JMIR SERIOUS GAMES Stammler et al

Original Paper

Negami: An Augmented Reality App for the Treatment of Spatial

Neglect After Stroke

Britta Stammler1; Kathrin Flammer2; Thomas Schuster3; Marian Lambert3; Hans-Otto Karnath1
1
Center of Neurology, Division of Neuropsychology, University of Tübingen, Tübingen, Germany
2
Flammer & Gläser UXplain GbR, Karlsruhe, Germany
3
XPACE GmbH, Pforzheim, Germany

Corresponding Author:
Hans-Otto Karnath
Center of Neurology
Division of Neuropsychology
University of Tübingen
Hoppe-Seyler-Strasse 3
Tübingen, 72076
Germany
Phone: 49 7071 29 80467
Email: Karnath@[Link]

Abstract
Background: A widely applied and effective rehabilitation method for patients experiencing spatial neglect after a stroke is
“visual exploration training.” Patients improve their ipsilesional bias of attention and orientation by training exploration movements
and search strategies toward the contralesional side of space. In this context, gamification can have a positive influence on
motivation for treatment and thus on the success of treatment. In contrast to virtual reality applications, treatment enhancements
through augmented reality (AR) have not yet been investigated, although they offer some advantages over virtual reality.
Objective: This study aimed to develop an AR-based app (Negami) for the treatment of spatial neglect that combines visual
exploration training with active, contralesionally oriented rotation of the eyes, head, and trunk.
Methods: The app inserts a virtual element (origami bird) into the real space surrounding the patient, which the patient explores
with the camera of a tablet. Subjective reports from healthy elderly participants (n=10) and patients with spatial neglect after
stroke (n=10) who trained with the new Negami app were analyzed. Usability, side effects, and game experience were assessed
by various questionnaires.
Results: Training at the highest defined difficulty level was perceived as differently challenging but not as frustrating by the
group of healthy elderly participants. The app was rated with high usability, hardly any side effects, high motivation, and
entertainment. The group of patients with spatial neglect after stroke consistently evaluated the app positively on the dimensions
of motivation, satisfaction, and fun.
Conclusions: The Negami app represents a promising extension by adding AR to traditional exploration training for spatial
neglect. Through participants’ natural interaction with the physical surrounding environment during playful tasks, side effects as
symptoms of cybersickness are minimized and patients’ motivation appeared to markedly increase. The use of AR in cognitive
rehabilitation programs and the treatment of spatial neglect seems promising and should receive further investigation.

(JMIR Serious Games 2023;11:e40651) doi: 10.2196/40651

KEYWORDS
spatial neglect; gamification; augmented reality; visual exploration training; stroke rehabilitation; serious games; rehabilitation;
stroke

spatial neglect is a large stroke in the right middle cerebral artery

Introduction area that affects a perisylvian network consisting of the
Spatial neglect is the dominant disorder after a brain lesion of superior/middle temporal cortex and the parietal and
the human right hemisphere [1,2]. The most common cause of ventrolateral frontal cortexes [3]. Affected patients behave as

