TITLE: There is limited evidence that suggests virtual reality therapy is as effective as
conventional therapy in improving perceived functional use and motor function of the affected
upper extremity or extremities in children with cerebral palsy.
Prepared by: Amy Abelman
Kayley Holman
Kelly Kuether
Date:
abelman.amy@uwlax.edu
holman.kayl@uwlax.edu
kuether.kell@uwlax.edu
December 4, 2012
CLINICAL SCENARIO:
Client population: Children with cerebral palsy (CP) between five and 16 years of age who
have impairments in perceived functional use and motor function in one or both upper
extremities (UE).
Treatment context: Virtual reality (VR) therapy is used in rehabilitation and laboratory
settings. It can also occur in inpatient, outpatient, home, and school settings.
Problem or condition: CP is a non-progressive disorder that begins during fetal or infant
development and affects the area of the brain that controls movement and posture
(Snider, Majnemer, & Darsaklis, 2010). CP typically results in impaired motor function in one
or both UEs, including difficulties isolating movements (Reid & Campbell, 2006), reaching,
grasping, and manipulation (Chen et al., 2007). VR therapy is used to address the impaired
motor function and functional use of the affected UE(s) in children with CP.
Intervention: VR therapy allows the child to experience an activity in a virtual environment
by providing sensory input during UE movements. VR therapy creates a fun and interactive
environment for the child, while focusing on specific therapy goals (Snider et al., 2010). VR
therapy protocol can be determined by occupational therapists, as they can choose VR games
appropriate for addressing goals in therapy. Availability of VR systems and games in the
clinic, hospital, school, or child’s home will determine the system and games used in therapy.
In general, VR games allow the child’s performance level to be challenged appropriately, as
difficulty of games can be graded to meet the needs of the child (Jannink et al., 2008).
Science behind intervention: VR therapy may be effective in improving perceived functional
use and motor function of the UE due to the neuroplastic changes that occur in response to
motor learning theory. Motor learning theory focuses on the necessity of practice and feedback
in motor skill acquisition (Bertoti, 2004). During VR therapy, the child repeatedly performs
movements and receives constant feedback from the VR system in regards to UE movement.
Feedback is given through the visual input on the screen as well as scores or points received
during the game. Input is adjusted as the child progresses by changing the level of difficulty,
thus making feedback more specific to the child’s performance level (Pendleton & Krohn,
2006). According to motor learning theory, the user adjusts his or her movement according to
the feedback received and learns from previous errors. Eventually, movements will become
automatic (Bertoti, 2004).
Automaticity of movements during VR games result from the neuroplastic changes that occur
throughout the motor learning process. Through repetition of a motor activity, new motor
pathways are developed, and pre-existing pathways are maintained (Bertoti, 2004). In VR
therapy, the repetition of games and continued feedback the child receives allow neural
pathways to adapt to make movement more efficient (Bertoti, 2004).
How is this intervention occupational therapy? VR therapy addresses client factors and
performance skills in the Occupational Therapy (OT) Practice Framework by encouraging the
child to perform different motor functions of the UE(s). Controlling one’s voluntary movement
is a component of client factors, and includes pronation, supination, bilateral integration, and
fine and gross motor control. Motor and praxis skills are a component of performance skills
and include reaching, grasping, releasing, drawing, pointing, and manipulating objects
(American Occupational Therapy Association, 2008). Addressing client factors and
performance skills may increase the functional use of the client’s UE(s) during activities of
daily living, education, volunteering, play, and leisure.
VR therapy is considered a purposeful activity, as it is meaningful, motivating, and allows the
child to develop skills that may improve occupational performance. VR therapy can also be an
occupation-based activity if the child’s valued occupation is playing video games.
FOCUSED CLINICAL QUESTION: What is the effectiveness of virtual reality therapy in
improving perceived functional use and/or motor function of the affected upper extremity or
extremities in children with cerebral palsy when compared to conventional therapy?
●
●
●
●
Patient/Client Group: Children with CP
Intervention: VR therapy
Comparison Intervention: Conventional therapy
Outcome(s): Improvement in perceived functional use and/or motor function of UE
SUMMARY: Is VR therapy as effective as conventional therapy in improving perceived
functional use and/or motor function of one or both upper extremities?
