Sandy K. Tatla

Virtual Reality Therapy for Adults Post-Stroke: A Systematic Review and Meta-Analysis Exploring Virtual Environments and Commercial Games in Therapy

Background The objective of this analysis was to systematically review the evidence for virtual reality (VR) therapy in an adult post-stroke population in both custom built virtual environments (VE) and commercially available gaming systems (CG). Methods MEDLINE, CINAHL, EMBASE, ERIC, PSYCInfo, DARE, PEDro, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were systematically searched from the earliest available date until April 4, 2013. Controlled trials that compared VR to conventional therapy were included. Population criteria included adults (>18) post-stroke, excluding children, cerebral palsy, and other neurological disorders. Included studies were reported in English. Quality of studies was assessed with the Physiotherapy Evidence Database Scale (PEDro). Results Twenty-six studies met the inclusion criteria. For body function outcomes, there was a significant benefit of VR therapy compared to conventional therapy controls, G = 0.48, 95% CI = [0.27, 0.70], and no significant difference between VE and CG interventions (P = 0.38). For activity outcomes, there was a significant benefit of VR therapy, G = 0.58, 95% CI = [0.32, 0.85], and no significant difference between VE and CG interventions (P = 0.66). For participation outcomes, the overall effect size was G = 0.56, 95% CI = [0.02, 1.10]. All participation outcomes came from VE studies. Discussion VR rehabilitation moderately improves outcomes compared to conventional therapy in adults post-stroke. Current CG interventions have been too few and too small to assess potential benefits of CG. Future research in this area should aim to clearly define conventional therapy, report on participation measures, consider motivational components of therapy, and investigate commercially available systems in larger RCTs. Trial Registration Prospero CRD42013004338

Evidence for outcomes of motivational rehabilitation interventions for children and adolescents with cerebral palsy: an American Academy for Cerebral Palsy and Developmental Medicine systematic review

This study reviewed evidence regarding the effect of motivational rehabilitation interventions on outcomes in children with cerebral palsy. Six databases were searched for literature published up to May 2012. Included studies measured the purported motivating effects of motor‐based rehabilitation interventions and the measured impact on outcomes. The American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) systematic review methodology was used as a framework. Eight studies evaluated outcomes of studies using virtual reality interventions and one in a functional therapy context. Conflicting evidence from three (level II and level III) studies exists about the impact of these motivating interventions on motor outcomes measured in body functions. No statistical evidence regarding activity and participation outcomes exists. A single level II study found no significant difference in participants’ motivation between motivational and conventional interventions. This review revealed a paucity of research on the effects of motivational interventions. Weaknesses include a lack of consistency in the examination of motivational interventions, limited use of definitions or theories to ground the concept of motivation, and reliance on non‐validated methodological tools. This body of evidence would be strengthened by the use and development of robust outcome measures of motivation.

Wii-habilitation as balance therapy for children with acquired brain injury

Purpose: To evaluate the effectiveness of the Nintendo Wii compared to traditional balance therapy in improving balance, motivation, and functional ability in children undergoing acute rehabilitation after brain injury. Methods: A non-concurrent, randomized multiple baseline single-subject research design was used with three participants. Data were analyzed by visual inspection of trend lines. Results: Daily Wii balance training was equally motivating to traditional balance therapy for two participants and more motivating for one participant. While improvements in dynamic balance were observed, the results for static balance remain inconclusive. All participants demonstrated improvements in functional ability. Conclusion: Wii balance therapy is a safe, feasible, and motivating intervention for children undergoing acute rehabilitation after an acquired brain injury. Further research to examine the effectiveness of Wii balance therapy in this population is warranted.

The GestureTek virtual reality system in rehabilitation: a scoping review

Abstract Purpose: To identify, to map out and to appraise research examining GestureTek virtual reality (VR) use for physical and cognitive rehabilitation and to highlight areas for future research. Method: Scoping review methodology was used to systematically and comprehensively search the academic and grey literature for GestureTek-specific research. Consensus was achieved following two reviewers’ independent inclusion screening, data extraction and appraisal. Results: Forty-four studies evaluated the utility and efficacy of the IREX, GX, VMall and Meal Maker software for rehabilitation across a range of populations, with few adverse events reported. Stroke and cerebral palsy research dominated, while geriatrics was largely overlooked. Efficacy research provided support for balance, mobility, upper extremity, cognitive, fitness and daily living skills outcomes for specific populations with effect sizes ranging from 0.19 to 3.34. Nevertheless, few strong quality or high-level studies are available, and no clear guidelines on optimal treatment characteristics exist. Outcomes of primary interest were at ICF body function and activity levels; evaluation of transfer of training across ICF levels is needed. Conclusions: This literature provides preliminary evidence for the technology’s efficacy for rehabilitation. Identified research gaps relate to study quality and design, treatment characteristics, populations and outcomes of interest, including transfer across ICF levels. Implications for Rehabilitation There is limited high-level evidence to support the use of the GestureTek virtual reality system for rehabilitation. Moderate to strong quality evidence exists primarily for the stroke and cerebral palsy populations, and primarily for balance, mobility and upper extremity outcomes. A lack of consistent outcome measures in this body of literature has created “silos” of research that cannot be quantitatively combined using a meta-analytic strategy.

