Archive for category Virtual reality rehabilitation

[ARTICLE] Non-Immersive Virtual Reality for Post-Stroke Upper Extremity Rehabilitation: A Small Cohort Randomized Trial – Full Text

Abstract

Immersive and non-immersive virtual reality (NIVR) technology can supplement and improve standard physiotherapy and neurorehabilitation in post-stroke patients. We aimed to use MIRA software to investigate the efficiency of specific NIVR therapy as a standalone intervention, versus standardized physiotherapy for upper extremity rehabilitation in patients post-stroke. Fifty-five inpatients were randomized to control groups (applying standard physiotherapy and dexterity exercises) and experimental groups (applying NIVR and dexterity exercises). The two groups were subdivided into subacute (<six months post-stroke) and chronic (>six months to four years post-stroke survival patients). The following standardized tests were applied at baseline and after two weeks post-therapy: Fugl–Meyer Assessment for Upper Extremity (FMUE), the Modified Rankin Scale (MRS), Functional Independence Measure (FIM), Active Range of Motion (AROM), Manual Muscle Testing (MMT), Modified Ashworth Scale (MAS), and Functional Reach Test (FRT). The Kruskal–Wallis test was used to determine if there were significant differences between the groups, followed with pairwise comparisons. The Wilcoxon Signed-Rank test was used to determine the significance of pre to post-therapy changes. The Wilcoxon Signed-Rank test showed significant differences in all four groups regarding MMT, FMUE, and FIM assessments pre- and post-therapy, while for AROM, only experimental groups registered significant differences. Independent Kruskal–Wallis results showed that the subacute experimental group outcomes were statistically significant regarding the assessments, especially in comparison with the control groups. The results suggest that NIVR rehabilitation is efficient to be administered to post-stroke patients, and the study design can be used for a further trial, in the perspective that NIVR therapy can be more efficient than standard physiotherapy within the first six months post-stroke.

