Ready Patient One: Video Games as Therapy

John Watson

Disclosures

July 10, 2018

The Dawn of Digital Medicine

When the medical impact of video games tends to be discussed, it is usually in terms that elicit concerned handwringing, much of it justified. Researchers warn about the health costs of idle hours spent on a couch with controllers in hand, of gamers' imperiled gray matter, and of simulated violence creeping into the real world. Yet these concerns have done little to curtail the cultural impact of video games, whose annual revenue is thought to now be in the range of $100 billion.[1]

It's this undeniable popularity that has garnered the interest of another set of researchers—ones who are seeking not to discourage use of video games, but rather to harness their immersive power in the service of improving patient health. Through a unique combination of medical, technological, and artistic endeavors, these researchers are discovering new avenues for using video games to treat a variety of neurologic and psychiatric conditions.

Can Rehabilitation Be Entertaining?

Leading stroke expert John W. Krakauer, MD, professor of neurology, neuroscience, and physical medicine and rehabilitation at Johns Hopkins University School of Medicine in Baltimore, Maryland, has spent a good part of his career investigating the means by which patients can reclaim some semblance of function after devastating neurologic injuries.

"We've known for a long time in the animal world that enrichment, engagement, motivation, and immersion have positive effects (on motor performance and brain repair)," he said. "My intuition was that gaming could be the human version of that."

In his role as director of Hopkins' Brain, Learning, Animation, and Movement lab (BLAM), Krakauer and his team created an idiosyncratic means to accomplish that goal: a simulated dolphin nicknamed Bandit.

Patients recovering from stroke who visit BLAM are seated with their arm in a robotic sling facing a screen where Bandit awaits their commands. With their arm movements sending the digital dolphin through a variety of oceanic activities, patients are also performing repetitive, therapeutic motions that wouldn't look out of place in a traditional rehabilitation protocol.

According to Krakauer, Bandit may simply seem like an endearing cartoon, but it's also a valuable conduit allowing patients to escape the frustrating strictures of rehabilitation.

"Basically, what we're saying is, 'Wouldn't it be therapeutic if you could be a character in a Pixar movie," he explained. "We want people to exist in a space that takes them away from an awareness of their disability and allows them to explore movement in a childlike way. Otherwise, they might not try because it's yoked to what they think is plausible in the joint space of a regular limb."

They have a childlike delight and tears of gratitude that are kind of striking. Being in a beautiful blue place with a beautiful animal, it's like being transported away from the mausoleum-like hell of your medical environment.

Krakauer has heard the criticisms that video game therapy is somehow frivolous, less medicine than entertainment, which he believes reflects an often unspoken taboo that accompanies ill health.

"I always say in my talks, if you're going to be ill, you should enjoy it. Somehow, in our deep puritanical roots, we don't want people who are ill to be happy."

It is not a reservation shared by the patients who have visited BLAM.

"We have to pry people out of the chair afterward. They have a childlike delight and tears of gratitude that's kind of striking. Being in a beautiful blue place with a beautiful animal, it's like being transported away from the mausoleum-like hell of your medical environment."

Krakauer said they are still some way out from incorporating this into routine care. He and his fellow researchers have just completed a small trial and are testing their interventions for a variety of neurologic conditions.

"The dream would be to be able to have a patient and even their loved ones partake in their own therapy."

Akili's Digital Prescriptions

"We are definitely not your typical biotech," said Eddie Martucci, PhD, founder and CEO of Akili Interactive, regarded as the leading light in the burgeoning field of digital medicine. "You won't find scientists in protective gear working in chemistry hoods. Instead, you'll find researchers working alongside artists and video game designers, coding and developing adaptive algorithms delivered through immersive video games."

This might evoke the image of a creatively freewheeling Silicon Valley start-up, a designation that fits the Boston- and San Francisco-based company, but their research model is built on rigid scientific foundations. Like many others, Martucci had noted the pioneering work of neuroscientist Adam Gazzaley, MD, PhD. Gazzaley, along with his colleagues, had demonstrated that a video game-like treatment called Neuroracer could limit cognitive interference, thereby extending robust and sustained benefits in the areas of attention, impulsivity, and multitasking.[2,3]

Gazzaley now serves as Akili's chief science advisor, and his and other researchers' contributions have helped the company expand their pipeline of digital interventions for indications that include autism spectrum disorder, multiple sclerosis, and major depressive disorder.

