- •Virtual reality technology improves cognitive function post-traumatic brain injury.
- •Optimal treatment protocol is; 10–12 sessions, 20–40 min in duration with 2–4 sessions per week.
- •There was weak evidence for positive effect of virtual reality on attention.
Archive for category Virtual reality rehabilitation
[Abstract] Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology
Traumatic brain injury (TBI) can causes numerous cognitive impairments usually in the aspects of problem-solving, executive function, memory, and attention. Several studies has suggested that rehabilitation treatment interventions can be effective in treating cognitive symptoms of brain injury. Virtual reality (VR) technology potential as a useful tool for the assessment and rehabilitation of cognitive processes.
The aims of present systematic review are to examine effects of VR training intervention on cognitive function, and to identify effective VR treatment protocol in patients with TBI.
PubMed, Scopus, PEDro, REHABDATA, EMBASE, web of science, and MEDLINE were searched for studies investigated effect of VR on cognitive functions post TBI. The methodological quality were evaluated using PEDro scale. The results of selected studies were summarized.
Nine studies were included in present study. Four were randomized clinical trials, case studies (n = 3), prospective study (n = 1), and pilot study (n = 1). The scores on the PEDro ranged from 0 to 7 with a mean score of 3. The results showed improvement in various cognitive function aspects such as; memory, executive function, and attention in patients with TBI after VR training.
Using different VR tools with following treatment protocol; 10–12 sessions, 20–40 min in duration with 2–4 sessions per week may improves cognitive function in patients with TBI. There was weak evidence for effects of VR training on attention post TBI.
[ARTICLE] Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study – Full Text
Virtual reality technologies show potential as effective rehabilitation tools following neuro-trauma. In particular, the Elements system, involving customized surface computing and tangible interfaces, produces strong treatment effects for upper-limb and cognitive function following traumatic brain injury. The present study evaluated the efficacy of Elements as a virtual rehabilitation approach for stroke survivors.
Twenty-one adults (42–94 years old) with sub-acute stroke were randomized to four weeks of Elements virtual rehabilitation (three weekly 30–40 min sessions) combined with treatment as usual (conventional occupational and physiotherapy) or to treatment as usual alone. Upper-limb skill (Box and Blocks Test), cognition (Montreal Cognitive Assessment and selected CogState subtests), and everyday participation (Neurobehavioral Functioning Inventory) were examined before and after inpatient training, and one-month later.
Effect sizes for the experimental group (d = 1.05–2.51) were larger compared with controls (d = 0.11–0.86), with Elements training showing statistically greater improvements in motor function of the most affected hand (p = 0.008), and general intellectual status and executive function (p ≤ 0.001). Proportional recovery was two- to three-fold greater than control participants, with superior transfer to everyday motor, cognitive, and communication behaviors. All gains were maintained at follow-up.
A course of Elements virtual rehabilitation using goal-directed and exploratory upper-limb movement tasks facilitates both motor and cognitive recovery after stroke. The magnitude of training effects, maintenance of gains at follow-up, and generalization to daily activities provide compelling preliminary evidence of the power of virtual rehabilitation when applied in a targeted and principled manner.
this pilot study was not registered.
Stroke is one of the most common forms of acquired brain injury (ABI), with around 60,000 new and recurrent strokes occurring every year in Australia alone . The clinical outcome of stroke is variable but often includes persistent upper-limb motor deficits, including weakness, discoordination, and reduced speed and mobility , and cognitive impairments in information processing and executive function [3, 4]. Not surprisingly, stroke is a leading cause of disability worldwide, and the burden of stroke across all levels of the International Classification of Functioning (ICF) – body structures/function, activity, and participation – underlines the importance of interventions that can impact multiple domains of functioning [5, 6].
