Effectiveness of the virtual reality on cognitive function of children with hemiplegic cerebral palsy: a single-blind randomized controlled trial

Transferability of an executive function intervention in children with cerebral palsy: A randomized controlled trial

AIM

To evaluate the transfer effects of a home-based computerized executive function intervention on non-targeted cognitive functions (visual perception and memory), quality of life (QoL), and participation in children with cerebral palsy (CP), and to determine whether any improvements were maintained 9 months after the intervention.

METHOD

Sixty children with CP (aged 8-12 years) were randomly allocated to the intervention (15 females/15 males, mean age 10 years 4 months [SD = 1 years 8 months], age range 8-12 years) or waitlist (control) (15 females/15 males, mean age 10 years [SD = 1 years 9 months], age range 8-12 years) group. The intervention group underwent a home-based executive function intervention programme for 30 minutes per day, 5 days a week, for 12 weeks. All participants were assessed before the intervention, immediately after and 9 months after the intervention was completed.

RESULTS

After the intervention was completed, performance in immediate verbal memory, verbal learning, and visual perception (object and picture recognition) was significantly better in the intervention group than in the waitlist (control) group. No improvements were found in visual memory, visuospatial perception, QoL, or participation after the intervention. Scores at the follow-up showed that any beneficial effects were not maintained 9 months after the intervention was completed.

INTERPRETATION

A home-based computerized executive function intervention produced transfer effects on memory and visual perception immediately after the intervention in children with CP, although any beneficial effects were not sustained at the 9-month follow-up.

Effects of Video-Based Exercises and Conventional Physiotherapy on Upper Extremity Functionality, Selective Motor Control, and Proprioception in Unilateral Cerebral Palsy: A Randomized Controlled Trial

Objective: The present study was conducted to evaluate the effects of video-based exercises added to conventional physiotherapy (CPT) on upper extremity functionality, selective motor control, and proprioception in individuals with unilateral cerebral palsy (UCP). Materials and Methods: Thirty patients with UCP were randomized into two groups: the intervention group (15 individuals with a mean age of 9.2 ± 3.8 years) and the control group (15 individuals with a mean age of 8.3 ± 4.1 years). The intervention group received 8 weeks of video-based exercises, and the control group received 8 weeks of conventional physiotherapy. Upper extremity functional abilities, upper extremity selective motor control, proprioception, and entertainment levels were evaluated before and after the intervention for all groups. Results: While a significant change was observed in the mean scores of the ABILHAND-Kids, Selective Control of the Upper Extremity Scale right-left scores, shoulder flexion, shoulder abduction, and elbow flexion proprioception angles after the video-based exercises in the intervention group (P < 0.05), a significant change was observed only in the 60-degree flexion angle in the control group (P = 0.001). In the comparison between the groups, there were significant differences in post-intervention value only in shoulder flexion and abduction angles, whereas there was no difference between the groups in elbow flexion angles (P > 0.05). Conclusion: Incorporating video-based exercises into the upper extremity rehabilitation processes of individuals with UCP is beneficial in terms of upper extremity functionality, selective motor control, and proprioception.

Application of Virtual Reality-Assisted Exergaming on the Rehabilitation of Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

BACKGROUND

Rehabilitation programs for children with cerebral palsy (CP) aim to improve their motor and cognitive skills through repeated and progressively challenging exercises. However, these exercises can be tedious and demotivating, which can affect the effectiveness and feasibility of the programs. To overcome this problem, virtual reality VR-assisted exergaming has emerged as a novel modality of physiotherapy that combines fun and motivation with physical activity. VR exergaming allows children with CP to perform complex movements in a secure and immersive environment, where they can interact with virtual objects and scenarios. This enhances their active engagement and learning, as well as their self-confidence and enjoyment. We aim to provide a comprehensive overview of the current state of research on VR exergaming for CP rehabilitation. The specific objectives are: To identify and describe the existing studies that have investigated the effects of VR exergaming on motor function and participation outcomes in children with CP. In addition, we aim to identify and discuss the main gaps, challenges, and limitations in the current research on VR exergaming for CP rehabilitation. Finally, we aim to provide recommendations and suggestions for future research and practice in this field.

