Research Report

B.J. Wilcox, PhD, Bioengineering

Joint-Specific Play Controller for Laboratory, Department of Ortho-

paedics, The Warren Alpert Medi-
cal School of Brown University and
Upper Extremity Therapy: Feasibility Rhode Island Hospital, 1 Hoppin
St, CORO West, Ste 404, Provi-

Study in Children With Wrist dence, RI 02903 (USA). Address all

correspondence to Dr Wilcox at:
bethany_wilcox@brown.edu.
Impairment M.M. Wilkins, PT, DPT, Meeting
Street, Providence, Rhode Island.
Bethany J. Wilcox, Megan M. Wilkins, Benjamin Basseches, Joel B. Schwartz,
Karen Kerman, Christine Trask, Holly Brideau, Joseph J. Crisco B. Basseches, BS, Bioengineering
Laboratory, Department of Ortho-
paedics, The Warren Alpert Medi-
cal School of Brown University and
Background. Challenges with any therapeutic program for children include the level of Rhode Island Hospital.
the childs 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 J.B. Schwartz, BS, Bioengineering
controllers that require specific and repetitive joint movements to trigger toy/game activation. Laboratory, Department of Ortho-
paedics, The Warren Alpert Medi-
cal School of Brown University and
Objective. The goal of this study was to evaluate a specially designed wrist flexion and Rhode Island Hospital.
extension play controller in a cohort of children with upper extremity motor impairments
K. Kerman, MD, Department of
(UEMIs). The aim was to understand the relationship among controller play activity, measures Pediatrics, The Warren Alpert
of wrist and forearm range of motion (ROM) and spasticity, and ratings of fun and difficulty. Medical School of Brown Univer-
sity and Rhode Island Hospital.
Design. This was a cross-sectional study of 21 children (12 male, 9 female; 4 12 years of C. Trask, PhD, Department of Psy-
age) with UEMIs. chiatry and Human Behavior, The
Warren Alpert Medical School of
Methods. All children participated in a structured in-clinic play session during which Brown University, and Depart-
measurements of spasticity and ROM were collected. The children were fitted with the ment of Psychiatry, Rhode Island
controller and played with 2 toys and 2 computer games for 5 minutes each. Wrist flexion and Hospital.
extension motion during play was recorded and analyzed. In addition, children rated the fun H. Brideau, MS, Bioengineering
and difficulty of play. Laboratory, Department of Ortho-
paedics, The Warren Alpert Medi-
cal School of Brown University and
Results. Flexion and extension goal movements were repeatedly achieved by children Rhode Island Hospital.
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 J.J. Crisco, PhD, Bioengineering
was associated with ROM measures, specifically supination, but toy perception ratings of Laboratory, Department of Ortho-
enjoyment and difficulty were not correlated with clinical measures. paedics, The Warren Alpert Medi-
cal School of Brown University and
Rhode Island Hospital.
Limitations. The reported results may not be representative of children with more severe
[Wilcox BJ, Wilkins MM, Basseches
UEMIs.
B, et al. Joint-specific play control-
ler for upper extremity therapy:
Conclusions. These outcomes indicate that the therapeutic controllers elicited repetitive feasibility study in children with
goal movements and were adaptable, enjoyable, and challenging for children of varying ages wrist impairment. Phys Ther.
and UEMIs. 2016;96:17731781.]

