Going beyond the game: Gamification in rehabilitation

Fariz (left) training stroke survivor Md Zin to use the MRVR equipment, with the help of Md Zin's family’s. — Courtesy Digi

AS games become a part of our everyday life, developers are turning them into tools for teaching and rehabilitation.

Facing the reality of a worldwide pandemic, Moocho Brain co-founder Khail Santia created the game In The Time Of Pandemia to teach players about crisis management.

For Khail, the work was a passion project, as his home in Barangay Guadalupe in Cebu City was among the hardest hit by the coronavirus in the Philippines.

“When the pandemic exploded in my city, I was anxious about contracting the virus, but I was more troubled by my feelings of helplessness, uselessness and guilt,” he said.

Khail’s feelings stemmed from the fact he was groomed by his family to become a doctor but he dropped out of pre-medical studies to pursue making games.

“As many of the health professionals in my family scrambled to fight in the frontlines of this global emergency, I was left wondering about my worth as a game maker in a world deep in crisis.

“Time Of Pandemia was my answer to these inner doubts,” he said.

The game was inspired by a Facebook post by game designer Raph Koster – the brains behind early massively multiplayer online role-playing titles Ultima Online and Star Wars Galaxy – who sketched a framework of what a Covid-19 crisis simulator should look like.

Developing In The Time Of Pandemia was Khail’s attempt to prove that games can go beyond entertainment and highlight issues to a public that may not be attentive to such a discourse.

It was designed to teach how contagion spreads, and the importance of following protocols by showing players the effects of compliance and non-compliance.

The Moocho Brain team realised people were obsessively following Covid-19 news, theorising that they would also be interested in a simulator that could give them a feeling of control in a situation where they are powerless.

However, educational games are generally not well received, he said, as even one of the beta testers said he would rather play games for escapism than be reminded of the pandemic.

Despite Khail’s initial concerns, the game debuted on Aug 1 as one of the highest rated titles on Newgrounds.com.

It was even picked up by the academia and one lecturer in the University of the Philippines Diliman is using the game as a teaching tool in class.

Khail, who was surprised by its success, said it was important for the studio to inject entertaining elements into the game.

“It’s a balance between education and entertainment. Veer too much towards education and the game becomes unplayable, too much towards playability and it becomes just a caricature,” he said.

For instance, to ground the game in reality, the team used contemporary research papers and local news reports on the pandemic, but simplified the concepts and limited the size of the community in the game.

Serious Games Australia & NZ Association (SGANZ) founder Dr Kathleen Yin said attempts to introduce educational and serious elements into games is not new – even board games have included them since the 1970s.

Using a game may sound counter-intuitive as it’s usually seen as a time waster, but health needs are often not the primary motive in people’s lives, she said.

“For many people, the pressures of modern life simply mean they have no time to think about their health.

“A busy worker often thinks he or she doesn’t have the extra hour in a day to exercise despite wanting to do so,” she said.

And the desire will diminish over time to the point that exercising may not seem worthwhile anymore, said Yin, adding that being health conscious requires both physical and mental energy.

“For example, people living with diabetes will say it’s mentally exhausting because they always have to think about blood sugar for every meal.

“They are thinking about blood sugar in the supermarket, at birthday parties, at weddings and any other occasion that involves food.

“This forms a great mental burden for diabetes patients and decreases motivation even for the most health conscious patient,” she said.

A healthy person with no diagnosed health conditions would find such mental stress even more exhausting, as they would see no immediate benefit in it, making them unlikely to remain motivated to improve health.

Games for purposes other than pure entertainment, also known as serious games, offer opportunities for health self-management that is fun and relaxing by minimising the mental burden, she said.

It’s one of the key reasons why it’s good for maintaining motivation for self-management.

Serious games have been growing alongside mainstream titles and are making major progress now due to virtual reality (VR) and mobile apps.

VR rehabilitation

Australia’s Tali Health is a tech company that develops software and games to address neurological conditions in early childhood, including attention difficulties.

