Effect of Virtual Reality in Spider Cage on Gross Motor Performance and Balance in Children With Spastic Diplegia
Phase: NA
Conditions: Cerebral Palsy
Sponsor: Amr Mohsen Mohamed Abo Khatwa

                  Kafrelsheikh University 
              Faculty of Physical Therapy, 
    Department of Physical Therapy for Growth and 
 Developmental Disorder in Children and its Surgery. 
 
 
 
EFFECT OF VIRTUAL REALITY IN SPIDER CAGE 
ON GROSS MOTOR PERFORMANCE AND BALANCE 
IN CHILDREN WITH SPASTIC DIPLEGIA 
 
Thesis Submitted 
By 
AMR MOHSEN ABO KHATWA 
Physiotherapist at shubrakhit general hospital, al buhayrah 
SUPERVISORS 
 
                          Dr.                                                              Dr. 
       Mohamed Bedair Ibrahim                         Nesma Elsayed Barakat 
Assistant Professor of Physical Therapy for Growth and           Lecturer of Physical Therapy for Growth and  
  Developmental Disorders in Children and its Surgery        Developmental Disorders in Children and its Surgery         
                Faculty of Physical Therapy                                                      Faculty of Physical Therapy 
                    Kafrelsheikh University                                                               Kafrelsheikh University 
  
Dr. 
 Abeer Muhammed Salamah 
Lecturer of Pediatrics 
Faculty of Medicine  
Kafrelsheikh University 
 
Faculty of Physical Therapy 
 Kafrelsheikh University 
2022/1444 

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CHAPTER I 
INTRODUCTION 
Cerebral palsy (CP) is a nonprogressive motor impairment syndrome 
caused by brain defects or lesions that occur in an immature brain before or 
during birth or within two years of birth (1).  
It is accompanied by motor disorder; disturbances of sensation, cognition, 
perception, communication, and behaviour; and seizure disorder and affects 
overall development (2,3). 
 Accordingly, children with CP show reduced postural control when 
engaging in several activities such as sitting, standing, and walking and have 
limitations in performing the activities of daily living (4,5). 
Therapeutic approaches for CP include neurodevelopmental treatment, 
Vojta therapy, sensory integration therapy, and conductive education. Specific 
therapeutic strategies for CP may differ, but they all aim to improve the 
independence of children with CP (6). 
Considering that the rehabilitation period of patients with CP is observed 
in a prolonged period of time, it is important to induce the sustained 
participation of these patients, making sure that the therapeutic interventions are 
interesting and easily performed (7). For this we will use this treatment tools in 
our study. 
Spider therapy is an intensive treatment approach which was originally 
developed in Poland. It involves suspending the child in the Centre of universal 
exercise unit by using a number of elastic bungee cords of different elasticity, 
these cords are attached to specific points on special belt around the child’s 
waist, forming a unique spider web around the child which provides them 
essential support (8). 
Virtual reality gaming augments a desirable motor processing skills 
through task-driven training and also encourage problem–solving. With a higher 

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concentration and engagement of goal-driven games, the virtual reality gaming 
might influence the cognitive-motor planning of children with CP (9). 
In the past, traditional neurophysiological approaches and novel emerging 
rehabilitation strategies addressed the gross motor function and balance capacity 
of children with CP (10). 
 Recommended that the group therapy, goal-directed motor practice, 
strengthening exercises, treadmill training, balance and walking training were 
beneficial for functional mobility of children with CP. In recent times, 
technological advancement has gained momentum in developing strategies for 
limb recovery and balance capacity of the paediatric and adult population with 
brain dysfunction (11). 
 
Statement of the Problem 
 
 This study will be conducted to answer the following research question: 
Is there any significant effect of virtual reality and physiotherapy in spider cage 
on gross motor performance and balance in children with spastic diplegia? 
 
Purpose of the Study 
  
This study will detect the effect of virtual reality in spider cage on gross 
motor performance and balance in children with spastic diplegia. 
 
