The effects of virtual reality-based bilateral arm training on hemiplegic children’s upper limb motor skills

Effectiveness of intensive motor learning approaches from working on a vertical surface on hemiplegic children's upper limb motor skills, a randomized controlled trial

PURPOSE

This study compares the effect of intensive motor learning approaches on improving the quality of upper extremity skills in children with unilateral cerebral palsy (UCP) by working on vertical surfaces versus horizontal surfaces during rehabilitation sessions.

MATERIALS AND METHODS

Forty UCP children of both sexes were randomized into two equal groups. All participants received 60 min of intensive motor learning approaches three days/week for three successive months. These approaches included constraint-induced movement therapy (CIMT), in which children wore a splint or sling on the unaffected upper limb, as well as hand-arm bimanual intensive training (HABIT) that requires the use of both hands during specific play-based activities. The control group received training on a horizontal surface while the child sat in front of an elbow-height table while the study group (vertical surface training) sat or stood in front of a wall/mirror/board. The task requirements were graded to ensure success.

RESULTS

Statistically significant differences were detected between the mean values of post-treatment of all scorers, with a greater percentage of improvement in favor of the study group.

CONCLUSIONS

This study revealed that working on a vertical surface improved upper limb motor skills more significantly than working on a horizontal surface.

Efficacy of videogames and exergames in pediatric neurorehabilitation: a systematic review

INTRODUCTION

In recent years, the rehabilitation of children with neurological disorders has taken into account the possibility of using videogaming consoles and virtual reality systems to make children's therapy more enjoyable, motivating, participated and effective. This study aims at conducting a systematic review about the use and the efficacy of digital games in pediatric neurorehabilitation.

EVIDENCE ACQUISITION

In accordance with the PRISMA approach, a rather wide-ranging search was conducted on PubMed, Scopus, and Web of Science databases by using different combinations of keywords based on MeSH terms.

EVIDENCE SYNTHESIS

Fifty-five papers have been included into this review, namely, 38 original studies and 17 reviews. The total number of children and adolescents is 573, with 58% of them being affected by cerebral palsy. Despite a wide variability in the adopted protocols, devices, assessment tools, and a more frequent focus on motor aspects than on cognitive ones, the results of the majority of the analyzed studies support the safety (i.e., absence of severe adverse effects) and efficacy of the videogame-based therapy.

CONCLUSIONS

Videogames, when administered by means of commercial consoles or ad-hoc digital systems, seem to be a valid support for physical therapy. Further researchers are needed to deeply investigate the role of this approach in cognitive therapy and cognitive outcomes.

Fast and Fun: A Pilot Feasibility Study Using Dual Joystick-Operated Ride-on Toys for Upper Extremity Rehabilitation in Children with Hemiplegia

AIM

Our study investigates the feasibility and utility of implementing a dual joystick-operated ride-on-toy navigation training (RNT) program within a 3-week intensive camp based on principles of modified constraint-induced movement therapy and bimanual training, to improve upper extremity (UE) function in children with unilateral cerebral palsy (UCP).

METHODS

We employed a single-group pretest posttest, mixed methods study design. Eleven 4-to-10-year-old children with UCP received RNT as part of camp activities. Sessions required children to use both arms together for navigation and completing gross and fine motor UE challenges. We collected exit questionnaires from children, caregivers, and clinicians to assess the feasibility, acceptance, enjoyment, and perceived efficacy of RNT. Videos of training sessions were coded using Datavyu behavioral coding software to assess children's facial expressions and affective states, indicative of their level of engagement during intervention sessions.

RESULTS

We found high levels of child engagement during RNT sessions based on video data and stakeholder feedback. The RNT program was smoothly integrated into the camp. Stakeholders acknowledged the highly motivating nature of RNT. When combined with other camp activities, the program led to stakeholder-reported improvements in bimanual skills and spontaneous daily use of the affected UE.

CONCLUSIONS

Our pilot study provides promising evidence for using joystick-operated ride-on toys as engaging therapy adjuncts. Our findings call for future studies to systematically assess the efficacy of these devices in improving UE function among children with UCP.