● Number of databases searched: 12
● Number of relevant articles located: 22
○ Three articles were reviewed
○ All were low-quality randomized controlled trials (PEDro level of 1/8, 3/8, 4/8)
● Criteria for choosing articles to review
○ Diagnosis: Specific to CP
○ Population: Children under the age of 18
○ Intervention: VR therapy alone or VR therapy with conventional therapy
○ Control: Conventional therapy
○ Variables: Functional use and/or motor function
○ Date of Publication: Within ten years
○ Language: Written or translated to English
○ Evidence: Studies with highest level of evidence that examined the variables
● Findings: VR therapy is as effective as conventional therapy in improving perceived
functional use and/or motor function of the affected UE(s) in children with CP.
CLINICAL BOTTOM LINE: There is limited evidence that suggests virtual reality
therapy is as effective as conventional therapy in improving perceived functional use and/or
motor function of the affected extremity or extremities in children with cerebral palsy.
Limitations of this Critically Appraised Topic: This critically appraised topic has been reviewed
by occupational therapy graduate students and the course instructor.
SEARCH STRATEGY:
Table 1: Search Strategy
Databases Searched
● PEDro
● OVID
● OT Seeker
Search Terms
● Virtual reality
● VR
● Virtual reality
therapy
Limits used
●
●
●
●
And
+
Not
Or
Inclusion and
Exclusion Criteria
Inclusion Criteria:
● Written within ten
years
● Written in English
●CINAHL Plus with
Full Text
● Cochrane Collection
Plus
● Medline with Full
Text
●Cochrane Central
Register of Controlled
Trials
● PSYCHInfo
● Education Research
Complete
● Alt Healthwatch
● Health Source:
Nursing/Academic
Edition
● Education Research
Complete
● Video games
● Video game therapy
● Cerebral palsy
● CP
● EyeToy
● Wii
● Upper extremity
● UE
● Upper extremity
function
● UE function
● Hemiparesis
● Virtual Environment
● Adolescents
● Children
● Reid
● Snider
● Translated to
English
● Include children
with cerebral palsy
● Evaluate perceived
functional use and/or
motor function of
affected UE
Exclusion Criteria:
● Children over 18
years old
● Children with
accompanying
conditions
RESULTS OF SEARCH:
Table 2: Summary of Study Designs of Articles Retrieved
Level
Level 1a
Study Design/
Methodology of
Articles Retrieved
Systematic
Reviews or
Metanalysis of
Randomized
Control Trials
Total
Number
Located
5
Data Base Source
Citation (Name, Year)
CINAHL Plus Full
Text
Galvin, J., & Levac, D.,
2011
CINAHL Plus with
Full Text
Galvin, J., McDonald,
R., Catroppa, C., &
Anderson, V., 2011
CINAHL Plus with
Full Text
Sandlund, Mcdonough,
& Häger, 2009
Level 1b
Individualized
Randomized
Control Trials
0
Level 2a
Systematic
reviews of cohort
studies
0
Level 2b
Individualized
3
cohort studies and
low quality
RCT’s (PEDRO <
5)
Level 3a
Systematic review
of case-control
studies
0
Level 3b
Case-control
studies and nonrandomized
controlled trials
1
CINAHL Plus with
Full Text
Snider, L., Majnemer,
A., & Darsaklis, V.,
2010
MEDLINE with Full
Text
Wang, M. & Reid, D.,
2011
MEDLINE Plus with
Full Text
Jannink, M., Van Der
Wilden, G., Navis, D.,
Visser, G., Gussinklo,
J., & Ijzerman, M.,
2008
CINAHL Plus with
Full Text
Reid, D. & Campbell,
K., 2006
MEDLINE
Sharan, D., Ajeesh, P.,
Rameshkumar, R.,
Mathankumar, M.,
Paulina, R., & Manjula,
M., 2012
MEDLINE with Full
Text
Bryanton, C., Bossé, J.,
Brien, M., Mclean, J.,
McCormick, A., &
Sveistrup, H., 2006
Level 4
Case-series and
poor quality
cohort and casecontrol studies
10
CINAHL Plus with
Full Text
Chen, Y., Kang, L.,
Chuang, T., Doong, J.,
Lee, S., Tsai, M., Jeng,
S., & Sung, W., 2007
CINAHL Plus with
Full Text
Deutsch, J.E., Borbely,
M., Filler, J., Huhn, K.,
& Guarrera-Bowlby, P.,
2008
CINAHL Plus with
Full Text
Golomb, M.,
McDonald, B., Warden,
S., Yonkman, J.,
Saykin, A., Shirley, B.,
Huber, M., Rabin, B.,
AbdelBaky M., Nwosu,
M.E. & Burdea, G.,
2010
MEDLINE with Full
Text
Golomb, M. Warden,
S., Fess, E., Rabin, B.,
Yorkman, J., Shirley,
B., Burdea, G., 2011
CINAHL Plus with
Full Text
Green D. & Wilson, P.,
2012
MEDLINE
Huber, M., Rabin, B.,
Docan, C., Burdea, G.,
AbdelBaky, M.
