One in 500 Canadians has cerebral palsy (CP), a lifelong condition affecting movement and function. Physical and occupational therapies greatly benefit children with CP but can be costly and difficult to access. Children, parents, and clinicians are interested in using movement-tracking video games for home-based hand/arm therapy. Yet, the technologies and evidence to support this approach are limited. We partnered with key stakeholders and an interdisciplinary team to co-create Bootle Blast. Bootle Blast tracks skeletal movements and interactions with real-life objects, engaging children in individualized play experiences rich in feedback, task specificity, and opportunities for goal-directed motor practice linked to meaningful activities. To establish Bootle Blast's clinical effectiveness, a large-scale randomized controlled trial (RCT) is needed. Pilot RCTs provide important insights that position large-scale RCTs for success. As a result, the goal of this Pilot RCT is to test whether a mixed-reality video game intervention (i.e. Bootle Blast) can improve upper-limb function, activity, and participation in children and youth aged 6-17 years with hemiplegic cerebral palsy. The main questions it aims to answer are: (1) Is it feasible and acceptable for families to use Bootle Blast at home for 12 weeks? (2) Does the intervention show preliminary improvements in hand-arm motor outcomes compared to usual care? Researchers will compare an immediate Bootle Blast intervention group to a waitlist comparison group that continues usual care for 12 weeks to see whether access to Bootle Blast leads to increased practice, greater engagement, and improved motor outcomes. Participants will: Complete three in-person assessments (baseline, 12 weeks, 24 weeks) with standardized motor and participation measures. Be randomized to begin 12 weeks of home-based Bootle Blast immediately or after a 12-week waitlist period. Use the Bootle Blast game at home for 15-20 minutes per day, 3-4 days per week, with all gameplay tracked automatically. A subset of participants will also receive weekly 10-minute support calls from a monitoring coach.
One in 500 Canadians has cerebral palsy (CP), a lifelong condition affecting movement and function.CP is the most common cause of physical disability in children. Hemiplegic CP (\~40% of CP diagnoses) affects one side of the body impacting arm/hand function. Between 60% and 83% of children with CP have upper limb involvement that can impact independence in activities of daily living, school and leisure, and social participation. Occupational and physiotherapy can help improve and/or maintain the many components of arm and hand function including gripping/releasing objects, reach, speed and accuracy, grip strength, and sensibility, often mitigating need for surgical interventions. While benefits of therapy can be significant, costs to the healthcare system and families are rising. Costs to manage CP over a lifetime average $1.2 million/person. Demand for therapy outpaces availability. In rural areas, families travel far to access services. While home-based therapy can improve outcomes, nearly half of families report low adherence due to limited time, lack of motivation, or forgetfulness. Sustaining child and parent motivation in home-based motor therapies is a long-standing challenge of great importance in pediatric practice. In fact, clinicians rate child motivation to be the most influential trait predicting success in motor therapies for CP. There is a clear need for new approaches to motivate and support children and families in home-based therapy. In line with this need, families and clinicians at Holland Bloorview Kids Rehabilitation Hospital (Holland Bloorview) and partner organizations affiliated with Empowered Kids Ontario (EKO), asked: can we use video games to create fun, effective opportunities for motor practice for children with CP? Finding no suitable video games to support hand/arm therapy, we partnered with diverse knowledge users (i.e. children with CP, their siblings, caregivers, clinicians), interdisciplinary researchers, specialists (e.g. engineers, games developers) and with guidance from provincial networks (CP-Net) and external partnerships (MaRS Innovation; Ubisoft), developed Bootle Blast. Bootle Blast was designed to overcome established limitations of video games currently used for hand-arm therapy including: lack of feedback, inability to target specific therapy goals and/or sustain engagement, and solo gameplay. Bootle Blast is the first video game for hand-arm therapy that systematically integrates best practices in motor learning, motivational theory, and game design. Using the Orbbec Persee (a 3D camera-computer), Bootle Blast provides real-time feedback on skeletal movements and interactions with real-life objects used in gameplay (e.g. building blocks) that is tracked over time. This "mixed reality" play experience offers greater task specificity to enhance transfer of skills to everyday activities. It enables individualized treatment plans by supporting practice of a wide range of motor skills with activities that can be calibrated to each child's abilities. Bootle Blast enables people of different abilities to play meaningfully together, enhancing social equalization. Game rewards are directly linked to therapeutic effort and incentivize frequent practice of goal-directed movements. These 5 attributes (feedback, task specificity, individualized treatment plans, social equalization, practice) are considered the system-level "active ingredients" of