Survey On Available Solutions and Their Validation

Received 26 August 2022, accepted 21 September 2022, date of publication 28 September 2022, date of current version 7 October 2022.
Digital Object Identifier 10.1109/ACCESS.2022.3210562
Visualization and Interaction Technologies in

Serious and Exergames for Cognitive Assessment
and Training: A Survey on Available Solutions
and Their Validation
CHIARA BASSANO, MANUELA CHESSA , (Member, IEEE), AND FABIO SOLARI
Department of Informatics, Bioengineering, Robotics, and Systems Engineering, University of Genoa, 16126 Genoa, Italy
Corresponding author: Manuela Chessa (manuela.chessa@unige.it)
This work was supported in part by the Interreg ALCOTRA Projects PRO-SOL We-Pro under Grant 4298, and in part by PRO-SOL Senior
under Grant 4128.
ABSTRACT Exergames and serious games, based on standard personal computers, mobile devices and
gaming consoles or on novel immersive Virtual and Augmented Reality techniques, have become popular
in the last few years and are now applied in various research fields, among which cognitive assessment
and training of heterogeneous target populations. Moreover, the adoption of Web based solutions together
with the integration of Artificial Intelligence and Machine Learning algorithms could bring countless advan-
tages, both for the patients and the clinical personnel, as allowing the early detection of some pathological
conditions, improving the efficacy and adherence to rehabilitation processes, through the personalisation of
training sessions, and optimizing the allocation of resources by the healthcare system. The current work pro-
poses a systematic survey of existing solutions in the field of cognitive assessment and training. We evaluate
the visualization and interaction technologies commonly adopted and the measures taken to fulfil the need
of the pathological target populations. Moreover, we analyze how implemented solutions are validated, i.e.
the chosen experimental designs, data collection and analysis. Finally, we consider the availability of the
applications and raw data to the large community of researchers and medical professionals and the actual
application of proposed solutions in the standard clinical practice. Despite the potential of these technologies,
research is still at an early stage. Although the recent release of accessible immersive virtual reality headsets
and the increasing interest on vision-based techniques for tracking body and hands movements, many studies
still rely on non-immersive virtual reality (67.2%), mainly mobile and personal computers, and standard
gaming tools for interactions (41.5%). Finally, we highlight that although the interest of research community
in this field is increasingly higher, the sharing of dataset (10.6%) and implemented applications (3.8%)
should be promoted and the number of healthcare structures which have successfully introduced the new
technological approaches in the treatment of their host patients is limited (10.2%).
INDEX TERMS Augmented reality, cognitive assessment, cognitive training, exergames, human-computer
interaction, interaction technologies, serious games, virtual reality, visualization technologies.
I. INTRODUCTION have started developing and validating new solutions, based

