Esports’ explosive growth prompts warnings, tips for clinicians
Esports — “competitive gaming at a professional level,” according to Newzoo, an organization that monitors the industry — is poised to become one of America’s newest favorite past times, data suggest.
Deloitte, a consulting services company, reports that in the fourth quarter of 2017, there were at least 18 million players engaged in competitive gaming on just FIFA 18 and Madden NFL 18 titles alone.
Esports’ explosion in popularity has become the latest chapter in the debate regarding how much time one spends in front of a television or computer screen.
Though the number of esports players continues to grow, awareness of the pros and cons to its participants may be limited in the primary care and other clinical settings.
Thus, Healio Primary Care Today spoke with clinicians and other experts about the possible benefits and risks associated with gaming. As with any activity taken too far, some behaviors associated with gaming can pose health risks, and experts offered warning signs that primary care physicians and other clinicians should watch for when their patient is an esport participant.
Potential negative impact
Joanne DiFrancisco -Donoghue, PhD, exercise physiologist in the department of osteopathic medicine at New York Institute of Technology College of Osteopathic Medicine, was one of the first to draw attention to the risks that are associated with esports.
In New York Institute of Technology College of Osteopathic Medicine’s survey of 65 U.S. esport participants who played as part of a college team, she found that eye fatigue was the most commonly reported physical complaint, followed by neck and back pain, wrist pain and hand pain.
The results regarding musculoskeletal pain were expected, but others were not, DiFrancisco-Donoghue said as she discussed the findings with Healio Primary Care Today.
“The negative impact of staring at a computer for hours on end, without any blue light filters, is an issue we may have brought to the surface. Blue light damage seems to be commonly overlooked in gamers, and we simply don’t know the long-term effects that this kind of exposure can have on the eyes over years of play,” she said.
Other studies have found other health-related concerns tied to video gaming.
A limited number of Nintendo game system users developed irritation of the thumb, hand, and/or wrist, which researchers dubbed “nintendonitis.”
The report also noted that enough players experienced ulcerative nintendinitis — a central palmar ulcer — that Nintendo offered a glove to protect players from the injury. As the home video game market expanded to include Wii consoles, The BMJ authors wrote of sporadic reports of upper extremities, face, and neck injuries, hand lacerations, bruising and black eyes.
The hours spent playing prompts some to revisit concerns that come with sedentary behavior, such as obesity, and CVD.
An article in PLoS One, found that children aged between 14 and 18 years, all either overweight or obese, found that only those who played video games (as opposed to viewing television and using a computer) had increased BP and lipid counts.
In discussing their findings, these researchers noted that video game playing was associated with an increase in “spontaneous food intake of energy dense snack foods compared to resting conditions which may have an adverse impact on obesity, BP and lipid profiles.” They also cited other studies that found the concentration, excitement and stress that comes with video games caused increased heart rate, elevated systolic and diastolic BP, increased sympathetic tone and mental workload compared to rest.
Critics of esports, and video games, also point to the social consequences of those who participate in such activities without supervision.
One group of researchers surveyed 564 students in Asia, and found that the students with the most engagement in video games had the least developed socialization skills — a finding, they wrote in Addiction and Health, mirrored in other studies on the same topic.
Esport participants are also at risk for stimulant abuse, whether the substance is used to enhance their focus or increase participation time. John T. Holden, JD, PhD, an assistant professor at the Spears School of Business at Oklahoma State University and colleagues wrote in in the Journal of Paediatrics and Child Health.
These researchers added that the activity is not an alternative to the physical risks often associated with more traditional physical contact sports.
“Out of an abundance of caution, parents may be content with children engaging in video gaming as a pastime; however, they may unknowingly be opening the door to gaming abuse and overuse-related risk factors, several of which have been associated with major conditions,” Holden and colleagues wrote.
“Considering the potentially destructive cocktail of esports combined with stimulants and inactivity, it is imperative to encourage more exercise and physical activity programs for esports enthusiasts. Absent proactive measures, esports will face their own concussion-like health crisis,” they concluded.
Sally Gainsbury, PhD, deputy director of the Gambling Treatment & Research Centre at the University of Sydney agreed, saying that parents with children who engage in esports cannot be passive observers.
She explained how PCPs can broach esports with the parents of their younger patients.
