Effectiveness of Game-Based Solutions in Patients with Total Hip and Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials

Abstract

The aim of this systematic review of randomized controlled trials (RCTs) was to evaluate the effectiveness of game-based solutions in patients with total knee arthroplasty or total hip arthroplasty. The systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies published prior May 2022 were identified from MEDLINE Ovid, Scopus, EBSCO Databases, Web of Science, and PubMed. The Joanna Briggs Institute Critical Appraisal Checklist for RCTs was used to evaluate the quality of the relevant studies published. A narrative synthesis was used to report the results while effect sizes were estimated for different outcomes. A total of 350 records were identified, and 5 RCTs were selected. Most of the game-based solutions were exergames to support rehabilitation. The findings indicate that game-based solutions have potential to induce positive impact on functional and cognitive performance; however, due to the low number of studies and moderate/weak quality of existing research, the area still lacks assertive evidence. Future research should pay attention to the methodological aspects to provide reliable information on the use of game-based solutions in the given context.

Introduction

The symptoms of osteoarthritis (OA) are progressive, leading to increased disability, persistent pain, and reduced health-related quality of life.^1,2 Although OA can be managed conservatively in the early and intermediate stages by lifestyle changes (e.g., weight loss, exercise) and pain management, total knee arthroplasty (TKA) and total hip arthroplasty (THA) are often indicated for symptomatic end-stage disease. The prediction is that in the next 10–20 years, primary TKA/THA rates will substantially increase, not only because of an aging population but also because of increasing use by patients younger than 60 years.^3,4 Delivery of any ongoing rehabilitation is needed to adapt to this trend.

In recent years, the attention to technology-assisted rehabilitation has been increasing worldwide.^5,6 Game-based solutions are commonly used to increase motivation and engagement in the supported behavior.^7,8 Games and game-based designs, in general, often satisfy our basic psychological needs, which in turn supports intrinsic motivation toward playing and thus being engaged in the game.^9,10 This potential has been sought to be harnessed when applying game-based design in health care contexts,^11,12 where motivation, long-term commitment, and engagement are commonly the key to achieving results.⁷

One major trend in technology-assisted rehabilitation has been the use of serious games (e.g., videogames) and exergames (e.g., video and computer games, virtual reality) to increase functional (e.g., Timed “Up and Go” [TUG] test; range of motion [ROM]) and cognitive (e.g., working memory) performance by using various game-based affordances (e.g., points, score, timer, avatars, motion tracking).^5,6 Prior systematic reviews have reported significant effects of gamified solutions on various psychological (e.g., affective, cognitive, attitude) and behavioral (e.g., engagement, physical measures) outcomes^7,8 also in older adults.¹³ Although the results generally rely on positive findings about the effectiveness of gamification, the number of conflicting results (mixed or neutral effects) is remarkable due to lack of high quality of evidence, homogeneity (e.g., dosing, instrumentation), and theoretical constructs.^5,7,8

Due to the contextuality of game-based solutions and their design, specific needs of different user groups,^7,14 and the consequential challenges in applying results from one context to another, further research in different health care settings is warranted. Thus, this systematic review aimed to evaluate the effectiveness of game-based solutions in patients with TKA/THA. With the word “game-based,” we refer to all interventions and solutions that are labeled by authors as games or gamification, thus containing elements or interactions common to games.

Methods

The systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.¹⁵

Search strategy

First, a limited review was conducted in electronic databases including Melinda and MEDLINE Ovid to identify initial key words and index terms. Second, five multidisciplinary databases (MEDLINE Ovid, Scopus, EBSCO Databases, Web of Science, and PubMed) were searched to identify relevant publications before May 2022. As appropriate, a search strategy was adopted involving comparison of advanced and basic searches with appropriate permutations in association with an information specialist. Combination of terms was used through the Boolean operators (“arthroplast*” OR “prosthe*” OR “endoprosthe*”) AND “joint*” AND (“game*” OR “gaming” OR “gamif*”) to enhance the search strategy. In addition, the reference lists of included studies were manually searched.

