Technology and Disability 14 (2002) 53–61 53

IOS Press

The use of virtual reality to improve

upper-extremity efficiency skills in children
with cerebral palsy: A pilot study
Denise T. Reid
Department of Occupational Therapy and Graduate Department of Rehabilitation Science, Faculty of Medicine,
University of Toronto, 26 McCaul St., Toronto, Ontario M5T 1W5, Canada
Tel.: +1 416 978 5937; Fax: +1 416 978 4363; E-mail: d.reid@utoronto.ca

Abstract. This paper presents the results of a pilot study of a virtual reality play based intervention. The results of four single case
studies are presented. The virtual reality intervention used the Mandala Gesture Xtreme technology. It was applied to four school
aged children with cerebral palsy. A pretest-posttest design was used. The relevant outcome of interest was upper extremity
control as measured with the Quality of Upper Extremity Skills Test (QUEST), item #6 of Subtest #5 of the Bruininks-Oseretsky
Test of Motor Proficiency (BOTMP), and a measure of percent accuracy . The total scores on the QUEST indicated clinically
significant changes in quality of upper extremity for two of the children. Changes were noted in other measures of upper extremity
control for each child.
Qualitative comments from the participants revealed a high degree of motivation, interest, pleasure, and opportunity for engage-
ment in play activities not previously engaged in. Overall, this pilot study suggests the viability of a virtual reality play based
intervention as part of the rehabilitation process for children with cerebral palsy. These results will form the basis of a larger
scale randomized clinical trial.

1. Introduction that there is very little research documenting the effects

Cerebral palsy (CP) refers to a group of posture and
movement disorders occurring as a result of a non-
progressive lesion of the developing central nervous
system [1]. Generally, a diagnosis is made before the
age of two years, and therapy interventions are pro-
vided. The emphasis of therapy programs, especially
for younger children with CP, has been on promoting
physical growth and development. There have been
many popular forms of therapy over the years, however
their real value and effectiveness has not been strongly
supported by empirical evidence [2,3]. For the older
school-age child with CP, the goal of intervention fo-
cuses on psychosocial growth and development as well
as on motor performance [4]. This is critical given the
challenges facing school-age children and adolescents
as they grapple with both developmental issues and
their motor disorder. However, a steadfast problem is
of rehabilitation therapy on motor outcomes.
The potential for use of virtual reality (VR) with
children with cerebral palsy (CP) holds tremendous
promise as a new and effective intervention for improv-
ing self-competence and motor performance. Inman et
al.’s study [5] showed that VR was effective in train-
ing powered mobility skills in children with CP. Ne-
mire and Crane’s study [6] allowed children with CP
to access educational experiences not otherwise pro-
vided to them. The results of these two studies sug-
gest that a simulated interactive environment available
through VR can offer children with CP an opportunity
to practice and try out new skills/movements without
the worry of embarrassment or the risk of injury. This
in turn can lead to improved motor performance, but
perhaps even more importantly,a sense of personal con-
trol or self-efficacy. Virtual reality has been described
as having the potential to be a powerful tool for use
in rehabilitation with many people with disabilities [7–

