Virtual reality-based paediatric interactive therapy system (PITS) for improvement of arm and hand function in children with motor impairment--a pilot study

Hand-worn devices for assessment and rehabilitation of motor function and their potential use in BCI protocols: a review

Introduction

Various neurological conditions can impair hand function. Affected individuals cannot fully participate in activities of daily living due to the lack of fine motor control. Neurorehabilitation emphasizes repetitive movement and subjective clinical assessments that require clinical experience to administer.

Methods

Here, we perform a review of literature focused on the use of hand-worn devices for rehabilitation and assessment of hand function. We paid particular attention to protocols that involve brain-computer interfaces (BCIs) since BCIs are gaining ground as a means for detecting volitional signals as the basis for interactive motor training protocols to augment recovery. All devices reviewed either monitor, assist, stimulate, or support hand and finger movement.

Results

A majority of studies reviewed here test or validate devices through clinical trials, especially for stroke. Even though sensor gloves are the most commonly employed type of device in this domain, they have certain limitations. Many such gloves use bend or inertial sensors to monitor the movement of individual digits, but few monitor both movement and applied pressure. The use of such devices in BCI protocols is also uncommon.

Discussion

We conclude that hand-worn devices that monitor both flexion and grip will benefit both clinical diagnostic assessment of function during treatment and closed-loop BCI protocols aimed at rehabilitation.

Effectiveness of functional trunk training on trunk control and upper limb functions in patients with autosomal recessive hereditary ataxia

BACKGROUND: Ataxia is a clinical syndrome characterized by coordination problems and postural disorders. OBJECTIVE: This study aimed to examine the effects of functional trunk training on trunk control and upper limb functions in autosomal recessive hereditary ataxia. METHODS: Twenty patients were randomly divided into treatment and control groups. Both groups received trunk stabilization and balance exercises, and the treatment group received additional functional trunk training sessions (3 days/week for 8 weeks). The International Cooperative Ataxia Rating Scale, Trunk Impairment Scale, Modified Functional Reach Test, Nine-Hole Peg Test and Quick-Disabilities of the Arm Shoulder and Hand questionnaire were used for assessments. RESULTS: The treatment group showed an increase in the upper limb performance bilaterally, whereas increased performance was seen only in the dominant upper limb in the control group. While the functional reach improved in the anterior-posterior (AP) and medial-lateral (ML) directions in the treatment group, it was improved only in the AP direction in the control group. Also, the mean changes in outcomes were not significantly different between the groups except for modified functional reach test. CONCLUSIONS: Functional trunk training may be a more effective method to improve upper limb performance and dynamic trunk balance in autosomal recessive hereditary ataxia.

Virtual Reality Aided Therapy towards Health 4.0: A Two-Decade Bibliometric Analysis

Health 4.0 aligns with Industry 4.0 and encourages the application of the latest technologies to healthcare. Virtual reality (VR) is a potentially significant component of the Health 4.0 vision. Though VR in health care is a popular topic, there is little knowledge of VR-aided therapy from a macro perspective. Therefore, this paper was aimed to explore the research of VR in aiding therapy, thus providing a potential guideline for futures application of therapeutic VR in healthcare towards Health 4.0. A mixed research method was adopted for this research, which comprised the use of a bibliometric analysis (a quantitative method) to conduct a macro overview of VR-aided therapy, the identification of significant research structures and topics, and a qualitative review of the literature to reveal deeper insights. Four major research areas of VR-aided therapy were identified and investigated, i.e., post-traumatic stress disorder (PTSD), anxiety and fear related disorder (A&F), diseases of the nervous system (DNS), and pain management, including related medical conditions, therapies, methods, and outcomes. This study is the first to use VOSviewer, a commonly used software tool for constructing and visualizing bibliometric networks and developed by Center for Science and Technology Studies, Leiden University, the Netherlands, to conduct bibliometric analyses on VR-aided therapy from the perspective of Web of Science core collection (WoSc), which objectively and visually shows research structures and topics, therefore offering instructive insights for health care stakeholders (particularly researchers and service providers) such as including integrating more innovative therapies, emphasizing psychological benefits, using game elements, and introducing design research. The results of this paper facilitate with achieving the vision of Health 4.0 and illustrating a two-decade (2000 to year 2020) map of pre-life of the Health Metaverse.

Clinical Application of Virtual Reality for Upper Limb Motor Rehabilitation in Stroke: Review of Technologies and Clinical Evidence

Neurorehabilitation for stroke is important for upper limb motor recovery. Conventional rehabilitation such as occupational therapy has been used, but novel technologies are expected to open new opportunities for better recovery. Virtual reality (VR) is a technology with a set of informatics that provides interactive environments to patients. VR can enhance neuroplasticity and recovery after a stroke by providing more intensive, repetitive, and engaging training due to several advantages, including: (1) tasks with various difficulty levels for rehabilitation, (2) augmented real-time feedback, (3) more immersive and engaging experiences, (4) more standardized rehabilitation, and (5) safe simulation of real-world activities of daily living. In this comprehensive narrative review of the application of VR in motor rehabilitation after stroke, mainly for the upper limbs, we cover: (1) the technologies used in VR rehabilitation, including sensors; (2) the clinical application of and evidence for VR in stroke rehabilitation; and (3) considerations for VR application in stroke rehabilitation. Meta-analyses for upper limb VR rehabilitation after stroke were identified by an online search of Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Library, and KoreaMed. We expect that this review will provide insights into successful clinical applications or trials of VR for motor rehabilitation after stroke.