Significance of the Study 
 
The current study will be directed to investigate effect of virtual reality on 
gross motor and balance as the weakness of the trunk muscles and lower limb 
muscles along with spasticity potentially predispose balance and walking issues 
of children with bilateral spastic CP (12). 
 
The balance deficits in children with CP are multifactorial. According to 
the system’s model proposed by Woollacott and Shumway-Cook, multiple 

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systems contribute to postural dysfunction in children with CP. Muscle 
weakness and stiffness of lower limb muscles account for biomechanical 
constraints and postural malalignment during standing and functional balancing 
(13). 
               Virtual reality is one of the novel technology-based approaches to treat 
balance and motor function in children with CP. It utilizes the interactive 
simulations created in computer hardware and software, in which the children 
find opportunities to engage in environments appearing real to them (14). 
              After reviewing the available previous published studies, it was found 
that there is no previous study directly compared between the effects of virtual 
reality and physical therapy in spider cage on gross motor performance and 
balance with diplegic children CP children. Both therapeutic modalities were 
found to induce good clinical outcomes when studied separately, so this study 
will be conducted to examine the effectiveness of virtual reality. 
              The greater demand for physical therapy for Paediatrics' signifies the 
need for more effective, safer and evident therapeutic modalities. The findings 
of this study will help both; the therapists and the children to save time, effort 
and reach the best results in concise times. 
 
Delimitations  
  
This study will be delimited to: 
• 30 children with spastic diplegia with age range from 6 to 12 years are enrolled 
in the study. 
•  Children will be randomly allocated into two equal groups; Group A will 
receive virtual reality and physiotherapy, while Group (B) will receive 
physiotherapy alone. 
•  All children will receive three sessions per week for twelve weeks. 
• Variables will be evaluated pre and post treatment for all child. 

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• Gross motor performance will be evaluated using Gross Motor Function 
Measure 88 (GMFM-88). 
•  Balance will be evaluated using Pediatric Balance Scale (PBS). 
 
Hypotheses 
  
This study will test the following hypothesis: 
There will be no significant the effects of virtual reality on gross motor 
performance and balance in children with spastic diplegia. 
 
Basic Assumptions 
It will be assumed that:  
 1. Assessment tools are valid and reliable. 
2. The participants will be cooperative during evaluation and treatment. 
3. All children will recognize and follow verbal order included in both testing 
and training techniques. 
4. Both genders will participate in the study. 
 
 
 
 
 
 
 
 
 
 
 
 

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CHAPTER II 
LITERATURE REVIEW 
The goal of the study is to see effect of virtual reality and physiotherapy 
in spider cage on gross motor performance and balance with diplegic children. 
This study reviews the following related titles as follows:  
1. Cerebral palsy.  
2. Spastic diplegia.  
3.Virtual reality. 
4.Gross motor performance. 
5.Balance. 
6.Gross Motor Function Measure 88 (GMFM-88). 
7.Pediatric Balance Scale (PBS).  
 
1. Cerebral palsy  
A. Definition  
Cerebral palsy (CP) refers to a group of disorders caused by faulty 
development or damage to motor areas in the brain that disrupts the brain's 
ability to control movement and posture (15).  
Cerebral palsy refers to a group of posture and movement disorders 
occurring as a result of a non-progressive lesion of the developing central 
nervous system. This damage to the immature brain leads to problems with 
balance, coordination, and movement (16). 
          Cerebral palsy is a motor impairment syndrome, which is a result of non-
progressive insults or anomalies in the early brain development period (17). 
 
 
 
 

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B. Etiology of Cerebral palsy 
Prenatal period: 
Prenatal period causes may be viral infections, radiation exposure, 
congenital brain malformation, problem of placental malfunctioning and 
maternal disorder (18). 
Perinatal period: 
Perinatal period causes may be pre-eclampsia, asphyxia or anoxia, 
trauma, intra-ventricular hemorrhage and respiratory disorders of prematurity, 
neonatal causes are infection, acute metabolic disorders and blood 
incompatibility (18). 
Post-natal period: 
Postnatal causes include head injury, infection, viral and bacterial 
meningitis, encephalitis, cardiovascular accident, malnutrition and toxins (14). 
Post-natal causes may be traumatic head injury, viral and bacterial meningitis, 
anoxia and toxins (18). 
 
