feasibility and effectiveness of a gaming mat in the
TRANSCRIPT
FEASIBILITY AND EFFECTIVENESS OF A
GAMING MAT IN THE REHABILITATION
OF CHILDREN WITH COORDINATION
AND/ OR BALANCE PROBLEMS A PRELIMINARY STUDY
01407765 Sarah Cornil
01313540 Charlotte Van Den Hende
01410469 Laura Van Renterghem
Supervisors: Prof. Dr. Hilde Van Waelvelde, Arno Penders
A dissertation submitted to Ghent University in partial fulfilment of the requirements for the degree
of Master in Rehabilitation Sciences and Physiotherapy
Academic year: 2019 - 2020
FEASIBILITY AND EFFECTIVENESS OF A
GAMING MAT IN THE REHABILITATION
OF CHILDREN WITH COORDINATION
AND/ OR BALANCE PROBLEMS A PRELIMINARY STUDY
01407765 Sarah Cornil
01313540 Charlotte Van Den Hende
01410469 Laura Van Renterghem
Supervisors: Prof. Dr. Hilde Van Waelvelde, Arno Penders
A dissertation submitted to Ghent University in partial fulfilment of the requirements for the degree
of Master in Rehabilitation Sciences and Physiotherapy
Academic year: 2019 - 2020
Acknowledgement
We are finalizing our thesis by writing this word of gratitude. It was a period in which we learned
a lot, scientifically, practically, but also personally. We would like to acknowledge our appreciation
towards the people who made it possible to write this thesis by their support and cooperation.
First of all, we want to express our gratitude to our promoter Prof. Dr. Hilde Van Waelvelde for all
the time and energy she spent during the two years of our master thesis. She guided us not only
in terms of content, but also in terms of structure. Furthermore, she was always open to our
questions and gave us a lot of practical help and constructive feedback.
Secondly, we want to thank Creative Therapy and in particular our co-promoter Arno Penders.
Especially for the information and advice according to the gaming mat ‘Matti®’. We also want to
emphasize our appreciation to Sébastien Michiels, Jamil Joundi and Ward Dehairs for their time
to come to the school and rehabilitation center to fix the mat when facing technical issues.
Thirdly, we want to thank Julie Van Winghem, Inge Mouton, Piet Verdegem, Astrid Verdegem,
Ann Declercq and Alien Schoenaers, the physiotherapists from Sint-Lievenspoort and CAR
Klimop, for participating in this study. We want to express our sincere appreciation for the time,
energy, creativity, space and practical help to ensure us to test and give therapy. We are also
very grateful to the parents from our participants and the children with their enthusiasm, for their
participation in this research.
Fourthly, we are grateful for the department of Physical Therapy and Rehabilitation Sciences of
Ghent University to give us permission to conduct this study.
Last but not least, we want to thank our parents and friends for the support and the
encouragements during our study process and in the realization of this thesis.
Tabel of contents
Acknowledgement ........................................................................................................................... 5
List of figures and tables ................................................................................................................. 8
Abbreviations .................................................................................................................................. 9
Literature study ............................................................................................................................. 11
Abstract and key words (English) ............................................................................................. 12
Abstract and key words (Nederlands)....................................................................................... 13
Introduction ................................................................................................................................ 14
Method ....................................................................................................................................... 17
Study design .......................................................................................................................... 17
Participants ............................................................................................................................ 17
Outcome measures ............................................................................................................... 17
Intervention: ........................................................................................................................... 20
Statistical analysis ......................................................................................................................... 21
Results ....................................................................................................................................... 22
Participants ............................................................................................................................ 22
Balance .................................................................................................................................. 22
Motivation .............................................................................................................................. 25
Qualitative observations ........................................................................................................ 26
Discussion ................................................................................................................................. 27
Most important results ........................................................................................................... 27
Future protocol....................................................................................................................... 31
Conclusion ................................................................................................................................. 32
References .................................................................................................................................... 33
Abstract (lekentaal) ....................................................................................................................... 37
Approval of ethical committee ...................................................................................................... 38
Appendix ....................................................................................................................................... 46
Appendix 1: Questionnaire IMI balance circuit ......................................................................... 46
Appendix 2: Questionnaire IMI Matti® ...................................................................................... 47
Appendix 3: Thermometer ........................................................................................................ 48
Appendix 4: Descriptives M-ABC-2-NL and KTK-NL for test moment 1, 2 and 3 ................... 48
List of figures and tables
Tables:
Table 1: Balance items of the M-ABC-2-NL
Table 2: Items of the KTK-NL
Table 3: Age and gender of the participants
Table 4: Total score of the IMI
Figures:
Figure 1: Protocol
Figure 2: Box-and-wisker plot of the results of the M-ABC-2-NL
Figure 3: Box-and-wisker plot of the results of the KTK-NL: backwards balancing
Figure 4: Box-and-wisker plot of the results of the KTK-NL: sideways jumping
Figure 5: Average scores of the IMI
9
Abbreviations
↑ Increase
↓ Decrease
= Remains the same
χ2 Chi-squared
ADHD Attention Deficit Hyperactivity Disorder
ASD Autism Spectrum Disorder
BB Balance Beam
BC Balance Circuit
CAR Center for Ambulatory Rehabilitation
CoP Center of Pressure
CP Cerebral Palsy
CET Cognitive Evaluation Theory
DCD Developmental Coordination Disorder
DLD Developmental Language Disorder
e.g. example given, for example
etc. etcetera
FASD Fetal Alcohol Spectrum Disorders
IMI Intrinsic Motivation Inventory
IQ Intelligence Quotient
IQR Interquartile Range
KTK-NL Körperkoordinationstest Für Kinder - Nederlandse vertaling
LJ Lateral Jumps
M-ABC Movement Assessment Battery for Children
M-ABC-2 Movement Assessment Battery for Children second edition
M-ABC-2-NL Movement Assessment Battery for Children second edition - Nederlandse vertaling
10
MQ Motor Quotient
P Significance
Q-Q Quantile-Quantile
RCT Randomized Controlled Trial
SD Standard Deviation
SDT Self-Determination Theory
SJ Single-lever Jumps
SPSS Statistical Package for the Social Sciences
STABEL Sensorimotor Training to Affect Balance, Engagement and Learning
T Testing
T0 Test at baseline
T1 Test after three weeks of balance circuit intervention
T2 Test after three weeks of intervention with Matti®
TP Transfers on Platforms
VR Virtual Reality
11
Literature study
12
Abstract and key words (English)
Background: Throughout the last decade, the use of Active Video Games (AVG) in the
rehabilitation of children has become more common with evidence for their use in achieving
rehabilitation goals. Besides, AVG are assumed to improve motivation and compliance. Matti® is
a gaming mat designed by Creative Therapy for use in physical rehabilitation.