Virtual reality-based treatment for regaining upper extremity function induces cortex grey matter changes in persons with acquired brain injury

Background

Individuals with acquired brain injuries (ABI) are in need of neurorehabilitation and neurorepair. Virtual anatomical interactivity (VAI) presents a digital game-like format in which ABI survivors with upper limb paresis use an unaffected limb to control a standard input device and a commonplace computer mouse to control virtual limb movements and tasks in a virtual world.

Methods

In a prospective cohort study, 35 ambulatory survivors of ABI (25/71% stroke, 10/29% traumatic brain injury) were enrolled. The subjects were divided into three groups: group A received VAI therapy only, group B received VAI and physical/occupational therapy (P/OT), and group C received P/OT only. Motor skills were evaluated by muscle strength (hand key pinch strength, grasp, and three-jaw chuck pinch) and active range of motion (AROM) of the shoulder, elbow, and wrist. Changes were analyzed by ANOVA, ANCOVA, and one-tailed Pearson correlation analysis. MRI data was acquired for group A, and volumetric changes in grey matter were analyzed using voxel-based morphometry (VBM) and correlated with quantified motor skills.

Results

AROM of the shoulder, elbow, and wrist improved in all three groups. VBM revealed grey matter increases in five brain areas: the tail of the hippocampus, the left caudate, the rostral cingulate zone, the depth of the central sulcus, and the visual cortex. A positive correlation between the grey matter volumes in three cortical regions (motor and premotor and supplementary motor areas) and motor test results (power and AROM) was detected.

Conclusions

Our findings suggest that the VAI rehabilitation program significantly improved motor function and skills in the affected upper extremities of subjects with acquired brain injuries. Significant increases in grey matter volume in the motor and premotor regions of affected hemisphere and correlations of motor skills and volume in nonaffected brain regions were present, suggesting marked changes in structural brain plasticity.

Trial registration

The trial “Limitations of motor brain activity – use of virtual reality for simulation of therapeutic interventions” has been registered under reference number ISRCTN11757651.

The medical avatar and its role in neurorehabilitation and neuroplasticity: A review

BACKGROUND

One of the most interesting emerging medical devices is the medical avatar - a digital representation of the patient that can be used toward myriad ends, the full potential of which remains to be explored. Medical avatars have been instantiated as telemedical tools used to establish a representation of the patient in tele-space, upon which data about the patient's health can be represented and goals and progress can be visually tracked. Manipulation of the medical avatar has also been explored as a means of increasing motivation and inducing neural plasticity.

OBJECTIVE

The article reviews the literature on body representation, simulation, and action-observation and explores how these components of neurorehabilitation are engaged by an avatar-based self-representation.

METHODS

Through a review of the literature on body representation, simulation, and action-observation and a review of how these components of neurorehabilitation can be engaged and manipulated with an avatar, the neuroplastic potential of the medical avatar is explored. Literature on the use of the medical avatar for neurorehabilitation is also reviewed.

RESULTS

This review demonstrates that the medical avatar has vast potentialities in neurorehabilitation and that further research on its use and effect is needed.

PEXO - A Pediatric Whole Hand Exoskeleton for Grasping Assistance in Task-Oriented Training

Children with hand motor impairment due to cerebral palsy, traumatic brain injury, or pediatric stroke are considerably affected in their independence, development, and quality of life. Treatment conventionally includes task-oriented training in occupational therapy. While dose and intensity of hand therapy can be promoted through technology, these approaches are mostly limited to large stationary robotic devices for non-task-oriented training, or passive wearable devices for children with mild impairments. Here we present PEXO, a fully wearable actuated pediatric hand exoskeleton to cover the special needs of children (6 to 12 years of age) with strong impairments in hand function. Through three degrees of freedom, PEXO provides assistance in various grasp types needed for the execution of functional tasks. It is lightweight, water proof, and inherently interacts safely with the user. It meets mechanical requirements such as force, fast closing movement, and battery lifetime derived from literature and discussions with clinicians. Appealing appearance, user-friendly design, and intuitive control with visual feedback of forearm muscle activity should keep the user motivated during training in the clinic or at home. A pilot test with a 6-years old child with stroke showed that PEXO can provide assistance in grasping various objects weighing up to 0.5 kg. These are promising first results on the way to make hand exoskeletons accessible for children with neuromotor disorders.

