User experience of a custom augmented reality-based exergame for children with cerebral palsy and acquired brain injuries

User experience of a custom augmented reality-based exergame for children with cerebral palsy and acquired brain injuries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article User experience of a custom augmented reality-based exergame for children with cerebral palsy and acquired brain injuries Maxime Balloufaud, Arnaud Boujut, Romain Marie, Mireille Belle Mbou Okassa, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8223292/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Conventional pediatric rehabilitation for cerebral palsy (CP) or acquired brain injury (ABI) prioritizes motor outcomes, often neglecting cognitive deficits and their interplay. Sessions are often perceived as repetitive and demotivating, reducing engagement. Immersive exergaming, especially through augmented reality (AR), enables simultaneous cognitive-motor training in safe, interactive settings. There is little evidence on immersive exergames for these children, and no immersive AR exergames target cognitive-motor rehabilitation or report on user experience (UX). Objective This study aims to assess the overall UX of a purpose-built immersive AR exergame for children with brain injuries. Methods Twenty-nine children (11.8 ± 1.6 years; 12 CP / 17 ABI) participated in two sessions using the Microsoft HoloLens2, each involving one cognitive-motor AR game (AR Corsi and AR Zoo). UX was assessed through standardized questionnaires: System Usability Scale (usability), Technology Acceptance Model (acceptance), AttrakDiff (perceived experience quality), MeCue (emotions), Intrinsic Motivation Inventory (motivation), and Rating scale of Perceived Exertion for Children (fatigue). Results The exergame was well accepted and perceived as easy to use. Scores for motivation, emotions, and perceived experience quality were high and positive. A small but significant increase in mental and physical fatigue was observed after the sessions (P < .01). No significant differences were found between the two game conditions. Conclusion This immersive AR exergame demonstrates a positive UX in children with brain injuries, supporting its potential use in rehabilitation. These results emphasize the importance of conducting comprehensive UX assessments when developing innovative rehabilitation tools and provide a basis for future investigations into therapeutic impact. Immersive Augmented Reality Exergame User Experience Cognitive-Motor Brain Injuries Pediatric rehabilitation Figures Figure 1 Figure 2 Figure 3 Introduction Cerebral palsy (CP) and acquired brain injury (ABI) are among the most common pediatric neurological disorders (Gmelig Meyling et al., 2022 ; Rosenbaum, 2017 ). They produce heterogeneous motor impairments affecting gait, posture and muscle tone (Baird et al., 2022 ; Salazar-Torres et al., 2024 ). Sensory and cognitive deficits are frequent (Blasco et al., 2023 ; Wotherspoon et al., 2023 ), particularly in visuospatial processing (Ego et al., 2015 ) and executive function (EF) such as working memory, mental flexibility, and inhibitory control (Chevignard et al., 2023 ; Pereira et al., 2018 ; Sadozai et al., 2024 ). Together, motor and EF limitations exacerbate difficulties in dual-task situations (Pena et al., 2019 ), and restrict participation in daily life (e.g., walking and navigating a space while following instructions (Almasri & Alquaqzeh, 2023 ; Makris et al., 2021 ). Few studies incorporate a cognitive dimension directly into the motor task in the context of rehabilitation, even though this approach more accurately reflects the daily activities of these children (Nossa et al., 2022 ; Novak et al., 2020 ). Most current rehabilitation approaches remain largely repetitive and sequential, with a predominant focus on motor rehabilitation (Novak et al., 2020 ; Salazar-Torres et al., 2024 ), while cognition is only sporadically addressed and often considered secondary objectives (Pedersen et al., 2023 ; Uhre et al., 2024 ). Recent review shows that rehabilitation should therefore target simultaneous motor–cognitive performance (Herold et al., 2018 ) and promote functional transfer to real-world activities (Rubsam et al., 2025 ). In this perspective, exergames—defined as interactive digital games that require purposeful physical exercise—are increasingly investigated in pediatric rehabilitation (Manser et al., 2025 ; Marsigliante et al., 2024 ; Polizzi et al., 2024 ). These playful, motivating, and customizable games simultaneously engage motor and cognitive functions, thereby enhancing children's engagement while reinforcing dual task mechanisms (Grosboillot et al., 2024 ; Iosa et al., 2022 ; S. Li et al., 2022 ). Several studies have shown that exergames can improve both motor and cognitive abilities in children with CP or ABI, with effects often comparable, and sometimes even superior, to those observed in traditional rehabilitation programs (Komariah et al., 2024 ; F. Li et al., 2025 ; Polizzi et al., 2024 ; Tobaiqi et al., 2023 ; Velasco Aguado et al., 2025 ). Many exergames use extended reality (XR) to deliver interactive tasks (Lampropoulos et al., 2025 ). XR includes virtual reality (VR), which immerses the user in a digital environment, and augmented reality (AR), which overlays digital content onto the real world (Lampropoulos et al., 2025 ; Rauschnabel et al., 2022 ). According to the theoretical model proposed by Rauschnabel et al. ( 2022 ), VR is organized along a telepresence continuum, which corresponds to the degree to which the user feels present in the virtual rather than the physical environment (Rauschnabel et al., 2022 ). This continuum extends from holistic VR (full immersive experience) to atomistic VR (partial virtual experience), which can be interpreted as the use of non-immersive technologies, a form most commonly found in exergames using commercially available systems such as Microsoft Kinect or Nintendo Wii (F. Li et al., 2025 ; Polizzi et al., 2024 ; Tobaiqi et al., 2023 ), which do not sufficiently apply motor learning principles that are nonetheless essential to optimize the effectiveness of rehabilitation for these children (Demers et al., 2021 ; Kilcioglu et al., 2023 ). Moreover, in these configurations, the child interacts via a television or computer screen, and although the experience may be enjoyable, the level of immersion, defined as the feeling of being “inside” the activity, remains limited. Immersive technologies, such as head-mounted displays (HMDs), may further enhance children’s engagement and motivation and amplify the benefits of exergames by increasing both practice intensity and level of involvement. When implemented in custom-built exergames specifically tailored to the rehabilitative needs of children with CP or ABI, they offer additional advantages over recreational commercial games (Manser et al., 2025 ). To date, the use of immersive technologies remains limited for the rehabilitation of children with CP and ABI. A few recent studies involving immersive VR have begun to demonstrate its benefits, particularly in enhancing motivation and improving certain motor dimensions (e.g., posture, gross motor function) (Lim et al., 2025 ; Maggio et al., 2024 ). However, this technology also presents several limitations, including the risk of cybersickness and limited interaction with the physical environment (Rauschnabel et al., 2022 ; Souchet et al., 2023 ). In this context, the emergence of immersive AR offers promising new perspectives for pediatric rehabilitation (Iosa et al., 2022 ; Yoo & Son, 2023 ). Immersive AR presents specific advantages that make it particularly relevant for the cognitive-motor rehabilitation of these children. Unlike VR, AR allows real-time perception of the physical environment, promoting more natural and safer bodily movements and displacements (Malick et al., 2022 ). It also helps reduce adverse effects such as cybersickness (Kirollos & Merchant, 2023 ) while maintaining a high level of immersion and interaction (Rauschnabel et al., 2022 ). By integrating visual cues from the real world, AR reduces apprehension, enhances engagement, learning, self-esteem, active involvement, and makes the experience more intuitive and stimulating, making it particularly relevant for the cognitive-motor rehabilitation of children with CP and ABI (Tobaiqi et al., 2023 ). Another advantage of this type of HMDs is that it can be used in different environments of the child’s daily life (rehabilitation centers, assisted living facilities, family homes). However, despite the potential of these technologies, studies using immersive AR have focused exclusively on gait training (Guinet et al., 2021 , 2022 ), without incorporating cognitive components or dual task training, which are nonetheless essential in the rehabilitation of these children. In this context, we developed the first custom AR exergame specifically dedicated to the cognitive-motor training with incorporated cognitive tasks of children with CP or ABI (Balloufaud et al., 2025 ). To do so, we relied on the MIDE framework (Multidisciplinary Iterative Design of Exergames) (Y. Li et al., 2020 ), an iterative, transdisciplinary, and user-centered guide grounded in co-design principles to create solutions that are as relevant, tailored, and effective as possible (Petrevska et al., 2025 ; Willingham et al., 2024 ), while actively involving the child in the process. A preliminary testing phase is first conducted with typically developing children (Balloufaud et al., 2025 ) to validate game mechanics and identify necessary improvements (Le Roy et al., 2024 ; Shah et al., 2023 ). The positive results obtained from this step now allow us to use the system with children with brain injuries. However, before assessing its therapeutic effectiveness, several methodological steps must be followed. Evaluating the user experience (UX) is a critical intermediate step, especially when dealing with a completely new custom exergame, as a satisfactory UX is considered a prerequisite for achieving therapeutic efficacy (Lallemand, 2018 ; Y. Li et al., 2020 ; Perez et al., 2025 ). UX results from a complex interaction between three fundamental components: the user, the system, and the context (Hassenzahl & Tractinsky, 2006 ). Several holistic and multidimensional theoretical models have been proposed to capture the different components of UX and their interactions, such as the model by Hassenzahl ( 2001 , 2003 ), which emphasizes the importance of combining the designer’s intention and the user’s subjective perception by evaluating the pragmatic and hedonic qualities of the system (Hassenzahl, 2001 , 2003 ). Another closely related model is that of Mahlke (2007), which also integrates emotions, considered central to the perception of instrumental qualities (usability, utility, etc.) and non-instrumental qualities (aesthetics, motivations) (Thüring & Mahlke, 2007 ). In the field of immersive exergames, UX can be influenced by various factors such as system functionality, content, aesthetics, interaction and immersion in the gaming environment (Chenais & Görgen, 2024 ; Kojić et al., 2023 ; Lorenz et al., 2024 ; Perez et al., 2025 ; Perrochon et al., 2025 ). Therefore, the assessment of UX in XR-based systems should be guided by these theoretical models and be as comprehensive as possible. However, to date, the available data on UX assessment of immersive exergames for the rehabilitation of children with CP or ABI remain very limited and tend to focus only on a few subcomponents most often usability (Ammann-Reiffer et al., 2022 ; Camardella et al., 2025 ), which is the most frequently assessed (Perez et al., 2025 ). Other dimensions, such as motivation and emotions, are often underassessed, despite their central role in multidimensional UX models (Hassenzahl, 2001 , 2003 ; Thüring & Mahlke, 2007 ), which is particularly problematic in pediatric rehabilitation where engagement with new technologies relies heavily on these factors (Iosa et al., 2022 ; Tobaiqi et al., 2023 ). The studies by Ammann-Reiffer (2022) and Camardella et al. ( 2025 ) are the only ones that have evaluated the UX of an immersive VR exergame designed for children with brain injuries, using HMD devices (Ammann-Reiffer et al., 2022 ; Camardella et al., 2025 ). In the case of Ammann-Reiffer’s (2022) study, the children responded positively to the system, with good ease of use and a strong sense of presence, while the therapists noted the absence of negative impact on movements and a higher level of engagement compared to that observed in conventional rehabilitation. This lack of studies represents a significant gap, as evaluating multiple UX components (Hassenzahl, 2001 , 2003 ; Thüring & Mahlke, 2007 ) is essential to determine whether a game meets users’ needs and has potential for successful implementation. Yet, to date, no equivalent AR exergame exists, and no studies have reported on the UX of these children using such technologies in rehabilitation settings. The main objective of this study is to assess the UX in terms of usability, acceptance, quality of perceived experience, motivation, emotions, and fatigue of our exergame, which consists of two AR games designed for the cognitive-motor rehabilitation of children with brain injuries. Additionally, this study aims to determine whether there are significant differences in UX outcomes between the two AR games. Based on the literature on exergame design and development for this population, as well as our previous study, we hypothesize that the AR exergame will be easily usable by CP and ABI children. We expect positive outcomes in terms of acceptance, attractiveness, motivation, and emotional responses. We also hypothesize that AR-based sessions will lead to an increase in physical and mental fatigue, but that this increase will remain moderate and within acceptable limits for rehabilitation in this population, without exceeding excessive thresholds. Finally, based on our previous study and given that both games are