Balance improvement after physical therapy training using specially developed serious games for cerebral palsy children: preliminary results

Serious Game with Electromyography Feedback and Physical Therapy in Young Children with Unilateral Spastic Cerebral Palsy and Equinus Gait: A Prospective Open-Label Study

The clinical effects of a serious game with electromyography feedback (EMGs_SG) and physical therapy (PT) was investigated prospectively in children with unilateral spastic cerebral palsy (USCP). An additional aim was to better understand the influence of muscle shortening on function. Thirty children with USCP (age 7.6 ± 2.1 years) received four weeks of EMGs_SG sessions 2×/week including repetitive, active alternating training of dorsi- and plantar flexors in a seated position. In addition, each child received usual PT treatment ≤ 2×/week, involving plantar flexor stretching and command strengthening on dorsi- and plantar flexors. Five-Step Assessment parameters, including preferred gait velocity (normalized by height); plantar flexor extensibility (XV1); angle of catch (XV3); maximal active ankle dorsiflexion (XA); and derived coefficients of shortening, spasticity, and weakness for both soleus and gastrosoleus complex (GSC) were compared pre and post treatment (t-tests). Correlations were explored between the various coefficients and gait velocities at baseline. After four weeks of EMGs_SG + PT, there was an increase in normalized gait velocity from 0.72 ± 0.13 to 0.77 ± 0.13 m/s (p = 0.025, d = 0.43), a decrease in coefficients of shortening (soleus, 0.10 ± 0.07 pre vs. 0.07 ± 0.08 post, p = 0.004, d = 0.57; GSC 0.16 ± 0.08 vs. 0.13 ± 0.08, p = 0.003, d = 0.58), spasticity (soleus 0.14 ± 0.06 vs. 0.12 ± 0.07, p = 0.02, d = 0.46), and weakness (soleus 0.14 ± 0.07 vs. 0.11 ± 0.07, p = 0.005, d = 0.55). At baseline, normalized gait velocity correlated with the coefficient of GSC shortening (R = -0.43, p = 0.02). Four weeks of EMGs_SG and PT were associated with improved gait velocity and decreased plantar flexor shortening. A randomized controlled trial comparing EMGs_SG and conventional PT is needed.

The Use of Serious Gaming to Improve Sensorimotor Function and Motivation in People with Cerebral Palsy: A Systematic Review

The aim of this systematic review was to review the evidence for serious gaming interventions in improving sensorimotor function in children and adults with cerebral palsy (CP). Seven databases were searched with terms related to serious gaming and CP. Articles were evaluated according to the Downs and Black rating scale and important principles of serious gaming defined by Whyte et al. Extracted data included the population, intervention, serious gaming elements, outcomes, and authors' conclusions. Fifty-seven articles were identified for inclusion. Participants' ages ranged from 3 to 57 years. Interventions tested included commercial videogames as well as specially designed games. Most interventions had themed content, short-term goals, rewards, feedback, and multiple games. Outcome measures and study designs were inconsistent between studies. Sensorimotor function results of noncomparative studies were positive or neutral overall, but results of comparative studies were more mixed. We concluded that serious gaming interventions may be a useful adjunct to treatment as they are noninvasive, were not associated with deterioration in most cases, and may improve compliance. More comparative studies need to be completed to assess compliance and treatment outcomes. Future games should also aim to adhere more closely to the principles of serious gaming.

Effect of Virtual Reality on Balance Function in Children With Cerebral Palsy: A Systematic Review and Meta-analysis

Virtual Reality (VR) therapy is popular in treating children with Cerebral Palsy (CP) as a new technology for rehabilitation. Nevertheless, no substantial evidence supporting VR therapy promotion has been developed to date. This study aimed to investigate the effects of VR therapy on balance in children with CP. We conducted a systematic search in PubMed and Web of Science (updated to December 30, 2021). The systematic review and meta-analysis included all randomized controlled trials that included children with CP. A total of 18 RCT studies were eligible for inclusion in the systematic review, and meta-analysis was performed on 16 of them. Results showed that the VR intervention was beneficial for balance (SMD 0.47 [95% CI, SD 0.28, 0.66]). We concluded that VR therapy interventions for children with CP have positive effects. However, cautious implementation is needed in clinical applications.

