Active Video Game Play in Children With Cerebral Palsy: Potential for Physical Activity Promotion and Rehabilitation Therapies

Digital motor intervention effects on physical activity performance of individuals with developmental disabilities: a systematic review

PURPOSE

Post-pandemic, use of digital technologies (e.g., mobile app, Zoom, virtual reality, and videogaming) to promote physical activity (PA) in populations with intellectual and developmental disabilities (IDD) has increased. The efficacy of various digital technologies in promoting PA in individuals with IDD varies. We conducted a systematic review to examine current literature findings on the efficacy of digital PA interventions on PA outcomes in individuals with IDD.

METHODS

Articles published between 1900 and 2024 that examined effects of technology-based PA interventions on PA levels/fitness of individuals with IDD using experimental or quasi-experimental study designs were included. Sixteen articles were retrieved from four health databases PubMed (914), PsycInfo (1201), SCOPUS (1910), and CINAHL (948).

RESULTS

Findings based on 604 participants (Autism: 383; Down Syndrome: 106; Developmental Disability: 83, Developmental Coordination Disorder: 37) provide the most support for exergaming/digital PA intervention benefits for populations with ID, Down Syndrome, and Autism; however, there was limited support for its use in those without ID (e.g., DCD).

CONCLUSION

Digital technology is an effective tool to promote improvements in PA/fitness, motor, cardiovascular performance in individuals with ID. Future studies need to build on this evidence to support the use of PA outcomes in individuals with different IDD diagnoses.

The Technology to Enhance Patient Motivation in Virtual Reality Rehabilitation: A Review

Virtual reality (VR) technology has experienced a steady rise and has been widely applied in the field of rehabilitation. The integration of VR technology in rehabilitation has shown promising results in enhancing their motivation for treatment, thereby enabling patients to actively engage in rehab training. Despite the advancement, there is a dearth of comprehensive summary and analysis on the use of VR technology to enhance patient motivation in rehabilitation. Thus, this narrative review aims to evaluate the potential of VR technology in enhancing patient motivation during motor rehabilitation training. This review commences with an explanation of how enhancing motivation through the VR rehabilitation system could improve the efficiency and effectiveness of rehabilitation training. Then, the technology was analyzed to improve patient motivation in the present VR rehabilitation system in detail. Furthermore, these technologies are classified and summarized to provide a comprehensive overview of the state-of-the-art approaches for enhancing patient motivation in VR rehabilitation. Findings showed VR rehabilitation training utilizes game-like exercises to enhance the engagement and enjoyment of rehabilitation training. By immersing patients in a simulated environment with multisensory feedback, VR systems offer a unique approach to rehabilitation that can lead to improved patient motivation. Both ultimately lead to improved patient outcomes, which is not typically achievable with traditional rehabilitation methods. The review concludes that VR rehabilitation presents an opportunity to improve patient motivation and adherence to long-term rehabilitation training. However, to further enhance patient self-efficacy, VR rehabilitation should integrate psychology and incorporate methods. Moreover, it is necessary to build a game design theory for rehabilitation games, and the latest VR feedback technology should also be introduced.

The effectiveness of exergames in improving physical activity behaviour and physical literacy domains in adolescents with developmental coordination disorder and cerebral palsy: A scoping review

BACKGROUND

A large proportion of adolescents with developmental coordination disorder (DCD) are physically inactive. Physical literacy has been described as an important determinant in promoting health behaviours. The potential of exergames to improve physical literacy and activity has been recognized in typically developing children. The aim of the present scoping review was to identify and map the available evidence of this potential for adolescents with DCD.

METHODS

A scoping review was performed via a literature search in PubMed, Web of Science, Embase, ERIC and CINHAIL.

RESULTS

From 2860 search records, six studies (two studies in DCD and four studies in cerebral palsy [CP]) assessed physical activity, 12 studies discussed exergame features and 16 studies assessed physical literacy domains. In DCD, one study showed positive effects of exergaming on physical activity and the other failed to show any significant effects of exergaming. In CP, all four studies demonstrated positive effects of exergaming on energy expenditure and daily physical activity. Furthermore, positive effects of exergames on the different physical literacy domains were shown, namely motor competence, self-concept and affect, motivation and social/experiential. Finally, exergame features including multiplayer modes, realism, game rewards, challenges and enjoyment were shown to have a significant effect on motivating and encouraging adolescents to exert more effort while playing.

CONCLUSION

Based on the positive effects of exergaming on physical activity in other populations, more in-depth research in adolescents with DCD is warranted such that the decline in physical activity behaviour that is present in individuals with DCD can be counteracted. Physical literacy should be regarded as an important determinant in this regard.

Physical and Psychosocial Benefits of Sports Participation Among Children and Adolescents with Chronic Diseases: A Systematic Review

BACKGROUND

This study aims to identify sports interventions for children and adolescents (CaA) with chronic diseases and evaluate their impact on physical, psychological, and social well-being. The findings of this study will contribute to our understanding of the potential benefits of sports interventions for CaA with chronic diseases and inform future interventions to promote their overall health and well-being.

METHODS

A systematic review was conducted in eight databases. This systematic review followed PRISMA guidelines and utilized a comprehensive search strategy to identify studies on sport-based interventions for CaA with chronic diseases. The review included randomized controlled trials and observational studies that focused on physical and psychosocial outcomes.

RESULTS

We screened 10,123 titles and abstracts, reviewed the full text of 622 records, and included 52 primary studies. A total of 2352 participants were assessed with an average of 45 ± 37 participants per study. Among the included studies involving CaA with chronic diseases with an age range from 3 to 18 years, 30% (n = 15) autism spectrum disorders, 21% (n = 11) cerebral palsy, 19% (n = 10) were attention deficit hyperactivity disorder, and 17% (n = 9) obesity. Other diseases included were cancer (n = 5), asthma (n = 1) and cystic fibrosis (n = 1). Interventions involved various sports and physical activities tailored to each chronic disease. The duration and frequency of interventions varied across studies. Most studies assessed physical outcomes, including motor performance and physical fitness measures. Psychosocial outcomes were also evaluated, focusing on behavioural problems, social competencies, and health-related quality of life.

CONCLUSION

Overall, sport-based interventions effectively improved physical and psychosocial outcomes in CaA with chronic diseases. Interventions are generally safe, and participants adhere to the prescribed protocols favorably. Despite that, there is little evidence that interventions are being implemented. Future studies should include interventions tailored to meet the common issues experienced by CaA with chronic conditions, providing a comprehensive understanding of the impact of sports interventions on those affected.

REGISTRATION

The methodology for this review was pre-determined and registered in the PROSPERO database (registration number: CRD42023397172).

Evaluating the impact of movement tracking feedback on engagement with home exercise programmes of children with cerebral palsy using a new therapy app: a protocol for a mixed-methods single-case experimental design with alternating treatments

INTRODUCTION

Children with cerebral palsy (CP) are prescribed home exercise programmes (HEPs) to increase the frequency of movement practice, yet adherence to HEPs can be low. This paper outlines the protocol for a single-case experimental design (SCED) with alternating treatments, using a new home therapy exercise application, Bootle Boot Camp (BBCamp), offered with and without movement tracking feedback. This study will explore the impact of feedback on engagement, movement quality, lower limb function and family experiences to help understand how technology-supported HEPs should be translated and the added value, if any, of movement tracking technology.

METHODS AND ANALYSIS

In this explanatory sequential mixed-methods study using a SCED, 16 children with CP (aged 6-12 years, Gross Motor Function Classification System levels I-II) will set lower limb goals and be prescribed an individualised HEP by their physiotherapist to complete using BBCamp on their home television equipped with a three-dimensional camera-computer system. Children will complete four weekly exercise sessions over 6 weeks. Children will be randomised to 1 of 16 alternating treatment schedules where BBCamp will provide or withhold feedback during the first 4 weeks. The version of BBCamp that results in the most therapeutic benefit will be continued for 2 final weeks. Goals will be re-evaluated and families interviewed. The primary outcome is adherence (proportion of prescribed exercise repetitions attempted) as a measure of behavioural engagement. Secondary outcomes are affective and cognitive engagement (smiley face ratings), exercise fidelity, lower limb function, goal achievement and participant experiences. SCED data will be analysed using visual and statistical methods. Quantitative and qualitative data will be integrated using joint displays.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Research Ethics Boards at Bloorview Research Institute and the University of Toronto. Results will be distributed through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT05998239; pre-results.

Effect of touch screen tablet use on fine motor functions in children with hemiparetic cerebral palsy: A randomized controlled trial

BACKGROUND

Cerebral palsy is the most frequent condition affecting the central nervous system and causing large disability.

OBJECTIVE

To determine the impact of touch screen tablet upon fine motor functions in children with hemiparesis.

METHOD

This was a randomized controlled trial involving 60 children, ranging in age from 5 to 7 years old, randomized into two groups: intervention or control group (30 children per group). Both groups were given 12 consecutive weeks of designed fine motor tasks. Additionally, for thirty minutes, the intervention group was given a fine motor exercise program on a touch screen tablet. Upper limb function, finger dexterity and pinch strength were measured pre and post the recommended treatment program using the quality of upper extremity skill test (QUEST), Nine-Hole Peg Test and Jamar hydraulic pinch gauge, respectively.

