Invest Clin 63(2): 185 - 201, 2022 https://doi.org/10.54817/IC.v63n2a08
Corresponding author: Sen Li. Shanghai Lixin University of Accounting and Finance, Shanghai 201620, China.
Email: lisen@lixin.edu.cn
Effect of video games training on the gross
motor skills of children with cerebral palsy:
systematic review and meta-analysis.
Yong He Pan1, Guang Feng Zhao2, Qiang Liu3 and Sen Li3
1 Shanghai Hesheng Sports Technology Co.LTD, Shanghai, China.
2 Shandong Sport University, Jinan, China.
3 Shanghai Lixin University of Accounting and Finance, Shanghai, China.
Key words: video games training; gross motor skills; cerebral palsy; intervention;
randomized controlled trial.
Abstract. The purpose of this work was to systematically evaluate the
intervention effects of video games training (VGT) on the gross motor skills
(GMS) development of children with cerebral palsy (CP). Seven Chinese and
English databases (PubMed, Embase, Web of Science, Cochrane Library, Chi-
na National Knowledge Infrastructure, Wanfang, EBSCO) were searched. Data
were retrieved from randomized controlled trials on the GMS among individu-
als with CP. The retrieval was from the inception of each database to March
16, 2021. The included studies were evaluated quantitatively using the PEDro
Scale. Then, relevant data were inputted and analyzed in Review Manager 5.4.
Thirteen papers were included: seven written in English and six in Chinese. In
the three subordinate concept of GMS, VGT could significantly improve loco-
motor skills (LS) (standardized mean difference = 0.80, 95% confidence inter-
val 0.55–105, P<0.00001), and non-locomotor skills (NLS) (standardized mean
difference = 0.83, 95% confidence interval 0.38–1.28, P=0.0003) in CP. How-
ever, there was no significant difference in object control skills (OCS), when
compared with the control group (standardized mean difference = 0.55, 95%
confidence interval -0.01–0.72, P=0.05). VGT can improve LS and NLS in CP,
but the effect on OCS is uncertain; therefore, it is recommended that addition-
al high-quality literature be included in the future. In general, VGT has been
proven an effective intervention tool on the GMS development in CP.
186 He Pan et al.
Investigación Clínica 63(2): 2022
Efecto del entrenamiento con videojuegos en la motricidad
gruesa de niños con parálisis cerebral: revisión sistemática
y meta-análisis.
Invest Clin 2022; 63 (2): 185 – 201
Palabras clave: entrenamiento con videojuegos; habilidades motoras gruesas; parálisis
cerebral; intervención; prueba controlada aleatoria.
Resumen. Este artículo intentó evaluar sistemáticamente el efecto de la
intervención del entrenamiento con videojuegos (VGT) en el desarrollo de las
habilidades motoras gruesas (GMS) de niños con parálisis cerebral (CP), basán-
dose en un cuerpo de datos logrado de las conclusiones de pruebas controladas
aleatorias sobre las habilidades motoras gruesas de niños con CP, obtenidos de
la búsqueda sistemática en siete bases de datos chinos y extranjeros, tales como
PubMed, Embase, Web of Science, Cochrane Library, China National Knowled-
ge Infrastructure, Wanfang y EBSCO. El lapso de búsqueda fue desde la fecha de
establecimiento de cada base de datos hasta el 16 de marzo del 2021. Se aplicó
la escala PEDro para realizar un estudio cuantitativo y después, se analizaron
los datos relevantes con Review Manager 5.4. Se incluyeron 13 publicaciones,
7 artículos escritos en inglés y 6 en chino. En el marco del concepto de los tres
subordinados de GMS, la VGT podría mejorar significativamente la habilidad
locomotora (LS) (diferencia de medias estandarizada = 0.80, intervalo de con-
fianza del 95%: 0.55-105, P<0.00001), y las habilidades no locomotoras (NLS)
(diferencia de medias estandarizada = 0.83, intervalo de confianza del 95%:
0.38-1.28, P= 0,0003) en PC; pero no hubo una diferencia significativa en las
habilidades de control de objetos (OCS), cuando se compararon con el grupo
control (diferencia de medias estandarizada= 0,55, intervalo de confianza del
95% -0,01-0,72, P= 0,05). En conclusión, el VGT puede mejorar las LS y NLS en
CP, pero el efecto sobre OCS es incierto; por lo que se recomienda la inclusión
de literatura adicional de alta calidad en el futuro. De este modo se pudo de-
mostrar que el VGT es una herramienta de intervención eficaz en el desarrollo
de las GMS en niños con CP.