Objectives: The aim of the present study was to evaluate the effectiveness of Matti® compared to
a conventional balance circuit at improving balance and motivation in children with mild
coordination and balance problems.
Study design: A feasibility study combined with a pilot study, to evaluate effectiveness of the
gaming mat, in order to enhance balance and motivation.
Methods: Twelve children (eight boys and four girls), aged between seven and 11 years old, with
balance problems participated. All children began with three weeks of intervention on a balance
circuit, followed by another three weeks of intervention on the gaming mat 'Matti®'. One baseline
assessment, one assessment after three weeks and one assessment after six weeks were
performed for balance using the Movement Assessment Battery for Children – second edition –
Nederlandse vertaling (M-ABC-2-NL) and the Körperkoordinationstest für Kinder - Nederlandse
vertaling (KTK-NL). To determine motivation, children had to complete the Intrinsic Motivation
Inventory (IMI) after each therapeutic session.
Results: The balance exercises on Matti® with the different adopted games were feasible to be
performed by the children. No significant improvement in scores of the subtests of the M-ABC-2-
NL and the KTK-NL was found between baseline, three weeks or six weeks. Nor was there any
statistical change in motivation.
Conclusion: Matti® seems to be a promising device to perform balance training in children.
Effectiveness in rehabilitation of balance or enhancement of motivation and participation has yet
to be shown.
Key words: Children, Matti® , Balance, Exergaming, Motivation
13
Abstract and key words (Nederlands)
Achtergrond: Doorheen de laatste decennia is het gebruik van Active Video Games (AVG) in de
revalidatie bij kinderen toegenomen en onderzoek suggereert mogelijks effectiviteit. AVG worden
verondersteld de motivatie te verhogen. De gaming mat ‘Matti®‘ werd ontworpen door Creative
Therapy met als doel om geïntegreerd te worden in fysische revalidatie.
Doelstellingen: Het doel van de huidige studie was om de effectiviteit van Matti® te evalueren, in
vergelijking met een conventioneel evenwichtsparcours, om het evenwicht en de motivatie te
verbeteren bij kinderen met milde coördinatie- en evenwichtsstoornissen.
Studie design: Een haalbaarheidsstudie gecombineerd met een piloot studie, om de effectiviteit
te evalueren van de gaming mat, met als doel het evenwicht en de motivatie te verbeteren.
Methode: Twaalf kinderen (acht jongens en vier meisjes tussen zeven en 11 jaar) met
evenwichtsproblemen, namen deel aan deze studie. Alle kinderen startten met een interventie
van drie weken met een evenwichtsparcours, gevolgd door een interventie van opnieuw drie
weken met de mat. De Movement Assessment Battery for Children – 2 (M-ABC-2-NL) en de
Körperkoordinationstest für Kinder (KTK-NL) werden gebruikt om het evenwicht te testen bij het
begin, na drie weken en na zes weken interventie. Om de mate van motivatie na te gaan, werd
aan de kinderen gevraagd om na elke interventie de Intrinsic Motivation Inventory (IMI) in te
vullen.
Resultaten: Het was haalbaar om evenwichtsoefeningen op Matti®, met de verschillende
aangepaste spelletjes, door kinderen te laten uitvoeren. Er werd geen significante verbetering
gevonden van de scores op de subtesten van de M-ABC-2-NL en de KTK-NL over het verloop
van de drie testmomenten. Dit geldt ook voor de IMI.
Conclusie: Matti® lijkt een veelbelovend middel om te werken aan evenwicht bij kinderen. De
effectiviteit moet nog bewezen worden zowel voor het verbeteren van evenwicht, als voor het
verbeteren van motivatie.
Sleutelwoorden: Kinderen, Matti®, Evenwicht, Active Video Games, Motivatie
14
Introduction
Research has been conducted into the effect of gaming devices on balance rehabilitation of
children with coordination disorders. Approximately 73 to 87% of children with poor motor
performance have problems with balance (1). This implies that those children have problems with
maintaining an upright position and with keeping the centre of gravity within the limits of support
(1). Balance problems are one of the most frequently reported problems in Developmental
Coordination Disorder (DCD). DCD is a common neurodevelopmental disorder, affecting 1,8 to
4% of school aged children (2). Affected children may experience difficulties in the planning,
organization and/or execution of movements resulting in delays in the acquisition of fine and
gross motor skills (3). Balance difficulties in children are not limited to those with a diagnosis of
DCD and are also present in conditions such as Autism Spectrum Disorder (ASD), Attention
Deficit and Hyperactivity Disorder (ADHD) and Cerebral Palsy (CP) (4). Children may encounter
problems with a range of motor tasks such as running, dressing and writing (5). Motor deficits
are particularly apparent in difficult, unexpected or novel situations (6). Difficulties in these skills
can make it harder for children to be socially included, for example in team sports (7), or to fulfil
the child's potential in school where an inability to record information quickly and neatly can be
mistaken for laziness or low academic ability. This often leads to harmful secondary
consequences such as poor academic achievement, low self-esteem (2, 7-9), reduced physical
activity participation (10) and obesity (8).
