# Design of Exergaming Platform for Upper Limb Rehabilitation Using Surface Electromyography
## 4 Evaluation Study  
Each of the two distinct and interrelated elements of the system, the health professional interface and the exergame, needs to be treated differently when being evaluated. This is partly because of their different end-users and goals and partly because of the supplementary nature of the professional interface and the primary position of the game presented in this study. For the evaluation of the system, user testing was performed, where the testing of the interface with health professionals was independent of the testing of the game with typical users, i.e., neurological patients. The professional testing was aimed at evaluating a variety of operations and scenarios, including but not limited to managing exercise programs and patient records, analyzing game sessions, and examining the usability of the graphical user interface. On the other hand, in the patient testing, the only goal for the participants was the completion of the game. In addition, the game was also tested by individuals without neurological disorders. However, this testing was solely conducted to gain a deeper understanding of the specific characteristics of the patients. In general, end-user testing is an effective way of determining a system's performance in real-world conditions. Conclusions drawn from how users interact with the system are particularly useful for a game aimed at patients, given the special needs of this population. We used a mixed-methods approach that included both quantitative and qualitative data collection and analysis. Specifically, we used system logs and video recordings of the patient and their screen to collect quantitative data about user interactions, while we conducted user satisfaction questionnaires to collect qualitative data in order to capture the subjective user experience and perceptions. The questionnaire consisted of nine questions and used a Likert scale expressing levels of agreement or disagreement with a given statement. Questions included in the questionnaire that was given to the participants are shown in Table 1. The integration of these methods was consistent with the framework for constructing mixed-methods studies presented in [42] and allowed us to triangulate our findings. It is worth noting that the tests were conducted in a clinical setting, and the think-aloud protocol was followed. Figure 4: Images capturing various stages of the gameplay. (**a**) During the hold time of the exercise. (**b**) Just after the hold time has passed but before the player stops the exercise. (**c**) During the rest time of the exercise. (**d**) Just before level completion. The characteristics of the participants in the study are shown in Table 2.  
All the patients, referred to as P1-P6, were selected by considering diversity as much as was possible in the context of this study. To be eligible for participation, patients had to meet specific inclusion criteria, as outlined in [38,39]. Firstly, patients needed to possess some degree of active movement in the wrist, hand, and fingers, specifically extension, to handle the input devices effectively. Additionally, they had to have a muscle strength of at least 3 on the Medical Research Council (MRC) scale, allowing them to perform movements against gravity. Patients with severe hypertony, indicated by a score of 3 or more on the Modified Ashworth Scale (MAS), were excluded due to potential difficulties with wrist and finger extension caused by increased spasticity. Cognitive function is also a critical criterion; patients must have scored above 24 on the Mini-Mental State Examination (MMSE) to comprehend instructions and provide informed consent. Furthermore, some degree of motor function in the hand and wrist is required to play the game, with the recommended minimum scores on the Fugl-Meyer Motor-Sensory Assessment being 5 out of 10 for the wrist, 7 out of 14 for the hand, and a passive range of motion exceeding 12 out of 24.