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A Telehealth System Incorporating a Serious Game Intervention to Aid Occupational Therapists in Identifying and Treating Children With Difficulty Crossing the Body’s Midline: Key Informant Interviews Among Occupational Therapists

A Telehealth System Incorporating a Serious Game Intervention to Aid Occupational Therapists in... Background: The midline is an imaginary line that isolates the left and right parts of the body. Crossing the midline infers that a body part (eg, hand or foot) can spontaneously move over to the opposite side of the body to perform an action. A child who has difficulty crossing the midline can physically perform actions that cross the center of the body; however, they do not intuitively cross the midline when challenged with a task that requires this movement, as their perceptual components prevent them from engaging on the contralateral side. This requires treatment from an occupational therapist. Owing to the recent COVID-19 pandemic, access to therapeutic sessions was not possible or reduced, putting the responsibility for treatment on caretakers at home. Caretakers do not have the knowledge and skills to provide treatment, and occupational therapists do not receive adequate feedback from caretakers on the child’s progress. Objective: The first objective is to adapt a simple serious game, or applied game, into a telehealth solution. Children will play the game at home under the supervision of a caretaker, and the results will be stored on the web. Occupational therapists can monitor progress via a web-based dashboard, receive additional valuable feedback about the child’s behavior during treatment, and easily adapt the game to target specific needs. The second objective is to evaluate whether the implemented telehealth solution is feasible as a treatment option for midline crossing difficulties and thus fit for purpose. Methods: To meet the first objective, engineering and game development stakeholders formed a team with an occupational therapist, and through a collaborative design process combined with an agile programming approach, a telehealth solution was designed to assist remote monitoring of the serious gameplay. For the second objective, 6 different occupational therapists were introduced to the game, had the opportunity to play the game, and then provided feedback regarding the feasibility, benefits, and applicability of the system during structured interviews. Results: A telehealth system was designed aimed to address this problem. All results are saved on the web and accessed by occupational therapists via a dashboard. In addition, observed behavioral information is also saved. During the interviews, occupational therapists indicated that the dashboard would support their treatment plan and was indeed a feasible solution. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Conclusions: The feedback from the occupational therapists for this telehealth solution suggests a feasible method to treat midline crossing problems remotely. The therapists commented on the convenience of integrating both assessment and treatment into the same application, as it assists them when grading a child. The therapists collectively agreed that the quantitative aspect the serious game creates by providing measurable and standardized data proves advantageous when compared with traditional methods of assessment and treatment. (JMIR Serious Games 2021;9(4):e27761) doi: 10.2196/27761 KEYWORDS serious games; input device; telehealth; occupational therapy; midline crossing development if it is not addressed in a timely manner. If a child Introduction does not get the needed intervention due to the COVID-19 lockdown, it can affect the child’s future. Being able to cross Background the midline is a developmental milestone. By the age of 5 years, Owing to the COVID-19 pandemic, numerous health care a child is expected to be able to cross the midline, that is, use practitioners were unexpectedly required to transition their both sides of the body simultaneously [5]. When the midline is standard in-person treatment to telehealth options, often without crossed spontaneously, supporting neural networks and pathways advance preparation or training [1]. Telehealth is becoming an for specific activities are developed. This is a prerequisite skill increasingly used service delivery model in rehabilitation essential for the development and maintenance of motor and services. Telehealth has the potential to alleviate provider cognitive demands associated with specific activities. shortages, decrease costs associated with providing therapy, Consequently, children who have trouble crossing the body’s and allow for treatment within a client's natural environment midline also frequently experience difficulty with reading, [2]. Telehealth can be used by occupational therapists for writing, tying their shoelaces, brushing their teeth, and evaluation, intervention, education, and prevention of injury or participating in physical activities [6]. exacerbation of conditions [3]. Telehealth facilitates Current treatment approaches used by therapists are arts and collaboration and consultation with other professionals, which crafts in which actions such as threading beads, cutting, pasting, facilitates coordination of care [4]. and folding paper are used as these actions require the midline The midline is an imaginary line that isolates the left and right to be crossed. Finger puppets or stickers are also used by placing parts of the body. Crossing the midline infers that a body or sticking the puppets or stickers on one of the child's hands part—for example, a hand or foot—can spontaneously move and then encouraging the child to remove the puppet or sticker over to the opposite side of the body to perform an action. To with the opposite hand. Other common methods used by clarify, a child who has difficulty crossing the midline can therapists include building blocks and playing Twister and physically perform actions that cross the center of the body; marching games using arms and legs. Occupational therapists however, they do not intuitively cross the midline when use standardized assessment tools such as the Movement challenged with a task. The diagnosis of children with midline Assessment Battery for Children, the Developmental Test of crossing difficulties requires a cluster of clinical observations Visual Motor Integration, and the Draw a Person Test to measure that indicate bilateral integration dysfunction [4]. A study was changes in function and occupational. These standardized tests performed in which 10% of the sample was considered to have procedures for administration and scoring [7]. However, constitute a possible deficit range, and a further 10% was when measuring the outcome of an intervention, there is still a considered to be in the suspect range. The remaining 80% was lack of tools available for objective measurement, particularly considered to fall in the normal range [4]. among children with perceptuomotor or attention deficit disorder [7]. Midline crossing is a difficulty that needs the intervention of an occupational therapist. Midline crossing difficulties may At present, occupational therapists observe if the child exhibits affect the child’s physical well-being as well as their future the actions given in Textbox 1. Textbox 1. How to identify whether a child has difficulties crossing the midline. How to identify whether a child has difficulties crossing the midline Swaps hands midway through a task when writing, drawing, painting, or coloring Uses the left hand for activities on the left side of the body and right hand for activities on the right-hand side Rotates their trunk to the opposite side when reaching across the body (to avoid crossing the body midline) Has difficulty visually tracking an object from one side of the body to the other, such as following text when reading Has poor pencil skills (pencil grip) Uses different feet to kick a ball (mixed dominance) Has difficulty coordinating gross motor patterns (eg, crawling, skipping, and star-jumps) https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al On the basis of their observations and discretion, they conclude introduced as a need to meet objectives that go beyond whether the child has difficulty crossing the midline. Assessment entertainment and benefit the user in the area that needs to be is an integral part of the occupational therapy process and is a mitigated. The applications created under the terminology of necessity for evidence-based practice. Without appropriate serious games induce motivation and engage the user [12]. measurement, therapists cannot provide evidence for the offered Objective interventions [8]. The assessment is subjective, and there are Before proposing how serious games can be integrated, a major issues with this subjectivity, as the same level of difficulty may obstacle to treating children in the conventional sense is be rated differently by different assessors. When therapists write boredom because of the intensive and repetitive practice reports for the child, it is challenging to justify the child's required. The advantage of incorporating input devices and the improvement as there is no criterion to compare it with. In use of serious games into treatment methods is that it combats addition, numerous children up to the age of 5 years living in the boredom factor. The child is placed into a game environment underdeveloped countries, including South African rural areas, that is similar to the real world in terms of the perceptual stimuli face exposure to multiple risks affecting their early childhood it exhibits, which then puts the child at ease [13]. The child then development [8]. These children and their parents are often not has the ability to manipulate and control some of the stimuli aware of the functional difficulties they may have, and even if and see the outcome of their actions in real time and adjust them they are aware, they need to travel long distances to receive the accordingly. This aspect, being the interactive component, therapy they require. Moreover, because of the recent creates an engagement with the environment, allowing the child COVID-19 pandemic and resulting lockdowns, many children to feel and be in control of their movement. This idea is who would normally receive occupational therapy could not explained as the perceptual illusion of nonmeditation [14]. The access occupational therapists or had to decrease their sessions. sensations that are familiar and present when playing the game If a child has a pathology of midline crossing, frustration in the and the ability of the child to control and manipulate the stimuli behavior of the child will be noticeable, as the child will become that surround them generate the psychological effects of angry when trying to engage in fine motor activities because of enjoyment and, particularly, involvement [14]. The unique less refined hand skills. The coordination of both sides of the merging of purpose and pleasure develops intrinsic motivation body will be less refined, leading to difficulties experienced in the child. when playing sports or doing any physical activity. In addition, Microsoft’s Kinect sensor has been highly investigated and used when children have difficulty with midline crossing, they may for the development of new complements that help improve or additionally have trouble visually tracking an object from left optimize rehabilitation processes worldwide. In 2012, Ruiz and to right. Thus, when the object reaches the midline, they often Cantos [15] designed a therapeutic tool using the Kinect for blink and have to refocus, and this results in their losing their neurorehabilitation using games to stimulate patients, cognitive place while reading. In addition, when drawing horizontal and functions, perceptions, and gross and visual motor skills through diagonal lines as well as writing letters such as an x, they may play. This tool verified that patients had fun while being treated segment these lines rather than overlap them because of midline in this manner; intrinsic motivation is achieved by merging crossing difficulties [9]. Some children may struggle to cross purpose and pleasure. the body’s midline easily. When a child shows hesitancy in reaching, stepping, or looking across the midline of the body, Moreover, using the Kinect and combining purpose and it is known as midline crossing inhibition. Sometimes, this delay pleasure, Chang et al [16] performed a study in Taiwan in 2013 can be seen when a child hesitates or is clumsy during gross that proposed the possibility of rehabilitating two 14-year-old motor tasks that require the arm or leg to cross over to the other adolescents with cerebral palsy through therapies personalized side. Some children with delayed midline crossing skills may to their condition. Data showed that the 2 participants had display some compensatory mechanisms in school that make significantly increased motivation for upper limb rehabilitation, writing awkward for them. Crossing the midline is a treatable thus improving exercise performance during the intervention affliction. If a child struggles to cross the body's midline and is phases. treated, milestones such as developing a dominant hand will Although Kinect is a useful device, it can, however, encounter occur [6]. Pencil skills and fine motor tasks will be refined, the problem of misdetection when it comes to extremity angles easing the transition to an academic environment where those or overlapping extremities [17]. In 2016, the Taiwan University skills are expected to be grasped [6]. The child will be able to proposed a new rehabilitation gaming system, which focuses complete self-care tasks, for example, brushing their teeth and on the upper part of the body with wireless