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Abstract. This paper presents the results of a pilot study of a virtual reality play based intervention. The results of four single case
studies are presented. The virtual reality intervention used the Mandala Gesture Xtreme technology. It was applied to four school
aged children with cerebral palsy. A pretest-posttest design was used. The relevant outcome of interest was upper extremity
control as measured with the Quality of Upper Extremity Skills Test (QUEST), item #6 of Subtest #5 of the Bruininks-Oseretsky
Test of Motor Proficiency (BOTMP), and a measure of percent accuracy . The total scores on the QUEST indicated clinically
significant changes in quality of upper extremity for two of the children. Changes were noted in other measures of upper extremity
control for each child.
Qualitative comments from the participants revealed a high degree of motivation, interest, pleasure, and opportunity for engage-
ment in play activities not previously engaged in. Overall, this pilot study suggests the viability of a virtual reality play based
intervention as part of the rehabilitation process for children with cerebral palsy. These results will form the basis of a larger
scale randomized clinical trial.
11]. Virtual reality is defined as an immersive and in- Practice is an essential component of learning a new
teractive three-dimensional (3D) computer experience motor skill. Feedback over performance also helps to
occurring in real time [12]. Virtual reality applications reinforce the patterns learned.
use 3D computer graphics, which respond to the user’s Applied to children with CP, neurodevelopmental
movements, thereby given the user the sense of being and motor learning theory, especially the importance
immersed in the virtual environment. of measuring constructs such as upper limb movement
At the present time, the technology of VR and its accuracy and efficiency suggests that the use of VR
application to the field of pediatric rehabilitation is in may enhance the quality of upper extremity skills in
an infancy stage. Each new study being conducted is children and provide them with a sense of mastery or
the first of its kind, however with ongoing research, the sense of control over their actions. Theoretically, as
evidence for judging the effectiveness of VR as a viable specified in motor learning theory, enhanced feelings
intervention will soon be available. Although, there of self-control will, in turn, result in improved mo-
have been only a limited number of studies exploring tivation and a desire to practice movement patterns,
the potential of VR in rehabilitation, and fewer still thereby developing greater movement control. Recent
in pediatric rehabilitation, previous applications with research by Rizzo and his colleagues [24] underscores
children with disabilities have demonstrated the poten- the advantage of the enjoyable game-like experience of
tial of VR to improve life skills, mobility and cognitive VR and its relationship to motivation, and movement
abilities, quality of life, and social opportunities [5,6, performance among children.
13–19].
Well-developed theories of behaviour change have
been proposed in fields beyond rehabilitation, and may 2. Methodology
be useful for developing hypotheses and specifying
mechanisms by which rehabilitation interventions for
2.1. Design
children with disabilities may work. A combination of
theoretical frameworks may be necessary to explain the
A single case design was used. The basic feature of
role and impact of various aspects of an intervention.
this design is the evaluation of clients for the outcome
In this study, neurodevelopmental theory [20,21] and
of interest both before (baseline) and after the interven-
motor learning theory [22,23] are used to explain the
tion. This design allows an individual to serve as their
impact of a VR intervention with children with cerebral
own control. It was used in this case to evaluate the
palsy. Neurodevelopmental theory states that antigrav-
ity postures, such as sitting, are supported by a large effects of a VR play intervention with a small number
contact area with the support surface. Over time, dy- of children in a pilot study prior to conducting a large
namic adaptations to the support surface enable greater randomized controlled study.
postural control. A substantial body of research sup-
ports this theory and indicates that proximal stability 2.2. Participants
is the dynamic interaction of stability and mobility be-
tween body parts to yield freedom of movement from Four children diagnosed with cerebral palsy, aged 8
a stable base in distal body parts with graded muscle to 12 years participated in the pilot study. They were
control. Efficiency in postural stability contribute to able to communicate verbally. Table 1 presents relevant
head and trunk alignment in sitting and better use of the subject characteristics. The children were recruited
upper extremities. Postural alignment is the body’s ori- from two large children’s rehabilitation centres in the
entation around the force of gravity and to the support greater Toronto region. Informed parental consent and
surface contact necessary to restore head position with ethical approval were obtained prior to commencing
the trunk, pelvis, and extremities for the maintenance the study.
