Effect of virtual reality therapy on functional development in children with cerebral palsy: A single-blind, prospective, randomized-controlled study

Effectiveness of Virtual Reality for Upper Extremity Function and Motor Performance of Children With Cerebral Palsy: A Systematic Review

IMPORTANCE

Research on the functional and motor performance impact of virtual reality (VR) as an intervention tool for children with cerebral palsy (CP) is limited.

OBJECTIVE

To understand whether VR is an effective intervention to improve upper extremity (UE) function and motor performance of children diagnosed with CP.

DATA SOURCES

Databases used in the search were EBSCOhost, One Search, PubMed, Cloud Source, CINAHL, SPORTDiscus, and Google Scholar.

STUDY SELECTION AND DATA COLLECTION

Studies published from 2006 to 2021 were included if children had a diagnosis of CP and were age 21 yr or younger, VR was used as an intervention, and measures of UE function and motor performance were used.

FINDINGS

Twenty-one studies were included, and the results provided promising evidence for improvements in areas of UE function, motor performance, and fine motor skills when VR is used as an intervention. To yield noticeable UE improvements in children with CP, VR should be implemented for 30 to 60 min/session and for at least 360 min over more than 3 wk. Additional areas of improvement include gross motor skills, functional mobility, occupational performance, and intrinsic factors.

CONCLUSIONS AND RELEVANCE

The use of VR as an intervention for children with CP to improve UE function and motor performance is supported. More randomized controlled trials with larger sample sizes focusing on similar outcomes and intervention frequencies are needed to determine the most effective type of VR for use in clinical occupational therapy. Plain-Language Summary: This systematic review explains how virtual reality (VR) has been used as an intervention with children with cerebral palsy (CP). The review synthesizes the results of 21 research studies of children who had a diagnosis of CP and who were 21 years old or younger. The findings support using VR to improve upper extremity performance, motor performance, and fine motor skills. The findings also show that occupational therapy practitioners should use a VR intervention at a minimum frequency of 30 to 60 minutes per session and for at least 360 minutes over more than 3 weeks to yield noticeable improvements in upper extremity, motor performance, and fine motor skills for children with CP.

Effectivity of Virtual Reality to Improve Balance, Motor Function, Activities of Daily Living, and Upper Limb Function in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

Background

Cerebral palsy (CP) is the most common motor disorder in childhood. CP limits movement, which can interfere with children's daily activities. As a technology that provides intensive mass practice to children, virtual reality (VR) can create an interactive and motivating environment. With the intensity set by the therapist and feedback that can be used to produce individualized therapy, VR has great potential to improve CP patients' quality of life, especially in a safe, enjoyable, and playful environment.

Purpose

This systematic review and meta-analysis sought to determine the effectiveness of VR for children with CP.

Methods

We conducted a comprehensive literature search based on the PRISMA guidelines through PubMed, Scopus, Embase, Wiley, and ProQuest to assess the efficacy of VR in managing children with CP up to 15 September 2022. Risk assessment of bias was performed using Cochrane RoB 2.

Results

Nineteen randomized controlled trials with 467 and 427 patients with CP were included in the intervention and control groups in qualitative and quantitative analyses. Participants consisted of cerebral palsy with hemiplegia (n=7), diplegia (n=2), a combination of both (n=4), and undefined (n=13). From all studies conducted, VR showed significant results where VR could improve balance (MD: 2.71[1.95, 3.48]; p < 0.00001), motor function (MD: 3.73 [1.67, 5.79]; p = 0.0004), and activity daily living (MD: 10.05 [2.89, 17.22]. However, VR showed not effective in improving upper limb function.

Conclusion

With its advantages and excellent effectiveness, VR may improve functional mobility and the quality of life of children with CP.

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.

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.

Effect of a Virtual Reality-Mediated Gamified Rehabilitation Program on Upper Limb Functions in Children With Hemiplegic Cerebral Palsy: A Prospective, Randomized Controlled Study

OBJECTIVE

The aim of the study is to investigate the effects of a virtual reality-mediated gamified rehabilitation program on upper limb functions, skills, range of motion, muscle tone, and quality of life in children with hemiplegic cerebral palsy.

DESIGN

This prospective, randomized, and controlled study included 36 children with hemiplegic cerebral palsy. Children were randomized into two groups, the virtual reality group ( n = 18) and the control group ( n = 18). Stretching and range-of-motion exercises were performed on the affected upper limb of the children in both groups. In addition to this exercise program, in the virtual reality group, virtual reality-mediated upper limb rehabilitation was performed under supervision. The children were assessed at baseline and 1 and 3 mos after the intervention.

RESULTS

There was a significant increase in Assisting Hand Assessment, ABILHAND-Kids, Quality of Upper Extremity Skills Test, and KINDL values in the virtual reality group. In addition, there were significant increases in the active joint range of motion of the finger flexion, wrist flexion, pronation, and supination in the virtual reality group.

