Archive for category Virtual reality rehabilitation

[Abstract] Wearable Hand Exoskeleton Systems for Virtual Reality and Rehabilitation


The aim is to overcome the limitations of conventional systems in terms of both wearability and portability. As the hand receives diverse physical information and manipulates different type of objects, conventional systems contain many sensors and actuators, and are both large and heavy. Thus, hand exoskeleton systems exhibiting high wearability and portability while measuring finger motions and delivering forces would be highly valuable. For VR hand exoskeleton systems, a wearable hand exoskeleton system with force-controllable actuator modules was developed to ensure free finger motion and force mode control. The linkage structure ensures motion with three degrees of freedom (DOF) and provides a large fingertip workspace; the finger postures assumed when interacting with objects are appropriate. A series elastic actuator (SEA) with an actuator and an elastic element was used to fabricate compact actuator modules. Actuator friction was eliminated using a friction compensation algorithm. A proportional differential (PD) controller, optimized by a linear quadratic (LQ) method featuring a disturbance observer (DOB), was used to ensure accurate force mode control even during motion. The force control performance of the actuator module was verified in force generation experiments including stationary and arbitrary end-effector motions. The forces applied to the fingertips, which are the principal parts of the hand that interact with objects, were kinematically analyzed via both simulations and experiments. To overcome the weak point of previous system, a wearable hand exoskeleton system featuring finger motion measurement and force feedback was developed and evaluated in terms of user experience (UX). The finger structures for the thumb, index, and middle fingers, which play important roles when grasping objects, satisfy full range of motion (ROM). The system estimates all joint angles of these three digits using a dedicated algorithm; measurement accuracy was experimentally evaluated to verify system performance. The UX performance was evaluated by 15 undergraduate students who completed questionnaires assessing usability and utilitarian value following trials conducted in the laboratory. All subjects were highly satisfied with both usability and the utilitarian nature of the system, not only because control and feedback were intuitive but also because performance was accurate. For rehabilitation, a highly portable exoskeleton featuring flexion/extension finger exercises was developed. The exoskeleton features two four-bar linkages reflecting the natural metacarpophalangeal (MCP) and proximal phalangeal (PIP) joint angles. During optimization, the design parameters were adjusted to reflect normal finger trajectories, which vary by finger length and finger joint ROM. To allow for passive physical impedance, a spring was installed to generate the forces that guided the fingers. The moments transmitted to the MCP and PIP joints were estimated via finite element method (FEM) analysis and the cross-sectional areas of the links were manually designed by reference to the expected joint moments. Finger motion and force distribution experiments verified that the system guided the fingers effectively, allowed for the desired finger motions, and distributed the required moments to the joints (as revealed by FEM analysis).; This thesis reports the development of hand exoskeleton systems, for use in virtual reality (VR) environments and for hand rehabilitation

via ScholarWorks: Wearable Hand Exoskeleton Systems for Virtual Reality and Rehabilitation

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[Abstract + References] Effect of Virtual Reality Rehabilitation Program with RAPAEL Smart Glove on Stroke Patient’s Upper Extremity Functions and Activities of Daily Living


Purpose : This study examined the effects of a virtual reality rehabilitation program on stroke patients’ upper extremity functions and activities of daily living (ADL).

Methods : The subjects were equally and randomly divided into an experimental group (n=16) to whom a virtual reality rehabilitation program was applied and a control group (n=16) who received traditional occupational therapy. The intervention was applied five times per week, 30 minutes per each time, for six weeks. Jebsen-Taylor hand function test was conducted and the subjects’ Manual Function Test was measured to examine their upper extremity functions before and after the treatment intervention, and a Korean version of modified Barthel index was calculated to look at their activities of daily living.

Results : After the intervention, the upper extremity functions and activities of daily living of the participants in both groups significantly improved (p<.05). However, the improvements in these parameters among the participants in the virtual reality rehabilitation program were significantly greater than those in the control group (p>.05).

Conclusion : The virtual reality rehabilitation program is a stable and reliable intervention method for enhancing the upper limb functions and activities of daily living of stroke patients.


