To explore the perceived barriers and facilitators of tele-rehabilitation (TR) by stroke patients, caregivers and rehabilitation therapists in an Asian setting.
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.
Virtual reality and active video games (VR/AVG) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice [1,2]. 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 [4,5] (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 [4,6,7]. These findings suggest a strong need for educational resources and knowledge translation (KT) supports to facilitate evidence-based technology adoption [4,6]. 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 [4,6]. 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
present an overview of factors known to limit or support VR/AVG adoption for rehabilitation;
describe the KT strategies that have been recommended or evaluated to address these factors and to report on their effectiveness, where possible; and
provide recommendations for technology development, research, and clinical implementation based on these findings.
To explore the perceived barriers and facilitators of tele-rehabilitation (TR) by stroke patients, caregivers and rehabilitation therapists in an Asian setting.
Qualitative study involving semi-structured in-depth interviews and focus group discussions.
Participants (N=37) including stroke patients, their caregivers, and tele-therapists selected by purposive sampling.
Singapore Tele-technology Aided Rehabilitation in Stroke trial.
Perceived barriers and facilitators for TR uptake, as reported by patients, their caregivers, and tele-therapists.
Thematic analysis was used to inductively identify the following themes: facilitators identified by patients were affordability and accessibility; by tele-therapists, was filling a service gap and common to both was unexpected benefits such as detection of uncontrolled hypertension. Barriers identified by patients were equipment setup–related difficulties and limited scope of exercises; barriers identified by tele-therapists were patient assessments, interface problems and limited scope of exercises; and common to both were connectivity barriers. Patient characteristics like age, stroke severity, caregiver support, and cultural influence modified patient perceptions and choice of rehabilitation.
Patient attributes and context are significant determinants in adoption and compliance of stroke patients to technology driven interventions like TR. Policy recommendations from our work are inclusion of introductory videos in TR programs, provision of technical support to older patients, longer FaceTime sessions as re-enforcement for severely disabled stroke patients, and training of tele-therapists in assessment methods suitable for virtual platforms.
People with epilepsy (PWE) are less physically active compared with the general population. Explanations include prejudice, overprotection, unawareness, stigma, fear of seizure induction and lack of knowledge of health professionals. At present, there is no consensus on the role of exercise in epilepsy. This paper reviews the current evidence surrounding the risks and benefits associated with physical activity (PA) in this group of patients. In the last decade, several publications indicate significant benefits in physiological and psychological health parameters, including mood and cognition, physical conditioning, social interaction, quality of life, as well as potential prevention of seizure presentation. Moreover, experimental studies suggest that PA provides mechanisms of neuronal protection, related to biochemical and structural changes including release of β-endorphins and steroids, which may exert an inhibitory effect on the occurrence of abnormal electrical activity. Epileptic discharges can decrease or disappear during exercise, which may translate into reduced seizure recurrence. In some patients, exercise may precipitate seizures. Available evidence suggests that PA should be encouraged in PWE in order to promote wellbeing and quality of life. There is a need for prospective randomized controlled studies that provide stronger clinical evidence before definitive recommendations can be made.
What are the attitudes, barriers and enablers to physical activity perceived by pregnant women?
In a systematic literature review, eight electronic databases were searched: AMED, CINAHL, Embase, Joanna Briggs Institute, Medline, PsycInfo, SPORTDiscus (from database inception until June 2016) and PubMed (from 2011 until June 2016). Quantitative data expressed as proportions were meta-analysed. Data collected using Likert scales were synthesised descriptively. Qualitative data were analysed thematically using an inductive approach and content analysis. Findings were categorised as intrapersonal, interpersonal or environmental, based on a social-ecological framework.
Attitudes and perceived barriers and enablers to physical activity during pregnancy.
Forty-nine articles reporting data from 47 studies (7655 participants) were included. Data were collected using questionnaires, interviews and focus groups. Meta-analyses of proportions showed that pregnant women had positive attitudes towards physical activity, identifying it as important (0.80, 95% CI 0.52 to 0.98), beneficial (0.71, 95% CI 0.58 to 0.83) and safe (0.86, 95% CI 0.79 to 0.92). This was supported by themes emerging in 15 qualitative studies that reported on attitudes (important, 12 studies; beneficial, 10 studies). Barriers to physical activity were predominantly intrapersonal such as fatigue, lack of time and pregnancy discomforts. Frequent enablers included maternal and foetal health benefits (intrapersonal), social support (interpersonal) and pregnancy-specific programs. Few environmental factors were identified. Little information was available about attitudes, barriers and enablers of physical activity for pregnant women with gestational diabetes mellitus who are at risk from inactivity.