A Pilot Feasibility Study on the Use of Dual-Joystick-Operated Ride-on Toys in Upper Extremity Rehabilitation for Children with Unilateral Cerebral Palsy

Children with unilateral cerebral palsy (UCP) require task-oriented practice several hours per week to produce meaningful gains in affected upper extremity (UE) motor function. Clinicians find it challenging to provide services at the required intensity and sustain child engagement. This pilot study assessed the acceptance and utility of a child-friendly program using dual-joystick-operated ride-on toys incorporated into an intensive UE rehabilitation camp. Eleven children with UCP between four and 10 years received ride-on-toy navigation training for 20-30 min/day, five days/week, for three weeks as part of camp programming. We report session adherence and percent time children spent in task-appropriate attention/engagement across sessions. The overall effects of camp programming on children's motor function were assessed using the Shriner's Hospital Upper Extremity Evaluation (SHUEE) from pretest to posttest and using training-specific measures of bimanual UE use and navigational accuracy. Children showed excellent adherence and sustained task-appropriate engagement across sessions. The combined program led to improved navigational accuracy (p-values ≤ 0.007) as well as spontaneous affected UE use during bimanual activities outside the training context (p < 0.001). Our pilot study provides promising evidence for using modified, commercially available ride-on toys to incentivize rehabilitation and boost repetitive, task-oriented UE practice among children with UCP.

A Training Program Using Modified Joystick-Operated Ride-on Toys to Complement Conventional Upper Extremity Rehabilitation in Children with Cerebral Palsy: Results from a Pilot Study

The pilot study assessed the utility of a training program using modified, commercially available dual-joystick-operated ride-on toys to promote unimanual and bimanual upper extremity (UE) function in children with cerebral palsy (CP). The ride-on-toy training was integrated within a 3-week, intensive, task-oriented training camp for children with CP. Eleven children with hemiplegia between 4 and 10 years received the ride-on-toy training program 20-30 min/day, 5 days/week for 3 weeks. Unimanual motor function was assessed using the Quality of Upper Extremity Skills Test (QUEST) before and after the camp. During ride-on-toy training sessions, children wore activity monitors on both wrists to assess the duration and intensity of bimanual UE activity. Video data from early and late sessions were coded for bimanual UE use, independent navigation, and movement bouts. Children improved their total and subscale QUEST scores from pretest to post-test while increasing moderate activity in their affected UE from early to late sessions, demonstrating more equal use of both UEs across sessions. There were no significant changes in the rates of movement bouts from early to late sessions. We can conclude that joystick-operated ride-on toys function as child-friendly, intrinsically rewarding tools that can complement conventional therapy and promote bimanual motor functions in children with CP.

Sports Activities in Children with Cerebral Palsy: A Narrative Review

Physical exercise is known to have beneficial effects on psychosocial well-being and cognitive performance. Children with cerebral palsy (CP) showed lower levels of physical activity (PA) than healthy children; this fact, in addition to the basic clinical condition, increased the sedentary habit with a psychological impact and motor impairment of these children. Furthermore, children and adolescents with CP are less committed to sports activities than typically developing children of the same age. The aim of the present narrative review was to increase the amount of knowledge regarding the effectiveness and importance of specific and individualized sports in children with CP. A comprehensive search of MED-LINE and EMBASE databases was performed, including specific search terms such as "cerebral palsy" combined with "sport", "physical activity", and the names of different sports. No publication date limits were set. We included studies with an age range of 0-18 years. The main results pointed out that most of the sports improved motor function, quality of life, and coordination in children and adolescents with CP. Physicians, therapists, and parents should become aware of the benefits of sports activities for this population of patients. Specific sports activities could be included as a usual indication in clinical practice in addition to rehabilitation treatment.

Effectiveness of virtual reality interventions of the upper limb in children and young adults with cerebral palsy: A systematic review with meta-analysis

OBJECTIVE

To examine the characteristics and the effectiveness of virtual reality systems on upper limb impairments in children and young adults with cerebral palsy.

DATA SOURCES

An electronic search was conducted on PubMed, PEDro, Web of Science, Central, and EMBASE.

METHODS

The protocol of this review was prospectively registered in the PROSPERO database (CRD42022302271). Randomized controlled trials that tested the effects of virtual reality-based interventions on the upper limb of participants with cerebral palsy were included. The methodological quality of the studies was measured by the PEDro scale. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation. The data of the studies were analyzed in meta-analysis and presented in forest plots and narrative synthesis.

