Entertainment interventions for pediatric fracture patients during cast room procedures: a scoping review

Introduction

Background

Children almost universally experience falls or injuries during their development (1). Population-based data indicate that fractures are common during childhood, with a high annual incidence reported in large cohort studies (2). During treatment, pediatric fracture patients typically undergo various cast room procedures, including cast application, cast removal, suture removal, and pin removal. Most cast room procedures are performed with children remaining fully conscious, while sedation or anesthesia is used selectively when clinically indicated (3). Although the duration of cast room procedures is relatively short, children commonly exhibit pronounced negative emotional responses, such as anxiety and fear, in clinical practice, often manifested as refusal to cooperate or strong resistance to treatment (4). In extreme cases, there has been a report of a child who developed cardiac arrest and died due to excessive anxiety during a cast removal procedure (5). Excessive anxiety and fear not only hinder the smooth completion of cast room procedures but may also result in serious adverse outcomes affecting the child’s prognosis.

During cast room medical procedures, diverting children’s attention helps to alleviate anxiety and fear related to the procedure (6). In recent years, clinical healthcare providers have applied a variety of entertainment-based distraction interventions for pediatric fracture patients during cast room procedures, including music (7), video-based approaches (8), immersive technologies such as virtual reality (VR) (9), and interpersonal interactive interventions such as therapeutic play (10) provided by trained hospital play specialists (HPS). Despite the diversity of entertainment interventions, their common goal is to redirect children’s attention away from the medical procedure, thereby reducing procedure-induced anxiety and fear and improving treatment adherence, ultimately facilitating the smooth completion of procedures.

Rationale and knowledge gap

Although several studies have reported the application of entertainment interventions during cast room procedures, and some scholars have conducted summary analyses, the existing research still presents notable limitations. The scoping review conducted by Maharjan et al. (11) focused only on cast removal as a single procedure, while the systematic review by Burkhart et al. (6) examined anxiety as the sole outcome measure. A systematic synthesis regarding the types of existing entertainment interventions, specific implementation strategies, outcome indicators, and assessment tools is still lacking, and the effectiveness of these interventions remains unclear. Such limitations hinder clinical healthcare providers from selecting appropriate entertainment interventions in practice and restrict the optimization and development of future intervention approaches.

Objective

Therefore, this study adopts a scoping review methodology to systematically search, organize, and summarize the application of entertainment interventions during cast room procedures. The aim is to provide a comprehensive overview of current research, identify existing gaps, offer references for clinical practice, and guide the development of future research directions and intervention strategies. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0173/rc).

Methods

Registration and protocol

This study strictly followed the methodological framework for scoping reviews proposed by Arksey and O’Malley (12). The study protocol has been registered on the Open Science Framework (OSF) (https://doi.org/10.17605/OSF.IO/QBK6Y).

Identification of research questions

The research questions were identified through a literature review and structured group discussions. The discussion group consisted of six multidisciplinary experts, including three pediatric nurses, one pediatric/orthopedic clinician, one specialist in pain management or sedation, and one expert in pediatric psychology/behavioral science.

A structured discussion approach was adopted. Preliminary research questions were first generated based on the literature review. These were then reviewed and refined through group discussions to ensure clarity, relevance, and clinical applicability. All members provided independent input, followed by collective deliberation to reach consensus. Disagreements were resolved through iterative discussion until agreement was achieved among all participants.

• What types of entertainment interventions are currently used for pediatric fracture patients during cast room procedures?
• What are the specific implementation methods of each type of entertainment intervention during cast room procedures?
• What outcome indicators and assessment tools are used for each type of entertainment intervention during cast room procedures?
• What are the effects of each type of entertainment intervention when applied during cast room procedures?