Game-Based Dual-Task Exercise Program for Children with Cerebral Palsy: Blending Balance, Visuomotor and Cognitive Training: Feasibility Randomized Control Trial

The objective of this exploratory randomized controlled trial (RCT) was to provide evidence for the feasibility and therapeutic value of a novel game-based dual-task balance exercise program in children with cerebral palsy (CP). Twenty children with CP were recruited and randomized into two groups: (a) the conventional balance training group (CG) and (b) the experimental group (XG), which received a game-based dual-task (DT) balance exercise program. Both groups received their respective therapy programs for 12 weeks at a frequency of three sessions per week. Semi-structured interviews with the parents and children and qualitative analysis were conducted to evaluate the children's experiences with the game-based exercise program. The quantitative analysis included (a) the Pediatric Balance Scale (PBS), (b) Gross Motor Function Measure-88 (GMFM-88), and (c) computerized measures of standing balance performance during various dual-task conditions. Compliance was 100% for all 20 participants. Four themes captured the range of each participant's experiences and opinions: (a) reasons for participation, (b) likes and dislikes with the technologies, (c) positive effects of the program, and (d) future expectations. Children in the XG demonstrated greater improvements in PBS, GMFM, and DT balance measures as compared to children in the CG. The findings demonstrate feasible trial procedures and acceptable DT-oriented training with a high compliance rate and positive outcomes. These findings support further research and development and progression to the next phase of a full-scale RCT to evaluate the clinical effectiveness of the game-based DT balance exercise program for children with CP.

Effects of modified pilates on trunk, postural control, gait and balance in children with cerebral palsy: a single-blinded randomized controlled study

OBJECTIVE

This study aimed to determine the effects of modified pilates exercises (MPE) and neurodevelopmental therapy (NDT) on trunk, postural control, gait, and balance in children with cerebral palsy (CP).

METHODS

18 children with CP between gross motor function classification system (GMFCS) I and III were randomized into two groups as study (Group A, MPE) and control (Group B, NDT). Physiotherapy (PT) took place 2 days a week for 8 weeks. Trunk control measurement scale (TCMS), seated postural control measurement (SPCM), pediatric reach test (PRT), pediatric berg balance measurement (PBBM), 6 minute walking test (6MWT), observational gait scale (OGS), core stability performance measurements, and muscle strength tests were performed.

RESULTS

Mean age of group A (n = 9) was 9 ± 1.58 years, and group B (n = 9) was 10 ± 2.73 years. Significant differences were found in the SPCM posture (p = 0.000), TCMS (p = 0.004), OGS right (p = 0.019) and left (p = 0.001) scores, abdominal fatigue test (AFT) (p = 0.014), modified side bridge (MSBT) test (right p = 0.04, left p = 0.031), pressure biofeedback unit test (PBU) (p = 0.024), and sit-ups test (SUT) (p = 0.011) in favor of group A. According to the initial measurements of the percentage changes of the tests, significantly difference was found in PBBMR (p = 0.001), PBBML (p = 0.000), SPCM posture (0.001), TCMS (0.000), MBSTET (0.000), MSBT left (p = 0.034), AFT (p = 0.002), PBU (p = 0.015), SUT (p = 0.000), MPUT (p = 0.018), and OGS right (p = 0.029) in favor of group A.

CONCLUSION

The results revealed that MPEs in children with CP positively affects trunk, postural control, gait, and balance compared to NDT. It is concluded that MPE can be used as an alternative treatment approach in children with CP. TRIAL REGISTRATION NUMBER/DATE OF REGISTRATION/STUDY START DATE/URL OF THE RECORD: NCT04035954/ 24/07/2019/ August 1, 2019/ https://clinicaltrials.gov/ct2/show/NCT04035954 .

An overview of the effects of whole-body vibration on individuals with cerebral palsy

The purpose of this review is to examine how whole-body vibration can be used as a tool in therapy to help improve common physical weaknesses in balance, bone density, gait, spasticity, and strength experienced by individuals with cerebral palsy. Cerebral palsy is the most common movement disorder in children, and whole-body vibration is quickly becoming a potential therapeutic tool with some advantages compared to traditional therapies for individuals with movement disorders. The advantages of whole-body vibration include less strain and risk of injury, more passive training activity, and reduced time to complete an effective therapeutic session, all of which are appealing for populations with physiological impairments that cause physical weakness, including individuals with cerebral palsy. This review involves a brief overview of cerebral palsy, whole-body vibration's influence on physical performance measures, its influence on physical performance in individuals with cerebral palsy, and then discusses the future directions of whole-body vibration therapy in the cerebral palsy population.

