Interactive gaming consoles reduced pain during acute minor burn rehabilitation: A randomized, pilot trial
Introduction
Interactive gaming consoles (IGCs) are being used increasingly as an adjunct to standard care or alternative therapies within rehabilitation settings, including those with burn [1], [2]. Further, 63% of Australian [3] and 51% of households in the United States [4] own an IGC indicating the ‘exposure’ to the technology and affordability is high for Western communities [2]. Being less cumbersome than other forms of immersive virtual reality (VR) [5], they are of interest for use in burn rehabilitation. Modern IGCs combine aspects of VR with popular imagery to create a more immersive experience than earlier consoles [1]. Game controls have advanced to become more sensitive to gross and fine movement (Nintendo Wii™ [NW], Playstation 3 Six Axis and Move™) and by incorporating cameras to detect movement (Xbox Kinect™, Playstation 2 EyeToy™, Playstation 3 EyeToy™), player interaction with the IGC environment has changed to include active play movements [6] which resemble those of daily life, sport and leisure. After burns, the distal neural fields and thus, the integument feedback ‘infrastructure’, are damaged. Studies involving visual and sensory training combined with movement have been shown to help to restore limb and body proprioception and the virtual body or homuncular representations in the brain, particularly where pain has altered the body schema [7], [8]. Interaction with IGCs requires the user to use visual feedback derived from the limb movement within the field of reception for the gaming device. This potentially enhances and supplements the relative lack of intrinsic sensory feedback with extrinsic mechanisms and is purported to aid the re-development of accurate limb and body proprioception and control [9], [10]. Rehabilitation techniques that encourage a patient to close their eyes or obliterate the visual field, expose the individual to reliance on faulty proprioception and virtual representations of the body [11]. This may be maladaptive, particularly when ‘reinforced’ by pain sensations, consequently perpetuating the incongruity between limb feedback and spatial incongruity of the body [9], [10]. If the mismatch between peripheral and cortical neural perceptions is not addressed, chronic pain and hypersensitivity syndromes are common outcomes [12], [13]. Video game play increases dopamine release in the midbrain [14] and provides cognitive distraction from noxious stimuli [15], which aids attenuation of supraspinal nociception [16] and modulation of pain perception by diverting attention away from the painful input [17], [18], [19]. Thus increased dopamine and distraction caused by IGC game play may result in decreased pain sensation [20]. Further, reduction in pain may lead to less guarding or fear avoidant movement patterns [21], [22], [23].
Using IGCs to reduce pain while promoting movement is appealing for post-burn rehabilitation [2]. Depending on the severity, location and size of the burn, the patient suffers regular pain due to repeated efforts to move, exercise and function with the aim to reduce the risk of contractures and complications of excessive scarring [19]. Thus, the aim of this study was to examine the use of the Nintendo Wii IGC as an adjunct to routine exercise therapy. The hypothesis was that in acute burn patients, the NW IGC, would be associated with reduced pain and fear avoidance while promoting or maintaining joint range of motion (ROM).
Section snippets
Study sample
This pilot study was designed as a randomized, controlled intervention trial. Subjects were recruited at Royal Perth Hospital (RPH) between 2009 and 2011. The study was established by the senior co-authors and subsequently completed, with ongoing support, as fulfillment of medical student research training requirements during 2010 and 2011. The sample size and recruitment pattern were dictated by the available student time within the university framework. The participants were block randomized
Participants
A total of 22 patients were recruited and all data were included in the analysis. The group consisted of 17 men and five women with age range of 16–59 years, TBSA range from 0.5 to 10% and a total length of stay (LOS) up to 14 days (Table 2). Fifteen (71%) underwent surgery. The intervention (n = 12) and control (n = 10) groups were determined to be not significantly different with respect to age (p = 0.137), gender (p = 0.323), TBSA (p = 0.805), LOS (p = 0.195) and number of surgeries (p = 0.087). The
Discussion
Despite small numbers, the study confirmed, that the NW IGC intervention was associated with a 17% greater reduction in within session pain, compared to controls completing routine exercises only. Our study affirms the trend in reduced pain (p = 0.07) with NW use in 23 burn patients, as identified by Yohannan et al. [31]. Further, examination of these pain outcomes may indicate more about those who could benefit, or not, from the use of the NW. The minimum clinically important change in VAS
Conclusion
This small study affirmed that, without causing complication, the Nintendo Wii, an interactive game console, reduced pain more than routine exercise therapy alone, particularly for those with higher baseline levels of pain.
