cerebral palsy ( cp ) is a no progressive disorder of the immature brain that results in 
 movement and postural control impairments . the syndrome of 
 cp encompasses a large group of childhood movement and postural disorders . the incidence of 
 cp , a lifelong disorder is 23.5 cases per 1,000 live births2 , 3 and has remained stable in 
 the past 40  years . therefore , studies and research on children with cp are important for the 
 improvement of patients disabilities . weightman et al.4 showed that the use of 
 computer games is good and provides a positive result for the recovery of muscle movements 
 in children with cp . to help improve the movement of the upper limbs of children with cp , 
 therapeutic games have been designed , especially for upper limb rehabilitation . in recent years , the importance of using technology to help improve therapies and patient 
 assessments has become accepted in rehabilitation . human integration of a computer or robot 
 has also been used in the medical field for rehabilitation5 , 6 . the use of video games to 
 help patients with their rehabilitation therapy has shown positive results7 , particularly the use of nintendo 
 wii games in rehabilitation5 , 
 8,9,10 . videogame therapy has also been used in elderly patients , resulting in a significant 
 improvement in balance and mobility in these patients in comparison with other participants 
 who received traditional therapy in a conventional treatment room8 , 11 . li et al.12 showed that the video game exercise could 
 engage participants attention for a longer period than traditional and tracking exercises . keith et al.13 showed that integrating 
 game into therapy can increase the time spent by patients in therapy . in addition , they 
 suggest that through detailed research and development , video games might be a safe , 
 cost - efficient , and effective supplement to conventional physical therapy . after using 
 nintendo wii games in rehabilitation , 75% of patients 
 indicated subjectively that it seemed as useful as , or even better , than conventional 
 rehabilitation , 81.3% found it fairly enjoyable , 87.5% wanted to continue using it as part 
 of their rehabilitation program , and 93.8% were willing to recommend it to other 
 patients5 . king et al . showed that the use of interactive platforms is more attractive for patients 
 than performing tedious and repetitive exercises14 . in addition , this kind of platforms allows patients to perform 
 their exercises at home7 , 9 , 16 , 17 ; thereby , patients are able to increase their therapy 
 time . the additional tools used in rehabilitations , such as computer programs , are easy to 
 install and physically simple , light , and small . for all these advantages , the computer is a 
 powerful support tool in rehabilitation . however , neurorehabilitation usability studies have found that off - the - shelf games may 
 actually provide negative additive and visual feedback because patients are not fast enough 
 or efficient enough to perform the movements required to play the game successfully7 . shah et al.19 reported that 
 rehabilitation games need to be designed specifically for the purpose of rehabilitation and 
 be customizable according to individual needs . several studies have shown the benefits of 
 using games developed specifically for rehabilitation purposes19 , 20 . hence , games specifically for rehabilitation of the upper limbs were developed , focusing on 
 application in children with cp , in order to achieve adequate support for patients . this 
 project allows interaction with the physician , in which the physician can design the path of 
 the game when a specific movement of the patient is required . a great advantage of this 
 rehabilitation game is that it can be customized to suit the specific needs of individual 
 patients . in order to use this therapeutic game that the study team developed , a regular computer 
 should be connected to a large screen , tv , or projector . a webcam or camera 
 ( eyecamera playstation 3 ) should be connected to the same 
 computer to video - record the whole process during the game . patients use a red , blue , or 
 green led pencil to install and manipulate the game ( fig . description map of installation using led pencil or bracelet led the reason for using a projector in the case study was that the size of the image was 
 adjustable ; therefore , adjustment could be made depending on the range of motion of the 
 patient s arms . the led pencil could be turned on in two ways as follows : switch to the top 
 or button , or retain in the middle . another prototype bracelet led was also made for the patients who could not hold 
 a led pencil . the led was placed inside a small sphere of glass and filled with hot melt . 
