Effects of Virtual Reality with Cerebral Palsy Children


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Effects of Virtual Reality with Cerebral Palsy Children

Nanyang Polytechnic

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  • I will begin our presentation with the following content Cerebral Palsy – what problems CP children and their parents faced Virtual Reality - VR as a rehabilitation tool; its application and its effectiveness. The Objective and hypothesis of our study.Michelle will bring you through the method of our study.YanTing will be touching on our how we categorise and progress the games during our intervention.Pei Shan will share the results and discussion.Last but not least, Roxanne will talk about the limitations of our study, areas of improvement and conclusion drawn from our study.
  • Cerebral palsy (CP) is a characterized by movement disorders caused by a non-progressive injury to the young immature brain.CP children commonly have problems in their muscle tone, strength, contractability and lengthSomasensory function is usually impaired.CNS deficits and biomechanical changes in postural alignment, CP children also experience altered balance and equilibrium.In a study on the concerns of parents of CP children, the ability to stand and walk was the most frequently quoted concern. Balance plays a vital role in the achievement of these functional movements.This prompts us to look into the balance of CP children in our project to help maximise their functional activity and alleviate care-giver effort.
  • Many of us have played computer games and is not new to the concept of virtual reality.Virtual Reality is a simulated environment that provides a multidimensional and multisensory experience.It provides a immersive and real time interactive engagement.Its strength lies in its ability to mimic real-life events.Increase amount of therapy time beyond PT session.Commonly deployed in social, entertainment and lesiure settings, its potential as a intervention tool has received much interest rehabilitation community. So what have studies found out so far?VR that target UE movement on CP children has shown improvements in UE skills and functions.However, there is very limited studies on VR on CP children that target balance. Nevertheless, VR intervention on stroke patients in small scale studies have shown improvements in balance, gait and mobility. Woollacott et al has also shown that reactive balance training is effective in improving balance in CP children.With all these encouraging results, our group is intrigued to find out if VR as a form of reactive balance training with respect to self-generated perturbation, could help improve balance of CP children? In view of this, there have already been studies that check out the potential of using VR as a rehabilitation tool. So what are the results so far?VR was deployed on CP children focusing on the UE and has shown improvement in UE skills and functions.VR was also tested out on stroke patients, albeit small scale studies, and there were improvements in balance, gait and mobility. There is very limited studies on VR on CP children that target balance. However, Woollacott et al has shown that reactive balance training is effective in improving balance in CP children.With all these in mind, our group is intrigued to find out if VR as a form of reactive balance training, could help improve balance of CP children?
  • As effectiveness of VR on balance training is not clear, our project team decide to investigate if VR has an impact on the balance of CP children when given as an adjunct to conventional PT instead of using VR as a mainstay treatment.
  • Our project was a collaboration between NYP which provided us guidiance and financial aid, and the Cerebral Palsy Centre, who helped us in allocating our subjects, lending us their space for outcome measures and carrying out our intervention for us.
  • The type of intervention our subjects underwent was our independent variable, while our dependent variable consisted of static balance which is the postural sway in quiet sitting/standing, dynamic balance which is the maximum excursion of forward reach + time of ambulation for a predetermined distance, balance confidence and motivation level.
  • Our subjects were selected based on our inclusion criteria which consist of subjects being diagnosed with CP, able to sit/stand independently for more than 30s and having good cognition level. Our exclusion criteria was any history of epilepsy, which may be complicated with the usage of virtual reality.
  • We had 5 different outcome measures, 3 of which are objective measurements while the other 2 are subjective questionnaires.Postural sway was used to measure static balance of antero-posterior and medial-lateral directions. Functional Reach measured the dynamic balance of our subjects as well as their anticipatory postural adjustment to a forward weight shift.Dynamic balance was also measured by the time up and go test, which also measured their functional mobility.The ABC and motivation questionnaires as implied, measures our subjects functional confidence level and their motivation level for the Wii Games.