Golomb, M., 2010
Health Source:
Nursing/Academic
Edition
Li, W., Lam-Damji, S.
Chau, T., & Fehlings,
D., 2009
CINAHL Plus with
Full Text
Reid, D., 2002a
Level 5
Expert Opinion
2
CINAHL Plus with
Full Text
Reid, D., 2002b
CINAHL Plus with
Full Text
Sandlund, M., Lindh
Waterworth, E.,
Haager, C., 2011
Education Research
Complete
Shallcross, L., 2007
Education Research
Complete
Snider L. & Majnemer,
A., 2010
STUDIES INCLUDED:
Table 3: Summary of Included Studies
Study 1: Reid, D., &
Campbell, K., 2006
Study 2: Jannink,
M.J.A., Van Der
Wilden, G.J., Navis,
D.W., Visser, G.,
Gussinklo, J., &
Ijzerman, M., 2008
Study 3: Sharan, D.,
Ajeesh, P.S.,
Rameshkumar, R.,
Mathankumar, M.,
Jospin, P.R., Manjula,
M., 2012
Design and
PEDro rating
Randomized controlled
trial, 4/8 on the PEDro
scale
Randomized controlled
trial, 3/8 on the PEDro
scale
Randomized controlled
trial, 1/8 on the PEDro
scale
Population
31 children ages 8 to 13 10 children ages 7 to 16
with CP
with CP
16 children ages 5 to 14
with CP who just
received unspecified
surgery
Intervention
Investigated
Interventions: VR
therapy alone
Interventions: VR
therapy in conjunction
with
conventional therapy
Interventions: VR
therapy in conjunction
with conventional
physical therapy (PT)
services
Comparison
Intervention
System/Games:
Mandala Gesture
Xtreme IREX; games
included sports
programs such as
soccer and volleyball,
music programs, such
as drumming, and
game-like programs,
such as jugglers,
sharks, and painting
System/Games:
Playstation 2 EyeToy;
Minigames included
Kung Foo (hit
characters falling from
tower with hand), Wishi
Washi (wash windows
with arm movement),
Keep Ups (keep up a
ball with arm
movements)
System/Games:
Nintendo Wii; games
included tennis,
baseball, golf, bowling,
and boxing, and
strength training of UE
with the Wii balance
board
Game Selection:
Children were given a
random number of
games to choose from,
and children selected
games to play
Game Selection: Based
on expert interviews
with PTs and OTs
Game Selection:
Selected by PT based on
children’s needs and
capabilities
Movements Required:
Reaching and
manipulation of the UE
Movements Required:
Gross motor movement
of the UE
Movements Required:
Gross motor movement
of the UE
Frequency/Duration: 1
time per week for 90
minutes for 8 weeks
Frequency/Duration: 2
times per week for 30
minutes for 6 weeks
Frequency/Duration:
Every alternate 3 days
per week for an
unspecified amount of
time for 3 weeks
Type: Conventional
therapy (OT, PT, or
both)
Type: Conventional
therapy (PT)
Type: Conventional
therapy (unspecified)
Frequency/Duration:
Occurred 1 time per
week on average for 8
weeks
Frequency/Duration:
Same as intervention
group
Frequency/Duration:
Not specified
Dependent
Variables
Perceived functional
use of UE (perceived
performance of daily
activities)
Motor function of UE
(reach, grasp, release,
and manipulation)
Perceived functional use
of UE (perceived
performance of
manipulating objects
during daily activities)
Melbourne Assessment
of Unilateral Upper
Limb Function
(Melbourne
Assessment)
Manual Ability
Classification System
(MACS)
The control group
varied from a 1%
decline to a 4%
improvement in motor
function. The
intervention group
varied from no change
in score to a 13%
increase in motor
function. No
statistically significant
differences were found
between groups. Pvalues could not be
calculated due to lack of
information regarding
the Melbourne
Assessment.
