GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 1, Number 5, 2012 Mary Ann Liebert,

, Inc. DOI: 10.1089/g4h.2012.0031

Original Articles

Videogames and Health Improvement: A Literature Review of Randomized Controlled Trials

1 Esmaeel Rahmani, MD, and Suzanne Austin Boren, PhD, MHA1,2

Abstract

Objective: There are potential benets of playing videogames for health improvement such as increasing knowledge about health-related issues by playing educational games and ghting a sedentary lifestyle by playing exergames. The number of systematic review articles about videogames and health improvement is limited. Therefore, the purpose of this study is to review those randomized controlled trials (RCTs) with the topic of videogames and health improvement. Materials and Methods: Several electronic databases were searched for RCTs testing videogames on health outcomes that were published in English between January 2000 and April 2012. Results: Forty-ve articles met the eligibility criteria and were categorized into ve groups: (1) videogames and patient pain and stress reduction (nine articles), (2) videogames and patient behavioral change (19 articles), (3) videogames and patient rehabilitation (eight articles), (4) videogames as diagnostic tools (three articles), and (5) videogames and cognitive ability (six articles). Conclusions: Most of the articles have shown promising results in using videogames within various elds of healthcare. Although exergames are the most prominent choice regarding health improvement, videogames have the potential to be used as a pain management tool, diagnostic tool, or educational tool. They also can be used as a facilitator in physical rehabilitation or cognitive loss prevention. More RCTs are needed to fully uncover the benets of using videogames for improving patients health.

Introduction ince the installation of the rst arcade videogame at Stanford University,1 videogames gradually have made their way into the lives of many people. Playing videogames has become one of the important free-time activities among children and young adults.2 School-age children dedicate an average of 60 minutes each day for playing videogames. The gaming industry is booming,3 and this amount of time is likely to be increased. The impact of videogames on everyday activity of children and young people has encouraged scientists to investigate the positive and negative effects of playing videogames on a persons health. There are studies focusing on the two major negative effects of videogame playing. Gentile et al.4 showed that playing videogames increases violence in children. Although a meta-analysis of published articles about the effect of violent videogames on childrens aggression debated that the term aggression is dened differently among researchers, most of the publications on this subject are biased, and there is no signicant evidence of
1 2

association between higher levels of aggression and violent videogames.5 The other negative effect is the relationship between sedentary lifestyle (minimum physical activity and obesity) and playing videogames68; however, some studies have found no such relationships.911 Also it has been discussed that game addiction or game dependency is another harmful effect of playing videogames, alongside with gender stereotyping.12 Speaking of positive effects, it has been proved that videogames not only improve cognitive abilities, but surprisingly enhance academic performancewhen played moderately. Additionally, studies have demonstrated that playing videogames has positive effects on cognitive, emotional, and social development of adolescents.12 One metaanalysis showed that childrens visuospatial cognition is improved by playing violent videogames.5 The potential of videogames being used as an educational tool has been researched in the past,13 and several studies have been done on using videogames for healthcare education. For example, Bartholomew et al.14 successfully used an adventure game to

Department of Health Management and Informatics, School of Medicine, University of Missouri, Columbia, Missouri. Informatics Institute, University of Missouri, Columbia, Missouri.

331

332 improve the self-management skills of patients with asthma. With the emergence of exergames, videogames that demand physical activity, studies have shown the ability of exergames to combat sedentary lifestyle in children and young people.15 Because exergames and games for health are relatively new elds, systematic reviews about the usage of videogames in personal health improvements are scarce. A systematic review focusing on active videogames and physical activity of

RAHMANI AND BOREN children and youth showed that during playing active videogames, energy expenditure increases 222 100 percent, and the heart rate rises 64 20 percent.16 Baranowski et al.17 identied 25 videogames that have been useful in changing a persons behavior regarding a health-related issue. Another article, reviewing the effectiveness of videogames in health education and physical education, has demonstrated promising but limited results.18 In addition to these articles, two

FIG. 1. Flow chart of how articles were selected for this study. CINAHL, Cumulative Index to Nursing and Allied Health Literature; RCT, randomized controlled trial.

