burns 46 (2020) 1347 1355

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Effects of interactive robot-enhanced hand

rehabilitation in treatment of paediatric
hand-burns: A randomized, controlled trial with
3-months follow-up

Ahmed F. Samhan a,c, *, Nermeen M. Abdelhalim a,c , Ragab K. Elnaggar b,c

a
Department of Physical Therapy, New Kasr El-Aini Teaching Hospital, Faculty of Medicine, Cairo University, Cairo,
Egypt
b
Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
c
Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Prince Sattam Bin
Abdulaziz University, Saudi Arabia

article info abstract

Article history: Purpose: To evaluate the effectiveness of the robotic-assisted exercise with virtual gaming on
Accepted 29 January 2020 total active range of motion (ROM) of the digits, hand grip strength (HGS), and hand function
in children with hand burns.
Methods: Thirty-three children with burn caused by thermal injury (flame or scald) with the
involvement of the wrist and hand, total body surface area (TBSA) <30%, and age between
Keywords: 6 12 years, were included in this study. The patients were randomly allocated to one of the two
Pediatric hand burns groups; control group (n = 16; received 60-min of the traditional hand rehabilitation program, three
End-effector robotic rehabilitation timesperweekfor two successive months) andexperimental group(n = 17; engagedinan additional
Range of motion 20 min of interactive robot-enhanced hand rehabilitation besides the traditional rehabilitation).
Hand grip strength Outcomes measured were the total active ROM of the digits, HGS, and hand function at three
Hand function occasions during the study: at the baseline, post-treatment, and 3 months follow-up.
Results: In the experimental group, results regarding total active (ROM) of the digits, HGS,
and hand function were statistically significant in comparison to the control group either
after treatment (P < .05, P = .04, and P = .005) respectively or at the follow-up (P < .05, P = .023,
and P = .012) respectively favoring the experimental group.
Conclusion: The robot-enhanced exercise with virtual gaming can increase total active ROM of
the fingers’ digits, improve HGS, and hand function in children with hand burns.
© 2020 Elsevier Ltd and ISBI. All rights reserved.