The effects of motivating interventions on rehabilitation outcomes in children and youth with acquired brain injuries: A systematic review

Abstract Primary objective: To systematically review the evidence of the effects of motivating rehabilitation interventions on outcomes in children with acquired brain injury (ABI). Methods: A literature search of six databases was conducted to identify intervention studies published until July 2013. The American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) systematic review methodology was used as a framework. Two reviewers independently extracted data and assessed level of evidence and quality of studies. Results: Of 891 records initially retrieved, 166 were screened by abstract and 31 by full text; 10 studies comprised of five randomized controlled trials, two case series and three single subject research design studies met the inclusion criteria. Studies fell into three intervention categories: (1) token economy based interventions; (2) virtual reality (VR); and (3) memory and attention interventions. Conclusions: A paucity of evidence has examined the effects of rehabilitation interventions with a motivational component. Token economies can significantly enhance memory and response inhibition performance in children with ABI. VR systems are motivating, yet findings are limited by the lack of use and availability of psychometrically evaluated measures of motivation. Findings point to the need for further research to evaluate the effects of motivation-based interventions.

Virtual reality as balance rehabilitation for children with brain injury: A case study

BACKGROUND: Balance impairments are common in children with acquired brain injury (ABI) and a need exists to explore motivating interventions with this population. Xbox Kinect is a gaming system that might assist therapists in providing meaningful rehabilitation. OBJECTIVE: To explore the effect of Kinect on improving balance and motivation in one child with ABI. METHODS: Using an A-B design, the participant received traditional balance therapy for five days, followed by 15 days of Kinect rehabilitation. Balance and motivation were measured daily; function measured weekly. Baseline and intervention trend lines were visually analyzed to assess changes in balance and motivation. RESULTS: Participant was unable to follow protocol; intervention was modified to use Nintendo Wii at day 14. While Kinect data showed greater improvement in balance when compared to traditional and Wii rehabilitation, Wii showed greater improvement in dynamic balance involving the body’s affected side. Motivation remained high between baseline and intervention. CONCLUSIONS: Kinect may be challenging to use therapeutically early in rehabilitation for improving balance in children with ABI. However, Kinect might improve balance more than traditional or Wii rehabilitation when used with the appropriate child at the right stage of rehabilitation. Motivation results remain inconclusive. Further research is warranted.

Toolbox of multiple-item measures aligning with the ICF Core Sets for children and youth with cerebral palsy

Selecting appropriate measure(s) for clinical and/or research applications for children and youth with Cerebral Palsy (CP) poses many challenges. The newly developed International Classification of Functioning, Disability and Health (ICF) Core Sets for children and youth with CP serve as universal guidelines for assessment, intervention and follow-up. The aims of this study were: 1) to identify valid and reliable measures used in studies with children and youth with CP, 2) to characterize the content of each measure using the ICF Core Sets for children and youth with CP as a framework, and finally 3) to create a toolbox of psychometrically sound measures covering the content of each ICF Core Set for children and youth with CP. All clearly defined multiple-item measures used in studies with CP between 1998 and 2015 were identified. Psychometric properties were extracted when available. Construct of the measures were linked to the ICF Core Sets. Overall, 83 multiple-item measures were identified. Of these, 68 measures (80%) included reliability and validity testing. The majority of the measures were discriminative, generic and designed for school-aged children. The degree to which measures with proven psychometric properties represented the ICF Core Sets for children and youth with CP varied considerably. Finally, 25 valid and reliable measures aligned highly with the content of the ICF Core Sets, and as such, these measures are proposed as a novel ICF Core Sets-based toolbox of measures for CP. Our results will guide professionals seeking appropriate measures to meet their research and clinical needs worldwide.

