Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2019;100:769-81

REVIEW ARTICLE (META-ANALYSIS)

Do Active Video Games Improve Motor Function in

People With Developmental Disabilities? A
Meta-analysis of Randomized Controlled Trials
Darren R. Hocking, PhD,a Hassan Farhat, BPsych (Hons),a Rebeca Gavrila, MSc,a
Karen Caeyenberghs, PhD,b Nora Shields, PhDc
From the aDevelopmental Neuromotor and Cognition Lab, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria;
b
Microstructural Imaging and Rehabilitative Plasticity Program, School of Psychology, Australian Catholic University, Melbourne, Victoria; and
c
Department of Rehabilitation, Nutrition and Sport, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia.

Abstract
Objective: To conduct a meta-analysis to examine the effectiveness of active video games (AVGs) interventions on motor function in people with
developmental disabilities.
Data Sources: An electronic search of 7 databases (PubMed, EbscoHost, Informit, Scopus, ScienceDirect, Proquest, PsychInfo) was conducted
for randomized controlled trials (RCTs) evaluating AVGs to improve motor function in people with developmental disability, published through to
May 2018.
Study Selection: Only articles in a peer-reviewed journal in English were selected and screened by 2 independent reviewers for RCTs that
compared AVGs to conventional therapy. Twelve RCTs involving 370 people with developmental disabilities met the inclusion criteria for
quantitative analysis.
Data Extraction: Two independent reviewers assessed risk of bias and study quality using the Egger’s R, grading of recommendation, assessment,
development and evaluation, and Template for Intervention Description and Replication checklists.
Data Synthesis: Three meta-analyses revealed a large effect size for AVGs to improve gross motor skills (Hedges’ gZ0.833, 95% confidence
interval [95% CI]Z0.247-1.420), small to medium effects for balance (gZ0.458, 95% CIZ0.023-0.948), and a small, nonsignificant effect for
functional mobility (gZ0.425, 95% CIZ
0.03 to 0.881). Training frequency (ie, number of sessions per week) moderated the effect of AVGs on
motor function in people with developmental disabilities.
Conclusion: We conclude that AVGs show task-specific effectiveness for gross motor skills but the effects are moderated by training intensity.
However, because of the low number of trials, diverse diagnoses, variable dosage, and multiple outcome measures of the included trials, these
results need to be interpreted with caution.
Archives of Physical Medicine and Rehabilitation 2019;100:769-81
ª 2018 by the American Congress of Rehabilitation Medicine

Motor impairments are a pervasive and prevalent feature in people
with developmental disabilities,1 including autism spectrum dis-
order, developmental coordination disorder, attention-deficit/
hyperactivity disorder, Down syndrome, and cerebral palsy.
There is evidence that early development of motor function has a
cascading effect on a child’s language and participation,2,3 and
Darren R. Hocking was supported by an ARC Discovery Early Career Researcher Grant
(grant no. DE160100042).
Disclosures: none.
may predict later sociocommunicative impairments in develop-
mental disability.4 Children with delay or impairment in motor
development are also at an increased risk for unhealthy weight
status and physical inactivity.5,6 Given the effect of motor im-
pairments on developmental outcomes, there has been a renewed
focus on providing opportunities for task-specific practice in
developmental disabilities, with the goal of promoting long-lasting
improvements in motor and cognitive functioning.7-10
A common challenge among people with developmental
disability is a lack of motivation to adhere to the requisite amount
of repetitive practice over long periods required to improve motor

0003-9993/19/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2018.10.021

Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
770
function. Consequently, the large amount of practice necessary to
improve motor function can become monotonous and tedious. Yet,
an assumption of motor learning principles is that intensity,
duration, and variability in intervention are critical for sustained
improvements in movement skills. One potential strategy is to
incorporate active video gaming (also known as exergames),
which require users to engage in movement during game play.
Off-shelf examples include Nintendo Wii Fit and Dance Dance
Revolution, Microsoft Xbox Kinect, Playstation Move, and Sony
Eye Toy. Recently, active video gaming as a training intervention
has gained popularity for practicing motor skills. These active
video games (AVGs) include features, such as novelty, diversity,
effort, feeling of successfulness, and enjoyment that are in line
with recommendations for promoting brain plasticity and cogni-
tive skills.11
Several trials have examined the efficacy of active video
gaming to improve gross motor skills, balance, and functional
mobility in people with developmental disability; however, the
results from these trials have been inconsistent. Recent trials have
shown the effectiveness of active video gaming on improving
motor proficiency in children with developmental coordination
disorder,12 cerebral palsy,13,14 and Down syndrome.15 In contrast,
other trials found either no improvement16 or superior effects from
neuromotor task training for children with developmental coor-
dination disorder.17,18 Thus, it remains difficult to make an
evidence-based recommendation for the effectiveness of active
video gaming in improving motor function in people with devel-
opmental disability.
Recently, 2 systematic reviews have summarized the effect of
AVGs on motor function in children with developmental dis-
abilities. Hickman et al7 concluded that active video gaming was
feasible for children with developmental disabilities; however,
the level of evidence based on the Centre for Evidence-Based
Medicine for their use as a therapeutic intervention was low.
Page et al8 also reviewed the effectiveness of active video
gaming on gross motor skills in children and adolescents with
developmental disabilities and concluded there was consistent
evidence of active video gaming (particularly the Wii console
platform) that led to improvements in balance for children with
cerebral palsy.8 Despite these promising conclusions, these re-
views were limited because the authors included study designs
other than randomized controlled trials (RCTs). Moreover, the
effect of dosage (eg, total dose, frequency of practice) on im-
provements in motor function was not investigated in detail.
Finally, none of the reviews performed quantitative analyses to
reveal the effects of moderators such as intervention and
participant characteristics (eg, age, diagnosis, setting). Apart
from one meta-analysis, investigating the effect of active video
List of abbreviations:
95% CI 95% confidence interval
AVG active video game
BOTMP/BOT-2 Bruininks-Oseretsky Test of Motor
Proficiency
GRADE grading of recommendation, assessment,
development and evaluation
MABC-2 Movement Assessment Battery for Children-2
PRISMA Preferred Reporting Items for Systematic
Reviews and Meta-Analyses
RCT randomized controlled trial
TIDieR Template for Intervention Description and
Replication
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
D.R. Hocking et al
gaming on cognitive functioning in people with neurologic
disorders,10 none of the reviews examined the effects of active
video gaming on motor function in people with developmental
disability. This highlights the need to explore a broad range of
moderators on specific motor skill improvements to inform
evidence-based practice.
Considering the growing interest in the role of AVGs in the
pediatric setting, the primary aim of this study was to conduct a
meta-analysis on the effect of active video gaming interventions
for improving motor function (specifically gross motor skills,
balance, functional mobility) in people with developmental
disability. A secondary aim was to describe the intervention and
participant characteristics (eg, dosage, frequency of practice,
setting) to inform decisions by clinicians on when and how to
incorporate active video gaming into practice.
Methods
Search strategies
Relevant trials were identified through searching 7 electronic da-
tabases (PubMed, EbscoHost, Informit, Scopus, ScienceDirect,
Proquest, PsychInfo) from inception to May 6, 2018. The
following search terms were used: exergame, AVG, active video
game, active video gaming, Wii, PlayStation, Kinect, virtual re-
ality, or virtual reality and ADHD, ASD, autism, fragile X syn-
drome, cerebral palsy, CP, developmental coordination disorder,
DCD or Down syndrome. In addition, the reference lists of
included studies were manually searched to identify further
potentially relevant published papers. Citation tracking on google
scholar was used to identify influential papers in the field or pa-
pers that have been cited by other influential authors.
Eligibility criteria
All RCTs that compared the effect of AVGs with conventional
therapy on motor function in people with a developmental
disability were included. All included trials needed to be pub-
lished in a peer-reviewed journal in English and no conference
abstracts were included. Any acquired conditions without a
developmental origin including traumatic brain injury were
excluded, or trials involving children with cerebral palsy after
surgery. Trials were excluded with only cognitive or physiological
outcomes in response to training, or where the trial used a non-
commercially available game.
Types of outcome measures
Outcome measures were classified using the International Clas-
sification of Functioning, Disability and Health model, after
selecting broad categories within disability and identifying
outcome measures that best fit the description codes. These
broad categories included functional mobility (ie, changing and
maintaining body position including balance) and neuromuscular
(ie, gross motor). Data were extracted from validated and reliable
measures to improve the quality of the overall review. The most
common measures used were the Movement Assessment Battery
for Children-2 (MABC-2) and the Bruininks-Oseretsky Test of
Motor Proficiency (BOTMP/BOT-2). Other measures included
functional mobility, balance, or agility centered tasks. The
outcome measures were grouped based on their similarity and
sorted into 3 different motor domains based on clinical judgment
of 2 reviewers (D.R.H., neuropsychologist and N.S.,
www.archives-pmr.org
AVGs and developmental disabilities 771