Over the last decade, the use of Active Video Games (AVG), also called exergames, has become
more common in the rehabilitation of children. Recent research suggests that the use of virtual
reality (VR) systems may be beneficial as an intervention tool for motor deficits in a variety
of situations (4). VR utilizes interactive simulations created with computer hardware and software,
providing opportunities to interact and manipulate virtual objects in real-time, in a
multidimensional and multisensory virtual environment (11). An example of a VR device is
the Nintendo Wii, which is frequently used in combination with a balance board. Several studies
found positive results by including Wii training into physiotherapy interventions in children with
DCD (12-15). Similar results were found with Sony’s PlayStation 2 (16), the Xbox (17) and lesser
known devices such as Sensorimotor Training to Affect Balance, Engagement and Learning
(STABEL) (18), the Grail system (19) and the iBalance system (20). It is believed active games
improve balance in motor impaired children by providing immediate feedback (15). Almost all
populations studied to date describe an improvement in balance as a result of exergames,
although further evidence is required to ensure these results reliable across multiple populations.
15
Exergames not only enhance motor performance, but are also stated to enhance motivation (21).
Motivation is essential in any aspect of behavioural change (22). Motivation is considered an
important prerequisite to successful rehabilitation (21). Adding game elements to a rehabilitation
program is expected to enhance motivation, though limited research currently exists. There are
preliminary indications that children who are more motivated by providing new opportunities and
more variety to rehabilitation paradigms, such as VR or a robotic assistant, have a better
rehabilitation outcome (23). It has the ability to fulfil the basic psychological needs of autonomy,
belonging and competence described by the Self-Determination Theory (SDT) (24). This theory
views internalization as the process of transforming external regulations into internal regulations
and, when the process functions optimally, integrating those regulations into the sense of one self
(24, 25). The theory uses the concepts of introjection and integration to describe two different
types of internalization that result in different qualities of regulation. Introjection refers to partial or
suboptimal internalization resulting in internally controlling regulation. Integration refers to optimal
internalization resulting in self-determined behaviour (26). Another theory that directly relates to
intrinsic motivation is the Cognitive Evaluation Theory (CET) (27). Intrinsic motivation is “based
on the satisfactions of behaving ‘for its own sake’ (28). If the situational context, e.g. playing
exergames on a device, promotes the three basic needs (autonomy, belonging and competence),
then the natural behaviour of a person is more likely to be self-motivated (22). The need for self-
competence can be fulfilled by varying game difficulty and player skills and by providing instant
feedback on performance to ensure the player is challenged but tasks are achievable (29).
Gaming devices, e.g. the Nintendo Wii, use a hand held controller and therefore cannot guarantee
that the expected full-body movements are being used by the child (30). Creative Therapy, a
team existing of engineers, game designers and developers, designed a gaming mat named
'Matti®' in collaboration with academic partners, physiotherapists and occupational therapists.
Matti® has shown its feasibility to be used in a real therapy setting for rehabilitation of children
with DCD (4). Matti® allows therapists to develop tailored therapy sessions using exergames to
challenge specific patient deficits. Furthermore, the online Creative Therapy Platform helps
therapists to follow the progress of their patients and adapt the therapy to the specific needs of
the patient (4, 21). It is expected that the gaming mat can be used as a supporting device to give
therapy and to motivate children at the same time (4), increasing patient enjoyment of
rehabilitation. The Intrinsic Motivation Questionnaire (IMI), a questionnaire to quantify motivation,
is among the most frequently used questionnaires in the context of sports and physical education
(27) and will be implemented in this study.
16
Research has indicated that exergames can be useful to improve balance, not only beneficial for
children with DCD, but also for those with other medical conditions or lower levels of physical
fitness (12, 16-18, 20, 21, 31-38). The exergames do not only influence balance, but also
motivation. To scientifically confirm these statements, more research is needed. Therefore, the
aim of this pilot study is to determine if the gaming mat 'Matti®' can improve the balance in children
and to determine if a difference in motivation exists between therapy on Matti® and conventional
balance therapy.
17
Method
Study design
A feasibility study combined with a pilot study to evaluate effectiveness of the gaming mat in order
to enhance balance and motivation. Ethical approval for this study was obtained from the ethical
commission of the University of Ghent. Written informed consent was obtained from the parents
of the children who participated in this study.
Participants
Two Centers for Ambulatory Rehabilitation (CAR), “CAR Klimop” and “CAR Impuls”, and one
school for special education type 7 and 9, “Sint Lievenspoort”, were contacted by email and phone
between July and September 2019. Inclusion criteria for the study were: (1) children aged
between seven and 16 years old; (2) with an Intelligence Quotient (IQ) above 70; (3) who receive
physiotherapy for mild coordination problems. Exclusion criteria were: (1) severe neuromotor
disabilities (e.g. CP, severe orthopedic problems, etc.) that would make it impossible to undertake
exercises on the mat. The parents of the participants were required to sign informed consent
forms prior to the child commencing participation in this study.
Outcome measures
M-ABC 2-NL:
The M-ABC-2-NL is the Dutch translation of the Movement Assessment Battery for Children –
second edition (M-ABC-2), a test of motor impairment that focusses on the identification and
description of impairments in motor function for children aged between three and 16 years old.
The test is divided in three age bands: three-six years old, seven-10 years old and 11-16 years
old. The test is comprised of eight item, grouped into three motor skills sets; manual dexterity,
ball skills and balance (39). This study only used the three items that correlate to balance skills
(Table 1).
The M-ABC-2-NL was assessed for each participant at baseline, following three weeks of
conventional balance therapy and following three weeks of intervention with the gaming mat. For
the second test assessment, some of the participants were tested on the same day as their last
intervention session of the balance circuit, while others were tested at a subsequent session prior
to the intervention with Matti®. Test scores of the participants were converted to percentile scores
and standardised scores for the age band of each participant. The balance standardised scores
were used for statistical analyses of the balance outcomes.
18
There is extensive data demonstrating the validity of the first edition of the Movement Assessment
Battery for Children (M-ABC), however this information cannot be generalised to the second
edition of the M-ABC-2, as the two versions differ greatly (39). The guidelines for the M-ABC-2
report that the content of the M-ABC-2 is representative for the component desired to measure
(40). Studies have shown a reasonable test-retest reliability for the M-ABC-2 (39), however
research on the validity and reliability of this measure is limited. Yet it is greatly used in research,
which makes it easy to compare scientific literature to this study.