Scoping Review of Systems to Train Psychomotor Skills in Hearing Impaired Children

OBJECTIVES

The aim of this work is to provide a scoping review to compile and classify the systems helping train and enhance psychomotor skills in hearing impaired (HI) children.

METHODS

Based on an exhaustive review on psychomotor deficits in HI children, the procedure used to carry out a scoping review was: select keywords and identify synonyms, select databases and prepare the queries using keywords, analyze the quality of the works found using the PEDro Scale, classify the works based on psychomotor competences, analyze the interactive systems (e.g., sensors), and the achieved results.

RESULTS

Thirteen works were found. These works used a variety of sensors and input devices such as cameras, contact sensors, touch screens, mouse and keyboard, tangible objects, haptic and virtual reality (VR) devices.

CONCLUSIONS

From the research it was possible to contextualize the deficits and psychomotor problems of HI children that prevent their normal development. Additionally, from the analysis of different proposals of interactive systems addressed to this population, it was possible to establish the current state of the use of different technologies and how they contribute to psychomotor rehabilitation.

User Perspectives on Exergames Designed to Explore the Hemineglected Space for Stroke Patients With Visuospatial Neglect: Usability Study

BACKGROUND

Visuospatial neglect due to stroke is characterized by the inability to perceive stimuli emerging in the area opposite to the side of brain damage. Besides adopting conventional rehabilitation methods to treat neglect symptoms, the use of virtual reality (VR) is becoming increasingly popular. We designed a series of 9 exergames aimed to improve exploration of the neglected side of space. When new VR interventions are designed, it is important to assess the usability aspects of such management strategies within the target population. To date, most studies used questionnaires to assess user satisfaction with the intervention or product being tested. However, only a combination of both quantitative and qualitative data allows a full picture of user perspective.

OBJECTIVE

The purpose of this study was to quantitatively and qualitatively assess patient and therapist perspectives of a VR intervention based on the series of 9 exergames designed to explore hemineglected space. Specifically, we wanted to evaluate (1) perceived-user friendliness of the exergames, (2) attitude towards using the exergames, and (3) intention to use the exergames in the future.

METHODS

A total of 19 participants (7 patients, 12 therapists) evaluated the exergames they had used 5 times a week during 3 weeks. The Technology Acceptance Model (TAM) questionnaire was filled out after the intervention. Based on those responses, we conducted focus group interviews (with therapists) and individual interviews (with patients). To analyze the TAM questionnaires, we used descriptive statistics. We adopted content and comparative analysis to analyze the interviews and drew illustration maps to analyze the focus group interviews.

RESULTS

The therapists took a more critical stance with a mean TAM questionnaire total score of 48.6 (SD 4.5) compared to the patients who had a mean total score of 56.1 (SD 12.3). The perceived user-friendliness score was 5.6 (SD 1.4) for patients and 4.9 (SD 1.4) for therapists. The attitude towards using the exergames was rated 4.8 (SD 1.9) by patients and 3.6 (SD 1.4) by therapists, respectively. The intention to use the exergames in the future was rated 3.9 (SD 2.1) by patients and 3.7 (SD 1.8) by therapists. We gained information on how to improve the exergames in the interviews.

CONCLUSIONS

Patients and therapists perceived the exergames as user-friendly; however, using the games further with the actual test version was not perceived as conceivable. The therapists were generally more critical towards future use than the patients. Therefore, involving both users to achieve acceptable and user-friendly versions of game-based rehabilitation for the future is deemed crucial and warranted.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02353962; https://clinicaltrials.gov/ct2/show/NCT02353962 (Archived by WebCite at http://www.webcitation.org/6soxIJlAZ).

Short-term balance training with computer-based feedback in children with cerebral palsy: A feasibility and pilot randomized trial

OBJECTIVE

To assess the feasibility of using short-term balance training with computer-based visual feedback (BTVF) and its effect on standing balance in children with bilateral spastic cerebral palsy (BSCP).

METHODS

Out of the fourteen children with BSCP (mean age = 10.31 years), seven children received four sessions of BTVF (two such sessions/day, each session = 15 min) in comparison to the control group that received standard care. Feasibility was measured as percentages of recruitment, retention and safety and balance was measured using a posturography machine as sway velocity (m/s) and velocity moment (m/s²) during quiet standing.

RESULTS

No serious adverse events occurred in either group. There were no differences in the retention percentages and in any clinical outcome measure between both groups.

CONCLUSION

Use of BTVF is feasible in children with BSCP but further investigation is required to estimate a dose-effect relationship.

Quantifying selective elbow movements during an exergame in children with neurological disorders: a pilot study

BACKGROUND

It is difficult to distinguish between restorative and compensatory mechanisms underlying (pediatric) neurorehabilitation, as objective measures assessing selective voluntary motor control (SVMC) are scarce.