  1. Wolf SL, Lecraw DE, Barton LA, et al(1989). Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol, 104(2), 125-132.
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  7. Baek SW(2017). Effect of mirror therapy with functional electrical stimulation on upper extremity function and activities of daily living performance in chronic stage stroke patients. Graduate school of Yonsei University, Republic of Korea, Master’s thesis.
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  19. Lee MJ, Koo HM(2017). The effect of virtual reality-based sitting balance training program on ability of sitting balance and activities of daily living in hemiplegic patients. J Korean Soc Integrative Med, 5(3), 11-19.
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  21. Neofect(2016). RAPAEL smart solution manual. Neofect. Korea.
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  23. Peurala SH, Kantanen MP, Sjogren T, et al(2012). Effectiveness of constraint-induced movement therapy on activity and participation after stroke: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil, 26(3), 209-223.
  24. Prange GB, Jannink MJ, Groothuis-Oudshoorn CG, et al(2006). Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke. J Rehabil Res Dev, 43(2), 171-184.
  25. Sears ED, Chung KC(2010). Validity and responsiveness of the Jebsen-Taylor hand function test. J Hand Surg Am, 35(1), 30-37.
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  27. Shin JH, Kim MY, Lee JY, et al(2016). Effects of virtual reality-based rehabilitation on distal upper extremity function and health-related quality of life: a single-blinded, randomized controlled trial. J Neuroeng Rehabil, 13(1), 17.
  28. Song CH, Seo SM, Lee KJ, et al(2011). Video game-based exercise for upper-extremity function, strength, visual perception of stroke patients. J Spe Edu & Rehabil Sci, 50(1), 155-180.
  29. Thieme H, Morkisch N, Mehrholz J, et al(2019). Mirror therapy for improving motor function after stroke. Stroke, 50(2), 26-27.

via Effect of Virtual Reality Rehabilitation Program with RAPAEL Smart Glove on Stroke Patient’s Upper Extremity Functions and Activities of Daily Living -Journal of The Korean Society of Integrative Medicine | Korea Science

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[ARTICLE] Virtual reality experiences, embodiment, videogames and their dimensions in neurorehabilitation – Full Text



In the context of stroke rehabilitation, new training approaches mediated by virtual reality and videogames are usually discussed and evaluated together in reviews and meta-analyses. This represents a serious confounding factor that is leading to misleading, inconclusive outcomes in the interest of validating these new solutions.

Main body

Extending existing definitions of virtual reality, in this paper I put forward the concept of virtual reality experience (VRE), generated by virtual reality systems (VRS; i.e. a group of variable technologies employed to create a VRE). Then, I review the main components composing a VRE, and how they may purposely affect the mind and body of participants in the context of neurorehabilitation. In turn, VRS are not anymore exclusive from VREs but are currently used in videogames and other human-computer interaction applications in different domains. Often, these other applications receive the name of virtual reality applications as they use VRS. However, they do not necessarily create a VRE. I put emphasis on exposing fundamental similarities and differences between VREs and videogames for neurorehabilitation. I also recommend describing and evaluating the specific features encompassing the intervention rather than evaluating virtual reality or videogames as a whole.


This disambiguation between VREs, VRS and videogames should help reduce confusion in the field. This is important for databases searches when looking for specific studies or building metareviews that aim at evaluating the efficacy of technology-mediated interventions.


In the context of stroke rehabilitation, new training approaches mediated by virtual reality and videogames are usually discussed and evaluated together in reviews and meta-analyses for upper limb [], and balance and gait []. Certainly, the expected superiority of virtual reality over conventional therapy post stroke has been questioned when using off-the-shelf (e.g., Nintendo Wii) or ad-hoc videogames. This conclusion, however, is based on the wrong assumption that videogames deliver same experiences than virtual reality applications. In my opinion, this represents a serious confounding factor that may lead to misleading, inconclusive outcomes in the interest of validating these new solutions. Indeed, in Laver’s Cochrane article, a positive effect for virtual reality versus conventional therapy for improving upper limb function post stroke is found only when dedicated virtual reality based interventions, i.e. specifically designed for rehabilitation settings, are used. The effect vanishes when standard off-the-shelf videogames are considered. Indeed, the use of Nintendo Wii (but referring to it as virtual reality) often leads to a non-inferiority clinical outcome, being as effective as conventional therapy [] or alternative playful interventions such as playing cards []. In another study with mobile-based and dedicated games (again referred to as virtual reality), partial functional and motor improvements were observed as compared to standard occupational therapy [].

