Implementing affordable technology to improve mobility and physical activity in an inpatient rehabilitation setting; a feasibility study.

This is a hybrid type II feasibility randomised control trial and therefore has two separate intervention components: 1) the implementation strategies delivered by the research team to physiotherapists to enable them to use the clinical intervention (digitally enabled rehabilitation) in practice; and 2) the clinical intervention (digitally enabled rehabilitation) delivered by physiotherapists to people undertaking inpatient aged care and neurological rehabilitation. Implementation strategies: The COM-B model of behaviour change has been used to design the implementation strategies to address the identified barriers to implementation identified from the AMOUNT trial and related qualitative work (access to devices, lack of training and support to use devices, IT problems). The COM-B intervention functions to be used include education, training, enablement, and environmental restructuring. A clinical champion who is a clinical physiotherapist at the site will be identified and trained by the Chief Investigator (Physiotherapist, Manager of parent AMOUNT trial (ACTRN12614000936628), who developed the original intervention protocol) and research physiotherapist (delivered intervention in parent AMOUNT trial (ACTRN12614000936628) in the use of digital devices and the intervention protocol. Digital devices will be loaned to the study site. The physiotherapy team will be provided with resources (e.g., intervention protocol) and face-to-face education and training through two workshops held approximately three months apart. The first workshop will be run for about 3 hours by the Chief Investigator and the research physiotherapist who conducted the phase 1 (ACTRN12614000936628) of this study at least 6 months before the trial is open for patient recruitment. The workshops will involve education on current evidence, hands-on practical sessions using different devices, case studies from the AMOUNT trial, and discussion and planning with the clinical team on how to embed the use of digital devices into practice to ensure quality and quantity of practice for patients randomised to the clinical intervention group. After the first workshop, the clinical physiotherapy team will be facilitated by the Clinical Champion to start using the devices (and intervention protocol) in clinical practice by regular clinical reasoning sessions. Audit and feedback of practice sheets will be used to provide feedback to clinical physiotherapists in the quality and quantity of digitally enabled rehabilitation delivered and their recording of usual practice dosage. The second workshop will be conducted 3 months from the first workshop by the research team including the Clinical Champion, which will run for about 3 hours. This workshop will overview progress to date, experiences of using devices, embedding devices into practice, recording dosage of practice and trial recruitment. Ongoing support will be provided by the Clinical Champion weekly to the clinicians as needed until the end of clinical intervention. New staff and students commencing on the rehabilitation ward after the initial workshops will have a one-hour lecture on use of digital devices (based on what was presented in Workshop 1) delivered by the Chief Investigator and one-on-one sessions with the Clinical Champion as part of their clinical practice to teach use of the different devices and clinically reason use of devices with their patients. A training log will be kept by the Clinical Champion to monitor staff training and delivery of implementation strategies. Clinical intervention (digitally enabled rehabilitation): Patients randomised to the clinical intervention group will receive tailored prescription of digital devices to improve mobility and increase physical activity in addition to the usual care in an inpatient rehabilitation unit of a public hospital. The additional devices will be prescribed by a clinical physiotherapist based on baseline assessment, participant goals and preferences, and the device (and games or exercises within that device) suitable to address their mobility limitations in accordance with the intervention protocol. The additional intervention devices will be provided between 30 and 60 minutes daily for five or more days per week. The total duration of the intervention will be for 3 weeks after randomisation. The prescription of digital devices to target mobility and physical activity problems may include, but will not be limited to recreational virtual reality systems (e.g. Nintendo Wii, Xbox Kinect), rehabilitation virtual reality systems (e.g. Humac, Fysiogaming, Lusio), exercise applications on tablets or smartphones (e.g. physiotherapyexercises) and activity monitors (e.g. StepWatch). Each device will 1) provide feedback about task performance; 2) enable individualised tailoring and progression of exercise or physical activity; 3) enables progress towards a functionally relevant goal(s); and 4) is relatively inexpensive. The clinical physiotherapist will teach participants to use the devices and will develop individualised exercise procedures to enable participants to use the technology safely to increase dose of practice. The exercises will be mostly functional exercises like sit-to-stand, stepping, walking etc. as well as individualised strengthening exercises like dorsiflexion, knee flexion in sitting etc. The types of exercises, devices used, and the repetition/duration of the exercises done by the participant using digital devices will be recorded in a digital devices practice sheet completed by clinical physiotherapist. Data on dosage of practice from devices that store this data (e.g., Fysiogaming) will be exported by the Clinical Champion and saved with the digital device practice sheets. If judged by staff to be safe to do so, participants will exercise unsupervised or with the supervision of family members/friends, nursing staff and hospital volunteers. The trial will also embed a qualitative sub-study in which the experiences and attitudes of physiotherapists delivering digitally-enabled rehabilitation to adults with decreased mobility will be explored. All physiotherapy clinicians with involvement in the delivery of the intervention will be invited to attend a focus group conducted by a researcher not directly involved in the trial intervention. Focus groups will be run during embedding the digital devices into practice before the trial begins and towards the end of the trial to capture data from all physiotherapists that take part in the trial due to staff changes (e.g., rotations, staff resignations) throughout the trial. The Normalization Process Theory, the Consolidated Framework for Implementation Research (CFIR) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) will guide the conduct and reporting of the qualitative part of the study.