A Digital, Game-based Application to Support Treatment of

Parkinson’s Disease: A Design Thinking Approach

Anne Mainz

and Sven Meister

1,2 b

Health Informatics, Faculty of Health, Witten/Herdecke University, Witten, Germany

Fraunhofer Institute for Software and Systems Engineering, Dortmund, Germany

Keywords: Design Thinking, Parkinson’s Disease, Rehabilitation, Physical Therapy, Motivation, Serious Game,

Exergame.

Abstract: One of the most common neurodegenerative disorders that affects more and more people at an advanced age

is Parkinson’s disease. Patients suffer from various symptoms and especially the motor restrictions and

psychological symptoms worsen the quality of life of the affected persons. The physical therapy for this

disease to improve motor performance and complementary exercises is characterised by repetitive training

and patients often suffer from a strong exhaustion and lack of motivation due to their disease. To address

these problems, a serious game concept for Parkinson's therapy was developed. The concept was created using

the Design Thinking methodology for a user-centred design. The final result is the concept and prototype of

a competitive multiplayer exergame that was developed to increase the motivation of the patients to participate

through social play and the idea of competition in order to support the motor therapy of Parkinson’s disease

patients.

1 INTRODUCTION

Parkinson’s disease is a neurodegenerative disorder

that affects 2-3% of the population over 65 years

(Poewe et al., 2017). The most associated symptoms

are the four cardinal signs concerning the motor

system: rest tremor, muscle rigidity, postural

instability and bradykinesia (Balestrino & Schapira,

2020). Rest tremor is manifested by alternating

involuntary movements of the hands, feet and

sometimes other body parts when the patient is at rest

(Helmich et al., 2012). Muscle rigidity refers to the

continuous and constant increase in muscle tone with

resistance to passive movements regardless of

movement speed and direction of movement

(Delwaide, 2001). Disturbed postural reflexes and

reduced control over one’s own movement often

cause balance difficulties in Parkinson’s patients,

leading to postural instability (Bloem, 1992).

Bradykinesia, the slowness of movement, often

occurs in connection with hypokinesia, the deceasing

of movement. The movements of the patients are

often under-scaled due to wrong motion perception

https://orcid.org/0000-0002-9790-6049

https://orcid.org/0000-0003-0522-986X

(Balestrino & Shapira, 2020). Through external

cueing and big flowing exercises as compensatory

movement strategies, this symptom can be alleviated

(Janssen et al., 2014).

Non-motor symptoms in Parkinson’s disease

range from autonomic dysfunctions to sensory

disorders and various psychiatric disorders. Self-

reports of patients show that especially nonmotor

symptoms like depression and fatigue affect their

perceived quality of life (Barone et al., 2009). Fatigue

is characterized by an intense feeling of tiredness,

exhaustion and listlessness and concerns more than

half of the patients with Parkinson’s (Krupp &

Pollina, 1996). Fatigue is additionally associated with

lack of motivation, pain, lower quality of life, poorer

perception of psychological well-being, more severe

depressive symptoms, and an increased prevalence of

sleep disturbances (Hagell & Brundin, 2009; Stocchi

et al., 2014). Friedman and colleagues advise physical

exercises and group motivational training to

counteract fatigue (Friedman et al., 2007).

A serious game is an interactive computer-based

game software that has been developed with the

Mainz, A. and Meister, S.

A Digital, Game-based Application to Support Treatment of Parkinson’s Disease: A Design Thinking Approach.

DOI: 10.5220/0010846100003123

In Proceedings of the 15th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2022) - Volume 5: HEALTHINF, pages 125-134

ISBN: 978-989-758-552-4; ISSN: 2184-4305

125

intention to be more than entertainment. It is used to

impart skills or knowledge embedded in a

motivational and entertaining context (Ritterfeld et

al., 2009). Serious games are used in various fields

from healthcare, marketing, social change, education,

military, occupation, well-being, advertising, cultural

heritage, interpersonal communication and academic

purpose (Laamarti et al., 2014; Ritterfeld et al., 2009).

A huge number of serious games in healthcare can be

classified as so-called exergames, often used for

motor rehabilitation. Exergames combine a playful

approach (game) with physical activity (exercise)

(Malaka et al., 2016). Instead of classic input devices

such as keyboard and mouse or controller,

physiological feedback from the player is used to

interact with game (Malaka et al., 2014).