Perceptions of Technology and Its Use for Therapeutic Application for Individuals With Hemiparesis: Findings From Adult and Pediatric Focus Groups

Background Digital technology is becoming an increasingly popular means of delivering meaningful therapy to individuals with neurological impairments. An understanding of clients’ technology use and their perspectives on incorporating technology into rehabilitation can provide researchers and designers with valuable information to inform development of technologies and technology-based rehabilitation programs. Objective This study was designed to establish the current use and perceptions of gaming, social media, and robotics technologies for rehabilitative purposes from the perspective of adults and children with upper limb impairments to identify barriers and enablers to their adoption and use. Methods We conducted three focus groups consisting of pediatric (n=7, mean age 11.0 years) and adult (n=8, mean age 60.8 years) participants with hemiparesis affecting their upper limb. We applied thematic analysis methods to the resulting data. Results We identified three key themes: (1) clients’ use of technology in everyday life and rehabilitation, (2) barriers to use, and (3) enablers to therapy. Participants had limited exposure to technology for therapeutic purposes, but all acknowledged the potential benefits in providing motivation and interest for the performance of repetitive task practice. Adult participants requested efficacious, simple, and easy-to-use technology for rehabilitation with programs that could be individualized for them and expressed that they wanted these programs to provide a motivating means of repeated practice of therapeutic movements. In contrast, pediatric participants emphasized a desire for technology for rehabilitation that offered opportunities for social interaction and interactive games involving their whole body and not only their affected limb. Perceived safety and privacy were concerns for both groups. Conclusions Our findings highlight that all participants were open to the integration of technology into rehabilitation. Adult participants were more pragmatically motivated by potential recovery gains, whereas pediatric participants were more intrinsically motivated by access to games.

The development of the Pediatric Motivation Scale for rehabilitation.

Background. Clinicians recognize that client motivation is key to optimizing rehabilitation; however, they are limited in its assessment by a paucity of motivation measures. Purpose. This paper presents the preliminary psychometrics of the Pediatric Motivation Scale (PMOT) designed to measure motivation from a child’s perspective. Method. Content validity of the PMOT was measured through expert feedback (n = 12), and field testing ocurred with 41 children, 21 in rehabilitation and 20 healthy. Pearson product-moment correlations were used to analyze subscale correlations, test-retest reliability, and convergent validity with the Pediatric Volitional Questionnaire (PVQ). Internal consistency was measured using Cronbach’s alpha. Findings. Preliminary psychometric evaluation indicates strong internal consistency for PMOT total (α = .96) and subscales (α = .79–.91). The PMOT and PVQ moderately correlated in the rehabilitation subsample (r = .71, p < .01); no correlation was found in the healthy subsample (p > .05). Test-retest reliability was excellent (r = .97). Implications. This study provides preliminary psychometric evidence of the PMOT for children undergoing rehabilitation. These pilot findings warrant ongoing scale development.

Charting the territory: Describing the functional abilities of children with progressive neurological conditions

AIMS Little is known about the functional abilities of children with progressive genetic, metabolic, or neurological conditions (PNCs). In this study, children with PNCs were followed over a 2-year period to assess their functional abilities over time. Specific aims were to: 1) describe the changes in functional skills and the effects of age for children with PNCs, 2) assess changes in these childrens need for caregiver assistance over time, and 3) examine relationships between these childrens functional skills and need for caregiver assistance. METHODS This study involved a longitudinal, descriptive design with three assessments occurring at Baseline, Year 1, Year 2. Functional skills and caregiver assistance were assessed by the Pediatric Evaluation of Disability Inventory (PEDI). The PEDI questionnaire was completed at baseline and then yearly by parents, along with the assistance of a trained research assistant (RA). RESULTS The study was completed with 83 children (mean age at Baseline=7.1yrs, SD=4.6). Mean Functional skills scores were in the low ranges at Baseline and did not change significantly across time points (F(2, 71)=0.437, p=0.58). Time point had no effect on caregiver assistance ratings (p<0.2); however, children required greater amounts of help with self-care at later time points than for other functional domains. Statistically significant correlations were found between PEDI-Functional skills and caregiver assistance ratings (r=0.80-0.90, p<0.01). CONCLUSIONS Functional skills were low for these children overall, irrespective of age. In children with PNCs: 1) mean functional skills did not change significantly over time; 2) caregiver assistance scores remained stable and 3) functional skills and levels of caregiver assistance were strongly positively correlated. Further research to explore the long-term functional trajectory in children with a PNC is recommended.