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though the left side of their surrounding space no longer exists. developed. It is based on the observation that visual exploration
The patient’s eyes and head are sustainedly oriented to the side training seems to be particularly effective when combined with
of the brain lesion (ie, mostly to the right side) [4,5]. When an active rotation of the trunk contralesionally [24]. An attractive
searching for objects, the patient’s visual and tactile exploration extension of this treatment principle is the innovative app named
is shifted to the right side. Accordingly, objects or people located Negami. This app is based on the principle that patients are
on the left side are ignored and not found. Many therapeutic playfully motivated to orient themselves to their neglected side
approaches to spatial neglect thus entail exercises (eg, search of the real room by (1) following and (2) searching for a virtual
training on large projection screens) and activities (eg, reading element (in this case an origami bird), actively exploring space
and copying tasks, picture descriptions) that require increased by turning their gaze, head, and trunk. In developing the game,
and active turning of the patients toward the neglected special consideration was given to the age group to ensure high
contralesional side [6-9]. In this training, termed “visual usability. Our goal was to develop a task that would motivate
exploration training” or “visual scanning training,” exploration the patients and that they would enjoy. By eliciting the
movements are improved, and compensatory search strategies subjective views of both healthy elderly participants (aged 57
are practiced, leading to improvements in neglect behavior in to 89 years) and patients with spatial neglect after stroke
important everyday situations. regarding our AR-assisted exploratory therapy app, we also
aimed to uncover barriers to its use and make recommendations
A critical component of neurorehabilitation and its success is
to improve the future development of therapies with AR.
related to patients’ motivation to train [10]. Improving the latter
is one of the main aspects of recent rehabilitation efforts known
as “gamification” [11,12]. Gamification describes the application
Methods
of game design elements in a nongame context to motivate Participants
desired behavior. Treatment motivation in stroke rehabilitation
can additionally be increased by gamified feedback (ie, giving Ten elderly neurologically healthy individuals with a mean age
feedback about the performance in the corresponding task by of 66 (SD 11.9) years, including 5 (50%) females, participated
awarding points) [13]. in this study. In addition, we included 10 patients, including 2
(20%) females, who were experiencing spatial neglect and
The principle of gamification is further emphasized when left-sided hemiparesis after a stroke in the neurological right
combined with virtual reality (VR) methods. The principle of hemisphere —5 (50%) with infarction and 5 (50%) with
active exploration training in spatial neglect has already been hemorrhages. They had a mean age of 61.3 (SD 15.2) years and
extended by several VR approaches. Nonimmersive VR a poststroke interval of 138.4 (SD 192.1) days when they were
procedures, in which a virtual environment is displayed on a tested for spatial neglect. More details of the patients are
monitor with which the patient interacts without being immersed provided in Multimedia Appendix 1.
in it, have been successfully used in group studies for therapeutic
purposes [14-16]. On the other hand, immersive VR procedures, The inclusion criterion for the patients was the presence of
in which the patient becomes part of a virtual 3D environment spatial neglect after a stroke. In addition to clinical behavioral
surrounding them by means of VR goggles, have also been observations, diagnostic criteria had to be met in at least 2 of
developed, gearing toward active exploration scenarios. Recent the following 4 neglect tests: the Letter Cancellation Test [25],
proof-of-concept studies have shown that healthy participants the Bells Test [26], a Copying Task [27], and a Line Bisection
and patients who have had a stroke perceive this technique as Task [28]. All 4 neglect tests were performed on a Samsung
highly motivating and enjoyable [17-19]. Moreover, immersive S7+ tablet with screen dimensions of 285 × 185 mm. The
VR applications have already been tested with individual severity of spatial neglect in the cancellation tasks was
patients with spatial neglect for treatment purposes [20,21]. determined by calculating the center of gravity of the target
stimuli marked in the search fields, known as the Center of
Another promising way to increase training motivation in Cancellation (CoC). A CoC value ≥0.08 indicated left-sided
poststroke rehabilitation is through augmented reality (AR). spatial neglect [3,29]. The Copying Task consisted of a complex
AR describes the computer-generated addition of virtual scene consisting of 4 objects (fence, car, house, and tree),
elements to reality. The visual, real world is augmented by wherein points were assigned based on missing details or whole
virtual images and figures via a video camera of an electronic objects. One point was given for a missing detail and 2 for a
device such as a tablet. The virtual addition takes place in real whole object. The maximum number of points was therefore 8.
time in the sense of a live transmission and thus combines the A score higher than 1 (ie, >12.5% omissions) indicated neglect
real and the virtual [22]. Bakker and colleagues [23] developed [27]. In the Line Bisection Task [28], patients were presented
the first game combining AR elements with visual scanning with 4 different line lengths eight times each (ie, 32 lines in
training in the context of neglect rehabilitation. It consisted of total). The cut-off value for spatial neglect was an end point
participants searching for virtual images projected onto a wall weightings bias (EWB) value ≥0.07 [30].
in the environment of a museum. Design decisions were made
based on expert opinion as well as the opinion of patients with In the group of patients, the mean CoC on the Letter
spatial neglect. Features to increase extrinsic motivation were Cancellation Test was 0.42 (SD 0.28), the mean CoC on the
rated as the most important design decision. Bells Cancellation Task was 0.38 (SD 0.29), the score on the
copying test was 4.4 (SD 1.51), and the EWB score on the Line
In this development and feasibility study, the application of an Bisection Task was 0.33 (SD 2.5).
AR technique for the treatment of spatial neglect is further

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Ethics Approval open-source cross-platform framework Xamarin (Microsoft

