TY - JOUR
AU - FACS, Roger W. Yurt, MD,
AB - Abstract The purpose of this study was to demonstrate feasibility and measure outcomes on pain, anxiety, active range of motion (AROM), function, enjoyment, and presence with the adjunctive use of Nintendo® Wii™ (Nintendo of America Inc., Redmond, WA) during acute burn rehabilitation. Participants were alternated and stratified based on the location of burn into Wii or control treatment groups. Joints of interest with limited AROM were the shoulder, elbow, wrist, hip, knee, and ankle. All participants received three consecutive sessions of passive range of motion and predetermined joint-specific exercises. This was followed by either designated Wii games or therapist-chosen interventions (control). The outcomes were compared between groups using t-tests (P < .05) and Cohen's d statistic. Data from 23 participants aged 20 to 78 years were analyzed. The difference in mean slopes suggested that the Wii group experienced less pain (x = −0.97, P = .07) than the control group over time. Overall, trends with anxiety (x = −0.1l, P = .77), AROM (x = 0.55, P = .81), function (x = −0.38, P = .43), and enjoyment (x = 0.09, P = .73) seemed to favor the Wii group. Presence minimally changed between successive treatment sessions for those in the Wii group. Although statistical significance was not reached in any category, feasibility was supported and the overall pattern for outcomes was positive for the Wii group, the most favorable being for pain reduction. Future research with larger sample sizes is warranted to explore best practice with video game technology throughout the continuum of burn rehabilitation with appropriate prescriptions. Effective rehabilitative management of patients during the acute phase of burn injury is warranted to minimize long-term physical and psychosocial sequelae.1 Despite therapies initiated early in the course of a patient's recovery, burn scar contractures commonly develop and lead to impairments in body structure and function, limitations in daily activities, and restrictions in the ability to participate within personal and environmental contexts.2,3 Pain and anxiety are complications of burn injuries that considerably influence the course of recovery, and acute pain is exacerbated by anxiety.4 Patients frequently experience poorly controlled procedural pain which promotes anticipatory anxiety and, in turn, decreases pain tolerance, increasing its intensity during burn care and therapy.5,–7 As pain medications alone tend to be insufficient in controlling these procedural symptoms, immersive virtual reality (VR) has been developed to provide adjunctive nonpharmacologic analgesia through distraction. VR is a computerized system that simulates an activity or experience. VR presence is characterized as the illusion of going inside a computer-generated virtual world.8,–10 Researchers propose that attention is drawn toward the virtual world, leaving fewer reserves of attention to focus on pain.8,–11 Patients typically show 25 to 50% reductions in pain during VR, and pain diminution in VR was correlated with the amount of enjoyment or “fun” reported.10,11 Feasibility and expense sometimes pose challenges with implementing formal VR systems during rehabilitation. The viability of VR in a regional burn center has been explored, and the investigators concluded that difficulties exist for smaller burn centers to allocate staff and time for the implementation of VR and to troubleshoot technical issues without direct on-site support.12 Although the cost of maximally immersive VR distraction systems is relatively high,13 Morris et al14 investigated the feasibility and potential effect of a low-cost VR system on adult patients with burns during range of motion (ROM) performed passively and found that 50% of participants had less severe pain and anxiety during the VR condition. The use of low-cost, commercially available active video game systems may be considered as an alternative approach during burn rehabilitation. VR is distinct from active video games in that it provides significant cognitive distraction with specific treatment or training objectives through a head-mounted display, which blocks the external view of the immediate environment while optimizing the field of view of the virtual world.15 VR may be useful for passive or active-assisted ROM;9,13 however, the systems have not been clinically harnessed for active mobilization during burn therapy. Active video games, although more generic and not customized for patient use, share similar properties of immersion and interaction within a computer-generated environment. Literature exploring the feasibility and efficacy of using video game systems during burn rehabilitation is limited. Haik et al16 suggest that the active movement requirements of the Sony PlayStation® II EyeToy™ (Sony Corporation, Foster City, CA) may be a simple, inexpensive approach to add to burn therapy to manage pain and discomfort, improve patient participation and motivation, and expedite functional goals. Similarly, the implementation of off-the-shelf gaming systems in rehabilitation has been explored with the Nintendo® Wii™ (Nintendo of America Inc., Redmond, WA) among other populations.17,–24 Multiple case reports propose benefits in balance, postural control, and function with the use of the Wii in rehabilitation for the elderly and patients with neurological