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Virtual reality (VR) is increasingly being used for the assessment and treatment of impairments arising from acquired brain injuries (ABIs) due to perceived benefits over traditional methods. However, no tailored options exist for the design and implementation of VR for ABI rehabilitation and, more specifically, traumatic brain injury (TBI) rehabilitation. In addition, the evidence base lacks systematic reviews of immersive VR use for TBI rehabilitation. Recommendations for this population are important because of the many complex and diverse impairments that individuals can experience. This study aims to conduct a two-part systematic review to identify and synthesize existing recommendations for designing and implementing therapeutic VR for ABI rehabilitation, including TBI, and to identify current evidence for using immersive VR for TBI assessment and treatment and to map the degree to which this literature includes recommendations for VR design and implementation. This review was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive search of 11 databases and gray literature was conducted in August 2019 and repeated in June 2020. Studies were included if they met relevant search terms, were peer-reviewed, were written in English, and were published between 2009 and 2020. Studies were reviewed to determine the level of evidence and methodological quality. For the first part, qualitative data were synthesized and categorized via meta-synthesis. For the second part, findings were analyzed and synthesized descriptively owing to the heterogeneity of data extracted from the included studies. In the first part, a total of 14 papers met the inclusion criteria. Recommendations for VR design and implementation were not specific to TBI but rather to stroke or ABI rehabilitation more broadly. The synthesis and analysis of data resulted in three key phases and nine categories of recommendations for designing and implementing VR for ABI rehabilitation. In the second part, 5 studies met the inclusion criteria. A total of 2 studies reported on VR for assessment and three for treatment. Studies were varied in terms of therapeutic targets, VR tasks, and outcome measures. VR was used to assess or treat impairments in cognition, balance, and anxiety, with positive outcomes. However, the levels of evidence, methodological quality, and inclusion of recommendations for VR design and implementation were poor. There is limited research on the use of immersive VR for TBI rehabilitation. Few studies have been conducted, and there is limited inclusion of recommendations for therapeutic VR design and implementation. Future research in ABI rehabilitation should consider a stepwise approach to VR development, from early co-design studies with end users to larger controlled trials. A list of recommendations is offered to provide guidance and a more consistent model to advance clinical research in this area.

In 2020 and 2021, people increasingly used the internet to connect socially and professionally. However, people with an acquired brain injury (ABI) experience challenges in using social media, and rehabilitation professionals have reported feeling underprepared to support them in its use. To date, no review of social media skills training to inform ABI rehabilitation has been conducted. This scoping review aimed to examine research on interventions addressing social media skills and safety, with a focus on people living with health conditions; free web-based resources for the general public on social media skills training; and currently available online support groups for people with ABI. An integrative scoping review was conducted, with a systematic search strategy applied in March and November 2020 across OvidSP (MEDLINE, AMED, PsycINFO, and Embase), Scopus, Web of Science, CINAHL, Google Scholar, Google, and Facebook. The data collected were critically appraised and synthesized to describe the key content and features of social media training resources. This review identified 47 peer-reviewed academic articles, 48 social media training websites, and 120 online support groups for people with ABI. A key recommendation was interactive training with practical components addressing cybersafety, how to use platforms, and how to connect with others. However, no social media training resources that were relevant and accessible for people with ABI were identified. Training resources to support people with ABI in safely using social media are limited. The key content to be addressed and the features to be incorporated into web-based social media training were determined, including the need for interactive training that is co-designed and safe and incorporates practical components that support people with ABI. These findings can be used to inform the development of web-based evidence-based support for people with ABI who may be vulnerable when participating in social media.