designed from the same core structure, we do not expect significant differences in UX results between the two games. Methods Population Patients were recruited from a neurological rehabilitation center and a motor education institute in France, following a pre-inclusion visit where the investigator confirmed eligibility through clinical examination. To be included in the study, patients had to meet the following criteria: (1) aged 10 to 16 years and diagnosed with CP or ABI; (2) sufficient oral comprehension skills to follow instructions and interact with the protocol; (3) affiliation with French social security; (4) personal assent to participate in the study; and (5) written informed consent from their legal representatives. Patients were excluded from the study if they met any of the following criteria: (1) a motor level greater than 3 according to the Gross Motor Function Classification System (GMFCS); (2) contraindications to using new technologies, such as photosensitive epilepsy; (3) atypical or uncorrected visual and/or hearing impairment; (4) an unstable medical condition; (5) simultaneous participation in another research protocol likely to interfere with the assessment of the AR exergame; or (6) refusal of participation by the child or their family. This study received approval from the ethical and individual protection board of Ile de France VIII (specific reference number: 2023-A00904-41) with a favorable decision obtained on June 19, 2023, and was registered on ClinicalTrials.gov (NCT06944613) AR exergame The methodology used in this study follows that of our previous work with healthy children, in which the design and technical specification of the two AR games were detailed (Balloufaud et al., 2025 ). AR games run on a HoloLens 2 head-mounted display, and therapists manage exercises with a Lenovo TAB M10 Plus tablet. Games The design of our cognitive-motor games is based on a balance between the playful aspect, with engaging game elements, mechanics, and dynamics, and a clinically grounded approach (Lyons, 2015 ; Tao et al., 2021 ). We drew upon existing literature by adapting validated cognitive tests to locomotor activities in the form of interactive games, which enabled us to create tasks in which the cognitive component is fully incorporated into the motor task (Herold et al., 2018 ). Each game includes different variants specifically designed to target EF such as working memory, cognitive flexibility, and inhibition. Furthermore, our development is guided by principles of motor learning (Demers et al., 2021 ; Foscan et al., 2024 ), incorporating features such as gradual progression, a high volume of repetitions, goal-oriented tasks, and tailored feedback, elements that are known to stimulate neuroplasticity and support the acquisition of motor skills (Demers et al., 2021 ; Kilcioglu et al., 2023 ). AR Corsi (Figure. 1A and Multimedia Appendix 1) The AR Corsi game, inspired by Magic Carpet (Belmonti et al., 2015 ; Demichelis et al., 2013 ; Meilinger et al., 2011 ; Perrochon et al., 2014 ) and the Virtual Walking Corsi Test (Perrochon et al., 2018 ), adapts the Corsi Block-tapping Test (Corsi, 1972 ) to the locomotor space, aiming to work on spatial orientation, visuospatial memory, and cognitive navigation strategies (Kronovsek et al., 2021 ). The game offers several variants (Balloufaud et al., 2025 ) : the "Classic" condition, where patients memorize a sequence of virtual floor tiles that light up one after another and reproduce it by walking on them in the real environment; the “Classic with objects” condition, which integrates spatial landmarks on the tiles to induce the development and use of alternative cognitive strategies; the "Virtual Agent" condition, where a virtual agent walks across the tiles following the illuminating sequence; and finally, the "Advanced" condition, which adds a dimension of inhibition and cognitive flexibility by asking the player to memorize certain tiles while inhibiting those that light up in red. AR Zoo (Figure. 1B and Multimedia Appendix 2) The AR Zoo game is an adaptation of the Zoo Map Test, a commonly used assessment tool to measure executive functions in children (Ballhausen et al., 2017 ; Engel-Yeger et al., 2009 ; Romundstad et al., 2022 ). In the traditional neuropsychological test, patients must plan a route through a zoo while respecting various constraints, such as choosing the fastest route and avoiding retracing steps. The AR Zoo game draws from this concept to target spatial orientation, planning, and cognitive navigation strategies (Balloufaud et al., 2025 ). In this AR version, the list of animals to visit is displayed at the beginning of each sequence and remains visible on the initial tiles, requiring patients to plan their full route before taking any action. The game presents three conditions: the "Classic" condition, where the player must plan and follow the optimal path to visit the animal enclosures; the "Virtual Agent" condition, where a virtual agent shows the optimal path; and the "Advanced" condition, which adds a further challenge by asking the player to adapt and plan a new route when obstacles appear. Legend : Representations of the AR Corsi (A) and AR Zoo (B) game environments. These illustrations depict the child within their real-world environment, along with the virtual environment that only the child can see through the AR headset. The procedure The procedure, previously described by Balloufaud et al., 2025 (Balloufaud et al., 2025 ), involved two AR sessions spaced one week apart, during which each child played one of the two games (90 minutes including breaks). The order of the games was counterbalanced across patients. Each session included three steps: (1) a pre-session assessment conducted after a short presentation video, including a pre-use technology acceptance questionnaire (TAM) and baseline ratings of pre-session physical and mental fatigue (RPE-C); (2) the main session, with a familiarization phase followed by gameplay using one of the two AR games. For each condition, difficulty increased progressively; children advanced after completing at least one of two trials, otherwise they moved to the next condition; (3) a post-session assessment with questionnaires on usability (System Usability Scale, SUS), post-use acceptance (Technology Acceptance Model, TAM), quality of perceived experience (AttrakDiff), emotions (MeCue), motivation (Intrinsic Motivation Inventory, IMI), and post-session physical and mental fatigue (Rating of Perceived Exertion for Children, RPE-C). UX assessment The usability of the device was assessed using the SUS questionnaire (Brooke, 1995 ). This tool was widely used in immersive technology assessment studies, including AR with the HoloLens 2 (Balani & Tümler, 2021 ). It consisted of 10 statements to which children responded by indicating their level of agreement on a 5-point Likert scale, ranging from "Strongly disagree" to "Strongly agree." The total score was then transformed into a standardized usability index, where a score above 85 was considered "excellent," a score between 75 and 85 was considered "good," and a score between 50 and 75 was considered "acceptable" (Bangor, 2009 ). The acceptance of the device before and after use was measured using the extended version of TAM (Davis, 1989 ; Venkatesh & Davis, 2000 ), proposed by Manis and Choi ( 2019 ) (Manis & Choi, 2019 ), based on four dimensions: perceived usefulness, perceived ease of use, perceived enjoyment, and behavioral intention to use. The pre-use assessment was conducted after a presentation of the game and its conditions through video supports. Children evaluated three statements per dimension (12 items in total) on a 7-point Likert scale ("Strongly disagree" to "Strongly agree"). Each dimension was analyzed independently. We chose to assess acceptance of the system at two different time points, pre- and post-use, as proposed by Mascret et al. (Delbes et al., 2022 ; Mascret et al., 2025 ). Evaluating technology acceptance prior to any actual use allowed for the identification of potential initial barriers and psychological factors that could lead to rejection before any hands-on experience with the device, and enabled the comparison of acceptance levels before and after use to observe whether the UX strengthened or weakened acceptance of the device (Mascret et al., 2025 ). Quality of perceived experience was evaluated using the AttrakDiff questionnaire (Hassenzahl et al., 2003 ; Lallemand et al., 2015 ), a recognized tool for analyzing the subjective perception of interactions with digital systems. It included 28 items divided into four dimensions: pragmatic quality, hedonic quality (stimulation), hedonic quality (identity), and overall attractiveness. Items were presented as pairs of opposite words, rated on a 7-point semantic differential scale (-3 to + 3). Scores for each dimension were analyzed independently: values between 0 and 1 reflected a functional but improvable UX, while positive scores (1 to 3) indicated favorable perception, and negative scores (-1 to -3) pointed to potential areas for improvement. The patients' motivation was evaluated using the IMI (Ryan et al., 1983 ). Among its seven dimensions, four were selected as particularly relevant for this study: Interest/Enjoyment, Perceived Competence, Effort/Importance, and Pressure/Tension, totaling 23 items. Each statement was rated on a 7-point Likert scale, from "Strongly disagree" to "Strongly agree," and scores were analyzed separately for each dimension. In addition, the UX assessment included the emotional dimension from the MeCUE questionnaire (Lallemand & Koenig, 2017 ; Minge et al., 2017 ), where children rated their feelings about eight emotions (four positive and four negative) using a 7-point Likert scale ranging from "Strongly disagree" to "Strongly agree." The side effects related to cognitive and physical effort (mental and physical fatigue) were assessed before and after session using the visual analog scales from the RPE-C (Groslambert et al., 2001 ). The scale ranged from 6 ("no fatigue") to 20 ("extreme fatigue") and included pictograms of expressive faces to facilitate understanding and self-assessment by children. Statistical Analysis Quantitative variables were described as mean ± standard deviation or median [Q1; Q3], depending on the normality of their distribution. The normality of distributions was assessed using the Shapiro-Wilk test. Consistent with our previous study (Balloufaud et al., 2025 ), the required sample size for this study was estimated at 30 patients. This calculation was based on an expected SUS score of 75, an effect size of 0.65, an alpha risk of 5%, a statistical power of 90%, and a dropout margin of 15% (Balani & Tümler, 2021 ). Data from the SUS and AttrakDiff questionnaires were analyzed using descriptive statistics, with mean scores calculated for SUS (both games) and mean or median values reported for each AttrakDiff dimension per game. Two tailed one-sample t-tests were performed for the emotion item of the MeCue questionnaire, as well as for the four dimensions of the IMI and TAM questionnaires, to determine whether the scores differed significantly from the theoretical value of 4 on a 7-point Likert scale for each game. This method was used in studies employing Likert scales to assess whether patients’ perceptions significantly differed from a judgment considered neutral (Delbes et al., 2022 ; Mascret et al., 2025 ; Mascret & Temprado, 2023 ). Additionally, to examine the change in acceptance between the pre- and post-session assessment, a Wilcoxon rank test was used to compare the scores before and after the use of the AR device for each TAM dimension and each game. A mixed analysis of variance (ANOVA) was conducted to examine the main effects of the factors "Time" (pre- and post-session) and "Game" (AR Corsi and AR Zoo), as well as their interactions on physical and mental fatigue. Depending on the data distribution, an independent sample T-test or a Mann-Whitney test was used to determine whether there are significant differences between the two games. All statistical analyses were conducted using RStudio® software (version 2025.05.1 + 513), with a significance threshold set at p < 0.05. Results Of the 43 eligible children contacted during follow-up consultations, 30 (70%) agreed to participate. One was lost to follow-up, and data from 29 patients (12 with CP, 17 with ABI; 8 girls, 21 boys; mean age 11.8 ± 1.6 years) were analyzed. Socio-demographic and clinical characteristics are summarized in Table 1 . Table 1 Socio-demographic and clinical characteristics of patients Characteristics Patients (n = 29) Age (mean ± SD) 11.8 ± 1.6 years Sex (F / M) 8 (28%) / 21 (72%) Brain injuries (CP / ABI) 12 (41%) / 17 (59%) GMFCS (Ι / ΙΙ / ΙΙΙ) 25 (86%) / 3 (10%) / 1 (4%) Motor disabilities (%) Diplegia Hemiplegia Fine motor skills 16 of 29 (55%) 1 5 10 Fatigue (%) 22 (76%) Pains (%) 8 (28%) Intellectual disabilities (%) 1 (3%) Slowdown (%) 7 (24%) Cognitive disorders (%) Attention deficit disorders Memory disorders Executive disorders Praxic disorders 25 of 29 (86%) 20 8 19 5 Sensory disorders (%) 12 (41%) The effective gameplay durations of AR Zoo (43.0 ± 13.7 minutes) was significantly longer than that of AR Corsi (33.4 ± 6.7 minutes) (P 0.05). The results regarding the acceptance before and after the use of the devices are presented in Fig. 2 . For the four TAM dimensions, the median scores were significantly higher than the theoretical scale value of 4, both before and after using the AR Corsi and AR Zoo games (P < 0.001). Regarding the behavioral intention to use dimension for the AR Corsi game, a significant increase between the pre-use assessment (6.3 [5.0–6.7]) and post-use assessment (7.0 [5.3–7]) (P < 0.05). Similarly, for the Perceived ease of use dimension of the AR Zoo game, a significant improvement was observed between the pre-use assessment (6.3 [5.3–7]) and post-use assessment (7.0 [6.0–7.0]) (P 0.05). Legend: Comparison of pre- and post-acceptance assessments for the four TAM dimensions (Perceived