# Design Recommendations for Virtual Reality–Based Upper Limb Exercises From People With Tetraplegia and Spinal Cord Injury Rehabilitation Specialists: Focus Group Study

## TL;DR

This study gathers insights from people with tetraplegia and SCI specialists to guide the design of VR-based upper limb rehabilitation tools.

## Contribution

The study provides design recommendations for VR-based upper limb rehabilitation co-developed with people with tetraplegia and SCI specialists.

## Key findings

- Five major themes were identified for acute SCI upper limb rehabilitation and VR intervention design.
- Participants highlighted motivations for therapy and suggested features for effective VR interventions.
- Potential pitfalls and software features to avoid were also identified.

## Abstract

The global incidence of spinal cord injury (SCI) is between 10 and 80 new cases per million people each year. This equates to between 250,000 and 500,000 injuries worldwide per year. In the United Kingdom, approximately 4400 people per year sustain an SCI. People with tetraplegia report upper limb function as their highest priority for improvement after SCI. Using immersive virtual reality (VR) headsets, physical rehabilitation exercises can be completed in engaging digital environments. Immersive VR therefore has the potential to increase the amount of therapy undertaken, leading to improvements in arm and hand function. There is little evidence supporting immersive VR as exercise in SCI, especially while patients with SCI are undergoing acute rehabilitation. In SCI research, co-design of new interventions is not a widely adopted approach, yet people with tetraplegia want to contribute with their expert knowledge on their experiences of SCI.

This study aims to explore the lived experiences of people with tetraplegia and specialist SCI therapists related to acute upper limb rehabilitation and identify design considerations for VR-based interventions targeting the upper limb.

We conducted 7 online focus groups using Microsoft Teams: 4 with people with tetraplegia (n=15; age range, 36-65 years) and 3 with occupational therapists and physiotherapists specializing in SCI rehabilitation (n=11). Participants were asked to discuss their experiences and expertise about acute SCI upper limb rehabilitation and their opinions and ideas on the use of VR for upper limb rehabilitation. The transcripts were analyzed using content analysis, enabling the proposition of design characteristics of a VR-based intervention for upper limb exercise.

The study identified 5 major themes describing the clinical features, treatment, and recovery of people with SCI during the acute stage of SCI, their motivations for participating in therapy, and suggestions for the design of a VR intervention in treating the upper limbs following SCI.

The themes identified in this study allow the elicitation of software requirements for a bespoke immersive VR platform for upper limb rehabilitation following SCI. They can also contribute to a better understanding of the advantages of using VR as an adjunct to upper limb rehabilitation. Additionally, participants used their expertise to suggest factors that would enable the development of a usable and effective intervention, as well as identifying potential pitfalls and software features to avoid during intervention development. These findings can be used to design accessible VR applications for use by people with tetraplegia and their therapists.