By Amish Patel, MD, MBA

Founder & CEO, Verity XR | Board-Certified Anesthesiologist and Pain Management Physician

Subacute rehabilitation facilities occupy one of the most important transition points in healthcare.

Patients often arrive after hospitalization, surgery, injury, or significant medical deconditioning with one primary goal:

Regain enough function to safely return home or transition to a lower level of care.

That goal sounds simple.

Achieving it is not.

Patients may need to rebuild strength, range of motion, balance, endurance, confidence, and independence over a relatively short rehabilitation stay. At the same time, many are coping with pain, fatigue, fear of falling, anxiety, and the frustration of temporarily losing abilities they previously took for granted.

As a pain-management physician, one thing has become very clear to me over the years:

Recovery is not something that can simply be delivered to a passive patient.

Patients have to participate in it.

They have to move.

They have to practice.

They have to repeat activities.

They have to progressively challenge themselves.

And they have to stay engaged long enough for rehabilitation to work.

For subacute rehabilitation facilities, that makes engagement more than a patient-experience issue.

It is part of the rehabilitation process itself.

Rehabilitation Intensity Matters

Research in skilled nursing and subacute rehabilitation settings has repeatedly suggested that the amount and intensity of rehabilitation patients receive are associated with meaningful outcomes.

A 2021 systematic review examined eight U.S. observational studies representing more than 923,000 skilled nursing facility patients. The review found moderate evidence that greater rehabilitation intensity was associated with higher community-discharge rates and shorter lengths of stay. Evidence for functional improvement was also positive, although lower in quality. (pubmed.ncbi.nlm.nih.gov)

Another study involving 4,988 patients in skilled nursing facilities found that higher physical and occupational therapy intensity was associated with shorter length of stay and greater likelihood of improvement in mobility and activities of daily living across several diagnostic groups. (pubmed.ncbi.nlm.nih.gov)

These studies do not suggest that every patient simply needs more therapy minutes.

But they reinforce a fundamental point:

What patients do during subacute rehabilitation matters.

Engagement Is Different From Scheduled Therapy Time

A patient can be present for a therapy session without being fully engaged in it.

That distinction matters.

One of the more interesting approaches developed in subacute rehabilitation is Enhanced Medical Rehabilitation, which was designed specifically to improve how actively patients participate in PT and OT.

The intervention did not fundamentally replace the underlying rehabilitation exercises.

Instead, therapists emphasized:

• patient-centered goals;
• frequent encouragement;
• immediate feedback;
• recognition of effort;
• motivation; and
• active participation.

In an early randomized study involving 26 older adults receiving rehabilitation in a skilled nursing facility, patients in the enhanced rehabilitation group demonstrated greater therapy engagement and intensity.

They also showed greater improvements in function.

Gait speed increased from approximately 0.08 to 0.38 meters per second, compared with 0.08 to 0.22 meters per second with standard rehabilitation.

Six-minute walking distance improved from approximately 73 to 266 feet, compared with 40 to 94 feet in the standard-care group. (pmc.ncbi.nlm.nih.gov)

The study was small, but the concept was compelling enough to test further.

Larger Research Reinforced the Importance of Engagement

A subsequent randomized clinical trial included 229 adults aged 65 years and older receiving skilled nursing rehabilitation.

Patients received either standard rehabilitation or an engagement-focused rehabilitation approach that incorporated principles of motivation and behavior change.

The difference in active participation was substantial.

Patients in the engagement-focused group were active during approximately 52.5% of their therapy time compared with 41.2% among patients receiving standard rehabilitation.

Functional recovery was also greater.

Barthel Index scores improved by approximately 35 points compared with 28 points in the standard rehabilitation group—roughly 25% greater functional recovery during the SNF stay. (pmc.ncbi.nlm.nih.gov)

What I find most important about this research is not the name of the intervention.

It is what the intervention changed.

It changed how patients experienced and participated in rehabilitation.

That should be highly relevant to subacute rehabilitation facilities.

We spend significant time deciding which exercises patients should perform.

Perhaps we should spend just as much time asking:

How do we keep patients actively participating in those exercises?

Why Engagement Can Be Difficult in Subacute Rehabilitation

Think about the typical patient entering a subacute rehabilitation facility.

They may have recently:

• undergone joint replacement;
• had spine surgery;
• experienced a fracture;
• completed a prolonged hospitalization;
• developed significant deconditioning;
• suffered a stroke or neurologic event; or
• lost mobility because of illness.

They may simultaneously be dealing with:

• pain;
• weakness;
• fear of falling;
• fear of reinjury;
• poor sleep;
• fatigue;
• anxiety;
• reduced confidence;
• and loss of independence.

