Exercise as it relates to Disease/Use of Video Games (virtual reality) for rehabilitation of Cerebral Palsy patients

The following wikibooks page is an analysis for the journal article "Use of a Low-Cost, Commercially Available Gaming Console (Wii) for Rehabilitation of an Adolescent With Cerebral Palsy" by Judith E Deutsch, Megan Borbely, Jenny Filler, Karen Huhn, Phyllis Guarrera-Bowlby published October 2008.

What is the background to this research?
Cerebral palsy is an umbrella term that refers to a group of disorders affecting a person’s ability to move. It is due to damage to the developing brain either during pregnancy or shortly after birth. “Cerebral palsy affects people in different ways, including body movements, muscle control, coordination, reflex, posture and balance.” In Australia, 1 in 500 children are diagnosed with cerebral palsy, and a total of approximately 34,000 people living with cerebral palsy. There are currently over 17 million people worldwide living with the condition. There is no known cure for cerebral palsy, making participation in recreation, education, social environments and professional opportunities some what impaired. Outside of surgical and pharmaceutical management, use of intensive physical and occupational therapy programs have demonstrated some effectiveness in the treatment of cerebral palsy.

Virtual Reality (VR) is defined as an 'immersive, interactive, 3-dimensional computer experience in real time.' It provides users an opportunity to engage in multidimensional, multi-sensory virtual environment. Virtual reality technology systems have been developed specifically for rehabilitation of both upper and lower body training and gait training. In a review of VR in rehabilitation, drawbacks such as high cost of design of VR were identified. Commercially available VR gaming system that could potentially be used for rehabilitation is the Nintendo Wii. This system utilises a remote control as the input into the virtual environment (VE).

Where is the research from?
This article is from the Journal of the American Physical Therapy Association. The study was undertaken by the following researchers:
 * Judith E Deutsch
 * Megan Borbely
 * Jenny Filler
 * Karen Huhn
 * Phyllis Guarrera-Bowlby

This project was funded by the Rivers lab and the University of Medicine and Dentistry of New Jersey Foundation Summer Internship Program.

What kind of research was this?
Te research conducted was a selected trial, at the time of intervention, the patient was an adolescent male age 13. He was attending a summer program at a school for children with developmental disabilities. He was diagnosed with spastic diplegic Cerebral Palsy, additional diagnosis included severe asthma and tonic seizure activity. This adolescent was a good candidate for trial testing the Wii gaming system. He met certain criteria including, adequate functional hand skills to manage the Wii remote, gross motor skills and sufficient cognitive skills to follow direction. The purpose of this case report is to describe the feasibility and outcomes of incorporating the Wii as an intervention for an adolescent with CP.

What did the research involve?
Several standardized measures were used to characterize the motor control profile of the patient. Testing of visual- perceptual discrimination, postural control and functional mobility were administered. Testing would occur immediately pre- and post intervention. To identify the patients motor control function, Quality of Upper Extremity Skills Test (QUEST) and the Gross Motor Function measure (GMFM) were used. Both measures were validated for use with patients with CP.

The patient participated in 11 training sessions, 2 of which included other players. Sessions were between 60 and 90 minutes in duration. Training was performed using the Wii sports games software, including boxing, tennis, bowling, and golf. He trained in both standing and sitting positions. Each game had differing motor control and visual demands. For example:
 * Golf-Requires judgement of force, distance and high accuracy.
 * Bowling -Requires trunk stabilization whilst moving a single upper body extremity.

Results
Outcomes were assessed at different periods throughout the training. Postural control was retested one day after training, and walking was evaluated by the treating therapist during training and three months post training.

Visual-perceptual improved in all domains except visual memory. Postural control improved in a variety of measures. Greater loading on the lower body was observed and less reliance on a walker during eyes-closed walking condition. Center of pressure sway decreased by approximately 60% in both conditions. A observation in medial-lateral weight distribution was also highlighted. Overall functional mobility (ambulant with forearm crutches) was measured independently of researchers. A significant increase from 4.6m to 45.7m was recorded, and continued to increase to 76.2m post training. This distance had never been achieved by the patient prior to this research.

What conclusion can we take from this?
The feasibility of using the system in the school-based setting during the summer session was supported. For this patient whose rehabilitation was augmented with the Wii, there were positive outcomes at the impairment and functional levels. Multiple hypotheses were proposed for the findings that may be the springboard for additional research.

Practical advice
The discoveries in this research were described as the 'first of its kind'. Whilst active games have demonstrated value in respect to learning and functional movement they may not be appropriate for all goals e.g. muscle building and strength building. Studies analyzing children’s movements during video games can provide some direction in appropriate selection of games and gaming consoles to target specific joints and movements. However, it’s unlikely that commercially available gaming consoles can address the range of goals of movement and abilities of the diverse cerebral palsy population.

Further information/resources
For further information relating to this article, vthe following papers have some valid research into Cerebral Palsy and the effect of video games for rehabilitation.


 * 1) Howcroft J, Fehlings D, Wright V, Zabjek K, Andrysek J, Bidiss E (2012) A Comparison of solo and multiplayer active videogames play in children with unilateral cerebral palsy. Games for health journal. http://www.medscape.com/viewarticle/770970
 * 2) Golomb MR, McDonald B, Warden S (2010) In-home virtual reality videogame tele rehabilitation in adolescents with hemiplegic CP. Arch. Phys. Med. Rehabil.91,1–7
 * 3) Stubbs P, Diong J. (2015) the effect of strengthening interventions on strength and physical performance in people with cerebral palsy (PEDro synthesis). British Journal of Sports Medicine.
 * 4) You SH, Jang SH, Kim Y, Kwon Y, Barrow I, Hallett M. (2005) Cortical reorganization induced by virtual reality therapy in a child with hemiparetic CP.
 * 5) Howcroft J, Klejman S, Fehlings D (2012) Active video game play in children with CP: potential for physical activity promotion and rehabilitation therapies.
 * 6) Wang M, Reid D. (2011) Virtual reality in pediatric neurorehabilitation: attention deficit hyperactivity disorder, autism and CP.
 * 7) Li W, Lam-Damji S, Chau T, Fehlings D. (2009) The development of a home-based virtual reality therapy system to promote upper extremity movement for children with hemiplegic CP.