This study developed and tested two types of pedal switches integrated with rehabilitation devices to improve balance and walking in children with cerebral palsy. One type connected to web games and the other to home appliances. Children used their feet to operate the devices for 15 weeks. Those using the web game device showed significantly greater improvements in sway patterns and balance/walking scores compared to the home appliance device, suggesting web games better motivate rehabilitation adherence. Maintaining motivation is important for rehabilitation success in children with cerebral palsy.

1. 1252 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 29, 2021
An Accessible Training Device for Children
With Cerebral Palsy
Guoqing Wan, Hsieh-Chun Hsieh , Chien-Heng Lin, Hung-Yu Lin , Chien-Yu Lin, and Wen-Hsin Chiu
Abstract— Walking and balance capabilities can be
improved upon using repetitive ankle dorsiflexion exer-
cises. Here we developed two types of pedal switches
incorporated with training devices to improve their walking
and balance performance of children with cerebral palsy.
The first type of pedal switch can be used to operate a
home appliance, while the second type of pedal switch can
connect them to web games. Pedal switches can be used
for home rehabilitation. This randomized controlled trial
included patients in the intervention (n = 24) and control
(n = 24) groups who completed 15 weeks of ankle training.
The experimental group performed ankle dorsiflexion using
a pressure-activated pedal switch connected to the web
games. The control group performed ankle dorsiflexion
exercises using a pedal switch that operated a home appli-
ance (a fan). Standing balance and walking performance
were estimated using the Zebris FDM system, a pressure
force platform, the Pediatric Balance Scale score, and the
1-minute walk test. The pre- and posttest data were analyzed
using analysisof varianceand analysisof covariance,which
revealed that the intervention group had more significant
improvements in sway patterns and balance and walking.
The developed facility of a modified pedal switch integrated
with web games can achieve better exercise adherence to
promote balance and walking performance than that with
home appliances. Maintaining motivation in children with
cerebral palsy plays a very important role in the rehabilita-
tion process.
Index Terms— Ankle rehabilitation, cerebral palsy,
postural balance, web games.
Manuscript received March 8, 2021; revised May 16, 2021; accepted
June 21, 2021. Date of publication June 24, 2021; date of current version
July 12, 2021. (Corresponding author: Hsieh-Chun Hsieh.)
This work involved human subjects or animals in its research. Approval
of all ethical and experimental procedures and protocols was granted by
the Ethics Committee at National Tsing Hua University.
Guoqing Wan is with Jilin Sport University, Changchun 130022, China
(e-mail: 912156976@qq.com).
Hsieh-Chun Hsieh is with the Research Center for Education and
Mind Sciences, Department of Special Education, National Tsing Hua
University, Hsinchu 30013, Taiwan (e-mail: hchsieh@mx.nthu.edu.tw).
Chien-Heng Lin is with the Department of Psychiatry, National Taiwan
University Hospital, Chu-Tung Branch, Hsinchu, Taiwan, and also with
the Graduate Institute of Clinical Medicine, National Taiwan University
College of Medicine, Taipei 10617, Taiwan (e-mail: sleepynaturefreak@
gmail.com).
Hung-Yu Lin is with the Department of Occupational Therapy, Asia
University, Taichung 41354, Taiwan (e-mail: otrlin@gmail.com).
Chien-Yu Lin is with the Department of Special Education, National
University of Tainan, Tainan 70005, Taiwan (e-mail: linchienyu@
mail.nutn.edu.tw).
Wen-Hsin Chiu is with the Department of Kinesiology,
National Tsing Hua University, Hsinchu 30071, Taiwan (e-mail:
whchiu@mail.nd.nthu.edu.tw).
Digital Object Identifier 10.1109/TNSRE.2021.3092199
I. INTRODUCTION
THE rehabilitation of balance and walking performance is
important for children with cerebral palsy (CP) [1], [2].
The lower limb control required for walking includes the
ability to perform a heel strike and requires dorsiflexors,
plantar flexors, invertors, and evertors (ankle) to make coor-
dinated movements [3]. Increased anterior tibial activity can
overcome the spasm and stiffness of plantar flexion during
gait training in children with CP [2], [4]. Repeated ankle
flexion/extension exercises improve gait and balance because
they promote muscle strengthening and ankle joint flexibility
and can prevent plantar flexor contracture [5], [6]. A previous
study also applied an ankle robot system for children with
CP to manipulate the device and improve their ankle range of
motion [7]. Therefore, here we observed the repetitive opera-
tion of a pedal switch to analyze the treatment effect on the
range of motion and balance involved in ankle rehabilitation.
