Game-based and gamification-enhanced telerehabilitation for physical therapy in people with multiple sclerosis: a scoping review

Abstract

Introduction

People with multiple sclerosis (MS) commonly experience balance, gait, and upper-limb impairments that require long-term physical therapy (PT). Home-based telerehabilitation can improve access to therapy, and game-enhanced interventions (serious games/exergaming) and gamification elements may enhance engagement and adherence.

Methods

This scoping review examined the current evidence and explored the implementation considerations of gamification-based telerehabilitation (GBT) systems designed to deliver home-based PT for people with MS. Following PRISMA-ScR guidance, the databases OVID Medline, OVID EMBASE, CINAHL, and EBSCO were systematically searched between January 2010 and November 2024. Fifteen studies satisfied the inclusion criteria. Study quality was appraised using the Downs and Black checklist, and evidence levels were classified according to a modified Sackett scale.

Results

The majority of the 15 studies were of fair-to-good methodological quality, and all used a quantitative design with small sample sizes. The included studies mainly focused on whole-body physical rehabilitation. Eleven studies used commercial games, while others developed customized hardware or software modules. No serious adverse events were reported. High levels of participant satisfaction and adherence in home settings supported feasibility. The effectiveness of GBT for people with MS is still uncertain because the results are mixed. Across controlled trials, balance and postural control outcomes showed the most consistent improvements, whereas fatigue, QoL, and participation outcomes were mixed and often not significant between the groups.

Conclusion

GBT solutions may serve as a therapeutic alternative to conventional therapy, particularly when access to traditional services is limited or when individuals with MS experience reduced motivation to maintain their exercise routines. More research is needed to find out which measures respond best, which subgroups benefit most, and to provide stronger evidence through the use of both within-group and between-group comparisons.

Introduction

Multiple sclerosis (MS) is a chronic, progressive, neurodegenerative condition which impacts approximately 2.8 million people worldwide, with the highest prevalence in Europe and North America [1] and a higher incidence in women than in men (sex ratio 2.5:1) [2]. MS is characterized by central nervous system lesions that can lead to severe physical and cognitive impairments, as well as neurological issues [2]. Common MS subtypes are (1) relapsing–remitting MS (RRMS), marked by short periods of symptom flare-ups, which then improve; (2) secondary progressive MS (SPMS), which starts as RRMS but later turns into a steady worsening of neurological function and  disability over time; and (3) primary progressive MS (PPMS), where symptoms worsen continuously from the onset without clear relapses. In progressive MS, gait disturbance and leg weakness are usually the earliest persistent symptoms and may dominate the clinical picture for roughly 7 years, whereas fine-hand control is typically preserved for much longer, but then may  worsen after an additional 7–10 years [3]. In relapsing MS, by contrast, the first attacks are often focal, striking a single arm or leg before disability gradually spreads [4, 5]. The resulting physical impairments from the disease may reduce a person's independence, limit their daily activities, and restrict their social participation [6].

Physical therapy (PT) and exercise have been shown to positively improve patients’ quality of life (QoL), their mobility-related activities, and cognitive functioning [7, 8]. Across the disease course, PT goals may shift from restoring function following relapses to maintaining mobility and endurance, preventing secondary complications, and supporting long‑term self‑management as disability and symptom burden change [7, 8].

To maintain their function and health,  people with MS often require long-term physical rehabilitation programs. A common issue associated experienced by patients undergoing these types of  programs is they often lose  motivation, which leads to a  reduced or complete loss of adherence to their prescribed exercise programs [9]. This occurs because the rehabilitation process can be tedious and demanding, often requiring individuals to perform repetitive exercises for extended periods. Furthermore, accessibility to rehabilitation centers can pose significant hurdles, particularly for those with mobility issues [10–12].

Game-based rehabilitation and gamification are two related approaches that may improve patients' motivation and adherence in their home programs [13, 14]. Serious games and exergames embe therapeutic movements within a game environment, while gamification applies discrete game design elements (e.g., points, feedback, challenges, and progress indicators) to non-game therapeutic activities [15]. These mechanisms may increase intrinsic motivation in patients by supporting autonomy, competence, and relatedness, consistent with self‑determination theory [16–18].

Exergame platforms such as the Nintendo Wii^® (https://www.nintendo.com), Xbox^® (https://www.xbox.com/), and Jintronix^® (http://www.jintronix.com/en/) are motion-based virtual reality (VR) platforms that have been widely used in physical rehabilitation research. These systems use body-movement tracking and sensory feedback to support interactive balance and exercise training, with different levels of immersion. They also allow real-time performance feedback and remote monitoring by clinicians.

In addition to incorporating gamification elements, gamification-based telerehabilitation (GBT) systems leverage remote delivery models to enhance accessibility and enable individuals to participate in rehabilitation from their homes [19, 20]. Telerehabilitation is defined as the provision of rehabilitation services at a distance through information and communication technologies, allowing assessment, intervention, monitoring, education, and communication between patients and healthcare providers [21]. This approach encompasses both synchronous and asynchronous models of care. Evidence indicates that telerehabilitation can effectively deliver physical therapy for individuals requiring long-term management [12], with growing evidence supporting its safety, feasibility, and effectiveness in MS care [22–25]. Moreover, telerehabilitation helps overcome barriers such as travel limitations and restricted access to specialized centers, which are particularly relevant for individuals with MS, many of whom experience mobility impairments. GBT platforms also provide tracking mechanisms, allowing individuals to monitor their progress easily and keep track of their achievements.

Given the current rise of telerehabilitation [22] further research is needed to clarify the feasibility and benefits of GBT in MS. Most existing studies emphasize VR-based interventions rather than standalone telerehabilitation. For instance, existing reviews [26–31] have synthesized VR’s effects on functional mobility, balance, QoL, and cognition in people with MS, but rarely examine how these interventions function when delivered remotely through telerehabilitation modalities from home settings. Notably, no studies have focused on the different elements of GBT interventions that can serve to inform implementation considerations for people with MS within a home setting.

To better strengthen our understanding of the growth of remote healthcare solutions, especially post-COVID, the aim of the present scoping review was to provide a descriptive overview of the existing literature on telerehabilitation solutions for PT in people with MS in home settings, focusing specifically on those incorporating gamification elements, such as reward collection (e.g., earning points, badges, or levels to reinforce adherence), interactive features (e.g., responding to virtual targets or avatars), and engaging feedback mechanisms (e.g., real-time visual or auditory cues that increase enjoyment and motivation).

This scoping review aimed to (1) map the reported clinical effectiveness outcomes of home-based PT GBT systems used with people with MS; (2) describe the implementation-related outcomes, including feasibility, usability, adherence, acceptability, and safety of these home-based PT GBT systems, and (3) identify the key software/hardware features of these systems.

Materials and methods

A scoping review methodology was selected because the telerehabilitation literature spans heterogeneous technologies (consumer platforms, rehabilitation‑specific systems, and mobile applications), intervention designs, and outcome measures, and our primary aim was to map system characteristics and implementation outcomes rather than to statistically combine results to estimate an overall treatment effect. This scoping review followed Arksey and O’Malley’s five-stage methodological framework [32]. Its findings were reported using the PRISMA-ScR checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) [33]. The protocol for this study was registered in Open Science Framework (Open Science Framework: https://osf.io/a7xfg).

Research question

This scoping review aimed to (1) identify the clinical effectiveness outcomes reported for home-based PT GBT systems for the MS population; (2) describe the implementation-related outcomes, including feasibility, usability, adherence, acceptability and safety outcomes of home-based PT GBT systems; and (3) map out the key software/hardware features embedded in such systems.

To the best of the authors’ knowledge, to date, no review has focused on the implementation considerations of integrated gamification and remote PT delivery for the MS population. Accordingly, this review focused on mapping existing evidence and identifying key technological and implementation characteristics to inform clinical practice as it relates to the delivery of home-based PT GBT for MS.

