VIRTUAL AND BOARD GAMES AS THERAPEUTIC RESOURCES FOR UPPER LIMB FUNCTIONALITY IN PARKINSON’S DISEASE: A PILOT STUDY

VIRTUAL AND BOARD GAMES AS THERAPEUTIC RESOURCES FOR UPPER LIMB FUNCTIONALITY IN PARKINSON’S DISEASE: A PILOT STUDY | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 24 September 2025 V1 Latest version Share on VIRTUAL AND BOARD GAMES AS THERAPEUTIC RESOURCES FOR UPPER LIMB FUNCTIONALITY IN PARKINSON’S DISEASE: A PILOT STUDY Authors : Philipe Corrêa , Carolina Thomazi , Arthur Lahude , Jênifer Cemim , Sandy Witt , Maria Eduarda Cabeleira , Gustavo de Castro Barroso 0000-0003-1090-2828 [email protected] , and Fernanda Cechetti Authors Info & Affiliations https://doi.org/10.22541/au.175868659.95498312/v1 178 views 115 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract To analyze and compare the effects of non-immersive virtual reality games with board games on upper limb functionality in individuals with Parkinson’s disease. Twenty subjects with Parkinson’s disease (Hoehn & Yahr 2-3) were randomized into a virtual reality group (n=10) or a board games group (n=10) for 30-minute sessions, twice weekly for 8 weeks. The primary outcome was activities of daily living, measured by the TEMPA test. Secondary outcomes included manual dexterity (Box and Block Test and Nine-Hole Peg Test), motor aspects (Unified Parkinson’s Disease Rating Scale Part III), grip strength and endurance (handgrip dynamometry), and quality of life (Parkinson’s Disease Questionnaire-39). Regarding the primary outcome, both groups significantly improved their performance in activities of daily living. For the secondary outcomes, both groups showed similar improvements in motor aspects (Unified Parkinson’s Disease Rating Scale Part III), gross manual dexterity (Box and Block Test), and quality of life (Parkinson’s Disease Questionnaire-39). A significant intergroup difference was found only in fine manual dexterity (Nine-Hole Peg Test), where the virtual reality group showed superior improvement with the left hand compared to the board games group. Both virtual reality and board games effectively improve performance in daily activities, motor symptoms, and quality of life for individuals with Parkinson’s disease. However, virtual reality demonstrates a specific advantage over board games in enhancing fine motor dexterity of the left hand. INTRODUCTION Parkinson’s disease (PD) is a chronic neurodegenerative disease of the central nervous system, characterized by the progressive loss of dopamine-producing cells in the substantia nigra, leading to both motor and non-motor symptoms, including impairment of upper limb (UL) (Sirajo et al., 2022). The disease affects approximately 10 million individuals worldwide, with an annual increase of nearly 60,000 new cases (Marras et al., 2018). The burden of motor symptoms and the impairment of some activities of daily living (ADLs), such as eating, hygiene and dressing, related to changes in functional mobility, have been identified as one of the main predictors of quality of life (QoL) in this disease (Jiménez-Barrios et al., 2023). Since the early stages of PD, changes occur causing impairments in speed and range of motion, resulting in manual function losses, directly affecting the reduction of ADLs and, consequently, the QoL for these individuals making them more dependent (Quinn et al., 2013). As the disease progresses, UL disturbances can lead to limitations in work, recreation, daily tasks (Proud et al., 2015) and the presence of rigidity, along with bradykinesia and tremor, hinders complex integrated or repetitive movements (Albano et al., 2023). For example, a change is observed in handwriting, where a sentence begins with well-formed letters and progressively deteriorates into smaller and slower letters (Proud et al., 2015). Actions such as shaving, brushing teeth, combing hair, buttoning, applying makeup, dressing or playing musical instruments become extremely difficult (de Paula Vieira et al., 2017). Thus, despite clear evidence of deficits in UL motor control and dexterity in PD, significantly impacting ADLs (Raggi et al., 2011), most rehabilitation research and clinical practice primarily focus on gait and postural balance-related issues (Lingo VanGilder et al., 2021). Therefore, considering that upper extremity motor disturbances are only slightly responsive to dopaminergic treatment, regular therapist monitoring in the rehabilitation process can bring numerous benefits to individuals with PD (Cabrera‐Martos et al., 2019). Among the modalities for treating UL disturbances in PD, non-immersive virtual reality (VR) games, defined as the use of simulations created from hardware and software that allow the user to engage with environments mimicking the real world (Schuch et al., 2020), stand out as a technological therapy recommended for improving movement learning. Through visual feedback, the individual can work on both motor and cognitive processes