1. 1
KOLLECT: Virtual Reality Rehabilitation for Youth with Cerebral Palsy
Introduction & Background
Patients and caregivers are critical members of the healthcare team and active partners in
clinical decision making.1
Children and youth (patients) with cerebral palsy (CP) and their
parents (caregivers) are encouraged to participate in management of the child’s health and
rehabilitation needs in family-centered service delivery models.2
However, youth with CP and
their families have involvement in research processes to integrate technology for clinical
decision making and health outcomes. It is important for youth with CP and their parents
participate in this research to be sure their goals and preferences are addressed.
CP is the most common physical disability of childhood with a prevalence of 2.0-3.0 per
1000 live births.3,4
Although CP is a non-progressive neuromuscular disorder, it is a lifelong
condition in which children often experience decreased physical activity, motor skills, functional
mobility and health problems.5,6
Despite these limitations, most children with CP are ambulatory,
however, children with moderate CP often need assistive devices (walkers, crutches) and may
rely on wheelchair use for community mobility.7
Parents of children with CP share concerns about their children’s walking and functional
mobility skills.8
They seek information for decisions on rehabilitation and health services to
promote their children’s function, quality of life, health and independence.9-10
Virtual reality (VR) is a popular rehabilitation strategy to promote health and fitness;
motor and cognitive skills; and increased confidence and self esteem in children and youth with
disabilities.11-14
VR provides a safe environment for children with CP to access active
recreation, games and sports.14
VR interventions are important because they motivate youth to
increase activity levels and adhere to rehabilitation programs with fun experiences.15-18
VR
may be especially important to children and youth with CP because there are few community
recreation facilities and opportunities for active recreation for health, function and socialization.19
Despite the growing popularity of VR in rehabilitation for youth with CP, supportive
research evidence is limited. 20
Most research evidence is focused on upper extremity function
with little research focused on health promotion, fitness, functional mobility, and physical
activity.12-13, 21-26
A small body of research examines VR for children with CP to improve
cognitive and executive function using neurotechnology designs.27
There is no research by
collaborative teams of youth with CP, their parents, their health providers and researchers from
rehabilitation and digital media fields to design and test VR in clinical and community setting.
Usability, scalability, and design of application
KOLLECT is the prototype VR gaming system that has been developed by the Drexel
ExCITe team with input from clinicians, youth with CP and their parents. The KOLLECT VR
game was developed using the Kinect SDK (Software Development Kit). The avatar interface
increases accessibility for youth with CP who often have limitations in hand function making it
difficult to use haptic devices. The Kinect SDK was used to create KOLLECT because
commercial games for the X-Box 360 Kinect system are not compatible to ability levels of youth
with CP (i.e., games are often too fast with too many distractions). Also, commercial games
don’t have enough flexibility to modify parameters to promote participation for youth with CP.
KOLLECT was designed as a proof-of-concept system to test various aspects of the final
goal system. This system was designed with flexible settings so parents or clinicians can adjust
parameters to challenge youth with CP and still promote play. The settings allow the clinician or
parent to adjust components of exercise prescription (FITTE principles) 28
to increase challenge
while improving overall health, function and mobility. FITTE principles are: Frequency, Intensity,
Time, Type and Enjoyment).

2. 2
KOLLECT’s architecture has broad scalability capacity in that it has built-in settings
flexibility and it has broad application via website access for game play remotely among multiple
players. While KOLLECT was prototyped with only a handful of accessible settings and control
game parameters such as game theming, gameplay characteristics (i.e., difficulty and duration),
and player characteristics (i.e., mobility), the architecture supports expanding the settings is in
full production to provide optimal controls for the clinician and widest application for youth with
CP of varying ages, gender, physical and cognitive levels, and recreational interests. This
feature is key for youth with CP to encourage ‘social networks’ of friends because youth with CP
may become isolated due to mobility restrictions and lack of resources and opportunities for
active recreation and play.19
KOLLECT was designed using simple gaming features so that the game has: 1) few
distracting elements; 2) objects that can move at different speeds (to challenge reaction time,
accuracy and precision) and across different trajectories to promote variable range of motion
and mobility; and 3) “hand prints” that cue the youth on hand placement to focus and anchor the
reaching activities. The user tests to date have been very successful in demonstrating
feasibility but further testing is needed for more and varied populations of persons with CP.
Innovation and creativity
KOLLECT is innovative and creative because it has distinct design features that were
included in the game in response to youth, parent and clinician input. All features have flexibility
to increase difficulty to match and challenge the players’ physical and cognitive abilities.
Current features that promote game play are: 1) less complex game objectives and tasks; 2)
slower moving and larger objects; 3) fewer distractions (ie, lights, noises) and 4) longer play
time (determined remotely by the clinician/therapist based on the recorded individual player
history and metrics) to promote fitness and functional mobility. The goal of this first KOLLECT
prototype was to be determine accessibility and enjoyment for youth with moderate CP who
may play video games in sitting or standing but who engage in the game with upper-extremities
more than lower extremities. The rationale for choosing these children and youth is that they
may have limited opportunity for active recreation.
Scientific rigor
Scientific rigor has been used in the design and testing of KOLLECT. A pilot study to
examine physical activity in youth with CP (n=52, average age = 12 years (SD: 3.35 years; 52%
girls) was recently completed. In this study youth completed a nine task physical activity
protocol in which each activity was 5-6 minutes in length to ensure that the children and youth
reached “exercise steady state” in each task (at approximately 3 minutes). However, two
activities included active X-box 360 Kinect commercial games which could not be adjusted for
more than 3 minutes of continuous play and for which no children were successful in getting
beyond 2-3 minutes of play. Therefore, no Kinect activity trials in the pilot study allowed for
extended play time for increased mobility, health-related fitness or fun! 29
The current KOLLECT video game has been tested by two youth with moderate CP
while their parents observed the sessions. The youth and parents completed questionnaires
about the experience (See Table 1 for select responses). Note that the youth many (n=5)
KOLLECT features as “Good to Excellent” with other features (n=6) as OK. Parents indicated
they would change nothing in the KOLLECT game features. One parent suggested that settings
and the ability to document her son’s reaching and range of motion provided good information
so she could track how he improves his reaching during play. She thought it would be good to
share this tracking data with her son’s doctor when they discuss his progress and medical
management.

