Review 1

The potential of physiological monitoring technologies in

esports

Aaron Koshya*, George Mathew Koshyb

a Light Laboratories, University of Leeds, Leeds, UK

b Sancheti Institute for Orthopedics and Rehabilitation, Pune, India

* Correspondence to Dr A Koshy, Light Laboratories, University of Leeds, Leeds, UK

Email: [email protected]

Abstract

Esports is a rapidly growing sector with increasing investment and large-scale international
tournaments offering significant prize pools. This has led to a greater focus on individual and
team performance with factors such as communication and team intelligence identified as
important for success. Over a similar time period, monitoring technologies have become
commonplace with clinical grade assessment available in a number of parameters that have
evidenced utility. Despite this, physiological monitoring is not routine within esports. In this
scoping review, we explore the options available for esports organisations and the potential
barriers to implementation. A model for effective integration of these tools has been devised
to mitigate the wastage of resources and increase collaboration between academia, healthcare
professionals esports organisations and industry. We expect that in the near future,
monitoring devices will become an essential part of performance assessment, enhancement,
injury prevention and general management for players and esports teams.

Keywords: Esports; Monitoring devices; Wearables; Performance

Highlights

• There are multiple monitoring devices available that can measure physiological
parameters of esports players without noticeably hindering their performance.
• Limitations and barriers exist within current physiological monitoring devices that
must be considered before implementation within the esports environment.
• We have devised a model to maximise value and safety in integrating physiological
monitoring technologies within an esports organisation.

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Background

Esports is the organised competition of players or teams within video gaming. It is

increasingly focused on performance and sporting success with many professional players
receiving a similar level of training to elite traditional sports athletes [1]. Esports has steadily
entered mainstream entertainment in the last decade and revolves around players or teams
working to beat their counterparts often in a series of objectives. Popular esports games such
as League of Legends or Counter Strike: Global Offensive enjoy viewership in the many tens of
millions at their premier live tournaments with figures that rival traditional sports [2].
Revenue streams into esports have also ballooned, bypassing $1 billion in 2019 [3]. This has
trickled down to major increases in spending within professional teams on players, coaching
and facilities to improve performance. The staff that support the players have also expanded to
include multiple managers, coaches, physiotherapists, sports psychologists and data analysts.

A number of studies have already scratched the surface of performance determinants within
esports. Unsurprisingly for team games, communication and collective intelligence are shown
to be predictors of success [4]. Teamwork is critical at a professional and casual level within
esports [5]. This expands to the point where players may not be selected or even dropped from
a team if there are weaknesses in these domains. Indeed, these qualities may translate into the
game through measurable and significant outcomes predictive of success, such as fewer deaths
and better map control [6]. For example, fewer deaths mean that the team generally has a
higher chance of winning decisive battles through higher damage or player numbers whereas
map control often forces the opposing team into disadvantageous positions.

With the rise of esports, consumer monitoring technologies and clinical grade assessments
have become more accessible. Smart watches and fitness trackers have a large market value
that is forecast to grow to $62 billion by 2023 [7]. As adoption increases, demand for
functionality has broadened from heart rate monitoring to heart rate variability and sleep
analysis. This shift also highlights the interest beyond non-physiological parameters, from
location and movement to physiological measurements (which directly or indirectly measure
body function), such as heart rate and temperature. It was identified as early as 1998 that non-
invasive devices can not only consistently display meaningful physiological data, but also serve
in situations where traditional measuring tools are not viable [8]. These clinical tools are now
routinely used in a variety of situations such as monitoring patients for signs of deterioration,
in the research setting as predictors of outcome or as a response to intervention. The
technologies are also employed in a number of occupations and sports with heart rate
monitoring shown to be an effective marker of stress in pilots during training [9]. The military
has also embraced assessment technology as a method of improving performance by collecting
information on soldier fitness, alertness and their psychological state [10]. Formula One racing
could be one of the earliest adopters of monitoring technologies in sports due to the
increasing awareness of the physical and mental strain applied on the drivers [11, 12].

As the rewards for success increase alongside knowledge of the stressors within esports, we
expect monitoring devices to play a key role in identifying and improving outcomes. This
article discusses the potential value of physiological monitoring within esports, the current

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tools that could be utilised, the barriers that must be overcome to ensure full implementation
and proposes a model for application.