involvement.17,–19 Larger studies have recently emerged with evidence supporting the Wii gaming technology as a safe, feasible, and beneficial modality during therapy.20,–22 Physiologically, it stimulates activity that is light to moderate in intensity and is enjoyable for both adolescents and adults.23,24 Presence with the Wii can be manipulated and can affect performance of the task.25 The degree of interaction and entertainment provided by the gaming system motivates patients to increase participation and adherence to exercise and ultimately may lead to better therapy results.21 Therefore, the Wii may engage patients who lack interest to complete normal exercise schedules21 and may serve as a particular advantage to burn survivors with extensive rehabilitation needs that are long-term, repetitive, and quite arduous. From a recent survey of physical and occupational therapists, Fung et al26 reported that the Wii was perceived to be easy to set up (71.4%), easy to use (68.3%), and safe for most patient populations (76.2%). The majority of therapists felt that the Wii would be a positive influence on improving treatment adherence and that skills learned during participation in the games could potentially transfer to daily function.26 The authors also found that 59% of therapists believe patients with burns would benefit from using the Wii, and 85% of burn therapists suggest that it would be specifically advantageous for burn therapy.26 The purpose of this study was to demonstrate feasibility and measure outcomes on pain, anxiety, active ROM (AROM), function, enjoyment, and presence with the adjunctive use of the Wii during acute burn rehabilitation. METHODS Study participants meeting eligibility criteria (Table 1) were recruited and enrolled at a large urban burn center. Participation in the study was entirely voluntary and required signing an informed consent form approved by the institutional review board. Participants were alternated into the Wii or control treatment groups and stratified based on joint region of burn. Joints of interest based on cutaneous functional units27 were those with the greatest limitations in AROM, relative to the contralateral side if bilateral burn injuries were sustained. Richard et al27 describe cutaneous functional units as fields of skin involved in a joint's ROM, which include the location of the burn injury relative to joint skin creases. Joint regions under investigation were the shoulder, elbow, wrist, hip, knee, and ankle. Table 1. Eligibility criteria View Large Table 1. Eligibility criteria View Large All participants received three consecutive sessions of standardized therapy consisting of passive ROM and a combination of predetermined, joint-specific exercises for 15 minutes (Table 2). This was followed by an additional 15 minutes of Wii game play for those in the Wii group or 15 minutes of therapist-chosen interventions for those in the control. If designated to the Wii group, participants completed a Wii introduction and competency checklist to ensure that they could physically and cognitively participate in the video game activity and appropriately follow its somatosensory feedback. Interventional therapists were guided by scripts to provide standardized therapy and treatment in the Wii group. For those participants in the control group, although treatment was tailored by the interventional therapist, criteria included incorporating the joint of interest with active movement to be compared with the active gaming in the experimental Wii group. Furthermore, standardized therapy or the outcome measure tool for function, as defined by the study protocol, were not to be repeated to avoid training effects. All interventional therapists were oriented to the study's procedures and completed a competency checklist to ensure proficient knowledge and skill. Table 2. Standardized therapy: predetermined exercises, all participants, n = 23 View Large Table 2. Standardized therapy: predetermined exercises, all participants, n = 23 View Large Outcome Measures Presession measurements for the Wii and control groups were recorded on pain, anxiety, and AROM. Function was measured before the initial session. The groups were measured after each session for presence (Wii group only), enjoyment, pain, anxiety, and AROM, with function again measured after the final session (Figure 1). All measurements, except for presence, were performed by one blinded investigator to prevent bias and preserve intrarater reliability. Figure 1. View largeDownload slide Study design. AROM , active range of motion. Figure 1. View largeDownload slide Study design. AROM , active range of motion. Pain and Anxiety Visual analogue scales (VAS) were used for pain and anxiety. The scales were 10-cm lines with points ranging from 0 to 10, with one end described as “no pain” and “no anxiety” (0) and the opposite end “worst possible pain” and “worst anxiety possible” (10). Subjective rating scales have been shown to be valid, reliable, and effective for quantifying pain and anxiety.28,–31 Administration of analgesic medications were patient-specific, as per standard of care practice. AROM and Function AROM was assessed through goniometry, using a 6-inch, 360-degree transparent goniometer, marked in 5-degree increments. Standard measurement protocol was followed, and normative ranges were based on the American Academy of Orthopedic Surgeons.32,33 Composite