AOASM Position Statement on Esports Medicine, Active Video Gaming, and the Role of the Sports Medicine Physician

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AOASM Position Statement on Esports Medicine, Active Video Gaming, and the Role of the Sports Medicine Physician

With much discussion surrounding the need for comprehensive esports medicine teams institutionalized in esports leagues, this article comes in a timely manner echoing many of the calls from the industry professionals working at the highest levels of esports medicine. The article is a position statement by the American Osteopathic Academy of Sports Medicine (AOASM) on esports medicine, active video gaming (AVG), and the role of sports medicine physicians in addressing injuries associated with esports. The paper highlights the growing popularity of esports and its potential health risks, especially among esports athletes. The paper emphasizes the need for a multidisciplinary approach to esports medicine that includes physical, cognitive, and mental health aspects. The evaluation of esports athletes requires a comprehensive history and physical examination to identify potential injuries and mental health conditions. The article lists common conditions and injuries associated with AVG and suggests various imaging modalities and screening tools that can be used for diagnosis. The treatment section suggests that combined physical-cognitive training may be beneficial for esports athletes, and highlights the importance of proper ergonomics and rest in preventing injuries.

Esports, which refers to competitive video gaming, has a global audience of over 300 million fans and generated over $1 billion in revenue in 2018. Esports athletes compete using video screens or computer monitors and can experience various health issues related to prolonged gaming sessions, including eye fatigue, neck and back pain, and wrist and hand pain.

In addition to esports, the article also highlights the growing interest in active video gaming (AVG), which involves physical activity beyond conventional hand-controlled games. AVG offers opportunities for physical activity, group participation, and competition, and has been used for recreation, health promotion, and rehabilitation purposes. AVG can also benefit individuals with disabilities, providing them with opportunities for physical activity and social engagement.

However, the article emphasizes that AVG should be approached with caution due to potential negative effects. These may include a lack of vigorous physical activity, exposure to inappropriate content, and displacement of other physical activities. Therefore, proper guidelines and recommendations should be followed when engaging in AVG to ensure the health and safety of individuals.

Esports medicine, which is a subset of sports medicine, focuses on the prevention, diagnosis, and treatment of injuries and health conditions related to esports. It requires a multidisciplinary approach to address the various physical, cognitive, and mental health aspects of esports athletes, both amateur and professional.

History and Physical Examination of Esports Athletes

History	History to include medical, surgical, obstetrical/gynecological (for females), and psychiatric history.
Personal/social history to include occupation/schooling and performance in those activities, home situation and significant others, sources of stress, leisure activities, sleep hygiene (use a validated sleep questionnaire such as the Pittsburgh Sleep Quality Index),16 exercise, and diet/nutrition habits.
Screen for addictive behaviors with substances such as tobacco, alcohol, and illicit drugs by using a screening tool such as ASSIST.18 Esports athletes should also be screened for depression, anxiety, and gaming addiction.
Family history, immunizations and screening tests, and complete review of systems.
Physical examination	Vision evaluation
 Assess the visual acuity and screen the visual fields.
 Evaluate position and alignment of the eyes and assess extraocular movements.
 Inspect the eyelids, sclera, and conjunctiva of each eye, cornea, iris, and lens.
 Compare the pupils and test their reactions to light.
 Assess the visual acuity using visual charts and phoropter.
 Perform the Vestibular Ocular Motor Screen.
 Assess near point of convergence to assess convergence amplitude.
 Assess near point of accommodation to assess accommodation amplitude.
 Perform fusional vergence by having the athlete read a line of print through a prism with increasing magnitude until the patient can no longer maintain a single image.17
 Test smooth pursuit by having the patient follow an object moved across their full range of horizontal and vertical eye movements.
 Test saccades by holding 2 widely spaced targets in front of the patient (such as the examiner's thumb on one hand and index finger on the other) and asking the patient to look back and forth between the targets in the horizontal and vertical plane.19
Musculoskeletal evaluation
 Use the Inspection, Palpation, Active Range of Motion, Strength, and Special Tests mnemonic to perform components of the examination.
Ergonomic assessment
 Monitor placement, chair type and placement, desktop placement, keyboard/mouse/controller placement, and assessment of lighting.20
 Proper ergonomics evaluation and game station fitting can benefit esports athletes by reducing injury risks, improve quality of performance, and reducing stress injuries.21
 There are a number of ergonomics assessment tools available in the public domain that have been developed by organizations such as the National Institute of Occupational Safety and Health21:
  WISHA Caution Zone Checklist and WISHA Hazard Zone Checklist;
  Lifting and Lowering Tasks: The NIOSH Lifting Equation;
  Entire Body Posture: Rapid Entire Body Assessment;
  Upper-Body Posture: Rapid Upper-Limb Assessment; and
  Hand-Arm Vibration Calculator.

The evaluation of esports athletes goes beyond assessing overuse injuries in the musculoskeletal and ophthalmologic systems and also includes psychological conditions such as mental fatigue, burnout, and anxiety. The article suggests that there is no standardized initial assessment for esports athletes, but a comprehensive evaluation should include a detailed history and physical examination.