simultaneously in a challenging and motivating environment (Dockx et al., 2016). Additionally, an external observer can monitor and record the user’s performance in the proposed task, analyzing its progress in the activity (Massetti et al., 2018). However, despite recent systematic review evidence of VR’s effects on manual dexterity (Lahude et al., 2023), little is known about the effects of this modality on aspects related to ADLs and the impact on the QoL of individuals with PD. On the other hand, board games, with evidence of improvement in cognition, fine motor skills and coordination in institutionalized elderly individuals (Ching-Teng, 2019), may be another resource for treating UL disturbances in PD. These games are played on tables and therefore do not require electronic devices. Compared to other types of games, they offer players concrete experiences that increase intention in participation, stimulate thinking and conflict resolution. Besides being a leisure activity, board games also offer players the opportunity to learn and experience a sense of achievement and satisfaction (d’Astous & Gagnon, 2007). Therefore, the impact of arms dysfunctions in PD demands increased research efforts to explore possibilities for treating these impairments. Thus, the objective of this study was to analyze and compare the effects of non-immersive virtual reality games and board games on the functionality of upper limbs, activities of daily living and quality of life of individuals with Parkinson’s disease. METHODOLOGY This study consisted of a single-blind, pilot trial design conducted in the subject’s home. It received ethical approval from the Federal University of Health Sciences of Porto Alegre (UFCSPA - no: 3.715.577) and was registered on Clinicaltrials.gov (IDNCT04796246). Before inclusion in the study, participants were properly informed about the study’s objectives and course and received written information, providing consent to participate. The protocol followed the standards established by the Declaration of Helsinki for experiments with human subjects. Individuals were recruited through telephone contact from a pre-existing list provided by the researchers. Participants diagnosed with PD (Calne et al., 1992), aged above 18 years, who were able to perform the tests and demonstrated an understanding of the games on the first day of familiarization were selected. Individuals with deep brain stimulation and those with recent upper extremity (UE) injuries were excluded from the study. Procedures and evaluations Clinical and sociodemographic characteristics were collected at the beginning of the study to describe the sample. These measures included age, gender, laterality and disease staging. All data were collected by an independent researcher who was unaware of the patient allocation group at the beginning and after the intervention program. All procedures, assessments and interventions were carried out in the “on” medication stage. The Test d’Évaluation des Membres Supérieurs de Personnes Agées (TEMPA) (Desrosiers et al., 1993) was used to assess the degree of UL disability. The Brazilian version of the instrument consists of 8 standardized tasks that simulate ADLs, with 4 bilateral and 4 unilateral tasks. The functional tasks are as follows: (1) picking up and carrying a pot (unilateral); (2) opening a pot and taking a full coffee spoon (bilateral); (3) picking up a jar and pouring water into a glass (unilateral); (4) unlocking a lock and opening a container with pills (bilateral); (5) writing on an envelope and sticking a stamp on it (bilateral); (6) shuffling and dealing cards (bilateral); (7) picking up coins (unilateral); and (8) picking up and moving small objects (unilateral). The scores obtained in TEMPA were based on execution speed measured in tenths of a second, the degree of functionality and task analyses. The degree of functionality refers to individual autonomy in each task, graded according to a 4-level scale: 0 - the task was successfully completed without hesitation or difficulty; 1 - some difficulty or hesitation in completing the task; 2 - the task was partially executed or some steps were performed with significant difficulty, possibly requiring task modification or assistance from the evaluator; and 3 - could not complete the task, even with assistance provided. Task analysis quantifies the difficulty encountered by the subject, according to 5 items related to sensorimotor skills of the UL: strength, range of motion, precision of broad movements, grip and precision of fine movements. When the subject obtains a score of -2 at the functional level, the execution speed is not listed. The value of the total functional grading represents the sum of right unilateral tasks (0 to -12), left unilateral tasks (0 to -12), and bilateral tasks (0 to -12), potentially ranging from 0 to -36. Similarly, the same summary is done for the other 5 dimensions of functional analysis