Research in Developmental Disabilities 34 (2013) 36543659

Contents lists available at ScienceDirect

Research in Developmental Disabilities

A Kinect-based upper limb rehabilitation system to assist

people with cerebral palsy
Yao-Jen Chang a,c,*, Wen-Ying Han b, Yu-Chi Tsai a
a

Department of Electronic Engineering, Chung Yuan Christian University, Chung-Li 320, Taiwan
Physical Therapy Services, National Tainan Special School, Tainan 709, Taiwan
c
Holistic Medical Device Development Center, Chung Yuan Christian University, Chung-Li 320, Taiwan
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 26 June 2013
Received in revised form 14 August 2013
Accepted 14 August 2013
Available online 4 September 2013

This study assessed the possibility of rehabilitating two adolescents with cerebral palsy
(CP) using a Kinect-based system in a public school setting. The system provided 3 degrees
of freedom for prescribing a rehabilitation program to achieve customized treatment. This
study was carried out according to an ABAB reversal replication design in which A
represented the baseline and B represented intervention phases. Data showed that the two
participants signicantly increased their motivation for upper limb rehabilitation, thus
improving exercise performance during the intervention phases. Practical and developmental implications of the ndings are discussed.
2013 Elsevier Ltd. All rights reserved.

Keywords:
Physical rehabilitation
Cerebral palsy
Kinect
Image recognition

1. Introduction
Cerebral palsy (CP) is a term denoting a group of non-progressive, non-contagious motor conditions that cause physical
disability in human development, mainly in the various areas of body movement (Rosenbaum et al., 2007). People with CP
experience limitations in ne motor control, strength, and range of motion. These decits can dramatically limit their ability
to perform daily tasks, such as dressing, hair combing, and bathing, independently. In addition, these decits can reduce
participation in community and leisure activities, and even negatively impact occupational perspectives (Gabriele & Renate,
2009; Lai, Studenski, Duncan, & Perera, 2002; Wagner, Lang, Sahrmann, Edwards, & Dromerick, 2007). Individuals with
access to intensive multidisciplinary rehabilitation programs demonstrate earlier and faster functional gains on functional
independence measures. Participating in repetitive exercises can help people with CP overcome the limitations they
experience. However, one study indicates that only 31% of people with motor disabilities perform the exercises as
recommended (Shaughnessy, Resnick, & Macko, 2006), which can result in negative consequences such as obesity-related
chronic health conditions. People often cite a lack of motivation as an impediment to them performing the exercises
regularly (Lloyd-Jones et al., 2010). Furthermore, the number of exercises in a therapy session is typically insufcient (Lang,
MacDonald, & Gnip, 2007). One solution to this issue is staff intervention; however, it may not be economically viable.
Research suggests that physical therapy can sufciently stimulate brain to remodel itself and provide better motor
control (Kleim, Jones, & Schallert, 2003). Identifying effective methods of encouraging people with CP to perform exercises is
crucial for helping them retain or enhance their motor control and increase their independence. Full reintegration into the
community and vocation are the ultimate goals. Strategies incorporating the use of various technologies for the people with

* Corresponding author at: Department of Electronic Engineering, Chung Yuan Christian University, Chung-Li 320, Taiwan. Tel.: +886 3 265 4630;
fax: +886 3 265 4699.
E-mail addresses: yjchang@cycu.edu.tw (Y.-J. Chang), winyn6214@yahoo.com.tw (W.-Y. Han), youji32@gmail.com (Y.-C. Tsai).
0891-4222/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ridd.2013.08.021