2016 American Physical Therapy

Association

Published Ahead of Print:

May 19, 2016
Accepted: May 5, 2016
Submitted: September 2, 2015

Post a Rapid Response to

this article at:
ptjournal.apta.org

November 2016 Volume 96 Number 11 Physical Therapy f 1773

Joint-Specific Play Controller for UE Therapy
C erebral palsy (CP) and related eti-
ologies can lead to impaired mus-
cle function of the extremities
including weakness, spasticity, contrac-
tures, joint deformities, and deficiencies
in somatosensory function.1 Physical
therapy and occupational therapy re-
main the primary noninvasive treatments
for these impairments. The need for ther-
apy is especially important during motor
development as children strive to learn
and master new and more challenging
motor tasks. Therapy is aimed at reduc-
ing the impact of these impairments, pre-
venting deterioration of existing motor
function, inhibiting acquired problems
such as joint contractures, and decreas-
ing disability.1,2 Physical therapy and
occupational therapy efforts in the pedi-
atric 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.35
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 lim-
itation is crucial when one considers that
the key concepts behind motor learning
theories include active participation
in the therapy and repetition of volun-
tary movements.1,8 Recent studies on
constraint-induced movement therapy
(CIMT) and robotic therapy have shown
that intensive, goal-directed rehabilita-
tion therapies substantially improve
patients motor function and their inclu-
sion in the community.3 Constraint-
induced movement therapy is a therapy
approach that utilizes task-specific exer-
cises 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 childs stron-
ger limb promotes use of the affected
limb, whichalong with intensive one-
on-one sessions with therapistsim-
proves 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 assis-
tance and movement guidance, can
increase task difficulty based on the
1774 f Physical Therapy Volume 96 Number 11
patients progress, and utilize sophisti-
cated virtual reality interfaces to increase
the patients motivation.3,12 Unfortu-
nately, 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 ther-
apists to monitor progress and adjust
modules to provide incremental chal-
lenge for children in a home-based set-
ting, 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, Washing-
ton), showed a significant improvement
in hand motor performance quality in
activities such as turning pages, feeding,
and stacking checkers.16 Although a ran-
domized, single-blind trial studying the
effect of Wii Sports Resort (Nintendo,
Kyoto, Japan) on upper limb training in a
similar population showed no improve-
ment in coordination, strength, or hand
function, the caregivers in this study per-
ceived 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 differ-
ence in hand function was not achieved
using a nonjoint-specific Wii controller,
as children with upper extremity (UE)
impairments tend to compensate for def-
icits in hand movements by exaggerated
shoulder and trunk movements.18 Collec-
tively, these findings suggest that motor
function improvements of a specific joint
can be maximized by targeting the ther-
apy 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 con-
trollers that require specific and repeti-
tive joint movements to trigger toy or
game activation. This approach capital-
izes on one of the primary learning ave-
nues of children, play, providing intrin-
sic motivation and maximizing the dose
of intervention.19 These controllers aim
to provide an inexpensive home-based
therapy to supplement institutional phys-
ical therapy or occupational therapy. In
the present configuration, the control-
lers 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 func-
tion, goal-directed wrist motion, and chil-
drens 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 activ-
ity would increase with enjoyment, the
study was limited to children who were
developing typically.
The aim of the current study was to eval-
uate 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 mea-
sures of range of motion (ROM) and spas-
ticity, and controller play activity. Addi-
tionally, we sought to evaluate how the
childrens ratings of fun and difficulty of
play would relate to controller play activ-
ity and impairment, as perceptions of
fun have been related to product
usability and childrens engagement in
physical activity.21,22
November 2016

