Lessons Learned From Clinicians and Stroke Survivors About Using Telerehabilitation Combined With Exergames: Multiple Case Study

Background In Canada, stroke survivors have difficulty accessing community-based rehabilitation services because of a lack of resources. VirTele, a personalized remote rehabilitation program combining virtual reality exergames and telerehabilitation, was developed to provide stroke survivors an opportunity to pursue rehabilitation of their chronic upper extremity (UE) deficits at home while receiving ongoing follow-up from a clinician. Objective We aimed to identify the behavioral and motivational techniques used by clinicians during the VirTele intervention, explore the indicators of empowerment among stroke survivors, and investigate the determinants of VirTele use among stroke survivors and clinicians. Methods This multiple case study involved 3 stroke survivors with chronic UE deficits and their respective clinicians (physiotherapists) who participated in the VirTele intervention, a 2-month remote rehabilitation intervention that uses nonimmersive virtual reality exergames and telerehabilitation aimed at improving UE deficits in stroke survivors. Study participants had autonomous access to Jintronix exergames and were asked to use them for 30 minutes, 5 times a week. The VirTele intervention included 1-hour videoconference sessions with a clinician 1 to 3 times a week, during which the clinician engaged in motivational interviewing, supervised the stroke survivors’ use of the exergames, and monitored their use of the affected UE through activities of daily living. Semidirected interviews were conducted with the clinicians and stroke survivors 4 to 5 weeks after the end of the VirTele intervention. All interviews were audiorecorded 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 (n=2, 67%, women and n=1, 33%, man), with a mean age of 58.8 (SD 19.4) years, and 2 physiotherapists participated in the study. Five major determinants of VirTele use emerged from the qualitative analyses, namely technology performance (usefulness and perception of exergames), effort (ease of use), family support (encouragement), facilitators (considerations of the stroke survivors’ safety as well as trust and understanding of instructions), and challenges (miscommunication and 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 stroke survivors. Lessons learned from using telerehabilitation combined with exergames are provided, which will be relevant to other researchers and contexts. Conclusions This multiple case study provides a first glimpse into the impact that motivational interviewing can have on adherence to exergames and changes in behavior in the use of the affected UE in stroke survivors. Lessons learned regarding the supportive role caregivers play and the new responsibilities clinicians have when using the VirTele intervention may inform the use of exergames via telerehabilitation. These lessons will also serve as a model to guide the implementation of similar interventions. International Registered Report Identifier (IRRID) RR2-10.2196/14629


