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Abstract

PURPOSE:

To determine the effect of rehabilitation using video games combined with conventional therapy in children with loss of range of motion (ROM) after conservative or surgical treatment of upper limb fractures.

METHODS:

This retrospective observational study included 12 children (9 boys, 3 girls; mean age: 6.75 $\pm$ 2.83 y) treated with combined video game and conventional physical therapy following upper limb fracture. Children completed 60 minutes of combined therapy (20 minutes of game therapy and 40 minutes of physical therapy) two times per week until therapy was no longer warranted. The flexion and extension ROM of the elbow and wrist, pronation and supination of the forearm, and pain during rest and effort were measured at the beginning and end of treatment.

RESULTS:

Children experienced significantly increased extension ( $p<$ 0.001) and flexion ( $p<$ 0.01) ROM of the elbow, increased flexion ROM of the wrist ( $p<$ 0.05), and reduced pain during effort ( $p<$ 0.05) after an average of 6 weeks of combined treatment.

CONCLUSION:

The use of video games with conventional therapy was effective in reducing pain and recovering ROM in children with upper limb fractures.

Keywords

Video games therapeutic use physical therapy modalities children upper extremity fracture

1. Introduction and purpose

Fractures of the upper limbs represent the majority of musculoskeletal injuries that occur in children and adolescents, with forearm fractures representing 40–50% of all fractures during childhood. The most common cause of upper limb fractures in children is falls, and the risk factors for such events include inactivity and obesity, as well as higher risk factors for the female sex, or those between the ages of 9 and 12 years [1, 2, 3, 4].

Upper limb fractures in children can lead to short and long-term complications which include: vascular compromise of the upper limb leading to a loss of nerve and muscle function, bone deformity due to an inappropriate reduction of the fracture, prolonged loss of mobility, and school absenteeism for children or work absenteeism for parents, with resultant adverse physical, social, and emotional consequences [5]. Upper limb injuries are also associated with restricted range of motion (ROM) in flexion-extension of the elbow as well as pronation-supination of the forearm, which may ultimately lead to limitations in a child’s daily activities [6, 7, 8].

The treatment options for upper limb fractures in children are surgical or conservative, according to the level, type, and severity of the injury [5]. In each of the two types of treatment, it is necessary to immobilize the limb with a cast for approximately 3 weeks in order to promote proper healing of the fracture, which can lead to elbow or wrist stiffness following cast removal [9]. Despite this risk, the use of physiotherapeutic treatment after removal of the cast is controversial, because there is evidence that suggests that normalization of ROM and function in children can be achieved after a certain period even without physical therapy [7, 9, 10]. In contrast, immobilization of the upper limb for longer than 2 weeks can lead to a reduction in the thickness of the primary sensory-motor cortex and vascularization of the local, synapse, and glial cells in the region corresponding to that limb. Due to these complications, physical and cognitive therapy are recommended [11].

Considering this scenario, rehabilitation that includes the use of video games is a viable option to minimize cortical alterations that can occur during prolonged immobilization thereby promoting the use of the affected upper limb, reducing the risk of joint stiffness, and increasing adherence to therapy in this population [12, 13].

There is no consensus in the literature regarding the most beneficial type of physiotherapeutic treatment following upper limb fracture in children. Furthermore, the hypothesis of rehabilitation that includes video game usage has not been tested in this population. Therefore, the purpose of this study was to verify the effect of rehabilitation using video games combined with conventional physical therapy in children with ROM deficiencies after conservative or surgical treatment of upper limb fractures.

2. Methods

2.1 Study design

This was a retrospective observational study of patients treated in the pediatric physical therapy ambulatory clinic at a tertiary hospital in São Paulo, Brazil.

2.2 Participants

Data from patients’ charts and records were collected and analyzed. Children who were subjected to either conservative or surgical treatment for upper limb fractures, and subsequently referred to a physical therapy service and treated with combined video game and conventional therapy were included in this study. Data was omitted for patients who were older than 13 years of age, had fractures involving other parts of the body, or did not receive video game therapy following surgical or conservative treatment of upper limb fractures.

