I thought it would be difficult, but this is actually something I can do – experiences with Virtual Reality-based cognitive training in persons with TBI

Abstract

Introduction

Virtual reality (VR) has been suggested as a promising technology for delivering cognitive training to persons with traumatic brain injury (TBI), as it can provide situations resembling everyday activities. Studies have demonstrated that persons with TBI manage utilizing VR in clinical settings; however, no studies have investigated VR use in home settings. The aim of this study was to explore how persons with TBI experience utilizing VR for rehabilitation at home and how they experience VR as cognitive training.

Methods

Individual qualitative interviews were conducted with ten persons with TBI, aged 18–65. Participants had experience using VR, as they were recruited from the intervention group in a randomized controlled trial investigating VR in cognitive training. The data were analyzed using thematic analysis.

Results

Participants highlighted the importance of creating new routines when fitting VR into everyday life. They addressed how being in a virtual world contributes to their motivation for cognitive training. Three themes were developed: ‘Fitting VR-training into everyday life’, ‘Navigating through change’ and ‘Being in two worlds at the same time’.

Conclusion

This study shows that participants experienced VR as motivating, engaging, and easy to use, regardless of prior experiences with VR. The participants demonstrated how they included VR in everyday life by creating new routines when they performed cognitive training. Therewere few reports of adverse events. However, some experienced that VR had a negative impact on their energy level. Participants described the importance of therapeutic involvement for individual tailoring of the intervention.

Introduction

Traumatic brain injury (TBI) can cause cognitive deficits affecting activities of daily living and survivors are often in need of long-term rehabilitation [1,2]. Among the most common cognitive deficits following TBI are problems related to processing speed, working memory, attention, memory, and executive functions [2], impairments often associated with difficulties in managing activities of daily living such as occupational and leisure activities, as well as social life [3]. Also, despite the fact that cognitive impairments tend to be persistent, many patients do not receive active rehabilitation efforts in the chronic phase. There is an ongoing shift in rehabilitation practices in many countries, from hospital-based to community- or home-based rehabilitation interventions, to maximize gains [4]. However, the primary focus of rehabilitation in the chronic phase tends to be on improving physical independence, leaving the need for cognitive rehabilitation frequently unmet [5].

A large European multicenter study reported that two-thirds of individuals with cognitive deficits in the chronic phase after TBI did not receive any cognitive rehabilitation six months after injury [6]. Similarly, Moksnes and colleagues [7] reported in a follow-up study of persons admitted to trauma centers in Norway, that 60% experienced unmet rehabilitation needs six months after injury. From clinical experience, we know that many persons with TBI search for ways to continue cognitive rehabilitation after discharge from post-acute rehabilitation, and that options enabling this are few. Recent studies have highlighted Virtual Reality (VR) as a promising technology for providing cognitive training to persons with TBI [8]. VR has the ability to engage the player in a virtual environment while outside stimuli is muted [9], and can help patients with attentional deficits keep distractions out. In addition, the games have clearly stated goals and give direct feedback [10], in line with existing rehabilitation principles as suggested important factors for VR use in rehabilitation [11]. VR equipment has undergone major technical improvements that make it more suitable for home use because the kits are less bulky and more affordable. These games have easy-to-follow step-by-step tutorials for the setup of hardware and downloadable games, which has increased the usability of home-based VR systems.

Studies have demonstrated that persons with TBI can utilize VR in clinical settings [12,13], but have also highlighted the importance of therapist involvement to help adjust difficulty levels and find the right game [14]. To our knowledge, no studies have investigated VR-use in a home setting, leaving questions regarding acceptability, tolerability and usability in home settings still unanswered. Acceptability reflects how people receiving healthcare interventions consider it appropriate based on anticipated experiential cognitive and emotional responses to the intervention [15]. Of the 13 studies included in a recent scoping review of VR as a rehabilitation for activities of daily living [16], seven studies did not investigate or report any adverse events. Of the remaining six studies, only one reported adverse events such as dizziness, discomfort on the nose from the VR headset, and fatigue [17]. In addition to nausea, these adverse events are common symptoms of cybersickness, a form of motion sickness caused by VR [18]. Some studies have provided suggestions on the duration of VR sessions, but there are no clear recommendations [14,19,20]. Another facet of acceptability is self-efficacy, or an individual’s belief in their capability to exercise control over challenging demands and their own functioning [21]. To the best of our knowledge, no qualitative studies on VR as cognitive training for persons with TBI have been conducted; consequently, self-efficacy related to VR use in this population has not been previously explored.

Current recommendations for the rehabilitation of attentional deficits include individualized approaches such as metacognitive strategies, training in dual tasks, and altering environments and/or tasks to enhance performance in everyday tasks [3]. Furthermore, it is recommended that activities be contextualized in daily life settings and goal oriented. The use of decontextualized computerized cognitive training for attention is not recommended because of the lack of evidence of transfer effects in everyday activities [3]. VR has the potential to provide rich, contextualized, and ecologically valid situations. Ecological validity is however influenced by the content of the VR experience [22]. Although the game utilized in this study cannot be considered ecologically valid in the sense of resembling an everyday task, it is still conducted in an immersive and engaging environment. While the potential for ecological validity depends on the VR-content, most VR-games offer players a strong sense of immersion as VR provides a sense of presence [22]. Presence is defined as a perceptual illusion of non-mediation, in which the medium (VR goggles) appears to become invisible [23]. This may increase situational motivation and user engagement [24,25], which is enhanced by a sense of being in the moment or flow [26]. Flow is experienced when perceived opportunities for action are balanced with the individual’s perceived skills [27]. Lemmens and colleagues investigated the relationship between game difficulty and flow in a VR game and found that an increased sense of flow was linked with greater performance and higher levels of psychological arousal in college students [28]. Immersion of VR occurs if the activities performed are experienced as highly motivating.