AROM was calculated as the sum of kinematic motions in all planes for the joint of interest, divided by the sum of its normative values. The percent difference between presession and postsession composite measurements was then computed to calculate the total change in AROM per each session and cumulatively over the course of the 3-day trial (Figure 2). Standard goniometry has demonstrated excellent interrater and intrarater reliability across multiple joints with burn injury.34 All measurements were taken with bulky dressings applied, and attempts were made to precondition the area through a few trials of the joint's motion before presession measurements.35 Figure 2. View largeDownload slide Calculation of composite active range of motion (AROM). Figure 2. View largeDownload slide Calculation of composite active range of motion (AROM). Function was characterized by the Valpar 9 Whole Body Range of Motion Work Sample Test, Transfer 4 (Valpar International Corporation, Tucson, AZ), and instructions were adapted from the Valpar 9 test administration manual.36,37 Widely used by therapists,38 Valpar 9 is a work-rate test with analysis based on whole body ROM, agility, and stamina through gross body movements of the trunk and extremities, from crouching to overhead reaching.39 In addition, insight may be provided into secondary characteristics, such as motivation and confidence.39 The Valpar 9 test was modified in a nonstandardized manner using 6 pegs instead of 12, and the speed to perform the task was measured to a hundredth of a second. The instructions entail the transfer of pegs and a triangle from an overhead panel, that is, panel 2, to the bottom most panel, that is, panel 4. Therefore, the test requires sustained low-level work, requiring above-eye-level reaching to squatting. If the joint of interest was of the upper extremity, then that side was used to manipulate the pegs and triangle. Enjoyment and Presence Postsession measurements of enjoyment and presence were measured with subjective rating questionnaires developed and used by Hoffman et al10 in previous VR studies. One query for enjoyment and two queries for presence were associated with 10-cm rating scales with whole integers and written descriptors along the continuum (Figure 3). Figure 3. View largeDownload slide Enjoyment and presence questionnaires. Adapted from Hoffman et al., 2004 (10). Figure 3. View largeDownload slide Enjoyment and presence questionnaires. Adapted from Hoffman et al., 2004 (10). Wii Experimental Condition The Wii consists of a gaming console and peripherals including a wireless handheld controller, LED sensor bar, and the Wii Balance Board. The handheld controller functions as an accelerometer that detects magnitude and direction of movement and monitors motion by interacting with the LED sensor bar that was placed on top of a 19-inch television on a portable cart. The Wii Balance Board, when stood on, functions as a scale and force plate that detects movement of an individual's center of gravity. Participants were assigned joint-designated games from the software packages Wii Sports™ and Wii Fit™ (Table 3) under standardized conditions. Written scripts were provided to guide the interventional therapist through the treatment to minimize variations in the instructions that participants received, while still allowing the therapist to independently modulate the session. To comply with infection control and safety measures, the handheld controllers and straps were covered with cling wrap. The intervention was administered in a closed (10 × 12.75 feet) room without external distractions or interruptions to maximize presence and the consistency of the intervention per session. Table 3. Wii therapy intervention View Large Table 3. Wii therapy intervention View Large Statistical Analysis Data were analyzed using the Statistical Program for the Social Sciences, version 15.0 (SPSS, Chicago, IL). A t-test for equality of means was used to compare mean individual pretest scores (pain, anxiety, AROM, and function) for the two treatment groups. This test was to ensure participants in both groups were equivalent in pretest scores before treatment. For all outcomes, treatment effect was measured using the t-test for equality of means of growth rates. Growth rates, session-to-session rates of change per individual in each outcome, were averaged across participants in the Wii and control groups to obtain group-specific rates. Without outliers, these growth rates were then tested for equivalence between groups, except for presence, which was applicable only to the Wii group. For all measures, P < .05 defined significance. Because of the small sample size, Cohen's d statistic was used to calibrate the magnitude of the mean difference in the group-specific growth rates and was determined by preestablished parameters (d = 0.20, a “small” effect size; d = 0.50, a “moderate” effect size; and d = 0.80, a “large” effect size).40 Furthermore, where r coefficients of 0.10 and 0.30 indicate “small” and “medium” correlations, respectively, values of 0.25 or greater were deemed trends worth noting.40 RESULTS A total of 28 participants were enrolled in the study from July 2009 to September 2010. Two participants were removed because of unstable vital signs before initial outcome measurements; three participants' data sets were removed because of an inability to perform functional testing. The