Information sources and search strategy

In consultation with a librarian experienced in systematic reviews, the research team developed a comprehensive search strategy to capture all relevant medical and engineering papers on the topic using the five scholarly databases, Ovid Medline, Ovid Embase, CINAHL, EBSCO, and Scopus, between January 2010 and November 2024. To retrieve information from the electronic libraries, all possible combinations of the following key word strings were used: Game OR gamification OR user-computer interface OR software, mobile OR cellphone OR iOS OR android, app OR application OR program, Rehabilitation OR Physiotherapy OR Physical therapy, Tele OR Remote OR Virtual OR home exercises OR Unsupervised (for the full list please refer to Sup 1). The full search strategy is detailed in Sup 2. We exported our findings from each database into a systematic review software system, Covidence, where the software’s de-duplication feature automatically removed duplicate entries [14].

Inclusion and exclusion criteria

We included English-language studies of any design (quantitative or qualitative) that involved adults with MS (≥ 18 years) and described the development or evaluation of hardware or software supporting home-based GBT PT for this population. Each study had to feature at least one gamification element. To keep pace with fast-moving technology, only papers published from 2010 onward were considered.

We excluded (1) gray literature, mini-reviews, review papers, letters, conferences, commentaries, and book chapters; (2) studies lacking any gamification components such as reward collection, interactive engagement, or motivational brain stimulation; (3) studies that offered only conceptual system designs, with no device built and no involvement of people with MS; and (4) immersive VR. It is important to distinguish between conventional and immersive VR. Conventional VR typically provides non-immersive experiences via a screen, whereas immersive VR uses head-mounted displays to fully surround the user within a virtual environment. Although immersive VR may enhance realism and engagement, it was excluded from this review due to safety concerns (e.g., motion sickness and disorientation), the requirement for strong balance control during use, and its limited practicality and scalability for home-based rehabilitation.

Study selection process

Study selection was conducted in two phases: (1) screening of titles and abstracts and (2) full-text reviewing. Four reviewers (SNG, SM, ZL, JM) independently contributed to the screening and reviewing phases. To calibrate their judgments, they jointly screened the first 80 abstracts and the first 30 full texts, achieving the preset threshold of ≥ 80% inter-rater agreement in both rounds. The remaining papers were then divided among them for data extraction. Any later disagreements were settled through discussion or, if needed, by consulting the designated fifth reviewer (SLH).

Data extraction

The extracted data included (1) study aim and design, (2) participant and intervention characteristics, (3) reported outcome and technology-related adverse events, and (4) features of the software and hardware modules.

Two reviewers (SM, SN) independently assessed the methodological quality of the included studies using the Downs and Black (D&B) tool [34]. Any disagreements in scoring were resolved through consultation with the third reviewer (SH). The D&B tool comprises 27 items that examine both external and internal validity by targeting sources of bias and confounding. We modified the final item, which originally used a 0–5 scale, to a binary 0–1 scale: studies received 1 point if they reported a power or sample-size calculation, and 0 if they did not or failed to justify their sample size. With this change, the highest possible score became 28, where higher totals indicate better methodological quality. Subsequently, the Sackett Scale was used to grade a level of evidence to each study (see Table 1), where level 1 indicates the strongest evidence and level 5 the weakest [35].

Table 1.

Sackett scale level of evidence

Level of evidence	Type of study
1A	Systematic reviews of randomized controlled trials
1B	Individual randomized controlled trials with narrow confidence interval
2A	Systematic reviews of cohort studies
2B	Individual cohort studies and low-quality randomized controlled trials
3A	Systematic reviews of case–control studies
3B	Case-controlled studies
4	Case series and poor-quality cohort and case–control studies
5	Expert opinion

Results

The search yielded 6,322 records; after removing duplicates, 4,078 unique citations remained. Title‐and‐abstract screening narrowed these to 812 articles for full-text review, of which 15 satisfied all inclusion criteria and were retained for the final synthesis. Search results are detailed in the PRISMA flowchart shown in Fig. 1.

Fig. 1.

PRISMA (preferred reporting items for systematic reviews and meta-analysis)

The mean Downs & Black score for the 12 studies that could be rated (summarized in Table 2) was 21.2 out of 28 (range = 18–26). Seven papers met the “good” threshold (≥ 21) ([17, 23, 24, 36–40]), while five were classed as “fair” (15–20) ([41–45]), none fell into the poor category, and three reports ([46–48]) lacked sufficient detail for scoring. Applying the modified Sackett hierarchy (Table 2), six studies provided level 1b evidence, one was level 2b, six were level 4, and three were level 5.

Table 2.

Study bias assessment and assigned level of evidence

Author	D&B score	Level of evidence	Author	D&B score	Level of evidence
Chanpimol [41]	20	4	Pau [43]	20	4
Forsberg [46]	N/A	5	Plow [48]	N/A	5
Goffredo [36]	22	4	Prosperini [40]	21	1B
Gutiérrez [37]	21	4	Thomas [17]	26	1B
Gutiérrez [38]	21	1B	Tramontano [23]	24	1B
Hoang [24]	24	1B	Van Beek [44]	18	4
Kramer [42]	18	2B	Van Geel [45]	18	4
Palacios-Ceña [47]	N/A	5	–	–	–

Study characteristics

Of the 15 studies, 13 used a quantitative methodology, and 3 utilized a qualitative approach [46–48]. The quantitative studies included: four randomized controlled trials (RCT) [17, 23, 24, 39, 40], four clinical studies [36–38, 41], three observational studies [43, 45, 46], one comparative study [42], and one usability study [44]. These included studies were conducted across six different countries: Italy (n = 4) [23, 36, 40, 43], Spain (n = 3) [37, 38, 47], the United States (n = 2) [41, 48], Germany (n = 1) [42], Australia (n = 1) [24], Benin (n = 1) [45], Sweden (n = 1) [46], Switzerland (n = 1)[44], and the United Kingdom (n = 1) [17].

Participant characteristics

Participant characteristics are reported in Table 3. The 15 eligible studies collectively involved about 900 adults with MS. Sample sizes ranged from a pilot study with only 9 participants [44] to larger trials [24], which allocated 223 and 230 participants to control and intervention arms, respectively. Mean ages varied widely, from 35 [40] to almost 80 years [36], although most cohorts were in their forties or fifties. Women predominated; two studies enrolled no men at all [44, 45]. Disability levels were usually mild-to-moderate, with the Expanded Disability Status Scale [49] (EDSS: widely used measure of disability in MS) of [1.0–6.0], but two studies included participants with severe impairment up to EDSS of 8.5 [23, 44]. Cognitive function was largely preserved, with many protocols requiring Mini-Mental State Examination [50] scores > 23/30 or reporting no apparent impairment.

Table 3.

