cerebral palsy ( cp ) is the most common cause of neurological disability in children1 , affecting approximately 1 in 1,300 live 
 births2 . at an early age ,
abnormal hand 
 postures such as thumb adduction and/or flexion with limited wrist extension are the primary 
 manifestations of hand involvement .
daily living activities and functional independence are 
 affected by increased tonus of the upper limb , impaired posture and function3 , 4 . in children with cp , neurodevelopmental treatment ( ndt )
is the most widely used treatment 
 approach , which aims to maximize the child s potential to improve motor functions while 
 preventing musculoskeletal complications5 , 6 . in the literature ,
it has been reported 
 that intensive neurodevelopmental treatment is effective for improvement of gross motor 
 function , hand functions , and the quality of upper - extremity movement7 , 8 .
virtual 
 rehabilitation is a relatively new method that has been adopted by physical therapists who 
 specialize in cp treatment . in recent years
, there has been growing interest in therapeutic 
 use of the nintendo wii and wii fit ( wii ) as virtual rehabilitation tools .
although limited 
 in number , some studies have suggested that use of these devices , could result in 
 significant therapeutic gains in motor function for children with cerebral palsy9 , 10 .
the theories of motor control and motor learning emphasize the importance of including 
 motivating , repetitive , purposeful exercises with games and fun to support development in 
 the rehabilitation of children with cp11 , 12 . during standard physiotherapy sessions
, 
 it can be difficult to motivate a child and encourage participation in activities . 

therefore , physical therapists need various motivational techniques and methods to gain the 
 most benefit from exercises applied to improve limb use13 .
virtual reality games can be motivating and entertaining for the 
 paediatric age group , thereby holding the interest of the child during treatment10 , 14 , whilst also improving upper extremity skills and control4 , 10 , 
 skills required for daily living activities15 , and speed of upper extremity use14 . in the literature , there are studies that have evaluated use of 
 thenintendo wii and similar games consoles for improvement of upper extremity functions in 
 patients with various diagnoses14 , 16,17,18 , but there are very few that have 
 investigated the effectiveness of use of technological systems to improve upper extremity 
 functions in children with cp . the current study aimed to determine the effects on quality 
 of upper extremity skills , movement speed of the upper extremity , disability , and functional 
 independence as a result of adding virtual reality games to a neurodevelopmental treatment 
 program .
a total of 33 children with spastic hemiparesis were evaluated , and 30 were included in 
 this study between june and september 2014 ( fig . 
 1fig .
the inclusion criteria were a ) aged between 6 and 15  years , b ) level 13 of the 
 manual ability classification system , c ) level 1or 2 of the gross motor function 
 classification system16 , 19 , 20 , d ) ability to 
 grasp and release an object , and e ) no history of surgery or botulinum toxin application to 
 the upper extremity in the previous 6 months . parents or legal guardians read and signed an 
 informed consent form before the study , and the marmara university health sciences institute 
 ethics committee approved the study ( 02.05.2014 - 13 ) . flow chart describing the progression of participants through the trial
the children were divided into two groups on the basis of arrival at the clinic .
we used 
 simple randomization with a random number generator ( 115 , group 1 ; 1630 : group 2 ) .
the 
 first 15 children were assigned as group 1 , and the program applied was ndt+wii .
the second 
 15 children were assigned as group 2 and received ndt5 , 6 only .
treatment in both 
 groups was applied by a physical therapist for 45 minutes per session , twice a week , for 6 
 weeks .
the patients in group 1 played virtual reality games of tennis , baseball , and boxing 
 ( each game 5 minutes ) for 15 minutes in addition to the standard neurodevelopmental 
 treatment in each treatment session , wich was focus on the hemiplegic hand .
two experienced 
 physical therapists selected the games for moving to the hemiplegic upper extremity .
the ndt program for both groups was applied according to each child s individual needs and 
 included tonus regulation , support of sensation , perception and motor development , 
 facilitating normal movement for upper extremity activities , upper extremity functional 
 skills training , and daily living activities such as getting dressed and eating . before starting the nintendo wii games ,
the patients were informed about the content of 
 each game and had one practice session , during which the children were supported verbally 
 and physically until they achieved the correct movements . in this study , use of the upper extremity was evaluated using the quality of upper 
 extremity skills test ( quest ) , which has been tested for validity and reliability in 
 children with neuromotor dysfunction .