An increasing number of studies have investigated the
effects of interventions in improving the functional abilities
of children with CP who have different ability levels. The
training effect on pediatric rehabilitation is dependent on
the physical characteristics associated with CP (e.g., muscle
tone, range of motion, and balance) [4]–[6] as well as traits
such as motivation, attention, and cognition [7]–[9]. However,
increasing motivation for pediatric rehabilitation is important.
Higher motivation leads to reductions in activity limitations,
behavioral problems, and family burden, whereas lower moti-
vation can negatively influence participation and the effects of
interventions.
Previous studies proposed strategies for children, peers, and
adults to increase the motivation of children to participate in
more challenging activities [7], [8]. According to the motor
learning theory, the key factors that enhance movement are
repetition, feedback, and motivation [10], [11]. One study [12]
reviewed studies on motor function in a virtual environment
in children with CP. The results showed that the virtual
environment had a positive transfer of motor abilities that
improved motor task learning and motor function. Researchers
have studied the ability of web games to improve the motion
abilities of children with CP. In particular, studies have
reported on web games in rehabilitation programs for gait
and balance training [12], [13]. These programs involved a
specific repetitive exercise task [13], [14]. Thus, applying web
games in rehabilitation might facilitate high participation and
feedback via ankle exercises.
This work is licensed under a Creative Commons Attribution 4.0 License. For more information, see https://creativecommons.org/licenses/by/4.0/

2. WAN et al.: ACCESSIBLE TRAINING DEVICE FOR CHILDREN WITH CP 1253
Fig. 1. Participant flow in the trial.
Owing to their attractive scenario and potential for inde-
pendent practice, web games have been popularly used in
motion training [5], [14]. Some researchers have studied
web games integrated with interactive sensory information
for rehabilitation [5], [15]. However, for children with CP,
specialized or commercial web games (e.g., PlayStation and
Xbox) are complex and expensive and not easy to operate.
A heel-ankle dorsiflexion rehabilitation device that integrates
a pedal switch and web game technology is lacking. Thus,
here we specifically asked, “Does a pedal switch with web
game training improve the balance and walking performance
of children with CP?” Our hypothesis was that web games
with a pedal switch can encourage and maintain the motiva-
tion and practice movements of these children. Accordingly,
we developed a pedal switch to operate home applications and
web games for children with CP and analyzed the effects of
its use on their walking and balance performance.
II. METHODS
A. Design
This randomized controlled trial used a pretest-posttest
design to compare the two types of interventions. The partici-
pant flow, which followed the guidelines of CONSORT 2010,
is shown in Figure 1. All patients received written information
concerning the intervention process. The experimental proce-
dures were approved by the Research Ethics Committee of
National Tsing Hua University for human research, and the
parents of each participant provided informed consent.
B. Participants
We assessed 60 children with CP (age range, 6–12 years)
who were recruited from four special education schools.
Twelve students were excluded because of concerns regarding
coronavirus disease 2019 (n = 10) or other medical problems
(n = 2). The inclusion criteria were as follows: a clinical
diagnosis of spastic CP, including hemiplegia, diplegia, and
quadriplegia (Table I); Gross Motor Function Classification
System (GMFCS) levels I–III [14] in the lower extremities;
and active ankle movements. An equal number of groups under
one block was chosen according to GMFCS level to perform
the block randomization. One research assistant managed the
randomization and recruitment process and was blinded to the
treatment information. A previous study showed that motor
training can improve center of pressure (CoP) sway from
baseline to week 12 with a standard deviation of 19 mm
according to the sample size estimation in clinical trials [5].
A clinically important difference of 0.5 and Cohen’s d of 20%
were considered acceptable.
n = 2(1.96 + 1.64)2
× 192
/202
= 23.39
Twenty-four children in each group were recruited for this
study according to the formula used to calculate the sample
size [16]. To eliminate sampling bias, a randomized block
design was used, and the 48 participants (n = 24) were
allocated to the web game training group (experimental group)
or pedal switch with appliances (control) group (Table I). All
participants had impaired locomotor function based on clinical
observation findings

3. 1254 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 29, 2021
TABLE I
PARTICIPANTS’ DEMOGRAPHIC DATA
C. Procedure
To test this hypothesis, variables were chosen to measure
physical activity (repeated ankle movements) and motiva-
tion (active participation) in the experimental group. In both
groups, the same 72 sessions were completed over 15 weeks.