The effectiveness of serious games in improving memory among the elderly with cognitive impairment: A systematic review and meta-analysis (Preprint)

Background

Objective

Methods

Results

Conclusions

Effects of Ankle Continuous Passive Motion on Soleus Hypertonia in Individuals with Cerebral Palsy: A Case Series

Background

Continuous passive motion device (CPM) provides repetitive movement over extended periods of time for those who have low functional ability. The purpose of this research was to evaluate the effects of a four-week program of continuous passive motion of the ankle joint on the changes in soleus hypertonia in individuals with cerebral palsy who suffered from life-long hypertonia.

Methods

A single group, repeated-measures study was conducted. Eight individuals (7 males and 1 female with a mean age of 21.8 ± 8.5 years) with spastic cerebral palsy underwent bilateral ankle CPM for 1 h a day, 5 days a week, for 4 weeks. The outcome measures included the Modified Ashworth Scale (MAS) score, passive range of motion (PROM) of the ankle, the ratio of maximum H reflex to maximum soleus M-response (H/M ratio), and post-activation depression (PAD). All outcomes were measured before and after the intervention. A paired t-test was used to examine treatment effects pre-versus post-intervention.

Results

Paired t-tests showed that the CPM program significantly decreased the MAS score (p = 0.006), decreased the maximum H/M ratio (p=0.001), improved PAD (p = 0.003, p = 0.040, and p = 0.032 at 0.2 Hz, 1 Hz, and 2 Hz, respectively), and increased the passive ankle range of motion (p = 0.049).

Conclusion

Ankle CPM not only reduced soleus hypertonia but also improved the PROM in individuals with cerebral palsy. The results of this study show ankle CPM to be an effective intervention for individuals with cerebral palsy.

An Accessible Training Device for Children With Cerebral Palsy

Walking and balance capabilities can be improved upon using repetitive ankle dorsiflexion exercises. Here we developed two types of pedal switches incorporated with training devices to improve their walking and balance performance of children with cerebral palsy. The first type of pedal switch can be used to operate a home appliance, while the second type of pedal switch can connect them to web games. Pedal switches can be used for home rehabilitation. This randomized controlled trial included patients in the intervention (n = 24) and control (n = 24) groups who completed 15 weeks of ankle training. The experimental group performed ankle dorsiflexion using a pressure-activated pedal switch connected to the web games. The control group performed ankle dorsiflexion exercises using a pedal switch that operated a home appliance (a fan). Standing balance and walking performance were estimated using the Zebris FDM system, a pressure force platform, the Pediatric Balance Scale score, and the 1-minute walk test. The pre- and posttest data were analyzed using analysis of variance and analysis of covariance, which revealed that the intervention group had more significant improvements in sway patterns and balance and walking. The developed facility of a modified pedal switch integrated with web games can achieve better exercise adherence to promote balance and walking performance than that with home appliances. Maintaining motivation in children with cerebral palsy plays a very important role in the rehabilitation process.

Randomised trial of virtual reality gaming and physiotherapy on balance, gross motor performance and daily functions among children with bilateral spastic cerebral palsy

BACKGROUND

Balance issues and poor gross motor function affect the daily needs of children with cerebral palsy.

PURPOSE

The study objective was to examine the effects of virtual reality gaming and physiotherapy on balance, gross motor performance and daily functioning among children with bilateral spastic cerebral palsy.

METHOD

Thirty-eight children with bilateral spastic cerebral palsy aged 6-12 years with GMFCS- level II-III, Manual Ability Classification System level I-III participated in this randomized controlled trial. The experimental group performed virtual reality games and physiotherapy, while the control group underwent physiotherapy alone. The exercise intensity was 60 minutes session a day, 4-days a week for 6-weeks. Paediatric Balance Scale (PBS), Kids-Mini-Balance Evaluation System Test (Kids-Mini-BESTest), Gross Motor Function Measure-88 (GMFM-88), and Wee-Functional Independence Measure (WeeFIM) were the outcome measures collected at baseline, 6-week post-training and 2-months follow-up.

