IntroductionBackground

Children with hand motor skills deficiencies face challenges daily. They may have difficulties with daily activities such as eating, getting dressed, or socializing with friends and families. Physical and occupational therapies can ameliorate the motor skills of these children []. One group with hand motor skills deficiencies is children with cerebral palsy (CP). Despite therapists’ efforts, the interventions available for this group are repetitive and thus perceived as demotivating []. Providing therapy via a motivating activity positively impacts improving motor skills, as patients are more willing to take part and adhere to the treatment. Therefore, rehabilitation researchers and therapists constantly look for ways to innovate and improve existing therapies.

Challenges of current therapy at home include lacking the means for personalization, monitoring of progress of the exercises, and high cost of devices. Children with CP present with a diverse degree of motor function, and no 2 children will be affected in the same way. Therapists therefore adjust the exercises according to each child; however, this type of personalization is challenging if the therapy is to be performed at home. In addition, therapists need to provide tailored and timely feedback for the child to sustain motivation and increase adherence when performing therapy at home. Trying to provide this help at home can increase the workload and pressure on the therapists and caregivers.

New technologies, such as the E-link, the HandTutor, or the surface electromyography, present advantages in hand rehabilitation such as data analysis, customization, feedback, and adaptability to the home environment []; however, their high cost means that families cannot make use of them easily. Two known approaches to increase motivation are the use of new technologies and play. The benefits of play in the development of children have been widely studied, showing that the motivational nature of play encourages children to participate and learn. Thus, one of the approaches that therapists have successfully used in rehabilitation centers is to perform exercises through play []. One successful example of play-based therapy is Pirate Therapy [], which highlights the importance of motivating children to work toward a goal through playful activities. Researchers have also studied the use of new technologies, such as virtual reality (VR), augmented reality, game consoles, and robots, which are familiar and appealing to children because they provide opportunities for play via interactive games while enriching the therapeutic experience [].

Furthermore, these new technologies provide monitoring and automatic feedback on performance, the opportunity for repetition to improve motor skills, and sharing experiences between children and others. These are also financially accessible technologies that require low technical support, making them appropriate for use at home. Some examples of successful studies on hand therapy for children with CP and other motor disabilities are the studies conducted by Reid [] and analyzed in the review by Pereira et al []. They concluded that VR is suitable for supporting hand therapy. Koutsiana et al [] concluded in their review that serious games are an alternative to provide motivation in therapy. Moreover, Winkels et al [] showed positive results in participants’ usability, user satisfaction, and enjoyment in gaming with the Nintendo Wii sports games, boxing, and tennis. In their review, Ayed et al [] highlighted that the interest in the field of VR systems for rehabilitation is increasing. However, none of these studies provide an overview of the extent and range of the research on playful technological interventions. There does not seem to be a systematic approach to how and when we use technology and play in therapy for children. Many studies have experimented with available technologies that can be adjusted for therapy without paying much attention to the play elements that can be applied. Therefore, there is a need to have an overview of what the field has been doing for the last decade and to deepen our understanding of the use of play in therapy.

Objectives

The range of playful technological interventions can be studied along multiple dimensions. First, the type of technology (motion sensing, game consoles, etc) can be used to categorize the research. Second, the type of playful elements (competition, rules, fantasy, etc) can help structure the analysis. Therefore, in this scoping review, we aim to identify which innovative technologies are part of playful hand therapies and what are the playful elements used in these interventions. This information will provide researchers, designers, and practitioners with an overview of current therapies for children with CP that make use of innovative technologies and play. Furthermore, we aim to provide starting points to design new therapies that are supported by innovative technology and play (which makes them suitable for other environments than just the rehabilitation center) and that engage and motivate children.

Designing Playful Interactions

To analyze and determine whether and which playful elements have been applied in technology-supported hand therapies for children with CP, we used the Lenses of Play []. The Lenses of Play is a design toolkit used to create playful interactions. For example, Almahmoud [] used the Lenses of Play to design a toy for children with autism. We have chosen to use it as our framework because it provides multidimensional examination of play beyond traditional therapist-centered approaches, making a distinction between games and free play [] and providing a diverse set of playful elements such as control and competition among others. Other frameworks or models used in therapy, such as Theraplay [] or SCOPE-IT [], refer more to the behavior of children in connection with their caregivers and occupational performance. Although play is an essential element, these frameworks lack the focus on what makes an activity or object playful for children. The Lenses of Play focus on the object, game, and user interaction. This framework will help us to better understand how playfulness is used and identify the necessary ingredients to design new playful experiences for therapy. In the future design of playful therapies, this can lead to a common and more specific language to be used by the different stakeholders involved in innovative, technology-supported therapies, including clinicians, children, and their parents, as well as technology developers.

