GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 1, Number 4, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2012.0015
A Comparison of Solo and Multiplayer Active Videogame Play in Children with Unilateral Cerebral Palsy Jennifer Howcroft, MHSc,1 Darcy Fehlings, MD, MSc,2 Virginia Wright, PT, PhD,3 Karl Zabjek, PhD,3 Jan Andrysek, PhD, PEng,1 and Elaine Biddiss, PhD1
Abstract
Objective: Active videogames (AVGs) have potential in terms of physical activity and therapy for children with cerebral palsy. However, the effect of social interaction on AVG play has not yet been assessed. The objective of this study is to determine if multiplayer AVG versus solo affects levels of energy expenditure and movement patterns. Subjects and Methods: Fifteen children (9.77 [standard deviation (SD) 1.78] years old) with hemiplegic cerebral palsy (Gross Motor Function Classification System Level I) participated in solo and multiplayer Nintendo ‘‘Wii Boxing’’ (Nintendo, Inc., Redmond, WA) AVG play while energy expenditure and punching frequency were monitored. Results: Moderate levels of physical activity were achieved with no significant differences in energy measures during multiplayer and solo play. Dominant arm punching frequency increased during the multiplayer session from 95.75 (SD 37.93) punches/minute to 107.77 (SD 36.99) punches/minute. Conversely, hemiplegic arm punching frequency decreased from 39.05 (SD 29.57) punches/minutes to 30.73 (SD 24.74) punches/minutes during multiplayer game play. Children enjoyed multiplayer more than solo play. Conclusions: Opportunities to play AVGs with friends and family may translate to more frequent participation in this moderate physical activity. Conversely, increased hemiplegic limb use during solo play may have therapeutic advantages. As such, new strategies are recommended to promote use of the hemiplegic hand during multiplayer AVG play and to optimize commercial AVG systems for applications in virtual reality therapy.
Introduction
T
he health and functioning of children with cerebral palsy (CP) can be significantly enhanced through regular physical activity and therapy.1 Nevertheless, children with CP have an even higher incidence of physical inactivity compared with the general population.2 Additionally, while increased usage of and practice with the hemiplegic limb are associated with improved function, many children with unilateral CP tend to rely heavily on their dominant limb in activities of daily living because of ‘‘developmental disregard.’’3 Developmental disregard is independent of the skill or measured capacity of the impaired limb and has a proposed neurological basis of repeated reinforcement of neglect.3 Strategies to increase these children’s participation in physical activity and use of their hemiplegic limbs in everyday activities are needed to improve health and functional abilities. One potential strategy is the use of active videogames (AVGs).
AVGs, like those for the Nintendo Wii (Nintendo, Inc., Redmond, WA), require some degree of physical activity (e.g., swinging arms and dancing) beyond that of conventional, hand-controlled games (e.g., keyboard or mouse). AVGs have the potential to be a low-cost, home-based, all-season, selfdirected, and potentially enjoyable medium for physical activity and virtual reality therapy for children with CP. AVG-based virtual reality therapies The use of AVGs in rehabilitation therapies is increasing, with several studies noting promising results in youth,4,5 specifically those with CP6,7 and amputations,8 and in adults with stroke.9 AVGs may be particularly suited to enacting neuroplastic change associated with improved rehabilitation outcomes given their ability to provide (a) virtual worlds/ roles/storylines that encourage practice and repetition, (b) advancing game levels that slowly increase the complexity/
1 Institute of Biomaterial & Biomedical Engineering and Departments of 2Paediatrics and 3Physical Therapy, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, Ontario, Canada.
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speed of movements, (c) points/feedback/tracking that enhance feelings of reward and self-efficacy, and (d) motivation to play via the ‘‘fun factor.’’ Promoting physical activity For children with10 and without11,12 disabilities, excessive screen time has been identified as a causative factor of physical inactivity. Nevertheless, screen time activities (e.g., television and videogames) are highly valued by children with and without disabilities.13 AVGs have the potential to promote physical activity by replacing sedentary screen time with active screen time.14 In a recent systematic review, children and adolescents (under 21 years of age) increased energy expenditure (EE) by 222 percent (SD 100 percent) during AVG play.15 Although little research is available pertaining to EE and AVG play with disability populations, AVGs may offer a different medium for physical activity that is less hindered by barriers to exercise, including16 motivational and environmental barriers and accessibility issues. One potentially important aspect of AVG play that has received little attention in the literature is social interaction, which is a well-established motivator enhancing both children’s and adults’ participation in physical activities.17 In this study, we will investigate children with hemiplegia engaged in AVG play against computer-generated adversaries (solo) and human challengers (multiplayer). The primary objective of this study is to determine if (a) EE and (b) movement patterns of either the dominant or hemiplegic limb differ during solo versus multiplayer AVG play.
A visual, cognitive, or auditory disability that would interfere with game play Receiving a botulinum toxin treatment in the last 3 months Receiving orthopedic surgery in the last 6 months Approval for this study was granted by the Holland Bloorview research ethics board and ErinoakKids Centre for Treatment and Development ethics board. Informed assent and consent was obtained from the child and guardian, respectively. Anthropometric measurements Body mass, to the nearest 0.5 kg, and body height, to the nearest 0.5 cm, were measured without shoes using an upright scale (Health o Meter Inc., Bedford Heights, OH). Energy measurements
Subjects and Methods
The Cosmed K4b2 cardiopulmonary testing unit (Cosmed Inc., Chicago, IL) was used to obtain physiological measures of oxygen consumption (VO2), EE, and heart rate (HR). EE was determined based on measures of VO2 and carbon dioxide exhalation (VCO2) using the following equation: EE = (3.781 · VO2) + (1.237 · VCO2). The HR monitor was a Polar (Lake Success, NY) HR monitor. The Cosmed K4b2 unit was calibrated prior to each session using the manufacturer’s protocols. Calibration of the O2 and CO2 sensors was completed using a sample gas of known concentrations. Respiratory volume was calibrated using a 3-L volume calibration syringe. A delay calibration was also performed to ensure adequate response time to a breathing cycle.
Study design
AVG
This study is a single-group, experimental study that applies objective outcome assessments and qualitative methodologies.
The AVG of focus in this study was ‘‘Wii Boxing,’’ which is part of the ‘‘Wii Sports’’ package and is played on the Wii gaming platform with the Wii Remote and Nunchuck (Nintendo, Inc.). ‘‘Wii Boxing’’ was selected as it was the AVG that achieved the highest levels of EE in a previous study24 and is a bilateral game that engages both the dominant and hemiplegic limbs.