C. Classifications 
Spastic-type CP is the most common type, comprising 85%-91% of all CP 
cases. Dyskinetic CP, which includes athetosis and dystonia, comprises 4%-7% 
of cases, whereas ataxic CP and hypotonic CP constitute 4%-6% and 2%, 
respectively (19). Spastic CP is further sub-classified into hemiplegia (38% of 
all spastic CP cases), diplegia (37%), and quadriplegia (constituting 24%). Thus, 
out of all the subtypes, hemiplegia is the most widely seen presentation in 
children with CP (19). 
 
2. Spastic diplegia. 
Children with spastic Cerebral Palsy (CP) have smaller and weaker 
muscles than healthy children. Muscle strength correlates with gait and motor 

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function and strength is more highly related to function than spasticity. Spastic 
muscles respond positively to strength training and strength gains have been 
shown to be similar or greater than those reported in the healthy population (20). 
Various studies have reported significant improvements in gait following 
strengthening programmes in terms of temporal parameters and Gross Motor 
Function Measure (GMFM) Dimension E (21).  
McPhail and Kramer found a direct correlation between the strength 
gained and functional improvement, but significant changes in gait kinematics 
following strength training appear difficult to achieve and have rarely been 
reported (22). 
 These strengthening studies, however, presume weakness is present, and 
reports specifically documenting the extent and distribution of muscle weakness 
in children with CP remain very limited. In Spastic Diplegia (SD), the most 
prevalent diagnostic category of CP, muscle strength has been quantified at the 
knee joint, and two lower limb strength profiles have been undertaken and 
compared with controls (23). 
3. Virtual reality (VR).  
Virtual reality is one of the novel technology-based approaches to treat 
balance and motor function in children with CP. It utilizes the interactive 
simulations created in computer hardware and software, in which the children 
find opportunities to engage in environments appearing real to them (24). 
The children get constant feedback about the movement and posture of 
their body in virtually immersive and non-immersive conditions that are 
contusive to motor learning (25). 
VR is reported to augment the desirable motor performance because of 
brain plasticity and brain reorganization through active participation, receiving 
feedback, and repetition of movements (26).  

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VR increases the exercise compliance level in achieving selective motor 
control and enhances conventional physiotherapy effectiveness (27). 
 Luna-Oliva et al10 showed improvement in the motor and processing 
skills, balance, gait speed, running, jumping, and manual dexterity in children 
with CP after 8 weeks of VR intervention. VR combined with physiotherapy 
appears to be a promising new treatment approach with wider future 
applications. Research over the past decade using VR intervention has reported 
benefits to children with CP. VR may assist children in acquiring new motor 
skills, sustaining the benefits from exercise, and enabling children to use their 
hands for more functional skills. If this is indeed, the case the combined 
approach may have the potential to greatly enhance the abilities of the child, 
improving independence 
alongside minimizing secondary implications 
associated with growth and development (28). 
4.Gross motor performance. 
The impairment in CP, including secondary impairments such as 
spasticity, muscle contracture, bone deformity, muscle weakness, and 
coordination disorders, is multifactorial and primarily affects the lower 
extremities, such as deficits in walking ability (29).  
The varying levels of impairment affecting children with CP can be 
described according to the Gross Motor Classification System. Physical 
inactivity in children with CP increases the risks of secondary problems such as 
pain, depression, social isolation, fatigue, pressure sores, and mobility 
limitations. Children with CP suffer from motor and cognitive disabilities, which 
usually require a long-term, multifaceted, and multidisciplinary approach (30).  
Children with CP also tend to have lower endurance, muscular strength, 
and cardiorespiratory fitness than the general population. The consequences of 
chronic muscle imbalance and the resultant deformities can cause increasing 
disability with age. One of the most significant problems faced by children with 

