Gaming Technology, Virtual Reality and Healthcare

Shepherdstown 26 April 2008This article provides a high level overview on virtual reality (VR) and gaming technology solutions and their application in the field of healthcare at this point in time. Gaming technologies and VR have many possible applications in healthcare, especially in physical therapy, recreational therapy, training, and 3D visualization of medical information. Recommendations are offered in this article on next steps healthcare organizations should consider taking with regards to the emerging field of gaming technology.

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Definitions & Key Concepts

Gaming Technology

Simply put, a game may be defined as a system in which players engage in an entertaining artificial activity, defined by rules, that result in a quantifiable outcome. A more exact definition of games was presented by Kesper Juul in "The Game, the Player, the World: Looking for a Heart of Gameness". He states that "A game is a rule-based formal system with a variable and quantifiable outcome, where different outcomes are assigned different values, the player exerts effort in order to influence the outcome, the player feels attached to the outcome, and the consequences of the activity are optional and negotiable."

In his article, Kesper Juul then goes on to provide the following explanation on the relationship of computers to games. "While computer games are just as rule-based as other games, they modify the classic game model in that it is now the computer that upholds the rules. This adds a lot of flexibility to computer games, allowing for much more complex rules; it frees the player(s) from having to enforce the rules, and it allows for games where the player does not know the rules from the outset."

Virtual Reality (VR)

Virtual reality (VR) is a multi-disciplinary field of computing technology that emerged from research on three-dimensional (3D) interactive graphics and pilot/vehicle simulations in the 1960s and 1970s. See http://accad.osu.edu/~waynec/history/lesson17.html

According to Stephen Ellis at NASA's Ames Research Center, "The technology of the 1980s was not mature enough." Virtual Reality (VR) helmets and their optics were too heavy, computers were too slow, and touch-feedback systems often didn't work. However, twenty years later, things have vastly improved. Computers are thousands of times faster; VR peripherals are more portable and lightweight; and systems deliver a greater sense of feedback and immersion to their users. Development and use of virtual reality systems are on the march again, especially in the field of computer simulation and gaming. See http://spaceresearch.nasa.gov/general_info/21jun_vr_lite.html

Gaming Industry Overview

Over the last three decades, gaming has gradually become one of the main entertainment media, comparable in revenue, customers and employees to the film and music industries. According to the Entertainment Software Association, 24% of Americans over the age of 50 played video games in 2007, and increase from 9% in 1999. In 2007, world-wide game spending exceeded $32 billion. U.S. computer and video game software sales grew six percent in to $9.5 billion - more than tripling industry software sales since 1996. Total video-game industry sales in the U.S. for both hardware and software jumped 43 percent last year to $17.9 billion. By 2011, the world-wide gaming market is expected to be worth $48.9 billion. See "Serious Games, Serious Money" by Eliane Alhadeff at http://www.slideshare.net/elianealhadeff/serious-games-a-sizeable-market

Virtual Reality (VR) & Gaming Technologies in Healthcare

In the examples below, you will see a variety of ways that gaming technologies and virtual reality (VR) are being applied in healthcare settings.

Physical Therapy & Exersystems

Gaming technologies and VR systems are being used in many physical therapy situations. For example:

Virtual Reality Treatment (ViRT) System - As reported in an article in Virtual Medical Worlds, ViRT uses chromokey technology and gesture control software to insert a patient into a virtual game environment allowing him to have fun while exercising. The patient is stimulated to exercise for longer periods and more frequently whereas the system monitors the progress of the patient. This evolutionary physiotherapy treatment method which applies technologies borrowed from the entertainment and broadcast industries was successfully tested at the Riverside Campus of the Ottawa Hospital. For more information see www.hoise.com/vmw/00/articles/vmw/LV-VM-06-00-26.html

Wiihabilitation - Nintendo's Wii video game system, whose popularity already extends beyond the teen gaming set, is fast becoming a craze in rehabilitation therapy for patients recovering from strokes, broken bones, surgery and even combat injuries. The Hines Veterans Affairs Hospital west of Chicago recently bought a Wii system for its spinal cord injury unit. At Walter Reed Army Medical Center, the therapy is well-suited to patients injured during combat in Iraq, who tend to be in the 19 to 25 age range, according to Lt. Col. Stephanie Daugherty. See http://ducknetweb.blogspot.com/2008/02/docs-use-games-for-rehab.html