interactive computer play for motor learning, while therapist support is considered an intervention-level "active ingredient" that can impact participant motivation and outcomes. Bootle Blast is the first technology to deliver all five active ingredients, while also applying engaging game design principles. With support from CIHR, NSERC and the Ontario Brain Institute, Bootle Blast has been iteratively co-created and tested with the Children's Advisory Council, in clinics, and with research participants culminating in a refined technology that reflects the lived experiences of our knowledge users. To establish the clinical effectiveness of Bootle Blast, a well-designed randomized controlled trial (RCT) is now needed. Efficacy RCTs are resource intensive. Pilot RCTs provide critical insights that position efficacy RCTs for success and help to ensure that resources are invested in trials likely to generate clinically meaningful results. Consequently, this pilot randomized controlled trial will examine whether it is feasible and acceptable to conduct a larger RCT to determine whether 12 weeks of home-based Bootle Blast use can improve upper-limb function, activity, and participation outcomes in children with hemiplegic CP compared to standard care. The study uses a mixed-methods design with a waitlist comparison group. Children aged 6-17 years with hemiplegic CP (MACS I-III) will be randomized using minimization to balance age, sex, and MACS level. The intervention group will receive Bootle Blast immediately for 12 weeks, while the comparison group continues their usual care for 12 weeks before crossing over. A subset of participants in each arm will be randomly assigned to receive weekly support from a monitoring coach to investigate whether coach contact affects adherence, engagement, or outcomes.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
DOUBLE
Enrollment
46
Bootle Blast is a movement-tracking, mixed-reality therapeutic video game delivered in the home using the Orbbec Persee 3D camera-computer. An occupational therapist calibrates the system to each child's range and speed of motion and targeted therapy goals. Families are trained to set up and use the system. Participants then complete 12 weeks of home-based practice targeting 15-20 minutes per day, 3-4 days per week. The system automatically records active play time, movement counts, and performance data. Some participants are randomized to receive weekly monitoring coach phone calls for motivational and technical support.
Participants continue with their usual care, which may include routine stretching, maintenance exercises, and consultative visits with their healthcare professionals. Targeted upper-limb therapies (e.g., constraint therapy, botulinum toxin, casting) are excluded during the study period.
Grandview Kids
Ajax, Ontario, Canada
NOT_YET_RECRUITINGChildren's Hospital of Eastern Ontario
Ottawa, Ontario, Canada
RECRUITINGHolland Bloorview Kids Rehabilitation Hospital
Toronto, Ontario, Canada
RECRUITINGRecruitment Rate
Number of participants enrolled per month across all study sites. Assessed against feasibility criterion of ≥4 participants/month.
Time frame: Throughout 24-week study period.
Attrition Rate
Number and proportion of enrolled participants who do not complete the scheduled assessments at 12 or 24 weeks. Feasibility criterion: \<15% attrition.
Time frame: Throughout 24-week study period.
Adherence to Bootle Blast Intervention
Adherence measured using system-logged data, including minutes of active therapeutic play, passive play, and number of intentional therapeutic movements (e.g., reach, cross-body reach, grasp-and-release). Target dose: ≥10 hours of active play over 12 weeks.
Time frame: Weeks 0-12 (Experimental Group), Weeks 12-24 (Waitlist Comparison Group).
Intervention Acceptability Survey
Child and parent ratings of (i) satisfaction with the Bootle Blast intervention (e.g. therapeutic content, game content, challenge level, support provided), (ii) perceived impact and any unmet needs; and (iii) appropriateness and burden of study protocols (e.g. outcome measures, target dose). Comparison participants will be asked about the acceptability of not getting the Bootle Blast program right away.
Time frame: Week 12 (Experimental Group), Week 24 (Waitlist Comparison Group).
Monitoring Coach Logbook
Documentation of weekly coach contacts (duration, content type, informational/motivational support) to assess feasibility and perceived value of coach involvement.
Time frame: Weeks 0-12 (Experimental Group), Weeks 12-24 (Waitlist Comparison Group).
Technical Assistance Requests
Frequency and nature of technical support inquiries related to Bootle Blast equipment setup, functionality, and home use.
Time frame: Weeks 0-12 (Experimental Group), Weeks 12-24 (Waitlist Comparison Group).
Semi-Structured Interviews
Qualitative interviews exploring enablers and barriers to engagement, motivational factors, and experience with the intervention. Conducted separately with children and caregivers.
Time frame: Week 12 (Experimental Group), Week 24 (Waitlist Comparison Group).
Engagement (PRIME-C and PRIME-P)
Parent- and child-reported engagement using the Pediatric Rehabilitation Intervention Measure of Engagement (affective, behavioral, cognitive components).
Time frame: Weeks 1, 6, and 12 of each participant's Bootle Blast intervention period.
In-Game Engagement Prompts
Child-reported ratings of enjoyment, challenge, and effort through weekly in-game prompts.
Time frame: Weekly during Bootle Blast intervention.