Inclusion criteria and study selection

The study selection process was carried out by two researchers independently. The research team included expertise in the topic area being reviewed and included expertise in systematic review methodology. Studies were included if they met the predefined inclusion criteria based on the research questions (“What is the effect of game-based solutions on functional performance?” What is the effect of game-based solutions on cognitive performance?”), population (adult patients [≥18 years] with TKA/THA), intervention (gaming, gamification), comparison (standard care, an active control intervention, or no treatment), type of outcome (quantitatively measured patient-related subjective and objective outcomes), and study design randomized controlled trial (RCT) written in English, Finnish, or Swedish, and published between January 1, 2000, and April 30, 2022, because the first exergames (Wii™; Nintendo Co. Ltd., Kyoto, Japan; PlayStation Move; Sony Corp, Tokyo, Japan; and Kinect; Microsoft, Redmond, WA, USA) were launched in the 21st century.

Study selection was performed in three stages to minimize the risk of errors and bias and to ensure that all relevant studies were included. In the first stage (N = 419), the studies were screened for duplicate hits, year of publication (<2000), and contraindicatory publications. In the second stage, potentially relevant studies were assessed by two reviewers independently by comparing the titles and abstracts (n = 350) against the predetermined inclusion criteria. In the third stage, the full texts (n = 18) of studies that appeared to meet the inclusion criteria were obtained for detailed assessment against the inclusion criteria. Based on the full texts, five studies were identified to meet the inclusion criteria. There was complete agreement between the reviewers' final selections. The study selection was carefully documented using the RefWorks web-based research management tool and Microsoft Excel spreadsheet to ensure its repeatability.

Quality assessment

The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for RCTs was used to assess the quality of the relevant studies (n = 5).¹⁶ Two reviewers assessed the quality (e.g., selection bias, blinding, data collection methods, withdrawals and dropouts, intervention integrity, and analyses) of the articles independently, and discrepancies were discussed until consensus was reached. The standardized checklist for RCTs uses a series of criteria that can be scored as being met (yes, 1 point), not met (no, 0 point), or unclear (0 point). All the five studies were included in the final review despite the low-quality rating of the studies. Two of the studies^17,18 was based on the same experimental setting, and thus, the same data set was used, but different patient-related outcomes were reported in the studies. Therefore, both were included in the review. These factors should be considered when evaluating the results of the review.

Data extraction and analysis

One of the authors extracted the data using a purpose-designed spreadsheet. Another author checked the data for accuracy. The extracted data included specific details about each study: study information (authors, year of publication, location of study, study design), participants, details of intervention, details of control conditions, follow-up period, primary and secondary outcomes, and study results. The criterion for statistical significance was P < 0.05. Statistical synthesis was limited due to the large variation in the interventions, outcome measures, and statistical heterogeneity. Additional outcomes were adverse events and resource utilization. Cohen's d values were used to measure the effect size of each studied outcome. We used the recommendations of Cohen to interpret effect sizes; d values of 0.2–0.5 indicate a small effect, the values of 0.5–0.8 indicate a moderate effect, and a value of >0.8 indicates a large effect.¹⁹ Negative Cohen's d values indicate that the intervention group had a better outcome.

Results

A total of five studies were included at the end of selection process (Fig. 1).

FIG. 1.

The flow of information through the different phases of the systematic review.

Study characteristics

The study comprised 209 patients from 5 studies. Three of the five reviewed studies focused on TKA patients^20–22 and two studies on THA patients;^17,18 however, the data set of these two THA studies was the same (Table 1).

Table 1.

Locations and Study Aim of the Included Studies

Authors	Location	Study aim
Brem et al (2010)¹⁸	Germany	Examining the effects of videogame playing on cognitive performance in the situation of prolonged hospitalization.
Fung et al (2012)²⁰	Canada	Examining the acceptability of Nintendo Wii Fit™ gaming activities as an adjunct to physiotherapy treatment in rehabilitation of patients following total knee replacement.
Lehrl et al (2012)¹⁷	Germany	Examining the effects of mental activation on physical rehabilitation.
Hardt et al (2018)²¹	Germany	Examining the effects of app-based visual feedback rehabilitation program on functional, clinical, and patient-reported outcome measures.
Bäcker et al (2021)²²	Germany	Examining the effects of app-based visual feedback rehabilitation program on functional outcomes.