1. Introduction

Stroke Alliance for Europe states that “every 20 s, someone in Europe has a stroke”, while in the United States, “someone has a stroke every 40 s” a leading cause of significant long-term disabilities [1,2]. According to a European Union (EU) report, Romania has the lowest annual healthcare expenditure per capita (€1029 in 2015, compared to the EU average of €2884). The highest risk factors of a stroke are smoking and alcohol drinking, with males accounting for more than 50% of those impacted. Additionally, the level of education influences both lifestyle and life expectancy, with the Romanian life expectancy being among the lowest in the EU (75.3 years in Romania versus 80.9 years in the EU, in 2015). Moreover, there were 61,552 stroke cases in Romania in 2015 and forecasts state that this number will increase by 24% until 2035 [3,4].Worldwide, the population faces high incidence rates of stroke and post-stroke sequelae with an increased need for neurorehabilitation services. In Europe, it is estimated that the number of annual stroke events will increase from 613,148 registered in 2015 to 819,771 in 2035, an increase of 34%. Considering that post-stroke survival rates have improved; estimations predict that the number of people living with strokes in Europe will grow from 3,718,785 in 2015 to 4,631,050 in 2035 [1].Stroke complications can be long-lasting; thus, at 15-years post-stroke, two-thirds of survivors live with a disability, nearly two of five suffer from depression, and more than a quarter have cognitive impairment [5]. Post-stroke disability significantly contributes to the increasing use of long-term medical care resources, thus highlighting that efficient rehabilitation can cut costs in the healthcare system [6] whereas telerehabilitation is still in the early phase of utilization in developing countries.Furthermore, international guidelines for stroke rehabilitation include physiotherapy techniques and methods for the recovery of the swallowing function and the urinary and bowel continence. These techniques and methods are also recommended for the improvement/prevention of shoulder pain, joint misalignments, and limb deviations caused by post-stroke spasticity, also used for secondary prevention of falling, as well as for enhancing the ability to perform self-care and daily living activities. Recovery from post-stroke impairments is facilitated, on the one hand, by increasing the motor function and, on the other hand, by improving the functionality of the limbs and body as a whole functional unit. In order to retrieve functional capacity, the existing guidelines recommend the use of intensive, repetitive training, improvement of functional mobility, use of orthoses, performing specific activities of daily living (ADLs) practiced repeatedly, progressive and bilateral training of the upper limb, the use of virtual reality and assisted robotic therapy, and the use of strength training exercises [7,8,9].The use of virtual reality technology as an adjunct or substitute for traditional physiotherapy has been studied and proved to be effective in improving patients’ functional rehabilitation. However, as regards strokes, some systematic reviews suggest that virtual reality (VR) has not brought more benefits to patients compared to standard physiotherapy alone, while other research advocates for specific VR training as a therapy with a better outcome compared to conventional physiotherapy in the rehabilitation of stroke survivors [10,11,12,13,14].Research on neuroplasticity and learning or relearning abilities shows that there are several principles of motor learning, including multisensory stimulation, explicit feedback, knowledge of results, and motor imagery. These principles, notably explicit feedback and multisensory stimulation, are found in the VR technology used for neuromotor rehabilitation. Accordingly, VR therapy becomes an alternative to classical physiotherapy, as it develops neuroplasticity. So, novel enriched environments are preferred in the context of current rehabilitation methods since guidelines do not provide an accurate record of evidence inferred from the specialized literature about motor skill learning. This evidence is essential in identifying practical methods and applications that could shape future approaches to neuromotor relearning. Furthermore, in animal research, it has been shown that aerobic exercise and environmental enrichment have pleiotropic actions that influence the occurrence of molecular changes associated with stroke and subsequent spontaneous recovery. These aspects may argue in favor of the efficient use of VR in motor and functional recovery after a stroke, by stimulating neuroplasticity [15,16].Over the past ten years, research and literature reviews regarding the use of VR in post-stroke recovery have been homogeneous. Many approaches have focused on the use of VR as adjunct therapy alongside standard physiotherapy, and in some studies, non-dedicated VR technologies have been used, for medical purposes, in the motor rehabilitation of post-stroke patients [17,18]. Previous research on NIVR and immersive VR-based activities suggests that these interventions improve upper extremity rehabilitation after a stroke by providing motivating environments, stimulating extrinsic feedback, or simulating gameplay to facilitate recovery. Besides non-immersive VR therapy use in post-stroke patient’s rehabilitation, immersive VR therapy is used but requires more space and is more expensive, compared to NVIR. Robotic therapy is gaining more ground in neuro-motor rehabilitation, but the costs are very high, and in the case of exoskeletons, complex technology requires a long period of time for physiotherapists to acquire skills in the use of equipment. Currently, research has shown that VR positively influences the recovery of the upper extremity in post-stroke patients, as an adjunct therapy, by using dedicated and non-dedicated technologies [19,20]. The VR action on upper extremity post-stroke rehabilitation, using dedicated NVIR technology as a standalone therapy has not yet been determined at a staged level according to the post-stroke phases. The present study aims to investigate the efficiency of a dedicated NIVR system used in the rehabilitation of patients with subacute and chronic stroke, on upper extremity functionality and motor function. The research was done through specific VR training that incorporates real-time 3D motion capture and built-in visual feedback which provide functional exercises designed to train and regain the neuromotor functions of the upper extremity.Our main goal was to evaluate the efficiency of the proposed protocol, by using staged, specific, and customized NIVR therapy on three levels of difficulty and by using specific exergames according to patient’s capacity, and adjusted by the level of difficulty, compared to standard physiotherapy. Besides, we were looking for differences in post-stroke clinical and functional status in the use of VR that improve or negatively influence the functional outcomes of the upper extremity when exposed to VR-based therapy compared to standard physiotherapy. […]

Continue —-> https://www.mdpi.com/2076-3425/10/9/655/htm

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[Abstract + References] A Virtual Reality Serious Game for Hand Rehabilitation Therapy – IEEE Conference Publication

Abstract

The human hand is the body part most frequently injured in occupational accidents, accounting for one out of five emergency cases and often requiring surgery with subsequently long periods of rehabilitation. This paper proposes a Virtual Reality game to improve conventional physiotherapy in hand rehabilitation, focusing on resolving recurring limitations reported in most technological solutions to the problem, namely the limited diversity support of movements and exercises, complicated calibrations and exclusion of patients with open wounds or other disfigurements of the hand. The system was assessed by seven able-bodied participants using a semistructured interview targeting three evaluation categories: hardware usability, software usability and suggestions for improvement. A System Usability Score (SUS) of 84.3 and participants’ disposition to play the game confirm the potential of both the conceptual and technological approaches taken for the improvement of hand rehabilitation therapy.