Due to the repetitive nature of Parkinson's therapy

patients get physically tired and mentally bored

during classic therapy training resulting in lack of

motivation (Assad et al., 2011). Serious exergames

offer themselves as a therapy supplement for

Parkinson's therapy due to their playful motivation to

move in combination with therapeutic effects (Rego

et al., 2014). Aim of this paper is an appropriate

exergame-concept developed for Parkinson’s disease

patients with mild to moderate Parkinson’s disease to

improve hypokinesia and fatigue.

2 METHODS

To develop a suitable serious game concept for

Parkinson’s therapy the design thinking methodology

is used which was developed to systematise creative

processes and to find user-centred solutions to

problems (Brown, 2008). Depending on the selected

model, the design thinking process is divided into five

or six phases that are iterated through. Within this

work we have chosen the model presented in the work

of Wölbling and colleagues (Wölbling et al., 2012),

consisting of understand, observe, point of view,

ideate, prototype and test.

2.1 Literature Review

In the understand-phase the initial definition of the

problem and a broad outline of the subject matter are

required. The topic, main stakeholders and the

context are identified. First results can be obtained

through literature research, as in this case. Often there

are unanswered questions that can be answered in the

next step (Wölbling et al., 2012).

To gain more insight, related work was

investigated. Applications were considered that can

be classified as serious games and that define patients

with Parkinson's disease as the target group. The

applications were identified through literature

searches on the online databases ACM Digital

Library, APA PsycNet, PubMed, ScienceDirect,

IEEE Xplore Digital Library, ResearchGate,

Semantic Scholar and Springer Link. Applications

were excluded that used gamification aspects but

were not implemented as a serious game, serious

games that did not aim at motor improvement, or

applications that were not explicitly conceptualised

and implemented for Parkinson's patients. The

following keywords were used in the search:

“exergame”, “active video game”, “serious game”,

“exercise”, “exercise therapy”, “digital

rehabilitation”, “digital therapy support”,

“parkinson’s disease”, “parkinson”.

2.2 Expert Interviews

The objective of the observe-phase is to understand

and empathize with the user to create a suitable

product for the target group. In most cases, qualitative

interviews or quantitative surveys are conducted. The

results are used to understand needs and obstacles and

answer open questions after the first phase (Wölbling

et al., 2012).

For the observe-phase expert interviews with

physiotherapists were hold. Expert interviews are

used to gain expert knowledge through a qualitative

survey (Meuser & Nagel, 2009). The decision was

made not to conduct the interviews with

representatives of the target group themselves, as they

might have difficulties in formulating general

requirements due to the very individual

characteristics of the disease. The expert interviews

with three physiotherapists were conducted to

identify requirements for a digital game-based

therapy support. The interviews were intended to

clarify open questions and substantiate the concept

with practical experience values. Each interview

lasted half an hour and they were held between the

23.02.32021 and the 26.02.2021 due to the pandemic

situation via the video conferencing tool Teams. For

later content analysis, the interviews were recorded

and later transcribed with consent of the participants.

Questions asked during the semi-structured interview

concerned

1. methods of motor therapy for Parkinson patients

that are suitable for a digital approach,

2. strategies for dealing with lack of motivation

during therapy,

3. requirements of the target group for game

perception and design,

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4. potentials and obstacles caused by the game

mechanics and interaction and

5. idea generation and wishes for an optimal game

design.

The analysis of the interviews follows the data

analysis of expert interviews according to Meuser and

Nagel (2009) in order to obtain interpretable results.

The data analysis according to Meuser and Nagel is

divided into transcription of the recorded interview,

paraphrasing the text according to thematic units,

ordering the paraphrased passages thematically,

category formation and comparison of the statements

and finally theoretical generalization through

arranging the categories according to their internal

relations.

2.3 Concept

During the point of view-phase the generated

information from the previous phases should be

clustered and provide answers to the questions: What

problem must be solved? For whom this problem

must be solved? In the ideate-phase ideas to solve this

problem are generated. With the help of the

knowledge base, that has been accumulated, a user-

centred solution can be found. For the prototype-

phase a concrete example implementation of the final

idea is created. The prototype gives the opportunity to

experience a tangible and assessable version of the

idea (Wölbling et al., 2012).

The result of the point of view-phase is used as a

reference point to develop a concrete concept idea.

This concept idea is implemented as a prototype using

the game engine Unity 3D in version 2020.3.1f1 in

the programming language C#.