In summary, there is a need to gain a better understanding of how persons with TBI experience VR, and whether VR could be a suitable intervention for home-based rehabilitation. Thus, the aims of this study were twofold:

1. To explore the experiences of persons with TBI in utilizing VR equipment for home-based rehabilitation

2. To increase our understanding of how persons with TBI experience using VR as a cognitive training method.

Methods

Design

A qualitative approach with individual semi-structured interviews was applied to fulfil the aims of the study. This study was conducted in accordance with the Consolidated criteria for Reporting Qualitative research (COREQ) (Appendix 1) [29].

Participant recruitment and study context

Participants were recruited from the intervention group of a randomized controlled trial (RCT) that investigated the effectiveness of VR as a method of cognitive training. The protocol for the complete trial has been published previously [30]. The inclusion criteria for the RCT were; radiologically verified complicated mild to severe TBI (CT/MRI), with severity of TBI classified by a combination of Glasgow coma scale [31], loss of consciousness and duration of post-traumatic amnesia [32]. The distinction between mild and complicated mild TBI was based on the criteria of the American Congress of Rehabilitation medicine [33]. Participants needed to have objective impairments of processing speed, working memory or sustained attention reported on neuropsychological assessment in their medical journal, between one- and 10-years post injury, and aged 18–65 years old. The current study utilized a combination of sampling strategies, as multiple sampling strategies may be employed in qualitative research [34]. Purposive sampling was used because the participants were selected intentionally as they needed experience with VR as a training method. In addition, convenience sampling was used because the participants were the first ten who volunteered to participate in an interview in the intervention group of the RCT [34]. All participants underwent post-acute rehabilitation at the hospital where the study was performed.

Description of the VR intervention

In the intervention arm of the RCT, the participants were instructed to play a commercially available VR game for 30 min per day five days a week, for 5 weeks. The intervention used the Oculus Quest 2 head-mounted display (HMD), which is an off-the-shelf stand-alone VR system, meaning that there is no need for an external computer to run the VR system. The system consisted of an HMD and two motion controllers, one for each hand. The system requires minimal space to play and is equipped with safety measures, such as a movement grid that the player sets each time the HMD is used in a new location, and it provides alerts if objects enter the playing area. Participants were all provided with the necessary VR-equipment after randomization at baseline and kept it during the intervention period.

The game used in the study is BeatSaber [35], which is one of the most downloaded VR games at all times [28] and has been suggested to be suitable for use in rehabilitation [36]. BeatSaber requires the player to react to colored blocks presented at rhythmic beats. As the game progresses, its requirements increase as the blocks are presented faster. BeatSaber uses motion to play the game, and there is a minimal need to coordinate movements by pressing buttons. Participants were provided with a 20–30-minute tutorial at the start of the intervention period. Throughout the intervention period, participants had access to therapist support.

Each 30-minute session was scheduled individually, with instructions to use a timer on their phone to keep track of time. The first author conducted a weekly 15-minute follow-up phone call during the five-week intervention period, where progress and possible adverse events were monitored through questionnaires and standardized questions regarding the experience of pain or discomfort during game play.

Procedures

The 10 qualitative individual interviews were conducted after the participants had finished their participation in the RCT, approximately 11 weeks after the last VR training session. The interviews were conducted at the rehabilitation hospital and lasted from to 40–60 min and audio was recorded. The first author conducted all interviews following an interview guide developed in collaboration with the co-authors (Table 1). The interview guide was based on the acceptability framework proposed by Sekhon and colleagues [15] and used as an outline for the interview, allowing follow-up of emerging themes with unplanned questions. The questions in the interview guide were developed as open-ended, and covered how the participants felt about the intervention, how they experienced the use of VR equipment, the perceived effort it took to partake, how they experienced their understanding of the intervention, whether the participants perceived the intervention to result in its intended purpose, and their own belief that they could participate in the intervention. In the introduction to the interviews, we emphasized that there were no wrong answers, and the participants were encouraged to express both positive and negative perspectives on the use of VR. In addition, open-ended questions were asked to ensure that participants were able to express in-depth descriptions of their experiences.

Table 1.

Excerpt of interview guide.

How was your experience with using the VR-equipment? What were your thoughts on VR before participating in this project? How did the VR-training fit into your everyday life? Did you have any experiences with pain or discomfort when using the VR-equipment? How was the duration and intensity of the training experienced? How do you feel about the content of the game? How did you experience your engagement or motivation for the VR-game throughout the intervention period?

Process of analysis

The first author transcribed the interviews verbatim, resulting in 92 pages of written text. The analysis process applied an inductive approach, in which codes and themes were first developed, and theoretical frameworks and relevant studies were considered later. The data were analyzed using reflexive thematic analysis as described by Braun and Clarke, following a six-step process [37]. The analytical process was conducted by the first, third, and last author, and an example of the process from initial codes and themes to redefined themes is presented in Table 2. The familiarization with the data was achieved by reading the transcripts multiple times. The first author read all transcripts, while the third and last author read four interviews. Then, the first author created the initial codes, and the third and last author reviewed these initial codes before new codes were generated. Initial themes were created from the codes and further developed through multiple workshops with the research group. The themes were named to reflect the content and meaning, and some were renamed multiple times. To ensure good quality and a rigorous reflexive thematic analytical process, the strategies suggested by Braun and Clarke were followed [37]. The first author kept a reflexive journal during the coding process, and analysis workshops were held with the third and last author. Through these discussions, the first author gained insights from more experienced researchers. In addition, an audit trail has been kept including mind maps, for multiple analytical efforts.

Table 2.

Example of analytical process.