The study consisted of 12 boys and girls aged 3–9 years of age. The patients were treated between May 2016 and May 2017. The Institute of Medical Assistance to the State Public Servant (IAMSPE) research ethics committee approved this study on June 19, 2017 (approval number: 2.124.064). The informed consent form and assent form were waived because this was a retrospective study and the data were collected from medical charts and institutional information systems as well as other clinical and informational sources that were available at the institution.

2.3 Procedures

Children were referred to the physical therapy service after presenting with persistent loss of ROM in the affected upper limb 4 weeks after removal of the immobilization cast. Immobilization casts were used following either surgical or conservative treatment of intercondylar and supracondylar humerus or distal radius and ulnar fractures. The children were subjected to the same physiotherapeutic treatment protocol, which consisted of the following: increasing flexion-extension ROM of the elbow, pronation-supination of the forearm, flexion-extension of the wrist and fingers through passive exercises, global muscular strengthening of the affected upper limb through active-resistive exercises, and game therapy using the Nintendo Wii ${}^{\rm TM}$ console and Wii Sports game, which included tennis, boxing, and bowling games. During the game therapy, tennis, boxing, and bowling games were chosen to encourage the use of the affected upper limb and to promote active mobilization of the elbow and wrist. The physical therapy sessions lasted 60 minutes, of which 20 minutes were dedicated to game therapy. These sessions occurred twice per week. The treatment protocol and the game therapy were applied by the same physiotherapist experienced in pediatric rehabilitation. Children completed therapy when they exhibited functional ROM of the affected upper limb and absence of functional limitations or complaints of pain.

2.4 Measurements

The ROM data for flexion and extension of the elbow and wrist and pronation and supination of the forearm were evaluated using goniometry. Additionally, the data regarding pain during rest and effort were collected and measured using the Visual Analog Scale (VAS), which was adapted for pediatric patients [14]. All data were collected prior to the start of treatment and again at the end of the treatment.

2.5 Statistical analysis

Data were analyzed using R software, version 3.1.1 for Windows (The R Foundation, Vienna, Austria). The following statistical methods were used: the Shap-iro-Wilk and Levene’s tests to evaluate the normality and homogeneity assumptions, paired Student’s $t$ -test for normal distribution, and the Wilcoxon signed rank test for related samples for the non-normal distribution. A $p$ value of $<$ 0.05 was considered statistically significant.

3. Results

3.1 Patient characteristics

Patient characteristics are presented in Table 1. The eight children who presented with intercondylar and supracondylar fractures were treated using Kirschner wires. Additionally, the two children who presented with distal radius and ulna fractures were treated using intramedullary nails, and the two children with distal radius fractures were treated conservatively. Regardless of the type of treatment, all children received 3–6 weeks of cast immobilization. Of the 12 children who were evaluated in this study, two presented with peripheral nerve injuries. One had an ulnar nerve injury and one had a radial nerve injury.

3.2 Passive range of motion

For the ROM data analysis, the patients were divided into children with humerus fractures and children with forearm fractures. In the group of children with intercondylar and supracondylar humerus fractures ( $n=8$ ), the initial and final ROM for flexion and extension of the elbow and pronation and supination were analyzed. In the group of children with forearm fractures ( $n=4$ ), initial and final ROM for wrist flexion and extension and pronation and supination were analyzed. The initial and final passive ROM results are described in Table 2.

In those with intercondylar and supracondylar hume-rus fractures, there was a statistically significant increase in flexion ROM of the elbow following treatment using the Wilcoxon signed rank test for related samples. A paired Student’s $t$ -test determined a statistically significant increase in extension ROM of the elbow following treatment; normality and homogeneity were confirmed for this variable. In contrast, Wilcoxon signed rank test for related samples showed that there was no significant difference in pronation and supination following treatment.