RESULTS

The time by group interaction of repeated measures ANOVA revealed no statistical significance for all the outcome measures except Kids-Mini-BESTest (p < 0.05). The PBS and, Kids-Mini-BESTest improved by a mean (standard deviation) score of 5.1(1.7) and 8.7(2.8) points, respectively in the experimental group as compared to control group [3.4(1.6) and 5.8(2.5) points]. These gains remained at follow-up (p < 0.001).

CONCLUSION

Combined virtual reality gaming and physiotherapy is not superior over physiotherapy alone in improving the gross motor performance and daily functioning among children with bilateral spastic cerebral palsy. Virtual gaming, along with physiotherapy, appears to be beneficial in their balance capacity, warranting further trials to investigate the same in children with GMFCS level-III.

Personalized balance games for children with cerebral palsy: A pilot study

PURPOSE

To assess the changes in balance function in children with cerebral palsy (CP) after two weeks of daily training with personalized balance games.

METHODS

Twenty-five children with CP, aged 5 to 18 years were randomly selected for experimental or control groups. Over a period of two weeks, all participants received 8-9 game sessions for 15-20 minutes, totaling 150-160 minutes. The experimental group used personalized balance games available from the GAmification for Better LifE (GABLE) online serious gaming platform. Children from the control group played Nintendo Wii games using a handheld Wii Remote. Both groups received the same background treatment. Recorded outcome measures were from a Trunk Control Measurement Scale (TCMS), Timed Up & Go Test (TUG), Center of Pressure Path Length (COP-PL), and Dynamic Balance Test (DBT).

RESULTS

After two weeks of training in the experimental group TCMS scores increased by 4.5 points (SD = 3.5, p< 0.05) and DBT results increased by 0.88 points (IQR = 1.03, p< 0.05) while these scores did not change significantly in the control group. Overall, TUG and COP-PL scores were not affected in either group.

CONCLUSION

This study demonstrates improvement of balancing function in children with CP after a two-week course of training with personalized rehabilitation computer games.

Slackline Training in Children with Spastic Cerebral Palsy: A Randomized Clinical Trial

Objective: To assess whether a slackline intervention program improves postural control in children/adolescents with spastic cerebral palsy (CP). Design: Randomized controlled trial. Setting: Patients’ association. Participants: Twenty-seven children/adolescents with spastic CP (9–16 years) were randomly assigned to a slackline intervention (n = 14, 13 ± 3 years) or control group (n = 13, 12 ± 2 years). Intervention: Three slackline sessions per week (30 min/session) for 6 weeks. Main outcome measures: The primary outcome was static posturography (center of pressure—CoP—parameters). The secondary outcomes were surface myoelectrical activity of the lower-limb muscles during the posturography test and jump performance (countermovement jump test and Abalakov test). Overall (RPE, >6–20 scale) rating of perceived exertion was recorded at the end of each intervention session. Results: The intervention was perceived as “very light” (RPE = 7.6 ± 0.6). The intervention yielded significant benefits on static posturography (a significant group by time interaction on Xspeed, p = 0.006) and jump performance (a significant group by time interaction on Abalakov test, p = 0.015). Conclusions: Slackline training improved static postural control and motor skills and was perceived as non-fatiguing in children/adolescents with spastic CP.

Effect of Virtual Reality Therapy on Balance and Walking in Children with Cerebral Palsy: A Systematic Review

Aim: To investigate the effect of Virtual Reality Therapy (VRT) on balance and walking in children with cerebral palsy (CP). Method: A systematic search in Pubmed and Embase was performed until the 9th of July 2019. Articles were included if the population consisted of children with CP and data on balance and/or walking were reported. Results were pooled in two meta-analyses. Results: 26 articles were included. For 'balance' 5 and for 'walking' 4 were used for the meta-analyses. The meta-analyses showed a significant result in favor of VRT for balance, SMD 0.89 [95% CI, SD 0.14, 1.63] and for walking, SMD 3.10 [95% Cl, SD 0.78, 5.35]. Interpretation: VRT seems a promising intervention for rehabilitation in children with CP. The meta-analysis confirmed this positive effect. These results must be interpreted with caution due to differences in the interventions used, the lack of randomized-controlled trials, and the relatively small groups.