of aligned antigravity postures while continuing to have
freedom of movement in the upper extremities. Finally, 2.3. Intervention
balance is making the postural adjustments necessary
to maintain the alignment between the body’s centre of There have been problems reported with the use of
gravity and the base of support while having freedom different VR systems that have important implications
of upper limb movement. for using VR successfully with children with disabili-
Motor learning theory suggests that with repetition ties. Critics of the head-mounted display systems have
a movement can be learned and used over and over. reported they tend to restrict movement, are heavy to
D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills 55
Table 1
Participant characteristics
Participant Age Grade Diagnosis Tone Functional status
1 10 5 Spastic Quadriplegia High GMFC level = 4
Does not ambulate
Uses manual wheelchair with sub-ASIS bar
Cannot sit unsupported on a bench
2 12 7 Spastic Quadriplegia Moderate GMFC level = 4
Uses walker for short distances indoors
Uses power wheelchair
Can sit unsupported on a bench
3 8 2 Spastic Diplegia Moderate GMFC level = 3
Uses walker
Can sit unsupported on a bench
4 10 Spastic Quadriplegia High GMFC level = 4
Uses manual wheelchair
Cannot sit unsupported on a bench
∗ Gross Motor Classification level based on classification system developed by Palisano and colleagues [25].
Fig. 2. Photograph of child playing “Orbosity”. Fig. 4. Photograph of child playing Soccer.
Fig. 3. Photograph of child playing Volleyball. Fig. 5. Photograph of child playing “Paint”.
ground consisting of a green field surrounded by a option of selecting a two-player game allowed for some
fence. In the horizon is a snow-capped mountain range.
competition during the sessions. In soccer, the child
The bright blue sky surrounds the child’s image and in
was the goal tender and was instructed to reach out to
the sky are brightly colored balls that float from dif-
the sides and above the head with his/her arms to block
ferent directions toward the child. The number, di-
incoming shots.
rection and speed of the balls was graded so that 3
Every session was standardized starting with a 15-
balls in sequential waves came from either the right
minute trial of Orbosity, then the child was allowed to
side of the screen or the left side. Each virtual ball
choose the applications he/she preferred to play. This
the child successfully touched, burst electronically into
procedure was used to encourage choice and control by
numerous colored particles. If touched gently, the ball
transformed into a bird and flew off the screen. The the children and maintain motivation. Fatigue did not
child had to visually track and locate all balls and grade seem to be an issue with the children. They had ample
the amount of pressure when making contact with the time to rest in between playing the different games.
balls. Auditory feedback was available when contact
was made. As well the computer kept track of the 2.4. Hypothesis and outcome measures
points the child made each time contact was made, and
these scores were shown to the participants at the end The study hypothesis was that quality of upper ex-
of each trial. For the volleyball game the child was tremity skills among children with cerebral palsy would
instructed to lift arms up to hit the ball that was hit over improve after engagement in a virtual play interven-
the net by the other player or the computer robot. The tion program. Therefore, the main outcome measure
D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills 57
Table 2
used was the Quality of Upper Extremity Skills Test Participants’ QUEST scores
(QUEST) [28]. The QUEST was designed as an out-
Participant Baseline score Posttest score
come measure with a structured scoring method to as-
1 46.86 31.06
sess the quality of a person’s upper extremity skills.
2 96.87 98.43
It conceptualizes upper extremity skills in terms of 3 100 100
four main constructs: dissociated movements, grasps, 4 92.18 94
weight bearing, and protective extension. Results of
validation studies show that the QUEST demonstrates
Table 3
good test-retest reliability and validity. Evidence for its Participants’ BOTMP scores
responsiveness is also available. Complete guidelines
Participant Baseline Posttest
for the administration and scoring of the QUEST are
1 1 2
contained in the QUEST manual. The QUEST uses a 2 2 5
2-point rating scale for each item. A score value of ‘1’ 3 2 5
reflects the most complete or mature response. A rating 4 2 3
of 0 indicates an abnormal or immature response. A
total standardized score is calculated. For this study,
3. Results
we administered the dissociated items only which in-
cluded shoulder, elbow, wrist, finger and grasp and
release items. While the QUEST has been validated The QUEST and the BOTMP scores are presented
with children up to the age of 8 years we chose to use in Tables 2 and 3. Participant #1 showed a decline
it with our slightly older sample because the authors in QUEST scores at posttest. This may be due to the
do suggest that the QUEST can be used with children fact that the intervention was not long enough to show
irrespective of age whose quality of movement is poor. an improvement in the movement patterns involved in
A trained pediatric occupational therapist adminis- reaching. Participant # 2 demonstrated an improve-
tered the QUEST at baseline and at post-test. ment on the QUEST. Although the score change is only
Two other outcomes measures were used: item #6 2 units this score change is clinically significant as it
“touching a swinging ball with preferred hand” from demonstrates an improvement in at least one or two
the subtest #5 of the Bruininks-Oseretsky Test of Mo- components of upper extremity movement. With par-
tor Proficiency (BOTMP) [29] and a measure of ac-
ticipant #3 there was no change as she achieved ceiling
curacy developed for the study using the VR Orbosity
on the test at baseline. Participant #4 also showed a
program. The BOTMP has acceptable psychometrics.
clinically significant improvement on the QUEST.