tasks. Considering that the precision of fine movement is not rated for tasks 1 and 3, and strength is not rated for tasks 5 to 8, the task analysis dimension can range from 0 to -150. The total score represents the sum of functional and task analysis grading, totaling -186. Although the original scale proposes a negative score, with 0 indicating no disability and negative values indicating greater disability, the values were used independently of the sign in the statistical analysis. Thus, for this study, higher values correspond to greater disability. To complete the assessment, handgrip strength (average of the 3 measurements of maximum strength performed alternately on each limb) and relative isometric muscle endurance (time of grip above half of the average maximum strength) should be measured using a handgrip dynamometer and a stopwatch (de Freitas et al., 2017). The Box and Block Test (BBT) was used to measure unilateral manual dexterity and consists of moving as many cubes as possible from one compartment to another in a wooden box, one by one, in one minute (Hwang & Song, 2016). The Nine-Hole Peg Hole Test (9HPT), used to assess unilateral manual dexterity, consists of nine pegs and a board with nine holes, in which the individual is instructed to pick up one peg at a time and insert it into the holes contained in the board and then remove the pegs and return them to the original location. The time to complete the task is timed by the researcher (Menacho et al., 2023). The updated Movement Society Disorders – Unified Parkinson’s Disease Rating Scale (UPDRS) encompasses four parts: part I, the impact of non-motor aspects of daily life; part II, motor aspects of daily life; part III, motor assessment; and part IV, corresponding to motor complications. Only Part II was applied, designed to be a self-report questionnaire, but it can be reviewed by the investigator to ensure clear and complete completion, and Part III, in which instructions for the evaluator to provide or demonstrate tasks to the individual and is filled out by the evaluator. A higher score corresponds to a worse state (“The Unified Parkinson’s Disease Rating Scale (UPDRS): Status and Recommendations,” 2003). The Hoehn & Yahr staging scale (H&Y) classify the motor stage of PD according to mainly symptoms. Subjects classified between one and three are in mild to moderate disability stages, while those in stages four and five are considered severely disabled (Hoehn & Yahr, 1967). Quality of life was assessed through the 39-item Parkinson’s Disease Questionnaire (PDQ-39), consisting of 39 questions divided into 8 subscales (mobility, ADL, emotional well-being, stigma, social support, cognition, communication and bodily discomfort). The total score is given by the sum of all items and is then transformed into a range of 0 to 100 (Souza et al., 2007). A lower value corresponds to a better perception of the subject’s QoL. Finally, the Montreal Cognitive Assessment (MoCA) for cognitive screening measures eight cognitive domains (short-term memory, visuospatial skills, executive function, attention, concentration, and working memory, language, orientation in time and space) that are scored within a range of 0 to 30 points (higher scores indicate better function) (Memória et al., 2013). The primary outcome measure was activities of daily living (TEMPA test), and the secondary outcomes were manual dexterity (BBT and 9HPT); motor and daily life aspects (UPDRS parts III and II); grip strength and manual grip endurance (handgrip dynamometry); and quality of life (PDQ-39). Participants were instructed to follow their normal medication and physical activity schedule without initiating any new exercise or medication program during the study. The pre- and post-tests occurred one hour after patients took their usual PD medications (the ”on” state) to minimize motor fluctuations and variability of motor symptoms, administered by a blinded assessor. Interventions After the initial assessment (pre-test), participants were randomized via a draw using the site https://app-sorteos.com/en/apps/random-teams-generator, and then allocated to either a non-immersive virtual reality game-based therapy (VR games group) or a board game-based therapy (board games group). A single physiotherapist conducted the sessions with each participant individually for each group over 8 weeks. The 30-minute sessions were conducted twice a week on non-consecutive days, totaling 16 interventions. Each game had a total time of 6 minutes when performed with both arms concurrently (bilateral). When performed unilaterally, the total time was divided into 3 minutes per limb, totaling the same 6 minutes. All participants underwent treatment in a seated position, utilizing a table positioned at the height of the middle third of the trunk, with an initial elbow flexion of 90°. For those patients necessitating assistance, therapists provided manual support, particularly