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Gaming for health

In the past, computer games have been associated with negative effects on wellbeing, but there is growing evidence that tailored technologies can provide great benefits

Gaming for healthFor years, computer games have been associated with negative effects on health, blamed for spawning a generation of lazy, overweight children who lack social skills because they spend their time indoors, sprawled in armchairs, staring at screens. More recently, however, computer games have become another way for people to carry out all sorts of activities, from escapism to art, exercise and education, as well as a wide range of innovative healthcare applications.

Reflecting that trend, the inaugural Games for Health Europe conference takes place in the Netherlands in October, complementing a North American event that has been running since 2004. The aim of the conference is to bring together games developers, medical professionals and researchers, according to Jurriaan van Rijswijk, a 15-year veteran of the gaming industry and the organiser of the event.

"The objective is to determine how we develop games that can be used effectively in training doctors and nurses, treating physical or psychological complaints of patients, and in the prevention of illness in general," he said.

It also hopes to raise awareness of the gaming for health concept, stimulate funding for this type of research in Europe and create a knowledgetransfer 'bridge' between Europe and the US.

Changing attitudes
The stereotyped image of feckless, often introverted children - generally male - was actually a product of the Nintendo era, from the mid-1980s, according to Ian Bogost, a professor at the Georgia Institute of Technology in the US and author of forthcoming book How To Do Things with Videogames.

Bogost points out that in the early 1970s, the first coin-operated games were played almost exclusively by adults and were placed in bars and taverns next to other diversions like pinball and darts.

"Even though it may not seem that way, coin-op arcade cabinets were far more physically demanding than we might remember, involving the whole body - not to mention the bike ride to the arcade or the corner store to play them," says Bogost.

Arguably, a pivotal moment in accelerating the games for health movement was the launch of the Nintendo Wii in 2006, heralding the entry of physical interface games into the mainstream. Initially launched with a handheld motion-sensing controller, the Wii was soon complemented with a balance board which opened up new applications in aerobics, balance and strength training.

Popularity
"The Wii was hardly the first example of this type of game, and it wasn't even the first popular example in the 2000s," says Bogost, noting that this accolade went to Dance Dance Revolution (known as Dancing Stage in Europe).

"However, it attached a very popular brand name to that effort, and it put it on television ads and got it into people's homes. It made games for health impossible to ignore."

Crucially, it is now accepted that gaming does not just provide some nebulous wellbeing effect on health, although that is also a factor. In recent years, hard data is being generated showing fundamental impact on patients' physical and mental health, including those with serious conditions such as cancer, as well as the effectiveness of healthcare providers.

Games for health come in many guises, but in simple terms can be divided into a handful of different categories, including: games for cognitive and emotional health; participatory health games, including social networking; exercise and fitness applications; rehabilitation, as well as medical education and training.

In the cognitive and emotional health category, a good example is Impulsar, a game designed to monitor and help curb aggressive impulses in patients. The premise is that players have control of a spaceship and need to fertilise planets across a galaxy. Some planets are inhospitable, however, and players are challenged to stop their ship fast and return home - a metaphor for deciding not to throw a punch. While still in development, early behavioural results have been encouraging, says van Rijswijk.

Video footage of HopeLab's Re-Mission

One often-cited example of what is achievable with gaming is Re-Mission, a game for teens and young adults with cancer.

In the participatory game category, it is a first-person shooter featuring a heroine who travels through the bodies of cancer patients to destroy cancer cells, battle infections and manage the effects of cancer treatments. In August 2008, an article published in the journal Pediatrics showed that patients aged 13 to 29 who played the game showed enhanced adherence to prescribed medications and had a greater understanding of their disease than non-players. There was also evidence of reduced stress hormones in the blood; higher levels of stress hormones are associated with slower recovery in chronic illness.

