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arxiv: 2605.17841 · v1 · pith:S5ZJNGKInew · submitted 2026-05-18 · 💻 cs.HC

A Collaborative Rehabilitation-Exercise Serious Game for People with Stroke and their Caregivers: A Pilot Study

Elizabeth D. Vasquez , Jonathan Siskind , Marion S. Buckwalter , Maarten G. Lansberg , Sean Follmer , Allison M. Okamura This is my paper

Pith reviewed 2026-05-20 09:43 UTC · model grok-4.3

classification 💻 cs.HC
keywords serious gamesstroke rehabilitationcollaborative gamingcaregiver exercisemotivation and affectpedal input devicepilot studyhuman-computer interaction
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The pith

Collaborative rehab game with pedal input trends toward higher motivation for stroke patients and caregivers

A machine-rendered reading of the paper's core claim, the machinery that carries it, and where it could break.

The paper introduces a serious game that pairs wrist rehabilitation movements for people recovering from stroke with seated marching exercise for their informal caregivers. One player controls an avatar through arm motions useful for stroke recovery while the other uses pedals or a keyboard to perform the march exercise, and they play together in collaborative or competitive modes. A pilot test with six healthy pairs acting as pseudo-patients and pseudo-caregivers found trends of higher interest scores for the caregiver player when using the pedal rather than the keyboard, plus higher positive affect and competence scores for the patient-role player when the partner used the pedal in collaborative play. These patterns suggest that exercise-based controls can make the shared activity more engaging for both roles at once. The work addresses the linked problems of low motivation for patient therapy and caregiver burnout after stroke.

Core claim

We present a collaborative, mutually beneficial, serious game designed to support therapy for persons with stroke and also exercise for their informal caregivers. One player performs rehabilitative wrist movements and the other performs a seated march exercise via pedals or a keyboard to control their avatar. While not statistically significant, we find that PCGs Interest subscale scores trended higher when using a pedal compared to a keyboard, regardless of game play mode. PPSs' positive affect scale scores and Competence subscale scores trended higher when their partner played collaboratively with a pedal compared to a keyboard. These trends encourage future work toward incorporating an e

What carries the argument

Collaborative serious game in which one avatar is controlled by wrist rehabilitation movements and the other by seated march exercise performed on pedals or keyboard

If this is right

  • Exercise-based input such as a pedal can raise interest scores for the caregiver-role player regardless of game mode.
  • Collaborative play with pedal input can raise positive affect and competence scores for the stroke-role player.
  • Future rehabilitative serious games should explore exercise-based devices to support players with different movement abilities.
  • The approach can simultaneously address movement therapy needs for stroke survivors and exercise needs for informal caregivers.

Where Pith is reading between the lines

These are editorial extensions of the paper, not claims the author makes directly.

  • Directly linking caregiver physical activity to patient rehab sessions could reduce long-term caregiver burnout by making support activities mutually beneficial.
  • Running the same game with actual stroke patients and their family caregivers could produce larger or differently patterned effects once real impairments and relationships are involved.
  • The same paired control mechanic could be adapted for other family or partner activities such as shared fitness tracking or dual therapy tasks.
  • Adding performance feedback or adaptive challenges based on each player's movements might strengthen the motivational trends already observed.

Load-bearing premise

Trends observed in six healthy dyads using assigned pseudo roles will generalize to real stroke patients and their informal caregivers, and the chosen questionnaire subscales will adequately capture motivation and emotional experience in this setting.

What would settle it

A larger study with actual stroke patients and real caregivers that measures no increase or a reversal in Interest, positive affect, or Competence scores when the caregiver player uses pedal input instead of keyboard.

Figures

Figures reproduced from arXiv: 2605.17841 by Allison M. Okamura, Elizabeth D. Vasquez, Jonathan Siskind, Maarten G. Lansberg, Marion S. Buckwalter, Sean Follmer.