focusing on the more affected side. Throughout the protocol, exercise intensity and volume were systematically augmented, tailored to the individual requirements of each patient, while ensuring adequate rest periods to prevent fatigue. The VR games group used the Leap Motion Controller (LMC), a Universal Serial Bus (USB) device capable of detecting hand and finger movements through a non-immersive VR with high precision and performance, connected to a laptop computer (Memória et al., 2013). The games used were ”Playground”, ”Project Takt”, ”Virtrum Air” and ”Joca - The Handglider”, extracted from the website gallery.leapmotion.com. The board games group used the games ”Cai-não-Cai”, ”Genius®️”, ”Disco-Bol”, and ”Futebol de Pinos”. The description of all games is provided in Table 1. (Table 1) Statistical Analysis The data were recorded in an Excel database and subsequently analyzed using Statistical Package for the Social Sciences (SPSS) version 20.0. The Shapiro-Wilk normality test indicated that the data had a non-parametric distribution. Continuous variables were described as median (minimum-maximum), while categorical variables were presented as absolute and relative frequency (n, %). The comparison of frequencies between groups (categorical variables) was performed using the chi-square test with adjusted residual analysis. To compare medians before and after interventions, Wilcoxon test (within groups) and Mann-Whitney test (between groups) were used. A significance level of p ≤ 0.05. Flowchart and Sample Characteristics The study included a total of 20 participants, who were randomized into two distinct groups: the VR games group, consisting of 10 participants, and the board games group, also with 10 participants. To ensure concealed allocation, the eligibility of study subjects was determined based on inclusion criteria established by a blinded assessor who was not involved in the randomization process. The study design and distribution of individuals among the groups can be visualized in figure 1. (Figure 1) Figure 1: Flowchart The analysis of the sample characterization data did not show any significant differences in any of the comparisons between the groups. The sample consisted of a total of 20 participants, with 10 in each group. The age range varied from 47 to 81 years, with medians of 67 and 69 years in the VR games group and board games group, respectively. Of the participants, 13 were male, and 7 were female. Regarding the distribution of PD subtypes, each group showed an equal proportion. In terms of the most affected side by the disease, 11 individuals had the left side compromised, with 5 in the VR games group and 6 in the board games group. Additionally, the majority of participants were right-handed, with 9 individuals in the VR games group and 10 in the board games group. Regarding the motor staging, subjects ranged between stages 2 and 3 on the Hoehn and Yahr scale (Table 2). (Table 2) Activities of Daily Living, Manual Dexterity, Motor Examination, and Quality of Life The results of the interventions before and after 16 sessions for both groups were compiled in Tables 3 and 4. Analyzing the TEMPA test data, no significant differences were found in the comparisons between the two groups in any of its domains. However, both the VR games group and the board games group showed improvements in execution time with the right hand, manual endurance of the left hand and functional scoring of the test. Additionally, the board games group also demonstrated improvements in bilateral execution time, manual endurance and manual strength of the right hand. The other variables did not show changes in the groups. Concerning the results of the BBT, improvement was observed in both groups, but with no significant differences in the comparisons within the groups. In the 9HPT, both groups showed improvement in execution with the right hand, and only the VR games group showed positive values in execution with the left hand, surpassing the board games group in this aspect. In the UPDRS - part II (Activities of Daily Living) analysis, both groups showed improvement in the total score. No significant differences were found in the comparison between groups. Regarding part III (Motor) of the UPDRS, only VR games group obtained a higher total score, showing more effectiveness in the comparison between the groups in this aspect. Regarding the participants’ quality of life, assessed by PDQ-39, both groups showed improvement in the total score and the emotional well-being item. However, the VR games group had isolated positive results in items related to activities of daily living and stigma. On the other hand, only in the board games group there was an improvement in mobility and communication items, showing superior results when compared to the VR games group in these aspects. The remaining analyses, including the MoCA test, did not show significant changes in either group. (Table 3) (Table 