Emerging Technologies

Examining the Characteristics of Health-Related Gaming Interventions Among Congenital Heart Disease Patients: A Scoping Review


Resources to support persons living with congenital heart disease are limited, and consist primarily of patient education booklets. However, these resources fail to provide opportunities for social and/or group interaction. Health related gaming is an alternative medium for the delivery of patient education materials. To date, these types of interventions have been used throughout the healthcare environment, however no extensive review has been conducted to determine the characteristics of these interventions.

The aim of this scoping review was to summarize and disseminate research findings, to identify research gaps, and to make recommendations for future intervention design and evaluation.  Forty-two articles were included in this review. None of the studies used interventions that incorporated individuals living with congenital heart disease or the use of multi-player online gaming options. Additional testing of these interventions using a variety of populations, in a number of settings, and incorporating multi-player options is required. 


Congenital heart disease (CHD) is a condition present at birth that encompasses a number of diseases involving the heart (Oliver et al., 2017). It consists of defects that may compromise the functioning of the heart and can affect the interior lining of its walls, valves, arteries, and veins (Oliver et al., 2017). CHD manifests in a number of forms which can range from simple defects that can have minimal symptoms and are more easily treated when diagnosed (e.g., narrowed valve, hole in septum) to multifaceted defects that can have life altering complications and require complex treatment (e.g., improper location of vessels leading to and from the heart, multiple defects that influence how the heart develops) (Opic et al., 2015). Over the years, the diagnosis and treatment of CHD has significantly advanced, allowing individuals to live into adulthood (Heery, Sheehan, While, Coyne, 2015). Consequently, lifelong complications exist, leading to individuals requiring additional care throughout their lives. Their capacity to partake in employment is sometimes limited, as many of these individuals tend to be too sick to work, and thus are more likely to be on permanent disability. Furthermore, the reoccurrence and/or exacerbation of symptoms results in increased use of the health care system, which often times is significantly higher than that of the average individual (Masoudi et al., 2017). Accordingly, the combination of the onset and/or aggravation of symptoms and limited work connections has led to decrease social interactions among these individuals.

Age and context appropriate interventions should be designed for the adult cohort with congenital heart disease since current resources are not optimal. Resources to support persons with CHD are limited and consist primarily of patient education booklets (Triedman & Newburger, 2016). However, these resources fail to provide opportunities for social and/or group interaction. Health related gaming interventions are an alternative resource for patient education interventions. They consist of online games that are created using a variety of health scenarios in which, players interact with a specific scenario to move through a gaming situation. As they proceed through the game, they acquire knowledge and health information. The player will then use this information to change their behavior within the game to engage in activities that are considered healthy in order to complete the game. It is anticipated that with increased involvement in health related gaming interventions; actual behavioral change leading to reduce complications will occur. Health related gaming interventions can also be designed to create a forum for social interaction and engagement, as well as entertainment (Triedman & Newburger, 2016). Accordingly, health related gaming interventions are online, in that a connection to the internet is required. This allows for the use of chat rooms and discussion forums throughout the gaming experience.

To date, online gaming interventions have been used throughout the healthcare environment, and has been shown to be beneficial to individuals living with various chronic diseases that include: obesity (Kharrazi et al., 2009), diabetes (Kharrazi et al., 2009), chronic kidney disease (Goldstein et al., 2013), and cognitive impairment (Yuan et al., 2013). The beneficial impact of gaming on memory and retention (Yuan et al., 2013), enhanced social capital and interactions (Beaudoin & Tao, 2007), increased engagement in physical and psychological therapy, improved performance of self-management skills, and improved physical activity (Primack et al., 2012) have been routinely identified throughout the literature (Primack et al., 2012). However no extensive review has been conducted to determine the characteristics of these interventions, such as specific features, length of time for delivery, process related to how it is delivered, who can access it, type of content delivered, and how often gaming intervention can be accessed, in addition to its effectiveness. This information is needed to effectively design, implement, and begin to evaluate the effectiveness of online gaming interventions delivered to adults diagnosed and living with CHD.