This heterogeneity in the reported virtual reality and videogames studies for neurorehabilitation calls for use of appropriate labelling for the approaches and variables assessed. A correct identification of the specific factors (and their weight) contributing to any eventual change post treatment are required for interpreting those changes and building further evidence on the specific solution. Therefore, in this paper I propose to reframe the traditional interpretation of the term virtual reality. I advocate disentangling two conceptual components that may help the field standardize its use: virtual reality experience (VRE) and virtual reality systems (VRS). I put emphasis on exposing fundamental similarities and differences between VREs and videogames, often mistakenly used as synonyms or exchangeable terms despite the different underlying interventional techniques and brain mechanisms they can enable. I then use neurorehabilitation as exemplary application field to discuss the implications of differentiating between them.[…]


Continue —->  Virtual reality experiences, embodiment, videogames and their dimensions in neurorehabilitation

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[Abstract] Home-based upper extremity stroke therapy using a multi-user virtual reality environment: a randomized trial



To compare participation and subjective experience of participants in both home-based multi-user VR therapy and home-based single-user VR therapy.


Crossover, randomized trial


Initial training and evaluations occurred in a rehabilitation hospital; the interventions took place in participants’ homes


Stroke survivors with chronic upper extremity impairment (n=20)


4 weeks of in-home treatment using a custom, multi-user virtual reality system (VERGE): two weeks of both multi-user (MU) and single-user (SU) versions of VERGE. The order of presentation of SU and MU versions was randomized such that participants were divided into two groups, first multi-user (FMU) and first single-user (FSU).

Main Outcome Measures

We measured arm displacement during each session (meters) as the primary outcome measure. Secondary outcome measures include: time participants spent using each MU and SU VERGE, and Intrinsic Motivation Inventory (IMI) scores. Fugl-Meyer Upper-Extremity (FMUE) score and compliance with prescribed training were also evaluated. Measures were recorded before, midway, and after the treatment. Activity and movement were measured during each training session.


Arm displacement during a session was significantly affected the mode of therapy (MU: 414.6m, SU: 327.0m, p=0.019). Compliance was very high (99% compliance for MU mode and 89% for SU mode). Within a given session, participants spent significantly more time training in the MU mode than in the SU mode (p=0.04). FMUE score improved significantly across all participants (Δ3.2, p=0.001).


Multi-user VR exercises may provide an effective means of extending clinical therapy into the home.

via Home-based upper extremity stroke therapy using a multi-user virtual reality environment: a randomized trial – Archives of Physical Medicine and Rehabilitation

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[Abstract] The influence of virtual reality on rehabilitation of upper limbs and gait after stroke: a systematic review – Full Text PDF


Stroke is the leading cause of functional disability in adults. Its neurovascular origin and injury location indicates the possible functional consequences. Virtual rehabilitation (VR) using patient’s motion control is a new technological tool for conventional rehabilitation, allowing patterns of movements in varied environments, involving the patient in therapy through the playful components offered by VR applications. The objective of this systematic review is to collect data regarding the influence promoted by VR in upper limb and hemiparetic gait. Full articles published between 2009 and 2015 in english were searched and selected in PubMed, Cochrane and Pedro databases. Eleven articles included (5 for VR and upper limbs; 4 for VR, gait and balance; and 2 for VR and neural mechanisms). The articles included demonstrate efficacy in VR treatment in hemiparetic patients in the variables analyzed.

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via The influence of virtual reality on rehabilitation of upper limbs and gait after stroke: a systematic review | Journal of Innovation and Healthcare Management

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[Abstract] A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors



Stroke is a leading cause of death and disability in the Western world, and leads to impaired balance and mobility.


To investigate the feasibility of using a Virtual Reality-based dual task of an upper extremity while treadmill walking, to improve gait and functional balance performance of chronic poststroke survivors.


Twenty-two individuals chronic poststroke participated in the study, and were divided into 2 groups (each group performing an 8-session exercise program): 11 participated in dual-task walking (DTW), and the other 11 participated in single-task treadmill walking (TMW). The study was a randomized controlled trial, with assessors blinded to the participants’ allocated group. Measurements were conducted at pretest, post-test, and follow-up. Outcome measures included: the 10-m walking test (10 mW), Timed Up and Go (TUG), the Functional Reach Test (FRT), the Lateral Reach Test Left/Right (LRT-L/R); the Activities-specific Balance Confidence (ABC) scale, and the Berg Balance Scale(BBS).