VIDEOGAMES AND HEALTH IMPROVEMENT other review articles have found virtual reality and videogames to have a good potential to be utilized as a tool for stroke rehabilitation.19,20 Randomized controlled trials (RCTs) are the gold standards for evidence-based medicine; thus systematic reviews based on RCTs with the topic of videogames and health improvement seem very essential for discovering the true power of videogames in healthcare. Kharrazi et al.21 did a scoping review providing information of the current status of health game research, and although RCTs were included in the study they were not the focus of study. Primack et al.22 showed that most RCTs have positive outcomes regarding health improvements; however, the information about each RCT was not fully presented. In this study we intend to show the most up-to-date information about every RCT study that has emphasized videogames and health improvements after 2000 in a categorized fashion, thus helping future researchers to have better knowledge on current trends of research in this eld. Materials and Methods PubMed, the Cumulative Index to Nursing and Allied Health Literature, Scopus, PsychInfo, and Consumer Health Complete were searched between January 2000 and April 2012 for RCTs testing the effects of videogames on health outcomes. Video games was searched as a key word, and the search was limited to only RCTs that were published in the English language. Using this search strategy, 261 articles were reviewed based on their abstracts and our inclusion criteria. Articles without information about the combination of video games and health improvement were excluded.

333 Also excluded were the articles focusing on the negative effects of games on patients or using videogames for training healthcare professionals. Finally, articles only discussing the plan to design a videogame and review articles were also excluded. The following information was abstracted from each of the eligible articles: country where the study was conducted, study goal, participant age range, number of participants (intervention group, control group), study duration, time spent on gaming, names of the games, game types (commercial or non-commercial), platform/device(s), and study results. A note about the game types categorization: If the game was available at videogame stores, it was labeled commercial; otherwise (e.g., online, specially designed), it was considered non-commercial. It should be noted that some of the articles did not provide all of the information needed for these topics. One author reviewed and coded the articles, and then the second author reviewed the coding. Any discrepancies in coding were resolved through discussions. The games were categorized based on the elds in which they have been utilized. Results The article selection process for this review is presented in Figure 1. Forty-ve articles met the eligibility criteria and were included in this systematic review, which covers the various elds of medicine and different types of games. Forty-two percent of the studies were conducted in the United States. The number of participants, duration of the study, and time playing games varied widely among the studies; for example, the number of participants spans from 14 to

Table 1. Videogames and Patient Pain and Stress Reduction

Study (year) Miller et al.23 (2011) Miller et al.24 (2010) Russniello et al.25 (2009) Russniello et al.26 (2009) Rutter et al.27 (2009) Dahlquist et al.28 (2007) Gold et al.29 (2006) Patel et al.30 (2006) Das et al.31 (2005)
a b

Country Australia Australia United States United States United States United States United States United States Australia

Age range (years) 310 310 NA Avg 24

Number of participants 20 intervention 20 control 40 intervention 40 controlb 38 intervention 31 control 103 intervention 31 controlc 28 intervention 28 controld 27 intervention 13 controle 10 intervention 10 control 38 intervention 76 controlf 13 intervention 13 controlg

Duration of study 1 session 3 sessions 1 session 1 session

Gaming time NA NA 20 minutes 20 minutes

Name of game Bobby Got a Burn Bobby Got a Burn Bejeweled II

Type of game Noncommercial Noncommercial Noncommercial Noncommercial

Platform/ device MMDa MMDa PC PC

1823 513 712 412 518

8 sessions 1 session 1 session 1 session NA

NA NA 10 + minutes 20 + minutes 3045 minutes

Bookworm Adventures, Bejewelled II, Peggle Finding Nemo Commercial Finding Nemo Street Luge NA NA Commercial

PS2 + HMD PS2 + HMD PC + HMD Handheld

Commercial NA

NonPC + HMD commercial

The multimodal distraction (MMD) device is a customized handheld device. Intervention: 20 MMD-Distraction, 20 MMD-Procedural Preparation-Intervention Control; 20 videogame, 20 standard distraction. c Intervention: Bookworm Adventures, n = 29; Bejewelled II, n = 38; Peggle, n = 36. d A crossover study. e Thirteen interactive intervention, 14 passive intervention. f Control: 38 midazolam, 38 parents. g A crossover study with nine participants, with some of them participating more than once. Avg, average; HMD, head-mount display; NA, not available; PC, personal computer; PS2, Sony PlayStation 2.