The purpose of this scoping review was to identify the body of literature pertaining to health related gaming interventions and to describe the characteristics associated with its delivery and implementation.



A scoping review was selected as opposed to a systematic review, as online gaming has not been thoroughly examined, described, or reviewed in the health related literature. Scoping reviews are typically used to present a broad overview of the evidence pertaining to a topic, irrespective of the quality of the study, and are useful when examining areas that are emerging, to clarify key concepts and identify gaps (Peters et al., 2015). The protocol for this study was developed using the scoping review methodological framework described by Peterson, Pearce, Ferguson, and Langford, (2017), which has since been revised by the Joanna Briggs Institute (Peters et al., 2015). The aim of this scoping review was to summarize and disseminate research findings, to identify research gaps, and to make recommendations for future intervention design and evaluation. For the purposes of this scoping review, we included studies based on their relevancy and contribution of evidence rather than their methodological rigor, thus we also included non-empirical papers. The body of literature surrounding online gaming will be mapped with a relevance to time (year published), source (empirical, theoretical, or grey literature), intervention characteristics, and type of outcome assessed.  

Inclusion Criteria

The search was limited to articles written in English, as this study was being conducted in English. Additionally, articles published between 1997 and 2017 were included. This timeframe was selected, as there has been a significant increase in the development, application, and evaluation of online gaming interventions in health care settings during this period. Studies that included individuals receiving ongoing healthcare were included in this review. This classification of study participant was intentionally kept broad to ensure the largest segment of the literature was reviewed. All studies included in this review had to discuss and/or evaluate an online gaming intervention. Furthermore, studies that used either qualitative or quantitative designs were also included in this review. Additionally, all outcomes were included, to determine the type of outcome that is typically evaluated with online gaming interventions. The search was conducted on a monthly basis and began August 2016 and concluded April 2017.

Initially, the search for articles that addressed the characteristics of health-related gaming interventions for adults living with congenital heart disease was conducted. No articles and/or reports of health gaming with the congenital heart population was found. Consequently, articles, reports, and studies that examined health-related gaming throughout healthcare was conducted.

Search Strategy

The search strategy began by consulting with university research librarians and online gaming experts. Their involvement allowed us to collect feedback about the study purpose and sources of literature. The librarian helped to develop a list of the most appropriate search terms and strategies.
Search terms that were used included: gaming and patient education, general medicine, gaming and healthcare, virtual gaming, computer gaming, online gaming, and simulated online gaming. Boolean operands such as AND/OR were used throughout the search. We began by searching electronic literature databases: ABI Inform, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, Cochrane Library, EMBASE, Ovid MEDLine, PsycINFO, HealthStar, and Eric. We then searched relevant websites that included: https://medlineplus.gov/games.html, www.silvergames.com/t/patient, www.surgerysquad.com, www.dentalsolutions.ca/, and smartbrain.com. Furthermore, Universal Resource Locator (URL) and reference lists of key materials were also reviewed, as were primary and secondary sources, synthesis documents, technical reports, theoretical papers, and narrative papers.

Extracting and Charting the Results

All articles retrieved were reviewed independently by both the first author and two trained research assistants. The screening process consisted of the research assistants reviewing the title, abstract, and then the full text. In case of any uncertainty about a paper based on its title and the abstract, the first author reviewed the full text. No discrepancies appeared at the final stage of screening. The search initially yielded 2380 articles. In order to refine the search, only articles that were available via electronic medium were considered. This allowed for a more in-depth analysis of the articles that examined or described online gaming in healthcare, in a timely manner. Thus, 73 abstracts were assessed, with the final screening process yielding a total of 42 papers for inclusion (Figure 1). Of the 34 articles that were excluded, 27 were reports of the same study and 7 were irrelevant reports.

Data Collection

A multi-stage process to chart the data was enacted in which common descriptive demographic information was extracted from individual articles based on specified categories: author(s), publication date (year), condition of study participants, type of published document (research/theory/commentary/summary of literature), type of study design (experimental, quasi-experimental, non-experimental), setting for data collection (rehabilitation/school/home/other inclusive of cardiologist and pediatric settings), type of data collected (self-reported/ observational), type of gaming intervention, length of time for intervention delivery, process for delivery, number of times intervention can be accessed, format for content delivery, type of content delivered, type of outcome measured, and with which outcome gaming interventions were deemed to be most effective.


