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

Evaluating the impact of virtual reality game training on upper limb motor performance in children and adolescents with developmental coordination disorder: a scoping review using the ICF framework

OBJECTIVE

This scoping review aims to explore published literature testing Virtual Reality (VR) interventions for improving upper limb motor performance in children and adolescents with Developmental Coordination Disorder (DCD). Our primary focus was on the types of VR systems used and the measurement tools employed within the International Classification of Functioning, Disability and Health Children and Youth Version (ICF-CY) domains in these studies.

METHODS

A comprehensive search of six electronic databases up to 11th January 2024 was conducted using predefined terms. Inclusion and exclusion criteria were applied to determine study eligibility, with two authors independently assessing titles, abstracts, and full-text articles.

RESULTS

Out of 788 potential studies, 14 met the eligibility criteria. Studies predominantly utilized non-immersive VR (nVR) systems, for example, commercial platforms such as Nintendo Wii. Most interventions targeted general motor coordination or balance, with only four studies specifically focusing on upper limb motor performance. The Movement Assessment Battery for Children-2 was the predominant assessment tool. However, the use of game scores and trial durations raised concerns about the accuracy of assessments. The majority of studies reported no significant improvement in upper limb motor performance following VR interventions, though some noted improvements in specific tasks or overall outcomes.

CONCLUSION

The findings suggest that, while nVR interventions are being explored for paediatric motor rehabilitation, their impact on enhancing upper limb motor performance in children with DCD is unclear. The variability in intervention designs, outcome measures, and the predominant focus on general motor skills rather than specific upper limb improvements highlight the need for more targeted research in this area.

IMPACT

This review underscores the importance of developing precise and clinically relevant measurement tools in a broader range of VR technologies to optimize the use of VR in therapy for children with DCD. Future research should aim for more rigorous study designs and emerging immersive technologies to maximize therapeutic benefits.

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.

An Immersive Virtual Kitchen Training System for People with Multiple Sclerosis: A Development and Validation Study

Rehabilitation via virtual reality (VR) training tools allows repetitive, intensive, and task-specific practice in a controlled and safe environment. Our goal was to develop and validate a novel immersive VR system based on the practice of real-life activities in a kitchen environment in people with multiple sclerosis (pwMS) with upper-limb dysfunction. The novel immersive VR kitchen application includes several tasks, i.e., tidying up the kitchen, preparing a hamburger and soup meal, and dish washing. Following the development phase, the system was tested for an 8-week intervention period on a small sample of pwMS suffering from upper-limb dysfunction. The Suitability Evaluation Questionnaire for VR systems served as the primary outcome. The scores for enjoyment, sense of comfort with the system, feelings of success and control, realism, easy-to-understand instructions, assists in rehabilitation therapy, were between 4.0 and 4.6, indicating a high satisfaction. The scores for eye discomfort, dizziness, nausea, and disorientation during practice were between 2.8 and 1.3, indicating a low-to-moderate interference of the system. The virtual kitchen training system is feasible and safe for upper-limb training in pwMS and paves the way for future RCTs to examine the benefits of the system compared with standard care, thus improving the functionality of the upper limbs in pwMS.

Application and Effect of Virtual Reality Technology in Motor Skill Intervention for Individuals with Developmental Disabilities: A Systematic Review

Children and adolescents with developmental disabilities are often impaired with motor function, and motor skills are related to the performance of daily living activities, and their defects may limit social participation and reduce the quality of life. With the progress of information technology, virtual reality is used as an emerging and alternative intervention method for the intervention of its motor skills. However, the application of this field is still limited in our country, so it is of great significance to systematically analyze the foreign intervention in this field. The research used Web of Science, EBSCO, PubMed, and other databases to search the literature published in the past ten years on the application of virtual reality technology in the motor skill intervention of people with developmental disabilities, and analyzed the demographic characteristics, intervention target behavior, intervention time, intervention effect, and statistical methods. The advantages and disadvantages of research in this field are summarized, and on this basis, the reflection and prospects for follow-up intervention research are put forward.

Treatment of knee hyperextension in post-stroke gait. A systematic review

BACKGROUND

Post-stroke, patients exhibit considerable variations in gait patterns. One of the variations that can be present in post-stroke gait is knee hyperextension in the stance phase.