RESULTS

Twenty-two studies involving 746 participants were included. Ten different virtual reality systems were used in the interventions, of which six were designed specifically for rehabilitation and four commercial video games. We found an effect in favor of virtual reality when it was used in combination with conventional therapy for upper limb activity (SMD = 0.65; 95% CI (0.19 to 1.11)). However, the certainty of the evidence of the comparisons ranged from very low to low.

CONCLUSION

Virtual reality seems to be an effective tool for upper limb activity in children and young adults with cerebral palsy. Nevertheless, future studies should present a better methodological quality, a larger sample size, and well-defined rehabilitation programs to reduce the inconsistency of the evidence in this domain.

A Scoping Review of the Serious Game-Based Rehabilitation of People with Cerebral Palsy

In a serious context, individuals with Cerebral Palsy (CP) have limited opportunities to engage in social interaction experiences. Through a review, this study provides an explanation and improved evidence of the methods for rehabilitation in games used in serious contexts for people with CP. Articles published from 2010 to 2022 focusing on serious game-based rehabilitation for people with CP are extracted from MEDILINE, Academic Search Ultimate, CINAHL, and the Web of Science. The articles were assessed based on the McMaster critical review form. This study analyzes the frequencies of goal and assessment tools according to the components using the International Classification of Functioning, Disability and Health (ICF). The evidence of all the studies is presented according to the principles of Population, Intervention, Comparison, Outcome (PICO) to organize the evidence. A total of 19 articles were selected. Five articles involved Randomized Controlled Trials (RCTs), six articles involved non-randomized one-group designs, three articles involved single experimental study designs, and five articles were case report designs. In the selected articles, the average score on the McMaster critical review form was 11.8 points. In the game-based rehabilitation for CP, more articles reported goals and assessment tools focusing on body function than goals and assessment tools focusing on activity and participation, according to the ICF. These findings provide a record of past work and identify the evidence to support the application of game-based rehabilitation for people with CP.

Postural control telerehabilitation with a low-cost virtual reality protocol for children with cerebral palsy: Protocol for a clinical trial

OBJECTIVE

To establish the feasibility and effectiveness of a rehabilitation programme using low-cost virtual reality aimed at improving postural control in children with cerebral palsy-spastic hemiplegia. It also aims to compare the effectiveness of this programme under two delivery modalities, telerehabilitation (TR) and face-to-face (FtF).

METHODS

This is a registered randomized controlled clinical trial protocol (ACTRN12621000117819). Eighteen sessions of low-cost virtual reality therapy will be provided through both, FtF and TR modalities using a Nintendo Wii balance board. Each programme will last for 6 weeks and will consist of 3 sessions per week of 25 minutes each. Twenty patients diagnosed with cerebral palsy-spastic hemiplegia will be recruited for each group: FtF or TR (n = 40). Participants will be assessed at baseline, by the end of weeks 2, 4, and 6, and at weeks 8 and 10 (post-intervention follow-ups). The primary outcome will be the Center of Pressure sway area (CoParea); secondary outcomes will be standard deviation and velocity of the CoP in the mediolateral and anterior-posterior directions; tertiary outcomes will include the Modified-Modified Ashworth Scale for lower limbs, Modified Ashworth Scale for upper limbs, timed up-and-go tests, the timed one-leg standing and 6-minute walk test.

RESULTS

This study provides an assessment of the feasibility and effectiveness of an affordable rehabilitation programme using low-cost virtual reality aimed at improving postural control in children with cerebral palsy.

CONCLUSION

The designed rehabilitation programme using low-cost virtual reality may improve postural control in children with cerebral palsy-spastic hemiplegia. The TR modality is likely to be as effective as the FtF modality. The TR programme has been designed to overcome access barriers to physiotherapy services for children with cerebral palsy in low-resource settings, remote areas, and in restricted mobility contexts.

Exploring the contribution of case study research to the evidence base for occupational therapy: a scoping review

BACKGROUND

Case study research is generating interest to evaluate complex interventions. However, it is not clear how this is being utilized by occupational therapists or how feasible it is to contribute to the evidence base. This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and analysis, and the range of practice contexts in which it is applied. We consider the viability of case study research for contributing to our evidence base.

METHODS

Opinion, text and empirical studies within an occupational therapy practice context were included. A three-step extensive search following Joanna Briggs Institute methodology was conducted in June 2020 and updated in July 2021 across ten databases, websites, peer-reviewed and grey literature from 2016 onwards. Study selection was completed by two independent reviewers. A data extraction table was developed and piloted and data charted to align with research questions. Data extraction was completed by one reviewer and a 10% sample cross checked by another.