2.4 Evaluation

The finished prototype is presented to potential users

during the test-phase to give feedback on the idea and

determine the usability of the solution. With the help

of the results, the solution approach can be iteratively

revised (Wölbling et al., 2012).

The prototype was evaluated through qualitative

interviews with experts. Six participants took part,

three of whom worked as software developers for

serious games (S1, S2, S3) and three as

physiotherapists (P1, P2, P3). Two of the

physiotherapists already had experience with serious

game applications in therapy (P1, P3). Due to the

ongoing pandemic situation, the interviews were

conducted via Teams. The subjects were not able to

use the application themselves because of the current

situation but they were shown screenshots of the

menus and interface and videos of various game

scenes (introduction, calibration, game, game end) of

the prototype with exemplary use. The participants

were then asked about the suitability of the

application for the therapy and the target group and

about the usability and development of the prototype.

The interviews were held between the 24.05.2021 and

the 30.05.2021 and each interview lasted 45 minutes.

The interviews were recorded, transcribed and

analysed according to Meuser and Nagel (2009).

3 RESULTS

The results of the different design thinking-phases are

shown below. The most important findings of the

literature review, the results of the expert interviews,

the final concept resulting from these findings and the

results of the evaluation are presented.

3.1 Literature Review

The search for related work resulted in 13 serious

games for therapy support in Parkinson's patients

(Assad et al., 2011; Dauvergne al., 2018; Dias et al.,

2017; Galna et al., 2014; Garcia-Agundez et al., 2017;

Hermann et al., 2013; Nuic et al., 2018; Pachoulakis

& Papadopoulos, 2016; Pachoulakis et al., 2018;

Palacios-Navarro et al., 2015; Paraskevopoulos et al.,

2014; Sanchez- Herrera- Baeza et al., 2020; Van der

Meulen et al., 2016).

Of the applications considered, almost all can be

classified as exergames for improvement of motor

skills. Only the game by Dauvergne et al. (2018)

trains the sense of rhythm. Evaluations of the

applications show that they are capable of improving

the skills of the patients.

Most used input device for the applications were

different kinect bodytracking solutions (Xbox 360

Kinect, Kinect for Windows, Kinect for Xbox One,

Kinect 2 for Windows, Azure Kinect). Especially due

to the use without additional input devices or optical

markers, they are well suited for the target group.

Except for the collaborative serious game

Window-Washer (Hermann et al., 2013), all games

are implemented as single-player applications. There

is potential here that has not yet been exploited by the

existing range of applications.

3.2 Expert Interviews

The most important statements on the various

subtopics of the expert interview are presented below.

A Digital, Game-based Application to Support Treatment of Parkinson’s Disease: A Design Thinking Approach

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3.2.1 Suitable Exercises

The participants reported that the motor therapy for

Parkinson’s disease patients is very diverse, and

patients are treated differently depending on their

main symptoms (P1, P2, P3). The exercises range

from gait training, stretching exercises to muscle

building but main target for every physiotherapist is

to maintain the capability to perform everyday

movements. Gait training (P2, P3), classic exercises

like squats (P2, P3) and the LSVT BIG program (P1,

P3) named the participants as suitable for a digital

game-based application.

3.2.2 Strategies to Increase Motivation

Day-dependent fatigue and depression were named as

a huge hindrance of therapy. In connection with this,

a lack of motivation often occurs (P1, P2, P3).

Sometimes patients even perform aggressive

behaviour (P3). Shame for symptoms is common but

decreases with increasing trust in the therapist (P1,

P3). The interview partners described that if a patient

is disinterested, lacking motivation, or exhausted they

often use pauses or rest periods (P1, P2, P3), but the

main goal is getting the patient back to the therapy

program (P3). In difficult cases, one participant

reported implementing an alternative stretching

program with patients (P1).

3.2.3 Requirements of the Target Group

In order to support patients in the use of technology

and to avoid safety risks, the participants agreed that

a therapist as a controlling authority should support

the patients in using the application and that a home

application would not be useful (P1, P2, P3).

According to the participants, it would be

important for the target group to be able to adjust the

difficulty of the game, because the patients should

neither be over-challenged nor under-challenged (P1,

P3). In particular, since the severity of Parkinson's

disease can vary greatly, digital therapy support

should offer a certain degree of variability (P3). For

example, the possibility to interact with the game

while standing or sitting was suggested (P1, P2, P3).

