What we learned about using telerehabilitation combined with exergames, from clinicians and chronic stroke survivors: A multiple case study (Preprint)

BACKGROUND In Canada, chronic stroke survivors have difficulty accessing community-based rehabilitation services, due to lack of resources. VirTele, a personalized remote rehabilitation program combining virtual reality exergames and telerehabilitation, was developed to offer chronic stroke survivors the opportunity to pursue rehabilitation of their affected upper extremity (UE) at home, while receiving ongoing monitoring by a clinician. OBJECTIVE The objectives of this study were to: 1) Explore the determinants of VirTele use among chronic stroke survivors and clinicians; 2) Identify indicators of support of psychological needs by clinicians, during VirTele intervention; and 3) explore indicators of empowerment among stroke survivors. METHODS This multiple case study involved three chronic stroke survivors participating in a VirTele intervention and their respective clinicians (physiotherapists). 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, which they were asked to use 5 times a week for 30 minutes periods. VirTele also included videoconference sessions with a clinician, 1 to 3 times a week (1-hour duration), using the Reacts application. During these sessions, the clinician was able to engage in motivational interviewing, supervise the stroke survivors’ use of the exergames and monitor the use of the affected UE through activities of daily life. Semi-directed interviews were conducted 4 to5 weeks after the end of the VirTele intervention. Two interview guides, adapted for clinicians and stroke survivors respectively, were developed to facilitate the interview administration while allowing new codes to emerge. All interviews were audiotaped and transcribed verbatim. RESULTS Three stroke survivors (2 females and 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 the technology performance (usefulness, perception of exergames), effort (ease of use), entourage support (encouragement), facilitators (stroke survivors’ safety, trust and understating of instructions), and challenges (miscommunication, exergames limits). At the end of the VirTele intervention, both clinicians demonstrated support of psychological needs, in terms of autonomy, competence and relatedness, all of which were reflected as empowerment indicators in the three-stroke survivors. Lessons learned from using telerehabilitation combined with exergames were provided, which will be relevant to other researchers and transferable to other populations and contexts. CONCLUSIONS This multiple case study provided a first glimpse at the impact that motivational interviewing can have on adherence to exergames and behavior modification of UE use in stroke survivors. Five major determinants of VirTele use have been identified, namely technology performance, effort, entourage support, facilitators and challenges. Lessons learned from these determinants may serve as a model to guide the implementation of similar interventions. INTERNATIONAL REGISTERED REPORT RR2-10.2196/14629