Published in Virtual Medical World, May 2008 http://www.hoise.com/vmw/08/articles/vmw/LV-VM-05-08-37.

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Gaming Technology, Virtual Reality and Healthcare

Introduction This article provides a high level overview on virt al realit! "V#$ and gaming technolog! sol tions and their application in the %ield o% healthcare at this point in time. &aming technologies and V# have man! possi'le applications in healthcare( especiall! in ph!sical therap!( recreational therap!( training( and 3) vis ali*ation o% medical in%ormation. #ecommendations are o%%ered in this article on ne+t steps healthcare organi*ations sho ld consider ta,ing with regards to the emerging %ield o% gaming technolog!. Definitions & Key Concepts Gaming Technology -impl! p t( a game ma! 'e de%ined as a s!stem in which pla!ers engage in an entertaining arti%icial activit!( de%ined '! r les( that res lt in a . anti%ia'le o tcome. / more e+act de%inition o% games was presented '! 0esper 1 l in 2The &ame( the 3la!er( the 4orld: Loo,ing %or a 5eart o% &ameness6. 5e states that 2/ game is a r le-'ased %ormal s!stem with a varia'le and . anti%ia'le o tcome( where di%%erent o tcomes are assigned di%%erent val es( the pla!er e+erts e%%ort in order to in%l ence the o tcome( the pla!er %eels attached to the o tcome( and the conse. ences o% the activit! are optional and negotia'le.7 8n his article( 0esper 1 l then goes on to provide the %ollowing e+planation on the relationship o% comp ters to games. 24hile comp ter games are 9 st as r le-'ased as other games( the! modi%! the classic game model in that it is now the comp ter that pholds the r les. This adds a lot o% %le+i'ilit! to comp ter games( allowing %or m ch more comple+ r les: it %rees the pla!er"s$ %rom having to en%orce the r les( and it allows %or games where the pla!er does not ,now the r les %rom the o tset.7 Virtual Reality (VR) Virt al realit! "V#$ is a m lti-disciplinar! %ield o% comp ting technolog! that emerged %rom research on three-dimensional "3)$ interactive graphics and pilot/vehicle sim lations in the ;<=0s and ;<70s. -ee http://accad.os .ed />wa!nec/histor!/lesson;7.html

/ccording to -tephen ?llis at @/-/As /mes #esearch Benter( 6The technolog! o% the ;<80s was not mat re eno gh.6 Virt al #ealit! "V#$ helmets and their optics were too heav!( comp ters were too slow( and to ch-%eed'ac, s!stems o%ten didnAt wor,. 5owever( twent! !ears later( things have vastl! improved. Bomp ters are tho sands o% times %aster: V# peripherals are more porta'le and lightweight: and s!stems deliver a greater sense o% %eed'ac, and immersion to their sers. )evelopment and se o% virt al realit! s!stems are on the march again( especiall! in the %ield o% comp ter sim lation and gaming. -ee http://spaceresearch.nasa.gov/generalCin%o/D;9 nCvrClite.html Gaming Industry O er ie! Ever the last three decades( gaming has grad all! 'ecome one o% the main entertainment media( compara'le in reven e( c stomers and emplo!ees to the %ilm and m sic ind stries. /ccording to the ?ntertainment -o%tware /ssociation( DFG o% /mericans over the age o% 50 pla!ed video games in D007( and increase %rom <G in ;<<<. 8n D007( world-wide game spending e+ceeded H3D 'illion. I.-. comp ter and video game software sales grew si+ percent in to H<.5 'illion J more than tripling ind str! so%tware sales since ;<<=. Total video-game ind str! sales in the I.-. %or both hardware and software 9 mped F3 percent last !ear to H;7.< 'illion. K! D0;;( the world-wide gaming mar,et is e+pected to 'e worth HF8.< 'illion. -ee 2-erio s &ames( -erio s Mone!7 '! ?liane /lhade%% at http://www.slideshare.net/elianealhade%%/serio s-games-a-si*ea'le-mar,et 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 & !ersystems Gaming technologies and VR systems are being used in many physical therapy situations. or example! Virtual Reality Treatment "ViRT# $ystem J /s reported in an article in Virt al Medical 4orlds( Vi#T ses chromo,e! technolog! and gest re control so%tware to insert a patient into a virt al game environment allowing him to have % n while e+ercising. The patient is stim lated to e+ercise %or longer periods and more %re. entl! whereas the s!stem monitors the progress o% the patient. This evol tionar! ph!siotherap! treatment method which applies technologies 'orrowed %rom the entertainment and 'roadcast ind stries was s ccess% ll! tested at the #iverside Bamp s o% the Ettawa 5ospital. Lor more in%ormation see www.hoise.com/vmw/00/articles/vmw/LV-VM-0=-00-D=.html Wiihabilitation $ @intendoAs 4ii video game s!stem( whose pop larit! alread! e+tends 'e!ond the teen gaming set( is %ast 'ecoming a cra*e in reha'ilitation therap! %or patients recovering %rom stro,es( 'ro,en 'ones( s rger! and even com'at in9 ries. The 5ines Veterans /%%airs 5ospital west o% Bhicago recentl! 'o ght a 4ii s!stem %or its spinal cord in9 r! nit. /t 4alter #eed /rm! Medical Benter( the therap! is well-s ited to