Examples of codes	Examples of initial themes	Examples of refined codes	Examples Subthemes	Example of redefined theme
Ease of use Adverse events Technology competency	Experiences with using VR at home	Planning Routines Facilitation Usability Prioritizing	Individualized routines Facilitation and ease of use Challenges and solutions	Fitting VR-training into an everyday life

Researcher’s role and preconceptions

The first author conducted all the interviews and met the participants through their participation in the RCT, where the first author was one of the investigators who had weekly contact with participants during the intervention period. In addition, he was the treating occupational therapist for three of the participants when they underwent post-acute rehabilitation several years prior to the interviews. Follow-up consisted of one phone call of approximately 15 min each week for five weeks, discussing their experiences with VR training.

In addition, the first author has worked with VR in rehabilitation for several years. This may have led the author to have an optimistic outlook on the potential of VR before developing the interview guide and conducting the interviews. The third and last author are senior researchers with extensive research and clinical experience in both rehabilitation of TBI, and in implementation of assistive technology into clinical practice. In addition, the last author has extensive experience with qualitative research.

Ethics approval and informed consent

This study was conducted in accordance with the Declaration of Helsinki and was presented to the Regional Committee for Medical Research Ethics (registration number 376999) and the Norwegian Data Protection Agency (registration number 172224). All participants provided written informed consent before the commencement of the baseline assessment of the main trial, including consent for the publication of their anonymized quotes and identifying details.

Results

Participants

The ten participants ranged in age from eighteen to sixty-five years of age, all lived in Norway, and two were female. Years since injury ranged from two to six years, and all were classified as having suffered severe TBI. At the time of the interviews, one participant was a full-time student, three had retired, two were on disability benefits, two were employed part-time, and two were employed full-time. Four participants described themselves as experienced gamers, two had some experience, and four had minimal experience playing video games before participating in the study. Some participants had tried VR before, but none had played VR on a regular basis. The participants did not have severe cognitive deficits at the start of the intervention and scored within 1 SD from the normative means on neuropsychological tests at the group level. None of the participants had any difficulties with hearing or vision, nor did any have any physical deficits that would affect their ability to use the VR-equipment. The participants were given pseudonyms in the results to ensure de-identification (see Table 3). In addition, age and videogame experience is included after each citation.

Table 3.

Participant presentation.

Participant nr.	Pseudonym	Age	Videogame experience
1	Ronald	50s	Intermediate
2	Lilly	40s	Experienced
3	Helen	30s	Intermediate
4	Connor	50s	Experienced
5	Stuart	60s	Beginner
6	Gordon	40s	Experienced
7	Harry	60s	Beginner
8	Arthur	20s	Experienced
9	James	30s	Beginner
10	Martin	60s	Beginner

Findings

During the process of analysis, three main themes were developed: ‘Fitting VR training into everyday life’, ‘Navigating through changes’, and ‘Being in two worlds at the same time’ .

Fitting VR-training into everyday life

The theme ‘Fitting VR-training into everyday life’ describes how the participants made the VR-training a part of their daily routine and which factors were necessary to enable them to utilize VR. Furthermore, the theme includes descriptions of obstacles to be overcome in order to incorporate VR into everyday life. The theme will be presented with three subthemes: ‘Individualized routines’, “Ease of use, and ‘Challenges and solutions’.

Individualized routines

The participants addressed many ways of incorporating VR into their everyday routines and demonstrated different trial and error approaches to determine how to perform VR training in a suitable way. Since there were no guidelines for what time of day the participants were to play, many described a process to find routines that best suited their everyday lives.

It started with me trying to figure out when it was best to play VR games during the day. In the morning, as soon as I got up, a little later in the day or just before I went to bed at night. I tried all the options (Helen, 30s, Intermediate).

As Helen describes, she tried different times of the day to find out what was the best routine. Some participants made their routines for practical reasons, such as when they had other appointments or planned activities, as described by Ronald:

I didn’t plan it that much. It wasn’t like Monday at 11 o’clock (I’m going to play). But I really just had a look at it every morning. You just look at what other things you’re going to do today. So you just have to make it fit in between everything else you’re doing (Ronald, 50s, Intermediate).

Others had even more arbitrary reasons, such as playing before showering due to the goggles messing up their hair or makeup. Some participants, however, made routines based on their energy level, as James described how the training affected his level of energy the rest of his day.

When I played after resting, I thought it went much better. Cause I thought a lot about it too. And then I thought, when I played in the morning, maybe I didn’t drain my capacity storage completely, but halfway. So then I could for instance build it up again towards lunch. And then the whole day would go smoothly (James, 30s, Beginner).

He further went as far as stating that If I didn’t play in the morning, but for instance went to work, then I dreaded playing (James, 30s, Beginner). However, there was no clear pattern regarding the optimal time of day, as there were others who found it best to play in the evening. I tried a few different things. I found that it suited me best to do it in the evening, so I could go straight to bed afterwards Helen stated and explained this being due to her eyes being strained from playing VR. The participants had mixed experiences regarding the duration of the intervention. Some stated that the intervention period could have lasted longer, both each day and in weeks, while others expressed that the set amount was more than sufficient. This indicates that personalization of the timing of the intervention may be key to enabling the successful integration of VR in everyday life. For some participants, routines were important in general, especially after injury. Helen stated the following.

I’m very fond of routines. I know it has something to do with the brain injury. I need things to happen a bit like that. Once it becomes a routine, I think it’s quite easy (Helen, 30s, Intermediate).

This quote points to the challenge of incorporating game play into the participants’ everyday life routines, and especially into well-established routines. Others have highlighted the flexibility of the intervention as positive. Gordon stated that being able to move around when to play within five days of a week made it possible for him to incorporate it easily.

You’re supposed to play five days in the week, and then I have two days I can skip. So if I know that tomorrow is a bit hectic, I can skip tomorrow and play the next day instead (Gordon, 40s, Experienced).