Fig 1 PRISMA flow diagram.

physiotherapist): functional mobility (including timed walk tests,
timed Up and Go tests, running speed, walk tray and talk tests),
balance (including standardized balance scales and center of
pressure sway measures), and gross motor skills (including
aiming and catching, bilateral coordination, and jumping and
joint coordination tests).
criteria then the full-text versions was retrieved for review. Any
disagreements between the 2 reviewers were settled through discus-
sion. If a consensus could not be reached, a third reviewer was asked
to decide, and this occurred for 3 studies. The search and selection
processes are shown in the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) flow diagram (fig 1).

Risk of bias within and across trials

Data extraction and assessment of study validity
1. Risk of bias for individual trials was rated using a checklist
Selection of studies developed by Page et al.8 The risk of bias assessment rated
Two reviewers independently screened titles and abstracts of the each study on a 10-point scale whereby each point corre-
search results. Where it was unclear if a trial met the inclusion sponded to the presence of an item in the checklist (box 1).

www.archives-pmr.org
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
772 D.R. Hocking et al

Box 1 Risk of bias items based on Page et al8
Risk of Bias Item
a. Randomization was clear.
b. Validity of the measures was provided.
c. Blinded outcome assessment.
d. Participant data were not excluded.
e. Covariates have been adjusted for.
f. Power calculated was reported.
g. Baseline characteristics were presented.
h. Dropout <30%.
i. Summary of effect size given.
j. Precision of effects given.
2. The grading of recommendation, assessment, development and
evaluation (GRADE)19 system was used to rate the overall
quality of the trials according to the motor outcomes. The scale
includes 5 subtraction rules that reduce the overall quality of
the studies and 3 addition rules that improve the overall quality
of the studies (box 2).
3. The TIDieR20 checklist was used to assess the replicability of
the individual studies by rating the presence of 12 items out-
lined by the list including study duration, dose, location,
blinded assessment, and other items.
Data extraction and data management
A customized Google Forms and Google Sheets document was
developed to standardize the data extraction. The data were
exported into Excel. The characteristics extracted were popula-
tion: condition, age, number of participants; methods: design,
intervention setting, risk of bias, platform used, outcome mea-
sures, exposure frequency and time, total training duration; re-
sults: a short description of the outcome of the study, results
obtained (pre- and posttrial means and standard deviations for
experimental and control groups, effect sizes if reported).
In the case of a randomized crossover controlled trial, only pre-
and postdata from the first period (before the crossover) were
used.21 If a combined result from both periods was reported, this
was used instead. The latest measurement was used if measure-
ments were taken at multiple intervals, whereas the latest
Box 2 GRADE addition and subtraction rules
measurement (immediately after the intervention) was used if the
last interval was a follow-up. When the data were not reported, the
authors were contacted to provide the missing information.
Data analysis
The analysis was conducted using the Comprehensive Meta-
Analysis Software version 2.22,a For trials that reported inter-
quartile ranges and medians, we approximated the means and
standard deviations using a method recommended by Wan.23 The
small sample sizes of the studies warranted the use of Hedges’ g
as an estimate of effect size. Hedges’ g, although similar to
Cohen’s d, has been found to be better suited to smaller sample
sizes (N<20). The results were interpreted using Cohen’s guide-
lines, with 0.2, 0.5, and 0.8 representing small, medium, and large
effect sizes, respectively.24
For the aim of the quantitative analyses, a standardized change
score and a pre-post treatment correlation coefficient of each study
are required. However, these correlations were not reported in the
studies, and therefore a conservative estimate of rZ0.7 was used,
as recommended by Rosenthal.25 To ensure validity, a sensitivity
analysis was conducted for a range of other correlation co-
efficients (0.5-0.9). If the way the results can be interpreted
remained consistent across the correlations, the estimate of 0.7
was retained.
Three meta-analyses were conducted to estimate the overall
effect of risk of bias on different domains of motor function
including functional mobility, balance, and gross motor skills,
respectively, when compared to conventional therapy. Trials
that used >1 measure to assess a single motor domain had the
most commonly reported measure used across studies instead.
These commonly reported measures were also the primary
outcomes for most of the trials minimizing the risk of bias
in reporting.
Publication bias was assessed using funnel plots generated
using the comprehensive meta-analysis program and via the
calculation of Egger’s R.26 The presence of outliers was examined
using the 1 study removed method, which assesses whether the
effect changes if 1 study was individually removed from the
analysis. The robustness and replicability of study designs were
rated using the TIDieR checklist.20
Finally, a meta-regression was conducted to examine whether
the changes in motor skill performance in response to training was
moderated by frequency, session length, number of weeks, or total
training duration, setting, age, and diagnosis.