First, we briefly describe the technologies used in this review. Subsequently, identifying the playful elements used within therapies that use new technology will support a more systematic reflection and understanding of the potential benefits of using these technologies.

Methods

A scoping review aims to compile the relevant literature and map the critical concepts of a specific topic. For this scoping review, we used the five-stage framework proposed by Arksey and O’Malley []: (1) identifying the research questions; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing, and reporting the results.

Identifying the Research Questions

In line with the main objectives of this scoping review, we aim to answer the following research questions:

Question 1. Which innovative assistive technologies are used in hand therapies for children with CP?Question 2. Which playful elements are embedded in the technology-supported therapy to motivate children with CP?Identifying Relevant Studies

To identify relevant studies, we performed comprehensive searches in the Scopus, Web of Science, and CINAHL databases for medical and human-computer interaction studies published in English between January 2009 and December 2022. The final search was performed on January 17, 2023. The keywords used were as follows: “cerebral palsy OR cerebral paresis OR cerebral palsies; AND play* OR game OR gamification OR toy; AND child OR children; AND therapy OR rehabilitation OR treatment; AND hand OR upper limbs.” The queries that were run on all the databases are presented in .

Study Selection

After removing duplicates, the titles and abstracts were analyzed according to the inclusion and exclusion criteria set by 2 reviewers (AB and TVPC). The inclusion criteria for the analyzed articles were as follows: (1) study participants were children (aged 0-18 years) with spastic CP; (2) the therapy described was focused on hands or upper limbs motor skills; (3) the therapy used innovative technology (ie, electronic tools, systems, and devices); (4) the therapy used playful elements such as video games or toys; and (5) the publications consisted of peer-reviewed academic articles or conference proceedings that were published between 2009 and 2022. The exclusion criteria included (1) insufficient information about the game or play activity or referred to traditional therapies without the support of technologies (eg, bimanual, constrained-induced movement, and Pirate Therapy), (2) lack of focus on the treatment used, (3) written in a different language than English, (4) unavailability to access the full text at the time of analysis, and (5) incomplete inclusion criteria. Disagreements between reviewers with regard to the exclusion criteria were resolved through discussion.

Charting the Data

The data extracted from the selected studies included authors, date of publication, research questions or aim, sample size, frequency, time and duration of therapy, hand movement, intended environment (home or rehabilitation center), the technology used, description of the system, and playful elements according to the Lenses of Play.

Collating, Summarizing, and Reporting the Results

The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines [] were followed for reporting the results; the PRISMA-ScR checklist is included in . The protocol was registered with the Open Science Framework. The authors (TVPC, BK, BS, and GL) met to determine the categories of technologies, evaluate the playful elements of the Lenses of Play, and analyze the extracted data. To determine the categories of technologies, we investigated their functionality and determined commonalities. For example, Kinect and Leap Motion are used to detect movement; hence, we created a motion sensor category. To identify the playful elements used in the interventions, we analyzed the information provided for each intervention through each of the Lenses of Play. To do so, we examined the design principles, play mechanisms, and goals that were included in the interventions and described in the paper. For commercially available games and technologies, we also investigated the information provided on the developers’ websites [-]. For example, when analyzing a study with the Lens of Play Playful experiences, if the intervention described a game where the player had to grab a specific number of virtual butterflies and place them in a jar, the game will be categorized under the playful experience completion because the player must complete a task. The same was performed with the other lenses by following the definitions of each element of the Lenses of Play.

ResultsOverview

The total number of studies found on Scopus was 166, whereas 126 studies were found on Web of Science (including MEDLINE) and 58 studies were found on CINAHL, resulting in 350 studies, including duplicates. The first author (TVPC) removed duplicate studies, resulting in 239 studies. The first 2 authors (TVPC and AB) conducted the analysis of titles and abstracts based on the inclusion and exclusion criteria. This yielded a total of 66 studies whose full text were reviewed for data extraction by 1 of the authors (TVPC). depicts the number of studies identified at each process stage following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. Finally, 54 studies were included in the study ().