There were statistically
significant
improvements in
perceived functional use
for the control group
(t=3.5, p<0.01) and the
intervention group
(t=2.28, p<0.05).
Effect sizes for motor
function could not be
calculated, as there is no
standard deviation
Effect size for perceived
functional use was small
between groups (.16).
Effect size was small
Motor function of UE
(isolated movements)
Outcome
Measures
Canadian Occupational
Performance Measure
(COPM) performance
scale
Quality of Upper
Extremity Skills Test
(QUEST)
Results
Both groups showed
improvements in
perceived functional
use. No statistically
significant differences
were found between
groups (t=-1.63,
p=0.12).
Both groups showed
improvements in motor
function. No
statistically significant
differences were found
between groups
(t=0.82, p=0.43).
Effect Size
Effect size was large
for perceived functional
use between groups
(0.93). Effect size was
No statistically
significant differences
were found between
groups (t=1.12, p>0.05).
large within groups for
both the intervention
group (2.95) and
control group (0.98).
available for the
Melbourne Assessment.
within both the
intervention group (0.28) and control group
(-0.39).
The use of Playstation
EyeToy in conjunction
with conventional PT
may be beneficial in
improving motor
functions of the UE in
children with CP.
Both groups showed
statistically significant
improvements, but there
were no statistically
significant differences
between the groups for
perceived functional
use.
Effect size was small
for motor function
between groups (-0.23).
Effect size was small
within both the
intervention group
(0.12) and control
group (0.33).
Conclusion
Both groups showed
improvements in
perceived functional
use and motor function,
but there were no
statistically significant
differences between the
groups for either
variable.
A large effect size was
found within both
groups for perceived
functional use,
indicating that both VR
therapy and
conventional therapy
groups had a large
change in perceived
functional use.
A large effect size
between groups was
found, indicating that
the VR therapy group a
larger change in
The use of Nintendo
Wii in conjunction with
conventional therapy
may be as effective as
conventional therapy in
improving perceived
functional use of the UE
in children with CP.
perceived functional
use than the
conventional therapy
group.
The use of Mandala
Gesture Xtreme IREX
may be beneficial in
improving perceived
functional use and
motor function of the
UE in children with CP.
The improvements seen
with VR therapy may
be as effective as
improvements seen in
conventional therapy.
IMPLICATIONS FOR PRACTICE, EDUCATION and FUTURE RESEARCH
Overall Conclusions:
The three reviewed studies compared VR therapy in conjunction with conventional therapy to
conventional therapy, with the exception of Reid and Campbell (2006), which compared VR
therapy alone to conventional therapy. The studies were low-quality randomized controlled trials
that measured perceived functional use and/or motor function in children with CP.
Perceived functional use is the child’s or caregiver’s perception of the child’s performance in selfcare activities, volunteering, or school (Reid & Campbell, 2006) or in handling items during daily
activities (Sharan et al., 2012). Studies found perceived functional use improved overall from pretest to post-test in both groups, but changes were not statistically significant. Reid and Campbell
(2006) found a large effect size within both groups, indicating that both the VR therapy and
conventional therapy groups had large improvements in perceived functional use. A large effect
size between groups was found, indicating the VR therapy group had a greater change in perceived
functional use compared to the conventional therapy group.