RESULTS

All outcome measures were equivalent between intervention groups at admission (P > 0.05). Significant improvements were found in all assessed variables within the two groups. Meanwhile, the intervention group had significantly higher improvements (P < 0.05) in finger dexterity, pinch strength, and upper limb function when compared with the control groups.

CONCLUSION

Including a touch screen smart tablet application with a specially designed fine motor program is an effective method that helps children with U-CP perform more effectively with their fine motor skills.

A Home-Based Exercise Program With Active Video Games for Balance, Motor Proficiency, Foot and Ankle Ability, and Intrinsic Motivation in Children With Chronic Ankle Instability: Feasibility Randomized Controlled Trial

Background

Children with chronic ankle instability (CAI) frequently experience ankle unsteadiness, causing trips, falls, and ankle sprain injuries resulting in poor quality of life. A specific exercise program focused on physical and psychological purposes in children with CAI is needed.

Objective

The purpose of this study was to investigate the feasibility of a 4-week home-based exercise training program using active video games (AVGs) for balance, motor proficiency, foot and ankle ability, and intrinsic motivation in children with CAI.

Methods

Sixty children with CAI (mean age 10, SD 2 years) were randomly assigned to an experimental group (AVG group; n=30) or a control group (CG; n=30). The AVG group played 2 selected video games, Catching Fish and Russian Block, while the CG received the traditional exercise program for CAI. Both programs were scheduled for 30 minutes per day, 3 times per week, for 4 weeks at home. The single-leg stance test was used to assess static balance. The walking forward on a line and standing long jump tests were used to assess motor proficiency. The Foot and Ankle Ability Measure (FAAM) and the Intrinsic Motivation Inventory questionnaire were used to assess foot and ankle ability and intrinsic motivation, respectively. Assessments were conducted at baseline and after 4 weeks.

Results

In the AVG group, the single-leg stand test (eyes open; on floor and on foam conditions), the FAAM (activities of daily living subscale), and intrinsic motivation (interest/enjoyment, pressure/tension, and value/usefulness dimensions) were improved compared with the CG (all P<.05). Motor proficiency did not differ between the 2 groups at the end of the 4-week program (P=.31 for the walking forward on a line, P=.34 for the standing long jump test).

Conclusions

A 4-week home-based exercise training program using AVGs can be beneficial and may be an effective approach for improving balance, foot and ankle ability, and enhancing positive motivation by increasing the interest/enjoyment and value/usefulness dimensions and lowering the pressure/tension dimension in children with CAI that require long-term rehabilitation sessions.

Evaluation of a computer game-assisted rehabilitation program for manual dexterity of children with cerebral palsy: Feasibility randomized control trial

BACKGROUND

There is a need for innovation to improve the engagement and compliance of rehabilitation programs for children with upper extremity (UE) motor impairments due to cerebral palsy (CP); a computer games-based rehabilitation platform (GRP) was developed to address this need. The GRP provides engaging task-specific exercises targeting manual dexterity (object handling and manipulation).

OBJECTIVE

To evaluate the therapeutic value and treatment effect size of an exercise program using the GRP in children with CP.

METHODS

A total of 63 children with CP, aged 4 to 10 years, were recruited. The Peabody Developmental Motor Scale-2 (PDMS-2) Grasp and Visual-Motor Integration (VMI) subscores and Computer game-based Upper Extremity (CUE) assessment of manual dexterity were used to assess participants before and after a 16-week intervention program, delivered three times per week. The experimental group (XG) received a computer games-based exercise program targeting object manipulation tasks. The active control arm (CG) consisted of task-specific training similar to the tasks used in constrained induced movement therapy.

RESULTS

There were only a few dropouts during the 16-week program, and compliance was high. Both groups showed significant improvements with medium to large effect sizes. Improvements in the PDMS-2 Grasp and VMI subscores observed in the XG were significantly greater than that in the CG. There were significant improvements (p < .01) in PDMS-2 grasp and VMI subscores for XG with moderate to large effect sizes (0.5-0.8). For CG, the Grasp and VMI subscores did improve but these changes were not statistically significant. There was a significant improvement observed in the majority of CUE object manipulation test scores for XG (p < .01) with moderate to large effect sizes (0.50-1.2) Although CG did show improvements in all CUE object manipulation test scores, the changes did not reach statistical significance (p < .01).

CONCLUSION

This study demonstrates the utility of the GRP to practice a broad range of object manipulation tasks in children with CP. The present findings are positive and support further research and development. The long-term effects of the GRP program in children with CP will need to be confirmed in a future randomized controlled trial. In addition to measures of structure and function, future trials should also include outcome measures such as health-related quality of life and level of participation to validate the findings.

The Use of Virtual Reality in the Rehabilitation of Chronic Nonspecific Neck Pain: A Systematic Review and Meta-Analysis

OBJECTIVES

There has been a major interest in using virtual reality (VR) as a pain-management tool. This systematic review evaluated the literature on the use of VR in the treatment of chronic nonspecific neck pain (CNNP).

METHODS

Electronic database searches were conducted in Cochrane, Medline, PubMed, Web of Science, Embase, and Scopus between inception and November 22, 2022. Search terms used were synonyms of "chronic neck pain" and "virtual reality." Inclusion criteria were as follows: chronic neck pain patients or pain lasting longer than 3 months; nonspecific neck pain; adult population; VR intervention; and functional and/or psychological outcomes. Study characteristics, quality, participant demographics, and results were independently extracted by 2 reviewers.

RESULTS

VR interventions demonstrated significant improvement in patients experiencing CNNP. Scores in the visual analogue scale, the Neck Disability Index, and range of motion were significantly improved compared with baseline but not better than gold standard kinematic treatments.

DISCUSSION

Our results suggest that VR is a promising tool for chronic pain management; however, there is a lack of VR intervention design consistency, objective outcome measures, follow-up reporting, and large sample sizes. Future research should focus on designing VR interventions to serve specific, individualized movement goals as well as combining quantifiable outcomes with existing self-report measures.

Exergaming and education: a relational model for games selection and evaluation

Exergaming, or technology-driven physical exercise, has gained popularity in recent years. Its applications include physical education, health promotion, and rehabilitation. Although studies have obtained promising results regarding the positive effects of exergaming, the outcomes of exergaming for different populations remain undetermined. Inconsistencies in the literature on this topic have multiple potential explanations, including the content and demand of the exergames and the capability of the exergamer. A model with a sound theoretical framework is required to facilitate matching between games and gamers. This article proposes a relational model based on a matrix of Bloom's taxonomy of learning domains and the performance components of exergames. Appropriate matching of the physical demands of an exergame and the ability of the exergamer would enhance the effective usage of exergaming for individuals with various needs. This theory-based exergame model is developed to promote the general development, physical status, and psychosocial well-being of students, older adults, and individuals with rehabilitation needs. This model may provide a resource for future research on the application, effectiveness, and design of exergaming.

Bimanual movements in children with cerebral palsy: a systematic review of instrumented assessments

BACKGROUND

Assessment of bimanual movements, which are frequently impaired in children with cerebral palsy, is highly challenging in clinical practice. Instrumented measures have been developed to evaluate and help to understand impaired upper limb movement during bimanual tasks in these children. The aim of this review was to report instrumented measurement tools (3D motion analysis, sensors, etc.) used for bimanual task movement analysis, and the metrological properties of the measures in children with cerebral palsy.

METHODS

A systematic review was conducted (Prospero CRD42022308517). PubMed, Web of Science, Cochrane and Scopus databases were searched with relevant keywords and inclusion/exclusion criteria. Article quality and biomechanical methods were evaluated with a customized scale and metrological properties with the COSMIN checklist.

RESULTS

In total, 452 children, mostly with unilateral cerebral palsy, mean age 10.9 (SD 3.2) years, underwent quantitative bimanual assessments in the 31 included studies (mean quality score 22/32 points [SD 4.7]). The tools used were 3D motion analysis (n = 26), accelerometers (n = 2), and other instruments (cube, digitizer, etc.) (n = 3). Children performed 1-5 bimanual tasks in laboratory settings, mostly activities of daily living or game scenarios. Analyses focused mostly on spatiotemporal variables, 6 of which were specifically developed for bilateral measures (task completion time, goal synchronization, movement overlap time, interlimb coupling, continuous relative phase and asynchrony). These instrumented measurements had moderate to good discriminant and convergent validity, but reliability and responsiveness assessments were lacking.

CONCLUSIONS

A large number of quantitative bimanual assessments involving different tools, bimanual tasks and specific variables developed to evaluate bimanual function were found. Development of other relevant variables and validation of these tools are needed to further determine their usefulness, both as research outcomes and to guide therapies in clinical practice. Future research, involving younger children and real-life assessments, will improve our understanding of bimanual function in children with cerebral palsy.

Home-based exergaming training effects for two individuals with spinal cord injury: A case report

INTRODUCTION

Exergaming is a type of serious game that requires active bodily movements for video gameplay. This game-based exercise is gaining interest as a form of leisure activity of moderate-vigorous dose intensity.