All participants gave their informed consent to participate in Corp) [32]. It allows the creation of native Android, iOS, and
the study, which was conducted following the ethical standards Windows apps by sharing UI and code across platforms. The
of the 1964 Declaration of Helsinki. This study was also Xamarin platform consists of [Link] and
approved by the ethics committee of the University Clinic of [Link] projects, which are implementations of the
Tübingen (373/2021B02). Mono framework for iOS and Android, respectively. Mono is
a cross-platform open-source .NET compatible software
The Negami App framework. Additionally, Xamarin includes the [Link]
library for the creation of cross-platform user interfaces using
Overview
XAML (Extensible Application Markup Language). A UI
Negami [31] is a mobile app that enables the treatment of spatial created in [Link] is automatically mapped to native
neglect using gamified AR. It is optimized for use on tablets controls on each platform during the build process. Xamarin
but also works on smartphones. In this study, a 3rd generation was chosen for the development of the Negami app because it
Apple iPad Pro 12.9” was used to run the app and conduct the provides native runtime performance, which is important for
therapy sessions. Negami provides 2 modes (Task A and Task game-based apps, as well as an abstraction layer over many
B), which are detailed in the subsequent section. In both tasks, platform-specific application programming interfaces (APIs),
the live video stream from the devices’ back cameras is thus increasing development speed. Additionally, Xamarin
displayed on the screen. Additionally, a virtual element (origami offers a set of bindings for full access to all device-specific APIs
bird) is added (augmented) as a 3D object that must be followed (Figure 1). Apps built with Xamarin are compiled into native
(Task A) or searched for (Task B) by moving the tablet in 3D packages for each platform. For the Android platform, the
space. An overlaying crosshair user interface (UI) element written code is compiled down to Intermediate Language (IL),
provides visual feedback and guidance for the patient. which is then just-in-time compiled to native assembly on app
Technical Background launch. On iOS, the app is fully ahead-of-time compiled into
native ARM (Advanced Reduced Instruction Set Computer
The Negami app can be achieved via the Negami website. The Machine) assembly code (Figure 1 [33]).
app was implemented in C# programming language using the
Figure 1. Architecture of an application developed using [Link] (left) and [Link] (right) [33]. AOT: ahead of time; API: application
programming interface.

Utilizing Xamarin, the implementation of the Negami app’s app settings with a remote Microsoft SQL (Structured Query
entire business logic and user interface could be shared across Language) database utilizing the [Link] library. As the
platforms. The development followed the actual data for each completed exercise session were too large
Model-View-View-Model design pattern and applied other best to be stored efficiently in a database, a file-based
practices such as the use of an inversion of control container synchronization was implemented using the Azure Blob Storage
for dependency injection, commands, and event aggregators. (Microsoft Corp) service.
Additionally, the app’s functionality was verified using both
Unlike the business logic and UI elements, the AR aspects of
unit tests and manual testing. To facilitate the data collection
the app had to be implemented in a platform-specific way
process, a data synchronization feature was implemented that
because Xamarin provides no abstraction layer for these APIs.
regularly syncs the local SQLite database (which enables the
The implementation was only completed for the iOS platform.
app’s offline usage) containing metadata about each patient and
For this, the Apple ARKit platform [34] was used (through