data of 23 participants were analyzed, which included 13 men and 10 women ranging in age from 20 to 78 years (37.08 ± 13.2 years) with TBSA injuries of 0.5 to 23% (6.76 ± 6.1%). The causes of burn injury included scald (52%), flame (39%), electrical (4.5%), and chemical (4.5%). Joints of interest included wrists (11), shoulders (4), elbows (4), hip (1), knees (0), and ankles (3). See Table 4 for demographic information between the Wii and control groups. At baseline, there were no statistically significant differences between the groups demographically or on any of the four presession outcomes applicable to both groups, P > .05 (Table 5). Table 4. Demographic summary View Large Table 4. Demographic summary View Large Table 5. Baselines for Wii and control groups View Large Table 5. Baselines for Wii and control groups View Large Significant difference was not statistically achieved in any of the six outcomes. The difference in mean slopes suggested that the Wii group experienced less pain (Wii b = −0.32, control b = 0.65, x = −0.97; P = .07) than the control group over time. A slower rate of growth in anxiety existed for participants in the Wii group relative to those in the control (Wii b = 0.12, control b = 0.23, x = −0.11; P = .77). Improved function (Wii b = −1.12, control b = −0.74, x = −0.38; P = .43), more so than AROM (Wii b = 2.26, control b = 1.71, x = 0.55, P = .81), seemed expedited among those participants in the Wii group. Enjoyment (Wii b = 0.39, control b = 0.30, x = 0.09; P = .73) seemed to be inappreciably greater for the Wii group relative to the control group (Table 6). On further analysis using Cohen's d statistic, the magnitude in mean differences between the two groups in effects size for pain and function were large and small to moderate, respectively (d 0.83 and 0.34 Table 7). On average, presence (query A) increased 0.16 of a VAS point between successive treatment sessions, leading to an overall increase of 0.32 of a point from the first to the last session (b = 0.16, P > .05). Presence (query B) declined 0.24 of a VAS point per session, with an overall decrease of 0.48 of a point (b = −0.24, P > .05). Table 6. Outcomes for Wii and control groups View Large Table 6. Outcomes for Wii and control groups View Large Table 7. Cohen's d statistic View Large Table 7. Cohen's d statistic View Large Trends noted in the Wii group were that older participants reported faster rates of growth in presence query A (r = 0.25) than their younger counterparts, and participants with prior use of the Wii exhibited faster declines in pain (r = −0.25) and presence query A (r = −0.25). No difference was noted between females and males with regard to presence query A (r = −0.17). DISCUSSION Burn injury leads to one of the most excruciating and protracted types of pain with physical and psychological distress.41 Among burn care that elicits procedural pain, rehabilitation entails withstanding intensive treatment that regularly stimulates nociceptive afferent fibers for extended periods of time.41 Pharmacologic intervention is routinely administered to address patients' background pain, but its efficacy in managing significant procedural pain during rehabilitative sessions is often suboptimal.9 Nonpharmacologic techniques such as VR have been reported to significantly reduce intensity, unpleasantness, and time spent thinking about pain through distraction, when added during procedures.8,–10,13,42 In this study, pain reduction outcomes in favor of the Wii group were the closest to approaching statistical significance (P = .07), and Cohen's d statistic indicated a strong effect (d = 0.83). The trend toward improved analgesia with the adjunctive use of the Wii in a short time frame clinically supports the potential for its use during acute therapy, especially when pain medications alone do not suffice. Procedural pain is not isolated to the acute phase of rehabilitation. With elongation of burn scar contracture during the later phases of rehabilitation, supplemental pain relief and patient adherence are essential for long-term outcomes.43 Therefore, exploring the use of the Wii throughout the continuum of burn rehabilitation would be valuable as patients progress toward independence. Patients also express high levels of anxiety that is related to burn pain during hospitalization.44 Costs are high for acute burn injury, and much of the expenditure is associated with analgesic and anxiolytic medications.45 Approaches to better manage pain and anxiety in this setting is critical for discharge and long-term functional results.46 Although the study results do not support the added use of the Wii for anxiety management during acute burn therapy, it may be speculated that the decrease in pain contributed to marginally slower growth rates in anxiety for participants in the Wii group relative to those in the control. In addition, participants for both groups had a lower baseline of anxiety than of pain, and none received or had a pre-admission history of taking antianxiety medications. Nonetheless, a closer parallel was expected between these two measures from session to session. Further studies are necessary to understand the interrelationship of burn pain and anxiety with active video gaming during burn therapy. Subsequently, patients with burns immobilized by pain and anxiety are at a risk for scar contracture formation.47 Incidences of contracture are