Received: 22-11-2021 Accepted: 18-12-2021
INTRODUCTION
Cerebral palsy (CP), is a group of per-
sistent central motor and postural devel-
opmental disorders and activity limitation
syndrome, which is caused by non-progres-
sive brain damage in developing fetuses or
infants 1. According to the statistics of the
World Health Organization (WHO), the inci-
dence rate of CP is around 0.2%-0.3% world-
wide, and there are more than forty thou-
sand new CP children in China every year 2.
Most of the children with CP have problems
such as dyskinesia, abnormal posture and
abnormal hemiplegic gait 3. The damage to
the advanced central nervous system of chil-
dren with CP may cause secondary injuries,
such as physical spasm, amyotrophy, skeletal
Effect of video games training on the gross motor skills of children with cerebral palsy 187
Vol. 63(2): 185 - 201, 2022
deformities and developmental coordination
disorder, which constrain the children’s abil-
ity to move, thereby impacting upon their
development of gross motor skills (GMS) 4-6.
The good development of GMS will promote
children and adolescents to participate in
activities actively, but the GMS disorder is
an important factor hindering children with
CP from participating in physical activities 7.
If they do not participate in physical activi-
ties for a long time, children with CP will not
only lag behind their peers in strength, co-
ordination and endurance, but also face the
risk of many mental diseases, such as depres-
sion, social phobia, and so on 8. Therefore,
it is very important to pay attention to the
development of GMS in children with CP.
People pay great attention to and sup-
port various sports activities to improve the
physique and abilities of special groups 9. The
quantity and quality of motor experience are
important for brain plasticity and functional
recovery 10, so motor skill intervention is
often provided to develop the gross motor
function of children with CP. However, tra-
ditional motor intervention therapy often
requires the help of various games and facili-
ties, and requires a large activity space and
experienced therapists to accurately control
the treatment process, so as to ensure the
participants’ interest in the treatment pro-
cess and the smooth progress of the treat-
ment 6. Most importantly, the level of motor
skills of children with CP is very poor, and
the highly structured and repetitive activi-
ties of traditional rehabilitation are difficult
to adhere to and to motivate their participa-
tion 11. A potential area of intervention may
lie in the attractiveness of playing and chil-
dren’s preference for and participation in
technology 12.
“Active video games” (AVGs), also
known as “exergaming” or “virtual reality
games” realize sports entertainment with
the help of high-tech technologies, such as
human–computer interaction, motion sens-
ing and virtual reality 13. AVGs can provide an
ecological environment similar to that in the
real world, where participants can practice
specific tasks, and the difficulty of tasks can
be adjusted readily in the game and provide
sufficient challenges 14. Such immersive ex-
perience in a safe, enjoyable, and playful en-
vironment is associated with less fatigue and
more relaxation, which may attract children,
including those with CP 15. Simultaneously,
due to the characteristics and animation ef-
fects of the game, it can also increase chil-
dren’s motivation and participation in the
gaming process, attract users to immerse
themselves in the sports environment 16, and
improve their cognitive function and motor
skills. Hence, video games training (VGT)
are very suitable as rehabilitation tools for
children, and gradually have developed into
a popular therapy of motor skill intervention
for special populations 17. A review of the lit-
erature on children with cerebral palsy sug-
gests that AVGs interventions can improve
GMS development, including their balance,
coordination and other physical fitness 18.
Many scholars have done research on
video game training to improve the GMS of
children with CP. However, the past research
often focused on one aspect of GMS, such
as the impact on stability skills, the impact
on upper limb skills, etc., and they lack of
a summary and discussion of the effects of
video games to improve the overall GMS of
children with CP. GMS refers to the move-
ment generated by large muscles or muscle
groups of the body, including walking, run-
ning, jumping, throwing, etc. According to
the change of spatial position and the con-
trol of external tools, the GMS can be divid-
ed into locomotor skills (LS), object control
skills (OCS) and non-locomotor skills (NLS)
19. It can be seen that GMS is a general term
that includes three subordinate concepts.