Usefulness, Perceived Ease of Use, Perceived Enjoyment, Behavioral Intention to Use) in the AR Corsi and AR Zoo games. The dashed red line represents the theoretical value set for the Likert scale (i.e., 4). For each variable, results are presented by the median, first and third quartiles (Q1 and Q3), and extreme values. * p < 0.05, ** p < 0.01, *** p < 0.001, NS = not significant . The results of the AttrakDiff questionnaire are presented in Fig. 3. The scores for pragmatic quality are (AR Corsi: 1.5 ± 0.9; AR Zoo: 1.4 ± 1.1), stimulation (AR Corsi: 1.5 ± 0.9; AR Zoo: 1.2 ± 0.6), identity (AR Corsi: 1.4 ± 1.0; AR Zoo: 1.3 ± 0.8), and overall attractiveness (AR Corsi: 2.2 ± 1.1; AR Zoo: 2.2 ± 1.0). No significant differences were found between the two AR games for any of the four dimensions (P > 0.05). Figure 3. Radar Chart of mean scores for the Attrakdiff questionnaire dimensions for AR Corsi and AR Zoo. Legend: Graphical representation of the mean scores for the four AttrakDiff dimensions: overall attractiveness, pragmatic quality, identity, and stimulation. The scores are interpreted as follows: a mean between 3 and 1 reflects a positive aspect of the device, between 1 and − 1 a neutral point, and between − 1 and − 3 a negative aspect of the device. Regarding motivation, the perceived competence (AR Corsi: 5.6 [5.3–6.6]; AR Zoo: 6.16 [5.5–6.5]) and interest/enjoyment (AR Corsi: 6.6 [6–7]; AR Zoo: 6.4 [6–6.8]) dimensions were significantly higher than the theoretical scale value of 4 (P < 0.001) for both games. For the "effort importance" dimension, the scores were also significantly higher than the theoretical value, with AR Corsi at 4.8 [3.4–6.4] (P < 0.05) and AR Zoo at 5.2 [3.8–6.8] (P < 0.01). In contrast, for the "Pressure/Tension" dimension, the averages were significantly lower than the theoretical scale value (P 0.05). In the emotions module of the MeCue questionnaire, patients gave a median score of 6.62 [5–7] for the Corsi game and 5.75 [5.13–6.63] for the Zoo game, both significantly higher than the theoretical scale value of 4 (P 0.05). The mental fatigue scores measured before and after the use of the games were as follows: for AR Corsi, the mean increased from 8.2 ± 2.6 to 9.4 ± 3.2, and for AR Zoo, from 7.9 ± 2.7 to 9.5 ± 3.6. Regarding physical fatigue, the mean scores changed from 7.7 ± 2.7 to 8.2 ± 2.8 for AR Corsi, and from 8.1 ± 2.8 to 9.1 ± 3.0 for AR Zoo. The mixed ANOVA results demonstrated a statistically significant main effect of the "Time" factor on both physical and mental fatigue, with p-values of P < 0.01 and P 0.05). Discussion The main objective of this study was to assess the UX of a custom AR exergame designed for the cognitive-motor rehabilitation of children with CP or ABI. The secondary objective was to determine whether UX differed significantly between the two games (AR Corsi and AR Zoo). The results indicated an overall very positive UX, with no notable difference between AR Corsi and AR Zoo. The usability scores obtained from the SUS questionnaire are considered good, with an average close to 78.5 out of 100, indicating that both games are usable by these children (Brooke, 1995 ), and also acceptable according to the SUS interpretation criteria proposed by Bangor et al. (2009) (Bangor, 2009 ). These usability results are very similar to those observed in our previous study conducted with typically developing children (average close to 78.1 out of 100) (Balloufaud et al., 2025 ), suggesting that the game’s ergonomics are appropriate and do not present usability barriers for clinical populations. Concerning acceptance, TAM results collected before and after the use of the games confirm that our exergame is well accepted by children. Among the 29 children included in our study, no initial reluctance was reported toward using either of the two games. For both games, scores across the four TAM dimensions were consistently and significantly above the threshold of 4, both before and after use. These findings are encouraging, as they indicate that interacting with the game further strengthened the children’s positive perceptions and enhanced their overall experience with the device. Our games are therefore perceived as useful, easy to use, and enjoyable, all of which contribute to a positive behavioral intention to use. But, the majority of studies most often focus on only one or two subcomponents of UX, particularly acceptance and usability, which are among the most frequently assessed dimensions (Consales et al., 2024 ; Perez et al., 2025 ), as opposed to hedonic components, which are equally important in multidimensional UX models (Hassenzahl, 2001 , 2003 ; Thüring & Mahlke, 2007 ). Perceived quality of experience was assessed using the AttrakDiff questionnaire. Results showed strong pragmatic and hedonic qualities (notably stimulation and identity) and high overall attractiveness, with all dimensions in the positive range (1 to 3) according to Hassenzahl et al. ( 2003 ), indicating that the system was perceived as engaging and well-designed by the children (Hassenzahl et al., 2003 ; Lallemand et al., 2015 ). These findings are broadly consistent with those previously observed in typically developing children (Balloufaud et al., 2025 ), with the notable exception that the “identity” dimension was rated higher by children with CP or ABI. This difference can be explained by the fact that the games were specifically designed to meet their needs, making them more likely to identify with the games and perceive them as useful and relevant for their rehabilitation, unlike typically developing children. With regard to motivation, we specifically chose to assess intrinsic motivation, as according to the self-determination theory by Ryan and Deci ( 2000 ), it refers to performing an activity for the inherent pleasure and interest it provides (Ryan & Deci, 2000 ). In the context of rehabilitation, this means that a child will choose to play the exergame willingly, because they find it fun and rewarding, rather than out of obligation (Biddiss et al., 2021 ; Iqbal et al., 2025 ). In our study, high scores on the IMI for the perceived competence and interest/enjoyment dimensions indicate that the children found the games appropriately challenging, felt capable of succeeding, and genuinely enjoyed the activity. The effort/importance dimension was also significantly elevated, suggesting that the children were actively engaged and valued their performance, without the activity feeling burdensome. Finally, the low scores on the pressure/tension dimension suggest that the children did not find the experience stressful or demanding. Positive motivation is generally accompanied by positive emotions, which was precisely the case in our study. Children reported significantly elevated levels of positive emotions, with scores exceeding the theoretical midpoint of 4 on the MeCue. This emotional response indicates that the experience was perceived as enjoyable and rewarding, thereby reinforcing the appeal of the activity (Pavic et al., 2022 ). These favorable emotions and strong intrinsic motivation likely supported sustained engagement in a safe and rewarding environment, enabling frustration-free progress and success. It was also important to assess the fatigue data induced by our exergame, since fatigue can influence overall UX and children with CP or ABI are known to be particularly vulnerable to fatigue-related disorders (Proschowsky et al., 2024 ; Puce et al., 2021 ). As expected from our previous study with typically developing children (Balloufaud et al., 2025 ), a statistically significant increase in both physical and mental fatigue was observed post-session in children with CP or ABI, although levels remained slight and no signs of exhaustion were reported during the session (mental fatigue reached 9.4 out of 20, and physical fatigue 8.6 out of 20). These low levels of fatigue are likely due to the relatively low exercise intensity inherent to our exergame’s design, which involves motor-cognitive training with incorporated cognitive tasks. As the literature does not provide recommendations regarding the optimal duration or intensity of immersive AR sessions for this population, it will be necessary in the future to personalize these exercises according to each child’s individual capacities, in order to ensure a sufficient level of intensity for each child and achieve therapeutic benefits. The positive UX observed with our exergame, composed of two cognitive-motor games, likely reflects the combined influence of a user-centered design process, theoretical foundations in game design and motor learning, a coherent gameplay architecture across games, and specific affordances of immersive AR. We believe that this favorable UX can be largely attributed to our user-centered design approach, based on the MIDE framework (Y. Li et al., 2020 ). This multidisciplinary and iterative model enabled us to anticipate and incorporate users’ needs from the earliest stages of development. The preliminary testing phase with typically developing children helped stabilize game mechanics, clarify instructions, and anticipate friction points, which provided a certain level of confidence and safety in conducting tests with children with CP and ABI, and reinforced our confidence in the positive UX outcomes observed (Balloufaud et al., 2025 ). Moreover, the development of our games was grounded in robust game design literature, incorporating elements such as progressive difficulty levels and challenge-based systems (Chenais & Görgen, 2024 ; Lyons, 2015 ; Manser et al., 2025 ; Martinez, 2022 ). We also sought to address the specific therapeutic needs of children with CP or ABI by drawing on motor learning principles, which we implemented as extensively as possible (Demers et al., 2021 ; Foscan et al., 2024 ). These elements likely contributed to shaping the children’s UX, by promoting both engagement and perceived relevance of the tasks. Additionally, by designing AR Corsi and AR Zoo around a shared central gameplay loop (Tao et al., 2021 ), we aimed to foster engagement while targeting different executive functions, and to reduce the likelihood of one game being perceived as more appealing than the other (Balloufaud et al., 2025 ). This coherent structure likely contributed to the absence of significant differences in UX ratings between the two games. In addition to the user-centered design principles and the personalization of our games, certain characteristics specific to immersive environments, as described by Hameed et al. ( 2024 ) such as immersion, interactivity, explorability, plausibility, and credibility may have contributed to the positive UX outcomes observed in our study (Hameed et al., 2024 ). Furthermore, the visual awareness of the environment, which is a specific feature of immersive AR (Kirollos & Merchant, 2023 ), likely helped limit side effects while enhancing the children’s sense of safety and the natural, intuitive quality of their interaction (Partarakis & Zabulis, 2024 ; Yang et al., 2021 ). However, it is important to note that these remain assumptions, as these specific characteristics were not directly assessed in this study, although the literature is beginning to provide preliminary evidence in that direction (Ahmed et al., 2025 ; Perrochon et al., 2025 ). Perspectives The aim of our study was to obtain an initial assessment of the UX of our AR exergame. To this end, we evaluated UX during two initial sessions; however, these results should be interpreted with caution. The children played each of our two games only once, and the initial enthusiasm generated by the discovery of an innovative immersive technology may have induced a “wow effect,” potentially biasing the highly positive assessments collected in this study. It will therefore be essential, in the next phases of the project, to assess UX longitudinally to determine whether our exergame continues to offer a good UX over time. In addition, to enrich and strengthen our future UX assessments, we plan to include new subcomponents specific to immersive environments (e.g., cybersickness, immersion, flow), which are likely to influence UX (Perrochon et al., 2025 ) and have not yet been considered in our studies. To do so, we could rely on theoretical models specifically designed to assess UX in immersive environments (Cheiran et al., 2025 ), such as the Tcha-Tokey model, which integrates additional components likely to influence UX, including immersion and flow (Tcha-Tokey et al., 2018 )—a particularly relevant dimension to evaluate during prolonged use. In addition to this enhanced long-term assessment of UX, the next step of the project will be to assess the effectiveness of our exergame on cognitive and motor functions within a multi-week rehabilitation program. This phase will be critical for confirming the clinical relevance of the system and for guiding its integration into pediatric rehabilitation programs. In parallel with this efficacy study, we also plan to gather feedback from therapists and parents regarding the use of this new type of exergame in clinical settings. Their insights will help us better understand the perceived usefulness of the system, assess its feasibility in real-world practice, and identify any potential barriers to its adoption. Limitations: This study has several limitations. First, although our UX assessment relied on validated questionnaires and rating scales, it may still be subject to a degree of subjectivity, and a social desirability bias may have occurred, particularly among younger patients. Children eager to please the investigators, or simply happy to participate in an enjoyable and novel activity, may have been reluctant to offer criticism or express negative feedback. This bias has also been reported in other study, where the children's overwhelmingly positive reactions to a proposed game raised questions about the extent of genuine satisfaction versus a perceived obligation to meet the evaluators’ expectations (Consales et al., 2024 ). Second, it is important to note that the UX measured in this