Abstract
Background Challenges with any therapeutic program for children include the level of the child's engagement or adherence. Capitalizing on one of the primary learning avenues of children, play, the approach described in this article is to develop therapeutic toy and game controllers that require specific and repetitive joint movements to trigger toy/game activation.
Objective The goal of this study was to evaluate a specially designed wrist flexion and extension play controller in a cohort of children with upper extremity motor impairments (UEMIs). The aim was to understand the relationship among controller play activity, measures of wrist and forearm range of motion (ROM) and spasticity, and ratings of fun and difficulty.
Design This was a cross-sectional study of 21 children (12 male, 9 female; 4–12 years of age) with UEMIs.
Methods All children participated in a structured in-clinic play session during which measurements of spasticity and ROM were collected. The children were fitted with the controller and played with 2 toys and 2 computer games for 5 minutes each. Wrist flexion and extension motion during play was recorded and analyzed. In addition, children rated the fun and difficulty of play.
Results Flexion and extension goal movements were repeatedly achieved by children during the play session at an average frequency of 0.27 Hz. At this frequency, 15 minutes of play per day would result in approximately 1,700 targeted joint motions per week. Play activity was associated with ROM measures, specifically supination, but toy perception ratings of enjoyment and difficulty were not correlated with clinical measures.
Limitations The reported results may not be representative of children with more severe UEMIs.
Conclusions These outcomes indicate that the therapeutic controllers elicited repetitive goal movements and were adaptable, enjoyable, and challenging for children of varying ages and UEMIs.
Cerebral palsy (CP) and related etiologies can lead to impaired muscle function of the extremities including weakness, spasticity, contractures, joint deformities, and deficiencies in somatosensory function.1 Physical therapy and occupational therapy remain the primary noninvasive treatments for these impairments. The need for therapy is especially important during motor development as children strive to learn and master new and more challenging motor tasks. Therapy is aimed at reducing the impact of these impairments, preventing deterioration of existing motor function, inhibiting acquired problems such as joint contractures, and decreasing disability.1,2 Physical therapy and occupational therapy efforts in the pediatric population also target reshaping of the nervous system, which is capable of reorganization and change through a variety of neural plasticity mechanisms, especially in the developing brain.3–5
The overriding consensus is that more, or mass-practiced, therapy leads to better clinical outcomes.6,7 However, a major limitation of any therapeutic or exercise program can be patient motivation, level of engagement, and adherence. This limitation is crucial when one considers that the key concepts behind motor learning theories include active participation in the therapy and repetition of voluntary movements.1,8 Recent studies on constraint-induced movement therapy (CIMT) and robotic therapy have shown that intensive, goal-directed rehabilitation therapies substantially improve patients' motor function and their inclusion in the community.3 Constraint-induced movement therapy is a therapy approach that utilizes task-specific exercises to capitalize on the plasticity of the central nervous system and has been shown to improve function in children with CP.3,9,10 Casting of the child's stronger limb promotes use of the affected limb, which—along with intensive one-on-one sessions with therapists—improves adherence and engagement. Robotic therapy also has been shown to increase functional strength and improve isolated movements in children with CP.11 Robots provide consistent assistance and movement guidance, can increase task difficulty based on the patient's progress, and utilize sophisticated virtual reality interfaces to increase the patient's motivation.3,12 Unfortunately, CIMT, robotic therapy, and other similar approaches are time-intensive or institution-based, and hence costly.13 Thus, there is a need for an engaging, inexpensive, and home-based approach to neuromuscular therapy.
Home-based neuromuscular therapy allows for increased therapy along with reduced involvement of therapists and caregivers, providing children with a sense of autonomy over their therapy.14 A randomized controlled trial of Mitii (“Move it to improve it”), a Web-based multimodal therapy that allows for therapists to monitor progress and adjust modules to provide incremental challenge for children in a home-based setting, resulted in improvements in motor and processing skills, goal attainment, and a trend toward improved speed and dexterity in the impaired upper limb of children with unilateral CP.15 Similarly, in a school environment, a preliminary study using Kinect Xbox 360 videogames (Microsoft Corp, Redmond, Washington), showed a significant improvement in hand motor performance quality in activities such as turning pages, feeding, and stacking checkers.16 Although a randomized, single-blind trial studying the effect of Wii Sports Resort (Nintendo, Kyoto, Japan) on upper limb training in a similar population showed no improvement in coordination, strength, or hand function, the caregivers in this study perceived that the children used their hands more and remained engaged enough to complete all of the play sessions.17 It is not surprising that a measurable difference in hand function was not achieved using a non–joint-specific Wii controller, as children with upper extremity (UE) impairments tend to compensate for deficits in hand movements by exaggerated shoulder and trunk movements.18 Collectively, these findings suggest that motor function improvements of a specific joint can be maximized by targeting the therapy to repetitive movements of that joint. In the case of play, this equates to coupling the movement of the specific joint with play, and thus decoupling the possibility of play with compensatory movements.