OBJECTIVE

This case report sought to assess the effects of exergaming training (i.e. Move Boxing, Move Tennis, and Move Gladiator Duel) on aerobic capacity, feasibility, enjoyment and motivation in two individuals with spinal cord injury (SCI).

CASE DESCRIPTIONS

Two males with SCI at the level of L4 and T10, aged 32 and 39, respectively, underwent home-based exergaming training sessions over a period of 12-18 weeks, conducted within moderate-vigorous intensity training zones for health improvements as recommended by health guidelines. Their peak oxygen consumption (VO₂), physical activity levels and perceived enjoyment were evaluated before, during and after the completion of the training.

OUTCOMES

Participant peak VO₂ improved (effect size g = 2.7) from their baseline values (Participant A: 16.0 ± 0.7 mL/kg/min to 41.7 ± 8.1 mL/kg/min; Participant B: 13.5 ± 0.8 mL/kg/min to 32.7 ± 5.2 mL/kg/min), with an increase in overall weekly physical activity levels. Both participants maintained a relatively high level of enjoyment scores throughout their training period (mean: 31.9 ± 3.2, p = .56, 95% CI 0.22-1.0).

CONCLUSION

A home-based exergaming training program improved aerobic capacity and level of physical activity, while maintaining adherence to the exercise within a relatively high perception of enjoyment for these two participants. The relatively high enjoyment scores maintained throughout the duration of the exergaming training period suggested its feasibility as a home-based exercise program and perceived as enjoyable by these individuals.

Clinician perspectives on the implementation of inpatient cycling-based exergames for children with cerebral palsy: A qualitative study

OBJECTIVE

To understand the perspectives of key stakeholder clinicians in implementing inpatient cycling-based exergames for children with cerebral palsy (CP) into pediatric rehabilitation.

METHODS

Sixteen clinicians (nurses, physiotherapists, recreational therapists) that participated in a study exploring the feasibility of implementing cycling-based exergames for inpatient children with CP were interviewed. Clinicians' responses were coded using the Theoretical Domains Framework (TDF). Beliefs were generated from each response and relevant domains were identified.

RESULTS

Ten domains from the TDF were identified as relevant. Key enablers to clinician participation in future implementation included revision of clinician roles and responsibilities, the belief that children with CP will benefit from exergames, and the belief in potential applicability to other pediatric populations. Barriers included clinician limited time and exergame responsibilities not aligning with perceived clinician roles.

CONCLUSIONS

This study identifies key barriers and enablers that future inpatient pediatric rehabilitation settings should consider when incorporating exergames into rehabilitation practice.

Feasibility of Using Joystick-Operated Ride-on-Toys to Promote Upper Extremity Function in Children With Cerebral Palsy: A Pilot Study

PURPOSE

To evaluate the feasibility of implementation, acceptance, and perceived efficacy of a joystick-operated ride-on-toy intervention to promote upper extremity (UE) function in 3- to 14-year-old children with hemiplegic cerebral palsy.

METHODS

Exit questionnaires were collected from children, caregivers, and clinicians/camp staff following a 3-week ride-on-toy training program incorporated within a summer camp for children with hemiplegic cerebral palsy. Training encouraged children to use their affected UE to maneuver the ride-on-toy. Questionnaires included Likert scale and open-ended questions to assess enjoyment, acceptance, feasibility, and perceived efficacy of the training.

RESULTS

All stakeholder groups indicated that the training was enjoyable. Clinicians/staff and caregivers indicated that the training increased children's motivation to use their affected UE and reported perceived improvements in UE movement control and function following training.

CONCLUSIONS

Our promising preliminary findings call for future research to systematically assess the efficacy of ride-on-toys to promote UE control and function in children with hemiplegic cerebral palsy.Supplemental Digital Content 1 video abstract, available at: http://links.lww.com/PPT/A404.

Exercise intensity of active video gaming in cerebral palsy: hip- versus wrist-worn accelerometer data

OBJECTIVE

The aim of this study was to compare exercise intensity of active video games (AVGs) between hip- and wrist-worn accelerometer data in cerebral palsy (CP).

METHODS

Twenty children and adolescents (9.35 ± 3.71 years) with CP performed two exercise sessions, completing a standardized series of AVGs. Exercise intensity was collected, while one accelerometer was fitted to wrist and hip in separate, counterbalanced sessions.

RESULTS

Accelerometer counts per minute and cut-points determined were significantly different between the wrist- and hip-worn outputs (p < .001). Metabolic equivalents (METs) of performing AVGs exceeded the three METs moderate intensity threshold in wrist-worn (3.12 ± 0.86) accelerometer and hip-worn data tend to underestimate intensity (1.16 ± 0.08).

CONCLUSIONS

Previous studies showed METs required to perform AVGs were related to moderate intensity (3-6 METs) in CP with mild deficits. Wrist-worn accelerometer, exceeding 3 METs, seem to have higher accuracy in measuring exercise intensity of AVGs than hip-worn.

Attitudes and Behaviors of Physical Activity in Children with Cerebral Palsy: Findings from PLAY Questionnaire

To investigate the domains of physical activity in children with cerebral palsy (CP) and to compare these findings to typically developed (TD) children. Methods: A cross-sectional study design. Responses of the four domains in Play Lifestyle and Activity in Youth (PLAY) questionnaire were descriptively analyzed and compared between children with CP (GMFCS I-II) and TD children. Results: Fifty-three children with CP (N = 53, 36 males and 17 females, age of 8.4 ± 1.7 years) and 58 TD children (N = 58, 34 males and 24 females, age of 7.6 ± 1.4 years) participated in this study. In analyses of daily behavior, reported participation in weekly (adaptive) physical education (PE) and sports were more frequent in children with CP (0.6 ± 0.5 days per week) compared to TD children (0.4 ± 0.6 days per week, p = 0.040). Outside play time including free play, organized (adaptive) sports and recess were higher in children with CP (2.7 ± 0.8 days per week) than TD children (2.4 ± 0.7 days per week, p = 0.022). About motivation/attitudes, a higher proportion of TD children feel sad if they are not able to play sports during the day (74.1%) compared to children with CP (48.7%, p < 0.001). Conclusion: Physical activity level was comparable between children with CP and age-matched TD children, while TD children showed higher scores in knowledge and understanding, motivation/attitudes, and physical competence.

Efficacy of Virtual Reality-Based Rehabilitation Interventions to Improve Balance Function in Patients with Cerebral Palsy: A Systematic Review and Meta-analysis of RCTs

Context: Cerebral palsy (CP) results from damage to the central nervous system, leading to disturbances of motor and sensory functions, especially the balance. Virtual reality exercise intervention (VRI) is a promising technique to improve motor function in children with CP by engaging such individuals in real-like world events through simulations. This review study examines the effects of VRI on static and functional balances and summarizes the effective protocols of virtual reality-based rehabilitation interventions for the CP patients. Methods: A comprehensive search was performed using the following databases: Medline/PubMed, Scopus, Cochrane Library, PEDro, EBSCOhost, and the Online Library of the University of London. The PEDro scale was used to assess the methodological quality. The data extracted from the reviewed studies were coded according to Cooper and Hedges’ guidelines considering the following criteria: (I) Patients' characteristics, (II) intervention protocols, (III) outcomes, and (IV) results. To this end, twelve RCTs with 248 patients aged 4 - 20 years old were analyzed and assessed as "fair" to "good" methodological quality according to Pedro’s scale (4 to 8). VRI alone or in combination with a standard physiotherapy program or with other tools such as tDCS was applied. Results: Twelve RCTs met the inclusion criteria. The meta-analysis showed the good effect of VRI on the static and functional balances of patients with CP (Cohen’s d = 0.66). The funnel plot revealed no significant asymmetry or heterogeneity among the studies (P = 0.271, I2 = 19.71%), reflecting the absence of publication biases. Conclusions: This review reports four major perspectives of the VRI applications: (1) VRI settings, (2) selection of exercises, (3) outcome measures, and (4) long-term effects. Moreover, this review summarizes the specific effects of VRI on balance improvement in patients with CP from different perspectives. However, considering the limited number of well-conducted RCTs in this field, a large homogeneous samples size is still needed for future RCTs.

Active Videogaming Interventions in Adults with Neuromuscular Conditions: A Scoping Review

This review synthesized active videogaming (AVG) intervention literature over a 10-year period (2010-2020) for people with neuromuscular conditions (18-64 years of age), examining interventions that aimed to improve health and secondary conditions, physical activity, and outcomes quality of life (QOL). Systematic searches yielded 40 eligible studies. The major groups were multiple sclerosis (40%) and stroke (33%), and the study participants had mostly mild-to-moderate disability who were able to play games in a standing position. Research designs primarily involved randomized controlled trials (65%) and pre/post-trial design without a control group (28%). The majority of interventions used commercial off-the-shelf gaming systems, such as Nintendo Wii and Microsoft Kinect. Studies reported significant improvements in health outcomes, specifically in balance (n = 30/36), mobility (n = 24/27), and cardiorespiratory fitness (n = 6/8). Positive changes were also seen in secondary conditions (n = 8/12), physical activity (n = 3/4), and QOL outcomes (n = 8/16). AVG research for people with neuromuscular conditions has grown in both quantity and quality but several gaps remain. Study findings provide a roadmap for future AVG trials on understudied populations, and highlight technology and targeted outcomes as drivers of future intervention research.