3. 3
Two pediatric physical therapists (PTs) participated in a KOLLECT demonstration to
learn game features and settings and they completed a questionnaire to rate the game.
(See Table 2) Both PTs rated the majority of KOLLECT features and all settings as good to
excellent. Also, they provided comments on other features to increase flexibility of features
and settings for clinical applications
The PLAN for the next phase of KOLLECT development is to expand testing and
obtain feedback from 25 youth and parents and 15-20 clinicians. These data will inform
next steps in revision of the KOLLECT prototype and dissemination of the game for wider
test distribution.
Patient-centeredness
The KOLLECT video game is patient-centered in that this first version was designed in
response to patient and clinician input. Parents, youth with moderate CP and PTs have
begun to test and provide feedback on this prototype. Thus, the game is designed with and
for youth, families and clinicians. Further development of the KOLLECT system in the next
phase will follow an Agile development approach guided by playtest sessions involving youth
with CP as well as adults with neurologic disabilities. The Agile process is an iterative method
frequently used in software design and game development, and has been taught at Drexel’s
nationally-ranked Game Design program for almost 10 years. This development and
associated scrum methodology leverages external stakeholders central to a project’s success to
guide development and revision of the project’s goals through the entire product timeline. The
goal of the KOLLECT game is to provide youth and families with a viable option for active
recreation that is fun and that contributes to improved health, functional mobility, fitness and
cognitive training. Future versions will have options for more complex gaming to promote
cognitive skills and executive function which is important for many youth with CP as
cognitive delay is a common co-morbidity for this condition.
Degree of development of model or prototype
The KOLLECT prototype was a functional prototype demonstrating every major component of
the system, and was architected in such a way that further development involves expanding the
level of support for each component.
The game play component addressed a range of physical capabilities of the children
with CP, and performed simple analysis to dynamically alter gameplay to address varying reach
space or speed of the child. The parameterized configuration interface permitted gross-level
control of numerous game characteristics such as duration, game object size and type, and
support for a single or both arms playing the game. The networked configuration interface
permitted adjustment of those same parameters via a clinician, doctor, or therapist at a remote
location. The database component supported archiving of a subset of game-generated data
such as collection points or joint angles, and display and simple plotting of this data over time
for any selected player or play session.
Utility of this prototype was demonstrated through use of the system by actual children
with CP, and subsequent playtest sessions with a diverse test population will help further define
themes, pacing, complexity, and other gameplay characteristics to best serve the CP
community. While KOLLECT in its current form has utility and benefits over many current
games for a subset of children with CP, the extensions to this as proposed in this document
would both address a larger target population of children with CP at various degrees of affect,
as well as provide a more powerful configuration and performance monitoring tool for the child’s
therapists, doctors, and other health professionals.