study reflects the experience of the entire system, that is, the Microsoft HoloLens 2 headset and the two games combined. We believe it is not possible to dissociate the game experience from the hardware used, as both are closely intertwined. For instance, using a different headset would likely have produced a different gameplay experience. This is precisely why we chose to use the term “system” in our questions. Although we made an effort to explain this to the children, the concept may have caused some confusion, potentially modifying their responses. Finally, a third limitation of our study lies in the composition of our participant sample, which primarily included children with good functional mobility (GMFCS level I). The limited inclusion of children with severe impairments restricts the generalizability of our findings to the broader brain-injured pediatric population. Future studies should include a more heterogeneous population in terms of both motor and cognitive abilities in order to better assess the accessibility and relevance of the exergame for more severely affected children. Conclusion Using a comprehensive, multidimensional assessment of UX, this study showed an overall highly positive UX for our custom AR exergame designed for the cognitive-motor rehabilitation of children with CP or ABI. Our exergame was found to be usable, acceptable, engaging, motivating, capable of eliciting positive emotions, and not excessively fatiguing. This favorable assessment supports the relevance of the game content and mechanics, which can largely be attributed to our user-centered design approach, based on the MIDE framework. In addition, specific features of the immersive AR environment may also have contributed to the positive UX observed. These findings suggest that our exergame is suitable for future use in rehabilitation for children with CP or ABI. More broadly, these results suggest that applying user-centered design principles and leveraging specific affordances of immersive AR may help developers create other rehabilitation exergames with similarly satisfactory UX. A satisfactory UX is a critical prerequisite for achieving therapeutic efficacy, even if it does not guarantee it. The next step in our research will be to evaluate long term UX and the therapeutic effectiveness of this exergame on the cognitive and motor functions of these children. Abbreviations ABI Acquired Brain Injury AR Augmented Reality CP Cerebral Palsy GMFCS Gross Motor Function Classification System HMD Head-Mounted Displays IMI Intrinsic Motivation Inventory MIDE Multidisciplinary Iterative Design of Exergame RPE-C Rating scale of Perceived Exertion for Children SUS System Usability Scale TAM Technology Acceptance Questionnaire UX User Experience VR Virtual Reality XR Extended Reality Statements and Declarations Acknowledgments The authors thank all the young patients, as well as the Esquirol Hospital Center and the IEM of Couzeix for their support. They also acknowledge the students from the 3iL engineering school for their contribution to the development of the augmented reality games. Finally, they thank the Nouvelle-Aquitaine region for its financial support of this project. Competing Interests: The authors declare no conflicts of interest. Data Availability Statement Anonymized data from the assessment of UX subcomponents are available from the author MB upon reasonable request. Author Contributions Conceptualization : Maxime Balloufaud, Arnaud Boujut, Romain Marie, Julia Hamonet-Torny, Anaick Perrochon ; Methodology : Maxime Balloufaud, Arnaud Boujut, Romain Marie, Julia Hamonet-Torny, Anaick Perrochon ; Formal analysis and investigation : Maxime Balloufaud, Mireille Belle Mbou Okassa, Julia Hamonet-Torny ; Writing - original draft preparation : Maxime Balloufaud ; Writing - review and editing : Maxime Balloufaud, Arnaud Boujut, Romain Marie, Mireille Belle Mbou Okassa, Laurent Fourcade, Julia Hamonet-Torny, Anaick Perrochon ; Funding acquisition : Anaick Perrochon ; Resources : Maxime Balloufaud, Arnaud Boujut, Romain Marie, Mireille Belle Mbou Okassa, Julia Hamonet-Torny, Anaick Perrochon ; Supervision : Arnaud Boujut, Anaick Perrochon References Ahmed N, Wu P, Huang K, Jung S, Rheem H, Tan G, Imani M, Islam R (2025) Human task performance and associated internal states in extended reality: A systematic review of cognitive, psychophysiological, and physiological dimensions. 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IEEE Trans Games 1–1. https://doi.org/10.1109/TG.2021.3118035 Yoo S, Son MH (2023) Virtual, augmented, and mixed reality: Potential clinical and training applications in pediatrics. Clin Experimental Pediatr 67(2):92–103. https://doi.org/10.3345/cep.2022.00731 Additional Declarations No competing interests reported. Supplementary Files MultimediaAppendix1.mp4 Multimedia Appendix 1 [AR Corsi game video] MultimediaAppendix2.mp4 Multimedia Appendix 2 [AR Zoo game video] Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8223292","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":561880230,"identity":"aa565653-11b6-4249-816b-ebf672fc995f","order_by":0,"name":"Maxime Balloufaud","email":"","orcid":"","institution":"Univ. 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1","display":"","copyAsset":false,"role":"figure","size":613189,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIllustrations of the AR Corsi game (1A) and the AR Zoo game (1B).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegend\u003c/em\u003e\u003cem\u003e\u003cstrong\u003e: \u003c/strong\u003e\u003c/em\u003e\u003cem\u003eRepresentations of the AR Corsi (A) and AR Zoo (B) game environments. These illustrations depict the child within their real-world environment, along with the virtual environment that only the child can see through the AR headset.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8223292/v1/a9fdf5e96b23ab1c61406c23.png"},{"id":98779459,"identity":"5552924d-47a1-4a30-ad65-e9e6bfaabc9b","added_by":"auto","created_at":"2025-12-22 12:30:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":308305,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of pre- and post-acceptance assessments of the TAM dimensions for AR Corsi and AR Zoo.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegend: Comparison of pre- and post-acceptance assessments for the four TAM dimensions (Perceived Usefulness, Perceived Ease of Use, Perceived Enjoyment, Behavioral Intention to Use) in the AR Corsi and AR Zoo games. The dashed red line represents the theoretical value set for the Likert scale (i.e., 4). For each variable, results are presented by the median, first and third quartiles (Q1 and Q3), and extreme values. * p \u0026lt; 0.05, ** p \u0026lt; 0.01, *** p \u0026lt; 0.001, NS = not significant\u003c/em\u003e.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8223292/v1/eacca99cbdf6137037dbd010.png"},{"id":98765139,"identity":"55c43fdc-b451-46be-b48a-8d3dd663f6a5","added_by":"auto","created_at":"2025-12-22 10:10:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":288153,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadar Chart of mean scores for the Attrakdiff questionnaire dimensions for AR Corsi and AR Zoo.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegend: Graphical representation of the mean scores for the four AttrakDiff dimensions: overall attractiveness, pragmatic quality, identity, and stimulation. The scores are interpreted as follows: a mean between 3 and 1 reflects a positive aspect of the device, between 1 and -1 a neutral point, and between -1 and -3 a negative aspect of the device.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8223292/v1/04f0425542fcea366706da15.png"},{"id":98786278,"identity":"8f285cb7-c505-4c90-9303-5a60c03f271b","added_by":"auto","created_at":"2025-12-22 12:43:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2022661,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8223292/v1/31854180-6bd6-492f-8bbe-eb789b59f724.pdf"},{"id":98765193,"identity":"22605fe4-17df-44ea-ab2d-f40575927e45","added_by":"auto","created_at":"2025-12-22 10:10:17","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":76404665,"visible":true,"origin":"","legend":"\u003cp\u003eMultimedia Appendix 1\u003c/p\u003e\n\u003cp\u003e[AR Corsi game video]\u003c/p\u003e","description":"","filename":"MultimediaAppendix1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8223292/v1/670260a287a836cf9e582545.mp4"},{"id":98765198,"identity":"8b9a402c-7b96-4dc5-b35f-570d5d7d3177","added_by":"auto","created_at":"2025-12-22 10:10:18","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":74943519,"visible":true,"origin":"","legend":"\u003cp\u003eMultimedia Appendix 2\u003c/p\u003e\n\u003cp\u003e[AR Zoo game video]\u003c/p\u003e","description":"","filename":"MultimediaAppendix2.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8223292/v1/4b3db408c301dfcc6aa4d950.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"User experience of a custom augmented reality-based exergame for children with cerebral palsy and acquired brain injuries","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCerebral palsy (CP) and acquired brain injury (ABI) are among the most common pediatric neurological disorders (Gmelig Meyling et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Rosenbaum, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). They produce heterogeneous motor impairments affecting gait, posture and muscle tone (Baird et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Salazar-Torres et al., \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Sensory and cognitive deficits are frequent (Blasco et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Wotherspoon et al., \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), particularly in visuospatial processing (Ego et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) and executive function (EF) such as working memory, mental flexibility, and inhibitory control (Chevignard et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Pereira et al., \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Sadozai et al., \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Together, motor and EF limitations exacerbate difficulties in dual-task situations (Pena et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), and restrict participation in daily life (e.g., walking and navigating a space while following instructions (Almasri \u0026amp; Alquaqzeh, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Makris et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFew studies incorporate a cognitive dimension directly into the motor task in the context of rehabilitation, even though this approach more accurately reflects the daily activities of these children (Nossa et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Novak et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Most current rehabilitation approaches remain largely repetitive and sequential, with a predominant focus on motor rehabilitation (Novak et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Salazar-Torres et al., \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), while cognition is only sporadically addressed and often considered secondary objectives (Pedersen et al., \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Uhre et al., \u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Recent review shows that rehabilitation should therefore target simultaneous motor–cognitive performance (Herold et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and promote functional transfer to real-world activities (Rubsam et al., \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this perspective, exergames—defined as interactive digital games that require purposeful physical exercise—are increasingly investigated in pediatric rehabilitation (Manser et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Marsigliante et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Polizzi et al., \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These playful, motivating, and customizable games simultaneously engage motor and cognitive functions, thereby enhancing children's engagement while reinforcing dual task mechanisms (Grosboillot et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Iosa et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; S. Li et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Several studies have shown that exergames can improve both motor and cognitive abilities in children with CP or ABI, with effects often comparable, and sometimes even superior, to those observed in traditional rehabilitation programs (Komariah et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; F. Li et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Polizzi et al., \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Tobaiqi et al., \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Velasco Aguado et al., \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Many exergames use extended reality (XR) to deliver interactive tasks (Lampropoulos et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). XR includes virtual reality (VR), which immerses the user in a digital environment, and augmented reality (AR), which overlays digital content onto the real world (Lampropoulos et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Rauschnabel et al., \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). According to the theoretical model proposed by Rauschnabel et al. (\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), VR is organized along a telepresence continuum, which corresponds to the degree to which the user feels present in the virtual rather than the physical environment (Rauschnabel et al., \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This continuum extends from holistic VR (full immersive experience) to atomistic VR (partial virtual experience), which can be interpreted as the use of non-immersive technologies, a form most commonly found in exergames using commercially available systems such as Microsoft Kinect or Nintendo Wii (F. Li et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Polizzi et al., \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Tobaiqi et al., \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), which do not sufficiently apply motor learning principles that are nonetheless essential to optimize the effectiveness of rehabilitation for these children (Demers et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Kilcioglu et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Moreover, in these configurations, the child interacts via a television or computer screen, and although the experience may be enjoyable, the level of immersion, defined as the feeling of being “inside” the activity, remains limited. Immersive technologies, such as head-mounted displays (HMDs), may further enhance children’s engagement and motivation and amplify the benefits of exergames by increasing both practice intensity and level of involvement. When implemented in custom-built exergames specifically tailored to the rehabilitative needs of children with CP or ABI, they offer additional advantages over recreational commercial games (Manser et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo date, the use of immersive technologies remains limited for the rehabilitation of children with CP and ABI. A few recent studies involving immersive VR have begun to demonstrate its benefits, particularly in enhancing motivation and improving certain motor dimensions (e.g., posture, gross motor function) (Lim et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Maggio et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, this technology also presents several limitations, including the risk of cybersickness and limited interaction with the physical environment (Rauschnabel et al., \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Souchet et al., \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In this context, the emergence of immersive AR offers promising new perspectives for pediatric rehabilitation (Iosa et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Yoo \u0026amp; Son, \u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Immersive AR presents specific advantages that make it particularly relevant for the cognitive-motor rehabilitation of these children. Unlike VR, AR allows real-time perception of the physical environment, promoting more natural and safer bodily movements and displacements (Malick et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). It also helps reduce adverse effects such as cybersickness (Kirollos \u0026amp; Merchant, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) while maintaining a high level of immersion and interaction (Rauschnabel et al., \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). By integrating visual cues from the real world, AR reduces apprehension, enhances engagement, learning, self-esteem, active involvement, and makes the experience more intuitive and stimulating, making it particularly relevant for the cognitive-motor rehabilitation of children with CP and ABI (Tobaiqi et al., \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Another advantage of this type of HMDs is that it can be used in different environments of the child’s daily life (rehabilitation centers, assisted living facilities, family homes). However, despite the potential of these technologies, studies using immersive AR have focused exclusively on gait training (Guinet et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), without incorporating cognitive components or dual task training, which are nonetheless essential in the rehabilitation of these children.\u003c/p\u003e \u003cp\u003eIn this context, we developed the first custom AR exergame specifically dedicated to the cognitive-motor training with incorporated cognitive tasks of children with CP or ABI (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). To do so, we relied on the MIDE framework (Multidisciplinary Iterative Design of Exergames) (Y. Li et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), an iterative, transdisciplinary, and user-centered guide grounded in co-design principles to create solutions that are as relevant, tailored, and effective as possible (Petrevska et al., \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Willingham et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), while actively involving the child in the process. A preliminary testing phase is first conducted with typically developing children (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) to validate game mechanics and identify necessary improvements (Le Roy et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Shah et al., \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The positive results obtained from this step now allow us to use the system with children with brain injuries. However, before assessing its therapeutic effectiveness, several methodological steps must be followed. Evaluating the user experience (UX) is a critical intermediate step, especially when dealing with a completely new custom exergame, as a satisfactory UX is considered a prerequisite for achieving therapeutic efficacy (Lallemand, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Y. Li et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Perez et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUX results from a complex interaction between three fundamental components: the user, the system, and the context (Hassenzahl \u0026amp; Tractinsky, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Several holistic and multidimensional theoretical models have been proposed to capture the different components of UX and their interactions, such as the model by Hassenzahl (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2001\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), which emphasizes the importance of combining the designer’s intention and the user’s subjective perception by evaluating the pragmatic and hedonic qualities of the system (Hassenzahl, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2001\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). Another closely related model is that of Mahlke (2007), which also integrates emotions, considered central to the perception of instrumental qualities (usability, utility, etc.) and non-instrumental qualities (aesthetics, motivations) (Thüring \u0026amp; Mahlke, \u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). In the field of immersive exergames, UX can be influenced by various factors such as system functionality, content, aesthetics, interaction and immersion in the gaming environment (Chenais \u0026amp; Görgen, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Kojić et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Lorenz et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Perez et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Perrochon et al., \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Therefore, the assessment of UX in XR-based systems should be guided by these theoretical models and be as comprehensive as possible. However, to date, the available data on UX assessment of immersive exergames for the rehabilitation of children with CP or ABI remain very limited and tend to focus only on a few subcomponents most often usability (Ammann-Reiffer et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Camardella et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), which is the most frequently assessed (Perez et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Other dimensions, such as motivation and emotions, are often underassessed, despite their central role in multidimensional UX models (Hassenzahl, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2001\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Thüring \u0026amp; Mahlke, \u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), which is particularly problematic in pediatric rehabilitation where engagement with new technologies relies heavily on these factors (Iosa et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tobaiqi et al., \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The studies by Ammann-Reiffer (2022) and Camardella et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) are the only ones that have evaluated the UX of an immersive VR exergame designed for children with brain injuries, using HMD devices (Ammann-Reiffer et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Camardella et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In the case of Ammann-Reiffer’s (2022) study, the children responded positively to the system, with good ease of use and a strong sense of presence, while the therapists noted the absence of negative impact on movements and a higher level of engagement compared to that observed in conventional rehabilitation. This lack of studies represents a significant gap, as evaluating multiple UX components (Hassenzahl, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2001\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Thüring \u0026amp; Mahlke, \u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) is essential to determine whether a game meets users’ needs and has potential for successful implementation. Yet, to date, no equivalent AR exergame exists, and no studies have reported on the UX of these children using such technologies in rehabilitation settings.\u003c/p\u003e \u003cp\u003eThe main objective of this study is to assess the UX in terms of usability, acceptance, quality of perceived experience, motivation, emotions, and fatigue of our exergame, which consists of two AR games designed for the cognitive-motor rehabilitation of children with brain injuries. Additionally, this study aims to determine whether there are significant differences in UX outcomes between the two AR games. Based on the literature on exergame design and development for this population, as well as our previous study, we hypothesize that the AR exergame will be easily usable by CP and ABI children. We expect positive outcomes in terms of acceptance, attractiveness, motivation, and emotional responses. We also hypothesize that AR-based sessions will lead to an increase in physical and mental fatigue, but that this increase will remain moderate and within acceptable limits for rehabilitation in this population, without exceeding excessive thresholds. Finally, based on our previous study and given that both games are designed from the same core structure, we do not expect significant differences in UX results between the two games.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003ePopulation\u003c/p\u003e\u003cp\u003ePatients were recruited from a neurological rehabilitation center and a motor education institute in France, following a pre-inclusion visit where the investigator confirmed eligibility through clinical examination. To be included in the study, patients had to meet the following criteria: (1) aged 10 to 16 years and diagnosed with CP or ABI; (2) sufficient oral comprehension skills to follow instructions and interact with the protocol; (3) affiliation with French social security; (4) personal assent to participate in the study; and (5) written informed consent from their legal representatives.\u003c/p\u003e\u003cp\u003ePatients were excluded from the study if they met any of the following criteria: (1) a motor level greater than 3 according to the Gross Motor Function Classification System (GMFCS); (2) contraindications to using new technologies, such as photosensitive epilepsy; (3) atypical or uncorrected visual and/or hearing impairment; (4) an unstable medical condition; (5) simultaneous participation in another research protocol likely to interfere with the assessment of the AR exergame; or (6) refusal of participation by the child or their family. This study received approval from the ethical and individual protection board of Ile de France VIII (specific reference number: 2023-A00904-41) with a favorable decision obtained on June 19, 2023, and was registered on ClinicalTrials.gov (NCT06944613)\u003c/p\u003e\u003cp\u003eAR exergame\u003c/p\u003e\u003cp\u003eThe methodology used in this study follows that of our previous work with healthy children, in which the design and technical specification of the two AR games were detailed (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). AR games run on a HoloLens 2 head-mounted display, and therapists manage exercises with a Lenovo TAB M10 Plus tablet.\u003c/p\u003e\u003cp\u003eGames\u003c/p\u003e\u003cp\u003eThe design of our cognitive-motor games is based on a balance between the playful aspect, with engaging game elements, mechanics, and dynamics, and a clinically grounded approach (Lyons, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Tao et al., \u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). We drew upon existing literature by adapting validated cognitive tests to locomotor activities in the form of interactive games, which enabled us to create tasks in which the cognitive component is fully incorporated into the motor task (Herold et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Each game includes different variants specifically designed to target EF such as working memory, cognitive flexibility, and inhibition. Furthermore, our development is guided by principles of motor learning (Demers et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Foscan et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), incorporating features such as gradual progression, a high volume of repetitions, goal-oriented tasks, and tailored feedback, elements that are known to stimulate neuroplasticity and support the acquisition of motor skills (Demers et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Kilcioglu et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAR Corsi (Figure. 