Level Up! Adaptive Gaming for Children With Upper Limb Differences
Phase: NA
Conditions: Upper Limb Amputation at the Wrist, Pediatric, Upper Limb Amputation, Upper Limb Amputation at the Hand, Amniotic Band Syndrome, Upper Limb Amputation Below Elbow (Injury)
Sponsor: University of Manitoba

 
 
 
Meghan Guglich and Rowen Guncheon 
7-18-2023 
Version 2 
Level Up! Adaptive 
Gaming for Children with 
Upper Limb Differences 
 NCT Number: TBD 

V2: July 18th, 2023 
 
1 
Level Up! Adaptive Gaming for Children with Upper Limb Differences – Study Protocol 
Play is an important part of childhood development [1], and it is fair to say that leisure, fun, and 
entertainment are all essential aspects of life. The ICF defines participation as the nature and extent of a 
person’s involvement in life situations [2]. Participation is essential to a child’s health, well being, and 
development, and is often the ultimate goal of pediatric rehabilitation [3]. All individuals should have 
the ability to participate in their choice of leisure activities [4]. 
Video games are a popular form of leisure and entertainment [4], especially among children and 
adolescents [5]. Video games encourage participation, increase motivation to complete goals, offer 
rewards and immediate punishments, and have adjustable difficulties to match skill level [4]. They also 
foster competitiveness, cooperation, immersion, sense of control, achievement of goals, and satisfaction 
[4]. Not only can video games be used for entertainment, but they can also be used in a more serious 
context, such as in education or rehabilitation [4]. Some of their uses include increasing strength and 
coordination, developing a sense of autonomy, increasing self confidence, and developing the ability to 
learn from error [4]. There are also genre specific benefits for different types of games. Some types of 
games promote problem solving skills and creativity. Other types of games promote healthy, optimistic 
motivational styles that can be seen reflected in other aspects of life, such as school or work. Other 
types still can foster improved mood, increased relaxation, and decreased anxiety [6]. Creating socially 
inclusive games and adapting game play to promote accessibility are necessary to support all children 
and youth in play. 
For children with an amputation or upper limb difference, full participation in playing video 
games is not always possible. Most mainstream video games and video game controllers require 
bimanual dexterity and multiple degrees of freedom in both hands to be able to operate all functions. 
For a child missing part or all of their hand or arm, it can be difficult to access all aspects of a controller.  
Current methods of video game adaptation often involve a change to the controller or game 
that reduces the amount of interaction the user has with the game [4]. These methods provide 
incomplete accessibility which can decrease the benefits of playing video games. For example, games 
that have been modified or designed with the intent to make the interaction simpler may result in less 
demands on strength, coordination, immersion, etc., meaning less benefits to be realized in these areas. 
The cost associated with adapting games or controllers may also be a barrier to their use. Adapted 
controllers also make it more difficult for users to play with others using a standard controller because 
controllers cannot be shared between players and the adaptive controller may have different 
requirements. Given that 70% of people who play video games play with others [6], the ability to 
participate with others is an incredibly important factor to participation.  
 
Providing children with an upper limb amputation or difference with the ability to play any video 
game with a standard controller increase their ability to participate in a main-stream childhood 
experience. At RCC, we have developed a video game controller adapter that allows for one-handed 
play. It is easily attached and removed to a standard Xbox controller, which allows inclusive play 
between children with and without an upper limb amputation or difference. We propose that this new 
technology will increase both video game performance and satisfaction, allowing children with an upper 
limb amputation or limb difference to realize all of the benefits of playing video games with ease. We 
hope that this will ultimately improve quality of life for this population.  