With the participant in the standing position with hand support,
the same ankle plantar flexion motion was performed as they
pressed the pedal switch, while ankle dorsiflexion occurred as
they released the pedal switch. The experimental group used
their feet instead of a computer mouse to play online games
(Fig. 2). The pedal switch module comprised a tilt ball switch
connected to a single click of the left mouse button, allowing
the user to press the pedal switch to activate the left click.
Free web games that used the left mouse button to operate
the games were selected for this study. These selected games,
obtained from owlieboo.com or i-gamer.net, use single-button
controls via the left click of a mouse (like Flappy Bird) (Fig.2).
For the control group, we prepared an adapted pedal
switch by connecting it to a home appliance (Fig. 3). The
disability-adapted switch module comprises a relay, DC 9V
battery, socket, and pedal switch for operating home appli-
ances. For safety, a relay was used to switch from high voltage
(AC 110V) to low voltage (DC 9V) for the pedal switch. Thus,
the children with CP in the control group were able to operate
home appliances, such as switching a fan on or off, by pressing
the pedal switch. These home appliances, including a blender,
lamp, radio, spiral mixer, food processor, and fan, were used
in this study to facilitate participation (Fig. 3).
We set up a web game rehabilitation (experimental group)
or home appliance operation (control group) program with
the modified pedal switch in the children’s playrooms or
classrooms. The mechanism of action of the pedal switch is to
facilitate active plantar flexion/dorsiflexion of the ankle joint
because children with CP often have spasticity in the plantar
flexors that impedes a normal heel strike. All interventions
were delivered during after-school programs by two research
Fig. 2. (a) Schematic diagram of the switch-adapted mouse, foot switch
(non-locking), and web game. (b) Top side of the printed circuit board
inside the mouse. In this procedure, the screws of the mouse are removed
using a screwdriver, and the solder points on the circuit board for the left
click button on the mouse are identified. (c) Two wires are soldered to
the prongs of the microswitch on the bottom side of the printed circuit
board. Children with CP in the intervention group played web games by
pressing the foot switch.
assistants under direct supervision from a school-based physi-
cal therapist with four years of experience. Participants in both
groups performed 40 min of ankle exercises with the modified
pedal switch at a frequency of 5 days per week (Monday
through Friday) from 16:00 to 18:00 for a 15-week period. The
participants in both groups also received 40 minutes of regular

4. WAN et al.: ACCESSIBLE TRAINING DEVICE FOR CHILDREN WITH CP 1255
Fig. 3. The disability-adapted switch module comprises a relay, DC 9V
battery, socket, and foot switch (non-locking) for operating home appli-
ances such as a fan. A person may receive an electrical shock through
contact with an electrical current from a small household appliance. For
this reason, the relay was converted from a high voltage of AC 110V to a
low voltage of DC 9V for the foot switch. Children with CP in the control
group operated the home appliance (fan) by pressing the foot switch.
related services. Related services in Taiwan aim to provide
communication skills, motor training, behavioral intervention,
and extended learning opportunities for children who need
supplementary support services.
D. Outcome Assessment
Three types of datasets were used to assess the participants’
walking ability, balance, and postural control: 1-minute walk
test (1 MWT) score, Pediatric Balance Scale (PBS) score, and
CoP sway patterns (sway path, sway area, and sway velocity).
All screening sessions were conducted by one occupational
therapist and one research assistant. The evaluators were
blinded to the group assignments. The Zebris FDM System
(Zebris Medical GmbH, Isnyim Allgäu, Germany), which
adopted a 100-Hz sampling frequency for force measurements,
was used to measure CoP sway patterns. The participants
stood on the FDM platform with parallel feet separated by
10 cm and the arms hanging loosely by their sides for the
balance assessment. This system includes capacitive force
sensors arranged in a matrix. These captured real-time force
distributions and the computation of the plantar pressure
data of the CoP for each foot. Three 30-second trials were
conducted with the children’s eyes open. There was a 3-min
rest time between trials for each participant to reduce fatigue.
