Effect of posture control training using virtual reality program on sitting balance and trunk stability in children with cerebral palsy

Abstract

OBJECTIVE:

We aimed to determine whether the posture control training in the sitting posture using virtual reality (VR) training program affects sitting balance and trunk stability in children with spastic cerebral palsy (CP).

METHODS:

The experiment was conducted for 4 weeks by randomly allocating 20 children with CP. The experimental group (n = 10) performed balance training in the sitting position using a VR training program, and the control group (n = 10) performed arm reach training in the sitting position. To evaluate static and dynamic sitting balance and trunk stability, the Wii Balance Board and Balancia software, the modified functional reach test, and the Korean version of the Trunk Control Measurement Scale were used.

RESULTS:

There were significant differences between the two groups in the changes in speed and postural swing distance before and after training (p < 0.05). The mFRT measurement showed significant differences in all directions before and after training between the two groups (p < 0.05). However, there was no significant difference between the two groups in the K-TCMS score.

CONCLUSIONS:

Posture control training in the sitting position using a VR training program was found to be more effective in improving the sitting balance and trunk stability of children with CP.

Keywords

Cerebral palsy posture control training sitting balance trunk stability.

1 Introduction

Cerebral palsy (CP) causes permanent impairment of motor and posture development and induces non-progressive damage to the developing brain. This is accompanied by secondary musculoskeletal disorders, behavioral disorders, spasms, and other problems, such as sensory, perception, cognitive, communication, and movement disorders (Rosenbaum et al., 2007). Most children with CP show unstable movements that do not cause co-contraction of the proximal muscles due to lack of experience in the womb and delayed development (Kwon & Lee, 1995). Further, trunk stability and head control are weak, making it difficult to maintain the correct posture (Bobath, 1991). There are additional problems with motor control, such as hypotonia of trunk muscles, the increased muscle tone of limbs, and loss or delay of postural reflex (Styer-Acevedo & Tecklin, 1999).

The weakening of the trunk muscle causes trunk instability. Trunk stability is essential for maintaining balance when external fluctuations occur during precise exercise or movement (Granata et al., 2005). Children with CP and weakened trunk muscles have difficulty in maintaining stable postural control and motor skills, resulting in poor mobility and a lack of balancing skills. Along with trunk stability, sitting balance is also important for maintaining the sitting position and posture when the center of gravity goes beyond the base plane while performing various activities using the upper limbs, such as playing or eating in the sitting position (Dean et al., 1999). The ability to control the sitting posture is essential for functional movements in daily life since children with CP spend most of their time in the sitting posture because of the difficulty in walking or independently maintaining the standing posture (Leveau & Bernhardt, 1984).

Clinically, various training methods, such as core stabilization training (El Shemy, 2018), training using a Swiss ball (Shahanawaz et al., 2015), and intensive weight-shift training (Ryu & Han, 2019) are used to improve the sitting balance of children with CP. These clinical approaches are simple rehabilitation exercises composed of repetitive movements, thus failing to induce interest among children. It has been stated that the lack of an accurate analysis and feedback process for movement leads to the accumulation of improper motor learning, and thus, reducing the effectiveness of the intervention (Burdea, 2003; Flynn et al., 2007). In addition, to maintain a stable balance, the mutual coordination of proprioceptive sensation, visual information, vestibular sensation, somatosensory sensation, musculoskeletal system, and cognitive functions are required neurologically, although training programs that utilize these sensations in combination are inadequate (Boswell-Ruys et al., 2010; Partridge, 2002).

To induce such interactions, research on virtual reality (VR) training programs using Wii, a VR training program, has been actively conducted, and their use for physical function improvement and evaluation is increasing (Coyne, 2008; Halton, 2008). The VR training program effectively controls movement by repeatedly training the target performance while receiving feedback in real-time, while the participant sits on a force plate and performs various tasks through games (Weiss & Katz, 2004). It is used as sensory-motor training to control the static and dynamic posture, improving the ability to control the trunk muscles and improve balance (Adamovich et al., 2009). In addition, VR offers advantages, such as children with CP can easily access virtual sports activities, prevent motor injuries, and have active interactions that are difficult to achieve in real-life (Merians et al., 2002). Moreover, the Wii Balance Board system can be easily purchased and is relatively easy to install; therefore, it has been proven to be an effective and independent exercise program not only in the treatment room but also at home.