Our approach was to develop goal-directed, therapeutic toy and game controllers that require specific and repetitive joint movements to trigger toy or game activation. This approach capitalizes on one of the primary learning avenues of children, play, providing intrinsic motivation and maximizing the dose of intervention.19 These controllers aim to provide an inexpensive home-based therapy to supplement institutional physical therapy or occupational therapy. In the present configuration, the controllers enable play with remote-controlled toys and computer games using wrist extension and flexion. Play thresholds, or wrist flexion and extension positions that trigger toy or game response, can be adjusted for each child, and all wrist motions during play are recorded and stored on the controller. Previously, a proof-of-concept study for these play controllers was completed in a group of children with typical development.20 The study evaluated play controller function, goal-directed wrist motion, and children's enjoyment of several different toys and games. Significant differences were found in the play activity among the toys and games, but they were all found to be equally enjoyable. Although these findings determined which toys and computer games elicit the greatest number of goal-directed movements and confirmed the assumption that play activity would increase with enjoyment, the study was limited to children who were developing typically.
The aim of the current study was to evaluate controller play activity, quantified by frequency of triggered play events, for several different toy and computer games in a group of children with upper extremity motor impairments (UEMIs), specifically of the wrist. We sought to understand the relationship between wrist impairment, quantified by measures of range of motion (ROM) and spasticity, and controller play activity. Additionally, we sought to evaluate how the children's ratings of fun and difficulty of play would relate to controller play activity and impairment, as perceptions of “fun” have been related to product usability and children's engagement in physical activity.21,22
Method
Participants
With institutional review board approval, children (N=21, 12 male, 9 female; 4–12 years of age) with UEMIs were recruited from Meeting Street (Providence, Rhode Island) and the Children's Rehabilitation Center at Hasbro Children's Hospital (Providence, Rhode Island) to participate in the study. The UEMIs included in the study were attributed to diagnoses, including, but not limited to, CP, developmental coordination disorders, chromosomal disorders, pediatric stroke, spina bifida, and traumatic brain injury (Table). Eligibility requirements specified that the children have the cognitive ability to follow instructions and have limitations of UE function, specifically those who (as identified by the occupational therapist or physical therapist at each site) would benefit from increasing isolated wrist motions of flexion and extension. For children with bilateral UEMIs, the more impaired wrist and forearm, again as identified by the occupational therapist or physical therapist at each site, were evaluated.
Details of Participants' Age, Sex, Diagnosis, AROM Measurements, Modified Ashworth Scale Scores, Play Threshold Frequency, and DVS Ratingsa
Study Design
All children participated in a structured in-clinic play session20 (at either Meeting Street or the Children's Rehabilitation Center at Hasbro Children's Hospital), during which they played with 2 toys and 2 computer games for approximately 5 minutes each. The sessions were conducted in designated rooms, free of distraction, with ample floor space for playing with the remote-controlled toys and a height-adjustable, wheelchair-accessible table for the computer games. The order of the toys and games was randomized prior to participant arrival. Before the start of the play session, measurements of spasticity and ROM were collected on the impaired wrist and forearm of each participant by an occupational therapist or physical therapist. Spasticity was quantified using the Modified Ashworth Scale (MAS)23 for the wrist flexors, wrist extensors, forearm pronators, and forearm supinators. Measurements of active range of motion (AROM) for wrist flexion and extension and forearm supination and pronation also were collected using goniometry.
