Disability and Rehabilitation, 2011; 33(17–18): 1579–1586

RESEARCH PAPER

Using video-capture virtual reality for children with acquired brain

injury

ORIT BART1, TAMI AGAM1, PATRICE L. WEISS2 & RACHEL KIZONY3

1
Department of Occupational Therapy, Tel Aviv University, Tel Aviv, Israel, 2Department of Occupational Therapy, Faculty
of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel, and 3Department of Occupational Therapy, Ono
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Academic College, Kiryat Ono, Israel

Accepted November 2010

Abstract
Objective. To assess the use of a video-capture projected VR system for children with acquired brain injury (ABI), and to
compare their performance to that of matched healthy controls.
Subjects. Thirty-three children (age range: 6–11.4 years) were divided into two groups: 17 children with ABI and 16
controls matched for age, gender and maternal education.
For personal use only.

Methods. Participants experienced three video-captured virtual environments and completed the SFQ child at the end of
each specific environment. Participants with ABI experienced three virtual reality (VR) sessions over a period of 10 days.
Attention was evaluated using the TEA-Ch. Upper extremity motor abilities were evaluated with the Melbourne Assessment,
and self-care abilities were evaluated with the PEDI.
Results. The video-capture projected system differentiated between the performance of children with ABI and control
participants. There was a correlation between VR performance and some attention factors and self-care abilities. No
significant correlations were found between performance in the Melbourne assessment and performance within VR.
Conclusions. The results highlight the potential of the video-capture virtual reality as a tool in the rehabilitation process of
children with ABI.

Keywords: Children, acquired brain injury, virtual reality, attention, self-care abilities

Introduction cognitive impairments (e.g. attention and memory

Acquired brain injury (ABI) is defined as brain
damage that occurs after birth. It may be caused by
external factors such as trauma or by internal factors
such as infection, tumours, vascular dysfunction or
metabolic problems [1]. The pathology and mechan-
ism of ABI in children differ from those observed in
adults due to dissimilarities in the anatomical
structure and developmental aspects. Survival rates
in children are higher compared to adults; however,
in children, the long-term consequences are more
severe due to the extensive damage caused by
increased brain water content and incomplete
myelinisation [2].
ABI may cause motor dysfunction (e.g. abnormal
muscle tone and limited range of motion) [3],
problems, slower processing and delayed response)
[4] and psycho-social problems (e.g. low self-esteem,
loneliness, anxiety, aggression and depression) [5].
These dysfunctions may limit participation in every-
day tasks, increase dependency and necessitate a
lengthy rehabilitation process [6]. For example,
Mortenson and Harris [7] assessed the level of
playfulness of eight children with ABI and found that
it was poorer than that of healthy children.
Enabling children with ABI to function optimally
in their natural environment is one of the main goals
of rehabilitation [8]. Emphasis is placed on the
therapeutic environment, where the goal is to create
meaningful, motivating and flexible opportunities
that are conducive to active participation [9]. A key
principle in rehabilitation is to adjust treatment