V2: July 18th, 2023 
 
2 
Research Purpose 
 
The aim of this research study is to explore whether a novel video game controller adapter 
designed at RCC can increase performance and/or user satisfaction while playing video games, in users 
with unilateral upper limb differences. This case series will use mixed quantitative and qualitative 
methods to compare performance and user satisfaction with and without the RCC designed video game 
controller adapter. We will assess performance using a standard Minecraft course for all participants. 
Satisfaction of the adapter will be assessed with a semi-structured interview and a Visual Analog Scale 
(VAS) for satisfaction, and the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) 
outcome measure to compare play with and without the adapter for each participant. 
Research Methods 
 
Participants & Sampling Technique: Participants will be selected through convenience sampling 
at the Rehabilitation Centre for Children in Winnipeg, Manitoba, to a sample size of 15-20. All 
participants will be between the ages of 7 and 17, with unilateral upper limb differences. The upper 
extremity limb difference will be from any cause (congenital, trauma, secondary to other medical 
complications), and of any level (partial hand, wrist disarticulation, transradial, elbow disarticulation, 
transhumeral, shoulder disarticulation). Participants will be able to communicate in English and have the 
cognitive ability to follow instructions. Participants will live in Winnipeg or be willing to travel to RCC for 
two in person appointments (initial evaluation and final evaluation). Participants will be included 
regardless of history of prosthesis use. 
 
Appropriate participants will be identified by their treating clinician (MG) and informed of the 
study. If they are interested in participating, they will sign a consent to contact for research form, and be 
contacted by another member of the research team (EH), who is not involved in their clinical care to 
review the consent form and ask any questions. Participants may also be recruited through self 
identification by sharing study information through posters at RCC, the RCC website and social media.  
 
Data Collection: Each participant will provide informed consent before participating in any study 
related activities. At initial evaluation, each participant will complete a demographic questionnaire, as 
well as a semi-structured interview about their previous video game playing experiences, and their 
motivation to participate in playing video games in the future. The interviewing team member will 
record the interview on their phone and ensure that their phone is disconnected from the cloud. The 
recording will be transferred to the data storage system and then deleted from the phone. Anonymized 
data will be stored in a University of Manitoba Microsoft Teams environment. Following this interview, 
they will receive a training session from a team member (RG) on how to use the adapter and how to 
play Minecraft. This video game was chosen for its age appropriateness and need to use almost every 
button on the controller. Following the training, we will collect initial outcome measure data for both 
the with and without adapter conditions: time to complete the specified Minecraft “obstacle course”, 
accuracy of obstacle course (errors counted), VAS of satisfaction after playing, and the QUEST. Order of 
data collection with and without the device will be randomized to minimize a training effect. 
 
Following the initial evaluation appointment, the participant will take home a tracking log, the 
video game controller adapter, and an Xbox with an Xbox One controller (if they do not already have 
one at home). Each participant will be asked to use the device daily and fill out the tracking log daily for 
7 days. After which, each participant will return to RCC for the final evaluation appointment. At this time 

V2: July 18th, 2023 
 
3 
the Minecraft “obstacle course” and evaluation will be repeated for gameplay with and without the 
adapter conditions. Finally, an exit semi-structured interview will be conducted to evaluate their 
experience with the adapter. Each participant will return the Xbox and controller if they were taken 
home. They will have the opportunity to keep the adapter if they wish. 
 
Data Analysis: The semi structured interviews will be analyzed using an inductive coding 
approach as described by Thomas [7]. A transcript of the audio recorded interview will be created, 
formatted, and analyzed for any initial impressions and general tone. Codes will be assigned to the 
content of the interviews and then codes will be grouped into categories based on similarity of intent. 
The categories will then be refined and revised as each interview is added as a data source. 
A paired t-test will be used to analyze the performance measures and QUEST responses in order to 
determine if there was a clinically important difference between playing with and without the adapter. 
A repeated measures ANOVA analysis will be used to evaluate the VAS satisfaction scores, in order to 
determine if there was an increase in satisfaction with increased use of the adapter. 
Knowledge Translation 
 