Improvements were observed in balance variables: BBS, FRT, LRT-L/R, (P < .01) favoring the DTW group; in gait variables: 10 mW time, also favoring the DTW group (P < .05); and the ABC scale (P < .01). No changes for interaction were observed in the TUG.


The results of this study demonstrate the potential of VR-based DTW to improve walking and balance in people after stroke; thus, it is suggested to combine training sessions that require the performance of multiple tasks at the same time.


via A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors. – PubMed – NCBI

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[Editorial] Virtual reality in stroke rehabilitation: virtual results or real values?

1Laboratory for the Study of Mind and Action in Rehabilitation Technologies, IRCCS Fondazione Santa Lucia, Rome, Italy.

Seven Capital Devices for the Future of Stroke Rehabilitation was the title of a review published seven years ago by our group, in which we analyzed the most promising technologies for neurorehabilitation1. They were: robots, virtual reality, brain computer interfaces, wearable devices for human movement analysis, noninvasive brain stimulators (such as transcranial direct current stimulation and transcranial magnetic stimulation), neuroprostheses, and computers/tablets for electronic clinical records and planning1.

Seven years later, we can now take stock of the situation. We must be honest: on one hand, we can surely affirm that the above-proposed technologies have really been the most developed and applied in these last years, but on the other hand, we should say that questions about their efficacy are still open, as reported by Cochrane reviews highlighting the need of further studies2,3.

However, every month, new studies claiming the efficacy of technological rehabilitation are published, and this continuously-growing amount of literature reveals the lack of definitive proof; otherwise all these studies would have been unnecessary. This “efficacy paradox” could potentially give us many more years of research without any conclusive results, especially because the more technology is adaptable to the needs of the patients (as clinicians want), the less the protocol to test the efficacy of that technology is standardizable (as researchers want)4.

Furthermore, the pressure on researchers to publish, the optimism about the use of technologies of some clinicians, the hopes of patients and their caregivers about new miraculous approaches, and the commercial interests of technology companies, may lead to some misleading claims in the mass media. For example, in many scientific and journalistic papers, some electromechanical devices without any intelligence on board are improperly called “robots”, nonimmersive video games are called “virtual reality”, the expressions “mind power” or “force of thought” are associated with brain computer interfaces1. Market analysts expect that the greatest developing field for robots in the next five years will be rehabilitation, compared with other fields5. Conversely, computers, the Internet and smartphones have changed our lives and were not directly developed for rehabilitation, but this clinical field may benefit from all the developed know-how. Virtual reality should be differentiated by video games, referring to a high-end user-computer interface involving real-time stimulation based on the three “I’s”: immersive experience, interaction, and imagination6.

In this scenario, the recent study by Ogun and colleagues clearly shows all the potentials of using a Leap Motion controller interfaced with 3D immersive virtual reality to improve the upper extremity functions in patients with ischemic stroke7. The Leap Motion controller is an optical tracking system including three infrared light emitters and two infrared cameras for tracking hand and finger kinematics, interfacing them with a virtual environment developed as a human-computer interface. In 2014, our group published the first feasibility pilot study proposing the use of Leap Motion in neurorehabilitation, noting its advantageous features: it is precise, markerless, low-cost, small, and easy to use8.

Ogun and colleagues have confirmed our intuition: they found that virtual reality rehabilitation guided by a Leap Motion controller appeared to be effective in improving upper extremity function and self-care skills (but not functional independence), more than conventional therapy, in a wide sample of patients7.

Many studies have reported that the sense of presence, of body ownership and agency elicited by virtual reality are similar to those in the real environment, and daily life activities have been replicated in virtual environments for training patients. But what is the real value of virtual reality in rehabilitation if it is just a replication of a real environment? Virtual reality can also elicit amusement, arousal and valence, even more than in the real environment, as happens in virtual reality-based video games. Amusement can improve participation, arousal can improve brain activities, valence can improve learning9. It seems to be time for a generation of amusing and immersive virtual reality for improving real outcomes in neurorehabilitation.


