Danielle Levac

BACKGROUND Extended reality (XR) technologies have shown promising results in pediatric rehabilitation and are increasingly perceived as engaging and motivating tools for children and youth. Despite increasing evidence supporting their clinical potential, the integration of XR into routine pediatric rehabilitation practice remains limited. OBJECTIVE This action research study aimed to examine the implementation process of XR technologies in two pediatric rehabilitation centers, involving rehabilitation professionals and decision-makers. Specific objectives were to i) identify multilevel implementation determinants using the Consolidated Framework for Implementation Research (CFIR); and ii) examine which implementation strategies were selected, adapted, and applied in the two different contexts and why they were selected. METHODS The study used a qualitative multiple-case study design with two pediatric rehabilitation centers conceptualized as distinct cases (A and B). It was conducted as an action research based implementation study involving both rehabilitation professionals, such as physiotherapists and occupational therapists, and decision-makers in a collaborative process. The implementation process was carried out over five phases adapted from the Knowledge-to-Action framework. The Technotheque model was chosen due to its clinical relevance. Data were collected during the process through focus groups and interviews. A deductive content analysis guided by the CFIR was conducted to identify multilevel implementation determinants across cases. RESULTS Across both cases, XR was perceived as an engaging and adaptable rehabilitation tool that supported children’s motivation and participation. However, important contextual differences emerged regarding implementation determinants and support needs. The main difference between cases concerned access to knowledge and training. In Case A, XR technologies were perceived as more complex, and rehabilitation professionals reported lower self-efficacy. In contrast, rehabilitation professionals in Case B perceived XR as easier to integrate into practice. In both cases, rehabilitation professionals expressed concerns about screen exposure and anticipated family acceptability, while emphasizing the importance of XR technologies that are engaging, affordable, and accessible for use at home. Differences were also observed between rehabilitation professionals and decision-makers regarding training adequacy and facilitation needs. These determinants informed the selection, intensity (frequency of support), and operationalization of multilevel implementation strategies across cases. Although both cases received educational materials and workshops, Case A focused on in-person facilitation, clinician champions, and structured opportunities for XR testing, whereas Case B relied more on existing peer-support mechanisms and autonomous learning. Organizational adaptations improved access to XR devices within each center. CONCLUSIONS XR implementation in pediatric rehabilitation is a dynamic, context-dependent process that requires tailored multilevel implementation strategies. Although similar implementation determinants were identified across sites, the intensity and operationalization of implementation strategies differed according to local needs, perceptions, and organizational realities. Access to knowledge, clinical decision-making support, organizational integration, and collaboration between rehabilitation professionals and decision-makers emerged as key implementation considerations. CLINICALTRIAL This study was registered at ClinicalTrial.gov under the identifier NCT06627049.

Aim: To explore children's and young people's experiences with extended reality (XR) in rehabilitation, their perceptions of its benefits and challenges, and their visions for its future integration. Method: A qualitative, interpretive, descriptive study was conducted using semi‐structured interviews and focus groups with children and young people who had used XR in rehabilitation. Thematic analysis using an inductive approach was conducted by an interdisciplinary team (including a research partner). Results: Twenty‐eight participants aged 6 to 20 years (mean = 12 years [SD 3 years 8 months]) were included. The five themes were: (1) If we play it at home, let's use it in rehab! Participants perceived XR as a familiar tool, naturally extendable to clinical settings; (2) Gaming for engagement. Participants described XR games as fun and motivating, increasing adherence; (3) Gaming for gains, that is, XR's therapeutic value. Participants described it as an effective tool that can support different rehabilitation goals; (4) Power to play: how XR can empower us. XR fostered a sense of empowerment; (5) Beyond play: challenges. Challenges were identified, including adverse events and redefining the therapist's role. Interpretation: Participants perceived XR for rehabilitation as both logical and necessary. Future rehabilitation models should integrate children's and young people's perspectives and prioritize engaging, inclusive usability across clinical and home settings.