3 – 6 years old 7 – 10 years old 11 – 16 years old
Item 1 One-leg balance One-board balance Two-board balance
Item 2 Walking heels raised Walking heel to toe
forwards
Walking heel to toe
backwards
Item 3 Jumping on mats Hopping on mats Zig-zag hopping on
mats
Table 1: Balance items of the M-ABC-2-NL
KTK-NL:
The Körperkoordinationstest für Kinder-Nederlandse vertaling (KTK-NL) is a test to assess gross
motor coordination. It consists of four tasks, however this study only utilised tasks one and three
(Table 2) to avoid exceeding the timeframe. The test is suitable for children between five and 15
years old with motor and/or intellectual disabilities and has been used to calculate normative data
for 2831 Flemish children (41).
The KTK-NL tests were conducted at the same time as the tests of the M-ABC-2-NL; at baseline,
following three weeks of conventional balance therapy and following three weeks of intervention
with the gaming mat to detect an evolution in balance. The scores of the participants were
converted into an age- and gender-related motor quotient (MQ).
19
The guideline of the KTK-NL declare that the test-retest reliability of the tasks separately are: BB
0.80 ; SJ 0.96 ; LJ 0.95 and TP 0.94, with the KTK-NL having a total reliability of 0.97. However,
a factor analysis showed that the KTK-NL only measures general dynamic coordination and body
control (41).
Intrinsic motivation inventory (IMI)
The IMI is a multidimensional measurement, invented by Ryan and colleges (27, 42), which
consists of 45 items divided in seven subscales (43). The IMI aims to assess intrinsic motivation
and the contributing factors that underly motivation (43).
The complete questionnaire is rarely used, with relevant subscales and items being utilised
individually. It has been assumed that the omission of one subscale has no negative influence on
the remaining factors. Shorter versions of each subscale have been used without change to the
intrinsic consistence, indicating the ability for some items to be eliminated as required (43). An
acceptable validity and reliability for the use of the IMI in competitive sport conditions has been
demonstrated (44). Tsigilis and Theodosiou (2003) also found a Greek version of the scale to be
reliable. Moreover, the IMI is assumed to be a temporal stable measure (45). This study excluded
the original IMI subscales of perceived choice and relatedness as they did not apply to the study
design. A 30-question questionnaire remained, which can be found in Appendix 1 for the balance
circuit and in Appendix 2 for Matti®. The questionnaire consisted of normal questions, reversed
questions and questions which needed to be answered with one word or sentence. The order of
the questions was randomised.
Items KTK
Task 1 Balance Beam (BB)
Task 2 Single-lever Jumps (SJ)
Task 3 Lateral Jumps (LJ)
Task 4 Transfers on Platform (TP)
fhf(ggggj((TP)(TP) Table 2: Items of the KTK-NL
20
The subscales that were used in this research were the 'interest/ enjoyment', 'perceived
competence', 'pressure/ tension', 'effort/ importance' and 'value/ usefulness'. The 'interest/
enjoyment' subscale is considered the most direct self-report measure of intrinsic motivation by
assessing the inherent joy of participants while performing an activity. The 'perceived
competence' subscale is a positive predictor of intrinsic motivation and is related to the SDT. It
measures how productive individuals feel when they are performing an activity. The 'pressure/
tension' subscale is a negative predictor of intrinsic motivation due to the evaluation of the
pressure that participants feel to succeed a task. The 'effort/importance' subscale assesses the
involvement of the participants. The 'value/usefulness' subscale assumes that people internalize
and develop more self-regulatory activities when an activity is considered as valuable and useful
for them (46).
After every training session, participants were required to score every item on a Likert scale going
from 'one' (completely disagree) to 'seven' (completely agree). A colourful thermometer was used
to visualise this scale (Appendix 3). This allows to calculate an average score per subscale and
a total score, which is the summation of all the subscales (43). For the balance circuit and for
Matti® an average of the three test scores of the IMI is made, so both scores could be compared.
Participants were advised that if an item was unclear, they could ask for an explanation. If a
researcher was unsure if the child understood an item, he or she was asked to summarise the
content of that item to ensure the questions were interpreted correctly.
Intervention:
The gaming mat intervention consisted of games that the children could play on Matti® to improve
balance. The intervention tool ‘Matti®’ is a mat of 1,5 m2 provided with pressure sensors which
can be used to play a game via a computer and a screen in front of the child. Software with games
were connected to Matti®, which registered the activity of the child. There were six different Matti®
games that the participants could choose from. The first game was 'Whack-a-light', where the
children had to jump from one light to another. The second game was 'The orchestra', where the
children had to shift their weight to keep their center of pressure (CoP) in the middle of a moving
circle. The third game was 'Simon says', where the children had to remember a sequence of
colors and then jump from color to color in the right order. The fourth game was called 'Twister',
where the children could play a 'twister by Creative Therapy' style game on the mat. The fifth
game was 'Balance beam', where they had to walk on a line from one point to another without
losing their balance. The last game was called 'Avoid the monster'. Here the participants had to
run away or jump over a monster that was moving around on the mat. These games were meant
21
to improve static and dynamic balance. Each week, the participants played a selection of these
games three times for four minutes in one session, with four minutes of rest in between. Each
session, the children chose three games that they wanted to play.
The conventional balance therapy consisted of 20 minutes of balance circuit training. One session
took place each week. A balance circuit, comprising of three sets of four minutes of exercises for
static and dynamic balance, was performed with four minutes rest between sets.
In this study the participants received six weeks of continuous intervention. The first three weeks
consisted of the conventional balance therapy, while the last three weeks consisted of the gaming
mat intervention (Figure 1). The participants were assessed by the M-ABC-2-NL and the KTK-NL
at baseline, after the conventional balance therapy and after the gaming mat intervention. The
therapy and assessment took place in the rehabilitation center and the school. They were
overseen by the researchers and were not blinded.
