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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 23  |  Issue : 2  |  Page : 94-100

Efficacy of Xbox Kinect virtual gaming system on hand function and quality of life in children with juvenile idiopathic arthritis


Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt

Date of Submission16-Jan-2018
Date of Acceptance08-Oct-2018
Date of Web Publication27-Dec-2018

Correspondence Address:
Shamekh M El-Shamy
Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, 7, Ahmed El-Zayat Street, Bein El-Sarayat, Dokki, Giza, 12612
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bfpt.bfpt_1_18

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  Abstract 


Background Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in childhood, which exerts a negative effect on a child’s daily life.
Purpose The purpose of this study was to investigate the effectiveness of Xbox Kinect system training on hand function and quality of life in children with JIA.
Patients and methods A total of 34 children with JIA, with ages ranging from 8 to 12 years, were selected for this randomized controlled study and randomly assigned into two groups. The study group received Xbox training involving five games for 50 min a day, three times a week for 12 weeks, plus conventional treatment. The control group received conventional treatment alone. Outcomes were hand grip strength measured using a handheld dynamometer, hand function measured using the Duruöz Hand Index, and quality of life measured using the Pediatric Quality of Life Inventory. Outcomes were measured at baseline and after 12 weeks of intervention.
Results Children in the study group showed significant improvement when compared with those in the control group. The grip strength after treatment was 24.4 and 17.5 kg for the study group and control group, respectively. The hand function scores after treatment were 5.2 and 15.7 for the study group and control group, respectively. The quality-of-life scores after treatment were 85.4 and 66.2 for the study group and control group, respectively.
Conclusion Xbox Kinect system training plus conventional treatment increases grip strength, hand function, and quality of life in children with JIA.

Keywords: Keywords, hand function, juvenile idiopathic arthritis, quality of life, Xbox training


How to cite this article:
El-Shamy SM. Efficacy of Xbox Kinect virtual gaming system on hand function and quality of life in children with juvenile idiopathic arthritis. Bull Fac Phys Ther 2018;23:94-100

How to cite this URL:
El-Shamy SM. Efficacy of Xbox Kinect virtual gaming system on hand function and quality of life in children with juvenile idiopathic arthritis. Bull Fac Phys Ther [serial online] 2018 [cited 2020 Jun 3];23:94-100. Available from: http://www.bfpt.eg.net/text.asp?2018/23/2/94/248811




  Introduction Top


Juvenile idiopathic arthritis (JIA) is the most well-known chronic rheumatic disorder in children, which negatively affects a child’s daily life regardless of illness status [1],[2]. Arthritis in JIA is described by stiffness, agony, and swelling of influenced joints [1]. The illness course of JIA may include flares of expanded sickness movement or endless persevering joint irritation, even into adulthood [3]. Different confusions may emerge auxiliary to continuous illness movement or treatment, including joint harm and distortion, development variations from the norm, and osteoporosis with fragility fractures [4],[5],[6].

The hands and wrists are the most included joints in JIA [7]. Hand contribution essentially influences daily living activities [8], and JIA brings about the weakening of hand work by causing swelling, torment, and distortion, in addition to causing a lessening in the range of movement in the joints, debilitated muscles, and loss of grip strength [9].

Physical therapy is an essential part of the treatment of JIA. It is imperative for the youngster to stay dynamic and be associated with games and exercises with their companions. Customary action and general exercise programs help to keep up range of movement in influenced joints, build and maintain strength, keep up function, and even help with manifestation reduction [10].

The beneficial outcomes of physical therapy are broadly recognized in the literature [11]. However, a major obstacle and key motivation for this project is that long-term engagement in exercise among patients with JIA is poor and does not exceed 50% when patients are not supervised [12].

Currently, gaming has pulled in impressive consideration because of the possibility to give a promising option or upgrade to the conventional rehabilitation programs [11],[12]. Much of the time, conventional exercises do not yield the expected outcomes because of poor patient adherence to the recommended schedules [10]. Individuals with dynamic incapacities report that conventional protocols can be unremarkable and exhausting because of their tedious nature. In addition, the absence of direct patient feedback with respect to their advance lessens their motivation to proceed. A conventional program is also often too hard to do during periods of JIA flare-ups, leading to inactivity, even when the pain phase is gone. At last, absence of computational detecting and estimation in conventional treatment may bring about mistakes when translating assessment information [12].