BACKGROUND To address barriers to interactive technology adoption in pediatric rehabilitation (access, space, support, knowledge), we developed the Technotheque: a dedicated clinical space equipped with 10+ interactive technologies (XR as an umbrella term), over 150 games, and trained knowledge brokers to support clinical XR use. OBJECTIVE This study evaluated the Technotheque’s feasibility over a 4-month period and identified factors influencing feasibility at our pediatric rehabilitation centre. METHODS Convergent mixed-methods design. Feasibility was assessed using 3 criteria (Bowen et al., 2009): demand, acceptability and implementation. Participation was open to all clinicians at our centre; Technotheque use objectives and frequency were self-determined. Measures included descriptive use patterns, self-reported satisfaction, pre-post Assessing Determinants of Prospective Take-up of Virtual Reality (version 2; ADOPT-VR2) scores, and semi-structured individual interviews. Quantitative analyses included descriptive and exploratory inferential statistics, while qualitative analyses followed a deductive thematic approach guided by the 3 feasibility criteria. Results were integrated using a mixed methods expansion approach, with qualitative findings contextualizing quantitative results. RESULTS Demand: One hundred and forty sessions were conducted over the 4-month period: 120 (86.0%) were therapy sessions (involving a client) and 20 (14.0%) were education sessions. Twenty-four clinicians used the Technotheque for therapy a median of 2 times (range: 0-22) with 34 clients of diverse ages, diagnoses and mobility levels; adolescents were most represented age group (75/120, 62.5%). Clinicians working with in-patient clienteles were the most frequent users. Acceptability: Clinicians reported high satisfaction with the extent to which Technotheque sessions met clinical objectives (median = 6/7, ‘Very satisfied’). Implementation: Overall, 25.2% of the 135 eligible clinicians participated in the study. Most therapy sessions required assistance from a knowledge broker (93/120, 77.5%). Independent use was strongly correlated with a higher number of sessions per clinician (rho = 0.657, P=.001). A significant pre-post improvement was observed for the ADOPT-VR2 Client Influence construct (Z = -2.294, P=.022); no change was observed for the other two constructs. Mixed methods integration showed that Technotheque use was driven by caseload relevance, with clinicians considering factors beyond diagnosis or functional abilities – such as therapy dosage, cognitive abilities, demographic characteristics or therapeutic alliance – when determining client suitability. Knowledge brokering was essential for aligning XR use with clinical needs and was a key contributor to clinician satisfaction. While the variety of XR systems supported diverse clinical needs, it also limited clinicians’ ability to achieve independent use within the study period. CONCLUSIONS The Technotheque appears to be a feasible model to support XR adoption in our pediatric rehabilitation centre. Results provide real-world insights into XR implementation, including facilitators and barriers that are generalizable to other sites. Findings inform ongoing refinements to the Technotheque model at our site and will guide future integration and evaluation efforts in other clinical settings with varying resources and needs. INTERNATIONAL REGISTERED REPORT RR2-10.1101/2025.04.15.25325879

Purpose: This descriptive qualitative study explored stakeholders’ perspectives on precision rehabilitation concepts, barriers, facilitators, and future directions as part of a convergent mixed methods scoping review. Materials and methods: Sixteen clinicians, administrators, and researchers from three North American tertiary care rehabilitation centers were recruited using convenience and snowball sampling to participate in individual semi-structured interviews. Conventional qualitative content analysis followed a deductive thematic approach based on predetermined categories. Results: Analyses revealed three main themes: 1) Although precision rehabilitation shares foundational concepts with precision medicine, there are certain elements, such as personalization, that are uniquely expressed; 2) Rehabilitation-specific facilitators to precision approaches include the use of unobtrusive technology to collect large amounts of data in real-world contexts, while barriers include rehabilitation’s typically small, heterogeneous sample sizes; and 3) The future of precision rehabilitation will require collaborative data-sharing to focus on determining care trajectories that enhance functional outcomes. Conclusion: Findings provide the first qualitative synthesis of stakeholder perspectives to complement quantitative evidence and inform the emerging field of precision rehabilitation.