Figure 1
Figure 1. Figure 1: Solo Mode: Solo player game mode is shown [PITH_FULL_IMAGE:figures/full_fig_p002_1.png] view at source ↗
Figure 2
Figure 2. Figure 2: Game System: Collaborative game mode is shown with the exercise input device used by the PCG on the left and the rehabilitative input device used by the PPS on the right. Balloons appear according to four randomized sinusoids of the form: x = A sin(2π · f · z) where x is the horizontal position, A is the amplitude of the sine wave, f is the frequency of the sinusoid (fixed at 0.08), and z is the depth into… view at source ↗
Figure 3
Figure 3. Figure 3: Study protocol: The study consists of four blocks. Each block is 8 trials, and each trial is 30 seconds long. The pedal and keyboard PCG input devices were counter balanced across participants. device – they preferred for themselves and which condition they thought their partner preferred. Before and after each block, participants completed the Intrinsic Motivation Inventory (IMI) [12] and Positive and Neg… view at source ↗
Figure 5
Figure 5. Figure 5: PPS Positive and Negative Affect Schedule: PPSs scores trended toward more positive emotions when PCGs played with the pedal in both play conditions. As shown in [PITH_FULL_IMAGE:figures/full_fig_p004_5.png] view at source ↗
Figure 4
Figure 4. Figure 4: PCG Positive and Negative Affect Schedule: PCG scores trended toward more positive emotions and fewer negative emotions in the pedal than keyboard input device when playing Solo Mode. This was reversed in Collaborative Mode [PITH_FULL_IMAGE:figures/full_fig_p004_4.png] view at source ↗
Figure 6
Figure 6. Figure 6: PCG Intrinsic Motivation Inventory: PCG scores trended toward slightly higher Interest when using the pedal than the keyboard in both game modes. Competence and Tension inversely related to game modes. Statistical significance is shown with an asterisk. As shown in [PITH_FULL_IMAGE:figures/full_fig_p005_6.png] view at source ↗
read the original abstract

Motivation to perform movement therapy and caregiver burnout are major challenges to post-stroke life. Serious games have been shown to support therapeutic tasks in people with stroke, but there are few activities that simultaneously support informal caregiver health, which is also impacted post-stroke. Here, we present a collaborative, mutually beneficial, serious game designed to support therapy for persons with stroke and also exercise for their informal caregivers. One player performs rehabilitative wrist movements - useful to people with stroke - and the other performs a seated march exercise - useful to informal caregivers - via pedals or a keyboard to control their avatar. We present a pilot study with 6 healthy dyads to evaluate how exercise-based input of one player, the Pseudo Caregiver (PCG), impacts motivation and emotional experience in both the PCG and Pseudo Person with Stroke (PPS). While not statistically significant, we find that PCGs Interest subscale scores trended higher when using a pedal (the exercised-based input) compared to a keyboard, regardless of game play mode. PPSs' positive affect scale scores and Competence subscale scores trended higher when their partner played collaboratively with a pedal compared to a keyboard. These trends encourage future work toward incorporating an exercise-based device, such as a pedal, to enhance the emotional and motivational experience of rehabilitative serious games for people with different movement ability levels.

Editorial analysis

A structured set of objections, weighed in public.

Desk editor's note, referee report, simulated authors' rebuttal, and a circularity audit. Tearing a paper down is the easy half of reading it; the pith above is the substance, this is the friction.

Referee Report

2 major / 2 minor

Summary. The manuscript presents a collaborative serious game for post-stroke rehabilitation and informal caregiver exercise, with one player performing wrist movements and the other a seated march via pedal or keyboard input. A pilot study with 6 healthy dyads (acting as Pseudo Person with Stroke and Pseudo Caregiver) reports non-significant trends: higher PCG Interest subscale scores with pedal input regardless of mode, and higher PPS positive affect and Competence scores when the partner uses a pedal in collaborative mode. The authors conclude these trends support future incorporation of exercise-based devices in rehabilitative serious games for varying movement abilities.

Significance. If validated in the target population, the mutually beneficial collaborative design could meaningfully address therapy adherence and caregiver burnout, a novel contribution to serious games in HCI and health. The work provides preliminary empirical data on input device effects on motivation and affect, with credit due for the pilot implementation and focus on dual-player benefits. However, the small sample and proxy participants limit the immediate significance to hypothesis generation rather than established findings.

major comments (2)
  1. The central claim that the observed trends 'encourage future work' for people with stroke rests on data from 6 healthy dyads simulating roles, yet the manuscript provides no validation step, literature support, or discussion of how subscale responses (Interest, positive affect, Competence) might differ under actual motor deficits, fatigue, or caregiving load. This proxy mismatch is load-bearing for generalizability to the stated motivation of post-stroke therapy and caregiver health.
  2. Abstract and Pilot Study description: Results are reported only as non-significant 'trends' with n=6 and no mention of power analysis, exact statistical tests performed, effect sizes, or baseline comparisons, which weakens the evidential basis for interpreting directional differences between pedal and keyboard conditions.
minor comments (2)
  1. Clarify the definitions and distinctions between the game play modes referenced in the abstract, and how they were counterbalanced with input device conditions.
  2. Provide more detail on the specific questionnaire instruments and subscales, including any prior validation in rehabilitation or collaborative gaming contexts.