Abbreviations: PHBs, pediatric hand burns; ROM, range of motion; ADL, activities of daily life; RTs, robotic therapies; PSAU, Prince Sattam
Bin Abdulaziz University; RHPT, rehabilitation health physical therapy; TBSA, total body surface area; PASS, power analysis and sample
size; SD, standard deviation; MP, metacarpophalangeal; PIP, proximal interphalangeal; DIP, distal interphalangeal; HGS, hand grip strength;
JHFT, Jebsen Taylor Hand Function Test; IBM Inc., International Business Machines Incorporation; USA, United States of America; SPSS,
Statistical Package for the Social Sciences; P-value, the probability that the study results are due to chance; ANOVA, analysis of variance; IQ,
interquartile ranges; BMI, body mass index.
* Corresponding author at: Department of Physical Therapy, New Kasr El-Aini Teaching Hospital, Faculty of Medicine, Cairo University,
Cairo, Egypt.
E-mail address: ahmedsamhan44@yahoo.com (A.F. Samhan).
https://doi.org/10.1016/j.burns.2020.01.015
0305-4179/© 2020 Elsevier Ltd and ISBI. All rights reserved.
1348 burns 46 (2020) 1347
1. Introduction
Paediatric hand burns (PHBs) are considered one of the common
reasons for hand injury that lead to a consequential deterioration
in the hand function [1]. Children are especially at higher risk of
burns due to risk-taking behaviors in exploring the surrounding
environment, fire play, and delayed defense reflex mechanism
[2]. Burn survival and the contributing factors of burn injury differ
as the child proceeds across the stages of normal development.
Hot liquids and scald burn often encountered in children younger
than 5 years and has been estimated at 65% of thermal injuries,
while flame burns frequently occur in older children and account
for 56% of the cases [3].
Although paediatric hand burns are not often the main
cause of increased mortality, they can lead to devastating
deformities and impairments [4], such as pain, numbness,
hypoesthesia, finger amputation, muscle weakness, and
limitation of joint range of motion (ROM), alone or in
combination [5]. All these impairments may affect the child’s
capability to carry out his/her activities of daily life (ADL), like
eating, dressing and playing, in addition to dexterity (fine
motor skills) like pencil skills (writing, coloring, drawing),
scissors skills (cutting), and construction skills (using clay,
puzzles, train tracks) [6].
The objectives of rehabilitation in paediatric hand burns are
to preserve function, develop compromised function, and avoid
theprogressiontodeformities, onthisbasis;hand rehabilitation
is a vital rule in the productive treatment. The most common
hand rehabilitation modalities include proper positioning,
splinting, exercise therapy, soft tissue manipulations, desensi-
tization therapy, developmentally appropriate activities for
children, and fine movement development [7]. Commonly,
inadequate rehabilitation or late rehabilitation is a significant
issue for diminshed hand function with undesirable outcomes
[8]. Pain and anxiety are dangerous features that may
extensively impact the progression of rehabilitation. Severe
pain is aggravated by anxiety [9]. Children are unlike adults in
the need for additional motivation approaches & rehabilitation
programs as they have movement phobia and always reject to
participate in rehabilitation programs because of pain, distress,
and anxiety [10].
One of the recently developed modalities to improve
motivation in children with physical impairment is robotic
therapies, which are in many cases are integrated with video
games and emphasize training at the range of impairment.
Firstly, robotic therapies were used successfully in children
with cerebral palsy to enhance hand function where training
based on models of motor learning and control and behavioral
neuroscience [11]. Using robotic therapies combined with
video games in children with physical impairment can
increase participation and concentration through encouraging
the repetition of definitely hard motor tasks. Additionally, the
robotic therapies permit the operator to control and improve
the quality and quantity of exercises for specific exercises
sitting or at a specific period [12].
Previous studies established that utilizing repeated train-
ing exercises with robotic therapies for finger movements
(simple flexion and extension) improve hand function after
stroke [13,14]. The capability to control training throughout
1355
treatment with robotic therapies enable improving hand
function, strengthening weakened muscles, and increasing
joints ROM.
Using endpoint control robotic maneuver is considered a
new treatment procedure in paediatric hand burns as a task-
specific training that concentrates specifically on the finger/
digits through digit covers that are passed together with
stabilized courses. By using this new technology that did not
report in the previous studies, the main objective of this study
was to evaluate the effectiveness of the robot-enhanced hand
rehabilitation on the digits ROM, hand grip strength, and hand
function in children with hand-burns.
2. Material and methods
2.1. Experimental design & ethics
This study was a two-arm, parallel randomized controlled trial
conducted over 18 months from June 2018 to November 2019 at
the outpatient physical therapy clinic and laboratories of Prince
Sattam Bin Abdulaziz University (PSAU), Al-Kharj, Saudi Arabia.
Ethical approval was obtained from the Physical Therapy
Research Ethics Committee at PSAU (No: RHPT/18/0047). The
study procedures were in consonance with the rules of ethics of
the Declaration of Helsinki 1964. A consent form was obtained
from the children’s parents/caregivers before registration.
2.2. Study participants
Thirty-three children with burn participated in this study.
Children were selected from the burn unit of King Khalid
Hospital, Al-Kharj, Saudi Arabia. Inclusion criteria were;
children with deep partial-thickness or full-thickness burn
caused by thermal injury (flame or scald) with involvement of
the wrist and hand, total body surface area (TBSA) <30%, age
between 6 12 years, recent discharge of inpatient acute care,
spontaneous healing (within 3 4 weeks) or grafting with split-
thickness or full-thickness skin grafts (at least before 2 weeks).
Exclusion criteria were; perception of persistent respiratory
problem related to a previous inhalation injury, signs of burn
infection (i.e., unclear fluid oozing from the wound, increased
pain, expanded redness and swelling), exposed tendons,
developmental and cognitive disorders, presence of fractures,
and the urgent need for re-admission.
Qualified children were randomly assigned to receive either
one of two interventions: a traditional hand rehabilitation
program (Control group) or an interactive robot-enhanced
hand rehabilitation in addition to traditional hand rehabilita-
tion (Experimental group). To reduce the allocation bias and
confounding, the random allocation was made in blocks, the
randomization block size was 4, and the allocation sequence
within each block was 2:2 generated by a web-based
randomizer (sealed envelopeTM, V1.18.0, available at https://
www.sealedenvelope.com/). The randomization was carried
out by an independent researcher who was not a part of this
work at any stage.
The sample size was estimated using PASS software version
15.0.5 (NCSS, Kaysville, UT, USA). In a test for two means in a
repeated measure design, a total sample size of 28 children
 burns 46 (2020) 1347
(14 children for each group) was needed to achieve 91% power to
detect a time-averaged difference in the ROM (=5 ) between the
two group means in a study design with 3-levels, having all
variances equal to SD2, and all covariances equal to zero, when
the SD is 7, the anticipated correlation between the within-
subject observations is .4, and the alpha level is .05 [15]. The
assumptions for sample size estimation were based on the
results of a small pilot study. The sample was increased to 36
children based on a presumed dropout rate of 20%.
2.3. Outcome measures
Children were assessed for the total active range of motion
(ROM) of the digits, hand grip strength, and hand function at
three occasions during the study: at the baseline, after
treatment, and 3 months follow-up. The outcome measures
were collected by a physical therapist who was blinded to the
treatment allocation.
2.3.1. Total active ROM
Total active ROM is the sum of the active metacarpophalangeal
(MP), proximal interphalangeal (PIP), and distal interphalangeal
(DIP) arc of motion in degrees of an individual digit [16]. The
measurement was performed via a hand-held steel finger