This research was aimed to explore the ef-
fects of VGT on the GMS development of
children with CP by employing a systematic
review and meta-analysis, and demonstrate
the effectiveness of VGT in intervening the
three subordinate concepts of GMS in chil-
dren with CP. In addition, if one aspect of
188 He Pan et al.
Investigación Clínica 63(2): 2022
GMS is significantly improved, the dose ef-
fect of intervention duration, intervention
frequency and intervention cycle will be dis-
cussed by subgroup analysis.
METHODS
Criteria for including studies
The criteria for including literature
were: (i) the study population was aged
3–14 years with CP; (ii) at least one of GMS
was objectively measured and reported
separately; (iii) the intervention was not a
single intervention; (iv) the study was pub-
lished and peer-reviewed in English or Chi-
nese; (v) the study was a randomized con-
trolled trial (RCT).
Criteria for excluding studies
The criteria for excluding studies were:
(i) evaluation of motor skill is a combination
of gross motor skill and fine motor skill; (ii)
data on the change of GMS before and after
the test (e.g., mean ± SD) were absent; (iii)
the subjects were not 3-14 years old.
Outcome indicators
(i) Index of LS, including walking, run-
ning, jumping, shuttle run, etc.; (ii) Index of
OCS, including throwing, catching, hitting
and beating, etc.; (iii) Index of NLS, includ-
ing balance beam standing, on one or both
feet, etc.
Literature-retrieval strategy
The databases we used were PubMed,
Cochrane Library, Embase, Elton Bryson
Stephens Company, Web of Science, China
National Knowledge Infrastructure, and
Wanfang. We retrieved data from random-
ized controlled trials (RCTs) from the incep-
tion of each database to March 16, 2021.
The search strategy was based on the
principle of PICOS (Population, Interven-
tion, Comparison, Outcomes and Study de-
sign). We employed three groups and used
search terms for them.
Group 1 was based on VGT: “active video
game*” (视频游戏), OR “exergam*”, （体感
游戏）OR “virtual realit*” OR “virtual ther-
ap*”, OR “virtual environment*”, OR “video
game*”, OR “computer game*”, OR “serious
gam*”, OR “Wii”, OR “Kinect”, OR “PlaySta-
tion”, OR “EyeToy”, OR “GestureTek”, OR
“IREX”.
Group 2 was based on GMS: “gross mo-
tor”（粗大动作）OR “motor coordination”,
OR “motor skill”. OR “movement skill”, OR
“fundamental motor skill”, OR “fundamen-
tal motor skill”, OR “fundamental movement
skill”, OR “motion capture”, OR “balance”.
Group 3 was based on the subject: “chil-
dren with CP” (脑瘫儿童), OR “children with
cerebral palsy” (脑性瘫痪儿童), OR “spastic
diplegia*”, OR“spastic diplegic”, OR“spastic
quadriplegic”.
Literature screening
Two researchers used independent dou-
ble-blind methods to screen the literature
based on the inclusion and exclusion crite-
ria stated above, and relevant data were ex-
tracted. If there was a disagreement on the
review, screening, and data-extraction stag-
es, a third researcher discussed whether to
include the data.
Data extraction
The data extracted from the literature
was the author names, year of publication,
and the basic characteristics of samples
(gaming platform, game type, outcome in-
dicators, and intervention environment/pe-
riod/duration/frequency) (Table 1).
Quality evaluation
All the literature included in our study
consisted of RCTs. The PEDro Scale was used
for evaluation of literature quality, and com-
prised 11 items. The PEDro scale has a to-
tal score of 10 points: <4 indicates “poor”
quality; 4–5 indicates “medium” quality;
6–8 indicates “good” quality; 9–10 indicates
“high” quality (Table 2).
Effect of video games training on the gross motor skills of children with cerebral palsy 189
Vol. 63(2): 185 - 201, 2022
Researchers Subjects Intervention
Setting
AVGs Platform AVGs Category Control group Intervention Outcome
Indicators
GMS
E/C Age (y) Cycle Time
Frequency
Alsaif et al.
(24) 2015
20/20 6-10 Home Nintendo Wii
Fit
Unreported Non-intervention 12 20 7 MABC,
BOT-2
②③
Arnoni et al.
(25) 2019
7/8 5-14 Unreported Xbox 360
Kinect
Jumping, Loading
exercises
Regular Exercise 8 45 2 GMFM-88, BSA ①③
Chen et al.
(26) 2013
15/15 3-6 Medical Clinic Q4 Scene
Interactive
Training
System
Billiard Ball,
Hopscotch
Regular Exercise 12 30 5 BBS,GMFM-88 ①③
Chen et al.
