Immersive virtual reality gameplay detects visuospatial atypicality, including unilateral spatial neglect, following brain injury: a pilot study.

BACKGROUND: In neurorehabilitation, problems with visuospatial attention, including unilateral spatial neglect, are prevalent and routinely assessed by pen-and-paper tests, which are limited in accuracy and sensitivity. Immersive virtual reality (VR), which motivates a much wider (more intuitive) spatial behaviour, promises new futures for identifying visuospatial atypicality in multiple measures, which reflects cognitive and motor diversity across individuals with brain injuries. METHODS: In this pilot study, we had 9 clinician controls (mean age 43 years; 4 males) and 13 neurorehabilitation inpatients (mean age 59 years; 9 males) recruited a mean of 41 days post-injury play a VR visual search game. Primary injuries included 7 stroke, 4 traumatic brain injury, 2 other acquired brain injury. Three patients were identified as having left sided neglect prior to taking part in the VR. Response accuracy, reaction time, and headset and controller raycast orientation quantified gameplay. Normative modelling identified the typical gameplay bounds, and visuospatial atypicality was defined as gameplay beyond these bounds. RESULTS: The study found VR to be feasible, with only minor instances of motion sickness, positive user experiences, and satisfactory system usability. Crucially, the analytical method, which emphasized identifying 'visuospatial atypicality,' proved effective. Visuospatial atypicality was more commonly observed in patients compared to controls and was prevalent in both groups of patients-those with and without neglect. CONCLUSION: Our research indicates that normative modelling of VR gameplay is a promising tool for identifying visuospatial atypicality after acute brain injury. This approach holds potential for a detailed examination of neglect.

The role of the physical environment in stroke recovery: Evidence-based design principles from a mixed-methods multiple case study.

Hospital design can impact patient outcomes, but there is very little healthcare design evidence specific to stroke rehabilitation facilities. Our aim was to explore, from the patient perspective, the role of the physical environment in factors crucial to stroke recovery, namely, stroke survivor activity (physical, cognitive, social), sleep, emotional well-being, and safety. We conducted a mixed-methods multiple-case study at two inpatient rehabilitation facilities in Victoria, Australia, (n = 20 at Case 1, n = 16 at Case 2) using "walk-through" semi-structured interviews, behavioural mapping, questionnaires, and retrospective audit. Four interrelated themes emerged: 1) entrapment and escape; 2) power, dependency, and identity in an institutional environment; 3) the rehabilitation facility is a shared space; and 4) the environment should be legible and patient-centred. Quantitative data revealed patterns in patient activity; stroke survivors spent over 75% of their time in bedrooms and were often inactive. Convergent mixed methods analysis was used to generate a new conceptual model of the role of the physical environment in stroke survivors' behaviour and well-being, highlighting the importance of variety and interest, privacy without isolation, and patient-centred design. This model can be used by designers, healthcare providers, and policy makers to inform the design of rehabilitation environments.

The attention atlas virtual reality platform maps three-dimensional (3D) attention in unilateral spatial neglect patients: a protocol.

BACKGROUND: Deficits in visuospatial attention, known as neglect, are common following brain injury, but underdiagnosed and poorly treated, resulting in long-term cognitive disability. In clinical settings, neglect is often assessed using simple pen-and-paper tests. While convenient, these cannot characterise the full spectrum of neglect. This protocol reports a research programme that compares traditional neglect assessments with a novel virtual reality attention assessment platform: The Attention Atlas (AA). METHODS/DESIGN: The AA was codesigned by researchers and clinicians to meet the clinical need for improved neglect assessment. The AA uses a visual search paradigm to map the attended space in three dimensions and seeks to identify the optimal parameters that best distinguish neglect from non-neglect, and the spectrum of neglect, by providing near-time feedback to clinicians on system-level behavioural performance. A series of experiments will address procedural, scientific, patient, and clinical feasibility domains. RESULTS: Analyses focuses on descriptive measures of reaction time, accuracy data for target localisation, and histogram-based raycast attentional mapping analysis; which measures the individual's orientation in space, and inter- and intra-individual variation of visuospatial attention. We will compare neglect and control data using parametric between-subjects analyses. We present example individual-level results produced in near-time during visual search. CONCLUSIONS: The development and validation of the AA is part of a new generation of translational neuroscience that exploits the latest advances in technology and brain science, including technology repurposed from the consumer gaming market. This approach to rehabilitation has the potential for highly accurate, highly engaging, personalised care.