METHODS

In June 2023, we conducted a systematic search on Scopus, Web of Science, PubMed, Cochrane, and Embase for randomized trials and cohort studies that applied VR-assisted exergaming to rehabilitating patients with CP. The inclusion criteria encompassed the following: (1) Randomized controlled trials (RCTs) and cohort studies involving the rehabilitation of children with CP; (2) the application of VR-based exergaming on the rehabilitation; (3) in comparison with conventional rehabilitation/usual care. The quality of the selected RCTs was evaluated using Cochrane's tool for risk of bias assessment bias includes. Whereas the quality of cohort studies was assessed using the National Institutes of Health (NIH) tool.

RESULTS

The systematic search of databases retrieved a total of 2576 studies. After removing 863 duplicates, 1713 studies underwent title and abstract screening, and 68 studies were then selected as eligible for full-text screening. Finally, 45 studies were involved in this review (n = 1580), and 24 of those were included in the quantitative analysis. The majority of the included RCTs had a low risk of bias regarding study reporting, participants' attrition, and generating a random sequence. Nearly half of the RCTs ensured good blinding of outcomes assessors. However, almost all the RCTs were unclear regarding the blinding of the participants and the study personnel. The 2020 retrospective cohort study conducted at Samsung Changwon Hospital, investigating the effects of virtual reality-based rehabilitation on upper extremity function in children with cerebral palsy, demonstrated fair quality in its methodology and findings. VR-assisted exergaming was more effective than conventional physiotherapy in improving the Gross Motor Function Measurement (GMFM)-88 score (MD = 0.81; 95% CI [0.15, 1.47], p-value = 0.02) and the GMFM walking and standing dimensions (MD = 1.45; 95% CI [0.48, 2.24], p-value = 0.003 and MD = 3.15; 95% CI [0.87, 5.42], p-value = 0.007), respectively. The mobility and cognitive domains of the Pediatric Evaluation of Disability Inventory score (MD = 1.32; 95% CI [1.11, 1.52], p-value < 0.001) and (MD = 0.81; 95% CI [0.50, 1.13], p-value < 0.0001) were also improved. The Canadian Occupational Performance Measure performance domain (MD = 1.30; 95% CI [1.04, 1.56], p-value < 0.001), the WeeFunctional Independence Measure total score (MD = 6.67; 95% CI [6.36, 6.99], p-value < 0.0001), and the Melbourne Assessment of Unilateral Upper Limb Function-2 score (p-value < 0.001) improved as well. This new intervention is similarly beneficial as conventional therapy in improving other efficacy measures.

CONCLUSIONS

Our findings suggest that VR-assisted exergaming may have some advantages over conventional rehabilitation in improving CP children's functioning and performance in daily life activities, upper and lower limb mobility, and cognition. VR-assisted exergaming seems to be as effective as conventional physiotherapy in the other studied function measures. With its potential efficacy, better feasibility, no reported side effects, and entertaining experience, VR-assisted exergaming may be a viable complementary approach to conventional physiotherapy in rehabilitating children with CP.

A randomized controlled trial of a home-based computerized executive function intervention for children with cerebral palsy

Children with cerebral palsy (CP) often show executive function (EF) impairments that are key to quality of life. The aim of this study was to assess whether a home-based computerized intervention program improves executive functions (EFs) compared to usual care. Sixty participants (30 females) with CP (8-12 years old) were paired by age, sex, motor ability, and intelligence quotient score and then randomized to intervention and waitlist control groups. The intervention group received a 12-week home-based computerized EF intervention (5 days/week, 30 min/day, total dose 30 h). Core and higher-order EFs were assessed before, immediately after, and 9 months after completing the intervention. The intervention group performed better than the waitlist control group in the three core EFs (immediately and 9 months after the intervention): inhibitory control (F = 7.58, p = 0.13 and F = 7.85, p = 0.12), working memory (F = 8.34, p = 0.14 and F = 7.55, p = 0.13), and cognitive flexibility (F = 4.87, p = 0.09 and F = 4.19, p = 0.08). No differences were found between the groups in higher-order EFs or EF manifestations in daily life.