goniometer ((Baseline1 , Fabrication Enterprises Inc., NY, USA)
in accordance with the standard protocol designated in a
previous study [17]. While measuring, children had the elbow
in flexion and resting on the examining table, with the wrist and
forearm in the neutral position. Initially, the assessor asked
children to flex each digit as maximally as possible and measured
the total active flexion. Then, the extension deficits of the same
digits were measured about the 0 extension. The total active
ROM was calculated by subtracting the total active flexion of
the MP, PIP, and DIP joints from the total extension deficit of the
same joints. The measurement categories were: <260 ; Normal,
220 259 ; Excellent, 180 219 ; Good, and <180 ; Poor [18]. The
continuous data for each digit and the categorical rating of the
total active ROM were used for statistical analysis.
2.3.2. Grip strength
The hand grip strength (HGS) was quantified bilaterally with the
use of JAMAR PLUS+1 digital hand dynamometer (Sam-mons
Preston, Bolingbrook, IL, USA). During testing, children were
seated on appropriate-size chairs with straight back in the
position suggested by the American Society of Hand Therapists,
where the shoulder was slightly abducted, elbow flexed to 90
and the wrist placed in the neutral position [19]. Children were
then verbally instructed to squeeze as hard as they can before
each test. Three maximum voluntary contractions were
allowed after one practice trial. The average peak force (kg)
was recorded for each hand. To ensure testing consistency, test
trials were performed under the same conditions during the
morning time in a quiet environment with the same investiga-
tor. Tests have also conducted alternately between both hands
with 2-min rest intervals to control for fatigue effect.
2.3.3. Hand function
The Jebsen Taylor Hand Function Test (JHFT) was applied for
providing a short, objective assessment of a range of gross and
fine motor skills, weighted and unweighted hand functions
1355 1349
frequently used in ADLs [20]. It is a clinician-administered,
performance-based measure, assesses the speed of perfor-
mance of the hand function through seven-items representing
diverse hand activities. These items are writing by copying a
24-letter sentence; turning over three- by five-inch cards;
picking up small objects and placing them in a container;
simulated feeding; stacking draughts; picking up large objects;
picking up large heavy objects. Children were assessed for both
hands starting with the non-dominant hand. The test items
were administered in an identical way for all children and in
the same sequence. The less desirable performance is
indicated by a slower time. The test-retest reliability for the
JHFT items was established, wherein the results were found to
be moderately to highly consistent (Pearson’s product-
moment correlation coefficient ranged from .60 to .99) with
a non-significant learning effect between test occasions [20].
2.4. Intervention
2.4.1. Traditional hand rehabilitation
A physical therapist-assisted and patient/family education
program was provided for children in the control and
experimental groups with the aim of maintaining or relocating
active/passive ROM of the affected joints, preventing hyper-
trophic scars, avoiding contractures and deformities, increas-
ing skin extensibility, and improving strength, dexterity, and
functional skills [21]. The program conducted in 60-min
sessions, three times per week for two successive months.
The program included immersing the hand in paraffin for 10
min; soft massaging with a moisturizing gel (such as contra-
tubex or dermatix) for 5 min; passive mobilization of the wrist,
MP, PIP, and DIP joints; active/passive ROM and stretching
exercises; strengthening exercises (done in static mode
initially and progressed in the second month to dynamic
strengthening using elastic bands); occupational therapy.
Concurrently, a home program with clearly outlined directives
was considered. Children and their families were instructed to
learn the anti-contracture positioning/splinting, scar massage
and exercises program, application of the custom garments
and inserts, and functional training to perform them on their
own at home. Written and illustrative instructions and
reciprocal demonstration sessions were provided to the
children and their families to ensure successful acquisition
and delivery of rehabilitation skills at home program. The
therapist was reported about children’s compliance with the
home program every couple of days [21].
2.4.2. Interactive robot-enhanced hand rehabilitation
Thirty minutes after completing the traditional hand rehabili-
tation, children in the experimental group received an
interactive hand rehabilitation program with the help of an
end-effector robotic system (Amadeo1 , Tyromotion GmbH,
Graz, Austria) with the aim of improving ROM, enhancing
muscle strength, and boosting hand function. The system
incorporates a robotic-assisted exercise with virtual gaming
and provides a controlled range of passive, active-assisted, and
active-resisted finger flexion and extension movements
through five finger slides. Finger slides operate the finger
individually (finger movement-isolation) or in combination
(like in grasping and releasing functions). These slides contain
1350 burns 46 (2020) 1347
force-sensors to determine the magnitude and direction of the
force applied by the user through an algorithm in the software.
The accumulated force (as determined from each slide) used to
create a magnitude and direction-equivalent vector. This
vector is used to control the training.
In preparation for the training, children assumed a
comfortable sitting on an 18-in. chair with their back
supported and a cushion under feet when the floor was not
reachable. The forearm of the affected side placed in the
pronation position in the forearm support, the wrist secured in
the neutral position with Velcro straps, and the fingers
connected to the slides by means of magnetic plates. In the
first session, the therapist adjusted the training parameters to
the limit of the available passive ROM for each child, which was
stored and used in the next sessions. Each treatment session,
children underwent the following training:
- A total of 5 min of passive ROM done by the robotic system
within the pre-determined finger flexion and extension range.
- Next, an additional 5 min of active-assisted ROM activities
for which real-time feedback was provided visually by way
of smiley faces in each direction. The robot assisted the
children to complete the entire ROM (finger flexion or
extension) while children were instructed to move actively
to assist the robot to complete the full ROM. When children
exerted more force in the indicated direction, the smile size
proportionally increased.
- Then, children completed 5 min of self-initiated finger
movements, where the children allowed initiating the
movement in the indicated direction and the robot assisted
them to complete the full ROM when they reached the limit
of active ROM.
Fig. 1 – Study flow chart according to CONSORT.
1355
- Finally, children participated in 5 min of virtual gaming. In
this exercise mode, children apply isometric force in
flexion/extension direction to move and indictor to reach a
specific target on the screen.
The interactive hand rehabilitation program was adopted
from two published reports [11,22], and was conducted for 20
min/session, three times per week for two successive months
with close supervision by two physical therapists.
2.5. Statistical analysis
Statistical analysis was performed using SPSS Version 23.0 (IBM
Corporation, Armonk, NY) with a significance level set at P < .05.
All data were checked for normality using Shapiro Wilk test. The
analysis revealed that all dependent variables were normally
distributed. The differences between groups in the baseline data
were computed using the unpaired t-test for continuous factors
and Pearson x2 test for categorical factors. The differences in the
dependent variables (i.e., total active ROM, HGS, and JHFT)
between and within groups were computed using the unpaired t-
test and repeated measure ANOVA respectively. When a
statistical difference was determined within groups, the post-
hoc Bonferroni test was then used for the pairwise comparisons
across the levels of the within-group factors (pre-, post-
treatment, and at the follow-up).
3. Results
Sixty-nine children were initially screened. Of them, 36 were
eligible to participate and made progress in the study phases.
 burns 46 (2020) 1347 1355 1351