Identifying relevant studies

A systematic search was conducted in PubMed, Web of Science, Embase, and the Cochrane Library from database inception to October 1, 2025, and the search was last updated on October 1, 2025. A combination of subject headings (MeSH/Emtree) and free-text terms was used, and additional manual searches of reference lists of relevant articles were performed to ensure completeness. Search terms included: “Pediatrics/child/children/adolescent/teen/youth” “Fractures, bone/Orthopedics/bone fracture/broken bones/torsion fracture/fracture” “video games/music/virtual reality/gamification/recreation/digital media/computer games/game/play/card/entertainment”. An example of the PubMed search strategy is as follows: (“pediatrics” [MeSH Terms] OR “child” [MeSH Terms] OR “adolescent” [MeSH Terms] OR “children” [Title/Abstract] OR “teen” [Title/Abstract] OR “youth” [Title/Abstract]) AND (“fractures, bone” [MeSH Terms] OR “orthopedics” [MeSH Terms] OR “fracture” [Title/Abstract] OR “bone fracture” [Title/Abstract] OR “broken bones” [Title/Abstract] OR “torsion fracture” [Title/Abstract]) AND (“video games” [MeSH Terms] OR “music” [MeSH Terms] OR “virtual reality” [MeSH Terms] OR “gamification” [MeSH Terms] OR “recreation” [MeSH Terms] OR “digital media” [MeSH Terms] OR “computer games” [Title/Abstract] OR “game” [Title/Abstract] OR “play” [Title/Abstract] OR “card” [Title/Abstract] OR “entertainment” [Title/Abstract]).

Selection criteria

The inclusion and exclusion criteria were established according to the PCC framework (population, concept, and context). Inclusion criteria: (I) population: pediatric patients with limb fractures undergoing cast room procedures(aged ≤18 years), given that age boundaries were not always explicitly defined, studies including participants aged 18 years were retained if the population was predominantly pediatric or conducted in pediatric settings; (II) concept: entertainment-based interventions (e.g., music, animation, video, games, VR) implemented during cast room procedures and their effectiveness evaluation; (III) context: original studies conducted within cast room procedures (e.g., cast removal, cast application, pin removal, fracture reduction, cast coverage, and splint placement), including quantitative research, qualitative research, and mixed-method studies. Exclusion criteria: studies without available full text, conference abstracts, review articles, study protocols, commentaries or opinion papers, duplicate publications, and non-English studies. These eligibility criteria were applied to ensure the relevance, accessibility, and methodological adequacy of the included evidence.

Study selection

The retrieved studies were imported into EndNote 21 for literature management. After removing duplicates via software processing and manual verification, two researchers trained in evidence-based methodologies independently screened the titles and abstracts against predefined inclusion and exclusion criteria. Full-text screening was then performed for studies that passed the initial screening. Any discrepancies during the screening process were resolved through discussion with a third researcher to reach consensus.

Charting the data

After the study selection was completed, two researchers collaboratively designed a data extraction form using Excel and independently extracted data from the included studies. The extracted information included the author, year of publication, country/region, study design, participants, sample size, age, type of entertainment intervention, intervention measures, outcome indicators, assessment tools, and intervention effects. Any disagreements during data extraction were resolved through discussion with a third researcher to reach a consensus.

Collating, summarizing, and reporting the results

The researchers repeatedly reviewed the included studies and conducted an integrative and descriptive analysis of the extracted data and their characteristics. The results were categorized according to the core themes of the research questions, including intervention types, intervention measures, outcome indicators, assessment tools, and intervention effects. The synthesized findings were subsequently discussed with the research team and experts in the relevant field to minimize researcher bias. Finally, the results were presented in tabular and narrative form.

Results

Eligible studies

A total of 10,982 records were initially identified through database searching. After removing 3,680 duplicates, 7,302 studies remained for screening. Two researchers independently conducted an initial screening of titles and abstracts using predefined inclusion and exclusion criteria, resulting in the exclusion of 7,215 records. Full-text screening was performed for the remaining 87 articles: 20 were excluded due to inappropriate study population, 28 for being unrelated to fractures, 4 for not involving cast room procedures, 15 for irrelevant interventions, and 4 for lacking reported outcomes. Ultimately, 16 studies were included in the final analysis. The complete study selection process is presented in Figure 1.

Figure 1 PRISMA flow diagram.

Study characteristics

A total of 16 studies were included in this review (7-10,13-24), of which 10 were conducted in the United States (7-10,13-17,24), 2 in the United Kingdom (18,19), 1 in China (20), 1 in Turkey (21), and 2 in Canada (22,23). All included studies were randomized controlled trials. The basic characteristics of the included studies are presented in Table 1.

