Should We Integrate Video Games Into Home-Based Rehabilitation Therapies for Cerebral Palsy?

Elaine Biddiss


Future Neurology. 2012;7(5):515-518. 

In This Article

Remapping the Brain With Video Games

Cerebral palsy (CP) is the most common pediatric physical disability, affecting one in every 500 children.[1] Caused by early damage to the motor centers of the developing brain, CP can be associated with a wide range of symptoms of varying severity, including: decreased muscle strength, spasticity and impaired sensation, all of which can limit a child's activities and participation in recreation, education and social and later, professional opportunities. Outside of surgical and pharmaceutical management, intensive physical and occupational therapy programs such as neurodevelopmental therapy, constraint-induced movement therapy and hand–arm bimanual intensive training have demonstrated some effectiveness in the treatment of CP, particularly the most prevalent form, hemiplegia, which primarily affects a single side of the body and most markedly, the upper limb.[1]

Much in the way that daily physical activity complements structured exercise in maintaining a healthy lifestyle, daily use of the affected limbs, in addition to intensive therapy sessions, is vital to rehabilitation outcomes.[2] While certainly not a new idea, the integration of video games into home-based rehabilitation therapies for children with CP is a growing area of interest. The vision of children running eagerly each day to participate in undirected, self-motivated physical therapy guided by a low-cost video game system is indeed alluring. Add to this the ability to remotely monitor progress and to foster social play with friends and siblings or through online companions, and it is easy to be swept away by the potential of video game-assisted rehabilitation, or more generally termed, virtual reality therapies (VRTs).[3]

What is new, however, is the technological milieu available for the implementation of VRTs. Previously, VRTs largely consisted of traditional or robot-assisted exercise equipment (e.g., treadmills, ergometers) linked to a video game or virtual environment for the purposes of motivation and distraction or specialized gaming systems designed to target specific therapeutic movements (e.g., hand grasps) detected via precise, and often costly, instruments (e.g., sensor gloves and motion-capture systems). With the growing popularity of movement-based or 'active' video gaming systems (e.g., Nintendo's Wii® and Microsoft's Kinect®), there is now the potential to use mainstream equipment to facilitate widespread access to low-cost, home-based VRTs. In contrast to expensive robotics, virtual immersive environments and technologically complex accessories housed at a handful of specialized rehabilitation facilities, 87% of American youth reportedly own at least one video console and spend an average of 73 min in play each day.[101] This widespread availability and use is reviving and accelerating interest in video games for physical rehabilitation.

Yet, the question remains: are VRTs effective in the physical rehabilitation of children with CP? This question is perhaps best addressed by first examining the potential of video games through the lens of neuroplasticity. Neuroplasticity refers to the brain's inherent ability to reorganize and restructure itself to compensate for an underlying brain lesion and to unlock new functional potential gained through the growth of more efficient neuronal connections. The keystones to neuroplasticity and motor learning are: motivation and reward, immediate feedback, incrementally increasing the difficulty of the task and repeated practice of skilled movements.[4] Video games certainly employ mechanisms to increase motivation and reward (e.g., through plotlines, point systems and unlocking new games or levels), and enjoyment of movement-based video games and VRT is reportedly high in children with CP.[5–11] Immediate feedback is provided cognitively through scoring and point accumulation, visually through onscreen avatars, and in some cases, through auditory and vibrotactile feedback as well.[5] The level of difficulty is reflected in advancing game levels and the complexity of movements required can also be moderated through the selection of appropriate games.[5] Finally, previous studies indicate that active video games do indeed encourage repetitive movements, although the frequency, intensity and types of movements depend largely on the game being played and the engagement/approach of the child playing.[5]

Theoretically, video games have all of the requisite ingredients to elicit neuroplasticity, but is it evident in practice? In their seminal paper, You et al. were the first to demonstrate cortical reorganization following a 4-week intervention with an 8-year-old child with hemiparetic CP who engaged in VRT for 60 min durations, five-times per week.[12] A positive shift in neural activations from the ipsilateral supplementary motor area to the contralateral primary sensorimotor cortices was observed through functional MRI, and was accompanied by increased scores on standardized motor assessments. Golomb et al. also demonstrated improved functional scores and altered cortical activation profiles during a grasp task in a study of three adolescents with hemiplegic CP who participated in VRT for 30 min per day, 5 days a week, over a 3-month period.[3] Of note, both of these studies utilized specialized systems designed to target specific therapeutic goals, as opposed to mainstream gaming systems. While a handful of studies have documented some functional improvements associated with the use of mainstream active video games in physical therapies for children with CP,[11,13] the efficacy of these systems for enacting cortical reorganization and improving long-term function remains unknown.

Current trends promoting the use of commercial video games designed for entertainment purposes as therapeutically relevant tools are met with a number of challenges.

Movement Variability

Children exhibit a wide range of movement variability and intensities when engaged in active video game play, particularly in unstructured environments such as the home.[5,14] This limitation may in part be addressed by the technology used to track movements (i.e., cameras demand more consistent movements than accelerometer-based tracking systems). However, it remains to be seen how well camera-based systems designed for able-bodied players can identify potentially atypical movement patterns, and to what extent finer motor movements of relevance to the rehabilitation of children with CP (e.g., of the wrist, hand and fingers) can be detected.

Therapeutic Relevance

While active video games have demonstrated some value with respect to sensorimotor learning,[13] they may not be appropriate for all therapeutic goals (e.g., strength building).[5] Identifying the therapeutic goal of interest and determining the appropriate game and gaming system are important steps in strategically applying this technology in practice. Our previous studies analyzing children's movements during active video game play can provide some guidance towards appropriate game selections for targeting specific joints or encouraging bilateral movements for instance.[5] However, it is unlikely that mainstream video games can address the wide range of therapeutic goals and varying abilities of the diverse CP population. Commercial systems (e.g., Microsoft's Kinect) that support software development platforms may offer a compromise between availability/affordability of mainstream hardware and the ability to design customized software that more effectively targets therapeutic goals relevant to the CP population.

Monitoring & Feedback

While the mechanisms for feedback and monitoring are inherent to commercial video-game systems, in-game rewards are not always in line with therapeutic goals. For instance, while use of the hemiplegic limb and/or bimanual use of the limbs are extremely important in a therapy context, they are usually rewarded only indirectly, if at all, during video game play. Previous studies have noted that the hemiplegic limb is used significantly less frequently during bilateral video game play than the dominant limb, and its use is decreased even more when children are highly motivated to win (i.e., when playing against a human opponent as opposed to a virtual opponent).[15] In structured rehabilitation settings, therapists can offer additional feedback to ensure that commercial video games are played in a manner that optimizes their therapeutic benefits. In home settings, where the value of these systems is perhaps most promising, additional monitoring and feedback is needed that is not provided by mainstream video games.

Enjoyment & Motivation

VRTs have certainly proven to be motivating and enjoyable for children with CP.[5–11] However, not all mainstream games are equally beneficial with regards to their therapeutic value.[5] VRT studies, both with commercial and specially designed systems, usually provide children with a limited selection of games (usually only one) to choose from. As such, maintaining interest and use over time in the home environment has been an obstacle to adherence.[3,11] To be truly appealing and motivating for children with CP and to be competitive with mainstream games, the variety and quality of video games used in therapies cannot be undervalued.