CONCLUSIONS

A home-based computerized EF intervention improved core EFs in children with CP, but further research is needed to identify strategies that allow the transfer of these improvements to everyday life.

TRIAL REGISTRATION

NCT04025749 retrospectively registered on 19 July 2019.

WHAT IS KNOWN

• One in two children with cerebral palsy has an intellectual impairment. Visual perception and executive functions are the most reported specific cognitive deficits. • The majority of interventions for cerebral palsy focus on motor impairments, but only a few randomized controlled trials have explored the effect of interventions on executive functions.

WHAT IS NEW

• A home-based computerized cognitive intervention can improve the core executive functions of children with cerebral palsy. • Short- and long-term effects on core executive functions have been found.

Areas of Research Focus and Trends in the Research on the Application of VR in Rehabilitation Medicine

OBJECTIVE

To establish the areas of research focus in the application of VR in rehabilitation medicine, analyze its themes and trends, and offer a reference for future related research in this field.

METHODS

This paper provides an in-depth analysis of the development process, areas of research focus, and research trends in the field of the application of VR in rehabilitation medicine, using the Web of Science core dataset as the source and using a bibliometric analysis with CiteSpace.

RESULTS

The application of VR in rehabilitation medicine was composed of three stages, and the research topics were reviewed from five perspectives: neurological rehabilitation, psychological treatment, pain distraction, cardiopulmonary rehabilitation, and visual-spatial disorder.

LIMITATIONS

The research data were sourced from the Web of Science core dataset only, and the data-sample size was not comprehensive.

CONCLUSIONS

Overcoming VR-technology-induced vertigo, mental disorders from the overuse of VR, individualized treatments, and integration with traditional therapy are all challenges in the application of VR in rehabilitation medicine that require research. In addition, developing VR products with better experiences, constructing standardized guidelines, and conducting more high-quality clinical studies are all future research topics related to the application of VR in rehabilitation medicine.

Research Status and Emerging Trends in Virtual Reality Rehabilitation: Bibliometric and Knowledge Graph Study

BACKGROUND

Virtual reality (VR) technology has been widely used in rehabilitation training because of its immersive, interactive, and imaginative features. A comprehensive bibliometric review is required to help researchers focus on future directions based on the new definitions of VR technologies in rehabilitation, which reveal new situations and requirements.

OBJECTIVE

Herein, we aimed to summarize effective research methods for and potential innovative approaches to VR rehabilitation by evaluating publications from various countries to encourage research on efficient strategies to improve VR rehabilitation.

METHODS

The SCIE (Science Citation Index Expanded) database was searched on January 20, 2022, for publications related to the application of VR technology in rehabilitation research. We found 1617 papers, and we created a clustered network, using the 46,116 references cited in the papers. CiteSpace V (Drexel University) and VOSviewer (Leiden University) were used to identify countries, institutions, journals, keywords, cocited references, and research hot spots.

RESULTS

A total of 63 countries and 1921 institutes have contributed publications. The United States of America has taken the leading position in this field; it has the highest number of publications; the highest h-index; and the largest collaborative network, which includes other countries. The reference clusters of SCIE papers were divided into the following nine categories: kinematics, neurorehabilitation, brain injury, exergames, aging, motor rehabilitation, mobility, cerebral palsy, and exercise intensity. The research frontiers were represented by the following keywords: video games (2017-2021), and young adults (2018-2021).

CONCLUSIONS

Our study comprehensively assesses the current research state of VR rehabilitation and analyzes the current research hot spots and future trends in the field, with the aims of providing resources for more intensive investigation and encouraging more researchers to further develop VR rehabilitation.

