Christopher Barr

Background: Vestibular disorders affect approximately 34% of adults over the age of 50. Vestibular rehabilitation (VR) is ideally provided by trained clinicians; however, access can be limited, particularly in rural and remote areas. Telehealth technologies offer alternative means of accessing healthcare. This scoping review aims to map use of telehealth technology in VR. Methods: A systematic search of five databases (CINAHL, Scopus, ProQuest, PubMed and Cochrane) was conducted to identify relevant qualitative and quantitative studies from 2010 to 2025. The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Data were analysed and reported using a convergent segregated approach, in line with the Joanna Briggs Institute's methodological guidance for the conduct of mixed methods systematic reviews. Results: Forty-three articles were included. Telehealth modalities included smartphone applications ( n = 18), telephone calls ( n = 3), videoconferencing ( n = 5), web applications ( n = 14), and store-and-forward video technologies ( n = 3). Telehealth technology was found to be accurate in recording oculomotor assessments and nystagmus, delivering canalith repositioning manoeuvres and undertaking outcome assessments. Improvements in health outcomes were demonstrated for subjective dizziness, balance, and oculomotor tests. Users reported telehealth technology to be feasible for remote VR with benefits including increased self-confidence with exercises, improved symptom awareness, and enhanced engagement and motivation for exercises. Conclusions: Telehealth technologies for VR show potential for improved health outcomes, diagnostic accuracy and positive user experience across a range of vestibular disorders. However, evidence for some vestibular disorders and telehealth modalities is limited by small sample sizes and a lack of studies. Further high-quality research is required in these areas.

Understanding the factors that influence the return to physical activity can help to modify behaviour to enhance the recovery of symptoms and physical activity. We conducted 14 semi-structured interviews to explore the barriers and facilitators to returning to physical activity in adults following a mild traumatic brain injury (TBI). The study design was informed by the Theoretical Domains Framework and Capability, Opportunity and Motivation-Behaviour model. Ten key factors were identified in the analysis: four factors consistently acted as barriers (fatigue, sensory overload, symptoms, social expectations), four as facilitators (physical activity, assistive items, social support, health professional support), and two demonstrated a more complex, bidirectional influence (mental health, environment). These ten factors were organized to four overarching thematic groups: intrinsic factors, environmental and adaptive factors, social influences and symptom management. Adults with symptoms lasting greater than 10 days post-mild TBI report that a combination of symptoms, including fatigue and sensory overload prevent their ability to return to physical activity. The environment, social support structures, and access to health professional support facilitated individuals with returning to their physical activities. These findings should be considered when providing interventions to patients in clinical practice to enhance patients' recovery of symptoms and physical activity.

BACKGROUND: Recent research recommends physical exercise rather than rest following a mild traumatic brain injury (mTBI). OBJECTIVE: To determine the effect of physical exercise on persistent symptoms in people with mTBI. METHODS: A search of randomized controlled trials was conducted in CINAHL, Cochrane Library, EMBASE, MEDLINE, SportDiscus and Web of Science, from 2010 to January 2021. Studies were included if they described the effects of a physical exercise intervention in people with mTBI on persistent symptoms. Study quality, intervention reporting, and confidence in review findings were assessed with the CASP, TIDieR and GRADE respectively. RESULTS: 11 eligible studies were identified for inclusion. Study interventions broadly comprised of two categories of physical exercise, i.e., aerobic (n = 8) and vestibular (n = 3). A meta-analysis (n = 3) revealed the aerobic exercise group improvement was significantly larger compared to the usual care group –0.39 (95% CI: –0.73 to –0.05, p = 0.03). Only three studies using vestibular exercise reported on persistent symptoms and yielded mixed results. CONCLUSIONS: This study demonstrated that the use of aerobic exercise is supported by mixed quality evidence and moderate certainty of evidence, yet there is limited evidence for the use of vestibular exercise for improving persistent symptoms in people with mTBI.

