To observe the results of novice users attempting to target various levels of contractions, a gamified training app, the Muscular Discretization Assessment Tool (MDAT), was developed in-house for user testing. The research team designed the MDAT to resemble the calibration system used by participants in a clinical trial testing the Limbitless Solutions prosthetic arm. Ensuring the effectiveness of the gamified MDAT controls before usage by prosthesis users was intended to optimize gameplay before distribution. When designing the gamified training app, complete parity with the functionality of the multigesture prosthesis was one of the main design aims. Each participant’s muscular contractions were displayed in a graph showing real-time voltage changes, as illustrated in Figure 1.

The app recorded and processed EMG input through the same mechanisms as the electromyographic prosthesis; once the user’s EMG signal passed the base resting threshold, all EMG values were recorded and saved until the signal fell below the resting threshold again. The EMG processing provides filtered data that directly corresponds to a muscular contraction, with a sampling rate of 1000 Hz. These steps include amplification, rectification, band-pass filtration ranging from 2 to 1000 Hz, and smoothing [13]. The highest recorded value between these 2 points was then identified and was considered the peak value of this contraction. This peak was used to determine which multigesture zone the contraction fell within. The app also allowed for the manual adjustment of each threshold, as well as a global scaling value, which amplified the measured EMG signal to allow users with weaker readings to still hit all thresholds easily. The prosthesis similarly allows for these levels to be adjusted and calibrated for a personalized experience.

The EMG Flex Controller sends data to the multigesture app approximately 60 times per second. These data are validated and processed by the app every time a new visual frame is calculated, which occurs at a capped rate of 30 times per second on the tablets available for user gameplay. This translates to a rate of processing and data reading from the controller once every 33.3 milliseconds. The app reads in muscle strength from the user directly as captured by the EMG sensors on the Flex Controller, and no additional adjustments are made to the readings by the game. The app also reflects the threshold system for triggering different gestures on the prosthetic, which provides one-to-one parity. Before app implementation in the study, internal testing was conducted. Since the software of the app was built on the framework of the calibration app used for the existing EMG-controlled prosthetic, the data are as reliable and seamless as they would be in real-world applications. The accuracy of this software has been tested before this study and has been implemented in ongoing clinical trials.

The calibration period consisted of participants completing a maximum muscular contraction. Based on where this signal ended, the sensitivity was adjusted. For example, if the participant was not able to easily reach the top of the screen via their muscular contraction, the signal sensitivity would be increased. This scale effectively “zooms in” the reading captured by the controller to bring the maximum captured value closer to the user’s readings without losing the accuracy and fidelity of data. This allowed for a standardized normalization process that was based on the user’s maximum contraction. The zone areas are initially segmented equally, but are customized to each participant such that they can feasibly hit all thresholds, with their baseline signal remaining below the lowest threshold. For additional support, the participant was prompted to hit each of the zones before actual gameplay.

The MDAT had a freeplay mode and various settings to replicate the multigesture thresholds analogous to the prosthesis control. The participant was fitted with an in-house developed Flex Controller around the forearm that contained surface electrodes to detect microvoltages from muscle contractions. The freeplay mode was used before data collection to calibrate the user’s Flex Controller to their personal muscle capabilities. The gameplay modes provided an environment for users to contract at various thresholds, recreating the muscle engagement required to operate the corresponding multigesture prosthetic device. In these gameplay modes, the screen was divided into 1, 3, or 5 sections, as presented in Figure 1.

