Making the  front page in 'NATURE'

With over 35 million downloads and a claimed 85 million users, Lumosity is certainly the world’s most popular brain-training app. However, startup Lumos Labs, the company behind the Lumosity brand, has been heavily criticised by the Food and Drug Administration (FDA), the agency responsible for authorising the sale of healthcare and medical products in the United States. Having been fined a massive $50 million, which it was of course quite unable to pay, Lumos Labs was subsequently forced to come up with a penalty of $2 million, to be used to reimburse some of its customers. The neuro-gaming startup clearly went overboard in its advertising on CNN, Fox News and many radio stations, claiming that training your brain with its app would not only help you improve your performance at work, at school or on the sports field, but also delay the appearance of conditions linked to ageing, such as dementia and Alzheimer’s, and even reduce the after-effects of a stroke.

The FDA lambasted Lumos Labs for not being able to substantiate the conclusions from its scientific studies, plus the fact that the startup could not even get the app’s users who were quoted on its website to testify to the app’s benefits.

Notwithstanding Lumosity’s impressive social credentials – the company set up the Human Cognition Project – condemnation of the US company and its marketing methods has called into question the overall effectiveness of this type of ‘therapy game’. However, a number of medical research firms are working to develop such games following scientific procedures which stand close comparison with those required for the certification of medicines. One of the pioneers of apps designed to treat cognitive disorders is San Francisco’s Neuroscape Lab, a translational neuroscience centre at the University of California, San Francisco (UCSF). Researchers there were the first to develop a game which was the subject of an article in the noted science journal Nature. NeuroRacer, the game developed by Dr Adam Gazzaley in partnership with George Lucas’ studio LucasArts in 2008, was even featured on the cover of this highly-reputed magazine in September 2013.

x-torp game

Since then, other research groups have followed in the US companies’ footsteps, one example being the CoBTek (Cognition Behaviour Technology) research team led by Professor Philippe Robert at the Hospital Centre at Nice University, France. Explains Professor Robert: “Our goal is to test and approve new technologies designed to assess and stimulate patients, from children to adults and elderly people. Video games should be regarded as a tool both for the therapist and for the patients themselves.” The French team took part in the development of the X-Torp game, and is now participating in clinical testing of the game. “Some games such as X-Torp have been developed for sessions led by a therapist. The game links physical and cognitive activity. Every Friday morning, we hold a ‘stimulation’ session and the psychologists suggest using X-Torp during some of these sessions. It’s an approach that can be useful not only in our Memory Resource and Research Centres (CMRR), but also in day centres and in homes for dependent elderly people,” underlines the Professor.

Games enable the patients concerned to work independently on their rehabilitation, as they might do for physiotherapy, for example.

Philippe Robert, Professor

Now that the populations of the developed countries are ageing, Professor Robert is convinced that video games have a role to play in the therapist’s toolkit. “I’m in charge of one of the Memory Resource and Research Centres (CMRR) which have been set up in French hospitals for diagnosis and screening.  A lot of patients come and see us because they’re afraid of developing Alzheimer’s. Fortunately, many do not have this condition but are just suffering from mild cognitive disorders. But when they asked the question, ‘So now, doctor, what can I do about it’, it was hard to give a straight answer. Coming back to do some memory training with a psychologist won’t be reimbursed through the social security system and in any case we don’t have enough psychologists to run this type of activity. So, we’ve created the MeMo (Memory Motivation) app. It’s free of charge and we suggest that patients who agree to play with it come back two months later with their results. Games enable the patients concerned to work independently on their rehabilitation, as they might do for physiotherapy, for example,” Professor Robert points out.

Games publishers play a key role in getting the market off the ground

The CoBTek team is made up of researchers, plus a large number of engineers. Interaction between them has enabled progress to be made in the approaches taken to deal with the condition. However, this kind of team has neither the human resources nor the skills to develop brain-training games of a quality comparable with their alter-egos from the video-gaming industry, which enjoy film production-level budgets. Professor Robert’s team is working with the France-based Genious Group, a publisher whose prime focus is developing ‘Serious Games’. Genious is betting on seeing therapy games really take off and has launched a dedicated platform called Cupary.com.

An expert eye

Pierre Foulon

Head of e-Health at the Genious Group

We started out working on educational serious games but in 2011, we realised that there was potential to move from the educational games field to therapy games.

Pierre Foulon, Head of e-Health at the Genious Group, explains how Genious came to be involved in publishing this type of game: “We started out working on educational serious games, but in 2011 we realised that there was potential to move from the educational games field to therapy games. This move meant we needed new skills and it was then that the ICM (the Paris-based Institute for the Brain and Spinal Cord) got in touch with us. This led to the development of an initial game designed for young people who have become hemiplegic as a result of a stroke. Our approach really took off when I was appointed to co-lead one of the Institute’s joint laboratories, alongside Marie-Laure Welter, a professor of neurophysiology, and we succeeded in combining technology and healthcare.” In contrast to Lumosity, Pierre Foulon deliberately chose to follow the strict regulatory requirements in force when bringing health sector products and services to market. He explains: "From the start I insisted on positioning our therapy games in the health sector rather than the well-being field. This meant we had to go through all the regulatory approvals, but from a company strategy viewpoint I reckoned that while there would be a lot of competition from small apps in the well-being market, very few companies would risk putting themselves through the complex time-consuming procedures required to bring a product or service on to the market in the medical sector.” In the medical world, creating a therapy game means identifying a real public health need and creating something that will get through the phase II and phase III clinical trial procedures, followed by an assessment of the medico-economic impact of the innovation on the health system as a whole. The game then has to be approved by the national regulatory authority for use among the general population.  

