EPSRC Programme Grant EP/G059063/1
Public Paper no. 238
AirFlow: Designing Immersive Breathing
Training Games for COPD
Yongqiang Qin, Chris Vincent,
Nadia Bianchi-Berthouze & Yuanchun Shi
Qin, Y., Vincent, C. J., Bianchi-Berthouze, N., & Shi, Y.
(2014). AirFlow: Designing immersive breathing training
games for COPD. Proceedings of the 2014 Conference on
Human Factors in Computing Systems (CHI-2014),
Extended Abstracts, 2419–2424. New York: ACM.
PP release date: 13 June 2014
file: WP238.pdf
AirFlow: Designing Immersive
Breathing Training Games for COPD
Yongqiang Qin
1
1,2
Chris Vincent
Information Science and Technology,
2
Department of Computer Science and
[email protected]
Nadia Bianchi-Berthouze
[email protected]
Yuanchun Shi
1,3
[email protected]
Pervasive Computing Division,
Tsinghua National Laboratory for
[email protected]
Technology, Tsinghua University,
2
Beijing 100084, China
2
UCL Interaction Centre
University College London
MPEB 8th Floor, UCL
Gower Street, London WC1E 6BT, UK
3
Department of Computer
Technology, Qinghai University,
Xining 810016, China
Permission to make digital or hard copies of part or all of
this work for personal or classroom use is granted
without fee provided that copies are not made or
distributed for profit or commercial advantage and that
copies bear this notice and the full citation on the first
page. Copyrights for third-party components of this work
must be honored. For all other uses, contact the
Owner/Author.
Copyright is held by the owner/author(s).
CHI 2014, Apr 26 - May 01 2014, Toronto, ON, Canada
ACM 978-1-4503-2474-8/14/04.
http://dx.doi.org/10.1145/2559206.2581309
Abstract
Chronic Obstructive Pulmonary Disease (COPD) refers
to a collection of lung diseases that result in breathing
difficulties. In some cases, the symptoms of COPD can
be reduced, by engaging in breathing exercises.
Technology can support, and we are developing AirFlow,
a suite of interactive computer games, to guide
breathing exercises and promote learning. To establish
requirements, we interviewed 20 people with COPD, in
China, to understand their use of breathing exercises,
and learn how technology might fit their lifestyle. The
findings informed our design goals. We outline a
prototype system, where respiration rate, waveform,
and amplitude are captured and used to control a
virtual environment. The system will guide users
through breathing exercises, and provide training
instructions, using a series of games. The immersive
environment aims to support a fun and motivating
experience, therefore underpinning user confidence.
Author Keywords
COPD; Immersive media; Life style change
ACM Classification Keywords
H.5.2. User Interfaces. Training, help, and
documentation.
Figure 1. Emphysema is a typical COPD.
It is a condition in which the alveoli,
grape-like clusters of air sacs at the end
of the smallest airways (the bronchioles)
are destroyed. (Retrived from
http://tinyurl.com/o2gfy2g)
Introduction
Technology to support COPD
In 2011, the WHO reported Chronic Obstructive
Pulmonary Disease (COPD) as being the fourth leading
cause of death in the world [12]. The disease causes an
abnormal inflammatory response in the lungs,
restricted airflow and shortness of breath [3] (e.g.
Figure 1). Although damage to the lungs is defined as
irreversible, the progression of COPD can be slowed,
and the symptoms treated [3]. For example, clinicians
can use medicine to open up the airways or assist
breathing. Besides medication, maintaining a healthy
lifestyle and practicing breathing exercises are
important supplemental approaches to slow down or
halt the progress of COPD [3].
Several research groups have developed systems to
support management of the condition. For example
videoconferencing systems, that allow physiotherapists
to deliver rehabilitation in the home, have been tested
and found to be feasible and acceptable [11]. Mobile
phone technologies have been used to train and
monitor physical exercise programs. They support
performance and quality, and can also be used in the
home [10]. The long-term physical activity of people
with COPD can be measured, using wearable sensors,
and classification algorithms used to help monitor the
status and development of the condition[4].
As in the case of other chronic conditions, unfortunately,
despite the contribution of breathing exercises,
research has shown that not all people maintain regular
exercises [5]. Limited exercise (e.g. only two or three
times a week), may not be sufficient, as efficacy has
been shown only on the basis of daily routine [8]. In
this paper, we interviewed people with moderate COPD
to explore why the lack of adherence happens.
After a literature survey and analysis of interview data,
we formed an initial design for AirFlow, involving a suite
of interactive computer games. The aim is to train
moderate COPD sufferers to perform correct breathing
exercises, whilst at the same time enjoying themselves.