Table 2. Exergames Age range (years) 912 Adults 1014 3 months 10 weeks 2 sessions 12 weeks 6 weeks 12 weeks 12 weeks 28 weeks 6 weeks NA Fuzion Frenzy NA Various gamese Wii Fit 6 months Various gamesc 2 sessions Wii Active 12 weeks Various games
a

Study (year) Commercial Commercial Commercial Commercial Commercial Commercial Commercial Commercial Commercial Commercial Commercial Commercial

Country

Number of participants

Duration of study

Gaming time

Name of game

Type of game

Platform/device(s) Nintendo Wii + equipmenta Nintendo Wii PS + EyeToy + dance mat Nintendo Wii PS2 + GameBike Microsoft XBox PS2,d PS3d PS2 + GameBike PS2 PS + EyeToy + dance mat PS2 + dance mat PS2 + GameBike

United States

Australia

New Zealand

17.28 minutes daily 15 minutes per session NA

United States

Canada 1830 810

3144 813 1217

United States

United Kingdom Canada Male college students 712f 1014 78 1825 3 30 minutes weekly NA

12.56 minutes daily 2 60 minutes weekly 30 minutes per session NA

334 80 minutes per day 89 82 minutes weekly 3 30 minutes weekly

United States

New Zealand Canada Australia

Baranowski et al.32 (2012) Kuys et al.33 (2011) Maddison et al.34 (2011) Owens et al.35 (2011) Adamo et al.36 (2010) Bonetti et al.37 (2010) Graves et al.38 (2010) Rhodes et al.39 (2009) Murphy et al.40 (2009) Ni Mhurchu et al.41 (2008) Maloney et al.42 (2008) Warburton et al.43 (2006) 41 intervention 37 control 19 intervention 19 controlb 160 intervention 162 control 21 intervention 21 controlb 13 Intervention 13 control 16 intervention 16 control 12 intervention 17 control 16 intervention 13 control 23 intervention 12 control 10 intervention 10 control 40 intervention 20 control 7 intervention 7 control Dance Dance Revolution EyeToy active games Dance Dance Revolution MAX2 Various gamese

Canada

The full list is available in the article. A crossover study. c For example, Play3, Kinetic, Sport, and Dance Factory. d Combined with tness jogging controller called jOG. e For example, Smugglers Run, ATV Offroad Fury, Gran Turismo 3, Nascar Heat, and Need for Speed. f Overweight population. NA, not available; PC, personal computer; PS2, Sony PlayStation 2; PS3, Sony PlayStation 3.

VIDEOGAMES AND HEALTH IMPROVEMENT 352 persons. As for the platform of the game, 49 percent of the games are PC-based. It should be noted that most of the studies have showed positive results by using the videogames in the intervention group compared with the control group. The articles have been divided into ve groups for a better understanding of the role of games in patient healthcare. Group 1: Videogames and patient pain and stress reduction In this category, games were used for either physical pain distraction or stress reduction (Table 1).2331 Three articles showed the positive results of using videogames as an alternative method for pain management in children with burns.23,24,31 One study demonstrated that the efcacy of videogames for pain reduction is not decreased by repetitive usage27 and also that active interaction (using a joystick) is more effective than passive interaction (using a head-mount display) in raising the pain threshold.28 Two studies were about using videogames as a distraction tool for reducing preoperative anxiety30 and intravenous placement pain in children.29 Two studies showed that playing casual videogames can reduce stress.25,26 Table 3. Educational Games Group 2: Videogames and patient behavioral change This is the largest group with 19 articles and is divided into two subgroups. The rst subgroup, exergames (Table 2), consists of those articles focusing on the benets of using the exergames for improving physical activity and changing the sedentary lifestyle.3243 Although Baranowski et al.32 showed that acquiring new interactive videogames does not result in more physical activity and others showed that using exergames will not change physical activity,35,38 other studies indicated that using videogames increases physical activity,41 reduces sedentary gaming time,42 gives obese children more aerobic tness,40 and reduces body fat.34 Playing exergames can even match isometric exercises in terms of maximal O2 uptake.37 Kuys et al.33 found exergames to be a suitable replacement for conventional exercise required of patients with cystic brosis. Although two studies showed that using interactive videogames encourages more young men to do physical exercise (cycling) than the traditional style,39,43 Adamo et al.36 demonstrated that adherence to music was higher than videogames for cycling exercise. The second subgroup, educational games (Table 3), includes those studies about using videogames for patient education.4450 Studies have shown success in increasing patient knowledge about certain diseases like cancer47,48 or changing their eating habits.4446 Shames et al.49 showed that using videogames as a part of a multicomponent self-management program in children with asthma improves quality of life; however, another study found no signicant improvement in reducing asthma symptoms compared with conventional methods.50 Group 3: Videogames and patient rehabilitation In this group, games are used for motor function rehabilitation (i.e., helping patients improve their movement abilities) (Table 4).5158 Some of the studies have shown that Super Nintendo Platform/device