Quality appraisal

A summary of the quality appraisal of the included studies is presented in Table 2. The quality of each reviewed study was assessed as moderate or weak. Study quality was predominately affected by high risk of selection bias, lack of blinding, and lack of intention-to-treat analysis. In the selection bias component, all scored somewhat likely to be presentative of the target population due to incomplete reporting of recruitment processes. The blinding of both outcome assessors and study participants was insufficient in all reviewed studies. All studies were rated as moderate/strong for data collection methods.

Table 2.

Assessment of Quality of the Methodology of the Included Studies (Joanna Briggs Institute's Tool for Assessing Risk of Bias)

	Brem et al (2010)¹⁸	Fung et al (2012)²⁰	Lehrl et al (2012)¹⁷	Hardt et al (2018)²¹	Bäcker et al (2021)²²
1. Is the assignment to treatment groups truly random?	Unclear	Yes	Unclear	Yes	Yes
2. Are participants blinded to treatment allocation?	No	No	No	No	No
3. Is allocation to treatment groups concealed from the allocator?	Unclear	Unclear	Unclear	Unclear	Unclear
4. Are the outcomes of people who withdrew described and included in the analysis?	Unclear	Unclear	Unclear	Yes	Unclear
5. Are those assessing the outcomes blind to the treatment allocation?	Unclear	Yes	Unclear	Unclear	Unclear
6. Are the control and treatment groups comparable at entry?	Yes	Yes	Yes	Yes	Yes
7. Are groups treated identically other than for the named intervention?	Yes	Yes	Yes	Yes	Yes
8. Are outcomes measured in the same way for all groups?	Yes	Yes	Yes	Yes	Yes
9. Are outcomes measured in a reliable way?	Yes	Yes	Yes	Yes	Yes
10. Appropriate statistical analysis used	No	No	No	Yes	No
Quality scoring	4/10	6/10	4/10	7/10	5/10

Game-based solutions

A summary of the game-based solutions is presented in Table 3. The interventions focusing on TKA patients used the Nintendo Wii Fit™²⁰ and GenuSport^21,22 systems, whereas the intervention for the THA patients used the Dr. Kawashima's Brain Training: How Old Is Your Brain? game.^17,18 The intervention using the Nintendo Wii Fit balance board included body-controlled games included in the Wii Fit package. The games the intervention patients engaged with targeted lateral weight shifting, multidirectional balance, and static and dynamic postural control. The Dr. Kawashima's Brain Training: How Old Is Your Brain? game used in the other intervention reported across two studies is designed and developed for the purpose of cognitive activation. The game is played using a handheld Nintendo DS console. The GenuSport application included two selectable modes with two different games. The game is played using a handheld tablet while the knee trainer (GenuSport Knietrainer) is positioned directly under the knee.

Table 3.