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CP have been developed for physical therapy across numerous settings. These innovative technologies provide a selection of
differing platforms and contribute to the user sensory experience. In particular, virtual reality (VR) and motion-based games
have been used for rehabilitation recently. Virtual reality systems demand focus and attention, can motivate the user to
move, and provide the user with a sense of achievement, even if they cannot perform that task in the real world. Burdea,
Deshpande, Liu, Langrana, and Gomez (1997) were the rst to incorporate VR technology for hand rehabilitation therapy. By
using sensors installed in gloves, users were provided with VR-based force feedback, and the system provided data records
regarding the grip forces achieved for every activity, and grip forces and bending angles of ngers. Jack et al. (2000) used a PC
based desktop virtual reality system for rehabilitating hand function in stroke patients. The system used two hand input
devices, a hand-centric 3D motion capture glove and a force feedback glove, to allow the user to interact with rehabilitation
exercises. Both gloves are complicated and may not be affordable to many people with motor disabilities. Virtual reality
needs a special setting such as caves or tents, making it less practical to many people that need it.
Industrial motion sensors (Bach-y-Rita et al., 2002; Foerster, Smeja, & Fahrenberg, 1999; Shih, 2011; Shih, Chang, & Shih,
2010a) and, in particular, entertainment oriented ones (Balaam et al., 2011) such as Nintendo Wii Remote (Alankus, Proftt,
iz, & Colomer,
Kelleher, & Engsberg, 2010; Shih, Chang, & Shih, 2010b) and Wii Balance Board (Gil-Gomez, Llorens, Alcan
2011) show research evidence that they are useful as physical rehabilitation tools. Furthermore, motion-based games that
combine motion sensor technology and fun with video games can motivate people to engage in exercises that games design
purposefully. Alankus et al. (2010) attached a Wii remote to the arms of a female patient with hemiparesis. The patient
controlled the motion of a helicopter in a game or caught a baseball by moving her arms. The researchers employed a gamebased approach to increase the patients motivation to participate in physical rehabilitation and adopted Wii remote features
to design movements or exercises suitable for rehabilitation. A drawback with motion sensors is that people have to fasten
them on limbs, hold them in the hands or even wear them on the body to detect motions and possibly generate force
feedback. Wearing sensors can cause inconvenience and discomfort.
A previous study used a Kinect-based system to assist people with motor impairments in rehabilitation (Chang, Chen, &
Huang, 2011). By using videos in which physical therapists demonstrated rehabilitation exercises and the action
recognition function in Kinect, the participants were able to independently perform rehabilitation without teacher presence.
However, although using Kinect allowed the participants to perform customized movements, the disadvantage of this
approach is that customized movements can only be identied based on displacement, which limits movements during
rehabilitation activities.
This study aims to enable physical therapists to design diversied movements based on the needs of participants with CP and
achieve the goal of developing customized rehabilitation exercises, by designing a system to help motivate people to increase
the number of exercises and improve the motor prociency and quality of life. We primarily employed the Microsoft Kinect
sensory device to establish an upper limb rehabilitation system for people with CP. This system enables physical therapists to
develop series of poses for rehabilitation based on the level of motor impairment for each participant. These poses can be
tailored for training participants to dress or undress, for training participants to hold objects, and for self-feeding, just to name a
few. Moreover, this Kinect-based system detects joint points and subsequently calculates various angles (i.e., shoulder exion,
shoulder extension, shoulder external abduction, shoulder external rotation, shoulder internal rotation, and elbow exion) for
the requested poses to determine whether the upper limb movements correspond to therapists expectations.
Microsoft Kinect is a webcam-style add-on peripheral intended for the Xbox 360 game console. Kinect enables users to
control and interact with the game console without the need to touch a game controller, through a natural user interface
using gestures. The device comes with an RGB camera and a depth sensor, which in combination provide full-body 3D
motion capture capabilities and gesture recognition. Going beyond the systems intended purpose of playing games, we
leveraged the human gesture recognition capabilities of Kinect to determine whether a user performed exercise correctly in
physical rehabilitation. Using Kinect means that the users need not be bothered with body sensors and that the system can
save the users from wearing sensors that can be intrusive.
The proposed system measures 3 degrees of freedom (DoF) in upper limb rehabilitation: 1 DoF for elbows and 2 DoF for
shoulders. It is a major upgrade of its previous 1 DoF design (Chang et al., 2011). The design with 3 DoF provides therapists with
greater exibility to prescribe customized rehabilitation programs to address individual needs. With the help of technology, a
therapist can specify angles of shoulder exion, shoulder extension, shoulder external abduction, shoulder external rotation,
shoulder internal rotation, and elbow exion for upper limb rehabilitation. Using this system, therapists can gauge the accuracy
of participant upper limb movements by measuring the above-mentioned angles. The system also includes an interactive
interface with audio and video feedback to enhance motivation, interest, and perseverance to engage in physical rehabilitation.
Details of rehabilitation conditions are also automatically recorded in the system, allowing therapists to review rehabilitation
progress quickly. Therefore, this system reduces staff workload, helps assess the quality of physical exercise, and enhances the
efciency of rehabilitation, which increases the ability to perform daily tasks independently.
2. Method
2.1. Participants
After the system was developed, a physical therapist in a special-education school invited two junior-high school
students to test the assistive device. Alice and Belle were identied for inclusion in the study. Alice, age 14, was diagnosed as

