Effectiveness of robot play for kids with CP

Case Series

Playfulness in Children with Limited Motor Abilities when using a Robot

Rios-Rincon, A. M., Adams, K., Magill-Evans, J. & Cook, A.

Physical & Occupational Therapy in Pediatrics, 00(00):1 – 15, 2015

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/26566226

Objective: For children with cerebral palsy, will robot play increase playfulness? Children with cerebral palsy may have fewer opportunities to play. “Promoting playfulness in children with CP… might have a positive effect on self-determination, adaptive behaviors, and problem solving in creative ways. "Will Test of Playfulness (ToP) scores increase during the intervention?"

Process: Four 4 – 9 year old children with Gross Motor Function Classification System (GMFCS) levels 4 or 5 and Manual Ability Classification Scale (MACS) level 4 or 5 and they needed to be able to respond to yes/no questions and to operate the robot using two switches. During the intervention phase, the children were encouraged by their mothers to play with the robot for 15 minutes twice a week for 5 weeks.

Findings: The baseline ToP scores for three of the four children were stable. During the intervention, all four children showed significantly increased scores. "This study adds to the limited evidence for the effectiveness of interventions for play… (and) that adapted Lego robots promote playfulness in children with cerebral palsy who have limitations in mobility and manual ability through free play in family routines."

Futures for Virtual Reality in Cerebral Palsy Management

Review

Role of Virtual Reality for Cerebral Palsy Management

Weiss, P. T., Tirosh, E. & Fehlings, D.
Journal of Child Neurology, 2014, 29(8): 1119 – 1124

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/24799367

Virtual reality can occupy a unique space in rehabilitation when designed by therapists as it can provide a motivating yet challenging place to learn transferrable skills and to capture performance feedback.

Objective: This article overviews several topics: virtual reality and clinical gaming for the population of children with cerebral palsy, key studies that identify different components of virtual reality systems as children with cerebral palsy interact with them, and aspects of virtual reality interaction beyond the enjoyable and motivating aspects of gameplay to measuring deeper emotional and psychological characteristics like autonomic responses to gaming.

"Virtual reality for rehabilitation has become more accessible and less expensive and more popular for clinicians… who want to take advantage of virtual reality’s assets for rehabilitation while ensuring that it is best suited to the client’s cognitive, motor and emotional abilities in the context of specific therapeutic goals". "Available data suggest exciting prospects for the use of virtual reality in the rehabilitation of children with physical disabilities."

VR Rehab Reviewed

Virtual Reality in Rehabilitation of Children with Cerebral Palsy

Review article

Gunel, M. K., Kara, K. O., Ozal, C. & Turker, D. (2014) In E. Svraka (Ed) Cerebral Palsy - Challenges for the Future (pp. 273-301). InTech: DOI: 10.5772/56981 Creative Commons BY 3.0 license

Link to full text: dx.doi.org/10.5772/57486

Chapter 9, Virtual Reality in Rehabilitation of Children with Cerebral Palsy, is found within the book Cerebral Palsy - Challenges for the Future, published as an open source volume by InTech. The book develops the following ideas… "lifelong re/habilitation (habilitation and rehabilitation) in persons with cerebral palsy is the first part of this book which has four chapters about management in children and adults with cerebral palsy through the life span, providing evidence-based and family-centered support and services. Three chapters of the second part are exploring the new therapy options which could improve the family quality of life. Third part has two chapters about complementary therapies with new possibilities for the future."

The chapter on virtual reality therapy begins with an ICF perspective. In CP treatment, VR (re)habilitation modalities are identified separately as ‘evidence-based and clinical’ applications. The authors provide an extensive review of CP rehabilitation from the ICF perspective, and connect to a history of VR. They consider the theoretical base of VR therapy and include a neurology lesson and a review of virtual reality systems used in pediatric rehabilitation (immersive or desktop). A classification of VR systems for rehabilitation from (Galvin and Levac) is provided. The chapter finishes with a review of VR studies relating to upper extremity, lower extremity, postural control, fitness and other topics.