A Description of the Interventions

Authors	Study design	Participants	Intervention(s)	Comparison
Brem et al (2010)¹⁸	Prospective, nonblinded, controlled longitudinal study	Intervention group: 16 patients who have undergone THA, mean age 66 (SD 9) years, 6 males, 10 females Control group: 16 patients, mean age 69 (SD 14) years, 6 males, 10 females	≥35-Minute daily play of Dr. Kawashima's Brain Training: How Old Is Your Brain? (in-game exercises of their choice) up to 9 days postoperation	No gameplay, care as usual
Fung et al (2012)²⁰	Preliminary RCT	50 Patients who have undergone TKA receiving twice weekly physiotherapy for postoperation rehabilitation, mean age 68 (SD 11) years, 17 males, 33 females Intervention group: 27 participants Control group: 23 participants	15 Minutes of Wii Fit™ gaming activity in addition to and following regularly scheduled 60-minute physiotherapy sessions (e.g., games targeting lateral weight shifting, multidirectional balance, and static and dynamic postural control)	15 Minutes of bilaterally provided lower extremity exercises (balance, posture, weight shifting, and strengthening) in addition to and following regularly scheduled physiotherapy sessions
Lehrl et al (2012)¹⁷	Prospective, nonblinded, controlled, and randomized study	Intervention group: 16 patients who have undergone THA, mean age 66 (SD 9) years, 6 males, 10 females Control group: 16 patients, mean age 69 (SD 14) years, 6 males, 10 females	30-Minute daily play of Dr. Kawashima's Brain Training: How Old Is Your Brain?	No gameplay, care as usual
Hardt et al (2018)²¹	Prospective, nonblinded, controlled, and randomized study	Intervention group: 33 patients who have undergone TKA, mean age 66 (SD 9) years, 15 males, 18 females Control group: 27 patients, mean age 69 (SD 10) years, 11 males, 16 females	The app-based program consists of a knee trainer and an app called GenuSport. Real-time visual feedback was given continuously. One training session last ∼5 minutes. Average 18.4 training sessions	No gameplay, care as usual
Bäcker et al (2021)²²	Prospective, nonblinded, controlled, and randomized study	Intervention group: 15 patients who have undergone TKA, mean age 63 (SD 8) years, 6 males, 9 females Control group: 20 patients, mean age 66 (SD 11) years, 8 males, 12 females	The app-based program consists of a knee trainer and an app called GenuSport. Real-time visual feedback was given continuously. One training session last ∼5 minutes.	No gameplay, care as usual

RCT, randomized controlled trial; SD, standard deviation; THA, total hip arthroplasty; TKA, total knee arthroplasty.

Regarding dosing, each study has distinct characteristics (Table 3). The Dr. Kawashima's Brain Training: How Old Is Your Brain? game took place over 9 days using the game daily for 30–35 minutes.^17,18 Nintendo Wii Fit games took place daily until the participant was discharged from physiotherapy services using the game daily for 15 minutes.²⁰ In addition, GenuSport^21,22 gaming activities were provided for 6 weeks to be used daily for three to five times.

Intervention effects

All study designs included a control condition with treatment as usual. Study results are summarized in Table 4. As the measured outcomes in the reviewed studies varied, no accumulated knowledge from several studies on any one outcome variable could be reported. A summary of Cohen's d values is presented in Table 5.

Table 4.

Outcome Measures and Author-Reported Results of the Included Studies

Authors	Outcome measures	Results
Brem et al (2010)¹⁸	Working memory capacity (including information processing, length of memory span); fluid intelligence (working memory capacity assigned to a Gaussian distribution of mental performance); HRQoL; Neuroticism–Extraversion–Openness–Five Factor Inventory; Patient-Reported Outcomes Scale; Mood (including pain)	Fluid intelligence (P = 0.006), working memory capacity (P = 0.004), and rate of information processing (P = 0.03) increased statistically significantly for the intervention group. However, there was a clear difference between the intervention and control groups already at prior point of measurement with the intervention group showing better results.
Fung et al (2012)²⁰	Active ROM of the knee; 2-minute walk test; Numeric Pain Rating Scale; LEFS; ABCS; length of outpatient rehabilitation; patient satisfaction	No statistically significant differences were found in Active Knee Flexion (P = 0.951), Active Knew Extension (P = 0.492), 2-minute walk test (P = 0.855), Numeric Pain Rating Scale (P = 0.115), ABCS (P = 0.523), LEFS (P = 0.079). No statistically significant differences were found in the length of outpatient rehabilitation and patient satisfaction (P = 0.201).
Lehrl et al (2012)¹⁷	Harris Hip score; Merle d'Aubigné score	Harris Hip scores increased statistically significantly for the intervention group (P = 0.041). No statistically significant differences were found in the Merle d'Aubigné scores (P = 0.312).
Hardt et al (2018)²¹	Active and passive ROM; KOOS; KSS; Knee extension strength; TUG test; 30-s Chair Stand Test; VAS of pain; 10-minute walk test (m/s)	KOOS ADL (P = 0.037), KSS knee (P < 0.001), KSS function (P = 0.011), 10-minute walk test (P = 0.032), and ROM (P = 0.034) increased and VAS pain at rest (P = 0.01) and at motion (P = 0.002) decreased statistically significantly for the intervention group. More training correlated with better health outcomes.
Bäcker et al (2021)²²	KOOS; KSS; Pain killer intake; VAS of pain; 10-minute walk test (m/s)	10-Minute walk test (P = 0.029) increased and VAS pain at rest and activity (P < 0.05) decreased statistically significantly for the intervention group. There was no statistically significant difference in KOOS and KSS. Less painkillers were needed in the intervention group (10% vs. 26.7%).