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Source: https://ieeexplore.ieee.org/abstract/document/9201789

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[Abstract + References] Virtual and Augmented Reality Platform for Cognitive Tele-Rehabilitation Based System – Conference paper

Abstract

Virtual and Augmented Reality systems have been increasingly studied, becoming an important complement to traditional therapy as they can provide high-intensity, repetitive and interactive treatments. Several systems have been developed in research projects and some of these have become products mainly for being used at hospitals and care centers. After the initial cognitive rehabilitation performed at rehabilitation centers, patients are obliged to go to the centers, with many consequences, as costs, loss of time, discomfort and demotivation. However, it has been demonstrated that patients recovering at home heal faster because surrounded by the love of their relatives and with the community support.

References

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Source: https://link.springer.com/chapter/10.1007/978-3-030-58796-3_17

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[BLOG POST] Advanced Integration of Virtual Reality in Physical Therapy

Written by: Arik Yates, PTA

Virtual Reality used in conjunction with the gait trainers (Pictured: Lokomat).
Virtual Reality used in conjunction with the gait trainers (Pictured: Lokomat).

In the previous blog post, we covered general integration of virtual reality into physical therapy, so let’s dig deeper today! One key thing I want to bring back up is just how simple the set up is for virtual reality. Most of Neuro Rehab VR’s exercises only require the VR headset and 2 controllers donned on the patient. Simple enough, right? For more complicated cases where integration seems more daunting, I have good news for you; applying VR continues to remain simple.

In fact, one might find that virtual reality compliments many functional positions and exercises you would normally perform within your sessions. From complex body weight support ambulation activities, to gait training, to sustaining balance in tall/half kneeling positions, and more; VR can be utilized. Below, I have compiled my experience integrating this wonderful immersive tool into patient goals from low functioning to high functioning; let’s get into it! 

First on our agenda is the standing frame. It comes in multiple forms and is even included in some electric wheelchairs. Standing frames offer a huge potential for VR utilization! Once the patient is safely up in their standing frame, knees aren’t hyper extended etc., apply the headset ensuring proper fit, and apply remotes to bilateral upper extremities with proper securing devices like active hands or ace bandages if needed. After verbal affirmation from the patient, select the Neuro Rehab VR exercise designed for their use case.

Neuro Rehab VR offers multiple therapeutic exercises that can be performed within a standing frame, but I am going to focus on Retail Therapy and Fowl Play. For Retail Therapy, despite being secured into a standing frame, focus can be put on reaching and grasping objects anterolateral with bilateral upper extremities i.e. for c5 and higher spinal cord injury patients. Doing this activity turns a static experience into a goal oriented weight bearing activity with bilateral upper-extremity and trunk usage. The same goes for Fowl Play, except no remotes are needed in the hand and all the focus is on the trunk due to having to dodge balls coming at you. Standing frames perfectly compliment the use of virtual reality. Lets move on to body weight support ambulation systems!

Virtual Reality used with the standing frame (Pictured: Omni Stand).
Virtual Reality used with the standing frame (Pictured: Omni Stand).
Virtual Reality used with the over-head body weight support system (Pictured: Zero G).
Virtual Reality used with the over-head body weight support system (Pictured: Zero G).

At first glance, body weight support ambulation systems had me scratching my head on how virtual reality could be properly integrated without taking away from the gait training aspects of these systems. With a VR headset donned, the patient is no longer paying attention to the individual intricate details of their gait, but rather focusing on the task presented in front of them within the virtual reality environment. Because of this, VR needs to be integrated at a specific time to ensure it does not inhibit the patient from working on improving gait mechanics. For instance, I have found focusing on fine tuned gait mechanics during the first portion of BWS (body weight supported) ambulation activities, then transition to focus on hammering out distance and carryover of practiced mechanics within the VR headset. When utilizing the Loko Sprint application from Neuro Rehab VR, traveling great distances is gamified by placing coins in front of the patient with slight deviations in positioning. Better yet, if their speed increases on the BWS ambulation system, so does their visible speed within the headset in real time without any modifications to settings required. Alright, onto higher functioning integration, while working on walking and static balance using VR and a BWS systems.

Patient kneels up against box in real life / a table in the VR environment.
Patient kneels up against box in real life / a table in the VR environment.

