Virtual Hand-Arm Assessments for Children With Cerebral Palsy

Condition(s) studied

Investigational drug(s) / intervention(s)

Upper-Limb Virtual and In-Person Assessment: Participants complete a standardized upper-limb assessment protocol that includes two virtual videoconference assessments-delivered one week apart to evaluate test-retest reliability-and one in-person clinic assessment with the same research therapist to enable within-participant comparison of virtual and in-person scores. After each session, children, caregivers, and therapists complete brief surveys assessing feasibility, ease of completion, acceptability, and preferences. Participants also wear bilateral wrist-worn inertial sensors for five consecutive days at home to collect continuous data on naturalistic upper-limb activity. Families also provide caregiver-recorded videos of the child performing two preselected meaningful activities in their home environment. These videos are later scored using the Perceived Quality Rating Scale (PQRS) to evaluate individualized functional performance.

Study summary

Cerebral palsy (CP) affects approximately 1 in 500 Canadian children, and the majority experience hand and arm limitations that impact independence, participation in daily activities, and overall quality of life. Many children require ongoing clinical assessments and therapy delivered in specialized centres, creating significant burden related to travel, scheduling, and interruptions to school and work. Barriers such as geography, socioeconomic factors, and pandemic-related service disruptions have further limited equitable access to in-person care. Although virtual care has expanded rapidly and families have expressed strong interest in hybrid care models, there is currently no validated approach for conducting comprehensive virtual hand-arm assessments for children with CP. Virtual administration of standardized assessments, individualized goal-based evaluations, and naturalistic observation tools has not been systematically studied. Evidence is urgently needed to determine which assessments can be administered virtually, how acceptable and feasible they are for families, and whether virtual and in-person assessment methods produce equivalent results.

Eligibility

Primary outcome measure(s)