Disclosures
Dr Edgar a part-time research fellow supported by Woodside Petroleum through the Fiona Wood Foundation.
Conflict of interest
All authors warrant that they have no competing interests to declare with respect to this study and the findings stated herein. Further, no sponsorship has been received from a proprietor, a distributor or the manufacturer of the equipment used in this study.
Acknowledgements
The authors thank the entire physical therapy team in RPH Burn Center for assisting with data collection throughout this study. In particular, Kristen Grove and Matt McClure should take a bow for keeping the ball rolling.
References (37)
- et al.
Commercially available interactive video games in burn rehabilitation: therapeutic potential
Burns
(2012) - et al.
Virtual reality: feasibility of implementation in a regional burn center
Burns
(2009) - et al.
Motor imagery for peripheral injury
Arch Phys Med Rehabil
(2009) - et al.
Kinematic and EMG characteristics of simple shoulder movements with proprioception and visual feedback
J Electromyogr Kinesiol
(2006) - et al.
Faulty proprioceptive information disrupts motor imagery: an experimental study
Aust J Physiother
(2007) - et al.
Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: preliminary results from 3 ongoing studies
Arch Phys Med Rehabil
(2007) - et al.
Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art
Pain
(2000) - et al.
The relationship between anxiety sensitivity and fear of pain in healthy adolescents
Behav Res Ther
(2001) - et al.
The pain anxiety symptoms scale: development and validation of a scale to measure fear of pain
Pain
(1992) - et al.
Validity of the pain anxiety symptoms scale (PASS): prediction of physical capacity variables
Pain
(2000)
Goniometry and linear assessments to monitor movement outcomes: are they reliable tools in burn survivors?
Burns
Goniometry and linear assessments to monitor movement outcomes: are they reliable tools in burn survivors?
Burns
Prospective validation of clinically important changes in pain severity measured on a visual analog scale
Ann Emerg Med
Clinical significance of reported changes in pain severity
Ann Emerg Med
Keeping up with video game technology: objective analysis of Xbox Kinect™ and Playstation 3 Move™ for use in burn rehabilitation
Burns
Use of Nintendo Wii Fit™ in the rehabilitation of outpatients following total knee replacement: a preliminary randomised controlled trial
Physiotherapy
The utility of a video game system in rehabilitation of burn and nonburn patients: a survey among occupational therapy and physiotherapy practitioners
J Burn Care Res
Digital Australia 2014
Cited by (24)
Use of Virtual Reality in Burn Rehabilitation: A Systematic Review and Meta-analysis
2023, Archives of Physical Medicine and RehabilitationUsing Virtual Reality Exposure Therapy in Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
2022, Value in HealthCitation Excerpt :A flowchart (Fig. 1) of the study selection process was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.21 After reviewing the title and abstract, 167 articles were screened for full-text review; 31 studies7,22-50 fulfilled all the criteria, which involved 1947 participants. Of these, 12 involved juvenile participants (age <18 years)22,25,28,31,32,34,35,38,40,47-49 and 16 involved adult participants.6.7,24,26,27,30,33,36,37,39,42-46,50 We divided the types of pain into acute pain (within 3 months) and chronic pain (more than 3 months).
Systematic Review on the Effects of Serious Games and Wearable Technology Used in Rehabilitation of Patients With Traumatic Bone and Soft Tissue Injuries
2018, Archives of Physical Medicine and RehabilitationCitation Excerpt :The game group showed a significantly greater improvement in functional outcomes than did the control group (Harris Hip Score, −37.6±14.0 out of 100 vs −28.6±12.4 out of 100; d=.68; P=.041).32 Ten25-31,33,35,36 of 12 included studies found no significant effects on functional outcomes between the intervention and control groups, although all showed clinical improvements in intervention and control groups. Punt et al29 compared functional outcomes after acute ankle sprains in a large randomized controlled trial with a low risk of bias.
Virtual Reality in the treatment of burn patients: A systematic review
2018, BurnsCitation Excerpt :Another randomized study, with a sample of 40 individuals showed that through the perception of nurses and family/caregivers, distress decreased significantly when VR was used [28]. Regarding the range of motion, the articles demonstrate that there was no significant difference between the control and intervention groups; however, the use of VR resulted in lower pain intensity during physical therapy exercises [36,43]. Moreover, studies in this review demonstrate positive results with the use of this technology associated with faster wound epithelization [24,27,47].