Deploying Serious Games for Cognitive Rehabilitation

Round 1

Reviewer 1 Report

This paper is an interesting job in the field of serious gaming. First, the authors underline the need for patients who suffer from cognitive rehabilitation to exercise themselves safely in their own homes, a demand that became stronger during the pandemic. For this purpose, the authors suggest creating open-source digital products that can allow access to a virtual environment through which such patients can exercise and recover their abilities in the shortest possible time. Next, the authors describe their Methodology to create low-cost solutions that exercise the patients and provide the doctors with valuable information. The developed system requires a mobile or fixed device with access to the web. Then, the doctor or therapist offers a set of exercises according to the type and severity of the patient’s cognitive deficit. Finally, the authors suggest three exercises for cognitive rehabilitation, “solving a puzzle,” “connect the dots,” and “Key turning in the lock” based on VR techniques. However, the paper needs some more work to reveal its scientific value.

Abstract

I would recommend some improvements in this section to provide only the vital information to the readers. Such information is the field, the research gap, the methodology, the results, and the implications. Each piece of information does not need more than one or two sentences.

Introduction

An introduction section is necessary to provide important information about the field and the problem to be solved (research gap), and what the authors suggest for solving this problem. Therefore, I strongly recommend the authors structure this section in this way. I will underline the need to say what you are suggesting clearly. Is it a methodology or a tool? The rest text of this section could be moved to the related work section. In addition, a small paragraph that describes the paper’s structure could be added here.

Related Work

I have the feeling that also this section does not fulfill its purpose. Maybe the authors could use subsections, ending with the use of this theory in their work.

Although the authors provide some info about similar efforts in a different type of rehabilitation, I would suggest some more content, especially if similar apps exist. Maybe a table with these apps and your own with their features to identify differences.

The Proposed Methodology

I think the title of this section could be just Methodology. I would also suggest some more information about how you designed these apps and a timeline.

Discussion

I think this is not a discussion section but a results section. Therefore, you need to discuss the paper in another section. The discussion section follows the structure of the related work section, describing how the authors used the theory in their research and if the implementation was successful. Moreover, they also need to discuss the research implications and limitations.

Author Response

Reviewer #1

Dear reviewer,

   All the authors would like to thank you for your positive comments on our work and your suggestions, which have greatly improved our work's quality.
We have highlighted all modified contents in red.

We describe below the actions taken in correspondence with your valuable indications:

• We carried out a significant revision of the entire article, correcting the critical points you highlighted.
• We have extended the abstract by collecting your suggestions and providing a more balanced presentation of our work to the reader.
• We have expanded the introduction to provide more background for the reader, hopefully clarifying we introduced a methodology.
• We have expanded the Related Works section.
  The changes made to this section and to the Introduction section, we guess will make our research more comprehensible 
• We have renamed the Section “The proposed system architecture” with the title “The system architecture” and improved the contents.
• We have modified the “Discussion” section. First of all, we have changed the title to "Implementing the case studies" as these represent examples of the methodology we present in the article.
  To make the examples more meaningful and accessible, we have expanded the content and inserted significant portions of code. 

Reviewer 2 Report

This submission is very well written and very well organized. The authors describe what appears to be a functional, flexible platform for delivering distributed assessments through gaming and gaming technologies. Their background section is solid and their description of the architecture reasonably clear. One concern is the lack of discussion of limitations, for instance, if a given patient does not have a VR headset for a task what are options, and indeed when would a VR headset truly be needed vs. when would it be fun but overkill for the rehabilitative need.

This reviewer's main question is whether or not it is publishable work. The paper comes across as a promotion for their platform. There is a description of three tasks but there are no data supporting the use of, benefit from, or impacts of their platform.

Author Response

Reviewer #2

Dear reviewer,

   All the authors would like to thank you for your positive comments on our work and your suggestions, which have greatly improved our work's quality.
We have highlighted all modified contents in red.

Briefly we describe you the global modification carried out:
 

• We carried out a significant revision of the entire article.
• We have extended the abstract providing a more balanced presentation of our work to the reader.
• We have expanded the introduction to provide more background for the reader, clarifying we introduced a methodology.
• We have expanded the Related Works section.
  The changes made to this section and to the Introduction section, we guess will make our research more comprehensible.
• We have renamed the Section “The proposed system architecture” with the title “The system architecture” and improved the contents.
• We have modified the “Discussion” section.
  We have changed the title to "Implementing the case studies" as these represent examples of the methodology we present in the article.
  To make the examples more meaningful and accessible, we have expanded the content and inserted significant portions of code. 

Concerning your criticism regarding the lack of experimental data, we would like to clarify that ours is not a product. However, instead, we present an approach validated by three use cases that could allow the development of countless low-cost and immediately available rehabilitation exercises, albeit with limitations related to software know-how.

Reviewer 3 Report

This manuscript focuses on gameful approaches for cognitive rehabilitation, a timely and important topic. However, the paper has several serious drawbacks that need to be addressed prior to consideration for publication.

In the abstract there are vital information missing regarding the methods and results of the article.

The article itself is very short and should be expanded significantly. The sections should be rearranged. For instance, section 4 should be moved to section 3 (system design) or renamed as it does not contain any discussion.

L84-92: This paragraph should be moved to a section about future directions for research.

As this is not a theoretical article, the proposed system should be evaluated. Therefore methods, results and discussion sections should be added.