Item Subtraction Rule Addition Rule Results

1 Score of 40% on risk
of bias assessment.
2 Results between studies
inconsistent.
3 Studies used indirect
measures to test
outcomes.
4 The accuracy of the way
the data was collected
raises concerns.
5 There is evidence of
publication bias.
1 point for large effect
size, 2 for very large.
There is evidence to a
dose response.
Confounding variables
were accounted for.
Study inclusion
The search strategy identified 574 potentially relevant articles.
After screening titles and abstracts, and citation tracking, 90 full-
text articles were retrieved for full-text scanning. After inclusion
and exclusion criteria were applied, 12 RCTs were included in the
final quantitative analysis.
Risk of bias
Two independent reviewers conducted a risk of bias assessment
using a set of criteria based on the PRISMA guidelines27 (table 1).

www.archives-pmr.org
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
AVGs and developmental disabilities 773

Table 1 Risk of bias assessment

Study A B C D E F G H I J Total
13
Alsaif and Alsenany X X e X e e X X e e 50%
Ashkenazi et al28 X X X X e e X X e e 60%
Cho et al29 X X X X e X X X e X 80%
Gatica-Rojas et al14 X X e X e X X X e X 70%
Hammond et al12 X X e X e e X X e e 50%
Chiu et al30 X X X X e X X X e X 80%
Mombarg et al31 X X e X e e X X X e 60%
Sajan et al32 X X e X e e X X X e 60%
Salem et al33 X X X X e e X X X e 70%
Silva et al15 X X X X e e X X X e 70%
Tarakci et al34 X X e X e e X X X e 60%
Ürgen et al35 X X e X e e X X X e 60%

Heterogeneity was assessed using Cochranes indices for each of
the following domains: functional mobility: QZ21.16, dfZ8,
PZ.007, I2Z62.184; balance: QZ27.06, dfZ8, PZ.001,
I2Z70.44; and gross motor: QZ13.3, dfZ4, PZ.01, I2Z69.92.
TIDieR checklist
The replicability of the studies was assessed using the TIDieR
checklist (fig 2). The items lacked the following information:
where the measures can be acquired (3b), whether the intervention
was tailored to the individual (9) or modified during the study
(10), and whether participants adhered to the interventions (11 of
12). All studies reported the number of sessions, duration, and
intensity (8a, 8c, 8d), and most studies (9 of 12) reported who
carried out the intervention(s) and where the training was carried
out (home environment, rehabilitation center) (5, 7).
GRADE assessment
The results of the GRADE assessment for overall quality of trials
are presented in table 2. The studies were grouped according to
their domains and assessed collectively for the quality of evidence.
All studies were ranked as high quality of evidence initially for
being RCTs. One point was removed from all domains for
inconsistency based on the high I2 values resulting in rating of
moderate quality. A further point was removed from gross motor
skills for accuracy of data concerns and 1 point was added for a
large effect size.
Study characteristics
The characteristics of the trials included are presented in table 3.
Participants
Trials included 370 participants with developmental disability.
Most participants had a diagnosis of cerebral palsy (nZ228,
61.6%), followed by developmental coordination disorder (nZ77,
20.8%) and other various developmental disabilities including
developmental delay (nZ40, 10.8%), and Down syndrome
(nZ25, 6.7%). Most of the participants with cerebral palsy

Fig 2 Number of included trials achieving each TIDieR checklist item.

