Commentary on “Digital play and rehabilitation for children and adolescents in hospitals,outpatient departments and rehabilitation centres: A scoping review”

Screens and digital play are ubiquitous in our society. In the United States, it is estimated that 90% of children older than two years and 97% of those aged 12–18 play video games, and that children 8–17 spend an average of 1.5–2 h per day playing video games. ¹ There can be a knee-jerk reaction that video games and screens are bad for development and promote a sedentary lifestyle. There are concerns regarding negative effects including a well-documented relationship between screen time and obesity and sleep disturbance. Risks of online bullying, gaming disorder, learning deficits in younger children and increased attention-deficit/hyperactivity disorder and violent behaviors have been suggested. Parents have received strong messages from health care providers about the dangers of overusing screens. The American Academy of Pediatrics has recommended against most screen time for children under two and limiting time to one hour for 3–5-year-olds. ¹

However, all video games and screen time are not the same. Studies of “exergames” involving physical activity have been shown to increase activity levels, promote weight loss and improve depression. Some videogame play is associated with improved problem-solving, memory, processing ability and improved reaction time. Socially active games can promote relationships. ¹ This is of great importance for patients who have limited ability to access the community due to immunocompromise or physical challenges.

There are also significant opportunities to use screens, videogames and other digital play to improve function for children with limited mobility, dexterity, cognitive skills and communication skills, like those targeted in pediatric rehabilitation medicine. The article “Digital play and rehabilitation for children and adolescents in hospitals, outpatient departments and rehabilitation centers: A scoping review” describes many ways this technology has been used to support rehabilitation goals. ² Exergames have been used successfully in patients with neurologic disability as discussed in a systematic review by Rosly et al. ³ Polizzi et al. also performed a systematic review of video and exergames in pediatric neurorehabilitation populations with findings suggestive of safety and efficacy in the use of these modalities. ⁴ In an additional systematic review by Ravi et al., virtual reality (VR) was found to have moderate evidence in improving balance and motor skills in children with cerebral palsy. ⁵ A small multicenter trial by Jung et al. of patients with cerebral palsy and Gross Motor Function Classification System levels 1 and 2 demonstrated improved lower extremity selective control and balance using kinetic video game training. ⁶

Most rehabilitation interventions require consistent active participation and engagement; thus, motivation is crucial to success. However, focused study of motivation in pediatric rehabilitation is quite limited. Tatla et al. performed a systematic review of motivating interventions on rehabilitation outcomes in children and adolescents that included digital play. ⁷ They found little evidence and scant use of psychometrically validated measures of motivation. A similar lack of well-designed studies measuring motivation was found in a systematic review by Meyns et al. evaluating motivation in pediatric motor rehabilitation. ⁸ This presents an important opportunity for further study given the huge impact it has on the success of our interventions.

Distraction during painful or anxiety provoking procedures or during prolonged hospitalizations is important to the pediatric rehabilitation population. VR and digital play have been found to have a meaningful impact on anxiety and perception of pain. ⁹ Arane et al. provides a broad overview of the use of digital play for patients who may have rehabilitative needs in a variety of settings. ¹⁰ While emergency department settings or medical issues like fractures or asthma likely have less clear applications for pediatric rehabilitation medicine, these are issues that our patients may encounter. These types of broad overviews can be valuable in increasing awareness in the varied ways digital play is used across patient populations.

Most of the studies involving digital play and pediatric rehabilitation medicine are quite small so a systematic review is a useful means to gather perspective. Multicenter trials with consistent protocols and larger enrollment would be quite helpful to provide more meaningful guidance on the impact of these interventions on specific rehabilitation goals. For example, studying the impact of digital play on improving compliance and duration of therapeutic activities; measuring tolerance, anxiety and pain levels with uncomfortable procedures; and measuring the rate of acquisition of new motor patterns would be very helpful. Also, our field would benefit from identifying the most useful access options for patients with functional limitations and populations that are variably resourced. These types of outcomes would provide strong guidance in our use of this technology.

An important goal of rehabilitative care in children is to enhance function in a way that is meaningful to their everyday function in as comfortable a way as possible. Play in all its forms is a cornerstone to pediatric therapies, and digital play is an increasingly viable option. In our current cultural environment, digital play is a part of everyday life for most children. Exploring this technology is an important addition to our care.