Lauren Switzer

Designing action-based exergames for children with cerebral palsy

Children with cerebral palsy (CP) want to play fast-paced action-oriented videogames similar to those played by their peers without motor disabilities. This is particularly true of exergames, whose physically-active gameplay matches the fast pace of action games. But disabilities resulting from CP can make it difficult to play action games. Guidelines for developing games for people with motor disabilities steer away from high-paced action, including recommendations to avoid the need for time-sensitive actions and to keep game pace slow. Through a year-long participatory design process with children with CP, we have discovered that it is in fact possible to develop action-oriented exergames for children with CP at level III on the Gross Motor Function Classification Scale. We followed up the design process with an eight-week home trial, in which we found the games to be playable and enjoyable. In this paper, we discuss the design of these games, and present a set of design recommendations for how to achieve both action-orientation and playability.

Characteristics of pain in children and youth with cerebral palsy

OBJECTIVES: Pain in children with cerebral palsy (CP) is underrecognized, undertreated, and negatively affects quality of life. Communication challenges and multiple pain etiologies complicate diagnosis and treatment. The primary objectives of this study were to determine the impact of pain on activities and to identify the common physician-identified causes of pain in children and youth ages 3 to 19 years across all levels of severity of CP. METHODS: The study design was cross-sectional, whereby children/youth aged 3 to 19 years and their families were consecutively recruited. The primary caregivers were asked to complete a one-time questionnaire, including the Health Utilities Index 3 pain subset, about the presence and characteristics of pain. The treating physician was asked to identify the presence of pain and provide a clinical diagnosis for the pain, if applicable. RESULTS: The response rate was 92%. Of 252 participants, 54.8% reported some pain on the Health Utilities Index 3, with 24.4% of the caregivers reporting that their child experienced pain that affected some level of activities in the preceding 2 weeks. Physicians reported pain in 38.7% and identified hip dislocation/subluxation, dystonia, and constipation as the most frequent causes of pain. CONCLUSIONS: One-quarter of our sample experienced pain that limited activities and participation. Clinicians should be aware that hip subluxation/dislocation and dystonia were the most common causes of pain in children/youth with CP in this study. Potential causes of pain should be identified and addressed early to mitigate the negative impact of pain on quality of life.

Informing evidence‐based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: a systematic review

Aim  The aim of this systematic review was to inform evidence‐based clinical practice guidelines for children with cerebral palsy (CP) and low bone mineral density (BMD).

Design of an exergaming station for children with cerebral palsy

We report on the design of a novel station supporting the play of exercise video games (exergames) by children with cerebral palsy (CP). The station combines a physical platform allowing children with CP to provide pedaling input into a game, a standard Xbox 360 controller, and algorithms for interpreting the cycling input to improve smoothness and accuracy of gameplay. The station was designed through an iterative and incremental participatory design process involving medical professionals, game designers, computer scientists, kinesiologists, physical therapists, and eight children with CP. It has been tested through observation of its use, through gathering opinions from the children, and through small experimental studies. With our initial design, only three of eight children were capable of playing a cycling-based game; with the final design, seven of eight could cycle effectively, and six reached energy expenditure levels recommended by the American College of Sports Medicine while pedaling unassisted.

Interactive Computer Play as "Motor Therapy" for Individuals With Cerebral Palsy

The aim of the study was to evaluate the quality of evidence for interactive computer play (ICP) to improve motor performance (including motor control, strength, or cardiovascular [CVS] fitness) in individuals with cerebral palsy. A computer-assisted literature search was completed, focusing on ICP as a therapeutic modality to improve motor outcomes in individuals of all ages with cerebral palsy with a specific focus on upper and lower extremity motor outcomes and promotion of CVS fitness. Articles were classified according to American Academy of Neurology guidelines and recommendation classifications were given based on the levels of evidence. Seventeen articles underwent full-text review including 6 on upper extremity motor function, 5 on lower extremity motor function, 1 on CVS fitness, and 5 on studies with a combination of upper or lower extremity or CVS fitness focus or both. Overall, there was level B (probable) evidence for ICP interventions to improve lower extremity motor control or function. However, there was inadequate evidence (level U) for ICP interventions improving upper limb motor control or function or CVS fitness. Although promising trends are apparent, the strongest level of evidence exists for the use of ICP to improve gross motor outcomes. Additional evidence is warranted especially when evaluating the effect of ICP on upper limb motor outcomes and CVS fitness.