patients in9 red d ring com'at in 8ra.( who tend to 'e in the ;< to D5 age range( according to Lt. Bol. -tephanie )a ghert!. -ee http://d c,netwe'.'logspot.com/D008/0D/docs- se-games-%or-reha'.html MET?0( a leading developer and provider o% high-. alit! motion capt re technolog!( implemented the %omputer &ssisted Rehabilitation n'ironment $ystem "%&R (# at the Iniversit! o% &roningen. B/#?@ allows a therapist to place the patient into a virt al environment to help diagnose medical disorders li,e 3ar,insonAs )isease as well as other ne rological a'normalities. 8n addition( B/#?@ ena'les therapists to introd ce d!namic corrections to a patientAs virt al and ph!sical realities( creating an interactive relationship that can red ce the reha'ilitation times %or ne ro-m sc lar and s,eletal in9 ries '! a'o t 50 percent. 8n t rn( the shorter reha'ilitation times c t treatment costs. -ee !!!%hoise%com& m!&'(&articles& m!&)V$V*$'($'($+%html (orthern &rm & )and %enter in ) l th( M@( is an pper e+tremit! tra ma and reha'ilitation center that o%%ers ;0 di%%erent comp ter games as ph!sical therap!. 3atients t!picall! pla! games %or =0 to <0 min tes several times wee,l! %or complicated or di%%ic lt in9 ries. The so%tware trac,s progress and displa!s a graph indicating the range o% movement. 8t even iss es a challenge %or improvement in the ne+t session( contri' ting to the potential %or patients overe+ercising. 1 st a hand% l o% I.-. ph!sical therap! clinics se this technolog!. -ee http://www.' sinessnorth.com/onthemove.aspM#8)N=5D *ther Therapeutic Treatments Gaming technologies and VR systems are starting to be used in a growing number of other therapeutic situations. or example! 4omen with 'reast cancer have %ewer adverse e%%ects %rom chemotherap! and less %atig e when sing virt al realit! as a distraction intervention d ring treatments( according to a st d! %rom the ) ,e Iniversit! -chool o% @ rsing and Base 4estern #eserve Bomprehensive Bancer Benter+ 8n the st d!( p 'lished in the 1an ar! D00F iss e o% Encolog! @ rsing Lor m( the researchers descri'ed how chemotherapy patients eased their %atig e and discom%ort '! solving a m!ster!( to ring an art galler! or going deepsea diving in a virt al environment as the! nderwent treatment. -ee !!!%hoise%com& m!&',&articles& m!&)V$V*$'-$',$.(%html P,-ii is c rrentl! 'eing developed '! #ed 5ill -t dios and the IB-L -chool o% @ rsing( with % nding '! the @85. The goal is to demonstrate the technical %easi'ilit!( therape tic e%%ectiveness( and sa%et! o% an innovative comp ter-'ased training program aimed at developing stronger gait and 'alance %or patients with 3ar,insonAs )isease. O anti%ia'le res lts are 'eing sed to trac, patient progress and are 'eing integrated into the patientAs overall regime. #es lts will 'e sed to 'ene%it % rther innovations in the %ield o% games %or health. -ee http://www.destr ctoid.com/gdc-08- sing-the-wiimote-%orph!sical-therap!-7;D07.phtml

