Evaluation of cervical posture improvement of children with cerebral palsy after physical therapy based on head movements and serious games

Background: This paper presents the preliminary results of a novel rehabilitation therapy for cervical and trunk control of children with cerebral palsy (CP) based on serious videogames and physical exercise. Materials: The therapy is based on the use of the ENLAZA Interface, a head mouse based on inertial technology that will be used to control a set of serious videogames with movements of the head. Methods: Ten users with CP participated in the study. Whereas the control group (n=5) followed traditional therapies, the experimental group (n=5) complemented these therapies with a series of ten sessions of gaming with ENLAZA to exercise cervical flexion-extensions, rotations and inclinations in a controlled, engaging environment. Results: The ten work sessions yielded improvements in head and trunk control that were higher in the experimental group for Visual Analogue Scale, Goal Attainment Scaling and Trunk Control Measurement Scale (TCMS). Significant differences (27% vs. 2% of percentage improvement) were found between the experimental and control groups for TCMS (p<0.05). The kinematic assessment shows that there were some improvements in the active and the passive range of motion. However, no significant differences were found pre- and post-intervention. Conclusions:Physical therapy that combines serious games with traditional rehabilitation could allow children with CP to achieve larger function improvements in the trunk and cervical regions. However, given the limited scope of this trial (n=10) additional studies are needed to corroborate this hypothesis

Games used with serious purposes: a systematic review of interventions in patients with cerebral palsy

The purpose of the present systematic review was to examine extant research regarding the role of games used seriously in interventions with individuals with cerebral palsy. Therefore, PubMed, PsyINFO, Web of Science, Scopus, and IEEE databases were used. Search terms included: "serious games" OR "online games" OR "video games" OR "videogame" OR "game based" OR "game" AND "intervention" AND "cerebral palsy." After the full reading and quality assessment of the papers, 16 studies met the inclusion criteria. The majority of the studies reported high levels of compliance, motivation, and engagement with game-based interventions both at home and at the clinical setting intervention. Regarding the effectiveness of the use of games, the results of the studies show both positive and negative results regarding their effectiveness. The efficacy was reported to motor function (i.e., improvements in the arm function, hand coordination, functional mobility, balance and gait function, postural control, upper-limbs function) and physical activity. Findings of this review suggest that games are used as a complement to conventional therapies and not as a substitute. Practitioners often struggle to get their patients to complete the assigned homework tasks, as patients display low motivation to engage in prescribed exercises. Data of this review indicates the use of games as tools suited to promote patients' engagement in the therapy and potentiate therapeutic gains.This study was conducted at Psychology Research Centre (UID/PSI/01662/2013), University of Minho, and supported by the Portuguese Foundation for Science and Technology and the Portuguese Ministry of Science, Technology and Higher Education through national funds and co-financed by FEDER through COMPETE2020 under the PT2020 Partnership Agreement (POCI-01-0145-FEDER-007653). SL and AP were supported by a Ph.D. fellowship from the Portuguese Foundation for Science and Technology (FCT). PM was supported by a Post-Doctoral fellowship from the Psychology Research Centre (CIPsi), University of Minho. JM was supported by a research scholarship from the Psychology Research Centre (CIPsi), University of Minho

The effects of virtual rehabilitation therapy on multiple sclerosis

In this review article, the effect of virtual rehabilitation therapy on multiple sclerosis, a neurodegenerative disorder, is explored. Multiple sclerosis is characterized by damaged nerves that result in incomplete signal processing between the brain and the spinal cord. The symptoms of this condition can include vision loss, decreased coordination, pain, fatigue, and deteriorating motor output. The severity of the symptoms and the rate of progression of multiple sclerosis can vary from person to person; some individuals live the majority of their lives with mild symptoms while others become bedridden and immobile. There is no cure for this disease, however implementation of virtual reality rehabilitation therapy shows promise in slowing the progression of deterioration in motor output and cognition. Through a variety of methods incorporating virtual reality, this review investigates the effects of this type of therapy on balance, manual dexterity, and mental health in patients with multiple sclerosis