The history should cover medical, surgical, obstetrical/gynecological (for females), and psychiatric history, personal/social history including occupation/schooling, home situation, sources of stress, leisure activities, sleep hygiene, exercise, and diet/nutrition habits. Screenings for addictive behaviors with substances and mental health conditions such as depression, anxiety, and gaming addiction should also be conducted.

The physical examination should include a vision evaluation, musculoskeletal evaluation using the Inspection, Palpation, Active Range of Motion, Strength, and Special Tests mnemonic, and an ergonomic assessment of the athlete’s gaming setup using available tools such as the WISHA Caution Zone Checklist, NIOSH Lifting Equation, Rapid Entire Body Assessment, Rapid Upper-Limb Assessment, and Hand-Arm Vibration Calculator to ensure proper ergonomics and reduce injury risks.

The article also discusses common conditions and injuries associated with active video gaming (AVG). While AVGs are not limited by physical strength, endurance, and training, specific characteristics of AVG play may lead to increased risk of acute and overuse injuries. Injuries incurred during AVG play are similar to those experienced by non-gaming athletes.

The intensity of activity varies greatly among participants of various fitness levels, interests, and ages, and the type of game being played also affects the level of physical exertion. Lower extremity activity in AVGs often results in higher energy expenditure, while hand-held devices may increase the risk of upper extremity injuries. Dance mats and balance boards may lead to lower extremity injuries.

Repetitive motion and volume of continual motion in esports may predispose athletes to muscle soreness, muscle fatigue, and overuse injuries such as impingement, tendonitis, and apophysitis. The nature of the game played, technique required to compete, and frequency and intensity of play must be understood by clinicians to appreciate the risks incurred by esports

The future of esports medicine will require the integration of traditional sports medicine practices into esports. This will involve developing roles and responsibilities for various healthcare providers such as athletic trainers, therapists, nutritionists, ophthalmologists, psychologists/psychiatrists, and team physicians.

Future Expansions of Esports Medicine

The esports medicine team	Outline the roles and responsibilities of the athletes, coaches, certified athletic trainers, physical and occupational therapists, nutritionists, strength and conditioning specialists, ophthalmologists, neuro/optometrists, sports psychologists/psychiatrists, and team physician, both primary care and orthopedic.
Preparticipation evaluation (PPE)	There are specific ergonomic, physical, and vision-based evaluations that could be assessed during a PPE for predisposing injury patterns before esports competition. Active video games (AVGs) should be placed in the PPE table “Classification of Sports by Physical Intensity.” We would recommend the following considerations:
 Potential classification of seated esports as an AI sport (<40% maximal O2 and <20% maximal voluntary contraction {MVC}) alongside billiards and riflery.
 Potential classification of AVG esports as an AII sport (<40% maximal O2 and 20%-50% MVC) alongside archery, auto racing, and motorcycling.
Education	Athlete, parent, coach, and healthcare provider education regarding overtraining and concerns related to musculoskeletal health, ergonomics, nutrition, cardiovascular activity, vision, sleep health, psychological well-being, practice and competition duration, and team dynamics.
Mental health	An esports athlete's career can involve pressure from competition and fan expectations, frequent international travel, and in some cases, living away from home for prolonged periods of time.
Mass participation event coverage	Esports tournaments are held in sold-out arenas and stadiums. This is considered a “mass participation event,” presenting unique challenges for medical professionals. In the era of COVID-19, mass touch points and potential aerosolized transmission of virus will necessitate the team physician develop safety protocols including masking, social distancing, and enhanced and frequent cleaning of touch-point surfaces and decisions about those allowed in the arena of play.
Performance enhancing substances	A future opportunity exists to decrease the use of addictive and potentially illegal substances, solidify the role of epsorts medicine involvement in esports, and promote the same expectations of athletic competition integrity as traditional sports.
Esports medicine research	Potential areas of esports research could include: (1) musculoskeletal injury awareness, diagnosis, treatment, and prevention; (2) ergonomic optimization; (3) esports vision screening and therapy; (4) esports health and wellness through nutrition strength and conditioning; (5) esports athlete longevity; and (6) esports performance assessment and enhancement.

Preparticipation evaluations (PPE) should include specific ergonomic, physical, and vision-based assessments to identify predisposing injury patterns before esports competitions. Education for athletes, parents, coaches, and healthcare providers will be important in areas such as musculoskeletal health, ergonomics, nutrition, cardiovascular activity, vision, sleep health, psychological well-being, practice and competition duration, and team dynamics. Mental health considerations, including the pressure of competition and frequent international travel, should also be addressed. Mass participation event coverage will require safety protocols for arenas and stadiums, especially in light of COVID-19 concerns. Addressing the use of performance-enhancing substances, conducting esports medicine research, and promoting guidelines specific to esports athletes, especially young athletes, will be critical for the future of esports and esports medicine. Coordination among sports medicine physicians is essential to build a future that provides legitimization and specialized care for esports athletes, similar to traditional sports athletes.


Franks RR, King D, Bodine W, Chisari E, Heller A, Jamal F 4th, Luksch J, Quinn K, Singh R, Solomon M. AOASM Position Statement on Esports, Active Video Gaming, and the Role of the Sports Medicine Physician. Clin J Sport Med. 2022 May 1;32(3):e221-e229. doi: 10.1097/JSM.0000000000001034. PMID: 35470342; PMCID: PMC9042337.

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