Particularly with regard to hypokinesia, three-

dimensional visualisation of the patient's body

movements would be useful to provide them with

external cues to recalibrate their body sensation and

thus help them adjust their movement size (P2).

The theme of the digital game application should

be chosen with care to appeal to the target group (P1,

P2, P3). Topics such as sports, dancing, music or

outdoor activities are interesting for most

representatives of Parkinson's patients, who are

mostly of older age (P3).

The possibility to take breaks is absolutely

necessary in a digital playful therapy supplement

because the patients tire quickly (P1, P2, P3). The

breaks should be determined by the accompanying

therapist or by the patient himself and not be dictated

by the game system (P2).

Due to the advanced age of the patients,

instructions on the correct execution of the exercise

and the use of the system should not be complex and

be given several times during the game (P1, P2).

3.2.4 Obstacles

The design as a competitive game could be

problematic if there is a large difference in

performance between the players (P3), if the players

are in poor daily form (P3) or if the players have set

themselves an unrealistic objective (P1, P3) and thus

rather reduce motivation instead of promoting it.

Another danger of the competitive situation could be

that the players overreach themselves if they are too

ambitious (P1). However, the pressure to perform or

the stress can be reduced by a well thought-out game

design. Possibilities here would be to set realistic and

individual goals (P1), to offer the prospect of partial

goals (P1), to offer incentives not to overdo oneself

(P1), to create a non-judgemental and exercise-related

environment (P3) and to direct the focus of the

application on the therapy purpose and not on

competition (P2).

Due to the age of the patients, initial scepticism

and reluctance towards the new form of interaction is

likely but should reduce over time (P2, P3). The

motor control could offer the players opportunities to

not execute the movements cleanly but still achieve

high scores (P1, P3). This should be addressed

through an appropriate exercise selection and good

movement instruction (P3). Interaction movements

should be designed with the patient's motor

symptoms in mind. In particular, tremor and the

cogwheel phenomenon could hinder interaction if

they are not taken into account (P2).

3.2.5 Potentials

All participants agreed that playful therapy methods

are a high motivational incentive for the patients.

They offer additional incentives and variety to the

therapy and expand it through gamification (P1, P3).

A competitive game design offers above all a

comparison of performance (both with one's own

performance and with that of the opponent) which can

generate strong motivation in the patients (P1, P2,

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P3). The social interaction that arises from a

competitive situation is a useful and motivating

complement to individual therapy that is also used in

group therapy (P1, P2, P3), which often incorporates

social interaction with a therapeutic purpose into a

playful setting (P1).

The motor game control through optical body

tracking as a new and interesting concept is a great

motivating factor that can encourage patients to use

the application (P3). The fact that no additional aids

are required makes it very easy to start using the

system (P1). Motor control through body tracking

technology can enable the possibility of linking

different training approaches (P1). Since the patients

themselves are responsible for the control, they can

determine the pace and the extent of movement

themselves (P1), which is not always the case with

other technical therapy supports. The visualisation of

body movement made possible by optical body

tracking can sensitise the patients' body perception

and support them in recalibrating their movement size

perception (P2).

3.2.6 Idea Generation

To optimally complement conventional therapy, the

participants wanted above all varied settings as a

playful digital supplement and ideally variable offers

for different patient interests (P1, P3). Interesting

topics mentioned were realistic scenarios from

everyday life (P1), sports to create a natural

competitive situation (P2) and the use of music and

rhythm (P2, P3).

3.3 Concept

The aim of this work is to develop a serious game that

supports and complements Parkinson's therapy. The

target group of the application are people with mild

to moderate Parkinson’s disease (Hoehn and Yahr-

scale stage I to III) (Hoehn & Yahr, 1967). In these

stages of disease, motor impairments of the patients

are present but the patients are able to manage his or

her daily life independently and the ability to stand

and walk is still given. Cognitive impairments of

memory and behaviour are not yet pronounced. The

planned application is intended to improve the

hypokinesia of the patients by integrating suitable

therapy contents and visualising the body movements

of the players on the one hand, and to counteract the

fatigue symptom through a motivating and social

game design on the other hand.