this test indicates four domains : dissociated 
 movement , grasp , weight - bearing , and protective extension21 .
hand function speed was assessed with the jebsen taylor hand function test ( jthft ) , which 
 has been shown to be reliable and normative for children22 , 23 . in this study ,
the 
 subtests to assess hand function included turning over cards 3  5 inches ( 7.5  cm  12.5  cm ) 
 in size , simulated feeding , picking up small common objects , stacking checkers , picking up 
 large objects , and picking up large heavy objects .
the time ( in seconds ) taken to perform 
 seven fine motor hand tasks was measured .
hand disability was assessed using the abilhand - kids test , which has been found to be valid 
 and reliable in children with cp .
turkish translation of the abilhand - kids test was 
 performed by the authors . in this test ,
21 mainly bimanual , activities are rated by the 
 children s parents on a 3-point scale ( 0=impossible , 1=difficult , 2=easy ) , describing their 
 child s perceived difficulty in performing each activity .
this is a useful tool for assessing 
 functional status in children with neurodevelopmental disabilities ; it includes 18 items 
 scored on a 7-level ordinal scale .
the reliability and stability of the scale has been 
 proven25 , 26 . in the current study ,
all assessments were performed twice : once at the start of the treatment program and again 
 at the end of the 6-week program . in addition , a user satisfaction questionnaire was 
 administered to the patients in group 1 .
this questionaire assessed parameters related to 
 virtual reality games including the level of difficulty of the game , motivation , cognitive 
 abilities , and physical effort of the player27 .
baseline characteristics were 
 compared using the independent samples t test and the chi- square test .
a comparison of the 
 groups was made using the independent samples t - test for the jebsen taylor hand function 
 test and the mann - whitney u test for the quality of upper extremity skills test , 
 abilhand - kids test , and weefim with an intention - to - treat analysis of the difference between 
 the baseline and final scores with a 95% confidence interval .
the paired sample t - test was 
 used to compare jthft outcomes before and after treatment . while the wilcoxon signed - rank 
 test was used to compare other outcomes before and after treatment .
the mann - whitney u test 
 was used to compare improvements and differences between the groups .
from the 33 patients with cp who were referred , 30 were included in the study for 
 evaluation and were divided into 2 groups ( fig . 
 1 ) .
there were no significant differences between 
 the groups with respect to demographics , clinical features , or baseline test scores ( tables 1table 1.the demographics and clinical features of the participantsndt+nw ( n=15)ndt ( n=15)age ( years ) ( mean sd)9.53  3.049.73  2.86*gender ( f / m ) ( n)7/89/6**macs ( medianscore- range)2 ( range 13)2 ( range 13)*effected extremity ( right / left)8/710/5**gmfcs9 cases-29 cases-2 * 6 cases-16 cases-1sd : standard deviation , f : female , m : male , ndt+nw : neurodevelopment treatment+nintendo 
 wii , ndt : neurodevelopment treatment , macs : manual ability classification system , gmfcs : 
 gross motor function classification system . * t - test .
sd : standard deviation , f : female , m : male , ndt+nw : neurodevelopment treatment+nintendo 
 wii , ndt : neurodevelopment treatment , macs : manual ability classification system , gmfcs : 
 gross motor function classification system .
* *  test following the 6-week treatment program , statistically significant improvement was seen in 
 the ndt+wii group in the scores for all domains of quest ( p=0.002 , p=0.003 , p=0.017 , 0.005 ) , 
 jthft ( p=0.001 ) , abilhand - kids ( p=0.001 ) , and weefim self - care ( p=0.026 ) scores . 