 when the pencil was switched on , if the top led switch is turned on in another direction , the light that seen on the 
 camera will be markedly decreased or even disappears . two sets of rehabilitation games were developed to stimulate the upper limb , in which 
 patients were required to perform flexion , extension , pronation , and supination of the arm 
 movements and hand grip , which are the fine motor skills of the arms and hands . the 
 rehabilitation game was designed with different levels of difficulty that can be played 
 depending on the outcome in patients . there by , patients are encouraged to improve their 
 fine mobility . in order to perform this therapeutic game , before the game starts , the patient needs to 
 hold the led pen and point it to the car movement on the screen during the game . when the 
 game starts , the patient moves the led pen and follows the road to the final destination . when the patient pushes the car on the 
 screen off the road , an error will be recorded . at the end of each level , information such 
 as playing time , number of errors , and the patient s evolution will be recorded ( figs . 2fig . car game and frog game patient perfomed the game the objective of the game is to stimulate patients to move their arms in straight , curved , 
 circle , square , rectangle , spiral , and triangle lines , among other movements . at the 
 most - advanced level , the roads are more complex and the widths of the roads are narrower 
 ( table 1table 1.road gamelevelroad width ( cm)road length ( cm)shaped roadlevel 120285fig . the more the patients can focus and perform more - complex and more - precise 
 movements , the better are the results obtained . the second game is called frog eating pastry . it consists of a frog eating pastry while avoiding touching moving bombs 
 ( fig . the 
 patients have to move their arms in straight , curved , and rectangular lines , among other 
 types of movement , but with more freedom and faster . the patients can exercise their thumbs while pressing the button at the same 
 time . the previous two games , besides being useful for exercising the arms , are also useful for 
 children to identify colors and images , and differentiate functions . the differentiation is 
 done by accounting and identifying the different sounds and their meanings as presented in 
 the games . when the patient goes to wrong way , a beeping sound would signal for the error . when the patient fails to point the car to 
 the correct direction , a sound will signal the patient to correct the error . all the experiments were completed in accordance with the ethical principles for medical 
 research involving human subjects of the declaration of helsinki developed by the world 
 medical association20 . thereby , the risks 
 for the participants in the performance of the tests were minimized as much as possible . in 
 addition , this study was reviewed by the institutional board . all the participants were 
 informed about the procedures of the test , and their written consent were obtained before 
 the study . in order to achieve the purpose of this study , children with cp aged between 6 and 12  years 
 who had some difficulty of the upper limbs and hand movement but still able to perform the 
 game were selected . this study was conducted with five children with cp whose ages ranged 
 from 6 to 10  years . the duration of playing the game for its therapeutic purpose is between 
 30 and 135 days . table 2table 2.data of the patientsp1p2p3p4p5age ( yrs)109867hand to exerciseleftrightleftrightrightheight ( m)1.451.401.351.201.30weight ( kg)3840303235espasticityleft hand and left footfeet , back , arms , and handsfeet , back , arms , and handshands and feethands and feetexercise time ( months)4.51.5212session duration ( min)3030303030positionstandsitsitstandstandhand commonly usedrightrightleftrightrightinitial descriptioncan walk , write with the right hand , but weak left handcannot stand up , can not straighten the back , can not take with both 
 hands , and have difficulty speakingcannot stand up , can not straighten the back , can not take with both 
 hands , and have difficulty speakingdoes not have good hand movementdoes not have good hand movementgmfcs leveliiviviiii presents the data of the patients at baseline and after performing the game 
 therapy . the progress of the patients in this study was based on the level of the games and errors 
 they made . the error refers to the number of times the patients deviated from the road 
 between the first and last weeks . the duration of the exercise represents the degree of 
 active movement of the arms and forearms . the number of times the patients went off the road 
 indicates limitations of active movement , flexion and extension of the fingers , wrists , and 
 forearms . table 3 presents the results of the average racing game that were played by patients for 16 
 weeks . it shows the average time in seconds and the number of times the patients got off a 
 defined road in the first 2 weeks and last 2 weeks . according to the results presented in table 
 3table 3.results of the average racing gamet0t1%reduced timesd*speed taken to finish a basic - level game ( levels 14 ) , s4124.440%11speed taken to finish a medium - level game ( level 4a5b ) , s7835.255%7.1speed taken to finish an advanced - level game ( levels 6 or7 ) , * 
 s63.13446%----number of times the patients got off a defined road : width , 2016 
 cm ( levels 14)5.245.266%38.34number of times the patients got off a defined road : width , 1511 
 cm ( levels 4a5b)18.79.549%14.27number of times the patients got off a defined road : width , 7 cm 
 ( level 6 or 7)*14.38.4641%----level achieved only by patient 1 ( p1 ) , t0 : average result of the first 2 
 weeks , t1 : average result of the last 2 weeks , sd : standard deviation of the 
 percentage of time reduction for all the patients , are makeable progress occurred between t0 and t1 ; the 
 results demonstrated an error reduction rate from 40% to 55%.the patients had improved their 
 active movement , and flexion and extension of arms and forearms . at the beginning of the 
 game , after several months , the patients were able to 