The technological evolution we have witnessed in the recent on serious games (SGs) and exergames (EGs). SGs are digital
years has led to important advances in many research fields, applications designed for a primary purpose other than pure
among which cognitive assessment and training. Researchers entertainment, as education, information, enhancement of
cognitive and physical functions. They usually emulate activ-
The associate editor coordinating the review of this manuscript and ities of daily living (school lessons, doing the shopping, doing
approving it for publication was Charalambos Poullis . housework, exploring environments) and indirectly assess
This work is licensed under a Creative Commons Attribution 4.0 License. For more information, see https://creativecommons.org/licenses/by/4.0/
VOLUME 10, 2022 104295
C. Bassano et al.: Visualization and Interaction Technologies in Serious and Exergames for Cognitive Assessment and Training
participants cognitive functions during gameplay. EGs are RQ2 Among the available interaction techniques, from
videogames which rely on technologies that track body move- touchful (e.g., mice and keyboards, touchscreens
ments and imply a form of physical exercise, as emulating a and controllers) to touchless (e.g., vision, sensors or
sport, playing an instrument, exercise or do racing. Advan- voice based), which are the most adopted solutions?
tages of using SGs and EGs for the ecological assessment Although the wide diffusion of gaming tools, during
and the rehabilitation of cognitive functions are disparate. the years, was there a rising interest on the search of
Firstly, gamification allows to indirectly evaluate patients alternate solutions?
avoiding causing stress and frustration, which could affect RQ3 In consideration of their eventual adoption in the
results of standard tests. Moreover, they ensure the creation standard clinical practice, how developed solu-
of safe, controlled, standardized settings and a strict control tions are actually validated? Moreover, given the
over experimental conditions and stimulus delivery. Besides, increased number of systems published per year,
thanks to the integration of different sensors, it is possible have we assisted, in parallel, to a growth in the num-
to record different measurements, useful for the assessment ber of available data and finally, subjects/patients
of patients’ cognitive and motor skills and the monitoring of effectively using such solutions?
their well-being state, behaviour and improvements. In the following sections, we first describe the adopted pro-
Another fundamental advantage is the possibility to cre- cedure to gather data (Section II), then we consider the differ-
ate personalized training sessions: in order to be effective ent technologies available for visualisation (Section III) and
and engaging, training difficulty has to match patient abil- interaction (Section IV), their core features, potentials and
ity and to avoid a ceiling effect [1]. Training personaliza- actual application. We then focus on the validation process,
tion approaches usually employ two main strategies, i.e. task in particular on the experimental designs currently adopted
difficulty adaptation (22.6%) and regulation of the training to test proposed solutions (Section V-A) and the way data
session duration (0.9%), which are crucial factors especially are collected and analysed, also considering the application of
when training sessions are self-administered without supervi- ML algorithms for predicting the onset of certain pathological
sion, as home rehabilitation applications. In particular, stan- conditions (Section V-B). Lastly, we evaluate the availability
dard multiple level applications still represent the preferred of proposed frameworks and datasets (Section V-C) and the
solution (21.3%). Access to a higher level is often bound effective adoption of SGs and EGs based solutions by health-
to the achievement of a certain score, accuracy or number care structures.
of consecutive correct trials or to the acquirement of certain
motor and cognitive abilities [2], [3], [4], [5], [6], [7], [8], II. PROCEDURE
[9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], The current survey is the result of a systematic search that
[20], [21], [22], [23], [24] and, sometimes, inadequate per- we conducted in several high profile databases, i.e. PubMed,
formance can lead to a negative level adjustment [25], [26], Scopus, Web of Knowledge and Science Direct, using the
[27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], search string
[38], [39], [40], [41], [42]. Alternative solutions include the (assessment OR training) AND ((cognitive AND (VR OR
use of AI techniques, as case-based algorithms [43], ontology AR OR serious game OR exergame OR WebGL OR AI))
based models [44], or open learner models [45], or giving OR ((memory OR attention OR executive functions) AND (VR
the therapists [46], [47], [48] and the patients [17], [49], [50] OR AR OR serious game OR exergame)))
the permission to intervene in the difficulty level selection. We included only articles written in English, both
Otherwise, difficulty adjustments can be done real-time, dur- peer-reviewed journal articles and conference proceedings or
ing gameplay, by modifying game parameters according to workshops and excluded abstracts, editorial, book chapters
players performance [51], [52], [53]. and review articles and we excluded articles for which full
The purpose of our review is to provide an analysis of the text was not available for our University. Finally, due to the
advancements of research on SGs and EGs applied to the constantly evolving nature of the technologies considered, the
cognitive assessment and training conjointly with the devel- search was limited to the period 2016 to the present. After
opment of new technologies for visualization and interaction, the first search and selection phase, summarized in Fig. 1,
i.e. Virtual Reality (VR) and Augmented Reality (AR) [54], we have selected 235 works (N = 235, in the following N
platforms for game deployment, i.e. mobile, computer, con- denotes the number of the works for the considered specific
soles and Web platforms, and Artificial Intelligence (AI). topic), including 197 journal articles, 38 conference proceed-
Specifically, this review addresses the following research ings and workshop articles.
questions: Papers included in this survey propose methodologies for
RQ1 Among the different visualization techniques, the cognitive training (N = 151), assessment (N = 83) or both
from non-immersive (e.g., monitor-based) to fully (N = 1) of heterogeneous target populations: elderly and age
immersive (e.g., head-mounted displays) methods, related diseases patients (N = 110); subjects with long term
which are the most adopted solutions? During the acquired disabilities caused by different pathological condi-
years, was there a rise in the use of immersive VR tions, as stroke, cancer, MS, epilepsy, traumatic and acquired
and AR devices? brain injuries (N = 32), or drugs and alcohol abuse (N = 5);
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to record responses and track participants performance over