4) DISCUSSION Our study aimed to compare the effects of non-immersive virtual reality games with board games on upper limb functionality, activities of daily living and quality of life in individuals with PD, finding a significant improvement in these variables within each group. However, no significant differences were found in the comparison between the groups. This demonstrates that regardless of the method used, the proposal of specific and challenging activities for upper limbs dysfunctions can lead to significant modifications in the daily functions PD individuals. In a study conducted by Proud et al. (Proud et al., 2015), it was highlighted that, among various tests, the BBT and 9HPT were considered useful tools to assess the level of arms activity in PD. However, these measures focus solely on the fine motor skills of individuals. This raised a subsequent question (de Freitas et al., 2017) about the ”clinical utility of evaluating limitations in arms activities with tests or tasks that do not represent these individuals’ ADLs and do not include the actual handling of objects?” In this context, the TEMPA test was developed as a tool that presents sequential tasks, including quantitative parameters (evaluation of execution speed) and qualitative parameters (functional scoring and task analysis) to detect upper limbs deficiencies (Desrosiers et al., 1993). By using this instrument specifically designed to evaluate UL motor function, as well as the ability to perform ADLs and functional independence (Guna et al., 2014), it became possible to infer, based on the improvement in quantitative and qualitative analysis evidenced by the TEMPA test in this study, that virtual and conventional game therapies are effective in improving ADL performance in PD. This finding reinforces the relevance of these therapeutic approaches in treating PD subjects, providing significant gains in UL functionality and, consequently, in the performance of daily activities. Considering the relevance of games in rehabilitation and the restoration of arms functionality, the challenging role they impose on individuals with PD is noteworthy. While conventional therapies follow predetermined series and repetitions by the therapist, games bring tasks with goals to be achieved, stages to overcome and the possibility of facing opponents, either virtual or real. A recent study (Ching-Teng, 2019) highlighted that playing board games is an excellent opportunity for social interaction for the elderly in long-term care facilities, as these adults often lack social stimuli. In the present study, it was also evidenced that both the ”social support” item and ”communication” item, evaluated by the PDQ-39, had superior results in individuals undergoing this intervention. Additionally, virtual games can stimulate neural plasticity and motor reorganization in humans, activating mirror neurons in areas related to cortical, subcortical and cerebellar motor control through the visualization of body parts projected on the screen. Active therapy with virtual games also reduces the boredom of the rehabilitation process, increasing participant motivation, providing direct feedback and allowing dual-task training (MAROTTA et al., 2023). Manual dexterity is an impactful factor for tasks performed with the UL and can be influenced by cognitive factors such as attention, planning and working memory (MOUMDJIAN et al., 2017). Therefore, interventions aiming improving cognitive function may indirectly benefit manual function in individuals with PD. A study conducted by Leung (Leung et al., 2015) showed that cognitive stimulation through computerized game-based interventions improves fine motor skills compared to control groups receiving other forms of intervention, such as balance training and speech therapies. Although our results did not show specific changes in cognition evaluated by the MoCA test, positive effects were observed in fine motor skills assessed by the BBT and 9HPT in both groups. This suggests that specific approaches for UL, combined with challenges imposed by games, have the potential to produce benefits in the fine coordination of PD individuals. Although the scientific literature on the specific use of board games in PD is limited, there are studies that highlight the general benefits of this modality for cognition, fine motor skills and social interaction. Chen (Chen et al., 2022) analyzed the effects of board games on the elderly, addressing improvements in cognition and reduced risk of cognitive decline. Although not exclusively focused on Parkinson’s disease, the mentioned study provides evidence of the potential of this intervention to stimulate cognition and functionality in individuals. Additionally, Joddrell (Joddrell et al., 2009) investigated the use of board games and video games as a form of treatment for older adults, highlighting the therapeutic benefits of improving fine motor skills, cognition and social interaction