3.3.1 Genre

The conceptualised game PARKinson can be

classified as a casual game. Casual games are

characterised by easy interaction, quick-to-learn

gameplay, fast achievements and the possibility of

short play sessions. They offer frequent rewards and

a benevolent play rating (Kuittinen et al., 2007). Since

casual games often have a low level of complexity,

they are particularly suitable for an older target group

in order to avoid cognitive overload (Gerling et al.,

2011). Playing casual games is additionally able to

reduce depressive symptoms of the players

(Russoniello et al., 2009).

The theme of the game is chosen according to the

preferences of the target group (McNaney et al.,

2015; Othlinghaus et al., 2011). A gardening theme

was chosen, which is also an activity associated with

relaxation and stress reduction (Scott et al., 2015).

3.3.2 Game Idea

The interaction movements are based on the basic

idea of the LSVT BIG training to improve the

hypokinesia of the patients with extensive and

flowing movements. The LSVT (Lee Silverman Voice

Treatment) Program is a therapy concept that targets

on increasing the amplitude of the speech motor

system (LSVT LOUD) or the limb motor system

(LSVT BIG). LSVT BIG aims to enlarge motions by

recalibrating the patient’s perception of his own

movement and thus improve the hypokinesia of the

patients. The program contains different exercises,

which encourages the patient to make great

movements (Fox et al., 2012). LSVT BIG was also

considered suitable by the interview partners to be

transferred into a digital therapy application. In the

game the players have to move within their entire

kinesphere (the space around the body that can be

reached by stretching and extending limbs) (Laban &

Ullmann, 1971) in order to interact with the game.

The players select objects scattered across the game

screen with their hand. Players' body movements are

captured using the Azure Kinect. The Azure Kinect is

a camera system consisting of a depth camera and an

RGB camera. The body tracking-feature of the Azure

Kinect is able to detect human bodies and connects

them with a skeletal representation containing 32

joints. This technology allows tracking the patients’

movements and embedding them into a playful

context.

Unlike most commercial exergames, the

movements in the game only serve as a means of

interaction and not as a basis for evaluation of the

game success. Because the assessment of movement

A Digital, Game-based Application to Support Treatment of Parkinson’s Disease: A Design Thinking Approach

129

in exergames was reported as not suitable for

Parkinson's patients (McNaney et al., 2015). The

success of the game is therefore not dependent on

motor performance, which is influenced by the

disease, but on abilities that are not influenced by the

disease in mild to moderate Parkinson's disease

(Poewe et al., 2017). For a successful game, players

need to use their visual-spatial working memory

(Schumann-Hengsteler, 1996).

The game principle is derived from the classic

Matching Pairs-game (also known as Concentration

or Pairs) In Matching Pairs, the players’ task is to

find matching pairs of cards from a series of cards that

lie face down in front of the players. Players take

turns turning over two cards and the game ends when

all cards have been successfully turned over. The

player who has matched the most pairs wins (Zwick

& Paterson, 1993). The well-known game concept of

Matching Pairs facilitates the target group’s entry

into the unfamiliar field of digital therapy support

(McNaney et al., 2015; Nap et al., 2009).

Matching Pairs is a competitive multiplayer

game. Both in the interviews and in the literature, the

motivational potential of social play is emphasised

(Ryan et al., 2006). Competitive play in particular has

positive effects in terms of motivation and fun (Peng

& Crouse, 2013; Göbel et al., 2010). In this game the

players are highly interdependent because they have

access to the same resources or cards and the actions

of the opponent influence their own actions. During

the game there is negative and positive

interdependence between the players: players take

resources from each other, but the actions of the

opponent can also give players important clues about

card positions for their own actions. High

interdependence forms and strengthens social ties

(regardless of whether it is positive or negative)

(Depping et al., 2018). Social connection is in turn

associated with motivation according to the self-

determination theory (Ryan & Deci, 2000). In

addition, in Matching Pairs it is not possible to make

mistakes: either you reveal a pair of cards, or you

expand your knowledge of the card positions during

a move.

The rules of the traditional Matching Pairs game

are slightly modified in the conceptualized digital

application. Unlike Matching Pairs, there is no

provision for a player to have another turn at a found

pair to avoid long periods of inactivity and not to

further emphasis a possible cognitive imbalance of

the players.

Players interact with the game through the

position of their selected hand. They move a hand

icon across the screen and can use it to select the cards

distributed on the screen. To select, they let their hand

remain on the respective card for five seconds (which

is visually supported by a loading bar around the

icon). The motif of the selected card is then revealed.