One child didn’t complete the treatment and two children lost
at the follow-up and their data were excluded from the
analysis (refer to the participant flowchart in Fig. 1). The
baseline demographic characteristics are demonstrated in
Table 1. There were no significant differences (P < .05) between
the control and experimental groups in age, boys-to-girls
distribution, anthropometric factors (weight, height, and BMI),
or the burn-related factors (injured side, TBSA, etiology of
burn, location of burn, skin graft type, hospital stay, and the
duration since injury).
The median treatment adherence was 93.75% (Interquartile
ranges [IQR]; 87.50% 98.95%) in the control group and 95.83%
(IQR; 91.67% 100%) in the experimental group, with no
difference between both groups (P = .26).
Differences in total active ROM of the digits are shown in
Table 2. The control and experimental groups were homoge-
nous pre-treatment (p < .05). There were statistically
significant differences between both groups regarding the
total active ROM of the thumb (p = .015, p = .013), index (p=.02,
p = .01), middle (p = .034, p = .02), ring (p = .016, p = .005), and little
(p = .03, p = .023) finger respectively post-treatment and at the
follow-up favoring the experimental group. Repeated measure
within-group analysis showed statistically significant changes
within both groups for total active ROM of all the digits (p < .05).
From pre- to post-treatment, the total active ROM increased
significantly in the control group (thumb; p= .02, index; p = .012,
middle finger; p=.002, ring finger; p = .01, and little finger;
p=.002). The attained total active ROM was maintained at
the follow-up only in the middle finger (p = .028) but was lost in
the thumb (p = .08), index (p = .122), ring finger (p = .12), and the
little finger (p = .197) when compared to the pre-treatment
values. Also, the total active ROM increased significantly in the
experimental group (thumb; p < .001, index; p = .003, middle
finger; p < .001, ring finger; p<.001, and little finger; p < .001).
The attained effect was maintained in all the digits (thumb;
p < .001, index; p = .014, middle finger; p < .001, ring finger;
p < .001, and little finger; p < .001) when compared to the pre-
treatment values.
A categorical specification of the total active ROM at the
follow-up is illustrated in Fig. 2. There was no between-group
difference regarding the frequency distribution of the normal
(control; 37.5% versus experimental 58.8%), excellent (control;
43.75% versus experimental 29.4%) or the good (control; 18.75%
versus experimental 11.8%) total active ROM categories
(Pearson x2 = 1.504; p = .57).
The HGS in both groups is shown in Table 3. The control and
experimental groups were similar at the baseline (p = .79).
There was a statistically significant between-group difference
in the post-treatment (p = .04) and follow-up (p = .023) values,
both favored the experimental group. The repeated measure

