Promoting Therapists’ Use of Motor Learning Strategies within Virtual Reality-Based Stroke Rehabilitation

Abstract

PurposeTherapists use motor learning strategies (MLSs) to structure practice conditions within stroke rehabilitation. Virtual reality (VR)-based rehabilitation is an MLS-oriented stroke intervention, yet little support exists to assist therapists in integrating MLSs with VR system use.MethodA pre-post design evaluated a knowledge translation (KT) intervention incorporating interactive e-learning and practice, in which 11 therapists learned how to integrate MLSs within VR-based therapy. Self-report and observer-rated outcome measures evaluated therapists’ confidence, clinical reasoning and behaviour with respect to MLS use. A focus group captured therapists’ perspectives on MLS use during VR-based therapy provision.ResultsThe intervention improved self-reported confidence about MLS use as measured by confidence ratings (p <0.001). Chart-Stimulated Recall indicated a moderate level of competency in therapists’ clinical reasoning about MLSs following the intervention, with no changes following additional opportunities to use VR (p = .944). On the Motor Learning Strategy Rating Instrument, no behaviour change with respect to MLS use was noted (p = 0.092). Therapists favoured the strategy of transferring skills from VR to real-life tasks over employing a more comprehensive MLS approach.ConclusionThe KT intervention improved therapists’ confidence but did not have an effect on clinical reasoning or behaviour with regard to MLS use during VR-based therapy.

Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review

“…Therapist experience with the system [4,14,18,22] Client experience with the system [30] Skills to optimize patient outcomes [17] Opportunity for practice [7,14,15,19,30,32] Interactive education/training for hands-on learning [5,6,17,19,20,29,30] Use of case examples [6] Video tutorials targeting specific learning needs [19,20] Individualized 1:1 clinical mentoring [6,22] Online support strategies [4,6] Competency development framework to guide self-evaluation and development of competencies required for clinical VR use [6,22,29] Social/professional role and identity: A coherent set of behaviors and displayed personal qualities of an individual in a social or work setting Attitude of therapist toward the technology [4,6,7,22,30] Attitude of patient toward the technology [7,19,21] Reconciling therapist role in gaming context [7,25] Being tech-savvy (clients and therapists) [4,14,22] Compatibility with treatment preferences/needs [4,…”

“…Beliefs about capabilities: Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use Self-perceptions of being generally tech-savvy [22] Availability of education opportunities [4,6,19,22] Perceived ease of use of the technology (for both clinicians and patients) [4,6,7,[14][15][16]19,22,24] Self-efficacy in clinical use of the technology [4][5][6][7]19,22,32] Practice opportunities with the equipment outside of clinical time to support skill development and self-efficacy [15,19,20,24,30] Graded/multistage training approach (general knowledge, then specific operational, then clinical skills) [6,19] Optimism: The confidence that things will happen for the best or that desired goals will be attained Therapists have to take responsibility to use it well [28] Skepticism about its benefits [4,6,22,27] Experience/use of the technology [27] Beliefs about consequences: Acceptance of the truth, reality, or validity about outcomes of a behavior in a given situation…”

“…Perceived therapeutic benefit to clients [4,6,14,16,19,22,27] Perceived match to client's goals/needs [4,6,7,14,17,19,22,25,30,31] Perceived match to therapist's needs [4,6,22,30,31] Perceived motivational utility [4,6,7,19,22,28] Evidence syntheses to raise awareness of the potential benefits of VR use [6,29] Demonstrate clinical utility in the clinical setting [30] Concerns about screen time [6,17] Transfer of training to real life [4,16,18,20,22,24,25,32] Privacy concerns of social media use/confidentiality of data [25] Potential for physical fatigue [26] Confidence in expert clinician/mentor [14] Ethical issues [24] Legal issues [24] Relative advantage over other options [4,…”

“…Competing technologies [4,6,17,22] Competing treatments [4,6,17,22] Multiple goals [22] Ease of identifying ways in which to target different goals [28] Applying evidence (research and clinical) related to VR effectiveness [30] Determining appropriate timing of VR introduction [6,22] Clinical decision-making framework to guide selection of VR systems based on therapeutically relevant characteristics [17,28,30] Clinical decision-making resourcesdfor activity selection, task grading, and medical documentation [6,17,27,28] Support for determining client appropriateness for VR-based therapy [6,22,28] Feedback about the use of a theoretical approach to VR-based treatment to promote reflection about therapist's performance in clinical VR use [20] Step-by-step guide for system operation [22,26] Providing time for therapist to make clinical observations of clients using VR/AVG [15] Make disadvantages of systems clear to therapists [30] Environmental context and resources: Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behavior…”

Hop.Skip.Jump.Games: The effect of “principled” exergameplay on children's locomotor skill acquisition

“…This facilitated significant improvements in object control skills over time. Commercial exergames have also been successfully deployed by clinicians to restore basic gross motor skills (eg, moving hand to mouth) in stroke patients (Levac et al ., ). In this setting, the human‐in‐the‐loop (clinician) adapts parameters of gameplay in line with the users' physical capabilities by adapting hardware, eg, adjusting the height of the Kinect ® and the user's position in relation to the sensor to manipulate motor skill outputs expected during gameplay.…”