Role of video games in cerebral palsy rehabilitation
There is many evidence for using of virtual reality active video games to promote active movement, improve balance, and increase energy expenditure in children with cerebral palsy.  
With the gain popularity of movement-based or 'active' video gaming systems (e.g., Nintendo's Wii® and Microsoft's Kinect®), and this systems is widespread access to low-cost, home-based virtual reality therapies. In contrast to expensive robotics, virtual immersive environments and technologically complex accessories housed at a handful of specialized rehabilitation facilities, There is widespread of using video games, about 87% of American youth reported own at least one video console and spend an average of 73 min in play each day. This widespread availability of video games should be reviving for physical rehabilitation.
Effect of video games on neuroplasticity
The keystones to motor learning and neuroplasticity are: motivation and reward, immediate feedback, and repeated practice of skilled movements. Video games certainly employ mechanisms to increase motivation and reward (e.g., through unlocking new games or levels), and enjoyment of movement-based video games and virtual reality is reportedly high in children with CP. Immediate feedback, through visual or auditory feedback is provided cognitively through scoring and point accumulation.  The level of game from simple to difficult is reflected in advancing game levels and the complexity of movements required can also be moderated through the selection of appropriate games. Finally, previous studies indicate that active video games do actually encourage repetitive movements, although the frequency, intensity and types of movements depend largely on the game being played and the engagement/approach of the child playing. so we can say theoretically, video games have all component to elicit neuroplasticity, You et al. were the first to demonstrate cortical reorganization following a 4-week intervention with an 8-year-old child with hemiparetic CP who participate in virtual reality for 60 min durations, five-times per week.  Golomb et al. also demonstrated improved functional scores and altered cortical activation profiles during a grasp task in a study of three adolescents with hemiplegic CP who participated in virtual reality games for 30 min per day, 5 days a
week, over a 3-month period. Both of these studies can be utilize to use of video games for specific therapeutic goals.
Advantage of video games
Video games rehabilitation is safe and feasible, self-motivated physical therapy guided by a low-cost video game system is indeed alluring, the ability to remotely monitor progress and to enhance social play with siblings and friends or through online associate, and it is easy to be swept away by the potential of video game-assisted rehabilitation, or more generally termed, virtual reality therapies.
Many Researches suggests that using motion-based virtual reality for rehabilitation can provide a very engaging and motivating approach for therapy . Patients who participate in virtual reality gaming therapy increase the intensity, frequency and duration of therapy movements, leading to enhanced motor performance.
Challenges for using of video games for therapeutic goals during rehabilitation
There are a number of barriers for use of video games in rehabilitation including, how to design effective program, efficient and easy-to-learn systems, challenges with compatibility of platform, ethical challenges, immature engineering processes, limited awareness and expectations by clinicians may be unrealistic, and perceptions that video game use eliminates or decrease the need for clinicians, may not allow for use in the home and are limited in the segments/joints they can train. In addition, games for many of these systems are designed by computer scientists and engineers making the games expensive and limited in selection and they may not be appropriate for all therapeutic goals (e.g., strength building).
Other barriers include:
- Monitoring and Feedback
While the mechanisms for feedback and monitoring are related to commercial video-game systems, in-game rewards are not always in line with therapeutic goals. For example, while use of the hemiplegic limb and/or bimanual use of the limbs are very important in physical rehabilitation, they are usually rewarded only indirectly during video game play. Previous studies have noted that the hemiplegic limb is used significantly less frequently during bilateral video game play than the dominant limb, and its use is decreased even more when children are highly motivated to win.
- Enjoyment and Motivation
virtual reality have confirmed, to be motivating and enjoyable for children with CP. but, not all mainstream games has the same with benefits regards to their therapeutic value. Virtual reality games studies, both with commercial and specially designed systems, usually provide children with a limited selection of games to choose from. So we should maintaining interest and use over time in the home environment has been an obstacle to adherence. 
The evidence support positive effect of virtual reality games for children and youth with CP is certainly positive for both specialized and commercial gaming systems.  However, effect of virtual reality games on motor or visual–perceptual skill attainment is not sufficient. 
A recently developed instrument to evaluate movement connected to video games has the potential to assist therapists in their decisions, but research shows the rating tool needs to be refined before introduction in clinical practice to help clinicians in choosing the right games for individual patients. 
Research opportunities of video games should be related to changes in functional outcomes, use of and enjoyment and motivation of game-based rehabilitation over time in the home environment, low-cost motion technologies available in markets or free internet video games
A new study used free internet videogames with the Microsoft Kinect motion sensor and Flexible Action and Articulated Skeleton Toolkit software (FAAST) to detect the range of motion. The team reported that children were highly motivated to play the video games that helping to improve the upper extremity abilities of children with CP. 