1A and Multimedia Appendix 1)\u003c/p\u003e\u003cp\u003eThe AR Corsi game, inspired by Magic Carpet (Belmonti et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Demichelis et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Meilinger et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Perrochon et al., \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) and the Virtual Walking Corsi Test (Perrochon et al., \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), adapts the Corsi Block-tapping Test (Corsi, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1972\u003c/span\u003e) to the locomotor space, aiming to work on spatial orientation, visuospatial memory, and cognitive navigation strategies (Kronovsek et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The game offers several variants (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) : the \"Classic\" condition, where patients memorize a sequence of virtual floor tiles that light up one after another and reproduce it by walking on them in the real environment; the “Classic with objects” condition, which integrates spatial landmarks on the tiles to induce the development and use of alternative cognitive strategies; the \"Virtual Agent\" condition, where a virtual agent walks across the tiles following the illuminating sequence; and finally, the \"Advanced\" condition, which adds a dimension of inhibition and cognitive flexibility by asking the player to memorize certain tiles while inhibiting those that light up in red.\u003c/p\u003e\u003cp\u003eAR Zoo (Figure. 1B and Multimedia Appendix 2)\u003c/p\u003e\u003cp\u003eThe AR Zoo game is an adaptation of the Zoo Map Test, a commonly used assessment tool to measure executive functions in children (Ballhausen et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Engel-Yeger et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Romundstad et al., \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In the traditional neuropsychological test, patients must plan a route through a zoo while respecting various constraints, such as choosing the fastest route and avoiding retracing steps. The AR Zoo game draws from this concept to target spatial orientation, planning, and cognitive navigation strategies (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In this AR version, the list of animals to visit is displayed at the beginning of each sequence and remains visible on the initial tiles, requiring patients to plan their full route before taking any action. The game presents three conditions: the \"Classic\" condition, where the player must plan and follow the optimal path to visit the animal enclosures; the \"Virtual Agent\" condition, where a virtual agent shows the optimal path; and the \"Advanced\" condition, which adds a further challenge by asking the player to adapt and plan a new route when obstacles appear.\u003c/p\u003e\u003cp\u003e \u003cem\u003eLegend\u003c/em\u003e: \u003cem\u003eRepresentations of the AR Corsi (A) and AR Zoo (B) game environments. These illustrations depict the child within their real-world environment, along with the virtual environment that only the child can see through the AR headset.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe procedure\u003c/p\u003e\u003cp\u003eThe procedure, previously described by Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), involved two AR sessions spaced one week apart, during which each child played one of the two games (90 minutes including breaks). The order of the games was counterbalanced across patients. Each session included three steps: (1) a pre-session assessment conducted after a short presentation video, including a pre-use technology acceptance questionnaire (TAM) and baseline ratings of pre-session physical and mental fatigue (RPE-C); (2) the main session, with a familiarization phase followed by gameplay using one of the two AR games. For each condition, difficulty increased progressively; children advanced after completing at least one of two trials, otherwise they moved to the next condition; (3) a post-session assessment with questionnaires on usability (System Usability Scale, SUS), post-use acceptance (Technology Acceptance Model, TAM), quality of perceived experience (AttrakDiff), emotions (MeCue), motivation (Intrinsic Motivation Inventory, IMI), and post-session physical and mental fatigue (Rating of Perceived Exertion for Children, RPE-C).\u003c/p\u003e\u003cp\u003eUX assessment\u003c/p\u003e\u003cp\u003eThe usability of the device was assessed using the SUS questionnaire (Brooke, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). This tool was widely used in immersive technology assessment studies, including AR with the HoloLens 2 (Balani \u0026amp; Tümler, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). It consisted of 10 statements to which children responded by indicating their level of agreement on a 5-point Likert scale, ranging from \"Strongly disagree\" to \"Strongly agree.\" The total score was then transformed into a standardized usability index, where a score above 85 was considered \"excellent,\" a score between 75 and 85 was considered \"good,\" and a score between 50 and 75 was considered \"acceptable\" (Bangor, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe acceptance of the device before and after use was measured using the extended version of TAM (Davis, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1989\u003c/span\u003e; Venkatesh \u0026amp; Davis, \u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e2000\u003c/span\u003e), proposed by Manis and Choi (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Manis \u0026amp; Choi, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), based on four dimensions: perceived usefulness, perceived ease of use, perceived enjoyment, and behavioral intention to use. The pre-use assessment was conducted after a presentation of the game and its conditions through video supports. Children evaluated three statements per dimension (12 items in total) on a 7-point Likert scale (\"Strongly disagree\" to \"Strongly agree\"). Each dimension was analyzed independently. We chose to assess acceptance of the system at two different time points, pre- and post-use, as proposed by Mascret et al. (Delbes et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mascret et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Evaluating technology acceptance prior to any actual use allowed for the identification of potential initial barriers and psychological factors that could lead to rejection before any hands-on experience with the device, and enabled the comparison of acceptance levels before and after use to observe whether the UX strengthened or weakened acceptance of the device (Mascret et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eQuality of perceived experience was evaluated using the AttrakDiff questionnaire (Hassenzahl et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Lallemand et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), a recognized tool for analyzing the subjective perception of interactions with digital systems. It included 28 items divided into four dimensions: pragmatic quality, hedonic quality (stimulation), hedonic quality (identity), and overall attractiveness. Items were presented as pairs of opposite words, rated on a 7-point semantic differential scale (-3 to + 3). Scores for each dimension were analyzed independently: values between 0 and 1 reflected a functional but improvable UX, while positive scores (1 to 3) indicated favorable perception, and negative scores (-1 to -3) pointed to potential areas for improvement.\u003c/p\u003e\u003cp\u003eThe patients' motivation was evaluated using the IMI (Ryan et al., \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e1983\u003c/span\u003e). Among its seven dimensions, four were selected as particularly relevant for this study: Interest/Enjoyment, Perceived Competence, Effort/Importance, and Pressure/Tension, totaling 23 items. Each statement was rated on a 7-point Likert scale, from \"Strongly disagree\" to \"Strongly agree,\" and scores were analyzed separately for each dimension.\u003c/p\u003e\u003cp\u003eIn addition, the UX assessment included the emotional dimension from the MeCUE questionnaire (Lallemand \u0026amp; Koenig, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Minge et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), where children rated their feelings about eight emotions (four positive and four negative) using a 7-point Likert scale ranging from \"Strongly disagree\" to \"Strongly agree.\"\u003c/p\u003e\u003cp\u003eThe side effects related to cognitive and physical effort (mental and physical fatigue) were assessed before and after session using the visual analog scales from the RPE-C (Groslambert et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). The scale ranged from 6 (\"no fatigue\") to 20 (\"extreme fatigue\") and included pictograms of expressive faces to facilitate understanding and self-assessment by children.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eQuantitative variables were described as mean ± standard deviation or median [Q1; Q3], depending on the normality of their distribution. The normality of distributions was assessed using the Shapiro-Wilk test. Consistent with our previous study (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), the required sample size for this study was estimated at 30 patients. This calculation was based on an expected SUS score of 75, an effect size of 0.65, an alpha risk of 5%, a statistical power of 90%, and a dropout margin of 15% (Balani \u0026amp; Tümler, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eData from the SUS and AttrakDiff questionnaires were analyzed using descriptive statistics, with mean scores calculated for SUS (both games) and mean or median values reported for each AttrakDiff dimension per game. Two tailed one-sample t-tests were performed for the emotion item of the MeCue questionnaire, as well as for the four dimensions of the IMI and TAM questionnaires, to determine whether the scores differed significantly from the theoretical value of 4 on a 7-point Likert scale for each game. This method was used in studies employing Likert scales to assess whether patients’ perceptions significantly differed from a judgment considered neutral (Delbes et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mascret et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Mascret \u0026amp; Temprado, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Additionally, to examine the change in acceptance between the pre- and post-session assessment, a Wilcoxon rank test was used to compare the scores before and after the use of the AR device for each TAM dimension and each game. A mixed analysis of variance (ANOVA) was conducted to examine the main effects of the factors \"Time\" (pre- and post-session) and \"Game\" (AR Corsi and AR Zoo), as well as their interactions on physical and mental fatigue. Depending on the data distribution, an independent sample T-test or a Mann-Whitney test was used to determine whether there are significant differences between the two games. All statistical analyses were conducted using RStudio® software (version 2025.05.1 + 513), with a significance threshold set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e Of the 43 eligible children contacted during follow-up consultations, 30 (70%) agreed to participate. One was lost to follow-up, and data from 29 patients (12 with CP, 17 with ABI; 8 girls, 21 boys; mean age 11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 years) were analyzed. Socio-demographic and clinical characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and clinical characteristics of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (F / M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (28%) / 21 (72%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrain injuries (CP / ABI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (41%) / 17 (59%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGMFCS (Ι / ΙΙ / ΙΙΙ)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (86%) / 3 (10%) / 1 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotor disabilities (%)\u003c/p\u003e \u003cp\u003eDiplegia\u003c/p\u003e \u003cp\u003eHemiplegia\u003c/p\u003e \u003cp\u003eFine motor skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 of 29 (55%)\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFatigue (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (76%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePains (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntellectual disabilities (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlowdown (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive disorders (%)\u003c/p\u003e \u003cp\u003eAttention deficit disorders\u003c/p\u003e \u003cp\u003eMemory disorders\u003c/p\u003e \u003cp\u003eExecutive disorders\u003c/p\u003e \u003cp\u003ePraxic disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 of 29 (86%)\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e19\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSensory disorders (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe effective gameplay durations of AR Zoo (43.0\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7 minutes) was significantly longer than that of AR Corsi (33.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7 minutes) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eUX assessment\u003c/p\u003e \u003cp\u003eRegarding usability, the mean scores for AR Corsi and AR Zoo were 78.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4 and 78.