Videogames and Health Improvement: A Literature Review of Randomized Controlled Trials

Current status and clinical perspectives of extended reality for myoelectric prostheses: review

Training with "Extended Reality" or X-Reality (XR) systems can undoubtedly enhance the control of the myoelectric prostheses. However, there is no consensus on which factors improve the efficiency of skill transfer from virtual training to actual prosthesis abilities. This review examines the current status and clinical applications of XR in the field of myoelectric prosthesis training and analyses possible influences on skill migration. We have conducted a thorough search on databases in the field of prostheses using keywords such as extended reality, virtual reality and serious gaming. Our scoping review encompassed relevant applications, control methods, performance evaluation and assessment metrics. Our findings indicate that the implementation of XR technology for myoelectric rehabilitative training on prostheses provides considerable benefits. Additionally, there are numerous standardised methods available for evaluating training effectiveness. Recently, there has been a surge in the number of XR-based training tools for myoelectric prostheses, with an emphasis on user engagement and virtual training evaluation. Insufficient attention has been paid to significant limitations in the behaviour, functionality, and usage patterns of XR and myoelectric prostheses, potentially obstructing the transfer of skills and prospects for clinical application. Improvements are recommended in four critical areas: activities of daily living, training strategies, feedback, and the alignment of the virtual environment with the physical devices.

Effect of touch screen tablet use on fine motor functions in children with hemiparetic cerebral palsy: A randomized controlled trial

BACKGROUND

Cerebral palsy is the most frequent condition affecting the central nervous system and causing large disability.

OBJECTIVE

To determine the impact of touch screen tablet upon fine motor functions in children with hemiparesis.

METHOD

This was a randomized controlled trial involving 60 children, ranging in age from 5 to 7 years old, randomized into two groups: intervention or control group (30 children per group). Both groups were given 12 consecutive weeks of designed fine motor tasks. Additionally, for thirty minutes, the intervention group was given a fine motor exercise program on a touch screen tablet. Upper limb function, finger dexterity and pinch strength were measured pre and post the recommended treatment program using the quality of upper extremity skill test (QUEST), Nine-Hole Peg Test and Jamar hydraulic pinch gauge, respectively.

RESULTS

All outcome measures were equivalent between intervention groups at admission (P > 0.05). Significant improvements were found in all assessed variables within the two groups. Meanwhile, the intervention group had significantly higher improvements (P < 0.05) in finger dexterity, pinch strength, and upper limb function when compared with the control groups.

CONCLUSION

Including a touch screen smart tablet application with a specially designed fine motor program is an effective method that helps children with U-CP perform more effectively with their fine motor skills.

Current State of Serious Games in Dentistry: A Scoping Review

Objective: Over the past decade, serious games (SGs) have played a growing role in medical education and health promotion; however, little is known about their use in the field of oral health. This study provides a comprehensive synthesis about SGs developed for training oral health professionals or for health promotion in oral health. Material and Methods: A systematic search was conducted. The following electronic databases were reviewed: MEDLINE (1966 to September 2019), Embase (1980 to September 2019), and Cochrane Central Register of Controlled Trials (CENTRAL), LILACS and Scopus from inception to September 2019. Two reviewers independently screened and assessed the study's quality and extracted data. The Sardi and collaborators' tool was used to assess the quality of the evidence presented. Results: A total of 19 studies (25 articles) were selected. Games were divided into two categories: for specific educational purposes and for oral health promotion. Most studies involved oral health professions' students (n = 9) or school/preschool children (n = 9). Two studies included preschool children and parents. Interactive SGs were as effective as traditional noninteractive methods in improving oral health outcomes. Nonetheless, participants' feedback reflected a higher level of satisfaction in learning through games. The quality of the studies was limited due to the lack of a proper technical description of the games and the absence of discussion of the limitations and challenges of the games. Conclusion: The use of SGs in oral health is limited, and little valid empirical evidence is available to confirm their effectiveness. Further studies are required for using more rigorous designs, evaluation, and follow-ups.

Enhancement of Anticipatory Postural Adjustments by Virtual Reality in Older Adults with Cognitive and Motor Deficits: A Randomised Trial

BACKGROUND

Postural activities involved in balance control integrate the anticipatory postural adjustments (APA) that stabilize balance and posture, facilitating arm movements and walking initiation and allowing an optimal coordination between posture and movement. Several studies reported the significant benefits of virtual reality (VR) exercises in frail older adults to decrease the anxiety of falling and to induce improvements in behavioural and cognitive abilities in rehabilitation processes. The aim of this study was thus to test the efficiency of a VR system on the enhancement of the APA period, compared to the use of a Nintendo Wii system.

METHODS

Frail older adults (n = 37) were included in this study who were randomized and divided into a VR exercises group (VR group) or a control group using the Nintendo Wii system (CTRL group). Finally, 22 patients were included in the data treatment. APA were studied through muscular activation timings measured with electromyographic activities. The functional reach test, the gait speed, and the time up and go were also evaluated before and after a 3-week training phase.