Methods

Monitoring devices can assess a plethora of parameters from heart rate to skin temperature,
many of which could vary during competitive esports games due to the associated stress,
complex decision making, teamwork and even duration of activity. For this scoping review, we
undertook a structured PubMed, ResearchGate and Google search from 20-26th May 2020 to
identify articles published from 1946 to May 2020 including the following search terms:
Esports, e-sports, gaming, video gaming, computer gaming, competitive gaming, monitoring,
wearables, portable devices, cardiac output (CO), heart rate (HR), heart rate variability (HRV),
blood pressure (BP), oxygen saturation (SO2) and non-invasive. Grey literature was also
searched using Google search and Google Scholar. The abstracts were reviewed and
considered for inclusion based on the description and relevance; specifically, devices were
included in this review if they could be utilised in the esports setting during training or
competitive matches without causing obvious hindrance. Technologies were excluded if they
only provide a single snapshot reading, fail to validate findings against the gold standard for
the relevant parameter, or were not commercially available at the time of searching.

Viable monitoring devices and measuring parameters in Esports

One of the most commonly utilised portable technologies are smartwatches and fitness
trackers. These devices have grown in variety with increasing functionality over successive
generations. It is now common for physiological parameters such as HR, temperature and
activity levels to be measured, often with the aim of improving health outcomes ranging from
self-management of diabetes to seizure monitoring [13]. However, despite high levels of
investment, few of these devices have managed to reach clinical grade accuracy or reliability
[14]. Similarly, sleep trackers are increasingly common place and are a cost effective tool for
monitoring sleep, though they appear to vary in reliability [15, 16]. In the context of esports,
these devices could be ideal in the setting of a gaming house; an arrangement in which players
cohabit a tailored facility with access to high speed internet and quality computing
equipment. In this environment, many factors are often more controlled such as sleep and
activity cycles.

Clinically focused wearables conversely have generally completed longer periods of device
evolution with more stringent standards for approval and application. These technologies are
often based on known physiological principles adapted for utility under controlled conditions.
Whilst this makes the readings more reliable, the devices themselves are more difficult to
exploit outside of their limited tested environment. Furthermore, a lack of awareness and the
generally higher cost make these options less accessible. We believe that both general
consumer and clinically focused technologies offer value to esports. A list of technologies has
been generated (table 1) that are validated against the gold standard, applicable in the esports

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environment and currently available to purchase. The devices range from a monitor placed on
the wrist to sensors distributed within clothing. Importantly, these devices should in theory
allow the player to compete as normal without hindrance. The diversity of tools enables
players and teams to work in a minimally restrictive manner whilst maximising analytical
potential with scope to combine technologies, expanding monitoring capability further.
Notably, portable devices frequently utilise technologies that can derive multiple physiological
parameters such as bioimpedance (a measure of electrical resistance through the body) to
obtain heart rate and respiratory rate with reasonable levels of accuracy [17, 18]. This is useful
as playing video games can increase psychophysiological arousal manifesting in parameters
such as heart rate change suggesting that the cognitive and subsequent physical load can be
significant [19]. The emergence of miniaturisation, new scientific techniques and consumer
demand enables a variety of physiological parameters to be measured, many of which have
associations to exercise and mental activities:

Cardiovascular

HR is one of the most commonly assessed physiological parameters and varies with both
physical and cognitive exertion [20]. It is often treated as a surrogate for sympathetic activity
and can be helpful to assess stress. Specific changes in heart rate are broadly termed as HRV.
This is an umbrella term for changes found in sections of the electrical cardiac cycle and has
been frequently associated with exercise and even mortality in patient groups [21, 22]. HRV
appears to vary within video gaming and may be related to a variety of factors such as the
activities within the game, the content shown or difficulty of the task [23]. Furthermore, work
by Lee et al [24] suggests that HRV will also differ based on the background of the player.
Participants fulfilling the criteria for internet gaming disorder more often have suppression of
high frequency HRV, a phenomenon that is associated with parasympathetic inhibition and
emotions such as stress or anxiety [25]. Additionally, the gold standard for analysing the
complete electrical cycle, the 12-lead electrocardiogram (ECG or EKG) can be employed. ECGs
are extremely effective at identifying the current HR and capturing on-going arrhythmias.
Unfortunately, this is rarely practical outside of the hospital setting, especially in the context
of body movement. Portable devices with ECG capability are common and generally utilise 1-3
leads making it viable for general monitoring but are rarely used in the diagnostic setting; with
acceptable accuracy only present in specific scenarios such as screening for arrhythmias like
atrial fibrillation [26]. Cardiac anatomy and function also relate to exercise performance [27].
The stroke volume (SV) is the volume of blood pumped from the heart per beat. The SV can be
multiplied by the HR to derive the cardiac output (CO) which is the volume of blood pumped
by the heart in one minute and is linked to exercise capacity. Notably, the SV and CO have
been shown to increase with higher cognitive load and exercise [28, 29].