Background Virtual reality (VR) and active video game (AVG) systems that offer repetitive practice and multimodal feedback in engaging environments are attractive pediatric rehabilitation intervention options. Evidence supports their effectiveness to improve functional outcomes in multiple pediatric populations. However, VR/AVG integration into clinical practice faces multiple barriers, including limited access to these often-expensive technologies, a rapid development sector resulting in frequent obsolescence, and insufficient educational resources to help clinicians select appropriate games that match children’s therapeutic objectives. Knowledge translation initiatives that primarily target clinician knowledge and attitudes about VR/AVG use have shown limited success in facilitating adoption. To address these challenges, we used the Consolidated Framework of Implementation Research (CFIR) to structure development of the Technotheque, a multi-faceted VR/AVG support initiative at our large pediatric rehabilitation centre. The Technotheque addresses both access- and knowledge-based barriers to VR/AVG use via a dedicated gameplay space staffed by knowledge brokers who directly support clinicians in VR/AVG implementation in therapy sessions and provide education towards independent VR/AVG use. Objective To evaluate the feasibility of the Technotheque as a knowledge translation initiative to enhance VR/AVG use at our pediatric rehabilitation centre, as measured by demand, acceptability, adaptation, and implementation criteria. Methods Convergent mixed-methods design. We will use convenience and snowball sampling strategies to recruit clinicians (physiotherapists, occupational therapists, speech therapists, special educators, and neuropsychologists) to participate in this 4-month study. Following informed consent, participants will complete a modified ‘Assessing the Determinants of Prospective Take-up of Virtual Reality’ (ADOPT-VR2) instrument. Participants can then request individualized training and/or clinical implementation support with our knowledge brokers at a self-determined frequency and duration, and with their choice of clientele. Participants will be free to begin and end their study participation at any point during the four months. Data collection will include study-specific Technotheque pre-session objective and post-session feedback forms, a post-study ADOPT-VR reassessment, a CFIR-based satisfaction questionnaire, and individual semi-structured interviews. Quantitative analyses will examine demand (participant demographics, usage patterns, correlations between usage and ADOPT-VR2 scores), acceptability (satisfaction scores in relation to usage patterns and ADOPT-VR2 changes), adaptation (variety of professions, client populations, and clinical objectives), and implementation (pre-post ADOPT-VR2 changes and patterns of support needs over time). Qualitative data will be deductively analysed using the four feasibility criteria as a coding framework. Quantitative and qualitative results will be integrated to identify areas of alignment and/or divergence. Results Research Ethics Board approval has been obtained. Conclusions The Technotheque initiative is designed to address both access and knowledge barriers to VR/AVG use in pediatric rehabilitation. Study results will inform subsequent research efforts to evaluate the effectiveness of VR/AVG as a rehabilitation intervention and to examine the impact of this initiative on sustained VR/AVG use.

Background: Physical activity supports the health and well-being of individuals with physical disabilities. Despite the significance of engaging in physical activity, barriers faced by individuals with disabilities, such as limited access to adapted facilities and lack of transportation, can restrict their participation. Community organizations play a role in addressing these challenges, but virtual reality (VR) also offers a way to diversify adapted activities. In some situations, VR can help overcome the resource limitations of organizations by providing accessible, engaging, and highly personalized options for physical activity. Objective: The aim of this study was to explore the needs and expectations of individuals with physical disabilities and their interventionists for the use of a VR physical activity platform in a community organization. Methods: A descriptive qualitative study was conducted using semistructured interviews with individuals with physical disabilities and their interventionists, all associated with a nonprofit organization promoting physical activity among people with disabilities. Data were analyzed using an inductive thematic approach. Results: In total, 15 participants, including 8 people with physical disabilities and 7 interventionists, were interviewed. Through this discussion, we gained insights into the everyday challenges faced by individuals with disabilities and identified priorities for community organizations. Subsequently, we discussed key considerations for using VR, including adapting activities, the possibility of fostering a more positive perception of physical activity, and harnessing the potential of VR to improve access to physical activity. We also discussed the importance of supporting personal goals and creating inclusive experiences while recognizing challenges such as technical difficulties and connectivity issues. Conclusions: By exploring the needs and expectations regarding VR technology from individuals with physical disabilities and their interventionists, this study provided essential insights for integrating immersive and nonimmersive VR into community organizations, informing next steps for the design of adapted physical activities in VR.