The user interface (UI) for the gamified MDAT was designed to communicate the EMG signal and thresholds to the user as clearly as possible. Other elements, such as score, game instructions, and options, were placed at the top of the screen space to maximize the area available for EMG-related elements. Clarity was provided through explicit instructions for which randomized muscle strength grading thresholds are hit, delivered in a similar fashion as a game of Simon Says or Bop It (Hasbro Inc). A limited yet bright color palette was chosen for the UI to ensure that important elements stand out to users. A thick, bright blue line represented the user’s EMG signal from the Flex Controller, allowing users to understand how their muscle activity was translated in-game. Horizontal green lines across the screen indicated gesture thresholds. These were the only green elements in the UI and were intentionally chosen to make thresholds easy to identify at any moment during playtime. To further enhance threshold identification, each zone was visibly labeled as a numerical range. This aided users in identifying which threshold they were being prompted to hit during gameplay, as the game presented messages in the form of “Hit threshold X!.” X, in this instance, would correspond to the assigned threshold number that was cued to be hit. The cued threshold zone was highlighted in green, intuitively demonstrating to users which threshold they must hit without having to read the instruction prompt.

The participant had 1 attempt to reach within the threshold, and there was no time limit on completing an attempt. An attempt was considered successful if the participant’s peak contraction was within the cued highlighted threshold. Successful attempts were scored out of 15 cues per round to record overall performance.

A total of 54 participants completed data collection, with ages ranging from 18 to 30 years old. Anyone was invited to participate if they were between the ages of 18 and 64 years, able to consent, had full control of their upper extremities, had no injuries to their hands or arms that would impact their upper extremity control during data collection, and if they had never used a Limbitless Solutions myoelectric prosthesis or Flex Controller. Participants were assigned a cohort (A1, A2, A3, or B1) based on participation order. Cohort A1 included 1 section for the users to contract within, while sections A2 and A3 corresponded to 3 and 5 threshold sections, respectively. Cohort A1 had an analytical population of n=9. Cohort A2 had an analytical sample of n=10. Cohort A3 had an analytical sample of n=9. Cohort B1 had an analytical sample of n=26. Each of these cohorts completed 3 rounds with their respective number of zones. B1 was the progressive cohort, in which participants progressed through the 1, 3, and 5 zone modes in sequence. Users were first fitted with the Flex Controller on the right forearm. The controller was calibrated in freeplay mode based on the ease of comfortably reaching each threshold. This was guided by the researcher and manipulated by changing the sensitivity of the surface electrodes. Before gameplay, each user was informed of their respective cohort and shown each of the thresholded screens. For participants in the progressive cohort, researchers further explained the thresholds as fixed increments that changed progressively after each of the 15 cues was presented. Each participant played through the 15-cue round 3 times, taking 1-minute breaks in between each round to avoid fatigue. This procedure was then repeated with the Flex Controller on the left forearm.

After the testing period concluded, postassessment surveys were delivered to participants. These surveys included the Systems Usability Scale (SUS) and the National Aeronautics and Space Administration Task Load Index (NASA-TLX) [33,34]. The SUS is a 10-item scale commonly used as an objective measure of a digital interface’s usability [33]. The NASA-TLX measures cognitive workload through 6 categories [34]. The Edinburgh Handedness Inventory (EHI) was also completed to determine the participants’ dominant hand [35]. Finally, the user’s grip strength was measured using a handheld dynamometer. Grip strength was measured on both the right and left hands, and each was tested twice. The highest score for each hand was recorded. Participants also reported confidence with video games, confidence with exercise, confidence with visual cues, and activities they have participated in during the current week.

These procedures were approved by the University of Central Florida Institutional Review Board on October 1, 2024 (STUDY00007067). The inclusion criteria for participation consisted of people aged 18-64 years with full control of their upper extremities. Full informed consent was presented in both a visual and an auditory manner. Participants were encouraged to ask questions throughout the informed consent process and to request extra rest periods as needed. Participant confidentiality was preserved wherever possible by assigning a randomly generated 8-digit user ID based on participation order. These IDs were generated and stored on a premade linking spreadsheet. Once an ID was used, it was marked as “claimed” on the spreadsheet to ensure each was used only once. The Qualtrics forms containing all of the study data were linked to this ID, and no identifiable participant information was retained or used for analysis. The only potential participant compensation was extra credit from an instructor, which was offered at the discretion of the instructor. Each instructor who offered extra credit from this study was required to provide an alternative assignment of equal time and effort for the same amount of credit in the case that a participant could not complete the study.