RESULTS AND DISCUSSION

As the main results, the training phase with VR improved the APA and the functional reach test score along the antero-posterior axis. Together, these results highlight the ability of a VR training phase to induce neuromuscular adaptations during the APA period in frail older adults. Then, it underlines the effective transfer from learning carried out during the VR training movements to control balance abilities in a more daily life context.

A quasi-experimental test of a virtual reality game prototype for adolescent E-Cigarette prevention

OBJECTIVE

To test the preliminary impact and participant experience/satisfaction of Invite Only VR: A Vaping Prevention Game (Invite Only VR), an electronic cigarette (e-cigarette) prevention game prototype using virtual reality (VR) hardware.

METHODS

Forty-seven adolescents (38 boys; mean age = 14.23 years, SD = 0.914) were enrolled to test the preliminary impact of Invite Only VR on knowledge, perceived likelihood of using e-cigarettes, perceptions of harm, attitudes, social norms, and self-efficacy to refuse e-cigarettes using a pre/post design. Experience/satisfaction was measured following gameplay. Paired-samples t-tests and associated effect sizes were used to assess changes in the dependent variables. Descriptive statistics were used to report on gameplay experience/satisfaction.

RESULTS

From pre- to post-gameplay, players significantly increased in knowledge (t(34) = -5.594, p < .001, Cohen's d = 0.946) and perceptions of e-cigarette harm (t(34) = -3.370, p = .002, Cohen's d = 0.530) and decreased their perceived likelihood of using e-cigarettes in the future (t(35) = 2.140, p = .039, Cohen's d = 1.274). No significant change was found for attitudes towards e-cigarettes, social norm perceptions, nor refusal self-efficacy. Participants reported that they enjoyed playing the game (M = 3.00, SD = 0.99) and that they would tell their friends to play (M = 3.08, SD = 0.91).

CONCLUSIONS

Invite Only VR may help players develop knowledge and correct harm perceptions regarding e-cigarettes while reducing their perceived likelihood of using them in the future. Participant enjoyment also provides an initial indication that the intervention may be acceptable for use with adolescents.

A Biofeedback Enhanced Adaptive Virtual Reality Environment for Managing Surgical Pain and Anxiety

Pain and anxiety are common accompaniments of surgery, and opioids have been the mainstay of pain management for decades, with about 80% of the surgical population leaving the hospital with an opioid prescription. Moreover, patients receiving an opioid prescription after short-stay surgeries have a 44% increased risk of long-term opioid use, and about one in 16 surgical patients becomes a long-term user. Current opioid abuse and addiction now place the US in an “opioid epidemic,” and calls for alternative pain management mechanisms. To mitigate the preoperative anxiety and postoperative pain, we developed a virtual reality (VR) experience based on Attention Restoration Theory (ART) and integrated the user’s heart rate variability (HRV) biofeedback to create an adaptive environment. A randomized control trial among 16 Total Knee Arthroplasty (TKA) patients undergoing surgery at Patewood Memorial Hospital, Greenville, SC demonstrated that patients experiencing the adaptive VR environment reported a significant decrease in preoperative anxiety ([Formula: see text]) and postoperative pain ([Formula: see text]) after the VR intervention. These results were also supported by the physiological measures where there was a significant increase in RR Interval (RRI) ([Formula: see text]) and a significant decrease in the low frequency (LF)/high frequency (HF) ratio ([Formula: see text]) and respiration rate (RR) ([Formula: see text]).

Effectiveness of active video game usage on body composition, physical activity level and motor proficiency in children with intellectual disability

BACKGROUND

Interventions with active video games (AVGs) can promote physical activity (PA) and health and are compatible with a school setting. The needs of children with intellectual disability (ID) in this area have been neglected.

METHODS

A two-arm trial was conducted among 203 students with intellectual disability. The intervention group was prescribed a 12-week intervention with AVG. The control group continued with usual PA.

RESULTS

Children's BOT-2 short-form score increased in both the intervention and control groups. However, the AVG intervention had no statistically significant effect on children's body composition, PA and motor proficiency overall, or in analyses of subgroups based on age, body weight and comorbid autism.

CONCLUSION

Active video game intervention had no marked effect on body composition, PA and motor proficiency in children with intellectual disability. The reasons for the lack of effectivity of the intervention are discussed; these may provide better guidelines for future AVG intervention in children with intellectual disability.

