The framework's position on the use of simulation in rehabilitation programs and the relevance of simulation tier to rehabilitation protocol design.
Simulation is used in rehabilitation programs across neurological, vestibular, motor, and cognitive domains. This document addresses the framework's position on how simulation classification tier may be relevant to rehabilitation protocol design — not as a clinical guideline, but as a framework-level proposition that classification information should be considered alongside other clinical and organizational factors in rehabilitation program decisions.
Simulation-based rehabilitation involves using simulation environments to facilitate neurological, vestibular, motor, or cognitive recovery. In this context, the simulation environment is not simply a training tool — it is a therapeutic environment that the nervous system is exposed to during a period when it may be actively remodeling its representations and responses.
The Human Outcomes Layer's core proposition — that the nervous system adapts to the environment it is exposed to — has particular implications in rehabilitation. A nervous system in recovery may be adapting to the rehabilitation environment with heightened plasticity. The quality and coherence of the inputs delivered during this period may affect the direction of that adaptation and the degree to which the resulting adaptations support recovery in the target real-world environment.
This is not a clinical claim. The framework does not prescribe therapeutic approaches, assess individual recovery trajectories, or make recommendations about specific rehabilitation programs. It proposes that simulation tier is a variable that carries structural meaning for what the nervous system experiences during rehabilitation, and that this structural meaning may be relevant to protocol design decisions.
The framework's position on tier relevance in rehabilitation is grounded in the same mechanisms that apply in training contexts, with additional considerations specific to populations in recovery:
| Consideration | Framework Proposition |
|---|---|
| Sensory coherence in recovery | A nervous system recovering from vestibular or neurological injury may be particularly sensitive to sensory conflict. Compensatory demand generated by incoherent inputs may require additional neurological processing in a system that may have reduced reserve available. |
| Adaptation direction in recovery | Rehabilitation seeks to build or rebuild specific capabilities in the nervous system. Adaptation directed toward the simulation environment rather than the real-world target environment may not support this objective. The coherence of the simulation environment may affect whether adaptation is directed toward real-world-relevant patterns. |
| Transfer of rehabilitation gains | Rehabilitation gains achieved in simulation are only therapeutically meaningful if they transfer to the real-world environment. Transfer potential, as defined in the Human Outcomes Layer, depends on the same structural conditions that apply in training contexts: sensory coherence, causative accuracy, and adaptation directed toward the target environment. |
| Reserve considerations in rehabilitation populations | Rehabilitation populations frequently include individuals with reduced neurological reserve. The interaction between compensatory demand and reduced reserve may be particularly relevant when the participant is in active recovery and reserve may be temporarily below baseline levels. |
The framework proposes that classification tier should be considered in rehabilitation protocol design alongside clinical and organizational factors. This consideration does not require any specific tier to be used or excluded. It means that the structural differences between tiers — in the conditions they create for sensory coherence, compensatory demand, and adaptation direction — are relevant information for the organizations and clinicians designing rehabilitation programs that use simulation.
Specific considerations that may be relevant to protocol design include:
Session structure and duration. If a simulation environment generates compensatory demand, the duration and intensity of sessions may need to account for the additional processing load on a system with potentially reduced reserve. This is not a dosing recommendation — it is a structural proposition that session design should consider whether the simulation environment adds compensatory demand to the total load on the nervous system during a rehabilitation session.
Population-specific tier considerations. Different rehabilitation populations may have different reserve profiles and different sensitivity to compensatory demand. Vestibular rehabilitation programs, for example, may involve populations for whom vestibular input coherence is particularly relevant, because the rehabilitation objective specifically involves retraining vestibular processing. In those contexts, the coherence of vestibular inputs in the simulation environment may be directly relevant to whether the rehabilitation environment supports or complicates the therapeutic objective.
Progress monitoring relative to tier. If different simulation tiers are used at different stages of a rehabilitation program, monitoring should account for the structural differences between those tiers in addition to participant performance metrics. Improvement in simulator performance does not confirm rehabilitation progress in the real-world environment; real-world performance assessment remains relevant to evaluating rehabilitation outcomes.
The SFR framework's position on fidelity and rehabilitation is as follows:
Simulation tier should be considered in the design of rehabilitation programs that use simulation environments, particularly when the rehabilitation population includes individuals with reduced neurological reserve, when the rehabilitation objective specifically involves sensorimotor or vestibular capabilities, or when the program relies on transfer of rehabilitation gains from the simulation environment to the real-world target environment.
The framework does not make specific tier recommendations for rehabilitation use cases. It provides the classification system that enables organizations and clinicians to identify the structural properties of the simulation environments they are using, and the Human Outcomes Layer terminology that allows those structural properties to be discussed in relation to rehabilitation objectives.
This document does not constitute clinical guidance, a rehabilitation protocol standard, or a recommendation for or against any simulation tier for any rehabilitation application. Rehabilitation program design, participant evaluation, therapeutic decision-making, and safety determinations remain the exclusive responsibility of qualified healthcare professionals. The framework provides classification information that may be relevant to those decisions.
See Reduced Neurological Reserve for the framework's position on reserve-specific considerations. See Patient Safety and Fidelity for the broader safety position. See the supplementary references High-Fidelity Simulation in Neurorehabilitation and When the Nervous System Is Already Compromised for extended research commentary.