Recovery of functional performance following stroke remains a significant challenge for rehabilitation specialists [7, 8], but may be enhanced by innovation in the use of new technologies like virtual reality [9, 10, 11, 12]. A critical goal is to find compelling ways of engaging individuals in their therapy by creating meaningful, stimulating and intensive forms of training . The term, virtual rehabilitation (VR), is used to describe a form of training wherein patients interact with virtual or augmented environments, presented with the aid of technology [14, 15]. The technologies can be either commercial systems (e.g. Nintendo Wii, Xbox Kinect) or those customised specifically for rehabilitation. VR offers a number of advantages over traditional therapies, including the ability to engage individuals in the simulated practice of functional tasks at higher doses [16, 17], automated assessment of performance over time, flexibility in the scaling of task constraints, and a variety of reward structures to help maintain compliance .
While evaluation research is still in its infancy, recent systematic reviews and meta-analyses show that VR can enhance upper-limb motor outcomes in stroke [10, 11, 19], yielding treatment effects of medium-to-large magnitude [10, 11], and complementing conventional approaches to rehabilitation. VR has been shown to engender high levels of engagement in stroke patients undergoing physical therapy [20, 21] and training of even moderate intensity can afford functional benefits at the activity/skill level [9, 19]. In the specific case of upper-limb VR, however, there is little available evidence that these benefits transfer to participation . Furthermore, most available data is on patients in chronic stages of recovery, with less on acute stroke . Notwithstanding this, use of VR has begun to emerge in clinical practice, recommended in Australian and international stroke guidelines as a viable adjunct in therapy to improve motor and functional outcomes [22, 23, 24].
Until recently, most VR systems have been designed to improve motor functions, with cognitive outcomes often a secondary consideration in evaluation studies [9, 10, 11]. Notwithstanding this, treatments that target both motor and cognitive functions are indicated for stroke, given evidence that cognitive and motor systems overlap at a structural and functional level [25, 26], and work synergistically in a “perception-action cycle”  in stroke patients undergoing rehabilitation . Recent studies provide preliminary evidence of improved attention and memory in stroke patients following motor-oriented VR [29, 30, 31, 32], amounting to a small-to-medium effect on cognition . When designed to address aspects of cognitive control and planning, VR has the potential to enhance dual-task control, resulting in better generalization of trained skills to daily functioning .
While evaluation research is still in its infancy, several recent customized systems (like Elements, the system evaluated here) have been deliberately designed to exploit factors known to enhance training intensity and motor learning. Informed by neuroscience and learning theory [for a recent review see 12], the Elements VR system was designed to enhance neuro-plastic recovery processes via: (1) an enriched therapeutic environment affording a natural form of user interaction via tangible computing and surface displays , which engage both the cognitive attention of participants and their motivation to explore training tasks; (2) concurrent augmented feedback (AF) on performance  offering participants additional information on the outcome of their actions to assist in re-building a sense of body position in space (aka body schema) and ability to predict/plan future actions; and (3) scaling of task challenges to the current level of motor and cognitive function , ensuring dynamic scaffolding of participants’ information processing and response capabilities. The Elements system, described in detail below and in earlier publications [37, 38], consists of a large (42 in.) tabletop surface display, tangible user interfaces, and software for presenting both goal-directed and exploratory virtual environments. Previous evaluations of the system in patients with traumatic brain injury showed improvements in both motor and cognitive performance, with transfer to activities of daily living [37, 39]. However, the impact of Elements in other forms of ABI, such as stroke, has not been evaluated.
The broad aim of current study was to evaluate the efficacy of the Elements VR interactive tabletop system for rehabilitation of motor and cognitive functions in sub-acute stroke, compared with treatment as usual (TAU). We were particularly interested in motor and cognitive outcomes, their relationship, and the transfer and maintenance of treatment effects. Training-related changes at the activity/skill level on standardized measures of motor and cognitive performance were investigated, together with functional changes. By offering an engaging, principled and customized form of interaction, we predicted that the Elements system would effect (i) greater changes on both motor and cognitive outcomes than with TAU alone; (ii) sustained benefits, as assessed over a short follow-up period, and (iii) transfer to everyday functional performance (i.e. participation).[…]
Continue —> Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study | Journal of NeuroEngineering and Rehabilitation | Full Text
Examples of the Elements (a) goal-directed Bases task with visual augmented feedback, and (b) exploratory Squiggles task
Health and wellness at Chatham-Kent Health Alliance soon won’t be confined to the hospital walls with new virtual reality technology available to some patients and staff.