Age Moderates Link Between Training Effects and Treatment Response to Attention Bias Modification Treatment for Social Anxiety Disorder

Attention bias modification treatment (ABMT) aims to reduce anxiety symptoms via practice on computerized attention training tasks. Despite evidence of efficacy, clinical effects appear heterogeneous. More research on ABMT mechanisms and moderators of treatment response is needed. Age is one potentially important moderator, as developmental differences in training effects may impact response. We examined developmental links between ABMT training effects and response in social anxiety disorder (SAD). We pooled data from two randomized controlled trials in treatment-seeking youths and adults with SAD (N = 99) that used identical ABMT methods. We first characterized learning effects associated with the eight-session ABMT training protocol. We then tested whether learning magnitude predicted the clinical (change in SAD symptoms) and cognitive (change in attention bias) responses to treatment. Finally, we tested whether age moderated the association between ABMT learning and treatment response. Results indicate that ABMT was associated with an incremental learning curve during the protocol, and that learning improved with age. Age further moderated the association between learning gains during the ABMT protocol and subsequent reduction in self-reported SAD symptoms, such that this association was stronger with age. These effects were not evident in bias scores or clinician ratings. Finally, pre-treatment SAD symptoms and bias scores predicted ABMT learning gains. This study highlights the links among age, learning processes, and clinical response to ABMT. These insights may inform attempts to increase the clinical efficacy of ABMT for anxiety.

Effectiveness of exergames for improving mobility and balance in older adults: a systematic review and meta-analysis

BACKGROUND

Exergaming is a fun, engaging, and interactive form of exercising that may help overcome some of the traditional exercise barriers and help improve adherence on the part of older adults, providing therapeutic applications for balance recovery and functional mobility. The purpose of this systematic review is to summarize the effects of exergames on mobility and balance in older adults.

METHODS

The PRISMA guidelines for systematic reviews were followed. The following databases were searched from inception to August 2019: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PEDro, CINAHL, and INSPEC. We selected randomized controlled trials that assessed the effects of exergames on balance or mobility of older adults without neurological conditions, in comparison to no intervention or health education. Two review authors independently screened the trials' titles and abstracts and identified trials for inclusion according to the eligibility criteria. An almost perfect agreement between the authors was observed with respect to interrater reliability of trial selection (kappa = 0.84; P < 0.001). We performed descriptive analysis of the quantitative data to summarize the evidence. Meta-analysis was carried out using RevMan. A random effects model was used to compute the pooled prevalence with 95% confidence intervals.

RESULTS

After screening 822 records, 12 trials comparing exergames with no intervention were included. A total of 1520 older adults participated in the studies, with a mean age of 76 ± 6 years for the experimental group and 76 ± 5 years for the control group. Quantitative synthesis showed significant improvements in balance and mobility based on the center of pressure sway (SMD = - 0.89; 95%CI = - 1.26 to - 0.51; P = 0.0001; I² = 58%), Berg Balance Scale (MD = 2.15; 95%CI = 1.77 to 2.56; P = 0.0001; I² = 96%), and on Timed Up and Go test (MD = - 2.48; 95%CI = - 3.83 to - 1.12; P = 0.0003; I² = 0).

CONCLUSIONS

Exergames improved balance and mobility in older adults without neurological disorders and motivate patients to keep performing balance exercises. High quality studies with standardized assessment protocols are necessary to improve the strength of the evidence.

Virtual Reality for Pediatric Traumatic Brain Injury Rehabilitation: A Systematic Review

Objective. Pediatric traumatic brain injury (TBI) is associated with physical and psychobehavioral impairment in children. Effective rehabilitation programs postinjury are critical for children with TBI. Virtual reality (VR) has been increasingly adopted for brain injury rehabilitation. However, scientific synthesis is lacking in evaluating its effectiveness in pediatric TBI rehabilitation. This article aimed to conduct a systematic review on the effectiveness of VR-based pediatric TBI rehabilitation. Methods. A systematic literature search was conducted in PubMed, PsycInfo, SCOPUS, CENTRAL, BioMed Central, CiNAHL, and Web of Science through November 2015. Personal libraries and relevant references supplemented the search. Two authors independently reviewed the abstracts and/or full text of 5824 articles. Data extraction and qualitative synthesis was conducted along with quantitative assessment of research quality by 2 authors. Results. A positive impact was found for VR-based interventions on children's physical rehabilitation post-TBI. The quality of research evidence was moderate, which largely suffered from small samples, lack of immersive VR experience, and lack of focus on socioemotional outcomes post-TBI. Conclusions. The present review identified positive effects of VR interventions for pediatric TBI rehabilitation especially in physical outcomes. Future research should include larger samples and broader post-TBI outcomes in children using VR-based interventions.

Cognitive-behavioral intervention via interactive multimedia online video game for active aging: study protocol for a randomized controlled trial

BACKGROUND

Due to the progressive aging of the population, programs to promote active aging have been recommended. However, older adults have difficulty accessing them. Interventions administered through online video games may increase their accessibility, and complementing these with a smartphone app will likely increase adherence and allow for ongoing professional monitoring. The objective of this study is to evaluate the efficacy of a cognitive-behavioral intervention for active aging administered through an online interactive multimedia video game that includes a smartphone app companion. The secondary objectives are to analyze the moderators and mediators of the change in the outcome variables and to evaluate the adherence to the intervention.