Table 1 – Baseline demographic characteristics.

Control group (n = 16) Experimental group (n = 17) P-value
Age, years 8.41  2.39 9.64  1.98 .12a
Gender, n (%)
Boys 9 (56.25) 11 (64.7) .62b
Girls 7 (43.75) 6 (35.3)
Weight, kg 31.21  6.36 33.91  8.47 .31a
Height, m 1.31  .15 1.36  .12 .29a
BMI, kg/m2 21.34  2.41 20.64  1.97 .37a
Injured Side, n (%)
D 11 (68.75) 9 (52.94) .48b
ND 5 (31.25) 8 (47.06)
TBSA, % 21.14  3.48 20.35  2.92 .48a
Location of hand burn, n (%)
Palmar 11 (68.75) 8 (47.06) .44b
Dorsal 3 (18.75) 5 (29.41)
Circumferential 2 (20.50) 4 (23.53)
Finger injury, n (%)
Present 6 (37.50) 5 (29.41) .72b
Not present 10 (62.50) 12 (70.58)
Skin graft on hand and wrist, n (%)
ST 8 (50) 11 (64.71) .68b
FT 3 (18.75) 2 (11.76)
None 5 (31.25) 4 (23.53)
Etiology of burn, n (%)
Flame 5 (31.25) 7 (41.18) .55b
Scalds 11 (68.75) 10 (58.82)
Hospital stay, days 39.75  5.30 37.82  6.41 .36a
Duration since injury, days 66.43  11.85 71.18  14.72 .32a

Data expressed as mean  SD or as frequency (percentage), BMI: body mass index, D: dominant, ND: non-dominant, TBSA: Total burn surface
area, ST: split-thickness skin graft, FT: full-thickness skin graft.
a
ANOVA test.
b
xPearson 2 test.
1352 burns 46 (2020) 1347 1355

Table 2 – The mean total active ROM of the fingers’ digits in the study groups.
Control group (n = 16) Experimental group (n = 17) P-value
Thumb Pre 75.19  19.06 69.82  14.72 .37
Post 83.18  16.62 96.82  13.77 .015*
Follow-up 81.56  15.56 94.76  13.14 .013*
p-value .009¥ <.001¥

