# Exercise as it relates to Disease/Targeting Cerebral Palsy in children, introducing virtual reality to active video game interventions

Critique of Article; Levac D, McCormick A, Levin MF, Brien M, Mills R, Miller E, et al. (2017), Active video gaming for children with cerebral palsy: Does a clinic-based virtual reality component offer an additive benefit? A pilot study. Physical & occupational therapy in pediatrics.38(1):74-87.

## What is the background to this research?

Cerebral Palsy (CP) is an umbrella term describing a group of disorders that affect a person’s ability to move, due to damage of the developing brain. In Australia there are around 34,000 people living with CP and 17 million worldwide according to 2015 statistics.
Home based exercises are commonly used in physiotherapy interventions to decrease spasticity in children, and are often described as boring. Therefore, research into the effectiveness of active video gaming (AVG) interventions has become more popular, and has been seen as beneficial in increased motivation.
Introducing virtual reality (VR) into active video gaming interventions may further enhance their effectiveness as suggested in Levac D, McCormick A, et al. 2017.

## Where is the research from?

A Canada based pilot study into the introduction of VR into AVG interventions has been done by Danielle Levac a Physical Therapist from Northeastern University, Boston, who has been involved in several studies on the use of virtual reality in patients. With Anna McCormick, Associate Professor and Medical Director PSU of the University of Ottawa.

## What kind of research was this?

The study can be described as a piolt non-randomized control trial. Quantitative and qualitative data were used to assess the effectiveness of the intervention along with self-reports of AVG play time. Compared to similar studies a relatively large number of participants were involved, due to a proportionally large control group.

## What did the research involve?

The study involved 11 children aged 7-18 with level I or II CP based on the Gross Motor Function Classification System (GMFCS), exclusion criteria included regular past use of an at home AVG system. 5 children were put into the AVG+VR group, one of which did not complete the final 2 assessments.
The AVG+VR group received 60-90minute VR sessions for 5 days, the AVG group had a 1 hour visit with the a therapist to select difficulty. Both groups then undertook a 6 week at home AVG intervention.
10 out of 11 participants responded weekly and game progression was decided based on ability and feedback.

## What were the basic results?
### Playing Time
#### Table 1. At Home AVG Play Time Per Day

| Group | Mean Time (min) | Standard Deviation (minutes) |
| AVG + VR | 24.5 | 1.4 |
| AVG Only | 42.1 | 4.9 |
The AVG+VR group had a significantly lower play time than the AVG only group, attributed by the article to the fact one of the AVG+VR participants did not complete all 5 weeks of the programme which is plausible considering the group sizes .

### Weekly question responses

AVG only participants found the at home programme more interesting initially however this changed in weeks 5 and 6. This could be a result of increase in difficulty or having the VR component at the beginning of the programme for the AVG+VR group.
The AVG+VR group also found the at home AVG intervention significantly more tiring during the first 3 weeks, where as the AVG group described the exercises as more tiring towards the end of the programme.
The article does highlight the fact that the games may have not been sufficiently challenging, this would require more frequent feedback, as suggested in the article by use of an app.

### Testing

Participants took part in a Gross Motor Function Measure Challenge (GMFM-CM), participants also undertook a 6 minute walk test (6MWT). The article describes improvement as significant or non-significant.
In order for improvement to be classified as significant in the GMFM-GC test median improvement in scores had to be above 4.4. The AVG only group improved by 4.5 however the AVG+ VR group did not show significant improvement. This is commented on as a possible result of the AVG play time.
There was a significant decrease in AVG+VR participants median 6MWT of 68.2m. There was also a decrease in 6MWT by the AVG only group however this is not classified as significant. The article rules out the possibility of decrease in other physical activity as a cause, however this could be investigated through parent interviews.
Discussion of findings appeared to be unbiased and highlighted adjustments that could be made to the methods used in future, more detailed data may have been beneficial in the discussion of test results.

## What conclusions can we take from this research?

Introducing VR did not increase play time or test scores. When reviewing the method used, the VR component may have had a greater effect if participants of the AVG+VR group had weekly VR sessions rather than an intensive programme. This would also allow face to face conversation as the study went on. Meetings would also be needed with the AVG only group to prevent bias. The use of a smart-phone app is a favourable suggestion as past studies suggest if games are too challenging or not challenging enough volition decreases. Nevertheless, if selected correctly can aid in motivation.
As the study was published in 2017 there is a lack of more recent research.

## Practical advice

This article does not support the use of VR in interventions for children with CP. However there are ways in which the method could have been altered such as improved feed back collection and use of weekly VR sessions.
For more information on Cerebral Palsy and support please visit the Cerebral Palsy Alliance Research Foundation.
For further reading on Active Video gaming in children; Howcroft J, Klejman S, et al., (2012), Active video game play in children with cerebral palsy: potential for physical activity promotion and rehabilitation therapies. Archives of physical medicine and rehabilitation, 93(8):1448-56.

## References

* ↑ [Internet] Cerebral Palsy Alliance, (2015), What is Cerebral Palsy?, Viewed 28 August 2018.
* ↑ [Internet] Cerebral Palsy Alliance, Research Foundation, (2015), What is Cerebral Palsy?, Viewed 29 August 2018.
* ↑ Howcroft J, Klejman S, et al., (2012), Active video game play in children with cerebral palsy: potential for physical activity promotion and rehabilitation therapies. Archives of physical medicine and rehabilitation, 93(8):1448-56.
* ↑ Sandlund M, Dock K, Häger CK, Waterworth EL, (2012), Motion interactive video games in home training for children with cerebral palsy: parents’ perceptions. Disability and rehabilitation. 34(11):925-33.
* ↑ Reid DT, (2002), The use of virtual reality to improve upper-extremity efficiency skills in children with cerebral palsy: a pilot study. Technology & Disability, 14(2):53-61.
* ↑ You SH, Jang SH, et al, (2005), Cortical reorganization induced by virtual reality therapy in a child with hemiparetic cerebral palsy. Developmental medicine and child neurology, 47(9):628-35.
* ↑ [Internet] Cerebral Palsy Alliance, Research Foundation, (2015), Gross Motor Function Classification System (GMFCS), Viewed 29 August 2018.
* ↑ Harris K, Reid D, (2005) The influence of virtual reality play on children's motivation. Canadian Journal of Occupational Therapy,72(1):21-9.