Ease of use

Several participants highlighted the tutorial by the therapist at the start of the intervention as an important factor for succeeding in using VR equipment. Several stated that they knew exactly what they were supposed to do when they began using VR at home. Harry said, I knew exactly what to do. How to connect everything. So it went smoothly from the start and referenced the tutoring that all participants received at baseline on how to perform the setup at home. Stuart expressed that tutoring was especially important for him due to him feeling that his thinking had become slower than it used to be:

Since my brain is a bit slow, it’s really nice to have proper training. So I have a basic understanding and confidence in what I’m about to do. That I can manage this, that I’ve tried this before and it’s not completely new…And I also believe that it can boost motivation. Because you’ve tried this and know a bit about it and know what you’re facing (Stuart, 60s, Beginner).

One of the facilitation measures taken in this study was that the content of the goggles was very limited, which was highlighted by multiple participants. Martin explained that because there was only one working application on the goggles, many sources of possible errors were eliminated. He also said that he was glad that the game selected was predetermined and that it was downloaded and ready for use when he received the VR equipment. He elaborated that I don’t think I would have managed if I had to enter lots of stuff in advance and move forward on my own (Martin, 60s, Beginner). James expresses the same sentiment in this way:

Well, everything was planned, I mean, games had been selected. You can pick a song, but that’s the only choice you have. That has helped a lot, in my opinion. If I’d gone to the Play Store and found an app, it would take several days to find a game out of the blue, and it would take a very long time to find something you like (James, 30s, Beginner).

This shows that the participants addressed the importance of the VR equipment being easily accessible and adapted to their needs. Many participants experienced that the VR technology was quite user-friendly, and in some cases was self-explanatory, regardless of their prior technology knowledge. Helen expressed her experiences as follows:

I get annoyed with computers quite quickly. If it doesn’t tell me what I’m supposed to (do).) But I never experienced that here. In a way, I found the menu and everything very easy to navigate. To choose other levels or other songs. It was simple (Helen, 30s, Intermediate).

Challenges and solutions

Although all the participants found the VR equipment easy to use and very few challenges were noted, some issues arose during the intervention period. Harry expressed that he did not feel that it was granted that the equipment would work as it should at any given moment; however, when it did not, he said that there were informative notifications in the VR environment that guided him to do what was needed. Connor sometimes became frustrated during this period and needed assistance to figure out what the problem was.

Then I became a little annoyed because I didn’t get it. Then I actually had to see a YouTube video of how it was done. Because I think I tried 40 different things, and nothing worked (Connor, 50s, Experienced).

Other factors that were noted as challenging for the participants were to have enough space at home, connecting the VR headset to the Internet, and changing the batteries. Overall, the participants needed very little assistance during the intervention period, although some described having received help from their families. Moreover, sometimes the simplest solution is the best, as Martin said, the VR-goggles did freeze sometimes, but it was just a matter of turning it off and on again. So I didn’t find it complicated (Martin, 60s, Beginner).

Several participants expressed that they had unmet rehabilitation needs. Helen further elaborated on the issue of the lack of possibilities of cognitive rehabilitation in her municipality after being discharged from the hospital, which encouraged her to participate in this study. She experienced a great deal of focus on physical rehabilitation. However, the cognitive issues with which many struggle are often forgotten. She expressed this in the following way:

I think this (VR training) could be good for many people to do at home, including me. Norway is a wide stretched country and for many it is a long way to travel to hospitals. Especially in the north, it’s a long way to rehabilitation … Perhaps this is something that could easily be offered in rural areas (Helen, 30s, Intermediate).

Navigating through changes

The theme ‘Navigating through changes’ entails the participants’ descriptions of how the VR-training affected them, their experienced changes in functioning and reasons why they believe VR-training had an impact on them or not. Furthermore, the theme explored changes in their belief that they would be able to utilize VR and changes in their attitudes towards VR. The participants’ experiences are presented in three subthemes: ‘Experienced changes in functioning’, “Undesirable events, and ‘Changes in self-belief’.

Perceived changes in cognitive functioning

Almost all participants shared examples of how they felt that VR had an impact on their cognitive function, both with specific examples from everyday life and a more subtle sense of impact. Ronald was the only person who did not feel that VR positively affected him. He stated that he thought he knew what the project was trying to achieve but felt that his thought processing had not improved. However, he did say that There haven’t been any negative experiences that have slowed things down, and I don’t have any negative thoughts about being a part of this … Still, I say no (it has not affected me) (Ronald, 50s, Intermediate). Some of the participants felt that playing VR had a positive impact on them but felt that it was quite hard to pinpoint exactly what had improved. Helen stated that I do believe that it’s been good. VR has indeed been good. But I’m not quite sure what it is that has improved. But something has improved. I think (Helen, 30s, Intermediate). Lilly said that even though she was unsure, she felt more focused and noticed things a bit quicker than before. Harry had a similar experience when he said,

My wife says there is a difference. She has noticed some improvement … she says you used to struggle a bit with this. Now you can do it straight away. But I can’t remember exactly what it was (Harry, 60s, Beginner)

This statement indicates that perhaps the impact of VR training is not necessarily easy to notice for the participant, but may be easier to notice for the next of kin. On the other hand, some participants had concrete examples of how they experienced how playing VR had affected their everyday lives. Gordon explained that his work required him to handle many issues simultaneously. After the injury, this had become challenging for him, and he had to do one thing at a time. However, after starting to play VR, he had this experience.

I’ve become a little better at dealing with hectic situations… Normally, after the accident, if something happens, I deal with it, but if another thing suddenly comes up, and another thing on top of that, then I don’t know what to choose. But with this game I know what to choose and solve first, and then I go back to the other problem. I’ve become better at changing focus (Gordon, 40s, Experienced).