Types of entertainment interventions

During cast room procedures for pediatric fracture patients, eight main types of entertainment-based distraction interventions were identified: music, iPad-game, iPad-video, instructional video, VR-based distraction intervention, VR-game, VR-video, and therapeutic play. Among the included studies, 3 involved VR-game interventions (9,17,22), 3 involved VR-video interventions (19,23,24), 1 involved both VR-game, VR-video and iPad-video interventions (13), 2 involved VR-based distraction interventions (14,18), 2 involved music interventions (7,16), 2 involved therapeutic play interventions (10,20), 1 involved instructional video interventions (21), 1 involved both iPad-video and iPad-game interventions (15), 1 involved both Instructional video and iPad-video interventions (8).

Implementation methods

The analysis of the included studies showed that a variety of entertainment-based interventions were used for pediatric patients undergoing castroom procedures. Although Table 1 provides an overview of each intervention, it offers limited guidance for direct clinical application. Therefore, the specific implementation details of each entertainment intervention are described below to support clinical practice. (I) Music intervention: Liu et al. (7) continuously played soft lullaby background music in both the waiting area and the cast room, with the volume controlled to ensure that communication between children and medical staff was not affected. In the study by Mahan et al. (16), children were provided with noise-canceling headphones connected to electronic devices after entering the cast room. They were allowed to select their preferred music, which continued throughout the procedure until completion. (II) iPad-game intervention: children played games on an iPad during their time in the cast room and throughout cast removal. Ko et al. (15) allowed children to freely choose games according to their personal interests. (III) iPad-video intervention: implemented similarly to iPad-game, children watched videos on an iPad during the cast room procedures. In Ko et al. (15), Children were permitted to select their preferred video content. (IV) Instructional video intervention: although also a video-based intervention, the instructional video differs from iPad-video in its purpose. Rather than providing entertainment, it aims to explain the upcoming medical procedure, helping children understand the steps and reduce anxiety caused by uncertainty. For example, Akan et al. (21) presented a 60-second instructional video developed by the research team before pin removal, using animated animal characters to demonstrate the removal process. (V) VR-game intervention: VR-game interventions were applied before and during the procedure, with children wearing VR headsets. VR-games were divided into interactive and non-interactive types (18). Interactive VR required children to use hand controllers to navigate immersive environments, such as dinosaur worlds or outer space. At the same time, non-interactive VR involved more straightforward gameplay without hand control, such as breaking balloons that appeared on-screen with head movements. (VI) VR-video intervention: VR-video interventions were implemented during the medical procedure, providing visually immersive video content to divert attention. In the study by Poppelaars et al. (19), children also wore headphones to provide combined audiovisual stimulation. (VII) Therapeutic play intervention: therapeutic play refers to interpersonal interactive play facilitated by professionally trained HPS, who use role-playing, toys, or dolls to divert attention and support emotional regulation. In the study by Wong et al. (20), the HPS used dolls to simulate both the doctor and the patient and reenacted the cast-removal scenario. While the HPS interacted with the child, the clinician simultaneously performed the actual cast removal. (VIII) VR-based distraction intervention: VR-based distraction intervention refers to the use of immersive VR via head-mounted devices to divert children’s attention during medical procedures. It may include both interactive games and passive audiovisual content (e.g., VR-video), but is not limited to either format. In Georgiadis et al. (14), children wore VR headsets throughout cast removal and were immersed in virtual content while the procedure was performed. Compared with VR-game or VR-video alone, VR-based distraction provides stronger immersion and attentional engagement through multisensory stimulation and reduced awareness of the clinical environment.

Outcome measures and tools

Procedures performed in the cast room typically include cast removal, cast application, suture removal, and pin removal. These procedures are likely to induce anxiety, pain, fear, and behavioral disturbances in pediatric patients, which may negatively affect both their physiological and psychological well-being and hinder the smooth completion of cast room procedures. Therefore, studies involving children undergoing cast room procedures commonly select anxiety, pain, heart rate, fear, and behavioral changes as outcome indicators, with anxiety being the most frequently reported.