"I mean everybody [friends and family] was happy and everybody spoke well about it and stuff
so I was like "ok, sure why not"…they thought it was amazing… I need to show them what I do…it is something that I had to do…".
Furthermore, Carolina appreciated the interaction with her clinician (relatedness support) as she said: "It was awesome. I felt very comfortable with him [the clinician]… it was easy to be around him [the clinician]. He had this way of talking which was calm… and effective".
Carolina demonstrated empowerment through autonomous decisions and actions (choice of parameters of difficulties, speak about UE use in daily activities), competencies to handle problems (text the clinician when a problem is faced and discuss the solution together) and feeling belongingness (feeling comfortable around the clinician). She also indicated that her clinician respected her decisions (let her speak and choose the difficulty parameters of exergames) and supported her when she needed help (encouragement, demonstrations, answer to questions, resolve problems) and made her feel comfortable through his calm way of talking. She also pointed out : "I can do stuff with my arm but not as hard as I wanted to. So I motivated myself.". Furthermore, she kept using her affected UE at the end of VirTele, in daily activities such as getting dressed, washing hair, etc.
Carolina's clinician (male) reported during the interview that 2 or 3 telerehabilitation sessions in a week, increased compliance to rehabilitation program, at a frequency (quantity of use of the exergames) that is much more interesting than face-to-face sessions and at a more affordable cost. He said: "This is a very good motivational tool. I don't know if this is just the context of the study, but I have never seen patients as motivated as that…using a technology, a game, with a regular monitoring, I think that has a lot to do with it" According to him, this contributed not only to the motivation of Carolina but also to her empowerment. He also appreciated the monitoring option of the participant's results (through the exergame platform) and the exergame graphics and color, which he described as : " …much more dynamic and interesting to the eye than other software that may exist in a healthcare context".
The clinician also noticed an improvement in the affected arm, mainly in the shoulder area as he explained that there were not many games that were specifically targeting the extension of the elbow and the hand. Regarding exergames, he indicated that the exergame is a good start, but at a certain point the exercises become redundant, as there was not a lot of variability in the levels of difficulty and progression. He suggested that it might be advantageous to use different shapes or different directions, other than what already exists. He also reported that the participant always forgot to recalibrate (Kinect camera detection of movements) before she started playing which explains why she had difficulties with Fish Frenzy. The clinician reported having a lot of apprehension regarding the lack of "physical contact" to simulate and demonstrate the movement, at the start of the intervention, as he said: "I had the impression that this was not optimal just by telecommunication.". The clinician's apprehension decreased during the intervention, as Carolina was able to understand the instructions and demonstrations.
As for effort, the clinician found the platform intuitive and easy to use both from his side or from the participant side. He mentions the same technical issues as those mentioned by Carolina, which he managed to resolve technically (Call the participant and give instructions on where to click) and emotionally (calm the participant down, explain that it's not her fault), over time.
Finally, the clinician reported that the safety of the participant and the establishment of a trusting relationship with the latter facilitated his experience with VirTele, even if he had a lot of apprehension prior to starting the intervention. Furthermore, the clinician corroborated Carolina's statements on the support of her autonomy (let the participant choose the level of difficulty and games) and adds that he felt trusted by Carolina, corroborating the support of relatedness.
The clinician's logbook indicated that self-directed exercises (in addition to exergames) were performed by Carolina, during the VirTele intervention, such as elbow flexion and extension using a stick, writing with the affected UE and shoulder abduction and adduction using a stick.
The clinician's logbook indicated also that he used BCT's techniques and motivational techniques such as reflective listening (express empathy) (Table 2), which support competence, relatedness and autonomy.

Case 2
Helene was an 89-year-old female stroke survivor (7 years since stroke) with moderate UE impairment (stage of arm: 5 in Chedoke McMaster). She was no longer receiving rehabilitation services and was doing some exercises for her affected UE. She was not comfortable with computers and had never used one before. Helene indicated that she had no expectation regarding the outcomes of the intervention on her affected UE and was negative regarding the intervention. However, when she received the technology at home, she said: Helene spent 1178,32 minutes or 20 hours on exergames and used them at least 5 times a week, including 37 autonomous sessions and 12 supervised exergame sessions. She stated that she perceived no important change on her UE since the beginning of the experience, but she was able to sustain motivation to continue playing, for external reasons such winning. In fact, Helene enjoyed the playful aspect of exergames which she compared to "Bridge card games" and said: " I'm a winner! Young, I was a winner! It had to work!...Not always winning, but you have to make it work." However, she pointed out a problem with the avatar of the Kitchen clean up game, which didn't follow the real hands movements. As for effort, Helene reported that she had difficulty launching the video-conferencing system and that it was her daughter who helped her turn on the system.
On the other hand, she managed to start up the exergames by herself.
Helene indicated that her daughter not only helped her use the technology but also encouraged her to start and continue using VirTele. Helene also pointed out how positive, encouraging and motivating her clinician was during the video-conference sessions. In addition, Helene reported that she felt comfortable interacting with the clinician who was patient and enthusiastic and supported her to use exergames and UE in activities of daily life, through advices on performance (performance of UE during exergames and some activities).
After the end of intervention period, Helene felt more motivated to resume physical activities to avoid the deterioration of her health condition (loss of autonomy, stiffening of the arm, chronic deficits of arm due to stroke) and use her UE in daily activities such as making her bed, combing her hair.
In an interview with Helene's clinician (female), she reported that the VirTele technology was very good for reducing travel, especially for people who have limited access to rehabilitation services and given that face-to-face intervention is no longer necessary at this stage (7 years post stroke). Prior to starting VirTele, the clinician apprehended the lack of the "hands on" to demonstrate a movement or show a compensation as she explained: "when we are face to face, it is easier because we are able to touch with our hands, we are able