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8 out of 100, with no significant difference between the two games (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe results regarding the acceptance before and after the use of the devices are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. For the four TAM dimensions, the median scores were significantly higher than the theoretical scale value of 4, both before and after using the AR Corsi and AR Zoo games (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Regarding the behavioral intention to use dimension for the AR Corsi game, a significant increase between the pre-use assessment (6.3 [5.0\u0026ndash;6.7]) and post-use assessment (7.0 [5.3\u0026ndash;7]) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Similarly, for the Perceived ease of use dimension of the AR Zoo game, a significant improvement was observed between the pre-use assessment (6.3 [5.3\u0026ndash;7]) and post-use assessment (7.0 [6.0\u0026ndash;7.0]) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, no significant differences between pre- and post-assessments were observed for the other TAM dimensions in both games (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eLegend: Comparison of pre- and post-acceptance assessments for the four TAM dimensions (Perceived Usefulness, Perceived Ease of Use, Perceived Enjoyment, Behavioral Intention to Use) in the AR Corsi and AR Zoo games. The dashed red line represents the theoretical value set for the Likert scale (i.e., 4). For each variable, results are presented by the median, first and third quartiles (Q1 and Q3), and extreme values. * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, NS\u0026thinsp;=\u0026thinsp;not significant\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eThe results of the AttrakDiff questionnaire are presented in Fig.\u0026nbsp;3. The scores for pragmatic quality are (AR Corsi: 1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9; AR Zoo: 1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1), stimulation (AR Corsi: 1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9; AR Zoo: 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6), identity (AR Corsi: 1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0; AR Zoo: 1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8), and overall attractiveness (AR Corsi: 2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1; AR Zoo: 2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0). No significant differences were found between the two AR games for any of the four dimensions (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 3. Radar Chart of mean scores for the Attrakdiff questionnaire dimensions for AR Corsi and AR Zoo.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eLegend: Graphical representation of the mean scores for the four AttrakDiff dimensions: overall attractiveness, pragmatic quality, identity, and stimulation. The scores are interpreted as follows: a mean between 3 and 1 reflects a positive aspect of the device, between 1 and \u0026minus;\u0026thinsp;1 a neutral point, and between \u0026minus;\u0026thinsp;1 and \u0026minus;\u0026thinsp;3 a negative aspect of the device.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eRegarding motivation, the perceived competence (AR Corsi: 5.6 [5.3\u0026ndash;6.6]; AR Zoo: 6.16 [5.5\u0026ndash;6.5]) and interest/enjoyment (AR Corsi: 6.6 [6\u0026ndash;7]; AR Zoo: 6.4 [6\u0026ndash;6.8]) dimensions were significantly higher than the theoretical scale value of 4 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) for both games. For the \"effort importance\" dimension, the scores were also significantly higher than the theoretical value, with AR Corsi at 4.8 [3.4\u0026ndash;6.4] (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and AR Zoo at 5.2 [3.8\u0026ndash;6.8] (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In contrast, for the \"Pressure/Tension\" dimension, the averages were significantly lower than the theoretical scale value (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) for both games (AR Corsi: 1.6 [1\u0026ndash;3]; AR Zoo: 2.2 [1.2\u0026ndash;2.8]). No significant differences were observed between AR Corsi and AR Zoo for the four dimensions (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eIn the emotions module of the MeCue questionnaire, patients gave a median score of 6.62 [5\u0026ndash;7] for the Corsi game and 5.75 [5.13\u0026ndash;6.63] for the Zoo game, both significantly higher than the theoretical scale value of 4 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant difference was found between AR Corsi and AR Zoo (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe mental fatigue scores measured before and after the use of the games were as follows: for AR Corsi, the mean increased from 8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 to 9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2, and for AR Zoo, from 7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 to 9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6. Regarding physical fatigue, the mean scores changed from 7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 to 8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 for AR Corsi, and from 8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 to 9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 for AR Zoo. The mixed ANOVA results demonstrated a statistically significant main effect of the \"Time\" factor on both physical and mental fatigue, with p-values of P\u0026thinsp;\u0026lt;\u0026thinsp;0.01 and P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively. In contrast, neither the main effect of Game nor the Time \u0026times; Game interaction was significant for physical or mental fatigue (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main objective of this study was to assess the UX of a custom AR exergame designed for the cognitive-motor rehabilitation of children with CP or ABI. The secondary objective was to determine whether UX differed significantly between the two games (AR Corsi and AR Zoo). The results indicated an overall very positive UX, with no notable difference between AR Corsi and AR Zoo.\u003c/p\u003e \u003cp\u003eThe usability scores obtained from the SUS questionnaire are considered good, with an average close to 78.5 out of 100, indicating that both games are usable by these children (Brooke, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1995\u003c/span\u003e), and also acceptable according to the SUS interpretation criteria proposed by Bangor et al. (2009) (Bangor, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). These usability results are very similar to those observed in our previous study conducted with typically developing children (average close to 78.1 out of 100) (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), suggesting that the game\u0026rsquo;s ergonomics are appropriate and do not present usability barriers for clinical populations. Concerning acceptance, TAM results collected before and after the use of the games confirm that our exergame is well accepted by children. Among the 29 children included in our study, no initial reluctance was reported toward using either of the two games. For both games, scores across the four TAM dimensions were consistently and significantly above the threshold of 4, both before and after use. These findings are encouraging, as they indicate that interacting with the game further strengthened the children\u0026rsquo;s positive perceptions and enhanced their overall experience with the device. Our games are therefore perceived as useful, easy to use, and enjoyable, all of which contribute to a positive behavioral intention to use. But, the majority of studies most often focus on only one or two subcomponents of UX, particularly acceptance and usability, which are among the most frequently assessed dimensions (Consales et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Perez et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), as opposed to hedonic components, which are equally important in multidimensional UX models (Hassenzahl, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2001\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Th\u0026uuml;ring \u0026amp; Mahlke, \u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePerceived quality of experience was assessed using the AttrakDiff questionnaire. Results showed strong pragmatic and hedonic qualities (notably stimulation and identity) and high overall attractiveness, with all dimensions in the positive range (1 to 3) according to Hassenzahl et al. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), indicating that the system was perceived as engaging and well-designed by the children (Hassenzahl et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Lallemand et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). These findings are broadly consistent with those previously observed in typically developing children (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), with the notable exception that the \u0026ldquo;identity\u0026rdquo; dimension was rated higher by children with CP or ABI. This difference can be explained by the fact that the games were specifically designed to meet their needs, making them more likely to identify with the games and perceive them as useful and relevant for their rehabilitation, unlike typically developing children. With regard to motivation, we specifically chose to assess intrinsic motivation, as according to the self-determination theory by Ryan and Deci (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e2000\u003c/span\u003e), it refers to performing an activity for the inherent pleasure and interest it provides (Ryan \u0026amp; Deci, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). In the context of rehabilitation, this means that a child will choose to play the exergame willingly, because they find it fun and rewarding, rather than out of obligation (Biddiss et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Iqbal et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In our study, high scores on the IMI for the perceived competence and interest/enjoyment dimensions indicate that the children found the games appropriately challenging, felt capable of succeeding, and genuinely enjoyed the activity. The effort/importance dimension was also significantly elevated, suggesting that the children were actively engaged and valued their performance, without the activity feeling burdensome. Finally, the low scores on the pressure/tension dimension suggest that the children did not find the experience stressful or demanding. Positive motivation is generally accompanied by positive emotions, which was precisely the case in our study. Children reported significantly elevated levels of positive emotions, with scores exceeding the theoretical midpoint of 4 on the MeCue. This emotional response indicates that the experience was perceived as enjoyable and rewarding, thereby reinforcing the appeal of the activity (Pavic et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These favorable emotions and strong intrinsic motivation likely supported sustained engagement in a safe and rewarding environment, enabling frustration-free progress and success.\u003c/p\u003e \u003cp\u003eIt was also important to assess the fatigue data induced by our exergame, since fatigue can influence overall UX and children with CP or ABI are known to be particularly vulnerable to fatigue-related disorders (Proschowsky et al., \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Puce et al., \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). As expected from our previous study with typically developing children (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), a statistically significant increase in both physical and mental fatigue was observed post-session in children with CP or ABI, although levels remained slight and no signs of exhaustion were reported during the session (mental fatigue reached 9.4 out of 20, and physical fatigue 8.6 out of 20). These low levels of fatigue are likely due to the relatively low exercise intensity inherent to our exergame\u0026rsquo;s design, which involves motor-cognitive training with incorporated cognitive tasks. As the literature does not provide recommendations regarding the optimal duration or intensity of immersive AR sessions for this population, it will be necessary in the future to personalize these exercises according to each child\u0026rsquo;s individual capacities, in order to ensure a sufficient level of intensity for each child and achieve therapeutic benefits.