Serious Game-based Intervention for Children with Developmental Disabilities

BACKGROUND

Children with developmental disabilities may need support with motor skills such as balance improvement, cognitive skills such as vocabulary learning, or social skills such as adequate interpretation of emotional expressions. Digital interactive games could support the standard treatments. We aimed to review clinical studies which investigated the application of serious games in children with developmental disabilities.

METHODS

We searched MEDLINE and Scopus on 05 May 2019 limited to the English language. We included people between two and 24 years of age who were affected by neurodevelopmental disorders and who received digital serious game-based medical interventions such as any computer- based or video-based games. We considered any study design reporting primary data. We used title, abstract, and full-text of journal articles to build diagnostic groups, and we described some selected specific game applications.

RESULTS

The majority of the 145 relevant studies reported on autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), developmental coordination disorder (DCD), and disabilities affecting intellectual abilities (DAIA). 30 of the 145 studies reported a randomized design. We detailed six specific applications aimed at improving abilities in children with ASD, ADHD, cerebral palsy, and Down syndrome. We visualized the diagnostic groups by bibliographic mapping, and limited the text to the title and abstract of journal articles.

CONCLUSION

We identified promising results regarding anxiety reduction, stress regulation, emotion recognition, and rehabilitation. Currently, there appears to be a lack of clinical evidence that children with neurodevelopmental disorders can benefit from the application of serious games.

E-Survey of Current International Physiotherapy Practice for Children with Ataxia Following Surgical Resection of Posterior Fossa Tumour

Objective

To determine current international practice regarding physiotherapy input for children with ataxia following surgery for posterior fossa tumour. Design: An e-survey covering the following domains: participant demographics, treatment/ intervention, virtual training, intensity/timing of treatment, and aims and outcomes of physiotherapy management.

Participants

Physiotherapists involved in the management of children with ataxia following surgical resection of posterior fossa tumour. Participants were contacted via 6 key groups; Paediatric Oncology Physiotherapy Network (POPs), Association of Paediatric Chartered Physiotherapists (APCP), European Paediatric Neurology Society (EPNS), International Society of Paediatric Oncology (SIOP)-Europe Brain Tumour Group, Posterior Fossa Society (PFS), and Pediatric Oncology Special Interest Group (SIG) (American Physical Therapy Association).

Results

A total of 96 physiotherapists participated: UK (n =53), rest of Europe (n = 23), USA/ Canada (n = 10), and Australia/NZ (n = 10). The most common physiotherapy interventions used were balance exercises, gait re-education and proximal control activities. The most frequently used adjuncts to treatment were mobility aids and orthotics. Challenges reported regarding physiotherapy treatment were: reduced availability of physiotherapy input following discharge from the acute setting, lack of evidence, impact of adjuvant oncology treatment, and psychosocial impact.

Conclusion

This e-survey provides an initial scoping review of international physiotherapy practice in this area. It establishes a foundation for future research on improving rehabilitation of ataxia in this population.

The immediate influence of various whole-body vibration frequency on balance and walking ability in children with cerebral palsy: a pilot study

The purpose of this pilot study is to examine the immediate effect of interventions based on the frequency of whole-body vibration on children with cerebral palsy’s balance and walking abilities. A total of 12 were selected as subjects. All subjects measured 10-m walking test (10MWT), Timed Up and Go (TUG) test and measured sway length (SL) and limit of stability (LOS) by bio-rescue. And those were performed again after the frequencies of the 12, 18, and 26 Hz were applied respectively. To check the immediate effect, all subjects performed only one frequency of interventions per day and no other treatment was performed in parallel to control the foreign variables. After intervention, 10MWT were significantly increased in the 12 and 18 Hz groups (P<0.05). TUG test and LOS were significantly increased in the 18 Hz group (P<0.05). There were no significant differences on TUG, SL, and LOS in the 12 Hz group. There were no significant differences on 10MWT, TUG, SL, and LOS in the 26 Hz group. Looking at the results of this study, the immediate effect of whole-body vibration shows that the frequency of the 18 Hz group is the most effective interventions in promoting walking and balancing abilities in children with cerebral palsy than frequencies of the 12 and 26 Hz groups.