RESEARCH QUESTION

What is the current evidence for the effectiveness of the treatment of knee hyperextension in post-stroke gait?

METHODS

MEDLINE, EMBASE, PEDro, CINAHL, and the Cochrane library were searched for relevant controlled trials. Two researchers independently extracted the data and assessed the methological quality. A best evidence synthesis was conducted to summarize the results.

RESULTS

Eight controlled trials (5 RCTs, 3 CCTs) were included. Three types of interventions were identified: proprioceptive training, orthotic treatment, and functional electrostimulation (FES). In the included studies, the time since the stroke occurrence varied from the (sub)acute phase to the chronic phase. Only short-term effects were investigated. The adjustment from a form of proprioceptive training to physiotherapy training programs seems to be effective (moderate evidence) for treating knee hyperextension in gait, as applied in the subacute phase post-stroke. Neither evidence for effects on gait speed nor gait symmetry were found as a result of proprioceptive training. Orthoses that cover the knee have some effects (limited evidence) on knee hyperextension and gait speed. No evidence was found for FES.

SIGNIFICANCE

This is the first systematic literature review on the effectiveness of interventions on knee hyperextension in post-stroke gait. We found promising results (moderate evidence) for some "proprioceptive approaches" as an add-on therapy to physiotherapy training programs for treating knee hyperextension during the subacute phase post-stroke, in the short-term. Therefore, initially, clinicians should implement a training program with a proprioceptive approach in order to restore knee control in these patients. Because only studies reporting short-term results were found, more high-quality RCTs and CCTs are needed that also study mid- and long-term effects.

Integration of Motor Learning Principles Into Virtual Reality Interventions for Individuals With Cerebral Palsy: Systematic Review

Background

Increasing evidence supports the use of virtual reality systems to improve upper limb motor functions in individuals with cerebral palsy. While virtual reality offers the possibility to include key components to promote motor learning, it remains unclear if and how motor learning principles are incorporated into the development of rehabilitation interventions using virtual reality.

Objective

The objective of this study was to determine the extent to which motor learning principles are integrated into virtual reality interventions targeting upper limb function in individuals with cerebral palsy.

Methods

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was performed in 10 databases using a combination of keywords related to cerebral palsy, virtual reality, video games, and rehabilitation. Studies were divided into 2 categories: commercial video game platforms and devices and custom virtual reality systems. Study quality was assessed using the modified Downs and Black checklist.

Results

The initial search yielded 1497 publications. A total of 26 studies from 30 publications were included, with most studies classified as “fair” according to the modified Downs and Black checklist. The majority of studies provided enhanced feedback and variable practice and used functionally relevant and motivating virtual tasks. The dosage varied greatly (total training time ranged from 300 to 3360 minutes), with only 6 studies reporting the number of movement repetitions per session. The difficulty progression and the assessment of skills retention and transfer were poorly incorporated, especially for the commercial video games.

Conclusions

Motor learning principles should be better integrated into the development of future virtual reality systems for optimal upper limb motor recovery in individuals with cerebral palsy.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020151982; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151982

Virtual reality rehabilitation in children with brain injury: a randomized controlled trial

AIM

To investigate the efficacy of a virtual reality rehabilitation system of wearable multi-inertial sensors to improve upper-limb function in children with brain injury.

METHOD

Eighty children (39 males, 41 females) with brain injury including cerebral palsy aged 3 to 16 years (mean age 5y 8mo, SD 2y 10mo) were assessed as part of a multicentre, single-blind, randomized controlled trial. The intervention group received a 30-minute virtual reality intervention and a 30-minute session of conventional occupational therapy while the control group received 60 minutes of conventional occupational therapy per session, with 20 sessions over 4 weeks. The virtual reality rehabilitation system consisted of games promoting wrist and forearm articular movements using wearable inertial sensors. The Melbourne Assessment of Unilateral Upper Limb Function-2 (MA-2), Upper Limb Physician's Rating Scale, Pediatric Evaluation of Disability Inventory Computer Adaptive Test, and computerized three-dimensional motion analysis were performed.

RESULTS

Both groups (virtual reality, n=40; control, n=38) significantly improved after treatment compared to baseline; however, the virtual reality group showed more significant improvements in upper-limb dexterity functions (MA-2, virtual reality group: Δ=10.09±10.50; control: Δ=3.65±6.92), performance of activities of daily living, and forearm supination by kinematic analysis (p<0.05). In the virtual reality group, children with more severe motor impairment showed significant improvements compared to those with less severe impairment.