View Data Extraction

Data Analysis

Following the data extraction, we conducted a narrative synthesis, grouping the findings by data type of health gaming intervention. Descriptive analyses were also conducted to describe the demographic characteristics of the articles retrieved.


The articles included in this review were published between 1997 and 2016, with the majority of papers being published in 2015 (n = 9, 21.4%). The condition of the participants included in the studies included varied from healthy (n = 10, 23.8%), having had a stroke (n = 10, 23.8%), or undergoing general rehabilitation following surgery (n = 6, 14.3%). For the most part, research studies (n = 36, 85.7%) were included, that contained quasi-experimental (n = 17, 40.5%), randomized controlled trials (n = 11, 26.2 %), and non-experimental, descriptive (n = 8, 19.0%) based designs. Rehabilitation (n = 16, 38.1%), home (n = 12, 28.6%), and school (n = 10, 23.8 %) were the most common settings, with self-reported data (n = 42, 100%) being included.

The interventions were typically designed for healthy individuals (n = 10, 23.8%), with the twofold purpose of providing self-care information and promoting behavioral change within the home environment. Data collection ranged between once (n = 10, 23.8%) to multiple times (n = 32, 76.1%). All interventions were designed with the intent to be used as health care interventions to promote and/or maintain health status.

The most common type of gaming intervention consisted of Nintendo Wii (https://www.nintendo.com/corp/history.jsp) gaming console (n = 28, 67%), computer simulations (n = 5, 11.9%), and web based games question and answer images embedded into the program (n = 3, 7.1%). The length of time for the online games ranged between 10 minutes (n = 1, 2.4%) to 5 hours (n = 1, 2.4%), with the most frequent length of time for interaction with the gaming intervention being 30 minutes (n = 9, 21.9%). The three most common methods for delivering online gaming interventions were through sensor motion detection devices (n = 16, 38.1%), hand held wireless controllers with motion detection (n = 12, 28.6%), and hand held wireless controllers (n = 4, 9.5%). On average, online gaming interventions were accessed at least twice a week (n = 6, 14.3%) in the form of virtual reality with motion sensors (n = 17, 40.5%), virtual sports games (n = 12, 28.6%), or virtual dance simulations (n = 6, 14.3% 9.5%). The majority of the online gaming simulations focused on educational content (n = 41, 97.6%), with data on bio physiological measures (i.e. range of motion, myocardial oxygenation, motor function, and strength) (n = 30, 71.4%) being collected, along with subjective data (n = 9, 21.4%) that measured emotion and mood, and learning outcomes (n = 1, 2.4%). Study findings suggested all (n = 42, 100%) outcomes had enhanced following exposure to online gaming interventions.


There is a lack of research in the area of online gaming throughout the congenital heart disease population. As such, prior to implementing an intervention with this cohort, the conduct of a scoping review was undertaken as a first step in navigating the use of online gaming throughout healthcare.
Findings from this review suggest, even though much of the online gaming interventions were designed with the intent that they be used with individuals experiencing chronic illnesses, many of these interventions were evaluated using healthy, young adults, and in many cases adolescents. Additional testing of these interventions using a variety of populations, that include individuals living with congenital heart disease, is required, across a number of settings that include: home, rehabilitation, long term care facilities, and nursing homes. The congenital heart disease population tend to be under the age of 50, and are more likely to have an increase awareness and familiarity with technology (Triedman & Newburger, 2016). Furthermore, even though the majority of the studies were evaluated using randomized controlled trials, their findings cannot be inferred or even associated with individuals diagnosed and living with CHD, as the samples used were significantly different.

Use of Nintendo Wii (https://www.nintendo.com/corp/history.jsp) consoles, twice a week, for an average of 30 minutes each session, with motion sensor detection devices embedded into the consoles appear to be the most common form of online gaming intervention designed for use within the healthcare arena. Findings reported suggest these interventions are effective in producing desired changes in outcomes related to biophysiological, subjective, and learning outcomes. However, no study used interventions that incorporated multi-player online gaming. Furthermore, no study has examined the effect of web based multi-player online gaming that may involve an online fee.