Participants Children between the ages of 7 and 13 years old with hemiplegia and Gross Motor Function Classification System (GMFCS) Level I were recruited to participate in this study.18,19 The level of motor function in the children, measured using the Manual Ability Classification System (MACS),20,21 was not restricted but was obtained when available. All children were recruited using convenience sampling by therapists independent of the research team from Holland Bloorview Kids Rehabilitation Hospital (Toronto, ON, Canada) and ErinoakKids Centre for Treatment and Development (Mississauga, ON, Canada). Children were screened using a modified Physical Activity Readiness Questionnaire22,23 and the following additional exclusion criteria:
Heart condition or chest pains during exercise Feeling faint or experiencing severe dizziness High blood pressure Broken bones in the last 6 months Epilepsy Chronic asthma An injury or disability that would make moderate exercise unsafe
Study procedure The study consisted of one visit by each child to the Holland Bloorview Kids Rehab Gait Laboratory. Anthropometric measures were taken, and the child was familiarized with the equipment and test procedures before testing began. The child was fitted with the Cosmed K4b2 cardiopulmonary testing unit. A DVD was played for the child, who sat quietly for 20 minutes as per the procedures of Mellecker and McManus25 and Mellecker et al.26 Physiological data were collected for the last 10 minutes to obtain a measure of resting energy levels. The child was allowed to familiarize him- or herself with the game before playing for a maximum of 5 minutes. The child then played ‘‘Wii Boxing’’ twice, once against the computer (i.e., solo) and a second time against a member of the research team (i.e., multiplayer). Of note is that the researcher was an experienced ‘‘Wii Boxing’’ player and reduced his skill level such that the child ‘‘just won’’ and was never more than one ‘‘knockout’’ ahead. The game was played for 8 minutes in both scenarios with a 5-minute rest in
CEREBRAL PALSY MULTIPLAYER ACTIVE VIDEOGAME between. The entire game play session was video-recorded. Muscle activity and energy data were collected for the entire 8 minutes of game play. The child ranked his or her level of perceived exertion after playing each game using the OMNI Scale of Perceived Exertion (OMNI), which has demonstrated good validity in children.27 After playing both games, the children were asked which scenario they enjoyed more (i.e., multiplayer or solo). Data analysis All data (except OMNI scores) are expressed as mean (standard deviation [SD]) values. The ordinal OMNI scores are expressed as median (interquartile range). Standard error bars are displayed on all graphs. For energy measures, the first 30 seconds of data associated with each new game was eliminated to allow for subject acclimatization. The metabolic equivalent for task (MET) was calculated by normalizing the average rate of VO2 during AVG play to the resting VO2. The frequency of punching during game play was determined from the collected video data. Three 1-minute segments at the beginning, middle, and end of the 8 minutes of game play were consistently extracted and analyzed for the multiplayer and solo play sessions. The number of punches was counted by two independent, blinded researchers. One of the researchers counted the punches twice (on two different days separated by 1 week) to assess repeatability. The resultant counts for all three 1-minute periods were then averaged to give a frequency of punches per minute, which was used in all subsequent analyses. All statistical analyses were performed using SPSS version 17.0 (SPSS, Inc., Chicago, IL) with a significance level of P < 0.05. Intraclass correlations were performed to assess the inter-rater reliability and repeatability of video-obtained frequency data. Normality of the data was assessed with the Kolmogorov–Smirnov and the Shapiro–Wilk tests of normality. For normal data, paired t tests were used to determine if significant differences existed between the solo and multiplayer scenarios. For non-normal data and ordinal data, a Wilcoxon test was used to compare OMNI scores between multiplayer and solo play. Results Participants Fifteen participants (10 boys and five girls) with hemiplegia, GMFCS Level I, were recruited to participate in the study. Demographic and anthropometric information is presented in Table 1. MACS levels were known for 12 of the 15 subjects. Of these 12, five were MACS Level 1, and seven were MACS Level 2; MACS levels were not available for the three par-
289 ticipants recruited from ErinoakKids Centre for Treatment and Development. The sample included a representative range of body mass indices with an average percentile of 58.80 percent (SD 32.24 percent) and a range of 10th–95th percentile. Of the participants, 87 percent (n = 13) were experienced with ‘‘Wii Boxing.’’ Physical activity levels Only 12 of the 15 participants wore the Cosmed K4b2 equipment, and the energy measures represent data from this subset. Three children found the cardiopulmonary testing unit too uncomfortable to wear: One child used a hearing aid and was aggravated by the frequency of the turbine, and the other two children had had previous hospital experiences that required them to wear an oxygen mask. Mean levels for the energy measures (e.g., VO2, MET, EE, HR) are presented in Table 2. The normality test demonstrated that the energy measures were normally distributed. As evident, children on average achieved moderate levels of physical activity during the games. For all energy measures except VO2, levels during solo play were slightly and insignificantly lower than those during multiplayer mode (Pq0.176). The percentage increase ranged from 1.51 percent for MET levels to 3.97 percent for HR. Perceived exertion, as measured by the OMNI, increased from 4 (‘‘Just feeling a strain’’) during solo play to 6 (‘‘Getting quite hard’’) during multiplayer mode, although this increase was not significant (P = 0.079). Frequency of punching Inter-rater reliability for video-derived punching frequency counts was strong with an intraclass correlation coefficient of 0.984 (95 percent confidence interval 0.910–0.953, P < 0.001) for the dominant (i.e., nonhemiplegic) arm and an intraclass correlation coefficient of 0.961 (95 percent confidence interval 0.849–0.984, P < 0.001) for the hemiplegic arm. Similarly, the repeatability of the counts was strong with an intraclass correlation coefficient of 0.995 (95 percent confidence interval 0.993–0.997, P < 0.001) for the dominant arm and an intraclass correlation coefficient of 0.979 (95 percent confidence interval 0.959–0.988, P < 0.001) for the hemiplegic arm. Normality tests indicated that the punching frequency counts were not normally distributed. As depicted in Figure 1, the frequency of punching for the dominant arm during multiplayer (107.77 [SD 36.99] punches/minute) and solo (95.75 [SD 37.93] punches/minute) play was significantly greater (P < 0.001) than for the hemiplegic arm during multiplayer (30.73 [SD 24.74] punches/minute) and solo Table 2. Energy Measures During Solo and Multiplayer ‘‘Wii Boxing’’ Game Play (n = 12)
Table 1. Participant Characteristics
Age (years) Height (cm) Weight (kg) BMI (kg/m2)
Females (n = 5)
Males (n = 10)
All subjects (n = 15)
9.60 – 1.82 139.80 – 8.98 38.00 – 10.42 19.32 – 4.01
9.85 – 1.86 142.40 – 11.57 37.15 – 10.92 18.04 – 3.00
9.77 – 1.78 141.53 – 10.52 37.43 – 10.38 18.47 – 3.28
BMI, body mass index.