statistically significant improvement was determined in the dissociated movements domain of 
 the quest ( p=0.007 ) , jthft ( p=0.001 ) , abilhand - kids ( p=0.002 ) , and weefim - self - care 
 ( p=0.007 ) scores in the ndt group ( table 
 2table 2.results of outcomes for two groups before and after the treatmentndt+nw groupbefore mean ( sd)after mean ( sd)mean change ( sd)quest dissociated movements ( score)80.1 ( 7.73)85.6 ( 8.54)5.5 ( 4.40)*quest grasps ( score)42.2 ( 18.76)47.1 ( 16.64)4.9 ( 3.61)*quest weight bearing ( score)69.2 ( 19.46)72.7 ( 19.60)3.5 ( 5.79)*quest protective extension ( score)72.9 ( 14.78)77 ( 12.66)4.0 ( 4.56)*jthft ( s)40.4 ( 16.44)32.9 ( 14.88)0.7 ( 0.99)*abilhand - kids ( logits)0.56 ( 2.34)1.33 ( 2.04)0.73 ( 1.16)*weefim ( score)46 ( 8.23)46.7 ( 7.51)7.5 ( 4.82)*ndt groupquest dissociated movements ( score)81.4 ( 10.70)86.4 ( 8.78)5.0 ( 4.94)*quest grasps ( score)53 ( 16.45)55.7 ( 15.30)2.7 ( 4.62)quest weight bearing ( score)75.4 ( 17.07)77.3 ( 15.43)1.8 ( 7.15)quest protective extension ( score)71 ( 23.52)74 ( 23.36)2.9 ( 6.84)jthft ( s)31.5 ( 9.57)29.9 ( 8.83)0.4 ( 0.27)*abilhand - kids ( logits)1.07 ( 1.90)1.51 ( 1.70)0.60 ( 0.63)*weefim ( score)48.3 ( 7.27)48.9 ( 7.14)1.5 ( 1.93)*ndt+nw : neurodevelopment treatment+nintendo wii , ndt : neurodevelopment treatment , 
 quest : quality of upper extremity skills test , jthft : jebsen taylor hand function 
 test . * significantly different from pre - treatment p<0.05 ) .
ndt+nw : neurodevelopment treatment+nintendo wii , ndt : neurodevelopment treatment , 
 quest : quality of upper extremity skills test , jthft : jebsen taylor hand function 
 test . *
significantly different from pre - treatment p<0.05 the within - group analysis showed that the jthft score of the ndt+wii group was superior to 
 that of the group receiving neurodevelopmental treatment only ( p=0.000 ) .
there were no 
 significant differences between groups with respect to the other test scores .
the results of 
 the user satisfaction questionnaire completed by the ndt+wii group are shown in table 3table 3.user satisfaction questionnary : answers in frequencies ( n=15)12345wii : presentationi could see all things in the game very well---78i found the moving things / objects in the game very 
 interesting-1 - 95the things i saw in the game were very 
 attractive---213the game reacted good on my movements-2256i could hear all sounds very well-1 - 410the sounds i heard out of the game were very 
 attractive-1 - 410i could not hear where all sounds out of the game 
 did come from6333-wii : level of difficultythe game was too hard35 - 7-i still must learn a lot , before i can play this 
 game-7152i had the feeling i could win---69the game was too easy-825-player : motivationi would find it nice if i could play the game 
 together with more children at the same time----15i liked it that the game was getting more 
 difficult-2265the game was so attractive that i lost all count of 
 time---411i would not like to play this game more often1012 - 2wii training is less fun than regular 
 physiotherapy----15player : cognitive capabilitythis game was easy to understand-1 - 68this game was easy to play11 - 85it was very logical playing the game by moving my 
 arm / hand1 - 275my experience with playing the game looks like real 
 life playing13 - 56player : physical efforti found it hard to play the game by moving my 
 hands39 - 3-i became more tired from this game than from the 
 regular physiotherapy26 - 52by playing the game , i learned new movements-1 - 311i think i could learn new movements by playing the 
 game more often-1 - 3111-completely disagree , 2-slightly disagree , 3-neutral , 4-slightly agree , 5-completely 
 agree .
five children found boxing and playing tennis and baseball too easy , and 
 seven children found the games easy .
in this study , the effects of ndt and ndt+nw on upper extremity functions , speed , manual 
 ability , and level of independence in activities of daily living were comparatively 
 investigated in the children with hemiparetic cp . in the study , improvements were achieved 
 in functional ability , speed , manual ability , and the dissociated movements subgroup of the 
 quest results in the group in which ndt ( 45  min ) was applied for 6 weeks . on the other hand , 
 improvements were observed in the results of all hand functions , speed and manual ability , 
 and all subgroup scores of the quest scale in the group in which ndt+nw ( 30  min+15  min ) was 
 applied .
the satisfaction questionnaire applied to the ndt+nw group showed that the children 
 were extremely satisfied with the practice .
