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Virtual reality (VR) technology has experienced a steady rise and has been widely applied in the field of rehabilitation. The integration of VR technology in rehabilitation has shown promising results in enhancing their motivation for treatment, thereby enabling patients to actively engage in rehab training. Despite the advancement, there is a dearth of comprehensive summary and analysis on the use of VR technology to enhance patient motivation in rehabilitation. Thus, this narrative review aims to evaluate the potential of VR technology in enhancing patient motivation during motor rehabilitation training. This review commences with an explanation of how enhancing motivation through the VR rehabilitation system could improve the efficiency and effectiveness of rehabilitation training. Then, the technology was analyzed to improve patient motivation in the present VR rehabilitation system in detail. Furthermore, these technologies are classified and summarized to provide a comprehensive overview of the state-of-the-art approaches for enhancing patient motivation in VR rehabilitation. Findings showed VR rehabilitation training utilizes game-like exercises to enhance the engagement and enjoyment of rehabilitation training. By immersing patients in a simulated environment with multisensory feedback, VR systems offer a unique approach to rehabilitation that can lead to improved patient motivation. Both ultimately lead to improved patient outcomes, which is not typically achievable with traditional rehabilitation methods. The review concludes that VR rehabilitation presents an opportunity to improve patient motivation and adherence to long-term rehabilitation training. However, to further enhance patient self-efficacy, VR rehabilitation should integrate psychology and incorporate methods. Moreover, it is necessary to build a game design theory for rehabilitation games, and the latest VR feedback technology should also be introduced.

Functional lateralization relates to a natural asymmetry in the dominance right or left body side, and is a fundamental principle of the brain. The hemispheres of the brain control the contralateral body side, and show subtle, yet striking, anatomical asymmetries and functional lateralization. Innovative technologies, including Virtual Reality (VR), are entering the areas of experimental research, modeling and simulation related to the study of lateralization, with new perspectives of different applications in modern medical practice. Researchers/clinicians note that there are fewer VR studies with healthy participants, and which are important in evaluating/interpreting clinical outcomes, and testing the usefulness, limitations, and sensitivity of VR. The presented influence of the domination of upper/lower limbs on the performance of VR exercises was studied in healthy right-handed adults. Virtual testing sessions were performed independently with both/ dominant/ non-dominant hands, and the similar VR sessions were conduced on a Wii Balance Board (WBB) with the choice of body side, at different levels of the difficulty. The obtained results are consistent with other studies which show that cognitive-motor training in VR with the WBB platform is a very sensitive and promising tool for recognizing/assessing functional asymmetries of the right-left body side not only in disturbed lateralization, but also in the test training of healthy subjects., (Copyright © 2021 The Author. Published by Elsevier B.V. All rights reserved.)

Objective: The objective of this pilot study was to analyze the efficacy on perceived health and the feasibility of a multicomponent psychological intervention to promote active aging through depression prevention, healthy lifestyle habits, and cognitive stimulation in middle-to-older adulthood administered through an interactive multimedia online videogame with a complementary smartphone app. Materials and Methods: Twenty-five participants from the general population aged 45 or older with computer and smartphone access and no difficulties in communication, sensory or mental health condition (64.0% women, mean age 54.9 years) participated in the intervention, which consisted of eight modules with tasks between sessions. The multicomponent intervention consisted of three components (depression prevention, healthy lifestyle habits, and cognitive stimulation) and was administered using an interactive online multimedia videogame (graphic adventure type), with a complementary smartphone app. Perceived health, dropouts, adherence to the intervention (performed modules and completed intersession tasks), and engagement were independently assessed. Results: After the intervention, participants exhibited significant improvement in their scores for General Health, Physical Functioning, Social Functioning, and Mental Health, with effect sizes ranging from small ( d  = 0.38) to medium ( d  = 0.59). The dropout rate was only 8%. The mean number of completed modules was 7.5 (SD = 1.8), and the mean number of tasks performed was 232.4 (out of 259) (SD = 15.4). Participants were highly satisfied ( M  = 27.7; SD = 3.1) and engaged ( M  = 42.7; SD = 4.7) with the intervention. Conclusion: The results support the efficacy and feasibility of using the videogame to promote active aging, and they encourage further evaluation through a randomized-controlled clinical trial. ClinicalTrials.gov NCT03643237.

Objective: Slowing information processing speed (IPS) is a biomarker of neuronal damage in patients with multiple sclerosis (pwMS). A focus on IPS might be the ideal solution in the perspective of promptly detecting cognitive changes over time. We developed a tablet-based home-made videogame to test the sensitivity of this device in measuring subclinical IPS in pwMS. Materials and Methods: Forty-three pwMS without cognitive impairment and 20 healthy controls (HCs) were administered the videogame task with a tablet. Response times (RTs) and accuracy were recorded. Results: PwMS (mean RTs = 505.5 ± 73.9 ms) were significantly slower than HCs (mean RTs = 462.3 ± 40.3 ms, P  = 0.014) on the videogame task. A moderate but significant correlation ( r  = -0.35, P  = 0.03) between mean RTs and the Symbol Digit Modalities Test was observed. Conclusion: Our videogame showed good sensitivity in measuring IPS in apparently cognitive normal pwMS. Computerized testing might be useful in screening initial cognitive dysfunction that should be monitored as a marker of underlying disease progression. IRB approval Number is 2332CESC.

A sample of 10,460 U.S. elementary schoolchildren was analyzed to identify early predictors of frequent use of online technologies (i.e., messaging, online gaming, and social networking). Children (M age  = 67.44 months) at greater risk displayed more externalizing problem behaviors in kindergarten (messaging OR = 1.11; online gaming OR = 1.21; social networking OR = 1.12) or were Black (messaging OR = 1.65; online gaming OR = 1.64; social networking OR = 1.68). Children from higher-income families were at lower risk (online gaming OR = 0.89; social networking OR = 0.89). Boys were more frequent users of online gaming (OR = 3.35) but less frequent users of messaging (OR = 0.62) and social networking (OR = 0.80). Protective factors included specific parenting behaviors., (© 2021 Society for Research in Child Development.)

Objectives: This study aims to explore the age-related changes in cerebral cortex activation and functional connectivity (FC) during finger-to-thumb opposition movement based on video games (FTOMBVG)., Methods: A electronic fingercot was developed for FTOMBVG. The oxygenated hemoglobin concentration (Delta [HbO]) signals, measured by functional near-infrared spectroscopy (fNIRS), were recorded from prefrontal cortex (PFC), motor cortex (MC) and occipital lobe (OL) of two groups of subjects (old and young)., Results: The cognitive region of the old group showed bilateral activation, while the young group only showed unilateral activation. Both groups showed a wide range of bilateral activation in the motor region. The FC between cognitive region and motor region of the old group was enhanced considerably., Conclusion: Changes in cerebral cortex activation and the FC of different brain regions in the old group help explain the decline in cognitive executive and motor control function in the old from the perspective of brain functional structure, and provide a theoretical reference for the prevention of neural diseases caused by aging., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: This study assessed the oxygen consumption [VO 2 mL/(kg·min)], liking, and relative reinforcing (motivating) value (RRV) of a moderately physiologically challenging exergame [Nintendo Wii-Sports Boxing (Boxing)] versus a minimally challenging exergame [Nintendo Wii Lego Star Wars (Lego)]. Materials and Methods: VO 2 and liking were recorded in children( N  = 28, 7.8 ± 1.3 years old) during three 10-minute conditions: recumbent resting (Resting), and playing Wii Boxing or Wii Lego. Resting was completed first, and the order of exergames was randomized. Next, children performed an operant button pressing task using a progressive fixed ratio to assess the RRV of the two videogame conditions. Children worked to earn up to 11 minutes for Boxing, Lego, or a combination of the two. The output maximum (O max ) performed to earn access to each game was the measure of RRV. Results: There was a significant ( P  ≤ 0.03 for all conditions) step-wise increase in VO 2 from Resting [4.3 ± 1.2 mL/(kg·min)] to Lego [5.3 ± 0.5 mL/(kg·min)] and from Lego to Boxing [11.7 ± 4.2 mL/(kg·min)]. Liking was significantly greater for Boxing ( P  = 0.003) and Lego ( P  < 0.0001, 7.1 ± 2.9 cm; 7.1 ± 2.7 cm, respectively) versus Resting (4.6 ± 3.8 cm), with no significant difference between Boxing and Lego ( P  = 0.358). Lastly, O max was significantly ( P  = 0.021) greater for Lego (257.7 ± 390.6 presses) than for Boxing (51.7 ± 131.0 presses). Conclusion: Oxygen consumption during Wii Boxing was significantly greater than during Wii Lego. Despite this greater physiological challenge, liking was similar for both Lego and Boxing. However, children were more motivated to play Lego than Boxing.