Method
Participants
With institutional review board
approval, children (N21, 12 male, 9
female; 4 12 years of age) with UEMIs
were recruited from Meeting Street
(Providence, Rhode Island) and the Chil-
drens Rehabilitation Center at Hasbro
Childrens Hospital (Providence, Rhode
Island) to participate in the study. The
UEMIs included in the study were attrib-
uted to diagnoses, including, but not lim-
ited to, CP, developmental coordination
disorders, chromosomal disorders, pedi-
atric stroke, spina bifida, and traumatic
brain injury (Table). Eligibility require-
ments specified that the children have
the cognitive ability to follow instruc-
tions 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 flex-
ion and extension. For children with
bilateral UEMIs, the more impaired wrist
and forearm, again as identified by the
occupational therapist or physical thera-
pist at each site, were evaluated.
Study Design
All children participated in a structured
in-clinic play session20 (at either Meeting
Street or the Childrens Rehabilitation
Center at Hasbro Childrens Hospital),
during which they played with 2 toys
and 2 computer games for approxi-
mately 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 com-
puter games. The order of the toys and
games was randomized prior to partici-
pant 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, fore-
arm 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.
November 2016
Joint-Specific Play Controller for UE Therapy
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 con-
troller that wirelessly interfaces with
toys and games (Fig. 1A).24 These con-
trollers (total weight185 g) comprise 4
main components: a removable and cus-
tomizable foam handle, plastic wrist
hinge, soft fabric forearm cuff, and elec-
tronics closure. Wrist flexion and exten-
sion motion during play is measured by a
rotational potentiometer (10-k linear
taper, 3005) housed in the wrist
hinge. The play controller was designed
to accommodate various wrist and fore-
arm 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 con-
troller was secured in this position using
the forearm cuff system.20
Therapists utilized the controllers soft-
ware and their own clinical judgment to
set participant-specific play thresholds
for wrist flexion and extension positions
near, but within, the range of the childs
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 provid-
ing the therapist with an easy approach
to expand the childs 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 com-
puter games were used with the control-
ler 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 elic-
ited repetitive targeted joint motions.
Toy 1 (Bounce Back Racer, Hasbro Inc,
Volume 96
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 ani-
matronic 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 repre-
sentative of the childs engagement.
Data Analysis
Wrist flexion and extension motion dur-
ing 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 ques-
tions were asked for each toy or game:
Number 11 Physical Therapy f 1775
1776
Table.

f
Details of Participants Age, Sex, Diagnosis, AROM Measurements, Modified Ashworth Scale Scores, Play Threshold Frequency, and DVS Ratingsa

Average
Participant AROM () Modified Ashworth Scale Play Average DVS Rating (SD)
Threshold,
ID Age Wrist Wrist Wrist Wrist Frequency Question Question Question
No. (y) Sex Diagnosis Pronation Supination Flexion Extension Flexors Extensors Pronators Supinators (SD) 1 2 3
1 9 F Pediatric stroke 90 90 90 90 1 1 1 1 0.40 (0.13) 5.0 (0.0) 3.5 (1.9) 5.0 (0.0)

Physical Therapy
2 9 M Cerebral palsy with right- 90 90 90 10 1 1 1 1 0.40 (0.14) 4.8 (0.5) 4.0 (2.0) 4.5 (1.0)
sided hemiplegia
3 9 F Cerebral palsy with right- 90 90 90 25 3 1 2 1 0.09 (0.03) 5.0 (0.0) 3.7 (2.3) 5.0 (0.0)
sided hemiplegia

Volume 96
4 4 M Cerebral palsy with left- n/a n/a n/a n/a n/a n/a n/a n/a 0.19 (0.07) 5.0 (0.0) 2.3 (1.5) 4.7 (0.6)
sided hemiplegia
5 4 M Pediatric stroke 90 0 90 10 3 1 3 1 0.11 (0.03) 4.0 (1.2) 3.0 (1.6) 4.0 (2.0)
6 10 F Cerebral palsy with left- n/a n/a n/a n/a n/a n/a n/a n/a 0.17 (0.08) 3.5 (0.6) 3.0 (0.8) 3.5 (0.6)
sided hemiplegia

