Virtual Reality Gaming for
Treadmill Training:
Improving Functional Ambulation
in Children with Cerebral Palsy
Karen Kott
School of Physical Therapy, Old Dominion University
Gianluca De Leo
Virginia Modeling Analysis and Simulation Center, Old Dominion University
Katrina Lesher
Physical Medicine and Rehabilitation, Eastern Virginia Medical School
Eleonora Brivio
Virginia Modeling Analysis and Simulation Center, Old Dominion University
Steven Morrison
School of Physical Therapy, Old Dominion University
Background

Cerebral Palsy1
 Describes
group of permanent disorders that
are non-progressive (2-3/1,000)
 Occur in the fetal or infant brain
 Impact development of movement and
posture
 Causing activity limitation
Background

Different clinical presentations
 Abnormal
muscle tone (hypertonia & hypotonia)
 Abnormal coordination (ataxia)
 Movement abnormality (dystonia & athetosis)

Accompanying impairments
 Sensation,
perception, cognition, communication,
behavior, seizures
 Secondary musculoskeletal system i.e. weakness and
limited range of motion
Background

Functional mobility or activity limitation
 Means
to classify severity of movement disability
 Key function of ambulation
 Ambulation is the basis for standardized system of
classification

Gross Motor Function Classification System (GMFCS)2
 Loss or limited ambulation
 Impacts the lifetime costs for care3
 Limits the quality of life
 Can lead to an early death4
Literature Review

Rehabilitation
 Ambulation

training
“Best practices” for motor learning movements5
Self-initiated and useful
 Able to adapt to the environment
 Practiced repetitively
 Goal driven related to functional tasks

Treadmill feasible tool for CP6
 How to make it interesting?

Integrate with play and Virtual Reality (VR)7,8
 VR + gait training can change spatiotemporal
parameters9

Research Pilot Study

Purpose: Design, develop, and test the use of
a virtual game to improve ambulation in children

Participants:
 CP
 ages
5-15 years
 ability to walk with no assistive devices except
orthoses
 no cardiopulmonary limitations
Research Study

Methods:
 One
group:
pre-test/post-test design
 Measurement tool:
Standardized Walking
Obstacle Course
(SWOC)10
Research Study

Treatment Protocol
 Watch
VR DVD (5,10,15 minutes segments)
 Walk on treadmill (completing 9 hours of training)




Initial speed calculated from walk hands free condition of the
SWOC
Monitor HR via pulse
Increased speed as tolerated by .1 mph
Safety and rest
 Receive
reinforcement via coins, diamonds and
verbal prompting
VR Game Solution




Toys do not have rules or goals
Puzzles have goals
Games have rules and goals
A game must include

Play activity
 Pretended reality
 A nontrivial goal
 Rules
VR Game Solution
1) design of the virtual environments,
 2) render of the virtual environments,
 3) edit of the final video.

Lightwave application software
 Rendered on a cluster
 Solution available on DVD

VR Game Solution
Positive reinforcements by:


Receiving verbal feedbacks from VR characters (“keep
walking we have to save the princess”)
Earning points. Points accumulated in the concrete form
of diamonds, coins, magic shield, staff and glue (used to
fight the dragon at the end) that adhered to a magic shirt
that the child wore.
The use of the magic shirt helped the child feel more
immersed in the game.
VR Game Solution
QuickTime™ and a
Sorenson Video 3 decompressor
are needed to see this picture.
Results
35
60
30
50
20
15
40
35
40
Time in Seconds
25
Time in Seconds
Time in Seconds
Average (SD) time all children pre-test to post-test condition of:
30
20
10
10
30
25
20
15
10
5
5
0
0
1
0
Pre and Post Tests
walk with hands free
2
Pre and Post Tests
walk with tray
1
2
Pre and Post Tests
walk with glasses
Results
-) Positive feedback from subjects, their brothers and sisters and their parents
-) All of the subjects completed the training (ca. 9 hours of walking)
References
1.Bax, M., Goldstein, M., Rosenbaum, P., Leviton, A., Paneth, N (2007)
Proposed definition and classification of Cerebral Palsy. Developmental
Medicine & Child Neurology, 109, 49: 571-576.
2. Palisano, R.J., Hanna, S.E., Rosenbaum, P.E., Russell, D.J., Walter, S.D.,
Wood, E.P, Raina, P.S., Galuppi, B.E. (1997). Development and reliability of
a system to classify gross motor function of children with cerebral palsy.
Developmental Medicine & Child Neurology, 39, 214-223.
3. Economic Costs Associated with Mental Retardation, Cerebral Palsy,
Hearing Loss, and Vision Impairment --- United States, 2003 Morbidity and
Mortality Weekly Report (2004), 53, 03, Jan 30.
4. Day, S.M., Wu Y.W., Strauss, D.J., Shavelle, R.M., Reynolds, R.J. (2007)
Change in ambulatory ability of adolescents and young adults with cerebral
palsy. Developmental Medicine & Child Neurology, 49, 647-653.
References
5.
Valvano, J. (2005). Neuromuscular systems: the plan of care. In S. Effgen
(Ed), Meeting the physical therapy needs of children. Philadelphia: FA
Davis. 258-266.
6. Richards, C.L., Malouin, F., Dumas, F., Marcoux, S., Lepage, C.,Menier, C.
(1997). Early and intensive treadmill locomotor training for young children
with cerebral palsy: a feasibility study. Pediatric Physical Therapy, 9,4, 158165.
7. Rodgers, S., Ziviani, J. (1999) Play based occupational therapy. International
Journal of Developmental Disability Education, 46, 337-365.
8. Grealy, M.A., & Heffernan, D. (2000). The rehabilitation of brain injured
children: the case for including physical exercise and virtual reality. Pediatric
Rehabilitation, 4, 2, 41-9.
9. Deutsch, J.E., Merians, A.S., Adamovich, S., Poizner, H.,Burdea, G.C.
(2004). Development and application of virtual reality technology to improve
hand use and gait of individuals post-stroke. Restorative Neurology and
Neuroscience, 22, 3-5, 371-86.
References
10. Held, S.L., Kott, K.M.,Young, B. (2006). Standardized Walking Obstacle
Course (SWOC): reliability and validity of a functional measurement tool in
children who are developing typically and atypically. Pediatric Physical
Therapy, 18, 1, 23-30.