Interactive Video Games as a Method to Increase Physical Activity Levels in Children Treated for Leukemia

Despite the beneficial effect of exercise, children treated for cancer do not engage in sufficient physical activity. It is necessary to search for attractive forms of physical activity, including interactive video games (IVGs). The aim of this study was to verify the effectiveness of the rehabilitation model developed by the authors based on the use of IVGs in children undergoing leukemia treatment. The study included a group of 21 children aged 7–13 years (12 boys, 9 girls) undergoing treatment for acute lymphoblastic leukemia (ALL) (n = 13) and acute myeloid leukemia (AML) (n = 8). The children were randomly assigned to an intervention group and a control group. To assess the level of cardiorespiratory fitness (CRF), each child participated in a Cardiopulmonary Exercise Test. Daily physical activity was assessed using the HBSC questionnaire. The study also used the Children’s Effort Rating Table Scale (CERT) to assess the intensity of physical effort. The children in the intervention group participated in 12 sessions of. The study participants managed to complete all stages of a progressive training program, which confirmed the feasibility of such physical effort by patients with cancer. Pediatric patients reported that the IVG training required a light to moderate physical effort despite high values of energy expenditure (EE).

Mental Health Benefits of Physical Activity in Youth with Cerebral Palsy: A Scoping Review

AIMS

Children and adolescents with cerebral palsy (CP) are at heightened risk for mental health problems. Physical activity is an effective strategy to promote quality of life (QoL) and reduce mental health symptoms along with evidence-based therapies. This study described existing literature examining the mental health outcomes (e.g., QoL, well-being, anxiety, and depression) of physical activity interventions in children and adolescents with CP to help inform the implementation of physical activity interventions for this population.

METHODS

Ascoping review framework was used to map the existing quantitative literature.

RESULTS

The search returned 243 articles; after titles, abstracts, and full manuscripts were reviewed, 21 articles were included. The association between physical activity and QoL was examined in most studies (n = 17) with mixed findings. Eight studies documented at least one significant positive association between physical activity and QoL, and four found that physical activity interventions were highly enjoyable. Only one study assessed anxiety and/or depression following a PA intervention.

CONCLUSIONS

Physical activity may benefit aspects of QoL and mental health symptoms; however, this was not a consistent finding in the existing literature. Along with other therapies, physical activity interventions may be valuable in improving QoL, and in turn, the mental health symptoms of children with CP.

Design and Evaluation of a Hands-Free Video Game Controller for Individuals With Motor Impairments

Over the past few decades, video gaming has evolved at a tremendous rate although game input methods have been slower to change. Game input methods continue to rely on two-handed control of the joystick and D-pad or the keyboard and mouse for simultaneously controlling player movement and camera actions. Bi-manual input poses a significant play impediment to those with severe motor impairments. In this work, we propose and evaluate a hands-free game input control method that uses real-time facial expression recognition. Through our novel input method, our goal is to enable and empower individuals with neurological and neuromuscular diseases, who may lack hand muscle control, to be able to independently play video games. To evaluate the usability and acceptance of our system, we conducted a remote user study with eight severely motor-impaired individuals. Our results indicate high user satisfaction and greater preference for our input system with participants rating the input system as easy to learn. With this work, we aim to highlight that facial expression recognition can be a valuable input method.

Upper Limb Movement Measurement Systems for Cerebral Palsy: A Systematic Literature Review

Quantifying the quality of upper limb movements is fundamental to the therapeutic process of patients with cerebral palsy (CP). Several clinical methods are currently available to assess the upper limb range of motion (ROM) in children with CP. This paper focuses on identifying and describing available techniques for the quantitative assessment of the upper limb active range of motion (AROM) and kinematics in children with CP. Following the screening and exclusion of articles that did not meet the selection criteria, we analyzed 14 studies involving objective upper extremity assessments of the AROM and kinematics using optoelectronic devices, wearable sensors, and low-cost Kinect sensors in children with CP aged 4–18 years. An increase in the motor function of the upper extremity and an improvement in most of the daily tasks reviewed were reported. In the population of this study, the potential of wearable sensors and the Kinect sensor natural user interface as complementary devices for the quantitative evaluation of the upper extremity was evident. The Kinect sensor is a clinical assessment tool with a unique markerless motion capture system. Few authors had described the kinematic models and algorithms used to estimate their kinematic analysis in detail. However, the kinematic models in these studies varied from 4 to 10 segments. In addition, few authors had followed the joint assessment recommendations proposed by the International Society of Biomechanics (ISB). This review showed that three-dimensional analysis systems were used primarily for monitoring and evaluating spatiotemporal variables and kinematic parameters of upper limb movements. The results indicated that optoelectronic devices were the most commonly used systems. The joint assessment recommendations proposed by the ISB should be used because they are approved standards for human kinematic assessments. This review was registered in the PROSPERO database (CRD42021257211).

Nintendo Wii Balance Board therapy for postural control in children with cerebral palsy: a systematic review and meta-analysis

AIM

To analyse the efficacy of Nintendo Wii therapy (NWT) on functional balance in children with cerebral palsy (CP).

METHOD

A systematic review with meta-analysis (PROSPERO identification number CRD42020169510) was performed using randomized controlled trials (RCTs) that examined the effect of NWT on functional, dynamic, and static balance in children with CP, assessed with the Pediatric Balance Scale, the Timed Get Up and Go Test, and the One Leg Stance Test respectively. The pooled effect was calculated using the Cohen's standardized mean difference (SMD).

RESULTS

Eleven RCTs with 270 children (when sex was reported: 43% females, 57% males) with CP (mean age [SD] 10y 1mo [1y 1mo], range 5-16y) were included. On functional balance, we found very low-quality evidence with a large effect of NWT compared with no intervention (SMD 0.95, 95% confidence interval [CI] 0.02-1.89) and moderate-quality evidence for using NWT plus conventional physical therapy (CPT) versus CPT (SMD 0.78, 95% CI 0.20-1.35) in sessions of approximately 30 minutes (SMD 0.86, 95% CI 0.20-1.52) and interventions lasting longer than 3 weeks (SMD 1.03, 95% CI 0.58-1.47). For dynamic balance, very low-quality evidence for a medium effect for using NWT plus CPT versus CPT (SMD 0.70, 95% CI 0.12-1.29) was found.

INTERPRETATION

NWT can be considered an effective treatment for improving functional and dynamic balance in children with CP, especially when combined with CPT in 30-minute sessions with interventions lasting longer than 3 weeks. What this paper adds Moderate-quality evidence with a large effect of Nintendo Wii therapy (NWT) on functional balance, compared with conventional physical therapy (CPT). Moderate-quality evidence with medium effect of NWT plus CPT on functional and dynamic balance, compared with CPT. Appropriate NWT sessions should be equal to or slightly less than 30 minutes. NWT interventions must be longer than 3 weeks.

Seriously Foolish and Foolishly Serious: The Art and Practice of Clowning in Children's Rehabilitation

This paper interrogates and reclaims clown practices in children's rehabilitation as 'foolish.' Attempts to legitimize and 'take seriously' clown practices in the health sciences frame the work of clowns as secondary to the 'real' work of medical professionals and diminish the ways clowns support emotional vulnerability and bravery with a willingness to fail and be ridiculous as fundamental to their work. Narrow conceptualizations of clown practices in hospitals as only happy and funny overlook the ways clowns also routinely engage with sadness, despair, discomfort and many other ways of being and doing. Our exploration of clown practices as foolish exposes the ways children's rehabilitation upholds particular neoliberal models of success and invites a re-centring of rehabilitation and health care research and practice towards relationship building, supporting meaningful projects and a continued nurturing of aesthetic and pleasurable ways of being-in-the-world in the present moment as valuable unto themselves.

Active Video Gaming Using an Adapted Gaming Mat in Youth and Adults With Physical Disabilities: Observational Study

Background

A common leisure-time activity amongst youth and adults in the United States is video gameplay. Playing video games is typically a sedentary endeavor; however, to encourage an increased level of physical activity in an engaging and enjoyable way, active video gaming has become popular. Unfortunately, the accessibility of gaming controllers is often an issue for persons with disabilities. A commercial off-the-shelf (OTS) gaming mat was adapted to facilitate use by individuals with mobility impairments to address this issue.

Objective

Our study aimed to examine energy expenditure, enjoyment, and gameplay experience in youth and adults with mobility impairment during active video gaming using an OTS and adapted versions of a gaming mat.