Number 11
7 8 M Cerebral palsy with right- 90 90 90 100 2 1 2 1 0.33 (0.14) 4.3 (1.0) 4.8 (0.5) 3.8 (1.5)
Joint-Specific Play Controller for UE Therapy

sided hemiplegia
8 10 M Cerebral palsy with right- 90 90 90 100 1 1 1 1 0.45 (0.25) 5.0 (0.0) 3.8 (1.5) 4.8 (0.5)
sided hemiplegia
9 5 M Cerebral palsy 90 75 45 90 2 3 1 1 0.38 (0.12) 3.8 (1.9) 2.5 (1.3) 3.0 (2.3)
10 12 F Upper extremity 90 90 40 60 1 1 1 1 0.41 (0.15) 3.0 (1.6) 2.8 (0.5) 3.3 (1.7)
weakness,
developmental delay
11 9 F Pediatric stroke 90 90 90 90 3 4 3 3 0.35 (0.18) 5.0 (0.0) 4.8 (0.5) 5.0 (0.0)
12 11 M Cerebral palsy 90 90 70 100 1 1 1 1 0.34 (0.07) 5.0 (0.0) 4.8 (0.5) 4.5 (1.0)
13 7 F Nemaline myopathy 90 90 80 75 1 1 1 1 0.23 (0.16) 5.0 (0.0) 5.0 (0.0) 5.0 (0.0)
14 9 M Perisylvian syndrome, 90 90 85 90 1 1 1 1 0.35 (0.15) 3.3 (2.1) 3.3 (1.5) 3.8 (1.5)
Chiari I malformation
15 9 F Spina bifida, Chiari 45 45 90 90 1 1 1 1 0.22 (0.08) 3.5 (1.7) 3.3 (1.7) 3.8 (1.9)
malformation
16 11 M Traumatic brain injury 90 30 25 50 2 2 2 3 0.05 (0.03) 5.0 (0.0) 4.3 (1.0) 5.0 (0.0)
17 9 M Cerebral palsy 90 90 35 65 1 1 1 1 0.35 (0.08) 4.8 (0.5) 4.8 (0.5) 4.8 (0.5)
18 7 F Microdeletion on 45 45 60 90 1 1 1 1 0.15 (0.04) 4.8 (0.5) 4.8 (0.6) 4.8 (0.5)
chromosome 16
19 6 F Developmental delay 45 45 60 45 1 1 1 1 0.25 (0.07) 5.0 (0.0) 5.0 (0.0) 4.5 (1.0)
20 8 M Down syndrome, delayed 45 45 80 70 1 1 1 1 0.20 (0.05) 5.0 (0.0) 2.0 (2.0) 5.0 (0.0)
motor development
21 12 M Spina bifida, Chiari II 90 90 90 70 1 1 1 1 0.25 (0.13) 5.0 (0.0) 5.0 (0.0) 5.0 (0.0)
malformation
a
AROMactive range of motion, DVSdiscrete visual scale, Ffemale, Mmale, n/anot applicable.

November 2016
 Joint-Specific Play Controller for UE Therapy

Figure 2.
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?

done using independent Kruskal-Wallis

tests with a post hoc Dunn test for mul-
tiple 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 quanti-
Figure 1. fied by maximum joint angle and total
Controller, remote-controlled toys, and computer games. (A) Specially designed play con- ROM. Maximum joint angle was the max-
troller used to wirelessly control toys and games. A potentiometer in line with the flexion and
imum angle reached in each direction of
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
flexion, extension, supination, and pro-
GoGo (toy 2). (C) Computer games: Bouncing Balls (game 1) and Snowman (game 2). nation. Full range of motion was defined
Modified from Crisco et al.20 as the total ROM in each direction of
movement, from maximum flexion to
maximum extension (flexion and exten-
(1) How much fun was this toy/game? the scales. A similar adaptation of 5 smi- sion ROM) and from maximum supina-
(2) How hard was it to use this toy/ ley faces has been used by Read and tion to maximum pronation (supination
game? and (3) How much do want to MacFarlane26 to measure fun in chil- and pronation ROM). The relationships
play with this toy/game again? Children drens response to an activity. In addi- of ROM measurements with play thresh-
responded using a discrete visual scale tion, Holder and colleagues27 used a sim- olds and play threshold frequency were
(DVS), similar to a Likert-type rating. The ilar face scale to assess happiness and examined by linear regression. The rela-
DVS is based on modification of the showed concurrent validity with 2 other tionship between spasticity (MAS score)
Wong-Baker pain assessment scale25 and measures of psychometric adjustment. and play threshold frequency was ana-
comprises colored smiley faces that cor- lyzed with Spearman correlation coeffi-
respond to ratings of 1 through 5, with 5 Statistical Analyses cients. The significance level was P.05.
being the most favorable (Fig. 2). This Comparisons of the play threshold fre-
method allowed nonverbal participants quency among toys and games were To examine whether the answers to the
to point to the number or smiley face on play perception questions differed by toy