$tro.e Rehabilitation / ?ngineers at # tgers( The -tate Iniversit! o% @ew 1erse!( have modi%ied a pop lar home video game s!stem to assist stro,e patients with hand e+ercises( prod cing a technolog! costing less than H=00 that ma! one da! rival s!stems ;0 times as e+pensive. The # tgers hand reha'ilitation s!stem is an e+ample o% virt al reha'ilitation( which com'ines virt al realit! - comp ter-generated interactive vis al environments in which sers control actions in a li%eli,e wa! - with traditional therap! techni. es. Virt al reha'ilitation gives therapists new tools to do their 9o's more e%%ectivel! and engages patients who ma! otherwise lac, interest or motivation to complete normal e+ercise regimens. #ead http://www.medicalnewstoda!.com/articles/50=<0.php 8n Ma!( D007( it was reported that a Multiple $clerosis and Par.inson0s ,isease virt al realit! device that com'ines a weara'le( cell phone-si*ed a dio component and a vis al %eed'ac, apparat s to improve wal,ing speed and stride length in patients s %%ering %rom m ltiple sclerosis has 'een developed at the Technion-8srael 8nstit te o% Technolog!. The integrated device has 'een in se at a n m'er o% medical centers in 8srael and the Inited -tates( incl ding the Iniversit! o% Bincinnati and the -tate Iniversit! o% @ew Por,. -ee http://www.mt'e rope.in%o/news/D007/7050;3.htm #esearchers %rom the Iniversit! o% Ilster and the stro,e nit at the #o!al 5ospitals have developed revol tionar! techni. es to help people with stro,e regain se o% their pper lim's with the help o% virt al realit!. The! have la nched a pilot st d! emplo!ing a low cost( virt al realit! s!stem which allows people with stro,e to 'e immersed in a virt al world. 3atients se a head-mo nted displa! and wear a %le+i'le glove connected to position and orientation sensors. These ena'le the patientAs hand and arm movements to 'e trac,ed in the virt al environment( providing vis al %eed'ac, to the patient. / dio %eed'ac, in the %orm o% a 1'irtual physiotherapist1 is also possi'le( o%%ering enco ragement and motivation d ring the tas,s. -ee www.hoise.com/vmw/0F/articles/vmw/LV-VM-07-0F-;;.html !posure Therapy and PT$, $ In an article entitled /0 Dose of Virtual Reality1 , Carlos 2ergfeld !rites that /one of the primary uses of irtual reality "VR# in a therapeutic role is its application to arious forms of e3posure therapy, ranging from pho4ia treatments to ne!er approaches for treating post$traumatic stress syndrome "5T6D#%1 The Virtual Reality *edical Center in 6an Diego, funded 4y the Office of 7a al Research "O7R#, has designed a VR system to help personnel returning from the !ars in Ira8 and 0fghanistan cope !ith acute 5T6D% 0 ersion of the system is 4eing distri4uted to arious facilities, including academic institutions and military healthcare installations% *ore information on this can 4e found in the follo!ing 2usiness 9ee: article ; 6ee http<&&!!!%4usiness!ee:%com&technology&content&=ul-''>&tc-''>'+-?@'(-.,-%htmA chanBtopCne!s@topCne!s Wellness & )ealthy 2i3estyles Games are an ideal way to engage people in activities that promote healthy lifestyles and tac"le their health problems head#on.