inertial measurement getting dressed. The child will be able to kick and hit balls as units (IMUs) and a Kinect device. The Kinect was used as a well as run as their gross and fine motor skills will be improved. base tracking system by the gaming system. Multiple sets of Finally, their ability to visually track across a page effectively IMUs were integrated into the extremity of the subject to will be better and, therefore, will result in fluent reading. calculate the angles through algorithms. Wireless IMUs were At the forefront of technological advancements in occupational also added to compensate for the error in the calculation of therapy are serious games [10]. For the purpose of this research, angles in the Kinect device [17]. This study exposed that the serious games are described, among other things, as digital use of the Kinect by itself may not be sufficient and, therefore, games, virtual environments, simulations, and a mixed reality additional sensors were needed to ensure correct motion capture. that engage the player. These serious games form encounters and experiences that convey meaning [11]. Serious games are https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Nintendo’s Wii Fit is a commercial product used for both fitness Sony’s motion capture system Intel RealSense enables and fun and was created to encourage people to exercise as well fine-motoric gesture recognition, and its small form factor allows as improve balance. The Wii Fit uses the Nintendo Wii console for preintegration into notebooks and tablets, substituting and a balance board. A study conducted by the University of conventional cameras [22]. This setup enables new methods of Naples found that the Wii Fit showed better improvements therapy in the form of serious games that are engaging and easy regarding physical therapy in terms of balance and to set up. Chhor et al [22] developed and evaluated a serious self-confidence than conventional treatment [18]. It was game prototype for rehabilitation using Intel's RealSense (called concluded that the Wii Fit is acceptable as an adjunct to virtual Breakout) based on a commercial game framework. Despite the rehabilitation interventions and provides an exciting new therapy fact that RealSense can easily integrate with the applications device [18]. The Wii console does not provide a platform or mentioned above, it is an expensive app. offer a game in which more specific impositions, such as Neuroplasticity refers to the ability of the brain to adapt difficulty crossing the midline, can be treated. If one wanted to structurally and functionally and is enhanced by training and use the Wii for treatment or training purposes, one would need experience. It is known that neuroplasticity is at its maximum to purchase not only the balance board but also the console and in a critical period, which corresponds to the first 7 years of a remote, thus making it too expensive for the communities that child’s life [23]. Therefore, with the development of a serious this study is aimed at. game and given the neuroplasticity of the child’s brain at this Ultraleap’s Leap Motion Controller is a computer hardware age, the child may be able to develop the required pathways sensor device analogous to a mouse [19]. Using motion capture necessary to conduct movements that once seemed impossible. technology, Leap Motion is able to process the input. It does With the integration of technology and the innovation and not require direct hand contact with the device as input; instead, creativity of this approach, a beneficial method of mitigating hand and finger motions are tracked. Despite the small size of impositions such as midline crossing could be developed to Leap Motion, it is capable of capturing smaller details, such as assist occupational therapists in the treatment of children. A finger movement. Leap Motion is smaller and cheaper than serious game with an input device was initially developed to Kinect; however, Kinect is more precise in capturing movement. assist in midline crossing therapy [24]. An improved wireless Sourial and Reichardt [20] proposed implementing a virtual input device that accompanied the serious game was developed therapist (VT) to help patients do their exercises at home in an [25]. The aim of this study is twofold. The first objective focuses engaging gamified environment. The VT artificial intelligence on the design of a web-based telehealth system that consists of used a hierarchical finite-state machine architecture. Hand a serious game, an input device, and a web-based dashboard therapy helps the patient regain the hand's full functionality that displays relevant data to occupational therapists. The second after a certain injury or surgery. Hand therapy could be a very objective focuses on whether the system is fit for its purpose tedious process that implies physical exhaustion [20]. In and can be adopted by occupational therapists to treat patients addition, finding appointments with the therapist frequently remotely. enough for an efficient healing process is difficult and costly. To test the efficiency of the VT, a web-based hand therapy Methods exercise was implemented using the Unity platform to build the Objective One: Designing a Remote Monitoring System exercise environment. Leap Motion technology was used to detect the information of the hand movement. This exercise was for a Midline Crossing Serious Game tested on 19 participants. The idea of being coached by a VT Overview was welcomed by the participants, as the exercise was fun and An agile software development life cycle approach was taken motivating to them. VT guidance and assessment were helpful to develop the end-to-end solution. This methodology was and easy to follow. However, some modifications are needed chosen because of the frequent feedback needed during the in the pain detection part to form a more efficient exercise [20]. design process, allowing the design team to give Another system using Leap Motion and capable of improving recommendations through collaborative design at the end of fine motor skills in children, was proposed by Hidalgo et al [21] each iteration. The design team comprised game designers, through a serious game and 3D environment. The proposed electronic engineers, and an occupational therapist. Figure 1 system allowed the therapist to choose among different levels shows the iterations of the agile software development life cycle. of serious games according to the child’s needs. The game It should be mentioned that each component of the solution excited the children; however, the children took time to adapt (serious game, input device, and telehealth system) was to the game because of the inaccurate readings of Leap Motion. developed separately through iterations; however, the Therefore, it can be noted that including different levels creates components were integrated and tested at the end of each excitement for the children as they experience different iteration. Furthermore, the initial serious game from the previous challenges; however, when technology interferes with the game project was used as a foundation to produce the web-based or is difficult to use, the child takes time to become familiar telehealth solution presented in this study [24]. with the system. A high-level solution design is shown in Figure 2. The sequence of events is illustrated in Figure 3. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 1. Iterations in the agile software development life cycle. Req: requirements. Figure 2. High-level design of solution. OT: occupational therapist. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 3. Sequence of events. OT: occupational therapist. The innovative low-cost input device shown in Figure 4 was the caretaker will explain to the child how to play and then developed previously and used so that the movement of the observe the child’s movements according to the guidelines child could act as an input for the game [25]. The input device designed by the occupational therapists, which will be discussed is designed in such a way that when the device is turned on and further in the Results section. The design of the data the game started, a connection is established. There are no visualization component and the new serious game is presented complicated installations or setup steps. The role of the caretaker in this study. is to help the child set up the device with the game. Additionally, Figure 4. Prototype of input device. published [25]. For the sake of completeness, a short overview Initial Serious Game of the input devices is given in this section. In the initial input The game genre chosen was a casual game because of its low device, an accelerometer and magnetometer were used to obtain system requirements, accessibility in most devices, and, at the the movement of the child [25]. Tilting of the device was not same time, not demanding high levels of concentration from the only issue that affected the feasibility of the design; before the player [26]. The game was not connected to the internet, every game, a calibration was required to obtain the reference and players had to install it to play it. The fact that the game of the sensor. It did not seem to be the most suitable solution does not take much concentration is an important factor in for therapists to expect the child to perform the calibration each ensuring that the child does not become fatigued and frustrated. time they wanted to play the game, ensuring that they do not Moreover, the duration of the game was purposely designed to tilt the sensor. Therefore, a more child-friendly design was be short to retain the child's concentration. The developed game needed that would be able to track the movement of the hand comprised a sprite controlled by the child [24]. Sprite is the from side to side (crossing the body's midline) and transform terminology used to describe an avatar, shape, or character that the position into the game. In addition to accurately transforming the child has control over. The device was attached to the hand the movement, a device that would not require calibrating the of the child, and the child moved the device in an arc shape with sensor was required. When discussions were held with an their arm extended in front of them while standing. The aim of occupational therapist during the design phase, it was suggested the game was to collect faces falling at a calculated position that an input device that would be placed on a surface be from the sky. The movements in the game ensured that the child designed. The idea behind this was to allow the child to move crossed the midline. The game intended to prompt the child to their hand from side to side and exhibit the same motion required perform particular movements that occupational therapists would when performing tasks that cross the midline, such as writing. invoke when using traditional methods of treatment. Through extensive research into suitable sensors or electrical devices that could be used, a clean, innovative solution was Input Devices reached. The design entailed the addition of a linear The problems encountered with the initial design of the input potentiometer; the input device is shown in Figure 4 [25]. device and the detailed new design have been previously https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al the occupational therapist through the game and explaining how Objective Two: Evaluate Whether the Online Game each stage of the game was played. The occupational therapists Is Fit for Purpose then had the opportunity to play the game and evaluate each After the prototype was developed, it was crucial to evaluate stage on their own. A semistructured interview took place, whether this solution was a feasible option for occupational allowing the researcher to further explore the insights provided therapists and whether it was fit for purpose. This was achieved by through semistructured interviews with occupational therapists. These occupational therapists all had between 5 to 10 years of the therapist. Each session was conducted individually to ensure experience. In addition, as many children have difficulty unbiased and objective responses. The interview aimed to crossing the midline, these occupational therapists were highlight the strengths and weaknesses of the solution as well competent to give feedback regarding the identification and as the suitability of administering the solution remotely. The treatment of midline crossing difficulties. Note that the interview provided the therapists with the opportunity to suggest occupational therapist who was part of the participatory design changes and offer recommendations. The questions were sessions was not included in the evaluation of the system. purposefully left open-ended so as not to limit the therapist's responses. The main themes that needed to be established from The researcher took each of the participants through a the interviews can be seen in Textbox 2. The questions contained presentation detailing the purpose of this research. The in each section can be seen in Textbox 3. researcher conducted a demonstration of the full solution, taking Textbox 2. Main themes established from interviews. Main themes The feasibility of using a serious game and input device to assist occupational therapists in identifying and treating children with midline crossing difficulties The benefits and applicability of the dashboard The applicability of the solution in areas where the availability of occupational therapy resources is limited Textbox 3. Questions asked to occupational therapists during the interviews. Questions In your professional context, comment on whether a serious game and input device would assist you as a therapist to identify children with midline crossing difficulties as well assist in your treatment process. Please include in your