Development and Feasibility of a Kinect-Based Constraint-Induced Therapy Program in the Home Setting for Children With Unilateral Cerebral Palsy

Joystick-Operated Ride-On Toy Navigation Training for Children With Hemiplegic Cerebral Palsy: A Pilot Study

IMPORTANCE

Children with hemiplegic cerebral palsy (HCP) require intensive task-oriented training to make meaningful gains in affected upper extremity (UE) motor function.

OBJECTIVE

To evaluate the acceptability and utility of single joystick-operated ride-on toy (ROT) navigation training incorporated into a modified constraint-induced movement therapy (CIMT) camp for children with HCP.

DESIGN

Single group pretest-posttest design.

SETTING

Three-wk structured CIMT camp.

PARTICIPANTS

Eleven children with HCP between ages 3 and 14 yr.

INTERVENTION

Children received group-based CIMT for 6 hr/day, 5 days/wk, for 3 wk. As part of camp activities, children also received ROT navigation training for 20 to 30 min/day, 5 days/wk, for 3 wk.

OUTCOMES AND MEASURES

We assessed children's acceptance of ROT training by monitoring adherence and evaluating child engagement (affect and attention) during training sessions. The effects of ROT training combined with other camp activities on children's affected UE motor function were also assessed with the standardized Quality of Upper Extremity Skills Test (QUEST) and training-specific measures of ROT maneuvering accuracy.

RESULTS

Children demonstrated high levels of training adherence, positive affect, and task-appropriate attention across weeks. Positive engagement during ROT sessions was correlated with independent navigation. We also found medium- to large-sized improvements in QUEST scores and toy-maneuvering capabilities after the combined program.

CONCLUSIONS AND RELEVANCE

Our pilot data support the use of joystick-operated ROTs as child-friendly therapy adjuncts that can be incorporated into intensive UE training programs to improve adherence and motivation in therapy programs, boost treatment dosing, and promote affected UE motor function in children with HCP. Plain-Language Summary: This pilot study offers promising evidence that supports the use of modified single joystick-operated ride-on toys (ROTs) for children with hemiplegic cerebral palsy (HCP). The study used ROTs as one of several interventions that were part of a constraint-induced movement therapy (CIMT) camp program for children with HCP. The ROTs boosted children's motivation, their engagement with and adherence to training, and their practice in using their affected upper extremity (UE) for goal-directed activities in their natural settings. ROTs are accessible, age-appropriate, and easy-to-use devices for both occupational therapy clinicians and families to encourage children to use their affected UEs by challenging their perceptual, motor-planning, problem-solving, and movement-control skills in an enjoyable and engaging way. ROTs can be used within and outside conventional rehabilitation settings.

The application of virtual reality to home-based rehabilitation for children and adolescents with cerebral palsy: A systematic review and meta-analysis

BACKGROUND

Home-based rehabilitation enables children and families to participate in therapeutic activities built into their daily routines without the barriers of arrangement and transportation to facilities. Virtual reality is an emerging technology which has shown promising outcomes in rehabilitation.

PURPOSE

This systematic review aims to examine the feasibility and effects of virtual reality-enhanced home rehabilitation on Body functions and structures, Activity, and Participation outcomes in children and adolescents with cerebral palsy.

METHODS

Interventional studies were searched across five biomedical databases on November 26, 2022. Two independent reviewers conducted study selection, data extraction, and quality assessment. The Physiotherapy Evidence Database scale and National Institutes of Health Study Quality Assessment Tools were used to evaluate the quality of included studies. Meta-analysis was performed to examine the effects of the intervention.

RESULTS

Eighteen studies were included in this review. Home-based virtual reality rehabilitation appears feasible with effects on upper extremity and gross motor function, strength, bone density, cognition, balance, walking, daily activity performance, and participation. Meta-analyses revealed significant improvements in hand function (SMD = 0.41, p= .003), gross motor function (SMD = 0.56, p= .0002), and walking capacity (SMD = 0.44, p= .01) following home-based virtual reality intervention.