Most previous studies concentrated on patients who had involvement of lower body joints. Although this corresponds to the general patterns in the overall population, and affection of the lower body has a tendency to have more effect on mobility and gait, there is as yet a noteworthy number of people with upper body-influenced JIA, especially in the hands. Upper body people would likewise be all the more promptly ready to take part in the weight-bearing movement without pain and may benefit from a more strength-centered program [13].

Commercially available video games have been used for a wide range of clinical populations with generally positive clinical outcomes [14],[15],[16],[17],[18],[19]. They have been shown to be active enough to provide an increase in energy expenditure and physical activity in children with cerebral palsy [20],[21]. Pre–post single-group studies using interactive games as a method of intervention have found that compliance is elevated and enjoyment is greater than usual therapy, and suggests there may be some clinical benefit in terms of balance [22],[23], mobility [24], and hand function [20].

In such manner, Xbox system is the future of reasonable virtual reality (VR) gaming consoles. It is a controller-free camera framework utilizing infrared innovation and works through smart innovation highlights, for example, the flood of the hand, outward appearances, discourse summons, and the development of the body. The product tracks different purposes of the body for upwards of two players continuously. This new innovation offers full-body motion and is the initial 3D full-body computer game framework that peruses the whole body’s movement and influences it to some portion of the game [25].

Chang et al. [26] concluded positively as far as the utility of the Kinect system, noting a significant improvement in motor function and also recording high levels of motivation and suggesting further examination. In the literature, no VR trials have focused on hand function and quality of life in youngsters with JIA. This trial is the first to research the effects of the Xbox system in youngsters with JIA. Therefore, the aim of this study was to investigate effects of the Xbox Kinect system on hand function and quality of life in children with JIA.


  Patients and methods Top


Design

A prospective, single-blind randomized controlled trial was undertaken ([Figure 1]). Participants with JIA were enrolled from the Maternity and Children Hospital, Makkah, Saudi Arabia. Participants were randomly allocated to either the study group (Xbox training plus conventional treatment) or the control group (conventional treatment only). The allocation schedule was generated by an independent investigator (the receptionist), who generated 34 random numbers and allocated even numbers to the study group and odd numbers to the control group before the commencement of the study. These numbers were put into sealed envelopes. Allocation was concealed to the recruiter, wherein each participant was asked to pick one of the 34 envelopes, which then revealed their group allocation. Outcomes were measured at baseline (before intervention) and at 12 weeks (after intervention) by one therapist who was blind to group allocation. This study was approved by the ethics committee of the Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia. This investigation was completed as per the code of ethics of the Declaration of Helsinki for experiments involving humans. Written consent was obtained from the parents of all children before their participation.
Figure 1 Design and flow of participants through the trial.

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Participants

Participants with JIA were recruited to the study if they fulfilled the following criteria: (a) were 8–12 years old; (b) had a finding of polyarticular JIA as indicated by the criteria built up by the International League of Associations for Rheumatology [27]; (c) did not have musculoskeletal disorders that would interfere with use of the Xbox system; (d) had normal or corrected hearing and vision; (e) had no previous experience with the Xbox system; and (f) were able to understand and follow simple directions to perform the tasks. Children were excluded from this study if they fulfilled the following criteria: (a) had undergone surgery in their upper extremities within the past 6 months; (b) suffered from congenital or acquired skeletal deformities, cardiopulmonary dysfunctions, and progressed radiographic changes; and (c) had medical conditions that made use of the Xbox system unsafe. During the study, children did not receive any treatment to improve their upper extremity functions other than the study interventions. Demographic (age, sex, BMI, and disease duration) information was collected to describe the sample.