Index Pre 162.81  17.06 168.06  18.15 .39

Post 171.06  11.52 182.17  14.65 .02*
Follow-up 169  9.75 180.65  12.90 .01*
p-value .01¥ .002¥

Middle Pre 159.88  14.10 165.35  12 .24

Post 169.75  15.58 180.29  11.47 .034*
Follow-up 167.13  14.88 178.53  11.76 .02*
p-value .001¥ <.001¥

Ring Pre 175.13  12.93 180.82  14.91 .25

Post 182.81  15.22 195.41  13.14 .016*
Follow-up 180.56  13.68 193.82  12 .005*
p-value .006¥ <.001¥

Little Pre 158.81  15.39 162.76  13.73 .44

Post 166.87  12.36 177.41  14.29 .03*
Follow-up 164.69  13.15 175.76  13.41 .023*
p-value .012¥ <.001¥

Data expressed as mean  SD.

*
Significant unpaired t-test.
¥
Significant repeated measure ANOVA test.

The mean JHFT scores are demonstrated in Table 4. Both

groups were identical (p = .12). There was a statistically
significant difference between both groups after treatment
(p = .005) and at the follow-up (p = .012) in favor of the
experimental group. Within group-analysis showed that the
time required to complete the JHFT-related functions de-
creased significantly in the control (p < .001) and experimental
group (p < .001) after treatment and that effect continued in
both groups to the follow-up (p < .001) regarding the pre- and
post-treatment scores.

4. Discussion

Children with hand burns exhibit a definite and major challenge

Fig. 2 – Total active ROM categories (%) in the study groups
during the follow-up.
within-group analysis indicated statistically significant
changes within the control group (p = .004) and the
experimental group (p < .001). The pairwise comparison
showed a significant increase in the HGS in the control group
post-treatment (p = .005) but was lost at the follow-up (p = .08)
as compared to the pre-treatment values (Fig. 3-A). Also, a
significant increase in the HGS in the experimental group post-
treatment (p < .001) existed and that increase retained at the
follow-up (P < .001) as opposed to the pre-treatment values
(Fig. 3-B).
to the rehabilitation members. This challenge comes from
movement phobia, pain, distress, and anxiety presented in the
traditional treatment interventions. They experience addition-
al complications exerted by their muscle weakness, contracted
scar and by their failure to recognize and cooperate in
rehabilitation programs. To overwhelm these complications
and attain ideal results, an engaging and enjoyable program
incorporating proper positioning, splinting, and ROM exercises
are suggested [23]. An interactive hand rehabilitation program
with the help of an end-effector robotic system permits the
operator to cooperate with a computer-simulated condition,
which delivers a nearby actual response on accomplishment
[24]. This study aimed to evaluate the effectiveness of the robo
t-enhanced hand rehabilitation on the digits ROM, hand grip
strength, and hand function in paediatric hand burns.
 burns 46 (2020) 1347 1355 1353

Table 3 – The mean hand grip strength (kg) in the study groups.
Control group (n = 16) Experimental group (n = 17) P-value
Pre 18.87  3.84 19.24  4.12 .79
Post 21.56  4.43 25.18  5.16 .04*
Follow-up 20.87  3.69 24.41  4.51 .023*
p-value .004¥ <.001¥

Data expressed as mean  SD.

*
Significant unpaired t-test.
¥
Significant repeated measure ANOVA test.

Fig. 3 – Pairwise comparison of HGS across the assessment levels in the control group (3-A) and experimental group (3-B).

Table 4 – The mean time (in seconds) to complete the Jebsen Taylor Hand Function Test in the study groups.
Control group (n = 16) Experimental group (n = 17) P-value
Pre 193.75  12.45 185.35  17.34 .12
Post 169.75  14.1 153.76  15.82 .005*
Follow-up 152.13  15.07 138.59  14.19 .012*
p-value <.001¥ <.001¥

Data expressed as mean  SD.

*
Significant unpaired t-test.
¥
Significant repeated measure ANOVA test.