To chtown( a compan! speciali*ing in operating video and comp ter in%ormation networ,s in senior comm nities have ' ilt and rolled o t a speci%ic dance game prod ct %or the senior citi*en mar,et. 4,anceto-n0 com'ines the % n o% arcade games with the 'ene%its o% dance and ph!sical e+ercise and applies it to the needs o% mat re ad lts. Ini. e to the design is a we'-'ased s!stem %or recording a pla!erAs per%ormance and trac,ing progress over time. / )ancetown pla!er( %amil! mem'er( or medical pro%essional can see at a glance how their dancing is progressing da! '! da!( wee, '! wee,( and month '! month. 3la!ers can also see how their scores improve on standardi*ed %itness meas rements s ch as the -enior Litness Test. -ee http://www.dancetown. s/ @intendo plans to ' l, p the appeal o% its 4ii video-game s!stem among cons mers with its highl! anticipated e+ercise game( Wii 5it+ 8t co ld 'e one o% the ind str!As 'iggest 'loc,' sters o% D008. 4ii Lit is alread! a hit in 1apan( where it has sold more than ;.5 million nits since its release last )ecem'er. 4ii Lit stresses %o r main categories o% ph!sical activit! - 'alance( aero'ics( !oga and strength training. @intendo is pitching it as a pastime that promotes a health! li%est!le. Isers can trac, their weight and training progress and receive points %or per%orming tas,s sing good %orm and increased intensit!. The game also comes with an electronic 'alance 'oard that allows sers to meas re their weight and 'od!-mass inde+( and g ides them thro gh s ch activities as !oga poses and m scle-toning e+ercises. #ead http://www.n!post.com/seven/033;D008/' siness/wiiC%itCstretchesC%orCnewCgamingCm ar,etC;0F330.htm 4ith the 6rain &ge games( thereAs a wa! to ma,e mental e+ercise % n( even competitive. 1 st min tes a da!( thatAs all it ta,es to challenge !o r mind. 8nspired '! the wor, o% prominent 1apanese ne roscientist )r. #! ta 0awashima( the Krain /ge games %eat re activities designed to help stim late !o r 'rain and give it the wor,o t it needs li,e solving simple math pro'lems( co nting c rrenc!( drawing pict res on the @intendo )to ch screen( and nscram'ling letters. The handheld s!stem also records !o r scores so !o can trac, changes over time in !o r memor! s,ills. 4ith @intendo )- porta'ilit!( !o can pla! Krain /ge at wor,( on vacation( or an!where !o r da! ta,es !o . -ee http://www.'rainage.com/la nch/inde+.9sp /rchimage 8nc.( in colla'oration with the BhildrenQs @ trition #esearch Benter o% 5o stonQs Ka!lor Bollege o% Medicine( have developed a serio s video game on health! eating and e+ercise called 7 scape 3rom ,iab8 to 'e released this !ear. The pro9ect was % nded '! a grant %rom the @ational 8nstit te o% )ia'etes and )igestive and 0idne! )iseases o% the @ational 8nstit tes o% 5ealth. Bhildhood o'esit! rates have tripled over the past F0 !ears( raising the ris,s o% T!pe D )ia'etes. /ccording to the - rgeon &eneral( 6/mericaAs o'esit! epidemic will dwar% the threat o% terrorism i% the nation does not red ce the n m'er o% people who are severel! overweight.6 )ia'etes is alread! the co ntr!Qs leading ca se o% new 'lindness( ,idne! %ail re and lower lim' amp tations. 8t is also the nationQs si+th leading ca se o% death. $%scape from &iab' p ts pla!ers inside a sci-%i action and advent re where health! li%est!le choices are the ,e!s to winning. Visit http://www.archimageonline.com/dia'.c%m