Intervention and patient population characteristics

Author	Study design	Participants characteristics					Targeted body part (TBT) and telerehabilitation program
		Mean age (SD) or range	Sample size	Gender (M/F)	Disease severity (stage range or stage/score mean and SD, M = XX (SD = XX)	Cognitive status
Chanpimol [41]	Clinical study	49.6 (9.0)	10	2/8	EDSS [3.0–6.5]	MMSE > 23/30	TBP: WB Exercise: active RoM, strength, balance or calisthenic movements Schedule: 30 min/session, 3x/week, 12 weeks
Forsberg [46]	Observational and qualitative study	52.6 (12.1)	15	6/9	EDSS [1.0–6.0]	No cognitive impairment present	TBP: WB Exercise: balance Schedule: 30 min/session, 2x/week, 12 sessions
Goffredo [36]	Clinical study	CG: 61.2 (11.06) EG: 79.6 (5.8)	132	CG: 30/37 EG: 29/36	EDSS ≤ 6.5	MoCA EG: 26.3 (2.7) CG: 25.7 (3.3)	TBP: LB Exercise: motor and cognitive rehabilitation exercises Schedule: 45 min/session, 5x/week, 30–40 sessions
Gutiérrez [37]	Clinical study	CG: 42.78 (7.38) EG: 39.69 (8.13)	CG: 25 EG: 25	CG: 9/14 EG: 11/13	EDSS [3.0–5.0]	MMSE > 23/30	TBP: WB Exercise: low-loads strength exercises, proprioception exercises on unstable surfaces and gait facilitation exercises, muscle–tendon stretching Schedule: 20–40 min/session, 4x/week, 40 sessions
Gutiérrez [38]	Clinical study	CG = 42.78 (7.38) EG = 39.69 (8.13)	CG: 25 EG: 25	CG: 9/14 EG: 11/13	EDSS [3.0–5.0]	MMSE > 23/30	TBP: WB Exercise: low-loads strength exercises, proprioception exercises on unstable surfaces and gait facilitation exercises, muscle–tendon stretching Schedule: 20 min/session, 4x/week, 40 sessions
Hoang [24]	RCT	CG: 51.9 (11.0) EG: 52.7 (12.4)	CG: 223 EG: 230	CG: 177/51 EG: 189/44	EDSS [2.0–6.0]	No apparent cognitive impairment	TBP: WB Exercise: cognitive-motor training using the step exergame system. games required accurately timed, bilateral steps, using both legs, to hit targets, combining physical stepping precision with cognitive timing and decision-making Schedule: 120 min/week, 6 months
Kramer [42]	Comparative study	47.9	61	17/44	EDSS ≤ 6	NR	TBP: WB Exercise: arm movements (tennis, table tennis, boxing, archery, and sword fight) or displacements of the whole body to control the game avatar (ski slalom, balance bubble, penguin picnic, soccer heading, tilt city, and perfect ten) Schedule: 3 weeks
Palacios-Ceña [47]	Qualitative study	36.9 (5.7)	24	11/13	EDSS [3.0–5.0]	MMSE > 24/30	TBP: WB Exercise: dynamic balance and agility, upper-/lower-limb strength or power, hand-eye coordination and reaction speed Schedule: 4x/week, 40 sessions, 10 weeks
Pau [43]	Observational study	44.6 (10.6)	27	NA	EDSS [1.5- 6.0]	NR	TBP: WB Exercise: balance Schedule: 30 min/session, 5x/week, 5 weeks
Plow [48]	Qualitative study	43.2 (9.3)	30	3/27	Mild to moderate	NR	TBP: WB Exercise: yoga, strength, and aerobic training Schedule: 3x/week, 14 weeks
Prosperini [40]	RCT	i-EG: 35.3 (8.6) i-CG: 37.1 (8.8)	i-EG: 18 i-CG: 18	i-EG: 5/13 i-EG: 6/12	EDSS ≤ 5.5	No cognitive impairment present	TBP: WB Exercise: balance Schedule: 30 min/session, 5x/week, 12 weeks
Thomas [17]	RCT	49.3 (8.7)	30	3/27	EDSS [1.5–5.5]	NR	TBP: WB Exercise: Wii fit and sports, Wii balance board Schedule: 12 months or 6 months
Tramontano [23]	RCT	CG: 52.3 (5.4) EG: 46.7 (10.4)	CG: 16 EG: 14	CG: 6/10 EG: 6/8	EDSS [5.0–8.5]	MMSE > 24/30	TBP: UB Exercise: task-oriented exercises with real-time neurocognitive feedback, precision tasks requiring 1-D and 2-D reactions, attention training, strength and movement control, coordination, and movement precision Schedule: 40 min/session, 3x/week, 4 weeks
Van Beek [44]	Usability study	53.9 (12.3)	9	0/9	EDSS [2.0–7.5]	MMSE > 21/30	TBP: UB Exercise: finger coordination, tapping, and pinch grip Schedule: 30 min/session, 5x/week, 4 weeks
Van Geel [45]	Observational study	NA	19	0/12	NR	NR	TBP: WB Exercise: walking Schedule: 10 weeks

Clinical studies Empirical investigations involving human participants that assess health-related outcomes, Comparative studies Studies evaluating and contrasting outcomes between two or more groups or interventions to determine relative effects, CG Control Group, EDSS Expanded Disability Status Scale, EG Experimental Group, i-CG Control group in the initial phase of a crossover study, i-EG Experimental group in the initial phase of a crossover study, LB Lower-limb body, M Mean, Min Minute, MoCA Montreal Cognitive Assessment, MMSE Mini-Mental State Exam, NR Not Reported, NA Not Applicable, RCT Randomized Controlled Trials, RoM Range of Motion, SD Standard Deviation, TBP Target Body Part, UB Upper-limb body, WB Whole-body

Interventions characteristics

Most studies targeted whole-body function and balance (11/15 studies), while a single study targeted lower-limb motor-cognitive control [36] and two focused on upper-limb dexterity via finger-coordination and precision tasks [23, 44]. Balance training dominated the content, delivered either alone [39, 40, 43, 46] or within exergaming suites [17, 41, 47]. Many protocols layered in low-load strengthening and proprioceptive drills, yoga, aerobic dance, or task-oriented VR with real-time neurocognitive feedback.

Prescriptions varied widely: sessions ranged from 20 min (4 times per week) [37, 38] to 120 min of weekly training sustained over 6 months [17, 24]. Program duration spanned 3 weeks to 6–12 months. All studies retained therapist oversight, most commonly via live videoconference monitoring of home sessions.

Outcome measures

Outcome measures are divided into two primary categories: clinical effectiveness and implementation (which includes feasibility and safety). These measures are detailed in Table 4.

Table 4.

