A Custom Serious Games System with Forced-Bimanual Use can Improve Upper Limb Function for Children with Cerebral Palsy: Results from a Randomised Controlled Trial

Background: Cerebral palsy (CP) is the most common cause of physical disability in childhood, with the condition affecting both motor and sensory function. Most children with CP favour their dominant upper limb during activities of daily living, resulting in a learned non-use phenomenon for their non-dominant (ND) limb, and consequently, decreased afferent inputs. The aim of this research was to design, develop, test and trial a custom serious gaming intervention to improve upper limb function, addressing both motor and sensory aspects of the limb, which was novel and had not been attempted before. The hypothesis was that sensory function could be significantly improved through regular use of a home-based haptic gaming system that required coupled bimanual integrated hand use to successfully play the games.

Method: The gaming system was developed using a stage-gate product development process for the hardware and an agile scrum methodology for the software. Universal Design principles, focus groups with children aged 4–16 years old, short-term in-home trials, and a co-design philosophy were adopted to produce the prototype system in 2.5 years. The system, known as OrbIT, is a standalone, self-logging, accessible and haptic serious gaming system that features 15 different games, which randomise game events to increase player engagement.

Eighteen children with CP (12 male; mean age: 10 yr 8 mo ± 3 yr 4 mo; Manual Ability Classification System Level: I(2), II(10), III(3), IV(3); CP type: hemiplegia (n= 13), diplegia (n= 5)) trialled OrbIT at home for 6 weeks. The experimental group (n= 10) received afferent haptic vibration to their ND hand via the controller, whereas the haptic feature was disabled for the control group (n= 8). Primary outcome measures were tests of sensation (pressure sensitivity, texture discrimination, distal proprioception, and stereognosis) and the Jebsen Taylor Hand Function Test (JFHFT). Assessments were conducted upon enrolment (A1), immediately after the intervention (A2), and 4 weeks post-intervention (A3).

Key results: All 18 children completed the trial, with 2 children withdrawing post-trial. OrbIT was rated highly by families (7.4 ± 1.9 out of 10, median = 8.0, n= 17) and overall average system usage was 377 ± 267 mins, with no statistical difference in usage between groups (p= 0.07). Statistical modelling revealed a significant between group difference for the ND hand for the test of stereognosis between A1 and A2 (p= 0.02) that did not persist at A3 (p= 0.41). When considered as a single cohort (n= 18), modelling revealed a strong statistically significant difference for the ND hand for the JTHFT total time (p= 0.001) between A1 and A3. However, a Type II error cannot be ruled out. A post-hoc analysis revealed an estimated sample size of 55 children for 80% power.

Conclusion: OrbIT proved to be an acceptable, feasible, and robust technology for children with both unilateral and bilateral CP, when upper limb sensory and motor impairments are present. Sensory improvements were recorded for the intervention group, but did not persist, whereas ND hand function improved significantly for all children post-trial. However, a larger and appropriately powered study needs to be conducted to validate the results of the trial.