significant despite specialized therapy in burn centers, highlighting the importance of intensive rehabilitation during hospitalization.47 AROM helps to improve skin elasticity and maintain full joint range and function48 and is integral to minimizing long-term disability. Patients must be persuaded to move through the pain and anxiety they experience.49 The direction of the mean difference in growth rates noted with AROM in the study were again positive; however, it was the least favorable outcome for the Wii group compared with other measures for both groups. One of the theoretical benefits of the Wii, compared with some VR systems, is the gross active and goal-directed movement that stimulates a task in a virtual environment. However, in clinical observation of patients using the Wii on the burn unit, compensatory movements were noticed to guard from exacerbating pain at the affected joints. These compensations allow participation in the game task but minimize the therapeutic benefits of localizing movement to the anatomical region of interest. The motions required and feedback offered by the Wii are not meant for increasing ROM of a joint region,50 which is critical in acute burn therapy. For example, the desired motion with Wii Sports Tennis was for AROM of the wrist. Despite the standardized and scripted verbal cues to isolate motion of play to the wrist, some participants instinctively performed the movement proximally with the elbow or shoulder to complete the task of the game and therefore required additional verbal cueing. No manual or physical constraints were applied by the interventional therapists to isolate movement in this study. Furthermore, because it is not customized for therapeutic use, a substantial portion of time was interrupted and compromised during each Wii session with screen loading and animations50 such as “instant replays.” Both groups participated in therapy for 3 consecutive days, which may be an abbreviated time frame to quantify change in ROM, as it is subject to frequent fluctuations during the acute phase.49 Considering the extensive periods of burn rehabilitation needed to maintain ROM of an involved joint region and that traditional exercise may quickly become routine and minimize patients' adherence, the small trend for AROM in this study warrants further exploration. The Wii may be a viable option to maintain and improve ROM if it can be better controlled or modified for compensations or adaptations through appropriate positioning, patient education, and monitoring over longer periods of time, potentially after discharge. Schneider et al47 examined the incidence and severity of contractures after burn injury and concluded that more than one third of patients with major burn injury presented with a contracture at discharge. The development of contractures puts patients at risk for deficits in basic function such as transfers, ambulation, and activities of daily living as well as reintegration to family, community, and return to work. Although not statistically significant, function as defined by the speed to perform a modified whole body movement task was the best improvement in favor of the Wii group (P = .43) after outcomes for pain. Analysis with Cohen's d statistic indicated a small-to-moderate effect size, d = 0.34. Enjoyment is a critical factor influencing the amount of time an individual devotes to playing video games.23 The rate of growth in enjoyment, although minimal, was slightly more for the Wii than the control group. One study evaluating motivation and video games revealed that 84% of the participants' main objective in playing video games was for “fun” or relaxation.51 The most common reason given for playing games was the temporary escape from their daily routine.51 When individuals are occupied in video games, specific tasks within the virtual environment direct behavior toward a goal that is concentrated and purposeful,51 which can be especially useful as an outlet for burn survivors throughout the continuum of recovery. Among other populations, use of the Wii and its peripherals has been shown to offer increased enjoyment, and clinicians report it as a useful training tool to facilitate a sense of accomplishment for patients.23,52 Demographics, personal background, and experience also may predict gaming preference and appropriateness. For example, in a study by Hoffman and Nadelson,51 males were almost twice as likely to be engaged in gaming as females. For this study, participants were not assigned to the Wii or control groups based on demographics or background nor was prior experience or preference considered in game selection for those in the Wii group. Patients requiring a high learning curve with technology, such as with the Wii, may actually experience greater frustration than gratification. The Wii may not necessarily make every patient's acute therapeutic course especially enjoyable; however, if prescribed appropriately, it may make it more tolerable. Video games can make therapy meaningful and effective and provide a resourceful and easily accessible avenue to change attitudes and develop skills.53 Goal achievement is the primary focus of occupational and physical therapy, and potential exists to connect the meaningfulness of active video games to achieve rehabilitative objectives as well as improve adherence to regular exercise. Moreover, interest in playing video games strongly