Respiration movements will be used as the game
controller; the system will have the ability to detect
movements relating to inhaling, exhaling, laughing and
coughing, as different input parameters. The system
will offer several modes or levels to provide a gradual
increment in challenge, with the objective of raising
confidence, whilst maintaining a daily routine.
For breathing techniques, mCOPD, a mobile phone
based lung function diagnosis tool, offers both
diagnostic potential and treatment potential, by
interfacing with games to make breathing exercises
engaging [13]. Other similar prototypes have included
the use of commercial controllers (Wiimote) to capture
breathing rate and provide guidance to patients [7].
Whilst these studies shows that technology can be used
to monitor breathing [7] and potentially support
rehabilitation [12], however there have not being
studies that focused on user engagement, and user
need, for the domain in question.
Videogames to support COPD
In healthcare, the use of videogames can increase
compliance with rehabilitation and support the
management of conditions. It can provide for a better
experience (e.g. for balance disorders see [9]). It can
provide clinical benefit, for example, the use of
computer games to manage COPD can lead to positive
short-term outcomes [1]. Although we expect that
computer games can help people manage COPD [2], we
Figure 2. Reported reasons for having
never tried the exercise.
RNR1!
100%!
75%!
50%!
25%!
0%!
RNR3!
RNR2!
need to know what type of game will be effective and
understand ways in which systems can engage users.
This is because there is a mixed literature, as to the
effectiveness of computer games to support healthcare.
For example, in similar applications, where games have
been used to support physiotherapy or occupational
therapy, there is a lack of long term follow up trials, to
show benefit [6]. The principles behind designing an
effective game for rehabilitation, are likely to be
different from those that provide games for more
general purposes. Different people like different games,
and some might not want to use games at all. Research
is required to understand how best to design and
deploy computer games to support healthcare. We
therefore chose to adopt a games based approach, not
only because it could improve or substitute for existing
mechanisms of care, but because there are many
unanswered questions about the best way forward. Part
of this involves understanding the everyday lives of
people with COPD, as per the following section.
The breathing exercise questions included 1) whether
the interviewee knew what breathing exercise was, and
what it involved, 2) whether & why they thought
breathing training was useful and 3) why they could not
practice breathing exercises regularly. Questions
concerning their quality-of-life included 1) how
shortness of breath affected their daily life, 2) what
they usually did in their spare time and 3) how they
perceived the development of their disease. Although
there various responses to the questions, we broadly
grouped the feedback as per the results.
Interviews
Twelve participants (60%) reported that they had very
limited time with doctors, and following the consultation,
were unclear as to the procedure; they had no way to
find additional instructions. The other eight participants
reported that their family members told them how, but
were not sure whether it was correct or not.
Procedure
Figure 3. Reported reasons for a
We spent 2 weeks conducting interviews in a threefailure to make the exercise routine.
level grade-A hospital in Beijing. People with COPD
TV!
were asked to participate in a 15-minute interview,
100%!
concerning topics relating to breathing exercises and
75%!
their daily life. Our participants included 20 people with
50%!
moderate COPD (10 male) and their family members.
25%!
The interview was an interactive process: interviewees
Gaming!
GrandChildren!
0%!
were asked questions about breathing exercise, in
addition to perspectives on COPD, their own quality-oflife, and suggestions for research. For privacy
considerations, no video or audio were recorded during
the interview, however the interviewer did take notes.
Chatting!
Figure 4. Reported everyday life.
Results
Breathing Exercise
Every participant knew about breathing exercise (they
had been told about it by their doctors), but only four
of the participants (20%) had ever tried it out. Three
main reasons of why participants had never tried the
exercises (RNT) emerged (figure 2):
RNT1.
RNT2.
Don’t know how.
Don’t think it’s useful.
Ten participants (50%) reported a lack of effect,
relating to the breathing exercise, although eight of
them had never tried it out. The two participants who
tried breathing training several times reported no
effects regarding their symptoms. The other two
participants said it might be useful, but weren’t sure.
Breathing Exercises
RNT3.
Pursed-Lip Breathing: people inhale
through their nose and exhale through
their mouth two or three times. They
exhale slower than they inhale. These
breathing exercises can help change the
pressure in the airways and prevent the
small airways from collapsing.
Three participants reported other diseases as barriers
to practice the exercises.
Holding Breath and Coughing: people
inhale deeply and slowly, hold the breath
for 5 – 10 seconds and then cough while
breathing out. These exercises help
improve functional exercise capacity and
tolerance.
Three reported many daily interruptions that cause
delays, or make them oblivious, or distracted from the
need to do the exercise. Ten participants that had
never tried the exercises also reported these issues.
Sensors
Connection to
the encoder
Figure 5. The sensors are worn over
clothes, on chest and abdomen. The
ProComp Infiniti encoder is not
illustrated in the figure.