Autism Spectrum Disorder (ASD) is often associated with impaired perspective-taking skills. Deception is an important indicator of perspective-taking, and therefore may be thought to pose difficulties to people with ASD (e.g., Baron-Cohen in J Child Psychol Psychiatry 3:1141-1155, 1992). To test this hypothesis, we asked participants with and without ASD to play a computerised deception game. We found that participants with ASD were equally likely-and in complex cases of deception even more likely-to deceive and detect deception, and learned deception at a faster rate. However, participants with ASD initially deceived less frequently, and were slower at detecting deception. These results suggest that people with ASD readily engage in deception but may do so through conscious and effortful reasoning about other people's perspective.

Electronic sports (esports), or competitive video gaming, is a rapidly growing industry and phenomenon. While around 90% of American children play video games recreationally, the average professional esports athlete spends 5.5 to 10 h gaming daily. These times and efforts parallel those of traditional sports activities where individuals can participate at the casual to the professional level with the respective time commitments. Given the rapid growth in esports, greater emphasis has been placed on identification, management, and prevention of common health hazards that are associated with esports participation while also focusing on the importance of health promotion for this group of athletes. This review outlines a three-point framework for sports medicine providers, trainers, and coaches to provide a holistic approach for the care of the esports athlete. This esports framework includes awareness and management of common musculoskeletal and health hazards, opportunities for health promotion, and recommendations for performance optimization.

Background: Physical inactivity has been identified as the fourth leading cause of death globally. It is now well established that a sedentary lifestyle is a unique risk factor for several diseases such as type 2 diabetes and cardiovascular disease, which account for about 30% of global mortality. Diabetes is a major preventable cause of costly and debilitating renal failure, heart disease, lower limb amputation, and avoidable blindness. In recent years, the idea of using interactive computing systems that leverage gamification to promote physical activity has been widely researched. Prior studies have shown that exergames, that is those that encourage physical activity, can increase enjoyment and intrinsic motivation compared with conventional exercises; as such, they can be effective in promoting physical and mental health. There has been some research on immersive virtual reality (VR) exergames; however, to the best of our knowledge, it is limited and preliminary. This work aims at filling the gap and investigates the effect of display type (DT) and viewing perspective (VP) on players' exertion, engagement, and overall game experience in immersive VR exergames. Objective: This article aims at examining whether DT and VP can affect gameplay performance, players' exertion, game experience, cybersickness, and electroencephalography (EEG) engagement index when playing a gesture-based (i.e., body motion) exergame. Materials and Methods: Study 1 employed a one-way between-subjects design with 24 participants equally distributed in two groups (immersive VR and 50-inch TV) to perform 12 pre-defined gestures. The main outcome measures were National Aeronautics and Space Administration-Task Load Index (NASA-TLX) workload for each group as well as 7 Likert scale and EEG engagement index for each gesture. Study 2 included 16 participants in playing a game with the gestures selected from study 1. All participants played 4 versions based on combinations of DT (immersive VR and 50-inch TV) and VP (first-person and third-person) to assess exertion (%HR max , calories consumption, and Borg RPE 6-20), game experience, cybersickness, and EEG engagement index. Results: Study 1 results showed that DT had no effect on the ratings of the gestures, NASA-TLX workload, and EEG engagement index. Study 2 results showed that immersive VR not only resulted in a significantly higher exertion (%HR max , calories consumption, and Borg RPE) but also helped achieve better positive game experience in challenge, flow, sensory and imaginative immersion, as well as lower negative affect. We also found that nausea and oculomotor were significantly higher in immersive VR. Conclusion: This pilot study demonstrates that youth who played gesture-based exergame in immersive VR had a higher level of exertion (%HR max, calories consumption, and Borg RPE), although the number of performed gestures were not significantly different. They also felt that immersive VR was much more challenging, immersive (flow, sensory and imaginative immersion), and had a lower negative affect than a 50-inch TV; however, immersive VR was more likely to make youth have higher cybersickness.

Sleep deprivation and emotional problems such as stress, anxiety, and depression commonly occur in university students. Exercise is beneficial to ameliorate those problems; however, university students are not serious to take up physical activity. Commercially available exergame such as Xbox ® 360 Kinect is one of the alternatives. This study aims at investigating the feasibility and the potential efficacy of using Xbox 360 Kinect game among health care undergraduate students. A pilot two-armed parallel randomized controlled trial was implemented. A total of 36 undergraduate students was recruited and randomly allocated into the intervention group (playing Xbox 360 Kinect) or the control group (continue with normal daily routine). The intervention group received 30 minutes of Xbox Kinect activity, three times per week for 6 weeks. Information on psychology (Depression, Anxiety, and Stress Scale-21) and sleep (Functional Outcome Sleep Questionnaire-30) status was collected at pre- and post-experiment. The researcher-developed feasibility questionnaire was given to the participants in the intervention group at post-experiment. Repeated-measures analysis of variance was used to investigate within-between group comparison, and significance value was set at p  ≤ 0.05. The analysis found potential improvement on sleep ( p  = 0.039) and psychological health ( p  = 0.002-0.067). The intervention protocol is feasible and highly accepted by the participants. The required optimum amount of dosage, sample size, and the use of outcome measures are suggested from the findings. This pilot and feasibility study supports the use of Xbox 360 Kinect games in practice and to be implemented for future research.

Objective: This article presents the results of a systematic review of the latest, state-of-the-art research on videogames designed for older adults (i.e., those aged 65 or older) and the health benefits derived from playing these games. Findings from each study that met the inclusion criteria were analyzed and summarized into emergent themes to determine the impact of digital games in promoting healthy behaviors and benefits among these older adults. Materials and Methods: Five databases (PubMed, ScienceDirect, IEEE Xplore, ACM Digital Library, and Google Scholar) were searched for studies that evaluated interventions of videogames for older adults aged 65 and older. The initial search yielded 806 articles. After evaluating them against the inclusion criteria, 23 studies remained. Results: Out of the 23 studies we reviewed, 20 reported the significant impact of videogame interventions on the elderly's physical health. In addition, 14 studies reported effects on the elderly's mental health. Exergame is the most popular type of game used in these videogame-based interventions. This review also includes the details of study design (e.g., type of intervention, length, frequency), population sample, and measurements used in the studies. Conclusions: This systematic review demonstrates that videogame-based interventions are helpful in promoting physical health (i.e., balance, mobility, strength, physical fitness, and walking performance/gait parameters) and mental health (i.e., balance confidence, executive functions, reaction time, and processing speed) among older adults. It can also be used by researchers in this field to inform their design decisions. We have listed guidelines that can be used to frame future research in the area and enhance its quality.

