1

Game Related Illnesses and Injuries

The accused, documented and related

Alan Au – May 27, 2010

Games for Health 2010

2

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

3

What Am I Playing?

4

This talk is about:

Physical injuries

(e.g. repetitive stress injury)

Physiological reactions

(e.g. motion sickness)

5

People Are Getting Hurt (?)

6

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 findhttp://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

7

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)

8

Blogs and Websites

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

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

9

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.

10

What’s 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)

11

Checking PubMed (t+1 year)

“video game” 1506 (1312) +14.8%“game injury” 824 (760) + 8.4%

“video game playing” 427 (367) +16.3%“video game health” 388 (327) +18.7%“video game therapy” 362 (314) +15.3%“video game violence” 129 (108) +19.4%“video game rehabilitation” 105 (88) +19.3%“video game injury” 89 (75) +18.7%“video game addiction” 90 (71) +26.8%

“videogame”* 70 (65) + 7.7%

12

Console Safety Manuals

http://www.nintendo.com/consumer/manuals/index.jsp

13

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.htmhttp://www.nintendo.com/consumer/manuals/index.jsphttp://www.us.playstation.com/Support/Manuals/PS3

14

Topics

• Hardware Problems (burns, electrical interference)• Repetitive Stress Injury• Lateral epicondylitis (tennis elbow)• Rashes and sores• Bruises and bumps• Foot injury and fall risk• Eyestrain and photosensitive epilepsy• Motion sickness (simulation sickness)• Addiction/Overuse and its side-effects• Physiological stress• Hearing loss

15

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

16

Radio 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:a3103http://americanheart.mediaroom.com/index.php?s=43&item=543

17

Electromagnetic 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.

18

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

19

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 (don’t pause either)

• What about real guitar-playing?– PubMed: “guitar hand injury” (6)– Google: “guitar hand injury” (87,600)

20

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.

21

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.

22

Bruises and Bumps

• Wii manual

• Blogs and websites

• Microsoft (Natal) and Sony (Move) controllers

• “Impact” vests?!

23

Foot Injury

• New England Journal of Medicine “A radiograph showed a small fracture of the base of

the fifth metatarsal. … The fracture probably resulted from the pull of the peroneus brevis muscle during inversion of the ankle.”

• Response (HealthDay) “Robert Gotlin, director of the Sports Rehabilitation

department at Beth Israel Medical Center in New York City, concurred with Eley's sense that while the risk for injury due to Wii gaming is real, it is not a cause for alarm.”

2010

Eley, K. A Wii Fracture. N Engl J Med. 2010 Feb 4;362:473-474. (letter to the editor)

24

Fall Risk

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

25

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

Misawa T, Shigeta S, et al. [Effects of video games on visual function in children] Nippon Eiseigaku Zasshi. 1991 Feb;45(6):1029-34. (in Japanese)

26

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

27

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

28

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.

Hearing Loss

• Noise-induced hearing loss

• Affects ~10 millions Americans a year

• >85 dB over a period of time (8 hrs)

• Associated with firearm use (veterans)

• 12%-15% of all children

2010

Harrison, R. Noise-induced hearing loss in children: A ‘less than silent’ environmental danger. Paediatr Child Health. 2008 May; 13(5): 377–382.

30

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.

31

Addiction vs. Overuse

• AMA notes that “overuse” still problematic

• Treatment programs and support groups

32

Sleep Deprivation

• Teen sleep deprivation a “growing” issue– Studies & reports are growing– Often cite gaming and other technologies

• Self-reported “addicts” suffer more– ~13% self-report rate– Remember, 98% of kids play games– Sleep deprivation a side-effect of overuse

2010

Woolems, A.G., Peszka, J.J., Mastin, D.F. The Effect of Console/Computer Game Play on Sleepiness and Sleep Hygiene. Sleep 2009;32:A415.Oka Y, Suzuki S, Inoue Y. Bedtime activities, sleep environment, and sleep/wake patterns of Japanese elementary school children. Behav Sleep Med. 2008;6(4):220-33.Jan Van den Bulck. Television Viewing, Computer Game Playing, and Internet Use and Self-Reported Time to Bed and Time out of Bed in Secondary-School Children. Sleep 2004;27(1):101-4.

33

Other Side-effects?

• 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.

34

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

35

Thank You!

• Special Thanks– Ben Sawyer– Freddy “Dr. Gamer” Chen, M.D.– Ching-Ping Lin (UW)

• Work in progress!

• Questions? Comments?

“How to win at Wii tennis…”

aau uw.edu@