Working to improve balance with higher functioning patients within the VR space has been one of the most rewarding experiences of my career. Don’t get me wrong, working with VR in general has been incredibly rewarding no matter the level of function. By being able to challenge the patients balance by coupling balance disks, blue foam pads, bosu balls, and more, provides a level of challenge and engagement unlike anything I have seen. For example, virtual reality in a tall kneeling position adds an extra layer of challenge not found elsewhere. Due to their exercise and instruction predominantly being within the headset, the therapist gets to solely focus on the patient’s position and movement without environmental distractions, or the utilization of a technician. Lets say we have a patient requiring glute/trunk strength, so we couple tall kneeling with Fowl Play, challenging the patient to not only stabilize in that position, but also dodge balls coming at them. When working on standing balance, once a patient is stabilized on a bosu ball, blue foam pad, incline wedge, etc., don the headset on your patient and let the “magic” begin!

To reiterate, utilizing VR can seem daunting when first dipping your toes in these unfamiliar waters of new technology, but I hope your worries are lessened and your excitement for virtual reality is growing. We are just scratching the surface of the therapeutic benefits of this technological modality. Be sure to reach out for more information regarding Neuro Rehab VR’s XR Therapy System for purchase or comment your questions that can be answered in future blog posts!

Source: https://www.neurorehabvr.com/blog/2020/9/1advanced-integration-of-virtual-reality-into-physical-therapy

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[Abstract + References] Move-IT: A Virtual Reality Game for Upper Limb Stroke Rehabilitation Patients – Conference paper

Abstract

Stroke rehabilitation plays an important role in recovering the lifestyle of stroke survivors. Although existing research proved the effectiveness and engagement of Non-immersive Virtual Reality (VR) based rehabilitation systems, however, limited research is available on the applicability of fully immersive VR-based rehabilitation systems. In this paper, we present the development and evaluation of “Move-IT” game designed for domestic upper limb stroke patients. The game incorporates the use of Oculus Rift Head Mounted Display (HMD) and the Leap Motion hand tracker. A user study of five upper limb stroke patients was performed to evaluate the application. The results showed that the participants were pleased with the system, enjoyed the game and found it was exciting and easy to play. Moreover, all the participants agreed that the game was very motivating to perform rehabilitation exercises.

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  13. 13.Grimm, F., Gharabaghi, A.: Closed-loop neuroprosthesis for reach-to-grasp assistance: combining adaptive multi-channel neuromuscular stimulation with a multi-joint arm exoskeleton. Front. Neurosci. 10, 284 (2016)Google Scholar
  14. 14.Dörner, R., Göbel, S., Effelsberg, W., Wiemeyer, J. (eds.): Serious Games, Foundations, Concepts and Practice. Springer, Cham (2016).  https://doi.org/10.1007/978-3-319-40612-1CrossRefGoogle Scholar
  15. 15.Yagv, B.: Overview of virtual reality technologies. In: Presented at the Interactive Multimedia Conference, University of Southampton, United Kingdom (2013)Google Scholar

Source: https://link.springer.com/chapter/10.1007/978-3-030-58796-3_23

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[ARTICLE] Virtual reality-based treatment for regaining upper extremity function induces cortex grey matter changes in persons with acquired brain injury – Full Text

Abstract

Background

Individuals with acquired brain injuries (ABI) are in need of neurorehabilitation and neurorepair. Virtual anatomical interactivity (VAI) presents a digital game-like format in which ABI survivors with upper limb paresis use an unaffected limb to control a standard input device and a commonplace computer mouse to control virtual limb movements and tasks in a virtual world.

Methods

In a prospective cohort study, 35 ambulatory survivors of ABI (25/71% stroke, 10/29% traumatic brain injury) were enrolled. The subjects were divided into three groups: group A received VAI therapy only, group B received VAI and physical/occupational therapy (P/OT), and group C received P/OT only. Motor skills were evaluated by muscle strength (hand key pinch strength, grasp, and three-jaw chuck pinch) and active range of motion (AROM) of the shoulder, elbow, and wrist. Changes were analyzed by ANOVA, ANCOVA, and one-tailed Pearson correlation analysis. MRI data was acquired for group A, and volumetric changes in grey matter were analyzed using voxel-based morphometry (VBM) and correlated with quantified motor skills.