\u003c/p\u003e \u003cp\u003eThe positive UX observed with our exergame, composed of two cognitive-motor games, likely reflects the combined influence of a user-centered design process, theoretical foundations in game design and motor learning, a coherent gameplay architecture across games, and specific affordances of immersive AR. We believe that this favorable UX can be largely attributed to our user-centered design approach, based on the MIDE framework (Y. Li et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This multidisciplinary and iterative model enabled us to anticipate and incorporate users\u0026rsquo; needs from the earliest stages of development. The preliminary testing phase with typically developing children helped stabilize game mechanics, clarify instructions, and anticipate friction points, which provided a certain level of confidence and safety in conducting tests with children with CP and ABI, and reinforced our confidence in the positive UX outcomes observed (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Moreover, the development of our games was grounded in robust game design literature, incorporating elements such as progressive difficulty levels and challenge-based systems (Chenais \u0026amp; G\u0026ouml;rgen, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Lyons, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Manser et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Martinez, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). We also sought to address the specific therapeutic needs of children with CP or ABI by drawing on motor learning principles, which we implemented as extensively as possible (Demers et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Foscan et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These elements likely contributed to shaping the children\u0026rsquo;s UX, by promoting both engagement and perceived relevance of the tasks. Additionally, by designing AR Corsi and AR Zoo around a shared central gameplay loop (Tao et al., \u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), we aimed to foster engagement while targeting different executive functions, and to reduce the likelihood of one game being perceived as more appealing than the other (Balloufaud et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). This coherent structure likely contributed to the absence of significant differences in UX ratings between the two games. In addition to the user-centered design principles and the personalization of our games, certain characteristics specific to immersive environments, as described by Hameed et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) such as immersion, interactivity, explorability, plausibility, and credibility may have contributed to the positive UX outcomes observed in our study (Hameed et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Furthermore, the visual awareness of the environment, which is a specific feature of immersive AR (Kirollos \u0026amp; Merchant, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), likely helped limit side effects while enhancing the children\u0026rsquo;s sense of safety and the natural, intuitive quality of their interaction (Partarakis \u0026amp; Zabulis, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yang et al., \u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, it is important to note that these remain assumptions, as these specific characteristics were not directly assessed in this study, although the literature is beginning to provide preliminary evidence in that direction (Ahmed et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Perrochon et al., \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePerspectives\u003c/p\u003e \u003cp\u003eThe aim of our study was to obtain an initial assessment of the UX of our AR exergame. To this end, we evaluated UX during two initial sessions; however, these results should be interpreted with caution. The children played each of our two games only once, and the initial enthusiasm generated by the discovery of an innovative immersive technology may have induced a \u0026ldquo;wow effect,\u0026rdquo; potentially biasing the highly positive assessments collected in this study. It will therefore be essential, in the next phases of the project, to assess UX longitudinally to determine whether our exergame continues to offer a good UX over time.\u003c/p\u003e \u003cp\u003eIn addition, to enrich and strengthen our future UX assessments, we plan to include new subcomponents specific to immersive environments (e.g., cybersickness, immersion, flow), which are likely to influence UX (Perrochon et al., \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and have not yet been considered in our studies. To do so, we could rely on theoretical models specifically designed to assess UX in immersive environments (Cheiran et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), such as the Tcha-Tokey model, which integrates additional components likely to influence UX, including immersion and flow (Tcha-Tokey et al., \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u0026mdash;a particularly relevant dimension to evaluate during prolonged use.\u003c/p\u003e \u003cp\u003eIn addition to this enhanced long-term assessment of UX, the next step of the project will be to assess the effectiveness of our exergame on cognitive and motor functions within a multi-week rehabilitation program. This phase will be critical for confirming the clinical relevance of the system and for guiding its integration into pediatric rehabilitation programs.\u003c/p\u003e \u003cp\u003eIn parallel with this efficacy study, we also plan to gather feedback from therapists and parents regarding the use of this new type of exergame in clinical settings. Their insights will help us better understand the perceived usefulness of the system, assess its feasibility in real-world practice, and identify any potential barriers to its adoption.\u003c/p\u003e \u003cp\u003eLimitations:\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, although our UX assessment relied on validated questionnaires and rating scales, it may still be subject to a degree of subjectivity, and a social desirability bias may have occurred, particularly among younger patients. Children eager to please the investigators, or simply happy to participate in an enjoyable and novel activity, may have been reluctant to offer criticism or express negative feedback. This bias has also been reported in other study, where the children's overwhelmingly positive reactions to a proposed game raised questions about the extent of genuine satisfaction versus a perceived obligation to meet the evaluators\u0026rsquo; expectations (Consales et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Second, it is important to note that the UX measured in this study reflects the experience of the entire system, that is, the Microsoft HoloLens 2 headset and the two games combined. We believe it is not possible to dissociate the game experience from the hardware used, as both are closely intertwined. For instance, using a different headset would likely have produced a different gameplay experience. This is precisely why we chose to use the term \u0026ldquo;system\u0026rdquo; in our questions. Although we made an effort to explain this to the children, the concept may have caused some confusion, potentially modifying their responses. Finally, a third limitation of our study lies in the composition of our participant sample, which primarily included children with good functional mobility (GMFCS level I). The limited inclusion of children with severe impairments restricts the generalizability of our findings to the broader brain-injured pediatric population. Future studies should include a more heterogeneous population in terms of both motor and cognitive abilities in order to better assess the accessibility and relevance of the exergame for more severely affected children.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUsing a comprehensive, multidimensional assessment of UX, this study showed an overall highly positive UX for our custom AR exergame designed for the cognitive-motor rehabilitation of children with CP or ABI. Our exergame was found to be usable, acceptable, engaging, motivating, capable of eliciting positive emotions, and not excessively fatiguing. This favorable assessment supports the relevance of the game content and mechanics, which can largely be attributed to our user-centered design approach, based on the MIDE framework. In addition, specific features of the immersive AR environment may also have contributed to the positive UX observed. These findings suggest that our exergame is suitable for future use in rehabilitation for children with CP or ABI. More broadly, these results suggest that applying user-centered design principles and leveraging specific affordances of immersive AR may help developers create other rehabilitation exergames with similarly satisfactory UX. A satisfactory UX is a critical prerequisite for achieving therapeutic efficacy, even if it does not guarantee it. The next step in our research will be to evaluate long term UX and the therapeutic effectiveness of this exergame on the cognitive and motor functions of these children.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eABI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; Acquired Brain Injury\u003c/p\u003e\n\u003cp\u003eAR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; Augmented Reality\u003c/p\u003e\n\u003cp\u003eCP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; Cerebral Palsy\u003c/p\u003e\n\u003cp\u003eGMFCS \u0026nbsp; \u0026nbsp;Gross Motor Function Classification System\u003c/p\u003e\n\u003cp\u003eHMD\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Head-Mounted Displays\u003c/p\u003e\n\u003cp\u003eIMI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intrinsic Motivation Inventory\u003c/p\u003e\n\u003cp\u003eMIDE\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; Multidisciplinary Iterative Design of Exergame\u003c/p\u003e\n\u003cp\u003eRPE-C\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; Rating scale of Perceived Exertion for Children\u003c/p\u003e\n\u003cp\u003eSUS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; System Usability Scale\u003c/p\u003e\n\u003cp\u003eTAM\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Technology Acceptance Questionnaire\u003c/p\u003e\n\u003cp\u003eUX\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; User Experience\u003c/p\u003e\n\u003cp\u003eVR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; Virtual Reality\u003c/p\u003e\n\u003cp\u003eXR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Extended Reality\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003eAcknowledgments\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors thank all the young patients, as well as the Esquirol Hospital Center and the IEM of Couzeix for their support. They also acknowledge the students from the 3iL engineering school for their contribution to the development of the augmented reality games. Finally, they thank the Nouvelle-Aquitaine region for its financial support of this project.\u003c/p\u003e\n\u003cp\u003eCompeting Interests: The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eData Availability Statement\u003c/p\u003e\n\u003cp\u003eAnonymized data from the assessment of UX subcomponents are available from the author MB upon reasonable request.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization\u003c/strong\u003e: Maxime Balloufaud, Arnaud Boujut, Romain Marie, Julia Hamonet-Torny, Anaick Perrochon ; \u003cstrong\u003eMethodology\u003c/strong\u003e: Maxime Balloufaud, Arnaud Boujut, Romain Marie, Julia Hamonet-Torny, Anaick Perrochon ; \u003cstrong\u003eFormal analysis and investigation\u003c/strong\u003e: Maxime Balloufaud, Mireille Belle Mbou Okassa, Julia Hamonet-Torny ; \u003cstrong\u003eWriting - original draft preparation\u003c/strong\u003e: Maxime Balloufaud ; \u003cstrong\u003eWriting - review and editing\u003c/strong\u003e: Maxime Balloufaud, Arnaud Boujut, Romain Marie, Mireille Belle Mbou Okassa, Laurent Fourcade, Julia Hamonet-Torny, Anaick Perrochon ; \u003cstrong\u003eFunding acquisition\u003c/strong\u003e: Anaick Perrochon ; \u003cstrong\u003eResources\u003c/strong\u003e: Maxime Balloufaud, Arnaud Boujut, Romain Marie, Mireille Belle Mbou Okassa, Julia Hamonet-Torny, Anaick Perrochon ; \u003cstrong\u003eSupervision\u003c/strong\u003e: Arnaud Boujut, Anaick Perrochon\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAhmed N, Wu P, Huang K, Jung S, Rheem H, Tan G, Imani M, Islam R (2025) Human task performance and associated internal states in extended reality: A systematic review of cognitive, psychophysiological, and physiological dimensions. 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Clin Experimental Pediatr 67(2):92\u0026ndash;103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3345/cep.2022.00731\u003c/span\u003e\u003cspan address=\"10.3345/cep.2022.00731\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Immersive Augmented Reality, Exergame, User Experience, Cognitive-Motor, Brain Injuries, Pediatric rehabilitation","lastPublishedDoi":"10.21203/rs.3.rs-8223292/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8223292/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eConventional pediatric rehabilitation for cerebral palsy (CP) or acquired brain injury (ABI) prioritizes motor outcomes, often neglecting cognitive deficits and their interplay. Sessions are often perceived as repetitive and demotivating, reducing engagement. Immersive exergaming, especially through augmented reality (AR), enables simultaneous cognitive-motor training in safe, interactive settings. There is little evidence on immersive exergames for these children, and no immersive AR exergames target cognitive-motor rehabilitation or report on user experience (UX).\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aims to assess the overall UX of a purpose-built immersive AR exergame for children with brain injuries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTwenty-nine children (11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 years; 12 CP / 17 ABI) participated in two sessions using the Microsoft HoloLens2, each involving one cognitive-motor AR game (AR Corsi and AR Zoo). UX was assessed through standardized questionnaires: System Usability Scale (usability), Technology Acceptance Model (acceptance), AttrakDiff (perceived experience quality), MeCue (emotions), Intrinsic Motivation Inventory (motivation), and Rating scale of Perceived Exertion for Children (fatigue).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe exergame was well accepted and perceived as easy to use. Scores for motivation, emotions, and perceived experience quality were high and positive. A small but significant increase in mental and physical fatigue was observed after the sessions (P\u0026thinsp;\u0026lt;\u0026thinsp;.01). No significant differences were found between the two game conditions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis immersive AR exergame demonstrates a positive UX in children with brain injuries, supporting its potential use in rehabilitation. These results emphasize the importance of conducting comprehensive UX assessments when developing innovative rehabilitation tools and provide a basis for future investigations into therapeutic impact.\u003c/p\u003e","manuscriptTitle":"User experience of a custom augmented reality-based exergame for children with cerebral palsy and acquired brain injuries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 10:09:17","doi":"10.21203/rs.3.rs-8223292/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5633240c-f1d6-467c-99dc-4ea0a150d5a7","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-08T11:01:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 10:09:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8223292","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8223292","identity":"rs-8223292","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}