Battling Illness One Joystick at a Time

The Serious Games Initiative—an organization founded at the Woodrow Wilson Center for International Scholars in Washington, DC—established Games for Health in an effort to bring together researchers, medical professionals, and game developers to promote the creation of video games that can help patients learn more about disease and illness. Although the concept may not be a new one (one of the first studies of interactive media in healthcare was conducted in 1985), technology today enables approaches and outcomes that were impossible even 10 years ago. This burgeoning industry is combining entertainment with education in a revolutionary approach to disease management with a focus on patient care, particularly that of children.

Dodging Disease

Research has shown that many people have the ability to work harder, concentrate more, and learn more when engaging in an interactive game. Games for Health seeks to tap into this phenomenon in order to improve health outcomes. Whether in the form of virtual snowball fights designed to help reduce pain in burn victims, such as the Virtual Reality Analgesia Research Center’s SnowWorld, or as a cancer cell shoot-out (HopeLab’s Re-Mission™), interactive games promote healing in ways that are inaccessible to more traditional forms of medicine.

Take, for example, Ben’s Game, launched in May 2004 by the Make-A-Wish Foundation. Inspired by 12-year-old leukemia patient Ben Duskin (who has since received a bone marrow transplant and is now in remission), Ben’s Game is the brainchild of Eric Johnston, Senior Software Engineer and Technical Director at LucasArts in California. The object of the game is to destroy all mutated cells and collect seven shields for protection from the common side effects of chemotherapy. The game’s unique approach uses three levels of ammunition: health you obtain from the hospital; medication you obtain from the pharmacy; and “attitude” you obtain from home. The realistic gameplay helps teach about the patient’s symptoms, making it easy for children to learn about their disease in a manner that is both fun and distracting. Download the latest version of the game here.

According to a November 2005 press release from the Make-A-Wish Foundation’s San Francisco office, the game is now available in nine languages (English, Dutch, French, German, Greek, Italian, Japanese, Russian, and Spanish). The game’s popularity is evident from the more than 200,000 downloads by worldwide Internet users since its official launch in June 2004. Ben and Eric were subsequently honored in a meeting with the Dalai Lama on November 6, 2005, where Ben was recognized as an “Unsung Hero for Compassion” because of his generosity.

Another game specifically geared toward pain management is FreeDive, a scuba diving simulation launched by BreakAway Games and the Believe in Tomorrow National Children’s Foundation. The interactive game is designed to distract pediatric patients from pain (requiring cognitive attention) and anxiety; children tested while playing the game demonstrated greatly increased tolerance for pain (as measured by how long they could keep one hand immersed in ice water during game play).

In addition to focusing patients’ attention away from pain, some health games are designed to improve cognitive functioning. A study conducted by HopeLab, a Palo Alto, California-based non-profit organization founded in 2001 by Pam Omidyar, showed that patients’ quality of life increased just by playing Re-Mission. Re-Mission takes players “on a journey through the bodies of young patients with different kinds of cancer.” In the 3-D game, players destroy cancer cells, battle bacterial infections, and “manage realistic, life-threatening side effects associated with cancer.”

The game was officially released in April 2006. Research studies in the United States, Canada and Australia have since emphasized the ability of Re-Mission to be both fun and educational, with the HopeLab website noting that the study found “playing Re-Mission produced significant increases in quality of life, self-efficacy, and cancer-related knowledge for adolescents and young adults with cancer. In addition, young people who played Re-Mission maintained higher blood levels of chemotherapy and showed higher rates of antibiotic utilization than those in the control group, both results suggesting that Re-Mission helps patients adhere to cancer therapy regimens.” More information about the game, including updates and ordering information, can be found online at www.re-mission.net. HopeLab President Pat Christensen said young cancer patients “were more likely to keep up with their drug treatments and had a stronger resolve to fight their disease” after playing Re-Mission.

Interactive video and computer games that focus on non-disease-related healthcare topics are also being developed. The Federation of American Scientists (FAS), along with Brown University and the University of Southern California, introduced the educational video game Immune Attack in Fall 2006. Designed to provide an introduction to basic concepts of immunology for high school and college students, the game is used in biology curriculums across the country. Interactive games such as Immune Attack, asserts Thomas H. Lee, MD, demonstrate that video games offer “a lower-cost approach for teaching, educating, and motivating patients to better manage their own health. What previously occurred only in medical exam rooms now can be learned at home, customized to match the patient’s level of sophistication in an environment conducive to learning”.

As the educational and therapeutic value of interactive video games becomes more accepted, developers and researchers at medical schools and other academic institutions, software design companies, and other organizations are creating games that promise a variety of healthcare benefits. InterAction Laboratories, in response to concerns over the poor exercise habits associated with extensive video game play, has developed the Kilowatt, an isometric exercise device that relies on a player’s body strength to control the action in a video game—basically, the harder a player pushes on the system’s special controller, the faster his or her video game character goes.

The company Morphonix has released a new game called Neuromatrix, which uses a story involving secret agents, top-secret neuroscience research facilities, and brain-invading nanobots to teach players about the structures of the human brain, explain how brain cells and synapses work, and demonstrate other brain functions. The company has also developed a game called Journey Into the Brain, which was funded by grants from the National Institute of Mental Health’s Small Business Innovation Research Program. The game teaches children key concepts of brain structure and functionality and about the effects of neurological disorders.