(27) 2016
20/20 3-6 Medical Clinic Q4 Scene
Interactive
Training
System
Billiard Ball,
Hopscotch
Regular Exercise 12 40 5 BBS,GMFM-88 ①③
Chiu et al.
(28) 2014
30/27 6-13 Home Nintendo Wii
Sports
Bowling, Aerial
sports, Frisbee
and Basketball
Regular treatment 6 40 3 TT ②
Pourazar et al.
(29) 2019
10/10 7-12 Medical Clinic Xbox 360
Kinect
Dance
rehabilitation
training
Regular treatment 6 85-
100
1 SEBT ③
Ren et al.
(30) 2016
19/16 3-6 Medical Clinic Q4 Scene
Interactive
Training
System
Unreported Regular Exercise+
Occupational
Therapy
12 40 5 BBS,GMFM-88 ①③
Rojas et al.
(31) 2017
16/16 7-14 Rehabilitation
centre
Nintendo Wii
Balance Board
Snowboard,
Penguin Slide,
Super Hula
Hoop,Yoga
Standard
Physiotherapy
6 30 3 COP ③
Table 1
List of basic characteristics of the included documents.
190 He Pan et al.
Investigación Clínica 63(2): 2022
Researchers Subjects Intervention
Setting
AVGs Platform AVGs Category Control group Intervention Outcome
Indicators
GMS
E/C Age (y) Cycle Time
Frequency
Urgen et al.
(32) 2016
15/15 7-14 Unreported Nintendo Wii
Fit
Jogging plus,
Penguin slide,
Heading, Ski
jump, Snowball
fight, Tilt city,
Perfect 10,
Segway circuit
play
Routine
Physiotherapy and
Rehabilitation
9 45 2 GMFM,
PBS,
TUGT
①③
Uysal et al.
(33) 2016
12/12 6-14 Rehabilitation
centre
Nintendo Wii
Balance
Basketball,
Tennis, Boxing
Routine
Physiotherapy
12 30 2 PBS ③
Zhang et al.
(2) 2019
20/20 3-6 Rehabilitation
centre
KMC1 Cycling game Regular treatment 12 20 5 GMFM-88 ①
Zhao(a) et al.
(34) 2018
21/21 3-6 Rehabilitation
centre
Xbox 360
Kinect
Boxing, Javelin
bowling ,
Universe bubble
ball,Bounce ball
Regular treatment 3 40 5 GMFM-88,
QUEST
①②
Zhao(b) et al.
(35) 2018
21/21 3-6 Rehabilitation
centre
Xbox 360
Kinect
Dance music
imitation
Regular treatment 3 40 5 GMFM-88, PBS ①③
Table 1
CONTINUATION
E= Experimental group; C= Control group; CP = cerebral palsy; MABC-2 = Movement Assessment Battery for Children-2; BBS = Berg Balance Scale; PBS =
Pediatric Balance Scale; TUGT = Timed Get Up and Go Test; COP = Center Of Pressure; BOT = Bruininks–Oseretsky Test of Motor Proficiency; QUEST=Quality
of Upper Extremity Skill Test; ①Locomotor Skills; ②Object Control Skills; ③Non-locomotor skills.
Effect of video games training on the gross motor skills of children with cerebral palsy 191
Vol. 63(2): 185 - 201, 2022
Statistical analyses
We employed Review Manager 5.4 for data
processing. The boundary value of “small”,
“medium”, and “large” effect sizes was 0.2, 0.5,
and 0.8 20. Also, 75%, 50%, and 25% denoted
the proportion of “high”, “medium” and “low”
inter-study heterogeneity, respectively 21. If sig-
nificant heterogeneity between the studies was
not observed (P > 0.1, I2 < 40 %), then we used
a fixed-effects model for analyses. If there was
significant heterogeneity between studies (P<
0.1, I2 ≥40%), then a random-effects model was
used for analyses, and further subgroup analy-
ses were carried out to discover the source of
heterogeneity.
If ≥2 tasks had been used to measure
the GMS of CP, the effect size is selected
from the most commonly used tasks 22. If
the study reported multiple measurements
on the same task (e.g., the ability to balance
in left, right, front, and back directions), the
standard deviation and variance were aver-
aged to represent the outcome of the task 23.