ISSN 1055-4181/02/$8.00  2002 – IOS Press. All rights reserved

54 D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills
11]. Virtual reality is defined as an immersive and in-
teractive three-dimensional (3D) computer experience
occurring in real time [12]. Virtual reality applications
use 3D computer graphics, which respond to the user’s
movements, thereby given the user the sense of being
immersed in the virtual environment.
At the present time, the technology of VR and its
application to the field of pediatric rehabilitation is in
an infancy stage. Each new study being conducted is
the first of its kind, however with ongoing research, the
evidence for judging the effectiveness of VR as a viable
intervention will soon be available. Although, there
have been only a limited number of studies exploring
the potential of VR in rehabilitation, and fewer still
in pediatric rehabilitation, previous applications with
children with disabilities have demonstrated the poten-
tial of VR to improve life skills, mobility and cognitive
abilities, quality of life, and social opportunities [5,6,
13–19].
Well-developed theories of behaviour change have
been proposed in fields beyond rehabilitation, and may
be useful for developing hypotheses and specifying
mechanisms by which rehabilitation interventions for
children with disabilities may work. A combination of
theoretical frameworks may be necessary to explain the
role and impact of various aspects of an intervention.
In this study, neurodevelopmental theory [20,21] and
motor learning theory [22,23] are used to explain the
impact of a VR intervention with children with cerebral
palsy. Neurodevelopmental theory states that antigrav-
ity postures, such as sitting, are supported by a large
contact area with the support surface. Over time, dy-
namic adaptations to the support surface enable greater
postural control. A substantial body of research sup-
ports this theory and indicates that proximal stability
is the dynamic interaction of stability and mobility be-
tween body parts to yield freedom of movement from
a stable base in distal body parts with graded muscle
control. Efficiency in postural stability contribute to
head and trunk alignment in sitting and better use of the
upper extremities. Postural alignment is the body’s ori-
entation around the force of gravity and to the support
surface contact necessary to restore head position with
the trunk, pelvis, and extremities for the maintenance
of aligned antigravity postures while continuing to have
freedom of movement in the upper extremities. Finally,
balance is making the postural adjustments necessary
to maintain the alignment between the body’s centre of
gravity and the base of support while having freedom
of upper limb movement.
Motor learning theory suggests that with repetition
a movement can be learned and used over and over.
Practice is an essential component of learning a new
motor skill. Feedback over performance also helps to
reinforce the patterns learned.
Applied to children with CP, neurodevelopmental
and motor learning theory, especially the importance
of measuring constructs such as upper limb movement
accuracy and efficiency suggests that the use of VR
may enhance the quality of upper extremity skills in
children and provide them with a sense of mastery or
sense of control over their actions. Theoretically, as
specified in motor learning theory, enhanced feelings
of self-control will, in turn, result in improved mo-
tivation and a desire to practice movement patterns,
thereby developing greater movement control. Recent
research by Rizzo and his colleagues [24] underscores
the advantage of the enjoyable game-like experience of
VR and its relationship to motivation, and movement
performance among children.
2. Methodology
2.1. Design
A single case design was used. The basic feature of
this design is the evaluation of clients for the outcome
of interest both before (baseline) and after the interven-
tion. This design allows an individual to serve as their
own control. It was used in this case to evaluate the
effects of a VR play intervention with a small number
of children in a pilot study prior to conducting a large
randomized controlled study.
2.2. Participants
Four children diagnosed with cerebral palsy, aged 8
to 12 years participated in the pilot study. They were
able to communicate verbally. Table 1 presents relevant
subject characteristics. The children were recruited
from two large children’s rehabilitation centres in the
greater Toronto region. Informed parental consent and
ethical approval were obtained prior to commencing
the study.
2.3. Intervention
There have been problems reported with the use of
different VR systems that have important implications
for using VR successfully with children with disabili-
ties. Critics of the head-mounted display systems have
reported they tend to restrict movement, are heavy to
 D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills 55

Table 1
Participant characteristics
Participant Age Grade Diagnosis Tone Functional status
1 10 5 Spastic Quadriplegia High GMFC level = 4
Does not ambulate
Uses manual wheelchair with sub-ASIS bar
Cannot sit unsupported on a bench
2 12 7 Spastic Quadriplegia Moderate GMFC level = 4
Uses walker for short distances indoors
Uses power wheelchair
Can sit unsupported on a bench
3 8 2 Spastic Diplegia Moderate GMFC level = 3
Uses walker
Can sit unsupported on a bench
4 10 Spastic Quadriplegia High GMFC level = 4
Uses manual wheelchair
Cannot sit unsupported on a bench
∗ Gross Motor Classification level based on classification system developed by Palisano and colleagues [25].

