Elsevier

Burns

Volume 42, Issue 1, February 2016, Pages 91-96
Burns

Interactive gaming consoles reduced pain during acute minor burn rehabilitation: A randomized, pilot trial

https://doi.org/10.1016/j.burns.2015.06.022Get rights and content

Highlights

  • Randomized, controlled trial design in minor burn patients.

  • Supports use of widely accessible interactive game console for adjunct use in acute burn patients.

  • The use of an interactive game console was associated with greater decrease in exercise induced pain.

Abstract

Introduction

Interactive gaming consoles (IGCs) have been used successfully in rehabilitation settings as an adjunct to conventional exercise for restoring or maintaining active function and augmenting pharmacological analgesia.

Aim

The objective of this pilot study was to assess if adjunctive use of the Nintendo Wii IGC was of benefit to acute burn patients.

Method

This was a randomized, controlled trial. The intervention group received routine rehabilitation in addition to up to 5 days of twice daily, 20–30 min of exercise using the Nintendo Wii IGC. The control group received routine rehabilitation exercise therapy.

Results

A total of 22 subjects were recruited and randomized by location of burn to intervention and control groups. Pain scores were significantly improved in the intervention group (r2 = 1.18; 95%CI −0.584 to −0.298, p = 0.019) as indicated by a 17% greater drop in the pre–post-study pain compared to controls. Fear avoidance and ROM measurements were not statistically different between the groups.

Conclusion

The Nintendo Wii IGC was associated with a greater reduction in pain, particularly in those with higher levels of pain at baseline.

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.

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