Correspondence: Orit Bart, Department of Occupational Therapy, Tel Aviv University, Tel Aviv, Israel. E-mail: o_bart@bezeqint.net
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2011 Informa UK, Ltd.
DOI: 10.3109/09638288.2010.540291
 1580 O. Bart et al.
activities to client’s abilities in a manner that will
enable them to be involved in the activity and to
improve their functioning without causing frustration
or fatigue [10]. Empirical evidence points to
activities that require a higher level of interaction
with the environment as being more successful than
those that require low levels of interaction [11,12].
For children, play is a meaningful and motivating
activity that encourages social participation and
cooperation [13]. In environments that encourage
play children can develop their motor, cognitive and
social skills [14]. Mortenson and Harris [7] sug-
gested incorporating play strategies in the interven-
tion process for children suffering from ABI.
During the last decade, various virtual reality (VR)
technologies have been used in rehabilitation for
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both evaluation and intervention [15–17]. VR has
many advantages for intervention, such as enabling
the grading of activities, obtaining precise perfor-
mance measures, providing a safe and ecologically
valid environment and being enjoyable and motivat-
ing [18]. VR also provides a distracting effect that
helps the participant focus on the task rather than on
painful or unpleasant medical procedures [19,20].
The familiarity of young people with computer
For personal use only.
technologies combined with the interactive, game-
like characteristics of VR makes it suitable for
children. Indeed, parents report that their children
are able to persevere in computer games longer than
in any other educational task [21]. Even young
adolescents with ABI report longer periods of
attention when using computer games [22]. VR
appears to present a way to create an interactive
environment that supports playfulness, thereby
motivating a child to take a more active role within
the evaluation and intervention process [23].
Several studies have demonstrated the feasibility of
VR-based intervention for children and young adults
with ABI. For example, Weiss et al. [24] and Yalon-
Chamovitz and Weiss [25] found that the use of
video-capture VR systems was successful in treating
young adults with cerebral palsy (CP). Even though
they had moderate to severe intellectual dysfunction,
they were unable to speak and possessed limited
motor capabilities, the activity increased their self-
esteem and the participants seemed to play the
games with great enthusiasm. In another study, the
same VR system was found to be effective in
improving upper extremity skills in four children
with CP [26]. Other VR technologies have also been
used. A virtual classroom viewed and controlled via a
head-mounted display unit differentiated between
children with attention deficit hyperactivity disorder
(ADHD) and healthy controls [27]. Children with
ADHD demonstrated longer reaction times and a
higher frequency of mistakes than the control group.
The virtual classroom was found to be a sensitive and
user-friendly assessment tool to aid diagnosis of
ADHD, and more acceptable to children than
the conventional Test of Variables of Attention
(TOVA) [28].
Although these initial results are encouraging, to
date, the number of VR studies in paediatric
populations is quite limited, and none of them
investigated the feasibility of this technology for
children with ABI. This study was conducted to
assess the use of a video-capture VR system for
children with ABI, and to compare their perfor-
mance to that of matched healthy controls.
In addition, the relationships between the chil-
dren’s performance within the virtual environments
and their performance in well-known tests of
attention, upper extremity motor skills and self-care
activities were examined. This was done in order to
explore the potential of this VR technology as a tool
for improving these skills, which are necessary for
their participation in daily life activities.
Methods
Participants
The sample consisted of 33 children who were
divided into study and control groups. The study
group consisted of 17 children, aged 6–11.4 years
(mean age ¼ 7.9, S.D. ¼ 1.4), with ABI, from the
Pediatric Rehabilitation Department at the Sheba
Medical Centre, Tel Hashomer. Elapsed time since
injury ranged from 10 to 120 days (mean ¼ 62.0,
S.D. ¼ 27.7). Inclusion criteria were ability to move
at least one of their upper extremities against gravity,
with full or partial range of motion and no continu-
ing signs of post traumatic amnesia (PTA), as
determined by the Children Orientation and Amne-
sia Test (COAT) [29]. Exclusion criteria were
significant visual impairment, pre-morbid psychiatric
illness or pre-morbid, progressive neurological im-
pairments or learning disability.
The control group included 16 healthy partici-
pants ranging in age from 6 to11.3 years (mean
age ¼ 7.9, S.D. ¼ 1.6). Children in the control group
were matched to the study group by age, gender,
ethnic background and maternal education
(Table I). No significant differences were found
between the two groups in any of the matching
parameters, namely, age (t ¼ 70.049, p 4 0.05),
gender (w2 ¼ 0.02, p 4 0.05) and ethnic background
(w2 ¼ 0.02, p 4 0.05) and maternal education
(t ¼ 70.55, p 4 0.05).
In the study group, 10 participants had traumatic
brain injury (2 mild, 3 moderate and 5 severe), six
participants had tumours (one meduloblastoma, one
fronto-parietal glioma, three cerebellar astrocitoma,
 Virtual reality intervention for children with ABI 1581

Table I. Demographic information of the study sample.

ABI group (n ¼ 17) Control group (n ¼ 16)

Number of subjects Percentages Number of subjects Percentages

Gender
Male 7 41.2 7 43.8
Female 10 58.8 9 56.3
Maternal education
Middle school 2 11.8 1 6.3
High school 8 47.1 7 43.8
Post-secondary education 6 35.3 7 43.8
Academic 1 5.9 1 6.3
Computer experience
computer 17 100 16 100
Dance pad/play station 3 17.6 6 37.5
VR system (projected/HMD) 0 0 0 0
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and one ependimoma) and one participant had an
infection. Fifteen participants had upper extremity
dysfunction, six of them in the dominant limb, seven
in the non-dominant limb and two in both limbs.
application does not use red glove mode since it does
not require reaching with the upper extremities).
Performance was measured by the percentage of
successfully avoided obstacles out of the total
number of obstacles.