VO2 (mL/minute) MET Energy expenditure (kJ/minute) Heart rate (bpm) OMNI
Solo
Multiplayer
551.51 – 222.06 3.32 – 1.57 10.07 – 3.75
549.76 – 200.51 3.37 – 1.28 10.29 – 2.84
137.04 – 19.96 4.25 (5.25)
142.48 – 13.44 6 (2)
bpm, beats per minute; MET, metabolic equivalent for task; OMNI, OMNI Scale of Perceived Exertion27; VO2, oxygen consumption.
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FIG. 1. Punching frequency during multiplayer and solo ‘‘Wii Boxing’’ game play. Error bars depict standard errors. *Multiplayer punching frequency greater than solo punching frequency (P = 0.008). {Solo punching frequency greater than multiplayer punching frequency (P = 0.003). {Dominant arm punching frequency greater than hemiplegic arm punching frequency (P < 0.001). (39.05 [SD 29.57] punches/minute) play. The frequency of punching by the dominant arm increased during multiplayer compared with solo play but not significantly (P = 0.071); punching frequency of the hemiplegic limb was significantly lower during multiplayer compared with solo play (P = 0.001). Reported enjoyment All participants preferred playing ‘‘Wii Boxing’’ in the multiplayer as opposed to the solo play scenario. Discussion Key findings This study examined EE and movement patterns during multiplayer and solo ‘‘Wii Boxing’’ game play. The key findings are as follows: 1.
Moderate levels of physical activity were obtained during both multiplayer and solo play with no significant differences in energy levels or HR observed. 2. Dominant arm activity increased during multiplayer game play. Conversely, hemiplegic arm activity significantly decreased during multiplayer game play. 3. Children preferred multiplayer game play. Interpretation Promoting physical activity. Children with unilateral CP can achieve moderate levels of physical activity during AVG play, specifically ‘‘Wii Boxing.’’ To date, only one
other study has investigated differences in energy levels between solo and multiplayer AVG play.28 That study investigated healthy adult males, and, in line with our study’s findings, no significant differences in EE, HR, and perceived exertion were found between solo and multiplayer scenarios.28 It is unclear whether moderate energy levels would occur in the home environment over the long term. A recent 13-week home study found no difference in youth activity levels playing AVGs and inactive videogames.29 This could be due to lack of motivation,5,30 inappropriate game difficulty, or absence of people with whom to play.29 The children in this study unanimously reported having more ‘‘fun’’ playing multiplayer ‘‘Wii Boxing.’’ Because ‘‘fun’’ is a major motivating factor in children’s participation in physical activity,31 this suggests that children would be more likely to play ‘‘Wii Boxing’’ in a multiplayer scenario. Therefore, to increase the likelihood of participation and maximize activity benefits, opportunities for multiplayer game play should be promoted. Therapeutic rehabilitation. Conflicting results were observed with respect to multiplayer versus solo play in terms of hemiplegic limb usage. As expected, in both game play scenarios, the dominant arm punching frequency was significantly greater than that of the hemiplegic arm. This is in line with current understanding of ‘‘developmental disregard.’’3,32,33 During multiplayer game play, hemiplegic arm activity significantly decreased. This may be due to an increased motivation to win when playing against a real opponent, resulting in increased reliance on their more
CEREBRAL PALSY MULTIPLAYER ACTIVE VIDEOGAME ‘‘reliable’’ limb (i.e., their dominant hand). Alternatively, the added challenge of a human component may have increased neglect of the hemiplegic limb. Therefore, it may be worthwhile to encourage solo game play when therapy as opposed to physical activity is the priority. Additional strategies with respect to game design and play conditions may also be adopted to maximize the therapeutic benefits of AVG play. Future work As opposed to encouraging children with CP to play AVGs by themselves, there may be more effective strategies for maximizing children’s enjoyment of the game while meeting therapeutic goals. For example, techniques to increase hemiplegic limb use during multiplayer game play could include coaching from clinicians/parents or swapping the remotes (i.e., Wii remote in the hemiplegic hand and Nunchuck in the dominant hand). Additionally, new games could be developed that reward children with extra points for using their hemiplegic arm. Future studies are needed to assess other bimanual AVGs to determine whether these findings are isolated to ‘‘Wii Boxing.’’ Additionally, assessment of AVG play in the home environment is strongly indicated. Multiplayer AVG play in the home environment has not been assessed to date to determine whether it increases game play time. If the increase is large enough, it may offset the multiplayer decrease in hemiplegic arm activity. It is also important that long-term motivation to engage in AVG play for physical activity promotion or as part of a rehabilitation therapy be assessed. The single session nature of this study only allowed for an assessment of initial enjoyment. However, other studies have indicated that motivation to play AVGs may decrease over time,5,30 making this
291 an important area for future study in a population of children with CP. Limitations This study only assessed children with hemiplegia diagnosed as GMFCS Level I and MACS Level 1 and 2. Results cannot be generalized to children outside of these diagnoses. The equation used to calculate EE was based on data from adults. Inaccuracies are likely present in these calculations when applied to children with CP. However, this equation is currently used to determine EE in children during AVG play34–37 and was therefore included to allow for comparisons between studies. VO2 and MET levels provide a more accurate representation of energy levels in a CP population.38 It is noted that our sample size was small, which introduces a risk for Type II errors (i.e., failure to detect a significant effect where one does indeed exist). However, the small deviations (i.e., 4 percent) in EE measures observed during solo and multiplayer AVG play were not clinically significant even if they became statistically significant in a larger population. Although not a primary measure of interest, measurements in a larger population might statistically confirm the observation that punching frequency associated with the dominant limb increased during multiplayer mode. All participants started the AVGs at a beginner level in an attempt to ensure consistency. This may have decreased energy levels for experienced players in the solo scenario from those they would achieve when playing at home or in the multiplayer scenario (i.e., closer to their actual skill level). Furthermore, the multiplayer scenario in this study was somewhat controlled and not a perfect representation of naturalistic settings (i.e., where a difference in skill level is likely to occur).