Objectives: Smartphone applications ("apps") can be used to promote health behavior change and expand the reach of behavioral interventions. To date, only a few existing apps have been developed for health promotion among adolescent survivors of childhood cancer. To address this gap, we developed an app-based intervention, using game design characteristics, theory-based behavioral strategies, and assistance from a health coach to motivate health behavior change for adolescent survivors of childhood cancer. This article describes the development and initial feasibility evaluation of the intervention. Methods: Using a theoretical framework and an extensive formative process, we developed an app-based game ("Mila Blooms") that promotes healthy eating and physical activity among adolescent survivors of childhood cancer. A single-arm 8-week intervention, using this app-based game, with assistance from a health coach, was conducted among a sample of pediatric cancer survivors ( n  = 15) to evaluate its initial feasibility for promoting health behavior change. Results: Results from the feasibility evaluation were encouraging. The majority of enrolled participants were retained throughout the 8-week intervention (93.8%). Participant satisfaction feedback indicated positive experiences, related to ease of use and enjoyment of the app. Although there was little evidence for behavior change attributable to the app in this first stage of development, there was a solid demonstration of the viability and appeal of the game features, and there were no adverse side effects. Conclusions: Results provide insights into how gamification can be used to promote health behaviors through an app-based intervention. Mila Blooms holds promise for promoting health behavior change. Lessons learned from our experiences could be useful for the future development and implementation of app-based adolescent health interventions.

Objectives: In older persons with heart failure (HF), an inability to self-manage their disease condition can result in poor health outcomes and quality of life. With the rise in smartphone use and digital game playing among older adults, digital tools such as sensor-controlled digital games (SCDGs) can offer accessible health-promoting tools that are enjoyable and easy to use. However, designing SCDGs that are compelling and aligned with their life values and self-management needs can be challenging. This article describes a qualitative study with older adults with HF who were recruited from a cardiac rehabilitation laboratory in central Texas to identify their perceptions and expectations regarding a SCDG for HF self-management. Materials and Methods: A low-fidelity prototype that demonstrated the features of a SCDG was used to obtain the participants' perceptions about the value of SCDGs for HF self-management with respect to content, customization, flexibility, and usability through qualitative interviews. Results: We interviewed 15 patients with HF (53% women; age range, 53-90 years; 60% white). The concept of SCDGs for HF self-management was highly acceptable (80%). Participants provided suggestions for game characters, progress in the game, and game notifications and incentives. Perceived benefits included helping users track their behaviors and establish routines, become informed on strategies to manage HF, and empower themselves to take charge of their health. Conclusions: The study's findings will guide personalization of SCDG development to motivate patient engagement in HF self-management behaviors.

Objective: We examine the extent that videogame avatars provide players with opportunities for identity exploration, aiming to test the findings of self-discrepancy theory research on the user/avatar relationship with novel cognitive anthropological methods. Specifically, we examine if avatar traits are idealized (more representative of players' ideal rather than actual self) or actualized (more representative of players' actual self) as a function of players' self-esteem. Materials and Methods: Utilizing cognitive anthropological methods, we examine the relationship between actual, avatar, and ideal selves . We first asked 21 respondents to list traits they associated with their various selves. We then asked 57 new respondents to perform four pile sorts of the salient items from these lists (1 unconstrained sort of like-traits, and 3 sorts of terms indicative of respondents' ideal/actual/avatar self). Analysis of this "free list" and "pile sort" data allowed us to clarify (in a manner sensitive to gamer culture) relationships between respondents' various conceptions of self, including how those relationships were modified by self-esteem. Illustrative quotes from the interviews further clarified these relationships. Results: Paired t -test analysis shows that informants as a whole describe their avatar compared with actual selves with fewer negative terms ( idealization ). Low-esteem players actualize what they deem as positive traits onto their avatars, while simultaneously idealizing avatars' negative traits by minimizing them. Compared with low-esteem gamers, high-esteem players associate significantly more positive attributes with all their various selves- actual, avatar, and ideal -while describing avatar compared with actual selves with fewer positive terms and comparable numbers of negative terms (the latter a process of actualization ). Conclusion: Results point to the necessity of theoretical accounts that recognize that avatars may reflect a complex relationship with the user's actual and ideal self, without assuming that avatar play frees gamers from offline social, psychological, or bodily constraints.

Background: Despite the variety of available treatments for mental health symptoms, many individuals do not engage with treatment and among those who do, dropout rates are often high. Therefore, providing alternative opportunities to access treatment is imperative. Research interest in the therapeutic effects of digital mental health initiatives and serious games has grown in recent years, but the potential of simple, easy-to-use casual videogames (CVGs) that can be played in short bursts of time has seldom been considered. Objective: The objective of the present study is to provide a systematic review of the literature examining the effects of CVGs on treating anxiety, depression, stress, and low mood. Method : A systematic search was conducted, using the terms (casual gam* or casual videogam* or mini gam* or minigam* or mini-gam* or gamif*) and (mental health or anx* or depress* or stress or mood) and (study or trial or treatment or prescribed or prevention) as "Title," "Abstracts," "Keywords," or "Topic" words across all years. A Google search was also completed to check for articles that may have been missed. Results: N  = 13 studies met inclusion criteria (no studies were added via the Google search). These studies reported findings for nine different CVGs, with six studies aimed at reducing anxiety, two examining effects for depression, and four investigating the effects of CVGs on treating stress or low mood. Promising effects were identified. Conclusion : CVGs may have promise for treating anxiety, depression, stress, and low mood.

Problematic Internet Use (PIU) encloses excessive online activities (like video gaming, social media use, web-streaming, pornography viewing, buying). Despite its psychological burden, risk factors related to PIU remain still unclear. In the present study we explored the role of personality traits and emotion dysregulation as potential vulnerability factors for PIU. In a sample of American young adults with different PIU risk levels (established through the Internet Addiction Diagnostic Questionnaire), we administered the Tridimensional Personality Questionnaire (TPQ), the Difficulties in Emotion Regulation Scale (DERS), the Barratt Impulsiveness Scale, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale. PIU participants were more likely to report lower TPQ scores in novelty seeking, harm avoidance and reward dependence. Moreover, DERS total scores significantly differed across PIU-risk groups, along with a progressively higher occurrence of depression, anxiety and impulsivity. These results preliminarily support the hypothesis of PIU as a mainly behavior aimed at 'escaping' from negative affects. Besides confirming the role of some personality traits and emotional dysregulation, we propose the concept of risk-trajectories to monitor and prevent the emergence of PIU. Gaining more insight into PIU vulnerability factors may allow us to establish targeted interventions to cope with emotion dysregulation and negative affects., Competing Interests: Declaration of Competing Interest Dr. Grant has received research grants from Biohaven, Promentis, and Otsuka Pharmaceuticals. Dr. Grant receives yearly compensation from Springer Publishing for acting as Editor-in-Chief of the Journal of Gambling Studies and has received royalties from Oxford University Press, American Psychiatric Publishing, Inc., Norton Press, and McGraw Hill. The other authors report no conflicts., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: to develop and assess the serious game e-Baby Família with parents of premature infants., Methods: a methodological study regarding the development of the serious game, with participatory design in scope definition, starting from parents' learning needs about premature infant care. A qualitative approach was performed in the assessment stage with parents, with content analysis of the speech of the eight participants., Results: the following categories emerged: Realistic appearance of the virtual setting and game content and Gameplay implications for the use of e-Baby Família. The game was satisfactorily assessed regarding content, appearance and dynamics use, motivating participants to learn., Final Considerations: in the context of prematurity as a public health problem in Brazil and the need to strengthen family health education for care, the serious game was assessed as motivating and appropriate for health learning.