CONCLUSIONS

In this study, it was determined that upper limb function, quality of life, and active joint range of motion of the children with hemiplegic cerebral palsy were increased with virtual reality-mediated upper limb rehabilitation.

Fully Immersive Virtual Reality Game-Based Training for an Adolescent with Spastic Diplegic Cerebral Palsy: A Case Report

BACKGROUND

Recently, virtual reality-based training (VR-based training) is receiving attention as greater emphasis is placed on the importance of interest and motivation in participation. However, studies investigating the effects of fully immersive VR-based training are insufficient.

CASE PRESENTATION

We report a case of using a fully immersive VR game-based training in a patient with cerebral palsy. A 15-year-old girl was diagnosed with spastic diplegia cerebral palsy Gross Motor Function Classification System level II. A six-week intervention (18 sessions) phase was performed with one fully immersive VR game using PlayStation^®VR in three sessions per week. After 18 sessions of training, the scores on the gross motor function measure-88 (Gross Motor Function Measure-88-GMFM-88), pediatric balance scale (PBS), timed up and go test (TUG), functional gait assessment (FGA), and 10 m walking test (10MWT) were improved: GMFM-88, 91.56 points (9.31 points increase); PBS, 45 points (6 points increase); TUG, 8.23 s (6.9 s decrease); FGA, 11 points (3 points increase); the 10 MWT, 5.27 s (6.59 s decrease).

CONCLUSIONS

This study found that a fully immersive VR game-based training using PlayStation^®VR may be an effective intervention for GMFCS level II adolescent, leading to some improvement of motor function, balance and gait skills in adolescents with cerebral palsy.

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

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

Virtual motor training to improve the activities of daily living, hand grip, and gross motor function among children with cerebral palsy: Meta-regression analysis

BACKGROUND

Given that cerebral palsy is a lifelong condition, continuous motor training is necessary to correct abnormal posture and patterns to improve functional performance.

OBJECTIVE

To explore the essential features of virtual motor training and identify its effects on the activities of daily living, hand grip function, and gross motor function among children with cerebral palsy.

METHODS

Ten databases were systematically searched for randomized controlled trials from inception until October 15, 2019. Studies with a randomized controlled trials design, children with cerebral palsy, comparisons of virtual motor training with other interventions, and activities of daily living, hand grip, and gross motor function outcomes were included. Subgroup analyses and meta-regression were performed. The effect size was assessed using random-effects meta-analysis and evaluated by using Hedges' g. Random effects univariate meta-regression model was used to examine the association of covariates with intervention effectiveness.

RESULTS

Seventeen randomized controlled trials with 853 participants were included. Meta-analysis indicated that the virtual motor training had significant positive effects on activities of daily living (g = 0.31, 95% confidence interval, CI = 0.10, 0.51), grip (g = 0.40, 95% CI = 0.08, 0.71), and gross motor (g = 0.71, 95% CI = 0.43, 0.99) function. Univariate random-effects meta-regression analysis indicated an increase in activities of daily living scores for motion capture systems that used depth imaging compared with those that used digital imaging.

SIGNIFICANCE

Our systematic review indicated that virtual motor function may significantly improve ADLs, hand grip, and gross motor functions among children with cerebral palsy.

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

BACKGROUND

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

OBJECTIVE

To evaluate the effectiveness of VR in patients with CP.

METHODS

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

RESULTS

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

CONCLUSION

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

PROTOCOL REGISTRATION

PROSPERO CRD 42018102759.

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.

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

The Effects of Virtual Reality on Upper Extremity in Patients with Obstetric Brachial Plexus Injury

The present study aimed to examine the effects of playing Nintendo Wii games on upper extremity functions compared with conventional physiotherapy, in children with obstetric brachial plexus injury (OBPI). Twenty-two patients with brachial plexus injuries were enrolled. The patients were divided into two groups by simple randomization. The control group (conventional physiotherapy group [CTG]: n = 11) received conventional physiotherapy for 6 weeks (40 minutes per day, for 4 days per week). The study group, called Nintendo Wii group (NWG; n = 11), received conventional physiotherapy as well as tennis, baseball, and boxing games with Nintendo Wii on days when there was no physical therapy. The upper extremity range of motion (ROM) was evaluated using a digital goniometer, motor function was assessed using the Active Movement Scale (AMS), and shoulder functions were assessed with the Mallet Scoring System (MSS). Virtual reality treatment had a positive effect on shoulder flexion, forearm pronation, wrist flexion, ROM, and functionality (p < 0.05). There was a significant improvement in shoulder abduction and shoulder external rotation in the CTG (p < 0.05). There was no significant difference in the MSS values of either groups (p > 0.05). As per the AMS, in the NWG, the shoulder internal rotation increased significantly (p < 0.05). Nintendo Wii treatment used in addition to conventional physiotherapy may be effective in increasing upper extremity functions in children with OBPI.