Beyond Fun: Players' Experiences of Accessible Rehabilitation Gaming for Spinal Cord Injury
Gabriele Cimolino, Sussan Askari, T.C. Nicholas Graham · 2021 · The 23rd International ACM SIGACCESS Conference on Computers and Accessibility (ASSETS 2021) · doi:10.1145/3441852.3471227
Summary
This paper explores how accessible rehabilitation games can affect the experiences of patients with spinal cord injury beyond simply making exercise more fun. Six participants with spinal cord injury (three with tetraplegia, three with paraplegia, aged 23-33) played three cycling-based rehabilitation games while using a MOTOmed viva2 motorized cycling device at a rehabilitation hospital. Two participants could actively pedal while four cycled passively (the machine moved their legs). The three games were Dino Dash and Dozo Quest (from the Liberi suite, originally designed for children with cerebral palsy and adapted for accessibility) and MOTOmax (a commercial game shipped with the viva2). Dino Dash and Dozo Quest were accessible to all participants through adaptive play techniques including joystick and bite switch input, while MOTOmax required active pedaling and was therefore inaccessible to four of six participants. Semi-structured interviews of approximately 30 minutes were conducted after gameplay and analyzed using reflexive thematic analysis. The study is framed as the first qualitative investigation specifically examining how rehabilitation gaming affects patients' experiences of spinal cord injury rehabilitation, going beyond prior quantitative studies that measured only usability and fun.
Key findings
Two major themes emerged from the analysis. The first, "The Ordeal of Spinal Cord Injury Rehabilitation," revealed that participants experienced grief, depression, hopelessness, boredom, and loss of identity during rehabilitation. Passive cycling was particularly demotivating — one participant regularly slept through sessions, another described "just letting the machine do everything." Free time during rehabilitation led to harmful rumination about their changed lives and uncertain futures. The second theme, "From Passive to Active," showed that accessible games transformed rehabilitation in four ways: gaming engaged the whole body (giving idle hands and minds something to do during cycling); gaming engaged body and mind simultaneously (providing interactivity that music or TV could not); gaming gave meaning to exercise (goals, progression, and competition made efforts feel purposeful rather than prescribed); gaming let patients win at something (offering a sense of accomplishment that passive cycling could not); and gaming enabled active participation in what was otherwise a passive, disabling activity. Critically, these benefits only materialized when games were accessible. MOTOmax, which required active pedaling, was useless and frustrating to participants who could not pedal. The findings align with self-determination theory's three psychological needs: autonomy (active participation in rehabilitation), competence (achievement and progress feedback), and relatedness (peer competition and social bonds).
Relevance
This study makes a compelling case that game accessibility in rehabilitation contexts has stakes far beyond entertainment — it directly affects patients' psychological recovery and willingness to engage in life-long rehabilitation. For accessibility practitioners, the most important finding is the stark contrast between accessible and inaccessible games: the same rehabilitation session was either transformative or pointless depending on whether the game accommodated the patient's abilities. The concept of "partial automation" — automatically handling game mechanics that a player cannot perform — offers a practical design pattern for making games accessible across a wide range of motor abilities. The self-determination theory framework provides a useful lens for evaluating whether rehabilitation technologies support meaningful engagement rather than just physical outcomes. Organizations developing rehabilitation technology should prioritize accessibility as a clinical necessity, not a nice-to-have feature, since inaccessible rehabilitation games can reinforce the very feelings of helplessness and exclusion that rehabilitation aims to overcome.
Tags: spinal cord injury · rehabilitation · game accessibility · digital games · assistive technology · mental health · self-determination theory · qualitative research