Date posted: May 19, 2006
Updated: Oct 24, 2006
By Arun Mathews, MD
Published: May 16th, 2005
[Pictures missing]
The concept of using support groups to aid in the management of individuals with rare disorders is not new. The advent of telecommunication and the Internet has allowed us to overcome the boundaries of geography (assuming that certain technology infrastructure requirements are met) and develop networks that aid patient communication and support mechanisms.
The development of these peer-support networks remains an elegant example of how communication has evolved aided by technology. This can be further classified into: live and direct, live and indirect, and intermittent and indirect. See Figure 1 for examples.
Figure 1: Communication Divided by Location and Time.
While communication has been developing steadily over the past years, a similar revolution was taking place in the relatively young field of computer-based interactive software. Ralph Baer, working for a small electronics company named Loral, embarked upon an engineer’s creative crusade to increase the functionality of the household television set[1]. Seeking interactivity, he designed a device that would simulate the game of table tennis on the television. The machine was called the Odyssey, and it debuted in 1970, kicking off the video game revolution.
The interactive digital entertainment has burgeoned into a multi-billion dollar industry. “Video games have rocketed past movies in mass appeal, driven by powerful technologies that have transformed games into fully interactive worlds. Players now get video games that are active experiences with movie-quality visuals and studio-caliber soundtracks.”[1] Last year, fourteen billion dollars were spent on watching films worldwide, but Americans alone spent eight billion dollars on games for their homes and a further seven billion at the arcades. Interactive digital entertainment is now a prominent part of mainstream American, European, and Asian cultures.
The use of interactive digital entertainment, or video games, in hospital settings is not new. Organizations such as the StarLight Foundation, mentioned above, have pioneered the use of computer entertainment and video games in the inpatient setting, and have further demonstrated the importance of play within pediatric healthcare. The work of Hoffman et al. details the use of virtual environments in reducing pain scores when such environments are employed as an adjunct to pharmacotherapy for patients with burns and dental pain [18,19,20]. What remains to be evaluated are a) groups of children playing a game together in a community environment, and b) the effect of such experiences on quality of life measures.
The two revolutions in communications and computer games occurred in tandem. The continuing advances in both areas represent exciting areas of technology evolution, with potential endpoints mapped out in the following figure. This paper will however focus on the niche area where these two concepts unite – the Graphical Multi-User Environment, or GMUE.
From the diagram, one can appreciate the emergence of the communal user environment. This is essentially a gaming experience that multiple players can play simultaneously from different locations. The first iterations of this were termed multi-user domains, or MUD’s. These games were bound by a set of rules programmed by the game designers, occasionally referred to as wizards. These games were set in which players create personas of characters through textual interaction. All interactions were described by typing out what the characters were doing.
Naturally, the next step was creating graphical interpretations of the worlds, with a game called Meridian 59 being the first to do so successfully. Ultima Online popularized this, being the first to secure over one hundred thousand subscribers. As these games became more complex, it became apparent that impressive precedents were being established. No longer just the realm of children and the technology savvy, the genre of the massively multiplayer environments began attracting people not typically associated with video game culture. Games such as The Sims Online, with its non-linear gameplay and complex economies, have attracted players from all walks of life.
Online communities represent a novel solution to allow patients to communicate with friends and family through a network-enabled computer. The majority of network interactions specifically designed for the hospital environment are text-based, utilizing chat and forum clients such as StarBright Web and the Hopkins Cystic Fibrosis Teens Initiative. There is a growing body of evidence suggesting that these communities, despite being limited to text interfaces, can improve pain scores and may improve depressive symptoms, reduce anxiety, and raise self-esteem. The popularity of these networks (StarBright Web alone has over 30,000 registered users) is proof positive of the amelioration that they provide.
Studies performed to test more graphical interfaces show a similar potential for gaming networks. The pioneering work of Bers et al. examined the use of a three-dimensional graphical virtual city, called Zora, which provided the setting for a pilot group of hemodialysis patients to meet and interact. The test networks for this study were small, allowing only three children to occupy a given space at one time. (The researchers conceded that the network was limited in terms of the actual community size.) It allowed these few users to occupy the same network space and to interact via their avatars. The study was primarily a safety and feasibility study and demonstrated high degrees of both, based on patient and healthcare staff feedback.
The experiences of hemodialysis patients within the Zora environment were strikingly different from those of healthy children. First, the hemodialysis patients tended to use more fantasy and imagination when creating their environments. (Zora allowed users to create and decorate their own virtual rooms.) Additionally, when designing their avatars, the dialysis patients preferred using cartoon characters rather than their own pictures, which the majority of healthy children tended to use. Secondly, the dialysis patients in general did not utilize many of the opportunities created to discuss their ailment. They tended to show little or no interest in discussing health issues with other patients online or with healthcare providers who logged on to participate. Instead, they described enjoying how Zora could be used as a distraction from the boredom of treatment. These studies demonstrate that the strength of a virtual world lies in the avenues it provides for an escape from reality. Or rather, it provides an entrance into a different kind of reality in which imagination takes precedence over suffering.
These are exciting times. In essence, a number of critical technologies have matured, establishing the Graphical Multi-User Environment. While it is easy appreciate the economic implications of computer entertainment, the scientific evidence for understanding online its healthcare implications remains limited. Bers work was admittedly pioneering, but a pilot study limited to evaluating safety and efficacy. It remains this author’s view that this represents a new and exciting body of knowledge that should be further explored for healthcare implications.
References:
1) Johnson KB, Ravert RD, Everton A.Hopkins Teen Central: Assessment of an internet-based support system for children with cystic fibrosis. Pediatrics. 2001 Feb;107(2):E24.
2) King B. “They Weren’t Meant to Be Games.” Wired News. http://www.wired.com/news/games/0,2101,54223,00.html [accessed Nov. 17 th, 2002]
3) Kovacs M, Lohr WD. Research on psychotherapy with children and adolescents: an overview of evolving trends and current issues. J Abnorm Child Psychol. 1995 Feb;23(1):11-30. Review.
4) Labellarte MJ, Ginsburg GS, Walkup JT, Riddle MA. The treatment of anxiety disorders in children and adolescents. Biol Psychiatry. 1999 Dec 1;46(11):1567-78. Review.
5) Popper CW. Psychopharmacologic treatment of anxiety disorders in adolescents and children. J Clin Psychiatry. 1993 May;54 Suppl:52-63. Review.
6) Varley CK, Smith CJ. Anxiety disorders in the child and teen. Pediatr Clin North Am. 2003 Oct;50(5):1107-38.
7) Velosa JF, Riddle MA. Pharmacologic treatment of anxiety disorders in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2000 Jan;9(1):119-33. Review.
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