Nick Preston

Engaging children in healthcare technology design: developing rehabilitation technology for children with cerebral palsy

This paper presents a case study of users’ involvement in the design and evaluation of two devices for upper limb rehabilitation for children with cerebral palsy to use in their homes. The devices comprise a computer game and a force feedback interface, designed to stimulate children with cerebral palsy to undertake fun arm exercises that are beneficial in terms of improving overall functional use of their impaired arm. This device was developed for children using a combination of informal and formal user-centred design methods. The methods used include standard questionnaires, interviews, a modified peer tutoring process and a comparative method, and have been applied to the iterative design of both the hardware and software components of the rehabilitation systems. Thirty-seven non-disabled children and 15 children with cerebral palsy in the 5–12-year-old age group were involved in the evaluation, held at six local primary schools. Prototypes of the final design were used by 18 patients with cerebral palsy for approximately 4 weeks as a therapeutic intervention. To evaluate the designs, qualitative and questionnaire-based opinion was sought from these children, and their parents, at the end of the intervention. An evaluation of the methodologies employed is presented.

HOME-BASED COMPUTER-ASSISTED UPPER LIMB EXERCISE FOR YOUNG CHILDREN WITH CEREBRAL PALSY: A FEASIBILITY STUDY INVESTIGATING IMPACT ON MOTOR CONTROL AND FUNCTIONAL OUTCOME

OBJECTIVE We developed a home-based rehabilitation exercise system incorporating a powered joystick linked to a computer game, to enable children with arm paresis to participate in independent home exercise. We investigated the feasibility and impact of using the system in the home setting. METHODS Eighteen children with cerebral palsy (median age 7.5 years, age range 5-16 years) were recruited from local National Health Service and the exercise system was installed in their home for approximately 4 weeks. Baseline and post-intervention assessments were taken: Canadian Occupational Performance Measure (COPM); kinematic measurement of movement quality (indexed by duration and smoothness) measured using a motion tracking system when performing a standardized computer task. RESULTS The system was used for a median time of 75 min (interquartile range (IQR) 17-271), equating to 606 outward and 734 inward movements. Pre-COPM, (median 4.2); post-COPM (median 6.0); obs=34; z=3.62, p<0.01). Kinematic analysis of pre- and post-intervention movements on the standardized task showed decreased duration and increased smoothness. CONCLUSION Some improvements in self-reported function and quality of movement are observed. This pilot study suggests that the system could be used to augment home-based arm exercise in an engaging way for children with cerebral palsy, although a controlled clinical trial is required to establish clinical efficacy. The feasibility of this technology has been demonstrated.

A systematic review of high quality randomized controlled trials investigating motor skill programmes for children with developmental coordination disorder

Objective: To identify effective motor training interventions for children with developmental coordination disorder from research graded as high quality (using objective criteria) for the purpose of informing evidence-based clinical practice. Data sources: We followed the guidance for conducting systematic reviews issued by the Centre for Reviews and Dissemination. Six OvidSP electronic databases (AMED, All EBM reviews (including Cochrane), Embase, Ovid MEDLINE, PsychARTICLES Full Text, PsycINFO) were searched systematically. We aimed to retain only randomized control trials and systematic reviews of randomized control trials, defined as the highest level of evidence by the Oxford Centre for Evidence-Based Medicine. We searched reference lists of retained articles to identify further appropriate articles. Review methods: Two reviewers critically appraised and categorized articles by effect size (including confidence intervals), inclusion of power calculations and quality using the Physiotherapy Evidence Database (PEDro) scale. Only studies scoring seven or more on the PEDro scale (classed by the PEDro as high reliability) were retained. Results: No systematic reviews met our criteria for inclusion from 846 articles yielded by the systematic search. Nine randomized control trials investigating 15 interventions to improve motor skills met our inclusion criteria for ‘high quality’. Nevertheless, not all included studies were adequately powered for determining an effect. Conclusion: Large effect sizes associated with 95 % confidence intervals suggest that ‘Neuromotor Task Training’, ‘Task-oriented Motor Training’ and ‘Motor Imagery + Task Practice Training’ are the most effective reported interventions for improving motor skills in children with developmental coordination disorder.

Development of a framework to define the functional goals and outcomes of botulinum toxin A spasticity treatment relevant to the child and family living with cerebral palsy using the International Classification of Functioning, Disability and Health for Children and Youth.

OBJECTIVE To define a sub-set of functional goals and outcomes relevant to children and families living with cerebral palsy following treatment with botulinum toxin type A using the International Classification of Functioning, Disability and Health for Children and Youth. METHODS We identified treatment goals and treatment outcomes from medical case records in 2102 assessments of 239 children with cerebral palsy treated with botulinum toxin between 1994 and 2009. Goals were set through assessment and discussion by experienced clinicians, therapists, parents and children. RESULTS There were 61 separate goals, mapping to 40 categories, falling mostly within Body Functions: b710 Mobility of joint functions (414 times); b770 Gait pattern functions (374 times); b7351 Tone of muscles of one limb (117 times). A total of 93 separate treatment outcomes were identified, mapping to 51 categories. Two of the 3 most common outcomes correspond to the 2 most common goals (gait pattern and mobility of joint functions). CONCLUSION The International Classification of Functioning, Disability and Health for Children and Youth provides a useful framework to categorize the reasons for using botulinum toxin in children and focuses the clinical consultation not only on impairments but also functional outcomes.

