For the roughly 2.8 million people worldwide living with multiple sclerosis, physical therapy is often a lifelong commitment—one that hinges on repetitive, demanding exercises that can become tedious enough to abandon altogether. A new scoping review suggests that turning those exercises into games, delivered remotely into patients’ living rooms, may help keep them moving. The analysis, published in BioMedical Engineering OnLine, finds that gamification-based telerehabilitation systems are safe, well tolerated and enthusiastically adopted at home, with the most consistent clinical gains appearing in balance and postural control, even as benefits for fatigue, quality of life and cognition remain uncertain.
Led by Somayeh Norouzi-Ghazbi of the University of Toronto and Sunnybrook Research Institute, the research team systematically searched five scholarly databases—Ovid Medline, Ovid Embase, CINAHL, EBSCO and Scopus—for studies published between January 2010 and November 2024. From 6,322 initial records, only 15 studies met the inclusion criteria, a figure that underscores how young this field remains. The review followed the PRISMA-ScR reporting checklist and Arksey and O’Malley’s five-stage scoping framework, with the protocol registered in advance on the Open Science Framework. Rather than statistically pooling treatment effects, the authors chose a scoping design to map the landscape of technologies, clinical outcomes and practical implementation issues—an appropriate choice given how heterogeneous the interventions proved to be.
The 15 studies collectively involved roughly 900 adults with multiple sclerosis, enrolled across nine countries including Italy, Spain, the United States, Germany, Australia, Benin, Sweden, Switzerland and the United Kingdom. Sample sizes ranged dramatically, from a nine-participant usability pilot to a large randomized controlled trial allocating 453 participants between intervention and control arms. Most cohorts were in their forties or fifties and predominantly female—unsurprising given that multiple sclerosis affects women roughly 2.5 times more often than men—though two studies enrolled no men at all. Disability was typically mild to moderate on the Expanded Disability Status Scale, ranging from 1.0 to 6.0, although two studies included participants with severe impairment reaching 8.5 on the scale. Cognitive function was largely preserved, with many protocols requiring Mini-Mental State Examination scores above 23 out of 30.
Methodologically, the field sits in a middle ground. Twelve studies could be rated with the Downs and Black checklist, a 28-point instrument assessing internal and external validity; the mean score was 21.2, with seven studies meeting the “good” threshold and five rated “fair,” while none fell into the poor category. Under a modified Sackett hierarchy, six studies provided level 1b evidence—the strongest tier—and six offered only level 4 or 5. Thirteen of the 15 used quantitative designs, including four randomized controlled trials, while just three were qualitative, a gap the authors argue leaves patients’ lived experiences underexplored.
The technological heart of these interventions is what researchers call exergaming: embedding therapeutic movements within game environments, sometimes supplemented by discrete gamification elements such as points, badges, progress indicators and challenges applied to otherwise ordinary exercise routines. Eleven of the 15 studies relied on off-the-shelf commercial platforms—Nintendo Wii and its Balance Board, Xbox 360 with the Kinect depth camera, the Jintronix rehabilitation system, the VRRS table system, and the PABLO upper-extremity trainer—while four deployed custom-built solutions, including a step-exergame platform, the Mii-vitaliSe gamification suite, the TAD-MS tablet application for finger dexterity, and the WalkWithMe virtual-coach application. Notably, the review excluded immersive virtual reality with head-mounted displays, citing safety concerns such as motion sickness, disorientation and the strong balance control such systems demand—luxuries many patients with multiple sclerosis cannot afford.
Sensor hardware shaped what each system could train. Force platforms and balance boards excel at static balance and weight-shifting drills; depth cameras track whole-body movement for dynamic tasks but are sensitive to lighting and cramped home spaces; wearables and touchscreens capture fine-motor precision at the cost of narrower functionality. Software was more uniform: every system provided real-time visual or auditory feedback, 13 of 15 supported adjustable challenge levels either automatically or through therapist-set goals, five included built-in exercise libraries, and two enabled remote data uploads or videoconferencing with clinicians. The gamification elements themselves were comparatively simple. Real-time feedback was the most common feature, appearing in eight studies; avatars and virtual coaches featured in three; explicit reward mechanisms in only two. Therapeutic tasks fell into six recurring movement categories, from free movements like virtual skiing and tiptoe standing to target-striking, object-carrying, trajectory tracking and fine-motor finger-tapping games.
On the clinical side, balance and mobility emerged as the clear star of the field. Fourteen of the 15 studies assessed these outcomes, and across controlled trials they produced the most consistent improvements—a finding that makes intuitive sense, since exergames can deliver engaging balance and postural-control tasks at high repetitions, precisely the kind of dose conventional home programs struggle to sustain. By contrast, quality of life and participation, cognition, fatigue and upper-limb function each received far less attention, and results in those domains were mixed, often showing significant within-group improvements that vanished in between-group comparisons. Several such contested measures appeared in the largest trial, which evaluated fatigue, depression, disability, fall-efficacy, cognition and a composite multiple sclerosis functional score without consistent between-group separation.