Three types of FDM trajectory data were used in this study:
1) CoP path length, which was in the CoP sway; 2) 95%
confidence ellipse sway area (sway area); and 3) CoP average
sway velocity (sway velocity) [17], [18].
The PBS, a modified version of Berg’s Balance Scale, tests
the pediatric balance abilities of children aged 4-15 years.
[19], [20]. The test-retest reliability of the PBS is high
(intraclass correlation coefficient [ICC], 0.998). The inter-rater
reliability of PBS was also high (ICC, 0.997) [21].
The 1 MWT assessed the walking speed of children with
CP by instructing them to start walking around a track with
markings for 1 min. The test-retest reliability of the 1 MWT
is high (ICC, 0.94), and the minimal clinically important
difference (MCID) range was 3.8–5.6 in children with spastic
CP (age range, 3–18 years) [22].
Open-ended questions for participant feedback were asked
to understand the children’s psyche and progress with respect
to the issues faced in therapy (eg, “How did you think or feel
while training with the modified pedal switch?”).
E. Data Analysis
Four kinds of data were used from the pre- and posttest
results: FDM trajectory data, 1 MWT, PBS, and children’s
feedback. SPSS for Windows (SPSS Inc., Chicago, IL, USA)
was used for the statistical analyses. Repeated-measures
analysis of variance (ANOVA) assessed the difference
between the pre- and posttest results. Later, multivariate
ANOVA (MANOVA) was used because there were two groups
(experimental and control groups) and seven dependent vari-
ables (trajectory data and functional test results). Wilks’
lambda () was defined as the multivariate statistical value
for the MANOVA. Finally, analysis of covariance (ANCOVA)
was used to compare the intergroup treatment effects from the
posttest data. The probability of rejecting the null hypothesis
when incorrect was defined as the power analysis value.
The participant interviews were held immediately after the
intervention, and parent feedback was collected.
F. Ethical Considerations
The study protocol was approved by the Ethics Committee
of the National Tsing Hua University. Each participant’s
parents provided informed consent.
III. RESULTS
Descriptive statistics and repeated-measures ANOVA results
for each group are presented in Table II. Repeated-measures
ANOVA was used to compare the means across the test scores
based on repeated assessments. In the repeated-measures
ANOVA, the posttest showed that the CoP kinematics sig-
nificantly improved in the experimental group (sway path,
F = 14.7, p = 0.001; sway area, F = 14.5, p = 0.001;
sway velocity, F = 12.6, p = 0.002). The posttest functional
scores also showed obvious improvement (1 MWT, F = 13.2,
p = 0.001; PBS total score, F = 10.0, p = 0.004). Only one
variable, the 1 MWT score, improved in the control group
(F = 5.1, p = 0.032).
The multivariate results of CoP sway performance (F =
5.347, p = 0.003, = 0.733) and functional tests were
significant (Table III). In the later ANCOVA, the two groups
showed significant differences. ANCOVA, which allows for

5. 1256 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 29, 2021
TABLE II
DESCRIPTIVE STATISTICS AND REPEATED MEASURE ANOVA FOR EACH GROUP
TABLE III
MULTIVARIATE ANALYSIS (MANOVA) AND ANALYSIS OF COVARIANCE (ANCOVA) SUMMARY BETWEEN TWO GROUPS
the equalization of initial differences between groups, was
used to compare the improvements between them. The
ANCOVA revealed significant improvements (p 0.05) in
CoP performance (sway path, F = 12.5, p = 0.001; sway
area, F = 6.7, p = 0.013) and functional tests (1MWT,
F = 5.72, p = 0.021; static PBS, F = 7.06, p = 0.011;
dynamic PBS, F = 5.70, p = 0.021; PBS total score,
F = 9.57, p = 0.003) after training with the gaming pedal
switch.
IV. DISCUSSION
The developed pedal switches can assist children with CP
in training ankle dorsiflexion. Pedal switches are important for
children with CP to operate home appliances and web games,
which may be played with the Internet or a web browser.
According to our analysis, the intervention of a pedal switch
incorporated with web games improved walking and balance
more significantly than the pedal switch with home appliances
because of boosting motivation. Increasing active ankle control
and movement speed can improve walking speed. When
children with CP operate the pedal switch to play web games,
ankle dorsiflexion can be performed repeatedly and quickly
to generate the next action by ankle plantarflexion (pressing
the pedal switch) and ankle dorsiflexion (releasing the pedal
switch). This is consistent with the findings of a previous
study, which also showed that assistive technology enhanced
active participation during web game activity [5], [12].