METHODS/DESIGN

A randomized controlled clinical trial will be conducted. Adults 45 years and older will be randomly assigned to a cognitive-behavioral intervention administered through an online multimedia video game that includes a smartphone app companion or to a control group that will receive online information on active aging (274 participants per group). The intervention will be administered in eight weekly 45-min modules. An investigator-blinded evaluation will be conducted using online self-administered tests at baseline, post-intervention, and 6- and 12-month follow-ups. The primary outcome will be mental health status as evaluated using the 36-item Short-Form Health Survey (SF-36) at post-intervention. Secondary outcomes will be emotional well-being, depressive symptoms, reinforcement, negative thoughts, self-reported memory, cognitive task performance, sleep hygiene behaviors, physical activity, eating habits, body mass index, social support, dropout, treatment adherence, and satisfaction with the intervention.

DISCUSSION

If the results are favorable, this study would involve the development of the first evidence-based active aging promotion intervention based on a video game that includes a smartphone app companion, providing evidence on its efficacy, accessibility, and clinical utility.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03643237. Registered 27 August 2018.

A Smartphone Game-Based Intervention (Tumaini) to Prevent HIV Among Young Africans: Pilot Randomized Controlled Trial

Background

There is a pressing need to ensure that youth in high HIV prevalence settings are prepared for a safer sexual debut. Smartphone ownership is increasing dramatically in low-income and middle-income countries. Smartphone games that are appropriately grounded in behavioral theory and evidence-based practice have the potential to become valuable tools in youth HIV prevention efforts in Sub-Saharan Africa.

Objective

To pilot-test a theory-based, empirically grounded smartphone game for young Kenyans designed to increase age and condom use at first sex, aiming to establish directionality of effects on behavior change.

Methods

Tumaini (“hope for the future” in Swahili) is an interactive, narrative-based game grounded in social cognitive theory. A randomized controlled pilot study was conducted in Kisumu, Western Kenya, from April to June 2017 with 60 participants aged 11-14 (mean 12.7) years. Intervention arm participants (n=30) were provided with an Android smartphone with Tumaini installed on it and were instructed to play the game for at least 1 hour a day for 16 days; control arm participants (n=30) received no intervention. All participants completed a survey on behavioral mediators, delivered via an audio computer-assisted self-interview system at baseline (T1), post intervention (T2), and at 6 weeks postintervention (T3). The postintervention survey for intervention arm participants included questions eliciting feedback on the game. Intervention arm participants and their parents participated in 8 postintervention focus group discussions. Game log files were analyzed to calculate the length of exposure to the game. Behavioral survey data were analyzed using two-sample t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. Descriptive statistics on game feedback questions were computed. Focus group transcripts were uploaded to MAXQDA software, where they were labeled with deductive and inductive codes. Data were analyzed thematically and compared across demographics.

Results

Intervention arm participants played Tumaini for a mean of approximately 27 hours. The intervention arm showed significant gains in sexual health-related knowledge and self-efficacy (both P<.001), behavioral intention for risk-avoidance strategies and sexual risk communication (P=.006), and overall survey scores (P<.001) compared with the control arm at T3. The postintervention survey revealed high subjective measures of the game’s value, relevance, and appeal. Focus groups identified a wide range of knowledge and skills the participants had gained, including setting goals and planning how to achieve them, which was perceived as a key motivator for avoiding or reducing risk.

Conclusions

The study supports the need for further research to assess the efficacy of the game-based intervention. If proven efficacious, smartphone games have the potential to dramatically increase the reach of culturally adapted behavioral interventions while ensuring fidelity to intervention design.

Trial Registration

ClinicalTrials.gov NCT03054051; http://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW)

Efficacy of the Fun For Wellness Online Intervention to Promote Multidimensional Well-Being: a Randomized Controlled Trial

Subjective well-being refers to people's level of satisfaction with life as a whole and with multiple dimensions within it. Interventions that promote subjective well-being are important because there is evidence that physical health, mental health, substance use, and health care costs may be related to subjective well-being. Fun For Wellness (FFW) is a new online universal intervention designed to promote growth in multiple dimensions of subjective well-being. The purpose of this study was to provide an initial evaluation of the efficacy of FFW to increase subjective well-being in multiple dimensions in a universal sample. The study design was a prospective, double-blind, parallel group randomized controlled trial. Data were collected at baseline and 30 and 60 days-post baseline. A total of 479 adult employees at a major university in the southeast of the USA were enrolled. Recruitment, eligibility verification, and data collection were conducted online. Measures of interpersonal, community, occupational, physical, psychological, economic (i.e., I COPPE), and overall subjective well-being were constructed based on responses to the I COPPE Scale. A two-class linear regression model with complier average causal effect estimation was imposed for each dimension of subjective well-being. Participants who complied with the FFW intervention had significantly higher subjective well-being, as compared to potential compliers in the Usual Care group, in the following dimensions: interpersonal at 60 days, community at 30 and 60 days, psychological at 60 days, and economic at 30 and 60 days. Results from this study provide some initial evidence for both the efficacy of, and possible revisions to, the FFW intervention.

