Trial of gamification on physical therapy following Traumatic Brain Injury

Single-case experiments will be conducted (N=10) within the Liverpool Brain Injury Rehabilitation Unit, testing the effectiveness of gamification technologies. These single-case experiments will be planned to ensure scientific rigor, using the Risk of Bias in N-of-1 Trials Scale. An A1-B1-A2-B2 withdrawal design will be employed with each phase lasting a fortnight. Each phase will commence immediately after the preceding phase with no wash out period to minimize changes associated with natural recovery and other rehabilitation interventions administered as part of routine care. Within each fortnight phase, three to eight fitness training therapy sessions will be delivered by a physiotherapist that are measured. The A 'baseline' phase will provide participants with usual feedback from the existing monitors on the gym equipment (e.g., the exercise bike, the treadmill). The B phase will be the intervention phase where feedback will employ virtual reality (VR) gamification strategies delivered by means of LCD monitors. Each session within the phases will typically last between 20-60 mins. Participants will be advised that a minimum requirement for each session is 20 minutes, however any further duration will be dependent on the participant’s ability and their motivational effort. The maximum number of sessions a participant can engage in per phase is eight to allow for phase-based outcome measures to be completed. While the aim is for participants to average approximately 5 sessions per phase, the minimum of 3 sessions is to account for unexpected reasons for missed sessions such as staffing, conflicting therapy/appointment/meeting and the participant feeling unwell. For each participant, all sessions will be completed on the same fitness training modality, i.e., either the bike or the treadmill. The decision of whether the participant completes therapy sessions on the bike or treadmill will be determined as a joint decision between the participant and their treating physiotherapist. This will be based on participant preference as well as clinical suitability deemed by the treating physiotherapist based on an assessment of the participant’s safety to perform semi-supervised sessions on the bike or treadmill and the participant’s current functional ability. The VR gamification will be non-immersive (i.e., without the use of VR goggles) and delivered by means of LCD monitors that will provide visual, interactive feedback to participants while they are conducting therapy sessions on the exercise bike or treadmill. The current monitors simply provide basic information about distance, steps and physiological parameters. The VR gamification will vary depending on the gym equipment. In the case of the bike exercises, the participant will see, on the monitor, a track that they are riding along, and they will be competing with other riders on the screen. The faster they pedal on the bike, the faster they ride along the track and the quicker they get to the finish line. In the case of the treadmill, the virtual environment may display a walk through the woods, with the person seeing more views if they walk more quickly. Adherence to the intervention will be monitored using session attendance checklists recorded by the treating physiotherapist. These checklists will record number of sessions attended per phase and the duration of each session, extracted from a heart rate monitor in real-time that the participant will have turned on during the session.