By TAYLOR DUFFY, MedSpeaks Contributor

The lack of adherence to prescribed medical regimens not only increases an individual's overall healthcare costs, but often leads to fatal outcomes. Various studies have estimated that nearly half of all chronically-ill patients do not follow treatment plans as prescribed¹. This nonadherence not only costs the U.S. health-care system from $100 billion to $300 billion a year, but also results in over 125,000 deaths each year².

This is especially prevalent among pediatric patients, where their environment, a lack of knowledge and understanding, comfort and enjoyment, all play critical roles in their final compliance to a given medical regimen. General Dr. C. Everett Koop once stated, "Drugs don't work for patients who don't take them."

Simply put, treatment plans are only effective if implemented properly. To improve the outcomes of pediatric patients and promote safe and effective therapy, it is imperative that health care providers strive to improve adherence from all angles. One approach many innovators are beginning to capitalize on is the aura of fun.

That's right, fun. While this term rarely finds its place within medical terminology, it plays a critical role in the adherence to prescribed treatment plans, especially among children. With surveys indicating over 90 percent of children play video games, many inventors are meeting practitioners and their patients half-way, creating interactive video games that serve as effective substitutions for otherwise monotonous treatment plans³.

One such video game, Re-Mission, takes players on a journey inside the human body to battle cancer at the cellular level. Armed with weapons and superpowers, such as chemotherapy, antibiotics, and the body's natural immunity, one must fight off infections, nausea, and other threats to ultimately defeat cancer.

With the help of over 120 pediatric cancer patients and a variety of physicians and scientists, developers succeeded in creating a virtual reality that matches the many symptoms and treatments of the same cancer patients behind the screen⁴.

In a 2014 study of cancer patients playing Re-Mission, subsequent FMRIs displayed strong activation of the brain circuits involved in positive motivation, leading to shifts in attitude regarding chemotherapy and other cancer treatments⁵. This shift in attitude as a result of playing Re-Mission was proven through a separate 375-subject study to improve adherence and self-efficacy to cancer treatment, in addition to newly-found knowledge of their own disease state⁶.

"A lot of times we don't really want to take our meds. We wonder, 'What is this doing? Where is it going? I'm tired of it. It's just going to make me throw up,'" said Jose Guevera, an 18-year-old who went through cancer treatment and helped design the Re-Mission 2 games. But when you see on the screen and visualize what's happening inside your body, and what the chemotherapy's doing -- you're not looking at a PowerPoint, you're playing a game, and you're being chemo, and you're killing your bad cells. I think Re-Mission 2 can really help a lot of us⁷."

Re-Mission not only encourages its young players to understand the basic science and implications of their disease and treatment, but empowers them to fight through each and every hardship they face outside of the game, just like they do as Roxxi, the protagonist, inside the game. Less established than Re-Mission is the French start-up Ki-Breath. While still in its developmental phase, Ki-Breath aims to serve as an interactive diagnostic and therapeutic tool for children suffering from Cystic Fibrosis.

Cystic Fibrosis (CF) is characterized by a defective gene that causes an influx of thick mucus within the lungs and gastrointestinal tract. While a cure has yet to be found for this genetic disease, aggressive medication and therapy has increased the average lifespan of those diagnosed with CF from 10 years old in 1962 to 37 years old today⁸. Even more promising, children born with CF in the 2000s are now predicted to live through to their 50s, if progress continues at a similar pace⁹.

Much of this increase in lifespan can be attributed to evidence-based treatments such as airway clearance techniques (ACTs)¹⁰. ACTs involve voluntary huffing, coughing, and deep breathing, often for hours, to ultimately loosen mucus from airway walls. Many children, however, adhere poorly to these daily ACTs and would much rather spend their time doing anything else. Ki-Breath sought to enhance the experience of pediatric ACTs by creating a series of iOS compatible games where your controller is a spirometer, and your choices are dictated by the varying intensities of breath you expire into the spirometer.

The prototype of Ki-Breath is detailed below through an interview at Microsoft Imagine Cup, a global competition for young innovators in the field of technology: Link: https://www.youtube.com/watch?v=04sGoQKxNao The sensitivity of the spirometer, and therefore the difficulty of the game, can be adjusted by the caretaker in order to manipulate the aggressiveness of the treatment. In addition to promoting airwave expiratory maneuvers such as deep breathing and huffing, the spirometer also acts as a pulmonary function test, accurately measuring a player's forced vital capacity (FVC), slow vital capacity (VC), and forced expiratory volume in one second (FEV1).

Research performed utilizing a spirometer and interactive respiratory video games has already shown to be just as effective of a pulmonary functioning test as any other existing method¹¹. With time and funding, platforms like Ki-Breath are capable of becoming standard forms of therapy for pediatric patients suffering from diseases that not only affect patients with mucus-filled airwaves, but patients with neuromuscular disorders requiring similar therapy due to weakened respiratory-related muscles¹². While medicine is certainly not all "fun and games," we cannot deny that the enjoyment of a treatment has a direct correlation to its resulting compliance, especially among pediatric patients. We owe it to children to continue being creative and investing in all sides of medicine, even "fun and games," to ultimately provide them with the best healthcare outcomes as possible.

References

1. Brown, M. T.; Bussell, J. K., Medication Adherence: WHO Cares? Mayo Clinic Proceedings 2011, 86 (4), 304-314.
2. Benjamin, R. M., Medication Adherence: Helping Patients Take Their Medicines As Directed. Public Health Reports 2012, 127 (1).
3. Riley, D., The video game industry is adding 2-17-year-old gamers at a rate higher than the group's population growth. NPD Group Press: 2011.
4. Saltzman, M. Re-Mission: Game sequel lets you blast cancer cells. https://www.usatoday.com/story/tech/columnist/saltzman/2013/09/19/re-mission-cancer-therapy-app/2838945/.
5. Cole, S. W.; Yoo, D. J.; Knutson, B., Interactivity and Reward-Related Neural Activation during a Serious Videogame. PLOS One 2012, 7 (3).
6. Kato, P.; Cole, S.; Bradlyn, A., A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial. Pediatrics 2008, 122 (2), 305-317.
7. Takahashi, D. Re-Mission 2 games reimagine how to help kids survive cancer. https://venturebeat.com/2013/04/28/re-mission-2-games-re-imagine-how-to-help-kids-survive-cancer (accessed October 23).
8. National Institute of Health. Cystic Fibrosis: Fact Sheets. https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=36 (accessed October 23).
9. MacKenzie, T., et al. Longevity of patients with cystic fibrosis in 2000 to 2010 and beyond: Survival analysis of the Cystic Fibrosis Foundation Patient Registry. Annals of Internal Medicine 2014, 161(4), 233-241.
10. Daniels, T., Physiotherapeutic management strategies for the treatment of cystic fibrosis in adults. Journal of Multidisciplinary Healthcare 2010, 3 (1), 201-212.
11. Bingham, P. M.; Lahiri, T.; Ashikaga, T., Pilot trial of spirometer games for airway clearance practice in cystic fibrosis. Respiratory Care 2012, 57 (8), 1278-1284.
12. Choi, J. Y.; Rha, D.; Park, E. S., Change in pulmonary function after incentive spirometer exercise in children with spastic cerebral palsy: A randomized controlled study. Yonsei Medical Journal 2016, 57(3).