At the start of the play session, the impaired wrist and forearm of each child (or more impaired wrist and forearm of children with bilateral impairments) was fitted with a specially designed play controller that wirelessly interfaces with toys and games (Fig. 1A).24 These controllers (total weight=185 g) comprise 4 main components: a removable and customizable foam handle, plastic wrist hinge, soft fabric forearm cuff, and electronics closure. Wrist flexion and extension motion during play is measured by a rotational potentiometer (10-kΩ linear taper, 300°±5°) housed in the wrist hinge. The play controller was designed to accommodate various wrist and forearm sizes, as well as differing levels of contractures among children with UEMIs. During the fitting process, the handle was customized to visually align the axis of the rotary potentiometer with the palpated distal tip of the radial styloid (an estimate of the location of the wrist flexion and extension axis), and the controller was secured in this position using the forearm cuff system.20
Controller, remote-controlled toys, and computer games. (A) Specially designed play controller used to wirelessly control toys and games. A potentiometer in line with the flexion and extension axis records wrist motion. Wrist position thresholds to trigger play are set using buttons on the electronics case. (B) Remote-controlled toys: Bounce Back Racer (toy 1) and GoGo (toy 2). (C) Computer games: Bouncing Balls (game 1) and Snowman (game 2). Modified from Crisco et al.20
Therapists utilized the controller's software and their own clinical judgment to set participant-specific play thresholds for wrist flexion and extension positions near, but within, the range of the child's maximum ROM.24 This adjustability was incorporated into the design to allow children with varying degrees of wrist motion and spasticity to have a complete play experience, while providing the therapist with an easy approach to expand the child's play thresholds as the ROM improves with treatment. The controller logs and time-stamps wrist position data for wrist movements greater than 4 degrees. The design of the controller has been previously detailed, and the accuracy of wrist measurements were found to be within 5 degrees of a standard motion capture system.24
Two different toys and 2 different computer games were used with the controller during the in-clinic play session. These toys and games were selected from the previous feasibility study,20 which evaluated how fun each toy and game was and to what extent they elicited repetitive targeted joint motions. Toy 1 (Bounce Back Racer, Hasbro Inc, Pawtucket, Rhode Island) (Fig. 1B) is a 2-sided (ie, no top or bottom), 1-degree-of-freedom, remote-controlled car that moves either forward or backward at a constant speed once the wrist flexion or extension threshold is exceeded. Toy 2 (GoGo, Hasbro Inc) (Fig. 1B) is an animatronic remote-controlled dog that turns left or right when the participant holds his or her wrist beyond the wrist flexion or extension threshold.
Game 1 (Bouncing Balls, NanoGames Inc, Christchurch, New Zealand) is a computer game where the controller is used to aim a cannon that shoots colored balls at a conglomerate of balls moving down from the top of the screen (Fig. 1C). When groups of 3 or more identically colored balls are created, the group disappears. Game 2 (Snowman, NanoGames Inc) (Fig. 1C) is a downhill skiing game where the controller is used to steer a snowman left and right in order to collect snowman body parts (sticks, coal, carrots), while avoiding trees.
The children played with each toy and game for approximately 5 minutes. The time period varied among toys and games and among participants, but it was mainly influenced by external factors such as time constraints of the child, parent, or clinic schedule. Therefore, time was not examined as an outcome variable, as it was unlikely to be representative of the child's engagement.
Data Analysis
Wrist flexion and extension motion during play was recorded and downloaded for analysis by toy or game. For each toy or game, play activity was reduced to a single variable: play threshold frequency. Play threshold frequency was computed as the number of wrist movements for which the peak flexion and extension values were greater than the thresholds (thus eliciting a response from the toy or game), divided by the time of play. This measure represents how many goal movements are met per second of play.
After each play session, the child was asked to answer a series of questions to assess the difficulty and fun of each toy or game.20 The same 3 play-rating questions were asked for each toy or game: (1) “How much fun was this toy/game?” (2) “How hard was it to use this toy/game?” and (3) “How much do want to play with this toy/game again?” Children responded using a discrete visual scale (DVS), similar to a Likert-type rating. The DVS is based on modification of the Wong-Baker pain assessment scale25 and comprises colored smiley faces that correspond to ratings of 1 through 5, with 5 being the most favorable (Fig. 2). This method allowed nonverbal participants to point to the number or smiley face on the scales. A similar adaptation of 5 smiley faces has been used by Read and MacFarlane26 to measure “fun” in children's response to an activity. In addition, Holder and colleagues27 used a similar face scale to assess “happiness” and showed concurrent validity with 2 other measures of psychometric adjustment.
A discrete visual scale was used to assess fun and difficulty of play. Other questions included “How hard was it to use this toy?” and “How much do you want to play with this toy again?”