It has been reported that training using a VR program significantly improved the balance in standing and sitting posture, as well as the performance of daily life (Barton et al., 2013; Brien & Sveistrup, 2011; Porras et al., 2018). Many previous studies have proven the effectiveness of rehabilitation training programs using VR, and there has been a tendency to focus on the training effects in participants who can stand or walk. However, there is a lack of research on the effectiveness of balance training using VR programs for children with CP who cannot independently stand and walk. Therefore, in this study, we aimed to determine whether posture control training in the sitting position using a VR training program affects sitting balance and trunk stability in non-ambulatory children with CP.

2 Materials and methods

2.1 Participants

We included 20 children aged 6–18 years who were medically diagnosed with spastic CP. Of these, 10 children had spastic quadriplegia and 10 had spastic paraplegias. The inclusion criteria were as follows: 1) children with no vision and hearing problems requiring a VR-based exercise program, 2) those with an appropriate cognitive level to understand a VR exercise program, 3) those who were not on any drug or underwent any surgery affecting balance, 4) Gross Motor Function Classification System levels 3–4, and 5) those who had not participated in VR training programs and specific training programs within the last 6 months. The children were randomly assigned to either the experimental group (posture control training was applied through the VR training program) or the control group (arm reach training was applied in the sitting posture).

2.2 Procedure

We selected children with Gross Motor Function Classification System levels 3–4 and documented their age, gender, and the presence or absence of braces. Each session lasted 40 min twice a week for 4 weeks. For the first 15 min, a therapist performed range of motion stretch and conventional neurological physical therapy equally in both groups within the range where there was no change in the muscle tone. Then, for 25 min, the experimental group performed sitting posture balance training using a VR training program, while the control group performed arm reach training in the sitting position.

2.2.1 Posture control training using a VR training program (experimental group)

The VR Wii Fit (Nintendo, Kyoto, Japan) was used, which comprises a Wii Balance Board system and Wii Fit software. The Wii Balance Board is a balanced plate comprising four sensors and a force plate that measures the user’s pressure center and weight distribution. The children in the experimental group were asked to perform the given program while sitting on a balanced plate with their hip and knee joints bent at 90°, looking at a monitor located 1.5 m in front of them. Safety support was placed in the front so that it could be held in case of a sudden loss of balance during balance training. The Wii Fit program provided a VR situation to move the body forward, backward, left, and right while looking at one’s image reflected through the screen and moving the center of pressure. The balance training program comprised four games (Meditation, Penguin slide, Table tilt, and Balance mii) to improve the left and right balance of weight transfer, movement, and sitting posture. Each game was played three times, with a 1-min break in between.

2.2.2 Arm reach training in the sitting position (control group)

In the sitting position, arm reach training was performed by participants trying to reach a distance beyond the arm length of the body by using the hand (Dean & Shepherd, 1997). The participant sat in a way that the thighs reached 55%of the height-adjustable treatment table, and the height of the treatment table was standardized to 85%of the length of the participant’s outer knee joint line from the floor. The ankle was positioned such that the instep had dorsiflexion of 80°, and the distance between the feet was 15 cm (Dean et al., 1999). The reaching was performed in three directions by raising the arm forward, at 45°, and 90°. Both the hands were involved, and the training was repeated in three sets, five times in each direction. The arm reach distance was set as the maximum distance that the participant could move while maintaining the sitting position (Dean & Shepherd, 1997). No feedback was provided on the participants’ movements. These actions were repeated for 4 min in each direction with a 1 min break between 3 sets.

2.3 Measurement of parameters

2.3.1 Estimation of the static balance

A Wii Balance Board (Nintendo, Kyoto, Japan) was used to measure the static balance in the sitting position. To collect data on center of pressure (COP) during static balance, participants were asked to sit on the Wii Balance Board and hold their posture for 30 s by placing their arms folded on their chests without supporting their feet and touching about 75%of their thighs. The measurements were repeated three times and their average value was noted (Choi et al., 2014). The COP information measured using the Wii Balance Board was analyzed using Balancia software ver. 2.0 (Mintosys, Korea) on a computer connected via Bluetooth. The results showed the postural swing distance and the speed for the X and Y axes of the COP. All data were sampled and extracted at 100 Hz (Park & Lee, 2014).

