Exploring Behavior Change Techniques in Virtual Reality-Based Rehabilitation after Total Knee Arthroplasty: A Scoping Review

ABSTRACT Objective: The main objectives of this review were to provide an overview of research concerning: 1- To explore used Behavior Change Techniques (BCTs) in VR-based intervention. 2-To code and analyze the state of BCTs in VR-based rehabilitation after TKA. Introduction: Total Knee Arthroplasty (TKA) is recommended to treat advanced-stage knee osteoarthritis (OA). While TKA can alleviate symptoms and improve knee function, most individuals require rehabilitation to aid in their recovery. Advances in immersive technology have led to Virtual Reality (VR) for delivering rehabilitation. Understanding how an intervention works is crucial to assess its effectiveness. Incorporating Behavior Change Techniques (BCTs) is critical to intervention design. This study aimed to investigate the presence of BCTs in eligible studies within this review. Since there was a lack of explicit descriptions of BCTs used in interventions, we employed Felsberg's methodology and Michie's BCTs Taxonomy to identify keywords and establish connections with the BCTs employed. Inclusion/ Exclusion Criteria: The inclusion criteria specify that participants must be 19 or older, physically stable, without severe medical illnesses, and possess adequate visual and auditory acuity. The review includes randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) published in English between 2010 and 2023, which saw significant advancements in VR technology. Participants with certain conditions, such as claustrophobia or cognitive disorders, are excluded from the study. Methods: This scoping review was conducted in five stages based on Arksey and O'Malley's framework, including (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data and (5) collating, summarizing, and reporting the results. Results: 1,455 studies were initially screened from four databases: PubMed, Medline (Ovid), CINAHL, and Embase (Ovid). Following removing duplicated and irrelevant studies, two independent reviewers reviewed the full text of 117 studies, and finally, nine studies of VR-based rehabilitation were included in this scoping review. Most studies did not describe the BCTs used in their methodologies. Concerning BCT, goal setting was used in 55.5% of the studies, and 88.9% of studies described intervention instructions. Self-recording and self-monitoring were detected in 55.5% of the studies, and monitoring outcomes with patient feedback were reported in 33.3%. Pain reduction due to distraction was observed in 44.4% of the studies while practicing specific tasks to improve performance was found in 22.2%. Conclusions: This scoping review explored using BCTs within VR-based rehabilitation following TKA. The review revealed that most studies emphasized clinical outcomes without explicitly mentioning the employed BCTs. We employed a triangulation approach to address this gap, combining Felsberg's method, Michie's BCTs Taxonomy, and our knowledge gained from the BCT workshop. This allowed us to identify VR components, mechanisms of action, and relevant keywords for coding BCTs within the interventions. The findings from this review revealed that specific BCTs, such as instruction and feedback, were commonly integrated into VR-based interventions, whereas others, like self-reward, were less frequently employed. This underscores the significance of considering both the VR components and BCTs in designing effective rehabilitation programs for TKA patients. Future research should prioritize the identification of the most effective BCTs for VR-based rehabilitation, explore the integration of technology, assess the role of healthcare providers, and investigate diverse patient populations to tailor rehabilitation programs more effectively. These efforts aim to enhance the development and adoption of efficient post-TKA rehabilitation programs, ultimately contributing to improved patient recovery and overall well-being.