Statistical analysis
Statistical Package for the Social Sciences (SPSS) statistics 26 was used for data analysis. The
normality of the data distribution was evaluated by the use of a Shapiro-Wilk test, a histogram
and Quantile-Quantile (Q-Q) plots. Based on these outcomes, non-parametric statistical tests
were chosen. Median and Interquartile Range (IQR) were used in descriptive statistics for balance
results (Figure 2, 3 and 4). A Friedman test was used to compare the results on the M-ABC-2-
NL, the KTK-NL and the IMI. The outcome of the balance tests was compared at baseline, after
the conventional balance therapy and after the intervention with Matti®. The average outcome of
the IMI after conventional therapy was compared to the average of the intervention with Matti®.
Additionally, the three scores of the IMI after each intervention on Matti® were compared to assess
whether the motivation attenuated. Significance (P) < 0,05 was determined as statistically
significant.
Figure 1: Protocol
22
Results
Participants
Fifteen children initially enrolled in this study. Three children dropped out due to lost to follow-up.
Twelve children (eight boys and four girls) with the age between seven and 11 years old remained
(Table 1). Six children were recruited from the school 'Sint Lievenspoort' and six children from
rehabilitation centre for children 'CAR Klimop'. Five children had a diagnosis of Autism Spectrum
Disorder (ASS), one child had a global developmental delay, one child had a brain injury, one
child had a diagnose of Developmental Language Disorder (DLD) and four children had a
diagnosis of both DLD and DCD. All of them had mild coordination problems. Due to health
problems of participants, technical problems with Matti® and time-management issues there is
missing data.
Gender
Total Male Female
Age (years) 7y 2 0 2
8y 3 0 3
9y 1 2 3
10y 1 1 2
11y 1 1 2
Total 8 4 12
Table 3: Age and gender of the participants
Balance
As the data was not normally distributed, a non-parametric statistical Friedman test was chosen
to evaluate the significance between outcome measures.
23
Descriptive statistics for balance component standard scores of the M-ABC-2-NL and the motor
quotients of the backwards balancing (BB) and sideways jumping (SJ) of the KTK-NL for the first,
second and third examination can be found in Appendix 4.
The distributions of the component standard scores for the M-ABC-2-NL and motor quotients for
the KTK-NL are represented using box-and-whisker plots (Figure 2, 3 and 4).
Figure 2: Box-and-wisker plot of the results of the Figure 3: Box-and-wisker plot of the results of the
M-ABC-2-NL KTK-NL: Sideways Jumping
Figure 4: Box-and-wisker plot of the results of the KTK-NL: Backwards Balancing
The subscores on balance for each child for every outcome measure (M-ABC-2-NL, KTK-NL: SJ
and KTK-NL: BB) and for each test moment (baseline (T0), after three weeks of the conventional
balance circuit intervention (T1) and after three weeks of the intervention with Matti® (T2)) can be
found in figure 5, 6 and 7, respectively.
24
Figure 5: Scores of the M-ABC-2-NL Figure 6: Scores of the KTK-NL: Sideways Jumping
Figure 7: Scores of the KTK-NL: Backwards Balancing
To examine whether there was a significant difference in balance scores between baseline (T0),
after three weeks of the conventional balance circuit (T1) and after three weeks of Matti® (T2), a
Friedman test was implemented. The Friedman test indicated no significant differences between
the test moments for all balance measures. Chi-squared ( χ2) = 1,45; p = 0.53 for the M-ABC-2-
NL balance subscale, χ2 = 3,32; p = 0.20 for the BB subscale of the KTK-NL and χ2 = 5,68; p =
0.06 for the SJ subscale of the KTK-NL. Since the p-values of the M-ABC-2-NL and KTK-NL are
higher than 0,05, the results are non-significant.
25
Motivation
The results of the IMI are individually reported in Table 4.
Child Balance
circuit 1
Balance
circuit 2
Balance
circuit 3
Matti® 1 Matti® 2 Matti® 3
1 27,91 27,73 27,73 28,14 27,54
2 25,55 21,4 30,02 22,44 27,6
3 29,96 23,66
4 31,4 26,24
5 31,6
6 25,96 23,98 27,83
7 31,4 32,6 32,2 30,9 30,74 32,94
8 29,27 32,69 32,15 29,98 27,82
9 28,08 32,6 31,4 31,4
10 25,34 29,81 27,67 33,4 28,58
11 29 27,72 31,4 28,24
12 28,16 27,87 28,58 26,56
Table 4: Total score on the IMI
An average of the two or three test scores was made of the IMI scores after the balance circuit
and of the scores after a session with Matti®. Figure 5 shows a bar chart of the mean IMI scores
after the balance circuit sessions versus the sessions with Matti® for each child.
26
Figure 5: Average of the scores of the IMI
Three children scored higher on the IMI after the Matti® sessions, while eight children had a higher
score on the IMI after the sessions with the conventional balance circuit. Due to missing data, it
was not possible to apply statistics on the IMI.
Qualitative observations
Since the therapy was given in two different locations and the researchers had to use different
materials, the balance circuits were different. Due to the fact that there was only one gaming mat
available for the two locations, the mat was not always available when necessary. Furthermore,
Matti® often did not work, resulting in missing data. Due to technical problems, the mat could not
be used 12 times.
Another problem was the IMI to be time consuming. From the 30 minutes reserved for the
intervention, it took at least 10 minutes to complete the IMI.
A third complication was the Likert scale where the numbers three to five were almost never used.
Most of the participants chose number 'seven' when they agreed with the sentence and number
'one' when they did not.
27
Discussion
Most important results
The aim of this study was to evaluate the feasibility of the gaming mat 'Matti®' in paediatric
rehabilitation, and the effect of exercising on the mat on balance and motivation with children with
mild coordination and balance problems. The mat could be integrated into a traditional
rehabilitation program. The results of the balance subtest of the M-ABC-2-NL and KTK-NL did not
statistically improve after conventional therapy or intervention with Matti®. However, results
following intervention with Matti® indicate a trend towards improvement, though not statistically
different from baseline measures. The low number of participants could account for the lack of
statistical significance. However, as this study was not a Randomised Control Trial (RCT), no
conclusions regarding effectiveness can be made. The results of the IMI show no trend in the
answers the children gave, with statistical analysis impossible as described before. There is no
evidence to conclude whether there is a difference in motivation between therapy with or without
the gaming mat. Higher scores can be found for eight children for the balance circuit, while only
three children scored higher for the gaming mat. It should be noted that those differences in scores
were considerably small, and could thus be neglected in broader research. To conclude, based
on this pilot study, it is not possible to make a statement about the effectiveness of Matti® in
improving balance, nor can it be shown that Matti® increases motivation.