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having severe cerebral palsy with inexibility of upper and lower limb movements and insufcient muscle endurance
after she was born. She has received substantial rehabilitation since she enrolled in the special education system. She
uses a wheel chair for transportation. She is an outgoing adolescent schoolgirl and owns good oral communication skills.
The function of her right hand far exceeds the function of the other hand. Therefore, her therapist puts more efforts in
rehabilitating her left hand to help her perform daily tasks independently. Belle, age 14, was diagnosed as having
acquired muscle atrophy and insufcient muscle endurance. She remains mobile on a wheelchair. She is an introvert
and only has very limited communication skills. She did not receive early intervention until she enrolled in the public
special education program. The therapist has worked for years to increase her task skills such as self-feeding and
reaching for things independently. Neither of the participants had previous experience with Kinect. The names of
participants have been changed in this report to protect their privacy. Informed consent was provided at the levels of
the service organization, individual staff members involved in the study, and the main caregivers on behalf of
participants with CP.
2.2. Setting
This study tested the proposed system at a suburban special education school, which receives students with special needs
from kindergarten to high school. Kinect was connected to an IBM T61 notebook computer on which the rehabilitation
system software developed in house was installed with Microsoft Windows 7. The computer has an audio module that we
used to deliver audio feedback whereas its 14-in. LCD screen was used for visual interaction. The software was coded in
Microsoft C# using Visual Studio as the integrated development platform. The interactive interface with audio and video
feedback can be programmed to reinforce students motivation to engage in physical rehabilitation. For optimal performance
of the Kinect sensor, participants were required to perform physical exercise approximately 3 feet in front of the Kinect
module. See Fig. 1 for a participant performing rehabilitation in front of the system.
2.3. Operational denitions of target behaviors
The rehabilitation movements used in the experiment were as follows: (1) lifting one arm upwards (hand up), (2)
lifting one arm to the front (hand forward), and (3) moving a hand to the mouth (hand to mouth). For the movement of
lifting one arm upwards, participants who sat on wheelchairs initially put both hands on the wheelchair armrests. When
exercises began, they lifted one arm upwards and stretched it as far as possible. After maintaining the posture for at
least 3 s, they put down their hand back to the initial position. For the movement of lifting one arm to the front,
participants sat on wheelchairs and had their both hands on the wheelchair armrests. When exercise began, they lifted
one arm from the initial position until their arm was in parallel with the ground and was stretched as far as possible.
After maintaining the target posture for at least 3 s, participants put down their hand to the initial position. For moving
a hand to the mouth, participants sat on wheelchairs and had their both hands on the wheelchair armrests. When
exercise began, they maneuvered the hand that did or was supposed to do the self-feeding from the initial position until
their hand reached the mouth. After maintaining the target posture for at least 3 s, participants put down their hand to
the initial position.
2.4. Experimental conditions
The study was carried out according to an ABAB reversal replication design in which A represents the baseline and B
represents intervention phases (Richards, Taylor, Ramasamy, & Richards, 1999). Based on participant ability, physical
therapists developed various movements for rehabilitation and established initial and nal poses for each movement. The
rehabilitation movements used in the experiment were as follows: (1) lifting one arm upwards (hand up), (2) lifting one arm
to the front (hand forward), and (3) moving a hand to the mouth (hand to mouth). The physical therapist instructed the
students to perform three types of movements (i.e., hand up, hand forward, and hand to mouth) 15 times each in a session.
The participants were requested to rest for 5 min before proceeding with the next type of movement. This process was
performed until the three types of movements were completed. A movement was considered correct if the participant
performed it to the prescribed standard where the angle of each DoF fell within the expected range. One session per day was
observed within each study period. Sessions were taped and recorded.
2.4.1. Baseline phases
In the baseline phase, the therapist instructed a participant the content of a rehabilitation program. The participant then
repeated what she heard. If there was any inaccuracy in movement types or numbers of exercise, the therapist corrected the
participant until the content of the prescribed program was understood without errors. Then the participant started to
perform physical exercise on the wheelchair. During the baseline phases, the participants followed the instructions and
demonstrations of the physical therapist and completed the required movements without assistance. The proposed system
detected inaccuracy in performance and counted the number of correct movements in each session. However, the system did
not provide any visual cues and any feedback to the participant. The therapist did not interfere with any inaccuracy in
performance that the participant might have.