[Effectiveness of robotic technology and virtual reality for the rehabilitation of motor function in cerebral palsy. Systematic review]

INTRODUCTION

Cerebral palsy (CP) is a health condition secondary to non-progressive damage that occurs during brain development in the fetal or infant stage. To evaluate the effectiveness of robotic technology and virtual reality on motor function in patients with CP compared to conventional rehabilitation strategies such as physical therapy, occupational therapy, neurodevelopmental intervention, and transcranial stimulation. A review of randomized controlled trials of the last 5 years was carried out. For the evaluation of the methodological quality of the included studies, the PEDro scale was used, with evaluation of the level of evidence and degree of recommendation according to the Oxford classification.

RESULTS

Seventeen articles met the eligibility criteria. Robotic technology and virtual reality proved to be effective in improving motor function, manual skills, and visual-perceptual skills in patients with CP, compared to the use of conventional rehabilitation strategies.

Interventions with an Impact on Cognitive Functions in Cerebral Palsy: a Systematic Review

This systematic review aimed at investigating those interventions that impact on cognitive functioning in children and adults with cerebral palsy (CP). A systematic database search was conducted and twenty-eight studies suitable for inclusion were identified, of which only nine were randomized controlled trials (RCTs). Among all the studies included, ten were multi-modal (cognitive and physical tasks), eleven physical, five cognitive, and two alternative and augmentative communication interventions. The evidence suggests that multi-modal and physical interventions improve general cognitive functioning. Multi-modal and cognitive interventions have an impact on visual perception. Both interventions, together with physical interventions have an effect on a specific executive function domain (inhibitory control), and only cognitive interventions improved other executive function domains such as working memory. However, no RCT assessed the effects of all executive function domains. Few studies have looked at interventions to improve memory and language, and there is a scarcity of long-term research. Future RCTs must be of higher quality and better account for age and sex differences, as well as the clinical heterogeneity of CP. To date, there is evidence that multi-modal, cognitive or physical interventions have an impact on general cognitive functioning, visual perception and executive functions in children with CP, which may support their cognitive development.The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO): CRD42020152616.

Investigation of the relationship between feeding problems and cognitive functions in premature children

Children with a history of premature birth may show various problems in feeding, and these problems may continue at school age. It is necessary to examine the role of cognitive functions in children's feeding with more detailed studies.Comparison of feeding problems and cognitive functions of premature and full-term children and examining the relationship between them. The parents of 60 children aged 6-10 completed the The Screening Tool of Feeding Problems, and the cognitive functions of the children were evaluated with the Dynamic Occupational Therapy Cognitive Assessment. Results are compared and correlations betweeen feeding problems and cognitive functions were examıned. Feeding problems of premature children are statistically higher than those born at term; their cognitive functions were statistically weaker (p < 0.001). It was found that feeding problems and cognitive functions were statistically related in premature children (p < 0.05). Feeding problems seen in premature children may be related to their weaker cognitive functions compared to their peers. It is important to evaluate cognitive functions and include them in the intervention in rehabilitation programs to be prepared for premature children with feeding problems.

Virtual Reality-Based Intervention for Enhancing Upper Extremity Function in Children With Hemiplegic Cerebral Palsy: A Literature Review

Cerebral palsy (CP) is the most common cause of motor disability in the pediatric population, with hemiplegia as one of the most widely seen subtypes of spastic CP. Although most of the children with hemiplegic CP are independent ambulators, deficits in hand function of the affected side remain a major concern of caregivers and children themselves. Children use the unaffected upper extremity to compensate for the weakness in the affected one, which consequently leads to the disuse of the hemiparetic upper extremity. Interactive virtual environments can enhance the activation of brain areas during training by providing feedback that can catalyze neuroplastic changes for improved function. Although numerous studies have been conducted on the impact of virtual reality (VR)-based rehabilitation in adults with stroke, studies on its use in the pediatric population are scarce. The three broad categories of VR systems based on the type of human-computer interactions are feedback-focused, gesture-based, and haptic-based. Preliminary studies have shown promising results of VR intervention in improving motor function, including upper extremity function, in children with hemiplegic CP. It is an engaging and entertaining intervention that adds an advantage of high compliance due to motivation. The current literature consists of studies with highly heterogeneous groups of participants and small sample sizes. Further investigation on children with a specific type of CP with advanced VR systems technology is warranted.