A first reason why no clear statements can be made is the study design for this research. The
participants underwent pre-post assessments without a control group. Originally the aim was to
adopt a cross over design, however due to logistic constraints this was not possible. As such, the
practice effect of repeated testing could not be monitored. The M-ABC-2-NL and the KTK-NL
were assessed three times in a row for each participant, with only three weeks between measures.
The study of Van Waelvelde et al. (2007) reported that repeated testing on the M-ABC-2-NL at
intervals of three weeks results in a systematic measurement error (47). Therefore, the
improvement shown in the results after the intervention with Matti® could be the result of a practice
or learning effect of repeated testing. Particularly since most of the participants played only once
or twice on the gaming mat. As the intervention with Matti® followed the balance circuit
intervention, it could be possible that the children improved their balance scores by building on
their already improved balance due to the balance circuit. It is also possible that balance
improvements require more than three weeks to demonstrate significant change.
28
A second limitation of this study concerns the missing data. Not every child that participated
attended the three test moments due to health problems, especially during the intervention with
Matti®. Additionally, during the three weeks of the Matti® intervention, the gaming mat experienced
repeated technical problems, preventing the gaming intervention from being carried out. At times
there was no connection between the computer and the gaming mat, resulting in the mat not
lighting up. Some participants could only play once during the three weeks intervention on Matti®,
while others were able to play three times within three weeks. Lastly, the IMI was taken each
week during the last 10 minutes of the session, after the intervention. In some circumstances a
lack of time occurred to complete the questionnaire. Although almost all participants underwent
the three weeks of the balance circuit therapy, not all of them were able to fill in the IMI. The IMI
data collection was also affected by sessions in which the Matti® intervention did not work as
expected. Comparing the average of three IMI's of the balance circuit to one IMI of Matti® could
bias the results. Due to the missing data, the statistical power of this study is very low.
A third limitation relates to the standardisation of the assessment and intervention. Because of
external factors, the proposed protocol was often disrupted. For example, unpredicted problems
with time management arose due to the distractibility of the participants. It was feasible to comply
with the time management during the Matti® intervention, as playtime was set to four minutes per
game. However, this was more difficult to control during the balance circuit where participants
were often slow to commence or move on from the exercises. Each week, the researchers
designed a new balance circuit to maintain adequate levels of challenge for all participants.
Nevertheless, some children performed better at the circuit than others, resulting in varied times
required to complete each circuit. The researchers tried to adapt the circuit according to the level
of the participant. However, this did not prove effective at normalising the speed of each
participant of completion of the circuit. Some participants had to do the circuit in pairs due to time
and equipment restraints, which may also have effected performance and outcomes. In pairs, the
time to finish the circuit was often more than four minutes and may have contributed to the
distraction exhibited by participants or may have affected motivation, thus resulting in the possible
biases in the outcome measures. These problems did not occur during Matti® sessions. The
games were all single-player and could be readily adjusted to the level of the child, ensuring
appropriate challenge without impact on motivation or distraction. Additionally, the balance circuits
differed between the two intervention locations. Furthermore, the testing moments were unable
to be standardised due to absenteeism. To avoid more missing data, some test moments had to
be rescheduled and took place directly following an intervention session. This could have affected
the results as some participants may have decreased performance secondary to fatigue.
29
A distinction can be made between Matti® and other exergames. Firstly, little space is needed and
the mat is easy to store. The mat is easy to use, especially for children with DCD. There are no
other items required than the mat, a computer with internet accessibility and a screen to
commence play. No boards could result in tripping hazards and no mandatory devices that they
should hold in their hands. Nevertheless, there is sufficient space to practise balance on the mat
according to its size. Additionally, researchers showed that a self-controlled exercise schedule, in
which the participant can determine which game he or she wants to play, ensures a positive
learning effect. This is based on the SDT (25). Due to access to a single mat between two
locations, the mat did not always arrive at the beginning of each intervention session, resulting in
decreased intervention time. This, together with the several technical break-downs of Matti®,
could have affected the motivation of the children.
The Matti® system would benefit from improved ease of use. Games should commence with a
brief demonstration outlining the goal of the game with specific instructions. An anti-slip coating
lining the underside of the gaming mat would greatly improve safety, particularly of jumping
games. The LED lights of the gaming mat should be brighter to improve visibility during daytime.
The program of the mat should be more specific on what constitutes a “failed” exercise. Currently,
when users jump three times when required to jump only twice the system determines that to be
a correct attempt, while the researchers would argue this lack of control should constitute a “fail”
score. Another suggestion would be to increase the sensitivity of Matti® to ensure it is able to
differentiate between single and double leg exercises allowing the mat to differentiate jumping
with one or two legs. This would also facilitate the inclusion of single leg static challenges while
monitoring for the second leg touching down on the mat.
One of the research questions of this study was: ‘Does gamification, more importantly Matti®,
increase motivation?’ To investigate this, the researchers used the IMI as assessment tool, based
on the article of Choi et al. (2010) (48). The IMI is based on the CET (25), which states that
intrinsic motivation derives from the need of the individual for autonomy, belonging and
competence. The CET is a sub-theory of the SDT (27). The hypothesis that the intrinsic motivation
of the child will enhance could not be analysed due to the low power of this study and the missing
data, particularly following intervention with Matti®. Because the IMI was scheduled for the end of
every session and required approximately 10 minutes to complete, a lack of time during sessions
resulted in incomplete answering of questionnaires.
30
During data analysis and intervention reflection, researchers identified several issues with the IMI
in determining motivation in this population. The primary concern was that the IMI was too long,
resulting in children losing focus and concentration on questionnaire completion. This may have
been confounded by taking the IMI at the end of each session when children were likely fatigued
Another problem was that the language of the IMI proved to be too advanced for the younger
participants, particularly for one who's native language was not Flemish. Most children did not
understand the purpose of the seven numbers and how they could use them to nuance their
responses to the Likert Scale. Most participants responded in a binary manner, choosing number
'seven' when they agreed with the sentence and number 'one' when they did not. Moreover,
research by Choi et al. (2010) showed the IMI to be a reliable and valid instrument for assessing
intrinsic motivation but is most suitable for people with at least a fourth-grade reading level (48).