A pilot single-blind multicentre randomized controlled trial to evaluate the potential benefits of computer-assisted arm rehabilitation gaming technology on the arm function of children with spastic cerebral palsy:

Objective: To evaluate the potential benefits of computer-assisted arm rehabilitation gaming technology on arm function of children with spastic cerebral palsy. Design: A single-blind randomized controlled trial design. Power calculations indicated that 58 children would be required to demonstrate a clinically important difference. Setting: Intervention was home-based; recruitment took place in regional spasticity clinics. Participants: A total of 15 children with cerebral palsy aged five to 12 years were recruited; eight to the device group. Interventions: Both study groups received ‘usual follow-up treatment’ following spasticity treatment with botulinum toxin; the intervention group also received a rehabilitation gaming device. Main measures: ABILHAND-kids and Canadian Occupational Performance Measure were performed by blinded assessors at baseline, six and 12 weeks. Results: An analysis of covariance showed no group differences in mean ABILHAND-kids scores between time points. A non-parametric analysis of variance on Canadian Occupational Performance Measure scores showed a statistically significant improvement across time points (χ2 (2,15) = 6.778, p = 0.031), but this improvement did not reach minimal clinically important difference. Mean daily device use was seven minutes. Recruitment did not reach target owing to unanticipated staff shortages in clinical services. Feedback from children and their families indicated that the games were not sufficiently engaging to promote sufficient use that was likely to result in functional benefits. Conclusion: This study suggests that computer-assisted arm rehabilitation gaming does not benefit arm function, but a Type II error cannot be ruled out.

Feasibility of school-based computer-assisted robotic gaming technology for upper limb rehabilitation of children with cerebral palsy

Abstract Introduction: We investigated the feasibility of using computer-assisted arm rehabilitation (CAAR) computer games in schools. Outcomes were childrens preference for single player or dual player mode, and changes in arm activity and kinematics. Method: Nine boys and two girls with cerebral palsy (6–12 years, mean 9 years) played assistive technology computer games in single-user mode or with school friends in an AB–BA design. Preference was determined by recording the time spent playing each mode and by qualitative feedback. We used the ABILHAND-kids and Canadian Occupational Performance Measure to evaluate activity limitation, and a portable laptop-based device to capture arm kinematics. Results: No difference was recorded between single-user and dual-user modes (median daily use 9.27 versus 11.2 min, p = 0.214). Children reported dual-user mode was preferable. There were no changes in activity limitation (ABILHAND-kids, p = 0.424; COPM, p = 0.484) but we found significant improvements in hand speed (p = 0.028), smoothness (p = 0.005) and accuracy (p = 0.007). Conclusion: School timetables prohibit extensive use of rehabilitation technology but there is potential for its short-term use to supplement a rehabilitation program. The restricted access to the rehabilitation games was sufficient to improve arm kinematics but not arm activity. Implications for Rehabilitation School premises and teaching staff present no obstacles to the installation of rehabilitation gaming technology. Twelve minutes per day is the average amount of time that the school time table permits children to use rehabilitation gaming equipment (without disruption to academic attendance). The use of rehabilitation gaming technology for an average of 12 minutes daily does not appear to benefit childrens functional performance, but there are improvements in the kinematics of childrens upper limb.

The nature of arm movement in children with cerebral palsy when using computer-generated exercise games

Abstract Purpose: To compare upper limb kinematics of children with spastic cerebral palsy (CP) using a passive rehabilitation joystick with those of adults and able-bodied children, to better understand the design requirements of computer-based rehabilitation devices. Method: A blocked comparative study involving seven children with spastic CP, nine able-bodied adults and nine able-bodied children, using a joystick system to play a computer game whilst the kinematics of their upper limb were recorded. The translational kinematics of the joystick’s end point and the participant’s shoulder movement (protraction/retraction) and elbow rotational kinematics (flexion/extension) were analysed for each group. Results: Children with spastic CP matched their able-bodied peers in the time taken to complete the computer task, but this was due to a failure to adhere to the task instructions of travelling along a prescribed straight line when moving between targets. The spastic CP group took longer to initiate the first movement, which showed jerkier trajectories and demonstrated qualitatively different movement patterns when using the joystick, with shoulder movements that were significantly of greater magnitude than the able-bodied participants. Conclusions: Children with spastic CP generate large shoulder and hence trunk movements when using a joystick to undertake computer-generated arm exercises. This finding has implications for the development and use of assistive technologies to encourage exercise and the instructions given to users of such systems. Implications for Rehabilitation A kinematic analysis of upper limb function of children with CP when using joystick devices is presented. Children with CP may use upper body movements to compensate for limitations in voluntary shoulder and elbow movements when undertaking computer games designed to encourage the practice of arm movement. The design of rehabilitative computer exercise systems should consider movement of the torso/shoulder as it may have implications for the quality of therapy in the rehabilitation of the upper limb in children with CP.