INTERPRETATION

The virtual reality rehabilitation system used in this study, which consists of wearable inertial sensors and offers intensive, interactive, and repetitive motor training, is effective in children with brain injury.

WHAT THIS PAPER ADDS

Both virtual reality rehabilitation and conventional occupational therapy were effective for upper-limb training. Virtual reality training was superior in improving dexterity, performance of activities of daily living, and active forearm supination motion. The effect of virtual reality training was significant in children with more severe motor impairments.

Conventional and Virtual Reality Mirror Therapies in Upper Obstetric Brachial Palsy: A Randomized Pilot Study

The abilities of children diagnosed with Obstetric Brachial Palsy (OBP) are limited by brachial plexus injuries. Thus, their participation in the community is hindered, which involves a lower quality of life due to worse performance in activities of daily living as a consequence of the functional limitations of the affected upper limb. Conventional Mirror Therapy (Conventional MT) and Virtual Therapy improve the affected upper limb functionality. Therefore, the aim of this study was to compare the effects of Conventional MT and Virtual Reality MT on the spontaneous use of the affected upper limb and quality of life of children with upper Obstetric Brachial Palsy between 6 and 12 years of age. A randomized pilot study was performed. Twelve children were randomly assigned to perform Conventional Mirror Therapy or Virtual Reality Mirror Therapy for four weeks. Ten children completed the treatment. Two assessments (pre/post-intervention) were carried out to assess the spontaneous use of the affected upper limb and the quality of life using the Children’s Hand-use Experience Questionnaire (CHEQ) and the Pediatric Quality of Life Inventory Generic Core Scales (PedsQL TM 4.0), respectively. There was a statistically significant increment in spontaneous use, observed in independent tasks (p = 0.02) and in the use of the affected hand with grasp (p = 0.04), measured with the CHEQ, for the Virtual Reality MT group. There were no statistically significant changes (p > 0.05) for the Conventional MT group in the spontaneous use of the affected upper limb. Regarding the quality of life, statistically significant changes were obtained in the Physical and Health activity categories of the parents’ questionnaire (p = 0.03) and in the total score of the children’s questionnaire (p = 0.04) in the Virtual Reality MT group, measured using the PedsQL TM 4.0. Statistically significant changes were not obtained for the quality of life in the Conventional MT group. This study suggests that, compared to Conventional MT, Virtual Reality MT would be a home-based therapeutic complement to increase independent bimanual tasks using grasp in the affected upper limb and improve the quality of life of children diagnosed with upper OBP in the age range of 6–12 years.

Effectiveness of virtual reality in the treatment of hand function in children with cerebral palsy: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Children with cerebral palsy (CP) may have limited use of their hands for functional activities and for fine motor skills. Virtual reality (VR) is a relatively new and innovative approach to facilitate hand function in children with CP.

PURPOSE OF THE STUDY

The primary purpose of this study was to determine the effectiveness of VR as an intervention to improve hand function in children with CP compared to either conventional physiotherapy or other therapeutic interventions. The secondary purpose was to classify the outcomes evaluated according to the International Classification of Functioning, Disability and Health (ICF) dimensions.

METHODS

A International prospective register of systematic reviews (PROSPERO)-registered literature search was carried out in August 2015 in MEDLINE, CINAHL, ERIC, HealthSTAR, AMED, BNI, Embase, PsycINFO, PEDro, Cochrane Central Register, DARE, OTSeeker, REHABDATA, HaPI, CIRRIE, and Scopus. PRISMA guidelines were followed. Only randomized controlled trials (RCTs) were included, and their methodological qualities were examined using the Cochrane collaboration's risk of bias (RoB) tool. A narrative synthesis was performed.

RESULTS

The 6 RCTs published on this topic provide conflicting results. Four studies reported improved hand function (2 low RoB, 1 high RoB, and 1 unclear RoB), whereas 2 studies reported no improvement. All of the RCTs reported the activity element of ICF, but no study explicitly described the effect of VR intervention based on the ICF model.

CONCLUSION

The role of VR ti imrpove hand fucntion in children with CP is unclear due to limited evidence; use as an adjunct has some support.

