Effectiveness of Interactive Computer Play on Trunk Control and Gross Motor Function in Children With Cerebral Palsy: a Pilot Randomized Controlled Trial
Phase: NA
Conditions: Cerebral Palsy, Exercise Therapy, Postural Balance
Sponsor: The Hong Kong Polytechnic University

 
Section 13: Proposed Research Project 
1 
 
 
 
Effectiveness of interactive computer play on trunk control and gross motor function 
in children with cerebral palsy: a pilot randomized controlled trial 
 
NCT number: NCT02975804 
 
Document date: April 10, 2018 
Document revised date: July 18, 2019 

 
Section 13: Proposed Research Project 
2 
PROPOSED RESEARCH PROJECT 
a) 
Title:   
 
Effectiveness of interactive computer play on trunk control and gross motor function in 
children with cerebral palsy: a pilot randomized controlled trial 
 
 
b) 
Introduction:  
 
Cerebral palsy (CP) is the most common physical disabilities in childhood, affecting 2 to 2.5 per 1000 
live-births worldwide[1] and about 1.3 per 1000 live-births in Hong Kong.[2] It is a non-progressive lesion 
of the developing central nervous system affecting the control of movements and postures in the 
children.[3] Children with CP are usually classified using the Gross Motor Function Classification 
System (GMFCS) according to age-specific gross motor function.[4] It is an ordinal grading system of 
five levels (I to V), in which self-initiated movements, such as sitting, standing or walking, are 
described in relation to different age groups. Distinctions between levels I to V are based on 
assessment of functional abilities and reliance on assistive devices (such as walking aids or wheeled 
mobility). Children of levels I and II can generally walk without aids while children of level III can walk 
with aids for short distances but usually choose wheeled mobility in community settings. Children at 
level IV have limited motor ability in assisted standing, stepping, and transfers. Children classified as 
level V are completely dependent on others for transportation in a wheelchair and lack antigravity 
postural control.[4] Numerous studies have shown that children with CP, regardless their GMFCS 
levels, demonstrate problems in their postural control in sitting[5] and standing[6] positions, which in turn 
affect their function and participation in daily life. The main deficits in postural control in sitting for 
children with CP are lack of ability to recruit direction-specific muscles in more severe children 
(GMFCS levels IV and V) or inability to fine-tune the degree of muscle contraction according to 
specific situations in less disabled children when their sitting balance is challenged.[5] Excessive 
contraction of antagonists is a common compensatory strategy.[5] In standing, for those more abled 
children with CP, i.e. GMFCS levels I to II, when their balance is challenged, the children will use more 
proximal muscles in the hips to maintain their balance.[6] As in sitting, contraction of both agonist and 
antagonist muscles around the joint is a common compensation for poor postural control in standing. 
These ineffective strategies to compensate their balance in sitting or standing positions will affect the 
children’s daily function such as desk work at school, transfers and ambulation.[7]  
 
Postural control involves controlling the body’s position in space for stability and motility.[7] Good 
postural control around the trunk or ‘trunk control’ in short, allows an individual to perform different 
tasks in an upright and vertical posture without losing the balance.[7] The control of trunk to maintain 
balance in either sitting or standing positions is usually tested in the following three conditions: (1) 
static balance- an ability to maintain a static posture without external support; (2) anticipatory balance- 
an ability to maintain the posture after internal perturbations such as self-initiated reaching 
movements; and (3) reactive balance- an ability to regain balance after external perturbations.[7] 
Assessment of trunk control in children is commonly part of a motor assessment such as Peabody 
Developmental Motor Scale or Bruininks-Osteretsky Test of Motor Proficiency.[7] The main limitation of 
these motor assessments is that the trunk is considered a one unit during a motor act, despite that 
there are different segments in the spine.[8] For example, it is unable to differentiate which region of 
trunk control, namely upper, middle or lower thoracic, upper or lower lumbar or full trunk, needs to be 
developed before a child is able to use his hands in sitting in play or feeding activities without losing 
balance. Preliminary findings in very young infants have shown that infants with lumbar control had 
better movement quality in reaching actions when compared to those with thoracic control only.[9] It 
seems that specific outcome measures on trunk control are necessary to demonstrate improvement in 
movement quality like this. There are specific outcome measures assessing balance, an indication of 