We plan to address knowledge translation in several ways through this study. On an 
organizational level, we hope to share the results with the rest of the Rehabilitation Centre for Children 
(RCC) and Specialized Services for Children and Youth (SSCY) partners by presenting them at the monthly 
learning series, Breakfast at SCCY. We hope the findings of this study may translate to help additional 
populations seen at SSCY centre (i.e., hemiplegia/Cerebral Palsy). We also plan to share the results and 
adapter design with the War Amps CHAMP program, so that other children with upper limb differences 
across the country may benefit from the adaptation. To share our results with other health care 
providers, we plan to submit our results to be presented at the Association of Children’s Prosthetic 
Orthotic Clinics (ACPOC), Orthotics Prosthetics Canada (OPC), and RESNA Annual Conferences. Finally, 
we plan to write an article for a peer reviewed open-access journal to support broader knowledge 
translation. 
Research Team 
Meghan Guglich is a Certified Prosthetist with five years of experience working with children with upper 
limb differences. She also has a Masters in Rehabilitation Science from McMaster University. Rowen 
Guncheon is an engineer-in-training with experience in assistive technology design and in facilitating 
computer access for children with disabilities using assistive technology. Elizabeth Hammond is a 
physical therapist and certified hand therapist (CHT) specializing clinically in upper extremity injuries for 
almost 20 years. Her research has focused on the upper extremity including quantification of fine motor 
control post simulation of a finger amputation model and peripheral neuropathy research on 
neuropathic pain and the impact of exercise on neuro-regeneration and neuroprotection from Taxane 
chemotoxicity. Jacquie Ripat is serving as a research project advisor. She is an occupational therapist, as 
well as an associate professor in the Department of Occupational Therapy and the associate dean of 
research for the College of Rehabilitation Sciences at the University of Manitoba. Her expertise is in the 
use of assistive technology and qualitative and mixed methods research. 
 
 

V2: July 18th, 2023 
 
4 
Proposed Timeline 
 
Relevance & Future Research 
We anticipate the work done in this project will inform further design changes and clinical 
decision making. In the future, the results of this study may help to inform treatment planning when 
treating individuals with a unilateral limb difference who are interested in playing video games. The 
results will also help to inform further design modifications, and potentially future research projects, as 
we continue to optimize the design of the video game controller adapter. Through knowledge 
translation of this study, we hope to share the design of the device further, so that other individuals 
outside of those treated at RCC may benefit from the use of this device. This project will also be used as 
a proof of concept to create adapters for other video game systems (such as Playstation, Nintendo, etc.). 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ethics Submission
November 2022-
December 2022
Data Collection
December 2022-
December 2023
Data Analysis
December 2023-
November 2024
Knowledge Translation
November 2024-
May 2025

V2: July 18th, 2023 
 
5 
References 
[1] El Jurid S, Montaner-Marco J, Garcia Sanjuan F, Jaen Martinez FJ & Nacher-Soler VE. A systematic 
review of game technologies for pediatric patients, Computers in Biology and Medicine, 2018, 97, pp 89-
112, https://doi.org/10.1016/j.compbiomed.2018.04.019 
[2] WHO. International Classification of Functioning, Disability and Health (ICF), 2022. Retrieved from: 
https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-
health 
[3] Michielsen A, Van WIjk, I & Ketelaar M. Participation and quality of life in children and adolescents 
with congenital limb deficiencies: A narrative review, Prosthetics and Orthotics International, 34(4), pp 
351-361. 
[4]  Compan-Rosique P, Molina-Carmona R, Gallego-Duran F, Satorre-Cuerda R, Villagra-Arnedo C & 
Llorens-Largo F. A guide for making videogames accessible to users with cerebral palsy. Universal Access 
in the Information Society, 2019, 18(3), pp 565-581, doi:10.1007/s10209-019-00679-6 
[5] Ehrel S & Jamet E. Digital game-based learning” Impact of instructions and feedback on motivation 
and learning effectiveness, Computers & Education, 2013, 67, pp 156-167. 
[6] Granic I, Lobel A & Engels RCME. The benefits of playing video games, American Psychologist, 2014, 
69(1), pp 66-78.  
[7] Thomas DR, A general inductive approach for analyzing qualitative evaluation data, American Journal 
of Evaluation, 2006, 27(2), pp 237-246.