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Use of Virtual Reality in Burn Rehabilitation: A Systematic Review and Meta-analysis

Open AccessPublished:August 28, 2022DOI:https://doi.org/10.1016/j.apmr.2022.08.005

      Abstract

      Objectives

      We systematically reviewed published clinical trials to evaluate the effectiveness of virtual reality (VR) technology on functional improvement, pain relief, and reduction of mental distress among burn patients undergoing rehabilitation.

      Data Sources

      Systematic searches were conducted in 4 databases, including PubMed, the Cochrane Library, Embase, and Web of Science, from inception to August 2021.

      Study Selection

      Randomized controlled trials (RCTs) evaluating any type of VR for the rehabilitation in burn patients with dysfunction were included.

      Data Extraction

      Two reviewers evaluated the eligibility, and another 2 reviewers used the Cochrane risk of bias assessment tool to assess the risk of bias. The extracted data included the main results of rehabilitation evaluation (quality of life [QOL], work performance, range of motion [ROM] of joints, hand grip and pinch strength, pain, fun, anxiety), the application performance of VR (realness and presence), adverse effects (fatigue and nausea), and characteristics of the included studies. Heterogeneity was evaluated using the chi-square tests and I2 statistics. Random- or fixed-effects models were conducted to pool the effect sizes expressed as standardized mean differences (SMDs).

      Data Synthesis

      Sixteen RCTs with 535 burn patients were included. VR-based interventions were superior to usual rehabilitation in QOL and work performance of burn patients and produced positive effect on the average gain of ROM (SMD=0.72) as well. VR was not associated with improved hand grip and pinch strength (SMD=0.50, 1.22, respectively) but was associated with reduced intensity, affective, and cognitive components of pain (SMD=−1.26, −0.71, −1.01, respectively) compared with control conditions. Ratings of fun in rehabilitation therapy were higher (SMD=2.38), and anxiety scores were lower (SMD=−0.73) than in control conditions.

      Conclusions

      VR-based burn rehabilitation significantly improves the QOL and work performance of burn patients, increases the ROM gain in the joints, reduces the intensity and unpleasantness of pain and the time spent thinking about pain, increases the fun in the rehabilitation therapy, reduces the anxiety caused by the treatment, and has no obvious adverse effects. However, it did not significantly improve hand grip or pinch strength.

      Keywords

      List of abbreviations:

      CI (confidence interval), QOL (quality of life), RCT (randomized controlled trial), ROM (range of motion), SMD (standardized mean difference), VR (virtual reality)
      Burns are a common accidental injury worldwide.
      World Health Organization
      Burns.
      Recent developments in medical technology have helped greatly increase the survival rate of burn patients.
      • Jeschke MG
      • van Baar ME
      • Choudhry MA
      • Chung KK
      • Gibran NS
      • Logsetty S.
      Burn injury.
      However, after wound healing, adverse effects such as scar contracture and deformity, limb dysfunction, and posttraumatic psychological disorder can seriously affect the patients’ quality of life (QOL).
      • Miller T
      • Bhattacharya S
      • Zamula W
      • et al.
      Quality-of-life loss of people admitted to burn centers, United States.
      Burn patients often have different degrees of joint dysfunction because of limb immobilization, tissue damage, and scar contracture. The main manifestations are the reduction of range of motion (ROM) or weakness of the adjacent joints, inability to complete normal activities, and joint deformities.
      • Schouten HJ
      • Nieuwenhuis MK
      • van Baar ME
      • van der Schans CP
      • Niemeijer AS
      • van Zuijlen PPM.
      The prevalence and development of burn scar contractures: a prospective multicenter cohort study.
      The incidence of joint dysfunction at discharge in patients with severe burns is 22%-42%, and although all joints can be affected, the hands, elbows, and shoulders are the most commonly affected joints.
      • Oosterwijk AM
      • Mouton LJ
      • Schouten H
      • Disseldorp LM
      • van der Schans CP
      • Nieuwenhuis MK.
      Prevalence of scar contractures after burn: a systematic review.
      Timely and effective rehabilitation is of great importance for the prevention and treatment of postburn joint dysfunction and can greatly improve the short- and long-term QOL of patients.
      • Young AW
      • Dewey WS
      • King BT.
      Rehabilitation of burn injuries: an update.
      Therefore, burn rehabilitation has become a hot topic among clinicians who treat burn patients in recent years.
      Rehabilitation exercises are necessary throughout the entire burn treatment process, which is long and difficult. Regular and intensive functional exercise is conducive to accelerate wound healing, joint function restoration, and recovery of functional daily living activities.
      • Richard R
      • Santos-Lozada AR.
      Burn patient acuity demographics, scar contractures, and rehabilitation treatment time related to patient outcomes: the ACT Study.
      However, traditional rehabilitation therapy with continuous therapeutic exercise including active and passive movement of joints is repetitive, is nonengaging, and often causes unbearable pain.
      • Dodd H
      • Fletchall S
      • Starnes C
      • Jacobson K.
      Current concepts burn rehabilitation, part ii: long-term recovery.
      These factors can have many negative effects on burn patients, such as anxiety or depression, low compliance, and poor treatment effects.
      • Dodd H
      • Fletchall S
      • Starnes C
      • Jacobson K.
      Current concepts burn rehabilitation, part ii: long-term recovery.
      Virtual reality (VR) is a computer simulation system for creating and experiencing authentic, interactive, and autonomous virtual worlds that provide multisensory experiences to the user. Virtual training scenarios are fun and engaging, and they impart to the user a skill, knowledge, or attitude that can be of use in the real world.
      • Slater M
      • Sanchez-Vives MV.
      Enhancing our lives with immersive virtual reality.
      Early computer-centered VR, such as VR videos, distracts users through 1-way presentation. Currently, user-centered VR, such as gamified VR, motivates users to give real-time feedback through 2-way interaction.
      • Slater M
      • Spanlang B
      • Sanchez-Vives MV
      • Blanke O.
      First person experience of body transfer in virtual reality.
      VR technology has been widely used in medical rehabilitation practice. Multiple studies have shown that VR has substantial effects on the rehabilitation of patients with stroke; Parkinson disease; and bone, joint, and nerve injuries.
      • Li L
      • Yu F
      • Shi D
      • et al.
      Application of virtual reality technology in clinical medicine.
      ,
      • Naro A
      • Calabrò R.
      What do we know about the use of virtual reality in the rehabilitation field? A brief overview.
      VR has several advantages with respect to more conventional rehabilitation, such as increased patients’ motivation and engagement, real-time interactivity, safety of the simulated environment, and greater personalization possibilities.
      • Indovina P
      • Barone D
      • Gallo L
      • Chirico A
      • De Pietro G
      • Giordano A.
      Virtual reality as a distraction intervention to relieve pain and distress during medical procedures: a comprehensive literature review.
      Hoffman et al are the first to use VR technology to relieve operative pain in burn patients during dressing changes.
      • Hoffman HG
      • Doctor JN
      • Patterson DR
      • Carrougher GJ
      • Furness TA.
      Virtual reality as an adjunctive pain control during burn wound care in adolescent patients.
      Subsequently, an increasing number of studies have examined the application of VR in the field of burns, mainly for pain management and psychological intervention during adjuvant therapy.
      • Scapin S
      • Echevarria-Guanilo ME
      • Boeira Fuculo Junior PR
      • Goncalves N
      • Rocha PK
      • Coimbra R
      Virtual reality in the treatment of burn patients: a systematic review.
      Few studies have been conducted on VR-based burn rehabilitation exercises, and most of them typically focused on the effects of VR on pain and anxiety. There is a lack of objective evaluations of the effect of VR on limb training, and the results of existing studies are controversial. Furthermore, several scholars have raised concerns about fatigue, dizziness, nausea, and other adverse effects caused by VR during rehabilitation therapy.
      • Luo H
      • Cao C
      • Zhong J
      • Chen J
      • Cen Y.
      Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: a systematic review and meta-analysis of randomized controlled trials.
      New technology is potentially cumbersome or expensive, and questions remain whether VR is ready for clinical implementation in burn rehabilitation.
      Hence, we performed this systematic review to provide a current comprehensive overview on the efficacy of VR for functional improvement, pain relief, and reduction of mental distress in burn patients undergoing rehabilitation therapy. Besides, we also focused on realness, presence, and adverse effects in clinical application of VR.