“Physicians should discuss with parents their children’s interests and hobbies they routinely engage in. Parents may say they are not too concerned about esports involvement as it may ‘keep children quiet’ or act as a form of babysitter. However, it is important to convey that children make time for many different activities for normal day-to-day functioning outside of school hours,” she said in an interview.
“If patients or their parents are reporting sleep disruption, stress, irritability, anxiety, social isolation, or appear to have poor hygiene through neglect, physicians should check their level of online engagement, including in esports,” Gainsbury continued, saying those could be signs of esports addiction. Other warning signs of addiction include those who cannot willingly give up the game or express anger or depression when being asked to do so.
Possible positive impact
Esports proponents point out that many participants are on organized teams and tournaments that have rules and regulations, which may prevent some of the negative consequences commonly associated with gaming.
Todd Sontag, DO, from Orlando Health, is also team physician for the Orlando Magic Gaming’s care team, a group of six players competing at the professional level that range in age from 18 to 29 years. He discussed some of the parallels between esports and traditional sports in an interview with Healio Primary Care Today.
“We spend about 8 to 10 hours training daily but only a portion of that is spent on playing video games. We also put a strong focus on building up the players’ core strength and working on their ergonomics so that injuries can be prevented as much as possible. This is no different than the traditional sports athlete, who engages in weightlifting and other sports to keep up his athletic prowess during the playing season and off-season,” he said.
Sontag also noted that like other traditional sports, Orlando Magic Gaming has well-rounded medical support: in addition to having a team physician, the team also utilizes athletic trainers, orthopedic surgeons, and mental health counselors.
“Many esports players are at their peak at the same age that they are graduating from high school or college. In one quick unexpected moment, that career can be over, so we keep the wide range of professionals on staff to assist in such transitions,” he explained.
Research has found physical, mental and behavioral health benefits to esports and video games that in some instances runs counter to the arguments against gaming.
Brian A. Primack, MD, PhD, of the department of medicine and pediatrics at the University of Pittsburgh and colleagues reviewed 38 randomized controlled trials with 2,662 participants from all age groups where video games provided psychological or physical therapy, health education, and/or distraction from discomfort; improved disease self-management, increased physical activity and offered skills training for clinicians.
Their article, which appeared in the American Journal of Preventive Medicine, acknowledged that video games have been linked to adolescent risk-taking in traffic, poor school performance, addiction, unfavorable changes in blood flow, seizures, motion sickness, the onset of obesity and physical injuries related to repetitive strain.
But they, and other researchers, found that video games, whether the content was medically-based or entertainment-based, could also be associated with benefits such as these:
- distracted from acute or chronic pain stemming from burn injuries;
- improved spirometry performance;
- reduced nausea during chemotherapy;
- lowered systolic BP while undergoing sickle cell disease treatment;
- provided physiotherapy and occupational therapy for arm and hand injuries; and
- facilitated blood glucose monitoring, reduced the frequency of hyperglycemia and unscheduled urgent doctor visits, improved diabetes knowledge, yielded better communication with parents about diabetes and self-care behaviors.
“It is an important finding that there are potential health-related benefits from using video games to address a variety of health conditions and sociodemographic groups,” he and his colleagues wrote.
Primack also told Healio Primary Care Today that there are many known negative effects of video games on public health, and that the purpose of this study was simply to look into what positive findings had been found and not to directly compare positives and negatives.
Some research has found evidence of a cognitive benefit from gaming. A trial published in PLoS One consisting of 152 healthy teenagers, who played video games an average of 12.6 hours a week concluded that cortical thickness was directly linked to self-reported duration of video gaming. Many also saw improvements in their reasoning, task switching, and working memory skills.
Participants also appear to have “superior performance” in hand-eye coordination, researchers wrote in a Perception of Motor Skills article.
“Esport participants will make split second decisions that either advance or terminate their game, which makes or breaks their status among their tournament competitors,” he said in the interview.
Studies suggest these hand-eye skills pay dividends beyond esports and video game participation.
Eighteen anesthesia residents with no experience in establishing airway access for a patient played a video game for 30 minutes a day for 5 days. After that time, they had shorter intubation times and higher first-time success rates than the 18 medical students who did not play the video game, researchers wrote in Anaesthesia Critical Care & Pain Medicine.