• Feasibility of Virtual Upper-Limb Assessments: Completion Rate of Virtual aROM — From enrollment through completion of the 2 virtual assessments (approximately 2 weeks).
  The percentage of enrolled participants who complete the virtually administered active range of motion (aROM) assessment. Feasibility success is defined a priori as \>70% completion.
• Feasibility of Virtual Upper-Limb Assessments: Completion Rate of Virtual Box and Block Test (BBT) — From enrollment through completion of the 2 virtual assessments (approximately 2 weeks).
  The percentage of enrolled participants who complete the virtually administered Box and Block Test (BBT). Feasibility success is defined a priori as \>70% completion.
• Feasibility of Virtual Upper-Limb Assessments: Completion Rate of Virtual Quality of Upper Extremity Skills Test (QUEST) — From enrollment through completion of the 2 virtual assessments (approximately 2 weeks).
  The percentage of enrolled participants who complete the virtually administered Quality of Upper Extremity Skills Test (QUEST). Feasibility success is defined a priori as \>70% completion.
• Feasibility of Virtual Upper-Limb Assessments: Completion Rate of Virtual SHUEE Spontaneous Functional Analysis (SHUEE-SFA) — From enrollment through completion of the 2 virtual assessments (approximately 2 weeks).
  The percentage of enrolled participants who complete the virtually administered SHUEE Spontaneous Functional Analysis (SHUEE-SFA). Feasibility success is defined a priori as \>70% completion.
• Feasibility of Virtual Upper-Limb Assessments: Recruitment and Attrition Metrics — From enrollment through completion of participation (approximately 3-4 weeks).
  Recruitment rate (number of participants enrolled over the recruitment period), attrition rate (percentage of enrolled participants who do not complete the virtual assessment component), and documented reasons for non-eligibility, non-participation, or withdrawal.
• Feasibility of Virtual Upper-Limb Assessments: Ability to Obtain Required Household Materials for Virtual Assessment — Prior to commencement of virtual assessments (Week 1)
  The percentage of families who report successfully obtaining all required household materials needed to complete the virtual standardized assessments from home.
• Feasibility of Virtual Upper-Limb Assessments: Technical, Environmental, Behavioral, and Cognitive Challenges During Virtual Sessions — During Virtual Assessment 1 and Virtual Assessment 2 (approximately 2 weeks)
  The number of technical (e.g., dropped connection), video quality (e.g., lighting, camera angle), behavioral (e.g., distraction), and cognitive (e.g., confusion) challenges observed during virtual assessment sessions, coded from session videos using the standardized Observational Checklist and Behavioural Observation Research Interactive Software (BORIS).
• Feasibility of Virtual Upper-Limb Assessments: Duration of Virtual and In-Person aROM — During Virtual Assessment #1, Virtual Assessment #2 and In-Person Assessment Session #1 (approximately 3 weeks)
  Time required to complete the active range of motion (aROM) when administered virtually compared to in person, as recorded using the standardized Observational Checklist.
• Feasibility of Virtual Upper-Limb Assessments: Duration of Virtual and In-Person BBT — During Virtual Assessment #1, Virtual Assessment #2 and In-Person Assessment Session #1 (approximately 3 weeks)
  Time required to complete the Box and Blocks Test (BBT) when administered virtually compared to in person, as recorded using the standardized Observational Checklist.
• Feasibility of Virtual Upper-Limb Assessments: Duration of Virtual and In-Person QUEST — During Virtual Assessment #1, Virtual Assessment #2 and In-Person Assessment Session #1 (approximately 3 weeks)
  Time required to complete the QUEST when administered virtually compared to in person, as recorded using the standardized Observational Checklist.
• Feasibility of Virtual Upper-Limb Assessments: Duration of Virtual and In-Person SHUEE-SFA — During Virtual Assessment #1, Virtual Assessment #2 and In-Person Assessment Session #1 (approximately 3 weeks)
  Time required to complete the SHUEE-SFA when administered virtually compared to in person, as recorded using the standardized Observational Checklist.
• Acceptability of Virtual aROM (Caregiver and Therapist) — Immediately after each virtual and in-person assessment (weeks 1-3).
  Acceptability of virtual administration of the active range of motion (aROM) assessment will be measured using a post-session Acceptability Survey administered via REDCap. After each assessment session, caregivers and the occupational therapist will each rate whether the virtual administration of the aROM was comparable or preferable to in-person administration. Acceptability success is defined a priori as \>70% comparable or preferable ratings.
• Acceptability of Virtual Box and Block Test (Caregiver and Therapist) — Immediately after each virtual and in-person assessment (weeks 1-3).
  Acceptability of virtual administration of the Box and Block Test will be measured using a post-session Acceptability Survey administered via REDCap. After each assessment session, caregivers and the occupational therapist will each rate whether the virtual administration of the BBT was comparable or preferable to in-person administration. Acceptability success is defined a priori as \>70% comparable or preferable ratings.
• Acceptability of Virtual QUEST (Caregiver and Therapist) — Immediately after each virtual and in-person assessment (weeks 1-3).
