Background: Physiotherapy involves a complex interplay of clinical and relational skills. The profession advocates for a person-centred approach, emphasising the importance of tailoring treatments to individual needs and circumstances, and actively involving patients in their own care. Traditional qualitative research methods provide insight into therapist and patient experiences of rehabilitation, but often lack a full and nuanced exploration of the complexities that underpin practice. Video-reflexive ethnography is a novel methodology which centres on participant’s ‘insider knowledge’ to unpack the taken-for-granted assumptions, implicit interactions and contextual dynamics that are integral to clinical practice.
Purpose: To explore the applicability and use of video-reflexive ethnography as a qualitative methodology for understanding physiotherapy practice from the perspective of physiotherapists and their patients.

Methods: We outline the purpose and principles of video-reflexive ethnography and discuss its relevance to physiotherapy. We describe three phases of data collection: a) observing a usual rehabilitation session between therapist and patient, b) videoing a usual rehabilitation session and c) reflexive interviewing where the therapist and patient (individually or jointly) watch video clips of their session to support the exploration of their thoughts and experiences in that moment. We discuss how this methodology can be used through an iterative, collaborative and robust qualitative process.

Results: Drawing on our own experiences, we present an example of video-reflexive ethnography which explored therapist and patient understandings, uses and experiences of ‘task challenge’ in stroke rehabilitation.

Conclusions: Video-reflexive ethnography offers a valuable approach to gaining insider knowledge of the complexities of physiotherapy practice, facilitating a deeper exploration of concepts and contexts that may otherwise be overlooked, but are integral to understanding and transforming physiotherapy education, research and clinical practice.

Implications: The use of video-reflexive ethnography in the physiotherapy profession holds significant implications for professional development, research advancement and meaningful change in clinical practice.

Background
Virtual reality (VR) holds promise in physical rehabilitation, yet concerns persist regarding its influence on the patient-therapist relationship, known as the therapeutic alliance. The therapeutic alliance, crucial for rehabilitative success, relies on patient-therapist agreement on tasks, goals, and interpersonal bonds.

Purpose
The purpose of this study was to understand the impact of immersive VR on patient-therapist dynamics in acquired brain injury rehabilitation, offering design insights for in-person rehabilitative VR systems. The key objectives were to uncover essential elements for rehabilitative VR systems in physiotherapy that foster therapeutic alliance, and to create applicable design guidelines.

Method
Observations were employed, coupled with semi-structured interviews. Patients were observed in a VR setting wearing a VR headset which obscured the therapist from their view, and in a traditional non-VR rehabilitation setting. Focus was placed on discerning shifts in patient-therapist interactions and alliance dynamics between settings. Discourse analysis techniques, including conversational analysis, were used to explore interaction patterns and challenges concerning the therapeutic alliance.

Results
Findings indicate shifts in patient-therapist interaction with VR introduction. Despite visual barriers, therapists maintained engagement through gestural and attempted eye contact. VR usage correlated with reduced informal conversation, increased shared laughter, and enhanced therapist verbal feedback. Findings highlighted the need for precisely controllable virtual environments to support the patient-therapist relationship in in-person rehabilitation, breaking down visual barriers impacting gestural cues and utilizing the aspect of shared laughter.

Conclusions
This research underscores the importance of understanding VR’s impact on patient-therapist relationships and interaction in acquired brain injury rehabilitation and physiotherapy more generally. Despite challenges, VR offers opportunities to strengthen patient-therapist bonds.

Implications
This research informs ways in which designers and physiotherapists can ensure seamless integration of VR, with a focus on leveraging VR design innovations that foster stronger patient relationships, ultimately facilitating improved rehabilitation outcomes in physiotherapy clinical practice.