Multi-player gaming provides individuals with the opportunity to engage with each other via a computer interface, allowing for the creation of a parallel world in which social interactions most frequently occur (Huang et al., 2017). Within this parallel domain, individuals are confined by technical restrictions and are sanctioned by formalized gaming rules (Huang et al., 2017). As such, individuals are able to express themselves in an unguarded setting, without appearance, symptoms, or perceived disabilities influencing their social interactions (Huang et al., 2017). As well, due to the highly interactive environment created by multi-player gaming interventions, opportunities for individuals to not only exchange information, (Park & Lee, 2017) but to create "strong friendships and emotional relationships” (Park & Lee, 2017)  have been shown to occur. This is of significance to the CHD population as these individuals tend to be more socially isolated due to symptoms associated with their condition. Engagement in a world that is perceived as providing a sense of anonymity and escape from daily health related routines can be empowering for many individuals diagnosed and living with CHD.


As a result, it is recommended multi-player gaming interventions should be designed, implemented, and evaluated within the CHD population. The nature and structure of the social interactions that develop within this population and the effect of these interactions on the overall quality of life of CHD individuals should also be examined further. The design and application of multi-player gaming interventions is not only innovative for this particular population but may have a positive effect on the healthcare system, as it can function as a medium for social support, repertoire of information, and an escape from the experience of living with CHD, as well as other chronic illnesses.

Citation: Fredericks, S., Lapum, J. & Goroscope, F. (Feb, 2018). Examining the characteristics of health-related gaming among congenital heart disease patients: A scoping review.  Online Journal of Nursing Informatics (OJNI), 22(1), Available at http://www.himss.org/ojni

The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

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Dr. Suzanne Fredericks is a Professor and the Graduate Program Director at the Daphne Cockwell School of Nursing at Ryerson University. Her research focus is on supporting patients following invasive procedures. Dr. Fredericks teaches in the undergraduate and graduate Nursing Programs, with an emphasis on Research Methods. Dr. Fredericks also acts as a graduate faculty adviser, student thesis supervisor, and student thesis committee member. Dr. Fredericks’ educational background consists of a Bachelor of Science in Nursing, a Masters of Nursing, and a PhD in Nursing.

Dr. Jennifer Lapum is an Associate Professor, a poet and an arts-based, narrative researcher at the Daphne Cockwell School of Nursing at Ryerson University. She is a registered nurse with extensive clinical background in critical care nursing, particularly in intensive care including cardiovascular intensive care nursing. In her research, she is focused on enhancing patients’ overall health and well-being and ensuring that no patient feels like “the 7,024th patient” when they enter and exit the health care system. As a scientist and artist, her focus is on the development of an arts-informed program of research in the health sciences to advance the capacity for humanistic approaches to health care. Dr. Lapum’s educational background consists of a Bachelor of Science in Nursing, a Masters of Nursing, and a PhD in Nursing.

Mr. Franklin Gorospe is an Instructor at the Daphne Cockwell School of Nursing at Ryerson University and a Registered Nurse. He was the Research Assistant for this study. Mr. Gorospe’s educational background consists of a Bachelor of Science in Nursing and a Masters of Nursing degree.

Articles included in the scoping review are identified with an *

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Beaudoin, C. E., & Tao, C. C. (2007). Benefiting from social capital in online support groups: An empirical study of cancer patients. CyberPsychology & Behavior, 10(4), 587-590.

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* Brown, E. V. D., Dudgeon, B. J., Gutman, K., Moritz, C. T., & McCoy, S. W. (2015). Understanding upper extremity home programs and the use of gaming technology for persons after stroke. Disability and health journal8(4), 507-513.

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* Cameirão, M. S., i Badia, S. B., Oller, E. D., & Verschure, P. F. (2010). Neurorehabilitation using the virtual reality based Rehabilitation Gaming System: methodology, design, psychometrics, usability and validation. Journal of neuroengineering and rehabilitation7(1), 48.

