| Individualisation | Allows clinicians to individualise treatment plans by offering a wide range of standing and seated range of motion/strengthening, balance and cardiorespiratory fitness lower limb exercises. Treatment parameters can be customised to the child’s abilities/needs (eg, number of repetitions, sets). Clinicians can identify whether exercises should be performed unsupported or supported (eg, holding on to the back of a chair) with video demonstrations for both versions available in addition to exercise instructions. Children can customise the game play environment by selecting a robot (ie, Helper Bot) to exercise with. The child’s chosen name also appears on the main menu screen of the game.
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| Opportunities for practice | Clinicians can specify the treatment parameters (eg, number of repetitions, sets). Children are encouraged to perform exercise sessions four times per week in alignment with the American College of Sports Medicine and the National Strength and Conditioning Association guidelines for people with CP that recommend strength/resistance training 2–4 times per week.59 60 A child is given 3 extra repetition attempts above what has been prescribed by their physiotherapist to try and complete repetitions with good quality. For timed exercises (eg, stretches), clinicians can prescribe up to 60 s for each exercise set. A child then has 3 attempts over a 2-minute period to hold the pose or perform the movement for the prescribed amount of time before the next exercise is loaded. These repetition/time caps will ensure a child does not spend too long on any exercise to minimise frustration/fatigue. Physiotherapists are made aware of built-in caps prior to plan prescription through an introductory Bootle Boot Camp video that they will watch during onboarding.
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| Social play equalisation | Children can complete exercise sessions in one-player or two-player mode, allowing for social interaction and barrier-free inclusion during game play that may sustain engagement. In multiplayer mode, both players complete the same plan which is tailored to the child who has been prescribed the home exercise programme.
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| Motivation | Choice and rewards help to support motivation within the game. Players are given a choice to play 1 of 3 games: Guess the Bootle, Fact or Fiction, or Would You Rather? Children are rewarded for optimal movement performance and exercise session completion with Bootle Bucks, the game’s form of currency. Bootle Bucks can be spent in the Bootle Bootique where children can choose from different accessories (eg, pets, gear) for their Helper Bot, different backgrounds and music. Children are rewarded with in-game badges and streaks for completion of the prescribed exercise sessions each week and across weeks. Examples of badges and streaks include: the Bootle Bump Badge (4 sessions completed during training week 1) and the Double Trouble Streak (8 sessions completed across 2 weeks). On movement feedback days, children are awarded star ratings after every exercise based on movement quality (ie, exercise fidelity). For repetition-based exercises, stars are awarded as follows: <50% of reps completed with appropriate fidelity=1 star; 50–75% of reps completed with appropriate fidelity=2 stars; >75% of reps completed with appropriate fidelity=3 stars. For timed exercises (eg, stretches), stars are awarded based on the best/longest time (of up to 3 trials) achieving movement criteria as follows: achieved for <50% of prescribed time=1 star, achieved for 50–75% of prescribed time=2 stars, achieved for >75% of prescribed time=3 stars. Post-exercise session completion, players are rewarded with a ‘You’re Done’ song and Bootle celebration.
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| Problem-solving | |
| Feedback | The game tracks the type and frequency of games played, game scores, duration of active and total play time, and number of exercise repetitions completed (with and without exercise fidelity). The child’s head, trunk and joint positions are tracked and compared with predefined movement acceptability criteria programmed into the software for each exercise. Each repetition is classified as acceptable (meets criteria, performed with exercise fidelity) or not acceptable. The game can be played with or without movement feedback. Children are made aware of the app version being played by the presence or absence of virtual Coach Botley. Key feedback characteristics6:
Method of presentation: immersive/multimodal (visual, audio and reward). Visual/audio feedback is offered through indicators (eg, movement speed) and prescriptive prompts (eg, take a bigger step back). Movement variable: based on movement execution (eg, completion of sit-to-stand), with joint angle (eg, hip flexion, knee extension) used to determine movement success using predefined movement acceptability criteria. Focus of attention: the system tracks participants’ body movements and performance and offers customised knowledge of performance feedback (ie, related to the quality of movement performance) (eg, visual speed indicator) and knowledge of results feedback (ie, related to the outcome of task completion) (eg, repetition counter that increases when a repetition is performed with exercise fidelity). Timing of feedback: concurrent during a repetition attempt (eg, visual indicator showing approximate degree of truncal lean), terminal (eg, repetition counter increases if movement is performed with exercise fidelity) and in summary form (eg, checklist of movement quality markers done well and those that can be improved upon for each exercise; graph showing star ratings for each exercise across exercise sessions). Frequency of feedback: faded based on the child’s performance (to promote mastery and prevent dependence). During initial task practice, feedback is consistent if <50% of repetitions are completed with appropriate fidelity. When 50–75% of repetitions are completed appropriately, feedback fades and is provided at the end of every other repetition for the next exercise session with movement tracking feedback. When >75% of repetitions are completed with appropriate fidelity, feedback is offered in summary form. Autonomy over feedback: a self-selected, detailed summary of the child’s exercise performance is available at the end of every exercise session on feedback days. The summary screen shows movement criteria that were done well and those that could be improved upon, current and average star ratings for the selected exercise, and a graph showing exercise star ratings across sessions (as recommended by knowledge holders).
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