ABCS, Activity-specific Balance Confidence Scale; ADL, activities of daily living; KOOS, Knee Injury and Osteoarthritis Outcome Score; KSS, Knee Society Score; LEFS, Lower Extremity Functional Scale; ROM, range of motion; TUG, Timed “Up and Go”; VAS, Visual Analogue Scale; HRQoL, health-related quality of life.

Table 5.

Effect Size of Each Studied Outcome

Authors	Outcome measures	Intervention group, mean (SD)	Control group, mean (SD)	P	Cohen's d
Hardt et al (2018)²¹	KOOS pain (%)	56.0 (14.0)	50.0 (18.0)	n.s.	0.37
Bäcker et al (2021)²²	KOOS pain (%)	56.0 (12.3)	53.2 (11.3)	n.s.	0.24
Hardt et al (2018)²¹	KOOS symptoms (%)	62.0 (15.0)	58.0 (13.0)	n.s.	0.29
Bäcker et al (2021)²²	KOOS symptoms (%)	61.7 (13.9)	63.1 (9.1)	n.s.	−0.13
Hardt et al (2018)²¹	KOOS activities (%)	54.0 (17.0)	42.0 (17.0)	0.037	0.71
Bäcker et al (2021)²²	KOOS activities (%)	54.6 (15.1)	51.0 (9.8)	n.s.	0.29
Hardt et al (2018)²¹	KOOS sport (%)	10.0 (12.0)	5.0 (8.0)	n.s.	0.50
Bäcker et al (2021)²²	KOOS sport (%)	9.5 (10.4)	8.1 (8.1)	n.s.	0.16
Hardt et al (2018)²¹	KOOS QoL (%)	30.0 (17.0)	26.0 (14.0)	n.s.	0.26
Bäcker et al (2021)²²	KOOS QoL (%)	26.7 (10.2)	30.8 (10.0)	n.s	−0.40
Hardt et al (2018)²¹	KSS function	45.0 (13.0)	37.0 (16.0)	0.011	0.55
Bäcker et al (2021)²²	KSS function	43.3 (12.4)	42.6 (10.4)	n.s.	0.06
Hardt et al (2018)²¹	KSS knee	73.0 (10.0)	59.0 (15.0)	0.0005	1.08
Hardt et al (2018)²¹	Pain at rest	2.0 (1.0)	4.0 (2.0)	0.01	−1.24
Bäcker et al (2021)²²	Pain at rest	2.7 (0.8)	3.6 (1.6)	0.033	−1.00
Hardt et al (2018)²¹	Pain in motion	4.0 (1.0)	5.0 (1.0)	0.002	−1.00
Bäcker et al (2021)²²	Pain in motion	4.0 (1.3)	5.1 (1.2)	0.021	−0.83
Fung et al (2012)²⁰	Pain	4.7 (2.2)	4.4 (1.9)	n.s.	0.15
Hardt et al (2018)²¹	10-Minute walk test (m/s)	0.6 (0.3)	0.5 (0.2)	0.032	0.50
Bäcker et al (2021)²²	10-Minute walk test (m/s)	19.7 (7.8)	27.1 (15.5)	0.029	−0.58
Fung et al (2012)²⁰	2-Minute walk test	87.7 (40.0)	90.4 (43.9)	n.s.	−0.06
Hardt et al (2018)²¹	Active ROM (°)	78.0 (12)	67.0 (18.0)	0.038	0.71
Bäcker et al (2021)²²	Active ROM (°)	70.9 (1.22)	77.2 (12)	n.s.	−0.52
Fung et al (2012)²⁰	Active knee flexion (°)	92.9 (15.6)	93.1 (17.5)	n.s.	−0.01
Fung et al (2012)²⁰	Active knee extension (°)	174.0 (.8)	174.0 (6.0)	n.s.	0.00
Hardt et al (2018)²¹	Passive ROM (°)	85.0 (11.0)	84.0 (11.8)	n.s.	0.09
Bäcker et al (2021)²²	Passive ROM (°)	83.7 (10.4)	87.3 (5.3)	n.s.	−0.46
Hardt et al (2018)²¹	Circumference (cm)	47.0 (4.5)	48.0 (5.5)	n.s.	−0.20
Bäcker et al (2021)²²	Circumference (cm)	46.7 (4.3)	49.0 (7.1)	n.s.	−0.38
Hardt et al (2018)²¹	GenuSport strength	17.3 (5.3)	14.9 (5.6)	n.s.	0.44
Hardt et al (2018)²¹	TUG test (s)	17.8 (8.2)	26.6 (17.1)	n.s.	−0.64
Hardt et al (2018)²¹	CHAIR STAND TEST (n)	2.2 (1.8)	2.4 (1.9)	n.s.	−0.07
Lehrl et al (2012)¹⁷	Harris Hip score	76.5 (4.5)	60.9 (14.1)	0.041	1.49
Lehrl et al (2012)¹⁷	Merle d'Aubigné	15.8 (1.8)	13.4 (3.1)	n.s.	0.95
Fung et al (2012)²⁰	ABCS	63.2 (25.2)	64.6 (23.0)	n.s.	−0.06
Fung et al (2012)²⁰	LEFS	31.8 (15.2)	35.4 (14.4)	n.s.	−0.24