The control group was instructed to use the foot switch
in the standing position to operate several home appliances
at the beginning of the 40-minute sessions, after which time

6. WAN et al.: ACCESSIBLE TRAINING DEVICE FOR CHILDREN WITH CP 1257
they could practice as much as they wanted. For the control
group, children showed interest in using the pedal switch to
operate the fan in the beginning; however, this task did not
require participants to press and release the switch repeatedly,
so they did not practice consistently. The intergroup difference
in results seemed attributable to the different frequencies of the
switch presses performed by each group. Motivating the child
to press the switch to play may be important to increasing
use frequency. A game-based design will be needed in future
studies to increase the frequency of foot switch use for home
appliances. For example, perhaps a fan can be used to blow
objects to increase the frequency of pedal use.
The mean MCID of the 1 MWT was 4.8 m according to
Franjoine et al. [22]. Therefore, the mean difference between
the pre- and posttest results of the 1 MWT in the experimental
group was 5.5 m (61 m vs 66.5 m), which was longer than the
MCID of the 1 MWT in the previous study [22], indicating
that the improvement in 1 MWT in our experimental group
showed a clinically important difference. In contrast, the mean
difference between the pre- and posttest of the 1 MWT in the
control group was 1.6 m (62.1 m vs 63.7 m), which was less
than that in the experimental group (Table II).
All of the experimental group participants indicated that
they found the pedal switch connected to the web games
fun and interesting. Playing web games with a pedal switch
induced positive feelings (emotional stability and optimism)
and positive actions (engagement, positive interactions, com-
petence, and achievement). Children with CP actively par-
ticipated in and controlled the game. A fun environment
was created wherein participants could actively respond to
achievable challenges without showing fatigue while being
motivated throughout the intervention.
Training using a pedal switch with web games can provide
repetitive task-specific activities in a multisensory environ-
ment, the key factors of balance control. These findings
agree with those of previous studies indicating that repetitive
exercise positively affects motor control and gait speed. This
is important for children with CP [23]–[25]. The interesting
target of the exercises (ie, scoring the greatest number of
points) motivated the children to continue playing the web
games. Majnemer et al. [9] revealed that motivation variables
play a major role in controlling the execution of rehabilitation
tasks. The results of this study agreed with Barlett’s findings,
which indicated that the interaction of biofeedback and learn-
ing motivation using games played with or without a web
browser can improve the motor control abilities of children
with CP.
A. Limitations
This study has a few limitations. First, the intervention
period was only 15 weeks long. Second, the shift direction
of the pedal switch on the ground is only suitable for training
ankle movement; to operate the switch using either hip or
knee movement, the switch must be set at the hip/knee
level to facilitate hip flexor/quadriceps femoris strengthening.
Third, all participants needed to remove their foot orthosis to
facilitate coordinated ankle joint movement; therefore, some
participants could not maintain the proper foot arch during
the exercise. Fourth, longitudinal studies may be needed to
explore the causal relationships and confirm whether playing
web games using the pedal switch intervention enhances
ankle control as indicated. Fifth, there were 24 participants
in the experimental group. More participants are needed to
further verify the training accuracy. Also, further studies may
be required to try a variety of modified home appliances
with different switches that can increase the frequency of
ankle movements and motivate participation. And finally, these
selected games did not require mouse X- and Y-axis; however,
if further studies can modify foot switches that require mouse
X- and Y-axis movements, more online games can be used by
clients in the future.
V. CONCLUSION
In this study, we developed two types of pedal switches
used as assistive devices for foot rehabilitation in children with
CP. The first switch can operate home appliances, while the
other can control web games. We studied the effects of foot
rehabilitation on both types of pedal switches in children with
CP. The results showed that pairing a pedal switch with a web
game provided an effective means of training ankle dorsiflex-
ion and plantar flexion in school environments. Compared with
children with CP who used the home appliance system, those
who used the web game system showed greater interest in
performing the same exercises (ankle dorsiflexion and plantar
flexion) and better balance and walking performance.
ACKNOWLEDGMENT
The authors are grateful to the parents and therapists who
participated in this study. They appreciate the referral services
of the Chinese Association of Child Potential.
DISCLOSURE STATEMENT
The authors report no conflicts of interest.
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