www.archives-pmr.org
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
774
Table 2 GRADE assessment
No. of
Outcomes No. of Studies Participants
Functional mobility 8 231
Balance 9 255
Gross motor 5 173
* All studies started with high quality of evidence for being RCTs.
suffered from spastic hemiplegia or diplegia, with gross motor
function classification levels I-III.13,14,29,30,32,34 Apart from 1
study31 using the MABC-2, all studies diagnosed participants with
developmental coordination disorder using the Developmental
Coordination Disorder Questionnaire. Eleven of the 12 studies
included children or adolescents (age range 4-18y, MageZ9.08, sex
M/FZ148/109), whereas 1 study15 included adults with Down
syndrome (age range 18-60y).
Study design
Eleven studies used a randomized controlled trial design and 1
study used a randomized crossover controlled design.12
Characteristics of the active video gaming intervention
The Nintendo Wii was the most popular platform used across
studies (11 of 12 trials). One trial used the PlayStation EyeToy, a
motion capture camera similar to the Xbox Kinect. The mean total
dose across trials was 807 minutes (range of 120-1680min). Six
trials administered the interventions 3 times per week, 3 trials
twice a week and 3 trials once, 6 and 7 times per week respec-
tively (MfreqZ3.12).
Motor function outcome measures
Across the 12 studies included in this meta-analysis, there were 34
different outcome measures used, which included upper extremity
function, balance, walking, functional mobility, or other related
functions. Functional mobility skills and balance were the most
commonly examined outcomes in 9 of 12 and 8 of 12 studies,
respectively. The most frequently used measures were the MABC-
213,28,31 and the BOT-2/BOTMP.12,13,31 Measures of functional
mobility included the 10-meter walk test and the 2-minute walk
test,29,33,34 timed Up and Go test,33,35 running speed, walk tray
and talk test,36 and gross motor function measure subsection
E.29,33,35 The most common measures of balance were the balance
subtests of the MABC-2 Balance Scale and the gross motor
function measure subsection D. Other measures included center of
pressure sway with eyes closed as assessed with a force plate
platform.14,32 Gross motor skills were often examined using the
MABC-2 aiming and catching subtests, BOT-2 bilateral coordi-
nation subtests, and jumping and joint coordination tests.
The effect of AVGs on functional mobility
Nine trials included at least 1 measure of functional mobility. Of these
studies only 2 reported significant effects.13,29 Alsaif and Alsenany13
found significant improvements in the 1-minute walk test in the AVG
intervention compared to conventional therapy. When all the mea-
sures of functional mobility were combined in the meta-analysis, the
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
D.R. Hocking et al
Quality of
the Evidence* Comments
Moderate Quality reduced due to inconsistency results
Moderate Quality reduced due to inconsistency
Moderate Quality increased for large effect size, but reduced
for inconsistency and imprecision
results showed that active video gaming had a small to moderate
nonsignificant effect on functional mobility (Hedges’ gZ0.425, 95%
confidence interval [95% CI]Z
0.03 to 0.881, PZ.067) (fig 3).
There was no evidence of publication bias. The 1 study removed
analysis revealed that with the removal of trials by Alsaif and Alse-
nany13 (Hedges’ gZ0.263, 95% CIZ
0.061 to 0.588, PZ.112) and
Silva et al15 (Hedges’ gZ0.323, 95% CIZ
0.076 to 0.721,
PZ.112), there was a decrease in the effect size, whereas the removal
of the study by Ashkenazi et al28 (Hedges’ gZ0.525, 95%
CIZ0.138-0.912, PZ.008) showed an increase in the effect size. The
other trials remained within the range of 0.411-0.483 with P values
between .031 and .069.
The effect of AVGs on balance
Nine trials included at least 1 measure of balance. Four trials
found significant effects of AVGs on balance.12-14,31 When
combining the measures of balance in the meta-analysis, the
results showed that AVGs had a significant small to medium
effect on balance (Hedges’ gZ0.458, 95% CIZ0.023-0.948,
PZ.039) (fig 4). There was no evidence of publication bias. The
1 study removed analysis revealed that with the removal of trials
by Alsaif and Alsenany13 (Hedges’ gZ0.352, 95% CIZ0.049-
0.786, PZ.113), Hammond et al12 (Hedges’ gZ0.396, 95%
CIZ0.059-0.871, PZ.101), and Mombarg et al31 (Hedges’
gZ0.420, 95% CIZ
0.080 to 0.920, PZ.099), there was a
decrease in effect sizes, whereas the removal of the study by
Gatica-Rojas et al14 (Hedges’ gZ0.638, 95% CIZ0.247-1.028,
PZ.001) showed an increase in effect size. The other trials
remained within the range of 0.476 and 0.510 with P values
ranging from 0.033 to 0.076.
The effect of AVGs on gross motor skills
Five trials included at least 1 measure of gross motor skills. Two
trials found significant effects on gross motor skills in the AVG
intervention groups.12,13 When all the measures of gross motor
skills were combined in the meta-analysis, the results revealed
that AVGs had a large significant effect on gross motor skills
(Hedges’ gZ0.883, 95% CIZ0.247-1.420, PZ.005) (fig 5).
There were a limited number of trials focusing on gross
motor skills as an outcome, and therefore results should be
interpreted with caution. The 1 study removed analysis revealed
consistent results across trials, with Hedges’ g ranging from
0.943 to 1.022 and P values ranging from .003 to .034. The trial
by Hammond et al12 (Hedges’ gZ0.598, 95% CIZ0.143-1.053,
PZ.010) and Alsaif and Alsenany13 (Hedges’ gZ0.715, 95%
www.archives-pmr.org
 www.archives-pmr.org

AVGs and developmental disabilities

Table 3 Study characteristics
Total
Intervention AVG Platform, Frequency, and Exposure Motor Skill Assessed; Assessment
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal

Study (Author) Condition Age (Sex) Sample Size Setting Length (min) Tool
Alsaif and Alsenany13
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.

CP spastic diplegia 6-10 y old* (NSL) 40 Home Wii BB, 20 min/d for 12 wk 1680 MABC-2, BOT-MP
Ashkenazi et al28 DCD MageZ5.2 (25 M, 5 F) 30 School Eye Toy PS2, ten 60-min sessions 600 MABC-2, Walking and Talking Test,
once a week for 10 wk 6MWT, DCD-Q
Cho et al29 Spastic CP MageZ9.8. (NSL) 18 Unclear Wii remote, one 30-min session/d 720 Manual muscle testing, GMFM,
3 times/wk for 8 wk 10MWT, 2MWT, PBS
Gatica-Rojas et al14 CP, spastic hemiplegia MageZ10.5 (NSL) 30 Laboratory Wii Balance board, three 30-min 540 GMFCS, GMFCS-ER, FSIQ,
or diplegia sessions/wk for 6 wk posturographic measures
Hammond et al12 DCD MageZ9 (14 M, 4 F) 18 School Wii balance board and remote, 120 BOT-2, CSQ, SDQ
three 10-min sessions/wk for
4 wk
Chiu et al30 Hemiplegic CP MageZ9.5 (28 M, 32 F) 60 Home based, Wii, 40 min 3 times/wk for 6 wk 720 Coordination of elbow or finger,
supervised by hand dex with 9-hole peg test
clinician or and self-reported measures
parents
Mombarg et al31 Balance problems MageZ9.6 (23 M, 6 F) 29 School Wii balance board, 30 min/r 540 MABC-2, BOT-2
session, 3 times/wk for 6 wk
Sajan et al32 Diplegic/triplegic/ MageZ11.5 (11 M, 9 F) 20 Clinical Wii Remote, control: 36 h of 810 Static posturography, Berg Balance
quadriplegic CP intervention per week. Scale, Box and Blocks Test,
Experimental: 36 h of QUEST, TVPS-3, walking distance
intervention þ six 45-min or speed
sessions/wk for 3 wk
Salem et al33 Developmental delay MageZ4 (22 M, 18 F) 40 Clinical Wii balance board þ remote, two 600 10MWT, TUG, 5 times Sit-to-Stand
30-min sessions/wk for 10 wk Test, timed Up and Down stairs
test, 2MWT, GMFM
Silva et al15 Down syndrome 18-60* (NSL) 25 Unclear Wii Balance board, three 1-h 1440 EuroFit test battery, TUG, BOTMP,
sessions/wk for 8 wk beanbag overhead throw
Tarakci et al34 Diplegic, hemiplegic, MageZ10.5 (11 M, 19 F) 30 Laboratory Wii balance board, two 50-min 1200 FFRT, FSRT, TGGT, STST, 10MWT,
dyskinetic CP sessions/wk for 12 wk 10SCT, Wee-FIM
Ürgen et al35 Spastic hemiplegic CP MageZ11.2 (14 M, 16 F) 30 Unclear Wii fit, two 40-min sessions/wk for 720 GMFM, GMPM, SFEO, single leg
9 wk balance, jumping balance, TUG,
PBS
Abbreviations: 2MWT, 2-minute walk test; 6MWT, 6-minute walk test; 10MWT, 10-meter walk test; CP, cerebral palsy; DCD-Q, Developmental Coordination Disorder Questionnaire; GMFCS, Gross Motor Function
Classification System; GMFM, gross motor function measure; NSL, no sex listed; TUG, timed Up and Go; MP, motor proficiency; PBS, Pediatric Balance Scale; FSIQ, Full-Scale Intelligence Quotient; CSQ, Client
Satisfaction Questionnaire; SDQ, Strengths and Difficulties Questionnaire; TVPS-3, Test of Visual Perceptual Skills; FFRT, Functional Forward Reach Test; FSRT, Functional Sit and Reach Test; TGGT, Timed Get Up
and Go Test; STST, Sit to Stand Test; 10SCT, 10 Second Climbing Test; GMPM, Gross Motor Performance Measure; SFEO, Soft Floor Eyes Opened.
* Studies that did not report a mean have their age ranges listed.