RESULTS
Literature characteristics
A total of 840 Chinese and English
studies were obtained from seven Chinese
and English databases. Six studies were
added through other means, so 846 studies
were imported into Endnote™ X9 (https://
endnote.com/). After removal of duplicates,
631 studies were obtained. Then, 126 stud-
ies were removed after reading the title and
abstract, which left 113 studies. Then, the
full text was read. According to the inclusion
and exclusion criteria stated above, 13 stud-
ies using RCTs were included: seven written
in English and six in Chinese (Fig. 1). The
Table 2
Methodological Quality Assessment for Included Studies.
Included Studies A B C D E F G H I J K Score
Alsaif et al. 2015 1 1 0 1 0 0 0 1 1 1 1 6
Arnoni et al. 2019 1 1 1 1 1 1 0 1 1 1 0 8
Chen et al. 2013 1 1 0 1 0 0 0 1 1 1 1 6
Chen et al. 2016 1 1 0 1 0 0 0 1 1 1 1 6
Chiu et al. 2014 1 1 0 1 0 0 1 1 1 1 1 7
Pourazar et al. 2019 1 1 0 1 1 1 0 1 1 1 0 7
Ren et al. 2016 1 1 0 1 0 0 0 1 1 1 1 6
Rojas et al. 2017 1 1 0 1 0 0 0 1 1 1 1 6
Urgen et al. 2016 1 1 0 1 0 0 0 1 1 1 0 5
Uysal et al. 2016 1 1 0 1 0 1 0 1 1 1 1 7
Zhang et al. 2019 1 1 0 1 0 0 0 1 1 1 1 6
Zhao(a) et al. 2018 1 1 0 1 0 0 0 1 1 1 1 6
Zhao(b) et al. 2018 1 1 1 0 0 0 0 1 1 1 1 6
a. eligibility criteria were specified; b. subjects were allocated randomly to groups; c. allocation was concealed; d.
the groups were similar at baseline with regard to the most important outcome indicators; e. there was blinding of
all subjects; f. there was blinding of all therapists; g. there was blinding of all assessors; h. measures of at least one
key outcome were obtained from >85% of subjects initially allocated to groups; i. all subjects for whom outcome
measures were available received treatment or, if this was not the case, data for at least one key outcome were
analyzed by intention-to-treat; j. the results of between-group statistical comparisons were reported for at least one
key outcome; k. the study provided point measures and measures of variability for at least one key outcome.
192 He Pan et al.
Investigación Clínica 63(2): 2022
characteristics of the studies are shown in
Table 1.
The 13 studies involved 447 subjects.
Overall (male and female) samples were
used in all studies, and the sex ratio was ap-
proximately equal. The sample size of one
study was >50, in the other 12 studies it
was between 20 and 40. In our meta-analy-
sis, Nintendo (Kyoto, Japan) Wii™ was the
dominant and most frequently used gaming
platform. Five studies used Nintendo gaming
platforms, including Wii Balance, Wii Fit (or
Wii Fit Plus) and Wii Sports. The KMC1 (IN-
NOVAID, Denmark) virtual situational move-
ment system was used in one studies ,Q4
Scene Interactive Training System was used
in three studies, and four studies used the
Xbox™ 360 gaming platform from Microsoft
(Redmond, WA, USA). Except for two studies
that did not mention explicitly the interven-
tion environment, medical institutions such
as rehabilitation hospitals and children’s
clinics were the main intervention venues
(nine studies) and two studies used family
homes as the intervention environments.
In terms of the types of active video
games, it covered almost all sports, including
routine sports such as dancing, table tennis,
basketball, boxing, bowling, ski jumping,
obstacle course, skateboarding and so on.
Compared with traditional sports interven-
tion methods, the content scope of games
is broader, providing more choice space for
participants.
Literature Quality Evaluation
Among the 13 RCTs, only one study
was rated as “medium” quality (PEDro Scale
Fig. 1. The flow chart of literature screening.
Effect of video games training on the gross motor skills of children with cerebral palsy 193
Vol. 63(2): 185 - 201, 2022
score = 5), and the other 12 studies were
rated between 6 and 8, all of which denoted
“good” quality. The most prevalent problem
in the included RCTs was a lack of blinding.
A lack of blinding in the subject interven-
tion or evaluation of the final outcome can
increase the risk of bias in the selection and
evaluation of participants, and may impinge
an artificial influence on the experimental
results 36. The quality evaluation of studies
included in our meta-analysis is shown in
Table 2.