The findings of this study advocate that utilizing robotic-
assisted exercise with virtual gaming combined with tradi-
tional hand rehabilitation in paediatric hand burns can
produce outcomes that are frequently superior to those
attained by using traditional hand rehabilitation alone in
terms of increasing total active ROM of the digits and
improving hand grip strength, and hand function. At the
same time, these improvements were continued 3 months
post-treatment. A potential clarification of these results is
that, when children with burned hands participated in a
robotic-assisted exercise with virtual gaming, their concen-
tration has deviated from movement phobia to motivation.
Earlier, before using randomised trials in rehabilitation of
hand burns, researches applied purposeful activities by using
versatile fun activities; the child’s attention is provoked and
offered motivation for active contribution in the rehabilitation
program. In a previous study by Omar et al., they reported that
children with hand burn gained more relief of pain, and
improvement in ROM and hand function when they partici-
pated in purposeful activities on the basis of playing games
than traditional exercise program [25]. Recently, applying
commercially available video games like Nintendo1 WiiTM,
Play-stationTM and Microsoft1 Xbox KinectTM becomes a
portion of the pediatric burn rehabilitation program. Lozano
and Potterton reported that using Xbox KinectTM was efficient
in attaining greater active ROM and higher scores in fun and
satisfaction in pediatric burned patients. They concluded that
using Xbox KinectTM has been revealed to be a valuable and
advantageous assistant in pediatric burn rehabilitation [26].
The interactive hand rehabilitation program with the help
of an end-effector robotic system has been successfully used in
rehabilitation of many neuromotor disorders like strokes in
adults [27], and cerebral palsy in children [11,22]. To the best of
our knowledge, there are no previous studies have used
robotic-assisted exercises with virtual gaming in PHBs. It is
believable one cause for development in hand function after
1354 burns 46 (2020) 1347
robotic-assisted exercise was the transformation from routine
exercises program to playing tasks. The absence of the fear
associated with hand movement may have also assisted in the
improvement in hand function. A pediatric rehabilitation
program, in combination with visual feedback, can improve
the impact of motor adaptation, skill gaining, and decision-
making as compared with traditional rehabilitation programs
[27]. Also, feedback could improve learning productivity [28].
The robotic-assisted exercise could supply both real-time
feedback on performance and encourage motor learning by
providing support and incentive clarifications (voices and
pictures), and thereby could encourage children to participate
in the rehabilitation program [29]. Furthermore, the robotic-
assisted training permits modification of exercises according
to children’s function. Appealing games in conjunction
with appropriate duty difficulty are important to preserve a
children’s conformance and motivation [30,31]. Accordingly,
to enhance the motor capability, the repetition of exercise
training is assured [32].
One advantage of applying this modality is that the digits
are connected to the apparatus through magnetic plates
guarded to the digits with adhesives and allows the digits to
move exposed on the apparatus track so that the burned hand
can be visually supervised by the physical therapist through-
out the procedure. Furthermore, the hand robotic apparatus
emphasizes exercise training on the hand and no other
segment in the upper limb, which supposed to enhance
children’s capability to use their hands in ADL. This may
explain why developments were distinguished in the hand by
increasing total active ROM of the hand, improvement of hand
grip strength, and hand function.
This study has some limitations worthy to be mentioned,
such as the absence of long follow-up assessments for 6
12 months to establish if the improvements were continued
by the time, the robotic system employed in this study trains
the hand in only one plane of movement (flexion and
extension), while training in multiple planes could achieve
better outcomes, and the lack of control over the home
program which may influence the results. Despite the results
of this study revealed that adding 20 min of robot-enhanced
hand rehabilitation to the traditional physical rehabilitation of
children with hand burns had favorable effects, we cannot
confirm if extending the duration of the program for the
control group for 20 min to balance the groups for treatment
durations would achieve similar results as the experimental
group. So, future studies should be consider long-term follow-
up, utilizing RTs to train hand in all planes of movement, a
validated assessment of satisfaction should be used and
attempting to incorporate between disability and skills-based
exercise training in the robotic system to aid in the daily
functional tasks.
5. Conclusion
The interactive hand rehabilitation program with the help of
an end-effector robotic system can implement a new exercise
training intervention that can be adjusted rapidly to variations
in child performance. Clinical evaluations have revealed that
robotic-assisted exercise with virtual gaming can increase
1355
total active ROM of the fingers’ digits, improve hand grip
strength, and hand function in children with hand burns.
Conflict of interest
The authors declare no conflict of interest.
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