Novel Virtual Environment for Alternative Treatment of Children with Cerebral Palsy

Cerebral palsy is a severe condition usually caused by decreased brain oxygenation during pregnancy, at birth or soon after birth. Conventional treatments for cerebral palsy are often tiresome and expensive, leading patients to quit treatment. In this paper, we describe a virtual environment for patients to engage in a playful therapeutic game for neuropsychomotor rehabilitation, based on the experience of the occupational therapy program of the Nucleus for Integrated Medical Assistance (NAMI) at the University of Fortaleza, Brazil. Integration between patient and virtual environment occurs through the hand motion sensor “Leap Motion,” plus the electroencephalographic sensor “MindWave,” responsible for measuring attention levels during task execution. To evaluate the virtual environment, eight clinical experts on cerebral palsy were subjected to a questionnaire regarding the potential of the experimental virtual environment to promote cognitive and motor rehabilitation, as well as the potential of the treatment to enhance risks and/or negatively influence the patient’s development. Based on the very positive appraisal of the experts, we propose that the experimental virtual environment is a promising alternative tool for the rehabilitation of children with cerebral palsy.Cerebral palsy is a severe condition usually caused by decreased brain oxygenation during pregnancy, at birth or soon after birth. Conventional treatments for cerebral palsy are often tiresome and expensive, leading patients to quit treatment. In this paper, we describe a virtual environment for patients to engage in a playful therapeutic game for neuropsychomotor rehabilitation, based on the experience of the occupational therapy program of the Nucleus for Integrated Medical Assistance (NAMI) at the University of Fortaleza, Brazil. Integration between patient and virtual environment occurs through the hand motion sensor “Leap Motion,” plus the electroencephalographic sensor “MindWave,” responsible for measuring attention levels during task execution. To evaluate the virtual environment, eight clinical experts on cerebral palsy were subjected to a questionnaire regarding the potential of the experimental virtual environment to promote cognitive and motor rehabilitation, as well as the potential of the treatment to enhance risks and/or negatively influence the patient’s development. Based on the very positive appraisal of the experts, we propose that the experimental virtual environment is a promising alternative tool for the rehabilitation of children with cerebral palsy

Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: a pilot randomized clinical trial in patients with acquired brain injury

