## 7 Discussion and Limitations of the Study  
Through the setup of the clinical study, patients engaged with the gamified elements of the _SuperPowerMe_ system, and the positive outcomes observed in patient adherence--supported by both self-reported and sensor-derived data--suggest that when children perceive their therapy as a game rather than a duty, their willingness to engage increases. This shift in perception is particularly critical given the lengthy duration required for effective treatment, which can often lead to frustration and non-compliance. This statement is supported by evidence, as our study found that, except during the summer season, compliance remained largely stable during the first 9 months of treatment, while the mean wear time was 8.6 h. This aligns with the existing literature, which consistently shows that compliance realistically ranges from 7 to 9 h [30], even when 8 to 15 h of daily wear is recommended [31; 32; 33; 34; 35; 36; 37; 38; 39; 40; 41; 42; 43; 44; 45; 46; 47; 48; 49; 50]  
In addition, different studies have reported that patients tend to overestimate perceived wear time [30; 31]. Our study reveals a consistent correspondence between self-reported wear time and sensor-derived data. This highlights the importance of objective monitoring in capturing wear time accurately to grasp misconceptions related to therapy protocol.  
In conclusion, the two analysed cases during the clinical trial showed that the _SuperPowerMe_ system facilitated a sense of autonomy and achievement, as the gradual decrease in parental prompts required for facemask use reflects a growing independence in patients. However, parental guidance persisted throughout the therapeutic period. Indeed, patients reported that parents' interventions were in the form of verbal incentives and explanations, rather than physical rewards. This underscores the importance of embedding motivational strategies within the therapeutic framework to support and maintain patients' compliance.  
The gamification strategy was effective, particularly thanks to the superheroes' design, which facilitated patients' mirroring process with them. Tables 6 and 7 show the appreciation of the patients of the game characters. Superheroes and their mythologies hold a unique appeal for children, offering relatable figures who solve problems, overcome challenges, and achieve success in ways that children often aspire to, but cannot yet achieve  
\begin{table}
\begin{tabular}{c c c c c} \hline \hline
**Evaluation** & **Overall Game** & **Game** & **Game Arena** & **Overall Feeling** \\  & **Experience** & **Characters** & **and Storyline** & **When Playing** \\ \hline \hline
\begin{tabular}{c} Scale ranging \\ from 1 to 10 \\ \end{tabular} & 6 & 8 & 7 & 7.5 \\ \hline \hline \end{tabular}
\end{table}
Table 7: Mean of the answers to the game experience questionnaire over 9 months on a scale from 0 to 10 (clinical case 2).  
themselves. These characters capture children's imaginations effortlessly. Studies demonstrated that children engage more in playing with superhero characters rather than with non-superhero toys [50].  
This flexible and imaginative approach opens countless possibilities for therapeutic engagement, leveraging the endless potential of both superheroes and the human imagination.  
Patient engagement with the game was generally positive, although more trials are necessary to fully assess the effectiveness of the game.