      Methods

      This study was carried out in strict accordance with the Cochrane Handbook for Systematic Reviews of Interventions (http://www.cochranelibrary.com/). All of the procedures of the systematic review and meta-analysis followed the Preferred Reporting Items of Systematic Reviews and Meta-analyses statement. This review was not registered on any platform.

      Literature search

      The keywords “Rehabilitation,” “Physical therapy,” “Burn,” and “Virtual reality” were used to search the PubMed, Cochrane Library, Embase, and Web of Science databases. The publication time of the literature was from the inception of the database to August 2021 (supplemental appendix S1, available online only at http://www.archives-pmr.org/). Additionally, the reference lists from the included articles and relevant reviews were separately assessed to identify additional studies meeting the inclusion criteria of our study.

      Inclusion and exclusion criteria

      The inclusion criteria were as follows: (1) study type: any randomized controlled trials (RCTs), regardless of the use of blinding; (2) study participants: burn patients, regardless of age and sex, no limitation on burn size and depth; (3) study interventions: the use of VR-based rehabilitation exercises in the VR group, and the use of conventional rehabilitation exercises as usual in the control group; no limitation on the joints resulting from burn, no limitation on the start or duration of rehabilitation therapy for the 2 groups of patients, and no limitation on the type of VR and use of analgesics; (4) study outcomes: QOL, work performance, hand function, hand grip and pinch strength, scar thickness, ROM of the tested joint, pain, anxiety, fun, compliance, fatigue, nausea, and realness and presence of VR; and (5) sufficient data: availability of sufficient data for a meta-analysis. The exclusion criteria were (1) studies that compared VR with other types of adjunctive therapies; (2) retrospective studies, reviews, case reports, and conference summaries; (3) inability to convert and apply the statistical data of the original study; (4) non–English-language publications; and (5) duplicate publications or original articles that could not be obtained through various channels.

      Literature screening and data extraction

      Two researchers independently screened the literature based on the inclusion and exclusion criteria and independently extracted the data using a predesigned data extraction table. Any disagreements during the screening were discussed until a consensus was reached. If disagreements persisted after the discussion, a third party was consulted to resolve the disagreement. The extracted data included the basic information of the included trials, such as the first author and the year of publication; the basic characteristics of the study participants, such as the number, age, sex, and burn area of the patients; the information of intervention measures, such as the type of VR used, use of analgesic drugs, and tested joints; the main results of rehabilitation evaluation, such as QOL, work performance, hand function, hand grip and pinch strength, scar thickness, ROM of the tested joint, pain, fun, compliance, and anxiety; the application performance of VR, such as realness and presence; adverse effects of VR intervention, such as fatigue and nausea; and the information of literature quality, such as randomization, allocation concealment, blinding method, and data integrity.

      Literature quality assessment

      Two trained researchers used the Cochrane risk of bias assessment tool to independently evaluate the included RCTs in terms of the following 7 indicators: (1) random sequence generation; (2) allocation concealment; (3) blinding of researchers and participants; (4) blinded evaluation of the study results; (5) data integrity of the study results; (6) selective reporting of the study results; and (7) other biases. Disagreements were discussed until a consensus was reached; if no consensus could be reached, a third party was consulted to resolve the disagreement.

      Statistical methods

      Meta-analysis was performed using R 4.1 software.a Measurement data were expressed as x¯±s. Weighted mean effect sizes were expressed as standardized mean differences (SMDs), and the 95% confidence interval (CI) was calculated. Heterogeneity was assessed using the chi-square tests (test level α=0.10), and the I2 test was used to quantitatively determine the heterogeneity. Values of P≥.1 and I2≤50% indicated homogeneous results and suggested that a fixed-effects model should be used for the meta-analysis; otherwise, the results indicated the presence of heterogeneity in the study results and suggested that a random-effects model should be used for the meta-analysis. Egger's test was used for bias testing; P<.05 indicates the presence of publication bias, and P≥.05 indicates the absence of publication bias. A sensitivity analysis was performed to evaluate the reliability of the results.

      Results

      Literature search and screening results

      From the initial searches of each database, 155 relevant articles were obtained. After reading the titles and abstracts, 31 articles that met the criteria were obtained. After the full text was read, 16 articles
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ.
      Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study.
      • 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.
      • Carrougher GJ
      • Hoffman HG
      • Nakamura D
      • et al.
      The effect of virtual reality on pain and range of motion in adults with burn injuries.
      • 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.
      • Yohannan SK
      • Tufaro PA
      • Hunter H
      • et al.
      The utilization of Nintendo(R) Wii during burn rehabilitation: a pilot study.
      • Schmitt YS
      • Hoffman HG
      • Blough DK
      • et al.
      A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.
      • Parry I
      • Painting L
      • Bagley A
      • et al.
      A pilot prospective randomized control trial comparing exercises using videogame therapy to standard physical therapy: 6 months follow-up.
      • Parker M
      • Delahunty B
      • Heberlein N
      • et al.
      Interactive gaming consoles reduced pain during acute minor burn rehabilitation: a randomized, pilot trial.
      • Soltani M
      • Drever SA
      • Hoffman HG
      • et al.
      Virtual reality analgesia for burn joint flexibility: a randomized controlled trial.
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      • Waked I
      • Eid M.
      Virtual reality: a non-pharmacological complementary strategy facilitating physical therapy procedures for adolescent burned patients.
      • Basha MA
      • Aboelnour NH
      • Aly SM
      • Kamel FH.
      Impact of Kinect-based virtual reality training on physical fitness and quality of life in severely burned children: a monocentric randomized controlled trial.
      • Joo SY
      • Cho YS
      • Lee SY
      • Seok H
      • Seo CH.
      Effects of virtual reality-based rehabilitation on burned hands: a prospective, randomized, single-blind study.
      • Kamel FAH
      • Basha MA.
      Effects of virtual reality and task-oriented training on hand function and activity performance in pediatric hand burns: a randomized controlled trial.
      • Ali RR
      • Selim AO
      • Abdel Ghafar MA
      • Abdelraouf OR
      • Ali OI
      Virtual reality as a pain distractor during physical rehabilitation in pediatric burns.
      that met the inclusion criteria were finally included. Figure 1 shows the detailed literature screening process.
      Fig 1
      Fig 1Results of the screening process and final article selection.