answer the following: Advantages Disadvantages Suggested changes Recommendations Comment on whether the use of the dashboard is beneficial and applicable to assist you as a therapist in identifying whether a child has pathology with midline crossing. Does the dashboard provide constructive tracking of the child's progress during treatment? Advantages Disadvantages Suggested changes Recommendations Comment whether the solution can be reasonably implemented and used effectively in areas where occupational therapy resources are limited. Advantages Disadvantages Suggested changes Recommendations https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al losing focus. Each stage addresses a certain intervention, which Results will be explained below; therefore, the input to each stage is different. The occupational therapist can set these inputs Objective One: Designing a Remote Monitoring System however they see fit (or advice the caretaker at home on which for a Midline Crossing Serious Game values to use during remote treatment). Adapted Serious Game The game environment is chosen by selecting a stage and The initial game, as described in the previous section, was used choosing the required values for the inputs for that stage. The as a base for the new telehealth system. The new system game commences with the hat (controlled by the child using comprised an adapted serious game (with distinct levels), an the input device) starting either on the left or right side of the input device, and a web-based backend system that enabled screen depending on the handedness of the child. For the purpose occupational therapists to access dashboards and behavioral of this explanation, a child who is right-handed will be used; information about the intervention. During the collaborative therefore, the sprite starts on the left. If the child were design sessions, it was decided that the serious game would be left-handed, the sprite would start on the right so that the child’s divided into different stages. Each stage has a specific aim, and first movement would be crossing the midline. The balls that different game variables can be set according to each child’s fall from the sky are strategically placed, depending on the stage, individual needs. The game comprises 4 stages: an assessment which will be discussed below. When the balls fall, the child stage, 2 intervention stages, and a maintenance stage [24]. In must catch the ball in the hat and return the hat to the starting each stage, there are 3 variables: distance, speed, and time, point (either the left or right side of the screen) to earn a point. which are used to create a specific environment for testing. The Textbox 4 shows the variables used in the equations. Table 1 time variable, set at 2 minutes, was kept constant for all stages. shows the inputs and equations for the variable set. The game The chosen duration was advised by the occupational therapist. flow is illustrated in Figure 5; depending on the stage, the The duration was purposely set to be short to allow the child to equations shown in Table 1 will be inserted. concentrate for a short amount of time without getting bored or Textbox 4. Variables used in the equations to set the game environment. Variables X is the starting distance • 0 I is the incremental distance S is the score DV is the distance variance Random (a,b) is the random function that provides a random number between a and b Sp is the initial speed Is is the incremental speed Table 1. Equations used in each stage to set the game environment. Stage Input Distance Speed Time a b c 1 Constant Constant X , I X +(IX ) 0 0 s 2 X +Random (–DV, DV) Constant Constant X , DV e f 3 X Sp +(Is SX) Constant 0 0 p X , Sp , Is 0 0 p 4 Random (–7.5,7.5) Constant Constant N/A X starting distance. 0: I: incremental distance. IX : incremental distance as function of score. DV: distance variance. Sp initial speed. 0: Is : incremental speed. N/A: not applicable. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 5. General game flow. eq: equation. and returned. A ball is considered returned when the hat reaches Stage 1 the left side of the screen if the child is right-handed; if the child Stage 1 takes the starting distance (X ) and incremental distance 0 is left-handed, the hat would need to be returned to the right (I) as input. The starting distance is the point on the x-axis where side of the screen. The score will update only after the hat has the first ball will be spawned from the sky (top of the screen). been returned. Consequently, the point at which the next ball The x-axis is depicted in Figure 6. The incremental distance is falls will increase by the incremental distance (increase to the the distance that is incremented from the starting distance. The right if the child is right-handed). If a ball is missed, intuitively, point on the x-axis where the balls are spawned is a function of the score will not increase, thus remaining the same; therefore, the score (S); as the score increases, so does the distance of the the ball will be spawned in the same place instead of being spawned ball. The score represents the number of balls caught spawned at the incremented distance. Figure 6. Position on x-axis in game. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Stage 1, which is the assessment stage, aims to determine the amount of external input required to achieve midline crossing child’s gross ability to cross the midline. In addition to the stages would be noted by the caretaker on the system. Although the incorporated into the game, an interface to input the specified game is designed to determine the core impairments of crossing variables determined by the therapist was introduced. These the midline, clinical reasoning, observations, and external variables create a tailored game environment for the child. In guidance from the occupational therapist are vital for a holistic stage 1, the speed and time variables remain constant, whereas and accurate assessment. In the event that an occupational the distance variable is incremented. The input device shown therapist is not performing the assessment (ie, caretaker, parent, in Figure 4 controls the movement of the hat illustrated in Figure teacher, or guardian), a notes page, shown in Figure 7, will need 6 from side to side, simulating the movement of crossing the to be completed, which is presented to the caretaker at the end midline while writing. After the child catches the ball, the hat of the game. A guidance script with key points of reference will needs to be moved all the way to the other side of the screen, be provided to the caretaker before the child plays the game to ensuring that the midline is crossed. assist and ensure accurate observations. Using the results, an individualized treatment plan tailored to the child’s needs would A reference point for the child’s baseline functioning, including be constructed and developed by the occupational therapist, their ability to cross the midline, was established in stage 1. The which can be done remotely. Figure 7. Notes page to fill in after each stage is completed. Stage 3, the second intervention stage, aims to enhance the Stage 2 child’s gross ability to cross the midline. The distance and time Stage 2 takes the starting distance (X ) and distance variance 0 variables will remain constant, whereas the speed variable will as inputs. Here, the distance variance is the distance from the be incremented. This increases sufficient accuracy and skill. starting distance, and the distance can be varied; for example, Stage 4 if the starting distance is 1.5 and the distance variance is 0.5, Stage 4 does not require any input as the position at which each the ball can be spawned between points 1 and 2 on the x-axis. ball is spawned is random. The point at which each ball is Stage 2 is the first intervention stage, aimed at improving the spawned is calculated using the random function Rand(). As child’s gross ability to cross the midline. This stage allows for shown in Figure 6, the x-axis spans from –7.5 to 7.5; therefore, the distance variable to be adjusted, whereas the speed and time the ball can be spawned at a random point on the axis. The speed variables are constant. The caretaker sets the distance at the of the ball remains constant and does not increase as a function specific distance where the child began experiencing problems of the score. The gameplay time is constant for stage 4. with midline crossing. This distance can then be adapted and The purpose of stage 4, the unregulated round, is to maintain graded during the intervention. the skills the child has obtained in the previous stages. In this Stage 3 stage, the speed and time variables will remain constant, whereas Stage 3 takes the starting distance (X ), initial speed (Sp ), and the distance variable will be random. 0 0 incremental speed (Is ) as inputs. The initial speed is the speed Scoring at which the ball starts to fall. The incremental speed is the The occupational therapist advised on the scoring criteria for increase in speed from the starting point. The ball will continue the stages during the collaborative design sessions. These to fall at the specified starting point; however, the speed at which scoring criteria were based on observations that occupational the ball falls will increase as each ball is caught. therapists would typically make during traditional treatments. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al The first three criteria were generated from the gameplay data meets the scoring for a criterion, a point will be awarded. The received from the game, and the following five criteria were criteria for the other stages are the same as those for stage 1, recorded by observation. To confirm that the child did not except for criterion 4. In the scoring criteria for stage 2, the display any form of pathology with midline crossing, a child effect of the random displacement of balls in a targeted area is would need to achieve a total of ≥4 points on their score card. determined rather than the increasing distance. In the scoring It should be noted that all 8 criteria should be used in criteria for stage 3, the effect of increasing the speed of the balls conjunction with one another and not assessed independently. is determined rather than increasing the distance. Finally, in the Table 2 shows the 8 criteria, the observation being assessed, scoring criteria for stage 4, the effect of the balls randomly and the measurement to score the criterion for stage 1. If a child falling is determined. Table 2. This table shows the scoring criteria for an assessment (stage 1). Criterion Observation Scoring 1 Balls caught >14 2 Balls missed <4 3 Average time between balls <7.5 4 Distance increasing No pattern 5 Follow instructions Yes 6 Eye movements Maintain visual focus 7 Body movement No gross adjustments 8 General behavior No verbal cues have been performed. Consequently, a dashboard was designed Data Visualization to aid occupational therapists by providing a collection of Occupational therapists can support children with difficulty objective data about children who have difficulty crossing the crossing the midline by helping them develop the skills needed midline. The proposed monitoring tool provides a solution in to perform activities of daily living. During therapy sessions, which the gameplay of the child during an assessment or occupational therapists use a variety of techniques to support treatment is recorded, and the data collected in the game can be rehabilitation, such as functional electrical stimulation, visualized by the therapist. The design of the system, and the constraint-induced motor training, facilitation, and virtual reality monitoring functionality in particular, allows for the game and applications [27]. This combination of therapy, exercise, and input device to be used by parents or guardians with the children context-specific retraining is critical for neuroplasticity, as in a home environment and to be used remotely. Therefore, the mentioned in the Introduction. Although retrospective recall game would not be restricted to only being played during and exercise diaries can gather subjective data, the quality of therapy sessions but rather can be played outside of these times these data is limited and relies on the notes and observations as well. A dashboard was designed using Microsoft’s PowerBI written by an occupational therapist; as such, occupational to display the data illustrated in Figure 8. therapists lack objective data about the degree to which exercises https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 8. Representative dashboard showing how the tooltips will be displayed using Microsoft PowerBI. During the evaluation process, the occupational therapists were as the distance increased, the child missed more balls. In this asked to play the game themselves and get familiar with how case, there are various factors that could impact the child’s the system works. Figure 9 shows an illustrative example of results. For example, the child may have felt bored and, how the dashboard would look for a child without midline therefore, did not play as they should have. A child with an crossing difficulties. The dashboard is accessible remotely. average performance result needs to be further assessed to see Figure 10 is an illustrative example of a dashboard for a child whether their results are because of pathology with midline with midline crossing difficulties. The red circle indicates that crossing or whether there are other factors yielding these results. Figure 9. Representative dashboard for a child whose performance was above average for stage 1. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 10. Representative dashboard for a child whose performance was below average for stage 1. One of the ways to identify whether a child has pathology with Objective Two: Evaluate Whether the Web-Based midline crossing is by observing whether the child has a midline Game Is Fit for Purpose jerk. This can be noticed when the child is performing actions The therapists commented on the convenience of integrating where the midline is crossed, and their eyes move from side to both assessment and treatment into the same application as it side in a rapid manner. Consequently, the therapist proposed assists the therapists when grading a child. The stages developed incorporating eye tracking to detect if the child’s oculomotor in the game were also commended by the therapists, as each functions are impaired. Additional monitoring through the use stage has a different focus point with a specific outcome. They of a laptop camera can also be provided to observe the eye collectively agreed that the quantitative aspect that the game movement, head adjustments, and posture of the child. creates by providing measurable and standardized data proves As part of the game, when the child catches the object falling advantageous when compared with traditional methods of in the hat, the child is required to return the hat to the side of assessment and treatment. When using a traditional method, the screen to receive a point. Even though an alert is sounded such as asking the child to build a puzzle or draw a line across when the object returns to the side, a suggestion was proposed a page, there are no quantitative measures that can be deduced; to display a reminder on the screen to return the object to the instead, the assessments are limited to mere observation. The side at the point where the child has caught the object. In proposed solution elicits not only quantitative data but also addition, when the child is playing the game and controlling allows observational data to be recorded using the notes page. the input device, the child may release the device. Consequently, Furthermore, they referred to the notes page as not only it was recommended that if the child releases the device during descriptive but also appreciated that it was designed to be the game, an alert should be shown to remind the child to grasp understood by nonmedical professionals, thereby making the the device. observational recording more effective and user-friendly. The Specific attention was given to the dashboard design as it is an notes page is viewed as an extremely beneficial aspect of the important part of enabling remote monitoring. Everyone serious game as it ensures that the assessor covers all the unanimously agreed that the dashboard’s ability to track the observational components included in the assessment and progress of the child would benefit their reports immensely. treatment. As a result of the movements triggered by the game The results represented in the dashboard would assist them in and the quantitative and observational data recorded by the supporting and verifying their observational conclusions. application, the occupational therapists concluded that the Furthermore, when submitting reports to their clients’ medical serious game, accompanied by the input device, would assist aids, the data from the dashboard can be used to solidify their them in identifying whether a child has pathology with midline conclusions and can be included in their reports. crossing. Moreover, the solution would also assist in treating the child’s pathology. Finally, the therapists thought that the The only disadvantage that was raised by the occupational solution could assist in exposing and identifying other gross therapists was that the dashboard might not be particularly easy and fine motor pathologies that a child might have, or it might to interpret for a layman; however, a suggestion was made to even reveal underlying behavioral, cognitive, or physical provide training to therapists on how to interpret and analyze impairments. It was suggested that the assessment stage should the dashboard. The other disadvantage was that the dashboard be standardized per age group. was limited to only showing the results for a midline crossing https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al assessment and no other difficulties that could be identified by development of a VT; however, with inaccurate readings the game. stemming from the device affecting the game experience, the device would not be suitable for children [21]. The RealSense There were suggestions to provide a way of showing the is a fitting tool; however, because of the high price of the device, standardized results for different categories by searching by it is not suitable [19]. age, for example, and, consequently, the results for that particular age group would be displayed. Introducing Studies with a serious game and Kinect showed that individuals standardized norms would allow the child to be compared with are more motivated, enjoy therapy, and even enable therapy to other children within the specific area being examined. Another be more accessible [12]. On the basis of the feedback from the suggestion that was made was to allow therapists to add occupational therapists, the child will also experience these additional comments on the results of the child displayed for benefits from the system presented in this paper. However, this further reference. Finally, it was proposed that artificial will only be proven in clinical studies. intelligence could be incorporated so that when comments are Limitations made on the notes page by the therapist or guardian, the When determining whether serious games are feasible as a observations can be translated into quantitative data that can be treatment option for midline crossing difficulties and are fit for used to calculate the scoring criteria instead of physically purpose, there appears to be a lack of clinical evidence about inputting the scores for the criteria that require observations. the benefit to children from the application of serious games The occupational therapists agreed that this solution could be [28]. Owing to ethical constraints regarding testing the solution used as a telehealth device. To further enhance these benefits, directly on children, professional opinions of occupational it was suggested that the game be deployed as a mobile app. therapists were gathered to validate the solution. The next step This would allow for the game to be available on smart devices, would be to obtain the needed clearance to test directly on which would, therefore, make it even more accessible than if it children without difficulties crossing the midline to attain a were only available on a laptop or computer. A second baseline. Thereafter, tests can be performed on children who proposition was to record the gameplay so that it could be played have difficulty crossing the midline. Although the dashboard back for reference. It was recommended that a video or chat was configurable, it was found to be slightly difficult to capability be introduced so that the child or guardian could interpret. It was suggested that therapists could be trained to communicate with the therapist. interpret and analyze the dashboard. The telehealth system focuses on only one intervention. Therefore, the possibility of Discussion using the serious game and input device to assist in exposing and identifying other gross and fine motor difficulties that a Principal Findings child might have could be investigated. A telehealth system consisting of a serious game accompanied Future Work by an input device and a dashboard can be implemented to address children’s midline crossing difficulties. The scoring The therapists were confident that the telehealth system system provides a quantitative aspect that proves advantageous presented will assist them in identifying and treating children when compared with traditional methods of assessment and with midline crossing difficulties. Therefore, the possibility of treatment, where the assessment is limited to mere observation. using this solution to expose and identify other gross and fine In addition, the notes page that is completed at the end of the motor difficulties that a child might have could be investigated. serious game ensures that the observational components that Furthermore, the solution could even reveal underlying are vital in assessing a child are still included in the overall behavioral, cognitive, or physical impairments. To clarify, the assessment. Therefore, the telehealth system elicits not only therapists would be able to identify other aspects, such as hand quantitative data but also allows observational data to be dominance, eye tracking, postural control, range of motion, recorded using the notes page. attention and focus of the child, and the child's hand functions (grips and grasps) when playing the game. Furthermore, when Although there are many input devices that can be used for identifying whether a child has midline crossing difficulties, a therapeutic reasons, as described in the literature section, they midline jerk can be observed. When a child is confronted with each have shortcomings that would need to be addressed to actions in which the midline is crossed, their eyes move from make them more suitable when used by a child with a pathology side to side rapidly. As a result, adding eye-tracking capabilities with midline crossing. The common drawback of all the devices to the solution was put forward. To mitigate the concern raised is their cost. It is not feasible to expect parents to buy expensive by the therapists regarding the fact that an older child may devices for treatment at home that will only be used for a limited achieve the game objectives quicker than a younger child, a time. A Kinect system will cost approximately US $399 and a standardized assessment stage per age group can be introduced. Wii, US $164, whereas the proposed system costs approximately US $32 to manufacture. This price may also decrease if large One of the actions required in the game when a falling object quantities are manufactured. is caught is to return the object to the side to receive a point. Currently, when the object is returned, an alert is sounded, The Wii provides a suitable solution for physical training and indicating that a point is scored. A suggestion was proposed to balance in particular; however, there are no games that explicitly display a reminder to return the object to the side. Moreover, aim to treat or assess children with midline crossing [18]. At when the child is playing the game using the input device, the first, Leap Motion seemed to be a suitable device for the https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al child may release the device. Consequently, it was suggested Conclusions that in the event that the device is released during the game, an A solution was designed to determine whether a telehealth alert should be displayed to remind the child to remain holding system comprising a serious game can assist occupational the device. In addition, the results presented on the dashboard therapists in identifying whether a child has pathology with are limited to displaying the results for 1 player at a time. A midline crossing and can assist in treating the child remotely. recommendation was proposed to provide a way of showing Serious games are introduced as a need to meet objectives that standardized results for different categories, such as age. This go beyond entertainment and benefit the user in the area that would allow the child to be compared with other children within needs to be mitigated. Through collaboration with occupational a specific area examined. therapists, the telehealth system was designed to make use of different levels in the serious game, where each level addressed In future iterations, artificial intelligence can be incorporated a different need of the therapy process. A novel, low-cost input so that when comments are made on the notes page by the device accompanies the serious game to track the movement of therapist or guardian, the observations can be translated into a child’s hand from side to side and transform the position into quantitative data that can be used to calculate the scoring criteria the game. All results are saved on the web, and occupational instead of physically inputting the scores for the criteria that therapists can access a dashboard that displays the results of require observations. Finally, the solution proposed in this each child. In addition, observed behavioral information will dissertation extracts gameplay data that can assist occupational also be saved to assist occupational therapists in making therapists in identifying and treating children with difficulty decisions regarding changes to the intervention. During the crossing the midline. 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[doi: 10.2174/1573396315666190808115238] [Medline: 31393252] Abbreviations IMU: inertial measurement unit VT: virtual therapist https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Edited by N Zary; submitted 05.02.21; peer-reviewed by I Manuaba, M Stein; comments to author 19.03.21; revised version received 11.05.21; accepted 19.06.21; published 01.11.21 Please cite as: Jacobs J, Heymann R, Greeff JJ A Telehealth System Incorporating a Serious Game Intervention to Aid Occupational Therapists in Identifying and Treating Children With Difficulty Crossing the Body’s Midline: Key Informant Interviews Among Occupational Therapists JMIR Serious Games 2021;9(4):e27761 URL: https://games.jmir.org/2021/4/e27761 doi: 10.2196/27761 PMID: ©Jonathan Jacobs, Reolyn Heymann, Jacob Jacobus Greeff. Originally published in JMIR Serious Games (https://games.jmir.org), 01.11.2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 17 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