Statistical Analyses
Comparisons of the play threshold frequency among toys and games were done using independent Kruskal-Wallis tests with a post hoc Dunn test for multiple comparisons. Significance in the mean differences was set a priori at P<.05, and when multiple comparisons are described, only the largest P value is reported. The AROM data were quantified by maximum joint angle and total ROM. Maximum joint angle was the maximum angle reached in each direction of flexion, extension, supination, and pronation. Full range of motion was defined as the total ROM in each direction of movement, from maximum flexion to maximum extension (flexion and extension ROM) and from maximum supination to maximum pronation (supination and pronation ROM). The relationships of ROM measurements with play thresholds and play threshold frequency were examined by linear regression. The relationship between spasticity (MAS score) and play threshold frequency was analyzed with Spearman correlation coefficients. The significance level was P<.05.
To examine whether the answers to the play perception questions differed by toy or game, clinical assessments, and play threshold frequency, generalized models were used with repeated measures from the same participants modeled as having correlated error (generalized estimating equations). The generalized model predictions of the play perception ratings of each question are reported as means and standard deviations. Alpha was maintained at .05 across comparisons using the Holm method to adjust P values.
Role of the Funding Source
The research reported in this publication was supported by The Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under Award Number R21HD071582. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Results
Overall
The average angle between the flexion and extension play thresholds was 49 degrees (SD=18.7). There were no trends or significant relationships between participants' play thresholds and their AROM or MAS scores (P values ranged from .174 to .699). Despite the many discernible differences among the 2 toys and 3 games, there were no significant differences in play threshold frequency among the toys and games (P>.05). Therefore, play threshold frequency was averaged across all toys and games for each child in the subsequent analyses. The study-wide average play threshold frequency for all children was 0.27 Hz (SD=0.11).
Clinical Measures
Measurements of ROM and MAS were collected on 19 of the 21 children. Two participants were not able to complete the clinical measures because of scheduling conflicts (Table); therefore, their data were not included in the comparisons. The participants in this study displayed a wide range of wrist and forearm AROM (Table). A larger full ROM in wrist flexion and extension was associated with increased play threshold frequency, but the relationship was not significant (P=.09, R2=.16, Fig. 3A). A significant correlation was found between play threshold frequency and maximum supination angle during AROM measurements (P<.001, R2=.585, Fig. 3B), where a greater ability to supinate was associated with a higher play threshold frequency. There was no correlation between MAS scores (Table) and play threshold frequency for all of the games and toys (P values ranged from .201 to .629).
(A) Play activity, quantified by play threshold frequency, increased with larger active range of motion in flexion and extension. (B) Additionally, play activity increased with larger maximum supination angle measured during active range of motion.
Discrete Visual Scale
The mean play perception rating did not differ significantly among the toys and games for question 1 (P=.9088), question 2 (P=.7849), or question 3 (P=.4374); therefore, a mean score (standard deviation) for each question across all games and toys for each child was reported. The mean of the perception ratings were all relatively high (Fig. 4), ranging from 3.8 (SD=1.0) to 4.5 (SD=0.5).
Mean toy perception ratings for each participant for question 1 (“How much fun was this toy?”), question 2 (“How hard was it to use this toy?”), and question 3 (“How much do you want to play with this toy again?”). DVS=discrete visual scale.
There were no significant correlations between the mean play perception ratings and AROM or MAS scores (P values ranged from .279 to .938). Additionally, there were no significant correlations with play threshold frequency and play perception ratings for each question (P values ranged from .3 to .8).
Discussion
Twenty-one children of varying ages and UEMIs were able to play with the toy controllers, found them to be fun and enjoyable (as evidenced by ratings and observations), and were motivated to repeatedly move their wrists to the targeted wrist flexion and extension positions set on the controllers. Mean play threshold frequency across all toys and computer games in the play sessions was 0.27 Hz. In other words, if a therapist were to prescribe 15 minutes of play with the toy controller per day, the targeted joint motions would be performed approximately 1,700 times per week. Our study sample represented a range of UE function, and we found that larger wrist flexion and extension ROM tended to correlate with higher play threshold frequency. This anticipated association did not reach statistical significance, but this is likely a consequence of the small sample size (N=20). Interestingly, play activity was found to correlate with maximum forearm supination angle, where children with greater supination angles had increased play threshold frequency. Although relationships between some measures of ROM and play threshold activity were found, all of the children in the study, regardless of degree of UEMI, were able to complete the targeted motions and play with the toys and games. Ratings of enjoyment and difficulty for each toy and game were not related to the children's clinical measurements. In general, the ratings of fun for all of the toys and games were positive. As noted by Read et al,21 when products are developed for use by children, “fun” may be a product requirement and can be a parallel measure of usability. Similarly, perceived “fun” has been studied and found to be an important motivational variable in sports participation or physical activity for children.22,28 The outcomes from this feasibility study indicate that the play controllers were enjoyable and adaptable enough to be usable, while still challenging, for children with a range of UEMIs.
