Approaches for Creating Therapy GamesJared Duval, University of California Santa Cruz, JDuval@ucsc.edu
AbstractTherapy games have the potential to offer people with disabilities a cost-effective, personalized, data-driven, connected, and motivating context for otherwise tedious and repetitive therapy. The paramount challenge in creating therapy games is creating a motivating experience with mechanics that translate into improved health outcomes—a wicked problem. To this end, I use research through design to explore multiple approaches to the co-creation of therapy games for various populations, including children with speech impairments, adults with developmental disabilities, children with Sensory-Based Motor Disorder (SBMD), and stroke survivors. I have collaborated on 3 therapy games, which serve as case studies where I explore identifying best practices, unique insights, and suggestions for future therapy game creators. Speciﬁcally, I discuss game-ﬁrst versus therapy-ﬁrst approaches, closed-game systems versus more open-ended playful systems, and potential future research directions.
Games are no longer used solely for entertainment. With the insurgence of approaches like gamiﬁcation  and playiﬁcation , games are increasingly used as a motivator in education , in the workplace , and in healthcare [15,25]. While many ethical concerns have been raised about the use of games in the pursuit of capitalistic agendas [3, 21], there is an opportunity for improved therapy experiences for various populations of people with disabilities (e.g. [1, 12, 23–25]). Therapy games, also referred to as Serious Games for Health , offer many potential beneﬁts including performance tracking , increased access to healthcare for those from lower socioeconomic statuses , reporting features for richer interactions with medical professionals , and personalized curricula  that dynamically adjust challenge based on performance. These beneﬁts are only available to players who play (because the game is fun) and beneﬁt from playing (because playing improves health).
Approaches and strategies for creating motivating experiences that translate into improved health outcomes is a wicked problem  and therefore can be engaged with via research through design (RtD). . The following 3 RtD case studies illustrate various approaches to co-creating therapy games for populations of people with disabilities in the pursuit of creating generalizable knowledge for future therapy game creators. In each case study, I describe the populations, motivations, methods, and current state of development. Then, I discuss a preliminary set of lessons learned including game-ﬁrst versus therapy-ﬁrst approaches and closed game system versus open-ended play approaches. Finally, I conclude with envisioned contributions to the ASSETS community and possible future research directions.
Case Study 1: SpokeIt
SpokeIt [8–11] (http://www.SpokeItTheGame.com), shown in the left-most position of Figure 1, is a speech therapy game for children born with orofacial cleft. SpokeIt’s gameplay is entirely driven by speech via two independent speech recognition systems that are capable of distinguishing correct speech from common speech errors . One speech recognition system operates ofﬂine for universal access while the second recognition system can be used in tandem with the ﬁrst when internet is available for improved accuracy and a larger corpus. A game controller can be used in lieu of the speech recognition systems for open-ended play, giving facilitators access to the beneﬁts of Wizard of Oz . SpokeIt was co-designed with medical professionals, developmental psychologists, children with cleft speech, and adults with developmental dis-abilities co-occurring with speech impairments  using Participatory Design [2, 26], Wizard of Oz , tangible design probes [11,17,19], and rapid medium-ﬁdelity prototyping . SpokeIt is gearing up for release in English (with more languages coming shortly after) and has been my primary project for the past 3 years. An in-the-wild evaluation using telemetry and longitudinal studies will follow release.
Case Study 2: Spell Casters
Spell Casters, shown in the middle image of Figure 1, is a social VR game previously developed purely for entertainment where teams of 5 wizards battle in a magical duel by drawing gestures with their "wands" to cast spells. Before the duel, players select a wizard hat which corresponds to their role and the set of available spells: attacker, tank, or support. Each team receives a pool of "lives" and the last team standing wins. By outﬁtting the "wand" in a Stroke Survivor’s weaker hand and changing the spell gestures to exercises that are beneﬁcial to rehabilitation, Spell Casters has the potential to demonstrate how games developed primarily for entertainment can be adapted for therapy purposes, reducing development time and costs with designs that have already proven to be fun. We are currently implementing a "training ground" for medical professionals to train the gesture recognition system and for players to practice casting the spells before battling against other players. After medical professionals validate the game is appropriate for use, we will begin evaluating and iterating the game with Stroke Survivors.
Case Study 3: Super Trouper
The collaboration, Super Trouper, shown in the right-most image in Figure 1, began with the development of 6 wearable training devices called Physical Training Technology Probes (TTPs)  that can sense and support SMBD therapies: including precise motor skills, gross movements, overall co-ordination, breathing, muscle strength, focus, balance, and posture . The TTPs were proven effective with trainers during authentic circus-themed training situations . In future work, we plan to stream data from the TTPs to an open-ended game to be played at home that will track and guide activities while employing identiﬁed motivators—a challenge because children in the training sessions relied on the instructor for engagement, motivation, and instruction.
Game-First or Therapy-First?
Spell Caster takes a game-ﬁrst, romantic (or designer-centric) approach while SpokeIt and Super Trouper each take a therapy-ﬁrst approach where user-centered, participatory methods were favored. Game-ﬁrst approaches should only be considered when source code is available, and the alterations needed to adapt the game for therapy use would be minimal. In these rare situations, the cost of creating the therapy game can be greatly reduced, but risk that the alterations may ruin the very qualities that made the game enjoyable in the ﬁrst place. In user-centered approaches, many of these risks are mitigated by the iterative process and stakeholder involvement which ensure the game is (hopefully) made right in the ﬁrst place but result in a much higher costs for time and development.
Closed Game System or Open-Ended Play?
Spell Casters is a closed game system whereas Super Trouper has been designed thus far with open-ended multiplicity in mind. SpokeIt is designed as a closed game system but attaching a game controller allows expansion of the magic circle. Therapy games that follow the closed system typically follow the patient-care-model and take the role of the medical professional by facilitating every aspect of the experience. The beneﬁts of this approach are ﬁnely tuned user experiences, validated metrics of efﬁcacy, and controlled magic circles, but runs the risk of frustrating players who are not accurately sensed or who feel they are being "ﬁxed by technology". The less common, open-ended play approach allows players and facilitators to use the technology for their own contexts, in-creasing ﬂexibility and adoption, capitalizing on surrounding expertise, and reaping the beneﬁts of social play, but running the risk of unpredictable usage—and therefore a much more challenging design space
Understanding approaches for co-creating effective and motivating therapy games is a wicked problem that I engage with through research through design. I have involved a diverse set of populations using a variety of methods including focus groups, rapid medium ﬁdelity prototyping, wizard of oz, bodystorming, and tangible design probes. The potential contributions of my work are 2-fold: 1) The games I make have the potential to improve some people’s therapy experiences (though their in-the-wild effectiveness needs evaluation), and 2) The breadth of approaches and applications I have worked on may provide unique insights and strategies. While I have some preliminary insights, such as game-ﬁrst versus therapy-ﬁrst approaches and closed game system versus open ended play, there are many more lenses that can be explored such as single player versus multiplayer experiences, symmetrical versus asymmetrical gameplay, and collaborative versus competitive gameplay.
Thank you, Sri Kurniawan, Katherine Isbister, Elena Márquez Segura, and my collaborators. This work is supported by NSF Grant #1617253. Any opinions, ﬁndings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reﬂect the views of the NSF.
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