Measures Test of everyday attention for children (TEA-Ch)

[32]. The test is comprised of nine subtests measur-
For personal use only.

Virtual reality system. Gesture Tek’s GX Interactive
Rehabilitation and Exercise system (IREX) was used
to provide the virtual reality experience [30,31]. In
this study, the user sat in front of a large screen onto
which the VR environment was projected. In two of
the virtual environments, the system was pro-
grammed to respond only to red objects (red glove
mode) such as a glove worn on one or both hands. In
this mode, the system responded only to arm
movements and not to movement of other body
parts. Three virtual environments were used in this
study:
Birds and balls. The user views himself in a pastoral
setting. He has to touch virtual balls emerging from
different locations on the screen and flying towards
him. Performance in this environment was measured
as the percentage of successfully touched balls out of
the total number of balls that appeared on the screen,
and by response time (i.e. the elapsed time from a
ball’s first appearances on the screen until it was
touched).
ing different components of attention: selective
attention, sustained attention, divided attention and
alternating attention. In this study, we used the short
screening version that includes the first four subtests
assessing the four attention components. The test
measures performance and completion time. The
TEA-Ch has age-related norms and is reliable (test–
retest r’s ¼ 0.65–0.87) and valid [33]. The scores are
converted into standardised scores to each age
group.
Melbourne assessment of unilateral upper limb function
[34]. This test was used to assess motor abilities. It
scores the quality of unilateral upper limb functional
movements using activities involving reach, grasp,
release and manipulation. The maximal score is 122
points, which indicates full function of the upper
limb. The scores are converted into percentiles. The
test has high internal consistency (a ¼ 0.96) [35] and
was validated with the Paediatric Evaluation of
Disability Inventory (PEDI) and correlations were
found to be high (r’s ¼ 0.72–0.94) [36].

Soccer. The user is a goalkeeper and has to prevent
the balls, which emerge from different locations,
from entering the net. Performance in this environ-
ment was measured in terms of percentage of
successfully repelled balls out of the total number
of balls.
Snowboard. The user is required to avoid obstacles
as he skis downhill, by leaning from side to side; this
Paediatric evaluation of disability inventory: PEDI [37].
This clinical assessment was used to evaluate
functional capabilities, performance and changes in
functional skills in children with disabilities. In this
study, 73 activities related to self-care, e.g. eating,
grooming, dressing and personal hygiene were
queried. The Caregiver Assistance Scale (CAS)
related to self-care, which measures the amount
and type of assistance the child needs, was also used
 1582 O. Bart et al.

[37]. The PEDI has internal reliability and test– abilities, upper extremity function and self-care
retest reliability (r ¼ 0.67–1.00). It has good content capabilities were assessed within 10 days of the VR
and construct validity [38]. session.

The short feedback questionnaire for children Data analysis

(SFQ-Child) [24]
This is an 8-item (three-point scale) questionnaire
based on the Presence Questionnaire developed by
Witmer and Singer [39] and the SFQ developed by
Kizony et al. [40]. It is designed to obtain informa-
tion about the subjective responses of the partici-
pants to the VR experience in each scenario,
including enjoyment, perceived difficulty of the task,
sense of presence and side effects. The SFQ has good
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An independent t-test was used to compare the ABI
group to the control group in order to determine
whether the two groups differed in their performance
in the virtual environments. Spearman correlation
tests were used to identify relationships between VR
performance and attention capabilities, upper ex-
tremity function and self-care capabilities. The non-
parametric Mann–Whitney test was used to compare
differences between the ABI and the control groups

Internal validity of a ¼ 0.81 [40] and moderate to on the SFQ-Child questionnaire.

good construct validity [39,41].