A Telehealth System Incorporating a Serious Game Intervention to Aid Occupational Therapists in Identifying and Treating Children With Difficulty Crossing the Body’s Midline: Key Informant Interviews Among Occupational Therapists

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Abstract

Background: The midline is an imaginary line that isolates the left and right parts of the body. Crossing the midline infers that a body part (eg, hand or foot) can spontaneously move over to the opposite side of the body to perform an action. A child who has difficulty crossing the midline can physically perform actions that cross the center of the body; however, they do not intuitively cross the midline when challenged with a task that requires this movement, as their perceptual components prevent them from engaging on the contralateral side. This requires treatment from an occupational therapist. Owing to the recent COVID-19 pandemic, access to therapeutic sessions was not possible or reduced, putting the responsibility for treatment on caretakers at home. Caretakers do not have the knowledge and skills to provide treatment, and occupational therapists do not receive adequate feedback from caretakers on the child’s progress. Objective: The first objective is to adapt a simple serious game, or applied game, into a telehealth solution. Children will play the game at home under the supervision of a caretaker, and the results will be stored on the web. Occupational therapists can monitor progress via a web-based dashboard, receive additional valuable feedback about the child’s behavior during treatment, and easily adapt the game to target specific needs. The second objective is to evaluate whether the implemented telehealth solution is feasible as a treatment option for midline crossing difficulties and thus fit for purpose. Methods: To meet the first objective, engineering and game development stakeholders formed a team with an occupational therapist, and through a collaborative design process combined with an agile programming approach, a telehealth solution was designed to assist remote monitoring of the serious gameplay. For the second objective, 6 different occupational therapists were introduced to the game, had the opportunity to play the game, and then provided feedback regarding the feasibility, benefits, and applicability of the system during structured interviews. Results: A telehealth system was designed aimed to address this problem. All results are saved on the web and accessed by occupational therapists via a dashboard. In addition, observed behavioral information is also saved. During the interviews, occupational therapists indicated that the dashboard would support their treatment plan and was indeed a feasible solution. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Conclusions: The feedback from the occupational therapists for this telehealth solution suggests a feasible method to treat midline crossing problems remotely. The therapists commented on the convenience of integrating both assessment and treatment into the same application, as it assists them when grading a child. The therapists collectively agreed that the quantitative aspect the serious game creates by providing measurable and standardized data proves advantageous when compared with traditional methods of assessment and treatment. (JMIR Serious Games 2021;9(4):e27761) doi: 10.2196/27761 KEYWORDS serious games; input device; telehealth; occupational therapy; midline crossing development if it is not addressed in a timely manner. If a child Introduction does not get the needed intervention due to the COVID-19 lockdown, it can affect the child’s future. Being able to cross Background the midline is a developmental milestone. By the age of 5 years, Owing to the COVID-19 pandemic, numerous health care a child is expected to be able to cross the midline, that is, use practitioners were unexpectedly required to transition their both sides of the body simultaneously [5]. When the midline is standard in-person treatment to telehealth options, often without crossed spontaneously, supporting neural networks and pathways advance preparation or training [1]. Telehealth is becoming an for specific activities are developed. This is a prerequisite skill increasingly used service delivery model in rehabilitation essential for the development and maintenance of motor and services. Telehealth has the potential to alleviate provider cognitive demands associated with specific activities. shortages, decrease costs associated with providing therapy, Consequently, children who have trouble crossing the body’s and allow for treatment within a client's natural environment midline also frequently experience difficulty with reading, [2]. Telehealth can be used by occupational therapists for writing, tying their shoelaces, brushing their teeth, and evaluation, intervention, education, and prevention of injury or participating in physical activities [6]. exacerbation of conditions [3]. Telehealth facilitates Current treatment approaches used by therapists are arts and collaboration and consultation with other professionals, which crafts in which actions such as threading beads, cutting, pasting, facilitates coordination of care [4]. and folding paper are used as these actions require the midline The midline is an imaginary line that isolates the left and right to be crossed. Finger puppets or stickers are also used by placing parts of the body. Crossing the midline infers that a body or sticking the puppets or stickers on one of the child's hands part—for example, a hand or foot—can spontaneously move and then encouraging the child to remove the puppet or sticker over to the opposite side of the body to perform an action. To with the opposite hand. Other common methods used by clarify, a child who has difficulty crossing the midline can therapists include building blocks and playing Twister and physically perform actions that cross the center of the body; marching games using arms and legs. Occupational therapists however, they do not intuitively cross the midline when use standardized assessment tools such as the Movement challenged with a task. The diagnosis of children with midline Assessment Battery for Children, the Developmental Test of crossing difficulties requires a cluster of clinical observations Visual Motor Integration, and the Draw a Person Test to measure that indicate bilateral integration dysfunction [4]. A study was changes in function and occupational. These standardized tests performed in which 10% of the sample was considered to have procedures for administration and scoring [7]. However, constitute a possible deficit range, and a further 10% was when measuring the outcome of an intervention, there is still a considered to be in the suspect range. The remaining 80% was lack of tools available for objective measurement, particularly considered to fall in the normal range [4]. among children with perceptuomotor or attention deficit disorder [7]. Midline crossing is a difficulty that needs the intervention of an occupational therapist. Midline crossing difficulties may At present, occupational therapists observe if the child exhibits affect the child’s physical well-being as well as their future the actions given in Textbox 1. Textbox 1. How to identify whether a child has difficulties crossing the midline. How to identify whether a child has difficulties crossing the midline Swaps hands midway through a task when writing, drawing, painting, or coloring Uses the left hand for activities on the left side of the body and right hand for activities on the right-hand side Rotates their trunk to the opposite side when reaching across the body (to avoid crossing the body midline) Has difficulty visually tracking an object from one side of the body to the other, such as following text when reading Has poor pencil skills (pencil grip) Uses different feet to kick a ball (mixed dominance) Has difficulty coordinating gross motor patterns (eg, crawling, skipping, and star-jumps) https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al On the basis of their observations and discretion, they conclude introduced as a need to meet objectives that go beyond whether the child has difficulty crossing the midline. Assessment entertainment and benefit the user in the area that needs to be is an integral part of the occupational therapy process and is a mitigated. The applications created under the terminology of necessity for evidence-based practice. Without appropriate serious games induce motivation and engage the user [12]. measurement, therapists cannot provide evidence for the offered Objective interventions [8]. The assessment is subjective, and there are Before proposing how serious games can be integrated, a major issues with this subjectivity, as the same level of difficulty may obstacle to treating children in the conventional sense is be rated differently by different assessors. When therapists write boredom because of the intensive and repetitive practice reports for the child, it is challenging to justify the child's required. The advantage of incorporating input devices and the improvement as there is no criterion to compare it with. In use of serious games into treatment methods is that it combats addition, numerous children up to the age of 5 years living in the boredom factor. The child is placed into a game environment underdeveloped countries, including South African rural areas, that is similar to the real world in terms of the perceptual stimuli face exposure to multiple risks affecting their early childhood it exhibits, which then puts the child at ease [13]. The child then development [8]. These children and their parents are often not has the ability to manipulate and control some of the stimuli aware of the functional difficulties they may have, and even if and see the outcome of their actions in real time and adjust them they are aware, they need to travel long distances to receive the accordingly. This aspect, being the interactive component, therapy they require. Moreover, because of the recent creates an engagement with the environment, allowing the child COVID-19 pandemic and resulting lockdowns, many children to feel and be in control of their movement. This idea is who would normally receive occupational therapy could not explained as the perceptual illusion of nonmeditation [14]. The access occupational therapists or had to decrease their sessions. sensations that are familiar and present when playing the game If a child has a pathology of midline crossing, frustration in the and the ability of the child to control and manipulate the stimuli behavior of the child will be noticeable, as the child will become that surround them generate the psychological effects of angry when trying to engage in fine motor activities because of enjoyment and, particularly, involvement [14]. The unique less refined hand skills. The coordination of both sides of the merging of purpose and pleasure develops intrinsic motivation body will be less refined, leading to difficulties experienced in the child. when playing sports or doing any physical activity. In addition, Microsoft’s Kinect sensor has been highly investigated and used when children have difficulty with midline crossing, they may for the development of new complements that help improve or additionally have trouble visually tracking an object from left optimize rehabilitation processes worldwide. In 2012, Ruiz and to right. Thus, when the object reaches the midline, they often Cantos [15] designed a therapeutic tool using the Kinect for blink and have to refocus, and this results in their losing their neurorehabilitation using games to stimulate patients, cognitive place while reading. In addition, when drawing horizontal and functions, perceptions, and gross and visual motor skills through diagonal lines as well as writing letters such as an x, they may play. This tool verified that patients had fun while being treated segment these lines rather than overlap them because of midline in this manner; intrinsic motivation is achieved by merging crossing difficulties [9]. Some children may struggle to cross purpose and pleasure. the body’s midline easily. When a child shows hesitancy in reaching, stepping, or looking across the midline of the body, Moreover, using the Kinect and combining purpose and it is known as midline crossing inhibition. Sometimes, this delay pleasure, Chang et al [16] performed a study in Taiwan in 2013 can be seen when a child hesitates or is clumsy during gross that proposed the possibility of rehabilitating two 14-year-old motor tasks that require the arm or leg to cross over to the other adolescents with cerebral palsy through therapies personalized side. Some children with delayed midline crossing skills may to their condition. Data showed that the 2 participants had display some compensatory mechanisms in school that make significantly increased motivation for upper limb rehabilitation, writing awkward for them. Crossing the midline is a treatable thus improving exercise performance during the intervention affliction. If a child struggles to cross the body's midline and is phases. treated, milestones such as developing a dominant hand will Although Kinect is a useful device, it can, however, encounter occur [6]. Pencil skills and fine motor tasks will be refined, the problem of misdetection when it comes to extremity angles easing the transition to an academic environment where those or overlapping extremities [17]. In 2016, the Taiwan University skills are expected to be grasped [6]. The child will be able to proposed a new rehabilitation gaming system, which focuses complete self-care tasks, for example, brushing their teeth and on the upper part of the body with wireless inertial measurement getting dressed. The child will be able to kick and hit balls as units (IMUs) and a Kinect device. The Kinect was used as a well as run as their gross and fine motor