In this example, Gordon demonstrates how he relates the games’ many moving parts to his everyday activities and that he has a sense that the game might have had an impact on how he handles everyday challenges. Arthur had a comparable experience, in which he saw similarities between the game and one of his everyday activities. He is an athlete at a relatively high competitive level in a sport requiring reaction and he said:

In a way, I felt that playing (VR games) helped improve athletic performance. Maybe it was a bit of a placebo effect, but it felt like my reflexes improved. I was just into everything all the time, and when you have boxes flying fast at you, and you’re supposed to hit them, it’s the same feeling as having to react in my sport. It felt like I performed a little better during training when I played that game. It’s weird, but it’s cool (Arthur, 20s, Experienced).

Arthur shows in this account that he had an experience in which the game affected his performance in another activity than the game itself, and that this was something that surprised him. For him, the content of the game was relevant to his everyday activities, and he found this similarity positive.

Undesirable events

Lilly stated that the content of the game is both positive and negative. She experienced that the bright colors in the game affected her energy level. She stated that the colors made the contrasts hard on the eyes. The levels (in the game) where the blocks were red and black against a white background made me more tired, without really knowing why (Lilly, 40s, Experienced). She further explained that this did not affect her motivation to play the game, and that this was a mere observation.

Some participants did, however, mention some slightly more serious adverse events that they had encountered during the period when they used the VR goggles. There were recollections of smaller incidents, such as bumping toes on chairs or hitting closets. Lilly stated that, at one point, she hit her dog during gameplay. When telling this story, she laughed and said that the dog did not disturb her when she was playing anymore. Of the other adverse events, multiple participants reported strained eyes and blurred vision. They all stated that these events faded quickly and were not that serious, although a few stated that they wanted to lay down after playing. James described how VR in the beginning gave him a headache that he had not experienced previously.

In the beginning, I felt a kind of throbbing sensation in my head when I was done…like a pulse in my head…I’m pretty sure I was overstimulated. But if I went out for a walk afterwards, it disappeared quite quickly (James, 30s, Beginner).

Interestingly, even though he felt this way, James did not want to stop playing, and he further explained that he found ways to cope with it. Another participant, Lilly, had an episode of benign paroxysmal positional vertigo (BPPV). She had a history of BPPV since the injury but had been rid of it for some time when she started playing VR. However, she was somewhat uncertain of the impact of VR on BPPV and if it was to blame. She explained this as follows.

I’m not sure if I should blame the VR goggles, because you are more prone to getting BPPV after a head injury, especially when you’ve had it once before. But I think I’m very affected by stress… and I have to admit that I had played a lot of the difficult levels for some days before I got it (Lilly, 40s, Experienced).

Lilly did not want to put full blame on the VR equipment, but she did indicate that she felt it played a part in the return of BPPV. However, she did not cease her participation in the study, and after a couple of days of treatment, she completed the intervention period.

Changes in self-belief on technology

Participants had varying beliefs about their technological competency. This ranged from descriptions of having no issues with utilizing different types of technology whatsoever to Stuart describing himself as technologically illiterate. The participants also differed in their beliefs regarding whether they would be able to use the VR equipment at home. Helen stated that I figured I’d maybe get it right. But I didn’t really think about it (Helen, 30s, Intermediate), indicating that she almost took it for granted that she would master the technology. She further reflected on whether this attitude could be due to her young age and whether it might not have been as easy for someone who did not grow up using technology the way she did. Others, such as Martin, who stated that he did not consider himself as a ‘computer-guy’ had a preconception that he described as follows:

No, I didn’t think this would be my thing. I didn’t believe I could do this. I thought it was a difficult thing that I didn’t need. So I didn’t get my hopes up (Martin, 60s, Beginner).

This statement indicates that he had a difficult time picturing himself using VR and enjoying it. However, after starting to use the VR-equipment at home, he described a feeling of being positively surprised by his own abilities and that he had a sense of achievement. This is something I can do, he said, and further elaborated that this affected his interest in the intervention. Others have expressed similar experiences. Even though they experienced the games and technology as challenging in the beginning, they experienced a sense of achievement through repeated use. Lilly expressed that she monitored her progress through the game by comparing scores and seeing whether she had completed different levels within the game. She expressed that The last time I tried that level, I did worse, so now I’m a little better. I’ve become good at it (Lilly, 40s, Experienced), while Gordon stated that It was a bit complicated, but eventually I got the hang of that as well (Gordon, 40s, Experienced). Stuart described that he not only surprised himself when he managed to utilize VR, but he also surprised other people he talked to about participating in the study. He said that,

Most people are surprised that it’s possible to re-learn things… And that’s a bit like this game, you start (playing) and you start to get the hang of it and remember it from previous times, and it really triggers the brain (Stuart, 60s, Beginner).

In addition, he stated that he felt that the game forced him to think faster. He further elaborates that he thinks that using games is an interesting way of thinking about rehabilitation, and he states that he experiences that you use parts of the brain that needs to be used. Repetition and slowly increasing the level of difficulty is something I believe in (Stuart, 60s, Beginner). Others also stated that they had a feeling that they had used their brains and that after the thirty minutes felt that they had used their brains ‘the right way’. Helen reflected that although she had made good physical progress, her cognitive abilities had not been given the attention she needed in the rehabilitation process. In that chain of thought, she stated that So if VR can help me improve my brain, then yes, please (Helen, 30s, Intermediate).

Being in two worlds at the same time

The theme ‘Being in two worlds at the same time’ describes the participants’ experiences with the context of VR, experiences with participating in a virtual world and how this affected the participants’ motivation for using VR. The participants’ experiences are presented in three subthemes: ‘Participation in the virtual world’, ‘Being in the bubble’ and ‘Motivational factors’.