Preliminary investigation of a videogame prototype for cigarette and marijuana prevention in adolescents

BACKGROUND

Videogames are becoming increasingly popular to deliver health interventions; however, their role in the primary prevention of cigarette and marijuana use has not yet been evaluated. The purpose of this study was to conduct a preliminary test of the efficacy of a role-playing videogame prototype, smokeSCREEN, aimed at developing knowledge and behavioral skills associated with primary prevention of cigarette and marijuana use. The authors also explored participants' gameplay experience.

METHODS

This study employed a 1-group pretest-posttest design with 25 adolescent boys and girls aged 11 to 14 years (M_age = 11.56, SD = 0.77) who had never tried cigarettes or marijuana. Participants played four 1-hour gameplay sessions over a 2-week period. Assessments of knowledge, self-efficacy, attitudes, perceived norms, and intentions related to cigarette and marijuana prevention were collected at baseline and 2-week and 12-week follow-ups. Ratings of gameplay experience were collected after the 2 weeks of gameplay. One-way repeated-measures analyses of variance (ANOVAs) were conducted.

RESULTS

Findings are (1) improvements in knowledge for both cigarette (Wilks' λ = 0.62, F(2, 23) = 7.21, P = .004) and marijuana (Wilks' λ = 0.67, F(2, 23) = 5.75, P = .009) use from pre- to post-gameplay that were characterized by large effects; and (2) nonsignificant trends in the expected direction emerged for changes in self-efficacy and perceived norms related to both cigarettes and marijuana that were characterized by medium-large effects. Overall, the players provided positive reports of their experience with the smokeSCREEN videogame prototype.

CONCLUSIONS

These findings provide preliminary evidence that a videogame has the potential to influence key cognitive and motivational variables and can be an engaging means to deliver a cigarette and marijuana prevention intervention.

The future of digital games for HIV prevention and care

PURPOSE OF REVIEW

Although there has been a significant increase in mHealth interventions addressing the HIV prevention and care continuum, interventions using game mechanics have been less explored. Digital games are rapidly becoming an important tool for improving health behaviors and supporting the delivery of care and education. The purpose of this review is to provide a historical context for the use of gamification and videogames (including those using virtual reality) used in technology-based HIV interventions and to review new research in the field.

RECENT FINDINGS

A review of recently published (1 January 2016-31 March 2017) or presented abstracts (2016) identified a paucity of technology-based interventions that included gamification elements or any terms associated with videogames or gameplay. A larger portfolio of digital gaming interventions is in the pipeline.

SUMMARY

Use of digital games that include elements of gamification or consist of standalone videogames or virtual-reality-based games, represent a promising intervention strategy to address the HIV prevention and care continuum, especially among youth. Our review demonstrates that there is significant room for growth in this area in designing, developing, testing and most importantly, implementation and dissemination these novel interventions.

Community Game Day: Using an End-of-Life Conversation Game to Encourage Advance Care Planning

CONTEXT

Advance care planning (ACP) is an important process that involves discussing and documenting one's values and preferences for medical care, particularly end-of-life treatments.

OBJECTIVES

This convergent, mixed-methods study assessed whether an end-of-life conversation card game is an acceptable and effective means for performing ACP for patients with chronic illness and/or their caregivers when deployed in a community setting.

METHODS

Twenty-two games (n = 93 participants) were held in community settings surrounding Hershey, PA in 2016. Participants were recruited using random sampling from patient databases and also convenience sampling (i.e., flyers). Quantitative questionnaires and qualitative focus group interviews were administered to assess the game experience and subsequent performance of ACP behaviors.

RESULTS

Both quantitative and qualitative data found that Community Game Day was a well-received, positive experience for participants and 75% of participants performed ACP within three months post-intervention.

CONCLUSIONS

These findings suggest that using a conversation game during community outreach is a useful approach for engaging patients and caregivers in ACP. The convergence of quantitative and qualitative data strongly supports the continued investigation of the game in randomized controlled trials.

Can Playing an End-of-Life Conversation Game Motivate People to Engage in Advance Care Planning?

BACKGROUND

Advance care planning (ACP) involves several behaviors that individuals undertake to prepare for future medical care should they lose decision-making capacity. The goal of this study was to assess whether playing a conversation game could motivate participants to engage in ACP.

METHODS

Sixty-eight English-speaking, adult volunteers (n = 17 games) from communities around Hershey, Pennsylvania, and Lexington, Kentucky, played a conversation card game about end-of-life issues. Readiness to engage in 4 ACP behaviors was measured by a validated questionnaire (based on the transtheoretical model) immediately before and 3 months postgame and a semistructured phone interview. These behaviors were (1) completing a living will; (2) completing a health-care proxy; (3) discussing end-of-life wishes with loved ones; and (4) discussing quality versus quantity of life with loved ones.