METHODS

We aimed to quantify SVMC of elbow movements in children with brain lesions. Children played an airplane game with the glove-based YouGrabber system. Participants were instructed to steer an airplane on a screen through a cloud-free path by correctly applying bilateral elbow flexion and extension movements. Game performance measures were (i) % time on the correct path and (ii) similarity between the ideal flight path and the actually flown path. SVMC was quantified by calculating a correlation coefficient between the derivative of the ideal path and elbow movements. A therapist scored whether the child had used compensatory movements.

RESULTS

Thirty-three children with brain lesions (11 girls; 12.6 ± 3.6 years) participated. Clinical motor and cognitive scores correlated moderately with SVMC (0.50-0.74). Receiver Operating Characteristics analyses showed that SVMC could differentiate well and better than clinical and game performance measures between compensatory and physiological movements.

CONCLUSIONS

We conclude that a simple measure assessed while playing a game appears promising in quantifying SVMC. We propose how to improve the methodology, and how this approach can be easily extended to other joints.

Effects of Nintendo Wii-Fit® video games on balance in children with mild cerebral palsy

BACKGROUND

This study compared the effects of Nintendo Wii-Fit^® balance-based video games and conventional balance training in children with mild cerebral palsy (CP).

METHODS

This randomized controlled trial involved 30 ambulatory pediatric patients (aged 5-18 years) with CP. Participants were randomized to either conventional balance training (control group) or to Wii-Fit balance-based video games training (Wii group). Both group received neuro-developmental treatment (NDT) during 24 sessions. In addition, while the control group received conventional balance training in each session, the Wii group played Nintendo Wii Fit games such as ski slalom, tightrope walk and soccer heading on balance board. Primary outcomes were Functional Reach Test (forward and sideways), Sit-to-Stand Test and Timed Get up and Go Test. Nintendo Wii Fit balance, age and game scores, 10 m walk test, 10-step climbing test and Wee-Functional Independence Measure (Wee FIM) were secondary outcomes.

RESULTS

After the treatment, changes in balance scores and independence level in activities of daily living were significant (P < 0.05) in both groups. Statistically significant improvements were found in the Wii-based game group compared with the control group in all balance tests and total Wee FIM score (P < 0.05).

CONCLUSION

Wii-fit balance-based video games are better at improving both static and performance-related balance parameters when combined with NDT treatment in children with mild CP.

Virtual Hand Feedback Reduces Reaction Time in an Interactive Finger Reaching Task

Computer interaction via visually guided hand or finger movements is a ubiquitous part of daily computer usage in work or gaming. Surprisingly, however, little is known about the performance effects of using virtual limb representations versus simpler cursors. In this study 26 healthy right-handed adults performed cued index finger flexion-extension movements towards an on-screen target while wearing a data glove. They received each of four different types of real-time visual feedback: a simple circular cursor, a point light pattern indicating finger joint positions, a cartoon hand and a fully shaded virtual hand. We found that participants initiated the movements faster when receiving feedback in the form of a hand than when receiving circular cursor or point light feedback. This overall difference was robust for three out of four hand versus circle pairwise comparisons. The faster movement initiation for hand feedback was accompanied by a larger movement amplitude and a larger movement error. We suggest that the observed effect may be related to priming of hand information during action perception and execution affecting motor planning and execution. The results may have applications in the use of body representations in virtual reality applications.

Preparing a neuropediatric upper limb exergame rehabilitation system for home-use: a feasibility study

Background

Home-based, computer-enhanced therapy of hand and arm function can complement conventional interventions and increase the amount and intensity of training, without interfering too much with family routines. The objective of the present study was to investigate the feasibility and usability of the new portable version of the YouGrabber® system (YouRehab AG, Zurich, Switzerland) in the home setting.

Methods

Fifteen families of children (7 girls, mean age: 11.3y) with neuromotor disorders and affected upper limbs participated. They received instructions and took the system home to train for 2 weeks. After returning it, they answered questions about usability, motivation, and their general opinion of the system (Visual Analogue Scale; 0 indicating worst score, 100 indicating best score; ≤30 not satisfied, 31–69 average, ≥70 satisfied). Furthermore, total pure playtime and number of training sessions were quantified. To prove the usability of the system, number and sort of support requests were logged.

Results

The usability of the system was considered average to satisfying (mean 60.1–93.1). The lowest score was given for the occurrence of technical errors. Parents had to motivate their children to start (mean 66.5) and continue (mean 68.5) with the training. But in general, parents estimated the therapeutic benefit as high (mean 73.1) and the whole system as very good (mean 87.4). Children played on average 7 times during the 2 weeks; total pure playtime was 185 ± 45 min. Especially at the beginning of the trial, systems were very error-prone. Fortunately, we, or the company, solved most problems before the patients took the systems home. Nevertheless, 10 of 15 families contacted us at least once because of technical problems.

Conclusions

Despite that the YouGrabber® is a promising and highly accepted training tool for home-use, currently, it is still error-prone, and the requested support exceeds the support that can be provided by clinical therapists. A technically more robust system, combined with additional attractive games, likely results in higher patient motivation and better compliance. This would reduce the need for parents to motivate their children extrinsically and allow for clinical trials to investigate the effectiveness of the system.