The hospital organization recently awarded staff members several innovation grants, two of which incorporate devices which put the user into different locations or scenarios.
Jarrod Prieur, the clinical manager for rehabilitation, pitched a $10,000 project meant to help stroke patients recover.
The virtual reality equipment will put these patients at places like a grocery store. When they move their arms to reach for a carton of milk, for example, they will see an arm capturing those same movements.
“It’s designed specifically for activities of daily living and with input from occupational therapists (and) physiotherapists, and part of why we haven’t been able to access some of this equipment in the past has been it’s expensive,” said Prieur.
Other scenarios will likely include preparing meals, caring for pets, folding laundry and gardening.
As someone who previously worked as an occupational therapist, Prieur said this is something he’s wanted to see at the hospital for over five years.
He said patients always ask how their rehabilitation is meant to be applied to their life once they return home and these types of programs give them actual practice with some of those tasks.
The Health Alliance currently uses peg boards – wooden boards with different-shaped holes which require patients to put pegs through the correct holes. Prieur said the different shapes of the pegs means the patient gets to practice different grips required in day-to-day life.
The hospital also has other boards which have features like a handle to turn on a hose, a faucet for a tap and electrical sockets.
“The reason we moved in this direction with the virtual reality is because that’s where the evidence is with stroke rehabilitation right now,” said Prieur. “I would say half of the research being done in stroke rehabilitation is how we use technology to further these patients’ journeys.”
About 150 to 200 people come through rehab at the hospital due to a stroke each year, according to Prieur, and they would be the primary users of this equipment. There will only be one virtual reality unit, but all of those patients should be able to use it, he said.
Some patients on the complex continuing care floor, including those with dementia, will be able to work with the equipment as well, he said.
Officials at the hospital said they have a request for proposals process they need to go through with this project, but they hope to have it available by April.
The hospital also gave out a $1,000 grant to occupational health, safety and wellness manager Alexis MacPherson for three virtual reality headsets.
These are meant for staff to be put in the mindset of someone with a mental illness to gain empathy for patients or to help with staff wellness through meditation and mindfulness programs.
“It’s like a simulation of what it’s like to have depression, go through an anxiety attack, have dementia and the thought processes that go on there,” said MacPherson, adding it also lets someone experience living with a visual impairment.
MacPherson said the programs and the hospital are considerate about any potential negative effects going through a schizophrenic simulation, as an example, could have on a user.
“Even at the beginning of some of the videos it says if you have these kinds of issues, it might be triggering to go through some of these processes,” she said. “Also, wearing these can kind of cause motion sickness for some people.”
Staff will go through education and training before using these devices.
Another side to these headsets will give staff the opportunity to go through a meditation, practise yoga or visit places like the Grand Canyon.
“There is high percentage of health care workers that are experiencing burnout and so we hope that this is a tool that they can use to help build their resiliency and decrease their stress,” said Lisa Northcott, vice president and chief nursing executive.
The headsets will be used to go along with monthly wellness themes the hospital is planning to start promoting. When they are not being used for those events, staff will be able to sign them out.
Virtual reality to help more military and other public safety workers cope with PTSD is central to the work of a new group launched in Edmonton.
Heroes in Mind, Advocacy & Research Consortium (HiMARC) is made up of those who want “to serve the men and women in uniform who have served us and continue to serve us daily,” Bob Haennel, dean of the University of Alberta’s Faculty of Rehabilitation Medicine, said in a Wednesday news release.
HiMARC’s Motion-Assisted, Multi-Modal Memory Desensitization and Reconsolidation (3MDR) research study — the largest of its kind in Canada with 40 Armed Forces participants — allows PTSD patients to use the Computer-Assisted Rehabilitation Environment (CAREN) system at the Glenrose Rehabilitation Hospital.
“It was incredible. I don’t know how else to describe it. My senses were heightened. I was even sensitive to the clanging sound of the carabiner on my harness,” said Capt. Anna Harpe, a social worker at CFB Edmonton, after experiencing the 3MDR system.