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native bindings provided by [Link]) to implement all the unaffected hand from the bottom/center. However, if the
AR-related logic, such as world tracking, placing and rendering tablet is too heavy for the patient to hold in this single-handed
of the objects in 3D space, and retrieving the current screen position, a loop with Velcro can be attached to the patient’s
position of the bird. For Android, the Google ARCore library wrist, which, in turn, is attached to the middle of the back of
was utilized in the future to implement the same logic. the tablet to help the patient carry the weight.
Design In addition to the patients, there is another user group: the
Since the target group consists mainly of elderly people, the therapists. This group of users has different requirements for
design of the app was tailored to their needs to facilitate the the app than the patients. Since therapists are often responsible
most positive user experience. The app was intended to reduce for several patients concurrently, they need to treat patients as
the distance and strangeness that this user group often feels efficiently as possible. For this purpose, the app offers the
from digital devices. We did not want it to feel like a therapist the possibility to easily adjust the corresponding
monotonous, mandatory clinical treatment. Instead, we wanted performance level of each patient to their current treatment
patients to playfully find the motivation to work on their status. The development of each patient's skills is easily visible
recovery. to the therapist. Further, the app offers the possibility to create
a plan for independent therapy at home. The patient's progress
A further aim was to ensure that patients—after discharge from thus is recorded and can be viewed by the therapist at any time,
inpatient treatment—can safely use the app to practice on their allowing them to make the exercises more difficult or easier
own or with family members to make further progress. This is depending on the patient's level of ability.
achieved through short distances in operation and simple
instructions and assistance. The same applies to large control Tasks Provided by the Negami App
buttons that are easy to reach even with shaky or stiff fingers. During the typical use of Negami, the participant sits in a chair
We also took into account that patients with spatial neglect or a wheelchair. If possible, the tablet is held with both the left
ignore information on the contralesional side. For example, this and right hands. If the participant is hemiparetic, the tablet can
was considered when placing and labeling the exercise buttons. be held from below with one hand positioned in the middle.
Simple letters like “A” and “B” presented on the right tablet Using arm movements in combination with trunk rotations, the
side were used instead of complex icons or text. Moreover, we tablet can then be moved to the left or right through real space
took into consideration that patients with spatial neglect are (Figure 2). The participants perform 2 different tasks in
often hemiparetic. Instead of holding the tablet from the right succession.
and left with both hands, hemiparetic patients can hold it with
Figure 2. Patient performing tasks of the Negami app. A virtual element (origami bird) was added (augmented) to the video stream of the surroundings
produced by the camera of a tablet.

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The patient’s first task (Task A: “follow the bird”) is to follow auditory feedback. Every time the patient manages to get the
the virtual origami bird through real space. The patient's bird into the orange circle, a short, bright tone is presented. If
straight-ahead eye/head/body orientation is set as 0. Beginning the patient manages to keep the bird continuously in the orange
at set point 0, the bird flies with random sinusoidal movements circle, the tone is presented every 2 seconds. When the task has
toward one side of space (in neglect patients toward the been successfully completed, the patient receives feedback
contralesional, neglected side). While doing so, the patient sees auditorily again through a different tone and visually through
an orange circle in the center of the screen (Figure 3). The bird the change of the color of the circle to green.
should be held in this circle while performing the task. As soon
At the end of a successful trial, the options “change angle” and
as the patient fails to successfully follow the bird and keep it in
“lead to point 0” are provided on the screen. If the
the circle during its flight, they are provided with an additional
patient/therapist wants to repeat the task, they can select “lead
orientation aid. A blue compass needle appears showing the
to point 0,” and if the difficulty of the task must be varied, the
patient in which direction the bird is located (see Figure 3). The
patient/therapist can select “change angle.” The patient/therapist
task is successfully completed as soon as the bird has finished
has 3 different difficulty levels to choose from: easy, medium,
its trajectory and the bird has been positioned centrally in the
or difficult (Table 1). The difficulty levels are saved as
orange circle. During the performance, the patient receives
templates.
Figure 3. Task A: “follow the bird." The patient has the task to follow the flying origami bird and to keep the bird within the orange/blue circle (A).
If the task is successfully solved the circle turns green (B).

Table 1. Difficulty levels provided with Task A (“follow the bird”)a.

Level Maximum distance of the bird’s path Speed of bird movement Amplitude of bird movement
Easy up to ±35° 2.3°/secb 6.8°

Medium up to ±55° 4.1°/sec 8.0°

Difficult up to ±85° 8.1°/sec 11.3°

a
Angular degrees are participants’ space coordinates, starting from their straight-ahead eye/head/body orientation, which is set as 0.
b
sec: second.

In the second task of the Negami app (Task B: “find the bird”), screen, they return the tablet to the patient's hand. The patient
the therapist hides the virtual origami bird in the room is then instructed to find the bird, and once found, to position
surrounding the patient. For this purpose, the patient's it centrally into the orange circle. No time limit is given. Should
straight-ahead eye/head/body orientation again is set as 0. the patient show difficulties in finding the bird, it is possible to
Starting from this location, the therapist hides the bird provide the patient with orientation assistance by turning on the
somewhere on the left/right side of the patient without the blue compass needle (Figure 4). The task is successfully solved
patient seeing it. The best way to do this is for the therapist to when the patient finds the bird and places it in the center of the
step behind the patient and hold the tablet above the patient's circle. As with Task A, the circle then turns green (Figure 3),
head in such a way that they cannot see where exactly the tablet and the patient hears a bright tone signaling the successfully
is pointing. The area within the bird that can be hidden by the solved task. After successful completion of the task, options
therapist is predefined by the app depending on the chosen “change angle” and “lead to point 0” are provided (see Figure
difficulty level of the task (Table 2). Once the therapist has 3) so that the task can be repeated or changed in difficulty.
positioned the bird in space by clicking on the center of the

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Table 2. Difficulty levels provided with Task B (“find the bird”)a.