2.3.2 Estimation of the dynamic balance

The dynamic balance in the sitting position was observed using the modified functional reach test (mFRT). The participant sat comfortably on a chair without a backrest, bending the hip and knee joints at 90°, and letting the feet touch the ground. The shoulder joint was bent by 90°, the elbow joint was extended to maintain a straight line with the hand, and the upper limb and trunk were moved to reach as far forward as possible in a direction parallel to the ground, and the distance was measure from the tip of the middle finger. The standard ruler for distance measurement was fixed to the wall according to the height of the participant’s shoulder blade peak. In the same way, the arm was rotated by 90° and reached to the side as far as possible to measure the moving distance of both sides. The average value was used following three-times measurements in three directions (front, right, and left). The test-retest reliability of this evaluation tool was 0.90–0.97 (Katz-Leurer et al., 2009).

2.3.3 Evaluation of trunk control

The Korean version of the trunk control measurement scale (K-TCMS) was used to evaluate trunk control and balance in static sitting balance, dynamic sitting balance, and dynamic arm reach. The K-TCMS comprises 15 items, and the total score is 0–58 points; the higher the score, the better the trunk control ability (Verheyden et al., 2004). The evaluation was performed in a seated position with the participant not wearing a brace on their feet and trunk, with their hands on their knees and close to the trunk without back support, and both thighs entirely touching the table without supporting the feet. Each item was performed three times, and the score from the best movement was used. The reliability of this evaluation tool was proven to be in the range of≥0.9 for the rapid internal correlation coefficient and 0.827–0.970 for the test-retest reliability (Jeon & Shin, 2014).

2.4 Data analyses

For general characteristics of the participants, descriptive statistics and frequency analysis were used. The Wilcoxon signed-rank test was used to compare the pre- and post-intervention changes in the experimental group and the control group. The Mann-Whitney U test was used to analyze the results of the pre- and post-intervention changes between the two groups. All statistical analyses were performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). The statistical significance level was set at α= 0.05.

2.5 Ethical statement

This study was approved by the Institutional Review Board of Cheongju University to ethically protect those under study. The study participants and their caregivers were adequately informed about the purpose and method of the study and provided informed consent.

3 Results

3.1 General characteristics of the study participants

The general characteristics of the participants are summarized in Table 1.

Table 1
Characteristics of subjects

General characteristics Experimental group (n = 10) Control group (n = 10)

Gender

Male 3 4

female 7 6

Age(years) 14.3±4.2 14.1±4.3

Height(cm) 144.2±20.4 145.4±21.6

Weight(kg) 41.4±15.8 42.5±15.1

Type

Diplegia 5(50%) 5(50%)

Quadriplegia 5(50%) 5(50%)

General characteristics	Experimental group (n = 10)	Control group (n = 10)
Gender
Male	3	4
female	7	6
Age(years)	14.3±4.2	14.1±4.3
Height(cm)	144.2±20.4	145.4±21.6
Weight(kg)	41.4±15.8	42.5±15.1
Type
Diplegia	5(50%)	5(50%)
Quadriplegia	5(50%)	5(50%)

Values are expressed as frequencies (%) or mean±SD.

3.2 Changes in sitting balance and trunk stability before and after training

3.2.1 Results of the Balancia program evaluation

Table 2 shows the results of the Balancia program measuring static balance in the sitting posture before and after training. There was a significant difference in the experimental group as a result of intervention in the speed and postural swing distance for the X and Y axes of COP (p < 0.05). In addition, there was a significant difference between the two groups in the magnitude of changes in speed and postural swing distance before and after training (p < 0.05). In terms of speed, the experimental group showed a difference of –1.57±1.35 cm/s, the control group showed a difference of –0.37±0.62 cm/s, and the postural swing distance was –47.19±40.58 cm in the experimental group and –15.2±25.59 cm in the control group.