A total of 14 studies (7-9,13-21,23,24) used anxiety as an outcome measure. Direct assessment tools included the Children’s Anxiety Meter (CAM) (17,21,24), the Short State Anxiety Inventory Scale (SAIS) (21,23), the Children’s Emotion Management Scales (CEMS) (20,21,23), the Visual Analogue Scale (VAS) (9,13,14,18,20), and the Chinese version of the State Anxiety Scale for Children (CSAS-C) (20). Elevated heart rate is widely recognized as a marker of autonomic nervous system activation, particularly increased sympathetic activity, which is closely associated with anxiety and stress responses. Heart rate-related indices, such as heart rate variability, have been shown to be effective physiological markers for identifying emotional states including anxiety and stress (25). During distressing medical procedures, anticipatory fear and procedural discomfort can trigger physiological arousal, leading to measurable increases in heart rate. Reductions in heart rate observed during distraction interventions may therefore reflect decreased anxiety levels and improved emotional regulation. Accordingly, four studies (7,8,15,16) used heart rate as an objective physiological indicator to directly assess anxiety responses in children during cast room procedures. Six studies (9,10,13,19-21) evaluated heart rate as an independent outcome rather than as an indirect indicator of anxiety. Heart rate was measured using a finger pulse oximeter or a monitoring machine, with the finger pulse oximeter most frequently used. Measurements typically lasted 1–2 minutes, with recordings taken every 15 seconds.

Nine studies (9,13,14,16,17,19,21,22,24) used pain as an outcome measure. Common pain assessment tools included the Wong-Baker Pain Scale (WBS) (9,21), the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) (21), the Numerical Rating Scale (NRS) (17,19,22), the VAS (13,24), and the Faces, Legs, Activity, Cry and Consolability (FLACC) scale (14,16). Fear was evaluated in three studies (19,22,24) using the Child Fear Scale (CFS). Behavioral changes were less frequently assessed, with only one study employing a self-created behavior scale (10).

Effects of entertainment interventions

Table 2 summarized the beneficial effects of each intervention type across different outcomes. For anxiety reduction, all VR-game (3/3), VR-video (3/3), VR-based distraction (2/2), iPad-video (2/2), and music (2/2) studies reported significant benefits. Therapeutic play also showed a positive effect (1/1). In contrast, only 1/2 instructional video studies reported improvement, and the single iPad-game study found no benefit (0/1). For pain reduction, only instructional video showed consistent benefit (1/1). One of three VR-game studies reported pain relief (1/3), while no studies demonstrated benefits for VR-video (0/2), VR-based distraction (0/2), or music (0/1). Regarding fear, both VR-game studies showed positive effects (2/2), as did the single VR-video study (1/1). For heart rate reduction, music (2/2) and iPad-video (2/2) consistently showed benefits. No significant effects on heart rate were found for VR-game (0/1), VR-video (0/1), instructional video (1/2), or therapeutic play (1/2). One VR-video study assessed nausea, with no improvement reported (0/1). One therapeutic play study found a positive effect on behavior (1/1).

The study by Fabricant et al. (13) compared VR-game, VR-video, and iPad-video interventions in the same trial, finding no significant differences in pain and anxiety reduction between the three distraction modalities. Since the study did not demonstrate a clear advantage of one intervention over another and could not independently attribute effects to a specific entertainment type, it was excluded from the present synthesis of intervention-specific outcomes. Additionally, two studies (8,15) reported findings from two parallel intervention arms each (iPad-video vs. iPad-game, and instructional video vs. iPad-video, respectively) for the purpose of synthesizing intervention-specific effects, each arm was analyzed separately, resulting in a total of 17 distinct intervention groups.

Given the wide age range of participants included in the review, further subgroup analysis comparing intervention effects in children versus adolescents is recommended to explore potential age-related differences in response to these distraction techniques.

Discussion

Key findings

This scoping review aimed to summarize the types of entertainment distraction interventions currently used for pediatric fracture patients undergoing cast room procedures, along with their implementation strategies, outcome indicators, assessment tools, and intervention effects. Eight categories of interventions were identified, including music, iPad-based interventions, VR-based interventions, and therapeutic play.

Among the reported outcomes, anxiety was the most frequently assessed, highlighting its central role in pediatric procedural experiences. Notably, immersive interventions such as VR-based approaches appeared to demonstrate more consistent benefits in reducing anxiety and fear. This may be explained by the higher level of immersion and interactivity provided by VR, which enhances attentional engagement and reduces awareness of the clinical environment compared with conventional screen-based interventions such as iPad.

A variety of assessment tools were used across studies, reflecting a lack of standardization in outcome evaluation. Overall, most entertainment interventions showed positive effects on psychological and physiological outcomes, supporting their potential value in clinical practice.

Comparison with similar research

Previous reviews have focused on single procedures or isolated outcomes. This study expands upon prior work by synthesizing multiple cast room procedures and multiple outcome indicators within a unified framework. The findings regarding music and VR interventions are consistent with previous literature reporting benefits in reducing pediatric procedural anxiety.