time [55]. Considering the level of immersion provided,
VR setups can be classified in three main categories, non-
immersive, semi-immersive and immersive. Non-immersive
systems are based on the use of screens (computers, mobile
devices, monitors and projectors). The VE is presented to the
users without occluding their Field of View (FOV), hence,
even if they feel involved and engaged in the task, the sense of
being in the real world while interacting with the virtual one
persists. Semi-immersive virtual experiences provide users
with a partial VE through the use of drive simulators or mul-
tiple screens. Sense of presence is moderate, since they will
still give the perception of being in a different reality, while
remaining connected to the physical surroundings. Finally,
immersive systems concern room-filling technologies, such
FIGURE 1. Flow diagram of the search and selection phase. as the CAVE1 or the CAREN High End,2 and head-mounted
displays (HMDs), both standalone and tethered, e.g. the Ocu-
lus3 or the Vive4 products. They completely occlude partic-
ipants FOV enhancing the sense of being physically present
in the VE. Moreover, they often include tracking systems,
which, on the one hand, are essential for the correct func-
tioning of the system, while, on the other hand, can provide
additional information on users movements and behaviour
inside the VE.
As shown in Table 2, non-immersive VR is still the most
diffused visualization technology (N = 150), followed by
FIGURE 2. Publications involving the different visualization technologies
immersive VR (N = 59), despite the recent success of VR
over the last five years. HMDs and the release of more affordable and perform-
ing devices, and despite its benefits, in terms of multisen-
people suffering of psychiatric, neurological and emotional sory stimulation, tracking of the head and body movements
disorders (N = 26); children and adolescents with learning, and higher sense of presence. The minor interest towards
social and cognitive impairments (N = 29); visually impaired semi-immersive VR systems (N = 4) can be justified by their
patients (N = 2). All reported studies aim at the imple- high cost and by the fact that they require an adequate space
mentation of solutions based on new interactive technologies for installation and assistance during task execution.
as a substitute or complementary tool to standard physio- The preference towards non-immersive VR may be par-
therapy, occupational or pharmacological therapy, in order tially explained by the fact that these technologies are acces-
to improve patients autonomy, cognitive functions and gen- sible, affordable and portable, which make them ideal for
eral well-being. Around two third of selected works adopt remote use and home rehabilitation applications. Moreover,
SGs (N = 173), whereas less explored alternatives are EGs target populations mainly include children or adolescents
(N = 25), the computerized version of the classic tests (CT, (N = 10) and adults (N = 14), who are used to these tech-
N = 27) or a combination of SGs and EGs (N = 9) and SGs nologies, or elderly (N = 25), who can more handily manage
and CTs (N = 1). a computer or a tablet rather than a headset for immersive
During the categorization and data extraction phase, arti- VR. Home rehabilitation applications are usually videogames
cles were classified considering the visualization and inter- smoothly accessible through Web platforms (N = 25) or
action technologies used as well as the chosen validation playing games directly installed on the devices (N = 24),
approaches, adopting the taxonomy further illustrated in owned by the participants or provided by the experimenter.
Table 1. The majority of works found are based on non-immersive
VR: PC (N = 20), mobile (N = 14), both (N = 8) or console
III. VISUALISATION TECHNOLOGIES (N = 5).
Our search highlights a strong interest in VR technologies Even if studies focusing on the comparison of immer-
(N = 223), which has become increasingly higher in the last sive and non-immersive solutions exist, results are not
few years, see Fig. 2. The popularity of VR is due to its ability
to reproduce realistic and ecologically valid two-dimensional 1 http://www.visbox.com/products/cave/
or three-dimensional objects and virtual environments (VE) 2 https://knowledge.motekmedical.com/product/carenhigh-end/
the user can interact with, while allowing to precisely 3 https://www.oculus.com/experiences/
control test administration and stimulus presentation, 4 https://www.vive.com/us/
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TABLE 1. Categories used for the classification of articles.
conclusive and strongly depend on the target population and