Trial registration

ClinicalTrials.gov NCT02368223

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-016-0141-x) contains supplementary material, which is available to authorized users.

Virtual Sensorimotor Balance Training for Children With Fetal Alcohol Spectrum Disorders: Feasibility Study

BACKGROUND

Diminished sensory adaptation has been associated with poor balance control for children with fetal alcohol spectrum disorders (FASD). A virtual reality system, Sensorimotor Training to Affect Balance, Engagement and Learning (STABEL), was developed to train sensory control for balance.

OBJECTIVES

The purpose of this study was to examine the STABEL system in children with FASD and children with typical development (TD) to (1) determine the feasibility of the STABEL system and (2) explore the immediate effects of the STABEL system on sensory attention and postural control.

DESIGN

This is a technical report with observational study data.

METHODS

Eleven children with FASD and 11 children with TD, aged 8 to 16 years, completed 30 minutes of STABEL training. The children answered questions about their experience using STABEL. Sensory attention and postural control were measured pre- and post-STABEL training with the Multimodal Balance Entrainment Response system and compared using repeated-measures analysis of variance.

RESULTS

All children engaged in game play and tolerated controlled sensory input during the STABEL protocol. Immediate effects post-STABEL training in both groups were increased postural sway velocity and some changes in entrainment gain. Children with FASD showed higher entrainment gain to vestibular stimuli. There were no significant changes in sensory attention fractions.

LIMITATIONS

The small sample size, dose of STABEL training, and exploratory statistical analyses are study limitations, but findings warrant larger systematic study to examine therapeutic effects.

CONCLUSIONS

Children completed the training protocol, demonstrating the feasibility of the STABEL system. Differences in postural sway velocity post-STABEL training may have been affected by fatigue, warranting further investigation. Limited immediate effects suggest more practice is needed to affect sensory attention; however, entrainment gain changes suggest the STABEL system provoked vestibular responses during balance practice.

Robots and ICT to support play in children with severe physical disabilities: a systematic review

PURPOSE

Play is an essential part of children's lives. Children with physical disabilities experience difficulties in play, especially those with severe physical disabilities. With the progress of innovative technology, the possibilities to support play are increasing. The purpose of this literature study is to gain insight into the aims, control options and commercial availability of information and communication technology (ICT) and robots to support play (especially play for the sake of play) in children with severe physical disabilities.

METHODS

A systematic literature search in the databases PubMed, CINAHL, IEEE and ERIC was carried out. Titles and abstracts were assessed independently by three reviewers. In addition, studies were selected using Google Scholar, conference proceedings and reference lists.

RESULTS

Three main groups of technology for play could be distinguished: robots (n = 8), virtual reality systems (n = 15) and computer systems (n = 4). Besides, ICT and robots developed for specific therapy or educational goals using play-like activities, five of the in total 27 technologies in this study described the aim of "play for play's sake".

CONCLUSIONS

Many ICT systems and robots to support play in children with physical disabilities were found. Numerous technologies use play-like activities to achieve therapeutic or educational goals. Robots especially are used for "play for play's sake". Implications for Rehabilitation This study gives insight into the aims, control options and commercial availability for application of robots and ICT to support play in children with severe physical disabilities. This overview can be used in both the fields of rehabilitation and special education to search for new innovative intervention options and it can stimulate them to use these innovative play materials. Especially robots may have great potential in supporting "play for play's sake".

Mitii™ ABI: study protocol of a randomised controlled trial of a web-based multi-modal training program for children and adolescents with an Acquired Brain Injury (ABI)

BACKGROUND

Acquired brain injury (ABI) refers to multiple disabilities arising from damage to the brain acquired after birth. Children with an ABI may experience physical, cognitive, social and emotional-behavioural impairments which can impact their ability to participate in activities of daily living (ADL). Recent developments in technology have led to the emergence of internet-delivered therapy programs. "Move it to improve it" (Mitii™) is a web-based multi-modal therapy that comprises upper limb (UL) and cognitive training within the context of meaningful physical activity. The proposed study aims to compare the efficacy of Mitii™ to usual care to improve ADL motor and processing skills, gross motor capacity, UL and executive functioning in a randomised waitlist controlled trial.

METHODS/DESIGN

Sixty independently ambulant children (30 in each group) at least 12 months post ABI will be recruited to participate in this trial. Children will be matched in pairs at baseline and randomly allocated to receive either 20 weeks of Mitii™ training (30 min per day, six days a week, with a potential total dose of 60 h) immediately, or be waitlisted for 20 weeks. Outcomes will be assessed at baseline, immediately post-intervention and at 20 weeks post-intervention. The primary outcomes will be the Assessment of Motor and Process Skills and 30 s repetition maximum of functional strength exercises (sit-to-stand, step-ups and half kneel to stand). Measures of body structure and functions, activity, participation and quality of life will assess the efficacy of Mitii™ across all domains of the International Classification of Functioning, Disability and Health framework. A subset of children will undertake three tesla (3T) magnetic resonance imaging scans to evaluate functional neurovascular changes, structural imaging, diffusion imaging and resting state functional connectivity before and after intervention.