in the elderly. Also, Noda (Noda et al., 2019) showed that, as a tool, board games can be expected to enhance knowledge comprehension, increase interpersonal interactions and motivate participants. On the other hand, the study by Hindle (Hindle et al., 2018), although focusing on cognitive rehabilitation in people with dementia associated with PD, emphasizes the importance of structured and goal-oriented activities, such as board games, to improve cognitive function and quality of life. Based on this, the present study demonstrated significant improvements in cognitive and functional skills in subjects who participated in board game-based interventions. Thus, it was possible to demonstrate an innovative and potentially positive therapeutic modality for UL functionality in PD. A recent systematic review developed by our research group showed that VR-based therapy has great potential and feasibility to be used as a rehabilitation protocol for fine and gross manual dexterity in PD individuals. In this study, six out of eight analyzed studies used the Leap Motion Controller device for treatment (Lahude et al., 2023). Fernandez (Fernández-González et al., 2019) identified that the LMC system and the designed serious games can be a viable rehabilitation tool for improving coordination, movement speed, and fine dexterity of UL in PD. Additionally, the feasibility of the tool for therapeutic execution in clinical and home environments was verified, ruling out possible adverse effects of computer screen use (Cemim et al., 2022). These results highlight that the use of virtual games through the LMC device represents a new therapeutic possibility for PD treatment, with the potential to increase arms functionality and have a direct impact on the ADLs of these individuals. Harrison (Harrison et al., 2009) revealed, based on their analysis of the UPDRS - part II scale in a cohort of 888 individuals, a robust correlation between ADL sub-scores and disease duration. This finding suggests that this measure could potentially serve as a superior marker of disease progression compared to the signs and symptoms assessed in other sections of the UPDRS, such as motor examination in part III. Paz (Paz et al., 2021) also observed that manual grip strength held predictive value for motor impairment in individuals experiencing freezing of gait. The recognition of VR and board games benefits for ADLs, assessed by the UPDRS - part II, along with the functional performance observed in the TEMPA test, has the potential to exert a direct impact on disease progression. Furthermore, the direct influence on overall quality of life as indicated by the PDQ-39 total score and the ADL subitem, specifically within the VR game group, is noteworthy. This could have significant implications for disease progress and the absence of changes in this subitem within the board game group may be due to lack of alterations prior to treatment. Muscular rigidity and bradykinesia can impair the performance of simple tasks such as dressing, buttoning, zipping up, putting clothes over the head and tying shoelaces. Additionally, impaired dexterity can lead to spills, difficulties in cutting food and delays in eating, which can result in nutritional problems and even a decrease in the pleasure of eating (DeMaagd & Philip, 2015). This can result in frustration and delays in the execution of these basic activities, which can also hinder the use of cutlery, such as holding and properly manipulating food (Keus et al., 2007). Thus, the improvement in the execution of ADLs and the reported quality of life, based on the proposed protocols, highlights the importance of treatment focused on the specificity of UL tasks, which, together with the impact on the daily life and well-being of individuals with PD, restore their independence and functionality to some extent. An important point to highlight is that, except for the body discomfort and cognition items of the PDQ-39 questionnaire, all others (ADLs, mobility, well-being, stigma, social support, and communication) showed positive results in one or both interventions. A recent study (Prell et al., 2023) showed that factors related to loneliness and greater isolation in PD were associated, among other factors, with greater limitation in ADLs, lower palmar grip strength, more physical inactivity, higher frequency of pain and lower quality of life. It was also shown that PD involves several social symptoms, such as difficulties in producing facial expressions and speech, which can have negative social consequences and greatly impact the QoL (Gerritzen et al., 2022). Thus, in the present research, a positive impact of direct interaction between the therapist and the individual was observed for issues related not only to ADLs and mobility but also to well-being, stigma, social support, and communication. Therefore, the role of the rehabilitator in approaches that provide moments of contact, interaction and