In recent years, there has been an increase in the interest in developing and researching hand therapies that use innovative assistive technology and playful elements. shows the distribution of the selected papers from 1999 to 2022.

‎Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of search process. Table 1. Summary of analyzed studies and assistive technology (original purpose of the technology and type of hardware).Study, yearStudyTechnology
GoalParticipantsCategory and systemCategory 1: therapeutic-specific technology
Bian et al [], 2020To develop toy modules in combination with Lego blocks to support hand and arm training5 children, aged 5-10 years; 1 with amentia and 4 with hemiplegiaCategory: Smart Tangibles (smart blocks)
System: path building with the smart blocks and Lego blocks

Guberek et al [], 2009To evaluate the level of cooperation and satisfaction of children when practicing arm and hand movements during play-like activities in a physical environmentChildren aged 5-12 yearsCategory: Motion Sensing (IREXa)
System: the IREX system with the game Zebra Crossing, the child attempts to touch as many stars as possible while advancing the crosswalk

Mandil et al [], 2015To use a tangible user interface in designing tabletop activities to help motivate children with motor disabilities to increase the number of exercises and improve the motor proficiency and quality of life4 children with CPb, aged 6-14 years; 3 physiotherapistsCategory: Smart Tangibles (PhysiTable)
System: PhysiTable with 3 different paths defined with LEDs. Music and color used for feedback. The player uses a cube to trace the path.

van Delden et al [], 2012To study the use of tangible, interactive games for the repetitive training of upper limbs in the therapy of children with CP4 therapists; 16 children with CP, aged 2.5-8 years; 14 non-CP children aged 8-9 yearsCategory: Smart Tangibles (smart toys and TagTiles)
System: the smart toys are used to manipulate the TagTiles

Wu et al [], 2022To develop an Interactive Story Box to facilitate rehabilitation of speech, cognition, and motion4 children with CP, aged 4-8 yearsCategory: Smart Tangibles (interactive story box)
System: Raspberry PI, RFIDc readers, and tangible objects to create an interactive box. Story maps are controlled with characters in the shape of a puzzle.
Category 2: consumer technology
Acar et al [], 2016To investigate the efficiency of Nintendo Wii games in addition to neurodevelopmental treatment in patients with CP30 children with CP, 16 female participants, aged 6-15 yearsCategory: game consoles
System: Nintendo Wii, with the VRd games (tennis, baseball, and boxing)

Avcil et al [], 2021To compare the effects of neurodevelopmental therapy and video game–based therapy for upper extremities30 children with CP, aged 6-15 yearsCategory: game consoles (Nintendo Wii) and motion sensing (Leap Motion)
System: 2 video games to improve hand and grip functions. “CatchAPet” to touch rabbits with repetitive wrist flexion or extension movements and “Leapball” to grasp a virtual ball with all fingers and throw it by finger extension.

Chen et al [], 2021To evaluate the feasibility of a Kinect-based constraint-induced therapy10 children with CP in phase 1 and 8 children with CP in phase 2Category: motion sensing (Kinect), computers
System: video game where the child is a warrior defending their island. The Kinect detects the hand movements to throw cannonballs.

Chiu et al [], 2014To investigate whether Wii Sports Resort training is effective and if any benefits are maintained62 children with hemiplegia aged 6-13 yearsCategory: game consoles (Nintendo Wii)
System: Nintendo Wii, with Wii Sports Resort games, from easiest to hardest: bowling, Air Sports, Frisbee, and Basketball. 10 minutes per game.

de Oliveira et al [], 2016To develop a VR game using Unity 3D to aid motor and cognitive rehabilitation in children with CP8 clinical expertsCategory: computer (PC), motion sensing (Leap Motion), and wearables (Mind wave)
System: 6 phases of a video game in a PC controlled by Leap Motion. Mind wave used to keep track of player’s attention.