      Basic information of the included trials

      Table 1 summarizes the basic information of the 16 clinical trials included in this study. Seven trials used a within-participants design, and the rest adopted a parallel group design. In terms of location, 8 trials were conducted in the United States, 4 trials were conducted in Egypt, and 1 trial each was conducted in Australia, South Korea, China, and South Africa. The included trials comprised 535 burn patients of all ages; 6 trials included children, 6 included adults, and 4 included mixed age groups. Most of the patients were male (n=400, 74.8%). The burn area of the experimental patients varied significantly, ranging from 0.5%-84.0% total burn surface area. Seven trials used “Snow World” and other high-level simulation videos to distract the patients; 8 trials used interactive VR games as interventions during the rehabilitation exercises; and 1 trial used exoskeleton equipment as an aid. Three trials mainly focused on hand function exercises and recovery, and the remaining trials focused mainly on the large joints of the upper or lower limbs. The burn patients in 9 trials routinely used analgesic drugs during their rehabilitation exercises. The hand function and daily ability assessment scales used in the trials differed, resulting in difficulties in consolidating the meta-analytical data. However, most of the indicators reported in the literature, such as joint ROM, hand grip and pinch strength, pain, fun, and anxiety, could conveniently be submitted to statistical analysis.
      Table 1Characteristics of included studies
      StudyRegionTrial DesignPatients (VR/C)Age (y)Sex (M/F)Mean TBSA (%)Intervention (VR)AnalgesicsTrial Sections (VR/C)JointOutcomes
      Hoffman et al
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ.
      Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study.
      USWithin-participants1219-4711/121Spider WorldY12/12NRSensory pain/cognitive pain/affective pain/bothersome/anxiety/nausea/

      realness/presence (VAS)
      Hoffman et al
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ
      • Sharar SR.
      Effectiveness of virtual reality-based pain control with multiple treatments.
      USWithin-participants79-326/13-60Spider/Snow WorldY21/21NRMaximum ROM (goniometry); sensory pain/cognitive pain/affective pain/unpleasant/nausea/realness/presence (VAS)
      Sharar et al
      • 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.
      USWithin-participants886-6574/141.5-60Snow WorldY146/146NRSensory pain/cognitive pain/affective pain/fun/nausea/realness/presence (VAS)
      Carrougher et al
      • Carrougher GJ
      • Hoffman HG
      • Nakamura D
      • et al.
      The effect of virtual reality on pain and range of motion in adults with burn injuries.
      USWithin-participants3935±1135/418.1±12.7Snow WorldY39/39Upper/lower limbROM (goniometry);sensory pain/cognitive pain/affective pain/nausea/realness/

      Presence (VAS)
      Morris et al
      • 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.
      South AfricaWithin-participants1125-548/32-55Chicken Little PC gameY11/11NRPain/anxiety (VAS)
      Yohannan et al
      • Yohannan SK
      • Tufaro PA
      • Hunter H
      • et al.
      The utilization of Nintendo(R) Wii during burn rehabilitation: a pilot study.
      USParallel group11/1237.1±13.213/106.8 ±6.1Wii games (sports/fit)N11/12Upper/

      lower limb
      ROM (goniometry);pain/anxiety/fun/

      realness/presence(VAS); function (Valpar 9 Whole Body Range of Motion Work Sample Test, Transfer 4)
      Schmitt et al
      • Schmitt YS
      • Hoffman HG
      • Blough DK
      • et al.
      A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.
      USWithin-participants5412.0±3.944/101.5-50Snow worldY54/54NRMaximum ROM (goniometry); sensory pain/cognitive pain/affective pain/fun/nausea/realness/presence (VAS)
      Parry et al
      • Parry I
      • Painting L
      • Bagley A
      • et al.
      A pilot prospective randomized control trial comparing exercises using videogame therapy to standard physical therapy: 6 months follow-up.
      USParallel group9/811.4±4.414/347.8±23.2PE videogamesN9/8Shoulder/

      elbow
      Planar ROM (goniometry);functional ROM (3-D motion analysis); sensory pain/fun/engagement/perceived exertion (VAS); compliance (compliance calendars); heart rate (heart rate monitor)
      Parker et al
      • Parker M
      • Delahunty B
      • Heberlein N
      • et al.
      Interactive gaming consoles reduced pain during acute minor burn rehabilitation: a randomized, pilot trial.
      AustraliaParallel group12/1016-5917/50.5-10Wii games (sports/fit)N12/10Upper/lower limbROM (goniometry); pain/anxiety (VAS)
      Soltani et al
      • Soltani M
      • Drever SA
      • Hoffman HG
      • et al.
      Virtual reality analgesia for burn joint flexibility: a randomized controlled trial.
      USWithin-participants3915-6636/314Snow WorldY39/39Upper limbROM (goniometry); sensory pain/cognitive pain/affective pain/fun (VAS)
      Wu et al
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      ChinaParallel group8/822.8± 3.56/1063.1±14.8LMC gamesN8/8HandPsychological and environmental problems after burns (BSHS-B); physical function; (QuickDASH); daily function (iADL, Barthel Index); pinch and grip
      Kilogram for grip and pinch.
      (dynamometer); ROM of thumb interphalangeal joint (goniometry); scar
      Millimeter for scar thickness.
      (ultrasonography)
      Waked et al
      • Waked I
      • Eid M.
      Virtual reality: a non-pharmacological complementary strategy facilitating physical therapy procedures for adolescent burned patients.
      EgyptParallel group28/2813.9± 2.031/2526.7± 6.23D videogameN28/28Lower limbROM (goniometer); pain (APPT)
      Basha et al
      • Basha MA
      • Aboelnour NH
      • Aly SM
      • Kamel FH.
      Impact of Kinect-based virtual reality training on physical fitness and quality of life in severely burned children: a monocentric randomized controlled trial.
      EgyptParallel group20/2013.0± 1.424/1651±5Xbox Kinect GamesN20/20NRCardiopulmonary fitness (Vo2peak)/muscle peak torque (Biodex dynamometer)/whole body and regional lean mass (dual-energy x-ray absorptiometry)/health-related quality of life (PedsQL)/enjoyment (Physical Activity Enjoyment Scale)/adherence rate
      Joo et al
      • Joo SY
      • Cho YS
      • Lee SY
      • Seok H
      • Seo CH.
      Effects of virtual reality-based rehabilitation on burned hands: a prospective, randomized, single-blind study.
      KoreaParallel group28/2944.9± 11.854/327.5 ±20.3Rapeal Smart GloveY28/29Hand/ twistPerformance speed of standardized task (JTT);
      Kilogram for grip and pinch.
      pinch and grip (dynamometer);perception of hand function (MHQ);fine hand motor functions and dexterity (PPT)
      Kamel et al
      • Kamel FAH
      • Basha MA.
      Effects of virtual reality and task-oriented training on hand function and activity performance in pediatric hand burns: a randomized controlled trial.
      EgyptParallel group17/1510.9±1.714/2021.1 ±3.7Xbox Kinect GamesN17/15HandHand Function (JTT, DHI)/daily function (COPM)/ROM (goniometry)/pinch and grip
      Kilogram for grip and pinch.
      (dynamometer)
      Ali et al
      • Ali RR
      • Selim AO
      • Abdel Ghafar MA
      • Abdelraouf OR
      • Ali OI
      Virtual reality as a pain distractor during physical rehabilitation in pediatric burns.
      EgyptParallel group11/1113.2±1.813/922.0 ±2.9VR videosY11/11Upper/lower limbROM (goniometry); pain (VAS)
      Abbreviations: APPT, Adolescent Pediatric Pain Tool; BSHS-B, Burn-Specific Health Scale-Brief; C, control; COPM, Canadian Occupational Performance Measure; DHI, Duruoz Hand Index; F, female; iADL, instrumental activities of daily living; JTT, Jebsen-Taylor Test of Hand Function; LMC, Leap Motion Controller; M, male; MHQ, Michigan Hand Outcomes Questionnaire; N, not use of analgesics; NR, no report; PC, personal computer; PE, PlayStation II Eye Toy; PedsQL, Pediatric Quality of Life Inventory; PPT, Purdue Pegboard Test; QuickDASH, Quick Disabilities of the Arm, Shoulder, and Hand; ROM, range of motion(degrees); TBSA, total body surface area; 3-D, 3-dimensional; VAS, visual analog scale (0-10); Y, routine use of analgesics; Vo2peak, peak oxygen consumption.
      low asterisk Kilogram for grip and pinch.
      Millimeter for scar thickness.