Efficacy of Multimodal Sensory Therapy in Adult Acquired Brain Injury: A Systematic Review.

Adults who experience an acquired brain injury often experience disorders of consciousness, physical difficulties, and maladaptive behaviours. Multimodal sensory therapy may benefit brain injured patients, however the extent this therapy can facilitate rehabilitation is not well understood. This systematic review aimed to synthesize multimodal sensory therapy research for adults affected by acquired brain injury. PRISMA guidelines were followed and searches for work published up until July 2021 were undertaken in 5 databases, finding 1054 articles. 43 articles were included in the study. Results describe 29 studies related to coma following an acquired brain injury and 14 to no coma studies (mostly stroke). Multimodal sensory therapy was mostly used as a coma arousal technique following traumatic brain injury, finding positive effects. Multimodal sensory therapy was less applied in stroke, no coma rehabilitation, where most studies found improvement in somatosensory sensation and motor control in an affected limb. In several no coma studies, effects were maintained after several months. The most common senses stimulated in coma studies were audio (N = 30), tactile (N = 28), visual (N = 26), olfactory (N = 22), and gustatory (N = 17), while the most common senses stimulated in stroke, no coma studies were proprioception (N = 7), tactile (N = 8), and stereognosis (N = 4). Multimodal sensory therapy can be beneficial for patients, especially those in a minimally conscious state or attempting physical rehabilitation following stroke. Negative findings are infrequent in the current literature base. Multimodal sensory therapy appears to be a low-risk intervention with positive outcomes.

Why hospital design matters: A narrative review of built environments research relevant to stroke care.

Healthcare facilities are among the most expensive buildings to construct, maintain, and operate. How building design can best support healthcare services, staff, and patients is important to consider. In this narrative review, we outline why the healthcare environment matters and describe areas of research focus and current built environment evidence that supports healthcare in general and stroke care in particular. Ward configuration, corridor design, and staff station placements can all impact care provision, staff and patient behavior. Contrary to many new ward design approaches, single-bed rooms are neither uniformly favored, nor strongly evidence-based, for people with stroke. Green spaces are important both for staff (helping to reduce stress and errors), patients and relatives, although access to, and awareness of, these and other communal spaces is often poor. Built environment research specific to stroke is limited but increasing, and we highlight emerging collaborative multistakeholder partnerships (Living Labs) contributing to this evidence base. We believe that involving engaged and informed clinicians in design and research will help shape better hospitals of the future.

Built environments for inpatient stroke rehabilitation services and care: a systematic literature review.

OBJECTIVES: To identify, appraise and synthesise existing design evidence for inpatient stroke rehabilitation facilities; to identify impacts of these built environments on the outcomes and experiences of people recovering from stroke, their family/caregivers and staff. DESIGN: A convergent segregated review design was used to conduct a systematic review. DATA SOURCES: Ovid MEDLINE, Scopus, Web of Science and Cumulative Index to Nursing and Allied Health Literature were searched for articles published between January 2000 and November 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Qualitative, quantitative and mixed-methods studies investigating the impact of the built environment of inpatient rehabilitation facilities on stroke survivors, their family/caregivers and/or staff. DATA EXTRACTION AND SYNTHESIS: Two authors separately completed the title, abstract, full-text screening, data extraction and quality assessment. Extracted data were categorised according to the aspect of the built environment explored and the outcomes reported. These categories were used to structure a narrative synthesis of the results from all included studies. RESULTS: Twenty-four articles were included, most qualitative and exploratory. Half of the included articles investigated a particular aspect of the built environment, including environmental enrichment and communal areas (n=8), bedroom design (n=3) and therapy spaces (n=1), while the other half considered the environment in general. Findings related to one or more of the following outcome categories: (1) clinical outcomes, (2) patient activity, (3) patient well-being, (4) patient and/or staff safety and (5) clinical practice. Heterogeneous designs and variables of interest meant results could not be compared, but some repeated findings suggest that attractive and accessible communal areas are important for patient activity and well-being. CONCLUSIONS: Stroke rehabilitation is a unique healthcare context where patient activity, practice and motivation are paramount. We found many evidence gaps that with more targeted research could better inform the design of rehabilitation spaces to optimise care. PROSPERO REGISTRATION NUMBER: CRD42020158006.