  • Subjects were recruited based on the inclusion criteria and exclusion criteria.Two classes from the school were recruited. One class (with students having a higher level of cognition) was assigned as the experimental group and the other the control group.Before the start of the intervention, baseline measurements were taken.Then intervention commences.At 6th week, there is a mid-intervention progress evaluation which aims to see if the games were pitched at the right level for the subjects.Based on the evaluation, games are maintained at the same level, progress to a higher level or step-down to a lower level.This will be elaborated later by ??The intervention continues for another 6 weeks after the evaluation.At the end of 12 weeks, a post intervention measurements are taken.1 subject from the control group drop out as the subject fell sick and could not turn up for the outcome measurement despite mulitple visits to the centre.
  • Now for our subject profiles, There was 6 subjects in our experimental group with a mean age of 11.2 years and they will be represented by the red men as seen hereOur control group had 5 subjects with a mean age of 13.5 years and in they same way, they will be represented by the green men in this slide. For Type of CP, both our experimental and control groups were mainly spastic. For the type of motor disability they possess, both groups were also mainly diplegic.According to the GMFCS level, our experimental group were more physically challenged, with most of them having a grade 3 while the control group were mainly grade 1.
  • Categorisation based on:- amount of displacement of centre of gravity from base of support- fast reaction time needed to shift one’s body weight drastically- duration of the game- amount of fine postural adjustment needed Starting with easy. An example is ski jump in Wii fit plus. This is categorised as easy as there is minimal weight shifting, only requiring one to change a position of squatting to standing of which both position are of double leg stance. This position change does not challenge the balance as much as the other 2 levels. Moreover, it is a short duration game.
  • Insert some examples of indications in the slide, but need not express it.http://www.google.com.sg/imglanding?q=progress+stairs&um=1&hl=en&tbs=isch:1&tbnid=U_fx6dfyAnR2mM:&imgrefurl=http://www.123rf.com/photo_6695949_hand-and-stairs-progress-isolated-on-white-background.html&imgurl=http://us.123rf.com/400wm/400/400/violin/violin1003/violin100300166/6695949-hand-and-stairs-progress-isolated-on-white-background.jpg&zoom=1&w=400&h=293&iact=hc&ei=tJMkTY3JJ8bNrQf3lLzKCw&oei=tJMkTY3JJ8bNrQf3lLzKCw&esq=1&page=1&tbnh=152&tbnw=262&start=0&ndsp=16&ved=1t:429,r:14,s:0&biw=1259&bih=629http://www.google.com.sg/imglanding?q=maintain+stairs&um=1&hl=en&tbs=isch:1&tbnid=9zFiOVMM1c8SyM:&imgrefurl=http://healthfitness.frs.com/exercises-firm-legs-4705.html&imgurl=http://photos.demandstudios.com/getty/article/90/0/sb10063469m-001_XS.jpg&zoom=1&w=370&h=400&ei=45QkTbDtLYfCcdyehL8B&biw=1259&bih=629&iact=rc&oei=npQkTbb5CcryrQfIvLXDCw&esq=16&page=3&tbnh=142&tbnw=126&start=35&ndsp=21&ved=1t:429,r:6,s:35http://elitechoice.org/tag/electronic-products/page/7/http://www.google.com.sg/imglanding?q=check+list&um=1&hl=en&biw=1259&bih=629&tbs=isch:1&tbnid=ZX4huC9lNoRcJM:&imgrefurl=http://www.houshanglivian.com/&imgurl=http://www.houshanglivian.com/system/wp-content/uploads/2010/04/checklist11.jpg&zoom=1&w=425&h=282&iact=rc&ei=zpkkTYinPIb0ceXriJAB&oei=pZkkTemVNIrNrQe6h-TECw&esq=7&page=1&tbnh=127&tbnw=191&start=0&ndsp=21&ved=1t:429,r:7,s:0
  • Still, we are not surprised or fazed by our objective results being non statistically significant as we recognise the variability of the condition, cerebral palsy, itself.According to an article by Liptak and Accardo 2004, they shared that there is significant variablity in cerebral palsy itself as variations in exist within each type and even in each subtype depending on the location of lesion, type and severity of impairment. Thus, some children who have spastic diplegia are minimally affected, whereas others have mental retardation, severe problems with mobility, seizures, visual impairment, malnutrition, and behavioral problems. Their genetic makeup, lifestyle and overall fitness would also contribute to the uniqueness of each individual cerebral palsy child.Given the range of subtypes, the variability within each subtype, and the existence of constitutional differences among persons with CP, the ability to predict outcomes and to evaluate the effects of an intervention become very complex.
