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Gamification and the theory of increased motivation through games

What is Gamification?

Gamification is defined as “the application of elements of game-design and principles of game in a non-game environment to improve user experience and user engagement, loyalty and fun “or “a process of consolidation of elements of a specific experience of the game in order to support the value created for the user.” (Huotari & Hamari, 2012; Richter et al., 2015)). The use of games in areas referred to as ”serious”, used in order to obtain therapeutic, educational or clinical benefits, have experienced a surge in popularity in recent years.


Attempting to harness the motivational power of games in order to promote participation, persistence and achievements, due to their beneficial effects on user engagement and that they disguise their immediate goal is, in fact, a serious one.  These games in conjunction with motion sensors can be used in many aspects of daily living, such as training and exchange of knowledge in all areas of life: defence, education, scientific research, healthcare, emergency management, city planning, engineering, religion, government and NGOs, business, marketing, communication and politics (Richter et al., 2015).




How is Gamification effective?


Game elements and rewards serve as a starting point to understand gamification effectiveness. For this reason we suggest understanding them within a broader context.

The factors that influence motivation (an individual’s choice to engage in an activity and the intensity of effort or persistence in that activity) combine extrinsic rewards such as levels, points, badges to improve engagement while striving to raise feelings of achieving mastery, autonomy, sense of belonging [1]. According to Deci and Ryan’s  Self-Determination Theory that encompasses both intrinsic and extrinsic motivations on a continuum from internal to external motivation [2], the effectiveness of games is within their design and how they combine various forms of motivation, according to player’s needs (like self-actualisation, aesthetics, knowledge, and other psychological needs).


“While the goal is to create and maintain intrinsic motivation, gamification is the application of extrinsic motivators. Careful selection and implementation of these motivators will trigger internal motivation and aid in maintaining it. “[1]


Fig 1. The self-determination continuum [3].



When it comes to rehabilitation exercises, studies show that an important trigger for treatment adherence is patients’ knowledge on how important their treatment is and to follow it (ie. Intrinsic Motivation) [3]. Furthermore, motivating patients to exercise can be challenging, especially with compliance to home exercises when the therapist is not present.  Some exercises can be repetitive and cumbersome, leading to demotivated patients. Adherence is traditionally extremely difficult to monitor, as reliance for information is based on what the patient tells you they completed. However could technology be providing alternatives to tackle this issue?

MIRA combines gaming elements with customisable clinical therapeutic interventions in order to trigger and increase patient’s intrinsic motivation in following treatment. The cloud-based software has the capacity to precisely monitor engagement with the exercises and games (exergames) in order to track progress.  Remotely, the therapist has the capacity to see the progress in real time and make necessary modifications. This combines both the motivation aspect and tracking the patient throughout their recovery.


“Some patients may be starting to exercise simply because they are being monitored and because of the insurance requirements for compliance. However, as they play, they receive incentives. The experience now becomes pleasurable and, with the capacity to track progress, they become empowered and the therapy becomes meaningful. Patients can notice their improvements, they start to understand the benefits. MIRA quickly becomes not just a way to get better, but also a fun way to spend their time. And so they arrive to be driven by intrinsic motivation to perform their rehab!”


What about Gamifying Physiotherapy?

Studies have shown that gamifying physiotherapy increases activity-levels and facilitates patients’ rehabilitation (Taylor et al., 2011). Physical inactivity can lead to major health problems that can be alleviated by at least 30 minutes of moderate-intensity exercise 5 days a week [6]. “Exergames” have the potential to facilitate rehabilitation, especially intensive repetitive movements that patients might find boring (McGlinchey et al., 2015), Furthermore, they can be used as evaluation tool (Moldovan et al., 2014) and positively influence the brain, being better perceived by patients than other medical interventions (https://www.mpg.de/research/video-games-brain, 2013).

Several clinical studies have found strong evidence for the use of games as treatment for cognitive and physical disorders such as cerebral palsy (Zoccolillo et al., 2015), stroke (Pirovano, 2014; Saposnik et al., 2010), balance and posture (Sato et al., 2015; Schubert et al., 15),  as well as for preventing falls and  promoting active ageing.

A systematic review (Bonnechère et al., 2016) of 126 studies show that in most cases, the introduction of video games (VG) training in physical rehabilitation offered similar results as conventional therapy. Therefore, VG’s could be added as an adjunct treatment in rehabilitation for various pathologies to stimulate patient motivation, and can be used at home to maintain rehabilitation benefits.





Crossing all barriers: Clinically- based Personalised Gaming

Mainstream technology has attempted to tackle the world of physical rehabilitation providing gaming environments that use external devices to promote aerobic conditioning, strengthening and balance.  Some therapists have adopted these tools into their therapy sessions with patients. Research is varied in demonstrating clear data and results, however it consistently demonstrates the need to work in collaboration with clinicians and users to ensure that games are appropriate and effective.

This can be taken even further with MIRA, by creating personalised exergames for specific types of rehabilitation. MIRA has integrated evidence-based clinical exergames to address the specific and targeted need of rehabilitation, increasing its treatment potential. The software can be individualised to fit the patient’s condition, needs and goals making it relevant and specific.

The psychological foundation and motivation for creating custom games is emphasised and measured by Bakkes et al. (2012) from the perspective of eight different components of the game, which can be adapted to the user: space game, mission / task, character, game mechanics, storyline, music / sound, fit players (multiplayer games) and balance difficulties. Bakkes et al. (2012) states that these issues are of utmost importance when designing games, considering the power of entertainment they have on the user. Moreover, designing games that are able to adjust these parameters to suit each user automatically is of utmost importance. All these aspects have been taken into consideration in the creation of the MIRA games, including input from clinicians and users.




By incorporating a gaming element in therapy, MIRA enables people to enjoy their rehabilitation and supports them in reaching and maintaining their motivation for engaging in their treatment to improve their health. The innovative world of gamification in health is growing and most probably will continue to grow as digitalising health is an escalating trend.  Furthermore, research findings are demonstrating the multiple benefits that it can provide and the feasibility of use with multiple patient populations and in various settings.



[1] Ganit Richter , Daphne R. Raban , and Sheizaf Rafaeli, Gamifi cation in Education and Business , Chapter 2 Studying Gamifi cation: The Effect of Rewards and Incentives on Motivation, Springer International Publishing Switzerland, pp. 21-47, 2015.

[2] Ryan, R. M., & Deci, E. L. (2000b). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55 (1), 68–78.

[3] Derwin K. Chan, BSSc, Chris Lonsdale, PhD, Po Y. Ho, MD, Patrick S. Yung, MD, Kai M. Chan, MD, Patient Motivation and Adherence to Postsurgery Rehabilitation Exercise Recommendations: The Influence of Physiotherapists’ Autonomy-Supportive Behaviors, Arch Phys Med Rehabil Vol 90, December 2009.

[6] Haskell WL, Lee IM, Pate RR, Powel KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A; American College of Sports Medicine; American Heart Association. Physical activity and public health: Updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1081–93. [PMID: 17671237] http://dx.doi.org/10.1161/CIRCULATIONAHA.107.185649

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