Procedure
This study was approved by the Sheba Medical
Centre Institutional Review Board. Informed con-
sent was obtained from the subjects’ legal guardians.
For personal use only.
Results
Statistically significant differences in VR perfor-
mance between the ABI group and the control group
were found in most of the measured variables. In
general, participants in the control group performed

Participants experienced all three virtual environ-
ments: Birds and Balls, Soccer and Snowboard. At
the start of each trial, the environment was intro-
duced, and participants were trained individually for
a period of 1 min. The participant then experienced
3 min of the environment with the difficulty level
increasing every minute. For the Soccer task, which
is more complex, the first 2 min were maintained at
level 1 (1a and 1b) and the third minute at level 2.
Between each environment, participants had 2 min
rest. The total experience time in the three environ-
ments lasted for about 20 min.
The SFQ-Child questionnaire was administered
after experiencing each VR environment. Attention
better than the participants in the ABI group
(Table II).
As shown in Table II, the success rate for Birds
and Balls was lower in the ABI group, but it was
statistically significant only at level 3 (t ¼ 73.05,
p 5 0.01). The mean response time for Birds and
Balls in the ABI group was significantly longer than
in the control group at all three levels: level 1
(t ¼ 3.86, p 5 0.001), level 2 (t ¼ 2.80, p 5 0.09) and
level 3 ( t ¼ 4.94, p 5 0.009).
Success rate in Soccer for the ABI group was
significantly lower than that of the control group, at
all levels: level 1a (t ¼ 73.04, p 5 0.01), level 1b
(t ¼ 72.29, p 5 0.05) and level 2 (t ¼ 73.73,

Table II. Differences between study and control groups in VR performance in the three environments (means and standard deviations).

ABI group Control group

VR environment Level Measure Mean (S.D.) Mean (S.D.) t p

Birds and Balls 1 Success rate (%) 98.72 (3.63) 100.0 (0.00) 71.39 1.73
Response time* 6.12 (1.28) 4.61 (0.87) 3.87 0.001
2 Success rate (%) 97.54 (5.11) 99.79 (0.80) 71.74 0.092
Response time* 5.84 (0.89) 4.89 (1.00) 2.81 0.009
3 Success rate (%) 94.59 (6.15) 99.39 (1.31) 73.06 0.005
Response time* 6.81 (1.00) 5.27 (0.74) 4.94 0.000
Soccer 1a Success rate (%) 55.70 (18.91) 74.36 (16.03) 73.05 0.005
1b Success rate (%) 57.41 (21.01) 73.75 (19.84) 72.29 0.029
2 Success rate (%) 42.23 (15.55) 61.62 (14.19) 73.73 0.001
Snowboard 1 Success rate (%) 85.71 (18.89) 94.64 ((8.84 71.72 0.095
2 Success rate (%) 80.14 (19.29) 95.31 (7.73) 72.93 0.006
3 Success rate (%) 85.29 (12.30) 98.12 (4.03) 3.97 0.000

*Response time in seconds.

 Virtual reality intervention for children with ABI 1583

Table III. Spearman’s correlation between performances within virtual environments and TEA-Ch test in the study group (n ¼ 16).

Focussed atten-
tion Alternating attention

VR environment Level Measure Score Time Sustained attention Score Time Divided ttention

Birds & Balls 1 Success rate (%) 0.22 0.29 0.49* 0.34 0.11 70.12
Response time 70.48 70.40 70.65** 70.55* 70.53* 70.25
2 Success rate (%) 0.22 0.34 0.45 0.16 0.13 0.02
Response time 70.32 70.33 70.40 70.41 70.36 70.11
3 Success rate (%) 0.42 0.38 0.22 0.34 0.37 70.08
Response time 70.50* 70.42 70.48 70.52* 70.52* 70.91
Soccer 1a Success rate (%) 0.49* 0.47 0.63** 0.45 0.47 0.30
1b Success rate (%) 0.39 0.36 0.43 0.39 0.53* 0.29
2 Success rate (%) 0.34 0.26 0.37 0.50* 0.49* 0.29
Snowboard 1 Success rate (%) 0.38 0.39 0.45 0.51* 0.21 0.00
2 Success rate (%) 0.16 0.15 0.53* 70.04 0.05 0.49*
3 Success rate (%) 70.05 0.04 70.10 70.24 70.20 0.06
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*p 5 0.05, **p 5 0.01.