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CP is defective postural control. Maintaining postural control, which is required 
to perform activities of daily living, is often a major challenge for children with 
CP (31). 
5.Balance. 
Spastic diplegia, the most prevalent type of CP, is characterized by a wide 
range of ambulatory outcomes. It affects bilateral lower extremities more than 
upper extremities in most cases. As a result, walking function and corresponding 
balance control are impacted (32). 
 Balance control is important in the performance of most functional skills. 
Postural balance control in children with CP deteriorates as compared to 
typically developing children, most likely due to slowed and impaired 
development of neural motor control mechanisms together with the common 
secondary musculoskeletal abnormalities (33). 
 Balance control plays a central role in the motor dysfunction in children 
with spastic diplegic cerebral palsy. Reduced ability of children with spastic 
diplegia to adapt the sensory and motor components of postural control to 
changing task and environmental demands affects their proper response to 
balance disturbance, the recovery from unexpected threats to stability that refer 
to reactive balance control, functional deficits and the subsequent limitations in 
mobility. The amount of time required to recover stability following a balance 
threat (time of stabilization) and the mean area of centre of mass (COM) 
displacement per second during balance recovery are increased in these children 
(34).  
Due to poor postural control, the delineation ‘‘walking by falling’’ is 
especially true for children with CP. A heightened fear of falling can also lead to 
restriction of activities. Although not all falls can be prevented, those due to 
poor postural control can be reduced by improving balance performance (35). 

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 Falls may result in pain, injury and disability, and individuals may lose 
confidence in their ability to perform routine activities. Because a relation has 
been established between constraints on balance control and functional 
limitations in children with CP, increased efficiency of postural balance control 
may be necessary for them to facilitate functional performance (36). 
 Therefore, many researchers have suggested that balance training should 
be a crucial component of any rehabilitation program for these children. Such 
training can modify postural balance control by modulating the amplitude of 
muscle activities and speeding recruitment of the postural muscles (37). 
 While there are many easy-to-use functional scales for assessing posture 
balance control, advanced laboratory systems provide more detailed information 
on both static and dynamic balance. The balance platform is commonly 
employed in balance analysis laboratories for assessing postural balance with 
regard to oscillations from the centre of pressure in the anterior-posterior and 
medial-lateral directions (38). 
6.Gross Motor Function Measure 88 (GMFM-88). 
The GMFM is used by a variety of rehabilitation specialists for clinical 
and research purposes to measure change over time, and the effectiveness of 
interventions to affect change (39). 
 The standardized measures provide objective information in an easy-to-
understand format. As stated earlier, the GMFM has become the standard tool 
for measuring change in gross motor function over time for children with CP. 
Given its unique purpose, its wide use, and the amount of research that has been 
conducted using this outcome measure, examining the usefulness as related to 
intervention is important to measure change over time for children with CP. the 
Gross Motor Function Measure (GMFM) and its subsequent revisions, has 
become the most common functional outcome measure used by rehabilitation 
specialists to measure gross motor functioning in children with CP and other 

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neurologically based conditions, such as Down syndrome and traumatic brain 
injury (40).  
This tool showed high validity at 0.91 when applied, the GMFM-88 was 
reported to be a useful method for measuring gross motor function in children 
with CP because of its high reliability, with inter-rater reliability of 0.77, test–
retest reliability of 0.88, and intra-rater reliability of 0.68 (41). 
 
7.Pediatric Balance Scale (PBS).   
The PBS is a standardized tool for testing balance. this tool developed by 
modifying the Berg Balance Scale to test the functional balance of the school-
age population with mild-to-moderate motor impairment. The tool has been 
confirmed to be reliable in terms of both intra-rater reliability (intraclass 
correlation coefficient (ICC) = 0.99) and inter-rater reliability (ICC = 0.99). The 
items can be measured within 15 min and do not require the use of specialized 
equipment (42). 
 