The patient may fully understand that rehabilitation is important while still struggling to participate consistently.

This is where rehabilitation becomes both physical and cognitive behavioral.

Physical Recovery Has a Cognitive Behavioral Component

Patients do not enter rehabilitation with only a physical impairment.

They also bring beliefs and expectations about that impairment.

A patient recovering from surgery may think:

If movement hurts, maybe I am damaging the surgical area.

A patient who recently fell may be afraid to challenge their balance.

Someone recovering from prolonged hospitalization may no longer trust their legs.

A patient with persistent pain may have progressively avoided certain movements for months or years.

These thoughts and behaviors can directly affect participation.

That is why I believe Cognitive Behavioral Rehabilitation should be considered alongside physical rehabilitation.

This does not mean every patient needs formal psychotherapy.

It means recognizing that:

• fear;
• expectations;
• confidence;
• pain beliefs;
• pacing;
• motivation; and
• avoidance

can all influence whether a patient moves.

For a subacute rehabilitation team, that changes the question from:

“What movement does this patient need?”

to:

“What may be preventing this patient from participating in that movement?”

Cognitive Behavioral Rehabilitation Can Support Physical Recovery

Several cognitive behavioral principles can be directly relevant to rehabilitation.

Pain Neuroscience Education

Patients may benefit from understanding that pain does not always indicate ongoing tissue damage.

This can be especially important when pain becomes a barrier to progressing movement.

Graded Exposure

Patients who are hesitant or fearful about particular movements may benefit from progressively reintroducing those movements within clinically appropriate limits.

Activity Pacing

Pacing can help patients avoid an excessive activity-rest cycle in which they overexert themselves on a good day and then withdraw from activity afterward.

Goal Setting and Feedback

Rehabilitation tasks become more meaningful when patients understand how they relate to walking independently, getting out of bed, climbing stairs, dressing, or returning home.

These concepts are cognitive behavioral, but their purpose is ultimately physical:

help the patient participate in movement.

Autonomic Regulation Can Help Address Another Barrier

Pain and recovery are also influenced by physiologic arousal.

An anxious or apprehensive patient may experience increased muscle tension, hypervigilance, fear, and difficulty focusing on movement.

Techniques such as:

• guided breathing;
• mindfulness;
• meditation; and
• relaxation

can provide selected patients with tools to manage that state.

These techniques are not substitutes for rehabilitation.

Their purpose is to help some patients become more comfortable participating in it.

This leads to a three-part rehabilitation model:

Cognitive Behavioral Rehabilitation

↓

Autonomic Regulation

↓

Movement Rehabilitation

The first two pillars support the third.

Movement remains the destination.

Why Immersive Rehabilitation Is Interesting in Subacute Care

Virtual reality becomes compelling in this setting not because a headset itself is therapeutic.

It is compelling because immersion can change the patient’s experience of rehabilitation.

The patient still needs to:

• reach;
• rotate;
• squat;
• shift weight;
• balance;
• perform repetitions;
• and progressively increase activity.

But instead of performing repetitive movements while staring at a wall or counting repetitions, those same movements can accomplish something inside an interactive environment.

A therapeutic reach can activate a target.

A trunk rotation can become part of a task.

A squat can contribute toward a goal.

A balance activity can provide visual feedback.

The underlying rehabilitation principle remains the same.

The experience becomes more interactive.

What the Research Says About Immersive Technology in Older Adults

One common concern is whether older patients will accept virtual reality.

The literature suggests that age alone should not be viewed as a barrier.

A 2023 systematic review and meta-analysis examined 54 studies involving 1,853 older adults and found generally positive attitudes toward immersive technology and willingness to use it again. (pubmed.ncbi.nlm.nih.gov)

That does not mean every subacute patient will be appropriate.

Cognitive impairment, visual or vestibular problems, medical instability, balance limitations, and ability to follow instructions remain important considerations.

But it challenges the assumption that immersive rehabilitation is inherently a younger-person technology.

Evidence Is Also Emerging Around Functional Mobility

A systematic review examining VR rehabilitation in adults over age 60 identified 18 studies, with 568 participants contributing to subgroup meta-analysis.

The authors found evidence suggesting potential benefits for functional mobility, although results varied by technology type, intervention design, and dose.

Programs involving more sessions appeared more effective in some comparisons, again reinforcing the importance of repeated participation. (pubmed.ncbi.nlm.nih.gov)

Balance is another area of interest.