CONCLUSION

Home-based virtual reality may serve as an adjunct to conventional facility-based therapy to promote participation in therapeutic exercises and maximize rehabilitation outcomes. Further properly designed randomized controlled trials using valid and reliable outcome measures with adequately powered sample sizes are warranted to enhance the current body of evidence using home-based virtual reality in cerebral palsy rehabilitation.

Role of telerehabilitation in the rehabilitation of children with cerebral palsy during COVID-19: A review

Individuals with cerebral palsy (CP) have limited mobility and are unable to actively participate in tasks that are part of their daily living. Thus, continuous therapeutic sessions are required to keep such individuals active and engaged in the environment. Due to the coronavirus disease of 2019 (COVID-19) lockdowns, rehabilitation for children with CP was inhibited which consequently put them at risk of losing their functional gains which were obtained through previous in-person therapies. In order to avoid this, an alternate to conventional therapy was required and this rendered it necessary to review the role of telerehabilitation (TR) and its various modes for the rehabilitation of children with CP. This study aimed to explore the effectiveness of TR for children with CP during COVID-19 through the present literature and to determine if TR is an alternate to conventional physical therapy in children with CP during the coronavirus outbreak. This scoping review was conducted by searching different databases such as PubMed, Cochrane Collaboration, Medline, and Google Scholar on the basis of inclusion criteria. Screening was performed from January 2019 to June 2022 and the initial screening attempt returned 469 studies. After applying the aforementioned criteria, all impertinent studies were excluded which resulted in 28 studies being included for this review as they contained information about the effectiveness of TR on children with CP during COVID-19. These 28 articles included randomised controlled trials, surveys, reviews, clinical trials, case reports, prospective studies, editorials, and longitudinal studies. Three out of the 7 randomised controlled trial studies revealed that action observation treatment can be a useful approach for TR in child with CP during similar pandemics. The other 3 studies supported the use of computer-based games, robots, nonimmersive virtual reality, and wearable haptic devices as a significant means of TR in child with CP as an alternate to routine therapy during COVID-19. TR is an affable mode of rehabilitation specifically for the pediatric population. In the future, it can be an alternate to routine therapy for those who are unlikely to get daily access to in-person therapeutic sessions due to various reasons or circumstances.

Playfulness and New Technologies in Hand Therapy for Children With Cerebral Palsy: Scoping Review

BACKGROUND

Innovative technologies such as game consoles and smart toys used with games or playful approaches have proven to be successful and attractive in providing effective and motivating hand therapy for children with cerebral palsy (CP). Thus, there is an increased interest in designing and implementing interventions that can improve the well-being of these children. However, to understand how and why these interventions are motivating children, we need a better understanding of the playful elements of technology-supported hand therapy.

OBJECTIVE

This scoping review aims to identify the playful elements and the innovative technologies currently used in hand therapy for children with CP.

METHODS

We included studies that design or evaluate interventions for children with CP that use innovative technologies with game or play strategies. Data were extracted and analyzed based on the type of technology, description of the system, and playful elements according to the Lenses of Play, a play design toolkit. A total of 31 studies were included in the analysis.

RESULTS

Overall, 54 papers were included in the analysis. The results showed high use of consumer technologies in hand therapy for children with CP. Although several studies have used a combination of consumer technologies with therapeutic-specific technologies, only a few studies focused on the exclusive use of therapeutic-specific technologies. To analyze the playfulness of these interventions that make use of innovative technologies, we focused our review on 3 lenses of play: Open-ended Play, where it was found that the characteristics of ludus, such as a structured form of play and defined goals and rules, were the most common, whereas strategies that relate to paidia were less common. The most commonly used Forms of Play were physical or active form and games with rules. Finally, the most popular Playful experiences were control, challenge, and competition.