These issues may have contributed to the lack of conclusive findings for the IMI.
The SDT states that giving the children more autonomy influences their intrinsic motivation (26).
As such, the researchers expected to see an increase in motivation while playing on the gaming
mat. Each session the participants could choose three games to play on Matti®, with no limit to
the number of times they selected the same games over the three weeks of intervention. Some
children played the same game repeatedly, while others showed greater variation in the game
selections. Studies have shown that variation in exercises is better for motivation than repeatedly
doing the same exercises (49). Not only the gaming mat itself was determinative for the
motivation, also letting the children choose their own game was a contributory factor. However,
there was a lack of standardisation in the method of game selection with Matti®. Due to the
variation in selection method, no conclusions can be made to see regarding the effect of increased
autonomy on intrinsic motivation.
Overall, participants scored the IMI of the gaming mat lower than that of the balance circuits. This
may be due to the technical and availability problems that occurred during the Matti® intervention
sessions. Some participants stated feeling disappointed when the Matti® system did not work,
which could have effected their motivation to play. It also should be noted that the researchers
made an effort to make the balance circuits as attractive as possible for the children in an attempt
to maximise enjoyment. The break from usual therapy of the participants and introduction of new
therapists should not be discounted when analysing the expected enjoyment of the balance circuit
interventions.
31
Future protocol
A blinded RCT, could be a cross-over design, is essential to prove the effectiveness of the gaming
mat to enhance motor performance. The effect size of the study should exceed the value of the
measurement bias. Power analysis is necessary to define the number of participants required to
obtain an appropriate effect size, with consideration of high drop-out rates of participants. The
intervention sessions should be adapted, with a longer duration for individual session and the
intervention period. For example, conventional balance therapy could be compared to
conventional balance therapy wherein the last 10 minutes consist of playing on the gaming mat,
as the child desires. The effect on coordination and balance needs to be measured using validated
outcome measures, e.g. the M-ABC-2-NL, the KTK-NL, the Bruininks-Oseretsky Test of Motor
Proficiency (BOT), or another equally reliable outcome measure. The Goal Attainment Scales
(GAS) could be used to evaluate the effect on patient-specific or parent-nominated activities, with
motivation being measured through age-appropriate scales or questionnaires.
Future research should also ensure multiple testing sites always offer identical interventions,
particularly concerning the balance circuits, ensuring the materials and difficulty adaptions are
consistent regardless of testing centre. A prolonged study with more participants, a control group
and a follow up test moment are recommended for future research.
32
Conclusion
Matti® seems to be a promising device to perform balance training with children. Effectiveness for
improving balance or motivation in children has yet to be shown. No significant improvement was
found in the balance scores of the M-ABC-2-NL and the KTK-NL, and no trend was found in the
results of the IMI. Because of time constraints and missing data, the protocol required mid-testing
alterations. A future protocol should account for difficulties experienced in this study to ensure
more accurate and available data. In order to obtain sufficient statistical power and increase the
level of evidence to consider the effect of Matti® in the rehabilitation of children with coordination
and balance problems, a RCT comprising of a larger sample size and follow-up is recommended.
Since Matti® is not a task specific intervention, the improvement in Matti® scores does not
necessarily transfer to daily life. A task-specific intervention, to expose a child repeatedly to a
given balance task under specific constraints (e.g. the natural environment of the child), is
currently one of the most common methods to improve the balance performance of children with
DCD (50). This treatment strategy is based on the principles of motor learning and neuroplasticity
(50). Research has shown that task-specific interventions can improve the motor performance of
children with DCD in hopping, skipping and various balance activities (50). Children with balance
impairments are recommended to train their balance in a task-oriented manner (e.g. training in
the context and activity that proves difficult) (51). Giboin et al. (2015) reports that balance training
improved performance only in the specific task that was trained with no transfer of balance skill
to other tasks (51). Consequently, since Matti® has a process specific approach, it is not possible
to say if this approach is effective. The outcomes of this study focussed solely on improved
function and motivation and no task-specific assessments were conducted.
33
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37
Abstract (lekentaal)
Achtergrond: In de laatste decennia is het gebruik van interactieve computerspelletjes in de
behandeling van kinderen toegenomen. Deze computerspelletjes worden verondersteld de
motivatie te verhogen. De speelmat Matti® werd ontworpen door Creative Therapy met als doel
om geïntegreerd te worden in de fysische revalidatie.
Doelstellingen: Het doel van de huidige studie was om de doeltreffendheid van Matti® te
evalueren, in vergelijking met een gewoon evenwichtsparcours, om het evenwicht en de motivatie
te verbeteren bij kinderen met milde coördinatie- en evenwichtsstoornissen.
Studie design: Een haalbaarheidsstudie gecombineerd met een piloot studie om de
doeltreffendheid te evalueren van de mat, met als doel om evenwicht en motivatie te verbeteren.
Methode: Twaalf kinderen (acht jongens en vier meisjes tussen zeven en 11 jaar) met
evenwichtsproblemen namen deel aan deze studie. Elk kind startte drie weken therapie met
behulp van een evenwichtsparcours gevolgd door opnieuw drie weken therapie, maar dan met
de mat. Twee testen werden gebruikt om het evenwicht te bepalen bij het begin, na drie weken
en na zes weken therapie. Om de mate van motivatie na te gaan, werd aan de kinderen gevraagd
om na elke therapiesessie een vragenlijst in te vullen.
Resultaten: Er werd geen beduidende verbetering gevonden van de scores op de verschillende
testen, over het verloop van de drie testmomenten.
Conclusie: Matti® lijkt een veelbelovend therapeutisch toestel om te werken aan het evenwicht bij
kinderen. De doeltreffendheid moet nog bewezen worden, zowel voor het verbeteren van het
evenwicht als voor het verbeteren van de motivatie.