Safety and feasibility, however, tell an encouraging story. No serious adverse events were reported anywhere in the reviewed literature. The handful of minor issues included transient hip pain, two non-injurious falls, five mild-to-moderate cases of back or knee pain linked to the Wii Balance Board, and several near-falls. Adherence was strikingly high, with a median of at least 80 percent across interventions, and satisfaction ratings ranged from 8 to 10 out of 10. Programs typically ran three to ten weeks at two to five sessions per week of roughly 25 to 60 minutes each, and dropouts—infrequent overall—stemmed mostly from setup difficulties or overprescription rather than usability problems. All interventions retained therapist oversight, most commonly through live videoconference monitoring of home sessions, suggesting that remote supervision is both workable and valued.
The authors frame these findings within the mechanistic logic of self-determination theory: games may bolster intrinsic motivation by supporting patients’ sense of autonomy, competence and relatedness, countering the motivation collapse that plagues long-term rehabilitation. This matters because the disease itself makes clinic access hard. Gait disturbance and leg weakness often dominate the clinical picture in progressive forms of multiple sclerosis for years, making travel to specialized centers a genuine burden, and telerehabilitation sidesteps that barrier entirely—an advantage that gained urgency during the COVID-19 pandemic.
Yet the review is candid about the field’s weaknesses. Commercial platforms like the Wii and Kinect have been discontinued, raising the specter of technological obsolescence: a therapy may be validated just as its hardware vanishes from shelves. Custom systems offer adaptability, particularly valuable in relapsing-remitting disease where impairments are often localized to a single limb or function, but they face scalability and sustainability challenges given the relatively small and heterogeneous patient population. The authors suggest a hybrid path forward—combining the accessibility of commercial hardware, the flexibility of open-source software, and emerging technologies such as artificial intelligence–driven motion capture and wearable sensors that can adjust interventions in real time while lightening clinician workload.
The gaps in coverage are equally instructive. Fatigue, cognitive changes and upper-limb dysfunction can present across every stage and subtype of multiple sclerosis, yet they remain comparatively understudied, and few systems address fine-motor control, cognitive-motor integration or multi-joint coordination—the very abilities that determine independence in daily life. Nearly all research has emerged from Europe, even though symptom patterns vary by region, limiting generalizability. Gender imbalances in study samples further obscure differences in acceptance, motivation and user experience between men and women. The authors call for standardized outcome sets, explicit between-group comparisons, gender-specific analyses and mixed-methods designs that capture not just measurable outcomes but patients’ lived experiences.
For now, the practical takeaway is measured but genuine. Gamification-based telerehabilitation appears to be a safe, engaging and feasible alternative or adjunct to conventional physical therapy—particularly for people whose access to clinics is limited or whose motivation has eroded—provided basic screening for balance capacity and fall risk precedes prescription. Balance and mobility are the domains where the evidence currently stands strongest. As the technology matures toward adaptive, modular, stage-sensitive designs, the field’s central challenge will be proving that what keeps patients playing also keeps them measurably better.
Subject of Research: Home-based gamification-based telerehabilitation systems delivering physical therapy for people with multiple sclerosis
Subject of Research: Medicine
Article Title: Game-based and gamification-enhanced telerehabilitation for physical therapy in people with multiple sclerosis: a scoping review
Article References: Norouzi-Ghazbi, S., Mirbaha, S., Mariyanayagam, J. M., Li, Z., Andrysek, J., Goldstein, R., & Hitzig, S. L. (2026). Game-based and gamification-enhanced telerehabilitation for physical therapy in people with multiple sclerosis: a scoping review. BioMedical Engineering OnLine, 25(1), Article 96. https://doi.org/10.1186/s12938-026-01589-4
Image Credits: AI Generated
DOI: 10.1186/s12938-026-01589-4
Keywords: Telerehabilitation, Physical therapy, Gamification, Exergaming, Multiple sclerosis, Balance training, Home-based rehabilitation, Serious games, Virtual reality, Scoping review
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Ophelia Keating. (September 7, 2026). Game-based telerehabilitation aids physical therapy in multiple sclerosis patients, review finds. Scienmag. https://scienmag.com/game-based-telerehabilitation-aids-physical-therapy-in-multiple-sclerosis-patients-review-finds/
Ophelia Keating. “Game-based telerehabilitation aids physical therapy in multiple sclerosis patients, review finds.” Scienmag, 7 September 2026, https://scienmag.com/game-based-telerehabilitation-aids-physical-therapy-in-multiple-sclerosis-patients-review-finds/. Accessed 7 September 2026.
Ophelia Keating. “Game-based telerehabilitation aids physical therapy in multiple sclerosis patients, review finds.” Scienmag. September 7, 2026. https://scienmag.com/game-based-telerehabilitation-aids-physical-therapy-in-multiple-sclerosis-patients-review-finds/
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