Patients who step into the CAREN unit walk on a treadmill toward a stimulus, sounds and images that may remind them of events that trigger traumatic memories. A therapist is with them through the process, guiding the patient confronting the memories.
While Harpe does not have PTSD, she said testing the 3MDR brought back vivid recollections of a mission in Afghanistan when she was in the infantry.
“I have worked with some clients who have been diagnosed with PTSD, and I have to say, the 3MDR is mind-blowing. My whole body was activated. You just cannot get the same thing through talk therapy in an office,” she said.
Study participants are receiving the therapy once a week for six weeks.
“By walking towards the fear, there is a shift in the brain,” said Suzette Brémault-Phillips, director of HiMARC in the Faculty of Rehabilitation Medicine and co-principal investigator for the study in Canada.
The 3MDR system — developed by Col. Eric Vermetten, head of research at the Military Mental Health unit of the Dutch ministry of defence in the Netherlands — has been effective in the Netherlands where it’s been used to treat the rise in PTSD cases there after its mission to Afghanistan.
Vermetten traveled to Edmonton to train Brémault-Phillips and her team to use the system.
HiMARC’s founding members also include the Royal Canadian Legion Alberta-NWT Command, NAIT, the Department of National Defence, Veteran Affairs Canada and Covenant Health.
“HiMARC is creating hope and I am so grateful for this group. I really believe this is just the beginning,” added Harpe.
[Abstract] Virtual Reality in Upper Extremity Rehabilitation of Stroke Patients: A Randomized Controlled Trial.
Virtual reality game system is one of novel approaches, which can improve hemiplegic extremity functions of stroke patients. We aimed to evaluate the effect of the Microsoft Xbox 360 Kinect video game system on upper limb motor functions for subacute stroke patients.
The study included 42 stroke patients of which 35 (19 Virtual reality group, 16 control group) completed the study. All patients received 60 minutes of conventional therapy for upper extremity, 5 times per-week for 4 weeks. Virtual reality group additionally received Xbox Kinect game system 30 minutes per-day. Patients were evaluated prior to the rehabilitation and at the end of 4 weeks. Box&Block Test, Functional independence measure self-care score, Brunnstorm stage and Fugl-Meyer upper extremity motor function scale were used as outcome measures.
The Brunnstrom stages and the scores on the Fugl-Meyer upper extremity, Box&Block Test and Functional independence measure improved significantly from baseline to post-treatment in both the experimental and the control groups. The Brunnstrom stage-upper extremity and Box&Block Test gain for the experimental group were significantly higher compared to the control group, while the Brunnstrom stage-hand, the Functional independence measure gain and Fugl-Meyer gain were similar between the groups.
We found evidence that kinect-based game system in addition to conventional therapy may have supplemental benefit for stroke patients. However, for virtual reality game systems to enter the routine practice of stroke rehabilitation, randomized controlled clinical trials with longer follow-up periods and larger sample sizes are needed especially to determine an optimal duration and intensity of the treatment.
[Abstract] Effectiveness of Virtual Reality Using PS4 Gaming Technology in Stroke Rehabilitation for Improving Upper Limb Function-A Pilot Study
Background: Hemiparesis resulting in functional limitation of an upper extremity and lower limb is common among stroke survivors. Virtual reality is one of the way of improving motor function in stroke, limited evidence is available on the efficacy of virtual reality for stroke rehabilitaton.
Methods: In this pilot study 2 parallel groups involving stroke patients, we compared the feasibility, safety and efficacy of virtual reality using the sony PS4 gaming technology to evaluate upper limb motor improvement. The primary feasibility outcome was the total time receiving the intervention. The… primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period. Efficacy, a secondary outcome measure, was evaluated with wolf motor function test and Spasticity Grading at 4 weeks after intervention. OUTCOME MEASURE: WOLF Motor function test and Box and Block test.
Result: This study shows that mean values obtained from WOLF motor function test showed no statistical significance and the mean values of Box and Block test showed statistical significance.
Conclusion: This study concludes that the PS4 gaming technology is a feasible, safe, and potentially effective intervention to enhance motor function recovery in patients with a recent stroke.