on the task. Performance in assessing cognitive functions
are usually comparable, whereas preference and usability of
HMDs seem to be more consistent, in terms of increased
motivation, more intuitive action control and greater enjoy-
ment associated with task fulfillment. However, these stud-
ies are often conducted on young subjects, hence, even if
results may encourage the use of immersive VR for the
assessment and treatment of emotional or neurological dis-
orders, they cannot be easily generalized to the senior popu-
lation. In [55], researchers specifically address this problem FIGURE 3. Publications involving the different interaction technologies
over the last five years.
and investigate the effect of the level of immersion (desk-
top screen and HMD) on seniors and young adults perfor-
mance in a virtual supermarket shopping task. While young even if VR outperforms AR in the immediate post-training
adult group score remains stable regardless of the platform test, AR is better suitable for long-term spatial memory
used, seniors’ scores are superior in the non-immersive case, transfer [58]. Nonetheless, physical displacements have been
even if their experiences do not differ between the two plat- shown to be important in acquiring spatial ability skills [59].
forms and only minimal and rare side effects are reported. Solutions combining non-immersive VR and AR technolo-
Moreover, in both groups, trial execution with the HMD gies also exist. Authors in [60] design a tool for screening
seems to be more influenced by fatigue. Opposite results are initial dementia: participants visit a virtual cultural relic exhi-
obtained by authors in [56], who demonstrate that a higher bition and have to complete a test while visiting the exhibition
level of immersion can significantly improve inhibitory con- by scanning the answer’s code shown on a ‘‘cognitive board’’
trol and task switching. Similarly, in [57] two different with a mobile phone.
games to train attention and working memory in children
with Attention-Deficit/Hyperactivity Disorder (ADHD) in IV. INTERACTION TECHNOLOGIES
two modes, immersive and non-immersive, are developed and Interaction is another important factor to consider when
tested on healthy subjects. Electroencephalography (EEG) designing applications in which participants can benefit from
signals and gameplay data are recorded and analyzed as a active learning and are asked to perform a specific task, which
measure of participants’ cognitive abilities and temporal cog- requires to interact with the VE. Thus, intuitive interfaces
nitive ability changes. Better results are associated to the should be promoted, in order to reduce learning time and
immersive trials. optimize the effects of the training. However, the choice of
A less explored alternative to VR is AR (N = 10), which the solution to be adopted is frequently bound to some con-
integrates digital and physical information in real-time and straints, since all target populations exhibit cognitive and/or
allows the user to interact with virtual and real worlds and physical impairments, which should be taken into account
objects at the same time. AR related articles have been during the design phase and the choice of the proper inter-
classified in two overarching categories, i.e. trigger versus face. Moreover, around half of the studies analysed address
view-based augmentation, see Table 2. As shown in Fig. 2, older adults, who are less experienced with Information and
our search reveals an increasingly higher interest in trig- Communication Technologies (ICTs), may have expectations
ger based AR solutions, which include applications for AR strictly anchored to mental models developed in their past
see-through headsets and for mobile devices in which mark- experiences with certain tools and could lack some basic
ers, body movements and locations are used to initiate the knowledge required to effectively interact with the techno-
augmentation. logical solutions proposed.
A comparison of the effect of VR and AR spatial memory Interaction modalities can be mainly classified in touchful
training on short-term and long-term memory, has shown that, and touchless, as shown in Table 3. In the first case, the user
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TABLE 2. Classification of articles based on the visualisation technologies and devices.
is required to handle a device and apply a physical pressure frustration. This explains the increased interest of researchers
to a surface to trigger events. Whereas, in the second case, over the year in the development of vision-based solutions,