Explanations of findings

With recent technological advancements, VR has become a promising distraction intervention in casting procedures. This study found that VR-game effectively alleviated anxiety and fear, but showed limited effects on pain intensity and heart rate, which may reflect variability in age, procedural pain, and the use of iPad distraction as an active control. Compared with iPad-based games, VR may provide greater immersion and interactivity, thereby enhancing attentional engagement. VR-game can be delivered in interactive or head-controlled non-interactive modes, allowing adaptation to children with limb immobilization. Both VR-video with headphones and iPad-video reduced anxiety, whereas VR-video without headphones did not, likely due to the stronger attentional capture of audiovisual stimulation compared with visual input alone (26). Therefore, intervention selection should be individualized according to the child’s cognitive level (i.e., the developmental ability to understand and engage with the intervention) and psychological preparedness (i.e., emotional readiness, including baseline anxiety and prior medical experiences), which have been shown to influence responsiveness to distraction and overall intervention effectiveness (27).

The iPad is an entertainment intervention applied during cast room procedures following music interventions and primarily includes two modalities: iPad-video and iPad-game. The findings of this review indicate that iPad-video demonstrates beneficial effects in alleviating anxiety and reducing heart rate among pediatric patients. In contrast, iPad-game shows no significant improvement in related outcome indicators. A potential explanation is that game operations typically require upper-limb movement, which may be inconvenient and challenging for children with upper-limb fractures who can only operate with one hand. This limitation may reduce enjoyment and even cause frustration. In contrast, watching video content, most commonly cartoons preferred by children, can effectively divert attention, thereby alleviating anxiety. Although instructional videos are also video-based, their purpose differs from that of entertainment videos. It is designed to educate children about upcoming medical procedures and operational steps through video demonstrations, rather than providing a distraction. Findings regarding its effectiveness remain inconsistent. Barnes et al. (8) suggested that excessive procedural information before cast room procedures may increase children’s attention to medical details, thereby intensifying fear and anxiety. Therefore, it is currently recommended that iPad-video be used as the primary video-based intervention during cast room procedures. At the same time, the applicability of instructional video should be further evaluated and optimized based on the child’s age, cognitive level, and psychological preparedness (28).

Music is one of the earliest forms of entertainment used in cast room procedures and has been shown to relieve anxiety among pediatric patients, consistent with the findings of Yücel et al. (29). Music interventions were mainly delivered as background lullabies or patient-selected music via noise-cancelling headphones. Background music before the procedure reduced baseline anxiety but showed limited benefit during the procedure, whereas patient-selected music via headphones significantly reduced procedural anxiety. This may be explained by stronger attentional capture and reduced environmental noise. A combined approach—background music during preparation followed by patient-selected music during the procedure—may further enhance effectiveness.

Most of the entertainment interventions mentioned above rely heavily on electronic devices, whereas therapeutic play emphasizes interpersonal interaction and emotional expression, which may reduce anxiety by enhancing emotional support and facilitating coping during medical procedures (30). Therapeutic play is typically delivered by HPS, who are professionally trained to provide therapeutic play activities for children undergoing medical treatment across various hospital departments. Particularly for younger children, when behavioral changes such as crying, fear, or refusal to cooperate occur, distraction techniques relying solely on electronic devices may fail to achieve the desired effect. The study by Pontes et al. (31) demonstrated that therapeutic play effectively improved resistance behaviors among children before vaccination. In this study, participants receiving therapeutic play intervention ranged in age from 2 to 12 years, and results showed that therapeutic play also reduced fear and resistance behaviors during cast room procedures, encouraging better cooperation with treatment. Therefore, for younger children or those with strong psychological resistance (e.g., refusal to cooperate, distress, or agitation), which can be assessed using behavioral observation or validated anxiety scales, medical institutions with appropriate resources should consider implementing therapeutic play in cast room procedures to improve adherence and overall care experience.

Implications and actions needed

Therefore, it is recommended that future researchers conduct higher-quality systematic reviews and network meta-analyses, and carefully consider factors such as patient age, gender, fracture site, and procedure types in cast rooms when designing studies, enabling more refined subgroup analyses. This approach may help guide clinical practice more accurately in selecting the most appropriate entertainment intervention for different pediatric patients.