Clinical impact and implementation outcomes

Author	Effectiveness, safety, feasibility
Chanpimol [41]	Outcome measure: 25FW, 2MWT, SPPB (total + balance/gait/chair-stand subscores), MFIS, MSWS-12; Acceptability Survey (satisfaction and willingness to reuse/recommend) Effectiveness: Significant improvements in 25FW time, 2MWT distance, and SPPB total. MFIS and MSWS-12 showed no significant changes Safety: No adverse events or withdrawals reported Feasibility: 36 sessions (3x/ week); high adherence; high satisfaction; All participants would reuse/recommend
Forsberg [46]	Outcome measure: Semi-structured interviews Effectiveness: Perceived improvements in balance and body control during sessions and in daily life (longer standing, safer/faster walking); gains attributed to better awareness of stability limits and technique. Competitive, fun gameplay drove effort and adherence Safety: Only transient muscle soreness/spasticity noted; no falls or injuries during training; Wii Fit regarded as a safe way to challenge balance when a walker or chair was available Feasibility: 2x/week; high adherence; widely rated fun and convenient, PTs saw clear value, but uptake faced four hurdles: two dropouts who “didn’t take” to the Wii, extra tech help needed for home setup, a few over-paced games, and kit + staff costs of ≈ £684 per patient
Goffredo [36]	Outcome measure: Mini-BESTest (total + dynamic-walking subscale); single- and dual-task Timed Up-and-Go (TUG and TUG-D); Montreal Cognitive Assessment (MoCA); MDS-UPDRS III; MSQoL-54 composites (multiple sclerosis) Effectiveness: The EG achieved significant between-group gains on the Mini-BESTest total score, its dynamic-walking sub-score, and the dual-task TUG. In contrast, single-task TUG, MoCA, and the disease-specific scales (MDS-UPDRS III, MSQoL-54) showed no significant difference between the EG and CG Safety: No adverse events reported Feasibility: 35 sessions (5x/ week) with high adherence across five centers, and explicit reporting that the VRRS was “well tolerated” demonstrate good real-world practicality. The platform’s combination of tablet, inertial sensors and clinician-monitored dashboards supported adherence without clinic visits
Gutiérrez [37]	Outcome measure: CES and sensory ratios (somatosensory, visual, vestibular, visual preference) Effectiveness: Significant improvements in CES in EG vs CG. Vestibular and visual-preference ratios likewise improved only in the EG, with no gains in CG Safety: No adverse events reported Feasibility: 40 sessions (4x/ week, 20 min); high adherence
Gutiérrez [38]	Outcome measure: CDP-SOT: CES + sensory ratios (SR, VR, VEST, PREF), CDP-MCT: latency, Clinical: BBS, TT Effectiveness: Significant improvements in overall CES, VEST, PREF, MCT latency, while visual (ViR) and somatosensory (SR) ratios stayed flat, and control changes were negligible Safety: 1/24 EG (MS relapse) and 2/23 CG withdrawals; no adverse events reported Feasibility: 40 sessions (4x/week, up to 20 min); high adherence
Hoang [24]	Outcome measure: Fall rate over 6 months (monthly calendars); secondary: falls 6–12 months, CSRT (+ inhibitory and Stroop variants), postural sway and balance tests, gait (10 m, 6MWT), strength, MFIS, PHQ-9, Icon FES, WHODAS, Trails A/B, COWAT, MSFC Effectiveness: No fall-rate reduction. Significant stepping gains: CSRT movement-time and total-response-time; and inhibitory CSRT movement-time. Other physical, cognitive, psychosocial outcomes show no significant change Safety: No serious intervention-related adverse events. One transient hip pain; two non-injurious assessment falls; no equipment-related incidents feasibility: 70 min per week over 6 months; mild adherence; minimum tech help; cost: kit AUD $750
Kramer [42]	Outcome measure: Force-plate sway-path static balance (Romberg EO/EC and 1-leg EO/EC ± phone); Posturomed displacement dynamic balance (single- vs dual-task golf-swing); 10 m Optogait gait speed and step-variability (single- vs dual-task Q-answer); weekly 6-month self-reports of home-practice adherence and falls Effectiveness: All three groups improved on every force-plate, Posturomed, and gait-velocity variable. Only the exergame group showed a dual-task-specific gain. For all other outcomes, groups changed equally over time Safety: No adverse events reported Feasibility: 72 sessions (3x/week, 30 min); high adherence compared with EG; the exergame group logged the fewest fallers
Palacios-Ceña [47]	Outcome measure: Qualitative unstructured interviews Effectiveness: Participants perceived functional gains: greater independence and body-control (“able to drink a coffee standing up”), renewed ability to jump/dodge, better fatigue self-management, and real-world transfer of game skills to daily tasks and community mobility Safety: No adverse events Feasibility: 40 sessions (4x/week, ≤ 20 min); supervised by video; high adherence; high satisfaction; program praised for convenience and family engagement, though some “over-exposure” (playing beyond prescription) and equipment cost were noted
Pau [43]	Outcome measure: Sway area, COP path length, COP max displacement and velocity in ML and AP planes measured under EO/EC conditions using force-platform posturography Effectiveness: Significant ML-plane improvements in sway area/EO, COP displacement (ML: EO/EC), and COP velocity (ML: EO; no AP improvements) Safety: 2 of 27 participants withdrew after unrelated accidental falls; no Wii-related adverse events reported Feasibility: 25 sessions (30 min); high adherence (participants averaged 24.2 h of training, well above the 12.5 h target)
Plow [48]	Outcome measure: Semi-structured interviews Effectiveness: Participants generally reported better balance, mobility, and confidence, saying Wii Fit let them stand, move, and do daily activities more safely and enjoyably, though a few felt gains were limited when game speed or feedback didn’t match their abilities Safety: Safety was high: no falls or injuries were reported; minor soreness and initial fear of stepping off the board were managed with a nearby chair or walker, and participants judged the home-based Wii Fit training safe overall Feasibility: Users reported that setup was easy; and they could fit sessions into daily life and stuck with the program; only minor hurdles, fatigue, time limits, or board safety worries; needed simple fixes like shorter sessions or a nearby chair
Prosperini [40]	Outcome measure: COP path (OE) via force-platform posturography, FSST, 25-FWT, MSIS-29, Self-reported number of accidental falls Effectiveness: Significant improvements in COP path, FSST, 25-FWT, MSIS-29, Proportion of non-fallers; All other reported outcomes (e.g., cognitive tests, non-targeted posturographic variables) showed no statistically significant change Safety: Adverse events reported: 5 WBBS-related (3 mild back/knee pain, 2 moderate back pain); 1 participant withdrawal; no falls during training Feasibility: High adherence; low therapist burden
Thomas [17]	Outcome measure: GLTEQ, activPAL (sedentary/stepping), HADS, EQ-5D-5L, MSIS-29, FSI, SF-36 v2 (PCS, MCS, SF-6D), SCI-ESES, MSSE, 2MWT, Step Test, Steady-Stance Test, i-TUG, gait stride-time rhythmicity, static posturography EQ, 9HPT, daily play log, interview on acceptability Effectiveness: A moderate boost in GLTEQ plus small-to-modest gains in i-TUG and exercise self-efficacy is reported. SF-36 PCS and EQ-5D-5L were unchanged in the same section Safety: 0 serious adverse event reported; minor Wii-related muscle/joint aches and three near-falls—all resolved without medical care Feasibility: 96 sessions (2x/week); high adherence; minimal staff input
Tramontano [23]	Outcome measure: Primary: 9HPT, manual dexterity. Secondary: MBI (ADL); RMI (transfers and gait); MSQoL-54; FSS; upper-limb strength by 22-item MRC scale Effectiveness: The EG showed a significant change in mobility on the RMI comparing to CG. The EG alone showed a significant within-group rise in QoL and upper-limb strength, but these gains did not differ significantly from the CG’s changes. Manual dexterity and fatigue were unchanged in both groups, and no other scales reached significance Safety: 0 intervention-related adverse events Feasibility: 12 sessions (3x/week, 40 min) added to conventional therapy, high adherence
Van Beek [44]	Outcome measure: 9HPT, adherence (% sessions completed), System Usability Scale (SUS), Custom User Engagement Questionnaire (CUEQ) scores Effectiveness: Not evaluated – the pilot focused on feasibility and usability, with no pre-/post-dexterity outcomes reported Safety: No adverse events or complications; zero dropouts Feasibility: High adherence, excellent usability score (SUS), excellent CUEQ score, no extra technical support needed, usability unaffected by age, disease variables, or baseline dexterity
Van Geel [45]	Outcome measure: IPAQ, 6MWT ± DWI, T25FW, MSWS-12, 5-STS, NHPT, PASAT + CFI, SDMT, MFIS, FSS, MSIS-29, SF-36 effectiveness: Significant improvements were observed in IPAQ-Walking, IPAQ-Leisure, SF-36 PF, 5-STS time, NHPT dominant-hand time, SDMT correct responses, and PASAT-CFI; no significant change in MFIS, FSS, MSIS-29, other SF-36 domains, 6MWT or T25FW safety: 7 out of 19 withdrawals (3 medical, 1 weather-related, 1 technical, 2 low use); no adverse events reported feasibility: 2x/ week with progressive schedule, mild adherence to self-set goals