775
776 D.R. Hocking et al

Functional mobility
Study name Statistics for each study Hedges' g and 95% CI
Hedge's Standard Lower Upper
g Error Variance limit limit Z value P value
Alsaif and Alsenany13 1.459 0.350 0.123 0.772 2.145 4.165 .000
Ashkenazi et al28 –0.423 0.359 0.129 –1.127 0.282 –1.176 .240
Cho et al29 0.054 0.449 0.202 –0.826 0.934 0.120 .905
Hammond et al12 0.476 0.459 0.210 –0.423 1.375 1.038 .299
Salem et al33 –0.042 0.310 0.096 –0.649 0.566 –0.135 .893
Silva et al15 1.249 0.426 0.181 0.415 2.083 2.935 .003
Tarakci et al34 0.425 0.359 0.129 –0.280 1.130 1.182 .237
Urgenet al35 0.273 0.357 0.127 –0.427 0.972 0.764 .445
0.425 0.232 0.054 –0.030 0.881 1.830 .067
–2.00 –1.00 0.00 1.00 2.00

Conventional Exergames

Fig 3 Meta-analysis and funnel plot results for functional mobility, Egger’s PZ.29.

CIZ0.053-1.377, PZ.034) had the largest effect on effect size Discussion

when removed from the analysis.
Moderator analysis
Because of the limited number of trials within each motor domain,
meta-regression on all studies using 7 moderators (total dose,
frequency per week, length of session, total number of weeks of
AVG exposure, age, diagnosis, setting) was conducted. Duplicate
trials were removed, and the most relevant measure for each trial
was chosen based on whether it was the most commonly used
measure or if it was the primary outcome measure to ensure the
same sample of participants was not included multiple times.
Frequency per week (test of change; QZ4.27, dfZ1,
PZ.0387, R2Z0.36) was a significant moderator of the relation
between AVGs and motor function outcomes. Length of session
(QZ3.66, dfZ1, PZ.056, R2Z0.17), total dose (QZ0.41, dfZ1,
PZ.5215, R2Z0.5125), and number of weeks (QZ0.17, dfZ1,
PZ.68, R2Z0.00) had no significant moderating effects on the
relation between AVGs and motor outcomes. Diagnosis (test of
change; QZ1.94, dfZ3, PZ.584, R2Z0.00), age (test of change;
QZ0.03, dfZ1, PZ.8682, R2Z0.00%), and setting (test of
change; QZ3.47, dfZ3, PZ.3245, R2Z0.00) also had no
moderating effects on motor function outcomes.
Although previous systematic reviews have gathered evidence for
the use of AVGs in children with developmental disability,7,8 this is
the first meta-analysis of RCTs to specifically examine the effect of
AVGs interventions for improving motor functions in people with
developmental disability. Although there were only a small number
of high-quality RCTs (nZ12), results indicated a strong effect of
AVGs on improving gross motor skills, while support was weak for
the efficacy of AVGs interventions on improving balance and
functional mobility in people with developmental disability.
Importantly, our analysis showed dose frequency influenced motor
outcomes in response to AVGs interventions. These findings have
implications for clinicians in recommending AVGs platforms for
people with developmental disability.
The effect of AVGs on motor domains in
developmental disability
The overall large effect size (Hedges’ gZ0.833) for AVGs to
improve gross motor skills is in keeping with previous findings in
children and adolescents with cerebral palsy.31,37-39 In this popu-
lation, the strongest level of evidence has been found for the use of
interactive game play to improve gross motor outcomes.40

www.archives-pmr.org
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
AVGs and developmental disabilities 777

Balance
Study name Statistics for each study Hedges ’ g and 95% CI
Hedge's Standard Lower Upper
g error Variance limit limit Z value P value
Alsaif and Alsenany13 1.411 0.348 0.121 0.729 2.092 4.056 .000
Ashkenazi et al28 0.583 0.363 0.132 –0.129 1.294 1.604 .109
Cho et al29 0.294 0.452 0.204 –0.591 1.179 0.650 .515
Hammond et al12 1.360 0.505 0.255 0.369 2.350 2.690 .007
Gatica-Rojas et al14 –0.731 0.357 0.127 –1.430 –0.032 –2.050 .040
Mombarg et al31 1.010 0.385 0.148 0.256 1.764 2.625 .009
Sajan et al32 0.495 0.456 0.208 –0.400 1.390 1.085 .278
Salem et al33 –0.011 0.310 0.096 –0.618 0.597 –0.035 .972
Urgen et al35 0.166 0.356 0.127 –0.532 0.863 0.466 .641
0.485 0.236 0.056 0.023 0.948 2.059 .039
–2.00 –1.00 0.00 1.00 2.00

Conventional Exergames

Fig 4 Meta-analysis and funnel plot results for balance, Egger’s PZ.18.