Analysis was conducted in Python (version 3.12.9) using the libraries pandas, NumPy, and scipy.stats. The analytic sample was 54 participants (N=54). Tests were 2-tailed with α=.05; results were not adjusted for multiple comparisons. Normality was assessed for within-subject differences for paired comparisons using the Shapiro-Wilk test. When a paired comparison showed evidence of nonnormal differences (Shapiro P<.05), a Wilcoxon signed-rank test was run as a nonparametric sensitivity analysis and both results were reported. Nonparametric checks were used for ordinal or multilevel factors. SDs use t_(n−1)=1 for effect size testing.

Score construction was in accordance with SUS standard guidelines (odd items: x–1; even items: 5–x; sum×2.5 to yield 0-100 scores) [33]. NASA-TLX raw inputs (1-21) were rescaled to 0-100 scores via (x–1)×5 [34]. The EHI laterality quotient was calculated via (R–L)/(R+L)×100, with R representing the responses associated with right-handedness, and L representing left-hand responses.

Within cohorts, trial scores were compared using paired, 2-sided t tests. The mean difference (95% CI), t_(df), P, and paired effect size Cohen d with Hedges g small-sample correction were calculated.

To assess the difference between a progressive and static mode of learning, in-between cohort comparisons were made between cohort B1’s trials and each of the respective A cohorts. For example, B1, B2, and B3 were compared with trial 1 of cohort A1, trial 2 of cohort A2, and trial 3 of cohort A3, respectively. This was done to make analogous comparisons based on the number of zones and trial numbers. Differing trials were isolated to account for users’ exposure time to the game and control system. Comparisons between cohorts were done using Welch 2-sided t tests due to unequal variances. The mean difference (95% CI), Welch t_(df) and P, and effect sizes (Cohen d, Hedges g, and average d_av), were determined using pooled Cohen d, Hedges g, and average d (d_av).

Associations between secondary variables (eg, confidence with video games, exercise, and cue use) and outcomes (trial scores, SUS, NASA-TLX, etc) were assessed using Spearman rank correlation computed within cohorts; ρ and P were reported. For ordinal factors with multiple levels, Kruskal-Wallis omnibus tests were conducted, with H and P reported where relevant. For multiselect variables (eg, videogame experience categories and activities), binary flags were created and compared groups via Welch t tests, reporting d_av. Odds ratios were not calculated in this study, as they were not appropriate considering the data. Gender comparisons used Mann-Whitney U tests with rank-biserial r as effect size, as normality could not be assumed in the smaller subsample of men (n=12).

Cohorts A1, A2, and B1 had the highest perceived usability as measured through the SUS, as seen in Table 3 [33]. The SUS is measured using a 100-point scale, with 100 portraying the best imaginable product, and 0 indicating an unusable product [33]. Cohorts A1 and A2 both had an average SUS score of 75 (cohort A1: mean 75.0, SD 18.9 and cohort A2: mean 75.0, SD 16.8). Cohort A3 had the lowest SUS score with an average of 63.3 (SD 16.2). Cohort B1 had the highest average SUS score with 76.2 (SD 11.7). The overall group SUS score was 73.6. A Welch t test showed a significant difference between cohorts A3 and B1 (P=.05).

SUS is a measure of perceived usability and was taken as a postassessment survey [33]. Average overall SUS scores and the respective SDs are separated by cohort. Cohorts A1, A2, A3, and B1 had overall average scores of 75.0 (SD 18.9), 75.0 (SD 16.8), 63.3 (SD 16.2), and 76.2 (SD 11.7), respectively. The overall average score between all the cohorts was 73.6 (SD 15.1), which falls in the “Good” category on the corresponding subjective scoring of the SUS [33].