MOTEK, a leading developer and provider of high-quality motion capture technology, implemented the Computer Assisted Rehabilitation Environment System (CAREN) at the University of Groningen. CAREN allows a therapist to place the patient into a virtual environment to help diagnose medical disorders like Parkinson's Disease as well as other neurological abnormalities. In addition, CAREN enables therapists to introduce dynamic corrections to a patient's virtual and physical realities, creating an interactive relationship that can reduce the rehabilitation times for neuro-muscular and skeletal injuries by about 50 percent. In turn, the shorter rehabilitation times cut treatment costs. See www.hoise.com/vmw/01/articles/vmw/LV-VM-01-01-7.html

Northern Arm & Hand Center in Duluth, MN, is an upper extremity trauma and rehabilitation center that offers 10 different computer games as physical therapy. Patients typically play games for 60 to 90 minutes several times weekly for complicated or difficult injuries. The software tracks progress and displays a graph indicating the range of movement. It even issues a challenge for improvement in the next session, contributing to the potential for patients overexercising. Just a handful of U.S. physical therapy clinics use this technology. See http://www.businessnorth.com/onthemove.asp?RID=652

Other Therapeutic Treatments

Gaming technologies and VR systems are starting to be used in a growing number of other therapeutic situations. For example:

Women with breast cancer have fewer adverse effects from chemotherapy and less fatigue when using virtual reality as a distraction intervention during treatments, according to a study from the Duke University School of Nursing and Case Western Reserve Comprehensive Cancer Center. In the study, published in the January 2004 issue of Oncology Nursing Forum, the researchers described how chemotherapy patients eased their fatigue and discomfort by solving a mystery, touring an art gallery or going deep-sea diving in a virtual environment as they underwent treatment. See www.hoise.com/vmw/04/articles/vmw/LV-VM-02-04-31.html

PDwii is currently being developed by Red Hill Studios and the UCSF School of Nursing, with funding by the NIH. The goal is to demonstrate the technical feasibility, therapeutic effectiveness, and safety of an innovative computer-based training programme aimed at developing stronger gait and balance for patients with Parkinson's Disease. Quantifiable results are being used to track patient progress and are being integrated into the patient's overall regime. Results will be used to benefit further innovations in the field of games for health. See http://www.destructoid.com/gdc-08-using-the-wiimote-for-physical-therapy-71207.phtml

Stroke Rehabilitation - Engineers at Rutgers, The State University of New Jersey, have modified a popular home video game system to assist stroke patients with hand exercises, producing a technology costing less than $600 that may one day rival systems 10 times as expensive. The Rutgers hand rehabilitation system is an example of virtual rehabilitation, which combines virtual reality - computer-generated interactive visual environments in which users control actions in a lifelike way - with traditional therapy techniques. Virtual rehabilitation gives therapists new tools to do their jobs more effectively and engages patients who may otherwise lack interest or motivation to complete normal exercise regimens. Read http://www.medicalnewstoday.com/articles/50690.php

In May, 2007, it was reported that a Multiple Sclerosis and Parkinson's Disease virtual reality device that combines a wearable, cell phone-sized audio component and a visual feedback apparatus to improve walking speed and stride length in patients suffering from multiple sclerosis has been developed at the Technion-Israel Institute of Technology. The integrated device has been in use at a number of medical centers in Israel and the United States, including the University of Cincinnati and the State University of New York. See http://www.mtbeurope.info/news/2007/705013.htm

Researchers from the University of Ulster and the stroke unit at the Royal Hospitals have developed revolutionary techniques to help people with stroke regain use of their upper limbs with the help of virtual reality. They have launched a pilot study employing a low cost, virtual reality system which allows people with stroke to be immersed in a virtual world. Patients use a head-mounted display and wear a flexible glove connected to position and orientation sensors. These enable the patient's hand and arm movements to be tracked in the virtual environment, providing visual feedback to the patient. Audio feedback in the form of a "virtual physiotherapist" is also possible, offering encouragement and motivation during the tasks. See www.hoise.com/vmw/04/articles/vmw/LV-VM-07-04-11.html

Exposure Therapy and PTSD - In an article entitled "A Dose of Virtual Reality", Carlos Bergfeld writes that "one of the primary uses of virtual reality (VR) in a therapeutic role is its application to various forms of exposure therapy, ranging from phobia treatments to newer approaches for treating post-traumatic stress syndrome (PTSD)." The Virtual Reality Medical Center in San Diego, funded by the Office of Naval Research (ONR), has designed a VR system to help personnel returning from the wars in Iraq and Afghanistan cope with acute PTSD. A version of the system is being distributed to various facilities, including academic institutions and military healthcare installations. More information on this can be found in the following Business Week article - See http://www.businessweek.com/technology/content/jul2006/tc20060725_012342.htm?chan=top+news_top+news

Wellness & Healthy Lifestyles

Games are an ideal way to engage people in activities that promote healthy lifestyles and tackle their health problems head-on.