FIG. 2. Punching frequency of the dominant and hemiplegic limbs during multiplayer and solo ‘‘Wii Boxing’’ during three time points of play (beginning, middle, and end). Note that no trends in punching frequency with respect to duration of play were observed.
292 The order of presentation of the solo or multiplayer activities was not randomized. Several post hoc analyses were conducted to ensure that the lack of counterbalancing did not affect the integrity of the results. First, 87 percent of participants were experienced with the game and had played it at home. As such, an additional 8 minutes of game play would be unlikely to increase their skill level. Within this subset of experienced players, the percentage of punches completed with the hemiplegic limb remained significantly lower in the multiplayer scenario (33 [SD 23] punches/minute) compared with solo play (43 [SD 29] punches/minute) (P = 0.038). With respect to fatigue, EE and perceived exertion during solo and multiplayer game play were comparable. Children rested for 5 minutes before taking part in the multiplayer scenario. No child reported fatigue at any point. Post hoc analyses were conducted to quantitatively assess the potential for fatigue. The frequency of punches was compared among three time points of play (beginning, middle, and end) for both the solo and multiplayer sessions (Fig. 2). If fatigue was an issue, a decrease in punching frequency would occur with time. A repeated-measure analysis of variance indicated no trends with respect to duration of play for either the dominant or hemiplegic limb in solo or multiplayer AVG play. Conclusions Significant differences in energy levels were not observed in multiplayer versus solo play scenarios. Both play scenarios increased energy levels significantly from rest to moderate levels of physical activity for children with mild, unilateral CP. Punching frequency decreased in the hemiplegic arm during multiplayer game play, which is a significant and clinically relevant finding. As a result, multiplayer play, while more enjoyable for children, may not be optimal for meeting therapeutic goals. Conversely, multiplayer play may encourage children to voluntarily participate more frequently in AVG play. Future work should focus on developing techniques to increase hemiplegic arm use during multiplayer AVG play in order to maximize both children’s enjoyment of the games and their therapeutic value. Acknowledgments We would like to thank Elizabeth Han, Delbert Hung, Ajmal Khan, and Jomy Varghese for aiding with data collections. We would also like to thank the study participants, Holland Bloorview Kids Rehabilitation Hospital, and ErinkoakKids Centre for Treatment and Development. We would like to acknowledge our funding sources—Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, Ontario Ministry of Training, Colleges and Universities, and the Holland Bloorview Kids Rehabilitation Hospital Foundation—for their generous support of this study. Author Disclosure Statement No conflicts of interest or competing financial interests exist. References 1. Damiano D. Activity, activity, activity: Rethinking our physical therapy approach to cerebral palsy. Phys Ther 2006; 86:1534–1540.
HOWCROFT ET AL. 2. Rimmer J. Physical fitness levels of persons with cerebral palsy. Dev Med Child Neurol 2001; 43:208–212. 3. Sutcliffe TL, Logan WJ, Fehlings DL. Pediatric constraintinduced movement therapy is associated with increased contralateral cortical activity on functional magnetic resonance imaging. J Child Neurol 2009; 24:1230–1235. 4. Parsons TD, Rizzo AA, Rogers S, York P. Virtual reality in pediatric rehabilitation: A review. Dev Neurorehabil 2009; 12:224–238. 5. Sandlund M, McDonough S, Hager-Ross C. Interactive computer play in rehabilitation of children with sensorimotor disorders: A systematic review. Dev Med Child Neurol 2009; 51:173–179. 6. Deutsch JE, Borbely M, Filler J, et al. Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Phys Ther 2008; 88:1196–1207. 7. Snider L, Majnemer A, Darsaklis V. Virtual reality as a therapeutic modality for children with cerebral palsy. Dev Neurorehabil 2010; 13:120–128. 8. Andrysek J, Klejman S, Steinnagel B, et al. Preliminary evaluation of a commercially available videogame system as an adjunct therapeutic intervention for improving balance among children and adolescents with lower limb amputations. Arch Phys Med Rehabil 201; 93:358–366. 9. Saposnik G, Teasell R, Mamdani M, et al. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation. Stroke 2010; 41:1477–1484. 10. Michelsen SI, Flachs EM, Uldall P, et al. Frequency of participation of 8–12-year-old children with cerebral palsy: A multi-centre cross-sectional European study. Eur J Paediatr Neurol 2009; 13:165–177. 11. Eagle TF, Gurm R, Goldberg CS, et al. Health status and behavior among middle-school children in a Midwest community: What are the underpinnings of childhood obesity? Am Heart J 2010; 160:1185–1189. 12. Kuhle S, Allen AC, Veugelers PJ. Prevention potential of risk factors for childhood overweight. Can J Public Health 2010; 101:365–368. 13. Faith MS, Berman N, Heo M, et al. Effects of contingent television on physical activity and television viewing in obese children. Pediatrics 2001; 107:1043–1048. 14. Maloney AE, Carter Bethea T, Kelsey KS, et al. A pilot of a video game (DDR) to promote physical activity and decrease sedentary screen time. Obesity 2008; 16:2074–2080. 15. Hillier A. Childhood overweight and the built environment: Making technology part of the solution rather than part of the problem. Ann Am Acad Polit Soc Sci 2008; 615:56–82. 16. Biddiss E, Irwin J. Active video games to promote physical activity in children and youth. Arch Pediatr Adolesc Med 2010; 164:664–672. 17. Allender S, Cowburn G, Foster C. Understanding participation in sport and physical activity among children and adults: A review of qualitative studies. Health Educ Res 2006; 21:826–835. 18. Palisano RJ, Rosenbaum PL, Walters SD, et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 1997; 39:214–223. 19. Wood E, Rosenbaum P. The Gross Motor Function Classification System for cerebral palsy: A study of reliability and stability over time. Dev Med Child Neurol 2000; 42:292–296. 20. Eliasson AC, Krumlinde-Sundholm L, Rosblad B, et al. The Manual Ability Classification System (MACS) for children
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with cerebral palsy: Scale development and evidence of validity and reliability. Dev Med Child Neurol 2006; 48:549–554. Morris C, Kurinczuk JJ, Fitzpatrick R, Rosenbaum PL. Reliability of the Manual Ability Classification System for children with cerebral palsy. Dev Med Child Neurol 2006; 48:950–953. Adams R. Revised Physical Activity Readiness Questionnaire. Can Fam Physician 1999; 45:992–993. Chisholm DM, Collis ML, Kulak LL, et al. PAR-Q Validation Report: The Evaluation of a Self-Administered Pre-Exercise Screening Questionnaire for Adults. Victoria, BC: BC Ministry of Health and Health and Welfare Canada, 1978. Howcroft J, Klejman S, Fehlings D, et al. Active video game play in children with cerebral palsy: Potential for physical activity promotion and rehabilitation therapies. Arch Phys Med Rehabil 2012 May 3 [Epub ahead of print]. DOI: 10.1016/j.apmr.2012.02.033. Mellecker RR, McManus AM. Energy expenditure and cardiovascular responses to seated and active gaming in children. Arch Pediatr Adolesc Med 2008; 162:886–891. Mellecker RR, McManus AM, Lanningham-Foster LM, Levine JA. The feasibility of ambulatory screen time in children. Int J Pediatr Obes 2009; 4:106–111. Robertson RJ, Goss FL, Boer NF, et al. Children’s OMNI Scale of Perceived Exertion: Mixed gender and race validation. Med Sci Sports Exerc 2000; 32:452–458. Bonetti AJ, Drury DG, Danoff JV, Miller TA. Comparison of acute exercise responses between conventional video gaming and isometric resistance exergaming. J Strength Cond Res 2010; 24:1799–1803. Baranowski T, Abdelsamad D, Baranowski J, et al. Impact of an active video game on healthy children’s physical activity. Pediatrics 2012; 129:e636–e642. Chin A Paw MJM, Jacobs WM, Vaessen EPG, et al. The motivation of children to play an active video game. J Sci Med Sport 2008; 11:163–166.