Electronic games delivered via smartphones have the potential to become valuable tools in HIV prevention in high-prevalence and low-resource international settings. To ground theoretical elaboration around novel mHealth interventions in contextual realities, it is important to understand the mechanisms of their effects as perceived by local populations. Such perspectives are particularly important when working cross-culturally. 'Tumaini' is an interactive narrative-based smartphone game that uses a 'choose-your-own-adventure' format. It is designed to prevent HIV among young African adolescents (aged 11-14) by increasing age and condom use at first sex. It was developed with a US-based commercial game developer and is grounded in social behavioral theory, evidence-based practice and contextually relevant scenarios. In a 2017 randomized pilot study (n = 60) in Western Kenya, 'Tumaini' showed promising effects on behavioral mediators of sexual debut. In subsequent focus group discussions, adolescent participants and their parents shared their perceptions of the game's mechanisms of effect, which included motivation to play, future orientation, decision-making, relationship to a diverse range of characters and a bridging of the virtual and real worlds. These findings align with our theoretical framework, confirm its successful translation into the intervention and will inform mediation analyses in an upcoming efficacy trial., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Health games provide opportunities for the treatment and prevention of childhood obesity. We developed a motion-controlled serious game for children that addresses 3 core topics of nutrition, physical activity, and stress coping. It is the first serious game that extensively targets the dietary energy density principle (DED-P) in relation to nutrition. The game is intended to provide an additional educational component for the prevention and treatment of obesity in children., Objective: The Kids Obesity Prevention study aimed to evaluate the newly developed game and to evaluate how well children are able to understand and apply the DED-P., Methods: This cluster randomized controlled trial collected data from 82 primary school children aged 9 to 12 years and their parents at baseline (T0), at 2 weeks after study commencement (T1), and at the 4-week follow-up (T2). The dropout rate was 3.6%. The intervention group (IG) played the game within 2 weeks (2 sessions with different game modules). One part of the game involves selection of food with the lower energy density when presented with a pair of foods. This allows assessment of whether the children have understood the DED-P and whether they can apply it to unknown foods under time pressure. The control group (CG) received a brochure about the food pyramid concept and physical activity. The primary outcome was the gain in knowledge (nutrition and stress coping) and measured with a pretested questionnaire. The secondary outcomes were the maintenance of knowledge, application of the DED-P, feelings during game play, game acceptance, and behavioral measures (physical activity, media consumption, and dietary intake)., Results: The knowledge score ranging from 0 to 100 increased from T0 (IG: 53 [SD 10], CG: 50 [SD 11]) to T1 (IG: 69 [SD 11], CG: 52 [SD 12]) in IG versus CG (P<.001). At T2, the knowledge score of IG remained at the same level as that of T1. Game data showed that after DED-P education, the classification under time pressure of unknown versus known food pairs according to their DED category was similar (hit rate around 70%). Overall, 95% of the children liked the game very much or much. No group changes were observed at the behavioral level., Conclusions: The Kids Obesity Prevention program sustainably increased knowledge in the areas of nutrition and stress coping, and children were able to apply the DED-P., Trial Registration: ClinicalTrials.gov NCT02551978; https://clinicaltrials.gov/ct2/show/NCT02551978., (©Isabelle Mack, Nadine Reiband, Carolin Etges, Sabrina Eichhorn, Norbert Schaeffeler, Guido Zurstiege, Caterina Gawrilow, Katja Weimer, Riyad Peeraully, Martin Teufel, Gunnar Blumenstock, Katrin Elisabeth Giel, Florian Junne, Stephan Zipfel. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 24.04.2020.)

Objective: A systematic review of health interventions using avatars ( N  = 18) was conducted to provide comprehensive knowledge of the effectiveness of using avatars to promote healthy behaviors, specifically in relationship to healthy eating and exercising. Materials and Methods: Two researchers identified field or laboratory studies that had quantified study results, which were published in peer-reviewed journals in English from January 2000 to March 2019. Databases (PsychInfo, PubMed, and Web of Science), forward reference, and manual searches were used to identify the studies. Search terms included avatar, the Proteus effect, exercise, and diet, among others. Two field interventions and 16 laboratory studies were identified. Information on sample characteristics, technologies used, study design and conditions pertaining to avatars, outcome measures, results, and conclusion were extracted. Results: Six different avatar characteristics used to elicit health outcomes were identified, which are the similarity with the user, avatar body size, self-domain (e.g., ideal-self), customizability, body transformation, and avatar's behaviors. Only a few studies had a no-avatar control group; thus, it was not possible to conclude whether employing avatars in health interventions increases the effectiveness of the interventions in comparison to not using an avatar. Conclusion: The results indicate that using an avatar that is physically active, fit, and similar-looking (to the user) is effective in eliciting healthy behaviors.

Neurofeedback video games respond to electrical brain signals instead to a mouse, joystick, or game controller input. These games embody the concept of improving physiological functioning by rewarding specific healthy body signals with success at playing a video game. In this paper, a threefold framework in reference to attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) treatment blending with neurofeedback techniques and video game implementation is presented. In particular, the specifications of a neurofeedback-based video game for children dealing with ADHD, in order to enhance attention and concentration skills, are analyzed. Potential boundaries of this cognitive enhancement approach and authors future directions are also discussed.

Objective: In recent years, immersive videogame technologies such as virtual reality have been shown to affect psychological welfare in such way that they can be applied to clinical psychology treatments. However, the effects of videogaming with other immersive gaming apparatuses such as commercial electroencephalography (EEG)-based brain-computer interfaces (BCIs) on psychological welfare have not been extensively researched. Thus, we aimed at providing early insights into some of these effects by looking at how videogaming with a commercial EEG-based BCI would impact mood and physiological arousal. Materials and Methods: A total of 26 participants were sampled. Participants were randomly assigned to either a BCI condition or a traditional condition wherein they played an action videogame with a commercial EEG-based BCI or a standard keyboard and mouse interface for 20 minutes. In both conditions, participants filled out the profile of mood states to assess mood and the perceived stress scale to control for stress. We also measured heart rate, heart rate variability as measured by the root mean square of successive differences, and galvanic skin response (GSR) amplitude differences. Results: Participants in the BCI condition overall reported a significantly higher total mood disturbance ( P  < 0.05), tension ( P  < 0.05), confusion ( P  < 0.05), and significantly less vigor ( P  < 0.05). We also found that participants in the BCI condition had significantly lower GSR amplitude differences between gaming and baseline ( P  < 0.05). Conclusion: The results suggest that the use of commercial EEG-based BCIs for playing with videogames can induce greater frustration and negative moods than playing with a traditional keyboard and mouse interface, possibly limiting their use in clinical psychology settings.

Video gaming as a popular form of leisure activity and its effect on cognition, brain function, and structure has come into focus in the field of neuroscience. Visuospatial cognition and attention seem to benefit the most, whereas for executive functions, memory, and general cognition, the results are contradictory. The particular characteristics of video games driving these effects remain poorly understood. We critically discuss major challenges for the existing research, namely, the lack of precise definitions of video gaming, the lack of distinct choice of cognitive ability under study, and the lack of standardized study protocols. Less research exists on neural changes in addition to cognitive changes due to video gaming. Existing studies reveal evidence for the involvement of similar brain regions in functional and structural changes. There seems to be a predominance in the hippocampal, prefrontal, and parietal brain regions; however, studies differ immensely, which makes a meta-analytic interpretation vulnerable. We conclude that theoretical work is urgently needed.
., (© 2019, AICH – Servier GroupCopyright © 2019 AICH – Servier Group. All rights reserved.)

Smartphones and other personal electronic devices present novel cortical processing tasks with potential for identification of novel EEG waveforms. A 17-year-old patient with epilepsy manifested as recurrent myoclonic seizures, absence seizures, and a single generalized tonic-clonic seizure was hospitalized to undergo video-EEG monitoring for seizure quantification and classification of the epilepsy syndrome. During the monitoring session, a frontocentral predominant 5 to 6 Hz theta rhythm was identified only when the patient was actively texting or playing a video game on his smartphone. Previously, patients with focal epilepsy have been found to have a frontocentral theta rhythm on EEG while texting on mobile devices. We report similar EEG findings in a patient with genetic generalized epilepsy during smartphone gaming to expand the population and triggers for this theta waveform. Given the young age and type of epilepsy, we suggest that the waveform represents the EEG manifestation of the attention-visuomotor pathway that is stimulus independent.