Inversely, NASA-TLX scores are on a 100-point scale, with 0 indicating the desired lowest cognitive workload, and 100 indicating the highest cognitive workload [34]. The NASA-TLX consists of 6 different subscales that are the main contributors to cognitive workload—mental demands, physical demands, temporal demands, frustrations, effort, and performance [34]. These subscales were selected due to underlying theories of workload that correspond to demands that a user perceives during a task [34]. These subscales are depicted visually per cohort in Figure 3. The performance subscale has an inverse relationship, where higher self-reported performance scores indicate a lower cognitive workload and are considered more favorable [34]. Average NASA-TLX scores were highest among cohort A3 in 5 out of 6 subcategories. From a Kruskal-Wallis test, each subscale had a P value. Only the performance subscale passed the significance threshold. These results are presented in Table 4. This follows the expected trend of cognitive workload increasing as the number of zones expands. Differences in perceived effort and perceived frustration were not statistically significant between cohorts. To clarify how these workload patterns varied between specific cohorts, pairwise comparisons of performance and temporal demand subscales are presented in Tables 5 and 6. The largest and most significant differences emerged in the performance subscale, where the single-gesture cohort A1 outperformed all other cohorts with large mean differences. The temporal demand subscale had significant comparisons involving cohort B1, with higher perceived time pressure than cohort A1 and cohort A3. Within the mental demand subscale, cohort A1 tested significantly lower than cohort B1 (P=.01, d_(av) =–0.80). In the physical demand subscale, no tests achieved statistical significance, but cohort A2 had a lower score than A3 (P=.15, d_(av)=0.70).

Successful attempts at scoring, SUS scores, and NASA-TLX scores are compared across cohorts in Figure 4. This allows for the visualization of trends and tradeoffs between the number of zones and accuracy, usability, and cognitive workload.

Grip strength was measured in kilograms using a dynamometer after the completion of the postassessment surveys. The average grip strength in kilograms is segmented by gender. The frequency of each reported gender and the SDs are included in Table 7.

Secondary measurements included the EHI and participants’ confidence with video games, exercise, and following visual cues. Participants were also asked to share activities they completed within the last 7 days that required the use of fine or gross motor skills. Based on EHI calculations, all participants tested into pure right-handedness, with a laterality total of >40. Across correlation tests per cohort, most associations were small and nonsignificant (median |ρ|=0.12, IQR 0.05-0.34). Only 2 showed significance after inspection, that is, exercise frequency vs grip strength (ρ=0.53-0.75, P=.03-.002) and cue-use confidence vs workload (ρ=0.45, P=.01).

Preassessment surveying also included demographics, video game experience, exercise, crafts, instruments, and other fine-motor tasks. Handedness inventory, self-reported dominant hand, and grip strength were assessed. There was no correlation between gender and performance (ρ=–0.11, P=.43), despite large grip strength differences between male and female participants (ρ=–0.57, P<.001).

This study aimed to evaluate potential trade-offs associated with increasing gesture capability in an electromyographic prosthetic arm actuated by a single sensor. Increased training time, increased perception of cognitive workload, decreased accuracy, and decreased usability may all be factors discouraging the implementation of multiple gestures. This study explored 1, 3, and 5 distinct gestures triggered by magnitude control and their training feasibility in a single-session rapid learning environment. In addition, differences between static and progressive learning modes were also evaluated. The progressive training mode (cohort B1) demonstrated the feasibility of reducing demand on the user.

Extrapolating from past work and the results of this study, a long-term training regime using a gamified interface that closely corresponds to the prosthetic device’s interface may allow users to improve multigesture use. Developing control of electromyographic inputs in a low-stress, low-consequence manner is critical to unlocking the prosthesis’s advanced functionality without patient rejection. Devices with more features and more advanced controls may result in frustration for patients and lead to rejection. Providing a “challenge mode” to test controls that can unlock additional device functionality may be a solution to this issue. The results of this work indicate that a 3-tiered gesture control scheme is capable with a limited training timeline. However, it is important to note that able-bodied users may experience different fatigue patterns or motivation levels compared with individuals with limb differences. In the prosthesis clinical trial protocol, the training games are delivered before the prosthetic arm in an effort to train basic muscle control and discretization. Once the prosthesis is delivered, it has a single threshold control for open and close functionality. Gamified training continues until a 3-threshold differentiation is easily achievable by the user, and only then is multigesture support unlocked in the prosthetic device. The goal is to have the majority of failures occur in the training games and increase initial success with the prosthetic device. The outcomes of this work show that a tiered approach is appropriate for training 3 thresholds. Future work will help determine if long-term training can support a 5-threshold model.