Respiratory

Breathing changes are expected during times of physical or mental stress [30]. Two common
parameters are the respiratory rate (RR), which is the number of breaths taken in one minute
and minute ventilation; the volume of air that is inhaled or exhaled in one minute. Activities
that require higher concentration or are more cognitively demanding result in a higher RR and
minute ventilation [30]. Furthermore, difficult mental tasks are associated with reductions in

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oxygen saturation (SO2) which is the proportion of oxygenated haemoglobin to total

haemoglobin in the blood [31].

Other

Skin temperature is frequently found on monitoring devices as historically, temperature has

been a key parameter of health. The temperature of the skin is also relatively easy to measure
with modern sensors which in turn enables an accurate estimation of the more clinically
valuable parameter, core body temperature [32]. Recently, skin temperature has been
identified as a potentially significant factor in aerobic performance suggesting intrinsic value
of this measure [33]. The expansion of smartphone use has also led to the development of
movement sensors such as accelerometers which are similarly commonplace in technologies
such as fitness watches. Despite their popularity, these tools are generally poorly validated
with variable accuracy and should be assessed on a case by case basis [33, 34].

Overall, the physiological parameters of players must be carefully managed in esports with
input from academic, healthcare or industry partners to ensure a high-quality methodology
and analysis, thus enabling a meaningful interpretation. Without such oversight there would
be a higher risk of false attribution or correlation, leading to wastage of resources or
potentially damaging organisational decisions.

Technology name Description Device location Parameters assessed

Bodyguardian*[35] Wireless monitor Placed over chest HR, ECG, RR and movement
BPro [36] Wireless BP Placed on wrist BP
(without cuff)
monitor
Equivital EQ02 Semi-wireless Electrodes and HR, HRV, ECG, RR, Skin
Lifemonitor [37] monitor device placed on temperature and movement
chest
Hexoskin [38] Wireless monitors Placed on chest HR, HRV, ECG, RR, minute
within a shirt ventilation, tidal volume and
movement
Ithlete with ECG Belt with attached Placed on chest HR and HRV
monitor [39] wireless monitor
Polar heart rate Belt with attached Placed on chest HR and HRV
sensor [40] wireless monitor
NICOM [41] Wired monitor Electrodes placed HR, SV and CO
on chest with
wired device
placed 1m away
Qardiocore [42] Belt with attached Placed on chest ECG, HR, HRV, Skin
wireless monitor temperature, respiratory rate
and movement
Oxitone 1000M Wireless monitor Placed on wrist HR and SO2
[43]
Somnotouch [44] Semi-wireless Placed on arm ± BP, SO2 and ECG
monitor hand
Suunto smart Belt with attached Placed over chest HR and HRV
sensor [45] wireless monitor
Zephyr BioPatch Belt with attached Placed over chest ECG, Body temperature, HR,

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HP [46] wireless monitor HRV, RR and movement

Zio XT [47] Wireless monitor Placed over chest ECG, HR and HRV
*Successful validation of some parameters.

Table 1 – Commercially available monitoring technologies (excluding sleep monitors) that are
validated against the gold standard and feasible for esports athletes during performance.
Validation studies have been referenced with the technology name. BP – Blood pressure, CO –
Cardiac output, HR – Heart rate, HRV – Heart rate variability, NA – Not applicable, RR –
Respiratory rate, SO2 – Oxygen saturation, SV – Stroke volume.

Barriers to monitoring technology uptake in esports

Utilising physiological monitoring devices must be considered with care. Performing at the
highest level of esports has multiple requirements including fine hand control, mental
concentration and teamwork. Many commercially available tools would fail at the most
practical level of not overly impeding these critical areas. For example, many BP monitors rely
on an inflatable cuff to control blood flow and derive a value. Furthermore, parameters such
as BP and HR are largely redundant in isolation, with the identification of trends being more
important. This leads to a situation where obtaining the physiological values may hinder
performance and even alter the measurements themselves.