Safe and Supportive Neurorehabilitation Environments: Results of a Structured Observation of Physical Features Across Two Rehabilitation Facilities.

OBJECTIVE: This research aimed to identify the extent to which physical features of two neurorehabilitation units appeared to support positive patient experience and recovery. BACKGROUND: Neurorehabilitation inpatient facilities must be focused on safety management and efficiency of care, as well as being supportive of the patient experience. While occupational safety and risk management is paramount, the supportive nature of the physical setting for inpatient neurorehabilitation following spinal cord injury or acquired brain injury is unclear. METHOD: Structured observation of two physical environments using an adapted observational tool comprising 237 items across 8 area zones, and 3 major categories (patient safety, worker safety and efficiency, and holistic patient experience). RESULTS: Results indicated that across both neurorehabilitation settings, the built environment attended well to occupational safety, risk reduction, harm prevention and internal security (up to 87% in spinal injury unit [SIU] and 95% in brain injury unit [BIU] patient rooms), but with limited evidence of physical features to support psychosocial needs or promote positive user experiences (up to 30% in SIU and 45% in BIU patient rooms). CONCLUSION: The built environments observed appeared to be an underutilized resource for supporting positive psychosocial neurorehabilitation experiences (including complex behavior support) beyond hazard management.

What's in a Building? A Descriptive Survey of Adult Inpatient Rehabilitation Facility Buildings in Victoria, Australia.

OBJECTIVE: To identify all the services that offer inpatient rehabilitation in Victoria, Australia, and to describe the buildings in which these services are housed, including their size, age, whether or not they were purpose-built, whether or not they are colocated with a tertiary hospital, the proportion of single-bed rooms, and ward layout. DESIGN: Cross-sectional survey of inpatient rehabilitation buildings. Data were collected via telephone questionnaire and websites. PARTICIPANTS: Sixty-four rehabilitation facilities were identified and all participated in the survey (37 public, 27 private). RESULTS: Results revealed heterogeneity on most variables measured, including size (number of beds ranged from 2-104), age (oldest building built in 1860, and 26% built since 2010), purpose-built status (48% purpose-built), freestanding status (34% freestanding), percentage of single-bed rooms (ranged from 0%-100%), and layout. All facilities had a therapy gym, and most had a communal area (96%). CONCLUSION: Since 2010, the proportion of buildings being purpose-built and colocated with a tertiary hospital has increased. The proportion of single-bed rooms has also increased and is especially high in privately funded facilities. Results suggest that rehabilitation design is influenced by norms and evidence from acute medical health care despite the purpose of care being different: acute care (short-term, medical illness) and rehabilitation (longer-term, recovery, relearning).

A Framework for Designing Inpatient Stroke Rehabilitation Facilities: A New Approach Using Interdisciplinary Value-Focused Thinking.

AIM: To use Value-Focused Thinking to investigate what is important in the design of inpatient stroke rehabilitation facility buildings. BACKGROUND: Many stroke patients require inpatient rehabilitation in a dedicated facility. Rehabilitation facilities are healthcare spaces, but they are also learning spaces where patients practice targeted tasks to acquire new skills and to reacquire skills and abilities that were compromised as a result of their stroke. There is currently no consensus regarding how the design of inpatient rehabilitation facilities could be optimized for patients' learning. METHOD: We used Value-Focused Thinking to develop a framework of what interdisciplinary experts consider important for inpatient stroke rehabilitation facility design. Two workshops were conducted. The following experts were invited to participate: past patients with experience of stroke rehabilitation; stroke rehabilitation clinicians; stroke rehabilitation academics; healthcare environments academics; learning environments academics; architects, designers, and wayfinders with experience designing healthcare or learning environments; and healthcare design policy makers. RESULTS: Thirty experts participated. The experts' final framework included 16 criteria that were considered fundamentally important for inpatient stroke rehabilitation facility design, and 14 criteria that were considered instrumentally important. Inpatient stroke rehabilitation facility design should maximize efficiency, maximize effectiveness (i.e., patients' clinical and functional outcomes), foster emotional well-being, and maximize safety. Opportunities to practice physical, cognitive, and social activity were considered important for patients' outcomes. CONCLUSIONS: Value-Focused Thinking was an effective and equitable means of engaging experts from multiple disciplines. Designers, planners, and developers of inpatient stroke rehabilitation facilities should consider the rehabilitation-specific framework developed in this study alongside evidence from other healthcare settings.