Table IV. Spearman correlation between performance within the TEA-Ch scores and performance in the Soccer
virtual environments and PEDI test in the study group (n ¼ 17). environment (Soccer percent of success in level 1a
PEDI and general alternate attention rs ¼ 0.54, p 5 0.03;
VR (therapist Soccer percent of success in level 1b and general
environment Level report) Caregiver alternate attention rs ¼ 0.53, p 5 0.034). No signifi-
cant correlations were found between the TEA-Ch
Birds & Balls 1 Success rate (%) 0.11 0.42
For personal use only.

Response time 70.61** 70.73*** and performance in the Snowboard environment at

2 Success rate (%) 0.16 0.30 all three levels for the control group. For both groups
Response time 70.31 70.50* the correlations indicated that better performance
3 Success rate (%) 0.42 0.75*** within the VR was related to better performance in
Response time 70.45 70.64**
the TEA-Ch.
Soccer 1a Success rate (%) 0.43 0.58**
1b Success rate (%) 0.61*** 0.76*** The mean Melbourne Assessment of Unilateral
2 Success rate (%) 0.57** 0.63** Upper Limb Function score for the ABI group was
Snowboard 1 Success rate (%) 0.19 0.35 92.4% (S.D. ¼ 14.3 %) and for the reaching sub-
2 Success rate (%) 0.40 0.58** tests it was 91.5% (S.D. ¼ 13.8%). Children in the
3 Success rate (%) 0.39 0.25
control group achieved a 100% score on all subtests,
*p 5 0.05, **p 5 0.01, ***p 5 0.001. reflecting the normative function of healthy children.
No significant correlations were found between
performance in the Melbourne assessment and
p 5 0.01). The differences between the two groups performance within VR.
for the Snowboard environment were significant for Significant moderate correlations were found
level 2 (t ¼ 72.99, p 5 0.01) and level 3 (t ¼ 74.07, between several of the self-care functional abilities
p 5 0.01). measured by the PEDI and performance within VR
Children in the ABI group performed worse on the by the study group. These correlations indicate that
TEA-Ch than children in the control group the more independent the child (i.e. higher achieve-
(M ¼ 4.75, SD ¼ 2.53, and M ¼ 10.40, SD ¼ 1.89, ments in PEDI), the better he performs in VR. Even
respectively). The correlation coefficients between stronger correlations were found between the care-
achievement in TEA-Ch and performance in VR in giver assistance scales and performance in VR
the study group are presented in Table III. In the (Table IV). No significant correlations were found
control group, a few significant correlations were between performance in the VR environment and the
found between the TEA-Ch and performance in the PEDI scores in the control group reflecting the high-
Birds and Balls environment and only in level 3 performance score healthy children achieve in the
(Birds and Balls percentage of success and divided PEDI.
attention rs ¼ 0.55, p 5 0.026; Birds and Balls reac- Three significant differences were found between
tion time and focussed attention time rs ¼ 70.57, the ABI and the control groups on the SFQ-child; in
p 5 0.021; and Birds and Balls reaction time and the enjoyment (z ¼ 72.16, p 5 0.05) and under-
focussed attention score rs ¼ 70.52, p 5 0.038). standing of the ‘Bird & Balls’ environment
Two significant correlations were found between (z ¼ 72.03, p 5 0.05) and understanding of the
 1584 O. Bart et al.
‘Soccer’ environment (z ¼ 72.15, p 5 0.05). These
results show that the children with ABI enjoyed ‘Bird
& Balls’ more than the children in the control group,
but had less understanding of either environment.
Discussion
The findings of this study indicate that on selected
tasks, the IREX video-capture VR system distin-
guished between children with and without brain
injury; the participants in the control group achieved
higher success rates than did the participants in the
ABI group. Statistically significant differences were
mostly obtained at the higher levels, where faster
responses are required. For example, response times
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in the Birds and Balls environment were significantly
longer for the ABI group. These findings are
consistent with previous studies which demonstrated
that children with ABI have decreased motor speed
and processing speed skills, especially only 3 months
after injury [42,43].
The findings also revealed significant moderate
correlations between some VR performance variables
in virtual environments and attention outcomes.
For personal use only.
Although success in the tested VR environments
entails a number of cognitive abilities (e.g. divided
attention) and visual motor abilities (e.g. visual
perception, sitting balance), there did not appear to
be any systematic association between VR perfor-
mance and perceptual-behavioural variables.
No significant correlations were found between
upper extremity function and performance within the
virtual environments, but positive correlations were
demonstrated in the reaching component. The
disassociations may be due to differences between
the items of the Melbourne Assessment that dissim-
ilar from the motor function that is needed to