RESULTS

Eighty-eight studies were included in the review consisting of (n = 84) empirical case study and (n = 4) non-empirical papers. Case study research has been conducted globally, with a range of populations across different settings. The majority were conducted in a community setting (n = 48/84; 57%) with populations experiencing neurodevelopmental disorder (n = 32/84; 38%), stroke (n = 14/84;17%) and non-diagnosis specific (n = 13/84; 15%). Methodologies adopted quantitative (n = 42/84; 50%), mixed methods (n = 22/84; 26%) and qualitative designs (n = 20/84; 24%). However, identifying the methodology and 'case' was a challenge due to methodological inconsistencies.

CONCLUSIONS

Case study research is useful when large-scale inquiry is not appropriate; for cases of complexity, early intervention efficacy, theory testing or when small participant numbers are available. It appears a viable methodology to contribute to the evidence base for occupation and health as it has been used to evaluate interventions across a breadth of occupational therapy practice contexts. Viability could be enhanced through consistent conduct and reporting to allow pooling of case data. A conceptual model and description of case study research in occupational therapy is proposed to support this.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework 10.17605/OSF.IO/PCFJ6.

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.

Use of virtual reality for targeted physical rehabilitation: Case report on managing functional motor disorder

Virtual reality (VR) technology has seen increasing use in physical rehabilitation and in the management of acute and chronic pain. Functional movement disorders (FMDs) are a source of disability with no known association to neurologic pathology, and patients are generally offered multidisciplinary treatment approaches to improve functional movement. However, patients who are not compliant with rehabilitation may have persistent FMD and long-term disability. Given VR's use in physical rehabilitation, it may serve as a useful adjunct for the management of FMD. Utilizing an application called MovementTM to create a playlist of targeted applications for the restoration of motor function and balance, this case study presents the application of VR as a tool to engage patients in physical therapy for the management of FMD. The VR games were selected to encourage movement while customization of levels within the games facilitated achievement of physical therapy goals. Physical rehabilitation aided by VR, when used in collaboration with a multidisciplinary care team, may be used to facilitate recovery from FMD.

The Effects of Prolonged Vibrotactile EMG-Based Biofeedback on Ankle Joint Range of Motion During Gait in Children with Spastic Cerebral Palsy: A Case Series

AIMS

The objective of this case series was to examine the feasibility of vibrotactile EMG-based biofeedback (BF) as a home-based intervention tool to enhance sensory information during everyday motor activities and to explore its effectiveness to induce changes in active ankle range of motion during gait in children with spastic cerebral palsy (CP).

METHODS

Ten children ages 6 to 13 years with spastic CP were recruited. Participants wore two EMG-based vibro-tactile BF devices for at least 4 hours per day for 1-month on the ankle and knee joints muscles. The device computed the amplitude of the EMG signal of the target muscle and actuated a silent vibration motor proportional to the magnitude of the EMG.

RESULTS

Our results demonstrated the feasibility of the augmented sensory information of muscle activity to induce changes of the active ankle range of motion during gait for 6 children with an increase ranging from 8.9 to 51.6% compared to a one-month period without treatment.

CONCLUSIONS

Preliminary findings of this case series demonstrate the feasibility of vibrotactile EMG-based BF and suggest potential effectiveness to increase active ankle range of motion, therefore serving as a promising therapeutic tool to improve gait in children with spastic CP.

Haptic Feedback-Based Virtual Reality Intervention for a Child With Infantile Hemiplegia: A Case Report

Virtual reality (VR) refers to an advanced technology that provides real life-like experience in a virtual environment. Numerous commercially available systems provide gaming opportunities with VR, while a few also provide haptic feedback along with VR. In the recent past, VR has been explored as a viable intervention in the field of neurorehabilitation. Although there are promising results for adults with hemiplegia, the research involving children with infantile hemiplegia is in the nascent stage. Infantile hemiplegia is manifested by sensory and motor deficits predominantly on one side of the body resulting in adverse effects on the functionality of the affected side since early life. VR gaming has an intense, motivational component that encourages children to put sustained voluntary effort to use both upper extremities. A six-year-old male with infantile hemiplegia presented with difficulty in using the left upper extremity. Pre-intervention scores of the nine-hole peg test (9HPT) and box and block test (BBT) were used to evaluate the manual dexterity, while those of ABILHAND-kids and functional independence measure for children (WeeFIM self-care section) assessed the functional independence. The child underwent treatment for six weeks (five days/week), with each session lasting for 60 minutes/day that included VR gaming with haptic feedback for 30 minutes and conventional physiotherapy for 30 minutes. Post-intervention scores were recorded and were compared with pre-intervention scores. Marked improvement in left upper extremity function was noted not only objectively by the outcome measures but also subjectively by the parents as well as by the child. Moreover, the child remarked that he enjoyed the therapy sessions. The findings of this report would facilitate the design of further research in this area in the form of larger trials.