Using the natural environment to address the psychosocial impact of neurological disability: A systematic review.

Engaging with the natural environment contributes to favourable psychosocial health outcomes. A systematic review of research published before June 2017 was conducted to establish how engaging with natural environments impact the psychosocial health of people with a neurological disability. Identified studies included populations with dementia (n=14), brain injury (n=2), and stroke (n=2). Evidence suggests that engaging with gardens, and gardening, can favourably impact the emotional and social health of people with dementia and, an explanatory theoretical model is proposed. Considerable research gaps exist and further research investigating the psychosocial impact of engaging with natural environments for people with different neurological conditions (for example spinal cord injury or stroke) is warranted.

"Everything Happens in the Hallways": Exploring User Activity in the Corridors at Two Rehabilitation Units.

OBJECTIVES: This research aimed to examine the role of the corridors in specialist inpatient rehabilitation units to inform future design of these spaces. BACKGROUND: In healthcare settings, such as rehabilitation units, corridors have often been designed simply as spaces allowing movement between other locations. However, research suggests that corridors may be places where important social and care-related activities take place. How corridors are used and understood by patients and staff in inpatient rehabilitation settings is unclear, and a greater understanding of the role of corridors in these settings could help to inform more supportive design of these spaces. METHODS: Independent observations of user activity were conducted at a major metropolitan inpatient spinal injury unit (SIU) and brain injury unit (BIU). Interviews were conducted with SIU patients ( n = 12), and focus groups were conducted with SIU staff ( n = 23), BIU patients ( n = 12), and BIU staff ( n = 10). RESULTS: Results from the observations showed that the corridors were used frequently across the day, particularly by staff. Thematic analysis of staff and patient experiences found three key themes describing how corridors were used: (1) moving around, (2) delivery and experiences of quality care, and (3) a "spillover space." CONCLUSIONS: Results demonstrate that corridors not only have an important role as connective spaces but are also used as flexible, multipurpose spaces for delivery of quality care and patient experiences. Future design should consider how these spaces can more deliberately support and contribute to patient and staff experiences of rehabilitation.

Nominal group technique for individuals with cognitive disability: a systematic review.

RATIONALE: Considering the perspectives of individuals with cognitive disability is important for their participation in their self-directed health care. The nominal group technique (NGT) has been identified as a method to gather opinions of people with cognitive disability; however, a synthesis of methodological considerations to undertake when employing the approach among people with cognitive disability is non-existent. METHOD: A systematic review guided by the preferred reporting items for systematic review and meta-analysis protocols was undertaken. Five databases (CINAHL, ISI Web of Science, ProQuest Social Science Journals, Scopus, and MEDLINE) were searched for peer-reviewed literature published before September 2016. Methodological considerations pertaining to the four stages of the NGT- generating ideas, recording ideas, clarification, and ranking - were extracted from each study. RESULTS: Nine publications contributing to eight studies were included. Methodological considerations focused on (i) the number of participants within discussion groups, (ii) research question introduction, (iii) support individuals and accessible methods, (iv) ranking, and (v) researcher training and counselling services. CONCLUSIONS: The use of the NGT to gain the health care perspectives of adults with cognitive disability is promising. Conducting nominal group techniques informed by the methodological considerations identified within this review can work towards ensuring that the health care perspectives of people with cognitive disability are considered. Implications for rehabilitation The emergent policy move towards self-directed health care for people with disability requires that the health care perspectives of people with disability are considered. Effective consultation and discussion techniques are essential to gain the health care perspectives of people with cognitive disability. After undertaking methodological considerations, the NGT can be an effective approach towards gaining the health care perspectives of people with cognitive disability.

