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BackgroundSeveral strategies have been proposed to improve patient motivation and exercise intensity during robot-aided stroke rehabilitation. One relatively unexplored possibility is two-player gameplay, allowing subjects to compete or cooperate with each other to achieve a common goal. In order to explore the potential of such games, we designed a two-player game played using two ARMin arm rehabilitation robots.MethodsThe game was an air-hockey task displayed on a computer monitor and controlled using shoulder movements in the ARMin robot. Three game modes were tested: single-player (competing against computer), competitive (competing against human), and cooperative (cooperating with human against computer). All modes were played by 30 unimpaired subjects and 8 impaired chronic stroke subjects. The subjects filled out the Intrinsic Motivation Inventory questionnaire after each game mode, as well as a final questionnaire about game preferences and their personality.ResultsNearly all unimpaired subjects preferred playing the two-player game modes to the single-player one, as they enjoyed talking and interacting with another person. However, there were two distinct player groups: one liked the competitive mode but not the cooperative mode while the other liked the cooperative but not the competitive mode. Unimpaired subjects who liked the competitive mode also put significantly more effort into it than into the other modes. Results from impaired subjects were similar, with even impaired subjects over 60 years old enjoying competitive gameplay. The subjects’ personalities roughly predicted which mode they would prefer, which was especially evident in a poorly-matched impaired pair that preferred the single-player mode.ConclusionsResults indicate great potential for two-player rehabilitation games, in the form of greater enjoyment as well as potentially more intensive exercise compared to single-player games. However, the right game type needs to be chosen for each subject depending on skill and personality, along with selecting an appropriate co-player. Further studies with patients that are currently enrolled in rehabilitation programs are recommended, and the subjective measures used in our study should be augmented with objective measures such as electromyography.

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BackgroundPeople with chronic arm impairment should exercise intensely to regain their abilities, but frequently lack motivation, leading to poor rehabilitation outcome. One promising way to increase motivation is through interpersonal rehabilitation games, which allow patients to compete or cooperate together with other people. However, such games have mainly been evaluated with unimpaired subjects, and little is known about how they affect motivation and exercise intensity in people with chronic arm impairment.MethodsWe designed four different arm rehabilitation games that are played by a person with arm impairment and their unimpaired friend, relative or occupational therapist. One is a competitive game (both people compete against each other), two are cooperative games (both people work together against the computer) and one is a single-player game (played only by the impaired person against the computer). The games were played by 29 participants with chronic arm impairment, of which 19 were accompanied by their friend or relative and 10 were accompanied by their occupational therapist. Each participant played all four games within a single session. Participants’ subjective experience was quantified using the Intrinsic Motivation Inventory questionnaire after each game, as well as a final questionnaire about game preferences. Their exercise intensity was quantified using wearable inertial sensors that measured hand velocity in each game.ResultsOf the 29 impaired participants, 12 chose the competitive game as their favorite, 12 chose a cooperative game, and 5 preferred to exercise alone. Participants who chose the competitive game as their favorite showed increased motivation and exercise intensity in that game compared to other games. Participants who chose a cooperative game as their favorite also showed increased motivation in cooperative games, but not increased exercise intensity.ConclusionsSince both motivation and intensity are positively correlated with rehabilitation outcome, competitive games have high potential to lead to functional improvement and increased quality of life for patients compared to conventional rehabilitation exercises. Cooperative games do not increase exercise intensity, but could still increase motivation of patients who do not enjoy competition. However, such games need to be tested in longer, multisession studies to determine whether the observed increases in motivation and exercise intensity persist over a longer period of time and whether they positively affect rehabilitation outcome.Trial registrationThe study is not a clinical trial. While human subjects are involved, they participate in a single-session evaluation of a rehabilitation game rather than a full rehabilitation intervention, and no health outcomes are examined.Electronic supplementary materialThe online version of this article (doi:10.1186/s12984-017-0231-4) contains supplementary material, which is available to authorized users.