A Personalized Home-Based Rehabilitation Program Using Exergames Combined With a Telerehabilitation App in a Chronic Stroke Survivor: Mixed Methods Case Study

Abstract

Background In Canada, only 11% of stroke survivors have access to outpatient and community-based rehabilitation after discharge from inpatient rehabilitation. Hence, innovative community-based strategies are needed to provide adequate postrehabilitation services. The VirTele program, which combines virtual reality exergames and a telerehabilitation app, was developed to provide stroke survivors with residual upper extremity deficits, the opportunity to participate in a personalized home rehabilitation program. Objective This study aims to determine the feasibility of VirTele for remote upper extremity rehabilitation in a chronic stroke survivor; explore the preliminary efficacy of VirTele on upper extremity motor function, the amount and quality of upper extremity use, and impact on quality of life and motivation; and explore the determinants of behavioral intention and use behavior of VirTele along with indicators of empowerment. Methods A 63-year-old male stroke survivor (3 years) with moderate upper extremity impairment participated in a 2-month VirTele intervention. He was instructed to use exergames (5 games for upper extremity) for 30 minutes, 5 times per week, and conduct videoconference sessions with a clinician at least once per week. Motivational interviewing was incorporated into VirTele to empower the participant to continue exercising and use his upper extremities in everyday activities. Upper extremity motor function (Fugl-Meyer Assessment–upper extremity), amount and quality of upper extremity use (Motor Activity Log-30), and impact on quality of life (Stroke Impact Scale-16) and motivation (Treatment Self-Regulation Questionnaire-15) were measured before (T1), after (T2) VirTele intervention, and during a 1- (T3) and 2-month (T4) follow-up period. Qualitative data were collected through logs and semistructured interviews. Feasibility data (eg, number and duration of videoconference sessions and adherence) were documented at the end of each week. Results The participant completed 48 exergame sessions (33 hours) and 8 videoconference sessions. Results suggest that the VirTele intervention and the study protocol could be feasible for stroke survivors. The participant exhibited clinically meaningful improvements at T2 on the Fugl-Meyer and Stroke Impact Scale-16 and maintained these gains at T3 and T4. During the follow-up periods, the amount and quality of upper extremity use showed meaningful changes, suggesting more involvement of the affected upper extremity in daily activities. The participant demonstrated a high level of autonomous motivation, which may explain his adherence. Performance, effort, and social influence have meaningful weights in the behavioral intention of using VirTele. However, the lack of control of technical and organizational infrastructures may influence the long-term use of technology. At the end of the intervention, the participant demonstrated considerable empowerment at both the behavioral and capacity levels. Conclusions VirTele was shown to be feasible for use in chronic stroke survivors for remote upper extremity rehabilitation. Meaningful determinants of behavioral intention and use behavior of VirTele were identified, and preliminary efficacy results are promising. International Registered Report Identifier (IRRID) RR2-10.2196/14629

Rehabilitation of Upper Extremity by Telerehabilitation Combined With Exergames in Survivors of Chronic Stroke: Preliminary Findings From a Feasibility Clinical Trial

“…However, the performance of approximately 17,000 repetitions of successful tasks or movements during exergames appears to be the gold standard for achieving clinical improvements in UE motor function. Although participant ID10 attained 30,000 repetitions, no improvement was observed in the FMA-UE, which suggests that intense repetition is not always the gold key to recovery, as reported in a previous study (where UE improvement was attained following 30,341 repetitions) [ 33 ]. Furthermore, participant ID10 reported increased fatigue in the affected UE and pain in the less-affected UE, which reflects symptoms of overexercising and may prevent or reduce potential improvement.…”

“…For further information regarding the Reacts app, Jintronix exergames, and motivational interviewing, refer to the published study protocol [ 32 ] or previous case studies exploring VirTele use among survivors of stroke [ 33 , 40 ].…”

“…The FMA-UE score has been shown to be valid in participants with stroke [ 46 ] and reliable for administration at a distance (video observation of an evaluator administering the FMA-UE on site) [ 47 ]. Given the COVID-19 pandemic, we tested the feasibility of administering the FMA-UE motor function at a distance with no on-site evaluator (video observation of the participant’s performance), which was pretested in a previous study with a first survivor of stroke [ 33 ]. With respect to the various collection methods (by videoconferencing, by telephone, or on site), the FMA-UE motor function score was adjusted to 60 in all participants (experimental and control groups) by eliminating the parts of the scale that could not be evaluated remotely (reflex activity component).…”

“…Thus, the use of VR and customized exergames combined with telerehabilitation (eg, VirTele) is particularly relevant for providing a survivor of stroke–centered and exergame-based rehabilitation program [ 32 , 33 ]. The VirTele technology was previously tested with a survivor of stroke and was shown to be feasible for use in remote UE rehabilitation, which helped inform this study’s protocol [ 33 ]. The preliminary efficacy results showed improvement in UE motor function, quantity and quality of use, and impact on quality of life, along with a high level of autonomous motivation [ 33 ], hence the interest in continuing to study the VirTele intervention with more participants.…”

“…The VirTele technology was previously tested with a survivor of stroke and was shown to be feasible for use in remote UE rehabilitation, which helped inform this study’s protocol [ 33 ]. The preliminary efficacy results showed improvement in UE motor function, quantity and quality of use, and impact on quality of life, along with a high level of autonomous motivation [ 33 ], hence the interest in continuing to study the VirTele intervention with more participants. In addition, given the novelty of VirTele, information on the optimal dose, time since stroke, and criteria for identifying participants who may benefit the most from VirTele is needed.…”