Table 2
Comparison of Balancia program between two groups

Experimeantal Group (n = 10) Control Group (n = 10) U p ^b

M±SD M±SD

Velocity (cm/s) Pre 7.25±4.99 6.78±5.19

Post 5.68±4.51 6.41±5.21

change –1.57±1.35 –0.37±0.62 19.00 0.019^*

p^a 0.005^* 0.169

Path length (cm) Pre 217.72±149.96 207.76±154.44

Post 170.53±135.41 192.56±156.30

change –47.19±40.58 –15.2±25.59 23.00 0.043^*

p^a 0.005^* 0.203

		Experimeantal Group (n = 10)	Control Group (n = 10)	U	p ^b
Velocity (cm/s)	Pre	7.25±4.99	6.78±5.19
	Post	5.68±4.51	6.41±5.21
	change	–1.57±1.35	–0.37±0.62	19.00	0.019^*
	p^a	0.005^*	0.169
Path length (cm)	Pre	217.72±149.96	207.76±154.44
	Post	170.53±135.41	192.56±156.30
	change	–47.19±40.58	–15.2±25.59	23.00	0.043^*
	p^a	0.005^*	0.203

M±SD: mean±standard deviation. ^aWilcosontest ^bMann-Whitneytest. ^*P < 0.05.

3.2.2 Results of the mFRT

Table 3 shows the results of the mFRT using the dynamic balance before and after training. After the intervention, there were significant differences in all directions in the experimental group (p < 0.05), although significant differences were found only in the right and left sides in the control group (p < 0.05). In addition, the comparison of the magnitude of change before and after training between the two groups showed significant differences in all directions (p < 0.05).

Table 3
Comparison of Modified Functional Reach Test between two groups

Experimeantal Group (n = 10) Control Group (n = 10) U p ^b

M±SD M±SD

Front (cm) Pre 16.02±4.52 16.08±4.48

Post 21.05±6.34 17.28±3.98

change 5.03±3.65 1.2±3.22 21.00 0.029^*

p^a 0.005^* 0.333

Right (cm) Pre 12.68±3.64 12.51±3.09

Post 19.8±6.59 15.45±4.05

change 7.12±3.96 2.94±2.31 19.00 0.019^*

p^a 0.005^* 0.007^*

Left (cm) Pre 13.89±3.19 13.73±3.13

Post 20.8±5.66 14.88±3.38

change 6.9±3.37 1.15±1.56 9.00 0.001^*

p^a 0.005^* 0.037*

		Experimeantal Group (n = 10)	Control Group (n = 10)	U	p ^b
Front (cm)	Pre	16.02±4.52	16.08±4.48
	Post	21.05±6.34	17.28±3.98
	change	5.03±3.65	1.2±3.22	21.00	0.029^*
	p^a	0.005^*	0.333
Right (cm)	Pre	12.68±3.64	12.51±3.09
	Post	19.8±6.59	15.45±4.05
	change	7.12±3.96	2.94±2.31	19.00	0.019^*
	p^a	0.005^*	0.007^*
Left (cm)	Pre	13.89±3.19	13.73±3.13
	Post	20.8±5.66	14.88±3.38
	change	6.9±3.37	1.15±1.56	9.00	0.001^*
	p^a	0.005^*	0.037*

M±SD: mean±standard deviation. ^aWilcosontest ^bMann-Whitneytest. ^*P < 0.05.

3.2.3 Results of the evaluation of trunk control ability

Table 4 shows the results of the evaluation of the K-TCMS before and after training. Both groups’ total score improved significantly after training compared with before training (p < 0.05). However, there was no significant difference in the total score change before and after training between the two groups (p > 0.05).

Table 4
Comparison of Korean version of trunk control measurement scale between two groups

Experimeantal Group (n = 10) Control Group (n = 10) U p ^b

M±SD M±SD

K-TCMS (score) Pre 19.5±9.67 17.3±7.7

Post 27.4±10.86 22.3±9.17

change 7.9±3.38 5.00±3.33 28.00 0.105

p^a 0.005^* 0.005^*

		Experimeantal Group (n = 10)	Control Group (n = 10)	U	p ^b
K-TCMS (score)	Pre	19.5±9.67	17.3±7.7
	Post	27.4±10.86	22.3±9.17
	change	7.9±3.38	5.00±3.33	28.00	0.105
	p^a	0.005^*	0.005^*

M±SD: mean±standard deviation. ^aWilcosontest ^bMann-Whitneytest. ^*P < 0.05.

