This review aimed to examine the intervention effects of AVGs on FMS development in NTDC. Seventeen RCTs were included in our meta-analysis, of which 11 were related to LS, 5 to OCS, and 14 to SS. Overall, AVGs showed the effectiveness of intervention on FMS in NTDC, however, for the three subordinate concepts of FMS, there were some differences in the intervention effect of AVGs.
Analyses of the intervention effect of AVGs on LS of NTDC
A meta-analysis of 11 studies included in this study with LS as an indicator showed that AVG had a significant effect on LS of NTDC (SMD=0.59). AVG is an interactive and personalized treatment method that can present the required environment and provide immediate feedback. By providing immediate feedback, virtual reality environments can elicit multisensory interactions that motivate and engage patients in longer and more intensive sessions. On the one hand, repetitive motor practice promotes neuroplasticity, on the other hand, in video game training, the standing posture is often used to complete a lot of weight fluctuation control, standing squatting, standing sitting, and other exercises, which require constant weight transfer between the lower limbs. This had a significant impact on the participants' lower limb strength and joint flexibility. These findings have promoted the continuous improvement of participants' LS, which is consistent with the results of a study conducted by Wuang et al.on 155 patients with Down syndrome aged 7-12 years.
However, some studies have shown that although the AVGs intervention group showed a greater trend of improvement compared with the control group, the difference between the two groups was not significant[2,17].This possibly because the intervention group did not provide participants with sufficient exercise intensity. AVGs have rich resources and the regulation of task difficulty, can improve participants' interest in practice, increased the amount of physical activity. Studies have shown that high-intensity repetition exercises can improve the physical function of the exercisers and produce better training results.Therefore, higher exercise intensity is required to achieve significant improvement in body function. At the same time, the literature included in the previous systematic evaluation studies was not randomized controlled experimental studies,2 and the literature quality was not high, so the conclusions may have some limitations.
Analyses of the intervention effect of AVGs on OCS of NTDC
There is a general lack of research on how AVGs interfere with the OCS of NTDC, and recent studies have shown varying results.There were only five studies on OCS included in this study, and the intervention effect was limited, which does not support its significant improvement in OCS.
The physical activities in these games include motor tasks that involve a wide range of sensory feedback,and visual feedback is dominant.Although AVGs can simulate rich real-world scenes, tactile is difficult to be fully practiced and developed in this simulation environment. Tactile is the feeling produced when contacting external stimuli, which is different from LS and SS, they require tactile stimulation to provide real-world experience, require upper or lower limbs to contact objects for object control, and perform actions such as throwing, slapping, and kicking. In this process, the touch between the body and object plays an important role, which is difficult to replicate in virtual reality technology. Neither the game handle in hand nor the controller worn on the body can provide timely haptic feedback, such as the weight and size of the control object.Therefore, some scholars began toproposal use haptic feedback gloves when using video games to simulate ball operations in real life. By wearing gloves, participants can timely feed back more haptic information to improve the intervention effect of AVGs on OCSs.
Although the overall effect of AVGs on improving OCS in this study was not significant, Chiu et al. showed that the range and frequency of use of children's upper limbs have a significant increase compared with the past after video game intervention, which greatly improves their independence level in daily activities.This undoubtedly has an important impact on the development and improvement of upper limb function in NTDC.
Analyses of the intervention effect of AVGs on SS of NTDC
Among the 17 studies included in this review, SS was the most concentrated (14 studies), and the intervention effect was also obvious (SMD=0.59). Visual feedback theory provides theoretical hypotheses for video games boosting participants' balance skills. The theory holds that when playing video games, children can see their actions on the video screen immediately, which constitutes a new effective learning method, implicit learning.
The tasks practiced during video games incorporate a wide range of visual–perceptual processing.The visual timely feedback enables the participants to continuously adjust and control the position of the body during the game. It enhanced the frequency and intensity of visual feedback, allowing participants to continuously perform posture detection and balance disturbance correction in response to different balance conditions. Meanwhile, the games exercises completed in the standing position increased the stability of the participants' trunk, the symmetry on both sides of the body was improved, the center of gravity of the body was evenly distributed on the lower limbs, the stability of standing was increased, and the ability of posture control was improved[44,45].
It is worth noting that when using AVGs to intervene in the SS of NTDC, attention should be paid to the control of exercise intensity and trying to avoid heavy load exercise in a short time. Ruzic et al. found that high-intensity exhaustive exercise load has a negative impact on both static and dynamic balance ability after studying the relationship between exercise load and balance ability with healthy people as samples. Although no similar study has been conducted on NTDC, it deserves our attention. With regard to exercise load, there may be some differences between the interventions of SS and LS, which requires more scientific experimental design and research based on different intensities in the future.
Moderating variable analysis of intervention effect of AVGs on FMS of NTDC
In this study, there was no significant difference in the improvement of OCS, therefore, only the LS and SS subgroups were analyzed. The subgroup analysis of the intervention effect on the LS of NTDC shows that the game intervention platforms are widely distributed, including Nintendo Wii, Xbox 360 Kinect, Q4 Scene Interactive Training System, and KMC1 virtual reality movement system. From the perspective of disease types and intervention settings, the intervention effect for children with cerebral palsy in medical and clinical institutions is more obvious, the conclusions of the intervention cycle, single intervention duration, and intervention frequency are relatively consistent, that is, the longer intervention cycle and intervention duration, as well as the higher intervention frequency every week, have a greater effect on the intervention effect of LS in NTDC.
The subgroup analysis of the intervention effect on SS of NTDC shows that research on intervention with Nintendo Wii games is the most concentrated. The Nintendo Wii balance platform is specially developed for balance games, and the intervention effect is also obvious,For children with CP, the effect of intervention in medical and clinical institutions is obvious, which is consistent with LS, In terms of intervention cycle, single intervention duration and intervention frequency, SS show different conclusions from LS. Short-term, high-frequency, and long-term interventions have more obvious effects on the SS of NTDC.
Due to the portable characteristics of video games, intervention treatment is not limited to specific clinical medical institutions but is gradually extended to schools and families. However, the results of this study found that the intervention effect in family and school environments was not significant, and the reason may be related to the degree of personalized support and guidance. When children play sports video games without any guidance, their skill execution ability is poor.In terms of intervention cycle, single intervention duration, and intervention frequency, there were certain differences in LS and SS in the subgroup analysis, mainly reflected in the unk dose of intervention. In the past, few studies have discussed the ideal frequency of AVG intervention in motor skill development, because other characteristics included in the study are different, which will also lead to some differences in intervention results. Therefore, it is difficult to identify the specific and scientific intervention doses. However, from the perspective of children's interest maintenance, long-term and high-frequency video game intervention (30 min of training every day within 20 weeks) is not conducive to the maintenance of children's learning interest and will make it difficult for participants to complete the intervention task.