higher success rates were achieved in terms of 
 speed in the group in which nintendo wii was added to ndt when compared with the ndt only 
 group .
ndt is a global therapeutic approach that addresses all requirements of a child and aims to 
 increase the child s functionality and participation in daily life .
although this approach 
 is not a therapeutic modality only for hand functions , it does include some activities in 
 the session that address daily use of the hand5 , 7 , 8 . in 
 the literature
, there are few studies that contain sufficient evidence and show the healing 
 effect of the ndt approach on upper extremity functions of children28 .
however , the 
 absence of a comparable  no treatment  control group is a limitation decreasing the power of 
 our results .
data from the literature suggest that the use virtual reality positively 
 affects participation of children in treatment and provides motivation and adaptation27 , 29 . in previous studies focusing on the upper extremity in cp ,
the study 
 periods were 430 , 625 , 31 , 32 and 8 weeks12 , 
 33 .
therefore , as in the literature , we 
 preferred a study period of 6 weeks to compare nintendo wii and ndt practices .
on the other 
 hand , time spent on virtual reality generally varied between 20 minutes and 3 , 5 hours , 35 
 days per week in the studies conducted using virtual reality13 , 30 , 33,34,35 . as it has also been suggested in the literature , we thought that 
 the nintendo wii , as a game - based approach , might be a useful part of rehabilitation for 
 children with cp .
therefore , in our study , we evaluated the contribution of the nintendo wii 
 to the upper extremity when used for a period of time period ( 15  min ) during a routine ndt 
 treatment session14 .
applied 15 minutes of nintendo wii game play in addition 
 to 30 minutes of conventional neurologic treatment twice a week in children with cerebral 
 palsy and obtained significant differences in eye - hand coordination and visual motor speed 
 in comparison of a virtual reality training group with a conventional neurological physical 
 therapy group36 .
the children in our study also regarded the virtual reality games as a reward given at the 
 end of ndt practices , but not as a treatment , which may be accepted as a condition that may 
 increase motivation and cooperation .
it was also clinically observed that the subjects in 
 our study were more motivated to participate in the activities during the ndt session .
this 
 was also observed in the satisfaction questionnaires completed by the ndt+nw group at the 
 end of the study . since
computer games have recently become an important from of 
 entertainment , which may be addictive , in the lives of children lives , this interest and 
 positive motivation in the children were expected .
in addition , the effort of the children to move quickly during nintendo wii practice to 
 score in the game and play better versus the computer might be the reason for the higher 
 scores in the ndt+nw group when compared with the ndt only group . it might be accepted as a 
 limitation that we obtained no records of the scores obtained by the children in the games 
 at the beginning and end of the study .
comparison of the scores between the beginning and 
 end of treatment might objectively show the development of the child s ability to play the 
 game . on the other hand ,
a powerful aspect of our study is that all cases had homogeneously 
 hemiplegic type cerebral palsy .
the quest has been used to measure the results in studies on virtual reality35 , 37 . in our study , the posttreatment quest scores of all participants in 
 the ndt+nw group were better compared with those of the ndt group ( p<0.05 ) . we think that 
 achieving a statistically significant increase in ndt+nw group with regard to weight bearing 
 and protective extension scores at the end of 6 weeks might be related to the effort of the 
 children to move their arms to better grasp and use the nintendo wii game console . during 
 the practice
, it was also clinically observed that some children were unable to firmly grasp 
 nintendo wii game console at the beginning of treatment , but were better able to grasp and 
 control the wii nunchuk at the end of 6-week treatment period .
the posttreatment increase in 
 quest grasps scores especially supports this clinical observation . in our study , jthft scores improved in both groups when compared with those for the to 
 pretreatment period .
although there was no statistically significant difference between the 
 two groups in terms of jthft results , it was observed that the ndt+nw group completed the 
 test 6 seconds earlier , on average , at the end of the 6-week treatment period .
this outcome 
 indicates that the use nintendo wii games was more effective than ndt in increasing the 
 speed of movement . in general ,
an important question about virtual reality practices is 
 about whether achieved gains  contribute to real life activities .  in our study , among the 
 cases tested by a method that includes measurements obtained using functional real life 
 activities , such as the jthft , the better results in the nintendo wii group represent 
 evidence showing that gained obtained by virtual environment therapies might be transmitted 
 to real life .