However, only 5 trials were included in the overall effect size
estimate, and the 1 study removed method indicated 2 trials12,13
were primary to the significance of the effect. There were some
limitations of these studies that should be acknowledged. For
example, the Hammond et al12 trial included only 10 children with
developmental coordination disorder, the specific gains in gross
motor proficiency were seen in only a selective subscale of the
BOT-2 (bilateral coordination), and there was a lack of blinding of
researchers in a crossover controlled trial. In respect of Alsaif and
Alsenany,13 the large effect of Wii Fit games on gross motor
performance in children with cerebral palsy may relate to the large
intervention dose (20min/d over 12wk; total 1680min) relative to
other studies and there was an inadequate level of detail provided
on the type of supervision given in the home setting. In addition,
because of the small number of trials, it was difficult to ascertain
the effect of AVGs on upper extremity skills versus whole body
activity, which may or may not generalize to overall gross motor
skills. Therefore, the results for the large effect of AVGs on gross
motor outcomes should be interpreted with caution.
The current finding of a significant small to medium effect
(Hedges’ gZ0.458) on balance for people in AVGs interventions
is consistent with a previous systematic review that concluded
AVGs improved balance in youth with nontypical patterns of
motor development.8 It is noteworthy that many people with
developmental disability show prominent impairments in balance
and postural stability,41-43 which highlight the potential for AVGs
to target these core impairments in so far because they resemble
real-world balance skills in a more effective way when compared
to conventional therapy. However, inspection of individual studies
revealed several inconsistencies. There were a number of inter-
vention studies using Nintendo Wii that did not reveal any sig-
nificant effect for balance in children with developmental
disability28,29,32,33,35; however, the reasons for these discrepancies
are unclear. In addition, the 1 study removed method indicated
several influential studies12,13,31 were driving the significance of
the effect, and therefore the effect of AVGs on balance also needs
to be interpreted with caution.
The nonsignificant effect for AVGs on functional mobility in
people with developmental disability is consistent with a lack of
transfer of trainingdthat is, a lack of skill generalization from 1
domain to different onesdand suggests that AVGs interventions may
only benefit performance on specific motor skill domains that are
commonly the target of conventional AVGs. This is perhaps not
surprising given that AVGs focus on balance skills and bilateral co-
ordination and less so on general abilities regarding moving around
the environment. As a whole, the AVGs interventions using

www.archives-pmr.org
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
778 D.R. Hocking et al

Gross Motor

Study name Statistics for each study Hedges'g and 95% CI

Hedges' Standard Lower Upper
g error Variance limit limit Z value P value
Alsaif and Alsenany13 1.267 0.341 0.116 0.599 1.935 3.718 .000
Hammond et al12 2.218 0.584 0.341 1.074 3.363 3.800 .000
Chiu et al30 0.251 0.256 0.066 –0.251 0.754 0.979 .327
Silva et al15 0.481 0.393 0.154 –0.290 1.251 1.223 .221
Urgen et al35 0.471 0.360 0.130 –0.236 1.177 1.306 .191
0.833 0.299 0.090 0.247 1.420 2.784 .005

–4.00 –2.00 0.00 2.00 4.00

Conventional Exergames

Fig 5 Meta-analysis and funnel plot results for gross motor, Egger’s PZ.06.

conventional games in people with developmental disability focus
less on other motor domains including fine motor skills and func-
tional mobility. Given that very few off-the-shelf AVGs focus on
improving fine motor skills, and studies have shown that fine motor
skills are predictors of academic outcomes for school-aged chil-
dren,44,45 future interventions using AVGs to improve fine motor
performance of children with developmental disability are warranted.
The effect of moderators on motor outcomes in
response to AVGs interventions
There were 2 previous systematic reviews that highlighted difficulty
in determining the relation between dosage of AVGs interventions
and effects on motor proficiency.7,8 Specifically, there was no
consistent pattern of higher dosage in length and duration and better
motor outcomes in people with developmental disability. From the
present synthesis of the data, the current review found that fre-
quency per week is the only significant moderator of the relation
between the effect of AVGs and motor outcomes in people with
developmental disability. We found that frequency per week
explained 18% of the variance of the treatment effects, which is
consistent with previous reviews evaluating the evidence for motor-
based interventions in people with developmental coordination
disorder.46 In contrast, other dosage characteristics (eg, length of
session, total dose, number of weeks), setting (eg, clinical, home,
school), diagnosis, and age were not significant moderators in this
review, and regardless of other intervention components (eg, total
dose of practice), training programs with more frequent practice
schedules significantly enhanced effects of AVGs interventions on
gross motor skill proficiency. These findings provide support for a
focus on the frequency of time on task in increasing training effects
on motor performance in response to AVGs interventions, and this
may be because of people with developmental disability requiring
more frequent bouts of time in motor skill learning compared to the
typically developing population.47
Study limitations
There are a number of limitations of this review. First, the results
are based on data from only 12 RCTs with insufficient sample
sizes, interventions of variable intensities, and multiple outcome
measures and included participants with diverse diagnoses.
Therefore, our conclusions should be considered preliminary.
Despite the advances in this research area and limited period of
time that AVGs have been used in developmental disability, our
confidence in these preliminary findings will only be strengthened
with further adequately powered RCTs. As such, the findings of
our review should be interpreted with caution. Future studies will