Background: Acquired brain injury (ABI) is the main cause of death and disability among young adults. In most cases, survivors can experience balance instability, resulting in functional impairments that are associated with diminished health-related quality of life. Traditional rehabilitation therapy may be tedious. This can reduce motivation and adherence to the treatment and thus provide a limited benefit to patients with balance disorders. We present eBaViR (easy Balance Virtual Rehabilitation), a system based on the Nintendo¿ Wii Balance Board¿ (WBB), which has been designed by clinical therapists to improve standing balance in patients with ABI through motivational and adaptative exercises. We hypothesize that eBaViR, is feasible, safe and potentially effective in enhancing standing balance. Methods. In this contribution, we present a randomized and controlled single blinded study to assess the influence of a WBB-based virtual rehabilitation system on balance rehabilitation with ABI hemiparetic patients. This study describes the eBaViR system and evaluates its effectiveness considering 20 one-hour-sessions of virtual reality rehabilitation (n = 9) versus standard rehabilitation (n = 8). Effectiveness was evaluated by means of traditional static and dynamic balance scales. Results: The final sample consisted of 11 men and 6 women. Mean ±SD age was 47.3 ± 17.8 and mean SD chronicity was 570.9 ± 313.2 days. Patients using eBaViR had a significant improvement in static balance (p = 0.011 in Berg Balance Scale and p = 0.011 in Anterior Reaches Test) compared to patients who underwent traditional therapy. Regarding dynamic balance, the results showed significant improvement over time in all these measures, but no significant group effect or group-by-time interaction was detected for any of them, which suggests that both groups improved in the same way. There were no serious adverse events during treatment in either group. Conclusions: The results suggest that eBaViR represents a safe and effective alternative to traditional treatment to improve static balance in the ABI population. These results have encouraged us to reinforce the virtual treatment with new exercises, so an evolution of the system is currently being developed. © 2011 Gil-Gómez et al; licensee BioMed Central Ltd.This study was funded in part by Ministerio de Educacion y Ciencia Spain, Projects Consolider-C (SEJ2006-14301/PSIC), "CIBER of Physiopathology of Obesity and Nutrition, an initiative of ISCIII" and the Excellence Research Program PROMETEO (Generalitat Valenciana. Conselleria de Educacion, 2008-157).Gil-Gómez, J.; Llorens Rodríguez, R.; Alcañiz Raya, ML.; Colomer Font, C. (2011). Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: a pilot randomized clinical trial in patients with acquired brain injury. Journal of NeuroEngineering and Rehabilitation. 8(30):1-9. https://doi.org/10.1186/1743-0003-8-30S19830Nichols-Larsen, D. S., Clark, P. C., Zeringue, A., Greenspan, A., & Blanton, S. (2005). Factors Influencing Stroke Survivors’ Quality of Life During Subacute Recovery. Stroke, 36(7), 1480-1484. doi:10.1161/01.str.0000170706.13595.4fTeasell, R., Meyer, M. J., McClure, A., Pan, C., Murie-Fernandez, M., Foley, N., & Salter, K. (2009). Stroke Rehabilitation: An International Perspective. Topics in Stroke Rehabilitation, 16(1), 44-56. doi:10.1310/tsr1601-44Sveistrup, H. (2004). Journal of NeuroEngineering and Rehabilitation, 1(1), 10. doi:10.1186/1743-0003-1-10Holden, M. K. (2005). Virtual Environments for Motor Rehabilitation: Review. CyberPsychology & Behavior, 8(3), 187-211. doi:10.1089/cpb.2005.8.187Crosbie, J. H., Lennon, S., Basford, J. R., & McDonough, S. M. (2007). Virtual reality in stroke rehabilitation: Still more virtual than real. Disability and Rehabilitation, 29(14), 1139-1146. doi:10.1080/09638280600960909Haas, B. M., & Burden, A. M. (2000). Validity of weight distribution and sway measurements of the Balance Performance Monitor. Physiotherapy Research International, 5(1), 19-32. doi:10.1002/pri.181Srivastava, A., Taly, A. B., Gupta, A., Kumar, S., & Murali, T. (2009). Post-stroke