      Bias risk assessment results

      In terms of the evaluation of study quality (table 2), the random grouping of the participants was described in detail in 12 trials, and the grouping method was not described in the other trials. Only 2 trials explicitly implemented allocation concealment. Because of the particularities of the intervention measures, it was impossible to blind the experimental participants and staff. Only 3 trials blinded the evaluators to the outcomes, and most of the trials did not specify relevant information. Most of the trials provided complete data, and even when there were missing data in individual trials, this did not affect the analysis of the results. In 4 trials, partial data were available. All trials had a low risk of selective reporting and other biases. In total (fig 2), the risks of bias regarding randomization, data integrity, selective reporting, and other bias were low. The risks of bias for allocation concealment and blinding of outcome evaluation were unclear. The risk of bias for blinding of researchers and participants was high. In summary, the overall risk of bias for all included trials was low to moderate.
      Table 2Risk of bias assessment of randomized controlled trial.
      StudyRandom Sequence GenerationAllocation ConcealmentBlinding of Participants and PersonnelBlinding of Outcome AssessmentIncomplete Outcome DataSelective ReportingOther Bias
      Hoffman et al
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ.
      Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study.
      ???+++
      Hoffman et al
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ
      • Sharar SR.
      Effectiveness of virtual reality-based pain control with multiple treatments.
      ???++
      Sharar et al
      • 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.
      +??+++
      Carrougher et al
      • Carrougher GJ
      • Hoffman HG
      • Nakamura D
      • et al.
      The effect of virtual reality on pain and range of motion in adults with burn injuries.
      ???+++
      Morris et al
      • 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.
      +?++++
      Yohannan et al
      • Yohannan SK
      • Tufaro PA
      • Hunter H
      • et al.
      The utilization of Nintendo(R) Wii during burn rehabilitation: a pilot study.
      ?++++
      Schmitt et al
      • Schmitt YS
      • Hoffman HG
      • Blough DK
      • et al.
      A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.
      +??++
      Parry et al
      • Parry I
      • Painting L
      • Bagley A
      • et al.
      A pilot prospective randomized control trial comparing exercises using videogame therapy to standard physical therapy: 6 months follow-up.
      +?+++
      Parker et al
      • Parker M
      • Delahunty B
      • Heberlein N
      • et al.
      Interactive gaming consoles reduced pain during acute minor burn rehabilitation: a randomized, pilot trial.
      +??+++
      Soltani et al
      • Soltani M
      • Drever SA
      • Hoffman HG
      • et al.
      Virtual reality analgesia for burn joint flexibility: a randomized controlled trial.
      ++?+++
      Wu et al
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      +?++++
      Waked et al
      • Waked I
      • Eid M.
      Virtual reality: a non-pharmacological complementary strategy facilitating physical therapy procedures for adolescent burned patients.
      +?+++
      Basha et al
      • Basha MA
      • Aboelnour NH
      • Aly SM
      • Kamel FH.
      Impact of Kinect-based virtual reality training on physical fitness and quality of life in severely burned children: a monocentric randomized controlled trial.
      +??++
      Joo et al
      • Joo SY
      • Cho YS
      • Lee SY
      • Seok H
      • Seo CH.
      Effects of virtual reality-based rehabilitation on burned hands: a prospective, randomized, single-blind study.
      ++?++
      Kamel et al
      • Kamel FAH
      • Basha MA.
      Effects of virtual reality and task-oriented training on hand function and activity performance in pediatric hand burns: a randomized controlled trial.
      +??+++
      Ali et al
      • Ali RR
      • Selim AO
      • Abdel Ghafar MA
      • Abdelraouf OR
      • Ali OI
      Virtual reality as a pain distractor during physical rehabilitation in pediatric burns.
      +??+++
      NOTE. “+” indicates low risk of bias; “−“ indicates high risk of bias; and “?” indicates unclear or unknown risk of bias.
      Fig 2
      Fig 2Risk of bias graph: authors’ judgments about each item of the risk of bias assessment presented as percentages among all included studies.

      System evaluation and meta-analysis results

      The included trials used a variety of rehabilitation evaluation methods; particularly common were evaluations of self-care ability, professional ability, and hand function. These data could not be effectively synthesized and analyzed. Therefore, a descriptive summary of these results was provided. Most of the studies showed that compared with those of the control group, the physical function, QOL, and work performance of burn patients who underwent VR-based rehabilitation were significantly improved. Wu et al used the Burn-Specific Health Scale-Brief, Quick Disabilities of the Arm, Shoulder, and Hand, instrumental activities of daily living, and Barthel Index to evaluate hand function. They found that compared with the control group, the burn patients in the VR group showed significant improvement in hand function.
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      Basha et al showed that compared with the control group, burn patients in the VR group showed significant improvements in heart and lung function, related muscle strength, and systemic or local lean mass after rehabilitation. In addition, the QOL of patients in the VR group was also significantly improved as evaluated by the Health-Related Quality of Life scale.
      • Basha MA
      • Aboelnour NH
      • Aly SM
      • Kamel FH.
      Impact of Kinect-based virtual reality training on physical fitness and quality of life in severely burned children: a monocentric randomized controlled trial.
      Joo et al used the Jebsen-Taylor Test of Hand Function, Michigan Hand Outcomes Questionnaire, and Purdue Pegboard Test to comprehensively evaluate various hand functions, and the results showed that compared with the control group, the burn patients in the VR group showed significant improvement in picking up small objects and completing daily life and work activities after the rehabilitation exercises.
      • Joo SY
      • Cho YS
      • Lee SY
      • Seok H
      • Seo CH.
      Effects of virtual reality-based rehabilitation on burned hands: a prospective, randomized, single-blind study.
      Kamel et al showed that there were significant differences in the Jebsen-Taylor Test of Hand Function and Duruoz Hand Index hand function scores, satisfaction scores on the Canadian Occupational Performance Measure, and performance scores between the 2 groups, with the VR group achieving higher scores.
      • Kamel FAH
      • Basha MA.
      Effects of virtual reality and task-oriented training on hand function and activity performance in pediatric hand burns: a randomized controlled trial.
      Only 1 trial showed that VR-based rehabilitation exercises did not offer any advantages for burn patients. Sharar et al used the Valpar 9 Whole Body Range of Motion Work Sample Test, Transfer 4, to assess the work and self-care abilities of patients after rehabilitation and found no significant difference between the 2 groups.
      • 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.