Assessment of upper limb movement with an autonomous robotic device in a school environment for children with Cerebral Palsy

Robotic devices are becoming more prevalent in rehabilitation of neurological disorders. Studies focus on clinical measures alongside robotic intervention, but assessment data can be collected as the subjects are using the rehabilitation device. As part of an autonomous robotic rehabilitation device in primary schools, this paper introduces an assessment tool that can engage subjects and measure performance on a more granular scale across an 8 week intervention. The deployments are split in to two parts of single and dual use with a 4 week washout period in-between. Analysis of the scores achieved on the assessment task show improvement on the rehabilitation system, and the data can also be used as part of an adaptive algorithm for the robotic assistance. The data on this pilot study with 11 children with Cerebral Palsy shows that the assessment task can pick up trends of improvement across the deployments. Although the data is noisy, there is significant difference over the washout period, which shows that improvement is maintained after rehabilitation training. The order of single and dual use of the device did not influence the improvement. The simplicity of the assessment tasks makes implementation easy, and collects enough data over a short period of time for significant changes.

The Cerebral Palsy Kinematic Assessment Tool (CPKAT): feasibility testing of a new portable tool for the objective evaluation of upper limb kinematics in children with cerebral palsy in the non-laboratory setting

Abstract Purpose: Efficacy of treatment to improve upper-limb activity of children with cerebral palsy (CP) is typically evaluated outside clinical/laboratory environments through functional outcome measures (e.g. ABILHAND kids). This study evaluates CPKAT, a new portable laptop-based tool designed to objectively measure upper-limb kinematics in children with CP. Methods: Seven children with unilateral CP (2 females; mean age 10 years 2 months (SD 2 years 3 months), median age 9 years 6 months, range 6 years 5 months, MACS II–IV) were evaluated on copying, tracking and tracing tasks at their homes using CPKAT. CPKAT recorded parameters relating to spatiotemporal hand movement: path length, movement time, smoothness, path accuracy and root mean square error. The Wilcoxon signed ranks test explored whether CPKAT could detect differences between the affected and less-affected limb. Results: CPKAT detected intra-limb differences for movement time and smoothness (aiming), and path length (tracing). No intra-limb tracking differences were found, as hypothesised. These findings are consistent with other studies showing that movements of the impaired upper limb in unilateral CP are slower and less smooth. Conclusion: CPKAT provides a potential solution for home-based assessment of upper limb kinematics in children with CP to supplement other measures and assess functional intervention outcomes. Further validation is required. Implications for Rehabilitation This paper demonstrates the feasibility of evaluating upper limb kinematics in home using CPKAT, a portable laptop-based evaluation tool. We found that CPKAT is easy to set-up and use in home environments and yields useful kinematic measures of upper limb function. CPKAT can complement less responsive patient reported or subjectively evaluated functional measures for a more complete evaluation of children with cerebral palsy. Thus, CPKAT can help guide a multi-disciplinary team to more effective intervention and rehabilitation for children with cerebral palsy.

Development of a parent‐reported questionnaire evaluating upper limb activity limitation in children with cerebral palsy

Abstract Background and purpose Upper limb activity measures for children with cerebral palsy have a number of limitations, for example, lack of validity and poor responsiveness. To overcome these limitations, we developed the Childrens Arm Rehabilitation Measure (ChARM), a parent‐reported questionnaire validated for children with cerebral palsy aged 5–16 years. This paper describes both the development of the ChARM items and response categories and its psychometric testing and further refinement using the Rasch measurement model. Methods To generate valid items for the ChARM, we collected goals of therapy specifically developed by therapists, children with cerebral palsy, and their parents for improving activity limitation of the upper limb. The activities, which were the focus of these goals, formed the basis for the items. Therapists typically break an activity into natural stages for the purpose of improving activity performance, and these natural orders of achievement formed each items response options. Items underwent face validity testing with health care professionals, parents of children with cerebral palsy, academics, and lay persons. A Rasch analysis was performed on ChARM questionnaires completed by the parents of 170 children with cerebral palsy from 12 hospital paediatric services. The ChARM was amended, and the procedure repeated on 148 ChARMs (from childrens mean age: 10 years and 1 month; range: 4 years and 8 months to 16 years and 11 months; 85 males; Manual Ability Classification System Levels I = 9, II = 26, III = 48, IV = 45, and V = 18). Results The final 19‐item unidimensional questionnaire displayed fit to the Rasch model (chi‐square p = .18), excellent reliability (person separation index = 0.95, α = 0.95), and no floor or ceiling effects. Items showed no response bias for gender, distribution of impairment, age, or learning disability. Discussion The ChARM is a psychometrically sound measure of upper limb activity validated for children with cerebral palsy aged 5–16 years. The ChARM is freely available for use to clinicians and nonprofit organisations.