Do video game interventions improve motor outcomes in children with developmental coordination disorder? A systematic review using the ICF framework

Background

Children with developmental coordination disorder (DCD) experience a range of difficulties that can potentially limit their academic, social and physical ability. Recent research has developed interventions that aim to improve motor outcomes in a variety of paediatric cohorts using video gaming equipment. Therefore, we aimed to systematically review the literature on virtual reality or video game interventions that aim to improve motor outcomes in children with DCD.

Methods

Seven databases were searched for studies using the following criteria: a) virtual reality or video game based intervention; b) children with DCD; and c) motor outcomes relating to body structure and function, activity or participation. Data were extracted relating to study design, participant characteristics, details of the intervention, outcome measures, results, and feasibility/adherence.

Results

Fifteen articles were included for review, including eight randomised controlled trials. No studies used virtual reality equipment, with all interventions using video games (Nintendo Wii in 12/15 articles). Mixed effects of video game intervention on outcome were found, with conflicting evidence across studies. Studies that reported on feasibility found most children enjoyed and adhered to the video game interventions.

Conclusions

This review found limited evidence for the effectiveness of video game interventions for children with DCD to improve motor outcomes due to limitations in the research including low sample sizes and low to moderate methodological quality. Further research is needed to determine the effect of video game or virtual reality interventions on motor outcomes in children with DCD.

Protocol registration

The protocol for this systematic review can be found on PROSPERO (CRD42017064427).

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1381-7) contains supplementary material, which is available to authorized users.

Nonsurgical Treatment Options for Upper Limb Spasticity

There are many nonsurgical treatment options for patients with upper limb spasticity. This article presents an algorithmic approach to management, encompassing evidence-based rehabilitation therapies, medications, and promising new orthotic and robotic innovations.

Computerised Tracking Training for Coordination in Children with Hemiplegic Cerebral Palsy: A Case Series

Objective: To examine whether elbow coordination training can improve elbow coordination in cerebral palsy and whether any benefit carries over to upper limb activity.

Methods: A case series A–B–C multiple baseline study was carried out. Two weeks of no intervention (A) was followed by 2 weeks of computerised tracking (B), which was followed by 2 weeks of no intervention (C). Six children (age range 7–12 years) with hemiplegic cerebral palsy (Level I–III of the Manual Ability Classification System) participated. Coordination training consisted of 10 × 1-min trials of computerised tracking each session for 10 sessions over a 2-week period. Coordination was measured as tracking performance using a different target from the training target. Upper limb activity was measured using the 9-Hole Peg Test. Data were analysed using the 2-SD band method.

Results: None of the participants appeared to improve tracking performance or 9-Hole Peg Test (9HPT) scores (p > 0.05) after the 2 weeks of intervention. On withdrawal of the intervention, visual analysis showed that tracking performance and 9HPT scores remained at the same level as the intervention phase.

Conclusions: Ten minutes of computerised elbow tracking daily for 10 sessions did not improve coordination in six children with cerebral palsy.

Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults: Prevention, Plasticity, and Participation

Use of virtual reality (VR) and serious games (SGs) interventions within rehabilitation as motivating tools for task specific training for individuals with neurological conditions are fast-developing. Within this perspective paper we use the framework of the IV STEP conference to summarize the literature on VR and SG for children and adults by three topics: Prevention; Outcomes: Body-Function-Structure, Activity and Participation; and Plasticity. Overall the literature in this area offers support for use of VR and SGs to improve body functions and to some extent activity domain outcomes. Critical analysis of clients' goals and selective evaluation of VR and SGs are necessary to appropriately take advantage of these tools within intervention. Further research on prevention, participation, and plasticity is warranted. We offer suggestions for bridging the gap between research and practice integrating VR and SGs into physical therapist education and practice.

Cerebral Reorganization in Subacute Stroke Survivors after Virtual Reality-Based Training: A Preliminary Study

Background

Functional magnetic resonance imaging (fMRI) is a promising method for quantifying brain recovery and investigating the intervention-induced changes in corticomotor excitability after stroke. This study aimed to evaluate cortical reorganization subsequent to virtual reality-enhanced treadmill (VRET) training in subacute stroke survivors.

Methods

Eight participants with ischemic stroke underwent VRET for 5 sections per week and for 3 weeks. fMRI was conducted to quantify the activity of selected brain regions when the subject performed ankle dorsiflexion. Gait speed and clinical scales were also measured before and after intervention.