Another study of 790 children that was published in Scandinavian Journal of Medical Science in Sports found that those with hand-eye coordination were in better physical shape and felt more positive about their body image vs. those children who did not have the coordination.
Proponents have also written about the educational and social skills the games provide.
An analysis that appeared in Social Psychiatry and Psychiatric Epidemiology reviewed questionnaires and behavior of 3,195 children, 20% of whom played video games for 5 hours a week. Researchers concluded that gamers were nearly twice as likely to be identified as having high intellectual functioning and high overall school competence. There were also no significant links with any child self-reported or mother- or teacher-reported mental health problems and players had decreases in peer relationship problems and in prosocial deficits.
Sontag said that he has seen these types of benefits among the members of his team.
“Many esports participants are introduced to other players all over the world. I’ve seen some of the biggest introverts come out of their shell, and it was only because of esports.”
Another study in Frontiers in Psychology found video games helped develop social and spatial ability skills in children and adolescents with autism, severely limited acquisition of speech and impulsive and attention deficit disorders.
Moderation the best approach to participation
The common ground between critic and proponents of esports likely lies in knowing when the gamer or the gamer’s parent or guardian knows when to pull the plug on the participant’s activity to maximize the benefits while avoiding the health risks.
“Parents need to remove access to these games after bedtime hours and use parental controls to monitor and limit the time spent playing,” DiFrancisco-Donoghue said
While the professional gamers on Sontag’s team have a staff of experts focused on their overall well-being, amateur gamers and their families have to establish and enforce limitations themselves.
“Esports can have a lot of benefits, so long as its participants do not go to the extreme level without proper supervision and training,” Sontag added.
The AAP does not have guidelines on esports, but told Healio Primary Care Today that clinicians should use its general media use recommendations when discussing esports with patients and parents which state that children aged 6 years and older should abide by consistent time limits on media use and type, and that media should never be used in lieu of sleep, physical activity and “other health essential behaviors.”
Sontag also recommended esport participants comply with American Optometric Association guidelines, which encourage rest, finding a “balance between the computer screen’s brightness and surrounding room and [establishing] proper ergonomic design and adjustment of the computer and the work environment.”
He acknowledged that most players are neither aware of the guidelines nor will admit to or recognize that their pain may be related to the activity.
“Therefore, PCPs should regularly check the posture of their patients who participate in esports or take notice if these patients to massage their arms, legs and backs or rub their eyes, as these may be signs of an esports-related injury,” he said.
DiFrancisco-Donoghue and colleagues proposed a health management model for professional esports teams that was published in BMJ Open Sport & Exercise Medicine.
This model encourages:
- esports players to be honest about the extent of the level of their participation and injuries;
- team physicians to ask “focused questions” on physical activity, nutrition, academic performance, musculoskeletal complaints and evaluate vision and social behavior;
- mental health specialists to assess for addictive behavior;
- sports medicine personnel to conduct body companion, flexibility, and standardized step up tests before the season starts, assess participants’ overall activity status and make recommendations as needed;
- physical or occupational therapy specialists to be on standby for referral and evaluate participants’ ergonomics; and
- ophthalmologists to be on standby for possible eye damage caused by “excessive” blue light exposure.
Primary care physicians have a pivotal role in the model’s implementation, Donoghue said.
“The PCP is the ‘gatekeeper’ to recognizing when a patient has health ramifications from extensive play,” she said.
Sontag and DiFrancesco-Donoghue stressed that an important part of PCPs being aware of esports-related injuries is to take the steps necessary to have the participant feel that open, honest dialogue about any component of the activity, good or bad, is encouraged.
“An open discussion between participant and PCP explaining how these side effects can shorten their play time — and may eventually lead to them not being able to play at all — can help patients understand that gaming is okay, but also remind them to be aware that if certain symptoms are not addressed, they may acquire a long-term injury,” DiFrancesco-Donoghue told Healio Primary Care Today
Sontag also noted that medical professionals will need to keep abreast of changes to esports.
“This is a new, exciting area of medicine, so what we say today may need to be updated tomorrow,” he said. – by Janel Miller
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Disclosures : Neither Donoghue nor Gainsbury report any relevant financial disclosures. Healio Primary Care Today was unable to determine Sontag’s relevant financial disclosures prior to publication.