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This excerpt from Serious Games: Games That Educate, Train, and Inform takes a look at how to utilize the educational benefits of video games, and how a number of serious games now exist that target healthcare and well-being, like the “exergaming” game, Yourself!Fitness, and the biofeedback game, The Wild Divine Project, which combines breathing techniques and meditation with biofeedback.

Sande Chen, Blogger

October 31, 2005

17 Min Read

The following is an excerpt from Serious Games: Games That Educate, Train, and Inform (ISBN 1592006221) published by Thomson Course Technology.


Healthcare professionals are looking to utilize the educational benefits of video games. A number of serious games now exist that target healthcare and well-being, like the “exergaming” game, Yourself!Fitness, and the biofeedback game, The Wild Divine Project, which combines breathing techniques and meditation with biofeedback. These new genres are recent developments.

More importantly, there has been an increase in the amount of research done in this area. In some of the research, games are used to probe the nature of the patient's condition. In other studies, the games are used therapeutically. Studies based on outcome research have always found positive implications of using games.

Dr. Mark Wiederhold, co-founder of the Virtual Reality Medical Center , talked about the many uses of video games (which he equated with “virtual reality”) in modern medicine during his presentation, “The Potential of Games in Healthcare,” at the 2004 Serious Games Summit in Washington , D.C. Some examples he gave were

  • Using video games to distract patients during painful medical procedures.

  • Using simulations to improve rehabilitation.

  • Using virtual reality (VR) environments to improve motor skills.

  • Using video games for therapeutic interventions.

Dr. Wiederhold's presentation focused on the use of inexpensive, off-the-shelf software and equipment. Especially inexpensive. “If it's not inexpensive, it won't be used,” he stated. Some games are less suitable to healthcare purposes, but others have been surprisingly effective. He talked about using first-person shooter (FPS) games to treat fear spiders, since shooting seems effective in that case, but he added that he would like to move past that to gameplay mechanics that offered more depth.

Japanese game companies have paved the way for wider mainstream acceptance of serious games with healthcare benefits. Namco has created “rehabilitainment” products, also called “games for elders,” and in 1999, entered the nursing home business. Konami, which acquired a fitness club franchise in 2001, expanded its brand with Konami Sports Club and Self Fitness Club and has been instrumental in merging fitness with entertainment. Similarly, Taito is moving into “amusement training.” Unfortunately, in the U.S., healthcare games have largely been developed by independents, nonprofits, healthcare professionals, or concerned parents.

Hospitals and Medicine

Hospitals and larger clinics, often partnering with non-profit organizations and research facilities, have begun to experiment with alternatives to traditional treatments and therapies. Among their experiments have been a growing number that attempt to integrate video games into the treatment and recovery process. Video games have been used to distract patients during painful medical procedures as well as to improve motor skills in physical therapy and to speed recovery for certain operations and conditions.

On the other side of the treatment equation, doctors and other healthcare professionals are beginning to use video games as training tools. The advantages of being able to practice delicate surgery or dangerous procedures without having to actually perform the surgery or procedure on a living person are obvious.

Distraction Therapy

How much pain a person experiences often depends on how much conscious attention the person gives to the pain signals. Video games and virtual reality (VR), with their ability to immerse the individual in a computer-generated environment, have been shown to be effective in focusing a patient's attention away from their medical treatment and the pain they are experiencing. Immersed in the world of the game, they are not as consciously aware of what is going on around them, and they miss a proportion of the pain signals.

The Believe In Tomorrow Foundation, an organization founded in 1982 with the goal of improving the quality of life for critically ill children, has long been an advocate of the use of virtual reality or computer games for pain management. The foundation's Management and Distraction Technology program uses distraction as a pain management technique and has been employed in hospitals nationwide for almost two decades. Participating doctors and hospitals give children kaleidoscopes, squeeze balls, hand-held video games, and so on, before and after treatment. This teaches children an important key to enduring pain: Don't focus on the painful stimuli. The squeeze ball or the video game gives them something else to focus on and think about. Video games, particularly those with virtual reality (VR) immersion via headsets or similar technology, are a recent extension of that program.