293 31. Borra S, Schwartz N, Spain C, Natchipolsky M. Food, physical activity, and fun: Inspiring America’s kids to more healthful lifestyles. J Am Diet Assoc 1995; 7:816–818. 32. Jaspers E, Desloovere K, Bruyninckx H, et al. Review of quantitative measurements of upper limb movements in hemiplegic cerebral palsy. Gait Posture 2009; 30:395–404. 33. Gordon AM, Charles J, Wolf SL. Methods of constraintinduced movement therapy for children with hemiplegic cerebral palsy: Development of a child-friendly intervention for improving upper-extremity function. Arch Phys Med Rehabil 2005; 86:837–844. 34. Haddock BL, Siegel SR, Wikin LD. The addition of a video game to stationary cycling: The impact on energy expenditure in overweight children. Open Sports Sci J 2009; 2:42–46. 35. Lanningham-Foster L, Jensen TB, Foster RC, et al. Energy expenditure of sedentary screen time compared with active screen time for children. Pediatrics 2006; 118:e1831–e1835. 36. Tan B, Aziz AR, Chau K, Teh KC. Aerobic demands of the dance simulation game. Int J Sports Med 2002; 23:125–129. 37. Unnithan VB, Houser W, Fernhall B. Evaluation of the energy cost of playing a dance simulation video game in overweight and non-overweight children and adolescents. Int J Sports Med 2006; 27:804–809. 38. Maltais DB, Pierrynowski MR, Galea VA, Bar-Or O. Physical activity level is associated with the O2 cost of walking in cerebral palsy. Med Sci Sports Exerc 2005; 37:347–353.
Address correspondence to: Elaine Biddiss, PhD Institute of Biomaterial & Biomedical Engineering Bloorview Research Institute Holland Bloorview Kids Rehabilitation Hospital 150 Kilgour Road Toronto, ON M4G 1R8, Canada E-mail: [email protected]
A Comparison of Solo and Multiplayer Active Videogame Play in Children with Unilateral Cerebral Palsy Jennifer Howcroft, MHSc,1 Darcy Fehlings, MD, MSc,2 Virginia Wright, PT, PhD,3 Karl Zabjek, PhD,3 Jan Andrysek, PhD, PEng,1 and Elaine Biddiss, PhD1
Abstract
Objective: Active videogames (AVGs) have potential in terms of physical activity and therapy for children with cerebral palsy. However, the effect of social interaction on AVG play has not yet been assessed. The objective of this study is to determine if multiplayer AVG versus solo affects levels of energy expenditure and movement patterns. Subjects and Methods: Fifteen children (9.77 [standard deviation (SD) 1.78] years old) with hemiplegic cerebral palsy (Gross Motor Function Classification System Level I) participated in solo and multiplayer Nintendo ‘‘Wii Boxing’’ (Nintendo, Inc., Redmond, WA) AVG play while energy expenditure and punching frequency were monitored. Results: Moderate levels of physical activity were achieved with no significant differences in energy measures during multiplayer and solo play. Dominant arm punching frequency increased during the multiplayer session from 95.75 (SD 37.93) punches/minute to 107.77 (SD 36.99) punches/minute. Conversely, hemiplegic arm punching frequency decreased from 39.05 (SD 29.57) punches/minutes to 30.73 (SD 24.74) punches/minutes during multiplayer game play. Children enjoyed multiplayer more than solo play. Conclusions: Opportunities to play AVGs with friends and family may translate to more frequent participation in this moderate physical activity. Conversely, increased hemiplegic limb use during solo play may have therapeutic advantages. As such, new strategies are recommended to promote use of the hemiplegic hand during multiplayer AVG play and to optimize commercial AVG systems for applications in virtual reality therapy.
Introduction
T
he health and functioning of children with cerebral palsy (CP) can be significantly enhanced through regular physical activity and therapy.1 Nevertheless, children with CP have an even higher incidence of physical inactivity compared with the general population.2 Additionally, while increased usage of and practice with the hemiplegic limb are associated with improved function, many children with unilateral CP tend to rely heavily on their dominant limb in activities of daily living because of ‘‘developmental disregard.’’3 Developmental disregard is independent of the skill or measured capacity of the impaired limb and has a proposed neurological basis of repeated reinforcement of neglect.3 Strategies to increase these children’s participation in physical activity and use of their hemiplegic limbs in everyday activities are needed to improve health and functional abilities. One potential strategy is the use of active videogames (AVGs).