RESULTS

Participants' (n = 68) mean age was 51.3 years (standard deviation = 0.7, range: 22-88); 94% of the participants were caucasian and 67% were female. Seventy-eight percent of the participants engaged in ACP behaviors within 3 months of playing the game (eg, updating documents, discussing end-of-life issues). Furthermore, 73% of the participants progressed in stage of change (ie, readiness) to perform at least 1 of the 4 behaviors. Scores on measures of decisional balance and processes of change increased significantly by 3 months postintervention.

CONCLUSION

This pilot study found that individuals who played a conversation game had high rates of performing ACP behaviors within 3 months. These findings suggest that using a game format may be a useful way to motivate people to perform important ACP behaviors.

Conversation Game Effectively Engages Groups of Individuals in Discussions about Death and Dying

BACKGROUND

Discussions about end-of-life (EOL) values, wishes, and beliefs are critical for effective advance care planning (ACP). New strategies are needed to engage individuals in EOL conversations.

OBJECTIVE

The study objective was to test the feasibility of using a conversation game to engage individuals in EOL discussions.

METHODS

This study used a mixed-methods approach. Participants played a conversation game that prompts players to answer and discuss 20 questions about death, dying, and EOL care. Participants completed pre- and postgame questionnaires and participated in postgame focus groups. Subjects were 70 healthy volunteers (18 groups of families, friends, or strangers). Demographics, emotional state, and perceived relational closeness were measured using preintervention questionnaires. Postintervention questionnaires measured conversation satisfaction, realism, self-rated quality, and emotional state. Postgame focus groups evaluated players' experiences playing the game.

RESULTS

Using a seven-point Likert scale (1 = low score, 7 = high score), players rated game conversations as satisfying (mean [M] = 6.1, SD = 0.9), realistic (M = 5.6, SD = 0.8), and of high quality (M = 5.7, SD = 0.9). There were no negative effects on emotional state immediately postgame (M = 1.3, SD = 0.5). A thematic analysis of participants' experiences (n = 55) revealed that (1) playing the game was an enjoyable, positive experience; (2) a game is a good framing for EOL discussions; and (3) there were mixed opinions about ideal game group composition.

CONCLUSIONS

This study established that healthy volunteers enjoyed engaging in a two-hour discussion about EOL issues when framed as a game. The game experience was a positive, satisfying, and enjoyable activity for participants. Further studies are needed to determine if health games can promote effective ACP.

Task-Oriented Gaming for Transfer to Prosthesis Use

The aim of this study is to establish the effect of task-oriented video gaming on using a myoelectric prosthesis in a basic activity of daily life (ADL). Forty-one able-bodied right-handed participants were randomly assigned to one of four groups. In three of these groups the participants trained to control a video game using the myosignals of the flexors and extensors of the wrist: in the Adaptive Catching group participants needed to catch falling objects by opening and closing a grabber and received ADL-relevant feedback during performance. The Free Catching group used the same game, but without augmented feedback. The Interceptive Catching group trained a game where the goal was to intercept a falling object by moving a grabber to the left and right. They received no additional feedback. The control group played a regular Mario computer game. All groups trained 20 minutes a day for four consecutive days. Two tests were conducted before and after training: one level of the training game was performed, and participants grasped objects with a prosthesis simulator. Results showed all groups improved their game performance over controls. In the prosthesis-simulator task, after training the Adaptive Catching group outperformed the other groups in their ability to adjust the hand aperture to the size of the objects and the degree of compression of compressible objects. This study is the first to demonstrate transfer effects from a serious game to a myoelectric prosthesis task. The specificity of the learning effects suggests that research into serious gaming will benefit from placing ADL-specific constraints on game development.

Rehab-let: touchscreen tablet for self-training impaired dexterity post stroke: study protocol for a pilot randomized controlled trial

BACKGROUND

Impaired dexterity of the weaker upper extremity is common post stroke and it is recommended that these individuals practice many repetitions of movement to regain function. However, stroke rehabilitation methods do not achieve the required intensity to be effective. Touchscreen tablet technology may be used as a motivating tool for self-training impaired dexterity of the weaker upper extremity post stroke.

METHODS/DESIGN

Rehab-let is a self-training protocol utilizing game apps on a touchscreen for practicing movement of the weaker upper extremity. We will conduct a pilot randomized controlled trial to assess Rehab-let compared to traditional self-training to improve dexterity of the weaker hand, and to increase self-training time and satisfaction in individuals with subacute stroke. Forty individuals with stroke undergoing subacute rehabilitation will be randomly allocated to Rehab-let or a traditional self-training program using therapeutic aids such as balls, blocks and pegs. All participants will be requested to perform self-training for 60 minutes a day, 5 times a week for 4 weeks. Dexterity assessed by The Nine Hole Peg Test is the main outcome measure. Assessments will be administered pre and post the self-training intervention by assessors blind to the group allocation.