no physical interaction with the device is needed. This cat- although to a lesser extent than touchless solutions, as shown
egory includes both different approaches for body posture in Fig. 3. Less explored alternative are eye tracking (N = 2)
and hand gesture detection and tracking, such as movement, and EEG (N = 9) based interfaces. Eye tracking is used to
electromyography (EMG) and vision-based techniques, and monitor students with autism spectrum disorders (ASD) dur-
interfaces exploiting gaze or brain activation through eye ing the interaction with their educators and to help direct their
trackers and wearable EEGs. attention [234]. Whereas portable EEG devices are employed
Touchful devices comprise the widely diffused tools to create Brain-Computer Interfaces (BCI), where signals
for gaming (N = 181) and physiotherapic devices (N = detected by the EEG are translated into inputs in the applica-
17), e.g. treadmills, cycle-ergometers and pressure sensi- tion. These BCI are designed with the aim of training atten-
tive plates, which are particularly suitable for rehabilitation and concentration in pre adolescents [84] or ADHD [94],
tion programs aimed at improving motor skills in subjects anxiety disorder [51] or Mild Cognitive Impaired (MCI) [73]
with age-related disorders [15], [50], [89], [95], [112], [147], patients.
[148], [149], [150], [204], [209], major neurocognitive disor- A minority of studies explores other solutions, namely ver-
ders (MNCD) [23], stroke [116], [152] and multiple sclero- bal (N = 18) and robot-based (N = 6) interaction. In the
sis (MS) [22] patients. In general, touchful interfaces ensure first case, the user is usually asked to watch a video [64],
stability, reliability and effectiveness. Nonetheless, although [153], observe a scenario [47], [203] or navigate a city [68],
the low ICT education level of some subjects, mice and key- [71], [86], [223] or a maze [199] and recall elements, pick
boards have been widely used since the last century and can up and correctly place objects in a house [193], [201],
be considered familiar tools. Hence, they represent the most solve problems by thinking aloud [78], [229], recall a list
common solution for interaction with a growing interest over of items before buying them [173], [218], listen to a list of
the years, see Fig. 3. However, as interaction is achieved by words and recall them [83], respond to visual or auditory
pressing buttons and triggers or sliding fingers on a touch- targets [217]. The second case includes hand end-effector
pad, which are not natural hand gestures, the transfer of robotic devices [24], exoskeleton gait robots [116], [152] and
skills acquired during training to daily life activities could be humanoid robots, programmed to substitute therapists during
questionable. test administration and provide adequate feedback. For exam-
Touchless approaches are often referred to as ecological, ple, in [134] Pepper humanoid robot administer a music mem-
as they are designed in order to reuse existing skills, through ory based game, requiring MCI patients to recognise songs
intuitive gestures requiring a little cognitive effort. Moreover, from the years they were younger; in [96] Pepper adminis-
they potentially allow for nearly unlimited input options, ters and shows the final score of a MoCA-like psychometric
as they theoretically could exploit all the 27 DOFs of the assessment; in [126] a tablet is mounted on a Lego robot
human hand. However, they often present interaction and that moves its arms and legs when the activity is correctly
tracking challenges, as they are prone to occlusion, noisy completed.
reconstruction and noisy artifacts, which undermine both A classification of articles based both on the interaction
their intuitiveness and their stability and efficiency, causing and visualization technologies used is shown in Table 4.
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V. VALIDATION
A. EXPERIMENTAL DESIGN AND DATA ANALYSIS
As highlighted by Fig. 4, games for training are usually
validated using three main experimental designs, i.e. within
subjects (N = 61), between subjects (N = 27) and ran-
domized control trial (RCT, N = 39). While in the former
case, all participants follow the same training procedure,
in the latter cases, they are divided in groups and asked
to follow two different training procedures, usually the tra-
ditional one and the videogame-based one, and results are
FIGURE 4. Experimental designs commonly used to validate the proposed
