Game Related Illness and Injuries A review of articles, rhetoric, and realities Alan Au – June 12, 2009 Games for Health 2009

Who Am I? Graduate student at the Univ. of Wash. Medical Education and Biomedical Informatics Looking for a job soon? Game industry freelance writer NOT a medical doctor NOT a movie industry art director

Graduate student at the Univ. of Wash.

Medical Education and Biomedical Informatics

Looking for a job soon?

Game industry freelance writer

NOT a medical doctor

NOT a movie industry art director

What Am I Playing?

This talk is about: Physical injuries (e.g. repetitive stress injury) Physiological reactions (e.g. motion sickness)

Physical injuries

(e.g. repetitive stress injury)

Physiological reactions

(e.g. motion sickness)

People Are Getting Hurt (?)

Why Should We Care? 97% of teens play games (in U.S.) Younger gamers prefer consoles, online play 53% of all adults play games (in U.S.) Older gamers prefer PCs, offline play Among gamers (in the U.S) 25% under age 18 49% between 18-49 26% over age 50 Numbers for Europe, Japan harder to find http://www.theesa.com/facts/pdfs/ESA_EF_2009.pdf http://www.pewinternet.org/~/media//Files/Reports/2008/PIP_Teens_Games_and_Civics_Report_FINAL.pdf.pdf http://www.pewinternet.org/~/media//Files/Reports/2008/PIP_Adult_gaming_memo.pdf.pdf

97% of teens play games (in U.S.)

Younger gamers prefer consoles, online play

53% of all adults play games (in U.S.)

Older gamers prefer PCs, offline play

Among gamers (in the U.S)

25% under age 18

49% between 18-49

26% over age 50

Numbers for Europe, Japan harder to find

Some Recent Headlines “Doctors Warn: Wii Puts 10 In Hospital a Week” (Fox News 2008) “Compulsive Video Gaming: Addiction or Vice?” (National Public Radio 2007) “A Wii Workout: When Videogames Hurt” (Wall Street Journal 2006)

“Doctors Warn: Wii Puts 10 In Hospital a Week” (Fox News 2008)

“Compulsive Video Gaming: Addiction or Vice?” (National Public Radio 2007)

“A Wii Workout: When Videogames Hurt” (Wall Street Journal 2006)

Blogs and Websites “ Wii Damage Toll: TVs Suffering The Most Abuse” (http://www.wiiinjury.com 2007) “ Denmark Destruction” (http://www.wiihaveaproblem.com 2007)

“ Wii Damage Toll: TVs Suffering The Most Abuse” (http://www.wiiinjury.com 2007)

“ Denmark Destruction” (http://www.wiihaveaproblem.com 2007)

Console Safety Manuals http://www.nintendo.com/consumer/manuals/index.jsp

Highlights From the Manuals Musculoskeletal stress injury Motion sickness Seizures Pacemaker interference Property damage Electric shock Laser and radiation hazard Battery leakage i.e. “Don’t open up your console.” http://www.xbox.com/en-US/support/familysettings/healthygamingguide.htm http://www.nintendo.com/consumer/manuals/index.jsp http://www.us.playstation.com/Support/Manuals/PS3

Musculoskeletal stress injury

Motion sickness

Seizures

Pacemaker interference

Property damage

Electric shock

Laser and radiation hazard

Battery leakage

Checking PubMed “ video game” (1312) “ game injury” (760) “ video game playing” (367) “ video game health” (327) “ video game therapy” (314) “ video game violence” (108) “ video game rehabilitation” (88) “ video game injury” (75) “ video game addiction” (71) “ videogame” (65)

“ video game” (1312)

“ game injury” (760)

“ video game playing” (367)

“ video game health” (327)

“ video game therapy” (314)

“ video game violence” (108)

“ video game rehabilitation” (88)

“ video game injury” (75)

“ video game addiction” (71)

“ videogame” (65)

What Else Is In PubMed? “injury” (753232) “fall risk” (7737) “thumb injury” (3251) “gambling addiction” (2715) “motion sickness” (2633) “photosensitive epilepsy” (1519) “tennis elbow” (1205) “repetitive stress injury” (475)

