199 DISCUSSION AND FUTURE PERSPECTIVES 9 care or research protocols) were seldom met, possibly limiting the potential effect of the desired intervention. Future research should therefore focus on achieving protein adequacy combined with sufficient mobilisation activities throughout the patient journey to improve long-term patient-reported outcomes in ICU-survivors. One way to achieve adequate adherence to, for example, mobilisation practices and thereby possibly limiting long-term physical health problems, is to provide personalised exercise options during and after ICU-stay. Similar to what is discussed in Chapter 6 and 7, there can be various patient and ICU-related barriers in providing adequate mobilisation practices in ICU-patients and survivors.21 Some of these barriers, like pain, patient refusal, lack of motivation, among others, may be overcome using personalised eHealth applications and serious gaming, like Virtual Reality (VR)-assisted therapy. VR provides an immersive environment, which may increase motivation and adherence to therapy.22,23 To investigate the potential of VR for physical rehabilitation during and after ICU-admission, Chapter 8 discusses the feasibility of a VR-exergame specifically designed with and for ICU-patients and their informal caregivers. Using a patient-centred and design-thinking approach throughout the developmental phases of this game, this game adheres to the patient’s needs and capabilities. To our knowledge, this is the first VR-game specifically designed for upper extremity training starting in the ICU. Patients were offered a puzzle game in a relaxing virtual living room. This first study indicated the use of serious games, like VR-assisted therapy, for physical rehabilitation as feasible in the ICU and the general ward. In addition, VR-assisted therapy is associated with improved mobility and improvements in handgrip strength in some patients. Patients were generally satisfied with the VR-assisted therapy as an addition to standard care physical therapy and would probably use the VR-assisted therapy in their home situation (78% probability). These findings emphasise the potential of VR-assisted therapy in ICU-patients as an addition to early mobilisation practices. In addition, it provides a first step towards a more blended, patient-centred aftercare program for critical illness survivors and their caregivers. FUTURE PERSPECTIVES This thesis and numerous other studies make clear that we, researchers, clinicians, and policy makers, leave the majority of ICU-survivors and their caregivers to fend for themselves in the search for meaningful recovery.
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