www.archives-pmr.org
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
AVGs and developmental disabilities
also enable a full consideration of potential moderators such as
setting (eg, clinic, laboratory, school), type of intervention (eg,
most studies used Nintendo Wii), and nature of control condition
(eg, usual care or other training programs). Second, the trial
design of included studies was limited by inadequate descriptions
of blinding and description of control conditions, and it is there-
fore likely that a high risk of bias exists for several of the studies.
Third, the 1 study removed method indicated that several influ-
ential trials were driving the significance of the effect and given
the small number of studies included in balance and gross motor
domains, results from the current meta-analysis should be inter-
preted with caution. In addition, several trials included multiple
outcome measures for each domain, and inclusion of each mea-
sure for a domain was based on clinical judgment as to the most
appropriate motor measure, which may have led to a loss of some
information. Finally, there were only a limited number of trials
that examined the extent to which training effects were retained at
a longer-term follow-up, and the beneficial effect of AVGs on
sustained improvements in motor performance could not
be evaluated.
Future directions
From this systematic review and synthesis of the data, there are
several avenues for future research. First, there is a need for in-
vestigators to conduct more RCTs with high methodological
quality including randomization with concealed allocation,
blinding of assessors and participants, and a priori statistical
power calculations to avoid underpowered trials. In addition, a
more detailed description of potential moderators would enable a
clearer picture of the true effects of AVGs on motor performance
in people with developmental disability. This would enable the
consideration of other factors that may influence the magnitude of
training effects including comorbidity and heterogeneity of the
children, setting and level of supervision, and treatment approach
in the control condition.
Second, there is a need for future trials to increase adherence
and engagement of people with varying levels of cognitive ability
by developing customized AVGs that target a greater range of
motor domains (eg, fine motor, gait, postural control) in a
personalized approach. One particularly important criterion will
be the capacity to customize level of difficulty, in motor and
cognitive load, to adapt to individual limitations and gradually
progress between sessions to ensure people are sufficiently chal-
lenged in task-specific training. It has been noted that a consistent
limitation in previous studies is the dosing of the AVGs inter-
vention and difficulty in providing sufficiently challenging task-
specific practice to significantly improve motor outcomes.16,48
Considering the current popularity and increased access and us-
ability of virtual-reality gaming systems for leisure and enter-
tainment, these AVGs could be developed to provide low-cost,
scalable interventions that focus on variability of practice to
improve motor and cognitive skill performance in developmental
disability.11
Finally, it should be noted that the current review considered
only motor functioning as the outcome measure. There was a lack
of good quality studies using RCT designs that examined far
transfer effects from motor skills to other cognitive, social, and
academic domains in response to AVGs in people with develop-
mental disability. Given the potential of AVGs to provide
www.archives-pmr.org
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
779
cognitively challenging tasks, and the link between motor skills
and a range of cognitive, social, and academic outcomes in
childhood through adolescence,4,49,50 a focus of future studies
should be the evaluation of far transfer effects to other domains in
response to AVGs interventions.
Conclusions
This review is the first to provide a quantitative synthesis of the
effects of AVGs on motor function in people with developmental
disability and consider potential moderating factors that influence
the strength of training effects. It is concluded that AVGs in-
terventions appear to show task-specific effectiveness for gross
motor skills over the short term in people with developmental
disability; however, the effects are influenced by the frequency of
the intervention supporting the importance of more frequent bouts
of practice. Because of the diverse range of diagnoses, dosage
intervals, age range, and multiple outcome measures, future
studies with adequately powered RCTs will be required to draw
stronger conclusions about the effects of AVGs on motor function
in developmental disability.
Supplier
a. Comprehensive Meta-Analysis Software version 2; Biostat, Inc.
Keywords
Developmental disabilities; Exercise; Gait; Movement; Posture;
Randomized controlled trial; Rehabilitation
Corresponding author
Darren R. Hocking, PhD, Developmental Neuromotor and
Cognition Lab, School of Psychology and Public Health, La
Trobe University, Bundoora, VIC 3086, Australia. E-mail
address: D.Hocking@latrobe.edu.au.
References
1. Hocking DR, Caeyenberghs K. What is the nature of motor impair-
ments in autism, are they diagnostically useful, and what are the
implications for intervention? Curr Dev Disord Rep 2017;4:19-27.
2. Mimouni-Bloch A, Tsadok-Cohen M, Bart O. Motor difficulties and
their effect on participation in school-aged children. J Child Neurol
2016;31:1290-5.
3. Iverson JM, Goldin-Meadow S. Gesture paves the way for language
development. Psychol Sci 2005;16:367-71.
4. Leonard HC, Hill EL. The impact of motor development on typical
and atypical social cognition and language:a systematic review. Child
Adolesc Ment Health 2014;19:163-70.
5. D’Hondt E, Deforche B, Gentier I, et al. A longitudinal study of
gross motor coordination and weight status in children. Obesity
(Silver Spring) 2014;22:1505-11.
6. Lopes VP, Rodrigues LP, Maia JA, Malina RM. Motor coordination
as predictor of physical activity in childhood. Scand J Med Sci Sports
2011;21:663-9.
780
7. Hickman R, Popescu L, Manzanares R, Morris B, Lee SP, Dufek JS.
Use of active video gaming in children with neuromotor dysfunction:
a systematic review. Dev Med Child Neurol 2017;59:903-11.
8. Page ZE, Barrington S, Edwards J, Barnett LM. Do active video
games benefit the motor skill development of non-typically devel-
oping children and adolescents: a systematic review. J Sci Med Sport
2017;20:1087-100.
9. Stanmore E, Stubbs B, Vancampfort D, de Bruin ED, Firth J. The
effect of active video games on cognitive functioning in clinical and
non-clinical populations: a meta-analysis of randomized controlled
trials. Neurosci Biobehav Rev 2017;78:34-43.
10. Mura G, Carta MG, Sancassiani F, Machado S, Prosperini L. Active
exergames to improve cognitive functioning in neurological dis-
abilities: a systematic review and meta-analysis. Eur J Phys Rehabil
Med 2018;54:450-62.
11. Pesce C, Croce R, Ben-Soussan TD, et al. Variability of practice as
an interface between motor and cognitive development. Int J Sport
Exerc Psychol 2016;13:1-20.
12. Hammond J, Jones V, Hill EL, Green D, Male I. An investigation of
the impact of regular use of the Wii Fit to improve motor and psy-
chosocial outcomes in children with movement difficulties: a pilot
study. Child Care Health Dev 2014;40:165-75.