Background: Video games have grown in popularity since the 1970s, and tobacco imagery is present in a substantial subset of games, including those oriented to youth. Much like exposure to tobacco content in films, exposure to tobacco content in video games may influence smoking uptake and use; however, the tobacco industry's role in facilitating or promoting the use of tobacco imagery in video games is unclear. We explored the industry's interest in and use of video games to market their products to youth and young adults., Methods: We retrieved and analyzed archival tobacco industry documents. We supplemented information from the documents with current and archived versions of several brand and corporate websites and one website containing user-supplied information on video games., Results: Tobacco companies recognized the youth appeal and marketing potential of video games as early as 1980. Initial marketing ideas included incorporating video game themes into product packaging and design. More fully realized plans focused on incorporating video games into product promotions in bars, as a high visibility way to attract younger patrons and increase long-term marketing opportunities by generating names for tobacco company direct-marketing databases. Tobacco companies also incorporated video games into in-home product promotions, primarily as components of brand websites, in order to enhance brand image and generate repeat website traffic. A similar desire to attract and keep visitors led to discussions about the inclusion of video games on corporate youth smoking prevention websites, although only one company, Lorillard, followed through., Conclusions: Video game players are an attractive target market for tobacco companies. Video games, as used by these companies, facilitate consumer engagement with particular tobacco brands or particular corporate messages. Eliminating the use of video games as a promotional vehicle may require limiting tobacco marketing in both physical and online environments., Competing Interests: The authors have declared no competing interests exist.

Objective: The aim of this study was to investigate which narrative elements of digital game narratives are preferred by the general adolescent population, and to examine associations with gender, socioeconomic status (SES), and gameplay frequency. Further, the study aims to discuss how results can be translated to serious digital games. Materials and Methods: Adolescents were recruited through school to complete a survey on narrative preferences in digital games. The survey included questions on sociodemographic information, frequency of gameplay, and an open-ended question on what could be an appealing narrative for them. Data were analyzed in a mixed-methods approach, using thematic analysis and chi-square analyses to determine narrative preferences and the associations between game narrative elements and player characteristics (gender, SES, and frequency of gameplay). Results: The sample consisted of 446 adolescents (12-15 years old) who described 30 narrative subthemes. Preferences included human characters as protagonists; nonhuman characters only as antagonists; realistic settings, such as public places or cities; and a strong conflict surrounding crime, catastrophe, or war. Girls more often than boys defined characters by their age, included avatars, located the narrative in private places, developed profession-related skills, and included a positive atmosphere. Adolescents of nonacademic education more often than adolescents of academic education defined characters by criminal actions. Infrequent players more often included human characters defined by their age than frequent players. After performing a Bonferroni correction, narrative preferences for several gender differences remained. Conclusion: Different narrative elements related to subgroups of adolescents by gender, SES, and frequency of gameplay. Customization of narratives in serious digital health games should be warranted for boys and girls; yet, further research is needed to specify how to address girls in particular.

Recent years have seen an emergence of social emotional computer games for individuals with Autism Spectrum Disorder (ASD). These games are heterogeneous in design with few underpinned by theoretically informed approaches to computer-based interventions. Guided by the serious game framework outlined by Whyte et al. (Journal of Autism and Developmental Disorders 45(12):1-12, 2014), this study aimed to identify the key motivating and learning features for serious games targeting emotion recognition skills from the perspectives of 11 youth with ASD and 11 experienced professionals. Results demonstrated that youth emphasised the motivating aspects of game design, while the professionals stressed embedding elements facilitating the generalisation of acquired skills. Both complementary and differing views provide suggestions for the application of serious game principles in a potential serious game.

This study explores brain-computer interfacing, its possible use in serious or educational games and frameworks. Providing real-time feedback regarding cognitive states and behaviours can be a powerful tool for mental health education and games can offer unique and engaging environments for these neurofeedback experiences. We explore how EEG neurofeedback systems can be affordably created for further research and experimentation and suggest design choices that may assist in developing effective experiences of this nature.

The field of technological behavioural addictions is moving towards specific problems (i.e., gaming disorder). However, more evidence of generalised versus specific Internet use-related addiction problems (generalised pathological Internet use (GPIU) vs. specific pathological Internet use (SPIU)) is still needed. This mixed methods study aimed to disentangle GPIU from SPIU. A partially mixed sequential equal status study design (QUAN→QUAL) was undertaken. First, through an online survey, which adapted the compulsive Internet use scale (CIUS) for three types of problems (i.e., generalised Internet use, and specific online gaming and social networking). Second, potential problem users' perceptions of the evolution of these problems (aetiology, development, consequences, and factors) were ascertained, through semi-structured interviews, together with their opinion on present Internet gaming disorder (IGD) criteria adapted to each problem studied. Findings showed the CIUS remains valid and reliable for GPIU and SPIUs examined; a prevalence between 10.8% and 37.4% was estimated for potential at-risk problem gamers and Internet users, respectively, who reported their preference for maintaining their virtual lives. Half of the sample had a risk of a unique or mixed profile of these problems. Moreover, device patterns, gender, and age issues emerged, such as problem gamers being proportionally equal male and female young or middle-aged adults. GPIU was highly associated with problem social networking use, and weakly with problematic gaming, but both SPIUs were independent. Concerning addictive symptoms, salience, deception, and tolerance required redefinition, especially for SPIUs, while better-valued IGD criteria applied to GPIU and SPIUs were: Risk relationships or opportunities, give up other activities, withdrawal, and continue despite problems. Thus, although problems studied are present as risk behaviours, SPIUs seem to cover the addictive symptomatology in those categorised as potential problem users, online gaming being the most severe behavioural addiction problem.

Background: Multiplayer games have emerged as a promising approach to increase the motivation of patients involved in rehabilitation therapy. In this systematic review, we evaluated recent publications in health-related multiplayer games that involved patients with cognitive and/or motor impairments. The aim was to investigate the effect of multiplayer gaming on game experience and game performance in healthy and non-healthy populations in comparison to individual game play. We further discuss the publications within the context of the theory of flow and the challenge point framework., Methods: A systematic search was conducted through EMBASE, Medline, PubMed, Cochrane, CINAHL and PsycINFO. The search was complemented by recent publications in robot-assisted multiplayer neurorehabilitation. The search was restricted to robot-assisted or virtual reality-based training., Results: Thirteen articles met the inclusion criteria. Multiplayer modes used in health-related multiplayer games were: competitive, collaborative and co-active multiplayer modes. Multiplayer modes positively affected game experience in nine studies and game performance in six studies. Two articles reported increased game performance in single-player mode when compared to multiplayer mode., Conclusions: The multiplayer modes of training reviewed improved game experience and game performance compared to single-player modes. However, the methods reviewed were quite heterogeneous and not exhaustive. One important take-away is that adaptation of the game conditions can individualize the difficulty of a game to a player's skill level in competitive multiplayer games. Robotic assistance and virtual reality can enhance individualization by, for example, adapting the haptic conditions, e.g. by increasing haptic support or by providing haptic resistance. The flow theory and the challenge point framework support these results and are used in this review to frame the idea of adapting players' game conditions.