The distraction is important before the treatment or procedure as well. Everyone is anxious before surgery and most other medical procedures. This is called anticipatory anxiety. Children seem to feel anticipatory anxiety more deeply than adults, to the extent that sometimes children need to be held down even for a simple injection with a hypodermic needle. The same distraction techniques can be used to alleviate anticipatory anxiety.

The Believe In Tomorrow Foundation found that developing games on its own, or contracting with experienced game developers, was cost-prohibitive. The immense budgets of modern games were beyond the foundation's nonprofit, donation-funded means. Thus the foundation sought partnerships, such as the one with BreakAway Games. BreakAway Games, intent on showcasing the effectiveness of its serious games products, donated its deep sea diving simulator for use by the foundation.

In the summer of 2005, the Believe In Tomorrow Foundation will be conducting a new study in the effectiveness of VR techniques. Specifically, the study will compare a patient's pain tolerance when playing a video game to that when interacting in a VR environment. The goal of the study is to show that immersive VR is even more effective than playing normal video games, either handheld or on a console with a TV.


A key element in the treatment of chronic diseases, such as asthma and diabetes, is self-management. It is imperative that the patients adjust their lifestyle and habits to deal with the disease. The consequences of ignoring chronic conditions could be increased health problems or even death.

In 2000, Patient Education & Counseling reported on Watch, Discover, Think, and Act, a computer game designed to enhance self-management skills and improve asthma outcomes in inner-city children with asthma. Children ages six to seventeen years old from four pediatric practices were selected and randomly assigned to either use the computer game or the usual asthma education and treatment. The game's protagonist's asthma condition was tailored to match those of the child's, and, at the child's choice, the main character in the game could also be made to match their own gender and ethnicity. The children played the computer game as part of their regular asthma visits. The study found that the treatment associated with the computer game resulted in “fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior.”

In the same vein, Packie & Marlon, by ClickHealth, was designed to help children and teenagers with diabetes improve their diabetes self-management. The game, originally released for the Nintendo SNES and Windows 95, saw use at home, in hospitals, in clinic waiting rooms, and in diabetes summer camps. In a clinical study performed with the National Institutes of Health, ClickHealth found that children who played Packie & Marlon showed gains in self-efficacy, communication with parents, and diabetes self-care. They also had fewer urgent doctor visits for diabetes-related problems. More recently, in early 2005, Guidance Interactive Healthcare released Glucoboy, a glucose meter that can be connected to a Nintendo GameBoy. As a reward for maintaining good blood sugar control, Glucoboy downloads video game programs into the GameBoy.

Health Education and Physical Fitness

Other games try to help healthy players stay healthy. These games teach the players about topics like nutrition, physical fitness, and sexually transmitted diseases. Beyond just providing information, the games also try to promote changes in the player's behavior and future choices: to eat better, to exercise more, and to practice safe sex.

Using a video game, Squire's Quest, and related take-home assignments, researchers at Baylor College of Medicine reported improvements in the diets of Houston-area fourth-graders. Squire's Quest is a medieval-themed game where the player is a squire seeking to become a full knight. The player's knowledge of the nutritional content of different foods is tested as he designs healthy meals for King Cornwell and the royal family in a virtual kitchen and battles a variety of vegetable-destroying enemies. After five weeks of playing the game about 40 minutes per week during class, the nearly 800 students who participated in the program increased their fruit and vegetable intake by one serving a day on average.

Video games can also promote other healthy habits. Education has “edutainment,” and now physical fitness has “exergaming” or “exertainment.” Exergaming, also called “fitness gaming,” is a new marketing term coined to describe the combination of exercise equipment or aerobic workout regimens with video games. These products seek to make physical exercise more attractive to people by adding the mentally engaging elements of video games to the activity.

Figure 1: Dance Dance Revolution uses a dance pad as its input device.

Konami's Dance Dance Revolution (DDR), originally released in Japan in 1991 as an arcade game, is an example of a video game that mixes physical activity with game play mechanics. DDR uses the special input controller (see Figure 1): a dance pad, with four panels, up, down, left, and right, arranged around where the player stands. The player presses the panels with his or her feet in response to arrows that flash on the game's screen. The arrows are synchronized to the rhythm or beat of a song played by the game, and success depends on the player's ability to time his or her steps accordingly. Since its days in the arcade, DDR has been released as specialized cabinets that players can buy to play at home and for game consoles like the Sony PlayStation.