1. Iosa M, Morone G, Fusco A, Bragoni M, Coiro P, Multari M, et al. Seven capital devices for the future of stroke rehabilitation. Stroke Res Treat. 2012;2012:187965. [ Links ]

2. Mehrholz J, Pohl M, Platz T, Kugler J, Elsner B. Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst Rev. 2018 Sep;9:CD006876. [ Links ]

3. Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2017 Nov;11:CD008349. [ Links ]

4. Iosa M, Morone G, Cherubini A, Paolucci S. The Three laws of neurorobotics: a review on what neurorehabilitation robots should do for patients and clinicians. J Med Biol Eng. 2016;36(1):1–11. [ Links ]

5. Ugalmugale S, Mupid S. Healthcare assistive robot market size by product. City: Global Market Insights, 2017. [ Links ]

6. Burdea GC, Coiffet P. Virtual reality technology. 2nd ed. Hoboken, NJ: John Wiley & Sons; 2003. [ Links ]

7. Ögün1 MN, Kurul R, Yaşar MF, Turkoglu SA, Avcı S, Yildiz N. Effect of leap motion-based 3D immersive virtual reality usage on upper extremity function in ischemic stroke patients. Arq Neuropsiquiatr 2019;77(10):681-88. [ Links ]

8. Iosa M, Morone G, Fusco A, Castagnoli M, Fusco FR, Pratesi L, et al. Leap motion controlled videogame-based therapy for rehabilitation of elderly patients with subacute stroke: a feasibility pilot study. Top Stroke Rehabil. 2015 Aug;22(4):306–16. [ Links ]

9. Tieri G, Morone G, Paolucci S, Iosa M. Virtual reality in cognitive and motor rehabilitation: facts, fiction and fallacies. Expert Rev Med Devices. 2018 Feb;15(2):107–17. [ Links ]


via Virtual reality in stroke rehabilitation: virtual results or real values?

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[ARTICLE] Effects of virtual reality-based planar motion exercises on upper extremity function, range of motion, and health-related quality of life: a multicenter, single-blinded, randomized, controlled pilot study – Full Text



Virtual reality (VR)-based rehabilitation is considered a beneficial therapeutic option for stroke rehabilitation. This pilot study assessed the clinical feasibility of a newly developed VR-based planar motion exercise apparatus (Rapael Smart Board™ [SB]; Neofect Inc., Yong-in, Korea) for the upper extremities as an intervention and assessment tool.


This single-blinded, randomized, controlled trial included 26 stroke survivors. Patients were randomized to the intervention group (SB group) or control (CON) group. During one session, patients in the SB group completed 30 min of intervention using the SB and an additional 30 min of standard occupational therapy; however, those in the CON group completed the same amount of conventional occupational therapy. The primary outcome was the change in the Fugl–Meyer assessment (FMA) score, and the secondary outcomes were changes in the Wolf motor function test (WMFT) score, active range of motion (AROM) of the proximal upper extremities, modified Barthel index (MBI), and Stroke Impact Scale (SIS) score. A within-group analysis was performed using the Wilcoxon signed-rank test, and a between-group analysis was performed using a repeated measures analysis of covariance. Additionally, correlations between SB assessment data and clinical scale scores were analyzed by repeated measures correlation. Assessments were performed three times (baseline, immediately after intervention, and 1 month after intervention).


All functional outcome measures (FMA, WMFT, and MBI) showed significant improvements (p < 0.05) in the SB and CON groups. AROM showed greater improvements in the SB group, especially regarding shoulder abduction and internal rotation. There was a significant effect of time × group interactions for the SIS overall score (p = 0.038). Some parameters of the SB assessment, such as the explored area ratio, mean reaching distance, and smoothness, were significantly associated with clinical upper limb functional measurements with moderate correlation coefficients.


The SB was available for improving upper limb function and health-related quality of life and useful for assessing upper limb ability in stroke survivors.


Virtual reality (VR)-based rehabilitation is being increasingly used for post-stroke rehabilitation []. A recent systematic review mentioned that VR is an emerging treatment option for upper limb rehabilitation among stroke patients []. The benefits of VR include real-time feedback, easy adaptability, and the provision of safe environments that mimic the real world []. The gaming property of VR allows patients to experience fun, active participation, positive emotions, and engagement []. Therefore, rehabilitation with VR enables more intense and repetitive training, which is important for rehabilitation and the promotion of neural plasticity [].

VR systems commonly used in the entertainment industry, such as Wii and Kinect, could be used for rehabilitation. However, these game-like systems are only applicable to patients with muscle strength above a certain value, thus limiting their use by more affected patients. Therefore, adjunct therapies, such as functional electrical stimulation and robotics, have been combined with these systems []. However, those adjunct therapies are costly and require continuous monitoring by healthcare professionals because of safety concerns []. Therefore, their use is restricted to clinical settings, and they are not actively used for telerehabilitation or home-based rehabilitation. A non-motorized or non-assisted device is required for more active use of VR for rehabilitation.