AVGs, like those for the Nintendo Wii (Nintendo, Inc., Redmond, WA), require some degree of physical activity (e.g., swinging arms and dancing) beyond that of conventional, hand-controlled games (e.g., keyboard or mouse). AVGs have the potential to be a low-cost, home-based, all-season, selfdirected, and potentially enjoyable medium for physical activity and virtual reality therapy for children with CP. AVG-based virtual reality therapies The use of AVGs in rehabilitation therapies is increasing, with several studies noting promising results in youth,4,5 specifically those with CP6,7 and amputations,8 and in adults with stroke.9 AVGs may be particularly suited to enacting neuroplastic change associated with improved rehabilitation outcomes given their ability to provide (a) virtual worlds/ roles/storylines that encourage practice and repetition, (b) advancing game levels that slowly increase the complexity/
1 Institute of Biomaterial & Biomedical Engineering and Departments of 2Paediatrics and 3Physical Therapy, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, Ontario, Canada.
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speed of movements, (c) points/feedback/tracking that enhance feelings of reward and self-efficacy, and (d) motivation to play via the ‘‘fun factor.’’ Promoting physical activity For children with10 and without11,12 disabilities, excessive screen time has been identified as a causative factor of physical inactivity. Nevertheless, screen time activities (e.g., television and videogames) are highly valued by children with and without disabilities.13 AVGs have the potential to promote physical activity by replacing sedentary screen time with active screen time.14 In a recent systematic review, children and adolescents (under 21 years of age) increased energy expenditure (EE) by 222 percent (SD 100 percent) during AVG play.15 Although little research is available pertaining to EE and AVG play with disability populations, AVGs may offer a different medium for physical activity that is less hindered by barriers to exercise, including16 motivational and environmental barriers and accessibility issues. One potentially important aspect of AVG play that has received little attention in the literature is social interaction, which is a well-established motivator enhancing both children’s and adults’ participation in physical activities.17 In this study, we will investigate children with hemiplegia engaged in AVG play against computer-generated adversaries (solo) and human challengers (multiplayer). The primary objective of this study is to determine if (a) EE and (b) movement patterns of either the dominant or hemiplegic limb differ during solo versus multiplayer AVG play.
A visual, cognitive, or auditory disability that would interfere with game play Receiving a botulinum toxin treatment in the last 3 months Receiving orthopedic surgery in the last 6 months Approval for this study was granted by the Holland Bloorview research ethics board and ErinoakKids Centre for Treatment and Development ethics board. Informed assent and consent was obtained from the child and guardian, respectively. Anthropometric measurements Body mass, to the nearest 0.5 kg, and body height, to the nearest 0.5 cm, were measured without shoes using an upright scale (Health o Meter Inc., Bedford Heights, OH). Energy measurements
Subjects and Methods
The Cosmed K4b2 cardiopulmonary testing unit (Cosmed Inc., Chicago, IL) was used to obtain physiological measures of oxygen consumption (VO2), EE, and heart rate (HR). EE was determined based on measures of VO2 and carbon dioxide exhalation (VCO2) using the following equation: EE = (3.781 · VO2) + (1.237 · VCO2). The HR monitor was a Polar (Lake Success, NY) HR monitor. The Cosmed K4b2 unit was calibrated prior to each session using the manufacturer’s protocols. Calibration of the O2 and CO2 sensors was completed using a sample gas of known concentrations. Respiratory volume was calibrated using a 3-L volume calibration syringe. A delay calibration was also performed to ensure adequate response time to a breathing cycle.
Study design
AVG
This study is a single-group, experimental study that applies objective outcome assessments and qualitative methodologies.
The AVG of focus in this study was ‘‘Wii Boxing,’’ which is part of the ‘‘Wii Sports’’ package and is played on the Wii gaming platform with the Wii Remote and Nunchuck (Nintendo, Inc.). ‘‘Wii Boxing’’ was selected as it was the AVG that achieved the highest levels of EE in a previous study24 and is a bilateral game that engages both the dominant and hemiplegic limbs.
Participants Children between the ages of 7 and 13 years old with hemiplegia and Gross Motor Function Classification System (GMFCS) Level I were recruited to participate in this study.18,19 The level of motor function in the children, measured using the Manual Ability Classification System (MACS),20,21 was not restricted but was obtained when available. All children were recruited using convenience sampling by therapists independent of the research team from Holland Bloorview Kids Rehabilitation Hospital (Toronto, ON, Canada) and ErinoakKids Centre for Treatment and Development (Mississauga, ON, Canada). Children were screened using a modified Physical Activity Readiness Questionnaire22,23 and the following additional exclusion criteria:
Heart condition or chest pains during exercise Feeling faint or experiencing severe dizziness High blood pressure Broken bones in the last 6 months Epilepsy Chronic asthma An injury or disability that would make moderate exercise unsafe
Study procedure The study consisted of one visit by each child to the Holland Bloorview Kids Rehab Gait Laboratory. Anthropometric measures were taken, and the child was familiarized with the equipment and test procedures before testing began. The child was fitted with the Cosmed K4b2 cardiopulmonary testing unit. A DVD was played for the child, who sat quietly for 20 minutes as per the procedures of Mellecker and McManus25 and Mellecker et al.26 Physiological data were collected for the last 10 minutes to obtain a measure of resting energy levels. The child was allowed to familiarize him- or herself with the game before playing for a maximum of 5 minutes. The child then played ‘‘Wii Boxing’’ twice, once against the computer (i.e., solo) and a second time against a member of the research team (i.e., multiplayer). Of note is that the researcher was an experienced ‘‘Wii Boxing’’ player and reduced his skill level such that the child ‘‘just won’’ and was never more than one ‘‘knockout’’ ahead. The game was played for 8 minutes in both scenarios with a 5-minute rest in