Following the same principle, the player then selects

a second card, and its motif is also revealed. If the

card motifs are identical, the player receives a point

and, for further visual support, the captured cards are

marked with flowers in the player's colour. The

players take turns to select two cards. The game ends

automatically when all pairs of cards have been found

but can also be ended manually at any time. In both

cases, a closing screen is displayed with the players'

scores.

Figure 1: Exemplary play scene of PARKinson.

In addition to the free hand selection, it is possible

to play the game both sitting and standing. The

individualization of the game that was suggested in

the interviews is complemented by the fact that the

arm span of both players is recorded in a calibration

phase and the outermost cards are placed in the

individual maximum range of the players in order to

create a higher equality of opportunity with different

sizes or degrees of mobility. Pauses, that are

considered absolutely necessary by the interview

partners, are possible at any time during the game

because the players themselves take the initiative for

actions and do not have to react to actions in the game.

If the exhaustion is too great that not all pairs of cards

can be found, it is possible to end the game manually

at any time and be forwarded to the final scene. The

body movements of the players are visualised during

the game by using the skeletal representation of the

Kinect body tracking. This visualisation was

considered useful by the interviewees and in the

literature external cues about the magnitude of one's

own body movement are advised (e.g. through verbal

cues or videos) in order to adjust the patient's body

awareness and improve hypokinesia (Berardelli,

2001).

The game should be used as a supplement in the

therapy setting and supervised by a therapist (e.g. in

group therapy).

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3.4 Evaluation

The introduction of the game was considered useful

by the interview participants in order to convey the

first basic information (goals, rules, characters) (P1,

P2, P3, S2). Especially the embedding in a story or in

a dialogue with one of the characters was rated

positively as this can create an interactive feeling and

more engagement (S2).

The playful and narrative embedded testing of the

interaction including the calibration of the arm span

was rated as entertaining for the patients and good

access to the game (P1). The possibility to adapt the

game individually to the players through the

calibration and the possibility to play both sitting and

standing increases the accessibility and makes the

game therapeutically useful (P1, P2). It was suggested

that the prototype should be supplemented with the

ability to recalibrate during the play session (P3). One

respondent suggested that it would be useful to

explicitly inform the supervising therapist about the

possibility of playing while standing or sitting. At the

same time, it would be important to make sure that

the players are not demotivated when the therapist

decides that they are "only" able to play sitting down

(P1). Free hand selection is considered very useful as

it gives the supervising therapist the freedom to

choose which hand to train: The strong or the weak

side, both of which can have positive effects: either

regarding the training effect or the motivation (P1).

For the main game, the participants suggested

even stronger visual and auditory highlighting of

game-relevant events and actions for better attention

control but also motivating effects (P1, S1, S3).

Likewise, they considered different levels for

different difficulty degrees and game lengths to be

useful. Different items and functions that are

unlocked over time would increase the long-term

motivation even more (P1, P2, P3, S1, S2, S3).

The gardening theme was rated as appealing to

the target group (P1, P2, S1) but one of the

participants noted that the subject is probably more

attractive for women than for men (P2). The game

concept was rated as simple and understandable, but

nevertheless creative and appealing (P1). The familiar

game concept offered an easy entry for the target

group (P1, S1, S2). The controller-less interaction

would be intuitive and particularly well suited to the

target group (P1). The card positioning and thus the

required movements are a good adaptation of the

basic idea of LSVT BIG (S2) and would motivate the

patients to make therapeutic movements without

them happening consciously, as in the case of

working through the exercises (P1). Large and

targeted movements are trained in this way (P1, S1).

The holding times would increase the therapeutic

effectiveness (P1). It was also positively emphasised

that there is no temporal component that could create

stress among the players (P2, P3, S2). The linking of

the movements with cognitive training is useful for

the target group (P1, S2).

The ending of the game even if it is ended

prematurely was emphasised positively, because this

would not create the feeling among the players that

they would abandon the game (S1).

The participants are of the opinion that the game

would be a suitable therapy support. The patients are

challenged to use their entire range of motion (P2).

The game offers a suitable and meaningful movement

interaction for the target group to reach their

movement amplitude and can increase motivation and

thus achieve the required number of repetitions (P3).

The interaction would have effects on mobility

because the concrete targets, i.e. the cards to be

reached, would prevent powerless and listless

movements (P1). The stretching would train the

flexibility of the chest and spine, which in turn would

support breathing (P1). At the same time, balance and

coordination are trained (P1). The design as a

competition could additionally increase motivation

and the new and interactive approach could create

more interest in using it (S2). One respondent noted

that the application was not only suitable for

Parkinson's patients but could also be used for

patients with hemiparesis or for neurological patients

(P2).