ABCS, Activity-specific Balance Confidence Scale; LEFS, Lower Extremity Functional Scale; QoL, Quality of Life; ROM, range of motion; SD, standard deviation; TUG, Timed “Up and Go” test.

Functional performance

Compared with standard care, game-based solutions showed significant difference in the Knee Society Score (KSS) Knee and the 10-minute walk test with a moderate to large effect size.^21,22 In addition, game-based solutions showed significant difference in the intensity of pain at rest and in motion^21,22 and the Harris Hip score with a large effect size.¹⁷ In the study of Hardt et al, the number of training sessions correlated with less pain at rest (P < 0.001) and in motion (P < 0.001).²¹ Compared with standard care, however, game-based solutions showed no significant difference in the painkiller intake.²²

Compared with standard care, game-based solutions showed no significant difference in the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain and symptoms with small effect size.^21,22 In addition, game-based solutions showed no significant difference in the circumference,^21,22 CHAIR STAND TEST,²¹ GenuSport strength,²¹ and the TUG test.²¹ In the study of Hardt et al, however, the number of training sessions correlated with the TUG results (P < 0.001) and strength (P = 0.0011).²¹ Compared with standard care, game-based solutions showed no significant difference in the KOOS sport or quality of life with small to moderate effect size.^21,22 In addition, game-based solution²⁰ showed no significant difference in the Activity-Specific Balance Confidence Scale²³ or Lower Extremity Functional Scale²⁴ scores. In the study of Hardt et al, however, the number of training sessions correlated with the KOOS sport (P = 0.008).²¹

Compared with standard care, game-based solutions showed conflicting results on KOOS activities of daily living (ADL), KSS function, and active and passive ROM with small to large effect size.^21,22 In the study of Hardt et al, however, the number of training sessions was found to correlate with the KOOS ADL (P = 0.02) and KSS function (P = 0.01).²¹

Cognitive performance

Compared with standard care, game-based solution showed significant difference in working memory (P = 0.004), fluid intelligence (P = 0.006), and the rate of information processing (P = 0.03).¹⁸ Compared with standard care, however, game-based solution showed no significant difference in the Merle d'Aubigné test.¹⁷

Discussion

The rigorous literature screening process resulted in five RCTs where game-based solutions had been used to improve functional and cognitive performance of patients with TKA/THA. The amount of research obtained thus indicates that the use of game-based solutions in the rehabilitation of TKA/THA patients is not yet common and research in the area is scarce. Thus, there is unexplored potential for game-based solutions in the treatment of this specific patient group. Future research in the area will, however, most likely be conducted, as suggested by the RCT study protocol published by Negus et al,²⁵ which will examine the effectiveness of Nintendo Wii Fit in home-based rehabilitation after TKA, and the pilot study by Ling et al,²⁶ which investigated the usability of Kinect-based exergames in THA patients.