Motor function includes movements of the UE(s), such as reaching, grasping, releasing, and
manipulating unilaterally (Jannink et al., 2008) and bilateral isolation of shoulder, elbow, wrist,
and fingers, and grasp and release (Reid & Campbell, 2006). Studies found motor function
improved overall from pre-test to post-test in both groups, but changes were not statistically
significant.
No statistically significant results were found for perceived functional use or motor function
despite differences among the articles. Intervention groups in Jannink et al. (2008) and Sharan et
al. (2012) received both VR and conventional therapy, while control groups received only
conventional therapy. The intervention group in Reid and Campbell (2006) received only VR
therapy, while the control group received conventional therapy.
Reid and Campbell (2006) used the Mandala Xtreme IREX, Jannink et al. (2008) used the
Playstation 2 EyeToy, and Sharan et al. (2012) used the Nintendo Wii/Wii Fit. Different games
were chosen depending on the system used. Jannink et al. (2008) and Sharan et al. (2012) selected
games based on the expertise of occupational and/or physical therapists. Games focused on UE
movements in all studies.
Children in the intervention group in Reid and Campbell (2006) received one 90-minute session
per week for eight weeks, for a total of 12 hours. Children in the intervention group in Jannink et
al. (2008) received two 30-minute sessions per week for six weeks, for a total of six hours. Children
in the intervention group in Sharan et al. (2012) received an unspecified amount of therapy, every
third alternating day per week, for three weeks.
Reid and Campbell (2006) occurred in a laboratory and Jannink et al. (2008) occurred in a
rehabilitation center. Reid and Campbell (2006), Sharan et al. (2012), and Jannink et al. (2008)
included 31, 16, and 10 children, respectively. Children in all three studies received therapy on a
one-to-one basis for both the intervention and control groups.
In conclusion, there is limited evidence from low-quality randomized controlled trials suggesting
VR therapy is as effective as conventional therapy in improving perceived functional use and
motor function of the affected UE(s) in children with CP.
Boundaries:
Studies used 57 children with CP, ages 5-16, with varying levels of tone. Children were included
if they possessed voluntary movement of at least one affected UE and no accompanying conditions,
with the exception of Sharan et al. (2012), in which children had recently undergone unspecified
surgery.
Implications for Practice:
Although no statistically significant differences were found between groups, improvements in
perceived functional use and motor function were noted in all groups. Improvements were found
regardless of whether VR therapy was used alone or in conjunction with conventional therapy.
Improvements were also found regardless of VR system, games, location, frequency, and duration.
Due to the limited research available, the most effective VR therapy protocol has not been
established. The following information regarding treatment protocol is unknown: which VR
system, game(s), treatment location, duration, and frequency are most effective, whether VR
therapy is more effective alone or in conjunction with conventional therapy, whether VR therapy
is effective in children who have an accompanying disorder(s), whether VR therapy is effective as
a home program, and whether VR therapy is effective in a group format.
As a result of the limited evidence available, further research is needed to determine the most
effective VR therapy protocol to improve perceived functional use and motor function in children
with CP.
REFERENCES:
Reviewed Articles
Jannink, M.J.A., Van Der Wilden, G.J., Navis, D.W., Visser, G., Gussinklo, J., & Ijzerman, M.
(2008). A low-cost video game applied for training of upper extremity function in
children with cerebral palsy: A pilot study. Cyberpsychology & Behavior, 11(1), 27-32.
Reid, D., & Campbell, K. (2006). The use of virtual reality with children with cerebral palsy: A
pilot randomized trial. Therapeutic Recreation Journal, 40(4), 255-268.
Sharan, D., Ajeesh, P., Rameshkumar, R., Mathankumar, M., Paulina, R., & Manjula, M. (2012).
Virtual reality based therapy for post operative rehabilitation of children with cerebral
palsy. Work (Reading, Mass.), 41, 3612-3615.
Related Articles (Not Individually Appraised)
Bryanton, C., Bossé, J., Brien, M., Mclean, J., McCormick, A., & Sveistrup, H. (2006).