335

PC

PC

PC

PC

Non-commerciald

PC

Non-commercial

Non-commercial

Age range (years) Number of Participants Duration of study

10 minutes

1 session

176 control 176 intervention 59 intervention 60 control 56 intervention 45 control 1329 512 United States Beale et al.48 (2007) Shames et al.49 (2004) Huss et al.50 (2003) United States 712

93 intervention 40 control 20 interventionc 10 control 15 intervention 7 control 164 intervention 140 control

6- and 12-week follow-up

Escape from Diab. Nanoswarm: Invasion from Inner Space. c Ten healthier snacks group, 10 less healthy snacks group. d An online game. Avg, average; NA, not available; PC, personal computer.
b a

2 months

3 months

3 months

Avg 20

1012

Baranowski United States et al.44 (2011) Pempek United States et al.45 (2009) United States Peng46 (2009)

Kato et al.47 (2008)

Study (year)

United States, Canada, Australia Australia

Country

1329

910

52 weeks

1 session

Bronkies Non-commercial Asthma Adventure 20 minutes Wee Willie Wheezie, Commercial for each game Magic Bus

Name of game

Non-commercial

Pac-Man (redesigned) Avg 42 minutes RightWay Cafe

Diab,a Nanob

Non-commercial

Type of game

Re-Mission

At least 1 hour per week

At least 1 hour per week NA

Gaming time

NA

Re-Mission

PC

Table 4. Videogames and Patient Rehabilitation Age range (years) 516 4785 4 weeksc 3 45 minutes weekly 3 months NA Number of participants Duration of study Gaming time Name of game Type of game Non-commercialb Non-commercial Platform/device PC PC

Study (year) 13 intervention 13 controla 11 intervention 11 control

Country

Wade et al.51 (2012) Broeren et al.52 (2008)

United Kingdom Sweden Norway

Canada NA 1680 1885 6585 Avg 61.1 10 intervention 10 control 4 weeksc 16 intervention 13 control 8 weeks 9 intervention 7 control 18 weeks

5297

4 weeks

Easy Games, Hamsterball Archery, Bingo, Memory, Simon, Space Tennis, Fish Tank Bowling game 6 difference gamese eBaViR

Commercial NA Non-commercial Commercial Non-commercial

Nintendo Wii PC PC-Nintendo Wii balance board Nintendo Wii PC

336 8 1-hour sessions 2 45 minutes weekly 5 days

Hsu et al.53 (2011) Kowalczewski et al.54 (2011) Gil-Gomez et al.55 (2011) 34 intervention 34 controla 18 intervention 18 controld 9 intervention 8 control 6 weeks for each hand Minimum 4 weeks

Canada, Australia Spain

2 20 minutes weekly 5 60 minutes weekly 20 1-hour sessions

Saposnik et al.56 (2010)

Canada

Szturm et al.57 (2011)

Canada

Yavuzer et al.58 (2008)

Turkey

Wii Sports, Cooking Mamma Under Pressure, Memory Match, Balloon Burst Eyetoy games

Commercial

PS

A crossover study. An online video game. c With follow-up at 3 months. d Eighteen (hands) intervention, 18 (hands) control. e More information about the type of each game is provided in the article. Avg, average; NA, not available; PC, personal computer; PS, Sony PlayStation.

VIDEOGAMES AND HEALTH IMPROVEMENT Table 5. Videogames as Diagnostic Tools Age range (years) Number of participants Duration of study Gaming time Name of game Type of game

337

Study (year)

Country

Platform/ device

Australia Schoene et al.59 (2011) Trivedi et al.60 Vilozni et al.61

a b

NA NA NonPCb 6590 47 intervention 2 sessions a commercial 1 week 47 control apart NonPC United States 816 72 intervention 1 session 4.5 minutes EyeSpy commercial (2010) 72 controla Germany 36 69 intervention NA NA SpiroGame NonSpirometer (2001) 48 control commercial