The primary strengths of the play controllers include not only the promotion of goal-directed, joint-specific movement, but the ability to monitor and evaluate “dose” or number of repetitions of movement. Previous studies have suggested that therapy involving many low-resistance repetitions of a particular motion will enhance local muscular endurance and lead to functional recovery.29 At a frequency of 0.27 Hz, a 15-minute session would elicit approximately 270 active repetitions. Although this is a lower repetition rate than in animal studies that have shown motor cortex reorganization after sessions eliciting 400 to 600 repetitions,30,31 it far surpasses previous observational studies in stroke rehabilitation that have shown averages of active UE repetitions from 17.5 to 54 per outpatient or inpatient session.32,33 Peters and colleagues34 counted UE active movement repetitions during 36-minute video gaming sessions and reported an average of 61.9 repetitions for the Nintendo Wii and 302 UE repetitions for the PlayStation 2 EyeToy (Sony Computer Entertainment, Tokyo, Japan). It should be noted for these studies that these repetitions represented repetitions of global UE motion and not joint-specific motion. Besides quantifying therapeutic “dose” and monitoring adherence, data recorded by the controller can be used by the therapist and caregivers to modify the play thresholds accordingly to increase or decrease the targeted motion.
Interestingly, this study did not demonstrate a correlation between play thresholds and measures of ROM and spasticity. Therapists and researchers were instructed to simply set the play thresholds “at a comfortable position near, but within, the child's maximum range of motion” for each child at the beginning of the session.24 Although question 2 indicated that toy or game play was challenging for all children, a limitation of this study is that these thresholds may not have been consistent across all participants. As this study was limited to a single visit, there was only a single flexion and extension play threshold set for each child. Ideally, children would play with the controller and toys and games over a period of time and their thresholds would be adjusted by a parent or therapist (either in the clinic or remotely through a Web-based therapy tracking application) as their function improves. It is important to note that for the answers to question 2, the ability of the children to move their wrists is directly tied to toy and game play. Although the answers did not differ across the toys and games for each child, the current approach does not allow for the distinction of whether the answers were more weighted to reflect how challenging the physical aspect of the activity was or how challenging the game or toy was to play with. An additional limitation of this study is the study sample's range of UEMIs, whereas many of the participants had substantial ROM and little spasticity. Therefore, the results reported herein may not be representative of children with more severe UEMIs.
Lastly, although it was beneficial to include a wide range of ages to evaluate size adaptability of the controller, it should be acknowledged that the large age range could have affected the outcomes of this study. It also is important to note that the test population's chronological ages and developmental ages were likely quite different. Although preliminary analysis revealed no association between age and play threshold frequency or ratings of fun and difficulty, a larger sample size would be necessary to discern the effect of age. Ultimately, this was a cross-sectional feasibility study; as such, a longitudinal study will be needed to demonstrate efficacy of the play controllers as therapeutic devices.
Although play activity in this study cannot be directly compared with the previous study by Crisco et al20 of children with typical development (N=20) of comparable age (5–11 years), as slightly different measures were used, play activity was generally (but not significantly) lower for the children with UEMIs than for the children without UEMIs. The ratings of fun and ease of use were comparable between the children with typical development and the children with UEMIs, indicating that children both with and without motor impairment found the games and toys fun and challenging. The previous study evaluated an additional computer game, Lineup (NanoGames Inc), which was similar to Connect Four (NanoGames Inc). This game was excluded from the current study because it elicited the lowest number of goal-directed movements.20 As stated above, the previous study quantified play activity with a slightly different measure (ie, ROM frequency) than the current study. Frequency of ROM was quantified as the number of flexion-extension cycles within 10% of the child's maximum ROM divided by the time over which play occurred. The limitation of ROM frequency is that the play thresholds determine how far a child has to flex or extend before the toy responds. Once the toy responds, there is no motivation to continue to increase the joint angle; thus, this measure is dependent on the thresholds being set close to the child's maximum ROM. The current study utilized play threshold frequency, that is, the number of flexion and extension cycles that reached or surpassed the set play thresholds divided by the time over which play occurred. This measure more accurately reflects the number of goal-directed, targeted motions that occurred during play.