Participation in the virtual world

The participants had different perspectives on their role in the virtual world and reflected on who they were in a given scenario. Some described it as standing outside and looking in, whereas others felt that they were part of a different world. Ronald connected his experiences to the degree to which he felt immersed in the VR world and expressed that he was aware that this was a game and that he did not fully participate in another world.

In a way I don’t feel like one of the main characters in the game itself. I separate the fact that, okay, I’m standing outside, and then I participate with the movements I make. Somehow, I don’t feel like I have been in somebody’s room or been any kind of participant with those who have been in the game (Ronald, 50s, Intermediate).

He further elaborated that he felt as an active observer (Ronald, 50s, Intermediate). He also described not feeling like the main character of the game. However, other participants had other experiences with their role in the game, as both Stuart and Martin described having a feeling of being just that, and Martin went on to stating that he felt like a star in the game. Arthur expressed that he felt like he was himself in the game, but at the same time he was another person.

You can enter (the VR world) and become a different person… I felt as if I was in control, and I felt like it was me. You can live a slightly different life then, inside the goggles. You can do things you couldn’t do normally, right? So there’s a sense of freedom (Arthur, 20s, Experienced).

Being in the bubble

Several of the participants had experiences of being in another world, and many described a feeling of being in their own bubble. Gordon put it this way:

It was like a world of its own in those glasses. It became my world. It wasn’t home. Well, I was at home, but it was a different environment (Gordon, 40s, Experienced)

He further elaborated that the design of the environment played a role in this feeling. He said that it would not feel real if the environment did not match the activity in the game. Many of the participants were in awe of the design and stated that they were impressed by what was possible and how realistic the situation was. Lilly highlighted the sense of purpose in the game as a factor that affected her feelings of immersion:

You’re present and sense that you have a job to do, or at least a game … you see the effect of what you do with your arm. It felt like it was my arms that were moving those swords. Then you get a bit absorbed, and a bit drawn into it and then it feels like you’re actually there (Lilly, 40s, Experienced).

She explained that the movements required to play the game impacted how the she felt included in the virtual environment and sense of immersion. She further explained that she felt removed from the outside world. Arthur indicated that even though he knew at one level that what happened in the VR environment was not really happening in the real world, he felt that it still affected him, and that it somehow tricked his brain into thinking that it was real.

Things that happen in the game can’t affect you, even though it might seem that way sometimes. Sometimes you lose yourself a bit, and act like it actually affects you… your reflexes kick in automatically. So if something’s flying at me, I have to duck (Arthur, 20s, Experienced).

This statement indicates that the immersion of the activity in some situations outweighed the situational awareness of the participants. Arthur further stated that it was important for him that the game was fun and engaging for him to commit to the notion of being somewhere else. Stuart also felt that the sense of achievement was important for him to feel engaged in the activity but explained that the level of difficulty also influenced his sense of participation. He said that sometimes he felt like "I’m not skilled enough for this" and then I wasn’t as involved. I felt like I was beaten (Stuart, 60s, Beginner).

Motivational factors

Many participants highlighted the fact that different levels of difficulty influenced their motivation for playing the game. Connor explained it this way:

The different songs got increasingly difficult. And challenges are fun. If I’d only had to play at level one, it would have been dead boring. Anything you can do straight away is boring (Connor, 50s, Experienced).

Several participants elaborated that this made them want to play more to try to reach the next level or obtain a higher score. Harry expressed that he found it motivating to see the score increase and connected this with the fact that he was getting faster.

It’s easy to see the improvement when you see that you can increase your speed and still pay attention. Then you know that something has changed. Because that wasn’t the case at first. It’s way too fast. But it can increase little by little. And that’s motivating (Harry, 60s, Beginner)

Harry further stated that this is something that is difficult to see from day to day, but in the game, the improvements are more tangible due to the scores he achieved. Since the participants were to play the game each day over a 5-week period, some experienced variable motivation during the period. Stuart compared VR to other activities that he usually performs in everyday life.

That feeling that “today I have to play again”, will come. I think it’s something you will experience no matter what you do. The important thing is to just do it. It’s like going to the gym or going for a run. There were days I wasn’t that motivated to do it. The feeling usually lasted until I got going and then it was forgotten (Stuart, 60s, Beginner)

With this, Stuart described a somewhat fluctuating motivation. However, he also accentuated the importance of perseverance in training and that, even though he sometimes did not look forward to doing the training, he still did it. In addition, he expressed that when he started training, he found it engaging when he got going. Some did state that after a while the captivation and motivation did decrease, and Arthur explained that In the beginning it was new and exciting and sort of fun…but eventually you run out of songs…and last week it was more like ‘I’m just doing this to finish’ (Arthur, 20s, Experienced). Connor compared playing the game to reading a book and stated that,

If I’d played it for longer, it could have become quite boring, because it’s the same thing all the time. Take for instance reading books. If you read the same book over and over again, you eventually get bored of that book (Connor, 50s, Experienced).

Furthermore, some expressed that after a while, VR went from something they looked forward to doing, to being something they felt they had to do. However, this was not an experience that was shared by all. Some participants experienced a change in what motivated them. Helen describes it like this:

My motivation changed along the way. In the beginning it was motivating because it was fun and exciting. But gradually it became more motivating because I felt that it had an effect on me (Helen, 30s, Intermediate).

Other participants also described similar experiences, stating the importance of seeing the usefulness of the game in prolonging the motivation of playing VR. I see the value of it and if I do it, maybe I can master the things I did before that I don’t anymore (Gordon, 40s, Experienced).