      Range of motion

      Most studies used ROM gain, that is, the gain in joint activity after rehabilitation exercises, as the primary outcome. Six trials reported the average ROM gain of the tested joints, and there was significant heterogeneity among their results (P<.01, I2=73.1%). Therefore, a random-effects model was used for the meta-analysis. The results showed that the average ROM gain of all joints was significantly higher in the burn patients in the VR group than in the control group, and the SMD was 0.72 (95% CI, 0.37-1.08, P<.01), as shown in fig 3.
      Fig 3
      Fig 3Forest plot of ROM comparing the adjunctive VR group with the control group.

      Hand grip and pinch strength

      A total of 3 trials reported the hand grip and pinch strength results. In terms of grip strength, the heterogeneity among the 3 trials was relatively large (P=.04, I2=68.3%); therefore, a random-effects model was used for the meta-analysis. The results showed that compared with that of the control group, the hand grip strength of the burn patients in the VR group was not significantly increased, and the SMD was 0.50 (95% CI, −0.32 to 1.32, P=.23), as shown in fig 4. In terms of pinch strength, the heterogeneity among the 3 trials was large (P<.01, I2=92.7%); therefore, a random-effects model was used for the meta-analysis. The results showed that after rehabilitation, the hand pinch strength of the burn patients in the VR group was not significantly greater than that of the control group, and the SMD was 1.22 (95% CI, −0.02 to 2.47, P=.05), as shown in fig 5.
      Fig 4
      Fig 4Forest plot of grip strength comparing the adjunctive VR group with the control group.
      Fig 5
      Fig 5Forest plot of pinch strength comparing the adjunctive VR group with the control group.

      Pain

      The included trials comprehensively and quantitatively evaluated the pain that the patients experienced during rehabilitation from the 3 dimensions of sensation, emotion, and cognition. Eleven trials provided quantitative data on the sensory component of pain, that is, pain intensity. Because of the considerable heterogeneity among these trials (P<.01, I2 = 88.0%), a random-effects model was used for the meta-analysis, and the results showed that VR-based rehabilitation therapy significantly reduced burn patients’ pain intensity during treatment. The SMD was −1.26 (95% CI, −1.96 to −0.55, P<.01), as shown in fig 6. A total of 6 trials quantified the emotional and cognitive components of pain. For these 2 outcomes, there was considerable heterogeneity among the 6 trials (P<.01, I2=72.1%; P<.01, I2=78.7%). A meta-analysis was performed using the random-effects model. The results showed that the burn patients in the VR group had significantly fewer unpleasant feelings and less time to think about pain during rehabilitation than the control group, with SMDs of −0.71 (95% CI, −1.09 to −0.33, P<.01) and −1.01 (95% CI, −1.50 to −0.52, P<.01), respectively, as shown in figs 7 and 8.
      Fig 6
      Fig 6Forest plot of pain intensity scores comparing the adjunctive VR group with the control group.
      Fig 7
      Fig 7Forest plot of unpleasantness scores comparing the adjunctive VR group with the control group.
      Fig 8
      Fig 8Forest plot of time spent thinking about pain comparing the adjunctive VR group with the control group.

      Fun and anxiety

      A total of 4 trials reported the fun scores of burn patients in rehabilitation. Because of the significant heterogeneity among these trials (P<.01, I2= 0.3%), a random-effects model was used for the meta-analysis. The results showed that VR-based burn rehabilitation therapy was more fun than conventional rehabilitation activities, and the SMD was 2.38 (95% CI, 0.66-4.09, P=.01), as shown in fig 9. The burn patients’ anxiety scores during rehabilitation were reported in 5 trials, and the heterogeneity among them was significant (P=.02, I2=66.8%); therefore, a random-effects model was used for the meta-analysis. The results showed that the burn patients in the VR group had significantly less anxiety than those in the control group during rehabilitation, and the SMD was −0.73 (95% CI, −1.35 to −0.11, P=.03), as shown in fig 10.
      Fig 9
      Fig 9Forest plot of fun scores comparing the adjunctive VR group with the control group.
      Fig 10
      Fig 10Forest plot of anxiety scores comparing the adjunctive VR group with the control group.

      Application performance of VR

      Five trials quantitatively scored the realness and presence of VR as well as the adverse effects associated with it. The results of the literature analysis showed that patients gave high scores for the realness and presence (2.56-5.82 and 3.51-6.38, respectively) of VR used during rehabilitation therapy; the associated nausea and discomfort scores were generally low, ranging from 0-1.57.

      Other results

      The results of 2 trials showed that the proportion of burn patients in the VR group who participated in and completed rehabilitation was 90%-96%, which was higher than that in the control group (85%-93%),
      • Parry I
      • Painting L
      • Bagley A
      • et al.
      A pilot prospective randomized control trial comparing exercises using videogame therapy to standard physical therapy: 6 months follow-up.
      ,
      • Basha MA
      • Aboelnour NH
      • Aly SM
      • Kamel FH.
      Impact of Kinect-based virtual reality training on physical fitness and quality of life in severely burned children: a monocentric randomized controlled trial.
      indicating that the patients in the VR group had better treatment compliance. Parry et al evaluated patients’ fatigue during rehabilitation and found that there was no significant difference in the scores of the 2 groups (3.9 vs 3.2, P=.41).
      • Parry I
      • Painting L
      • Bagley A
      • et al.
      A pilot prospective randomized control trial comparing exercises using videogame therapy to standard physical therapy: 6 months follow-up.
      Wu et al measured the scar thickness on the dorsal side of the wrist and the back of the hand in patients before and after rehabilitation and found that the patients of VR group had significantly thinner scars on the back of the hand after treatment (4.64 vs 4.08, P=.01), but there was no such change in the scars on the dorsal side of the wrist (4.38 vs 4.15, P=.23).
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.

      Sensitivity analysis and publication bias

      The sensitivity analysis of each outcome showed that the results of the meta-analysis for hand grip and pinch strength and anxiety were not robust. Four trials contributed to this lack of robustness
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ.
      Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study.
      ,
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ
      • Sharar SR.
      Effectiveness of virtual reality-based pain control with multiple treatments.
      ,
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      ,
      • Kamel FAH
      • Basha MA.
      Effects of virtual reality and task-oriented training on hand function and activity performance in pediatric hand burns: a randomized controlled trial.
      ; therefore, these results should be carefully interpreted (supplemental appendix S2, available online only at http://www.archives-pmr.org/). Egger's test results showed that there was no publication bias for the outcomes such as average ROM gain, hand grip and pinch strength, fun, and anxiety (P=.96, .78, .99, .16, .15, respectively). But, for the 3 components of pain, that is, sensation, emotion, and cognition, Egger's regression test showed some evidence of publication bias (P<.05).