 
 
 
 
 
 
 
 
 
 
 

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CHAPTER III 
SUBJECTS, MATERIALS, AND PROCEDURES 
I. Subjects 
 The current study will target children with spastic diplegia. Patients will 
be recruited, for convenience, in three physiotherapy clinics. The study will 
include three governmental hospitals at Kafr-Elsheikh governorate and El 
bouhira, comprising desouq general hospital, shubrakhit general hospital, and 
Pediatric Out-patient Clinic of Faculty of Physical Therapy, Kafr-Elsheikh 
University. 
 
Sample size calculation: 
 
Using G-power version 3.1.9.7 for windows and regarding t-test study, 
alpha level of 0.05, confidence interval 80% and effect size of 1.135 calculated 
from the previous study of Krishna et al. (43), the total sample size will be 28 
children (fourteen in each group), (Figure 1). We will increase number to be 30 
children (Fifteen in each group) to avoid any drop out. 
 
To avoid selection bias, the children will be randomly allocated by simple 
random method via choosing one of two wrapped cards representing the two 
treatment groups, which are: 
• Group (A): will receive virtual reality in addition to the traditional 
exercise program. 
• Group (B): will receive traditional exercise program. 

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    Figure 1: Sample size calculation in G-power software program. 
 

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Inclusion criteria:  
            Children will be included in the study if they fulfil the following criteria: 
1. A medical diagnosis of spastic diplegic CP made by pediatricians or pediatric 
neurologists. 
2. Children with spasticity grades ranged from 1 to 2+ according to Modified 
Ashworth scale (MAS). 
3. Their age range from 6 to 12 years. 
4. Children who can sit on the chair with good balance and recognize and follow 
verbal orders and commands included in both testing and training techniques. 
Exclusion criteria: 
Children with a permanent spastic diplegia, who might have one or more 
of the following, will be excluded: 
1. They had a permanent deformity (bony or soft tissue contractures). 
2. Children having visual or auditory defects.  
3. Current hospitalization for urgent medical reasons. 
4. Severe mental retardation.  
5. Children who will undergo fewer than twelve regular sessions of physical 
therapy at their place will not be included in the survey. 
6. Children with history of epileptic seizure or any diagnosed cardiac or 
orthopedic disability that may hinder assessment methods and treatment. 
Ethical consideration 
The study's protocol will be reviewed and approved by the Research 
Ethical Committee, Faculty of Physical Therapy Kafrelsheikh University. 
Assessment instruments 
1. . Modified Ashworth scale: to measure the degree of spasticity to enroll 
children in the study, Appendix I. 

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2. Gross Motor Function Measure 88 (GMFM-88) to measure Gross 
motor performance. Appendix II. 
3.  Pediatric Balance Scale (PBS) to measure Balance. Appendix III. 
4.  Virtual reality glasses (figure 2). 
5. Smart display. 
6. Spider cage for suspension (figure 3). 
7. Smart phone for virtual reality games. 
 
                   Figure 2:  virtual reality glasses  
 
Procedure  
  A. Patients preparation 
1. To start the treatment program, an agreement will be taken from the 
manager of the outpatient clinics, Faculty of Physical Therapy Kafrelsheikh 
University. 
2. To provide safe and effective treatment, all interventions, evaluation and 
recording of all measurements at the beginning and at the end of the study 
will be performed by the primary investigator (the same therapist). 
3. All the children parents fitted the inclusion criteria, will be given 
explanation of the treatment protocol in their understandable language and 

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they will allow their children to participate after signing a consent form, 
Appendix IV. 
4. All the children demographic and outcome measures data will be collected 
in especially well-designed sheets, (Appendix V) and (Appendix VI). 
 