Virtual reality (VR) use in brain injury rehabilitation is emerging. Recommendations for VR development in this field encourage end user engagement to determine the benefits and challenges of VR use; however, existing literature on this topic is limited. Data from social networking sites such as Twitter may further inform development and clinical practice related to the use of VR in brain injury rehabilitation. This study collected and analyzed VR-related tweets to (1) explore the VR tweeting community to determine topics of conversation and network connections, (2) understand user opinions and experiences of VR, and (3) identify tweets related to VR use in health care and brain injury rehabilitation. Publicly available tweets containing the hashtags #virtualreality and #VR were collected up to twice weekly during a 6-week period from July 2020 to August 2020 using NCapture (QSR International). The included tweets were analyzed using mixed methods. All tweets were coded using inductive content analysis. Relevant tweets (ie, coded as \"VR in health care\" or \"talking about VR\") were further analyzed using Dann's content coding. The biographies of users who sent relevant tweets were examined descriptively. Tweet data networks were visualized using Gephi computational analysis. A total of 260,715 tweets were collected, and 70,051 (26.87%) were analyzed following eligibility screening. The sample comprised 33.68% (23,596/70,051) original tweets and 66.32% (46,455/70,051) retweets. Content analysis generated 10 main categories of original tweets related to VR (ie, advertising and promotion, VR content, talking about VR, VR news, general technology, VR industry, VR live streams, VR in health care, VR events, and VR community). Approximately 4.48% (1056/23,596) of original tweets were related to VR use in health care, whereas 0.19% (45/23,596) referred to VR in brain injury rehabilitation. In total, 14.86% (3506/23,596) of original tweets featured commentary on user opinions and experiences of VR applications, equipment, and software. The VR tweeting community comprised a large network of 26,001 unique Twitter users. Users that posted tweets related to \"VR in health care\" (2124/26,001, 8.17%) did not form an interconnected VR network, whereas many users \"talking about VR\" (3752/26,001, 14.43%) were connected within a central network. This study provides valuable data on community-based experiences and opinions related to VR. Tweets showcased various VR applications, including in health care, and identified important user-based considerations that can be used to inform VR use in brain injury rehabilitation (eg, technical design, accessibility, and VR sickness). Limited discussions and small user networks related to VR in brain injury rehabilitation reflect the paucity of literature on this topic and the potential underuse of this technology. These findings emphasize that further research is required to understand the specific needs and perspectives of people with brain injuries and clinicians regarding VR use in rehabilitation.

People with acquired brain injury (ABI) experience communication breakdown in everyday interactions many years after injury, negatively impacting social and vocational relationships. Communication partner training (CPT) is a recommended intervention approach in communication rehabilitation after ABI. Access to long-term services is essential, both in rural and remote locations. Digital health has potential to overcome the challenges of travel and improve cost efficiencies, processes, and clinical outcomes. We aimed to collaboratively develop a novel, multimodal web-based CPT intervention (convers-ABI-lity) with key stakeholders and evaluate its feasibility for improving conversation skills after brain injury. This mixed methods study consisted of 3 key stages guided by the Integrate, Design, Assess, and Share (IDEAS) framework for developing effective digital health interventions. Stage 1 included the integration of current end-user needs and perspectives with key treatment and theoretical components of existing evidence-based interventions, TBI Express and TBIconneCT. Stage 2 included the iterative design of convers-ABI-lity with feedback from end-user interviews (n=22) analyzed using content analysis. Participants were individuals with ABI, family members, health professionals, and paid support workers. Stage 3 included the evaluation of the feasibility through a proof-of-concept study (n=3). A total of 3 dyads (a person with ABI and their communication partner [CP]) completed 7 weeks of convers-ABI-lity, guided by a clinician. The outcome measures included blinded ratings of conversation samples and self-report measures. We analyzed postintervention participant interviews using content analysis to inform further intervention refinement and development. Collaborative and iterative design and development during stages 1 and 2 resulted in the development of convers-ABI-lity. Results in stage 3 indicated positive changes in the blinded ratings of conversation samples for the participants with traumatic brain injury and their CPs. Statistically reliable positive changes were also observed in the self-report measures of social communication skills and quality of life. Intervention participants endorsed aspects of convers-ABI-lity, such as its complementary nature, self-guided web-based modules, clinician sessions, engaging content, and novel features. They reported the intervention to be relevant to their personal experience with cognitive-communication disorders. This study presents the outcome of using the IDEAS framework to guide the development of a web-based multimodal CPT intervention with input from key stakeholders. The results indicate promising outcomes for improving the conversation skills of people with ABI and their CPs. Further evaluation of intervention effectiveness and efficacy using a larger sample size is required.