Rationale: Mental and behavioral health recovery includes concepts related not just to symptom improvement, but also to participating in activities that contribute to wellness and a meaningful life. Video game play can relieve stress and provide a way to connect, which may be especially important for military veterans., Objective: We examined how military veterans used video game play to further their mental and behavioral health recovery by conducting an exploratory thematic analysis of the gaming habits of 20 United States military veterans who were in treatment for mental or behavioral health problems., Method: We conducted semi-structured interviews in 2016 and used a framework analytic approach to determine salient themes linking video gaming to mental and behavioral health recovery., Results: Veteran participants reported that video games helped not only with managing moods and stress, but also with three areas related to other aspects of recovery: adaptive coping (e.g. distraction, control, symptom substitution); eudaimonic well-being (confidence, insight, role functioning); and socializing (participation, support, brotherhood). Meaning derived from game narratives and characters, exciting or calming gameplay, and opportunities to connect, talk, and lead others were credited as benefits of gaming. Responses often related closely to military or veteran experiences. At times, excessive use of games led to life problems or feeling addicted, but some veterans with disabilities felt the advantages of extreme play outweighed these problems., Conclusion: Video games seem to provide some veterans with a potent form of "personal medicine" that can promote recovery. Although reasons and results of gaming may vary within and among individuals, clinicians may wish to discuss video game play with their patients to help patients optimize their use of games to support recovery., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: With limited social options, young Saudis are increasingly relying on media for entertainment. The media impact has been greatest among the younger generation, which constitutes half of the population of the Kingdom of Saudi Arabia (KSA). Therefore, this study aims to examine the association between exposure to varied types of media and substance use among adolescents in the KSA and explores whether these associations differ by gender., Methods: Data were obtained from a national cross-sectional survey of school students aged ten to 19 years (N = 12121). A self-administered questionnaire was used to assess exposure to three types of media: television, the Internet and video games with the use of legal substances such as cigarette/shisha smoking, solvents sniffing and misuse of medications, and illegal substances, such as alcohol, marijuana and other illicit drugs., Results: Logistic regression analyses revealed that the odds of using tobacco, legal and illegal substances were higher for students who were watching television, surfing the Internet, or playing video games for more than two hours compared with their peers who watched less than two hours (P < 0.05). For males, results showed the heavy and light use of the Internet were both significantly associated with smoking. Whereas for females, only excessive use of the Internet was associated with smoking., Conclusion: Despite the conservative nature of the Saudi society, findings showed a significant association between tobacco or substance use and media exposure among adolescents. This suggests increased attention to the growing role media might play in shaping adolescents health risk behaviors in the KSA., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aim: The Scratch programming language allows learner developers to write games. The Kinect2Scratch extension makes Scratch games with bodily motion control possible by connecting to Microsoft's Kinect sensor. This study examined the feasibility and possible efficacy of a suite of motion-controlled games designed for upper extremity (UE) training in children with cerebral palsy (CP) using Kinect2Scratch., Materials and Methods: This is a proof-of-concept study. We developed three games, requiring three UE movement patterns (shoulder holding, reaching, and handclap), for use in children with CP. The primary outcome was feasibility, addressed by adherence, engagement, satisfaction, and safety. The secondary outcome was efficacy, which was evaluated by Quality of Upper Extremities Skills Test (QUEST), Box and Block Test (BBT), Melbourne Assessment 2 (MA2) test, and ABILHAND-kids score., Results: Thirteen children with CP (mean age 6.9 years) received 24 sessions of training (30 minutes per session). The adherence rate was 100%. During the first 2 weeks of training, children had a significantly higher level of participation in Kinect2Scratch training than in conventional rehabilitation [Pittsburgh Participation Scale, median (interquartile range [IQR]), 6 (3-6) vs. 4 (3-6) P = 0.04]. However, during the last 2 weeks of training, there was no significant difference in participation between the Kinect2Scratch and conventional training [Pittsburgh Rehabilitation Participation Scale, median (IQR), 4 (3-5) vs. 4 (3-6) P = 0.55]. Most children enjoyed playing the games. The mean score of enjoyment was 4.54 ± 0.66. There were no adverse events during the training periods. The children had significant improvement in total score of QUEST and MA2. There were no significant improvements in BBT and ABILHAND-kids score., Conclusion: Using Kinect2Scratch games for UE training is a feasible adjunctive program for children with CP.

Background: Current evidence for the effectiveness of specialist multidisciplinary programs for burdensome chronic pain and functional somatic syndromes drives the effort to improve approaches, strategies, and delivery modes. It remains unknown to what extent and in what respect serious gaming during the regular outpatient rehabilitation can contribute to health outcomes., Objective: The objectives of our study were to determine the effect of additional serious gaming on (1) physical and emotional functioning in general; (2) particular outcome domains; and (3) patient global impressions of change, general health, and functioning and to determine (4) the dependency of serious gaming effects on adherence., Methods: We conducted a naturalistic quasi-experiment using embedded qualitative methods. The intervention group patients received an additional guided (mindfulness-based) serious gaming intervention during weeks 9-12 of a 16-week rehabilitation program at 2 sites of a Dutch rehabilitation clinic. Simultaneously, 119 control group patients followed the same program without serious gaming at 2 similar sites of the same clinic. Data consisted of 10 semistructured patient interviews and routinely collected patient self-reported outcomes. First, multivariate linear mixed modeling was used to simultaneously estimate a group effect on the outcome change between weeks 8 and 16 in 4 primary outcomes: current pain intensity, fatigue, pain catastrophizing, and psychological distress. Second, similar univariate linear mixed models were used to estimate effects on particular (unstandardized) outcomes. Third, secondary outcomes (ie, global impression of change, general health, functioning, and treatment satisfaction) were compared between the groups using independent t tests. Finally, subgroups were established according to the levels of adherence using log data. Influences of observed confounding factors were considered throughout analyses., Results: Of 329 eligible patients, 156 intervention group and 119 control group patients (N=275) with mostly chronic back pain and concomitant psychosocial problems participated in this study. Of all, 119 patients played ≥75% of the game. First, the standardized means across the 4 primary outcomes showed a significantly more favorable degree of change during the second part of the treatment for the intervention group than for the control group (beta=-0.119, SE=0.046, P=.009). Second, the intervention group showed a greater outcome change in depressive mood (b=-2.748, SE=1.072, P=.011) but not in "insufficiency" or concentration problems. Third, no significant group effects on secondary outcomes were found. Fourth, adherence was generally high and invariant., Conclusions: The findings of this study suggest a very small favorable average effect on relevant health outcomes of additional serious gaming during multidisciplinary rehabilitation. The indication that serious gaming could be a relatively time-efficient component warrants further research into if, when, how, and for which patients serious gaming could be cost-effective in treatment and why., Trial Registration: Netherlands Trial Registry NTR6020; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6020 (Archived by WebCite at http://www.webcitation.org/71IIoTXkj)., (©Miel AP Vugts, Margot CW Joosen, Agali Mert, Aglaia ME Zedlitz, Hubertus JM Vrijhoef. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 15.08.2018.)

Background and Aims: An important theory of attention suggests that there are three separate networks that execute discrete cognitive functions: alerting, orienting and conflict networks. Recent studies showed that there was a dysfunction of attention in Internet Addiction. In order to investigate the underlying mechanism of attention dysfunction in Internet Addiction, we recorded performance related to the Attentional Network Test (ANT) in youth., Methods: The ANT, a behavioral assay of the functional integrity of attention networks, was used to examine the performance in Internet Addiction and healthy controls., Results: Performance on the ANT clearly differentiated the participants with and without Internet Addiction in terms of mean reaction times (RTs). Compared with control group, the Internet Addiction group detected targets more slowly and this effect was evident only for spatial cue condition. The Internet Addiction group demonstrated deficits in the orienting network in terms of slower RT. There was no demonstration of a deficit in both the alerting and conflict network in Internet Addiction on this task., Conclusions: The youth with Internet Addiction demonstrated deficits in the orienting network but normal functioning of the alerting and conflict attention networks., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Our aim was to quantify the health risks and benefits of Pokémon Go, an augmented reality game played on the mobile phone utilizing real-world locations., Materials and Methods: Healthcare encounters containing references to Pokémon Go in Kaiser Permanente Northern California (KPNC) from July 5, 2016 to November 5, 2016 were reviewed. Subjects were classified according to the nature of the healthcare encounter subsequent to playing Pokémon Go: adverse event/injury, self-reported benefit, or incidental mention. Comparisons were made using the Wilcoxon-Mann-Whitney nonparametric test where variables were continuous and the chi-squared or Fisher's exact test where variables were binomial., Results: Of 222 Pokémon Go players reporting an adverse event or benefit, 75 (33.8%) experienced adverse events and 147 (66.2%) reported benefits. Among our cohort, 114 subjects (54.0%) were obese, and 62 (27.9%) were diabetic or prediabetic. More subjects reporting benefits had an endocrine-related comorbidity than those reporting injuries (40.1% vs. 16.0%, P < 0.001). Median family income was higher in the benefit group than in the adverse event group ($83,846 vs. $70,378, P = 0.027). Of 75 subjects having adverse events, 8 (10.7%) had severe injuries, including fractures and head trauma, with 4 (5.3%) having inpatient stays. Most adverse events were musculoskeletal or skin injuries (n = 51, 68.0%)., Conclusions: Injuries were similar to those seen with other light-to-moderate outdoor physical activities. Given KPNC's membership of 3.85 million, the number of severe injuries reported was low; this suggests that the game is safe to play. Pokémon Go may be reaching a population that requires increased physical activity.

