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Exergame Rehabilitation System for Severe Cerebral Palsy

By William Farr,Sussex Community NHS Foundation Trust, Brighton and Sussex Medical School,Will.farr@nhs.net

Marilyn Poole, Birmingham Community NHS Foundation Trust, Paediatric Physiotherapy, Birmingham,  marilynpoole@nhs.net

Clive Thursfield, Birmingham Community NHS Foundation Trust, Priestley Wharf, Birmingham, Clive.thursfield@bhamcommunity.nhs.uk

Ian Male, Sussex Community NHS Foundation Trust, Brighton and Sussex Medical School, Brighton, Ian.male@nhs.net


Published in Proceedings CHI PLAY ’17 Extended Abstracts Publication of the Annual Symposium on Computer-Human Interaction in Play, pp. 255-260 , Amsterdam, The Netherlands — October 15 – 18, 2017. Copyright is held by the owner/author(s). Publication rights licensed to ACM.



Computer-enhanced therapy can complement conventional intervention. Seven children and families took part in a trial day to test acceptance and applicability of MIRA rehabilitation software for children with neuromotor disorders. MIRA software has had limited use e.g. elderly rehabilitation, stroke patients, but requires clinical validation. A parent and child questionnaire was used to gather feedback. Results show MIRA is acceptable but requires more appropriate adaptation before re-application to children due to accessibility problems e.g. self-occlusion, image comprehension.



Neurodisability describes a group of congenital or acquired long conditions that occur as a result of impairment to the brain/neuromuscular system, and can cause functional limitation [1]. Neurodisability can change over time, be co-morbid, vary in complexity and severity, and affect emotion, behaviour, communication, thinking, sight and hearing [1]. Children with neurodisability such as Cerebral Palsy experience barriers in their care and wider participation to society [e.g. see 2], experience less therapeutic contact, and most effort is often put into those with severe needs, whilst less severe forms often experience greatest gains [3]. Utilising whole body interaction for functional gain using novel and motivating methods that can be used across a variety of settings (home, school, clinic) is timely and cost-effective [4,5]. “Virtual reality therapy” (VRT) [as defined by 7,8] is a method using motion capture digital technology to assist with therapy. So far VRT had good impact [e.g. 6] but further exploration is needed as more products are developed. We report here on VRT with a gesture-based Kinect game.

Utilizing children’s bodily interaction with virtual objects for neuromotor disorders is becoming more prevalent for therapeutic benefit [7]. However, aspects of technology, so-called “active ingredients” [8], are still being identified. Active ingredients are those facets of the technology that make promote positive therapeutic change.  According to Levac [8] active ingredients in a paediatric populations are:

  • Child interest in the technology
  • Family support
  • Ability of the child to undertake exercise conveniently
  • Contact with a therapist who individualizes programs of therapy

For therapists and researchers utilizing virtual systems, the impact of these systems may be more ”hype than hope” [9] especially as many systems are trialled initially in geriatric populations e.g. individuals recovering from stroke due to population bias, then re-applied to paediatrics. This approach presents with a common problem found in medicine of “off-label” use of pharmacological technology [10]. Medical staff know drugs and systems work with adults and do not automatically lend themselves to paediatric populations, but still use them with children whilst parents are unaware [10]. Technological interventions are beginning to suffer the same problem – where anecdotal evidence leads to technology use without thorough testing, breaching health services duty of care [e.g. 11]. Buxton and Greenberg [12] suggest: “the choice of evaluation methodology – if any – must arise from and be appropriate for the actual problem or research question under consideration” [12. p119]. Here, “active ingredients” in virtual reality therapy point toward the massive importance of technical acceptability in children and families.



This work-in-progress presents initial results on the acceptability and usability of MIRA rehab limited, a commercially available software package. NHS trusts involved in this early evaluation were approached by MIRA to test out the system’s use with children with a neurodisability. Before exploring physical gains, motivational factors are essential to tackle first as acceptability is paramount [e.g. see 6, 8]. To that end we asked the following acceptability questions:

  1. Do children and families like the software?
  2. Do therapists like the software?
  3. Does the software do what is claimed?
  4. Is adaptation required?


MIRA software

MIRA software (see figure 1) is designed to make physiotherapy fun and convenient for patients recovering from surgery or injury (see sidebar for images). Figure 2 shows the broad scope of the software from hemiparesis to Autism to shoulder flexion. The system takes existing physical therapy exercises and transforms them to interactive video-games, using an external Kinect sensor to track and assess patient compliance. To increase patient compliance, MIRA customizes video games to the client. All games have a simple design. Patient compliance is supposed to be good, reducing recovery time. This inexpensive technology may make MIRA suitable for clinic and home-use.



