Objectives: The general objective of this dissertation was to determine the efficacy of combining a gamified virtual reality environment (GVRE) with transcranial direct current stimulation (tDCS) in treadmill-based gait rehabilitation for individuals with Parkinson’s disease (PD). To achieve this goal, we set several specific objectives: (1) to synthesize existing evidence on the use of gamification in technological devices for motor rehabilitation in PD (article I), (2) to design, develop, and evaluate the feasibility of a GVRE gait rehabilitation intervention tailored to people with PD (article II), (3) to design a study protocol for a randomized controlled trial (RCT) evaluating the combined intervention of GVRE and tDCS in gait rehabilitation for PD (article III), and (4) to assess preliminary outcomes from the RCT regarding gait variables, clinical assessment and user experience (article IV).

Methodology: To address specific objectives 1 and 2, a scoping review and a co-creation feasibility study were conducted. The scoping review identified the extent and characteristics of gamified technology use in PD rehabilitation. The feasibility study was carried out using participatory design methodologies with people with PD and healthcare professionals. To address objectives 3 and 4, a mixed-methods RCT was developed and conducted. The trial enrolled individuals with PD to randomly receive gait rehabilitation training in one of three groups: (1) treadmill + GVRE + tDCS; (2) treadmill + GVRE; (3) treadmill. Quantitative outcomes included gait parameters, executive function assessment and clinical measures; qualitative data captured participant experience and satisfaction.

Results: Gamification was found to enhance motivation, engagement, and adherence in PD rehabilitation technologies. The designed intervention was feasible and well-received, emphasizing simplicity, personalization, and safety. Preliminary findings from the RCT suggest that the combined use of treadmill, GVRE and tDCS is not significantly better at improving gait parameters than its control counterparts. However, participants in the Treadmill+GVRE and Treadmill+GVRE+tDCS groups reported subjective improvements in stride regulation, walking confidence, and cognitive awareness. Select cognitive gains, including improved inhibitory control, emerged at follow-up, suggesting possible delayed effects of neuromodulation. Participants reported high acceptability and engagement to the GVRE intervention.

Conclusions: The integration of GVRE and tDCS into gait rehabilitation for PD proved an effective tool to enhance engagement, but potential improvements regarding gait-related outcomes are unclear. Future research should aim to conduct further research with larger, more diverse sample sizes and further personalize gamified content based on aimed experience and characteristics of individuals with PD. Interventions should aim to balance cognitive load, physical challenge, and motivational support to meet the unique needs of people with PD.