To determine if including multiple gestures is feasible, it is necessary to consider performance, usability, and cognitive workload. The 3-gesture mode demonstrated similar usability scores as the single-gesture cohort, with better cognitive workload and performance scores than the 5-gesture mode. This suggests that incorporating 3 gestures may strike a functional balance between difficulty and usability for first-time interactions with the system. Additionally, a progressive mode of learning demonstrated the highest perceived usability, despite incorporating up to 5 gestures, which had the lowest scores and the highest cognitive workload in the static mode of learning. Capping initial progressive training at 3 gestures has the potential to increase perceived usability further while retaining the higher accuracy and lower cognitive workload of cohort A2.

Previous studies have shown that increased time on task is associated with higher user performance outcomes with the electromyographic controls [23,36]. Additionally, close correspondence of a training period with posttest tasks resulted in greater performance scores, demonstrating the importance of task-specific training.

The overall SUS scoring of 73.6 falls into the “ok” designation, demonstrating that this system was likely deemed usable by the participants [33]. Individual cohort scoring indicated that cohort A3 had the lowest perceived usability. Since this cohort had also reported the greatest perceived mental workload and the lowest performance among participants, this was expected to have the lowest usability scoring. Cohort B1 has the highest perceived usability, which is supported by lower NASA-TLX scores and similar performance scores to the nonprogressive cohorts [34]. The 12.9-point SUS difference between cohort A3 and cohort B1 is both statistically significant (P=.05) and meaningful with a Cohen d of −0.91. This indicates a substantial difference between cohort averages relative to within-group variability. Clinically, a significant difference with a large effect size implies that users in a progressive learning environment experience are likely related to higher levels of usability than users in a static 5-zone learning environment.

The NASA-TLX, measuring perceived cognitive workload, demonstrated that cognitive workload increased as the number of gestures increased [34]. Similar to the trend in scoring, difficulty tended to increase with the inclusion of more gestures, so it was expected that cognitive workload would follow the same pattern. NASA-TLX scores were aligned with scoring deficits instead of perceived usability as measured through SUS [33,34]. Cohort A3 demonstrated the highest cognitive workload in 5 of the 6 NASA-TLX subcategories [34].

One limitation of this study was the unintentional inclusion of exclusively right-handed participants. Although a small proportion of participants self-reported as left-handed (n=6), the EHI score indicated right-hand bias [35]. This may not be representative of true population proportions, however, and instead may be due to the relatively small sample size of this study.

Similarly, 40 of the 54 participants in the study were female. This can be explained by smaller sample sizes and convenient population sampling of college students. Throughout the data collection process, minor collection discrepancies were accounted for. One participant withdrew from the study due to a personal situation during data collection. The participant revoked their consent to participate, and the research session was terminated immediately. Their data were removed from the dataset. During another session, one user ID was claimed by 2 distinct participants during the data collection process. Since both participants completed the study independently of each other, the datasets were differentiated with an (a) and (b) at the end of their identifier, and both datasets were used in the final analysis.