 
Section 13: Proposed Research Project 
3 
trunk control in recovering stability after internal or external perturbations such as Pediatric Reach Test 
(PRT), Pediatric Balance Scale (PBT), Trunk Control Measurement Scale, Segmental Assessment on 
Trunk control (SATCo) and Sitting Assessment for Children with Neuromotor Dysfunction (SACND). It 
has been found very few of the commonly used outcome measures on balance have covered 
assessing all three aspects of balance as mentioned above.[10] Most of these outcome measures 
require the children to be able to sit independently with or without hand support, making it unsuitable 
for children with CP of GMFCS levels IV and V.[10] Furthermore, most of these outcome measures 
have the same limitation in considering the trunk as one whole unit, not consisting of different regions. 
Among all the commonly used assessment of trunk control, SATCo is a recently refined assessment 
on segmental trunk control in children.[8] The child’s trunk control is examined by progressively 
reducing the trunk support from the shoulder girdle to the pelvis in order to assess the head control, 
upper thoracic, mid-thoracic, lower thoracic, upper lumbar, lower lumbar and full trunk control.[8] The 
trunk control is tested under 3 different conditions in sitting: to maintain the posture (static control), 
during voluntary head movements (active control) and recovery of trunk control after a disturbance of 
balance by a nudge (reactive control).[8] The preliminary results of the SATCo showed a high 
inter-rater reliability (ICC ≥ 0.8) and moderate to good correlations with other established motor 
assessments (r from 0.65 to 0.88).[8] Besides assessing the trunk in different segments, SATCO is one 
of the rare ones being able to assess reactive balance.[10] It has been recommended that to increase 
the comprehensiveness in assessing the balance mechanism in children with CP, researchers can use 
the SATCo in combination of outcome measures assessing more dynamic sitting balance, such as the 
PRT.[10] 
 
With the advances in computing technology, interactive computer play (ICP) has become popular in 
rehabilitation for people with motor impairments, including children with CP.[11-14] During an ICP, a child 
interacts and plays with virtual objects in a computer-generated environment, through the use of a 
computer console or platform and the software, allowing the child to control the games through certain 
body movements.[13]  Because the computer games are fun and enjoyable, the child will repeat the 
required body movements in numerous times so as to get a high score in the game without losing the 
interest. These numerous repetitions (essentially mass practice) and feedback from the game scores 
(knowledge of performance and results) are important in motor learning and enhancing 
neuroplasticity.[15] Hence, ICP may be a feasible way to improve trunk control in children with CP, in 
addition to the conventional therapies. Up to date, there are six published studies using ICP or virtual 
reality in improving balance in children with CP.[16-21] 
 
In a small randomised controlled trial (RCT) (n=6), children with CP were randomly allocated to an 
intervention group, who received two sessions of ICP for 90 minute per session for 4 weeks when the 
control group received the regular therapies.[21] All three children in the intervention group showed 
improvement in their postural control in terms of postural tone, proximal stability, postural alignment 
and two of them showed extra improvement in their balance as measured using the SACND. No 
statistical analysis was performed in this study due to small sample size.[21] In the case study by 
Deutsch et al (2008),[16] a 13-year-old boy with CP received 11 training sessions over 4 weeks with 60 
to 90 minutes per session using a commercially available ICP (Nintendo Wii). It was found that his 
postural control was improved in increasing more symmetrical weight-bearing on both lower 
extremities and decreasing in body sway after the intervention.[16] Sharan and colleagues (2012) used 
the Nintendo Wii Fit as an intervention for a group of 16 children with CP, 3 times per week for 3 weeks 
along with their conventional rehabilitation modalities in their RCT.[19] Both the intervention and control 
groups improved significantly in their scores in the PBT and the intervention group had significantly 
higher score than the control group.[19] In another small RCT by Wade and Porter (2012), 13 children 
with CP of GMFCS levels IV and V were randomly allocated to the intervention and control groups and 