4 Discussion

Children with CP have to sit on a wheelchair or a chair due to trunk instability. We investigated the effectiveness of VR-based posture control training in the sitting position to understand its influence on sitting balance and trunk stability. Based on the data from the Balancia program and mFRT evaluation, the group that used the VR training program showed statistically significant improvement in all categories. The experimental group showed greater reductions in the postural sway distance and speed than those in the control group.

Our results are consistent with those of previous studies. Yatar and Yildirim (2015) argued that a VR training program using visual feedback improves weight transfer ability and is effective for postural control. Dursun et al. (1996) reported that biofeedback training using VR improved sitting balance and trunk control ability, which consequently improved walking ability in stroke patients. Betker et al. (2006) suggested that VR training in the form of games induces patient motivation and improves the dynamic balancing ability of the sitting posture. In addition, Kizony et al. (2005) reported that a VR training program improved static balance of sitting posture in patients with spinal cord injury. Roopchand-Martin and Bateman (2012) reported that the training method using the Nintendo Wii game was effective in controlling sitting balance in patients with American Spinal Cord Injury Association-Grade A. In our study, posture control training using a VR training program improved trunk control ability and sitting balance in children with CP.

The experimental group showed an improvement in arm extension after the intervention. Sitting balance is an essential ability for independent living. The ability to extend arm to hold objects at various distances and maintain balance while holding objects in a variety of seated environments are also essential (Dean & Shepherd, 1997). To maintain a stable balance, the neurological integration of visual information, vestibular function, proprioceptive sensation, and musculoskeletal system is required (Shumway-Cook & Woollacott, 1995). The VR training program Nintendo Wii used in this study provides visual and auditory feedback through avatars and sounds on the screen, and visual information that plays the most important role in maintaining balance is provided more efficiently. Visual feedback helps to recognize incorrect movements when performing active and repetitive movements during VR training. This affects the motor area and helps reduce errors. In this study, dynamic balancing ability was improved through integrating various senses, such as proprioceptive sensation, vestibular sensation, and somatosensory sensation related to balancing ability by providing various visual and auditory stimuli to children with CP, which is thought to help in improving the ability to perform daily activities of children with CP. Our study is in line with Khurana et al. (2017) who reported that the distance stretched from mFRT improved after using a VR program in the sitting position in patients with spinal cord injuries. In addition, their score also improved on the independent living standard evaluation scale.

The K-TCMS evaluation was conducted to evaluate the static and dynamic sitting balancing ability, body control, and balancing ability in dynamic arm stretch. There was a significant improvement in both groups, and the experimental group showed more improvement than the control group. However, there was no significant difference in the comparison between the groups. K-TCMS offers sufficient reliability and validity to evaluate balance and trunk control in the sitting position in patients with CP. However, in previous studies, it was reported that K-TCMS had evaluation items that did not consider trunk movement in children with CP and that the difference in movement by score was not large, making it difficult to accurately evaluate the score. In addition, in the item evaluating the selective movement control of dynamic sitting balancing ability, children had difficulty in understanding and performing movements (Heo & Shin, 2018). Thus, the difference between the two groups might not be have been found in our study due to the low sensitivity of the K-TCMS evaluation.

Trunk stability is essential for the effective performance of independent daily activities in children with CP, and sitting balance plays a very important role in children who lack sitting posture ability. The VR training program helps to improve sitting balance and trunk control ability, and improves the attention and motivation of children with CP to achieve the goal during the program, thereby increasing the degree of participation in treatment. In addition, as compared to other interventions, VR training has advantages, such as relatively easy treatment environment control and ease of selection, immediate sensory feedback for task performance, and self-learning opportunities in a safe environment (Jack et al., 2001). Thus, the VR training program is expected to be an intervention tool that can be used for posture control and balance training in the sitting position not only in hospitals but also at home.