solutions based on the intervention goal, e.g. training, assessment or compared. Test-retest reliability is often used for validation
both. and is obtained by administering standard validated pencil-
and-paper tests at different moment of the training sched-
ule, namely before, after and follow-up. Similarly, games
In addition to the choice of the interaction technology, for cognitive assessment are usually validated using a within
researchers must pay particular attention to the graphic design subjects experimental design (N = 48) or comparing healthy
of the interface. As participants could suffer from visual control (HC) with patients (N = 25) or young and elderly
and hearing problems or have troubles with attention, visual healthy subjects (N = 2), whereas a between subjects exper-
scenes have to be as simple as possible and search space imental design is only used by [224] to compare different
should be reduced. During gameplay, simple and immedi- visualization technologies (immersive and non-immersive).
ate data as a countdown timer, the number of remained In general, participants are asked to play the game, and
chances to guess an answer, the current score or achieved their performance is correlated with the results of standard
goals are often shown to incentive the subject to answer pencil-and-paper tests. High correlations suggest the con-
as quickly and accurately as possible [3], [14], [17], [19], struct validity of the proposed solution, which could become
[20], [22], [24], [26], [28], [29], [30], [31], [33], [38], [39], an alternative to standard assessment methods with the advan-
[40], [41], [44], [49], [50], [52], [53], [72], [73], [80], [84], tage of allowing for ecological assessment in a controlled
[97], [98], [100], [101], [107], [110], [116], [121], [125], environment.
[126], [131], [132], [133], [138], [139], [143], [151], [162],
[165], [180], [192], [210], [212], [213], [232], [233]. More-
over, because of memory impairments, cues and instructions
should be repeatedly provided using redundant channels and
different modalities, while increasing signal strength of mes-
sages, especially warnings, and reducing sources of noise.
For example, in some applications, therapists, automated
audio-visual messages or machine learning agents commu-
nicate with the patient by displaying and/or verbally provid-
ing comprehensive instructions [29], [46], [91], [166], [209],
[233]. Immediate feedback after actions can also be useful,
as it could help the users knowing when they succeeded or FIGURE 5. Number of participants involved in the experimental sessions
over the last five years.
failed and why, recognizing their errors, recovering strategies,
reducing their frustration and increasing their motivation.
To this purpose, multimodal feedback are often provided, The increasing number of participants involved in the
through congratulation messages, hints or events, like objects experimental sessions, as shown in Fig. 5 can be an indi-
disappearing if correctly selected or sounds of clapping hands cator of the research community’s interest and efforts to
to highlight the correctness of a given answer [4], [5], [6], develop solutions for cognitive assessment and training as
[13], [20], [41], [43], [50], [58], [60], [107], [113], [126], well as the level of progress towards actual practical appli-
[134], [163], [209], [211], [212], [213]. Finally, since the cation in standard clinical practice. In fact, even if studies
benefits of cognitive training might only be noticed in the presenting new prototypes, applications at an initial develop-
long term, healthy competition is greatly appreciated as it can ment phase and user tests, which usually involve less than
positively affect patients psychological well-being and pro- 20 participants, are common (N = 77), there is an increasing
mote social networking. To this aim, authors can opt for the number of works that describe solutions at the validation
implementation of rewards systems, which allow patients not phase, which typically involve a larger number of partici-
only to be aware of their performance and progresses but also pants (N = 158). Representative samples in combination with
to share their results with their friends [237], or multiplayer large sample sizes are fundamental indexes when the goal
platforms stimulating competition, as multiplayer racing is collecting informative data and extending the results of a
games [140]. research.
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TABLE 3. Classification of articles based on the interaction technologies and devices.
B. DATA COLLECTION AND ANALYSIS