 
Section 13: Proposed Research Project 
4 
then crossed over.[20] Children in the intervention group practised active trunk movements through a 
purposely built force platform connected to computer games in sitting for 3 months (no intervention 
dosage provided). Significant differences were found in the shoulder girdle position and spinal profile 
and significant increase in the overall scores at rest (specifically associated postural reaction) and 
during reaching (specifically the proximal stability rating) according to the SACND after intervention.[20] 
The Nintendo Wii Fit was used again in a repeated-measure multiple single-subject study conducted 
by Jelsma and colleagues (2013).[17] A group of 14 children with hemiplegia CP of GMFCS levels I and 
II were randomly allocated to start the intervention first or 2 weeks later.  During the intervention, the 
children received training using the console, four times a week for 25 minutes per session for three 
weeks. Significant improvement in balance, as measured with the modified Bruininks-Osteretsky Test 
of Motor Proficiency Version 2 (BOT2), was found immediately and 2-month post-intervention but no 
changes were found in the running, agility and speed in the BOT2 and Timed up and downstairs.[17] 
However, in a small RCT, 18 children with CP of GMFCS levels I or II were randomised into an 
intervention group and a control group and then crossed over after five weeks.[18] The children 
received practice on the Nintendo Wii Fit Balance games at least 30 minutes, five days a week during 
the intervention period. No significant difference was found in the change of centre of pressure during 
the modified Sensory Organization Test, in the muscle responses after perturbations and in the control 
of anterior-posterior and medial-lateral directions in the rhythmic weight shift test between the 
intervention and control groups.[18] In summary, promising though conflicting results were found 
among these studies whether ICP is effective in improving trunk control in children with CP. The main 
limitations of these studies are the overall low levels of study quality, small sample sizes and 
heterogeneous population groups under the umbrella term CP. In fact, similar conclusions for future 
studies with larger sample sizes and rigorous study designs have been echoed from four recent 
systematic reviews on the topic.[11-14] 
 
One of possible reasons for the conflicting conclusion on the use of ICP in rehabilitation for children 
with CP may be lack of sensitive outcome measures to capture the specific changes in the trunk 
control post-intervention. The above-mentioned studies were either using general motor assessments 
or outcome measures with unknown psychometric properties to assess the posture of the participants. 
Besides, when the child received the ICP intervention in a standing position, compensatory strategies, 
due to uncontrolled degrees of freedom in lower limbs, might be used to maintain their trunk control in 
this more challenging position than a sitting position. These compensatory strategies may in turn, 
water down the overall effect of the ICP intervention on the trunk control. This may have explained the 
negative results from the study by Ramstand et al (2012).[18] Most of these studies examined only one 
or two aspect of the trunk control as testing the static or anticipatory balance of the children. 
Furthermore, the commercially available gaming consoles, such as Nintendo Wii Fit, are not 
specifically developed for children with CP to elicit targeted movements to overcome their impairment 
and the software may not be sensitive enough to translate the subtle movement changes to an 
increase in the game scores as well to an adequate challenge for these children.[15] 
 
Tymo (Tyromotion, Austria, www.tyromotion.com) is a wireless force plate detecting the movement of 
the centre of pressure, either in a sitting or standing position. Force and weight distribution can be 
measured using the software provided with the Tymo in these two positions. During the assessment, 
the user will move the trunk forward, backward and sideways as far as they can. The amplitude of the 
force and weight distribution between the two sides of the body will be recorded. This information will 
be used when the user uses the Tymo as a balance training module, in which the user will move the 
trunk forward, backward and sideways to participate in a computer game. For example, the user will 
move their trunk in different directions so as to manoeuvre a basket to catch the falling apples or 
manoeuvre the hot-air balloon through an obstacle course (Tables 1 and 2). The difficulties of the 

 
Section 13: Proposed Research Project 
5 
game will be adjusted according to the information provided during the assessment so that the user 
needs to move their body accordingly in different directions without losing their balance. This 
equipment is specially designed for rehabilitation for people with movement disorders, hence unlike 
the commercial games, there are no flashing lights or sudden noises during the games. To our best 
knowledge, there has been no study published using Tymo as an intervention for training trunk control 
in children with CP. 
 
 
c) 
Aims and Hypotheses to be Tested: 
 