  Acceptability of virtual administration of the QUEST will be measured using a post-session Acceptability Survey administered via REDCap. After each assessment session, caregivers and the occupational therapist will each rate whether the virtual administration of the QUEST was comparable or preferable to in-person administration. Acceptability success is defined a priori as \>70% comparable or preferable ratings.
• Acceptability of Virtual SHUEE-SFA (Caregiver and Therapist) — Immediately after each virtual and in-person assessment (weeks 1-3).
  Acceptability of virtual administration of the SHUEE-SFA will be measured using a post-session Acceptability Survey administered via REDCap. After each assessment session, caregivers and the occupational therapist will each rate whether the virtual administration of the SHUEE-SFA was comparable or preferable to in-person administration. Acceptability success is defined a priori as \>70% comparable or preferable ratings.
• Equivalence of Virtual and In-Person aROM Scores — Across the two virtual assessments and subsequent in-person assessment (approximately 3 weeks).
  Agreement between virtual and in-person assessment aROM scores (scored live, 2-3 days apart) will be examined using mean absolute differences, intraclass correlation coefficients (ICCs; target ICC ≥0.90, lower 95% CI \>0.60), Bland-Altman limits of agreement, and coefficient of variation (\<10%). Equivalence is met if 80% confidence limits fall within each test's minimally important change or smallest detectable difference. Factors contributing to low agreement (e.g., internet quality, scope of view) will be explored using session videos.
• Equivalence of Virtual and In-Person BBT Scores — Across the two virtual assessments and subsequent in-person assessment (approximately 3 weeks).
  Agreement between virtual and in-person assessment BBT scores (scored live, 2-3 days apart) will be examined using mean absolute differences, intraclass correlation coefficients (ICCs; target ICC ≥0.90, lower 95% CI \>0.60), Bland-Altman limits of agreement, and coefficient of variation (\<10%). Equivalence is met if 80% confidence limits fall within each test's minimally important change or smallest detectable difference. Factors contributing to low agreement (e.g., internet quality, scope of view) will be explored using session videos.
• Equivalence of Virtual and In-Person QUEST Scores — Across the two virtual assessments and subsequent in-person assessment (approximately 3 weeks).
  Agreement between virtual and in-person assessment QUEST scores (scored live, 2-3 days apart) will be examined using mean absolute differences, intraclass correlation coefficients (ICCs; target ICC ≥0.90, lower 95% CI \>0.60), Bland-Altman limits of agreement, and coefficient of variation (\<10%). Equivalence is met if 80% confidence limits fall within each test's minimally important change or smallest detectable difference. Factors contributing to low agreement (e.g., internet quality, scope of view) will be explored using session videos.
• Equivalence of Virtual and In-Person SHUEE-SFA Scores — Across the two virtual assessments and subsequent in-person assessment (approximately 3 weeks).
  Agreement between virtual and in-person assessment SHUEE-SFA scores (scored live, 2-3 days apart) will be examined using mean absolute differences, intraclass correlation coefficients (ICCs; target ICC ≥0.90, lower 95% CI \>0.60), Bland-Altman limits of agreement, and coefficient of variation (\<10%). Equivalence is met if 80% confidence limits fall within each test's minimally important change or smallest detectable difference. Factors contributing to low agreement (e.g., internet quality, scope of view) will be explored using session videos.
• Test-Retest Reliability of Virtual aROM — Between Virtual Assessment 1 and Virtual Assessment 2 (1-week interval).
  Reliability will be evaluated using ICCs for (a) the two virtual assessments performed one week apart (live scoring), and (b) live scoring versus video-based scoring. Paired t-tests will examine systematic differences across repeated sessions.
• Test-Retest Reliability of Virtual BBT — Between Virtual Assessment 1 and Virtual Assessment 2 (1-week interval).
  Reliability will be evaluated using ICCs for (a) the two virtual assessments performed one week apart (live scoring), and (b) live scoring versus video-based scoring. Paired t-tests will examine systematic differences across repeated sessions.
• Test-Retest Reliability of Virtual QUEST — Between Virtual Assessment 1 and Virtual Assessment 2 (1-week interval).
  Reliability will be evaluated using ICCs for (a) the two virtual assessments performed one week apart (live scoring), and (b) live scoring versus video-based scoring. Paired t-tests will examine systematic differences across repeated sessions.
• Test-Retest Reliability of Virtual SHUEE-SFA — Between Virtual Assessment 1 and Virtual Assessment 2 (1-week interval).
  Reliability will be evaluated using ICCs for (a) the two virtual assessments performed one week apart (live scoring), and (b) live scoring versus video-based scoring. Paired t-tests will examine systematic differences across repeated sessions.
• Predictors of Feasibility, Acceptability, and Equivalence — From enrollment through completion of participation (approximately 3-4 weeks).
  Logistic regression analyses will examine whether participant characteristics (age, disability level \[MACS\], gender, sex, ethnicity, socioeconomic status) predict three dichotomized outcomes: (1) completion of virtual standardized assessments (yes/no), (2) willingness to participate in future virtual assessments (yes/no), and (3) acceptable agreement between virtual and in-person assessment scores (yes/no).

Trial sites (3)

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