Perspectives of self-direction: a systematic review of key areas contributing to service users' engagement and choice-making in self-directed disability services and supports.

Self-directed disability support policies aim to encourage greater choice and control for service users in terms of the health and social care they receive. The proliferation of self-directed disability support policies throughout the developed world has resulted in a growing amount of research exploring the outcomes for service users, and their families and carers. Our understanding of the issues faced by people with disabilities, particularly how they make health and social care decisions and the key areas that determine their engagement with service providers within a self-directed environment is limited. A synthesis of research is timely and can provide knowledge for service users and health and social care support providers to ensure their successful participation. A systematic review guided by the PRISMA approach explored (i) the key areas determining service users' engagement with self-directed disability services and supports, and (ii) how service users make informed decisions about providers. In October 2014 and April 2016, three databases - MEDLINE, CINAHL and Web of Science - were searched for research and review articles. Eighteen sources met the search criteria. Findings were mapped into either: key areas determining service user engagement, or service users' informed decision-making. Findings concerning key areas determining engagement fell into three themes - personal responsibility for budgeting, personalised approaches, and a cultural shift in practice and delivery among service providers. Findings about decision-making yielded two themes - supporting informed decision-making and inhibiting informed decision-making. Literature suggests that self-directed models of care may provide service users with increased control over the services that they receive. Increased control for some service users and their families requires independent external decision-making support, particularly around the domains of budgeting, planning and hiring. Future research must continue to investigate the perspectives of service users pertaining to their engagement, as their participation is central to the effectiveness of the approach.

Making every Australian count: challenges for the National Disability Insurance Scheme (NDIS) and the equal inclusion of homeless Aboriginal and Torres Strait Islander Peoples with neurocognitive disability.

This article highlights the dearth of accurate evidence available to inform the National Disability Insurance Scheme (NDIS) regarding the extent and nature of neurocognitive disability amongst homeless Aboriginal and Torres Strait Islander people. Without accurate prevalence rates of neurocognitive disability, homeless Aboriginal and Torres Strait Islander people are in danger of not being counted by the NDIS and not receiving supports to which they are entitled. Addressing this knowledge gap is challenged by a range of factors, including: (1) the long-term effect of profound intergenerational disenfranchisement of Aboriginal and Torres Strait Islander people; (2) Aboriginal and Torres Strait Islander cultural perspectives around disability; (3) the generally unrecognised and poorly understood nature of neurocognitive disability; (4) the use of research methods that are not culturally safe; (5) research logistics; and (6) the absence of culturally appropriate assessment tools to identify prevalence. It is argued that an accurate evidence base that is informed by culturally safe research methods and assessment tools is needed to accurately guide the Commonwealth government and the National Disability Insurance Agency about the expected level of need for the NDIS. Research within this framework will contribute to the realisation of a truly inclusive NDIS.

What housing features should inform the development of housing solutions for adults with neurological disability?: A systematic review of the literature.

Despite the recent emphasis in Australian political, academic, and legislative narratives to more actively promote real housing choice for people with high healthcare and support needs, there is a lack of understanding regarding the specific housing features that might constitute better housing solutions for this population. Inclusive housing provision in Australia rightly emphasises safety and accessibility issues but often fails to incorporate factors related to broader psychosocial elements of housing such as dwelling location, neighbourhood quality, and overall design. While the importance of these broader elements appears obvious, it is not yet clear what specific housing features relate to these elements and how they might contribute to housing solutions for people with high healthcare and support needs. For individuals with complex neurological conditions such as brain injury or cerebral palsy, who require maximum support on a daily basis yet want to live independently and away from a primary care hospital or health facility, a more detailed understanding of the housing features that might influence design and development is needed. Thus, in order to clarify the broader factors related to housing solutions for this population, a systematic review was conducted to identify and synthesise the current research evidence (post-2003) and guide future housing design and development opportunities. From the included studies (n=26), 198 unique housing features were identified. From the 198 features, 142 related to housing design (i.e., internal or external characteristics of the dwelling and its land), 12 related to the dwelling's location (i.e., its proximity to available resources), and 54 related to the nature of the surrounding neighbourhood (i.e., the physical, social, and economic conditions of the area). The findings of this review contribute significantly to the literature by reporting a broader scope of relevant housing features for people with neurological disability, presenting preliminary guiding principles for housing design and development for this population, and identifying opportunities for future research.

