[ARTICLE] Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review – Full Text

Abstract

Virtual reality and active video games (VR/AVGs) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice. However, clinical adoption remains low despite a growing evidence base and the recent development of clinically accessible and rehabilitation-specific VR/AVG systems. Given clinicians’ eagerness for resources to support VR/AVG use, a critical need exists for knowledge translation (KT) interventions to facilitate VR/AVG integration into clinical practice. KT interventions have the potential to support adoption by targeting known barriers to, and facilitators of, change. This scoping review of the VR/AVG literature uses the Theoretical Domains Framework (TDF) to (1) structure an overview of known barriers and facilitators to clinical uptake of VR/AVGs for rehabilitation; (2) identify KT strategies to target these factors to facilitate adoption; and (3) report the results of these strategies. Barriers/facilitators and evaluated or proposed KT interventions spanned all but 1 and 2 TDF domains, respectively. Most frequently cited barriers/facilitators were found in the TDF domains of Knowledge, Skills, Beliefs About Capabilities, Beliefs About Consequences, Intentions, Goals, Environmental Context and Resources, and Social Influences. Few studies empirically evaluated KT interventions to support adoption; measured change in VR/AVG use did not accompany improvements in self-reported skills, attitudes, and knowledge. Recommendations to target frequently identified barriers include technology development to meet end-user needs more effectively, competency development for end-users, and facilitated VR/AVG implementation in clinical settings. Subsequent research can address knowledge gaps in both clinical and VR/AVG implementation research, including on KT intervention effectiveness and unexamined TDF domain barriers.

Introduction

Virtual reality and active video games (VR/AVG) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice [,]. A steady increase in the number of peer-reviewed articles evaluating the effects of VR/AVG interventions in many rehabilitation populations has been observed over the past 20 years. This increase reflects a growing interest in VR/AVG from the rehabilitation research and development sectors. Ideally, newly developed and empirically evaluated products and interventions that are found to be safe and effective would be quickly integrated into clinical practice. Yet what we are observing in patient care follows a more typical pattern for the adoption of evidence-based treatment techniques or tools: one of slow and variable progress [].

Collaboration between engineers and product end-users can inform the development of useful VR/AVG technologies that meet the needs of clients and therapists. Moving VR/AVG technology into the hands of therapists allows clients to benefit from its therapeutic potential. Systematically examining the factors that impact VR/AVG adoption in rehabilitation, and the effect of knowledge translation (KT) strategies on behaviors related to their use, is critical for guiding the successful implementation of these technologies. A clear understanding of how VR/AVG is being used by clinicians, the limitations clinicians face in integrating the technologies into their daily treatment routines, and the most effective strategies for supporting clinicians in technology adoption are paramount to informing these implementation approaches.

Recent surveys of occupational and physical therapists in Canada [], the United States (Levac et al., in preparation), and Scotland [] on their use of VR/AVG and their learning needs related to future use of these technologies provides a foundational knowledge base about current clinical use. Nearly half of the 1071 respondents in Canada [] and 76% of the 491 U.S. respondents (Levac et al., in preparation) had used VR/AVG clinically. However, only 12% of respondents in Canada [], 31% in the United States (Levac et al., in preparation), and 18% of the 112 respondents in Scotland [] reported current use. This discrepancy indicates the need for additional efforts to identify and to address existing barriers to VR/AVG use. Commercially available AVG systems were the most common systems in use in all 3 countries [,] (Levac et al., in preparation); the use of rehabilitation-specific VR systems by Canadian [] and U.S. therapists (Levac et al., in preparation) was much lower (<3% of respondents for any given system).

Despite low reported daily use, VR/AVG systems were perceived by therapists to be widely relevant to rehabilitation for a number of different client populations, functional recovery goals and practice settings []. Sixty-one percent of respondents in Scotland reported that they would use gaming if it were available to them []. The majority of respondents in both Canada [] (76.3%) and the United States (69.9%) (Levac et al., in preparation) reported low self-efficacy in using VR/AVG clinically, but were interested in learning more. Commonly reported learning needs included knowledge and skills in selecting appropriate systems and games for individual clients, grading activities, evaluating outcomes, and integrating theoretical approaches to treatment [,,]. These findings suggest a strong need for educational resources and knowledge translation (KT) supports to facilitate evidence-based technology adoption [,]. KT is the process of moving evidence into practice []. KT interventions have the potential to support adoption by targeting known barriers to change, including a lack of knowledge and skills [].

Strong insights into the factors influencing therapists’ adoption of VR/AVG have emerged only in the past 5 years. A decomposed Theory of Planned Behavior, which integrates constructs from the Technology Adoption Model and the Diffusion of Innovation theory forms the theoretical basis for the majority of this research [,]. The Theoretical Domains Framework (TDF) is another approach that can be used to conceptualize the evaluation of barriers and facilitators of change, including technology adoption []. The TDF is an implementation framework that integrates 128 theoretical constructs drawn from 33 behavior change theories into 14 barrier/facilitator domains []. Although the framework has not been applied yet to this body of literature, it offers a more comprehensive approach to the identification and classification of barriers and facilitators of change than a single theory or framework alone. Drawn from the KT literature, the framework can be used to structure the assessment of barriers and facilitators of change across a range of contexts, as well as the selection of interventions to target these barriers and facilitators [].

The purpose of this scoping review was to apply the TDF to examine the extent, range, and nature of studies assessing VR/AVG barriers and facilitators and/or recommending or evaluating KT interventions to promote VR/AVG adoption in rehabilitation since 2005. Our objectives were to

  1. present an overview of factors known to limit or support VR/AVG adoption for rehabilitation;

  2. describe the KT strategies that have been recommended or evaluated to address these factors and to report on their effectiveness, where possible; and

  3. provide recommendations for technology development, research, and clinical implementation based on these findings.

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