TECHNOLOGY AND DEVELOPMENT
Game-based balance training in rehabilitation
Development and clinical evaluation of a sensor-based game application for device-based balance training for the rehabilitation of balance disorders as part of a clinical feasibility study
Jakob Tiebel
Health Business Consultant
Balance training is an integral part of rehabilitative care. This study by Simsek and Kutlu investigates how an existing training system can be supplemented with sensor-based game applications to influence patients’ training perception.
Publication context and objective
The paper by Simsek and Kutlu was published in October 2025 in the journal Medical Engineering & Physics. It describes the development and clinical trial of a sensor-supported, game-based training system for the rehabilitation of balance disorders. The starting point of the work is the established role of balance training in orthopaedic and neurological rehabilitation and the assumption that visual feedback and gaming elements can support patients’ therapy adherence and motivation level. At the same time, the authors point out the high costs of many existing feedback systems and formulate the goal of investigating a technically simple and economically practicable solution.
THERA-Trainer balo as an established balance training system
The THERA-Trainer balo was used as a therapy device. It is a medical device established in clinical practice for static and dynamic balance training. The mechanical structure of the device was not changed in the study. The balo served as a physical training base on which the subjects performed balance exercises while standing.
Sensors and game application
The actual development involved a game application based on the additional sensor module. The patient’s movements and weight shifts were recorded via the microcontroller-operated sensor system. This data was transferred in real time to a game environment developed in Unity, where it controlled the movement of an avatar. The aim was to translate balance movements directly into visual feedback and to combine the training with clearly defined target tasks.
Clinical application and study design
The clinical application was carried out with a total of 36 patients with orthopaedic and neurological balance disorders. The training protocols comprised several sessions of standardised duration. The difficulty of the exercises and the resistance of the platform were individually adapted to the age, state of health and performance ability of the patients. The focus of the study was not on objective changes in balance performance, but rather on subjective aspects of training perception.
Therapeutic effect is not achieved through game mechanics alone – it is achieved through the precise coordination of movement, feedback and clinical objectives.
Motivation as the primary endpoint
The Intrinsic Motivation Inventory was used for the evaluation. The results show that a large proportion of participants perceived the training as enjoyable and motivating. Over 90 per cent of patients stated that they found the system appealing, and almost all respondents saw a potential benefit for their rehabilitation process. The authors interpret these findings as an indication that game-based, goal-orientated feedback can support acceptance and willingness to participate in balance training.
Categorisation of the results
In the discussion, the authors emphasise that the system was developed at a comparatively low cost compared to many existing feedback solutions. At the same time, they refer to clear inter-individual differences in the training values, which are related to age, clinical picture, severity of restriction and physical performance, among other things. This variability is expected and typical for clinical populations with impairments in postural control.
Limitations and outlook
The short observation period and the lack of long-term functional outcome parameters are cited as limitations of the study. Based on the available data, it is not possible to draw any conclusions about the long-term improvement in balance or the reduction in the risk of falling. The authors therefore view the work as an investigation into the feasibility of such goal-orientated, game-based extensions.
Comments
The paper presents a feasibility study in which a THERA-Trainer balo, an established balance training device, was enhanced to include visual play feedback via the external sensor module. The results indicate a high level of acceptance and increased motivation among patients with balance disorders, but do not enable any conclusions to be drawn about clinical efficacy in the narrower sense. The article therefore fits in well with the growing literature on game-based feedback systems in rehabilitation and provides an example of how existing training platforms can be technically extended and systematically analysed.
However, it should be critically noted that the technological entry barrier for the development of game-based systems is comparatively low today. Modern game engines such as Unity or Unreal facilitate the development of interactive, visually appealing applications with a manageable use of resources. The mere implementation of a game or game-like interface is therefore not the main challenge. There is a danger of underestimating the development effort for therapeutic games with a one-sided focus on motivation, acceptance and technical feasibility.