balance training: Role of force platform with visual feedback technique. Journal of the Neurological Sciences, 287(1-2), 89-93. doi:10.1016/j.jns.2009.08.051Deutsch, J. E., Borbely, M., Filler, J., Huhn, K., & Guarrera-Bowlby, P. (2008). Use of a Low-Cost, Commercially Available Gaming Console (Wii) for Rehabilitation of an Adolescent With Cerebral Palsy. Physical Therapy, 88(10), 1196-1207. doi:10.2522/ptj.20080062Yong Joo, L., Soon Yin, T., Xu, D., Thia, E., Pei Fen, C., Kuah, C., & Kong, K. (2010). A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. Journal of Rehabilitation Medicine, 42(5), 437-441. doi:10.2340/16501977-0528Clark, R. A., Bryant, A. L., Pua, Y., McCrory, P., Bennell, K., & Hunt, M. (2010). Validity and reliability of the Nintendo Wii Balance Board for assessment of standing balance. Gait & Posture, 31(3), 307-310. doi:10.1016/j.gaitpost.2009.11.012Young, W., Ferguson, S., Brault, S., & Craig, C. (2011). Assessing and training standing balance in older adults: A novel approach using the ‘Nintendo Wii’ Balance Board. Gait & Posture, 33(2), 303-305. doi:10.1016/j.gaitpost.2010.10.089Shih, C.-H., Shih, C.-T., & Chiang, M.-S. (2010). A new standing posture detector to enable people with multiple disabilities to control environmental stimulation by changing their standing posture through a commercial Wii Balance Board. Research in Developmental Disabilities, 31(1), 281-286. doi:10.1016/j.ridd.2009.09.013Shih, C.-H., Shih, C.-T., & Chu, C.-L. (2010). Assisting people with multiple disabilities actively correct abnormal standing posture with a Nintendo Wii Balance Board through controlling environmental stimulation. Research in Developmental Disabilities, 31(4), 936-942. doi:10.1016/j.ridd.2010.03.004Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). «Mini-mental state». Journal of Psychiatric Research, 12(3), 189-198. doi:10.1016/0022-3956(75)90026-6Geurts, A. C. H., de Haart, M., van Nes, I. J. W., & Duysens, J. (2005). A review of standing balance recovery from stroke. Gait & Posture, 22(3), 267-281. doi:10.1016/j.gaitpost.2004.10.002Marsden, J. F. (2005). The vestibular control of balance after stroke. Journal of Neurology, Neurosurgery & Psychiatry, 76(5), 670-679. doi:10.1136/jnnp.2004.046565Perron, M., Malouin, F., & Moffet, H. (2003). Assessing advanced locomotor recovery after total hip arthroplasty with the timed stair test. Clinical Rehabilitation, 17(7), 780-786. doi:10.1191/0269215503cr696oaMcDowell, B. C., Kerr, C., Parkes, J., & Cosgrove, A. (2005). Validity of a 1 minute walk test for children with cerebral palsy. Developmental Medicine & Child Neurology, 47(11), 744. doi:10.1017/s0012162205001568O’Shea, S. D., Taylor, N. F., & Paratz, J. D. (2007). Measuring Muscle Strength for People With Chronic Obstructive Pulmonary Disease: Retest Reliability of Hand-Held Dynamometry. Archives of Physical Medicine and Rehabilitation, 88(1), 32-36. doi:10.1016/j.apmr.2006.10.002Tyson, S. F., Hanley, M., Chillala, J., Selley, A. B., & Tallis, R. C. (2007). The Relationship Between Balance, Disability, and Recovery After Stroke: Predictive Validity of the Brunel Balance Assessment. Neurorehabilitation and Neural Repair, 21(4), 341-346. doi:10.1177/1545968306296966Brooks, D., Davis, A. M., & Naglie, G. (2006). Validity of 3 Physical Performance Measures in Inpatient Geriatric Rehabilitation. Archives of Physical Medicine and Rehabilitation, 87(1), 105-110. doi:10.1016/j.apmr.2005.08.109Jørgensen, H. S., Nakayama, H., Raaschou, H. O., Vive-Larsen, J., Støier, M., & Olsen, T. S. (1995). Outcome and time course of recovery in stroke. Part II: Time course of recovery. The copenhagen stroke study. Archives of Physical Medicine and Rehabilitation, 76(5), 406-412. doi:10.1016/s0003-9993(95)80568-0Ferrarello, F., Baccini, M., Rinaldi, L. A., Cavallini, M. C., Mossello, E., Masotti, G., … Di Bari, M. (2010). Efficacy of physiotherapy interventions late after stroke: a meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry, 82(2), 136-143. doi:10.1136/jnnp.2009.19642

