# Developing a Serious Video Game to Engage the Upper Limb Post-Stroke Rehabilitation
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Feedback represents the manner in which the game reacts to alterations or decisions executed by the user, and it is indispensable for the creation and maintenance of meaningful gameplay [14]. In the realm of rehabilitation, heightened attention is placed on positive feedback, given its pivotal role in fostering patient motivation and engagement. Negative feedback should be used very cautiously, or not at all, as it may provoke feelings of demotivation and frustration, particularly among post-stroke individuals grappling with motor impairments and potentially experiencing depression. Also, a decrease in tolerance or motivation often leads to intentional or unintentional cheating or, in the worst-case scenario, avoiding performing the rehabilitation exercises altogether [14]. Typically, feedback manifests in three modalities: visual, auditory, and haptic. Visual feedback mechanisms encompass score displays [9; 10; 11; 13] or graphs [9]. Auditory feedback methods entail the emission of sound cues signifying task completion and fostering a sense of accomplishment [10; 13; 15], along with in-game instructions designed to enhance exercise execution [15]. In a haptic context, there exists the potential for vibration of the input device [12]. Within the domain of rehabilitation gaming, addressing failures and management of difficulty must be taken even more seriously, particularly due to the technical inexperience of most post-stroke patients, which increases the likelihood of encountering setbacks. Consequently, these setbacks necessitate careful management to foster patient encouragement and facilitate their training regimen. Rather than terminating the game following a failure or defeat, or ascribing negative connotations to such instances, such as loss of points, patients should instead be incentivized for their participation. This approach encourages renewed engagement with the games, enabling them to strive toward achieving rehabilitation objectives more effectively. It is imperative to maintain a balance in the management of difficulty, ensuring that tasks are not overly simplified, which could lead to user boredom. Similarly, tasks should not be excessively challenging, as this may result in user frustration and disillusionment. In both scenarios, demotivation ensues, ultimately impacting the effectiveness of rehabilitation. The implementation of diverse difficulty levels is commonly observed across all genres of games. Level progression should be contingent upon the patient's performance status [16]. Upon completion of a level, patients advance to the subsequent level, motivating them to achieve success in the new stage. Adaptivity is a strategy grounded in an algorithm that dynamically adjusts the difficulty of the game in real-time, based on the performance and skills of the patient. This ensures an appropriate level of challenge that can result in the game becoming either easier or harder, depending on the player's performance [15]. Prior to the development of this game, several existing applications were thoroughly analyzed to create an innovative solution capable of addressing challenges observed in previous works. Regarding hardware, certain examples demonstrated the use of head-mounted displays (HMDs) to enhance the immersive virtual reality experience in serious gaming applications [11; 13]. For motion capture, various approaches were identified, such as the use of motion capture cameras like Kinect V2 for full-body tracking [17], Leap Motion for hand tracking [9; 13], and data gloves [10]. At the software level, the majority of reviewed examples utilized Unity3D (2022.3.27f1) [18] for the development of games and 3D environments [9; 10; 11; 13]. In terms of gameplay, the primary objective consistently centered on encouraging users to perform movements in engaging and varied ways to maintain their motivation.