Background: The insertion of a chest tube should be as quick and accurate as possible to maximize the benefit and minimize possible complications for the patient. Therefore, comprehensive training and assessment before an emergency situation are essential for proficiency in chest tube insertion. Serious games have become more prevalent in surgical training because they enable students to study and train a procedure independently, and errors made have no effect on patients. However, up-to-date evidence regarding the effect of serious games on performance in procedures in emergency medicine remains scarce., Objective: The aim of this study was to investigate the serious gaming approach in teaching medical students an emergency procedure (chest tube insertion) using the app Touch Surgery and a modified objective structural assessment of technical skills (OSATS)., Methods: In a prospective, rater-blinded, randomized controlled trial, medical students were randomized into two groups: intervention group or control group. Touch Surgery has been established as an innovative and cost-free app for mobile devices. The fully automatic software enables users to train medical procedures and afterwards self-assess their training effort. The module chest tube insertion teaches each key step in the insertion of a chest tube and enables users the meticulous application of a chest tube. In contrast, the module "Thoracocentesis" discusses a basic thoracocentesis. All students attended a lecture regarding chest tube insertion (regular curriculum) and afterwards received a Touch Surgery training lesson: intervention group used the module chest tube insertion and the control group used Thoracocentesis as control training. Participants' performance in chest tube insertion on a porcine model was rated on-site via blinded face-to-face rating and via video recordings using a modified OSATS tool. Afterwards, every participant received an individual questionnaire for self-evaluation. Here, trainees gave information about their individual training level, as well as previous experiences, gender, and hobbies. Primary end point was operative performance during chest tube insertion by direct observance., Results: A total of 183 students enrolled, 116 students participated (63.4%), and 21 were excluded because of previous experiences in chest tube insertion. Students were randomized to the intervention group (49/95, 52%) and control group (46/95, 48%). The intervention group performed significantly better than the control group (Intervention group: 38.0 [I 50 =7.0] points; control group: 30.5 [I 50 =8.0] points; P<.001). The intervention group showed significantly improved economy of time and motion (P=.004), needed significantly less help (P<.001), and was more confident in handling of instruments (P<.001) than the control group., Conclusions: The results from this study show that serious games are a valid and effective tool in education of operative performance in chest tube insertion. We believe that serious games should be implemented in the surgical curriculum, as well as residency programs, in addition to traditional learning methods., Trial Registration: German Clinical Trials Register (DRKS) DRKS00009994; https://www.drks.de/drks&#95;web/navigate.do?navigationId=trial.HTML&TRIAL&#95;ID=DRKS00009994 (Archived by Webcite at http://www.webcitation.org/6ytWF1CWg)., (©Patrick Haubruck, Felix Nickel, Julian Ober, Tilman Walker, Christian Bergdolt, Mirco Friedrich, Beat Peter Müller-Stich, Franziska Forchheim, Christian Fischer, Gerhard Schmidmaier, Michael C Tanner. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.05.2018.)

Objective: To evaluate whether people with Duchenne muscular dystrophy (DMD) practicing a task in a virtual environment could improve performance given a similar task in a real environment, as well as distinguishing whether there is transference between performing the practice in virtual environment and then a real environment and vice versa., Methods: Twenty-two people with DMD were evaluated and divided into two groups. The goal was to reach out and touch a red cube. Group A began with the real task and had to touch a real object, and Group B began with the virtual task and had to reach a virtual object using the Kinect system., Results: ANOVA showed that all participants decreased the movement time from the first (M = 973 ms) to the last block of acquisition (M = 783 ms) in both virtual and real tasks and motor learning could be inferred by the short-term retention and transfer task (with increasing distance of the target). However, the evaluation of task performance demonstrated that the virtual task provided an inferior performance when compared to the real task in all phases of the study, and there was no effect for sequence., Conclusions: Both virtual and real tasks promoted improvement of performance in the acquisition phase, short-term retention, and transfer. However, there was no transference of learning between environments. In conclusion, it is recommended that the use of virtual environments for individuals with DMD needs to be considered carefully.

Objective: Finding suitable and engaging ways for older people living in long-term care (LTC) to engage in physical activity, to maintain function is challenging. There is a need to explore the use of exergames for LTC residents who have mobility and cognitive impairments. We investigated the effect of a group-based Xbox Kinect (Microsoft Corp., Redmond, WA) exergame program on mobility in LTC residents with and without cognitive impairment., Methods: Facilities were randomly assigned to the intervention (four facilities, n = 29, aged 84.7 ± 7.4 years) or control group (five facilities, n = 36, aged 85.8 ± 7.2 years). The intervention group played Xbox Kinect exergames twice weekly for 8 weeks. The control group continued usual activities. The primary outcome measure was mobility, assessed pre- and postintervention using the de Morton Mobility Index (DEMMI)., Results: DEMMI scores improved in residents who played exergames, although this did not reach significance (P = 0.06). There was no interaction between cognition scores and DEMMI scores (P = 0.86). Participants attended an average of 55% of scheduled exergames sessions., Conclusion: The trend toward improvement in mobility, as well as attendance rates indicate that the Xbox Kinect exergames were engaging for a proportion of residents. On this basis, further exergames development for LTC residents warrants attention.

Objective: The most productive methods of recruitment for a videogame for health (G4H) trial are not known. Success or failure of recruitment methods has been reported for a variety of clinical trials, but few specifically for G4H trials. This study's goal was to recruit 444 overweight or obese (body mass index percentile between the 84.5th-99.4th percentiles) children between the ages of 10-12 years. The article reports the results of different methods of participant recruitment., Materials and Methods: Participants had to agree to three fasting blood samples (baseline, immediately after, and 2 months later); be willing to wear an accelerometer for 7 days at each assessment; read and speak English fluently (because the games were in English); have no history of any condition that would affect what he/she could eat or how much physical activity he/she could get; and have an eligible home computer purchased in the last 5 years with high-speed internet. Hardware criteria reflected the types of computers upon which Diab-Nano could be effectively played. Recruitment was conducted over a 35-month period and included electronic media, print advertising, community recruitment, and an internal volunteer list. Respondents were guided to a web-based screening questionnaire that asked for source of hearing about the study., Results: Although diverse recruitment methods were used, slow recruitment resulted in obtaining only 45% of the recruitment goal (n = 199). Electronic media (e.g., radio, television, and internet), which reached millions of targeted parents, resulted in only 76 respondents, of whom 13 became participants; print media (e.g., magazine, newsletter/newspaper, and mail), which also reached large numbers of parents, resulted in 192 respondents, of whom 19 became participants; community recruitment (e.g., school, friend or family, doctors office, flyer, work, community program) resulted in 162 respondents, of whom 38 became participants; and the internal volunteer list resulted in 413 respondents, of whom 128 became participants., Conclusion: Inclusionary and exclusionary criteria and restricted access by gatekeepers could be deterrents to successful recruitment. The documented payoff of alternative comprehensive methods of recruitment should benefit other investigations in optimally allocating their recruitment resources.

Background: Hand strength weakness affects the performance of most activities of daily living. This study aims to design, develop, and test an electromyography (EMG) biofeedback training system based on serious games to promote motivation and synchronization and proper work intensity in grip exercises for improving hand strength., Materials and Methods: An EMG surface sensor, soft balls with different stiffness and three exergames, conforms the system to drive videogame clues in response to EMG-inferred grip strength, while overseeing motivation. An experiment was designed to study the effect of performing handgrip (HG) exercises with the proposed system versus traditional exercises. Participants, organized into two groups, followed a training program for each hand. One group followed a HG exergame training (ET) with the dominant hand and traditional HG training with the nondominant hand and inverse sequence by the second group. Initial and final grip forces were measured using a digital dynamometer. Questionnaires evaluated motivation and user experience, and exercise performance was evaluated in terms of work and rest time percentage and maximal voluntary contraction percentage over contraction periods. Data were analyzed for statistically significant differences and increase of means., Results: Participants showed significantly better exercise performance and higher grip forces, with sustained intrinsic motivation and user experience, with the ET., Conclusion: Improvement in force level arises evidently from the synchronized work-rest time pattern and appropriated intensity of the muscle activity. This leads to support that EMG biofeedback exergames improve motor neurons firing and resting.

