CASE SERIES: STANDARD VERSUS VIRTUAL REALITY SUPPLEMENTED HAND ARM BIMANUAL INTENSIVE THERAPY IN CHILDREN WITH UNILATERAL CEREBRAL PALSY

Background & Purpose: Hand arm bimanual intensive therapy (HABIT) has demonstrated efficacy in improving upper limb function in children with unilateral cerebral palsy (UCP)1,2. However, the traditional HABIT camp format presents challenges, leading to limited accessibility for families3,4. Camps are typically held once a year due to the need for substantial time and resources. Moreover, emerging evidence suggests that the effects of HABIT may last only 3-6 months5. To address these challenges, a team of research engineers, occupational and physical therapists developed HABIT in virtual reality (HABIT-VR), a software that delivers HABIT-style treatment through virtual reality video games. HABIT-VR was designed to adhere to the core motor learning principles of HABIT while making it more accessible year-round and outside camp settings. This case series aims to preliminary investigate the effect on upper extremity function after a camp using HABIT-VR compared to a standard HABIT camp.

Case Description: Three children with UCP participated in two summer camps: a HABIT-VR camp in 2021 and a standard HABIT camp in 2022. Child 1 (9-10 yrs, female) had right hemiplegia and a MACS level of 2. Child 2 (10-11 yrs, female) had right hemiplegia with a co-diagnosis of seizure disorders and a MACS level of 3. Child 3 (7-8 yrs, male) had right hemiplegia and a MACS level of 2. Both camps were 4 hours per day for 10 weekdays. The standard HABIT camp was 40 hrs of self-selected bimanual, age-appropriate activities. The HABIT-VR camp was 20 hrs of self-selected bimanual, age-appropriate activities and 20 hrs of self-selected bimanual, age-appropriate virtual reality games. Upper extremity function was assessed a week pre- and post-camp using the Box and Blocks Test (BBT) and the 9 Hole Peg Test (9HPT).

Outcomes: After the standard HABIT camp, the three subjects moved 3.6% fewer blocks with their dominant hand and 9.8% more with their non-dominant hand in the BBT. They placed 1.6% fewer pegs per second with their dominant hand and 4% fewer pegs/second with their non-dominant hand on the 9HPT after the camp. After the HABIT-VR camp, the children moved 2.9% more blocks with their dominant hand and 8% more with their non-dominant hand in the BBT. They placed 7% more pegs per second with their dominant hand and 0% more with their non-dominant hand on the 9HPT after the HABIT-VR camp.

Discussion: The results of BBT indicated similar manual dexterity changes in both camps, excluding divergent change in the BBT with the dominant hand. Minimal changes in the 9HPT indicate that neither camp influenced fine motor skills. The preliminary findings suggest that this HABIT-VR camp was comparable to the standard HABIT camp for manual dexterity improvements. This study provides early evidence that HABIT-VR could be an alternative approach to be implemented at home, especially for families that do not have access or resources for standard camps.