STUDY AND DEVELOPMENT OF CUSTOM “SERIOUS GAMES” FOR PATIENTS AND USERS Dissertation submitted to the Catholic University of Portugal in partial fulfilment of the requirements for the Master’s Degree in Management for the Creative Industries Catarina Matos Vieira Porto, July 2020 STUDY AND DEVELOPMENT OF CUSTOM “SERIOUS GAMES” FOR PATIENTS AND USERS Dissertation submitted to the Catholic University of Portugal in partial fulfilment of the requirements for the Master’s Degree in Management for the Creative Industries Catarina Matos Vieira Supervised by Professor Dr. André Perrotta And co-supervised by Professor João Novais Porto, July 2020 Study and development of custom “Serious Games” for patients and users Abstract Video games are part of our culture and permeate several segments of society, from casual entertainment to serious purposes. This research work focuses on the latter, more specifically on the use of Serious Games in the healthcare context. In this sense, Serious Games have been researched through clinical studies, implemented to improve several conditions and have already proved to be efficient and valid, especially due to their ability to captivate and motivate the patient. With this in mind, this research explored the use of Serious Games for physical rehabilitation of stroke impaired patients and how this approach could be implemented in the Portuguese healthcare system. The research started with a thorough literature review of the validity and effectiveness of the use of Serious Games for this type of patients. Then, through surveys and interviews with healthcare professionals and game developers, the main barriers to the implementation and development of Serious Games for physical rehabilitation were accessed. Posteriorly, the feasibility of implementing a business model for this specific niche (in Portugal) was evaluated through a market analysis, abridging social, economic, political and technological aspects that culminated in the design of several hypothetical scenarios that envisioned the possibility of making this approach work. This research allowed to achieve an understanding of what needs to be overcome in order for this technique to be successful: Serious Games are still widely unknown among healthcare professionals and there is an underlying stigma against video games that clouds the possible benefits of using Serious Games. Moreover, the social context of future users will also determine their acceptance and compliance. Nevertheless, the research has evidenced that the implementation of this paradigm is economically viable as it would indirectly allow the monetization of rehabilitation therapies by making them available to a larger slice of the disabled population, which is of utmost importance, mainly during the times we currently live in. Keywords: serious games, healthcare, physical rehabilitation, stroke rehabilitation v vi Study and development of custom “Serious Games” for patients and users Resumo Os videojogos fazem parte da nossa cultura e permeiam vários segmentos da sociedade, desde entretenimento casual até propósitos mais sérios. Este trabalho de investigação concentra-se na segunda opção – mais especificamente, no uso de Serious Games no contexto da saúde. Neste sentido, os Serious Games têm sido investigados através de estudos clínicos, implementados para melhorar diversas condições e patologias e já provaram ser eficientes e válidos, principalmente graças à sua capacidade de motivar e cativar o paciente. Tendo isto em conta, esta investigação explorou o uso dos Serious Games para reabilitação física de pacientes pós-AVC e de que forma é que esta abordagem poderia ser implementada no Serviço Nacional de Saúde. A investigação começou com uma revisão bibliográfica completa da validade e eficácia do uso de Serious Games para este tipo de pacientes. De seguida, através de questionários e entrevistas a profissionais de saúde e desenvolvedores de videojogos, as principais barreiras para implementação e desenvolvimento de Serious Games para reabilitação física foram levantadas. Posteriormente, a viabilidade de executar um business plan para esse nicho específico (em Portugal) foi avaliada através de uma análise de mercado, abrangendo aspetos sociais, económicos, políticos e tecnológicos, que culminou no desenho de vários cenários hipotéticos que previam a possibilidade de fazer com que este paradigma se tornasse possível e funcional. Este trabalho de investigação permitiu atingir uma compreensão daquilo que necessita de ser ultrapassado para que esta abordagem tenha sucesso: os Serious Games ainda são amplamente desconhecidos entre os profissionais de saúde e existe um estigma subjacente aos videojogos que obscurece os possíveis benefícios do seu uso. Para além disso, o contexto social dos futuros utilizadores também irá determinar a sua aceitação e adesão. No entanto, esta investigação evidenciou que a implementação deste modelo é economicamente viável, pois iria permitir, de uma forma indireta, a rentabilização de terapias de reabilitação ao fazer com que estas fossem acessíveis a uma fatia mais larga da população debilitada, o que é de extrema importância, principalmente nos dias de hoje. Palavras-chave: jogos sérios, saúde, reabilitação física, reabilitação pós-AVC vii viii Study and development of custom “Serious Games” for patients and users Acknowledgements First of all, I ought to thank my advisor, Professor Dr. André Perrotta, for the never-ending support and patience, as well as for his enthusiasm and valuable insight. I also want to show my gratitude to my co-advisor Professor João Novais, for always pushing me forward, for his enthusiasm and for all the help provided throughout construction of this dissertation. Besides my direct advisors, I want to thank all the Professors from the School of Arts of the Catholic University of Portugal, for always being available and extremely helpful and for giving me the chance to study what I want, and allowing me to pursue what makes me happy and what I believe in. I want to particularly thank Professor Dr. Sahra Kunz for all the help and support provided throughout the years and for always being available. I want to thank my parents from the bottom of my heart for all their unconditional support and help throughout the year. Without them, this would not have been possible. Last but not the least, I want to show my gratitude to those who were, directly or indirectly, involved in the making of this dissertation as well as those who believed in the value of this topic and took the time to participate in the research process, as their insight and participation allowed this dissertation to fly higher. ix x Study and development of custom “Serious Games” for patients and users Table of Contents List of Acronyms .................................................................................................................................. xiii List of Figures ....................................................................................................................................... xv List of Tables ....................................................................................................................................... xvii 1. Introduction ......................................................................................................................................... 1 1.1. Motivation and Context ................................................................................................................ 1 1.2. Research Questions and Objectives ............................................................................................. 2 1.3. Methodology ................................................................................................................................ 4 1.4. Road Map ..................................................................................................................................... 6 2. Video Games: From Fun to Serious .................................................................................................... 7 2.1. The Era of Video Games. ............................................................................................................. 7 2.1.1. The Visual Novel as a video game genre .............................................................................. 9 2.2. More than Entertainment ............................................................................................................ 11 2.2.1. Serious Games in healthcare ............................................................................................... 15 3. Understanding the relevance, development, design and application of Serious Games for physical rehabilitation ......................................................................................................................................... 23 3.1. Case Studies ............................................................................................................................... 23 3.1.1. COTS (Commercial Off-the-Shelf Games) ......................................................................... 24 3.1.2. Custom-Made Serious Games: “Point & Click” and “Drag & Drop” ................................. 26 3.1.3. Custom-Made Serious Games: Rehabilitation Assisted through Virtual Reality ................ 32 3.1.4. Custom-Made Serious Games: Virtual x Real Approach .................................................... 35 3.1.5. Comparison between Custom-Made Serious Games versus COTS ...................................