[NEWS] New Virtual Reality Therapy game could offer relief for patients with chronic pain, mobility issues
A Virtual Reality Therapy game (iVRT) which could introduce relief for patients suffering from chronic pain and mobility issues has been developed by a team of UK researchers.
Dr Andrew Wilson and colleagues from Birmingham City University built the CRPS app in collaboration with clinical staff at Sandwell and West Birmingham Hospitals NHS Trust for a new way to tackle complex regional pain syndrome and to aid people living with musculoskeletal conditions.
Using a head mounted display and controllers, the team created an immersive and interactive game which mimics the processes used in traditional ‘mirror therapy’ treatment. Within the game, players are consciously and subconsciously encouraged to stretch, move and position the limbs that are affected by their conditions.
Mirror therapy is a medical exercise intervention where a mirror is used to create areflective illusion that encourages patient’s brain to move their limb more freely. This intervention is often used by occupational therapists and physiotherapists to treat CRPS patients who have experienced a stroke. This treatment has proven to be successful exercises are often deemed routine and mundane by patients, which contributes to decline in the completion of therapy.
Work around the CRPS project, which could have major implications for other patient rehabilitation programmes worldwide when fully realised, was presented at the 12th European Conference on Game Based Learning (ECGBL) in France late last year.
Dr Wilson, who leads Birmingham City University’s contribution to a European research study into how virtual reality games can encourage more physical activity, and how movement science in virtual worlds can be used for both rehabilitation and treatment adherence, explained, “The first part of the CRPS project was to examine the feasibility of being able to create a game which reflects the rehabilitation exercises that the clinical teams use on the ground to reduce pain and improve mobility in specific patients.”
“By making the game enjoyable and playable we hope family members will play too and in doing so encourage the patient to continue with their rehabilitation. Our early research has shown that in healthy volunteers both regular and casual gamers enjoyed the game which is promising in terms of our theory surrounding how we may support treatment adherence by exploiting involvement of family and friends in the therapy processes.”
The CRPS project was realized through collaborative working between City Hospital, Birmingham, and staff at the School of Computing and Digital Technology, and was developed following research around the provision of a 3D virtual reality ophthalmoscopy trainer.
Andrea Quadling, Senior Occupational Therapist at Sandwell Hospital, said “The concept of using virtual reality to treat complex pain conditions is exciting, appealing and shows a lot of potential. This software has the potential to be very helpful in offering additional treatment options for people who suffer with CRPS.”
[Abstract] Efficacy of Virtual Reality Combined with Real Instrument Training for Patients with Stroke: A Randomized Controlled Trial
To investigate the efficacy of real instrument training in VR environment for improving upper-extremity and cognitive function after stroke.
Single-blind, randomized trial.
Enrolled subjects (N=31) were first-episode stroke, assessed for a period of 6 months after stroke onset; age between 20 and 85 years; patients with unilateral paralysis and a Fugl-Meyer assessment upper-extremity scale score >18.
Both groups were trained 30 min per day, 3 days a week, for 6 weeks, with the experimental group performing the VR combined real instrument training and the control group performing conventional occupational therapy.
Main Outcome Measures
Manual muscle test, Modified Ashworth scale, Fugl-Meyer upper motor scale, Hand grip, Box and Block, 9-hole pegboard, Korean mini-mental status examination, and Korean-Montreal cognitive assessment.
The experimental group showed greater therapeutic effects in a time-dependent manner than the control group, especially on the motor power of wrist extension, spasticity of elbow flexion and wrist extension, and box and block tests. Patients in the experimental group, but not the control, also showed significant improvements on the lateral, palmar, and tip pinch power; box and block, and 9-hole pegboard tests from before to immediately after training. Significantly greater improvements in the tip pinch power immediately after training and spasticity of elbow flexion 4 weeks after training completion were noted in the experimental group.
VR combined real instrument training was effective at promoting recovery of patients’ upper-extremity and cognitive function, and thus may be an innovative translational neurorehabilitation strategy after stroke.