CONCLUSIONS

The inventory and analysis of innovative technology and playful elements provided in this study can be a starting point for new developments of fun and engaging tools to assist hand therapy for children with CP.

Outcomes Associated with a Single Joystick-Operated Ride-on-Toy Navigation Training Incorporated into a Constraint-Induced Movement Therapy Program: A Pilot Feasibility Study

Our research aims to evaluate the utility of joystick-operated ride-on-toys (ROTs) as therapeutic adjuncts to improve upper extremity (UE) function in children with hemiplegic cerebral palsy (HCP). This study assessed changes in affected UE use and function following a three-week ROT navigation training incorporated into an existing constraint-induced movement therapy (CIMT) camp in 11 children (3-14 years old) with HCP. We report changes in scores on the standardized Shriners Hospital Upper Extremity Evaluation (SHUEE) from pretest-to-posttest and changes from early-to-late sessions in percent time spent by the affected arm in: (a) "moderate-to-vigorous activity", "light activity" and "no activity" bouts based on accelerometer data and (b) "independent", "assisted", and "no activity" bouts based on video data. We also explored relationships between standardized measures and training-specific measures of affected UE activity. We found small-to-medium improvements in the SHUEE scores. Between 90 and 100% of children also showed medium-to-large improvements in affected UE activity from early-to-late sessions using accelerometers and small improvements via video-based assessments. Exploratory analyses suggested trends for relationships between pretest-posttest and training-specific objective and subjective measures of arm use and function. Our pilot data suggest that single joystick-operated ROTs may serve as motivating, child-friendly tools that can augment conventional therapies such as CIMT to boost treatment dosing, promote affected UE movement practice during real-world navigation tasks, and ultimately improve functional outcomes in children with HCP.

An analysis of clinical outcomes and essential parameters for designing effective games for upper limb rehabilitation: A scoping review

Background and Aims

Upper limb disabilities are one of the most common disabilities among different groups of people who always need rehabilitation. One of the important methods in helping to carry out efficient rehabilitation processes and exercises is the use of games. The aim of this study is to identify the parameters necessary to design a successful rehabilitation game and the outcomes of using these games in upper limb disabilities rehabilitation.

Methods

This scoping review was conducted by searching the Web of Science, PubMed, and Scopus. The eligibility criteria were: any form of game-based upper limb rehabilitation, published in a peer-reviewed journal, published in English, and not include articles that did not focus upper limb disabilities rehabilitation games, review, meta-analysis, or conference papers. Analysis of collected data was done using descriptive statistics (frequency and percentage).

Results

The search strategy retrieved 537 relevant articles. Finally, after removing irrelevant and repetitive articles, 21 articles were included in this study. Among the six categories of diseases or complications of upper limb disabilities, games were mostly designed for stroke patients. Smart wearables, robots and telerehabilitation were three technologies that were used for rehabilitation along with games. Sports and shooters were the most used games for upper limb disability rehabilitation. Among 99 necessary parameters for designing and implementing a successful rehabilitation game in ten categories. "Increasing the patient's motivation to perform rehabilitation exercises", "Game difficulty levels", "Enjoying and the attractiveness of the game for patients", and "Providing positive or negative audiovisual feedback" were the most important parameters. "Improvement in musculoskeletal performance" and "Increasing users' enjoyment/joy of therapeutic exercises and their motivation to perform these exercises" were the most important positive outcomes, and "Mild discomfort such as nausea and dizziness when using games" was the only negative outcome.

Conclusions

The successful design of a game according to the parameters identified in the present study can lead to an increase in the positive outcomes of using games in the rehabilitation of disabilities. The study results indicate that upper limb therapeutic exercise augmented with virtual reality games may be highly effective in enhancing motor rehabilitation outcomes.