November 2016 Volume 96 Number 11 Physical Therapy f 1777

Joint-Specific Play Controller for UE Therapy

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 pre-
dictions of the play perception ratings of
each question are reported as means and
standard deviations. Alpha was main-
tained 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 Num-
ber 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 (SD18.7). 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 sig-
nificant differences in play threshold fre-
quency among the toys and games
(P.05). Therefore, play threshold fre-
quency 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 (SD0.11).
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 sched-
uling conflicts (Table); therefore, their
data were not included in the compari-
sons. The participants in this study dis-
played 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
Figure 3.
(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 maxi-
mum supination angle measured during active range of motion.
threshold frequency and maximum supi- There were no significant correlations
nation angle during AROM measure- between the mean play perception rat-
ments (P.001, R2.585, Fig. 3B), ings and AROM or MAS scores (P values
where a greater ability to supinate was ranged from .279 to .938). Additionally,
associated with a higher play threshold there were no significant correlations
frequency. There was no correlation with play threshold frequency and play
between MAS scores (Table) and play perception ratings for each question
threshold frequency for all of the games (P values ranged from .3 to .8).
and toys (P values ranged from .201 to
.629). Discussion
Twenty-one children of varying ages and
Discrete Visual Scale UEMIs were able to play with the toy
The mean play perception rating did not controllers, found them to be fun and
differ significantly among the toys and enjoyable (as evidenced by ratings and
games for question 1 (P.9088), ques- observations), and were motivated to
tion 2 (P.7849), or question 3 (P repeatedly move their wrists to the tar-
.4374); therefore, a mean score (standard geted wrist flexion and extension posi-
deviation) for each question across all tions set on the controllers. Mean play
games and toys for each child was threshold frequency across all toys and
reported. The mean of the perception computer games in the play sessions was
ratings were all relatively high (Fig. 4), 0.27 Hz. In other words, if a therapist
ranging from 3.8 (SD1.0) to 4.5 were to prescribe 15 minutes of play
(SD0.5). with the toy controller per day, the tar-