predicts presence in a positive correlation.54 Presence is defined as the experience of being in one environment even when physically situated in another place.55 Levels of presence are dependent on providing a constant stream of stimuli to limit the cognitive resources from multitasking (eg, not focusing on pain), and it is enhanced by the ability to control the environment and receive adequate sensory feedback.25,55 The Wii requires concentration to perform the gaming task, providing real-time control in a virtual world and allowing the player to manipulate the handheld controller or distribute weight on the Balance Board while receiving auditory, visual, and haptic (somatosensory) feedback. In this study, when participants in the experimental group were asked to rate to what extent they felt like they “went inside” the computer-generated world while playing the Wii (query A), results indicated a positive rate of growth across the three treatment sessions. On average, presence for those in the Wii group increased 0.16 VAS points between successive treatment sessions, leading to an overall increase of 0.32 VAS points from the first to the last session. However, this rate of growth is small and failed to reach statistical significance. Hoffman et al10 compared Low Tech vs High Tech VR, and the results indicated that increasing presence-enhancing properties of the VR hardware configurations improved the sense of illusion and led to higher presence ratings. Therefore, with a stronger sense of illusion, participants were more distracted.10 Improved vividness, interactivity, and multisensory input of video games help to engross the players into convincing virtual worlds.54 Our positive trends for presence (query A) may corroborate the need to explore modifications with the Wii which can better immerse patients with burns into a virtual world. The Wii's software applications are not specifically designed for rehabilitation and as such present with additional limitations in task customization, modulating levels of challenge, grading, feedback, and assessment during therapy.50 Recently, devices that economically combine the benefits of VR and the Wii in a hospital setting for rehabilitation have been developed and are under investigation.50 With regards to how “real” the virtual objects seemed when playing the Wii (query B), a minor decline appeared in this measure over time. This suggests that the virtual environment, objects, or characters may lack realism to satisfactorily maintain presence. In this study, participants did not choose or adapt their character or “avatar.” “Self-presence” is defined as a connection to one's virtual representation.25 Ratan et al25 reported that participants engaged in Wii gaming who chose avatars that were dissimilar to themselves expressed significantly less self-presence. Presence as a blanket term encompasses self-presence among other factors,25 and the proper management of each of these variables may provide improved immersion from this low-cost gaming platform. A relatively small 19-inch television set was used, and image size is a determinant of presence.54 Average play time is also a strong predictor of presence, which generally increases with longer durations.54 Fung et al26 report that 58.7% of therapy practitioners surveyed recommend 15- to 30-minute durations per session. For this study, the Wii was administered at the shorter end of this proposed dosage, as extra caution was taken to avoid potential injuries.56 Studies exploring appropriate dose-to-response ranges for active video game technology are necessary to justify and optimize its usefulness during burn rehabilitation. The feasibility of integrating the Wii in the acute burn rehabilitation setting was supported. The small sample size in this preliminary study was a major limitation in finding statistically significant differences between the two treatment conditions. Recruitment was inherently limited for this pilot study with stringent eligibility criteria for a more homogeneous sample and a shorter duration to ensure consecutive treatment sessions and micro-monitoring of outcomes. With power probabilities calculated conventionally at ≥0.80 indicating a high likelihood of detecting effects, a much larger sample size would be required for all outcomes, except for pain, as indicated by the “large effect” (d = 0.83) with Cohen's d statistic. If the mean difference between the Wii and control groups remained the same for pain (ie, −0.32 vs 0.65) in a follow-up study, the sample would need to double to reach near a power of 0.80. An alternating stratification design was used for this smaller pilot study to help support an equivocal distribution of participants between the experimental and control groups and joints of interest. Larger randomized controlled trials are suggested for future appropriately powered and stronger studies. Furthermore, similar to immersive VR studies, it is worthwhile to understand the Wii's effect on the comprehensive pain experience, that is, “worst pain intensity,” “pain unpleasantness,” and “time spent thinking about pain” that correspond to sensory, affective, and cognitive pain, respectively.8,–11 Other limitations of this study include that treatment for both groups did not account for an association between pain with anxiety, the qualitative differences at impairment and functional levels, nor longer term patterns of growth