A place to call my own: Young people with complex disabilities living in long-term care.

It is important to consider the nature of home in more detail when thinking about living environments for vulnerable groups of people, especially as it has been found that the nature of home can impact on the quality of life. The aim of this study was to understand the "lived experience" of home for a group of young people with complex disabilities who had recently relocated to a specially designed residential apartment building. Multiple domains of home, as they were experienced over time, were examined through a series of semi-structured interviews conducted with seven residents at their apartments. The findings revealed two major themes ("perceived quality of the place" and "identity in place") that were inextricably interlinked. To the extent that they overlapped, the experience of home was enhanced. The interaction between the two themes was associated with a dynamic ongoing process whereby the sense of home was either created or damaged ("deconstruction and reconstruction of home"). The current study has implications for how residential care workers are trained and supported if the well-being of individuals with complex disabilities is to be promoted within residential settings.

Holistic Practice in Traumatic Brain Injury Rehabilitation: Perspectives of Health Practitioners.

Given that the literature suggests there are various (and often contradictory) interpretations of holistic practice in brain injury rehabilitation and multiple complexities in its implementation (including complex setting, discipline, and client-base factors), this study aimed to examine the experiences of practitioners in their conceptualization and delivery of holistic practice in their respective settings. Nineteen health practitioners purposively sampled from an extensive Brain Injury Network in Queensland, Australia participated in individual interviews. A systematic text analysis process using Leximancer qualitative analysis program was undertaken, followed by manual thematic analysis to develop overarching themes. The findings from this study have identified several items for future inter-professional development that will not only benefit the practitioners working in brain injury rehabilitation settings, but the patients and their families as well.

Study protocol: developing a decision system for inclusive housing: applying a systematic, mixed-method quasi-experimental design.

BACKGROUND: Identifying the housing preferences of people with complex disabilities is a much needed, but under-developed area of practice and scholarship. Despite the recognition that housing is a social determinant of health and quality of life, there is an absence of empirical methodologies that can practically and systematically involve consumers in this complex service delivery and housing design market. A rigorous process for making effective and consistent development decisions is needed to ensure resources are used effectively and the needs of consumers with complex disability are properly met. METHODS/DESIGN: This 3-year project aims to identify how the public and private housing market in Australia can better respond to the needs of people with complex disabilities whilst simultaneously achieving key corporate objectives. First, using the Customer Relationship Management framework, qualitative (Nominal Group Technique) and quantitative (Discrete Choice Experiment) methods will be used to quantify the housing preferences of consumers and their carers. A systematic mixed-method, quasi-experimental design will then be used to quantify the development priorities of other key stakeholders (e.g., architects, developers, Government housing services etc.) in relation to inclusive housing for people with complex disabilities. Stakeholders randomly assigned to Group 1 (experimental group) will participate in a series of focus groups employing Analytical Hierarchical Process (AHP) methodology. Stakeholders randomly assigned to Group 2 (control group) will participate in focus groups employing existing decision making processes to inclusive housing development (e.g., Risk, Opportunity, Cost, Benefit considerations). Using comparative stakeholder analysis, this research design will enable the AHP methodology (a proposed tool to guide inclusive housing development decisions) to be tested. DISCUSSION: It is anticipated that the findings of this study will enable stakeholders to incorporate consumer housing preferences into commercial decisions. Housing designers and developers will benefit from the creation of a parsimonious set of consumer-led housing preferences by which to make informed investments in future housing and contribute to future housing policy. The research design has not been applied in the Australian research context or elsewhere, and will provide a much needed blueprint for market investment to develop viable, consumer directed inclusive housing options for people with complex disability.