Conducting a pilot single-blinded randomised controlled trial (RCT), the overall objective is to 
investigate the effect of a 6-week training programme using an interactive computer play training tool 
on the segmental trunk control, sitting and/or standing balance and gross motor function in children 
with CP. 
The hypotheses to be tested are: 
(1) That after 6 weeks of training using the interactive computer play training tool, Tymo, the children 
with CP will show significant improvement in their segmental trunk control as demonstrated in the 
SATCo. 
(2) That after 6 weeks of training using the interactive computer play training tool, Tymo, the children 
with CP will show significant improvement in their balance in sitting and/or standing positions as 
demonstrated in the PRT. 
(3) That after 6 weeks of training using the interactive computer play training tool, Tymo, the children 
with CP will show significant improvement in gross motor activities as demonstrated in the GMFM 88. 
(4) That after 6 weeks of training using the interactive computer play training tool, Tymo, children with 
CP, who are able to ambulate independently with a walking aid, will show a significant improvement in 
the distance covered in 2 minutes. 
 
 
d) 
Plan of Investigation: 
 
(i)  Subjects  
 
 
Selection criteria:  
(1) Children with a diagnosis of CP will be of GMFCS levels III to IV, who in general, require 
walking aid (level III) during ambulation and with limited walking ability (level IV).[4] Aiming to 
achieve a higher homogeneity of the recruited children, for those with level III, only those 
requiring physical assistance to climb stairs will be recruited and so it is believed that only those 
with lower motor ability, i.e. similar to level IV, will be included. 
(2) Children, with non-CP physical disabilities, will have similar gross motor function as in (1). 
(3) Aged from 6 to 12 years old and  
(4) Able to follow instructions to interact in simple computer games 
Sample size calculation: There is no previous published study using the primary outcome 
measure (see below under Methods) to examine the effect of the ICP on trunk control in this 
population group, hence, no sample size calculation is possible based on previous data. Thus it 
is estimated that 20 children with 10 children in each arm for this pilot RCT is appropriate and 
feasible. The sample size will be the largest among the previous studies in this area. 
Exclusion criteria: 
(1) Children with epilepsy/ seizures that could be elicited by flashing lights or sudden loud noises 
from computer screens 
 
(ii)  Methods   
 
 
Outcome measures (OM) used in this proposal include:  
Primary study outcome: 
(1) Segmental Assessment on Trunk control (SATCo)[8] assessment on the child’s segmental 
trunk control by progressively reducing the trunk support from the shoulder girdle to assess the 

 
Section 13: Proposed Research Project 
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head control, through support at the axillae (upper thoracic), inferior scapula (mid-thoracic), 
lower ribs (lower thoracic), below ribs (upper lumbar), pelvis (lower lumbar) and no support to 
measure full trunk control.[8] The trunk control is tested under 3 different conditions in sitting: to 
maintain the posture (static control), during voluntary head movements (active control) and 
recovery of trunk control after a disturbance of balance by a nudge (reactive control).[8] 
 
Secondary study outcomes: 
(2) Pediatric Reach Test (PRT)[22] assessment on balance in sitting and standing positions. The 
distance how far the child can reach forward, to right and to left will be measured in sitting and 
standing. High construct validity has been shown between the PRT in standing and a laboratory 
test of steadiness in quiet stance (r= 0.79) and age (r= 0.83) in a group of 19 typically developing 
children. High construct validity has also been shown between the total PRT score and GMFCS 
level (r= 0.88) among a sample of 10 children with cerebral palsy. Test-retest reliability and 
inter-tester reliability with children with cerebral palsy was moderate to high (intraclass 
correlation coefficients= 0.54 to 0.88 and 0.50 to 0.93 respectively)[22] and 
(3) Gross Motor Function Measure 88 (GMFM 88)[23] assessment on general gross motor 
function in various positions including lying, sitting, 4-point kneeling, high kneeling and standing.  
The intra- and inter-rater reliability of the GMFM 88 have been shown to be very high (ICC= 0.99 
in both cases).[23] 
(4) 2-minute walk test[24] distance covered in a period of 2 minutes with self-chosen comfortable 
speed will be measured. The walk test has been shown to have high test-retest, intra- and 
inter-rater reliability.[24] 
(5) The height and weight of the children 
 
