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Disabil Rehabil, Early Online: 1–4

! 2015 Taylor & Francis. DOI: 10.3109/09638288.2015.1073373

RESEARCH PAPER

Balance improvement after physical therapy training using specially

developed serious games for cerebral palsy children: preliminary results
Bruno Bonnechère1, Lubos Omelina2,3, Bart Jansen2,4, and Serge Van Sint Jan1
1
Laboratory of Anatomy, Biomechanics and Organogenesis, Université Libre de Bruxelles, Brussels, Belgium, 2Department of Electronics and
Informatics, Vrije Universiteit Brussel, Brussels, Belgium, 3Institute of Computer Science and Mathematics, Slovak University of Technology,
Bratislava, Slovakia, and 4iMinds, Department of Medical IT, Ghent, Belgium
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Abstract Keywords
Purpose: Cerebral palsy (CP) leads to various clinical signs mainly induced by muscle spasticity Cerebral palsy, exercise, motor control, new
and muscle weakness. Among these ones impaired balance and posture are very common. technology, posture, rehabilitation
Traditional physical therapy exercise programs are focusing on this aspect, but it is difficult to
motivate patients to regularly perform these exercises, especially at home without therapist History
supervision. Specially developed serious games (SG) could therefore be an interesting option to
motivate children to perform specific exercise for balance improvement. Method: Ten CP Received 27 October 2014
children participated in this study. Patients received four sessions of SG included into Revised 18 May 2015
conventional therapy (1 session of 30 min a week during 4 weeks). Trunk control and balance Accepted 13 July 2015
For personal use only.

were assessed using Trunk Control Motor Scale (TCMS) before and after interventions. Results: Published online 3 August 2015
Children presented a significant improvement in TCMS global score after interventions [37.6
(8.7) and 39.6 (9.5) before and after interventions, respectively, p ¼ 0.04]. Conclusion: SG could
therefore be an interesting option to integrate in the conventional treatment of CP children.

ä Implication for Rehabilitation

 Cerebral palsy (CP) leads to balance issues.
 Rehabilitation exercises are not performed (enough) at home.
 Serious games (SG) could increase patients’ motivation.
 SG increase balance control of CP children.