Results

Increased activation in the primary sensorimotor cortex of the lesioned hemisphere and supplementary motor areas of both sides for the paretic foot (p < 0.01) was observed postintervention. Statistically significant improvements were observed in gait velocity (p < 0.05). The change in voxel counts in the primary sensorimotor cortex of the lesioned hemisphere is significantly correlated with improvement of 10 m walk time after VRET (r = −0.719).

Conclusions

We observed improved walking and increased activation in cortical regions of stroke survivors after VRET training. Moreover, the cortical recruitment was associated with better walking function. Our study suggests that cortical networks could be a site of plasticity, and their recruitment may be one mechanism of training-induced recovery of gait function in stroke. This trial is registered with ChiCTR-IOC-15006064.

Impact of multi-modal web-based rehabilitation on occupational performance and upper limb outcomes: pilot randomized trial in children with acquired brain injuries

AIMS

To determine whether the multi-modal web-based rehabilitation 'Move it to improve it' (Mitii) is more effective than wait list control (usual care) to improve occupational performance, upper limb function, and visual perception in children with acquired brain injury (ABI).

METHOD

Fifty-eight randomly allocated children (53% males; mean age 11y 11mo, SD 2y 6mo; Manual Abilities Classification Scale equivalent I=32, II=24, III=2; mean Full-scale IQ 75.8, SD 16.2) received either 20 weeks of Mitii (n=29) or usual care (n=29). Mitii comprised upper limb, cognitive, visual perception, and gross motor tasks, recommended for 30 minutes per day, 6 days per week, over 20 weeks. Outcomes were the Assessment of Motor and Process Skills (AMPS), Melbourne Assessment of Unilateral Upper Limb Function, Jebsen-Taylor Test of Hand Function, Test of Visual Perceptual Skills, Assisting Hand Assessment (AHA), and Canadian Occupational Performance Measure. The primary comparison at 20 weeks between groups on the AMPS process and motor measures used generalized estimating equations.

RESULTS

Groups were equivalent at baseline. Participants completed on average 17.6 hours (range 0-46h) of Mitii. There were no differences between groups on the primary outcome (AMPS process: estimated mean difference -0.1, 95% CI -0.3 to 0.2, p=0.589; and AMPS motor: estimated mean difference 0.2, 95% CI -0.1 to 0.5, p=0.192). There were no differences between groups on overall visual perception, upper limb, and occupational performance outcomes.

INTERPRETATION

Mitii led to negligible changes on all primary and secondary outcomes compared with usual care. This likely reflects the small dose achieved and poses questions around the acceptability and feasibility of home-delivered Mitii in this population of children with ABI.

Using Free Internet Videogames in Upper Extremity Motor Training for Children with Cerebral Palsy

Movement therapy is one type of upper extremity intervention for children with cerebral palsy (CP) to improve function. It requires high-intensity, repetitive and task-specific training. Tedium and lack of motivation are substantial barriers to completing the training. An approach to overcome these barriers is to couple the movement therapy with videogames. This investigation: (1) tested the feasibility of delivering a free Internet videogame upper extremity motor intervention to four children with CP (aged 8–17 years) with mild to moderate limitations to upper limb function; and (2) determined the level of intrinsic motivation during the intervention. The intervention used free Internet videogames in conjunction with the Microsoft Kinect motion sensor and the Flexible Action and Articulated Skeleton Toolkit software (FAAST) software. Results indicated that the intervention could be successfully delivered in the laboratory and the home, and pre- and post- impairment, function and performance assessments were possible. Results also indicated a high level of motivation among the participants. It was concluded that the use of inexpensive hardware and software in conjunction with free Internet videogames has the potential to be very motivating in helping to improve the upper extremity abilities of children with CP. Future work should include results from additional participants and from a control group in a randomized controlled trial to establish efficacy.