(iii) Study design  
 
 
20 children with CP or similar physical disabilities will be recruited from 2 special schools for 
children with physical disabilities in Hong Kong for this pilot RCT (see ‘Existing facilities’ for 
details). Informed consent will be sought from the parents or guardians before the study will 
commence. After the initial assessment, all study children will be randomly allocated into a 
control group or treatment group (10 children in each arm) using a ‘draw card from the hat’. The 
randomization will be separately done in each school so as to take into account the 
heterogeneity of the children and treatment regime in each school. The children in the treatment 
group will receive training on their trunk control using the Tymo in sitting 4 times per week for 20 
minutes per session. The treatment will last for 6 weeks. All study children will continue their 
usual therapies at school but will be asked to stop playing any interactive computer play, which is 
designed to train balance such as Nintendo Wii balance board, during the study period. As there 
is no strong research evidence that commercial computer games are effective in improving the 
balance for children with CP and this type of commercial computer play is not a routine training 
exercises for balance in the treatment sessions at the schools, it is believed that discontinuing 
this type of ‘training’ for 6 weeks would not cause detrimental effect on the balance of the study 
children. 
All the assessment will be carried out by a blinded assessor (PA), who is not aware of the group 
allocation of the children. All the children will be assessed at the beginning, and 3, 6 and 12 
weeks after the commencement of the intervention. The last assessment aims to examine the 
medium-term effect on their trunk control post-intervention. 
Intervention: 
All participating children will be calibrated using the Tymo in a static sitting position in each 
treatment session by the research staff. Force and weight distribution will be calibrated by asking 
the child to move the trunk forward, backward and sideways as far as s/he can. The amplitude of 
the force and weight distribution between the two sides of the body will be recorded. These 

 
Section 13: Proposed Research Project 
7 
information will be used to set up the Tymo as a balance training module (the intervention) by the 
software, in which the child will move the trunk forward, backward and sideways to participate in 
a computer game in a sitting position (Tables 1 and 2). The child will be allowed to choose which 
game they want in each treatment session and they have to stay on the same game for at least 
10 minutes before changing to another game. In other words, the child will have a maximal 
choice of 2 computer games in each treatment session. All children will start at a medium level of 
difficulty. Only if the child is unable to score any point in 3 trials in a row, the difficulty level will be 
reduced to one level down. Similarly, if the child scores full points in 3 trials in a row, the difficulty 
level will be increased to one level up. The progression of the intervention will then be closely 
monitored by the research staff. A logbook will be used for each child to record the level of 
difficulty in each treatment session, the number of treatment sessions, duration of each session 
and general comments on the child in each session during the intervention phase. The 
intervention will be supervised by a research assistant, who will be employed for the study. 
 
 
(iv) Data processing and analysis  
 
 
Statistical analyses: SPSS for Windows (version 20) will be used to analyse the results. Mann 
Whitney U test will be used to compare the results of the OM(1) between the intervention and 
control groups and independent t-test for OM(2) to OM(5). The statistical significance level is set 
at p < 0.05. 
 
[Word Court: 3814 ]  
 
 
e) 
Existing Facilities:   
 
Both the PA and co-applicant are very experienced paediatric physiotherapists with over 20 years of 
experience in managing young children with movement disorders. The mother institution of the PA is 
the only University in Hong Kong running the undergraduate degree in Physiotherapy and the 
Department of Rehabilitation Sciences at the Hong Kong Polytechnic University has abundant 
experiences in conducting research studies on individuals with movement disorders. Space will be 
provided for data storage (both hard and soft data) and statistical software will be provided for the 
present study. The co-applicant is the developer of the SATCo and is active in conducting research 
studies with collaborating researchers in USA and Denmark in examining trunk control in children with 
CP. 
The Medical Technologies Ltd is the sole agent in Asia, which manages the Tymo Therapy plate. The 
agent will provide training and support in using the Tymo Therapy plate to all relevant personnel in this 
study in Hong Kong, as part of their quote on the equipment. 
Initial contact has been made with the physiotherapists in-charge at 3 special schools in Hong Kong, 
namely the John F Kennedy Centre, the Red Cross Princess Alexandra School and Pui Oi School (all 
are special schools for children with physical disabilities), who all show interests to participate in the 
study. Specifically, the study children will be recruited from the first two schools and these schools will 
accommodate the Tymo Therapy Plate on site during the intervention phase. The physiotherapists 
in-charge tentatively believed that recruitment of 20 children with CP or similar physical disabilities is 
feasible in the first 2 schools. In case the recruitment falls short or a substantial drop-outs during the 
study period, Pui Oi School would be approached for further recruitment. 
 