Discussion

The aims of this study were to explore the experiences of persons with TBI in utilizing VR equipment for home-based rehabilitation and to increase our understanding of how they experience the use of VR as a cognitive training method. The participants demonstrated how they fit VR training into their everyday lives at home, with minimal adverse events. However, some experienced that the VR-training increased their fatigue. Some participants highlighted that tutoring in advance was key to enabling the use of the VR equipment. The participants reported some technical challenges to overcome during the intervention period, such as trouble with charging, motion controllers not connecting to the goggles or updating the software. They expressed that the ‘sense of being in another world’ or presence, positively affected their training motivation. Most participants felt that VR had affected their cognitive functioning, however most had difficulty pinpointing exactly what had improved. This study has shed light on how the participants were utilizing VR equipment in a home setting, how they used VR as a training method, how they tolerated the amount of effort and adverse events, and how they perceived self-efficacy.

Utilizing VR in a home setting

The participants described multiple approaches to fit VR into their everyday schedules and how they managed to utilize VR at home. They all created their own new routines to incorporate VR into their everyday lives. Individual tailoring of the intervention could play a role in facilitating the incorporation of VR into everyday life for some. The procedures in this study gave no direction on how or when during the day the training should be performed, leading most of the participants to utilize a learning-by-doing approach. There was no clear pattern in the time of day the participants found best to perform the VR training, and they had different explanations for their choices. Multiple participants highlighted the importance of routines in their everyday life due to cognitive impairments after brain injury and expressed a need to continue their own routines even though they were to add something new. This may imply that when implementing VR in rehabilitation for persons with TBI, there is a need for an individualized approach that takes into account that people need the structure and planning of everyday life. The need for individualization is in line with general guidelines for brain injury rehabilitation [3,38,39]. Implementation of VR could also be eased by education of both patients and therapists, as the participants highlighted the importance of therapy involvement in the process. This is in line with the recommendations on supporting implementation of VR [11]. Also, implementation of VR in rehabilitation might be performed both as training activity during hospital stays, but also as follow-up therapy after the patients are dismissed to their homes. One could also plan for VR-therapy being conducted at out-patient clinics in combination with other rehabilitation efforts.

Several participants stated that they had experienced unmet rehabilitation needs since they were discharged from the rehabilitation hospital, especially related to cognitive disabilities. They further reflected that VR could be a way of providing this type of rehabilitation at home since it was relatively easy to use. In this study, the participants were provided with VR-equipment during the intervention. If participants asked how they could continue their training after the study, they were informed about the costs and where they could buy the equipment. Even though the majority enjoyed the training, few bought VR after their participation in the project. One reason may be that VR is quite expensive to acquire for individuals. Financing of technology can thus be a factor that impacts implementation of VR in clinical practice. With the current shift in rehabilitation policies towards more community-based rehabilitation efforts [3], there is a need to have access to evidence-based cognitive rehabilitation interventions that users are able to utilize at home. The findings in this study provide evidence of feasibility and acceptability, but effect studies are needed to potentially confirm the effects of VR on cognition. The future results of the ongoing RCT that this study is part of will contribute to this [30].

Experiences with VR as a training method

The participants stated that their experiences with VR were mainly positive and that they found training to be both engaging and motivating. This finding is in line with previous studies on VR in the brain injury population [14,25]. Gamification factors such as immediate feedback, and clearly stated goals and rules, are incorporated in almost every commercial VR game, which can provide motivation and engagement over time [40]. The participants had the experience of being able to utilize VR at home, regardless of previous knowledge of VR. While previous research has shown that persons with TBI are able to utilize VR in a clinical setting [19], the results of this study might expand these findings to include the home setting. In addition, the participants expressed that the possibility of adjusting difficulty levels was important for their own sense of achievement, possibly reflecting a sense of flow in which the experienced challenges match an individual’s perceived skill [27]. A study investigating the sense of flow in graduate students playing BeatSaber found that matching the level of difficulty to the player’s ability led to a higher sense of flow and better performance; when the difficulty exceeded the perceived ability, the sense of flow decreased [28]. However, some participants in this study described a sense of boredom when they played the game at a too easy setting and over long periods of time, which may indicate that the initial excitement of using VR might fade with extended use. This might be seen in relation to Gustavsson and colleagues findings, where they highlighted the importance of therapist involvement in adjusting difficulty levels when playing VR over a longer period [14]. Playing at a level where demands meet the person’s ability is important to uphold the player’s sense of flow, especially as Lemmens and colleagues found that a stronger sense of flow led to better performance, more enjoyment, and higher psychological arousal [28].

Many participants described the feeling of being somewhere else while playing the VR game. This can be related to the ‘sense of presence as transportation’ , as described by Lombard and Ditton [23], meaning that the participants were transported to another place through the VR goggles and perceived the goggles as invisible. This sense of presence and being somewhere else may increase motivation and engagement with a given activity. Some even stated that the game provides a sense of purpose. Grassini and colleagues found that a high sense of presence is associated with increased skill learning and training performance in VR [41]. The ability of VR to situate players into realistic but virtual situations while being motivating and engaging is one of the reasons for optimism with regards to using VR as a method of cognitive training [8].

It is important to note that Beat Saber is a commercially developed game designed primarily for entertainment rather than rehabilitation. While its gamification elements, such as immediate feedback and adjustable difficulty levels, can be beneficial for rehabilitation purposes, it does not specifically target cognitive deficits commonly associated with TBI. On the other hand, VR games developed specifically for rehabilitation purposes often neglect the importance and significance of true gamification elements, leaving the games less motivating. Thus, rehabilitation games should involve users in their development [11]. Future research could explore whether VR applications specifically designed for cognitive rehabilitation provide greater benefits compared to commercial games.

