A Biofeedback-Enhanced Virtual Exergame for Upper Limb Repetitive Motor Tasks

Upper Limb (UL) Rehabilitation in Multiple Scle- rosis (MS) is an open research field due to the complex interplay between cognitive and physical dysfunctions. Virtual Reality (VR) can face such an issue by enriching physical training with engaging features, including biofeedback strategies to self- regulate autonomic functions according to the visualisation of indices like heart rate variability (HRV). In the present work, HRV biofeedback is introduced in a VR-based exergame (a game designed to promote exercising), tailored to rehabilitation of the dominant upper limb in Persons with MS (PwMS). The exergame is based on a dual-task paradigm, integrating a UL motor rehabilitative task with a breathing task. The aim is to investigate how the design developed for the HRV biofeedback affects engagement and performance during the exergame session. As a preliminary study, sixteen able-bodied subjects are tested in a within-subjects design, to assess the quality of the game features and design, before approaching MS patients. Two conditions are presented, with and without biofeedback. The proposed HRV biofeedback has two possible levels, depending on whether or not the desired respiratory rate of six breaths/min is successfully maintained. It is used to control game elements and change difficulty of the session. The main finding of this study is that biofeedback improves both user performance and experience in healthy subjects. These results underline the great potential of this technique to promote engagement. Thus, they point to fostering the rehabilitative effectiveness of repetitive motor tasks and encouraging adherence to the long- term training. Future studies will encompass fine tuning of the experimental setup and include PwMS to further adjust the game to patients' needs and observe the setup compliance to rehabilitation settings.