El-Shamy and El-Banna [], 2020To investigate the effect of Wii training on hand function40 children with hemiplegic CP, aged 8-12 yearsCategory: game consoles (Nintendo Wii)
System: playing 4 Wii games: tennis, boxing, bowling, and basketball

Elsaeh et al [], 2017To develop a high-level control in which the human brain is stimulated by the visual, audio, and tactile sensation to transmit instructions to the affected upper limb’s joints2 children with hemiplegia, 1 7 years old female participant, and 1 10 years old male participantCategory: computer (PC), controller (Novint Falcon) system: 3 video games on a PC using the Novint Falcon controller

Garcia-Hernandez et al [], 2021To examine how the subjective experience of seeing and controlling a half-body avatar or an abstract hand representation in a virtual environment for training upper limb movements may affect motor performance19 children aged 7-9 yearsCategory: computer and motion sensing (Kinect)
System: a video game with body or hand representation where participants have to reach and grab a ball

Gieser et al [], 2015To recognize and classify static gestures from Leap Motion by comparing classification techniques, decision trees, support vector machines, and k-nearest neighbors. Create and evaluate a game to detect hand gestures.Volunteers and expertsCategory: computer (PC) and motion sensor (Leap Motion)
System: virtual game developed on Unity for PC and controlled via Leap Motion.

Golomb et al [], 2009To describe the learnings of providing home telerehabilitation to people with CP and to suggest ways to address some of the barriers to home telerehabilitation in this population3 adolescents with CPCategory: console (PlayStation 3) and controller (5DTD Ultra sensing glove).
System: custom games programmed in Java3D for PlayStation 3 and controlled with a 5DT5 Ultra sensing glove.

Golomb et al [], 2010To investigate whether in-home remotely monitored VR video game–based telerehabilitation in adolescents with hemiplegic CP can improve hand function and forearm bone health and demonstrate alterations in motor circuitry activation3 patients with severe right hemiplegic CP, aged 13-15 yearsCategory: console (PlayStation 3) and controller (5DTD Ultra sensing glove).
System: the 5DT5 Ultra sensing glove has 5 fiber optic sensors in each of the 5 fingers; it is connected to a PlayStation 3 with Linux, and the games were programmed using open source Java3D APIe.

Goyal et al [], 2022To report the use of a VR gaming system and haptic feedback and its effectiveness1 child, aged 6 yearsCategory: game consoles (PlayStation)
System: a driving simulation game with PlayStation 4

Gregory et al [], 2012To enable play for children with CP that continuously entertains, which will allow extended play over long durationsN/AfCategory: smart tangibles (Pleo) and controller (Wii Nunchuk) system: a Wii Nunchuk is used to teach dance movements to Pleo.

Hernández et al [], 2018To test the usability of the gaming station with clinicians and children with CP and to establish the feasibility in a 12-week clinical trial6 therapists and 6 children with CP, aged 7-16 yearsCategory: controller (Novint Falcon)
System: force feedback Novint Falcon game controller, custom grips, arm and wrist supports, and software to be used with mainstream games

Hsieh et al [], 2020To improve hand performance while playing with Chinese puppets modified with Lego robots42 children with CPCategory: smart tangibles (Lego Mindstorms NXT)
System: modified puppets with Lego, using servo motors, sensors, and connecting cables

Hung et al [], 2018To study the feasibility and possible efficacy of a suite of motion-controlled games designed for upper-extremity training in children with CP using Kinect2Scratch13 children with CP; mean age 6.9 yearsCategory: computer (PC), motion sensor (Kinect) system: 3 video games in a PC with a screen with a Kinect sensor
Scratch visual programming and Kinect2Scratch software

Kassee et al [], 2017To compare a Nintendo Wii intervention to single-joint resistance training for the upper limb6 children with spastic hemiplegic CP aged 7-12 yearsCategory: game Consoles (Nintendo Wii) System: experimental group: Nintendo Wii controllers, and selected games. Control group: TheraBand, Elite band and squeeze ball with a list of exercises.

Kottink et al [], 2017To assess the feasibility, in terms of gaming experience, a mixed-reality system for rehabilitation of the arm and hand function5 children aged 7-12 years with CP and 10 adults aged 30-70 years with stroke or brain injuryCategory: motion sensing (Kinect), computers (PC)
System: HandsOn game—reaching, grasping, and releasing a physical object to control a PC video game using Kinect

Leal et al [], 2020To verify if there was any performance improvement in a task performed in a virtual environment and if it is transferable to the real environment28 children with CP, aged 6-15 yearsCategory: motion sensing (Kinect), computers, and smart tangibles (touchscreen)
System: Check Limit Game, pop bubbles with the touchscreen or gestures

Li et al [], 2009To assess if a low-cost VR therapy home-based system can promote movements of the hemiplegic upper extremity that the child finds difficult5 children with CP aged 8 yearsCategory: motion sensing (EyeToy) and game console (PlayStation2)
System: VR therapy home-based system that consists of video games (Secret Agent and Mr Chef) for PlayStation2 and controlled with EyeToy