In particular the Bruininks item is a part of the subtest
upper limb coordination which has reported good re- All the participants showed an improvement on the
liability and discriminative validity results. While the BOTMP item “touching a swinging ball” at posttest.
Bruininks did not have cerebral palsy children as part of Two subjects #1 and #4 showed a change score of 1
their discriminative validity sample they had children whereas the other two #2 and #3’s change scores were
with learning disabilities a symptom found in many 3 points. These scores reflect greater movement effi-
children with cerebral palsy. ciency.
The last measure was called “average percent accu- With respect to the average percent accuracy data
racy score” which was calculated based on the average participants results are presented in Figs 6–9. Par-
number of hits of balls over 40 trials for a total of balls ticipant #1 showed a marked improvement in the left
120 balls (3 balls/trial). The test retest reliability of this hand. At baseline on the left side the score was 78.9;
measure was tested with two independent raters and it at posttest it was 95.4. Performance in the right hand
was found to be 94%. declined from 69.7 at baseline to 52.6 at posttest. Par-
ticipant #2 no change in the left hand and a slight de-
2.5. Data analysis
cline in performance in the right hand, from 77.8 to
The QUEST, BOTMP and the average percent ac- 68.7. Participant #3 showed improvement in the left
curacy scores were descriptively analyzed and graphi- hand going from 79 at baseline to 91.1 at posttest. Also
cally presented for each participant. Given the design in her right hand performance she changed from 80.1
of the study and the small number of participants, the to 85. Participant #4 showed minimal change in his
data were visually inspected for clinically significant left hand 86 to 85.6 but slight change in the right hand
changes. (64.4 to 69).
58 D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills
100
90
80
70
Average Percentage of Balls Hit
60
Baseline
50
Post-test
40
30
20
10
0
Right Left
Hand Used
100
90
80
70
Average Percentage of Balls Hit
60
Baseline
50
Post-test
40
30
20
10
0
Right Left
Hand Used
100
90
80
70
Average Percentage of Balls Hit
60
Baseline
50
Post-test
40
30
20
10
0
Right Left
Hand used
score for the left hand. His QUEST score was worse perceived he was able to move his arms much better by
at posttest as was the percent accuracy score for his the end of the sessions.
right hand. His left hand was his preferred hand. The Participant #3 who was the less involved child in
aspects showing most change for this participant were the study showed no change on the QUEST as she had
related to accuracy in movement as shown by his im- reached ceiling level at baseline and could not show
provement on the BOTMP task and the birds and balls any improvements. She did improve on the BOTMP
task. The qualitative changes in the patterns of upper task by 3 points at posttest and showed greater accuracy
extremity movement were not seen. It is important to on the percent accuracy test in both her hands. Partici-
note that this participant’s physical abilities were less pant #4 showed improvement on the QUEST and also
than the other participants. Performing the reaching demonstrated change on the right side for the percent
movements was very challenging for this child. The accuracy test.
level of effort and fatigue over the trials at the posttest Participant #4 showed improvement on the QUEST
may have greatly accounted for the poor score. In ad- and also a gain on the BOTMP. His performance with
dition the number of sessions may have not been suf- respect to percent accuracy was varied with a decline
ficient to detect a change in the quality of his upper of one point on the left side and an improvement of five
extremity skills as measured with the QUEST.
points on the right side which was the side with less
Participant #2 displayed motivation over the sessions
tone.
and a willingness to reach with his best effort during the
As predicted, the virtual play intervention was a great
activities. He showed a change in both his accuracy of
deal of fun for the participants. Informal comments
movement and the quality of his upper extremity skills.
made from the children suggest the VR intervention
While his performance on the test of percent accuracy
was a pleasurable experience and was motivating for
showed little change for his left hand and poorer change
for his right hand, his change score on the BOTMP them. The following are some quotes made to reflect
task was 3. He was much more accurate on this task this:
at posttest. His QUEST score was also improved at “I didn’t think it would be this exciting.” Its kinda
posttest reflecting a clinically significant change. This like making a dream come alive.” “You get to be as
participant spoke about how he felt stronger and that crazy and wild as you want.”
60 D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills
100
90
80
70
Average Percentage of Balls Hit
60
Baseline
50
Post-test
40
30
20
10
0
Right Left
Hand Used
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