A limitation of this study is that the results are difficult to generalize to all children with CP because of small sample size. It is also not known whether the effect was consistently due to the short duration of the intervention. The effect on balance and daily life activities in environments other than treatment time was also not sufficiently considered. Finally, the Wii program used in this study is an exercise method developed for normal people, and its use is limited in children with CP. However, only a few studies have applied self-control training using a Wii Balance Board in a sitting position; therefore, our study has high clinical value. It is necessary to develop a program tailored for rehabilitation by supplementing these points, and research should be continued by increasing the number of participants and performing long-term VR training.

5 Conclusions

In our study, there was a statistically and clinically significant improvement in Balancia program and m-FRT in the experimental group. The results of our study indicate that posture control training in the sitting position using a VR training program was found to be more effective in improving the sitting balance and trunk stability of non-ambulatory children with CP compared to the control group. Therefore, our results suggest that development of various interventions applying VR training program in the sitting position in the future will help improve the independent movement performance and quality of life of non-ambulatory children with CP.

Footnotes

Acknowledgments

The authors would like to express their appreciation to all childrens and their parents for their co-operation and participation in this study.

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Adamovich,

S. V.

, Fluet,

G. G.

, Tunik,

, & Merians,

A. S.

(2009). Sensorimotor training in virtual reality: A review. NeuroRehabilitation, 25(1), 29–44. https://doi.org/10.3233/NRE-2009-0497

Barton,

G. J.

, Hawken,

M. B.

, Foster,

R. J.

, Holmes,

, & Butler,

P. B.

(2013). The effects of virtual reality game training on trunk to pelvis coupling in a child with cerebral palsy. Journal of NeuroEngineering and Rehabilitation, 10(1), 15. https://doi.org/10.1186/1743-0003-10-15

Betker,

A. L.

, Szturm,

, Moussavi,

Z. K.

, & Nett,

(2006). Video Game–Based Exercises for Balance Rehabilitation: A Single-Subject Design. Archives of Physical Medicine and Rehabilitation, 87(8), 1141–1149. https://doi.org/10.1016/j.apmr.2006.04.010

Bobath,

(1991). A Neurophysiological Basis for the Treatment of Cerebral Palsy. Cambridge University Press.

Boswell-Ruys,

C. L.

, Harvey,

L. A.

, Barker,

J. J.

, Ben,

, Middleton,

J. W.

, & Lord,

S. R.

(2010). Training unsupported sitting in people with chronic spinal cord injuries: A randomized controlled trial. Spinal Cord, 48(2), 138–143. https://doi.org/10.1038/sc.2009.88

Brien,

, & Sveistrup,

(2011). An Intensive Virtual Reality Program Improves Functional Balance and Mobility of Adolescents With Cerebral Palsy: Pediatric Physical Therapy, 23(3), 258–266. https://doi.org/10.1097/PEP.0b013e318227ca0f

Burdea,

(2003). Virtual rehabilitation-benefits and challenges. Yearbook of Medical Informatics, 12(01), 170–176.

Choi,

S.-J.

, Shin,

W.-S.

, Oh,

B.-K.

, Shim,

J.-K.

, & Bang,

D.-H.

(2014). Effect of training with whole body vibration on the sitting balance of stroke patients. Journal of Physical Therapy Science, 26(9), 1411–1414. https://doi.org/10.1589/jpts.26.1411

Coyne,

(2008). Video“Games”in The Clinic: PTs Report Early Results. PT-ALEXANDRIA-, 16(5), 22.

10.

Dean,

C. M.

, & Shepherd,

R. B.

(1997). Task-Related Training Improves Performance of Seated Reaching Tasks After Stroke: A Randomized Controlled Trial. Stroke, 28(4), 722–728. https://doi.org/10.1161/01.STR.28.4.722

11.

Dean,

C. M.

, Shepherd,

R. B.

, & Adams,

R. D.

(1999). Sitting balance II: Reach direction and thigh support affect the contribution of the lower limbs when reaching beyond arm’s length in sitting. Gait & Posture, 10(2), 147–153. https://doi.org/10.1016/S0966-6362(99)00027-2

12.