In the group of children with forearm fractures, a paired Student’s $t$ -test determined a statistically significant increase in flexion ROM of the wrist following treatment. Conversely, Wilcoxon signed rank test for related samples determined that there were no significant differences in pronation, supination, or wrist extension ROM following treatment.

Table 1
Patient characteristics presented as frequency or mean $\pm$ standard deviation

	Patients ( $n=$ 12)
Sex (male/female)	9/3
Age (y)	6.75 $\pm$ 2.83
Humerus fracture	8
Supracondylar	5
Intercondylar	3
Forearm fracture	4
Distal radius and ulna	2
Distal radius	2
Treatment
Conservative	2
Surgical	10
Duration between immobilization cast removal and start of physical therapy (wk)	3.45 $\pm$ 2.91
Total physiotherapeutic treatment time (wk)	6.63 $\pm$ 2.83

y: years; wk: weeks.

Table 2

Passive range of motion of the upper limb by fracture site presented as mean $\pm$ standard deviation

Passive ROM (degrees)
	Initial evaluation	Final evaluation
Children with humerus fracture ( $n=$ 8)
Elbow flexion ${}^{{\dagger}}$	115.4 $\pm$ 14.72	131.9 $\pm$ 5.94
Elbow extension ${}^{\mathbf{{\ddagger}}}$	$-$ 38.75 $\pm$ 7.90	0.00 $\pm$ 6.78
Pronation	68.75 $\pm$ 18.60	85.00 $\pm$ 3.77
Supination	68.12 $\pm$ 18.31	85.14 $\pm$ 3.82
Children with forearm fracture ( $n=$ 4)
Wrist flexion*	48.25 $\pm$ 22.03	79.00 $\pm$ 7.79
Wrist extension	42.50 $\pm$ 2.89	85.00 $\pm$ 4.08
Pronation	72.50 $\pm$ 28.43	88.75 $\pm$ 2.50
Supination	66.25 $\pm$ 24.62	86.25 $\pm$ 4.78

Statistically significant at: * $p<$ 0.05; ${}^{\mathbf{{\dagger}}}p<$ 0.01; ${}^{\mathbf{{\ddagger}}}p<$ 0.001. ROM: range of motion.

Table 3

Child-reported pain during rest and effort presented as mean $\pm$ standard deviation

VAS score
	Initial evaluation	Final evaluation
Pain during rest	0.38 $\pm$ 0.74	0
Pain during effort*	2.12 $\pm$ 1.81	0

* Statistically significant at $p<$ 0.05. VAS: Visual analog scale.

3.3 Pain

For the data analysis regarding pain during rest and effort, the collective sample ( $n=12$ ) was used. Data from three children who were younger than 4 years of age were omitted because they had difficulty understanding the VAS, as well as reliably reporting the intensity of pain, although all three children reported pain during effort. The results obtained are described in Table 3.

The Wilcoxon signed rank test for related samples determined that there was no significant difference between the initial and final evaluations for pain during rest. Conversely, the same statistical method revealed that pain during effort was significantly reduced following treatment. Of note, both conditions (i.e., rest and effort) yielded a VAS score of zero at the final evaluation.

4. Discussion

This study evaluated the efficacy of combining game therapy with conventional physical therapy in the rehabilitation of children who were treated either surgically or conservatively following an upper limb fracture. Based on the available literature, this was the first study to assess the effect of including such a method to physiotherapeutic treatment in this population.