* Chan, T. C., Chan, F., Shea, Y. F., Lin, O. Y., Luk, J. K. H., & Chan, F. H. W. (2012). Interactive virtual reality Wii in geriatric day hospital: a study to assess its feasibility, acceptability and efficacy. Geriatrics & gerontology international12(4), 714-721.

* Chuang, T. Y., Sung, W. H., Chang, H. A., & Wang, R. Y. (2006). Effect of a virtual reality–enhanced exercise protocol after coronary artery bypass grafting. Physical therapy86(10), 1369-1377.

* Combs, S. A., Finley, M. A., Henss, M., Himmler, S., Lapota, K., & Stillwell, D. (2012). Effects of a repetitive gaming intervention on upper extremity impairments and function in persons with chronic stroke: a preliminary study. Disability and rehabilitation34(15), 1291-1298.

* Fachko, M. J., Xiao, C., Bowles, K. H., Robinson, K. M., & Libonati, J. R. (2013). Cardiovascular effects and enjoyment of exercise gaming in older adults. Journal of gerontological nursing, 39(12), 43-54.

* Gamito, P., Oliveira, J., Coelho, C., Morais, D., Lopes, P., Pacheco, J., ... & Barata, A. F. (2017). Cognitive training on stroke patients via virtual reality-based serious games. Disability and rehabilitation, 39(4), 385-388.

Goldstein, K., Briggs, M., Oleynik, V., Cullen, M., Jones, J., Newman, E., & Narva, A. (2013). Using digital media to promote kidney disease education. Advances in Chronic Kidney Disease, 20(4), 364-369.

* Hawn, C. (2009). Games for health: the latest tool in the medical care arsenal. Health Affairs28(5), w842-w848.

Heery, E., Sheehan, A. M., While, A. E., & Coyne, I. (2015). Experiences and outcomes of transition from pediatric to adult health care services for young people with congenital heart disease: a systematic review. Congenital heart disease, 10(5), 413-427.

* Henry, J. M. (1997). Gaming: A teaching strategy to enhance adult learning. The Journal of Continuing Education in Nursing28(5), 231-234.

Huang, H. C., Huang, L. S., Chou, Y. J., & Teng, C. I. (2017). Influence of Temperament and Character on Online Gamer Loyalty: Perspectives from Personality and Flow Theories. Computers in Human Behavior.

* Hughes, T. F., Flatt, J. D., Fu, B., Butters, M. A., Chang, C. C. H., & Ganguli, M. (2014). Interactive video gaming compared with health education in older adults with mild cognitive impairment: a feasibility study. International journal of geriatric psychiatry29(9), 890-898.

* Jaarsma, T., Klompstra, L., Ben Gal, T., Boyne, J., Vellone, E., Bäck, M., ... & Chialà, O. (2015). Increasing exercise capacity and quality of life of patients with heart failure through Wii gaming: the rationale, design and methodology of the HF‐Wii study; a multicentre randomized controlled trial. European journal of heart failure17(7), 743-748.

* Jameson, E., Trevena, J., & Swain, N. (2011). Electronic gaming as pain distraction. Pain Research and Management16(1), 27-32.

* Joo, L. Y., Yin, T. S., Xu, D., Thia, E., Chia, P. F., Kuah, C. W. K., & He, K. K. (2010). A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. Journal of rehabilitation medicine42(5), 437-441.

* Kahol, K. (2011). Integrative gaming: a framework for sustainable game-based diabetes management.

Kharrazi, H., Faiola, A., & Defazio, J. (2009, July). Healthcare game design: behavioral modeling of serious gaming design for children with chronic diseases. In International Conference on Human-Computer Interaction (pp. 335-344). Springer Berlin Heidelberg.

* King, M., Hijmans, J. M., Sampson, M., Satherley, J., & Hale, L. (2012). Home-based stroke rehabilitation using computer gaming. New Zealand Journal of Physiotherapy40(3), 128.

Kolo, C., & Baur, T. (2004). Living a virtual life: Social dynamics of online gaming. Game studies, 4(1), 1-31.