Feasibility, motivation, and selective motor control: Virtual reality compared to
conventional home exercise in children with cerebral palsy. Cyberpsychology &
Behavior, 9(2), 123-128.
Chen, Y., Kang, L., Chuang, T., Doong, J., Lee, S., Tsai, M., Jeng, S., & Sung, W. (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. doi:10.2522/ptj.20060062
Deutsch, J.E., Borbely, M., Filler, J., Huhn, K., & Guarrera-Bowlby, P. (2008). Use of a lowcost,
commercially available gaming console (wii) for rehabilitation of an adolescent with
cerebral palsy. Physical Therapy, 88(10), 1196-1207. doi:10.2522/ptj.20080062
Galvin, J., McDonald, R., Catroppa, C., & Anderson, V. (2011). Does intervention using virtual
reality improve upper limb function in children with neurological impairment: A
systematic review of the evidence. Brain Injury, 25(5), 435-442.
Galvin, J., & Levac, D. (2011). Facilitating clinical decision-making about the use of virtual
reality within paediatric motor rehabilitation: Describing and classifying virtual reality
systems. Developmental Neurorehabilitation, 14(2), 112-122.
Golomb, M., McDonald, B., Warden, S., Yonkman, J., Saykin, A., Shirley, B., Huber, M., Rabin,
B., AbdelBaky M., Nwosu, M., & Burdea, G. (2010). In-home virtual reality videogame
telerehabilitation in adolescents with hemiplegic cerebral palsy. Archives Of Physical
Medicine & Rehabilitation, 91(1), 1-8.
Golomb, M., Warden, S., Fess, E., Rabin, B., Yorkman, J., Shirley, B., Burdea, G. (2011).
Maintained hand function an forearm bone health 14 months after an in-home virtualreality videogame hand telerehabilitation intervention in an adolescent with hemiplegic
cerebral palsy. Journal of Child Neurology, 26(3), 389-393.
Green, D. & Wilson, P. (2012). Use of virtual reality in rehabilitation of movement in children
with hemiplegia: A multiple case study evaluation. Disability & Rehabilitation, 34(7),
593-604.
Huber, M., Rabin, B., Docan, C., Burdea, G., AbdelBaky, M., & Golomb, M. (2010).
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Li, W., Lam-Damji, S., Chau, T., & Fehlings, D. (2009). The development of a home-based
virtual reality therapy system to promote upper extremity movement for children with
hemiplegic cerebral palsy. Technology & Disability, 21(3), 107-113.
Reid, D. (2002a). Benefits of a virtual play rehabilitation environment for children with cerebral
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Reid, D. (2002b). 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.
Sandlund, M., Lindh Waterworth, E., & Häger, C. (2011). Using motion interactive games to
promote physical activity and enhance motor performance in children with cerebral palsy.
Developmental Neurorehabilitation, 14(1), 15-21. doi:10.3109/17518423.2010.533329
Sandlund, M., Mcdonough, S., & Häger, C. (2009). Interactive computer play in rehabilitation of
children with sensorimotor disorders: a systematic review. Developmental Medicine &
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Shallcross, L. (2007). I want my therapy! Now!. ASEE Prism, 16(8), 45.
Snider, L., & Majnemer, A. (2010). Virtual reality: We are virtually there. Physical &
Occupational Therapy In Pediatrics, 30(1), 1-3. doi:10.3109/01942630903476131
Snider, L., Majnemer, A., & Darsaklis, V. (2010). Virtual reality as a therapeutic modality for
children with cerebral palsy. Developmental Neurorehabilitation, 13(2), 120-128.
Wang, M., & Reid, D. (2011). Virtual reality in pediatric neurorehabilitation: attention deficit
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Additional References
American Occupational Therapy Association. (2008). Occupational therapy practice framework:
Domain and process. American Journal of Occupational Therapy, 56, 625–683.
Bertoti, D.B. (2004). Functional neurorehabilitation through the life span. Philadelphia, PA:
F.A.
Davis Company.
Pendleton, H.M., & Krohn, W.S. (Eds.). (2006) Pedretti’s occupational therapy: Practice skills
for physical dysfunction (6th ed.). St. Louis, MO: Mosby, Inc.