Level Extension of the area (along the horizontal dimension of the surroundings)
within which the bird can be hidden
Easy 0° to −40° (or 0° to +40°)
Medium −40° to −75° (or +40° to +75°)
Difficult −75° to −90° (or +75° to +90°)

a
Angular degrees are the participants’ space coordinates, starting from their straight-ahead eye/head/body orientation, which is set as 0. Negative values
indicate positions to the participant’s left, while positive values indicate positions to the participant’s right.

Figure 4. Task B: “find the bird." The patient has to search for the bird that has been hidden by the therapist somewhere in the surrounding room (in
this image, at the corner located at the foot of the stairs) and has to transfer it into the orange/blue circle.

Training Questionnaire (PGTQ) [37] were administered to the

Procedure participants directly after the training session.
All neurological patients received training with Negami in their
room in the ward of the respective rehabilitation facility. The To assess usability, the participants answered the 10 questions
healthy participants also received the training indoors for of the SUS through a 5-point Likert scale ranging from 1 (fully
comparability. The healthy participants had 1 training session disagree) to 5 (fully agree). The mean score was calculated for
with Negami that lasted 20 to 25 minutes. They completed Task each participant across all questions. To capture the presence
A in the first half and Task B in the second half, each at the of side effects of simulation technologies, the SSQ was applied.
highest difficulty level. If patients were not able to use both For this purpose, the presence of a series of symptoms grouped
hands to hold the tablet due to hemiparesis, they were instructed under “cybersickness” was tested by a 4-point Likert scale
to hold the tablet with the unimpaired hand only by grasping ranging from 0 to 3 (not at all, slightly, moderately, and
the tablet in the middle from the top or bottom. A video example strongly). The following 15 symptoms were recorded in total:
of a patient working with Negami is shown in Multimedia general discomfort, fatigue, headache, eyestrain, difficulty
Appendix 2. To assess feasibility, usability, and game focusing, increased salivation, sweating, nausea, difficulty
experience, the System Usability Scale (SUS) [35], Simulator concentrating, fullness of the head, blurred vision, dizziness,
Sickness Questionnaire (SSQ) [36], and Perception of Game vertigo, stomach awareness, and burping. Again, the mean score
was calculated across all items for each patient. Finally, the

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patients were asked via the PGTQ, which uses a 7-point Likert
scale ranging from 1 (fully disagree) to 7 (fully agree), about
Results
how motivating, frustrating, challenging, and enjoyable they Healthy Participants
found the training with Negami to be. Since each of the 4
questions covers a different aspect of the perception of Negami, The results of the healthy elderly participants from the SUS on
no mean value was calculated. usability resulted in a mean value of 4.3 (SD 0.6), indicating
that the usability of the Negami app was rated on average as
The patients with spatial neglect received a 2-week application high to very high. Moreover, there were hardly any side effects
with 5 training sessions per week. Each session lasted 20 to 25 detected, as assessed by the SSQ and indicated by a mean score
minutes. As the healthy participants, they completed Task A in of 0.8 (SD 1.32). More specifically, only 1 patient (10%)
the first half and Task B in the second half. The tasks were reported mild symptoms of fatigue, headache, difficulty
always initiated for the patients with the easiest difficulty level. focusing, and blurred vision. In addition, 2 (20%) other
The criterion for success in advancing to the next difficulty participants reported mild problems with strained eyes and
level was that the task was successfully completed 3 times in a focusing. None reported moderate or strong side effects. Finally,
row. A return to a lower difficulty level was indicated when the the PGTQ captured the dimensions of motivation, frustration,
task was not solved 2 times in a row. Upon completion of the challenge, and entertainment during training with Negami. The
treatment, subjective reports about the use of the Negami app healthy participants’ evaluations on these dimensions are shown
were collected from the patients by using the following three in Figure 5. The participants found Negami to be motivating
questions: (1) How satisfied were you with the treatment? (2) (mean 6.1, SD 0.7) and highly entertaining (mean 6.5, SD 0.9).
How motivating did you find the treatment? (3) How much did As indicated by a mean score of 1.5 (SD 0.7), the training was
you enjoy the treatment? The answer options varied from 1 to not perceived as frustrating. However, some participants found
6, with 1 being the best result. The patients were further asked the training challenging, while others did not (mean 4.1, SD
whether they would recommend the treatment to others (yes/no) 1.7).
and in an open response format, whether they had any
suggestions for improvement.
Figure 5. Percentage of healthy, older adults (n=10) evaluating training with the Negami app on the dimensions “motivation,” “frustration,” “challenge,”
and “entertainment,” on a 7-point scale (1 = "I fully disagree"; 7 = "I fully agree").