Tolerated effort, adverse events and self-efficacy

The participants in this study had variable experiences with the 30 min duration of sessions in the intervention. Some stated that they could have played for longer periods of time, while others experienced the intervention as quite energy demanding. This is related to the burden construct described in the acceptability framework proposed by Sekhon and colleagues [15], that is, how the perceived amount of effort required to participate in the intervention is experienced. Moraes and colleagues highlighted that participants with moderate to severe TBI did not show any fatigue during the 20-minute VR-sessions [19], and Gustavsson and colleagues found that persons with stroke tolerated VR well [14]. The participants in Gustavsson and colleagues’ study performed 30 sessions over ten weeks, each lasting 30–45 min [14]. In the present study, the intervention period was 5 weeks, and the sessions were 30 min per day, totaling 25 sessions, with varying descriptions of the tolerability of the training volume. This suggests that individual differences should be considered when deciding the length of each session and that providing one recommendation that is suitable for all might not be feasible. However, there is a need to establish what intensity level of VR-training is needed for it to be effective.

Some participants reported minor adverse events, such as eyestrain, bumping into objects, and a need for rest, but two events were more severe. One participant had benign paroxysmal positional vertigo before the intervention period and had a relapse during the intervention, which was perceived as being related to using VR. Another participant described severe fatigue during the intervention period that affected his everyday life, suggesting that the duration of the intervention and/or the length of the training sessions might have exceeded their capacities. Fatigue is one of the most commonly reported symptoms after TBI, and in a study from 2021, almost half of the participants experienced fatigue that affected the person’s ability to perform everyday activities 6 months post injury [42]. Eyestrain and fatigue could be signs of cybersickness, and some participants reported having experienced these factors during the intervention period. Interestingly, none of our participants reported nausea or sustained dizziness, which is traditionally the most common and severe symptoms of cybersickness [18]. Moraes and colleagues observed a decrease in cybersickness over time, demonstrating a possible increase in tolerability with the prolonged use of VR. They also found that short breaks during the sessions were effective in reducing cybersickness [19]. In line with this, our participants also provided descriptions of having an experience of increasing their tolerability towards VR during the period of use. Other than the two significant adverse events reported in this sub-sample, only one severe adverse event was reported in the total VR-group. This event was related to dizziness and blurred vision leading to the participant dropping out. However, there were some minor events like the ones described in this study. Quantitative data on the development of cybersickness in the total population of our ongoing RCT will be published at a later stage.

Participants described some lack of confidence in their ability to use the VR-equipment before starting the intervention, indicating low self-efficacy related to VR. Regarding acceptability, Sekhon and colleagues described self-efficacy as participants’ confidence in their own ability to perform the intervention [15]. The participants described that when their understanding of the intervention increased, their self-efficacy increased. As described by Schwarzer and Luszczynska, self-efficacy facilitates goal setting, effort investment, and persistence in the face of barriers [21], which was reflected in our participants’ experiences of how they invested time and energy in performing the VR-training and overcoming challenges along the way.

Strengths and limitations

This study has some notable strengths. The analytical process was transparent and performed as described by Braun and Clarke [37]. Measures to ensure good quality of the reflexive thematic analysis were incorporated, such as audit trails and reflexive journaling. In addition, multiple analysis workshops in groups were conducted by researchers with different professional backgrounds [37].

However, this study does have some limitations. The first author’s role in delivering the VR intervention might contribute to partiality in the data, as this might have led to social desirability in the direction of providing overly positive responses. However, the interview data have been reviewed and analyzed back and forth by researchers with different backgrounds, and we have been striving to be transparent in describing the process. The authors were aware of this possible source of partiality in the data; hence, the interview guide was developed in a manner that would provide honest subjective responses and contribute to a deeper understanding of the use of VR as a tool for cognitive training.

The sampling methods utilized in this study resulted in inclusion of eight male and two female participants. This might lead to an imbalance in the data and potentially leave gender-specific differences unnoticed. However, since men are more prone to TBI than women, the sample is nearly representative of the TBI population as a whole [43]. The interviews were performed 11 weeks after the participants had ended their intervention period, which may have resulted in the participants not fully recollecting how the intervention was experienced. However, the collected data was rich, and some saturation was experienced towards the end.

This study contributes towards filling a knowledge gap as it qualitatively explores whether persons with TBI can utilize VR-equipment in a home setting and thus creates a better understanding of how using VR as a method of cognitive training is experienced. The results of this study are based on experiences from persons that have received tutoring in the use of VR, and the equipment and game have been adapted to ease their use. In addition, part of the inclusion criteria for the RCT was that participants were able to physically use the VR equipment and understand verbal instructions. With this in mind, the experiences in this study might not be representative of the general TBI population. Furthermore, this study provides a deeper understanding of the tolerability of VR in the TBI population. This knowledge is important for future guidelines and recommendations regarding the use of VR in cognitive rehabilitation.

Conclusions

The study findings indicate that the participants, in general, found VR motivating, engaging, and easy to use. Most participants found 30 min per day to be adequate and tolerable. However, several participants stated that five weeks of intervention was too long. Thus, efforts towards establishing recommendations for intervention duration should be the focus of future studies. It is important to note that participant experience should not be the sole determinant of intervention duration, and effect analyses from RCTs will be essential.

This study also showed that participants were able to utilize VR as a method of training at home with minimal tutoring. We acknowledge that not all individuals with TBI might be able to utilize VR without therapist involvement. However, participants’ previous technological competencies did not seem to be of importance in this study. In addition, some participants described changes in their everyday life that they attributed to the use of VR. There were minimal adverse events; however, this is a small sample and this subject need further exploration in larger samples. Furthermore, the participants described a need for individualization of the intervention, and there were no clear patterns in when during the day the participants found VR best to use.

Some participants expressed a need for rehabilitation of cognitive functions after their post-acute rehabilitation and said that if VR was proven effective, they would use it at home. Therefore, further research should focus on whether the use of VR in a home setting could be used by persons with TBI to fill an unmet rehabilitation need.

Funding Statement

The project is funded by The DAM foundation, project number 2022/FO387039.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that supports the findings of this study is not available as it is regulated by Norwegian laws regarding data protection and research ethics, and distribution of data is prohibited.