      Discussion

      Our review and meta-analysis found that VR-based burn rehabilitation had better effect in improving the QOL and work performance of burn patients, increasing ROM of joints and fun scores, and receding pain and anxiety, and it did so without obvious adverse effects.
      Dysfunction of the affected joints after a burn has a very serious effect on patients’ lives and work, with loss of hand function having an especially profound effect.
      • Johnson SP
      • Chung KC.
      Outcomes assessment after hand burns.
      Three trials used multiple hand function assessment scales and reached a consistent conclusion, that is, that VR-based hand and wrist rehabilitation therapy has significant effects,
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      ,
      • Joo SY
      • Cho YS
      • Lee SY
      • Seok H
      • Seo CH.
      Effects of virtual reality-based rehabilitation on burned hands: a prospective, randomized, single-blind study.
      ,
      • Kamel FAH
      • Basha MA.
      Effects of virtual reality and task-oriented training on hand function and activity performance in pediatric hand burns: a randomized controlled trial.
      which is the same as the results that were obtained for a VR intervention for nontraumatic hand dysfunction rehabilitation in patients with stroke.
      • Karamians R
      • Proffitt R
      • Kline D
      • Gauthier LV.
      Effectiveness of virtual reality- and gaming-based interventions for upper extremity rehabilitation poststroke: a meta-analysis.
      The VR system can simulate various daily scenes, requiring patients to complete various activities accurately, appropriately, and within a reasonable time while providing feedback.
      • Pereira MF
      • Prahm C
      • Kolbenschlag J
      • Oliveira E
      • Rodrigues NF.
      Application of AR and VR in hand rehabilitation: a systematic review.
      • Hoffman HG
      • Boe DA
      • Rombokas E
      • et al.
      Virtual reality hand therapy: a new tool for nonopioid analgesia for acute procedural pain, hand rehabilitation, and VR embodiment therapy for phantom limb pain.
      , These targeted and adjustable individualized rehabilitation exercises significantly improve various physical functions, in addition to the QOL and work performance of burn patients. Surprisingly, VR intervention has a positive effect on the thickness and texture of scars on the hand.
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      We supposed that it mainly benefited from scar stretching caused by more active hand movements in the VR group. However, hand grip and pinch strength, which are important measures of hand function, did not significantly improve. The reason is that the hand function exercise in the VR intervention focused on the stability and flexibility of the proximal muscles of the upper limbs and could not provide effective strength training.
      • Pereira MF
      • Prahm C
      • Kolbenschlag J
      • Oliveira E
      • Rodrigues NF.
      Application of AR and VR in hand rehabilitation: a systematic review.
      Only 3 trials that examined this outcome were included in this study, and they all had small sample sizes; therefore, the results may be unreliable. The sensitivity analysis results also illustrated this point.
      Most of the studies used ROM gain, which is closely related to postburn scar formation and joint contracture, as an important outcome of the effect of rehabilitation therapy.
      • Oosterwijk AM
      • Mouton LJ
      • Schouten H
      • Disseldorp LM
      • van der Schans CP
      • Nieuwenhuis MK.
      Prevalence of scar contractures after burn: a systematic review.
      In theory, better pain management often means better rehabilitation effects,
      • Luo H
      • Cao C
      • Zhong J
      • Chen J
      • Cen Y.
      Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: a systematic review and meta-analysis of randomized controlled trials.
      and this study confirmed this point. VR technology alleviated pain during rehabilitation therapy and significantly increased the ROM gain of the tested joints. However, 4 trials showed that compared with the control group, the group that received VR-based rehabilitation exercise did not have significant improvements in ROM.
      • Carrougher GJ
      • Hoffman HG
      • Nakamura D
      • et al.
      The effect of virtual reality on pain and range of motion in adults with burn injuries.
      ,
      • Yohannan SK
      • Tufaro PA
      • Hunter H
      • et al.
      The utilization of Nintendo(R) Wii during burn rehabilitation: a pilot study.
      ,
      • Schmitt YS
      • Hoffman HG
      • Blough DK
      • et al.
      A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.
      ,
      • Soltani M
      • Drever SA
      • Hoffman HG
      • et al.
      Virtual reality analgesia for burn joint flexibility: a randomized controlled trial.
      Previous systematic reviews have suggested that ROM gain is a measurement indicator favoring long-term rehabilitation.
      • Luo H
      • Cao C
      • Zhong J
      • Chen J
      • Cen Y.
      Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: a systematic review and meta-analysis of randomized controlled trials.
      In the above trials, neither short-term VR intervention nor several courses of VR could fully demonstrate positive effects.
      • Indovina P
      • Barone D
      • Gallo L
      • Chirico A
      • De Pietro G
      • Giordano A.
      Virtual reality as a distraction intervention to relieve pain and distress during medical procedures: a comprehensive literature review.
      ,
      • Luo H
      • Cao C
      • Zhong J
      • Chen J
      • Cen Y.
      Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: a systematic review and meta-analysis of randomized controlled trials.
      We believe that the duration and frequency of rehabilitation were not the main reasons for the poor effect of VR intervention and that the VR device and type of VR might have been key factors. The VR intervention technique used in the above 4 trials was generally simple and was based on the “Snow World” game first used by Hoffman et al.
      • Hoffman HG
      • Doctor JN
      • Patterson DR
      • Carrougher GJ
      • Furness TA.
      Virtual reality as an adjunctive pain control during burn wound care in adolescent patients.
      The use of VR videos with rich content,
      • Ali RR
      • Selim AO
      • Abdel Ghafar MA
      • Abdelraouf OR
      • Ali OI
      Virtual reality as a pain distractor during physical rehabilitation in pediatric burns.
      interactive VR games,
      • Parry I
      • Painting L
      • Bagley A
      • et al.
      A pilot prospective randomized control trial comparing exercises using videogame therapy to standard physical therapy: 6 months follow-up.
      ,
      • Parker M
      • Delahunty B
      • Heberlein N
      • et al.
      Interactive gaming consoles reduced pain during acute minor burn rehabilitation: a randomized, pilot trial.
      ,
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      ,
      • Waked I
      • Eid M.
      Virtual reality: a non-pharmacological complementary strategy facilitating physical therapy procedures for adolescent burned patients.
      ,
      • Kamel FAH
      • Basha MA.
      Effects of virtual reality and task-oriented training on hand function and activity performance in pediatric hand burns: a randomized controlled trial.
      and high-performance VR systems with wearable devices
      • Joo SY
      • Cho YS
      • Lee SY
      • Seok H
      • Seo CH.
      Effects of virtual reality-based rehabilitation on burned hands: a prospective, randomized, single-blind study.
      significantly increased ROM gain. In addition, as the duration of rehabilitation increases, when the activity of the tested joint is close to normal or when severe contractures are present, rehabilitation exercises no longer bring ROM gains. Therefore, final rehabilitation data are not ideal for evaluating the effect of long-term VR intervention, as was strongly demonstrated by Parry et al, whose experimental results showed that the ROM gain in the upper limb joints, such as the shoulder and elbow, of burn patients in the VR group was significantly greater than that of burn patients in the control group at 3 weeks, but there was no significant difference in gain after 6 months.
      • Parry I
      • Painting L
      • Bagley A
      • et al.
      A pilot prospective randomized control trial comparing exercises using videogame therapy to standard physical therapy: 6 months follow-up.
      Several previous systematic reviews have shown that VR technology was a good tool for the management of burn pain, but most reviews only provided general conclusions and did not specifically describe its use for burn rehabilitation
      • Indovina P
      • Barone D
      • Gallo L
      • Chirico A
      • De Pietro G
      • Giordano A.
      Virtual reality as a distraction intervention to relieve pain and distress during medical procedures: a comprehensive literature review.
      ,
      • Scapin S
      • Echevarria-Guanilo ME
      • Boeira Fuculo Junior PR
      • Goncalves N
      • Rocha PK
      • Coimbra R
      Virtual reality in the treatment of burn patients: a systematic review.
      ,
      • Luo H
      • Cao C
      • Zhong J
      • Chen J
      • Cen Y.
      Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: a systematic review and meta-analysis of randomized controlled trials.
      ,
      • Scheffler M
      • Koranyi S
      • Meissner W
      • Strauss B
      • Rosendahl J.
      Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: a systematic review and meta-analysis of randomized controlled trials.
      ,
      • Georgescu R
      • Fodor LA
      • Dobrean A
      • Cristea IA.
      Psychological interventions using virtual reality for pain associated with medical procedures: a systematic review and meta-analysis.
      ; the others presented only descriptive summaries or discussions.
      • Hoffman HG
      • Boe DA
      • Rombokas E
      • et al.
      Virtual reality hand therapy: a new tool for nonopioid analgesia for acute procedural pain, hand rehabilitation, and VR embodiment therapy for phantom limb pain.
      ,
      • Haik J
      • Tessone A
      • Nota A
      • et al.
      The use of video capture virtual reality in burn rehabilitation: the possibilities.
      Apparently, this study was different than before. We specifically and objectively confirmed that compared with the control treatment, VR-based burn rehabilitation effectively reduced pain intensity, pain unpleasantness, and time spent thinking about pain, indicating that VR technology plays a significant role in pain management during burn rehabilitation. Pain during rehabilitation therapy is operative pain and is an important factor in the patient's participation in rehabilitation therapy.
      • Morgan M
      • Deuis JR
      • Frosig-Jorgensen M
      • et al.
      Burn pain: a systematic and critical review of epidemiology, pathophysiology, and treatment.
      Drug intervention alone is not effective for this type of pain, and the long-term use of large doses of analgesics easily causes adverse effects such as vomiting, constipation, respiratory depression, and drug dependence.
      • Khademi H
      • Kamangar F
      • Brennan P
      • Malekzadeh R.
      Opioid therapy and its side effects: a review.