DISCUSSION

Mitii™ provides an alternative approach to deliver intensive therapy for children with an ABI in the convenience of the home environment. If Mitii™ is found to be effective, it may offer an accessible and inexpensive intervention option to increase therapy dose.

TRIAL REGISTRATION

ANZCTR12613000403730.

Upper limb training using Wii Sports Resort™ for children with hemiplegic cerebral palsy: a randomized, single-blind trial

Objective:

To investigate whether Wii Sports Resort™ training is effective and if any benefits are maintained.

Design:

Randomized, single-blind trial.

Participants:

Sixty-two hemiplegic children with cerebral palsy (6–13 years).

Intervention:

Experimental group undertook six weeks of home-based Wii Sports Resort™ training plus usual therapy, while the control group received usual therapy.

Main measures:

Outcomes were coordination, strength, hand function, and carers’ perception of hand function, measured at baseline, six, and 12 weeks by a blinded assessor.

Results:

There was a trend of mean difference (MD) for the experimental group to have more grip strength by six (MD 4.0 N, 95% confidence interval (CI) −0.8 to 8.8, p = 0.10) and 12 (MD 4.1 N, 95% CI −2.1 to 10.3, p = 0.19) weeks, and to have a higher quantity of hand function according to carers’ perception by six (MD 4.5 N, 95% CI −0.7 to 9.7, p = 0.09) and strengthened by 12 (MD 6.4, 95% CI 0.6 to 12.3, p = 0.03) weeks than the control group. There was no difference between groups in coordination and hand function by six or 12 weeks.

Conclusion:

Wii™ training did not improve coordination, strength, or hand function. Beyond the intervention, carers perceived that the children used their hands more.

The effects of motivating interventions on rehabilitation outcomes in children and youth with acquired brain injuries: a systematic review

PRIMARY OBJECTIVE

To systematically review the evidence of the effects of motivating rehabilitation interventions on outcomes in children with acquired brain injury (ABI).

METHODS

A literature search of six databases was conducted to identify intervention studies published until July 2013. The American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) systematic review methodology was used as a framework. Two reviewers independently extracted data and assessed level of evidence and quality of studies.

RESULTS

Of 891 records initially retrieved, 166 were screened by abstract and 31 by full text; 10 studies comprised of five randomized controlled trials, two case series and three single subject research design studies met the inclusion criteria. Studies fell into three intervention categories: (1) token economy based interventions; (2) virtual reality (VR); and (3) memory and attention interventions.

CONCLUSIONS

A paucity of evidence has examined the effects of rehabilitation interventions with a motivational component. Token economies can significantly enhance memory and response inhibition performance in children with ABI. VR systems are motivating, yet findings are limited by the lack of use and availability of psychometrically evaluated measures of motivation. Findings point to the need for further research to evaluate the effects of motivation-based interventions.

Effect of virtual reality on upper extremity function in children with cerebral palsy: a meta-analysis

PURPOSE

To systematically examine the effect of virtual reality (VR) on upper extremity (UE) function in children with cerebral palsy (CP) and assess the association among VR effects and children's characteristics and an intervention protocol.

METHOD

A systematic literature search was conducted in PubMed, CINAHL, Cochrane, and PsycINFO up to June 2013. Research studies involving children with CP that used VR as the intervention method and UE outcome measures were included.

RESULTS

The search yielded 14 research articles, including 3 randomized controlled trials and 11 case series. Overall, VR provided a strong effect size (d = 1.00) when comparing pre- and postintervention. In subgroup analyses, younger children receiving home-based or laboratory-based VR and using an engineer-built VR system showed better improvement.

CONCLUSIONS AND IMPLICATIONS

Virtual reality is a viable tool to improve UE function in children with CP. However, a more vigorous research design is needed to make a conclusive recommendation.

Technology-aided programs to support exercise of adaptive head responses or leg-foot and hands responses in children with multiple disabilities

OBJECTIVE

Assessing the effectiveness of technology-aided programs to help three children with multiple disabilities exercise adaptive head or leg-foot and hands responses independently.

METHOD

The response selected for the two children included in Study I was head rotation (i.e. movements of at least 25 degrees to the left that could start from a full right position as well as from other positions). The responses selected for the child included in Study II involved forward movement of the left leg-foot and forward movement of his hand(s) to touch objects. Tilt or optic microswitches were used to monitor the responses and a computer system regulated the stimuli contingent on them.

RESULTS

The responses targeted in the two studies showed large frequency increases during the intervention phases of the studies (i.e. when followed by stimulation).

CONCLUSION

Technology-aided programs can be a useful resource to help children with multiple disabilities exercise relevant responses independently.