communication is of fundamental importance, as well as therapies that encompass these aspects, promoting greater potential in PD rehabilitation. Limitations of our study are the sample restriction regarding motor staging (Hoehn & Yahr 2-3), harm the power of the study to generalize prevents the generalization of results to more advanced cases of PD. Additionally, it is relevant to consider the feasibility of proposing the same board games in the virtual environment to enable a more specific comparison of the approach, despite the positive results presented here. Electromyographic analysis of specific muscle activation in different approaches may broaden the discussion about other factors influencing the improvement of UL. Therefore, possibilities are open for future studies that can elucidate other impacts of game use in the treatment of UL in PD. CONCLUSION The use of games for the treatment of arms functionality in Parkinson’s disease represents an important rehabilitation tool, especially in the early to moderate stages of the disease. The ease of use, non-invasive nature, and, most importantly, the challenging environment proposed, whether in a virtual setting using the LMC or in a real setting using board games, allows for stimulating the functions of the upper limbs affected by the disease beyond what is usual. Thus, the continuous development of methods with diverse approaches becomes crucial, aiming to improve activities of daily living and quality of life for individuals at all stages of Parkinson’s disease. The design of new strategies and approaches that adapt to individual needs is essential, promoting a holistic and comprehensive intervention to better face the challenges imposed by PD. ACKNOWLEDGEMENTS This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de nível Superior—Brasil (CAPES)—Finance Code 001. DISCLOSURE STATEMENT There are no conflicts of interest to report. FUNDING The author(s) reported there is no funding associated with the work featured in this article. REFERENCES Albano, L., Agosta, F., Basaia, S., Cividini, C., Stojkovic, T., Sarasso, E., Stankovic, I., Tomic, A., Markovic, V., Canu, E., Stefanova, E., Mortini, P., Kostic, V. S., & Filippi, M. (2023). Altered Functional Connectivity of the Subthalamic Nucleus in Parkinson’s Disease: Focus on Candidates for Deep Brain Stimulation. 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The game features a time limit to advance to the next stage. Unilateral “Joca – The Handglider” Maneuver an ”airplane” to collect as many coins as possible and be careful not to collide with obstacles. Movements involve pronation/supination of the hand and flexion/extension of the shoulder. Unilateral Board Games (n=10) “Cai-Não-Cai” Remove the highest number of sticks without letting the balls fall. Interaction with thin sticks, using pinch movements (thumb and index finger). Unilateral “Genius®️” Tap on the sequence of colors proposed by the equipment itself with memorization and quick response, performing elbow and wrist flexion/extension movements. Bilateral “Futebol de Pinos” Simulate a soccer game, using the sticks to drive the ball to the opponent’s goal with just one touch. Bilateral movements of wrist flexion/extension and pinch. Unilateral “Disco-Bol” Hit the disc towards the opposite goal to score a goal and prevent the opponent from scoring in your own goal. The movements involve elbow and wrist flexion and extension in a pronated position. Unilateral Table 2: Sample Characterization Virtual Reality Games (n=10) Board Games (n=10) p Age (years) 67 (47-81) 69 (63-72) 0,448 Gender Female Male 3 (30) 7 (70) 4 (40) 6 (60) 0,639 Laterality Left Right 5 (50) 5 (50) 6 (60) 4 (40) 0,653 Dominant Hand Left Right 1 (10) 9 (90) 0 (0) 10 (100) 0,305 Hoehn & Yahr 2 and 3 4 (40) 6 (60) 6 (60) 4 (40) 0,371 Continuous variable expressed as median (minimum-maximum). Categorical variables expressed as n (%). ”p” value obtained for continuous variable through the Mann-Whitney test and categorical variables through the chi-square test with adjusted residue analysis. Laterality, side of symptom onset. Table 3: Results of pre - and post - intervention clinical tests. Virtual Reality Games (n=10) Board Games (n=10) PRE POST p a PRÉ POST p a pΔ b TEMPA Unilateral R (s) 46,6 (37,6-59,8) 40,6 (27,9-53,5) 0,022* 45,6 (33,0-82,7) 42,9 (30,9-49,3) 0,012* Δ (s) -7,5 (-27,5-3,5) -6,2 (-33,3-0,5) 0,762* Unilateral L (s) 47,0 (32,1-65,7) 45,1(27,0-69,8) 0,202* 46,8 (26,7-76,0) 44,1 (29,4-46,1) 0,168* Δ (s) -3,4 (-21,8-15,4) -2,4 (-29,9-2,6) 0,494* Bilateral (s) 97,0 (83,9-182,7) 109,0 (81,1-142,6) 0,284* 115,9 (72,3-139,6) 99,7 (63,3-131,7) 0,012* Δ (s) -9,6 (-40,0-24,0) -9,6 (-22,1-1,4) 0,880* Total Time (s) 204,9 (167,0-291,8) 194,4 (136,1-239,8) 0,074* 217,7 (132,2-298,4) 187,9 (126,3-227,3) 0,005* Δ (s) -13,5 (-52,4-18,4) -26,8 (-71,1- -2,6) 0,705* Endurance R (s) 43,0 (16,0-64,0) 55,6 (6,9-72,4) 0,074* 45,8 (20,7-55,2) 66,4 (47,3-120,1) 