Introduction their therapist or to increase the function in the best case

scenario). Unfortunately the compliance to treatment is known to
Balance and posture control are important for functional
be very low: indeed it is estimated that only 30% of the patients
activities. Cerebral palsy (CP) children have poor postural
perform home exercises regularly [4]. One of the most frequent
balance control compared to normal children due to slowed and
reasons reported for patient dropout is related to a lack of patient
impaired development of their neural motor control mechanisms
motivation [5]. Integration of rehabilitation schemes and exercises
combined with so-called secondary musculoskeletal abnormal-
into video game interfaces has been previously suggested to
ities (e.g. muscle spasticity, muscle weakness, low proprioception
increase patient compliance to planned exercises and to prevent
and bone deformations) [1]. Balance training is an important part
patients’ demotivation [6–8]. Commercial video games (e.g.
of rehabilitation of CP children because it has been shown that
Nintendo Wii FitÔ) have been recently tested as a supplementary
there is a relation between constraints on balance control and
treatment for CP children with encouraging results on balance and
functional limitations of CP children [2]. Specific balance training
motivation [9]. However, these games were primary designed for
exercises integrated into rehabilitation programs could therefore
fun and not for rehabilitation, therefore for some heavily disabled
modify postural balance by increasing postural muscle control
patients it is not obvious to integrate them into rehabilitation (e.g.
and increasing the range-of-motion of the trunk [2,3]. In order to
because of the speed required from the patient to play or the visual
maximize benefits of the rehabilitation session it is advised
complexity disturbing many CP patients suffering from visual
to patients to perform supplementary exercises at home (i.e. to
impairment). Therefore, specific patient games must be developed
maintain the gain obtained during rehabilitation performed with
from real clinical specifications including rehabilitation schemes
and therapists’ expectations; only such integration can answer the
practical rehabilitation field constraints [10]. The aim of this
study was to test if specially developed serious games (SG) for
Address for correspondence: Bruno Bonnechère, Laboratory of Anatomy,
Biomechanics and Organogenesis, Université Libre de Bruxelles, Lennik physical rehabilitation can be integrated in the treatment of CP
Street, 808, 1070 Brussels, Belgium. Tel: +32 25556262. E-mail: children, and an improvement of the patient balance can be
bbonnech@ulb.ac.be obtained.
 2 B. Bonnechère et al.
Figure 1. Specially developed games. (A) Flight simulator (lateral translation of CoP), (B) hit the boxes (lateral translation of CoP), (C) follow me
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(oblique translation of CoP), (D) balls (lateral translation of CoP) and (E) wipe out (translation in all directions of CoP).
Figure 2. Different potential used of the WBB
during the games [configuration used in this
study in sited on the WBB (upper left
corner)].
For personal use only.
Materials and methods
Ten CP children [10 ± 3 years old, Gross Motor Function
Classification System (GMFCS) 1.7 (0.8), 4 females] participated
in this study. Participants were included in this study if they were
diagnosed with spastic CP, aged between 5 and 15, GMFCS I–III
and having sufficient cognitive level to understand how to play the
games. The GMFCS is a scale used to categorize CP patients in
five different levels according to gross motor skills ranging from
level I for patients that can walk and run without support to level
V for patients that cannot independently walk [11].
Exclusion criteria were (one of these or a combination of):
having a trunk support, showing behavioral disorders, orthopedic
interventions or botulinum toxin injections in the last 6 months or
intrathecal baclofen. This study was approved by the Academic
Disabil Rehabil, Early Online: 1–4
Bio-Ethical Committee/Human Research Brussels and informed
consent was obtained from parents and children.
Five specific games have been developed (snapshots of the
games are presented in Figure 1, movies of the games can be seen
from http://www.youtube.com/ict4rehab).
Within this study, all games were controlled with a Nintendo
Wii Balance Board (WBB) linked to a computer via Bluetooth.
One game (Balls see Figure 1D) was controlled with a WBB and a
Kinect sensor, simultaneously. Because some of the patients could
not stand alone and/or for a sufficiently long period of time, all
patients were seated on the middle of the WBB when playing
(Figure 2). These games are based on relevant clinical schemes as
performed in conventional rehabilitation and highly configurable.
It is thus therefore possible to adjust games’ setting in order that
every patient, regardless the severity of the disability, is able to
 DOI: 10.3109/09638288.2015.1073373
control and play the games [e.g. the center of pressure (CoP)
displacement required to control the game can be easily modified
from almost 0 in case of highly disabled patients to an important
displacement in case of light handicap] [12].
Four sessions of games (once a week) were integrated into the
usual physical therapy (PT) program that these patients are
following on a regular basis for several years (5 ± 2 years).
Children played each game for 3 min with 2 min of rest in-
between. The duration of the session, including installation, was
about 30 min what is the average duration of a conventional
PT session.
Two different approaches are available to assess balance (e.g.
diagnosis and evaluation of a treatment): quantitative evaluation
using force plates [13] or qualitative evaluation using a clinical
scale [14]. Balance assessment before and after interventions
was performed using the qualitative Trunk Control Motor Scale
(TCMS) [14].
This scale was chosen because it allows to study balance in
sitting position which was interesting in this study since the
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training was performed in sitting position. TCMS is subdivided
into three categories: static sitting balance, dynamic sitting
balance and dynamic reaching. The total maximal score is 58
points for healthy subjects, 20 points for static sitting, 28 points
for dynamic sitting and 10 point for dynamic reaching.
Wilcoxon signed-rank test was computed to compare scores.
Statistical analysis was conducted using Matlab (MathWorks,
Natick, MA).
Results
For personal use only.