Most importantly, the article claims to deal with a serious game. Serious games are systems that offer meaningful choices with specific rules and goals, usually within a narrative involving characters. However, the proposed playful exercises do not constitute a coherent serious game. Therefore, the title and wording in the entire document should change.

Author Response

Reviewer #3

Dear reviewer,

   All the authors would like to thank you for your positive comments on our work and your suggestions, which have greatly improved our work's quality.
We have highlighted all modified contents in red.

Briefly we describe you the global modification carried out:

• We carried out a significant revision of the entire article, correcting the critical points you highlighted.
• We have extended the abstract by collecting your suggestions and providing a more balanced presentation of our work to the reader.
• We have expanded the introduction to provide more background for the reader, hopefully clarifying we introduced a methodology.
• We have expanded the Related Works section.
  The changes made to this section and to the Introduction section, we guess will make our research more comprehensible 
• We have renamed the Section “The proposed system architecture” with the title “The system architecture” and improved the contents.
• We have modified the “Discussion” section. First of all, we have changed the title to "Implementing the case studies" as these represent examples of the methodology we present in the article.
  To make the examples more meaningful and accessible, we have expanded the content and inserted significant portions of code. 

We have expanded the related works section with the intention of highlighting how serious games are widely used in telerehabilitation. Patients with severe neurological disorders need very simple contexts, possibly enriched with elements that stimulate the memory of the experience.

In the Conclusions section, we pointed out that in our future work we will extend the approach by defining different levels of involvement and complexity inversely proportional to the gravity of the neurological disease.

Round 2

Reviewer 1 Report

Dear authors,

you have made a good job revising your article. My major concerns are still related to your paper's structure. In general, a reader needs to find quickly the information he wants otherwise, he might not read your paper at all. 

Introduction: 

I do not think that lines 21-22 are related to this paragraph's content.

I find that the aim of the paper is clearly described. However, the next subsections must contain info about how you will achieve this and the implications of this job. As I have previously said, the rest of the content must be moved to the related work section. 

The related work section nicely describes the sub-topics and their relation with your work except for the virtual reality subsection.

I also suggest that VR subsection could include the info about the SGs?

Also, consider adding the negative aspects based on the literature.

The system's architecture

This subsection is quite clear but I could suggest adding the link to your repo if this is possible? Actually, what I miss here is described by the following question: if I would like to use your open access methodology, what I could do? Consider two cases (doctor or/and developer?). Maybe a diagram of the required steps that a doctor must follow could be helpful.

Implementing the case studies

I do not find it necessary to include figures with the code. Instead, it could be very useful to add the doctor's interface for each case. 

Conclusions

I suggest that limitations and future work could be improved

Abstract

Finally, I will repeat that your abstract needs much more work. A big abstract is not a good abstract! So, I will repeat: please describe the topic, the gap, what you will do about it and how, your results (the case studies), and your implications but in only 1-2 lines each.

In general, you have done very promising work and therefore people must read it!

Author Response

Dear reviewer,

   All the authors would like to thank you for your positive comments on our work and your suggestions, which have greatly improved our work's quality.
We removed the previous areas colored and  highlighted in red all modified contents in the 2nd round.

We describe below the actions taken in correspondence with your valuable indications:

• We carried out a significant revision of the entire article, correcting the critical points you highlighted.
• We modified the abstract by collecting your suggestions.
• We modified the introduction according to your suggestions.
• We expanded the Related Works section. 
• We added the link to the repository and the implemented platform. 
• We added the diagram of the whole process.
• We included the images of the doctor’s user interface.

We sincerely hope that the changes made, even considering the necessary harmonisation with the requests of the other reviewers, will be regarded as satisfactory.

Reviewer 2 Report

The authors have done a very good job addressing previous comments and re-positioning the paper.

Author Response

Dear reviewer,

   All the authors would like to thank you for your positive comments on our work and your suggestions, which have greatly improved our work's quality.
We removed the previous areas coloured and highlighted in red all modified contents in the 2nd round.

We describe below the actions taken in correspondence with your valuable indications:

• We carried out a significant revision of the entire article, correcting the critical points you highlighted.
• We modified the abstract by collecting your suggestions.
• We modified the introduction according to your suggestions.
• We expanded the Related Works section. 
• We added the link to the repository and the implemented platform. 
• We added the diagram of the whole process.
• We included the images of the doctor’s user interface.

We sincerely hope that the changes made, even considering the necessary harmonisation with the requests of the other reviewers, will be regarded as satisfactory.

Reviewer 3 Report

Dear authors,

Thank you for the revised manuscript. Please also address the following points:

Are the exercises described in your manuscript serious games? Please provide additional evidence for this claim.

As this is not a theoretical article, the proposed applications should be evaluated for their effectiveness. Therefore, methods and results sections should be added.

Author Response

Dear reviewer,

   All the authors would like to thank you for your feedback.

We would highlight that the rich bibliography produced concerning serious games applied to the medical field is in line with how we understood the term serious games, which inspired our research work.

We also have provided ample evidence that the software platform we have developed indicates a strategy for designing telerehabilitation exercises using open and easily accessible tools. Therefore, we have not considered having to carry out usability measures on our system. We add that your request to carry out this measurement in 10 days is impossible, considering this operation involves patients with neurological issues. The simple request for authorisation to carry out these measurements requires times longer than the time allowed for the 2nd round of major revision.