Reference
Galvin, J. and Levac, D. (2011). Faciliating clinical decision-making about the use of virtual reality within paediatric motor rehabilitation: describing and classifying virtual reality systems. Developmental neurorehabilitation, 2011:14 (2):112-22

Virtual vs. Real: Strategies for validity testing virtual reality

Instrument design

The potential value of virtual environments in rehabilitation
Lehman, L. A.
Journal of Mobile Technology in Rehabilitation 4:3 October, 2015

Link to full text: www.journalmtm.com/2015/the-potential-value-of-virtual-environments-ves-in-rehabilitation/

Virtual Reality is a “computer-generated, immersive, interactive simulation”. How do rehabilitation activities performed in a virtual environment compare with activities in the real world? The object of this paper is to create a pathway to test rehabilitation virtual environments for internal and external validity, compared to real world activities.

Face validity helps to determine that an assessment is evaluating what it is expected to be testing. This is done by first polling clinicians and experts using focus groups, surveys and meetings. Then end users can be asked how accurate the assessments are. External validity is the degree to which a test can be generalized. It is necessary to establish that a task completed in the virtual reality environment is similar to results in a real environment. Here, the same results in virtual and ‘real’ settings would see how well the virtual tasks mimic the real life activities.

Gaming vs.Bobath: Function and Ability

Randomized Trial

Video-game based therapy performed by children with cerebral palsy: a cross-over randomized controlled trial and a cross-sectional quantitative measure of physical therapy

Zoccolillo, L., Morelli, D., Cincotti, F., Muzzioli,L., Gobbetti, T., Paolucci, S. & Iosa, M.
Eur J Phys Rehabil Med. 2015 Feb 5.

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/25653079

Objective: In children with cerebral palsy, does video gaming intervention improve upper limb motor movements, hand function (and have more movements) compared to conventional, Bobath-based therapy?

Method: 22 children, 4 to 14 years old, with cerebral palsy (GMFCS levels I – IV) received 16 sessions of conventional therapy before or after 16 sessions of video game therapy, over a period of 8 weeks. QUEST (Quality of Upper Extremity Skills Test) was used to assess upper extremity function and Abilhand-kids for hand ability. Instrumentation was applied to the childrens’ forearms to quantify movements.

Findings: Upper limb functioning measured by QUEST improved more with video gaming than with conventional therapy. Manual ability improved better with conventional therapy. Video gaming resulted in more movements than conventional therapy.

Wii Balance Boards: One is as good as another

Measurement study

Interchangeability of the Wii Balance Board for Bipedal Balance Assessment

Bonnechere, B., Jansen, B., Omelina, L., Rooze, M & Van Sint Jan, S.

JMIR Rehabilitation and Assistive Technologies 2015; 2(2):e8
DOI:10.2196/rehab3832

Link to full text: rehab.jmir.org/2015/2/e8

Objective: How well do different Wii Balance Boards compare with each other, and with laboratory force plate measurements?

Process: Six subjects used four (out of the box, uncalibrated) Wii Balance Boards three times each in order to compare the Wii Balance Boards with each other and a laboratory force plate.

Findings: Balance and posture measurements from Wii Balance Boards did not differ significantly from one to another. The Balance Boards each compare very well to the laboratory force plate. Multi-site studies and use of larger populations can be accessed for research.

Video Game Treatment for Kids with Developmental Disabilities

Single group

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

Hsieh HC, Lin HY, Chiu WH, Meng LF & Liu CK.

American Journal of Occupational Therapy 2015 Jul-Aug;69(4):6904290020p1-5.

doi: 10.5014/ajot.2015.014480.

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/26114467

Objective: For children with developmental disabilities, does active video game play, compared before and after the intervention, increase motor function and visual-motor integration?

Method: 20 children with developmental disability (Beery-Buktenica Developmental Test of Visual Motor Integration (VMI) score of less than 80) played a novel video game for 30 minutes, 3 times a week for 5 weeks. Before and after, the children were scored on VMI and the Peabody Developmental Motor Scale – 2 (PDMS-2).