ABC Activities-specific Balance Confidence Scale, activPAL activPAL3 tri-axial accelerometer, AP Anteroposterior, BBS Berg Balance Scale, CDP Computerized Dynamic Posturography, CES Composite Equilibrium Score, CG Control Group, COP Center of Pressure, COP path length Center of Pressure path length, DGI Dynamic Gait Index, EC Eyes-closed, EG Experimental group, EO Eyes-open, EQ Equilibrium Quotient, EQ-5D-5L EuroQol 5-Dimension 5-Level, FSI Fatigue Symptom Inventory, FSS Fatigue Severity Scale, GLTEQ Godin Leisure-Time Exercise Questionnaire, HADS Hospital Anxiety and Depression Scale, i-TUG Instrumented Timed Up-and-Go, MBI Modified Barthel Index, MCID Minimal Clinically Important Difference, MFIS Modified Fatigue Impact Scale, ML Mediolateral, MCT Motor Control Test, MRC Medical Research Council Scale, MSIS-29 Multiple Sclerosis Impact Scale-29, MSQoL-54 Multiple Sclerosis QoL-54, MSSE Multiple Sclerosis Self-Efficacy Scale, MSWS-12 Multiple Sclerosis Walking Scale-12, PREF Visual Preference Ratio, RMI Rivermead Mobility Index, SCI-ESES Spinal Cord Injury Exercise Self-Efficacy Scale, SF-36 v2 (PCS, MCS, SF-6D) Short Form-36 version 2 (Physical and Mental Component Summaries, SF-6D utility index), SOT Sensory Organization Test, SR Somatosensory Ratio, SPPB Short Physical Performance Battery (total + balance/gait/chair-stand subscores), ST Posturographic Stability Indicator, TUGT Timed Up-and-Go Test, TT Tinetti Test, VEST Vestibular Ratio, ViR Visual Ratio, WBBS Wii Balance Board System, 2MWT Two-Minute Walk Test, 25FW 25-Foot Walk, 9HPT Nine-Hole Peg Test

Effectiveness outcomes

Clinical effectiveness outcomes were categorized into five domains: (1) balance and mobility; (2) QoL and participation; (3) cognition; (4) fatigue; and (5) upper-limb function. To facilitate synthesis of the findings, Fig. 2 presents the frequency with which each outcome domain was evaluated across the included studies. It also lists the specific outcome measures used within each domain.

Fig. 2.

Effectiveness (clinical) outcomes; balance and mobility [17, 23–25, 36, 40–43, 45, 48, 51], quality of life and participation [17, 23, 24, 36, 45], cognition [24, 36, 45, 48], fatigue [24, 41, 45], upper-limb function [23, 44, 45]. List of abbreviations ABC: activities specific balance confidence scale, activPAL: activPAL3 tri-axial accelerometer, AP: anteroposterior, BBS: Berg balance scale, CDP: computerized dynamic posturography, CES: composite equilibrium score, CG: control group, COP: center of pressure, COP path length: center of pressure path length, EC: eyes closed, EG: experimental group, EO: eyes open, EQ: equilibrium quotient, EQ-5D-5L: EuroQol 5-dimension 5-level, FSI: fatigue symptom inventory, FSS: fatigue severity scale, GLTEQ: Godin leisure-time exercise questionnaire, HADS: hospital anxiety and depression scale, i-TUG: instrumented timed up and go, MBI: modified Barthel Index, MCID: minimal clinically important difference, MFIS: modified fatigue impact scale, ML: mediolateral, MCT: motor control test, MRC: medical research council scale, MSIS-29: multiple sclerosis impact scale-29, MSQoL-54: multiple sclerosis QoL-54, MSSE: multiple sclerosis self-efficacy Scale, MSWS-12: multiple sclerosis walking scale-12, PREF: visual-preference ratio, RMI: Rivermead mobility index, SCI-ESES: spinal cord injury exercise self-efficacy scale, SF-36 v2 (PCS, MCS, SF-6D): short form-36 version 2 (physical and mental component summaries, SF-6D utility index), SOT: sensory organization test, SR: somatosensory ratio, SPPB: short physical performance battery (total + balance/gait/chair-stand subscores), ST: posturographic stability indicator, TUGT: timed up-and-go test, TT: Tinetti test, VEST: vestibular ratio, ViR: visual ratio, WBBS: Wii balance board system, 2MWT: two-minute walk test, 25FW: 25-foot walk, 9HPT: nine-hole peg test

Balance and mobility outcomes were assessed in most of the reviewed studies (14 of 15). Approximately 30% of the studies evaluated QoL and participation outcomes, as well as cognitive outcomes. Fatigue and upper-limb function were assessed in only 20% of the studies.

In Fig. 2, to enhance transparency, outcome measures associated with controversial findings, defined as statistically significant within-group improvements without corresponding significant between-group differences, are highlighted in bold. Several of these measures were evaluated in the largest study included in this review, which enrolled 453 participants. In that study, the outcomes assessed included the MFIS (fatigue), PHQ-9 and WHODAS (QoL and participation), COWAT and Trail Making Test A/B (cognition), and two balance and mobility measures: the Icon-FES, a fall-related confidence measure, and the MSFC. The MSFC is a performance-based composite outcome comprising three components: upper-limb function, cognitive function (processing speed/working memory), and walking speed.

Overall, the findings suggest that the intervention is particularly promising for improving balance and mobility. In contrast, the effects on fatigue and QoL/participation appear to be more limited.

Feasibility and safety outcomes

Feasibility was supported by high adherence (median ≥ 80%), strong satisfaction ratings (8 to 10 out of 10), and minimal technical burden across interventions lasting 3–10 weeks (2–5 sessions/week; ~ 25–60 min/session) [17, 23, 24, 37–41, 43, 45–48]. Common enablers included remote physiotherapist supervision [37, 38, 40, 41], intuitive exergame interfaces (e.g., Wii Balance Board, Kinect) [39, 43, 46, 48], and flexible home setups.

Dropouts were infrequent [37, 46] primarily related to setup challenges or overprescription rather than usability issues. Overall, these findings indicate that GBT for MS yields functional gains and is well accepted by patients in home contexts.

Most MS telerehabilitation studies reported no serious adverse events. However, some studies documented minor issues, including one case of transient hip pain and two non-injurious falls [24]; five mild-to-moderate cases of back or knee pain associated with the Wii Balance Board and one participant withdrawal [40]; minor Wii-related muscle or joint aches and three near-falls [51] and seven withdrawals due to medical reasons, weather conditions, technical difficulties, or low program adherence [45].

Hardware and software modules

A full inventory of software features and hardware devices in the 15 included studies is presented in Tables 5 and 6. Eleven interventions employed off-the-shelf commercial systems, Jintronix Rehabilitation System [41], Wii^® games [39, 40, 43, 46, 48], VRRS Table [36], Xbox 360 Kinect^® titles [37, 38], Kinect Virtual Home-Exercise Program (KVHEP) [47], and PABLO^® Upper Extremity [23], while four used customized solutions: a step-exergame platform [24], the Mii-vitaliSe gamification suite [17], the TAD-MS tablet app [44], and WalkWithMe [45].

Table 5.