DISCUSSION

The outcomes of this study will inform the design of a fully powered randomized controlled trial to evaluate the effectiveness of Rehab-let. If found to be effective, Rehab-let can be used during subacute rehabilitation to increase treatment intensity and improve dexterity. Potentially, Rehab-let can also be used after discharge and might be ideal for individuals with mild stroke who are often not referred to formal rehabilitation.

TRIAL REGISTRATION

Current Controlled Trials NCT02136433 registered on 17 September 2014.

A meta-analysis of serious digital games for healthy lifestyle promotion

Several systematic reviews have described health-promoting effects of serious games but so far no meta-analysis has been reported. This paper presents a meta-analysis of 54 serious digital game studies for healthy lifestyle promotion, in which we investigated the overall effectiveness of serious digital games on healthy lifestyle promotion outcomes and the role of theoretically and clinically important moderators. Findings showed that serious games have small positive effects on healthy lifestyles (g=0.260, 95% CI 0.148; 0.373) and their determinants (g=0.334, 95% CI 0.260; 0.407), especially for knowledge. Effects on clinical outcomes were significant, but much smaller (g=0.079, 95% CI 0.038; 0.120). Long-term effects were maintained for all outcomes except for behavior. Serious games are best individually tailored to both socio-demographic and change need information, and benefit from a strong focus on game theories or a dual theoretical foundation in both behavioral prediction and game theories. They can be effective either as a stand-alone or multi-component programs, and appeal to populations regardless of age and gender. Given that effects of games remain heterogeneous, further explorations of which game features create larger effects are needed.

A Systematic Review and Meta-analysis of Interventions for Sexual Health Promotion Involving Serious Digital Games

OBJECTIVE

Serious games may be effective in promoting sexual health behavior. Their confidential nature may encourage users to discuss sensitive sexuality topics. Furthermore, they can tailor messages to the individual's needs and may be intrinsically motivating. This meta-analysis investigates the effectiveness of interventions for sexual health promotion that use serious games.

MATERIALS AND METHODS

A database search was conducted in PubMed, Web of Science, CINAHL, and PsycINFO for publications before the end of July 2013. Serious digital games studies measuring effects on behavior or its determinants, using a control condition, allowing the calculation of an effect size (Hedges' g, random-effects model) were included.

RESULTS

Seven game studies for sexual health promotion were included. These showed positive effects on determinants (g=0.242; 95 percent confidence interval, 0.129, 0.356), albeit of small effect size. The effects on behavior, measured in only two studies, were not significant (g=0.456; 95 percent confidence interval, -0.649, 1.561). Most games did not use many game features that are considered to be immersive or enhancing flow. Instead, there was a strong reliance on pure gamification features, such as rewards and feedback.

CONCLUSIONS

The effectiveness of the next generation of games may be enhanced by building on the behavioral change and educational gaming literatures (e.g., using role-play and simulation game formats, individual tailoring, offering adaptation in the difficulty of the challenge, and amount and timing of the feedback). There is a need for studies with rigorous evaluations of game effectiveness, longer-term follow-up, and using measures of behavior rather than merely their determinants.

Can Exergaming Promote Physical Fitness and Physical Activity?

This systematic review of systematic reviews evaluates the effectiveness of exergaming on physical fitness and physical activity. A systematic literature search was conducted on 10 databases, and 1040 articles were identified. Sixty-eight articles were found potentially relevant and were selected for closer screening. Cross-referencing was conducted to find other potentially relevant articles. The quality of all relevant articles was evaluated using the AMSTAR tool. After all the duplicates were removed and inclusion, exclusion, and quality criteria were implemented, six articles remained for review. The results indicate that exergaming is generally enjoyed and can evoke some benefits for physical fitness and physical activity, but the current evidence does not support the ability of exergaming to increase physical fitness or physical activity levels sufficiently for significant health benefits. This systematic review also revealed several gaps in previous research. Additional high-quality research and systematic reviews concerning exergaming are needed.

Game-based digital interventions for depression therapy: a systematic review and meta-analysis

The aim of this study was to review the existing literature on game-based digital interventions for depression systematically and examine their effectiveness through a meta-analysis of randomized controlled trials (RCTs). Database searching was conducted using specific search terms and inclusion criteria. A standard meta-analysis was also conducted of available RCT studies with a random effects model. The standard mean difference (Cohen's d) was used to calculate the effect size of each study. Nineteen studies were included in the review, and 10 RCTs (eight studies) were included in the meta-analysis. Four types of game interventions-psycho-education and training, virtual reality exposure therapy, exercising, and entertainment-were identified, with various types of support delivered and populations targeted. The meta-analysis revealed a moderate effect size of the game interventions for depression therapy at posttreatment (d=-0.47 [95% CI -0.69 to -0.24]). A subgroup analysis showed that interventions based on psycho-education and training had a smaller effect than those based on the other forms, and that self-help interventions yielded better outcomes than supported interventions. A higher effect was achieved when a waiting list was used as the control. The review and meta-analysis support the effectiveness of game-based digital interventions for depression. More large-scale, high-quality RCT studies with sufficient long-term data for treatment evaluation are needed.