To assess (1) step count accuracy of the Fitbit Zip, compared to manual step count, in people receiving outpatient rehabilitation, in indoor and outdoor conditions, and (2) impact of slow walking speed on Fitbit accuracy. Observational study. A metropolitan rehabilitation hospital. Adults (n = 88) attending a subacute rehabilitation outpatient clinic with walking speeds of between 0.4 and 1.0 m/s. Two 2-minute walk tests, one indoors and one outdoors, completed in random order. Step count recorded manually by observation and by a Fitbit Zip, attached to the shoe on the dominant or non-affected side. Subgroup analysis included assessment accuracy for those considered limited community walkers (slower than 0.8 m/s) and those considered community walkers (faster than 0.8 m/s). The Fitbit significantly (P < 0.05) undercounted steps compared to manual step count, indoors and outdoors, with percentage agreement slightly higher outdoors (mean 92.4%) than indoors (90.1%). Overall, there was excellent consistent agreement between the Fitbit and manual step count for both indoor (ICC 0.83) and outdoor (ICC 0.88) walks. The accuracy of the Fitbit was significantly (P < 0.05) reduced in those who walked slower than 0.8 m/s outdoors (ICC 0.80) compared to those who walk faster than 0.8 m/s (ICC 0.90). The Fitbit Zip shows high step count accuracy with manual step count in a mixed subacute rehabilitation population. However, accuracy is affected by walking speed, with decreased accuracy in limited community walkers.

Benefits of community participation and physical activity for the health and wellbeing of older adults are well documented. This review aims to answer the question; “How is community participation ...

Objective: Virtual reality (VR) technologies are increasingly used in physical rehabilitation; however, it is unclear how VR interventions are being delivered, and, in particular, the role of the therapist remains unknown. The purpose of this study was to systematically evaluate how commercially available VR technologies are being implemented in gait, posture, and balance rehabilitation, including justification, content, procedures, and dosage of the intervention and details of the therapist role. Methods: Five databases were searched between 2008 and 2018. Supervised interventional trials with >10 adult participants using commercially available VR technologies to address mobility limitations were independently selected by 2 authors. One author extracted reported intervention characteristics into a predesigned table and assessed methodological quality, which was independently verified by a second author. A total of 29 studies were included. Results: Generally, minimal clinical reasoning was provided to justify technology or activity selection, with recreational systems and games used most commonly (n = 25). All but 1 study used a single interventional technology. When explicitly described, the intervention was delivered by a physical therapist (n = 14), a therapist assistant (n = 2), both (n = 1), or an occupational therapist (n = 1). Most studies reported supervision (n = 12) and safeguarding (n = 8) as key therapist roles, with detail of therapist feedback less frequently reported (n = 4). Therapist involvement in program selection, tailoring, and progression was poorly described. Conclusion: Intervention protocols of VR rehabilitation studies are incompletely described and generally lack detail on clinical rationale for technology and activity selection and on the therapist role in intervention design and delivery, hindering replication and translation of research into clinical practice. Future studies utilizing commercially available VR technologies should report all aspects of intervention design and delivery and consider protocols that allow therapists to exercise clinical autonomy in intervention delivery. Impact Statement: The findings of this systematic review have highlighted that VR rehabilitation interventions targeting gait, posture, and balance are primarily delivered by physical therapists, whose most reported role was supervision and safeguarding. There was an absence of detail regarding complex clinical skills, such as tailoring of the intervention and reasoning for the choice of technology and activity. This uncertainty around the role of the therapist as an active ingredient in VR-based rehabilitation hinders the development of implementation guidelines. To inform the optimal involvement of therapists in VR rehabilitation, it is essential that future studies report on all aspects of VR intervention design and delivery.

Background: Cognitive function of older people is not routinely assessed in orthopedic rehabilitation, after elective and non-elective surgery. The aim of this study was to assess cognitive impairment and its impact on both length of stay and functional outcomes, of older people admitted to orthopedic rehabilitation. Methods: Retrospective audit, inclusion criteria: aged >65 years, orthopedic diagnosis, discharged from hospital. Results: 116 files were audited, mean age of 82.3 (SD = 7.5) years. Diagnostic groups: fractured neck of femur, (n = 44, 37.98%); elective surgery (n = 42, 36.21%); and other orthopedic conditions (n = 30, 25.86%). Overall 71.55% (n = 83) had cognitive impairment, with a median of mild cognitive impairment across all diagnoses. Both measures of cognition (MoCA/FIM Cognitive) were significantly associated with length of stay (p < 0.01), function (p < 0.05), and discharge destination (p = 0.01). Conclusions: A high percentage of older orthopedic patients in rehabilitation with both elective and non-elective diagnoses have cognitive impairment. Cognitive screening is recommended for all older orthopedic patients in rehabilitation, to inform an individualized rehabilitation plan to improve outcomes and length of stay. Further research is required to explore cognitive strategies to maximize rehabilitation outcomes in the geriatric orthopedic population.