Outcome measures

This was a proof-of-concept feasibility study. Feasibility of Kinect2Scratch gaming training was the primary outcome of interest, including adherence, engagement, satisfaction, and safety.^16,17 We also recorded the technical problems of delivery with the Kinect2Scratch games.

Adherence was represented by session attendance. We used the Pittsburgh Rehabilitation Participation Scale (PRPS)¹⁸ to assess the average degree of children's engagement in the first and last 2 weeks of either Kinect-based or conventional training according to the training records of the therapists. This assessment is a six-point scale of observed treatment engagement (effort and motivation). The PRPS had high inter-rater reliability (intraclass correlation coefficient [ICC] = 0.91 for occupational therapists, ICC = 0.96 for physical therapists).¹⁸ Satisfaction was evaluated at the end of the 12-week intervention. Children used 5-point Likert scales to rate the enjoyment of the Kinect2Scratch games training from “strongly not enjoyed” (1) to “strongly enjoyed” (5) and ranked the three games according to their preference. For children who did not understand the meaning of 5-point Likert scales, we used the bar chart to help the description of the 5-point Likert scales. The caregivers were interviewed to ask about the change of the children's UE function, children's motivation, and the general comments. About safety, we recorded any adverse events within the treatment sessions and during the study period.

Possible efficacy of Kinect2Scratch games was the secondary outcome of interest and was assessed at the beginning (T0) and after 24 sessions of training (T1) of the treatment. We used Quality of Upper Extremities Skills Test (QUEST)^19,20 to assess the change of body function of the participants. Activity level was assessed by using the Box and Block Test (BBT),²¹ Melbourne Assessment 2 (MA2),²² and ABILHAND-kids score.²³

QUEST evaluates four domains: upper limb dissociated movements, grasp function, protective upper limb extension, and weight bearing. The total score and each domain score were used for further analysis.

The BBT is a reliable and valid assessment tool of hand function.^21,24 Children were asked to grasp small wooden cubes and move them from one side of the box to the other as fast as possible within 60 seconds.

The MA2 is a tool for evaluating quality of unilateral upper limb movement (movement range, accuracy, dexterity, and fluency) in children with neurological conditions aged from 2.5 to 15 years. It comprises 14 test items of reaching to, grasping, releasing, and manipulating simple objects.^22,25

The QUEST and MA2 were recorded by video for scoring, scorers were blinded to the group allocation and the time point of assessments.

The ABILHAND-kids is a Rasch-derived, parent-completed questionnaire of 21 unilateral and bilateral activities. Each item is graded as easy, difficult, or impossible for the child to achieve.^26,27