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Neglect Patients coefficients between the dimensions of satisfaction, motivation,

An analysis of the reports by the patients regarding the use of and fun and the severity of spatial neglect (expressed as the
the app revealed that all 10 patients recommended treatment mean value of the CoC from the 2 cancellation tasks) were not
with Negami. The patients’ evaluation of the app treatment on significant (satisfaction: r=.21, motivation: r=.57, fun: r=.42;
the dimensions of fun, satisfaction, and motivation are shown all P≥.086). Regarding suggestions for improvement in the open
in Figure 6. The results demonstrate that all patients evaluated response format, 3 (30%) of the 10 patients with hemiparetic
the app treatment on all 3 dimensions with the best 2 scores. neglect reported that they had trouble holding the tablet due to
Only 1 (10%) of the patients chose a score of 4 on the dimension the weight. They had to hold the tablet with 1 hand instead of
of satisfaction. Consistent with these very positive ratings by both. One (10%) patient noted that older patients might be
the patients with spatial neglect, the Spearman rank correlation digitally overwhelmed with the treatment. All other patients
had no suggestions for improvement.
Figure 6. Percentage of stroke patients (n=10) with spatial neglect evaluating training with the Negami app on the dimensions “satisfaction,” “motivation,”
and “fun,” on a 6-point scale (1 is the best score; 6 is the lowest score).

the top or bottom). However, 3 (30%) of the 10 patients with

Discussion hemiparesis complained about the heaviness of the tablet, so
Principal Findings the use of even lighter devices seems beneficial.