Assessment of the Impact of the Tipstim® Device Application and the Study Position on Motor Coordination and Grip Strength of the Affected Upper Limb Post-Ischemic Stroke—A Randomized Parallel Crossover Trial

In the acute phase of stroke, most patients have reduced efficiency of the upper limb and in the chronic phase more than half of these patients still have a deficit in the mobility of the upper limb. The aim of this study was to investigate the effect of using the tipstim® device and the tested position of the body and affected upper limb on parameters of motor coordination and grip strength in patients after an ischemic stroke. A randomized, parallel crossover study was conducted in the Rehabilitation Department. The study included 29 people aged 68 ± 9.2 years, 5–7 weeks after ischemic stroke. Patients were randomly assigned to two parallel groups (A/B = 15 people and B/A = 14 people). In each of them, the patient received both experimental (A = tipstim®) and control (B = placebo effect) treatment in a specific order. The HandTutor was used to measure the parameters of motor coordination (maximum range of motion and frequency of motion). We also used an electronic dynamometer to measure the handgrip strength. The patients were examined in two positions: sitting (unstable) and lying with the trunk and affected upper limb stabilized. Results: The analysis showed smaller differences between the measurements in the A/B group than in the B/A group, both without stabilization and with stabilization (wrist Hz = p ˂ 0.001; fingers 2–5 Hz = p ˂ 0.001; handgrip strength = p ˂ 0.049 and p ˂ 0.003). When comparing the influence of the tested position on the results of motor coordination and the handgrip strength, statistically significant differences were found in the placebo group in a stable position (Hz wrist p = 0.007, MaxROM wrist = 0.038, HzF5 = 0.039, MaxROM F4 = 0.035, HzF3 = 0.035, MaxROM F3 = 0.010, HzF2 = 0.049). Conclusions: Repeated use of the tipstim® device did not improve the tested parameters. A significant improvement in the results of coordination of movements and grip strength is possible in a stable position, lying down.

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.

Gaming Technology for Pediatric Neurorehabilitation: A Systematic Review

INTRODUCTION

The emergence of gaming technologies, such as videogames and virtual reality, provides a wide variety of possibilities in intensively and enjoyably performing rehabilitation for children with neurological disorders. Solid evidence-based results are however required to promote the use of different gaming technologies in pediatric neurorehabilitation, while simultaneously exploring new related directions concerning neuro-monitoring and rehabilitation in familiar settings.

AIM OF THE STUDY AND METHODS

In order to analyze the state of the art regarding the available gaming technologies for pediatric neurorehabilitation, Scopus and Pubmed Databases have been searched by following: PRISMA statements, PICOs classification, and PEDro scoring.

RESULTS

43 studies have been collected and classified as follows: 11 feasibility studies; six studies proposing home-system solutions; nine studies presenting gamified robotic devices; nine longitudinal intervention trials; and eight reviews. Most of them rely on feasibility or pilot trials characterized by small sample sizes and short durations; different methodologies, outcome assessments and terminologies are involved; the explored spectrum of neurological conditions turns out to be scanty, mainly including the most common and wider debilitating groups of conditions in pediatric neurology: cerebral palsy, brain injuries and autism.

CONCLUSION

Even though it highlights reduced possibilities of drawing evidence-based conclusions due to the above outlined biases, this systematic review raises awareness among pediatricians and other health professionals about gaming technologies. Such a review also points out a definite need of rigorous studies that clearly refer to the underlying neuroscientific principles.