Touchtown, a company specializing in operating video and computer information networks in senior communities have built and rolled out a specific dance game product for the senior citizen market. 'Dancetown' combines the fun of arcade games with the benefits of dance and physical exercise and applies it to the needs of mature adults. Unique to the design is a web-based system for recording a player's performance and tracking progress over time. A Dancetown player, family member, or medical professional can see at a glance how their dancing is progressing day by day, week by week, and month by month. Players can also see how their scores improve on standardized fitness measurements such as the Senior Fitness Test. See http://www.dancetown.us/

Nintendo plans to bulk up the appeal of its Wii video-game system among consumers with its highly anticipated exercise game, Wii Fit. It could be one of the industry's biggest blockbusters of 2008. Wii Fit is already a hit in Japan, where it has sold more than 1.5 million units since its release last December. Wii Fit stresses four main categories of physical activity - balance, aerobics, yoga and strength training. Nintendo is pitching it as a pastime that promotes a healthy lifestyle. Users can track their weight and training progress and receive points for performing tasks using good form and increased intensity. The game also comes with an electronic balance board that allows users to measure their weight and body-mass index, and guides them through such activities as yoga poses and muscle-toning exercises. Read http://www.nypost.com/seven/03312008/business/wii_fit_stretches_for_new_gaming_market_104330.htm

With the Brain Age games, there's a way to make mental exercise fun, even competitive. Just minutes a day, that's all it takes to challenge your mind. Inspired by the work of prominent Japanese neuroscientist Dr. Ryuta Kawashima, the Brain Age games feature activities designed to help stimulate your brain and give it the workout it needs like solving simple math problems, counting currency, drawing pictures on the Nintendo DS touch screen, and unscrambling letters. The handheld system also records your scores so you can track changes over time in your memory skills. With Nintendo DS portability, you can play Brain Age at work, on vacation, or anywhere your day takes you. See http://www.brainage.com/launch/index.jsp

Archimage Inc., in collaboration with the Children's Nutrition Research Center of Houston's Baylor College of Medicine, have developed a serious video game on healthy eating and exercise called "Escape from Diab" to be released this year. The project was funded by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. Childhood obesity rates have tripled over the past 40 years, raising the risks of Type 2 Diabetes. According to the Surgeon General, "America's obesity epidemic will dwarf the threat of terrorism if the nation does not reduce the number of people who are severely overweight." Diabetes is already the country's leading cause of new blindness, kidney failure and lower limb amputations. It is also the nation's sixth leading cause of death. "Escape from Diab" puts players inside a sci-fi action and adventure where healthy lifestyle choices are the keys to winning. Visit http://www.archimageonline.com/diab.cfm

The Amazing Food Detective Game is aimed at children ages 9-10 and available to everyone at www.kp.org/amazingfooddetective. It complements Kaiser Permanente's nationally recognized childhood obesity clinical strategy. Based on a popular character from Kaiser Permanente's Educational Theatre Program, the Amazing Food Detective takes children through activities that show how to choose healthy foods and get more active. Children playing the game follow the routines of eight culturally diverse children whose activities or conditions would benefit from healthy food and exercise choices.

Glymetrix specifically built their diabetes management game to target adults with diabetes. Glymetrix not only targeted adults because they are a large patient population but also for aspects of adult cognition and how games fit into adult life. More importantly, the software attempts to put diabetes in better context for their players by both teaching them about the disease and its lifestyle management issues but by assessing them as well and thus creating a contextual profile of them as a patient which can feed future areas of play that increasingly target issues players must master to improve their life.

Health Education & Training

While its use is still not widespread, virtual reality (VR) is finding its way into the training of health care professionals as well as their patients.