More than 135 million people worldwide live with acquired brain injury (ABI) and its many psychosocial sequelae. This growing global burden necessitates scalable rehabilitation services. Despite demonstrated potential to increase the accessibility and scalability of psychosocial supports, digital health interventions are challenging to implement and sustain. The Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework can offer developers and researchers a comprehensive overview of considerations to implement, scale, and sustain digital health interventions. This systematic review identified published, peer-reviewed primary evidence of implementation outcomes, strategies, and factors for web-based psychosocial interventions targeting either adults with ABI or their formal or informal caregivers; evaluated and summarized this evidence; synthesized qualitative and quantitative implementation data according to the NASSS framework; and provided recommendations for future implementation. Results were compared with 3 hypotheses which state that complexity (dynamic, unpredictable, and poorly characterized factors) in most or all NASSS domains increases likelihood of implementation failure; success is achievable, but difficult with many complicated domains (containing multiple interacting factors); and simplicity (straightforward, predictable, and few factors) in most or all domains increases the likelihood of success. From a comprehensive search of MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, speechBITE, and neuroBITE, we reviewed primary implementation evidence from January 2008 to June 2020. For web-based psychosocial interventions delivered via standard desktop computer, mobile phone, tablet, television, and virtual reality devices to adults with ABI or their formal or informal caregivers, we extracted intervention characteristics, stakeholder involvement, implementation scope and outcomes, study design and quality, and implementation data. Implementation data were both narratively synthesized and descriptively quantified across all 7 domains (condition, technology, value proposition, adopters, organization, wider system, and their interaction over time) and all subdomains of the NASSS framework. Study quality and risk of bias were assessed using the 2018 Mixed Methods Appraisal Tool. We identified 60 peer-reviewed studies from 12 countries, including 5723 adults with ABI, 1920 carers, and 50 health care staff. The findings aligned with all 3 hypotheses. Although studies were of low methodological quality and insufficient number to statistically test relationships, the results appeared consistent with recommendations to reduce complexity as much as possible to facilitate implementation. Although studies excluded individuals with a range of comorbidities and sociocultural challenges, such simplification of NASSS domain 1 may have been necessary to advance intervention value propositions (domain 3). However, to create equitable digital health solutions that can be successfully implemented in real-world settings, it is recommended that developers involve people with ABI, their close others, and health care staff in addressing complexities in domains 2 to 7 from the earliest intervention design stages. PROSPERO International Prospective Register of Systematic Reviews CRD42020186387; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020186387. RR2-10.1177/20552076211035988.

Digitally enabled rehabilitation may lead to better outcomes but has not been tested in large pragmatic trials. We aimed to evaluate a tailored prescription of affordable digital devices in addition to usual care for people with mobility limitations admitted to aged care and neurological rehabilitation. We conducted a pragmatic, outcome-assessor-blinded, parallel-group randomised trial in 3 Australian hospitals in Sydney and Adelaide recruiting adults 18 to 101 years old with mobility limitations undertaking aged care and neurological inpatient rehabilitation. Both the intervention and control groups received usual multidisciplinary inpatient and post-hospital rehabilitation care as determined by the treating rehabilitation clinicians. In addition to usual care, the intervention group used devices to target mobility and physical activity problems, individually prescribed by a physiotherapist according to an intervention protocol, including virtual reality video games, activity monitors, and handheld computer devices for 6 months in hospital and at home. Co-primary outcomes were mobility (performance-based Short Physical Performance Battery [SPPB]; continuous version; range 0 to 3; higher score indicates better mobility) and upright time as a proxy measure of physical activity (proportion of the day upright measured with activPAL) at 6 months. The dataset was analysed using intention-to-treat principles. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000936628). Between 22 September 2014 and 10 November 2016, 300 patients (mean age 74 years, SD 14; 50% female; 54% neurological condition causing activity limitation) were randomly assigned to intervention (n = 149) or control (n = 151) using a secure online database (REDCap) to achieve allocation concealment. Six-month assessments were completed by 258 participants (129 intervention, 129 control). Intervention participants received on average 12 (SD 11) supervised inpatient sessions using 4 (SD 1) different devices and 15 (SD 5) physiotherapy contacts supporting device use after hospital discharge. Changes in mobility scores were higher in the intervention group compared to the control group from baseline (SPPB [continuous, 0-3] mean [SD]: intervention group, 1.5 [0.7]; control group, 1.5 [0.8]) to 6 months (SPPB [continuous, 0-3] mean [SD]: intervention group, 2.3 [0.6]; control group, 2.1 [0.8]; mean between-group difference 0.2 points, 95% CI 0.1 to 0.3; p = 0.006). However, there was no evidence of a difference between groups for upright time at 6 months (mean [SD] proportion of the day spent upright at 6 months: intervention group, 18.2 [9.8]; control group, 18.4 [10.2]; mean between-group difference -0.2, 95% CI -2.7 to 2.3; p = 0.87). Scores were higher in the intervention group compared to the control group across most secondary mobility outcomes, but there was no evidence of a difference between groups for most other secondary outcomes including self-reported balance confidence and quality of life. No adverse events were reported in the intervention group. Thirteen participants died while in the trial (intervention group: 9; control group: 4) due to unrelated causes, and there was no evidence of a difference between groups in fall rates (unadjusted incidence rate ratio 1.19, 95% CI 0.78 to 1.83; p = 0.43). Study limitations include 15%-19% loss to follow-up at 6 months on the co-primary outcomes, as anticipated; the number of secondary outcome measures in our trial, which may increase the risk of a type I error; and potential low statistical power to demonstrate significant between-group differences on important secondary patient-reported outcomes. In this study, we observed improved mobility in people with a wide range of health conditions making use of digitally enabled rehabilitation, whereas time spent upright was not impacted. The trial was prospectively registered with the Australian New Zealand Clinical Trials Register; ACTRN12614000936628.