The design and development of a computer game on insulin injection

BACKGROUND

Insulin therapy is of high importance in glycemic control and prevention of complications in type 1 diabetes in children. However, this treatment is unpleasant and stressful for many children, and it is difficult for them to accept. The purpose of the study was to design and develop an educational computer game for diabetic children to familiarize them with insulin injections.

METHODS

After a review of the literature and the collection of basic information, we discussed the purpose of this research with some diabetic children, their parents, and nurses. The findings that we acquired from the discussion were considered in designing and developing the game. Then, following the principles associated with the development of computer games, we developed seven different games that related to insulin injections, and the games were evaluated in a pilot study.

RESULTS

The games developed through the design and programming environment of Adobe Flash Player and stored on a computer disk (CD). The seven games were a pairs game, a puzzle game, a question and answer game, an insulin kit game, a drawing room game, a story game, and an insulin injection-room game). The idea was that diabetic children could become acquainted with insulin injections and the injection toolkit by playing a variety of entertaining and fun games. They also learned about some of the issues associated with insulin and experienced insulin injection in a simulated environment.

CONCLUSIONS

It seems that the use of new technologies, such as computer games, can influence diabetic children's acquaintance with the correct method of insulin injection, psychological readiness to initiate insulin therapy, reduction in stress, anxiety, and fear of insulin injection.

Mental Health on the Go: Effects of a Gamified Attention Bias Modification Mobile Application in Trait Anxious Adults

Interest in the use of mobile technology to deliver mental health services has grown in light of the economic and practical barriers to treatment. Yet, research on alternative delivery strategies that are more affordable, accessible, and engaging is in its infancy. Attention bias modification training (ABMT), has potential to reduce treatment barriers as a mobile intervention for stress and anxiety, but the degree to which ABMT can be embedded in a mobile gaming format and its potential for transfer of benefits is unknown. The present study examined effects of a gamified ABMT mobile application in highly trait anxious participants (N = 78). A single session of the active compared to placebo training reduced subjective anxiety and observed stress reactivity. Critically, the long (45 minutes) but not short (25 minutes) active training condition reduced the core cognitive process implicated in ABMT (threat bias) as measured by an untrained, gold-standard protocol.

Autonomous exercise game use improves metabolic control and quality of life in type 2 diabetes patients - a randomized controlled trial

BACKGROUND

Lifestyle intervention in type 2 diabetes mellitus (T2DM) is effective but needs a special local setting and is costly. Therefore, in a randomized-controlled trial we tested the hypothesis that the autonomous use of the interactive exercise game Wii Fit Plus over a period of 12 weeks improves metabolic control, with HbA1c reduction as the primary outcome, and weight loss, reduction of cardiometabolic risk factors, physical activity and quality of life (secondary outcomes) in T2DM patients.

METHODS

Participants (n = 220) were randomized into an intervention and a control group. The intervention group was provided with a Wii console, a balance board and the exercise game Wii Fit Plus for 12 weeks. The control group remained under routine care and received the items 12 weeks later. At baseline and after 12 weeks (and for the control group additionally after 12 weeks of intervention) the participants' health parameters, medication, physical activity and validated questionnaires for quality of life (PAID, SF12, WHO-5, CES-D) were requested and compared in a complete case analysis using the Mann-Whitney test and the Wilcoxon signed rank test.

RESULTS

80% of participants completed the 12-week study. Patients in the intervention group significantly improved HbA1c (from 7.1 ± 1.3% to 6.8 ± 0.9%; -0.3 ± 1.1%; p = 0.0002) in comparison to the control group (from 6.8 ± 0.9% to 6.7 ± 0.7%; -0.1 ± 0.5%) and also significantly reduced fasting blood glucose (from 135.8 ± 38.9 mg/dl to 126.6 ± 36.6 mg/dl; p = 0.04), weight (from 97.6 ± 19.2 kg to 96.3 ± 18.7 kg; p < 0.001) and body mass index (from 34.1 ± 6.5 kg/m2 to 33.5 ± 6.5 kg/m2; p < 0.001). Daily physical activity increased significantly (p < 0.001). Diabetes-dependent impairment, mental health, subjective wellbeing and quality of life also improved significantly, and the number of patients with depression decreased. Similar improvements were seen in the control group after exercise game intervention.

CONCLUSIONS

In this trial a low-threshold intervention with the interactive exercise game Wii Fit Plus was able to motivate T2DM patients to improve physical activity, glucometabolic control and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01735643.