(1)
Laboratory of Anatomy, Biomechanics and Organogenesis, Université Libre de Bruxelles, Brussels, Belgium
(2)
Department of Electronic and Informatics – ETRO, Vrije Universiteit Brussel, Brussels, Belgium imec, Leuven, Belgium
The best way to predict your future is to create it. – Abraham Lincoln
7.1 Problems to Solve
Although the fact that serious games have been tested since several years in clinics, there are still a lot of problems to be solved before using them in daily clinics. Some of these problems concern the technology (precision, price, usability) but the biggest problem seems to be the human mind: how to convince people that playing games is not just fun but can really be helpful in rehabilitation? We saw in the previous chapter that well-conducted clinical studies, large-scale Randomized Clinical Trials, are needed because as presented in the Chap. 4 such kind of studies are still missing. Nonetheless in order to conduct such kind of a study, the clinicians must be convinced of the benefits, safety, and the scientific basis of this new approach.
7.1.1 Technological Issues
A lot of new (gaming) devices and technologies have been presented throughout this book as well as plenty of clinical trials and studies on the use of new kind of technology. Nevertheless, the current technology is, currently, not fully adapted to the clinics and further development and improvement are needed.
7.1.1.1 Accuracy and Precision
These two terms are often misused and confounded although they are used for two totally different things. The accuracy of a measurement system is the degree of closeness of measurements of a quantity to that quantity’s true value. The precision of a measurement system, related to reproducibility and repeatability, is the degree to which repeated measurements under unchanged conditions show the same results. Several studies have been performed in order to validate the use of gaming devices to perform some simple biomechanical and functional assessment (see Chap. 1). Paradoxically, the biomechanics community appears to be skeptical about the use of this technology with patients during functional analysis, and often does not consider it as a potential complementary tool to standard equipment (Bonnechère et al. 2016).
It appears that scientists are mainly concerned with the accuracy of instruments in order to accept them as clinical tools.
Yet, most of the daily clinical activities rely more on measurement precision rather than on instrument accuracy to perform patient follow-up. The term precision includes reproducibility (i.e., interobserver measurement) and repeatability (i.e., intraobserver measurement).
Previously published studies on the gaming hardware validation have shown that WBB and Kinect hardware accuracy is lower than gold standards (e.g., Clark et al. 2010, Huurnink et al. 2013 for the WBB; Bonnechère et al. 2013, Cippitelli et al. 2015 for the Kinect); for the WBB, these differences were mainly due to the lack of rigorous calibration of the gaming hardware.
However, gaming hardware showed a similar precision to gold standards (Clark et al. 2010 for the WBB; Bonnechère et al. 2013, 2014a, 2014b for the Kinect). This precision seems to indicate that gaming hardware could be useful for clinical applications in order to monitor patients during follow-up activities. As such, and because of their cost-effectiveness and easiness of use, such hardware could be used for very frequent (e.g., weekly) assessments of patients to, for example, quantify their progresses without the need of sending the patients to specialized centers. The latter centers would still be involved to perform a full and detailed analysis at less frequent intervals (e.g., monthly or bi-annual). As the readers can see, there is a high and obvious complementarity between both systems: on the one hand, accurate and very detailed analysis using high-end equipment, on the other hand, precise and very flexible general assessment using cost-effective transportable and intuitive hardware. The availability of the latter hardware would allow more frequent functional analysis in the practice of private therapists or even at the patient’s home.
7.1.1.2 Calibration and Customization
Each patient is unique with specific pathology inducing functional impairment and limitations. Therefore, the games used for the rehabilitation of these patients should also be adapted. This is by definition not the case with commercial games in which it is not possible to modify any relevant parameters.
Specific games have been developed to fulfill, partially, the need of rehabilitation and the capacities of these new kinds of “players.”
Two different approaches are currently being used to adapt the games for each patient.
If the games are played under therapist supervision, the clinician can configure the different parameters of the games (range of motion, joints, speed, acceleration, visual background and complexity, sounds, etc.) manually. User-friendly interfaces have been developed to enable real-time modifications in these parameters while the patient is playing in order to have direct feedback of these changes (Omelina et al. 2012).