      Based on the gate control theory of pain, VR can draw the patient's attention to the simulated environment. Because the central nervous system only processes a limited amount of information within a certain period of time, this distraction can weaken the patient's perception of pain.
      • Gold JI
      • Belmont KA
      • Thomas DA.
      The neurobiology of virtual reality pain attenuation.
      Up to this point, the analgesic properties of VR had been mostly attributed to its powerful distractive capacity. As an important nondrug analgesia method, VR generally has no adverse effects and is noninvasive and nonaddictive.
      • Scheffler M
      • Koranyi S
      • Meissner W
      • Strauss B
      • Rosendahl J.
      Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: a systematic review and meta-analysis of randomized controlled trials.
      In addition, during burn wound debridement and dressing changes, the analgesic effect of VR is not lost or reduced over time.
      • Faber AW
      • Patterson DR
      • Bremer M.
      Repeated use of immersive virtual reality therapy to control pain during wound dressing changes in pediatric and adult burn patients.
      ,
      • Hoffman H
      • Patterson D
      • Carrougher J
      • Nakamura D
      • Moore M
      • Garcia-Palacios A.
      The effectiveness of virtual reality pain control with multiple treatments of longer durations: a case study.
      For patients with high initial pain scores, the analgesic effect of VR seems to be more substantial.
      • Maani CV
      • Hoffman HG
      • Morrow M
      • et al.
      Virtual reality pain control during burn wound debridement of combat-related burn injuries using robot-like arm mounted VR goggles.
      We believe that these conclusions are also valid when VR is applied for pain management during burn rehabilitation. For the 3 outcomes of pain that were considered in this study, there was significant reporting bias; however, the sensitivity analysis did not find a specific source of heterogeneity. We believe that there are 3 possible reasons for the publication bias, that is, (1) the objective heterogeneity of the VR interventions used in the trials; (2) analgesic drug use was a potential confounder; (3) the difference in the scale and design of the visual analog scale used to quantify pain.
      Addressing mental distress such as anxiety during burn rehabilitation is very important because they seriously affect patient compliance.
      • Lohse K
      • Shirzad N
      • Verster A
      • Hodges N
      • et al.
      Van der Loos HF. Video games and rehabilitation: using design principles to enhance engagement in physical therapy.
      Fun can be considered synonymous with a positive emotional state. Consistent with almost all similar studies, this study revealed that the use of VR during burn rehabilitation provided strong and lasting enjoyment for the patient.
      • 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.
      ,
      • Schmitt YS
      • Hoffman HG
      • Blough DK
      • et al.
      A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.
      ,
      • Soltani M
      • Drever SA
      • Hoffman HG
      • et al.
      Virtual reality analgesia for burn joint flexibility: a randomized controlled trial.
      ,
      • Basha MA
      • Aboelnour NH
      • Aly SM
      • Kamel FH.
      Impact of Kinect-based virtual reality training on physical fitness and quality of life in severely burned children: a monocentric randomized controlled trial.
      At the same time, this study proved that VR effectively reduced the anxiety caused by rehabilitation therapy because less pain and more fun could lead to less anxiety and better compliance.
      • Zis P
      • Varrassi G
      • Vadalouka A
      • Paladini A.
      Psychological aspects and quality of life in chronic pain.
      However, the sensitivity analysis suggested that the reduction in anxiety might not be reliable, and this uncertainty was caused by 2 of the included trials.
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ.
      Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study.
      ,
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ
      • Sharar SR.
      Effectiveness of virtual reality-based pain control with multiple treatments.
      The reason may be that “bothersomeness,” one of the primary outcomes used in these 2 trials, is not strictly a measure of anxiety. For patients who were prone to anxiety, the distraction caused by VR was significantly reduced, and its analgesic effect was greatly reduced.
      • Jeffs D
      • Dorman D
      • Brown S
      Effect of virtual reality on adolescent pain during burn wound care.
      The emotional management of patients who are prone to anxiety during burn treatment should be the focus of future study.
      The VR systems used in the included trials were quite different. Early studies used “realness” and “presence” scores to quantify patients’ VR experience
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ.
      Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study.
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ
      • Sharar SR.
      Effectiveness of virtual reality-based pain control with multiple treatments.
      • 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.
      • Carrougher GJ
      • Hoffman HG
      • Nakamura D
      • et al.
      The effect of virtual reality on pain and range of motion in adults with burn injuries.
      ,
      • Schmitt YS
      • Hoffman HG
      • Blough DK
      • et al.
      A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.
      and believed that a good experience was the basis for VR's effect.
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ.
      Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study.
      ,
      • Hoffman HG
      • Patterson DR
      • Seibel E
      • Soltani M
      • Jewett-Leahy L
      • Sharar SR.
      • et al.
      Virtual reality pain control during burn wound debridement in the hydrotank.
      ,
      • Hoffman HG
      • Sharar SR
      • Coda B
      • et al.
      Manipulating presence influences the magnitude of virtual reality analgesia.
      But these studies using immersive VR did not include more interactive training. Some gamified VR seemed to help motivate the patient to perform therapeutic exercises.
      • Yohannan SK
      • Tufaro PA
      • Hunter H
      • et al.
      The utilization of Nintendo(R) Wii during burn rehabilitation: a pilot study.
      ,
      • Parker M
      • Delahunty B
      • Heberlein N
      • et al.
      Interactive gaming consoles reduced pain during acute minor burn rehabilitation: a randomized, pilot trial.
      ,
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      ,
      • Basha MA
      • Aboelnour NH
      • Aly SM
      • Kamel FH.
      Impact of Kinect-based virtual reality training on physical fitness and quality of life in severely burned children: a monocentric randomized controlled trial.
      Overall, regardless of whether VR took the form of videos or games, the burn patients included in the trials gave them high scores for “realness” and “presence.” Interestingly, 1 trial reported that patients with a presence score >3.4 exhibited better pain reduction during burn wound debridement than those with a presence score <3.4.
      • Hoffman HG
      • Patterson DR
      • Seibel E
      • Soltani M
      • Jewett-Leahy L
      • Sharar SR.
      • et al.
      Virtual reality pain control during burn wound debridement in the hydrotank.
      Therefore, there may be a correlation between the presence score and pain reduction efficacy of VR. Similarly, this correlation also exists in the process of burn rehabilitation. This finding prompted us to improve the efficacy of VR by using better-quality VR products. Furthermore, a RCT noted that the “realness” and “presence” scores given by minors were significantly higher than those given by adults, but there was no corresponding difference in the analgesic effect of VR,
      • 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.
      which indicates that the VR experience is closely related to age and that VR-based rehabilitation seems to be more suitable for younger burn patients. The continuous improvements in VR technology have led to the creation of a complete set of technical criteria for commercially available VR devices and software.
      • Brennesholtz MS.
      3-1: Invited paper: VR standards and guidelines.
      Therefore, several recent studies did not evaluate the VR experiences of the participants.
      • Wu YT
      • Chen KH
      • Ban SL
      • Tung KY
      • Chen LR.
      Evaluation of leap motion control for hand rehabilitation in burn patients: an experience in the dust explosion disaster in Formosa Fun Coast.
      • Waked I
      • Eid M.
      Virtual reality: a non-pharmacological complementary strategy facilitating physical therapy procedures for adolescent burned patients.
      • Basha MA
      • Aboelnour NH
      • Aly SM
      • Kamel FH.
      Impact of Kinect-based virtual reality training on physical fitness and quality of life in severely burned children: a monocentric randomized controlled trial.
      • Joo SY
      • Cho YS
      • Lee SY
      • Seok H
      • Seo CH.
      Effects of virtual reality-based rehabilitation on burned hands: a prospective, randomized, single-blind study.
      • Kamel FAH
      • Basha MA.
      Effects of virtual reality and task-oriented training on hand function and activity performance in pediatric hand burns: a randomized controlled trial.
      • Ali RR
      • Selim AO
      • Abdel Ghafar MA
      • Abdelraouf OR
      • Ali OI
      Virtual reality as a pain distractor during physical rehabilitation in pediatric burns.
      However, the VR experience for special populations, such as burn patients, still needs to be further studied and elucidated.
      Five trials evaluated the adverse effects of the VR intervention, such as nausea. Overall, nausea was rare or extremely mild. In these 5 trials, the researchers evaluated only the incidence of nausea during the VR intervention (VR+standard analgesia) and did not perform a comparative analysis with the control group (standard analgesia).
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ.
      Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study.
      • Hoffman HG
      • Patterson DR
      • Carrougher GJ
      • Sharar SR.
      Effectiveness of virtual reality-based pain control with multiple treatments.
      • 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.
      • Carrougher GJ
      • Hoffman HG
      • Nakamura D
      • et al.
      The effect of virtual reality on pain and range of motion in adults with burn injuries.
      ,
      • Schmitt YS
      • Hoffman HG
      • Blough DK
      • et al.
      A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.
      Therefore, this adverse reaction cannot be completely attributed to VR and may also be an adverse effect of opioid analgesics. Another study confirmed that VR intervention did not cause additional physical and mental fatigue in participants.
      • Parry I
      • Painting L
      • Bagley A
      • et al.
      A pilot prospective randomized control trial comparing exercises using videogame therapy to standard physical therapy: 6 months follow-up.
      In addition, no reports on potential eye fatigue, disorientation, headache, or other adverse effects of VR intervention were found.