the user, cause motion sickness, have a limited field of

view, and are not very comfortable [26]. The major
limitation with the use of desk-top VR which is ac-
complished through projecting the virtual environment
(VE) onto the computer monitor and the user inter-
acts with the VE with the use of a joystick, mouse, or
keyboard is a diminished sense of immersion [27].
To overcome these problems, in this study we
used the 1996 patented Mandala
R
Gesture Xtreme
(VX) technology developed by Vivid Group Inc., from
Toronto. This system uses a video camera as a cap-
turing and tracking device to put the user inside VR
experiences. With the GX technology, the user is at the
center of the action, inside a computer world, where by
Fig. 1. Photograph of child showing VR set-up.
watching themselves on the screen they can physically
participate in a virtual world. Sophisticated artificial in-
telligence and video gesture control technology allows In a lab environment, children sat either in their
them both intricate manipulation of virtual objects and wheelchair system or unsupported on a bench in a de-
3D navigation of the virtual landscape. The GX tech- marcated area viewing a large TV screen with a video
nology offers an alternative to the problems inherent in camera mounted on the top (see Fig. 1). One session
other forms of VR, because users do not have to wear a week for 8 weeks were provided. Each intervention
Head Mounted Displays (HMD), Data Gloves, or other session was 11/2 hours. Each session was designed so
devices that tether them to the computer. In fact, users that approximately each 15 minutes was spent playing a
do not have to wear, touch, or hold anything, leaving different application. Each application except for three
them free to actively move about in the real world while required the child to control his/her arm movements
they use their entire body to interact with the computer. to interact with objects on the screen and to play the
Through the use of the system’s “video gesture” ca- game. Examples were Orbosity, Drums, Paint, Vol-
pability, the movements (e.g., reaching, bending) trig- leyball and Soccer (Figs 2–5). The other applications
ger visible or invisible icons to score points, and ma- required the child to use mid-line trunk control through
nipulate animations (e.g. playing a virtual drum kit, using lateral flexion and trunk rotation movements. An
playing volleyball). The system requirements include example of such an activity which required these skills
an intel Pentium ll BX Motherboard 400 mhz CPU, was Snowboarding.
128 MB RAM, 4.3 GB HD, 12 meg, 3D video card, The software application “Orbosity” will be de-
CCD video camera and cables, capture board, 4 MB scribed to provide some detail regarding what was typ-
S-3 Video card, 16 bit sound card, and the patented ically expected from the child in most applications.
Gesture Xtreme (GX) software. On the television screen the child sees a tranquil back-
56 D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills
Fig. 2. Photograph of child playing “Orbosity”.
Fig. 3. Photograph of child playing Volleyball.
ground consisting of a green field surrounded by a
fence. In the horizon is a snow-capped mountain range.
The bright blue sky surrounds the child’s image and in
the sky are brightly colored balls that float from dif-
ferent directions toward the child. The number, di-
rection and speed of the balls was graded so that 3
balls in sequential waves came from either the right
side of the screen or the left side. Each virtual ball
the child successfully touched, burst electronically into
numerous colored particles. If touched gently, the ball
transformed into a bird and flew off the screen. The
child had to visually track and locate all balls and grade
the amount of pressure when making contact with the
balls. Auditory feedback was available when contact
was made. As well the computer kept track of the
points the child made each time contact was made, and
these scores were shown to the participants at the end
of each trial. For the volleyball game the child was
instructed to lift arms up to hit the ball that was hit over
the net by the other player or the computer robot. The
Fig. 4. Photograph of child playing Soccer.
Fig. 5. Photograph of child playing “Paint”.
option of selecting a two-player game allowed for some
competition during the sessions. In soccer, the child
was the goal tender and was instructed to reach out to
the sides and above the head with his/her arms to block
incoming shots.
Every session was standardized starting with a 15-
minute trial of Orbosity, then the child was allowed to
choose the applications he/she preferred to play. This
procedure was used to encourage choice and control by
the children and maintain motivation. Fatigue did not
seem to be an issue with the children. They had ample