Effect of a Home-Based Virtual Reality Intervention for Children with Cerebral Palsy Using Super Pop VR Evaluation Metrics: A Feasibility Study

Objective. The purpose of this pilot study was to determine whether Super Pop VR, a low-cost virtual reality (VR) system, was a feasible system for documenting improvement in children with cerebral palsy (CP) and whether a home-based VR intervention was effective. Methods. Three children with CP participated in this study and received an 8-week VR intervention (30 minutes × 5 sessions/week) using the commercial EyeToy Play VR system. Reaching kinematics measured by Super Pop VR and two fine motor tools (Bruininks-Oseretsky Test of Motor Proficiency second edition, BOT-2, and Pediatric Motor Activity Log, PMAL) were tested before, mid, and after intervention. Results. All children successfully completed the evaluations using the Super Pop VR system at home where 85% of the reaches collected were used to compute reaching kinematics, which is compatible with literature using expensive motion analysis systems. Only the child with hemiplegic CP and more impaired arm function improved the reaching kinematics and functional use of the affected hand after intervention. Conclusion. Super Pop VR proved to be a feasible evaluation tool in children with CP.

Upper-Limb Rehabilitation With Adaptive Video Games for Preschool Children With Developmental Disabilities

OBJECTIVE

This study used a novel device to make video games accessible to children with developmental disabilities (DD) by modifying the training software and interfaces to enhance motor training.

METHOD

In the pretest-posttest design, 20 children (13 boys, 7 girls; mean age=5.2 yr) with DD received adaptive upper-limb motor rehabilitation consisting of fifteen 30-min individual sessions 3 times per week for 5 wk.

RESULTS

Improvement in Beery-Buktenica Developmental Test of Visual Motor Integration and Peabody Developmental Motor Scales, Second Edition, scores for children with DD indicated significant differences between pretest and posttest.

CONCLUSION

The rehabilitation device modified for the needs of children with DD is effective in improving visual-motor performance of children with DD.

"Kinect-ing" with clinicians: a knowledge translation resource to support decision making about video game use in rehabilitation

Microsoft's Kinect for Xbox 360 virtual reality (VR) video games are promising rehabilitation options because they involve motivating, full-body movement practice. However, these games were designed for recreational use, which creates challenges for clinical implementation. Busy clinicians require decision-making support to inform game selection and implementation that address individual therapeutic goals. This article describes the development and preliminary evaluation of a knowledge translation (KT) resource to support clinical decision making about selection and use of Kinect games in physical therapy. The knowledge-to-action framework guided the development of the Kinecting With Clinicians (KWiC) resource. Five physical therapists with VR and video game expertise analyzed the Kinect Adventure games. A consensus-building method was used to arrive at categories to organize clinically relevant attributes guiding game selection and game play. The process and results of an exploratory usability evaluation of the KWiC resource by clinicians through interviews and focus groups at 4 clinical sites is described. Subsequent steps in the evaluation and KT process are proposed, including making the KWiC resource Web-based and evaluating the utility of the online resource in clinical practice.

Promoting leisure participation as part of health and well-being in children and youth with cerebral palsy

Participation in leisure is a human right and is central to the health of children and youth. The World Health Organization's International Classification of Functioning, Disability and Health for Children and Youth supported a change in thinking about what outcomes are most relevant in the context of children's health and places participation as one of the constituent elements of health. Participation is also a fundamental rehabilitation and health promotion outcome for children with cerebral palsy as identified by youth, parents, and health professionals. Several studies have identified individual and environmental factors related to participation in leisure; new studies are now determining the best interventions to promote participation. This article summarizes recent findings and proposes important topics for neurologists to consider in exploring leisure pursuits with children with cerebral palsy and their families and in working with rehabilitation professionals to promote engagement in leisure opportunities as part of integrated care.

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.

GRIN: "GRoup versus INdividual physiotherapy following lower limb intra-muscular Botulinum Toxin-A injections for ambulant children with cerebral palsy: an assessor-masked randomised comparison trial": study protocol

BACKGROUND

Cerebral palsy is the most common cause of physical disability in childhood. Spasticity is a significant contributor to the secondary impairments impacting functional performance and participation. The most common lower limb spasticity management is focal intramuscular injections of Botulinum Toxin-Type A accompanied by individually-delivered (one on one) physiotherapy rehabilitation. With increasing emphasis on improving goal-directed functional activity and participation within a family-centred framework, it is timely to explore whether physiotherapy provided in a group could achieve comparable outcomes, encouraging providers to offer flexible models of physiotherapy delivery. This study aims to compare individual to group-based physiotherapy following intramuscular Botulinum Toxin-A injections to the lower limbs for ambulant children with cerebral palsy aged four to fourteen years.

