1. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering UPPER LIMB REHABILITATION IN CHILDREN WITH CEREBRAL PALSY USING A MULTI-TOUCH TABLE Lucia Bonzi, Gloria Vergara-Diaz, Alan Dunne, Michelle Coldwell, Giacomo Severini, Donna Nimec, Jim Niemi, Paolo Bonato Department of Physical Medicine and Rehabilitation Harvard Medical School, Spaulding Rehabilitation Hospital Wyss Institute for Biologically Inspired Engineering Harvard Medical School

2. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering We have no relevant financial disclosure We have received permission to use the pictures

3. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering Cerebral Palsy (CP) and Rehabilitation Gaming Technology Group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain ( Rosenbaum et al. 2007) Different treatments for improving functional performance, range of motion and coordination of upper limb in children with CP Therapy involves a child performing repeated movements of their arms, hands and fingers ( Sakzewski et al. 2014) Children can be motivated and interested making this movements into videogames Rehabilitation Gaming Technology ( Zocolillo et al. 2015; Valdes et al. 2014; Preston et al. 2014; Chiu et al. 2014)

4. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering Rehabilitation Multitouch Technology (Leitner et al. 2007; Annett et al. 2009; Alcañiz et al. 2009; Dunne et al. 2010)

5. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering OBJECTIVE This study aims to assess the usability of a multi-touch table as a therapeutic tool toward a more effective and quantifiable rehabilitation of the upper limb by engaging children in task-specific exercises while playing interactive games

6. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering SYSTEM

7. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering STUDY PROTOCOL  Design: Cross-sectional study  Setting: Pediatric rehabilitation hospital (outpatient)  Inclusion/Exclusion Criteria: 6-12 y.o. with an upper extremity dysfunction due to Cerebral Palsy able to fulfill directions in English, without severe vision impairments  Written parental consent and child assent  Main Outcome Measures:  Compensatory trunk movements  Compensatory motions with the unaffected arm  Visual Analog Scale (VAS) of satisfaction  Number of movement repetitions using the affected arm Fun Boring Easy Uncomf. Difficult Comfortable

8. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering STUDY PROTOCOL Interventions:  Demographic and clinical data  Box and Blocks Test  Sensors: 7 wireless sensors  5 interactive games  Video recordings: Quality of movements  Subjects’ feedback

9. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering SAMPLE DESCRIPTION  Population:10 Subjects  Median Age: 9 [7-12] years old  Gender: 60% males  Spastic: 80% hemiparesis, 20% tetraparesis  Box and Block test:  Dominant arm 34.1±12.9; Non dominant 18.7±17.80 (p=0.009)

10. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering QUALITY OF MOVEMENT AND SATISFACTION  Compensatory Movements: 30% trunk and 60% unaffected hand  Satisfaction: High rates measured with a VAS  100% would like to play the games again, either during regular therapy or like home therapy  90% would like to do it instead of regular therapy FunEasyComfortable Fruits 90.5 [82-95]53.5 [7-94]90.5 [85-95] Boats 94 [89-95]93.5 [29-96]95 [85-97] Butterflies 88.5 [86-95]58.5 [7-81]85 [78-95] Puzzle 91.5 [89-97]87 [65-95]90 [80-96] Hockey 93.5 [90-95]72 [13-88]90 [89-931]

11. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering SENSOR DATA  No significant differences  Number of repetition  Number of repetition in 1 minute  Correlation ‘Fun‘ and ‘easy‘ rating of - Hockey and Butterflies and the number of repetition - Butterflies and number of repetitions in 1 minute GAMESMOVEMENT AFFECTED ARM * NON AFFECTED ARM * FruitsRepetitionLateral19 [16,29]24 [20,28] Rep in 1 minuteLateral5.15 [ 4.2-7.3]5.35 [4.2-7.9] BoatsRepetitionVertical41 [23,80]83.5 [27,138] Rep in 1 minuteVertical7 [ 4.4-10.3]11.2 [8.9-713.1] ButterfliesRepetitionVertical17.5[8,32]34 [18,52] Rep in 1 minuteVertical5.25 [ 3.5-6.7]11.3 [9.7-13.7 Puzzle RepetitionLateral22.5 [15,27]37 [29,47] RepetitionVertical17.5[ 9-57]38 [19-94] Rep in 1 minuteLateral5.15 [4,7.1]8.8 [7.9,9.6] Rep in 1 minuteVertical5.2 [ 1.9-8.2]9.55 [5.3-15.3] Hockey RepetitionLateral18.5 [14,21]24 [20,25] RepetitionVertical21 [ 16-36]59 [17-101] Rep in 1 minuteLateral3.1 [2.7,5.6]5.75 [3.4,8.5] Rep in 1 minuteVertical3.95 [ 3.2-7.9]9.05 [4.8-14.5] * Median [P25-P75] p Value > 0.05 r = 0.37; r = 0.37 r = 0.30

12. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering CONCLUSIONS The Multi-Touch Table appears to be a helpful tool to engage children with CP in therapy, allowing a more effective treatment and therefore improving outcomes for upper extremity rehabilitation  Level of Evidence : Level IV

13. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering Acknowledgments Clinicians at Spaulding Rehabilitation Hospital and Children’s Hospital (Boston) Peabody Foundation and the Wyss Institute Gloria Vergara-Diaz, MD gvergaradiaz@partners. org Thank you for your attention

14. PB2014 PM&R, Harvard Medical School Spaulding Rehabilitation Hospital Motion Analysis Laboratory Wyss Institute for Biologically Inspired Engineering Summary of Citations & Level of Evidence 1.Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy April 2006. Developmental medicine and child neurology. Supplement. 2007;109:8-14. 2.Sakzewski L, Gordon A, Eliasson AC. The state of the evidence for intensive upper limb therapy approaches for children with unilateral cerebral palsy. J Child Neurol. 2014 Aug;29(8):1077-90; LOE – Level 1. 3.Zoccolillo L, Morelli D, Cincotti F, Muzzioli L, Gobbetti T, Paolucci S, Iosa M. Video-game based therapy performed by children with cerebral palsy: a cross-over randomized controlled trial and a cross-sectional quantitative measure of physical activity. Eur J Phys Rehabil Med. 2015 Feb 5; LOE – Level 2-4. 4.Valdés BA, Hilderman CG, Hung CT, Shirzad N, Van der Loos HF. Usability testing of gaming and social media applications for stroke and cerebral palsy upper limb rehabilitation. Conf Proc IEEE Eng Med Biol Soc. 2014;2014:3602-5; LOE – Level 4. 5.Preston N, Weightman A, Gallagher J, Holt R, Clarke M, Mon-Williams M, Levesley M, Bhakta B. Feasibility of school-based computer-assisted robotic gaming technology for upper limb rehabilitation of children with cerebral palsy. Disabil Rehabil Assist Technol. 2014 Jun 25:1-8; LOE – Level 4. 6.Chiu HC, Ada L, Lee HM. Upper limb training using Wii Sports Resort for children with hemiplegic cerebral palsy: a randomized, single-blind trial. Clin Rehabil. 2014 Oct;28(10):1015-24; LOE – Level 2. 7.Dunne A, Do-Lenh S, O' Laighin G, Shen C, Bonato. Upper extremity rehabilitation of children with cerebral palsy using accelerometer feedback on a multitouch display. Conf Proc IEEE Eng Med Biol Soc. 2010;2010:1751-4. 8.Annett M et al. Using a Multi-touch Tabletop for Upper Extremity Motor Rehabilitation. OZCHI 2009, November 23-27, 2009, Melbourne, Australia. 9.Leitner M et al. Designing tangible tabletop interfaces for patients in rehabilitation. Conference & Workshop on Assistive Technologies for People with Vision & Hearing Impairments Assistive Technology for All Ages CVHI 2007, M.A. Hersh (ed.). 10.Alcañiz M, Abarca V, Lozano JA, Herrero N. Analysis of multitouch technology for neurorehabilitation. Journal of Cybertherapy & Rehabilitation. Fall 2009, Volume 2, Issue 3.