time to rest in between playing the different games.
2.4. Hypothesis and outcome measures
The study hypothesis was that quality of upper ex-
tremity skills among children with cerebral palsy would
improve after engagement in a virtual play interven-
tion program. Therefore, the main outcome measure
 D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills
used was the Quality of Upper Extremity Skills Test
(QUEST) [28]. The QUEST was designed as an out-
come measure with a structured scoring method to as-
sess the quality of a person’s upper extremity skills.
It conceptualizes upper extremity skills in terms of
four main constructs: dissociated movements, grasps,
weight bearing, and protective extension. Results of
validation studies show that the QUEST demonstrates
good test-retest reliability and validity. Evidence for its
responsiveness is also available. Complete guidelines
for the administration and scoring of the QUEST are
contained in the QUEST manual. The QUEST uses a
2-point rating scale for each item. A score value of ‘1’
reflects the most complete or mature response. A rating
of 0 indicates an abnormal or immature response. A
total standardized score is calculated. For this study,
we administered the dissociated items only which in-
cluded shoulder, elbow, wrist, finger and grasp and
release items. While the QUEST has been validated
with children up to the age of 8 years we chose to use
it with our slightly older sample because the authors
do suggest that the QUEST can be used with children
irrespective of age whose quality of movement is poor.
A trained pediatric occupational therapist adminis-
tered the QUEST at baseline and at post-test.
Two other outcomes measures were used: item #6
“touching a swinging ball with preferred hand” from
the subtest #5 of the Bruininks-Oseretsky Test of Mo-
tor Proficiency (BOTMP) [29] and a measure of ac-
curacy developed for the study using the VR Orbosity
program. The BOTMP has acceptable psychometrics.
In particular the Bruininks item is a part of the subtest
upper limb coordination which has reported good re-
liability and discriminative validity results. While the
Bruininks did not have cerebral palsy children as part of
their discriminative validity sample they had children
with learning disabilities a symptom found in many
children with cerebral palsy.
The last measure was called “average percent accu-
racy score” which was calculated based on the average
number of hits of balls over 40 trials for a total of balls
120 balls (3 balls/trial). The test retest reliability of this
measure was tested with two independent raters and it
was found to be 94%.
2.5. Data analysis
The QUEST, BOTMP and the average percent ac-
curacy scores were descriptively analyzed and graphi-
cally presented for each participant. Given the design
of the study and the small number of participants, the
data were visually inspected for clinically significant
changes.
57
Table 2
Participants’ QUEST scores
Participant Baseline score Posttest score
1 46.86 31.06
2 96.87 98.43
3 100 100
4 92.18 94
Table 3
Participants’ BOTMP scores
Participant Baseline Posttest
1 1 2
2 2 5
3 2 5
4 2 3
3. Results
The QUEST and the BOTMP scores are presented
in Tables 2 and 3. Participant #1 showed a decline
in QUEST scores at posttest. This may be due to the
fact that the intervention was not long enough to show
an improvement in the movement patterns involved in
reaching. Participant # 2 demonstrated an improve-
ment on the QUEST. Although the score change is only
2 units this score change is clinically significant as it
demonstrates an improvement in at least one or two
components of upper extremity movement. With par-
ticipant #3 there was no change as she achieved ceiling
on the test at baseline. Participant #4 also showed a
clinically significant improvement on the QUEST.
All the participants showed an improvement on the
BOTMP item “touching a swinging ball” at posttest.
Two subjects #1 and #4 showed a change score of 1
whereas the other two #2 and #3’s change scores were
3 points. These scores reflect greater movement effi-
ciency.
With respect to the average percent accuracy data
participants results are presented in Figs 6–9. Par-
ticipant #1 showed a marked improvement in the left
hand. At baseline on the left side the score was 78.9;
at posttest it was 95.4. Performance in the right hand
declined from 69.7 at baseline to 52.6 at posttest. Par-
ticipant #2 no change in the left hand and a slight de-
cline in performance in the right hand, from 77.8 to
68.7. Participant #3 showed improvement in the left
hand going from 79 at baseline to 91.1 at posttest. Also
in her right hand performance she changed from 80.1
to 85. Participant #4 showed minimal change in his
left hand 86 to 85.6 but slight change in the right hand
(64.4 to 69).
58 D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills

Average Percentage Balls Hit: Baseline vs. Post-test for S #1

100

90

80

70
Average Percentage of Balls Hit

60

Baseline
50
Post-test

40

30

20

10

0
Right Left
Hand Used

Fig. 6. Percent accuracy scores for participant #1.

Average Percentage Balls Hit: Baseline vs. Post-test for S #2

100

90

80

70
Average Percentage of Balls Hit

60

Baseline
50
Post-test

40

30

20

10

0
Right Left
Hand Used

Fig. 7. Percent accuracy scores for participant #2.

4. Discussion with four children with cerebral palsy. Following the 8

Overall, this pilot study has demonstrated beneficial
results in terms of quality of upper extremity skills as
measured with Quality of Upper Extremity Test and the
Bruininks-Oseretsky Test of Motor Proficiency, subtest
#5 item #6, and a derived percent accuracy measure
sessions of intervention children showed varying levels
of improvement in aspects of quality of upper extremity
skills.
With respect to individual participants, participant
#1’s upper extremity control changed slightly as re-
flected by his BOTMP score and his percent accuracy
 D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills 59

Average Percentage Balls Hit: Baseline vs. Post-test for S #3

100

90

80

70
Average Percentage of Balls Hit

60

Baseline
50
Post-test

40

30

20

10

0
Right Left
Hand used

Fig. 8. Percent accuracy scores for participant #3.

score for the left hand. His QUEST score was worse
at posttest as was the percent accuracy score for his
right hand. His left hand was his preferred hand. The
aspects showing most change for this participant were
related to accuracy in movement as shown by his im-
provement on the BOTMP task and the birds and balls
task. The qualitative changes in the patterns of upper
extremity movement were not seen. It is important to
note that this participant’s physical abilities were less
than the other participants. Performing the reaching
movements was very challenging for this child. The
level of effort and fatigue over the trials at the posttest
may have greatly accounted for the poor score. In ad-
dition the number of sessions may have not been suf-
ficient to detect a change in the quality of his upper
extremity skills as measured with the QUEST.
Participant #2 displayed motivation over the sessions
and a willingness to reach with his best effort during the
activities. He showed a change in both his accuracy of
movement and the quality of his upper extremity skills.
While his performance on the test of percent accuracy
showed little change for his left hand and poorer change
for his right hand, his change score on the BOTMP
task was 3. He was much more accurate on this task
at posttest. His QUEST score was also improved at
posttest reflecting a clinically significant change. This
participant spoke about how he felt stronger and that
perceived he was able to move his arms much better by
the end of the sessions.
Participant #3 who was the less involved child in
the study showed no change on the QUEST as she had
reached ceiling level at baseline and could not show
any improvements. She did improve on the BOTMP
task by 3 points at posttest and showed greater accuracy
on the percent accuracy test in both her hands. Partici-
pant #4 showed improvement on the QUEST and also
demonstrated change on the right side for the percent
accuracy test.
Participant #4 showed improvement on the QUEST
and also a gain on the BOTMP. His performance with
respect to percent accuracy was varied with a decline
of one point on the left side and an improvement of five
points on the right side which was the side with less
tone.
As predicted, the virtual play intervention was a great
deal of fun for the participants. Informal comments
made from the children suggest the VR intervention
was a pleasurable experience and was motivating for
them. The following are some quotes made to reflect
this:
“I didn’t think it would be this exciting.” Its kinda
like making a dream come alive.” “You get to be as
crazy and wild as you want.”
60 D.T. Reid / The use of virtual reality to improve upper-extremity efficiency skills

Average Percentage Balls Hit: Baseline vs. Post-test for S #4

100

90

80

70
Average Percentage of Balls Hit

60

Baseline
50
Post-test

40

30

20

10

0
Right Left
Hand Used

Fig. 9. Percent accuracy scores for participant #4.

Children also spoke about how playing the VR games Acknowledgements

provided them with new opportunities and increased
their level of confidence:
“Yes, I have done lots of things that I didn’t used
to be able to do.” “Now I know that you can do
anything you want to do if you put your mind to
it.” “It was fun because it gave me a lot more
confidence. I had to work really hard.” “Well,
I think it has been very worthwhile and exciting
because I wouldn’t get to learn all this stuff and do
all this stuff.”
In summary, this pilot study suggests that a virtual
play environment provides children with an opportu-
nity to interact with virtual play activities which are en-
joyable and non-threatening. This opportunity allows
for increased play engagement and an opportunity to
exercise control over their actions. To this end, this
overall experience enables the development of a sense
of mastery while at the same time challenging the un-
derlying elements of upper extremity control. The re-
sults of this pilot study will be used for conducting a
blinded-randomized clinical trial with a larger group of
children with cerebral palsy.
This study was funded by a grant from Kids Action
Research. The author is grateful for the assistance of
Stacey Miller and Kristan Harris, research assistants
for intervention delivery, and to Karen Bonnah, occu-
pational therapist for data collection. Thanks to the
children who participated.
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