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Fig. 1. A participant performing rehabilitation in front of the system.

2.4.2. Intervention phases

In this phase, the proposed system was used. The participant used the cues on the screen to complete the prescribed
program. The proposed system detected the inaccurate movements of participants during rehabilitation activities and
determined whether the movements corresponded to the requirements of therapists. It automatically counted the
number of correct movements in each session. In addition, picture- and voice-based feedback was used to enrich
the rehabilitation process and increase motivation to engage in rehabilitation. The computer screen displayed
favorite cartoon characters each time a correct posture was achieved and played theme music when a type
of movements was completed. The therapist did not interfere with any inaccuracy in performance that the participant
might have.
2.5. Inter-observer agreement
In addition to machine counting of correct movements throughout the experiment, reliability observers collected
data on the number of movements performed correctly during at least 40% of the sessions and across all phases of the
study for each participant (range 4372%). Two special education graduate students who acted as the observers were
trained by the physical therapist we collaborated within the public special education school to collect data by providing
participants with the rehabilitation programs, performing participant evaluations, verbally explaining the procedures,
and answering all questions regarding the process. The observers responded during participant sessions in three
different ways: incorrect, correct and no response. The same two observers were used across both participants; they
were required to have 100% accuracy across 10 consecutive trials during practice before working with participants.
Agreement between the trainer and reliability observers on the correctly performed movements was calculated on a
session-by-session basis, using the following formula: agreements/(agreements + disagreements)  100%. The resulting
percentages of agreement were consistently above 97%. Moreover, machine reading and human observation showed an
agreement of 98% for all the sessions involving observers. Therefore, the results can be reliably collected from machine
reading.
2.6. Results
The rst baseline phase lasted for 4 days for both participants. The rst intervention phase lasted for 8 days for both
participants. The second baseline phase lasted for 3 days for both participants. The second intervention phase lasted for 7
days for Alice and 5 days for Belle. Belle dropped two sessions in the second intervention phase because she was ill. Fig. 2
shows data for Alice. The baseline and intervention phases observed the number of correct movements of each type. During
the rst baseline phase (4 sessions), the number of correct movements for each type was 3, 3, and 2 on the average. During
the rst intervention phase (8 sessions), the number of correct movements for each type increased to approximately 13, 14,
and 13, respectively. The number of correct movements decreased to 4, 2, and 4 during the second baseline (3 sessions) and
increased again, reaching nearly 14, 14, and 13 during the second intervention phase (7 sessions). The difference of numbers
of correct movements between the baseline and the intervention was signicant (p < .05) on the KolmogorovSmirnov test
(Siegel & Castellan, 1988).
Fig. 3 shows data for Belle. During the rst baseline phase (4 sessions), the number of correct movements for each type
was 1, 2, and 3 on the average. During the rst intervention phase (8 sessions), the number of correct movements for each
type increased to approximately 8, 12, and 13, respectively. The number of correct movements decreased to approximately 4,
4, and 4 during the second baseline (3 sessions) and increased again, reaching nearly 12, 14, and 13 during the second
intervention phase (5 sessions). The difference of numbers of correct movements between the baseline and the intervention
was signicant (p < .05) on the KolmogorovSmirnov test (Siegel & Castellan, 1988).