Medical education and training is another fertile development area. A study published in the February 2007 edition of Archives of Surgery found that surgeons who had played video games for at least three hours a week in the past were 27 per cent faster, with 37 per cent fewer errors, than non-players, in simulations of laparoscopic surgery. The authors suggested that it might be of benefit for surgeons to use video games to 'warm up' before these procedures and they called for the development of specific surgery simulation games. One such game is Birthplay, a game that uses a motion-sensing device to train obstetricians with grips and techniques that can help deliver breech births more safely.

Exercise games - notably Wii Fit, EA Sports Active and Dance Dance Revolution - are perhaps the most recognisable category in games for health, as they are already widely used. While popular, they often go the way of the exercise bike in many households, however, and start to gather dust after initial enthusiasm wanes. More systemic change could come from adoption by clinics, organisations, or even health insurance organisations, Bogost believes, especially if the games can become integrated into the apparatus of health activities.

The rehabilitation category has some interesting examples, including games to help soldiers returning from combat duty to cope with post-traumatic stress disorder. Virtual Iraq and Virtual Afghanistan are based on the principle of exposure therapy, allowing veterans to "experience the sights, sounds and smells necessary to emotionally process traumatic memories," according to a white paper published by the Entertainment Software Association.

Pharma's slow start
It is notable that the Games for Health conferences are attended mainly by people from the gaming industry and medical research, with drugmakers having a low profile. On the whole, the pharmaceutical industry has been slow to get involved in the gaming sector, says van Rijswijk, although there are some notable exceptions.

Bayer, for example, commissioned a game for the Nintendo DS handheld console - called Didget - which turns glucose monitoring into a game for children with type 1 diabetes. Try an online demonstration of Didget.

The glucose meter itself plugs into the Nintendo console and children can use the points they earn from testing in an adventure game called Knock 'Em Down World Fair, for example by unlocking new characters or activating mini games.

Most other drugmakers have yet to get involved in gaming, however, one of the factors holding them back being regulatory restrictions, says Bogost.

"Any communication that makes claims about the effectiveness of a pharmaceutical is heavily restricted," he said. "As a result - and since games are still unfamiliar - most drugmakers have not yet dipped their toes in the water."

Van Rijswijk would like to get more pharma involvement in gaming to help Europe maintain a level playing field with its peers across the Atlantic.

"The quality of research in Europe is at least as good as that in the USA, but has been hampered by a lack of access to funding," he says. For example, the games for health movement in the US has benefited from the patronage of organisations such as the Robert Wood Johnson Foundation, an $8.25m fund which has already provided more than $4m in funding for a range of serious game initiatives in health.

"To carry out a randomised clinical trial on a serious game takes up to four years and costs up to €2m," notes van Rijswijk. "It's an expensive business to develop games for healthcare, but there is a sense that momentum is building behind the concept in Europe now."

Video footage of Microsoft's XBox Kinect

Technology developments
Motion sensors may have transformed the gaming category, but new interface systems, such as cameras that allow the body to be the control device - already on the market in the form of Microsoft's Xbox Kinect system - are the next step forward, according to van Rijswijk.

Other innovative sensors for both input or output are also being used for health, among them Green Goose's embedded wireless sensors, which can be attached to everyday items and monitor physical actions, adds Bogost. The company is developing games that will turn everyday activities into games. For example, brush your teeth on time and take exercise regularly and you can be rewarded with points, which could be traded in for real-world rewards, potentially.

Other games designed to boost physical activity, notably Humana's Gold Walker and Colorfall, are using mobile devices to try to make modest improvements in daily physical activity that, over time, could have a profound impact on fitness.

"That's the great thing about mobile platforms: you always have them with you, so games that use small bits of attention over time offer promising applications," says Bogost.

Proponents of the games for health initiative believe that there will be a lot more investment in training and compliance applications of games, many of which the general public may never see. And - provided health insurance providers get on board - the use of preventative health applications will increase too.

"Maybe in the near future, your doctor's office will hand out games instead of pamphlets," says Bogost.

Phil Taylor

The Author

Phil Taylor is a freelance journalist specialising in the pharmaceutical industry.






20th September 2011

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