During experimental sessions lots of heterogeneous data can
be collected, however, as highlighted by Fig. 6, interest is
often mainly focused on gameplay data and standard cog-
nitive test results. Gameplay scores and parameters or log
data are recorded for the evaluation of performance and
the monitoring of user actions in the VE. These scores are
usually compared with standard cognitive pencil-and-paper
tests results or, rarely, with performance obtained in real
life tasks. In recent years, authors have become more inter-
ested in using a user-centered design approach, and validated FIGURE 6. Data collected during experimental sessions over the last five
years. ’Other’ includes observation from the experimenters and
questionnaires on usability, presence, workload or simulation behavioural data.
sickness have emerged as key tools. Behavioural, observa-
tional, physiological and kinematic data, useful to monitor
patients motor skills, task workload and the possible onset of of pathological and non pathological subjects, in particu-
negative side effects when using a certain technology, instead, lar concerning age related diseases [79], [86], [115], [130],
have always been poorly exploited, although recordings can [196], [208] and ADHD [188]. Since some pathological
be easily acquired using non-invasive methods, which do not conditions can take long periods before being actually diag-
interfere with task execution or reduce sense of presence. nosed with the means currently available, an early diagno-
For example, vision based approaches, as motion tracking sis through prediction methods allows to intervene promptly,
systems and cameras, can provide kinematic information on preventing or limiting the onset of severe symptoms and
body movements, postures and gait, while wearable sensor, debilitating conditions. Digital biomarkers, i.e. kinematics
e.g. armbands, bracelets or EEG headsets, allow to obtain data, gameplay, clinical and neuropsychological data, can
physiological measurements, as heart rate, skin conductance be used for the creation of predictive models for the iden-
or brain activation signals. tification of MCI pathological patterns [220], for scoring
Table 5 proposes a classification of articles based on the elderly brain’s ability [201] or for the clinical developmental
goal of the intervention, the experimental design, the acquired assessment of preschooler [138]. Authors in [143] use Rein-
data and the number of participants, which summarizes the forcement Learning to train bots to generate synthetic data
previously reported results. plausibly emulating a large population of players, at various
In some cases, data acquired during gameplay are used stages of learning, or conversely, various levels of cognitive
in combination with ML techniques for the classification decline. Subsequently a prediction model is applied to new
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TABLE 4. Classification of articles based on the visualization and interaction technologies and devices.
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TABLE 5. Classification of articles based on the aim of the study, the experimental design, the data acquired and the number of participants.
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TABLE 5. (Continued.) Classification of articles based on the aim of the study, the experimental design, the data acquired and the number of participants.
TABLE 6. Classification of the articles according to the practical usability of SGs and EGs in healthcare structures and research centres.
gameplay data to classify different levels of play. These exam- would be very important for the research community and
ples suggest the feasibility of the adoption of ML techniques for the medical doctors. Dataset is sometimes made explic-
in biomedical applications where the number of patients is itly available online [49], [215] or from the corresponding
small, symptoms could be non-homogeneous and the com- author on reasonable request because of privacy policies,
plexity of the setting can be challenging. In other cases, ethical or proprietary constraints [10], [15], [19], [23], [30],
ML techniques are adopted for runtime analysis of data. [34], [44], [60], [78], [80], [108], [110], [113], [115], [121],
In [47] two supervised algorithms, namely random forest [137], [153], [174], [176], [209], [214], [216], [218]. More-
and support vector machine, analyse verbal and non-verbal over, excluding commercial and proprietary applications,
input. Outputs are employed both for the classification of MS we can still find free download [65], [81], [100], [123], [185],
and Parkinson Disease subjects and for the recognition and open source [78] and freely accessible Web applications [21],
automatic verification of the given verbal answers. Authors [30], [107].
in [78] develop a multi-label classification model for driven Finally, considering the effective use of proposed solutions
automatic assessment to track and assess the cognitive and with pathological subjects, patients involved in the experi-
emotional states of individuals with ASD during VR-based mental sessions usually have a diagnosed disease and are
training. In [99] authors describe the implementation and recruited from hospitals, clinics, community-dwelling, spe-
efficacy of a linear regression model for the assessment of cialized day care centers or retirement homes. This implies a
intrinsic motivation and performance using Big Five person- collaboration between these structures and research groups,