A novel balance training approach: Biomechanical study of virtual reality-based skateboarding

Introduction: The use of virtual reality (VR) technology in training and rehabilitation gained increasing attention in recent years due to its potential to provide immersive and interactive experiences. We developed a novel VR-based balance training, VR-skateboarding, for improving balance. It is important to investigate the biomechanical aspects of this training, as it would have benefited both health professionals and software engineers. Aims: This study aimed to compare the biomechanical characteristics of VR-skateboarding with those of walking. Materials and Methods: Twenty young participants (10 males and 10 females) were recruited. Participants underwent VR-skateboarding and walking at the comfortable walking speed, with the treadmill set at the same speed for both tasks. The motion capture system and electromyography were used to determine joint kinematics and muscle activity of the trunk and legs, respectively. The force platform was also used to collect the ground reaction force. Results: Participants demonstrated increased trunk flexion angles and muscle activity of trunk extensor during VR-skateboarding than during walking (p < 0.01). For the supporting leg, participants' joint angles of hip flexion and ankle dorsiflexion, as well as muscle activity of knee extensor, were higher during VR-skateboarding than during walking (p < 0.01). For the moving leg, only hip flexion increased in VR-skateboarding when compared to walking (p < 0.01). Furthermore, participants increased weight distribution in the supporting leg during VR-skateboarding (p < 0.01). Conclusion: VR-skateboarding is a novel VR-based balance training that has been found to improve balance through increased trunk and hip flexion, facilitated knee extensor muscles, and increased weight distribution on the supporting leg compared to walking. These differences in biomechanical characteristics have potential clinical implications for both health professionals and software engineers. Health professionals may consider incorporating VR-skateboarding into training protocols to improve balance, while software engineers may use this information to design new features in VR systems. Our study suggests that the impact of VR-skateboarding particularly manifest when focusing on the supporting leg.

Comparative effects of kinect-based versus therapist-based constraint-induced movement therapy on motor control and daily motor function in children with unilateral cerebral palsy: a randomized control trial

BACKGROUND

Constraint-induced movement therapy (CIMT) is a prominent neurorehabilitation approach for improving affected upper extremity motor function in children with unilateral cerebral palsy (UCP). However, the restraint of the less-affected upper extremity and intensive training protocol during CIMT may decrease children's motivation and increase the therapist's workload and family's burden. A kinect-based CIMT program, aiming to mitigate the concerns of CIMT, has been developed. The preliminary results demonstrated that this program was child-friendly and feasible for improving upper extremity motor function. However, whether the kinect-based CIMT can achieve better or at least comparable effects to that of traditional CIMT (i.e., therapist-based CIMT) should be further investigated. Therefore, this study aimed to compare the effects of kinect-based CIMT with that of therapist-based CIMT on upper extremity and trunk motor control and on daily motor function in children with UCP.

METHODS

Twenty-nine children with UCP were recruited and randomly allocated to kinect-based CIMT (n = 14) or therapist-based CIMT (n = 15). The intervention dosage was 2.25 h a day, 2 days a week for 8 weeks. Outcome measures, namely upper extremity and trunk motor control and daily motor function, were evaluated before and after 36-h interventions. Upper extremity and trunk motor control were assessed with unimanual reach-to-grasp kinematics, and daily motor function was evaluated with the Revised Pediatric Motor Activity Log. Between-group comparisons of effectiveness on all outcome measures were analyzed by analysis of covariance (α = 0.05).

RESULTS

The two groups demonstrated similar improvements in upper extremity motor control and daily motor function. In addition, the kinect-based CIMT group demonstrated greater improvements in trunk motor control than the therapist-based CIMT group did (F(1,28) > 4.862, p < 0.036).

CONCLUSION

Kinect-based CIMT has effects comparable to that of therapist-based CIMT on UE motor control and daily motor function. Moreover, kinect-based CIMT helps decrease trunk compensation during reaching in children with UCP. Therefore, kinect-based CIMT can be used as an alternative approach to therapist-based CIMT.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02808195. Registered on 2016/06/21, https://clinicaltrials.gov/ct2/show/NCT02808195 .