B. Assessment procedures 
1. Evaluation of gross motor performance using GMFM-88: 
The Gross Motor Function Measure (GMFM) 88 will be used to 
determine the severity of each case and to assess the child’s motor performance 
in five dimensions: lying and rolling (17 items); sitting (20 items); crawling and 
kneeling (14 items); standing (13 items); and walking, running, and jumping (24 
items). All items will be checked and scored before interpretation of child’s 
performance in each dimension. Scores of each dimension will be expressed as 
percentage of maximum scores for that dimension. Total score will be obtained 
by averaging percentage scores across the 5 dimensions. Individual dimensions 
of GMFM-88 can be administered depending on the child’s current level of 
function (41). 
2. Evaluation of balance using Pediatric Balance Scale (PBS): 
The PBS is a standardized tool for testing balance. The items can be 
measured within 15 min and do not require the use of specialized equipment. 
The Pediatric Balance Scale is a modified version of the Berg Balance Scale that 
is used to assess functional balance skills in school-aged children. The scale 
consists of 14 items that are scored from 0 points (lowest function) to 4 points 
(highest function) with a maximum score of 56 points (42). 
C. Treatment procedures: 
1. Treatment protocol in Group A, virtual reality protocol: 
• A specialized VR glasses will be used and VR games application. 

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• Smart phone used can screen mirroring to lcd display. 
• During use of VR glasses therapist observe what child do in the game. 
• The child stands in the spider cage at treatment period (figure 3). 
• Use 360-degree video. 
• The treatment duration will be 30 minutes. 
• The treatment protocol will be repeated 3 times per week for 12 weeks. 
 
                                               Figure 3: spider cage 
2. The traditional exercise program (given to both groups): 
• The training program of gross motor performance: 
All the tests in gmfm 88 will be used as a treatment program and exercises such 
as basic rolling, sitting, crawling and walking. 
• The selected physical therapy program: 
1. Neurodevelopmental approach: aims to facilitate typical motor development 
and function and to prevent secondary impairments (figure 4). 
2. Approximation: aims to control spasticity and stimulate the joint 
mechanoreceptors (figure 5). 
3. Stretching exercise: aims to maintain length and flexibility of shorten muscles 
(figure 6). 
4. Strengthening exercise: aims to improve the functional ability (figure 7). 

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5.Spider suspension exercise for 30 minutes (figure 8). 
5. Gait training activities: aims to improve balance (figure 9). 
6. Balance training program: aims to improve balance (figure 10). 
• The treatment protocol will be repeated for 12 weeks. 
 
Figure 4: Neurodevelopmental approach 
 
Figure 5: Approximation 
 
 
Figure 6: Stretching exercise 

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Figure 7: Strengthening exercise 
 
Figure 8: Spider suspension exercise 
 
Figure 9: Gait training activities 

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Figure 10: Balance training program 
 
Data collection and statistical analysis: 
Data of all children in both groups will be collected and include: 
1. Name, serial number and age (years). 
2. gross motor performance pre- and post-treatment with GMFM 88. 
3. balance pre and post treatment with PBS. 
B. Statistical analysis 
For testing the study hypotheses, the following statistical methods will be used: 
1. Descriptive statistics (mean and standard deviation) of the demographic data 
of all patients in both groups. 
2. The suitable statistical tests will be used according to the nature of the 
collected data. 
3. Level of significance for all tests will be set at p-value ≤ 0.05. 
4. The statistical package for social sciences (SPSS) version 26 for windows 
(Armonk, NY: IBM Corp) will be used for data statistical analysis. 
 
 

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APPENDICES 
Appendix I 
Modified Ashworth Scale 
 
 
 
 
 
 
 
 
 
 
 

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Appendix II 
 

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Appendix III 
Pediatric Balance Scale (PBS) 
 

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-31- 
 
 
 

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Appendix V 
Demographic Data Sheet 
• Name: 
• Age: 
• Gender: 
• Diagnosis: 
• Date of onset: 
• Type of onset: 
• Type of CP: 
• Starting date of physical therapy: 
• Main problems: 
• E-mail address: 
• Telephone number: 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Appendix VI 
Outcome measures Sheet 
 
• Child name 
 
• Serial number 
 
  
  Outcome measures  
Pre-Treatment 
Evaluation 
Date….../…./….…. 
Post-Treatment  
Evaluation 
 
Date….../…. /….…. 
 
GMFM 88 
 
 
 
PBS 
 
 
 
 
 
 
 
 
 
 
 

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