Findings: Game play had a positive and significant effect on visual-motor integration as measured by the VMI, and on motor function as measured on the fine motor quotient, gross motor quotient and total motor quotient subscales of the PDMS-2.

Measuring Upper Extremity Function - Systematically

Systematic Review

Upper limb function evaluation scales for individuals with cerebral palsy: A systematic review

Journal of Physical Therapy Science 27:1617 – 1620, 2015.

Santos, C. A., Franco de Moura, R. C., Lazzari, R. D., Dumont, A. J., Braun, L. A. & Oliveira, C. S.

Link to full text: www.ncbi.nlm.nih.gov/pmc/articles/PMC448345

Objective: What is the state of the evidence for scales and methods used to evaluate upper extremity function in cerebral palsy?

Method: Two reviewers independently assessed randomized controlled (RCT) trial articles published between 2006 and 2014. The Physiotherapy Evidence Database (PEDRO) scale was used to evaluate studies to see if there is sufficient accompanying information for (internal) validity and for the reader to interpret and reproduce results.

Findings: Five studies achieved 6/10 “good” or higher on PEDRO (1 – 9/10, 1 – 8/10, 2 – 7/10, 1 – 6/10). The various studies analyzed:

• Quality Upper Extremity Skill Test and the Besta scale (Fedrizzi et al.)
• Upper Extremity Functional Test and Peabody Developmental Motor Scales-2 (PDMS-2), Xu et al.
• PDMS-2, Bruninks-Oseretsky Test of Motor Proficiency and Pediatric Motor Activity Log, Lin et al.
• Melbourne Assessment of Unilateral Upper Limb Function, Koman et al.
• Redman et al. used the Pediatric Quality of Life Scale.

"…no consensus has been reached on the most appropriate scale or which has ideal clinical applicability to this population".

References
PEDRO www.pedro.org.au/

Fedrizzi E, Rosa-Rizzotto M, Turconi AC, et al. : GIPCI Study Group: Unimanual and bimanual intensive training in children with hemiplegic cerebral palsy and persistence in time of hand function improvement: 6-month follow-up results of a multisite clinical trial. J Child Neurol, 2013, 28: 161–175. [PubMed]

Xu K, Wang L, Mai J, et al. : Efficacy of constraint-induced movement therapy and electrical stimulation on hand function of children with hemiplegic cerebral palsy: a controlled clinical trial. Disabil Rehabil, 2012, 34: 337–346. [PubMed]

Lin KC, Wang TN, Wu CY, et al. : Effects of home-based constraint-induced therapy versus dose-matched control intervention on functional outcomes and caregiver well-being in children with cerebral palsy. Res Dev Disabil, 2011, 32: 1483–1491. [PubMed]

Koman LA, Smith BP, Williams R, et al. : Upper extremity spasticity in children with cerebral palsy: a randomized, double-blind, placebo-controlled study of the short-term outcomes of treatment with botulinum A toxin. J Hand Surg Am, 2013, 38: 435–46.e1. [PubMed]

Redman TA, Finn JC, Bremner AP, et al. : Effect of upper limb botulinum toxin-A therapy on health-related quality of life in children with hemiplegic cerebral palsy. J Paediatr Child Health, 2008, 44: 409–414.[PubMed]

Down syndrome and VR effectiveness

Systematic Review

Motor Learning and Virtual Reality in Down Syndrome: A Literature Review

Del Ciello de Menezes, L., Massetti, T., Olivereira, F. R., de Abreu, L., C., Herrero, D., Malheiros, S. R. P., Trevizan, I. L., Moriyama, C. H. & de Mello Monteiro, C. B.

International Archives of Medicine, 8:119 2015.

DOI:10.3823/1718

Link to full text: www.imed.pub/ojs/index.php/iam/article/download/1157/945

Objective: In children with Down syndrome, do virtual reality games result in positive outcomes compared with conventional therapy interventions?