 
f) 
Justification of Requirements: 
 
Staffing- a Physiotherapist will be employed to supervise the children to carry out the ICP at respective 
schools. Salary for this personnel is set as point 19 (median point of Physiotherapist II) of MPS, i.e. 
$32,560 per month + $1,500 MPF per month for 6 months= $204,360 because the personnel is 
required to have experience in managing paediatric clients with physical disabilities and has 

 
Section 13: Proposed Research Project 
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understanding of postural control in children. 
Equipment- hiring Tymo Therapy plate and associated equipment= $61,405. The Medical 
Technologies Ltd is the sole agent in Asia, which manages the Tymo Therapy plate and this is the only 
equipment, as far as the PA knows, that provides this type of training on trunk control using the 
concept of ICP. The quote provided by the agent includes assembling, transporting and disassembling 
the equipment across the 2 special schools. 
Travel cost for intervention= $100 per returned trip X 5 days X 16 weeks = $8,000 
Travel cost for blinded assessments= $100 per returned trip X 4 assessments per child X 10 trips 
(assessing 2 children per day)= $4,000 
Gifts to participating children= $20 X 20 children = $400 
External hard drive for data storage= $500 
Total= $278,665 
 
 
g) 
Purpose and Potential: 
 
Cerebral palsy (CP) is the most common physical disability in childhood, affecting about 1.3 per 1000 
live-births in Hong Kong.  Regardless the severities of the disability, children with CP have inadequate 
control in their trunk, affecting their balance in maintaining their posture in sitting and standing 
positions and regaining their balance if challenged in both positions. With the advance in computing 
technology, interactive computer play (ICP) has become popular in rehabilitation for people with motor 
impairments, including children with CP. During an ICP, a child interacts and plays with virtual objects 
in a computer-generated environment, through the use of a computer console or platform and the 
software, allowing the child to control the games through certain body movements. Because the 
computer games are fun and enjoyable, the child will continuously repeat the required body 
movements so as to get a high score in the game without losing the interest. The numerous repetitions 
and feedback from the game scores fulfil the principles of motor learning. Hence, ICP may be a 
feasible way to improve trunk control in children with CP, in addition to the conventional therapies. Up 
to date, there is controversial evidence in using ICP or virtual reality in improving balance in children 
with CP. The main reasons for inconclusive effectiveness of ICP in improving trunk control on this 
population group include low quality of research study designs, small sample sizes and insensitive 
outcome measures. In addition, use of commercial ICP may not be able to specifically train the trunk 
control and translate the improvement in the trunk control into the game scores. 
The present study is designed to overcome these shortfalls. It is a single blinded controlled trial with 
20 children with CP in each arm. The intervention, ICP is a specifically designed balance training tool 
for rehabilitation (www.tyromotion.com). One of the outcome measures used is an assessment of 
segmental trunk control, which will capture subtle changes in trunk control in different segments, 
instead of considering the whole trunk as one unit. The targeted children with CP are relatively 
homogeneous. It is the first of the series in using ICP for children with movement disorders. If the 
intervention is proven to be effective, ICP may be an adjunct to the conventional Physiotherapy to 
children with movement disorders. With the future Hong Kong Children’s Hospital in mind, the ICP 
may be an essential piece of equipment in the rehabilitation program in the wards. Furthermore, future 
studies on different population groups with movement disorders, such as Developmental Coordination 
Disorders and children with preterm birth, will be conducted using the ICP. 
Results of the present study will be presented in local and overseas conferences, e.g. Hong Kong 
Physiotherapy Association conference, American Academy of Cerebral Palsy and Developmental 
Medicine conference etc. Results will also be submitted for publication in high ranking journals such as 
Developmental Medicine and Child Neurology (impact factor 3.292) and Journal of Physiotherapy 

 
Section 13: Proposed Research Project 
9 
(impact factor 2.894). 
 
 
h) 
Key References:   
 