We developed the Rapael Smart Board™ (SB; Neofect Inc., Yong-in, Korea), which is a VR-based rehabilitation device incorporating planar motion exercise that does not require additional gravity compensation. This two-dimensional planar movement with full gravitational support, which lessens the need for antigravity muscle facilitation, allows for much easier participation than three-dimensional movement under gravity. Additionally, it is known to be safe and easy to learn, and it has been shown to improve motor ability with less aggravation of shoulder pain and spasticity; therefore, it is useful to patients with reduced motor ability []. Planar motion exercises provoke less maladaptive compensatory movements. Additionally, the nearly zero friction of the linear guides enable a wide range of repetitive active range of motion (AROM) exercises. Furthermore, the SB adopted Rapael Clinic software that was originally developed for patients with disabilities and has proven efficacy for stroke rehabilitation []. Therefore, the SB, which has multiple advantages because of its hardware and software, might be beneficial for the functional improvement of the upper extremities. Moreover, the SB could have a role as an assessment tool because VR has been reported to be useful for objective kinematic measurements of the upper extremities [].

The present pilot study aimed to assess the availability of this newly developed VR-based rehabilitation device incorporating planar exercises for the upper extremities as an intervention and assessment tool among stroke patients in the chronic phase of recovery. To assess the availability in terms of clinical effectiveness, we compared the effects of an intervention involving the SB and that involving dose-matched occupational therapy (OT) on upper extremity function and health-related quality of life (HRQoL). We also investigated the correlations between kinematic data from the SB and data from clinical scales regarding upper extremity function.


Continue —>  Effects of virtual reality-based planar motion exercises on upper extremity function, range of motion, and health-related quality of life: a multicenter, single-blinded, randomized, controlled pilot study | SpringerLink

Fig. 1Hardware of the Smart Board. The board and forearm-supported controller. Three linear guides with an H-shape configuration enable two-dimensional planar motion of the handlebar, which is attached to the horizontal linear guide

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[WEB PAGE] Restoring Veterans’ Health Through Virtual Reality

POST WRITTEN BY Eran Orr. Eran Orr is the founder of XRHealth, the leader in extended reality and therapeutic applications.



Veterans returning home from war zones after serving in combat face a myriad of health concerns. Most of these concerns have to do with pain. A 2016 survey by the NIH found that 65.5% of U.S. military veterans said they have pain, and the pain is severe for 9.1% of the group surveyed. Whether it is reported in a vet’s back, neck, knees or shoulders, the pain usually persists. Chronic pain (pain that lasts for more than 12 weeks) affects many of the 20 million U.S. veterans.

And on too many occasions, it isn’t properly treated.

All of these difficult issues, including nonspecific physical complaints, such as fatigue, cognitive disturbances, memory or concentration problems, are tied together. Far too often, you’ll see these problems getting lumped into what’s known as post-traumatic stress disorder (PTSD). This is a serious psychological issue that garners its fair share of attention and sometimes unhelpful distortion from the news and entertainment media.

The question for far too many years has been: What can be done about it? How do we provide veterans with meaningful healthcare and rehabilitation that can help ease them back to their normal lives again? We’re learning that virtual reality (VR), delivered through technologically advanced headsets, can have an impact on the treatment of chronic pain and could become a powerful alternative to opioid interventions. Years ago, this was something that couldn’t have been imagined, but the same gear associated with video gaming and entertainment is indeed helping veterans with pain management, physical rehabilitation and the cognitive disorders associated with PTSD.

I am a cofounder and CEO of a company that in the last four years has sought to elevate the use of extended reality and therapeutic applications for healthcare. But it goes much deeper than that. As a military man in the Israeli Air Force, I toiled in the field of physical therapy with specific expertise in spinal cord damage prevention. I myself also experienced a long but successful injury rehabilitation process, which included VR as a means to heal. That experience convinced me that the use of virtual reality could change healthcare for the better.

What VR can provide and the reason it can be so effective for the patient is that it creates an immersive 360-degree world. Patients are guided through this virtual world with sophisticated software on virtual reality headsets, which provides a smooth and relaxing environment. The patient’s focus is redirected while being guided through a virtual world that provides a distraction from the pain or anxiety they are being treated for. Many patients get to the point where they are tricked into really believing they are in another reality.