Method: Literature search results were screened and full texts were read by two reviewers. Of 194 studies, 7 articles were selected; 5 studies analyzed Down syndrome and motor learning, and 2, Down syndrome and virtual reality. Three studies had PEDRO (Physiotherapy Evidence Database http://www.pedro.org.au/ ) scores of 6/10 "good", three had 5/10 and one had 4/10 "fair".

Findings: "The motor learning in individuals with Down syndrome… is more effective in the presence of visual feedback and self-control. Individuals with Down syndrome respond positively and effectively…when stimulated with different and complementary tasks to conventional therapy".

Wii Fit improves GMFCS 3 motor skills

RCT

Effects of interactive games on motor performance in children with cerebral palsy

AlSaif, A. A.& Alsenany, S.

Journal of Physical Therapy Science 27: 2001-2003, 2015

Link to full text: www.ncbi.nlm.nih.gov/pmc/articles/PMC4500030/

Objective: For children with cerebral palsy, what is the effect of training with Nintendo Wii on motor performance compared with no training?

Method: 40 6-to-10 year old children GMFCS 3 were randomly divided into a ‘no training’ group and a group that received game time at home for 20 minutes a day for 12 weeks. Subjects had a lower limb muscle power of no less than grade 4 and no fixed lower limb contractures.

Findings: Outcome measures used were the Movement Assessment Battery for Children-2 (mABC-2) manual dexterity, ball skills of aiming and catching and balance; Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) upper limb co-ordination (subtest 5:6), and the one-minute walk test. Significant results were found before and after the intervention between groups and within the treatment group, but not within the control group.

Active video games and Developmental Coordination Disorder

RCT

A crossover randomised and controlled trial of the impact of active video games (AVG) on motor coordination and perceptions of physical ability in children at risk of Developmental Coordination Disorder (DCD)

Straker, L., Howie, E., Smith, A., Jensen, L., Piek, J. & Campbell, A.

Human Movement Science, 42 (2015) 146 – 160

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/26037276

Objective: In children with DCD, does exposure to AVG vs video game avoidance result in changes to motor coordination, or changes to parents’ or subjects’ perception of motor coordination.

Method: Twenty-one 9 to 12 year old children at risk of DCD were randomized in an unblinded cross-over study. They completed the Movement Assessment Battery for Children-2 (MABC-2) and 3D motion analysis at the beginning of the study and after each condition; video game avoidance and AVG. AVG was done for a minimum of 20 minutes a day for at least 4 days a week for 16 weeks. Parents completed the Developmental Coordination Disorder Questionnaire (DCDQ) and their children, used a global scale to report changes in their physical skills.

Findings: No significant differences were noted in MABC-2 scores, in 3D motion analysis or in the parents DCDQ ratings. "The children reported their motor skills to be significantly enhanced as a result of the AVG intervention in comparison to the period of no intervention".

Kinect: Clinician's Resource

Resource development
Levac, D., Espy, D., Fox, E., Pradhan, S. & Deutsch, J. E.
"Kinect-ing" with Clinicians: A Knowledge Translation Resource to Support Decision Making About Video Game Use in Rehabilitation
Physical Therapy 2015;95:426-440.

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/25256741

Problem: There is a perceived need for support to use of Kinect clinically.

Objective: “…development and preliminary evaluation of a knowledge translation resource to support clinical decision making about selection and use of Kinect games in physical therapy”.

Process: Interviews or focus groups were conducted with 16 clinician participants over 4 sites.

Outcome: Production of “Kinecting With Clinicians Resource (KWIC). Categories include game selection (player or game driven, stability, mobility, mobility plus); game play (spatial accuracy, temporal accuracy, duration, cognitive operators, augmented feedback, progression, score).

Rapid Review: Commercial Gaming Systems for Neurorehabilitation

Commercial Gaming Systems for Neurorehabilitation: Clinical Effectiveness
Published February 18th, 2015 by CADTH

Link to full text

This rapid review is provided by the Canadian Agency for Drugs and Technologies in Health. CADTH reviews drugs, devices, tests and treatments. Rapid reviews are an increasingly popular product, with a turn-around in as little as 3 days.

Objective: What is the evidence of clinical effectiveness of commercial gaming systems for patients undergoing neurorehabilitation?

