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Top1. Introduction
Mental stress has detrimental effects on one’s mind and body (Lupien et al., 2009), and in the long run may lead to chronic diseases like cardiovascular problems (Larkin, 2005) and diabetes (S. Cohen et al., 2012). In developing countries like India, for the productive population, stress from the number of contributing factors is responsible for mental disorders which contribute to greater morbidity and is a matter of serious concern (Murthy, 2017). Besides traditional interventions for stress management like Cognitive Behavioral Therapy, technological intervention like biofeedback is also becoming popular (L. Kennedy & Parker, 2019). In a biofeedback session, the physiological parameters (like heart rate) of an individual are shown in real-time and one can learn to better manage them by following some specific protocol (like paced breathing) (Schwartz, 2010).
However, the routine of a traditional biofeedback session can be quite monotonous and may offer a lesser appeal to the young participants (Pope & Palsson, 2001). One way to increase engagement with biofeedback sessions is to use video games as a biofeedback delivery mechanism (Bersak et al., 2001; Mandryk et al., 2013; Pope & Palsson, 2001; Wang et al., 2018; Zafar et al., 2020). In this case, the individual plays a game specially created/modified for biofeedback application. The physiological state of the individual is shown as a change of in-game elements or game-mechanics, instead of directly showing the physiological measures (Wang et al., 2018). In this way, the participant/player aims to control the game state by following the biofeedback protocol and thus have an engaging and fun experience during the biofeedback intervention.
There are some challenges with using video games for biofeedback. The lack of use of the same game or game genres across various studies creates difficulty with the replication and comparison of results. The non-availability of the game in the public domain and proprietary source code of the study further add to the challenges. Moreover, there is a higher cost associated with game development and maintenance which reduces the appeal of biofeedback research to groups with limited funding support.
The retro games developed for Nintendo Entertainment System (NES1) (Nintendo, Kyoto, JP) can address these issues. These are 8-bit games that run on NES hardware or NES emulator and are popular among people. The simple gameplay and meticulous level design of these games makes them excellent candidate for delivering biofeedback. Therefore, the authors have developed an open-source system to leverage NES games for multimodal2 biofeedback. The system consists of data acquisition (DAQ) hardware (H/W), software (BioNES3), and a game system, which can be used to deliver heart rate (HR) and/or heart rate variability (HRV) biofeedback via any NES game. The player has to follow biofeedback protocol (like deep breathing) to keep the HRV deviation from baseline value at a minimum while simultaneously playing the biofeedback-enabled game. The in-game feedback continuously shows the current deviation of HRV to the player. Failing to keep up with the biofeedback protocol triggers additional game mechanics (like warning beep, change in player life) which brings about enhancements to the original gameplay of the NES game. The appeal of the system is that one does not need to know the proprietary source code of the NES games and the game mechanics can be modified and feedback can be displayed by using the support of the NES emulator. In this way, any available game created for the NES platform can be leveraged for delivering biofeedback.
In this paper, an attempt is made to understand the efficacy of the developed system in inducing mental relaxation. Super Mario Bros. (SMB) (Super Mario Bros. - Super Mario Wiki, the Mario Encyclopedia, n.d.), a popular NES game was used. The purpose of this study can be summarized in two steps.