to demonstrate with our hands, but this [VirTele] is more like a different approach"
The clinician's apprehension decreased over time as the stroke survivor was able to understand the instructions provided on how to perform the exergame and use their UE. The clinician also noticed a high compliance of Helene to exergames and a more frequent use of UE in activities of daily life as described by the participant. As for effort, the clinician reported only minor technical issues (video cut off and internet problem) which were managed by Helene's daughter or the clinician. She added that the use of the technology by Helene who had no previous experience with computers, was very difficult. According to the clinician, it is important to be at least comfortable at turning on a computer and using a mouse. The clinician stated that it was safe to provide the intervention at home since it implies performing exercises while sitting (no risk of falling) and pointed out that the videoconference component and shared decision making component played an important role in establishing a trusting relationship with the participant. Furthermore, the clinician indicated that she included Helene in every decision made: "I make sure to share my thought and see why I am progressing, why I am not increasing the difficulty; then I also take their [Helene and Jack]

opinion, then I try to compromise"
The clinician's logbook indicated that Helene often felt fatigued after exergames sessions, and that no complementary exercises were suggested. The logbook' notes also indicated that the clinician used BCT's and motivational techniques (eg, reflective listening) (Table 2), which support competence, relatedness and autonomy.

Case 3
Jack was a 50-year-old male stroke survivor (4 years since stroke) with moderate impairment of the UE (stage of arm: 4 in Chedoke McMaster). He was no longer receiving rehabilitation services and was still using his UE for some household activities. He was very comfortable with computers (accessible at home) and used it at least once a week. He was the only participant with previous experience in information technology and videogames (he used to work as engineer in a company of videogames). Prior to starting the intervention, Jack had some hesitation and questions about the therapeutic value of exergames, which evolved over time with practice and resolved, as he said: "There were question marks which were quickly resolved by doing them [exergames]. There have been cases where I said to myself: um! Will it really do me good? After five times of practice, I saw the things that I understood was useful. It became more interesting." Jack appreciated the exergames as he said: " it was a good activity to do because it's short, it's straightforward, you knew exactly what to do". He spent 996,97minutes or 17 hours on exergames and used them at least 5 times a week, including 46 autonomous sessions and 12 supervised exergame sessions. Jack reported that he felt better and described the change in his affected UE as subtle and positive. Jack believed that VirTele could be useful at the end of inpatient and outpatient rehabilitation services, depending on the stroke survivor's level. He also suggested that exercises could be taught while in clinic: "…people have things and exercises to learn before. Then, when they are ready enough, we offer them the exercises [VirTele]." Jack pointed out to one limit of exergames which was the lack of sufficient rest time between sets of repetitions in each game and suggested a break of 10 or 20 seconds. As for effort, Jack indicated that it was easy to use the system due to his previous experience and that he faced two major problems, the first related to internet access and the second related to his difficulty to communicate his ideas with the clinician due to aphasia. He also added that he could place the technology material (computer and Kinect camera) in his office. Jack demonstrated autonomy in making decisions related to choices of exergames and level of difficulty, and indicated that the clinician supported his use of exergames, through tips, demonstrations and feedback. He also pointed out that he was autonomously motivated to play exergames and no one forced him to do it. Jack, who was followed by the same clinician as Helene, indicated that she was kind.
In addition to what was reported in case two, Jack's clinician indicated that a ceiling effect was rapidly reached in the difficulty level of exergames, for this participant, which impacted his motivation. She added that Jack understood the instructions and that it was easy to work with him. Minor technical issues were identified (the screen froze or slowed down, limited access to internet, faced by Jack). The clinician pointed out communication challenges faced during videoconference sessions with Jack due to the aphasia, which made it difficult for her to understand Jack's needs and customize the intervention appropriately.
The clinician also stated that the participant had demonstrated a lot of resistance to using his affected UE in daily activities, even if he was responsible and compliant, with regards to exergames.
Finally, the clinician indicated that she supported Jack's autonomy through shared decision making and Jack's relatedness through reflective listening. Regarding competence support, Jack's clinician indicated that she managed to show the participant that he was able to succeed in the exergames by valorizing small successes and encouraging him to maintain some positions, even for a few seconds.
The clinician's logbook indicated that self-directed exercises (in addition to exergames) were performed by Jack, during the VirTele intervention period and included, for example, elbow extension and supination, use of UE to turn on the lights, shoulder abduction and adduction using a stick. Furthermore, the logbook notes indicated that the clinician used BCT's and motivational techniques (eg, reflective listening) ( Table 2), which support competence, relatedness and autonomy.