“injury” (753232)

“fall risk” (7737)

“thumb injury” (3251)

“gambling addiction” (2715)

“motion sickness” (2633)

“photosensitive epilepsy” (1519)

“tennis elbow” (1205)

“repetitive stress injury” (475)

Topics Repetitive Stress Injury Lateral epicondylitis (tennis elbow) Rashes and sores Bruises and bumps Fall risk Burns Eyestrain Photosensitive epilepsy Motion sickness (simulation sickness) Addiction Physiological stress

Repetitive Stress Injury

Lateral epicondylitis (tennis elbow)

Rashes and sores

Bruises and bumps

Fall risk

Burns

Eyestrain

Photosensitive epilepsy

Motion sickness (simulation sickness)

Addiction

Physiological stress

A Long Tradition Space Invaders’ Wrist (NEJM 1981) Video games and health (BMJ 2005) Wii have a problem: a review of self-reported Wii related injuries (Inform Prim Care 2009) McCowan, T. C. Space Invaders Wrist. N Engl J Med. 1981 May 28;304(22):1368. Griffiths, M. Video games and health. BMJ 2005;331:122-123. Sparks D, Chase D, et al. Wii have a problem: a review of self-reported Wii related injuries. Inform Prim Care. 2009;17(1):55-7.

Space Invaders’ Wrist (NEJM 1981)

Video games and health (BMJ 2005)

Wii have a problem: a review of self-reported Wii related injuries (Inform Prim Care 2009)

Repetitive Stress Injury ‘ Nintendo Thumb’ Points to RSI (Wired 1998) PubMed: repetitive stress injury (475) U.S. Bureau of Labor Statistics 2008 “ Injuries from repetitive motion continue to be the event with the highest median days away from work for all private industries and service-providing industries.” http://www.bls.gov/news.release/osh2.nr0.htm

‘ Nintendo Thumb’ Points to RSI (Wired 1998)

PubMed: repetitive stress injury (475)

U.S. Bureau of Labor Statistics 2008

“ Injuries from repetitive motion continue to be the event with the highest median days away from work for all private industries and service-providing industries.”

Fake Plastic Guitar vs. Real Guitar “ Guitar hero? Pitcher hurt playing video game” (msnbc.com 2006) Joel Zumaya of the Detroit Tigers “ Endless Set List” achievement Play everything in one session?! Iron Bladder What about real guitar-playing? PubMed: “guitar hand injury” (6) Google: “guitar hand injury” (87,600)

“ Guitar hero? Pitcher hurt playing video game” (msnbc.com 2006)

Joel Zumaya of the Detroit Tigers

“ Endless Set List” achievement

Play everything in one session?!

Iron Bladder

What about real guitar-playing?

PubMed: “guitar hand injury” (6)

Google: “guitar hand injury” (87,600)

Lateral Epicondylitis PubMed: tennis elbow (1205) Dubbed “Wii-itis” in NEJM letter to editor “ Yet another result of Wii Tennis” (http://www.wiiinjury.com 2007) Elbow is tennis players’ most injured joint Also called “cell phone elbow” Jayanthi N., Sallay P., et al. Skill-level related injuries in recreational competition tennis players. Med Sci Tennis 2005. 10:12–15. Struijs, PA, Kerkhoffs, GM, et al. Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both-a randomized clinical trial. Am J Sports Med 2004; 32:462.

PubMed: tennis elbow (1205)

Dubbed “Wii-itis” in NEJM letter to editor

“ Yet another result of Wii Tennis” (http://www.wiiinjury.com 2007)

Elbow is tennis players’ most injured joint

Also called “cell phone elbow”

Rashes and Sores PlayStation palmar hidradenitis Holding controller tightly Lots of button-pressing The “How!” sign Rubbing controller against palm Kasraee B, Masouyé I, Piguet V (April 2009). "PlayStation palmar hidradenitis". Br. J. Dermatol. 160 (4): 892–4. Wood, J. The "How!" sign—a central palmar blister induced by overplaying on a Nintendo console. Arch Dis Child. 2001 April; 84(4):288.