In a rehabilitative context in particular, game mechanics not only need to be entertaining, but also need to be tailored to therapeutic objectives and specific movement patterns. Motivation alone is not a sufficient criterion for therapeutic benefit. Rather, the focus is on targeted movement control, the quality of movement execution and the support of motor learning – requirements that cannot be derived directly from classic game design principles. They require a close intermeshing of therapeutic expertise, motor learning research and technical implementation.
Adaptive elements such as the sensitive adaptation of level of difficulty to the individual performance level or the integration of reward and progression mechanisms are particularly demanding. Such systems must avoid over- and underchallenging users in order to support effective learning processes without creating frustration or undue stress. These requirements go far beyond conventional game design and explain why the development of high-quality therapeutic games remains complex, time-consuming and resource-intensive despite the availability of technical frameworks.
Against this background, the chosen focus on feasibility and acceptance makes sense, but falls short if it is not clearly distinguished from questions of therapeutic effectiveness and the quality of movement control. The study provides valuable information on technical feasibility and user acceptance, but should not be misunderstood as evidence that game-based rehabilitation is primarily a technological or motivational problem. The central challenge lies in the demanding task of translating between game mechanics and therapy – and this is precisely where the clinical and economic value of such systems is ultimately decided.
The paper presents a feasibility study in which a THERA-Trainer balo, an established balance training device, was enhanced to include visual play feedback via the external sensor module. The results indicate a high level of acceptance and increased motivation among patients with balance disorders, but do not enable any conclusions to be drawn about clinical efficacy in the narrower sense. The article therefore fits in well with the growing literature on game-based feedback systems in rehabilitation and provides an example of how existing training platforms can be technically extended and systematically analysed.
However, it should be critically noted that the technological entry barrier for the development of game-based systems is comparatively low today. Modern game engines such as Unity or Unreal facilitate the development of interactive, visually appealing applications with a manageable use of resources. The mere implementation of a game or game-like interface is therefore not the main challenge. There is a danger of underestimating the development effort for therapeutic games with a one-sided focus on motivation, acceptance and technical feasibility.
In a rehabilitative context in particular, game mechanics not only need to be entertaining, but also need to be tailored to therapeutic objectives and specific movement patterns. Motivation alone is not a sufficient criterion for therapeutic benefit. Rather, the focus is on targeted movement control, the quality of movement execution and the support of motor learning – requirements that cannot be derived directly from classic game design principles. They require a close intermeshing of therapeutic expertise, motor learning research and technical implementation.
Adaptive elements such as the sensitive adaptation of level of difficulty to the individual performance level or the integration of reward and progression mechanisms are particularly demanding. Such systems must avoid over- and underchallenging users in order to support effective learning processes without creating frustration or undue stress. These requirements go far beyond conventional game design and explain why the development of high-quality therapeutic games remains complex, time-consuming and resource-intensive despite the availability of technical frameworks.
Against this background, the chosen focus on feasibility and acceptance makes sense, but falls short if it is not clearly distinguished from questions of therapeutic effectiveness and the quality of movement control. The study provides valuable information on technical feasibility and user acceptance, but should not be misunderstood as evidence that game-based rehabilitation is primarily a technological or motivational problem. The central challenge lies in the demanding task of translating between game mechanics and therapy – and this is precisely where the clinical and economic value of such systems is ultimately decided.
Jakob Tiebel
Health Business Consultant
Jakob Tiebel is OT and studied applied psychology with a focus on health economics. He has clinical expertise from his previous therapeutic work in neurorehabilitation. He conducts research and publishes on the theory-practice transfer in neurorehabilitation and is the owner of an agency for digital health marketing.
References:
- Simsek, O. S., & Kutlu, M. (2025). Goal-oriented balance rehabilitation system for balance disorder. Medical Engineering & Physics, 144, Article 104386. https://doi.org/10.1016/j.medengphy.2025.104386
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