Methods

The study used an observational design. During visit 1, physical function was assessed, and participants were given a familiarization period with the gaming system. For visit 2, based on observation during the physical function tests and discussion with the participant, it was decided whether the participant would play in a standing or seated position. For standing gameplay, the mat was placed on the floor, and for seated play, the mat was placed on a height-adjustable and tilt-adjustable tabletop. Metabolic data were collected during a 20-minute baseline and four 10-minute bouts of Wii Fit Plus gameplay, with 2 bouts on each of the mats (adapted and OTS). During gameplay, the research staff observed and rated participants’ ability to use the game controller (mat) and the quality of gameplay. At the end of each game set, participants reported their rating of perceived exertion on a scale from 0 to 10. During rest, participants completed the physical activity enjoyment scale. Participants also answered additional questions regarding the system's usability with each controller (adapted mat and OTS mat). Statistical analyses were computed using Stata 16 (version 16.1; StataCorp). Linear mixed-effects maximum likelihood regression was performed separately for individuals who could play standing and for those who played seated.

Results

A convenience sample of 78 individuals with mobility impairments between the ages of 12 and 60 years (mean 39.6, SD 15.8) participated in the study. Of the sample, 48 participants played the video games in a seated position, while 30 played the games standing. Energy expenditure and heart rate tended to be higher in the OTS mat condition for seated players, while values were similar for both conditions among standing players. However, seated participants reported greater gameplay experience, and both groups exhibited a higher quality of gameplay during the adapted mat condition.

Conclusions

Active video gaming using an adapted gaming mat provided an enjoyable exercise activity for individuals with mobility impairments. The use of the adapted controller provides a means by which this population can engage in light to moderate intensity active video gaming, thereby reducing sedentary leisure time.

Trial Registration

ClinicalTrials.gov NCT02994199; https://clinicaltrials.gov/ct2/show/NCT02994199

Performance Variability During Motor Learning of a New Balance Task in a Non-immersive Virtual Environment in Children With Hemiplegic Cerebral Palsy and Typically Developing Peers

Background: Motor impairments contribute to performance variability in children with cerebral palsy (CP) during motor skill learning. Non-immersive virtual environments (VEs) are popular interventions to promote motor learning in children with hemiplegic CP. Greater understanding of performance variability as compared to typically developing (TD) peers during motor learning in VEs may inform clinical decisions about practice dose and challenge progression. Purpose: (1) To quantify within-child (i.e., across different timepoints) and between-child (i.e., between children at the same timepoint) variability in motor skill acquisition, retention and transfer in a non-immersive VE in children with CP as compared to TD children; and (2) To explore the relationship between the amount of within-child variability during skill acquisition and learning outcomes. Methods: Secondary data analysis of 2 studies in which 13 children with hemiplegic CP and 67 TD children aged 7-14 years undertook repeated trials of a novel standing postural control task in acquisition, retention and transfer sessions. Changes in performance across trials and sessions in children with CP as compared to TD children and between younger (7-10 years) and older (11-14 years) children were assessed using mixed effects models. Raw scores were converted to z-scores to meet model distributional assumptions. Performance variability was quantified as the standard deviation of z-scores. Results: TD children outperformed children with CP and older children outperformed younger children at each session. Older children with CP had the least between-child variability in acquisition and the most in retention, while older TD children demonstrated the opposite pattern. Younger children with CP had consistently high between-child variability, with no difference between sessions. Within-child variability was highest in younger children, regardless of group. Within-child variability was more pronounced in TD children as compared to children with CP. The relationship between the amount of within-child variability in performance and performance outcome at acquisition, retention and transfer sessions was task-specific, with a positive correlation for 1 study and a negative correlation in the other. Conclusions: Findings, though preliminary and limited by small sample size, can inform subsequent research to explore VE-specific causes of performance variability, including differing movement execution requirements and individual characteristics such as motivation, attention and visuospatial abilities.

The Effects of Virtual Reality on Upper Extremity in Patients with Obstetric Brachial Plexus Injury

The present study aimed to examine the effects of playing Nintendo Wii games on upper extremity functions compared with conventional physiotherapy, in children with obstetric brachial plexus injury (OBPI). Twenty-two patients with brachial plexus injuries were enrolled. The patients were divided into two groups by simple randomization. The control group (conventional physiotherapy group [CTG]: n = 11) received conventional physiotherapy for 6 weeks (40 minutes per day, for 4 days per week). The study group, called Nintendo Wii group (NWG; n = 11), received conventional physiotherapy as well as tennis, baseball, and boxing games with Nintendo Wii on days when there was no physical therapy. The upper extremity range of motion (ROM) was evaluated using a digital goniometer, motor function was assessed using the Active Movement Scale (AMS), and shoulder functions were assessed with the Mallet Scoring System (MSS). Virtual reality treatment had a positive effect on shoulder flexion, forearm pronation, wrist flexion, ROM, and functionality (p < 0.05). There was a significant improvement in shoulder abduction and shoulder external rotation in the CTG (p < 0.05). There was no significant difference in the MSS values of either groups (p > 0.05). As per the AMS, in the NWG, the shoulder internal rotation increased significantly (p < 0.05). Nintendo Wii treatment used in addition to conventional physiotherapy may be effective in increasing upper extremity functions in children with OBPI.

Active Video Games and Low-Cost Virtual Reality: An Ideal Therapeutic Modality for Children With Physical Disabilities During a Global Pandemic

Current guidelines against spread of coronavirus (COVID-19) interrupt non-essential rehabilitation services. Thus, individuals with physical disabilities such as children with cerebral palsy can no longer benefit from physical rehabilitation during this undetermined period. Using either a synchronous or asynchronous format, in collaboration with a therapist via telerehabilitation, we suggest that active video games and low-cost virtual reality are a promising delivery mode for at-home rehabilitation in the context of a global pandemic. This therapeutic modality, incorporated into an at-home individualized treatment plan, provides a means to lessen the impact of an interruption in rehabilitation services while not loosing the pre-pandemic, in-person physical activity gains. Growing evidence supports active video games and low-cost virtual reality as viable therapeutic interventions for children with physical disabilities. These technologies are especially well-accepted by pediatric populations for the ludic and motivating features that lend themselves to nearly seamless incorporation into telerehabilitation. Advantages for rehabilitation of active video games and low-cost virtual reality include a rich, challenging, multi-modal training environment in which high numbers of movement repetitions can be accomplished, and a unique opportunity to foster engaged practice actions that go beyond household activities. We offer suggestions for the clinician about how to adopt active video games and low-cost virtual reality into your practice during a global pandemic.

Impact of Kinect-based virtual reality training on physical fitness and quality of life in severely burned children: a monocentric randomized controlled trial

BACKGROUND

Pediatric burns lead to persistent and detrimental muscle breakdown, weakness and poor quality of life, so rehabilitation is integral for improving physical and psychological outcomes. However, children with burns are a major challenge to a rehabilitation team. To overcome these challenges, enjoyable and interesting interventions are suggested.

OBJECTIVE

We aimed to determine the impact of the Xbox Kinect on cardiopulmonary fitness, muscle strength, lean mass, quality of life and enjoyment in severely burned children after hospital discharge.

METHODS

This was a randomized controlled trial in a single centre. Participants (n= 40 children) with burn injuries were randomized to the Xbox training group (n=20) or control group (n=20) during 12 weeks. All children received a home programme rehabilitation and Xbox training children received Xbox training. Outcomes included cardiopulmonary fitness (VO2peak), muscle strength (peak torque), lean mass (whole-body and regional), quality of life and physical activity enjoyment at baseline, immediately after hospital discharge, and 12 weeks after the intervention.

RESULTS

The mean (SD) age of the 40 children was 12.97 (1.42) years and total body surface area of burn was 51% (5). The groups did not differ in characteristics at baseline (P < 0.05). After 12 weeks of the intervention, the groups significantly differed in VO2peak, peak torque, quality of life (p<0.001), lean mass and leg lean mass (p<0.05) in favour of Xbox training. The mean difference in VO2peak, peak torque, lean mass and leg lean mass was 3.25 (2.1; 4.5) ml/kg/min, 7.5 (5.8; 9.2) Nm, 1.81 (0.5; 3.1) kg, and 1.1 (0.1; 2.1) kg, respectively. Lean trunk mass did not significantly differ between groups (p=0.07). The Xbox training group reported significantly more enjoyment than did the control group (p<0.001).

CONCLUSION

Xbox Kinect training can increase cardiopulmonary fitness, muscle strength, lean mass and quality of life in burned children. It is one of the most enjoyable, motivated and efficient treatment modalities that should be widely introduced into the pediatric burn rehabilitation.

Physiological Responses of Exergaming Boxing in Adults: A Systematic Review and Meta-Analysis

Objective: Studies investigating the effects of exergaming in available platforms are still limited. This review aims to systematically identify available studies on physiological intensities of exergaming boxing in able-bodied adults and recategorize them based on different platforms or environments. The meta-analysis further analyzes the physiological responses during exergaming boxing into a set of pooled data for any evidence of outliers, heterogeneity, or publication bias. Materials and Methods: A systematic search was conducted by using databases from Google Scholar, PubMed, and Web of Science. Population, intervention, comparison, and outcomes (PICO) and preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used in the study selection process for the review. Results: From the 1534 articles examined, 16 articles were included for further analyses. Results indicated that exergaming boxing exhibits a wide range of metabolic equivalent of task (MET) values and intensity, from very light to vigorous, with elements of heterogeneity and bias detected. The Xbox^® Kinect boxing platform produced higher MET (mean = 5.3) compared with the Nintendo^® Wii^™ boxing (mean = 3.8). Conclusion: The results of this review suggest that boxing exergames can produce intensity-adequate physical activity among younger adults that are beneficial for cardiometabolic improvements, regardless of platforms used. Exergaming boxing may be employed as an effective exercise tool to increase energy expenditure and physical activity level in young adults.