The aim of this study was to explore trends in novice users as they were exposed to different controls. This study used a proxy population of college-aged students who had full control of their upper extremities, which is not fully representative of our target population of prosthesis users. Although these findings cannot be completely generalized to prosthesis users, the intention of this initial testing is to ensure positive outcomes among users before implementation in limb-different population groups. Additionally, the target population is primarily pediatric patients, which is seen as a vulnerable population group for testing purposes. In order to limit confounding variables, such as different levels of limb difference and the effect of differing anatomical muscle structure, a proxy, an able-bodied population, was then used. Past work in prosthesis development has shown a significant difference in muscular activation between amputees and nonamputees [32]. As such, the use of a proxy population then allows for standardization that may prove more difficult in the intended population, as well as identification of potential errors, streamlining eventual delivery. Serious games have also been tested in a proxy population of college-aged students and have been further implemented with patients with a limb difference [23,36]. The observed performance measures, including accuracy scoring, SUS, and NASA-TLX, have been used independently among studies that include different limb users [33,34]. Additionally, future work may strengthen findings through the use of a pre-post comparison. Past work in the facility has evaluated the efficacy of motor learning through serious games and evaluated participant scoring before and after intervention [23]. Future work may evaluate long-term changes in scoring using the training app. This study demonstrated the efficacy of the MDAT within a proxy population, with the intention that future work will include testing in the intended clinical population of upper limb prosthesis users.

The unequal and relatively small sample sizes in cohorts A1, A2, and A3 limit statistical power, particularly for between-cohort comparisons with the progressive cohort B1. Although effect sizes were calculated and in several cases were small to moderate, the absence of statistically significant differences between cohorts may reflect limited power rather than true equivalence. Therefore, findings comparing progressive and static modes should be interpreted cautiously and considered hypothesis-generating. Further testing with the application will be ongoing with the current proxy population and a representative limb-different population.

Another limitation of this study is the single-gesture scoring metric for cohort A1. Cohort A1 had a mean score of 15.0 (SD 0.0). This is because all contractions that are above threshold are considered a success, as there is only 1 zone. This creates a ceiling effect that may have affected variance and statistical analysis. This also highlights the functionality of single-gesture mode testing for novice users. There is a possibility of a fatigue effect due to 3 repetitive trials, which the researchers aimed to minimize by implementing mandatory 1-minute rest periods per round and offering continued rest if the participant wanted more recovery time.

The most clinically relevant and statistically significant results were found from the SUS scoring [33]. Specifically, the significant increase in perceived usability for the progressive cohort seen in this study may influence user adherence to training, addressing one of the primary concerns surrounding prosthetic device rejection. There were no statistically significant differences between cohorts in scoring for progressive mode and static mode, and there were only 2 statistically significant subscales of the NASA-TLX [34]. Both the SUS scores and the NASA-TLX scores displayed a trend that difficulty increases with the inclusion of more gestures as anticipated [33,34]. This is supported by the results from cohort A3, which had the lowest accuracy scoring and the highest cognitive workload.

Especially among young prosthesis users, maintaining adherence to a training regime is particularly difficult [20]. The usability of training systems is necessary to encourage motivation in pediatric training regimes [37]. Overall, these results suggest that implementing up to 3 gestures with a progressive training mode may have the potential to balance the increasing complexities required for additional gestures. This work aims to increase the functionality while not introducing an undue burden. Since reducing the complexity of a training regimen may discourage device rejection, this is an essential consideration. This may enable expanding device capabilities while maintaining accuracy, perceived usability, and a lower cognitive workload.

This control schema will be implemented in a gamified training format to teach users the musculature engagement and control required to operate an upper limb prosthesis with multiple gesture states. This progression will be introduced to the intended population through long-term clinical trials of individuals with a limb difference who are training to use a prosthetic device.

Implementing these training controls into a gamified regimen may increase time on task [23]. Prolonging the time engaged in a training measure can increase its effectiveness; this engagement may decrease the time needed to learn controls, as reinforcement learning can begin with the first introduction to controls. Reinforcement learning in gamified training may significantly improve performance scores [38-41]. Applying this principle to future training applications has the potential to encourage pediatric compliance with a training program, as time on task and reinforcement learning lead to improved performance and engagement.

Future work aims to evaluate these controls in a longer-term research trial incorporating a 2-gesture step toward training up to 3 gestures progressively. This can be implemented into the pre-existing gamified training protocol used in current pediatric clinical trials. Increasing the in-game difficulty may prepare users for the increased difficulty associated with additional gestures on the prosthetic device. One eventual aim of future work is to discern what form of gamified training would be most effective to establish device use on the first day of delivery.