A crossover study. Combined with a custom-made mat. NA, not available; PC, personal computer.

videogames are effective in helping people with an acquired brain injury or stroke to get better test scores on motor functioning,5458 one study showed videogames are not more effective,52 and one study indicated they are not more effective than real-life activities.53 One study focused on using videogames for rehabilitation of people with cerebral palsy had good results, promising potential for future research.51 Group 4: Videogames as diagnostic tools Three articles in this group focused on using videogames for diagnosing health problems (Table 5).5961 One article was about using a game for facilitating spirometry in children.61 Trivedi et al.60 have successfully used a videogame for screening the vision acuity of the children. The last article focused on using a custom-made dance mat as a device to assess the fall risk and stepping ability of older people.59 A notable feature in two of these articles59,60 is having the same participants for both the intervention and control groups (e.g., crossover trial) because the purpose of the study was comparing the videogame-based screening method with the conventional one. Group 5: Videogames and cognitive ability This category has six articles (Table 6).6267 Studies have shown that if older people play videogames they would gain better executive control functions,62,63,66 even in as little time as 7 days after surgery.64 The most recent article has shown that playing games exclusively designed for enhancing brain functions (e.g., Brain Age) is more effective than simply playing any videogame.62 Tanaka et al.65 have successfully utilized a special videogame, Lets Face It, in helping children with autism disorder achieve better face recognition skills, although another study focusing on usage of videogames for improving the attention span of intellectually challenged patients showed that the positive effects fade out 5 weeks after the intervention.67 Discussion Reviewing these articles shows notable ndings. First, compared with the number of articles published about the negative effects of videogames on health, those RCT studies focused on the positive effects of using videogames for

healthy purposes are a relatively small number. The possible reason for this situation lies on the initial purpose of videogamesto entertainand like any other entertainment medium (e.g., TV, movies), videogames have advantages and disadvantages. Because videogames are gaining in popularity every day and have become inseparable from childrens and even adults lives, more RCTs are needed to fully discover the potential power of videogames on improving health. Analyzing the ve categories reveals more useful information. Group 1: Videogames and patient pain and stress reduction Using videogames as a pain management tool in children is an affordable and viable option, taking into account that, unlike drugs, patients will not become tolerant to the effects of videogames with frequent usage.27 Miller et al.24 have shown that instead of using a random game, using a game with the same content as the patients problemin this case, burn injuriesmakes patients more compliant to the procedure. As shown in the these studies,23,24,29,31 head-mount displays and handheld devices are good candidates to be used for pain reduction because they do not interfere with the medical procedures compared with common videogame devices, which require the full attention of the player. Although only two studies have focused on the effects of casual videogaming on reducing stress,25,26 the ndings were strong (based on electroencephalographic and heart rate variability changes), indicating more studies need to be done in this eld. Group 2: Videogames and patient behavioral change This is the most versatile and promising category of systematic review. Thanks to new technologies, exergames are gaining in popularity among children and their parents. Exergames eliminate one of the main disadvantages of videogames: Sedentary lifestyle. The current exergames also do not contribute to the other problem for which videogames are blamed: Violent behavior, because most of these are based on friendly sport games. These features make them one of the best candidates, among the videogames, to be used for patient health improvement. Additionally, because of the emergence of new game devices like Kinect from Microsoft

