Computer Games to Decrease Pain and Improve Mood and Movement Maureen J. Simmonds 1Dept
of Physical Therapy, UT Health Science Center at San Antonio 2Center for Research to Advance Community Health 3School of Public Health, University of Texas, Regional Academic Campus, San Antonio
Dimitrios Zikos Heracleia lab, CSE, UT Arlington, 19015, 500 UTA Blvd.
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ABSTRACT Pain is a pervasive problem that can compromise mood and movement leading to depression and disability. Computer games can enhance self-esteem, mood, and movement in healthy individuals. To what extent such games can improve mood and movement and decrease pain in individuals with chronic pain is not known. This study compared the effects of two computer games on pain, mood and movement in patients with fibromyalgia (FM) compared to a pain free cohort. Twenty-nine people with (FM) and 19 healthy controls were randomized to play a game to enhance mood or a game with no emotional salience. Standardized measures of clinical pain, thermal pain thresholds, self-efficacy, mood, self-esteem and physical performance were obtained before and after game play. Both games improved pain threshold, mood and physical performance (p≤.019). There was no differential effect of games suggesting that for these subjects and after one game play, attention to the game rather than the game itself is the likely explanation.
Categories and Subject Descriptors G.3 [Probability and Statistics]: statistical software, [Life and Medical Sciences]: health.
General Terms Measurement
Keywords Pain, pain threshold, quantitative computer game, fibromyalgia
sensory testing,
1. INTRODUCTION 1.1
The problem of pain
Pain is the most frequent symptom for which patients seek professional health care regardless of the illness or injury. It is also the most frequent health related reason for activity limitation across age groups, including the elderly [1]. This is problematic because activity is known to have health protective effects physically, psychologically and socially. Pain is a complex, costly, and challenging multidimensional problem with sensory, Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. Copyrights for components of this work owned by others than ACM must be honored. Abstracting with credit is permitted. To copy otherwise, or republish, to post on servers or to redistribute to lists, requires prior specific permission and/or a fee. Request permissions from
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emotional, cognitive, and motor components. And it has long been known that when pain persists it can become distressing, depressing, and disabling [2]. Research over the last decade has shown that pain is also associated with tremendous financial costs as well as human costs. In the United States, costs of medical treatment and lost productivity are estimated at $635 billion annually [1]. Despite the huge costs and the pervasiveness of the problem, pain is frequently inadequately understood, assessed, and managed [1]. Studies have shown that the psychological components of pain perception (cognitions, emotion or moods, attention state, attitudes, expectation, and automatic thought processes) are extremely difficult to manage [3, 4]. The need to transform the manner in which pain is researched and managed is generally accepted but there is little consensus on what management approaches are safe and effective and able to ameliorate the broad and integrated impact of pain on mood and movement.
1.2
Fibromyalgia
Fibromyalgia (FM) is a type of chronic pain disorder characterised by widespread pain. Its associated symptoms include fatigue and sleep disturbance, often negatively affecting mood, anxiety, and self-esteem as well as activity. Patients with such a negative affective state frequently present perceptual abnormalities such as heightened responsiveness or greater sensitivity to sensory stimulation including lower pain thresholds to experimental pain [5,6]. Such patients also present with compromised movements and physical dysfunction. Noteworthy, improvements in movement and mood can decrease perceived pain.
1.3
Pain and Computer Games
Computer games have been designed to improve mood and selfesteem in healthy pain free individuals Recently, Dandeneau and Baldwin [7] showed that negative bias can be inhibited by playing a game that requires a player to repeatedly and as quickly as possible identify positive images or words e.g. the person with smiling face in a 4x4 matrix of people with neutral or angry facial expressions [7]. It has also been shown that this game can improve self-esteem and self-efficacy. Given that individuals with FM frequently have depressed mood, lowered self-esteem and self-efficacy, it is plausible that the mood and self-esteem of patients with FM could improve by playing such a computer game. And since emotional state can alter pain perception [1,2] the positive mood and enhanced self-esteem induced by playing computer games could also decrease pain perception and perhaps even improve movement. The purpose of this study was to compare the effects of two computer games on pain, mood and movement in patients with chronic pain due to FM compared to a pain free cohort.
2. METHOD Following appropriate institutional review and approval of the study subjects who met the inclusion criteria were recruited and invited to participate. All potential participants were advised about the purpose of the study and had the opportunity to ask questions and have them answered prior to signing an informed consent.
2.1 Subjects In this controlled study, 19 healthy pain free individuals (17 females and 2 males) and 29 patients with FM (27 female and 2 males) participated. Subjects were aged between 34 to 69 years and had a mean age of 52 years.
2.2 Computer games Subjects were randomized to play one of two computer games. The experimental game, aimed to have participants focus on positive images in order to reduce vigilance to negative or socially threatening information. It requires participants to identify the one happy face as quickly as possible from a series of presentations of 16 faces, 15 of which have neutral or unhappy/angry expressions. The control game had no emotional salience but the images were similar in size and number to the experimental game. The control game required participants to identify the one flower with 5 petals from a series of presentations of 16 flowers, 15 of which had 7 petals. Games were played online and a 17 inch monitor was used. Participants were instructed to click on the appropriate image as quickly as possible in order to proceed to the next trial which only appears if the image was correctly identified. Each participant received six practice trials before completing 112 training task trials.
Fig. 1. For the experimental game, subjects were required to identify the one happy face from a series of presentations of 16 faces, 15 of which had neutral or angry expressions. For the control game, subjects were required to identify the one flower with 5 petals from a series of presentations of 16 flowers, 15 of which had 7 petals.
2.3 Outcome Measures All measures used in this study were standardized and had well established good to excellent levels of reliabilities and validities in this subject sample. In addition, all measures were obtained pre- and post- intervention with the exception that experimental pain threshold was also measured during the game play. The measures were as follows.
Clinical pain in the FM group was measured with two 10 cm. visual analogue scales, one measured pain intensity and the second measured pain bothersomeness.
Pain self-efficacy was measured with the pain self-efficacy questionnaire (PSEQ) [10]. The PSEQ measures the respondent’s beliefs and confidence in their ability to do things despite pain.
Self-esteem -Trait and State, were measured with the Rosenberg Self-Esteem Scale (RSES) and the Self Esteem State Scale (SESS) respectively [11,12].
Mood was measured with the short-form Profile of Mood State (POMS-SF) which has 37 items divided into 6 subscales: depression, vigor, confusion, tension, anger, and fatigue [13].
Physical Performance was measured using three tests from the Simmonds Performance Battery [14]. Participants are required to complete each task as quickly as they can and the time taken or distance walked is recorded. The tasks were; the timed (5 rep) sit-stand, the 50-foot fast walk, and the 6 minute distance walk.
Experimental pain thresholds to heat and cold stimuli were measured on the anterior aspect of the forearm using the standard method of limits protocol and the Medoc Thermal Sensory Analyzer (TSA-II; Ramat Yishai, Israel).potential to be boosted, and potentially become significant candidates for the output, depending on the supplementary user feedback.
Fig. 2. Experimental Set-up
3. RESULTS There was no significant difference in demographic characteristics (age and gender) between the two subject groups. All outcome variables were tested using Kolmogorov-Smirnov test and showed to be normally distributed (p