The &ma9ing 5ood ,etecti'e Game is aimed at children ages <-;0 and availa'le to ever!one at www.,p.org/ama*ing%ooddetective. 8t complements 0aiser 3ermanenteAs nationall! recogni*ed childhood o'esit! clinical strateg!. Kased on a pop lar character %rom 0aiser 3ermanenteAs ?d cational Theatre 3rogram( the /ma*ing Lood )etective ta,es children thro gh activities that show how to choose health! %oods and get more active. Bhildren pla!ing the game %ollow the ro tines o% eight c lt rall! diverse children whose activities or conditions wo ld 'ene%it %rom health! %ood and e+ercise choices. Glymetri! speci%icall! ' ilt their dia'etes management game to target ad lts with dia'etes. &l!metri+ not onl! targeted ad lts 'eca se the! are a large patient pop lation ' t also %or aspects o% ad lt cognition and how games %it into ad lt li%e. More importantl!( the so%tware attempts to p t dia'etes in 'etter conte+t %or their pla!ers '! 'oth teaching them a'o t the disease and its li%est!le management iss es ' t '! assessing them as well and th s creating a conte+t al pro%ile o% them as a patient which can %eed % t re areas o% pla! that increasingl! target iss es pla!ers m st master to improve their li%e. )ealth ducation & Training (hile 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 T*:%) Pro;ect is a colla'orative e%%ort o% the Iniversit! o% 5awaii and the Iniversit! o% @ew Me+ico -chools o% Medicine. 8ts goal is to e+plore the impact o% advanced comp tational and telecomm nications technolog! on h man comprehension. The approach has 'een to develop three-dimensional immersive virt al environments that place st dents in medical ed cational conte+ts where the! ma! p rs e e+plorator! and e+periential learning. These learning conte+ts incl de scenarios where patients can 6practice6 treating ac tel! ill virt al patients witho t endangering h man li%e. Ether conte+ts allow st dents to learn 'od! % nction and ph!siolog! '! e+ploring and interacting with environments that are ph!sicall! inaccessi'le to them. The a'ilit! to se virt al environments in a colla'orative mode that allows st dents( colleag es and teachers to interact with learning o'9ects and each other is seen as central to the pro9ects mission. -ee www.paci%ich i.org and www.tatrc.org Virtually 6etter creates virt al realit! environments %or se in the treatment o% an+iet! disorders s ch as %ear o% %l!ing( %ear o% heights( %ear o% p 'lic spea,ing as well as posttra matic stress disorder "3T-)$. Virt all! Ketter designed 6Virt al 8ra.6 to s pport e+pos re therap! %or veterans o% an+iet! disorders res lting %rom high-stress 'attlegro nd environments. -ee http://www.virt all!'etter.com/ and www.hoise.com/vmw/05/articles/vmw/LV-VM-;D-05-;8.html 4hen a child is diagnosed with a serio s illness( the da!-to-da! 9o!s o% childhood ta,e a 'ac, seat to the rigors o% treatment and hospitali*ation. Lor more than two decades( $tarlight $tarbright %hildren<s 5oundation has dedicated itsel% to improving the . alit!

o% li%e %or children with serio s medical conditions '! providing entertainment( ed cation and %amil! activities that help them cope with the pain( %ear and isolation o% prolonged illness. Man! o% these activities thro gho t -tarlightAs histor! have involved the se o% videogames %or general entertainment %or children in hospitals and especiall! programs to help sic, children nderstand common hospital proced res and manage illnesses s ch as cancer( sic,le cell anemia( c!stic %i'rosis( asthma( 8K) and ,idne! disease. #esearch cond cted on select -tarlight -tar'right programs indicates patient 'ene%its incl de red ced pain( greater compliance with treatment( and an increased sense o% peer s pport( sel% e%%icac!( ,nowledge( responsi'ilit! %or disease management( and a'ilit! to cope. Malaria is a disease that ravages not onl! those citi*ens who inha'it the co ntries it a%%licts ' t also the man! people who travel to s ch locals. 2i3e and ,eath in the &ge o3 Malaria is a sim lation game c rrentl! in development at the Iniversit! o% 4isconsinAs -chool o% @ rsing and is designed to especiall! help those traveling and wor,ing in areas o% high ris, %or malaria. Visit http://elianealhade%%.'logspot.com/D008/03/gFh-D008serio s-games-enhancing.html The =id<s >nteracti'e %reation =ios. "=>%=# is a to ch screen s!stem and so%tware activit! pac,age developed with !o ng children in mind. 8nitial design o% the s!stem was %oc sed on hospital waiting rooms and other similar healthcare settings. )eveloped '! a team o% grad ate st dents at Barnegie MellonAs ?ntertainment Technolog! Benter the pro9ect was originall! aimed to lower stress %or =0(000 children who visited 3itts' rgh Medicial Benters ?# each !ear. ) ring the testing phase( the pro9ect gathered a lot o% research on how to deplo! s ch s!stems in healthcare settings. -ee http://www.serio sgamesso rce.com/item.phpMstor!N;0D3; Conclusion &ames are not 9 st %or ,ids. The se o% gaming technologies and V# in healthcare is growing at an ever increasing pace. 8t has the potential to 'e reall! 'ig in the coming !ears. /s we have shown( electronic gaming s!stems are 'eing sed to assist in ph!sical therap!( recreation therap!( health ed cation( pain distraction( dia'etes training( al*heimers treatment( ph!sical %itness training( stro,e reha'ilitation and so m ch more. /s the! s!stems 'ecome more sophisticated( gather and store data( and are then inter%aced to 3ersonal 5ealth #ecord "35#$ s!stems their potential is greatl! magni%ied. )apers on many other pro*ects involving virtual realit and medicine from the last Medicine Meets Virtual Reality "MMVR# %on3erence can be found online at http<&&!!!%4oo:sonline%iospress%nl&Content&Vie!%asp3ApiidB?((+ )apers are also available on many other pro*ects involving gaming technology and healthcare from the Games 5or )ealth %on3erence ate http://www.games%orhealth.org and also http://www.changema,ers.net/en- s/node/7D5/mosaic