In addition, the interviewees mentioned several

tangible suggestions for improvement of the interface

and the game mechanics during the evaluation, which

would go beyond the scope of this paper to mention

them all, but which were implemented additionally

after the interviews.

4 DISCUSSION

The aim of the work was to develop a concept for an

exergame for Parkinson’s disease patients with mild

to moderate Parkinson’s disease to improve

hypokinesia and fatigue. The interaction with this

exergame is made via optical body tracking through

the Azure Kinect without additional devices like

controller or physical marker.

The interview results show that the lack of

motivation, which is often caused by the disease

(Hagell & Brundin) but also by the repetitive nature

of the therapy (Fox et al., 2012), is a common

problem in Parkinson's therapy. Due to their

A Digital, Game-based Application to Support Treatment of Parkinson’s Disease: A Design Thinking Approach

131

motivating nature, serious games are suitable to be

used as a therapy addition (Rego et al., 2014). Serious

games offer a very high potential, but some

requirements and challenges have been identified for

their use as a therapy supplement for Parkinson's

patients.

This includes choosing an appropriate theme for

the target group, therefore a gardening theme was

chosen that appeals to the target group (McNaney et

al., 2015; Othlinghaus et al., 2011) and is associated

with relaxation (Scott et al., 2015). The adaptability

to the abilities of the respective players is realized

through different play modes (sitting/standing), hand

selection and calibration through arm span of the

players. In order to visualise the body movements to

recalibrate body awareness (Berardelli, 2001) the

three-dimensional skeletal representation detected by

the Kinect body tracking is displayed parallel to the

game. The last requirement mentioned in the

interviews was the possibility for players to take a

break at any time. In the concept developed, this is

made possible by the fact that the players themselves

interact proactively with the game and do not have to

react to the game. The game can be paused and, in the

event of severe exhaustion, also be stopped at any

time.

Obstacles identified in the interviews of the

requirements analysis were a possible scepticism of

the patients towards the new technical application,

which should be overcome by using a familiar casual

game concept (Nap et al., 2009) and an appealing

theme (Othlinghaus et al., 2011). As requested in the

interview, the focus is diverted from the (motor)

competition in order to avoid demotivation and

overexertion. For this reason, the Matching Pairs

concept, which challenges the visual-spatial working

memory, was chosen. The high interdependence of

the players in this concept ensures social connections

(Depping et al., 2018) and thus higher motivation

(Ryan & Deci, 2000).

The LSVT BIG training was named as a therapy

concept suitable for transfer to a digital therapy

support, which is used to improve hypokinesia (Fox

et al., 2012), which is also the aim of the application.

The basic idea of this training concept of wide and

flowing movements was adopted and combined with

a competitive game design of Matching Pairs.

In the expert interviews evaluating the concept

and the prototype, the application was rated very

positively and as suitable for supporting the therapy

of Parkinson's patients. The expert interviews were

conducted as a formative evaluation and were well

suited to identify areas for improvement and further

research potential. Unfortunately, it is not possible to

make any substantiated statements about the player's

experience, as the test persons were only able to view

screenshots and videos of the application. In order to

finally evaluate the usability and effectiveness of the

application, the comparison of objective health

variables by means of standardised measuring

instruments of a user group with a suitable control

group is necessary. In addition, individual experience

reports of the test persons should be collected (Kato,

2012). Unfortunately, this kind of testing was not

possible due to the current pandemic situation, but it

will be carried out as soon as possible. However, the

interviews revealed some potential for improvement

of the current prototype in the sense of a formative

evaluation, which can be implemented or further

investigated in the future.

Limitations for the results of both qualitative

studies are the small sample sizes. Unfortunately, the

corona pandemic has made a laboratory study for

evaluation impossible, which makes the significance

for interaction assessment very weak. A patient

perspective on the prototype would have further

enriched the evaluation, which will be included in

further studies.

Overall, the results support the assumption that a

serious exergame can be a suitable therapy

supplement for Parkinson's patients and some

characteristics for a suitable application could be

identified. In any case, further studies are needed to

evaluate training effects and to obtain assessments of

the prototype by patients and potential users. These

are planned for the near future.

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