Robot-assisted and computer-enhanced therapies for children with cerebral palsy: current state and clinical implementation

The field of pediatric neurorehabilitation has rapidly evolved with the introduction of technological advancements over recent years. Rehabilitation robotics and computer-assisted systems can complement conventional physiotherapeutics or occupational therapies. These systems appear promising, especially in children, where exciting and challenging virtual reality scenarios could increase motivation to train intensely in a playful therapeutic environment. Despite promising experience and a large acceptance by the patients and parents, so far, only a few therapy systems have been evaluated in children, and well-designed randomized controlled studies in this field are still lacking. This narrative review aims to provide an overview about the to-date robot-assisted and computer-based therapies and the current level of evidence and to share the authors experience about the clinical implication of these new technologies available for children with cerebral palsy.

Virtual reality games for movement rehabilitation in neurological conditions: how do we meet the needs and expectations of the users?

PURPOSE

To review quantitative and qualitative studies that have examined the users' response to virtual reality game-based interventions in people with movement disorders associated with chronic neurological conditions. We aimed to determine key themes that influenced users' enjoyment and engagement in the games and develop suggestions as to how future systems could best address their needs and expectations.

KEY MESSAGE AND IMPLICATIONS

There were a limited number of studies that evaluated user opinions. From those found, seven common themes emerged: technology limitations, user control and therapist assistance, the novel physical and cognitive challenge, feedback, social interaction, game purpose and expectations, and the virtual environments. Our key recommendations derived from the review were to avoid technology failure, maintain overt therapeutic principles within the games, encompass progression to promote continuing physical and cognitive challenge, and to provide feedback that is easily and readily associated with success.

CONCLUSIONS

While there have been few studies that have evaluated the users' perspective of virtual rehabilitation games, our findings indicate that canvassing these experiences provides valuable information on the needs of the intended users. Incorporating our recommendations may enhance the efficacy of future systems to optimize the rehabilitation benefits of virtual reality games.

Defining the active ingredients of interactive computer play interventions for children with neuromotor impairments: a scoping review

Rehabilitation researchers who investigate complex interventions are challenged to describe the "active ingredients" of their interventions: the reason(s) why a treatment is expected to be effective. Interactive Computer Play (ICP) is an emerging complex intervention in rehabilitation practice and research. The purpose of this scoping review is to identify the active ingredients of ICP interventions that are designed to improve motor outcomes in children with neuromotor impairments. Eleven potential active ingredients were identified with the following foci: ICP system or game properties; intervention effects on the user; and therapist roles. However, few studies explicitly evaluate the impact of particular ingredients on outcomes. Identification of active ingredients in ICP interventions can inform trial design and clinical decision-making. Research and clinical practice will benefit from studies that utilize a framework such as motor learning theory to guide hypotheses and measurement of the active ingredients of complex interventions.

Motion interactive video games in home training for children with cerebral palsy: parents' perceptions

PURPOSE

To explore parents' perceptions of using low-cost motion interactive video games as home training for their children with mild/moderate cerebral palsy.

METHOD

Semi-structured interviews were carried out with parents from 15 families after participation in an intervention where motion interactive games were used daily in home training for their child. A qualitative content analysis approach was applied.

RESULTS

The parents' perception of the training was very positive. They expressed the view that motion interactive video games may promote positive experiences of physical training in rehabilitation, where the social aspects of gaming were especially valued. Further, the parents experienced less need to take on coaching while gaming stimulated independent training. However, there was a desire for more controlled and individualized games to better challenge the specific rehabilitative need of each child.

CONCLUSIONS

Low-cost motion interactive games may provide increased motivation and social interaction to home training and promote independent training with reduced coaching efforts for the parents. In future designs of interactive games for rehabilitation purposes, it is important to preserve the motivational and social features of games while optimizing the individualized physical exercise.

Facilitating clinical decision-making about the use of virtual reality within paediatric motor rehabilitation: application of a classification framework

AIM

Multiple virtual reality (VR) systems are used to improve motor function in children and youth with neurological impairments. Galvin and Levac developed a classification framework to facilitate clinical decision-making about VR system use. This paper applies the classification framework to identify its strengths and limitations.

METHOD

The classification framework is applied to three case studies where therapists may consider using VR with children involved in paediatric rehabilitation programmes.

RESULTS

The classification framework identified VR systems that met each child's individual needs. The relevance of each category to clinical decision-making varied depending on each child's goals. Categories requiring further development and suggestions for additional categories are discussed.

CONCLUSIONS

The classification framework facilitates child-centred decision-making about the use of VR as a therapeutic intervention. It has shown initial utility but requires further validation with clinicians working in a variety of clinical settings and with a range of client populations.

What's new in new technologies for upper extremity rehabilitation?

PURPOSE OF REVIEW

The field of new technologies for upper-limb rehabilitation is exploding. The review presents new trends and studies of effectiveness from recent literature regarding robots, virtual reality and telerehabilitation for neurorehabilitation of the upper limb.