  • From our results, there is no effect of wii as an adjunct to physiotherapyFurther emphasizes the fact that Conventional therapy is still the most crtical vital in rehab for CP children.Any changes in intervention group is not significant to prove that improvement is from Wii
  • Our study was limited by the level of control in terms of additional intervention that our subjects were exposed to as some of them has botox, extra sessions of neurodevelopent training, etc. As we were not the main therapist who conducted the intervention, there were insufficient control over how it was being conducted, hence the certain details and instructions were not followed as planned like using of arms for additional support and the variety of games played per session. For this same reason, it affected the dosage of Wii. Our Wii intervention was subjected to the subject’s school timetable which only allowed 1 session per week even though studies we have read supported a higher frequency of sessions for better results. This was further compromised in terms of consistency duration in between sessions when the subject had a school excursion or was absent from schoool which may affect the retention of knowledge gained from each session. We are also unable to generalise the results across the CP population as there wasn’t a consistent change across the subjects with exposure to wii intervention probably due to the variability of each individual CP subject. Perhaps with future trial with a larger sample size will allow more conclusive results.
  • More recommendations that future researches can take home from our study other than increase in dosage of Wii intervention is that it would be preferable to match the age and level of function of the subjects to allow an easier comparison across the groups.Our study also lacked blinding and control which could make a related study more reliable.A greater variety or change of games may be good to maintain a high level of motivation among the subjects.Measurement tools which are more child friendly should also be utilise as reliability of measurement tools like postural sway, which has been used in measurements of elderly fall risk, may be compromised by the short attention span of young subjects.
  • Hence, from our study, our group failed to reject null hypothesisThere is no effect of VR as an adjunct to conventional therapy on balance of cerebral palsy children
  • Effects of Virtual Reality with Cerebral Palsy Children

    1. 1. Effects of <br />Virtual Reality with Physiotherapy <br />on Balance of Cerebral Palsy children<br />Chung Hai Yong<br />Michelle Koh<br />Roxanne Foo<br />Chua Pei Shan<br />Poh Yan Ting<br />
    2. 2. Content<br /><ul><li>Cerebral Palsy (CP)
    3. 3. Virtual Reality (VR) in Rehabilitation
    4. 4. Objective & Hypothesis
    5. 5. Method
    6. 6. Results
    7. 7. Discussion
    8. 8. Limitations
    9. 9. Areas of Improvement
    10. 10. Conclusion</li></li></ul><li>Cerebral Palsy<br />
    11. 11. VR in Rehabilitation<br />Virtual Reality (VR)<br />Simulated environment<br /><ul><li>Multidimensional
    12. 12. Multisensory
    13. 13. Immersive
    14. 14. Interactive
    15. 15. Comparable to real events</li></ul>(Reid., 2002, <br />Deutsch & Borbely., 2008)<br />VR on CP children for Balance Training?<br />
    16. 16. Objective<br />To investigate if VR has an impact on the balance of CP children when given as an adjunct to conventional physiotherapy<br />
    17. 17. Null Hypothesis<br />VR has no additional effects to conventional physiotherapy to improve balance of CP children<br />
    18. 18. Collaboration<br />Cerebral Palsy Centre (CPC)<br />
    19. 19. Variables<br />
    20. 20. Subjects Selection<br />
    21. 21. Outcome Measures<br />