* Kuys, S. S., Hall, K., Peasey, M., Wood, M., Cobb, R., & Bell, S. C. (2011). Gaming console exercise and cycle or treadmill exercise provide similar cardiovascular demand in adults with cystic fibrosis: a randomised cross-over trial. Journal of physiotherapy57(1), 35-40.

Masoudi, F. A., Ponirakis, A., de Lemos, J. A., Jollis, J. G., Kremers, M., Messenger, J. C., ... & Vincent, R. N. (2017). Executive Summary: Trends in US Cardiovascular Care. Journal of the American College of Cardiology, 69(11), 1424-1426.

* Mazzoleni, S., Montagnani, G., Vagheggini, G., Buono, L., Moretti, F., Dario, P., & Ambrosino, N. (2014). Interactive videogame as rehabilitation tool of patients with chronic respiratory diseases: Preliminary results of a feasibility study. Respiratory medicine108(10), 1516-1524.

* Meldrum, D., Herdman, S., Vance, R., Murray, D., Malone, K., Duffy, D., ... & McConn-Walsh, R. (2015). Effectiveness of Conventional Versus Virtual Reality–Based Balance Exercises in Vestibular Rehabilitation for Unilateral Peripheral Vestibular Loss: Results of a Randomized Controlled Trial. Archives of physical medicine and rehabilitation, 96(7), 1319-1328.

* O’Donovan, C., & Hussey, J. (2012). Active video games as a form of exercise and the effect of gaming experience: a preliminary study in healthy young adults. Physiotherapy, 98(3), 205-210.

Oliver, J. M., Gallego, P., Gonzalez, A. E., Garcia-Hamilton, D., Avila, P., Yotti, R., ... & Fernandez-Aviles, F. (2017). Risk factors for excess mortality in adults with congenital heart diseases. European Heart Journal, ehw590.

Opić, P., Roos-Hesselink, J. W., Cuypers, J. A., Witsenburg, M., van den Bosch, A., van Domburg, R. T., ... & Utens, E. M. (2015). Psychosocial functioning of adults with congenital heart disease: outcomes of a 30–43 year longitudinal follow-up. Clinical Research in Cardiology, 104(5), 388-400.

* Park, D. S., & Lee, G. (2014). Validity and reliability of balance assessment software using the Nintendo Wii balance board: usability and validation. Journal of neuroengineering and rehabilitation11(1), 99.

Park, B., & Lee, D. H. (2017). The Interplay between Real Money Trade and Narrative Structure in Massively Multiplayer Online Role-Playing Games. International Journal of Computer Games Technology. DOI: https://doi.org/10.1155/2017/3853962.

* Parker, M., Delahunty, B., Heberlein, N., Devenish, N., Wood, F. M., Jackson, T., ... & Edgar, D. W. (2016). Interactive gaming consoles reduced pain during acute minor burn rehabilitation: a randomized, pilot trial. Burns42(1), 91-96.

Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015). Guidance for conducting systematic scoping reviews. International journal of evidence-based healthcare, 13(3), 141-146.

Peterson, J., Pearce, P. F., Ferguson, L. A., & Langford, C. A. (2017). Understanding scoping reviews: Definition, purpose, and process. Journal of the American Association of Nurse Practitioners, 29(1), 12-16.

Primack, B. A., Carroll, M. V., McNamara, M., Klem, M. L., King, B., Rich, M., ... & Nayak, S. (2012). Role of video games in improving health-related outcomes: a systematic review. American Journal of Preventive Medicine, 42(6), 630-638.

* Rajaratnam, B. S., Gui KaiEn, J., Lee Jialin, K., SweeSin, K., Sim FenRu, S., Enting, L., ... & Teo SiaoTing, S. (2013). Does the inclusion of virtual reality games within conventional rehabilitation enhance balance retraining after a recent episode of stroke?. Rehabilitation research and practice2013.

* Rego, P., Moreira, P. M., & Reis, L. P. (2010, June). Serious games for rehabilitation: A survey and a classification towards a taxonomy. In Information Systems and Technologies (CISTI), 2010 5th Iberian Conference on (pp. 1-6). IEEE.