perform in the virtual environment [30]. For
example, in the Melbourne Assessment, a single
movement is tested, while repetitive upper extremity
movements are required in the virtual environments,
entailing muscle endurance.
Several significant correlations were found be-
tween self care functional abilities measured in the
PEDI and VR performance outcomes. Those corre-
lations indicate that the more independent the child
(i.e. higher achievements in PEDI), the better the
performance in VR. More and stronger correlations
were found between the caregiver assistance scales
and performance in VR. In contrast to the PEDI
score which is based on a child’s potential (as
determined by the examiner, usually an occupational
therapist), the caregiver assistance score is deter-
mined by the actual function of the child. The
caregiver assistance score reflects motor, cognitive
and emotional components, such as self-regulation
and motivation that reflect the components required
to engage in the VR environment. This may account
for the stronger correlations between the two.
In general, high levels of satisfaction following the
VR experiences were reported by both groups with
no statistical differences between them with regard to
the sense of presence and satisfaction, or for most
indices of the SFQ-Child questionnaire. These
findings are in accordance with other IREX VR
studies [23,24,26,44]. In the ABI group, the highest
sense of presence was reported for the snowboard
environment, which was perceived as the easiest. The
sense of control in this environment was high for
both groups; 28 of 30 children preferred it over the
other two environments, asking to repeat it at the end
of the VR session. Note that Snowboard differs from
the other two environments since its motor demands
were lighter, focussing more on trunk tilt and less on
upper extremity movements. It included competitive
and challenging elements, yet allowed for a sense of
control and of success. These are important motiva-
tion and volition enhancers and contribute to
participation and activity engagement [23]. Similar
to previous results from adult participants with stroke
and spinal cord injury [44,45], the lowest scores were
obtained in the ‘Soccer’ environment where per-
ceived difficulty was highest.
No participants from the control group reported
discomfort while using the video-capture environ-
ments, whereas four from the study group did; one
participant reported general discomfort during the
‘Birds and Balls’ environment and three reported it
during the ‘Soccer’ environment. These ‘symptoms’
appeared to be related to general fatigue or high
exertion rather than to optical or vestibular cyber-
sickness side effects such as dizziness or nausea as
video capture VR systems do not typically generate
cyber-sickness side effects in users [46]. The results
of this study reinforce the general usability of the
IREX VR system for a wide variety of ages and
disabilities [30].
Conclusions and limitations
This study highlights the potential of video-capture
virtual reality as a tool in the rehabilitation process of
children with ABI. The findings show its ability to
distinguish between performance of children with
ABI and those of matched healthy controls. These
differences may be due to reduced processing speed
and reduced response time. Correlations were found
between performance within virtual environments
and different attention capacities, and, to some
extent, between self-care functions and upper ex-
tremities functionality. In addition, high levels of
satisfaction were reported following the VR experi-
 Virtual reality intervention for children with ABI
ence. This study has several limitations deriving from
the small size of the sample and relatively large range
of ages. It seems warranted to conduct a large sample
study, in the future, that includes a variety of virtual
environments among different children populations.
The playful characteristics and ability to enhance
motivation by this type of VR technology points to its
potential success for rehabilitation of children with
ABI. The results of this study are thus consistent
with previous literature [17,25–29,35] in indicating
that usage of VR projected systems may constitute an
innovative and meaningful tool for rehabilitation.
Taken together, the results of this study suggest
that children with ABI may benefit from the use of
VR technologies in promoting children’s function
and health. By using this user-friendly, motivating
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and safe tool children’s enjoyment of the rehabilita-
tion process may be enhanced. In recent years, VR
technologies have become increasingly available (e.g.
[31]) although some are still expensive and techni-
cally complex. We anticipate that continued research
to demonstrate its effectiveness for evaluation and
intervention as well as the commercial development
of low-cost systems will lead to increased use in
clinical practice.
For personal use only.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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