RESULTS OF META-ANALYSIS
Meta-analysis of the intervention effects
of VGT on LS of Children with CP
Eight randomized controlled experi-
ments were included in the study on the
intervention of VGT on LS of CP, includ-
ing 274 subjects. The analysis results are
shown in Fig. 2. Heterogeneity test results
showed that there was low heterogeneity be-
tween studies (X2=4.43, I2=0%, P=0.73),
the fixed-effect model was used to com-
bine effect size and effect size [SMD=0.80,
95%CI(0.55,1.05), P<0.00001], the differ-
ence was statistically significant, indicating
that VGT could significantly improve the LS
of CP, and the LS were significantly improved
compared with the control group. To further
explore the source of potential heterogene-
ity, a subgroup analysis of potential modera-
tors was conducted (Table 3).
Meta-analysis of the intervention effects
of VGT on OCS of Children with CP
Only three studies reported the inter-
vention effect of AVGs on OCS of children
with CP. The heterogeneity test showed
(Fig. 3) a high degree of heterogene-
ity between studies (X2 = 5.21, I2 = 62%,
P = 0.07), the random-effect model was
used to combine effect size and effect size
[SMD=0.55,95%CI(-0.01,0.72),p=0.05],
the difference was not statistically signifi-
cant. Indicating that VGT had no significant
difference in improving OCS of Children
with CP when compared with the control
group.
Fig. 2. Effects of VGT on LS of Children with CP.
Fig. 3. Effects of VGT on OCS of Children with CP.
194 He Pan et al.
Investigación Clínica 63(2): 2022
Table 3
Subgroup analyses of the intervention effects of VGT on LS of Children with CP.
Moderator variable Subgroup Included
literature
Heterogeneity test Effect
size
95% CI Two-tailed test
χ2 P I2 Z P
Gaming platform Nintendo Wii™ 1 0 0.00 0 0.67 (-0.07,1.41) 1.78 0.08
Xbox™ 360 3 0.58 0.75 0% 0.71 (0.30,1.12) 3.40 0.0007**
Q4 Scene Interactive
Training System
3 3.20 0.20 37% 0.94 (0.42,1.46) 3.54 0.0004**
KMC1 1 0 0.00 0 0.84 (0.19,1.49) 2.53 0.01*
Intervention cycle ≤8 weeks 3 0.58 0.75 0% 0.71 (0.30,1.12) 3.40 0.0007**
9-12 weeks 5 3.53 0.47 0% 0.85 (0.54,1.17) 5.35 <0.00001**
Duration of single
intervention
≤30 min 2 0.03 0.86 0% 0.87 (0.38,1.37) 3.47 0.0005**
≥40 min 6 2.78 0.73 0% 0.57 (0.29,0.86) 3.93 <0.0001**
Intervention
frequency
<3 times/week 2 0.24 0.63 0% 0.56 (-0.04,1.16) 1.84 0.07
3-5 times/week 6 3.46 0.63 0% 0.85 (0.58,1.12) 6.10 <0.00001**
*: p<0.05; **: p<0.01.
Effect of video games training on the gross motor skills of children with cerebral palsy 195
Vol. 63(2): 185 - 201, 2022
Meta-analysis of the intervention effects
of AVGs on NLS of Children with CP.
VGT were the most widely studied in-
tervention on NLS of Children with CP, and
10 randomized controlled experiments were
included in the study on the intervention of
VGT on NLS of Children with CP, including
298 subjects. The analysis results are shown
in Fig. 4. The heterogeneity test showed a
high degree of heterogeneity between stud-
ies (X2 = 28.42, I2 = 68%, P=0.0008), the
random-effect model was used to combine
effect size and effect size [SMD=0.83,95%C
I(0.38,1.28),p=0.0003], the difference was
statistically significant, indicating that VGT
could significantly improve NLS of Children
with CP, and the NLS were significantly im-
proved compared with the control group. To
further explore the source of potential het-
erogeneity, a subgroup analysis of potential
moderators was conducted (Table 4).
DISCUSSION
With the continuous development and
improvement of virtual-reality technology,
VGT are increasingly applied in the field of
sports rehabilitation, and the intervention of
VGT in special children is centered on the
mobility, balance and motor development
of children with autism 37-39, CP 23-35 and
developmental coordination disorder 40,41.