RedOctane, makers of Ignition Pad, the top-selling dance pad in 2004, created the Get Up & Move PR campaign in January 2004. According to the Get Up & Move Web site, Tanya Jessen, the campaign spokesperson, lost 95 pounds (43 kilograms) by repeatedly playing the Dance Dance Revolution series of games. Dean Ku, speaking at the Serious Games Summit at the 2005 Game Developer's conference, said that the campaign grew out of RedOctane's decision to stay close to the dance game community. After receiving a lot of e-mails from players who were losing weight, the company decided to see if it could help promote this type of wellness program. Tanya Jessen, for example, didn't start dancing to lose weight. It happened naturally as she began playing the game and noticed a slimmer figure. In addition to helping players lose weight, the Get Up & Move campaign had a huge sales impact for DDR and its sequel, DDR2.

DDR has been the subject of a number of studies in recent years. In a 2005 research study, George Graham and Stephen Yang of Penn State University measured the heart rates of children who played DDR for 45 minutes. The researchers found that the children had an average heart rate of 144 beats per minute when playing, compared to the average resting heart rate of 60 to 70 beats per minute. The increased heart rate increases the metabolism and causes the body to burn more calories.

In another study currently underway, researchers at West Virginia University also aim to study children playing DDR. The six-month study, coordinated with the state's Public Employees Insurance Agency, examines the possibility of cutting claim costs from obesity. In the same vein, Bryan Haddock, an Associate Professor of Kinesiology at Cal State San Bernardino, is planning a summer 2005 study with Riverside-based game company, QMotions, on how exergaming products can help reduce childhood obesity.

Figure 2: The EyeToy allows players to interact with specially designed games by moving their bodies, including their head, arms, hands, and legs.

In 2003, Sony released the EyeToy (see Figure 2), a digital camera device for the PlayStation 2 that allows players to interact with specially designed games by moving their bodies, including their head, arms, hands, and legs. Lisa Liddane, in her February 26, 2005, article for the Orange County Register, “Acting Out: Kids Get into the Game,” described a nine year old boy playing EyeToy: Play, a collection of mini-games: “As the animated fighters jump from balconies on the screen, Mitchell jabs swiftly into the air to knock them down. He executes a sharp kick with his left leg and bounces an opponent out of the screen. Every now and then, he shuffles left and right like a boxer. For bonus points, he breaks wooden boards left and right.”

Following the examples of DDR and the EyeToy, there is an emerging market for new controllers and interfaces, and accompanying games, that allow players to get involved with video games in new, highly active ways. The Cateye GameBike and the Reebok CyberRider hook up to a game console, such as the PlayStation 2 or XBox, so that the player can pedal a stationary bike and play games that involve driving or riding vehicles. Priced at $1200 (as of this writing), these peripherals show the revenue potential for exergaming.

At the 2005 Electronic Entertainment Expo (E3), QMotions showed off its baseball controller for console and PC video games, adding to its line of full-motion video game controllers. Many other companies were also showcasing their new exercise-oriented gaming products. Such controllers make the experience of playing the video game versions of sports like baseball and golf much more like the original sport. At the least, with these controllers the player's interaction with the game exceeds the standard “activity” of clicking buttons and pushing a mouse around.

Mark Wolf, in his book The Medium of the Video Game, listed other games that involved physical activity that have been released over the years. Many of these were full-sized arcade games, and players would sit inside or ride on top of the consoles. The player's physical movements control the game to simulate everything from driving to flying, pedaling a bicycle (Prop Cycle, 1993), or holding ski pole handles while standing on moveable skis (Alpine Racer, 1995). Other examples include Sega's Top Skater (1997), which has a skateboard, and Namco's Final Furlong (1997), a game about racehorse riding.

Another use of serious games is in sex education and/or the prevention of sexually transmitted diseases, such as herpes and HIV/AIDS. The very serious nature of the subject matter, combined with the political and religious controversies, could be enough to make designers look for less-troublesome arenas, but these types of games are just another type of self-management. An example of a game that does tackle these issues is Will Interactive's HIV Interactive Nights Out. Designed to promote HIV prevention, the game was given to over 200 soldiers ages 19 to 29 years old in a study by the U.S. Army. The study found that more than half of the soldiers voluntarily played the game more than once and that the program reinforced the participants' existing inclinations to protect themselves against HIV infection.