Software features

Author	Type: customized or commercial game Game company: if commercial game names	Additional functional features
Chanpimol [41]	Type: Commercial Product name: Jintronix rehabilitation system Games: Popping balloons, skiing, rock climb, rabbit bop	Game tool: VR, virtual exercise coach Game challenge customization for patients: Yes, through goal setting manually by PT Exercise library: Yes Patient/PT communication via Software: Not specified Additional functions: (1) parameters such as repetitions, duration of activity, and tasks completed successfully were closely monitored when progressing activities; (2) adherence was calculated using the login date and time
Forsberg [46]	Type: Commercial Product name: Wii fit™ Games: Wii fit™ balance exercises	Game tool: VR Game challenge customization for patients: Yes Exercise library: No Patient/PT communication via software: No Additional functions: (1) full tracking of patients' performance; (2) monitoring correct implementation of exercises; (3) real-time visual feedback to patients on their performance
Goffredo [36]	Type: Commercial Product name: VRRS Tablet home telerehabilitation system (Khymeia Srl, Noventa Padovana, Italy) Games: Balance and lower-limb exercises (e.g., one-leg stance, marching in place, tiptoe standing, squatting)	Game tool: VR Game challenge customization for patients: Yes Exercise library: yes Patient/PT communication via software: No Additional functions: (1) real-time visual and auditory feedback on users participants; (2) remote monitoring of repetitions, duration, and task success through the serious-game environment
Gutiérrez [37]	Type: Commercial Product name: Xbox 360 Games: Kinect sports™, Kinect joy ride™, Kinect adventures™	Game tool: VR Game challenge customization for patients: Yes, automatic Exercise library: No Patient/PT communication via software: No Additional functions: (1) telerehabilitation treatment was monitored via videoconference; (2) full tracking of patients' performance; (3) monitoring correct implementation of exercises; (4) real-time visual feedback to patients on their performance
Gutiérrez [38]	Type: Commercial Product name: Xbox 360 Games: Kinect sports™, Kinect joy ride™, Kinect adventures™	Game tool: VR Game challenge customization for patients: Yes, automatic Exercise library: No Patient/PT communication via software: No Additional functions: (1) telerehabilitation treatment was monitored via videoconference full tracking of patients' performance; (2) monitoring correct implementation of exercises real-time visual feedback to patients on their performance
Hoang [24]	Type: Customized Product name: Step exergame system Games: NA	Game tool: VR Game challenge customization for patients: Yes – six difficulty levels, manual goal setting and progression tailored by pt during home visits Exercise library: Built-in library of eight cognitive-motor stepping games Patient/PT communication via software: Daily automatic data upload to a central server for remote monitoring, with follow-up calls triggered if adherence falls below threshold Additional functions: (1) performance tracking; (2) automatic adherence alerts; (3) provision of support frame for high-risk users, with clinical-judgment criteria
Kramer [42]	Type: Commercial system combining nintendo wii games with an unstable posturomed platform product name: Wii exergame balance training on posturomed surface Games: Wii sports/sports resort/fit titles (tennis, table tennis, boxing, archery, sword fight, ski slalom, balance bubble, penguin picnic, soccer heading, tilt city, perfect ten)	Game tool: VR Game challenge customization for patients: Yes – patients select from multiple game options, and therapists adjust postural difficulty based on balance ability Exercise library: No Patient/PT communication via software: No Additional functions: (1) real-time visual/auditory feedback from the wii games; (2) adherence tracking through weekly self-reports and follow-up calls for missing data
Palacios-Ceña [47]	Type: Commercial Product name: Kinect virtual home-exercise program (KVHEP) Games: NR	Game tool: VR Game challenge customization for patients: Yes, the software automatically adjusts difficulty levels based on individual performance and progress; therapists also tailor session duration (up to 20 min) according to patient fatigue Exercise library: Yes, built-in library of three game titles targeting balance, coordination, and postural control Patient/PT communication via software: yes, real-time remote supervision and interaction via videoconferencing (webcam) during home sessions Additional functions: (1) real-time visual and auditory feedback to guide movement; (2) automatic difficulty progression; (3) adherence monitoring
Pau [43]	Type: Commercial Product name: Wii Games: penguin slide, table tilt, balance bubble	Game tool: VR Game challenge customization for patients: Not specified exercise library: No Patient/PT communication via software: No Additional functions: (1) full tracking of patients' performance; (2) monitoring correct implementation of exercises; (3) real-time visual feedback to patients on their performance
Plow [48]	Type: Commercial Product name: Wii Games: yoga, balance, strength and aerobic training	Game tool: VR Game challenge customization for patients: Yes, exercises duration was tailored to each participant based on rate of perceived exertion when playing “basic run” Exercise library: No Patient/PT communication via software: No Additional functions: (1) full tracking of patients' performance; (2) monitoring correct implementation of exercises; (3) real-time visual feedback to patients on their performance
Prosperini [40]	Type: Commercial Product name: Wii Games: zazen, table tilt, ski slalom, penguin slide, tightrope walk, soccer heading, balance bubble	Game tool: VR Game challenge customization for patients: Yes, automatic Exercise library: No Patient/PT communication via software: No Additional functions: (1) full tracking of patients' performance, (2) real-time visual feedback to patients on their performance, (3) every week follow-up phone call
Thomas [17]	Type: Customized gamification package based on the commercial game of Wii Product name: Mii-vitalise, Wii Games: Wii fit plus, Wii sports, Wii sports resort	Game tool: VR game challenge customization for patients: No Exercise library: No Patient/PT communication via software: No Additional functions: (1) individualized goal setting; (2) providing feedback; (3) action and coping planning and monitoring of progress through in-person and phone visits with PT, and checking the patient's personal activity workbook; (4) allowing participants to self-monitor their activity/progress through a self-reported daily play log (in terms of frequency, intensity, duration); (5) software games with space for notes/comments
Tramontano [23]	Type: Commercial Product name: PABLO® upper extremity (Tyromotion) Games: NR	Game tool: VR Game challenge customization for patients: Yes, intensity and difficulty can be progressively adapted to individual needs, allowing variable challenge levels Exercise library: Yes, a built-in library of motor and neurocognitive rehabilitation exercises Patient/PT communication via software: NR Additional functions: (1) real-time audio-visual feedback; (2) quantitative monitoring of repetitions, strength, and active range of motion, with all data stored in an electronic database
Van Beek [44]	Type: Customized Product name: Tablet app–based dexterity Games: Selective finger tapping (“balloons”), acrobat seesaw (pinch grip), the wheel (rotation and flexion/extension), and elevator i (selective finger rotation)	Game tool: VR Game challenge customization for patients: Yes, therapists set session duration and progression manually, and the app’s design (perceived usefulness, ease of use, enjoyment) supports tailored challenge levels Exercise library: Built-in library of six unique dexterity exercises Patient/PT communication via software: No Additional functions: (1) remote monitoring—clinicians log into a web portal to review each patient’s session performance and adherence; (2) instructional videos and text cues for each exercise; (3) adherence tracking
Van Geel [45]	Type: Customized Product name: Walkwithme Games: N/A	Game tool: Virtual exercise coach Game challenge customization for patients: Yes, through goal setting manually by PT Exercise library: No Patient/PT communication via software: No Additional functions: (1) full tracking of patients' performance; (2) monitoring correct implementation of exercises; (3) real-time visual feedback to patients on their performance

Table 6.

Hardware features

Author (year)	Customized hardware (yes/no)	Sensor type	Supporting platform	Additional hardware
Chanpimol [41]	No	Kinect camera	Tablet	No
Forsberg [46]	No	Wii balance board	Wii console	Home TV
Goffredo [36]	No	VRRS	VRRS tablet	No
Gutiérrez [37]	No	Kinect	Xbox360® console with Microsoft® Kinect	Home TV
Gutiérrez [38]	No	Kinect	Xbox360® console with Microsoft® Kinect	Home TV
Hoang [24]	Yes	Wireless step mat	Computer	Software and instruction/safety booklet, home TV
Kramer [42]	No	Wii	Wii console	Home TV
Palacios-Ceña [47]	No	Microsoft® kinect infrared sensors and multi-array microphone for full-body, hands-free motion capture and avatar control	Xbox 360® console	Home TV
Pau [43]	No	Wii balance board	Wii console	Home TV
Plow [48]	No	Wii balance board	Wii console	Home TV
Prosperini [40]	No	Nintendo Wii balance board	Wii console	Home TV
Thomas [17]	No	Wii balance board, two Wii remote controls, two Nunchuk controls	Wii console	Home TV
Tramontano [23]	No	PABLO® wearable inertial sensors (three accelerometers + one force sensor)	Computer	No
Van Beek [44]	No	Touch screen	Tablet	No
Van Geel [45]	No	Smart phone’s built-in sensors	Smart phone	No

All interventions leveraged non-immersive VR or virtual exercise coaching. Software modules uniformly offered real-time visual and/or auditory feedback; most (13/15) supported patient-tailored challenge settings, either automatically [40, 47] or manually via physiotherapist goal setting [24, 36, 41]. Five systems provided built-in exercise libraries [23, 24, 36, 41, 47], and two enabled remote data uploads or videoconferencing for patient/therapist interaction [24, 47].