skills will be improved. base tracking system by the gaming system. Multiple sets of Finally, their ability to visually track across a page effectively IMUs were integrated into the extremity of the subject to will be better and, therefore, will result in fluent reading. calculate the angles through algorithms. Wireless IMUs were At the forefront of technological advancements in occupational also added to compensate for the error in the calculation of therapy are serious games [10]. For the purpose of this research, angles in the Kinect device [17]. This study exposed that the serious games are described, among other things, as digital use of the Kinect by itself may not be sufficient and, therefore, games, virtual environments, simulations, and a mixed reality additional sensors were needed to ensure correct motion capture. that engage the player. These serious games form encounters and experiences that convey meaning [11]. Serious games are https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Nintendo’s Wii Fit is a commercial product used for both fitness Sony’s motion capture system Intel RealSense enables and fun and was created to encourage people to exercise as well fine-motoric gesture recognition, and its small form factor allows as improve balance. The Wii Fit uses the Nintendo Wii console for preintegration into notebooks and tablets, substituting and a balance board. A study conducted by the University of conventional cameras [22]. This setup enables new methods of Naples found that the Wii Fit showed better improvements therapy in the form of serious games that are engaging and easy regarding physical therapy in terms of balance and to set up. Chhor et al [22] developed and evaluated a serious self-confidence than conventional treatment [18]. It was game prototype for rehabilitation using Intel's RealSense (called concluded that the Wii Fit is acceptable as an adjunct to virtual Breakout) based on a commercial game framework. Despite the rehabilitation interventions and provides an exciting new therapy fact that RealSense can easily integrate with the applications device [18]. The Wii console does not provide a platform or mentioned above, it is an expensive app. offer a game in which more specific impositions, such as Neuroplasticity refers to the ability of the brain to adapt difficulty crossing the midline, can be treated. If one wanted to structurally and functionally and is enhanced by training and use the Wii for treatment or training purposes, one would need experience. It is known that neuroplasticity is at its maximum to purchase not only the balance board but also the console and in a critical period, which corresponds to the first 7 years of a remote, thus making it too expensive for the communities that child’s life [23]. Therefore, with the development of a serious this study is aimed at. game and given the neuroplasticity of the child’s brain at this Ultraleap’s Leap Motion Controller is a computer hardware age, the child may be able to develop the required pathways sensor device analogous to a mouse [19]. Using motion capture necessary to conduct movements that once seemed impossible. technology, Leap Motion is able to process the input. It does With the integration of technology and the innovation and not require direct hand contact with the device as input; instead, creativity of this approach, a beneficial method of mitigating hand and finger motions are tracked. Despite the small size of impositions such as midline crossing could be developed to Leap Motion, it is capable of capturing smaller details, such as assist occupational therapists in the treatment of children. A finger movement. Leap Motion is smaller and cheaper than serious game with an input device was initially developed to Kinect; however, Kinect is more precise in capturing movement. assist in midline crossing therapy [24]. An improved wireless Sourial and Reichardt [20] proposed implementing a virtual input device that accompanied the serious game was developed therapist (VT) to help patients do their exercises at home in an [25]. The aim of this study is twofold. The first objective focuses engaging gamified environment. The VT artificial intelligence on the design of a web-based telehealth system that consists of used a hierarchical finite-state machine architecture. Hand a serious game, an input device, and a web-based dashboard therapy helps the patient regain the hand's full functionality that displays relevant data to occupational therapists. The second after a certain injury or surgery. Hand therapy could be a very objective focuses on whether the system is fit for its purpose tedious process that implies physical exhaustion [20]. In and can be adopted by occupational therapists to treat patients addition, finding appointments with the therapist frequently remotely. enough for an efficient healing process is difficult and costly. To test the efficiency of the VT, a web-based hand therapy Methods exercise was implemented using the Unity platform to build the Objective One: Designing a Remote Monitoring System exercise environment. Leap Motion technology was used to detect the information of the hand movement. This exercise was for a Midline Crossing Serious Game tested on 19 participants. The idea of being coached by a VT Overview was welcomed by the participants, as the exercise was fun and An agile software development life cycle approach was taken motivating to them. VT guidance and assessment were helpful to develop the end-to-end solution. This methodology was and easy to follow. However, some modifications are needed chosen because of the frequent feedback needed during the in the pain detection part to form a more efficient exercise [20]. design process, allowing the design team to give Another system using Leap Motion and capable of improving recommendations through collaborative design at the end of fine motor skills in children, was proposed by Hidalgo et al [21] each iteration. The design team comprised game designers, through a serious game and 3D environment. The proposed electronic engineers, and an occupational therapist. Figure 1 system allowed the therapist to choose among different levels shows the iterations of the agile software development life cycle. of serious games according to the child’s needs. The game It should be mentioned that each component of the solution excited the children; however, the children took time to adapt (serious game, input device, and telehealth system) was to the game because of the inaccurate readings of Leap Motion. developed separately through iterations; however, the Therefore, it can be noted that including different levels creates components were integrated and tested at the end of each excitement for the children as they experience different iteration. Furthermore, the initial serious game from the previous challenges; however, when technology interferes with the game project was used as a foundation to produce the web-based or is difficult to use, the child takes time to become familiar telehealth solution presented in this study [24]. with the system. A high-level solution design is shown in Figure 2. The sequence of events is illustrated in Figure 3. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 1. Iterations in the agile software development life cycle. Req: requirements. Figure 2. High-level design of solution. OT: occupational therapist. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 3. Sequence of events. OT: occupational therapist. The innovative low-cost input device shown in Figure 4 was the caretaker will explain to the child how to play and then developed previously and used so that the movement of the observe the child’s movements according to the guidelines child could act as an input for the game [25]. The input device designed by the occupational therapists, which will be discussed is designed in such a way that when the device is turned on and further in the Results section. The design of the data the game started, a connection is established. There are no visualization component and the new serious game is presented complicated installations or setup steps. The role of the caretaker in this study. is to help the child set up the device with the game. Additionally, Figure 4. Prototype of input device. published [25]. For the sake of completeness, a short overview Initial Serious Game of the input devices is given in this section. In the initial input The game genre chosen was a casual game because of its low device, an accelerometer and magnetometer were used to obtain system requirements, accessibility in most devices, and, at the the movement of the child [25]. Tilting of the device was not same time, not demanding high levels of concentration from the only issue that affected the feasibility of the design; before the player [26]. The game was not connected to the internet, every game, a calibration was required to obtain the reference and players had to install it to play it. The fact that the game of the sensor. It did not seem to be the most suitable solution does not take much concentration is an important factor in for therapists to expect the child to perform the calibration each ensuring that the child does not become fatigued and frustrated. time they wanted to play the game, ensuring that they do not Moreover, the duration of the game was purposely designed to tilt the sensor. Therefore, a more child-friendly design was be short to retain the child's concentration. The developed game needed that would be able to track the movement of the hand comprised a sprite controlled by the child [24]. Sprite is the from side to side (crossing the body's midline) and transform terminology used to describe an avatar, shape, or character that the position into the game. In addition to accurately transforming the child has control over. The device was attached to the hand the movement, a device that would not require calibrating the of the child, and the child moved the device in an arc shape with sensor was required. When discussions were held with an their arm extended in front of them while standing. The aim of occupational therapist during the design phase, it was suggested the game was to collect faces falling at a calculated position that an input device that would be placed on a surface be from the sky. The movements in the game ensured that the child designed. The idea behind this was to allow the child to move crossed the midline. The game intended to prompt the child to their hand from side to side and exhibit the same motion required perform particular movements that occupational therapists would when performing tasks that cross the midline, such as writing. invoke when using traditional methods of treatment. Through extensive research into suitable sensors or electrical devices that could be used, a clean, innovative solution was Input Devices reached. The design entailed the addition of a linear The problems encountered with the initial design of the input potentiometer; the input device is shown in Figure 4 [25]. device and the detailed new design have been previously https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al the occupational therapist through the game and explaining how Objective Two: Evaluate Whether the Online Game each stage of the game was played. The occupational therapists Is Fit for Purpose then had the opportunity to play the game and evaluate each After the prototype was developed, it was crucial to evaluate stage on their own. A semistructured interview took place, whether this solution was a feasible option for occupational allowing the researcher to further explore the insights provided therapists and whether it was fit for purpose. This was achieved by through semistructured interviews with occupational therapists. These occupational therapists all had between 5 to 10 years of the therapist. Each session was conducted individually to ensure experience. In addition, as many children have difficulty unbiased and objective responses. The interview aimed to crossing the midline, these occupational therapists were highlight the strengths and weaknesses of the solution as well competent to give feedback regarding the identification and as the suitability of administering the solution remotely. The treatment of midline crossing difficulties. Note that the interview provided the therapists with the opportunity to suggest occupational therapist who was part of the participatory design changes and offer recommendations. The questions were sessions was not included in the evaluation of the system. purposefully left open-ended so as not to limit the therapist's responses. The main themes that needed to be established from The researcher took each of the participants through a the interviews can be seen in Textbox 2. The questions contained presentation detailing the purpose of this research. The in each section can be seen in Textbox 3. researcher conducted a demonstration of the full solution, taking Textbox 2. Main themes established from interviews. Main themes The feasibility of using a serious game and input device to assist occupational therapists in identifying and treating children with midline crossing difficulties The benefits and applicability of the dashboard The applicability of the solution in areas where the availability of occupational therapy resources is limited Textbox 3. Questions asked to occupational therapists during the interviews. Questions In your professional context, comment on whether a serious game and input device would assist you as a therapist to identify children with midline crossing difficulties as well assist in your treatment process. Please include in your answer the following: Advantages Disadvantages Suggested changes Recommendations Comment on whether the use of the dashboard is beneficial and applicable to assist you as a therapist in