CEREBRAL PALSY MULTIPLAYER ACTIVE VIDEOGAME between. The entire game play session was video-recorded. Muscle activity and energy data were collected for the entire 8 minutes of game play. The child ranked his or her level of perceived exertion after playing each game using the OMNI Scale of Perceived Exertion (OMNI), which has demonstrated good validity in children.27 After playing both games, the children were asked which scenario they enjoyed more (i.e., multiplayer or solo). Data analysis All data (except OMNI scores) are expressed as mean (standard deviation [SD]) values. The ordinal OMNI scores are expressed as median (interquartile range). Standard error bars are displayed on all graphs. For energy measures, the first 30 seconds of data associated with each new game was eliminated to allow for subject acclimatization. The metabolic equivalent for task (MET) was calculated by normalizing the average rate of VO2 during AVG play to the resting VO2. The frequency of punching during game play was determined from the collected video data. Three 1-minute segments at the beginning, middle, and end of the 8 minutes of game play were consistently extracted and analyzed for the multiplayer and solo play sessions. The number of punches was counted by two independent, blinded researchers. One of the researchers counted the punches twice (on two different days separated by 1 week) to assess repeatability. The resultant counts for all three 1-minute periods were then averaged to give a frequency of punches per minute, which was used in all subsequent analyses. All statistical analyses were performed using SPSS version 17.0 (SPSS, Inc., Chicago, IL) with a significance level of P < 0.05. Intraclass correlations were performed to assess the inter-rater reliability and repeatability of video-obtained frequency data. Normality of the data was assessed with the Kolmogorov–Smirnov and the Shapiro–Wilk tests of normality. For normal data, paired t tests were used to determine if significant differences existed between the solo and multiplayer scenarios. For non-normal data and ordinal data, a Wilcoxon test was used to compare OMNI scores between multiplayer and solo play. Results Participants Fifteen participants (10 boys and five girls) with hemiplegia, GMFCS Level I, were recruited to participate in the study. Demographic and anthropometric information is presented in Table 1. MACS levels were known for 12 of the 15 subjects. Of these 12, five were MACS Level 1, and seven were MACS Level 2; MACS levels were not available for the three par-
289 ticipants recruited from ErinoakKids Centre for Treatment and Development. The sample included a representative range of body mass indices with an average percentile of 58.80 percent (SD 32.24 percent) and a range of 10th–95th percentile. Of the participants, 87 percent (n = 13) were experienced with ‘‘Wii Boxing.’’ Physical activity levels Only 12 of the 15 participants wore the Cosmed K4b2 equipment, and the energy measures represent data from this subset. Three children found the cardiopulmonary testing unit too uncomfortable to wear: One child used a hearing aid and was aggravated by the frequency of the turbine, and the other two children had had previous hospital experiences that required them to wear an oxygen mask. Mean levels for the energy measures (e.g., VO2, MET, EE, HR) are presented in Table 2. The normality test demonstrated that the energy measures were normally distributed. As evident, children on average achieved moderate levels of physical activity during the games. For all energy measures except VO2, levels during solo play were slightly and insignificantly lower than those during multiplayer mode (Pq0.176). The percentage increase ranged from 1.51 percent for MET levels to 3.97 percent for HR. Perceived exertion, as measured by the OMNI, increased from 4 (‘‘Just feeling a strain’’) during solo play to 6 (‘‘Getting quite hard’’) during multiplayer mode, although this increase was not significant (P = 0.079). Frequency of punching Inter-rater reliability for video-derived punching frequency counts was strong with an intraclass correlation coefficient of 0.984 (95 percent confidence interval 0.910–0.953, P < 0.001) for the dominant (i.e., nonhemiplegic) arm and an intraclass correlation coefficient of 0.961 (95 percent confidence interval 0.849–0.984, P < 0.001) for the hemiplegic arm. Similarly, the repeatability of the counts was strong with an intraclass correlation coefficient of 0.995 (95 percent confidence interval 0.993–0.997, P < 0.001) for the dominant arm and an intraclass correlation coefficient of 0.979 (95 percent confidence interval 0.959–0.988, P < 0.001) for the hemiplegic arm. Normality tests indicated that the punching frequency counts were not normally distributed. As depicted in Figure 1, the frequency of punching for the dominant arm during multiplayer (107.77 [SD 36.99] punches/minute) and solo (95.75 [SD 37.93] punches/minute) play was significantly greater (P < 0.001) than for the hemiplegic arm during multiplayer (30.73 [SD 24.74] punches/minute) and solo Table 2. Energy Measures During Solo and Multiplayer ‘‘Wii Boxing’’ Game Play (n = 12)
Table 1. Participant Characteristics
Age (years) Height (cm) Weight (kg) BMI (kg/m2)
Females (n = 5)
Males (n = 10)
All subjects (n = 15)
9.60 – 1.82 139.80 – 8.98 38.00 – 10.42 19.32 – 4.01
9.85 – 1.86 142.40 – 11.57 37.15 – 10.92 18.04 – 3.00
9.77 – 1.78 141.53 – 10.52 37.43 – 10.38 18.47 – 3.28
BMI, body mass index.
VO2 (mL/minute) MET Energy expenditure (kJ/minute) Heart rate (bpm) OMNI
Solo
Multiplayer
551.51 – 222.06 3.32 – 1.57 10.07 – 3.75
549.76 – 200.51 3.37 – 1.28 10.29 – 2.84
137.04 – 19.96 4.25 (5.25)
142.48 – 13.44 6 (2)
bpm, beats per minute; MET, metabolic equivalent for task; OMNI, OMNI Scale of Perceived Exertion27; VO2, oxygen consumption.
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FIG. 1. Punching frequency during multiplayer and solo ‘‘Wii Boxing’’ game play. Error bars depict standard errors. *Multiplayer punching frequency greater than solo punching frequency (P = 0.008). {Solo punching frequency greater than multiplayer punching frequency (P = 0.003). {Dominant arm punching frequency greater than hemiplegic arm punching frequency (P < 0.001). (39.05 [SD 29.57] punches/minute) play. The frequency of punching by the dominant arm increased during multiplayer compared with solo play but not significantly (P = 0.071); punching frequency of the hemiplegic limb was significantly lower during multiplayer compared with solo play (P = 0.001). Reported enjoyment All participants preferred playing ‘‘Wii Boxing’’ in the multiplayer as opposed to the solo play scenario. Discussion Key findings This study examined EE and movement patterns during multiplayer and solo ‘‘Wii Boxing’’ game play. The key findings are as follows: 1.
