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.

Keywords: motivation; rehabilitation; stroke; telerehabilitation; upper extremity; video games; virtual reality.

Figure 1

All phases of the Fish Frenzy task are depicted from (a) to (f). At the start of the game session, an example of the gameplay with a human model is shown on the screen. At the GO signal, the stroke survivor starts moving the fish to follow a path or catch the stars. The stroke survivor must complete the journey as fast as he can and repeat the same journey as often as possible for a predetermined period, as assigned by the clinician. The stroke survivor has to control his upper extremity when moving the fish to avoid touching the black objects surrounding the stars, which results in a loss of points. When finished, the final score is shown.

Figure 2

All phases of running the exergames and the videoconference system simultaneously are depicted from left to right. After entering their email and password into Reacts, the stroke survivor waits for the clinician’s call and then clicks on the answer button to start the videoconference session. Once the videoconference begins, they must click on the share button. After launching screen sharing, the stroke survivors may start playing the games. In this phase, the clinician can see the gameplay overview and the stroke survivor.

Figure 3

Factors that influence behavioral intention and use behavior of VirTele.