Exergaming Case Study—responDESIGN's Yourself!Fitness

In late 2004 and early 2005, responDESIGN, a Portland, Oregon, company devoted to creating “games that are good for you,” released Yourself!Fitness for the XBox, PC, and PlayStation 2. Designed to surpass fitness videos and self-help books, Yourself!Fitness bills itself as “the first game title created solely to improve the health and fitness of the user.” With information provided by the player, the game creates a personalized fitness program, and Maya, a virtual personal trainer, coaches the player through the training sessions.

Yourself!Fitness incorporates yoga, Pilates, cardio fitness, strength training, flexibility exercises, and targeted weight loss routines. Yourself!Fitness will also integrate any training equipment the player has. Unlike home fitness DVDs, which only provide a list of options that users can choose from and a static set of exercises and activities, company co-founder Phineas Barnes said the game provides all the tools to create a “personal, interactive, goal oriented fitness program at home.” The personalization is derived from information inputted by the user about his or her personal fitness level at the start of Yourself!Fitness. Yourself!Fitness then creates a customized fitness program based on user fitness and preferences. Add to that full user control over the camera angles, the playback speed of the exercise demonstration, different environments, and adjustable order of exercises each day, and the product offers a lot of advantages over the traditional home fitness DVD.

Barnes does not consider Yourself!Fitness a game. Though Yourself!Fitness employs game elements like a system of rewards, including new environments, new music, and new levels, its primary aim is to be a personal fitness program. Even so, it was important to responDESIGN to make the product fun and engaging.

Yourself!Fitness required a development budget of less than $500,000, which, Barnes pointed out, is a fraction of the budgets required for most console titles, and it was created with 100 percent game technology. The 21 members of the project team, which included a number of fitness experts, put special effort into guaranteeing correct joint movement in Maya, the virtual personal trainer. As seen in Figure 3, this ensures that when Maya demonstrates a particular exercise or technique, the player is seeing it done exactly right.

Correct joint movement in Maya, the virtual personal trainer in Yourself!Fitness, ensures that when she demonstrates a particular exercise or technique, the player is seeing it done exactly right.

The home fitness market sells 30 to 40 million fitness videos and DVDs each year, with 90 percent of those purchases being made by women. That is the market segment reponDESIGN wanted to tap into with Yourself!Fitness, and so, the game was designed to appeal to women. However, the company has heard from men who have started using Yourself!Fitness as well. Getting men to participate, Barnes noted, is considered a significant achievement in the home fitness market.

Unlike video game sales, home fitness sales do not peak at Christmas and are at the highest just after the beginning of the year, in January and February. responDESIGN has targeted this period for its marketing. However, with its game-like properties, Yourself!Fitness can capitalize on both the shortage of new video games on store shelves just before Christmas and the general home fitness craze that follows the holiday season.

This combination of elements from two markets, though, has also forced responDESIGN to explore alternatives to the normal video game retail outlets. Further, because the product resembles a home fitness DVD, but isn't a DVD, and requires either a computer or game console, the company has also run into issues selling to some home fitness retail outlets. Despite those issues, responDESIGN has been able to reach mothers in video game stores, professional women at stores like Best Buy, and a wide range of female buyers at Nordstrom. It continues to look for new marketing venues and would like to be able to reach even into the hardcore game player arena.

Barnes said that responDESIGN has big plans for the future. Eventually, the company expects Yourself!Fitness to be a full “health lifestyle monitoring tool.” responDESIGN wants users to be able to track their progress through the use of networked equipment and next-generation game consoles. This tracking could even extend throughout the day, covering diet and other lifestyle aspects. “The more information you plug in,” Barnes added, “the more access to health and fitness resources you'll have through the program.”


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About the Author(s)

Sande Chen


A co-founder of Writers Cabal, Sande Chen works as a game writer and designer. In 2008, she was nominated for a Writers Guild of America Award in Outstanding Achievement in Videogame Writing. While still at film school at USC, she was nominated for a Grammy in music video direction. She can be reached at: [email protected]

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