Technological Advances

At one corner of the pyramid are technological advances such as mobile health monitoring devices, commercial devices such as the Kinect sensor, emergency notification devices, virtual reality and game-based rehabilitation devices, and applications of smartphones, tablets, and computers. As an example, Winstein mentioned an elastic tape that is placed on a person’s back and monitors posture over the course of the day. Similarly, the use of robotics for assessment and rehabilitation has expanded rapidly. A PubMed search for “robotic rehabilitation stroke” that she did returned 394 hits, with 196 since 2010.

Motivational Influences on Behavior Change

At another corner of the pyramid are motivational influences on behavior change, which Winstein analyzed in terms of three fundamental psychological needs: autonomy, competence, and social relatedness. Autonomy involves the need to determine or feel in control of one’s actions. For example, simply giving people a choice can increase autonomy. Competence relates to the need to perceive oneself as capable. For example, giving people feedback that they have been successful doing something makes them feel good. This is particularly an issue for people engaging in rehabilitation, who often do not feel competent because of a loss of function. Finally, social relatedness involves the need to feel included, accepted, or connected to others. For example, the use of social media can increase satisfaction in one’s involvement in the social world.

Virtual-reality simulation technology is ideally suited to incorporate these basic psychological needs, Winstein observed. Best practice in rehabilitation is focused on a specific skill or task, has adjustable levels of difficulty, is quantifiable in order to assess progress, is administered repetitively and hierarchically to allow the right amount of challenge, provides the user with feedback about success, has some relevance to real-world function, and motivates and engages the user. Virtual reality–based exercise programs can achieve all these ends.

Aging in Place

At the third corner of the pyramid is aging—and rehabilitation—in place. Rehabilitation is not something that happens just in the hospital or clinic. It can also happen at home and in the community. Closing the gap between the current evidence base and common practice could keep seniors and people with disabilities in their homes and communities longer. For example, one of the greatest fears of seniors in surveys is that they will fall and



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