However, there are few meta-analyses on the
intervention of gross motor skills and their
subordinate concepts in VGT, and the main
purpose of this study is to evaluate quantita-
tively the results of VGT on the development
of GMS in children with CP to verify its in-
tervention effect.
Analyses of the intervention effect of VGT
on LS of CP
Locomotor Skills refers to the ability to
move and change body direction and posi-
tion quickly and effectively under control,
which requires the integration of indepen-
dent motor abilities including balance, co-
ordination, speed, reflection, strength and
endurance, and is the embodiment of com-
prehensive ability. Meta-analysis of eight
papers included in this study with LS as an
indicator, showed that VGT had a significant
effect on LS of CP (SMD=0.80). This is con-
sistent with the results of the study conduct-
ed by Wuang et al. on 155 patients with Down
syndrome aged 7-12 years. After a 24-week,
2,880 minute virtual-reality game interven-
tion, they found that the AVGs intervention
group showed significant improvements in
speed and agility compared with the non-ex-
ercise group and the standard occupational
therapy group 42.
In video game training, the standing
posture is often used to complete a lot of
weight fluctuation control, standing-squat-
ting, standing-sitting and other exercises,
Fig. 4. Effects of VGT on NLS of Children with CP.
196 He Pan et al.
Investigación Clínica 63(2): 2022
Table 4
Subgroup analyses of the intervention effects of VGT on NLS of Children with CP.
Moderator variable Subgroup Included
literature
Heterogeneity test
Effect size 95% CI
Two-tailed test
χ2 P I2 Z P
Gaming platform
Nintendo Wii™ 4 2.79 0.43 0% 0.91 (0.52,1.30) 4.60 <0.00001**
Xbox™ 360 3 24 <0.00001 92% 1.81 (-0.41,4.03) 1.60 0.11
Q4 Scene Interactive
Training System 3 0.23 0.89 0% 0.58 (0.19,0.97) 2.90 0.004**
Intervention setting
Home 1 0 0 0 0.97 (0.31,1.63) 2.89 0.004**
Medical institutions 7 24.66 0.0004 76% 1.04 (0.43,1.65) 3.36 0.0008**
Intervention cycle
≤8 weeks 4 24.06 <0.0001 88% 1.34 (0.01,2.68) 1.98 0.04*
9-12 weeks 6 4.36 0.50 0% 0.74 (0.44,1.04) 4.85 <0.00001**
Duration of single
intervention
≤30 min 4 2.38 0.50 0% 0.91 (0.54,1.28) 4.81 <0.00001*
≥40 min 6 24.49 0.0002 80% 0.86 (0.09,1.62) 2.19 0.03*
Intervention
frequency
<3 times/week 4 26.39 <0.00001 89% 1.63 (-0.03,3.29) 1.92 0.06
3-5 times/week 6 1.39 0.93 0% 0.68 (0.41,0.96) 4.88 <0.00001*
*: p＜0.05; **: p＜0.01.
Effect of video games training on the gross motor skills of children with cerebral palsy 197
Vol. 63(2): 185 - 201, 2022
which need to constantly transfer the weight
between the lower limbs. All of these stim-
ulated the player’s muscle strength, espe-
cially the lower limbs, and improved the in-
dividual’s functional muscle strength. The
integrated development of strength, bal-
ance, and coordination, coupled with the
continuous involvement of neural networks
and cognitive components, as well as visual
or auditory feedback, triggered positive neu-
roplasticity changes in participants 13. These
are important reasons to improve the speed
and agility of participants.
Analyses of the intervention effect of VGt
on OCS of CP
There is a general lack of research on
how AVGs interfere with OCS of CP, and re-
cent studies have shown varied results 43.
There are only three studies on OCS includ-
ed in this study, and the intervention effect
is limited, the conclusion does not support a
significant improvement of OCS. The reason
for this may be that the OCS are relatively
complex. When applying force to an object
or intercepting an object, it includes not
only the gross motor, such as balance and
upper limb coordination, but also the hand-
eye coordination and even the flexible ability
of fingers, which is the combination of fine
motor and gross motor 44. Simple upper limb
or arm movement training has limited im-
pact on tasks requiring hand-eye upper limb
coordination.