Intrapersonal themes were the most frequently reported barriers and enablers to physical activity during pregnancy. Social support also played an enabling role. Person-centred strategies using behaviour change techniques should be used to address intrapersonal and social factors to translate pregnant women’s positive attitudes into increased physical activity participation.
Physical activity has substantial benefits for women with uncomplicated pregnancies, minimal risks, and is recommended in pregnancy guidelines.1, 2, 3 The benefits of physical activity during pregnancy include improved physical fitness,3, 4, 5 reduced risk of excessive weight gain,6 reduced risk of pre-eclampsia and pre-term birth,7reduced low back pain,8, 9 improved sleep,10 reduced anxiety and depressive symptoms,11, 12 and improved health perception13 and self-reported body image.14
Physical activity is also important for pregnant women with comorbidities and complications such as obesity1 or gestational diabetes mellitus (GDM).15, 16, 17 Physical activity assists with weight control and reduces the risk of GDM in obese pregnant women.1 In women diagnosed with GDM (a common pregnancy-related complication occurring in 3.5 to 12% of pregnancies),15, 16 physical activity is beneficial as an adjunctive intervention in the management of glycaemic control.15, 17, 18, 19, 20 Managing glycaemic control is critical for reducing adverse effects associated with poorly controlled GDM.21 Consequently, aerobic exercise performed at moderate intensity for 30 minutes on most days of the week is recommended for healthy pregnant women,1, 3 those with GDM15, 22,23 and those who are overweight or obese.24
Despite well-documented health benefits,1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 24, 25, 26, 27 60 to 80% of pregnant women28, 29, 30, 31 – including those who are overweight or obese31 – and more than 60% of women with GDM32 do not participate in physical activity as recommended. Pregnant women from backgrounds other than Caucasian are also less likely to engage in physical activity.29 However, to improve pregnant women’s participation in physical activity (ie, leisure time physical activities or structured exercise programs), we need to understand their attitudes to it, the reasons why they do not engage in physical activity, and enablers that could be harnessed to design effective physical activity interventions or programs that facilitate behaviour change and thereby improve their participation in physical activity during pregnancy.
The inclusion of behaviour change techniques into physical activity interventions has been reported as helpful in improving physical activity levels during pregnancy.33 Behaviour change techniques such as goal setting, planning and education to shape knowledge appear most effective when delivered with face-to-face feedback about goal achievement.33 However, to facilitate uptake of these effective physical activity interventions, clinicians need to know which barriers, enablers and attitudes are common among pregnant women, so they can effectively target their education and evidence-based behaviour change strategies. A systematic review of barriers, enablers and attitudes of pregnant women to physical activity would provide valuable information to enable clinicians to effect a positive behaviour change of increased physical activity in this group.
Identification of women’s attitudes and perceptions of barriers and enablers to physical activity in pregnancy could be informed by quantitative or qualitative research approaches. A review that collates data from studies using either method would benefit from the advantages of each: improving generalisability and providing deeper insights into pregnant women’s beliefs and perceptions about physical activity during pregnancy. Inclusion of qualitative findings may assist in better understanding the factors that can influence women’s attitudes and perceptions. Such deeper understanding would provide valuable insight that clinicians can use to plan strategies to encourage pregnant women – in particular at-risk groups of women such as those with GDM – to participate in physical activity. It would also inform the design of realistic and acceptable interventions to be tested in an effectiveness study. No systematic review has collated quantitative data or provided a meta-summary of attitudes and perceptions of barriers and enablers to physical activity in pregnant women.
Therefore, the research question for this review was:
What are the attitudes, barriers and enablers to physical activity perceived by pregnant women, including women diagnosed with gestational diabetes mellitus?
Our mission is working for a world with zero barriers. Worldwide, the Zero Project finds and shares models that improve the daily lives and legal rights of all persons with disabilities. The focus of the year 2014 is accessibility.