E-survey of current international physiotherapy practice for children with ataxia following surgical resection of posterior fossa tumour.

ObjectiveTo determine current international practice regarding physiotherapy input for children with ataxia following surgery for posterior fossa tumour. Design: An e-survey covering the following domains: participant demographics, treatment/ intervention, virtual training, intensity/timing of treatment, and aims and outcomes of physiotherapy management.ParticipantsPhysiotherapists involved in the management of children with ataxia following surgical resection of posterior fossa tumour. Participants were contacted via 6 key groups; Paediatric Oncology Physiotherapy Network (POPs), Association of Paediatric Chartered Physiotherapists (APCP), European Paediatric Neurology Society (EPNS), International Society of Paediatric Oncology (SIOP)-Europe Brain Tumour Group, Posterior Fossa Society (PFS), and Pediatric Oncology Special Interest Group (SIG) (American Physical Therapy Association).ResultsA total of 96 physiotherapists participated: UK (n =53), rest of Europe (n = 23), USA/ Canada (n = 10), and Australia/NZ (n = 10). The most common physiotherapy interventions used were balance exercises, gait re-education and proximal control activities. The most frequently used adjuncts to treatment were mobility aids and orthotics. Challenges reported regarding physiotherapy treatment were: reduced availability of physiotherapy input following discharge from the acute setting, lack of evidence, impact of adjuvant oncology treatment, and psychosocial impact.ConclusionThis e-survey provides an initial scoping review of international physiotherapy practice in this area. It establishes a foundation for future research on improving rehabilitation of ataxia in this population

Rapid Development Environments for Therapy Games: Looking Glass Therapy Games for Cerebral Palsy Treatment Utilizing the Kinect

Cerebral palsy is a group of neurological disorders that impair body movement, muscle coordination, hearing, vision, and cognitive function. Symptoms vary but can include muscle weakness, muscle and joint tightness, abnormal or unsteady gait, seizures, learning disabilities, speech problems, as well as hearing or vision problems [1]. Although cerebral palsy cannot be cured, treatments such as physical and occupational therapy can greatly help affected children develop motor skills needed to increase mobility and foster independence [2]. Computer based therapy games have shown promise in helping stroke survivors recover from stroke [3]. Initially, stroke therapy games developed in Looking Glass utilized Nintendo Wii remotes (informally known as Wiimotes) to sense user’s movements. Challenges unfolded with stroke patients who were unable to grasp Wiimotes, thereby limiting and inhibiting game development and the user experience [3]. In this paper, I describe my efforts to integrate the Microsoft Kinect with Looking Glass and build therapy games that utilize the Kinect to track user movements. I detail the Kinect integration and discuss its advantages of seated skeletal tracking with no hand held devices required by the user

Studying Serious Games for the Therapy of Children with Disabilities following a Co-Design Process

Therapy can be a long and tedious process where progress is usually not immediately visible. This slow process can discourage younger patients, especially children who do not understand exactly what they are doing. Serious Games can help in these situations since they are games designed for a primary purpose other than pure entertainment. These games can be helpful as therapy tools because they promote engagement on the side of the patients, which in turn will make them feel more motivated to follow the therapeutic programme. In order to develop a game with a meaningful experience for users, beyond the fun of playing it, which helps them in their therapy, experts in the area need to be involved through close collaboration throughout the whole research process. Therefore, we de- veloped a game suite for the therapy of children with disabilities following a co-design process that included Cresce com Amor as the partner clinic. Cresce com Amor provided therapy expertise to the research team, collaborating in several phases of the process. Furthermore, by developing a classification system for serious games, based on the International Classification of Functioning, Disability and Health (ICF), which matches each game with body functions and therapy areas, we intend to support the classification of serious games in order to make them more suitable for their ultimate purpose. An in-house developed platform, called PLAY, supports the games by acting as a repository for the data collected and giving the therapists an interface to interact with and adjust the game parameters. The games use different interaction methods, other than the usual keyboard and mouse, to allow patients to seamlessly perform exercises that simulate the ones done in current traditional therapy sessions. By using off-the-shelf controllers, such as the balance board and dance mat, we can translate real-life movements more naturally into character movements in the virtual space.A terapia pode ser um processo longo e tedioso onde o progresso geralmente não é imedi- atamente visível. Este processo lento pode desencorajar os pacientes mais jovens, especi- almente as crianças que não entendem exatamente o que estão a fazer. Jogos Sérios podem ajudar nestas situações, uma vez que são jogos concebidos com um propósito principal que não seja apenas entretenimento. Estes jogos podem ser úteis como ferramentas te- rapêuticas porque promovem o envolvimento do lado dos pacientes, o que, por sua vez, fará com que se sintam mais motivados para seguir o programa terapêutico. Para desenvolver um jogo com uma experiência significativa para os utilizadores, para além da diversão de jogar, que os ajude na sua terapia, os especialistas na área precisam de estar envolvidos através de uma estreita colaboração ao longo de todo o processo de investigação. Assim, desenvolvemos uma suite de jogos para a terapia de crianças com incapacidades seguindo um processo de co-criação que incluiu a Cresce com Amor como clínica parceira. A Cresce com Amor adicionou conhecimentos terapêuticos à equipa de investigação, colaborando em várias fases do processo. Além disso, ao desenvolver um sistema de classificação para jogos sérios, baseado na Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF), que combina cada jogo com funções corporais e áreas de terapia, pretendemos apoiar a classificação de jogos sérios, a fim de torná-los mais adequados ao seu propósito final. Uma plataforma desenvolvida internamente, chamada PLAY, suporta os jogos, agindo como um repositório para os dados coletados e dando aos terapeutas uma interface para interagir e ajustar os parâmetros do jogo. Os jogos utilizam diferentes métodos de interação, além do habitual teclado e rato, para permitir que os pacientes realizem exercícios que simulam os que são feitos nas sessões de terapia tradicional atuais. Usando controladores comerciais, "prontos para uso", como a balance board e o dance mat, podemos traduzir de forma mais natural movimentos da vida real em movimentos de personagens no espaço virtual