Design and evaluation of a networked game to supportsocial connection of youth with cerebral palsy

Youth with cerebral palsy (CP) can experience social isolation, in part due to mobility limitations associated with CP. We show that networked video games can provide a venue for social interaction from the home. We address the question of how to design networked games that enhance social play among people with motor disabilities. We present Liberi, a networked game custom-designed for youth with CP. Liberi is designed to allow frictionless group formation, to balance for differences in player abilities, and to support a variety of play styles. A ten-week home-based study with ten participants showed the game to be effective in fostering social interaction among youth with CP.

Investigating the impact of pain, age, Gross Motor Function Classification System, and sex on health-related quality of life in children with cerebral palsy.

To explore whether health‐related quality of life (HRQOL) can be predicted by pain, age, Gross Motor Function Classification System (GMFCS) level, and sex in children with cerebral palsy (CP) and whether different pain etiologies have varying effects on HRQOL.

Informing evidence‐based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: an update

To investigate the impact of new evidence for weight‐bearing, bisphosphonates, and vitamin D and calcium interventions, towards updating the systematic review and clinical practice guidelines for osteoporosis in children with cerebral palsy (CP) published in 2011.

Resting State and Diffusion Neuroimaging Predictors of Clinical Improvements Following Constraint-Induced Movement Therapy in Children With Hemiplegic Cerebral Palsy.

The aim was to identify neuroimaging predictors of clinical improvements following constraint-induced movement therapy. Resting state functional magnetic resonance and diffusion tensor imaging data was acquired in 7 children with hemiplegic cerebral palsy. Clinical and magnetic resonance imaging (MRI) data were acquired at baseline and 1 month later following a 3-week constraint therapy regimen. A more negative baseline laterality index characterizing an atypical unilateral sensorimotor resting state network significantly correlated with an improvement in the Canadian Occupational Performance Measure score (r = –0.81, P = .03). A more unilateral network with decreased activity in the affected hemisphere was associated with greater improvements in clinical scores. Higher mean diffusivity in the posterior limb of the internal capsule of the affect tract correlated significantly with improvements in the Jebsen-Taylor score (r = –0.83, P = .02). Children with more compromised networks and tracts improved the most following constraint therapy.

Further evaluation of the scoring, reliability, and validity of the Hypertonia Assessment Tool (HAT).

We assessed the impact of videotape analysis on scoring of the Hypertonia Assessment Tool (HAT) that discriminates between hypertonia subtypes. The HAT was administered to 28 children with cerebral palsy (mean age 9 years, range 4-17 years, 61% male). HAT examinations were videotaped; scores were assigned before and after videotape review. Neurological examination provided the gold standard diagnosis. Interrater reliability, criterion validity and individual item validation were assessed using prevalence and bias-adjusted kappa (PABAK). Videotape review did not significantly change the HAT item scores or diagnoses. Item validation eliminated 1 dystonia item. Interrater reliability was moderate for dystonia (PABAK = 0.43) and excellent for spasticity and rigidity (PABAK = 0.86-1.0). Criterion validity was substantial for spasticity (PABAK = 0.71), moderate for dystonia (PABAK = 0.43-0.57) and excellent for the absence of rigidity (PABAK = 1.0). The HAT can be administered without videotape review. Dystonia item 1 did not change the HAT hypertonia diagnosis and will be removed from the HAT.