1. Oskoui, M., et al., An update on the prevalence of cerebral palsy: a systematic review and 
meta-analysis. Developmental Medicine and Child Neurology, 2013. 55(6): p. 509-519. 
2. Yam, W., et al., Prevalence study of cerebral palsy in Hong Kong children. Hong Kong Medical 
Journal, 2006. 12(3): p. 180-184. 
3. Mutch, L., et al., Cerebral palsy epidemiology: where are we now and where are we going? 
Developmental Medicine & Child Neurology, 1992. 34: p. 547-551. 
4. Palisano, R.J., et al., Development and reliability of a system to classify gross motor function in 
children with cerebral palsy. Developmental Medicine & Child Neurology, 1997. 39: p. 214–23. 
5. Carlberg, E.B. and M. Hadders-Algra, Postural control in sitting children with cerebral palsy, in 
Postural Control: a Key Issue in Developmental Disorders, M. Hadders-Algra and E.B. Carlberg, 
Editors. 2008, Mac Keith: London. p. 74-96. 
6. Woollacott, M.H. and P. Crenna, Postural control in standing and walking in children with cerebral 
palsy, in Postural Control: a Key Issue in Developmental Disorders, M. Hadders-Algra and E.B. 
Carlberg, Editors. 2008, Mac Keith: London. 
7. Hadders-Algra, M. and E.B. Carlberg, eds. Postural Control: a Key Issue in Developmental 
Disorders. 2008, Mac Keith Press: London. 
8. Butler, P.B., et al., Refinement, reliability, and validity of the segmental assessment of trunk control. 
Pediatric Physical Therapy, 2010. 22(3): p. 246-57. 
9. Rachwani, J., et al., Segmental trunk control acquisition and reaching in typically developing infants. 
Experimental Brain Research, 2013. 228(1): p. 131-9. 
10. Banas, B.B. and E.J.R. Gorgon, Clinimetric properties of sitting balance measures for children with 
cerebral palsy: a systematic review. Physical & Occupational Therapy in Pediatrics, 2014. 34(3): p. 
313-34. 
11. Fehlings, D., et al., Interactive computer play as "motor therapy" for individuals with cerebral palsy. 
Seminars in Pediatric Neurology, 2013. 20(2): p. 127-38. 
12. Laufer, Y. and P. Weiss, Virtual reality in the assessment and treatment of children with motor 
impairment: a systematic review. Journal of Physical Therapy Education, 2011. 25(1): p. 59-71. 
13. Sandlund, M., S. McDonough, and C. HÄGer-Ross, Interactive computer play in rehabilitation of 
children with sensorimotor disorders: a systematic review. Developmental Medicine & Child 
Neurology, 2009. 51(3): p. 173-179. 
14. Snider, L., A. Majnemer, and V. Darsaklis, Virtual reality as a therapeutic modality for children with 
cerebral palsy. Developmental neurorehabilitation, 2010. 13(2): p. 120-128. 
15. Gordon, A.M. and R.A. McGill, Motor Learning: Application of Principles to Pediatric Rehabilitation, 
in Physical Therapy for Children, S.K. Campbell, R.J. Palisano, and M.N. Orlin, Editors. 2012, Elsevier 
Saunders: Missouri USA. p. 151-174. 
16. Deutsch, J.E., et al., Use of a low-cost, commercially available gaming console (Wii) for 
rehabilitation of an adolescent with cerebral palsy. Physical Therapy, 2008. 88(10): p. 1196-207. 
17. Jelsma, J., et al., The effect of the Nintendo Wii Fit on balance control and gross motor function of 

 
Section 13: Proposed Research Project 
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children with spastic hemiplegic cerebral palsy. Developmental neurorehabilitation, 2013. 16(1): p. 
27-37. 
18. Ramstrand, N. and F. Lygnegard, Can balance in children with cerebral palsy improve through use 
of an activity promoting computer game? Technology and Health Care, 2012. 20(6): p. 501-10. 
19. Sharan, D., et al., Virtual reality based therapy for post operative rehabilitation of children with 
cerebral palsy. Work, 2012. 41 Suppl 1: p. 3612-5. 
20. Wade, W. and D. Porter, Sitting playfully: does the use of a centre of gravity computer game 
controller influence the sitting ability of young people with cerebral palsy? Disability & Rehabilitation 
Assistive Technology, 2012. 7(2): p. 122-9. 
21. Reid, D., Changes in seated postural control in children with cerebral palsy following a virtual play 
environment intervention: a pilot study. Israel Journal of Occupational Therapy, 2002. 11(3-4): p. 
E75-E95. 
22. Bartlett, D. and T. Brimingham, Validity and Reliability of a Pediatric Reach Test. Pediatric Physical 
Therapy, 2003. 15: p. 84–92. 
23. Russell, D., et al., Gross Motor Function Measure (GMFM-66 & GMFM-88) Use's Manual. 2nd 
ed2013, Ontario, Canada: Mac Keith Press. 
24. Pin, T.W., Psychometric Properties of 2-Minute Walk Test: A Systematic Review. Archives of 
Physical Medicine and Rehabilitation 2014. 95: p. 1759-1775. 
 
