Authors: Michelle Meade, Sean Petty, Joseph Hornyak, Josh Marshbanks, Drew Clayborn, Douglas Rakoski, & Eric Maslowski

Physical Medicine & Rehabilitation • School of Medicine • UM 3D Lab• Library System

University of Michigan • Ann Arbor, Michigan

-

Conclusions

Health games have the potential to promote

skill development and behavior change;

however, before this can occur, they have to

be accessible and engaging to the target

group. We are currently in the alpha stage of

the development of a health game to promote

self-management skills among the

population of adolescents and young adult

males with SCI. Our poster presentation will

articulate relevant design issues and be

supplemented by the availability of iPod

Touch and iPad devices, so that audience

members can view and play the current

version of the game.

Background

Traumatic SCI

• Affects about 259,000 individuals in the U.S., with nearly 12,000 new injuries each year1

• Mean age is 40.2 years old 1 but about half of new injuries happen to those between the ages of 16 to 29

years old2

• Younger patients:

• Are overwhelmingly male

• Often need serious medical care for the first time in their lives

• Are likely to be single (never-married) and have a high-school education or less

• There is a subset injured through participation in high-risk behaviors / violence

• with lower education and literacy levels and fewer resources

• many are from ethnic and racial minority backgrounds3

• Have a high degree of technical sophistication which can be leveraged to

promote the transfer of knowledge and self-management skills

The Millenial or Net Generation

• Born between 1980 and 2000

• Comfortable with technology and have learning styles adapted for

this medium – specifically active and visual learning styles.4

• Prefer information in short, direct, focused segments4,5

• Can deal with a lot of information

• Have a high ability to multi-task

• Characterized by shorter attention spans, a low threshold for boredom, and resistance to memorization

and busy work

• Want and expect high interactivity, fast pacing and high impact images 6

Secondary Conditions after SCI:

• Often not direct nor necessary consequences of SCI7

• Can be prevented or minimized with appropriate management – including performance of health

maintenance behaviors and compensatory strategies7, 8

• However, research has demonstrated that education alone is seldom sufficient to produce behavior

change or induce adherence with medical recommendations.9

• Effective interventions need to be based around techniques that have been proven effective in

changing behaviors.

• See Table 1 for required behaviors

Self-Management:

• Refers to the ability of an individual with a chronic condition to manage their health and its physical &

psychosocial consequences 10

• Requires the ability to make decisions and lifestyle choices that will optimize functioning and allow for

greater participation in family, social, community and vocational roles and environments11

• An evidence-based approach to managing chronic illness that provides education and skill-building

related to self-monitoring, communication, problem-solving and relaxation

• Proven to be effective for improving health status and health behaviors, increasing self-efficacy,

improving compliance with medication regimens, decreasing pain, and lowering health-care costs 9,12-21

• Protocols have been effectively tailored to meet the needs and concerns of minority populations22-28

• Health Mechanics program created by M. Meade, specifically for individuals with SCI

• Skills include

- Attitude - Self-Monitoring - Problem-Solving

- Communication - Organization - Stress-management

Levels Level 1: Brave New World

- Player wakes up in the hospital and learns that they have a SCI

- Meet with health care providers and learns how to function

- Return home (parent’s home) and must organize their space

Level 2: Helping Hands

- Meet and learn to work with assistant

- Return to hospital for outpatient follow-up

- Need to monitor their health statistics, including stamina, stress and overall health., and perform

required behaviors

- Party at Home

- Key Skills: Communication, Organization

Level 3: Independence Day - Learn to drive

- DVM and get van

- Meet friends at club

- Skill: Problem-solving

Level 4: Viva La Resistance

- Recruited into the Underground Resistance

- Gain a secret identity / live a double life

- Training and missions

- Skill: Multi-tasking

Level 5: The Big Stink

- Final level is the final confrontation with Dr. Schyrnk

- You have to unravel his complex plot and defeat him.

- Once you do, you can continue to access any of the areas of the world, this time using the

additional equipment and skills you have gained along the way.