The TOUCH Project is a collaborative effort of the University of Hawaii and the University of New Mexico Schools of Medicine. Its goal is to explore the impact of advanced computational and telecommunications technology on human comprehension. The approach has been to develop three-dimensional immersive virtual environments that place students in medical educational contexts where they may pursue exploratory and experiential learning. These learning contexts include scenarios where students can "practice" treating acutely ill virtual patients without endangering human life. Other contexts allow students to learn body function and physiology by exploring and interacting with environments that are physically inaccessible to them. The ability to use virtual environments in a collaborative mode that allows students, colleagues and teachers to interact with learning objects and each other is seen as central to the projects mission. See www.pacifichui.org and www.tatrc.org

Virtually Better creates virtual reality environments for use in the treatment of anxiety disorders such as fear of flying, fear of heights, fear of public speaking as well as post-traumatic stress disorder (PTSD). Virtually Better designed "Virtual Iraq" to support exposure therapy for veterans of anxiety disorders resulting from high-stress battleground environments. See http://www.virtuallybetter.com/ and http://www.hoise.com/vmw/05/articles/vmw/LV-VM-12-05-18.html

When a child is diagnosed with a serious illness, the day-to-day joys of childhood take a back seat to the rigors of treatment and hospitalization. For more than two decades, Starlight Starbright Children's Foundation has dedicated itself to improving the quality of life for children with serious medical conditions by providing entertainment, education and family activities that help them cope with the pain, fear and isolation of prolonged illness. Many of these activities throughout Starlight's history have involved the use of videogames for general entertainment for children in hospitals and especially programs to help sick children understand common hospital procedures and manage illnesses such as cancer, sickle cell anemia, cystic fibrosis, asthma, IBD and kidney disease. Research conducted on select Starlight Starbright programs indicates patient benefits include reduced pain, greater compliance with treatment, and an increased sense of peer support, self efficacy, knowledge, responsibility for disease management, and ability to cope.

Malaria is a disease that ravages not only those citizens who inhabit the countries it afflicts but also the many people who travel to such locals. Life and Death in the Age of Malaria is a simulation game currently in development at the University of Wisconsin's School of Nursing and is designed to especially help those traveling and working in areas of high risk for malaria. Visit http://elianealhadeff.blogspot.com/2008/03/g4h-2008-serious-games-enhancing.html

The Kid's Interactive Creation Kiosk (KICK) is a touch screen system and software activity package developed with young children in mind. Initial design of the system was focused on hospital waiting rooms and other similar healthcare settings. Developed by a team of graduate students at Carnegie Mellon's Entertainment Technology Center the project was originally aimed to lower stress for 60,000 children who visited Pittsburgh Medicial Centers ER each year. During the testing phase, the project gathered a lot of research on how to deploy such systems in healthcare settings. See http://www.seriousgamessource.com/item.php?story=10231

Conclusion

Games are not just for kids. The use of gaming technologies and VR in healthcare is growing at an ever increasing pace. It has the potential to be really big in the coming years. As we have shown, electronic gaming systems are being used to assist in physical therapy, recreation therapy, health education, pain distraction, diabetes training, Alzheimer's treatment, physical fitness training, stroke rehabilitation and so much more. As the systems become more sophisticated, gather and store data, and are then interfaced to Personal Health Record (PHR) systems their potential is greatly magnified.

Papers on many other projects involving virtual reality and medicine from the last Medicine Meets Virtual Reality (MMVR) Conference can be found online at http://www.booksonline.iospress.nl/Content/View.aspx?piid=5117

Papers are also available on many other projects involving gaming technology and healthcare from the Games For Health Conference at http://www.gamesforhealth.org and also http://www.changemakers.net/en-us/node/725/mosaic

Recommendations & Next Steps

The following are some recommendations and next steps healthcare organizations should consider taking with regards to gaming technologies and VR systems.
  • Consider establishing a workgroup to identify functional requirements and/or potential uses of gaming technologies for use by your health care organization.
  • Conduct a detailed literature search annually and obtain lessons learned from gaming and VR technology projects underway at other healthcare institutions.
  • Consider attending the next "Games for Health" Conference.
  • Identify potential organizations to collaborate with on the research, development, testing and use of gaming and VR systems in healthcare, e.g. medical schools, vendors.
  • Conduct a feasibility and cost/benefit study into the use of gaming and VR technologies and select potential pilot projects, e.g. diabetes, physical therapy, etc.
  • Look for health gaming solutions that collect and transfer data into a personal health record (PHR).
  • Put aside any bias against 'gaming' technologies and get started now.

Selected References & Resources

The authors recently completed a book on collaboration, open solutions and innovative technology entitled "Medical Informatics 20/20", published by Jones & Bartlett in 2007. See http://www.jbpub.com/catalog/0763739251

Authors

Peter J. Groen is on the faculty of the Computer & Information Science Department at Shepherd University in West Virginia and is one of the founders of the Shepherd University Research Corporation (SURC) - see www.shepherd.edu/surc/cosi

Douglas Goldstein is an "eFuturist", author, speaker, and President of Medical Alliances, Inc. Visit www.douglasgoldstein.com or contact him at doug@medicalalliances.com


Peter Groen, Douglas Goldstein

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