Study Design

Seven children (2 girls, 5 boys, mean age: 9.7y) were presented with MIRA and attended a special school for children with physical and cognitive needs. Children were presented with the MIRA software exergames in a freeplay session on easy settings lasting 10-30 minutes. Groups were split according to severity of their motor impairment using the Gross Motor Function Classification System [13]. Level I children are ambulatory with mild impairments, level V children depend upon a wheelchair for mobility and require considerable postural support. Four children were GMFCS IV, 2 x GMFCS 1, 1 x GMFCS III (70% severe). Some children had wheelchairs and were unable to stand without support or a splint. Parents and children were afterwards asked to complete a questionnaire on the use and acceptability of the software.




Seven families gave feedback on the MIRA system (see table 1). Seven children and six adults (5 parents, 1 care worker) responded. The questionnaire took the form of 8 quantitative questions (see table 1) asking for a score on a scale of 1 to 5, 1 with 1 “not at all” and 5 being “a lot”. Two qualitative questions are reported in table 2, and further qualitative responses are reported in the “therapist and parent themes”. Children and adults reported high scores of satisfaction for the games (86.7%, 4.3/5), and thought they were successful in the playing of them (88.3% completely satisfied, or 4.4/5). 75% reported game difficulty as “very easy”.

Parents and children overwhelmingly state they would play these games either at home or at school. However children reported they would play games several times a day whilst parents were split between once a day and several times a day. Therapists reported children’s attitudes to playing games exceeded capability. Results show that stakeholders (children, therapists, parents) have varying goals and desires for therapeutic outcomes.


Therapist and parent feedback themes


Children with moderate learning difficulties struggled with abstraction of relating virtual objects to their own physical movement. Widespread familiarity with touch screens (e.g. iPads) also now means children want to touch screens even if they are not interactive. MIRA software screens are not interactive, nor does the game allow such interaction. Children regularly touched screens resulting in calibration loss due to self-occlusion. Children with cognitive difficulties also experienced attention lapses and would move out of sensor coverage. On-screen instructions also require adaptation to a lower level of language comprehension, inclusion of verbal instruction, and addition of sign languages such as Makaton.

 Table 1. Questionnaire results from 7 children with CP of varying severity, and 6 adults





Child rating (out of 5) Adult rating (out of 5) Overall % of satisfaction



Did you enjoy the games? 4.7 4 87
Did you feel as if you were exercising? 4.3 3.7 79
Overall did you think you were successful in the games? 4.9 4 88
Did you feel in control of the games? 3.7 3.3 70
Did the games keep you interested? 4.3 3.8 81
How clear and interesting were the instruction videos? 4.8 3.3 81
How clear and interesting was the feedback given? 4.6 4.2 88
Did you dislike any of the experience? 3.8 5 88
How difficult was the game for you? 1.6 1.5 69


 Table 2. Percentage of respondents reporting willingness to play and preferred place of engagement


  % respondents
Question Child Parent  


Care worker

1. Where would you play these games?      
School & home 85% 83% 100%
School & physio 15% 0% 0%
Home 0% 17% 0%
2. How often would you be willing to play these games?      
Once a week 0% 20% 0%
Every few days 0% 0% 100%
Once a day 0% 40% 0%
Several times a day 100% 40% 0%




Children with physical access problems e.g. wheelchairs had issues with system recalibration. Headrests interfered with sensors detection, standing frames were a possible solution but repositioning children results in the system detecting assisting therapists and not the child. Children were also unable to calibrate games from a seated position, and calibration is lengthy. The system was also too fast for many users to fully comprehend how movement related to on-screen action.



More freedom is needed for children to be able to play games. Point scoring does not appear to work, and interactive experiences or joyful images such as sounds or ripples in a puddle give positive feedback and are more aligned to this population.



Screens often move from left to right in gameplay following Western text-tracking, but children with hemiplegia require tracking of games from right to left  fitting with their preferred direction of weight shifting.





Children with neurodisability need to be able to equitably access software. Software needs appropriate adaptation to children, and customized to the point where able-bodied children, and those without learning difficulties can play fairly with a handicapped system (similar to golf),  The drive to mainstream inclusion of children with neurodisability means greater adaptation is needed for future specialized intervention and rehabilitation.



At present the MIRA system is suited to precise movements for musculoskeletal patients e.g. those recovering from stroke. Focused work is needed to make MIRA applicable to children with neurodisability. Future work will use validated tools e.g. TAM [14] to explore quantitative acceptance measures. Physical gains will be verified using gold standard tools e.g. Gross Motor Function Measurement Scale [15]. Future work will establish which software aspects achieve real gain or are only positive distractions from pain or discomfort.



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