Virtual Reality Interventions' Effects for Children with Cerebral Palsy

Four out of the seven systematic reviews included focused on CP, which suggests that VR rehabilitation approaches for this neurodevelopmental disorder have been addressed more frequently in the literature than the others included here. In part, the reasons for this might be that the characteristics of CP are more clearly detectable than other neurodevelopmental disorders during childhood and that clinicians and scientists have accumulated more experience and observed more cases related to CP (Baxter 2015) in their practices. Also, the prevalence of CP worldwide is large, since about three to four children out of 1,000 live births are affected by it (Jonsson et al. 2019). Taken together, this information may encourage new forms of rehabilitation, such as those based on VR.

According to the information from the four systematic reviews, commercial VR equipment was used more often than engineer-built systems (Ravi et al. 2017, Chen et al. 2018, Rathinam et al. 2019, Warnier et al. 2019). However, engineer-built systems better promoted high levels of evidence than commercials ones did (Chen et al. 2018), since commercial systems are not made for the


Characteristics of the Systematic Reviews Included

Target Neurodevelopmental





Warnier et al. (2019)

To investigate the effect of virtual reality therapy (VRT) on balance and walking in children with cerebral palsy (CP)

Balance and walking

Cerebral palsy

Rathinam et al. (2019)

To determine the effectiveness of VR as an intervention to improve hand function in children with CP compared to either conventional physiotherapy or other therapeutic interventions. The secondary purpose was to classify the outcomes evaluated according to the International Classification of Functioning. Disability and Health (ICF) dimensions

Hand function

Cerebral palsy

Chen et al. (2018)

To update the current evidence about VR by systematically examining the research literature



Cerebral palsy

Ravi et al. (2017)

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

Balance and motor skills

Cerebral palsy

Cavalcante Neto, de

Oliveira et al. (2019)

To synthesize evidence on the effectiveness of VR interventions for motor performance improvement in children with DCD

Motor performance


coordination disorder

Mentiplay et al. (2019)

To systematically review the literature on virtual reality or video game interventions that aim to improve motor outcomes in children with DCD

Motor performance


coordination disorder

Mesa-Gresa et al. (2018)

To carry out an evidence-based systematic review including both clinical and technical databases about the effectiveness of VR-based intervention in ASD

Social and emotional skills

Autism spectrum disorder

specific disability demands present in children with CP. As most of the CP children had impaired hand function and unbalanced postural control, commercial VR accessories were not able to fit these children’s body profiles, whereas engineer-built ones were. Nintendo's Wii Fit and other Nintendo’s Wii equivalent systems were the most frequently used brands in the studies (Ravi et al. 2017, Chen et al. 2018, Rathinam et al. 2019, Warnier et al. 2019). However, the improvements observed for those studies were achieved precisely due to the Wii Fit accessories, such as balance boards. Along with the fact that VR promotes a motivational environment (Harris and Reid 2005), this accessory appears to be key for improving motor skills outcomes in CP children mainly by helping them gain better balance and postural control, which generally lag behind in these children.

There was no consensus among studies regarding the dosage of VR treatment for children with CP. All studies synthetized various durations, frequency, and number of sessions. The total duration of therapy ranged from one day to 20 weeks with several intensities and per-week frequencies, ranging from 15 to 120 minutes a session and from one single session to seven days per week. All the included studies observed better results with high-intensity sessions than with a lower intensity (Ravi et al. 2017, Chen et al. 2018, Rathinam et al. 2019, Warnier et al. 2019). Also, more major improvements occurred in studies under a therapist or researcher’s supervision than in those with games performed at home by children alone (Ravi et al. 2017, Chen et al. 2018, Rathinam et al. 2019, Warnier et al. 2019).

Regarding CP classification, different types were observed across studies, such as hemiplegia, diplegia, spastic, mixed or still not specified CP, slightly prevailing spastic, and mixed cases. In addition, most studies considered the level of functionality according to the Gross Motor Function Classification System (GMFCS), particularly levels I and II, as inclusion criteria for children be part of the study. GMFCS is a tool used to assess the level of functionality based on children’s ability to self-initiate gross motor movement as well as their need to be assisted by technology or other mobility resources (Palisano et al. 1997). The reported use of this classification for children with CP across studies not only legitimates this tool as a standard procedure to be adopted with this group but also demonstrates that the focus is mainly on the functionality of these children. In addition, the majority of systematic reviews (Ravi et al. 2017, Chen et al. 2018, Rathinam et al. 2019) employed the International Classification of Functioning, Disability, and Health (ICF) to classify the outcomes measured. This tool has facilitated the understanding of health-related outcomes and functional improvements in children with CP related to the demands of their daily lives (World Health Organization (WHO) 2001), even using a technology resource like VR equipment. Regarding the effects of interventions, all systematic reviews agreed that VR improved the majority of outcomes evaluated, such as balance and walking performance (Warnier et al. 2019); hand function (Rathinam et al. 2019); arm function, ambulation, and postural control (Chen et al. 2018); and balance and motor skills (Ravi et al. 2017). However, it is necessary to discuss in more detail the specifics among these studies’ results, taking into account their VR intervention effects calculated across studies.

For example, the effect sizes found by Chen et al. (2018) ranged from medium to large. For the general analyses considering the intervention effects of VR versus other interventions, the effect size was large (d = 0.861), as it was when considering the effects on postural control (d = 1.003) and arm function (d = 0.835). For ambulation, the effect size was medium (d = 0.755) but still clinically important. Warnier et al. (2019) performed a meta-analysis of five studies considering balance as an outcome and another meta-analysis with four studies considering walking as an outcome. For the first analysis, the standardized mean difference (SMD) was 0.89 (95% CI. SD 0.14, 1.63), while for the second, the SMD was 3.10 (95% CI, SD 0.78, 5.35). Both analyses attested to a large effect size (using SMD as effect measure) in favor of VR for these outcomes compared to the control group, who performed no VR therapy. In contrast, Rathinam et al. (2019) did not perform a meta-analysis since procedures among studies were heterogeneous. The authors concluded the study with conflicting results and limited evidence because 66% of their included studies showed improvements on children’s hand function while 34% showed no improvements. Similarly, Ravi et al. (2017) highlighted that the evidence about the effects of VR for other motor skills is inconclusive, since the authors only found promising moderate evidence regarding improvements in balance and overall motor development after VR intervention.

Therefore, when comparing traditional rehabilitation approaches like conventional physiotherapy, all studies had only weak evidence to support superior benefits from one rehabilitation type to another (Ravi et al. 2017, Chen etal. 2018. Rathinam et al. 2019, Warnier et al. 2019). Additionally, regarding the improvements in the outcomes of VR rehabilitation for children with CP, the best recommendation from all systematic reviews accessed is toward the use of VR approaches as complementary therapeutic modalities. Because of the heterogeneity among the studies retrieved by the four systematic reviews used here, proper evidence about the effectiveness of VR rehabilitation treatment for children with CP remains to be found.

< Prev   CONTENTS   Source   Next >