You may remember that back in August 2016, AppAttic acquired some nifty virtual reality kit with the view to exploring ideas around using VR and games as a means to optimising rehabilitation, health and wellness. Many a Friday afternoon was spent crawling around the office floor in a VR headset as we explored the technological capabilities of VR and it’s application for improving stroke rehabilitation as part of our MAGIC PCP phase 1 proposal.
The proposal was successful and below we outline some useful research around the Behaviour (COM-B) model and increasing rehabilitation activity…
Challenges in stroke rehabilitation
There are now more people than ever before surviving stroke (National Institute for Health and Care Excellence, 2013), yet the loss of physical function caused by such an event has become one of the main reasons for physical disability in adults across the world.
Common problems after stroke include muscle weakness or paralysis usually on one side of the body, which can affect mobility and balance. Approximately 80% of people will experience paralysis down one side of the body in the hours and days immediately following a stroke, and in 40% of people, these symptoms will persist long-term (Hatem et al, 2016). Such complications can severely limit a person’s ability to carry out everyday tasks such as dressing, eating and bathing. These functions are referred to in the health and social care context as activities of daily living.
Rehabilitation aims to recover lost function and to increase independence post-stroke (Hatem et al., 2016), maximising social participation and minimising distress for people with stroke and their families (NICE 2013). Starting rehabilitation activities promptly and performance of increasingly higher intensities and durations of exercises help patients regain primary motor cortex functionality. There is strong evidence to support intensive repetitive task-oriented training for recovery after stroke (Connell et al, 2015) to stimulate new pathways in the brain and recover lost movement (Hatem et al., 2016). Regular and frequent performance of activities by patients at home is crucial to the rehabilitation process. However, the physical and mental capacity of people with stroke to participate in at-home rehabilitation exercises varies widely (NICE 2013), and studies suggest adherence to prescribed programmes is suboptimal (Miller et al., 2016).
So how may adherence to home-based stroke rehabilitation be increased? Adherence has been defined as ‘the extent to which a person’s behaviour corresponds with agreed recommendations from a healthcare provider’ (World Health Organization, 2003). When adherence is considered as such, i.e., as a behaviour, it has been proposed that attempts to improve adherence may be more successful if they align with psychological theory of behaviour change (Holmes et al., 2016).
Luckily, there is a plethora of theories and models that seek to predict how and why people may behave in certain ways under certain conditions. One such model that has been gaining traction in behaviour change circles is the Capability, Opportunity, Motivation — Behaviour (COM-B) model (Michie et al., 2011). The COM-B model is the result of a systematic review and synthesis of 19 different behaviour change models by a group of behaviour change experts (Michie et al., 2011). The model conceptualises the relationship between capability (a person’s psychological and physical capacity to engage in an activity), opportunity (the factors that lie outside a person that make them able to perform an activity or prompt it) and motivation (the brain processes that promote behaviour). Stimulation of all three factors has the potential to change behaviour, either alone or in combination. The model also suggests that enhancing opportunity and capability can also increase motivation, and performance of the behaviour can in fact influence all three factors through positive feedback.
So, when we consider this model with respect to stroke rehabilitation, what this model effectively provides are targets for interventions that aim to increase adherence to rehabilitation activities.
For a person to be adherent to his or her rehabilitation exercises, they need to first be able to perform them, that is, they need to know or be shown how to perform the exercises and they need to be physically able to do them. There is strong evidence to support the practices used in stroke rehabilitation, such as repetitive task-oriented training (Connell et al. 2015). However, it has been suggested that clinical benefits of rehabilitation activities are often not achieved because repetitive tasks are not performed at the high intensities and frequencies required (Connell et al., 2015). The psychological and physical capabilities of people with stroke to perform the activities required of them, at the frequency and intensity advised, will vary from person to person, and within individuals themselves depending on their stage of recovery. Fluctuations in pain, energy and mood may also affect a person’s own ability to perform tasks from day to day. Rehabilitation programmes need to consider these factors and dynamically adapt to the changing needs and capabilities of the people they are designed to benefit. For some people, the repetition of tasks required in stroke rehabilitation can be difficult and monotonous (Burdea, 2003). To increase duration and intensity of participation, rehabilitation activities should be interesting, engaging and fun.
In the COM-B model, opportunity refers to factors external to the individual that can encourage or prompt the wanted behaviour (Michie et al. 2011). In the context of stroke rehabilitation, the wanted behaviour is the regular and frequent performance of rehabilitation exercises. Restructuring the environment can provide an opportunity to perform the behaviour more regularly, for example, having a dedicated space in the home for exercises may be conducive to high participation. Yet any equipment used should be accessible and portable so that the exercises can be performed wherever the person goes.
Social opportunity refers to how a person’s social and cultural background influences how they think about things and behave in certain ways (Michie et al., 2011). Performance of a complex activity may be more likely if an alternative purpose to the activity that aligns with social norms, such as a video game, is provided. The larger the number of users, the more socially acceptable and ‘normal’ a game becomes driving further engagement. In a study of a web-based health intervention involving 84,828 participants, people with social ties were significantly more engaged in the intervention compared with participants with no social ties, suggesting that social influence can drive engagement. (Proirier et al., 2012)
Moving on to motivation
Kate Allat, who experienced a stroke seven years ago and now works to empower and engage stroke survivors in their rehabilitation, believes that patients need greater support from the NHS to adhere to the rehabilitation regimens prescribed for them. She argues, “It is futile prescribing a stroke rehabilitation plan if the patient is unmotivated before the therapy session starts or they are left at home trying to manage their own condition” (Allat, 2017).
She adds that enhancing motivation to participate in and adhere to physical rehabilitation programmes in people who may also be experiencing additional emotional, social and cognitive difficulties post-stroke can be a challenge for the healthcare professionals caring people with stroke, as well as their family and friends (Allat, 2017).
Michie et al., (2011) define motivation as as the brain processes that “energise and direct behaviour”. This does not just include reflective processes such as goal-setting and conscious decision-making, but automatic processes, involving the emotions and impulses that arise from previous experiences (Michie et al., 2011). Providing regular incentives, rewards and encouragement for a wanted behaviour can create pleasurable experiences and memories, making people more likely to continue the behaviour. Intrinsic motivation, which is derived from the inherent satisfaction of action, is considered to be the core type of motivation underlying play and sport (Ryan, 2006), and this motivation exists even when there are no external rewards or incentives. Techniques such as gamification can engage, motivate and empower people to increase their participation in rehabilitation activities that would otherwise be considered boring or laborious (Ryan, 2006).
In conclusion, although there is no magic bullet to increasing adherence to stroke rehabilitation and there will never be a ‘one size fits all’ solution, by considering adherence to be a behaviour that is amenable to change you open the door to new ways to influence behaviour, thus expanding the choice of components for new, innovative health interventions. AppAttic are pursuing evidence that new and immersive virtual reality hardware combined with behaviour changing games and wellbeing experiences can maximise activity participation in stroke rehabilitation, thus improving the quality, efficiency and efficacy of home-based rehabilitation programmes.