or deterioration in enjoyment and presence with the Wii beyond a brief exposure and duration. CONCLUSION This pilot study demonstrates that the Wii is safe and feasible for patients during the acute phase of burn rehabilitation. Although statistical significance was not reached, the most compelling trend in this study was for pain reduction with the adjunctive use of the Wii. Participants in the Wii group did not exhibit worse results compared with those assigned to conventional therapy alone. In fact, an internal coherence of promising proclivities existed in the Wii group across all outcomes. Statistically powered research with larger sample sizes over longer periods of time and across all phases of burn therapy is necessary to explore alternative therapeutic and cost-effective tools. As advanced and affordable gaming technologies continue to emerge and become available to the general public, it is suggested that these findings serve as a catalyst for further investigation toward burn rehabilitation and translation more globally to other patient populations. ACKNOWLEDGMENTS We thank the New York Firefighters Burn Center Foundation for their ongoing support and generosity. We also thank Dr. Marc Glassman for his statistical expertise, Reginald Richard, Alexander Bagley, and Dr. Judith Deutsch for their invaluable input, and Jane Selegean and Chava Cogan for their assistance in preparing the article. REFERENCES 1. Richard RL, Hedman TL, Quick CD, et al. A clarion to recommit and reaffirm burn rehabilitation. J Burn Care Res 2008;29:425–32. 2. Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA. Burn rehabilitation: state of the science. Am J Phys Med Rehabil 2006;85:383–413. 3. World Health Organization. Towards a common language for functioning, disability and health: The International Classification of Functioning, Disability and Health (ICF); available from http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf; accessed January 18, 2011. 4. Weinberg K, Birdsall C, Vail D, Marano MA, Petrone SJ, Mansour EH. Pain and anxiety with burn dressing changes: patient self-report. J Burn Care Rehabil 2000;21:157–61. 5. Byers JF, Bridges S, Kijek J, LaBorde P. Burn patients' pain and anxiety experiences. J Burn Care Rehabil 2001;22:144–9. 6. Carrougher GJ, Ptacek JT, Honari S, et al. Self-reports of anxiety in burn-injured hospitalized adults during routine wound care. J Burn Care Res 2006;27:676–81. 7. Wiechman Askay S, Patterson DR, Sharar SR, Mason S, Faber B. Pain management in patients with burn injuries. Int Rev Psychiatry 2009;21:522–30. 8. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study. Clin J Pain 2000;16:244–50. 9. Hoffman HG, Patterson DR, Carrougher GJ, Sharar SR. Effectiveness of virtual reality-based pain control with multiple treatments. Clin J Pain 2001;17:229–35. 10. Hoffman HG, Sharar SR, Coda B, et al. Manipulating presence influences the magnitude of virtual reality analgesia. Clin J Pain 2004;111:162–8. 11. Hoffman H, Seibel E, Richards T, Furness TA, Patterson DR, Sharar SR. Virtual reality helmet display quality influences the magnitude of virtual reality analgesia. J Pain 2006;7:843–50. 12. Markus LA, Willems KE, Maruna CC, et al. Virtual reality: feasibility of implementation in a regional burn center. Burns 2009;35:967–9. 13. Sharar SR, Carrougher GJ, Nakamura D, Hoffman HG, Blough DK, Patterson DR. Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: preliminary results from 3 ongoing studies. Arch Phys Med Rehabil 2007;88:S43–9. 14. Morris LD, Louw QA, Crous LC. Feasibility and potential effect of a low-cost virtual reality system on reducing pain and anxiety in adult burn injury patients during physiotherapy in a developing country. Burns 2010;36:659–64. 15. Morris LD, Louw QA, Grimmer-Somers K. The effectiveness of virtual reality on reducing pain and anxiety in burn injury patients: a systematic review. Clin J Pain 2009;25:815–26. 16. Haik J, Tessone A, Nota A, et al. The use of video capture virtual reality in burn rehabilitation: the possibilities. J Burn Care Res 2006;27:195–7. 17. Deutsch JE, Borbely M, Filler J, Huhn K, Guarrera-Bowlby P. Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Phys Ther 2008;88:1196–207. 18. Clark R, Kraemer T. Clinical use of Nintendo Wii bowling simulation to decrease fall risk in an elderly resident of a nursing home: a case report. J Geriatr Phys Ther 2009;32:174–80. 19. Pigford T, Andrews AW. Feasibility and benefit of using the Nintendo Wii Fit for balance rehabilitation in an elderly patient experiencing recurrent falls. J Student Phys Ther Res 2010;2:12–20. 20. Saposnik G, Teasell R, Mamdani M, et al.; Stroke Outcome Research Canada (SORCan) Working Group. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle. Stroke 2010;41:1477–84. 21. Yong Joo L, Soon Yin T, Xu D, et al. A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. J Rehabil Med 2010;42:437–41. 22. BMC Research Notes. Exercising with computer in later life (EXCELL)—pilot and feasibility study ability of the Nintendo Wii Fit in community-dwelling fallers; available from http://www.biomedcentral.com/1756-0500/3/238; accessed January 21, 2011. 23. Graves LEF, Ridgers ND, Williams K, Stratton G, Atkinson G, Cable NT. The physiological cost and enjoyment of Wii Fit in adolescents, young adults, and older adults. J Phys Act Health 2010;7:393–401. 