Results

AROM of the shoulder, elbow, and wrist improved in all three groups. VBM revealed grey matter increases in five brain areas: the tail of the hippocampus, the left caudate, the rostral cingulate zone, the depth of the central sulcus, and the visual cortex. A positive correlation between the grey matter volumes in three cortical regions (motor and premotor and supplementary motor areas) and motor test results (power and AROM) was detected.

Conclusions

Our findings suggest that the VAI rehabilitation program significantly improved motor function and skills in the affected upper extremities of subjects with acquired brain injuries. Significant increases in grey matter volume in the motor and premotor regions of affected hemisphere and correlations of motor skills and volume in nonaffected brain regions were present, suggesting marked changes in structural brain plasticity.

Background

Neurological disorders, including acquired brain injuries (ABIs) are important causes of disability and death worldwide [12]. Although age-standardized mortality rates for ischemic and hemorrhagic strokes have decreased in the past two decades, the absolute number of stroke survivors is increasing, with most of the burden in low- and middle-income countries [3]. Another major issue is that trends toward increasing stroke incidence at younger ages has been observed [4]. Moreover, this type of ABI is the leading cause of long-term disability in the United States, with an estimated incidence of 795,000 strokes yearly [2].

In more than 80% of stroke survivors, impairments are seen in at least one of the upper limbs. Six months after a stroke, 38% of patients recover some dexterity in the paretic arm, though only 12% recover substantial function even in spite of having received physical/occupational therapy (P/OT) [5]. Only a few survivors are able to regain some useful function of the upper limb. Failing to achieve useful function has highly negative impacts on the performance of daily living activities [67]. Regaining control and improving upper limb motor function after ABIs are therefore crucial goals of motor system rehabilitation. In left-sided limb impairment, neglect syndrome can contribute to a worsened clinical state, making the alleviation of symptoms even more difficult to achieve. Mirror therapy has been reported as a promising approach to improve neglect symptoms [89].

MRI has been used to track changes in brain connectivity related to rehabilitation [10], and several studies of healthy individuals playing off-the-shelf video games have demonstrated changes in the human brain resulting from interactions in a virtual world (VW) [1112]. Furthermore, playing video games results in brain changes associated with regaining improved, purposeful physical movements [1314]. The socio-cultural relevance of virtual reality (VR) and VW applications lies, more generally, in the fact that these technologies offer interactive environments to users. These interactive environments are actually present in the users’ experiences while less so in the world they share as biological creatures [15]. The way in which we engage with VWs allows for rehabilitation exercises and activities that feel similar to their actual physical world counterparts [11]. In the past two decades, researchers have demonstrated the potential for the interactive experiences of VWs to provide engaging, motivating, less physically demanding, and effective environments for ABI rehabilitation [916,17,18].

One of the suitable rehabilitation methods seems to be exercises and tasks in VW called virtual anatomical interactivity (VAI) [19]. This method provides sensory stimulation / afferent feedback and allows the independent control of an anatomically realistic virtual upper extremity capable of simulating human movements with a true range of motion. ABI survivors are able to relearn purposeful physical movements and regain movement in their disabled upper extremities [19]. Contrary to conventional therapy, which exercises impaired upper limbs to improve limb movement, the general VAI hypothesis is that brain exercises alone (or combined with traditional therapy) may positively influence neuroplastic functions. In the VW, subjects can move their virtual impaired limbs using their healthy hands, meaning simulated physical movements are survivor-authored. Virtual visuomotor feedback may help regain functional connectivity between the brain and the impaired limb, therefore also regaining voluntary control of the limb.

The aim of the study was to test if the shoulder, elbow, and wrist movement; hand pinch strength; and grip strength of the paretic side improved through the use of VAI exclusively or combined with P/OT for upper extremities and how these approaches improved functional outcomes measured by the Action Reach Arm Test [20]. The relationship between changes in abilities to control upper extremities and volumetric changes in cortex grey matter measured by VBM and using MRI was also explored.[…]

Continue —-> https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-020-00754-7

figure1
Examples of VAI games: multi-finger actions to pick up a spoon and drop it into a cup, tapping actions using the index and middle fingers on a remote control, removing a light bulb and reinserting it into another fixture designated by a letter of the alphabet, choosing letters of the alphabet to form words and phrases. All actions are performed by clicking and draging mouse on the appropriate body part

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[VIDEO] A Virtual Reality Therapy Solution – Neuro Rehab VR – YouTube

Our product XR Therapy System consisting of a library of various different physical therapy exercises designed for each patients specific needs and ability in therapy, with a data analytics portal to quantify patient improvements is now currently available for in-clinic use. Reach out to us at info@neurorehabvr.com to receive more information.