Figure 6. Example waveform of captured
respiration signal. The amplitudes are
different according to different types of
breathing.
Other diseases.
Four participants reported on reasons for not being able
to maintain a daily exercise routine (RNR) (figure 3):
RNR1. Interrupted by daily chores
RNR1.
Couldn’t exercise together.
Two participants reported that if they had partners,
they might be able to create a routine. Ten participants
who had never tried the exercise also reported that
partners would help them to learn and practice
breathing training.
RNR2.
Embarrassment.
Two participants reported that they felt silly whilst
doing the breathing exercise.
Everyday life
As shown in figure 4, during their spare time, the most
common activities were watching TV (eighteen), taking
care of grandchildren (eight of twelve did this), chatting
with the community (ten) and online gaming (two).
Fifteen subjects reported that they were not familiar
with online gaming at all. When asking about their
understanding of the development of COPD, all
participants knew that the disease wouldn’t be cured,
but only half of them (ten) had the desire to control the
development of the disease. The others were holding
the opinion “that’s it”. This is concerning, but by
introducing self-management technology; the attitudes
of this group could change, because they would be
empowered to manage their own condition. This
remains a topic for future research. All of them
reported that they hoped that the doctors could know
more about the disease in the future.
From Interview to Design
Based on the interview results, three main barriers to
help control the development of COPD were identified:
C1.
C2.
C3.
Lack of confidence in the effects of breathing
exercises.
Little knowledge of how to do breathing exercises.
An inability to make breathing exercises routine.
We realized that providing therapy at home is
important for people with COPD, however during the
design of technology we need to address these barriers.
We proposed the following design goals:
G1.
G2.
G3.
G4.
G5.
Support breathing training through the use of
computer games. (RNT1) (RNR1-3)
Provide positive feedback especially when people
feel silly or suffer poor performance. (RNR3)
Support long-term performance records. (RNT2)
Provide deep engagement, to attract more
attention from other activities such as watch TV.
(RNR1)
Support online competitions, across a wider COPD
community. (RNR2)
AirFlow
System Design
In seeking to develop a prototype system, we used
Commercial Off-The-Shelf (COTS) components to
establish a proof of principle, and understand what type
of inputs could be used to control the games. A full
Figure 7. Example waveform of captured
signal: deep breath, cough and talking.
Figure 8. The Balloon game, which is
designed to train Pursed-Lip Breathing.
system has yet to be built. When people breathe, their
chest and abdomen expand and contract accordingly.
Measuring the corresponding circumferences can
capture people’s respiration movements. To do this, we
used a non-invasive sensor and encoder set from
Thought Technology Ltd (http://tinyurl.com/q5ueyhf).
Sensors were worn over clothes (Figure 5). The sensors
were connected to an encoder box (we choose ProComp
Infiniti encoder), which was connected to a laptop PC,
running Windows 7. The captured data was available
via an API, in real-time at 256 Hz, which provided
enough resolution to capture the aspects of the
respiration signal that we required (Figure 6).
Respiration Signals
Players will be required to wear the sensors and
breathe as normal to calibrate the controllers. The
amplitude of normal breath is used as baseline to
normalize the other kinds of respiration signals, e.g.
deep breathing, coughing and laughing (see figure 7).
The normalized amplitude and duration of inhale and
exhale phases are used as the game controller’s input.
We expect the players to be seated to avoid noisy input
from body movements.
Breathing Exercise
Breathing exercises can help individuals with COPD to
take deeper breaths and reduce shortness of breath [4].
The two main types of breathing exercises listed in the
lietarture [5] (left hand box) guided the design of the
gaming elements of AirFlow. The better they perform,
the higher the score they get.
Figure 9. The Eating game. The player
controls the character on the right (green
clothes). The character on the left (with
red clothes) provides the rhythm.
Computer Games
AirFlow is a set of computer games. In our prototype,
we have three games:
The Balloon Game: The balloon game is designed to
train the player to do Pursed-Lip Breathing. During the
game, the player inhales to make the balloon inflate
and then exhales to blow a flabellum, thus lifting a
bucket from a well. Only when the exhale speed is two
or three times slower than the inhale speed, does the
bucket get lifted to the highest point. The water from
the bucket is used to irrigate flowers. The flowers
bloom when they get an appropriate amount of water.
This can only be achieved when the players exercise
everyday, or the flower will become withered.
The Eating Game: The eating game aims to train
players to breathe rhythmically. During the game,
rhythm is provided. If the player’s breath matches the
rhythm, the character eats more. The character is only
satisfied when he gets the right food, everyday. This
can only be achieved when the players exercise
everyday, or the character will become weak.