    22. 22. Experimental Procedure<br />Subjects recruited from 2 classes in CPC<br />N=12<br />Subjects Assignment<br />Control (n = 6) / Experimental (n = 6)<br />Baseline measurement<br />Training to therapy assistants (TA)<br />30 min/ session<br />1 session/ wk<br />6-week intervention<br />Control : Conventional Therapy<br />Experimental : Conventional Therapy + Wii Games<br />20 min/ session<br />1 session/ wk<br />Mid-intervention progression evaluation<br />Continue another 6-week intervention<br />Control : 1 drop out. Unavailable due to sickness<br />Post intervention measurement<br />
    23. 23. Subject Profile<br />Experimental (n = 6)<br />Mean age = 11.2 years<br />Control (n = 5)<br />Mean age = 13.5 years <br />4<br />3<br />4<br />3<br />5<br />2<br />2<br />4<br />*GMFCS – Gross Motor Function Classification System<br />
    24. 24. Games Categorisation<br />Easy<br />
    25. 25. Games Categorisation<br />Medium<br />
    26. 26. Games Categorisation<br />Difficult <br />
    27. 27. Intervention-Wii Game Session<br />
    28. 28. Games Progression<br />Indications:<br /><ul><li>Therapy assistants’ feedback
    29. 29. Subjects’ feedback
    30. 30. Objective measure – Bubble game</li></ul>Regress<br /><ul><li>3 indications to regress</li></ul>Progress<br /><ul><li>≥ 1 indication(s) to progress</li></ul>Maintain<br /><ul><li>≥ 1 indication(s) to maintain</li></li></ul><li>Final Progression<br />
    31. 31. Results<br />Control group <br />
    32. 32. Results<br />Control vs Experimental group<br />Mann Whitney U test <br />Differences between pre and post intervention values<br />No significant difference<br />
    33. 33. Results<br />VR has no additional effects to conventional physiotherapy to improve balance of CP children<br />
    34. 34. Motivation Level<br />
    35. 35. Discussion<br />Motivation level in VR rehabilitation<br />
    36. 36. Discussion<br />Dosage of VR intervention<br />CP adolescent training Balance<br />Stroke patients training Balance<br /> CP children training Upper Extremity<br />
    37. 37. Discussion<br />Overall Fitness<br />Genetics<br />Variability of CP<br />Liptak & Accardo, 2004<br />
    38. 38. Clinical Implications<br />
    39. 39. Limitations<br />
    40. 40. Recommendations for Future Studies<br />
    41. 41. Conventional treatment is vital<br />There was no significant difference with addition of Wii<br />There is potential of VR in rehabilitation<br />Conclusion<br />
    42. 42. Acknowledgments <br />Dr Bala S. Rajaratnam<br />SHS Project Manager<br />Mr D. Senthil Kumar<br />FYP External Coordinator<br />CP Centre Senior PT<br />Ms Michelle Ng<br />SHS Lecturer<br />Ms ChiaChoon Yee<br />SHS Lecturer<br />Staff & children from Cerebral Palsy Centre<br />Mr Patrick Tan<br />Laboratory Assistant<br />Coursemates<br />
    43. 43. THANK YOU<br />
    44. 44. References<br />Burtner, P.A., Woollacott, M.H., Craft, G.L. & Roncesvalles M.N. (2007). The capacity to adapt to changing balance threats: A comparison of children with cerebral palsy and typically developing children. Developmental Neurorehabilitation, 10 (3), 249-260.<br />Chen, Y.P., Kang, L.J., Chuang, T.Y., Doong, J.L., Lee, S.J., Tsai, M.W., Jeng, S.F. & Sung, W.H. (2007). Use of virtual reality to improve upper-extremity control in children with cerebral palsy: A single-subject design. Physical Therapy, 87 (11), 1441-1457.<br />Deutsch, J.E., Robbins, D., Morrison, J. & Guarrera, B.P. (2009). Wii-Based compared to standard of care balance and mobility rehabilitation for two individuals post-stroke. Proceedings of Virtual Rehabilitation International Conference (pp. 5174216) Israel: Research in Virtual Envrionments & Rehabilitation services.<br />Deutsch, J.E., Borbely, M., Filler, J,, Huhn, K. & Guarrera-Bowlby, P. (2008). Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Physical Therapy, 88 (10), 1196-1207.<br />Golomb, M.R., McDonald, B.C., Warden, S.J., Yonkman, J., Saykin, A.J., Shirley, B., Huber, M., Rabin, B., AbdelBaky, M., Nwosu, M.E., Barkat-Masih, M. & Burdea, G.C. (2010). In-home virtual reality videogame telerehabilitation in adolescents with hemiplegic cerebral palsy. Archive Physical Medicine Rehabilitation, 91, 1-8.<br />
