Little big heroes – supporting children’s patients in therapy with virtual reality

Reach small and large goals easily and playfully, without being aware of the effort involved. This is a vision that drives researchers and practitioners in various fields of application around the topic of gamification. In this article, I describe how we apply gamification in practice in the Mighty U research project to help children with motor disabilities with therapy.

In the last few years, gamification has increasingly developed into a topic with a strong media presence in the German-speaking world, with which numerous TV reports, newspaper articles and conferences have also been in touch. But Gamification not only received a positive response in the media. We at Centigrade also receive more and more request in the gamification and enterprise gaming area, of which some have already been implemented.

Kinder spielen

The projects around the topic of gamification often have in common that the addressed “non-playful” application contexts are little or even not intrinsically motivating at all for the focused target group. “Intrinsic motivation” occurs when a person performs an activity for his or her own sake and not because he or she expects an external reward. The fun of the action alone is incentive enough to carry it out. The idea of using games not only for entertainment purposes but also to tap their potential for other areas is not new. Some of the first recommendations for digital games, for example, were made by Malone in 1982. Here, three categories of motifs are mentioned that can be supported by games: Challenge, Fantasy and Curiosity. The aim is to motivate people to perform a task with pleasure and fun, through the use of gamification.

We have often reported in other Blog-Articles on the positive effect of gamification on motivation in many areas.

In Medicine for example, there are already convincing examples from research and development, which makes the use of gamification seem meaningful at this point. The topic became known through the 3rd Person Shooter Re-Mission, which is used to support the chemotherapy of children and adolescents suffering from cancer. Re-Mission already has a successor, a collection of mobile casual games, which have been published under the title Re-Mission 2. In Re-Mission, the player fights cancer cells with the help of weapons based on chemotherapy drugs. The aim of the game is to strengthen the self-efficacy of the patients – and therefore the therapeutic success of the chemo. In addition, the players should learn something about the course and mode of action of the therapy. In the end, the patient should be motivated to take the drugs regularly.

In a large-scale study, Re-Mission was tested for its effectiveness in therapy support. The experimental group consisting of 164 participants was asked to play the game for at least one hour per week. The control group of 140 participants continued to follow regular chemotherapy without playing the game. The study results confirm the intended effect. In the experimental group, the drugs important for chemotherapy were taken significantly more frequently and regularly. The concentration of cancer-fighting substances from the chemo in the blood of these individuals was therefore higher than in the control group. Furthermore, the perceived self-efficacy as well as the knowledge about chemotherapy was provably higher in the playgroup than in the non-players.

So much for theory. But how can the challenge of a very special application context and a target group with special needs in the health sector be addressed in practice? Especially when the target group has lot of potential for such a playful solution on the one hand, but also holds many risks and pitfalls on the other hand. This is exactly the question we ask ourselves in a research project, which I would like to present in more detail in this article …

MightyU Logo Color mobile

The beginning of an exciting journey

After a long preparation the time had finally come in March 2019 – the long-awaited research project called “Mighty U” was in the starting blocks and could finally pick up speed. The project, funded by the Federal Ministry of Education and Research (in German: BMBF) and the Association of German Engineers (VDI), is concerned with the development of a playful virtual reality application to support the therapy of children and adolescents with infantile cerebral palsy (ICP). Infantile cerebral palsy is a chronic disease of the musculoskeletal system that leads to motor impairment in early childhood due to damage to the central nervous system.

Regular therapy and independent practice of movement sequences in everyday life are extremely important for the young patients. The aim of such exercises is to improve the ability to move and thus also the independence in everyday life in small steps or to keep it constant. What furthermore counteract a worsening of the complaints. Treatment goals are, for example, the support of active erection, the promotion of movement transitions and the improvement of action competence (e.g. targeted grasping). Physiotherapy and ergotherapy are particularly helpful here. However, such movement exercises are usually not very varied and very challenging for the children, as they are often associated with great physical and cognitive exertion. So, what could be the path to a successful product that ultimately fulfils its purpose – motivating children and adolescents with ICP to practice regularly?