Dursun Erbil , Hamamci Nigar , Dönmez Semra , Tüzünalp Önder , & Çakci Aytül . (1996). Angular Biofeedback Device for Sitting Balance of Stroke Patients. Stroke, 27(8), 1354–1357. https://doi.org/10.1161/01.STR.27.8.1354

13.

El Shemy,

S. A.

(2018). Trunk endurance and gait changes after core stability training in children with hemiplegic cerebral palsy: A randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation, 31(6), 1159–1167. https://doi.org/10.3233/BMR-181123

14.

Flynn,

, Palma,

, & Bender,

(2007). Feasibility of using the Sony PlayStation 2 gaming platform for an individual poststroke: A case report. Journal of Neurologic Physical Therapy, 31(4), 180–189.

15.

Granata,

K. P.

, Lee,

P. E.

, & Franklin,

T. C.

(2005). Co-contraction recruitment and spinal load during isometric trunk flexion and extension. Clinical Biomechanics, 20(10), 1029–1037. https://doi.org/10.1016/j.clinbiomech.2005.07.006

16.

Halton,

(2008). Virtual rehabilitation with video games: A new frontier for occupational therapy. Occupational Therapy Now 9(6), 12–14.

17.

Heo,

J.-Y.

, & Shin,

H.-K.

(2018). Reliability analysis of the Korean version of the trunk control measurement scale in cerebral palsy. Journal of Physical Therapy Science, 30(1), 1–4. https://doi.org/10.1589/jpts.30.1

18.

Jack,

, Boian,

, Merians,

A. S.

, Tremaine,

, Burdea,

G. C.

, Adamovich,

S. V.

, Recce,

, & Poizner,

(2001). Virtual reality-enhanced stroke rehabilitation. IEEE Transactions on Neural Systems and Rehabilitation Engineering, 9(3), 308–318.

19.

Jeon,

J.-Y

, & Shin,

W.-S.

(2014). Reliability and validity of the Korean version of the Trunk Control Measurement Scale (TCMS-K) for children with cerebral palsy. Research in Developmental Disabilities, 35(3), 581–590.

20.

Katz-Leurer,

, Fisher,

, Neeb,

, Schwartz,

, & Carmeli,

(2009). Reliability and validity of the modified functional reach test at the sub-acute stage post-stroke. Disability and Rehabilitation, 31(3), 243–248.

21.

Khurana,

, Walia,

, & Noohu,

M. M.

(2017). Study on the effectiveness of virtual reality game-based training on balance and functional performance in individuals with paraplegia. Topics in Spinal Cord Injury Rehabilitation, 23(3), 263–270.

22.

Kizony,

, Raz,

, Katz,

, Weingarden,

, & Weiss,

P. L. T.

(2005). Video-capture virtual reality system for patients with paraplegic spinal cord injury. The Journal of Rehabilitation Research and Development, 42(5), 595. https://doi.org/10.1682/JRRD.2005.01.0023

23.

Kwon,

H. C.

, & Lee,

C. H.

(1995) Advanced physical therapy I. Hyunmoon.

24.

Leveau,

B. F.

, & Bernhardt,

D. B.

(1984). Developmental biomechanics: Effect of forces on the growth, development, and maintenance of the human body. Physical Therapy, 64(12), 1874–1882.

25.

Merians,

A. S.

, Jack,

, Boian,

, Tremaine,

, Burdea,

G. C.

, Adamovich,

S. V.

, Recce,

, & Poizner,

(2002). Virtual Reality-Augmented Rehabilitation for Patients Following Stroke. Physical Therapy, 82(9), 898–915. https://doi.org/10.1093/ptj/82.9.898

26.

Park,

D.-S.

, & Lee,

(2014). Validity and reliability of balance assessment software using the Nintendo Wii balance board: Usability and validation. Journal of Neuroengineering and Rehabilitation, 11(1), 99.

27.

Partridge,

(2002) Neurological Physiotherapy. Bases of evidence for practice. WileyBlackwell. https://kar.kent.ac.uk/8051/

28.