 extend their arms a little more and did not get tired easily . table 3 also shows improvement in terms of correctly drawing the 
 car within the defined road . in the basic road , , the 
 number of times the direction deviated from the road was not reduced . the standard deviation 
 of the number times the direction deviated from the road in the basic level was 38.34 . it is 
 because some patients wanted to achieve their target levels eagerly and did not pay much 
 attention about how well they were able to finish the game . level achieved only by patient 1 ( p1 ) , t0 : average result of the first 2 
 weeks , t1 : average result of the last 2 weeks , sd : standard deviation of the 
 percentage of time reduction for all the patients in the medium level of the game , results show a 55% increase in speed and 49% correct 
 movements inside the road . the numbers demonstrate significant improvement in flexion and 
 extension of the hands , wrist , and fingers . after the therapeutic games , the patients could 
 hold the marker better , displaying better agility of the finger to press the button to start 
 the game and better wrist movements . these improvements were caused by the reduction in the 
 number of times the direction deviated from the road . however , at the advanced level , only 
 one patient ( p1 ) achieved the goal . the game is designed to allow the patient to enter the 
 next level after completing the previous levels . the standard deviation of the increases in speed of the five patients was 11 and 7.1 . however , among those 
 patients , patient 1 participated the longest time ( 4.5 months ) in the study . he also had 
 better study results , 63.7% increase in speed in the medium level , and an average of 74% 
 reduction in the number of times he deviated from a defined road . even though the therapeutic duration of each patient varied , the improvement of each 
 patient was noticeable . the patients who participated in the game longer showed significant 
 improvements , including the reduction in the time to finish the game , better movement inside 
 the defined road , and better ability to hold the marker . at the end of the therapies , several questions were asked , such as the following :  do you like this 
 therapeutic game ?   do you find the games interesting to use ?   would you like to continue 
 performing this game ? the survey results show that the participants felt interested to use 
 the rehabilitation games , and the duration of the therapies was increased . table 4table 4.comparison between before and after the experimentbefore the experimentafter the experimentp1left hand , wrist , and fingers weakleft hand had enough strength to catch a ball and turn a key to 
 open the door , among other fine motor exercisesp2could not take with both handscould paste paper inside a shape and draw a straight line on paper , 
 could hold the pencil harder , could paint hard and inside a picture frame , and 
 could cut sheets of paper straighter than beforep3could not hold well the marker and had trouble moving the arm and 
 point maker inside the game routecould hold the marker better and had better arm movementp4could not hold well the marker and had trouble with wrist movement had better arm and wrist movementsp5could not hold well the marker and had trouble moving the arm and 
 point maker inside the game routecould hold the marker better and had better arm movement shows the comparison of the activities and movement of the patients between 
 the baseline and after the game rehabilitation therapy . the study results from the five patients provide a breakthrough in the movement abilities 
 of the arms and hands of the patient . these results show that rehabilitation games can be a 
 good tool to support therapy for children with cp . such treatment not only focuses on arm 
 movement but also helps identify images , colors , and sounds . these games can encourage children to exercise 
 because they become more motivated to perform the therapies12,13,14 . in addition , another advantage is that patients can perform 
 exercises at home with less restrictions7 , 9 , 15 , 16 . in the present study , the comparison between before and after the experiment showed 
 significant improvement in the speed and fine movements of the children . only five patients 
 were selected in the present study . however , more patients are required to obtain more 
 reliable results . the main contribution of this research is to demonstrate that therapeutic 
 games can provide additional help for patients with fine - movement problems in their arms and 
 hands . moreover , the devices used in these games are economical and flexible . in future studies , the number of cases should be increased to ensure the validity of study 
 results . patients are able to play the rehabilitation game at home and thus achieve faster 
 improvement . in addition
[ purpose ] the purposes of this study were to evaluate whether the therapeutic games 
 developed by the study team are significantly effective for upper limb rehabilitation of 
 patients with cerebral palsy and to assess the development of the games and the evolution 
 of patients throughout the therapy sessions . [ subjects and methods ] this study 
 demonstrates the results of using therapeutic games in patients with infantile cerebral 
 palsy . 
 the therapies were performed in 30-minute sessions for about 1 to 4 months . 
 this 
 study shows the progress of five children with cerebral palsy during the sessions . the 
 time it took the children on each road and the times required to complete a task were 
 measured . 
 in addition , the level of difficulty of the games was gradually increased at 
 each session . 
 [ results ] results have shown good progress on the accuracy of the movements 
 and an increase in concentration level during the execution of the games , showing an 
 improvement in the patients performance by 4055% faster . [ conclusions ] health games 
 encourage children to comply with therapy . 
 the advantage of the game is that the patient 
 can perform the therapy at home , which could help achieve further progress in 
 patients .