24. Miyachi M, Yamamoto K, Ohkawara K, Tanaka S. METs in adults while playing active video games: a metabolic chamber study. Med Sci Sports Exerc 2010;42:1149–53. 25. Ratan R, Santa Cruz M, Vorderer P. Multitasking presence and self-presence on the Wii. Presence 2007;388:167–77. 26. Fung V, So K, Park E, et al. 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 2010;31:768–75. 27. Richard RL, Lester ME, Miller SF, et al. Identification of cutaneous functional units related to burn scar contracture development. J Burn Care Res 2009;30:625–31. 28. Benotsch EG, Lutgendorf SK, Watson D, Fick LJ, Lang EV. Rapid anxiety assessment in medical patients: evidence for the validity of verbal anxiety ratings. Ann Behav Med 2000;22:199–203. 29. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 2001;8:1153–7. 30. Lundeberg T, Lund I, Dahlin L, et al. Reliability and responsiveness of three different pain assessments. J Rehabil Med 2001;33:279–83. 31. Lara-Muñoz C, Ponce de Leon SP, Feinstein AR, Puente A, Wells CK. Comparison of three rating scales for measuring subjective phenomena in clinical research: use of experimentally controlled auditory stimuli. Arch Med Res 2004;35:43–8. 32. Norkin CC, White DJ. Measurement of joint motion a guide to goniometry. 3rd ed. Philadelphia, PA: F.A. Davis Company; 2003. 33. American Academy of Orthopedic Surgeons. Joint motion: method of measuring and recording. Chicago, IL: American Academy of Orthopedic Surgeons; 1965. 34. Edgar D, Finlay V, Wu A, Wood F. Goniometry and linear assessments to monitor movement outcomes: are they reliable tools in burn survivors? Burns 2009;35:58–62. 35. Barbenel JC, Evans JH. The time-dependent mechanical properties of skin. J Invest Derm 1977;69:318–20. 36. Buys T, Van Biljon H. Functional capacity evaluation: an essential component of South African occupational therapy work practice services. Work 2007;29:31–6. 37. Valpar Assessment Systems: whole body range of motion reference manual. Tucson, AZ: Valpar International Corporation; 1993. 38. Hakkinen A, Sokka T, Lietsalmi AM, Kautiainen H, Hannonen P. Effects of dynamic strength training on physical function, Valpar 9 work sample test, and working capacity in patients with recent-onset rheumatoid arthritis. Arthritis Rheum 2003;49:71–7. 39. Valpar component work samples uses in allied health. Tucson, AZ: Valpar International Corporation; 2006. 40. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates Publishers; 1988. 41. Abdi S, Zhou Y. Management of pain after burn injury. Curr Opin Anaestesiol 2002;15:563–7. 42. Hoffman HG, Patterson DR, Seibel E, Soltani M, Jewett-Leahy L, Sharar SR. Virtual reality pain control during burn wound debridement in the hydrotank. Clin J Pain 2008;24:299–304. 43. Meyer WJ, Patterson DR, Jaco M, et al. Management of pain and other discomforts in burn patients. In: Herndon D, editor. Total burn care. 3rd ed. Philadelphia, PA: Saunders; 2002. 44. Aaron LA, Patterson DR, Finch CP, Carrougher GJ, Heimbach DM. The utility of a burn specific measure of pain anxiety to prospectively predict pain and function: a comparative analysis. Burns 2001;27:329–34. 45. Patil V, Dulhunty JM, Udy A, Thomas P, Kucharski G, Lipman J. Do burn patients cost more? The intensive care unit costs of burn patients compared with controls matched for length of stay and acuity. J Burn Care Res 2010;31:598–602. 46. Alvi T, Assad F, Aurangzeb, Malik MA. Anxiety and depression in burn patients. J Ayub Med Coll Abbottabad 2009;21:137–41. 47. Schneider JC, Bassi S, Ryan C. Barriers impacting employment after burn injury. J Burn Care Res 2009;30:294–300. 48. Carrougher GJ, Hoffman HG, Nakamura D, et al. The effect of virtual reality on pain and range of motion in adults with burn injuries. J Burn Care Res 2009;30:785–91. 49. Ward SR. Physical rehabilitation. In: Carrougher G, editor. Burn care and therapy. 1st ed. St. Louis, MO: Mosby; 1998. 50. Anderson F, Annett M, Bischof WF. Lean on Wii: physical rehabilitation with virtual reality Wii peripherals. Stud Health Technol Inform 2010;154:229–34. 51. Hoffman B, Nadelson L. Motivational engagement and videogaming: a mix method study. Educ Tech Res Dev 2010;58:245–70. 52. Lange B, Flynn S, Rizzo A. Initial usability assessment of off-the-shelf video game consoles for clinical game-based motor rehabilitation. Phys Ther Rev 2009;14:355–63. 53. Hawn C. Games for health: the latest in the medical care arsenal. Health Aff 2009;28:842–8. 54. Ribbens W, Abeele MV. Socio-demographic and psychological determinants of presence in a gaming experience. In: Spagnolli A, Gamberini L, eds. Presence 2008: Proceedings of the 11th Annual International Workshop on Presence. Padova, Italy: Cooperativa Libraria Universitaria Padova; 2008:163–73. 55. Witmer BG, Singer MJ. Measuring presence in virtual environments: a presence questionnaire. Presence 1998;7:225–40. 56. Sparks D, Chase D, Coughlin L. Wii have a problem: a review of self-reported Wii related injuries. Inform Prim Care 2009;17:55–7. Footnotes 1 Presented at the 43rd Annual Meeting of the American Burn Association, Chicago, IL, March 30, 2011. Copyright © 2012 by the American Burn Association
TI - The Utilization of Nintendo® Wii™ During Burn Rehabilitation: A Pilot Study
JO - Journal of Burn Care & Research
DO - 10.1097/BCR.0b013e318234d8ef
DA - 2012-01-01
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SP - 36
EP - 45
VL - 33
IS - 1
DP - DeepDyve
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