The clinical use of curcumin on neurological disorders: An updated systematic review of clinical trials

Neuroprotective effects of curcumin have been shown in previous studies. This updated systematic review of clinical trials aimed to investigate the effect of curcumin on neurological disorders. Databases including PubMed, Scopus, Web of Science, and Google Scholar were systematically searched to identify clinical trials investigating the effects of curcumin/turmeric supplements alone, or in combination with other ingredients, on neurological diseases. Nineteen studies comprising 1,130 patients met the inclusion criteria. Generally, intervention and study outcomes were heterogeneous. In most of the studies, curcumin had a favorable effect on oxidative stress and inflammation. However, with the exception of AD, curcumin supplementation either alone, or in combination with other ingredients, had beneficial effects on clinical outcomes for the other aforementioned neurodegenerative diseases. For example, the frequency, severity, and duration of migraine attacks, scores on the revised ALS functional rating scale, and the occurrence of motor complications in PD were all significantly improved with curcumin supplementation either alone or in combination with other ingredients. However, in three studies, several adverse side effects (mostly gastrointestinal in nature) were reported. Curcumin supplementation may have favorable effects on inflammatory status and clinical outcomes of patients with neurological disease, although the results were not consistent.

Motor coordination and grip strength assessed after the break and in various positions of the upper limb in patients after stroke in relation to healthy subjects. An observational study

BACKGROUND

Stroke patients often have weakness of the shoulder (scapular) stabilizers, which may contribute to motor impairment of the hand and wrist.

AIM

of the study was to analyze the effect of stabilization of the affected upper limb and the break in the examination on hand motor coordination and grip strength in patients after stroke in relation to healthy subjects.

DESIGN

An observational study.

SETTING

A hospital Rehabilitation Department.

POPULATION

Eighty post-stroke patients mean, 62 ± 17 years, and 77 healthy individuals mean, 25,7 ± 6,5 years.

METHODS

A Hand Tutor device and manual dynamometer were used to measure hand motor coordination parameters. Subjects were assessed in two positions: supine with the tested upper extremity extended perpendicularly to the vertical axis of the body (i.e., passive stabilization of the trunk; no stabilization of the shoulder), and supine with the tested upper extremity held close to the body (i.e., passive stabilization of the trunk and shoulder).

RESULTS

Stabilization of the shoulder improved the motor coordination parameters of the fingers and the wrist, and resulted in greater grip strength in post-stroke patients and healthy subjects (P ˂ .001). Local stabilization of the shoulder was particularly beneficial for improving hand motor coordination in females and non-dominant hands.

CONCLUSIONS

A stable position of the upper extremity can improve motor coordination and grip strength during stroke rehabilitation.

CLINICAL REHABILITATION IMPACT

Placing subjects in a supine position and stabilizing their affected upper limb may help restore motor coordination of the hand and wrist following stroke.

The Effect of Video-Based Games on Hand Functions and Cognitive Functions in Cerebral Palsy

Objective: The purpose of this study is to investigate the effect of Leap Motion Based Exergame Therapy (LMBET) on upper limb gross grip strength (GGS), pinch forces, hand functions, gross motor function, and cognitive functions in patients with cerebral palsy (CP). Materials and Methods: Twenty patients with CP (11 hemiplegia and 9 diplegia) were included in the study. Structured Neurodevelopmental Therapy-based hand rehabilitation (SNDTBHR) (first treatment period) was applied a total of 12 sessions, 2 sessions per week (total 6 weeks), and then LMBET (second treatment period) was applied a total of 12 sessions, 2 sessions per week (total 6 weeks). GGS was evaluated by "dynamometer," pinch strengths were evaluated by "pinch meter," hand skills were evaluated by "Manual Ability Classification System (MACS)" and "Jebsen-Taylor Hand Function Test (JHFT)," the gross motor level was evaluated by "Gross Motor Function Classification System (GMFCS)," and cognitive functions were evaluated by "Wisconsin Card Sorting Test (WCST)." Results: Significant difference was found between LMBET and SNDTBHR on GGF, pinch forces, JHFT, and WCST in favor of LMBET (P < 0.017). There was no significant difference between both MACS and GMFCS measurements (P > 0.05). Conclusion: Positive effects of both SNDTBHR and LMBET have been found. However, measurements after LMBET are statistically more significant. Future research should take into account higher patient allocation. Including additional leap motion training to conventional physiotherapy is feasible and might be promising to train cognitive function in children with CP.