- Skill: Continue to manage health while save the world…

University of Michigan

Development of a Health Game to Promote Self-Management Skills

Among Adolescents and Young Adult Males with Spinal Cord Injury (SCI)

Issue to

manage

How to manage How to monitor For Planning Consequence

Skin Pressure reliefs (every 30 min) Timer

Recognize that pressure

reliefs have to be done at

regular intervals

continuously throughout the

game

Skin break down

Decreased health

Bowel Bowel program

(1x / day)

• Timer

• Stink clouds

Need to be home/ HQ

May need help

• Bowel accident

• Stink cloud

• Decreased health

• Embarrassment / increased stress

• Impaired communication

Bladder Cathing

(every 4 hours)

Timer

Urine trails

• Need correct supplies

• Need privacy

Bladder accident

Stink cloud

Impaired communication

Impact heath

Fitness Eat healthy things

Drink enough water

Avoid unhealthy food

Exercise

• Remember

behaviors

• Check POS

• Can bring meals from

home

• Can purchase meals

• Go to PT to exercise

• Change in body type

• Impact stamina and health

Stress

Monitor stress levels

Make time for stress-

relieving activities (yoga,

deep breathing)

Enhance cognitive resilience

POS • Regularly monitor

• Take time for stress-

relieving exercises

• Decrease attention / concentration

• Decline in navigation ability

Cognitive

Flexibility /

Resilience

Enhance problem-solving,

attention, memory

POS Plan to work on cognitive

tasks with Dr. Schyrnk

• Impacts health

• Impacts resistance to Chillex 3000

Health Perform all health behaviors

Improve fitness

Decrease stress

Increase Cognitive Resilience

POS • Impacts stress

• Impacts stamina

• Impacts ability to accomplish tasks

Energy /

Fatigue

• Fitness

• Stress

• Health

• Practice / therapy

POS Optimize all behaviors • Impacts navigation

• Influences ability to accomplish

tasks

Table 1: Health Metrics and Required Behaviors

Considerations for Accessibility & Engagement Limited or no arm functioning Age Cost

Slowed physical functioning Cost Humor

Flow of Story Graphics Engagement

Expectations Playability Pace

REFERENCES 1. NSCISC. Spinal Cord Injury Facts and Figures at a Glance. 2011. www.uab.edu/NSCISC. Accessed September 4, 2009.

2. SCI-Info-Pages: Quadriplegic, Paraplegic & Caregiver Resources. 2009; http://www.ohsu.edu/oidd/cca/oodh/projects/HL/index.cfm. Accessed December 30, 2009.

3. Burnett DM, Kolakowsky-Hayner SA, White JM, Cifu DX. Impact of minority status following traumatic spinal cord injury. NeuroRehabilitation. 2002;17(3):187-194.

4. Oblinger DG, Oblinger JL. Educating the Net Generation. In: Oblinger DG, Oblinger JL, eds2005: www.educause.edu/educatingthenetgen. Accessed January 2, 2010.

5. Thietje R, Giese R, Pouw M, et al. How does knowledge about spinal cord injury-related complications develop in subjects with spinal cord injury? A descriptive analysis in

214 patients. Spinal Cord. 2011;49:43-48.

6. Litten A, Lindsay B. Teaching and learning from generation Y2001.

7. Krause JS. Secondary Conditions and spinal cord injury: A model for prediction and prevention. Topics in Spinal Cord Injury Rehabilitation. 1996;2(2):58-70.

8. Lammertse D. Maintaining health long-term with spinal cord injury. Topics in Spinal Cord Injury Rehabilitation. 2001;6(3):1-21.

9. Steed L, Cooke D, Newman S. A systematic review of psychosocial outcomes following education, self-management and psychological interventions in diabetes mellitus.

Patient Educ Couns. Sep 2003;51(1):5-15.

10. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: A review. Patient Educ Couns. 2002;48:177-187.

11. Creer TL, Holroyd KA. Self-management of chronic conditions: the legacy of Sir William Osler. Chronic Illness. 2006;2:7-14.

12. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. Nov 20 2002;288(19):2469-2475.

13. Lorig KR. Arthritis self-management: a patient education program. Rehabil Nurs. Jul-Aug 1982;7(4):16-20.

14. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a

randomized trial. Med Care. Jan 1999;37(1):5-14.

15. Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M. Effect of a self-management program on patients with chronic disease. Eff Clin Pract. Nov-Dec 2001;4(6):256-262.

16. Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. Aug 2003;26(1):1-7.

17. Lorig K. Self-management education: more than a nice extra. Med Care. Jun 2003;41(6):699-701.

18. Holman H, Lorig K. Patient self-management: a key to effectiveness and efficiency in care of chronic disease. Public Health Rep. May-Jun 2004;119(3):239-243.

