RESEARCH QUESTION AND OBJECTIVES This feasibility study will use a multi-stage mixed methods design20. It aims to address the possibility of successfully implementing the BB program intervention in a small scale, semi-controlled, real-world environment among Costa Rican families with children with hemiplegic CP. It will address our overall research question: To what extent is a video game designed for upper limb therapy (BB) feasible for use in a home rehabilitation program for children with hemiplegic CP in Costa Rica who experience barriers accessing therapy services? In this study, the investigators are particularly interested in four areas of feasibility: demand, implementation, limited-efficacy testing and acceptability as defined by Bowen et al17. Demand looks at the extent to which an intervention is likely to be used in a given setting or population. Implementation evaluates the extent to which the intervention can be implemented as proposed. Limited-efficacy aims to inform the potential of the intervention in a limited way (e.g., convenience sample). Acceptability focuses on how participants react to the intervention.
To address our research question, our specific objectives are:
1. To understand demand for the BB intervention, including expressed interest in the program, capacity to integrate BB into the family home and routine, and the expectations of children with hemiplegic CP and their parents for the BB intervention.
Indicators:
* Recruitment rate of 3 child-parent dyad a month for 5 months (n=15), with a ≥10% response rate (i.e., expressed interest, fit the eligibility criteria)
* At least 80% of families who wish to participate will have an appropriate screen and space to play BB.
* The family-directed play time goal, which is sensitive to family schedules and routines, provides a "therapy dose" that could reasonably be expected to be clinically meaningful \[i.e., at least 45 minutes a week13\].
* The family can define at least one therapy goal that aligns with the scope of the BB intervention.
* Identify the expectations that children and their parents have of the BB program (e.g., improving in a meaningful activity involving the upper limb, having a fun alternative to exercise their hands/arms).
2. To establish limited efficacy by measuring pre-post intervention changes in clinical outcomes related to upper limb function, activities and participation in children with hemiplegic CP using BB for 8 weeks at home.
Indicators:
● At least 75% of the children will show clinically meaningful improvements from pre- to post-intervention16 in: a) one of the dimensions of the Quality of Upper Extremity Skills Test (QUEST)the and/or, b) perceived performance on a self-identified upper limb goal area as measured by the Canadian Occupational Performance Measure (COPM)20. Secondary outcome measures are detailed in the methods section.
3. To evaluate implementation of the 8-week BB home intervention among children with hemiplegic CP, including ability to meet family-directed play time goals.
Indicators:
* ≥80% of children will a) achieve their weekly play time goal in at least 6 out of the 8 weeks, and b) complete the 8-week intervention.
* Number and type of reported technical barriers.
* ≤20% of participants will experience a technical barrier which will prevent use of the system for more than 4 days (e.g., technical difficulties will be easy to overcome with phone/video assistance).
4. To explore acceptability of the BB intervention through children's and parents' game and therapy related experiences
Indicators:
• To explore the perceived value of the intervention by children and their parents, including factors related to motivation1, the modality of therapy (i.e., home based), the use of the family-centered approach (e.g., family-directed play time goal), and the barriers they face accessing therapy services.
These feasibility success criteria were developed with reference to previous studies of similar upper extremity, home-based interventions in children with CP8,16,18
OVERVIEW OF STUDY DESIGN Two teams of researchers (Universidad de Costa Rica - HB, appendix M - research team) will carry out this study. This study follows an advanced multistage mixed methods design framework, with three sequential stages of data collection21 detailed in three phases. Each phase will address a specific objective.
Phase 1 - Demand \[QUAL (quant)\] : This phase addresses objective one and involves both a quantitative and a qualitative component. Data on recruitment rates, and access to appropriate space and technology to play indicators (quant) will be collected at the screening stage. Additionally, eligible children and their parent will be interviewed to establish their expectations for the BB intervention, and to understand how/if the intervention can be tailored to the family's needs and context (QUAL). Data collected in this phase will inform sampling and the intervention design for phase two. For example, if a family's expectations for the intervention do not align with what can be achieved by participating in the BB program, then they will not be included in the intervention phase (phase 2). Data from the semi structured interview from eligible participants will also be used to tailor the intervention in a family-centred way, to maximize potential for positive outcomes. For example, defining a realistic play time goal that aligns with the family's schedule and context.