PlayStation palmar hidradenitis

Holding controller tightly

Lots of button-pressing

The “How!” sign

Rubbing controller against palm

Bruises and Bumps Wii manual Blogs and websites Microsoft and Sony have waggle controllers in the works “ Impact” vests

Wii manual

Blogs and websites

Microsoft and Sony have waggle controllers in the works

“ Impact” vests

Fall Risk Most references talk about Wii being used to improve balance and reduce fall risk

Most references talk about Wii being used to improve balance and reduce fall risk

Burns “ Lawsuit Claims Microsoft Xbox Sparked Fire That Killed Baby” (Information Week 2007) Xbox power-supply overheating Device problem, not activity problem Microsoft issued a recall but didn’t fix design PubMed says 8 hits, but mostly burn recovery, or burn-related training

“ Lawsuit Claims Microsoft Xbox Sparked Fire That Killed Baby” (Information Week 2007)

Xbox power-supply overheating

Device problem, not activity problem

Microsoft issued a recall but didn’t fix design

PubMed says 8 hits, but mostly burn recovery, or burn-related training

Eyestrain PubMed: eyestrain (759) PubMed: video game eyestrain (5) 1991 Japanese study Shorter viewing distance while gaming (vs. TV) More complaints after gaming >120 min. Games use more rapid eye motion (vs. VDT work) Clinically, games and word processing are similar

PubMed: eyestrain (759)

PubMed: video game eyestrain (5)

1991 Japanese study

Shorter viewing distance while gaming (vs. TV)

More complaints after gaming >120 min.

Games use more rapid eye motion (vs. VDT work)

Clinically, games and word processing are similar

Photosensitive Epilepsy Pokemon TV show 1997 Over-reported cases due to media coverage Primarily a childhood disorder 5.7% of teenage epilepsy in U.K. 1995 PubMed: photosensitive epilepsy (1519) Quirk J., Fish D., et al. Incidence of photosensitive epilepsy: a prospective national study. Electroencephalography and Clinical Neurophysiology. 1995;95(4):260-267

Pokemon TV show 1997

Over-reported cases due to media coverage

Primarily a childhood disorder

5.7% of teenage epilepsy in U.K. 1995

PubMed: photosensitive epilepsy (1519)

Motion Sickness Not a new problem Flight simulators Since 1950s (Army report) Causes? Sensory conflict theory Postural instability theory Solutions? Adaptation No same-day flying 2%-3% cannot adapt http://www.hqda.army.mil/ari/pdf/RR%201832.pdf

Not a new problem

Flight simulators

Since 1950s (Army report)

Causes?

Sensory conflict theory

Postural instability theory

Solutions?

Adaptation

No same-day flying

2%-3% cannot adapt

Medical Addiction PubMed: video game addiction (71) PubMed: gambling addiction (2715) 2009 AMA ruling says not “addiction” 2008 article in Int J Ment Health Addiction “ The evidence so far suggests that genuinely excessive players are likely to have other underlying problems, and/or have inadequate time management skills. Excessive video game playing is therefore likely to be a symptom and not the cause of their problem.” Wood, R. Problems with the Concept of Video Game "Addiction": Some Case Study Examples. Int J Ment Health Addiction (2008) 6:169–178.

PubMed: video game addiction (71)

PubMed: gambling addiction (2715)

2009 AMA ruling says not “addiction”

2008 article in Int J Ment Health Addiction

“ The evidence so far suggests that genuinely excessive players are likely to have other underlying problems, and/or have inadequate time management skills. Excessive video game playing is therefore likely to be a symptom and not the cause of their problem.”

Addiction vs. Overuse AMA notes that “overuse” still problematic Treatment programs and support groups

AMA notes that “overuse” still problematic

Treatment programs and support groups

Carbon Monoxide Poisoning Google: "carbon monoxide poisoning" "video games“ (30,200) Almost all hits refer to a single article “5 incidents in which video games were being powered [during Hurricane Ike] accounted for 75% (15 of 20) of the pediatric poisonings.” Fife, C., Smith, L., et al. Dying to Play Video Games: Carbon Monoxide Poisoning From Electrical Generators Used After Hurricane Ike. Pediatrics 2009;123;e1035-e1038.