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[VIDEO] Virtual Reality in Physical Therapy by Neuro Rehab VR – Clip from the show Information Matrix TV – YouTube

Information Matrix TV Reviews Virtual Reality in Physical Therapy at Neuro Rehab VR with Host Laurence Fishburne

http://www.NeuroRehabVR.com

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[Abstract] Impact of virtual reality game therapy and task-specific neurodevelopmental treatment on motor recovery in survivors of stroke

Abstract

Background/Aims

This study aimed to compare the impact of virtual reality game therapy and task-specific neurodevelopmental training on the motor recovery of upper limb and trunk control, as well as physical function, in people who have had a stroke.

Methods

This randomised, assessor-blinded clinical trial was conducted with 34 patients with post-stroke duration of 135 ± 23 days. Patients with first-onset cortical stroke aged 40–60 years, Mini-Mental State Examination score >20, ability to complete a nine-hole peg test within 120 seconds, ability to lift the affected arm at shoulder level and independent standing were included. Patients were excluded if they had unilateral neglect and musculoskeletal injuries of the affected limb in the past 2 months. Outcome measures used were the Fugl-Meyer Upper Extremity Scale, Action Research Arm Test, Trunk Impairment Scale and Stroke Impact Scale-16. The virtual reality game therapy group performed interactive table tennis, boxing and discus throwing games. The neurodevelopmental treatment group underwent task-specific movements of the upper limb in sitting and standing. All patients performed 45 minutes of treatment, 5 days a week for 4 weeks.

Results

Both groups showed improvements in all measures after training (P<0.05). There was a between-group difference of 3.47 points in Fugl-Meyer Upper Extremity Scale in favour of the virtual reality game therapy.

Conclusions

Both treatment regimens resulted in equal improvements in hand dexterity and trunk control after stroke. Virtual reality game therapy improved the upper limb motor recovery of stroke survivors to a greater extent than neurodevelopmental treatment.

Source: https://www.magonlinelibrary.com/doi/abs/10.12968/ijtr.2019.0070

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[ARTICLE] Acceptability of a Mobile Phone–Based Augmented Reality Game for Rehabilitation of Patients With Upper Limb Deficits from Stroke: Case Study – Full Text

ABSTRACT

Background: Upper limb functional deficits are common after stroke and result from motor weakness, ataxia, spasticity, spatial neglect, and poor stamina. Past studies employing a range of commercial gaming systems to deliver rehabilitation to stroke patients provided short-term efficacy but have not yet demonstrated whether or not those games are acceptable, that is, motivational, comfortable, and engaging, which are all necessary for potential adoption and use by patients.

Objective: The goal of the study was to assess the acceptability of a smartphone-based augmented reality game as a means of delivering stroke rehabilitation for patients with upper limb motor function loss.

Methods: Patients aged 50 to 70 years, all of whom experienced motor deficits after acute ischemic stroke, participated in 3 optional therapy sessions using augmented reality therapeutic gaming over the course of 1 week, targeting deficits in upper extremity strength and range of motion. After completion of the game, we administered a 16-item questionnaire to the patients to assess the game’s acceptability; 8 questions were answered by rating on a scale from 1 (very negative experience) to 5 (very positive experience); 8 questions were qualitative.

Results: Patients (n=5) completed a total of 23 out of 45 scheduled augmented reality game sessions, with patient fatigue as the primary factor for uncompleted sessions. Each patient consented to 9 potential game sessions and completed a mean of 4.6 (SE 1.3) games. Of the 5 patients, 4 (80%) completed the questionnaire at the end of their final gaming session. Of note, patients were motivated to continue to the end of a given gaming session (mean 4.25, 95% CI 3.31-5.19), to try other game-based therapies (mean 3.75, 95% CI 2.81-4.69), to do another session (mean 3.50, 95% CI 2.93-4.07), and to perform other daily rehabilitation exercises (mean 3.25, 95% CI 2.76-3.74). In addition, participants gave mean scores of 4.00 (95% CI 2.87-5.13) for overall experience; 4.25 (95% CI 3.31-5.19) for comfort; 3.25 (95% CI 2.31-4.19) for finding the study fun, enjoyable, and engaging; and 3.50 (95% CI 2.52-4.48) for believing the technology could help them reach their rehabilitation goals. For each of the 4 patients, their reported scores were statistically significantly higher than those generated by a random sampling of values (patient 1: P=.04; patient 2: P=.04; patient 4: P=.004; patient 5: P=.04).