 
 

 
Section 13: Proposed Research Project 
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Table 1 One-dimensional therapy games 
 
Therapy module  
Content  
Exercise  
Shaping  
Applehunter 
 
Falling apples must be caught with a 
basket: 
active 
repetition 
of 
a 
coordinated 
motion 
sequence, 
or 
application of a strength value to a 
selected hand function  
Motion 
control, 
strength, 
strength 
control, tonus control, goal-oriented 
motor, coordination, attention, balance 
and postural control  
Number and speed of falling apples, 
size of the basket, mirroring  
Balloon  
 
 
Manoeuvring a balloon through a 
course and past obstacles: dynamic 
motion 
sequence, 
and/or 
the 
application of a strength value over a 
longer period of time  
Motion control, motion coordination, 
strength 
control, 
permanent 
contraction, 
concentration, 
balance 
and postural control  
Number of obstacles, flying speed, 
width and height of air lane, mirroring  
 
 
Shooting cans  
 
Cans move past a fixed reticule on the screen. 
Pulling the trigger at the right time will shoot the 
cans: timely activation of strength and/or motion 
Triggering of motion, concentration, 
precise 
and 
quick 
application 
of 
strength, 
coordination, 
reaction, 
Speed and size of the cans, 
mirroring  

 
Section 13: Proposed Research Project 
12 
 
impulses  
 
 
 
 
 
balance and postural control  
Firefighters  
 
 
Flaring flames must be extinguished with a water 
jet as precisely as possible: achieving and 
maintaining the required strength and/or motion 
level  
 
 
 
 
 
 
 
Strength control, strength rationing, 
coordination, 
goal-oriented 
motor, 
permanent 
contraction, 
attention, 
balance and postural control  
Number 
of 
fires, 
duration 
of 
extinguishing the fires, width of the 
water jet, mirroring  
Recycle  
 
 
Grabbing different pieces of waste with a gripper 
and 
depositing 
them 
in 
the 
corresponding 
container: achieving and maintaining the required 
strength and/or motion level  
 
 
 
 
Strength control, strength rationing, 
coordination, 
goal-oriented 
motor, 
permanent 
contraction, 
attention, 
balance and postural control  
Speed, number of pieces of waste, 
mirroring  
 

 
Section 13: Proposed Research Project 
13 
Table 2 Two-dimensional games 
Therapy module  
Content  
Exercise  
Shaping  
Farm  
A chicken must be controlled while it is picking worms 
from the ground: achieving active and efficient 
motions without compensation  
Goal-oriented repetitive motions, complex 
motions with every day-relevance, learning 
how to correctly control motions, prevention of 
compensation during the learning process, 
tonus control and tonus normalisation, training 
of spatial orientation and of reactions  
Speed, number of worms, time 
target, mirroring  
Labyrinth  
A ball must be guided through a labyrinth with 
obstacles: achieving active and efficient motions 
without compensation  
Goal-oriented repetitive motions, complex 
motions with everyday-relevance, learning how 
to correctly control motions, prevention of 
compensation during the learning process, 
tonus control and tonus normalisation, training 
of spatial orientation and of reactions  
Number 
and 
complexity 
of 
obstacles, speed, time, mirroring  
Set the table  
Correct allocation of dishes to place mats on the table 
(as if the person itself is standing in front of the table): 
achieving active and efficient motions without 
compensation  
Goal-oriented repetitive motions, complex 
motions with every day-relevance, prevention 
of compensation during the learning process, 
training of spatial orientation and of cognition  
Number of dishes and place mats, 
spatial changes, mirror-inversion, 
speed, time  

 
Section 13: Proposed Research Project 
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