Macintosh et al [], 2020To assess the feasibility of an intervention that combines a cocreated gaming technology with biofeedback and coaching19 children, aged 8-18 yearsCategory; wearables (MYO Armband) and computers
System: Dashy Square video game played with the use of electromyography and an MYO armband

Macintosh et al [], 2022To describe the design and evaluation of a biofeedback virtual game9 childrenCategory; wearables (MYO armband) and computers
System: Dashy Square video game played with the use of electromyography and an MYO armband

Nai et al [], 2019To analyze the use of Vive trackers to estimate forearm axial rotation for the purpose of supporting interaction with serious games8 healthy participants aged 21-31 yearsCategory: motion sensing (HTC Vive trackers) and computers (PC)
System: HTC Vive trackers attached to a wrist bracer to control a serious game system on a PC. One tracker used around the palm and another around the center of the forearm.

Pruna et al [], 2017Evaluate the use of a haptic device and VR games in upper limb rehabilitation in children5 children with mild spasticity, aged 7-12 years; 4 children with Down syndrome and difficulty of movement in upper limbs, aged 9-12 yearsCategory: controller (Geomagic Touch) and VR headsets (Oculus Rift)
System: 2 interactive virtual environment games (watering plants and order objects). The haptic device (Geomagic Touch) acquires the movement generated by the user, and an Oculus Rift provides immersion in the use of the system.

Stansfield et al [], 2015To further investigate whether improved measures of motor performance will be seen with the use of motion-based VR gameplay1 boy aged 10 yearsCategory: computers (PC) and wearables (Polhemus Liberty)
System: PC with the Polhemus Liberty tracking sensor, a screen, and a memory game played alone, in cooperation or competition

Tarakci et al [], 2020To study the potential efficacy of an 8-week program with the Leap Motion controller-based training as a therapeutic method for upper-extremity rehabilitation in comparison with conventional rehabilitation programs in children with CP, juvenile idiopathic arthritis and brachial plexus birth injury.Group 1 (CP: n=15; JIAg: n=18; and BPBIh: n=9). Group II (CP: n=15; JIA: n=25; and BPBI: n=10). Aged 5-17 years.Category: motion sensing (Leap Motion) and computers (PC)
System: 2 rehabilitative video games on PC using Leap Motion: Fizyosoft CatchAPet and Fizyosoft Leapball

Winkels et al [], 2013To explore the effect of the Nintendo Wii training on upper-extremity function in children with CP15 children with CPCategory: game consoles (Nintendo Wii). System: children played the boxing and tennis games provided in the Nintendo Wii Sports video game console.

Yildirim et al [], 2021To investigate the effect of leap motion–based exergame therapy20 children with CP, aged 8-15 yearsCategory: motion sensing (Leap Motion) and computers
System: 2 video games controlled with a leap motion. Leap Ball: grab a ball and throw it into a box of matching color. Catch a Pet: touch the moles in a certain order

Zoccolillo et al [], 2015To investigate the effectiveness of video game therapy with respect to conventional therapy in improving upper limb motor outcomes22 children with CP, aged 4-14 years. GMFCi between I and IV.Category: game consoles (Xbox) and motion sensing (Kinect)
System: a videogame of the console Xbox using the Kinect device for motion capture. Six games available: “Space pops,” “20.000 Leaks,” “Rally Ball,” boxing, volley, and bowling.
Category 3: therapeutic and consumer technology
Amonkar et al [], 2022To evaluate the feasibility of implementation, acceptance, and perceived efficacy of a joystick-operated ride-on-toy intervention to promote upper-extremity function11 children with CP, aged 3-14 years; 11 caregivers; and 6 cliniciansCategory: joystick ride-on-toy
System: children rode the ride-on-toy (car) navigating with the spastic hand and performing a task throughout the path (collecting objects, throwing balls, and avoiding obstacles)

Bortone et al [], 2020To determine the efficacy of immersive virtual environments and wearable haptic devices8 children with CP or developmental dyspraxiaCategory: wearable (haptic device for the fingertip) and VR headsets (Oculus Rift VK2) System: collecting coins in a VR environment and placing them in a moving piggy bank. Slide a token out of a virtual labyrinth with the finger. Difficulty changes with time.

Choi et al [], 2021To investigate the efficacy of a VR rehabilitation system of wearable multi-inertial sensors for upper limb80 children, aged 3-16 years with brain injury including CPCategory: wearable (Neofect Smart Kids) and computers
System: games with activities of daily living promoting wrist and forearm articular movements using wearable inertial sensors.