A 2024 systematic review and meta-analysis found that immersive VR training improved standing balance, with a standardized mean difference of 0.51, and improved Berg Balance Scale scores by an average of 2.36 points across four studies involving 190 participants.

The same analysis did not demonstrate significant benefits for gait, general mobility, or fear of falling, highlighting the importance of being precise about where evidence is strongest. (pubmed.ncbi.nlm.nih.gov)

A separate 2024 meta-analysis also found improvements in Berg Balance Scale and Timed Up and Go performance with VR-based interventions among older adults. (pubmed.ncbi.nlm.nih.gov)

The Opportunity Is Bigger Than the Therapy Session

This is where I think subacute rehabilitation facilities have a particularly interesting opportunity.

Direct therapist time is extremely valuable.

But the patient’s entire day does not consist of direct PT or OT.

There may be additional opportunities, when clinically appropriate, for patients to participate in therapist-directed or clinician-directed rehabilitation activities outside traditional one-on-one therapy time.

That might include:

• additional movement practice;
• range-of-motion activities;
• reaching;
• balance exercises;
• cognitive behavioral education;
• guided relaxation;
• or other assigned rehabilitation content.

Technology can potentially help extend the rehabilitation plan, not replace the rehabilitation professional.

The model is:

Clinician evaluates

↓

Clinician establishes goals and parameters

↓

Patient completes therapist-directed rehabilitation

↓

Technology supports additional appropriate activity

↓

Objective performance information is captured

↓

Rehabilitation team reviews progress and adjusts care

That is a much more interesting use of technology than simply placing VR in the therapy gym.

Where EnGaugeXR Fits

Verity’s EnGaugeXR system was designed around this broader rehabilitation model.

It is a clinician-directed immersive rehabilitation platform integrating three components.

Cognitive Behavioral Rehabilitation

EnGaugeXR includes immersive content incorporating:

• pain neuroscience education;
• graded exposure;
• activity pacing;
• movement confidence;
• and other cognitive behavioral concepts relevant to rehabilitation.

The goal is to help appropriate patients better understand recovery and address cognitive or behavioral barriers to participation.

Autonomic Regulation

The platform also includes experiences involving:

• guided breathing;
• mindfulness;
• meditation;
• relaxation;
• and optional physiologic feedback where configured.

These modules can complement rehabilitation for patients whose stress or apprehension interferes with participation.

Movement Rehabilitation

Movement remains the central component.

Interactive activities can support clinician-directed:

• range of motion;
• functional reaching;
• upper- and lower-extremity movement;
• cervical and trunk movement;
• squatting;
• coordination;
• balance;
• progressive movement exposure;
• and other appropriate therapeutic activities.

The treating clinician determines what is appropriate.

The technology provides another way to deliver and experience those activities.

Objective Progress Can Help Patients See Recovery

One of the frustrations patients experience during rehabilitation is that improvement can feel subjective.

Technology creates the opportunity to capture applicable information such as:

• range of motion;
• repetitions;
• task completion;
• session participation;
• movement progression;
• balance performance;
• and other activity-specific measures.

That information can potentially serve two audiences.

For clinicians, it can provide additional visibility into what patients are doing.

For patients, it can make progress tangible.

Instead of simply hearing:

“You’re getting better,”

the patient may be able to see:

“I reached farther today.”

“I completed more repetitions.”

“I tolerated the activity longer.”

“I accomplished something that I could not do last week.”

That can matter in a rehabilitation environment where confidence is often being rebuilt alongside physical function.

Patient Experience and Facility Differentiation Matter Too

Subacute rehabilitation facilities also operate in a competitive environment.

Hospitals, referral sources, patients, and families evaluate rehabilitation programs on more than clinical outcomes alone.

They also notice:

• rehabilitation capabilities;
• patient experience;
• technology;
• staff engagement;
• communication;
• and confidence that the facility is actively helping the patient progress toward home.

An immersive rehabilitation offering can be a visible representation of investment in advanced rehabilitation.

But the technology has to be clinically meaningful.

The objective is not:

“We have VR.”

The objective is:

“We are using technology to create a more engaging, measurable, and modern rehabilitation experience.”

That is a much stronger value proposition.

What Could an Implementation Program Explore?

For a subacute facility interested in immersive rehabilitation, the most useful questions are operational and clinical.

For example:

• Which patient populations are most appropriate?
• How frequently will patients use the system?
• Can the technology be incorporated easily into current PT and OT workflows?
• Does it allow selected patients to complete additional clinician-directed movement activity?
• Do patients find the experience enjoyable and motivating?
• Can objective performance information provide useful feedback?
• Does cognitive behavioral content help patients address movement-related fear or apprehension?
• Does the experience improve patient or family perceptions of rehabilitation?
• And over time, how does engagement relate to functional progress?