Scientific methodology now being used to assess the effectiveness of therapy games 

For the X-Torp game, which was designed for patients who have been diagnosed with Alzheimer’s, the scientists started by setting targets for what the treatment should help to achieve, at cognitive or physical level. They incorporated into the game traditional tests for measuring the progress of the medical condition. X-Torp went through phase II clinical trials and the results were published in The Journal of Alzheimer’s Disease, an international peer-reviewed medical journal. The game has now begun phase III clinical trials with 180 patients in the Provence-Alpes-Côte d'Azur, (PACA) region in south-eastern France, led by Professor Robert, and in the Greater Paris region by Professor Bruno Dubois, Director of the Cognitive and Behavioral Neurology Center and of the Memory and Alzheimer’s Disease Institute at the Salpétrière Hospital in Paris – two renowned authorities on Alzheimer’s. Professor Robert reveals: “Our objective now is to demonstrate the effectiveness of the game not only in a small clinical trial but with a larger number of subjects, and not just, as we’ve done up to now, in a specialised CMRR, but also at day centres and homes for dependent elderly people, taking as prime criteria not only the effectiveness of the software but also its medico-economic outcomes. Does the game make a difference to a patient’s quality of life, and to the cost of the care required? The future of therapy games depends on these outcomes: they will have to demonstrate both their clinical effectiveness in the short, medium and long term, and also show that they have a real impact on people’s lives.” Many scientific articles have been published on the work of the CoBTek researchers and, more generally, on therapy games. 2014 saw the publication of a peer-reviewed article which presented the measured results from three games designed to aid Alzheimer’s patients: the X-Torp app; the music therapy game MinWii developed by researchers from the Saint-Maurice Hospital and the Computer Research Centre at the MINES ParisTech research institute; and ‘Kitchen and Cooking’, a game developed under the EU-funded Verve project. Professor Robert reveals: “During the clinical trials we asked patients to come for a training session three times a week for one month, and to use a specific set of criteria to assess the game’s effectiveness.”

The toap run game 

The Cupary.com platform, which was launched in 2011, hosts the Genious Group’s therapy video games. There are another ten or so games currently undergoing clinical trials. Apart from X-Torp, the Toap Run game is designed for patients suffering from Parkinson’s disease, and JeMime is a serious game for children with autism that helps them to learn to mimic emotions. Genious also has games to help deal with cognitive disorders, with re-educating the frontal lobe of the brain after a stroke, plus an ophthalmology game for those suffering from age-related macular degeneration, and a venture called ReMinAry, which uses motor imagery (MI) for orthopaedic and neurological rehabilitation. Some 5,000 healthcare professionals are involved in the platform and around 1,000 patients are already using it. Healthcare professionals enjoy free-of-charge access to Curapy.com; the business model is patient-based. Patient access to the games is also free, but patients wishing to actually see the results are required to take out a subscription for €5 a month, or €10 if they also want advice from their healthcare professional. In addition to making the games available, the Curapy platform records a huge amount of information on the patients playing the games, and all this data is handed over to healthcare practitioners who can then track how patient game-playing is evolving day-to-day.

So it is now up to researchers and healthcare practitioners to get together and work out how they can use this new approach on a wider scale. Many researchers feel that at the moment not enough practitioners are interested in using video games, but Olivier Richard, a psychology PhD who heads up a French company called UMEO that develops online tools for psychologists, argues that his colleagues are very much at ease with the new tools emanating from the gaming world: “I don’t think therapists are reluctant to use this type of approach, but they don’t go looking for this sort of material because they just don’t have enough information about the fields researchers are currently working on. The tools that we produce – which are still very much paper and pencil-based – are selling pretty well. Psychologists are actually very fond of this sort of tools and if they had access to this type of app or even knew about them, they would certainly get hold of them. I firmly believe that this type of app is set to grow,” predicts Dr Richard.

dr kawashima

Olivier Richard is well aware of how useful his company’s software is in helping healthcare practitioners with the exercises they give their patients. He nevertheless points out the limitations of games intended for the general public, such as Lumosity or the well-known advanced ‘Brain Training from Dr. Kawashima’ programme, which was published by Nintendo on the Nintendo DS platform in 2005 and subsequently on the Wii console. Dr Richard underlines: “The idea behind this sort of memory stimulation game enables players to enhance their skills, but only for the game itself. These aren’t necessarily skills that would have an impact in real life. I therefore have some reservations as to the ability of such games to help Alzheimer’s patients recover their memories, although the games could perhaps help to slow the pace of deterioration.”

There is little doubt that in the very near future games will play an ever-greater role in the fields of psychology and neuropsychology, and many more areas besides. The surge in the use of Virtual Reality in the medical sector will certainly help this trend to take further hold.

By Alain Clapaud
Independent journalist specialising in the new technologies