Effectiveness of virtual reality in children and young adults with cerebral palsy: a systematic review of randomized controlled trial

BACKGROUND

Cerebral palsy (CP) is one of the main causes of disability in childhood. Virtual reality (VR) has been used as a treatment option in this population, however its effectiveness is unclear.

OBJECTIVE

To evaluate the effectiveness of VR in patients with CP.

METHODS

We conducted electronic searches in EMBASE, MEDLINE, Cochrane library, PEDro, AMED, PsycoINFO, and LILACS databases and trial site registries such as ClinicalTrials.gov and ICTRP. We included randomized controlled trials that tested the use of VR alone or in combination with other interventions compared to more conventional rehabilitation or usual care in individuals with CP. The primary outcomes were upper and lower limb function, postural control, and balance. The secondary outcomes included global motor function, perception, cognition and spatial functions, motivation, motor learning, and adverse events. Two independent reviewers extracted and assessed included articles for risk of bias using the Cochrane risk of bias tool. We use a meta-analysis with random effect model whenever possible. We analyzed the quality of evidence using theGRADE approach.

RESULTS

We included 38 trials (pooled n = 1233 participants) in this review. There is very low quality of evidence that VR plus conventional rehabilitation is better than conventional rehabilitation for upper limb function. There is also very low quality evidence that VR alone is no better than conventional rehabilitation for upper and lower limb function. No adverse events were observed among the 10 trials that provided information on this outcome.

CONCLUSION

At present we have very limited to limited confidence in effect estimation for utilization of VR in this population. Future studies may change our confidence in results and effect estimates.

PROTOCOL REGISTRATION

PROSPERO CRD 42018102759.

Effect of Anodal Transcranial Direct Current Stimulation Combined With Cognitive Training for Improving Cognition and Language Among Children With Cerebral Palsy With Cognitive Impairment: A Pilot, Randomized, Controlled, Double-Blind, and Clinical Trial

About 30-45% of cerebral palsy (CP) patients have cognitive impairment. Previous studies showed the evidence that transcranial direct current stimulation (tDCS) may have some benefits in attention-deficit/hyperactivity disorder, autism spectrum disorder, and motor development in CP. The aim of this study is to evaluate the effect of tDCS on cognition, language, and activities of daily living (ADL) among children with CP with cognitive impairment. It was a pilot, randomized, controlled, double-blind, clinical trial in a tertiary pediatric hospital, and 13 children with CP and a cognitive age under 42 months were enrolled. tDCS group (n = 8) had active tDCS and cognitive training (20 min/session, total 20 sessions, for 12 weeks) and sham group (n = 5) had sham tDCS and cognitive training. Primary outcome was the Bayley Scales of Infant Development II (BSID II). Secondary outcomes were the Pediatric Evaluation of Disability Inventory (PEDI), the Laboratory Temperament Assessment Battery (Lab-TAB), the Early Childhood Behavior Questionnaire (ECBQ), the Korean version of MacArthur-Bates Communicative Development Inventories (M-B CDI-K), the Sequenced Language Scale for Infants (SELSI) and the Preschool Receptive-Expressive Language Scale (PRES). After intervention, the tDCS group showed significant improvements in all measurements (p < 0.05) except the M-B CDI-K (grammar), whereas the sham group only showed significant improvements in the Lab-TAB (manipulation domain), the ECBQ (attentional shifting), and the M-B CDI-K (comprehension). The between-group differences in the degree of post-intervention improvement were not statistically significant. The degree of improvement was associated with better baseline cognitive function and younger age (p < 0.05). There were no major adverse events after tDCS. The combined application of tDCS and cognitive training was feasible and associated with improvements in cognitive function, ADL, and language among children with CP with cognitive impairment. However, considering that it is a pilot study, further larger-scale systematic investigation is needed. Clinical Trial Registration: The trial was registered in the Clinical Research Information Service database, identifier: KCT0003023.