Cifuentes-Zapien et al [], 2011To study if a video game can be used as an interface for a robot for the rehabilitation of the pronation and supination movements of children with CP1 healthy right-handed child aged 11 years.Category: computers (PC) and robotics (robotic arm).
System: a PC video game developed for an upper limb rehabilitation robot for children with CP. The video game simulates a formula one race car on a racetrack. The car’s horizontal position is controlled by the pronation and supination motions.

Crisco et al [], 2015Evaluate play activity recorded by the controller for 2 toys and 3 computer games.20 children aged 5-11 yearsCategory: controller (arm and elbow remote), smart tangibles (smart toy: car and dog), and computers (PC).
System: a specially designed arm and elbow remote controller was used to interface wirelessly with 2 smart toys.
System: A specially designed arm and elbow remote controller was used to interface wirelessly with 3 video games.

Crisco et al [], 2015To develop and evaluate the measurement accuracy of innovative, motion-specific play controllers that are engaging rehabilitative devices for enhancing therapy and promoting neural plasticity and functional recovery in children with CP6 typically developed children (3 male participants and 3 female participants aged 5-11 years)Category: controller (arm and elbow remote) and smart tangibles (smart toy: car)
System: the play arm and elbow remote controller was designed with a conformable, ergonomic handle to accommodate varying levels of contractures among children with CP and control a car.

Dunne et al [], 2010To describe the hardware platform, present the design objectives derived from iterative design phases and meetings with clinical personnel, and discuss the current game designs and identify areas of future workExpert clinicians on CPCategory: wearables (accelerometer) and smart tangibles (multitouch display, tangible objects).
System: 3 games played (Find the bone, Spelling, and Catch the butterflies); the tangible objects control the game in a multitouch display. An accelerometer measures body changes and modifies the game, for example, butterflies fly off the jar.

Fu et al [], 2020To determine if children could tolerate 9 laboratory treatment sessions and administer up to 7.5 h/wk of CCFESj video game therapy at home3 children aged 8-11 years with hand hemiplegiaCategory: computer, wearables (arm sensors and electrical stimulation electrodes)
System: 4 video games (Paddle Ball, Sound Tracker, Skee-Ball, and Marble Maze)

Hernandez et al [], 2021To explore the effectiveness of interactive computer play with haptic feedback13 children with CP, aged 7-16 yearsCategory: controllers (Novint Falcon and Custom levers) and computers
System: 4 commercial video games to train wrist movement: Crazy Rider, Swooop, Funky Karts, and Lil Mads and the Gold Skull. 5 video games to train elbow and shoulder movement: Looney Tunes Dash, Heroes of Loot, Bird Brawl, Pac-Man, and Save the Day.

Minh et al [], 2021To test a design of 2 interactive toys and an open game4 children with CP, aged 2-3 yearsCategory: computers and smart tangibles (smart toys)
System: a stuffed stick toy with a 6-DOF inertial measurement unit (IMU) and force sensor–incorporated gloves to squeeze a ball used to play “Catch the worms in the garden”

Mirich et al [], 2021To assess the efficacy of VR rehabilitation1 child aged 4 yearsCategory: wearables (Neofect Smart Kids) and computers
System: a functional activity game with different activities such as turn pages, painting, wiping a table, and playing ping pong selected based on the needs of the patient

Mittag et al [], 2020To present the design and implementation of a tangible device for hand trainingN/ACategory: wearables (arm sensors) and computers
System: a video game controlled by the sensors and interactions with the tangible controller.

Parmar et al [], 2021To improve rehabilitation programs for children and adults with neurodevelopmental disorders in a game-based telerehabilitation.6 children with CP; 10 adults recovering from a strokeCategory: wearables (motion therapy mouse) and computers
System: the motion mouse is attached to different objects such as a ball, to control movement in a commercial video game (Big Fish Game).

Peper et al [], 2013To examine the potential effects of the training on bimanual coordination and identify if the training had beneficial effects on the affected arm’s performance6 children with CP aged 7-12 yearsCategory: controller (custom levers) and computers (laptop)
System: 2 horizontal levers, a laptop computer, and an additional monitor. Left-hand movements produce vertical displacements, and right-hand movements produce horizontal displacements.