The quality assessment of the studies indicated that the quality of the research in the area is moderate or weak. The reviewed studies lacked, for example, in blinding and reporting details of the study settings. Gamification and game research in general,⁷ and in health contexts specifically,⁸ have been noted to often lack controlled study settings or to not meet high-quality standards. Similarly, common methodological problems in the field include short intervention periods and a low number of intervention participants.⁸ These are clear points of development for future research in game-based solutions for TKA/THA patients and for gamification of health and health games research in general.

The interventions in the reviewed studies were all based on commercially available videogame solutions. Research on health games and gamification delivered via commercial videogames is beneficial from the perspective that the used game solutions are available for purchase, and thus, private individuals or institutions can more easily take advantage of the research and given game solutions than of solutions custom-made for the purposes of the research.⁸ However, from the perspective of research on the game-based solutions, using commercial games is problematic as such games are complex systems with a multitude of affordances and interactions affecting the user and the gameplay.²⁷ This complicates the identification of what actually are the aspects of the game-based solution that engage the user, have the motivational effects, and lead to the positive results.^7,8

In terms of game technologies, future research is encouraged to take further advantage of the motion capturing or body-controlled gaming technologies for the given patient group. Only one study utilizing such gaming technology was identified in this review,²⁰ even though prior research has indicated that the motion capturing, or body-controlled gaming technologies can be beneficial, for example, with rehabilitative balance and gait training.²⁸ The potential benefits for TKA/THA patients are further supported, for example, by findings of Su, who reports on development and effectiveness of a Kinect-based exercise game for rehabilitation of TKA patients.²⁹

The study suggests that the gaming systems can support the motivation of TKA patients to engage in rehabilitation exercises and thus lead to positive physical outcomes. Furthermore, various sensor technologies present another avenue for employing game-based solutions to rehabilitation of TKA/THA patients, as indicated by the work of Qiu et al, in which a smart knee sleeve enhanced with sensors is used as the input device for a rehabilitation game for patients who have undergone TKA.³⁰

More nuanced research on the types of game-based solutions used is important also for increasing understanding of the needs of specific target groups. Demographic and personality differences in perceptions of gamification have been noted to exist,^8,14 and research exploring the effects of game-based solutions, for example, for older adults, who form the main target group of TKA/THA operations, is still its infancy.¹³ Older adults have been found, however, to be interested in health gamification technology due to its advantages such as possibilities for activity tracking and being rewarded for activities.¹¹ To understand the specific motivational needs of older adults, especially in health contexts, and how to address these via game-based solutions, more research is needed in the area.

This review is limited in terms of the generalizability of its results due to the low number of studies included in the study. Furthermore, only RCTs were included in this review. This has excluded research reports describing study protocols or more preliminary phases of research from this work.

Conclusion

Game-based solutions are gaining interest in the field of rehabilitation of TKA/THA patients, but research in this area is still very much in its infancy. Based on preliminary research, game-based solutions have potential to induce positive impact on functional performance; however, due to the low number of studies and moderate/weak quality of existing research, the area still lacks assertive evidence. Future research should pay attention to the methodological aspects, such as careful RCT planning, sufficient intervention duration, and enough intervention participants, to provide reliable information on the use of game-based solutions in the given context.

Footnotes

Acknowledgment

The authors wish to acknowledge Informational Specialist Sirpa Grekula from the Oulu University Medical Library.

Authors' Contributions

M.M.J. and J.K. contributed equally to this study. M.M.J.: Study design, study implementation, data analysis, data interpretation, drafting, and critical revision. J.K.: Study implementation, data analysis, data interpretation, drafting, and critical revision. Both authors were accountable for the final version of the article.

Author Disclosure Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding Information

The research was performed in the project “An Intelligent Customer-driven Solution for Orthopedic and Pediatric Surgery Care,” which was funded by Business Finland, a Finish funding agency, for 2018–2021 (grant number: 409/31/2018).

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