Tali chief scientist Azadeh Feizpour said attention deficit disorder (ADD) affects around 136 million children globally and it’s crucial to diagnose it within the first three to five years.

Otherwise the child would be left behind in class and would have difficulty catching up without intervention.

Medication addresses symptoms but not the core issues, she claimed, adding that brain training games are a good non-invasive solution to consider.

However, there is a need for moderation, said Azadeh, adding that the company’s games limit play to just 20 minutes a day.

Daehan Rehabilitation Hospital Putrajaya president and consultant rehabilitation physician Dr Fazah Akhtar Hanapiah said it too sets limits for rehabilitation programmes which uses games.

“Studies have shown that a minimum of three hours per day of intensive rehabilitation for at least five days a week will achieve the optimal outcome.

“In the three hours, it is acceptable to have medical rehabilitation virtual reality (MRVR) for 30 to 45 minutes per day, depending on a patient’s ability to cope with the activity and training,” said Dr Fazah.

A rehabilitation doctor for the last 16 years, she has worked on MRVR as an associate professor at Universiti Teknologi Mara (UiTM) and in collaboration with her brother Fariz Hanapiah, creative director at design firm Experience Design Team (EDT).

Her research aims to use MRVR to aid patients who suffer from Hemineglect, a medical condition that causes the brain to ignore a part of the body.

“Learning is a big aspect of rehabilitation and you learn better in a 3D environment.

“During the pandemic, students are studying online but it’s not the same as being in a classroom,” she said, as there is a lack of interaction and immersion.

There are four 3D MRVR modules – Multi-sensory Room, Back To Kampung, Deep Sea Diving and Dual Cognitive Task.

Based on the concepts of conventional rehabilitation, each module uses an enriched environment and imagery to engage patients in goal oriented activities.

For instance, a patient who trains in front of a mirror to move a partially paralysed limb has to imagine what the movement is like but a MRVR can simulate it for them.

She added it was also beneficial to have patients in a controlled environment where doctors could add virtual challenges – like a drain to step over or environmental noise like passing cars – which increases the intensity of the session without actually putting them at risk.

The other main benefit is cost savings, which will make rehabilitation more accessible to experts and patients, said Dr Fazah, who estimated that building a fixed multi-sensory environment in a hospital would cost upwards of RM150,000.

In comparison, the setup cost of MRVR is fairly minimal, with the patient only having to buy compatible hardware and modules prescribed by a physician.

She also recommended therapists to get a monitor – this would allow them to see what the patient is undergoing and guide the person in accomplishing tasks.

EDT’s Fariz said the price of VR headsets have dropped steadily over the last few years, now costing about RM2,000 to RM3,000.

The improvement in hardware – some headsets, for instance, are wireless and are not tethered – has also helped make the experience seamless.

They also offer higher frame rates, he said, which is essential as games under 60fps (frames per second) tended to make patients dizzy.

MRVR goes hand-in-hand with telemedicine, as doctors could be based in, say, Klang Valley and treat a patient with a VR headset in Kedah.

Dr Fazah said the stereotype that games are meant for the youth is not true, as even her older patients find them engaging.

“Our previous experience of using off-the-shelf games in rehabilitation have shown that the games were not age related.

“Physical and cognitive functions are the main determining factors when creating and designing the games and modules,” she said.

The patients find it so enjoyable that they relate their experiences to their family members, making even them want to try out MRVR games, she added.

The popularity of serious games depended on the country, said SGANZ’s Yin.

North Europe, especially the Netherlands, Belgium, Denmark and Finland are countries where serious games for health and mental well-being have gone mainstream.

The United States, Canada and continental Europe follow closely behind, said Yin, adding that serious games have also been approved by the US Food and Drug Administration for the treatment of ADD.

Brazil and South America have also been quick to embrace the medium, but for the rest of the world, it is still very much a niche industry.

The main drivers are technological capacity, as some developing countries may not be able to afford the hardware required, and cultural attitudes.

Asia Pacific countries such as Japan, South Korea and Australia have successfully commercialised gaming but predominantly consider it as entertainment and a “waste of time” but this is expected to change, said Yin.