Hardware platforms included tablet computers [24, 41, 44], gaming consoles (Wii, Xbox 360 with Kinect), and desktop workstations (VRRS [36], PABLO^® [23]). Sensors ranged from depth cameras (Kinect [37, 38, 41, 47] and balance boards [39, 40, 46, 48], to wearable inertial units (PABLO^® [23]) and touchscreen inputs [44]. Two systems (WalkWithMe [45], Mii-vitaliSe [17]) forewent external sensors, relying instead on virtual-coach avatars and in-app performance tracking.

Together, these configurations demonstrate the flexibility of non-immersive exergaming for home-based MS rehabilitation, ranging from off-the-shelf gaming consoles to custom sensor-based systems, some of which allow remote clinician interaction.

Applied gamification elements and game dynamics

Table 6 lists the hardware module features of the reviewed studies. The MS exergames incorporated a variety of gamification techniques to boost engagement and tailor the challenge. Across the included studies, real-time feedback was the most frequently implemented gamification element, reported in eight studies [23–25, 36, 41, 45, 46, 52]. Avatars or virtual coaches were incorporated in three systems [17, 41, 45] to provide guidance and motivational cues. Reward mechanisms, such as points or achievement-based incentives, were used in two studies [24, 40]. Self-monitoring tools, including in-app logs or tracking features, were reported in two interventions [44, 45], while remote supervision via videoconferencing was described in one study [47]. Task variety was a common feature across nearly all systems, with the exception of one study [46], indicating an emphasis on maintaining engagement through multiple game modules. Finally, explicit difficulty adjustment mechanisms were implemented in four studies [23, 24, 42, 47], supporting personalized progression based on user performance.

Therapeutic tasks are clustered into six movement categories, often combined within a single session: (1) free movements (e.g., virtual skiing, marching in place, tiptoe standing) in Jintronix [41], VRRS lower-limb tasks [36], Wii Sports Resort titles [42], and Plow’s balance/aerobic routines [48]; (2) reach and hit the target, such as popping balloons [41], ski-slalom gates [39], and goal-directed step strikes in the exergame [24]; (3) catch and pick up the target, seen in Penguin Slide and Balance Bubble [39, 43], and the right/left weight shifts of step-exergame coin-catching tasks [24]; (4) carry and move the target, featured in rock-climb holds [41], balance board weight transfers [40, 46], and VRRS object-transport exercises [36]; (5) follow and track the moving target, such as Table Tilt’s shifting platform [39, 43] and the trajectory-guided avatar in WalkWithMe [45]; (6) fine-motor dexterity tasks, unique to TAD-MS’s six finger-tapping and rotation games [44, 45] and PABLO^®’s wrist/elbow coordination challenges [23].

By blending whole-body and fine-motor dynamics, these exergames address the multifaceted mobility and dexterity deficits in MS, while their built-in customization and feedback loops help ensure each patient can progress safely at home.

Discussion

This scoping review aimed to explore the available literature on home-based PT GBT systems provided to people with MS. The rehabilitation process and the hardware and software-driven technology solutions were reviewed to identify the clinical effectiveness outcomes reported for GBT systems, to describe the key implementation-related outcomes, and to map out the technological and game-based features embedded in these systems for people with MS. Some additional insights regarding the state of the field are also reported.

The 15 articles included in this review were mostly conducted in Europe, and primarily focused on quantitative research methodologies, indicating a predominant emphasis on objective and measurable outcomes. While quantitative studies provide essential data and insights, incorporating both quantitative and qualitative types of studies would offer a deeper and more realistic understanding of the topic, including not only the measurable outcomes but also the individuals’ lived experiences and satisfaction with these innovative solutions. Given the evidence showing that the pattern and frequency of MS symptoms vary by region/continents [53–56], broader and region-specific studies are also needed to guide locally appropriate interventions.

Studies/intervention characteristics

The majority of the reviewed studies focused on addressing impairments related to balance and mobility, which were assessed in 14 out of 15 studies. These domains are more commonly affected in progressive forms of MS but can also be seen in individuals with long-standing RRMS [57]. In contrast, outcomes such as fatigue, cognition, and upper-limb function were less commonly assessed. While a limited number of studies have explored upper-limb dexterity, the predominant emphasis on lower-body function and postural control suggests that interventions have largely targeted symptoms associated with more advanced functional limitations.

This distribution of outcomes may reflect the characteristics of the study populations, which often included individuals with mixed or progressive forms of MS, or did not stratify findings by subtype. However, it may also indicate a broader tendency in the literature to prioritize mobility-related impairments over more localized or variable symptoms, such as those frequently experienced during relapses or throughout the course of RRMS. As a result, symptoms that can present across different stages and phenotypes of MS, including fatigue, cognitive changes, and upper-limb dysfunction, remain comparatively underrepresented. This highlights a gap in the literature regarding more comprehensive and symptom-targeted rehabilitation approaches.

The quality of the studies included was moderate. Most were rated fair-to-good, typically with medium sample sizes. However, an encouraging sign is that a number of RCTs have been conducted despite the recent introduction of GBT for MS. While we also identified many other lower-level evidence studies using clinical, observational, comparative, usability, or qualitative designs, these approaches still provide valuable insights. Relatedly, the effectiveness of GBT interventions for individuals with MS cannot yet be stated with certainty, as outcome measures showed mixed results across studies. Several of these measures were evaluated in the largest study included in this review, which enrolled 453 participants [24], lending weight to the possibility that the effects of GBT may be domain-specific rather than broad reaching. Since most interventions used a similar frequency and duration, the variability in outcomes likely stems from differences in study design, disease phase, sample characteristics (e.g., gender balance, age range, and disease stage), and the sensitivity of the outcome tools to these factors. For instance, most studies enrolled more women than men, which is not surprising given that the disease is about twice as prevalent in women, but this limits our understanding of potential gender-related differences in acceptance, participation barriers, patient-centered care, motivation, and user experience. Future research should incorporate gender-specific analyses and design features to create interventions that are more personalized, effective, and equitable for all people living with MS. As well, there is a need to better define which measures are most responsive to GBT and to explore which subgroups of people with MS benefit most. Importantly, studies should report both within-group and between-group comparisons to offer a clearer view of clinical impact.

Outcome measures

Effectiveness outcomes

Overall, balance and mobility outcomes showed the most consistent improvements across controlled trials. This aligns with the capability of most GBTs that can specifically provide engaging balance/postural control game solutions in high repetitions. In contrast, gait, fatigue, and QoL outcomes were more heterogeneous. These domains may require longer interventions, behavioral support, and contextualized functional training to build measurable changes. Future trials should prioritize standardized outcome sets and clearly report between-group effects and clinically meaningful change thresholds where available.

These findings align with prior reviews, including those from a 2021 systematic review [58], which found that home-based active video games improved static and dynamic balance, though results for gait and mobility were mixed. Another review [59] concluded that exergaming yields positive cognitive, motor, and psychological effects in MS. Together, these broader findings reinforce our observation that while GBT interventions show clear promise, particularly for balance and stepping, results across other domains remain inconsistent and warrant further investigation.

Feasibility and safety outcomes

Based on the included studies and the low rate of the participant withdrawals from the research trials, it appears that participants with MS are able to tolerate interventions ranging from 2 to 12 months in duration and with the frequency of 3 to 5 times per week, for a minimum of 20 min and a maximum of 45 min per session. This duration of physical activity aligns with existing guidelines for home exercises for the MS population, which recommend 20–40 min of activity per week [60]. This target time can be reached through continuous or intermittent activities. According to the reviewed studies, a PT-prescribed GBT program which is appropriately adjusted for duration, intensity, and game content can facilitate adherence to physical activity recommendations (i.e., resistance training, stretching, etc.), and support long-term engagement in safe and independent home-based exercise sets. Importantly, GBT appears to be safe for MS patients, where most trials reported no treatment-related serious adverse events. Three studies reporting adverse events had infrequent and mild ones like muscle pain and soreness that resolved without care. Hence, when preceded by basic screening (e.g., evaluating balance capacity, and fall risk), GBT can be offered as a treatment with minimal risks. As well, withdrawals were infrequent, but when they occurred, they were mainly due to unrelated medical conditions, lack of engagement, or logistical and technical issues such as weather disruptions, which also affected indoor conditions, equipment problems, or low system use (Table 4).