Another reason may be that OCS re-
quire upper or lower limbs to contact objects
for object control and perform actions such
as throwing, slapping and kicking. In this
process, the touch between the body and the
object plays an important role, which is dif-
ficult to replicate in virtual reality technol-
ogy. Neither the game handle in hand nor
the controller worn on the body can provide
timely haptic feedback, such as the weight
and size of the control object. Therefore,
some scholars began to try to use haptic
feedback gloves when using video games to
simulate ball operations in real life. By wear-
ing gloves, participants can timely feedback
more haptic information, so as to improve
the intervention effect of VGT on OCS 45.
Although the overall effect of VGT on
improving OCS in this study is not signifi-
cant, the research of Chiu et al. 27 shows that
the range and frequency of use of children’s
upper limbs have a significant increase,
compared with the past, after video game
intervention, which greatly improves their
independence level in daily activities 46, This
undoubtedly has an important impact on
the development and improvement of upper
limb function in CP. Because there is few lit-
erature on the impact of VGT on OCS, the
conclusions may have some uncertainty.
Analyses of the intervention effect of VGT
on NLS of CP
Balance ability is the ability to maintain
the human body’s posture and is a very im-
portant physiological function 47. Gait insta-
bility or difficulty in maintaining balance is
an important behavior of many special chil-
dren, so the intervention of balance ability
is an important measure to promote their
gross motor. Posture control ability and
muscle tension deficiency are considered to
be important factors affecting poor gait and
balance ability, and AVGs are considered to
improve the posture control ability in CP 48.
Among the 13 research literature included
in this study, the research on NLS is the most
concentrated (10 studies), and the interven-
tion effect was also obvious (SMD=0.83). A
reason for the impact of VGT intervention
on NLS may be that the AVGs platform is a
whole-body interactive video game, which
uses sensory motor experiences, such as vi-
sion and sound to simulate environment and
activities, and its design method can more
fully replicate the balance skills of the real
world 45. Using virtual games to perform bal-
ance training on the screen provides users
with the ability to mirror in real time and
adjust their action amplitude, speed and ac-
curacy 27,49. Lee et al. found that virtual re-
ality tools can provide more realistic visual
198 He Pan et al.
Investigación Clínica 63(2): 2022
feedback, which is the key to balance and
control skills 50.
Video game training requires players
to perform fast and accurate local or whole
body movements in the standing position,
which is very important to promote trunk
stability and posture adjustment required
for balance during movement 51. It can sig-
nificantly improve the symmetry of both
sides of the body, make the body center
of gravity evenly distributed in the lower
limbs, increase the stability of standing,
and improve the posture control ability 52.
In a systematic review of groups of CP by
Page and colleagues 43, 10 of the 15 studies,
that included balance measures, found sig-
nificant improvement, with the most com-
pelling evidence being for improvement in
balance, those data are consistent with the
results of our meta-analysis.
Research Limitations
This study had three main limitations.
First, only 13 RCTs were included in our
meta-analysis. Second, the sample size was
relatively small. Third, although the subjects
included in the studies all CP, there may be
differences in etiology and pathogenesis,
and the severity of the disease is inconsis-
tent. The final intervention effect may have
been different because of different disease
mechanisms.
CONCLUSIONS
VGT provide a safe and interesting en-
vironment, produces less fatigue and greater
load intensity and total amount by the body,
which increases the physical activity level of
game participants and improves the practice
effect. The results of this study show that
VGT is an effective rehabilitation treatment
tool in the intervention of GMS of CP. Espe-
cially in stability skills and locomotor skills,
the research conclusions are relatively con-
sistent and the intervention effects results
in a large effect. The intervention effect
of VGT on OCS is uncertain because there
are few studies published. Future research
should increase the inclusion of high qual-
ity literature and a larger sample size, and it
is expected that more scientific conclusions
can be drawn on the intervention of VGT in
the development of GMS in CP.
Funding statement
This research was funded by Shanghai
Sports Bureau Decision Consulting Project
(grant number TY202025).
Conflicts of Interest
The authors declare that they have no
conflicts of interest.
Author’s ORCID numbers
• YongHe Pan:
0000-0003-3124-2320
• GuangFeng Zhao:
0000-0002-2533-298X
• Qiang Liu:
0000-0003-3991-7847
• Sen Li:
0000-0002-8859-1292
Authors’ Contributions
All authors contributed to the concep-
tion and design of this meta-analysis. Yong-
He Pan drafted the manuscript. GuangFeng
Zhao and Qiang Liu searched the literature
and determined which studies should be in-
cluded and excluded. Sen Li proffered sug-
gestions for modification of the manuscript.
All authors approved the final version of the
manuscript.
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