Intervention

Xbox Kinect system training

The study group received Xbox training plus conventional treatment. The dose of Xbox training was 50 min, three times a week for 12 weeks, that is, 30 h over 36 sessions, using the Xbox gaming system (Xbox 360 Kinect console; Microsoft Inc., Redmond, Washington, USA). The games were anticipated onto a 45-inch Samsung television. The TV was put around 8–10 ft far from participant arranged at chest level. As required, a therapist guarded the child from behind to maintain a strategic distance from movement sensor obstruction. The content of Xbox training consisted of practicing five Xbox games (fruit ninja, volleyball, table tennis, boxing, and bowling). Children practiced each game for 10 min, bringing about every session enduring 50 min. These games were chosen because they target the upper limbs, are fun, provide immediate feedback, are easy to learn and play, and progression is built into the game. All games were played at the basic level. On the initial trial day, the child was asked to complete one round of each game, as an introduction. Scores were documented as a baseline. During the initial trial round, verbal instruction and explanation of the game was given before starting; no cues were given following the start of the game. During the second session, technical training was provided following the first round of trials for each game. The child was instructed to obtain as many points awarded as possible. To prevent a risk of falling, the child was guarded throughout the entire gaming practice [28].

Conventional treatment

The dose of conventional treatment was 45 min, three times a week for 12 weeks, 36 sessions over 27 h. The content of conventional treatment consisted of passive stretching for elbow and wrist flexors, weight-bearing exercises for the upper limbs, and protective extensor thrust to stimulate the protective reactions of the upper limbs. Strengthening exercises were conducted for elbow and wrist muscles using different toys and motivation to encourage the children to perform the desired exercises. Exercises facilitating hand skills included basic reach, grasp, carry and release, skills of in-hand manipulation, and bilateral hand use. The children performed these exercises while they sat on a chair and the therapist sat at the side to guide and assist the children in performing the exercises correctly.

Outcome measures

Hand grip strength was measured utilizing a hydraulic hand dynamometer (Patterson Medical, Warrenville, Illinois, USA) and reported in kilograms. Participants performed three trials, and the average was used for analysis. Each child was instructed to sit on an adjustable-height chair with back support and the trunk secured to the back of the chair using a belt, with the head maintained in mid-position, and with the hips and knees flexed to 90° with the feet fully supported on the ground in a neutral position. The arm was positioned beside the body with the elbow joint flexed 90°, the forearm midway between supination and pronation, and the wrist joint in a neutral position. The child was then instructed to hold the handle of the dynamometer and squeeze it maximally before releasing it [29].

Hand functions were evaluated using the Duruöz Hand Index (DHI). It is a self-reported questionnaire comprised of 18 questions about activities of daily living (kitchen, dressing, cleanliness, office, and other), which are ordered into three groups of elements. The first factor represents activities requiring power and rotational movements, the second factor represents activities requiring dexterity and precision, and the third factor represents dynamic activities requiring adaptability of the initial three fingers. Every item is scored independently on a scale from 0 (without difficulty) to 5 (impossible). Scores from the five total classifications are summed to yield a total score running from 0 to 90. The DHI takes around 3 min to finish [30],[31].

Health-related quality of life (HRQoL) was estimated utilizing the Pediatric Quality of Life Inventory, version 4.0 (PedsQL), a particular instrument for estimating the HRQoL in kids and teenagers matured 2–18 years. The PedsQL Generic Core Scales may be used in healthy populations as well as in populations with acute or chronic health conditions. The questionnaire comprises 23 items and four subscales: physical, emotional, social, and school functioning. Higher scores mean better HRQoL [32].

Statistical analysis

Data were analyzed using SPSS, version 16.0 (SPSS Inc., IBM, Chicago, Illinois, USA). Descriptive statistics of mean and SD presented the children’s ages, BMI, and disease duration. The mean values of all measured parameters were taken. Comparison of assessments before and after the treatment in each group (study or control) was performed using paired t test, whereas the comparison of assessments between both groups before and after treatment was carried out using an unpaired t test. However, a between-group and within-group variance was carried out using a mixed analysis of variance test. P value less than 0.025 was accepted as significant. To avoid a type II error, a preliminary power analysis (power, 0.95; α, 0.05; effect size, 0.8) determined a sample size of 34 for this study. The sample size was calculated using G Power, version 3.1 (Heinrich-Heine-Universität, Düsseldorf, Germany). The high-effect size was recommended to only observe major differences between groups, which yielded a realistic sample size that allowed for observations of major differences in the variables that we measured [33].