ality traits values (openness to experiences, conscientious- however the nature of this collaboration nor the duration
ness, extraversion, agreeableness, and emotional stability). is often unclear, even if specialized research centers having
stable and long-lasting collaborations with health facilities
C. AVAILABILITY AND EFFECTIVE CLINICAL APPLICATION exist (12.3%). For this reason, it is difficult to understand the
Authors frequently do not explicitly share information about practical feasibility and usability in hospitals, rehabilitation
the availability of raw data and applications used, though this centers and daycare centers of the methodologies proposed.
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Nonetheless, as reported in Table 6, we could find some clin- kinematic (5.1%) data are employed by a minority of
ics (10.2%), which have successfully integrated the new tech- the works, although they can be easily recorded through
nological approaches in the treatment of their host patients. non-invasive methods and could provide additional objective
quantitative information on the pathological conditions, per-
VI. CONCLUSION formance and workload. Moreover, we highlight an increas-
The current survey aims at providing an analysis of the ing interest over the years in the development of validated
research on SGs and EGs for the assessment and training applications aiming at becoming a standard in the clinical
of cognitive dysfunctions related to different pathological practice, since the majority of proposed solutions have been
conditions, conjointly with technological advancements in tested on a number of participants between 20 and 60 (37.9%)
visualization and interaction technologies, platform for game or higher than 60 (29.4%). However, the number of sub-
deployment and AI, in the last five years. After the first search jects/patients effectively using such solutions and their actual
and selection phase conducted in high profile databases, adoption by healthcare structures (10.2%) or research cen-
we categorized articles and extracted data according to the ters having stable and long-lasting collaborations with health
classification shown in Table 1. facilities (12.3%) is still limited. Although results are promis-
Considering RQ1, the analysis of the visualization tech- ing and literature is rich, the exchange and sharing of data and
nologies highlights a greater and increasingly higher inter- applications within the large community of researchers and
est in VR (94.9%), in particular non-immersive (67.2%) and medical professionals is limited. In fact, datasets are some-
immersive VR (28.5%), than AR (4.3%). The diffusion of times available online (0.9%) or can be obtained from the
non-immersive with respect to immersive VR, although the corresponding author on reasonable request (9.8%), whereas
recent success and widespread diffusion of immersive VR implemented applications are rarely freely accessible, i.e.
HMDs, may be justified by the affordability and portability Web applications (1.3%), free downloaded (2.1%) and open
of PCs and mobile devices, their accessibility and easiness source (0.4%), by hampering a real impact of the research
of use, even in absence of supervision, which make them works.
particularly suitable for home rehabilitation and applications
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reality-based training system to promote spatial visualization ability for FABIO SOLARI is an Associate Professor with
the elderly,’’ Universal Access Inf. Soc., vol. 18, no. 2, pp. 327–342,
the Department of Informatics, Bioengineering,
Jun. 2019.
Robotics, and Systems Engineering, University
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tive map development and wayfinding performance with immersive aug-
of Genoa, Italy. His research interests include
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Oct. 2021, Art. no. 101432. develop computational models of vision process-
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L. Zuniga, ‘‘Towards the improvement of ADHD children through aug- ments for natural interaction and ecological visual
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Eng. Educ. Conf. (EDUCON), Apr. 2018, pp. 843–848.
Open Access funding provided by ‘Università degli Studi di Genova’ within the CRUI CARE Agreement
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Survey On Available Solutions and Their Validation

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Received 26 August 2022, accepted 21 September 2022, date of publication 28 September 2022, date of current version 7 October 2022.

Digital Object Identifier 10.1109/ACCESS.2022.3210562

Visualization and Interaction Technologies in

I. INTRODUCTION have started developing and validating new solutions, based

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to record responses and track participants performance over

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TABLE 1. Categories used for the classification of articles.

conclusive and strongly depend on the target population and

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TABLE 2. Classification of articles based on the visualisation technologies and devices.

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TABLE 3. Classification of articles based on the interaction technologies and devices.

B. DATA COLLECTION AND ANALYSIS

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