Acquired brain injuries (ABIs), such as stroke and traumatic brain injury, commonly cause cognitive-communication disorders, in which underlying cognitive difficulties also impair communication. As communication is an exchange with others, close others such as family and friends also experience the impact of cognitive-communication impairment. It is therefore an internationally recommended best practice for speech-language pathologists to provide communication support to both people with ABI and the people who communicate with them. Current research also identifies a need for neurorehabilitation professionals to support digital communication, such as social media use, after ABI. However, with >135 million people worldwide affected by ABI, alternate and supplementary service delivery models are needed to meet these communication needs. The \"Social Brain Toolkit\" is a novel suite of 3 interventions to deliver communication rehabilitation via the internet. However, digital health implementation is complex, and minimal guidance exists for ABI. This study aimed to support the implementation of the Social Brain Toolkit by coproducing implementation knowledge with people with ABI, people who communicate with people with ABI, clinicians, and leaders in digital health implementation. A maximum variation sample (N=35) of individuals with living experience of ABI, close others, clinicians, and digital health implementation leaders participated in an explanatory sequential mixed methods design. Stakeholders quantitatively prioritized 4 of the 7 theoretical domains of the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework as being the most important for Social Brain Toolkit implementation. Qualitative interview and focus group data collection focused on these 4 domains. Data were deductively analyzed against the NASSS framework with stakeholder coauthors to determine implementation considerations and strategies. A collaborative autoethnography of the research was conducted. Interrelationships between considerations and strategies were identified through a post hoc network analysis. Across the 4 prioritized domains of \"condition,\" \"technology,\" \"value proposition,\" and \"adopters,\" 48 digital health implementation considerations and 52 tailored developer and clinician implementation strategies were generated. Benefits and challenges of coproduction were identified. The post hoc network analysis revealed 172 unique relationships between the identified implementation considerations and strategies, with user and persona testing and responsive design identified as the potentially most impactful strategies. People with ABI, close others, clinicians, and digital health leaders coproduced new knowledge of digital health implementation considerations for adults with ABI and the people who communicate with them, as well as tailored implementation strategies. Complexity-informed network analyses offered a data-driven method to identify the 2 most potentially impactful strategies. Although the study was limited by a focus on 4 NASSS domains and the underrepresentation of certain demographics, the wealth of actionable implementation knowledge produced supports future coproduction of implementation research with mutually beneficial outcomes for stakeholders and researchers. RR2-10.2196/35080.

This paper describes the value of collaboration from two perspectives. The first perspective highlights the benefit of teaching communication partners collaborative communication strategies to facilitate the interactions of people with traumatic brain injury (TBI). Collaborative strategies encompass the provision of collaborative intent, emotional and cognitive support, positive questioning styles and collaborative turn taking. Translating research outcomes into accessible resources is described with reference to the TBI Express website which has video demonstrations of conversation strategies for communication partners of people with TBI.

IntroductionAphasia is a language impairment that affects one-third of people who experience a stroke. Aphasia can impact all facets of language: speaking, understanding, reading and writing. Around 60% of people with aphasia have persistent language impairments 1 year after their stroke, requiring ongoing healthcare and support. In recent years, the internet has become a key resource for the self-management of chronic health conditions. Navigating web content, however, requires language use, and as such, people living with aphasia are more likely to be excluded from digital health and support services. Web Content Accessibility Guidelines exist; however, they do not fully address the unique and diverse needs of people with aphasia, and a significant proportion of websites (over 90%) do not fully adhere to them. This protocol paper describes the first two stages of the Bridging the Digital Divide project, which aims to codesign and develop (a) a web-browser extension to re-render webpages to an ‘aphasia-friendly’ (accessible) format, (b) training tools to help users and health professionals customise the web-browser extension and (c) guidelines for developing communication-accessible websites.Methods and analysisThe research will be conducted using experience-based codesign. In Stage 1a, focus groups will be held with (1) people with aphasia, (2) family members or significant others and (3) health professionals working with people with aphasia. Participants will be asked to share their experiences of accessing (or supporting a person with aphasia to access) healthcare, information and support services on the web. The nominal group technique (NGT) will be used to identify priorities for improving web accessibility for people with aphasia. Focus group data will be analysed using reflexive thematic analysis, and prioritisation data will be analysed using inductive qualitative content analysis. In Stage 1b, eight codesign workshops will be held with representatives of the three key stakeholder groups to iteratively codesign and develop a web-browser extension, training tools and guidelines to support web accessibility.Ethics and disseminationEthical clearance for Stage 1a and Stage 1b of this project has been approved by the University of Queensland Human Research Ethics Committee (Stage 1a approval number: 2023/HE000528, Stage 1b approval number: 2024/HE000721). The outcomes of this research will be disseminated in peer-reviewed journals and presented at national and international conferences. A dissemination and celebration event will be held at the completion of the project.