13. Alsaif AA, Alsenany S. Effects of interactive games on motor per-
formance in children with spastic cerebral palsy. J Phys Ther Sci
2015;27:2001-3.
14. Gatica-Rojas V, Méndez-Rebolledo G, Guzman-Muñoz E, et al. Does
Nintendo Wii balance board improve standing balance? A random-
ized controlled trial in children with cerebral palsy. Eur J Phys
Rehabil Med 2017;53:535-44.
15. Silva V, Campos C, Sá A, et al. Wii-based exercise program to improve
physical fitness, motor proficiency and functional mobility in adults
with Down syndrome. J Intellect Disabil Res 2017;61:755-65.
16. Straker L, Howie E, Smith A, Jensen L, Piek J, Campbell A. A
crossover randomised and controlled trial of the impact of active
video games on motor coordination and perceptions of physical
ability in children at risk of developmental coordination disorder.
Hum Mov Sci 2015;42:146-60.
17. Ferguson G, Jelsma D, Jelsma J, Smits-Engelsman B. The efficacy of
two task-orientated interventions for children with developmental
coordination disorder: neuromotor task training and Nintendo Wii Fit
training. Res Dev Disabil 2013;34:2449-61.
18. Smits-Engelsman BC, Blank R, Van Der Kaay AC, et al. Efficacy of
interventions to improve motor performance in children with devel-
opmental coordination disorder: a combined systematic review and
meta-analysis. Dev Med Child Neurol 2013;55:229-37.
19. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines:1. Intro-
ductiondGRADE evidence profiles and summary of findings tables.
J Clin Epidemiol 2011;64:383-94.
20. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of in-
terventions: Template for Intervention Description and Replication
(TIDieR) checklist and guide. BMJ 2014;348:g1687.
21. Higgins JP, Green S. Cochrane handbook for systematic reviews of
interventions. Wiley Online Library; 2008. Available from http://
handbook.cochrane.org. Accessed January 2, 2019.
22. Borenstein M, Hedges L, Higgins J, Rothstein H. Comprehensive
meta-analysis version 2. Englewood, New Jersey: Biostat, Inc.; 2005.
23. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and
standard deviation from the sample size, median, range and/or
interquartile range. BMC Med Res Methodol 2014;14:135.
24. Cohen J. Statistical power analysis for the behavioral sciences. New
Jersey: Lawrence Erlbaum; 1988.
25. Rosenthal R. Meta-analytic procedures for social science research.
Educ Res 1986;15:18.
26. Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis
detected by a simple, graphical test. BMJ 1997;315:629-34.
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
D.R. Hocking et al
27. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting
items for systematic reviews and meta-analyses: the PRISMA
statement. PLoS Med 2009;6:e1000097.
28. Ashkenazi T, Laufer Y, Orian D, Weiss P. Effect of training
children with developmental coordination disorders in a virtual
environment compared with a conventional environment. Virtual
rehabilitation (ICVR). 2013 International Conference on IEEE;
2013. p 46-50.
29. Cho C, Hwang W, Hwang S, Chung Y. Treadmill training with virtual
reality improves gait, balance, and muscle strength in children with
cerebral palsy. Tohoku J Exp Med 2016;238:213-8.
30. Chiu H-C, Ada L, Lee H-M. Upper limb training using Wii Sports
Resort for children with hemiplegic cerebral palsy: a randomized,
single-blind trial. Clin Rehabil 2014;28:1015-24.
31. Mombarg R, Jelsma D, Hartman E. Effect of Wii-intervention on
balance of children with poor motor performance. Res Dev Disabil
2013;34:2996-3003.
32. Sajan JE, John JA, Grace P, Sabu SS, Tharion G. Wii-based inter-
active video games as a supplement to conventional therapy for
rehabilitation of children with cerebral palsy: a pilot, randomized
controlled trial. Dev Neurorehabil 2017;20:361-7.
33. Salem Y, Gropack SJ, Coffin D, Godwin EM. Effectiveness of a low-
cost virtual reality system for children with developmental delay: a
preliminary randomised single-blind controlled trial. Physiotherapy
2012;98:189-95.
34. Tarakci D, Ersoz Huseyinsinoglu B, Tarakci E, Razak Ozdincler A.
Effects of Nintendo Wii-Fit video games on balance in children
with mild cerebral palsy. Pediatr Int 2016;58:1042-50.
35. Ürgen MS, Akbayrak T, Günel MK, Çankaya Ö, Güçhan Z,
Türkyýlmaz ES. Investigation of the effects of the Nintendo Wii-Fit
training on balance and advanced motor performance in children
with spastic hemiplegic cerebral palsy: a randomized controlled trial.
Int J Ther Rehabil 2016;5:146-57.
36. Verghese J, Buschke H, Viola L, et al. Validity of divided attention
tasks in predicting falls in older individuals: a preliminary study. J
Am Geriatr Soc 2002;50:1572-6.
37. Jelsma D, Geuze RH, Mombarg R, Smits-Engelsman BC. The impact
of Wii Fit intervention on dynamic balance control in children with
probable developmental coordination disorder and balance problems.
Hum Mov Sci 2014;33:404-18.
38. Jelsma J, Pronk M, Ferguson G, Jelsma-Smit D. The effect of the
Nintendo Wii Fit on balance control and gross motor function of
children with spastic hemiplegic cerebral palsy. Dev Neurorehabil
2013;16:27-37.
39. Luna-Oliva L, Ortiz-Gutierrez RM, Cano-de la Cuerda R, et al.
Kinect Xbox 360 as a therapeutic modality for children with cerebral
palsy in a school environment: a preliminary study. Neuro-
Rehabilitation 2013;33:513-21.
40. Fehlings D, Switzer L, Findlay B, Knights S. Interactive computer
play as “motor therapy” for individuals with cerebral palsy. Semin
Pediatr Neurol 2013;20:127-38.
41. Geuze RH. Postural control in children with developmental coordi-
nation disorder. Neural Plast 2005;12:183-96.
42. Lim YH, Partridge K, Girdler S, Morris SL. Standing postural control
in individuals with autism spectrum disorder: systematic review and
meta-analysis. J Autism Dev Disord 2017;47:2238-53.
43. Maı̈ano C, Hue O, Tracey D, Lepage G, Morin AJ, Moullec G. Static
postural control among school-aged youth with Down syndrome: a
systematic review. Gait Posture 2018;62:426-33.
44. Cameron CE, Brock LL, Murrah WM, et al. Fine motor skills and
executive function both contribute to kindergarten achievement.
Child Dev 2012;83:1229-44.
45. Grissmer D, Grimm KJ, Aiyer SM, Murrah WM, Steele JS. Fine
motor skills and early comprehension of the world: two new school
readiness indicators. Dev Psychol 2010;46:1008.
www.archives-pmr.org
AVGs and developmental disabilities 781

46. Yu JJ, Burnett AF, Sit CH. Motor skill interventions in children with
developmental coordination disorder: a systematic review and meta-
analysis. Arch Phys Med Rehabil 2018;99:2076-99.
47. Bishop JC, Pangelinan M. Motor skills intervention research of
children with disabilities. Res Dev Disabil 2018;74:14-30.
48. Howie EK, Campbell AC, Abbott RA, Straker LM. Under-
standing why an active video game intervention did not improve
motor skill and physical activity in children with developmental
coordination disorder: a quantity or quality issue? Res Dev
Disabil 2017;60:1-12.
49. Piek JP, Dawson L, Smith LM, Gasson N. The role of early fine and
gross motor development on later motor and cognitive ability. Hum
Mov Sci 2008;27:668-81.
50. Rigoli D, Piek JP, Kane R, Oosterlaan J. Motor coordination, working
memory, and academic achievement in a normative adolescent sample:
testing a mediation model. Arch Clin Neuropsychol 2012;27:766-80.

www.archives-pmr.org
Descargado para Anonymous User (n/a) en University of La Sabana de ClinicalKey.es por Elsevier en abril 16, 2021. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.