  Results Top


A total of 34 children with JIA (14 boys and 20 girls) were recruited to this study. The children were assigned randomly into two equal-sized groups (n=17 each). The demographic and clinical characteristics of the patients were similar in both groups ([Table 1]).
Table 1 Demographic and clinical characteristics of the children at baseline

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Baseline measurements revealed no significant difference in the mean values of the grip strength (kg) between the study and control groups (P=0.45). However, there was a significant difference between the mean values of grip strength obtained at the baseline and during post-treatment assessments (P<0.001) ([Table 2]).
Table 2 Pretreatment and post-treatment mean values of grip strength, hand function, and quality of life within each group and between groups

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At baseline, no significant differences (P=0.37) were noted in the mean values of DHI scores between the study and control groups. There were significant differences (P<0.001) in the DHI scores obtained at the baseline and during post-treatment assessments ([Table 2]).

No significant differences (P=0.18) were noted in the mean values of PedsQL scores between the study and control groups at baseline. There were significant differences (P<0.001) in the PedsQL scores obtained at the baseline and during post-treatment assessments ([Table 2]).


  Discussion Top


This randomized controlled trial found that children with polyarticular JIA who carried out 12 weeks of Xbox training plus conventional treatment experienced an improvement in grip strength, hand function, and quality of life compared with conventional treatment alone.

The improvement in the study group, which may be caused by a positive effect of practicing with Xbox Kinect, was anticipated and may be related to several key features of immersive VR. As was highlighted by several authors, VR allows practice in a realistic, safe, and motivating environment. While utilizing movements similar to those made in the equivalent physical world [34], VR tasks can incorporate elements essential for the successful restoration of motor abilities. These include the manipulation of timing and precision of environmental interactions, something not easily achieved in the real world [35], ongoing execution feedback [36], and motivation which is strengthened by the competitive idea of VR games and the modification of difficulty to offer a level of achievement [37]. For instance, execution of real-world tasks in a standard therapeutic setting is constrained by the client’s capacity, and dissatisfaction and absence of achievement in these exercises can demotivate the patient from practicing [38]. Conversely, game-based exercise offers an assortment of situations in which mistakes do not represent any hazard to the participant and criteria for execution achievement can be scaled by the client’s capacity. Reinforcement of progress energized participant and increased compliance as a result [39].

The results of this study are consistent with those of Arman and colleagues, who reported the use of Xbox protocol that include client-centered task-oriented activity training has shown improvements on upper extremity functions and activity performance in patients with JIA. Furthermore, Xbox system is more fun and provides motivation and may be a preferable method of treatment for patients with JIA, but further studies are needed to compare with the potential benefits of video-based games and conventional therapy in patients with JIA [40].

The utilization of custom VR game plans without a doubt can build task specificity and additionally therapist control of exercise intensity and progression. However, the clinical appropriation of these laboratories developed games is significantly impeded in the close term because of potential research, financial, advertising, and execution challenges. In any case, the coming of recreations planned particularly for rehabilitation purposes holds guarantee as their accessibility and utility increase after some time [41]. In our investigation, we effectively utilized commercial games in a regulated way to enhance hand function and quality of life in children with JIA.

Moreover, the results of this study are consistent with those of Voon and colleagues, who suggested that using the Xbox system was beneficial in motivating compliance by promoting measurably greater satisfaction with prescribed activities, in addition to more time completing exercises and adjective activities. They surmised that this may be attributable to the fact that (whole body) gameplay is enjoyable, potentially relaxing and decreases the monotony of repeating prescribed exercises regularly [42].

By allowing the children to be more engaged in the Xbox system experience and games, they were distracted and thus experienced less pain as previously described by Parker et al. [43]. This decline in pain assists in reducing the fear associated with movement these children experience and assist in improvements related to activity and ultimately age-appropriate play and activities of daily life.

This study is not exempt of limitations: first, we did not follow up the children after the cessation of intervention. Future research is recommended to examine the long-term effect of Xbox training on hand function in children with JIA. Second, the effect may be owing to the extra training rather than the type of training. All children received the same amount of conventional treatment, whereas the children in the study group received additional time for the Xbox training. It would be interesting to investigate this issue by comparing Xbox training with the same amount of conventional treatment in future studies.


  Conclusion Top


This study provides evidence that Xbox training plus conventional treatment increases grip strength, hand function, and quality of life in children with JIA.

Acknowledgements

The author would like to express his appreciation to all of the children and parents who participated in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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