Quality of Upper Extremity Skills Test (QUEST)
Unimanual domain scores assessing dissociated movement, grasp, weight bearing, and protective extension.
Time frame: Baseline, 12 weeks, 24 weeks.
Grip Strength (Modified Sphygmomanometer)
Grip strength of the hemiplegic hand as an indicator of selective motor control.
Time frame: Baseline, 12 weeks, 24 weeks.
Active Range of Motion (aROM)
Active range of motion of wrist, elbow, and shoulder on the hemiplegic side measured using a manual goniometer.
Time frame: Baseline, 12 weeks, 24 weeks.
Box and Block Test (BBT)
Manual dexterity measured as the number of blocks transferred in one minute for each hand.
Time frame: Baseline, 12 weeks, 24 weeks.
Assisting Hand Assessment (AHA)
Evaluates spontaneous use and effectiveness of the impaired hand during bimanual activities.
Time frame: Baseline, 12 weeks, 24 weeks.
Shriners Hospital Upper Extremity Evaluation - Spontaneous Functional Analysis (SHUEE-SFA)
The 15 min SHUEE is designed for children with spastic hemiplegic CP aged 3 to 18 years. This measure was designed by the Shriners Hospital for Children to evaluate functional and spontaneous ability, and dynamic segmental alignment of the upper limb of children with hemiplegic CP. The SHUEE includes the assessment of active and passive range of motion, tone, performance of activities of daily living (client reported) and evaluation of 16 activities using the hand and arm. The assessment is videorecorded and scored at a later time. Of note, in this study, sections of the SHUEE (aROM, performance of activities of daily living) will be excluded as they will be captured separately. The 16 hand and arm activities are evaluated based on the dynamic segmental alignment (DSA) and the spontaneous functional analysis (SFA) of the involved UL. The scoring uses a numerical scale from 0-5 for the SFA, and 0-3 for the DSA, where 0 is the lowest / less functional score.
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Time frame: Baseline, 12 weeks, 24 weeks.
Canadian Occupational Performance Measure (COPM)
Three child/family-identified goals related to activities of everyday living (e.g. self-care, leisure) that they hope to improve on. Participants then rate their performance and satisfaction for each goal/challenge area on a scale from 1 to 10 (low to high). Average scores for performance and satisfaction are calculated across the goals. The COPM is extensively used with children with CP in the target age range and with success in the research team's pilot work. It has good validity, responsiveness, reliability, and ability to track change over time. A change of 2 points on either the performance or satisfaction scale is considered clinically significant.
Time frame: Baseline, 12 weeks, 24 weeks.
Performance Quality Rating Scale (PQRS)
Rater-scored (1-10) analysis of caregiver-recorded videos of child performing COPM-related tasks, assessing accuracy, timeliness, safety, and overall quality. Assessors will be trained on practice videos to establish consistent scoring practices. Assessors will be blinded to the time point at which the video recording was collected.
Time frame: Biweekly throughout the 24-week study.
Children's Hand-use Experience Questionnaire (CHEQ)
Caregiver-reported quality and effectiveness of the child's use of the affected hand in 29 bimanual activities.
Time frame: Baseline, 12 weeks, 24 weeks.
Inertial Sensor Activity Counts (Optional)
Wrist-worn inertial sensor data assessing continuous daily hand/arm activity in a child's natural context, including the ratio of non-dominant to dominant arm activity. As long as they are acceptable and do not interfere with the assessments, children will be asked to wear inertial sensors on their wrists during the assessment sessions. Additionally, for those who are willing and subject to availability of sensors, children will be asked to wear the inertial sensors for 5 consecutive days (at least 6 hours per day) at home pre- and post-intervention.
Time frame: Baseline, Week 12 and Week 24; Pre- and post-intervention (5 consecutive days each period).
Bootle Blast Computer Logs
Computer logs will be used as a measure of adherence to the Bootle Blast intervention. Every time the computer is turned on to play, a video game log is automatically generated. These logs will record details for each play session providing information about active play time, game performance and progress. The game logs active (i.e., minutes spent actively engaging in therapeutic movements) and passive play time (e.g., time spent navigating menus). Additional data recorded in game logs include game scores, games played, and rewards collected, as well as skeletal data and video footage of game play if participants have consented to the latter. Data will be securely uploaded and saved into the cloud (Cloud Storage for Firebase \& Cloud Firestore by Google, servers in Montreal, Canada).
Time frame: Weeks 0-12 (Experimental Group), Weeks 12-24 (Waitlist Comparison Group).
Child Mood, Energy, and Pain Ratings
Self-reported ratings of mood, fatigue (battery scale), and pain (Wong-Baker FACES) at each clinical assessment.
Time frame: Baseline, 12 weeks, 24 weeks.