The Baylor College of Medicine is working alongside video game developer Archimage Inc. to educate young patients on the benefits of healthy diet and exercise in order to reduce the risk of diabetes and obesity through Escape from Diab.

From Humble Beginnings to a Bright FutureHealth-related video games have come a long way in the last two decades. According to an article in the July 2003 issue of Journal of Pediatric Oncology Nursing, a simple program called What Are Blood Counts? was one of the first cancer-based computer programs designed with patients in mind. It was a “computer-assisted instructional intervention” that taught children about blood cells, bone marrow, and platelets and “prepared them for possible side effects related to their chemotherapy treatment.” The program presented information using interactive text and graphics; a questionnaire study “revealed that children’s knowledge about blood significantly increased after playing the game.”

Nowadays, vastly more powerful computers make it possible for designers to create complex, immersive virtual worlds that engage players on so many more levels than the old text-and-graphics-based games. Thanks to the Internet and the greater availability of high-speed connections, kids can play with and against other players all over the world, and in the process connect with peers who are undergoing similar experiences with disease and illness. The new possibilities inherent in this technology are attracting attention. At the Third Annual Games for Health conference—held September 2006 in Baltimore, MD—more than 250 health and healthcare professionals, game developers, government program managers, policy advocates, educators, and researchers gathered to exchange information regarding this innovative approach to disease management. The conference included on-site demonstrations of the latest technologies and advances in the medical field. Go to the Games for Health website at www.gamesforhealth.org to read day-by-day recaps of the presentations and other events (actual presentations can be downloaded here. Organizer for the event, the Serious Games Initiative, targets two areas for continued Games for Health development: personal treatment (including disease management, physical therapy, and mental health treatment) and professional practice (health messaging, modeling, simulation, and training). Following the success of the 2006 event, there are already plans in motion to launch a games contest that will award cash prizes to two winners who develop the best storyboards and game treatments, with a grand prize going to the best working prototype/game. Go to www.gamesforhealth.org/competition for details and official rules.

The Cost of Care

An article published in the August 14, 2006 issue of U.S. News & World Report discussed video games’ abilities to help soothe and heal the sick and talked about the promise of utilizing virtual environments as a method of combating illness. The piece also touched on the topic of expense. For example, it pointed out that the headset required for SnowWorld (the snowball fight game mentioned previously; more information is available at www.hitl.washington.edu/projects/vrpain) is priced at $30,000. Other games, however, are less costly. Re-Mission, which can be found at www.re-mission.net, is available free of charge. Many experts think a balance can be struck between high-cost systems that are more appropriate for the hospital setting, and low-cost systems and games suitable for use in the office setting or at home.

With the health-related video game market currently estimated at approximately $50 million, health game sales are barely a blip on the radar when compared with the $7 billion commercial games market. However, rising healthcare costs and growing recognition of the games’ usefulness among patients, payers, and providers may combine with the proliferation of available games to produce a rapid increase in utilization.

Although some case studies have demonstrated some adverse side effects associated with playing video games—including wrist and neck pain, decreased attention span, and obesity—there is no disputing the evidence of their ability to distract, leaving it to the discretion of the physician and patient whether to incorporate this technology into any treatment plan. Video game companies are left with the challenge of creating games that are equally as beneficial as they are engaging.

The Proof is in the Patient

How have patients responded when given the opportunity to use this technology as part of their treatment? Quite favorably, especially in the area of pain management, where the high degree of concentration required for playing the games provides patients an important element of distraction away from their pain. In fact, health game companies are pointing to the benefits of video games as aids in pain management as proof of their value. One case study involved the use of a handheld video game to help prevent an eight-year-old boy from picking at the neurodermatitis on his upper lip. The game was originally given to the child simply to keep his hands occupied. The tactic was so successful that the boy’s lip healed after a couple weeks. Related studies have shown that patients who played similar games reported lower systolic blood pressure and nausea, and used fewer analgesics, as well.

Physicians at the University of Medicine and Dentistry of New Jersey found using games to treat pre-operative anxiety in pediatric patients to be particularly effective. Whereas behavioral preparation is noted to be an effective method of coping with pain, health games have proven to be more obviously beneficial in increasing dopamine neurotransmission and absorption. The games are designed to divert attention away from the discomfort and pain associated with the patient’s disease or the treatment they are undergoing and on to the game. It’s a mind game in and of itself—one that tricks the brain into focusing on an interactive situation.

A Whole New World

The sky really does seem the limit when it comes to the ways in which video games can be applied to healthcare. According to a report by the International Gaming Research Unit, video games aid in the development of social and special ability skills in children and adolescents, particularly in those with severe learning disabilities or other developmental problems (such as autism or attention deficit disorder). Video games may also have preventive as well as therapeutic applications: studies have shown that people who maintain healthy cognitive loads—promoted by brain-intensive activities such as playing chess, doing crosswords, and perhaps playing some video games—appear to have lower incidence of dementia, Alzheimer’s disease, and other cognitive ailments.

Because games have shown promise in a variety of healthcare applications, many different players and organizations are getting involved in development; funding for game development has been provided by such government agencies as the National Institute on Drug Abuse and the Office of Naval Research. As with the introduction of any new treatment, there is an element of risk involved; for example, a broad base of evidence to support the long-term benefits or possible side effects of health gaming has yet to be developed. Yet, it is difficult to dispute the readily apparent “fun” element and anecdotal evidence in support of the benefits to be gained by incorporating games into treatment.