Preston et al [], 2016To study the feasibility of using computer-assisted arm rehabilitation computer games in schools, their preference for single player or dual player mode, and changes in arm activity and kinematics9 boys and 2 girls with CP aged 6-12 years; mean age 9 yearsCategory: robotics (robotic arm) and computers (PC)
System: an assistive robotic arm connected to a computer with cooperative and competitive games

Psychouli et al [], 2017To propose a system that can enhance children’s motivation during the implementation of a CIMTk session and that could explore differences in compliance rates, motivation levels, and intervention feasibilityNon-CP children and 3 groups of CP children (CIMT, RTl, and CIMT+RT), aged 5-11 yearsCategory: wearables (arm sensors) and smart tangibles (smart toys)
System: arm and hand with sensors (accelerometer, magnetometer, gyroscope for upper and lower arm, and flex sensors on the wrist and fingers) that control the 4-wheeled robotic vehicle (DFRobot Cherokee)

Sabry et al [], 2020To develop a low-cost VR rehabilitation system with a data glove and virtual games8 children with CP, aged 5-12 yearsCategory: wearables (data glove) and computers
System: a data glove is used to play video games: “Grasp the ball”

Stroppini et al [], 2022To determine the feasibility and efficacy of the MusicGlove to motivate hand function3 children with hemiparetic CP, aged 6-17 yearsCategory: wearables (MusicGlove) and computers
System: a video game is controlled with the glove. The patients tap their fingers to make musical notes according to the notes that show up on the screen.

van Loon et al [], 2011To test a set of video games, developed to loosen the coupling between the hands of children with CP7 children with spastic unilateral CP, aged 7-12 yearsCategory: controller (custom levers) and computer (PC) system: 3 computer games that challenged the participants to move their hands according to 6 different bimanual coordination patterns executed with custom levers.

Weightman et al [], 2011To compare upper limb kinematics of children with CP using a passive rehabilitation joystick with adults and able-bodied children to better understand the design requirements of computer-based rehabilitation devices9 adults (aged 23-30 years), 9 children (aged 7-9 years), and 7 children with CP (aged 5.5-7 years)Category: a controller (joystick) and computers (PC)
System: a computer game in which the child controlled a “spaceship” collecting “satellites” with the use of a joystick.

aIREX: immersive rehabilitation exercise.

bCP: cerebral palsy.

cRFID: radio frequency identification.

dVR: virtual reality.

eAPI: application programming interface.

fN/A: not applicable.

gJIA: juvenile idiopathic arthritis.

hBPBI: brachial plexus birth injury.

iGMFC: gross motor function classification.

jCCFES: contralaterally controlled functional electrical stimulation.

kCIMT: constraint-induced movement therapy.

lRT: robot-assisted therapy.

‎Figure 2. Publications per year. Innovative Assistive Technology

The authors identified 2 ways to classify the innovative assistive technologies used in the analyzed studies: the original purpose of the technology and the type of hardware.

Original Purpose of the Technology

This first type of classification refers to therapeutic-specific technology, consumer technology, and the combination of therapeutic and consumer technology. shows the details of the studies per category. Therapeutic-specific technology was developed for the sole purpose of being used in hand therapy and has been used in 5 studies. An example of this type of technology is the immersive rehabilitation exercise, which is a video gesture control technology that allows patients to be immersed in a video game where users can exercise by interacting with the elements of the game []. Consumer technology is a commercially available technology used in entertainment or other fields but that has been modified to be used in hand therapy, consumer technology was used in 29 studies. The authors of the included studies identified this type of technology as potentially beneficial and motivating because of its existing functionalities, interactions, familiarity, and lower costs []. For example, Acar et al [] investigated the efficiency of Nintendo Wii games together with neurodevelopmental treatment in patients with CP. They analyzed “out-of-the-box” games, such as tennis, baseball, and boxing, focusing on the upper extremities. In addition to the observed improvements in speed and functional independence, the children perceived the use of the Nintendo Wii as a reward. The rest of the studies (20 in total) made use of a combination of therapeutic-specific technology and consumer technology; an example is presented in the studies by Golomb et al [,], where custom games were developed to be used with the PlayStation 3 console (consumer technology) in combination with the 5DT Ultra sensing glove (therapeutic-specific technology). The games encouraged hand movements such as opening and closing or thumb extension; speed was also trained by challenging the player to chase a butterfly by flexing or extending the fingers rapidly.