Phase 2 - Limited Efficacy and Intervention \[QUANT (qual)\]: In this phase, 15 children-parent dyads will be provided with BB to play at home for 8 continuous weeks, and the necessary computer system to use it, namely the Orbbec Persee14. In phase two, children and parents will also participate in a weekly videocall (Zoom) where several research clinical assessments will be evaluated(QUANT Additionally, during the 8-week intervention a monitoring therapist (qual) will perform weekly 15-minute check-in video calls to each participant. During these video calls a short video assessment will also be conducted (Perceived Quality Rating Scale, PQRS). Data collected in Phase 2 related to play adherence, reported technical barriers, and field notes from the monitoring therapist will be used to inform and better guide the conversations during the post-intervention interviews in phase 3. For example, if a marked increase or decrease in play was observed at different time points in the intervention, this might be explored in further detail in the post-intervention interview.
Phase 3 - Acceptability \[QUAL\]: This strand will adopt a qualitative descriptive approach21 in order to explore participants' experiences about the intervention via a semi-structured, post-intervention interview. Analysis of these data will be used to better understand the results from the clinical research assessments. Additionally, the investigators will identify the extent to which family expectations for the BB intervention (established in the pre-interview phase) aligned with the experiences reported in the post-interviews during phase 3.
In rehabilitation clinical practice it is impractical to separate clinical outcomes from the social environment of the patient. The nature of this work calls for a mixed methods research approach since the quantitative and qualitative components cannot stand alone, and need to be integrated to fully answer the research question22. Data from each phase will be first analyzed separately and then brought together for analysis and comparison. Appendix F visually details how the data generated in each phase will be integrated to address our specific research objectives.
MIXED METHODS ANALYSIS AND INTEGRATION Integration will occur at the design, methods, interpretation and reporting levels. Members of the research team involved in the integration of results include researchers with clinical background in childhood disability, quantitative and/or qualitative expertise. At the methods level, the study uses a mix of connecting, building and merging approaches20. Integration using a contiguous approach will be used at the interpretation and reporting levels20. Appendix F visually details how each objective informs/links to each other at different integration levels.
Phase 1 and 2: A sample of participants from phase 1 will be selected to participate in phase 2, following the process and criteria described in the participants sections. Second, preliminary analysis from the pre-intervention interviews (phase 1) will be used to individually tailor the BB intervention in a family-centred way to maximize potential for positive outcomes in phase 2.
Phase 2 and 3: Field notes from the weekly phone calls and results from the computes logs from phase 2 will be used to better guide the conversation during the semi-structured interview with each participant in phase 3. For example, if a marked increase or decrease in play was observed at different time points during the intervention, if a participant reported technical barriers and/or an increase in play motivation during some of the weeks, this can be explored in further detail in the post-intervention interview.
Additionally, results from both phases will be brought together for interpretation. Quantitative and qualitative results will be merged to better understand changes in hand/arm clinical outcomes, contextual factors that influenced the results of the intervention, detailed information about the nature of the experience of the participants, and development of recommendations that might be necessary for future real-world implementation of similar interventions.
Phase 1 and 3: Results from both phases will be brought together to identify the extent to which the family expectations for the intervention in phase 1 coincide and/or align with the experiences reported in phase 3.
Integration with a contiguous approach will be used for all phases at the interpretation and reporting levels, where results from each phase will first be presented separately, and then interpret together in the discussion section to answer our research question20. Intention to maintain rigour in this mixed methods proposal has been addressed by following the GRAMMS guidelines48.
IMPACT Worldwide, children face accessibility barriers to motor therapy services. This study will provide valuable learnings on how low-cost therapy gaming interventions (like BB) technologies, such as motion-based video games, can/should be implemented to bridge accessibility gaps and improve access to rehabilitation for children with PC. The focus on the patient and family-centered approach of this project also intends to facilitate knowledge translation and dissemination of results to the community with PC, since for these families the results of research studies can generally be difficult to generalize.
Video games such as BB can facilitate access to therapy for children with PC, especially for those living in low-income families and / or rural areas. This aligns with the international right of children to access adequate medical care, and with Costa Rica's public policy regarding disability and child health care. Study results will also inform future work to establish BB as an effective, accessible, and fun option for upper-limb home rehabilitation in developing countries. For our particular project and as per the Costa Rican bioethical law, children who complete the 8 week-intervention will keep the BB video game and the necessary computer system to play it.