Regardless of the complexity involved in the implementation of a monitoring technology, the

device manufacturers may need to be involved at an early stage to ensure that the esports
environment; with the various potential confounders such as high density of digital
equipment and alternating activity regimen, would not significantly disturb the accuracy or
reliability of the assessment tool [48]. An example would be the smartwatch and wearables
market. These are frequently found with optical heart rate sensors that are accurate at rest
but are often less reliable during exertion or HR changes; undoubtedly a consideration in
competitive gaming which may be compounded by player discomfort when competing whilst
wearing the device [49].

The wearables market is rapidly evolving with previously dominant or successful products
ending up unused or obsolete. Indeed many of the technologies published in previous reviews
are no longer available for a myriad of reasons, such as lack of efficacy post analysis or funding
issues [50, 51]. This emphasises the value of a trial period, expert guidance and empirical
research.

The introduction of monitoring devices into competitive games will also need to be evaluated
by the game publisher or tournament organisers. These tools could be misused to gain an
unfair competitive advantage or, indeed inadvertently cause communication issues with
essential equipment. For example, increasing the density of wireless communication pathways
can cause starvation of data transfer across commonly used wireless protocols [52].

Finally, the cost of implementation may be prohibitive for some esports organisations. Some
of the devices in Table 1 have significant capital costs which may increase to obtain extended
support for additional monitoring and impact. As the translatable gains are yet to be

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evidenced, some organisations may have to follow successful implementation from

competitors instead of pioneering themselves.

Future of physiological monitoring devices in esports

Esports has grown with the rise of available technologies making the concept of live
monitoring players during training and matches not only viable but potentially game
changing. Our research suggests that there is increasing overlap between clinically focused
devices and general consumer wearables with clinical grade measuring capability, making this
an exciting area for further study. This is a novel route for esports players and staff thus we
have designed a model for the implementation of monitoring devices (figure 1). With a
plethora of options that are likely to increase further, it will be difficult for teams to select the
ideal device or composition of tools. Along with collaboration, it would be expected that
devices are trialed with a clear methodology and set expectations to avoid poor outcomes and
maximise value.

Figure 1 – Proposed model for integration of monitoring devices into Esports teams.

We expect monitoring to extend outwards from training to the live stage. Indeed, DreamHack
2011 had esports players compete with live heart rate monitoring [53]. Whilst this was short-
lived, it gives an insight into the potential of monitoring devices and may also provide another
exciting dimension for the spectator. The integration of monitoring devices into esports
training and competitive games may represent a paradigm shift in performance for players and
teams. The objective measures could explain certain performance issues or clutch decision
making. Physiological parameters can also aid the physical and sports psychology training that
is relatively common within teams. Using a similar model, Sousa et al [54] found that
haemodynamic changes are present during esports activity with a modified effect depending
on the type of game played. Eye tracking and facial recognition are other areas with advances

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in software enabling automated analysis to take place rapidly and accurately, leading to the
possibility of a gold standard in the near future [55]. This is particularly exciting for esports as
there is likely to be a high visual load during activity which through assessment could improve
performance, especially when used in conjunction with other technologies [56]. If carefully
implemented, monitoring devices could lead to further rewards such as team modelling
enabling fanciful concepts such as ideal team role allocation and optimised professional player
acquisition based on objective data. The novel application of technology is also showing utility
in improving performance. Minor electrical stimulation of the frontal cortex through a
forehead patch is associated with a significant improvement in working memory [57].
Alternatively, virtual reality has evidenced value in the acquisition and retention of skills
(across physical and psychological domains) within traditional sports such as rowing [58].
Esports as a burgeoning sector is well placed to leverage these advancements to improve the
quality of training and competition whilst developing understanding of these applications
further; indeed, potentially resulting in the production of esports specific devices. As revenue
and mainstream demand increases, we expect partnerships between esports organisations,
academia, healthcare and industry to dramatically increase in order to achieve these
overlapping areas of interest.

Conclusion

There are multiple market ready technologies that are viable for esports players and teams to
integrate into their training and competitive games. This is expected to be a key step in
improving performance in esports under careful management and collaboration with
academia, healthcare professionals and industry partners.

Conflict of interest

The authors declare they do not have anything to disclose regarding a conflict of interest with
respect to this article.

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