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Sports Medicine Researcher Examines Esports Injury Risk

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Hallie Zwibel, the 34-year-old director of sports medicine at New York Institute of Technology College of Osteopathic Medicine, played "Madden NFL" in college, but by no means does he consider himself a gamer. In fact, the whole notion of esports was foreign to him — until his school became one of hundreds of institutions nationwide that have launched varsity esports programs in recent years. As head of NYIT's Center for eSports Medicine, Zwibel's research has found that 56 percent of esports athletes experience eye fatigue, 42 percent report neck and back pain, 36 percent wrist pain and 32 percent hand pain — but only 2 percent are likely to seek medical treatment. AB senior editor Paul Steinbach asked Zwibel to diagnose this phenomenon that last year saw $16 million awarded in esports scholarships, as well as its side effects.

What prompted you to consider esports injuries?
We were informed that athletics was starting an esports team here at the Institute of Technology. First of all, we didn't know what esports was, so we had to find that out. But after we came to understand everything that was entailed with esports, we realized we couldn't retrofit the model for a soccer player or a lacrosse player to these esport athletes. So we went to look at the medical literature out there and we found next to nothing on this topic. So we really felt that this needed to be discussed, needed to be investigated further to determine what the health considerations were in this population, because as you may know it's now more than 200 colleges across the country.

When you realized how fast it's growing at the college level, what was your reaction?
We were all very surprised. I'm not particularly advanced in age, and I didn't even know this was on the radar. I think it was just a big learning experience for all of us in terms of what esports entailed, how many hours they practice, how they choose the games, how they compete, the scope and expanse, the fandom that's associated with it — really the whole world was kind of under our radar.

Are you still on your own in terms of this type of research?
No, luckily I've had a few colleagues reach out to us and we've reached out to other schools that have esports teams and are into research. We've been trying to collaborate with different institutions to try and work synergistically and come to better population studies and really expand the scope of our understanding of esports.

How did you go about your research and come up with your numbers?
The way we came up with the statistics in terms of the prevalence of different symptoms and conditions and the amount of exercise that the esports players have was we put together, in association with our director of clinical research here at the College of Osteopathic Medicine, a survey instrument that we ran by our own esports team, as well as the rest of our medical team, to see if it was in line, if there was anything else we should be asking. We sent it to eight different universities that we communicated with that also had varsity-level esports teams, and we had more than 60 individuals respond. These are all varsity college esports players, so the findings are unique to that group. You can extrapolate to different populations, but in the college community this is some of the best data out there.

What in your data surprised you the most?
I think the most surprising aspect was the limited amount of exercise and, in turn, the amount of sedentary behavior. We knew they practiced a lot. We knew they weren't exercising a lot. But just the fact that fewer than 50 percent of players got up every two hours to just take a standing break really was a shock to us.

You found 40 percent of esports participants get no physical activity in any given day. Can esports even be considered sports?
That's one of the first questions we get from most of the people in our profession, especially when we give talks at different conferences and events: Is this really a sport? And I have a few things to say about that. First, in my role as a physician, it doesn't matter to me whether it's a sport or not. My job is to take care of the patient in front of me and to do my best job in working toward their health and helping them meet their healthcare goals. So whether it's a sport or not doesn't really matter. There are papers out there questioning if this really is a sport, and by some means, you could argue it's not. But on the other hand, you have organizations such as the International Olympic Committee that have a lot more gravitas than myself that say it is a sporting activity, so I guess it depends on who you ask.

Your research refers to "internet gaming disorder." Can you describe what is meant by that?
Internet gaming disorder has become an actualized diagnosis in the past two years for both the American Psychological Association and the World Health Organization. And what it speaks to is pathologic use of gaming, similar to pathologic use of any substances or gambling. Doing an activity could be fine or inconsequential, but you're doing it to the extent that it's interfering with and setting back other priorities in your life, and putting you at a disadvantage. You're not taking care of your family obligations, you're not showing up to work, you're not getting enough sleep, you're not taking care of yourself. It's all you're thinking about. So there are lot of different qualities associated with it, but it's an addiction, at the end of the day, for some people.

What percentage of collegiate esports participants might fall into that category?
What we know from the research out there is that the prevalence, meaning the amounts of internet gaming disorder, period, among the total population is fairly low — between 1 and 5 percent. There have been interesting studies out there that look at the brain chemistries and the functional MRIs — which regions of the brain are more active and things like that, and for people who are diagnosed with internet gaming disorder and those who are higher-level competitive gamers, their brains couldn't be more different for the most part. So the brain imaging and functionality of an individual with internet gaming disorder will have more activity in those reward, behavior, response centers of the brain, and most professional or organized gamers don't exhibit that. So I would say it's probably lower than that 1 to 5 percent in the collegiate varsity population.

Do you have recommendations for the sports medicine staffs at schools that have elevated esports to varsity status?
In one of our most recent articles, we create a medical model that speaks to the different areas of concern and what clinicians — whether it be an athletic trainer, a physician, a physical therapist, whoever is dealing with these patients — can do or things to look out for. Some simple things that they can do are related to the setup of their gaming stations. So just talking to them about proper posture, limiting the amount of bright lights, limiting the amount of computer use or screen time before bed as it lowers you melatonin, your naturally occurring sleep hormone. We know there is a really significant breakdown in good posture the longer they're gaming. So just talking about posture, talking about how it relates to back pain, neck pain, wrist pain, which we found are at fairly high levels in this population. Some simple eye relaxation exercises and techniques can really relax the muscles in the eye that can become tense from looking at these pixilated images for too long. And just really talking to these people about being aware that there could be possible mental health considerations, to talk about the importance of exercise and nutrition and the dangers of overly sedentary behavior, to make them think about their overall health and how that can benefit them not only in the long term but in the short term, in terms of probably playing better by having better concentration from sleeping more. So try to relate it to their goals individually.

What's next?
We're actually looking at a study to see if there is any cognitive decline in terms of your reaction speed, acuity, the longer you play, and if so at what point that happens. That's what we're looking at now.

This article originally appeared in the January | February 2020 issue of Athletic Business with the title "Sports medicine researcher examines esports injury risk." Athletic Business is a free magazine for professionals in the athletic, fitness and recreation industry. Click here to subscribe.


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