Porras,

D. C.

, Siemonsma,

, Inzelberg,

, Zeilig,

, & Plotnik,

(2018). Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review. Neurology, 90(22), 1017–1025.

29.

Roopchand-Martin,

, & Bateman,

(2012). An exploration of the concept of using the Nintendo Wii for balance training in patients with paraplegia. New Zealand Journal of Physiotherapy, 40(1).

30.

Rosenbaum,

, Paneth,

, Leviton,

, Goldstein,

, Bax,

, Damiano,

, Dan,

, & Jacobsson,

(2007). A report: The definition and classification of cerebral palsy April 2006. Developmental Medicine and Child Neurology. Supplement, 109, 8–14.

31.

Ryu,

H.-N.

, & Han,

J.-T.

(2019). The Effect of Intensive Weight Shift Training on Seated Postural Balance in Children With Spastic Cerebral Palsy: A Case Study. The Journal of Korean Academy of Sensory Integration, 17(1), 9–18. https://doi.org/10.18064/JKASI.2019.17.1.009

32.

Shahanawaz,

S. D.

, Palekar,

T. J.

, & Shah,

(2015). Effect of Swiss ball on balance in children with spastic diplegia: A case study. Journal of Paediatrics, 1(1), 8–11.

33.

Shumway-Cook,

, & Woollacott,

M. H.

(1995). Theory and Practical Applications. 3.

34.

Styer-Acevedo,

, & Tecklin,

J. S.

(1999). Physical therapy for the child with cerebral palsy. Pediatric Physical Therapy.

35.

Verheyden,

, Nieuwboer,

, Mertin,

, Preger,

, Kiekens,

, & De Weerdt,

(2004). The Trunk Impairment Scale: A new tool to measure motor impairment of the trunk after stroke. Clinical Rehabilitation, 18(3), 326–334. https://doi.org/10.1191/0269215504cr733oa

36.

Weiss,

P. L.

, & Katz,

(2004). The potential of virtual reality for rehabilitation. J Rehabil Res Dev, 41(5), 7–10.

37.

Yatar,

G. I.

, & Yildirim,

S. A.

(2015). Wii Fit balance training or progressive balance training in patients with chronic stroke: A randomised controlled trial. Journal of Physical Therapy Science, 27(4), 1145–1151. https://doi.org/10.1589/jpts.27.1145

Effect of posture control training using virtual reality program on sitting balance and trunk stability in children with cerebral palsy

Abstract

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1 Introduction

2 Materials and methods

2.1 Participants

2.2 Procedure

2.2.1 Posture control training using a VR training program (experimental group)

2.2.2 Arm reach training in the sitting position (control group)

2.3 Measurement of parameters

2.3.1 Estimation of the static balance

2.3.2 Estimation of the dynamic balance

2.3.3 Evaluation of trunk control

2.4 Data analyses

2.5 Ethical statement

3 Results

3.1 General characteristics of the study participants

Table 1 Characteristics of subjects General characteristics Experimental group (n = 10) Control group (n = 10) Gender Male 3 4 female 7 6 Age(years) 14.3±4.2 14.1±4.3 Height(cm) 144.2±20.4 145.4±21.6 Weight(kg) 41.4±15.8 42.5±15.1 Type Diplegia 5(50%) 5(50%) Quadriplegia 5(50%) 5(50%)

3.2.1 Results of the Balancia program evaluation

Table 4 Comparison of Korean version of trunk control measurement scale between two groups Experimeantal Group (n = 10) Control Group (n = 10) U p b M±SD M±SD K-TCMS (score) Pre 19.5±9.67 17.3±7.7 Post 27.4±10.86 22.3±9.17 change 7.9±3.38 5.00±3.33 28.00 0.105 pa 0.005* 0.005*

5 Conclusions

Footnotes

Acknowledgments

Conflict of interest

References

Table 4
Comparison of Korean version of trunk control measurement scale between two groups

Experimeantal Group (n = 10) Control Group (n = 10) U p ^b

M±SD M±SD

K-TCMS (score) Pre 19.5±9.67 17.3±7.7

Post 27.4±10.86 22.3±9.17

change 7.9±3.38 5.00±3.33 28.00 0.105

p^a 0.005^* 0.005^*