338 Platform/device

RAHMANI AND BOREN (Redmond, WA) and PlayStation Move from Sony (Tokyo, Japan), exergames will be more popular than ever. This situation provides a great opportunity for researchers to study the benets of exergames on patients health. Regarding videogames as an educational tool,13 the educational content can be embedded in a complete action game like Re-Mission47,48 or in an online short game.45 For unleashing the full potential of videogames in patient education, these conditions should be taken into account. First, the game should be designed very well in every aspect (story, graphics, sound, music, game play, etc.). Second, the educational content should be demonstrated as a cool and interesting knowledge hidden in the game story or game play. Also, the time of game exposure or game playing should be adequate. Too much time or too little time will reduce the efcacy of the game tremendously. The mentioned problem could be considered as the reason why Huss et al.50 did not nd using videogames for educating children with asthma more effective than conventional methods. Educational videogames have the ability to be an innovative method for improving patients knowledge about their health, and with proper dedication of time and money on developing suitable games, this ability could be fully exploited. Group 3: Videogames and patient rehabilitation Rehabilitation, especially in people who suffer from acquired brain injury, is a long (which is the reason for the lengthy game play time), expensive, and boring process. Using a videogame in this procedure will improve the effectiveness by adding the enjoyment factor to the formula. Although the number of participants in these studies was very small, except for one study with 34 patients,53 the results were promising. RCT studies with adequate power are recommended to improve understanding the role of videogames in patient rehabilitation. In the majority of the articles, a specially designed game, along with some mechanical devices, was used. This problem could be a potential barrier for using videogames in patient rehabilitation because it requires spending huge amounts of time and energy on designing an optimal combination of software/hardware. However, using53,58 and customizing55,56 current game consoles and devices could be a good solution for this problem. Group 4: Videogames as diagnostic tools The duration of these studies and the amount of time spent on playing games were short. This phenomenon was predictable because in these articles videogames are used as a screening tool rather than a new treatment or intervention method, and screenings are almost always faster than treatments. The target population for these types of videogames are either kids (316 years old)41,43 or older people (more than 65 years old).42 When it comes to these two particular groups, conventional diagnostic methods are prone to error due to lack of cooperation, leading to misdiagnosis. Videogames can alleviate this problem with their entertaining nature, encouraging people to participate in the diagnosis process. Group 5: Videogames and cognitive ability Several studies have shown that cognitive abilities decline with age.66 In the reviewed articles the benets of using

Nintendo DS PC

Nintendo DS

PC

PC Commercial 78 weeks

Noncommercial Commercial

Noncommercial

Type of game

Commercial

Space Fortress

Dr. Kawashimas Brain Training: How Old Is Your Brain? Lets Face It!

Name of game

Table 6. Videogames and Patient Cognitive Ability

5 15 minutes weekly 3 60 minutes weekly Avg 45 minutes daily

Brain Age

24 months

12 weeksb

Duration of study

4 weeks

9 days

14 intervention 14 control 17 intervention 37 control 16 intervention 16 control

Children, adolescents, and young adults Avg 70

34 intervention 28 control

18 intervention 16 control 60 mentally disabled males Basak et al.66 (2008) Rezaiyan et al.67 (2007)
b a

Number of participants

NA
Eighteen active control, 19 passive control. Follow-up evaluation at 6 months. A kind of path-nding game. Avg, average; NA, not available; PC, personal computer.
c

Age range (years)

Avg + 65

Avg 69

Avg + 45

Canada, United States

United States, Israel Germany

United States

Country

Japan

Nouchi et al.62 (2012) Stern et al.63 (2011) Brem et al.64 (2010)

Study (year)

Tanaka et al.65 (2010)

Iran

NA

At least 100 minutes weekly 15 90-minute sessions 2030-minute sessions

Gaming time

Rise of the Nations NAc

NA

PC

VIDEOGAMES AND HEALTH IMPROVEMENT videogames to combat the cognitive decline in older people have been promising.6264,66 A nding regarding these studies is the fact that it only requires the cost of a regular PC and a suitable computer game to ght the cognitive decline. Thus advocating playing computer games to older adults with or without cognitive problems would be a cost-effective and innovative method of preventing cognitive loss, in addition to being an amusing one. However, the duration of game playing should be long and continuous because the effects of any short-term exercise will soon fade away. Also, the content of the games should be designed specically toward stimulating brain functions as they result in better improvement.62 Lets Face It is a great example of using videogames in treating people with autism.65 It has the potential to be used as a regular training program for face recognition in autism, helping healthcare professionals to provide better care for people with cognitive disabilities. Limitations Our systematic review only includes articles with an RCT study design. The majority of the articles discussing games and their impact on health improvement (e.g., observational, retrospective, etc.) are left unreviewed. Another limitation of the study is the time period, which is between 2000 and mid2012. Before 2000, there would be fewer RCTs about this subject. Only articles in the English language were included. Considering the popularity of videogames in the Far East and also observing that some of the reviewed articles are from Europe, it would be a good idea to expand the search for articles in foreign languages with useful information about videogames and patient health improvement. Author Disclosure Statement No competing nancial interests exist. References
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10.

11.

12.

13. 14.

16.

17.

18.

19.

20.

22.

23.

24.

25.

26.

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Address correspondence to: Esmaeel Rahmani, MD Department of Health Management and Informatics School of Medicine University of Missouri Columbia, MO 65212 E-mail: ery87@mail.missouri.edu