Alternative exercise methods for children with cerebral palsy: effects of virtual vs. traditional golf training

Aim: Sport activities can increase the number of motor tasks performed by children with disabilities, helping to motivate these children to sustain life-long exercise. The aim of this study was to investigate the effects of virtual and traditional golf training on balance, muscle strength, lower extremity flexibility and aerobic endurance in children with cerebral palsy. Methods: 19 children with unilateral cerebral palsy were divided into two groups, each of them received either virtual (n = 9) or traditional (n = 10) golf training, for over 12 weeks with three days of a 60-minute session/day. The effect of golf training was assessed with the Gross Motor Function Measure-88, the Modified Ashworth Scale and Lateral Step Up, Curl Up, Six-Minute Walk, Sit and Reach, Modified Thomas, and balance tests. Results: Both training methods were associated with improved lower extremity flexibility and muscle strength, aerobic endurance and Gross Motor Function Measure-88 compared with the pre-training baseline values (p < 0.05). There was no difference found between virtual and traditional golf training groups except for balance and lateral step up tests (p > 0.05). Conclusions: Both virtual and traditional golf training applied for 12 weeks on children with unilateral cerebral palsy improved lower extremity functions and physical performance. The use of virtual and traditional training as a complementary application to reduce motor problems in children with cerebral palsy could enhance the sustainability of this type of training because of its edutainment features. Virtual golf has an important advantage over traditional golf in that (a) the latter can be expensive and inaccessible for people with disabilities, and (b) making virtual golf a safer activity.

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

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.

Single-case Design Studies in Children with Cerebral Palsy: A Scoping Review

Aim: To critically evaluate single-case design (SCD) studies performed within the population of children/adolescents with cerebral palsy (CP).Methods: A scoping review of SCD studies of children/adolescents with CP. Demographic, methodological, and statistical data were extracted. Articles were evaluated using the Risk of Bias in N-of-1 Trials (RoBiNT) Scale and the Consolidated Standards of Reporting Trials (CONSORT) extension for N-of-1 trials (CENT 2015). Comments regarding strengths and limitations were analyzed.Results: Studies investigated the effects of a wide range of interventions on various outcomes. Most SCD types were adopted in multiple studies. All studies used visual inspection rather than visual analysis, often complemented with basic statistical descriptives. Risk of bias was high, particularly concerning internal validity. Many CENT items were insufficiently reported. Several benefits and limitations of SCD were identified.Conclusions: The quality of evidence from results of SCD studies needs to be increased through risk of bias reduction.

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

PURPOSE

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

PARTICIPANTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of speed-accuracy trade-off in a computer task in individuals with cerebral palsy: a cross-sectional study

BACKGROUND

Individuals with Cerebral Palsy (CP) present with sensorimotor dysfunction which make the control and execution of movements difficult. This study aimed to verify the speed-accuracy trade-off in individuals with CP.

METHODS

Forty eight individuals with CP and 48 with typical development (TD) were evaluated (32 females and 64 males with a mean age of 15.02 ± 6.37 years: minimum 7 and maximum 30 years). Participants performed the "Fitts' Reciprocal Aiming Task v.1.0 (Horizontal)" on a computer with different sizes and distance targets, composed by progressive indices of difficulty (IDs): ID2, ID4a and ID4b.

RESULTS

There were no statistical differences between the groups in relation to the slope of the curve (b1) and dispersion of the movement time (r²). However, the intercept (b0) values presented significant differences (F(1.95) = 11.3; p = .001]), with greater movement time in the CP group compared to the TD group. It means that for individuals with CP, regardless of index difficulty, found the task more difficult than for TD participants. Considering CP and TD groups, speed-accuracy trade-off was found when using different indices of difficulty (ID2 and ID4). However, when the same index of difficulty was used with a larger target and longer distance (ID4a) or with a narrow target and shorter distance (ID4b), only individuals with CP had more difficulty performing the tasks involving smaller targets. Marginally significant inverse correlations were identified between the values of b1 and age (r = -0.119, p = .052) and between r² and Gross Motor Function Classification System (r = -0.280, p = .054), which did not occur with the Manual Ability Classification System.

CONCLUSION

We conclude that the individuals with CP presented greater difficulty when the target was smaller and demanded more accuracy, and less difficulty when the task demanded speed. It is suggested that treatments should target tasks with accuracy demands, that could help in daily life tasks, since it is an element that is generally not considered by professionals during therapy.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03002285 , retrospectively registered on 20 Dec 2016.