Effectiveness of interactive computer play on balance and postural control for children with cerebral palsy: A systematic review

BACKGROUND

Interactive computer play (ICP) becomes popular in rehabilitation for children with cerebral palsy (CP). With the nature of ICP, it could be an effective intervention specifically to improve balance and postural control for children with CP. The present paper aimed to review the effectiveness of ICP on postural control and balance for children with CP.

METHODS

Electronic databases including Medline, AMED, EBSCOhost, PsycINFO, Embase, the Cochrane Library and the DARE were searched up to September 2018. Studies were included if (1) participants were aged under 18 and had CP, (2) ICP intervention was performed, (3) an explicit objective was postural control and balance of the participants, and (4) results were fully published in English-language peer-reviewed journals. Characteristics of study participants, ICP protocols and study results were extracted. Level of evidence of each studies was graded using the guidelines from the American Academy of Cerebral Palsy and Developmental Medicine. Methodological quality was graded using the Physiotherapy Evidence Database (PEDro) scale. Effect sizes were calculated on available data.

RESULTS

Twenty studies were included, with nine of level I or II evidence. Most studies had fair methodological rigor. Huge variations in the study designs and protocols of ICP were found among the studies.

CONCLUSIONS

ICP seemed to be more effective than conventional therapy in improving postural control and balance, with medium to large effect sizes for children with mild to moderate severity of CP. Future studies of high methodological rigour are required to verify the role of on-site guidance of the children during ICP and the effect on children with more severe CP.

Interaction Modalities Used on Serious Games for Upper Limb Rehabilitation: A Systematic Review

This systematic review aims to analyze the state-of-the-art regarding interaction modalities used on serious games for upper limb rehabilitation. A systematic search was performed in IEEE Xplore and Web of Science databases. PRISMA and QualSyst protocols were used to filter and assess the articles. Articles must meet the following inclusion criteria: they must be written in English; be at least four pages in length; use or develop serious games; focus on upper limb rehabilitation; and be published between 2007 and 2017. Of 121 articles initially retrieved, 33 articles met the inclusion criteria. Three interaction modalities were found: vision systems (42.4%), complementary vision systems (30.3%), and no-vision systems (27.2%). Vision systems and no-vision systems obtained a similar mean QualSyst (86%) followed by complementary vision systems (85.7%). Almost half of the studies used vision systems as the interaction modality (42.4%) and used the Kinect sensor to collect the body movements (48.48%). The shoulder was the most treated body part in the studies (19%). A key limitation of vision systems and complementary vision systems is that their device performances might be affected by lighting conditions. A main limitation of the no-vision systems is that the range-of-motion in angles of the body movement might not be measured accurately. Due to a limited number of studies, fruitful areas for further research could be the following: serious games focused on finger rehabilitation and trauma injuries, game difficulty adaptation based on user's muscle strength and posture, and multisensor data fusion on interaction modalities.

The Effects of a 5-Day Virtual-Reality Based Exercise Program on Kinematics and Postural Muscle Activity in Youth with Cerebral Palsy

Aims: To determine the effects of a 5-day virtual reality (VR)-based intervention on anticipatory and reactive mechanisms of postural control in children and adolescents with cerebral palsy (CP). Methods: Eleven youth with CP (GMFCS levels I and II), ages 7-17, were allocated to intervention (N = 5) and control (N = 6) groups. Both groups attended balance assessment sessions 1 week apart. Participants in the intervention group received 1-hour one-on-one physiotherapist-supervised VR balance games for 5 consecutive days between assessments. For balance assessments, participants stood erect with eyes open on a movable platform that translated progressively through four speeds in the anterior/posterior direction. Participants performed two trials each of experimenter-triggered and self-triggered perturbations. Postural muscle activity and kinematics were recorded. The Anchoring Index and body segment cross-correlations were calculated as an indication of body stabilization, and the number of steps taken to regain balance/avoid falling were counted. Mann-Whitney U tests for between group differences in change scores were undertaken with an accepted significance level of 0.01. Results: No consistent differences in change scores were identified between groups. Conclusions: There was no effect of a 5-day VR-based intervention on postural control mechanisms used in response to oscillating platform perturbations. Subsequent studies will further tailor VR interventions to patients' functional balance needs.