Conclusions: Based on the questionnaire scores, the patients with upper limb motor deficits following stroke who participated in our case study found our augmented reality game motivating, comfortable, engaging, and tolerable. Improvements in augmented reality technology motivated by this case study may one day allow patients to work with improved versions of this therapy independently in their own home. We therefore anticipate that smartphone-based augmented reality gaming systems may eventually provide useful postdischarge self-treatment as a supplement to professional therapy for patients with upper limb deficiencies from stroke.

Introduction

Background

Stroke induces a variety of functional impairments, as well as pain and other ailments, depending on its type and location [1]. Common deficits associated with ischemic stroke include motor function, spatial neglect, and psychological changes [1]. Motor function deficits after stroke often include partial or total loss of function of the upper or lower limbs on a given side, with associated muscle weakness, poor stamina, lack of muscle control, and even paralysis [2]. These deficits impact the patient’s independent lifestyle and decrease their performance of activities of daily living [1]. According to the National Institute of Neurological Disorders and Stroke, the most important part of rehabilitation programs is “carefully directed, well-focused, repetitive practice [3].”

Prior Work

Patients who engage in rigorous, time-intensive, and challenging therapeutic exercises after ischemic stroke tend to experience greater functional recovery, while if ignored or insufficiently treated, impairments may remain [4,5]. The dosage of motor skill practice correlates to the extent of motor recovery following a stroke [4]. In addition, the type of therapy delivered relative to patient’s impairment determines outcomes after therapy. For example, for those who have upper limb motor impairment, best therapeutic practice modifies the prescribed exercises as the patient’s symptoms evolve [5,6]. Regrettably, patients report their experiences of conventional repetitive stroke rehabilitation therapies as tedious and difficult to hold their interest, which conflicts with the fact that patient motivation is often required to obtain good clinical outcomes [710].

Rehabilitation doctors and medical staff, therefore, face a significant problem: how can they provide high intensity therapy in large quantities for upper limb impairments with this seemingly intrinsic motivational deficit? Especially problematic are patient’s therapeutic needs after their discharge from the hospital—their therapeutic needs still exist, but medical staff have substantially reduced access to the patient to provide targeted care. Given the difficulty of this problem, an insufficient percentage of patients regain the full functional potential of their upper limb after ischemic stroke [11]. This regrettable outcome motivates an ongoing search for new therapeutic approaches that provide acceptable (motivational, comfortable, and engaging) experiences, hence, effective therapy, especially at the patient’s home. 

Use of commercial augmented reality devices has found recent application in stroke rehabilitation using existing expensive commercial headsets [4,617]. However, there are few studies that assay the acceptability of augmented reality gaming system–based patient rehabilitation after stroke [10,12,1719], and then, only in a cursory fashion. For example, 30 patients recovering from stroke were surveyed for their opinions on game-based rehabilitation, and the researchers concluded that though games for patients recovering from stroke existed, they were primarily designed for efficacy, not entertainment [10]; they suggest investing in a single, affordable gaming platform for patient rehabilitation after stroke that also focuses on entertainment and provides diverse gaming content [10]. Augmented reality technology and an upper-limb assistive device were tested on 3 individuals recovering from stroke for 6 weeks, and the study reported that both the user and therapist believed that their augmented reality environment was user friendly due to the lightness of the assistive devices and the simplicity of set-up [18]. Finally, a study of 4 patients recovering from stroke who were exposed to several gaming platforms reported that manually adjusting the difficulty of games to provide a challenge and creating games with deeper story lines helped the patients stay motivated to perform their gaming exercises [17]. To the best of our knowledge, our case study is the first of its kind that analyzes the opinions of patients recovering from stroke regarding the problems of current augmented reality–specific game-based rehabilitation systems to provides insight into future designs of augmented reality game-based stroke rehabilitation systems. Augmented reality, provided by one of a variety of device designs, represents one such approach. Augmented reality projects a live camera view of a user’s environment and computer-generated objects with a variety of properties—movement and sound, typically. As an example, Pokémon Go, a smartphone-based augmented reality game, has had documented success sustaining the interest of users for extended periods of time while consistently increasing their physical activity [13], making augmented reality a prime candidate for facilitating otherwise tedious therapy.