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Fig. 2. Number of correct movements for Alice completing the rehabilitation program.

Fig. 3. Number of correct movements for Belle completing the rehabilitation program.

3. Discussion
This study assessed the effectiveness of the proposed system for motivating physical rehabilitation using a baseline/
intervention reversal replication design. Results indicate that for the two individuals with CP, the proposed system in
conjunction with operant conditioning strategies may facilitate autonomous physical rehabilitation prescribed by the
therapist.
During the baseline phases, the number of correct movements for each type performed by Alice and Belle were low
because the required movements were relatively difcult for them to perform. In addition, the absence of feedback resulted
in a lack of enthusiasm for rehabilitation. For example, when performing the hand-up movement, the participants lowered
their arms before reaching the specied angle; thus, the quality of the movements failed to satisfy the therapists
expectations and achieve effective rehabilitation. During the intervention phases, the performance of Alice and Belle
increased substantially compared to those obtained during the baseline phases. Observations during the experimental
process showed that after completing the movements, the participants demonstrated considerable interest toward the
displayed feedback pictures.
A limitation of the study is that the results are based on two cases. Therefore, a general conclusion cannot be extrapolated
regarding the efcacy of the proposed system. Future studies should include experiments involving more participants with
motor impairments and focus on further evaluating the training system. Additionally, more interactive features should be
added to enhance the user experience. This technology can be used in other settings for other types of motor rehabilitation.
In addition to people with CP, the technology can be used with other populations, such as people with traumatic brain injury
(TBI), stroke, and spinal cord injury (SCI).
People with cerebral palsy (CP) must undergo long-term physical rehabilitation to enhance neural development.
Currently, commercial specialized rehabilitation products cannot be easily customized and are expensive; consequently,
public special-education schools generally cannot afford these products. One solution is the use of enhanced hardware or

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software assistive technology that can repurpose commercial high-technology products, turning them into high
performance assistive devices to match the special needs of persons with disabilities (Chang et al., 2010; Chang & Wang,
2010b). This study employed the Kinect technology and image recognition technology to create a rehabilitation system
applicable for people with CP. The rehabilitation system in this study demonstrated the use of commercial off-the-shelf
products and leveraged their advantages, such as affordability, availability, after-care service, technical support, and low
concern about social stigma (Chang & Wang, 2010a; Shih, 2011; Shih et al., 2010a, 2010b). Consequently, the study shows a
potential for people to rehabilitate at home because it is affordable and easy to set up, use and maintain, while still providing
appropriate and accurate interactions so that the user can practice motor activities independently. Evidence shows that the
proposed system with gesture recognition capabilities can be a viable rehabilitation tool that reduces impediments to
individuals performing the exercises. This device reduced staff intervention and enabled the participants to enhance their
motivation for physical rehabilitation. Their achievement enhances a sense of self-determination, a feeling of independence,
and improves the quality of life for individuals with disabilities (Felce & Perry, 1995; Wehmeyer & Schwartz, 1998; Wessels,
Dijcks, Soede, Gelderblom, & De Witte, 2003).
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