PICO

• Patients undergoing rehabilitation therapy (acquired or traumatic brain injury, stroke, cerebral palsy, multiple sclerosis, etc.)
• Intervention Use of commercial gaming systems (e.g., Xbox, Kinect, Wii, Wii Fit, etc.)
• Comparator None, or any other established method of neurorehabilitation
• Outcomes Clinical benefits: improved function outcomes (e.g., upper extremity function, range of motion, strength, coordination, balance, mobility, gait, etc.)
• Study Designs Health technology assessments, systematic reviews, meta-analyses, randomized controlled trials, non-randomized studies.

Process: Searches identified six systematic reviews and seventeen randomized controlled trials that were suitable for inclusion.

Outcomes: Each article is summarized in a table; general conclusions are not drawn.

Video Gaming for Rehab

Scoping review

A scoping review of video gaming in adult rehabilitation

Ravenek, K. E., Wolfe, D. L. & Hitzig, S. L.

Disability and Rehabilitation Assistive Technology Early online 1 – 9 DOI: 10.3109/17483107.2015.1029538

Link to abstract: informahealthcare.com/doi/abs/10.3109/17483107.2015.1029538

Objective: To review published research for video gaming with adult rehabilitation.

Process: Five databases were searched for articles arising from 1990. 30 articles met the criteria; they are published in English, use commercially available game systems for adults in rehabilitation settings, describe an intervention and an outcome that is measured.

Scoping reviews take a wide view of emerging topics to synthesize a summary of research and research gaps. The scoping review methodology is taken from Levac et al. “Scoping Studies: Advancing the Methodology”. The process: identify a research question, find studies, filter, organize, synthesize and communicate the results.

Outcome: Nintendo Wii was most often used for adults in rehabilitation settings at risk for falls or with decreased balance (Intervention), and most commonly measured with the Berg Balance Scale (Outcome measure).

Reference: Levac, D., Colquhoun, H. & O’Brien, K. K. Scoping Studies: Advancing the Methodology, Implementation Science, 2010;5:67-77. Full text: www.implementationscience.com/content/pdf/1748-5908-5-69.pdf

New Center for Digital Games Research

New Resource

The Center for Digital Games Research, at the University of California at Santa Barbara, takes a wide, cross-disciplines approach to the design and play of video games and digital media in general.

Digital games, now so embedded in our culture, have a place “in helping us make healthier decisions and foster healthier lifestyles.” The Center for Digital Games Research considers how people interact with health games and how games can be improved to be more effective.

Included in center’s activities are 21 funded projects, and the publication of a health games database, which catalogues “information about hundreds of games, publications, organizations and events - all focused on the use of digital games for health and health care”.

Center for Digital Games Research www.cdgr.ucsb.edu

Database www.cdgr.ucsb.edu/db

News article www.news.ucsb.edu/2015/014784/games-people-play

Therapists’ thoughts on Gaming and Social Media

Qualitative Study

Therapist’s Perceptions of Social Media and Video Game Technologies in Upper Limb Rehabilitation

Tatla, S. K., Shirzad, N., Lohse, K. R., Virji-Babul, N., Hoens, A. M., Holsti, L., Li, L. C., Miller, K. J., Lam, M. Y. & Van der Loos, H. M.

JMIR Serious Games, 2015 3 (1):e2 DOI: 10.2196/games.3401
PMID: 25759148

Full content*: games.jmir.org/2015/1/e2

Objective: The objective of (this) study was to explore therapists’ perceptions of how young people and adults with hemiplegia use gaming and social media technologies in daily life and in rehabilitation, and to identify barriers to using these technologies in rehabilitation.

Method: A purposive sample of occupational and physical therapists was gathered for two focus group sessions. Participants were guided through a semi-structured interview with open questions. The content was audio recorded and transcribed. Coding allowed themes to emerge; participants were involved in affirming the findings.