1778 f Physical Therapy Volume 96 Number 11 November 2016


Figure 4.
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?). DVSdiscrete visual scale.
geted 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 (N20). Interestingly, play
activity was found to correlate with max-
imum 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 diffi-
culty for each toy and game were not
related to the childrens clinical measure-
ments. 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. Simi-
larly, perceived fun has been studied
and found to be an important motiva-
tional variable in sports participation or
physical activity for children.22,28 The
outcomes from this feasibility study indi-
cate that the play controllers were enjoy-
able and adaptable enough to be usable,
while still challenging, for children with
a range of UEMIs.
November 2016
Joint-Specific Play Controller for UE Therapy
The primary strengths of the play con-
trollers include not only the promotion
of goal-directed, joint-specific move-
ment, but the ability to monitor and eval-
uate dose or number of repetitions of
movement. Previous studies have sug-
gested that therapy involving many low-
resistance repetitions of a particular
motion will enhance local muscular
endurance and lead to functional recov-
ery.29 At a frequency of 0.27 Hz, a
15-minute session would elicit approxi-
mately 270 active repetitions. Although
this is a lower repetition rate than in
animal studies that have shown motor
cortex reorganization after sessions elic-
iting 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 repeti-
tions for the Nintendo Wii and 302 UE
repetitions for the PlayStation 2 EyeToy
(Sony Computer Entertainment, Tokyo,
Japan). It should be noted for these stud-
ies that these repetitions represented
repetitions of global UE motion and not
joint-specific motion. Besides quantify-
ing therapeutic dose and monitoring
adherence, data recorded by the control-
ler can be used by the therapist and care-
givers to modify the play thresholds
accordingly to increase or decrease the
targeted motion.
Volume 96
Interestingly, this study did not demon-
strate a correlation between play thresh-
olds and measures of ROM and spasticity.
Therapists and researchers were
instructed to simply set the play thresh-
olds at a comfortable position near, but
within, the childs maximum range of
motion for each child at the beginning
of the session.24 Although question 2
indicated that toy or game play was chal-
lenging for all children, a limitation of
this study is that these thresholds may
not have been consistent across all par-
ticipants. As this study was limited to a
single visit, there was only a single flex-
ion 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 thresh-
olds 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 distinc-
tion 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 samples 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 out-
comes of this study. It also is important
to note that the test populations chro-
nological ages and developmental ages
were likely quite different. Although pre-
liminary analysis revealed no association
between age and play threshold fre-
quency 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
Number 11 Physical Therapy f 1779
Joint-Specific Play Controller for UE Therapy
to demonstrate efficacy of the play con-
trollers as therapeutic devices.
Although play activity in this study can-
not be directly compared with the pre-
vious study by Crisco et al20 of children
with typical development (N20) of
comparable age (511 years), as slightly
different measures were used, play activ-
ity was generally (but not significantly)
lower for the children with UEMIs than
for the children without UEMIs. The rat-
ings of fun and ease of use were compa-
rable 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 chal-
lenging. 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 num-
ber of goal-directed movements.20 As
stated above, the previous study quanti-
fied 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
childs maximum ROM divided by the
time over which play occurred. The lim-
itation 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 childs maximum ROM. The
current study utilized play threshold fre-
quency, that is, the number of flexion
and extension cycles that reached or sur-
passed 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 train-
ing 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 sys-
1780 f Physical Therapy Volume 96
tems such as the Nintendo Wii,35,36 has
clear benefits, repetitive targeted ther-
apy 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 asso-
ciated 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 con-
trollers is that they facilitate gains in
AROM, improve motor control, and
decrease spasticity. An additional advan-
tage 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 therapeu-
tic approach. This element may benefit
children with physical disabilities who
have not been able to engage in typical
play activities and thus experience sec-
ondary social and emotional disabili-
ties.19 It should be noted that this tech-
nology 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 adapt-
able, enjoyable, and challenging for chil-
dren 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, spe-
cifically 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.
Number 11
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 understand-
ing of the UE limitations of these chil-
dren, the inclusion of such a wide group
of diagnoses prohibited the use of a func-
tional 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.
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 procure-
ment. Dr Wilkins, Dr Kerman, and Ms
Brideau provided participants. Dr Wilkins, Dr
Kerman, and Professor Crisco provided facil-
ities/equipment. Dr Kerman provided insti-
tutional liaisons. Mr Basseches, Dr Kerman,
and Dr Trask provided consultation (includ-
ing review of manuscript before submission).
The authors are indebted to Richard Mad-
docks and his associates at Hasbro Inc, Paw-
tucket, Rhode Island, for their support. The
author gratefully acknowledge and thank
Emily Lennon, OTR/L, and Albert Hulley,
PTA, at Meeting Street, and Heather Bren-
nan, MS, OTR/L, and Casey ORourke,
OTR/L, at Hasbro Childrens Rehabilitation
Center for all of their support on this project.
This study was approved by the Institutional
Review Board at Rhode Island Hospital (Prov-
idence, 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 Insti-
tutes 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 childs arm using a
malleable inner structure. The patent is
November 2016

owned by his employer, Rhode Island Hos-
pital, Providence, Rhode Island.
DOI: 10.2522/ptj.20150493
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