This study aimed to develop and assess the usability, side Gamification and the Negami App
effects, and game experience of a new rehabilitation app These positive results give us reason to believe that the new
(Negami) for patients with spatial neglect. By using AR, the app could become a very useful tool in the treatment of patients
app was designed to playfully encourage patients to actively with spatial neglect. Ogourtsova and colleagues [38] have shown
explore space by turning their gaze, head, and trunk. Our that patient expectation of performance is the most important
investigation showed that Negami was perceived as motivating factor for acceptance of the use of VR technologies in
and entertaining by the healthy elderly controls. Training at the rehabilitation. Therefore, when defining the 3 different difficulty
highest defined difficulty level was perceived as differently levels of training with Negami, our focus was on ensuring that
challenging but not as frustrating. The survey further revealed the easiest task could be solved relatively quickly even for
high usability and no to very low side effects such as headache, patients with more severe neurological impairment. This could
strained eyes, or blurred vision. Additionally, the second group also be the reason why Negami was so well received by the
evaluated in this study (ie, the patients experiencing spatial tested patients who had a stroke. The use of different difficulty
neglect after a stroke) consistently evaluated the app positively levels, as well as auditory and visual feedback on performance
on the dimensions of motivation, satisfaction, and fun. during training, are elements that supported the gamification of
Furthermore, we observed that the app and the tablet could also the Negami app. Gamification for the purpose of rehabilitation
be used by patients with hemiparesis (by holding the tablet with has been shown to have positive effects on the patients’
the unimpaired hand only, grasping the tablet in the middle from engagement and motivation for their treatment [39]. Another
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reason for the positive feedback from both patients and healthy well cared for in terms of their recovery, but what happens after
participants could be due to our app design in that we paid discharge from inpatient rehabilitation? An answer to that could
special attention to the age group, as 75% of patients who have be remote/telerehabilitation. Easy-to-understand instructions
had a stroke are aged over 65 years [40] and are typically not for the tasks in Negami can allow patients to practice
“digital natives” [41]. In implementing short distances in independently from home. With online data storage, the therapist
operation, simple instructions, and assistance, we aimed to has external access to patients’ treatment data and can monitor
ensure that this age group feels comfortable in dealing with an them remotely.
electronic device such as a tablet when using the Negami app.
Limitations
AR Versus VR Techniques and Telerehabilitation One limitation of this study is the small sample size. We only
A third aspect that might have contributed to the positive ratings could include 10 elderly neurologically healthy individuals and
by the 2 groups tested could be the choice of the AR over VR 10 patients experiencing spatial neglect and left-sided
technique. It is a frequent observation that the use of VR may hemiparesis after a stroke in the right brain hemisphere.
evoke symptoms that are summarized under the term Therefore, testing the Negami app with a larger number of
“cybersickness” [42]. These include symptoms such as participants in a future study will be useful. It would also be
drowsiness, headache, balance and coordination problems, desirable to evaluate the use of the app on the part of the
nausea, and blurred vision. We observed that such symptoms therapists in the future. It should be further mentioned that
were absent during the training with Negami. The reason for Negami thus far can only be used on Apple devices. However,
this could be that the risk of sensory mismatch concerning it is being further developed with the aim of being able to use
visual, vestibular, and proprioceptive information, which is on Android devices as well. The further development of all
considered one of the causes of cybersickness [43], is reduced smart devices with different operating systems would also ensure
to a maximum—if not completely avoided—when working the use of lighter devices, as 3 (30%) of the patients complained
with AR. The AR-based Negami app prompts people to move about the weight of the tablet. At this point, it should also be
in the real world by actually moving their heads and bodies. mentioned that very severely affected patients, who are not yet
The use of the tablet merely adds a virtual object to the real able to hold a tablet in the acute phase after a stroke, may not
world. In this respect, manipulation is kept to a minimum. benefit from Negami initially, and other therapeutic approaches
should be considered first for them.
Negami can also offer an advantage over VR games in terms
of cost. The development of a VR system is often associated Conclusion
with high costs due to the need for dedicated hardware [42]. AR represents a promising extension to the traditional “visual
Since Negami is available online (see the Negami website), it exploration training” for spatial neglect. The natural interaction
can be easily downloaded to any available tablet or smartphone. with the environment during playful tasks appears to markedly
This provides wide availability and ensures that additional costs increase patient motivation. An advantage of AR, as
are avoided. The use of already existing technical hardware also implemented in Negami, over immersive VR-based treatments
offers immense opportunities regarding remote/telerehabilitation. may be that it minimizes the risk of sensory mismatch
This is important because, in one-third of patients experiencing concerning visual, vestibular, and proprioceptive information,
spatial neglect in the acute phase of the stroke, the disorder which is considered one of the causes of cybersickness.
becomes chronic [44]. During their inpatient stay, patients are

Acknowledgments
This work was supported by Hector Stiftungen, Weinheim (M2107).

Conflicts of Interest
None declared.

Multimedia Appendix 1
Demographic and clinical data of all 10 patients with right brain damage and spatial neglect.
[DOCX File , 19 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Patient performing Task B on Negami.
[MP4 File (MP4 Video), 21397 KB-Multimedia Appendix 2]

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Abbreviations
API: application programming interface
AR: augmented reality
ARM: Advanced Reduced Instruction Set Computer Machine
CoC: Center of Cancellation PGTQ: Perception of Game Training Questionnaire
EWB: end point weightings bias
IL: Intermediate Language
SQL: Structured Query Language
SSQ: Simulator Sickness Questionnaire
SUS: System Usability Scale
UI: user interface
VR: virtual reality
XAML: Extensible Application Markup Language

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Edited by G Eysenbach, N Zary; submitted 30.06.22; peer-reviewed by B Puladi, M Kapsetaki, J Heo, D Costa; comments to author
18.11.22; revised version received 06.12.22; accepted 11.01.23; published 27.02.23
Please cite as:
Stammler B, Flammer K, Schuster T, Lambert M, Karnath HO
Negami: An Augmented Reality App for the Treatment of Spatial Neglect After Stroke
JMIR Serious Games 2023;11:e40651
URL: [Link]
doi: 10.2196/40651
PMID:

©Britta Stammler, Kathrin Flammer, Thomas Schuster, Marian Lambert, Hans-Otto Karnath. Originally published in JMIR
Serious Games ([Link] 27.02.2023. This is an open-access article distributed under the terms of the Creative
Commons Attribution License ([Link] which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete
bibliographic information, a link to the original publication on [Link] as well as this copyright and license
information must be included.

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