19. Lorig KR, Ritter PL, Laurent DD, Plant K. Internet-based chronic disease self-management: a randomized trial. Med Care. Nov 2006;44(11):964-971.

20. Lorig K, Ritter PL, Villa FJ, Armas J. Community-based peer-led diabetes self-management: a randomized trial. Diabetes Educ. Jul-Aug 2009;35(4):641-651.

21. Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet. Oct 23-29 2004;364(9444):1523-1537.

22. von Goeler DS, Rosal MC, Ockene JK, Scavron J, De Torrijos F. Self-management of type 2 diabetes: a survey of low-income urban Puerto Ricans. Diabetes Educ. Jul-Aug

2003;29(4):663-672.

23. Rosal MC, Olendzki B, Reed GW, Gumieniak O, Scavron J, Ockene I. Diabetes self-management among low-income Spanish-speaking patients: a pilot study. Ann Behav

Med. Jun 2005;29(3):225-235.

24. Carbone ET, Rosal MC, Torres MI, Goins KV, Bermudez OI. Diabetes self-management: perspectives of Latino patients and their health care providers. Patient Educ Couns.

May 2007;66(2):202-210.

25. Vincent D, Clark L, Zimmer LM, Sanchez J. Using focus groups to develop a culturally competent diabetes self-management program for Mexican Americans. Diabetes

Educ. Jan-Feb 2006;32(1):89-97.

26. Lorig KR, Ritter PL, Gonzalez VM. Hispanic chronic disease self-management: a randomized community-based outcome trial. Nurs Res. Nov-Dec 2003;52(6):361-369.

27. Lorig KR, Ritter PL, Jacquez A. Outcomes of border health Spanish/English chronic disease self-management programs. Diabetes Educ. May-Jun 2005;31(3):401-409.

28. Lorig K, Ritter PL, Villa F, Piette JD. Spanish diabetes self-management with and without automated telephone reinforcement: two randomized trials. Diabetes Care. Mar

2008;31(3):408-414.

29. Wikepedia. Serious Games. 2009; <http://en.wikipedia.org/wiki/Serious_games>. Accessed 1/29/2009.

30. Lieberman DA. Management of Chronic Pediatric Diseases with Interactive Health Games: Theory and Research Findings. Journal of Ambulatory Care Management.

2001;24(1):26-38.

Objectives: • To develop an electronic game for an iPod Touch or similar device that will teach and / or

promote the use of key skills necessary for managing a spinal cord injury (SCI).

• Ultimately, we hope that playing the game will increase knowledge and confidence, normalize

and promote self-management behaviors, and reduce secondary conditions and health care

costs

• This game application is based on the self-management principles and specifically on the

Health Mechanics program

Results Researchers in the Department of Physical Medicine

and Rehabilitation are collaborating with programmers

and artists at the University of Michigan 3D Lab to

create the health game based on self-management

skills, as articulated in the Health Mechanics program.

Advisory Board members provide critical input and

feedback about game appearance, accessibility,

relevance and enjoyment. A range of issues continue to

arise during development and adaptation of the self-

management program, including the accessibility and

play-ability of the game to individuals with tetraplegia,

development of dialogue that is understandable and

relevant to target population, and the creation of

characters and a story line that players can relate to.

Next Steps •Continued development of levels

•Alpha Continued •Alpha Stage Evaluation

•Beta Stage •Beta Stage Evaluation

•Evaluating efficacy •Marketing / outreach •Adapt for other populations

About Serious games:

• As used in the computer gaming industry, a serious game is

“a game designed for a primary purpose other than pure

entertainment”29

• Serious games based on development of self-management

skills have been developed for asthma, diabetes, surgery

preparation, safe sex negotiation, and promoting nutrition

and physical activities.

• Found to be effective in improving self-care, reducing

symptoms, minimizing secondary conditions, reducing

emergency room visits and decreasing health care costs30

Art Team Programming Team

Stephen Bizer Sean Petty

Austin Cascarelli Sean Sheehan

Stephanie O’Malley Michael Skrzynski

Scott Spangler Alejandro Guerrero*

Andrew Bobo*

Andrew Smith*

Michael Theodore*

* indicates individuals who are not

actively working on the project