Results of the TCMS and statistics before and after interventions
are presented in Table 1 (complete results for each items are
presented in Supplementary material).
Significant improvements were found for static sitting
[increase of 4.5% (0.9 points of 20) after intervention,
p ¼ 0.031] and for total score [increase of 3.5% (2 points of 58)
after intervention, p ¼ 0.047]. Neither difference was found for
dynamic sitting (p ¼ 0.156) nor for dynamic reaching (p ¼ 1).
Discussion
The first aim of this study was to see if it is possible to integrate
specially developed balance games into conventional PT treat-
ment of CP children. All 10 children who participated in this
study had 100% attendance for the 4-week period. Compared to
conventional PT patients prefer doing games (increase of 1 point
of 10 of a Visual Analog Scale). This study indicates that these
games can be used in physical rehabilitation of CP children with
GMFCS levels I–III.
We observed a statistical significant overall change of two
points (3.5%) on the TCMS following the 4-week training period.
The TCMS is separated into three different subcategories: we
observed significant changes (increase of 5%) only in the static
sitting subsection although the games required dynamic control of
Table 1. Mean (SD) TCMS before and after intervention for the three
categories and the total score.
TCMS Before After p Value
Static sitting (/20) 16.8 (3.4) 17.7 (3.4) 0.031
Dynamic sitting (/28) 12 (6.2) 13 (6.9) 0.156
Dynamic reaching (/10) 8.8 (1.3) 8.9 (1.3) 1 further studies must focused on clinical evolution [16–22], the
Total (/58) 37.6 (8.7) 39.6 (9.6) 0.047
p Values are the results of Wilcoxon signed-rank test.
Serious games for balance training 3
the trunk. For the dynamic sitting we observed an increase of 8%
but this difference was not significant (p ¼ 0.156). Contrariwise
the overall PT protocol, including the games, used in this study
seems to have no effect on the dynamic reaching. This can be
explained by the fact that the CoP displacement that the patients
have to reach during the games are less important that the
displacement reached during the TCMS for dynamic sitting. In
rehabilitation, especially in neurology, benefits are specific to the
training [15]. During the games CP children trained CoP
displacement is in a range more similar that those achieved
during the static sitting testing than the dynamic one. Results of
this study are difficult to compare with previous ones because
both methodology (i.e. number and duration of the sessions) and
rehabilitation games were different. Indeed most of the previous
studies related to SG for balance training of CP children were
about the use of commercial video games (e.g. Nintendo Wii with
the Balance Board). Although those games are designed for
balance training, they are also – and especially – designed for
gaming purposes of healthy players. Therefore, those games are
not adapted at all for disabled patients. Eight studies [16–22] were
found in the literature based on the use of Nintendo Wii FitÔ in
the treatment of CP children with a variable amount of sessions
(between 1 and 24) making comparison difficult. The outcomes of
these studies (balance scale and score, GMFCS, initial physical
activity level, patient improvement) are very variable between
these studies. However, there are fewer papers studying the use of
specially developed games for CP children. To the best of the
authors’ knowledge, only one study has tested an intensive
program of specially developed games (5 consecutive days of
training, 90 min a day) with CP children classified GMFCS I. The
authors observed significant improvement in mobility and func-
tion and these results were maintained 1 month after the
intervention [23] (note only four subjects were included in this
study, making generalization of the conclusions difficult).
This study included a limited amount of patients (10) and a
relatively small amount of sessions (four sessions of 30 min).
Despite this, patients showed improvements in their TCMS score.
It must be emphasized that it is difficult to state if the observed
changes are due to the games or due to the increase of training
(i.e. 2 h of supplementary training in this study). However, the
patients who took part to this study are following intensive PT
training for many years during their childhood like most CP
children [24]. Therefore, one can conclude that the addition of
rehabilitation games within their usual PT program allowed to
improve their TCMS score. Nevertheless we can estimate that due
to the fact that those patients are going through an intensive
rehabilitation program during their childhood the observed
evolution is not only due to the increase of training during the
4 weeks.
Future work is needed in order to evaluate the potential of this
new approach. A lot of questions are yet to be answered: what
type of patients (e.g. hemiplegic and diplegic) will benefit most
from this support? Are the games more effective when they are
played standing or sitting? What is the best frequency and
duration of the session? What is the best use of the WBB (some
potential uses are presented in Figure 2)? Could the games be
counter-productive if the exercises are not performed in the right
way? Are there any adverse effects for those patients (e.g. risk of
fall, seizure, epilepsy)?, etc. Standardized protocols are needed to
explore this new field because currently it is impossible to
compare studies because the methodologies and the interventions
are totally different making any interpretation difficult [25]. These
number and duration of session but also on short- and long-term
motivation [6–8] and on users’ (patients, physiotherapists, doc-
tors) acceptance [26].
 4 B. Bonnechère et al.
Conclusion
The presented method including a series of mini-games seems to
be an interesting supplementary method to be added in the PT
treatment of CP children. Patients enjoyed playing and did not
experience any difficulties to play the games because those games
are specially adapted for this pathology and are highly configur-
able and therefore adapted for each patient and each pathology. It
appears that even after only four sessions the presented method
has a beneficial impact on the posture of CP children and on their
TCMS results.
Acknowledgements
The authors thank Miss Anna Mavriki for the picture.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article. This study is
a part of the ICT4Rehab and RehabGoesHome projects
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(www.ict4rehab.org). These projects are funded by Innoviris
(Brussels Capital Region).
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