From virtual reality to real life skill: enhancing potential of virtual environments for rehabilitation in children with cerebral palsy – Funded by the Charles H. Hood Foundation Child Health Research Awards Program

Children with cerebral palsy (CP), a common physical disability, have problems with movement and balance that limit their participation in daily functional activities. Physical therapists help them learn new movement skills using interventions that motivate children to practice repeatedly.  Virtual reality video games are attractive treatment options in this regard because they challenge movement skills in a motivating virtual environment. However, despite promising evidence that children with CP can gain skill from practicing in virtual environments, a major issue is that these skills have shown limited transfer to the real world.  This means that children aren’t necessarily any better at functional real-life activities after taking part in this therapy. It is important to determine how we might better promote transfer from virtual environments to real life skills.

To explore these questions, we designed a new task that takes place in either a physical environment, a two-dimensional (2D) flat screen virtual environment or a three-dimensional (3D) head mounted display virtual environment. We will have school-aged children with CP practice the task in either the physical environment, 2D or the 3D virtual environment, and measure how their movement skills change as they practice, and how well what they have learnt transfers to an unpracticed real-life task.  We believe that children who practice in the 3D virtual environment will be best able to transfer skills because this environment is most like real-life.

This research is necessary because video games in virtual environments are being used frequently in physical therapy and because new 3D head-mounted displays will soon be low cost and widely-accessible, so we should understand whether they offer advantages over 2D flat-screen displays. Our study is the first to explore mechanisms that may enhance transfer from virtual reality to real life skills in children with CP. The results will help researchers design better virtual environments and assist physical therapists in understanding which virtual environments most improve the movement skills of children with CP. Ultimately, this will enhance the quality of physical therapy treatments that use these tools and promote optimal functional outcomes for children with CP and other developmental disabilities.

Influence of virtual environment complexity on motor learning in children with cerebral palsy: Implications for virtual reality use in rehabilitation (Co-PI, Dr. Nathan Ward, Tufts University) – Funded by the Tufts Clinical and Translational Science Institute Pilot Studies Program

Motion-controlled video games in virtual environments are popular alternative physical therapy interventions for balance skill learning in children with cerebral palsy (CP). Virtual environments (VEs) feature enriched aesthetics that deliver complex stimulation designed to maximize engagement and adherence, features which are lacking in traditional approaches. However, 50% of children with CP have attentional impairments that hinder motor learning. The cognitive demands of interacting with enriched VEs may explain the current inconclusive evidence base for learning balance skills. To explore this issue, we propose a scaled approach emphasizing elements overlooked in previous research: adequate power and paradigm feasibility. Specifically, we will use multi-faceted, innovative recruitment strategies to build a recruitment database. Secondly, we will systematically evaluate the feasibility of our approach and will gather estimates required to power a federally-funded subsequent study. Our paradigm explores whether environmental enrichment enhances or impairs motor learning in children with CP by randomly assigning children to practice the same balance task in either a complex VE with enhanced audiovisual stimuli or a simplified control VE. We will administer standardized measures of attention and balance before acquisition, retention and transfer trials. Additionally, we will measure subjective (self-report) and objective (neurophysiological) measures of cognitive workload and engagement during acquisition. This project will position us to obtain federal funding to rigorously explore how changes in cognitive workload and engagement interact with children’s attention and impact motor learning in VEs. Findings from this bench-to-bedside translational program will enhance the efficacy of this promising alternative to traditional physical therapy interventions..

Usability evaluation of the FITBoard (Fun Interactive Therapy Board): A motivating, movement-based rehabilitation tool for children with disabilities- Funded by the Deborah Munroe Noonan Memorial Research Fund

Children with physical and/or developmental disabilities participate in physical therapy (PT) and occupational therapy (OT) activity programs over extended periods to learn new skills, maintain strength and range of motion, and maximize capacity for self-care and independent living. Amount of practice is the single biggest factor predicting rehabilitation success, but children and families find it challenging to adhere to lengthy, boring activity programs. Lack of practice leads to functional deterioration and reduced quality of life. Using technologies such as virtual reality (VR) gaming systems in rehabilitation motivates children to enhance practice dosage. However, many VR systems are expensive and inaccessible to young children or those with significant disabilities. To address this issue, we have used game design principles to integrate the advantages of VR into an accessible, low-cost physical toy. The FITBoard (Fun Interactive Therapy Board) is a rehabilitation tool consisting of a tablet and custom modular pieces that parents can assemble in different ways. The pieces contain a variety of touch-based interfaces that can control sounds, videos, or games. The FITBoard will motivate children to engage in repetitive practice of functional head, body, arm or leg movements, depending on its configuration. It can support users of differing ages and cognitive capacities because the ‘plug and play’ nature of its contact interfaces can be integrated with any existing media application. Our objective is to determine FITBoard usability in a sample of children, parents, and therapists in two pediatric rehabilitation settings. We will use standardized methods to assess users’ interaction with the FITBoard and evaluate factors that may impede or facilitate its use in rehabilitation. Our findings will inform future clinical trials. Ultimately, the FITBoard can be integrated into home, school or clinic interventions to increase practice dosage, enhance functional outcomes and improve quality of life for children with disabilities.

Does narrative feedback enhance motor larning of a virtual balance task in children with cerebral palsy? – Co-PI, Amy Lu, Bouvé College of Health Sciences and College of Arts, Media and Design – Funded by a Northeastern University Tier 1 Seed Grant

Cerebral palsy is the primary cause of childhood disability in the United States, leading to balance impairments that interfere with functional mobility and impact a child’s ability to learn new skills. The feedback provided by physical therapists during motor skill learning is important because it can help children plan movements and detect errors. Feedback should be salient and motivating to enhance adherence in abundant practice trials. However, little is known about the best ways to provide feedback to children with CP for effective motor learning. Since we know that many children are attracted to fantasy narratives, we want to know whether receiving narrative feedback might help children learn a new movement task better than regular feedback. This research project will compare the effects on retention and transfer of learning of two types of feedback provided in a virtual environment during learning of a new virtual reality (VR) balance task: narrative feedback (in the context of a story related to the VR task) and regular feedback. The goal is to establish proof of concept and lead to further research studies in this area. VR is an increasingly popular physical therapy intervention for children with CP, and our partnership with VR game developers can translate the findings into practice to create VR games for children with CP that incorporate narrative feedback conditions.