38
Approval of ethical committee
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43
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46
Appendix
Appendix 1: Questionnaire IMI balance circuit
Interesse/ plezier
o Ik vond het evenwichtsparcours heel leuk
o Ik had plezier tijdens het evenwichtsparcours
o Ik vond het evenwichtsparcours saai
o Ik kon mijn aandacht helemaal niet bij het evenwichtsparcours houden
o Ik zou het evenwichtsparcours beschrijven als heel interessant
o Ik vond het evenwichtsparcours redelijk plezierig
o Terwijl ik het evenwichtsparcours aan het spelen was, dacht ik na over hoe leuk ik het vond
Ervaren competentie
o Ik denk dat ik redelijk goed ben in het evenwichtsparcours
o Ik denk dat ik het evenwichtsparcours heel goed deed, in vergelijking met andere kinderen
o Nadat ik het evenwichtsparcours een tijdje gedaan had, voelde ik mij hier redelijk goed in
o Ik ben tevreden over mijn prestatie op het evenwichtsparcours
o Ik deed het evenwichtsparcours redelijk goed
o Ik kon het evenwichtsparcours niet heel erg goed
Moeite/ belang
o Ik heb hier veel moeite voor gedaan/ mijn best gedaan
o Ik heb niet heel goed geprobeerd om het evenwichtsparcours goed te doen
o Ik heb heel hard mijn best gedaan voor het evenwichtsparcours
o Het was belangrijk voor mij om het evenwichtsparcours goed te doen
o Ik heb hier niet veel energie in gestoken
Druk/ spanning
o Ik voelde mij niet zenuwachtig terwijl ik dit aan het doen was
o Ik voelde mij heel gespannen terwijl ik het evenwichtsparcours aan het doen was
o Ik was heel relaxed, rustig, ontspannen terwijl ik dit aan het doen was
o Ik was angstig terwijl ik het evenwichtsparcours aan het doen was
o Terwijl ik dit aan het doen was, voelde ik mij onder druk gesteld
Waarde/ nut
o Ik geloof dat het evenwichtsparcours een meerwaarde kan zijn voor mij
o Ik denk dat het evenwichtsparcours nuttig zijn voor...
o Ik denk dat dit belangrijk is om te doen omdat...
o Ik zou dit graag nog eens doen omdat het een weerwaarde heeft voor mij
o Ik denk dat het doen van het evenwichtsparcours mij kan helpen om...
o Ik geloof dat het evenwichtsparcours nuttig/ voordelig kan zijn voor mij
o Ik denk dat het evenwichtsparcours belangrijk is
47
Appendix 2: Questionnaire IMI Matti®
Interesse/ plezier
o Ik vond het spelen op de mat heel leuk
o Ik had plezier tijdens het spel/ de spelletjes
o Ik vond de spelletjes saai
o Ik kon mijn aandacht helemaal niet bij de spelletjes houden
o Ik zou deze spelletjes beschrijven als heel interessant
o Ik vond de spelletjes redelijk plezierig
o Terwijl ik de spelletjes aan het spelen was, dacht ik na over hoe leuk ik het vond
Ervaren competentie
o Ik denk dat ik redelijk goed ben in deze spelletjes
o Ik denk dat ik deze spelletjes heel goed deed, in vergelijking met andere kinderen
o Nadat ik deze spelletjes een tijdje gedaan had, voelde ik mij hier redelijk goed in
o Ik ben tevreden over mijn prestatie op deze spelletjes
o Ik deed deze spelletjes redelijk goed
o Dit waren spelletjes die ik niet heel erg goed kon
Moeite/ belang
o Ik heb hier veel moeite voor gedaan/ mijn best gedaan
o Ik heb niet heel goed geprobeerd om de spelletjes goed te spelen
o Ik heb heel hard mijn best gedaan voor deze spelletjes
o Het was belangrijk voor mij om de spelletjes goed te doen
o Ik heb hier niet veel energie in gestoken
Druk/ spanning
o Ik voelde mij niet zenuwachtig terwijl ik dit aan het doen was
o Ik voelde mij heel gespannen terwijl ik de spelletjes aan het spelen was
o Ik was heel relaxed, rustig, ontspannen terwijl ik dit aan het doen was
o Ik was angstig terwijl ik aan de spelletjes aan het spelen was
o Terwijl ik dit aan het doen was, voelde ik mij onder druk gesteld
Waarde/ nut
o Ik geloof dat deze spelletjes een meerwaarde kunnen zijn voor mij
o Ik denk dat deze spelletjes nuttig zijn voor...
o Ik denk dat dit belangrijk is om te doen omdat...
o Ik zou dit graag nog eens doen omdat het een weerwaarde heeft voor mij
o Ik denk dat het spelen van deze spelletjes mij kan helpen om...
o Ik geloof dat het spelen van deze spelletjes nuttig/ voordelig kan zijn voor mij
o Ik denk dat het spelen van deze spelletjes belangrijk is
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Appendix 3: Thermometer
Appendix 4: Descriptives M-ABC-2-NL and KTK-NL for test moment 1, 2 and 3
M-ABC_1 M-ABC_2 M-ABC_3
Median 5,50 6,00 6,00
Minimum 1,00 1,00 1,00
Maximum 9,00 12,00 10,00
Percentile 25 2,50 2,00 2,00
Percentile 50 5,50 6,00 6,00
Percentile 75 8,75 9,00 9,00
49
KTK_BB_1 KTK_BB_2 KTK_BB_3
Median 77,00 76,00 81,00
Minimum 60,00 53,00 59,00
Maximum 124,00 112,00 109,00
Percentile 25 63,00 67,00 77,00
Percentile 50 77,00 76,00 81,00
Percentile 75 85,75 90,00 90,00
KTK_SJ_1 KTK_SJ_2 KTK_SJ_3
Median 65,00 78,00 77,00
Minimum 9,00 23,00 46,00
Maximum 94,00 94,00 111,00
Percentile 25 47,75 56,00 53,00
Percentile 50 65,00 78,00 77,00
Percentile 75 85,50 86,00 106,00