared to conventional therapy alone. This result is not reflected in inferential statistical analysis.