Hypothesis

Since patient motivation often drives a larger dosage of rehabilitation therapy, hence, improved clinical outcomes [20,21], we hypothesized that augmented reality deployed on a relatively inexpensive and readily available platform—a smartphone—could provide a motivational, comfortable, and engaging rehabilitation experience. To test this hypothesis, we first developed a candidate rehabilitation game on a smartphone that could encourage a patient’s hand motions through use of simple visual cues with a custom-made app. We then asked patients with acute upper-motor stroke to use this system and report their experiences via a questionnaire that assayed the acceptability of the game in terms of motivation to continue to play, comfort, and engagement.

Methods

Overview

This acceptability study was conducted at Harborview Medical Center in Seattle, Washington from November 2018 to March 2019. Inpatients who were recovering from an acute ischemic stroke participated and provided consent. These patients had impaired strength as determined by physical and occupational therapists. To be included in the study, they had to have at least antigravity strength in deltoid or biceps muscles as well as the ability to perform internal and external shoulder rotations. All patients in this study had a Medical Research Council manual muscle score of 3 or 4 in the affected limb.

Intervention

We designed and built an augmented reality game using Unity (Unity Technologies) that is deployable on any modern smartphone with a camera (Table 1 and Figure 1). The game presents users with a view of an augmented reality dolphin swimming under the ocean with the task of capturing fish and feeding turtles, worn on the hand associated with the upper-limb deficit (Multimedia Appendix 1). To experience the game, patients wore an augmented reality headset, which did not obscure the camera mounted on the phone, and a custom device on their hand. We used two headsets—the Google Daydream headset, which required us to remove the front panel that held the phone in place, and the Merge augmented reality/virtual reality headset, which did not require any modification (Figure 1). The game also required users to place the hand associated with their motor deficits within a padded box that replaced their hand as seen in augmented reality with a dolphin (Figure 1). Finally, we required the user to look at a complex landscape through their headset while wearing the padded box and while playing the game. Instead of holding the phone, the headset supported the phone for the user. We built customized controllers with different interior sizes that changed the effective grip strength of the controller; this was important because our patients’ ability to hold the controllers varied. Viewing the complex landscape through the augmented reality system caused our software to create a seascape that contained a turtle, fish, and other underwater flora and fauna (Multimedia Appendix 1). Successful placement of the dolphin over a fish allowed the dolphin to capture the fish. Placement of the dolphin plus fish over the turtle allowed the user to feed the turtle, thereby winning points.

Notably, we used the TeamViewer (TeamViewer AG) app to project the screen view of the patient from the phone to a laptop, so we could see the patient’s view with, however, the complex landscape was also projected in the background, so we could check the viewer’s alignment with the landscape while they played (Figure 1).

Set-up of the game, to ensure that system function was verified, occurred prior to patients using the system. Patients followed verbal directions and instructions from study staff on how to use the system, facilitated by demonstration of the game using the TeamViewer app. Examples of directions included how to start the game, the actions required to pick up the fish, and how to colocate the dolphin plus fish with the turtle for point accumulation. Some patients required physical assistance to adjust the view of the environment. Examples of physical assistance included moving the patient’s chair or wheelchair closer or farther away from the images recognized by the camera (Figure 1).

Table 1. Vuforia compatible mobile devices.
Figure 1. (A) phone: Asus Zenfone 2, phone operating system: Android 7 Nougat, Unity version: 2018.2.10, developer operating system: Windows 10; (B) headsets: Google Daydream (left) Merge augmented reality/virtual reality goggles (right); (C) controllers with various grip sizes consisting of soft foam inserts; (D) virtual dolphin avatar; (E) image target; (F) study staff during game play with (1) smartphone (2) headset (3) controller (4) image target; (G) user experience.

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Source: https://rehab.jmir.org/2020/2/e17822/

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