Advancing Brain-Computer Interface Applications for Severely Disabled Children Through a Multidisciplinary National Network: Summary of the Inaugural Pediatric BCI Canada Meeting

Thousands of youth suffering from acquired brain injury or other early-life neurological disease live, mature, and learn with only limited communication and interaction with their world. Such cognitively capable children are ideal candidates for brain-computer interfaces (BCI). While BCI systems are rapidly evolving, a fundamental gap exists between technological innovators and the patients and families who stand to benefit. Forays into translating BCI systems to children in recent years have revealed that kids can learn to operate simple BCI with proficiency akin to adults. BCI could bring significant boons to the lives of many children with severe physical impairment, supporting their complex physical and social needs. However, children have been neglected in BCI research and a collaborative BCI research community is required to unite and push pediatric BCI development forward. To this end, the pediatric BCI Canada collaborative network (BCI-CAN) was formed, under a unified goal to cooperatively drive forward pediatric BCI innovation and impact. This article reflects on the topics and discussions raised in the foundational BCI-CAN meeting held in Toronto, ON, Canada in November 2019 and suggests the next steps required to see BCI impact the lives of children with severe neurological disease and their families.

Effect of Wii-habilitation on spatiotemporal parameters and upper limb function post-burn in children

BACKGROUND

Limb burns can cause different functional disorders that greatly impact one's quality of life.

AIM

The purpose of the current study was to compare the effect of Nintendo Wii sports intervention, and traditional treatment methods on spatiotemporal parameters and upper limb function post-burn in children.

METHODS

Thirty children their age ranging from 7-12 years, with dominant side upper limb burn participated in the study.Vicon3-D motion analysis system and Jebsen hand function test were used to evaluate spatiotemporal parameters (movement duration, peak velocity, and time to peak velocity percentage in three functional tasks) and upper limb function respectively. The children were randomly divided into study and control groups. The study group was rehabilitated with Wii training in addition to traditional therapy, while the control group rehabilitated only with the traditional therapy program. For the study group, the games selected were Wii Bowling, Baseball, and Tennis. Both groups were trained for 60 min daily, three times/week for six weeks. The outcomes were measured pre and post the treatment period.

RESULTS

The whole-time duration and peak velocity improved significantly in the study group across the hand to head task (p = 0.001, p < 0.001, respectively), hand to mouth (p = 0.001), and hand to shoulder (p < 0.001, p = 0.0018, respectively) compared with the control group. The time to peak velocity percentage was enhanced significantly in the study group (p < 0.001) than the control group in all three-measured tasks. Moreover, the Jebsen hand function test improved significantly (p < 0.001) in the study group than in the control group.

CONCLUSION

Wii-habilitation could be advised as an effective tool in the rehabilitation program of children with post-burn injuries.

Effectiveness of active video game usage on body composition, physical activity level and motor proficiency in children with intellectual disability

BACKGROUND

Interventions with active video games (AVGs) can promote physical activity (PA) and health and are compatible with a school setting. The needs of children with intellectual disability (ID) in this area have been neglected.

METHODS

A two-arm trial was conducted among 203 students with intellectual disability. The intervention group was prescribed a 12-week intervention with AVG. The control group continued with usual PA.

RESULTS

Children's BOT-2 short-form score increased in both the intervention and control groups. However, the AVG intervention had no statistically significant effect on children's body composition, PA and motor proficiency overall, or in analyses of subgroups based on age, body weight and comorbid autism.

CONCLUSION

Active video game intervention had no marked effect on body composition, PA and motor proficiency in children with intellectual disability. The reasons for the lack of effectivity of the intervention are discussed; these may provide better guidelines for future AVG intervention in children with intellectual disability.

Sticking to It: A Scoping Review of Adherence to Exercise Therapy Interventions in Children and Adolescents With Musculoskeletal Conditions

OBJECTIVE

To identify and categorize barriers, facilitators, and strategies to boost exercise therapy adherence in youth with musculoskeletal conditions to inform research and clinical practice.

STUDY DESIGN

Scoping review.

LITERATURE SEARCH

We searched MEDLINE, CINAHL, SPORTDiscus, Scopus, PEDro, and ProQuest from inception to October 1, 2019.

STUDY SELECTION CRITERIA

Studies written in English, with original data featuring an adherence barrier, facilitator, or boosting strategy for exercise therapy in youth (age, 19 years or younger) with musculoskeletal conditions, were included.

DATA SYNTHESIS

Arksey and O'Malley's framework and the PRISMA Extension for Scoping Reviews guided data synthesis. Study quality was assessed with the Mixed Methods Appraisal Tool. Descriptive consolidation included study and sample characteristics, exercise therapy details, and adherence measurement specifics. Inductive thematic analysis of adherence barriers, facilitators, and boosting strategies followed Braun and Clarke's 6-step guide.

RESULTS

Of 5705 potentially relevant records, 41 studies, representing 2020 participants (64% girls; age range, 2-19 years) with 12 different musculoskeletal conditions and multiple exercise therapy interventions, were included. Despite poor reporting of adherence concepts, time constraints, physical environment (eg, location), and negative exercise experiences were commonly identified barriers. Social support and positive exercise experiences were frequently identified facilitators. Reinforcement, exercise program modification, and education were recurring boosting strategies, despite being infrequent barriers or facilitators.

CONCLUSION

A diversity of barriers to and facilitators of exercise therapy for youth with musculoskeletal conditions were identified. Efforts to link adherence-boosting strategies to an individual's needs should be considered. Making exercise enjoyable, social, and convenient may be important to maximizing adherence in this population. J Orthop Sports Phys Ther 2020;50(9):503-515. Epub 1 Aug 2020. doi:10.2519/jospt.2020.9715.

The Effect of a Rehabilitation Specific Gaming Software Platform to Achieve Individual Physiotherapy Goals in Children with Severe Spastic Cerebral Palsy: A Randomized Crossover Trial

Cerebral palsy (CP) is the most common cause of permanent neurological disabilities in children. Many children require long-term daily physiotherapy (PT), and videogaming is a promising tool to increase motivation in rehabilitation. The short- and medium-term effects of an intervention with rehabilitation specific videogames were evaluated on individually defined therapy goals, gross motor function, and motivation. Thirty-two children with bilateral spastic CP, Gross Motor Function Classification level III-IV, and 6-15 years were randomized into an intervention group (regular PT and gaming) or a control group (regular PT), followed by a crossover. The effects of both training periods (each 12 weeks) were compared using the Goal Attainment Scale (GAS), Trunk Control Measurement Scale (TCMS), Pediatric Balance Scale (PBS), Gross Motor Function Measure-88 (GMFM-88), and Dimensions of Mastery Motivation Questionnaire (DMQ). After 3 months follow-up, children were retested using the GMFM, TCMS, and PBS. The GAS change scores were significantly higher after the intervention compared to the control period (8.5 and 2.4, P < 0.001). The change scores for standing exercises (3.85 and 0.22, P = 0.04) and dynamic sitting balance (5.9 and -1.7, P < 0.001) were also significantly higher. After 3 months follow-up the results did not persist. A combined approach of regular PT and rehabilitation specific gaming showed significant effects on individually defined therapy goals, dynamic sitting balance, and standing exercises. However, the lack of persistent effect indicates that continuous individual goal-oriented PT with the addition of gaming is needed.

A biofeedback-enhanced therapeutic exercise video game intervention for young people with cerebral palsy: A randomized single-case experimental design feasibility study

Importance/Background

Movement-controlled video games have potential to promote home-based practice of therapy activities. The success of therapy gaming interventions depends on the quality of the technology used and the presence of effective support structures.

Aim

This study assesses the feasibility of a novel intervention that combines a co-created gaming technology integrating evidence-based biofeedback and solution-focused coaching (SFC) strategies to support therapy engagement and efficacy at home.

Methods

Following feasibility and single-case reporting standards (CONSORT and SCRIBE), this was a non-blind, randomized, multiple-baseline, AB, design. Nineteen (19) young people with cerebral palsy (8–18 years old) completed the 4-week home-based intervention in France and Canada.

Participant motivations, personalized practice goals, and relevance of the intervention to daily activities were discussed in a Solution Focused Coaching-style conversation pre-, post-intervention and during weekly check-ins. Participants controlled a video game by completing therapeutic gestures (wrist extension, pinching) detected via electromyography and inertial sensors on the forearm (Myo Armband and custom software).

Process feasibility success criteria for recruitment response, completion and adherence rates, and frequency of technical issues were established a priori. Scientific feasibility, effect size estimates and variance were determined for Body Function outcome measures: active wrist extension, grip strength and Box and Blocks Test; and for Activities and Participation measures: Assisting Hand Assessment (AHA), Canadian Occupational Performance Measure (COPM) and Self-Reported Experiences of Activity Settings (SEAS).