RECENT FINDINGS

There appears to be a greater focus on technological developments than on clinical trials or studies to evaluate the mechanisms behind the effectiveness of these systems. Developments are most abundant in the field of robotics. However, the first well designed and powered randomized-controlled trial on robot rehabilitation has appeared, confirming that the effectiveness of robot therapy lies in the number of repetitions provided. There is a move towards studies in populations other than stroke, particularly cerebral palsy with a few studies on multiple sclerosis and traumatic brain injury. There is also an increasing trend for the use of robotic devices as evaluation tools.

SUMMARY

Despite the fact that new technologies are based on knowledge from motor control and learning literature and that they provide an exciting potential for varied rehabilitation, recent evidence suggests that the only contribution to clinical practice currently is the provision of intensive, repetitive movements.

Facilitating clinical decision-making about the use of virtual reality within paediatric motor rehabilitation: describing and classifying virtual reality systems

AIM

The use of virtual reality (VR) as a therapeutic intervention to improve motor function is an emerging area of rehabilitation practice and research. This paper describes VR systems reported in research literature and proposes a classification framework that categorizes VR systems according to characteristics relevant to motor rehabilitation.

METHODS

A comprehensive database search was undertaken to explore VR systems used in motor rehabilitation for children. Description of these systems, motor learning literature and expert opinion informed development of a classification framework.

RESULTS

Six VR systems are included. The descriptive analysis describes each system according to 12 user, system and context variables. The classification framework identifies three features common to all VR systems. Seven categories are proposed to differentiate between systems.

CONCLUSION

This paper organizes available information to facilitate clinical decision-making about VR systems and identifies areas of research to support the use of VR as a therapeutic intervention.

Using motion interactive games to promote physical activity and enhance motor performance in children with cerebral palsy

OBJECTIVE

To explore the feasibility of using low-cost motion interactive games as a home-based intervention for children with cerebral palsy (CP).

METHODS

Fourteen children with CP, 6-16 years old, practiced with the EyeToy for PlayStation2® in their homes during 4 weeks. Outcome measures were physical activity monitors, Movement Assessment Battery for Children-2 (mABC-2), Bruininks-Oseretsky Test of Motor Proficiency (sub-test 5 : 6), 1 Minute Walk Test and gaming diaries.

RESULTS

Motivation for practice and compliance of training were high. The children's physical activity increased during the intervention and activity monitors were feasible to use, although data loss may be a concern. According to mABC-2 the children's motor performance improved, but there were both floor and ceiling effects. The two additional motor tests showed only non-significant progress.

CONCLUSION

It is highly feasible to use motion interactive games in home rehabilitation for children with CP. Specific motor effects need to be further explored.

Does intervention using virtual reality improve upper limb function in children with neurological impairment: a systematic review of the evidence

BACKGROUND

Virtual reality (VR) is an emerging area of paediatric clinical and research practice, however the majority of research to date has focused on outcomes for adults following stroke. This paper appraises and describes current evidence for use of virtual reality interventions to improve upper limb function of children with neurological impairment.

METHODS

A comprehensive database search was undertaken to explore literature on the use of VR systems for rehabilitation of upper limb skills of children with neurological impairment. Studies investigating the use of robotics or other mechanical devices were excluded. Five studies were found and were critiqued using the Downs and Black scale for measuring study quality.

RESULTS

One randomized control trial and four case studies were found. No study scored over 50% on the Downs and Black scale, indicating methodological limitations that limit generalizability.

CONCLUSIONS

Current evidence for the use of VR to improve hand and arm skills is at an emerging stage. Small sample sizes and inconsistencies in outcome measurement limit the ability to generalize findings. Further studies are required to investigate the ability to maintain gains made in VR over time and to determine whether gains transfer from the VR to real life tasks and activities.

Interfacing a haptic robotic system with complex virtual environments to treat impaired upper extremity motor function in children with cerebral palsy

OBJECTIVE

To investigate the ability of the New Jersey Institute of Technology Robot Assisted Virtual Rehabilitation (NJIT-RAVR) system training to elicit changes in upper extremity (UE) function in children with hemiplegia secondary to cerebral palsy.

METHODS

Nine children (mean age 9 years, three males) participated in three pilots. Subjects trained 1 hour, 3 days a week for 3 weeks. Two groups performed this protocol as their only intervention. The third group also performed 5-6 hours of constraint-induced movement therapy.

RESULTS

All subjects participated in a short programme of nine, 60-minute training sessions without adverse effects. As a group, subjects demonstrated statistically significant improvements in Melbourne Assessment of Unilateral Upper Limb Function Test, a composite of three timed UE tasks and several measurements of reaching kinematics. Several subjects demonstrated clinically significant improvements in active shoulder abduction and flexion as well as forearm supination.

CONCLUSION

Three small pilots of NJIT-RAVR training demonstrated measurable benefit with no complications, warranting further examination.