Types of Hardware

This second type of classification refers to a more general category of hardware or technologies, such as VR headsets, game consoles, wearables, motion sensing, controllers, smart tangibles, and robotics (). When analyzing the types of hardware, it was found that the most common technologies used were computers (32/54, 59%), as they were often used to deploy a video game and to connect with other types of technology. Wearables were one of the most used technologies (19/54, 35%); wearables are continuously in close contact with the body to capture the movement of the hand or arm while they can provide direct haptic feedback. Some of these technologies include gloves such as 5DT Ultra sensing gloves, the Neofect Smart Kids, the Data glove, and the Music glove. Smart tangibles were used in 15 studies, including smart toys such as the TagTile, a device similar to an electronic board game [], and the dancing dinosaur Pleo! Dance! []. Motion-sensing technology was also frequently used (14/54, 25%); a device that belongs to this category is the Kinect, which was used in the studies by Hung et al [], Kottink et al [], and Zoccolillo et al [] because of its ability to capture the upper extremities and movements of the users from a distance. Another widely used type of hardware was controllers (11/54, 11%), for example, the Novint Falcon, a haptic device that acts as a controller similar to a computer mouse but with a shape that allows for higher degrees of freedom. This device, which allows for resistive force feedback on the spastic hand, was used by Elsaeh et al [] and Hernández et al, [,], where limitations of movements and direction are adapted to the interactions needed in the virtual games used and the possibilities of the spastic hand. The full list of types of hardware used in the studies can be found in the [,-]. Some studies focused on using only one type of innovative assistive technology. In contrast, most studies (43/54, 80%) used a combination of ≥1 type, such as PCs with robotic arms [], smart toys with an arm and elbow remote controller and a PC [], wearables and smart tangibles [], and custom levers with a PC []. The complete list of studies that used a combination of different types of hardware is provided in [,,,,-,,,,-].

Table 2. Technology classification based on type of hardware.Type of hardware and nameValue, n (%)Computers (n=32)
PC26 (81)
Laptop4 (17)
Tablet2 (6)Controllers (n=11)
Custom levers3 (27)
Geomagic Touch1 (9)
Joystick2 (18)
Motion Therapy mouse1 (9)
Novint Falcon3 (27)
Wii Nunchuk1 (9)Game consoles (n=11)
Nintendo Wii6 (55)
PlayStation4 (36)
Xbox1 (9)Motion sensing (n=14)
EyeToy1 (7)
HTC Vive trackers1 (7)
IREXa1 (7)
Kinect6 (43)
Leap Motion5 (36)Robotics (n=2)
Robotic arm2 (100)Smart tangibles (n=15)
Interactive Story Box1 (7)
Lego Mindstorms NXT1 (7)
Multitouch display2 (13)
Pleo!1 (7)
PhysiTable1 (7)
Ride-on-toy1 (7)
Smart blocks1 (7)
Smart toys5 (33)
TagTiles1 (7)
Tangible objects1 (7)VRb headsets (n=2)
Oculus Rift2 (100)Wearables (n=19)
5DT sensing gloves2 (10)
Accelerometer1 (5)
Arm and elbow remote2 (10)
Arm sensors4 (21)
Electrical stimulation electrodes1 (5)
Data glove1 (5)
Mindwave2 (10)
Music glove1 (5)
MYO Armband2 (10)
Neofect Smart Kids2 (10)
Polhemus Liberty1 (5)

aIREX: immersive rehabilitation exercise.

bVR: virtual reality.

Lenses of PlayOverview

Bekker et al [] defined the Lenses of Play as a toolkit that includes different perspectives on play that can inform design decisions throughout the design process. Initially, 4 lenses were defined: Open-ended Play, Forms of Play, Stages of playful interactions, and Playful experiences. In a later publication, Bekker et al [] introduced a fifth lens, Emergence, which relates to the system’s perspective and how it can provide meaningful interactions. This analysis focuses on the Open-ended Play, Forms of Play, and Playful experiences () lenses, and the Stages of playful interactions and Emergence lenses have been omitted because little information was provided about these aspects of play in the studies included in this review. It was possible to identify the playful elements used in the proposed interventions for the other lenses ().

‎Figure 3. Lenses of Play; the size of the circles represents the frequency of use of the play element in the publications. Table 3. Summary of analyzed studies by Lenses of Play.Lens and play elementCategories
Therapeutic-specific technologyConsumer technologyTherapeutic and consumer technologyOpen-ended Play
Improvisation[]