Strengths and limitations

Through this scoping review, the present study provides a comprehensive summary and analysis of entertainment interventions used in pediatric fracture patients during cast room procedures, including intervention types, implementation strategies, outcome indicators, assessment tools, and intervention efficacy, offering valuable guidance for future research directions.

Entertainment interventions may generate different preferences and effects depending on children’s age and sex. Although the included studies covered a wide age range (2–18 years), subgroup analyses by age group and gender were not conducted in this review, which may have affected the precision of the findings. In addition, various medical procedures are performed in cast rooms (e.g., cast removal, cast application, suture removal, pin removal, and fracture reduction), and this study did not conduct subgroup analyses by procedure type. As a result, potential differences in intervention effects may have been overlooked, leading to possible bias.

Conclusions

Different entertainment interventions vary in their implementation methods and effects, and except for the iPad-game intervention, the other entertainment interventions generally demonstrated potential positive benefits for children during cast room procedures. Clinical healthcare providers may select the most appropriate intervention based on the department’s available resources and the child’s specific manifestations of anxiety, pain, or behavioral responses. Future research should focus on developing or optimizing new forms of entertainment interventions to enrich the range of intervention types and on exploring individualized strategies tailored to children across different age groups, genders, and fracture types to optimize their treatment experience further.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0173/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0173/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0173/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Fortin K, Bertocci G, Nicholas JL, et al. Long bone fracture characteristics in children with medical conditions linked to bone health. Child Abuse Negl 2020;103:104396. [Crossref] [PubMed]
2. Larsen AV, Mundbjerg E, Lauritsen JM, et al. Development of the annual incidence rate of fracture in children 1980-2018: a population-based study of 32,375 fractures. Acta Orthop 2020;91:593-7. [Crossref] [PubMed]
3. Tom D, Reeves S. Pediatric Procedural Sedation. Pediatr Ann 2024;53:e324-9. [Crossref] [PubMed]
4. Shepherd K, Shanmugharaj Y, Kattan O, et al. Can virtual reality headsets be used safely as a distraction method for paediatric orthopaedic patients? A feasibility study. Ann R Coll Surg Engl 2022;104:144-7.
5. Katz K, Fogelman R, Attias J, et al. Anxiety reaction in children during removal of their plaster cast with a saw. J Bone Joint Surg Br 2001;83:388-90. [Crossref] [PubMed]
6. Burkhart RJ, Hecht CJ 2nd, McNassor R, et al. Interventions to Reduce Pediatric Anxiety During Orthopaedic Cast Room Procedures: A Systematic and Critical Analysis Review. JBJS Rev 2023;
7. Liu RW, Mehta P, Fortuna S, et al. A randomized prospective study of music therapy for reducing anxiety during cast room procedures. J Pediatr Orthop 2007;27:831-3. [Crossref] [PubMed]
8. Barnes BJ, Abdou C, Wendling K, et al. Instructional Video did not reduce anxiety during pediatric cast removal: a prospective cohort study. J Pediatr Orthop B 2021;30:410-3. [Crossref] [PubMed]
9. Desai B, Newcomb N, Plost B, et al. Virtual reality use in pediatric patients for orthopedic clinical procedures: A randomized prospective trial of efficacy. J Child Orthop 2024;18:414-20. [Crossref] [PubMed]
10. Schlechter JA, Avik AL, DeMello S. Is there a role for a child life specialist during orthopedic cast room procedures? A prospective-randomized assessment. J Pediatr Orthop B 2017;26:575-9.
11. Maharjan P, Murdock D, Tielemans N, et al. Interventions to Improve the Cast Removal Experience for Children and Their Families: A Scoping Review. Children (Basel) 2021;8:130. [Crossref] [PubMed]
12. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 2005;8:19-32.
13. Fabricant PD, Gross PW, Mackie AT, et al. Virtual Reality Distraction Is No Better Than Simple Distraction Techniques for Reducing Pain and Anxiety During Pediatric Orthopaedic Outpatient Procedures: A Randomized Controlled Trial. Clin Orthop Relat Res 2024;482:854-63. [Crossref] [PubMed]
14. Georgiadis AG, Schavee PE, Koester TM, et al. Virtual Reality as an Adjunct to Pediatric Cast Removal: A Randomized Controlled Trial. JB JS Open Access 2025;10:e24.00244.
15. Ko JS, Whiting Z, Nguyen C, et al. A Randomized Prospective Study Of The Use Of Ipads In Reducing Anxiety During Cast Room Procedures. Iowa Orthop J 2016;36:128-32.
16. Mahan ST, Harris MS, Lierhaus AM, et al. Noise Reduction to Reduce Patient Anxiety During Cast Removal: Can We Decrease Patient Anxiety With Cast Removal by Wearing Noise Reduction Headphones During Cast Saw Use? Orthop Nurs 2017;36:271-8. [Crossref] [PubMed]
17. Richey AE, Hastings KG, Karius A, et al. Virtual Reality Reduces Fear and Anxiety During Pediatric Orthopaedic Cast Room Procedures: A Randomized Controlled Trial. J Pediatr Orthop 2022;42:600-7. [Crossref] [PubMed]
18. Oh N, Parrish N, Lee IW, et al. Using Virtual Reality to Reduce Anxiety and Improve Hospital Experience in Paediatric Orthopaedic Patients and Their Parents. Children (Basel) 2023;10:1409. [Crossref] [PubMed]
19. Poppelaars MA, van der Water L, Koenraadt-van Oost I, et al. Virtual reality reduces anxiety of children in the plaster room: a randomized controlled trial. Bone Joint J 2024;106-B:728-34. [Crossref] [PubMed]
20. Wong CL, Ip WY, Kwok BMC, et al. Effects of therapeutic play on children undergoing cast-removal procedures: a randomised controlled trial. BMJ Open 2018;8:e021071. [Crossref] [PubMed]
21. Akan İ, Bacaksız T, Bozoğlan M, et al. Animated video reduces pain and anxiety during pin removal in children with supracondylar humerus fractures: a randomized controlled trial. Arch Orthop Trauma Surg 2024;144:4293-301. [Crossref] [PubMed]
22. Guingo E, Debeurme MH, Dos Santos RP, et al. Efficacy of Virtual Reality vs. Tablet Games for Pain and Anxiety in Children Undergoing Bone Pins Removal: Randomised Clinical Trial. J Adv Nurs 2026;82:1791-802.
23. Jivraj BA, Schaeffer E, Bone JN, et al. The use of virtual reality in reducing anxiety during cast removal: a randomized controlled trial. J Child Orthop 2020;14:574-80. [Crossref] [PubMed]
24. Richey AE, Khoury M, Segovia NA, et al. Use of Bedside Entertainment and Relaxation Theater (BERT) to Reduce Fear and Anxiety Associated With Outpatient Procedures in Pediatric Orthopaedics. J Pediatr Orthop 2022;42:30-4. [Crossref] [PubMed]
25. Liu W, Wang S, Gu H, et al. Heart rate variability, a potential assessment tool for identifying anxiety, depression, and sleep disorders in elderly individuals. Front Psychiatry 2025;16:1485183. [Crossref] [PubMed]
26. Cai B, Xu L, Gao Y, et al. Congruent audiovisual stimulation drives efficient guidance of attention by memory-irrelevant features. Cogn Process 2026; Epub ahead of print. [Crossref]
27. Mustafa MS, Shafique MA, Zaidi SDEZ, et al. Preoperative anxiety management in pediatric patients: a systemic review and meta-analysis of randomized controlled trials on the efficacy of distraction techniques. Front Pediatr 2024;12:1353508. [Crossref] [PubMed]
28. Shen T, Wang X, Xue Q, et al. Active versus passive distraction for reducing procedural pain and anxiety in children: a meta-analysis and systematic review. Ital J Pediatr 2023;49:109. [Crossref] [PubMed]
29. Yücel Ş, Küçük Alemdar D. The effect of listening to music and foot reflexology on nausea, pain and anxiety in children during perioperative period: A randomized controlled study. J Pediatr Nurs 2024;75:e16-27. [Crossref] [PubMed]
30. Abdi F, Karamoozian A, Lotfilou M, et al. Effect of play therapy and storytelling on the anxiety level of hospitalized children: a randomized controlled trial. BMC Complement Med Ther 2025;25:23. [Crossref] [PubMed]
31. Pontes JE, Tabet E, Folkmann MÁ, et al. Therapeutic play: preparing the child for the vaccine. Einstein (Sao Paulo) 2015;13:238-42. [Crossref] [PubMed]