Elsevier

Physiotherapy

Volume 103, Issue 3, September 2017, Pages 245-258
Physiotherapy

Systematic review
Effectiveness of virtual reality rehabilitation for children and adolescents with cerebral palsy: an updated evidence-based systematic review

https://doi.org/10.1016/j.physio.2016.08.004Get rights and content

Abstract

Background

The use of virtual reality systems in the motor rehabilitation of children with cerebral palsy is new, and thus the scientific evidence for its effectiveness needs to be evaluated through a systematic review.

Objective

To provide updated evidence-based guidance for virtual reality rehabilitation in sensory and functional motor skills of children and adolescents with cerebral palsy.

Data sources

PubMed, PEDro, Web of Science, OTseeker, PsycINFO and Cochrane Library were searched from their earliest records up to 1 June, 2016.

Study selection

Two reviewers applied the population intervention comparison outcome (PICO) question to screen the studies for this review.

Data extraction

Information on study design, subjects, intervention, outcome measures and efficacy results were extracted into a pilot-tested form. Method quality was assessed independently by two reviewers using the Downs and Black checklist.

Data synthesis

Thirty-one studies included 369 participants in total. Best evidence synthesis was applied to summarize the outcomes, which were grouped according to International Classification of Functioning, Disability and Health. Moderate evidence was found for balance and overall motor development. The evidence is still limited for other motor skills.

Conclusions

This review uncovered additional literature showing moderate evidence that virtual reality rehabilitation is a promising intervention to improve balance and motor skills in children and adolescents with cerebral palsy. The technique is growing, so long-term follow-up and further research are required to determine its exact place in the management of cerebral palsy.

Systematic review registration number PROSPERO 2015:CRD42015026048.

Introduction

Cerebral palsy refers to a category of non-progressive neurological disorders appearing in infancy or early childhood that have a permanent effect on sensory motor capabilities [1]. The worldwide prevalence of cerebral palsy is estimated to be 1.5 to 4 per 1000 live births, making it the most common motor disability in childhood [1]. The child’s normal functioning is affected by a variety of neuromuscular and musculoskeletal impairments. Besides motor functioning, cerebral palsy also affects cognitive, affective and behavioral performances. To date, there is no single agreed cure for cerebral palsy, but motor functional outcomes of affected individuals can be improved with early therapeutic intervention [1], [2]. A variety of treatments are available and appear to be effective, including physical therapy, occupational therapy, medications, surgery and orthotic devices. Physical therapy plays a central role in disease management, focusing on posture, balance, mobility, strength and function improvement. However, children find physical therapy to be mundane and monotonous when undergoing it for a longer period [2].

Virtual reality rehabilitation is an emerging therapy for motor rehabilitation of children with cerebral palsy [2]. The therapy is provided through a computer-simulated environment where they interact with real-world-like objects and events through sight, sound, smell and touch. Virtual reality technologies vary greatly in immersion, cost and complexity. The interacting interface could be anything from a simple joystick (e.g. Wii Remote) to a complex motion camera (e.g. Kinect sensor), and display hardware include standard computer/television screens and head mount displays. Accordingly, virtual reality rehabilitation is categorized as immersive, semi-immersive and non-immersive. Neuroplasticity studies have demonstrated that virtual reality rehabilitation is positively associated with active engagement and motivation during interventions. In addition to motivation, virtual therapy also enhances neural re-organization that appears to optimize rehabilitation outcomes in children with cerebral palsy [2], [3]. A review of growing research found increasing evidence for the use of virtual therapy to improve sensory and functional motor abilities. The virtual scenario seems to foster motor learning, retention of learned skills, and skill transfer to real-world situations [4]. Specifically, a few studies have shown that virtual therapy improves posture and balance, upper limb function, joint control and gait [4], [5]. Establishing augmented biofeedback in neuromotor rehabilitation has allowed therapists to methodically design and control intervention strategies.

Although virtual therapy is highly recommended for active engagement of participants, there is a lack of research consensus to support it for improvement in motor skills. Chen et al. [6] focused on upper extremity function, and reported significant improvement in the treatment group compared with the control group. However, their meta-analysis, which included three randomize controlled trials (RCTs), found no significant difference between pre and post intervention. Nonetheless, the number of high-quality studies was limited and evidence on other important motor skills, such as balance, was lacking. Similarly, a critical review [7] reported inconclusive evidence for the effectiveness of virtual therapy on body structure and functions, and found only moderate evidence for a positive effect of the technique on personal factors in children with cerebral palsy. The results of these reviews were largely based on a very small number of quality research designs (RCTs), and there was insufficient high-level evidence on the improvement of motor skills to support clinical application of virtual therapy. More recent studies have used therapeutically relevant virtual reality environments from off-the-shelf gaming systems, and the number of RCTs addressing the various motor skills has increased; as such, there is a need for an updated systematic review. This article seeks to update the latest evidence and summarize the current body of literature. The findings should be useful to optimize approaches in clinical research and clinical practice on virtual therapy for treatment of cerebral palsy. This systematic review aims to update previous reviews, and incorporate the latest evidence for efficacy of virtual reality rehabilitation in the treatment of children and adolescents with cerebral palsy; and to provide recommendations for future clinical research.

Section snippets

Search strategy

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [8]. A comprehensive literature search of PubMed, PEDro, Web of Science, OTseeker, PsycINFO and Cochrane Library was performed for articles published prior to 1 June, 2016. The search strategy was based on medical subject heading (MeSH) and non-MeSH search terms (see Appendix A, online Supplementary material). Additionally, articles in the reference lists

Study selection

The literature search identified a total of 284 potentially relevant articles. After the removal of duplicates (n = 87), rejection based on title and abstract (n = 120), and inclusion and exclusion criteria (n = 46), 31 articles comprising seven case studies, five single-subject designs, 11 pretest–post-test designs and eight RCTs were included for the quality assessment and best evidence synthesis. The selection procedure, including reasons for exclusion, is summarized in Fig. A (see online

Discussion

Virtual therapy interventions are potentially advantageous for treating children and adolescents with cerebral palsy. The primary objective of this review was to critically appraise articles that demonstrate the above hypothesis. This review included all articles, regardless of study design, considering that the topic is relatively new and the evidence is emerging gradually. Most of the studies included in this review had very small sample sizes, and lacked the sample size and power

Conclusions

There is moderate evidence that virtual reality rehabilitation can be used to improve balance and motor skills in children and adolescents with cerebral palsy. The evidence base is weak for other parameters, but the therapy shows some potential for improvement. The above findings are not sufficient to recommend virtual therapy for clinical practice. Future research should include well-designed multicentre RCTs with high quality, large sample size and follow-up.
Funding: The study was partly

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