4. 4
Ability to serve “hard-to-reach” audiences and stakeholders
VR gaming system used to promote a child’s functional mobility should be easy to: 1) use by the
child, parent and clinician; 2) use at home or in the clinic; 3) modify on site or remotely; and 4)
low cost and portable for home, school and community purchase; and 5) interactive and able to
be link into social networks so that children can “play” with other children remotely when they
cannot access recreation centers or active-recreation games and events in their communities.
Low cost and remote features will make the KOLLECT VR gaming system more readily
available for families with children with CP who have limited means and for those from rural
populations where community mobility is limited. The system can be run on low-cost hardware
across several operating systems, and only requires a low-cost Kinect interface which is the
fastest selling consumer electronics device ever launched with over 8 million sales in its first 2
months.25
Any web connectivity with minimal bandwidth permits remote access and monitoring
by the child’s heath care professionals. This gaming system will be useful in inner city urban
areas where there is limited access community recreation centers due to limited transportation
services, unsafe neighborhoods, or community centers that lack services for individuals with
disabilities. The KOLLECT game has features that will improve access to fun, healthy active
recreation in hard to reach underserved and under-resourced neighborhoods and communities
and will provide active recreation to a vulnerable population (youth with disabilities) that is
classified as experiencing “health disparities” because of limited access to health resources.
Table 1: Parent & Child KOLLECT Questionnaires: Specific Item Responses
Items & Responses (n=2)
KOLLECT video game features you rate as Good to Excellent (Child) (n=11 features)
Child: #1 FIVE (Look & feel; Hand prints; Play in sit or stand; Overall goal; Overall sound)
Child #2: FIVE (Adjust object speed; Play in sit or stand; Overall goal; Overall fun; Overall look of game)
KOLLECT – what needs to be improved (Parent)
Parent #1: NOTHING Parent #2: NOTHING
Table 2: Physical Therapist (PT) KOLLECT Questionnaire: Specific Item Responses
Item & Responses (n=2)
Rating KOLLECT video features (n=11)
PT #1: THREE@EXCELLENT(adjust object speed and trajectory; play in sitting or standing);
FIVE@GOOD (look and feel of objects; “hand prints”; overall goal; overall difficult/ complexity; overall
“sound”); THREE@OK (look of the “Red Bombs”; overall fun, overall “look” of the game)
PT#2: FOUR@EXCELLENT (look and feel of objects; ability to adjust objects trajectory);
SEVEN@GOOD (look and feel of the “Red Bombs”; adjust object speed; “hand prints”; overall difficulty/
complexity; overall fun; overall “look”; overall “sound”)
PT COMMENTS: Would be nice if….
 the “Red Bombs” were optional since might be too difficult for some
 there was an option of foot print too for balance or leg exercise for w/c users
 there were more options for different kinds of games with more variety in sounds/music
Rating KOLLECT video game settings (n=5)
PT#1: THREE@EXCELLENT (change play time; change settings remotely; multiple players (real space
or remotely); TWO@GOOD (scatter plots; line graphs)
PT#2: TWO@EXCELLENT (change settings remotely; multiple players (real space or remotely);
THREE@GOOD (scatter plots; line graphs; ability to change play time)
PT COMMENTS:
 For changing settings remotely - love the idea but not sure the children will like that feature!
 For scatter plots - Can you tell which arm (or leg) was used?
 For line graphs - Can this include head and trunk movements (esp. for youth with severe CP)
 For time setting – have options for more time in game play

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The goals of this grant application are to continue development of the KOLLECT
prototype for an innovative game system that will:
Be valid and accessible in the “field” (home or community environment) 30
 The prototype system was developed to support the commercial Kinect stand-alone
controller. The Kinect for the Xbox console is widely found in the home and porting to
support this platform lessens the need to purchase any additional hardware.
 Current network connectivity involves a combination web-email interface for the remote
setting of the configuration file. In the final version, the remote monitoring and control of
the player system would be transparent.
Adapt game play to individual player capabilities to support longer duration
 Player population varies tremendously in age, physical abilities, and cognitive function,
so the game has to be individually adapted. The prototype has rudimentary analysis of
reach space which drove the spawn points of the collected items. In the final version,
the heuristics to intelligently adapt and support players with varying ability will include:
 Spawning and motion dynamically adaptable to monitored player capabilities.
While remote parameter setting will permit complete control over the play
environment by the clinician, the game will support adaptation to the individual
play session.
 Complexity of spawned objects to support varying cognitive function and player
skill. Sequences, patterns, and variety will be supported to enable minimal
complexity for children with lower-function while permitting extension and
engagement for the most patients with high physical and cognitive function.
Address goals of KOLLECT as a remote or in person rehabilitation tool by examining/validating
metrics such as range of motion and joint tracking systems and by using other instruments
(heart rate monitors, accelerometers) during play to examine physical activity and fitness.30
 The Kinect’s use of skeletal tracking permits measuring of joint limits, joint speed, reach
space, and other metrics which requires both monitoring and filtering as well as archiving
and analysis over time. The system will be expanded for increased access and time-
based trending of the data.
 In addition to the purely physical capabilities of the player as defined by the reach
metrics, the game will be made more adaptable for cognitive function with cognitive
metrics such as identification of colors and shapes or the ability to identify and perform
sequences of actions/goals ranging in complexity.31
Provide custom character and theme selection for promoting engagement and motivation for
players in activities they normally are not physically able to participate in;
 Engagement is the key to a successful experience, and the prototype system
demonstrated theming with a sports theme and shape theme. This will be greatly
expanded to support a variety of childhood interests such as animals, music, sports, etc.
for child and teen audience. One expansion may be the ability to customize the
collection objects with images meaningful to the player
Support networked access of player metrics and game configuration by parents, youth,
clinicians (doctors, therapists, etc) involved in designing and modifying therapeutic interventions
 A minimal network interface was prototyped for viewing player session data, but the
controls for the selection and archiving of this data was minimal.
The Drexel ExCiTe Team: Dr. Maggie O’Neil, Associate Professor, College of Nursing and
Health Professions, Dr. Paul Diefenbach and Prof. Dave Mauriello, College of Media Arts and
Design; Tim Day, School of Biomedical Engineering. Our Advisory Stakeholder Group includes
two youth with CP, their parents and two PTs. We will expand this group in the next phase.

6. 6
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