* Rosipal, N. C., Mingle, L., Smith, J., & Morris, G. S. (2013). Assessment of voluntary exercise behavior and active video gaming among adolescent and young adult patients during hematopoietic stem cell transplantation. Journal of Pediatric Oncology Nursing, 30(1), 24-33.

* Roubidoux, M. A. (2005). Breast cancer detective: A computer game to teach breast cancer screening to Native American patients. Journal of Cancer Education, 20(S1), 87-91.

* Sabel, M., Sjölund, A., Broeren, J., Arvidsson, D., Saury, J. M., Blomgren, K., ... & Emanuelson, I. (2016). Active video gaming improves body coordination in survivors of childhood brain tumours. Disability and rehabilitation, 38(21), 2073-2084.

* Saposnik, G., Teasell, R., Mamdani, M., Hall, J., McIlroy, W., Cheung, D., ... & Bayley, M. (2010). Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation. Stroke41(7), 1477-1484.

* Saethang, T., & Kee, C. C. (1998). A gaming strategy for teaching the use of critical cardiovascular drugs. The Journal of Continuing Education in Nursing29(2), 61-65.

* Scholten, H., Malmberg, M., Lobel, A., Engels, R. C., & Granic, I. (2016). A randomized controlled trial to test the effectiveness of an immersive 3D video game for anxiety prevention among adolescents. PloS one11(1), e0147763.

* Schott, G., & Hodgetts, D. (2006). Health and digital gaming: The benefits of a community of practice. Journal of Health Psychology11(2), 309-316.

* Shin, J. H., Ryu, H., & Jang, S. H. (2014). A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: a usability test and two clinical experiments. Journal of neuroengineering and rehabilitation, 11(1), 32.

* Taylor, M. J., & Griffin, M. (2015). The use of gaming technology for rehabilitation in people with multiple sclerosis. Multiple Sclerosis Journal21(4), 355-371.

* Taylor, M. J., McCormick, D., Shawis, T., Impson, R., & Griffin, M. (2011). Activity-promoting gaming systems in exercise and rehabilitation. Journal of rehabilitation research and development, 48(10), 1171-1186.

Triedman, J. K., & Newburger, J. W. (2016). Trends in congenital heart disease. Circulation133(25), 2716-2733.

Yuan, K., Cheng, P., Dong, T., Bi, Y., Xing, L., Yu, D., ... & Qin, W. (2013). Cortical thickness abnormalities in late adolescence with online gaming addiction. PloS One, 8(1), e53055.

* Ward, A. K., & O'brien, H. L. (2005). A gaming adventure. Journal for Nurses in Professional Development21(1), 37-41.

* Wardini, R., Dajczman, E., Yang, N., Baltzan, M., Préfontaine, D., Stathatos, M., ... & Wolkove, N. (2013). Using a virtual game system to innovate pulmonary rehabilitation: safety, adherence and enjoyment in severe chronic obstructive pulmonary disease. Canadian respiratory journal20(5), 357-361.

* Wargo, C. A. (2000). Blood clot: Gaming to reinforce learning about disseminated intravascular coagulation. The Journal of Continuing Education in Nursing, 31(4), 149-151.

* Widman, L. M., McDonald, C. M., & Abresch, R. T. (2006). Effectiveness of an upper extremity exercise device integrated with computer gaming for aerobic training in adolescents with spinal cord dysfunction. The journal of spinal cord medicine29(4), 363-370.

* Wille, D., Eng, K., Holper, L., Chevrier, E., Hauser, Y., Kiper, D., ... & Meyer-Heim, A. (2009). Virtual reality-based paediatric interactive therapy system (PITS) for improvement of arm and hand function in children with motor impairment—a pilot study. Developmental neurorehabilitation12(1), 44-52.

* Zimmerli, L., Jacky, M., Lünenburger, L., Riener, R., & Bolliger, M. (2013). Increasing patient engagement during virtual reality-based motor rehabilitation. Archives of physical medicine and rehabilitation94(9), 1737-1746.