In this study, we found that additional 3-week VR training could improve self-efficacy and ADL; however, the occupational performance, satisfaction, and upper extremity function were not superior in participants who had VR training.
About half of the demands of COPM were in the area of self-maintenance, such as personal care and functional mobility; this finding was similar to that of another study.[37] Specifically, walking was the most frequently mentioned activity of patients with stroke, which was followed by eating and dressing. Moreover, the most important activity in the area of productivity was working, which was followed by housework; this finding was also similar to previous research results.[38, 39] For leisure, the demands appeared to be of diversity and be related to patients’ interests. Most patients considered playing mahjong as the first priority for leisure activities, and this might be associated with the Chinese culture. Besides, social engagement is associated with the interaction of different occupations, which can support expected community and family involvement, as well as activities involving peers and friends.[40]
In our study, positive changes in the score of occupational performance were observed in both groups; the score was 2 points greater than the baseline, indicating a clinically significant improvement in occupational performance, and no between-group difference was found. The result of our study was consistent with those of current studies,[25, 41] although the number of VR-related studies using occupational performance as an outcome indicator is insufficient. Furthermore, it was reported that a patient-centered treatment enables therapists to fully consider each patient's satisfaction, desire, and goals, which in turn makes the promotion of enthusiasm among participants easier, thereby resulting in adherence to intervention and patient satisfaction.[25] However, the VR training in our study was not designed for target therapeutic activities. The movements in the VR games were designed in a single direction; thus, the VR group could not transform the therapeutic activity to complex daily activities during training. In addition, the demand of productive activities and recreational activities was about 52%, and target training in our VR training program was lacking. Moreover, because of the relatively large sample size and short training protocol compared with two previous randomized controlled trials,[30, 41] implementing a patient-centered treatment in clinical practice was difficult. These results may explain the absence of a significant difference between two groups in COPM.
According to Bandura's theory of social cognition, the following four principles could guide the intervention for self-efficacy: mastering the experience of successfully completing a task, acquiring indirect experience (modeling), verbal persuasion and encouragement, and understanding physiological states and signals.[6] Therefore, the most feasible way to assist participants to obtain and improve self-efficacy is to use these four principles.[42] VR training is a task-oriented, imitative, and repetitive training, and it has the advantage to integrate these four principles. Firstly, a human-shaped model displayed on the screen could guide the participants to learn basic movements and provide direct verbal instructions from the system and therapists. Secondly, participants could acquire successful experience through repetitive activities. Thirdly, appropriate guidance, encouragement, and reminders from the therapists and family members could be integrated. Hence, VR training could help improve the self-efficacy of the participants by integrating Bandura’s principles into a complete training program.
Currently, studies that used holistic self-efficacy as an outcome indicator in VR training are insufficient, and only a few studies investigated balance self-efficacy.[21, 32, 43, 44] Previous studies found that VR could increase participants' confidence, motivation to participate, and functional activities based on the remodeling and reorganization of brain function.[25, 45, 46] Learning by mimicking models and "mirroring" neural networks may induce the formation of an imitative tissue around the motor cortex. Similarly, participants receiving sensory feedback in VR training were likely to learn the target motor behavior. The feedback could promote the development of use-dependent cortical plasticity, leading to the recovery of motor function.[47] Moreover, the functional improvement induced by motor learning through VR training could greatly improve participants' confidence and self-efficacy in a new environment.[21, 31, 32, 43, 44] In addition, a study reported that participants regarded VR training as an interactive and enjoyable sports game rather than a training; thus, they were more motivated to engage in the training.[48] The participants in our study showed improvement in upper limb function and ADL; such improvement could in turn enhance their confidence and self-efficacy. Thus, we could infer that VR training has a positive effect on self-efficacy of patients with stroke.
Our study found that VR training is beneficial for patients with stroke in terms of ADL but not upper limb function. These results were consistent with those of a previous study.[20] The possible reasons may be as follows: the overall intervention time of this study was relatively short. Although a review confirmed that a total intervention time more than 15 hours would become a trend of customization,[20] the regulations of medical insurance prevented us from having a longer treatment duration. Additionally, the VR equipment used in this study was mainly focused on the proximal joint of the upper limb, and thus lacked functional training for the distal joints (hand and wrist), which possibly contributed to the difficulty in enhancing upper limb function scores. In our study, both self-efficacy and ADL improved compared with control group. The improvement of ADL might be related to the improvement of self-efficacy. A previous study revealed that patients with high self-efficacy performed better in daily activities than patients with low self-efficacy.[4]