Simulated Author's Rebuttal

2 responses · 0 unresolved

We thank the referee for their constructive feedback on our pilot study manuscript. We have carefully considered the major comments and provide point-by-point responses below, along with planned revisions to address the concerns.

read point-by-point responses

  1. Referee: The central claim that the observed trends 'encourage future work' for people with stroke rests on data from 6 healthy dyads simulating roles, yet the manuscript provides no validation step, literature support, or discussion of how subscale responses (Interest, positive affect, Competence) might differ under actual motor deficits, fatigue, or caregiving load. This proxy mismatch is load-bearing for generalizability to the stated motivation of post-stroke therapy and caregiver health.

    Authors: We recognize that the proxy participant design is a key limitation for generalizability, as noted in the manuscript's framing as a pilot study. To strengthen the paper, we will expand the Discussion section to include literature support on the use of proxy measures in stroke rehabilitation research and explicitly discuss potential differences in motivation and affect under real motor impairments and caregiving burdens. This will better contextualize the trends as hypothesis-generating for future studies with the target population. revision: yes

  2. Referee: Abstract and Pilot Study description: Results are reported only as non-significant 'trends' with n=6 and no mention of power analysis, exact statistical tests performed, effect sizes, or baseline comparisons, which weakens the evidential basis for interpreting directional differences between pedal and keyboard conditions.

    Authors: We agree that more detailed statistical reporting is warranted even in a pilot study. In the revision, we will specify the statistical tests employed, report effect sizes, and include a statement on the lack of power analysis given the exploratory design with small n. Baseline comparisons will be added if not already present. We maintain that the non-significant trends are appropriately described as such due to the sample size. revision: yes

Circularity Check

0 steps flagged

No circularity: purely empirical pilot study with direct questionnaire observations

full rationale

The paper reports a small-scale user study with 6 healthy dyads, collecting questionnaire responses on subscales like Interest, positive affect, and Competence. No mathematical derivations, model fits, predictions, or self-citation chains appear in the provided text or abstract. All reported trends are direct empirical observations rather than outputs derived from prior inputs or self-referential definitions. The work is self-contained as an exploratory pilot without load-bearing theoretical steps that reduce to their own assumptions.

Axiom & Free-Parameter Ledger

0 free parameters · 1 axioms · 0 invented entities

The central observations rest on the validity of standard psychological scales (Interest/Enjoyment, Positive Affect, Competence) to measure the intended constructs in a game setting, and on the assumption that healthy participants can adequately simulate the motor and motivational experiences of stroke patients and caregivers.

axioms (1)
  • domain assumption Standard validated questionnaires accurately capture motivation and emotional experience for this population and activity.
    The study interprets subscale scores as direct indicators of interest, positive affect, and competence without additional validation in the stroke-caregiver context.

pith-pipeline@v0.9.0 · 5798 in / 1289 out tokens · 50659 ms · 2026-05-20T09:43:48.078134+00:00 · methodology

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Reference graph

Works this paper leans on

15 extracted references · 15 canonical work pages

  1. [1]

    A critical review of the concept of patient motivation in the literature on physical rehabilitation,

    N. Maclean and P. Pound, “A critical review of the concept of patient motivation in the literature on physical rehabilitation,”Social Science & Medicine (1982), vol. 50, no. 4, pp. 495–506, 2000

    work page 1982

  2. [2]

    Home-based technologies for stroke rehabilitation: A system- atic review,

    Y . Chen, K. T. Abel, J. T. Janecek, Y . Chen, K. Zheng, and S. C. Cramer, “Home-based technologies for stroke rehabilitation: A system- atic review,”International Journal of Medical Informatics, vol. 123, pp. 11–22, 2019

    work page 2019

  3. [3]

    Increasing the Motivation to Train Through Haptic Social Interaction – Pilot study,

    A. Nehrujee, E. Ivanova, S. Srinivasan, S. Balasubramanian, and E. Burdet, “Increasing the Motivation to Train Through Haptic Social Interaction – Pilot study,” inInternational Conference on Rehabilitation Robotics (ICORR), 2023

    work page 2023

  4. [4]

    The use of game modes to promote engagement and social involvement in multi-user serious games: A within-person randomized trial with stroke survivors,