This technology has the potential to deliver repetitive, motion-specific training in a fun, challenging, and engaging way that can be done inexpensively in a home or clinical setting. The controllers' joint-specific requirement stemmed from observations that although global, whole-body exercise, facilitated with systems such as the Nintendo Wii,35,36 has clear benefits, repetitive targeted therapy of specific muscle groups is essential in all stages of a rehabilitation program.37 The short-term goal of this approach is that these controllers reduce stress associated with therapy while promoting happiness and enjoyment through play, ultimately improving adherence and maximizing dose of therapy. In the long term, the goal of the joint-specific controllers is that they facilitate gains in AROM, improve motor control, and decrease spasticity. An additional advantage of these play controllers is that they were designed to control commercially available toys and computer games. The idea that children with UEMIs can be playing with the same toys as their peers while getting therapeutic benefit adds a positive social element to this therapeutic approach. This element may benefit children with physical disabilities who have not been able to engage in “typical” play activities and thus experience secondary social and emotional disabilities.19 It should be noted that this technology is applicable to other joints of both lower extremities and UEs and to patients of any age, as it has been shown that neurodevelopment continues throughout the life span.3
In conclusion, the outcomes from this feasibility study indicate that the play controllers elicited repetitive, goal-directed movements and were adaptable, enjoyable, and challenging for children of varying ages and UEMIs. The associations between ROM, specifically in ability to supinate, and play threshold frequency should be addressed in future studies and incorporated into the design of the therapeutic play controllers for the wrist. It has been demonstrated that wrist and forearm posture affects wrist ROM, and it has been established that wrist motion is coupled between the planes of motion.39–41 Therefore, future studies should evaluate ulnar and radial deviation during play controller use, specifically as the typical posture pattern for hemiplegic CP is forearm in pronation, wrist in flexion, and ulnar deviation.42 Incorporation of accelerometry as an additional degree of freedom could allow for monitoring of posture and promote targeted forearm position during play. Future longitudinal studies are needed to evaluate the efficacy of these controllers as therapeutic devices. Although the measures of ROM and spasticity used in this study provided a general understanding of the UE limitations of these children, the inclusion of such a wide group of diagnoses prohibited the use of a functional classification scale such as the Manual Abilities Classification System43 used for children with CP. To evaluate efficacy, the target population would have to be narrowed to individuals with UEMIs attributed to a single diagnosis, and a classification scale, such as the MACS, would provide a clearer measure of impairment.
Footnotes
All authors provided concept/idea/research design and writing. Dr Wilcox, Dr Wilkins, Mr Basseches, Mr Schwartz, Ms Brideau, and Professor Crisco provided data collection. Dr Wilcox, Mr Basseches, and Professor Crisco provided data analysis. Dr Wilcox, Mr Schwartz, Dr Kerman, and Professor Crisco provided project management. Dr Kerman and Professor Crisco provided fund procurement. Dr Wilkins, Dr Kerman, and Ms Brideau provided participants. Dr Wilkins, Dr Kerman, and Professor Crisco provided facilities/equipment. Dr Kerman provided institutional liaisons. Mr Basseches, Dr Kerman, and Dr Trask provided consultation (including review of manuscript before submission).
The authors are indebted to Richard Maddocks and his associates at Hasbro Inc, Pawtucket, Rhode Island, for their support. The author gratefully acknowledge and thank Emily Lennon, OTR/L, and Albert Hulley, PTA, at Meeting Street, and Heather Brennan, MS, OTR/L, and Casey O'Rourke, OTR/L, at Hasbro Children's Rehabilitation Center for all of their support on this project.
This study was approved by the Institutional Review Board at Rhode Island Hospital (Providence, Rhode Island).
The research reported in this publication was supported by The Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under Award Number R21HD071582. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Professor Crisco is an inventor on a patent describing a method for facilitating fitting of the play controller to a child's arm using a malleable inner structure. The patent is owned by his employer, Rhode Island Hospital, Providence, Rhode Island.
- Received September 2, 2015.
- Accepted May 5, 2016.
- © 2016 American Physical Therapy Association
References
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