0,028* Δ (s) 7,7 (-9,7-37,1) 27,1 (-3,8-64,8) 0,449* Endurance L (s) 53,5 (11,8-59,1) 60,6 (6,6-108,7) 0,012* 37,4 (19,9-63,3) 72,6 (28,1-100,3) 0,005* Δ (s) 13,3 (-5,2-57,4) 12,0 (0,0-80,0) 0,130* Strength R (kg) 25,2 (16,8-40,0) 25,3 (20,1-44,1) 0,444* 18,8 (14,2-20,7) 22,4 (17,2-38,5) 0,036* Δ (kg) 2,9 (-14,7-15,1) 3,5 (-3,3-17,7) 0,545* Strength L (kg) 26,3 (17,9-36,8) 24,1 (17,6-35,5) 0,386* 18,0 (8,1-28,0) 18,8 (9,3-42,0) 0,332* Δ (kg) -0,2 (-14,5-11,0) 1,1 (-3,3-13,9) 0,325* Functional Assessment 20,0 (17,0-24,0) 17,0 (12,0-23,0) 0,017* 16,5 (14,0-22,0) 14,0 (12,0-22,0) 0,038* Δ (s) -3,0 (-7,0-0,0) -2,0 (-2,0-0,0) 0,268* BBT BBT D 27,0 (21,0-37,0) 30,0 (25,0-44,0) 0,012* 30,0 (23,0-35,0) 33,5 (21,0-47,0) 0,033* Δ (s) 3,0 (0,0-14,0) 4,5 (-3,0-16,0) 0,733* BBT E 30,5 (21,0-36,0) 35,0 (26,0-42,0) 0,005* 28,5 (21,0-40,0) 32,0 (28,0-48,0) 0,009* Δ (s) 5,0 (1,0-10,0) 6,0 (-1,0-13,0) 0,879* 9HPT 9HPT D (s) 28,3 (20,1-80,6) 25,4 (18,2-62,0) 0,007* 31,9 (26,2-45,6) 31,3 (23,5-36,8) 0,097* Δ (s) -3,3 (-18,0-0,9) -2,6 (-9,9-2,1) 0,650* 9HPT E (s) 29,6 (21,7-65,3) 26,4 (18,1-52,0) 0,028* 35,6 (25,6-40,4) 34,9 (25,6-44,3) 0,779* Δ (s) -4,5 (-13,2-6,1) 0,9 (-6,8-6,9) 0,015* Data presented as median (minimum-maximum). pa, intragroup analysis (Wilcoxon). pΔb intergroup variation comparison (Mann-Whitney). TEMPA, Test d’Évaluation des Membres Supérieurs de Personnes Âgées. R, right. L, left. s, seconds. kg, kilograms. BBT, Box and Block. 9HPT, Nine-Hole Peg Test. *Significant data (p ≤ 0.05). Table 4: Results of pre- and post-intervention questionnaires Virtual Reality Games (n=10) Board Games (n=10) PRE POST p a PRÉ POST p a pΔ b MDS-UPDRS II Total 12,0 (2,0-29,0) 10,5 (2,0-25,0) 0,011* 15,5 (12,0-20,0) 10,5 (9,0-15,0) 0,005* Δ -3,0 (-12,0-0,0) -5,0 (-7,0- -2,0) 0,092* III Total 18,0 (7,0-26,0) 14,0 (6,0-19,0) 0,031* 15,0 (9,0-19,0) 15,0 (9,0-17,0) 0,334* Δ -4,0 (-13,0-4,0) 0,0 (-2,0-2,0) 0,039* PDQ-39 Mobility 37,5 (2,5-67,5) 17,5 (7,5-77,5) 0,382* 65 (20,0-72,5) 17,5 (15,0-77,5) 0,034* Δ -1,2 (-30,0-10) -16,2 (-50,0-10) 0,181* ADL 41,6 (0,0-100) 29,1 (0,0-83,3) 0,027* 27,0 (0,0-50,0) 27,0 (0,0-58,3) 0,864* Δ -4,1 (-50,0-0,0) -4,1 (-8,3-16,6) 0,509* Emotional well-being 45,8 (8,3-75,0) 20,8 (0,0-50,0) 0,011* 58,3 (4,1-75,0) 20,8 (0,0-45,8) 0,036* Δ -8,3 (-29,1-0,0) -16,6 (-45,8-4,1) 0,703* Stigma 50,0 (0,0-68,7) 31,2 (0,0-43,7) 0,035* 12,5 (0,0-60,0) 12,5 (0,0-31,2) 0,480* Δ -12,2 (-28,7-6,2) 0,0 (-28,7-6,2) 0,213* Social support 0,0 (0,0-50,0) 0,0 (0,0-50,0) 1,000* 8,3 (0,0-50,0) 0,0 (0,0-50,0) 0,158* Δ 0,0 (-8,3-41,6) -8,3 (-33,3-41,6) 0,134* Cognition 25,0 (6,2-62,5) 25,0 (0,0-62,5) 1,000* 25 (0,0-33,3) 21,8 (0,0-43,7) 0,339* Δ 0,0 (-37,5-18,7) -1,0 (-6,2-18,7) 0,697* Communication 25,0 (8,3-66,6) 25,0 (8,3-66,6) 1,000* 16,6 (0,0-41,6) 14,1 (0,0-41,6) 0,044* Δ 0,0 (-25,0-33,3) -8,3 (-16,6-0,0) 0,010* Bodily discomfort 33,3 (8,3-50,0) 33,3 (11,1-50,0) 0,952* 29,1 (16,6-75,0) 29,1 (0,0-91,6) 0,351* Δ 1,3 (-25,0-25,0) -8,3 (-16,6-16,6) 0,470* Total 36,8 (6,4-80,7) 28,2 (5,7-68,5) 0,049* 35,8 (8,9-42,9) 19,5 (4,4-41,0) 0,012* Δ -2,2 (-15,8-1,9) -8,0 (-23,7-0,6) 0,197* MoCA Total 24,0 (18,0-29,0) 26,0 (16,0-29,0) 0,605* 23,0 (19,0-29,0) 23,0 (20,0-30,0) 0,070* Δ 0,5 (-2,0-5,0) 0,5 (0,0-4,0) 0,716* Data presented as median (minimum-maximum). pa, intragroup analysis (Wilcoxon). pΔb intergroup variation comparison (Mann-Whitney). MDS-UPDRS: Unified Parkinson’s Disease Rating Scale; Part II, Activities of Daily Living; Part III, Motor. PDQ-39, Parkinson’s Disease Questionnaire (scoring). MoCA, Montreal Cognitive Assessment. *Significant data (p ≤ 0.05). Figure 1. Flowchart Supplementary Material File (table1.docx) Download 664.21 KB File (table2.docx) Download 15.59 KB File (table3.docx) Download 20.12 KB File (table4.docx) Download 19.47 KB File (title pageejn.docx) Download 15.59 KB Information & Authors Information Version history V1 Version 1 24 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords activities of daily living parkinson disease play and playthings virtual reality Authors Affiliations Philipe Corrêa UFCSPA View all articles by this author Carolina Thomazi UNICNEC View all articles by this author Arthur Lahude UFCSPA View all articles by this author Jênifer Cemim UNICNEC View all articles by this author Sandy Witt UNICNEC View all articles by this author Maria Eduarda Cabeleira UFCSPA View all articles by this author Gustavo de Castro Barroso 0000-0003-1090-2828 [email protected] UFCSPA View all articles by this author Fernanda Cechetti Universidade Federal de Ciencias da Saude de Porto Alegre View all articles by this author Metrics & Citations Metrics Article Usage 178 views 115 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Philipe Corrêa, Carolina Thomazi, Arthur Lahude, et al. VIRTUAL AND BOARD GAMES AS THERAPEUTIC RESOURCES FOR UPPER LIMB FUNCTIONALITY IN PARKINSON’S DISEASE: A PILOT STUDY. Authorea . 24 September 2025. 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