    45. 45. References<br />Goulding, A., Jones, L.E., Taylor, R.W., Piggot, J.M. & Taylor, D. (2003). Dynamic and static tests of balance and postural sway in boys: effects of previous wrist bone fractures and high adiposity. Gait and Posture, 17, 136-141.<br />Graaf-Peters, V.B., Cornill H.B., Tineke D., Hanneke B., Arie F., Bos, M.H. (2007). Development of postural control in typically developing children and children with cerebral palsy: Possibilities for intervention? Neuroscience and Biobehavioral Reviews, 31, 1191–1200.<br />Hsue, B.J., Miller, F. & Su, F.C. (2009). The dynamic balance of the children with cerebral palsy and typical developing during gait, Part II: Instantaneous velocity and acceleration of COM and COP and their relationship. Gait & Posture, 29, 471–476.<br />Jannink, M.J.A., Wilden, G.J., Van der, Navis, D.W., Visser, G., Gussinklo, J. & Maarten, L. (2008). A low-cost video game applied for training of upper extremity function in children with cerebral palsy: A pilot study. Cyberpsychology & Behaviour, 11 (1), 27-32.<br />Jang, S.H., Sung H.Y., Hallett, M., Yun, W.C., Chong, M.P., Cho S.H., Lee H.Y. & Kim T.H. (2005). Cortical reorganization and associated functional motor recovery after virtual reality in patients with chronic stroke: an experimenter-blind preliminary study. Archive of Physical Medicine Rehabilation,86, 2218-2223.<br />
    46. 46. References<br />Liptak, G.S. & Accardo, P.J. (2004). Health and social outcomes of children with cerebral palsy. Journal of Paediatrics, 145, 36-41<br />Reid D.T. (2002). The use of virtual reality to improve upper-extremity efficiency skills in children with cerebral palsy: A pilot study. Technology and Disability,14, 53-61.<br />Volkman, K.G., Stergiou, N., Stuberg, W., Blanke, D. & Stoner, J. (2009). Factors affecting functional reach scores in youth and typical development. Paediatric Physical Therapy, 21, 38-44.<br />Walker, M.L., Ringleb S.I., Maihafer, G.C., Walker, R., Crouch, J.R., Van, L.B. & Morrison, S. (2010). Virtual reality–enhanced partial body weight–supported treadmill training post stroke: Feasibility and effectiveness in 6 subjects. Archive Physical Medicine Rehabilitation, 91, 115-122.<br />Woollacott, M.H., Shumway-Cook, A., Hutchinson, S.C.M., Price, R. & Kartin, D. (2005). Effect of balance training on muscle activity used in recovery of stability in children with cerebral palsy: A pilot study. Developmental Medicine & Child Neurology, 47, 455–461.<br />Woollacott, M.H. & Shumway-Cook, A. (2005). Postural dysfunction during standing and walking in children with cerebral palsy: What are the underlying problems and what new therapies might improve balance? Neural Plasticity, 12 (2-3), 211-219.<br />
    47. 47. References<br />Woollacott., M.H., Burtner, P., Jensen, J., Jasiewicz, J., Roncesvalles, N. & Sveistrup, H. (2008). Development of postural responses during standing in healthy children and children with spastic diplegia. Neuroscience and Biobehavioural Reviews, 22 (4), 583-589. <br />Yang, Y.R., Tsai, M.P., Chuang, T.Y., Sung, W.H. & Wang, R.Y. (2008). Virtual reality-based training improves community ambulation in individuals with stroke: A randomized controlled trial. Gait & Posture, 28, 201-206.<br />