Results

Recruitment response (31%) and assessment completion (84%) rates were good and 74% of participants reached self-identified practice goals. As 17% of technical issues required external support to resolve, the intervention was graded as feasible with modifications. No adverse events were reported.

Moderate effects were observed in Body Function measures (active wrist extension: SMD = 1.82, 95%CI = 0.85–2.78; Grip Strength: SMD = 0.63, 95%CI = 0.65–1.91; Box and Blocks: Hedge’s g = 0.58, 95%CI = -0.11–1.27) and small-moderate effects in Activities and Participation measures (AHA: Hedge’s g = 0.29, 95%CI = -0.39–0.97, COPM: r = 0.60, 95%CI = 0.13–0.82, SEAS: r = 0.24, 95%CI = -0.25–0.61).

Conclusion

A definitive RCT to investigate the effectiveness of this novel intervention is warranted. Combining SFC-style coaching with high-quality biofeedback may positively engage youth in home rehabilitation to complement traditional therapy.

Trial registration

ClinicalTrials.gov, U.S. National Library of Medicine: NCT03677193.

The design and evaluation of electromyography and inertial biofeedback in hand motor therapy gaming

This article details the design of a co-created, evidence-based biofeedback therapy game addressing the research question: is the biofeedback implementation efficient, effective, and engaging for promoting quality movement during a therapy game focused on hand gestures? First, we engaged nine young people with Cerebral Palsy (CP) as design partners to co-create the biofeedback implementation. A commercially available, tap-controlled game was converted into a gesture-controlled game with added biofeedback. The game is controlled by forearm electromyography and inertial sensors. Changes required to integrate biofeedback are described in detail and highlight the importance of closely linking movement quality to short- and long-term game rewards. After development, 19 participants (8-17 years old) with CP played the game at home for 4 weeks. Participants played 17 ± 9 min/day, 4 ± 1 day/week. The biofeedback implementation proved efficient (i.e. participants reduced compensatory arm movements by 10.2 ± 4.0%), effective (i.e. participants made higher quality gestures over time), and engaging (i.e. participants consistently chose to review biofeedback). Participants found the game usable and enjoyable. Biofeedback design in therapy games should consider principles of motor learning, best practices in video game design, and user perspectives. Design recommendations for integrating biofeedback into therapy games are compiled in an infographic to support interdisciplinary knowledge sharing.

CORRELATING COMMON CLINICAL POSTURAL STABILITY MEASUREMENTS WITH BALANCE ASSESSMENTS

Postural stability assessments are typically used for training and tracking. The training results of stroke patients are investigated in terms of task execution and experimental methods. However, the selection of evaluation and training tools has not been discussed in depth. To explore the postural stability evaluation index, we used a range of widely applied assessment tools in occupational therapy. Methods: We studied the rehabilitation of 15 patients who had suffered chronic strokes for at least two years. The tools include the Timed Up and Go Test, which is used by rehabilitation professionals in postural stability evaluations, the biodex balance evaluation instrument, and a Kinect game developed for virtual reality therapy. Results: We propose an active and a passive assessment model. For training, we recommend combining active and passive assessments for confirmations. For assessments, the evaluation tool should be selected according to the postural stability task (active or passive). In the predictive models, if the different tools are considered simultaneously, static postural stability should be used as the main investigation. We suggest that by first studying the tools used to investigate postural stability assessments, balance assessments in stroke patients can also be improved.

Benefits of a Dance Intervention on Balance in Adolescents with Cerebral Palsy

AIMS

Cerebral palsy (CP) impacts motor functions such as balance, limits of stability and walking, and may also affect other functions such as attention and rhythm production. Motor and non-motor deficits lead to difficulties in daily life activities. The main objective of this study was to evaluate the effects of a dance intervention on balance in adolescents with CP. The secondary objectives were to evaluate the effects of this intervention on walking speed, attention, and rhythm production.

METHODS

A pre-post design study with a double baseline was conducted on ten adolescents with CP in order to assess the effects of a 10-week dance intervention. The dance intervention focused on improving balance and limits of stability. Outcomes on static and dynamic balance were evaluated with clinical and laboratory tests before and after the intervention. Walking speed, attention, and rhythm production were also evaluated before and after the intervention.

RESULTS

Balance improved after the dance intervention as assessed with both the clinical tests and a laboratory test. Rhythm production also improved after the dance intervention.

CONCLUSIONS

Results suggest that a 10-week dance intervention is an effective activity to improve static and dynamic balance as well as rhythmic production in adolescents with CP.

Jogos eletrônicos na atenção à saúde de crianças e adolescentes: revisão integrativa

Resumo No contexto atual encontramos brincadeiras que envolvem tecnologias avançadas, como o uso de notebooks, smartphones e videogames, sejam no cenário hospitalar, ambulatorial, em clínicas ou em casa, esses dispositivos inovadores estão inseridos na promoção, prevenção, tratamento e recuperação da saúde. Diante do exposto, este estudo tem como objetivo descrever através de revisão integrativa a utilização de jogos eletrônicos na atenção à saúde da criança e adolescentes. Trata-se de uma revisão da literatura nacional e internacional, dos artigos publicados entre os anos de 2007 a 2017, que abordam as implicações do uso de jogos eletrônicos. A coleta de dados foi realizada no período entre janeiro e abril de 2018, por meio de consulta na Biblioteca Virtual em Saúde (BVS), selecionando-se as bases de dados (MEDLINE, LILACS e BDENF) utilizando os Descritores em Ciências da Saúde (DeCS), pela Biblioteca Virtual em Saúde (BVS). Foram utilizados os seguintes descritores: “Criança hospitalizada/ Child Hospitalized”; “Jogos de vídeo/Video Games”; “Promoção da saúde/Health Promotion”. A análise foi realizada a partir da amostra final com 11 artigos. Diante dos achados, foi possível identificar que a literatura aborda questões relacionadas na utilização de jogos eletrônicos. Temáticas relacionadas com promoção, prevenção, tratamento e recuperação da saúde em situações de doenças crônicas e o estímulo de atividades físicas, foram evidenciados no estudo. Com isso, percebe-se a relevância que os profissionais de saúde, em especial os de enfermagem, têm em saber que os jogos eletrônicos podem auxiliar no cuidado de crianças com doenças agudas ou crônicas, que estejam ou não hospitalizadas.

Interventions to improve upper limb function for children with bilateral cerebral palsy: a systematic review

AIM

To systematically review the efficacy of interventions on upper limb function in children 0 to 19 years of age with bilateral cerebral palsy on the basis of outcome measures of upper limb function and measures of activities and/or participation according to the International Classification of Functioning, Disability and Health.

METHOD

Cochrane, PubMed, Embase, CINAHL, and Web of Science were searched from inception to September 2017. Methodological quality and strength of evidence were analysed by two independent raters using Sackett's level of evidence and the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) guidelines.

RESULTS

Fifteen studies with a large variety of interventions and heterogeneity in outcome measures met the inclusion criteria. Twelve studies provided level IV evidence according to AACPDM guidelines. For three small randomized controlled trials the level of evidence was II. Only one of these trials showed strong methodological quality: a study on hand-arm bimanual intensive therapy including lower extremities.

INTERPRETATION

We identified a large variety of interventions, heterogeneity in outcome measures, and generally weak to moderate methodological quality for most studies. We recommend further research specifically aimed at bimanual-intensive, goal-directed, and task-specific training programmes for the upper limb in children with bilateral cerebral palsy, using either high-quality (multicentre) trials or well-designed single-case trials.

WHAT THIS PAPER ADDS

There is a large variety of interventions on upper limb function in children with bilateral cerebral palsy. Heterogeneity of outcome measures and interventions impeded firm conclusions about intervention efficacy. Most studies had low-level evidence and weak to moderate methodological quality. The strongest evidence from a small randomized controlled trial was for hand-arm bimanual intensive therapy including lower extremities.

Mapping Study on the Use of Digital Games for Persons with Disabilities in Upper Members

Digital games are no longer seen as a form of entertainment detrimental to health. They have become an important tool to improve the treatment of patients, ranging from those who are experiencing a serious illness, such as cancer, to those requiring milder procedures such as physiotherapy. However, there are people who are physically disabled and have difficulty playing digital games. In this line of reasoning, this work presents a systematic review on the use of digital games for people with physical disabilities in the upper limbs. The sources of research were the following indexed databases: IEEE Xplore, Portal of Periodicals of the Coordination of Improvement of Personnel of Higher Level (CAPES), PubMed, Scielo, Science Direct, Scopus and Web of Science. It should be noted that the application of Systematic Mapping in the elaboration of a bibliographical review allowed to identify the main gaps for the development of new research, and to redirect to the main publications related to the study. Finally, the results shows that it is an area that is constantly expanding.

Energy Expenditure and Enjoyment During Active Video Gaming Using an Adapted Wii Fit Balance Board in Adults with Physical Disabilities: Observational Study

Background

Individuals with physical disabilities have fewer opportunities to participate in enjoyable physical activity. One option for increasing physical activity is playing active video games (AVGs); however, many AVGs are inaccessible or offer limited play options.

