JMIR Publications

ABSTRACT

Background:

In Canada, chronic stroke survivors have difficulty accessing community-based rehabilitation services due to a lack of resources. VirTele, a personalized remote rehabilitation program combining virtual reality exergames and telerehabilitation, was developed to provide chronic stroke survivors an opportunity to pursue rehabilitation of their affected upper extremity (UE) at home while receiving ongoing follow-up from a clinician.

Objective:

The objectives of this study were to: 1) identify the behavioral and motivational techniques used by clinicians during VirTele intervention; 2) explore the indicators of empowerment among stroke survivors and 3) explore the determinants of VirTele use among chronic stroke survivors and clinicians.

Methods:

This multiple case study involved three chronic stroke survivors and their respective clinicians (physiotherapists) who participated in a VirTele intervention. VirTele is a two-month, remote rehabilitation intervention, using non-immersive virtual reality exergames and telerehabilitation aimed at improving UE deficits in chronic stroke survivors. Study participants had autonomous access to Jintronix exergames and were asked to use them for 30 minutes, five times a week. VirTele also included one-hour videoconference sessions with a clinician 1 to 3 times a week, using the Reacts application (audio-video platform). During these sessions, the clinician was able to engage in motivational interviewing, supervise the stroke survivors’ use of the exergames and monitor their use of the affected UE through activities of daily living. Semi-directed interviews were conducted with clinicians and stroke survivors 4 to 5 weeks after the end of the VirTele intervention. All interviews were audiotaped and transcribed verbatim. An abductive thematic analysis was conducted to generate new ideas through a dynamic interaction between data and theory.

Results:

Three stroke survivors (2 females; 1 male), with a mean age of 58.8 years (SD=19.4), and two physiotherapists participated in the study. Five major determinants of VirTele use emerged from the qualitative analyses, namely technology performance (usefulness, perception of exergames), effort (ease of use), family support (encouragement), facilitators (stroke survivors’ safety, trust and understanding of instructions), and challenges (miscommunication, exergame limits). During the VirTele intervention, both clinicians used motivational and behavioral techniques to support autonomy, competence and connectivity. All these attributes were reflected as empowerment indicators in the three stroke survivors. Lessons learned from using telerehabilitation combined with exergames were provided and suggest useful strategies to optimize the potential of this technology for the rehabilitation of the affected UE.

Conclusions:

This multiple case study provides a first glimpse into the impact that motivational interviewing can have on adherence to exergames and on changes in behavior in the use of the affected UE in stroke survivors. Lessons learned from the results of this study may serve as a model to guide the implementation of similar interventions to VirTele, in other contexts and populations.