Virtual Reality as a Therapy Tool for Walking Activities in Pediatric Neurorehabilitation: Usability and User Experience Evaluation

Background: Many essential walking activities in daily life, such as crossing a street, are challenging to practice in conventional therapeutic settings. Virtual environments (VEs) delivered through a virtual reality (VR) head-mounted display (HMD) would allow training such activities in a safe and attractive environment. Furthermore, the game-like character and high degree of immersion in these applications might help maintain or increase children's motivation and active participation during the rehabilitation process. Objective: This study aimed to investigate the usability, user experience, and acceptability of an immersive VE experienced through a VR HMD to train everyday life walking activities in pediatric neurorehabilitation. Methods: In a cross-sectional study, 21 youths (median age 12.1 years; range 6.8-17.7 years) with a neuromotor impairment undergoing inpatient or outpatient neurorehabilitation tested a VE experienced through the VR HMD Oculus Quest. The participants, accompanied by their physiotherapists, moved freely around a 4.4 by 10-meter VE, displaying a magical forest and featuring various gamified everyday activities in different game designs. Using their hands, represented in the VE, the participants could interact with the virtual objects placed throughout the VE and trigger visual and auditory feedback. Symptoms of cybersickness were checked, and usability, user experience, and acceptability were evaluated using customized questionnaires with a visual analog scale for youths and a 5-point Likert scale for their therapists. Results: None of the participants reported any signs of cybersickness after 20 minutes of VR HMD exposure time. They rated comfort (median 10/10) and movement ability (median 10/10) with the VR HMD as high. The VE was perceived as being really there by the majority (median 8/10), and the participants had a strong feeling of spatial presence in the VE (median 9.5/10). They enjoyed exploring the virtual world (median 10/10) and liked this new therapy approach (median 10/10). Therapists' acceptance of the VR HMD was high (4/5). There were 5 patients that needed more support than usual, mainly for supervision, when moving around with the VR HMD. Otherwise, therapists felt that the VR HMD hardly affected their patients' movement behavior (median 4.75/5), whereas it seemed to increase their level of therapy engagement (median 4/5) compared to conventional physiotherapy sessions. Conclusions: This study demonstrates the usability of an immersive VE delivered through a VR HMD to engage youths in the training of everyday walking activities. The participants' and therapists' positive ratings on user experience and acceptance further support the promising application of this technology as a future therapeutic tool in pediatric neurorehabilitation. Keywords: adolescent; auditory; child; feasibility study; feedback; head-mounted display; pediatric; rehabilitation; therapy; tool; usability; user; virtual reality; visual; walking; youth