2019 study with 120 participants looked at on-demand VR therapy compared to specialized “health and wellness” television programming for pain reduction in hospitalized patients. The results showed that VR was “significantly” better at reducing pain and was “most effective” as a remedy for severe pain. Today, VR is also being used as a vehicle for a treatment technique called exposure therapy. For example, one such program called Virtual Iraq immerses veterans from the Iraq war suffering from chronic PTSD in an environment that, according to Veterans Families United, produces “visuals of a war zone and … the other senses, sound, smell, touch that is experienced in a war zone.” The hope is that the everyday things that can trigger fear and panic become insignificant through virtual repetition and the reactions to the memory become disconnected from the memory itself.

An additional benefit of virtual reality is that when it is incorporated with artificial intelligence, it can be the basis of gaining comprehensive real-time data from the vet’s work with the headset. The data provides an opportunity for a therapist to adjust the program immediately if need be. The data can also be made available instantly to the patient and shared with other veterans. Despite recent advances, more attention and research will need to be applied to the treatment of veterans utilizing virtual reality. Market education is the toughest challenge right now. AR/VR platforms for therapeutic purposes are aimed at providing clinicians with an option to better manage their patients’ care via specialized extended reality technology solutions and data analysis. It is our job to educate the marketplace and continue to provide clinical evidence to the United States Food and Drug Administration (FDA) that the platform is worthy of designation as a medical device.

In the meantime, wider adoption of this tech by more healthcare organization leaders would help position VR as a routine treatment option. There are many companies out there, such as AppliedVR and BehaVR, that are also working toward the same health-related, therapeutic goals, especially in pain management. As an industry, we understand and can demonstrate how VR/AR therapy supports rehabilitation services, cognitive assessment and training, and pain management. Conversations with healthcare leaders about how it works and its enormous potential will need to continue so they can see this tech in operation.

Perhaps the tipping point for the adoption of VR therapy platforms will occur once it becomes designated as a medical device. When it happens, I believe you could eventually see VR headsets in every hospital, every nursing home and every healthcare facility in the next couple of years. More than any other subset of the population, military personnel are familiar with VR as used as a digital training tool for war exercises and other training. This familiarity is an ideal rationale for continued strategic advances in VR healthcare therapy and the development of VR medical devices, incorporating hardware and software that can be widely used to provide a significant variety of post-deployment treatment for veterans.


via Council Post: Restoring Veterans’ Health Through Virtual Reality

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[ARTICLE] Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE): A pilot clinical trial for chronic traumatic brain injury – Full Text



Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation. However, little is known about the effectiveness of VR rehabilitation for TBI-related cognitive deficits. In response to these clinical and research gaps, we developed Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), an intervention designed to improve cognitive performance, driving safety, and neurobehavioral symptoms.


This pilot clinical trial was conducted to examine feasibility and preliminary efficacy of NeuroDRIVE for rehabilitation of chronic TBI.


Eleven participants who received the intervention were compared to six wait-listed participants on driving abilities, cognitive performance, and neurobehavioral symptoms.


The NeuroDRIVE intervention was associated with significant improvements in working memory and visual search/selective attention— two cognitive skills that represented a primary focus of the intervention. By comparison, no significant changes were observed in untrained cognitive areas, neurobehavioral symptoms, or driving skills.


Results suggest that immersive virtual environments can provide a valuable and engaging means to achieve some cognitive rehabilitation goals, particularly when these goals are closely matched to the VR training exercises. However, additional research is needed to augment our understanding of rehabilitation for driving skills, cognitive performance, and neurobehavioral symptoms in chronic TBI.

1. Introduction

Each year, emergency departments treat approximately 2.5 million traumatic brain injuries (TBIs) (). TBI can affect a wide range of brain systems, resulting in sensorimotor deficits (e.g., coordination, visual perception), cognitive deficits (e.g., memory, attention), emotional dysregulation (e.g., irritability, depression), and somatic symptoms (e.g., headache, fatigue) (). These TBI-related impairments can have significant life consequences. Studies conducted across a wide range of neurological and psychiatric conditions show that neuropsychological abilities are strongly associated with functional skills and employment outcomes (). For example, challenges in attention and concentration could result in distractibility and errors in work settings, and deficits in executive functions could lead to poor organization and problems with setting and achieving occupational goals. As many as 3.2–5.3 million people in the US are living with TBI-related disability ().