there are also some other studies presented in the literature demonstrating 
 that similar successful results have been achieved regarding the transmission of through 
 virtual reality therapy skills gained here to real life15 , 33 . in our study ,
independence of the children was evaluated with the weefim , which revealed 
 similar developments in both groups in terms of eating , care , bathing , and the upper and 
 lower trunk dressing fields .
there is one study in the literature that included a case with 
 hemiplegic cp and showed results similar to our findings in terms of improvement in daily 
 self - care activities15 .
furthermore , a 
 posttreatment improvement was observed in both groups in terms of the scores of the 
 abilhand - kids which was previously used in studies in which virtual reality was applied to 
 measure specific daily life skills of the hand31 , 
 35 , while no significant difference was 
 present between the groups . we could measure these functional gains in our study only at the 
 questionnaire level .
we suggest that magnetic resonance imaging of this kind of gain might 
 increase the objectivity and power of further studies .
the part of the user satisfaction questionnaire concerning the difficulty of the nintendo 
 wii games , all children in the ndt+nw group in our study stated that they could  win the 
 games  in spite of their physical limitations .
this situation may indicate that the games 
 strongly motivated the children who tried the virtual reality games , in spite of their 
 physical limitations .
some children stated that the games were more tiring than the other 
 methods applied in ndt .
although they were very tired , all children stated that playing with 
 the nintendo wii was much more fun when compared to conventional therapy .
in addition , all 
 cases specified that the games were attractive and that they lost track of time during 
 therapy .
we interpreted this situation as indicating that supporting traditional therapies , 
 which become boring and monotone for children during long rehabilitation periods in children 
 with cp , with virtual reality games might increase the motivation of children in therapy . 

virtual reality games , which have become a part of daily life , make children perform desired 
 activities voluntarily and in a more motivated way .
these results suggest that the children 
 were very pleased with the virtual reality games added to therapy .
the game console used in this study relies mostly on use a controller , it was observed that 
 the children with cp sometimes lost control of the controller due to excitement - related 
 increased spasticity and that the device failed to sense their movements .
we think that 
 further studies are required that , include a higher number of participants and use more 
 current systems with sensors sensitive to not only movements of a controller but also all 
 body movements . in conclusion ,
application of nintendo wii virtual reality games combined with ndt had 
 benefical effects on upper extremity functions , upper extremity speed , and independence 
 level in daily life activities in the children with hemiplegic cp .
the increase in speed was 
 more prominent in the ndt+nw group than in the ndt group .
since the nintendo wii increases 
 motivation and provides on opportunity for enjoyable therapy , we think that it increases 
 adaptation of children to rehabilitation programs and that it may be added to conventional 
 treatment programs .
use of virtual reality as a treatment modality for improving 
 functionality in children is considered a rich study field in which further results may be 
 obtained from randomized studies with larger sample sizes and control groups .
 [ purpose ] the aim of this study was to investigate the efficiency of nintendo 
 wii games in addition to neurodevelopmental treatment in patients with cerebral palsy . 
 [ subjects and methods ] thirty hemiparetic cerebral palsy patients ( 16 females , 14 males ; 
 mean age , 615 years ) were included in the study and divided into two groups : a 
 neurodevelopmental treatment+nintendo wii group ( group 1 , n=15 ) and a neurodevelopmental 
 treatment group ( group 2 , n=15 ) . 
 both groups received treatment in 45-minute sessions 2 
 days / week for six weeks . 
 use of the upper extremities , speed , disability and functional 
 independence were evaluated using the quality of upper extremity skills test , jebsen 
 taylor hand function test , abilhand - kids test , and pediatric functional independence 
 measure ( self - care ) before and after treatment . 
 [ results ] there were statistically 
 significant improvements in all parameters for group 1 and group 2 ( except quality of 
 function ) after six weeks of treatment . 
 intergroup analysis showed that group 1 was 
 superior to group 2 in mean change differences in the jebsen taylor hand function test . 
 
 [ conclusion ] our results showed that neurodevelopmental treatment is effective for 
 improving hand functions in hemiplegic cerebral palsy . to provide a enjoyable , 
 motivational , safe , and effective rehabilitation program , 
 the nintendo wii may 
 be used in addition to neurodevelopmental treatment . 