identifying whether a child has pathology with midline crossing. Does the dashboard provide constructive tracking of the child's progress during treatment? Advantages Disadvantages Suggested changes Recommendations Comment whether the solution can be reasonably implemented and used effectively in areas where occupational therapy resources are limited. Advantages Disadvantages Suggested changes Recommendations https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al losing focus. Each stage addresses a certain intervention, which Results will be explained below; therefore, the input to each stage is different. The occupational therapist can set these inputs Objective One: Designing a Remote Monitoring System however they see fit (or advice the caretaker at home on which for a Midline Crossing Serious Game values to use during remote treatment). Adapted Serious Game The game environment is chosen by selecting a stage and The initial game, as described in the previous section, was used choosing the required values for the inputs for that stage. The as a base for the new telehealth system. The new system game commences with the hat (controlled by the child using comprised an adapted serious game (with distinct levels), an the input device) starting either on the left or right side of the input device, and a web-based backend system that enabled screen depending on the handedness of the child. For the purpose occupational therapists to access dashboards and behavioral of this explanation, a child who is right-handed will be used; information about the intervention. During the collaborative therefore, the sprite starts on the left. If the child were design sessions, it was decided that the serious game would be left-handed, the sprite would start on the right so that the child’s divided into different stages. Each stage has a specific aim, and first movement would be crossing the midline. The balls that different game variables can be set according to each child’s fall from the sky are strategically placed, depending on the stage, individual needs. The game comprises 4 stages: an assessment which will be discussed below. When the balls fall, the child stage, 2 intervention stages, and a maintenance stage [24]. In must catch the ball in the hat and return the hat to the starting each stage, there are 3 variables: distance, speed, and time, point (either the left or right side of the screen) to earn a point. which are used to create a specific environment for testing. The Textbox 4 shows the variables used in the equations. Table 1 time variable, set at 2 minutes, was kept constant for all stages. shows the inputs and equations for the variable set. The game The chosen duration was advised by the occupational therapist. flow is illustrated in Figure 5; depending on the stage, the The duration was purposely set to be short to allow the child to equations shown in Table 1 will be inserted. concentrate for a short amount of time without getting bored or Textbox 4. Variables used in the equations to set the game environment. Variables X is the starting distance • 0 I is the incremental distance S is the score DV is the distance variance Random (a,b) is the random function that provides a random number between a and b Sp is the initial speed Is is the incremental speed Table 1. Equations used in each stage to set the game environment. Stage Input Distance Speed Time a b c 1 Constant Constant X , I X +(IX ) 0 0 s 2 X +Random (–DV, DV) Constant Constant X , DV e f 3 X Sp +(Is SX) Constant 0 0 p X , Sp , Is 0 0 p 4 Random (–7.5,7.5) Constant Constant N/A X starting distance. 0: I: incremental distance. IX : incremental distance as function of score. DV: distance variance. Sp initial speed. 0: Is : incremental speed. N/A: not applicable. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 5. General game flow. eq: equation. and returned. A ball is considered returned when the hat reaches Stage 1 the left side of the screen if the child is right-handed; if the child Stage 1 takes the starting distance (X ) and incremental distance 0 is left-handed, the hat would need to be returned to the right (I) as input. The starting distance is the point on the x-axis where side of the screen. The score will update only after the hat has the first ball will be spawned from the sky (top of the screen). been returned. Consequently, the point at which the next ball The x-axis is depicted in Figure 6. The incremental distance is falls will increase by the incremental distance (increase to the the distance that is incremented from the starting distance. The right if the child is right-handed). If a ball is missed, intuitively, point on the x-axis where the balls are spawned is a function of the score will not increase, thus remaining the same; therefore, the score (S); as the score increases, so does the distance of the the ball will be spawned in the same place instead of being spawned ball. The score represents the number of balls caught spawned at the incremented distance. Figure 6. Position on x-axis in game. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Stage 1, which is the assessment stage, aims to determine the amount of external input required to achieve midline crossing child’s gross ability to cross the midline. In addition to the stages would be noted by the caretaker on the system. Although the incorporated into the game, an interface to input the specified game is designed to determine the core impairments of crossing variables determined by the therapist was introduced. These the midline, clinical reasoning, observations, and external variables create a tailored game environment for the child. In guidance from the occupational therapist are vital for a holistic stage 1, the speed and time variables remain constant, whereas and accurate assessment. In the event that an occupational the distance variable is incremented. The input device shown therapist is not performing the assessment (ie, caretaker, parent, in Figure 4 controls the movement of the hat illustrated in Figure teacher, or guardian), a notes page, shown in Figure 7, will need 6 from side to side, simulating the movement of crossing the to be completed, which is presented to the caretaker at the end midline while writing. After the child catches the ball, the hat of the game. A guidance script with key points of reference will needs to be moved all the way to the other side of the screen, be provided to the caretaker before the child plays the game to ensuring that the midline is crossed. assist and ensure accurate observations. Using the results, an individualized treatment plan tailored to the child’s needs would A reference point for the child’s baseline functioning, including be constructed and developed by the occupational therapist, their ability to cross the midline, was established in stage 1. The which can be done remotely. Figure 7. Notes page to fill in after each stage is completed. Stage 3, the second intervention stage, aims to enhance the Stage 2 child’s gross ability to cross the midline. The distance and time Stage 2 takes the starting distance (X ) and distance variance 0 variables will remain constant, whereas the speed variable will as inputs. Here, the distance variance is the distance from the be incremented. This increases sufficient accuracy and skill. starting distance, and the distance can be varied; for example, Stage 4 if the starting distance is 1.5 and the distance variance is 0.5, Stage 4 does not require any input as the position at which each the ball can be spawned between points 1 and 2 on the x-axis. ball is spawned is random. The point at which each ball is Stage 2 is the first intervention stage, aimed at improving the spawned is calculated using the random function Rand(). As child’s gross ability to cross the midline. This stage allows for shown in Figure 6, the x-axis spans from –7.5 to 7.5; therefore, the distance variable to be adjusted, whereas the speed and time the ball can be spawned at a random point on the axis. The speed variables are constant. The caretaker sets the distance at the of the ball remains constant and does not increase as a function specific distance where the child began experiencing problems of the score. The gameplay time is constant for stage 4. with midline crossing. This distance can then be adapted and The purpose of stage 4, the unregulated round, is to maintain graded during the intervention. the skills the child has obtained in the previous stages. In this Stage 3 stage, the speed and time variables will remain constant, whereas Stage 3 takes the starting distance (X ), initial speed (Sp ), and the distance variable will be random. 0 0 incremental speed (Is ) as inputs. The initial speed is the speed Scoring at which the ball starts to fall. The incremental speed is the The occupational therapist advised on the scoring criteria for increase in speed from the starting point. The ball will continue the stages during the collaborative design sessions. These to fall at the specified starting point; however, the speed at which scoring criteria were based on observations that occupational the ball falls will increase as each ball is caught. therapists would typically make during traditional treatments. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al The first three criteria were generated from the gameplay data meets the scoring for a criterion, a point will be awarded. The received from the game, and the following five criteria were criteria for the other stages are the same as those for stage 1, recorded by observation. To confirm that the child did not except for criterion 4. In the scoring criteria for stage 2, the display any form of pathology with midline crossing, a child effect of the random displacement of balls in a targeted area is would need to achieve a total of ≥4 points on their score card. determined rather than the increasing distance. In the scoring It should be noted that all 8 criteria should be used in criteria for stage 3, the effect of increasing the speed of the balls conjunction with one another and not assessed independently. is determined rather than increasing the distance. Finally, in the Table 2 shows the 8 criteria, the observation being assessed, scoring criteria for stage 4, the effect of the balls randomly and the measurement to score the criterion for stage 1. If a child falling is determined. Table 2. This table shows the scoring criteria for an assessment (stage 1). Criterion Observation Scoring 1 Balls caught >14 2 Balls missed <4 3 Average time between balls <7.5 4 Distance increasing No pattern 5 Follow instructions Yes 6 Eye movements Maintain visual focus 7 Body movement No gross adjustments 8 General behavior No verbal cues have been performed. Consequently, a dashboard was designed Data Visualization to aid occupational therapists by providing a collection of Occupational therapists can support children with difficulty objective data about children who have difficulty crossing the crossing the midline by helping them develop the skills needed midline. The proposed monitoring tool provides a solution in to perform activities of daily living. During therapy sessions, which the gameplay of the child during an assessment or occupational therapists use a variety of techniques to support treatment is recorded, and the data collected in the game can be rehabilitation, such as functional electrical stimulation, visualized by the therapist. The design of the system, and the constraint-induced motor training, facilitation, and virtual reality monitoring functionality in particular, allows for the game and applications [27]. This combination of therapy, exercise, and input device to be used by parents or guardians with the children context-specific retraining is critical for neuroplasticity, as in a home environment and to be used remotely. Therefore, the mentioned in the Introduction. Although retrospective recall game would not be restricted to only being played during and exercise diaries can gather subjective data, the quality of therapy sessions but rather can be played outside of these times these data is limited and relies on the notes and observations as well. A dashboard was designed using Microsoft’s PowerBI written by an occupational therapist; as such, occupational to display the data illustrated in Figure 8. therapists lack objective data about the degree to which exercises https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 8. Representative dashboard showing how the tooltips will be displayed using Microsoft PowerBI. During the evaluation process, the occupational therapists were as the distance increased, the child missed more balls. In this asked to play the game themselves and get familiar with how case, there are various factors that could impact the child’s the system works. Figure 9 shows an illustrative example of results. For example, the child may have felt bored and, how the dashboard would look for a child without midline therefore, did not play as they should have. A child with an crossing difficulties. The dashboard is accessible remotely. average performance result needs to be further assessed to see Figure 10 is an illustrative example of a dashboard for a child whether their results are because of pathology with midline with midline crossing difficulties. The red circle indicates that crossing or whether there are other factors yielding these results. Figure 9. Representative dashboard for a child whose performance was above average for stage 1. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Figure 10. Representative dashboard for a child whose performance was below average for stage 1. One of the ways to identify whether a child has pathology with Objective Two: Evaluate Whether the Web-Based midline crossing is by observing whether the child has a midline Game Is Fit for Purpose jerk. This can be noticed when the child is performing actions The therapists commented on the convenience of integrating where the midline is crossed, and their eyes move from side to both assessment and treatment into the same application as it side in a rapid manner. Consequently, the therapist proposed assists the therapists when grading a child. The stages developed incorporating eye tracking to detect if the child’s oculomotor in the game were also commended by the therapists, as each functions are impaired. Additional monitoring through the use stage has a different focus point with a specific outcome. They of a laptop camera can also be provided to observe the eye collectively agreed that the quantitative aspect that the game movement, head adjustments, and posture of the child. creates by providing measurable and standardized data proves As part of the game, when the child catches the object falling advantageous when compared with traditional methods of in the hat, the child is required to return the hat to the side of assessment and treatment. When using a traditional method, the screen to receive a point. Even though an alert is sounded such as asking the child to build a puzzle or draw a line across when the object returns to the side, a suggestion was proposed a page, there are no quantitative measures that can be deduced; to display a reminder on the screen to return the object to the instead, the assessments are limited to mere observation. The side at the point where the child has caught the object. In proposed solution elicits not only quantitative data but also addition, when the child is playing the game and controlling allows observational data to be recorded using the notes page. the input device, the child may release the device. Consequently, Furthermore, they referred to the notes page as not only it was recommended that if the child releases the device during descriptive but also appreciated that it was designed to be the game, an alert should be shown to remind the child to grasp understood by nonmedical professionals, thereby making the the device. observational recording more effective and user-friendly. The Specific attention was given to the dashboard design as it is an notes page is viewed as an extremely beneficial aspect of the important part of enabling remote monitoring. Everyone serious game as it ensures that the assessor covers all the unanimously agreed that the dashboard’s ability to track the observational components included in the assessment and progress of the child would benefit their reports immensely. treatment. As a result of the movements triggered by the game The results represented in the dashboard would assist them in and the quantitative and observational data recorded by the supporting and verifying their observational conclusions. application, the occupational therapists concluded that the Furthermore, when submitting reports to their clients’ medical serious game, accompanied by the input device, would assist aids, the data from the dashboard can be used to solidify their them in identifying whether a child has pathology with midline conclusions and can be included in their reports. crossing. Moreover, the solution would also assist in treating the child’s pathology. Finally, the therapists thought that the The only disadvantage that was raised by the occupational solution could assist in exposing and identifying other gross therapists was that the dashboard might not be particularly easy and fine motor pathologies that a child might have, or it might to interpret for a layman; however, a suggestion was made to even reveal underlying behavioral, cognitive, or physical provide training to therapists on how to interpret and analyze impairments. It was suggested that the assessment stage should the dashboard. The other disadvantage was that the dashboard be standardized per age group. was limited to only showing the results for a midline crossing https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al assessment and no other difficulties that could be identified by development of a VT; however, with inaccurate readings the game. stemming from the device affecting the game experience, the device would not be suitable for children [21]. The RealSense There were suggestions to provide a way of showing the is a fitting tool; however, because of the high price of the device, standardized results for different categories by searching by it is not suitable [19]. age, for example, and, consequently, the results for that particular age group would be displayed. Introducing Studies with a serious game and Kinect showed that individuals standardized norms would allow the child to be compared with are more motivated, enjoy therapy, and even enable therapy to other children within the specific area being examined. Another be more accessible [12]. On the basis of the feedback from the suggestion that was made was to allow therapists to add occupational therapists, the child will also experience these additional comments on the results of the child displayed for benefits from the system presented in this paper. However, this further reference. Finally, it was proposed that artificial will only be proven in clinical studies. intelligence could be incorporated so that when comments are Limitations made on the notes page by the therapist or guardian, the When determining whether serious games are feasible as a observations can be translated into quantitative data that can be treatment option for midline crossing difficulties and are fit for used to calculate the scoring criteria instead of physically purpose, there appears to be a lack of clinical evidence about inputting the scores for the criteria that require observations. the benefit to children from the application of serious games The occupational therapists agreed that this solution could be [28]. Owing to ethical constraints regarding testing the solution used as a telehealth device. To further enhance these benefits, directly on children, professional opinions of occupational it was suggested that the game be deployed as a mobile app. therapists were gathered to validate the solution. The next step This would allow for the game to be available on smart devices, would be to obtain the needed clearance to test directly on which would, therefore, make it even more accessible than if it children without difficulties crossing the midline to attain a were only available on a laptop or computer. A second baseline. Thereafter, tests can be performed on children who proposition was to record the gameplay so that it could be played have difficulty crossing the midline. Although the dashboard back for reference. It was recommended that a video or chat was configurable, it was found to be slightly difficult to capability be introduced so that the child or guardian could interpret. It was suggested that therapists could be trained to communicate with the therapist. interpret and analyze the dashboard. The telehealth system focuses on only one intervention. Therefore, the possibility of Discussion using the serious game and input device to assist in exposing and identifying other gross and fine motor difficulties that a Principal Findings child might have could be investigated. A telehealth system consisting of a serious game accompanied Future Work by an input device and a dashboard can be implemented to address children’s midline crossing difficulties. The scoring The therapists were confident that the telehealth system system provides a quantitative aspect that proves advantageous presented will assist them in identifying and treating children when compared with traditional methods of assessment and with midline crossing difficulties. Therefore, the possibility of treatment, where the assessment is limited to mere observation. using this solution to expose and identify other gross and fine In addition, the notes page that is completed at the end of the motor difficulties that a child might have could be investigated. serious game ensures that the observational components that Furthermore, the solution could even reveal underlying are vital in assessing a child are still included in the overall behavioral, cognitive, or physical impairments. To clarify, the assessment. Therefore, the telehealth system elicits not only therapists would be able to identify other aspects, such as hand quantitative data but also allows observational data to be dominance, eye tracking, postural control, range of motion, recorded using the notes page. attention and focus of the child, and the child's hand functions (grips and grasps) when playing the game. Furthermore, when Although there are many input devices that can be used for identifying whether a child has midline crossing difficulties, a therapeutic reasons, as described in the literature section, they midline jerk can be observed. When a child is confronted with each have shortcomings that would need to be addressed to actions in which the midline is crossed, their eyes move from make them more suitable when used by a child with a pathology side to side rapidly. As a result, adding eye-tracking capabilities with midline crossing. The common drawback of all the devices to the solution was put forward. To mitigate the concern raised is their cost. It is not feasible to expect parents to buy expensive by the therapists regarding the fact that an older child may devices for treatment at home that will only be used for a limited achieve the game objectives quicker than a younger child, a time. A Kinect system will cost approximately US $399 and a standardized assessment stage per age group can be introduced. Wii, US $164, whereas the proposed system costs approximately US $32 to manufacture. This price may also decrease if large One of the actions required in the game when a falling object quantities are manufactured. is caught is to return the object to the side to receive a point. Currently, when the object is returned, an alert is sounded, The Wii provides a suitable solution for physical training and indicating that a point is scored. A suggestion was proposed to balance in particular; however, there are no games that explicitly display a reminder to return the object to the side. Moreover, aim to treat or assess children with midline crossing [18]. At when the child is playing the game using the input device, the first, Leap Motion seemed to be a suitable device for the https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al child may release the device. Consequently, it was suggested Conclusions that in the event that the device is released during the game, an A solution was designed to determine whether a telehealth alert should be displayed to remind the child to remain holding system comprising a serious game can assist occupational the device. In addition, the results presented on the dashboard therapists in identifying whether a child has pathology with are limited to displaying the results for 1 player at a time. A midline crossing and can assist in treating the child remotely. recommendation was proposed to provide a way of showing Serious games are introduced as a need to meet objectives that standardized results for different categories, such as age. This go beyond entertainment and benefit the user in the area that would allow the child to be compared with other children within needs to be mitigated. Through collaboration with occupational a specific area examined. therapists, the telehealth system was designed to make use of different levels in the serious game, where each level addressed In future iterations, artificial intelligence can be incorporated a different need of the therapy process. A novel, low-cost input so that when comments are made on the notes page by the device accompanies the serious game to track the movement of therapist or guardian, the observations can be translated into a child’s hand from side to side and transform the position into quantitative data that can be used to calculate the scoring criteria the game. All results are saved on the web, and occupational instead of physically inputting the scores for the criteria that therapists can access a dashboard that displays the results of require observations. Finally, the solution proposed in this each child. In addition, observed behavioral information will dissertation extracts gameplay data that can assist occupational also be saved to assist occupational therapists in making therapists in identifying and treating children with difficulty decisions regarding changes to the intervention. During the crossing the midline. 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[doi: 10.2174/1573396315666190808115238] [Medline: 31393252] Abbreviations IMU: inertial measurement unit VT: virtual therapist https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jacobs et al Edited by N Zary; submitted 05.02.21; peer-reviewed by I Manuaba, M Stein; comments to author 19.03.21; revised version received 11.05.21; accepted 19.06.21; published 01.11.21 Please cite as: Jacobs J, Heymann R, Greeff JJ A Telehealth System Incorporating a Serious Game Intervention to Aid Occupational Therapists in Identifying and Treating Children With Difficulty Crossing the Body’s Midline: Key Informant Interviews Among Occupational Therapists JMIR Serious Games 2021;9(4):e27761 URL: https://games.jmir.org/2021/4/e27761 doi: 10.2196/27761 PMID: ©Jonathan Jacobs, Reolyn Heymann, Jacob Jacobus Greeff. Originally published in JMIR Serious Games (https://games.jmir.org), 01.11.2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2021/4/e27761 JMIR Serious Games 2021 | vol. 9 | iss. 4 | e27761 | p. 17 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious GamesJMIR Publications

Published: Nov 1, 2021

Keywords: serious games; input device; telehealth; occupational therapy; midline crossing

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