Those are the kinds of questions that can help facilities determine whether immersive rehabilitation has a meaningful place in the subacute environment.

Reimagining the Subacute Rehabilitation Day

I believe the future of subacute rehabilitation will be less about isolated therapy encounters and more about creating a continuous recovery environment.

A patient can receive excellent PT and OT.

But recovery does not stop when the therapy session ends.

There may be opportunities throughout the day to reinforce:

• movement;
• education;
• confidence;
• relaxation;
• practice;
• and progress.

Imagine a rehabilitation environment in which:

• patients understand why movement matters;
• cognitive behavioral strategies help address fear and avoidance;
• relaxation tools help appropriate patients regulate apprehension;
• therapeutic movement is interactive;
• progress is visible;

and technology extends the rehabilitation team’s plan without attempting to replace the rehabilitation team.

That is the opportunity I see for immersive technology in subacute care.

The science still determines what the patient needs to do.

Cognitive behavioral principles help us understand what may prevent them from doing it.

Immersive technology may offer another way to improve how they experience doing it.

And ultimately, the goal of subacute rehabilitation remains straightforward:

Help patients participate more actively, move more confidently, regain function, and get back home.

Selected References

1. Prusynski RA, Gustavson AM, Shrivastav SR, Mroz TM. Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review. Physical Therapy. 2021;101(3):pzaa230. Eight observational studies representing more than 923,000 SNF patients were included. Greater therapy intensity was associated with higher community-discharge rates and shorter length of stay. (pubmed.ncbi.nlm.nih.gov)
2. Jette DU, Warren RL, Wirtalla C. The Relation Between Therapy Intensity and Outcomes of Rehabilitation in Skilled Nursing Facilities. Archives of Physical Medicine and Rehabilitation. 2005. This study of 4,988 SNF patients found associations between higher PT/OT intensity, shorter length of stay, and improved mobility and ADL outcomes. (pubmed.ncbi.nlm.nih.gov)
3. Lenze EJ, Host HH, Hildebrand MW, et al. Enhanced Medical Rehabilitation Increases Therapy Intensity and Engagement and Improves Functional Outcomes in Postacute Rehabilitation of Older Adults: A Randomized-Controlled Trial. Journal of the American Medical Directors Association. 2012;13(8):708-712. The pilot study included 26 older adults and demonstrated increased engagement and greater improvements in gait speed and six-minute walking distance. (pmc.ncbi.nlm.nih.gov)
4. Lenze EJ, Lenard E, Bland M, et al. Effect of Enhanced Medical Rehabilitation on Functional Recovery in Older Adults Receiving Skilled Nursing Care After Acute Rehabilitation: A Randomized Clinical Trial. JAMA Network Open. 2019. In 229 older adults, engagement-focused rehabilitation increased active therapy time and produced approximately 25% greater functional recovery during the SNF stay. (pmc.ncbi.nlm.nih.gov)
5. Doré B, Gaudreault A, Everard G, et al. Acceptability, Feasibility, and Effectiveness of Immersive Virtual Technologies to Promote Exercise in Older Adults: A Systematic Review and Meta-Analysis. Sensors. 2023;23(5):2506. The review included 54 studies and 1,853 participants and found generally positive acceptability of immersive technologies among older adults. (pubmed.ncbi.nlm.nih.gov)
6. Corregidor-Sánchez AI, Segura-Fragoso A, Rodríguez-Hernández M, et al. Effectiveness of Virtual Reality Technology on Functional Mobility of Older Adults: Systematic Review and Meta-Analysis. Age and Ageing. 2021;50(2):370-379. Eighteen studies were included and suggested potential mobility benefits, while highlighting heterogeneity and limitations in the evidence base. (pubmed.ncbi.nlm.nih.gov)
7. Lee J, Phu S, Lord SR, Okubo Y. Effects of Immersive Virtual Reality Training on Balance, Gait and Mobility in Older Adults: A Systematic Review and Meta-Analysis. Gait & Posture. 2024;110:129-137. Immersive VR was associated with improved standing balance and Berg Balance Scale performance. (pubmed.ncbi.nlm.nih.gov)
8. Huang WY, Chang ST, Lee CH, Liou IH, Cherng RJ. Effects of Virtual Reality on the Balance Performance of Older Adults: A Systematic Review and Meta-Analysis. Journal of Physical Therapy Science. 2024;36(8):457-470. VR-based interventions were associated with improvements in selected balance and mobility measures. (pubmed.ncbi.nlm.nih.gov)