Moderate levels of physical activity were obtained during both multiplayer and solo play with no significant differences in energy levels or HR observed. 2. Dominant arm activity increased during multiplayer game play. Conversely, hemiplegic arm activity significantly decreased during multiplayer game play. 3. Children preferred multiplayer game play. Interpretation Promoting physical activity. Children with unilateral CP can achieve moderate levels of physical activity during AVG play, specifically ‘‘Wii Boxing.’’ To date, only one
other study has investigated differences in energy levels between solo and multiplayer AVG play.28 That study investigated healthy adult males, and, in line with our study’s findings, no significant differences in EE, HR, and perceived exertion were found between solo and multiplayer scenarios.28 It is unclear whether moderate energy levels would occur in the home environment over the long term. A recent 13-week home study found no difference in youth activity levels playing AVGs and inactive videogames.29 This could be due to lack of motivation,5,30 inappropriate game difficulty, or absence of people with whom to play.29 The children in this study unanimously reported having more ‘‘fun’’ playing multiplayer ‘‘Wii Boxing.’’ Because ‘‘fun’’ is a major motivating factor in children’s participation in physical activity,31 this suggests that children would be more likely to play ‘‘Wii Boxing’’ in a multiplayer scenario. Therefore, to increase the likelihood of participation and maximize activity benefits, opportunities for multiplayer game play should be promoted. Therapeutic rehabilitation. Conflicting results were observed with respect to multiplayer versus solo play in terms of hemiplegic limb usage. As expected, in both game play scenarios, the dominant arm punching frequency was significantly greater than that of the hemiplegic arm. This is in line with current understanding of ‘‘developmental disregard.’’3,32,33 During multiplayer game play, hemiplegic arm activity significantly decreased. This may be due to an increased motivation to win when playing against a real opponent, resulting in increased reliance on their more
CEREBRAL PALSY MULTIPLAYER ACTIVE VIDEOGAME ‘‘reliable’’ limb (i.e., their dominant hand). Alternatively, the added challenge of a human component may have increased neglect of the hemiplegic limb. Therefore, it may be worthwhile to encourage solo game play when therapy as opposed to physical activity is the priority. Additional strategies with respect to game design and play conditions may also be adopted to maximize the therapeutic benefits of AVG play. Future work As opposed to encouraging children with CP to play AVGs by themselves, there may be more effective strategies for maximizing children’s enjoyment of the game while meeting therapeutic goals. For example, techniques to increase hemiplegic limb use during multiplayer game play could include coaching from clinicians/parents or swapping the remotes (i.e., Wii remote in the hemiplegic hand and Nunchuck in the dominant hand). Additionally, new games could be developed that reward children with extra points for using their hemiplegic arm. Future studies are needed to assess other bimanual AVGs to determine whether these findings are isolated to ‘‘Wii Boxing.’’ Additionally, assessment of AVG play in the home environment is strongly indicated. Multiplayer AVG play in the home environment has not been assessed to date to determine whether it increases game play time. If the increase is large enough, it may offset the multiplayer decrease in hemiplegic arm activity. It is also important that long-term motivation to engage in AVG play for physical activity promotion or as part of a rehabilitation therapy be assessed. The single session nature of this study only allowed for an assessment of initial enjoyment. However, other studies have indicated that motivation to play AVGs may decrease over time,5,30 making this
291 an important area for future study in a population of children with CP. Limitations This study only assessed children with hemiplegia diagnosed as GMFCS Level I and MACS Level 1 and 2. Results cannot be generalized to children outside of these diagnoses. The equation used to calculate EE was based on data from adults. Inaccuracies are likely present in these calculations when applied to children with CP. However, this equation is currently used to determine EE in children during AVG play34–37 and was therefore included to allow for comparisons between studies. VO2 and MET levels provide a more accurate representation of energy levels in a CP population.38 It is noted that our sample size was small, which introduces a risk for Type II errors (i.e., failure to detect a significant effect where one does indeed exist). However, the small deviations (i.e., 4 percent) in EE measures observed during solo and multiplayer AVG play were not clinically significant even if they became statistically significant in a larger population. Although not a primary measure of interest, measurements in a larger population might statistically confirm the observation that punching frequency associated with the dominant limb increased during multiplayer mode. All participants started the AVGs at a beginner level in an attempt to ensure consistency. This may have decreased energy levels for experienced players in the solo scenario from those they would achieve when playing at home or in the multiplayer scenario (i.e., closer to their actual skill level). Furthermore, the multiplayer scenario in this study was somewhat controlled and not a perfect representation of naturalistic settings (i.e., where a difference in skill level is likely to occur).
FIG. 2. Punching frequency of the dominant and hemiplegic limbs during multiplayer and solo ‘‘Wii Boxing’’ during three time points of play (beginning, middle, and end). Note that no trends in punching frequency with respect to duration of play were observed.
292 The order of presentation of the solo or multiplayer activities was not randomized. Several post hoc analyses were conducted to ensure that the lack of counterbalancing did not affect the integrity of the results. First, 87 percent of participants were experienced with the game and had played it at home. As such, an additional 8 minutes of game play would be unlikely to increase their skill level. Within this subset of experienced players, the percentage of punches completed with the hemiplegic limb remained significantly lower in the multiplayer scenario (33 [SD 23] punches/minute) compared with solo play (43 [SD 29] punches/minute) (P = 0.038). With respect to fatigue, EE and perceived exertion during solo and multiplayer game play were comparable. Children rested for 5 minutes before taking part in the multiplayer scenario. No child reported fatigue at any point. Post hoc analyses were conducted to quantitatively assess the potential for fatigue. The frequency of punches was compared among three time points of play (beginning, middle, and end) for both the solo and multiplayer sessions (Fig. 2). If fatigue was an issue, a decrease in punching frequency would occur with time. A repeated-measure analysis of variance indicated no trends with respect to duration of play for either the dominant or hemiplegic limb in solo or multiplayer AVG play. Conclusions Significant differences in energy levels were not observed in multiplayer versus solo play scenarios. Both play scenarios increased energy levels significantly from rest to moderate levels of physical activity for children with mild, unilateral CP. Punching frequency decreased in the hemiplegic arm during multiplayer game play, which is a significant and clinically relevant finding. As a result, multiplayer play, while more enjoyable for children, may not be optimal for meeting therapeutic goals. Conversely, multiplayer play may encourage children to voluntarily participate more frequently in AVG play. Future work should focus on developing techniques to increase hemiplegic arm use during multiplayer AVG play in order to maximize both children’s enjoyment of the games and their therapeutic value. Acknowledgments We would like to thank Elizabeth Han, Delbert Hung, Ajmal Khan, and Jomy Varghese for aiding with data collections. We would also like to thank the study participants, Holland Bloorview Kids Rehabilitation Hospital, and ErinkoakKids Centre for Treatment and Development. We would like to acknowledge our funding sources—Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, Ontario Ministry of Training, Colleges and Universities, and the Holland Bloorview Kids Rehabilitation Hospital Foundation—for their generous support of this study. Author Disclosure Statement No conflicts of interest or competing financial interests exist. References 1. Damiano D. Activity, activity, activity: Rethinking our physical therapy approach to cerebral palsy. Phys Ther 2006; 86:1534–1540.
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Address correspondence to: Elaine Biddiss, PhD Institute of Biomaterial & Biomedical Engineering Bloorview Research Institute Holland Bloorview Kids Rehabilitation Hospital 150 Kilgour Road Toronto, ON M4G 1R8, Canada E-mail: [email protected]