Finally we should develop video games with specific therapeutic goals and address the challenges of movement variability, therapeutic relevance and appropriate feedback, and maintain children's interest and motivation.
- Mitchell L, Ziviani J, Oftedal S, Boyd R. The effect of virtual reality interventions on physical activity in children and adolescents with early brain injuries including cerebral palsy. Dev Med Child Neurol. 2012 Jul;54(7):667–71.
- Dewar R, Love S, Johnston LM. Exercise interventions improve postural control in children with cerebral palsy: a systematic review. Dev Med Child Neurol. 2015 Jun;57(6):504–20. doi: 10.1111/dmcn.12660. [PubMed] [Cross Ref]
- Rideout V, Foehr UG, Roberts DF. Generation M2: media in the lives of 8–18 year olds: a Kaiser family foundation study (2010). www.kff.org/entmedia/upload/8010.pdf (Accessed 20 June 2012)
- Charles J, Gordon A. Development of hand–arm bimanual intensive training (HABIT) for improving bimanual coordination in children with hemiplegic cerebral palsy. Develop. Med. Child Neurol.48,931–936 (2006).
- Howcroft J, Klejman S, Fehlings D et al. Active video game play in children with CP: potential for physical activity promotion and rehabilitation therapies. Arch. Phys. Med. Rehabil. 2012;93(8):1448–1456
- Li W, Lam-Damji S, Chau T, Fehlings D. The development of a home-based virtual reality therapy system to promote upper extremity movement for children with hemiplegic CP. Technol. Disabil. 2009;21:107–113
- You SH, Jang SH, Kim Y, Kwon Y, Barrow I, Hallett M. Cortical reorganization induced by virtual reality therapy in a child with hemiparetic CP. Dev. Med. Child Neurol.2005;47:628–635
- Deutsch JE, Borbely M, Filler J, Huhn K, Guarrera- Bowlby P. Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescents with CP. Phys. Ther. 2008;88:1196–1207
- Golomb MR, McDonald B, Warden S et al. In-home virtual reality videogame telerehabilitation in adolescents with hemiplegic CP. Arch. Phys. Med. Rehabil.2007;91:1–7
- Chen, Y.P.; Kang, L.J.; Chuang, T.Y.; Doong, J.L.; Lee, S.J.; Tsai, M.W.; Jeng, S.F.; Sung,W.H. Use of virtual reality to improve upper-extremity control in children with cerebral palsy: A single-subject design. Phys. Ther. 2007; 87:1441–1457.
- Green, D.; Wilson, P.H. Use of virtual reality in rehabilitation of movement in children with hemiplegia—A multiple case study evaluation. Disabil. Rehabil. 2012; 34: 593–604
- Reid, D.T. Benefits of a virtual play rehabilitation environment for children with cerebral palsy on perceptions of self-efficacy: A pilot study. Pediatr. Rehabil. 2002;5: 141–148.
- James, S.; Ziviani, J.;Ware, R.S.; Boyd, R.N. Randomized controlled trial of web-based multimodal therapy for unilateral cerebral palsy to improve occupational performance. Dev. Med. Child Neurol. 2015; 57: 530–538.
- Cioi, D.; Kale, A.; Burdea, G.; Engsberg, J.; Janes, W.; Ross, S. Ankle Control and Strength Training for Children with Cerebral Palsy Using Rutgers Ankle CP. In Proceedings of the 2011 IEEE International Conference on Rehabilitation Robotics, Zurich, Switzerland, 29 June–1 July 2011
- Rizzo Albert, Kim Gerard Jounghyun. A SWOT Analysis of the Field of Virtual Reality Rehabilitation and Therapy. Presence: Teleoperators and Virtual Environments. 2005 Apr;14(2):119–146
- Howcroft J, Fehlings D, Wright V, Zabjek K, Andrysek J, Biddiss E. A comparison of solo and multi-player active video game play in children with unilateral CP. Games Health doi:10.1089/g4h.2012.0015 (2012)
- Wang M, Reid D. Virtual reality in pediatric neurorehabilitation: attention deficit hyperactivity disorder, autism and CP. Neuroepidemiology 2011;16(36):2–18
- Snider L, Majnemer A, Darsaklis V. Virtual reality as a therapeutic modality for children with CP. Dev. Neurorehabil. 2010;13(2):120–128.
- Levac D, Nawrotek J, Deschenes E, et al. Development and Reliability Evaluation of the Movement Rating Instrument for Virtual Reality Video Game Play. Eysenbach G, ed. JMIR Serious Games. 2016;4(1)
- Sevick M, Eklund E, Mensch A, Foreman M, Standeven J, Engsberg J. Using Free Internet Videogames in Upper Extremity Motor Training for Children with Cerebral Palsy. Hunter SJ, ed. Behavioral Sciences. 2016;6(2):10.