Findings: The authors identified three themes relating to social media and gaming technologies: the presence or uptake in the lives of rehabilitation clients; barriers to use in therapy, and possible benefits. Clients varied in their use of social media and gaming technologies, and therapists also made limited use of these. Barriers to use included age appropriateness, the therapists’ concern with client’s privacy, questionable transferability of skills, lack of accessibility, and “reconciling (the) therapist role within the gaming context”. Benefits included the social-emotional, rehabilitation and usability features of social media and videogaming.

Examined through the lens of Diffusion of Innovation Theory, barriers to uptake included “increased complexity, limited relative advantage, perceived lack of compatibility with values of some clients and therapists’ reconciling compatibility with their values”. Facilitators of uptake included “motivation, trialability, social connection as key benefit, and perceived compatibility with values of some clients”.

---

*This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included.

Remapping the Brain with Videogames

Review

Should we integrate video games into home-based rehabilitation therapies for cerebral palsy? Biddess, E. Future Neurology 2012;7 (5) 515-518

For full text Google: “Should we integrate video games into home-based rehabilitation therapies for cerebral palsy?”

Summary: This article reviews the effectiveness of video games on neuroplasticity. Two articles are cited, each using specialized gaming systems and showed neural changes related to specific neurological goals. You et al.(1) found “cortical reorganization following a 4 week intervention with an 8 year old child with hemiparetic CP who engaged in videogame play for 60 min durations, 5 times a week.” Goloumb et al.(2) showed “improved functional scores and altered cortical activation profiles during a grasp tasks in a study fo three adolescents with hemiplegic CP who participated in videogame play for 30 min per days, 5 days a week over a three month period.”

Other trends noted with video games used in therapeutic environments are that games that allow a latitude of movement variability typically would diminish therapeutic benefits, that games typically offer limited possibilities of movement regimes that fit with therapeutic goals, and that in-game feedback and rewards are not always sufficient to motivate the player to persist to the level of therapeutic benefits.

1. You SH, Jang SH, Kim Y, Kwon Y, Barrow I, Hallett M. Cortical reorganization induced by virtual reality therapy in a child with hemiparetic CP. Dev. Med. Child Neurol.47,628–635 (2005).
2. Golomb MR, McDonald B, Warden S et al. In-home virtual reality videogame telerehabilitation in adolescents with hemiplegic CP. Arch. Phys. Med. Rehabil.91,1–7 (2010).

Game attributes that best fit with rehabilitation

Review

Expose, Distract, Motivate and Measure: Virtual Reality Games for Health

Albert “Skip” Rizzo

TISE conference December 9-11, 2014 Fortaleza, Brazil

Link to full text: www.tise.cl/2010/archivos/tise2006/01.pdf

Summary: Virtual Reality games have properties that can contribute to rehabilitation. This review illustrates four characteristics that benefit rehabilitation: exposure, distraction, motivation and measurement.

Clients using virtual reality can be repeatedly exposed to simulated, relevant stimuli. Their engagement in the VR environment may provides distraction from the current situation. Play offers motivation that can be channelled into rehabilitation goals, and the system has capacity to measure movement.Full text online with illustrations and references.

Motor learning through virtual reality in cerebral palsy

A Literature Review

Massetti, T., da Silva, T. D., Ribeiro, D. C., Pinheiro Malheiros, S. R., Nicolai Re, A. H., Favero, F. M. & de Mello Monteiro, C., B.

Medical Express 2014; 1(6): 302-306 DOI: 10.5935/MedicalExpress.2014.06.04

Link to full text: www.medicalexpress.net.br/details/99/motor-learning-through-virtual-reality-in-cerebral-palsy---a-literature-review

Objective: to investigate benefits to motor skills improvement from VR in children with CP.

Process: A pubmed search resulted in 40 studies were found regarding virtual reality and cerebral palsy. Few (10) studies reference “the use of virtual reality in children with cerebral palsy in gross motor function and improvements in motor learning with skill transfer to real-life situations”. These studies were evaluated using the Pediatric Evidence Database (PEDro); 3 scored ‘good’ or better, limited largely by small sample sizes.

Outcome: “Improvements in performance were specific to the practice environment; there was no transfer of learning”.