Objective

This study aimed to examine energy expenditure and enjoyment in adults with mobility impairment during AVG play using off-the-shelf (OTS) and adapted versions of the Wii Fit balance board (Nintendo).

Methods

During visit 1, participants completed a functional assessment and the familiarization period. During visit 2, metabolic data were collected during a 20-minute baseline and four 10-minute bouts of Wii Fit Plus game play, with two bouts on each of the boards. During the resting period, participants completed the Physical Activity Enjoyment Scale (PACES). Statistical analyses were computed using SPSS software. Data were analyzed separately for individuals who were able to play while standing on both boards (StdStd); those who could not play while standing on the OTS board, but were able to play while standing on the adapted board (aStd); and those who could only play while sitting on the adapted board (aSit).

Results

Data were collected for 58 participants (StdStd, n=17; aStd, n=10; aSit, n=31). The sample included 31 men and 27 women with a mean age of 41.21 (SD 12.70) years. Energy expenditure (metabolic equivalent [MET]) during game play was significantly greater than that during rest for all players. Only 17 participants (StdStd group) were able to play using the OTS board. During game play on the adapted board, the average MET values for the two game sets were 2.261 (SD 0.718) kcal/kg/hour and 2.233 (SD 0.751) kcal/kg/hour for the aSit group, 3.151 (SD 1.034) and 2.990 (SD 1.121) for the aStd group, and 2.732 (SD 0.655) and 2.777 (SD 0.803) for the StdStd group. For game play on the adapted board, self-reported ratings of perceived exertion on a 0-10 scale suggested greater exercise intensity levels, with median scores ranging from moderate (3) to very hard (7). The PACES scores indicated that all players enjoyed using the adapted board, with a median score of 4 on a 5-point scale.

Conclusions

The adapted Wii Fit balance board provided an opportunity for individuals with mobility impairments, including wheelchair users, to engage in AVG. All participants were able to utilize the adapted controller and enjoyed the AVG activity. Although the average MET values achieved during AVG represented light-intensity exercise (<3 METs), 16% of sitting participants and 41% of standing participants achieved moderate-intensity exercise (3-6 METs) in at least one of the games. Factors not accounted for, which may have influenced the intensity of exercise, include game selection, limited familiarization period, and discomfort wearing the COSMED portable metabolic system for measurement of oxygen consumption. Accessible AVG controllers offer an innovative approach to overcome various barriers to participation in physical activity. The next steps include assessment of an AVG intervention using an adapted board gaming controller on health and fitness outcomes.

Trial Registration

ClinicalTrials.gov NCT02994199; https://clinicaltrials.gov/ct2/show/NCT02994199 (Archived by Webcite at http://www.webcitation.org/75fc0mN39).

Analysis of motor performance in individuals with cerebral palsy using a non-immersive virtual reality task - a pilot study

PURPOSE

To evaluate the performance improvement of individuals with hemiparesis cerebral palsy (CP) using a virtual task.

PARTICIPANTS AND METHODS

Twenty individuals were selected and distributed into two groups. The experimental group (CP group) comprised ten individuals with a medical diagnosis of CP, and ten individuals with typical development (sex- and age-matched) composed the control group (TD group). Both groups followed the same intervention protocol, which included a virtual coincident timing task: the participants performed upper limb movements in front of a computer's webcam and interacted with the task with the aim of virtually intercepting spheres that fell in four rows following the rhythm of a pre-selected song during an 8-minute period. To verify the influence on a real task, pre- and posttests were performed in a similar task, but with physical contact (using the spacebar on the keyboard of a computer). To analyze the data, we evaluated the variable, constant, and absolute errors during the task and in the pre- and posttests.

RESULTS

The results showed that there was an improvement in performance between the pre- and posttests; that is, after practicing the task in an environment without physical contact, there was a performance improvement in posttests in the real task, but only for the CP group. Moreover, there were significant differences in precision and accuracy between the two groups, with worse performance in the CP group.

CONCLUSION

Individuals with CP presented better performance in the real task after practice in a virtual reality task, albeit with worse performance compared with individuals with TD. This is an interesting result that supports the possible use of virtual tasks for the rehabilitation of individuals with CP.

A Tablet-Based Interactive Movement Tool for Pediatric Rehabilitation: Development and Preliminary Usability Evaluation

BACKGROUND

Motivating interactive tools may increase adherence to repetitive practice for children with disabilities, but many virtual reality and active video gaming systems are too challenging for children with significant needs.

OBJECTIVE

The objective of this study was to develop and conduct a usability evaluation of the Fun, Interactive Therapy Board (FITBoard), a movement toy bridging digital and physical interactions for children with disabilities.

METHODS

The FITBoard is a tablet app involving games controlled by hand, head, or foot touch of configurable, wired surfaces. Usability evaluation involved a cognitive walkthrough and think-aloud processes. Participants verbalized aloud while completing a series of 26 task actions involved in selecting a game and configuring the FITBoard to achieve the therapeutic goal. Therapists then responded to questions about usability perceptions. Unsuccessful actions were categorized as goal or action failures. Qualitative content analysis supported understanding of usability problems.

RESULTS

Participants included 5 pediatric physical therapists and 2 occupational therapists from 2 clinical sites. Goal failure was experienced by all participants in 2 tasks, and action failure was experienced by all participants in 2 tasks. For 14 additional tasks, 1 or more patients experienced goal or action failure, with an overall failure rate of 69% (18 of 26 tasks). Content analysis revealed 4 main categories: hardware usability, software usability, facilitators of therapy goals, and improvement suggestions.

CONCLUSIONS

FITBoard hardware and software changes are needed to address goal and action failures to rectify identified usability issues. Results highlight potential FITBoard applications to address therapeutic goals and outline important practical considerations for product use by therapists. Subsequent research will evaluate therapist, parent, and child perspectives on FITBoard clinical utility when integrated within regular therapy interventions.

Force Resistance Training in Hand Grasp and Arm Therapy: Feasibility of a Low-Cost Videogame Controller

OBJECTIVE

To design and evaluate a low-cost gaming station that supports force resistance training in pediatric arm/hand grasp therapies through mainstream videogame play.

METHODS

The gaming station was developed through an iterative participatory design process and includes a force feedback game controller (Novint Falcon), custom grips, arm/wrist supports, and software to interface with mainstream games and manage difficulty settings in the controller. The station was tested for usability and feasibility with six therapists and six children with cerebral palsy, 7-16 years of age, attending weekly therapy sessions over 12 weeks. Pre- and post-assessments of perceived performance and satisfaction on self-identified goals were measured on the Canadian Occupational Performance Measure (COPM).

RESULTS

The gaming station was considered highly usable by therapists with a score of 76.7 (standard deviation [SD] = 6.1) on the System Usability Scale. Overall, children enjoyed the games, achieved high repetition rates for wrist extensions and arm movements, and all made clinically significant progress on therapy goals. Increases of 3.13 (SD = 1.69) on the performance scale and 2.97 (SD = 0.98) on the satisfaction scale were reported on the COPM. Conclusiion: In-clinic force resistance training for development of upper limb functional capacities is feasible using low-cost video game components adapted to therapy through a participatory design process.

"It's all about incentive": Social technology as a potential facilitator for self-determined physical activity participation for young people with physical disabilities

PURPOSE

To investigate the perceived role of social technologies in promoting physical activity participation for young people with physical disabilities and to identify design considerations that should be addressed when creating social technologies to promote physical activity.

METHOD

Interactive design workshops for young people with physical disabilities aged 12-18 (n = 8) were held. Data were analyzed using interpretive thematic analysis.

RESULTS

Young people perceived significant benefit for social technologies to promote physical activity as they have the potential to overcome many barriers to physical activity participation. Design features recommended by the participants included (1) options for diverse interests and preferences, (2) provision of informational support, (3) support through equitable technology design, (4) incentive through competition and play, and (5) opportunities to develop community.

CONCLUSIONS

Social technology has potential to provide tailored, equitable opportunities for social engagement and physical activity participation for young people with physical disabilities through needs- and preference-specific design.

Games Used With Serious Purposes: A Systematic Review of Interventions in Patients With Cerebral Palsy

The purpose of the present systematic review was to examine extant research regarding the role of games used seriously in interventions with individuals with cerebral palsy. Therefore, PubMed, PsyINFO, Web of Science, Scopus, and IEEE databases were used. Search terms included: “serious games” OR “online games” OR “video games” OR “videogame” OR “game based” OR “game” AND “intervention” AND “cerebral palsy.” After the full reading and quality assessment of the papers, 16 studies met the inclusion criteria. The majority of the studies reported high levels of compliance, motivation, and engagement with game-based interventions both at home and at the clinical setting intervention. Regarding the effectiveness of the use of games, the results of the studies show both positive and negative results regarding their effectiveness. The efficacy was reported to motor function (i.e., improvements in the arm function, hand coordination, functional mobility, balance and gait function, postural control, upper-limbs function) and physical activity. Findings of this review suggest that games are used as a complement to conventional therapies and not as a substitute. Practitioners often struggle to get their patients to complete the assigned homework tasks, as patients display low motivation to engage in prescribed exercises. Data of this review indicates the use of games as tools suited to promote patients’ engagement in the therapy and potentiate therapeutic gains.