Recommendations & 7e3t 6teps The %ollowing are some recommendations and ne+t steps healthcare organi*ations sho ld consider ta,ing with regards to gaming technologies and V# s!stems. Bonsider esta'lishing a wor, gro p to identi%! % nctional re. irements and/or potential ses o% gaming technologies %or se '! !o r health care organi*ation. Bond ct a detailed literat re search ann all! and o'tain lessons learned %rom gaming and V# technolog! pro9ects nderwa! at other healthcare instit tions. Bonsider attending the ne+t 2&ames %or 5ealth7 Bon%erence. 8denti%! potential organi*ations to colla'orate with on the research( development( testing and se o% gaming and V# s!stems in healthcare( e.g. medical schools( vendors. Bond ct a %easi'ilit! and cost/'ene%it st d! into the se o% gaming and V# technologies and select potential pilot pro9ects( e.g. dia'etes( ph!sical therap!( etc.. Loo, %or health gaming sol tions that collect and trans%er data into a personal health record "35#$. 8nitiate a pilot pro9ect involving the se o% gaming technolog! inter%aced to ?M# or 35# s!stems. 3 t aside an! 'ias against +gaming, technologies and get started now. 6elected References & Resources

/@&8L- J http://www.angils.org/ &ames %or 5ealth Bon%erence J http://www.games%orhealth.org MMV# Bon%erence - http://www.ne+tmed.com/mmvrCvirt alCrealit!.html -erio s &ames -o rce J http://serio sgamesso rce.com/ Virt al #ealit! @ews R #eso rces - www.V#oot.org 4i,ia &aming - http://gaming.wi,ia.com/ ?lectronic &aming Monthl! - http://www.; p.com/do/p 'sMdidND 3la! %or 5ealth - http://www.iconnecto.com/ 4est Virginia &ames Lor 5ealth - http://wvgames%orhealth.wv .ed 1o rnal o% Virt al #ealit! - www.springer.com/9o rnal/;0055/

The a thors recentl! completed a 'oo, on colla'oration( open sol tions and innovative technolog! entitled 2Medical 8n%ormatics D0/D07( p 'lished '! 1ones R Kartlett in D007. -ee http://www.9'p '.com/catalog/07=373<D5; 0uthors )eter -. Groen is on the faculty of the .omputer / Information 0cience &epartment at 0hepherd 1niversity in (est Virginia and is one of the founders of the 0hepherd 1niversity Research .orporation (01R.) # see www.shepherd.ed /s rc/cosi

&ouglas Goldstein is an $ e uturist2, author, spea"er, and )resident of 3edical 4lliances, Inc. Visit www.do glasgoldstein.com. or contact him at do gSmedicalalliances.com