Background: Motor learning, a primary goal of pediatric rehabilitation, is facilitated when tasks are presented at a “just-right” challenge level—at the edge of the child’s current abilities, yet attainable enough to motivate the child in persistent efforts for success. Immersive virtual reality (VR) may be ideally suited for “just-right” task challenges because it enables precise adjustments of task parameters in motivating environments. Rehabilitation-specific VR tasks often use dynamic difficulty algorithms based on task performance to personalize task difficulty. However, these approaches do not consider relevant cognitive processes that could also impact “just-right” challenges, such as attention and engagement. Objective physiological measurement of these cognitive processes using wearable sensors could support their integration within “just-right” challenge detection and prediction algorithms. As a first step, it is important to explore relationships between objectively and subjectively measured psychophysiological states at progressively challenging task difficulty levels. Objective: This study aims to (1) evaluate the performance of wearable sensors in a novel movement-based motor learning immersive VR task; (2) evaluate changes in physiological data at 3 task difficulty levels; and (3) explore the relationship between physiological data, task performance, and self-reported cognitive processes at each task difficulty level. Methods: This study uses the within-participant experimental design. Typically developing children and youth aged 8-16 years will be recruited to take part in a single 90-minute data collection session. Physiological sensors include electrodermal activity, heart rate, electroencephalography, and eye-tracking. After collecting physiological data at rest, participants will play a seated unimanual immersive VR task involving bouncing a virtual ball on a virtual racket. They will first play for 3 minutes at a predefined medium level of difficulty to determine their baseline ability level and then at a personalized choice of 3 progressive difficulty levels of 3 minutes each. Following each 3-minute session, participants will complete a short Likert-scale questionnaire evaluating engagement, attention, cognitive workload, physical effort, self-efficacy, and motivation. Data loss and data quality will be calculated for each sensor. Repeated-measures ANOVAs will evaluate changes in physiological response at each difficulty level. Correlation analyses will determine individual relationships between task performance, physiological data, and self-reported data at each difficulty level. Results: Research ethics board approval has been obtained, and data collection is underway. Data collection was conducted on December 12, 2023, and April 12, 2024, with a total of 15 typically developing children. Data analysis has been completed, and results are expected to be published in the fall of 2024. Conclusions: Wearable sensors may provide insights into the physiological effects of immersive VR task interaction at progressive difficulty levels in children and youth. Understanding the relationship between physiological and self-reported cognitive processes is a first step in better identifying and predicting “just-right” task challenges during immersive VR motor learning interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/55730

BACKGROUND Motor learning, a primary goal of pediatric rehabilitation, is facilitated when tasks are presented at a “just-right” challenge level—at the edge of the child’s current abilities, yet attainable enough to motivate the child in persistent efforts for success. Immersive virtual reality (VR) may be ideally suited for “just-right” task challenges because it enables precise adjustments of task parameters in motivating environments. Rehabilitation-specific VR tasks often use dynamic difficulty algorithms based on task performance to personalize task difficulty. However, these approaches do not consider relevant cognitive processes that could also impact “just-right” challenges, such as attention and engagement. Objective physiological measurement of these cognitive processes using wearable sensors could support their integration within “just-right” challenge detection and prediction algorithms. As a first step, it is important to explore relationships between objectively and subjectively measured psychophysiological states at progressively challenging task difficulty levels. OBJECTIVE This study aims to (1) evaluate the performance of wearable sensors in a novel movement-based motor learning immersive VR task; (2) evaluate changes in physiological data at 3 task difficulty levels; and (3) explore the relationship between physiological data, task performance, and self-reported cognitive processes at each task difficulty level. METHODS This study uses the within-participant experimental design. Typically developing children and youth aged 8-16 years will be recruited to take part in a single 90-minute data collection session. Physiological sensors include electrodermal activity, heart rate, electroencephalography, and eye-tracking. After collecting physiological data at rest, participants will play a seated unimanual immersive VR task involving bouncing a virtual ball on a virtual racket. They will first play for 3 minutes at a predefined medium level of difficulty to determine their baseline ability level and then at a personalized choice of 3 progressive difficulty levels of 3 minutes each. Following each 3-minute session, participants will complete a short Likert-scale questionnaire evaluating engagement, attention, cognitive workload, physical effort, self-efficacy, and motivation. Data loss and data quality will be calculated for each sensor. Repeated-measures ANOVAs will evaluate changes in physiological response at each difficulty level. Correlation analyses will determine individual relationships between task performance, physiological data, and self-reported data at each difficulty level. RESULTS Research ethics board approval has been obtained, and data collection is underway. Data collection was conducted on December 12, 2023, and April 12, 2024, with a total of 15 typically developing children. Data analysis has been completed, and results are expected to be published in the fall of 2024. CONCLUSIONS Wearable sensors may provide insights into the physiological effects of immersive VR task interaction at progressive difficulty levels in children and youth. Understanding the relationship between physiological and self-reported cognitive processes is a first step in better identifying and predicting “just-right” task challenges during immersive VR motor learning interventions. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/55730