Hardware and software modules

Most included studies used commercial gaming systems, particularly the Nintendo Wii (with the Balance Board) and Kinect, likely due to their intuitive design and relevance to balance impairments in MS. These platforms are cost-effective, widely recognized, and supported by strong evidence. However, they often lack accessibility features, such as adaptable difficulty levels or clinician dashboards, which may limit their use in individuals with greater disability.

In contrast, custom-developed systems allow for tailored interventions, especially through individualized difficulty adjustment. This is particularly valuable in relapsing–remitting MS, where impairments are often localized. However, in progressive MS, where symptoms are more widespread, adapting such systems may be more complex and less scalable. Custom systems also face challenges in long-term sustainability due to the relatively small and heterogeneous MS population.

Technological obsolescence is another concern, especially for commercial platforms like the Wii and Xbox 360, which have been discontinued. By the time clinical effectiveness is established, such systems may no longer be available. While this mainly affects commercial technologies, custom systems face challenges in scalability and long-term sustainability, particularly given the small and heterogeneous MS population. This highlights a key trade-off between the adaptability of custom systems and the accessibility and longevity of commercial platforms. Open-source solutions may help address this by offering flexibility and reducing reliance on proprietary technologies.

Emerging technologies, including artificial intelligence (AI)-powered motion capture and wearable sensors, provide greater precision and adaptability [61, 62]. These systems can track fine-motor movements, collect multidimensional data, and adjust interventions in real time, reducing clinician burden. A hybrid approach, combining commercial accessibility, open-source flexibility, and advanced technologies, may offer the most promising path for optimizing gamified telerehabilitation in MS.

Across the included studies, systems could be grouped into three types: (1) consumer exergaming platforms (e.g., Wii/Wii Fit, Wii Balance Board, and Kinect), (2) rehabilitation-oriented platforms (e.g., VRRS, Jintronix, and custom Kinect-based systems), and (3) mobile or tablet applications targeting specific skills. Consumer platforms typically use force platforms or depth cameras; they are low cost and familiar but offer limited customization, variable accuracy, and risk of obsolescence. Rehabilitation platforms often combine depth cameras or multi-sensor setups with PC or tablet interfaces, enabling better personalization and remote monitoring, though they require more setup, connectivity, and technical support. Mobile and tablet apps rely mainly on touchscreen input, sometimes with external sensors; they are highly accessible and scalable but usually focus on narrow tasks and require further validation. Overall, these categories reflect trade-offs between adaptability, scalability, cost, and long-term sustainability.

Balance and mobility outcomes were assessed across both commercial and custom platforms, with most studies using commercial systems. Frequently used platforms included Xbox 360-based systems, Nintendo Wii-based systems, and Jintronix. Significant improvements in balance were reported across both platform types, suggesting that clinical impact depends more on task specificity and real-time feedback than on the platform itself. QoL and participation outcomes were examined across both system types, with no clear advantage. Fatigue and upper-limb outcomes were more often studied using customized systems, which included targeted modules (e.g., tablet-based dexterity training). Higher levels of evidence were found in both categories, indicating that platform type does not determine study quality. Larger samples were more common in balance and mobility studies, which may explain their more consistent findings. Overall, balance and mobility appear most responsive to  GBT, while fatigue and upper-limb outcomes are more often addressed through customized, task-specific systems.

Sensor modality shapes what can be trained and measured at home. Force platforms are well suited for static balance and weight shifting, while depth cameras enable whole-body tracking for dynamic tasks but can be sensitive to lighting and space. Mobile and tablet systems reduce cost and increase access but target fewer functions and need validation of sensor-based metrics. The discontinuation of widely used devices (e.g., Wii, Kinect) underscores the need for sustainable hardware, modular designs, and clear reporting to support replication and clinical use.

Our review found that GBT solutions mainly use simple gamification features, such as target-based tasks (e.g., balloon popping, step strikes), avatar or virtual-coach guidance, and basic motion tracking with real-time feedback. These elements support ease of use and lower barriers to engagement [63], especially for older adults with MS who may prefer intuitive interfaces. However, most interventions focus on single-task exercises and balance training, reflecting the needs of individuals in progressive MS, where gait and lower-limb impairments are common. This emphasis may overlook those in earlier relapsing–remitting stages, where impairments are often localized (e.g., upper-limb or sensory deficits). Few systems address fine-motor control, cognitive–motor integration, or multi-joint coordination, which are critical for maintaining independence.

To better reflect the stage-specific progression of MS [3], GBT systems should move beyond one-size-fits-all designs. Future platforms should adopt modular, stage-sensitive approaches, enabling progression from simple tasks to more complex, full-body and dual-task activities. Incorporating adaptive progression, guided by clinicians or AI, would allow difficulty and content to evolve with the patient’s functional status, improving personalization, engagement, and clinical effectiveness across disease stages.

Limitations

This review has several limitations. The review was restricted to English-language publications and did not include gray literature, potentially excluding relevant evidence. While not a limit of the review itself per se, most included studies were conducted in Europe, which may limit the generalizability of our findings to other healthcare settings.

As a scoping review, the focus was on mapping technological features, clinical outcomes, and implementation aspects of GBT, rather than evaluating effectiveness in depth. In addition, qualitative data were limited, with few studies exploring user experiences or implementation factors. Future research should incorporate qualitative or mixed-methods approaches to better understand engagement, barriers, and long-term adoption, supporting improved personalization, usability, and clinical integration.

Conclusion

This scoping review mapped the current landscape of GBT for individuals with MS, highlighting growing interest in using game-based systems to support home-based care. The evidence suggests GBT can enhance PT engagement and help address mobility and balance impairments, especially in progressive MS. However, variability in effectiveness, limited cognitive and upper-limb targeting, and underrepresentation of relapsing–remitting MS indicate a need for more tailored, stage-specific solutions. As GBT technology evolves, future research should focus on refining interventions through adaptive, modular game design and rigorously evaluating their clinical and psychosocial impacts across MS subtypes. Overall, this scoping review provides a structured overview of the current landscape and highlights areas requiring further methodological and implementation-focused investigation.

Author contributions

Conceptualization: S., Norouzi-Ghazbi; J., Andrysek; R., Goldstein; S., L. Hitzig. Data curation: S. Norouzi-Ghazbi; S., L. Hitzig. Formal analysis: S. Norouzi-Ghazbi; S., Mirbaha; Z. Li; S., L. Hitzig. Funding acquisition: S., Norouzi-Ghazbi; J., Andrysek; R., Goldstein; S., L. Hitzig. Methodology: S., Norouzi-Ghazbi; S., Mirbaha; Z., Li; J.; M. Mariyanayagam; S., L. Hitzig. Project administration: S., L. Hitzig. Supervision: J., Andrysek; R., Goldstein; S., L. Hitzig. Writing—original draft: S., Norouzi-Ghazbi; S., Mirbaha. Writing—review and editing: J., M. Mariyanayagam; Z., Li; J., Andrysek; R., Goldstein; S., L. Hitzig.

Funding

This project is funded through Mitacs Accelerate (Application Ref. IT28534). Dr. Sander Hitzig is supported by the John C. and Sally Horsfall Eaton Chair in Rehabilitation Research, a joint Hospital-University named Chair between the University of Toronto, the Sunnybrook Health Sciences Centre, and Sunnybrook Health Sciences Centre Foundation.

Data availability

No datasets were generated or analyzed during the current study.

Declarations

Competing interests

The authors declare no competing interests.