7.1.2 Ethical Issues
Several ethical issues are raised by the development of serious games and telemedicine. The new paradigm of communication between the different actors of rehabilitation is presented in Fig. 7.1. The database, including not only the data storage but also the data analysis and data mining tools, is the key piece of telerehabilitation. As such it is put in the middle of the organigram. Data protection authority and agencies in charge for the protection of medical data, including ethical committees, pay a lot of attention to the security of databases containing medical or health-related data (encrypted data, patient anonymization). Solid lines represent the communication between patients or clinicians and the database. These connections must also be highly secured and encrypted to allow safe transfer of the health-related data (sensitive data).
Fig. 7.1
The communication between the different actors of rehabilitation. Dotted lines are used to present the traditional and conventional way of communication, solid lines are used for telemedicine and telerehabilitation. Note the central position of the database
Unfortunately, it is almost impossible to guarantee inviolable system since hackers seem able to bypass almost all the security systems, even the more complicated ones. Of course, hackers are more involved in security and financial system but apparently health care services are not spared as illustrated by the case of a hacker having recently taken control of the pacemaker of a patient1 or hackers tacking control of self-driving cars.
7.1.3 People’s Mind
In physical rehabilitation, although there is the world “serious” in it the use of games or serious games is, too often, only associated to fun. Therefore some clinicians, and patients, think that they are only playing and not doing rehabilitation exercises. However, they are doing exactly the same kind of motions in the games that during a conventional rehabilitation session using especially dedicated games.
People are often reluctant to use new technology, especially in the health care sector. The use of games in rehabilitation must thus tackle these two problems: proves that new technologies, issue from the games, and the games themselves can be beneficial in the health care services.
With the “web generation,” or the digital native (Prensky 2007), there is no doubt that the mentalities are going to change and there is no reason that these technologies could not be used in rehabilitation; it is certainly just a matter of time.
For the more septic, and more scientific (?), people there is a need of scientific and clinical validation of the use of this new approach in the conventional treatment of different health-related conditions. It is therefore important to conduct clinical validation studies following strict protocol used in clinics to validate new treatment (see Chap. 6).
Ultimately, as final user, patients must be convinced that serious games are beneficial for them. Easy-to-use and user-friendly interfaces must be developed to run the games for all kind of patients (elderly, patients with cognitive impairment, etc.) (Laver et al. 2011). The games must also be easy to play and patients have to understand what they have to do (Plow and Finlayson 2014). Last but not least, the interface must allow a follow-up of the patients and plots the progresses over the time to motivate and stimulate them to perform the rehabilitation exercises during a long time of period.
7.1.4 Financial Aspects
We already mentioned the financial issue as potential barrier to rehabilitation. The main and most important question is who is going to pay for this new kind of service. Such kind of device could be installed in private practice, large clinical center (hospital), or at patient’s home. Different business model and option must thus be discussed.
In the first case, the material should be bought by the clinician (or group of clinicians), as it is the case with any other health care material. In some cases (choc wave therapy, cryotherapy), clinicians are free to ask a financial participation of the patient in addition to the session.
If the system is installed at home, several scenarios are possible. Either the patient buys the system or he rents it for the duration of the treatment. In this case, is it the clinician who buys the system and rents it to patients (Business-to-Business solution)? Do the companies provide the system with a monthly subscription directly to the patient (Business-to-Customer solution)?
Current companies are relatively young and the products are still in development; therefore, we are not able to provide more information about the best sales strategy or approach.
Last questions: Are the health-care systems going to participate in the reimbursement, fully or partially, of this new kind of intervention? Is it that the patients need to pay everything? What about the use of serious games in emerging countries?
7.2 A Lucrative Market?
7.2.1 Targeted Populations
The benefits generated by the industry of commercial video games are huge: 25 billion dollars estimated for 20142. Compared to this market how important can the serious games industry be? The different pathologies discussed in the Chap. 4 have been listed in Table 7.1. The number of patients suffering from these pathologies in the different region of the world has been estimated.
Table 7.1
Number of patients suffering from different pathologies in different regions of the world
Pathology | Africa | Americas | Asia | Europe | Oceania | Total (by pathology) |
|---|---|---|---|---|---|---|
Strokea | 2 millions | 2.2 millions | 19 millions | 1.8 millions | 100,000 | ≈ 25 millions |
Cerebral palsy | 3.3 millions | 2.9 millions | 13 millions | 2.2 millions | 120,000 | ≈ 21.5 millions
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