Google: "carbon monoxide poisoning" "video games“ (30,200)

Almost all hits refer to a single article

“5 incidents in which video games were being powered [during Hurricane Ike] accounted for 75% (15 of 20) of the pediatric poisonings.”

Wireless Interference BMJ 2008: “Wii seems safe with pacemakers” Wii-mote uses Bluetooth (2.4 GHz RF) Nintendo advises >9 inches Pacemaker companies say minimum of 2-9 inches American Heart Association warns about headphones but not devices or Bluetooth transmissions Xbox 360 uses proprietary 2.4 GHz RF PS3 controllers use Bluetooth Rajani R, Kumar A, et al. Cardiac Pacemakers and Wii BMJ 2008;337:a3103 http://americanheart.mediaroom.com/index.php?s=43&item=543

BMJ 2008: “Wii seems safe with pacemakers”

Wii-mote uses Bluetooth (2.4 GHz RF)

Nintendo advises >9 inches

Pacemaker companies say minimum of 2-9 inches

American Heart Association warns about headphones but not devices or Bluetooth transmissions

Xbox 360 uses proprietary 2.4 GHz RF

PS3 controllers use Bluetooth

Electrical Interference PubMed: iPod pacemaker (5) 2007 study says avoid < 2 inches 2008 and 2009 study say no risk Headphones seem to be a bigger problem because of the magnets Int. Heart J: “Electromagnetic interference with a bipolar pacemaker by an induction heating rice cooker.” Thaker JP, Patel MB, et al. Electromagnetic interference with pacemakers caused by portable media players. Heart Rhythm. 2008 Apr;5(4):538-44. Bassen, H. Low frequency magnetic emissions and resulting induced voltages in a pacemaker by iPod portable music players. Biomed Eng Online. 2008 Feb 1;7:7. Chiu CC, Huh J, et al. A prospective pediatric clinical trial of digital music players: do they interfere with pacemakers? J Cardiovasc Electrophysiol. 2009 Jan;20(1):44-9. Nagatomo T, Abe H, et al. Electromagnetic interference with a bipolar pacemaker by an induction heating (IH) rice cooker. Int Heart J. 2009 Jan;50(1):133-7.

PubMed: iPod pacemaker (5)

2007 study says avoid < 2 inches

2008 and 2009 study say no risk

Headphones seem to be a bigger problem because of the magnets

Int. Heart J: “Electromagnetic interference with a bipolar pacemaker by an induction heating rice cooker.”

Physiological Stress Cortisol (“stress” hormone) Increased blood pressure Cardiovascular activity Gastric secretion Music in games can increase stress Wii “Vitality Sensor” Pulse oximeter Games for relaxation Hebert S., Beland R. et al. Physiological stress response to video-game playing: the contribution of built-in music. Life Sciences 76 (2005) 2371–2380.

Cortisol (“stress” hormone)

Increased blood pressure

Cardiovascular activity

Gastric secretion

Music in games can increase stress

Wii “Vitality Sensor”

Pulse oximeter

Games for relaxation

Summary Growing media coverage Some scientific literature, but not much More people play games than exercise Games becoming more like exercise Most game injuries caused by overuse The old complaint used to be inactivity The emerging problem is overactivity

Growing media coverage

Some scientific literature, but not much

More people play games than exercise

Games becoming more like exercise

Most game injuries caused by overuse

The old complaint used to be inactivity

The emerging problem is overactivity

Work in Progress! Acknowledgements Ben Sawyer Freddy “Dr. Gamer” Chen, M.D. Ching-Ping Lin (UW) Work in progress! Questions? Comments? “How to win at Wii tennis…” aau@u washington edu

Acknowledgements

Ben Sawyer

Freddy “Dr. Gamer” Chen, M.D.

Ching-Ping Lin (UW)

Work in progress!

Questions? Comments?