This is where MightyU comes in. Together with our project partners Fraunhofer ISST, University Hospital Bochum, Velamed und Meap, we are working over the next three years on the development of a motivational technology for training support that accompanies children and adolescents over a long period of time and, depending on their individual abilities, “grows with” the patient. The aim is to motivate the young patients to perform the important exercises more frequently. We want to achieve this by recording muscle activity and kinematic data of movements with the help of EMG sensors close to the body and making these usable for game mechanics. In this way, the game can be controlled by movement and detects when the patient is making a wrong, too weak or too strong movement, for example. This data is then used both to generate in-game feedback for the patient and for control by the treating therapist.

This is a great opportunity for all of us to try something new and enter a previously unexplored field. Something new – i.e. also the vision to influence their therapy success positively. This makes an orientation to the special needs of the target group even more important. Be it in terms of game mechanics, genre and motivation aspects or in terms of the technology that will ultimately be used. Either way, one thing is for sure, we are on the verge of an exciting journey, but it is also a great challenge that needs to be mastered.

In the following I will give you a small foretaste of how we approach the problem and what steps will follow in the MightyU project.

Procedure in the MightyU project

Step 1: Limit the target group!

The first step in a project is called scoping. We reported in detail about this format in one of the last blog articles. The aim of the Scoping Workshop is to prepare and define the project. What is our project and what is our goal? Which problem do we want to solve and for whom exactly is the solution intended? Even with “classic” projects it is important to ask these questions in advance. But this is even more important in a project like this, where hardly any member of the target group resembles the other. The children and adolescents with ICP differ greatly in terms of their individual abilities, the clinical picture, but also in terms of their interests and age. So how to generate a solution that suits them all?

As part of the scoping process, we met with the project partners, who all have different perspectives, as well as with therapists and doctors to jointly develop the project definition. In addition, we formulated initial personas and scenarios to develop empathy for our target group and identify starting points for the gamified solution.

Persona Mightyu

Step 2: Get to know your target group!

  • What should a game look like that children and teenagers like to play? And what interests and skills are dominant in the target group?
  • How do we motivate these children so that at best they don’t even notice that they are being trained?
  • How can parents, friends, classmates etc. be involved in the game without the sick children falling behind the “healthy” players despite restrictions?

These are just some of the questions we asked ourselves after the scoping. In our opinion, the product can only have the desired effect if we continuously involve the target group as well as other stakeholders such as therapists and doctors in the development process. Based on this philosophy, we conducted a series of interviews with ICP children and their families, visiting them at home in their normal environment and at therapy sessions to get the most comprehensive picture possible.

It was particularly beneficial to talk to the young patients about their interests and hobbies. We learned that the children like the same video games as healthy children of the same age, for example the Batman Arkham series. With one small difference – because in many cases playing by oneself is not possible due to the motor limitation of the hand musculature. Nevertheless, the children do not allow themselves to be held up, but look for solutions in order to be able to participate. For example, they play together with their friends, give tips and say where the character should be steered. This is of course a particularly exciting insight for us. Wouldn’t it be great if the children at MightyU could play together with their friends, but also finally control the game and contribute to the action?

Step 3: Test ideas and solutions continuously!

In addition to the content component of the playful solution, the technical component is of course also an important factor. The big players in the field of game consoles and software already offer technical solutions that could be promising for our application purpose. Especially interesting for us are systems that offer innovative and flexible control possibilities and include player movement. We have already dealt with such games and hardware components in several playtesting sessions. We found the Labo Robo set for the Nintendo Switch particularly exciting. With the help of an easy-to-use craft set, strings are attached to a kind of backpack. During the interaction with the game, the player carries it on his back and controls a virtual robot with the “controllers”. Even whole-body movements have a result in the game. If the player ducks, the robot transforms into a car with which he can jet through the game world. Of course, we have to make sure that our ICP patients have a good balance between motor skills and fun. The game must not lead to excessive demands, neither must the fun of the game suffer from the fact that even relatively small successes for the patients are sometimes associated with great effort.

In order to find the right balance at this point, we will continue to test the game and work closely with the target group.

Spiele Test Nintendo VR

And what’s next?

After we have gotten to know the target group and looked at the already existing ideas for solutions, we will start into the ideation and concept phase. Together with the project partners, we will select suitable game elements and finally decide on a technology. The concept will then be continuously evaluated together with the target group and iteratively adapted.

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