    F. Pereira, S. Berm ´udez i Badia, C. Jorge, and M. S. Cameir ˜ao, “The use of game modes to promote engagement and social involvement in multi-user serious games: A within-person randomized trial with stroke survivors,”Journal of NeuroEngineering and Rehabilitation, vol. 18, no. 1, 2021

    work page 2021

  5. [5]

    Balancing the playing field: Collaborative gaming for physical train- ing,

    M. Mace, N. Kinany, P. Rinne, A. Rayner, P. Bentley, and E. Burdet, “Balancing the playing field: Collaborative gaming for physical train- ing,”Journal of NeuroEngineering and Rehabilitation, vol. 14, no. 1, 2017

    work page 2017

  6. [6]

    Towards customizable games for stroke rehabilitation,

    G. Alankus, A. Lazar, M. May, and C. Kelleher, “Towards customizable games for stroke rehabilitation,” inProceedings of the SIGCHI Con- ference on Human Factors in Computing Systems. Association for Computing Machinery, 2010, pp. 2113–2122

    work page 2010

  7. [7]

    The Global Prevalence of Anxiety and Depressive Symptoms Among Caregivers of Stroke Survivors,

    A. Z. Loh, J. S. Tan, M. W. Zhang, and R. C. Ho, “The Global Prevalence of Anxiety and Depressive Symptoms Among Caregivers of Stroke Survivors,”Journal of the American Medical Directors Association, vol. 18, no. 2, pp. 111–116, 2017

    work page 2017

  8. [8]

    A population-based assessment of the impact and burden of caregiving for long-term stroke survivors,

    C. S. Anderson, J. Linto, and E. G. Stewart-Wynne, “A population-based assessment of the impact and burden of caregiving for long-term stroke survivors,”Stroke, vol. 26, no. 5, pp. 843–849, 1995

    work page 1995

  9. [9]

    Caregiving in the context of ethnicity: Hispanic caregiver wives of stroke patients,

    E. M. O. Garcia, “Caregiving in the context of ethnicity: Hispanic caregiver wives of stroke patients,” Ph.D. dissertation, University of California, Irvine, 1999

    work page 1999

  10. [10]

    Rehabilitation of grasping and forearm pronation/supination with the haptic knob,

    O. Lambercy, L. Dovat, H. Yun, S. K. Wee, C. Kuah, K. Chua, R. Gassert, T. Milner, C. L. Teo, and E. Burdet, “Rehabilitation of grasping and forearm pronation/supination with the haptic knob,” in IEEE International Conference on Rehabilitation Robotics, 2009, pp. 22–27

    work page 2009

  11. [11]

    Effects of a 12-week marching in place and chair rise daily exercise intervention on ADL and functional mobility in frail older adults,

    Y . Kato, M. M. Islam, D. Koizumi, M. E. Rogers, and N. Takeshima, “Effects of a 12-week marching in place and chair rise daily exercise intervention on ADL and functional mobility in frail older adults,” Journal of Physical Therapy Science, vol. 30, no. 4, pp. 549–554, 2018

    work page 2018

  12. [12]

    On the factorial and construct validity of the Intrinsic Motivation Inventory: conceptual and operational concerns,

    D. Markland and L. Hardy, “On the factorial and construct validity of the Intrinsic Motivation Inventory: conceptual and operational concerns,” Research Quarterly for Exercise and Sport, vol. 68, no. 1, pp. 20–32, 1997

    work page 1997

  13. [13]

    Development and validation of brief measures of positive and negative affect: The PANAS scales,

    D. Watson, L. A. Clark, and A. Tellegen, “Development and validation of brief measures of positive and negative affect: The PANAS scales,” Journal of Personality and Social Psychology, vol. 54, no. 6, pp. 1063– 1070, 1988

    work page 1988

  14. [14]

    Inclusion of Other in the Self Scale and the structure of interpersonal closeness,

    A. Aron, E. N. Aron, and D. Smollan, “Inclusion of Other in the Self Scale and the structure of interpersonal closeness,”Journal of Personality and Social Psychology, vol. 63, no. 4, pp. 596–612, 1992

    work page 1992

  15. [15]

    Social-Cultural Factors in the Design of Technology for Hispanic People with Stroke,

    E. D. Vasquez, A. M. Okamura, and S. Follmer, “Social-Cultural Factors in the Design of Technology for Hispanic People with Stroke,” 2022, arXiv:2203.08889. [Online]. Available: https://arxiv.org/abs/2203.08889

    work page arXiv 2022