With regard to physiotherapeutic treatment following the removal of an immobilization cast in children who were treated for upper limb fractures, Spencer et al. [7], Schmale et al. [9], Keppler et al. [10] and Zorilla et al. [15] concluded that this type of treatment was unnecessary. These studies reported that patients had the ability to recover ROM of the elbow and function of the upper limb without performing physiotherapeutic treatment within a period of 48 weeks of the injury, and that there were no additional benefits to physiotherapeutic treatment in this population. However, these conclusions are questionable as the authors considered the ROM and function variables without considering pain and the other systems that can be involved in an injury, such as the sensory-motor system. Additionally, the authors assume that physical therapy (PT) is as effective as no-PT but they did not properly describe the rehabilitation protocol used in these studies, making it difficult to be reproduced. Furthermore, Spencer et al. [7] reported that older children and those subjected to surgical treatment had poorer outcomes in the absence of physiotherapeutic treatment. Schmale et al. [9] suggested that an ineffective treatment session comprised only 30 minutes, which was divided among the use of heat, stretching, and functional activities and did not include an explanation of how these techniques were used (i.e., time, series, repetitions, and frequency).

Langer et al. [11] demonstrated that immobilization of the upper limb for approximately 2 weeks following an injury could lead to a reduction in the thickness of the sensory-motor cortex in the corresponding region, reorganization of the sensory-motor system, and favoring of the unaffected limb. Presumably, these outcomes can occur in children who suffered an injury of the upper limb that required prolonged immobilization for treatment, which could potentially lead to impairments in their coordination and psychomotor development. Children with coordination impairments may be more prone to sedentary behavior and experiencing falls and consequently may be at risk for new fractures during childhood and adulthood [16, 17]. Game therapy and virtual rehabilitation are widely used for the rehabilitation of children because these methods increase children’s motivation and therapy attendance [12, 18, 19, 20]. These therapies also produce changes in the brain, which may lead to an improvement in spatial orientation, increased use of the upper limbs, increases in primary motor cortex and corticospinal tract plasticity, and improvements in coordination [21, 22, 23, 24, 25].

Among the studies that evaluated the efficacy of physical therapy in children with upper limb fractures [7, 9, 10], the duration of functional and ROM recovery averaged approximately 1 year. In the present study, with respect to improvements in ROM of the elbow, the children who were treated physiotherapeutically using game therapy combined with conventional physical therapy had similar or even superior results, in comparison to those in previous studies over a shorter period (approximately 6 weeks). Ultimately, at the end of the treatment period, none of the 12 children felt pain in the affected upper limb during rest or effort; previous studies did not evaluate this variable. It is important to emphasize that persistent pain after an upper extremity fracture in a child can lead to poorer quality of life, mood alteration, and school absenteeism in addition to causing anxiety, fear, and irritability. Also, children who experience persistent pain after an upper extremity fracture tend to favor the unaffected arm, which can reduce their level of physical activity and lead to coordination issues and motor development impairment [26].

With respect to ROM, the children achieved statistically significant increases in extension and flexion of the elbow and an increase in wrist flexion between the initial and final evaluations. However, the other evaluated ROMs did not yield statistically significant results in response to the combined treatment. This finding could be related to the fact that the types of games chosen for the game therapy (tennis, boxing, and bowling) demanded greater flexion and extension ROM of the elbow and flexion of the wrist as opposed to other upper limb movements.

This study had some limitations, including a small number of subjects and a retrospective study design. These limitations are justified by the fact that there is no consensus between orthopedists and physical therapists regarding the optimal physiotherapeutic treatment in the pediatric population. Therefore, only a few patients were referred for physical therapy service within a 1-year period. Furthermore, this is an exploratory study and future randomized controlled studies with a larger number of patients are needed in order to evaluate the efficacy of adding game therapy to conventional physical therapy in children with upper limb fractures.

In conclusion, game therapy combined with conventional physical therapy was effective in reducing pain and recovering upper limb ROM in children with upper limb fractures.

Footnotes

Acknowledgments

We thank the Institute of Medical Assistance to the State Public Servant (IAMSPE) Orthopedic Physical Therapy Group and the Association of Volunteers of the State Public Servant Hospital (AVOHSPE) for the donation of the Nintendo Wii™ consoles and games that were used in this project. This study was not supported by any grants.

Conflict of interest

The authors have no conflict of interest to report.

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The use of video games combined with conventional physical therapy in children with upper limb fractures: An exploratory study