Rehabilitation has been shown to improve outcomes for those experiencing chronic effects of TBI (). Previously-validated rehabilitation approaches for TBI include both ‘cognitive’ and ‘functional’ approaches. ‘Cognitive’ methods of rehabilitation are focused on improving performance on individual cognitive tasks, with the hope that these gains will generalize to functional activities (). Restorative cognitive training approaches have been shown to improve cognitive functioning across multiple conditions such as schizophrenia, traumatic brain injury, and normal aging (). Some of the most promising results to date have been demonstrated for training of attention and working memory, which have been shown to correspond to changes in functional brain activity (). Evidence suggests that the format of therapist-guided rehabilitation is able to harness some of the well-established benefits of the therapeutic relationship, and may be preferable to computer-guided training (). While there is some evidence indicating that benefits of cognitive remediation extend to untrained tasks, a number of studies have shown that improvements in performance on individual cognitive tasks tend to generalize very weakly, if at all, to other cognitive tasks and functional abilities (). This weak transfer of training might be attributable to low levels of correspondence between the cognitive and sensorimotor demands of rehabilitation tasks and those encountered during challenging real-world situations.

In contrast to methods of rehabilitation that rely upon generalization of cognitive benefits to functional outcomes, ‘functional’ methods of rehabilitation focus on improving performance on real-life activities through direct practice of those activities (). This approach requires effective targeting of specific functional tasks that are relevant to each patient and may be limited by the physical environments available within the treatment setting (e.g., a simulated home environment used to practice activities of daily living). However, the basic functional tasks that are often emphasized in functional rehabilitation (e.g., self-care, food preparation) may not be sufficiently challenging to address more subtle or ‘higher order’ cognitive and functional deficits that many mild to moderate TBI patients experience in the long-term phase of recovery ().

Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation (). The guiding concept for VR rehabilitation is to provide an immersive, engaging, and realistic environment in which to practice cognitive, sensorimotor, and functional skills. VR scenarios can simulate a wide range of real or imagined tasks and environments. While VR may not be necessary for tasks that are easily recreated in existing therapy environments, it is particularly well-suited for tasks that are challenging or dangerous to recreate within real-world treatment environments, such as driving an automobile ().

Driving is one of the most universal, cognitively challenging, and potentially-dangerous activities of everyday life. Safe driving requires continuous synchronization of processes like reaction time, visuo-spatial skills, attention, executive function, and planning (). Whereas it would be obviously unsafe to place an impaired patient into many real-world driving situations, VR allows for safe assessment and rehabilitation of driving-relevant skills at the true limits of the individual’s current capabilities. Individuals with TBI are at elevated risk for motor vehicle accidents and other driving difficulties (). Many individuals with severe TBI never return to driving (), and an estimated 63% of those with severe TBI who do return to driving are involved in motor vehicle accidents (). Available evidence suggests that deficits in attention and visual search may underlie these driving impairments. While most of this research has been conducted with moderate-to-severe TBI populations, these issues are not exclusive to severe forms of TBI. Individuals recovering from mild TBI have also been found to exhibit slower detection of driving hazards in simulated driving experiments () and to be at increased risk for real-world motor vehicle accidents ().

Previous results suggest that VR driving rehabilitation can be effective for improving driving skills among those with moderate-to-severe TBI (). However, these findings have not been replicated or validated for those with symptomatic mild TBI. Additionally, little is known about the effectiveness of VR rehabilitation programs for TBI-related cognitive deficits (). In response to these clinical and research gaps, we developed an intervention known as Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), which was designed to improve cognitive performance and overall driving safety by providing integrated training in these skills. In contrast to intervention approaches that are geared toward more severely impaired individuals, NeuroDRIVE was designed for use with a wide range of TBI patients (i.e., mild, moderate, or severe TBI) who are seeking treatment in these areas and have the capability to engage in the driving process. This pilot clinical trial examined feasibility and preliminary efficacy of NeuroDRIVE for improving VR driving performance, cognitive performance, and symptom outcomes among those with chronic TBI. Given the focus of the intervention, effects on attention and working memory were of particular interest. Additionally, we have provided the NeuroDRIVE treatment manual as a supplementary document to facilitate continued development of VR rehabilitation for those with TBI.



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T3 VR Driving Simulator.

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