[Abstract] Immersive virtual reality mirror therapy for upper limb recovery following stroke – A pilot study
Objective This study was designed to examine the feasibility of immersive virtual reality(VR) mirror therapy for upper limb paresis after stroke using a head-mounted display, and provide preliminary evidence of efficacy.
Design Ten outpatients with chronic stroke, upper limb hemiparesis, and a low predisposition for motion sickness completed a 12-session program of 30 minutes each of immersive VR mirror therapy. The VR system provided the illusion of movement in the hemiparetic upper limb while suppressing the visual representation of the non-paretic side. Feasibility was assessed via patient compliance, adverse event tracking, the System Usability Scale, and the Simulator Sickness Questionnaire. Preliminary efficacy was evaluated using the Fugl-Meyer Upper Extremity (FM-UE) and Action Research Arm Test.
Results Immersive VR mirror therapy for patients with chronic stroke was safe, well-tolerated, and without adverse events, such as simulator sickness. Motor outcomes revealed a small improvement for the FM-UE from 21.7 (SD= 8.68) to 22.8 (SD= 9.19) that did not achieve statistical significance (p=0.084).
Conclusion Four weeks of immersive virtual reality mirror therapy was well-tolerated by chronic stroke patients. Our findings support further clinical trials of immersive VR technologies and visually-enhanced mirror therapies for stroke survivors.
[WEB SITE] Assisto & VHAB will dramatically change how people with neuromuscular disabilities communicate
April 4, 2019
In our series #TechThursdays, we bring you news about Virtual Rehabilitation (VHAB) and Assisto devices. VHAB, which is based on virtual reality and Assisto, which is on artificial intelligence, are targeted at people with neuromuscular disabilities.
Tech giant Tata Consultancy Services (TCS) are looking to enable people with neuromuscular disabilities in a big way with VHAB (Virtual Rehabilitation) and Assisto. The two devices use the latest available technologies to enhance communication skills.
Assisto addresses the communication difficulties that many people with cerebral palsy face by tuning their voices for better clarity. This is achieved with Algorithm, a speech synthesis. So, when the user speaks, the listener will hear a clearer enunciation.
VHAB, on the other hand, us targeted at children with neuromuscular disabilities like cerebral palsy and autism. Many children diagnosed with disabilities are put through rigorous physiotherapy sessions which can be tiring. VHAB makes these sessions game-based with the help of virtual reality. Gesture analysis, finger-mapping and motion sensors will be used for this.
Both Assisto and VHAB have been successfully tested on children at the Adarsh School in Kochi.
Ashwin Kumar, Principal, Adarsh School believes taht the devices will revolutionize the way people with neuromuscular disabilities communicate.
People with cerebral palsy and autism may have issues with their tongue muscles that can affect communication. Assisto and VHAB devices are definitely going to help them. The software that was developed by TCS was tested on two of our children and it worked really well. In their next phase of the project, they are planning to introduce this to more children and reach out to people who need it.- Ashwin Kumar, Principal, Adarsh School
These devices will also make day-to-day tasks also easier for children with neuromuscular disabilities. The team fine-tuned the devices over three years.
“They provide a gameified app platform and a game environment is created for the user”, says Robin Tommy one of the members of the team that worked on developing them. “It is a combination of physical and game therapies and pain-free as well so kids would love it. The devices aim to enable movements for the user and motivate them to do daily activities with ease. It is mainly based on gesture and motion”.
Seema Lal, Co-founder of TogetherWeCan, a well known parents supports group in Kerala, believes that technologies like these will be game changers for people with disabilities.
‘We often talk about how technology can be a curse when it comes to things like game addiction and so on. At the same time, it can be a boon for children with neuromuscular disabilities. The United Nations is already talking about the benefits of assistive technology for people with disabilities, and in enabling them to participate actively in many things. I believe this new initiative from TCS is brilliant. Communication is the key for any person and technology is truly a boon”, says Lal.
This is a CSR project of TCS and the great news is that it plans to look at ways to introduce Assisto and VHAB in other schools as well as NGOs. VHAB was recently launched at the ZEP Rehabilitation Centre in Pune,