Cerebral palsy (CP) is the most common motor disability in children. It refers to a group of neurological disorders that affect individuals’ movement and posture. Internationally, the estimated occurrence of CP is two to three per 1,000 live births, and this ratio appears to be similar locally (Ghirxi, Bondin, 2021, personal communication).

CP is caused by abnormal development of the brain or damage in parts of the brain that control movement. This can happen before, during or shortly after birth, or also in the first few years after birth while the brain is still developing. In many cases, the main cause of CP is unknown.

CP differs both in severity and type from one child to another. Children with CP experience different motor chal­lenges that relate to the type of cerebral palsy they are diagnosed with. Some types of cerebral palsy include hemiplegia, diplegia, spastic quadriplegia, athetoid and ataxic CP. These may translate into neuro motor limitations such as weakness in the upper or lower limbs, increased or decreased tone (stiff or floppy muscles), lack of coordination, involuntary movements and lack of precise movements, among others.

CP is classified as a non-progressive disorder, and although there is no cure for it, there are various supportive treatments such as medication, surgery and therapies that can help individuals improve their motor skills and overall abilities. Habilitation is the main care to help children with CP attain daily living functions through occupational, physio and speech therapy. Unlike rehabilitation, habilitative therapy is aimed for individuals, especially children, whose goal is to make them acquire new functional abilities they have not yet developed.

Nowadays, therapy sessions are being enhanced through the introduction of smart wearable devices to support therapy goals. These novel devices have the potential to support children of all ages to achieve better function, participation and improve the quality of life.

The devices which are typically employed in habilitative therapy are off-the-shelf, meaning that they might not necessarily cater for the individual needs of the user, considering that different abilities vary from one person to another, especially when it comes to CP.

Parents typically spend considerable amounts of money on off-the-shelf habilitation devices, which after all, may not satisfy their children’s needs as expected, leading to customer dissatisfaction. This, in fact, was shown in research studies (Suguwara et al, 2018) that similar devices used for (re)habilitation and/or assistance have a high rejection rate, both from the purchaser (the parents or occupational therapists) and the user (the child).

Within this context, the University of Malta has teamed up with Invent3D Ltd and Human Ltd to develop a customisable, wearable smart device that allows children with CP to be engaged in a therapy session by means of digital game playing. In order to achieve this goal, the research team on this project is taking a user-centred approach by putting the users as the main focus of the design process.

Consequently, a profile of four children with CP was generated, in consultation with their parents and paediat­ric occupational thera­pists (OTs). The aim of this exercise was to identify the distinctive characteristics of each child, including their motivations and functional requirements, as well as assessment of their abilities and limitations, focusing on hand functions and movements.

The device needs to be tailored according to the requests of the child

Three online focus groups were also conducted to attain insights from the children’s parents, OTs and technical experts in the field of engineering and gaming. The results clearly indicate the importance of meeting the individual­ needs of children with CP when designing the wearable device and game. Parents and OTs noted that they would be interested to be part of the development process of the device and the game to be able to give their views.

Motivation is an important factor that occupational thera­pists consider paramount for children to participate during habilitative therapy (Ziviani, Poulsen & Cuskelly, 2012). Meanwhile, the children’s parents emphasised that motivation is subjective to the individual, and therapeutic medium needs to be persona­lised in order to entice them. Thus, the device, as indicated, needs to be tailored according to the requests of the child and designed in a way which interests them to be willing to interact with it.

Similarly, the digital game needs to be customised in order to motivate a child to participate. Other game characteristics identified include: elements of randomness, challenging levels to encourage children to progress, recognition of achievements through rewards and feedback, subtle inclusion of habilitative exercises and, most importantly, achieving functional therapy goals set for the children by their occupational therapist.

The use of such a device beyond the clinic setting and the home into community settings, such as schools, was another important finding. This may allow children the opportunity to participate by being involved in school life: namely to interact more during lessons by using it as a learning tool or as a means to play with their friends. This, in turn, demands that an easy set-up for using the wearable device at home for parents/ guardians with little to no technical knowhow, is a must. Furthermore, technical cha­rac­teristics on motion capture and data processing were discussed to help build a reliable and effective device.

Based on the requirements elicited from the various stakeholders, the next step is to design the physical device and develop the game.

The device will be 3D printed, so it can be personalised according to the child’s likings and, ultimately, be manufactured inexpensively. This prospect will help make the device accessible to more children.

The findings presented in this article are part of a project entitled ‘A smart user centred product service system for evaluating and developing functional hand skills in children with cerebral palsy’ (SMARTCLAP), which is  funded by the Malta Council for Science and Technology (project reference R&I-2019-003-T).

The project is led by Philip Farrugia from the Department of Industrial and Manufacturing Engineering at the University of Malta. Other members of the research team are Matthew Bonello, Joseph Mercieca, Simon G. Fabri, Alexiei Dingli, Owen Casha, Mario Farrugia, Nathalie Buhagiar and David Sciberras.

The SMARTCLAP team endeavours to jointly develop a smart wearable habilitation device and digital games for children with CP, to provide a fun way to conduct therapy and achieve the children’s individual functional goals.

Further project details are available at www.um.edu.mt/ projects/smartclap/.