METHODS/DESIGN

An assessor-masked, block randomised comparison trial will be conducted with random allocation to either group-based or individual physiotherapy. A sample size of 30 (15 in each study arm) will be recruited. Both groups will receive six hours of direct therapy following Botulinum Toxin-A injections in either an individual or group format with additional home programme activities (three exercises to be performed three times a week). Study groups will be compared at baseline (T1), then at 10 weeks (T2, efficacy) and 26 weeks (T3, retention) post Botulinum Toxin-A injections. Primary outcomes will be caregiver/s perception of and satisfaction with their child's occupational performance goals (Canadian Occupational Performance Measure) and quality of gait (Edinburgh Visual Gait Score) with a range of secondary outcomes across domains of the International Classification of Disability, Functioning and Health.

DISCUSSION

This paper outlines the study protocol including theoretical basis, study hypotheses and outcome measures for this assessor-masked, randomised comparison trial comparing group versus individual models of physiotherapy following intramuscular injections of Botulinum Toxin-A to the lower limbs for ambulant children with cerebral palsy.

TRIAL REGISTRATION

ACTRN12611000454976.

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.

A new virtual reality tool for unilateral cerebral palsy rehabilitation: two single-case studies

OBJECTIVE

To examine the "clinical utility" of a new virtual rehabilitation tool in order to treat upper-limb motor deficit in cerebral palsy (CP) patient.

METHODS

Single-case experimental designs. Virtual reality intervention was performed in two left unilateral spastic CP adolescent patients. The virtual reality intervention was given for 60 minutes per session, two sessions a day, and 5 days a week over 2 weeks.

RESULTS

For each patient and for both hands, the number of blocks transported within one minute (box and block test scores) is increased. The nonoverlap of all pairs indices for the paretic hand were calculated as 0.95 for subject 1 and 0.93 for subject 2, and the nonoverlap of all pairs indices for the nonparetic hand were calculated, respectively, as 0.92 and 1.

CONCLUSION

We provide empirical evidence in support of a new simple Virtual Rehabilitation system in CP patient to improve upper-limb motor function.

Rehabilitation of children with hemiparesis: a pilot study on the use of virtual reality

Background. A wide range of treatments have been used to improve upper arm motor performances in children with congenital hemiplegia. Recent findings are suggesting that virtual reality based intervention could be a promising tool also in pediatric rehabilitation. Methods. Six patients with congenital hemiplegia (age: 4–16 years) were recruited among those treated in the Child Neuropsychiatry and Rehabilitation Unit of the IRCCS “Santa Maria Nascente” (Milan, Italy), for a preliminary investigation about using nonimmersive virtual reality for upper limb rehabilitation. Ten sessions using VRRS system (Khymeia, Padova, Italy) were weekly administered as a part of the rehabilitative treatment. Melbourne Assessment of Unilateral Limb Movement, Ashworth Scale, and Arm's PROM were selected as main outcome measures. At the end of treatment, participants filled in an ad hoc satisfaction questionnaire. Results. All subjects completed the proposed treatment, and they also gave a positive judgment regarding this rehabilitative method. Melbourne score increased in all patients. Conclusion. Our findings seem to support the evidence that VR treatment could be a promising and engaging tool for pediatric rehabilitation. However, the limited size of the population and the small number of sessions require further investigations and RCTs to confirm our positive results.

Wii™-habilitation of upper extremity function in children with cerebral palsy. An explorative study

OBJECTIVE

Commercially available virtual reality systems can possibly support rehabilitation objectives in training upper arm function in children with Cerebral Palsy (CP). The present study explored the effect of the Nintendo Wii™ training on upper extremity function in children with CP.

METHODS

During six weeks, all children received twice a week training with the Wii™, with their most affected arm. The Melbourne Assessment of Upper Limb Function and ABILHAND-Kids were assessed pre- and post- training. In addition, user satisfaction of both children and health professionals was assessed after training. Enjoyment in gaming was scored on a visual analogue scale scale after each session by the children.

RESULTS

Fifteen children with CP participated in the study. The quality of upper extremity movements did not change (-2.1, p > 0.05), while a significant increase of convenience in using hands/arms during performance of daily activities was found (0.6, p < 0.05).

CONCLUSION

Daily activities seem to be easier performed after Wii™ training for most of the included children with CP.

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.