The Penguin Game: The penguin game is an Angry
birds like game, which uses a players inhale to stretch
the slingshot. They then need to hold their breath to
get the best launch angle and cough to shoot the
penguin. Players can make penguins fly a long way by
inhaling as deeply as they can, holding their breath (for
a period), and then coughing as quickly as possible.
Only limited numbers of penguins are allowed to fly on
a given day; and a set number of penguins must fly or
the number of available penguin for the next day will
be decreased.
Social Ranking: To avoid loneliness, as well as provide
opportunities for communication, a social ranking
mechanism is proposed. In order to avoid negative
impacts through comparison with other more successful
players (their COPD condition might be different),
AirFlow only display the players’ scores that have
similar rexpiratory volume in normal breathing.
Discussion and Future Work
Figure 10. The Penguin game. The
dashboard on the upper left corner
indicates the potential distance of flight:
inhale more air to get more power and hold
breath longer to get better launch angle.
Acknowledgements
Supported by National Science and
Technology Major Project of China under
Grant No. 2013ZX01039001-002 and by
the Exchange of Excellence in Ubiquitous
Computing Technologies to Address
Healthcare Challenges under Grant No.
FP7-PEOPLE-2012-IRSES. Thanks to the
reviewers for their constructive input.
[3] “Chronic obstructive pulmonary disease”. Retrieved
from http://tinyurl.com/postcrr
[4] Chen, B.-r., Patel, S., Toffola, L. D. and Bonato, P.
Long-term monitoring of COPD using wearable sensors.
In Proc. Wireless Health’11 (2011).
Although the above remains a work in progress, it
provides the basis for a more involved development
and testing process, focusing on the needs and
everyday experiences of COPD sufferers. The
contribution is, and will be, to actively engage the
community we seek to support, during the design of
technology. This helps us move from current
technology focused studies (e.g. solving the problem of
detecting respiration), to ones that help us fit
technology to purpose. Potential limitations could
include the efficacy of the breathing exercises, as they
may not work for the spectrum of COPD sufferers. To
address this, we are planning a long term, formal
development and evaluation process. We are also
planning to widen the range of observational
techniques used (e.g. diary studies, observational
studies, conceptual modeling). We want to make use of
best practice in games research, to provide an
immersive experience, and one that optimizes the
quality and benefit of the exercises, as well as
supporting learning and adherence.
[5] Eakin, E. G. and Glasgow, R. E. The Patients'
Perspective on the Self-management of Chronic
Obstructive Pulmonary Disease. Journal of health
psychology, 2, 2 (1997), 245-253.
References
[11] Taylor, A., Aitken, A., Godden, D. and Colligan, J.
Group pulmonary rehabilitation delivered to the home
via the internet: feasibility and patient perception. In
SIGCHI’11, (2011) 3083-3092.
[1] Albores, J., Marolda, C., Haggerty, M.,
Gerstenhaber, B., and Zuwallack, R. The use of a home
exercise program based on a computer system in
patients with chronic obstructive pulmonary disease.
Journal of Cardiopulmonary Rehabilitation and
Prevention 33, (2013) 47-52.
[2] “Computer Game Helps COPD Patients Breathe
Better, Study Shows”. Retrieved from
http://tinyurl.com/ohgdt45
[6] Griffiths, M., Video games and health. BMJ 331,
(2005) 122-123.
[7] Julián Guirao Aguilar. Breathing as user interface
for pulmonary rehabilitation: Respiration tracking using
the Wii remote controller. Retrieved from
http://tinyurl.com/qf7xj27
[8] Ides, K., Vissers, D., De Backer, L., Leemans, G.
and De Backer, W. Airway Clearance in COPD: Need for
a Breath of Fresh Air? A Systematic Review. Journal of
COPD, 8, 3 (2011), 196-205.
[9] Meldrum, D., Glennon, A., Herdman, S., Murray, D.,
and McConn-Walsh, R. Virtual reality rehabilitation of
balance: Assessment of the usability of the Nintendo
Wii ® Fit Plus. Disability and Rehabilitation: Assistive
Technology 7, (2012) 205-210.
[10] Spina, G., Huang, G., Vaes, A., Spruit, M. and Amft,
O. COPDTrainer: a smartphone-based motion
rehabilitation training system with real-time acoustic
feedback. In Proc. Ubicomp (2013), 597-606.
[12] "The 10 leading causes of death in the world, 2000
and 2011". Retrieved from http://tinyurl.com/kkf23kg
[13] Xu, W., Huang, M.-C., Liu, J. J., Ren, F., Shen, X.,
Liu, X. and Sarrafzadeh, M. mCOPD: mobile phone
based lung function diagnosis and exercise system for
COPD. In Proc. PTRAE’2013:45. (2013)