Study Objectives: Insufficient sleep among adolescents carries significant health risks, making it important to determine social factors that change sleep duration. We sought to determine whether the self-reported sleep duration of U.S. adolescents changed between 2009 and 2015 and examine whether new media screen time (relative to other factors) might be responsible for changes in sleep., Methods: We drew from yearly, nationally representative surveys of sleep duration and time use among adolescents conducted since 1991 (Monitoring the Future) and 2007 (Youth Risk Behavior Surveillance System of the Centers for Disease Control; total N = 369,595)., Results: Compared to 2009, adolescents in 2015 were 16%-17% more likely to report sleeping less than 7 h a night on most nights, with an increase in short sleep duration after 2011-2013. New media screen time (electronic device use, social media, and reading news online) increased over this time period and was associated with increased odds of short sleep duration, with a clear exposure-response relationship for electronic devices after 2 or more hours of use per day. Other activities associated with short sleep duration, such as homework time, working for pay, and TV watching, were relatively stable or reduced over this time period, making it unlikely that these activities caused the sudden increase in short sleep duration., Conclusions: Increased new media screen time may be involved in the recent increases (from 35% to 41% and from 37% to 43%) in short sleep among adolescents. Public health interventions should consider electronic device use as a target of intervention to improve adolescent health., (Copyright © 2017 Elsevier B.V. All rights reserved.)

The American Psychiatric Association recently included Internet gaming disorder (IGD) as a potential diagnosis, recommending that further study be conducted to help illuminate it more clearly. This paper is a summary of the review undertaken by the IGD Working Group as part of the 2015 National Academy of Sciences Sackler Colloquium on Digital Media and Developing Minds. By using measures based on or similar to the IGD definition, we found that prevalence rates range between ∼1% and 9%, depending on age, country, and other sample characteristics. The etiology of IGD is not well-understood at this time, although it appears that impulsiveness and high amounts of time gaming may be risk factors. Estimates for the length of time the disorder can last vary widely, but it is unclear why. Although the authors of several studies have demonstrated that IGD can be treated, no randomized controlled trials have yet been published, making any definitive statements about treatment impossible. IGD does, therefore, appear to be an area in which additional research is clearly needed. We discuss several of the critical questions that future research should address and provide recommendations for clinicians, policy makers, and educators on the basis of what we know at this time., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Bavelier is a founding member and on the scientific advisory board of Akili Interactive. Dr Petry is a member of the American Psychiatric Association Diagnostic and Statistical Manual, Fifth Edition Workgroup on substance use and related conditions. Opinions and points of view expressed are those of the authors and do not necessarily reflect the official position or policies of the US Navy, the Department of Defense, the American Psychiatric Association, or other organizations with which the authors are affiliated. Dr Cash and Ms Rae are affiliated with reSTART Life, LLC, an Internet gaming disorder treatment facility; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

In this article, we examine the impact of digital screen devices, including television, on cognitive development. Although we know that young infants and toddlers are using touch screen devices, we know little about their comprehension of the content that they encounter on them. In contrast, research suggests that children begin to comprehend child-directed television starting at ∼2 years of age. The cognitive impact of these media depends on the age of the child, the kind of programming (educational programming versus programming produced for adults), the social context of viewing, as well the particular kind of interactive media (eg, computer games). For children <2 years old, television viewing has mostly negative associations, especially for language and executive function. For preschool-aged children, television viewing has been found to have both positive and negative outcomes, and a large body of research suggests that educational television has a positive impact on cognitive development. Beyond the preschool years, children mostly consume entertainment programming, and cognitive outcomes are not well explored in research. The use of computer games as well as educational computer programs can lead to gains in academically relevant content and other cognitive skills. This article concludes by identifying topics and goals for future research and provides recommendations based on current research-based knowledge., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: The smartphone game Pokémon Go™ has attracted much scientific attention regarding its potential health-related outcomes. Most studies, however, limited their investigation to short-term outcomes. The aim of the present study is to investigate the role of personality traits in predicting sustained playing to the game on a 6-month period as well as related health outcomes in terms of distance walked per day., Materials and Methods: Pokémon Go players from 10 countries were recruited through social media and answered an online questionnaire. At Phase I (August 2016), 402 participants provided their game statistics and filled an extensive personality inventory (six main personality traits, impulsivity, need for cognition, need for closure, competitiveness, and self-efficacy). At Phase II (December 2016), 151 participants indicated whether they were still playing or not and provided updated game statistics., Results: No personality traits predicted the distance walked by the players. However, the probability of still being playing the game at Phase II was positively predicted by three personality traits: agreeableness, perseverance, and premeditation. Distance walked per day significantly decreased between Phases I and II but remained substantial., Conclusion: This study identified three personality traits that predicted sustained playing and thus potentially higher game-related physical activity in the long run. In comparison with prior work, this study goes a step forward by (i) investigating personality traits underlying use of the game and related health outcomes, and (ii) providing longitudinal data concerning the use of the game. Findings open new perspectives for the development of other exergames.

Background: Studies exploring the association between physical activity, screen time and sleep and pain usually focus on a limited number of painful body sites. Nevertheless, pain at different body sites is likely to be of different nature. Therefore, this study aims to explore and compare the association between time spent in self-reported physical activity, in screen based activities and sleeping and i) pain presence in the last 7-days for 9 different body sites; ii) pain intensity at 9 different body sites and iii) global disability., Methods: Nine hundred sixty nine students completed a questionnaire on pain, time spent in moderate and vigorous physical activity, screen based time watching TV/DVD, playing, using mobile phones and computers and sleeping hours. Univariate and multivariate associations between pain presence, pain intensity and disability and physical activity, screen based time and sleeping hours were investigated., Results: Pain presence: sleeping remained in the multivariable model for the neck, mid back, wrists, knees and ankles/feet (OR 1.17 to 2.11); moderate physical activity remained in the multivariate model for the neck, shoulders, wrists, hips and ankles/feet (OR 1.06 to 1.08); vigorous physical activity remained in the multivariate model for mid back, knees and ankles/feet (OR 1.05 to 1.09) and screen time remained in the multivariate model for the low back (OR = 2.34. Pain intensity: screen time and moderate physical activity remained in the multivariable model for pain intensity at the neck, mid back, low back, shoulder, knees and ankles/feet (Rp 2 0.02 to 0.04) and at the wrists (Rp 2  = 0.04), respectively. Disability showed no association with sleeping, screen time or physical activity., Conclusions: This study suggests both similarities and differences in the patterns of association between time spent in physical activity, sleeping and in screen based activities and pain presence at 8 different body sites. In addition, they also suggest that the factors associated with the presence of pain, pain intensity and pain associated disability are different.

Objective: To describe the Papo Reto [Straight Talk] game and reflect on its theoretical-methodological basis., Method: Analytical study on the process of elaboration of the Papo Reto online game, destined to adolescents aged 15-18 years, with access to the Game between 2014 and 2015., Results: the interactions of 60 adolescents from Belo Horizonte and São Paulo constituted examples of the potentialities of the Game to favor the approach to sexuality with adolescents through simulation of reality, invention and interaction. Based on those potentialities, four thinking categories were discussed: the game as pedagogic device; the game as simulation of realities; the game as device for inventive learning; and the game empowering the interaction., Conclusion: By permitting that the adolescents take risks on new ways, the Game allows them to become creative and active in the production of senses, in the creation of their discourses and in the ways of thinking, feeling and acting in the sexuality field.