To win over a perhaps skeptical medical community, however, Akili knew they had to follow a traditional pharma-like model and conduct rigorous clinical trials. A proof-of-concept study[4] successfully showed the promise of Akili's Project: EVO, a digital intervention built from the prototype of Gazzaley's Neuroracer. Project: EVO looks like a modern video game, but is designed to address underlying areas of neurocognitive functioning impacted in attention-deficit/hyperactivity disorder (ADHD).

As Martucci explained, the video game is merely the interface through which their technologies work—the pill that contains the medicine. Its efficacy resides elsewhere.

"Akili's technology is a closed-loop system in which specific adaptive algorithms deliver the presentation of stimuli that engage targeted specific neural systems," he said. "In the case of our ADHD and depression product, it's the prefrontal cortex, the area of the brain known to play a key role in cognitive function. With the right stimuli, Akili's technology can produce physiologic changes in the brain, resulting in the improvement of symptoms."

In late 2017, the company announced successful results from a multicenter randomized controlled trial in over 300 participants with pediatric ADHD.[5] Project: EVO was significantly superior in improving attentional functioning, compared with no improvement in the active control group (P = .006). After full data analysis, the company plans to submit to the US Food and Drug Administration for approval in this indication, which, if successful, would make it the first prescription digital medicine.

An Accidental Therapy

The work of Doris C. Rusch, PhD, the founder of Deep Games Laboratory at DePaul University in Chicago, represents another means of potentially reaching patients. It was one she came upon nontraditionally, through her deep-seated interest in narrative archetypes and how they impact human behavior.

Hailing from a humanities background, with no background in gaming, Rusch used her relative naivety as an asset. Not knowing what game had to be, she could instead focus on what they "could be."

While a postdoc at the Massachusetts Institute of Technology's GAMBIT Game Lab, she created Akrasia, which offered a metaphorical take on addiction. After presenting the work at Games4Health, a global student game design competition, she drew the attention of a child psychiatrist, with whom she then partnered on Elude, a game about depression.

"We didn't really set out to make a mental health game," she explained. "We set out to make a game that used metaphors to model a complex, abstract concept."

She wasn't interested in proving her games' medical utility, and still finds the demand for measurable outcomes creatively limiting. But as more players and clinicians encountered her games, the more the feedback she received from them began to invoke their therapeutic value. Rusch stated:

We play-tested Elude particularly with friends and relatives of people with depression and got some really good feedback. It then got picked up by a bunch of self-help depression blogs and made the rounds through this community. I'm still getting emails from all over the world from people with depression who said that this game helped them sit down with their friends or family members, have them play it, and then have a dialogue around "what it feels like."

One of the most recent offerings from Deep Games, for which Rusch serves as creative director, is Soteria—Dreams as Currency, which is designed to help patients overcome anxiety disorders. "It communicates one, essential message: The key to overcoming anxiety lies in stopping to reject and avoid fear and moving toward it instead," she said. "The game's structure and mechanics mirror the therapeutic process: from avoiding discomfort, to getting stuck, to enduring, provoking, and overcoming fear."

However, Rusch is quick to point out that "these games are not meant to be a cure or therapeutic in and of themselves." Instead, she sees their value as opening a dialogue with patients.

"Therapists need to know what to expect from these games. They can be really great ice-breakers and reflective prompts, particularly for younger patients for whom video games are their home turf. But the game is not an equivalent to medication or a concrete cure."

The Gamer Will See You Now

If the last significant time you spent with a video game involved one of the Mario Brothers saving a princess in an unpersuasively animated netherworld, you could be forgiven for finding these digital interventions' potential value overstated. However, Rusch cautions that this simply isn't the case for a younger generation for whom these would be hardly recognizable as video games.

"If we damn their medium of choice, we lose connection with them," she said. "For clinicians, that's a real hindrance, assuming they also want to connect to young people, who often have incredibly powerful relationships with games."

As researchers build a stronger case for the efficacy of these digital interventions, the challenge for clinicians will be incorporating these technologies into patient care.

"If the companies making games and virtual reality goggles are just plunking their technology into hospital environment where you don't have people who speak that language, then it's going to be the blind leading the blind," said Krakauer, who envisions "engineers, gamers, and nerds" someday becoming an integral member of the care team.

"One day, as Adam Gazzaley has said, doctors will prescribe games just like they prescribe drugs," Krakauer said. "But now it's early. We just don't have definitive evidence yet for how these things will be incorporated into medical practice, but they will be. We need to accept that but not overhype it and love it just because it's tech. It needs to be incorporated in an intelligent way on the basis of biological and medical principles and be considered a unique solution because of its properties. Then, I think we'll have real advances."

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