      Future directions

      VR-based burn rehabilitation has many advantages, but there are many problems associated with its application in practice. The high costs of the research, development, and application of VR technology make it impossible to popularize and promote this method, especially in developing countries.
      • Brown NJ
      • David M
      • Cuttle L
      • Kimble RM
      • Rodger S
      • Higashi H.
      Cost-effectiveness of a nonpharmacological intervention in pediatric burn care.
      Medical personnel lack systematic knowledge and training on VR, which could affect the effectiveness of VR interventions.
      • Wu WW
      • Liu SM
      • He TT
      • Wu SF.
      [Advances in the research of virtual reality technology for pain intervention after burns] [Chinese].
      VR-related testing, guidance, treatment, cleaning, and maintenance require considerable labor and material resources, and the feasibility of its clinical application is questionable.
      • Markus LA
      • Willems KE
      • Maruna CC
      • et al.
      Virtual reality: feasibility of implementation in a regional burn center.
      Children and elderly adults have a high incidence of burns, but their use of VR is greatly restricted because children have insufficient cognitive ability to comply with the treatment, and elderly adults have very limited acceptance of VR.
      • Wu WW
      • Liu SM
      • He TT
      • Wu SF.
      [Advances in the research of virtual reality technology for pain intervention after burns] [Chinese].
      In addition, most current VR technology requires the use of head-mounted displays, which limits its use in patients with head and facial burns.
      • Khadra C
      • Ballard A
      • Dery J
      • et al.
      Projector-based virtual reality dome environment for procedural pain and anxiety in young children with burn injuries: a pilot study.
      Fortunately, with the development of science and technology and the continuous efforts of researchers, these problems are being gradually solved. Recently, 2 studies showed that low-cost VR systems have high practicability and effectiveness in burn treatment.
      • Ford CG
      • Manegold EM
      • Randall CL
      • Aballay AM
      • Duncan CL.
      Assessing the feasibility of implementing low-cost virtual reality therapy during routine burn care.
      ,
      • Huang SW.
      Comments on “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”.
      In summary, cost control, professional training, VR resource sharing, and user-friendly equipment will be major issues to be addressed in the field.

      Study limitations

      The main limitations of this study are as follows: (1) The diversity of participants, environments, intervention measures, and outcome indicators may have led to unexplained heterogeneity. Therefore, the uncertainty regarding the actual effect of VR-based burn rehabilitation therapy is a shortcoming of this study; (2) The included trials generally had small sample sizes, especially the limited numbers of female participants, and different experimental designs, that is, within-participant and parallel group trials, which could have also led to inaccurate results; (3) In a few trials, only partial data were available. Although we actively contacted the corresponding authors to obtain complete data, these data could not be obtained. Incomplete data may have adversely affected the results. Equally important, all of the included trials were published in English, and the locations were also concentrated in the United States and Egypt, which may have caused some degree of publication bias; (4) The authors of the included trials did not provide more underlying characteristic information of patients, so we were unable to perform valid grouping for some subgroup analyses. Additionally, because the sample size was too small, the relevant results of subgroup analyses would have been unreliable. Although there are many shortcomings, this study still provides valuable information, which needs to be further verified by large, multicenter clinical trials.

      Conclusions

      According to the current status of evidence, VR-based burn rehabilitation significantly improves the QOL and work performance of burn patients, significantly increases the ROM gain of the tested joints, effectively reduces the intensity and unpleasantness of pain and the time spent thinking about pain, increases the fun of the rehabilitation therapy, further reduces the anxiety caused by the treatment, and has no obvious adverse effects. However, it does not significantly improve hand grip and pinch strength. Furthermore, the substantial heterogeneity of the results cannot be ignored. Many challenges remain in the actual clinical application of VR. In the future, low-cost and highly operable VR technology may have broad prospects for application in the field of burn rehabilitation.

      Supplier

      • a.
        R 4.1 software; Free Software Foundation Inc., Boston, MA.

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